drtfyur Dolney Stougl^ton.
COLLEGE OF OSTEOPATHIC PHYSICIANS
AND SURGEONS LOS ANGELES, CALIFORNIA
PRESS NOTICES OF THE FIRST EDITION.
" The work can be earnestly recommended as a faithful exponent of American gyne-
cology, conceived in a spirit of moderation and conservatism." Medical Record,
New York.
" While written in a concise way, it is exceedingly full, and covers the whole ground
of gynecology. Boston Medical and Surgical Journal.
" The chapter on the Anatomy of the Female Pelvic Organs cannot be too highly
commended. . . . The author shows a wide knowledge of therapeutics and a com-
mendable wealth of resource. . . . The author's descriptions of operations are particu-
larly lucid." Annals of Surgery.
" We think it one of the few really good books on gynecology for the general
practitioner." New York Medical Journal.
" It is in every sense a safe text-book to place in the hands of the student and gen-
eral practitioner; while the style is so lucid, concise, and forcible that no one can
misunderstand a single statement." American Journal of the Medical Sciences.
" A useful work. A capital index makes consultation easy." Edinburgh Med-
ical Journal.
" The chapter on Diseases of the Fallopian Tubes is up to date, complete, and
instructive, as are also the chapters on Uterine Fibroids, Diseases of the Ovaries, and
Peri-uterine Inflammation." American Medico-Surgical Bulletin.
" The surgeon will find much to interest him, and he will turn to its pages for hurried
consultation much oftener than to some of the more elaborate ' text-books ' and ' sys-
tems.' " Journal of the American Medical Association.
" The special merits of this work are that it is a book of moderate size, and hence
comparatively inexpensive ; that it is thoroughly modern ; that the subjects are so well
tabulated and indexed that reference is easy ; that the author's style is singularly con-
cise and clear. . . . The illustrations are copious and admirable." Therapeutic
Gazette.
" One is struck with its clearness and practical value." Annals of Gynecology
and Pediatrics.
" This work is in our opinion the most practical text-book on gynecology (from
the standpoint of the general practitioner) thus far published." Hahnemannian
Monthly.
" We do not know of any work which is so replete with technique and fair detailed
instructions." Chicago Clinical Review.
PROFESSIONAL COMMENTS.
" One of the best text-books for students and practitioners which has been published
in the English language; it is condensed, clear, and comprehensive. The profound
learning and great clinical experience of the distinguished author find expression in this
book in a most attractive and instructive form. Young practitioners, to whom expe-
rienced consultants may not be available, will find in this book invaluable counsel and
help." THAD. A. REAMY, M. D., LL.D., Professor of Clinical Gynecology, Medical
College of Ohio; Gynecologist to the Good Samaritan and Cincinnati Hospitals.
" I can heartily recommend it to students and practitioners. It is concise, compre-
hensive, and consistent. I have in my library almost every recent author on this sub-
ject, and among them all I find none better fitted for a text-book than the volume you
have just published. I do not see how it can fail of being very popular." JOHN W.
STREETER, Professor of Gynecology, Chicago Homeopathic Medical College.
A TEXT-BOOK
OF THE
DISEASES OF WOMEN.
BY
HENRY J. GARRIGUES, A. M., M. D.,
Professor of Gynecology and Obstetrics in the New York School of Clinical Medicine ; Gyne-
cologist to St. Mark's Hospital in New York City ; Gynecologist to the German Dispen-
sary in the City of New York ; Consulting Obstetric Surgeon to the New York
Maternity Hospital ; Ex-President of the German Medical Society of the City
of New York ; Fellow of the American Gynecological Society ; Fellow
of the New York Academy of Medicine ; Member of the Society
for Medical Progress, of the Eastern Medical Society,
of the New York County Medical Society, etc.
CONTAINING THREE HUNDRED AND THIRTY-FIVE ENGRAVINGS
AND COLORED PLATES.
SECOND EDITION, THOROUGHLY REVISED.
PHILADELPHIA :
W. B. SAUNDERS,
925 WALNUT STREET.
1897.
\)J?l0
& p.<-l 1
1*17
Copyright, 1897, by
W. B. SAUNDERS.
ELECTHOTYPED BY
WC8TCOTT * THOMSON, PHILAOA.
PRESS OF .
W. B. SAUNDERS. PHItAOA.
TO
ABRAHAM JACOBI, M. D.,
PROFESSOR OF DISEASES OF CHILDREN IN THE NEW YORK COLLEGE OF PHYSICIANS AND
SURGEONS ; EX-PRESIDENT OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK ;
EX-PRESIDENT OF THE NEW YORK ACADEMY OF MEDICINE, ETC., ETC.,
THIS WORK
IS RESPECTFULLY INSCRIBED
BY
THE AUTHOR.
PREFACE.
THE term " Diseases of Women " is understood to designate the
affections of the genital organs in the female sex other than those
connected with pregnancy, childbirth, and the puerperal state. That
branch of medical science and art that is devoted to this subject is
called Gynecology.
In writing this book I have first had in view the large class of
physicians who have not had the advantage of hospital training,
and who go to a post-graduate school in order to learn gynecology.
They can only stay a short time, and they want a full but concise
exposition, up to date, of the nature and treatment of the diseases
peculiar to women.
Secondly, I have tried to satisfy the requirements of that much
larger class who would like to go to such an establishment, but who
find it impossible to leave their practice. They are busy men, who
have to keep abreast of recent progress as best they can in all
branches of a general practitioner's work. They want information
about the present state of gynecology, but cannot find time to study
large works.
If in large cities it is better for the general practitioner, as well
as for his patient, to leave the treatment of most gynecological
cases to those who have special experience and skill in this line,
the same does not always hold good in country practice. The
long distances in this immense country make it very difficult, and
often impossible, to send patients to places where they can be treated
by specialists. American physicians are enterprising, and some
men practicing in a village have achieved world-wide renown, and
become the leaders of their city confreres.
Finally, I think the book will be found useful by undergradu-
ates studying in medical colleges. They will probably at that stage
30987
2 PREFACE.
of their development skip many details about operations, which they
will be glad to take up later, when the responsibility of a medical
practitioner lies heavy on their shoulders. The division into a gen-
eral and a special part will presumably be useful for the beginner,
and he will hardly care to pay much attention to what has been
placed in notes under the text.
This being a book for General Practitioners and Students, I
have omitted all reference to the historical development by which
gynecology has attained its present stage, as well as all reports of
special cases.
The limits and the nature of the work have not allowed me to
speak of all methods of treating every disease, but I have striven
to give a clear and succinct description of the best modes of treat-
ment ; and the reader will in this book find many details which he
would look for in vain in larger works.
My aim has been to write a practical work. The reader's time
is not taken up by theoretical discussions, and the pathology has
been treated very briefly. On the other hand, I have tried to help
the reader to make a diagnosis, and to teach him how to treat the
different diseases. In this respect I have gone into minute details
affording manifold information about points which practitioners who
live in large cities learn from one another or by visits to the shops
of the instrument-makers.
I have treated so discursively of the anatomy of the female geni-
tals because this subject, to a great extent, has been worked up by
the gynecologists themselves, and is not as yet described satisfactorily
in the text-books of anatomy, but only in large works of an encyclo-
pedic character or in articles in journals to which many have not
access.
I expect to be criticised for having devoted special chapters to
Hemorrhage and Leucorrhea. I know well that they are not dis-
eases ; but they are symptoms that play so great a part in the diseases
of women, and so often require symptomatic treatment, that I take
it to be in the interest of the general practitioner to treat them sep-
arately; and besides, by so doing infinite repetitions are avoided.
This being a text-book for beginners and a manual for general
practitioners, names of authors have been omitted as much as possi-
ble from the text, except when it was necessary in order to designate
PREFACE. 3
different methods of operations. In making use of the work of
American authors I have, however, given them credit for it in
foot-notes, and I trust that it will be found that a large amount
of information of this kind has been embodied in the text.
In indicating the treatment of the various affections, I mention
always the simpler and innocuous means before the more compli-
cated and dangerous, medical and electrical treatment being accorded
precedence over surgical.
Throughout the work a chief object has been to give modes of
treatment as they are practiced in America, by which I hope that
it will be found more useful for American students and practitioners
than the works written by or translated from foreign authors.
The Illustrations form a complete atlas of the embryology and
anatomy of the female genitalia, and represent numerous operations
and pathological conditions. Many come from my own operations,
dissections, and microscopical examinations.
155 LEXINGTON AVENUE, New York, January, 1894.
PREFACE TO THE SECOND EDITION.
THE first edition of this work met with a most appreciative recep-
tion by the medical press and profession both in this country and
abroad, and a large number of colleges in the United States and
Canada have recommended the book to their students.
If I have enjoyed the praise bestowed upon the book, I have paid
no less attention to just criticisms, and have embraced the oppor-
tunity afforded by this revision to bring the work up to date.
In this second edition old-fashioned patterns of instruments have
been replaced by new ones, defective original illustrations have been
artistically redrawn, and many new figures have been added.
Aseptic surgery, which was in its infancy when the first edition
was written, has been more carefully considered, still retaining its
forerunner, antisepsis, which in many respects, by the nature of
things, is indispensable, and often is all that can be obtained in
private practice.
Parts of the text and some of the illustrations that seemed anti-
quated or of minor importance have been omitted, and considerable
new material has been incorporated.
The whole surgical treatment of Uterine Fibroid and Cancer has
been rewritten and much simplified.
Vaginal Section has been placed on equal terms with Abdominal
Section.
Descriptions of the chief methods employed in Intestinal Sur-
gery have been added to the Appendix.
I have more extensively expressed my own opinion on the com-
parative value of different methods of treatment, but the applicability
of these methods to particular cases depends upon circumstances of
which only the attending physician or surgeon is judge.
716 LEXINGTON AVENUE.
4
CONTENTS.
GENERAL DIVISION.
PART I.
PAGE
DEVELOPMENT OF THE FEMALE GENITALS 19
PART II.
ANATOMY OF THE FEMALE PELVIC ORGANS 35
PART IIL
PHYSIOLOGY 114
CHAPTER I.
PUBERTY 114
CHAPTER H.
MENSTRUATION AND OVULATION 115
CHAPTER IIL
COPULATION 121
CHAPTER IV.
FECUNDATION 121
CHAPTER V.
THE CLIMACTERIC 103
PART IV.
ETIOLOGY IN GENERAL .
PART V.
EXAMINATION IN GENERAL
Verbal Examination 13:2
Age 13-2
Social Position and Pursuits 132
Duration of Sickness 132
Condition 132
Childbirth and Miscarriages 132
5
6 CONTENTS.
PAGE
Menstruation 133
Discharge 134
Micturition and Defecation 134
Pain 134
Nutrition and Strength 134
Family History 134
Special Questions 135
Physical Examination 135
I. Positions 136
II. Examination of the Pelvis 139
A. Inspection 139
B. Digital Examination 139
C. Artificial Prolapse of the Uterus 143
D. Specula 143
E. Sound 152
F. Probe 153
G. Curette 153
H. Dilatation 154
I. Examination of Virgins 156
III. Examination of the Abdomen ] 57
A. Inspection 157
B. Palpation 157
C. Percussion 158
D. Auscultation 158
E. Mensuration 158
F. Development of Gas and Injection of Water 158
G. Charts 158
IV. Other Means of Investigation common for Pelvic and Abdominal Diseases 159
A. Exploratory Aspiration 159
B. Exploratory Incision 159
C. Urinary Analysis 160
D. Catheterization of the Bladder 161
E. Microscopical Examination 161
F. Chemical Examination 161
G. Examination under Anesthesia 161
H. Examination of the Bladder and the Ureters 161
PART VI.
TREATMENT IN GENERAL 168
CHAPTER I.
PREVENTIVE TREATMENT 168
CHAPTER II.
EXTERNAL TREATMENT 170
A.- Applications ' . . . . 170
B. Injections 171
Vaginal 171
CONTENTS.
Intra-uterine ......................... j-y
Eectal ..... ... ............. 174
Vesical ..................... - ....... 175
C. Curetting ......................... 173
D. Tampoiiade .......................... 177
Pledgets iu the Vagina ....................... 178
Packing the Vagina ......................... 173
The Hemostatic Plug ..................... 179
Tamponade of the Uterus ........ .......... . 130
Abdominal Tamponade ....................... 131
E. Hemostasis ..................... ..... 131
Hot Water ............................. 132
Styptics .................... .......... 132
Cauterization ........................ Igo
Ligature ................. ............. 132
Forcipressure ............................ 134
F. Dilatation ......................... 134
G. Drainage ............................... 134
H. Bloodletting ...................... 13^
I. Heat and Cold ......................... 137
J. Counter-irritation ....................... . 133
K. Tapping and Aspiration .................... . 183
L. Abdominal Belt ..................... 190
M. Massage ......................... 190
N. Gymnastics ....................... 191
0. Operations in general .................... 192
1. Time for Operating ......................... 192
2. Preparation ............................ 193
Room .............................. 193
Table .............................. 194
Assistants ............................ 195
Spectators ............................ 196
Patient ..................... ' " ...... 196
Vessels and Towels ........................ 198
Disinfection, Asepsis, and Antisepsis ................ 198
Sponges ............................. 200
Gauze ............................ -201
Silk .............................. 201
Catgut ............................. 202
Silkworm Gut .......................... 204
Horsehair ........................... 204
Kangaroo Tendon .......... .............. 204
Silver Wire ........................... 204
lodoform ............... ............. 205
Antiseptic Fluids ........................ 205
Bichloride of Mercury .................... 205
Carbolic Acid ......................... 205
Creolin ............................ 205
Lysol ............................. 206
Hydronaphthol ........................ 206
8 CONTEXTS.
PAGE
Borosalicylic Solution (Thiersch's Solution) 206
Thymol .206
3. Anesthesia 206
Ether 206
Chloroform 208
Cocaine 209
Chloric ether 210
4. Common Instruments and their Use 211
Vaginal Retractors 211
Tenacula 212
Volsellse 212
Tenaculum-forceps , . 213
Sponge-holders 213
Knives 213
Scissors 213
Pressure-forceps 214
Needles 214
Needle-holders 215
Ligature-carrier 217
Ligatures 217
Sutures 217
Sponging and Irrigation 222
How to Clean and Keep Instruments 223
Selection of Instruments 223
5. Combination of Operations 223
6. After-treatment 223
CHAPTER III.
IKTEBNAL TREATMENT 224
Food and Drink 224
Aperients 225
Tonics 226
Anodynes 226
Sedatives 226
Hypnotics 226
Resolvents 226
Hemostatics 227
Antipyretics 228
CHAPTER IV.
ELECTRIC TREATMENT 229
Frankliuism 229
Faradism 229
Galvanism 229
Different Qualities of the Two Poles 233
Apostoli's Method 233
Chemical Galvanocauterization of the Cervix 234
Galvanopuncture 235
Thermal Galvanocauterizatiou 235
Metallic Interstitial Electrolysis 236
CONTEXTS. 9
PAGE
PART VII.
ABNORMAL MENSTRUATION AND METRORRHAGIA 238
CHAPTER I.
AMENORRHEA 238
CHAPTER II.
VICARIOUS MENSTRUATION 241
CHAPTER III.
DYSMENORRHEA 242
CHAPTER IV.
PRECOCIOUS AND TARDY MENSTRUATION 244
CHAPTER V.
MENORRHAGIA 245
CHAPTER VI.
METRORRHAGIA 247
CHAPTER VII.
GENERAL MENSTRUAL DISORDERS . 247
PART VIII.
LEUCORRHEA . . 250
SPECIAL DIVISION.
PART I.
DISEASES OF THE VULVA 255
CHAPTER I.
MALFORMATIONS , 255
1. Absence of the Vulva 255
2. Hypospadias 255
3. Epispadias 25(5
4. Abnormalities of the Clitoris 256
5. Abnormalities of the Labia Minora 258
6. Abnormalities of the Labia Majora 25S
7. Epithelial Coalescence 25M
8. Hermaphrodism 25S
CHAPTER II.
RUPTURES (HERNIA , 260
1. Anterior Labial, or Inguinolabial, Hernia 2(iO
2. Posterior Labial, or Vaginolabial, Hernia 261
CHAPTER III.
TUMORS CONNECTED WITH THE EXTRAPELVIC PORTION OF THE ROUND LIG-
AMENT 262
1. Hydrocele 262
10 CONTENTS.
PAGE
2. Hematocele of the Canal ot Nuck 263
3. Hematoma of the Bound Ligament 263
4. Fibroma of the Bound Ligament 264
CHAPTEB IV.
INJURIES 265
CHAPTEB V.
VULVITIS 266
CHAPTEB VI.
INFLAMMATION OF THE URETHEAL DUCTS 270
CHAPTEB VII.
GANGRENE OF THE VULVA 270
CHAPTEB VIII.
EXANTHEMATOUS DISEASES 271
Herpes Progenitalis 271
CHAPTEB IX.
TRICHIASIS 272
CHAPTEB X.
PRURITUS VULV.E 272
Burning Sensation in the Genitals and the Abdomen 274
CHAPTEB XI.
HYPEHESTHESIA OF THE VULVA 275
CHAPTEB XII.
TUMORS OF THE VULVA 275
1. Hyperplasia 275
2. Varicose Veins 276
3. Hematoma, or Thrombus 276
4. Papilloma 277
5. Elephantiasis, or Pachydermia 279
6. Fibroma 280
7. Myoma, Myxoma, Lipoma 281
8. Enchondroma of the Clitoris 281
9. Horn of the Clitoris 282
10. Urethral Caruncle, Angioma, and Neuroma of the Vulva 282
11. Cysts 283
12. Cancer 283
13. Lupus ; Esthiomene ; Chronic Inflammation, Infiltration, and Ulceratiou 285
CHAPTEB XIII.
TUBERCULOSIS 288
CHAPTEB XIV.
PROGRESSIVE ATROPHY OF THE NYMPHJE, OR KRAUROSIS 288
CHAPTEB XV.
DISEASES OF THE VULVOVAGINAL GLANDS . .... 289
CONTENTS. 11
CHAPTER XVI.
VENEBEAL DISEASES . 391
1. Gonorrhea 291
2. Chancroid 291
3. Syphilis 293
CHAPTER XVII.
PROLAPSE OF THE UEETHRA 296
CHAPTER XVIII.
MASTURBATION 297
Clitoridectomy 300
PART II.
DISEASES OF THE PERINEUM 301
CHAPTER I.
INJURIES 301
-I. Injuries from Without 301
II. Injuries from Within 301
A. Recent Lacerations 301
Primary Operation 303
Rupture of the Outer Ring 303
Rupture of the Inner Ring 305
Intermediate Operation 307
B. Old Lacerations 307
1. Tait's Flap-splitting Operation 307
a. For Incomplete Laceration 307
b. For Complete Laceration 310
2. Colpoperineorrhaphy 311
a. Hegar-Garrigues' for Incomplete Laceration 311
6. Hegar's for Complete Laceration 314
3. T. A. Emmet's Operation 316
a. For Incomplete Laceration (the new operation) . 316
b. For Complete Laceration 320
Preparation and After-treatment 322
CHAPTER II.
GARRULITY OP THE VULVA, OR FLATUS VAGINALIS 323
CHAPTER III.
COCCYGODYNIA 23
CHAPTER IV.
HYGROMA PERIN^I .... . 325
PART III.
DISEASES OF THE VAGINA 32t>
CHAPTER I.
MALFORMATIONS . . . , 32ti
12 CONTENTS.
PAGE
A. Malformations of the Hymen 326
1. Absence of the Hymen 326
2. Atresia Hymenalis 326
3. Abnormal Openings in the Hymen 328
4. Double Hymen 328
5. Fleshy Hymen 328
B. Malformations of the Vagina 328
1. Atresia and Stenosis of the Vagina 328
2. Double Vagina 332
3. Blind Canals in the Vagina 333
4. Faulty Communications of the Vagina 333
CHAPTER II.
VAGINAL ENTEEOCELE 334
CHAPTER III.
PROLAPSE OF THE ANTERIOR WALL OF THE VAGINA ; CYSTOCELE 335
CHAPTER IV.
PROLAPSE OF THE POSTERIOR WALL OF THE VAGINA; RECTOCELE 340
GENERAL PROLAPSE AND INVERSION 340
CHAPTER V.
INJURIES; THROMBUS, OR HEMATOMA 341
CHAPTER VI.
FOREIGN BODIES ....".. 342
CHAPTER VII.
VAGINITIS 343
A. Catarrhal Vaginitis 344
Exfoliative Vaginitis 348
Emphysematous Vaginitis 349
Mycotic Vaginitis 349
B. Exudative Vaginitis 350
C. Phlegmonous Vaginitis 351
CHAPTER VIII.
GANGRENE 352
CHAPTER IX.
ERYSIPELAS 353
CHAPTER X.
CICATRICES 353
CHAPTER XI.
VAGINISMUS 355
CHAPTER XII.
NEOPLASMS 353
1- Cysts . 358
CONTENTS. 13
PAGE
2. Fibroids 359
3. Mucous Polypi . . 361
4. Sarcoma 361
5. Carcinoma 361
6. Tuberculosis 362
CHAPTER XIII.
FISTULA 363
A. Urinary Fistulas 363
1. Vesicovaginal Fistula 363
2. Urethrovagiual Fistula 373
3. Ureterovaginal Fistula 373
4. Vesico-uterine Fistula 376
5. Vesico-utero vaginal Fistula 377
6. Uretero-uterine Fistula 377
7. Ureterovesicovaginal Fistula 377
Genital Cleisis 378
Urinals 378
Operations for Incontinence 379
B. Fecal Fistulas 380
PART IV.
DISEASES OF THE UTERUS 387
CHAPTER I.
MALFORMATIONS 387
A. Excessive Development and Precocity 387
B. Arrest of Development during the First Half of Intra-uteriue Life . . . 387
1. Absence of the Uterus 387
2. Rudimentary Uterus 388
3. Uterus Duplex Separatus, or Uterus Didelphys 388
4. Uterus Unicornis 389
5. Uterus Bicornis . . 390
6. Uterus Septus, or Uterus Bilocularis . 390
7. Atresia Uteri 391
C. Arrest of Development during the Second Half of Tntra-uterine Life . . 392
1. Fetal and Infantile Uterus 392
2. Pubescent, or Congenitally Atrophic, Uterus 393
3. Uterus Parvicollis and Acollis 393
4. Congenital Anteflexion 394
D. Irregular Development 394
1. Obliquity 394
Lateroflexion 394
Lateroversion 394
2. Malposition 394
Lateroposition 394
Anteposition 394
Retroposition 394
3. Hernia Uteri 394
4. Elongated Cervix and Stenosis of the Cervical Canal 394
14 CONTENTS.
CHAPTER II.
INJURIES 394
A. Injuries of the Body 394
B. Laceration of the Cervix 396
CHAPTER III.
FOREIGN BODIES 403
CHAPTER IV.
METRITIS 403
A. Acute Metritis 403
Diphtheritic Metritis 406
Dissecting Metritis 406
B. Chronic Metritis 407
1. Chronic Endometritis 407
2. Chronic Parenchymatous Metritis 416
CHAPTER V.
CLOSURE OF THE UTERUS (ACQUIRED ATRESIA) 420
CHAPTER VI.
STENOSIS OP THE CERVIX 421
CHAPTER VII.
ULCERS OP THE CERVIX 424
CHAPTER VIII.
HYPERTROPHY OF THE UTERUS 404
A. Infravaginal Hypertrophy of the Cervix 425
B. Supravaginal Hypertrophy of the Cervix 426
CHAPTER IX.
ACQUIRED ATROPHY or THE UTERUS (SUPERINVOLUTION) 431
CHAPTER X.
GANGRENE OF THE UTERUS 432
CHAPTER XI.
HYSTERALGIA 432
CHAPTER XII.
DISPLACEMENTS OF THE UTERUS . 433
A. Anteversion 433
B. Auteflexion 43g
C. Retrovereion 442
D. Retroflexion 443
E. Lateroversion and Lateroflexion 454
F. Prolapse 454
G. Elevation 460
H. Inversion . . 459
I. Hernia 466
CONTENTS. 15
PAGE
CHAPTER XIII.
NEOPLASMS OF THE UTERUS 467
A. Cysts : Adenoma ; Mucous Polypi ; Myxoma 467
B. Cavernous Angioma 468
C. Fibroids, Fibroid Polypi, and Fibrocysts 469
D. Sarcoma 503
E. Carcinoma 507
F. Papilloma 521
G. Euchoudroma 522
H. Tuberculosis . 522
PART V.
DISEASES OF THE FALLOPIAN TUBES 524
CHAPTER I.
MALFOBMATIONS 524
CHAPTER II.
SALPINGITIS * 525
Cystic Salpingitis 541
Pyosalpinx 543
Hydrosalpinx 544
Hematosalpinx 545
CHAPTER III.
DISPLACEMENTS 546
CHAPTER IV.
NEOPLASMS 546
A. Cysts 546
B. Fibroma 547
C. Lipoma 547
D. Papilloma 547
E. Cancer (Carcinoma and Sarcoma) 547
F. Tuberculosis . . . 547
PART VI.
DISEASES OF THE OVARIES 549
CHAPTER I.
MALFORMATIONS 549
CHAPTER II.
DISPLACEMENTS 550
Extrapelvic Displacements 550
Intrapelvic Displacements, or Prolapse 551
CHAPTER III.
HYPEEEMIA AND HEMATOMA . .... 554
16 CONTEXTS.
PAGE
CHAPTER IV.
OOPHORITIS 557
A. Acute Oophoritis and Ovarian Abscess 557
B. Chronic Oophoritis 559
Gyroma and Endothelioma 563
CHAPTER V.
NEOPLASMS 567
A. Ovarian Cysts 567
I. Dropsical Graafian Follicles . . . . . 568
Rokitanski's Tumor 570
II. Proliferating Cysts 571
a. Glandular 572
b. Papillary 580
e. Mixed 581
III. Dermoid Cysts 581
IV. Tubo-ovarian Cysts, or Hydrocele of the Ovary 583
Origin of Ovarian Cysts 587
Etiology 588
Symptoms 588
Accidents 593
Hemorrhage 593
Inflammation and Suppuration 593
Torsion of the Pedicle 593
Rupture of the Cyst . 593
Ascites 594
Peritonitis 594
Intestinal Obstruction 594
Explorative Puncture 595
Diagnostic Value of the Fluid 595
Explorative Incision 596
Differential Diagnosis 596
A. Pelvic Tumor 596
B. Abdominal Tumor 597
Complications 602
Prognosis 603
Treatment 603
Tapping 604
Ovariotomy 606
Vaginal Ovariotomy 607
Abdominal Ovariotomy 607
Difficulties met with during Operation 616
Incomplete Operations 623
Complications of Ovarian Cysts 629
Complications during After-treatment 631
Prognosis of Ovariotomy 635
B. Solid Ovarian Tumors 636
I. Fibroma . . . 636
II. Papilloma 637
III. Sarcoma 638
IV. Endothelioma (Ackermann) 639
CONTENTS. 17
PAGE
V. Carcinoma 639
VI. Tuberculosis _ 641
CHAPTEE VI.
Ob'PHOBALGIA
642
PART VII.
DISEASES OF THE PELVIS .643
(The Peritoneum, the Connective Tissue, the Vessels of the Pelvis, and the Liga-
ments of the Uterus.)
CHAPTER I.
MALFORMATIONS 643
CHAPTER II.
ANEURYSM OF THE UTEEINE ARTERY 643
CHAPTER III.
DISEASES OF THE BROAD LIGAMENT 644
A. Varicocele 644
B. Cysts 645
C. Solid Tumors 648
CHAPTER IV.
DISEASES OF THE ROUND LIGAMENT 648
CHAPTER V.
DISEASES OF THE SACRO-TJTERINE LIGAMENT 648
CHAPTER VI.
PELVIC HEMORRHAGE 649
A. Intraperitoneal Hemorrhage 649
B. Hematocele 650
C. Hematoma 655
CHAPTER VII.
PERIMETRIC INFLAMMATION 657
A. Pelvic Peritonitis 657
B. Pelvic Cellulitis 669
C. Pelvic Phlebitis . . . H75
D. Pelvic Lymphangitis and Lymphadenitis
CHAPTER VIII.
SARCOMA AND CARCINOMA OF THE PELVIC PERITONEUM AND CONNECTIVE
TISSUE 678
CHAPTER IX.
HYDATIDS OF THE PELVIS <579
APPENDIX.
I. STERILITY . 68:2
II. LACK OF ORGASM 687
III. INTESTINAL SURGERY 688
DISEASES OF WOMEN
OR
GY.
GENERAL DIVISION.
DISEASES OP WOMEN.
GENERAL DIVISION".
PART I.
DEVELOPMENT OF THE FEMALE GENITALS.
THE history of the development of the female genitals being an
indispensable key to the understanding of their malformations, which
are of frequent occurrence and often of great importance in regard
to life and happiness, we give here a resume of the same.*
THE WOLFFIAN DUCTS.
The first organs belonging to the genital sphere which appear in
the male as well as the female embryo are the Wolffian ducts.
There is one on either side of the body, situated between the proto-
Transverse Section through the Median Part of the Body of the Embryo of a Rabbit of nine
days and two hours (enlarged 158 times): dd, hypoblast : dr, intestinal groove: ch, noto-
chord ; ao, descending aortse ; un, protovertebra f mr, medullary tube ; itny, Wolffian durt :
O/p, visceral division of the mesoblast ; g, vessels in the deeper" parts of the visceral meso-
blast ; hp, parietal mesoblast ; h, epiblast ; pp, pleuro-peritoneal cavity (Kolliker).
vertebral column and the lateral plates (Fig. 1). Originally it is a
* This is an abstract of the author's more elaborate article on the subject in A
System of Gynecology by American Authors, edited by M. D. Mann, Philadelphia,
1887.
19
20
DISEASES OF WOMEN.
solid string, but it is later tunnelled, so as to form a tube. The
upper end lies on a level with the fourth or fifth vertebra, and con-
nects soon with the Wolffian body, forming its outlet. The lower
end opens into that part of the allantois which is situated in the
body of the embryo and communicates with the cloaca. After the
separation between the urogenital canal and the intestine the "W olf-
fian duct ends in the urogenital sinus (Fig. 2).
FIG. 2.
Sagittal Section through the Posterior Part of the Body of the Embryo of a Rabbit of eleven
days and ten hours (enlarged 45 times) : wg, Wolffian duct; n, ureter; ', beginning formation
of the kidney ; ug, urogenital sinus ; cl, cloaca ; hg, region in which, in the mesial plane,
the hind-gut, opens into the cloaca ; ed, post-anal gut ; a, anus, or fissure of the cloaca ; s,
tail ; r, perinea! fold (Kolliker).
In the male the Wolffian duct becomes, in the course of time, the
tail of the epididymis and the vas deferens. In the female it disap-
pears more or less completely. Still, in the cow and the sow it per-
sists as Gartner's canal. In woman remnants of it are found in the
broad ligaments.
THE WOLFFIAN BODIES.
Shortly after the Wolffian ducts appear the Wolffian bodies.
These are two long prismatic bodies, one on either side of the
median line (Fig. 3). The upper end is fastened to the dia-
phragm, the lower to the inguinal region by a ligament which in
course of time becomes the round ligament of the uterus, or the
gubernaculum testis in the male (Fig. 4). They fill the hollow of
the posterior wall of the abdominal cavity, leaving a narrow fissure
on either side. In the inner one of these is later developed the gen-
ital gland ; in the outer lies the Wolffian duct, and later also the
Miillerian duct.
DEVELOPMENT OF THE FEMALE GENITALS.
21
These bodies originate from the endothelium of the peritoneum,
and form at first a long row of pear-shaped solid bodies. Later,
FIG. 3.
Human Embryo of thirty-five days (front view) : 3, left external nasal process ; 4, superior
maxillary process ; z, tongue ; b, aortic bulb ; 6', first permanent aortic arch ; 6", second
aortic arch ; b'", third aortic arch, or ductus Botalli ; y, the two filaments to the right and
the left of this letter are the pulmonary arteries, which just begin to be developed ; c, the
trunk of the superior vena cava and right azygos vein ; c', the common venous sinus of
the heart ; c", the common trunk of the left vena cava and left azygos vein ; o, left auricle
of the heart; v, right ventricle ; v', left ventricle ; ae, lungs; e, stomach; ?', left omphalo-
mesenteric vein ; s, continuation of the same behind the pylorus, which afterward
becomes the vena porta; x, vitello-intestinal duct; o, right pmphalo-mesenteric artery;
m, Wolman body; i, gut ; n, umbilical artery ; u, umbilical vein ; 8, tail ; 9, anterior limb ;
9', posterior limb. The liver has been removed. The white band at the inner side of the
Wolman body is the genital gland, and the two white bands at its outer side are the Miil-
lerian and the Wolman ducts (Coste).
these are separated from the peritoneum and become hollow, form-
ing a row of vesicles called the segmented vesicles, each of which soon
connects with the Wolffian duct by the absorption of the tissue inter-
vening between their cavities and the bore of the duct. The former
22
DJSEASES OF WOMEN.
vesicles appear now as branches of the Wolffian duct (Fig. 5), which
grow rapidly and connect at the other end with arterial tufts in the
same way as the uriniferous ducts and the Malpighian tufts in the
kidneys.
In the male the Wolffian body later is transformed into the epidi-
didymis and the organ of Giraldez (Fig. 6) ; in the female into Rosen-
FTG. 4.
The Genital and Urinary Organs of the Embryo of Cattle :
1, from a female embryo 1% inches long (double size) : w, Wolffian body ; wg, Wolffian and
Mullerian dncts ; i, inguinal ligament of Wolffian body ; o, ovary with an upper and lower
peritoneal fold : n, kidney ;nn, suprarenal body; g, genital cord, composed of the united
Wolffian and Mullerian ducts.
2, from a male embryo 2]4 inches long (nearly three times natural size) : one of the testicles
has been removed. Letters as in Fig. 1, and, besides, m, Mullerian duct ; TO', upper end
of the same : h, testicle ; h', lower ligament of testicle ; h", upper ligament of testicle ; d,
diaphragmatic ligament of Wolffian body ; a, umbilical artery ; v, bladder.
8, from a female embryo (enlarged nearly three times). Letters as in Figs. 1 and 2, and, be-
sides, t, opening of the upper end of Muller's duct ; o', lower ovarian ligament ; u, thick-
ened part of Mullerian duct, which later becomes the uterine horn (Kolliker).
mulleins organ, or the parovarium, and stray tubes found between
the parovarium and the uterus (Fig. 7).
THE OVARIES.
In the beginning the sexual glands are identical in both sexes.
At the end of the second month the ovary and the testicle begin to
differ from one another, the testicle becoming broader and shorter,
while the ovary stays long and narrow. The ovary has a much more
developed columnar epithelium than the testicle.
The sexual glands are situated on the inner side of the Wolffian
body (Fig. 4), to which they are fastened by a fold of the peritoneum
DEVELOPMENT OF THE FEMALE GENITALS. 23
called the mesorchium in the male and the mesoarium in the female.
At the upper end is a ligament which unites with the diaphragmatic
ligament of the Wolffian body ; at the lower end is another ligament,
which is fastened to the Wolffian duct, opposite the starting-point of
the inguinal ligament of the Wolffian body, and which later becomes
the permanent ligament of the ovary.
The shape of the ovary undergoes great changes. At first it is a
long flat body. Later it grows, especially at the edges, so that a
transverse section has the shape of a bean or a mushroom (Fig. 8),
and finally the transverse section becomes pear-shaped.
The ovary is subject to a descent just as the testicle. At the birth
of the child the ovaries are yet situated above the ileo-pectineal line,
and descend into the true pelvis during the first two or three months
Posterior End of the Embryo of a Dog, with budding alantoid. The mesoblast and the hypo-
blast, or the beginning of the intestine and the neighboring parts of the blastodefmic
vesicle, are thrown back in order to show the Wolffian bodies (enlarged 10 times), a,
Wolffian bodies, with the duct and the single blind canals ; 6, proto vertebrae ; c, spinal
marrow ; d, entrance to the pelvic intestinal cavity (Bischoff).
of the child's life. This descent is partly apparent and partly real :
it is chiefly due to the greater growth of the parts above the ovaries ;
but, besides that, a shrinking of the round ligament of the uterus
takes place, by which the ovaries indirectly are pulled down. At the
same time there is a change in position by which the upper end sinks
considerably downward and outward, and the whole organ turns
around its long axis until the inner edge becomes the lower, where
the hilum is ; the outer becomes the upper, free edge ; the anterior
surface becomes the inner, the posterior becomes the outer. The
relations to the Fallopian tube are changed in such a way that the
24
DISEASES OF WOMEN.
ovary, instead of lying inside of the Miillerian duct, as it does at first,
finally lies behind and below the tube.
FIG. 7.
Oabd
FIG. 6.
E -&
Mp
U U s
FIG. 6. Internal Genitalia of a Human Fetus, 9 cm. long (enlarged 8 times): H, testicle ; E,
epididymis (epididymal part of Wolffian body) ; U, organ of Giraldez (uropoetic part of
Wolffian body) ; 6, bundle of connective tissue containing vessels ; Y, vas deferens
(Wolffian duct) (Waldeyer).
FIG. 7. Internal Genitalia of a Human Female Fetus, 9 cm. long (enlarged 10 times) ; 0, ovary ;
T, tube ; abd., abdominal ostium of tube ; E, parovarium ; U, uropoetic part of the Wolff
ian body remaining as tubes between parovarium and uterus ; Y, Wolffian duct disap-
pearing lower down; Mp., Malpigbian bodies (Waldeyer).
The ovarian vessels enter originally at the upper end of the
Transverse Section of Ovary of Human Embrvo of three months (enlarged 43 times) : a,
mesoarium : a', stroma of the hilum (medullary substance) ; b, glandular tissue (cortical
substance) (Kolliker).
DEVELOPMENT OF THE FEMALE GENITALS.
25
mesoarium from the posterior wall of the abdomen, and are enclosed
in a fold of the peritoneum, which in the course of time becomes the
infundibulo-pelvic ligament, extending from the fimbrise of the tube to
FIG. 9.
Transverse Section through the Ovarian Region of a Human Embryo of five months ; lower
surface seen from above (enlarged 3 times) : oi, os ilium ; s, sacrum ; mo, mesoarium and
hilum of ovary, bounded by two lips ; o, cut surface of the ovary ; i>, free ventral surface,
or lateral part of the ventral surface, of the ovary ; m, rectal surface of ovary, or medial
part of its ventral surface ; t, tube ; mi, mesentery of tube (later ala vespertilionis) ; r,
rectum ; M, uterus ; wr. ureter ; au, umbilfcal artery ; ie, external iliac vessels ; nc, ante-
rior crural nerve (Kolliker).
the wall of the pelvis. To the outer side of the mesoarium is attached
the mesosalpinx (Fig. 9), or mesentery of the tube, which later is called
FIG. 10.
Ovary of a Human Fetus of ten or eleven weeks : a, superficial stratum of cells : b, layer of
connective tissue : c, trabeculse of connective tissue, the cells having been removed ; d,
mesoarium ; e, part near surface seen with higher power ; n, natural size of the specimen
(H. Meyer).
26
DISEASES OF WOMEN.
cda vespertilionis (the bat's wing), and contains the remnants of the
Wolffian body, especially the parovariura, but at this period has no
connection with the uterus.
The Formation of Ova and Graafian Follicles. At the earliest
stage the ovary is represented by a mass of cells developed from the
peritoneal cover of the Wolffian body, and soon a protuberance of
connective tissue enters from behind into this cell-mass. These two
elements build up the whole ovary, the cells forming the parenchyma,
or glandular element, and the connective tissue the stroma. Pro-
FIG. 11.
Part of Ovary near Surface, from Human Fetus of sixteen weeks, showing formation and
separation of ova (H. Meyer).
FIG. 12.
Part of Ovary near Surface, from Human Fetus of twenty-eight weeks. In some places
appears the permanent epithelium, composed of a single layer (H. Meyer).
FIG. 13.
Part of Ovary near Surface, from a Human Fetus of thirty-six weeks. The single layer of
epithelium is interrupted by a belated primordial ovum with its follicular epithelial cells
longations from the connective tissue grow in between the cells and
separate them, forming groups, and grow together over them; but
from this cover new prolongations start, and new cells are constantly
formed on the surface (Fig. 10). ' In this way irregular tubes filled
DEVELOPMENT OF THE FEMALE GENITALS.
27
with cells are formed which connect with one another, much like the
canals found in a sponge (Figs. 11, 12, 13j; but finally the whole
surface is only covered by a single layer of cells, the columnar epi-
thelium, under which is found a layer of connective tissue, the albu-
ginea, and under that we find clusters of cells surrounded by connect-
ive tissue (Fig. 14), or sometimes a long row of large cells, each
FIG. 14.
Part of Section from Surface to Hiluiu of Ovary of Girl three days old : s, single layer of epi-
thelium yet in connection with cluster of primordial ova. All ova have disappeared from
the surface. A broad layer of stroma separates in most places the epithelium from the
follicular zone. The farther we go from the surface toward the hilurn. the fewer ova are
there in one nest, until, finally, there is only one in its primary follicle ; n, natural size
of the whole ovary (H. Meyer).
surrounded by smaller cells, until finally all these clusters and col-
umns are broken up into small compartments, each containing one
28
DISEASES OF WOMEN.
large cell and one or more smaller ones (Fig. 15). The large cells
have each a large nucleus and nucleolus, and are the future ova, and
FIG. 15.
FIG. 16.
Perpendicular Section through the Ovary of a Bitch of six months (Hartnack, ?) : a, the epi-
thelium ; 6, epithelial pouch opening on the surface ; c, larger group of follicles ; d, ovarian
tube filled with ova; e, oblique and transverse sections of ovarian tubes (Waldeyer).
are called primwdial ova ; and the small cells multiply and form the
epithelium of the primary follicles, which are the beginning of the
Graafian follicles (Fig. 16).
The small cells increase in number
and form several layers. A fissure is
formed between them, and a fluid ac-
cumulates in this space, the beginning
of the future liquor folliculi. The outer
layers form the epithelium of the Graaf-
ian follicle, the so-called membrana
granulosa ; the inner continue to sur-
round the ovum, forming the discus
proligerus (Fig. 1 7). The fibrous mem-
brane of the follicles is formed by a dif-
ferentiation of the surrounding stroma.
It will be seen from the above de-
scription that the ova, the surface epi-
thelium of the ovary, and the epithe-
lium of the Graafian follicles have all
one common origin, the cellular mass
formed on the inner edge of the Wolffian body. As mother to so
many epithelial formations, this is called the germ-epithelium. The
formation of ova on the surface of the ovary ceases from the time
the single layer of epithelium is formed, about the end of the seventh
month, but it seems that the ova themselves multiply by division
Three Graanan Follicles from the
Ovary of a New-born Girl (en-
larged 350 times) : 1, natural condi-
tion : 2, treated with acetic acid ;
a, structureless membrane ; 6, epi-
thelium (membrana granulosa) ; c,
yolk : d. germinal vesicle, with ger-
minal spot; e, nuclei of the epi-
thelial cells ;/, vitelline membrane
(Kolliker).
DEVELOPMENT OF THE FEMALE GENITALS.
29
(Fig. 18). Their number is enormous: it has been computed that
the two ovaries together contain 72,000 ova.
THE MULLERIAN DUCTS.
The Miillerian ducts appear shortly after the Wolffian body as a
funnel-shaped invagiuatiou from the endothelium of the peritoneum
FIG. 17.
Graafian Follicle from a Girl seven months old (enlarged 220 times ; natural size, 0.351 mm.
longest diameter) : a, epithelium (membrana granulosa) detached from fibrous membrane ;
b, discus proligerus, situated far away from the surface. It contains the ovum, on which
the zona pellucida and the germinal vesicle are visible. The surrounding fibrous mem-
brane is not yet separated into two layers, and there is no distinct line of demarkation
between it and the surrounding stroma'(Kolliker).
at the inner side of the upper end of the Wolffian body (Fig. 1 9).
Thence it extends behind this body and comes to lie outside of the
Wolffian duct, but turns in a spiral line round the latter, so as to
FIG. 18.
Primordial Ova undergoing division, from a Human Embryo of six months (enlarged 400
times) : 1, two primordial ova surrounded by a common layer of epithelium, one of which
has a prolongation by means of which it probably was attached to another ovum, as in 2,
where two primordial 9va are linked together by a band of protoplasm, the whole sur-
rounded by one epithelial layer ; 3 primordial ovum with two nuclei (germinal vesicles)
(Kolliker).
30
DISEASES OF WOMEN.
pass in front of it, and finally lie behind it. The lower part is at
first formed by a solid column of cells which later is tunnelled so as
to form a tube.
The Miillerian duct has a mesentery, by which it is fastened to the
Wolffian body. After the disappearance of that body it springs from
the posterior abdominal wall; still later from the mesoarium (Fig. 9),
until, finally, in the fully-developed body we find it as part of the
broad ligament of the uterus.
In the male the Miillerian ducts soon disappear, leaving as rem-
nants the hydatid of Morgagni on the epididymis and the vesicula
FIG. 19.
Transverse Section through the upper end of the Wolffian Body of the Etnbryo of a Rahbit of
fourteen days (enlarged 114 times): wg, Wolffian duct; m, connection between a tubule
of the Wolffian body with a Malpighian body : t, entrance to the Miillerian duct (later the
abdominal ostium of the Fallopian tube) ; gg', mesentery of the Wolffian body, containing
a glandular tubule; IV, surface of the liver; hb, posterior abdominal wall; mg, lateral part
of the Miillerian duct (Kolliker).
prostatica (sinus copularis, or male uterus). In the female they form
the Fallopian tubes, the uterus, and the vagina.
The Fallopian Tubes. The Fallopian tubes are formed of that
part of the Miillerian ducts which lies above the round ligament of
the uterus (the inguinal ligament of the- Wolffian body, Fig. 4).
The cells of the wall form the fibrous, muscular, and mucous coat of
the fully-developed tube, and fringes grow out around the abdominal
opening, forming the fimbrice. The duct follows the ovary in its
descent, and comes to lie above and in front of that organ, running
from the upper corner of the uterus to the wall of the pelvis.
DEVELOPMENT OF THE FEMALE GENITALS.
31
The Uterus and the Vagina. The part of the Mullerian ducts
below the round ligament forms, together with the lower ends of the
FIG. 20.
3
/ooi'V*
i !L
A <U
FIG. 21.
Transverse Section of the Genital Cord of the Embryo of a Cow, iy 2 inches long (enlarged 14
times) : 1, from the upper end of the cord (the ducts have been "cut somewhat obliquely) :
2, somewhat lower down ; 3 and 4, from the middle of the cord, showing incomplete and
complete fusion of Miiller's ducts ; 5, from the lower end, showing the two Miillerian
ducts separated ; a, anterior side of genital cord ; p, posterior side ; m, Miiller's ducts ; u-g,
Wolffian duct (Kolliker).
Wolffian ducts, a quadrangular cord with rounded edges, the genital
cord (Fig. 20). The tissue that separates the two Miilleriau ducts is
gradually absorbed until there is one canal instead
of two at the end of the second month. The
genital cord is developed so as to form the uterus
above and the vagina below. While the fusion of
the Mullerian ducts is incomplete, they are yet
separated above, forming the two horns of the
uterus (Fig. 21). About the middle of pregnancy
the uterus forms one sac without horns (Fig. 22).
The Mullerian ducts open into the lower part
of the urachus, that part of the allantois which is
included in the body, and later forms the bladder
(Fig. 23). This lower part, situate below the
openings of the Mullerian and Wolffian ducts, is
called the urogenital sinus (Fig. 2). Originally
this sinus opens into the cloaca (Fig. 24). Later
a septum is formed, dividing the cloaca and thereby
separating the sinus urogenitalis from the rectum,
and the urogenital opening from the anus, and
forming the perineum (Fig. 25). The urogenital
sinus grows much less than the other parts. The
urethra is differentiated as a special organ from the
bladder, with which it heretofore formed one sac called the urachus,
and the vagina is undergoing a great development. Thus the change
Ovaries. Tubes, and
Uterus of Human
Embryo from the
tenth "week, 26 mm
long: 1, natural size
2, enlarged 4 times.
a, round ligament
b, rectum(H. Meyer;
32
DISEASES OF WOMEN.
is brought about that the urogenital sinus, which seemed to be a con-
tinuation of the bladder, now appears as the continuation of the vagina,
and forms the vestibule (Fig. 26).
FIG. 22.
Abdominal and Pelvic Viscera of Female Fetus of five months (length from vertex to sole,
19 cm.) : t. tube ; r, round ligament ; v, bladder ; u, umbilical artery ; ur, urachus ; c, caecum ;
pv, vermiform appendix (Kolliker).
In the fifth and sixth months the vagina is separated from the
uterus by the formation of a ring (Fig. 26, 3), which finally becomes
the vaginal portion.
FIG. 23.
FIG. 24.
FIG. 25.
FIG. 23. all, allantois, which becomes the bladder: r, rectum ; m, Muller's duct, which later is
transformed into the vagina; a, indentation of the skin, which forms the anus (Schroeder).
FIG. 24. cl, cloaca ; all, allantois; m, Muller's duct ; r, rectum (Schroeder).
FIG. 25. su, urogenital sinus ; r. rectum, separated from the former by the perineum ; v,
vagina (lower part of Muller's duct) ; 6, bladder ; , urethra (Schroeder).
About the same time the cervix is being distinguished from the
DEVELOPMENT OF THE FEMALE GENITALS. 33
body of the uterus by the formation of transverse folds on its mucous
membrane.
In the new-born child the cervix is nearly twice as long as the
body of the uterus, and its walls are much thicker. The anterior
and posterior surfaces of the body have longitudinal folds, and in
either edge is found another longitudinal ridge from which start to
both sides fine transverse folds, ending at the longitudinal folds of
the surfaces.. They are a continuation of the transverse folds of the
cervix. Later in life all these folds disappear from the cavity of the
body of the uterus, while those in the cervix remain.
During the first ten or twelve years of the child's life the uterus
changes very little, even in size, but at the approach of menstruation
the organ undergoes a great development ; and this increase in size
FIG. 26.
V (I
*J
Urogenital Sinus and its Appendages, from Human Embryos (life-size) : 1, from a three-
months' fetus ; 2, from a four-months' ; 3, from a six-months' ; 6, bladder ; h, urethra ; ug,
urogenital sinus ; g, genital canal (common rudiment of vagina and uterus) ; s, vagina ;
M, uterus (Kolliker).
continues until the rest of the body has attained the limit of its
growth.
After the differentiation between the uterus and the vagina, about
the middle of pregnancy, the vagina becomes much wider, and its
columns and rugae make their appearance.
The Hymen. The hymen is formed in the fifth month by a devel-
opment of the posterior wall of the vagina.
THE'VUI,VA.
We have seen that originally the urogenital and the digestive tract
open into one common cavity called the cloaca. Toward the end of
the first month the cloaca opens on the surface of the body by a slit
called the cloacal opening. In front of this opening there appears in
the sixth week a protuberance called the genital tubercle, which soon
thereafter is surrounded by two lateral folds called the genital folds.
The genital tubercle grows, and toward the end of the second month
34
DISEASES OF WOMEN.
there is formed a groove on its lower surface which extends to the
cloacal opening, and is called the genital furrow (Fig. 27).
So far, the organs are identical in both sexes, and they cannot be
distinguished before the tenth week.
The genital tubercle becomes the
clitoris, the genital folds form the
labia majora, the edges of the geni-
tal furrow are developed into the
labia minora, a fold of which later
surrounds the clitoris, forming its
prepuce.
In the tenth week the separation
between the rectum and the uro-
genital sinus is consummated. The
genital folds grow together at their
posterior end, forming a perineum,
which unites with the partition be-
tween the urogenital sinus and the
rectum. While at first the two
canals are in close contact, in the
fourth month there is a well-formed
perineal body between them.
In the male the genital tubercle
forms the penis ; the edges of the
genital furrow grow together, form-
ing the urethra; and the genital
folds form the scrotum and peri-
neum. The line of coalescence is
elevated above the surroundings,
forming the raphe, which extends
from the anus to the meatus urin-
Development of the External Sexual Organs
in the Male and the Female from the in-
different type : A, the external sexual or-
gans in an embryo of about nine \veeks,
in which external sexual distinction is
not yet established, and the cloaca still
exists; B, the same in an embryo some-
what more advanced, and in which, with-
out marked sexual distinction, the anus
is now separated from the urogenital
aperture; C, the same in an embryo of
about ten weeks, showing the female
type ; D, the same in a male embryo some-
what more advanced ; pc, common blas-
tema of penis and clitoris or genital tuber-
cle (to the right of these letters in Fig. A
is seen the umbilical cord) ; p, penis ; c,
clitoris ; d, cloacal opening ; ug. urogenital
opening ; a, anus ; to, cutaneous elevation
which becomes the labia or the scrotum,
genital folds ; I, labium ; , scrotum ; co,
caudal or coccygeal elevation (Ecker).
arus.
In the open condition, which continues until the eleventh or twelfth
week, the external genital parts are alike in both sexes, and resemble
very much the advanced female organs.
PART II.
ANATOMY. 1
Division. The genitals are divided into two groups : the external
genitals, which are organs of copulation ; and the internal, which are
organs of reproduction. To the external genitals belong the mons
Veneris, the vulva, and the vagina; to the internal, the uterus, the
Fallopian tubes, and the ovaries.
THE MONS VENERIS.
The mons Yeneris (Venus' mount) is the lowest part of the
anterior abdominal wall, and the only part of the genitals that is
visible when the woman stands on her feet. It has somewhat the
shape of a trapezoid, and is limited above by a transverse sulcus that
separates it from the hypogastric region, on the sides by the inguinal
folds, and below it is continuous with the labia majora. It lies in
front of the pubic bones and the lower end of the abdominal muscles.
It has a convex surface, and falls gently off toward the surrounding
parts. It consists of skin, adipose tissue, with many interwoven
fibrous and elastic bands, and part of the common superficial fascia.
It is rich in nervous fibrils. The skin is coarse, has many sebaceous
glands, and is covered by a growth of coarse hair, which is limited by
a straight or convex upper line (Fig. 28), and does not extend up to
the umbilicus, as in man. It is in most women curly, and darker
than the hair of the head. This growth appears about puberty.
Function. During copulation these hairs come in contact with the
corresponding growth of the other sex, and by the irritation thus
1 Those who wish further information than that warranted by the limits of this
work are referred to the excellent articles by Henry C. Coe in the System of Gyne-
cology, and Ambrose L. Kannev, Am. Jour. Obstetrics, March, April, May, June,
1883.
My own special investigations on anatomical questions are found incorporated in
the following papers: " Gastro-elytrotomy," N. Y. Med. Jour., Oct. and Nov., 1S7S;
"The Obstetric Treatment of the Perineum," Am. Jour. Obsl., April, 1880; "Rest
after Delivery," ibid., Oct., 1880; "Laceration of the Cervix Uteri," Archives of
Medicine, Oct., 1881 ; " Additional Remarks on Gastro-elytrotomy, Am. Jour. Obat..
Jan., 1883; "Gartner's Canals," N. Y. Med. Jour., March 31, 1883; and "The Im-
proved Csesarean Section," Am. Jour. Med. Sciences, May, 1888.
35
36
DISEASES OF WOMEN.
FIG. 28.
caused in the nerves at their root give a pleasurable sensation. The
vessels and nerves come from the same sources as those of the vulva
(see below).
THE VULVA.
The vulva (Fig. 28) forms and surrounds the entrance to the genital
canal.
The following organs compose it : The labia majora, with the four-
chette; the labia miuora, with the
clitoris; the vestibule, with the bulbs;
the fossa navicularis; and the vulvo-
vaginal glands.
The labia majora (larger lips, Fig.
28, 1) are two prominent ridges, one
on either side of the median line. A
transverse incision shows a triangular
cut surface. They are situated in front
of the descending ramus of the pubes
and the ascending ramus of the
ischium. The outer surface is convex,
of darker color than the rest of the
skin, covered with a continuation of
the hair on the mons Veneris, and has
numerous and large sebaceous and
sudoriferous glands. The inner sur-
face is rose-colored, and forms a transi-
tion from skin to mucous membrane,
having the same glands as the outer
surface, and even a few downy hairs.
The place where they unite anteriorly
is called the anterior commissure, and
the place where they unite behind is
called the posterior commissure. Here
the tissue becomes very thin by the
disappearance of the fat which forms
a great part of the labia majora. Thus
a thin fold is formed called the four-
chette. Exceptionally, the fourchette is a continuation of the labia
minora. Its lower surface consists of skin which has a dark color,
similar to that of the external surface of the labia, while its upper
surface is pink, and looks like mucous membrane. In the adult nul-
liparous woman the lower edges of the labia majora are in contact,
cover all the other parts of the vulva, and form a line running in an
antero-posterior direction and called rima pudendL In the new-born
child, in whom the labia majora are incompletely developed, the labia
Virginal Vulva: 1, labia majora; 2,
fourchette;" 3, labia minora; 4, glans
clitoridis ; 5, meatus urinarius ; 6, ves-
tibule ; 7, entrance to the vagina ; 8,
hymen ; 9, orifice of Bartholin's
gland; 10, anterior commissure of
labia majora ; 11, anus; 12, blind re-
cess; 13, fossa navicularis; 14, body
of clitoris (modified from Tarnier).
ANATOMY. 37
miuora protrude between them ; and when by childbirth or age the
labia majora become flaccid and gape, the labia minora, the entrance
to the vagina, and even part of that canal itself, become visible.
The structure of the labia majora is similar to that of the rnons
Veneris, but presents some peculiar features. Immediately under
the skin forming the outer surface is found a layer of unstriped mus-
cular fibres, which has been called ivoman's dartos. Under the dartos
is found a layer of adipose and connective tissue, and under that,
again, a pear-shaped sac called Broods pouch, or the pudendal sac,
attached with its mouth to the external inguinal ring, and extending
with its broad part to the perineum, with the superficial fascia of
which it coalesces. This pouch is composed of elastic fibres, and
contains connective tissue and fat. Occasionally the prolongation of
the peritoneum called the canal of Nuck, which accompanies the
round ligament of the uterus, is found in it.
Function. The labia majora protect the deeper parts, lead the
male organ to them, and serve as buffers during coition.
The Labia Minora (small lips) or Nymphcc. These are two small
folds of skin (Fig. 28, 3) of the same dark color as the outside of the
labia majora and the fourchette. They present a triangular surface
when cut at right angles, having an outer and an inner free surface
and a lower edge. At the anterior end they separate into two layers,
the lower layer fastening itself to the lower surface of the glans cli-
toridis, forming its frenulum, and the upper passing above the clitoris,
forming its prepuce. The extension backward of the labia minora varies
very much. In some women they go back to the middle line, so as to
form a complete ring inside of that formed by the labia majora. In
others they do not even reach the level of the meatus urinarius. In
most women they extend back about halfway between the clitoris and
the posterior commissure. At the base of the inside is a more or less
well-marked whitish line, which forms the limit between the skin and
the mucous membrane. Their length from the base to the free edge
varies likewise very much. In all the women of the Bushmen in South
Africa and in some of the Hottentot women they hang halfway do\vn
to the knees, forming the so-called Hottentot apron (Fig. 29).
The labia minora are covered with several layers of epidermic
cells. Beneath the epidermis they are composed of connective tissue,
elastic fibres, and smooth muscular fibres, and contain large venous
plexuses. They have no hairs nor fat, but numerous sebaceous
glands and papillae containing bulb-shaped terminal organs of nerves.
Function. Their physiological significance seems to be to ensure
more perfect adaptation and to act as an irritant for the nerves of the
male member at the same time that their own nerves are acted on.
The Clitoris. This corresponds to the penis in the male, but the
urethra and the corpus spongiosum are separated from it. It is a
38 DISEASES OF WOMEN.
small cylindrical body about an inch long, placed in the median line,
below the anterior commissure, and running in an antero-posterior
direction. It is divided into the glans, the body, and the crura.
The glans (Fig. 28, 4) is a roundish or pointed tubercle which forms
the end of the clitoris. It is the only part of it that is visible, and
even that in many women only on pulling the prepuce back. It is cov-
ered with mucous membrane, and has a prepuce and frenulum formed
by the labia minora. The body (Fig. 28, 14) is surrounded by a
fibrous sheath, and consists of two corpora cavernosa separated by
an incomplete pectiniform septum. These corpora cavernosa consist
of fibrous trabeculae, elastic fibres, unstriped muscular fibres, and
venous plexuses, with numerous anastomoses. The body is attached to
the anterior surface of the symphysis pubis by the suspensory liga-
ment. Arrived at the pubic arch, the body separates into two ci'ura
(Fig. 30), small fibrous cylinders attached to the rami of the pubes
FIG. 30.
Front View of the Perineal Septum, showing entire clitoris : 1, glans ; 2, suspensory ligament ;
3, crura of clitoris; 4, subpubic ligament; 5, dorsal vein of clitoris; 6, perineal septum
(Savage's name for the deep perineal fascia or triangular ligament) ; 7, superficial trans-
verse muscle ; u, meatus urinarius ; v, vagina ; P, site of perineal body (Savage).
and the ischium. They are covered by the erector clitoridis muscle,
which has its origin on the tuberosity of the ischium and is inserted
on the crura, where they unite.
Blood-vessels. The clitoris is an erectile organ, with helicine (spi-
ral) arteries and numerous anastomosing veins. It receives the two
end branches of the internal pudic artery, the dorsal artery, running
on the upper surface, and the artery of ike corpus cavernosum in the
depth of that body. The veins go to the dorsal vein, running in the
middle line between the two arteries, and ending in the pudic plexus,
ANATOMY. 39
which surrounds the upper part of the urethra. Those of the glans
communicate with the bulbus vaginae.
The lymphatics go to the superficial inguinal glands.
Nerves. The clitoris has a rich nerve-supply (Fig. 31) from the
dorsal nerve of the clitoris, a branch of the pudic nerve, and from the
sympathetic, which form a kind of nervous sheath round the glans,
with a peculiar kind of end-bulbs called genital corpuscles.
Function. The clitoris is the chief seat of sexual excitement in
women, and therefore often the object of masturbation. During
coition it is enlarged, arched, and the glans is pressed against the
dorsurn penis.
The vestibule (Fig. 28, 6) is the triangular space between the clit-
oris, the labia minora, and the entrance to the vagina. It corre-
sponds to the urogenital sinus of the embryo. In the middle line we
have the meatus urinarius, which in most women forms a small isos-
celes triangle, with the base turned back toward the vaginal entrance,
from which it is about a quarter of an inch distant, while the distance
from the clitoris is about three times as long. On either side of this
opening, just inside of the labia minora, is a deep blind recess (Fig.
28, 12). As these recesses are always plainly visible, and the urethral
opening sometimes does not appear, the former become valuable land-
marks in catheterizatiou by eyesight. By placing the catheter just
midway between the two blind sacs we cannot miss the urethra. In
catheterization under cover the tip of the forefinger is introduced into
the vagina, the bulb toward the urethra ; the catheter is slid along
the median line of the finger until it reaches the vestibule, and then
raised a quarter of an inch.
There are many other smaller depressions, both in the recesses and
in other parts of the vestibule, which are the openings of compound
racemose glands (glandulce vestibulares minores] that secrete a mucous
fluid. Sebaceous glands are absent.
The vestibulo-vaginal bulbs (Fig. 32) are two leech-shaped organs,
one on either side of the vestibule and the entrance to the vagina.
Together they are equivalent to the bulb of the urethra in the male.
The posterior end is round, and reaches back toward the posterior part
of the vaginal orifice, where it is in contact with the vulvo-vaginal
gland, and partly covers it. The anterior end is thinner, and nearly
reaches the clitoris. It lies under the mucous membrane and the
superficial fascia of the perineum, and inside of the sphincter vaginae
muscle. It consists of a fibrous sheath, and inside of that numerous
veins from the internal pudic, complicated venous plexuses, some
nerves, mostly belonging to the sympathetic system, unstriped mus-
cular fibres, and connective tissue. The veins have numerous com-
munications with those of the surrounding parts. Near the anterior
end of the bulbs they go from one side to another, uniting the two
40 DISEASES OF WOMEN.
both behind and in front of the meatus urinarius, forming the pars
intermedia, and from here they communicate with the corpora cav-
ernosa of the clitoris.
The fossa navicularis is that part of the vulva situated between the
vaginal entrance in front and the fourchette behind, and limited on
the sides by the labia majora and above by the perineal body. It
FIG. 32.
Front View of the External Erectile Organs : a, vestibule- vaginal bulb ; 6, sphincter vaginae
muscle; ce, pars intermedia; /, glans clitoridis; g, connecting veins; h, dorsal vein of
the clitoris; k, veins passing behind the pubes; I, obturator vein (Kobelt).
The bulbs are over-distended with injection-fluid and reach too far back.
does not exist as a hollow when the labia majora are in contact. It
is first formed, and gets its boat-shape when they are separated from
each other. On stretching them from side to side we see the pos-
terior commissure advance until it reaches the level of the posterior
border of the entrance to the vagina. Thus a fold and a hollow are
formed. The fold is the fourchette ; the hollow is the fossa navicularis.
In virgins the fourchette projects a little forward, even without
stretching, but in women who have had frequent intercourse it becomes
so lax that the projection is lost or much diminished. During child-
birth it is often torn. The lining membrane of this fossa seems to
make a transition from skin to mucous membrane.
Function. The vestibule and fossa navicularis form together one
cavity, which, lying deeper (i. e. higher up in the erect posture) than
the surroundings, and being coniform, in connection with the larger
space formed by the labia majora, lead the entering member of copu-
lation to the entrance of the vagina.
The vulvo-vaginal glands, or Bartholin's glands (Fig. 33, 6), are
two small oval bodies, of the size of a beau to that of an almond, situ-
ated one on either side of the entrance to the vagina close' up to the
posterior end of the vestibulo-vaginal bulb, in front of the superficial
FIG. 31.
The Nerves of the Pelvis : A, abdominal aorta ; B. lumbar vertebrae with intervertebral disks .
C, the right portion of the sacrum sawn after removal of os innominatum ; D, ureter; E,
pyriformis muscle cut at its exit from the pelvic cavity ; F, the curve of the rectum, cor-
responding to the anterior surface of the sacrum ; H, virginal uterus feebly developed ;
K, right ovary displaced somewhat upward; L. bladder; M, levator ani muscle, cut in
part: N, ischio-cavernosus muscle; O, corpus cavernosum clitoridis, joining on the other
side the clitoris, covered with nerve-filaments: F, symphysis pubis (the whole body
being inclined forward, it has become horizontal); T, fimbriated end of Fallopian tube;
1, Lumbar nervea, passing out of the intervertebral foramina to form the lumbar plexus ; the
lower lumbar and the upper sacral nerves joining to form the sacral plexus in front of the
pyriformis muscle ; 3, gluteal nerves cut ; the pudic nerve springing by several roots from
the plexus formed by the lower sacral nerves; 5, fine twigs passing from the pudic nerve
to the ischio-cavernosus muscle; the main trunk goes under the symphyris, and ends as
the dorsal nerve of the clitoris (21) ; 6, branches of communication which carry sympathetic
twigs to the spinal nerves and spinal twigs to the hypogastric plexus of the sympathetic;
7, principal trunk of the sympathetic in front of the lumbar vertebra; 8, continuation of
the sympathetic in front of the sacrum ; 9, aortic plexus ; 10, hemorrhoidnl plexus, following
the arteries of the same name ; 11. superior hypogastric plexus, or ttio-hypogastric plexus,
which receives many spinal and sympathetic branches ; 12, inferior hypnqastric plexus, com-
municating with 13, anterior sacral plexus, made up of spinal and sympathetic branches ;
14, from the many ganglia placed in this plexus it has a network appearance ; lo, inferior
rectal twigs, which pass down even to the sphincter, where they form a network covered
by the levator ani ; 16, vaginal plexus; 17. that part of the inferior hypogastric plexus in
the shape of a fine network at the upper end of the vagina gives branches to the bladder,
the Fallopian tube, and the clitoris; 18. nerve-twigs which run on the side wall of the
uterus (giving branches to it) upward to the Fallopian tube and ovary, where they join the
nerves following the ovarian artery, which correspond to the spermatic plexus in man;
19, vesical nerves; 20, uterine plexus; 21, dorsal nerve of clitoris, which joins with the cav-
ernous plexus of the clitoris from the sympathetic to the glans clitoridis (Rydygier).
ANATOMY.
41
transversus perimei muscle, and between the posterior third of the
side of the vaginal entrance and the erector clitoridis muscle. They
lie between the two layers of the deep
perineal fascia, or sometimes under (/. e.,
above in the erect posture) the deep layer. 1
They are compound racemose glands, se-
creting a mucous fluid, just like the
smaller glands of the vestibule, and are
sometimes called glandulce vestibulares
majores. Their excretory duct opens with
a minute aperture just in front and out-
side of the hymen, on the inside of the
labia majora, or labia minora if these ex-
tend so far back. They contribute to the
lubrication of the vulva, especially when
pressed upon by the surrounding muscles
during sexual excitement.
In the erect posture the vulva is hidden
between the thighs. When not artificially
spread out, the two lateral halves are in
contact in the normal adult woman.
The vulva receives its arteries from the
superficial perineal branch of the internal
pudic and the external pudic arteries com-
ing from the femoral. The veins accom-
pany the arteries. On account of the free
communications between themselves and with those of the pelvis
even a small wound of the vulva, especially when during pregnancy
they swell, may cause dangerous or even fatal venous hemorrhage.
The lymphatics open into the superficial inguinal glands, which are
in communication with the deep inguinal glands and external iliac
glands. The nerves come from the superficial perinea! nerve, which
is a branch of the pudic, the inferior pudendal nerve, which is a
branch of the small sciatic nerve, and from the pelvic, or inferior
hypogastric, plexus of the sympathetic nerve.
Special features of the vessels and nerves of the clitoris and the bulbs
of the vestibule have been treated under the descriptions of those organs.
THE VAGINA.
Until within a few years all descriptions and drawings of the
vagina gave a very erroneous idea of this organ. It is a slit in the
pelvic floor (Fig. 34, A), having a slanting direction from above and
1 Ambrose L. Ranney found in every case Bartholin's glands lying posterior to
triangular ligament ("The Female Perineum," N. Y. Med. Jour., July-August,
1882, vol. xxxvi. p. 45).
Vulvo-vaginal Gland. Thelabium
majus and minus, the sphincter
vaginae muscle, and the bulb
have been partly removed on the
right side in order to expose the
gland : A A', section of labium
majus and minus; B, gland; C,
excretory duct; (7, stylet intro-
duced into the duct ; D, glandu-
lar end of duct ; E, free end of
duct : F, section of bulb ; G, as-
cending ramus of ischium (Hu-
guier).
42
DISEASES OF WOMEN.
behind downward and forward, at an angle of 60 with the horizon,
situated between the bladder and the urethra in front and the rectum
FIG. 34.
Sagittal Section of Pelvis (Waldeyer) : a, symphysis pubis ; 6, bladder ; c, small intestine ; d,
large intestine; e, anus ; /, perineal oody ; g, vulva ; h, vagina ; i, uterus.
behind, and extending from the vulva below to the uterus above. It
has a slight curve with the concavity forward, corresponding to the
shape of the male member when in erection a curve which is much
increased during parturition, when the child rounds the symphysis
pubis. When distended it has the shape of a truncated cone with
the apex at the vulva and the base at the uterus ; but when not dis-
tended it is folded together in such a way that the slit on a cross-
section has somewhat the shape of the letter H, the anterior and
posterior wall being in contact in the middle, and each side wall being
folded against itself at the ends (Fig. 35, va). At the lower end it
dips into the vulva, forming the hymen, in the same way as at the
upper end the uterus dips into the vagina, forming the vaginal por-
tion. At the upper end it forms a cup, adapting itself closely to the
vaginal portion of the uterus, as does the cup to the ball of the toy
called "bilboquet" or "cup and ball." The upper, broader end is
called the roof or fornix, and in its adaptation to the vaginal portion
it forms a shallow pouch in front and a much deeper behind, united by
side pouches, forming an even transition from one to the other. The
lower end, when we remove the hymen (which will be considered later),
forms a circular opening, surrounded by the constrictor vaginae muscle.
ANATOMY.
43
In olden times authors, just as the laity often do yet, comprised
the whole parturient canal under the term " womb " or uterus. Now
the profession has learned to distinguish the womb from the vagina,
but the latter is yet in obstetrical and gynecological language fre-
quently confounded with the vulva. We must, therefore, expressly
call attention to the limits between these two parts of the parturient
canal, and the difference between the two openings at its beginning.
The entrance to the vulva is formed by the rima pudendi, a slit in
the skin running in a straight line, in
an antero-posterior direction ; the en-
trance to the vagina lies an inch or two
deeper, is circular, surrounded by mu-
cous membrane and muscles, and is
marked by the hymen or its remnants.
The size of the vagina varies enor-
mously in different individuals and dif-
ferent conditions. In the adult virgin
the anterior wall is about 2 inches, the
posterior about 2J inches long, and the
width near the upper end about 1J
inches. By coition, and especially child-
birth, these dimensions are much in-
creased. During copulation it has the
size of the body that distends it. Dur-
ing pregnancy great proliferation of tis-
sue, swelling of veins, and serous infil-
tration take place, so that at the time
of delivery the canal not only is wide
enough to let the child pass, but be-
comes so elongated that it can accom-
pany the child far beyond the limits of the outlet of the bony pelvis.
The vagina is composed (Figs. 36, 37) of an outer sheath of con-
nective tissue, containing fat, a muscular layer with longitudinal and
transverse fibres, and a mucous membrane with flat epithelium. The
muscular fibres can be followed to the posterior surface of the pubic
bone and the anterior surface of the sacro-iliac articulation (Rouget).
In the perineal region the muscle-fibres reach the bone between the
two layers of the triangular ligament. The mucous membrane forms
on the anterior wall a longitudinal ridge in or near the median line,
from which folds, so-called rugce, go out to the sides, like the teeth
of a comb; a similar but less distinct formation is found on the
posterior wall. They are called the anterior and posterior columns.
The anterior often ends below in a round protuberance, called the
tubercle of the vagina, which is situated immediately behind the
meatus urinarius. Often the anterior column is divided by a lou-
Horizontal Section of the Soft Parts
in the Inferior Strait of the Pelvis
(Henle) : Va, vagina : Ur, urethra ;
R, rectum ; L, levator ani.
44
DISEASES OF WOMEN.
gitudinal furrow into two halves. The rugse are covered witli micro-
scopical papillae. The columns and the rugae disappear in the upper
part of the vagina. They are organs of sexual excitement, and con-
FIG. 36.
FIG. 36. Longitudinal Section of the Posterior Wall of the Vagina of a girl twenty-four years
old.
FIG. 37. Transverse Section of the Same (Breisky) : a, mucous membrane ; b, muscular layer,
with a, circular, and ^, longitudinal fibres; c, fibrous layer containing adipose tissue.
tribute probably to the enlargement of the vagina during pregnancy and
childbirth. After the latter they are much less prominent or disappear
entirely. The presence of glands in the mucous membrane is disputed. 1
The vagina possesses the power of absorption. This faculty is in-
creased in pregnant, puerperal, and feverish women. 2
The vagina has a rich vascular supply. The arteries (Fig. 38) come
from the vaginal, the uterine, the vesical, and the internal pudic, which
all are branches of the anterior division of the internal iliac.
1 In a woman in the fifth month of pregnancy I have seen the whole vagina red
and full of openings like a tonsil, out of which a solid yellowish discharge could be
pressed. I do not see what these openings could have been except entrances to
glandular follicles.
2 Coen and Levi : Centralblatt fiir Gynakologie, 1894, No. 49, p. 1261.
o
5 3 ">,2 x 5 v " ' /-,
^.S*! 5'^5 P
^lll^H-
5s's7l
i-H-^ll^B
ANATOMY.
45
The veins form a dense network (Fig. 39), and communicate with
those of the vulva, the bladder, the rectum, the uterus, and the broad
ligament. Finally, the blood is carried to the internal iliac veins.
The lymphatics from the lower fourth go to the superficial inguinal
. 39.
The Venous Plexuses of the Vagina and the Vulva, as seen in mesial section (Savage) : B,
bladder partially inflated ; b, ureter ; V. vagina ; P, section of pubes ; R, rectum ; C, clitoris ;
1, bulb; 2, its urethral process; 3, lower efferent veins ; 4, dorsal vein of the clitoris; 5,
urethral venous plexus: 6, commencement of vaginal venous plexus; 7, 8, 9, 10, sciatic
and gluteal veins; il, uterine veins; 12, obturator vein; 13, internal iliac vein; o, pyri-
forrnis muscle ; b, greater sacro-sciatic ligament ; c, levator ani and coccygeus muscles ;
d, os coccygis ; e, suspensory ligament of clitoris ; F, vulvo-vaginal gland ; ggg roots of
sacral plexus of nerves.
glands, like those from the vulva ; those from the upper three-fourths
go to the internal iliac glands, and perhaps the obturator glands,
which again communicate with the inguinal glands.
The nerves (Fig. 31) come from the sympathetic, and form a vrtf/inal
plexus on either side of the vagina, communicating with the inferior
hypogastric. Their final fibrillse terminate in end-bulbs.
Function. The vagina has a double physiological function. Dur-
ing copulation it receives the penis, and during parturition it helps
move the child forward along the curve of Cams. The vagina can
become distended independently of the introduction of any distending
solid body or air-pressure, which works when the patient is examined
in the knee-chest or Sims's position. This must be due to the con-
traction of the muscular fibres that are attached to the pelvic bones.
I have often found this ballooning during examinations with a single
46
DISEASES OF WOMEN.
finger with the patient lying on her back, and in nullipane with a
tight vaginal entrance. The same applies to the rectum.
THE HYMEN.
The hymen begins, as we have seen in the history of the develop-
ment, as a protuberance from the posterior wall of the vagina. It is
a fold of the mucous membrane containing elastic fibres, blood-vessels,
lymph -vessels, nerves, and sometimes smooth muscular fibres. It
closes the vagina more or less completely, and varies much in shape,
but in most cases it is more developed behind than in front. The
most common shape, especially in childhood, is that of a strip of
tissue bent so as to form two lateral halves touching one another in a
straight middle line (Fig. 40). In other cases it forms a ring with a
FIG. 41.
FIG. 40.
Hymen with Linear Opening (Tardieu).
Annular Hymen (Tardieu).
round opening (Fig. 41). In others, again, it has the shape of a
crescent (Fig. 42). Often the border is indented (Fig. 43), a form
that is easily distinguished from a lacerated hymen by the softness of
the tissues, the absence of cicatrices, the round contour of the tongues,
and, above all, by the decided resistance that is felt in trying to enter
the finger. Sometimes the hymen is only represented by a low circu-
lar or crescentic ridge. The upper surface shows a continuation of
the ruga? of the vagina, of which it only forms the lowest, thinned
part, somewhat in the manner of the relation between the fourchette
and the posterior end of the labia majora.
The hymen is, as a rule, torn by the first successful coition, into
two or three, rarely a greater number of flaps, but there is no loss
of substance. By putting the flaps in contact we can reproduce its
original shape. In childbirth, on the contrary, it suffers so much
ANATOMY.
47
that only three or four roundish prominences are left of it, the
so-called earunoulce myrtiformes.
In a strictly intact vulva considerable resistance is felt, and pain is
caused by the examining finger, be it at the opening of the hymen or
at its base, where it joins the rest of the vagina. An easy accessi-
FIQ. 42.
FIG. 43.
Crescent-shaped Hymen (Tardieu).
Indented Hymen.
bility of the vagina without laceration of the hymen is due to a
gradual dilatation by a comparatively small body. It must be borne
in mind that this not always means masturbation. It may as well be
the result of careful gynecological treatment, while a careless examina-
tion may rupture the membrane, producing a result similar to that
of coition.
THE UTERUS.
The uterus (Fig. 44) is a hollow body with thick muscular walls
situated between the vagina below and the small intestines above, the
bladder in front, and the rectum behind. It has somewhat the shape
of a flattened pear, and may be divided into two parts, called the neck,
or cervix and the body, or corpus. A subdivision of the neck is the
vaginal portion (Fig. 44, A, a), which dips down into the vagina ; and
a subdivision of the body is the fundus (Fig. 44, C, /), which lies
above the entrance of the Fallopian tubes. The neck is cylindrical
or rather barrel-shaped, being thicker in the middle than at the ends,
and the line of demarkation between it and the body is marked out-
side, on its anterior surface, by the fold formed by the peritoneum
when from the uterus it passes over on the bladder.
48
DISEASES OF WOMEN.
The vaginal portion or infravaginal part of the cervix forms a
rounded cone nearly one-half inch high, on the top of which is
found a transverse slit measuring about one-quarter of an inch from
side to side, and called the os externum, os tincce (i. e. the mouth of a
tench), or simply the os uteri. If we imagine this opening prolonged
so as to divide the cervical portion into two halves, the anterior is
called the anterior lip, and the posterior the posterior lip a condi-
tion that often is produced by childbirth, but then is pathological.
FIG. 44.
Virgin Uterus, natural size (Sappey) : A, front view : the appendages and the vagina are cut
away ; a, vaginal portion of cervix ; b, isthmus ; c, body.
B, the same in vertical mesial section: a, anterior surface; the letter is placed a little above
the bottom of the vesico-uterine pouch.
C, the same with cavity exposed by coronal section : e, qs externum ; d, os internum ; /,
fundus, the letter placed just above utenne opening of Fallopian tube.
The anterior lip dips lower down than the posterior, but the pouch
formed by the vagina being much deeper behind than in front (Fig.
44, B) the posterior lip goes much higher up, so that it is longer than
the anterior. The vaginal portion is covered with a smooth mucous
membrane with flat epithelium, like that of the vagina.
The supravaginal part of the neck is about f inch long, and is
bound with rather loose connective tissue to the bladder in front, and
on the sides to the mass forming the base of the broad ligaments of
the uterus, and called the parametrium. Behind, it is free, being
separated from the rectum by a part of the peritoneal cavity called
Douglas's pouch.
The body of the uterus, in the more restricted sense of the word,
is triangular. It forms a flattened truncated cone, with the end
turned down to the cervix and the base up to the fundus. The sides
ANATOMY. 49
are a little convex (Fig. 44, A). The anterior surface is convex from
side to side, and straight or slightly concave from above downward.
The posterior surface is strongly convex in all directions. The fun-
dus is moderately convex from side to side, and much more so from
the anterior to the posterior surface (Fig. 44, B and (7).
The interior of the womb contains a cavity (Fig. 44, B and C), the
anterior and posterior walls of which are in contact. It is 2 inches long
in the nulliparous woman, and is divided into three parts, the cervical
canal, the isthmus, and the cavity of the body. The cervical canal is
about 1 inch long, is spindle-shaped, and on the anterior and posterior
wall there is found a longitudinal ridge from which branches go out-
ward and upward, separated by deep pouches. The whole formation
is called arbor vitce, palmce plicatce, or plicce palmatce. The isthmus,
or os internum, is the narrowest part of the cavity, nearly cylindrical,
about ^ inch long and -| inch in diameter. The median ridge of the
arbor vitce extends to its upper end. The cavity of the body is tri-
angular, with curved sides bulging into the cavity and smooth sur-
faces. At the two upper angles are found the uterine apertures of
the Fallopian tubes.
The wall is about -| of an inch thick in the thickest parts, which
are the middle of the edges of the body, the middle of the fundus,
and the middle of the cervix. It is thinnest at the entrances to the
Fallopian tubes and at the external os.
The size of the womb increases somewhat by sexual intercourse,
and still more by childbirth. The length measures in virgins 2
to 2^ inches, in nulliparse 2 to 2| inches, in multipart 2^ to 3
inches. The width on the level of the Fallopian tubes, the broadest
part, is in virgins 1^ to If, in nulliparse the same, in multipart ]|- to
2 inches. The thickness is about the same in all three classes, varying
from -| of an inch to 1^ inches.
The cervix is about 1^ inches from side to side in the middle, and
a little less at the ends.
The body is only a little longer than the neck in nulliparee ; in
those who have borne children it becomes three-fifths or two-thirds
of the length of the whole organ.
The wall is composed of three layers a serous, a muscular, and a
mucous. The serous coat is formed by the peritoneum, and does not
cover the anterior surface and the sides of the cervix.
The muscular part of the wall may be divided into three layers,
which become distinct during pregnancy : an outer longitudinal layer,
which sends prolongations into the round and the ovarian ligaments,
the tubes, and the sacro-uterine ligaments ; a middle layer of interlacing
longitudinal and transverse fibres, which is in connection with the
muscular coat of the vagina ; and an internal transverse layer, which
is especially developed in what was formerly the two horns, and near
4
50
DISEASES OF WOMEN.
the internal os, in which latter place it forms a sphincter. It enters
also the folds of the plicae palmatse. The middle layer is the thickest
and contains the vessels.
FIG. 45.
Vertical Section through the Mucous Membrane of the Human Uterus (Turner) : e, columnar
epithelium; the cilia are not represented ; 0,17, utricular glands; ct, interglandular con-
nective tissue ; v,v, blood-vessels ; mm, muscular layer.
The mucous membrane (Fig. 45) lines the whole cavity. In the body
it is thin and intimately connected with the muscular layer, bundles
of the muscles and connective tissue extending from one to the other.
When fresh it is pink. It consists of fine threads of connective tissue
and round or oblong cells (Figs. 46 and 47), and is perforated by numer-
ous tubes, composed of a basement membrane and a layer of ciliated col-
umnar epithelium, and called the utricular glands. They have a general
direction parallel to one another, but are tortuous, and have often two
or three branches in the deeper parts of the mucous membrane. 1
In the cervix the mucous membrane is thicker, is composed of
1 According to Dr. Arthur W. Johnstone of Danville, Ky., the mucous membrane
is an adenoid tissue, like that of the tonsils, the thyroid body, the spleen, the thy-
mus, the lymphatic glands, and the lymph-tissues in the wall of the alimentary
canal. The cells originate as granules in the fibres. They are only found between
the age of puberty and the climacteric (Trans. Brit. Med. <S'oc., June 23, 1886).
ANATOMY.
51
FIG. 46.
Section of the Mucous Membrane of
the Uterus parallel to the surface,
enlarged 150 times (Henle) : 1, 2, 3,
glands (the epithelium has fallen
out from 2) ; 4, blood-vessel.
fibrous connective tissue without adenoid structure, has racemose
glands, and is separated from the mus-
cular layer by a distinct submucous
layer of looser connective tissue. The
epithelium is columnar and ciliated on
the free surface of the body, 1 in the
utricular glands, and on the edges of
the branches of the arbor vitse. In the
depressions between them it is goblet-
shaped, without cilia. In the glands
of the cervix it is cuboidal, without
cilia.
Shape and Position. Opinions as to
the normal shape and position of the
womb differ so much that it has almost
become a confession of faith to say any-
thing about it ; but, since I have made
gynecological examinations for the last
twenty years, and have paid special at-
tention for the last ten years to what
can be seen and felt in regard to the
anatomy of the genitals, I think I may
be able to express an opinion that is not
altogether without foundation in facts, as are so many descriptions and
drawings given of these parts. We have five sources of informa-
tion viz. dissections of dead bodies, sections of frozen bodies,
bimanual palpation of living women, laparotomies, and the devel-
opment of the fetus, all of which methods have some advantages
and some drawbacks ; but by combining them all I think we get
a pretty accurate idea of the true relations. After death, the
body lying on its back, the whole pelvic floor, especially in multip-
arae, is apt to sink, so that the fundus of the uterus comes to lie
considerably deeper than in the living woman, 2 and at the same time
it falls back toward the sacrum. Thus all descriptions based on
autopsies and sections of frozen bodies become unreliable. On the
1 Having stated elsewhere that the epithelium of the body was columnar without
cilia a view shared by such an authority on the microscopical anatomy of the
female genitals as De Sinety (Manuel pratique de Gynecologic, Paris, 1879, p. 239)
and having been told that I was wrong, I addressed Dr. Johnstone on the subject,
who recently has made a special study of the mucous membrane of the uterus. He
answered : " The cause of the difference of opinion is that the epithelium on the free
surface of the corporeal endometrium is shed every twenty-eight days, and the differ-
ent observers have each described a different stage of its regeneration. I have seen it in
all conditions, from a simple round cell up to a fully-developed columnar epithelium,
and in a few instances have seen what looked like cilia. But before they become
perfect the menstrual flow strips off the epithelial coat, and the cycle repeats itself."
2 According to Sappey, it should lie f inch to 1 inch below the superior strait.
52
DISEASES OF WOMEN.
other hand, examinations of the living do not admit of the same
degree of accuracy as those of dead bodies.
FIG. 47.
Fibre of Endometrium, showing different degrees of corpuscular development. Enlarged
3000 times (Johnstone).
The canal of the normal uterus is straight or slightly curved, with
the concavity turned forward (Fig. 49), or S-shaped. The presence
FIG. 48.
Epithelial Cells from the Uterus of a Woman sixty years old. From edge of a plica palmata :
a, ciliated columnar cell (rare): b, plain columnar cell (the majority); c, large goblet
cells. From the deepest part of the valley between two plicae palmatse: d, small goblet
cells. From inner surface of body : e, front view; /, side view, columnar, non-ciliated;
nucleus situated nearer lower or upper end, and containing one or two nucleoli.
of an angle opening anteriorly, or of a considerable curvature forward,
is an abnormal condition called anteflexion, and constitutes, even if
it does not give rise to other symptoms, a considerable hindrance to
conception. Any kind of backward curvature constitutes the abnor-
mal condition called retroflexion. The fundus reaches a little above
ANATOMY.
53
the brim of the pelvis (Fig. 50), and lies a little nearer to the right
side than to the left. When the rectum and bladder are empty, the
longitudinal axis of the womb forms a right or obtuse angle with
that of the vagina. A full bladder will tilt the womb back and press
it up against the sacrum, and a full rectum presses it forward to-
ward the symphysis. The small intestine is regularly found in the
FIG. 49.
Mesial Section of the Pelvis of a Girl seventeen years old, half natural size (Kolliker) : ur,
ureter opening into bladder; u, vesical opening of urethra; d, clitoris; h, hymen.
upper part of the recto-uterine excavation, not in the lowest, narrow
part of it, Douglas's pouch; it is also found in the vesico-uterine
excavation if the bladder contracts in such a way as to form a Y
(Fig. 34), but not if it contracts by apposition of its anterior and
posterior wall, in which case the womb and the bladder lie close up
to each other (Fig. 49).
During pregnancy the uterus increases enormously in size, which
is especially due to the formation of new muscular cells and enormous
increase in size of the old ones.
After the menopause the organ shrinks, the cervical portion forms
a small protuberance or disappears altogether, and the mucous mem-
brane of the body loses nearly all its cells and consists of common
connective tissue (Fig. 51).
DISEASES OF WOMEN.
FIG. 50.
Diagram of a Supposed Mesial Section of the Pelvis of a living woman (Foster-Ranney) : o,
anal canal ; r, rectum ; v, vagina ; c, clitoris ; 6, bladder when collapsed ; u, uterus ; d,
valve of rectum (Houston) ; S, symphysis pubis ; S ', sacrum ; C, coccyx.
FIG. 51.
Endometrium of Woman sixty years old (Johnstoue). ,
The Ligaments of the Uterus. There are eight ligaments (Fig.
ANATOMY.
55
52) which contribute more or less to determine the position and
shape of the uterus : the vesico-uterine in front, the sacro-uterine
behind, the broad and the round at the sides.
FIG. 52.
Diagram of the Ligaments of the Uterus (Hodge).
The vesico-uterine ligaments are two small semilunar folds, one on
either side of the median line formed by the peritoneum, when from
the bladder it passes over to the uterus, on the level of the internal os.
The sacro-uterine ligaments are much larger peritoneal folds,
extending from the anterior surface of the second sacral vertebra to
the uterus on a level with the os internum. Together they form an
oval opening, with the narrow part turned toward the uterus. Their
concave inner edge is turned inward toward the rectum (Fig. 53),
and forms the upper border of Douglas's pouch. They contain
unstriped muscle-fibres, a direct continuation of those of the womb,
and have been called the retractor muscles of the uterus (Luschka).
Besides, they contain loose and fibrous connective tissue. They form,
together with the anterior vaginal wall, an elastic beam on which the
uterus is suspended. 1 They prevent the uterus from being pulled
down in the normal condition beyond the entrance to the vagina.
1 Frank P. Foster, Trans. Am. Gyn. Soc., 1881, voL vi. p. 434.
56 DISEASES OF WOMEN.
Working together with the round ligaments, their shortening produces
anteflexion.
The broad ligaments are two quadrangular folds of the peritoneum,
one on either side, situated between the uterus and the pelvic wall,
and forming a partition in the true pelvis between an anterior and a
posterior pouch. The inner edge is attached to the edge of the
uterus, the outer edge to the wall of the pelvis in a line extending
FIG. 53.
Superior View of the Pelvis and its Organs (Savage) : B, bladder ; U, uterus (drawn down by
loop e) ; F, Fallopian tubes ; O, ovaries ; L, round ligaments ; g, ureter ; a, ovarian vessels,
often prominent under their peritoneal covering.
from a point midway between the sacro-iliac articulation and the
ilio-pectineal eminence, downward and backward, between the great
sacro-sciatic notch and the obturator foramen, to the level of the spine
of the ischium (Fig. 54). The upper edge is formed by the Fallopian
tube inward and the infundibulo-pelvic ligament outward. The
lower edge is attached to the mass of connective tissue lying to the
side of the cervix, and called parametrium or parametric connective
tissue. The upper edge is free ; the three other edges are continuous
with the peritoneal covering of the uterus, the sides and the floor of
the pelvis. It is composed of an anterior and a posterior layer. The
anterior layer covers the round ligament ; the posterior layer contains
an opening, in which the base of the ovary is inserted. Between
these two layers lie loose connective tissue, unstriped muscular fibres,
blood-vessels, lymphatics, and nerves. The muscular fibres are a
continuation of the outer layer of the uterine muscular coat, and form
ANATOMY. 57
a kind of flat muscle (platysma Savage) between the uterus, the
ovaries, and the tubes, from which a bundle goes along the ovarian
artery, up to the vertebral column, called the superior round ligament
{Fig. 55, LS). This whole muscular expansion is capable of producing
FIG. 54.
The Right Wall of the Pelvis (Polk): A, , internal iliac artery; B, uterine artery; C, ovarian
artery; D, course of the ureter, projected on pelvic wall; E, line of pelvic attachment
of the broad ligament of the uterus in a nullipara ; F, line of attachment of the levator
ani, marking the level of the base of the broad ligament.
a kind of erection of the internal genitals, and it is probably also
instrumental in adapting the fimbrise of the tube to the ovary during
ovulation (Fig. 60).
During pregnancy the broad ligaments are dragged upward and
backward by the uterus, so that at full term their base lies on a level
with the ilio-pectineal line, and extends from the ilio-pectiueal emi-
nence to the sacro-iliac articulation. 1 The broad ligaments allow the
uterus to be pushed or bent forward or backward to any extent ; they
allow also an excursion upward and downward of two inches in
either direction, but they check the movement from side to side some-
what ; and when the utero-sacral ligaments are cut or have lost their
1 W. M. Polk, " Landmarks in the Operation of Gastro-elytrotomy," N. Y. Mcd.
Jour., May, 1882, vol. xxxv. pp. 449-454 ; as well as his " Observations upon the
Anatomy of the Female Pelvis," ibid., Dec., 1882, vol. xxxvi. pp. 561-569. These
papers, based upon original investigation on the bodies of pregnant women, contain
most valuable information not to be found anywhere else, to my knowledge.
58
DISEASES OF WOMEN.
elasticity, the broad ligaments, as well as the pelvic connective tissue,
are put on the stretch by pulling the uterus down.
The round ligaments (Fig. 55, LI) are two strings, one on either side,
springing from the anterior surface of the uterus immediately below
and in front of the Fallopian tube, and going in a curve first upward
FIG. 55.
-L8
The vessels of the vagina and the internal genitals in their relation to the superficial muscu-
lar structures (Rouget). The specimen is seen from behind. Vascular system: VP,
vaginal plexus ; PC, cervical plexus ; PU, uterine plexus ; HP, helicine arteries of uterine
body ; h, helicine arteries of hilum of ovary. Muscular system : VP, insertion of the
muscle-bundles of the vagina on the pubes; VS, bundles of the same muscular coat com-
ing from the region of the sacro-iliac articulation ; US, uterine muscle-bundles which
accompany the preceding, and constitute to a great extent the posterior layer of the broad
ligament; UR, recto-uterine or sacro-uterine ligaments; LI, inguinal or pubic round
ligament, spreading over the whole anterior surface of the uterus; LO, ovarian ligament;
.LS', superior or lumbar round ligament, which accompanies and envelops the internal
spermatic, or ovarian vessels; a, muscular bundles coming from the ovarian ligament
(LO), spreading and interlacing with the bundles, b, coining from the superior or lumbar
ligament (LS). in the interior of the ovary, and beyond in the ala vespertilionis, before
they insert themselves on the tube and the fimbriae ; a', bundles starting from the ovary,
which, together with others corning directly from the superior ligament, form the
fimbria ovarica.
and outward, then inward and forward, outside of the bladder, to the
internal inguinal ring, then through the inguinal canal, following its
lowest and outermost angle, and out through the external ring. Here
it breaks up into different strands, ending in the mons Veneris, the
symphysis pubis, and the upper end of the labium majus. Some
strands are given off to the surrounding parts during the passage
through the inguinal canal.
The ligament consists of fibrous connective tissue, unstriped mus-
ANATOMY. 59
cular fibres from the uterus, and striated fibres coming from the
trausversalis muscle and the pubic spine. An artery from the deep
epigastric runs through its centre and anastomoses with one from the
uterus. The artery is accompanied by a vein. The genital branch of
the genito-crural nerve lies in front of the ligament at the external
ring. Other veins and nerves join it from below. At first it lies
under the anterior layer of the broad ligament. When it leaves the
broad ligament it has a peritoneal covering of its own, which, as a rule,
stops at the internal ring in the adult. During fetal life the perito-
neum forms a pouch which accompanies it through the inguinal canal,
and is called the canal of Nuck, and corresponds to the processus
vaginalis in the male. This pouch normally grows together, forming
a fibrous string, but abnormally it may persist and give rise to female
hydrocele, or be found as a sheath of the ligament in Alexander's
operation. (See Retroflexion of Uterus.)
During pregnancy the round ligament becomes finger-thick. It is
only found in women and the higher apes, who occasionally take the
erect position. It contracts when stimulated by electricity like other
muscles. Both ligaments being contracted at the same time they tilt
the fundus uteri forward, and as they contract simultaneously with
the abdominal muscles, they prevent retroversion from being produced
by coughing, lifting, straining at stool, etc. 1
During copulation they produce probably a kind of suction, and by
their intimate connection with the muscular platysma of the broad
ligament, and working together with the superior round ligament, they
cause erection of the inner genital organs. During labor they pull
the fundus forward and downward, and thus give it the most favor-
able direction in relation to the superior strait.
The arteries of the uterus come from three sources : the uterine
artery from the internal iliac ; the ovarian from the aorta ; and the
insignificant artery of the round ligament from the epigastric. The
uterine goes behind the peritoneum on the posterior wall of the
pelvis, down into the parametrium, and forms a loop in front of the
ureter, a short distance ffom the anterior lateral fornix of the vagina
(Fig. 56). (Compare Fig. 54.) Hence it goes up between the two
layers of the broad ligament, following the edge of the uterus to the
corner of the same, where it anastomoses with the ovarian artery. It
sends numerous branches off at right angles to the uterus, where they
anastomose with those from the other side (Fig. 38). At the level
of the internal os such anastomosing branches in front and behind
form the circular artery. The trunk has a very tortuous course, and
the branches are wound like corkscrews, helicine arteries (Fig. 55,
H. P.). These branches have so small a lumen and so thick a nms-
1 J. H. Kellogg of Battle Creek, Mich., Trans. Am. Ass. Obstet. and Oyn., 1889, vol.
ii. p. 266.
60
DISEASES OF WOMEN.
cular coat that in many cases the whole uterus can be cut loose from
the broad ligament without using ligatures or clamps for arresting
hemorrhage.
During pregnancy the uterine artery stays comparatively small, its
calibre equalling that of the ureter, while the ovarian is much thicker.
The uterine veins form a network in the muscular coat, and open
into a conglomeration of veins lying at the edges of the uterus.
From the middle of this plexus the two uterine veins follow the
uterine artery, and carry the blood to the internal iliac vein. At its
upper end this plexus anastomoses with the branches of the ovarian
FIG. 56.
t c
The Uterine Artery in its Relation to the Ureter : a photographic reproduction of a section of
the pelvis, extending from the pectineal eminence above to the lesser sacro-sciatic fora-
men below (Polk). On the right side the broad ligament has been removed : U, uterus,
right side freed of peritoneum ; 0, ovary ; C, base of bladder showing urethral orifice,
the organ having been cut away on a level with the utero-vesical peritoneal fold ; the
dotted line running across its upper edge corresponds to the utero-vaginal junction;
above this, at F, we have the circular artery of the cervix; A, uterine artery ; BB, ureter,
with a probe passing through it ; D, ovarian artery ; E, round ligament, held up to show
the ovary and vessels behind it ; R, rectum.
vein, and below with the vaginal and vesical plexuses. The ureter
passes right through it (Fig. 57). During pregnancy the uterine
veins are enormously enlarged and form the so-called sinuses, large
spaces the walls of which only consist of the internal coat of the
veins, and are intimately bound to the surrounding muscular tissue.
The Lymphatics. The uterus is exceedingly rich in lymphatic
spaces and vessels. They begin in the mucous membrane as open
spaces lined with endothelium, and separating the bundles of con-
nective tissue. In the muscular layer are found similar spaces and
vessels, and they all communicate with a superficial network of ves-
sels in the serous membrane. From the uterus the lymphatics go
ANATOMY.
61
through the broad ligament. Those from the cervix go to the obtu-
rator glands, situated at the inner entrance of the obturator canal and
communicating with the inguinal glands. Those from the body go
to the internal iliac glands, situated between the external and internal
iliac artery, and which, again, send vessels to the sacral glands on the
anterior surface of the sacrum and to the lumbar glands in front of
the lumbar vertebrae. The gland of the isthmus is situated in the
lower inner angle of the broad ligament.
FIG. 57.
The Uterine Veins and the Ureter (Luschka). The bladder being considerably distended, it
was cut off sufficiently to show the inner surface of its posterior wall where it is in con-
tact with the uterus and the vagina. On the right side also part of the posterior wall
of the bladder was removed in order to show the course of the ureter on the anterior wall
of the vagina. Where the uterus and the vagina are concealed by the bladder their con-
tours are marked with heavy black lines: a. anterior surface of uterus, showing how far
it is covered with peritoneum when the bladder is full ; t>. portion of supra vaginal part of
cervix covered by the bladder; c, vaginal portion of uterus; d, vault of vasrina : r. ante-
rior wall of vagina; ff, cut surface of bladder-wall ; <j, trigone; h, vesical opening of
urethra ; i, i, i, venous plexus at the side of the uterus and the vagina ; k, right ureter ; I,
left ureter. (Two-thirds natural size.)
Tlie Nerves. Branches from the second, third, and fourth sacral
(spinal) nerves meet with others from the hypogastric plexus (sympa-
thetic) in a large ganglion on either side of the cervix, from which
cervical ganglion branches go to the uterus, the vagina, and the blad-
62 DISEASES OF WOMEN.
der. Those of the uterus end in the nucleus of the muscular cells,
and in ganglia in the mucous membrane.
Function. The r6le the uterus plays as a copulative organ is not
quite settled, but much evidence has been adduced in favor of the
theory that it exerts a suction by which the semen is drawn into its
cavity. 1 But it is a well-demonstrated fact that conception may take
place independently of such action.
The most important physiological destination of the womb is to
furnish a place of attachment for the ovum, to shelter the fetus during
its development, and to expel the child during parturition. 2
The uterus is the seat of the chief portion of the menstrual flow.
At the menstrual period its epithelium is thrown off, and a new one
is formed in the interval between two menstruations.
THE FALLOPIAN TUBES.
The Fallopian tubes, or oviducts (Fig. 58), are two long, slender,
round tubes connected with the upper angles of the uterus. Their
FIG. 58.
Posterior View of Left Uterine Appendages (Henle): 1, uterus; 2, Fallopian tube; 3, fimbri-
ated extremity and opening of the Fallopian tube ; 4, parovarium ; 5, ovary ; 6, broad
ligament ; 7, ovarian ligament ; 8, infundibulo-pelvic ligament.
length varies between 3 and 5 inches. The tube starts from the
highest point of the corner of the womb, above the round ligament
in front and the ovarian ligament behind. From thence it goes first
outward, and turns then backward, lying near the wall of the pelvis,
* Joseph E. Beck, Am. Jour. Obst., 1874, vol. vii. pp. 353-391.
' Several cases are on record of women with a fracture of the spine, causing com-
plete paralysis of the abdominal muscles, in whom the child was expelled by the
mere contractions of the womb.
ANATOMY. 63
above and in front of the ovary, ami finally it curves round the free
end of the ovary, the abdominal end being turned against the ovary
and the bottom of the pelvis. Sometimes it has even been found
surrounding the ovary entirely, with the abdominal end resting on
the ovarian ligament.
It may be divided into three parts the isthmus, the ampulla, and
the fimbria?. The isthmus comprises about the inner third. It begins
FIG. 59.
Fallopian Tube laid open (from Playfair, source unknown) : ab, uterine portion of tube ; cd,
folds of mucous membrane ; e, tubo-ovarian ligament, or fimbria ovarica ; /, ovary ; g,
round ligament.
in the outermost and uppermost corner of the uterine cavity with an
opening called the ostium uterinum, which is so fine that it barely
admits a bristle. It goes through the wall of the uterus, and extends
as a cord about inch thick outward. The ampulla is the middle
part, which is twice as thick or more, curved, and follows a serpentine
course. It has also been called the receptaculum seminis, because it
seems to be particularly destined to hold and preserve the spermato-
zoids until they come in contact with the ovum. Its calibre admits
a uterine sound. The fimbrice are the outermost part. They sur-
round the outer end of the ampulla like a collar with long flaps.
One of these, the fimbria ovarica, is attached to the free end of the
ovary, and forms a gutter. In the middle of the fimbria? is the oatium
abdominale, which again is a very fine opening, leading into the peri-
toneal cavity. Often a pedunculated hydatid is found at the abdom-
inal end. This was originally the end of the Mullerian duct, of
which the tube is a development.
As we have seen in the chapter on Development, the tubes have a
common origin with the uterus. The point that forms the limit
between the two is the insertion of the round ligament. The tube,
like the uterus, is composed of three layers a serous, a muscular,
and a mucous and each of these is continuous with the corresponding
64 DISEASES OF WOMEN.
layer of the uterus. The serous coat is formed by the uppermost part
of the broad ligament. That part of this ligament which is situated
immediately below the tube, between it and the ovary, is called the
mesosalpinx, or the ala vespertilionis (bat's wing). The mesosalpinx
is continued beyond the end of the tube as the so-called infundibulo-
pelvic ligament, which goes from the fimbrias outward and backward
to the iliac fossa, whence it carries the utero-ovariau vessels (internal
spermatic) to the tube and ovary.
The muscular coat consists of an outer longitudinal, an inner circu-
lar layer, and near the uterus another longitudinal layer. 1 It contains
most of the blood-vessels.
The mucous membrane forms large and small longitudinal folds
(Fig. 59). It covers the inner side of the fimbrise, while the outer
side is covered with peritoneum. It has a single layer of ciliated
columnar epithelium, the cilia of which move in such a way as to
push the ovum in the direction of the uterus. With increasing age
the ciliated epithelium is, however, partially replaced by non-ciliated
columnar and flat epithelium. The mucous membrane has no glands. 2
The muscular expansion from the outer layer of the uterus extends
to the tube, and seems to be able to cause an erection of it.
The uterine end moves with the uterus; the remainder is still
more freely movable, since the tube is much longer than the straight
line between its two ends, and its movements are only checked by the
thin, loose, elastic mesosalpinx, the fimbria ovarica, by which it is
connected with a movable ovary, and the infundibulo-pelvic liga-
ment.
The arteries of the Fallopian tubes come from the ovarian artery
(Fig. 38).
The veins go to the pampiniform plexus in the broad ligament.
The lymphatics unite with those of the ovary and go to the lumbar
glands.
The nerves come from the inferior hypogastric plexus of the sym-
pathetic.
Function. The Fallopian tubes are the canals through which the
ova pass from the ovaries to the uterus, and in which probably, in
most cases, impregnation takes place by the union of an ovum and
one or more spermatozoids. It seems that during menstruation the
fimbriae are spread out and applied with their mucous side to the
ovary, so as to catch the ovum when it leaves the Graafian follicle
(Fig. 60). The surface of the ovary being four or five times larger
than that of the fimbriae, it seems, however, impossible that these
should always cover a bursting follicle. Many ova doubtless fall into
the peritoneal cavity. The accompanying blood, if in small quantity,
1 J. Whitridge Williams, Am. Jour. Med. Sci., Oct., 1891, vol. cii. p. 378.
2 Otto Cohen, Med. Monatsschr, New York, Sept., 1890, vol. ii. p. 413.
ANATOMY. 65
is absorbed. If copious, it forms periuterine hematocele. The ova
perish or give rise to abdominal pregnancy. Some may also be sec-
FIG. 60.
Tube and Ovary of a Woman who died during menstruation, natural size (Farre) : I, broad
ligament ; o, ovary ; rr, old corpora lutea ; /, istbmus of tube ; i, flmbriated end spread
over ovary.
ondarily attracted to the Fallopian tubes by the current produced by
the movement of their cilia.
THE OVARIES.
The ovaries (Fig. 61) are two oval bodies situated in the true
pelvis, to the sides of the uterus, below, behind, and to the inner side
of the Fallopian tubes. They are about 1J inches long, 1 inch wide,
and ^ inch thick. They are, as it were, inserted in a hole in the
posterior layer of the broad ligament, as a diamond is fastened to a
ring. They are covered with a single layer of hexagonal columnar
epithelial cells, 1 such as we find on mucous membranes, and entirely
different from the large, flat endothelial cells covering the peritoneum.
Their long axis is placed diagonally in the pelvis. They have an
inner anterior end, an outer posterior end, an anterior outer edge, a
posterior inner edge, an upper anterior outer surface, and a lower
posterior inner surface. 2 The inner end is fastened to the corner of
the uterus, behind and below the tube, by means of the ligament of
1 As some authors deny the fact, first pointed out by Waldeyer, that the ovary is
not covered with peritoneum, I wish to state that I have satisfied myself by numer-
ous examinations of ovaries of women of the correctness of tine above.
2 The reader will understand this much more readily if he takes an oblong box
and gives the surfaces, ends, and edges the above indicated directions.
5
66
DISEASES OF WOMEN.
the ovary, a round string, about an inch long, running at the upper
edge of the broad ligament, between its two layers, and composed of
connective tissue and unstriped muscle-fibres, which are a continua-
tion of the outer layer of the uterine muscular tissue. This inner
FIG. 61.
LO
Ovary and Tube of a Nineteen-year-old Girl (Waldeyer) : U, uterus; T, tube; LO, ovarian
ligament (of unusual length) ; o, ovary ; x, limit of peritoneum. (The inner end of the
ovary is too high.)
end of the ovary is tapering and thinner than the outer. The outer
end is broader, fastened above to the fimbria ovarica and below to
the infundibulo-pelvic ligament (Fig. 61). The anterior edge is
nearly flat, and bound to the posterior layer of the broad ligament.
The place where the vessels and nerves enter is called the hilum. A
white line marks the abrupt transition from the peritoneum to the
ovarian epithelium, and this is situated on a higher level on the
anterior surface than on the posterior. The anterior surface is less
convex than the posterior. The posterior edge is strongly convex
and free. 1 The ovaries lie above the retro-ovarian shelves (which
will be described later in speaking of the pelvic peritoneum), are sur-
rounded with coils of the small intestine, and lie near the rectum.
By introducing one or two fingers into the vagina as high up as pos-
sible to the sides of and behind the uterus, and depressing the abdom-
inal wall in the region of the iliac fossa, the ovaries can sometimes be
felt.
In a young girl the surface of the ovary (Fig. 61) is even, smooth,
velvety, of pearl-gray color.
Later, each ovulation leaving a little puckered cicatrix, the surface
1 By the data given above it is easy to distinguish the left from the right ovary,
but the only way of obtaining a correct idea of the ovary is by remembering that it
has a uterine end and a tubal end, an attached border and a free border, a smaller
and a larger surface, for the organ is so movable that it is found in the most different
positions, so that expressions like upper and lower, inner and outer, are taken in
the opposite sense by different authors.
ANATOMY.
67
becomes harder and shows irregular depressions (Fig. 62), and in old
age it becomes nearly cartilaginous and loses partly its epithelium.
As to its composition, the ovary may even macroscopically be
divided into an outer part, called the parencJiymatous zone, or corti-
FIG. 62.
LO''
Ovary and Tube of Girl twenty-four years old (Waldeyer) ; U, uterus; T, tube ; LO, ovarian
ligament ; o, ovary ; x, limit of peritoneum ; 6, cicatrice after ruptured Graaflan follicle.
cat substance, and an inner, called the vascular zone, or medullary
substance.
The microscopical examination shows a greater number of layers.
Under the columnar epithelium is found a narrow, somewhat harder
layer called the albuginea (Figs. 63 and 64). It is intimately con-
nected with the subjacent parenchyma, from which it cannot be dis-
sected off. Under the microscope three layers may be distinguished
in it. It is composed of fibrous connective tissue with interspersed
unstriped muscle-fibres. Under the albuginea is found a zone dis-
tinguished by the presence of small follicles containing an ovum, the
so-called ovisacs, or young Graafian follicles. Inside of this zone is
found another with much larger Graafian follicles. The tissue in
which these follicles are imbedded consists chiefly of unstriped mus-
cle-fibres and connective tissue, which are arranged in circles around
each follicle. The centre is formed by the so-called meduttary sub-
stance, or vascular zone. Here the connective tissue is much looser
than in the parenchymatous zone, but it is full of unstriped nmscle-
fibres, as well as the parenchymatous zone. The largest vessels are
found most centrally and nearest the hilum. Nearer the surface and
the free end they are smaller. A diagram (Fig. 65) may help to
realize how these zones are distributed on a transverse section of a
human ovary. The whole section appears pear-shaped, the zones
68
DISEASES OF WOMEN.
being narrower near the hilura and increasing in width toward the
free border. 1
The small follicles, measuring from 0.02 to 0.08 millimeter in
diameter, are the same we have described in the history of the devel-
opment (p. 26), but of the enormous number comparatively few are
left. The large follicles constitute more properly what is called
Graafian follicles, and can be seen with the naked eye as vesicles of
the size of French peas.
FIG. 63.
Section of the Ovary of a Cat, enlarged six times (Schron) : 1, outer covering and free border
of the ovary (epithelium and albuginea) ; 1', attached border; 2, vascular zone, or medul-
lary substance ; 3, parenchymatous zone, or cortical substance ; 4, blood-vessels : 5, Graafian
follicles in their earliest stages, lying near the surface ; 6, 7, 8, more advanced follicles,
imbedded more deeply in the stroma ; 9, an almost mature follicle, containing the ovum
in its deepest part ; 9', a follicle from which the ovum has accidentally escaped ; 10, corpus
luteum.
There are from six to twenty of these large follicles in an ovary.
The ovisacs do not migrate. It is simply by their increased size that
the larger follicles seem to form a zone inside of the small ones. In
growing they push the surrounding tissue aside and extend deep into
the interior of the ovary, and at the same time closer to its sur-
face, until finally all tissue between the follicle and the surface is
absorbed and the follicle can burst there.
The wall of the Graafian follicle (Fig. 66) consists of two layers, an
outer, denser, called tunica fibrosa, composed of fibres of connective
tissue, and an inner, more delicate, softer, called tunica propria, and
containing many cells and a fine network of capillary vessels. Al-
though there is, microscopically, no line of demarkation between the
follicles and the surrounding tissue, they are easily pulled out. Inside
of the tunica propria are found several layers of epithelial cells, together
1 When I state above that the ovary is pervaded by unstriped muscle-fibres, it is
because I have good authority for it (Sappey and others), and because I have myself
occasionally seen them form bundles exactly like those in other organs where their
identity is recognized by everybody. But some authors do not admit that the cells
we see forming the bulk of the tissue between the follicles are of muscular nature.
ANATOMY.
69
called the membrana gmnufosa, and between the epithelial cells and
the tunica propria there is a structureless membrane. On one side
FIG. 64.
Part of the Same Section as represented in Fig. 63, more highly enlarged (Schron) : 1. the epi-
thelium and albuginea; 2, fibrous stroma; 3, 3', less fibrous, more superficial stroma; 4,
blood-vessels ; 5, small Graafian follicles near the surface ; 6, one or two more deeply
placed; 7, one further developed, enclosed by a prolongation of the fibrous stroma; 8, a
follicle still further advanced; 8', another, which is irregularly compressed ; 9, part of
the largest follicle : a, membrana granulosa ; b, discus proligeriis ; c, ovum ; d, germinal
vesicle; e, germinal spot.
these epithelial cells form a mass protruding into the cavity of the
FIG. 65.
Zone of fine
vessels
Loose connect-
ive tissue with
large vessels.
j layers
Zone of small
follicles
Zone of large
follicles
Columnar
epithelium
ffilum
Diagram of Zones in Human Ovary.
follicle, and called discus proligerus (Fig. 64, 6). The outermost
70
DISEASES OF WOMEN.
layer of epithelial cells of the Graafian follicle has a regular columnar
shape ; the inner ones are more irregular and breaking down, except
those immediately surrounding the ovum, which again form a regular
single layer of columnar cells. The space between this epithelium
and the discus proligerus is filled with a clear serous fluid called
liquor folliculi, which contains a few cells, albumin, and paralbumin.
It is formed by liquefaction of the cells of the membrana granulosa.
FIG. 66.
Graafian Follicle of Adult Woman, 40 : 1 (De Sinety) : a, external layer, or tunica fibrosa ; b,
internal layer, or tunica propria ; c, blood-vessels ; d, membrana granulosa ; e, discus
proligerus ; I, liquor folliculi (coagulated) ; o, ovum.
In the discus proligerus is imbedded the ovum (Fig. 67). The
human ovum is 0.2-0.3 millimeters in diameter, or just about visible
with the naked eye. The surrounding cells form a regular epithelial
layer of short columnar cells all around it. Inside of that is found
a fine membrane with radiating striae, the zona pellucida, or vitelline
membrane. 1 The interior is filled with a semifluid mass called the
viteUus. This is composed of larger clear bodies and minute dark
ones, and one much larger vesicle called the germinal vesicle. The
latter contains a little round body called the germinal spot. In the
interior of the latter are found a few small dark granules, and some-
times similar bodies are found in the germinal vesicle outside of the
germinal spot.
After the climacteric age the follicles and ova disappear, the whole
organ shrinks, and its surface is very uneven.
Corpivs Lideum of Menstruation. The Graafian follicle undergoes
certain changes. As a rule, one attains during the intermenstrual
1 The vitelline membrane is something entirely different from the yolk-sac,
although one name might seem to be a translation of the other.
ANATOMY. 71
period the size of a liazelnut (J inch or more in diameter), the tissue
between it and the surface becomes thinner and thinner, until, finally,
it bursts and lets the ovum escape. The follicle is then filled with
blood, which coagulates, forming a cherry-colored clot (Fig. 69). A
few days later the wall begins to be enlarged and thickened, and this
enlargement within a confined space causes it to become folded upon
itself in short zigzag reduplications, mainly at the deeper part of the
FIG. 67.
Mature Ovum of Rabbit, Hartnack f (Waldeyer) : a, cells from the discus proligerus (epi-
thelium of ovum); 6, zona pellucida; c, vitellus; d, germinal vesicle; e, germinal spot;
/, large globules with dull lustre in the germinal vesicle.
follicle (Fig. 70). These folds grow into the clot, and finally replace
it. In this way is formed, during the intermenstrual period, a corpus
luteum, occupying the substance of the ovary immediately beneath
the superficial cicatrix which marks the site of the ruptured follicle
(Fig. 71). Subsequently the whole structure diminishes in size, and
becomes more and more intimately connected with the surrounding
tissue, so that it can no longer be peeled out in toto. In a regularly
menstruating woman it seldom happens that we do not find three or
more corpora lutea in dhTerent stages of growth or retrogression.
The volume of the menstrual corpora lutea varies between about one-
half and one cubic centimeter. By the eleventh week after menstrua-
tion it is less than one-twentieth of a cubic centimeter.
Corpus Luteum of Pregnancy. If pregnancy takes place, no new
corpora lutea are formed, but the one corresponding to the last men-
struation becomes larger and stays longer. After the first mouth it
continues to increase in size, or, at least, does not diminish, and its
convoluted wall assumes the strong yellow hue which has given rise
72
DISEASES OF WOMEN.
to its name. At the same time the central clot becomes fully decolor-
ized, growing denser and firmer in proportion as it diminishes in
bulk, until a firm white fibrinous clot is found in the centre of the
yellow ring (Fig. 72). Sometimes this clot has itself a central cavity
tilled with a serous fluid. Beyond a certain period of pregnancy, the
date of which is not precisely known, the corpus luteum diminishes
in size, and loses the freshness of its yellow hue. At the end of
pregnancy it is reduced to about one-half of a cubic centimeter. 1
1 According to Dr. Mary A. Dixon Jones, working under the auspices of Dr.
Charles Heitzmann, the process taking place in the ovary, in connection with men-
Btruation, is a different one. They claim that the wall of the follicle bursts, not only
on the surface of the ovary, but in many places, and that an extravasation of blood
follows into the surrounding tissue, where it sets up a mild degree of inflammation.
The fibrous connective tissue, as well as the unstriped muscle-fibres, in the vicinity
of the follicle are reduced to a protoplasmic condition, and immediately outside of
the follicle the tissue is infiltrated with granular inflammatory corpuscles ( or medul-
lary elements) which enter the follicular cavity (Fig. 68), and gradually are
FIG. 68.
Menstrual Follicle ten to twelve days after rupture X 600 (M. Dixon-Jones) : E, extravasated
blood ; S, structureless membrane ; C, capillary blood-vessels ; F, fibrous connective tissue.
transformed there to a myxomatous tissue, destitute, as a rule, of blood-vessels, but
showing now and then cavities, probably caused by a liquefaction of the myxomatous
substance (Fig. 74). With advancing age the myxomatous tissue becomes less
and less, until nothing is left of the original follicular wall but the so-called struc-
tureless membrane distinctly convoluted and imbedded in ovarian tissue, (New York
Med Jour., May 10 and 17, 1890).
According to Dr. Jones, the so-called corpus luteum of pregnancy is a pathological
FH;. 7.,.
FIG. 69. Ovary of Woman two days after Menstruation (Dalton), showing earliest stage o
a ruptured and bloody Graarian follicle into a corpus luteum.
Fiu. 70 Ovary of Woman twenty days after Menstruation (Dalton). Besides large fresh
seen two smaller old ones, and Graatian follicles of different size.
Fiu. 71. -Ovary of Woman nine days after Menstruation (Dalton). The dark spot is the
rounding yellow circle is the corpus luteum shining through the transparent tissue.
Fio. 72. Ovary of Woman at Term of Pregnancy (Dalton), showing corpus luteum with linu
FIG. 78. False Corpus Luteum (Dalton).
ANATOMY.
73
False Corpora Lutea. Sometimes Graafian follicles degenerate.
The wall becomes thick, opaque, whitish, and assumes a slightly car-
Normal Menstrual Body X 100 (M. Dixon-Jones) : CC, cortex of ovary ; S, so-called structure-
less membrane, broken; 3f, myxomatous tissue filling the previous follicle; 0, old men-
strual body, remnants of structureless membrane ; VV, veins.
tilaginous consistency. The fluid in the interior disappears, and the
opposite surfaces come in contact with each other. The ovum dis-
formation which she calls gyroma, and which we shall describe in speaking of
oophoritis. It may be found in women who have never been pregnant, and be
absent in those who have borne children (New York Med. Jour., May 10 and 17,
1890; Times and Register, Philad., Apr. 30, 1892). In my opinion, the gyromas,
the existence of which I am familiar with myself, are what Patenko has described
under the name corpora fibrosa (Virchow's Archiv, 1881, vol. Ixxxiv. pp. 193-207)
an abnormal formation which differs from the normal corpus luteum of preg-
nancy.
74 DISEASES OF WOMEN.
appears also. These follicles lie in the deeper parts of the ovary, and
do not communicate with the surface (Fig. 73, colored plate, p. 72).
They may be called false corpora lutea. 1 When the corpus luteum
has lost its yellow color and most of its vessels, and is chiefly com-
posed of connective tissue, it is called corpus albicans. If such a
body contains dark pigment, it is not white, but dark brown or black,
and is called corpus nigrum or corpus nigricans. 2
Quite frequently large or small extravasations of blood are found
in the tissue of the ovary. 3
The ovary has a rich supply of blood- and lymph-vessels, which
enter at the hilum. The arteries (Fig. 38, colored plate, p. 44) come
from the ovarian artery, follow a spiral course, and end in a fine cap-
illary network in the tunica propria of the follicles. They have very
thick walls and a small calibre. The veins follow the arteries, and go
to the pampiniform plexus in the broad ligament. From that the
blood is carried through the ovarian veins. The right opens into the
inferior vena cava, and has a valve ; the left opens into the renal vein
at right angles, and has no valve. The latter circumstance is per-
haps the explanation of the much greater frequency of pain in the
left side of the pelvis than the right in gynecological patients. The
ovarian veins anastomose with the uterine (Fig. 57, p. 61). They
are imbedded in the tissue in the same manner as those of the uterus.
The lymphatics begin around the follicles, follow the veins, and go to
the lumbar glands. The nerves come from the inferior hypogastrio
plexus (Fig. 31, colored plate, p. 39).
Function. The ovary produces and expels the ova by which the
species is propagated. The expulsion is probably brought about by
contraction of the unstriped muscle-fibres which form so large a
portion of the organ, combined with congestion.
THE PAROVARIUM.
The parovarium (Fig. 78) is a remnant of the Wolffian body (see
p. 22). It is situated in the connective tissue between the two layers
1 The term " false corpus luteum " is often, but less properly, used in the sense
of corpus luteum of menstruation.
2 John C. Dalton, " Report on the Corpus Luteum," Am. Gyn. Trans., 1877, vol. ii.
pp. 111-160.
3 In 1879-80, while investigating abdominal fluids, I made numerous sections of
apparently normal human ovaries. In so doing I got the impression that there are
many processes going on in the ovaries which are not yet described. Other work
has prevented me from following this track, but it may be permissible here to point
out the large number of yellow masses we find in seemingly normal ovaries of
women. Fig. 75 is drawn in natural size from the ovary of a woman thirty-six
years old, cut open lengthwise. Under the albuginea was found a red zone with
three Graafian follicles, and the whole interior was taken up by yellow tissue indis-
tinctly divided into several parta
Fig. 76 is likewi. drawn from nature, in the exact size. It represents the ovary
ANATOMY. t 75
of the broad ligaments, between the outer end of the ovary and the
ampulla of the Fallopian tube. It can be seen
by holding the broad ligament up against the FIG. 75.
light. It is a small, flat, triangular organ, the
apex of which touches the attached edge of the
ovary. It is composed of from six to thirty spiral
tubules. At the base these tubules open into one
transverse tube, which may be followed as a solid
cord in the direction of the uterus. This tube f""
and cord correspond to Gartner's canal in certain
animals (see p. 20), and are a remnant of the ovary of woman thirty-
Wolffian duct. The tubules have a wall com- si^ e ^aib 1 uVm1fa U ; r &!
posed of con uecti ve tissue, unstriped m uscle-fi bres, fed zone ; c, d, e, Graaf-
, ... , . i ! * i ian follicles situated
and a ciliated columnar epithelium. At the outer in the red zone, which
side there are some tubules which do not reach the the remainders taken
ovary, and one of them, the end of the transverse llfdisSnctf^^divfded
tube, terminates often in a small cvst similar to int< ? several parts,
,, ', , ..j ,. T,r / orn * A A -LU probably corpora lu-
the fiyaatid of Morgagm (p. 30). At the inner tea of menstruation
j i_"L i ! IL i. i j.u in retrograde meta-
side there are some tubules which have lost their morphosfs.
lumen and become fine cords.
The parovarium has no function, but is liable to become the seat
of cystic degeneration.
THE URINARY ORGANS AND THE RECTUM.
The urethra, the bladder, the ureters, and the rectum are so closely
connected with the genitals, and the gynecologist is so often called
upon to treat diseases in these parts, that a brief re'sume' of their
anatomy would seem indispensable.
THE URETHRA.
The urethra is a canal leading from the bladder to the vulva. It
is from 1 to 1J inches long and ^ inch in diameter, but very dis-
tensible. It is usually said to be straight or slightly S-shaped,
but these descriptions are based upon post-mortem examinations.
The fact that a catheter is best introduced by performing a curve
round the lower end of the symphysis pubis, leads me to believe that
of a woman forty -seven years old. It shows a corpus luteum, a large yellow mass,
and thirteen distinct small yellow masses. Examined under the microscope, these
masses prove to be follicles with irregular lumps of yellow pigment interspersed in
the thin tissue between the follicles, and sometimes in the follicles themselves. I
wonder if all this yellow pigment is not a remnant of old corpora lutea ?
Fig. 77 is also drawn from nature, in actual size, and shows a corpus luteum
transformed into a cyst, numerous yellow masses with remnant of a central cavity,
and two corpora nigra.
76
DISEASES OF WOMEN.
FIG.
Ovary of Woman forty-sev-
en years old (natural
size): a, corpus luteum
with central cavity ; 6,
another corpus luteum;
c, a third small one: be-
sides this thirteen yellow
bodies could be counted
in the invisible parts of
the ovary.
it follows a curved course, with the concavity forward. It is
imbedded in the vaginal wall.
It is suspended to the pubic arch by the pubo-vesical ligament,
and passes through the triangular ligament,
between the layers of which it is surrounded
by the compressor urethras muscle, or Outline's
muscle. Another sphincter muscle surrounds
the urethra and the vagina together as a nar-
row belt just behind the vestibulo-vaginal bulbs.
The urethra has an outer layer of circular
unstriped muscle-fibres, an inner longitudinal
layer, and a mucous membrane.
The meatus urinarius has already been de-
scribed in speaking of the vulva (see p. 39).
The mucous membrane, when not distended,
forms longitudinal folds. It has many de-
pressions and blind canals, so-called Morgag-
ni's lacunce, and racemose glands (Littre's l
glands). Near the floor, just inside of the
meatus, are found two canals, Skene's glands*
or urethral ducts (Fig. 79), one on either side. They admit a No. 1
probe of the French scale, and extend upward, parallel to the long
axis of the urethra, from -| to ^ of
an inch, in the muscular tissue, below
the mucous membrane. The mouths
of these tubules are found upon the
latter ^ of an inch from the meatus.
If the mucous membrane is everted
which it often is in those who
have borne children the openings
are exposed to view on either side of
the entrance to the urethra. The
upper end of these tubes terminates
in a number of divisions which branch
off into the muscular wall of the
urethra.
The mucous membrane of the
urethra is of pink color, surrounded by a rich network of veins, and
has a stratified flat epithelium.
Vessels and nerves are derived from those of the vagina.
1 This name is often erroneously spelt Littre, which is that of the author of a
dictionary, just as Gartner almost invariably is called Gartner, and Bartholin often
Bartholini. Both were Danes.
2 Skene, "The Anatomy and Pathology of Two Important Glands of the Female
Urethra," Am. Jour. Obstet., 1880, vol. xiii. p. 265. Their glandular nature has
been contested.
e
Ovary of Woman twenty-nine years old:
a, corpus luteum transformed into
cyst ; b, numerous yellow masses with
remnant of central cavity : cc, corpora
nigra ; </, albuginea.
ANATOMY.
77
Functions. The function of the urethra is to serve as an outlet
from the bladder. Its muscular tissue works probably as a sphincter
for the same.
FIG. 78.
Adult Ovary, Parovarium, and Fallopian Tube (Kobelt) : aa, parqvarium (or epophoron); b,
remains of the uppermost tubes of the Wolffiaii body ; c. middle set of tubes forming
parovarium ; d, lower, atrophied tubes; e, atrophied remains of Wolffian duct (Gartner's
canal);/, the terminal bulb or hydatid of the Wolffiaii duct; h, the Fallopian tube; i,
hydatid of Morgagni ; I, ovary.
THE BLADDER.
The bladder is a hollow muscular organ situated in the median
line, between the pubic bones in front and the vagina and uterus
behind. When empty, it is in the true pelvis ; Avhen distended, it
reaches more or less high up in the abdominal cavity, lying close up
against the abdominal wall. When empty, it has been found in two
different shapes either so that the upper part falls against the lower,
the cavity combined with the canS.1 of the urethra having the shape
of a Y, of which the two upper branches represent the bladder, and
the lower trunk the urethra, or so that the anterior wall comes in
contact with the posterior. In the latter case the combined lumen
of the bladder and the urethra form a C or an L. 1
The female bladder is shorter than the male in the antero-posterior
direction, but more than makes up for this by being broader. I have
myself drawn three quarts of urine from a woman who had no reten-
tion of urine, and I have read that four litres have been evacuated
from a female bladder. When distended it has an ovoid shape.
We distinguish the base, the summit, the anterior and the posterior
1 Hart and Barbour (Manual of Gynecology, 4th ed., p. 35) suggest ingeniously
that the Y-shape is that of relaxation, and that the oval shape represents systole
i. e. contraction : but if the oval shape were due to muscular contraction, it could
hardly be maintained after death.
78
DISEASES OF WOMEN.
FIG. 79.
surface, and two sides. The base orfundus 1 is the lowest part of the
organ. It is bound by rather dense connective tissue to the anterior
wall of the vagina and the neck of the womb. Three openings are
found on it. In front is the internal opening of the urethra, which
is flat, crescent-shaped. There is no funnel-shaped part here, so that
the term " neck " is a misnomer. The urethra opens abruptly on
the wall of the bladder. Behind there are two fine, lengthy slits
where the ureters open into the bladder. The
triangle between these three openings is called
the trigone (Fig. 80). Each of its sides meas-
ures about an inch. The base is formed by
the intra-ureteric ligament. The distance from
this to the cervix uteri varies. I have found
it immediately under the os and half an inch
below it. When the bladder is distended the
distance increases to 1 inch.
The surface on which the bladder is in
contact with the vagina is heart-shaped. The
boundary-line runs in the lower part parallel
to and a little outside of the trigone. In the
upper part it follows the outline of the vagina.
The bladder extends f inch up on the cervix.
From the summit the urachus, one of the false,
ligaments of the bladder, goes to the umbilicus.
The anterior surface lies up against the body
of the pubic bones and the anterior abdominal
wall. It has no peritoneal covering. The
posterior wall is covered with peritoneum down
to the level of the internal os, where it passes over on the uterus.
Under this fold lies some loose connective tissue. The sides are like-
wise covered with peritoneum. The posterior wall is alternately in
contact with the uterus or the small intestine, which latter likewise
at times touches the sides. The wall varies in thickness, according to
the degree of distension, between ^ and J inch. It is composed of
a serous, a muscular, and a mucous coat. The serous coat is formed
by the peritoneum. During pregnancy the connective tissue that binds
it to the underlying tissue becomes so loose that during labor the blad-
der becomes entirely stripped of its peritoneal coat. The muscular
coat has an outer longitudinal and an inner circular layer of unstriped
fibres. When the bladder is much distended, the bundles can be seen
to separate so as to present a kind of lattice-work. The muscular tissue
is thicker around the opening to the urethra, which disposition prob-
ably serves to press out the last drops of urine during micturition.
1 The reader will notice that in speaking of the bladder the word " fundus " is
taken in an entirely different sense from that applied to the uterus.
The Urethra laid open from
behind ; probes introduced
into the urethral ducts
(Skene).
ANATOMY.
79
The mucous membrane, examined with the galvanic cystoscope,
has a lively pink color. In general it is loosely attached to the
muscular layer, and forms folds when the bladder is empty. But at
FIG. 80.
Uterus, Ureters, and Upper Part of Vagina of Woman forty years old, j natural size. All
measurements were made in situ with compasses, and then marked on the paper without
regard to foreshortening : a, ureters ; 6, uterus ; c, Fallopian tube : d. ovary ; e, round liga-
ment; .F, broad ligament; g, connective tissue; h, bladder (the antero-superior part re-
moved to show attachment to cervix and vagina); i, vesical opening of ureters; j. inner
aperture of urethra ; k, urethra ; t, vagina ; m, incision and rent in the operation called
gastro-elytrotomy as originally performed by Baudelocque.
the trigone it is attached more solidly. It contains numerous lacuna?
and racemose glands. It is covered with a transition epithelium, in
which several layers are discernible, an upper of flat and several
deeper of large and small pear-shaped cells (Figs. 81, 82). The
mucous membrane seems to be able to absorb substances injected into
the bladder.
Between the mucous membrane and the muscular coat there
80 DISEASES OF WOMES.
is, with the exception of the trigone, a well-developed submucous
layer composed of connective tissue, elastic fibres, vessels, and
nerves.
Ligaments. The bladder has four true and five false ligaments.
The true are thickened parts of the pelvic fascia. The anterior true
ligaments are two in number, a narrow but strong band on each side,
consisting to a great extent of involuntary muscle-fibers, and passing
from the lower part of the pubis to the anterior surface of the blad^
FIG. 81. FIG. 82.
X350. W \U VX350
FIG. 81. Superficial Layer of the Epithelium of the Bladder, front view, composed of poly-
hedral cells of various sizes, with one, two, or three nuclei (Klein and Noble Smith).
FIG. 82. Deep Layers of Epithelium of Bladder, side view, showing large club-shaped cells
above and smaller, more spindle-shaped, cells below, each with an oval nucleus (Klein
and Noble Smith).
der, above the urethral opening. On the outer side of the anterior
ligament the part of the fascia which descends to the side of the
bladder is known as the lateral true ligament.
The false vesical ligaments are folds of the peritoneum. There
are two posterior, two lateral, and one superior. The posterior are
the vesico-uterine ligaments (see p. 55) ; the lateral false ligaments
extend from the iliac fossae to the sides of the bladder, each separated
from the posterior ligament by the obliterated hypogastric artery.
The superior false ligament (ligamentum suspensorium) is the portion
of peritoneum between the ascending parts of the hypogastric arteries,
and reaches from the summit of the bladder to the umbilicus. It
covers the urachus, a fibrous cord which lies between the linea alba
and the ligamentum suspensorium.
The urachus is a remnant of the atlantoid of fetal life, and has pre-
served a long cavity, subdivided by partitions and lined with epithe-
lium similar to that of the bladder. Sometimes this cavity commu-
nicates with the bladder.
Vessels and Nerves. The arteries come directly from the internal iliac
(the superior, middle, and inferior vesical arteries) or from its branches,
the sciatic, internal pudic, middle hemorrhoidal, and uterine arteries.
The veins form large plexuses communicating with those of the uterus,
vagina, vulva, and rectum, and sending their blood to the internal
iliac vein. The lymphatics follow the veins and open into the hypo-
ANATOMY. 81
gastric glands. The nerves come from the hypogastric plexus of the
sympathetic and the sacral nerves (cerebro-spinal).
Function. The bladder serves as a reservoir for the urine, which
is intermittently thrown into it from the ureters. It is emptied by
the contraction of its own muscle-fibers, while the sphincters are placed
in the urethra.
THE URETERS. 1
There are two ureters, long, slender cylindrical tubes, leading from
the kidneys to the bladder. They are 16 to 18 inches long, and
thick as a goose-quill in circumference. They are the continuation
of the renal pelvis. They lie behind the peritoneum, imbedded in very
loose connective tissue, and are much longer than the direct line be-
tween their two ends. At their upper ends the distance between them
is 2J inches. From this point they go, excepting slight windings,
parallel with one another, down to the spot where they cross the iliac
vessels at the brim of the pelvis. In this part of their course they lie
in front of the psoas muscle. They are crossed about midway by the
ovarian vessels ; the right lies close to the outer side of the inferior
vena cava, behind the ileum. The left lies behind the sigmoid flex-
ure of the colon. They cross the lower end of the common iliac artery
or the upper end of one of its two branches, the external and the in-
ternal iliac (Fig. 83), and enter the pelvis. Here they describe a large
curve. First they diverge, running downward, backward, and a little
outward on the wall of the pelvis to a point near the spine of the
ischium ; then they bend downward, forward, and considerably in-
ward, so as to converge toward the bladder. They lie outside of the
internal iliac artery, behind the broad ligaments, running down to
their base, and then under them, and at the brim of the pelvis they
lie behind the ovarian vessels where these turn inward through the
infundibulo-pelvic ligament. They go right through the large plexus
of veins found at the sides of the cervix uteri (Fig. 57, p. 61), behind
the loop formed by the uterine artery (Fig. 56, p. 60). They cross
the cervix at the distance of about \ inch, from behind, at an acute
angle, so as to come in front of and below it. On reaching the wall
of the bladder they turn rather sharply inward, run for J inch in the
wall, perforating it gradually, and open with a small longitudinal slit
in the interior of the bladder. But their substance is continued from
side to side as the interureteric ligament, a ridge that forms the base
of the trigone.
1 The knowledge of the topography of the ureter has acquired special importance
in regard to the extirpation of the uterus. The questions involved have been inves-
tigated by Polk and myself, separately and conjointly (Polk, N. Y. Med. Jour., May,
1892, vol. xxxv. pp. 451-53; Garrigues, on " Gastro-elytrotomy," New York, Apple-
ton, 1878, pp. 67-74, also N. Y. Med. Jour., Nov., 1878) ; Garrigues, "Additional
Eemarks on Gastro-elytrotomy," Amer. Jour. Obstel., 1883, vol. xvi. pp. 45-49).
82
DISEASES OF WOMEN.
In crossing the cervix the ureters lie outside and above the anterior
part of the side wall of the vagina on a spot as large as the tip of the
finger.
During pregnancy the course of the ureters undergoes a great
change. Its middle part, that which in the un impregnated condition
sinks down to the spine of the ischium, is lifted up, together with the
broad ligaments. From the point where the ureter crosses the iliac
arteries it goes forward, downward, and outward, lying immediately
under the peritoneum, on the wall of the false pelvis. A little behind
FIG. 83.
The Course of the Ureters, from a woman fifty-seven years of age, with atrophic uterus, \ nat-
ural size. Specimen drawn in situ. Ureters laid bare from the place where they cross
the iliac vessels to the place where they pass under the broad ligaments. Bladder dis-
sected from uterine neck and upper part of the vagina and drawn down in order to show
the curve of the ureters and the trigone. The oroad ligaments have been removed
and the bladder cut in the median line, so as to show the inside of it : a, ureter; b, com-
mon iliac artery ; c, external iliac artery ; d, internal iliac artery ; e, uterus (appendages
cut off ) ; /, bladder ; g, site of vesical ap'erture of ureter on the inner surface ot bladder
(not visible) ; h, vesical aperture of urethra ; i, base of trigone (interureteric ligament) ;
j, incision in bladder ; k, vagina.
the end of the transverse diameter of the pelvis the ureter dips down
into the true pelvis, and goes in a curved line inward, forward, and
downward till it reaches the bladder. In this way it passes under
the broad ligaments, and in front of these it lies again immediately
under the peritoneum. From the point where it opens into the blad-
ANATOMY.
83
FIG. 84.
der to the posterior surface of the pubis behind the spine is a distance
of 3 inches. It will thus be seen that while the posterior part of the
course of the ureter through the pelvis is lifted up to so high a level,
the anterior end retains its position.
Structure. The ureters have a fibrous coat, a muscular coat, with
an outer circular and an inner longitudinal layer, and a mucous
membrane, with a transition epithelium composed of an inner short
layer, a middle columnar with long processes, and a deep layer of
more round smaller cells (Fig. 84). The cells of the deeper layers
resemble those in the deeper layers
of the bladder epithelium very much.
When not distended the mucous mem-
brane forms longitudinal folds. It has
no glands.
Vessels and Nerves. The ureters re-
ceive arteries from the renal, ovarian,
internal iliac, and vesical arteries. The
veins correspond to the arteries. The
lymphatics lead to the lumbar glands.
The nerves come from the sympathetic.
Function. The ureters lead the urine
from the kidneys to the bladder. In
cases of extroversion of the bladder or
of large vesico-vaginal fistulse, it can be
seen how the urine is spurted out with
pretty regular intermissions. That the
ureters may become much distended by
accumulated urine may be concluded
from the fact that if the bladder has
been overfilled and is emptied, fresh de-
sire for emptying it recurs soon, and
gives issue to a disproportionately large
amount of urine. The ureters are kept
closed by the elastic tension in the mus-
cle-fibres which surround them, while
they perforate the bladder, which tension is overcome when the pres-
sure reaches a certain point.
THE RECTUM.
The rectum is the lowest division of the intestine, extending from the
colon to the anus. Although the word " rectum " means straight, the
intestine curves and bends so as to form three distinct parts. It enters
the pelvis in front of the left ilio-sacral articulation (Fig. 53, p. 56), goes
first downward, backward, and inward, in front of the third or fourth
sacral vertebra, to4he median line ; here it turns forward and lies in con-
Epithelium of Pelvis of Kidney of
man X 350 (Kolliker;: A, single
cells ; B, the same, in situ ; a, small
flat cells: 6, large flat cells ; c, simi-
lar ones with bodies like nuclei in
the interior ; d, cylindrical and
cone-shaped cells from the deeper
layers ; e, transitional forms.
84
DISEASES OF WOMEN.
tact with the cervix and the vagina (Fig. 50, p. 54) ; finally, an inch
from its end it turns rather sharply downward and backward at a
FIG. 85.
Rectum inflated with Air (Chadwick) : D, D', anterior and posterior segments of the superior
detrusor feecium (so-called third sphincter) ; B, rectal ampulla ; f and *. the same points
so marked in Fig. 88.
right angle with the second part. This last part is called the anal
canal (Figs. 50, p. 54, and 34, p. 42), and is the narrowest por-
AX ATOMY.
85
tion, while the part situated immediately above it is the widest, and
is called the rectal ampulla. From here the gut tapers gradually to
the upper end (Fig. 85). It is about 8 inches long, and when empty
FIG.
The Lower End of the Rectum in Vertical Section (Rydygier) : 1, rectal mucous membrane;
2, line of separation between mucous membrane and skin of buttock ; 3, fat ; 4, levator
ani muscle; 5, 6, external sphincter; 7, internal sphincter; 8, 9, longitudinal muscular
fibers interlacing with those of sphincter; 10, filiform terminations of longitudinal fibers;
11, circular fibers ; 12, 13, longitudinal fibers of muscularis mucosse.
about 1J inches from edge to edge, but capable of such a distention
that it sometimes nearly fills the pelvic cavity. The way in which
it collapses when empty depends probably on the condition of the
vagina and the bladder. If these are empty, the rectum collapses
from side to side (Fig. 35, p. 43), but if the other cavities are dis-
tended, it becomes compressed in an antero-posterior direction.
86
DISEASES OF WOMEN.
Structure. The rectum is composed of a peritoneal coat, a muscular
coat, and a mucous membrane. In regard to its relation to the peri-
toneum, it may be divided into three parts : the upper is completely
covered, and has even sometimes a mesorectum ; the middle is cov-
FIG. 87.
Muscles of the Perineum (Breisky) : 1, glans clitoridis ; 2, corpus clitorldis ; 3, meatus urin-
arius; 4, tendon of ischio-cavernosus muscle; 5, bulb; 6, ischio-cavernosus muscle; 7,
vaginal entrance : 8, sphincter vaginae or bulbo-cavernosus muscle ; 9, fossa navicularis
10, Bartholin's gland ; 11, superficial transversus perinsei muscle ; 12, anus ; 13, sphincter
ani externus; 14, 15, levator ani muscle; 16, coccygeus muscle; 17, great sacro-sciatic
ligament ; 18, obturator internus muscle ; 19, glutseus maximus ; 20, os coccygis.
ered with peritoneum in front only (Douglas's pouch) ; and the third
has no peritoneal covering at all. The last part measures 1 to 2
inches from the anal opening. , .
The muscular coat has an outer longitudinal and an inner circular
layer. The longitudinal layer is spread all over, and does not form
such bands as on the colon. Besides this, the mucous membrane con-
AX ATOMY. 87
tains a layer of longitudinal fibers. At the lower end all the longi-
tudinal fibers are intimately interlaced with certain other muscles that
are attached to the rectum the levator ani muscle, the external
sphincter ani muscle, and the internal sphincter ani muscle and can
be followed down through them to the skin (Fig. 86).
The external sphincter ani muscle (Figs. 87, 13) is an elliptic layer
of striped muscular fibers which surround the anal opening and lie
directly under the skin. Behind it is fastened with a tendon to the
tip of the coccyx ; in front it blends with the transversus perinei and
sphincter vagina? muscles. It is the true voluntary sphincter by
which faeces and gases are kept back.
The internal sphincter ani muscle is only a thicker part of the cir-
cular layer of the rectum situated inside of the external sphincter, and
consists of unstriped muscle-fibres, with a considerable admixture of
striped fibers. It gets fibers from the deep layer of the deep perineal
fascia, from the superficial trausversus periuei, and from the bulbo-
cavernosus muscles. It surrounds the anal canal, and is an inch
high. It contracts and relaxes by reflex action, and is not subject to
the will.
The levator ani muscle (Figs, 87, 14, 15) forms an important part
of the pelvic floor, and will be considered under that heading.
The mucous membrane shows numerous folds. In the lower part
of the rectum these have a longitudinal direction, and are called the
columns of Morgagni, and the depressions between them are called
the sinuses of Morgagni. In the upper part transverse folds prepon-
derate. Three of these (more rarely only two or one), situated within
reach of the examining finger, are particularly developed, and called
Houston's valves. Commonly one of them is placed on the anterior
wall, about 2 inches above the anus ; the others an inch higher up,
on the posterior wall. They are semicircular, and, the transverse
muscles extending from one to the other (Fig. 88), they form together
a kind of circular valve, which ordinarily lies below the accumulated
feces. This apparatus has been described as a third sphincter, but is,
according to Chad wick, a detrusor ; that is, it serves to expel the feces. 1
The mucous membrane is covered with columnar epithelium and
has many glandular pouches. The transition from the skin to the
mucous membrane is distinctly marked by a so-called white line.
Relations. The rectum lies in contact outside with the left ureter
and left internal iliac artery. It has the left ovary in front, and rests
on the pyriformis muscle and the sacral plexus. It is bound to the
sacrum by the mesorectum in the upper part, and by fibrous connect-
ive tissue and fat lower down. It lies in the gap left between the
1 J. K. Chadwick, " The Functions of the Anal Sphincters, so-called, and the Act
of Defecation," Trans. Am. Gyn. Soc., ii. pp. 43-56. I have, however, frequently
palpated these folds on patients, and do not find that it causes any expulsive effort.
88
DISEASES OF WOMEN.
sacro-uterine ligaments. Loops of the small intestine lie between its
upper part and the uterus, unless the latter be pushed far back by an
overfilled bladder. In the narrow lower part of Douglas's pouch
there are, as a rule, no intestines ; the rectum hugs the cervix and
lies close up to the vagina. The anal canal forms the posterior wall
FIG. 88.
Rectum cut open longitudinally, and the mucous membrane dissected off, so as to show the
circular muscular fibres (Chadwick) : DD 1 , anterior and posterior segment of the superior
detrusor fsecium (or third sphincter) ; S, inferior detrusor fsecium (or internal sphincter);
A, anus; t and * correspond to the same points in Fig. 85. This drawing shows the mus-
cular fibres passing from the anterior to the posterior segment of the superior detrusor, by
the action of which they may be approximated to each other.
of the perineal body, which separates it from the entrance to the
vagina and the vulva.
Vessels and Nerves. The rectum has an abundant blood-supply.
The arteries are the superior hemorrhoidal from the inferior mesen-
teric, the middle hemorrhoidal from the internal iliac or one of its
branches, a branch of the middle sacral, and the inferior hemorrhoidal
ANATOMY. 89
from the internal pudic. The veins form a rich plexus, and lead the
blood through the inferior and middle hemorrhoidal to the internal
iliac, and through the superior hemorrhoidal to the superior mes-
enteric, a branch of the vena porta. The lymphatics go to the sacral
FIG. 89.
Pelvic Peritoneum with Empty Bladder ; mesial section of frozen body, J (Fiirst). The dotted
line indicates the peritoneum ; a, rectum ; 6, vagina ; c, bladder ; d, uterus ; e, below pouch
of Douglas ; /, symphysis pubis.
glands. The nerves come partly from the sympathetic nerve (the
hypogastric plexus), partly from the cerebro-spiual system (sacral
plexus).
Function. The rectum is a receptacle for the feces, and expels
90
DISEASES OF WOMEN.
them by the combined action of its circular and longitudinal fibers,
the first contracting above and relaxing below the mass to be removed,
and the latter preventing sacculation, straightening the canal, and
pulling the relaxed part of the intestine up over the fecal mass. The
internal sphincter can, by its contraction, push the mucous membrane
out through the anus, and thus becomes an expulsive muscle, as is
veiy apparent in the horse. The mucous membrane is capable of
absorbing, which explains many bad effects of constipation, and is
utilized for the administration of drugs and artificial alimentation.
THE PELVIC PERITONEUM.
The pelvic peritoneum is a continuation of the abdominal perito-
neum, and covers the organs in the pelvis more or less completely.
FIG. 90.
Diagram designed to show the antero-posterior outline of the pelvic peritoneum in the mesial
pelvic plane, with distended bladder (Ranney): PP, peritoneum ; B, rectum; U, uterus;
B, bladder ; S, symphysis pubis. The vesico-abdominal, the vesico-uterine, and Douglas s
pouch are made very apparent.
It has been likened to a cloth which is being lifted up by pushing
the organs from below up under it, by which they themselves acquire
a covering and certain folds and pouches are formed. Thus the reader
may imagine that the peritoneum is represented by a sheet of thin
muslin, and that an apple representing the bladder, a pear represent-
ing the uterus, and a banana representing the rectum are placed under
ANATOMY. 91
it. Beginning in front, the peritoneum passes from the anterior
abdominal wall at the upper end of the symphysis pubis over on the
top of the bladder (Fig. 89), covers its posterior wall down to the
level of the internal os of the uterus, and its sides behind the oblit-
erated hypogastric artery. When the bladder is much distended it
rises up into the abdominal cavity, and the peritoneum forms a pouch
between the abdominal wall and the bladder (the vesico-abdominal
pouch), the deepest point of which lies an inch above the symphysis
(Fig. 90).
From the posterior surface of the bladder the peritoneum passes
over on the anterior wall of the uterus, covering it entirely above the
cervix, and leaving a pouch between the two called the vesico-uterine
pouch. When the bladder is over-distended, the bottom of this
pouch is raised a little, as represented in the figure. Next, the peri-
toneum covers the whole posterior surface of the uterus, and goes
even generally an inch down behind the posterior wall of the vagina,
and passes then over on the rectum, leaving a pouch between the two
called Douglas's pouch or the recto-uterine pouch. This pouch varies
very much in depth, sometimes ending at the posterior utero-vagi-
nal junction, and in other cases extending down as far as the
entrance of the vagina. Next, the peritoneum covers the anterior
surface of the middle portion of the rectum, surrounds the whole
upper portion of the same, and passes over on the sacrum as the meso-
rectum.
From the sides of the uterus the peritoneum passes out to the wall
of the pelvis, forming the broad ligaments, which cover the Fallopian
tubes, the round ligaments, the ovarian ligaments, and the attached
border of the ovaries.
The uterus and the broad ligaments together form a partition which
divides the pelvic cavity into an anterior inferior and a posterior
superior part (Fig. 52, p. 55). The anterior compartment as a whole
is called the utero-abdominal pouch. In it we notice the utero-vesical
ligaments and the round ligaments of the uterus. It is filled by the
bladder, and, when this is empty, by loops of the small intestine. Its
lateral parts, where the entrance is to the obturator canal, have been
designated as the obturator pouch, or paravesical pouch (Fig. 91, II).
When the bladder is moderately filled, the loops of the small intestine
are found in the upper part of the utero-vesical pouch.
The posterior compartment may be subdivided into a central deep
part i. e. Douglas's pouch and two shallower lateral parts called
para-uterine pouches (Fig. 91, 1). The bottom of the latter has been
designated particularly as the retro-ovarian shelves (Polk). The
boundary-line between these three parts is the sacro-uterine ligaments.
On the side wall of the para-uterine pouch is seen the ureter running
under the peritoneum (Fig. 53, p. 56). The ovaries project into
92 DISEASES OF WOMEN.
them, and they contain loops of the small intestine. These are like-
wise found in the upper part of Douglas's pouch.
About the elevation of the peritoneum during pregnancy, see the
description of the broad ligaments and the ureters, pp. 57 and 82.)
The para-uterine pouch is lifted up to the pelvic brim ; the para-
FIG. 91.
Position of Viscera at the Pelvic Brim (Hasse) : v, bladder ; , uterus ; t, tube ; o, ovary ; c,
caecum : r, rectum; Ir, round ligament; pv, appendix vermiformis ; d, Douglas's pouch ;
jyu, fold covering ureter; I, para-uterine pouch; II, para-vesical, or obturator pouch;
ip, infundibulo-pelvic ligament; s. i, small intestine.
vesical pouch is only lifted in its posterior part ; and Douglas's
pouch is not interfered with.
The parts that have no peritoneal covering are the anterior wall
of the bladder, the anterior surface and the sides of the cervix uteri,
the whole lower part of the rectum, and the posterior portion of the
middle part of the same.
Function. The function of the peritoneum is to allow free; smooth
movement between the viscera. It presents a large surface, with
great power of absorption.
ANATOMY.
93
THE PELVIC CONNECTIVE TISSUE.
The dense connective tissue forming true ligaments or fasciae has
already been considered, or will be considered in describing the pelvic
floor. Here we have only in view the loose connective tissue, which
is found everywhere underlying the peritoneum in larger or smaller
quantity, and forming one continuous layer, which is a continuation
of the corresponding layer of the adjacent parts. In some places it
contains fat. Just above the symphysis pubis, behind the linea alba,
is found a considerable layer of adipose tissue, the preperitoneal fat,
which constitutes an important landmark in the performance of lapa-
FIG. 92.
Coronal Section of Pelvis, showing the three cavities of the pelvis : the peritoneal, the sub-
peritoneal, and the subcutaneous (Luschka).
rotomy. It is continued behind the symphysis as retro-pubic fat
(Fig. 89), and lies here in front of the bladder. Between the base
of the bladder and the vagina the connective tissue is rather tight.
On the posterior surface of the vagina there is a very loose layer. A
large mass is found on both sides of the cervix uteri (Fig. 92), form-
ing under the broad ligaments the parametria, which are united by a
thinner portion in front and behind. On the body of the uterus there
is only very short connective tissue without fat, but during pregnancy
it becomes much looser and increases in bulk. The rectum and the
vagina are again imbedded in considerable masses of fatty connective
94 DISEASES OF WOMEN.
tissue. At the posterior fornix the distance between the vagina and
the peritoneal cavity does not exceed one-third of an inch. From the
uterus and the parametrium a thin layer extends between the two
layers of the peritoneum which form the broad ligaments, and is here
mixed with many elastic fibers and unstriped muscle-fibers. From
here it is again continued up into the iliac fossae and the lumbar
region, and forward and backward along the pelvic wall.
The chief bulk of the subperitoueal connective tissue forms a fun-
nel-shaped mass around the cervix and downward around the vagina
to the insertion of the levator ani muscle (see Figs. 92 and 97).
Function. The function of the connective tissue is to fill out all
free spaces between the organs, to furnish a soft padding around
organs of very changeable size, and to be the carrier of vessels and
nerves.
THE PELVIC FLOOR.
The pelvic cavity may be divided into three well-marked subdi-
visions : the pelvi-peritoneal cavity, the subperitoneal space, and the
subcutaneous space (Fig. 92). 1
Of these we have already described the first and the second. The
boundary-line between the second and the third is a muscular dia-
phragm the levator ani muscle which is covered above and below
with a fascia, and has openings for the passage of the urethra, the
vagina, and the rectum.
We shall now consider what remains to be studied under the three
headings the pelvic fascia, the pelvic diaphragm, and the perineal
region.
I. The pelvic fascia (Fig. 93) is a continuation of the iliac fascia.
It is attached to the iliac part of the ilio-pectineal line and to an
oblique line on the posterior surface of the body of the pubic bone,
extending from the upper and inner part of the obturator foramen to
a point a little below the symphysis. At the upper end of the said
foramen it leaves an opening free for the obturator canal. It descends
on the inside of the bodies of the ilium and ischium, about halfway
down the pelvic wall, where a strong sinewy cord, the so-called
tendinous arch, extends from the spine of the ischium to the pubic
bone just inside of the obturator canal (Fig. 94). This part of the
pelvic fascia covers the obturator internus muscle, and is also called
the obturator fascia. It sends a thinner prolongation backward,
covering the pyriformis muscle, and called the pyriformis fascia.
At the tendinous arch the pelvic fascia is split into two layers, an
upper layer called the vesico-rectal fascia, which bends inward over
the levator ani muscle, and a lower layer, which continues to follow
1 The distinction was made by Luschka, but his names, cavum peritoneale, cavum
subperitoneale, and cavum subcutaneum are bewildering, the two latter " cavities "
being filled with solid tissue.
ANATOMY.
95
the obturator interims muscle down to the inner edge of the ischio-
pubic branches, and keeps the name of obturator fascia. Just
below the insertion of the levator ani muscle this fascia gives off
another investment of this muscle, called the anal fascia. Together
with that part of the obturator fascia situated below the tendinous
arch it forms the lining of the ischio-rectal fossa.
FIG. 93.
Fascia of Pelvic Floor (Savage): B, bladder; V, vagina; R, rectum; P, symphysis publs;
S, sacrum; a, fascia covering psoas muscle; b, obturator fascia; c, tendinous arch: d,
reflection of fascia on to the rectum, vagina, and bladder ; e, posterior portion of fascia
covering sacral vessels and nerves ; /, iliac fascia covering iliac vessels ; g, gluteal ves-
sels ; h, sciatic vessels ; i, internal pudic vessels ; k, obturator vessels.
From its insertion on the pelvic wall the vesico-rectal fascia goes
inward and downward, covering the upper surface of the levator ani
muscle, to the base of the bladder, the vagina, and the rectum. In
front, near the middle line, a thicker, narrow part of this fascia forms
the anterior true ligaments of the bladder, or the pubo-vesical ligaments
(see p. 80).
Between the two ligaments the fascia is thin and depressed. Out-
side of this ligament lies another, thicker band, the lateral true liga-
ment of the bladder, which is attached to the side of the bladder.
96 DISEASES OF WOMEN.
From the under surface of the vesico-rectal fascia a prolongation fol-
lows down with the vagina, surrounding it with a sheath that lies
outside of the venous plexus and forms a strong ring around the
vaginal entrance, where it coalesces with the deep perineal fascia.
From the ischial spine goes a band to the side of the rectum, which
is called the ligament of the rectum, and prevents too great lateral
movement of the intestine. The fascia follows the rectum down as
a sheath which gradually disappears near the anus. From the place
FIG. 94.
The Levator Ani : appearance when the pelvic outlet is looked at squarely. The cut ends
projecting inward are those fibres which run into the recto-vaginal septum (Dickinson).
where it strikes the rectum it is continued over on the pyriformis
muscle as the pyriformis fascia.
In some parts a double layer of fascia, with intervening loose con-
nective tissue, serves to allow a sliding movement of one part on the
other. Thus the fascia forms a pouch between the base of the blad-
der and the neck of the womb, extending an inch lower down than
the corresponding vesico-uterine pouch of the peritoneum. Between
the vagina and the rectum a similar pouch is found which descends
nearly to the vaginal entrance.
In its totality the pelvic fascia forms a very irregular fibrous layer
under the peritoneal cavity and the underlying loose connective tissue,
the function of which is to strengthen the pelvic floor and give sup-
port to the organs found in it, especially the bladder, the vagina, and
the rectum.
ANATOMY. 97
II. The Pelvic Diaphragm (Fig. 94). Under the pelvic fascia,
which forms a fibrous layer of the pelvic floor, is found a horseshoe-
shaped muscular expansion, which is open in front, is attached all
around to the wall of the pelvis, and forms a double loop behind the
vagina and the rectum. It is generally described as two muscles, the
levator ani and the coccygeus, but they touch each other with their
edges, so that one is a continuation of the other, and sometimes
they are even grown together. This diaphragm has also been de-
scribed as composed of three muscles : the pubo-coceygeus, the obturato-
coccygeus, and the ischio-coccygeus (Savage), but not one of the fibers
that start from the pubes are inserted on the coccyx.
The levator ani muscle takes its origin from an oblique line on the
posterior surface of the body of the pubic bone, running from the
upper end of the obturator foramen to the lower end of the symphysis
pubis, just above and inside of the insertion of the obturator internus
muscle (M. pubo-coceygeus). It starts half an inch from the middle
line of the symphysis. Its other bony origin is a small circle just
in front of the base of the ischial spine. Between these two points
it springs from the tendinous arch of the pelvic fascia (M. obturato-
coccygeus).
The pubic portion (M. pubo-coceygeus) goes backward and inward,
is in connection with the deep layer of the triangular ligament, and is
attached to the urethra. It crosses the vagina, and is united to it by
strong connective-tissue attachments, besides that the longitudinal
fibers of the vagina on its lateral aspects are interwoven with those
of the levator. Some loops go from side to side between the vagina
and the rectum, but the greater part go behind the rectum, forming
loops without intermediate tendon. They hug the concavity of the
end-curve of the rectum and support it from below (Fig. 95). The
muscle goes in between the external and internal sphincter, and in-
termingles with both of them, as well as with the longitudinal
fibers of the rectum. Some of the fibers are inserted on the thin
mesial aponeurosis, extending from the coccyx to the anus (raphe
ano-coccygea).
The fascial portion of the levator ani muscle (M. obturato-coc-
cygeus) goes with convergent fibers to the rectum and the coccyx.
It takes part with the pubic portion in the formation of a loop behind
the rectum, and another part of it is inserted 'on the fourth coccygeal
vertebra.
The ischio-coccygeal muscle (= the coccygeus) forms likewise a tri-
angle, but the base of this triangle is turned inward. It takes its
origin on the spine of the ischium and the lesser sacro-sciatic liga-
ment, and is inserted on the side of the upper part of the coccyx and
the last two vertebrae of the sacrum.
Function. The pelvic diaphragm strengthens the pelvic floor; in
7
98
DISEASES OF WOMEN.
connection with the two fasciae that cover its upper and lower surface
(the vesico-rectal and the anal fasciae) it forms a strong sheet on
which rest the uterus and the bladder. It is the antagonist of the
thoracic diaphragm, being relaxed under inspiration and contracting
under expiration. By inserting a Sims speculum it is easy to see
FIG. 95.
Anus
Side View of the Levator Ani (L) after Removal of the Ischium. The lower bundles are the
strong and heavy ones. The sphincter ani is shown surrounding the anus, and the
coccygeus (C) is faintly indicated (Luschka-Dickinson) :
the rhythmical movement synchronous with the respiration. The
anterior wall of the vagina goes downward and backward under
inspiration, and then upward and forward during exspiration.
The pelvic diaphragm lifts the rectum up during the act of defeca-
ANATOMY.
99
tion, and draws the auus forward in the direction of the symphysis.
It exercises a similar function toward the vagina during childbirth
bv pulling it upward and pushing the child forward, so as to make
it turn round the pubic arch. By means of the loops that go between
the vagina and the rectum it becomes a sphincter vagina?, which can
produce coarctation of the vaginal entrance. It draws the coccyx
forward.
III. The Perineal Region. The perineal region is a somewhat
rhomboid space bounded by the symphysis and the descending ramus
of the pubic bone, the ascending ramus and the tuberosity of the
ischium, the lower edge of the glutens maximus muscle, and the tip
of the coccyx. In depth it comprises all the tissue lying within these
boundary-lines between the surface and the pelvic diaphragm. It is
shorter and broader than in man, and contains more fat. It may be
subdivided by a line drawn just in front of the tuberosity of the
Fro. 96.
Diagram of the Fascia of the Pelvic Floor in mesial section, to show how the levator ani
muscle is backed by strong and dense sheets of fibrous tissue (Dickinson) : 1, superficial
perineal fascia, outer layer (this we call simplv subcutaneous adipose tissue^ : 2. super-
ficial perineal fascia, inner layer (our superficial perineal fascia): 3, triangular ligament,
or deep perineal fascia, outer layer: 4, triangular ligament, or deep perineal fascia, inner
layer; 5, vesico-rectal (part of pelvic) fascia.
ischium on either side into two triangles, an anterior, or uro-genital
region, and a posterior, or anal region.
100
DISEASES OF WOMEN.
FIG. 97.
In the anterior triangle we distinguish the following layers :
Skin;
Adipose tissue ;
Superficial perineal fascia;
Deep perineal fascia divided into two layers;
Anterior continuation of ischio-rectal fossa ;
Levator ani muscle ;
Vesico-rectal fascia (i. e. part of pelvic fascia).
In the posterior triangle are found the following layers :
Skin;
Adipose tissue entering and filling ischio-rectal fossa ;
Anal fascia inside, lower part of obturator fascia outside ;
Levator ani muscle inside, obturator muscle outside ;
Vesico-rectal fascia.
A. The Perineal Fascia and Ligaments. The uro-genital region
has under the skin a layer of adipose tissue (Fig. 96), which is a
continuation of the similar layer on the surrounding parts (Fig. 97).
Under that layer is found a sheet
of dense connective tissue called
the superficial perineal fascia. It
is fastened in front and on the
sides to the edge of the rami of the
pubis and ischium, and behind it
turns over the superficial trans-
versus perinsei muscle, and is here
grown together with the deep peri-
neal fascia. In its anterior part it
is grown 'together with Broca's
pouch (p. 37), and at the ramus
of the ischium with the obturator
fascia.
The deep perineal fascia, also
called the triangular ligament of
the urethra, has two layers an
anterior, or superficial layer, and a
posterior, or deep layer. The su-
perficial layer is at the sides at-
tached to the rami of the pubes
and ischium, in front to a strong
transverse ligament called the
transverse ligament of the pelvis
(Henle), which lies immediately
under and behind the' subpubic
ligament, an opening for the dorsal
vein of the clitoris separating the two. Behind it is grown together
2PM4
Transverse Section of Pelvis through Axis
of Vagina (Savage) : V, vagina, snowing
posterior wall; O, ischio-rectal fossa filled
with fat; I, ischial tuberosity ; B, perito-
neal cavity; D, recto- vesical fascia cover-
ing upper surface of levator ani muscle ;
C, anal fascia covering lower surface of
levator ani; N, obturator fascia; P, pos-
terior aponenrosis of perineal septum, or-
the deep layer of the triangular ligament ;
M, anterior aponeurosis of the same, or
superficial layer of the triangular liga-
ment; S, superficial perineal fascia; 1,
cross-section of right crus clitoridis and
erector clitoridis muscle ; 2, superficial
transversus perinaei muscle ; 3, bulb ; 4,
deep perineal muscles.
ANATOMY. 101
with the superficial perineal fascia and with the deep layer of the
deep fascia. The deep layer of the deep fascia is likewise fastened to
the rami of the pubes and the ischium, where it joins the obturator
fascia (p. 94), and covers the anterior part of the lower surface of
the levator ani muscle. At its anterior attachment it is contiguous
with the vesico-rectal fascia. Behind it is continued as a dense fascial
sheet covering the lower surface of the levator ani muscle (the anal
fascia, or levator fascia).
The deep perineal fascia is perforated by the urethra and the vagina.
Where the superficial perineal fascia and the two layers of the deep
periueal fascia come together, at the posterior margin of the super-
ficial transversus perinsei muscle, they are fortified by a strong trans-
verse fibrous band, the ischio-perineal ligament, which is inserted on
the ramus of the ischium, just in front of the tuberosity, and forms the
boundary-line between the uro-genital and the anal regions. It is a
strong cross-beam, which by its connection with all the adjacent parts
forms the chief support of the pelvic floor. Together with the pos-
terior end of the superficial and deep perineal fasciae it forms a parti-
tion between the anterior and posterior part of the perineal region,
called the transverse perineal septum.
In the anal region the skin is darker and has large sebaceous glands.
The anus forms an opening at the deepest point of the sulcus between
the nates. It is closed from side to side so as to show a line of closure
in the antero-posterior direction (Fig. 87, 12). It is surrounded by
radiating folds of the skin, and often hairs. In women the raphe
between the anus and the vulva (perineal raphe) is often effaced, and
has sometimes a whitish color, much like a cicatrix, which has to be
borne in mind in answering the question whether a subject for
examination has given birth to a child or not. Under the skin is
found a thick layer of adipose tissue. There is no special superficial
fascia, and the deep perineal fascia does not extend so far back.
Between the rectum and the ischium is found a space on either
side which is called the ischlo-rectal fossa, and has the shape of an
irregular triangular pyramid. Its top is at the spine of the ischium ;
the inner wall is formed by the levator aui muscle, covered by the
anal fascia, the outer by the obturator internus muscle, covered by
the obturator fascia, below the line of demarkation between that fascia
and the vesico-rectal fascia covering the upper surface of the levator
ani muscle (p. 94). Its entrance from below is bounded by the
lower edge of the gluteus maximus and the greater sacro-sciatic liga-
ment behind, the transversus perinaei superficialis muscle in front, and
the external sphincter ani on the inner side. Posteriorly these two
spaces communicate by means of the loose adipose tissue behind the
rectum and pelvic fascia. In front the fossa is limited by the line
of junction of the superficial and deep perineal fascise. Here it be-
102 DISEASES OF WOMEN.
conies narrow, but may be followed above the deep fascia of the
perineum along the origin of the levator ani muscle. It appears
triangular both on perpendicular and horizontal section (Figs. 92
and 97).
The above-mentioned fasciae constitute a frame-work in which lie
imbedded muscles, blood-vessels, nerves, and other organs.
B. Perineal Muscles. In the uro-genital triangle we find a super-
ficial layer of three pairs of muscles (Fig. 87, p. 86) situated between the
Perineal Muscles (Henle) : CL, clitoris turned over to the left side ; CCC, corpus cavernosum
clitoridis; CCU, corpus cavernosum urethrse, or vestibulo-vaginal bulb; CVA, anterior
column of vagina ; CW, vulvo-vaginal gland ; BC, 1, 2, 3, bulbq-cavernosus muscle ; JC, 1, 2,
ischio-cavernosus muscle ; TPS, transversus perinsei superficialis ; TPP, transversus peri-
nsei profundus muscle; S, 1, 2 ,3, sphincter ani externus; XX, layer of smooth muscle-
fibers between vagina and rectum ; +, limit of pubes and ischium.
superficial perineal fascia and the anterior layer of the deep perineal
fascia namely, the ischio-cavernosus, or erector clitoridis muscle; the
bulbo-cavernosus, or sphincter vaginae, muscle; and the superficial
transversus perincei muscle.
The ischio-cavernosus muscle is a long, slender muscle which arises
by two slips on the inside of the tuberosity of the ischium and the
ascending ramtis of the same (Fig. 98). It covers the corpus cav-
ernosum of the clitoris, and is inserted with a tendinous expansion
on the free part of the clitoris. Its function in the female is insig-
nificant compared with that in the other sex.
The bulbo-cavernosus muscle receives some fibers from the external
sphincter ani and levator ani and the superficial transversus perinsei
'/'
ANATOMY. 103
muscles, and others originate on the ischio-perineal ligament and
neighboring tendinous tissue. The posterior ends are united by
organic muscular libers. It goes forward, outside of the vulvo-vagi-
nal bulb, and splits tip into three tendons, inserted one on the poste-
rior aspect of the bulb, another on the mucous membrane between
the clitoris and the urethra, and the third on the lower surface of the
clitoris. It compresses the bulb, and thus aids in the erection of the
clitoris. It may squeeze out the secretion accumulated in Bartholin's
gland. The role of sphincter it divides with the constrictor vagina?,
and, above all, the levator ani muscle.
The superficial transversus perincei muscle originates from the inside
of the tuberosity of the ischium, behind the ischio-cavernosus muscle,
goes across the perineal region, and is inserted in the transverse sep-
tum of the perineum in the angle between the bulbo-cavernosus and
the sphincter ani externus, intermingling with both. In many women
its course is more forward, so that it does not reach the perineal body,
but is fastened to the outer edge of the bulbo-cavernosus muscle.
When it has its normal insertion it helps to steady the perineal body
and push the presenting part of the child forward toward the pubic
arch during parturition. With its abnormal insertion it can only
help to open the vaginal entrance.
In the anal region we find immediately under the skin surround-
ing the anus the external sphincter ani muscle (p. 87).
Under the tendon of the sphincter ani muscle, between it and the
levator ani muscle, in front of the tip of the coccyx, lies the so-called
Goccygeal gland, a small body of the size of a pea, which seems to be
a remnant of a more developed middle sacral artery, such as it is
in animals with a tail. 1 It consists of round or tubuliform vesicles
formed by a structureless membrane, inside of which are found cells.
The whole is surrounded by a capsule of connective tissue, and re-
ceives numerous branches from the middle sacral artery and the sym-
pathetic nerve, especially the coccygeal ganglion.
The deep muscles in the uro-geuital region are not well develojred
or clearly separated from one another. They are, therefore, enu-
merated and described differently by different anatomists. Most
commonly the following three are recognized : the constrictor urethrce,
the deep transversus perincei, and the constrictor vagince muscles. 2
They are all situated between the two layers of the deep perineal
fascia.
The constrictor urelhrce, or compressor urethrce, or Guthriffs muscle,
1 An interesting article on this subject, illustrated with figures, was published by
Augustus C. Bernays of St. Louis in the Medical Brief, Nov., 1887, vol. xv. p. 419.
2 Some describe a depressor urelhrce (or Jarjavay's muscle), a transverse muscle join-
ing the constrictor from below and going from side to side over the urethra, and a
transversus urethrce muscle, coming from above and inserted on the upper surface of
the same. They are probably only parts of the constrictor urethrce.
104 DISEASES OF WOMEN.
consists of transverse fibers arising from the ischio-pubic rami and
both layers of the deep perineal fascia, and crossing from side to side
above and below the urethra, for which thev form an upper sphincter
( P . 76).
The deep transversus perincei muscle arises from the ramus of the
ischium just behind the constrictor urethras, and goes horizontally to
the side of the vagina. By some it is merely regarded as the poste-
rior fibers of the constrictor. It helps to steady the vagina.
The constrictor vaginae muscle consists of a few fibers which arise
from the transverse septum of the perineum, and encircle the vaginal
entrance as a sphincter. Thus the deep transversus and the con-
strictor vaginae correspond to the superficial transversus and the
bulbo-caveruosus of the superficial layer.
In the anal region we have the internal sphincter' ani (p. 87) and
the levator ani, inclusive of the ischio-coccygeus (p. 97). The ante-
rior part of the levator ani lies immediately on the deep layer of the
deep perineal fascia.
C. The Perineal Body. The name of perineal body has been given
to the tissue comprised between the rectum and the genital canal,
below the point where the former turns backward (p. 84). Much
diversity obtains among authors about its shape a divergence of
opinion easily accounted for when \ve notice how different its shape
appears on sagittal section (Figs. 34, 49, 89). Sometimes the whole
space between the rectum and the vagina up to the cervix uteri forms
one triangular surface. In other cases this space is easily distinguish-
able into an upper narrow and a lower broad part, the latter alone
deserving the name of perineal body ; but this body, again, appears
with very different forms, and differs in extension upward. Some-
times the whole body lies below the hymen ; in other cases it extends
more or less up behind the vagina. The shape is sometimes nearly
quadrangular, with one surface to the skin, one to the rectum, one to
the vulva, and one to the vagina. In others it has the shape of the
quadrant of a circle; in others, again, that of the receiver of a retort,
the neck of which is formed by the narrow part between the vagina
and the rectum. When we take into consideration that all the parts
concerned consist of more or less soft tissue, this great diversity of
form is easily understood.
The perineal body (Fig. 99) is composed of the posterior ends of
the bulbo-cavernosi muscles, the organic muscular fibers uniting them
behind, fibers belonging to the superficial transversus perinaei, the
external and internal sphincter ani, and the levator ani muscles, the
ischio-perineal ligament, the posterior part of the superficial and deep
perineal fasciae, the anal fascia, and adipose tissue. It is covered
below by the skin lying between the anus and the rima pudendi ;
behind by the rectal mucous membrane ; above and in front by the
ANATOMY. 105
mucous membrane of the vulva and sometimes of tne vagina. It
has no definite lateral limits, unless we arbitrarily suppose it con-
FIG. 99.
fianoular iyaitf
Juperticialjayer.
Sup-Perintal fofria.
Sagittal Section of the Perineal Body, showing its component structures (life size ;
Dickinson].
tinued to the tuberosity of the ischium. The cutaneous surface is
shorter than in man. It measures | to 1 inch in length, while the
distance from the anus to the entrance of the vagina (p. 43), the
true length of the perineal body, is about If inches. According to
what has just been said about its upper limit, no definite height can
be ascribed to it.
Small as this body is, it is of great importance by forming the cen-
tre of the whole perineal region, where muscles, fasciae, and ligaments
come together. They being fastened to the surrounding bones, the
perineal body becomes the chief support of the whole pelvic floor.
Especially it keeps the vagina and the rectum in their proper relative
position. During childbirth it forms a strong barrier against which
the child is being pressed from above and pushed by passive and
active counter-pressure forward around the pubic arch.
D. The Projection of the Pelvic. Floor. The perineal region forms
a curve in the antero-posterior direction. The most projecting por-
tion is that immediately surrounding the anus. The average dis-
tance from this point to a straight line drawn from the tip of the
coccyx to the top of the pubic arch (i. e. the diagonal diameter of the
outlet of the pelvis) is 1 inch. 1
E. The Arteries of the Perineal Region are the internal pudic and
branches thereof, and the superficial and deep external pudic. The
internal pudic artery, a branch of the internal iliac, is much smaller
than in the male. It passes downward and outward, emerges from
the pelvis through the greater ischiadic foramen, between the pyri-
1 Foster, Amer. Jour. Obstei., 1880, vol. xiii. pp. 35, 36.
106
DISEASES OF WOMEN.
formis and ischio-coccygeus muscles, goes behind the spine of the
ischium, re-enters the pelvis through the lesser ischiadic foramen, goes
inside of the ischium, 1| inches above the lower end of the tuberosity,
where it lies on the obturator interims muscle in a sheath formed by
the obturator fascia and the falciform ligament, a prolongation of the
greater sacro-sciatic ligament. It reaches the margin of the ascending
branch of the ischium, perforates the deep layer of the deep perineal
fascia, continues its course along the margin of the descending branch
of the pubis, perforates the superficial layer of the same fascia, and
finally divides into its two end-branches, the dorsal artery of the
clitoris and the artery of the corpus cavernosum. Before that it gives
oif four branches to the perineum the inferior hemorrhoidal, the
superficial perineal, the transverse perineal) and the artery of the
bulb (Figs. 100 and 101).
FTG. 100.
Superficial Structures of the Female Perineum (Weisse): a, external superficial perineal
nerve ; 6, internal superficial perineal nerve : c, superficial perineal artery { d, inferior
pudendal nerve ; e, pudic nerve ; /, internal pudic artery ; g, inferior hemorrhoidal
artery ; h, inferior hemorrhoidal nerve ; i, tendinous center of perineum ; j, coccyx.
The inferior hemorrhoidal consists of two or three branches which
start on the inside of the tuberosity, cross the ischio-rectal fossa, and
Ay ATOMY.
107
end between the skin and external sphincter aui, giving branches to
them and the levator ani.
FIG. 101.
Dissection of Female Perineum ; on the left side the perineal muscles are exposed by the
reflection of the perineal fascia ; on the right side the muscles and the superficial layer
of the triangular ligament have been removed, thereby exposing the deep layer of the
ligament (modified from Weisse) : a, dorsal vein of clitoris; b, dorsal artery of clitoris;
c, inferior pudendal nerve; d, artery of bulb; e, pudic nerve; /, internal pudic artery :
g, inferior hemorrhoidal artery; h, inferior hemorrhoidal nerve; i, tendinous perineal
center; ;', superficial transversus perinaei muscle.
The superficial perineal artery is a longer branch. It originates a
little in front of the former, runs parallel to the ischio-pubic branches,
either above or below the transversus perinsei muscle, between the
superficial and the deep perineal fascia, and between the ischio-cav-
ernosus and bulbo-cavernosus muscles. It then passes through the
superficial perineal fascia, in which respect it differs from the corre-
sponding artery in the male. It sends branches to the named muscles
and ends in the vulva.
The transverse perineal artery perforates the deep layer of the deep
perineal fascia, follows the superficial transverse perineal muscle, and
supplies this muscle, the vestibule-vaginal bulb, and Bartholin's gland.
The artery of the bulb is smaller than in the opposite sex. It comes
108 DISEASES OF WOMEN.
from the internal pudic between the two layers of the deep perineal
fascia, and pierces the superficial layer of the same. It supplies the
vestibulo-vaginal bulb and the meatus urinarius.
The artery of the corpus cavernosum and the dorsal artery of the
clitoris are much smaller than in the male, and that of the corpus cav-
ernosum is again the smaller of the two, while in the other sex the
opposite is the case. The artery of the corpus cavernosum is dis-
tributed in the crus. The dorsal artery of the clitoris follows the
upper surface of the clitoris, and ends in the glans and prepuce.
The superficial external pudic artery is a branch of the femoral,
passes through the saphenous opening, and spreads on the labia
majora.
The deep external pudic artery comes likewise from the femoral.
It crosses the pectineus muscle, pierces the fascia lata at the inner
side of the thigh, and goes to the labia majora, where it anastomoses
with the superficial perineal artery.
Hemorrhage. In the median line of the perineal region there is
no artery of any importance. The nearer an incision is made to the
tuberosity of the ischium and the ischio-pubic branches, the greater
is the danger of hemorrhage. The internal pudic artery is the only
one that requires ligature on both ends (Ranney).
F. The Veins of the Perineal Region lead to the internal pudic and
the internal saphenous veins. From the hemorrhoidal plexus (p. 89)
the inferior hemorrhoidal vein follows the homonymous artery to the
internal pudic vein. In the uro-genital region the veins do not cor-
respond with the arteries. There is a single dorsal vein of the clit-
oris, beginning with small twigs from the glans and prepuce, running
backward in the median line between the two dorsal arteries. It
goes through an opening between the infrapubic ligament and the
transverse ligament of the pelvis (p. 100), and divides into two
branches that open into the pudic plexus, which surrounds the upper
part of the urethra. To this plexus go likewise the veins of the
corpus cavernosum i. e. several short, thick trunks which originate
in the interior of the corpus cavernosum and form one branch on
either side and several veins of the bulb. The pudic plexus anasto-
moses with the vesical and vaginal plexuses (pp. 80 and 45) and the
obturator vein. From this plexus two internal pudic veins on either
side follow the corresponding artery through the sheath of the obtu-
rator fascia and open into the internal iliac vein.
The external pudic veins follow the corresponding arteries, and
open into the internal saphenous vein.
G. The lymphatics of the perineal region lead to the inguinal glands.
H. The Nerves of the Perineal Region. The perineal. region re-
ceives its nerve-supply from the pudic nerve and from the inferior
pudendal branch of the small sciatic nerve.
AX ATOMY. 109
The pudic nerve comes from the sacral plexus, follows the internal
pudic artery out through the great sacro-sciatic foramen, behind the
spine of the ischium, and in through the lesser sacro-sciatic foramen.
Its branches are the inferior hemorrhoidal, the perineal, and the dorsal
nerve of the clitoris.
The inferior hemorrhoidal nerve crosses the ischio-rectal fossa, lies
between the skin and the superficial perineal fascia, and gives branches
to the external sphincter ani and the skin around the anus. Its ante-
rior branches combine with those of the superficial periueal and inferior
pudendal nerves.
The perineal nerve is the chief branch. It lies inside of
the ischium, below the internal pudic vessels, in the same sheath
of the obturator fascia. It breaks up into superficial and deep
branches.
The superficial perineal nerves are two in number an external or
posterior and an internal or anterior. They run forward between the
superficial and the deep perineal fascia, perforate the superficial fascia
so as to come to lie between it and the skin, one on either side of the
superficial perineal artery, and end in the labia majora. They give
branches to the skin, and connect with branches from the inferior
hemorrhoidal and the inferior pudendal nerves.
The deep perineal nerves generally arise by a single trunk, and are
distributed to nearly all the muscles of the perineal region the
sphincter ani externus, levator ani, transversus, bulbo-cavernosus, and
ischio-cavernosus and to the vestibulo-vaginal bulb.
The dorsal nerve of the clitoris is the deepest branch. It lies above
the pudic vessels in the sheath of the obturator fascia, then between
the two layers of the deep perineal fascia, perforates the suspensory
ligament of the clitoris, and is distributed on the clitoris, where it
combines with twigs from the sympathetic and forms a nervous sheath
(p. 39). It supplies the constrictor urethrse muscle and the corpus
cavernosum.
The inferior pudendal nerve is a branch of the small sciatic. It
passes under the tuberosity of the ischium, pierces the fascia lata,
runs between the skin and the superficial periueal fascia to the labia
majora, communicating with the inferior hemorrhoidal and superficial
perineal nerves.
I. Distribution of Organs between the Fasciae. The following table
may help to memorize the distribution of the muscles, vessels, nerves,
etc. of the perineal region :
( External sphincter ani muscle ;
j i. , i _j Inferior hemorrhoidal vessels and nerves ;
i ^ | Superficial perineal artery, veins, and nerves ;
1 External pudic arteries ;
Superficial perineal nerves.
110
DISEASES OF WOMEN.
Between the super-
ficial perineal and
the deep perineal
fascia.
Between the two
layers of the deep
perineal fascia.
Ischio-cavernosus )
Bulbo-cavernosus > muscles;
Superficial transversus periusei )
Pudendal sac ;
Yestibulo- vaginal bulb (in a particular sheath) ;
Artery of bulb ;
Dorsal artery of clitoris ;
Artery of corpus cavernosum ;
Venous plexuses ;
Superficial perineal nerves and vessels.
Constrictor urethrse ^|
Deep transversus perinaei > muscles ;
Constrictor vaginae
Internal pudic artery with its branches, trans-
verse perineal artery and artery of the bulb ;
Venous plexuses ;
Internal pudic veins ;
Deep perineal nerves ;
Dorsal nerve of clitoris ;
Volvo-vaginal glands (sometimes above the
deep layer).
Between the deep perineal and f Levator ani muscle (anterior part) ;
the pelvic fascia. \ Vulvo-vaginal glands (sometimes).
J. The Structural Anatomy of the Pelvic Floor. The vagina per-
forates the pelvic floor at an angle of 60 with the horizon. 1 What
lies in front of the vaginal slit has been called the pubic segment, and
what lies behind it the sacral segment. The pubic segment is composed
of loose tissue, and is loosely attached to the symphysis pubis. (Com-
pare pp. 87 and 93.) The sacral segment is made up of dense tissue,
and is firmly bound to the sacrum and coccyx. During labor the
pubic segment is drawn up so that the empty bladder lies above the
symphysis, while the sacral segment is being driven down by the
pressure of the child.
Another division of the pelvic floor is into the entire displaceable
portion and the entire fixed portion. The boundary between these
two is a continuous layer of loose connective tissue, beginning as the
retro-pubic fat (p. 9.3), then forming the loose tissue on the inside of
the obturator internus and upper portion of the levator ani, and finally
between the vagina and the rectum (Figs. 102 and 103).
The entire displaceable portion lies inside of the entire fixed portion,
and consists of the bladder, the urethra, and the vagina. It has resting
upon it the uterus, the broad ligaments, the tubes, and the ovaries.
1 Hart is the first who has explained the structure of the pelvic floor in his re-
markable thesis, The Structural Anatomy of the Pelvic Floor (Edinburgh, 1880).
Ill
Horizontal Section of Pelvis at Plane of Hip-joint (Rydygier) : o, coccyx ; b, ischio-rectal
fossa; c, rectum ; d, vagina; e, bladder; /, retro-pubic fat; g, hip-joint.
The entire fixed portion has the shape of a funnel, wide above and
narrow below. These two different divisions may be contrasted
the following way :
in
Seen in Sagittal Mesial
Sections.
Pubic segment.
Sacral segment.
i
Seen in Horizontal Sec-
tions.
Entire displace-
able portion.
Entire fixed por-
tion.
Bladder with urethra.
Anterior vaginal wall.
Posterior vaginal wall.
Tissue attached to sacrum.
( Rectum.
All outside of inner aspect of
levator ani.
K. The Function of the Pelvic Floor. The pelvic floor counteracts
the abdominal pressure from above. The loose tissue surrounding the
bladder and the rectum allows these organs to be distended and emp-
tied. Its role during the act of copulation has been referred to in
describing the vulva and the vagina, and the effect of the contraction
of the perineal muscles and the levator ani in narrowing the genital
canal is easily understood.
During parturition the entire displaceable portion is being pulled
upward by the contractions of the muscular fibers of the uterus, which
are continued on the vagina (p. 49). The child is pushed through
the vagina, exerting a strong pressure on its posterior wall, on account
of the angle between the uterus and the vagina. The active and
112
DISEASES OF WOMEN.
FIG. 103.
Coronal Section of Frozen Body (Rydygier) : 1, right lung; 2, right atrium with fovea ovalis;
3, left atrium; 4, right branch of pulmonary artery; 5, arch of aorta; 6, left lung: 7,
liver ; 8, stomach ; 9, ascending colon ; 10, bridge of tissue between stomach, and duode-
num left by removing pylorus; 11, pancreas; 12, duodenum ; 13, 13, small intestines; 14,
fundus uteri; 15, bladder; 16, obturator internus muscle ; 17, descending colon; 18, sig-
moid flexure; 19, mesentery; 20, obturator externus muscle: 21, corpus cavernosum
clltondis ; 22, meatus urinarius ; 23, labia minora ; 24, labia majora ; 25, femur.
AXATOMY.
113
passive counter- pressure exercised by muscles and fasciae (pp. 99, 101,
102, 103) turn the child forward around the pubic arch.
The result of parturition is, first, to dilate the vagina and the vulva ;
second, to tear the perineal body more or less deeply ; and third, to
elongate and slacken the layer of loose connective tissue between the
entire displaceable and the entire fixed portion of the pelvic floor,
thus predisposing to prolapsus of the vagina and the uterus.
THE ABDOMINAL REGIONS.
By means of certain imaginary lines the abdomen is divided into
regions, the familiarity with which is a great help in gynecological
examinations and the recording of erases. One line is supposed to be
drawn across from the highest point of the iliac crest on one side to
the corresponding point on the other. Another transverse line goes
from the lowest point of the wall of the thorax on one side (the car-
tilage of the tenth rib) to the corresponding point on the other side.
Finally, a line is supposed drawn perpendicularly up from the ilio-
pectineal eminence. 1
Thus nine regions are formed, the names and relations of which
are seen in this table :
Right hypochondriac.
Epigastric.
Left hypochondriac.
Right lumbar.
Umbilical.
Left lumbar.
Right iliac.
Hypogastric.
Left iliac.
The chief contents of each region are best learned by a study of
the accompanying figure (Fig. 103).
If we take into consideration the weight of all the organs pressing
on the bladder, it is evident that that of a slightly enlarged or simply
anteflexed uterus is hardly of any account. The discomfort often
complained of in the bladder under such circumstances is either due
to an affection of that organ itself or to a nerve reflex. The figure
illustrates well the large amount of loose connective tissue found in
the pel vis (p. 110).
Different anatomists draw these lines somewhat differently.
PART III.
PHYSIOLOGY.
CHAPTER I.
PUBERTY.
PUBERTY and the climacteric are two important epochs in woman's
life, one marking the beginning, the other the end, of the fruitful
period. Puberty is the change from childhood to womanhood. It
is a gradual development, which generally takes place in the four-
teenth or fifteenth year of the girl's life. At that time the breasts
become larger, the uterus increases in size (p. 33), the hips become
broader, and the contour of the whole body is rounded off. The
external genitals get their growth of hair, menstruation begins, and
one sex feels attracted to the other.
Normal Development of Mammary Gland simulating Tumor.
When at puberty the mammary glands become the seat of greater
development, it happens often that one lobule grows faster than other
parts, gives rise to some pain, and becomes a little tender. Thus a
more or less distinct round or oval swelling is formed, which often
inspires fear and brings the young girl to the physician, who might
himself be deceived and make a prognosis or even institute a treat-
ment that might hurt his reputation, and, perhaps, harm the patient.
It is enough to know of the frequent occurrence of such a condition
in order to avoid mistakes. A wet compress covered with gutta-
percha tissue, or rubbing with an anodyne liniment e. g. chloroform
mixed with twice the quantity of olive oil relieves the pain, and a
good prognosis disperses the anxiety.
Difference between Puberty and Nubility. Puberty is the period
when the possibility of reproduction begins, but by no means the
time when it is desirable that the girl should marry and become a
mother. Statistics show a very great mortality among married women
under twenty years of age. It is evidently against nature's laws that
women should become mothers before they are full-grown. Their
uteri should have attained their maximum development, the breasts
should be fit for nursing, the pelves should have reached a size that
114
PHYSIOLOGY. 115
allows the passage of a full-grown child, the muscles should have
acquired strength enough to propel it, and the whole system should
have been endowed with full power of resistance and endurance. It
may, therefore, be stated that most women should not marry before
they are twenty years old.
CHAPTER II.
MENSTRUATION AND OVULATION.
MENSTRUATION is the discharge of a bloody -fluid from the cavity
of the uterus at regular intervals. It is also called the menses, the
catamenia, the menstrual period, the monthly sickness, the monthly
flow, courses, or turns.
This phenomenon is peculiar to woman and some monkeys. 1 It
is probably due .to the erect position, which necessitates a harder tis-
sue of the womb, and excludes the presence of the enormously devel-
oped lymphatic system which is found in the horizontal animals,
together with a flabby uterus. 2
The menstrual flow commences in most women in the temperate
zone between the fifteenth and seventeenth years of their life. It
begins earlier in warm climates than in cold, earlier in cities than
in the country, and earlier in the higher walks of society than in the
lower. 3 It returns in periods of twenty-eight days, 4 and lasts on an
average four days. The amount varies very much. Four or five ounces
are said to be the average. 5 It is increased by exercise, corporeal work,
chalybeates, and stimulants. The blood differs from that from other
sources by a more or less considerable admixture of mucus and epi-
thelial cells. It has also the peculiar " heavy " odor characteristic of
the genitals. It comes from the mucous membrane of the body of
the uterus and the tubes, while the cervix has no part in the process
of menstruation. Before its appearance the woman feels a certain
heaviness in the lumbar region, while pain is always a sign of an
abnormal condition. Often the breath has an unpleasant odor during
1 Bland Sutton, BriLGyn. Jour., Nov., 1886, Part vii. p. 285.
2 A. W. Johnstone, Amer. Gyn. Trans., 1889, vol. xiv. p. 284.
3 Special statistics are found in Hannover's Om Menstruationens Betydning, Copen-
hagen, 1851, p. 18 ; and T. A. Emmet, The Principles and Practice of Gynecology, 2d
ed., 1880, p. 153 et seq. In a total of 2330 cases, Dr. E. found the average age at
the first menstruation to be 14.23 years, but, his patients being from the " better
classes," this average is too low.
4 Most women are entirely unreliable in regard to their statement of the occur-
rence of menstruation. Very commonly they state that they have it on a certain
date of each month. It is, therefore, advisable for the gynecologist to keep book
himself of the beginning and the end of the periods of those under his treatment.
Thus many an error is proved, many a complaint settled.
5 Funcke, Lehrbuch der Physiologic, 4th ed., 1866, vol. ii. p. 991.
116
DISEASES OF WOMEN.
the period. If menstruation has been evolved from the rut in
animals, it has changed very materially. While female animals
only admit the male during this period of heat, woman not only has
an aversion for sexual intercourse during her menstruation, but the
act performed during the catamenial period exposes both sexes to dis-
ease the woman to retro-uterine hematocele, the man to urethritis
and orchitis. As a rule, menstruation ceases during pregnancy and
lactation, but exceptions, especially from the latter rule, are by no
means infrequent.
The anatomical basis of menstruation is a regularly recurrent de-
velopment of the endometrium. 1 About a week before menstruation
FIG. 104.
Uterus during Menstruation (Courty). Cut open to show the swelling of the whole organ,
and particularly the mucous membrane: A, mucous membrane of cervix ; B, C, mucous
membrane of corpus, much thickened ; D, muscular layer ; E, uterine opening of tube ;
F, os internum (the mucous membrane tapers down to these openings).
sets in the raucous membrane of the uterus begins to swell, so that
from 2 or 3 millimeters (| inch) in thickness it becomes 6 or 7 milli-
meters (J inch) thick. It acquires the greatest thickness on the mid-
dle of the surfaces and fundus, and falls gradually off toward the
edges (Fig. 104). Its surface becomes wavy in consequence of the
1 Leopold, Archiv fur Oyniik., 1877, vol. xi. p. 110 et seq.
PHYSIOLOGY.
117
disproportion between it and the underlying muscular tissue. Its
arteries become much enlarged and form spirals. There is likewise
so great a development of capillaries immediately under the epithelium
that they form a plexus discernible with the naked eye. On the
other hand, there are only lew and small veins. The utricular glands
become much wider and elongated, forming spiral- and zigzag-shaped
tubes. The tissue itself is composed of connective-tissue cells inter-
spersed with an enormous amount of round cells, like lymph-corpus-
FIG. 105.
Microscopical Section of Endometrium of a Menstruating Woman, aged twenty, showing
utricular follicles denuded of epithelium, and one still containing the epithelial cast
(Johnstoue).
cles, and giant-cells with many nuclei. According to Leopold, these
cells are found in a condition of active proliferation, while, according
to Johnstone, who has worked with much more powerful lenses, the
corpuscular elements are formed from granules in the threads of con-
nective tissue forming the bulk of the mucous membrane (Fig. 47,
p. 52). Before menstruation begins the blood-pressure is increased
(Stephenson). Some of the capillaries near the surface burst and the
blood escapes, partly into the tissue, forming small extravasations,
partly on the surface, lifting up and tearing off the epithelium. The
epithelium is also shed in that part of the utricular glands that lies
nearest to the cavity of the uterus (Fig. 105). Five or six days after
the beginning of menstruation the regeneration of the epithelium
118 DISEASES OF WOMEN.
begins from the utricular glands. Eight or nine days after the
beginning of menstruation the regeneration is already completed.
The glands are no longer twisted into spirals, the arteries have become
smaller, the capillary net shrinks, the scars in the capillaries heal, and
the whole surface is covered with epithelium. Most of the corpuscu-
lar elements have disappeared.
The tubes take part in the process of menstruation. Their mucous
membrane is swollen, the epithelium is shed in some places, and they
are filled with a thin bloody fluid containing blood -corpuscles and
cast-off epithelial cells.
From this brief description of the condition of the endometrium
during menstruation it is easy to draw several practical conclusions.
We can understand how easily we can do harm by the introduction
of the sound during the catamenia ; how a normal menstruation may
become a pathological hemorrhage, if the woman works hard or takes
much exercise; and how the menstrual discharge may be intermit-
tent a thing that appears so surprising to many women.
Ovulaiion. In mammalia the connection between the processes
that take place in the ovaries and in the womb are perfectly known.
One or more Graafian follicles become mature and burst before each
recurrence of rut. The ovum escapes into the tube and passes into
the uterus, the mucous membrane of which is in a similar condition
in regard to the presence of medullary elements (the bodies that look
like lymph-corpuscles) to that of a menstruating woman. 1 If copu-
lation takes place, the ovum meets the spermatozoids somewhere on
this passage from the ovary through the tube to the uterus, and, as a
rule, impregnation takes place. In the ovaries are found as many
corpora lutea as there are fetuses in the uterus. We do not know
if a similar thing takes place in women ; that is to say, we do not
know if ovulatiou is a periodical process, and, if so, we do not know
if the cyclus is the same as for menstruation. That there is some
connection between the two seems to be proven by the correspondence,
generally admitted, between the time elapsed since the beginning of
menstruation and the degree of development of the corpus luteum
(p. 71). But this correspondence is denied by others, who have large
experience in the removal of the uterine appendages. 2
We know for sure that a single coition at any time may result in
the impregnation of a woman, but the likelihood of impregnation is
much greater shortly after or shortly before menstruation than mid-
way between the end of one menstrual period and the beginning of
the next. Of the two terms, that preceding a menstruation seems,
again, to give the best chances for impregnation. This is, among
others, proved by embryology. In the young embryo the'develop-
1 A. W. Johnstone, Brit. Ned. Jour., Nov., 1887, Part xi. p. 384.
2 Lawson Tait, Diseases of Women, Philadelphia, 1889, pp. 312-317.
PHYSIOLOGY. 119
meut is so rapid that an interval of three weeks makes an enormous
difference in the condition of the organs. In this way it was found
that three-fourths of young embryos corresponded to the first skipped
menstruation, and only one-fourth to the end of the preceding. 1
The fact that a woman may be impregnated at any time does, how-
ever, not prove that an ovum is detached at that time, for we know
that both ovum and spermatozoids may be preserved for some time
in the genital canal. The first has been found on the fourth day of
menstruation in the uterine part of the tube (Hyrtl 2 ) and in another
case 1^ inches above the internal os (Beuham 2 ). How long it stays
in the uterus and keeps its faculty of becoming fertilized is unknown.
We know as little, or still less, about the time the spermatozoids
retain their fructifying power in the genitals of woman, but analogy
from animals teaches that this is probably a longer one. They have
been found alive in the os on the ninth day after coition. 3 We can,
therefore, easily imagine that in the case of impregnation taking place
in consequence of a single connection in the middle of the intermen-
strual period, the spermatozoids are preserved and meet an ovum
detached at the following menstruation.
On the other hand, it is a fact that copulation may be performed
on any day of the intermenstrual period without resulting in preg-
nancy.
Influence of Operations on Menstruation. It is very common that
during the first days after the removal of the ovaries a bleeding takes
place from the uterus, even if the patient had menstruated just before
the operation. 4 In some cases the hemorrhage occurs from other
organs : I have seen it come from the bladder, the rectum, and the
nose. This determination of normal or vicarious menstruation is
probably due to the irritation exercised on the nerves in the pedicle
by the tightening of the ligature.
On the other hand, menstruation ceases in most cases after double
ovariotomy or oophorectomy, but exceptions from this rule are by no
means rare. There are cases in which menstruation is repeated with
more or less regularity for several months or even years. In other
cases menstruation does not occur during the first three or six months
following the operation, but then it reappears for a year or two,
occasionally in the shape of a severe flooding. 5
1 His, Anatomie menschlicher Embryonen, Leipzig, 1882, ii. p. 73. The whole num-
ber, however, being only sixteen, this argument loses some of its weight.
2 Leopold, /. c., p. 121.
3 R. Percy, of New York, Amer, Jour. Med. Sci., July, 1876, p. 158.
4 In order to avoid this extra loss of blood, which in anemic patients may turn the
scales, Mr. Tait advises to operate immediately before or during menstruation (/. c.,
p. 312).
5 George Engelmann of St. Louis, "Menstruation and the Removal of Both
Ovaries," Trans. Southern Surgical and Gynecol. Assoc., Sept., 1889; reprint, p. 1.
This is not in itself a proof against the ovulation theory, for if the presence of a
120 DISEASES OF WOMEN.
At the time the extra-peritoneal treatment of the pedicle was yet
in vogue I saw menstruation after ovariotomy accompanied by bleed-
ing from the tube in the stump. With the present iutraperito-
neal method there may, therefore, occasionally occur a retro-uterine
hematocele under such circumstances.
According to Tait, the removal of the Fallopian tubes is of much
greater importance in bringing on the menopause than that of the
ovaries ; but it is not unlikely that the influence of the removal of
the tubes is again due to a large nerve-trunk which is seen running
to the uterus in the broad ligament, in the angle between the round
ligament and the tube. 1 When the object of the operation is to bring
on the menopause, special care should, therefore, be taken to go close
up to the uterus and include this nerve in the ligature ; and in cases
in which the removal of the uterus or its appendages proves impos-
sible, it is advisable to ligate the tubes, including the nerve.
Theory of Menstruation. The cause of menstruation is unknown.
Most likely it has a yet unknown centre in the central organs of the
nervous system. According to Johnstone, menstruation is a necessity
in women and erect animals, because there are not sufficient lym-
phatics to carry off the lymph-corpuscles. The uterus is, according
to him, a hollow lymphatic gland without a lymph-stream, and his
definition of menstruation is, " a periodical washing away of those
corpuscles which are too old to make a placenta." (Compare p. 50,
foot-note.) If there is any connection between ovulation and men-
struation, both are controlled by a common impulse from the central
nervous system.
In some patients I have observed that alternately one and the other
ovary undergoes a regular swelling at the time of every menstruation,
but whether the same is the case in healthy women I do not know.
third ovary of the size of the normal ones is so rare as not to count in this connec-
tion, small supernumerary ovaries have been found twenty-three times in 500
bodies (Beigel j. Another explanation is that a part of the two large ovaries has been
left behind a thing that sometimes is unavoidable. But perhaps the presence of
ovarian tissue is not needed at all for the recurrence of menstruation. Tait has seen
menstruation recur regularly for many years in a case of Porro's operation in which
ovaries, tubes, and most of the uterus were removed (L c., p. 320). Rut can also
occur in animals after complete removal of the ovaries ( Barthele'my, Jour, de Mede-
dne veterinaire ; Med. Record, Sept. 27, 1890, p. 368).
1 Johnstone, Brit. Med. Jour., Nov., 1887, p. 387.
PHYSIOLOGY. 121
CHAPTER III.
COPULATION.
COPULATION is the act by which the male and female bodies are
sexually united. Under normal circumstances it is preceded by sex-
ual appetite or desire. All its phases, perhaps with the exception of
the desire, seem to be much less pronounced in woman than in man.
The clitoris, the vestibulo-vagiual bulbs, and perhaps the inner geni-
tal organs enter into a state of erection. Friction between the male
and female copulative organs causes a peculiar pleasurable sensation,
which ends in orgasm, the acme of nervous excitement, which seems
to be weaker in the female than in the male, and is altogether absent
in some women, who nevertheless are capable of being impregnated.
The orgasm is accompanied by an ejaculation of a mucous fluid from
the glands of the vulva. If orgasm is less pronounced than in the
other sex, it leaves far less feeling of exhaustion than in man. It is
followed by relaxation which at any time may again give place to new
excitement and erection. This difference is easy to understand when
we take into consideration the difference between the fluids ejaculated
and the profound shock sustained during orgasm by the central ner-
vous system in the male.
The disturbance of these normal conditions which makes copulation
painful or impossible is called dyspareunia, 1 and may be caused by
many different affections or malformations of the genitals or other
organs.
CHAPTER IV.
FECUNDATION.
FECUNDATION, or FERTILIZATION, is the union of the male and the
female generative elements, the spermatozoid and the ovum, by which
in the latter commences the formation of a new individual. It is
likely that the two elements, as a rule, meet in the tubes, although
the well-authenticated phenomenon of ovarian pregnancy proves that
the combination may take place in the ovary, and in mammalia the
spermatozoids are found on it within twenty-four hours after coition.
1 Robert Barnes, A Clinical History of the Medical and Surgical Diseases of Women,
London, 1873, p. 61.
122 DISEASES OF WOMEN.
In animals the ovum is no longer capable of fertilization when it has
FIG. 106.
Portions of the ova of Asterias glacialis, showing the approach and fusion of the spermatozoon
with the ovum (Hertwig) : a, fertilizing male element ; 6, elevation of protoplasm of egg ;
6', b", stages of fusion of the head of the spermatozoon with the ovum.
left the upper part of the tubes. It seems, therefore, highly improb-
FIG. 107.
Fertilized Ova of Echinus (Hertwig): A, The male (a) and the female pronucleus (b) are
approaching; in B they have almost fused. C, ovum of Echinus after completion of
fertilization; s.n, segmentation-nucleus.
able that in woman the ovum should retain the possibility of being
PHYSIOLOGY. 123
fecundated for weeks after it has left the ovary, whilst no fact is
known that would conflict with the supposition that the spermato-
zoids keep their vitality for weeks in the folds of the ampulla, and,
on the contrary, such possibility is absolutely proved in animals. 1
If union of the two elements took place in the cervix, the ovum
would be lost, as this part of the uterus is not fit for the formation
of a placenta.
The analogy from animals makes it also highly probable that a part
of the spermatozoid enters through the zona pellucida and combines
with the germinal vesicle (p. 70), so that the formation of the new
individual begins by the physical union of material derived from the
father as well as from the mother (Figs. 106 and 107). This leads
us at least one step farther in the comprehension of the wonderful
transmission through heredity of physical and mental peculiarities,
aptitudes, and acquired talents, as well as diseases, from the father to
his offspring.
CHAPTER V.
THE CLIMACTERIC.
THE CLIMACTERIC also called the menopause, or change of life is
the end of the fruitful part of woman's existence. Like puberty, it
is not a momentary nor a single event. It comes on gradually, ex-
tending over a period of two or three years, and if the cessation of
menstruation is the most characteristic symptom of it, it reverberates
through the whole system, causing considerable physical and mental
changes. It comprises the time when menstruation begins to be
irregular, gradually diminishes, and finally ceases altogether. In
most women the menopause supervenes when they are from forty-five
to fifty years old, and the length of the fruitful period is in most
women thirty-four years. Those who begin to menstruate early
(under sixteen years) continue, as a rule, longer than those who have
their first menstruation late (after sixteen). From this rule there is only
one exception, and that is due to the influence of climate : in cold cli-
mates menstrual life begins and ceases late, while in hot climates it
begins and ceases early. The fruitful period is longer in those women
who have borne children and nursed them themselves than in nul-
Iipara3 and those who have not nursed their children. On the other
hand, early sexual intercourse and a rapid sequence of childbirths or
miscarriages shorten the period of fertility. It is shorter in the labor-
1 His, Anatomie menscfdicher Embryonen, Leipzig 1880, i. p. 167.
124 DISEASES OF WOMEN.
ing classes than in women who lead an easy life. It is likewise
shorter in fat women than in thin, and shorter in weak women than in
strong. Those who suffer from chronic metritis or are weakened by
uterine hemorrhages arrive sooner at the menopause than healthy
women. Often it is brought on suddenly by severe diseases, such as
cholera, typhoid fever, malaria, or a fall, a blow, a great fright, or
deep mental depression. Such sudden entrance of the menopause is,
as a rule, accompanied by especially violent disturbances in the whole
organism, and it is therefore much better for a woman when it comes
on gradually.
The most serious side of the climacteric is that it is the time when
carcinoma most frequently appears in the uterus or the breasts.
The first symptom of the approaching menopause is irregularity
in the menstrual flow in regard to time and quantity. As a rule, the
interval between two menstrual periods becomes longer say, six or
eight weeks but sometimes, on the contrary, menstruation becomes
more frequent. The quantity of the discharge diminishes, but occa-
sionally profuse hemorrhages occur. Menstruation lasts longer say
six or eight days. Most of the accompanying symptoms may be
referred to active or passive hyperemia (congestion or stasis). Thus
we find congestion in the head, causing a red face, headache, indis-
tinct vision, a buzzing sound in the ears, vertigo, restless sleep dis-
turbed by harassing dreams, and bleeding from the nose. The passive
hyperemia of the intestinal tract produces catarrh of the stomach and
of the intestines, hyperemia of the liver, with icterus, swelling and
bleeding of the hemorrhoidal veins. The hyperemia of the lungs
causes bronchial catarrh and attacks of dyspnea. That of the kidneys
shows itself in sediment in the urine. Leucorrhea is very frequent.
The skin is frequently the seat of flashing heat and profuse perspira-
tion. Acne rosacea appears often in the face ; there may be intoler-
able itching, burning, or smarting sensations all over the body, and
the vulva may be the seat of a most distressing pruritus. The nerv-
ous system shows signs of a profound shock. Besides the symptoms
already mentioned in reference to the head and skin, the patient often
complains of backache and neuralgia; sometimes tremor occurs in
her limbs; she suffers from palpitations; her temper is subject to
great and sudden changes ; the sexual appetite is often inconveniently
increased ; and she may become delirious or even insane.
A peculiar functional affection of the heart has been observed : it
is characterized by palpitations, dyspnea on exertion, a feeling of dis-
tress in the region of the heart, faintness or syncope, a very rapid
pulse without any rise in temperature, edema at the malleoli and the
hypogastric region, and pallor of the face. The attacks usually last
a week. The disease begins and disappears gradually.
The whole appearance of the person changes often at the meno-
PHYSIOLOGY. 125
pause. Most women become stout, but some lose flesh. Sometimes
gout makes its appearance.
Considerable anatomical, changes take place in the genitals. The
uterus becomes atrophic. Sometimes the external or internal os or
both close, and if at the same time there is catarrh of the mucous
membrane, the mucus accumulates, forming hydrometra, or, if gases
are developed in the fluid, physometra. if both the internal and
external os close and a catarrhal discharge takes place both in the
body and the cervix, a characteristic swelling is formed, composed of
two globes separated by a transverse furrow (uterus bicameratus
vetularum). The mucous membrane becomes thin and loses its cor-
puscular elements (Fig. 51). Sometimes a vessel ruptures in the fun-
dus or posterior wall, causing an extravasation of blood (apoplexy of
the uterus).
The ovaries become small and hard ; the epithelium is lost on large
areas ; the follicles disappear, and are replaced by dense fibrous con-
nective tissue.
The tubes become both thinner and shorter, and not seldom the
walls grow together in different places.
In the breasts the glandular tissue disappears, and they become
atrophic, or if they retain their size, or even become larger, it is due
to the development of fat. Sometimes a serous fluid is found in them
before the gland has all been absorbed a circumstance which, to-
gether with abnormal sensations in the abdomen, tympanites, and the
cessation of the menses, often lead the patient, and sometimes the
physician, to the erroneous belief that she is pregnant.
Treatment Although the climacteric is a physiological process,
normally occurring in every woman's life if it is sufficiently extended,
the dangers with which it threatens are so serious, and the normal
condition passes so easily and frequently into the domain of dis-
ease, that the physician is often consulted about it. The treatment
of the real diseases connected with it will be discussed in later chap-
ters, under the diseases of the different organs affected, or must be
looked for in works on the practice of medicine. Here we can only
indicate a few points, especially in reference to hygiene.
A chief point is to keep the Bowels open, preferably by means of
aperient salts or waters. Sometimes enemas of plain water or muci-
laginous and oily substances or glycerin may advantageously be com-
bined with or substituted for the aperient medicine. Derivation to
the skin by washing the whole body with cold water and rubbing
the skin well with Turkish towels is both pleasant and useful. For
the loaded urine it is good to drink a syphonful of Vichy, Rhens,
or Seltser water in the course of the day, or to take bicarbonate of
soda (3ss) in a tumblerful of water: The congestion of the head and
visual disturbance are often much benefited by the use of hot foot-
126 DISEASES OF WOMEN.
baths, with or without mustard, of the cold eye-douche five minutes
three times a day, combined with scarification of the cervical portion.
A glycerin pledget introduced morning and evening into the vagina
may also relieve congested organs by causing a watery discharge. A
lukewarm general bath taken two or three times a week keeps the
skin in good order and tranquillizes the nerves. The diet should be
bland, but must vary according to the constitution. In those women
who have a tendency to stoutness it ought to be as much restricted as
possible, and all fat-producing food (cereals and sugar) ought especially
to be taken in very small quantities; milk and beer are prohibited.
Fish, meat, green vegetables, lettuce salad, and juicy fruits ought to
constitute the bill of fare. Tea and coffee ought only to be taken weak.
Upon the whole, the less the woman drinks the better, for even water
makes her fat. Alcoholic stimulants are best avoided altogether, but
if there are special indications making their use desirable, or the
patient has a craving for them, a light acid white wine (Moselle),
mixed with plain water or a mild alkaline water, will do least harm.
When the stoutness takes the proportions of pronounced obesity, a still
stricter diet is necessary (Banting cure), and special treatment at certain
mineral springs (Carlsbad. Marienbad, Tarasp) may be indicated.
Those more exceptional women who lose flesh, must be well fed
and have chocolate and plenty of milk to drink, if they can digest
them. Cereals ought to be a chief part of their diet-list, but all
sorts of animal food ought to be given besides.
As a sudden suppression of the menses is particularly dangerous,
the patient ought to take special precautions in that respect during
the climacteric. She must beware of cold feet or a wet skin Mhen
she has her menses, not wash the genitals with cold water, and still
less take a cold bath when the menses are present.
As congestion of the pelvic organs might cause hemorrhage, she
should abstain from sexual intercourse. When first the menopause
is well established marital relations may be resumed without danger.
The mental diet is of no less importance than the physical. The
physician may relieve much unnecessary anxiety by giving a good
prognosis. The patient should occupy her mind by useful work, and
exercise as much self-control as her mental condition and acquired
habits will allow.
When hemorrhage supervenes, it ought to be checked just as under
other circumstances when a proper amount of blood corresponding
to a menstrual period has been discharged. For this purpose we use
hot douches, an ice-bag over the hypogastric region, tamponade, and
drugs that have that effect (see Menorrhagia) ; and the patient ought to
be kept in bed lightly covered in a cool room, and on cool, spare diet.
The above-mentioned menstrual cardiopathy is treated with digitalis
and other heart tonics.
PART IV.
ETIOLOGY IN GENERAL.
THE causes of gynecological diseases may be divided into predis-
posing and exciting.
Predisposing Causes. The first class, although more remote in
their effect, are more important on account of their frequency.
Heredity may play a double role, either that the same defect that is
found in the mother is transmitted to her daughter, especially mal-
formations and malignant diseases, or that the child inherits a gener-
ally weak constitution from one or both of her parents, which, in
combination with her sex and the other predisposing factors, gives
rise to diseases of the genitals and pelvic organs. In the latter respect
it must be noted that children of parents advanced in life at the time
of their procreation as a rule are less vigorous than those engendered
in younger years.
Education has great influence in the development of gynecological
diseases. Too great assiduity in study in early youth concentrates
the nerve-energy on the brain, and deprives the uterus and ovaries of
their share at a time when these organs are undergoing an enormous
development, and preparing for the important functions of womanhood
and motherhood. Too great interest in and practice of music, by its
profound effect on the emotions and the constantly repeated physical
thrill in the nerves, is particularly dangerous.
Everything that causes active or passive hyperemia of the pelvic
organs is a source of disease. In this category belongs sexual excite-
ment brought on by reading prurient novels ; by looking at obscene
pictures ; by seeing representations on the stage that aim at the ex-
posure of so much of the body as existing laws and public opinion
will permit; by masturbation, sapphism (the same as tribadism), sod-
omy, and even normal coition if performed too violently.
The neglect of the skin, by which a chief emunctory is nearly
blocked up, is hardly found in the better classes in this country, but
is exceedingly common among the poorer women, especially immi-
grants, of certain nationalities. 1
Insufficient exercise and lack of open air are a frequent cause of dis-
ease, and favor the stagnation of blood in the pelvis ; but in this
1 The Jewesses from Russian Poland in my dispensary experience exceed all others,
and make, in fact, the impression of never bathing or washing their body.
127
128 DISEASES OF WOMEN.
respect, as also in regard to food, a great change has taken place in
the higher classes during the last decade. The ideal of the American
girl is no longer to be thin and pale. The young men having taken
an ever-increasing interest in athletics and all sorts of sports, most
of which are cultivated in the open air, the girls do not want to stay
behind. The dull croquet has speedily been followed by the lively
tennis; muscular strength is developed by swimming, riding, fencing,
skating, and ballet-dancing ; and now the girls begin even to have
gymnasiums of their own, where every part of the body may be
developed by properly adapted exercises.
In regard to food there is also great improvement, but it is too
often necessary to inculcate the importance of taking a proper amount
of good, wholesome nutriment. Many girls have a loathing for food
in the morning, and will, if allowed to do so, go to school with an
empty stomach, and let their brain work for hours before they take
any substantial food. A very bad habit, that spoils the appetite, causes
a sour stomach, and in consequence impoverishes the blood and gives
rise to nervous troubles, is the immoderate use of candy, which among
women and children corresponds to alcoholic beverages and tobacco in
men.
A fruitful source of disease among women is the lack of attention
to the excretions. The vast majority of gynecological patients suffer
from constipation. They will go for days nay, sometimes a whole
week without a movement of the bowels. This accumulation of
feces gives rise to local trouble by pushing the uterus out of its place
and interfering with the free circulation of the blood in the pelvis ;
but, besides, it causes absorption of the gaseous and liquid part of the
fecal material, that shows its deleterious effect in bloodless lips,
headache, neuralgia, and fatigue. The excretion of the urine is no
less neglected. The requirements of polite society will often prevent
women from emptying the bladder in time, which may lead to
paralysis of that organ, not to speak of rupture, and not uufrequently
is the cause of cystitis and neuralgic pain, besides predisposing to
uterine disease by pushing the womb out of place.
The mode of dressing, although changing under the varying caprices
of fashion, is always fundamentally wrong and conducive to disease.
The " decollete" " evening dress and the bell-shaped nether garments
drive the blood from the periphery to the pelvis. The lower part
of the abdomen is generally insufficiently protected from cold air and
blasts of wind, which become particularly dangerous to women who
skate. High heels, when worn at an early age, while all articulations
are yet subject to change, not only alter the shape of the foot, but are
apt to cause neuralgia in the legs and a change in the inclination of
the pelvis and the normal curvature of the back. 1
1 S. Busey, Trans. Amer. Oyn. Soc., 1882, vol. vii. pp. 243-261.
ETIOLOGY IN GENERAL. 129
Of much greater importance yet is the use of corsets. Even a loose
corset exercises a pressure of 30 pounds, which has still greater effect
on the abdominal cavity than on the thoracic. The abdominal wall
is thinned and weakened. In the erect posture the liver and intes-
tines are pushed forward, driving the weakened abdominal wall in
front of them, and in sitting the normal pressure backward from the
abdominal wall against the spinal column is changed into one going
directly down into the pelvic cavity. By tight lacing the pelvic
flk*>r is bulged down to the extent of one-third of an inch. 1
Late hours, social gatherings beginning at the time when the girl
ought to go to bed, have a very bad effect on the nervous system, and
predispose to much greater suffering from actual trouble than is felt
by those leading a more natural life.
Neglect during menstruation seems to be a fruitful source of female
complaints. Women not only move about, but dance and skate, at a
time when a process is going on that is so easily turned in an abnor-
mal direction.
We have seen in the chapter on Physiology how differently women
are constructed from men in regard to sexual excitement. It is
very unlikely that the mere frequency of normal sexual intercourse
does a healthy woman any harm, but it is quite different when the
natural relations are disturbed. The sin of Onan, 2 sodomy, and even
the use of condoms, injections made in a hurry immediately after
ejaculation at a moment when nature calls for rest, and often with a
fluid of improper temperature, all cause a tension of the nervous system
and a congestion of the genitals which in the course of time result in
hemorrhage, leucorrhea, chronic metritis, fibroids, or other affections.
Marriage with existing disease of the pelvic organs often lays the
foundation of much wretchedness for both husband and wife. If a
flexion of the uterus may be cured by childbirth, provided conception
takes place in spite of it, how different is it when the ovaries or tubes
are the seat of chronic inflammation, which causes excruciating pain
at the mere touch during a careful examination !
If married life has its dangers, celibacy does not offer entire pro-
tection. Especially is the liability to the formation of fibromas of
the uterus greater in unmarried and nulliparous women than in those;
who have borne children, as if the uterus, deprived of the function
of building up a new being, were more liable to use the material for
the formation of a tumor.
1 The question of the effect of the corset and other wearing apparel has been ably
discussed by Dr. Eobert L. Dickinson in the New York Med. Jour., Nov. 5, 1 887,
Hare's System of Therapeutics, vol. iii. pp. 730-784, and Trans. Amer. Gyn. Soc., 1893,
vol. xviii. pp. 411-433.
2 A careful perusal of Genesis xxxviii. 9 will convince the render that thereby is
not meant the vice which erroneously has been named after that man, and which
properly is called masturbation, but the practice commonly known as " withdrawal."
130 DISEASES OF WOMEN.
In married as well as unmarried women the climacteric predisposes
to disease a point which has been considered in a previous chapter
(p. 124).
Exciting Causes. Sometimes a faulty development of the fetus
constitutes directly a disease. Too great closure of the two halves
forming the body gives rise to atresia ; too little results in hypospa-
dias, epispadias, or extroversion of the bladder. Arrest of develop-
ment may also cause an infantile uterus. The genitals may be more
or less completely absent. These conditions will be discussed under
the diseases of the special organs.
Coition during menstruation has often been the cause of retro-uterine
hematocele.
Childbirth is a fruitful source of disease to women, sometimes with-
out, but oftener with, fault on the part of the obstetrician. Tears of
the vaginal entrance often lay the foundation of prolapse of the vagina
or the uterus. A torn cervix gives rise to ectropion of the mucous
membrane, leucorrhea, hemorrhage, cystic degeneration of the cervix,
secondary sterility, neuralgia, impaired nutrition, and carcinoma or
sarcoma of the uterus. Too early rising after confinement, while the
uterus is still large and soft, often causes subinvolution or displace-
ment of that organ. 1 Through deficient antiseptic precautions inflam-
mation is started in the uterus, the tubes, the connective tissue of the
pelvis, or the peritoneum conditions which, if they do not end the
patient's life at once, often leave her sterile or a sufferer for life.
Abortions, spontaneous or legitimately induced to avert greater
evil, may give rise to conditions calling for the gynecologist's inter-
ference ; but of by far greater importance is the criminal abortion so
frequently resorted to by women in all classes of society, in the coun-
try as well as in cities. Sometimes the ignorance and recklessness
of the abortionist go so far that he makes a hole in the uterus through
which one can put one's thumb, and through which the intestines
may find their way into the vagina and down between the thighs; 2
and it is by no means rare to read in the reports of coroners' autopsies
in suits for malpractice that wounds inflicted with some sharp or
pointed instrument are found in the genitals of those who have suc-
cumbed in consequence of criminal abortion. But, even apart from
these surgical injuries, there are two immediate dangers of abortion
namely, hemorrhage and septicemia, which are due to retention of
the whole or part of the ovum. Hemorrhage occurs in two forms :
either in the shape of sudden considerable flooding or as a constant
or frequently-repeated loss of small amounts of blood, which is due
1 This question has been considered at length in my article " Rest after Delivery,"
Amer. Jour. Obstetrics, vol. xiii. No. iv. Oct., 1880, pp. 851-863.
2 Cases of this kind were reported by Thomas and Noeggerath in the Obstetrical
Society of New York, Amer. Jour. Obstet., 1882 (Supplement, pp. 4-6).
ETIOLOGY IN GENERAL. 131
to fungosities of the endometrium, and undermines the most, robust
constitution.
The more remote effects of abortion are similar to those of too early
rising after childbirth, especially subinvolutious and displacements. 1
Gynecological Treatment. Unfortunately, our list of the chief
direct causes of gynecological diseases would be incomplete, if we left
out the gynecological treatment itself. Even with the greatest care,
our procedures are frequently not free from danger, and, if we ne-
glect antiseptic precautions, the danger increases manifoldly. Espe-
cially is all intra-uteriue treatment with sounds, curettes, tents, dilators,
and pessaries 2 fraught with danger on account of the absorption of
septic material, which so easily takes place through the lymphatics"
of the endometrium.
Gonorrhea. Greater than any other danger is, however, sexual
intercourse with a man who has gonorrhea, or who has, perhaps, had
one many years ago which has not been thoroughly cured. While a
gonorrhea in man in most cases is a trifling disorder, although excep-
tions, iu which it leaves a serious condition, and even becomes fatal,
are not so very rare, in women it is one of the most serious diseases.
If it only aifects the vagina and the urethra, it is of less consequence.
It is already more serious if it extends into the vulvo-vaginal glands,
but if it works its way up through the uterus to the tubes, ovaries,
and pelvic peritoneum, it jeopardizes not only the woman's life, but,
if she survives, she is most frequently left sterile, and is often an
invalid for life, being subject to a chronic inflammation of the tubes
and ovaries, with frequent acute attacks of peritonitis and an incur-
able uterine catarrh due to reinfection from the tubes. If sterility
does not follow, such women often have an attack of puerperal endo-
raetritis in every confinement.
Under the name of latent gonorrhea has been described a condition
in which a woman is infected by a man who had a gonorrhea months
or years before. No acute gonorrhea is produced, but the women
become ailing, remain sterile, and are affected with chronic, subacute,
sometimes acute, very often relapsing, inflammation of the internal
genitals. 3
1 An interesting paper on " Abortion and its Effects " was read by Dr. J. T. John-
son of Washington, D. C., before the Medical and Chirurgical State Faculty of
Maryland, on April 23, 1890 (Maryland Med. Jour.).
2 Garrigues, "Danger of Stem Pessaries," Amer. Jour. Obstet., Oct., 1879, vol. xii.
p. 756.
3 Emil Noeggerath, "Latent Gonorrhea," Trans. Amer. Gyn. Soc., 1876, vol. i. p.
268, et seq.
PART V.
EXAMINATION IN GENERAL.
THE examination of a gynecological case is verbal and physical.
Verbal Examination. The aim of this work being to offer a prac-
tical guide for general practitioners, I shall not expatiate about all
that we might be led to surmise by a number of symptoms elicited
by a protracted conversation conundrums that, anyhow, only find
their solution by a physical examination ; but I shall briefly state the
questions I ask a patient before proceeding any further.
Age. The age ought to be ascertained, because it often gives a
measure of the weakness or robustness of the constitution of the pa-
tient, may throw some light on the nature of the affection for which
she consults us, and may give us a hint in regard to special epochs in
her life, such as puberty or the climacteric.
Social Position and Pursuits. It is useful to know whether we
have to do with a society lady, whose greatest fatigue is her social
obligations; a shop-girl, who is kept standing or tripping about all
day long ; or a washerwoman, who stands bent over the tub rubbing
linen day after day. It is of importance to know whether the patient
spends her day in studying or in artistic pursuits conditions which,
as a rule, are combined with a highly-developed but over-sensitive
nervous system. It is necessary to know something about the finan-
cial resources of the patient. In the poor recourse to more radical
measures is often imperative, while those who possess adequate means
may be benefited by a less vigorous but more protracted treatment.
Duration of Sickness. The knowledge of the length of time during
which the patient has been sick teaches us at once whether we have
to deal with an acute or a chronic disease.
Condition. It is of the very greatest importance to know whether
our patient is single, married, or a widow, or has sexual connection
without being married. If she is married, we want to know how
long she has been so.
Childbirth and Miscarriages. Next we want to know how many
children she has borne, the age of the oldest and the youngest, and if
she has had any miscarriages. A rapid succession of pregnancies is
in many cases an important etiological point. Often the disease for
which we are consulted may be referred to the last confinement. If
132
EXAMINATION IN GENERAL. 133
she is sterile, we must find out if it is a natural condition or due to
the use of preventives. If we find sterility combined with dysmen-
orrhea, we nearly always find a flexion of the womb, and most fre-
quently an auteflexion, often combined with a narrow os. If there
have been many miscarriages, we must ask if they were spontaneous
or induced. If criminal abortion has been performed, that gives often
the clue to the origin of the disease, while, on the other hand, repeated
spontaneous miscarriages generally are due to a misplacement of the
uterus or to syphilis, either in the patient or her husband, or both.
Menstruation. The normal period is twenty-eight days, of which
menstruation lasts four (p. 115). Some women have periods of
twenty-seven or twenty-nine days; some even of only three weeks.
The duration varies likewise a good deal within normal limits. Some
women menstruate only a day or two, others for a whole week ; but,
as a rule, such conditions are allied to symptoms which show that we
have to do with something abnormal. The amount of blood lost at
the menstrual period is of greater importance than its duration, since
one will lose more in a day than another in a week. As a rule,
women are able to tell whether they lose much or little, even if they
do not use diapers, the numbers of which are often given as measure
of the amount of the discharge. Normally, menstruation is only
preceded and accompanied by a feeling of heaviness, especially in the
loins. Menstrual pain is always a sign of disease. If it precedes the
flow for many days, it is probably of ovarian origin, while a pain felt
for a day and relieved by the flow is in most cases referable to a
flexion of the uterus, and a pain continuing during menstruation
points toward a diseased condition of the endometrium.
If menstruation is absent, we ask if it has ever been established.
If it has not, we must take the patient's age into consideration
(p. 115) and ascertain if she has molimina i. e. if at regular intervals
of four weeks she suffers from abdominal pain, cerebral congestion,
and general malaise. If the patient has reached the age of puberty,
is otherwise well developed, and has monthly molimina, a physical
examination is imperatively called for, in order to find out whether
some malformation forms a barrier which prevents the blood from
escaping from the genitals. We must inquire if the patient is subject
to a regular bleeding from other parts which might have the charac-
ter of a vicarious menstruation (Part VII., Chap. II.).
If menstruation has been established, we must ask if it is the first
time it has failed to appear, or if similar periods of amenorrhea have
preceded. We must ask if it has been suddenly suppressed, and if
any cause for such suppression is known e. g. exposure to cold.
Under all circumstances of disappearance of the menstrual flow the
physician must think of the possibility of pregnancy, and inquire
about nausea and vomiting, and if the patient is unmarried, under
134 DISEASES OF WOMEN,
some plausible pretext, obtain an examination of the breasts, which
may give such corroborative information that a vaginal examination
must be proposed. Even with married women he must remember
that they may be pregnant without knowing it, or may be led by the
secret desire that something may be done that will put an end to
their pregnancy.
So-called menstruation recurring a year or more after the meno-
pause is very suspicious, as it generally is a hemorrhage caused by
cancer.
Discharge. We ask the patient if she lias any discharge from the
genitals between her periods, and if so what color, consistency, and
odor it has. A discharge is always an abnormality. A white, milky
discharge is of least importance; a thick, glairy one comes from the
cervix, and is often hard to cure ; a bloody one comes probably from
ulcers or granulations ; a purulent one is a sign of a deeper inflam-
mation, which often is of gonorrheic origin, or it may come from
ulcers ; an offensive one is particularly found in cancer.
Micturition and Defecation. After these questions about the geni-
tals proper we inquire about the condition of the neighboring organs.
Very often we find frequent or painful micturition, even without
disease of the urinary organs, and constipation.
Pain. The symptom that most frequently brings the patient to
seek help is pain. The pain has certain places of predilection, which,
according to decreasing frequency, may be arranged in the following
list : the left iliac fossa, the right iliac fossa, or both ; backache, pain
under the left breast, pain in the epigastric region, headache, neuralgia
on the anterior surface of the thigh (anterior crural nerve), neuralgia
on the external surface of the same (external cutaneous nerve), pain
in the coccygeal region or in the interior of the pelvis when sitting.
As a rule, the pain is increased by walking or other exertions. Fre-
quently coition is painful (dyspareuma). When a pain is felt on
one side of the body, it is, as a rule, on the affected side, but some-
times it is referred to the opposite side.
Worse than real pain are sometimes other abnormal sensations,
such as itching or burning.
Sometimes patients suffer from a pricking pain in the eyeballs, with
weak eyesight (asthenopia), palpitations, and the different nervous
symptoms known as hysteria.
Nutrition and Strength. Most frequently gynecological patients
are thin and anemic, their appetite is poor, and they suffer from dys-
pepsia. They complain of feeling tired, and are unable to do the
same amount of work as before they were taken sick.
Family History. Sometimes the family history helps to a diag-
nosis, especially in regard to such hereditary diseases as tuberculosis
and cancer.
EXAMINATION IN GENERAL.
135
Special Question.*. In special cases many other questions suggest
themselves. For instance, if the patient has an enlarged abdomen,
it is of great importance to know in what locality the enlargement
was first noticed. If during the physical examination we find great
tenderness in a married woman, it is a pertinent question to ask if
coition is painful, and, if so, how often it takes place. When there
is a deficient development of the genitals, it is proper to ascertain if
the patient has a normal sexual appetite and feels any normal satis-
faction in sexual intercourse. Venereal affections call for a close
examination in regard to the time of their first appearance, preceding
or concomitant symptoms (ulcers, rash, sore throat, alopecia), and the
health of the husband. Sometimes it becomes necessary to ask the
patient if she masturbates, which usually can be done by asking if
she suffers from heat in the genitals, if she touches them, if she
scratches herself, and so forth. But all such special questions will,
as a rule, best be put during or after the physical examination.
Physical Examination. For the physical examination we must
make use of four of our senses viz. sight, touch, smell, and hearing
and certain instruments or apparatus. Most examinations can be
satisfactorily made with the patient lying in her bed or on a lounge,
and in private practice, in the home of the patient, most examinations
are made in this way. Certain things are, however, felt much better,
or are first brought out, when the patient lies on an even, unyielding
surface, and office practice is much expedited by having a couch
especially made for the purpose. There are numerous examining
chairs and tables in the market and in more or less common use.
Tables are by far to be preferred to chairs, the latter not allowing so
easily and so completely a change from the dorsal to the lateral pos-
ture. A common table with a hard
mattress may be used, but it is a
great improvement to have a table
that can easily be made to slant
backward, and to that side which is
to the right of the physician when
he stands at the foot of the table
and turns his face to the patient.
The most perfect table is, I believe,
Daggett's, of Buffalo, N. Y. (Fig.
108). Whatever table is used
should be placed near a window,
with the foot end turned toward as
good a light as can be obtained. Daggett's Table.
The bladder and the rectum must
be empty. If the bladder is more or less full, the urine may be
drawn when the patient is on the table. If the rectum is loaded, it
FIG. 108.
136
DISEASES OF WOMEN.
is better to postpone the examination until the intestines have been
emptied by means of an enema and an aperient. By neglecting these
precautions the beginner may fall into serious errors, such as to dia-
gnosticate pregnancy or tumors that are destined soon to disappear in
the water-closet.
I. POSITIONS. The two chief positions used for examining a
gynecological patient are the dorsal and Sims's. Of less importance
are the genu-pectoral, the erect, Trendelenburg's, and the ventral
positions.
The Dorsal Position. The patient lies on her back, the head
slightly raised on a cushion, the knees drawn up and widely sepa-
FIG. 109.
Dorsal Position.
rated, and the heels placed on the table or in front of it or above
its foot-end in some kind of holes or stirrups (Fig. 109). The skirts
are pushed up on the abdomen. For a complete examination of the
abdomen the corset must be removed, and all bands round the waist
opened, but for an exploration of the pelvic cavity we need only
insist on the removal of closed drawers. In this way we save much
time and cause the patient less trouble. When she is in position, she
should be covered up to the breasts with a sheet, which thereafter is
folded in between her legs, so as to leave only the vulva exposed.
EXAMINATION IN GENERAL.
137
the
If no inspection is intended, but only a digital examination,
patient remains entirely covered under the sheet.
The modification of the dorsal position called breech-back position
will be described under " Preparation for Operations in General " and
tinder " Urinary Fistula."
Sims' s Position (Fig. 110) is a position on the left side, but by no
means is every left-side position Sims's position. In the latter the
patient lies on her left side half turned over on her front. The left
side of the face rests on a cushion; the left breast touches the table;
FIG. 110.
Sims's Position.
the left arm is placed behind the body ; and, if the table is narrow,
both arms hang down beside it, but if it is too broad, the right fore-
arm and hand may rest on the cushion in front of the face ; the nates
form an inclined plane, the right being a little nearer the head and in
front of the left; the right leg lies on the left, but is drawn a little
higher up toward the pelvis.
These two positions should be used in every case at the first exam-
ination. The dorsal position is the best for bimanual examination,
for the use of the plurivalve speculum, and for the examination of
the abdomen. "Sims's position allows us to introduce one or two fin-
gers much higher up behind the uterus than when the patient is in
the dorsal position. Even things in the anterior part of the pelvis
138
DISEASES OF WOMEN.
are sometimes felt better ; for instance, au anteflexion which cannot
be made out while the patient is on her back, may become quite plain
when the bent uterus falls forward over the tip of the examining
finger in Sims's position. The chief advantage of this position is,
however, that it admits of the use of Sims's speculum, and is prefer-
able to others in certain operations.
The genu-pectoral position is rarely used for diagnostic purposes,
but is sometimes useful in replacing a retroflexed gravid uterus, or a
prolapsed ovary. The patient rests on her knees, the upper part of
the chest, the right side of the face, and the right forearm (Fig. 111).
The thighs are kept perpendicular and the back hollowed.
The erect position is useful in order to ascertain if there is any pro-
lapse of the vagina or uterus. The patient stands with the feet about
FIG. 111.
Genu-pectoral Position (H. F. Campbell).
half a yard apart, slightly bent forward. The physician sits in front
of her and introduces the index-finger into the vagina.
Ti'endelenburg's 1 position (Fig. 112) is sometimes useful in deter-
mining the connection between an abdominal tumor and the pelvic
organs. The patient lies on her back on a strongly inclined plane,
with much-elevated pelvis, and her legs hang over a flap that can be
raised from the table. This position, which rarely is used for diag-
nostic purposes, is of the highest value in operations in the depth of
the pelvis. In protracted operations in Trendeleu burg's position the
pelvic organs become comparatively anemic, and when the patient is
brought back to the horizontal position, a congestion takes place, which
may cause hemorrhage corresponding to what takes place after the
artificial anemia brought on by Esmarch's method. It is, therefore,
1 The accent is on the first syllable: Tren 'del en-burg. This surgeon has called
particular attention to this position, but it was already described by Bardenhener
(Drainirung der Peritonealhohlt, Stuttgart, 1881, p. 276), and is said to have been used
still earlier by Billroth in Vienna,
EXAMINATION IN GENERAL.
139
a wise precaution to raise the foot-end of the bed during the first two
or three hours after the operation. 1
The ventral position is needed when we want to use percussion on
the lumbar region ; e. (j. in a case of supposed floating kidney. The
patient lies stretched out on her front surface and one side of her face,
and the physician stands at her side.
When the patient is placed in the proper position, we proceed to
examine her, and, in order not to overlook anything, we will consider
separately the examination of the pelvis, the examination of the abdo-
men, and other diagnostic means.
II. THE EXAMINATION OF THE PELVIS. The means employed
are inspection ; digital examination through the vagina, the rectum,
and the bladder; combined examination; artificial prolapse of the
uterus; specula; the uterine sound; the probe; and dilatation of the
cervical canal.
A. Inspection is performed while the patient is in the dorsal posi-
tion. Having in mind the normal anatomy of the external genitals
(pp. 35 to 47), we pay attention to every deviation from the standard.
FIG. 112.
Trendelenburg's Position (Leopold's apparatus) : a, adjustable flap ; b, supporter ; c, wooden
frame fastened with clamps to table.
B. Digital Examination. The fingers, especially the two index-
fingers, are instruments of exploration of the very greatest value.
The touch can to a great extent replace vision, and is sometimes
superior to it e. g. in judging of the extent of a cervical laceration
1 H. C. Coe, New York Policlinic, Sept., 1893.
140 DISEASES OF WOMEN.
but a good deal of practice is needed before the limit of all the possi-
bilities of this sense are reached. Great care should be taken to cul-
tivate both index-fingers, as it is an immense advantage to feel equally
well with both. By being able to do so, we can often avoid changing
the position in which we find the patient, which in private practice
often is preferable. Besides, the patient being in the dorsal position,
we feel best with the homonymous finger i. e. we feel what is in the
right side of the pelvis best with the right index-finger, and what is
in the left side with the left index-finger.
The fingers and the hand are used in several ways. The index-
finger may be introduced into the vagina, the rectum, or the bladder;
the fingers of the other hand are used on the abdomen ; and dif-
erent forms of these explorations may be combined.
Cleanliness. It goes without saying that the physician shall have
clean hands and short nails, kept clean with brush and steel, but strict
asepsis, which is the absolute duty of the obstetrician, is not required
for common gynecological examinations.
Lubricants. Before the finger is introduced into the vagina it
ought to be made slippery with some suitable lubricant, such as
vaseline, olive oil, or a solution of soap. In rectal examinations it is
a good plan first to fill the space under the nail by running it over
a cake of soap. For vesical examination only the mildest lubricants,
such as vaseline or olive oil, should be used.
Vaginal Examination. The patient is in the dorsal position. The
physician stands in front of her, observing her face, which will often
give valuable information in regard to tenderness, pain, or sexual
excitement. If the vulva does not gape, the labia majora are sepa-
rated with the thumb and index-finger of one hand, while the index-
finger of the other is introduced. As a rule, only the index-finger is
use^ in the vagina. It is stretched, the last three fingers are bent
flat in against the hand, so that one right angle is formed at the
joints between the metacarpus and the first phalanges, and another
between the first and second row of phalanges The index-finger,
again, forms a right angle with the first phalanx of the middle
finger, and the thumb is either extended so as to form a right
angle with the metacarpal bone of the index-finger, or bent
against the second phalanx of the middle finger (Fig. 113). In
exceptional cases, and in women with large vaginal entrances, both
the index and the middle finger may be used simultaneously in the
vagina, which allows us to penetrate fully an inch deeper, but causes
some pain. In entering it is well first to ascertain the condition of
the vaginal entrance, especially the perineal body. In proceeding
we notice the condition of the walls of the vagina in regard to- smooth-
ness, rugosities, hardness, adhesions, cysts, etc. Next, w r e place the
tip of the finger on the os, and examine its size, shape, and direction.
EXAMINATION IN GENERAL.
141
We notice the length, thickness, shape, and consistency of the cervical
portion. The remainder of the vaginal examination is done much
better by the bimanual method than by the unassisted finger. For
this purpose the physician places the four fingers of the other hand
on the hypogastric region in the middle for the examination of the
uterus, over the right and left iliac fossa for that of the appendages,
the broad ligaments, the parametria, etc. and presses well down, so
as to bring the organs within easier reach of the finger in the vagina,
and at the same time palpate them from above.
The index-finger is placed against the anterior part of the vaginal
roof, while the fingers of the other hand rest on the fundus. Thus we
easily sweep over the anterior surface of the uterus. Next we place
the inside finger against the posterior part of the roof of the vagina,
the so-called cul-de-sac, and push the fingers of the other hand with
the tips turned downward and the pulp forward, far down behind
the uterus, which in lean women allows us to examine the whole pos-
terior surface of that organ. After that we place the inside finger on
the left lateral part of the vaginal roof, and the outside fingers over
the corresponding iliac fossa. By pushing the inside finger well
FIG. 113.
Combined Examination (Schroeder).
upward and backward, a little outside of the edge of the uterus, we
are sometimes enabled to feel the ovaries, the tubes, the sacro-uterine
ligaments, cysts of the broad ligaments, exudations, infiltrations, pel-
vic abscesses, etc. Finally, we examine the right side of the pelvis
in the same way.
142 DISEASES OF WOMEN.
Rectal examination is best performed with the patient in Sims's
position. We look for hemorrhoidal tumors, fissures, mucous patches,
chancroids, etc. The physician stands behind the patient, and intro-
duces his right index-finger as far as it goes, which is to the so-called
third sphincter (p. 87), and in so doing pays attention to tumors,
ulcers, or strictures of the intestine itself, and to the condition of the
genitals in front and the sacro-uterine ligaments to the sides. Some-
times the uterine appendages are felt better from the rectum than
from the vagina. In cases of abdominal tumors this examination
ought never to be neglected, as valuable information is often gained
thereby which cannot be obtained in any other way. But in most
cases the diagnosis can be made by the other modes of examination,
and as this one is particularly disagreeable to physician and patient,
and much more painful than a vaginal examination in a woman who
has had sexual intercourse, it is by no means used in every case.
A peculiar evolution of the rectal touch is Simon's intestinal examin-
ation, by which the four fingers, the whole hand, and even a great
part of the forearm, are introduced through the anus, the rectum, the
sigmoid flexure, and all the way up to the upper end of the de-
scending colon. The feasibility of this procedure shows how disten-
sible the spincter ani is, but it is a dangerous manipulation, which
has caused i rupture of the intestine, and is one of the diagnostic means
which formerly, when abdominal surgery was yet in its infancy, was
of value, but which has fallen into disuse since laparotomy has become
so harmless that we do not hesitate to perform it for diagnostic pur-
poses.
Vesical Examination. The urethra can easily be dilated by means
of a set of seven coniform tubes with obturators (Fig. 114) vary-
ing from 1^ to 2f inches in circumference, until the index-finger
can be introduced into the interior of the bladder. This procedure
permits the palpation of tumors in the bladder itself or between the
uterus and the bladder, facilitates the introduction of instruments into
the ureters, and may decide about the presence or absence of the
internal genitals in a case of atresia of the vagina. The patient is, of
course, anesthetized, and occupies the dorsal position. The method
is valuable, but, as sometimes it has led to incurable incontinence, 1 it
ought only to be risked in cases in which the information sought is
of great importance and cannot be obtained in any other way. 2 As
a rule, we can reach our goal by means of a catheter in the bladder
and a finger in the vagina or the rectum, or both.
Combined Examination. Sometimes it is an advantage to combine
1 T. A. Emmet, Principles and Practice of Gynecology, 2d ed , 1880, p. 732.
2 I have, for instance, done it successfully in an old lady with a large cancer-
ous mass situated on the base of the bladder, so as to preclude incision from the
vagina.
EXAMINATION IN GENERAL.
143
several of the above-mentioned methods. Thus, a good mode of
examining the perinea! body is to introduce the index-finger into the
rectum and the thumb into the vagina simultaneously. In other
cases the middle finger is introduced into the intestine, the index-
finger into the vagina, while the four fingers of the other hand
palpate through the abdominal wall.
C. Artificial Prolapse of the Uterm, by which this organ is pulled
down by means of a volsella to the entrance of the vagina, is much
practiced abroad, and has some advocates in this country. 1 The
method is not without danger, as it is liable to set up an acute peri-
tonitis or cellulitis where there are remnants of old similar affections,
and even endanger the integrity of the tubes or large veins in the
broad ligaments if, perhaps, they are bound by old adhesions which
escape our attention. It is better not to be too zealous a diagnostician
Fia. 114.
Gustav Simons's Urethral Specula : B represents the largest size ; A is one number
smaller (Two-thirds natural size).
than to risk making the condition of the patient worse in trying to
determine its precise character. 2
D. ^pecula. In order to see the deeper parts of the canals leading
to the pelvic organs we have instruments called " specula," which at
the same time are of great importance for treatment, since they render
it possible to make applications to, or perform operations on, the
1 Howard Kelly.has constructed a special kind of hook for the purpose (Amer. Jour
Obsfet., 1891, vol. xxiv. No. 2, p. 141 ).
* For details the reader is referred to a paper by H. C. Coe, Med. Record Aue ( J
1890, vol. xxxviii. p. No. 6, p. 141.
144 DISEASES OF WOMEN.
parts exposed. We have vaginal, cervical, rectal, urethral specula,
and the cystoscope.
Vaginal Specula. Of these there are a great variety, but virtually
they may be reduced to three types : the tubuliform, the plurivalve,
and the univalve specula.
Of the tubuliform specula, Fergusson's is the one most in use (Fig.
115). It is made of glass, covered with black varnish on the outside.
FIG. 115.
Fergusson's Vaginal Speculum.
A layer of tin-foil is inserted between the glass and the varnish.
The proximal end has a flange which serves as handle and as check
in introducing the instrument. It is mostly used with the patient
on her back. The labia majora are separated, the most prominent
end is introduced through the vagina, pressing on the periueal
body. The anterior and posterior walls of the vagina shall be seen all
the time touching one another in a transverse line until the vaginal
portion with the os takes their place. This speculum gives excellent
light, but is inferior in all other respects : it pushes the uterus away ;
it spreads out a torn cervix, so that the tear may b.e overlooked j 1 it
cannot be used for the inspection of the f'ornix of the vagina, which
is often of as much interest to see as the os ; it does not allow us to
introduce the sound through it, unless we take a very wide and short
one, which, again, can only be used where the vagina is exceptionally
wide, and which causes pain ; and it is hard to clean.
Of the plurivalve specula, some modification of Cusco's bivalve
e. g. Brewer's speculum (Fig. 116) is most generally useful. A
good instrument of this class should have few blades, for the more
blades the more folds of the vagina will get in between them and
obstruct the view. It should have a rounded end, so as to be intro-
duced without causing pain. It should have a very wide opening,
in order to admit much light, and at the same time be narrow at the
vaginal entrance, so as not to cause too much distension and pain
there. The blades should be of the same length : if the anterior be
1 The almost exclusive use of this speculum in England accounts in a' great meas-
ure for the tardiness with which Emmet's laceration and its cure by operation were
recognized there.
EXAMINATION IN GENERAL.
145
half an inch shorter than the posterior, as in some instruments of
this kind, the os cannot be seen if the uterus is anteverted.
Fin. 116.
Brewer's Speculum.
The bivalve speculum is used to greatest advantage in the dorsal
position. Before introducing it the physician ascertains by touch the
position of the os, and directs the instrument, closed, in that direction
to its full length or till he reaches the vaginal portion. Then the
branches are separated by turning the screw, and the instrument
pushed a little farther in, so as to reach the fornix of the vagina.
The univalve, or Sims' s speculum (Fig. 117) is the only one that
FIG. 117.
Sims's Speculum.
shows the uterus and the anterior wall of the vagina in their normal
position and relation, since all it does is to pull back the perineal body
and the posterior vaginal wall. It covers a smaller part of the vagina
than the other two. It alone allows us to combine touch with sight,
10
146 DISEASES OF WOMEN.
and it is indispensable in the performance of operations for conditions
which before its invention were incurable.
Sims's speculum is most frequently used with the patient in the
genu-pectoral or in Sims's position, but it is often also used either on
the posterior or on the anterior wall of the vagina, or on both at the
same time, in the dorsal decubitus. Generally, two Sims's specula,
of different sizes, are combined in one instrument, but for use on the
posterior wall of the vagina in the dorsal decubitus a single one, with
a suitable handle, is required.
Sims's own way of introducing his speculum was to hold the han-
dle with the left hand and use the thumb and index-finger of the
right hand as a guide (Fig. 118); and where there are folds or other
obstacles in the way, this is the best way of introducing it, the end
of the finger being used to push the obstacles aside and place the end
FIG. 118.
Introduction of Sims's Speculum.
of the speculum behind the cervix. But in ordinary cases the physi-
cian seizes the handle with the right hand, placing the tip of the index-
finger at the base of the blade to be introduced. He stands behind the
patient, separates the labia, holds the speculum so that its plane forms
an angle of 45 with the top of the table, pushes it slowly in along
the posterior wall to the posterior cul-de-sac, and brings it then over
on the right side of the coccyx. After that he performs a move-
Tnent in the direction of part of a circle, by which the perineal body
and the posterior vaginal wall are pulled back. In so doing he gives
the air free access to the vagina, and the viscera, falling by their own
weight, up against the anterior abdominal wall and the diaphragm,
the air distends the vagina so that it becomes more like a hollow
globe than a cylinder the so-called ballooning. This 1 ballooning
may, however, occur under circumstances in which air-pressure can-
not be the moving principle. I have often felt it in examining
EXAMINATION IN GENERAL.
147
.patients in the dorsal position, and I have felt an exactly similar dis-
tension of the rectum when the examining finger excluded all entrance
of air. In such cases the ballooning is, in my opinion due to con-
traction of muscles extending from the wall of the cavity in question
to fixed points in the surroundings (p. 43 and Fig. 55, p. 58).
If the os and posterior lip do not present themselves, they must be
brought forward in some way, either by pulling on the anterior lip
with a tenaculum, or, since this causes some pain, preferably by intro-
ducing the end of a sound into the os, if that can be reached, or by
using a depressor on the anterior wall of the vagina, such as Sims's,
consisting of a flexible metal rod with a loop at each end (Fig. 119),
FIG. 119.
Sims's Double Depressor.
or, better, J. B. Hunter's, a silver-plated copper rod ending in a spoon
at each end (Fig. 120), or my own, which will presently be described.
FIG. 120.
Hunter's Depressor.
Modifications of Sims's Speculum. Munde's speculum (Fig. 121)
is a Sims's speculum to which is added a flange that holds the upper
nates out of the way. Hubbard W. MitchelFs speculum (Fig. 122) is
a single Sims's speculum with Munde's flange and wings, which give
a good hold for the index- and middle fingers.
Self-holding Sims's Specula. If a man holds one of these flanged
specula in his left hand, or a common Sims's speculum, requesting
the patient to lift the upper nates herself, and he holds the depressor
in the right hand, he can see well enough, but no hand is left for
treatment. The consequence is, that he must have an assistant. The
presence of a third person, especially a female nurse, offers many
advantages, but not everybody who wants to use Sims's speculum,
has sufficient gynecological practice to make it pay to keep one for
the purpose. A number of instruments have, therefore, been con-
structed with the aim of making the assistant superfluous by render-
148
DISEASES OF WOMEN.
ing Sirns's speculum self-holding. The best instrument of this class
is, in my opinion, that of the late Dr. Ehrich of Baltimore (Fig.
123). It is true, no in-
strument can surpass the FlG - 122 -
hand of an experienced
nurse, but to hold Sims's
speculum for any length of
time is very trying, and
Eh rich's speculum is infi-
nitely more useful than the
hand of an assistant who
has not had great practice
in holding it. It is a sin-
gle Sims's speculum with
FIG. 121.
Mund^'s Speculum.
H. W. Mitchell's Speculum.
flanges for both nates, fastened to a curved metal rod articulating
with a plate which rests on the sacrum, and is kept in place
by means of a band going over the patient's left shoulder. If
sometimes a little help is needed, it may be rendered by any by-
stander, since all that is required is to pull the curved rod a little
backward.
All these self-holding apparatus are, however, bulky, expensive,
apt to scare the patient, and take much more time to apply than a
common Sims's speculum. In order to have all the advantages of
EXAMINATION IN GENERAL.
149
the latter without being obliged to have an assistant for a mere appli-
cation, curetting, and
similar manipulations, I Fio. 123. 1
have had a vaginal de-
pressor constructed which
is held with the same
hand as the speculum
(Fig. 124). 2 The han-
dle, seen to the left, is
held against the middle
part of a double Sims
speculum. The other end
is placed in front of the
cervical portion. The
bow in the middle cor-
responds to the vulva
and leaves the vagina
unencumbered. It is on
purpose that there is no
connection between the
depressor and speculum.
A slight pressure with
the thumb allows the
physician to bring the
depressor in whatever Ehrich's speculum.
FIG. 124.
Garrigues' Vaginal Depressor.
1 This figure represents the speculum so modified that the vaginal blade is divided
into two lateral halves, which can be separated and approximated by means of a
screw. It has also a depressor for the anterior wall which is fastened to the upper
flange. This depressor prevents one from pulling the uterus down and has not ap-
peared practical to me.
2 H. J. Garrigues, "A Vaginal Depressor," Med. Record, 1881, vol. xx. p. 698.
150
DISEASES OF WOMEN.
direction may be needed for the inspection of any irregularly placed
os, and the instrument is easy to cleanse.
All specula are smeared with a similar lubricant as the one used
for the examining finger (p. 140). When the cervix is exposed it is
in most cases necessary to wipe away the mucus that covers it, which
FIG. 125.
Bozeman's Dressing Forceps.
is done by means of a long pair of dressing-forceps (Fig. 125) holding
a pledget of absorbent cotton dipped in some antiseptic fluid.
Cervical specula (Fig. 126) are conical or cylindrical tubes on a
long shaft which are pushed into the cervical canal. They are less
used for seeing than for preventing any application destined for the
FIG. 126.
Burrage's Cervical Speculum : a, tube ; b, handle ; c, movable clasp, preventing ends of wire
composing handle from slipping out of d, small tube at right angles to main tube ; e,
smaller cervical tube to replace a; /, obturator titling the two tubes.
cavity of the uterus from being rubbed off on the cervical wall, and
for packing the uterine cavity with gauze.
Rectal specula cause much pain, and should therefore not be used
unless imperatively needed for diagnosis or treatment. Often a Sims
or bivalve vaginal speculum may be used instead of a special rectal
speculum. Ashton's rectal speculum is constructed on the same prin-
ciples a.s Fergussou's vaginal, but with a closed round end and fenestra
on the side (Fig. 127). Kelsey's bivalve rectal speculum is the best
I know of (Fig. 128).
Urdhral specula are sometimes needed. Jackson's (Fig. 129) con-
sists of a tapering glass tube, closed at one end and provided with a
EXAMINATION IN GENERAL.
FIG. 127.
151
Ashton's Rectal Speculum.
flange at the other, and having a fenestra on one side. It is conve-
nient to have a set of three such tubes, but the one two and a half
Fia. 128.
Kelsey's Rectal Speculum.
inches long and half an inch in outside diameter will be suitable for
most cases. 1 Skene has adapted Folsom's nasal speculum to the
FIG. 129.
Jackson's Urethra! Speculum.
urethra (Fig. 130). It consists essentially of two oblong eyes of
1 A. Reeves Jackson, Amer. Gyn. Trans., 1877, vol. ii. p. 575.
COLLIE
152
DISEASES OF WOMEN.
metal wire separated by spring force, and capable of being kept at the
desired distance by means of a set-screw. For the inspection of the
deeper parts of the urethra reflected light is
FIG. 130. necessary.
Oystoscope. By the introduction of a minute
electric lamp into the bladder Nitze and Leiter
have made this hidden cavity as distinctly visi-
ble as the glottis illuminated by the laryngo-
scope. 1
E. The Uterine Sound (Fig. 131) consists of
a somewhat flexible silver-plated copper rod
with a flat handle. At the end it has a little
knob, at 2| inches a small protuberance with
a notch marking the normal depth of the ute-
rine cavity, and other notches with figures by
which the deptli to which the sound enters is
easily read off.
The sound is a very useful, and, when properly used, harmless,
instrument, but in handling it we must never forget that it is a metal
FIG. 131.
Folsom - Skene's Urethral
Speculum.
Simpson's Uterine Sound.
rod hard enough to perforate the wall of the womb, and that it is
introduced into a cavity from which absorption easily takes place.
The greatest gentleness of manipulation and antiseptic precautions are
therefore indicated. As to the latter, it is hardly feasible to carry
them out strictly in every case, but we ought at least to disinfect the
sound, and, if there is any bad discharge in the vagina, it ought to
be removed by an injection and swabbing before the sound is intro-
duced. By the use of the sound pathogenic germs may be brought
from the vagina, where they abound, or from the cervix, where they
often are found, into the cavity of the corpus, which never is their
normal habitat. But in order that the reader may not form an exag-
gerated idea of the danger of this mode of infection, I may state that
with a very free use of the sound, and that for many years, before
I used any antiseptic precautions, I have only four times seen inflam-
mation occur-; once acute metritis, and in the other cases exudative
peritonitis.
The sound is commonly used in the dorsal or in the lateral posi-
1 Willy Meyer, "On Cystoscopy," New York Med. Jour., Apr. 21, 1888.
EXAMINATION IN GENERAL. 153
tion, with or without speculum. As a rule, I think the introduction
in the left lateral position without speculum is the best. The sound
should never be used before the position and the shape of the uterus
have been ascertained by palpation, and if there is any marked devia-
tion from the normal direction of the uterine canal, the sound should
be curved so as to correspond to it, apart from the slight curve which
always is given to the last 2| inches in order to introduce it more
easily into the canal, which forms an angle with the vagina (p. 53).
The tip of the left index-finger is applied to the os ; the lubricated
or wet sound, held between the thumb and index-finger of the right
hand, is slid along the palmar surface of the finger till it reaches the os;
then the finger is placed on the front or back of the uterus and used
to tilt that organ in the proper direction in order to facilitate the
introduction of the sound. A peculiar snap is felt when the sound
passes the internal os. Often it is caught in the folds of the cervix
(p. 49) ; then it must be pulled a little back, and turned in another
direction. When once it has passed the internal os, the handle is
pushed well back until the stem points in the direction of the umbili-
cus. As soon as the resistance of the fund us is felt we desist from
further pushing.
In cases of anteflexion the introduction is often greatly facilitated
by introducing the sound with the concavity turned backward as far
as it goes, and then reversing it, or by giving it a sharp curve near
the end like a prostate catheter.
In order to measure the depth of the uterus, the handle of the sound
is held with the left thumb and index-finger, the tip of the right
index-finger is applied to the sound just below the anterior lip, the
sound is grasped with the right hand and withdrawn, and finally
the distance from the tip of the finger to the end of the sound is
read off.
Often the sound is used in connection with a finger in the vagina or
in the rectum, or fingers pressed down behind the symphysis in order
to locate tumors in the wall or in the neighborhood of the uterus ;
and sometimes it is used for moving the uterus in different directions,
and thus ascertaining the relation of this organ to tumors in its
vicinity.
F. The Probe. The probe is a much thinner, very flexible rod
with handle, used exclusively for exploring the inside of the uterine
cavity. It is made of metal, hard rubber, or whalebone.
G. The Curette. The curette is an instrument used for scraping
something off the inside of the uterus. It is mostly used as a thera-
peutic agent, but sometimes it is employed in the service of diagnosis
in order to obtain a specimen for microscopical examination. The
chief curettes are Sims's (Fig. 132) and Simon's (Fig. 133) sharp
and stiff, and Thomas's dull and flexible curettes (Fig. 134). In
154
DISEASES OF WOMEN.
the choice of a Thomas dull wire curette the purchaser should take
good care not to buy one that is so flexible that it bends while being
FIG. 132.
Sims's Sharp Curette.
used. It should only be so flexible that it can be bent to adapt itself
to the shape of the uterus in which it is going to be used. Simon's
FIG. 133.
Simon's Sharp Curette.
seems to me the best instrument for the cervix, and of late years I
use it also more and more in the body of the uterus. In curetting
FIG. 134.
Thomas's Dull Wire Curette.
great care should be taken to disinfect the instrument, the vagina,
and the interior of the womb both before and after operating.
H. Dilatation. Sometimes it becomes necessary for diagnostic
purposes to dilate the cervical canal sufficiently to introduce the
curette or the finger. This may be done slowly by means of tents, or
rapidly by means of cones or diverging rods working on the principle
of a glove-stretcher.
Tents are cones made of substances that swell by absorption of
fluid, especially sponges, sea-tangle (laminaria), tupelo root, and slip-
pery-elm bark. It is next to impossible to get these tents disinfected,
and they are therefore dangerous, and ought only to be used in very
exceptional cases, especially for the dilatation of fistulous tracts.
Laminaria tents are disinfected by placing them for one or two
minutes in boiling antiseptic fluid. This makes them, at the same
time, so soft that they can be curved to fit a bent cervical canal, and,
on being placed in cold fluid, they become immediately hard again.
Still, they should never be brought in contact with a fresh wound.
If the sound is used and a drop of blood appears, the introduction
of the tent should be postponed for twenty-four hours. The patient
must keep absolutely quiet for a few hours until the tent is suffi-
EXAMINATION IN GENERAL.
155
ciently swollen to be retained. The labor-like pain produced by the
swelling may be relieved by applying a hot-water bag, cloths wrung
out of hot water, or a hot poultice to the abdomen. Jf needed, four
or more tents may be introduced, one after the other, changing them
twice in twenty-four hours, and washing out the uterus at the same
time. 1
The tent is introduced with a pair of dressing forceps or Barnes's
tent-carrier (Fig. 135).
For diagnostic purposes, and as part of treatment, dilatation is
FIG. 135.
Barnes's Tent-Introducer. A tent is seen fitted to the end ready for introduction. When it
has been placed, the stylet on which it is mounted is withdrawn through the larger tube,
with which the tent is steadied till the stylet is quite free from the tent.
much safer when performed rapidly. For the lower degrees of dila-
tation a few of Hanks's coniform hard-rubber dilators (Fig. 136) are
FIG. 136.
Hanks's Uterine Dilator.
very serviceable. Where there is great narrowness of the os, it may,
however, become necessary first to make a small incision in its edge.
For the next degree of dilatation, up tol^ inches, a strong instrument
of the diverging kind is required. I have had one made which I
FIG. 137.
Garrigues' Uterine Dilator.
think unites the best features of the different instruments of this class
(Fig. 137). It has Ellinger's parallellogram ; only one handle, in
1 This is the method of B. S. Schultze, Centralblatt fiir Gyndkol., 1878, vol. ii.
p. 150.
156 DISEASES OF WOMEN.
order not to lose light ; fine ridges on the lower part of the branches,
in order to prevent the instrument from slipping without bruising
the uterus too much ; curved branches, since these are more easily
introduced than the straight, and the uteri upon which they are used,
are commonly ante- or retroflexed. For the very highest degrees of
dilatation which, however, scarcely are needed for mere diagnosis
another set of instruments originated by Hanks for the treatment of
abortion are excellent. They consist of a set of oblong balls of
hard rubber screwed on each end of a curved shaft of the same
material. One of the balls serves as a handle while the other is
being slowly pressed through the cervix, the lips of which are in
the beginning pulled gently over the ball ; but later on pressure alone
is used to propel the same through the internal os. Filling out the
gap between these two sets of dilators, the author has had a series of
ten hard-rubber olives made, which can be screwed on a metal shaft.
Since dilatation cannot be resorted to without bruising and tearing
the tissues to some extent, it goes without saying that the rules of
antiseptic surgery must be scrupulously observed.
Dilatation has been carried to such an extent as to make the whole
cavity of the uterus visible up to the fundus (Vulliet's method *).
This is obtained by introducing small bulbs of absorbent cotton im-
pregnated with iodoform ether (1 part iodoform to from 10 to 30
ether), dried, and tied to strings. These balls are carried with
dressing-forceps and sound right up to the fundus. Local anesthesia
is produced with pledgets dipped in cocaine solution. The patient is
in the genu-pectoral posture. If the cervical canal is too narrow, it
is first dilated by means of the above-mentioned dilators. The tam-
pons are left in for forty-eight hours.
In order to get the cervix and lower uterine segment dilated, it is
sometimes necessary to combine the use of these cotton balls with a
bundle of laminaria tents, the cotton ball being pushed up in the
centre of the bundle as far as the middle of the cervical canal, so as
to form a cone which is left in from ten to fifteen hours. After the
dilatation of the cervix has been obtained in this way, only cotton
balls are used and the packing renewed. Occasionally this method
might prove valuable both for diagnostic purposes and for the re-
moval of tumors from the cavity of the body of the womb.
I. Examination of Virgins. The vaginal examination ought to be
avoided as much as possible in virgins. In cases where the symptoms
are not grave, such as leucorrhea, menstrual disturbances, backache,
etc., it is better to desist from an attempt at an exact diagnosis, and first
try the effect of medical treatment. Some information may be gained
by the rectal exploration. If, however, the symptoms point toward
more serious trouble, a vaginal examination becomes imperative, but
1 Vulliet et Lntaud, Lemons de Gynecologie op&ratoire, Paris, 1890, p. 75.
EXAMINATION IN GENERAL. 157
ought only to be undertaken with great care and deliberation. Un-
fortunately, many girls are easy enough to examine, but in a really
intact girl the introduction of the finger meets with considerable
resistance, and the sharp edge of the hymen is felt like a fine steel
cord on the pulp of the finger. With the exception of a few urgent
cases, in which it is necessary for treatment's sake to make a speedy
diagnosis, it is better first to prepare the hymen by the introduction
twice daily of a small tampon of absorbent cotton soaked in glycerin.
By gradually increasing the size of the tampon at every change the
parts will in a few days be sufficiently softened and dilated to allow
the index-finger to pass. It should be carefully lubricated all over
and introduced very slowly, in order to avoid causing unnecessary pain
and rupturing the hymen. When once the finger has passed, a small-
sized speculum may be used if necessary.
III. The Examination of the Abdomen. The patient occupies the
dorsal position ; the physician stands at her right side. The diag-
nostic resources at his command are inspection, palpation, percussion,
auscultation, mensuration, injection of water into the intestine, and
production of carbonic acid in the stomach.
A. Inspection. The practiced eye can frequently, at the first glance,
distinguish the more pointed prominence caused by a tumor or preg-
nancy from the flat enlargement due to an accumulation of free fluid
in the abdominal cavity or to hyperplasia of adipose tissue. We
look for changes in pigmentation (linea fusca), subepidermal tears in
the skin (strice albicantes), and the protrusion of the navel.
B. Palpation is superficial or deep. By folding the abdominal wall
we judge of its thickness and mobility. By slight pressure we some-
times get a crackling sensation due to fresh adhesions. By deep
pressure we try to gain as much information as possible about the
contents of the abdomen. We examine if there is any abnormal ten-
derness anywhere. We feel for hard masses. If we find any, we
try their mobility. If it is the uterus that is enlarged and has risen
up into the abdomen, the best way of testing its mobility is to place the
index-finger on the os and move the fundus from side to side, when the
cervix will be felt to move in the opposite direction. If the mass
contracts while being palpated, we know that is the gravid uterus.
If a patient makes a deep inspiration, a tumor of the liver will
ascend under the following expiration while all other tumors may
be kept down with the hands. 1
In palpating tumors the bimanual examination (Fig. 113, p. 141)
is likewise often used. The physician stands then between the legs
of the patient. Often an assistant is needed to lift the tumor or
move it from side to side. By placing the fingers of one hand lightly
1 Kaunyn, reported by Minkowski, Centralblatt fur Gynakologie, 1888, vol. xii.
p. 790.
158 DISEASES OF WOMEN.
in one place and pressing on another with those of the other hand, we
ascertain if there is any fluctuation a sign which denotes the presence
of a fluid. In a case of pregnancy we may be able to recognize certain
parts of the fetus.
C. Pwcussion. By means of percussion we find out whether we
have the normal tympanitic sound of the intestines containing gas, or
a dull or flat sound characteristic of a solid mass or a fluid. We note
very carefully the limits of the dull area, by which we get valuable
information in regard to the starting-point of the tumor. If it is a
fluid, we make the patient alternately lie on the back and on either
side while \ve use percussion. If the fluid sinks down, leaving a
tympanitic area above, we conclude that the fluid moves freely in the ab-
domen (ascites), whereas it cannot change position if enclosed in a cyst.
D. Auscultation often gives information of the very greatest im-
portance. Whenever we have to examine an enlarged abdomen we
ought always to bear pregnancy, normal or extra-uterine, in mind as
the key to the whole condition or as a complication. We listen,
therefore, for the double sound characteristic of the fetal heart, for
the sound caused by fetal movements, and for the blowing sound
(uterine souffle) formed in the large vessels running along the sides
of the womb. The latter may, however, also be heard in fibro-cystic
tumors of the uterus. The bruit produced in an aneurism of the
abdominal aorta has a different character, and is accompanied by
other characteristic signs.
E. Mensuration. The measures are taken with a tape-measure in
the dorsal position. This method is especially used in order to form
an idea of the size of a tumor, and gives sometimes information in
regard to its starting-point. The measures usually taken are the
girth at the level of the umbilicus, the girth at the most prominent
point of the swelling, the distance from the umbilicus to the symphy-
sis, the ensiform process, and the anterior superior spine of the ilium.
F. Development of gas in the stomach and injection of water into
the intestine have recently been recommended for diagnostic purposes.
The stomach is expanded by giving bicarbonate of sodium and tar-
taric acid together. Later the stomach is evacuated by introducing a
soft-rubber oasophageal sound, and tepid water is injected into the
intestine by means of a fountain syringe. In this way a tumor is
displaced in the direction from which it has started. 1
G. Charts. It saves much time and contributes to a precise diag-
nosis to use printed charts representing the outline of the abdomen
and pelvis in front and side view, and mark on them the location of
any swelling found by examination. 2
1 Naunyn, Centralblatt f. Gyn., 1888, vol. xii. p. 790.
2 Rubber stamps for recording cases are manufactured by the Barton Manufactur-
ing Co., No. 338 Broadway, New York.
EXAMINATION IN GENERAL. 159
IV. Other Means of Investigation Common for Pelvic and Abdom-
inal Diseases. Such are exploratory aspiration, exploratory incision,
urinary analysis, microscopic examination, chemical examination, ex-
amination under anesthesia, and examination of the ureters.
A. Exploratory aspiration is used less now than it was some years
ago. It is done in order to ascertain the presence of a fluid or to
obtain a sample of such fluid for examination. If the fluid is thin,
it may be drawn out by the common hypodermic syringe. For use
in the vagina such a syringe has been made with a longer needle and
an attachment by means of which the piston can be pulled out. 1 In
most cases it is preferable to use a real aspirator, such as Dieulafoy's,
Potain's (Fig. 138), or Emmet's. Even the finest hypodermic nee-
dle ought to be carefully disinfected before being plunged into the
interior of the body, and the same precaution ought to be taken in
regard to the skin it is going to perforate. As a rule, a cavity once
entered should be totally emptied in order to prevent the fluid from
finding its way into the peritoneal cavity. As this may be very
tedious, a syphon action may be substituted for the aspiration by
attaching a rubber tube to the needle and placing the other end,
armed with a plunger, in a vessel with water. Aspiration ought
never to be performed in the office or dispensary, and the patient
ought to be kept in bed for four days. In order to lessen as much as
possible the danger of wounding blood-vessels, the finest instrument
that will do the work is preferable, and it ought to be introduced
slowly, so as to push arteries aside which it might meet in its way. If
the puncture is made through the skin, the opening should be pressed
together from side to side and covered with a piece of rubber adhesive
plaster. (Compare " Tapping," under Treatment of Ovarian Cysts.)
B. Exploratory Incision. With the increasing iunocuousness of
opening the peritoneal cavity the exploratory incision has to a great
extent replaced exploratory aspiration. It is, of course, in many cases
only the first act of a capital operation, and must therefore only be
undertaken by a person qualified to perform the latter, and after all
preparations for such an operation have been made. The incision may
be made through the abdominal wall or through the vagina. The
incision in the abdominal wall is not made larger than is necessary to
clear up the existing doubt, for which purpose the introduction of one
or two fingers often suffices. As a rule, it is made in the median line
and so that the lower end of the incision comes to lie two finger-
breadths above the symphysis pubis.
The exploratory incision in the vagina may be made in the anterior
or the posterior vault. In most cases an opening in the posterior
vault large enough to admit two fingers allows us to explore the whole
1 Campbell, southwest corner Lexington Avenue and Thirty-fourth Street, has
made such a syringe for me.
160
DISEASES OF WOMEN.
pelvis, and, this being the simpler operation, it should, as a rule, be
preferred. 1 The incision may be made either transversely at the utero-
vaginal junction, or perpendicularly, extending from the cervix to the
bottom of Douglas's pouch. In exceptional cases the anterior incision
is preferable, which involves the separation of the bladder from the
uterus (see Vaginal Hysterectomy).
Aspirator. This instrument consists of a clear glass bottle, with a graduated scale showing
the amount of fluid contained. It is closed by a rubber stopper, through the centre of
which a double-current tube, 2, passes. It is attached to an elastic hose, 3, with an ex-
hausting pump, 4, and another elastic hose, 5, with a stopcock, 6. On the top of the latter
fit needles and trocars, 7, of different sizes.
C. Urinary analysis ought to be made in every case before an ope-
ration is undertaken, and even before the patient is subjected to the
influence of anesthetics, as the result of the analysis may decide which
anesthetic should be preferred (see Anesthesia). But even in minor
1 Garrigues, " Vaginal Hysterectomy and Oophorectomy after Symphysiotomy,"
Med. Record, Feb. 23, 1895, vol. xlvii. No. 8, p. 234.
EXAMINATION IN GENERAL. 161
gynecology the examination of the urine often gives valuable hints as
to diagnosis or treatment. The urine should be examined chemically
and microscopically.
D. Catheterization of Bladder. In most cases the patient may pass
her urine herself and send it for examination, but if there is any
complaint referable to the bladder, the urine should be drawn with
the catheter. To do this under the clothes is easy enough, but entirely
antiquated. We know that by introducing mucus from the vagina
or vulva into the bladder we may set up cystitis. The meatus urin-
arius should, therefore, be exposed, the patient being either in the
dorsal or" left-lateral position. The vulva is opened with the fingers
of the left hand, and the vestibule wiped with a pledget of absorbent
cotton wrung out of an antiseptic solution. Next the disinfected
catheter, held with the thumb and index-finger of the right hand, is
introduced. A metallic catheter is preferable, as it is easier to keep
clean, and in many examinations a stiff rod is needed. It ought to
be smeared with vaseline or olive oil, and introduced in a curve
hugging the symphysis pubis.
E. Microscopical examination is of great diagnostic value for the
gynecologist. It is applied to the urine, pathological fluids obtained
by aspiration, and solid bodies removed with the curette or cutting
instruments. In examining urine special attention is paid to the
presence of epithelial cells from the different parts of the' urinary
tract and the external genitals (Fig. 139), to casts characteristic of
nephritis, and to the different crystals abnormally seen in urine. 1
As a sample of fluid let us take that from an ecchinococcus. A
single booklet or a particle of the structureless stratified cuticula,
revealed by the microscope, settles the diagnosis. A piece of tissue
scraped off with a curette or cut off with scissors may tell us if it
comes from a part affected with carcinoma.
F. Chemical Examination. Chemical reactions are especially used
to reveal the presence of sugar, albumin, or gall in urine or other
fluids.
G. Examination under anesthesia is, of course, only used in more im-
portant cases, since the process always contains an element of danger ;
but this is so small, and the benefit to be derived for the diagnosis so
great, that this means of investigation is perfectly justifiable. Some
women contract their muscles so persistently that it is impossible to
make a thorough examination without having recourse to this means,
when often the existence of a condition calling for active interference
will be brought to light.
H. Examination of the Bladder and the Ureters. The size, sensi-
1 For details the reader is referred to the work of Charles Heitzmann, Microscopic
Morphology of the Animal Body in Health and Disease, New York, 1883, with its
excellent illustrations.
11
162
DISEASES OF WOMEN.
tiveness, and elasticity of the bladder can be tested with a metal cath-
eter, and its inside can be seen with the galvanic cystoscope or the
bladder-speculum.
FIG. 139.
Epithelial Cells found in Urine X 500 (C. Heitzmann) : B, from bladder, superficial layer ;
BM, from middle layers of bladder ; BD, from deepest layer of bladder ; P, from the
prostate ; E, from the ejaculatory duct ; V, from superficial layer of vagina ; \'M, from
middle layers of vagina ; VD, from deepest layer of vagina ; C, from the outer surface of
the cervix uteri ; U, from the cavity of the ute'rus ; PK, from pelvis of kidney ; KC, from
the convoluted tubes of the kidney ; KS, from the straight tubes of the kidney.
The galvanic cystoscope is an instrument that has somewhat the
shape of a lithotrite and carries a minute Edison electric lamp into the
bladder, the whole inside of which can be made distinctly visible.
EXAMINATION IN GENERAL.
163
The instrument can be introduced without dilatation through any
urethra admitting a No. 23 French bougie. 1
Howard Kelly's bladder-speculum 2 necessitates previous dilatation
of the urethra, but offers the advantage that the inside of the bladder
can not only be seen, but can be treated locally on any limited area.
The patient is at first placed in the common dorsal position, and the
bladder emptied with a catheter. By means of a coniform calibrator
FIG. 140.
Kelly's Urethral Dilators.
introduced into the urethra as far as it will readily go, the measure
of the meatus urinarius is taken. A dilator (Fig. 140) of the same
size is inserted instead of the calibrator, and gradually replaced by
thicker ones. The average female urethra can easily be dilated up to
12 millimeters in diameter with only a slight external rupture. As
FIG. 141.
Method of Holding the Speculum during Introduction, the thumb pressing upon the
handle of the obturator (Kelly).
soon as a dilatation of 12 to 15 millimeters is reached, a speculum
(Fig. 141) of the same diameter as the last dilator is introduced and
1 Willy Meyer, " On Cystoscopy and the New Cvstoscope of Nitze and Leiter,"
N. Y. Med. Journ., April 21, 1888.
2 This method and the instruments used have been claimed by Pawlik as his
(Amer. Jour. Obst., March, 1896, vol. xxxiii. pp. 387-405, and August, 1896, vol.
xxxiv. pp. 253-261).
164
DISEASES OF WOMEN.
its obturator removed. The hips of the patient are now elevated on
cushions 8 to 16 inches above the table. The examiner puts on a
head-mirror in a dark room, and reflects the light from a source held
close to the patient's symphysis pubis; or a good direct light from a
window will suffice. Upon withdrawing the obturator, the pelvis
being elevated, the bladder becomes distended with air. If a pool of
urine remains in the bladder, it should be withdrawn by a suction
apparatus made for the purpose (Fig. 142). If the residuum is not
FIG. 142.
Suction Apparatus (three-fourths natural size), used for withdrawing residual urine (Kelly).
more than 2 or 3 cubic centimeters, it can easily be removed by little
balls of absorbent cotton grasped with a long mouse-toothed forceps.
In some inflammatory cases the bladder will not balloon out in the
ordinary position, owing to its thickened walls. Then the genu-pec-
toral position (p. 138) is used. This position is, upon the whole, best
for a first examination. If the patient cannot remain long enough in
this position, its advantages may often be secured by placing her for
a short time in that position until the viscera gravitate up and out of
the pelvis, and introducing a catheter into the bladder, which at once
fills with air. The catheter is now withdrawn, and the patient gently
returned to the dorsal position with more or less elevated hips. Upon
introducing the speculum the bladder will be found distended with air.
In nervous patients it is often best first to make a thorough examina-
tion under anesthesia. A pledget of absorbent cotton saturated with
a 5 per cent, solution of cocaine and left for five minutes in the urethra
greatly facilitates the dilatation and is often the best form of anesthesia. 1
The ureters may be examined by inspection, by catheterization, and
by palpation.
1 Howard Kelly, Amer. Jour. Obst., January and July, 1894.
EXAMINATION IN GENERAL. 165
With the galvanic cystoscope the nreteral openings can be seen, as
well as the discharge of urine that takes place through them. In
cases of unilateral pyelonephritis clear urine is seen coming through
one of the openings, and a purulent fluid through the other. Casper's
improved galvanic cystoscope allows one also to introduce a fine flexi-
ble catheter into the ureter.
If Kelly's bladder-speculum is used, by elevating the handle of the
instrument the field of vision sweeps over the base of the bladder
until the region of the interureteric ligament comes into view, often
marked by a transverse fold or a distinct difference in color. By
turning the speculum thirty degrees to one side or the other and look-
ing sharply, a ureteral orifice is discovered. In order to ascertain that
it is the ureter which lies in the field, a searcher that is a long deli-
cate sound with a handle is introduced through the speculum into
the supposed ureteral opening. If it is the ureter, the searcher passes
easily from 2 to 6 centimeters up the canal. The searcher may then
be replaced by a metal catheter or by hard-rubber bougies, which lat-
ter may be introduced before hysterectomies and prevent injury to the
ureters during the operation. After some practice it is possible even
to catheterize the ureters with the patient in the dorsal position with-
out elevating the pelvis. Commonly a speculum 10 millimeters in
diameter suffices for inspection, catheterization, and treatment of the
ureters.
Catheterization of the Ureters by PawliK's Method. The anterior
vaginal wall presents folds corresponding to the trigone (Figs. 83 and
143), and permitting us to locate the openings of the ureters. The
patient is placed in the dorsal position, with legs strongly flexed on
the abdomen, and the posterior vaginal wall drawn down with a single
Sims speculum. A delicate catheter (Fig. 144) is then carried into the
bladder, and poised between thumb and index-finger. The position of
the end of the catheter is plainly seen in the vagina as it sweeps gently
over the floor of the bladder. The ureteral orifice is to be sought
for about an inch back of the internal opening of the urethra and
about one-half or three-quarters of an inch from the median line on
either side. This position of the ureter, however, is not constant,
and cannot be relied upon alone. Far more characteristic is the
slight tripping sensation given to the point of the catheter as it
glides over the ureteral prominence. As soon as this sensation is per-
ceived the catheter must be at once brought back to the place where
it was felt, and gentle attempts made to engage its point by repeatedly
carrying the handle upward and outward to the other side, and direct-
ing the point toward the posterior lateral wall of the pelvis. With
each of these sweeping motions the catheter is rotated until the point
is directed fully outward or slightly upward. Once caught, the
catheter sweeps readily in, and, if lightly held, directs its own course,
166
DISEASES OF WOMEN.
the fingers simply following. The anterior vaginal wall is seen lifted
up in advance and to one side of the cervix, forming a distinct pocket
on the side on which the ureter is being catheterized.
FIG. 143.
Pawlik's Vaginal Trigone, corresponding to Lieutaud's vesical trigone : L, labia minqra ; 0,
ir.eatus urinarius ; O,' O,' urethral ledge ; .S, S, lateral folds corresponding to the sides of
the vesical trigone ; B, fold corresponding to the basis of the vesical trigone ; V, vaginal
portion of uterus.
Before trying to catheterize the ureters the bladder is injected with
about six ounces of a blue anilin solution, which removes rugosities of
FIG. 144.
Pawlik's Ureteral Catheter.
the bladder, makes Pawlik's folds more distinct, and by the, difference
of the color of the fluid shows when the ureter has been reached. 1
1 Howard Kelly, Annals of Gynecology and Pcediatry, August, 1893, p. 642.
EXAMINATION IN GENERAL. 167
On withdrawing the stopper of the catheter a few drops of urine
run out, and then cease, keeping up an intermittent discharge entirely
characteristic. The catheter can be pushed beyond the brim of the
pelvis, up to the pelvis of the kidney, by introducing an index-finger
into the rectum, and lifting and guiding the catheter while it is being
pushed up. Sometimes the ureters may even be catheterized without
anesthetizing the patient.
Palpation of the Ureters. When there is no disease the ureters
can usually be felt with facility as more or less flat cords about one-
eighth of an inch in diameter, movable to an extent of one-half to
three-quarters of an inch, in the loose pelvic connective tissue at the
side and in front of the cervix. The patient may be in the dorsal
position, and both hands used, the homonymous index-finger in the
vagina (i. e. the left for the left ureter, the right for the right), or
she may be in Sims's position. In both positions the vaginal roof
is pushed well upward, when the ureter may be felt, hooked, brought
down, and compressed.
A practical and safe method of obtaining urine from one ureter
alone is very desirable in order to locate and treat disease there, and
to ascertain the presence and healthy condition of the second kidney,
when the removal of one is contemplated.
It goes without saying that the puke should be counted and its
character noted, the temperature measured with a clinical thermometer,
and such other investigations made in regard to the condition of other
organs and the general health of the patient as the case may call for.
PART VI.
TREATMENT IN GENERAL.
THE treatment of gynecological diseases is preventive and curative ;
the latter, again, is carried out by external manipulations, by the inter-
nal use of drugs, or by electricity.
CHAPTER I.
PREVENTIVE TREATMENT.
WHAT can be done and is to be attempted in the way of pre-
venting gynecological diseases, can easily be inferred from a study
of the chapter on etiology, but the beginner must not be too
sanguine in his expectations or too positive in his demands, if he
will avoid disappointment or the loss of his patient. As soon as
his advice clashes with that of the dressmaker or social habits, ninety-
nine women will be decided by these last two factors for one who
will follow the first. Where this antagonism does not come into play,
much good may, however, be done by timely warning.
At puberty girls should not be exposed to mental overwork, and
at no time should the practice of music be carried so far as to engen-
der nervousness. All sexual excesses and unnatural practices should
be avoided. The skin should be kept clean. The muscles should be
strengthened by exercise and games. Some time, at least an hour
every day, should be spent in the open air. Good, wholesome food
should be taken at proper times, and in sufficient quantity to make
up for the physiological tissue-consumption. The bladder should be
emptied when a desire is felt to do so. An evacuation from the
bowels should take place once or twice a day. The body should be
sufficiently covered, especially in the cold season. In winter time
women should wear woollen drawers, but they should not be " closed,"
as this tempts to neglect proper evacuation of the bladder. Corsets
ought to be banished from the dress of children, girls, and young
women. All of them ought to go early to bed as a rule, not later
168
TREATMENT IN GENERAL. 169
than ten o'clock. During menstruation they should carefully avoid
exposure, violent exercise, or sexual intercourse. If suffering from
chronic pelvic inflammation they had better abstain from marriage.
Good midwifery, both as to surgical help and conscientious use of
antiseptics, not only in hospitals, but in private practice, 1 goes far to
prevent later disease. Puerperse should be kept in bed until the
uterus has receded into the pelvis.
Lacerations of the cervix and the perineum, if not healed immedi-
ately after delivery, should be repaired by the proper operations
before the bad effects consequent upon them make their appearance.
Women should be told to what enormous dangers they expose them-
selves by availing themselves of abortionists, and miscarriages should
be treated with great care according to the tenets of modern mid-
wifery, and especially all the products of conception should be re-
moved. Antiseptic precautions should be taken as far as feasible,
even in minor gynecological operations and examinations. A man
who has had a gonorrhea should not marry before a careful examina-
tion by a competent judge has ascertained that he is perfectly cured.
1 The writer has since 1883 repeatedly called the attention of the profession
to the importance of aseptic and antiseptic midwifery. He was the first to in-
troduce strict antisepsis in this country. On the first day of October, 1883, the
whole arrangement of the New York Maternity Hospital was changed, and the
results were so striking that the example was soon followed by others, and that the
treatment then inaugurated has been kept up ever since with insignificant modifica-
tions. His first report was given in a paper on " The Prevention of Puerperal
Infection " read before the Medical Society of the County of New York, and pub-
lished in the Medical Record, December 29, 1883, vol. xxiv., pp. 703-706. Soon
followed an article under the same title, especially on the use of injections, published
in the New York Medical Journal, March 1, 1884. Then came a paper on " Puerperal
Diphtheria" published in Transactions, Amer. Gynecol. Soc., vol. x. 1885, pp. 96-113.
Next, he treated the whole subject of puerperal infection at greater length in book-
form in his Practical Guide in Antiseptic Midwifery, Detroit, Mich., 1886, and in a long
article on "Puerperal Infection" in the American System of Obstetrics, edited by
Hirst, Philadelphia, 1889, vol. ii. pp. 290-378, as well as in a similar article in the
American Text-book of Obstetrics, edited by Norris, Philadelphia, 1895, pp. 683-734.
The article on "Corrosive Sublimate and Creolin" in Amer. Jour. Med. Sci., Au-
gust, 1889, contained the only change he in the course of time found it advisable
to make.
In hospital practice strict antisepsis is now used everywhere, but in private prac-
tice we lag yet in a deplorable way behind other countries, and the result is to be
found in frequent disease and death among the well-to-do, which have nearly dis-
appeared from the lying-in hospitals. It is to be hoped that the general practitioner
soon will follow the lead of the expert obstetrician in this field. At my motion the
following resolution was unanimously adopted on October 27, 1892 ; " In the opinion
of the Section on Obstetrics and Gynecology of the New York Academy of Medi-
cine, it is the duty of every physician practicing midwifery to surround such cases
in private practice with the same safeguards that are being used in hospitals " (Garri-
gues, "Reprehensible, Debatable, and Necessary Antiseptic Midwifery, Med. JVeics,
Nov. 26, 1892).
170 DISEASES OF WOMEN.
CHAPTER II.
EXTERNAL TREATMENT.
A. Applications. Applications of medicinal substances are made
to the vagina or to the uterus. The patient is in Sims's position, the
parts are exposed with Sims's speculum and my depressor (p. 149).
After having wiped the mucus off with absorbent cotton, the vaginal
vault is painted with common tincture of iodine, by means of a large
camel's-hair brush on a long handle. The throat-brushes with wooden
handle that are found in the drug-stores, are quite serviceable for this
purpose. As the iodine smarts when it reaches the vulva, care should
be taken not to fill the brush too much, and to wipe the superfluous
fluid off with absorbent cotton before the patient rises. In the vagina
I prefer the common tincture of iodine to Churchill's, as I have seen
the latter produce ulceration.
For applications to the interior of the uterus an applicator is needed.
Budd's (Fig. 145), which is a flexible flattened hard rubber stick, is
as good as any, recommends itself by its simplicity, and is easy to keep
FIG. 145.
Budd's Uterine Applicator.
clean. It is sold straight, but it ought to be curved like a sound.
This is easily done by warming it over an alcohol lamp and bending it.
A little absorbent cotton is fashioned so as to form a thin rectan-
gular pledget, 3 inches long by 1 wide. The applicator is held at right
angles a little inside of one of the ends and one of the sides, and the
cotton is rolled round it with the fingers of the left hand, going down
in a spiral line toward the handle. By a little practice it becomes
easy to put it on smoothly and of variable thickness, according to the
caliber of the cervical canal. The thick mucus that is often found
in the cervical canal must first be \viped off with dry cotton, or, if
this proves impossible, it is coagulated by applying a mixture of
equal parts of tincture of iodine, tannin, and carbolic acid.
Some prefer to make applications to the inside of the uterus by
means of a glass pipette, or through a cervical speculum (p. 150).
If the canal is too narrow it must be dilated (p. 154). For the endo-
metrium, I use mostly Churchill's tincture of iodine, liquor ferri
chloridi undiluted, chloride of zinc (20 to 50 per cent.), and occa-
sionally sol. argent, nitrat. 1 to 12, or pure carbolic acid.
As some patients are very sensitive to intra-uterine applications, it
TREATMENT IN GENERAL.
171
is best to restrict the first application to the cervix, and gradually
penetrate into the cavity of the body up to the funclus.
Drugs may also be made up as ointments, and applied in the inte-
rior of the womb by means of Barnes's ointment carrier, a silver tube
with large side openings and a piston. Or they may be incorporated
in small rods, so-called bacilli, made with cacao-butter or althaea,
which are pushed through a metallic tube with open end (E. Martin's
pistol). Powders, especially boracic acid, iodoform, and aristol, may
be applied in the interior of the uterus by means of a similar instru-
ment. All these tubuliform instruments have, however, the grave
drawback that it is next to impossible to keep them clean. I have,
therefore, of late years, discarded them all in favor of the applicator
wound with cotton.
Applications are, as a rule, repeated twice a week.
B. Injections. Injections are made into the vagina, the uterus,
the rectum, and the bladder, with plain or medicated water, by means
of a syringe.
Vaginal injections are used to greatest advantage in the dorsal posi-
tion on a bed-pan (Fig. 146). A good bed-pan should be large, and
have an opening near the bottom with an attached rubber tube to
carry off the water into a larger vessel placed under the bed. If it does
not have such a contrivance, and is not large enough, the water may
FIG. 146.
Bed-pan, holds nearly seven pints : A, tube closed with plug, B, unless used to make connec-
tion with rubber hose leading to vessels placed under the bed ; C, tube for emptying pan ;
>, cover to be screwed on the same when not in use.
be gradually pumped out by means of a bulb-and-valve syringe
(Davidson's syringe) while running into the bed-pan.
Patients who are obliged to help themselves may also take their
vaginal douche standing over a chamber-pot placed on a chair, or
sitting on a bidet.
It is best to use a fountain syringe; that is, a bag of soft rubber,
or a metal pail, a so-called douche-can, with a long soft rubber tube
and a nozzle of metal or preferably hard rubber. The nozzle should
only have holes at or near the end, and it should be pushed in so far
that the openings are behind and above the os uteri. If there are
172 DISEASES OF WOMEN.
side openings lower down or the nozzle is not introduced to the proper
depth, an opening may face the os and some fluid be injected into the
uterus, which gives rise to a very painful and alarming uterine colic.
If the chief aim of the injection is to combat inflammation and
cause absorption of inflammatory exudations, plain hot water is the
best. The amount should not be less than two quarts. The tem-
perature should be as high as the patient can stand it i. e. so that
she just can hold her hand in it (110 to 115 F.). In exceptional
cases hot water increases instead of relieving pain, and is then advan-
tageously replaced by lukewarm water. Cold injections are injurious.
For merely cleansing the vagina for instance, when a pessary is
worn a pint of tepid water suffices, and its effect may be increased
by adding a heaping teaspoonful of common salt or bicarbonate of
sodium.
If an astringent is called for, alum, borax, or equal parts of sul-
phate of copper and alum are dissolved in the water. Of alum or
borax, a teaspoonful is added ; of the mixture of copper and alum,
only half a teaspoonful.
If there is a spongy os uteri giving rise to hemorrhage, I use half
a teaspoonful of the liquor ferri chloridi to a pint of water.
For antiseptic injections carbolic acid (1 to 2 per cent.) or creolin
(^ to 1 per cent.) are used. The latter is also an excellent hemo-
static, but in some patients it produces a smarting sensation. Bichlo-
ride of mercury should be avoided, except for gonorrhea, on account
of its poisonous properties, 1 and the solution should not be stronger
than 1 to 3000 or even 5000.
As an emollient injection a decoction of flaxseed tea or slippery-elm
bark, a heaping teaspoonful to each quart of water, is good.
Vaginal douches are, in chronic cases, as a rule, used morning and
evening, and in acute three times a day, or even every three hours.
Intra-uterine injections are much more dangerous than vaginal
injections, and should always be administered by the physician him-
self. We distinguish between small and large intra-uterine injections.
The former are really only applications of drugs made on a larger
scale. The injection is made by means of a small glass syringe with
a long nozzle, with one or more fine openings near the end (Fig.
147). Having seen several cases of alarming collapse follow the use
of this method, and knowing that it has been fatal in the hands of
others, I have entirely discarded it.
Large uterine injections are used for cleaning and disinfecting the
uterus and for checking hemorrhage. If the cervix has been thor-
oughly dilated before injecting, a single-current tube is preferable, as
it leaves more room for evacuation of large ddbris. For this purpose
1 Garrigues, "Corrosive Sublimate and Creolin in Obstetric Practice," Amer. Jour.
Med. Sci., Aug., 1889, vol. xcviii. pp. 109-128.
TREATMENT IN GENERAL. 173
I find the so-called soft-metal male catheters sold in the stores of the
instrument-makers very convenient, as they are easily bent so as to
adapt themselves to any shape of the uterine canal. By adding a
flange at the open end, connection is easily established with a fountain
FIG. 147.
Braun's Uterine Syringe.
syringe (Fig. 148). If the cervical canal is not so wide, a double-cur-
rent uterine tube (Fig. 149) should be used. When it is of import-
ance to bathe the whole inside, cervix and body, it is best to use two
FIG. 148.
Garrigues' Single-current Intra-uterine Tube.
single-current catheters, a thinner afferent and a thicker efferent.
The fluid then comes out partly through the thick tube and partly
between and around both.
The patient is placed on a table, unless she is so weak that it is
deemed better to leave her in her bed, and only move her sufficiently
beyond one edge to have a free back-flow from the vagina. The outer
leg is placed on a chair. Whether she remains in bed or is placed on
a table, a rubber sheet or oil-cloth is pushed in under her buttocks,
and pinned with two pins so as to form a funnel, the lower end of which
opens into a slop-pail. Intra-uterine injections ought only to be
given in the dorsal position in order to avoid the entrance of the fluid
through a possibly dilated tube into the peritoneal cavity. The
vagina is first disinfected by injecting some of the fluid and by swab-
bing the wall thoroughly with large pieces of absorbent cotton dipped
in the same. Cusco's speculum is introduced. The intra-uterine tube
is attached to the tubing of the fountain syringe, and, all air having
been expelled, is pushed up to the fundus of the uterus while the
fluid is turned on. The physician watches the flow all the time to
make sure that there is no obstruction. I use about a quart for the
vagina and from a pint to a quart for the uterus. When the uterus
is deemed to be sufficiently washed out, it is squeezed in order to
remove all fluid from its cavity. Finally, the vagina is again douched,
and the perineum depressed so as to allow all fluid to flow off.
For these injections I prefer creolin (1 per cent.), as it is a non-
174 DISEASES OF WOMEN.
poisonous reliable disinfectant and an excellent hemostatic. Lysol is
also good, and has the advantage of forming a nearly clear mixture
FIG. 149.
Goelet's Double-current Intra-uterine Tube.
with water. I have never seen any untoward symptoms follow this
kind of injections.
If the patient is anesthetized, it is better to dilate the cervix, intro-
duce a cervical speculum (p. 150), and introduce an intra-uterine tube
through the speculum all the way up to the ftindus.
Rectal injections, enemas, or clysters are used for emptying the lower
part of the bowels, or as a vehicle for medicinal substances to be
applied to the diseased mucous membrane, or in order to exercise an
influence on the pelvic organs, or to overcome an obstruction in the
intestine, or to mark the course of the intestine (p. 158). If the
object is only to cause a movement of the bowels, plain lukewarm
water may be used, or a teaspoouful of salt may be added, or soap-
suds or an infusion of linseed-meal (a tablespoonful to a quart) may
be injected. In cases of constipation with inipaction of hard feces
the following is an excellent enema: a teaspoonful of inspissated
ox-gall, a tablespoonful of glycerin, a tablespoonful of castor-oil, and
a heaping teaspoonful of salt, to a quart of linseed-meal infusion.
The ox-gall is stirred with the warmed glycerin, the oil is added,
then the flaxseed tea, and finally the salt.
For tympanites an enema with a teaspoonful of oil of turpentine,
a tablespoonful of castor-oil, and a quart of soap-suds or flaxseed tea
is good. All these enemas are given lukewarm.
In diseases of the rectum often astringents or sedatives are used in
injections. As the fluid in these cases is meant to be retained for
some time, the amount should be small ( 3j to ,liv).
Large injections (1 to 2 quarts) of hot water (110 F.) into the
rectum have been recommended instead of vaginal injections in
uterine and other pelvic disease. 1 They offer the advantage that the
hot water reaches a larger area in the pelvis, but the aperient and
weakening effect is in most cases a drawback.
1 J. E. Chadwick, Trans. Amer. Gyn. Soc., 1880, vol. v. p. 282.
TREATMENT IN GENERAL.
175
After operations rectal injections of a pint of tepid water may be
used to relieve thirst. Similar injections of very hot water may be
used to combat collapse caused by loss of blood.
All rectal injections are best given with the patient lying on her
left side. Evacuant enemas are preferably administered by means of
a bulb-and-valve-syriuge (Davidson's), but where it is desirable that
as much water as possible should enter the bowel, the fountain-syringe
used with very little pressure is by far better.
Vesical injections are used very much in diseases of the bladder.
The patient occupies the dorsal position. For large injections Reyes's
FIG. 150.
Keyes's Irrigator for Bladder.
irrigator (Fig. 150) may be used. It is essentially a fountain-syringe
with a two-way stop-cock, which allows alternately to fill and empty
the bladder simply by turning the stopcock. It may be used with
any hard or soft catheter. Another good and simple apparatus for
washing out the bladder consists of a catheter, an intermediate piece
of rubber tubing about two feet long, and a funnel. The funnel
is held up during injection, and is brought down below the level
of the bladder when we want to empty it, thus establishing a si-
phonage. Care should be taken to let as little air as possible
enter the bladder. Where shreds are to be washed out, Notfs
double-current catheter (Fig. 151) with its large eyes will be found
176
DISEASES OF WOMEN.
to answer a good purpose. For smaller injections, Thompson's rubber
bag with stopcock (Fig. 152), inserted into a soft catheter with hard
FIG. 151.
Nott's Double-current Catheter.
rubber mouth-piece is handy. For the injections is used plain
water, or solutions of chloride of sodium (1 per cent.), salicylic acid
(1 per thousand), boracic acid (3 per cent.), tannin (J to 1 per cent.),
FIG. 152.
Thompson's Rubber-bag with Stopcock.
carbolic acid (J per cent.), creolin (J per cent.), permanganate of po-
tassium (^ to 2 per thousand), nitrate of silver (2 to 5 per thousand),
etc. The amount of fluid used varies from half a pint to a quart;
for small injections one to four ounces are used. Generally the fluid
should be pleasantly lukewarm (95 F.), but as hemostatic hot or ice-
water is used. The irrigation of the bladder is repeated once, twice,
or three times a day.
Intravenous, subcutaneous, or intraperitoneal injection of a hot solu-
tion of 6 parts of chloride of sodium in 1000 parts of hot water (110
to 115 F.), or about a flat teaspoonful to a quart, is used with great
benefit to counterbalance loss of blood in operations. (See Uterine
Fibroids.)
C. Curetting. The instruments used for scraping the inside of the
uterus have been described in the preceding chapter (p. 153). The
patient is placed on a table arranged for infra-uterine injection (p. 173).
As the procedure is often protracted and painful, she ought to be
TREATMENT IN GENERAL. 177
anesthetized. 1 The vagina and uterus are disinfected with creolin
(p. 173). The cervix is dilated (p. 154). The condition of the in-
side of the uterus is ascertained by sound (p. 152) or finger. The
index-finger is preferable if the cervix admits it. In introducing it
counter-pressure is made on the fund us with the other hand. The
nail of the finger is often used itself as curette. It is safer than, but
not so efficient as, instruments. In gynecological cases I use the dor-
sal position and introduce the curette through disco's speculum (p.
144) ; or if the patient is anesthetized, I pull the uterus down to the
vulva with a tenaculum-forceps while the perineum and the posterior
vaginal wall are being pulled back with a single Sims speculum. The
curette is moved up and down along the surfaces and edges and from
side to side along the fundus. In cases of incomplete abortion I often
turn the patient on her left side and work with the left index-finger
and the large dull wire curette simultaneously. The scraping should
be continued until everything is removed and the inside of the uterus
is smooth. Then the patient is turned back into the dorsal position.
Finally, the uterus and vagina are again disinfected, and a tampon is
put in the latter until the following day. The hemorrhage is not very
considerable. It is very rarely necessary to renew the tampon. On
changing it a vaginal injection with creolin or carbolic acid is given,
and after its final removal twice a day as long as there is any dis-
charge. The patient is kept in bed for four days. If there is any
pain, which is an exception, an ice-bag is applied over the symphysis
and the patient is given an opiate.
Thomas's dull-wire curette being rather short to be used through
Cusco's speculum (he uses himself Sims's position and speculum), I
have had one made that is eleven inches long. The instrument should
only be used for scraping in the direction from the fundus to the os
and along the fundus. In moving the curette up toward the fundus
great gentleness should be used, as otherwise the instrument may per-
forate the uterus. If this should happen, the beginner need not be
particularly alarmed. It has happened twice to me, and no bad con-
sequences were observed, but in such a case it is necessary to desist
from washing out the uterus, an omission which, of course, in other
respects is undesirable. The smaller the loop of the curette, the
greater is the danger of perforation. We should, therefore, always
use as large an instrument as will enter the cervix and is in reason-
able proportion to the mass to be removed. In cases of incomplete
abortion before the end of the second month, when the large dull-wire
curette does not enter, Recamier's curette (Fig. 1 53) is sometimes useful.
D. Tamponade. The word tampon is French, and means a small
mass of cotton or other soft material which is carried into a wound or
1 This applies to strictly gynecological cases ; in cases of hemorrhage due to recent
abortion, anesthesia can be dispensed with except in very nervous women.
12
178 DISEASES OF WOMEN.
cavity for the purpose of filling it, so as to prevent hemorrhage, or
applying drugs to it, or exercising pressure on it. A tampon being
used for so very different purposes, becomes a very different thing,
and we will, therefore, consider separately the application of rnedi-
FIG. 153.
R6camier's Curette.
cated pledgets in the vagina, the packing of the vagina, the hemo-
static vaginal plug, and the tamponade of the uterus.
Pledgets in the Vagina. Small rolls of absorbent cotton, about
2J inches long and 1 inch thick, with a string of strong crochet-
yarn fastened round the middle and made long enough to hang an
inch or two outside the vulva, are impregnated with some medicinal
substance and pushed up to the posterior vault of the vagina. They
are, as a rule, withdrawn morning and evening, when an injection is
made and a new pledget put in. The cotton may be impregnated
with different substances. The most generally useful and least ob-
jectionable is pure glycerin, which produces a watery discharge, re-
lieves pain, and scatters swelling. I have used iodine-glycerin (5 per
cent.) and an iodoform ointment,
Jfy. lodoformi,
Balsami Peruvian!, ad 3j ;
Vaselini, 3j ;
but have always come back to the plain glycerin. Of late years I
use much ichthyol-glycerin (5 per cent.), which has a special resolv-
ing power and some anodyne effect. As an astringent, for instance,
for a spongy cervix, tannin-glycerin (10 per cent.) is very efficient,
but, as it stains the clothes, it is necessary to wear a napkin with it.
Others prefer boroglyceride or sulphate or acetate of aluminium, in
the proportion of 3j to glycerin Oj. 1
Packing of the vagina differs from the application of a pledget, as
heretofore considered, by the combined action of drugs and pressure
in the treatment of diseases of the uterus, ovaries, and periuteriue
structures. The patient is placed in the knee-chest position, Sims's
speculum is introduced, and the vagina is packed tightly with pledgets
of cotton so as to form an inverted coniform column, filling the poste-
rior cul-de-sac and resting on the pubic arch and the perineum below.
The uppermost pledget, which covers the cervical portion and part of
1 Wiley, Ned. Record, October 8, 1887, vol. xxxii. p. 483.
TREATMENT IN GENERAL. 179
the vaginal roof, should be saturated with pure glycerin. The others are
rolled into cylinders and put in dry. The patient herself or a nurse
withdraws the tampon after thirty-six hours, when a hot douche is
given. The columnizing is repeated two or three times a week. 1
By this method adhesions may be lengthened, cicatrices stretched,
exudations absorbed, congestion relieved, and the vagina lengthened ;
but if the parts are too tender to stand the pressure, other methods
must first be used to overcome the sensitiveness.
The Hemostatic Vaginal Plug. Plugging of the genital canal is one
of the most potent remedies against hemorrhage. A vaginal plug
must be put in in such a way as fully to distend the vagina, for
which often two dozen good-sized pieces of cotton are necessary.
Generally I prefer common cotton batting to any other material.
The balls should be soaked in a 1 per cent, creolin emulsion and
squeezed dry. Thus they acquire both styptic and antiseptic proper-
ties. The first may also be obtained by squeezing them out of an
alum solution, the latter by using carbolized water (1 per cent.). 2
When there is much bleeding from an accessible surface e. g. after
curetting a cancerous cervix the three or four upper pledgets which
immediately touch the cervix should be wrung out of a mixture of
one part of liq. ferri chloridi and ten parts of water. The liquor
should never be used undiluted on a tampon. I have seen it cause
deep ulcers which took weeks to heal, and the removal of the tampon
is very painful. Bichloride of mercury is not good for tampons, as
by imbibition with blood they lose their antiseptic properties.
Instead of cotton batting, a roller bandage, lampwick (Foster), or,
if nothing else can be obtained, clean pocket-handkerchiefs, may be
used, all of which ought to be treated with disinfectants. A strip of
iodoform gauze four finger-breadths wide is good, and may be made
more antiseptic and styptic by powdering it with equal parts of iodo-
form and tannin. The iodoform gauze acts at the same time as a
drain, and is, therefore, particularly appropriate in the treatment of
cancer, but on account of the very porosity of this material I would
not rely on it in severe hemorrhage.
The vaginal tampon is best applied in Sims's position and with
Sims's speculum. The rectum and bladder having been emptied, the
first pledgets are placed around the cervix and then over it, and the
same principle should be followed if a continuous long strip of some
kind is used. Whatever we use should be evenly and tightly put in
with a strong pair of dressing-forceps until the vagina is filled all
the way down to the entrance (but not the vulva). If the patient
1 Nathan Bozemann, " The Value of Graduated Pressure in the Treatment of
Diseases of the Vagina, Uterus, Ovaries, and other Appendages," Atlanta Medical
Register, January, 1883.
2 A stronger solution takes off the whole epithelium.
180 DISEASES OF WOMEN.
cannot pass her urine spontaneously, it must be drawn four times a
day, but that is an exception. The tampon should be removed and,
if necessary, renewed within twenty-four hours, except if made of
iodoform gauze, when it may stay in for five or six days if necessary.
In exceptional cases of severe hemorrhage the vulva, too, must be
filled, and a tightly-rolled towel placed on the perineum and held
tightly pressed against it by means of a bandage which surrounds the
pelvis, and from which one or preferably two tails are carried between
the thighs and fastened in front to the band surrounding the pelvis.
If a strip of some substance has been used, all that is necessary
for its removal is to pull on the lower end, which should be left
hanging just outside the vulva. If cotton pledgets have been em-
ployed, the patient is again placed in Sims's position, Sims's speculum
is introduced a short distance, some pledgets are pulled out with the
dressing- forceps, and the speculum is gradually pushed farther in
until the whole tampon has been removed. Then the patient is
turned on her back and given a vaginal injection with creolin. 1
Tamponade of Uterus. For the uterine cavity only iodoform gauze
should be used. This method is not only used to great advantage in
post-partum hemorrhage, which does not concern us here, but like-
wise for many gynecological conditions, either as hemostatic or for
applying medicinal powders or fluids to the mucous membrane of the
womb, or for causing changes in the structure of the uterine muscular
FIG. 154.
Garrigues' Curved Intra-uterine Packing-forceps.
tissue, especially in chronic endometritis and metritis, and even in the
hope of causing depletion from inflamed tubes. It is used both in the
cervix and in the body of the womb. Even a nulliparous uterus will
admit a strip of gauze 8 inches long and inch wide. On account
of the antiseptic properties of the iodoform the intra-uterine tampon
may be left undisturbed for five or six days.
I have constructed a forceps for its application through an undi-
1 To attach a string to each pledget does not facilitate their removal. The so-called
kite-tail, made by tying all the pledgets to one string, is indeed more easy to remove,
but more troublesome to put in.
TREATMENT IN GENERAL. 181
lated cervix (Fig;. 154). 1 But, as a rule, the cervix should be pulled
down to the entrance of the vagina with a bullet-forceps and dilated
with Hanks' dilators. The uterus should be curetted and washed
out through Barrage's cervical speculum (Fig. 126, p. 150), with a
single-current tube (Fig. 148, p. 173) reaching to the fundus, and the
uterine cavity packed with a strip of iodoform gauze 4 centimeters
wide and folded so as to form four layers 1 centimeter wide, the end
of which strip is left hanging in the vagina, and a pad of the same
material is placed in the vagina. The gauze is pushed through the
speculum by means of a straight forceps (Fig. 155).
FIG. 155.
Garrigues' Straight Intra-uterine Packing-forceps.
Abdominal Tampon. The iodoform-gauze tampon is even used in
the abdominal cavity. Sometimes there may be considerable oozing
of blood after a laparotomy, which does not yield to hot water poured
into the peritoneal cavity. In such cases the hemorrhage is some-
times checked effectually by packing the pelvis with iodoform gauze
through the abdominal wound. The end is left hanging from the
lower end of the wound, and in closing the same one or two of the
lowest sutures are left untied till the next day and the removal of the
tampon. In the mean time sufficient adhesive matter has been formed
to shut off the abdominal cavity from that part where the tampon
was put in, but the adhesions are, of course, weak, and it would be
too great a risk to use injections through the wound. It is a good
plan first to introduce the centre of a large square piece of iodoform
gauze and make a pouch of it, which is subsequently filled with long
strips of gauze the ends of which remain outside (Mickulicz's method).
This tampon acts not only as a plug, but at the same time, on
account of the porosity of the gauze, as a drain. Sometimes it is
necessary to combine the intra-abdominal tampon with one in the
vagina. In order to remove the abdominal tampon, each strip is
pulled out separately and finally the surrounding gauze by pulling
on a strong silk thread inserted for that purpose in its center before
introducing it.
E. ffemostasis. Besides the hemostatic tampon, of which we have
just spoken, other means of preventing or checking hemorrhage are
available: hot water, styptics, cauterization, ligature, suture, and ford-
pressure.
1 Amer. Jour. Obst., vol. xxv. No. 1, January, 1892.
182 DISEASES OF WOMEN.
Hot water is used in vaginal injection (p. 171 et seq.} before opera-
tions in order to diminish bleeding during them (T. A. Emmet). It
is also used to check hemorrhage during operations. Thus a stream
of some hot antiseptic solution may be kept continually flowing over
the field of operation l or may occasionally be directed against the
bleeding surface. At the end of laparotomy hot water is often poured
by the pitcher or through a finger-thick glass tube right into the peri-
toneal cavity. Hot-water injections are also used as a hemostatic
independently of operations, both in the vagina and in the uterus
(pp. 172, 173).
Styptics, especially alum, tannin, and chloride, persulphate or sub-
sulphate of iron (Monsel's solution), are used as applications (p. 170),
on tampons (p. 177), or in injections (p. 172). The undiluted liq. ferri
chloridi or subsulphatis may be applied with cotton to small bleeding
surfaces. Diluted with 10 parts of water, it may be used in injections
or left in on a tampon. A very convenient way of using styptics on
small wounds is in the shape of dry styptic cotton as sold in the drug-
stores.
Cauterization is an excellent hemostatic and, at the same time, an
antiseptic, but as it leaves an eschar, it can, as little as styptics, be
used where healing by first intention is aimed at. The dry heat of
the actual cautery is so powerful a hemostatic that it may even be
used to sever the pedicle of an ovarian tumor without using any
ligature. A very convenient apparatus is Paquelin's thermo-cautery
(Fig. 156), in which a tip of platinum may be kept at different de-
grees of heat by a more or less abundant supply of benzine vapor.
Independently of its hemostatic effect, cauterization is often used
as an antiseptic to sear a wound surface, and thus make it impene-
trable to bacilli. Thus, some use it on the stumps left after removal
of the ovaries or the uterus.
Cauterization by means of the gahano-cautery will be described
under Electric Treatment.
Ligature. Spurting arteries, or more rarely bleeding veins, may
be ligated with silk or catgut, according to the general rules of sur-
gery, but in gynecological practice we are oftener than in other de-
partments obliged to tie, not the isolated bleeding vessel, but a more
or less considerable mass of the surrounding tissue with it (mass liga-
ture). Arteries may be tied where they are severed or in continuity.
Ligature of the Uterine Artery. The uterine artery may be tied
from the vagina. According to Martin, the patient is placed in the
dorsal posture with raised knees. A broad, short, and flat specu-
lum is introduced. The operator, sitting in front of the table,
tries to locate the artery by its pulsation. The cervix is pulled well
over to one side with a volsella. A middle-sized, strong, curved
1 Geo. Engelmann of Boston, Trans. Amer. Med. Assoc., 1885.
TREATMENT IN GENERAL. 183
needle is introduced into the anterior part of the fornix of the vagina,
a finger-breadth [?] from the cervix and on a line with its anterior
circumference. The needle is carried deep in, and pushed out on a
line with the posterior wall of the cervix. Next, the ligature is tied
very tightly. If needed, the same may be done on the other side. 1
FIG. 156.
Thermo-cautery.
There is danger of comprising the ureter in the ligature ; and, since
the ureter lies about half an inch outside of the cervix (p. 81), a fin-
ger-breadth, as advised by Martin, would be a particularly dangerous
distance. In the opinion of the writer, one-third of an inch is the
proper distance.
Fritsch 2 is opposed to methods by which the uterine artery is tied
by means of a mass ligature applied through the vaginal roof. He
says by so doing we do not know what we tie, and even if the uterine
artery is included in the ligature, it is not sure that it is made imper-
vious. He makes an incision an inch and a quarter long in the pos-
terior roof of the vagina on the right and left sides. This incision
divides, as a rule, first the two vaginal branches. Next he cuts deeper
until he has severed the uterine artery, which is then seized and tied
or surrounded by a mass ligature. Then the same is done on the other
side. The wounds are filled with iodoform gauze in order to prevent
rapid healing and the formation of a collateral circulation.
The safest procedure is to make a transverse incision in front of the
cervix, just below the bladder, separate this from the uterus, carry the
bladder and ureters forward with a retractor, ligate the artery by carry-
ing a silk ligature around it with Schroeder's or Folk's needle (see
Uterine Fibroids) from the front backward, cut the ligature short,
and close the vagina with a running suture of catgut.
The uterine artery may also be tied from the abdominal cavity after
performing laparotomy (see Uterine Fibroids).
Ligature of the Internal Pudic Artery. As a rule, this artery
should be cut down upon where it bleeds and both ends tied, but it
1 A. Martin, Pathologic und Therapie der Frauenkrankheiten, Leipzig, 1885, p. 22.
2 H. Fritsch, Billroth und Luecke, Handb. der Frauenkrankheiten, Stuttgart, 1885.
vol. i. p. 949.
184
DISEASES OF WOMEN.
FIG. 157.
may also be tied in continuity by cutting through the skin and fascia
in an oblique line running downward and outward a little above the
spine of the ischium, separating the fibers of the glutens maximus,
holding them apart with retractors, and tearing the deep fascia.
Sometimes sutures are used for hemostatic purposes e. g. a run-
ning catgut suture may be put over a bleeding tear in the broad liga-
ment; or an artery imbedded in tissue may be made to stop bleeding
by passing a needle with thread under its course and tying ; or a
bleeding surface of the abdominal wall may be
excluded from the abdominal cavity by folding
the wall, so as to press one-half of the bleeding
surface against the other, and put sutures
through from side to side as in a mattress (mat-
tress suture). These sutures may be made more
efficacious by using quills, a couple of lead-pen-
cils or pen-holders serving as such.
Forcipressure. Much time is saved by sub-
stituting a temporary strong pressure with Koe-
berle"'s clamp (Fig. 157), a kind of artery-
forceps with catch that has been modified by
many other operators, and therefore goes under
different names (Plan's, Spencer Wells's, Tait's,
etc.). When made of proper size and left for
twenty-four hours, such forceps may be made to
secure even the uterine and the ovarian arteries
in the extirpation of the uterus ; but in most
operations small clamps, five or six inches long,
are used temporarily, and removed toward the
end of the operation when the bleeding is stopped.
If, exceptionally, a vessel yet bleeds, it may, of
course, be seized again with the forceps and secured with a ligature.
F. Dilatation and G. drainage are so intimately connected that we
will treat of them together. In regard to dilatation of the cervix
the reader is referred to what has been said on the subject in the
chapter on Examination (pp. 154-156).
Dr. Outerbridge of New York has constructed an ingenious instru-
ment for permanent dilatation of the cervix and drainage of the
uterus. It consists of a silver- or gold-plated steel wire (Fig. 158),
made so as to form an anterior and posterior blade, with a slight
eversion at one end and bent at right angles at the other. It is self-
retaining, and varies in length and curvature. For its introduction
the patient may be in Sims's or in the dorsal position. The univalve
or bivalve speculum is introduced, the cervix steadied with- a tenacu-
lum, and the dilator put into the grasp of a carrier made for the pur-
pose (Fig. 1 59). It consists of a fork with a movable ball and spiral
Koeberl6's Artery-
Clamp.
TREATMENT IN GENERAL.
185
spring sliding up and down a metal rod with handle. The dilator is
introduced five or six days before expected menstruation, left in
FIG. 159.
Outerbridge's Permanent Dilator of Cervix.
during, and at least from five to eight days
after the same, unless conception takes place
and menstruation does not come on. The in-
strument may be removed with a finger or by
means of speculum and teuaculum or a blunt
hook. 1
Sometimes a perforated glass or hard-rubber
stem is introduced into the uterus, and on the
same principle I have had a glass vaginal plug
made with an opening at the top.
Sometimes an opening is made with knife or
trocar in the vaginal roof, behind the uterus,
with or without laparotomy. This opening is
enlarged by means of a diverging uterine di-
lator and a soft-rubber drainage-tube inserted.
The same may be carried through the abdom-
inal wound. If it is only introduced through
an opening in the vagina into a space shut off from the peritoneal
cavity, the drain should have
a T shape, the upper bar of
the T serving as wings to re-
tain the tube in situ.
In laparotomies often a glass
tube (Fig. 160) is left leading
from the bottom of Douglas's Abdominal Glass Drainage-tube.
pouch or of a cyst which can-
not be entirely removed to the lower end of the wound, where it i*
1 P. E. Outerbridge, Med. Record, April 20, 1889, vol. xxxv. p. 430.
Carrier for Outerbridge's
Dilator.
FIG. 160.
186 DISEASES OF WOMEN.
held, between the lips of the incision, by the sutures. The tube is
closed with a stopper of iodoform gauze, and the accumulating fluid
pumped out at short intervals in the beginning every hour by means
of a small glass syringe and attached rubber tube. It is still better to
utilize the capillarity of iodoform gauze and fill the tube loosely with
a strip of this material, through which the fluid will trickle out.
Great diversity of opinion obtains among leading gynecologists as
to the frequency with which abdominal drainage should be used and
the length of time, the tube should be left in. The more strictly
antisepsis is carried out during operations the less drainage becomes
necessary, and the absorbent power of the peritoneum may to a great
extent be relied upon to remove blood and serum from the abdominal
cavity.
We have already spoken of the use of iodoform gauze for drainage
of the uterus and the abdomen (pp. 179-181). For further particulars,
see Ovariotomy.
H. Bloodletting. Leeches, from two to four in number, may be
applied through Fergusson's speculum to the vaginal portion. In
order to prevent them from entering the uterus a small cotton plug
should be placed in the cervical canal. This method is little used here.
The artificial leech may be substituted with advantage (Fig. 161).
FIG. 161.
Reese's Uterine Leech. It consists of a glass cylinder with scale. By pressure on the plate,
A, a lance-shaped knife is pushed into the tissue of the cervix to a depth regulated by
screwing the disc, I. along the piston, B, and then withdrawn. By pulling the piston out
a vacuum is created, into which the blood enters. The metal fitting, C, can be unscrewed,
so as to allow the removal of the piston and the cleaning of the tube.
Scarification. In most cases no sucking apparatus is needed. A
small spear (Fig. 162) is pushed to the depth of three-quarters of an
FIG. 162.
Buttle's Uterine Scarificator.
inch into the vaginal portion in three or four places, and from half
an ounce to two ounces of blood are withdrawn twice a week. The
posterior lip is less sensitive than the anterior. If the flow does not
stop of itself, the small openings are pressed together with a pledget
of cotton dipped into cold water, or if that does not suffice liquor
ferri is applied or a hot douche is administered.
TREATMENT IN GENERAL.
187
FIG. 163.
Bloodletting is a very valuable remedy in cases of chronic conges-
tion, not only of the uterus, but also of other pelvic organs. It has
great power to relieve pain.
I. Heat and Cold. We have spoken above of hot, lukewarm, and
cold injections (pp. 171-176 and 182). Heat is applied to the
abdomen in the shape of a flaxseed-meal poultice or a rubber bag
filled with hot water or a double sheet of flannel wrung out of hot
water. Sometimes the anodyne effect of such a stupe or fomentation
is increased by sprinkling it with oil of turpentine or laudanum.
Poultices or a small rubber bag with hot water may also be used in
the vagina.
In acute inflammations an ice-bag or a coil with running ice-water
is a more expeditious remedy, and checks in most cases the pain more
efficaciously. Four layers of muslin should be inserted between the
ice-bag and the skin in order to avoid local freezing.
When the acute stage is passed, Priessnitz's compress i. e. a towel
wrung out of cold water and covered with some waterproof material
and held in place with a flannel binder is preferable to both hot and
cold applications. It is changed every six hours and becomes warm
in a few minutes. This change from cold to heat is
a powerful absorbent.
A great variety of baths may be used as valuable
adjuvants in gynecological diseases. A tepid general
bath, of a temperature slightly below blood-heat,
taken for fifteen or twenty minutes twice a week,
keeps not only the skin in good order, but has a
marked soothing influence on irritated nerves. Sitz-
baths of similar temperature may be taken for ten
minutes once a day. The effect on the pelvic organs
may be enhanced by the use of a bath-speculum (Fig.
163), which is introduced into the vagina and allows
the water to fill the same.
Turkish and Russian baths may sometimes be
substituted for warm baths, but are often too irri-
tating or too fatiguing. An artificial steam-bath may
be improvised by placing an alcohol lamp under a
chair and an open umbrella partly over the chair
and partly over the patient lying in bed, and cover-
ing all well with blankets and waterproofs. If the
patient is well enough, she may sit on the chair cov-
ered with a waterproof. Perspiration may also be induced by the
hot pack. The patient is wrapped up tightly to the neck in a blanket
wrung out of hot water, and covered with several layers of dry
blankets. Perspiration should not be allowed longer than from half
an hour to two hours.
Bath-speculum.
188 DISEASES OF WOMEN.
Sea-baths are often very beneficial as a nerve tonic and to check a
disposition to hemorrhage and leucorrhea. A complete hydrothera-
peutic treatment may also do good. On a smaller scale cold water
may be used to great advantage in the shape of shower-baths, sponge-
baths, the wet sheet, or towel-baths. For a sponge-bath the patient
stands in a tub and has a pailful of cold water standing at her side
the contents of which she presses all over her body with a large sponge.
For a sheet-bath a sheet is dipped into a pail of cold water and
thrown from behind over the patient, who is rubbed with it for sev-
eral minutes all over the body. Thereafter the wet sheet is exchanged
for a dry warm one and the rubbing repeated until she is dry all over.
The towel-bath is less powerful, but by no means without effect, in
keeping the skin in order, strengthening the nerves, and brightening
the mind. It has the advantage that no help is needed for its admin-
istration. All that is required is three Turkish towels and a large
basinful of cold water. The patient immerses one of the towels in
the water, presses it a little, and washes the upper half of her body
with it. Then she dries herself with the two other towels, and finally
she repeats the procedure on the lower half of the body, except the
feet, which in most people are treated to greater advantage with warm
foot-baths.
Some European springs enjoy a particular reputation for their sup-
posed effect on female complaints, such as Franzeusbad and Marien-
bad in Austria, Ems and Kreuznach in Germany, and Plombieres in
France ; but it would be a grave mistake to think that any watering-
place can be more than an adjuvant in the proper treatment of diseases
of women.
J. Counter-irritation. Tincture of iodine is often painted once a
day on the skin over a swelling in the deeper parts. When the epi-
dermis is hardened a little, it is well, in order to avoid cracking, to
cover it with a compress soaked in the following wash :
I^j. Acid, cartel, TTLxl ;
Glycerini, ss ;
Aquse, q. s. ad iv.
This allows one to continue the use of the iodine indefinitely.
(Compare p. 170.)
Spanish fly blisters are sometimes used on the abdomen to combat
inflammation in the deeper parts. A large blister is a painful remedy,
and it has appeared doubtful to me if it is any better than other means ;
but half a dozen small blisters, 24 square inches, one of which is put
on every evening, often relieve pain in chronic cases.
K. Tapping and Aspiration. The difference between these two
operations is only that in simple tapping a fluid is given outlet
through the canula of a trocar by pressure from behind, and in aspi-
TREATMENT IN GENERAL.
189
ration by forming a vacuum in front ; but on account of the greater
efficacy of the latter method a smaller trocar, or even a needle, may
be used instead of the large trocar used in simple tapping. The
object is to remove a fluid collected in a normal cavity or a cyst.
Tapping is used much less now-a-days as a separate and complete
gynecological operation than a decade or two ago. Tumors are sel-
dom tapped, the more radical operation of removal being preferred ;
but ascitic fluid has often to be evacuated by tapping. Tapping is
used during ovariotomy to diminish the cyst, and aspiration is often
used as part of a more comprehensive operation e. g. in removing a
pyosalpinx or opening a pelvic abscess. Aspiration through the vagi-
nal roof is used to remove encysted peritonitic exudation or a collec-
tion of pus in the parametrium. Straight and curved, fine and large,
trocars or needles may be needed. We have already spoken of the
use of the aspirator for diagnostic purposes (p. 1 59).
A patient who is going to be tapped through the abdominal wall
should sit on a chair or lie on her side with the abdomen turned to-
ward the operator. The abdomen should be surrounded above and
below the point selected for the operation with a sheet, the ends of
which are crossed in front and pulled upon during evacuation. The
object thereof is not only to produce the necessary pressure for the
evacuation, but to avoid a sudden suction of blood to the abdominal
viscera, which might cause syncope. A quarter of a grain of cocaine
should be injected with a hypodermic syringe into the skin at the
place selected, which, as a rule, should be in the mesial line, midway
between the symphysis and the umbilicus. Full antiseptic precau-
tions should be used. The bladder should be emptied with the
catheter. The trocar is thrust in, the stylet withdrawn, and the fluid
FIG. 164.
Trocar, composed of canula with cap, pointed stylet, and blunt staff.
directed into a pail placed on the floor. When all has been removed,
the abdominal wall is lifted in a fold around the canula, the latter
190 DISEASES OF WOMEN.
is withdrawn, the opening is compressed from side to side, and a piece
of rubber adhesive plaster placed over it.
In the vagina only the aspirator should be used. So far as possible,
the puncture should be made behind the uterus. In front is the
bladder and to the sides are the uterine artery and the ureter. The
latter organs may, however, sometimes be felt and avoided.
Tapping has occasionally proved fatal by lesion of a blood-vessel
in the abdomen. Septicemia may be avoided by antiseptic precau-
tions.
Sometimes the canula is left in as a drainage-tube, and has for that
purpose two eyes for the insertion of cords or wire. The puncture
may be followed by incision or dilatation ; then the pointed stylet
is withdrawn, and a blunt guide with a longitudinal furrow sub-
stituted. The canula is withdrawn and a knife is slid along the fur-
row in the guide (Fig. 164).
L. Abdominal Belts. An elastic abdominal belt (Fig. 165) is often
FIG. 165.
Abdominal Belt.
useful, especially in fat women, to take off some of the pressure on
the pelvic organs, and is used during the first year after laparotomy
to take off the strain on the cicatrix.
When a special pressure above the symphysis is required, an ab-
dominal supporter, with a solid hypogastric pad, is used (Fig. 166).
M. Massage. Certain manipulations inside of the pelvis and
through the abdominal walls constitute a valuable mode of treatment
in many diseases of women, especially chronic metritis, cellulitis,
peritonic exudations, adhesions, hematoma, and oophoritis. Often a
general massage of other parts of the body or the whole body is
added. In this way exudations, infiltrations, hypertrophies, and
adhesions are made to disappear, weak ligaments and muscles
strengthened, and displaced organs brought back and kept in their
normal position. The procedures being rather painful, there is no
danger of causing sexual excitement. The manipulations are quite
complicated, have to be adapted to the special abnormal conditions
TREATMENT IN GENERAL. 191
obtaining, and can hardly be learned except by seeing them carried
out by an expert. Unfortunately, this treatment requires so long sit-
tings l that a gynecologist or general practitioner will hardly find
time to use it himself, and, on the other hand, such fine diagnosis is
necessary that nobody who has not a large experience in abdominal
examinations can be entrusted with it. 2 If blood or pus has
accumulated in the Fallopian tube, massage is counterindicated,
as there is danger of the fluid being pressed into the peritoneal
cavity.
FIG. 166.
Fitch's Abdominal Supporter.
N. Gymnastics. Gymnastic movements, active and passive, are
sometimes a direct cure for certain diseases, perhaps even the best of
all e. g. Thure Brandt's s wonderful cure for procidentia uteri.
In other cases the Swedish movement cure may be a valuable adju-
vant, combined with other methods, and even common gymnastic ex-
ercises, if not too violent, are not only an excellent preventive of
1 Up to three-quarters of an hour ! The length of the sittings is, however, par-
tially counterbalanced by the great efficacy of the treatment, which often leads to
a cure in a short time.
2 The limits of this work forbid me even to give an outline of the different
manipulations used in massage. Those interested in it are referred to the paper by
A. Reeves Jackson of Chicago, on " Uterine Massage as a Means of Treating certain
Forms of Enlargement of the Womb," Trans. Amer. Gyn. Soc., 1880, vol. v. p. 80 ; to
that by H. J. Boldt of New York, on the " Manual Treatment in Gynecology,"
Amer. Jour. Obst., June, 1887, vol. xxii. p. 579 ; to that by H. N. Vineberg on " The
Treatment of Ketrodisplaeements of the Uterus with Adhesions by Brandt's Method,"
N. Y. Med. Record, July 11, 1891; and to Profanter's pamphlet, Die Massage in
der Gynakologie, Vienna, 1887.
8 This is the name of a Swedish layman who is the inventor and successful per-
former of most of the special massage and gymnastics applied in gynecology.
192 DISEASES OF WOMEN.
pelvic diseases, but may be used to advantage toward the end of a
cure begun on other lines. 1
O. Operations in General. 1 . Time for operating. If we have a
choice, operations should be avoided in this climate during the hot
season. It is no small discomfort for the patient to lie in bed for
weeks, when not even the nights bring coolness, and it is rather trying
for the operator to work when the thermometer is in the nineties in
the shade. But I have had hospital-service during the hottest time
of the year, and performed both laparotomies and plastic operations
without the slightest disturbing influence on perfect success.
In general, operations should not be performed on pregnant women,
on account of the danger of producing miscarriage. It would seem
that interference with the rectum is particularly liable to have this
effect. As to the genitals, we may say that the farther the seat of
operation is removed from the uterus the less is the danger of pro-
voking abortion. Sometimes the very presence of pregnancy may
call for operative interference. Vomiting in pregnancy, which may
lead to the patient's death, may be treated successfully by applying
nitrate of silver in substance or in solution to a granular os, or by
stretching the os and lower part of the cervical canal (Copelantfs
method} with the index-finger. Large polypi hanging from the cervix
may be the source of hemorrhage or become an obstruction during
labor. It may, therefore, be wise to remove them with the galvano-
caustic wire. Ovarian cysts should be removed if discovered early.
If the patient is far gone or in labor, tapping may be preferable. If
a cancer of the cervix can be removed, it is better to do so even with
the risk of causing abortion, as the cancer, as a rule, grows rapidly
during pregnancy, and may cause an obstruction during labor that
may cost the life of both mother and child. 2
As a rule, we avoid operations during or near menstruation, on
account of the great congestion of the pelvic organs. Most operators
prefer to operate eight or ten days after menstruation has ceased, but
since we have seen (p. 118) that the menstrual process is finished even
in the uterus itself eight or nine days after the beginning of the flow,
there is no occasion to wait more than four or five days after it has
stopped. As the removal of the ovaries, or probably rather the tying
of the pedicle, very commonly brings on a menstrual flow, even if the
patient has just gone through her menstrual period (p. 119), it may
be preferable in anemic patients, in order to avoid this extra loss of
blood, to operate immediately before or during menstruation. H. P.
1 The value of gymnastics as preventive of and cure for pelvic disorders has been
inculcated by John IT. Kellogg, Med. News, November 8, 1890, No. 930, p. 468.
2 Further information may be found in a paper by M. D. Mann of Buffalo, N. Y. :
" Surgical Operations on the Pelvic Organs of Pregnant Women," Trans. Amer. Gyn.
Soc., 1882, vol. vii. p. 340.
TREATMENT IN GENERAL. 193
C. Wilson [ of Baltimore even prefers, in regard to laparotomies, to
select the " uterine flood " rather than the " uterine ebb," during
which he thinks patients are more liable to passive hemorrhages, the
absorption of septic poison, and the deadly influence of shock, than
when the system is under the stimulus of the uterine flood. More-
over, he believes that the local bloodletting from the uterine mucous
membrane is a healthy derivation from many of the dangers of lapar-
otomy. Tait, 2 Goodell, 3 and Thomas-Munde 4 do not care whether the
patient menstruates or not. Operators may, therefore, be warranted
in not paying much attention to the time of menstruation in regard
to the performance of laparotomies, and sometimes even in preferring
the approacli or the presence of the flow. If the patient menstru-
ates, her vagina, after having been disinfected, should be filled with a
tampon of iodoform gauze. Goodell recommends curetting during
menstruation or metrorrhagia, but to avoid this time in myomectomy
or hysterectomy.
Plastic operations ought always to be performed shortly after men-
struation, as the occurrence of this flow might be mistaken for hem-
orrhage or interfere with proper after-treatment.
Lactation need not interfere with operations. It is only necessary
to discontinue nursing for twenty-four hours, on account of the effect
of the anesthetic on the child, and press or pump out the milk of the
breasts.
The time of the day most suitable for serious operations is the
morning, when the operator may be sure not to have come near any
case from which pathogenic germs might be brought to the patient,
and his own nerves are refreshed by rest and sleep. But other con-
siderations often prevail, and many operate in the afternoon. Day-
time should always be preferred, as no artificial light but the elec-
tric can replace a good daylight. If it is necessary to operate at night,
care should be taken to obtain as perfect an illumination as possible.
2. Preparation for Operations. The more thought the operator
and his assistants bestow beforehand on every detail of a contemplated
operation, the more smoothly it will come off, and, other things being
equal, the better the result will be.
Room. If we have the choice, we should select a large room with
a good light for operating, and, if possible, this should be another
room than the one in which the patient shall lie after the operation,
but contiguous with it. The best room should be reserved for the
after-treatment. According to the season this should either be cool
or have a southern exposure. For an important operation, especially
1 Amer. Gyn. Trans., 1889, vol. xiv. p. 45.
2 Tait, Diseases of Women, p. 212.
3 Wm. Goodell, Med. News, Nov. 29, 1890, p. 560.
4 Thomas, Diseases of Women, 6th ed., p. 718.
13
194
DISEASES OF WOMEN.
a laparotomy, all superfluous furniture should be removed, the carpet
should be taken up, the bedding aired, the floor and, if they are oil-
painted, also the walls should be scrubbed, not only with soap and
water, but thereafter with a solution of bichloride of mercury
(1 : 1000). No curtains should be allowed round the bedstead.
Every object should be carefully dusted. The room should be pleas-
antly warm, about 70 F., or, if the abdominal cavity is to be opened,
even a little more than that.
The bed should have a horse-hair mattress and blankets. If possi-
ble, it is a great advantage to have two beds. With proper precau-
tions even a very sick patient may be moved from one bed to another,
and it contributes much to her comfort.
Table. A strong narrow table should be placed with one end in
front of a window. A common kitchen table four feet long and two
wide is very convenient. It should be covered with a folded blanket
or quilt, a muslin sheet, and a rubber sheet or oil-cloth. The latter
should be pinned together, so as to form a funnel leading at the lower
end of the table, down into a slop-pail. Instead of the latter arrange-
FIG. 167.
Inflatable Surgical Rubber Cushions. 1
ment inflatable rubber cushions (Fig. 167) may be used to advantage.
A towel or sheet may be rolled so as to form a hard cylinder, which
is bent so as to form part of a circle or the three sides of a square,
and in the latter case tied with strings at the corners. This frame is
covered with a rubber sheet. The first part of this arrangement may
be improvised, and the latter is easily carried in a satchel. A pillow
is placed at the head of the table, and this end is slightly raised
1 Howard Kelly, Amer. Jour. Obst., 1887, vol. xx. p. 1030, but H. O! Marcy of
Boston claims many years' priority ( Trans. Amer. Association of Obstetricians and
Gynecologists, 1893, reprint, p. 13,
TREATMENT IN GENERAL. 195
so that fluids may gravitate clown into the pail. For laparotomy it
is better to have the table level with drainage to the side where the
operator stands.
In hospitals tables are preferably used that can be thoroughly dis-
infected. Good tables for this purpose, and with facility for Tren-
delenburg's position (p. 138), have been constructed by Cleveland,
Edebohls, Foerster, and Boldt.
Leopold uses for Trendelenburg's position an apparatus that has
the advantage of being inexpensive and so simple that any carpenter
can make it. It consists of a frame 50 inches long and 20 inches
wide, with a hinged flap that can be raised up. The shorter, lower
part of the flap, upon which the legs rest, can be bent downward, so
as to form a right angle with the upper part, upon which lie the
thighs and the pelvis, and which is a yard long. By means of a
support the flap can be raised as much as 20 inches above the frame,
so that the support forms an angle of about 30 with the upper part
of the flap. The frame is fastened with iron clamps to a table (see
Fig. 112, p. 139).
McNaughton l has had made of galvanized iron a portable attach-
ment that also can be used on common kitchen tables. In hospitals
two long wooden foot-stools, about six inches high, should be in readi-
ness to be used when the patient is brought into Trendelenburg's
position.
Most tables are of a convenient height for the operator to stand at,
but not only are perineal and vaginal operations performed sitting,
but some prefer also to perform laparotomies in the sitting posture.
Then the table should be rather low, and the operator seated on a
high chair between the legs of the patient.
Assistants. For most operations three, four, or even five assistants
are needed, and each of them should have his part distinctly allotted
and explained to him beforehand. One should exclusively be charged
with the anesthesia, and as the patient's life in most cases depends
much more on him than on the operator, this function should be con-
fided to the most experienced man available. In operations with the
patient in the lithotomy position one assistant should hold either knee
under his axilla, thus keeping both hands free for sponging, holding
speculum or tenaculurn, or for such other assistance as may be needed.
In laparotomies one stands opposite the operator and the other at his
left. A fourth assistant may be used to hand instruments, which
saves time and allows the operator to keep his eyes uninterruptedly
on the field of operation ; but, in order to limit the possible sources
of infection as much as possible, some operators prefer to place their
instruments within reach and dispense with this assistant. As a
1 McNaughton's attachment is sold by H. A. Kavsan in Brooklyn, N. Y.. for
$12.00.
196 DISEASES OF WOMEN.
rule, the assistance of a nurse is required to hand and clean sponges,
and attend to fluids, basins, pitchers, syringes, dressing-material, etc.
Spectato?'s. There can hardly be any doubt that the fewer persons
are present in the operating-room, the better, other things being equal,
are the chances of the patient. Particularly in laparotomies the
presence of persons coining from- a case of erysipelas, scarlet fever,
diphtheria, typhoid fever, or other zymotic disease constitutes an
element of danger. On the other hand, nobody can learn to operate
by reading descriptions of operations. The accumulated experience
of mankind in this line can only be acquired by seeing others at
work. And it is, therefore, in the interest of humanity in general
that operators admit students and fellow-practitioners to witness
their operations. To what extent and with what restrictions this
should be done depends on many circumstances which cannot be
considered here. Fortunately, experience has shown that when those
who come in contact with the field of operation follow all the rules
of antiseptic surgery the mere presence of other persons in the room
has little or nothing to do with the result of the operation.
Patient. The patient's urine should be examined with special ref-
erence to the presence of albumin in the same, as it may be deemed
necessary to postpone the operation or desist from it altogether if the
kidneys are in a bad condition, or at least to prefer chloroform to
ether as an anesthetic, the latter having proved particularly dangerous
in patients with inflamed kidneys, 1 or to use opium or cocaine, or
operate without an anesthetic. If there is albumin in the urine, it
should also be examined microscopically for casts. If there is an ex-
cess of pigment and salts in the urine, it is well to prepare the patient
for an important operation by the use of Vichy or lithia water. If
the urine contains sugar, the patient would not be a fit subject for any
plastic operation until she had been properly treated for glycosuria.
The presence of pus or many epithelial cells may likewise call for
special preparatory treatment before an operation is undertaken.
The heart and the lungs should also be examined. If the heart is
diseased, chloroform is particularly dangerous. Advanced phthisis is
a counter-indication for nearly all operations ; in lighter pulmonary
affections ether should be avoided.
On the day preceding that of the operation the patient should have
a warm bath and be scrubbed with soap all over, in order to have the
skin in as good a condition as possible. To move her bowels she should
toward evening take a heaping teaspoonful of compound liquorice
powder or another suitable aperient, and after that she should receive
no other food than a little coifee or beef tea.
Six hours before the operation she should be given an enenia of a
quart of soap-suds.
1 T. A. Emmet, 1. c., p. 745.
TREATMENT IN GENERAL.
197
Twenty minutes before anesthesia is begun I give a hypodermic
injection of ^ of a grain of morphine and ^ of a grain of sulphate
of atropine, the first of which has the effect that less of the anesthetic
is needed, and the second, that of strengthening the heart.
Immediately before the operation begins, the bladder should be
emptied with the catheter, even if the patient says she can urinate
herself.
The patient should be in night-dress, and the feet, legs, and thighs
covered with leggings made of a woollen or other warm stuff. In pri-
vate practice stockings are sufficient. Besides, she should be covered
with a sheet and towels in such a way as never to expose more of her
body than needed to give access to the field of operation.
The field of operation should be smeared with potassa soap, shaved,
and washed with alcohol, if it is on the skin, and bichloride of mer-
cury (1 : 2000). For laparotomies the field is surrounded with four
sterilized towels, pinned together and to the clothes, and the vagina is
carefully disinfected by swabbing with tinctura saponis viridis, fol-
lowed by corrosive-sublimate solution. Even for laparotomies the
genitals should be shaved and disinfected. For operations on the
FIG. 168
Clover's Crutch.
external genitals the buttocks are covered with a large piece of steril-
ized gauze in which a hole is cut in front of the vulva.
For perineal and vaginal operations the knees are lifted more or
less up, and kept separate by means of Clover's o'utch (Fig. 168), an
198 DISEASES OF WOMEN.
expensive apparatus which, however, may easily be replaced at small
cost by placing a two-feet-long broomstick in the popliteal spaces,
tying it with some figure-of-eight turns to each knee with a roller-
bandage, and leading part of the bandage up behind the neck of the
patient.
An inexpensive leg-holder is that of Robb (Fig. 169). It is easily
FIG. 169.
Robb's Leg-holder.
rolled up, and takes up little room in the satchel. It surrounds the
lower part of the thigh, passes under the right shoulder and above
the left, which is protected against pressure by a thick pad of cotton
batting being placed between it and the leg-holder. I have, however,
seen several cases of semi-paralysis, numbness, and pain in the arm
or leg follow its use. But similar effects are observed with other
apparatus, and seem to be due to the anesthetic and not to pressure.
Good operating- tables have special uprights with stirrups to which
the feet are attached in an elevated position.
Vessels and Towels. Two instrument trays of hard rubber, enam-
elled iron, china, or glass should be kept ready, likewise 4 plates for
ligatures, sutures, iodoform gauze, and gutta-percha tissue ; 4 basins ;
4 pitchers, with hot water, cold water, carbolized water (5 per cent.),
solution of bichloride of mercury (1 : 1000); 2 fountain syringes or
douche-cans, with a straight glass nozzle 6 inches' long, and a hard-
rubber nozzle with a stopcock easily opened and closed with the thumb
(Fig. 170).
At least a dozen towels will be needed.
Disinfection, Asepsis, and Antisepsis. In hospitals and so far as
possible in private practice operations should be performed according
TREATMENT IS GENERAL. 199
to the rules of aseptic surgery, but in private practice this is some-
times not feasible, and then a high degree of safety is yet obtainable
by strict adherence to antiseptic measures. Common for both sys-
tems is the disinfection of the room, the field of operation, the ope-
rator and his assistants. In aseptic surgery the disinfectant agent
FIG. 170.
Nozzle with Stopcock.
relied on is heat in the shape of boiling water or moving steam ; in
its antiseptic forerunner the same is aimed at by means of chemicals
that possess germicidal power. In the instrument-stores are found
more or less costly apparatus for rendering instruments, gauze pads,
towels, coats, etc., aseptic, but the same may be obtained at small expense
by using utensils that are on the market for other purposes. Thus,
an agate-ware asparagus-boiler is an excellent instrument-boiler,
and a large-sized Arnold milk sterilizer can be used for gauze,
towels, etc.
Instruments are boiled for five minutes in a solution of bicarbonate
of sodium a tablespoonful to the quart. Even cutting and pricking
instruments are disinfected in this way, but should be wrapped up in
gauze so as not to be mechanically injured. Gauze, towels, and other
material are disinfected by having a current of steam circulate through
them for an hour.
We have already referred to the disinfection of the room and the
field of operation. The operator and his assistants take off their
coats, turn up their sleeves to the elbow, scrub their hands and fore-
arms with potassa soap and hot water, using a rather stiff nail-brush,
wipe their hands, remove all dirt from under the nails with a steel
nail-scraper, and scrub the hands in a solution of bichloride of mer-
cury (1 : 2000) for at least three minutes, after which they should
not wipe the hands. To combine the use of soap and corrosive sub-
limate in disinfecting the hands is wrong, as the soap deprives the
drug of some of its power. On the other hand, disinfection is much
improved by immersing the hands in alcohol or washing them with
the same for five minutes before rinsing them in bichloride solution.
It is convenient to put on a rubber apron covering the whole front
of the body from the neck down to a little above the feet, and to pin
to this a towel wrung out of carbolized water, or sterilized, or, still
better, to put on a sterilized coat and cap.
For dressing, the antiseptic materials, such as iodoform gauze or
corrosive-sublimate gauze, sold by druggists and instrument-makers,
200
DISEASES OF WOMEN.
may be used, but much of so-called aseptic ligature and suture mate-
rial and sponges found on the market is unreliable. 1
Entirely reliable sterile sutures are prepared by Geo. St. John
Leavens, 72 Bible House, New York. They come in sealed glass
tubes, and are sterilized by boiling in absolute alcohol at 250 Fahr.
FIG. 171.
A
Leavens' Suture-tubes : A, sterilized at 250 F. after sealing ; B, opened at operation.
for forty-five minutes after sealing. At the time of operating the
tubes are broken (Fig. 171).
Sponges. The raw sponges are beaten in order to soften them and
remove sand, and then immersed in acidulated water (acid, hydro-
chlor. %j to each quart of water) in order to dissolve the calcareous
matter. Part of this trouble may be avoided by buying the sponges
already prepared ; but even then they have to be treated with the
acidulated water, and wrung many times out of water until all sand
has been removed.
When sponges have been used in an operation, they are cleaned in
the following way : They are first washed with soap and water until
the water remains clean ; then they are left for an hour in a solution
of potassa (liquor, potassse 3j to each quart of water) which draws
out all the blood. If the sponges have been unusually soaked in
blood, it may become necessary to change this solution. Then they
are again wrung out of plain water till it stays clear. After that
they are left for an hour in a solution of bichloride of mercury
(1 : 1000), wrung out, dried in the sun or in front of a fire, and kept
in a muslin bag. By keeping them in this dry way they do not be-
come rotten so soon as when kept in an antiseptic fluid. Before
using them the next time they are left for five or ten minutes in a
1 Aseptic material may be prepared in many ways ; I describe only the one I
follow myself.
TREATMENT IN GENERAL. 201
similar solution of bichloride, after having soaked them well by
pressing all the air out of them, wrung out, and kept in carbolized
water (2 or 2J per cent.) or plain boiled water during the opera-
tion.
Three sizes of sponges are needed: small round about 1 inches
in diameter; large round, about 3 inches in diameter ;' and large flat
sponges, J inch thick.
Most operators, in order to avoid infection from sponges or the
trouble of disinfecting them, have discarded them altogether, and use,
instead of round sponges, small pads of sterilized gauze or round balls
of absorbent cotton wound with gauze, and instead of the flat sponges
pads of several layers of gauze, about 8 by 6 inches. Such gauze
sponges are sterilized with heat in Arnold's milk-sterilizer or some
other apparatus through which steam circulates.
Silk. Twisted or braided silk is used : the latter is stronger.
Four thicknesses are needed : Nos. 1, 2, 5, and 12 of the braided.
In order to render it aseptic it is boiled in a small china casserole
over an alcohol lamp for half an hour, and soaked in a solution of
bichloride of mercury (1 : 1000) for an hour, wound on glass spools,
several of which may be suspended on one glass stand and kept in
alcohol in a well-corked glass with a heavy bottom. Such glasses
can be obtained from the instrument-makers. The different ends
may be run through holes in the cork or rubber stopper covering the
glass, and thus the silk is unwound without opening the bottle. If
there is a hitch, great care should be taken only to use a perfectly
aseptic pair of forceps to get hold of the silk or the spools. New
alcohol must be constantly poured into the bottle to keep it full, and
FIG. 172.
Schimmelbusch's Metal Box for Sterilizing Silk and Keeping it Sterile: A, box opened in
order to expose the silk to the circulating steam of the sterilizer; B, partly closed as
when in use.
if not used often the silk should from time to time be boiled again,
and the alcohol renewed altogether. Where a steam sterilizer is avail-
"^CO LLUG : :
R-i V c C
202 DISEASES OF WOMEN.
able, the silk is sterilized immediately before each operation by being
placed in the sterilizer. Schimmelbusch of Berlin has constructed a
practical metal box for this purpose (Fig. 172).
I have had a ligature-box made (Fig. 173) which is a modification
of that described by Greig Smith. 1 It consists of a solid hard rubber-
box, to which is screwed a cap. A -leather washer is placed at the
bottom of the screw. Into this case fits a leaden disk which is heavy
enough to remain stationaiy while the silk is being drawn out, and
on this disk, supported by upright rods of German silver, are placed
four metal reels of the same material. A glass plate perforated in
four places for the threads is screwed to the top of a central bar.
This whole inner part may be boiled in water or any solution the ope-
rator may prefer, and the box is immersed in a solution of corrosive
sublimate ; and when once all is aseptic, it is kept so by keeping the
box filled with alcohol. By winding the reels with finest black iron-
dyed silk, and braided No. 2, 4 or 5, and 12, the operator is prepared
FIG. 173.
Greig Smith's Ligature-box (modified).
for everything that needs tying, from a wound in the intestine to the
thickest pedicle of a tumor.
Catgut, so called, is in reality sheep's gut. It is so hard to render
it aseptic, and keep it so, that some have given it up altogether, but
its absorbability makes it very valuable for ligatures and buried su-
tures. A simple and excellent way of preparing it is to boil it in so-
called absolute alcohol (97 per cent., or even in the common 95 per
cent.) for an hour and keep it in the same alcohol. 2
1 Greig Smith, Abdominal Surgery, 2d ed., Philadelphia, 1888, p. 65.
1 George E. Fowler of Brooklyn, N. Y. Med. Record, 1890, vol. xxxviii. p. 178.
U
TREATMENT IN GENERAL.
203
This method has been made easy, inexpensive, and safe by means
of Dowd's condenser, represented in Fig. 174. 1 The catgut is wound
on glass reels enclosed in small glaas jars, which are immersed in
alcohol in a larger jar placed in a water-bath on a gas-stove. From
the top of the large jar the vapor of the boiling alcohol rises into a
coil of tin, in which it is condensed by having cold water flowing
through the surrounding copper cylinder, and from which it drops
back into the jar below. For hospital use the catgut may simply be
boiled in a covered glass with alcohol standing iu a casserole with
water during the preparation for the operation.
For the intestines No. is required ; for closing the peritoneum in
laparotomies I use No. 1 ; for the perineum a medium size is used ;
FIG. 174.
Dowd's Apparatus for the Sterilization of Catgut.
and for the pedicles of tumors a very thick one. Different manufac-
turers use different numbers, so that I cannot designate the thickness
in that way.
1 Charles N. Dowd of New York, Med. Record, Dec. 3, 1892.
204 DISEASES OF WOMEN.
Catgut has the advantage over silk that it is soon dissolved and
absorbed, which recommends it for ligatures in wounds or cavities
from which it cannot be removed, and for sutures in so far as its
removal becomes unnecessary. The thick grades are so strong that
they never break in being tightened. It has therefore been recom-
mended as exclusive material for both ligatures and sutures, while
others as exclusively use silk for all purposes. On the other hand,
catgut is more difficult to tie, becomes easily untied, so that triple
knots are necessary where there is any strain on it, and, as before
stated, it is more difficult to render and keep aseptic. Its great dis-
solvability proves even sometimes a fault instead of a virtue ; which,
however, can be remedied by preparing it with chromic acid in the
following way : Soak the catgut in oil of juniper for twenty-four hours ;
wash off the juniper oil by soaking the catgut in ether a few minutes;
soak the catgut in a watery solution of bichromate of potassium grs.
2 to the ounce for from fifteen to thirty minutes, according to the
length of time one wants it to remain unabsorbed ; wash the catgut in
alcohol ; place the catgut in bottles ; fill up with alcohol, and boil for
five minutes in a water-bath. If the catgut is to be wound on reels,
this should be done after it has been taken from the bichromate-of-
potassium solution and before it has been washed in alcohol. 1
Silkwwm gut is sold "prepared" in a long bundle tied at both ends.
It may be disinfected by boiling it in water. As many single threads
as are likely to be used are cut off before the operation, washed in a
solution of bichloride (1 : 1000), and kept in carbolized water (2 per
cent.) during it, just like sponges. It is, of all materials, the best for
operations on the perineum. It does not absorb fluid like silk, does
not become corroded like catgut, and does not hurt in removal like
silver wire.
Horsehair is an excellent material for many purposes, especially for
enterorrhaphy according to Maunsell's method. 2 The hair should be
taken from a male animal. The longest and strongest hairs without
a flaw should be selected, tied at one end, brushed up with soap and
water. Next they should be immersed in bichloride-of-mercury solu-
tion (1 : 4000) for two or three hours. After that they, are shaken out
and placed in a large glass-stoppered bottle. Before being used they
should be immersed in bichloride solution for several hours, in order
to make them pliable.
Kangaroo tendon shares with catgut the advantage of being absorb-
able, and resists for a longer time absorption, which makes it particu-
larly valuable for certain operations, such as radical hernia operations,
but its high price is in the way of a general use of it.
Silver Wire. Silver wire, or its much cheaper substitute silver-
1 Private communication from Dr. A. Palmer Dudley.
2 Maunsell, Amer. Jour. Med. Sci., March, 1892.
TREATMENT IN GENERAL. 205
plated copper wire, is made aseptic by immersion in 5 per cent, car-
bolized water or by drawing it through the flame of an alcohol lamp,
and is kept during the operation in carbolized water or alcohol. The
thicknesses commonly used are No. 26 for the perineum, No. 27 for
the cervix, and No. 28 for the vagina. But it is used much less now
than some years ago.
lodoform is not, in itself, an antiseptic, but it seems that it is de-
composed by the very appearance of pus-cocci and the formation of
ptomaines in such a way as to become a germicide. However this
may be, experience has shown that it is a most valuable preventive
of suppuration and sepsis. Its disagreeable odor may be covered by
adding 1 part of thymol to 5 parts of iodoform. 1 A chemical com-
bination of the two has been introduced under the name of aristol.
Coumarin, the odoriferous principle in Tonka beans (1 part to 5),
and ground coffee are also recommended for the purpose. lodoform
gauze may be disinfected by placing it in a closed glass jar in the
sterilizer for half an hour. Its color changes partially to blue by a
combination of the iodine and the starch contained in the gauze, but
in contact with tissue iodoform is reproduced.
Antiseptic Fluids. Bichloride of mercury is a powerful antiseptic,
but so poisonous that it has to be used with great circumspection.
Experiments have shown how fatal the effect of a solution of bichlo-
ride of mercury is when it is kept in contact with a wound leading
into the subcutaneous connective tissue, and the same applies, of
course, to the submucous. Even the intact mucous membrane of the
vagina absorbs it. 2 I have, therefore, nearly entirely discarded it for
intra-uterine and vaginal injection and irrigation of wounds or the
peritoneal cavity. I use it almost exclusively for washing the skin
and the vagina, and for the hands of the doctors and nurses. It is
convenient to have a solution of 1 : 1000, which may be diluted by
adding hot water.
Carbolic acid is used for instruments and sponges. It is best to
have a 5 per cent, solution, and add hot water so as to get a 2J or 2
per cent, solution.
Creolin forms no solution, but an emulsion, with water. This
emulsion should be prepared by pouring the creolin into cold water,
stirring it, and adding as much hot water. The strength that answers
best in most cases is a 1 per cent, emulsion (2 tablespoonfuls to 3
quarts of water), but both J per cent, and 2 per cent, solutions are used.
The emulsion looks like milk with a little coffee. It has the fault of
being opaque and of producing a smarting sensation in the vagina of
some patients. It is not so powerful an antiseptic as bichloride of
1 Med. World, 1886, p. 89.
2 Details may be found in my article on "Corrosive Sublimate and Creolin,"
Amer. Jour. Med. Sci., 1889, vol. xcviii.
206 DISEASES OF WOMEN.
mercury, but, compared with carbolic acid, it has the advantage of
being an excellent hemostatic, of being almost innocuous, of making
the tissues slippery, of having a rather pleasant odor, and of not affect-
ing the operator's skin and nerves. I use it after curetting, especially
for cancer, where its hemostatic powers prove of great value.
Lysol has the advantage over creolin of forming a nearly clear mix-
ture with water. It is used in the same strength, is slippery, and has
a less pungent odor. For injection it has to a great extent replaced
the other disinfectants, but it is not suitable for operations, as it be-
comes nearly black by mixture with blood, renders tissue and instru-
ments too slippery, and foams.
Hydro-naphthol is much praised by the few who use it. " It is harm-
less and does not injure instruments or operator's hands. The strength
used is a saturated solution in hot water. The peritoneal cavity may
be repeatedly filled with this solution with perfect impunity." *
Boro-salieylic solution, or Thiersch's solution (R : Acidi borici 12,
Acidi salicylici 2, Aquae 1000), is a bland fluid that likewise may be
used in the peritoneum or for irrigation of wounds. 2
Thymol (1 : 1000) is also a bland disinfectant.
3. Anesthesia. The two chief anesthetics used are ether and chlo-
roform. Ether, as the safer of the two, should be preferred, except
when the kidneys, the lungs, the larynx, or trachea are affected or in
patients suffering from congestion of the brain, for under these cir-
cumstances ether is the more dangerous of the two. It seems, also,
that there are differences of susceptibility to the effect of the two
drugs in different persons. I have had cases where one of them,
ether as well as chloroform, failed to induce anesthesia, but caused
alarming symptoms, such as convulsions or arrest of respiration,
while the other worked satisfactorily.
Some prefer mixtures of ether and chloroform in different propor-
tions, usually combined with absolute alcohol. A combination of this
kind is known as the A. C. E. mixture :
I|i. Alcohol absoluti, sj ;
Chloroformi purificati, gij ;
JEtheris fortioris, liij.
M. S. A. C. E. mixture for inhaling.
Personally I have been much pleased with this mixture. 3
1 Clinton Gushing, Pacific Med. Jour., July, 1890, reprint, p. 7. First recom-
mended by Geo. R. Fowler of Brooklyn, N. Y., New York Med. Jour., 1885, vol.
xiii. p. 374 et seq., and endorsed by R. J. Levis of Philadelphia, ibid., p. 593.
8 A convenient way of making this solution is by dissolving Thiersch's tablets in
water, 1 tablet to each quart.
8 It is much praised by John C. Reeve, Dayton, O. ( Trans. Amer. Gynecol. Soc.,
1891, vol. xvi. p. 20) ; and Lawson Tait declares the combination to be a' great ad-
vance over either ether or chloroform used separately (Buffalo Med.-Sury. Jour.,
quoted in Med. Brief, May, 1894, p. 630).
TREATMENT IN GENERAL.
207
In giving ether constant watch should be kept on the respiration.
As soon as it stops, etherization should be interrupted, and artificial
respiration by Sylvester's method or Richardson's double-acting
bellows be instituted. In giving chloroform special attention has to
be directed to the pulse, for when breathing stops under the use of
that drug there is great danger that the heart will be fatally affected.
In case of collapse during chloroform ization, the best treatment is the
combination of artificial respiration with Nelaton's method, which
consists in suspending the patient by holding her knees over the
shoulders of an assistant and letting her head hang down. I have
succeeded every time with this combination.
Another method that may answer a good purpose, even at a later
stage, is Koenig's rapid compression of the heart. The ball of the
thumb is pressed against the wall of the chest between the apex of
the heart and the left edge of the sternum 120 times or oftener in
the minute. When the pupils contract and the patient breathes, a
pause is made until the former dilate again and the respiration
stops.
If there has been considerable loss of blood and the heart threatens
to become paralyzed, an intravenous injection of a 6-per-thousand
solution of common salt (sodium chloride) at the temperature of the
blood may yet save the patient's life.
Ether is given with Attis's inhaler (Fig. 175), a frame of metal
with many parallel long side-openings,
through which a roller bandage is drawn
and surrounded by a soft rubber cover.
The inventor describes its use in the fol-
lowing words : " Placing it over the face, I
sprinkle on a few drops of ether : I mean,
literally, but a few drops. In a few sec-
onds I add a few more drops, and usually
in from half a minute to a minute I find
that I can drop it more constantly. As
soon as I notice the deep inspiration I pour
on a small stream, watching carefully lest I
irritate the larynx ; and as soon as I find
the patient tolerant of its vapor, I add it in
larger quantities, and as rapidly as it can be
evaporated, and am usually gratified by see-
ing my patient pass quietly under its influ- Aiiis's Ether-inhaler.
ence in from three to ten minutes. A slight
dripping will suffice to prolong the effect." The chief virtue of
Allis's inhaler is the free access of air, and his method is much to be
preferred to the one usually followed. ,
Often a substitute is improvised by folding a newspaper and a
FIG. 175.
208 DISEASES OF WOMEN.
towel together, so as to form a kind of cap, into the bottom of which
is put a little absorbent cotton. About a fluidounce of ether is
poured on the cotton, and more added when it has evaporated.
Other inhalers e. g. Ormsby's admit very little air, and make the
patient all the time inspire the same air she expires, so that there
really is a combination of etherization and poisoning with carbonic
acid. This class of instruments use a much smaller amount of ether.
Ormsby's has a metal cone with a small sponge at the top and an in-
flatable rubber ring at the brim, which can be placed air-tight over
the face. The ether is poured on the sponge through a small funnel.
Air may be admitted in small quantities through an opening on the
side of the cone, which can be made larger or smaller. On the other
side of the sponge is a rubber bag into which the patient expires, and
from which she again inspires. This method is in my opinion more
dangerous than that of Allis.
As often a considerable amount of ether is used, it is best to have
a pound of it on hand, but divided into quarter-pound cans. Even
in hospitals it is better to have these .small cans, because ether under-
goes some change as soon as the can has been opened, in consequence
of which it loses part of its anesthetic power, and a larger quantity is
needed to produce the same effect.
The use of a hypodermic injection of morphine before giving ether
does not abridge the time required to induce anesthesia, but offers the
advantage that very little or nothing is needed to keep up the effect.
The vapor of ether is inflammable. Great care must, therefore, be
taken not to bring the ether-cone or bottle too near the flame or in-
candescent body when a cautery is used, or when the operation is
performed with artificial light, or in a room with an open fire. It is
safe to have gas-lights a yard above the operating table. 1 My own
experiments have, indeed, proved that a compress saturated with ether
does not catch fire from a burning candle before the flame is approached
to the distance of one inch from below or from the side, and even
half an inch from above. Ether vapor contained in the breath is
not inflammable.
Of chloroform it is well to have four ounces. It is best adminis-
tered on Esmarch's mask (Fig. 176), which consists of a wire skeleton
covered with Canton flannel. It lies over nose and mouth, and the
chloroform is dropped on it without removing it. Instead of the
mask a pocket-handkerchief may be used, but then the face should
be smeared with vaseline in order to protect the skin from irritation.
Chloroform should be given in the dose of 5 to 10 drops poured on
the mask at intervals of half a minute. Death from chloroform
appears in four modes : (a) By syncopal apnea ; (6) by epileptiform
1 J. K. Corate, " Ether et Chloroforme," Revue medicate de la Suisse Romande, 20
F^vrier, 1890, p. 87.
TREATMENT IN GENERAL.
209
syncope ; (c) by paralysis of the heart with paralysis of the muscular
system generally ; (d) by chloroform combined with surgical shock. 1
FIG. 176.
Esmarch's Chloroform-Mask.
Since in chloroformizatiou there is so much danger of paralysis of
the heart, it is well to add -^ grain of sulphate of atropine to the
preliminary hypodermic injection.
The A. C. E. mixture is administered with Allis's inhaler, from 20
to 30 drops at a time, repeated every half minute.
"Whatever anesthetic is used, false teeth should be removed before
beginning ; a gag to separate the jaws, a long dressing forceps, and
some gauze or lint should be within reach for the removal of froth,
which sometimes accumulates in the throat. The tongue should
always be kept forward, which can be done by pressing both rami of
the lower jaw forward. Special tongue-forceps are found in the
instrument-stores. The tongue should not be pinched with artery-
forceps, which causes bad-looking and painful ulcerations.
Particular care should be taken when Trendelenburg's position is
used, as it tends to produce congestion of the brain. Some prefer for
this reason to use chloroform. 2 At all events, the patient should be
anesthetized in the horizontal position, not kept inclined longer than
necessary, and brought back to the horizontal position, at least tem-
porarily, if she becomes cyanosed.
Cocaine. Although great operations, such as ovariotomy and am-
putation of the breast, have been successfully performed under the
anesthesia brought on by hypodermic injection of hydrochlorate of
cocaine, so many cases of alarming depression following the use of
even very small doses are on record that I think the use of this drug
should be very limited in gynecological practice. Perhaps it inter-
feres also with healing by the first intention. 3
It is, however, in many cases, a great advantage to dispense with
general anesthesia, and it has been noticed that the dangerous collapse
1 Benjamin Ward Richardson, "On Death by Chloroform," The Asdepiad, 1st
quarter, 1890.
2 Cleveland and Goodell, Amer. Jour. 06s/., Oct., 1891. vol. xxiv. p. 1240.
8 H. T. Hanks, Amer. Jour. Obst., 1888, vol. xxi. p. 316.
14
210 DISEASES OF WOMEN.
is less likely to occur the farther away from the head cocaine is used.
I have been well satisfied with the application of a 10 per cent, solu-
tion before cauterization with chloride of zinc in diphtheritic inflam-
mation of the genitals. The cervix may be dilated without pain
after pledgets soaked in a 5 to 20 per cent, solution are placed for
five minutes around it, and in its cavity if it is sufficiently wide to
allow it.
In cases in which general anesthesia was deemed to be too danger-
ous on account of heart disease, even the largest operations, such as
ovariotomy and abdominal hysterectomy, have been performed with
local anesthesia produced with a spray of chloric ether, or ethyl chlo-
ride. This substance is, at a temperature below 50 Fahr., a fluid.
It is stored in tubes and a stream of the rapidly volatilizing fluid be-
comes a spray. It should be held 10 inches away from the part
treated in order to avoid excessive and useless cold. The gas is very
inflammable, and in operations the neighborhood of a flame must be
avoided.
Whatever agent be used to produce anesthesia, the most powerful
stimulants should be kept ready. A few drops of nitrite of amyl are
good where there are signs of anemia of the brain (chloroform, cocaine).
Hypodermic injections of several syriugefuls of brandy often increase
the volume of a sinking or indiscernible pulse. Still more powerful is
the hypodermic injection when 5 to 10 minims of tincture of digitalis
are added. 1 Spiritus glonoini (i. e. nitro-glycerin), tTL i to iv, is also
a reliable heart tonic :
3^. Spts. glonoini, ttlv ;
Alcohol, 3j.
M. S. One or two hypodermic syringefuls @ twenty minims.
Strychnine has a powerful effect on respiration. 2 Injection of
of a solution of 1 part of camphor in 4 parts of olive oil into the deltoid
or vastus externus muscle is efficacious and harmless. 3 Faradization
of the diaphragm may occasionally prove useful.
Against the collapse caused by cocaine have been recommended in-
halation of nitrite of amyl, subcutaneous injections of ether or caffeine,
or a warm or cold infusion of coffee by the mouth.
1 The injection of camphor dissolved in acetic ether, used in several hospitals of
this city as well as elsewhere, ought to be discarded, as it in several cases has pro-
duced paralysis.
8 Horatio C. Wood of Philadelphia has made special experiments in regard to the
effect of drugs during anesthesia, and laid the results before the International Medi-
cal Congress in 1890 (Abstract in Practice, Feb., 1891, p. 58-59). According to
him, alcohol is ineffective in small doses and dangerous in large. Nitrite of
amyl, caffeine, and atropine are of little or no use. Ammonia has some little influ-
ence on the heart. He recommends digitalis for the heart and strychnine for the
respiration.
3 H. C. Coe, The New York Polyclinic, vol. i. No. 1, p. 20.
TREATMENT IN GENERAL.
211
FIG. 177.
Both ether and chloroform are very apt to cause vomiting. The
patient should, therefore, not have any solid food the day of the opera-
tion. AVhen she vomits, she should be turned on her side, so as to
give the ejected masses a free outlet and prevent their entrance into
the larynx. After the operation she should only have hot water or
ice-water in teaspoonful doses to relieve her thirst until all nausea
has stopped. A little black coffee is grateful, and seems to have a
good effect on the stomach. If vomiting continues, I give, with ex-
cellent effect, the following mixture :
ty. Acidi hydrocyanic! dil., 3ss ;
Acidi citrici,
Sodii bicarbon, ad. 5\j ;
Syr. rubi Idaei, BSS;
Aquae, ad svj. M.
Sig. A tablespoouful every one, two, or three hours.
Common Instruments, and their Use. Some instruments are so
generally useful that they are needed for nearly all gynecological
operations, and should always be on
hand. Such are a uterine sound (p.
152), bivalve and univalve specula
(pp. 144 and 145), a vaginal depressor
(p. 147), tenacula, volsellse, sponge-
holders, knives, scissors, several pairs
of artery-forceps (p. 184), needles, a
needle-holder, counter-pressure-hook,
suture-twister, and suture-shield. With
some of these we are already acquainted
from the chapter on Examination. In
regard to the others I shall make a few
remarks.
Weight Speculum. For certain ope-
rations which are best performed with
the patient in the dorsal posture, such
as trachelorrhaphy and vaginal hyster-
ectomy, it is a great advantage to have
a speculum that is held in place by its
own weight, and at the same time can
be easily removed and replaced (Fig.
177).
Vaginal Retractor's. Besides the
specula and depressors described in
speaking of how to make an exam-
ination, lateral retractors, such as Schroeder's (Fig. 178) or Engc-1-
mann's, are often needed in operations in the dorsal position.
Garrlgues' Weight Speculum
212
DISEASES OF WOMEN.
Tenacula. A tenaculum is a sharp-pointed steel hook with handle,
which should be made of one piece of metal. Two shapes of hooks
FIG. 178.
Schroeder's Vaginal Retractor.
are most convenient : one is simply bent so as to form a little less
than a right angle ; in the other the point has a second flexure in the
direction of the handle (Fig. 179).
FIG. 179.
Emmet's Tenaculum.
Tenacula are used to put tissue on the stretch, to lift up tissue to
be cut, to manipulate silver sutures, etc.
FIG. 180.
Volsella.
A volsella (Fig. 180) is a pair of forceps, each blade of which ends
in a double hook. It is used for seizing and pulling tissue. For
FIG. 181.
Pean's Traction-forceps.
vaginal hysterectomy Plan's traction-forceps (Fig. 181) is excellent
almost indispensable.
an
TREATMENT IN GENERAL.
213
A tenaculum-forceps is a modified volsella with single or double
hooks, and, as a rule, of more slender build.
A tissue-forceps (Fig. 182) is a pair of forceps with side teeth, con-
venient for holding a strip of tissue while cutting it off.
FIG. 182.
Tissue-forceps.
A sponge-holder (Fig. 183) should be made of one piece of nickel-
plated steel. It is a rod with a handle at one end, and divided at the
FIG. 183.
Sims's Sponge-holder. (At a a piece of the shaft is left out.)
other into two halves with teeth, which are brought together with a
ring. Four sponge-holders are needed. Often long pressure-forceps
or stout dressing-forceps are preferred, especially when pads are used
instead of sponges (p. 196).
Knives are used much less than in general surgery. A medium-
sized scalpel is about all that is needed.
Scissors are in most cases used to great advantage as cutting instru-
ments. They cause less hemorrhage than knives, are more expedi-
tious, and can do more delicate work. Often they are used closed as
a blunt instrument. The chief shapes needed are straight, curved on
the flat, and knee-bent on the edge. They must for most purposes
have long shanks.
When a surface is to be pared a tenaculum is passed into the
mucous membrane at the end nearest to the operator and at the lowest
part of the field to be denuded, so as to avoid having blood running
over the upper part that is to be denuded later. The mucous mem-
brane is lifted a little, and the scissors are made to cut off a thin strip
of tissue under the tenaculum in such a way that the tenaculum stays
in the loosened strip. When once the strip is cut loose, it is often
more convenient to exchange the tenaculum for a tissue-forceps. The
strip should be cut of as uniform breadth and thickness as possible,
and from one end of the surface to be denuded to the other. If this
is wider than the strip, one or more similar strips are cut off parallel
214
DISEASES OF WOMEN.
to the first, taking great care not to leave any part undenuded. While
this is being done the denuded surface is kept free from blood by irri-
gation or sponging. Especial care is also taken to get a regular line
of incision all around the pared surface without any projecting tongues
or receding bays.
Pressure-forceps, of lighter or heavier construction, are put on
bleeding vessels. If it is a large vessel that spurts, the pressure-
forceps takes simply the place of the old artery-forceps before the
vessel is secured by means of a ligature, but on small vessels the
pressure exercised by the pressure-forceps suffices within a few min-
Fio. 184.
Needles : a, short straight round ; b, long straight round; c, trocar- pointed straight; d, semi-
curved, crescent-ground (Sims's fistula-needle) ; e, semi-curved, trocar-pointed (Emmet's
cervix-needle); /, curved, crescent-ground; g, curved, trocar-pointed ; h, i, old-fashioned
strongly curved surgical needles with three edges ; j, semicircular Hagedorn needle ; k,
half-curved Hagedorn needle ; I, fishhook-shaped needle.
utes to arrest the hemorrhage permanently, so that no ligature is
needed.
Needles. A variety of needles (Figs. 184 and 185) are used, and
special kinds made for gynecological work have in certain operations
been found preferable to the old-fashioned needles used in general
surgery. We use straight, more or less curved, round, trocar-
pointed, crescent-ground, Hagedorn, and handled (sharp-pointed or
dull) needles. Common English sewing-needles, short and long, may
be used in the vulva and the vagina. They are harder to push through
the tissues, but make only a round hole, which, on account of the elas-
ticity of the penetrated tissue, closes round the suture. The same kind
of needles are also curved, which makes it easier to push them in a
curved line. But where the tissues offer much resistance it is neces-
sary to make the round needle cutting near the point by grinding it
TREATMENT IN GENERAL.
215
so as to form a crescent-shaped surface with two cutting edges, or
three sharp edges like the point of a trocar or a spear. Hagedorn's
needles are flat from side to side, with a straight cutting edge near
the point. They have a very large eye, which makes them particu-
larly useful when catgut is used. When the suture inserted with
Hagedorn's needles is tightened, the edges of the wound made by
the needle are drawn together from side to side, instead of being
pulled apart, as when a needle is used that cuts at right angles to the
direction of the suture.
In order to avoid turning or breaking of the curved needles when
grasped by the needle-holder, the part nearest the eye should be
FIG. 185.
Needles with Handles : a, slightly curved, sharp-pointed or dull ; b and c, strongly curved,
dull ; d, Marcy's needle, sharp-pointed, with eye from side to side.
straight and flat. For operations on the intestines long English cam-
bric needles, about No. 7, are used.
^ Needle-holder. For all these needles a needle-holder is needed.
Sims's (Fig. 186), that has rings like scissors, is indispensable for fine
work in the vagina, especially operations for fistula; Hagedorn's
(Fig. 187) is adapted to his needles, and Crosby's can be used for
any needle, opens by mere pressure, and is easy to disinfect (Fig.
188).
As a rule, the needle-holder should be applied to the needle just in
216
DISEASES OF WOMEN.
front of the eye, for if the latter is comprised in the grasp of the
forceps, the needle is very liable to break.
FIG. 186.
Situs's Needle-holder.
Much time is saved and a good adaptation more easily obtained by
using handled needles (Fig. 185), but in order to be strong enough to
FIG. 187.
Hagedorn's Needle-holder.
pass through resistant tissues they must be made so thick that they
make a large hole, which, however, immediately contracts, and, there-
FIG. 188.
Crosby's Needle-holder.
fore, is without importance if the patient is anesthetized. When only
slightly curved and ending in a sharp point, these needles are partic-
TREATMENT IN GENERAL. 217
ularly useful for closing wounds in the perineum or the abdominal
Avail, and are often called perineum-needles (Fig. 185, a). They have
the eye near the point, and are threaded after having been pushed
through the tissue. A blunt needle of this kind is used in ovariotomy
and similar operations, and will be described later.
Instead of a needle and needle-holder a ligature-carrier (Fig. 189)
may sometimes be used with advantage. It is a half sharp-pointed
FIG. 189.
Cleveland's Ligature-carrier.
curved forceps, between the jaws of which the ligature is seized and
carried around the tissue to be ligated.
Ligatures. For ligatures is used silk or catgut (pp. 201-204).
They should be tied in the so-called square knot, and, as we have seen
above, catgut requires sometimes an additional knot. In most opera-
tions the ends are cut short and the ligature left in the body.
Under particular circumstances (see Lupus Vulvas, Fecal Fistulas,
Fibroids of the Uterus, etc.) the elastic ligature of rubber is used.
It consists of solid round strings varying in diameter from less than
-fa up to ^ inch, or in rubber tubing twice as thick. Rubber soon
loses its elasticity, and in order to be reliable a ligature of this sub-
stance must be rather new. It is, however, said to preserve its elas-
ticity for a whole year or more by being kept in a 4-per-thousand
solution of bichloride of mercury in alcohol. 1
Sutures. The chief materials used for .sutures are silk, catgut,
silver wire, silkworm gut, and kangaroo tendon (pp. 201205). Silk
is generally tied in a surgical knot, for which catgut and silkworm gut
are not pliable enough. Where the surgical knot cannot be used, an
assistant may by pressure prevent the suture from opening while the
second knot is being tied. Silk sutures may be left in the abdominal
wall for a week.
Silk sutures placed near a drainage-tube or a tampon, from which
septic material may come, are apt to become secondarily infected.
In order to avoid this they should not be used in such places, but
preference given to silver wire or silkworm gut, which do not absorb
fluids.
1 Fasola and Martinelty, Cenlralblalt f. Gynak., 1891, Nov. 24, p. 50(5.
218
DISEASES OF WOMEN.
Silk may be rendered more resistant to infection by immersing it
during the operation in a mixture containing iodol :
Glycerini,
Alcohol,
Iodol,
ad 5 parts ;
1 part.
In the vagina I have often left silk sutures for a month without
causing suppuration or cutting through. When silk or silkworm
gut is to be removed, the ends are seized with a pair of pressure-
forceps and slightly lifted ; the end of one blade of a pair of sharp-
pointed scissors is inserted under the suture, and the latter is cut close
up to the skin or mucous membrane on one side, in order to prevent
that part of the suture that has been exposed, and is often dirty, from
being drawn through the stitch-canal.
Silver wire may be fastened directly in the eye of a needle e. g.
in stitching a torn perineum but for most plastic operations it is
necessary to use a thread of silk, linen, or hemp as a wire-carrier.
Both ends of a linen thread (No. 70) two feet long are passed from
the same side, one after the other, through the eye of the needle, and
then the two ends together are tied with the loop on the other side
of the needle, so as to form a half knot just behind it. If the free
ends are made about 4 inches long, we get a loop about 8 inches long.
A piece of silver wire 10 or 12 inches long is bent at a distance of f
of an inch from one end under a sharp angle, which is done by seizing
it in a needle-holder and bending it close up to the edge of the
instrument. At the same time we straighten the wire and ascer-
FIG. 190.
Two Denuded Surfaces, showing where the sutures He.
tain that there are no kinks in it by sliding the nails of the thumb
and middle finger down its full length. The hook thus formed at
one end of the silver wire is passed through the loop of the thread
and given a little twist, so as to prevent it from coming off. When
one pared surface is to be applied against the other, the needle is, as
TREATMENT IN GENERAL.
219
a rule, inserted about a quarter to half an inch from the outer edge
of one of the denuded surfaces, carried deep in under the same, and
pushed out just on the inner line between pared and unpared tissue,
reinserted at the corresponding point on the other side, and pushed
out a quarter or half an inch beyond the pared surface (Fig. 190).
When the point of the needle emerges from the tissue, a dull hook,
much like a button-hook and called a counter-pressure hook (Flo:.
191), is inserted under the point and pressed against the tissue, while
FIG. 191.
Emmet's Counter-pressure Hook.
the operator pushes the needle farther in. Next he takes the needle-
holder off from the posterior part of the needle and seizes the point
above the counter-pressure hook, and pulls the needle through.
When the thread has been drawn through under both surfaces, it is
suddenly pulled on, so as to jerk the silver wire through the tissue.
When the wire is pulled halfway through, the hook is detached from
the loop, and one end of the wire is made to form a slip-knot round
the other, and this suture is temporarily put aside until all have
been inserted.
Only if there is much hemorrhage, it may exceptionally be neces-
sary to close a suture immediately after passing it.
When all the sutures are in place we proceed to close them, begin-
ning with the uppermost. The slip-knot is pushed down and the free
end pulled farther out, taking care not to cut the tissue with the wire,
until the loop is reduced to a little over an inch in length. The two
ends are now seized below the slip-knot with the wire-twister (Fig.
192), the long free end cut off, the suture drawn taught and shouldered
/. e. bent with a tenaculum at the point that will come to lie just
FIG. 192.
Emmet's Wire-twister.
at the line of union when the edges are brought together (Fig. 193).
Next, the suture-shield (Fig. 1 94) is placed around both wires and
pushed gently down to the tissue. The wires are now bent against
the sharp inner edge of the shield, and turned round until the twisted
part thus formed just reaches the shield.
This is the nicest point in the whole procedure. If you do not
220
DISEASES OF WOMEN.
FIG. 193.
twist enough, the suture will be loose and not bring the denuded
edges in contact ; and if you twist too much, you will strangle the
tissue included in the loop, and the suture will
cut through.
While the end is yet held with the twister
the shield is withdrawn, a tenaculum pressed
against the wire just where the twisted part
ends, and the latter bent to a side at right
angles to the line of union. At a distance of
half an inch the tenaculum is pressed against
the twisted wire, another right angle formed,
and the end cut off at this point. The wire
should lie quite flat against the skin or mucous
membrane. When there are many sutures, it
is sometimes an advantage to turn them alter-
nately to either side. The number of sutures
should always be counted at the end of the
operation and marked in the history of the
case, as they sometimes become so imbedded that they are hard to
find. I have seen a forgotten silver suture work its way into the
bladder and form the nucleus of a stone, and have heard of over-
looked silk sutures causing septicemia and death.
FIG. 194.
Shouldering Wire Suture :
a, twisted suture bent to
a side and cut short ; b,
shouldered suture.
Sims's Suture-shield.
In most operations silver sutures are left in for nine days, but on
the cervix some leave them for a month, in order to ensure reliable
union or to save a perineum operated on at the same time. When
the time comes for removing them, the end is seized with the twister;
the suture is pulled gently up until a minute triangular space appears
between the wires and the tissue; one point of the wire-scissors, a
strong pair of curved scissors with rather sharp points, is inserted
under one of the wires, which should be cut close up to the point
where it enters the tissue ; and finally the twisted end is pulled in
the direction of this same point, by which we press the newly-united
edges against one another, instead of pulling them apart. Slight
irregularities caused by the imbedding of the wires disappear soon
after their removal.
The kind of suture most used in gynecological work is the inter-
rupted. Rarely the quitted suture is required. The continuous, suture
is often used in laparotomy, in bringing together the edges of the
peritoneum in closing the abdominal wall, or after the removal of
TREATMENT IN GENERAL.
221
tumors or organs. Some use it also much in plastic operations for
lacerated cervix, cystocele, or prolapse of the uterus. A particular
FIG. 195.
Beginning of a Catgut Tier-suture (A. Martin).
modification of this suture is the so-called continuous tier-suture
(Fig. 195).
Suppose an oval denudation has been made on the anterior vaginal
wall. The needle, armed with a catgut thread a yard long, is carried
through both edges and under the whole pared surface from the
operator's right side to the left, near the upper end of the wound.
The catgut is pulled through until within about three inches from
the end, and tied in a knot as for an interrupted suture. The free
end is seized and drawn up with a pressure-forceps. Then several
turns are made in the same way below the first, but with a continuous
suture, always drawing the thread taut. When the tension becomes
too great, the needle is not carried under the whole wound-surface,
but only under the part of it lying nearest the median line, thus
placing a deep tier at the bottom of the wound. When the operator
reaches the lower narrow part of the oval, he comprises again the
edges in the suture. If necessary, a second tier of buried sutures
may be placed over the first (Fig. 196), avoiding interference with
it, and finally the superficial tier is inserted. The best way of knot-
222
DISEASES OF WOMEN.
ting the suture is by pulling the free end so far out that it can be
tied together with the loop carrying the needle. This method of
suturing is expeditious, and has the advantage of bringing broad
surfaces in contact with each other.
Interrupted sutures may also be placed in tiers above one another
e. g. in closing the abdomen after laparotomy.
FIG. 196.
Second Deep Row of Tier-Sutures (A. Martin).
Chain-suture is used to secure thick pedicles, and will be described
under Ovariotomy.
Sponging and Irrigation. During most plastic operations very
small sponges or pads on sponge-holders are needed, and the assistant
should press the sponge very gently against the bleeding place, with-
out rubbing it, and he should always keep those points clean where
the needle is to be inserted or pushed out. In operations performed
in the dorsal decubitus irrigation with some hot antiseptic fluid or hot
sterilized water may advantageously be substituted for sponging (pp.
182 and 199); and under all circumstances it is advisable to irrigate
the wound before closing the sutures and to remove all clots. The
smoother and cleaner the cut surfaces are, the sooner they will grow
together by first intention.
TREATMENT IN GENERAL. 223
How to Clean and Disinfect Instruments. Instruments should be
boiled in a solution of soda before every operation (p. 199). After an
operation they should be scrubbed with soap or, better, sapolio and
water, and nail-brush, rinsed with clear water, and wiped perfectly
dry with at least two towels. During the operation they should be
immersed in sterilized water or a 2J per cent, solution of carbolic acid.
Selection of Instruments. In preparing for an operation the ope-
rator or his assistant should carefully go through the different steps
of the operation in their mind, and take out all instruments that are
sure to be used ; but, besides, they ought, within reasonable limits, to
prepare themselves for the unexpected by having such instruments
in readiness as may be required under certain eventualities, and by
having more than one of the most indispensable instruments, such as
knives, scissors, needles, pressure-forceps, etc.
5. Combination of Operations. If several operations are needed
on one patient, it is, as a rule, best to perform them at different sit-
tings ; but as this would sometimes take more time and cost more
money than the patient can afford, it may become necessary to per-
form two or more in one sitting. This ought, however, only to be
done when the single operation does not require much time nor cause
much shock, for, other things being equal, the danger increases with
the length of the operation. A torn cervix, a cystocele, and a lace-
rated perineum may all be operated on in one sitting; likewise
shortening of the round ligaments and perineorrhaphy ; but if lap-
arotomy and a vaginal or perinea! operation are required, it is
better to do the laparotomy first and the other a week later. I
prefer to follow the same principle in regard to the cervix, and post-
pone the other operations until the sutures are removed, for a sec-
ondary hemorrhage may occur or menstruation come on prematurely,
as happens so often ; or, as I have seen once in a very scrofulous
patient, the whole cervical portion may ulcerate, and the necessary
measures for the diagnosis or treatment may frustrate the operations
performed on the walls of the vagina. 1
After-treatment. If there is no danger of shock, the best way is
to let the patient sleep after the operation until she wakes of her own
account ; but if there is shock, it is better to rouse her by aspersion
of cold water, shaking, talking, etc.
If she vomits, the measures recommended in treating of anesthesia
(p. 204) should be taken.
For the thirst, frequently repeated teaspoonful doses of hot water
are often good, but in other cases nothing is like small quantities of
ice-water. Ice itself does not quench thirst. An injection of tepid
water into the rectum has sometimes proved useful (p. 170).
1 How far some operators go in combination, and yet get good results, may be seen
in a paper by Edebohls, Amer. Jour. Med. Sci., Sept., 1892, p. 262.
224 DISEASES OF WOMEN.
No food is given as long as nausea continues. As a rule, a fluid
diet of peptonized milk, buttermilk, kumyss, matzoon, beef-tea, 1 and
oatmeal gruel may be begun the day after the operation. ^Nothing
solid should be taken until the bowels have been moved, which in
perineal operations is done on the fourth day, and in laparotomies and
vaginal hysterectomies on the third, by giving castor oil, laxol, com-
pound licorice powder or sodium sulphate. (See Ovariotomy.)
Pulse, temperature, and respiration should be marked graphically
on charts, so that the surgeon may judge of the condition at the first
glance. The nurse should also keep a record of food taken, urine
excreted, and movements of the bowels.
CHAPTER III.
INTERNAL TREATMENT.
FEW gynecological diseases can be cured by internal treatment
alone, but, combined with external treatment, the internal is a valu-
able and often indispensable adjuvant.
The reader is, of course, supposed to be conversant with general
therapeutics. He will ever bear in mind that the body from the ver-
tex to the sole forms one system, all parts of which are most inti-
mately connected ; he will watch for symptoms pointing to disorders
in any division of the body ; and in his treatment of gynecological
cases he will make such modifications as are called for by the condi-
tions of other organs or the constitution in general.
Food and Drink. Most gynecological patients are suffering from
anemia, and often from anorexia at the same time. Attention must
therefore, first of all, be paid to their diet. They should be encour-
aged to eat as much albuminoid food as possible, and, by taking six
small meals a day instead of the usual three more copious ones, much
can be done to increase the amount of food taken every day. The
physician should give as precise orders as possible in regard to time,
quality, and quantity of meals, and look to a proper variety in order
to avoid disgust. Mild alcoholic drinks, such as beer, Johann Hoff's
malt extract, Rhine wine, Moselle wine, French or Hungarian claret,
Burgundy, vin Mariani, port, or tokay, 2 should be taken with meals
unless especially contraindicated.
1 Monsqnera's beef-jelly is excellent for the purpose.
2 Where economy is an object the strong California wines, such as port, sherry,
angelica, and tokay, are to be recommended. Good wines can be obtained for 50
cents a bottle, and superior kinds are sold for $1. These wines are certainly much
to be preferred to the cheap mixtures often sold as imported wines. I have been
particularly pleased with the " Sunset " wines.
TREATMENT IN GENERAL. 225
Weir Mitchell's rest cure, in which the patient is removed from
her friends, put to bed, fed by a nurse to the limit of her digestive
powers, and treated with massage and electricity, 1 may be indicated
in exceptional cases, but, as a rule, gynecological patients should be
encouraged to take as much exercise in the open air as they can with-
out increasing their sufferings.
If the patient cannot digest her food, she should take pepsin and
hydrochloric acid after each meal :
3^. Pepsi nee, 3\] ;
Acid, hydrochlor. dilut. 3\j ;
Syr. aurant., 3ss ;
Aqua?, ad Sviij. M.
Sig. Shake well. A tablespoonful after meals.
I have also found Parke, Davis & Co.'s pepsin cordial very bene-
ficial.
In severe cases of indigestion rectal alimentation may even become
necessary. 2
Very commonly gynecological patients suffer from constipation
and need some aperient. A heaping teaspoonful of Carlsbad salts 3
or sulphate of sodium, dissolved in a tumblerful of hot water and
taken on an empty stomach in the morning, often effects a cure in
the course of six weeks. A heaping teaspoonful of compound licorice
powder, taken in the evening, gives a passage the next morning, and
many like that powder. As a rule, I combine the aperient with a
tonic by giving Blaud's pills with aloes :
!fy. Ferri sulph.,
Potass, carb., da 3ij ;
Aloes Socotrinae, gr. v to xv ;
Extr. gentianse co.. q. s.
Ft. pil., No. Ix.
Sig. Three pills three times a day, after meals.
Sometimes nausea or vomiting call for symptomatic treatment.
They should be treated with bismuth, for instance :
Tfy. Bismuthi subnitr., gij ;
Magnesise carb.,
Sacchari, ad. ss. M.
Sig. A heaping teaspoonful three times a day, between meals ;
1 S. Weir Mitchell, Fat and Blood, and how to Make them, 2d ed., Philadelphia
1878.
2 An important paper on this subject, by Henry F. Campbell of Augusta, Ga., is
found in Trans. Amer. Gyn. Soc., 1878, vol. iii. p. 268, et seq.
3 The artificial salt seems to be just as good, and costs only one-fourth of the im-
ported.
15
226 DISEASES OF WOMEN.
or Liq. iodi co. (Tflj every two hours); creosote (iflj every three hours);
ac. hydrocyan. dilut. (flliij every one to three hours); tinct. nuc. vora.
(ttliij every three hours), each diluted with a tablespoonful of water;
or cocaine hydrochlorate (gr. J every two or three hours) ; or cerium
oxalate (gr. iij to v, t. i. d., in pills).
Tonics are nearly always needed, especially iron, quinine, strych-
nine, arsenic, and phosphorus. I do not know of any better tonic than
the solution of ferrous malate (American Pharmaceutical Manufactur-
ing Company) and the compound tincture of cinchona, equal parts.
M. Sig. A teaspoonful three times a day.
Another valuable combination is the following:
1^. Strychninse sulph., gr. j ;
Ferri et quininae citrat., 3ij ;
Syr. aurant, 5ss ;
Aquae, ad |iij. M.
Sig. A teaspoouful in a wine-glass full of water, three times a
day, after meals.
Plain Blaud's pills are also excellent. If a malarial element is
present, full doses of quinine and other antiperiodics are required.
In carnogen, the extract of red bone-marrow, given in teaspoonful
doses, we have a new and powerful remedy against anemia.
In tympanites, so often accompanying gynecological diseases,
strychnine answers an excellent purpose.
Anodynes are sometimes indispensable, but they should only be
used for a short time and in as small doses as will suffice. Magen-
die's solution of morphine, 4 to 8 drops three times a day ; tincture
of opium, 15 drops; or suppositories with 1 grain of opium every
three hours, are the most common anodynes. Hydrobromate of
hyoscine, gr. ^, has been much praised of late. I find phenacetiu,
in doses of vii ss grains, repeated after one hour, and if needed a
second time after three hours, has an excellent effect in relieving
pelvic pain.
Extract of conium in the dose of 1 or 2 grains, L i. d., is also good,
lodoform or aristol, 5 grains, in suppositories, t. i. d., often dulls pain.
Among sedatives, the bromides of potassium, sodium, and ammo-
nium, single or combined, are often required. An embrocation with
chloroform (1 part) and olive oil (3 parts) gives at least temporary
relief in the troublesome backache so generally complained of.
If the patient is troubled with insomnia, it has to be met with one
of the many hypnotics chemistry has offered us in late years. I have
been particularly pleased with sulphonal (gr. x), chloralamid (gr. xlv),
or trional (gr. xv).
Resolvents are often called for in chronic inflammations. The most
important are iodine, gold, and mercury. We have spoken in another
TREATMENT IN GENERAL. 227
place (pp. 170 and 188) of the application of tincture of iodine to
the vaginal roof and the abdominal wall. Internally, iodine is best
given as iodide of potassium, gr. viij-x, t. i. d. The chloride of
sodium and gold has seemed to me to have a decided effect, espe-
cially in chronic oophoritis. It is given in the dose of gr. ^ to ,
t. i. d., after meals. The bichloride of mercury (gr. y 1 -^, t. i. d.) has
been recommended in chronic metritis.
Hemostatics. In acute hemorrhages from the womb, menstrual or-
mtermenstrual, ergot is the best drug (Extr. ergotse fl. 3j, t. i. d., or
so-called ergotin, gr. ij, t. i. d.}. It works by causing contraction
of the unstriped muscle-fibers composing the bulk of the womb and
those found in the walls of the arteries. It is also useful in subin-
volution, chronic metritis, active or passive hyperemia, in intramural
and submucous fibroids, but not in polypi, in which it is apt to
increase the hemorrhage.
In chronic cases cotton-root is in my experience superior to all
other remedies, whatever the cause of the hemorrhage may be. 1 The
fluid extract is not so efficacious as a decoction prepared fresh every
morning by boiling three heaping teaspoonfuls of rasped cotton-root
bark with one pint of water for a quarter of an hour, during which
one-half of the fluid evaporates. It is then strained, and one-third
taken cold three times a day (1^. Gossypii radicis corticis raspati, siv).
This decoction not only checks hemorrhage when present, but seems
to have a tonic influence on the uterus and the general health. The
patients may take it for months, only interrupting its use from two
to four days in the beginning of menstruation. I have found that
in fibroids it even takes the concomitant pain away, besides checking
the hemorrhage and arresting the growth of the tumor. It works,
like ergot, by causing contraction of the muscular tissue of the uterus,
and is often used in the South to produce abortion.
Another uterine hemostatic that I sometimes have seen help when
the two first named had failed is the mistletoe (I$j. Extr. visci albi
fl. 3ij. Sig. A teaspoonful three times a day).
Bromides are good when the cause of the hemorrhage is nervous
excitement. If malaria is at the bottom of it, quinine, followed by
small doses of arsenic (Liq. potass, arsenitis, gtt. iij to v, t. i. (/.), is
indicated. Arsenic is also recommended in the menorrhagia of grow-
ing girls and young women, and that occurring at the climacteric.
In syphilitic patients mercury is to be prescribed.
Digitalis is recommended for the passive hyperemia consequent on
weakness of the heart or mitral insufficiency. Opium becomes a
hemostatic by subduing excitement. Cannabis Indica operates prob-
ably in a similar way (Bf. Tinct. cannabis Indicse, Ij. Sig. 20-40
1 Garrigues, The Post-Graduate, Jan., 1887, vol. ii. No. 2, p. 117, and Xew Yorker
Medicinische Presse, Nov., 1886, vol. ii. No. 6, p. 231.
228 DISEASES OF WOMEN.
drops three times a day). It has been especially extolled in the hem-
orrhages of the climacteric. Witch-hazel has been accorded a high
position on the scale of uterine hemostatics in passive engorgement 1
(!^. Extr. hamamelis fl. Dose, from a few drops up to 2 drachms).
Among astringents are used gallic acid (gr. v to xv in pills or
powder, t. i. d.), and alum (gr. x to xx, i. i. d., especially in the form
of alum-whey, prepared by boiling 2 drachms of alum with a pint
of milk, and straining. Dose, a wineglassful, containing 15 grains of
alum).
Other drugs that are recommended for uterine hemorrhage are
Viburnum prunifolium (Extr. fl., 3j, t. i. </.) ; hydrastis Canadensis
(Extr. fl., gtt. xx, t. i. d.\ or hydrastiuinse hydrochloras (gr. %, in a
capsule, four times a day) ; terebinthina Chieusis (gr. vj, t. i. c/. 2 ) ;
tinct. capsici (5 drops in a tablespoouful of water every hour) ; smut
of Indian corn (Extr. ustilaginis maidis fl., 3j, t. i. d.), and the root
of Caulophyllum thalictroides (3j-3ij of the infusion or decoction
made with an ounce of the root to a pint of water, or 3J 3y of the
tincture made with four ounces to the pint), which both cause uterine
contraction ; the nettle (Urtica urens and U. dioica, as decoction,
3j to Oj of water. Dose, a cupful several times a day). Chlorate
of potassium, given together with ergot, is also regarded with much
favor.
In cases of uterine hemorrhage the bowels should be kept open,
so as to avoid congestion of the pelvic organs. Sulphate of sodium,
the old " sal mirabile Glauberi," a heaping teaspoonful dissolved in
a little hot water every four hours till effective, answers a good
purpose.
When we see an exsanguinated person, we are tempted to give
iron, but this drug should be carefully avoided during uterine hem-
orrhages, which I invariably have found increase when any chalyb-
eate is used. Even in the interval between the hemorrhages it has
to be used tentatively, as it sometimes increases the amount of blood
lost at the next flow. The same applies to alcoholic drinks. I pre-
fer under such circumstances first to use cotton-root, ergot, cinchona,
and sulphuric acid, combined with local treatment and non-alcoholic
malt preparations, until the tendency to bleeding has been overcome.
Antipyretics. In acute cases there are often indications for reducing
the temperature. If ice-bags and sponging with equal parts of cold
water and alcohol do not suffice, recourse is had to antipyretic drugs,
such as quinine (in 10-grain doses), salicylate of sodium (gr. xv), anti-
pyrine (gr. x), phenacetin (gr. vii ss), or antifebrin (gr. v), repeated
with two hours' interval.
1 Chauncey D. Palmer of Cincinnati, O., Trans. Amer. Gyn. Soc., 1887) vol. xii.
p. 182.
2 J. R. Chadwick, Boston, Trans. Amer. Gyn. Soc., xii. p. 88.
TREATMENT IN GENERAL.
229
CHAPTER IV.
ELECTRIC TREATMENT.
ELECTRICITY is of great value in gynecology. The different kinds
of electricity and differently constructed machines and batteries have
very different effects, and must, therefore, be considered separately.
We distinguish between franklinism, faradism, and galvanism, and, as
a subdivision of the last named, galvano-cauterization.
1. Franklinism, or frictional electricity, is produced by rubbing a
glass plate against cushions covered with amalgam. The patient may
be insulated by sitting on a stool with glass feet, her body more or
less filled with electricity, and sparks drawn from her by approaching
a metal rod to different parts of her body. Another way of using
frictional electricity is by means of sparks and shocks from a Leyden
jar. This kind of electricity is little used, and can hardly have any
other effect than as a nerve-stimulant and counter-irritant in hyper-
esthesia and neuralgic pain.
2. Faradism, or inductional electricity,
is produced by leading the electricity
generated in one or more voltaic cells,
usually composed of zinc and carbon
immersed in a fluid containing bichro-
mate of potassium, sulphuric acid, and
water, through a short coil of coarse
insulated copper wire called the primary
coil, in such a way that the current is
broken and closed at short intervals. The
effect is much enhanced by placing a bun-
dle of varnished wires of soft iron inside
of the coil. Outside of the primary coil
is another called the secondary coil, which
consists of a much longer and finer insu-
lated copper wire. The current going
through the first coil is called the pri-
mary current, and that induced in the
second the secondary current.
The primary current produces muscu-
lar contraction, but the secondary, having
the same effect in a higher degree, is in
more general use for this purpose.
One electrode may be applied in the
uterus or in the vagina, the other on the
abdominal Avail over the fundus of the
uterus, or both poles may be combined in one uterine or vaginal elec-
trode (Fig. 197). The advantages of the bipolar method are that it
Apostoli's Bi-polar Uterine and Va-
ginal Excitors: 1, small uterine;
2, medium uterine ; 3, larire ute-
rine : 4, vaginal, used in the ute-
rus after confinement.
230 DISEASES OF WOMEN.
is less painful, the sensitive skin not being enclosed in the current,
and that, consequently, a much stronger current can be borne.
If the primary current goes through a thick and short wire, it has
a great quantity of electricity ; and if the secondary current is in-
duced in a very long and thin wire, it acquires a high degree of ten-
sion. 1 Such a current of tension has great power in subduing pain
(ovaralgia, abdominal pain in hysterical women, vaginismus, and pain
arising from pelvic inflammations). It is also an emmenagogue.
The faradic current is, as a rule, applied three times a week, some-
times daily ; each sitting lasts from ten to thirty minutes. The elec-
trodes should be applied first, and then the current turned on very
slowly, the patient's feeling serving as a guide as to the strength
applied. At the end the strength of the current is again gradually
decreased until it stops before the electrodes are withdrawn. The
reason for so doing is that the vulva is much more sensitive than the
vagina and uterus, and that a strong current is more endurable when
it is increased and decreased gradually than when it begins and ceases
suddenly. The cervix is also much more sensitive than the body of
the womb.
3. Galvani&m, or chemical electricity, is produced in a so-called
battery, a combination of jars containing the elements and the exciting
fluids. As strong currents often are needed, it is necessary to have
a powerful battery. 2
One of the electrodes is applied to the abdomen or, exceptionally,
to the back. It ought to be very large, so as to distribute the current
over a large surface, and thereby diminish its density. Apostoli's 3
external electrode consists of wet clay 4 in a bag of muslin 10 or 12
1 Lapthorn Smith recommends a primary coil of No. 14 or 16, 25 yards long, with
a secondary coil No. 40, a mile long (Med. News, Jan. 25, 1890). Rockwell has con-
structed an apparatus which is made by the Jerome Kidder Manufacturing Company,
820 Broadway, New York (New York Med. Jour., May 13, 1893). With the latest
improvements this battery consists of a fixed coil of No. 21 wire, 62 to 65 feet long,
for the primary current, and a movable secondary coil, operated by a rack-move-
ment. The total length of this secondary coil is 7,962 feet, with the following sub-
divisions: 726 feet of No. 21 wire, tapped at 252 and 474 feet; 2,574 feet of No. 32
wire, tapped at 1,224 and 1,350 feet ; and 4,662 feet of No. 36 wire, tapped at 1,632
and 3,030 feet. The machine is provided with a circle-switch, allowing the selection
of the total length of the wire, or any part, or any subdivision of any part, of the
coil, and with a rheostat for modifying minutely the strength of the current.
2 A battery of forty large Leclanche" cells, each with an electro-motor power of one
and a half volts, or one of thirty acid cells, each producing two volts, is much used here.
8 Electricity had been used in gynecology as long as it has existed as a special
branch of medicine, and important work had been done in this line also in this
country by Kimball of Lowell, Mass., Ephraim Cutter of New York, J. N. Freeman
and John Byrne of Brooklyn, N. Y., and others. But since 1884, Apostoli of Paris
has given this kind of treatment such an impetus by opening new and large fields
for it, and introducing great improvements in its application, that his name is on
all lips, and, therefore, this historical note may be pardoned as an exception.'
4 In order to prevent it from getting dry, it is a good plan to add glycerin to the
water (Lapthorn Smith of Montreal, Amer. Jour. Obstet., Aug., 1889, vol. xxii. p. 798).
TREATMENT IN GENERAL. 231
inches long and 6 or 8 inches wide. It has the advantage of adapt-
ing itself perfectly to the surface ; but it has the drawback of soiling
physician, patient, and office, and may, therefore, advantageously be
replaced by Enc/elmann's electrode, which consists of a flexible plate
of lead 7 by 6 inches, perforated with many holes and covered with
punk and chamois ; or Martin's electrode, w r hich is a nickel-plated
concave plate, 8 inches in diameter, covered with a membrane and
containing a pint of warm water. The skin should be well moist-
ened before the current is turned on, as otherwise a resistance is
formed by the horny epidermis. It is an advantage to have the
cutaneous electrode immersed in plain warm water. To add salt is
not always good, although it aids in overcoming the resistance of the
skin ; but when salt is used the sensibility increases, and consequently
we cannot use so strong currents as without it. 1 The inner electrode
is, as a rule, applied in the cavity of the uterus all the way up to the
fundus.
Apostoli's intra-uterine electrode is made of platinum and shaped
like a uterine sound, with a movable sheath of celluloid. This sound
has the advantage of being incorrodible. It is, however, a disadvan-
tage that it is stiff, has a tube hard to clean, and is very expensive.
To obviate this, sounds have been constructed in which only the last
two inches are made of platinum, while the remainder is a flexible
gum catheter with a wire in the middle. Aluminium cannot re-
place platinum, as it becomes corroded. Finding it sometimes diffi-
cult or impossible to introduce the flexible sound, I have had one
made with a tip of platinum, No. 9 French, 2 inches long, mounted
on a brass rod covered with hard rubber (Fig. 198). The anterior
FIG. 198.
Garrigues' Intra-uterine Electrode.
part is bent like a sound, the posterior end split for the introduction
of the tip of the rheophore. This electrode is very easy to introduce
and to keep clean, and has given me entire satisfaction. 2 The burn-
ing part being so small, it must, of course, gradually, both in the same
sitting and at different sittings, be applied to different parts of the
endometrium. Dr. Goelet has had stiff iutra-uterine electrodes made
of wrought iron and steel by a process of treatment which renders the
metal non-corrosive and non-attackable by acids for a considerable
length of time. 3
1 A. H. Buckmaster, New York, " The Galvanic Treatment of Fibro-m yomatn,"
Brooklyn Med. Jour., Nov. and Dec., 1888.
2 It was made by Waite & Bartlett, 142 East Twenty-third street, New York.
3 A. H. Goelet, The Medical News, June 22, 1889.
232 DISEASES OF WOMEN.
The stiff electrode should be introduced without speculum after
disinfecting the vagina. 1
If the inner pole is applied to the vaginal roof, a ball of metal or
gas-carbon, one-half to three-quarters of an inch in diameter, mounted
on a hard-rubber stem with central wire, may be employed ; but a
thick layer of cotton should be wound around the bulb and made
thoroughly wet. By so doing we avoid burning the vagina.
The current is led from the battery to the electrodes by means of
rheophores, flexible cords of fine copper wire covered with gutta-
percha and silk, with metal tips at the ends, which are easily adapted
and kept in place by a set-screw or the elasticity of a cleft in the
electrode.
To measure the strength, or so-called intensity, of the current a
mUliamperemeter is needed, a kind of galvanometer, the scale of which
should show at least 250 milliamperes.
In order to be able to turn the current on and off very gradually
a collector, or a rheostat, is used. The collector is a differently con-
structed metal contrivance which allows us to use as many and as few
cells of a battery as we wish. It ought to be so arranged as to en-
able the operator to include or exclude one element at a time. The
rheostat is a bottle half full of water, into which dip two carbon
plates connected with the zinc pole of the battery. Between the two
is a third carbon plate connected with the carbon pole of the battery,
bevelled at its lower end and ending in a platinum point. This plate
can be moved up and down by means of a ratchet. When it is out
of the water there is no current, and by gradually immersing it the
current becomes stronger until the full strength of the battery is
turned on.
The current coming from a battery may be used as a constant or as
an interrupted current. The latter causes a shock and muscular con-
traction, but is more or less painful, and with strong currents even
dangerous.
By using large and wet electrodes we chiefly get the interpolar
effect, which is that of electrolysis. By using small and dry electrodes
we chiefly obtain the polar effect, which, when the current is strong
1 In order to have the chemical cauterizing effect of the intra-uterine electrode, it
has been calculated that it should present a surface of 1 square centimeter for each
25 milliampSres (F. H. Martin, Trans. Amer. Gyn. Soc., 1888, vol. xiii. p. 275).
Apostoli has a series of seven intra-uterine electrodes made of gas-carbon, which
conducts readily, is little subject to the corroding action at the positive pole, and may
be had at small expense. The length is the same in all, 1 inch, but the thickness
varies from 5 to 12 millimeters (J to i inch) in diameter. They are screwed on an
insulated metallic stem, the insulating sheath of which has a circular groove for
every inch. This electrode is used in irregular and deep uterine cavities, and by
withdrawing it from groove to groove the cauterizing effect is extended from one
part to the other (Apostoli, "Novelties," Brit. Med. Ass., August, 1888, reprint,
p. 26).
TREATMENT IN GENERAL. 233
enough, becomes a chemical cauterization. By combining a large wet
electrode on the skin with a small dry electrode in the uterus we
avoid burning the skin and obtain the chemical cauterization of the
uterus.
Experiments on living animals have shown that when a galvanic
current of 50 M. is applied to the intestine of a dog, the same be-
comes blanched. When it is applied to the heart, and the part en-
compassed between the poles is examined under the microscope, the
stria) of the muscular fibrillse are found in a granular condition a sign
of beginning disintegration. 1
That the molecules are moved by the galvanic current can even
be seen in a physical experiment. When a vessel is divided into
two compartments by a porous partition, and the compartments are
filled to the same height with water, and a galvanic current is led
through them, the water rises in that compartment in which the
negative pole is. This electric osmosis, or so-called cataphoresis, may
be used for introducing drugs, such as cocaine or iodide of potassium,
into the body by applying a solution of them to the anode. 2
Different Qualities of the Poles. The two poles of the battery have
different physical and physiological effects. The positive pole attracts
acids, while alkalies collect at the negative. The eschar produced by
the positive pole is dry ; that at the negative is softer, larger, and lets
the galvanic current penetrate through it. The positive is, therefore,
used against hemorrhage and leucorrhea, the negative, where it is de-
sirable to draw blood to the interior of the uterus and for galvano-
puncture. The negative pole has a more pronounced denutritive
effect. But if, in spite of these general rules, the expected effect is
not obtained, it is advisable to try the other pole, and in the course of
the treatment of the same case it is often indicated to change poles
according to the changed circumstances.
Apostoli's Method. The operation may be performed in the pa-
tient's home or in the physician's office. Sexual connection should
be forbidden.
Before operating with a battery with collector, the physician should
try the battery in order to ascertain that there is no break in the cur-
rent, which would cause a shock. This may be done by including
one cell after the other in the current and watching the deviation of
the needle of the milliampe'rerneter.
The patient should remove her corset. 8 She lies on her back, with
her knees drawn up. If there are any erosions of the skin, they
must be covered with collodium or paper before the electrode is placed
1 Buckmaster, /. c., pp. 12-14.
2 Frederic Peterson, " Electric Cataphoresis as a Therapeutic Measure," JS T . 1".
Med. Jour., April 27, 1889.
3 In using Engelmann's electrode it is enough to open the lower part of it.
234 DISEASES OF WOMEN.
over them. Strict antisepsis is used in regard to hand, vagina, uterus,
and internal electrode. The current should not be turned on until
all pain caused by the introduction of the intra-uterine electrode has
ceased. Then it is turned on slowly, so that it, takes half a minute to
a minute before the full strength is reached. In the beginning some
pain is felt on the skin, due to the resistance oifered by the epidermis.
Then we wait till it has ceased before increasing the strength of the
current. The strength of current used varies according to the nature
of the case and the sensitiveness of the patient. As a rule, an in-
tensity of little less than 100 milliamperes is used, but when there is
a subacute inflammation of the parts situated near the uterus, and in
hysterical patients, only 40 to 50 milliamperes can be tolerated. 1
Under all circumstances it is advisable not to go too far at the first
sitting, but to stop, say, at 50 M. There must never be any severe
pain felt in the uterus. In large uteri the intensity must be increased
or the surface of the intra-uteriue pole diminished. The current is
kept up from five to ten minutes, in most cases only five. At the
end it is turned off as slowly as it was turned on. The vagina is
again disinfected, and the patient is directed to use antiseptic injec-
tions the following days.
The sittings are, as a rule, repeated on out-door patients once a
week, but in more urgent cases twice a week : in private practice the
applications are made two or three times a week. But hemorrhage
may call for treatment every day ; and, on the other hand, where
there is perimetric inflammation, it may not be tolerated more than
once in eight or ten days. As a rule, the applications are made in
the intermenstrual period, but if there is severe hemorrhage it may
be necessary to operate immediately. Twenty, thirty, or more sittings
may be needed to effect a cure.
Immediate Effect. Often some uterine colic is felt immediately
after the treatment, and may last from a few minutes to several hours,
or even till the next day. Sometimes the patient may lose a little
dark blood, and on the following days, when the eschar is being
thrown off, there is always some sero-purulent discharge. Exception-
ally, even enormous amounts of a watery fluid are discharged through
the vagina. It is therefore by no means rare that the symptoms, on
the whole, get worse during the first five or six sittings before im-
provement begins. Sometimes fever and other signs of inflammation
may necessitate the temporary interruption of the galvanic treatment.
Chemical Galvano-cauterization of the Cervix. Apostoli has con-
structed a special bipolar electrode of carbon, to be used for cauteriz-
1 When it is desirable to use strong currents in hysterical patients, they should go
to bed an hour before treatment and take a full dose of morphine and atropine, and,
if that is not enough, chloroform is used. The current is used for ten minutes.
The patient remains in bed for at least six hours after the treatment. In this way
200 to 400 milliampSres have been tolerated (F. H. Martin, Med. Neivs, Jan. 25, 1890).
TREATMENT IN GENERAL. 235
ing the cervix. It is used with strong currents (150 to 200 M.) for
a very short time (two to ten seconds). The writer has obtained
excellent results by using a milder current, 40 M., a longer time
(five minutes), and a carbon electrode wound with very little, nearly
dry cotton, forming the positive pole, while the negative was an
Engelmann electrode applied to the abdomen (see Chronic Endo-
metritis).
Galvano-puncture. If a tumor is situated in the uterus in such a
way that the sound cannot be made to enter the uterine canal, galvano-
puncture is used. A trocar- or lance-head-pointed platinum or gold
needle is pushed through the vaginal roof into the tumor, and then
connected with the negative pole of the battery. In inserting the
needle care is taken to feel for and avoid pulsating arteries, and to
push in such a direction as to reach the uterus. On account of the
anatomical relation to the bladder such punctures cannot be made in
front, but only behind and to the sides of the cervical portion ; and in
the latter locality we must keep clear of the ureters and the uterine
artery. Counter-pressure is made on the fundus through the abdom-
inal wall. A fine needle should be used and introduced without spec-
ulum. The introduction of the needle may be much facilitated by
making it the negative pole of a mild galvanic current. The puncture
is made on the point where the uterus bulges most into the vagina. The
needle is not pushed deeper in than a quarter to half an inch. It is
either used to form a communication with the cervical canal, so that,
the artificial canal once made, the usual galvano-cauterization may be
performed on the uterine mucous membrane, or goes simply into the
tissue of the uterus and perhaps a tumor situated in its wall. Hemor-
rhage may be stopped by interpolar action alone, without cauterization
of the mucous membrane of the uterus.
Galvano-puncture is a more serious interference than galvano-cau-
terization of the inside of the uterus, and should not be repeated
oftener than every eight or fifteen days. It has to be repeated several
times before the canal remains open. It may be combined with posi-
tive or negative cauterization according to indications. Upon the
whole, galvano-puncture is more dangerous than other methods that
will be described in treating of uterine fibroids, and cannot be rec-
ommended.
Thermal Galvano-cauterization. The thermal galvano-cauterization
differs from the chemical by using heat as the therapeutic agent. It
is produced by another kind of battery especially constructed for the
purpose. The principle is to produce a large quantity of electricity,
which, being led through a comparatively thin platinum wire, that offers
great resistance, heats the wire to incandescence. Two sizes of wire
are used a thin and a thick. The former forms a loop that can be
drawn round and through a cylindrical body e. y. the cervix uteri.
236 DISEASES OF WOMEN.
The latter is shaped into knives and domes for cutting and burning. 1
By means of these galvano-cauteries diseased parts may be excised
without loss of blood ; but in order to obtain this the knife or wire
must never be brought to a white heat, and they should be carried
slowly and interruptedly through the part to be severed. The knife
should be applied cold, in order not to wound the vagina while intro-
ducing it. If the wire loop cannot easily be applied, a furrow may
first be made for it with the cautery knife. When the wire has
entered the submucous tissue, traction may be made with a volsella
on the mass to be removed, so as to give to the cut surface the shape
of a hollow cone.
Thermal galvano-cauterization does not only present the advantage
over other cauteries (p. 182) that it can be applied with a flexible
loop, but it has less radiating heat, and is, therefore, less liable to
scorch the surrounding parts ; it seems to possess a power of modify-
ing the tissue, even at some distance from the cut surface, by diffusion
of the electricity ; and it has a powerful antiseptic effect, which
appears clinically in the remarkable immunity from peritonitis, cellu-
litis, and septicemia which distinguishes it from other surgical pro-
cedures, and has been proved experimentally by direct application to
germ-cultures.
Where there are large masses of diseased tissue in the interior of
the womb, it is often preferable first to remove some of them with the
curette before using the galvano-cautery. But then bleeding must
first be stanched by irrigation with creolin, sponging, and the appli-
cation of the cautery to open vessels. After that every part of the
cavity is gone over repeatedly with the dome-shaped galvano-cautery,
and each time that blood oozes from the seared tissues the cavity is
to be sponged, until finally it is charred all over. The ragged bor-
ders of the excavation should next receive attention, and no raw spot
should be permitted to escape the cautery. Finally, the cavity and
the vagina are tamponed with iodoform gauze (pp. 179, 180).
Metallic Interstitial Electrolysis. Under this name has been de-
scribed a procedure which in reality is a cataphoresis of drugs formed
by the electric current itself. By using an intra-uterine electrode of
copper connected with the positive pole oxychloride of copper is formed,
and is, by the electric osmosis or cataphoresis, driven into the tissue.
A current of 20 to 30 M. is used for from five to ten minutes. Dur-
ing the application the electrode should be kept in motion in order to
avoid its sticking to the wall. If this, however, should happen, all
that is needed to loosen it is to reverse the direction of the current
1 The best instrument of this class is that of John Byrne of Brooklyn, H. Y., who
also has constructed a special speculum for galvano-caustic operations (Clinical
Notes on the Electric Cautery in Uterine Surgery, New York, 1873, and Trans. Amer.
Qyn. Soc., 1892, vol. xvii. pp. 42-46).
TREATMENT IN GENERAL. 237
for a few minutes. The cervical canal must be patulous for subse-
quent drainage, and it should, if possible, be excluded from the action
of the copper. This treatment has proved very valuable in uterine
hemorrhage and endometritis. A much stronger current, 80 to 100
M., has been used for ten minutes in the cervix for gonorrhea. After
three applications all gonococci had disappeared. In a similar way
zinc has been used. It forms an oxychloride, which has the property
of softening the tissue, and has been used successfully in cases of
sclerosis and fibroid. After having been used, these corrodable elec-
trodes are polished with emery cloth. 1
1 A. H. Goelet, The Times and Register, 1893, pt. 2, p. 743.
PART VII.
ABNORMAL MENSTRUATION AND METRORRHAGIA.
THE normal process of menstruation has been considered in Part
III. (pp. 115-120). This process is subject to disturbances which
may occur in very different gynecological diseases or without any
affection of the genitals. It may be absent (amenorrhea) or scanty ;
the bleeding may take place from another part (vicarious men-
struation); it may be painful (dysmenorrhea) ; it may begin too
early in life (precocious menstruation) ; or it may be profuse (men-
orrhagia).
Finally, there may be hemorrhage from the uterus at other times
than the menstrual period (metrorrhagia).
CHAPTER I.
AMENORRHEA.
AMENORRHEA is the absence of the menstrual flow. This may
either be so that the flow had begun and suddenly stopped, which is
called suppression of menses, or so that it does not come on at all
amenorrhea proper.
1. Suppression of Menses. Etiology. The suppression of menses
may be due to exposure during menstruation, by which the feet or
the skin becomes wet and cold (compare p. 129) ; to emotions, especially
a fright ; or to the appearance of an acute inflammation, such as pneu-
monia or erysipelas.
Symptoms. The symptoms are sometimes slight or none, and the
courses reappear at the next period ; but sometimes the sudden sup-
pression of the menstrual flow gives rise to acute congestion or inflam-
mation of the womb or the appendages, to extravasation of blood
into the peritoneal cavity or the pelvic connective tissue, and the
amenorrhea may last long or be final.
Treatment. It is proper to try to bring tne flow back by hot appli-
cations to the abdomen, hot hip-baths, hot vaginal and rectal injec-
238
ABNORMAL MENSTRUATION AND METRORRHAGIA. 239
tions ; but, as a rule, this medication succeeds only in so far as it
relieves pain. The same is accomplished by opiates.
2. Amenorrhea, in the proper sense of the word, is the condition
in which the menstrual flow fails to appear, although the patient has
reached the proper age and feels as if she would be relieved by its
coming, or where it does not reappear at the usual period in persons
who have already menstruated.
Etiology. We have seen above that menstruation, as a rule, is
absent during pregnancy and lactation. In persons who have never
menstruated the cause may be congenital faulty development : absence
of the ovaries and tubes; absence or imperfect development of the
uterus, such as a rudimentary or infantile uterus ; absence or atresia
of the vagina. Often, especially in young servants, the cause is over-
work, sometimes combined with insufficient food. The causes may
also be the same that are at work in making menstruation stop in
those who have already menstruated. A common cause is a change
of climate and habits. Thus amenorrhea is often found in women
who move from the country to large cities, and in those who have
recently immigrated from Europe. It is often a sequel of debilitating
diseases, such as anemia, phthisis, malaria, typhoid fever, diabetes,
or chronic mercurial poisoning. It is not rare in insane women
and morphiomaniacs. It is sometimes found in the late stage of
chronic metritis, in inflammation of the uterine appendages, in cases
of malignant disease of both ovaries, or in women afflicted with a
vesico-vaginal fistula. It is a frequent accompaniment of the devel-
opment of obesity.
About the effect of the removal of the uterine appendages see p. 119.
Symptoms. The symptoms of amenorrhea, besides the absence of
the flow, may be insignificant, but it is quite common that the patient
complains of headache, flashing heat, heaviness in the abdomen, ner-
vousness, nausea or vomiting, and sometimes she may even suffer from
convulsions of the hysterical or epileptic type. If the lack of flow
is due to atresia of the genital canal, the fluid accumulates behind the
partition, considerable pain is experienced at each recurrence of the
menstrual period, and a tumor is felt in the pelvis corresponding to
the distended vagina, uterus, or both. The abnormal sensations
occurring at the time of the menstrual period are called the menstrual
molimen.
Diagnosis. The most important diagnostic question is if the amen-
orrhea might not be physiological and due to pregnancy, normal <>r
ectopic i. e. outside the uterine cavity. In this respect every sign
of pregnancy as taught in works on obstetrics must be thought of,
especially the early signs, such as the softening of the lower uterine
segment, the increased diameter of the uterus in the antero-posterior
direction, morning sickness, and small tongues of brown pigmentation
240 DISEASES OF WOMEN.
shooting out from the superior external circumference of the areola,
the first beginning of what is known as the secondary areola.
In ectopic gestation we may, besides the signs of pregnancy, find a
tumor outside of the uterus corresponding in size to the duration of
the amenorrhea.
Treatment, Idiopathic amenorrhea should not be regarded or
treated as a disease. In the beginning of menstrual life it is quite
common that a period or two are skipped. If the girl is otherwise
well no treatment is called for. If the cause of the amenorrhea is
anemia, be it from loss of blood, from defective assimilation, or from
wasting diseases, the only aim should be to ameliorate the general
condition by proper alimentation, tonics (p. 226), moderate exercise
in the open air, horseback riding, mild gymnastics, or massage.
Aperients have some influence in bringing on the flow, and the
one most credited with emmenagogue power is aloes. In malaria
quinine and arsenic are the chief remedies. If the nervous system
is upset, bromides, antipyrin, or phenacetin is very useful. Hot
vaginal and rectal injections, warm hip-baths, warm foot-baths with
or without mustard, and long, warm general baths will sometimes
bring back the courses. The mere introduction of the sound works
as a stimulus to the uterus, and may have the same effect. Elec-
tricity in all its forms (p. 229) is a powerful remedy, especially
bipolar intra-uterine faradization, with secondary current, and, best
of all, galvanism, with the negative pole in the uterus.
Besides iron, quinine, strychnine, and aloes, the following drugs have
more or less well-founded reputation as emmenagogues : Manganese in
the form of the permanganate of potassium or the binoxide (gr. ij to
iv, t. i. d.) ; chlorate of potassium (gr. v to xx, t. i. d.) in combi-
nation with iron ; santonin (gr. ij or iij, t. i. d.) ; oleum sabinae (tlfliij
to vj, t. i. d.) ; oleum rutse (Tfl,iij to vj, t. i. d.} ; oleum tanaceti (HI iij
to vj, t. i. d.) oleum hedeomae (ttlij to x, t. i. d.) or a warm infusion
made of the herb ; ergot (p. 227) ; radix gossypii (p. 227) ; tinct.
cantharidis (lfl,x, xx, up to fej, t. i. d.) ; tinct. hellebori nigri (Tltxx to
xl, t. i. d.). As their effect is very uncertain, it is wise to combine
several in one prescription e. g. :
fy. Strychnine sulph., gr. j ;
Aloes Socotr., Bj ;
Quininae sulph., 3ij ;
Ferri sulphat. exsiccat., 9ij ;
Ol. sabinae, 3j ;
Extr. gentian, co., q. s.
Ft. pill. No. Ix.
Sig. Three pills three times a day.
It is also well to combine the use of drugs with the other remedial
agents recommended.
ABNORMAL MENSTRUATION AND METRORRHAG1A. 241
If in cases of rudimentary uterus the development is so insufficient
that there is no hope of help from electricity and the other remedies,
and if the nervous symptoms are very distressing, the removal of the
uterine appendages is indicated. If the apparent ameuorrhea is in
reality retention of the menstrual blood behind an obstruction in the
genital canal, the removal of the obstruction by operations that will
be described in treating of the diseases of the special organs, is the
only means of saving the patient's life.
Scanty menstruation is a lower degree of ameuorrhea, and is treated
on the same principles especially with tonics and electricity.
CHAPTER II.
VICARIOUS MENSTRUATION.
VICARIOUS menstruation, or xenomenia, consists in the occurrence,
at the time of menstruation, of bleeding from another part of the
body than the uterus, or the appearance of another secretion. The
vicarious bleeding may sometimes take place alone, instead of the nor-
mal uterine monthly discharge, or it may be combined with it so as to
be supplementary. In the latter case the flow from the normal source is
generally scanty. Vicarious menstruation has been found to appear on
nearly every mucous membrane and every part of the skin, the most
common places being the stomach, the breasts, and the lungs. As to
other secretions, serous diarrhea and increase of leucorrheal discharge
have been observed to accompany or replace menstruation. I have
myself seen colostrum in the breasts and profuse perspiration appear
at the menopause. 1
Vicarious menstruation is a rather rare condition. It is mostly
found in weak, nervous, hysterical women. Wounds, ulcers, and
varicose veins predispose to it.
Symptoms. Generally the patient has both menstrual molimen in
the pelvis and congestion, swelling, and pain in the place where the
vicarious bleeding is to occur.
Prognosis. The importance of the affection depends on the nature
of the locality affected. A bleeding from the skin or the nose is far
less serious than that from the stomach and the lungs. In general
the chances of stopping the abnormal loss of blood are good if we
succeed in bringing back or increasing the normal flow.
Treatment. The treatment is chiefly directed to the relief of the
amenorrhea or scanty menstruation (p. 240). The ectopic bleeding
calls only for treatment if it becomes excessive, and is then treated
according to the general rules of medical and surgical practice.
1 Garrigues, Amer. Jour. Obst., 1884, vol. xvii. p. 524.
16
242 DISEASES OF WOMEN.
CHAPTER III.
DYSMENORRHEA.
DYSMEXORRHEA is the condition in which the menstrual process
gives rise to pain in the pelvic organs. The pain may precede or
accompany the flow. It may be due to diseases of the ovaries, the
tubes, the uterus, the pelvic peritoneum, or connective tissue, or be of
purely nervous origin. If the dysmenorrhea is due to inflammation
of the uterine appendages and the contiguous part of the peritoneum
and connective tissue, i.t appears, as a rule, earlier as much as eight
days before the flow begins and a relief is felt when the congestion
is diminished by the physiological rupture of capillaries taking place
in the mucous membrane (p. 117). The pain is situated in the sides
of the pelvis or the iliac fossa?. Sometimes it seems to be due merely
to a toughness in the texture of the ovary which interferes with the
free development of the Graafian follicle.
If the dysmenorrhea comes from the uterus itself, it may be due
to inflammation of the mucous membrane or the muscular tissue
(endometritis or parenchymatous metritis). There may be an intra-
uterine polypus playing the role of a ball valve, or the simple swell-
ing of the mucous membrane, especially at the internal os, may pre-
vent the escape of the blood from the cavity, or the uterus may be so
bent that the crookedness of its canal opposes a barrier to the free
outflow of the blood.
It is especially anteflexion which predisposes to dysmenorrhea, but
the more pronounced cases of retroflexion have a similar effect. The
cervical canal may be too narrow, especially at the internal or external
os (stenosis). Sometimes clots are formed in the uterus, the expulsion
of which causes labor-like pain in the back and behind the symphysis.
Sometimes the whole mucous membrane is thrown off and expelled
with similar pains a condition called membranous dysmenorrhea.
Uterine dysmenorrhea is felt more centrally and appears a shorter
time before the appearance of the flow, and continues often for several
days after it has begun.
That dysmenorrhea which is due to closure of the genital canal
and retention of the menstrual blood has already been mentioned in
the chapter on Amenorrhea (p. 239).
Nervous dysmenorrhea may be due to over-sensitiveness of the
nerves, so that the normal congestion of menstruation is perceived as
a painful pressure, and it may be caused by muscular contraction of
the internal os.
The degree of dysmenorrhea varies from a slight discomfort to the
most excruciating pain, that unfits the patient for any work and
almost makes life unendurable.
ABNORMAL MENSTRUATION AND METRORRHAGIA. 243
Prognosis. The prognosis varies, especially with the etiology. In
most cases we may promise relief, if not a cure.
Treatment. The treatment varies likewise very much with the
causes. In young, undeveloped girls, without any inflammatory
complications, we try to avoid a vaginal examination. Even a rectal
one may be dispensed with for some time. Tonics (p. 226), exercise
in open air, gymnastics (p. 191), general massage (p. 190), towel-baths,
shower-baths, and sea-bathing (p. 188), are the chief remedies. Where
there is any form of inflammation exercise can only be taken with
great caution and within narrow limits, and the patient ought to stay
in bed during the attack. The treatment of the special diseases
causing dysmenorrhea will be found under the description of the dis-
eases of the different organs, but for convenience's sake we will briefly
refer to it here.
In all inflammatory conditions we use hot vaginal injections (p.
171), painting of the vaginal roof with tincture of iodine (p. 170),
pledgets with glycerin, iodine-glycerin, or ichthyol-glycerin (p. 178),
faradization with the secondary current (p. 229), galvanism or scar-
ification of the vaginal portion (p. 186). In endometritis we make
applications to the endometrium (p. 170).
In anteflexion the regular use of the uterine sound gives great
relief. A retroflexed womb is replaced and a Hodge's pessary intro-
duced into the vagina. Outerbridge's intra-uterine drainage pessary
(p. 184) may prove useful. For flexions or mere stenosis the cervical
canal is dilated with Hanks' and Garrigues' dilators (p. 155), either
moderately (below half an inch) or to the full extent of the latter
instrument (divulsion). The narrow canal may also be gradually
dilated with the negative pole of the galvanic battery. In cervical
anteflexion it may become necessary to split the. posterior lip of the
cervix (Sims's operation). In desperate cases of dysmenorrhea due
to inflammation of the ovaries and tubes salpingo-oophorectomy is
the last resort.
The purely nervous dysmenorrhea is treated with tonics and seda-
tives (p. 226).
During the attack all forms need some immediate relief. Since
these conditions often last long and a baneful habit might be acquired,
we should be careful not to abuse narcotics, but in bad cases they are
unavoidable. I often use an anti-dysmenorrheic pill of the following
composition :
1^. Extr. conii ale., 9j ;
Extr. strammon. ale.,
Extr. opii, da. gr. v.
Ft. pil. No. x.
Sig. One pill at most three times a day.
In the milder cases hot dry or wet fomentations of the abdomen,
244 DISEASES OF WOMEN.
and hot drinks, such as hot tea or hot brandy and water or an infu-
sion of antherais or matricaria, may suffice. Antipyrin (gr. x),
antifebrin (gr. v), and phenacetin (gr. viiss) should all be tried before
narcotics are used ; and they have often splendid effect. If necessary,
a second dose is given after an hour, and a third after three hours.
Viburnum prunifolium is also a uterine sedative : since the taste and
odor of the fluid extract are most offensive to many patients, it is
well to give it inspissated in capsules (dose 3j of the fluid extract,
t. i. d.).
Among the older drugs apiol (a capsule with TTLv from three to six
times a day), pulsatilla (iTtij iij of the fluid extract in water, three or
four times a day during the week preceding menstruation), and can-
nabis Indica (20 drops of the tincture every three hours during the
pain), are yet praised.
There is a widespread popular belief that marriage is a panacea for
all sufferings in a girl, but nothing could be more erroneous. If
marital relations may work as a stimulus, like electricity, to imper-
fectly developed genitals, calm an irritated nervous system, effectually
cure a stenosis or flexion, by the occurrence of conception and child-
birth, on the other hand inflammatory conditions of the pelvic organs
get much worse by the congestion produced by coition and the stretch-
ing of all the organs unavoidably connected with pregnancy and
childbirth (p. 129).
CHAPTER IV.
PRECOCIOUS AND TARDY MENSTRUATION.
A SINGLE discharge of blood from the genitals is sometimes found
in little children, even in the new-born, without any apparent disease.
Irregular bleeding may take place from a sarcoma. But we can only
speak of precocious menstruation when there is a regular return of
the bleeding from the genitals every four weeks in children below
the age of puberty. This is a very rare affection. It has been
observed in a child less than a year old, and several cases are on
record dating from the second year. As a rule, both the external
and internal genitals and the breasts are abnormally developed in
such children, and sometimes they show sexual appetite. Their con-
stitution suffers under the untimely loss of blood. There is nothing
to be done for them except to try to combat the general weakness,
keep them quiet at the time of menstruation, and watch them in
regard to masturbation. To check the flow might lead to vicarious
menstruation.
ABNORMAL MENSTRUATION AND METRORRHAGIA. 245
Tardy menstruation is the first appearance of the menstrual flow at
an unusually advanced age. It has been seen to begin as late as
thirty-one years. This condition has been considered under the
subject of Amenorrhea.
CHAPTER V.
MENORRHAGIA.
MENORRHAGIA is too great a loss of blood from the uterus at the
time menstruation is due. The increased loss may either be due to a
shortening of the interraenstrual period, or to a protracted duration
of the flow, or, most of all, to an increase of the amount lost at each
period. Since the normal amount is not known, and, at all events,
varies much, we cannot indicate in an exact \vay where meuorrhagia
begins, but, practically, we call the flow so if it suddenly becomes
much more profuse than the woman usually has it, and if it weakens
her.
Etiology. Menorrhagia is in most cases due to a disease of the
uterus, such as endometritis, chronic metritis, subinvolution, lacerated
cervix, a granular condition of the os, a fibroid tumor, a polypus, or
cancer. It may also be due to the different kinds of displacements
of the uterus. Secondly, it may be due to ovarian diseases, especially
oophoritis and small ovarian tumors. Thirdly, certain general acute
infectious diseases are apt to cause profuse menstruation, especially
cholera, small-pox, scarlet fever, typhoid fever, and inflammatory
rheumatism. Among the chronic diseases hemophilia, syphilis, chlo-
rosis, and malaria especially give rise to profuse menstruation.
Sometimes the cause is to be sought in diseases of the heart, the
liver, or the kidneys.
Sometimes no cause can be assigned e. g. for the not infrequent
menorrhagia found in young girls at the beginning of menstrual life.
Symptoms. Besides the increased loss of blood, there are other
symptoms due to it. If the loss is very heavy, it may cause acute
anemia with rapid, flagging pulse, dyspnea, pallor, cold clammy skin,
faintness, or syncope. But oftener we find a chronic anemia charac-
terized by pallor, weakness, asthenopia, and backache.
Diagnosis. The diagnosis between menorrhagia and metrorrhay'm
i. e. uterine hemorrhage occurring independently of menstruation
is sometimes difficult or impossible when so frequent hemorrhages
take place that the patient does not herself know what would be the
regular time for a menstrual flow to come on ; but in most cases the
distinction can be made by the time elapsed since the last bleeding,
by the sensations which generally precede the menstrual flow, by the
246 DISEASES OF WOMEN.
admixture of mucus with the blood, and by the gradual way in which
it appears.
Prognosis. It is doubtful if ever a woman has died directly of
menorrhagia, but repeated losses undermine health and shorten life.
Treatment. In the mildest cases we prescribe ergot and other
internal hemostatics (p. 227), rest, cool diet, and abstinence from
alcoholic drinks and coffee. The bowels should be kept open with
saline aperients (p. 225). If there is any excitement, bromides
and opiates, especially opium suppositories (p. 226), are indicated.
If this treatment does not have the desired effect, vaginal injec-
tions with hot water may be added. If they do not check the
hemorrhage, we add liq. ferri chloridi to the water (p. 182). If the
bleeding continues, an intra-uterine injection of hot water with or
without liq. ferri is given (p. 172). A bag with hot water applied to
the lumbar region is sometimes effective. An ice-bag is placed over
the symphysis (p. 187). If all this is ineffectual, or if the hemorrhage
is alarming, we tampon the vagina (p. 179) or the uterus (p. 180).
In the intermenstrual period a treatment is instituted according to
the cause of the menorrhagia. If the endometrium is affected, the
uterus is treated with applications of liquor ferri (p. 170), curetted
(p. 176), or cauterized by means of chemical galvano-cauterization
(p. 233) with the positive pole in the uterus. Granulations are de-
stroyed, the torn cervix united, a polypus removed, and a fibroid
treated as taught under the discussion of that disease. Ovarian
inflammation is treated with injections, applications, resolvents (p.
226), glycerin pledgets, galvanism, etc.
At the same time we try by means of hemostatics, tonics, and food
to build up the patient as much as possible before the occurrence of
the next menstruation (pp. 224-228).
In cases of heart disease a moderate bleeding gives relief, and
should, therefore, not be checked too soon. Digitalis, strophanthus,.
and aconite are valuable remedies under such circumstances. When
the liver is torpid, attention to diet, abstention from alcoholic drinks,
and the administration of calomel, pulv. hydrargyri cum creta, or
euonymin (gr. ss-v) are indicated. In kidney disease especial atten-
tion should be paid to the vicarious functions of the skin and bowels.
The physician must not forget that a moderate loss of blood
is a normal condition, a kind of safety-valve, for the female economy.
He must, therefore, allow a reasonable amount of blood to escape
before he begins to check the flow. As a rule, I let patients suffering
from menorrhagia bleed from two to four days before interfering, but
a dangerous loss of blood should be stopped at any time by the most
potent measures. How to act in a given case can only be learned by
tact and experience. If everything else fails to check menorrhagia,
Tait recommends the removal of the appendages.
ABNORMAL MENSTRUATION AND METRORRHAG1A. 247
CHAPTER VI.
METEORRHAGIA.
METRORRHAGIA is a profuse uterine hemorrhage occurring at
another time than the menstrual flow. Its causes, symptoms, and
treatment are essentially the same as those of menorrhagia, just de-
scribed, with the exception that this flow, being entirely abnormal,
need not be allowed, and may, therefore, be treated more actively from
the very beginning, unless the bleeding has a beneficial influence on
some diseased condition e. g. pelvic inflammation.
CHAPTER VII.
GENERAL MENSTRUAL DISORDERS.
THE menstrual process being a general condition of which the
secretion of blood from the mucous membrane of the uterus is only
one feature, there is hardly any part of the body in which we may
not find more or less important disturbances connected with it. These
occur especially before the flow appears or in the beginning of the
same. They may accompany a normal bloody discharge from the
genitals, but are more commonly combined with amenorrhea or scanty
menstruation.
The Nervous System. Headache, especially in the shape of
migraine, is quite common. Sometimes neuralgic pains are felt,
especially in the arms and legs. Hysteria may be entirely due to
menstrual disorders or get worse at every period. In exceptional
cases it may reach the highest degree, so-called hystero-epilepsy.
True epilepsy may only appear at the time of impending menstrua-
tion, or the attacks may be worse every time the period recurs. In
insane women the influence of menstruation is very marked. As a
rule, maniacal attacks get worse or appear only at that time. Symp-
toms of impulsive insanity, such as kleptomania or the impulse to
murder, are sometimes decidedly increased by menstruation. The
insanity of girls at puberty, especially that pyromania which drives
them to set houses or hayricks on fire irrespective of consequences,
may be parallelized with that of the menopause which we have
already mentioned (p. 124).
The Eyes. Existing inflammation gets very frequently worse. In
those suffering from exophthalmic goiter the eyes are more prominent.
The condition known as hysteric copiopia l acquires generally increased
1 This disease, described by Foerster, is characterized by pain in the region of the
248 DISEASES OF WOMEN,
intensity. Blood may be extravasated into the anterior camera or
behind the retina. Papillary inflammation, optic neuritis, ueuro-reti-
nitis, and complete amaurosis have been observed. The formation
of sties is very common.
The Ear. Vicarious menstruation may occur from the ear. Exist-
ing granulations swell ; purulent discharge, buzzing sound, and deaf-
ness increase frequently.
The Nose. Profuse epistaxis may be due to vicarious menstruation.
The skin is often the seat of exanthemata, such as acne, urticaria,
eczema, exudative erythema, herpes, etc. The latter appears not
infrequently on the genitals, which also are liable to become the prey
of pruritus. The legs and the face may become edematous. Some-
times there is free perspiration, with or without an unpleasant smell,
or seborrhea of the scalp. Besides vicarious menstruation in the
shape of blood trickling out through fissures forming in the skin,
there are sometimes minute ecchymoses in the same.
The Digestive Tract. Sometimes the tongue is coated ; the patient
suffers from toothache, aphthous stomatitis, or sore throat. As men-
tioned above, the stomach may be the seat of vicarious menstruation,
from a few teaspoonfuls to over two pounds of blood being vomited.
There may also be a hemorrhoidal flow or diarrhea. In rarer cases a
dull pain in the right hypochoudrium betokens a congestion of the
liver, which may even lead to jaundice.
The Respiratory System. The thyroid body swells not infre-
quently, especially in those afflicted with goiter, and this swelling
may cause such a compression of the trachea that tracheotomy be-
comes necessary. We have mentioned above that the lungs are one
of the seats of predilection for vicarious menstruation. This hemor-
rhage may be dangerous in itself, and may be a precursor of phthisis.
The circulatory system does not suffer much, except that palpitations
are not uncommon, and that angiomas and varicose veins are liable to
increase.
The Urinary Organs. The sufferings due to floating kidney be-
come worse during the congestion preceding menstruation. There is
a frequent desire of evacuating the urine, and the bladder may be the
seat of vicarious menstruation.
conjunctiva! fold, in or behind the eye, the forehead, less frequently in the malar
bones or the superior maxilla, and by a peculiar kind of photophobia experienced
in regard to artificial light in a dark room, besides a great variety of hyperesthetic
phenomena. It attacks both eyes. It is incurable, but disappears spontaneously,
often after many years. It is frequent in the higher classes, and is by far more
common in women than in men. It is said in the former to be a reflex neurosis
from chronic parametritis. As treatment it is recommended to let the patient take
drachm of Canadian castoreum and 1 drachm of extract of valerian in the
course of four days, which gives relief for several weeks. At the same time the
patient should use eye-drops with acetate of zinc (W. A. Freund, Gyndkologische
Klinik, Strasburg, 1885, vol. i. pp. 265-272).
ABNORMAL MENSTRUATION AND METRORRHAGIA. 249
The Genitals. Displaced ovaries may become particularly painful,
and the swelling of the ovary enclosed in a hernia may give rise to
strangulation. Fibroids often grow larger, and intra-uterine polypi
may be pushed down into the cervix or the vagina. In cases of
atresia we have seen that the pain increases at each new outpouring
of blood that finds no vent. Leucorrhea precedes or follows very
frequently the menstrual flow, or appears, as stated above, as a sub-
stitute for it.
The breasts not uncommonly become swollen and painful, and
they are one of the more frequent seats of vicarious menstruation.
Patients affected with divers chronic diseases often feel more dis-
comfort during menstruation. It is claimed that amenorrhea, with-
out the presence of any other disease, may cause edema and ascites,
and that menstruation has a very bad effect on the progress of osteo-
malacia.
Treatment, In all affections connected with ameuorrhea or scanty
menstruation the first indication is to try to bring on or increase the
menstrual flow, except in those cases in which there is a general
debility that, presumably, would be made worse by any loss of blood.
Under these latter circumstances the first thing to do is to strengthen
the general health. Secondly, the different special disturbances call
for treatment. Headache and neuralgia are often relieved by the
administration of phenacetin, antipyrin, antifebrin, caffeine (gr. j to iij
t. i. rf.), or the combination called effervescent granulated bromo-caf-
feine (a heaping teaspoonful), pulv. paulliniee (gr. xx, L i. d.\ extr.
cannabis (gr. J to ^, or 20 to 40 minims of the tincture, t. i. <). A
favorite combination of mine is
1^!. Phenacetini, 3j ;
Caffeina?, gr. xxiv ;
Sodii bromidi, sij.
M. Div. in ptt. aequ. No. xii. Det. ad chart, cerat.
Sig. 1 powder repeated, if needed, after 1 and 3 hours.
In regard to the treatment of the manifold other disturbances men-
tioned above we must refer the reader to works on the practice of
medicine, special treatises, and later chapters of this Manual. 1
1 Those familiar with German may find much valuable information in Leopold
Meyer's Der Menstruation sprozess und seine Krankhaften Abweichungen, Stuttgart, 1890.
PART VIII.
LEUCORRHEA.
NORMALLY, the genital tract is just moist enough to be soft and
slippery ; nowhere a drop of fluid is visible. Any mucous, serous, or
purulent discharge is abnormal, and constitutes in itself a disease or
is a symptom of one.
The word " leucorrhea " means a white flow, but it is used to des-
ignate any discharge other than blood coming from the genitals.
Popularly the disorder is called " the whites."
The discharge may come from the vulva, the vagina, the neck or
the body of the womb. That from the vulva and the vagina is acid,
that from the uterus alkaline. The microscope reveals flat epithelial
cells in vulvar and vaginal leucorrhea, an abundance of mucous cor-
puscles in the cervical, and columnar epithelial cells, sometimes cili-
ated, in that coming from the uterus, be it from the neck or the body
(p. 51). The fluid is serous, mucous, or purulent, and may have an
admixture of a little blood. It may be colorless, white, yellow, green,
red, or brown. The white color is due to the presence of epithelial
cells, the yellow to pus, the red to fresh blood, and the brown to
decomposed blood. It may be nearly as thin as water or more or
less thick like cream and soft cheese. A colorless, thick fluid like
the raw white of an egg is exclusively secreted by the goblet-shaped
cells found in the depressions between the branches of the arbor
vitae (p. 51).
Leucorrnea is idiopathic, specific, or symptomatic. A leucorrhea is
called idiopathic when it is not due to any permanent structural ana-
tomical lesion. It is then constitutional and forms a disease in itself.
The specific leucorrhea is that due to gonorrheic infection.
A leucorrhea is symptomatic when it is one symptom among others
of a certain disease.
Causes. 1. Idiopathic Leucorrhea. 1 Like other catarrhal affec-
tions, and often combined with them, it may be due to a cold, damp
climate or residence. It may be connected with plethora or anemia.
It may be induced by anything that weakens the constitution, such
as protracted lactation, bodily or mental fatigue, emotions, especially
of a depressing kind, and insufficient nourishment. It occurs fre-
quently in persons predisposed to pulmonary phthisis. It is some-
1 Fordyce Barker's paper, " Leucorrhea considered in Relation to its Constitutional
Causes and Treatment," Trans. Amer. Gyn. Soc., 1882, vii. pp. 130-141, contains
many valuable hints on this topic that has disappeared from many modern treatises
on gynecology.
250
LEUCORRHEA. 251
times brought on by local irritation, such as masturbation, frequent
coition, gravidity, childbirth, or abortion ; or it appears in consequence
of amenorrhea or scanty menstruation as a supplementary or vicarious
menstruation, not only during the period of menstrual life, but fre-
quently after the climacteric has been established. In this way it
may also take the place of lactation, suppressed perspiration, hernor-
rhoidal flow, diarrhea, and other discharges.
2. The specific leucorrhea due to gonorrheic infection will be con-
sidered under Vaginitis.
3. Symptomatic Leucorrhea. It may be a symptom of rheuma-
tism, scrofulosis, tuberculosis, malaria ; of numerous local diseases of
the genitals, such as vulvitis, colpitis, endometritis, metritis, subinvo-
lution, granulations at the os or in the interior of the womb, ulcers,
a lacerated cervix, polypi, fibroids, sarcoma, carcinoma ; or of diseases
in other organs which interfere with a free circulation in the genitals,
such as disease of the heart and the liver.
Symptoms. The leucorrheic discharge is a drain on the system,
which has given rise to the popular belief that the white stuff coming
out of the genitals is the spinal marrow that melts. While it may
be brought on by anemia, it may also lead to it. The patients com-
plain of weakness, backache, neuralgia in different parts of the body,
and often an irritable bladder. Commonly they suffer from anorexia
and dyspepsia. Frequently there are menstrual disturbances, espe-
cially too frequeat, too long, and too copious menstruation, or, on the
other hand, amenorrhea. Local changes in the cervix and the vagina,
especially excoriations, ulcerations, granulations, and eversion of the
mucous membrane, may be due to the irritation caused by the dis-
charge, just as we find vegetations, eczema, erythema, intertrigo spring-
ing up in the groins, at the vulva, and on the inside of the thighs.
Prognosis. Since leucorrhea is found under such extremely different
conditions, nothing can be said in a general way about the prognosis.
It depends mostly on the cause.
Treatment. The same applies to the treatment, but here we may
add that, as a rule, a general and a local treatment should go hand in
hand. The more the condition depends on constitutional causes, the
more general treatment is needed, and the more powerful it is ; the
more local disease predominates, the more actively must the leucor-
rhea be combated in its seat.
The most substantial food and invigorating drinks that the stomach
can digest must be given (p. 224), and digestion is to be helped arti-
ficially if necessary. The patient must have a passage once in twenty-
four hours. She must wear sufficiently warm clothes, especially
woolen underwear (pp. 128 and 168). Tonic medicines (p. 226), general
massage (p. 190), gymnastics (p. 191), and exercise in the open air,
are useful. Change of climate, locality, and surroundings is a great
252 DISEASES OF WOMEN.
help. The patient should, if possible, be sent to a warm dry climate
or high up in the mountains, but at the same time pleasant company
should be provided. A cold and damp dwelling must be exchanged
for a dry and sunny one. Different kinds of baths (p. 187) are to
be recommended : warm hip-baths, tepid general baths, Turkish or
Russian baths, are especially indicated where there is a rheumatic
diathesis. Otherwise, it is better to strengthen the nerves and harden
the skin by means of towel-, sheet-, or sponge-baths, shower-baths,
hydrotherapy, or sea-baths. In many cases of idiopathic leucorrhea
a treatment carried out on these lines will suffice to effect a cure.
This ought especially to be tried in intact girls, so that even a physical
examination may be avoided.
In most cases, however, recourse to local treatment is an imperative
addition to the general treatment. Applications of tincture of iodine,
solution of nitrate of silver, carbolic acid, chloride of iron, chloride
of zinc (20 to 50 per cent.), etc. are made to the affected parts (p. 170).
If there is no free drainage from the uterus, the cervical canal should
be dilated (p. 155). Vaginal injections with hot water or astringents
are beneficial in most cases' (p. 170). It may become necessary to
remove granulations from the cervix or fungoid growths from the
inside of the corpus and fundus, or to scrape the endometrium with
the curette (p. 154), or to burn the cervical canal with the thermo-
cautery (p. 182) or by means of thermic or chemical galvano-cauteri-
zation (pp. 235 and 231). The mucous membrane of the cervix may
also be cut away.
As to the special indications to be met in regard to underlying
general or local diseases, the reader is referred to works on the prac-
tice of medicine and to later chapters of this manual.
Some internal remedies, such as aletris (cordial, 5j t. i. d.\ hydras-
tis (fluid extract, gtt. xx, t. i. rf.), cimicifuga (fluid extract, 3ss to 3j),
inula (a decoction of the root, siij to water q. s. ad iv, to be taken
every morning), seem to have the special virtue of checking leucorrhea.
In phthisical patients the leucorrheal flow is by some regarded as
a kind of issue, to dry up which would precipitate the destruction
of the lung. The local treatment should, indeed, be of the mildest or
may be dispensed with altogether, but all the internal remedies rec-
ommended, such as cod-liver oil, terraline, hydroleine, 1 etc., only
strengthen the whole constitution, and thus benefit the lungs indi-
rectly, and the leucorrhea, if abundant, being in itself a drain on the
physical strength, can hardly fail to have a bad influence on the
pulmonary affection.
1 Terraline is a product gained from petroleum. Hydroleine is a mixture of
cod-liver oil, boracic acid, and other substances. Both of these medicines have
seemed to me to have so decided an effect in wasting diseases that I do not hesitate
to mention them here.
DISEA.SES OF WOMEN.
II.
SPECIAL DIVISION.
SPECIAL DIVISION.
PART I.
DISEASES OF THE VULVA.
CHAPTER I.
MALFOKMATIONS. 1
1. Absence of Vulva. By an arrest of development in the first
month of fetal life the external genitals and the anus may be absent,
the skin covering the region uninterruptedly. (See p. 32.) This
condition is almost always combined with arrest of development in
other organs, and is only found in non-viable fetuses.
If the anus is formed, life may be continued without external geni-
tals, the urine being evacuated through the navel. Such a case is
on record, and was cured by the formation of an artificial urethra
and closure of the opening of the urachus at the umbilicus.
2. Hypospadias. In consequence of an insufficient closure in the
median line the lower wall of the urethra may be split more or less
deeply (Fig. 199). If the defect extends very deeply, so as to divide
the different sphincters of the urethra (p. 76), the patient cannot
retain her urine. A small degree of hypospadias is, by far, not so
important in woman as in man, and will hardly call for treatment.
The complete congenital hypospadias has been successfully treated by
paring and uniting the surrounding mucous membrane to such an
extent as to form an artificial urethra, the relations of which to the
bladder were much like those of a spout to a teapot. 2
1 In this chapter I have to some extent used my article on this subject in Ameri-
can System of Gynecology, edited by Mann, Philadelphia, 1887, vol. i. pp. 235-282.
2 For details the reader is referred to T. A. Emmet's Gynecology, 2d ed., pp. 649-654.
256
DISEASES OF WOMEN.
3. Epispadias. Epispadias (Fig. 200) is the name for the condi-
tion characterized by a lack of union of the upper wall of the urethra.
It is generally combined with a similar defect in the anterior wall of
the bladder (extroversion). The clitoris and the symphysis pubis
may be cleft or not. These defects are due to the intracorporeal part
FIG. 199.
Hypospadias (Mosengeil) : a, open canal, formed by the anterior wall of the urethra; b, pos-
terior, closed part of the urethra : c, entrance to vagina ; d, hymen.
of the allantois being pulled abnormally forward, becoming over-
filled, and finally bursting.
Epispadias, like hypospadias, has been cured by different plastic
operations. One way is to form a transverse flap of the mucous
membrane of the vestibule and stitch it to the meatus. Another is
to denude two lateral surfaces and unite them in front of the open
urethra.
4. Abnormalities of the Clitoris. Sometimes the clitoris is split in
two lateral halves, without any cleavage of the urethra or bladder,
but in connection with a non-united symphysis and an opening in
the abdominal wall above the bladder. Such cases are exceedingly
rare. The cleavage of the clitoris is of no importance. The defect
in the abdominal wall may be closed according to the general rules
of plastic surgery.
The clitoris may be absent or very small, or, on the other hand, as
large as a medium-sized penis.
This hypertrophy of the clitoris may be inconvenient, and can then
DISEASES OF THE VULVA.
257
be remedied by amputation with the galvano-caustic wire (p. 235),
with the e'craseur, or with Paquelin's thermo-cautery (p. 282).
The prepuce is very frequently adherent to the glans, and in many
cases this condition gives rise to reflex neuroses, even epilepsy and
nymphomania.
Treatment. The vulva should be washed with bichloride-of-mer-
cury solution. A couple of drops of cocaine solution are thrown
Epispadias (Kleinwacbter) : q, fissure in the bladder; b, labium majus; c, clitoris ; d, labi
minus ; e, hymen ; /, vaginal entrance.
into the glans clitoridis with a hypodermic syringe, and four or five
drops more are thrown into the prepuce. If one margin of the pre-
puce is then seized with a fixation-forceps, the thumb-nail will easily
complete the work of clearing the glans. Raw surfaces are sprinkled
with aristol and the prepuce packed with a little ball of corrosive-
sublimate gauze. As there is a marked tendency to recurrence of the
17
258 DISEASES OF WOMEN.
adhesions, and the consequent nervous reflexes, this packing must be
repeated every two or three days until the appearance of normal
smegma shows that the mucous surfaces have developed sufficiently
to take care of themselves. 1
5. Abnormalities of the Labia Minora. The labia minora may
be absent. They may be multiple, each being split lengthwise in
two or three flaps. They are sometimes too long, which is found
physiologically in whole tribes. (See, for instance, Hottentot apron,
p. 37).
This condition may interfere with coition, and may then be reme-
died by cutting away the superfluous tissue and uniting the edges of
the wound, which will heal by first intention.
6. Abnormalities of the Labia Majora. These may likewise be
split by longitudinal clefts, so as to become double or triple.
Alone or together with the labia minora they may extend so far
back as to reach behind the anus, so that there is no perineum.
7. Epithelial Coalescence. During the second half of fetal devel-
opment the large and small labia may grow superficially together
from behind forward. It is rare that the coalescence goes so far as to
prevent micturition in the new-born child. Sometimes it may, how-
ever, give an inconvenient direction to the jet of urine. Menstrua-
tion may become difficult, and the small dimensions of the vulvar
opening may oppose a serious obstacle to coition or childbirth.
If the coalescence is combined with hypertrophy of the clitoris, the
sex may become doubtful.
Treatment. The parts ought to be cut open in the median line on
a director introduced through the existing opening, and kept sepa-
rated during the healing process, or, if the cut surface is large, the
edges of each side may be brought separately together by stitches.
It is not rare that the urethra alone is agglutinated, so that the
child cannot pass its urine. All that is needed in such cases is to
introduce a silver probe into the bladder. Once opened, the canal
stays open.
8. Hermaphrodism. Hermaphrodism, or hermaphroditism, is the
condition in which the characteristics of the two sexes become more
or less blended in one individual.
From the history of the development of the genitals we know
that they are composed of three parts, each of which has its inde-
pendent embryonal foundation namely, the sexual glands, the two
sets of ducts (Wolffian and Mullerian), and, finally, the external
genitals (pp. 20, 22, 30, and 33). It is, therefore, not so difficult to
understand how one of these parts may be developed according to a
sexual type differing from that of the others.
1 Robert T. Morris of New York, Trans. Amer. Obstetricians and Gynecologists,
1892.
DISEASES OF THE VULVA. 259
It is more difficult to understand how there can be more than one
set of reproductive glands, for we have seen (p. 22) that it is one
and the same body that, identical in* the beginning, later becomes
either an ovary or a testicle. But while the connective-tissue part is
identical in the two kinds of glands, ovary and testicle, it is not
unlikely that the epithelial part of them has a different origin in the
two sexes. Some anatomists claim, indeed, that the seminal canals in
the testicle are formed as invaginations from the Wolffian duct, while
we know that the follicles in the ovaries are derived from the germ-
epithelium (p. 28).
We know, furthermore, that we may have supernumerary ovaries
(p. 120), and the same is claimed in regard to testicles, although it is
infinitely rarer with them than with ovaries.
Hermaphrodism is true or spurious. True hermaphrodism is that
in which at least one ovary and one testicle are found in the same
person. There may be found a complete double set of sexual glands
*". e. two ovaries and two testicles (true bilateral hermaphrodism) ; or
there might be found one sexual gland on one side, be it a testicle or
an ovary, and on the other both a testicle and an ovary (true unilateral
hermaphrodism), but it is somewhat doubtful if such a case actually
has been observed or not ; or, finally, there may be one ovary on one
side and one testicle on the other (true latei'al hermaphrodism).
True hermaphrodism is at best exceedingly rare, and its existence
is not even universally admitted.
Spurious hermaphrodism, or pseudo-hermaphrodiwi, is that condi-
tion in which the sexual glands belong to one sex, either masculine
or feminine, and the passages leading from them, as well as the exter-
nal parts, approach more or less the other. Spurious hermaphrodism
is subdivided into male or female according to the nature of the sexual
gland. Each of these classes comprises three groups : the first is
formed by those cases in which the ducts alone belong to the oppo-
site sex (internal male or female pseudo-hermaphrodism) ; the second,
by those in which the external parts alone represent the opposite sex
{external male or female pseudo-hermaphrodism) ; and the third, those
in which both the ducts and the external parts approach the type of
the other sex (internal and external or complete male or female
pseudo-hermaphrodism).
Pseudo-hermaphrodism, as well as true hermaphrodism, is a mal-
formation that dates from the earliest periods of fetal development.
It is much more frequently found in the male than in the female sex,
and reaches also a much higher degree in the former, so that a vagina,
uterus, and tubes may be found more or less developed in an indi-
vidual with testicles, vasa deferentia, seminal vesicles, and male
external genitals. The presence of menstruation does not settle the
sex, since a periodical bloody discharge has even been observed to
260 DISEASES OF WOMEN.
take place from normal male genitals, and especially in males suffering
from hypospadias.
The external genitals being formed in both sexes of the same sub-
stance, it is impossible to have a double set of them, one male, the
other female, but some portions may assume more the male, others
more the female, type.
The general appearance of the body, especially in regard to the
length of the hair, the development of the breasts, the prominence
of Adam's apple, the breadth of the hips, and the angularity or
rotundity of the form, presents a mixture of both sexes, the prepon-
derance being, not with the real sex, as determined by the sexual
glands, but with the external genitals.
The diagnosis of the sex of hermaphrodites is often difficult, some-
times impossible, in the living individual ; nay, even the pathological
specimens, when examined after death, present so many deviations
from the normal conditions that they are interpreted in a different
manner by different observers of equal ability.
When there is any doubt about the sex of an individual, it ought
always to be declared a male. This will not only give it better
chances to make a living and certain privileges in regard to political
and hereditary rights, but it is also much safer to bring it up as a
boy. A " girl " with a testicle can, if the sexual appetite awakens,
do much harm in a boarding-school, and if it does not awaken she
may many without knowing that she, from a physical standpoint, is
an unsatisfactory mate.
CHAPTER II.
RUPTURES (HERNLE).
Two kinds of hernise find their way into the labia majora viz.
the anterior, or inguino-labial, hernia and the posterior, or vagino-
labial, hernia.
1. The anterior labial, or inguino-labial, hernia in women corre-
sponds with the inguinal hernia in men, and is not very rare. It
comes out through the inguinal canal, follows the round ligament,
and descends into the anterior part of the labium majus. It may be
found on both sides simultaneously (double inguinal hernia). At
first it forms a round tumor in the region of the external abdominal
ring; later, when descending toward and into the labium majus, it
becomes pear-shaped. It may contain the gut, the omen turn, the
ovary, and the uterus, and when impregnation takes place even a
fetus in the uterus.
Diagnosis. When near the external inguinal ring, it may be mis-
DISEASES OF THE VULVA. 261
taken for a tumor of the round ligament, or kydrocele. In the
labiuni it may be mistaken for an abscess, cyst, or tumoi\ As a rule,
it will be possible to make the distinction by paying attention to the
history, by a resonant percussion-sound, by the increase in size caused
by coughing and abdominal pressure, by the possibility of bringing
it back into the abdominal cavity through the inguinal canal, by the
peculiar sensation of the gut slipping away under the fingers, by a
gurgling sound heard during taxis, by the absence of local inflamma-
tion, and by the absence of fluid, or by the nature of the fluid when
aspiration is made with a hypodermic syringe.
Treatment. The treatment is like that in the male as a rule, by
means of a truss, sometimes by the radical operation. When it is
strangulated and cannot be reduced, heruiotomy is imperative. It
may become necessary to extirpate an ovary found in the sac and to
perform Cesarean section, or, preferably, Porro's operation when
pregnancy occurs in the imprisoned uterus.
A variety of inguinal hernia found in little girls is the hernia in
the canal of Nuck, corresponding with the hernia of the tunica vagi-
nalis in the male. It is extremely rare. The treatment is the same.
2. Posterior Labial, or Vagino-labial, Hernia. This form is much
rarer than the preceding. The escaping abdominal viscera here
descend in front of the uterus, along the vagina and bladder, between
them and the levator ani muscle, and form a swelling at the posterior
end of the labium majus. The course corresponds with the ascending
branch of the ischium. It usually contains a part of the small intes-
tine, but the large intestine and the omentum have also been found
in it.
Diagnosis. It differs from anterior labial hernia by its position
farther back, by the freedom from swelling of the space between it
and the inguinal canal and of the latter itself, and by being reduci-
ble, not in the direction of the external inguinal ring, but in that of
the vagina.
The diagnosis from other affections is made in the same way as
just pointed out for the anterior variety.
Treatment. It is hard to hold this kind of hernia back, but, as it
may become very large, the attempt should be made with vaginal
pessaries, of which an inflatable rubber bag would be most likely to
answer, or a truss. Once a surgeon obtained retention by denuding
the mucous membrane in a circle round the lower end of the hernia,
doubling it up and stitching it together ; after thus having thickened
the integument covering it, it could be held back with a truss. 1
1 Winckel, Die Pathologic der Weiblichen Sexualorgane, Leipzig, 1881, p. 284.
262 DISEASES OF WOMEN.
CHAPTER III.
TUMORS CONNECTED WITH THE EXTRAPELVIC PORTION OF THE
ROUND LIGAMENT.
In connection with the extrapelvic portion of the round ligament
may be found: 1, hydrocele; 2, hematocele of the canal of Nuck ; 3,
hematoma of the round ligament ; and, 4, fibroma of the round liga-
ment.
1. Hydrocele* is a swelling due to an accumulation of serum in
connection with that part of the round ligament which lies in or
below the inguinal canal. It is a rather rare disease. The fluid
may be contained in the canal of Nuck (p. 37), or in the surround-
ing connective tissue, or in the ligament itself. The space, if formed
by the canal of Nuck, may yet communicate with the abdominal
cavity, or may be shut off from all connection with it by adhesion
between its walls at the upper end. It is covered by the skin, the
superficial fascia, and the fascia transversalis. It is sometimes
divided into several compartments. The fluid is, as a rule, serous
and of a slightly greenish-yellow color, like serous collections in
other parts of the body, but in traumatic cases it may be more or
less bloody, and, when inflammation occurs in the sac, it may become
purulent and contain gas. It begins as a small, painless, oblong
swelling in the inguinal canal, and extends in its slow growth down
into the anterior part of the labium majus. It may be found on
both sides. At first it often disappears when the patient lies on
her back or when it is being compressed. If the fluid is found in a
closed sac, the swelling is immovable, elastic, not very tender unless
inflamed, and translucent, as the corresponding affection of the tunica
vaginalis in man. It may become as large as a child's head at term,
and may interfere with locomotion, render coition impossible, and
oppose a serious obstacle to childbirth.
Diagnosis. The diagnosis is sometimes difficult, particularly in
regard to inguinal hernia. The characteristic points are the slow
development ; the disappearance on pressure if there is communica-
tion with the peritoneal cavity, without the feel of any solid body
being displaced ; the elasticity if the sac is closed ; and the translti-
cency. When inflamed, hydrocele may cause vomiting, but not con-
stipation, as does a strangulated hernia.
Treatment. If the sac communicates with the peritoneal cavity, it
may suffice to press it back and let the patient wear a truss until
adhesion takes place between the walls. If the cavity is closed,
1 A comprehensive article on this subject by Wm. C. Wile is found in Amer. Jour.
Obst., 1881, vol. xiv. p. 584.
DISEASES OF THE VULVA. 263
simple aspiration has effected some cures* If that does not suffice, a
few drops of tincture of iodine or carbolic acid should be injected
after evacuating the fluid, so as to induce adhesive inflammation.
During the injection the inguinal canal should be compressed, and
the injected fluid should be sucked out again with the syringe. It
may become necessary to make an incision, fill the sac with iodoform
gauze, and let it heal from the bottom by granulation. The whole
sac has also been extirpated. If the contents of the cyst have become
purulent or sanious, it must be laid open and thoroughly washed
with disinfecting fluids (p. 205).
2. Hematocele of the Canal of Nuck. If hydrocele of the canal of
Nuck is rare, hematocele of the same is unique. 1 In the only case
known it was of nine years' standing, and dated from childbirth. It
formed a tumor of the size of a large hen's egg lying on the descend-
ing ramus of the left pubic bone. It was of tense, elastic consistency,
without pain or tenderness on pressure, and covered by the skin of
the expanded labium majus and minus, which was normal and mov-
able. Its surface was smooth. It was not translucent, could not be
diminished by pressure, did not increase during cough, and gave a
dull sound on percussion. From its upper end a rather hard pedicle
could be traced into the inguinal canal. It contained a thick choco-
late-colored mass of the consistency of an ointment. The wall was
hard to cut through ; the cavity was entirely regular and smooth.
Diagnosis. It differs from intestinal hernia by the dull percussion,
the immobility, and the lack of increase during cough ; from hernia
of the ovary by its lack of sensitiveness ; from hydrocele by being less
soft and by not being translucent ; from hematoma of the vulva by the
even surface and its chronic course, whereas hematoma of the vulva
is soon absorbed or forms an abscess.
Etiology. Injury (childbirth) in a person with a canal of Nuck
the lower part of which has remained open, may cause an extravasa-
tion of blood into that cavity. The irritation of the foreign body
causes the thickening of the surrounding membrane.
Treatment. A long incision was made, the contents turned out,
the sac washed, cauterized, and left to heal by granulation.
3. Hematoma of the round ligament has likewise, so far, only been
found once. 2 It consists in a collection of blood in the interior of
the round ligament. When operated on it had been noticed about
four years. It formed a tumor in the right inguinal region of the
size of a hen's egg, and had been taken for a hernia. The surface
was smooth, the consistency tense and elastic, the skin normal and
movable ovej* the tumor. From the upper end a pedicle half an inch
in diameter could be traced into the inguinal canal. The tumor was
1 Kobert Koppe, Centralblatt f. Gynak., 1886, vol. x. p. 179.
2 Sigmund Gottschalk, Centralblatt f. Gynak., 1887, vol. xi. p. 329.
264 DISEASES OF WOMEN.
not diminished by pressure, nor could it be pushed up into the
inguinal canal. It gave a dull percussion-sounci, and was not trans-
lucent. An incision was made through skin, subcutaneous adipose
tissue, and fascia, the tumor easily enucleated, the pedicle tied and
cut off, and the edges united by interrupted silk sutures, without
drainage-tube. The wound healed by first intention. The tumor
proved to be a cyst, the wall of which was inch thick. The con-
tents were a dark bloody fluid. Microscopical examination showed
that the wall was composed of longitudinal unstriped muscle-fibers,
and that the fluid was blood.
Diagnosis. In regard to intestinal and ovarian hernia, hematoma
of the vulva, and hydrocele we refer to what has just been said under
Hematocele. From hematocele of the canal of Nuck it may, perhaps,
be diagnosticated by the sensitiveness and pain found when the tumor
is situated in the ligament, and consequently is dragged upon by any
movement imparted to the womb.
Treatment. To what has been already said is only to be added
that the pedicle ought to be comprised in the sutures, so as to avoid
a displacement backward of the womb.
4. Fibroma of the Round Ligament. The round ligament may
become the seat of the formation of a fibrous tumor anywhere in its
course from the horn of the uterus through the pelvis and the inguinal
canal to the groin and the vulva. The situation outside of the
inguinal canal is the most common. The tumor appears first below
the external inguinal ring, covering the inner third of Poupart's liga-
ment, and extends by growth usually down into the labium majus,
more rarely up through the inguinal canal and along the anterior
abdominal wall up to the umbilicus. In the beginning it is more
or less movable. It is hard, round, painless, and covered with nor-
mal skin. Sometimes a pedicle can be traced to the inguinal canal.
It grows slowly, and has been found varying in size from a walnut
to a cocoanut.
Diagnosis. The diagnosis is often difficult. From intestinal and
ovarian hernia it differs by its hardness, lack of sensitiveness, and
lack of increase during cough ; from hydrocele, by its hardness and
lack of pellucidity ; from hematocele, by its hardness ; from hematoma,
by its chronic course. Chronic inflammation or lympho-sarcoma of
an inguinal gland forms an immovable tumor, without pedicle, and
affects, as a rule, several glands. Diffuse fibroma of the vulva begins
in the labia majora, and is immovable.
Prognosis. In itself innocuous, it may become troublesome by its
size and situation.
Treatment. It is easily removed by an incision along its greatest
diameter. The tumor is enucleated, the pedicle tied and comprised
in the sutures uniting the edges.
DISEASES OF THE VULVA. 265
CHAPTER IV.
INJURIES.
THE vulva may be the seat of bruises or wounds in consequence
of a fall on some sharp object, for instance the back of a chair or the
edge of a table, or of blows and kicks. The injury in such cases is
mostly found on the labia majora. On account of the sharp edge of
the ascending ranius of the ischium and the descending ramus of the
pubes, even contact with a blunt object may cause a clear cut.
Coition seldom gives rise to trail matism of the vulva except in
cases of rape. The fossa navicularis may, however, be penetrated,
resulting in the formation of a permanent vulvo- rectal fistula. 1
Children and old women are more liable to injury during sexual
connection, on account of the lack of development in the former, and
senile involution, with loss of elasticity, in the latter.
Parturition is the most frequent cause of injuries to the vulva.
Lacerations of the perineum will be considered later. Superficial
tears of the labia majora are quite common, but need no special atten-
tion if my antiseptic occlusion dressing is used. 2 Sometimes a tear
occurs in the vestibule, near the clitoris, which gives rise to dangerous
or fatal hemorrhage. 3
The symptoms vary according to the cause and the degree of the
violence. If the skin remains unbroken, there are pain, soreness,
swelling, discoloration, or perhaps subcutaneous extravasation of blood
(pudendal hematoma). If the skin is broken, the hemorrhage is often
alarming (p. 41).
Treatment. If the skin is unbroken, the pain is often best relieved
by hot-water fomentations, to which may be added tinct. of arnica
(3j to 3j). After that lead-and-opium stupes (tinct. opii, liq. plumbi
subacetat., da 3j ; aquse, .Iviij) may be applied with advantage.
If the hematoma is of so large a size that complete resorption is
not to be expected, the best treatment is to apply Braun's colpeu-
rynter filled with ice-water in the vagina, and compression on the
skin for three or four days. When, then, the danger of hemor-
rhage is passed, a free incision is made on the internal surface of the
labium majus, parallel and near to its lower edge. The blood-clots
are turned out, and the cavity washed out with antiseptic fluid, pref-
erably creolin, on account of its hemostatic properties. If any vessels
are seen bleeding, they should be tied with catgut, or if there is oozing
the surface should be seared with the thermo-cautery. Next the sac
1 Joseph Price, Amer. Jour. Obst., 1886, yol. xix. p. 832.
2 Garrigues, Practical Guide to Antiseptic Midwifery, Detroit, Michigan, 1886, p. 27.
3 Mund6, Amer. Jour. Obst., 1875, vol. viii. p. 537.
266 DISEASES OF WOMEN.
is packed with iodoform gauze. The dressing should be renewed
every day, and the cavity washed out with antiseptic fluid.
If an abscess is formed, the pus should be given a free outlet by
incision, and the wound treated antiseptically. A slight tear is
dressed with iodoform ointment (p. 178). If there is any hemor-
rhage, a careful examination should be made for its source. Spurting
arteries are twisted or tied. Bleeding surfaces are brought into con-
tact and united by deep sutures. If this does not check the hemor-
rhage, the wound should be covered with styptic cotton (p. 182), the
vagina tamponed (p. 179), and the external genitals covered with
compresses or a folded towel tightly fastened with a T-bandage. A
fistula is treated by paring the edges and uniting them with silkworm
sutures. If the contusion has been considerable enough to cause the
death of the tissue, the wound should be kept clean with an antiseptic
solution, the dead tissue cut away as soon as feasible after a line
of demarkation has formed, and the wound dressed with iodoform
ointment.
CHAPTER V.
VULVITIS.
VULVITIS is inflammation of the vulva. It appears under five
different forms: the catarrhal, the foUicular, the phlegmonous, the
venereal, and the diphtheritic inflammation.
Etiology. The causes of catarrhal and follicular vulvitis are lack
of cleanliness, irritation produced by discharges from the uterus or
vagina, or from the bladder if the patient is afflicted with a vesico-
vaginal fistula; masturbation, excess in coition, rape; friction pro-
duced by physical exercise in fat women ; pin-worms that find their
way from the anus to the vulva, and ants that creep in from the
skin. The scrofulous diathesis predisposes to the disease, especially
in children.
The phlegmonous form may result from the catarrhal or be caused
by violence. It is mostly found in prostitutes. The venereal is due
to infection with one of the three venereal diseases, gonorrhea, chan-
croid, or syphilis. The diphtheritic occurs in childbed and in grave
fevers, such as scarlet fever, small-pox, and typhoid fever.
Symptoms. The catarrhal vulvitis is either acute or chronic. The
acute is more common. The mucous membrane is red, swollen, and
covered with a muco-purulent secretion. There is a sensation of heat
and pain, especially smarting during micturition. In the chronic
form the mucous membrane is of a less bright red color, and often
the seat of abrasions or superficial ulcers. On the denuded places
DISEASES OF THE VULVA.
267
the papillae are hypertrophied and bleed easily. Redness and exco-
riations are often found in the groin and on the inside of the thighs.
Intolerable itching drives the patient mad, prevents sleep, and may
easily lead to masturbation. Sometimes the glands of the groins-
swell, the lymphatics leading to them from the excoriated patches
becoming inflamed.
In foUicular vulvitis the seat of the inflammation is the hair-follicles,
the- sebaceous and sudoriparous glands, and, less frequently, the
mucous follicles, the intervening mucous membrane remaining healthy.
FIG. 201.
Follicular Vulvitis (Huguier).
This gives a peculiar appearance to the vulva, the labia majora and
minora being studded with small round red protuberances of the size
of a millet-seed to a hemp-seed (Fig. 201). Often a hair comes out
from the middle, and a drop of pus may be pressed out through the
center. As a rule, the inflamed follicle bursts and shrivels up, but
exceptionally the disease may end in induration, when small hard
nodules remain after the inflammation has run its course.
In phlegmonous vulvitis the inflammation extends to the submucous
and subcutaneous connective tissue. Deep abscesses and sloughs may
form, and end in permanent fistulous tracts if not properly treated.
Gonorrheal vulvitis is much like the simple acute catarrhal, but
redness and swelling are more intense, the discharge is more purulent,
268 DISEASES OF WOMEN.
and the inflammation has a tendency to implicate the urethra, and is
usually accompanied by gonorrhea! vaginitis. Micturition causes
burning pain, the urethra is swollen and tender, and a drop of thick,
creamy pus may be pressed out from it. In children the veins of the
labia majora and minora are congested and varicose. The presence
of gouococci may be revealed by the microscope. Valuable as these
signs are from a diagnostic standpoint, they are not so pathognomouic
that, called as expert in a lawsuit, the physician should not be careful
not to be too positive in his assertions. 1 (See below under Vaginitis.)
Chanwoids and chancres will be considered under Venereal Diseases.
Diphtheritic vulvitis is characterized by the formation of a gray
diphtheritic membrane on and in the mucous membrane or wounded
surfaces. The surrounding parts are edematous, dark red, or other-
wise discolored. In this form there is also high fever and general
disturbance of the whole system.
Prognosis. The acute catarrhal and follicular forms are of little
importance and short duration. The chronic form may be very pro-
tracted. The gonorrheal may extend upward, and is then, as we
shall see later, a very dangerous disease. The infective agent has
also a tendency to remain in Bartholin's glands, and may thus cause
infection long after the woman is seemingly cured. The phlegmonous
form is rather serious. The diphtheritic form is only found as
part of the most severe diseases. Besides endangering the patient's
life, it may lead to more or less complete destruction of important
parts, coalescence, and atresia of the genital canal.
Treatment. If the patient is feverish, she should be kept in bed,
have a saline aperient and aconite ; in the diphtheritic form large
doses of quinine and alcoholic drinks, and in the later stage tinct.
ferri chloridi. The genitals should be carefully cleansed, lukewarm
or hot sitz-baths given two or three times daily ; vaginal injections
with carbolized water (p. 172) should be used as often. If there is
any irritating discharge from the uterus or the vagina, it is a good
plan to keep it away by means of a cotton ball introduced into the
vagina. This ball ought to be wrung out of a weak antiseptic fluid.
The genitals should be covered with fomentations of the same de-
scription, part of which should be applied between the labia. When
the acutest stage is over the lead-and-opium wash may be substituted
for the carbolic acid, or both combined. In the gonorrheal form
hydrargyrum bichloride is preferable for injections and fomentations
(p. 1721.
Later, the mucous membrane of the vulva may be painted several
times daily with Monsel's solution of subsulphate of iron or the liq.
1 The reader is referred on this point to the timely warning of so high an authority
as Robert W. Taylor, Atlas of Venereal and Skin Diseases, Philadelphia, 1888, pp.
57-58.
DISEASES OF THE VULVA. 269
ferri chloridi, each of them diluted with eight parts of glycerin. If
this does not effect a cure, the inflamed parts should be painted every
other day with a solution of nitrate of silver (gr. x-sj) or tinct.
iodinii co., diluted with two parts of water. When the mucous mem-
brane has nearly recovered, dry powders, such as oxide of zinc, sub-
nitrate of bismuth, iodoform, or even inert powders, as lycopodium,
talcum, or corn starch, often hasten the process. These same powders
are used for the accompanying intertrigo.
If the urine is alkaline, benzoate of ammonium or sodium should be
given (gr. x xx every four hours). When, on the other hand, the
urine is too acid, bicarbonate of sodium or liquor potassee are indi-
cated :
Ify. Tinct. belladonna?, 3ij ;
Liq. potass., 3J ;
Aquae, ad siv.
M. Sig. A teaspoouful in a wineglassful of water, t. i. cZ.).
In gonorrheal urethritis the urethra should be washed out with hot
water or flaxseed tea by means of a reflux catheter. When the
inflammation subsides somewhat, carbolized water (J per cent.) or
corrosive sublimate (^ gr. to 3j), or nitrate of silver (-^ gr. to 3j), or
chloral hydrate (gr. x 5J), should be used. Pain may be relieved by
instillation of cocaine with a glass pipette. If necessary, a few drops
of a strong solution of nitrate of silver (gr. x to xxx-sj) may be
injected or applied with applicator through an endoscope. Antiblen-
norrhagic medicines (copaiva, cubebs, and sandal oil) should only be
given in the subacute or chronic stage. Itching is relieved by chloral
hydrate, camphor, or hydrocyanic acid :
fy. Chloral, hydrat., 3j-ij ;
Yaselini albi, gij.
!}. Chlorali hydrat.,
Camphorse, da. 3j ;
Vaselini albi, Sij.
I^j. Acid, hydrocyan. dil., gij ;
Plumbi acetat., 9ij ;
Glycerini, gij.
1^. Chlorali hydrat.,
Camphorse, dd. 3ij ;
Acidi oleici, ij.
When nothing else will help, the whole mucous membrane must
be excised.
In the phlegmonous form abscesses should be laid open by free
270 DISEASES OF WOMEN.
incisions, washed out with disinfectants, and filled with iodoform
gauze.
Parts affected with diphtheritic infiltration should be cauterized
with chloride of zinc dissolved in equal parts of distilled water. 1
The healing process should be carefully watched, so as to avoid sec-
ondary deformities.
'CHAPTER VI.
INFLAMMATION OF THE URETHRAL DUCTS.
THE urethral ducts described on p. 76 may become inflamed.
Their mouths are then seen outside of the meatus in consequence of
the swelling and prolapse of the mucous membrane. They appear
like very small ulcers of a yellowish-gray color, surrounded by a
deep-red circle, and a purulent fluid may be pressed out of them.
The lower third of the urethra is sometimes swollen. It is exquis-
itely tender to touch, and causes the patient much discomfort, but
micturition is not particularly painful.
Treatment. The ducts should be washed out by injecting carbolized
water or the saturated solution of boracic acid. If a more active
treatment is needed, tincture of iodine or a strong solution of nitrate
of silver (1 : 4) may be injected, or a fine probe covered with nitrate
of silver in substance may be introduced into them. In a recalci-
trant case I obtained a cure by introducing a probe and slitting the
canals open from the vagina with Paquelin's thermo-cautery (p. 182).
CHAPTER VII.
GANGRENE OF THE VULVA.
THE vulva may become gangrenous in consequence of contusion,
or overdistension due to edema or extravasated blood, or from the use
of a tampon with undiluted liquor ferri chloridi (p. 179). Gangrene
may also be caused by inflammation, especially diphtheritic infiltra-
tion. It occurs sometimes in eruptive fevers. An idiopathic gan-
grene identical with noma is found in young children, and is said to
be contagious. It begins as a white blister, which soon changes into
an ulcer, that takes a diphtheritic aspect and becomes gangrenous.
It is a dangerous disease, usually ending in septicemia.
1 For the details of this treatment I must refer the reader to my other writings:
"Puerperal Diphtheria," Trans. Amer. Gyn. Soc., 1885, vol. x. p. 109; "Puerperal
Infection," Amer. Syst. Obst., ii. p. 363 ; Antiseptic Midwifery, p. 61.
DISEASES OF THE VULVA. 271
Treatment. The affected part should be cauterized with a 50 per
cent, solution of chloride of zinc, or with the thermo-cautery, and
covered with iodoform or compresses dipped into a saturated solution
of chlorate of potash. Tonics and stimulants should be used freely.
As soon as a line of demarkation is formed the dead tissue should
be removed.
CHAPTER VIII.
EXANTHEMATOUS DISEASES.
IN exanthematous fevers the genitals may be the seat of an erup-
tion like other parts of the body. They may also be attacked by
skin diseases, such as furunculosis, erythema, eczema, etc. ; but as
these diseases offer nothing peculiar in this region, and are treated as
in other parts, the reader is referred in regard to them to works on
the practice of medicine and skin diseases. Only one exudative skin
disease shall be described here, on account of its frequent occurrence
and great diagnostic importance viz. herpes.
Herpes Progenitalis. Herpes progenitalis is a mild inflammatory
affection, consisting of one or more vesicles or groups of vesicles.
The eruption may occur without any prodromal symptoms, but in
most cases it is preceded by a burning and itching sensation.
First appears a small round red spot. On this the epidermis is
soon raised, forming a vesicle of the size of a pin-head to a hemp-seed,
filled with clear serum. This ruptures and leaves a shallow ulcer of
the size of the vesicle. Its floor is at first of a deep rosy red, with
a finely uneven surface and its edges sharply cut as with a punch,
and sometimes undermined, but, as a rule, not to the same extent as
in chancroid. Sometimes there is so much edema of the labia minora
that the eruption is concealed until they are separated. On the skin
the vesicle is followed by a scab. The disease lasts from a few days
to two weeks, but is apt to return. It may lead to the development
of a bubo.
Etiology. It is due to congestion and inflammation of the genitals
and pelvic organs. It is only found in adults, especially in prosti-
tutes. It appears often as a concomitant of menstruation.
Diagnosis. It may be very like a chancre in the erosive stage,
but this has a deeper and duller red, coppery color, and its floor is
smooth and shining, without the small granulations found in herpes.
Its areola is very slight and of a dark red color, and there is a gen-
eral absence of inflammation about the lesion. On pressure a chan-
crous erosion does not yield any fluid, while a herpetic vesicle gives
issue to several drops. The history may also offer some help to a
272 DISEASES OF WOMEN.
diagnosis, but it is advisable to be a little reserved until we see the
course the disease takes.
Treatment. The parts should be cleansed and all irritation avoided.
Milder cases get speedily well when covered with lint soaked in
fy. Acidi carbol., TTLxl j
Glycerini, 3ss ;
Aquae, ad 3iv.
The dry powders mentioned above (see Vulvitis, 269) hasten the
healing, and the iodoform ointment (p. 178) relieves pain. Persistent
neuralgic and burning pains require cauterization with carbolic acid
or a strong solution of nitrate of silver (1 : 8), followed by the lead-
and-opium wash. 1
CHAPTER IX.
TRICHIASIS.
INVERSION of the hairs of the labia is a rare condition which causes
intense itching. The offending hairs must be removed and their
bulbs destroyed by electrolysis.
CHAPTER X.
PRURITUS VULV.E.
PRURITUS VULVJE is characterized by an itching sensation on the
inner or outer surface of the vulva, sometimes extending up into the
vagina or over the lower half of the abdominal wall. It may be
symptomatic or idiopathic. When it is symptomatic it may be a
symptom of a disease of the genitals, especially follicular vulvitis,
eczema pudendi, or trichiasis, or it may be a reflex symptom of disease
in other organs, such as hemorrhoids, pin-worms in the rectum, diseases
of the kidneys, ureters, bladder, or urethra, congestion of the pelvic
organs, etc.
Predisposing causes are pregnancy, menstruation, the menopause,
old age, the gouty diathesis, or general nervousness. Sometimes the
itching is due to direct irritation by parasites (lice or acarus scabiei),
acrid discharges from the vagina or uterus, or urine containing sugar.
In other cases no cause, near or remote, can be found, and then it
has been surmised that the disease is located in the nervous centers.
1 For further details the reader is referred to Robert W. Taylor's Atlas of Venereal
and -Stin Diseases, Philadelphia, 1888, p. 72.
DISEASES OF THE VULVA. 273
Symptoms. The chief symptom is an itching that is so violent that
it irresistibly drives the patient to scratch herself, a procedure which
gives a momentary relief, paid for by increased itching. The scratch-
ing produces excoriations and inflammatory conditions, especially
eczema, which, again, contribute to the morbid sensation.
In its higher degrees the disease is a very serious one. The patient
scratches so that she wears off the hair of the rnons Veueris and
labia majora ; she avoids company ; she becomes melancholy and
morose ; she loses her appetite ; her sleep is disturbed ; she becomes
the victim of an abnormally increased sexual desire or contracts the
habit of masturbation ; she may finally become insane, succumb to
exhaustion, or end her miserable existence by suicide.
The itching may be continuous, but is more frequently interrupted
by free intervals of hours and days. It increases by heat, and is,
therefore, worse at night, in a warm room, and during physical
exertion.
Prognosis. The prognosis depends on the possibility of removing
the cause. If no cause can be found, it is often very obstinate, and
sometimes, it would seem, incurable.
Treatment. First of all, we must try to find and remove the cause.
If there are crab-lice among the hairs on the pubes, the hairs should
be cut short or shaved off, and the skin smeared with blue ointment
or Peruvian balsam, or washed with a strong solution of corrosive
sublimate (1 gr. to alcohol and water da. gss), and general warm
baths with 2 drachms of the same drug should be given.
If the acarus scabiei is the offender, as a rule a treatment for itch
of the whole body will be needed. Locally, beta-naphthol in vaseline
(gr. xxv to j) or sulphur ointment should be rubbed in.
Inflammation of the vulva must be treated as described above
(p. 260). Eczema is treated with unguent, diachyli. Pin-worms are
removed from the rectum by means of extr. sennse et spigelise fl. (ss,
t. i. d.\ given by the mouth, and rectal injections of a strong infusion
of quassia (Bij-Oj) or corrosive sublimate (gr. ^ in gviij of water).
Hemorrhoids, glycosuria, and other diseases causing the pruritus
should be treated according to the rules of medical and surgical
practice.
The diet is of great importance. Besides the special diet called for
by diabetes and gout, alcoholic drinks and spiced food should be
avoided. The food should be nourishing, but bland. Milk in large
quantities (two or three quarts a day) is to be recommended if it can
be digested. If it causes dyspepsia in its natural state, it should
be tried boiled, skimmed, or peptonized.
The general treatment should be tonic, sedative, and narcotic.
Arsenic and quinine are particularly recommended. Bromide of
potassium in large doses (3J-ij daily) is often very valuable. Tinct.
18
274 DISEASES OF WOMEN.
cannabis Indica (20 to 40 drops, L i. d.) is preferable to opium. It
may be necessary to procure sleep by means of chloralamid, sulphonal,
urethane, trional, or the other modern hypnotics.
The local treatment is of the greatest importance. Vaginal injec-
tions and affusions of plain hot water, solutions of carbolic acid,
bichloride of mercury, or borax should be freely used many times a
day. If any irritating discharge dribbles from the vagina, relief is
obtained by keeping it back by means of a cotton tampon wrung out
of some mild antiseptic solution. The vulva may be covered with
fomentations of lead-water with or without opium or the saturated
solution of potassium bromide, or painted several times a day with
glycerin mixed with chloroform (1 : 8), hydrocyanic acid (p. 269),
or morphine (gr. ij or iij to 3j), or the parts may be painted at longer
intervals with a 10 per cent, solution of cocaine in water, a similar
solution of carbolic acid, or a strong solution of nitrate of silver (p.
269), followed by cold applications. For base of ointment vaseline
is the best. It may be mixed with acetate of lead, chloral, camphor
(p. 269), or chloroform (of each 3J-3J). The affected part may be
rubbed with a menthol stick or solid nitrate of silver. Some claim
to have successfully applied the galvanic current. 1 As a last resort,
when everything else had failed, the removal of the affected portions
of skin or mucous membrane by cutting instruments has effected a
cure in several cases.
During pregnancy only the milder of the above-named remedies
may be used. Large and frequent vaginal injections must be avoided.
A tampon soaked in equal parts of sulphurous acid and glyceratum
boracis may be introduced into the vagina. One case is reported in
which tobacco-smoking gave relief.
Burning Sensation in the Genitals and the Abdomen. This affec-
tion is probably nearly related to pruritus, but differs from it in the
character of the sensation. It is not very rare in my experience, if
anything, more common than its universally recognized sister, and
still itself is hardly mentioned anywhere. It seems to be fully as
recalcitrant to treatment, if not more so. Applications of compresses
soaked in cold water to the abdomen, the above-mentioned vaginal
injections, and bromide of potassium internally have given me the
best results.
1 W. Blackwood, Polydinic, Philadelphia, 1885, No. 9, vol. ii. p. 141.
DISEASES OF THE VULVA. 275
CHAPTER XL
HYPERESTHESIA OF THE VULVA.
DR. T. G. THOMAS has described, under the name of hyperesthesia,
a disease of the vulva that is sufficiently well marked to deserve a
special place in the system of gynecological diseases. 1 Although by
no means frequent, it is, according to him, not a very rare disease,
either. It consists in an excessive sensibility of the nerves supplying
the mucous membrane of some part of the vulva.
The slightest friction excites intolerable pain and nervousness ;
even a cold and unexpected current of air produces discomfort; and
any degree of pressure is absolutely intolerable. Sexual intercourse
is, therefore, hateful or impossible a condition elegantly called dys-
pareunia (p. 121).
The disease appears near or at the menopause ; hysteria and despond-
ency predispose to it. Sometimes it is found combined with vulvitis
or a painful urethral caruncle, but in other cases no cause can be
found. It differs from pruritus by the absence of itching, and from
vaginismus by not causing any spasmodic contraction of the vagina.
The treatment is unsatisfactory. Even the complete destruction
of the mucous membrane of the sensitive area with caustics or its
removal with the knife has failed to produce a permanent cure.
Sexual intercourse should be absolutely forbidden. If feasible, the
patient should be sent away from home to a place offering healthful
surroundings and cheerful company. The general treatment should
consist in tonics, sea-baths or warm general baths, and massage.
The local affection should be treated with hot sitz-baths, injections,
and affusions, and calmative, astringent, and derivative applications,
as detailed in the preceding chapter.
CHAPTER XII.
TUMORS OF THE VULVA.
1. Hyperplasia. "Without containing diseased tissue, parts of the
vulva may acquire abnormally large proportions. Thus we have seen
that the labia minora in certain races become enormously developed
(p. 37), and that in some individuals the clitoris may have the size
of the male organ (p. 256).
1 T. Gaillard Thomas, A Practical Treatise on the Diseases of Women, 6th ed.,
Philadelphia, 1891, p. 150.
276 DISEASES OF WOMEN.
2. Varicose Veins. The veins of the vulva, especially of the labia
majora, may swell so as to form tumors of considerable size, even
that of the fetal head.
This condition is in most cases connected with pregnancy, but may
occur independently thereof. It is produced by everything that
obstructs the free flow of venous blood from the vulva, such as
tumors pressing on the pelvic veins, lifting of heavy burdens, pro-
tracted standing, habitual constipation, etc.
The swollen veins form dark blue, nearly black, globular, oval, or
serpentine soft swellings, that collapse on pressure, and refill immedi-
ately when the pressure is discontinued. They increase during preg-
nancy, and become smaller after the birth of the child ; but often
they do not disappear altogether. They cause an uncomfortable sen-
sation of heat and weight, especially during bodily exertion, and
sometimes pruritus. They may burst spontaneously, but usually
that accident is produced by the passage of the child or by external
injury. If the skin holds, a hematoma is formed ; if it breaks, a
serious, and sometimes fatal, hemorrhage follows (p. 41).
Treatment. During pregnancy the patient should rest in a recum-
bent position in the middle of the day, in order to relieve the pressure
of the child on the veins of the pelvis. At times even complete rest
in bed or on a lounge is indicated. Fomentations with lead-water
relieve heat and tension. A pad may be adapted in such a way as
to compress the swelling. The patient should be informed of the
dangers of hemorrhage, and instructed how to check it by compression
till she can get help. When a rupture has taken place and the blood
escapes, the hemorrhage should be controlled by means of deep
sutures, tamponade of the vagina and vulva (pp. 179-180), combined
with pressure on the skin by means of a compress rolled so as to
form a hard cylinder placed against the cutaneous surface of the labia
majora and retained with a T-baudage.
3. Hematoma, or thrombus, is a swelling due to extravasation of
venous blood in the connective tissue of the vulva. It is most com-
mon in the labium majus, and, as a rule, it affects only one side.
Varicose veins predispose to hematoma. The exciting causes are
external violence, such as a blow or a fall, and straining, especially
during childbirth.
The hematoma may consist in a small swelling of the size of a hazel-
nut or acquire the dimensions of a fist or a fetal head at term. It is
of dark blue or purple color and tender on pressure. The blood may
be absorbed or the tumor may become inflamed, suppurate, and even
fall a prey to gangrene. When inflammation sets in, swelling, ten-
derness, and heat increase, the skin takes a brighter purple .color, the
temperature rises, and symptoms of septicemia may develop. The
swelling may oppose a serious obstruction to the passage of the child
DISEASES OF THE VULVA. 277
or cause retention of urine. It may also burst, causing the dangerous
hemorrhage just mentioned. As a complication of delivery it has
proved fatal in 20 per cent, of the cases reported.
Treatment. A small hematoma may be let alone or treated with
cold, astringent, or absorbent fomentations (ice-bag, ice- water coil,
lead-and-opium wash, arnica). If it is larger than a fist, it should
be at once opened with a long incision, the clots" turned out, bleeding
veins secured by suture or forcipressure (p. 184), and the cavity
packed with iodoform gauze or styptic cotton. As soon as pus is
formed the hematoma must under all circumstances be opened and
thoroughly disinfected.
4. Papilloma is a tumor produced by hyperplasia of the papillae
of the skin or mucous membrane, with corresponding development
of the blood-vessels and epidermis. It appears on the female genitals
in three well-marked forms : common warts, vegetations, and mucous
patches.
Warts, generally of round form, more or less pediculated, of the
size of a pea or a bean, with a dry, uneven surface of dark brown
color, are occasionally found on the skin of the vulva, especially the
mons Veneris, as in other parts of the body. They are insignificant,
and do not call for any treatment.
Vegetations, also called venereal warts or condylomata acuminata,
stand in special relation to the genitals, male and female. They are
often found in patients suffering from gonorrhea, chancroid, or
syphilis, especially gonorrhea, but may also be entirely independent
of any venereal affection, and are then due to lack of cleanliness.
They are most common on the fourchette, at the vaginal entrance,
and the labia minora or niajora, but may extend through the whole
vagina and to the vaginal surface of the vaginal portion of the uterus,
the inside of the thighs, and around the anus. On the mucous mem-
brane they are soft; on the skin they are harder. They begin as
small erosions, which soon change to pin-head-sized granular papules.
After that they grow rapidly, forming sessile or pediculated, club- or
cockscomb-shaped protuberances. Their color varies much : some are
light gray, others are pink, deep red, or purplish. They vary in
size from a hemp-seed to a raspberry, but if neglected the different
isolated growths come in contact with one another and may form a
tumor as large as the fetal head. Their surface shows always pro-
tuberances separated by deep furrows, and they can be separated into
smaller cauliflower-like parts springing from a narrow base. They
exhale a mucoid secretion of a sickening odor. Even the dry vege-
tations on the skin are apt to become eroded and secrete such fluid.
The acrid secretion may cause vulvitis and vaginitis, and the tumors
may mechanically obstruct the meatus urinarius, the vaginal entrance,
and the anus, so as to interfere with micturition, coition, defecation,
278 DISEASES OF WOMEN.
and childbirth. When they are destroyed new ones are very prone
to spring up. In elderly persons they have a tendency to become
malignant and change into epithelioma. The secretion, if carried
into the eyes, is apt to cause purulent ophthalmia. During childbirth
there is the same danger for the eyes of the baby, and besides that
the risk of puerperal infection of the mother. The tumors may also
become gangrenous, and in that way cause the patient's death.
Diagnosis. Flat and broad vegetations may sometimes be so like
mucous patches that one affection may be mistaken for the other ; but
with mucous patches we have the history of preceding syphilitic
infection and, as a rule, other concomitant symptoms of syphilis.
They are few in number, and develop more slowly.
Treatment. The sooner these tumors are removed the better. If
they are small, they may be snipped off with curved scissors or
scraped off with the sharp spoon, after which the base should be
touched with liq. ferri chloridi or the actual cautery. They may
also be destroyed with corrosive-sublimate collodium (3ss j) or sali-
cylic acid dissolved in collodium (3J-BJ), glacial acetic acid, lactic,
nitric, or chromic acid, and other caustics. The tincture of Thuya
occidentalis is said to be a specific for these growths. They should
be constantly moistened with it. In my experience the thermo-cau-
tery has proved the only radical cure even for small vegetations.
If they are of medium size up to an inch in diameter they
may be tied with a silk or rubber ligature. If they are still larger,
the galvano-caustic wire is the best means for their removal.
At the same time, great cleanliness should be inculcated. Vaginal
douches with carbolic acid or corrosive sublimate, hot sitz-baths, and
hot affusions should be used several times a day. The affected sur-
faces should be kept dry and separated with antiseptic gauze.
If operation is contraindicated, even large tumors can be made to
shrink by covering them with equal parts of calomel and salicylic
acid. 1 If these vegetations have invaded the meatus urinarius, care
must be taken to use methods that will not cause stricture.
Even during pregnancy vegetations should be removed by some of
the above-named means, since they present a double danger for
mother and child. Minor operations may be performed with cocaine
(1 : 8 or 10) ; the larger require etherization.
Mucous patches will be considered later.
To papilloma seems also to belong a disease that has been de-
scribed under the name of oozing tumor. It is a very rare disease
if it is not simply the same as large flat vegetations. It is said to
occur mostly in middle-aged, fat women. It forms a large flat tumor
on one or both labia majora, divided with deep fissures, and is cha-
racterized by discharging a large amount of an acrid, offensive fluid.
1 E. W. Taylor, 1. c., p. 30.
DISEASES OF THE VULVA. 279
In a case operated on by Dr. Emmet l with knife and sutures the
hemorrhage was profuse. It is therefore preferable to remove the
mass with the thermo- cautery or galvano-cautery.
5. Elephantiasis, or pachydermia, is a chronic recurring inflamma-
tion of lymph-vessels accompanied by hyperplasia of the connective
tissue, the skin, mucous membrane, and epidermis, leading to the
formation of large tumors.
Etiology. Sporadic cases are very rarely found in North America
and Europe, but the disease is endemic in the West Indies, the coasts
of Central and South America, Africa, and on the islands of the
Pacific. It is mostly found in adults, but seems to begin in child-
hood. The dark races are much more frequently affected than the
white. It occurs especially in marshy localities. It is mostly due to
the presence of a parasite called filaria sanguinis in the blood, in
which it is supposed to be introduced through mosquito-bites. It
may also be due to primary occlusion of lymphatics and destruction
of the lymphatic glands of the groin.
Symptoms. The endemic form begins with all the symptoms of
lymphangitis. The patient is feverish ; the affected part becomes
swollen and red ; the redness may follow the lymphatics or blood-
vessels as red streaks, or cover the whole surface as in erysipelas. The
inguinal glands become swollen and tender. This acute stage lasts a
week or two, subsides slowly, and leaves often the parts in an ede-
matous condition. After that there follows a free interval varying
in length from a month to several years, when the same process is
repeated, each attack leaving the affected part more swollen and
harder, until all pitting ceases and the tissue becomes hard as the
rind of ham. The skin has a dark color. The surface may be
smooth or rough, covered with warts, the seat of fissures, or, when
the tumor is rubbed, ulcerations may form and allow a serous fluid to
ooze out. Most frequently the labia majora are the seat of the dis-
ease, after them the clitoris, and most rarely the labia minora. The
tumors may reach such a size that they hang down to the knees or
even to the ankles, and weigh many pounds. They prevent sexual
connection, and cause discomfort by their bulk and weight, but they
do not affect the general health. They do not become strictly pedun-
culated, but when they are large the base, however, is somewhat nar-
rower than the middle of the tumor. Exceptionally they may give
rise to thrombosis and pyemia. Chyluria is a frequent accompani-
ment of elephantiasis.
Pathological Anatomy. The swelling is chiefly situated in the
skin and mucous membrane; the lymphatics are dilated and the
papillae enlarged. The underlying subcutaneous connective tissue and
the epidermis are also increased in thickness. In the tissue compos-
1 L. c., p. 603.
280 DISEASES OF WOMEN.
ing these tumors are found yellow elastic fibers and deposits of pig-
ment. According to the different consistency of the tumors the tissue
contains more or less serum.
Diagnosis. It differs from diffuse fibroid by the history of a fever-
ish beginning or repeated attacks of lymphangitis. The inguinal
glands are often affected. Not only the connective tissue, but the
skin itself, is thickened. When the tumors are examined micro-
scopically, we find dilated lymph-spaces and yellow elastic fibers.
Prognosis. The disease never disappears spontaneously, and is
only curable in the beginning. Its progress extends over many
years. It does not shorten life except in the rare cases of thrombosis
and pyernia.
Treatment During the acute stage antipyretics and cold applica-
tions are used. Change of climate is desirable. In young subjects
sulphide of calcium (gr. 1-1 J, twice a day) is claimed to have effected
a cure in a month or two. Massage and electrolysis may, under
similar circumstances, prove useful and may be combined with it.
In cases of long standing amputation is the only remedy. This may
be performed in different ways :
a. Schroeder's method is to cut from below upward, a small part
at a time, and unite the edges by deep sutures before progressing
with the operation.
6. Mund6 introduced long pins through the base of the tumor,
surrounded it with a temporary elastic ligature, cut the tumor off,
loosened the ligature, tied bleeding vessels, and united the edges.
c. Silver-wire sutures may be drawn through the base before cut-
ting, the vessels tied with catgut, and the sutures closed.
d. The tumor may be removed with the galvano-caustic wire or
the thermo-cautery.
The cutting operations are preferable, since there is good hope of
obtaining complete or partial union by first intention.
6. Fibroma. A fibroid or fibroma is a tumor composed of fibrous
connective tissue. It occurs in the vulva in two forms the diffuse
and the circumscribed.
The etiology is obscure.
The diffuse fbroma is much like elephantiasis in appearance, and
the seat is the same ; but while in elephantiasis the chief thickening
takes place in the skin and the mucous membrane, the fibroma is
formed by hyperplasia of the connective tissue, without growth of
the skin and mucous membrane. The tumors are more or less irregu-
lar, often divided into lobes or shooting-off pedunculated portions.
The skin covering them is pink, whitish, or brownish. They have
no intrinsic tendency to ulceratiou, but through friction superficial
ulcers may form, and again heal up, leaving cicatrices. These
tumors are not sensitive nor the seat of spontaneous pain, except
DISEASES OF THE VULVA. 281
when they become inflamed. They grow slowly, but may become
very large. They do not affect the constitution, but incommode
the patient by their size and weight, and are a hindrance to coition,
sometimes amounting to complete dyspareuuia.
Minute Anatomy. The microscope shows connective-tissue fibers,
with infiltration of round cells surrounding the vessels, but no change
in the vessels themselves or the skin, and no yellow elastic fibres ;
which features distinguish fibroma from elephantiasis.
Treatment Amputation is the only remedy, and is carried out as
stated under Elephantiasis.
The circumscribed fibroma is a rare affection. It is composed of
the same tissue as the diffuse form, but soon becomes pedunculated,
and hangs down from the labium majus.
The treatment consists in cutting the pedicle near its base, tying
with catgut the artery that nourishes it, and uniting the edges with
sutures.
7. Myoma, Myxoma, Lipoma. Tumors entirely similar to fibromas
may be formed of unstriped muscle-fibers (myoma) of a delicate
fibrous reticulum, the meshes of which contain a homogeneous basis-
substance and cells (myxoma) or of adipose tissue (lipoma). Quite
commonly the different kinds of tissue are intermingled with more
or less fibrous tissue, forming myo-fibromas, myxo-fibromas, 1 etc. They
are all benign, but the only treatment is amputation. 2
8. Enchondroma of the Clitoris? A single case has been reported
of a pedunculated tumor, of the size of a fist, attached to the clit-
1 On account of the great rarity of these tumors, I may be pardoned for stating
that on March 12, 1884, I removed one from a Swedish cook, set. 34 : it had been
first noticed nine years before. It hung from the middle of the left labium majus,
to which it was attached by a pedicle of the length and thickness of a finger. The
tumor itself was pear-shaped, measured 8 centimeters in length, 7 from side to side,
and 4 in thickness. It had the color of normal skin, and was covered with peeling-
off' epidermis. At the lower end was seen an irregular slough of the size of a fifty-
cent piece, surrounded by a suppurating line of demarkation which exhaled an
offensive odor. In the pedicle was felt a pulsating artery of the size of the umbilical,
and in it and near it on the labium majus were varicose veins. The tumor did not
cause any pain, nor was it tender on pressure. I put a clamp on the base of the
pedicle, formed two small flaps, tied the artery, and united the edges with catgut.
it healed by first intention. When cut open a moderate amount of blood flowed
from the tumor; the surface was smooth, the skin not thickened, but so intimately
connected with the tumor that it could not be dissected off'. Microscopical exam-
ination proved it to be a myxo-fibroma. 1 have, in St. Mark's Hospital, seen a case
almost entirely like the preceding one.
4 Geo. M. Tuttle of New York has removed a large fibroma mottuscum from the
labium majus. It measured 17i in. in circumference ; had a thick capsule, in cut-
ting through which the appearance was strikingly like gut : thin, translucent, gas-
eous in feeling, and very resonant on percussion (Amer. Jour. Obstet., June, 1891,
vol. xxiv. p. 715).
3 Tumors of the clitoris are extremely rare. Grace Peckham has described a cysi
as large as a hen's egg, and collected twenty cases of different kinds of tumors of this
organ (Amer. Jour. Obstet., Oct., 1891, vol. xxiv. pp. 1153-1172).
282 DISEASES OF WOMEN.
oris, and composed of a cartilaginous mass, which in some places
was softened, in others hard as a stone, probably through calcareous
deposit. No microscopical examination seems to have been made.
The treatment was, of course, removal of the tumor.
9. Horn of the clitoris is likewise a gynecological curiosity. A
case is reported of a horny mass, in size and shape like the talon of
a tiger, growing under the prepuce of the clitoris. Such a growth
might wound the male during coition, and ought to be removed with
the thermo- or galvano-cautery.
10. Urethral Caruncle, Angioma, and Neuroma of the Vulva.
The names urethral caruncle, vascular tumor of the urethra, painful
tumor of the urethra, and irritable vascular excrescence of the urethra
have been applied to a kind of growths found at or near the meatus
urinarius, and characterized by their great vascularity. It is a quite
common affection, and is often seen accidentally in patients examined
for other complaints, without causing any symptoms. On the other
hand, it may cause great pain, especially during micturition, and be
so tender to the touch that sexual intercourse is rendered hateful or
impossible. Even the friction of the clothes may suffice to start the
pain. Sometimes there is only one such tumor, in other cases many.
They are usually found just at the meatus, but may also develop more
or less high up in the urethra. They are sessile or pediculated, of
bright red color, usually sensitive, and apt to bleed after small
injuries. They vary in size from a hemp-seed to a cherry. Even
when thoroughly destroyed they are apt to recur, or new ones may
spring up in the neighborhood of the first.
Microscopical examination has shown that these tumors are full of
dilated capillaries and nerve-fibers, with hyperplasia of the papillae
and connective tissue. Anatomically speaking, they are, therefore,
angiomas and sometimes neuromas. The different composition ac-
counts probably for the great difference in symptoms.
Vascular tumors (angiomata) and nervous tumors (neuromata) form
in rare cases small tumors on other parts of the vulva and the peri-
neum.
Diagnosis. The bright red color, the great sensitiveness (when
found), their insertion at the meatus, and their even, globular surface,
make them easily distinguishable from vegetations.
Treatment. The only thing that affords help is the removal of the
tumor. If there is a thin pedicle, it needs only to be twisted off with
a pressure-forceps. Small sessile tumors may be destroyed with
chromic or nitric acid, neutralizing the superfluous acid by bathing
the parts with a solution of bicarbonate of soda. Cocaine (10 per
cent.) may be used for local anesthesia. Larger sessile tumors are
best removed with the thermo- or galvano-cautery under general
anesthesia. In the interior of the urethra they must be exposed with
DISEASES OF THE VULVA. 283
a urethral speculum (p. 150), especially Jackson's, and cut or scraped
off or destroyed with caustics. The latter should even be used on
the base after cutting or scraping, in order to prevent recurrence.
11. Cysts. Except those situated in the vulvo- vaginal glands,
which will be considered later, cysts of the vulva are rather rare.
They are single or multiple, and range in size from that of a pea to
that of a fetal head. They differ much in origin. Some are dermoid
cysts, with the characteristic hairs, bones, and teeth in the interior.
Others are atheromas, formed by occlusion of a sebaceous follicle, and
contain a pultaceous mass. Most of them are filled with a serous
fluid. Some seem to be due to an old extravasation of blood or to
expansion of lymphatic vessels.
If small, they do not give rise to any symptoms, but if they acquire
large proportions, they may incommode the patient by their weight
and size, and cause dyspareunia. If they become inflamed, they are
painful, and are accompanied by fever and other systemic disturbances.
Treatment. As they are intimately connected with the surrounding
tissue, it may be difficult to enucleate them. If so, a part of the wall
is excised, the interior cauterized, packed with iodoform gauze, and
left to heal by granulation.
12. Cancer. Compared with the uterus, the vulva is rarely the
starting-point of cancer. Different kinds are found here epithelioma,
medullary carcinoma, atrophic carcinoma (or scirrhus), and sarcoma,.
with its variety melano-sarcoma, the cells of which contain brown pig-
ment. They are all malignant, tending toward local destruction,
undermining the constitution, and ending in death.
Epithelioma (Fig. 202) is in so far less malignant than the other
varieties of cancer as its course is slower.
Etiology. Cancer appears mostly after the fortieth year, but has
even been found in childhood. Psoriasis of the parts has a tendency
to become cancerous. Otherwise the cause is unknown.
Symptoms. The most common starting-point is the sulcus between
the labiurn majus and minus or the lower edge of the labium majus,
more rarely the clitoris or the meatus urinarius. It begins as small
nodules in the skin or mucous membrane, covered with an increased
mass of epithelium, which often causes distressing itching. Later,
these nodules become excoriated, secrete a thin, malodorous fluid,
form ulcerations that become confluent, and spread over the neigh-
boring parts. Soon the inguinal glands become swollen. The ulcers
are irregular, have discolored margins, an elevated floor, and are often
covered with a new growth of cancerous tissue, which gives them the
appearance of a raspberry. They have no tendency to enter the
vagina. They are liable to bleed and cause pain. Sometimes the
surroundings become hard as a board, and the vaginal and urethral
openings may become obstructed.
284
DISEASES OF WOMEN.
Prognosis. The patients usually succumb at the end of two or
three years.
Diagnosis Lupus heals in one place while destruction extends in
another, is not so hard, causes slight pain, and is inodorous. The
FIG. 202.
Epithelioma of Vulva (P. Zweifel) : a, clitoris ; b, fossa navicularis ; c, vaginal entrance ; d,
torn perineum ; gg, cancerous nodules in the skin.
inguinal glands swell late or not at all. The general health remains
good. Chancroid is not indurated, has sharply-cut, perpendicular
edges, and the inguinal glands are implicated much sooner. Chan&'e
presents a surface much like that of the excoriated cancer nodule, and
has the indurated floor, but the history, the early appearance of
adenitis, and the development of other syphilitic symptoms will soon
clear up the diagnosis. Mucous patches, even if excoriated, do not
form destructive ulcers, and disappear soon under local and general
treatment.
Treatment. The nodules and ulcers ought to be eradicated at once.
If possible, it should be done with knife and scissors, and the edges
united by deep sutures, which allows of union by first intention ;
otherwise the therm o- or galvano-cautery is used. If the urethra
is implicated, as much of it as feasible should be left, in order not to
DISEASES OF THE VULVA. 285
interfere with the retentive power. If the inguinal glands are
affected, they must be enucleated, but even if they are removed en-
tirely, the disease cannot be arrested permanently.
13. Lupus, Esthiom&ne (Huguier) ; Chronic Inflammation, Infiltra-
tion, and Ulceration (R. W. Taylor). The doubtful position of lupus
of the vulva in the system of gynecological diseases necessitates an
exception from the rule followed in this work not to enter into his-
torical developments. In 1849, Huguier, a French physician, de-
scribed a disease of the vulvo-aual region under the name of esthio-
m&tie, which was claimed to be identical with lupus as found especially
on the face. The name " lupus" has prevailed, and a certain number
of cases have been reported in different countries. 1
The pathology of lupus itself is not yet settled, and so much the
less can we decide whether the disease attacks the external female
genitals or not. According to Koch's great authority, lupus is simply
tuberculosis of the skin, and only that affection which is caused by
the presence of his bacillus tuberculosis deserves the name ; but this
microbe has so far been looked for in vain in lupus vulvse. Others
claim that an infiltration with small round cells, clustering together in
nodules, especially around the capillary vessels of the skin, or a diffuse
infiltration of the papillary layer or around the glands and hair-follicles
of the skin, constitutes lupus. Still others lay particular stress on the
presence of giant cells in the clusters of small round cells. Others,
again, contend that all this is not characteristic of lupus, but may
be found in any inflammation with formation of granulation tissue
and proliferation of the cells of the connective tissue. 2 R. "W.
Taylor 3 denies altogether the existence of lupus in the female geni-
tals. Based on his large experience in Charity Hospital, he includes
all the inflammations and infiltrations of the vulva of non-malignant
origin in the following categories :
1. Small hyperplasiffi, caruncles, and papillary growths;
2. Large hyperplasiae.
3. Hyperplasia resulting from acute and chronic chancroids ;
4. Indurating edema of syphilis ;
5. Hyperplasia resulting from chronic ulcers, so-called chancroids,
in intermediary and old syphilis ;
6. Hyperplasia in old syphilitics, presenting no specific character
and occurring soon or long after the period of gummy infiltration, in
some cases being coexistent with specific lesions elsewhere.
The cases of formation of tumors, combined with ulceration, con-
1 Grace Peckham, in an excellent paper fortified by microscopical examinations
by H. C. Coe (A'mer. Jour. Obst., 1887, vol. xx. p. 78o), has collected 48 cases, of
which she eliminates some as tubercular, carcinomatous, or not ulcerative, and
retains 33, inclusive of her own.
2 Coe, 1. c., Ira Van Gieson in R. W. Taylor's paper.
S R. W. Taylor, X. Y. Med. Jour., Jan. 4, 1890.
286
DISEASES OF WOMEN.
stituting the condition commonly called lupus vulvse, that have come
under my own observation, were all developed on a foundation of
recent or old syphilis.
What has been called lupus vulvse (Fig. 203) consists in ulcera-
tive lesions of the vulva characterized by their slow development,
FIG. 203.
Lupus of Vulva (Haberlin).
absence of pain, a violaceous color, thickening, induration, and forma-
tion of detached tumors. Hyperplasia and destruction go hand in
hand, but the hyperplastic process preponderates. The deformity
extends often to the perineum and the anus. The inguinal glands
may become swollen, but are oftener not affected. The general
health stays good for years, and those who are not cured succumb
usually to constriction of the intestine and peritonitis. Locally, great
destruction takes place. Fistulous tracts may burrow into the labia
DISEASES OF THE VULVA. 287
and around the rectum, and fistulse may open into the urethra, the
bladder, or the rectum. Fortunately, this destructive hyperplastic
affection of the vulva is a rare disease.
Etiology. Those who do not look upon the ulcerative hyperplasia
of the vulva as a disease sui generis, attribute it to the large vascular
and nervous supply of the genitals, to the injuries they are frequently
exposed to, to their dependent position between the thighs, to lack of
cleanliness and care, and the irritation caused by uterine or vaginal
discharges.
Diagnosis. Epiihelioma is usually more localized, of much greater
density even to stouiness is productive of a large warty or papilla-
matous and ulcerated surface, and is very soon accompanied by
enlargement of the inguinal lymphatic glands. The ulceratious of
epithelioma are upon the surface, while those in so-called lupus are
mostly found in interstices, fissures, and at the base of tumors. Epi-
thelioma gives rise to lancinating pain ; lupus is painless or causes
only smarting or pruritus, especially after micturition. The discharge
that emanates from the ulcers in lupus has little or no odor. An
ulcerated part may heal spontaneously or in consequence of treatment,
but the cicatrice is liable to be affected by a new growth of lupus.
The microscope settles the question with certainty by showing the
epithelioma to contain cancer-nests of concentrically arranged cells of
the epithelial type.
Prognosis. We have already stated that the disease is a very
tedious one, extending over years. It does not in itself undermine
the constitution, but may lead to intestinal obstruction and peritonitis
or general exhaustion. In patients over forty any vulvar tumor,
even a caruncle or a papilloma, may degenerate and become cancerous.
If not checked, the disease may cause great destruction, and give rise
to much annoyance by perforating the partitions between the different
hollow pelvic viscera and the external genitals.
Treatment. On account of the dangers lurking in the background
treatment ought to be quite active. The indication is to remove
tumors and heal ulcers. Simon's sharp spoon, strong caustics e. g.
nitric acid, the thermo-cautery, the galvano-cautery, the galvano-
caustic wire may all be used to advantage, but, if possible, it is
preferable to cut away all diseased tissue and unite the edges with
sutures. Fistulous tracts may be laid open by means of the elastic
ligature. It goes without saying that the utmost cleanliness should
be practised by means of baths, fomentations, and injections. Often
a tonic treatment with iron, quinine, cod-liver oil, etc., or local or
general antisyphilitic treatment, may be called for in combination
with the mechanical local treatment.
288 DISEASES OF WOMEN.
CHAPTER XIII.
TUBERCULOSIS.
TUBERCULOSIS of the vulva is an exceedingly rare affection ; which
is strange, since one would think that occasions of direct inoculation,
either from the same or another individual, by means of fingers,
handkerchiefs, towels, or the sexual act, would present themselves
frequently. But the fact is that the more we approach the surface
of the body the rarer becomes tuberculosis in the genital system.
It forms ulcers with sharp edges, sinuous contour, and a depressed
grayish-yellow bottom covered with a cheesy detritus. Around the
ulcers are often found small opaque, yellow nodules. In the dis-
charge of the ulcers and in the tissue forming them and the nodules
are found tubercle bacilli. In the mucous membrane are found clus-
ters of polygonal cells surrounded by a zone of small round cells, and
containing giant cells, in the interior of which may be found tubercle
bacilli. As a rule, similar affections will be found in other parts of
the genitals and in the lungs.
Treatment. The general treatment is the same as for tuberculosis
in other parts nutritious diet, tonics, sunshine, and fresh air. The
local treatment consists in application of tincture of iodine or iodoform.
If this does not suffice to eradicate the disease, removal with the knife
or destruction with caustics or cautery is indicated in the early stages.
If the patient is far gone, more palliative treatment with the curette
and iodoform or aristol is all that should be attempted.
CHAPTER XIV.
PROGRESSIVE ATROPHY OF THE NYMPH^E (L. TAIT), KRAUROSIS
(BREISKY).
AT or after the menopause, and quite exceptionally in younger
years, is sometimes found a peculiar atrophy of the mucous membrane
of the inner side of the labia minora. It begins as small red spots,
depressed under the level of the surrounding mucous membrane, ten-
der and prone to bleed, transitory or spreading. They may disappear
in one place and reappear in another, or spread serpiginously. Later,
the mucous membrane contracts, so as to cause considerable coarcta-
tion of the vestibule. The stenosis may be so great that hardly a
finger can be introduced into the vagina. Coition becomes painful,
and childbirth is accompanied by tears of the tissues. When the dis-
ease is fully developed, the labia minora seem to be absent. The
DISEASES OF THE VULVA. 289
mucous membrane appears dry, smooth, and cicatricial. Sometimes
there is a slight yellow discharge. In many cases itching or burning
is complained of.
The cause of the disease is unknown. Its course is very slow.
Pathological Anatomy. Microscopical examination of the red spots
shows dilated capillaries, with thinned walls, and nerve-fibers. All
over the aifected part of the mucous membrane the rete mucosum is
thin, so that in many places the horny epidermis-cells lie directly on
the papillae. These are of uneven length, mostly short ; the papillary
body is composed of straight fibers like a cicatrice, and the sebaceous
and sudoriferous glands disappear.
Treatment. Kraurosis vulvse is a very intractable disease. Cocaine
is said to increase the sufferings. Applications of strong carbolic acid
and a pledget steeped in a saturated solution of acetate of lead are
recommended. A cure has been obtained by cutting the aifected part
of the mucous membrane away and uniting by sutures. It may also
be destroyed with the thermo- or galvano-cautery.
CHAPTER XV.
DISEASES OF THE VULVO-VAGINAL GLANDS.
THE vulvo-vaginal glands may be the seat of catarrh, cystic
degeneration and abscess.
1. Catarrh of the gland is rare. It is characterized by hypersecre-
tion of mucus and redness of the mucous membrane surrounding the
opening. The duct may become dilated, so that a uterine sound may
be passed through it, or it may become closed, and then a retention
cyst is formed. Sometimes the accumulated secretion may be thrown
off in paroxysms, constituting a kind of nocturnal emission.
The treatment is not satisfactory. The duct should be dilated with
probes, and astringent antiseptic fluids injected. On account of the
emissions, it has been recommended to extirpate the glands.
2. Oysts. There may be a superficial or a deep cyst. The former
is supposed to be formed by the duct. It forms a small round tumor
immediately under the mucous membrane, just outside the vaginal
entrance. It may vary in size from that of a hazeluut to that of a
hen's egg. The deep cyst is situated in the gland itself, and may be
unilocular or multilocular. It forms a large tumor which is situated
in the posterior part of the labium majus. Both form well-defined
globular or oval, elastic tumors. The contents are ordinarily like the
raw white of an egg, but may be chocolate-colored from admixed
blood or purulent when inflammation has taken place. As a rule, the
duct is closed, but by increased pressure it sometimes opens again. If
19
290 DISEASES OF WOMEN.
not inflamed, these cysts are indolent, but they may cause some dis-
comfort by their size and be an obstacle to sexual intercourse.
The most common cause is gonorrheal infection.
Diagnosis. Hydroeele is situated more forward, below the external
inguinal ring. The same applies to anterior labial hernia. Hernia
of the ovary is harder, and pressure on it causes a peculiar sickening
feeling. Posterior labial hernia can be replaced through the vagina.
Vulvar abscess has less distinct limits, is more tender, and the skin is
red. Abscess of the gland is tender, hot, red, and accompanied by
fever.
Treatment. Part of the contents may be drawn out with a hypo-
dermic syringe, and replaced by an injection of chloride of zinc
(1 to 10). The contents may be withdrawn entirely, and an injection
made with pure tincture of iodine or a 5 per cent, solution of car-
bolic acid. The anterior wall may be cut off, the cavity washed out
with a solution of bichloride of mercury, and packed with iodoform
gauze, which has to be renewed every few days till the cavity is filled
by granulations. Finally, the whole gland may be extirpated, and
union by first intention attempted by means of sutures. It may be
advisable to use tier-sutures of catgut (p. 221). Pozzi 1 facilitates
the extirpation by emptying the cyst with a hydrocele trocar, and
injecting it with spermaceti molten at a low temperature and hard-
ened after injection by the application of ice. Combined with injec-
tion of cocaine, the cold serves as an anesthetic.
3. Abscess. With or without preliminary formation of a cyst the
gland may suppurate and form an abscess. The left gland is more
frequently affected. The process is accompanied by the usual signs
of inflammation pain, swelling, redness, heat, and considerable sys-
temic disturbance. The inguinal glands are commonly implicated.
If left to Nature's sole efforts, it breaks on the inside of the labium
majus in one or more places, and often fistulous tracks remain.
There is in many women a tendency to repetition of such abscesses.
The pus has the same offensive odor as abscesses in the ischio-rectal
fossa or near the fauces. Gonococci have been found in the pus-cells.
The abscesses may leave a chronic suppuration of the gland, or
such a condition may develop without abscess. There is then little
swelling and tenderness, but a continual discharge of a purulent fluid
through the duct of the gland. This suppuration is perhaps always
brought on by gonorrhea, and continually gives rise to new infection.
Diagnosis. Furuncles are situated in the skin. Phlegmonous vul-
viiis has not the distinct limits and the peculiar situation of the
abscess of the gland. A stercoral abscess originates nearer the anus.
Treatment. The abscess must be laid open by a long incision on the
1 Samuel Pozzi, "Trait4 de Gyncologie clinique et operatoire," Paris, 1890, p.
1032.
DISEASES OF THE VULVA. 291
inner side of the labium majus, disinfected, and packed with iodoform
gauze. The opening may conveniently be made with Paquelin's cau-
tery. If there is frequent recurrence of the formation of such abscesses
or a chronic suppuration, it is best to extirpate the gland in toto. It is
not worth while trying primary union. It rarely succeeds, and it is
better to pack the wound with iodoform gauze. The extirpation of
the gland should be done at a time when the surrounding tissue is
not inflamed. In using the knife, it should be remembered that the
gland lies close up to the vulvo-vaginal bulb, only separated from it
by a thin fascia. Wounding the bulb might give rise to troublesome
hemorrhage.
CHAPTER XVI.
VENEREAL DISEASES.
VENEREAL DISEASES form so great a part of the affections that
come under the observation of the gynecologist, and are so often the
cause of others treated by him, that a brief re'sume of the most com-
mon features of these diseases seems desirable in a work of this kind.
1. Gonorrhea. We have already spoken of the gonorrheal vulvitis
(p. 267). It has so great a tendency to implicate the urethra that
the presence or absence of urethritis has a certain diagnostic import-
ance. It enters often the duct of the vulvo-vaginal gland, and may
cause catarrh, cyst, abscess, or chronic inflammation of the gland. In
most cases the inflammation spreads up the vagina to the vaginal
portion of the uterus. Fortunately, it generally stops here, but some-
times it invades the cavity of the uterus, causing purulent endome-
tritis; attacks the lining membrane of the tube, producing salpingitis
and pyosalpinx; and reaches finally the ovary and the peritoneal
cavity, giving rise to oophoritis and peritonitis conditions that may
make the patient an invalid for life or necessitate capital operations.
It will, therefore, be seen that a gonorrhea in the female is a much
more serious disease than the corresponding affection in the male.
If limited to easily accessible parts, the disease may be cured in a
few weeks ; but if it invades deeper parts, especially the vulvo-vaginal
glands or the tubes, it may become chronic and persist indefinitely
until the focus of infection is removed.
In regard to treatment of the external genitals, sufficient has been
said in speaking of vulvitis (p. 268) and the diseases of the vulvo-
vaginal glands. As to that of the internal genitals, the reader is
referred to later chapters, where the diseases of the vagina, uterus,
tubes, and ovaries are discussed.
2. Chancroid. Chancroid, or soft chancre, is frequently found on
292 DISEASES OF WOMEN.
the vulva and surrounding parts of the skin, while it is rare on the
walls of the vagina, but appears more frequently on the vaginal por-
tion of the uterus.
Whether inoculation takes place at once in several places, or that
from the first affected part the poison is carried to other points, as a
matter of fact chancroids are commonly multiple in women. A
chancroid is a contagious, inflammatory, destructive ulcer. On the
mucous membrane it begins as a minute yellow spot surrounded by
a red ring. Soon the epithelium over the spot is lifted so as to form
a pustule, and is then carried off, leaving an ulcer. On the skin the
ulcer may form without the intervention of a pustule. The ulcer is
usually round or oval, but may become irregular by extension or the
confluence of several single ulcers. The edges are cut perpendicularly,
minutely jagged, and more or less undermined. The ulcer is sur-
rounded by a red halo or areola. The floor is uneven and covered
with a yellow film of debris. The secretion is in the beginning rather
abundant, and has a peculiar, very penetrant, and nauseating odor.
It is thinner than that of gonorrhea, and has a brownish color from
admixed blood. Under the microscope are seen pus-corpuscles, red
blood-corpuscles, and detritus, or broken-down tissue.
If properly treated, chancroids heal in a few weeks. If neglected,
they persist for many months, go on forming new ulcers indefinitely,
and may cause great destruction, and even, in rare cases, become fatal*
Complications are less common than in the male. It is even rare
to see an inguinal gland become inflamed and form an abscess.
Occasionally, however, in unhealthy and weak subjects phagedena
may set in, and extend far over the nates and the abdominal wall.
Peculiar to women is what is called the chronic chancroid. It
begins as an acute chancroid, but loses its infecting power, and causes
often hyperplasia of the surrounding parts. (See Lupus, p. 285.)
It is entertained by lack of cleanliness, gonorrheal and leucorrheal
discharges, and drink. The term is even used in speaking of " any
good-sized intractable ulcer " of the vulva, although there is no proof
that it began as a typical acute chancroid. 1 For years women affected
with such ulcers and hyperplastic formations may feel well, but in
the course of time the ulcers may perforate the urethra, the bladder,
and the rectum, or burrow far away under the skin, forming large
cavities, which may open by fistulous tracts about the buttocks or the
thighs. Hemorrhages of greater or less severity may take place, or
erysipelas start from the genitals. In the course of years such women
may fall a prey to pulmonary phthisis or succumb to kidney and
liver complaints. Some are subject to chronic diarrhea and dys-
entery, or are finally carried off by pyemic infection.
Treatment. The acute chancroid should be destroyed with undi-
1 K. W. Taylor, N. Y. Med. Jour., Jan. 4, 1890. '
DISEASES OF THE VULVA. 293
luted carbolic acid, nitric acid, or Paquelin's ther mo-cautery, under
local anesthesia with cocaine. The affected parts must be kept from
contact with others by covering them with pieces of absorbent lint or
pledgets of absorbent cotton dipped in some mild solution e. g.,
fy. Acidi carbolici, TTL XX to xl ;
Glyceriui, 3ss ;
Aquse, ad siv,
or smeared with the iodoform -balsam of Peru ointment (p. 178).
Vaginal injection with bicarbonate of soda or borax, followed by cor-
rosive sublimate (1 : 5000), should be used several times daily. The
substance that makes the ulcers granulate fastest after cauterization
is iodoform, which is powdered on them daily.
As a colorless and odorless substance, salicylic acid mixed with 4
or 8 parts of subnitrate of bismuth is often preferred, and may answer
a good purpose. When granulation is started, it may be hastened by
dressing with sol. argenti nitrat. (gr. j iv), liq. sodii chlorinat.
(jjij ,3iv), sol. acidi borici satur., or vinum aromat. diluted with 4
parts of water.
If a chancroid becomes phagedenic, the constitution of the patient
must be improved with nourishing diet, stimulants, and tonics. The
unhealthy tissue may be removed with the curette, or by touching it
with nitric acid, bromine-glycerin (1 : 3), or Paquelin's cautery. After
that the patient should use hot sitz-baths (98-102 F.) from eight
to twelve hours daily.
Bubos are painted with tincture of iodine. If they suppurate, they
must be opened in their full length, washed out with disinfectants,
packed with iodoform gauze, covered with a compress of the same
material, and over that a peat-bag or a layer of moss impregnated
with corrosive sublimate or a thick layer of plain cotton-wool.
Pressure by means of a spica promotes recovery in a marked degree.
This dressing is changed daily.
The curette may be used to remove broken-down glandular tissue.
When the cavity granulates, the iodoform ointment or the pure bal-
sam of Peru is used for dressing. An occasional painting with
nitrate-of-silver solution (gr. x or xx to 3j) hastens the process of
healing. Pure boracic acid is also excellent for dressing.
3. Syphilis. The initial lesion of syphilis, the hard chancre, is
often not to be found on the genitals of women. The cause of this
is twofold : First, the lesion by which inoculation of the syphilitic
virus takes place is much more frequently than in man situated on
other parts of the body, especially the' breast and the lips. This is
so in 25 per cent, of all cases. Secondly, the characteristic induration
of the true infecting chancre is often missing. The syphilitic neo-
plasm is there, but the new-formed cells are so few in number or so
294 DISEASES OF WOMEN.
loosely patched together that the characteristic sclerosis is not devel-
oped. When, furthermore, we take into consideration that the female
genitals, on account of their shape, are much less open to inspection,
even to the patient herself, and that the initial lesion may heal with-
out leaving any visible cicatrix, it will be understood that sometimes
it is entirely overlooked, and that secondary and tertiary symptoms
may appear although there is no history of any sores on the genitals
or elsewhere, and no evidence can be found of their previous existence.
The first period of incubation that is, the time elapsing between
the infection and the appearance of the hard chancre varies in
length from ten to seventy days. The second period of incubation
that is to say, the time from the appearance of the chancre to that of
general or constitutional symptoms of syphilis occupies from forty
to seventy days. The first and second periods of incubation together
commonly last from sixty to ninety days. During the second period
of incubation the primary lesion acquires greater development and
the inguinal glands become swollen. This happens from five to ten
days after the appearance of the chancre.
The syphilitic poison may come from a hard chancre, from sec-
ondary syphilitic manifestations, especially mucous patches, or be
inoculated with blood or lymph.
Any part of the vulva and its surroundings may be the seat of the
initial lesion. Most commonly it is found on the labia majora. It
is sometimes developed on the cervix uteri, but very rarely on the
walls of the vagina.
It begins as a superficial, flat, reddish erosion, which soon forms a
round or oval flat ulcer of dark red or grayish color, with smooth
floor, sparse serous secretion, and sometimes a more or less hard base.
Often an infection with pyogenic microbes takes place simultaneously
with the introduction of the syphilitic virus. Then the secretion of
the ulcer becomes more purulent and the floor shows local gangrene.
Exceptionally, a syphilitic lesion may become phagedenic. If a double
infection with syphilitic virus and that from a chancroid takes place
simultaneously, the chancroid is first developed, and changes in the
course of time its appearance, so as to form a syphilitic chancre
(mixed chancre).
The primary lesion is commonly single, but may be multiple and
may be combined with soft chancres. It stays a variable length of
time even several months but, as a rule, heals readily, and may dis-
appear without leaving any trace.
The inguinal glands form a cluster of indolent swellings. But
where there is a suppurating ulcer, there may also occur inflammation
and abscess of the inguinal glands.
Diagnosis. Since the characteristic induration is often absent, the
diagnosis of the primary lesion becomes more difficult in women than
DISEASES OF THE VULVA. 295
in men. The following points ' may occasionally be found useful in
making a differential diagnosis : In herpes progenitalis the inguinal
glands are not affected ; the base is soft ; the contour is polycyclic
that is to say, composed of regular segments of small circles that have
been blended together ; the development is more limited, and the exco-
riation heals rapidly ; the affection itches ; and, as a rule, the erosions
are multiple. Chancroid is nearly always multiple. It forms a
deep ulcer of yellowish red color, with perpendicular, undermined
edges, uneven, worm-eaten floor, soft base, and abundant purulent
secretion ; the pus, when inoculated on the patient, forms another
chancroid ; the inguinal glands are not swollen or form an inflamma-
tory bubo which may produce an abscess with simple or chancroidal
pus.
Treatment. The primary lesion being a symptom of an infection
that already has taken place, cauterization is useless, and objectionable
on account of the inflammation it brings about in the circumference.
The genitals should be kept clean and the ulcer dressed with absorb-
ent lint or cotton soaked in bichloride-of-mercury solution (1 : 1000
or 2000) or one of the other solutions mentioned above in speaking
of chancroid, the dressing to be changed every two hours. If the
ulcer suppurates or is the seat of molecular disintegration, it should
be dusted with iodoform or equal parts of calomel and bismuth, or
dressed with the lotio hydrargyri flava containing corrosive sublimate,
or lotio hydrargyri nigra, made with calomel. In cases of consider-
able induration blue ointment may be rubbed on the seat of the swell-
ing and applied to it spread on lint.
If the sore is covered with a pultaceous mass, cauterization with
carbolic acid, nitric acid, or chloride of zinc, dissolved in equal parts
of distilled water is indicated. In regard to phagedena the treatment
is the same as described under Chancroid, combined with general
antisyphilitic treatment.
Secondary Syphilis. The vulva is the seat of predilection of mucous
patches in women. In the vagina they are exceedingly rare, but appear
more frequently on the cervical portion of the uterus. They are
often found symmetrically on both sides of the vulva, not on account
of auto-inoculation, but because the irritation is the same. They
form round or oval spots, with a tendency to coalesce. They are a
little elevated above the mucous membrane, and have well-defined
steep borders. The color is rosy or grayish red. They have a some-
what granular surface, and secrete a malodorous serous fluid. They
are quite amenable to treatment, but may, if neglected, form large
cauliflower-shaped tumors like vegetations, and may, like them, be-
come gangrenous. On the vaginal portion mucous patches appear as
1 A. Fournier, Lemons sur la Syphilis etudiee particuliZrement chez la Femme, Paris,
1873, pp. 261, 281.
296 DISEASES OF WOMEN.
small red erosions, or, more rarely, as superficial ulcers. Combined
with general mercurial treatment, mild cauterization with nitrate of
silver makes mucous patches soon shrivel and disappear, without
leaving any cicatrix.
Tertiary Syphilis. Gummous nodes are not rare in the labia
majora. They form first deep-seated globular tumors, which may
break and leave ulcers. These latter may be difficult to diagnosticate
from other ulcers in the same locality, but are distinguished from
them by being rapidly healed by the internal use of potassium iodide.
At the same time, the usual precautions in regard to cleanliness and
protection that have been detailed above should be observed.
CHAPTER XVII.
PROLAPSE OF THE URETHRA.
To describe all the diseases of the urethra and the bladder would
require more space than we can afford, and they do not strictly be-
long to those organs the diseases of which form the subject of this
treatise. It might, however, be advisable to say a few words about
prolapse of the urethra, on account of the diagnosis and the treat-
ment.
While a slight eversion of the mucous membrane of the urethra is
exceedingly common, especially in women who have borne children,
the extrusion of a sufficiently large part of it to form a tumor is of
rare occurrence. It is mostly found in children, old people, or weak
subjects. It is caused by straining during micturition or defecation
e. g. when a stone is lodged in the bladder or the anus is the seat
of a fissure.
The disease may implicate the whole circumference of the urethra
or only a part of it, most commonly the lower. In the first case the
urethral canal is found in the centre of the tumor ; in the second, it
is placed excentrically.
The prolapse gives rise to or increases vesical tenesmus and may
produce cystitis. In the beginning the tumor has the appearance of
the normal mucous membrane, but later it becomes darker and denser,
and is sometimes excoriated.
Diagnosis. When the prolapse is total, the presence of the lumen
of the canal in its center settles at once the diagnosis. If it is partial,
it may be taken for a caruncle, but it differs from the latter by always
having a broad base and by being easily reduced.
Treatment. Simple reduction with a finger or sound, followed by
the use of a cupped bougie, with tannin or the application of tincture
DISEASES OF THE VULVA. 297
of iodine, rest in bed, and hot vaginal douches and affusions, may be
tried. If they do not succeed which can only be expected in slight
cases operative interference is called for: 1. The tumor may be
transfixed at its base, tied in two halves, and cut off. 2. The deeper
part of the mucous membrane may be secured by inserting a suture
on either side, and uniting the two edges of the wound with a continu-
ous catgut suture after cutting the redundant tissue off. 3. Emmet's
buttonhole-operation may be performed by placing the patient in
Sims's position, introducing his speculum, making a longitudinal
incision on the vaginal wall corresponding to the course of the
urethra down to the mucous membrane of the latter, pulling this
through the opening made, introducing some transverse sutures
through the vaginal and urethral mucous membrane, cutting off the
redundant tissue over the sutures, and closing the latter.
The prolapsed portion may also be cut off in front of the meatus
with galvano- or thermo-cautery, but then steel bougies should be
introduced during and after the healing in order to avoid stenosis.
The cutting operations with sutures are the best.
CHAPTER XVIII.
MASTURBATION.
MASTURBATION consists in the production of venereal orgasm by
means of the hand, the tongue, or any kind of foreign body on one's
self or another person. It is also called onanism, but not correctly,
for a closer scrutiny of the ninth verse of the thirty-eighth chapter
of Genesis will show that Onan had sexual intercourse with Tamar,
but deprived her of his semen by spilling it outside of her body (au
act called withdrawal). It is not usual to treat of this subject in
works on gyuecology, but since the thing exists, since it appears in
innocent childhood, since it produces certain symptoms, since it may
be the cause of the most serious diseases, since the physician called as
expert in a suit for rape may be able to exonerate an innocent man
by knowing the effects of masturbation, it is, in my opinion, proper
to give some information about it here.
Masturbation may be indulged in by infants of either sex who
have no idea what they are doing. 1 They may either be taught the
vice by unscrupulous nurses in order to make them quiet, or they
may accidentally find out that certain movements produce a pleasur-
1 A. Jacobi, " On Masturbation and Hysteria in Young Children," Amer. Jour. Obst.,
vol. viii. No. 4, 1875, and vol. ix. No. 2, 1876.
298 DISEASES OF WOMEN.
able sensation. In older female children I do not believe the vice is
so common as among boys, but later in life it is probably much more
so in women than in men. This cannot be explained merely by the
greater facilities offered the male sex for normal satisfaction of the
sexual instinct without running the risk of having offspring. There
are several reasons for it, one of which is the less degree of orgasm
felt by women during normal sexual intercourse (p. 121). This, at
least, would seem to explain the fact that many married women are
given to this vice a thing that certainly is exceedingly rare in the
male sex.
The most common form of masturbation in women consists in
titillation of the clitoris, be this executed by the person's own hand
or that of another, or by the tongue of another human being or of a
dog, or by any other object. Less frequently the finger or other more
or less penis-shaped bodies, such as roots or needle-cases, are intro-
duced into the vagina.
1. Masturbation in Infancy. Masturbation in early childhood
being in many respects peculiar, we must consider its symptoms and
treatment separately. In some cases there may be local changes, such
as redness of the entrance of the vagina, moisture of the labia and
vagina from over-secretion of the glands of Bartholin and the smaller
muciparous glands of the vulva. But these cases are by no means
frequent. Of much greater importance are certain other changes
observable in the child, such as the occurrence of sudden redness in
the face, followed by paleness, twitching of the muscles about the
eyes, hurried breathing, and a deep sigh. These spells come on when
the child is sitting on the floor, often rocking to and fro or pressing
the fists into the iliac fossa? or against the genitals. These attacks
lead to anemia, bloatedness, and irritability of temper.
Treatment. First of all, infants and their nurses should be care-
fully watched. If there are pin-worms in the rectum, they should be
removed (p. 273). If the composition of the urine is abnormal, it
should be remedied by proper medicine, especially alkalies and ano-
dynes. The couch should be hard, the cover not warmer than what
is necessary to protect the child. It should not have too rich food :
large quantities of meat, eggs, spices, salt, and beer are injurious.
Drugs that irritate the uropoietic system, such as cantharides or nitrate
or chlorate of potash, should be avoided or handled with care.
During the act the child should be taken up, her thighs separated,
her hands removed from her abdomen, and her mind diverted. The
anemia and nervousness should be treated with strychnine, iron, and
arsenic.
2. Masturbation in Older Children and Adults. Symptoms.
The frequently repeated act of self-abuse or masturbation with another
person leaves certain local changes in the genitals which it is useful
DISEASES OF THE VULVA. 299
to know. It is true that uot one of them is pathognomonic, but the
presence of several of them must, to say the least, awaken suspicion
and may help to find out the truth. The clitoris is both thickened
and elongated. The glans is red and protrudes beyond the pre-
puce. The prepuce is lax, red, and thickened. The labia minora
are elongated, flaccid, wrinkled, of brown, gray, or slate-like color,
with black irregular spots due to the deposit of pigment in the
deep layer of the epidermis. This change in size and aspect is
often unilateral. On the inner surface of the labia minora is found
a series of minute white or yellow spots like insect eggs, formed by
hypertrophied glands. Sometimes the labia majora are likewise
enlarged, flaccid, and wrinkled. The hymen may be torn, but is
more commonly not so, but so lax that the finger enters without
meeting any resistance. The vaginal entrance and the rima pudendi
may be gaping. Often leucorrhea and other signs of vulvitis (p. 266)
are present. The vulvo-vaginal glands may be inflamed. The vulva
may show fresh scratches or old cicatrices, and the clitoris has been
found wounded and nearly bitten off conditions which may cause
hemorrhage or leave wounds slow to heal.
As to the general health, women seem to have a greater power of
resistance in regard to the effects of masturbation than men. There
are, indeed, women who are confirmed masturbators, and yet enjoy
excellent health, but, as a rule, they pay as well as the other sex for
their illicit pleasure by pain, ache, and ailment. The works of
specialists in this line must, however, be read with more criticism
than their authors usually show in writing them, nearly every known
disease, inclusive of pneumonia, that ever has been observed in a
woman addicted to masturbation having been put on the list of the
consequences of the habit. Certain diseases are, nevertheless, found
so often in masturbators, and the connection between them and the
vice is so easy to understand, that we do not hesitate in looking upon
them as cause and effect. We find inflammation of any part of the
genitals, periuterine hematocele, and pelvic peritonitis conditions
which all stand in a natural relation to the irritation and frequent
congestion of the genitals and pelvic organs.
The nervous system suffers more than any other, and in all its
functions : the hands are apt to tremble or the gait may become
unsteady ; the perception of all the senses loses more or less of its
acuteness ; the memory weakens ; interest in all intellectual matters
diminishes; wandering pains of neuralgic origin are quite common ;
hysteria, epilepsy, chorea, paralysis, and insanity may be developed,
but it may be hard to decide whether the masturbation was the cause
of the insanity or if the lurking insanity impelled to masturbation.
I have seen a peculiar nemesis in a young lady who was accustomed
to discount the pleasures of married life, and Avho, when she married
300 DISEASES OF WOMEN.
a strong young man, failed to feel the slightest satisfaction in the
normal relation between man and wife.
Nutrition suffers, as a rule, soon. The patient loses flesh, the face
becomes pale, dark rings appear under the eyes, the appetite is poor,
the digestion difficult, and the bowels constipated. It is said that
fresh cicatrices are liable to break up and ulcerate.
The neighboring organs are apt to suffer. Sometimes the sphincter
muscles of the urethra become paralyzed. Cystitis may be caused by
the irritation, and the inflammation may spread up to the kidneys.
Stone may form around foreign bodies used for masturbation which
are lost hold of and enter the bladder e. g. a hair pin. The sphinc-
ter of the anus may become relaxed and give rise to a prolapse of the
rectum.
Masturbation entails often sterility or abortion, and if children are
carried to term, they are apt to be puny, neurotic, and weak.
Treatment. The treatment must be moral as well as physical.
The physician must use every effort to impress upon the mind of the
patient the bad consequences of her vice. Any palpable cause of
irritation, such as pin-worms, accumulated smegma, bladder catarrh,
calculi, or hemorrhoids, must be removed. The food should be
bland ; alcoholic beverages and spicy dishes should be forbidden.
The body should be tired with manual work, gymnastics, or walking ;
the mind occupied by attractive subjects. Cold baths should be used
in the morning, but not in the evening on account of the following
reaction. The patient should lie on a hard mattress, lightly covered,
with the arms above the cover, and in a cool room. The nervous
system must be quieted with camphor, lupulin, the bromides of
ammonium, potassium, and sodium, or monobromide of camphor.
In the worst cases clitoridectomy is indicated, and has effected some
remarkable cures. It is a simple operation, but, as it has led to sep-
tic peritonitis and death, it ought to be performed with antiseptic
precautions. It is only the glans and body that are removed. This
may be done with a bistoury or curved scissors and sutures applied,
or one may use the thermo- or galvano-cautery. There is no reason
why this little bit of flesh should not be removed, and, as it certainly is
the most excitable part of the genitals, it is rational to do so in cases
of abnormal excitability irresistibly leading to masturbation, ruining
the health of the patient, depriving her of her mental faculties, or
driving her to suicide.
PART II.
DISEASES OF THE PERINEUM.
CHAPTER I.
INJURIES.
HERE we only have to deal with the anal part of the perineal re-
gion, the injuries to the vulva having been considered above (p. 265).
For convenience' sake we will, however, simply call it the perineum.
The perineum is exposed to injuries from without and from within.
I. Injuries from Without. Contusions and contused, punctured,
incised, or torn wounds, involving a more or less complete laceration
of the partition between the genitals and the rectum, are produced
by falling down on the upright of a chair, a slat of a fence, a pitch-
fork, or similar pointed object, or by sliding down the balusters of a
staircase against the boss of the newel-post. Similar lesions are some-
times caused by the horns of cattle or result from rape where there is
a marked disproportion in the size of the organs that come in contact.
Treatment. The treatment is the same as for injuries of the vulva.
II. Injuries from Within. These are especially caused by childbirth.
Lacerations of the perineum may be recent or old, complete or
incomplete, open or submucous.
A. Recent Lacerations of the Perineum. The recent laceration of
the perineum is a condition that is considered at length in treatises
on obstetrics. 1 Here we will only briefly allude to a few points which
are necessary in order to understand the old lacerations, or have
special surgical importance.
As we have seen in the description of the anatomy of these parts
(p. 43), the parturient canal is, near and at its end, limited by two
comparatively narrow openings, the vaginal entrance and the rirna
pudendi, the first of which is circular from the beginning, while the
second becomes so when distended by the child being pushed through
1 More detailed information on the subject may be found in my papers on " The
Obstetric Treatment of the Perineum," Amer. Jour. Obstet, April, 1880, vol. xiii.
p. 231, et seq. ; and on " So-called Lacerations of the Perineum," Med. yews, April,
1891, vol. Iviii. p. 454, et seq.
301
302 DISEASES OF WOMEN.
it. Of these rings the inner one is again the narrower. They are
the seats where laceration commonly begins during childbirth, and
from which it may extend more or less into the neighboring tissues.
The inner ring, the vaginal entrance, being the narrower of the two,
suffers more constantly. But a superficial tear here, even if it extend
far up into the vagina, is of little importance. A deep tear of this
ring, involving the levator ani muscle with its two fasciae (pp. 94-95),
is, on the contrary, a fruitful source of future suffering. The tear in
the levator ani muscle is usually found backward and outward in the
direction of the tuberosity of the ischium, probably because the mus-
cle gets caught between this point and the head, while in the median
line the rectum furnishes a soft pad between the vagina and the leva-
tor ani muscle. The tear is much more common on the right than on
the left side, which is probably due to the preponderance of the left
occipito-anterior position, the occiput escaping from the genital canal,
while the forehead is pressed against the posterior wall of the vagina.
The external ring, formed by the extended vulva, escapes often
any injury through childbirth, so that even the thin edge of the four-
chette is found entire in women who have borne children. It may,
however, suffer in different places. The most common is a tear in
the median line, beginning at the posterior commissure, from which
it may extend down to and into the anus and up to and through the
vaginal entrance. More rarely this perineal rupture begins in the
center of the perineum, and extends forward into the vulva, forming
a similar tear as if it had started from the fourchette ; and in the
rarest of all cases the tear in the perineum becomes sufficiently
large to admit of the passage of the child through it without impli-
cating the rima pudendi or the anus (centred laceratioii).
If the perineum escapes or suffers little, the injury often takes the
shape of superficial tears on the labia majora or deeper tears in the
labia minora and vestibule near the clitoris (p. 265).
Nearly all tears being due to circular expansion, the parts separate
laterally, and the rents have a longitudinal direction more or less
parallel to the axis of the parturient canal ; but if the severed halves
of the perineum do not unite by first intention, they heal separately,
each forming one-half of a cicatrice, in which way cicatrices with a
transverse direction are formed. This has given rise to the erroneous
conception that the fresh tear also had been transverse, which it
hardly ever is.
Sometimes nature can effect complete agglutination and coalescence
by first intention of any tear. I have myself seen this in incomplete
laceration where the whole periueal body was severed to the rectum,
and I have heard of the same lucky result in cases of complete lace-
ration, in which nothing was done except to tie the patient's knees
together. But such a process is of so extremely rare occurrence that
DISEASES OF THE PERINEUM. 303
it is foolhardiness to wait for it. In the great majority of cases the
natural healing is altogether insufficient. Au incomplete tear in the
median line will heal together a little by granulation at the bottom
of the angle; the remainder will only heal over and form a con-
tracted transverse scar. A complete tear will leave the anal ring
broken : the sphincter retracts, its ends being plainly marked by a
little pit of the size of a large pea on either side ; where the perineal
body should be is seen a V-shaped cleft ; the mucous membrane of
the rectum rolls out, forming a little red, soft, puckered cushion at
the posterior circumference of the anal opening ; and the patient has
no control over flatus and feces, which escape involuntarily and make
the poor woman an object of disgust to herself and others.
A tear involving the levator ani and the sinewy structures at the
vaginal entrance weakens the support of the pelvic structures above.
As soon as she gets up the patient complains of a disagreeable feeling
of looseness and bearing-down. In course of time the vaginal
mucous membrane bulges out in front and behind, the bladder sinks
down, the uterus is first retroverted, then retroflexed, then it descends,
and may finally hang between the legs. The strain on the utero-
sacral and broad ligaments causes pain and backache. The vagina is
inverted, and becomes unfit for one of its purposes. Exposed to
friction against the clothes, the vaginal portion of the uterus becomes
the seat of a deep ulceration.
Treatment. Fresh tears should be united immediately after the
termination of childbirth (primary operation).
Rupture of the Outer Ring. If the tear begins at the posterior
commissure and extends more or less far toward the
anus without implicating it (incomplete laceration), and FIG. 204.
is not much over half an inch high (up toward the
vagina), this may in most cases be done more easily
and speedily, and with much less pain, by means of
serrefines (Fig. 204) fine self-holding clamps working
on the principle of clothes-pins. These little instru-
ments are applied, from one to three in number, by
placing the patient on her left side, lifting the torn
perineum between the thumb and index-finger, and em-
bracing it with the legs of the serrefine. The first is
placed half an inch from the end of the tear, the fol-
lowing with half an inch interval, and the last at the
anterior end of the tear. Good serrefines should have so
little spring-force that the obstetrician can put them on the web
between his own thumb and index-finger without feeling pain, and
the legs must be half an inch long beyond the crossing. 1
1 Most serrefines on the market are of very inferior make, but Geo. Tiemann &
Co. keep some good ones under my name.
304 DISEASES OF WOMEN.
In fat women the perineum cannot be folded as described, and, there-
fore, the serrefines cannot be used, and recourse must be had to sutures.
Sutures should always be used where the vaginal entrance is torn.
If the tear extends up into the vagina, separate vaginal sutures should
be passed, beginning at the upper end and going down as far as the
perineal body. It may be done with catgut, by interrupted or con-
tinuous suture. For the perineal body silkworm gut is the best mate-
rial. As a rule, three sutures are needed on the perineum proper.
The patient is placed across the bed, with the buttocks drawn to
the edge; the knees are bent and held by assistants, the feet are
placed each on a chair ; and the operator sits on a third between the
two or kneels. The parts are irrigated with a disinfectant fluid, pref-
erably creolin ; a large cotton tampon with an attached thread is
pushed up into the vagina above the tear, in order to keep blood
away from the field of operation. Shreds that hang loose by a pedicle
are cut off. The left index-finger is introduced into the rectum,
while the assistants stretch the torn parts symmetrically from side
to side. A rather long curved needle is inserted on the left side, a
quarter to half an inch outside of the edge of the tear and at the same
distance from the posterior end of the tear, and carried underthe torn
surface over to the corresponding point on the other side. The sec-
ond suture is placed about half an inch farther forward, parallel to
the first, and is likewise entirely imbedded. It embraces often the
lower end of the mucous membrane above the tear. The third and
last is placed a little below the posterior commissure. It goes only
under the tear in the left labium majus; the needle emerges on the
line of demarkation between this torn surface and the mucous mem-
brane, is again entered on the corresponding point on the right
labium, and is pushed out on the corresponding point of the skin.
These three sutures correspond to sutures 2, 4, and 6 in Fig. 206.
Executed with proper antiseptic precautions, this operation is nearly
always successful.
Before closing the sutures the tampon is pulled out ; the parts are
again irrigated and dusted with iodoform. Sly perineal pad, or anti-
septic occlusion dressing, is applied. This consists of (1) a piece of
absorbent lint, 12 by 8 inches, folded twice lengthwise, so as to be-
come 3 inches wide, the average distance from one genito-femoral
sulcus to the other ; or a pledget of absorbent cotton of somewhat
larger dimensions, in order to allow for shrinkage ; (2) a piece of
gutta-percha tissue, 9 inches by 4 ; (3) a large pad of cotton batting ;
and (4) a piece of unbleached muslin J yard square. The lint or
absorbent cotton is wrung out of some antiseptic fluid and carefully
applied over the vulva and the anus. The gutta-percha is washed
with the same solution and placed over the first layer, turning the
edges forward against the thighs. The outer layer of cotton batting
DISEASES OF THE PERINEUM. 305
serves only to give bulk, and is pressed up against the genitals by the
muslin, which is folded like a cravat 5 inches wide and fastened to
an abdominal bandage, so-called belly-binder, in front and behind.
This dressing is changed three or four times in twenty-four hours, or
ofteuer if the patient has a movement from the bowels or passes her
urine in the mean time. Before a fresh dressing is put on the parts
are irrigated externally with antiseptic fluid, the patient lying on a
bed-pan. No vaginal injection is given ; indeed, the genitals are not
touched. 1 The knees are bound loosely together, so as to prevent
wide separation, but permit limited motion. This is obtained by
surrounding the knees with a wide ring of muslin, or two rings with
a connecting piece like eye-glasses, which are prevented from sliding
down by fastening them on either side to the abdominal binder by
means of a long narrow strip of muslin called a suspender. The
patient is allowed to urinate herself if she can, and the bowels are
kept open by means of a mild aperient.
If the tear extends into the anus and more or less far up the rec-
tum (complete laceration), the immediate operation is particularly
indicated. Even if only partial success should be obtained, and a
recto-vaginal fistula should remain, the general shape of the parts is
retained and a subsequent operation much facilitated. Under these
circumstances it is best to make a triangular suture, one row along
the rectum, one along the vagina and vulva, and the third along the
cutaneous surface of the perineum. The first two should be deeper, the
last more superficial, by doing which the formation of a recto-vaginal
fistula above the perineal body is best obviated. For the first two
rows catgut or fine silk is used ; for the last silkworm gut or silver
wire is preferable. Special care should be taken to unite the ends of
the sphincter ani muscle on the principle that will be described below
in speaking of Emmet's operation for the old rent.
If the parts are very edematous, the edges of the wound will gape
when the swelling subsides. In such cases it is advisable to wait
twenty-four hours or longer before operating, or, instead of tying the
suture, half a dozen perforated shot may be passed over the free ends,
and the last compressed so as to hold the suture in place. When,
then, the wound later is found to gape, the last shot is seized with a
pair of forceps and pulled upon, carrying the suture with it, until the
edges are again in contact, when the next shot is compressed and the
first cut off. 2 With this method it is better to use silver wire, the ends
of which may be turned out, so as to give a firmer hold on the shot.
Rupture of the Inner Ring. Since the rupture of the ring forming
the vaginal entrance has much more serious consequences than that
1 More details and an illustration are found in Garrigues' Antiseptic Midwifery, p.
27, and Amer. Syst. of ObsL, ii. p. 351.
3 J. H. Carstens, Detroit, Mich., Amer. Jour. ObsL, 1884, vol. xvii. p. 241.
20
306
DISEASES OF WOMEN.
of the outer ring, except when the latter implicates the sphincter
muscles of the rectum, medical science calls for its immediate treat-
ment ; but in most cases medical diplomacy and other considerations
will throw their weight into the other scale. These tears are mostly
produced by an unskilful conduct of labor, such as the administration
of oxytocics, manual expulsion of the child by pressure on the fundus,
a precipitate use of the forceps, or, at the very least, the omission of
means to ensure a slow dilatation of the vaginal entrance and the
vulva during the birth of the child ; and accoucheurs who will commit
such faults and midwives are not likely to examine for a tear that
is not visible on the skin, and, if they did, would hardly be compe-
tent to remedy the injury. It will also be hard for the general prac-
Recent Tears inside the Vagina and Suturing (H. Kelly) : A, vaginal sutures passed ; B,
sutures tied on left side; C, sutures tied on both sides aiid cutaneous crown-suture in
place ; D, all sutures tied.
titioner to persuade the patient and her friends to allow him to per-
form a protracted operation for a condition the importance of which
is doubtful to their minds. But if circumstances permit us to follow
the dictates of science, the injury should be remedied by passing a
row of deep sutures from above downward through the edges of the
lateral tear. The needle should be carried well downward in the
direction of the vaginal entrance and then up through the other lip,
lifting up the pelvic floor, as will be explained in describing Emmet's
operation for old tears. Catgut is the best material, since it need not
be removed. A single cutaneous suture disposes of what is not united
by the preceding sutures (Fig. 205). For the latter silkworm gut
or silver wire is preferable.
If the sphincter ani is torn, its ends should be brought together
DISEASES OF THE PERINEUM. 307
with two sutures one corresponding to the innermost, and the other
to the outermost, fibers, inserted in the way to be explained below in
describing Emmet's method for old tears.
Serrefines are removed on the fifth day, sutures in the incomplete
laceration 011 the eighth day. In the complete laceration the cutane-
ous are left in nine or ten days ; the rectal take care of themselves,
catgut being dissolved and silk being allowed to cut through ; the
vaginal, if silk has been used, are removed after three or four weeks,
when the perineum is strong enough to allow the use of a speculum.
The same applies to the deep laceration of the vaginal ring.
Intermediate Operation. If several days have passed since the
laceration took place and the surface has begun to granulate, it may
yet be made to grow together. It is for this purpose scraped with
the edge of a knife, dusted with iodoform, and united as described
above with serrefines or sutures. Union by first intention has in this
way been obtained in operations performed from one to three weeks
after delivery.
The subcutaneous tear of the levator ani muscle might be treated
in the same way as the open tear in the same locality, after making
an incision through the mucous membrane down to the torn ends of
the muscle. But, so far, nobody has undertaken this at the time
of delivery, so far as I know, and I think such a procedure would
meet with considerable opposition, not only in the public, but even
in the profession. This accident is therefore left until bad conse-
quences develop, and is then operated on according to the rules
presently to be laid down.
B. Old Lacerations. If the lacerated perineum has not been
united by the primary or intermediate perineorrhaphy, the so-called
secondary perineorrhaphy will in many cases become necessary. In
the mean time, the patient has not only suffered, but some of the
conditions enumerated above may have formed, and the shape of the
parts involved has been changed. Instead of broad surfaces corre-
sponding to one another, we have irregularly contracted cicatrices.
In some way or other new raw surfaces must, therefore, be produced,
and, as the cicatrices are much smaller than the original tear, it
becomes necessary to borrow from the surroundings and unite tissues
that do not belong to one another in the normal condition.
Of the very large number of operations invented for the repair of
old lacerations of the perineum, we will describe three only, one of
which, in my opinion, will give satisfaction in any case :
1. Tait's Flap-splitting Operation. 1 a. Incomplete Laceration.
1 Tait's priority has been contested, and I have myself seen Demarquay operate by
the flap-method in Paris in 1872, many years before anybody had heard of Tait's
operation of this kind, but there can be no doubt that the revival and simplification
of the operation are due to the great gynecologist of Birmingham.
308
DISEASES OF WOMEN.
The patient is placed on the table in the dorsal position, with knees
drawn up by Clover's crutch or Robb's leg-holder (p. 199). The
left index- and middle fingers are introduced into the rectum. One
blade of sharp-pointed scissors, bent on the edge, is pushed in in the
median line, midway between the anus and the posterior commissure,
to a depth of about f inch. It is next pushed over to the patient's
left side in a curved line ending at the anterior edge of the labium
majus, at a point situated at such a distance from the clitoris that
there is left just room enough for copulation. All these tissues are cut
through with one sweep of the scissors. These are now brought
back to the starting-point, turned with the points to the right, and a
similar incision is made on this side. The wound gapes, and is made
to gape wider by pulling the cut surfaces apart. If arteries spurt,
FIG. 206.
Tait's Perineal Flap-splitting Operation for Incomplete Laceration (MacPhatter).
they are caught with pressure-forceps and may be tied with catgut
(Fig. 206).
A handled needle, slightly curved near the end, is pushed through
the skin -fa inch outside of the wound, and about | inch behind
One difficulty in describing his operation arises from the fact that he has per-
formed it in different ways, and that those who have seen him operate have given
very different descriptions of it e. g. Macphatter (Amer. Jour. Obst., Nov., 1889, vol.
xxii. p. 1146) and Munde" (ibidem, July, 1889, p. 673). In the text I describe it as
I have performed it myself with good results.
DISEASES OF THE PERIS EUM.
309
the anterior end of the incision, 1 passes under the cut surface,
emerges on the boundary-line between the cut surface and the inner
portion of skin (vaginal flap), is carried over to the other labium,
reinserted at the corresponding point, pushed under the right cut
surface, and out through the skin y 1 ^ inch outside of the wound. A
piece of silkworm gut 10 inches long is drawn through the eye of
the needle ; the latter is pulled back and freed from the suture,
the two ends of which are held together with a pressure- forceps,
and thrown up on the abdomen. Another suture is introduced in a
similar way J inch farther back. One of the sutures ought to catch
the end of the vaginal flap. One, two, or three more, according to
the size of the wound, are introduced under the whole cut surface
behind the vaginal flap. In tightening the sutures care is taken to
adapt the cut surfaces against one another. The outer flaps of each
\ on the two sides are turned outward, and the inner turned inward,
and when the sutures are tightened they are in this way approximated
FIG. 207.
Tail's Perineal Flap-splitting Operation for Complete Laceration (MacPhatter) : 1 to 1, first
transverse incision ; 1 to 2, incisions forming vaginal flap ; 3 to 4, incisions forming rectal
nap.
as plane surfaces, and so they unite. If there is much redundant
tissue to dispose of, the vaginal flap is turned forward and a special
1 Tait teaches to insert the needle well within the margin of the wound ( Diteaxe*
of Women, i. p. 67 ), but in my hands the sutures cut through if placed in that way,
and the skin is not accurately brought together.
310
DISEASES OF WOMEN.
suture passed through its whole width. Between each two of the
deep sutures a superficial catgut suture is put through the skin alone.
6. Complete Laceration (Fig. 207). The cicatrix in the recto-
vaginal septum being put on the stretch by separating the buttocks,
the scissors are run from one end of it to the other (Fig. 208, A\
making an incision about f inch deep, by which are formed a vaginal
and a rectal flap. From each end of this first incision another is
FIG. 208.
A
Diagrams illustrating Incisions and Sutures in Tait's Operation for Complete Laceration of
the Perineum : A, first incision following the cicatricial line between rectum and vagina,
the buttocks being stretched (natural size) ; B, incisions to anterior edge of labium majus
and outside of anus (without tension) ; C, naps thrown up and down and put on the stretch ;
sutures inserted in the order marked : the third corresponds to the angle between the flaps
(the bottom of the first incision); the first goes right through the ends of the broken sphinc-
ter ; D, continuous catgut suture carried through the edges of the wound, now turned into
the vagina (the same as the upper edge of the first incision, B, a b).
carried at an obtuse angle, forward and outward, into each labium
majus for about an inch (Fig. 208, B, a d and 6 c), and, again start-
ing from the ends of the first, a fourth and fifth, one-third of an inch
in length, are made backward and outward (Fig. 208, J5, a f and
6 e) just outside of the ends of the torn sphincter.
The vaginal flap is held upward, the angles dab and c b a being
pulled by forceps diagonally upward and inward toward the median
line. The rectal flap is held downward, the angles fab and e b a
being pulled in a similar manner downward and inward. Thus the
DISEASES OF THE PERIXEUM. 311
lines d f and c e become curved with convexity turned outward
(Fio-. 208, C, aa and 66). The needle is carried as described above,
with this difference, that it is made to emerge about ^ inch from
the bottom of the wound and enter at the corresponding point
on the opposite side (except the hindmost closing the sphincter,
which is buried altogether). The sutures are inserted, beginning
at the anus and going forward. Finally, the middle of the raw
edge a b, now situated in the new-formed vagina, is seized with a
tenaculum, and the wound closed with a continuous suture of fine
catgut (Fig. 208, D).
If there has been much loss of tissue by previous denuding opera-
tions, deep relaxing incisions should be made parallel to the ramus
of the ischium on both sides. The sutures are left in for three or
four weeks, the bowels being kept loose. The ends of the sutures
should be left rather long (J inch), as they become deeply imbedded
and are hard to find.
Tait's operation is by far the most expeditious perineorrhaphy, and
results in the formation of a thick and broad beam between the anus
and the vulva. For the complete tear it is, in my experience, superior
to all others. It is easy to perform, takes a short time, and yields
perfect results.
2. a. Incomplete Laceration. Hegar-Garrigues 1 Colpoperineor-
rhaphy. 1 The patient is in the dorsal posture, as in the preceding
operation. The object is to remove the whole vaginal wall and the
mucous membrane of the vulva over a triangular surface on the pos-
terior part of the vagina and vulva, bring the two halves together
from side to side, and at the same time lift the posterior wall of the
vagina up against the anterior.
According to the amount of tear and relaxation of the vaginal
entrance and the perineum, a point (Fig. 209, A, a] is chosen in the
median line more or less high up toward the cervical portion. This is
pulled forward and upward with a pair of bullet-forceps with catch or a
tenaculum-forceps. A small nick is made on the inside of each labium
majus near the edge at such a distance from the clitoris that there will
be left proper space for copulation (6 and c). The triangle formed
between these three points is put on the stretch, and another pair
of bullet-forceps introduced where the side line of the triangle
intersects the furrow on either side of the vagina (d and e\ With a
blunt-pointed pair of scissors, bent on the flat, and with the concave
side turned toward the operator, a small incision is made through
the vaginal wall just inside of the forceps on the patient's left
side, and the scissors pushed up under the wall to the forceps
at the upper end of the triangle, and then swept down to the third
1 I describe this operation with such modifications as have proved of practical
value in my own hands.
312 DISEASES OF WOMEN.
forceps on the right side, all of which is doue with the greatest facil-
ity and without great loss of blood. Next, this upper part of the tri-
angle is cut loose on the two lateral sides (e a and a d). The scissors
are then introduced at c, the nick made on the left labium, and pushed
up to e and down to the line of demarkation between the mucous
membrane and the skin and over toward the other side. Finally,
they are introduced at 6, the nick made on the right labium, and used
in a similar way until the lower part of the triangle is denuded. The
more we approach the base (6 c) the more the mucous membrane
adheres, and it may be bound to the underlying parts by cicatricial
tissue, which may require small uicks with the scissors. Finally,
the flap is cut off along the lines e c, c b, and 6 d.
Sutures are put in from above downward at a distance of a quarter
of an inch from one another, deep ones alternating with superficial
ones, which latter go through the edges of the mucous membrane
only. Near the upper end the deep are buried all the way under
the raw surface. When the surface becomes broader, the needle is
brought out a quarter of an inch from the median line and reinserted
at the corresponding point on the other side. The following sutures
(Fig. 198, A, 5, 7, 9) are not carried horizontally across, but made to
dip toward the base of the triangle, so that when tightened they will
raise the posterior wall forward and upward. Thus one suture is
inserted and tied after the other until the lines / c and / b (Fig. 198,
B) have the same length as g c and g b. Then a silkworm suture
(10) is carried deep under the wound from a point about half an inch
from the median line (g) and f inch from the edge of the denuded sur-
face up under the wound, about two-thirds of the distance from the end
of the closed line (/), and down to the corresponding point on the other
side. A second suture (1 1 ) is inserted midway between the ti rst and the
point c, brought out on the edge of the denuded surface at //, reinserted
on the other side at i, and brought out on the skin. Finally, the last
suture (12) is inserted near the outer end of the wound (c), brought
out at k midway between h and c, reinserted at i, the corresponding
point on the other side, and brought out on the skin below 6. These
three sutures are not tightened until all are put in and the surface
well irrigated. The direction given to the sutures ensures, a very
perfect adaptation of the edges, and makes the surfaces that come in
contact sufficiently broad to form an excellent substitute for the
original perineal body.
1 use catgut, medium-sized for the deep, and fine for the superficial
vaginal sutures, and silkworm gut for the perineum. Each vaginal
suture is tied and cut as soon as it is inserted. Large curved Hage-
dorn's needles can be used in most cases. Finally, in order to ensure
perfect adaptation of the edges, a couple of superficial silk sutures are
introduced on the perineum, between the deep sutures (Fig. 209 C).
DISEASES OF THE PERINEUM.
FIG. 209.
"->.
o
/^
A
313
A, Hegar-Garrigues' Colpoperineorrhaphy : sutures 5, 7, and 9 slant downward toward tin-
entrance, and are brought out about a quarter of an inch from the median line; B, the
triangle shown in A having been closed, the perineal sutures are inserted 10, all buried :
11 and 12, partly free all in a slanting direction ; C, perineal sutures tied.
314 DISEASES OF WOMEN.
I remove the middle perineal suture on the fifth day, the others on
the eighth.
Buried Catgut Sutures. Some prefer to close the whole wound
with buried catgut sutures, either interrupted or continuous. The
latter is begun at the upper end of the triangle, and the first circle
closed with a knot, leaving the end three inches long. This end is
seized with a pair of forceps and pulled upward by an assistant,
which facilitates the introduction of the remaining sutures very much.
The needle is introduced through the edges of the mucous membrane
and under the raw surface until the tension becomes too great, when
the suture is continued in the depth of the wound down to the
vaginal entrance. From this it is carried upward, forming a second
row of buried spirals, after which it is brought down between the
edges of the mucous membrane, and finally down the perineum. It
is tied as stated in describing tier-sutures (p. 221).
b. Complete Laceration. Hegar's Operation. 1 The patient is in
the dorsal position. The buttocks are pulled aside and the anterior
vaginal wall lifted up with Siras's speculum. A sponge soaked in an-
tiseptic fluid, or a pad of iodoform gauze, may be introduced into the
rectum, and withdrawn before the last rectal sutures are introduced.
A tenaculum-forceps is introduced at x (Fig. 210) in the median
FIG. 210.
c d
Hegar's Operation for Complete Laceration of the Perineum.
line of the posterior vaginal wall, three-quarters of an inch above e,
which is the upper point of the tear in the recto-vaginal partition.
Two other pairs of tenaculum-forceps are introduced at a and 6 on
the lower edge of the labia majora, at the distance from the clitoris
where we want the posterior commissure to be, slightly above the
anterior end of the cicatrice marking the situation of the old perineal
body. These three points are now put on the stretch, and, beginning
1 For simplicity's sake I leave this operation under Hegar's name, but it has
evolved gradually in the hands of Dieffenbach, Simon, and others.
DISEASES OF THE PERINEUM. 315
at x, the operator draws, with the point of a scalpel, a curved line to
6, with the convexity turned toward himself. Next he continues the
line from 6 to <7, with a slightly convex curve outward, down to a
point just outside and behind the pit marking the torn sphincter.
Next, an exact counterpart of this line is drawn on the right side.
Finally, the pit is seized with a tenaculum and cut off with blunt
scissors curved on the flat, and the strip continued along the whole
edge of the rent in the rectum over to the corresponding point on
the other side, so as to remove all the cicatricial tissue. The mucous
membrane is seized in the middle of the incision, at e, with a toothed
forceps, and the scissors pushed up under it to the limits of the sur-
face circumscribed with the scalpel. Where it meets with resistance
small nicks are made through the resisting tissue. Finally, the flap
thus formed is cut off with the scissors.
It is rarely necessary to use hemostatic forceps on bleeding vessels.
If so, the tissue grasped between the jaws of the forceps should be
cut away before closing the wound, in order to avoid having any
dead tissue in its depth. Fine silk (braided No. 2) is best for the
rectal sutures, silkworm gut for the vaginal and perineal. Only
round needles, straight and curved, two inches long, should be used.
Cutting needles make large holes in the soft tissues to be united,
which seriously interfere with success.
The first suture is put in a little below x, and followed by several
others parallel to it running from side to side under the whole raw
surface, x m n. In order to avoid penetrating into the rectum the
movements of the needle are guided with the finger in the intestine.
Next, some rectal sutures are inserted. The needle is introduced
on the rectal surface -fg inch below the top of the rent, and at the
same distance from the edge, and carried under the raw surface above
the rent, pushed out in the median line, reintroduced with the point
turned down in the same place, carried under the raw surface on the
right side, and out on the rectal surface at a point corresponding to
that of entrance. The following rectal sutures are merely pushed in
a slanting line from the rectum to the raw surface outside it on the
left side, introduced in the corresponding place on the right side, and
carried down through the rectal wall. Thus raw surfaces are brought
in contact and the edges turned into the rectum. The last two sutures
are made to embrace the ends of the broken sphincter. The rectal
sutures are quite close to one another, about -^ inch apart, superficial
alternating with deep. Next, the lines m a and n b are brought
together with sutures ^ inch apart, alternately a deep, reaching half-
way under the raw surface, and a superficial. Finally, four or five
are placed rather superficially on the perineum. Every suture is tied
and cut immediately when inserted, the ends being turned up out of
the way of the following suture.
316
DISEASES OF WOMEN.
If the tear is over 1 J inches long, the upper half of it is stitched
from the vagina alone, the septum being too thin for a vaginal and
a rectal row of sutures. The lower half is treated as described above.
Silk threads entering the rectum become easily conductors of septic
material, and small abscesses form, which often result in a small recto-
vaginal fistula. This may be obviated by using buried submucous
catgut sutures (Fig. 21.1). These sutures are introduced from the
raw surface a quarter of an inch from the edge to be united, and
pushed out on the same surface quite near the edge, inserted on the
corresponding point near the opposite edge, and pushed out a quarter
of an inch from the edge on the raw surface. The vaginal sutures
Submucous Sutures (Lauenstein) : r, rectum ; v, vagina.
are put in in the same way, and finally the perineum is closed with
silver-wire or silkworm-gut sutures. 1
For incomplete laceration in cases where the inner ring has suffered
much, my modification of Hegar's operation is in my opinion the best.
It interposes between the vulvo-vaginal canal and the rectum a strong
wedge reaching up as far as the operator wishes, and this body is sus-
pended from above, being attached to the bones of the pelvis.
In cases of complete laceration, on the other hand, one is very apt
to get a small recto-vaginal fistula by Hegar's method.
3. T. A. Emmet's Operation. a. Incomplete Laceration. 2 The
aim of this operation is to lift up the pelvic floor and dispose of a
so-called rectocele.
The patient is in the dorsal position, with bent knees and with
feet held up by two assistants.
First Step. The top of the rectocele (Fig. 212, A, a) is caught with
a tenaculum and held by an assistant over to the left side of the vulva.
1 Carl Lauenstein, CentralblaU f. Gynak., 1886, vol. x. p. 50.
* This is Dr. Emmet's new operation. His old was like that for complete lacera-
tion with the exception of what has reference to the tear in the septum.
DISEASES OF THE PERINEUM. 317
Another tenaculum is inserted at the caruncula myrtiforrnis on the
FIG. 212.
Diagram of T. A. Emmet's Operation for Incomplete Laceration of the Perineum.
FIG. 213.
\
right side (6). A third tenaculum is inserted at the posterior com-
missure (c). Finally, a fourth tenaculum
is inserted at d ; that is, a point so far up
*in the side sulcus of the vagina that it
does not yield on being pulled down. The
four tenacula being pulled in divergent
directions, a rhomboidal part of the mu-
cous membrane of the vagina is put mod-
erately on the stretch, and the isosceles
triangle, a d 6, denuded with two snips of
curved, rather sharp-pointed scissors from
below upward. Next, silver sutures are
put in, forming curves, or rather angles,
the top of which points down toward the
vulva, the operator guiding himself by in-
troducing a finger into the patient's rectum
(Fig. 213). While they are being passed
the assistant always lifts the last, in order to check hemorrhage.
Second Step (Fig. 212, B). The top of the rectocele is carried
Emmet's Suture for lifting the
Pelvic Floor: The needle is in-
troduced at a, pushed out at b.
and when it has been pulled
through, it is reinserted at b
and carried to c.
318
DISEASES OF WOMEN.
over to the right side, and the triangle, a f e, on the left side treated
in the same way as the right.
Third Step (Fig. 212, C). The patient's feet being lowered to the
top of the table, the surface, a b e g that is, all the mucous mem-
brane between the top of the rectocele, the two carunculse myrtiformes
on the side of the vaginal entrance, and a curved line running a quar-
ter of an inch inside of the posterior circumference of the rima pudeudi
and parallel with it is denuded, and sutures are put in from side to
side. One is carried through the two caruuculae, 6 and e, and behind
the tip of the tongue of mucous membrane left between the denuded
surfaces, a. Three or four more are put in from side to side, as seen
in the figure, all entering on the mucous membrane inside of the skin.
Fourth Step. The sutures are twisted, beginning from the tops of
the triangles, d and /, and ending at g, cut oif, and bent backward
into the vagina. When all are closed they form a Y, and are all in
the vagina and the vulva, while the skin is not touched at all.
This operation reduces the parts to a condition very much like in
appearance the normal one, but it requires more time, more skill, and
better assistance than the other operations.
Outerbridge 1 has simplified Emmet's operation by using only three
sutures. The first is medium-sized catgut, 10 to 12 inches long, armed
FIG. 214.
Outerbridge's Suture. The sutures are numbered in the order in which they are tied, not
inserted.
with a straight cervix-needle at each end. It is passed from the end
of the central undenuded tongue to the upper end of the lateral denu-
1 Outerbridge, Med. Record, April 21, 1894, vol. xlv. p. 493.
DISEASES OF THE PERINEUM.
319
dation on both sides. It is not tied, but the needles are thrown up
over the symphysis. Next, the second suture, which is of silver wire,
is passed from the highest point of the denudation on the labium
majus, under the whole wound, across to the corresponding point on
the other side. Then the first suture is tied, and from this now cen-
tral point one of the needles is passed under the denuded surface and
brought out on the inside of the labium, half an inch above the
lowest point of denudation. The other needle is passed in the same
way to the corresponding point on the other labium. Now this lower
suture is drawn tight and tied. Finally, the silver suture is twisted.
The bowels are moved on the third day, and the silver suture removed
on the eighth (Fig. 214).
Cleveland's Suture. Cleveland T has recommended the use of cat-
gut and passing the suture in the shape of the figure 8. The first
FIG. 215.
Cleveland's Suture.
suture (A, Fig. 215) is passed in at 1, midway between the posterior
commissure (D) and the upper end of the denudation on the left
labium, a quarter of an inch outside of the edge, is carried well back
1 Clement Cleveland, Medical Record, Feb. 14, 1891, vol. xxxix. p. 193.
320 DISEASES OF WOMEN.
deep under the tissues so as to embrace the retracted muscles, across
between the denuded surface and the rectum, to the center of the
denuded surface, then down and out a quarter of an inch from the
edge, at 2, situated on the right labium, midway between the point
corresponding to 1 and the posterior commissure (Z)). It is then
entered at 3, the point on the left labium corresponding to 2, brought
under the denuded surface to its center, and then out at 4, which
corresponds to 1.
The second suture (B) is passed in a similar way. It is entered at
l,a point just below the summit of the denudation on the left labium,
and passed, buried close to the denuded edge, around the angle in the
left sulcus to the highest point of denuded surface on the columna
(C), and thence, still buried, across to 2, situated midway between
the upper end of the denudation on the right labium and 4, where
the first suture came out. Here it is brought out, a quarter of an
inch from the edge, re-entered at 3, the corresponding point on the
left labium, carried to C, then close to the edge of the denuded sur-
face at the right lateral sulcus, and out at 4, which corresponds to the
first point of entrance, B 1. As a protection a third suture (E) is
usually introduced just above the upper end of the denuded surface
on the left labium, carried through the labium, and out on the
mucous membrane ; then it takes up about a third of an inch of
mucous membrane on the columna at C, and finally passes through
the right labium. This protection suture should be of silver wire
or silkworm gut. It becomes unnecessary if one of these materials
has been used for the two other sutures.
The sutures are closed from behind forward in the order they have
been put in.
In extreme cases of extension of the laceration into one or both
sulci, the Emmet sutures may be used to close the angles, or the
Cleveland suture may be applied separately to each angle before the
two perineal sutures are inserted.
6. Complete Laceration. Special care is taken to get the entire
FIG. 216.
Diagram of Broken Sphincter Ani Muscles (T. A. Emmet): D C, first suture; B A, second
suture.
ends of the broken sphincter brought together. The above-men-
DISEASES OF THE PERINEUM.
321
FIG. 217.
tioned pits marking these ends are seized with a tenaculum and
removed, together with a strip of mucous membrane on the posterior
vaginal wall and the internal surface of the labia majora, as in
Hegar's operation. The first suture (Dr. Emmet uses always silver
wire) is inserted a quarter of an inch behind and inside the end of
the broken and retracted sphincter muscle, which now forms a convex
surface (Fig. 216), and carried under the denuded surface parallel to
the rent in the recto-vaginal septum, so as to unite the innermost
fibers of the sphincter (Fig. 217, C, D\ The second suture (A, B)
is inserted at the outer end of the broken
sphincter and carried around the rent in
the septum, parallel to the first. These
two sutures when closed bring the two
ends of the broken ring together, and
unite it at the same time with the lower
end of the septum. Next, a couple of
sutures (Fig. 218, 3 and 4) are brought
from the perineum under the whole de-
nuded surface over to the other side, the
uppermost comprising the end of the un-
denuded part of the vagina. The last but
one (5) goes through the labium majus,
emerges near the side sulcus of the vagina just on the line of
demarkation between the pared and unpared surface, enters the
FIG. 218.
Dia
agram of Broken Sphincter Ani
(T. A. Emmet), showing how the
ends are brought together by
tightening the sutures.
: R, rectum ; J , vagina ;
v x
Diagram for Emmet's Operation for Complete Laceration of Perineum : R, rectum ; \
P, perineum. The figures mark the order in which the sutures are inserted
corresponding point on the other side, and emerges on the skin
opposite the point of entrance. The last (6) unites the tops of the
denuded surfaces on the labia majora.
322 DISEASES OF WOMEN.
If the rent in the recto-vaginal septum is over one inch long, it
should be diminished by denuding the vaginal surface near the edges,
down to the sphincter, and introducing sutures from side to side.
When these have been removed after about nine days, and the
denuded surfaces have grown together, the above-described operation
for the closure of the sphincter and perineum is performed.
Outerbridge uses his above-described three sutures after having
overstretched the sphincter and united the edges of the gut either
with continuous or interrupted catgut sutures, taking care to insert
one suture through the ends of the broken sphincter.
Preparation and After-treatment. In regard to preparations for
any of these operations for lacerated perineum, the reader is referred
to what has been said in the chapter on Treatment in General (p. 196).
The bowels are emptied and the labia are shaved, but the hairs on
the mons Veneris need not be interfered with. The knees are kept
tied together for two weeks. The diet during the first few days,
until the bowels have been moved, should be exclusively albuminoid
(milk, beef extracts, raw oysters, and eggs), so as to have as little
fecal matter as possible.
As a rule, some pain will call for small doses of morphine (gr. ^) ;
otherwise opiates should be avoided, as they render the feces hard.
The patient may lie on her back or her side, but should move slowly
and with the assistance of her nurse.
On the morning of the fourth day Ol. ric. fl.^iij is given. When
the patient feels that evacuation is near, four ounces of olive oil
should be injected into the rectum. In this way an easy, loose move-
ment or two are brought on. Thereafter every morning just enough
castor oil (about 3ij) is given to have one easy movement. The urine
should be drawn with a catheter. When, after a few days, there
appears some discharge, a vaginal injection of carbolized water (sss
to Oij) should be given morning and evening, and, in complete lace-
ration, half a pint of lukewarm water injected at the same time into
the rectum. If the patient is troubled with flatus, much relief is
afforded by the occasional cautious introduction of a well-greased
soft-rubber rectal tube of the size of the little finger.
As a rule, perineal sutures must be removed at the end of a week
(compare Tait's method) ; vaginal, which are difficult to reach with-
out risking the destruction of the union in the perineum, are left in
for three to four weeks, or more if necessary ; rectal are left to them-
selves. In removing vaginal sutures a virginal Sims speculum and
Hunter's depressor (p. 147) will be found very useful. The ends of
each suture are seized separately with the suture-twister and lifted a
little. Great care should be taken to insert one of the points of a
pair of pointed scissors into the loop, and cut close up to the entrance
of the stitch-canal. The sutures should be removed from below
DISEASES OF THE PERINEUM. 323
upward, and when the rent begins to bleed the removal of the others
should be postponed.
The patient may leave the bed after two or three weeks. Coition
should not take place for two months.
CHAPTER II.
GARRULITY OF THE VULVA.
UNDER the queer name "garrulity of the vulva" has been de-
scribed a condition which is characterized by the entrance of air into
the vagina and its expulsion with a noise from the same. Another
name for the same phenomenon is flatus vaginalis.
Etiology. It is a rare disease. It is only possible when the vulva
and vaginal entrance gape. It may be due to tears of the perineum
and vaginal entrance, episiotomy, loss of flesh, and varicose veins of
the vulva.
Treatment. The indication is to diminish the entrance to the geni-
tal canal by the performance of one of the operations described above
for laceration of the perineum, or by excision of cicatrices and union
by suture.
CHAPTER III.
COCCYGODYNIA.
UNDER the name of " coccygodynia " are united different and par-
tially unknown pathological conditions, the common feature of which
is intense pain at the coccyx, whence it may radiate into the peri-
neum, the hips, the uterus, and the bladder.
Pathological Anatomy. Sometimes there are palpable diseases or
deformities of the coccyx, such as caries, fracture, aukylosis, too great
a length, luxation, or other displacement. In other cases the condi-
tion is combined with diseases of the uterus, ovaries, or rectum. In
a third class it is of a purely neuralgic nature. It is not unlikely
that the coccygeal " gland " (p. 103), with its exceedingly rich nerve-
supply, has something to do with it. Still, this gland is found in
both sexes and at all ages, while the disease is never found in man,
and is exceedingly rare in childhood.
Etiology. The disease is only found in women, especially adults
who have borne children, but occurs also in virgins, and very rarely in
children. By far the most common cause is childbirth. As a rule,
it appears after tedious labor with long-sustained pressure, tears, or
324 DISEASES OF WOMEN.
straining of muscles or ligaments, or after instrumental delivery ;
but it may also begin before delivery, and is then probably due to
the pressure of the head against the last two sacral and the coccygeal
nerves. The disease is sometimes due to violence from without, such
as a kick, a fall, or horseback riding, or to exposure to cold, especially
in individuals suffering from rheumatism. Sometimes it seems to be
a reflex neurosis due to muscular contraction of the sphincter ani, the
levator ani, or the bulbo-cavernosus muscles, such as is found in con-
sequence of painful caruncle or hemorrhoids.
Sympto'tns. Severe pain is felt in sitting, especially in sitting down
or getting up ; nay, the tenderness may be so great that the patient
can only sit on one-half of the nates, near the edge of a chair, using
her hands to get up and down. All movements of the coccyx and
the ligaments and muscles attached to it, induced by walking, riding,
defecation, coition, etc., increase the pain enormously.
Diagnosis. The condition is easily recognized by placing the pa-
tient on her left side and introducing the index-finger into the rectum,
while the thumb rests on the skin over the coccyx. The slightest
movement of the bone causes severe pain, and sometimes it may be
possible to feel a diseased condition of the bone or the surrounding
parts.
Treatment. The general treatment consists in tonics or antirheu-
matics. Suppositories with five grains of iodoform or one-third of
a grain of morphine ; hypodermic injection of cocaine or morphine ;
inunction with ointments of veratrine or aconitine ; blisters ; cauteri-
zation; and galvanism or faradization with the secondary current
with high tension (p. 230) ; besides treatment of concomitant diseases
in neighboring organs, have each effected cures. But cases that
have resisted all other remedies have yet been cured by the extir-
pation of the coccyx, whether diseased or healthy. This operation,,
which may be called coccygectomy, is performed by placing the patient
on the right side or on the abdomen, introducing the index finger of
the left hand into her rectum, pressing it outward, and making an in-
cision in the median line, about four inches long, and reaching from
half an inch below the tip to one and a half inches above the base,
down to the bone. The soft tissues are pushed aside with a blunt in-
strument and a few touches of the knife, until the whole bone, inclusive
of the projecting transverse processes of the uppermost vertebra, is laid
bare. The attachments of the bone throughout its whole length are
freely separated on each side, and the knife passed through the articu-
lation with the sacrum and the lateral ligaments. The left hand is
now disengaged, and, armed with Fergusson's bulldog-forceps, used to
seize the bone, which is pulled firmly outward, while some flat, blunt
instrument like Hay's director is passed behind it and severs all re-
maining connections, except the tendon of the levator ani muscle.
DISEASES OF THE PERINEUM. 325
which has to be cut with a knife. In exceptional cases it may be-
come necessary to sever the bone with a cutting bone-forceps or a small
saw. As a rule, there is not much hemorrhage, and the wound may
be united by deep interrupted sutures (preferably silkworm gut). If
there is much hemorrhage, it may be necessary to pack the wound
with styptic cotton and let it heal by granulation.
The coccyx in women is flat and shorter than in man, about two
inches long, and forms a nearly equilateral triangle. When it is re-
moved, we look into a deep hollow, at the bottom of which is seen
the levator ani muscle, covered by the anal fascia (p. 95). The deep
sutures ought to embrace all the edge, inclusive of the severed lesser
sacro-sciatic ligament, but not the levator ani muscle.
After the operation the patient is pulled down over the end of the
table ; the wound is dusted with iodoform, covered with iodoform
gauze and cotton, and a double spica is applied, inserting a piece of
gutta-percha tissue so as to leave the anus and vulva free and keep
the dressing clean. The sutures are removed after a week.
CHAPTER IV.
HYGROMA.
UNDER the redundant name of " perineal cystic hygroma " has
been described a cystic tumor formed by an accumulation of fluid in
the cavities of the coccygeal gland. It forms a round, elastic, immov-
able tumor, situate between the anus and the tip of the coccyx, and
covered with normal skin. It may attain the size of a fetal head at
term, annoy the patient by its size and weight, cause dyspareunia,
and present a serious obstacle in the way of childbirth. Like simi-
lar tumors in other localities, it may become inflamed and form an
abscess.
Treatment. If it resists the resolvent action of painting with tinc-
ture of iodine, it may be emptied through a hydrocele trocar and
injected with the same. Part of the skin and subcutaneous tissue
covering it may be cut oif, the cavity packed with iodoform gauze, and
left to fill by granulation. The whole tumor has also been successfully
extirpated. If suppuration has occurred, the cyst should be freely
laid open from end to end with a bistouiy, washed out with disinfect-
ants, and filled with iodoform gauze.
PART III.
DISEASES OF THE VAGINA.
CHAPTER I.
MALFOEMATIONS. 1
A. Malformations of the Hymen.
1. It is doubtful if the hymen is ever absent.
2. Atresia hymenalis is the condition in which the hymen forms an
imperforate diaphragm. It is probably due to an excess of growth
of the hymen. Like a transverse septum situated higher up in the
vagina, it prevents mucus, cast-off epithelial cells, and menstrual
blood from flowing out, and causes, therefore, an accumulation of
blood or mucus above it. Such an accumulation of blood in the
vagina is called hematocolpos ; in the uterus, hematometra. If the
blood is changed to pus, the conditions are respectively called pyocol-
pos and pyometra. As a rule, the blood forms a thick, dark brown,
tarry mass.
Even in young children the closure of the hymen may give rise to
a retention of mucus, forming a tumor which bulges out between the
labia and obstructs micturition and defecation. But much more
commonly it is at the time of puberty that the accumulation of men-
strual blood causes pain, increasing at each menstrual period, and
the formation of a tumor gradually growing in size from below up-
ward. First the vagina is distended, then the cervix, the two form-
ing one globular mass, on the top of which is felt the undilated body
of the uterus, until, finally, this also takes part in the dilatation.
The tubes form sometimes large tumors filled with blood (hematosal-
pinx), which not always communicate with the uterus, the blood not
being pressed up from the uterus, but coming from the mucous mem-
brane of the tubes themselves. Diverticula may bulge out from them.
They may be divided into a series of three or four compartnients by
internal lamella? growing from the wall or by bands of peri ton itic
1 I have treated this subject somewhat more extensively in American System of
Gynecology, vol. i. pp. 257-278.
326
DISEASES OF THE VAGINA. 327
origin, forming constricting rings without, and they may be bound
to the wall of the pelvis by strong adhesions.
The tumor formed by the vagina and uterus may nearly fill the
pelvic cavity and press on the rectum and the bladder, causing
dysuria and dyschezia. The hymen becomes thick and fleshy, as
do the walls of the vagina, especially the muscular coat, above any
transverse septum wherever located. It may form a tumor in the
perineum as large as the fetal head, which flattens out the frenulum
and is continuous with the skin on the distended perineum and
labia of the vulva. In front is found the meatus urinarius. This
tumor is fluctuating.
Strangely enough, irnperforate hymen may be found combined with
pregnancy, which can only be explained by supposing that there has
been a minute opening, admitting spermatozoids, which has closed
after menstrual discharge had stopped.
Diagnosis. The bulging of the perineal region is pathognomonic.
Often an occlusion is found at the lower end of the vagina, just above
the hymen, but this does not form a tumor in the perineum, and on
close inspection the hymen with its opening will be found below and
in contact with the occluding membrane.
Prognosis. In itself, the condition leads to rupture of the vagina,
uterus, or tubes, and even operative interference is fraught with
danger.
Treatment. Spontaneous rupture through the hymen being very
rare, and rupture of the tube being much more likely to occur, an
outlet must without delay be given to the accumulated fluid. The
operation consists in making a crucial incision through the closed
hymen or in cutting it off along its insertion. This may simply be
done with knife or scissors. If the membrane is removed, it is well
to stitch the edges of the wound together. Some prefer the thermo-
cautery or galvano-cautery for slitting open the diaphragm, in order
to protect the wound against infection. No pressure should be exor-
cised on the tumor, as it might lead to rupture of the tubes. But
the uterus should be washed out with a warm alkaline solution (bicar-
bonate of sodium or liquor potassae, 3ss Oij), which dissolves the
thick blood, and, after that has been removed, with a disinfectant.
Permanent irrigation of the vagina has been used as after-treatment,
which prevents the entrance of air and keeps up some degree of
pressure.
If hematosalpinx can be made out before the operation, it is best first to
perform laparotomy, and remove the distended tubes with the ovaries ;
or vaginal hysterectomy and salpingo-oophorectomy may be preferable.
Dangers of the Operation. The membrane being comparatively
thin and of easy access, there is no difficulty in incising or removing
it; but, simple as the operation appears, it has more than once proved
328 DISEASES OF WOMEN.
fatal. The two dangers are rupture of the tubes and sepsis, the latter
of which, being so much more common, must carry greater weight in
deciding the measures to be adopted. In regard to the first, the
operator should, as stated above, abstain from pressure, or may per-
form preliminary extirpation of the tubes. In order to avoid the
second, a large opening should be made and the accumulated fluid
washed out immediately. The use of the cautery, sutures, and per-
manent irrigation is also based on the fear of sepsis.
3. Abnormal Openings. Instead of having one opening, the
hymen may have two placed side by side. If the bridge between
them is broad, the condition is called hymen bi/oris or hymen bifenes-
tratus. If it is narrow, it is called hymen septus. Sometimes such a
partition grows out from the anterior or posterior wall without reach-
ing the opposite wall, which formation is called hymen subseptus.
There may also be many small openings, a condition known as
hymen cribriformis.
4. Double Hymen. The hymen may be double in different ways.
One may be placed above the other, which probably is only due to
the presence of a transverse septum in the lower part of the vagina.
One may also be placed beside the other, the vagina itself being
double.
Treatment. If the shape of the hymen interferes with coition or
childbirth, the condition is easily remedied by removing the septum,
making a crucial incision, or removing the whole membrane.
5. Fleshy Hymen. Sometimes the hymen becomes so thick that it
is not ruptured in contact with the penis, but constitutes an insur-
mountable obstacle to its entrance into the vagina. This may cause
considerable pain, and become a source of much nervous irritability
(vaginismus).
The condition is easily remedied by cutting the offending part off
with curved scissors and stitching the edges of the wound together.
B. Malformations of the Vagina.
1. Atresia and Stenosis. The word "atresia" means a lack of
bore, and ought only to be used in speaking of a complete closure
of the vagina, whereas "stenosis" means narrowness, and may
properly be applied to any condition in which the vagina has not its
proper width. But authors often use the word atresia even when
there is an opening in the septum obstructing the vagina, and then
divide atresia into complete and incomplete.
The lower end of the vagina may be closed by a thin membrane
(septum retrohymenale), or one or more solid transverse septa may be
found higher up iu the vagina, or, finally, there may be a complete
absence of the vagina. In such cases the uterus is commonly absent
too, but sometimes a more or less normal uterus may be found beyond
the tissue where the vagina ought to be.
DISEASES OF THE VAGINA. 329
Complete vaginal atresia gives rise to retention of the menstrual
flow and the other conditions described above in treating of atresia
of the hymen. It prevents impregnation, and, if the septum is situ-
ated low down, it causes more or less dyspareuuia. The pouch may,
however, in course of time, by continued use, become considerably
deeper. Sometimes connection takes place in the urethra or the rec-
tum, especially the former, and, strangely enough, such considerable
dilatation causes only exceptionally incontinence of urine.
Much more common than this complete closure is the presence in
the vagina of a transverse septum with one or more openings. Some-
times the opening is so minute that it can only be discovered at the
time of menstruation, when blood may be seen trickling through it.
Under such circumstances impregnation becomes possible, and we
may, therefore, find labor obstructed by a transverse septum in the
vagina, presenting an obstacle similar to that of an imperforate hymen.
Different theories have been proposed in order to explain the
formation of transverse septa in the vagina. One is, that adhesion
and coalescence have taken place between opposite walls of the vagina ;
another is, that the Miillerian ducts failed to be tunneled in the place
where the diaphragm is found ; and, according to a third, the vagina
above the septum is formed by one of these ducts, and below the
septum by the other.
A general narrowness of the vagina may be due to an arrest of
development a condition often combined with an infantile uterus
and sometimes only one of the Miillerian ducts is developed, while
the other disappears, so that there really is only half a vagina. This
narrowness may cause dyspareunia.
The treatment consists in gradual dilatation by means of the bivalve
speculum or plugs of glass or hard rubber, and the use of lubricants
in attempts at coition. This same treatment is to be followed when
the narrowness is relative ; that is to say, when the female organs are
normal, but the husband has an excessively large penis.
So far, we have only had in view congenital conditions, which con-
stitute what is called malformations. But similar septa may be
acquired. They may be the result of sloughing and adhesion conse-
quent upon disease, or be the result of violence, strong acids, or even
a red-hot iron, being applied in the vagina by fiendish wretches.
Treatment. The reader is referred to all that has been said about
the dangers of imperforate hymen and its treatment. But, besides
what has been said there, the transverse septa and the absence of the
vagina offer special features. The thinner the septum is, the more
the treatment will be like that for imperforate hymen ; the thicker it
is, the more it approaches that for absence of the vagina, which we
now shall consider.
The first thing to do in a case of absence of the vagina is to make
330 DISEASES OF WOMEN.
a thorough examination, preferably under ether, by using simulta-
neously a hand on the abdomen, a finger in the rectum, and a cath-
eter in the bladder, and, taking the presence or absence of menstrual
molimina into consideration, to find out whether the patient has a
uterus and ovaries or not. If there is no uterus, no attempt should
be made to make a vagina. It is not only hardly justifiable to expose
the patient to the dangers of the operation merely in the hope of
forming an organ of copulation, but experience has shown that the
hope is futile. Where there is no uterus the artificially formed vagina
closes again. The situation is entirely different if there is a uterus
and the menstrual flow takes place internally. Then the operation
becomes imperative, in order to save the patient's life, and by proper
care the new-formed vagina may be kept pervious. If even ovaries
are present, impregnation and childbirth may take place, but would
be attended by great danger.
Modus Operandi. The patient is placed on her back with her knees
drawn up. The vulva is stretched from side to side. The mucous
membrane is seized with a tenaculum, and a transverse incision made
midway between the urethra and the anus. Now the operator works
his way slowly and very carefully up between the bladder in front
and the rectum behind, using a pair of closed blunt scissors and his
forefinger to tear the connective tissue between both, and keeping a
metal catheter in the bladder and his left forefinger in the rectum,
until he reaches the os, which can be, felt from the rectum. He intro-
duces the scissors through the os, when the accumulated mucus and
blood flow out. With a dilator he stretches the cervical canal about
half an inch, washes out the uterus with warm solution of bicarbo-
nate of sodium (sj-Oj) and after that with creolin (1 per cent.).
A hollow glass plug (Fig. 219) in proportion to the size of the new-
formed vagina is introduced into it, covered with antiseptic gauze and
cotton, and held in place by a T-bandage. I think it is an improve-
ment to have a hole (a) at the bottom of the plug in order to allow
escape of fluid, and one (6) on each side of the rim from which a
string goes to the bandage surrounding the pelvis. 1
The wound heals over the plug, epithelial cells growing out from
the vulva in the course of a month, during which time the plug is
taken out and cleansed every day and the vagina disinfected. If
healing is slow, it may be furthered by painting the raw surface once
a day with a weak solution of nitrate of silver (gr. ij-3j)- The patient
should wear the plug daily for at least an hour during a whole year,
but as this is tiresome and hurts some, she is liable to neglect it, and
then the canal shrinks again from the uterus downward, and it be-
comes necessary to dilate it gradually or repeat the operation, which is
1 John Reynders & Co., cor. Fourth ave. and Twenty-third St., have made such
plugs for me.
DISEASES OF THE VAGINA.
331
still more difficult and dangerous than the first time, when the tissue
yields more easily. 1
Other Methods for Keeping the Canal Open. Instead of the per-
manent use of the plug, some prefer, after granulation is well estab-
FIG. 219.
Vaginal Glass Plug.
lished say, the end of a month to dilate with finger and speculum
every two or three days a very painful procedure.
To cut out flaps of the surrounding skin and turn them into the
new-formed vagina is not advisable, on account of the hairs growing
on these parts; but flaps of mucous membrane have been obtained
from the vulva and used with success. Thus, Kiistner cut loose the
labia minora to their posterior end, split them open by a longitudinal
1 On Jan. 25, 1890, 1 operated on Annie K , American, fifteen and a half years
old, for absence of vagina, combined with uterus unicornis. She had for some time
complained of severe abdominal pain; had a temperature of 101 and a pulse of
128. The hymen was normal, but the vagina was only a quarter of an inch deep.
Through the abdominal wall, the vagina, and the rectum was felt a hard, slightly
elastic swelling, nearly filling the pelvis, especially in the left side, and extending
up into the left iliac fossa. 1 had to form a vagina to the full length of my index-
finger, 2 inches, and there was so little tissue between the bladder and the rectum
that only a thin transparent membrane was left between the artificial opening and
the rectum. There was no cervix, but the os could be felt far upward and back-
ward. Finally, I succeeded in introducing the scissors into the os. A considerable
amount of thick yellowish mucus, mixed with old blood, flowed out. The tumor
diminished, and was washed out as stated in the text. She improved immediately,
and made a good recovery, and menstruated three times while she was under my
observation. She was ordered to use her glass plug one hour every day, but so<>n
got tired of it. When I saw her again, about a year later, the upper half of the
vagina had contracted again to the size of a cervical canal, just admitting the sound.
She had a cyst in the left iliac fossa, without connection with the genitals, from
which I evacuated a yellowish clear fluid. This was thereafter successfully treated
with injection of iodoform ether, and I have not seen her since.
332 DISEASES OF WOMEN.
incision, and stitched them together so as to form a sac outside of the
vulva, which sac he then stitched to the artificial canal formed between
the rectum and bladder. In another case he successfully lined the
hollow with the mucous membrane of a part of the resected intestine
of another patient.
If the atresia is only partial, the wound may be covered by stitch-
ing the edges of the upper and lower segments of the vagina together. 1
Oophorectomy. If absence of the vagina is combined with absence
of the uterus, but active ovaries are present, causing menstrual
molimiua, the ovaries should be extirpated by laparotomy.
2. Double Vagina. The vagina may be divided by a more or less
complete longitudinal partition into two halves, each of which corre-
sponds to one Mulleriau duct. Commonly, but not always, double
vagina is combined with double uterus.
The two halves of the vagina may be unequally developed, the
larger one alone being used for coition. If this one is closed above,
fecundation can, of course, not take place.
Instead of a long partition there may only be found a more or less
narrow baud as remnant of the original septum between the Mullerian
ducts.
As a rule, a fully-developed double vagina does not give any
trouble, and is discovered accidentally. If childbirth takes place, the
septum is more or less completely torn.
Treatment. If the septum interferes with coition or impregnation,
it may be split lengthwise. Both halves are distended with specula
and retractors, so as to put the septum on the stretch, and then it is
severed midway between the anterior and posterior walls by means
of the thermo- or galvano-cautery.
A mere band oftener causes dyspareunia and dystocia, and may be
severed with scissors. If there is any bleeding, it is checked by
cautery, styptic cotton, or tampon. If the band is fleshy, it is prefer-
able to tie near the two ends and cut out the middle piece.
Double Vagina with Atresia. Double vagina may be combined
with atresia on one or both sides. If one side is pervious, men-
struation and impregnation may take place, and the condition is,
therefore, often overlooked for a long time. The right half is much
more liable to be closed than the left. The uterus is with few ex-
ceptions two-horned.
Menstrual molimina, due to retention in the closed half, are pres-
ent, combined with menstrual flow through the open half. The
tumor formed by the retained fluid bulges very much into the latter,
and may distend the vulva and interfere with micturition. The
upper part of the tumor lies on the side of the uterus. The lateral
atresia leads much more frequently to spontaneous rupture than
1 O. Kiistner, Centralblatt fur Gynak., voL xvi. No. 23, p. 533, June 10, 1893.
DISEASES OF THE VAGINA. 333
atresia of the single vagina, and the perforation always takes place
in the septum of the cervix uteri ; but this does not effect a cure.
The contents are only partially evacuated, air and microbes enter, the
stagnating fluid becomes purulent or putrid (lateral pyocolpos and
pyometra), and causes inflammation and ulceration of the walls. The
inflammation may extend to the tubes and the peritoneal cavity.
At times the tumor increases again in size until, after great pain, a
new discharge takes place through the opening in the septum. For
diagnostic purposes it is of importance that pressure on the vaginal
tumor causes a purulent discharge through the os uteri of the open
half of the vagina.
Diagnosis. Lateral atresia has been taken for hematocele, but the
history of a chronic disease with monthly exacerbations, and the shape
and position of the tumor, will help to avoid this mistake. In lat-
eral atresia the tension of the wall often varies at different times, and
if it is not very great it is sometimes possible to invaginate the lower
part of the tumor and feel the muscular ring formed by the os.
If the septum is situated very high up, the tumor may also be con-
founded with cysts adherent to the uterus or a myoma in the wall of
the latter. An exploratory puncture may become necessary to settle
the diagnosis.
Treatment. Sims's speculum is introduced in the open half, and
the septum slit open with knife, scissors, or preferably thermo- or gal-
vano-cautery. In cases of double atresia one side is first opened, as
in atresia of the single vagina, and afterward the septum incised.
3. Blind Canals. Immediately above the entrance of the vagina,
laterally, are occasionally found blind canals, which may be an inch
and a half long and wide enough to admit the little finger. They are
lined with smooth mucous membrane, and are probably only unu-
sually developed lacuna?. They are without practical importance,
except that they may become receptacles for gonococci. If the affec-
tion cannot be cured with injections, it may become necessary to lay
the canals open.
4. Faulty Communications. Familiarity with the history of devel-
opment (p. 31) allows us to recognize as consequences of developmental
arrest certain abnormal conditions sometimes met with. Thus we
have complete atresia i. e. absence of any opening on the cutaneous
surface leading into the intestinal or urogenital canal, while under the
skin is found a common cloaca into which open bladder, vagina, and
rectum. The next step in development is represented by cases where
this cloaca has an opening on the surface of the body. The rectum
opens apparently into the vagina or vulva (atresia ani vaginalis
or vestibularis.) It may have a sphincter or not. In other cases the
vagina and the urethra apparently open into the rectum, but in real-
ity these cases are only modifications of a persistent cloaca.
334 DISEASES OF WOMEN.
If the development has been arrested still later, the partition be-
tween the rectum and the urogenital sinus may have been formed,
but the urethra seems to open into the vagina. This is really due to
a persistent urogenital sinus.
Complete atresia is only found in non-viable fetuses. The other
conditions hardly ever become the object of operative interference.
If the rectum opens into the vulva or vagina, an artificial anus
might be made ; but if there is a sphincter, it might lose its inner-
vation, and the patient be left in a worse condition than she was
before. In very rare cases there is a normal anus, but a communica-
tion between the rectum and vagina higher up a congenital recto-
vaginal fistula. This may be closed in the same manner as the
acquired fistula.
It is likewise very rare that a ureter opens into the vagina instead
of the bladder. This may be loosened and fastened with sutures in
the wall of the bladder. 1
CHAPTER II.
VAGINAL, ENTEROCELE.
VAGINAL ENTEROCELE, or vaginal hernia, is a tumor formed by
the intestines, and sometimes the omentum or ovary, by inverting the
vaginal wall. Sometimes the protrusion takes place through an open-
ing in the muscular coat of the vagina, so that there is a- hernial ring,
and the prolapsed intestine is only covered by the mucous membrane.
Commonly this protrusion begins in Douglas's pouch, but it may also
occur between the uterus and the bladder, or in the scar left by vagi-
nal hysterectomy.
Causes. The hernia may be caused by a fall, lifting a heavy bur-
den, straining at stool, but most commonly it is due to pregnancy
and childbirth.
Symptoms. In acute cases there is a sudden pain and feeling of a
rupture. If the development is chronic, there is a dragging sensa-
tion, constipation, and dyspareunia. No case of strangulation is
known, but during childbirth a dangerous pressure is exercised on
the tumor when it is being pushed down in front of the presenting
part. On examination is found a pear-shaped, soft tumor protruding
in the lumen of the vagina or descending through the vulva. It
increases on cough, can be pushed up into the abdominal cavity, may
give a gurgling sound on handling, and, if accessible in front of the
vulva, will give a tyrapanitic percussion-sound. 2
1 W. H. Baker of Boston, New York Medical Journal, Dec., 1878.
1 On account of the great rarity of this affection the following notes of the only
case I have ever met with may be of interest : Elise V., aet 27, widow, unipara,
DISEASES OF THE VAGINA. 335
Diagnosis. It has been mistaken for a uterine polypus a mistake
that seems impossible except in consequence of unjustifiable care-
lessness. It may be much like a vaginal cyst, but this does not
diminish on pressure.
Treatment. The intestine may sometimes be reduced and kept up
by some form of pessary, especially the more bulky ones, such as
Hoffmann's, Fowler's, Garriel's, or a globe-shaped one which will
be described in treating of the uterus. Thomas has performed lapa-
rotomy, inverted the sac, and fastened it in the abdominal wound.
Perhaps colporrhaphy (p. 340) may succeed in retaining the intes-
tines in the pelvic cavity. As a last resort, the sac may be opened,
superfluous tissue cut away, and the edges united by interrupted
sutures.
Prolapse of the intestine into an unusually deep Douglas's pouch
(p. 91) is a somewhat kindred condition, which may give rise to
constipation, a sensation of weight, and other discomfort. The intes-
tine may perhaps be kept up by one of the above-named bulky
vaginal pessaries. If this does not succeed and the condition causes
considerable trouble, an incision may be made in the posterior fornix
and the pouch closed by a continuous suture of catgut.
CHAPTER HI.
PROLAPSE OF THE ANTERIOR WALL OF THE VAGINA ;
CYSTOCELE.
ANY part of the vaginal tube may be pushed into its own caliber,
so as to form a swelling there. We have already mentioned entero-
cele, which is the rarest of these prolapses, and in which the intestine
is found in the tumor. Little less rare is a bulging out of the lateral
walls, because these normally are drawn to one side by the attachment
of the levator ani muscle and bands of connective tissue interspersed
with elastic fibers extending to the rami of the pubes and the ischium.
The most common of all, on the contrary, is a prolapse of the ante-
rior wall, and on account of the shortness and tightness of the con-
nective tissue between the vagina and the bladder this latter organ
of robust appearance and excellent constitution, applied at the German Dispensary
on October 10, 1893. She had been perfectly well until three weeks before I saw
her, when she fell down into a cellar and struck the right side of the abdomen
against a wooden box. Since then she had bloody discharge from the uterus and
abdominal pain. By vaginal examination the uterus was found retroHexed and
very tender, but it could easily be replaced. In the left and posterior wall of the
fornix was found a soft elastic tumor of the size and shape of a hen's egg and very
tender. It could be partially pushed back into the abdominal cavity, when a sharp
oval ring was felt surrounding it, probably an opening in the pelvic fascia.
336 DISEASES OF WOMEN.
always follows the anterior wall of the vagina more or less in its
descent.
Causes. By far the most common cause of this displacement is
childbirth. During pregnancy all the constituent parts of the vagina
and the surrounding connective tissue grow and become infiltrated
with serum. During childbirth these parts are bruised and torn.
During the lying-in period, and when the patient gets up, the weight
of the accumulated urine presses on the yet soft and yielding anterior
vaginal wall. If the perineum has been ruptured or the vaginal
ring is broken or over-distended, there is a still greater lack of sup-
port from below. The increased weight of the vagina itself, due to
subinvolntion, contributes also to the prolapse.
Cystocele may occur apart from childbirth, in consequence of excess
in venery, or even in virgins who work hard and are underfed ; but
such cases are exceedingly rare.
Symptoms. The condition gives rise to frequent and often imper-
fect micturition. The bladder is not entirely emptied, and the
retained urine undergoes alkaline decomposition and produces catarrh.
When the patient lies on her back with flexed and separated knees,
the anterior vaginal wall is seen forming a round swelling protruding
through the vaginal entrance. By means of a catheter we can easily
satisfy ourselves that this swelling contains the base of the bladder.
If the condition is complicated with procidentia uteri (see below), the
bladder forms in front of the uterus, which hangs between the thighs,
a large soft swelling.
Treatment. Minor degrees of cystocele may be successfully treated
with astringent suppositories or injections, by galvanism, by repairing
a torn perineum and a posterior vaginal wall, and by a general tonic
regimen. More pronounced cases call for direct surgical interference.
These operations are called anterior colporrhaphy. It may be median,
lateral, or bilateral. The median operation may be performed accord-
ing to Sims's or Stolz's method.
Sims' 's Method (Fig. 220). The patient is in the dorsal position,
the knees drawn up and separated by means of Clover's crutch or
Robb's leg-holder (p. 198). The posterior wall is pulled down with a
single Sims speculum, a tenaculum-forceps is fastened in the median
line just below the point corresponding to the inner end of the
urethra, which is marked by a transverse ridge (Fig. 143, p. 166),
and another at the lowest point near the cervix. The operator seizes
the mucous membrane of the anterior wall of the vagina somewhere
near the lateral sulci with two tenacula, and draws them together.
Thus he ascertains how much tissue is redundant, and makes a snip
with a pair of scissors on each side, in order to mark the greatest
width of the surface to be denuded. Just outside of these points he
inserts a tenaculum-forceps, so that the whole surface to be pared may
DISEASES OF THE VAGINA.
337
be put on the stretch. With a pair of scissors curved on the flat
a strip of mucous membrane about inch wide, and extending
from the lower forceps to the upper, is cut off. Similar strips
are cut off parallel to the first on the right side until the landmark
is reached. Then the same procedure is repeated on the left. In
this way an elliptical surface, with the long axis in the direction
of that of the vagina, is denuded. Next silk or silkworm-gut
sutures are inserted from side to side, alternatively deep, under the
whole surface, and superficial, only through the edges. It is very
convenient to use irrigation instead of sponges (pp. 182, 199, and
222). The sutures are removed from nine days to four weeks after
FIG. 220.
f. ^
2
u J
*
6
Diagram of Sims's Cystocele Operation : A, denudation by cutting off longitudinal strips
of mucous membrane with scissors ; B, insertion of sutures, alternatively deep (1, 3, 5, 7)
and superficial (2, 4, 6).
the operation, according to their accessibility, which again depends
on whether other operations are performed simultaneously on the
perineum and on the posterior wall of the vagina or not. This
method leaves a linear cicatrix in the median line. Some prefer
a continuous catgut suture inserted in superposed tiers (p. 221).
Stolz's Method (Fig. 221) differs from Sims's by the circular shape
of the denuded surface and the insertion of a purse-string suture along
the circumference. The denudation is made in exactly the same way.
For the suture is used a strong silk thread (No. 4 or 5 braided),
armed at both ends with a medium-sized curved needle without cut-
ting edges except quite near the point. One of the needles is given
to an assistant ; the other is seized with a needle-holder, introduced
in the median line (a) | inch behind the denuded surface, carried ^
inch to the left under the mucous membrane, then made to emerge
inch outside of the denuded surface (6), reintroduced | inch nearer
22
338
DISEASES OF WOMEN.
to the meatus, and carried in the same way alternately below and
above the mucous membrane at a short distance from the denuded
surface. Arriving a little beyond the middle line (c), under the
meatus (m), the operator hands this first needle to an assistant, and
introduces the other exactly in the same way on the other side, until
the whole denuded surface is surrounded with the thread. The two
ends are now pulled together, while the assistant pushes the denuded
surface back with a uterine sound. The suture is tied, and the two
ends fastened with adhesive plaster to the abdominal wall. Thus
the pared surface is brought together and closed like a tobacco-pouch.
FIG. 221.
Diagram of Stolz's Cystocele Operation: 1, first needle; 2, second needle; o, first point of
entrance; 6, first point of exit; c, last point of exit with first needle ; m, meatus urinarius.
There is formed a small puckered cicatrice, which gives excellent
support to the bladder.
The suture is removed after nine or ten days if of easy access ;
otherwise it may stay for weeks.
Walking's Method l is lateral or bilateral. According to its author,
laceration of the anterior vaginal wall is unilateral or bilateral. It
is usually submucous, and occurs at or near the insertion of the fascia
into the bony pelvis. The location and extent of the tear are detected
by touch and by inspection of the change in the shape that occurs in
the anterior vaginal wall, which normally presents a convexity cor-
responding to the urethral curve, a marked concavity corresponding
to the trigone of the bladder, and a straight line or slight .convexity
from this point to the uterus.
1 T. J. Watkins of Chicago, 111., Jour, of Gynecology, Toledo, O., Aug., 1891, vol. L
No. 5, p. 305.
DISEASES OF THE VAGIXA. 339
For Watkins's operation the patient is placed in Sims's position,
and the anterior vaginal wall exposed with his speculum. A point
of the mucous membrane to the side of the urethra, near its meatus,
is caught with a tenaculum. The denudation is carried from this
point, along the antero-lateral wall of the vagina, to a point beyond
the prolapse. This point may be opposite the neck of the bladder,
or the denudation may extend even as far back as the lateral aspect
of the cervix uteri. The breadth of the denuded surface is dependent
upon the extent of the urethrocele and cystocele, all the redundant
tissue of which it should take in. The denudation is made on one
or both sides according as the laceration is unilateral or bilateral.
Silkworm-gut sutures are passed, beginning at the uterine end of the
denudation, from side to side in a curved line which has its convexity
outward and forward. Each suture as inserted is tied, and traction
is being exerted toward the cervix while the next suture is being
introduced and tied. The sutures should include as much connective
tissue as possible, care being taken not to injure the bladder, the
ureters, or the urethra. After passing the trigone of the bladder the
sutures should be passed deeply into the lateral wall near its insertion
into the pubes, and as deeply into the anterior vaginal wall as the
increased thickness of the vesico-vaginal septum from this point out-
ward will permit. The stitches may be removed after a week or be
allowed to remain for two or three weeks. It is claimed that this
operation cures the incontinence of urine that sometimes is a distress-
ing feature of cystocele and urethrocele. (Compare Pawlick's ope-
ration for incontinence, under Urinary Fistula.)
In any of these operations the bladder should be emptied every
four hours. If the patient can urinate, she may be allowed to do so.
If not, the urine is drawn, preferably with a soft-rubber catheter.
The patient should stay in bed three weeks.
Oystopexy. A new French operation for cystocele, by which the
anterior wall of the bladder is fastened to the abdominal wall, has
been performed several times with success. The bladder is injected
with five ounces of solution of boracic acid. A transverse incision
2 inches long is made through the abdominal wall in the hypogastric
region. Two catgut sutures are carried through the lower edge of
the wound except the skin, then through the outer layers of the
anterior wall of the bladder, and through the upper edge of the
wound. After tying these sutures the skin is stitched together.
During the first six days the catheter is used twice a day only.
340 DISEASES OF WOMEN.
CHAPTER IV.
PROLAPSE OF THE POSTERIOR VAGINAL WALL; RECTOCELE.
NEXT to the prolapse of the anterior wall, that of the posterior is
the most common form of prolapse of the vagina. It is commonly
called " rectocele," but this name is only used correctly if the pro-
lapse contains the rectum, which, as a rule, is not the case. The con-
nective tissue between the rectum and the vagina being much longer
and looser than that between the bladder and the vagina, the latter slides
away from the rectum, doubles up, and forms a round swelling bulging
out through the vaginal entrance. By pinching this fold and by intro-
ducing a finger into the rectum we can easily satisfy ourselves that
this is so. But in the course of time the anterior rectal wall, lacking
its normal support in front, may become distended and form a pouch
descending inside of that formed by the vagina.
Etiology. The causes are similar to those enumerated for cysto-
cele, except the weight of the bladder, for which here is substituted
constipation.
Symptoms. The symptoms are a similar dragging sensation. Con-
stipation, besides being a cause of rectocele, is a sequence of it, and
may lead to proctitis with ulceration of the mucous membrane. When
the patient lies on her back with separated knees, a globular swelling,
formed by the posterior wall of the vagina, is seen protruding through
the vaginal entrance a swelling that increases in size when she bears
down or stands on her feet.
Treatment. Posterior colporrhaphy consists in the denudation on
the posterior wall of an elliptic surface similar to that described in
treating of Cystocele, but is seldom resorted to. A? a rule, the peri-
neum and the vaginal entrance have been injured, and the operation
called for is Hegar's or Emmet's colpoperineorrhaphy. (See pp. 311
and 316.)
Vaginal Prolapse and Inversion. When the whole vagina sinks
down all around, the condition is particularly called prolapse of the
vagina, and if this goes so far that the whole tube is turned inside out
and forms a sausage-shaped mass hanging between the thighs and sur-
rounding the prolapsed uterus and bladder, and sometimes the rectum,
it is called inversion.
The mucous membrane, exposed to the air, becomes dry and scaly,
and, on the other hand, the thrown-oif epithelial cells, if the parts
are not kept clean, form a white, malodorous smegma in the pouch be-
tween the prolapse and the perineum, which irritates the mucous mem-
brane and gives rise to vaginitis. This condition is connected with
prolapse of the uterus, and will be considered in treating of that disease.
DISEASES OF THE VAGINA. 341
CHAPTER V.
INJURIES; THROMBUS OR HEMATOMA.
THE tear in the hymen produced by the first coition may cause a
severe and even fatal hemorrhage. If' an artery is found spurting,
it must be tied. In other cases an application of, or injection with,
liquor ferri will suffice to check the hemorrhage (pp. 170 and 172).
In order to prevent its recurrence the tear should be given time to
heal, and some vaseline applied before intercourse until the vaginal
entrance is dilated.
Much more serious are the tears in the vagina that occur under
similar circumstances. The wall has been found torn from the vagi-
nal entrance to the fornix. Tears are also occasionally produced dur-
ing coition with women who have had frequent intercourse or even
borne children, but then there is a strong suspicion, sometimes cor-
roborated by confession, that some hard object has been introduced
simultaneously with the penis. Such a tear may also be caused by
coition with old women where senile atrophy has taken place, or
with women afflicted with stenosis or atresia of the vagina or double
vagina. Transverse tears of the fornix have occurred during coition
after the operation for lacerated perineum. In such cases it is prob-
ably due to the shortening of the posterior wall. Sometimes the
lesion is due to unusual postures during the act.
During childbirth the vagina is quite frequently torn. In most
cases the lesion extends only through the thickness of the mucous
membrane, and is then of little importance, but it may penetrate
through the whole thickness of the wall into the surrounding con-
nective tissue. In regard to these lesions the reader is referred to
works on obstetrics.
The vagina may also be injured by falls on a pointed object, by
attacks of horned animals, etc., or by obstetrical and surgical opera-
tions, especially the extraction of the child by means of the forceps,
the replacement of an inverted uterus, or the removal of a large
uterine fibroid. Even a fall with the abdomen against the sharp
edges of a step on a staircase has indirectly caused a tear of the mucous
membrane of the vagina. 1
Symptoms. These tears are, of course, accompanied by consider-
able pain. They may cause severe hemorrhage. Sometimes the intes-
tine prolapses and may become gangrenous, leaving an ileo- vaginal
fistula. There may also remain an opening into the peritoneal cavity,
through which the intestine can slip out and be brought back. All
1 Centralbl.jur Gynak., 1892, No. 31, xvi. p. 614.
342 DISEASES OF WOMEN.
the symptoms of septicemia may be developed. A permanent recto-
or vesico- vaginal fistula may remain.
Prognosis. With proper surgical help the prospects are good.
Treatment. The vagina is cleaned of clots, spurting arteries tied
with catgut, the edges of the wound united with sutures, and a few
pledgets of iodoform gauze placed over the wound. These are re-
newed about every three days.
Thrombus or hematoma is a swelling formed by the extravasation
of blood under the mucous membrane. It is nearly always due to
childbirth, and the reader is, therefore, referred to works on obstetrics
for information concerning it.
CHAPTER VI.
FOREIGN BODIES.
FOREIGN BODIES are by no means rare in the vagina. Most com-
monly they are objects used by the patient herself in masturbating or
as preventives of conception. Sometimes they have been placed there
for therapeutic purposes by a physician or a midwife. In rare cases
their introduction is due to brutal jokes or acts of vengeance.
The most diverse objects, such as pessaries, sponges, hairpins, sticks,
needle-cases, snuff-boxes, glasses, pomade-jars, bottles, etc., have
been introduced and remained for months or years in the vagina.
Intestinal worms and insects have found their way to the same place.
Symptoms. According to their size, shape, and length of sojourn
foreign bodies may give rise to a great variety of symptoms. The
patient complains of pain in the pelvis, the hypogastric and the lum-
bar regions, or shooting down along the inside of the thighs. A
purulent and offensive discharge, dysuria, dyschezia, and dyspareunia
are developed. The presence of the foreign body may cause ulcera-
tion ; gangrene ; fistulous communications between the vagina and the
urethra, the bladder, or the rectum ; peritonitis ; and pelvic abscess.
Diagnosis. Often the patient has forgotten the origin of her
trouble or is restrained by shame from telling it. Besides a vaginal
examination with finger and speculum, often the examination through
the rectum or with catheter or finger in the bladder may be of great
help in arriving at a diagnosis. The object may change much in
shape by the deposit of calcareous matter around it. It may become
entirely hidden from view by burrowing into the tissues, which close
over it, or migrate into the abdominal cavity. A sponge giving rise
to hemorrhage and a foul discharge has more than once been taken
for a carcinomatous cervix.
Treatment. The treatment consists in the removal of the foreign
DISEASES OF THE VAGINA. 343
body and in combating the inflammation and other disorders caused
by its presence. While the first indication in most cases is simple
enough to fulfil, in others all the ingenuity of a surgical mind and
the resources of a good armamentarium are required. As a rule, the
object can be removed through the vulva, but in exceptional cases it
has been found advantageous to withdraw it through the rectum or
the bladder. Lengthy objects occupying a transverse position must
be seized near one of the ends. Large objects must sometimes be
broken with shears or lithotriptic instruments. Considerable help
is often afforded by introducing a finger into the rectum and hooking
it over the body from above. In regard to hairpins, it must be
remembered that they almost invariably are introduced with the ends
pointing downward to the vulva, which ends must be freed before
the pin can be extracted. Sometimes an incision must be made to
reach the body. If the vagina contains pieces of broken glass with
sharp edges, the walls should be lubricated and plaster of Paris poured
in, which will settle around the pieces and form one mass with them
that may be withdrawn without cutting the vagina. 1
The second indication will in most cases be met by using antiseptic
and astringent vaginal injections. Sometimes a consecutive eudo-
metritis calls for treatment, and in rare cases fistula operations, or
even laparotomy, may be required.
CHAPTER VII.
YAGINITIS.
VAGINITIS is the word commonly used in America to designate
inflammation of the vagina, but as the suffix -itis is of Greek origin
and vagina Latin, exception has been taken to it. German authors
have substituted the term colpitis, and English sometimes use elytritis.
Under the term " vaginitis " are comprised so very different con-
ditions that it is necessary to admit certain divisions and subdivisions
of the subject, which is done in many different ways by different
authors choosing different standpoints.
Thus we distinguish between acute and chronic vaginitis, the differ-
ence being not only limited to the time the disease lasts, but also to
the greater and lesser intensity of the symptoms. The acute form
commonly ends in less than a month ; the chronic has no definite
limit.
A vaginitis is called primary when it appears first in the vagina;
secondary if the inflammation invades this organ from another part
1 R. J. Levis of Philadelphia.
344 DTSEASES OF WOMEN.
of the body, especially the vulva, the uterus, the rectum, or the
urethra.
In regard to the chief feature of the disease we distinguish between
catarrhal vaginitis, characterized by a discharge from the mucous
membrane ; exudative vaginitis, in which a solid inflammatory exu-
dation takes place either on the surface of the mucous membrane
(croupous vaginitis) or in the depth of the same (diphtheintic vaginitis) ;
and phlegmonous vaginitis, also called dissecting vaginitis or peri-
vaginitis, in which the inflammation has its seat in the connective
tissue surrounding the vagina, and leads to the severance and expul-
sion of the whole tube.
As subdivisions we unite under the term " catarrhal" the following
forms of vaginitis : 1, the granular (also called follicular, or glandu-
lar) ; 2, the simple ; 3, the adhesive ; 4, the gonorrheal ; 5, the exfoli-
ative; and 6, the emphysematous vaginitis. To the diphtheritic
vagiuitis belongs the dysenteric.
A. Catarrhal Vaginitis. Pathological Anatomy. In granular
vaginitis the epithelium as a whole becomes thicker, the papilla? be-
come larger, and circumscribed groups of small round cells are formed
under them and send proliferations into them. When the papilla?
increase in length and width, the epithelial cover immediately over
them, and the tongues it sends in between them become thinner ; at
the same time the blood-vessels are much developed. These cell-
groups and the swollen papillae on their top form on the surface of
the vagina circular prominences as large as lentils.
In simple catarrhal vaginitis a similar process takes place on a
smaller scale, so that the cell-groups and the swollen papilla? remain
under the level of the epithelium. In the chronic form pigment is
imbedded in the deeper cells of the epithelium.
The adhesive form is especially found in old women, but clinically
a similar condition is also observed in young children. The vagina
is spotted or striped, being the seat of ecchymoses and superficial
ulcerations, and there is great tendency to coalescence between the
surfaces lying in contact with one another. The microscope reveals
similar cell-groups under the surface as in the two other forms, but
here the whole epithelial layer is lost over the infiltrated spots.
In the discharge is commonly found an infusorial animalcule called
Trichomonas vaginalis. Even in the secretion of the normal vulvo-
vaginal tract in children there are found epithelial cells, in some quite
a number of pus-cells, numerous bacteria, cocci, diplococci, bacilli,
and spirilla, but never the gonococcus of Neisser, which is pathogno-
monic of gonorrhea. It is a diplococcus found in the interior of the
epithelial cells and of pus-corpuscles, and is characterized by becoming
decolorized by Gram's method. 1
1 Gram's Method. The cover-glass smeared with the substance to be examined is
DISEASES OF THE VAGINA. 345
Etiology. Old women are liable to have vaginitis without any
other particular cause than their age. Young children often suffer
likewise from vaginitis, due to the accumulation of old epithelial cells
in the vagina, whence they do not easily escape on account of the
smallness of the opening in the hymen. The great afflux of blood
and formation of new tissue that take place in pregnancy lead very
frequently to it. Even menstruation is liable to cause it, or make it
worse if already present. Anemia and scrofula predispose to it.
Often it accompanies eruptive fevers, especially measles. Direct
causes are exposure to cold, especially sitting on a cold stone ; exces-
sive coition, masturbation, or rape ; the presence of foreign bodies,
especially pessaries ; the use of too hot or too strong injections ; opera-
tive interference ; the irritation caused by urine or fecal matter enter-
ing the vagina through fistula?, or by an acrid discharge coming down
from the uterus or from a pelvic abscess. The most common cause
by far of the acute form is infection with gonorrheal discharge in
whatever way the infecting principle may enter the vagina.
Symptoms. The patients have a disagreeable sensation of heat in
the vulva and the vagina. They have pain in the pelvis and the
groins, which increases by walking or any other exercise. They com-
plain of general malaise, and are often feverish. Micturition is ac-
companied by a burning sensation. Defecation may also be painful.
The vagina is so tender to the touch that the introduction of a specu-
lum causes great pain, and sexual intercourse becomes impossible.
The mucous membrane is red and swollen. At first it is dry, but
in a day or two a discharge begins, which first is mucoid, then muco-
purulent, and finally consists of thick creamy pus. The vaginal por-
tion presents a deep red areola around the os, which easily bleeds on
being wiped, and a plug of thick muco-purulent matter is seen in the
cervical canal. By pressing on the urethra a drop of pus is commonly
brought out. The inflammation is apt to remain long in the upper
part of the vagina. Sometimes it spreads to the vulvo-vaginal or the
inguinal glands, where it may end in resolution or induration, or
cause the formation of an abscess. At the menstrual periods the
symptoms of vaginitis are apt to become more marked, and a decided
exacerbation is caused by pregnancy and childbirth.
In chronic catarrhal vaginitis the symptoms have much less
passed quickly through the flame, and placed from two to three minutes in a solution
of gentian violet, prepared according to the following formula: to 10 cc. of water add
2 cc. aniline oil, shake well, and filter through moist filter-paper. To the clear ani-
line water obtained add 1 ec. of 97 per cent, alcohol and 1 cc. of a saturated alco-
holic solution of gentian violet. The excess of fluid is drained off from the cover-
glass with filter-paper. Next, the cover-glass is placed for five minutes in Grams
iodine solution, which consists of iodine, 1 part ; iodide of potash, 2 ; water, 300 ; and
then placed directly into alcohol, 97 per cent., in order to wash out all the coloring
matter. (Henry Heiman, " A Clinical and Bacteriological Study of the Gonococcus
(Neisser)," New York Medical Record, June 22, 1895.)
346 DISEASES OF WOMEN.
intensity. The patient may, however, complain -of a sensation of
heaviness or smarting. The chief symptom is the discharge, which
sometimes is more purulent, in other cases more mucoid. The vagina
is of a dark red, bluish, or grayish color, and often the seat of ero-
sions. The mucous membrane is thickened, folded, and often more
or less prolapsed.
Vaginitis may have the chronic type from the beginning, or the
chronic may be a continuation of the acute form. Gonorrheal vagi-
nitis is particularly liable to become chronic, because the infecting
element is retained in the urethral ducts, the ducts of the vulvo-
vaginal glands, or the small vestibular glands.
The chronic form is often secondary, due to an irritating discharge
trickling from the uterus, or of constitutional origin in scrofulous or
chlorotic women. It is a frequent accompaniment of old age, and is
quite common during pregnancy.
Diagnosis. The signs of vaginitis are so distinct that the disease
is easily recognized. Still, the physician must be on his guard in
order not to mistake for vaginitis a discharge from the interior of the
womb due to endometritis, cancer, fibroma, or other affections of the
uterus, or a pelvic abscess discharging its contents through a fistulous
tract into the vagina.
The differential diagnosis between gonorrheal and simple non-viru-
lent catarrh is of great importance, both as to treatment and from a
medico-legal standpoint, but science, as a rule, does not warrant us
in going beyond a diagnosis of probability in this respect. We try
to obtain the history of the case. Very often the mere behavior of
the patient furnishes already a strong suspicion that her conscience
is burdened with guilt, and by following this hint the physician may
be able to elicit a confession. Sometimes it is possible to examine
the man who is the source of the infection. The presence of purulent
ophthalmia in children of the family makes the gonorrheal nature
of the vagiuitis probable, the germs of the disease having been carried
to the children by fingers, sponges, towels, etc. On the other hand,
the presence of a gonorrheal vaginitis in a child may be traced to the
same disease in the mother or other female member of the household,
and thereby an innocent man, who is accused of rape, saved from
unmerited punishment, There is no feature in the disease itself that
with absolute certainty can serve to prove whether it is of gonorrheal
origin or not. Severe cases of common catarrhal vaginitis produce a
pus that is contagious. Certain circumstances, however, are more
frequently found in gonorrhea than in non-specific catarrh. The
mucous membrane is of a particularly bright red color ; the discharge
consists of thick creamy pus ; as a rule, the cervical canal aind the
urethra are implicated ; there is greater tendency to inflammation of
Bartholin's glands; the development of vegetations, if the patient is
DISEASES OF THE VAGINA. 347
not pregnant, speaks also in favor of the specific nature of the case.
The presence of recent tears and bruises may be of great importance
as evidence of rape, in which connection it may be worth mentioning
that, unfortunately, there reigns a wide-spread superstition among
uncultivated men that a gonorrhea is cured by connection with a
virgin, which often leads to assaults upon little girls.
The most conclusive proof is thought to be the presence of gonococci,
but there are as yet so great differences between the views of bacteriolo-
gists on this subject, that it would be unjustifiable to base on the bacteri-
ological investigation alone an assertion which may cause the conviction
of an innocent man accused of rape or east the opprobrium of infidelity
on a faithful wife. From a clinical standpoint we must say there is
always doubt as to the specific or non-specific nature of vaginal
catarrh, and therefore, when called upon to give an opinion as experts,
we must give the accused the benefit of the doubt. I have seen cases
of urethritis followed by epididymitis where it was as sure as any
human thing can be that neither husband nor wife had worshiped
strange gods, and I have also seen a newly-married girl, of good
family, set. 17, get all symptoms of gonorrhea, inclusive of salpingitis,
although the husband was examined by a prominent andrologist, who
declared there were no gonococci, but many other kinds of cocci, in
his urethra.
Prognosis. Non-virulent catarrhal vaginitis is, as a rule, not a
dangerous disease. The acute form yields readily to treatment : the
chronic form may be protracted through years. Gonorrheal vaginitis
is a much more serious disease than gonorrhea in men. It is true
that urethritis, on account of the wideness, shortness, and compara-
tively straight course of the canal is cured more easily than in men,
even without treatment, the mere gush of urine serving the purpose
of a thorough cleansing. But, on the other hand, the disease is apt
to linger in the folds of the vagina, in the deep depressions of the
plica? palmatae, in the cervical canal, in Bartholin's glands, in the
urethral ducts, and in the smaller vestibular glands, so that it is
hardly possible to prognosticate its duration. If it extends up through
the uterus and the tubes to the peritoneal cavity, it becomes not only
a disease hard to cure, and sometimes calling for capital operations,
but it jeopardizes of itself the life of the patient. Even in children
it has become necessary to remove the appendages of the uterus on
account of pyosalpinx due to gonorrhea. Apart from the danger to
life and health, it is apt to cause sterility by closure of the tubes or
by imbedding the ovaries in exudative inflammatory masses. If the
woman conceives and gives birth to a child, the chances of catching
puerperal infection are much increased, probably because the presence
of gonococci facilitate the development of pyogenic microbes.
Treatment. Patients affected with severe acute vaginitis should
348 DISEASES OF WOMEN.
stay in bed for eight or ten days, or at least lie quietly on a lounge.
They should l>e given a saline aperient. Their diet should be bland
in quality and moderate in amount. Vaginal injections of plain hot
water should be given, and in order to reach all the recesses of the
vagina it is best to stretch it by means of a wire speculum e. g.
Blakeley's resilient speculum. If the tenderness is so great that no
instrument can be introduced, much relief is experienced by frequent
hot alkaline affusions of the external genitals (borax or bicarbonate of
soda 3j to Oj, with addition of tinct. opii 3j). To the water used for
injection may be added emollient or aromatic substances, such as lin-
seed meal or chamomile flowers. When the pain and tenderness sub-
side and the discharge diminishes, bichloride of mercury (1 : 5000) or
chloride of zinc (1 : 100) are used: In pregnant women it is better,
on account of the risk of mercurial poisoning, to avoid the corrosive
sublimate, and use creolin or permanganate of potassium (1 per cent.)
instead. Still later it is well to paint the affected part of the vagina
with nitrate of silver in substance or in a strong solution (3ss-.lj)
twice a week. If the uterus is affected, that should be treated sepa-
rately. If it is not, a tampon of absorbent gauze with astringent
substances mixed with glycerin, such as subnitrate of bismuth (1 : 4),
boroglyceride (1 : 16), tannin (1:8, see p. 178), is introduced, and
changed every day. lodoform gauze has also a very good effect, but
has an offensive and tell-tale odor. After the nitrate of silver has been
used several times, powdered boracic acid may be introduced through
a speculum into the fornix vaginaB, and retained by means of a tampon.
Antibknnoi-rhagic drugs (oL.santali, bals. copaiva?, and cubebs) are
less well borne by women than by men, and should, therefore, be given
in somewhat smaller doses. They should only be used in the sub-
acute and chronic stages.
In chronic vaginitis astringent injections and applications are used.
Extr. pini Canadensis, used on tampon, is praised. For chronic
urethritis small rods made of iodoform and cacao-butter are intro-
duced and squeezed against the walls. If the gonorrheal poison
lurks in glands and ducts, these must be slit open, touched with pure
carbolic acid, and dressed with iodoform gauze. For further infor-
mation the reader is referred to the chapter on Leucorrhea (p. 250).
Exfoliative, or Epithelial, Vaginitis is a rare disease. It is mostly
combined with exfoliative endometritis (membranous dysmenorrhea)
and found in hysterical women. The vagina shows the usual changes
due to catarrh. Membranes as much as an inch in diameter, and con-
sisting of the epithelium and blood-corpuscles, are, with larger or
shorter intervals, sometimes as often as twice a week, found lying
loose in the vagina, or are easily detached from it without causing
bleeding. At other times the membranes consist of coagulated fibrin,
including blood-corpuscles and epithelial cells.
DISEASES OF THE VAGINA. 349
Astringents make the condition worse. General treatment, espe-
cially with bromide of potassium in large doses, has had better effect.
Emphysematous Vaginitis (Colpohyperplasia cystica Winckel).
Although not very common, this disease is frequent enough to have
been observed by a number of different gynecologists, and some have
treated several cases of it. A prominent gynecologist of this city has
told me how puzzled he felt when he was consulted about a case of this
kind, as he had not the slightest idea what it was. It is characterized
by the presence in the upper part of the vagina arid on the vaginal
portion of numerous translucent, pink, gray, or blueish, soft cysts,
varying in size from a millet-seed to a hazelnut. They are situated
superficially, contain a serous fluid, and often gas. Some have a
central depression. Sometimes they give a crackling sensation like
emphysema. When pricked, the gas escapes with a distinct wheezing
sound and the cyst collapses. The disease is most common in preg-
nancy, but has been found in virgins, but always in women suffering
from profuse catharrhal discharge. It does not give rise to any symp-
toms, except that the introduction of the speculum is painful, and it
disappears within two weeks after childbirth.
It is not definitely determined where the gas is found, whether in the
interstitial connective tissue, in lymph -follicles, or lymphatic vessels ;
but it seems most likely that the condition is caused by stasis in veins
and lymphatics, extravasation of blood, and decomposition of the same,
with formation of gas. That atmospheric air should be drawn in and
prevented from escaping by closure of the entrance seems hardly pos-
sible.
Treatment. In pregnant women no treatment is needed, since the
disease causes no discomfort and disappears after childbirth. In others
it has been recommended to pour dilute hydrochloric acid (1 per cent.)
through a Fergusson speculum on the affected parts, or use injections
with solutions of carbolic acid or corrosive sublimate.
Mycotie Vaginitis. Two kinds of fungi may grow in the vagina
namely, Leptothrix vaginalis and O'idium albicans. Leptothrix con-
sists in fine threads with oval spores. Oi'ditim has hair-like branches.
It is probably the same fungus as the one forming thrush in the
mouth.
Symptoms. Leptothrix gives rise to hardly any discomfort. Oidium
causes sometimes intense pruritus, a burning sensation, swelling, dis-
charge, and even fever. The disease may end in a few days, but
may also last several weeks or months, especially in pregnant women.
The mucous membrane of the vagina is red, tender, and studded with
small white spots, which can only be removed together with the epi-
thelium, and under the microscope prove to be composed of liyphee
and spores.
Etiology. Vaginitis and pregnancy predispose to the development
350 DISEASES OF WOMEN.
of fungi. These may be directly brought in during coition with men
affected with diabetes, a disease which frequently is accompanied by
the presence of fungi between the prepuce and the gland. They may
also be carried on fingers that have handled flour e. g those of mil-
lers or bakers.
Prognosis. The prognosis is good, and the disease can be cured in
a fortnight.
Treatment. Frequent vaginal injections with sulphate of copper
(1-2 per cent.), salicylic acid (1-2 per thousand), carbolic acid (3 per
cent.), creolin (1 per cent.), or corrosive sublimate (1-2 per thousand).
The last-named substance should not be used in pregnant women,
on account of the danger of absorption (p. 199). The same solutions
may be used for swabbing the vagina through a speculum. Warm
sitz-baths, with addition of a little soda or borax, or injections with
flaxseed tea and similar emollient substances, are particularly indi-
cated in the beginning, if the inflammation is more acute.
B. Exudative Vaginitls. A fibrinous exudation takes place on
the surface or in the mucous membrane of the vagina. It makes its
first appearance as discrete spots not larger than millet-seeds, but soon
these spots extend in all directions and melt together, so as to form
one or more large, thick patches. The parts surrounding the patches
are more or less swollen, dark red, brown, or dirty greenish. 1
It is not settled whether this condition is identical with the process
that takes place in the throat in the disease called diphtheria or
not.
Etiology. It is the most common form of puerperal infection. It
appears also in severe general diseases, such as typhus, small-pox, and
measles. Gonorrhea rarely gives rise to it. Local irritants, such as
too strong injections of bichloride of mercury, may cause it. 2
Prognosis. When due to local irritation exudative vaginitis is of
slight importance; when symptom of a general disease, it is a sign
of serious systemic disturbance; and when caused by local infection
during childbirth or in the puerperium, there is imminent danger of
general infection, which may end in death.
Treatment. If the condition is due to local irritants, they must, as
far as possible, be removed and mild healing substances, such as vase-
line, glycerate of tannin, a weak solution of borax, used for applica-
tion or injection.
If it appears as result of local infection, an entirely different course
should be followed. In my experience the best practice is to use
cauterization with chloride of zinc dissolved in equal parts of dis-
1 For further details see Garrigues, " Puerperal Diphtheria," Trans. Afaer. Gyn.
Soc., 1885, vol. x. p. 96.
* Garrigues, " Corrosive Sublimate and Creolin in Obstetric Practice," Amer. Jour.
Med. Sci., 1889, vol. xcviii. p. 115.
DISEASES OF THE VAGINA. 351
tilled water. Others use pure carbolic acid, Monsel's solution of sub-
sulphate of iron mixed with glycerin, tincture of iodine, iodoform, etc.
When it is a part of a general systemic infection, the preparations
of iodine and iron may be used locally in connection with general
tonic treatment.
Dysenteric Vaginitis. This is a variety of exudative vaginitis,
sometimes found in patients suffering from chronic dysentery, and
who have a gaping vulva, through which the dysenteric process
extends into the lower part of the vagina. Small gray membranes,
composed of loosened epithelium, and superficial ulcers surrounded
by a dark area with overfilled blood-vessels, form on the mucous
membrane. In and under the epithelium are found layers of micro-
cocci.
Treatment. Besides treating the affection of the intestine espe-
cially by regulation of diet, astringent medicines, injection with a
teaspoonful of subnitrate of bismuth in a cupful of boiled starch, or
even cauterization with nitric acid the vagina must be treated as
stated above.
C. Phlegmonous Vaginitis. Phlegmonous vaginitis is the inflam-
mation of the connective tissue surrounding the vagina.
1. One form of this, and the most characteristic, is that known as
dissecting vaginitis, in which the whole vagina, with the vaginal por-
tion of the uterus, is loosened by suppuration from the neighboring
tissue and expelled in one mass. Only a few cases of this affection
have been reported. They appeared in the course of severe feverish
diseases, such as typhoid fever, pneumonia, perhaps gonorrhea, and
the affection in all came on immediately after menstruation.
Symptoms. The patient complains of more or less intense pain.
There is a sanious discharge. The labia majora are swollen and the
seat of superficial ulceration. The mucous membrane of the vagina
is swollen, pale, or necrotic. After the expulsion of the vagina the
surface heals by granulation, and considerable stenosis is liable to
follow.
Treatment. A tampon soaked in camphor emulsion
R. Camphorae, 3ss;
Mucilag. acacise, 3j ;
Aquae, 3iv.
M. Sig. Shake well
should be kept in the vagina until all necrosed tissue is separated.
The separation should be aided by cautious pulling and cutting of
resistant sinewy strings. After expulsion the surface should be dusted
with iodoform or smeared with iodoform ointment, and stenosis should
be guarded against by the use of tampons and the frequent introduction
of a speculum.
352 DISEASES OF WOMEN.
2. Another form of phlegmonous vaginitis is caused by the burrow-
ing of pus from a pelvic abscess. For a time a fluctuating swelling is
felt somewhere on the wall of the vagina, and later this opens into
the vagina or the rectum. Often fistulous tracts remain for a long
time, and the suppuration may finally exhaust the patient's strength
and lead to her death.
Treatment. An abscess of the latter kind should be freely opened
from the vagina as soon as felt. The cavity should be injected with
antiseptic fluids and loosely packed with iodoform gauze. Later it
may be necessary to dilate fistulous tracts with laminaria or the knife.
Vulvo-vaginitis in Children. The vagina and vulva are not infre-
quently inflamed in infants and children. The inflammation may
be catarrhal or gonorrhea! . The catarrhal form is produced by
uncleanliness, foreign bodies, pinworms, masturbation, enuresis, hyper-
acid urine, or eruptive fevers. The gonorrheal is due to the pres-
ence of the gonococcus. There seems also to be an infectious, non-
gonorrheal form.
The treatment should consist in cleanliness, antacids given inter-
nally, and injections of a quart of 1 : 3000 solution of permanganate
of potash, made with a soft-rubber catheter and repeated three times
a day. This leads to a cure in from twelve to fifteen days.
CHAPTER VIII.
GANGRENE OF THE VAGINA.
Etiology. Gangrene of the vagina may be caused by the presence
of foreign bodies e. g. pessaries, or the contact with caustics e. g.
a tampon soaked in undiluted liquor ferri chloridi (p. 179). It may
be due to pressure of the head of the child where, in consequence of
mechanical disproportion between the child and the pelvic canal, im-
paction is allowed to take place. The most common locality of this
occurrence is the upper part of the anterior wall of the vagina, which
is caught between the head of the child and the symphysis pubis, and
leads after the separation of the necrosed plug to the formation of a
vesico-vaginal fistula.
Gangrene of the vagina, like that of the vulva, may appear in
conjunction with noma, and is then perhaps due to direct transmission
of toxic material from the cheek to the genitals. It may also be
brought about by diptheritic ^vaginitis (p. 350).
Morbid Anatomy. The whole mucous membrane, inclusive of that
DISEASES OF THE VAGINA. 353
covering the vaginal portion of the uterus, may be changed to a black,
pulpy malodorous mass, and the destruction may extend more or less
into the depth of the underlying tissue.
Symptoms. Gangrene is accompanied by pain, dysuria, inability to
walk, and sometimes hemorrhage, which may even become fatal.
Fever is not always present.
Treatment. The vagina should be injected with solutions of car-
bolic acid, creolin, or acetate of alumina (1 per cent.), and a tampon
with the above-mentioned camphor emulsion (p. 351) or a saturated
solution of chlorate of potash left in it. Dead tissue should be
removed as soon as feasible. The granulating surface should be
dusted with iodoform or smeared with iodoform ointment, and care
taken to obviate stenosis (pp. 330, 331). The general treatment con-
sists in a liberal use of stimulants, tonics, and a nourishing diet.
CHAPTER IX.
ERYSIPELAS OF THE VAGINA.
IN a patient who died of general erysipelas the affection had spread
to the vagina. The entire mucous membrane was red, swollen, wrin-
kled, and studded with vesicles, and in some places the epithelium
had been thrown off.
Treatment. If the erysipelatous inflammation is discovered in
time, the vagina should be cleaned 'with creolin injections and dusted
with iodoform in conjunction with the general treatment of erysipelas.
CHAPTER X.
CICATRICES.
THE vagina is often the seat of cicatricial tissue, resulting from
inflammation, ulceration, or gangrene. 1
Etiology. The most common cause is a laceration and sloughing
occurring in childbirth. Cicatrices may also be formed by the use
of caustics e. g. chloride of zinc for diphtheritic ulcers (p. 350).
Unsuccessful plastic operations, where large surfaces heal by granula-
tions, leave also large scars.
Symptoms. The presence of such cicatricial tissue may give rise to
1 A valuable paper on this subject by Skene, with important remarks by T. A.
Emmet, is found in Tram. Amer. Gyn., 1876, vol. i. p. 91, et seq.
23
354 DISEASES OF WOMEN.
pain, which, although the lesion is permanent, may be intermittent or
remittent. This pain is probably due to irritation of fine nervous
fibrillaB enclosed in the scar. By reflex action neighboring organs
often become painful, so that the patient suffers from dysuria and
dyschezia ; but reflex neuroses may also appear in remote parts of the
body e. g. in the pit of the stomach, under the left breast, etc.
Cicatricial bands extending between the walls of the vagina or be-
tween them and the vaginal portion of the uterus, or ring-shaped
contraction of the vagina, may cause dyspareunia, and, when the
constriction is considerable, even dysmenorrhea. The condition may
end in complete atresia with all its consequences.
The cicatricial band may frustrate the use of vaginal pessaries, and
place serious obstacles in the way of success in operating for vaginal
fistulae.
The scar tissue is harder, less elastic, of lighter color than the
normal vaginal wall, and has a smooth surface. During pregnancy
it softens very much, so that even extensive scars need not give
trouble in a subsequent childbirth.
Treatment. As prophylaxis care should be taken, in employing
caustics, not to use them on larger surfaces nor to a greater depth than
is absolutely necessary. To prevent the formation of these cicatricial
bands after childbirth by the use of sutures is hardly feasible, since
they are formed on bruised and sloughing tissues which could not be
united in that way. Sometimes a judicious use of tampons or dila-
tors during the healing of a suppurating surface may, however, limit
the evil considerably.
The curative treatment has recourse to three methods incision,
excision, and insertion of flaps of healthy tissue. A projecting thin
band may simply be severed.
If the cicatrice is imbedded in the tissue like a cord and is not too
extensive, it may be cut out, and the edges united with sutures. If
it is very long, it is divided into sections ; the edges of which are
separated half an inch or more if possible, and healthy tissue brought
in between from each side to fill the gap, where it is secured by inter-
rupted sutures.
If the cicatricial surface is spread out and superficial, it is to be
snipped through with the points of a pair of scissors at regular inter-
vals. Another parallel column of incisions is formed in the same
manner, but in such a way that the cuts are placed opposite the
spaces between two and two incisions in the first column. Thus the
whole surface is gone over and kept on the stretch during the heal-
ing process by means of a glass plug (p. 330), or better , by Boze-
man's vaginal dilators, consisting of cylinders of hard rubber with
rounded ends and attachment for a string. Others recommend slip-
pery-elm bark made into a roll and beaten till it is soft. Before
DISEASES OF THE VAGINA. 355
introduction it is dipped in carbolized water (1 per cent.). It swells
slowly and promotes healing.
CHAPTER XL
VAGINISMUS.
VAGINISMUS consists in a painful tetanic contraction of one or
more muscles surrounding the vagina.
According to its seat it may be divided into two species superficial
and deep vaginismus. The superficial has its seat at the entrance of
the vagina (see p. 43), probably in the bulbo-cavernosus muscle.
The deep is a spasm of the levator ani muscle. The superficial is
commonly found in women with an intact hymen, the disease itself
preventing sexual connection, but may be developed in women who
have even borne children.
Etiology. Nearly always some palpable local disease is found in
the genitals or the neighboring organs, such as an inflamed hymen,
irritable carunculee myrtiformes, fissures of the fourchette or vaginal
entrance, a neuroma of the fossa navicularis, a urethral caruncle, a
fissure of the neck of the bladder or of the anus, vulvitis, vaginitis,
a granular os uteri, eudometritis, displacement of the uterus, or pelvic
inflammation. An unusually large male member or awkwardness in
its use may bring about some of the above-named conditions, and thus
be the cause of the disease, but more frequently the underlying fault
is a nervous disposition and fear of pain in the female. Lead-poison-
ing is also said to produce vaginismus.
Symptoms. In superficial vaginismus it is not only the attempt at
coition that brings on a spasm of the muscles surrounding the vagi-
nal entrance, which closes it against the introduction of the penis, but
the spasm is observed when the physician tries to make a digital
examination or introduce a speculum ; even the slightest touch witli a
feather or a camel's-hair brush or the introduction of a catheter into
the urethra may suffice to bring about the tetanic contraction. Some-
times the sphincter aui muscle may enter into a similar condition, or
even general convulsions of the whole body be added. I have seen
opisthotonus arise which would have sufficed to throw any man aside.
Deep vaginismus also called penis captivus, is a much rarer affection,
consisting of a similar spasm in the depth of the vagina. It occurs
during coition or during a digital examination. No difficulty is expe-
rienced at the vaginal entrance, but in the depth of the tube a resist-
ance is met with in the shape of a tetanically contracted circular band,
which prevents further progress. If the spasm occurs after full intro-
356 DISEASES OF WOMEN.
duction of the penis, the corona is encircled, and the attempts to
withdraw the penis cause great pain to both participants in the
act.
Prognosis. If neglected, vaginismus is a source of great physical
and mental misery; if properly treated a cure may always be effected.
Treatment. If one of the above-named causes is found, it must
first of all be removed. Fissures of the hymen, vaginal entrance, or
anus are best treated with pledgets soaked in a 4 per cent, solution of
chloral hydrate. Others recommend ointments with opium, bella-
donna, or other narcotics. Neuromata, urethral caruncles, and car-
unculse myrtiformes are snipped off with curved scissors. A fissure
of the neck of the bladder is treated with overdistension, cocaine
bougies left to melt in the urethra
Jfy. Cocaina? hydrochlorat, gr. xij ;
Ol. theobroraatis, q. s.
M. Ft. bacilli, No. xii,
Sig. One morning and evening
and application of a strong solution of nitrate of silver. In regard
to the other affections named, the reader is referred to the chapters
in which they are discussed.
Much benefit may be derived from the use of warm hip-baths, sup-
positories with iodoform (gr. v), atropine ointment (gr. ij to j), and
the application twice a week of a solution of nitrate of silver (gr. x
or xx to 3j) to the vulva and hymen, followed by cold, and later
lukewarm, applications.
The galvanic current, with the soothing positive pole on the affected
parts, has given good results..
The general treatment is of the very greatest importance, and its
aim must be to brace the patient up physically and morally. If feas-
ible, she should be separated for a time from her husband, and, at all
events, all attempts at sexual intercourse must be strictly forbidden.
She should have pleasant surroundings, cheerful company, and much
exercise in the open air, preferably on horseback. She should take a
regular course of gymnastics tending toward muscular development
of other parts and control over the nerves. Hydrotherapy is also very
useful in drawing away the abnormally concentrated sensibility from
the genitals.
If these two lines of treatment, removal of the cause and general
tonic treatment, do not lead to a cure, sharper local treatment is re-
quired. The patient is anesthetized and the vaginal entrance forcibly
distended with two fingers or a plurivalve speculum. As after-treat-
ment a vaginal glass plug (p. 330) is used morning and evening for
a couple of hours.
Sometimes the removal of a fleshy, resistant, hyperesthetic hymen
by means of a pair of curved scissors will promptly lead to a com-
DISEASES OF THE VAGINA. 357
plete recovery. In other cases it is neceasary to follow this operation
up with incision of the vaginal entrance.
The simplest way of doing this is to insert a Sims speculum under
the pubic arch, put a finger into the rectum, press the sphincter ani
up against the posterior vaginal wall, and divide with scissors on
each side of the median line the fibers encircling the vaginal entrance,
leaving a space of three-quarters of an inch between the two incisions
(T. A. Emmet).
Another mode of incision is to imitate the tear in the median line
through the perineal body that often takes place in childbirth (T. G.
Thomas).
Sims's operation is a very bloody one, and may with advantage be
replaced by one of the two already mentioned. After excision of the
hymen the left index and middle fingers are introduced into the
vagina and spread out, so as to dilate the vagina as much as possible
and put the posterior commissure on the stretch. Next a deep incis-
ion is made with a scalpel through the vaginal tissue on one side of
the median line, downward and inward, ending in the raphe of the
perineum. This incision forms one branch of a Y. Then the knife is
reintroduced into the vagina, which is yet kept dilated by the fingers,
and a similar incision is made on the other side from above downward
and inward. These two incisions are united in or near the raphe,
and prolonged as a single incision to the integument of the perineum.
Each of these incisions will be about two inches long namely, half
an inch above the edge of the bulbo-cavernosus muscle, half an inch
across its fibers, and an inch from its lower edge to the skin of the
perineum. The glass plug is introduced immediately, and effective
compression exercised by means of compresses and a T-bandage.
Neurotomy of the pudic nerve in the perineum has been advised,
but reference to the anatomical description (p. 109), will show that
not even its main branch, the perineal nerve, is within reach. The
branches of the latter may indeed be cut by deep lateral incisions, but
the danger of a hemorrhage hard to control is very great, and simply
severed nerves grow easily together.
The deep vaginismus is treated by attention to the cause, especially
a granular os, by the same general treatment as recommended for
the superficial form, and to overcome the spasm that keeps the penis
captive the introduction of a finger into the rectum has been recom-
mended. All attempts at violent separation must be desisted from.
The captive has to remain imprisoned until the subsidence of the
spasm or erection allows an easy withdrawal. If ether is available,
the mere administration of it would probably end the spasm, even
before anesthesia is produced.
358 DISEASES OF WOMEN.
CHAPTER XII.
NEOPLASMS.
1. Cysts. 1 Cysts are rather frequently found in the vagina. As
a rule, the patients are adults, but congenital cysts have been seen in
the vagina of new-born children. Commonly these cysts are single,
but occasionally two or more are found in the same individual. They
are most frequently situated on the anterior wall. They are globular
or oblong, mostly sessile, but may become pedunculated and hang out
from the vulva. They grow very slowly, and have often been
observed for many years. They vary in size from that of a pigeon's
egg to that of a goose egg, but may exceptionally reach the size of
the fetal head at term.
The wall varies in thickness from half a millimeter (^ inch) to
a centimeter (|- inch). It is composed of connective tissue, and some-
times muscle-fibers. The inside may be lined with simple or ciliated
columnar or with flat epithelium, or be without epithelium.
The contents may also vary very much. They may be serous, yel-
lowish, purulent, or thick and chocolate-colored. Sometimes they do
not contain form-elements ; in other cases we find blood-corpuscles,
pus-corpuscles, oil-globules, granular cells, epithelial cells, or choles-
terin crystals.
As a rule, the mucous membrane covering the cyst is freely mov-
able and normal, but sometimes it becomes atrophic. The cysts may
burst spontaneously with or without suppuration, or be ruptured by
injury, especially childbirth. The contents may be discharged into
the vagina, the bladder, the urethra, or through the perineum.
Vaginal cysts may have very different origins. They may be
formed by condensation of the perivaginal connective tissue round
an extravasation of blood. They may be retention cysts, due to
closure of the outlet of the glands of the mucous membrane which
some observers have found (p. 44). Some have been explained as
dilated lymphatics. Another theory is that some are developments
of part of one of the Miillerian ducts which has failed to unite with
its fellow in the formation of the vagina. Some are most likely
formed in Gartner's canal, and may then communicate with a par-
ovarian cyst. 2 Perhaps some are developed from periurethral glands.
Symptoms. If these cysts are small they may not give rise to any
symptoms, and are discovered accidentally during delivery or gyne-
1 An exhaustive paper on the subject hy Dr. G. W. Johnston of Washington, D.
C., can be found in Amer. Journ. Obst., 1887, vol. xx. p. 1121.
2 Garrigues's report on a cyst extirpated by Dr. K. Watts, Amer. Jour. Obst., 1881,
p. 849, and a note on Gartner's canals in New York Med. Jour., March 31, 1883, vol.
xxxvii. p. 348.
DISEASES OF THE VAGINA. 359
cological examination instituted for other purposes. If they are of
considerable size, they cause dyspareunia and a bearing-down sensation.
They may also cause leucorrhea, dysuria, and dyschezia. Sometimes
they are fluctuating.
Prognosis. Many of them give no trouble; they grow slowly or
become stationary ; if necessary they can easily be removed.
Diagnosis. Cystocele may resemble a cyst very much, but the
swelling disappears when a catheter is introduced into the bladder.
In emphysematous vaginitis there is a large number of small cysts in the
fornix, and on being punctured they are found to contain gas. Cysts
of the vagina are single or few in number, of larger size and filled
with a fluid. From solid growths they differ by their fluctuation or
elasticity, or by yielding fluid when exploratory puncture is resorted
to. Hydatids of the pelvis are filled with a clear, colorless fluid without
albumin, containing the characteristic booklets, or perhaps a piece of
cuticula with its pathognomonic parallel structureless lay ere.
Treatment. The best way is to extirpate them and unite the edges
by suture. In order to facilitate the extirpation if the wall is thin,
they may be emptied and injected with melted spermaceti, which is
thereafter solidified by the application of ice. 1 But their relation to
the bladder may be so intimate that we would risk cutting into that
viscus. Under such circumstances partial excision of the wall is
preferable. The most prominent point is seized with tenaculum-for-
ceps or volsella and the anterior wall of the cyst cut off with the
covering mucous membrane of the vagina, leaving the bottom of the
cyst undisturbed. In order to arrest hemorrhage and avoid sup-
puration the edges of the mucous membrane may be sutured to those
of the cyst (Schroeder's method), the wall of which changes character
and becomes like the rest of the vagina. It may also simply be left,
and is later exfoliated. During this process antiseptic injections should
be used.
When the vaginal cyst communicates with a parovarian cyst, it is
recommended to open the vaginal cyst as far as the base of the broad
ligament with the therm o-cautery, and treat the parovarium with
iodized injections and a drainage-tube. 2
2. Fibroids (Fibroma, Myofibroma, Fibromyoma). Fibrous tumors
of the vagina are rather rare, especially when compared with their
frequency in the uterus. Their most common seat is the upper part
of the anterior wall. They are very rarely pure fibroids ; that is to
say, composed of connective tissue alone. As a rule, this tissue is
intermixed with a greater or lesser amount of unstriped muscular
fibers. Their starting-point may be in the submucous or perivaginal
connective tissue or in the muscular coat of the vagina. Sometimes
1 Pozzi's method. (Compare p. 290.)
2 Amand Routh, Trans. Obst. Soc. London, vol. xxxvi.
360 DISEASES OF WOMEN.
a fibroid in the recto-vaginal partition is in reality a uterine fibroid
that has developed downward, just as, on the other hand, a true vagi-
nal fibroid may extend into the vulva.
According to the predominance of the connective or muscular ele-
ment, these tumors are harder or softer. Like similar tumors of the
uterus, they may undergo a softening by accumulation of serous fluid
in the mesh work of their interior.
Originally they are globular sessile tumors imbedded in the wall of
the vagina, but when their weight increases they have a tendency to
become pedunculated, and may then even protrude through the vulva.
Such pedunculated tumors are called fibroid vaginal polypi. Exposed
to the air and friction of the clothes, they may begin to ulcerate on
the exposed surface. In the lower part of the vagina they often
become intimately adherent to the urethra.
As a rule, they are single.
Etiology. They may be small as a pea, but they may also become
quite large and weigh up to ten pounds. Their growth is a very slow
one, and may extend over many years. They are commonly found
in adults, but may occur in children. The cause that produces them
is unknown.
Symptoms. When small they give rise to no symptoms, and are
found accidentally. When they increase in size they cause leucorrhea.
When they become still larger and heavier, they cause a dragging sen-
sation, dyspareunia, dysuria, dyschezia, and may oppose a very serious
obstacle to childbirth. Sometimes they are accompanied by severe
hemorrhage.
Diagnosis. When small or middle-sized, they are easy to diagnos-
ticate by their elastic hardness. It is true, a thick -walled cyst gives a
somewhat similar sensation, but all doubt may be dispelled by means
of an aspirator. When they are large enough to fill the vagina, it
may be difficult to differentiate them from uterine fibroid polypi. If
it is possible to reach the os, this will be found undilated, and no ped-
icle passes out through it. From sarcoma a fibroid is distinguished
by its slow growth ; it does not undermine the constitution ; and the
microscopical structure is entirely different.
Prognosis. The prognosis is favorable. Small fibroids give no
trouble. They grow slowly, and if necessary they can be removed
by operation. When they suppurate, there is, however, danger of
septicemia.
Treatment. A pedunculated fibroid may be removed by tying an
elastic ligature around the pedicle, which will be severed in a few
days. Or it may be cut at once with an ecraseur or a gal vano- caustic
snare, or transfixed with a needle armed with a strong double silk
ligature, which is cut in the middle, and the two halves crossed and
tied on either side, when they are interlocked like the links of a chain.
DISEASES OF THE VAGINA. 361
Finally the tumor is cut off. Any of these methods prevents hemor-
rhage.
A sessile fibroid is removed by making an incision over its longest
diameter and enucleating it. In order to avoid hemorrhage, fingers
and blunt instruments should be used as much as possible. The
galvano-caustic knife or the thermo-cautery may occasionally be used
to advantage when there is much hemorrhage. If the tumor is large,
a part of the mucous membrane covering it is included between two
curved incisions blending at their ends, and the circumscribed piece is
left on the tumor. After plain enucleation the edges of the wound
are brought together with deep sutures. Otherwise the wound must
be packed with iodoform gauze.
3. Mucous Polypi. Rarer than the hard fibroid polypi are soft
growths of similar shape, in structure like the mucous, or glandular,
polypi so common in the cervical canal. They give rise to the same
symptoms as fibroid polypi. They are very vascular, and the safest
way to remove them is, therefore, by means of the elastic ligature or
by transfixion of the pedicle, as just described.
4. Sarcoma. This is a rare disease. It appears in t\vo forms
one circumscribed, forming interstitial globular tumors like fibroids;
the other diffuse, extending along the surface like carcinoma.
It has been noticed that of the small number of cases recorded
comparatively many have occurred in early childhood.
In the circumscribed form the development is slower, and may
take a couple of years, but, as a rule, the malignancy of the tumor
reveals itself by its rapid growth.
The prognosis as to a complete cure is very doubtful, as this affec-
tion has great tendency to relapse even after complete extirpation.
Symptoms. In adults they are insignificant in the beginning.
Later there are leucorrhea, hemorrhage, dysuria, and sensation of
pressure. The tumor ulcerates and discharges a sanious fluid. The
neighboring organs become implicated, and the general health is
undermined. In children the symptoms referable to pressure on the
organs in the pelvis soon become pronounced.
.Diagnosis. The diagnosis from fibroid and carcinoma can only be
made by microscopical examination.
Treatment. Circumscribed tumors are extirpated like sessile
fibroids. The diffuse form may be kept in check for a time by
curetting and cauterization with thermo- or galvano-cautery, or chlo-
ride of zinc as in cancer of the uterus.
5. Carcinoma. Primary carcinoma of the vagina is a rare disease.
As a rule, it is secondary, either propagated by continuity from
neighboring organs, especially the cervix uteri, or appearing as
metastatic deposits from carcinoma in remote parts.
It is found in two forms, either as a circumscribed papillary growth,
362 DISEASES OF WOMEN.
and then it is epitheliomatous in structure, or as a diffuse carcinoma-
tous infiltration, which again may have the medullary or scirrhous
type. The diffuse form affects sometimes the shape of a ring.
The cause is unknown. The disease is rarely found before the age
of thirty years.
Cancerous tumors develop rapidly. The center ulcerates while the
periphery spreads over the neighboring tissues. In consequence of
the central breaking down, fistulous communications with other canals
may be formed, the most frequent of which is a recto-vaginal fistula.
The lymphatic glands in the pelvis and at the groin soon swell.
The chief symptoms are the sanious, dirty, ill-smelling discharge
from the ulcer, hemorrhage and pain, to which may come the common
symptoms due to pressure and obstruction, dyspareunia, dysuria, dys-
chezia, and dystocia.
Diagnosis. The broad basis, the friable substance, and the hem-
orrhage caused by touch are characteristic. The friability, the ulcera-
tion, and the hemorrhage serve to distinguish the papillary epithelioma
from simple papillomatous vegetations (p. 277). From sarcoma car-
cinoma can only be distinguished by means of a microscopical exam-
ination. The distinction between primary and secondary carcinoma
is of great importance in regard to treatment. Bearing in mind that
the vagina is rarely the original seat of carcinoma, we must carefully
examine all neighboring organs from which it may have spread, and
even other organs from which germs may have been detached and
carried to the vagina.
Prognosis. The disease, as a rule, has made so much headway
before it comes under treatment that a radical cure is impossible.
Even after seemingly complete extirpation relapse is common. The
whole body is gradually infected, and the disease soon ends in death.
Treatment. If there is any possibility of operating in healthy tis-
sue, the whole tumor should be extirpated and the wound closed by
sutures, which both will arrest hemorrhage and bring about union by
first intention. In this respect it is advised not even to abstain from
excising parts of the bladder and the rectum, the edges having good
tendency to unite if properly brought together by sutures. Of late
it has even been demanded that under all circumstances the uterus
should be removed. 1
In most cases only a palliative treatment can be attempted, but life
may be prolonged and sufferings alleviated by a judicious use of the
sharp curette, thermo- or galvano-cautery, chloride of zinc, or bro-
mine, applications or injections of chloride of iron, creolin injections,
tonics and narcotics, in which respect the reader is referred to the
chapter on Carcinoma of the Uterus.
6. Tuberculosis. Tuberculosis of the vagina is much more common
1 Mackenrodt, Oentralbl.f. Gynak., 1896, vol. xr. No. 5, p. 129.
DISEASES OF THE VAGINA. 363
than that of the vulva, but is still rather rare. It forms ulcers on
the posterior wall of the vagina, owing to stagnation of infecting
material from the uterus, the disease in the vast majority of cases
being only found in connection with tuberculosis of that organ.
Miliary nodules, ulcers, and caseous masses are visible in the vagina
and on the vaginal portion of the uterus, and the microscopical exam-
ination shows the presence of bacillus tuberculosis. Tuberculous
ulcers form easily fistulas opening into the bladder, the urethra, or
the rectum. The tuberculous nature of these fistulas is revealed by
the presence of nodules and bacilli around their opening.
Such fistulas must be cut out in a wide circumference. Operations
for their closure oifer scant hope of success. For further information
the reader is referred to what has been said about the same affection
in the vulva (p. 288).
CHAPTER XIII.
FlSTUL^E.
Definition. A fistula is an abnormal opening leading from the
genital canal to the urinary tract or the intestines.
In a more limited sense the word is only applied to such openings
the edge of which is covered with epithelium, leaving out fresh
wounds extending from one canal to the other, or ulcers eating their
way through the partition between them.
Pathological Anatomy. According to the nature of the extraneous
matter that finds its way through the fistulas into the genital canal
they are divided into urinary and fecal fistulas.
A. Urinary fistulce are again divided, according to the organs
through which the fistula goes, into (1) vesico-vaginal, (2) urethro-
vaginal, (3) uretero-vaginal, (4) vesico-uterine, (5) vesico-utero-vaginal,
(6) ureter o-uterine, and (7) uretero-vesico-vaginal.
There may be one or more fistulas, and in size they vary from a
scarcely perceptible aperture to an opening measuring two inches in
diameter.
1. Vesico-vaginal Fistula. The most common urinary fistula is the
vesico-vaginal variety. The following description applies, therefore,
more particularly to it, and the peculiarities of the rarer forms will
be mentioned later on.
Etiology. By far the most common cause of fistula is childbirth.
The mechanism maybe twofold. The abnormal communication may
be due to a tear, and appear immediately after delivery, or it may be
due to pressure with consequent necrosis, and not be developed before
several days or even weeks have elapsed since parturition took place.
364 DISEASES OF WOMEN.
Tears are especially found in old primiparse or after the use of ergot or
in cases in which the forceps was applied before the cervix was suffi-
ciently dilated. Pressure is due to a disproportion between the child
and the genital canal, a distended bladder, a loaded rectum, a stone in
the bladder, abnormal presentations, etc. In this connection it must
be noted that the tissues withstand much better the same degree of
pressure if it is exercised for a shorter time. Fistula? from pressure
are, therefore, as a rule, not due to the use of forceps, but to improper
delay in their use. As soon as the presenting part becomes impacted
and does not move to and fro during and between labor-pains, artificial
help ought to be given immediately. In consequence of the im-
proved midwifeiy and the much more frequent use of the forceps
fistula? have become much rarer now than they used to be, and come
mostly from remote localities where proper assistance is not avail-
able.
Fistula? are sometimes due to operations, not only the bungling
attempt of the ignorant abortionist, but also in legitimate operations
performed by skillful operators. Thus the formation of a vesico-
vaginal fistula is a not uncommon accident in vaginal hysterectomy
i. e. the removal of the uterus.
In rare cases foreign bodies, such as a pessary in the vagina or a
stone in the bladder, have gnawed a hole through the partition be-
tween the urinary and genital tract.
A pelvic abscess opens sometimes in such a way as to give rise to a
urinary fistula.
Symptoms. The chief symptom is the more or less constant drib-
bling of urine from the vagina, but this does not suffice for a diagno-
sis, as the same takes place if the sphincters of the urethra are lost
or paralyzed, and, on the other hand, if the urinary fistula is situated
high up, the urine may be retained for a long time in the erect pos-
ture, and in urethro- vaginal fistula it may be entirely retained except
during voluntary micturition.
In spite of the utmost cleanliness fistula patients have a disagree-
able ammouiacal odor. If the fistula is large, it may be felt by digi-
tal examination.
In most cases it can be seen by introducing a speculum and placing
the patient in different positions, especially Sims's, the genu-pectoral,
and the dorsal with elevated pelvis (p. 197).
Sometimes, however, the opening is so minute that it cannot be
discovered, or it may be hidden by a projecting cicatrix. By inject-
ing a colored fluid for instance, milk into the bladder the presence
of a vesico- vaginal fistula may be established. A good way to find
a minute opening is to cover with a piece of linen the space within
which the opening is supposed to be. Urine will go right through it
and make the linen wet (Bozeman). Sometimes the opening cannot
DISEASES OF THE VAGINA. 365
be made visible and accessible before intervening cicatricial bands are
cut and distended (p. 354).
Prognosis. Small fistula? heal sometimes spontaneously, even after
a number of years. A later pregnancy has been seen to effect a cure.
Until Sims's time most urinary fistula? were, however, practically in-
curable. Now, on the contrary, the operations have been brought to
such a degree of perfection that very few resist treatment. It is, how-
ever, quite frequent that two or more operations are needed before
complete success is obtained. With proper care the danger of the
operation is very small.
Treatment. The remedies at our command are cleanliness, cauter-
ization, and closure by means of suture, either at the fistula or at a
more or less remote point.
1. Q,eanliness. A fresh fistula, even of considerable size, may be
much diminished, and sometimes closed altogether, by giving hot vagi-
nal injections and using remedies that render the urine normal. As
it has a tendency to become alkaline and deposit phosphates, acids are
indicated, especially benzoic, boric, nitric, and phosphoric. 1
Phosphatic incrustations should be removed mechanically, and
the parts lubricated with vaseline or zinc ointment. Raw sur-
faces are brushed over with a solution of nitrate of silver (gr. x
to 3j) twice a week. Sitz-baths, once or twice a day, are also very
useful.
2. Cauterization. This method is little used now-a-days, since the
perfection of the closure by suture. It may, however, be tried for
small fistula?, and is often used successfully, when a small opening
remains or forms in a stitch-canal after the operation by suturing.
The part is rendered insensitive by means of cocaine (p. 209). The
galvano- or thermo-cautery may be used. Among chemical caustics,
the nitrate-of-silver stick, nitric acid, carbolic acid, and tincture of
cantharides are the best. The cauterization ought not to be repeated
until granulations have developed, and do not grow any more. The
effect of the cauterization is much enhanced by the use of a permanent
catheter.
3. Closure by Suture at the Seat of the Fistula. This is the most
reliable and satisfactory of all methods. We must consider sepa-
rately the preparatory treatment, the operation, and the after-treat-
ment, all of which are of great importance in effecting a cure.
The best time for operating is six or eight weeks after confinement.
1 Dr. Emmet recommends Acid, benzoici ^ij, Sodii borat. ^iij, Aqu. ^xii. M. Sic;. :
A tablespoonful in water three or four times a day. When the nrine has become acid
the dose should be reduced. The benzoates of ammonium, lithium, or sodium (gr.
v-xxx have the same effect. I have also seen good effect of a saturated solution of
boric acid, a tablespoonful four times a day; 8 drops of dilute nitric acid in a medi-
cine four times a day ; and Horsford's acid phosphates, a teaspoonful in a wineglass
of water, three times a day.
366 DISEASES OF WOMEN.
Before that period spontaneous closures might take place or cauteriza-
tion might suffice for the purpose. The lochial discharge would be
unfavorable for healing by first intention, and the sutures would be
more liable to cut through the friable tissue. Later the bladder con-
tracts and cicatrices become harder.
The preparatory treatment consists in the same measures we have
just mentioned under the heading of Cleanliness namely, hot vagi-
nal douches, sitz-baths, acid medicines, removal of incrustations, the
use of mild ointments, and painting with astringents. Hairs that are
incrustated with urinary deposits are cut off. Cicatricial bands are
cut with knife or scissors and the vagina dilated by the introduc-
tion of a Bozeman dilator (p. 354). When the first incisions are
healed, new ones may be made and treated in the same way. By this
combination of cutting and pressure not only room is gained, which
renders the fistula more accessible, but the cicatrical traction which is a
serious obstacle to agglutination is done away with.
This local preparation may occupy from three to five weeks or longer.
Of no less importance is the general preparation. The patient's gen-
eral health should be improved as much as circumstances will permit.
If the fistula is due to hysterectomy for cancer, it is not worth while
trying to close it until sufficient time has elapsed to prove that the sur-
rounding tissue is healthy. If the patient has syphilis, that should first
be treated. Anemic patients should undergo a preparatory tonic treat-
ment. Faults in the digestion should be remedied. Sometimes a sea-
voyage or a sojourn in the country may be a great help in building up
the debilitated constitution.
The operation is performed according to different methods, which
may be divided into two groups: the denudation methods and tlieflap-
splitting methods. To the first belong the methods of Sims, Bozeman,
and Simon ; to the latter those of Blasius (Tait), and Walcher.
Sims's Method. The patient is placed in Sims's position (p. 137),
Sims's speculum, or one of the self-holding modifications thereof (p.
147), is introduced. The most dependent part of the circumference
of the fistula is seized with a tenaculum, and the edge cut off all
around in one strip with scissors. In so doing we go close up to the
mucous membrane of the bladder without implicating the same, as
that causes troublesome and sometimes dangerous hemorrhage. If the
denuded surface is not broad enough, a second strip is cut off from
the vaginal mucous membrane outside of and contiguous to the first
(p. 337). The edges should be brought together in that direction in
which there is least tension. At the angles the denudation is carried
far enough away from the fistula to include the folds of mucous mem-
brane which will be formed when the edges of the fistula are brought
in contact. Thus even a very small round hole may necessitate an
elliptic denudation half an inch wide and an inch long.
DISEASES OF THE VAGINA.
367
Silver wire is used for suturing (pp. 204 and 218). It is pulled
through with linen thread. Round, slightly curved needles made cut-
ting near the point (Fig. 185, (f) and 1 inch long are best. They are
introduced with Sims' s needle-holder. If possible, the needle is seized
below the eye, but if the fistula is being closed in a transverse line, the
needle must be seized at its blunt end and held in the long axis of
the needle-holder (Fig. 186, p. 216). The needle should be entered
about a quarter of an inch from the edge of the denuded surface,
brought deep into the tissue, pushed out just in front of the mucous
membrane of the bladder, and carried through the corresponding
points of the opposite lip. Five sutures are put in for each inch of
line of union. As to the use of the counter-pressure hook, twister,
suture-shield, and cutting of wires, the reader is referred to the general
rules given above (pp. 219, 220).
The patient is now turned on her back, the bladder washed out
with a double-current catheter, and Sims's self-retaining, sigmoid,
block-tin catheter with many small side openings introduced. This
catheter should be bent so as to move freely behind the pubes as a
key turns in a lock. Many now prefer soft-rubber or glass catheters.
After-treatment. The patient should lie on her back, at times
stretched out, at others with a round pillow under her knees. A
dose of opium is given to relieve pain, and may be repeated several
times daily in order to keep the bowels constipated for three days.
FIG. 222.
I/
Bozeman's Operating-Table.
On the fourth day the bowels are moved by means of an aperient
and an olive-oil enema (liv). The sutures are generally removed on
the eighth, ninth, or tenth day.
The catheter is taken out and cleaned several times a day. A
368
DISEASES OF WOMEN.
small flat cup (a bird bathing-tub) is placed under it to catch the
urine dripping from it. It is left in a few days after the removal of
the sutures. The patient is allowed to sit up some time during the
third week after the operation.
FIG. 223.
Bozernan's Speculum : a, surface of third blade which is applied to the vagina ; b, a short
plate which is pushed under the ends c and d, and thereby kept in place.
Bozeman's Method. Bozeman places the patient in the knee-elbow
position, in which she is retained by a special apparatus of his (Fig.
222). His speculum (Fig. 223), which allows one to operate with less
assistance and throws light into every part of the vagina, is introduced.
The denudation is made perpendicularly, or so as to form a steep
funnel, and comprises occasionally the mucous membrane of the blad-
der. He cuts with knife or scissors. He uses silver wires, but he
secures them by means of his button ; that is, a small concave plate of
thin lead (Fig. 224) with a hole for each suture. The concave side
is pressed against the wound, a perforated shot
is pushed down over the two ends of each suture,
and crushed with a forceps so as to serve as a
clamp. The wires are cut at a short distance
from the shot and turned down over its sides.
Bozeman uses permanent catheterization, and
removes the sutures on the seventh day.
Simon's Method. The patient is placed in the
dorsal position, with raised pelvis and the legs
drawn up so-called breech-back position, be-
cause the breech presents as in deliveries with breech presentation.
FIG. 224.
Bozeman's Button.
DISEASES OF THE VAGINA. 369
Large broad specula and retractors are used, according to circum-
stances, on the anterior, posterior, and lateral walls. The vaginal
portion of the uterus is seized with a volsella and pulled down to the
entrance of the vagina, where a couple of strong threads are drawn
through it and used to pull on instead of the volsella. The edges are
cut off with a knife perpendicularly or in a slightly slanting direction.
The incision goes through the mucous membrane of the bladder.
Fine silk is used for the sutures. These are of two kinds, deep
relaxing sutures and superficial uniting sutures, which alternate with
each other. From eight to ten are inserted for each inch of union.
No catheter is left in the bladder. The patient may urinate herself
if she can. Otherwise the urine is drawn with catheter every four
hours. The bowels are kept loose. The patient may lie in what
position she prefers, and eat every thing she likes. If easily accessi-
ble, the sutures are removed on the fourth or fifth day ; in difficult
cases they are left till the sixth or seventh day. On the eighth day
the patient is allowed to get up.
The Suprapubie Method. For fistula? that cannot be reached in
any other way Trendeleuburg makes a transverse incision just above
the symphysis pubis, through the abdominal wall. Next he makes
a transverse incision in the bladder, if necessary all across. Then he
denudes the edges of the fistula and inserts silk sutures, which he
ties in the vagina, or catgut sutures, which he ties in the bladder.
Biasing's Method. This is a flap-splitting operation which has
been revived by Lawson Tait and others. Nothing is cut away.
There is merely made an incision parallel to the vaginal and vesical
mucous membrane. This incision is made on the white line of cica-
trice at the edge to the depth of from one-eighth to three-eighths of
an inch, according to the thickness of the septum. If the fistula is
small, it is surrounded by a suture like the string of a tobacco-pouch
in the following way : a curved and eyed handled needle is introduced
through the mucous membrane of the vagina a quarter of an inch out-
side of the lower end of the incision, and made to travel in the thick-
ness of the vesico-vaginal septum in a curved direction, following the
curve of the separation of the flaps till it comes to the opposite pole of
the diameter of the fistulous opening, and then the point of the needle
is made again to emerge into the vagina. The needle is now threaded
and withdrawn, one-half of the fistula being thus embraced by the
suture. The needle is again made to pass similarly round the oppo-
site half of the fistula, the points of ingress and egress being identical
with those of the first half of the proceeding. The needle is again
threaded and withdrawn, and in this way the circumvention of the
fistula is completed. When the thread or wire is drawn tight and
secured, it will be found that the flap of vaginal mucous membrane is
made to front into the vagina, and that of the vesical mucous mem-
24
370
DISEASES OF WOMEN.
FIG. 225.
brane to front correspondingly into the bladder, whilst the raw sur-
faces between them are brought fully together.
If the fistula is so large that it is advisable to close it in a linear
direction, the needle is made to enter the raw surface of the vaginal
flap at the line of incision, burying it deeply in the tissue of the sep-
tum just beyond the point of division of the limbs of the V formed
by the incision, and bringing it out on the corresponding point of the
posterior limb of the same V. The needle is then threaded and with-
drawn. Next, the needle is pushed in the same way through the
two limbs of the V on the other side i. e. the anterior and posterior
flap ; it is threaded with the distant end of the first thread and pulled
back. When such threads, in sufficient number, are placed parallel
to one another, the sutures are closed. Tait uses always silver wire.
He says it is generally much easier to insert the sutures by means of
the forefinger guiding the needle without any speculum than with the
assistance of the latter instrument. 1
Watcher's Method (Fig. 225). All cicatricial tissue is cut away,
sparing as much as possible all healthy
mucous membrane. When the cica-
tricial tissue is thoroughly removed
the edges of the fistula acquire an
astonishing mobility, and can be ap-
plied to one another without tension.
On the place most remote from the
field of operation, on the side turned
toward the bladder, he makes a super-
ficial incision around the cicatricial
edge of the fistula. Next he makes
a similar incision around the cicatrix
in the vagina, and then he cuts out
the whole cicatrix as deep as possible.
In some places larger cieatricial masses
have to be removed ; in others, where
healing had taken place by first inten-
tion, the edge is simply split into an
anterior and posterior flap. As long
as there are immovable parts or parts
moved with difficulty, the cicatricial
tissue has to be removed or cut through.
Finally, the. wall of the bladder be-
comes so movable that in many cases
it can be pulled out through the wound
Now the vesical flaps are brought together in a line
He introduces the needle on the raw
Walcher's Fistula Operation : a, fistula ;
b, bladder ; c, vaginal wall rolled out.
like a loose sac.
by a row of catgut sutures.
1 L. Tait, The British Gynecological Journal, Nov., 1887, Part xi. p. 368.
DISEASES OF THE VAGIXA. 371
surface a quarter of an inch from the fistula, and pushes it out on the
line of demarkation between the raw surface and the raucous mem-
brane of the bladder, just comprising the latter in the suture (compare
submucous sutures, p. 316). Next, the needle is carried through the
corresponding points on the other side. When all the sutures are in
place they are tied. After thus closing the bladder the vaginal flaps
are united in a line above the other by means of silk sutures.
The Abdominal Method. Vesico- vaginal fistula? so situated that it
is impossible to reach them from the vagina have been operated on by
performing laparotomy and separating the bladder from the uterus
and the vagina..
Dangers and Difficulties. With ordinary care there is not much
danger of sepsis. In operations near the fornix the peritoneal cavity
may be opened an accident which used to be much dreaded, but now
has lost most of its importance.
Primary hemorrhage may be quite considerable. Often it may be
arrested by injecting hot or ice-cold water into the bladder and the
vagina, or by temporary pressure, but sometimes it may become
necessary to ligate an artery. This may be done by inserting a silver
wire through the vaginal wall so as to embrace the bleeding vessel,
which experience has shown usually comes from the neck of the
bladder or the neck of the womb (T. A. Emmet).
Secondary hemorrhage is very rare. Bloodclots in the bladder
should be broken up with catheter or dull-wire curette. Hot and
ice-cold injections should be made. If these measures do not check
the hemorrhage, the sutures must be removed and the bleeding vessel
looked for and tied.
One of the greatest dangers in fistula operations is that of injuring
or ligating the ureters. The first accident may lead to the formation
of a uretero-vaginal fistula more difficult to heal than the original
vesico-vaginal fistula. The ligation of a ureter leads to acute hydro-
nephrosis with high fever and vomiting. If the field of operation
extends more than half an inch from the median line, the operator
should look out for the ureter. Sometimes it can be seen at the edge
of the fistula. Then the ureter must first be split open from the
bladder to the extent of half an inch and the edges of the wound
allowed to heal separately, so as to throw the mouth of the ureter
further back into the bladder before the fistula is closed.
The operator should note the number of sutures he introduces and
be sure to remove them all, as an overlooked or cut-off suture may
form the nucleus of a calculus in the bladder.
When there is great loss of substance it is often impossible to unite
the edges on one line. It may then become necessary to give to the
line of union the shape of a Y, a T, or an I .
In large fistulse it is also sometimes found advantageous not to
372 DISEASES OF WOMEN.
denude the whole edge at once, but to operate in sections, paring and
uniting one part before the next is taken hold of. In this way much
blood may be saved and the field kept clean.
Long tine fistulse in front of the cervix have been closed by fresh-
ening the surface with a dentist's engine, substituting cutting edges
for the blunt ones, and approximating the vivified walls with deep
sutures. 1
If the fistula is situated near the bone the flap-splitting operations
may hold out the best prospects for effecting a cure.
Before removing the sutures it may be well to try if the fistula is
closed by injecting a little milk into the bladder. If the edges and
stitches look healthy and there is a leakage, complete closure may be
obtained by leaving the sutures in for a day or two longer.
Combination of Methods. By a judicious combination of the best
features of the operations described above an operator may obtain
better results than by adhering tenaciously to the rules laid down by
one of the inventors of methods. Preparatory cutting and stretching
of cicatrices are of great importance. Bo/eman's or Simon's position
give sometimes better access to the fistula than Sims's. It is often impos-
sible to pull the fistula down so as to operate near the vaginal entrance,
as prescribed by Simon. The dislocation of the uterus may give rise
to pelvic hemorrhage or inflammation. It is, therefore, better to ope-
rate in situ, and for this silver wire is much preferable to any other
material. The largest speculum that finds room should be used, but, as
a rule, the larger the fistula the smaller the speculum must be. The per-
manent catheter is liable to cause cystitis, which again interferes with
healing by first intention. It is also very uncomfortable for the patient
to lie constantly on her back. The introduction of a hard catheter
has sometimes mechanically interfered with healing. If the bladder
has retained a reasonable degree of capacity, it is better to let the
patient urinate or draw the urine with a velvet-eye, soft rubber catheter.
But in large fistulse with great retraction of the bladder the use of the
permanent catheter is preferable. It is a decided advantage to keep
the bowels open and let the patient take plenty of substantial food.
2. Urethro-vaginal Fistula. In this kind, the wall of the septum
being very thin, the denudation must be extended over the nearest
part of the vagina. The edges are brought together from side to
side over a metal catheter, and if the tension is great, an incision is
made on both sides parallel to the line of union.
Atresia of the upper part of the urethra may be combined with a
vesico-vaginal fistula. Then the closed canal may be perforated with
a trocar and kept open by the daily use of sounds. Another method
is to cut out the closed portion of the urethra and unite the lower to
the neck of the bladder.
1 Thomas, Diseases of Women, 6th ed. p. 274.
DISEASES OF THE VAGINA. 373
If the atresia is situated between a urethral and a vesico- vaginal
fistula, the occluded position is bridged over by uniting the upper
edge of the vesical fistula with the lower of the urethral, or if the
loss of substance at the base of the bladder is so great that this can-
not be done, or would cause so much tension on the urethra that
incontinence would follow, an artificial transverse vesico-vagiual fistula
is made just above the neck of the bladder, between the two other
fistulse. The upper edge of this artificial fistula is stitched to the
lower edge of the urethral fistula, and after healing has taken place,
the edges of the original vesico-vaginal fistula are brought together
from side to side.
The whole urethra may be destroyed and may be restored by bor-
rowing tissue from* the surrounding mucous membrane (compare p.
255).
3. Uretero-vaginal Fistula. Remembering the relations between
the ureter, the neck of the womb and the fornix of the vagina (p. 81),
we can easily imagine how a fistula may be formed between the ureter
and the uterus or the ureter and the vagina, but it is fortunate such
communications are rare, since they are difficult to cure.
A uretero-vaginal fistula is situated on the anterior wall of the
vagina, a little below and outside of the vaginal portion of the ute-
rus. It is distinguished from a vesico-vaginal fistula by introducing
an elastic catheter, which, if the fistula is ureteral, can be pushed
deep in in the direction of the corresponding kidney, and urine will
be secreted in jets from it. Milk injected through the urethra will
come out immediately through the fistula if it is vesico-vaginal, but
will not pass through a ureteral fistula. Often that part of the ureter
which is situate between the fistula and the bladder becomes obstructed.
If under such circumstances the fistula were closed, acute hydronephro-
sis with all its dangers would be the result. The perviousness of rho
lower portion of the ureter is made out by introducing one probe
through the fistula and an another through the urethra, which will
come in contact in the bladder if there is free communication between
the fistula and that organ.
The causes of uretero-vaginal fistula are pressure during child-
birth, the gnawing of a pessary, hysterectomy, or the operation for
a vesico-vaginal fistula, in consequence of which the ureter may be
injured.
Treatment Three operations are available : closure of the fistula,
implantation of the ureter in the bladder, or nephrectomy.
A. Closure of the Fistula. The fistula has been directly closed in
different ways.
a. Bandl's Method (Fig. 226). Bandl made an elliptic incision
around the fistula in the course of the ureter, cut out some tissue at the
lower end of this incision and made an opening into the bladder, press-
374
DISEASES OF WOMEN.
ing it out from behind with a sound. Next he introduced a fine
flexible catheter (French No. 2) into the bladder through the urethra,
FIG. 226.
Diagram of Bandl's Operation for Uretero- vaginal Fistula (the patient is in geuu-pectoral pos-
ture): SS, vaginal wall; V, line of union after closing a vesico-vaginal fistula in a pre-
vious operation, which had led to the formation of the uretero-vaginal fistula; B, bladder;
U, vaginal portion of uterus; H, right ureter ; H', left ureter opening at a into the vagina;
cc, first incision ; de, flat denudation in the vagina : 6. artificial opening into the bladder.
drew its point with a forceps through the artificial opening made i
the bladder, out into the vagina, and pushed it into the ureter. Next
he denuded the vagina outside of the first line of incision and brought
the raw surfaces together with four silver wire sutures, over the cath-
eter. He used Bozeman's position, speculum, and button, and left
another catheter in the bladder. 1
b. Schede's Method. 2 Schede cut out an oval piece of the vesico-
vaginal septum with an area of three-quarters of an inch square and
having the opening of the ureter at its upper end, and stitched the
vesical and the vaginal mucous membranes together. Two weeks
later he introduced a flexible catheter with the eye-end into the ureter
and with the other into the bladder, whence he pulled it out through
the urethra. Like Bandl, he left a narrow strip of undenuded tissue
1 Ludwig Bandl, Die Bozemamche Methode der Blasenscheidenftstel- Operation und
Beitrage zur Operation der Hamleiter-und Blasemcheidenfisteln, Wien, 1883, p. 42.
* For the difficulties he met with before he obtained success the reader is referred
to his own article in Centralbl. f. Gyndk., 1881, vol. v, p. 549.
DISEASES OF THE VAGINA. 375
round the ureteral fistula, denuded outside of this, and closed the
fistula.
c. Pozzi's Method. Pozzi used the flap-splitting method in a case
of uretero-vesico- vaginal fistula. He placed the patient in the knee-
chest position, made a transverse incision extending half an inch
beyond the borders of the vesico- vaginal fistula and a perpendicular at
each end so as to form an H. Next he dissected the two flaps off to
a distance of half an inch, brought them together over the openings of
both fistulse with three deep silver-wire sutures and three superficial
sutures. 1
B. Implantation of the Ureter in the Bladder ( Uretero-cystostomy).
This may be accomplished by the iutraperitoneal or by the extra-
peritoneal method.
a. The Intra-peritoneal Method. The abdomen is opened in the
median line as in other laparotomies. The ureter is dissected out,
and an opening made in the posterior wall of the bladder by cutting
down on a closed forceps introduced through the urethra. A thin
flexible catheter is introduced into the ureter and pulled out through
the urethra. The ureter is then fastened to the wall of the bladder
by means of interrupted silk sutures. A self-retaining soft-rubber
catheter is inserted through the urethra into the bladder beside the
ureteral catheter; and finally the abdomen is closed.
6. The Extra-peritoneal Method. In order to avoid the dangers of
intestinal occlusion if the ureter forms a cord drawn through the cav-
ity of the pelvis, a method has been invented by which the ureter is
displaced, and the bladder drawn up toward it outside of the perito-
neum. 2 The patient is placed in Trendelenburg's position. Median
laparotomy is performed. Next, a small incision is made through the
peritoneum where the ureter crosses the bifurcation of the iliac artery
(p. 81), in doing which the surgeon must, however, bear in mind that
the ovarian vessels lie in front of the ureter at this place. By pulling
on the ureter here he makes its lower course apparent, and makes a
second small incision through the broad ligament about the middle
of its height. Through this he pulls the ureter out, ties it with a double
ligature, and cuts it across on a little pad. The protruding mucous
membrane of the lower end is cut off, the peritoneum sutured over the
opening, and the stump dropped. The upper end of the severed ureter
is pushed behind the peritoneum up to the upper opening, where it is
seized with a long narrow forceps, which is carried from the side of the
bladder, outside of the peritoneum, above the ilio-pectineal line, and
from where it is pulled down. Next, the two small openings in the peri-
toneum and the incision in it in the median line are closed with fine cat-
gut. The bladder, distended with a small quantity of boric-acid solution,
1 Pozzi, Traite de Gynecologic cliniqueet operatoire, Paris, 1890, p. 934.
2 O. Witzel of Bonn, Centralbl. fur GynaJc., 1896, vol. xx. No. 11, p. 290.
376 DISEASES OF WOMEN.
is now easily drawn up toward the ureter until they are in contact in the
length of an inch and a half. The end of the ureter is cut slantingly,
and a small hole is made in the wall of the bladder by cutting down
on a catheter introduced through the urethra, and the mucous mem-
brane of the ureter is stitched with fine catgut to that of the bladder,
and then the wall of the ureter is stitched to the sides of the hole in
the wall of the bladder. The bladder is raised in two folds above
and below the ureter, and these folds are stitched together over it, so
as to form an oblique canal one and a half inch long, simulating the
normal obliquity of the course of the ureter through the wall of the
bladder. A small drain is left in an opening cut through the skin
corresponding to the place of union between bladder and ureter.
Finally, the abdominal wound is closed, and a catheter left in the
bladder for four days.
C. Nephrectomy. (See below, under Uretero-uterine Fistula.)
Of these three operations the closure of the fistula, as the safest and
simplest, should first be tried. The implantation of the ureter in the
bladder has given good results in several cases, and should be pre-
ferred to the mutilating nephrectomy.
4. Vesico-uterine Fistula. Fistulous communication between the
urinary system and the uterus can only take place in the cervix.
The other end of the fistula may be in the bladder or in the ureter,
and it is of vital importance to distinguish between these two condi-
tions. Common for both is the discharge of urine from the os uteri.
The vesico-cervical fistula forms a small round hole opening in the
middle of the cervix, a condition which has been brought about by
imperfect healing of a tear through the anterior wall of the cervix
and the base of the bladder.
Diagnosis. Sometimes a probe can be brought from the bladder
through the fistula into the cervical canal, where it comes in contact
with a uterine sound held there. Milk injected into the bladder will
come out of the os uteri. If the cervical canal is plugged with a
lamiuaria tent, no systemic disturbance will result, while acute hydro-
nephrosis is developed if it is a uretero-cervical fistula.
Prognosis. This kind of fistula has an unusual tendency to spon-
taneous healing, which probably is due to the thickness of the wall
in which it is situated.
Treatment. This tendency to spontaneous closure may be furthered
by cauterization. If that does not succeed, closure by suture may be
attempted in different ways.
a. Emmet's Method. The anterior lip of the cervix is split open in
the median line, so as to reproduce a condition similar to that, obtain-
ing when the injury was fresh. In this way the fistula is reached, and
pared, and the wound united by silver-wire sutures from side to side.
b. Fold's Method. The urethra is dilated so as to admit the index-
DISEASES OF THE VAGINA, 377
finger, and the cervix is pulled down to the vaginal entrance. A
transverse incision is made in front of the cervix, the bladder dis-
sected off, and the opening in the bladder closed, the finger in the
urethra aiding the introduction of the sutures.
It seems that even the somewhat risky dilatation of the urethra
(p. 142) may be dispensed with. 1
As a last resort the cervix may be turned into the bladder by
suturing it to the borders of a hole cut from the vagina into the
bladder.
5. Vesico-utero- vaginal Fistula. This fistula goes from the blad-
der through the anterior lip of the cervix and ends in the vagina.
Treatment. If there is left enough of the anterior lip of the cervix
a denudation is made here and stitched together with a correspond-
ingly pared surface on the anterior wall of the vagina.
If there is not tissue enough left in front the posterior lip of the
cervix is pared and brought together with the anterior lip of the
opening in the bladder. By this procedure the cervix is turned into
the bladder, and the menstrual flow is secreted with the urine through
the urethra.
6. Uretero-uterine Fistula. In this variety, as in the vesico-ute-
rine, urine flows from the os, but the exact condition can be made
out in different ways. Milk injected into the bladder will not come
out through the os. If the cervical canal is plugged there will soon
appear symptoms of acute hydronephrosis, such as pain in the lumbar
region, vomiting, and fever. The most conclusive test is, however,
that of Berard. The bladder is emptied with catheter, and the patient
is placed on a vessel that will collect all the urine coming from the
vagina. At the end of two hours the urine is again drawn from the
bladder by means of a catheter. The amount obtained will equal
that which has flowed from the vagina, each being the secretion of
one ureter. The ureter may perhaps be felt swollen (p. 167). That
it should be possible to introduce a ureter-catheter into the uterus
from the bladder (p. 165) is very unlikely.
This variety of fistula is exceedingly rare.
Treatment. The cervix must be turned into the bladder as de-
scribed above. As the lower portion of the ureter is usually oblit-
erated, it is not allowable simply to close the os uteri, apart from the
trouble that might be anticipated by the stagnation of urine in the
uterus.
Another method more dangerous, but offering the advantage of
not interfering with fertility, consists in nephrectomy ; that is, the
removal of the corresponding kidney through an incision made in
the lumbar region (Simon).
7. Uretero-vesico-vaginal Fistula. When the ureter has been partly
1 A, Benckisser, Centrcdblatt f. Gynak., 1893, vol. xvii. p. 847.
378 DISEASES OF WOMEN.
destroyed at the same time as a vesico-vaginal fistula is formed, the
opening of the former is found somewhere on the edge of the latter.
We have seen above how this condition may be cured, either with or
without slitting up the ureters.
Genital Clems. When it is impossible to close a fistula, relief
from the troublesome, constant escape of urine may be afforded by
closing the genital canal below the seat of the fistula, an operation
called cleisis, or closure.
We have already alluded to the closure of the uterine os (hystero-
cleisis), the turning in of the cervix into the bladder (hystero-cysto-
cleisis). The vulva may be made the seat of the closure (episio-deisis),
but this is a very objectionable procedure, since it not only renders
impregnation impossible, but prevents coition, causes stagnation of
urine, and may give rise to the formation of stone in the lower part of
the vagina. The most common seat of this closure is the vagina
(colpodeisis). In performing this operation the operator should
always keep in view the desirability of preserving as much of the
depth of the vagina as possible. Closure should therefore not be
made at a lower point than necessary, and often much can be gained
by giving the line of union a slanting direction.
The patient is placed in Simon's position (p. 368). A narrow strip
is cut off from the mucous membrane of the vagina in such a way that
the denuded part of the anterior wall fits to that of the posterior.
These are now brought together by sutures according to general rules.
During the insertion of sutures on the anterior wall a sound is kept
in the bladder, and while working on the posterior wall the operator
uses a finger in the rectum as a guide.
Through the development of better methods for the direct closure
of urinary fistula, the use of genital cleisis has become more and more
rare. Still, the operation is yet occasionally indicated in cases of
great loss of substance, when there is much cicatricial tissue around
the fistula partly adherent to the bone, when the bladder is inverted
and filled with part of the intestine, and especially in certain cases of
uretero-uterine and vesico-utero- vaginal fistula. (See above.)
When the urethra had been lost or its lower edge was too weak to
be pared and stitched, Von Nussbaum combined cleisis with the
formation of an artificial supra-pubie urethra. He punctured the
bladder above the symphysis, and left the canula in place for two
weeks. Then the patients were allowed to get up, and directed to
empty the bladder every two or three hours with a female catheter.
At the end of a few months the catheter could be dispensed with, the
urine being driven out at will, in a jet, by contraction of the abdom-
inal muscles. In the interval the recti and pyramidales muscles kept
the little opening closed.
Urinals. If for some reason or other no operation can be per-
DISEASES OF THE VAGINA. 379
formed, the patient may derive more or less comfort from the use of
a urinal. These may be divided into two classes, the extra- and
intra-vaginal. To the first belong rubber bags with a wide opening
covering the vulva, and fastened to the pelvis and the thigh. To the
second belong the ingenious apparatus of Bozeman and Jay. Boze-
man's consists in a flat pear-shaped receiver of silver with a number
of holes on the side that comes in contact with the anterior vaginal
wall. The urine enters through one or more of these holes, and is
led through a tube to a rubber bag attached to the thigh. Jay's con-
sists in a strong soft-rubber ring, to which is attached a bag of the
same material, ending in a tube which is compressed by a shut-off.
The ring is introduced into the vagina where it stays by its own
expansion. The patient takes a daily sitz-bath, and slips the nozzle
of a syringe into the exit-tube and fills the urinal repeatedly with
warm soap-suds. 1
I have, however, found that patients, for different reasons, such as
pain, excoriations, lack of coaptation, get tired of wearing urinals and
prefer to protect themselves with towels.
Operations for Incontinence. It happens sometimes, after a com-
plete closure of a fistula, that the patient continues having a con-
stant dribbling of urine, which now escapes involuntarily through
the urethra. This condition may be due to the loss of the sphincter
muscles of the urethra, or to traction being exercised on the urethra,
by which it is kept open, or simply to the habit of contraction acquired
by the bladder while the fistula was open. Sometimes a spontaneous
cure takes place by shrinkage of a cicatrix running across the neck
of the bladder; but this is at best slow work. Pawlik 2 has devised
an operation by which the condition is remedied at once (Fig. 227).
The patient is placed in knee-elbow po-
sition. The urethra is pulled to one side
with a tenaculum as far as possible (a).
The limits of the fold thus formed are
marked on the mucous membrane. From
these points two parallel lines are drawn
up and made to converge at their upper
end near the subpubic ligament. Next
the meatus is pulled as far as possible Pawlik , s operation for mconti-
tOWard the clitoris without Using Undue nence: //, urethra; A denuda-
i i /IN rr<i tlon ' a < point to which the
force, and that point marked (6). Ihe urethra can be pulled to a side :
I- n , j 6, point to which it can he pulled
lines oi incision are now continued in a in the direction of the clitoris.
slightly convergent direction to b. The
thus circumscribed tissue is cut out in the shape of a wedge, and the
1 John C. Jay, Jr., New York Medical Record, Aug. 28, 1886, vol. xxx. p. 251.
The urinal is made by Parker, Stearns & Sutton, 228 South street, New York.
2 Pawlik, Wiener Med. Wochenschrift, 1883, Nos. 25-26, p. 772, and Zeilschrift fur
Geburtshiilfe und Gynak., 1882, vol. viii. p. 38.
380 DISEASES OF WOMEN.
wound united with deep sutures of carbolized silk and covered with
iodoform. After seven days the sutures are removed, and, the wound
having healed by first intention, the other side is treated in the same
way.
The object of this operation is to stretch the urethra from side to
side, and at the same time to bend it in the direction of the clitoris,
by which double process its posterior and anterior walls are brought
in contact.
The same operation may be performed when the urethra is gaping
and the patient suffers from incontinence without having had a fistula.
Sometimes the cause of incontinence is irritation caused by a band
attached to the urethra and spreading itself over the anterior aspect
of the vulvo-vagiual junction. A cure may then be effected by clip-
ping this band. In other cases wings of mucous membrane are found
attached to the urethra. The treatment consists in their excision and
union of the wound by interrupted sutures. In still other cases the
cause of the enuresis seems to be an enlarged rueatus. An incision
is then made in the sagittal plane on either side of the urethra, and the
edges are united at right angles to the incision. The patient should
be kept in bed for two or three weeks. The wound is smeared with
cold-cream, 1 or, better, dusted with stearate of zinc. The patient may
then urinate herself.
B. Fecal Fistuke. A fecal fistula is one leading from the intes-
tine to the genital canal. They are much less common than urinary
fistulse.
Pathological Anatomy. There may be one or more openings. The
fistulous communication may take place between the rectum and the
vulva recto-vulvar or recto-labial fistula ; the rectum and the vagina
recto-vaginal fistula ; between the ileum or the sigmoid flexure of the
colon and the vagina or uterus entero-vaginal, ileo-vaginal, and ileo-
uterine fistula.
The size differs from that of an opening so fine that it may be very
difficult to discover to that of one easily admitting a finger. Often
the aperture is larger on the vaginal side than on the intestinal. The
seat varies also very much. A fecal fistula may be situated anywhere
between the intestine and the vagina, but it is most commonly found
either immediately above the sphincter ani muscles or at the fornix.
As a rule, it is found on the posterior wall of the genital canal, but the
entero-vaginal variety may exceptionally open in front of the uterus.
Sometimes the length is almost nil, the rectal and vaginal walls com-
ing in contact in the thin septum between the two. In other cases,
when the fistula is the result of an abscess, the inner opening may be
as much as three inches and a half up the rectum, while the outer is
found on the inside of the labium majus.
1 D. Tod Gilliam of Columbus, O., Amer. Jour. Obst., 1896, vol. xxxiii., No. 2, p. 177.
DISEASES OF THE VAGINA. 381
Etiology. The causes of fecal fistulae are in many respects like those
determining urinary fistulse. The most common is childbirth, and the
fistula may either be due to pressure between the fetal head and some
bony prominence in the pelvis or remain as the result of imperfect
spontaneous healing of a tear through the perineal body. It may be
brought about by rupture of the vagina or uterus, an intestinal knuckle
being caught in the rent and becoming necrotic, or by diphtheritic and
gangrenous processes due to puerperal infection.
Frequently a fistulous opening remains just above the artificially
united perineal body after perineorrhaphy. Rarely hysterectomy has
led to the formation of such a fistula at the fornix.
Occasionally the fistula is due to a neglected vaginal pessary, that
gnaws a hole into the rectum.
Abscesses, either pelvic, vulvar, or prerectal, end sometimes with the
formation of a fecal fistula. At the foruix it is due to a suppurating
dermoid cyst or extra-uterine pregnancy ; at the vulva the inflamma-
tion begins often in Bartholin's glands.
We have mentioned above that direct injury, especially violent
coition, may cause a permanent fistula (p. 265) and that the solution
of continuity may be due to ulcers cancerous, tubercular, or syphi-
litic perforating the partition between the two canals.
In syphilitic patients the fistula is often found just above a strict-
ure of the rectum.
Symptoms. The escape of flatus and, when the bowels are loose,
thin fecal matter, through the vagina soon attracts the patient's atten-
tion. The irritating contact with the excrementitial matter causes
catarrhal vulvitis and vaginitis.
Of entero- vaginal fistulae there are two varieties with very different
symptoms. If the opening is small (ileo-vaginal fistula), they do not
differ materially from any other fecal fistula, but if the whole circum-
ference of the intestine has been destroyed and the edges have coa-
lesced with the rent in the vagina (jpreternatural anus), all the feces
find their exit through the vagina. If the affected part, as usual, is
the ileum, undigested food mixed with bile will make its appearance
at the fistula about two hours after meals, and the patient \\ ill loose
flesh and finally die from starvation. Her weakness may alr-o cause
ameuorrhea.
Large fecal fistula? can be felt, small ones maybe seen, but are often
hard to find on account of their diminutive size. Probing and injec-
tion with colored fluid may help to find the inner opening.
In an entero-vaginal fistula, a whole intestinal knukle having been
destroyed, there may be two openings with a so-called spur between
them.
Prognosis. Fecal fistulae have in so far a better prognosis than
urinary as a larger number of them heal spontaneously, but, on the
382 DISEASES OF WOMEN.
other hand, those which have no such tendency, are harder to heal
by operation, the reason of which is doubtless that while urine is
harmless or can easily be given an exit, the intestine is always full
of pathogenic microbes, which it is difficult or impossible to keep
away from the wound. Mechanical difficulties are likewise of much
importance in jeopardizing closure by first intention. If "\ve induce
constipation large fecal masses will accumulate, and their final expul-
sion may tear open the already healed fistula. If, on the other hand,
we keep the bowels loose, the contraction of the perineal muscles
during the act of defecation is liable to cause a fistulous tract to
remain just above the sphincter ani muscles.
We have already intimated that in certain forms of fecal fistulae
nutrition becomes insufficient.
Treatment. Preventive Treatment. Much can be done to prevent
the formation of fecal fistula? by having their etiology in mind.
Thus an enema of soap-suds should invariably be given in every
labor case before the head enters the pelvic cavity.
The pelvis should be carefully ^examined before labor in regard to
narrowness or projecting points, and according to circumstances re-
course should be had early to the high-forceps operation, version,
craniotomy, or even Cesarian section.
Pessaries should always be kept clean with daily vaginal injections,
and removed at least once every two months. If there is any gnaw-
ing, the pessary should be left out for a week and carbolized injections
used until all abrasions or ulcers are healed.
It goes without saying that most strenuous efforts should be made
to prevent syphilitic ulcers from forming fistula?. Perhaps we will
soon have in one of the many remedies now being experimented with
a means of checking tuberculous ulcers in their destructive progress.
Even at the height of sexual passion men should exercise a reas-
onable control over themselves, especially if nature has endowed them
with an unusual development of the part concerned. Pus in the
pelvis or near the lower end of the rectum should be given an exit
by timely operative interference.
Curative Treatment. A cure may be obtained by cleanliness, the
elastic ligature, or cutting operations.
A. Since many small fecal fistula? have a decided tendency to close
of themselves, this happy result should be facilitated by scrupulous
cleanliness, especially sitz-baths, rectal and vaginal injections, and
prevention of constipation, combined with cauterization (p. 365).
B. Ligature. In recto-labial fistula, which we have seen often
extends far up the gut, a cutting operation would be liable to cause
great hemorrhage, and by forming a cloaca leave the patient in a
worse condition than she was before. This affection is treated suc-
cessfully by changing it into a common fistula in ano, and treating
DISEASES OF THE VAGINA.
383
that with the elastic ligature. 1 The usual surgical silver probe,
armed with an elastic ligature, is introduced into the labial orifice,
pressed down to the perineum just outside of the sphincter ani, where
the end is liberated by an incision and the probe withdrawn. A more
ductile one is substituted, and passed through the sinus from the labial
opening to the rectal opening, having the eve threaded with the other
end of the ligature. The finger introduced into the rectum recognizes
the probe, which is then curved and gently drawn through the rectum
and anus. The two ends of the ligature are tied, shotted, and clamped
(Fig. 228). The labial orifice is left to itself and closes in a few days,
FIG. 228.
Barton-Taylor's Operation for Recto-labial Fistula: A, anal end of ligature; B, labial fistula ;
C, incision in perineum. The fine dotted lines mark the course of the recto-labial sinus ;
the heavy dotted lines represent the ligature where it is imbedded in the tissues.
or at most two weeks, for just as soon as the rectal opening is united
and the ulceration or sinus gradually healing up, there can no longer
pass any gas or fluid feces through the sinuous tract and the labial
orifice.
This treatment is so little painful that the patient need not even
be kept in bed. The ligature will cut through in from three to eight
days, and if the elastic thread ceases its pressure the remnant of
1 This method originated with Rhea Barton of Philadelphia, and was improved by
I. E. Taylor of this city, who, on November 18, 1885, read a paper on Recto-labial
and Vulvar Fistula before the New York State Medical Association.
384 DISEASES OF WOMEN.
embraced tissue is easily severed with scissors or Paquelin's cau-
tery.
C. Catting operations may be performed from the perineum, the
vagina, or the rectum.
I. For a rectal fistula situated low down three different suture-
operations recommend themselves.
1. Emmet's Method. Split the perineal body with scissors in the
sagittal plane up to the fistula, cut its wall away and unite as for
ruptured perineum (p. 320).
2. Tait's flap-splitting method with circular suture (p. 369) is well
adapted to these small openings.
3. Fritsch's Flap-sliding Method. A crescent incision is made
on the vaginal wall with the convexity turned down and just touch-
ing the upper border of the fistula. A similar incision is made
between the ends of the first extending half an inch below the fistula.
The enclosed crescent-shaped part of mucous membrane is dissected
off. Finally, the flap above the fistula is drawn down so as to cover
this denuded surface and the fistula, and fastened all around with
sutures 1 to the mucous membrane or the skin.
Whichever method be used it is best first to paralyze the sphincter
ani muscle by overstretching it.
II. Rectal fistula situated higher up in the vagina are, as a rule,
operated on from the vagina in one of three ways : Bureau and Vi-
gnard's treble tier-suture, Tait's flap-splitting operation, or Hegar's
colpo-perineorrhaphia.
1. Bureau and Vignard made a vertical incision in the median line,
extending half an inch above and below the fistula, dissected the vagina
from the rectum to a distance of half an inch from the fistula, form-
ing two rectal and two vaginal flaps. The edges of the rectum were
united by a continuous suture of chromicized catgut, avoiding to pene-
trate into the interior of the gut. Relaxation sutures were inserted
at the angle between the rectal and the vaginal flaps, but not tied.
Next, the edges of the vaginal flaps were brought together with a
continuous suture of chromicized catgut. Finally, the relaxation
sutures were tied. 2
These fistulae have strongly beveled edges, the vaginal opening being
much larger than the rectal.
Sometimes the vaginal edges can be brought together after making
lateral incisions in the vagina, but cases are occasionally met with in
which no extent of division of tissue on the vaginal surface will
permit of the edges being brought together. In such a case it
is necessary to split the edges of the fistula on each side to a depth
sufficient to permit the edges of the rectal wall to be brought to-
1 H. Fritsch, CentralblaU f. Gyndk., 1888, vol. xii. p. 806.
2 Bureau and Vignard, Centralbl. /. Gyndk., 1894, vol. xviii. No. 40, p. 991.
DISEASES OF THE VAGINA. 385
gether bslow, leaving the vaginal opening to be filled up by gran-
ulation. 1
Denudation in fecal fistulae must be made much larger than in
urinary. In the lower part of the vagina the edges are, as a rule,
united from side to side. In the upper, when there is much loss of
substance, the edges must sometimes be brought together in a trans-
verse line.
2. Tail's flap-splitting with interrupted suture (p. 370) may be
available.
3. German authors recommend a denudation and adaptation from
side to side as in Hegar's operation for incomplete rupture of the peri-
neum (p. 311).
Operation from the Rectum. In exceptional cases it may be impos-
sible to bring the rectal fistula into view on account of a cicatricial
band at the outlet of the vagina. As this band works as a substitute
for the lost sphincter urethrse by keeping the walls of the urethra in
contact (compare p. 379) it should not be divided. Under such cir-
cumstances the operation is performed from the rectal side. 2
The intestine should not only be cleaned out by high enemas of
water and irrigated with an antiseptic solution during the operation
(p. 222), but it may even be well to try to combat the germs in the
upper part of the intestine by the internal administration of naphtha-
line (gr. ij to viij pro dosi, up to gr. Ixxx in twenty-four hours) or
salicylate of bismuth (gr. x every two hours). The sutures are put in
near the edge on the rectal side, but should go out a quarter of an
inch from the edge on the vaginal side.
Entero-vaginal Fistulas? -If the fistula is only lateral it may be
closed by denudation and suture like another fecal fistula. In a case
of vaginal anus it must be ascertained if the lower part of the bowel
is pervious, as it is evident that no closure must be attempted unless
an exit can be given to the fecal matter.
Different operations have been performed or proposed for the relief
of this kind of fistula.
1. If there is a double opening the spur between the two may be
cut by introducing Dupuytren's enterotome, or another strong pair of
forceps, to the depth of one and a quarter inches, and the edges of the
fistula denuded and united by sutures.
2. Laparotomy may be performed, the intestine cut loose from the
vagina or uterus, and the ends united by enterorrhaphy.
If the lower end is closed or too narrow an anastomosis may be
effected between the upper end and the large intestine.
1 T. A. Emmet's Gyruxology, p. 662.
a Emmet, /. c., p. 666.
3 Thirty-nine cases have been collected by H. L. Petit, Annales de Gynecologic,
vols. xviii., xix., xx., 1882-83.
25
386 DISEASES OF WOMEN.
3. It has also been proposed to loosen the intestine and insert it in
the rectum from the vagina.
4. After having made an artificial recto vaginal fistula, colpocleisis
may be performed under it.
General Remarks about the Operation for Fecal Fistulce. In ope-
rations from the vagina or the perineum Simon's position (p. 368)
should be used. It is often a help to introduce a small Sims specu-
lum under the symphysis pubis and lateral retractors on the sides of
the vagina. In operations from the rectum Sims's position or the
genupectoral should be used.
Silver-wire sutures are preferable. If used in the rectum they
should be turned down toward the anus sa as not to offer any resist-
ance to the exit of the feces. They may be left in two weeks while
silk must be removed at the end of the first week. The bowels
should of course be emptied before operating. After the operation
they are best let alone for three days. After that daily loose pas-
sages should be secured by means of medicines (pp. 2,25 and 322).
The patient may urinate herself.
PART IV.
DISEASES OF THE UTERUS.
CHAPTER I.
MA INFORMATIONS.
MALFORMATIONS of the uterus may be due to excessive develop-
ment and precocity, to arrest of development or to irregular development.
Those due to arrest of development correspond again either to the first
or the second half of fetal life. By bearing in mind the history of the
normal development of the uterus (p. 30) the many abnormal forms
of uteri due to arrest of this development are easily understood.
Since the uterus is formed by the fusion and further development of
the middle part of the Miillerian ducts we have no difficulty in
realizing that that part may originally have been absent or may have
been destroyed, or that the originally solid filaments may have failed
to become tunneled, or that the muscular tissue which should be formed
around them may do so in an imperfect way, or that fusion does not
take place between the two tubes, or does so only partially, or that
only one of the tubes undergoes its regular development, while the
other stays rudimentary or is absent. 1
A. Excessive Development and Precocity. Sometimes the uterus in
the new-born child has the size and shape of that of a girl at puberty
(p. 33).
As to menstruation during early childhood we refer to what has
been said on p. 244.
B. Arrest of Development during the First Half of Intra-uterine
Life 1. Absence of Uterus. Complete absence of every vestige of
a uterus is a rare occurrence. It may, however, be found in other-
wise well built women, but it is mostly combined with other defects
in the genitals or in other parts of the body.
Diagnosis. The total absence of the uterus cannot be diagnosti-
cated in the living woman, and even in post-mortem examinations
the pathologist must be on his guard.
1 Those who want more information about malformations than that warranted
by the limits of this book are referred to my article on the subject in the Amer.,
JSyst. of GynecoL, vol. i., pp. 238-257.
3S7
388 DISEASES OF WOMEN.
2. Rudimentary Uterus. In some extremely rare cases the uterus
has only been represented by a solid fibrous or muscular mass. In
others it consists of a membranous vesicle.
In none of the cases of rudimentary uterus authenticated by autopsy
was there any menstrual flow, but often molimina.
3. Uterus Duplex Separatus, or Uterus Didelphys (Fig. 229). This
variety is produced when the two Miillerian ducts do not even come
FIG. 229.
Uterus Didelphys (Ollivier) : a, right body ; b, left body ; c, right ovary ; d, right round liga-
ment ; e, left round ligament ; /, left tube ; g, left cervix ; h, right cervix ; i, right vagina ;
j, left vagina ; k, partition between the two vaginae ; I, right tube.
in contact with one another in that part of their course in which they
usually melt together forming the uterus. Consequently there are
two entirely separate uteri, but each of them represents only one-half
of the total organ. Each half has at its upper end one Fallopian
tube and one round ligament. At the lower end the double cervix
opens into a single or double vagina, or this organ may be more or
less defective.
The uterus didelphys is mostly found in still-born children, but
occurs also in adults. 1 Pregnancy and childbirth may be entirely
normal.
It is hardly possible to diagnosticate the uterus didelphys from
a uterus bicornis in the living woman, through the closed abdominal
wall.
1 I have seen one in performing laparotomy on a girl twenty years old. In this
case the vagina was normal.
DISEASES OF THE UTERUS. 389
4. Uterus Unicornis (Fig. 230). The one-horned uterus is due
to the development of one of Miiller's ducts, while the other is
FIG. 230.
Uterus Unicornis with Rudimentary Right Horn (Schroeder) : LH, left horn ; Lo, left ovary ;
LT, left tube ; LLr, left round ligament ; RH, right horn ; Ro, right ovary ; RT, right tube ;
Riff, right round ligament.
absent or stays rudimentary. It is always very long, forms a curve
with the concavity turned outward, and ends in a point without
fundus.
The diagnosis may sometimes be made by bimanual and rectal
examination, by the shape and position. Pregnancy and childbirth
may take their normal course.
But attached to the point where the cervix merges into the body of
the unicorn uterus is sometimes found a rudimentary horn. If preg-
nancy takes place in that, the condition is a very grave one, the rudi-
mentary horn being incapable of producing the necessary muscular
tissue to form a sac for the growing fetus. The condition is, then,
practically the same as in tubal pregnancy, from which it cannot be
distinguished clinically. Even anatomically the examiner may be
led into error, if he does not bear in mind that the round ligament
forms the line of demarkation between the uterus and the tube
(p. 58). A tube, be it ever so narmw, if situated inside of the
round ligament, is a horn of the uterus, while the Fallopian tube
starts from the same point as the round ligament aud extends out-
ward.
The treatment is also like that for tubal pregnancy namely, a
strong electric current for the purpose of killing the fetus, or removal
by means of laparotomy.
In very rare cases menstrual blood has accumulated in the rudi-
mentary horn, forming a tumor (hematometra). In such a case lapa-
rotomy, ligature of the pedicle, and removal constitute the only
means of relief. (Compare Salpingo-oophorectomy under Diseases
of the Tubes.)
390 DISEASES OF WOMEN.
5. Uterus Bicornis (Fig. 231). When the Miillerian ducts remain
more or less separated from one another in that part which forms the
uterus, this organ appears with two more or less distinct horns at its
upper end. There may be a complete partition going all the way
down to the external os, so that there is a double cervix, or the cervix
may be single, or the partition may be absorbed more or less high up
between the two horns, until it is only represented by a ridge at the
FIG. 231.
ag*
Uterus Bicornis (Hunkemiiller) : ur, urethra cut off; iu, meatus urinarius; vag and vug*,
entrance to the double vagina, the anterior wall of which has been removed, showing
the two vaginal portions of the two-horned uterus.
fundus inside, while the Jjorns are only separated by a corresponding
slight depression on the outside, so that both the external contour and
the cavity have somewhat the shape of a heart on playing-cards.
6. Uterus septus, or bilocularis, is a uterus with a complete partition
between the two halves, but with the normal shape of a uterus out-
side, a kind that is of much rarer occurrence than the corresponding
bicoruute variety.
If part of the septum has been absorbed, the uterus is called sub-
septus i. e. partially partitioned.
In all forms of double uterus, be it horned or not, the vagina may
be single or double (p. 332). The menstrual flow may come from
one or both halves, and if from both, it may either come fr6m both
sides at the same time or alternately from each half.
Pregnancy may take place in either half or in both at once. Even
if it is confined to one side, the other, as a rule, partakes in the pro-
DISEASES OF THE UTERUS. 391
cess, forming a decidua, and producing muscular hyperplasia and
hypertrophy.
The presence of a double uterus serves to explain many cases of
superfetation, an occurrence that is impossible in a single uterus after
the third month of gestation.
Childbirth takes in most cases a normal course, but complications
are comparatively much more frequent than with a normal uterus.
Diagnosis. The presence of a two-horned uterus may sometimes
be felt by bimanual examination or from the rectum.
The condition of the septum in a double uterus is ascertained by
simultaneous use of two sounds, one in either half of the uterus. If
there is a communication between the two, the sounds may be brought
in direct contact.
7. Atresia Uteri. Just as we have seen above (pp. 326 and 328)
that the hymen or the vagina may be closed, the uterine canal itself,
although more rarely, may be the site of atresia. The mucous mem-
brane of the vagina may cover the whole vaginal portion without
forming any external os, or the cervix forms one uninterrupted mus-
cular mass without bore. In such cases the vaginal portion may be
well developed or totally absent. In a bicornate uterus one horn
may be closed.
In regard to symptoms, prognosis, diagnosis, and treatment, we
refer to what has been said above in treating of atresia of the hymen
and the vagina (pp. 327330). Wherever the genital canal is
closed the symptoms due to retention, such as amenorrhea, pain,
menstrual molimina, and the formation of a tumor, are the same.
Here w r e will only mention a few special features belonging to
atresia when it is situated in the uterus. The vagina can be ex-
plored to its full extent with the finger and the speculum. Above
it the uterus forms a round elastic tumor, iu the differentiation of
which the examiner must especially think of pregnancy, fibroma,
and hematocele.
In a case of pregnancy the patient will, as a rule, have menstruated
before being impregnated, and more or less of the well-known signs
of pregnancy will be present. A fibroid forms a hard nodular tumor,
and causes often menorrhagia. Hematocele appears suddenly and
forms a broader mass, which pushes the uterus forward.
If the uterus is double, the atresia is found much more frequently
on the right side. As a rule, the tumor will begin to form at the
time of puberty and increase with every monthly period, as in atresia
of the single uterus, but sometimes the development is slow and
irregular. Blood may accumulate in the corresponding tube, which
gives way before the stronger uterine wall is ruptured. The closed
horn may become adherent to the anterior abdominal wall, and rup-
ture take place through it. The hematometra may also rupture into
392 DISEASES OF WOMEN.
the stomach or the intestine, which leads to septicemia and death.
The least dangerous rupture is that through the partition into the
pervious part of the uterus, in which way a permanent cure may be
effected ; but in other cases the opening closes again and a new accu-
mulation takes place, which in consequence of the entrance of pyo-
genic bacilli becomes purulent (pyomt&ra). This abscess may again
open into the normal half of the uterus, from which the pus then flows
out, or it may burst into the peritoneal cavity, causing septic perito-
nitis.
Exceptionally, the contents of the closed horn are only mucus
(hydrometrd). If a purulent collection becomes decomposed gases
are formed in the cavity of the uterus, a condition called physo-
metra.
Treatment. If the uterus is single, a puncture should be made
through the cervix with a trocar and enlarged with a bistoury or a
metrotome. After evacuation an iodoform-gauze drain should be left
in the uterus, and after its removal a perforated intra-uterine glass
stem should be inserted in order to keep the cervix open. Later,
curetting of the endometrium and packing with iodoform gauze will
combat endometritis and help to bring the distended and, as a rule,
hypertrophied uterus back to a normal condition.
If the accumulation is found in one half of a double uterus it is
still an advantage, if possible, to enter through the cervix, but often
there is no choice and the tumor must be punctured at its lowest point
in the vagina. Puncture alone, even repeated, rarely effects a cure,
and it should, therefore, be followed by an incision, or even an exci-
sion, of a portion of the wall, so as to insure permanent communica-
tion with the open half of the genital canal. When the closed half
has been punctured and evacuated it may be possible to dilate the
open half by Vulliet's method (p. 156) and remove a part of the
partition between the two halves of the uterus.
If the swelling cannot be reached from the vagina, laparotomy
should be performed and the affected horn or the whole uterus re-
moved as for a fibroid.
If blood has collected in the Fallopian tube, and there is no com-
munication with the uterine cavity, it is best to let it alone, as it may
perhaps be reabsorbed. If the tubal sac grows, it may be punctured
from the uterus or the vagina, and in the latter place treated with
injection and drainage. Laparotomy and removal of the distended
tube may be tried, but it is liable to prove difficult or impossible on
account of adhesions.
C. Arrest of Development during the Second Half of Intra-uterine
Life. 1. Fetal and Infantile Uterus. Some adult women have a
womb that in size and configuration corresponds to that of a fetus
toward the end of pregnancy or that of a young child. Sometimes
DISEASES OF THE UTERUS. 393
it is only an inch and a half deep ; in other cases it has the size of a
virgin uterus, but is characterized by the preponderance of the neck
over the body and the thinness of the walls of the latter. The folds
of the mucous membrane may either be confined to the cervix or
extend more or less up into the cavity of the body.
The fetal uterus may at the same time be two-horned (p. 390), as
the result of a double arrest of development. The other organs may
be normal, but often the condition is combined with other abnormali-
ties, especially of the ovaries.
2. The pubescent, or congenitally atrophic, uterus is one that is char-
acterized by its small weight, which does not exceed one ounce, but
the cervix and body have about the same length.
Etiology, Besides simple arrest of development from unknown
causes, exudative perimetric inflammation, chlorosis, and tuberculosis
may cause the deficient development of the uterus.
Symptoms. Menstruation is, as a rule, absent or scanty. Often
the patient suffers from dysnieuorrhea, and sometimes vicarious men-
struation (p. 241) takes place. All sorts of disorders in organs out-
side the pelvis (pp. 247-249) may occur with, or instead of, the men-
strual flow.
Sexual appetite may be unimpaired, but as a rule women with too
small a uterus are sterile, or if they conceive they are apt to abort.
Prognosis. The prognosis, especially in regard to sterility, should
be guarded, but a late development of the uterus, leading to concep-
tion and childbirth, has been observed.
Diagnosis. The condition can, as a rule, be made out by palpa-
tion, especially through the rectum, and the use of the sound.
Treatment. If tuberculosis or chlorosis be present, the practitioner
should carefully abstain from any local treatment that is likely to
bring on the courses: the patient being anemic, her condition will
only become worse by losing blood. In such cases a general tonic
treatment is indicated (pp. 224-226).
If the patient is in good health, and sterility the chief complaint,
galvanic treatment with the negative pole in the uterus and faradiza-
tion have often good effect.
If she suffers from dysmenorrhea, vicarious menstruation, and dys-
menorrheic disorders outside of the pelvis, she should be treated
according to the rules laid down above (pp. 241, 243, 244, 249) in
discussing those conditions, especially with tonics, a strengthening
regimen, sedatives, electricity, and the uterine sound.
3. Uterus Parvicollis and Acollis. Sometimes the body of the
uterus is well developed, but the cervix is too small, or the vaginal
portion is absent. In other cases the body is likewise too small, but
the hypoplasia is most pronounced in the neck. These deformities
have more pathological than clinical interest.
394 DISEASES OF WOMEN.
4. Anteflexion of the uterus is often congenital, and simply a con-
tinuation of the shape of the uterus found in the fetus and young
children. This condition will be considered together with other dis-
placements of the uterus.
D. Irregular Development. 1. Obliquity. The uterus may be con-
genitally bent to one side (later oflexion), the two Miilleriau ducts that
formed it not having kept pace with one another. Or a similar con-
dition may be produced by fetal peritonitis and cicatricial shrinkage
of one of the broad ligaments.
A normally shaped uterus may be tilted to one side (lateroversioii),
especially when there is a beginning ovarian hernia.
2. Malposition. In consequence of an uneven development of the
broad ligaments the uterus may be placed not in, but to one side of,
the median line of the pelvis, later oposition.
A similar irregular development of the parts situated in front of
and behind the uterus leads to anteposition, when the uterus is situ-
ated too near the symphysis, or retr oposition, when it is drawn too
near to the sacrum.
3. Hernia Uteri. The uterus has been found in a congenital
inguinal hernia. In such cases the ovary descends first through
the inguinal canal, just as the testicle descends, or rather is drawn,
into the scrotum. The uterus has also been found in a crural her-
nia. Such hernise are exceedingly rare. The patient may become
impregnated and the fetus develop in the hernia, whence it has to
be removed by Cesarian section. If the condition comes under
observation earlier and gives trouble, hysterectomy might be per-
formed.
4. Elongated Cervix and Stenosis of the Cervical Canal are often
found as a congenital irregularity, but will be treated of together
with the same conditions when acquired later in life, in a subsequent
chapter. (See Hypertrophy of Uterus).
CHAPTER II.
INJURIES.
A. Injuries of the Body. On account of its position in the depth
of the pelvic cavity the unimpregnated uterus is little exposed to
injuries, but when during pregnancy it rises up from the pelvis and
rests gainst the abdominal wall it is so much more frequently the seat
of traumatic lesions, such as goring with a bull's horn, kicks with
heavy boots, stab-wounds, or shot-wounds. 1
1 An interesting case of the last kind was reported by Dr. George A. B. Hays,
of Plaqueminos, La., in Gaillard's Med. Jour., Nov., 1879, p. 402, et. seq.
DISEASES OF THE UTERUS. 395
While in such cases injury is inflicted through the abdominal wall,
the pregnant uterus is exposed through the vagina to the manipula-
tions of abortionists. In reading the evidence in suits for malpractice
one is at a loss to decide whether the rascality, the recklessness, or
the ignorance of these people is the greatest. In their eagerness to
destroy the fetus they sometimes make a wound in the uterus large
enough to admit the thumb and allow the intestines to enter the uterus. 1
But even in legitimate gynecological operations the uterus is occa-
sionally wounded. Some uteri are so soft that they are easily pene-
trated by the sound or the dull-wire curette. Sometimes in perform-
ing laparotomy the gravid uterus has been mistaken for an ovarian
cyst and a trocar thrust into it. 2
In regard to rupture of the gravid uterus during labor the reader
is referred to works on obstetrics.
Prognosis. With the exception of the simple perforation of the
uterus with sound or curette, which if the instruments are clean, and
injection of irritating fluid is omitted, has no bad consequence, most
of these injuries are very serious, lead, as a rule, to miscarriage, and
are sometimes accompanied by hemorrhage or peritonitis and death.
Still, if the ovum has not been opened, and occasionally even after
evacuation of the liquor amnii, pregnancy may take its course to term.
In those cases in which a pregnant uterus is ripped open by the horn
of cattle the prognosis is better than one would expect from the vio-
lence of the injury, which can only be accounted for by the excellent
health of the persons wounded in this way. 3
Treatment. In cases of wounds through the abdominal wall rest,
opium, and antiseptic dressing of the wound probably offer the best
chances, but if there are signs of internal hemorrhage, laparotomy
should be performed, and the bleeding vessel tied. If possible the
fetal sac should not be disturbed.
When the uterus has been wounded from within, as a rule, no trcat-
'ment but rest is required. If there is prolapse of the intestine, lap-
arotomy should be performed in order to withdraw the intestine and
close the uterus. If the intestine is gangrenous, part of it may be
resected; or it may be left undisturbed, when an intestine-uterine
fistula will form, a condition that not only is compatible with life,
but may be cured by nature's sole efforts.
If the gravid uterus is punctured in laparotomy and the ovum
opened, Cesarean section should be performed, but if the trocar does
1 Cases of this kind were mentioned by Thomas, Munde, and Nfeggerath in the
N. Y. Obst. Society, April 5, 1881, Amer. Jour. Obst., 1882, Supplement, p. 5.
2 An interesting paper on this subject by Dr. C. C. Lee is found in Tranx. Avici:
Gyn. Soc., 1883, vol. viii., p. 154.
3 Out of 14 cases 9 recovered, R. P. Harrison, Amer. Ned. Jour. '., Oct., 1891,
vol. cii., p. 376, and Monograph : Abdominal and Uterine Tolerance in Prcqnnnt
Women, Philadelphia, 1892, pp. 12-15.
396 DISEASES OF WOMEN.
not enter the ovum the opening in the uterus may be closed with silk
sutures and pregnancy allowed to take its normal course.
B. Laceration of the Cervix. By far the most common injury to
the uterus is that sustained by the cervix during childbirth, when it
is ruptured, or lacerated, that is to say, torn.
Pathological Anatomy. These tears occupy always the direction
of the radius of the os. They may be complete that is to say, go
through the whole thickness of the cervix or incomplete, Avhen the
tear in the cervical canal does not reach the mucous membrane of the
vagina. There may be one, two, or many tears. The one most com-
monly observed is the bilateral, and next to that the unilatei-al,
which is more frequent on the left than on the right side, doubtless
on account of the greater frequency of the left occipito-anterior posi-
tion of the fetus. The laceration may also be stellate ; that is, when
there are at least three tears forming a starlike figure. It is funnel-
shaped when there are several incomplete tears, which result in a
patulous os. Sometimes it becomes crescentic through the bulging
of a hyperplastic anterior lip. In other cases the tear is found in
the posterior or anterior lip alone. 1
The tear extends often more or less beyond the vaginal junction and
enters the parametrium or the connective tissue behind the uterus,
or extends into the bladder. Often it gives rise to cellulitis in these
parts, which through cicatricial contraction may lead to displacements
of the uterus. If the tear implicates the bladder, it may leave a
vesico-vaginal or vesico-uterine fistula (pp. 363 and 377).
Commonly the laceration of the cervix is followed by chronic
inflammation of the neck and the body of the uterus. In conse-
quence of hyperplasia and hypertrophy of the glands of the cervical
mucous membrane, infiltration with round cells in the interstitial
connective tissue, which later are replaced by new fibers, and abnormal
afflux of blood, the mucous membrane becomes swollen, red, and rolls
out (ectropium), and the lips become separated, a condition which is
increased by pressure against the posterior wall of the vagina. Often
the outlet of the glands becomes closed, and then small round cysts
are formed, which are filled with a fluid like the raw white of an egg,
feel like shot, and appear as translucent yellowish spots.
The connective tissue in the muscular layer of the cervix becomes
also hyperplastic, so that the cervix becomes larger and harder than
normal. The lips, especially the anterior, become elongated.
The body of the womb does not undergo the normal involution, but
stays large and heavy, and becomes the seat of a chronic inflammation.
Tears may heal completely by first or second intention, but in the
1 Most of these varieties are beautifully represented on colored plates accompany-
ing an excellent article on the Indications for Hystero-trachdorrhaphy by P. F. Munde
in the Amer. Jour. Obst., 1879, vol. xii. p. 134.
DISEASES OF THE UTERUS. 397
latter case the proce&s is often incomplete. : a cicatricial plug of hard
connective tissue is formed in the angle between the lips, and the
lower part of these does not unite.
On the other hand, the tear may heal from the tip of the cervical
portion to near its base, leaving a small opening, which constitutes a
utero-vaginal fistula without importance. A similar opening may
remain after artificial closure.
Symptoms. In the moment the laceration takes place, it may be
accompanied by arterial hemorrhage. An old laceration gives also
frequently rise to abnormal loss of blood, be it menorrhagia or met-
rorrhagia (pp. 245 and 247) from the cervix or from the endomet-
rium of the body. In the interval, the patient suffers from leucor-
rhea. This double drain produces soon anemia. The patient loses
her strength. She gets easily tired, becomes nervous and irritable,
and has often neuralgic pain in the localities described above (p. 134),
and sometimes strangely perverted sensations and hallucinations. 1 She
loses her appetite, her nutrition becomes insufficient, she is pale, and
her features have a suffering expression.
Laceration of the cervix is often accompanied by secondary ster-
ility, probably in consequence of the uterine catarrh to which it gives
rise. The hyperplastic lips and the unyielding cicatricial plug in the
angles between them oppose a considerable resistance to the dilatation
of the cervix in childbirth, entailing a tedious and painful labor.
Digital examination reveals the tear in the cervix, the thick, vel-
vety everted mucous membrane, often studded with small hard bodies
formed by the obstructed glands. Pressure with the nail in the
angle causes often great pain on the spot or in remote places.
The condition is best seen by means of Sims's speculum. The
tubular speculum, by pressing the lips apart, is apt to conceal the
true condition entirely. The bivalve is liable to make the laceration
and ectropiurn appear larger than they really are. In general, the
laceration is plainer to the touch than to inspection, but when exposed
by means of Sims's speculum the original shape of the cervix may
be approximately reproduced by hooking a tenaculum in each lip in
front of the red cervical membrane, where the os uteri was situated
before the laceration occurred, and pulling the two lips against one
another.
Diagnosis. By the means just indicated it is easy to demonstrate
the laceration. Sometimes the hyperplasia of the lips and the cystic
development may be so great that the diagnosis from cancer may
become difficult, but the effect of treatment will soon dispel all doubt.
1 A curious instance of this kind is found in my paper on Laceration of the Cervix
Uteri, Archives of Medicine, October, 1881. The same paper contains a description
of the microscopical composition of the tissue removed in trachelorrhaphy, and a
case illustrating the obstetric indication for the operation.
398 DISEASES OF WOMEN.
Some women have a congenital cleft of the vaginal portion in one
or two places. The lips thus formed may become the seat of a chronic
inflammation, and thus a condition may be brought about in a uullip-
arous woman that is entirely like a bilateral laceration. 1
Prognosis. Many lacerations of the cervix heal spontaneously and
give rise to no trouble. Sometimes the nervous phenomena men-
tioned above may, however, develop even if the tear is completely
healed. If the laceration is neglected the whole constitution suffers,
as we have seen above, and even a phthisical condition may be the end.
Tears of the cervix seem also decidedly to predispose to cancerous
degeneration. If properly treated the laceration and its consequences
may be entirely cured.
Treatment. The prophylaxis consists in abstaining from giving
ergot or other ecbolic drugs, from pressing on the fundus uteri, or
from using the forceps before complete dilatation has taken place.
On the other hand, the use of drugs that favor dilatation of the cer-
vix, such as belladonna, chloral, and antipyrin is beneficial.
The accoucheur should not feel or look for lacerations of the cervix
except in case of arterial hemorrhage. 2 Otherwise he exposes his
patient to infection, that may do much more harm than lacerations,
most of which probably heal spontaneously.
If, however, a fresh tear has been discovered and gives rise to
hemorrhage, it should be closed with sutures. If circumstances do
not allow of such an operation, a very densely packed tampon and a
tightly fitting T-bandage suffice to arrest the hemorrhage.
Fresh tears that do not bleed may be treated with antiseptic vagi-
nal injections or the application of a strong solution of nitrate of
silver (si-Bi)- 3
Old tears are treated differently, according to their size and the
other local and general conditions. Small nicks round the os may
be looked upon as a nearly normal incident of childbirth and need
no treatment.
Medium tears are often cured by curetting, and the application of
liquor ferri subsulphatis, twice a week, or pledgets with glycerite of
tannin (3i-|i), changed * morning and evening, and the use of hot
vaginal injections.
1 I have treated a girl who was about twenty years old and had an anteflexion
of the womb. The hymen was not ruptured, but very lax, probably in consequence
of masturbation. The anterior vaginal wall was everted. The cervix was split into
an anterior and a posterior lip, which were entirely separated, and bent forward and
backward into the fornix. The opening in the cervical canal formed a transverse
slit J inch wide. The anterior lip measured 1 inch, the posterior f inch in length.
The everted mucous membrane was edematous, bled easily, and was covered with
abundant glairy mucus.
* Garrigues, "The Immediate Closure of the Laceration of the Cervix," Amer.
Jour. Obstet., vol. xxiv. No. 11, 1891.
8 Elwood Wilson, Gynecological Trans., 1886, vol. xi. p. 92.
DISEASES OF THE UTERUS. 399
Unilateral tears can, as a rule, be treated successfully in a similar
way.
Large bilateral tears, or even healed tears if they cause neuralgia,
call for operative help, an operation that is called after its inventor
Emmet's operation, trachdorrhapliy (i. e. neck-sewing), or, more
explicitly, hystero-trachelorrhaphy (/. e. womb-neck-sewing).
Preparatory Treatment. Before performing this operation the in-
flamed mucous membrane should, however, first be treated with tinc-
ture of iodine, Monsell's solution, chloride of zinc solution, sulphate
of copper solution, or tannin glycerite, and hot douches. Cysts should
be pricked with a scarifier and painted with Churchill's tincture of
iodine. This preparatory treatment may take several months. If
circumstances do not warrant so protracted a treatment, the whole
mucous membrane may be excised at the time of the operation.
Trachelorrhaphy : The pubic hairs having been shaved off and the
genitals, inclusive of the vagina, disinfected, the patient is placed in
the dorsal position, the legs tied with Robb's legholder, and the peri-
neum drawn back with a single Sims speculum or my weight specu-
lum (Fig. 177). A Schroeder vaginal retractor (p. 211) helps often
considerably in making the parts accessible. I use strong full-curved
trocar-pointed needles, 1 J inches long, 1^ inches the straight line from
end to point (Fig. 184, g), and Crosby's needle-holder (Fig. 188).
I begin the operation by seizing the lips separately with a bullet-
forceps, pulling the uterus gently down, and inserting a strong linen
or silk thread through the middle of each lip. These guys serve
to steady the uterus, separate or approach the lips, mark the canal
which is to be kept open, and they facilitate the operation very
much. Next, a tenaculum is hooked into the cervical mucous mem-
brane on one side of the posterior lip. With a scalpel a piece is
cut off going in under the tenaculum, and the strip is continued into
the angle of the tear. Many use scissors. The great variety of those
invented suggests, however, that others have had similar difficulties to
those experienced by the writer, until he replaced the scissors by the
knife. Often it is easier to begin by cutting right into the angle from
the cervical canal to the vagina or vice versa. A corresponding surface
is denuded on the anterior lip. Then similar strips are cut off on the
other side, leaving an undenuded surface corresponding to the cervical
canal. This ought to be about half an inch wide at the os, as con-
traction always takes place later, and would result in too narrow an
os if there had not been left tissue enough. Particular care should be
taken to remove the cicatricial plug from the angle. The cut surfaces
bleed freely, but there is, as a rule, no hemorrhage of consequence.
The result of the cutting is that we have four denuded surfaces,
each two of which are continuous in the depth of the angle, and
between the denuded surfaces a trumpet-shaped undenuded piece
400
DISEASES OF WOMEN.
of mucous membrane is left on the anterior and posterior lips of the
cervix (Fig. 232).
The second step is to introduce the sutures. The first needle is
pushed in a quarter of an inch outside of one of the denuded surfaces
FIG. 232.
Diagram Illustrating Trachelorrhaphy in a case of Bilateral Laceration: A, posterior lip ; B,
anterior lip; C, cervical canal (apparent os surrounded by red and swollen rnucous mem-
brane, which used to be regarded as an ulcer). The numbers mark the order in which
the sutures are inserted. When they are tied A comes in contact with B and forms the
real os (e,f, g, h). The reader can easily realize the whole effect of the operation by copy-
ing this figure on a piece of paper and folding it at a line uniting D and D, which repre-
sents the angle between the lips.
of the posterior lip near the angle. It is pushed transversely under
the denuded surface and made to emerge just on the line of demarka-
tion between this and the undenuded central portion. Next, it is
inserted on the corresponding point of the anterior lip, and carried
under the denuded surface and made to emerge a quarter of an inch
outside of it, on a point corresponding to the first in which the needle
was pushed in. When the point of the needle emerges anywhere the
assistant holds the counter-pressure hook (p. 219) in under it, and
presses against the tissues in order to facilitate the passage of the
needle. The needle carries a loop of linen thread (p. 218) into which
is hooked a silver wire 10 inches long. This is closed temporarily
as explained on p. 219, and held aside so as to be out of the way. As
a rule, three such sutures are inserted on either side, and when they
all are in place they are twisted and cut off, beginning nearest the
angle. The ends ought to be left at least half an inch long, as they
are apt to become imbedded and are hard to find when you want to
remove them. It takes more time to use silver wire than other mate-
rial, but in this particular operation I have sometimes found decided
advantages in using silver wire. Later I have abandoned silver wire
for silkworm-gut or chromicized catgut, which does away with the
suture-carrier and the twisting.
Before and after closing the sutures I thoroughly irrigate with
some antiseptic fluid.
DISEASES OF THE UTERUS. 401
Originally, the operation was performed in Sims's position, but the
insertion of the needles and disinfection are much facilitated by the
dorsal position.
After having described the most common form of trachelorrhaphy
we must mention some of the many conditions that call for a modifi-
cation of the operation.
Modifications. If it has been necessary to cut very deep into the
angle between the lips, the wound cannot be closed in a reliable way
by inserting the sutures from the vagina as described above. Then
the uppermost should go much deeper in than it is possible to get
it when starting from the vagina. This is obtained by using two
needles, each with a loop of thread. One of them is introduced from
the cervical canal and pushed out through the posterior lip, the other
is in the same way carried from within outward, through the anterior
lip. Next the posterior loop is passed through the other, and the
latter pulled out through the anterior lip, carrying the posterior
loop with it. Finally, the suture is hooked into this loop and carried
back through both lips.
In the unilateral tear only one side is operated on.
In the stellate tear it is sometimes necessary to cut off a whole lobe
between two fissures on one or even both sides.
If there is much glandular hypertrophy and cystic degeneration, it
may be necessary to remove the whole mucous membrane from one or
both lips. This may be done before the operation by means of
Simon's spoon, and hemorrhage staunched with liquor ferri or tam-
ponade. The operation is then postponed until the parts are healed
over. It may also be done at the time of the operation by omitting
to leave an undenuded strip in the center for the canal or by curet-
ting it. If this is done on both sides, some provision must be made
for preventing the cervical canal from growing together. I have used
an intra-uterine glass stem for the purpose or introduced a probe re-
peatedly during the healing process. Others leave a silk thread or
reopen the canal by electrolysis. 1
When there is much hyperplasia, so that the lips stand far apart,
and when brought together offer two convex surfaces, it is necessary
to hollow the denuded surfaces well out in order to approximate
them.
If one lip is longer than the other, the position of the angle must
be changed by cutting the tissues in such a way as to get the angle
over on the longer lip, and thus obtain two lips of the same length
that will form a regular os.
If besides the cervix the perineum is torn, we are in general com-
pelled to do both operations at one sitting ; but if there came second-
1 Geo. Engelmann of St. Louis, Gyn. Trans., 1885, vol. x. p. 202, and 1886, vol. xi.
p. 90.
26
402 DISEASES OF WOMEN.
ary hemorrhage necessitating taraponade the perineal work would be
destroyed, and if menstruation came on unexpectedly, which some-
times happens, it might be hard to diagnosticate (p. 223).
As a rule, there is no more hemorrhage than that the operator can
go on as described above. If, in very exceptional cases, the circular
artery bleeds considerably, the deepest suture should be inserted im-
mediately on the bleeding side. As soon as the two lips are in appo-
sition all bleeding stops. In rare cases it may be necessary to cut out
a cicatrice from the foruix of the vagina. Here, also, an artery may
spurt that should be seized with pressure-forceps. It will hardly
be necessary to tie any artery.
If the operator has denuded a larger surface than he can cover
there may come serious hemorrhage, which, however, can be con-
trolled with styptic cotton and a tampon of common cotton, and need
not interfere with a perfect result.
Great care should be taken to have a perfect line of union, the
vaginal mucous membrane on one lip coming in contact with that of
the other. If necessary one or two superficial catgut sutures may be
inserted besides the deeper sutures.
If the lips of the torn cervix are adherent to the vaginal wall, the
adhesions should be separated sufficiently to allow the lips to be
brought together. The gap made by the incision in the vagina should
be packed with iodoform gauze.
Upon the whole, small as the field is, and free from danger as the
operation is, if performed aseptically, trachelorrhaphy requires, in my
opinion, as much judgment and skill as any other gynecological
operation I know of.
At the end of the operation I cover the cervix with a long strip of
iodoform gauze, packed loosely into the fornix of the vagina. The
patient may urinate herself. The bowels are kept open if necessary.
On the fourth and the seventh day the tampon is changed and the
vagina swabbed with antiseptic solution. On the tenth day the sutures
and the tampon are removed, and some vaginal injection administered
morning and evening. The patient stays nine more days in bed.
The effect of the operation both locally and as to general health is
wonderful. The womb diminishes in size, the nervous phenomena
disappear, the patients grow fat, a new period full of comfort and
blooming health follows in the course of a few months, and very
often conception puts an end to sterility.
The stitched surface may, of course, be ruptured in a new labor,
just as the intact cervix was, but very often it goes uninjured through
subsequent childbirths.
DISEASES OF THE UTERUS. 403
CHAPTER III.
FOREIGN BODIES.
FOREIGN bodies are by far not so common in the uterus as in the
vagina. Still, occasionally an intra-uteriue instrument, especially a
glass tube, may break and the end remain inside, or absorbent cotton
used for applying drugs to the interior may come off. Sometimes a
leech applied through Fergusson's speculum to the vaginal portion
has slipped into the interior of the womb. A hairpin used to pro-
duce abortion has also been found there. A Hodge pessary slipped
from the vagina into the cervix while the patient lifted another
person. 1
Treatment. If any object is in the womb which cannot be with-
drawn, the patient should be anesthetized, the cervix dilated, and the
foreign body removed with finger, curette, or forceps. If it is a liv-
ing leech, a strong solution of table-salt injected into the womb will
make it loosen its grip. If there is any hemorrhage the uterus should
be tamponed with iodoform gauze.
CHAPTER IV.
METRITIS.
METRITIS is inflammation of the uterus.
As in vaginitis a large number of different forms of metritis are
described according to the special part affected, the cause, the course,
and certain peculiarities. As this is not a treatise on morbid anatomy,
but above all a guide to the recognition of the diseases of the female
genitals and their treatment, it would not only lead us too far, but
cause unnecessary repetition and confusion, if we were to admit all
these distinctions as special diseases. We will only mention such
varieties as are clinically distinct or call for different treatment.
In regard to time and severity of symptoms we distinguish between
acute and chronic metritis.
Acute Metritis. In the acute inflammation the whole organ body,
cervix, mucous membrane, muscular layer, and peritoneal covering is
more or less implicated. The peritoneal inflammation so-called pcri-
metritis is, however, not always found, and if found extends gener-
ally to neighboring parts of the peritoneum, and will, therefore, be
treated of under Pelvic Peritonitis.
The inflammation of the mucous membrane is called endometritis,
that of the muscular layer parenchymatous metritis, that of the cervix
1 Henry Heiman, Med. Record, March 17, 1894, p. 347.
404 DISEASES OF WOMEN.
has been designated as cervicitis, and that of the raucous membrane
of the cervix as endocervicitis.
Pathological Anatomy. The whole uterus is enlarged and softened,
the cut surface is red with yellow points. The mucous membrane is
swollen and red. Microscopical examination shows both in the mucous
membrane and between the muscle-fibers an abundant infiltration with
small round cells, dilated blood-vessels, and masses of extravasated
blood. The inflammation extends sometimes to the peritoneum and
the pelvic connective tissue, either through the tubes or through the
lympathics (p. 60). Sometimes it is combined with vaginitis.
It is doubtful if ever an abscess is formed in the uterine tissue,
except in puerperal cases where the metritis appears as part of a more
comprehensive infection.
Etiology. Menstruation being accompanied by a development that
has much in common with that of inflammation, predisposes to the
latter. Thus exposure to wet or cold is more liable to end in acute
metritis during the menstrual period than at other times. Coition
during menstruation may have a similar effect. Parturition and mis-
carriage are the most common causes, either through direct puerperal
infection or as a predisposing element : if a woman who has recently
given birth to a child or aborted, fatigues herself, catches cold, or
has sexual intercourse, she is more liable to have an acute inflamma-
tion of the womb than otherwise. Coition ought not to take place
before involution is completed say, two months after childbirth and
one month after early abortion.
Acute metritis may be brought on by any gynecological operation,
even the mere introduction of a sound, and still more easily by curet-
ting, or by the irritation caused by an intrauterine stem or even a badly-
fitted vaginal pessary. Trachelorrhaphy or incision of the cervix has
often led to endometritis extending through the tubes to the peritoneal
cavity and ending fatally. Retained blood may become decomposed
and cause acute metritis. The true agent in all these cases is doubt-
less the introduction of pathogenic microbes, for by proper antiseptic
precautions the evil may be avoided.
Acute metritis appears sometimes in the exanthematous fevers,
typhoid fever, cholera, acute yellow atrophy of the liver, phosphorus-
poisoning, and in persons affected with syphilis.
As we have seen above (pp. 131 and 291), gonorrheal infection
invades sometimes the uterus.
Symptoms. Acute metritis is accompanied by fever, a sensation of
heat in the pelvis, bearing-down pain, a painful sensation of contrac-
tions called cramps, or pain extending up to the lumbar region.
Sometimes the patient complains of vomiting, diarrhea, dyschezia,
and dysuria. Often she suffers from suppressio mensium or menor-
rhagia, or has a purulent discharge from the uterus. In gonorrheal
DISEASES OF THE UTERUS. 405
metritis t'here is especially an abundant secretion of thick creamy,
often blood-tinged pus, teaming with gonococci. The abdomen is
tympanitic and tender.
Vaginal examination reveals a hot vagina, a swollen, congested
cervix, with patulous, often eroded, os, and a large, soft, tender
body.
Prognosis. In most cases the disease ends in recovery in the course
of from two to four weeks. Repeated attacks of acute metritis are,
however, liable to end in chronic metritis. The possibility of the
extension of the inflammation to the tubes and the peritoneal cavity,
especially in gonorrheal and septic metritis, must also make us cau-
tious in our prognostication.
Treatment. Prophylaxis. A perusal of the causes of acute metri-
tis gives the necessary indications in regard to, how to avoid the dis-
ease. At the time of menstruation, in the puerperal state, and after
abortion, women should be particularly careful to avoid too great
bodily exertion and exposure to cold. They should abstain from
sexual intercourse. Obstetricians and gynecologists should use all
antiseptic precautions, even in normal deliveries, as well as small
gynecological manipulations and operations.
Curative Treatment. The patient should stay in bed. An ice-bag
or ice-\vater coil should be applied over the symphysis (p. 187),
except when the cause is suppression of menses by exposure to cold.
In the latter case a warm poultice or hot-water bag is substituted.
If there is no bleeding, some bloodletting by means of leeches,
the artificial leech, or simple scarification (p. 186) sometimes affords
considerable relief; but all these manipulations necessitate the use of
a speculum, and, if the tenderness is great, this does more harm than
good.
Vaginal douches of plain warm water should be administered
three times a day or oftener. In these acute cases lukewarm water
(100-105 F.) has often a more soothing effect than the hot (110-
115). The addition of flaxseed or slippery elm increases perhaps
this effect of the douche somewhat (p. 1 72).
A lukewarm sitz-bath (p. 187) once or twice a day or a general
warm bath every other day is also useful, if the slight movements
inseparable from these procedures do not hurt the patient. Anodynes
are best given as opium suppositories (p. 226). Five grains of qui-
nine should be given every four hours, and the bowels kept open.
When the most acute symptoms have subsided, the ice-bag may to
advantage be exchanged for Priesznitz's compress (p. 187), tincture
of iodine may be painted on the abdomen and on the roof of the
vagina (p. 188), and glycerin tampons (p. 178) may be introduced
into the vagina. If the discharge is purulent, the uterus should bo
curetted.
406
DISEASES OF WOMEN.
Gonorrheal raetritis necessitates a more active treatment. The ute-
rus should be washed out (p. 172) at least once a day with a solution
of corrosive sublimate (1 : 3000), permanganate of potash (1 : 1000).
or chloride of zinc (1 : 100). Twice a week the interior of the uterus
should be painted all over with a solution of chloride of zinc (20 per
cent.) or nitrate of silver (1 : 12). Some use curetting (p. 176). A
milder treatment, with a somewhat similar effect, consists in packing
the uterus once or twice with iodoform gauze (p. 180) in order to
remove all pus and some of the epithelium, and finally leaving a
strip well dusted with iodoform in the uterus. Far from causing
pain, it seems to have a soothing effect.
Diphtheritic Metritis. A particular variety of the acute metritis is
the diphtheritic, in which there is a yellow exudation in and on the
endometrium. This condition is mostly due
FIG. 233. to puerperal infection, but is also found as
/f" part of general diphtheria. It occurs com-
/" bine*! with gangrene of the vagina (p. 352) in
Hi, scarlet fever, typhoid fever, cholera, and other
|H infectious diseases.
If In puerperal cases the diphtheritic infiltra-
tion may extend in a layer from the endome-
trium to the neighborhood of the peritoneum,
cutting off a large part of the muscular tissue,
which, after weeks or months, is expelled as a
pear-shaped body (Fig. 233), a condition which
is little known, but of which I have observed
and described under the name of dissecting
metritis not less than eight cases. 2
Diphtheritic metritis is, as a rule, combined
with a similar condition in the vulva and the
vagina, and may be made visible when it at-
tacks the cervix. Dissecting metritis cannot
be diagnosticated before the loose body is ex-
Dissecting Metritis.i pel led, but its existence may be surmised, if
after diphtheritic vaginitis and cervicitis there
continues an abundant purulent discharge from the uterus.
If the cervix is attacked, its whole inner surface should be thor-
oughly painted once with chloride-of-zinc solution, 50 per cent. The
uterus should be washed out with carbolized water once a day. An
iodoform pencil
1 Specimen expelled by B. R. at Maternity Hospital, on Oct. 20, 1883. This was
the eighth case of the report published in N. Y. Med. Record, vol. xxiv. .p. 664.
The figure taken from a photograph is a little below natural size.
2 Garrigues, " Dissecting Metritis," New York Medical, Journal, 1882, vol. xxxvi. p.
537; Archives of Medicine, April, 1883; and Archivfiir Gyndkologie, 1890, vol. xxxviii.
p. 511.
DISEASES OF THE UTERUS. 407
1^. lodoformi, 3v;
Amyli, 3ss ;
Glycerini, fl. 3ss ;
Acacise, 3J.
M. Sig. Divide in three suppositories of the size and shape of
the little finger.
should be introduced up to the fundus and left to melt. The internal
treatment consists in the administration of quinine, stimulants, and
chloride of iron.
Some recommend in severe puerperal infection hysterectomy and
removal of the appendages, either by the vaginal method or abdom-
inal section. The operation is said to be especially indicated when
there are foci of suppuration or infection in the uterine body, an in-
fected endometrium, persistent metrorrhagia, or widespread suppura-
tion and disintegration of the broad ligaments. In the writer's ex-
perience these patients are in most cases too weak to stand so serious
an operation, and the operation itself spreads often the infection. In
the majority of cases better results may be expected from medical
treatment, opening and draining of abscesses, etc. More radical ope-
rations are often to advantage postponed till the patient has gained
more strength.
B. Chronic Metritis. While we have treated of the acute form of
metritis as one entity without distinguishing between the inflamma-
tion of the mucous membrane and that of the muscular tissue, in
regard to the chronic form of inflammation of the uterus, it is bet-
ter to describe endometritis and parenchymatous metritis separately.
It is true that the inflammation of the mucous membrane always
extends somewhat into the muscular layer, and that an inflammation
of the latter always implicates the former, but still there are marked
clinical differences between the two, and certain points in the treat-
ment apply only to one or the other.
1. Chronic Endometritis. Pathological Anatomy. In the chronic
form of endometritis the mucous membrane of the uterus is swollen,
soft, friable, of dark red or slate color. In some places are seen ecchy-
moses. On account of the swelling the mucous membrane does not
find room enough in the uterus and bulges out through the os, form-
ing a so-called ectropium. The glands of the cervix become occluded
and form cysts most of which are small as hemp-seed or peas, and
shine with a white or yellow color through the surface of the vaginal
portion. In olden time these retention cysts were mistaken for the
human ovulurn and are yet known under the name of ovufa of Xa~
both. Occasionally these cervical cysts acquire, however, the size of
a cherry. When pricked open a thick colorless fluid, like the raw
white of an egg, flows out from them. The interior of the body has
408 DISEASES OF WOMEN.
lost its even smoothness, and is raised in ridges or in papillary growths,
or long club-shaped polypi hang down from the fundus and the side
walls. This has been described under the name of hyperplastic or
fungous endometritis. Similar mucous polypi form in the mucous
membrane of the cervix and may hang out from the os as peduncu-
lated tumors.
Around the os, on the outer surface of the vaginal portion, is found
a red velvety area, and similar red spots may be found further out on
the vaginal portion, apart from the os. They are often called erosions,
and they form what is known as a granular os. They used erroneously
to be called ulcers of the cervix, an expression that is yet often used
by patients.
Microscopical examination shows that the swelling of the mucous
membrane in chronic endometritis is due to a great development of
its glands, to infiltration with round cells, and to dilatation of the
blood-vessels. The glands penetrate into the muscular layer. When
this considerable development of glands takes place, the condition is
sometimes designated as benign adenoma as opposed to malignant ade-
noma, which is beginning cancer of the mucous membrane.
The fungoid growths on the inside of the uterus are sometimes
nearly exclusively formed by glands ; in others they consist of round
cells like the granulations on a wound ; and in a third variety they
are almost entirely composed of dilated blood-vessels. In some
places the formation of connective tissue gets the upper hand, and
the glands become atrophic or disappear. A similar difference is
observed on different points of the membrane, if it remains compara-
tively smooth.
The so-called erosions are due to a change in the epithelium cover-
ing the vaginal portion, which normally is flat like that of the vagina,
but becomes columnar. In the interior is found an infiltration with
round cells, as in all inflammations. By invagination the epithelium
forms bays and tubules, which constitute new glands and, when they
become closed, are transformed into cysts.
Etiology. Many points have already been discussed in the chapter
on Etiology in General (pp. 127-131), and the reader is referred to
what is stated there about hyperemia of the pelvic organs, con-
stipation, exposure to cold, improper dress, neglect during men-
struation, certain abnormalities in regard to coition, puerperal in-
fection, and abortion.
The influence of gonorrhea has been spoken of on pp. 131 and
291, and we have seen how it may cause acute metritis (p. 404),
but after the acute stage is over it may remain as a chronic inflam-
mation.
During childbirth the cervix, and especially its mucous membrane,
is subjected to such pressure and abrasions that often a chronic endo-
DISEASES OF THE UTERUS. 409
cervicitis follows. This is especially the case if the cervical portion
is torn (p. 396).
Parts or the whole of the decidua may remain after childbirth and
abortion and continue to live as part of the endometrium, a condition
that has been described as decidual endometritis.
Old age gives rise to a peculiar form of endometritis called
atrophic endometritis. The normal columnar epithelium becomes
changed to an irregular horny one, more like the flat epithelium of
the vagina. There is a profuse purulent discharge. Sometimes the
opposite walls grow together, especially at the internal os, which gives
rise to senile pyometra.
Symptoms. A prominent symptom is pain. In the general divi-
sion of this book we have enumerated the order of frequency with
which a neuralgic pain is found in certain localities (p. 134). Besides,
the patient, as a rule, complains of " bearing down," a disagreeable
sensation of heaviness extending from the interior of the pelvis to the
external genitals, and often of " cramps," a painful feeling of muscu-
lar contraction of the uterus caused by retention of blood or mucus
above the internal os. Sometimes, although the ophthalmologist finds
no fault in her eyes, she complains of pricking pains in them, of weak
eyesight and photophobia, often combined with pain in the occiput,
where the visual centers are located.
It is not rare that a feeling of discomfort necessitates frequent mic-
turition although the urine is normal, a condition designated as
irritable bladder.
As a rule, the menstrual discharge is preceded and accompanied by
more or leas severe dysmenorrhea (p. 242).
Secondly, abnormal loss of blood from the uterus is of frequent
occurrence, and easily explained by the vascular development de-
scribed in the paragraph on morbid anatomy. There may be meu-
orrhagia (p. 245) or metrorrhagia (p. 247), or both, and often pro-
tracted menstruation, the menstrual process extending over an unusual
number of days, although perhaps the total loss of blood does not
exceed the normal quantity. When loss of blood is a prominent
feature the condition has been described as hemorrhagic endometritis.
In very weak patients endometritis is, on the other hand, occa-
sionally accompanied by amenorrhea.
A third symptom that brings the patient to seek help is leucorrhea,
which is easily accounted for by the hyperplasia of the normal glands
and the constant formation of new ones. The fluid secreted by the
cervix is like raw white of an egg (p. 250), that from the interior of
the body is more milky. Both are alkaline, and both may become
purulent, which is especially the case in gonorrheal and atrophying
endometritis. As to the microscopical composition, see p. 250. If
the discharge is at all abundant, it weakens the constitution (p. 251).
410 DISEASES OF WOMEN.
When leucorrhea predominates, the disease has been called catarrhal
endometritis or catarrh of the uterus.
In some patients there is a very free discharge of a muco-serous
fluid, a condition called hydrorrhea. At times the secretion may be
retained above the internal os, probably on account of the swelling
of the mucous membrane or a spasmodic contraction of the surround-
ing muscular tissue. The uterus may then become quite distended,
and the patient has considerable pain until the obstacle gives way, and
the accumulated fluid rushes out in a gush, when she feels relieved
until the same process repeats itself. Apart from pregnancy hydror-
rhea is a rare disease. 1
The hydrorrhea of pregnancy, hydrorrhea gravidarum, on the con-
trary, is rather common. Watery fluid may be discharged any time
during pregnancy, but it is most common during the last month of
gestation, and gives often rise to the erroneous supposition that the
" waters have broken."
A similar condition is sometimes found after childbirth puer-
peral hydrorrhea. It is then commonly due to the retention of a
portion of the placenta or of clots, but a polypus may produce like
results. 2
The patient afflicted with endometritis loses her appetite, and suf-
fers often from nausea, dyspepsia, and constipation. She becomes
weak and pale, with black rings under her eyes.
Some patients complain of a feeling of oppression in breathing.
Some have palpitations.
The nervous system suffers much. These patients are quite fre-
quently despondent and melancholy. I have seen cases of acute
mania and epilepsy. The group of symptoms classed as hysteria is
so rare that it is doubtful if there is a causative relation between it
and endometritis.
An inflamed endometrium does not seem to be a favorable ground
for the implantation and development of the ovum. The abundant
leuchorrhea helps also perhaps to expel it. So much is sure that
patients afflicted with endometritis often are sterile, or if they con-
ceive they have a tendency to abortion. It is also claimed that pla-
centa praevia may be caused by it, the ovum sinking down to the os
internum before it becomes fastened to the endometrium.
By vaginal examination we find, in most cases, at least in women
who have borne children, the os patulous, velvety, or granular, often
studded with small, round, hard bodies (pvula of Naboth). In nul-
1 I have seen a case in which the uterus was purple, slightly tender, and meas-
ured, when the patient consulted me, 3o inches, but before that it had been ,as much
as 5 inches, as measured by other gynecologists of this city. Her discharge was so
copious that " she used forty diapers a day, that it wetted sheets, and that she could
pass it on a bed-pan and fill bottles with it."
2 R. Barnes, Diseases of Women, London, 1873, p. 81.
DISEASES OF THE UTERUS. 411
liparous women, on the other hand, the external os is often too nar-
row, and the secretion accumulates in the cervix or in the body of the
uterus or in both simultaneously.
The cervix is quite commonly enlarged, either too soft, when the
cellular infiltration, the formation of glands and cysts, and the dila-
tation of the blood-vessels predominate, or too hard, when the hyper-
plasia of connective tissue has caused atrophy or disappearance of the
softer structures. The uterus is tender on pressure.
The introduction of the sound and dilator is unusually painful and
often causes some bleeding. By moving the sound along the interior
surface it is often felt to be rough or the seat of polypi.
Diagnosis. In lumbo-abdominal neuralgia certain parts of the
uterus, especially on the level with the internal os may be tender on
pressure, but then all the other symptoms, especially hemorrhage and
leucorrhea, are absent.
A fibroid tumor often causes hemorrhage and leucorrhea, but the
presence of the tumor can be made out by bimanual examination. If
it is % fibroid polypus, it can be felt with the sound.
The diagnosis from the early stage of cancer may be difficult. In
cancer we find, however, such friability of the tissue that parts can be
scraped oif with the nail, or are spontaneously expelled from the inte-
rior of the womb, which is never the case in endometritis. On the
other hand, this soft tissue is surrounded by one that is much harder
than in mere inflammation. Cancer is accompanied by a profuse
discharge of a watery fluid or thin pus with a peculiar pungent and
offensive odor. As to hemorrhage, when the patient is in the prime
of life, has a subinvoluted uterus, and suffers merely from menorrha-
gia, the probability is in favor of hyperplastic endometrits, and against
malignant disease. On the other hand, bleeding after the menopause
is a very suspicious symptom. Many lay much stress upon irregular
bleeding in the intermenstrual period, especially after coition, but I
have often seen this in cases of lacerated cervix with ectropion. Pain
is, as a rule, absent in beginning cancer, but sometimes the patient has
vague shooting pains in the pelvis. Cancerous tissue is well differenti-
ated from the surroundings, forming a glistening prominence not unlike
currant jelly. The effect of treatment will soon dispel all doubt.
The diagnosis is made sure by cutting out a piece of the suspicious
tissue from the cervix, imbedding it and preparing microscopical
specimens of it. In the same way the malignant or benign
nature of scrapings from the interior of the womb is ascertained.
Mere "teasing" with two needles does not furnish conclusive
specimens.
Prognosis. Chronic endometritis is at best a very tedious disease,
and it is not safe to promise more than improvement. This applies
particularly to the catarrhal discharge. But even this is sometimes
412 DISEASES OF WOMEN.
completely cured. As to conception, the prognosis should be still
more reserved, especially in cases of catarrhal endometritis involving
the body of the womb.
Hemorrhage may undermine the constitution and even prove fatal,
but in this respect our therapeutic resources are manifold and powerful.
As to pain and other nervous phenomena, the outlook is favorable.
Treatment. What prophylactic measures are to be taken, is self-
evident by reference to the above paragraph on etiology. Here we
will only notice the importance of removing the endometrium with a
curette after abortion, and of not allowing pieces of placenta or mem-
brane to stay behind after delivery.
In patients affected with gonorrhea of the urethra and vagina, the
extension of the disease to the uterus may perhaps be prevented by
the use of a tampon soaked in the following solution :'
1^. Acidi tannici,
lodoformi, da 3n ;
Glycerini, 3v. M.
Patients affected with chronic endometritis need a good deal of
rest. Gymnastics, dancing, bicycling, machine-sewing, and similar
fatiguing movements, make their condition worse. Moderate exercise
in the open air is good, but the patient ought never to walk so much
as to increase her pain. In order to avoid pelvic congestion, she
should abstain as much as possible from sexual intercourse. For the
same reason the bowels should be kept open if she is constipated (p.
225). An elastic belt surrounding the whole abdomen (p. 190) is
often useful in stout women by shifting over on the spinal column
and the lower extremities some of the pressure exercised on the uterus
by the intestines and other abdominal organs.
A warm bath (p. 187) twice a week has often a very soothing effect
on the nerves, and probably withdraws blood from the uterus by dilat-
ing the capillaries of the skin. Warm sitz-baths have a similar
effect. By the use of the bath-speculum (p. 187) this may still
be enhanced. Sea-bathing, shower-, sponge-, sheet-, or towel-baths,
or a regular hydrotherapeutic treatment is excellent in combating
catarrh, hemorrhage, and debility. Certain spas (p. 188) have a repu-
tation for being beneficial in chronic endometritis.
The disease being of long duration, we should use anodynes
(p. 226) very sparingly. Backache is temporarily relieved by rub-
bing the region with a mixture of 1 part of chloroform with 3 parts
of olive oil four times a day. The pain in the eyeballs accompanying
asthenopia disappears rapidly under the use of a douche of cold water
directed three times a day for five minutes against the closed eyes.
1 H. Fritsch in BUlroth's und Luecke's Handb. d. Frauenkr., vol. i. p. 1043.
DISEASES OF THE UTERUS. 413
Certain fountain-syringes are accompanied by a nozzle in the shape
of the rose of a watering-pot, which answers the purpose. With this
treatment I combine, as a rule, scarification of the cervical portion
and the administration of tonics (p. 225).
For irritable bladder I use the following mixture :
3$j. Tinct. belladonna?, 3\j ;
Liq. potassse, 3J ;
Aquam, ad 3iv.
M. Sig. 1 teaspoonful in a wineglassful of water 3 times a day,
between meals.
In regard to hemorrhage the reader is referred to what has been
said on p. 246.
If the measures described there fail to check the uterine hemor-
rhage, the uterine artery may be ligated on both sides (p. 182).
Sometimes salpingo-oophorectomy has been performed, and even
hysterectomy.
If in hyperplastic endometritis the endometrium is studded with
prominences, curetting (p. 176) has a prompt effect. If the whole
membrane is swollen, the intra-uterine chemical galvano-cauterization
according to Apostoli's method is excellent. The galvano-cautery
has also been used for this purpose, but is probably an unnecessarily
harsh treatment.
The treatment of amenorrhea is discussed on p. 240. It occurs
sometimes for from one to four months after curetting, and should
then not be interfered with, as it is a beneficent pause after the drain
on the system for which the curetting was done.
For the treatment of leucorrhea directions are found on p. 251.
Since we have seen above how the glands of the mucous membrane
become enlarged and dip into the muscular layer, it is easy to under-
stand how fruitless often all applications prove, and how important it
is to combine general with local treatment.
Curetting, chemical irritants, the actual cautery, and other powerful
revulsives, work not only by removing diseased tissue, but the tissue is
returned to a medullary state, and taking a new start the new-formed
tissue may become healthy.
Oppression and palpitations are treated with bromides, especially
monobromated camphor (gr. i-x, t. i. c?., in emulsion or capsules).
Ovula Nabothi are pricked open and then painted with tincture of
iodine. Exceptionally, the whole cervical portion may be one agglom-
eration of cysts, which do not yield to this treatment, Then they
should gradually be destroyed with a needle-shaped Paqueliu's cau-
tery or galvano-cautery.
For erosions there is no better treatment than to bathe the vaginal
414 DISEASES OF WOMEN.
portion in a tubuliforra speculum for a couple of minutes with acidum
pyrolignosum rectificatum twice a week ; but this substance has such
a pungent odor that it is disagreeable to most people. A 10 per cent,
solution of sulphate of copper applied in a similar way for a few min-
utes two or three times a week is also very good. Erosions may also
be treated with carbolic, chromic, or nitric acid, followed by a solution
of bicarbonate of soda in order to neutralize the superfluous acid.
Injections of chloride of zinc, chloride or subsulphate of iron, and
nitrate of silver are also valuable. I often combine curetting by
means of Simon's sharp spoon with the application of liquor ferri
chloridi.
I have obtained excellent results by applying to the eroded os,
through Cusco's speculum, the positive pole of a galvanic battery in
the shape of a ball of gas-carbon wound with very little cotton,
squeezed nearly dry. It is used for five minutes with as strong a
current as the patient can stand (about 40 milliamp^res). It leaves
an eschar followed by suppuration. A few such applications re-
peated once a week produce a healthy mucous membrane in shorter
time than any astringent. Apostoli has constructed a special elec-
trode for the purpose (p. 234).
If the cervix is lacerated, trachelorrhaphy should be performed
(p. 399).
In the interior of the body of the uterus the above-named acids
and astringents are also used. The substances I personally use for
treating the endometrium are Churchill's tincture of iodine, chloride
of zinc, nitrate of silver, and chloride of iron, and I apply them all
on absorbent cotton wound around Budd's applicator (p. 1 70).
Iodine is the mildest and the most generally useful ; chloride of
iron is best in the hemorrhagic, chloride of zinc and nitrate of silver
in the catarrhal form.
Besides the intra-uterine application, I paint the vaginal roof with
tincture of iodine (p. 170), which probably acts as a counter-irri-
tant.
The patient herself introduces a pledget with glycerin morning and
evening (p. 178). As we want the iodine to enter the tissue by endos-
mosis, and glycerin causes a powerful exosmosis, it is better not to
introduce the pledget immediately after painting the vagina.
As an astringent on a spongy cervix, glycerite of tannin is very
good (p. 178). Duke recommends boracic acid in powder applied
with a tube and piston (p. 171).
Scarification is used not only for opening and destroying cervical
cysts, but also to give exit to some blood. When the uterus' appears
congested, this procedure gives often great relief (p. 186).
If the external os is too narrow, mucus often accumulates in the
cervix, which is distended in the shape of a barrel. In such cases
DISEASES OF THE UTERUS. 415
the treatment must begin by gradual dilatation of the cervical canal
(p. 154). If the os is so small that not even a common uterine sound
can enter, it is necessary first to make a little nick with a knife.
In chronic endometritis of gonorrheal origin the treatment is sim-
ilar to that in the later stage of the acute (p. 405).
In cases that had resisted all other treatment the writer has obtained
a cure by cutting off the whole mucous membrane of the cervix, and
leaving the wound to heal over an intra-uterine glass stem.
Exfoliating Endometritis. Exfoliating endometritis, also called men-
strual endometritis, or membranous dysmenorrhea, is a rare variety of
eudometritis that presents so peculiar features that we are obliged to
treat it separately. It forms a link between acute and chronic endo-
metritis in so far as it is an acute process that repeats itself every
four weeks.
Pathological Anatomy. The mucous membrane of the body of
the womb is swollen and red. It is thrown off in shreds an inch in
diameter or even as one piece representing a cast of the uterine cavity
with an inner smooth and outer rough surface and three openings
corresponding to the internal os and the apertures of the Fallopian
tubes.
Microscopical examination shows that the uterine glands are un-
changed, but that there is great hyperplasia of the cells of the endo-
metrium, which retain their normal size, but are packed so closely
together that little space is left for the inter-cellular substance.
Etiology. Exfoliating eudometritis is a form of chronic endometri-
tis. It is sometimes allied to fibroids, and occurs in women affected
with syphilis, tuberculosis, or suffering from acute phosphorus-
poisoning.
Symptoms. The disease is characterized by severe pain in the
pelvis recurring at each menstrual period and followed by the expul-
sion of the above described parts of the endometrium. It may be
found at any age during menstrual life. Persons affected with it
may become pregnant, and are liable to abortion, but may even give
birth to children and then again be affected in the old way.
Diagnosis. Exfoliating endometritis is, as we have said, a very rare
disease, and assertions to the contrary are based on errors of diagnosis.
A chief point in the diagnosis is the regularity of the expulsion of
membranes, but even that may be simulated for some time by regu-
larly repeated abortions. The microscope alone can positively settle
the diagnosis. The presence of villi chorii is absolute proof that the
specimen is a product of conception, and even the decidua of preg-
nancy differs from that of menstruation by the large size of the cells
of the endometrium.
In extra-uterine pregnancy a similar expulsion of the endometrium
may take place. In order to avoid errors as much as possible the pel-
416 DISEASES OF WOMEN.
vis must be examined most carefully for a tumor that might be the
fetal sac, and all signs of pregnancy, genital, pelvic, abdominal, sto-
machic, mammary, cutaneous, and nervous, looked for.
7}'eatment. Spontaneous cures are reported, but, as a rule, the inter-
vention of the healing art is solicited. The endometrium should be
destroyed so as to give a chance for a new and better growth. This
is done by the curette followed by the application of tincture of iodine
or iodoform pencils, or by the galvano-chemical cauterization accord-
ing to Apostoli's method.
2. Chronic Parenchymatous Metritis. Pathological Anatomy.
The size and weight of the uterus are increased, the wall is thicker,
the cavity larger, and the tissue harder. Microscopical examination
shows that the muscular bundles are separated by much broader layers
of connective tissue than in the normal uterus. The walls of the
arteries in the muscular tissue of the uterus are thickened and par-
tially changed to connective tissue. The lymph-spaces are enlarged,
and the peritoneal covering thickened. If the case is due to subin-
volution after childbirth or abortion, the muscular fibers are found
enlarged and abnormally numerous (hypertrophy and hyperplasia). 1
Etiology. The parenchymatous metritis may arise by extension
from chronic endometritis. Frequent attacks of acute metritis may
finally lead to the chronic form. It may be due to exposure to cold,
especially living in a cold climate and in a damp basement.
Too frequent coition and still more a connection that is interrupted
without ending in orgasm and the normal sensation of contact with
the ejaculated semen, abortion, subinvolution after childbirth, and too
rapidly recurring pregnancies, favor its development. It frequently
accompanias displacements, especially retroflexions, fibroids, and
cancer of the uterus, as well as ovarian tumors.
Symptoms. As a rule, the patient has no fever, but occasionally a
rise of temperature up to 102 Fahrenheit shows an acute exacerbation
in the chronic condition. She has an unpleasant bearing-down sensa-
tion, often combined with pain in the groins and backache. Men-
struation is usually more or less painful. Quite often the patient
feels an irritation of the bladder, compelling her to empty that organ
frequently, although the composition of the urine is normal. Con-
stipation is very common.
Hysteria is not found oftener than in other women, and is, there-
fore, probably independent of the disease.
Menorrhagia and leucorrhea are very common. Nervous reflexes,
such as swelling of the breasts, mastodynia, and intercostal neuralgia,
accompany it frequently.
The dilatation and growth of the uterus during pregnancy is ac-
companied by pain, and is often interrupted by abortion.
1 Welch of Baltimore, quoted by A. P. Dudley, N. Y., Med. Jour., Sept. 4, 1886.
DISEASES OF THE UTERUS. 417
Some patients have, in the middle of the interval between two
periods, a so-called intermenstrual pain, much like that occurring
with menstruation, but of shorter duration, and sometimes accom-
panied by the excretion of bloody mucus.
Vaginal examination reveals the enlargement and tenderness of
the body of the uterus, and often a thickened, hard, eroded, and
granular vaginal portion.
In nervous and anemic persons a tumor is sometimes felt in one
of the edges of the uterus at the junction of the neck and the body.
It may become as large as a hen's egg. It is semiglobular, of the
consistency of a myoma, and sensitive on pressure. It is only con-
gestive, is formed during hemorrhage, and disappears when the bleed-
ing stops. After the bleeding follows an offensive discharge like
lochia. These tumors have been described by French authors under
the name of "tumeurs fluxionnaires" and are supposed to be due to
metritis.
Diagnosis. Cancer of the body of the womb causes greater hard-
ness, forms a tumor that can be felt, and is accompanied by a thin,
purulent, malodorous discharge. By means of the sound the inner
surface of the womb may be found to be irregular and to contain
spots where the tissue is unusually soft.
Prognosis: Chronic parenchymatous metritis does not, as a rule,
threaten the patient's life unless the hemorrhages should be profuse
enough to undermine her constitution, but it is an exceedingly tedious
disease, sometimes extending over many years, and a perfect cure is rare,
although much can be done to alleviate the sufferings of the patient.
Treatment. In order to avoid needless repetition the reader is
referred to what has just been said about chronic endometritis, which
always accompanies the parenchymatous form. Here we will only
add measures particularly indicated where the muscular coat of the
uterus is implicated.
Among internal medicines, a long-continued use of small doses of
chloride of gold, or of corrosive sublimate (p. 227) may succeed here as
in other parts of the body in reducing the abnormal deposit of con-
nective tissue.
In cases of subin volution, Tait praises the effect of chlorate of
potassium, gr. viiss, t. i. d., given in a medicine with a few r drops of
dilute hydrochloric acid.
Faradization has a similar effect by causing muscular contraction.
The bipolar intra-uterine method (p. 229) is particularly recom-
mendable. Apostoli praises the primary current.
The galvanic current (p. 229) may help to reduce the bulk of the
uterus by electrolysis.
Massage (p. 190) causes absorption by mechanical manipulations.
Finally, operative interference not only serves to remove redundant
27
418
DISEASES OF WOMEN.
tissue mechanically, but experience has shown that it so modifies the
nutrition of the womb that that organ may shrink considerably in
the course of several months following the operation. If the cervix
is lacerated, trachehrrhaphy (p. 399) should be performed. If it is
not torn, but much enlarged, it may be diminished in different ways.
1. Gordon's Method} If the cervical canal is so large that it
can be done without causing stenosis, a wedge-shaped piece may be
cut out, having the base at the os and the apex at or somewhat beyond
the utero- vaginal junction. This operation is performed exactly like
trachelorrhaphy, and recommends itself by its safety and simplicity
and by leaving a normal vaginal portion, which may be needed for
the adaptation of a pessary.
2. Hegar's Method consists in the removal of the whole vaginal
portion. The patient being in dorsal decubitus, the vaginal portion
is exposed by means of a single Sims speculum (p. 145) and side
retractors (p. 211), and the uterus pushed and pulled down. The
cervical portion is split open with scissors on both sides up to
the vaginal vault. Each lip is seized with a volsella or bullet-
forceps and cut off with scissors bent at right angles. In dealing
with the anterior lip the operator must take care not to go beyond
the boundary-line of the bladder, which may be ascertained by
means of a metal catheter. Next, the mucous membrane of the
cervical canal is united by a row of sutures to that of the vagina,
comprising part of the cut surface, but skipping that part which is
farthest away from the mucous membranes (Fig. 234). Sometimes it
FIG. 234.
Hegar's Amputation of the Cervical Portion : a, two sutures on each side do not enter the cer-
vical canal ; b, all sutures are passed from the vaginal to the cervical mucous membrane.
In both cases a portion of the cut surface is skipped in inserting the sutures.
is better only to do this in the middle, and to unite the vaginal mucous
membrane in front and behind at the sides- This is done with rather
1 S. C. Gordon of Portland, Me., Amer. Jour. Obst., 1884, vol. xvii. p. 1205.
DISEASES OF THE UTERUS.
FIG. 235.
419
Simon's Coue-mantle-shaped Excision of the Vaginal Portion : a, sutures inserted ; b, sutures
tied. (There ought to be one or two on each lateral incision).
strong, curved, round, crescent-ground, or trocar-pointed needles or
the fishhook-shaped needles (Fig. 184, /, g, and E), held in a needle-
holder. 1
FIG. 236.
A B C
Schroeder's Single-flap Excision of the Vaginal Portion : A, excision made, sutures placed
on anterior lip and tied on posterior; 1 and 2, lateral sutures. B, longitudinal section
through cervix ; d e, transverse incision ; / e, longitudinal incision joining the first ana
severing the mucous membrane and part of the muscular tissue from the cervix : b c,
course of a suture ; g, ovula of Naboth. C, longitudinal section after the sutures are tied.
3. Simon's Method, the so-called cone-mantle-shaped excision.
After having made the two lateral incisions a wedge-shaped piece is
1 I have had some especially made by Reynders & Co., corner Fourth avenue and
Twenty-third street, New York.
420 DISEASES OF WOMEN.
cut out with a knife of the whole width of each lip from side to side.
Next, the two flaps of each lip are united by sutures, and, finally, the
two lateral incisions are similarly closed (Fig. 235).
This method is especially indicated when the cervix is very thick
and hard and the mucous membrane of the cervical canal healthy.
4. Schroeder's Method. The same lateral incisions as in the other
methods are used, but then the whole mucous membrane of each lip
with part of the muscular tissue is cut away. For this purpose a
transverse incision is made through the mucous membrane of the cer-
vix at the base of each lip, and then a wedge-shaped piece is cut off
from the os to the first incision. Each of the lips is folded trans-
versely, and the lower end of the cut surface united to the upper.
Finally, the side incisions are closed (Fig. 236). This method is
more difficult to perform, but is preferable when the cervical mem-
brane is in a bad condition.
The removal by means of the galvano-caustic snare is less appro-
priate than the cutting operations, since it necessitates the healing of
the wound by granulation and may lead to stenosis of the cervical
canal.
If there is leucorrhea, menorrhagia, or metrorrhagia, it is proper
to combine curetting with the amputation.
In dangerous hemorrhage salpingo-odphorectomy may be performed,
and if that does not suffice to arrest the loss of blood, the uterus may
have to be removed by vaginal hysterectomy.
CHAPTER V.
CLOSURE OF THE UTERUS (ACQUIRED ATRESIA).
IN the description of malformations we have seen that atresia of
the uterus may be congenital (p. 391), but the uterus may also become
closed later in life acquired atresia.
Although not so rare as the congenita.1 form, the acquired is still
a rare affection.
The closure is most common at the external os, after that at the
internal os, but more or less of the whole cervical canal may be closed.
Etiology. This condition may be brought about by adhesions
forming after childbirth or abortion, cauterization with strong acids
or nitrate of silver, the red-hot iron, or the galvano-caustic apparatus
(p. 235). Ulceration of the cervix, diphtheria, small-pox, and scarlet
fever may lead to it. Sometimes it is simply due to old age,, and is
especially found in old women suffering from prolapse of the uterus.
Symptoms. In menstruating women the acquired closure gives
rise to symptoms similar to those of the congenital closure, such as
DISEASES OF THE UTERUS. 421
amenorrhea, abdominal pain, menstrual molimina, and swelling of
the uterus in consequence of accumulation of blood (hematometra),
mucus (hydrometra), or pus (pyometra). If the contents of the uterus
become decomposed and gases are formed, the condition is called phy-
sometra. Under these circumstances the percussion sound becomes
tympanitic, whereas otherwise it is dull.
After the menopause the atresia hardly gives rise to any symptoms,
unless it is complicated with some other disease of the womb, espe-
cially cancer or fibroma.
The size of the womb in hydrometra hardly surpasses that of a
fist. The walls are distended and sometimes thinner than in the nor-
mal condition. If the closure is at the external os, the cervix and
the body form together one globular tumor.
The course is chronic. Sometimes the disease, especially in physo-
metra, terminates spontaneously, the obstruction in the cervix giving
way and the gas escaping.
Treatment. The cervix should be perforated with a curved trocar
and then dilated. The uterine cavity should be washed out with an
antiseptic fluid, and packed with iodoform gauze (p. 180). In regard
to the dangers of the operation the reader is referred to what has
been said in speaking of atresia in other parts of the genital canal
(p. 327).
CHAPTER VI.
STENOSIS OF THE CERVIX.
STENOSIS, or narrowness, of the cervical canal is somewhat similar
to atresia, but the difference is that the cervical canal is open, although
the caliber is too small. Like atresia it may be congenital or acquired.
It is often combined with a conical cervix, which may be hyper-
trophic, of normal dimensions, or atrophic. It accompanies also dis-
placements, especially anteflexion.
It is most common at the external os, which forms a round open-
ing, sometimes so narrow that it does not even admit the common
uterine sound (pinhole os). Less frequently it is found at the inter-
nal os. Sometimes the whole cervical canal from end to end takes
part in the stenosis, but in other cases it is, on the contrary, dilated
between the two narrow openings so as to form a barrel-shaped cavity.
The etiology of the acquired form is identical with that of atresia.
Symptoms. If the menstrual blood is secreted in larger amount
than what can pass in the same time through the narrow cervix, the
patient has pain (obstructive dysmenorrhea). Often the blood coagu-
lates, and the clots are expelled with painful cramps. Also mucus
422 DISEASES OF WOMEN.
may stagnate in the cervix or the body and give rise to bearing-down
pain, relieved from time to time by the expulsion of the accumulated
fluid. Sometimes all the symptoms of chronic endometritis and
parenchymatous metritis (pp. 409 and 416) are developed.
Some women are, however, in excellent health in spite of their
stenosis, and they consult us only on account of sterility. Although
pregnancy may take place when there is only the smallest opening
admitting the spermatozoids, it is indisputable that a narrow cervical
canal is a great impediment to conception.
Diagnosis. The stenosis of the external os can be felt by a prac-
tised finger and is seen by means of the speculum. That of the
internal os can only be inferred from the difficulty with which the
sound passes. The beginner must, therefore, be on his guard, as he
will find many cases of stenosis of the internal os, which in my
experience is by no means common. The normal bore is only \ inch
(p. 49), and it is tight enough to be distinctly felt as a yielding
obstruction, when the knob of the uterine sound passes it. Before
diagnosticating a stenosis of it, the physician must make sure that the
end of the sound is not caught between the folds of the plicae
palmatse or arrested by a flexion. For this purpose it must be intro-
duced in all directions and with dhTerent degrees of curvature. The
best proof that a stenosis really exists is that the common sound is
arrested while a thinner probe passes.
Treatment.- Stenosis used to be treated with incision, either bilat-
erally or in the median line of the posterior lip. The cervical por-
tion was split open up to the vaginal junction with Kilchenmeister's
scissors (Fig. 237), that have a blunt and longer blade for entering
FIG. 237.
Kiichenmeister's Scissors.
the cervix and a shorter blade ending in a sharp hook, which prevents
the scissors from sliding. Besides, the incision was carried more or
less up to or through the internal os with Sims's uterine knife. For
cutting the internal os and more or less of the whole cervix Simpson's
DISEASES OF THE UTERUS. 423
metrotome (Fig. 238) was used, a sheathed knife, the excursion of
which is regulated by a screw, and which cuts in one direction at a
time, or Greenhalgh's metrotome, that cuts both sides at the same time.
When it was found that this deep cutting not infrequently was accom-
panied by dangerous or fatal hemorrhage or by not less dangerous
FIG. 238.
Simpson's Metrotome.
and fatal pelvic septic inflammation, superficial trachelotomy was sub-
stituted. 1 Cutting for stenosis has in a great measure been replaced
by dilatation. I make only a very small nick at the external os
if it is necessary for the introduction of the sound. I also cut out
a wedge-shaped piece of the cervix if the os besides being too nar-
row is situated exceutrically. There is no hemorrhage, and inflam-
mation is avoided by the use of antiseptic precautions (p. 199).
In most other cases I only use dilatation with blunt conical and
diverging instruments (p. 155), which is much safer than any degree
of incision or the use of tents. I have, indeed, never seen any trou-
ble arise from rapid dilatation. In most cases 1 treat the patient in
the office twice a week. I use first the lower numbers of Hanks's
dilators, and then my own diverging dilator up to one-half inch ex-
pansion. I never go farther in one sitting than that the patient can
stand the pain without an anesthetic. In more exceptional cases I
operate in the patient's house, etherize her, use the strictest antiseptic
precautions, and open the dilator to full expansion, one and a quarter
inches in all directions. In order to avoid tearing the tissues this must
be done very slowly and gradually. I introduce some iodoform into the
cervix, and cover it with iodoform gauze. The patient is kept in bed
for four days. A glass stem (see chapter on Flexions) is placed in
the cervical canal while it is contracting.
The canal of the cervix may also be enlarged by means of electro-
lysis. For this purpose the galvanic current is to be used with the
negative pole in the uterus, the positive on the abdomen. For the
latter I have used Engelmann's electrode (p. 231), for the former
Fry's, which has six nickel-plated conical tips, ranging from 11 to 25
millimeters in circumference, to be screwed on the same handle. I
have, however, not found any advantage in the electric treatment over
the mechanical.
1 Peaslee, Amer. Journ. Obst., 1876, vol. ix. p. 374.
424 DISEASES OF WOMEN.
CHAPTER VII.
ULCERS OF CERVIX.
WE have mentioned, in treating of chronic endometritis (p. 408)
that the term ulcer is often erroneously applied to erosions and gran-
ulations of the cervix. But the cervix may be the seat of true
ulceration i. e. an inflammatory process in which there is molecular
loss of substance. Such ulcers may be chancroids, chancres, tubercu-
lar ulcers, simple ulcers, or corroding ulcers.
Chancroids have been described on p. 291 and chancres on p. 293,
tuberculous ulcers p. 288 and p. 363, in treating of the diseases of
the vulva and the vagina.
Simple ulceration takes place when the cervix protrudes through
the vulva, be it in consequence of hypertrophy or prolapse. It is due
to friction against the clothes. There is a flat more or less irregular
loss of substance surrounding the os, or what seems to be it, if the case
is complicated with bilateral laceration of the cervix. The surround-
ings have a blue or purple color and are harder than normal. With
proper treatment these ulcers heal easily. If they accompany simple
hypertrophy, the cervix is amputated and no treatment directed to
the ulcer. If the uterus is prolapsed, it should be replaced, kept
inside the vagina by a perineal bandage, and the wound covered
with a piece of lint smeared with the ointment of iodoform and
balsam of Peru (p. 178), to be changed morning and evening.
Corroding ulcer looks much like a cancerous ulcer, and is destruc-
tive in character. It may open into the bladder, but on microscopical
examination no epithelial elements are found. It seems to be due to
senile gangrene induced by calcification of the internal iliac artery. 1
The diagnosis can only be made by means of the microscope.
The treatment is the same as for cancer, especially total extirpation
before the formation of a fistula.
CHAPTER VIII.
HYPERTROPHY OF THE UTERUS.
AN increased size of the uterus, apart from neoplasms, is commonly
due to subinvolution or chronic metritis (p. 416), but it may be due
to simple hypertrophy independently of all inflammatory action. The
uterus presents abnormally large dimensions, but there is no .change
in structure.
This hypertrophy may be general or partial.
1 John Williams, Trans. Obst. Soc. of London, vol. xxvii., reprint.
DISEASES OF THE UTERUS. 425
General hypertrophy is a very exceptional condition. Partial
hypertrophy has rarely its seat in the body. As a rule, then, it is the
cervix that is the affected part. We distinguish between infravaginal
and supravaginal hypertrophy. 1
A. Infravaginal hypertrophy consists in an increase in size of the
vaginal portion of the uterus, which, as a rule, takes place chiefly or
exclusively from above downward, resulting in an elongated cervix.
This hypertrophy may be congenital (p. 394) or acquired, and the
condition differs somewhat in the two classes.
The congenitally hypertrophied cervix is only elongated, cylindrical,
or conical, sometimes trunk-shaped in consequence of the greater
development of one of the lips, mostly the posterior, or more rarely
club-shaped. The os is round, of normal size, or too narrow. The
elongation may be slight or so considerable that the cervix protrudes
penis-like from the vulva.
In the acquired form of hypertrophy the cervix is commonly not
only elongated, but thickened, and it is frequently thicker near the
end than at the base, forming a club- or cabbage-shaped mass. The
os is large and forms a transverse slit. Very often the cervix has
sustained bilateral laceration (p. 396), and frequently the condition
is combined with prolapse of the uterus, but in these two classes of
cases I think we have to deal with chronic metritis, and no longer
pure hypertrophy. The acquired form is exclusively found in women
who have borne many children.
Etiology. The cause of the congenital hypertrophy is unknown.
The acquired is evidently due to childbirth.
Symptoms. Sometimes hypertrophy of the cervical portion does
not give rise to any symptoms. In other cases the patient complains
of a bearing-down sensation and discomfort in walking or sitting
down. Sometimes she has considerable dysmenorrhea, but this is
probably due to the accompanying stenosis of the os (p. 421).
The friction against the vaginal walls may cause leucorrhea. When
the cervix protrudes from the vulva it is liable to become ulcerated
(p. 424). If the hypertrophy is pronounced, it gives rise to dys-
pareunia, the male member meeting with an obstruction, which is
pushed forward, causing discomfort and even pain to the female, and
sometimes to the male too. The semen, being ejaculated into the deep
pouch formed behind the cervix, does not easily enter the os, and
sterility is, therefore, quite common.
Diagnosis. The diagnosis is easy. By vaginal examination the
finger may be carried round the hypertrophied cervix. The vaginal
1 Schroeder has added as a third category the hypertrophy of what he calls the
intermediate portion ; that is, that part of the cervix that is bound to the bladder in
front, but has behind the deep pouch formed by the posterior fornix of the vagina
(p. 42); from a practical standpoint this variety maybe taken together with the
supravaginal.
426 DISEASES OF WOMEN.
vault is found normal. The sound may enter from three to six
inches, and yet bimanual examination finds the fundus uteri at its
normal place.
Prognosis. The disease is chronic and has no tendency to retro-
gression. In virgins, in whom the vaginal walls and the uterus have
preserved their normal resiliency, an elongated cervix does not find room
enough, but is pushed down in the direction of the outlet and serves
as a lever to tip the uterus backward into the position called retro-
version.
Treatment. Slight degrees of elongation may successfully be
treated with dilatation (p. 154), which enlarges the os and shortens
the canal. In more pronounced cases the redundant tissue must be
removed by amputation. For simple elongation, Hegar's method
(p. 418) is the best; for hypertrophy with thickening of the cervix
Simon's cone-mantle-shaped excision (p. 419) recommends itself.
In order to control hemorrhage it is a good plan to surround the base
with an. elastic ligature. If feasible, this should even be placed above
one or two needles perforating the cervical portion at right angles and
preventing the ligature from slipping, or sewed to the cervix with a
few stitches. The common 6craseur has the fault of having a tendency
to pull in neighboring tissue while being tightened, by which the
peritoneal cavity or the bladder may be opened.
The galvano-cautery, and the common cautery even more, expose
to stenosis of the cervical canal (p. 421).
B. Supravaginal hypertrophy consists in the increase, especially
elongation, of that part of the cervix that is situated above the utero-
vaginal junction.
Pathological Anatomy. The supravaginal part of the cervix is felt
as a long cylindrical body, somewhat flattened in the antero-posterior
direction. As a rule, it is of normal circumference, but exceptionally
it may either be thinner or thicker than normal. The dimensions of
the infravaginal portion and of the body are not much increased. In
growing the cervix descends, and pulls the neighboring organs down
with it. Thus the vaginal fornix sinks down. In front the pouch
formed by it disappears entirely, while behind more or less of it still
remains. The vagina becomes inverted. The bladder forms, as a
rule, a swelling in front of the hypertrophied cervix (eystocele) ;
Douglas's pouch descends with it behind, and sometimes there is a
rectocele, but in many cases the rectum retains its place. The os uteri
forms a large slit, and descends to or beyond the rima pudendi. The
interior of the uterus measures from six to ten inches in depth, the
increase coming nearly exclusively from the elongation of the upper
part of the cervix.
Etiology. This condition is due to prolapse of the vagina (p. 340).
The body of the womb remaining in its place, and the cervix being
DISEASES OF THE UTERUS. 427
pulled down, it is drawn out like a rubber tube. At the same time
free circulation is impeded, the blood stagnates, and chronic metritis
sets in, with formation of new cells, new connective tissue, and new
muscle-fibers, rendering the total increase in bulk possible.
Those conditions which promote prolapse of the vagina, such as
laceration of the vaginal entrance, frequent childbirth, too early get-
ting up after delivery, subinvolution, occupations that keep the woman
in a standing position, and venereal excesses, lead indirectly to hyper-
trophy of the supra vaginal cervix.
Symptoms. The symptoms are like those of prolapse of the vagina
and uterus, combined with those of infra vaginal hypertrophy. The
patient complains of bearing-down, backache, an uncomfortable sen-
sation in the vagina, especially in walking and sitting down. She has
often dysmenorrhea. She has frequent desire to micturate, and finds
it often difficult to empty the bladder. She is constipated. The fric-
tion in the vagina produces leucorrhea, especially in the posterior pouch.
Connection is rendered unsatisfactory.
That part of the vagina that is turned out of the body becomes
horny, like epidermis. The enlarged cervix is seen and felt, while
the body of the uterus is felt above of nearly normal size, often ante-
flexed, and the infravaginal portion is not much elongated, if at all.
Nearly always there are signs of bilateral laceration of the cervix, and
the cervix partakes in the inversion, so that the lips of the os uteri are
situated far apart, and the inverted cervical canal appears between
them, more or less inflamed or even ulcerated (p. 424).
Diagnosis. A polypus and an inverted uterus have no opening at
the lower end. In the infravaginal hypertrophy the vaginal vault is
normal. The chief point in the diagnosis is the distinction from pro-
lapse of the uterus, with which the supravaginal hypertrophy is often
confounded, but the finger-shaped mass formed by the cervix is easily
felt by bimanual palpation with one finger in the rectum ; the uterus
is felt in its place ; the uterine cavity is much deeper ; a catheter intro-
duced into the bladder is not felt from the rectum, the uterus inter-
vening between the two canals. Frequently, however, the hypertro-
phy is combined with prolapse.
Prognosis. No spontaneous cure is to be expected.
Treatment. In the lesser degrees the uterus may be pushed up, the
body becoming strongly anteverted, and much comfort may be afforded
by the use of a cup-shaped supporter attached to an abdominal belt.
(See Prolapse.) If this plan does not succeed, recourse must be had
to an operation.
1. Hegar's Method, funnel-shaped excision (Fig. 239). Dorsal
posture. The cervical portion is exposed with a'single Sims specu-
lum and lateral retractors, seized with a volsella, and pulled down.
A circular incision is made below the utero-vaginal junction. From
428 DISEASES OF WOMEN.
this the knife is carried in a slanting direction upward and inward to
the cervical canal. When the canal has been opened in front and the
FIG. 239.
Hegar's Funnel-shaped Excision of Supra vaginal Cervix (natural size).
hemorrhage is considerable, a suture is passed immediately under the
whole wound in the cervix, and so as to comprise the mucous mem-
brane of the canal. If there is not much bleeding, the excision is
continued from the sides and from behind with knife and scissors.
The excised piece forms a cone, the length of which above the utero-
vaginal junction may be 1^ to 1| inches or more. The mucous mem-
brane of the cervix is sutured all around to that of the vagina, pass-
ing the sutures with small, strongly curved needles under the whole
wound a procedure that is very difficult. Some prefer, therefore, to
apply the thermo-cautery as soon as a part is cut, and continue alter-
nating with the cutting and the searing instrument.
2. Schroeder's Method (Fig. 240) is still more radical. A circular
incision is made as in Hegar's. If vaginal arteries bleed, the hem-
orrhage is checked with ligatures or clamps. Then the cervix is
separated with the finger and blunt instruments in front and behind.
Next it is pulled over to one side, and with a half-blunt aneurism-
needle bent to the side (Fig. 269, p. 487) a ligature is carried around
the tissue going to the side of the cervix and containing the blood-
vessels. After having tied the ligature tightly and cut the tissue
between the ligature and the cervix, another ligature is placed above
the first. The other side is treated in the same way.
When the cervix has been loosened sufficiently high up, the ante-
rior wall is cut through to the cervical canal, and a deep suture is
carried through the vaginal wall, the parametral connective tissue, and
DISEASES OF THE UTERUS.
429
the severed cervical wall, and out through the cervical canal. If
necessary to check hemorrhage, several such deep sutures are passed
FIG. 240, A.
FIG. 240, B.
Schroeder's Supravaginal Amputation of Cervix.
and tied before the posterior wall is severed. These sutures are left
long, and serve to keep the uterus down. When the posterior part
of the cervix has been cut, it is treated in the same way as the ante-
rior, thus stitching the uterus all around to the vagina.
If it happens that the peritoneal cavity is opened, the rent may be
closed separately with silk or catgut, or comprised in the sutures fixing
the posterior cervical wall to the vagina.
The vagina being much larger in circumference than the cervix, it
forms folds and on the sides two gaps, through which the ligatures
hang down.
3. Kaltenbach's Method (Fig. 241). After emptying the bladder
and pushing the intestines up from Douglas's pouch, the cervix is
constricted at the vaginal entrance with an elastic ligature, which is
stitched to the inverted vagina in front and behind, or the uterine
artery is secured on both sides (p. 182). A circular incision is made,
and the elongated stipravaginal cervix is easily separated from the
surrounding tissue with knife and scissors, and even partly with blunt
instruments. When this has been done to the extent deemed neces-
sary, sometimes even above the internal os, the cervix is divided with
Kuchenmeister's scissors (p. 422) into an anterior and a posterior half,
a transverse incision is made through the mucous membrane of each
half, an inch from the top, and the mucous membrane is dissected off,
430 DISEASES OF WOMEN.
except at the top, about half an inch. Then the remainder of the
cervix is cut off transversely at the base of the flaps. These flaps
Kaltenbach's Supravaginal Amputation of the Cervix.
are stitched to the vaginal wall with three or four deep sutures, com-
prising some of the muscular part of the stump. If we go too near
up to the constrictor, the stumps of the cervix are apt to retract
beyond it.
Next, a triangular piece is cut out on both sides of the collar formed
by the receding vagina, and a couple of deep sutures are passed through
the edges and around the vessels running on the side of the cervix,
the base of the triangle being about a quarter of an inch from the
outermost suture on either side and the top at the constrictor. This
excision allows us to exercise tighter pressure on the ligated blood-
vessels, and affords an excellent adaptation of the fornix to the stump.
Finally, the contact between the edges of the two. mucous mem-
branes is perfected with a running suture of catgut. Then the con-
strictor is removed, and if there is any bleeding, one or more deep
sutures are inserted on the sides of the stump.
This is the best of all the operations, in so far as it exposes less to
hemorrhage and leaves a fine stump.
The amputation of a conical piece of the cervix, as in Hegar's opera-
tion, may also be accomplished by means of the galvano-caustic knife
or wire (p. 235). But even this does not prevent secondary hemorrhage,
and is liable to cause stenosis of the cervical canal (p. 421), The
patient should, therefore, be carefully watched during the healing
process.
Besides primary and secondary hemorrhage, those methods of the
DISEASES OF THE UTERUS. 431
supravaginal amputation which leave a large deep-seated, more or leas
anfractuous wound predispose to sepsis.
4. Vaginal Hysterectomy. These drawbacks are avoided by
removing the whole uterus, which may be done from the vagina or
from the abdomen. The vaginal operation will be described below
under Prolapse of tfie Uterus.
5. Abdominal Hysterectomy. If the supravaginal hypertrophy of
the cervix is combined with such an hypertrophy of the body that
the removal of the uterus through the vagina would be difficult, it
may be undertaken through the abdominal wall, exactly as for a
myomatous uterus. (See below, under Fibroid.)
CHAPTER IX.
ACQUIRED ATROPHY ; SUPERINVOLUTIOX.
ATROPHY of the uterus may be congenital or acquired. We have
described the congenital form above (pp. 392, 393) as the fetal, the
infantile, and the pubescent uterus.
Acquired atrophy is a normal condition after the climacteric (p.
123), senile atrophy, but in consequence of the atrophy closure of
the cervical canal, especially at the external or internal os, may occur
and give rise to hydro- or pyometra (p. 421).
The writer has also always found atrophy of the uterus in removing
this organ after having previously performed salpingo-oophorectomy
on the same patients.
Pathological Anatomy. In the non-puerperal form the uterus is
small, the vaginal portion disappears sometimes entirely, so that the
vagina ends in a narrow funnel, at the bottom of which is situated
the os. The tissue is hard, its arteries often calcareous, and it some-
times contains foci of extravasated blood. The cavity of the uterus
is leas deep than normal.
The puerperal atrophy differs in some respects from the non-puer-
peral form. The walls are thin and often very soft, and the uterine
cavity may preserve its normal depth.
Etiology. Puerperal atrophy, or superin volution, is a rare disease.
It is, perhaps, oftener connected with abortion than with childbirth.
It is caused by loss of blood, protracted lactation, debilitating dis-
eases, such as scarlet fever, tuberculosis, chlorosis, syphilis, diabetes,
Bright's disease, and exophthalmic goiter.
Atrophy can also be caused mechanically by pressure of a uterine
fibroid or an ovarian cyst.
It may be brought about by trachelorrhaphy, amputation of cervix,
or oophorectomy.
432 DISEASES OF WOMEN.
Sometimes salpingo-ob'phoritis seems to be the cause of it, and it
has been found together with paraplegia.
Symptoms. Senile atrophy does not give rise to symptoms unless
it is combined with atresia.
Before the climacteric atrophy is characterized by amenorrhea
and sterility. Some patients complain of sacral pain, headache, in-
somnia, mental depression, anorexia, indigestion, and general weak-
ness. Sometimes the uterine cavity measures only an inch or an
inch and a half, but in the puerperal form the sound often enters to
the normal depth (pp. 49 and 152). Its knob is felt with unusual
distinctness through the abdominal wall.
Prognosis. Puerperal superinvolution is sometimes only transitory,
whereas the other forms are permanent.
Treatment. The treatment is the same as for congenital atrophy
(p. 393).
CHAPTER X.
GANGRENE.
GANGRENE of the uterus may occur as a result of puerperal infec-
tion. An inverted uterus, a fibroid, or a cancerous tumor, may slough,
and in this way a spontaneous cure may take place.
Treatment. The patient's strength should be kept up by means of
quinine, strong alcoholic drinks, and nourishing food. Locally, fre-
quent antiseptic injections should be used in the vagina (p. 172), and
even in the interior of the uterus.
CHAPTER XI.
HYSTERALGIA.
HYSTERALGIA, or neuralgia of the uierus, may be idiopathic or
symptomatic.
Idiopathic hysteralgia is a rare disease.
Etiology. It is most common at the menopause, but may be found
in young girls, especially before menstruation is well established. It
is also found in anemic, nervous, and hysterical women. Sometimes
it is of malarial origin or due to rheumatism.
Symptomatic hysteralgia may accompany any of the organic diseases
of the womb, especially metritis and cancer.
Symptoms. Hysteralgia is characterized by sudden attacks of
severe pain in the uterus, often radiating to the sacral region, the
iliac fossa, and down the leg, which recur with regular or irregular
intervals.
Diagnosis. The chief point is to discover whether the affection is
DISEASES OF THE UTERUS. 433
purely nervous or whether the neuralgic attacks accompany organic
disease.
Prognosis. The prognosis is favorable if the neuralgia is not
grafted on malignant disease.
Treatment. During the neuralgic attack nothing equals in cer-
tainty and swiftness of action the hypodermic injection of morphine.
In the intervals the underlying disease, if any, should be treated, and
the idiopathic form should be treated, according to the etiology, with
tonics (p. 225), antiperiodics, or antirheumatic medicines. The gal-
vanic current, with the positive pole in the vagina or uterus (pp. 231,
232), is very effective, and so is the high-tension faradic current (p.
230).
CHAPTER XII.
DISPLACEMENTS.
THE normal shape and position of the uterus have been discussed
above (p. 51), and we have seen how it changes position according to
the degree of fullness or emptiness obtaining in the bladder and the
rectum (p. 53). Every breath makes it perform a see-saw movement.
During inspiration the fundus is pushed forward and downward,
while the cervix moves upward and backward. During expiration the
opposite movement takes place. During urination and defecation it
is pushed down ; during copulation it is lifted up. It is therefore
clear that the uterus is an unusually mobile organ. But certain per-
manent changes and deviations from the normal take place under
certain conditions, and constitute the so-called displacements. These
are anteversion, antejlexion, retroversion, retroflexion, lateroversion,
laterqftexion, anteposition, retroposition, lateroposition, prolapsus, ele-
vation, inversion, and hernia.
Anteposition, retroposition, and lateroposition, if they are not due
to pressure from a neighboring tumor, are developmental abnormalities
of merely anatomical interest (p. 394).
A.' Anteversion.
Anteversiou (Fig. 242) is that position of the uterus in which the
fundus points forward, and sometimes downward, to the symphysis
pubis, the os backward, and sometimes upward, toward the sacrum.
The uterine canal preserves its normal direction in a line that is
straight or slightly curved forward (p. 52).
Pathological Anatomy. The uterus is more or less enlarged and
in a condition of chronic metritis. Sometimes adhesions are found
28
434
DISEASES OF WOMEN.
between the fundus and the peritoneum or signs of cellulitis round
the cervix ; or the ovary or tube may be found adherent to the anterior
wall of the pelvis. Often the vaginal portion is unusually short.
FIG. 242.
Anteverted Uterus (Fritsch).
Etiology. Anteversion is due to inflammation of the parenchyma
of the womb, in consequence of which the organ becomes larger and
heavier and tips down in the erect and sitting posture ; or to inflam-
mation of the pelvic peritoneum or the appendages, in consequence
of which the fundus uteri is dragged forward and downward.
Anteversion is sometimes due to subinvolution after childbirth or
abortion, but is not rare in virgins.
Symptoms. These are the same as in chronic endometritis and
parenchymatous metritis (pp.409 and 416), especially frequent mic-
turition, dysmenorrhea, menorrhagia, leucorrhea, and sterility. The
frequency of micturition is probably due to pressure of the enlarged
uterus, just as we commonly find it in pregnancy. The dysmenor-
rhea may be mechanical, the exit for the blood being less free when
the uterine canal is horizontal or even lies higher with its open than
with its closed end ; or it may be explained by the increased sensitive-
ness due to the inflammation of the uterus or its surroundings. The
menorrhagia and leucorrhea are likewise probably due partly to me-
DISEASES OF THE UTERUS.
435
chanical interference with free circulation and partly to the structural
changes in the uterus.
If there are no adhesions, a peculiar, uncomfortable feeling is pro-
duced by the movements of the enlarged and stiff uterus.
Diagnosis. By bimanual examination the fundus of the uterus is
found tipped forward, the anterior surface forms a straight line or
nearly so, and the os is not situated centrally in the pelvis, within
easy reach, but points backward and is only reached with difficulty.
Prognosis. Anteversion does not threaten life, but is hard to cure,
mechanical disadvantages increasing the troubles inherent in the sub-
jacent inflammatory conditions.
Treatment. The treatment is directed against the inflammation,
or is intended to overcome the mechanical disadvantage. In regard
to the first, the reader is referred to what has been said above (pp.
412-415 and 417, 418). The remedies especially useful are the hot
douche, glycerin or ichthyol tampon,
FIG. 243. scarification, electrolysis, gold, corrosive
sublimate, massage, and hemostatic meas-
ures (pp. 181, 182 and 227).
The uterus may be lifted up by means
FIG. 244.
Graily Hewitt's Antevereion Pessary:
a 6, anterior bow resting on the ante-
rior wall of the vagina ; c e, upper
end pressing on the anterior surface
of the uterus ; d, posterior bow going
behind cervix.
Thomas's Anteversion Pessary : A, lower end rest-
ing just inside the vaginal entrance ; B, upper
end to be introduced in the posterior pouch of
the fornix ; C, anterior, movable bow, which is
to lift the uterus through the anterior pouch of
the fornix.
of vaginal pessaries that is, supporters. Those most used for this
purpose are Graily Hewitt's cradle pessary (Fig. 243), Thomas's two
kinds (Figs. 244 and 245) of anteversion pessaries, Geh rung's pes-
sary (Fig. 246). If the uterus bends over these instruments and
an anteflexion is formed, they do, however, more harm than good.
There is a soft-rubber Vienna pessaiy consisting of a thick elas-
tic ring which surrounds the cervix, and a straight piece lying
in the canal of the vagina, which I occasionally have found very
useful.
436
DISEASES OF WOMEN.
General Remarks about Pessaries. Some pessaries, such as elastic
rings, work by pressing exeeutrically on the vaginal walls ; others, a
class to which the above-mentioned
Thomas pessary (Fig. 244) belongs, Sto. 246.
rest against the muscles and fasciae ,'"" "~ "*"" \
forming the vaginal entrance;
Gehrung's pessary and Thomas's
FIG. 245. /
Thomas's Horseshoe-shaped
Anteversion Pessary.
Gehrung's Pessary.
horseshoe pessary find support on the anterior and the posterior
vaginal walls.
In the choice of a pessary great care should be taken never to
choose a larger one than necessary. If it is made of some hard
material, it is liable to erode, and even to burrow deep into the flesh
and perforate the rectum or the bladder. The vagina ought, there-
fore, to be inspected three or four days after the introduction of a pes-
sary, in order to make sure that there is no erosion, and later the exam-
ination ought to be repeated at least once every two months. If at
any time it is found that the vagina becomes excoriated, the pessary
ought to be left out for a week, during which the patient should use
injections with carbolized water.
In order to avoid erosion the ring forming the pessary should be
rather thick and perfectly smooth.
Soft rubber, and in some women even hard rubber, emits an
unpleasant odor when in contact with vaginal discharges. This may
be obviated by using block-tin for the construction of the pessary,
but that has the fault of being heavy. An excellent material is
aluminium.
Pessaries are introduced while the patient occupies the dorsal or
left lateral position. In antedeviations the former is preferable, in
retrodeviations the latter. The uterus ought, as a rule, to be replaced
in the right position with the fingers or sound before introducing the
pessary, just as fractures are set before the splint is applied. The pes-
sary, except the part seized by the physician, should be smeared
with a lubricant (p. 140).
DISEASES OF THE UTERUS. 437
Graily Hewitt's cradle pessary is inserted with the patient on her
back. First, one ring is introduced inside of the vaginal entrance
along the posterior wall of the vagina, then the middle part is pushed
up in front, and finally the second ring. The first ring is placed
round the cervix ; the middle part presses against the anterior fornix
of the vagina ; and the second ring rests on the anterior vaginal wall.
In removing it the index-finger is hooked into the lower ring and
pulled back. Thus this ring will come out first, rolling over the
perineum, then the middle piece, and finally the upper ring.
Thomas's ante version pessary with movable front bow is introduced
closed behind the cervix, and then withdrawn a little, so as to allow
one to separate the anterior bow from tli rest of the instrument and
push it in front of the cervix ; finally, the whole is pushed up until
both bows rest on the vaginal vault, one in front and the other behind
the cervix. (Compare rules for introducing Hodge's pessary under
Retroflexion.)
Thomas's horseshoe-shaped pessary is introduced open ; the horse-
shoe is placed against the anterior surface of the uterus, and the lower
bow turned forward against the anterior vaginal wall. In withdraw-
ing it this bow is seized, when the remainder of the instrument
follows easily.
Gehrung's pessary is placed with the upper horseshoe turned down
on a table, the two bows uniting the horseshoes pointing toward the
doctor. Next he seizes the nearest bow with the right thumb and
index-finger, pushes the opposite bow into the right side of the pelvis,
then the bow he holds, into the left side, and finally he turns the whole
pessary in the vagina, until the two uniting bows rest on the posterior
wall and the two horseshoes embrace the cervix anteriorly. In with-
drawing the same movements are gone through in opposite order.
The best-fitting pessary irritates the vagina somewhat. Whenever
one is worn, the woman must, therefore, at least once a day use an
injection of a pint of lukewarm water, to which may be added a tea-
spoonful of borax or carbolic acid, in order to keep the pessary clean.
She should also be instructed to remove it immediately if it causes
pain, as neglect in this respect may cause serious pelvic inflammation.
An elastic abdominal belt may give comfort by taking off pressure
from above and steadying a large mobile uterus. The latter object
is attained still better by an abdominal supporter with a solid hypo-
gastric pad, such as Fitch's (Fig. 166, p. 191).
Certain operations have proved useful in different ways. If the
cervix is thick, Simon's cone-mantle-shaped excision (p. 419) may be
performed, and result in a considerable reduction in the size of the
body of the uterus (p. 418).
Sims folded the anterior wall of the vagina transversely, denuded
the edges of the fold just in front of the cervix and an inch and a
438 DISEASES OF WOMEN.
half lower down, and united the two somewhat crescent-shaped sur-
faces with silver-wire sutures (p. 218).
B. Anteflexion.
We know from the anatomical part (p. 52) that the canal of the
uterus is normally straight or slightly curved, with the concavity for-
ward, or slightly S-shaped. When it forms a more decided curve or an
angle, the condition is abnormal, and is called anteflexiou (Fig. 247).
FIG. 247.
Anteflexion (Graily Hewitt).
Classification. A time-honored division of anteflexion is that
according to the size of the angle between the cervix and body, an
obtuse angle constituting the first degree, a right angle the second,
and an acute angle the third. A better classification, because of
greater practical value in regard to treatment, is that into corporeal,
in which the body of the womb dips too far forward and downward,
while the cervix has the normal direction; cervical, in which the
cervix is turned forward ; and cervico-corporeal, in which both the
body and the neck are turned forward ; each of which varieties may
again be reducible that is, the flexion can be overcome with pressure
of the fingers or by the introduction of a sound ; or irreducible,' when
the uterus cannot be straightened. 1
1 T. G. Thomas, Gynecol. Trans., 1888, vol. xiii. p. 142 a paper of the greatest
value to anybody who undertakes to treat anteflexion.
DISEASES OF THE UTERUS. 439
Still another classification is that which distinguishes a congenital,
or rather developmental, form from an acquired.
Pathological Anatomy. The bend in the uterus is, as a rule, situ-
ated at the internal os, but may exceptionally be situated higher up
in the body or lower down in the neck. At the angle is often found
fatty degeneration, atrophy, or cicatricial tissue. The uterus is often
in a condition of chronic metritis (p. 416), with enlargement of the
cavity. Frequently the supravaginal portion is elongated (p. 426).
In the developmental form the anterior vaginal wall is short, the
cervical portion elongated and coniform, with a small os, which some-
times is situated on the anterior surface instead of the end of the
cervix. Sometimes the sacro-uterine ligaments are swollen or short-
ened. The fundus may be bound with adhesions to the anterior w r all
of the pelvis, or similar adhesions implicate the ovaries and tubes.
Sometimes the anteflexed uterus is at the same time anteverted or
retro verted.
Etiology. The uterus undergoes a great development from the
time of approaching puberty until the woman is full-grown, say be-
tween the ages of twelve and twenty years (p. 33). During this fime
it is more liable to become anteflexed than after it is fully formed.
The pressure of corsets (p. 129) and the weight of heavy skirts are apt
to force the body down. An accumulation of hard scybala in the
rectum presses the cervix forward and impairs the general health
(p. 128), which again weakens the tissue of the womb. The latter
condition is also a consequence of lack of substantial food (p. 128).
Masturbation (p. 297) causes hyperemia, and thus furthers anteflexion.
Exposure during menstruation (p. 129) may have a similar effect.
The acquired form is mostly due to inflammation of the uterus or
its surroundings: metritis, which makes the uterus heavier; cellulitis
around the utero-sacral ligaments, which pulls the angle between cor-
pus and cervix upward and backward ; and perimetritis or inflamma-
tion of the appendages, resulting in adhesions pulling the fundus
forward and downward. These inflammations are again caused by
gonorrheal or puerperal infection, or are simply due to colds ; that of
the sacro-uterine ligaments may also originate in irritation caused by
the passage of hard scybala.
Anteflexion may also be due to subinvolution following childbirth
or abortion ; pressure from an abdominal tumor ; the presence of a
growth, especially a fibroid, in the wall of the corpus ; and softening
of the uterine parenchyma in consequence of wasting diseases or
insufficient nutrition.
Symptoms. Sometimes women with pronounced anteflexion enjoy
perfect health, and the only thing that brings them to the physician
is sterility. The symptom next in frequency is dysmenorrhea (p.
242), which may be due to obstruction at the angle with formation
440 DISEASES OF WOMEN.
of clots, and which, perhaps, in other cases is rather attributable to
the concomitant inflammation, the menstrual congestion pressing on
the tender inflamed tissue of the womb or the surrounding parts.
Young girls affected with the developmental form may also suffer
from amenorrhea. The patient often complains of pelvic pain or
diverse reflex disorders, especially pain in the epigastrium, with dys-
pepsia, intercostal neuralgia, headache, backache, asthenopia (p. 409),
etc. She has often leucorrhea. She is often inconvenienced by fre-
quent micturition, as in anteversion. Anteflexion predisposes to
abortion and to hyperemesis during pregnancy.
Diagnosis. When the cervix is turned forward the observer might
think of retroversion, but by bimanual examination the whole shape
of the womb, and especially the presence of the fundus at the ante-
rior vaginal fornix. is distinctly felt. If in stout women there is any
doubt, the flexion is felt still better by placing the patient in Sims's
position, when the fundus tips forward on the examining finger. The
direction of the canal can be made out with the sound or probe
(p. 152, 153).
In anteversion the os points backward and the uterus is straight.
The presence of a fibroid in the anterior wall can be made out by
introducing a sound, which will enter with the normal curvature
turned forward, and feeling the tumor between the sound and the
vaginal vault.
Inflammation and shortening of the sacro-uterine ligaments are
characterized by the high position of the vaginal portion, its approxi-
mation to the posterior wall of the pelvis, its forward direction, and
the diminished or suspended mobility of the uterus. By direct pal-
pation through the anus one or both folds are felt swollen, tender,
or hardened.
Prognosis. Less pronounced cases are much benefited by treat-
ment, and often cured, especially if pregnancy occurs, which is often
the case. Otherwise there is tendency to relapse. I have never seen
an anteflexed womb become straight, but the symptoms may disappear
and the patient feel well. Irreducible cases have to be treated with
operations which are neither free from danger nor sure to cure.
Treatment. The treatment is partly directed against the inflamma-
tion and partly it is mechanic. The patient should avoid violent
exercise and tight lacing. Her skirts should be suspended by means
of braces from the shoulders. Her bowels should be kept open, and
a tonic treatment followed in regard to food, regimen, and medicines
(p. 225).
Congestion and inflammation are combated with hot vaginal
douches (p. 171), glycerin or ichthyol tampons (p. 178), painting
with iodine (p. 170), and scarification (p. 186). When there is a
tendency to hemorrhage, curetting (p. 176), with or without intra-
DISEASES OF THE UTERUS.
441
uterine packing with iodoform gauze (p. 180), does a great amount
of good.
The sound is introduced with a curvature nearly as strong as that
of the uterine canal, withdrawn, straightened, and reintroduced.
Soon, if not in the first sitting, it is turned with the concavity back-
ward, establishing a transient retroflexion. The uterus may also be
stretched bi manually by pushing the cervix back with a finger in the
vagina, and pressing, with the other hand, on the fund us through the
abdominal wall. If the patient is treated at home, she should con-
tinue in the dorsal posture for an hour, keeping up pressure on the
replaced fundus by means of a hard-rolled towel applied over the
symphysis.
Mild or complete dilatation with Hanks's and my dilators (p. 155)
not only overcomes the obstruction in the canal at the angle, but
straightens the whole uterus. By the insertion of a glass stem while it
recontracts, a better shape may be obtained. Permanent dilatation
is secured by Outerbridge's instrument (p. 184).
Some praise electrolysis (p. 423).
An abdominal belt or supporter FIG. 248.
(p. 190) may serve to take off pres-
sure from above.
The same pessaries as for antever-
sion may be used for anteflexion. Per-
sonally, I have almost abandoned
them, and find that I obtain better
results without them.
If a vaginal pessary may irritate
and cause inflammation, the intra-
uterine stem (Fig. 248) is still more
dangerous. 1 It should be of glass,
and half an inch shorter than the
cavity of the uterus. It may be
solid or hollow, straight or slightly
bent. In order to hold it in place,
it is sometimes combined with a vagi-
nal pessary having a little cup into
which the plate of the stem fits. It should have a string attached
to it. It is introduced with the fingers or a dressing forceps (p. 150)
through a Sims speculum.
Irreducible cases may be treated by one of the following ope-
rations :
1. Sims' s Discission of the Posterior Lip. The patient is in Sims's
position ; the cervix is exposed with his speculum ; the posterior lip
1 Garrigues, " Case Illustrating the Danger of Stem Pessaries," Amer. Jour. Obst.,
1879, vol. xii. p. 756.
Intra-uterine Stem and Retroflexion-
Pessary with Cup (T. G. Thomas).
442 DISEASES OF WOMEN,
is cut in the median line up to the vaginal junction with Kiichen-
meister's scissors ; and a second incision carried in a straight line from
the internal os to the upper end of the first incision. The wound is
packed with iodoform gauze, and the vagina tamponed as long as there
is any danger of hemorrhage. The dressing is changed daily. The
patient should stay in bed until the wound is healed ; that is, from two to
four weeks. When granulation is established an intra-uterine stem may
be introduced. The granulating wound is often slow to heal, and may
give rise to a troublesome discharge resisting astringent applications.
2. Amputation of the Cervix. If there is considerable flexion of
the cervix with elongation, the cervical portion is removed by Hegar's
method (p. 418).
3. Dudley's Operation. Recently ! a plastic operation has been pro-
posed with a view to straighten the anteflexed uterus. The patient
occupies the left lateral position. The cervical canal having been
exposed with Sims's speculum, and a little dilated, and the uterus
curetted and disinfected, the posterior lip of the cervix is divided
with scissors considerably past the utero-vaginal junction. The cut
surfaces are separated with tenacula, and the incision somewhat deep-
ened, especially on the side of the cervical canal. On each side the
surface thus incised is now folded upon itself from before backward,
and secured by silkworm-gut sutures. Thereby the os extern urn is
carried directly back to the angle of the incision. Then the anterior
lip of the cervix is caught with a tenaculum and partially removed,
the section extending to the external os, but not into the canal. This
cut surface is folded upon itself from side to side and secured with
deep sutures. Normal or sclerotic uterine tissue is too stiff for such
folding as prescribed. The possibility of performing this operation
seems, therefore, limited to cases in which the cervix is abnormally
soft.
Salpingo-oophorectomy. If the flexion is caused by, or at least
combined with, inflammation of the uterine appendages, and milder
means do not lead to a satisfactory result, much benefit may be ob-
tained by removal of these organs.
C. Retroversion.
The retrodeviations or displacements backward of the uterus are
twofold retroversion, corresponding to anteversion ; and retroflexion,
corresponding to anteflexion.
In retroversion the uterus as a whole is tipped backward over a
transverse axis. According to the degree to which the tilting is car-
ried the os points downward or forward against the symphysis' pubis,
and the fundus, just opposite it, turns upward or backward toward the
sacrum. The longitudinal axis is straight. In most cases retroversion
1 E. C. Dudley of Chicago, Amer. Jour. Obst., 1891, vol. xxiv., p. 142.
DISEASES OF THE UTERUS.
443
is only a transition to retroflexion ; the pathology, the symptoms, and
the treatment are identical, and, since the flexion is so much more com-
mon than the version, we prefer to describe them under that heading.
Diagnosis. We have seen above (p. 440) that the direction of the
cervix might lead one to think of anteflexion, but by bimanual exam-
ination and the sound the direction of the fundus backward is easily
made out. An anteflexed uterus may at the same time be retroverted.
Then it is curved or bent forward, os and fundus being approxi-
mated in front of the anterior surface, and this curved uterus is tilted
backward as a whole. In these cases the os is turned forward and
upward, the fundus or the posterior surface is felt lying against the
rectum, the anterior surface is felt concave, and the posterior convex.
The difference between retroversion and retroflexion is that in version
the uterus forms a straight line, while in flexion it is bent with the
concavity backward.
D. Retroflexion.
Retroflexion is that displacement in which the body of the uterus
is bent backward, the cervix remaining in its normal position (Fig.
FJG. 249.
Retroflexion of the Uterus (Fritsch).
249). It is often combined with retroversion, when the os points
downward and forward.
444 DISEASES OF WOMEN,
Pathological Anatomy. Besides the peculiar shape of the uterus,
we find, as a rule, signs of chronic raetritis, and often of pelvic peri-
tonitis, salpingitis, oophoritis, or cellulitis. In many cases adhesions
are found between the posterior surface and the rectum or between the
appendages and broad ligaments and the posterior wall of the pelvis.
Most of these adhesions are thread-like and friable ; others are spread
over a large surface and very tough.
The uterus is commonly enlarged, situated lower down than normal,
and has a large os and a thick cervix.
Retroflexion may by twisting the broad ligaments interfere with the
free circulation in the pelvic veins.
Etiology. Retroflexion may be congenital, but that is much rarer
than congenital anteflexion. As a rule, it is acquired. It may be
due to subinvolutiou after childbirth. Parts of the placenta may re-
main attached to the anterior wall and cause incomplete involution, by
which the anterior wall becomes larger than the posterior, and a retro-
flexion is the result. A frequently over-filled bladder may predispose
to it. In the normal condition the abdominal pressure from above
in the erect posture keeps the uterus in an anteverted and often
slightly anteflexed position ; but when the fundus is lifted up, so
that the direction of the pressure comes to lie in front of it, the uterus
is more and more tipped and bent backward. This will be favored
by weakness of the round and broad ligaments, which again, in most
cases, is a sequel of childbirth.
This tilting may also be due to elongation of the cervical portion,
or to shallowuess of the cul-de-sac at the posterior vaginal fornix.
The most common cause is some form of perimetric inflammation.
Endometritis, very often gonorrheal in origin, leads to salpiugitis, the
inflammation spreads to the peritoneum, and adhesions are formed
between the broad ligaments, the appendages, and the uterus on one
side, and the posterior wall and the floor of the pelvis with the rec-
tum on the other, which adhesions drag these organs with them
backward and downward. In other cases the inflammation may
spread directly through the wall of the uterus, and cause parenchy-
matous raetritis and perimetritis with adhesions between the fundus
and posterior surface of the uterus in front and the rectum behind.
Symptoms. In rare cases retroflexion does not give rise to any
symptoms. In most they are those usually found in uterine disease,
and especially in chronic metritis (p. 416) : pain, dysmenorrhea, men-
orrhagia, metrorrhagia, leucorrhea, dyspareunia, and dysuria. Ster-
ility is not so common as in anteflexion, the direction of the uterine
canal being more favorable for the entrance of the semen. Consti-
pation is very common, and is easily explained by the mechanical
obstruction offered by the fundus pressing against the rectum. Ner-
vous reflexes and general malnutrition arej as a rule, prominent
features.
DISEASES OF THE UTERUS. 445
Diagnosis. By bimanual examination the peculiar shape and posi-
tion of the uterus are easily made out. It is not enough to feel a
mass in the posterior cul-de-sac of the vagina. That may as well be
a fibroid in the posterior wall of the uterus or an exudation or a .sar-
coma in Douglas's pouch. If the uterus cannot be mapped out, the
direction of the uterine cavity may be ascertained with the sound or
probe.
There are cases of flabby uterus without adhesions in which the
corpus moves at the level of the internal os, as if there were a hinge,
and the uterus is sometimes found anteflexed and at other times retro-
flexed.
A chief point in the diagnosis is to discover whether the uterus is
movable or bound by adhesions. For this purpose examination in
the dorsal decubitus is insufficient. Sometimes a uterus can be
replaced with the sound in this position in such a way that the ante-
rior wall of the rectum follows the uterus. This is not the case in
the genu-pectoral position. By introducing a finger into the rectum
in this position the adhesions are felt as tense bands.
Sometimes it is possible, under ether, to replace a retroflexed uterus
which seems immovable, and to retain it by a pessary.
Prognosis. In the great majority of cases we may expect to cure
the patient, or at least make her comfortable, with a pessary. Retro-
displacements predispose to prolapse. If pregnancy occurs, a serious
condition may be brought about in case the uterus does not rise spon-
taneously out of the pelvis. In some cases operations are necessary
in order to procure relief, and in the laboring classes, in which harder
work is combined with less cleanliness and care, they are preferable
to pessaries.
Treatment. If the uterus and its surroundings are tender, the
inflammation should be combated with hot vaginal douches (p. 171),
painting with iodine (p. 170), and ichthyol or glycerin tampons (p.
178) before any attempt is made to replace and retain the uterus in a
better position. If there are signs of chronic metritis, curetting (p.
176) and packing with iodoform gauze (p. 180) may reduce the bulk
of the uterus and form a useful introduction to other measures.
Replacement. The retroflexed uterus may be replaced in different
ways.
Air-pressure. One way is to place the patient in the genu-pectoral
position (p. 138) and introduce Sims's speculum. In rare cases this
may suffice to make the fundus uteri spontaneously sink forward.
The pressure may be increased by means of a sponge on a sponge-
holder or a cotton tampon held in a dressing-forceps applied against
the posterior vaginal vault.
Bimanual Manipulation. Another way is to* place the patient in
the dorsal decubitus, introduce one or two fingers into the vagina, and
446 DISEASES OF WOMEN.
press their tips, with the volar surface turned up, into the posterior
vault. The four fingers of the other hand are inserted above the
syrnphysis pubis and press the abdominal wall down until the fundus
of the uterus is reached and can be pulled forward, while the vaginal
fingers push in the same direction. This method can only be used
on rather lean patients.
Digital Pressure. A good way is to place the patient in Sims's posi-
tion and introduce the middle and index-fingers into the vagina with
the dorsal surface turned against the back of the uterus, and press
upward and forward. If the uterus is enlarged, some advantage is
obtained by directing the pressure toward the sacro-iliac synchondrosis.
Pepositors. Special instruments have been invented for replacing
the uterus, but the simplest way is to do it with the uterine sound.
It is introduced as described on p. 152, but with the concavity turned
backward, and when the knob has passed the internal os the handle
is pushed forward until the knob touches the fundus. Then the
handle is made to circumscribe one-half of a large circle, so as to keep
the knob on the same point in the interior of the uterus. When the
concavity turns forward, the handle is brought gently back, the index-
finger of the left hand helping to tilt the uterus forward by pressing
on its posterior surface. As soon as a resistance is felt or the reposi-
tion causes pain, the operation should be discontinued.
Pessaries. When the uterus is replaced, it is kept in the normal
position by means of a pessary. The best is Emmet's modification
of Hodge's (Fig. 250). It is made of hard rubber, and is introduced
FIG. 250.
Hodge-Emmet Pessary.
in the following way : The patient being in Sims's position, and
the doctor standing behind her back, the pessary is seized by the
lower, narrow end with the right thumb and index-finger, lubri-
cated, and held in the sagittal plane in front of the vulva. With
the left thumb and index-finger the labia are separated, and the
pessary is pushed through the vaginal entrance pressing upward
toward the promontory and backward against the perineum.
When the broadest part has passed the vaginal entrance, the pessary
DISEASES OF THE UTERUS. 447
is turned into the coronal plane. Next the lower end is seized with
the left thumb and index-finger, and the right index-finger is applied
to the inside of the upper arch, which by a combined movement with
both hands is brought up behind the cervix, as high up as possible.
Finally, the right index-finger is inserted in front of the lower arch
and pushes it back, the effect of which is to push the upper arch well
forward against the posterior surface of the uterus. Beginners are
apt to insert the pessary in front of the cervix, but by following the
above directions they will soon succeed in placing it behind the same.
In a spacious vagina the pessary may be introduced while pull-
ing the perineum back with Sims's speculum, a method which offers
the advantage that the hand is guided by the eye.
Most pessaries on the market have too strong a curvature. This
may be remedied by dipping them in oil and heating them in the
flame of an alcohol lamp, when the hard rubber becomes soft and
can be shaped at will. A well-fitting pessary extends from the depth
of the posterior cul-de-sac to the vaginal entrance, and takes its sup-
port there. It follows the normal curvature of the vagina. The
lower end is bent back a little, so as to avoid pressure on the urethra.
If there is much tenderness of the womb or a displaced ovary, the
pressure of the hard-rubber pessary sometimes becomes intolerable.
In such cases one of a similar shape, but made of whalebone covered
with soft rubber, may yet prove useful. Practitioners will find a
great variety of pessaries in the stores and catalogues which we can-
not enumerate in a work of this kind.
If the posterior cul-de-sac is too shallow to allow the Hodge pes-
sary to penetrate far enough along the posterior uterine surface to keep
the corpus bent forward, it is apt to bend
backward over the pessary, which then Fl - 251.
does more harm than good. To obviate
this the vagina may be deepened by meth-
odical packing (p. 178). In exceptional
cases I have succeeded with Fowler's
pessary (Fig. 251) when others failed.
Some use the intra-uterine stem with or
without Vaginal Support (p. 441). Fowler's Pessary.
Postural Treatment. Some help may
be derived in the treatment of retroflexion by directing the patient to
spend the night on her abdomen, or at least on the sides in a semi-
prone position, and to avoid lying on her back. Besides, it is recom-
mended to let her, on retiring, take the knee-chest position, and pull
back the perineum with a finger, or, better, introduce a glass tube that
will admit the air right up to the vault. 1
In many women it is only necessary to use the Hodge pessary for
1 Henry F. Campbell, Gyn. Trans., 1885, vol. x., p. 305.
448 DISEASES OF WOMEN.
some time, say from three to six months. Others need it all their
lives.
General remarks about pessaries are found on p. 436. An
elastic abdominal belt (p. 190) may be useful, especially in stout
patients.
If these milder means do not succeed in curing or relieving the
patient, recourse may be had to different operations viz. perineor-
rhaphy, trachelorrhaphy, excision of cervix, extraperitoneal shorten-
ing of the round ligaments, forcible tearing of adhesions, massage,
hysteropexy, and intraperitoneal shortening of ligaments.
1. Perineorrhaphy. If the vaginal entrance is torn, and the pessary
does not find the necessary support, the perineum must be repaired
(p. 307).
2. Trachelorrhaphy and Wedge-shaped Excision of Cervix. If the
cervix is torn, it should be brought together (p. 399), and even if it
is not torn, but bulky and presenting a large canal, Gordon's operation
(p. 418) should be performed. The involution caused in the body
of the uterus by operations on the cervix (p. 418) is in many cases,
together with postural and astringent treatment, sufficient to ensure
the reposition of the displaced womb. 1
3. Extraperitoneal Shortening of the Round Ligaments (Alex-
ander's Operation). This operation is chiefly indicated in cases where
there are no adhesions. Its object is to keep the fund us forward by
removing a part of the round ligaments without opening the abdom-
inal cavity. It is contraindicated in women who have passed the
menopause, as this event entails fatty degeneration and atrophy of
the ligaments.
Modus Operandi. The patient lies stretched out at full length on
her back. The operator stands on the side of the table opposite to
the ligament to be operated on. The pubic hairs are shaved off.
The operator feels for the spine of the pubis, and makes with his nail
a little dent in the skin over it. An incision is made parallel to
Poupart's ligament from 1^ to 3 inches in length, according to the
amount of subcutaneous adipose tissue, passing through the dent
and going down to the tendon of the obliquus externus abdom-
inis muscle. The left index-finger is placed on the pubic spine and
the pillars of the ring, and the intercolumnar fascia, with its trans-
verse fibers, laid bare by scraping with the handle of the scalpel.
The ring is situated immediately above and a little outside of the
spine. Bleeding vessels are tied or compressed. From the ring
emerges a bunch of adipose tissue that contains the ends of the round
ligament, which spread out in fine filaments often hard to distinguish.
This whole mass is seized with a pressure-forceps, and an aneurism-
1 Gordon and Engelmann, International Medical Congress, 1884, C&mpte-rendu des
travaux de la Section <f Obstetrique et de Gynecologie, pp. 157-160.
DISEASES OF THE UTERUS. 449
needle inserted under it close to the bone. Next we pull on the mass,
and see the white genital branch of the genito-crural nerve, which lies
just in front or to one side of the ligament. It is severed with knife
or scissors, and so are some fine tendinous fibers running from the lig-
ament to the wall of the canal. Sometimes the peritoneum is invagi-
nated and accompanies the ligament, from which it must be stripped
with the fingers and pushed back. When the ligament begins to peel
out easily, this side is covered with an antiseptic pad.
The operator now steps over to the other side of the table, and
repeats the operation on the other ligament.
When both ligaments are free, an assistant pushes the uterus for-
ward with the sound or a repositor, and the ligaments are pulled out
from 2 to 4 inches until we meet with a decided resistance.
Next, the ligaments are secured in their new position by passing
two or three sutures of silk or chromicized catgut through the pillars
and the ligament, whereby we should keep outside of the center of
the ligament in order not to tie the artery running there (p. 60), which
might lead to sloughing. It is well to carry the last suture, not only
through the pillars, but through the fibrous tissue covering the pubes.
Finally, the redundant part of the ligament is cut off, the edges of
the superficial fascia united with a running catgut suture, and the ex-
ternal wound closed with interrupted silk or silkworm-gut sutures.
In very fat women, or if the tissues have been much bruised, a soft-
rubber drainage-tube is left in the whole length of the wound. An
antiseptic dressing is put on and left for a week. Then the outer
sutures are removed. The patient is kept in bed for a month, and
should wear a Hodge's pessary for six months or longer. If Alex-
ander's operation is combined with perineorrhaphy, the pessary is
introduced at the end of four weeks.
If the ligament cannot be found or breaks, it is necessary to split
the anterior wall of the inguinal canal.
Nobody should undertake this operation without having tried it
several times on the cadaver, 1 since even experienced surgeons have
found it difficult or impossible to find the ligaments.
If there are signs of endometritis, it is a good plan to curette the
uterus before performing Alexander's operation.
Several cases of childbirth after this operation are on record.
If the fundus is held back by adhesions, a transverse incision should
be made in the vagina, behind the cervix, as in hysterectomy, and the
adhesions should be torn with the fingers or cut with the thcrmo-cau-
tery. If there is no bleeding the opening may be closed immediately.
1 It is also advisable to study the papers, full of practical details, published bv
Polk in N. Y. Med. Record, July, 1886, p. 1 ; Munde, in Amer. Jonr. Obntef., Nov",
1888, vol. xxi. p. 1121 ; and J. H. Kellogg, Trans. Amer. Assoc. of Obstetricians and
Gynecologists, 1888, vol. i. p. 223.
29
450 DISEASES OF WOMEN.
Otherwise it is packed with iodoform gauze. When the adhesions
are disposed of, Alexander's operation is performed in the usual way.
4. Forcible Tearing of Adhesions (Schnitzels Method}. When the
uterus is bound down with adhesions Schultze dilates the cervical
canal with aseptic latuinaria (p. 154). He introduces the index- and
middle fingers into the vagina, and the latter up to the fundus. Next
he uses this finger to replace the uterus, while the other hand grasps
it through the abdominal wall. W r hen the uterus is replaced, it is
kept in situ with a pessary. Most adhesions are easily separated, and
the operator will, of course, use a good deal of judgment in deciding
which resistance he will try to overcome, and when to desist, but on
account of the uncertainty as to the conditions found in the pelvis,
this method is fraught with dangers, which are still enhanced by
substituting a thick sound for the finger. 1 It is much safer to open
the cul-de-sac.
5. Massage (Brandtfs Method). Not less efficacious and safer than
Schultze's is Brandt's method, that obtains similar results by means
of manipulations directed through the abdominal wall and the vagina
(p. 190). By this method the adhesions are stretched gradually, and
made to be absorbed by increase in vital processes. 2 If, however,
there be a pyosalpinx or other purulent collection in the pelvis, the
pus may be pressed into the peritoneal cavity and cause an acute
inflammation that may end fatally.
6. Hysteropexy, or Womb-fastening. 3 There are different operations
by which the uterus is stitched to other parts in order to make it
adhere in a position that prevents it from falling back again. They
may be divided into two classes, according to the point chosen for
the adhesion viz. vaginal hysteropexy and abdominal hysteropexy.
A. Vaginal Hysteropexy or Vagino-Jixation. The patient is in
the dorsal position with raised feet. Garrigues' self-retaining weight
speculum (Fig. 177, p. 211) and Engelmann's side retractors are intro-
duced. The uterus is pulled downward and backward as far as pos-
sible with two volsellse or bullet-forceps, one on either lip of the cer-
vical portion. Another bill let- forceps is fastened in the median line
of the vagina, about an inch behind the meatus urinarius. The ante-
rior wall having been put on the stretch, an incision is made through
the mucous membrane, extending from the upper forceps down to the
line of demarkation between the bladder and the cervix, which is as-
certained by introducing a metal catheter into the bladder or by the
difference of the rugosities of the vagina and the smooth surface of
the vaginal portion of the uterus. Next, the mucous membrane is
1 Erich of Baltimore, Amer. Jour. Obst., Oct., 1880, vol. xiii. p. 836'; Van de
Warker of Syracuse, Gyn. Trans., 1881, vol. vi. p. 185.
2 For details the reader is referred to Dr. Vineberg's paper, quoted on p. 188.
3 Hystera, womb ; pegnymi, I fasten. This name is more correct than hysterori-haphy,
which only means womb-sewing.
DISEASES OF THE UTERUS. 451
partly dissected, partly pushed back with blunt instruments from the
bladder to the extent of an inch to either side of the incision. There-
after the bladder is in a similar way separated from the uterus, com-
mencing with a transverse incision of the cervix. A strong silk thread
is passed with a strong curved needle transversely through the an-
terior wall of the uterus, and serves to pull the uterus down, so that
another thread can be inserted half an inch higher up, which is used
in a similar way until a third can be inserted, and finally the fundus
of the uterus appears in the wound. Instead of these traction threads
bullet-forceps may be used for anteverting the uterus, if the tissue is
hard enough not to tear out.
When the fundus has been reached, a silk suture is passed through
it from side to side, but not tied. Two more are inserted parallel to
the first and below it, with about half an inch interval. Each of the
six ends is carried by means of a silk loop (p. 401) through the loos-
ened mucous membrane, far out to the side. Then all the traction
threads are removed, the edges of the vaginal incision are united by
a continuous catgut suture, which in the lower part enters the tissue
of the cervix, and finally the three deep sutures are tied across the
vagina.
The patient is kept in bed for two weeks, and the sutures are
removed at the end of four weeks after the operation. 1
After the menopause, when Alexander's operation is contraindi-
cated, vaginal hysteropexy may answer a good purpose. During the
ohildbearing period it exposes to pain during pregnancy, abortion, or
great difficulties in delivery, even the Cesarean section having become
necessary on account of the unnatural position of the os upward and
backward, which prevented engagement of the fetus. In virgins
Alexander's operation is also preferable, in order to avoid undue
distention of the vagina.
The appendages can easily be drawn down into the wound, in-
spected, and, if diseased, they may be removed.
If the retroflexion is complicated with a cystocele, a part of the
mucous membrane of the vagina may be cut off before uniting the
dges of the wound.
If there is any difficulty in raising the uterus, it may be done with
a thick uterine sound having a uterine and a perineal curvature.
If the uterus is adherent in the hollow of the sacrum, a transverse
incision should be made at the utero-vaginal junction, behind the cer-
vix, large enough to admit two fingers, with which the adhesions are
severed. If there is any bleeding, the pelvic cavity is tamponed witli
iodpform-gauze or sterilized gauze. (See Hysterectomy.)
1 Mackenrodt, Deutsche med. Wochenschr., 1892, No. 22, with improvements by
Winters (Centralbl. f. Gyndk., 1893, No. 27, p. 627), Duhrssen (ibid., No. 30, p. 690),
Orthmann (ibid., No. 45, p. 1038), and others.
452 DISEASES OF WOMEN.
B. Abdominal Hysteropexy, or Ventro-fixation of the Uterus. In
this operation the uterus is attached to the abdominal wall. There
are many varieties, the most important being the following viz. :
a. Olshausen's Method. One suture is carried through the round
ligament near the edge of the uterus and the anterior layer of the
broad ligament behind, and the parietal peritoneum and part of the
the rectus abdominis muscle in front, three-quarters of an inch
from the middle line. Two more sutures are inserted below the
first, only through the anterior layer of the broad ligament and
the abdominal wall as just stated. All six sutures are inserted before
any of them is tied. The uterus should be lifted sufficiently to leave
only a narrow slit between it and the bladder. Before tying, the
operator makes sure that neither the intestine nor the omentum is
in the way.
b. Leopold's Method. Leopold fastens the uterus itself to the
abdominal wall. A suture is carried through the whole abdominal
wall and transversely under the peritoneum and the most superficial
part of the muscular tissue on the anterior surface of the uterus,
between the two starting-points of the round ligaments, on a line
half an inch long, and then out through the abdominal wall on the
other side. Two more such sutures are placed above the first and
parallel to it.
In order to insure adhesion the perimetrium is scraped with the
back of a bistoury in the space comprised between these sutures.
Other sutures are carried through the abdominal wall alone, below
and above those going through the uterus, and finally all are tied.
Those going through the uterus are left in place from twelve to
fifteen days.
c. Czemy's Method is like Leopold's, with this difference that he uses
only two uterine sutures of catgut treated with corrosive sublimate,
and carries them only through the peritoneum, muscle, and fascia, but
not through the integument.
d. Pozzi's Method. Beginning at the lower end of the incision, a
continuous suture of fine silk is brought through the abdominal wall,
except the skin and sucutaneous adipose tissue (as in Czerny's method),
and through the perimetrium, which is comprised three times in the
suture. The remainder of the abdominal wall is closed with a con-
tinuous tier-suture of catgut, in two layers (p. 221).
e. Kelly's Method} A ligature is carried through the parietal peri-
toneum and adjacent tissue one-eighth of an inch deep and a third of
an inch wide and through the posterior wall of the uterus, below the
fund us and finally through the peritoneum and adjacent tissue on the
other side. When this suture has been tied, a second is carried in a
1 Howard Kelly, " Suspension of the Uterus," Jour. Amer. Ned. Assoc., Dec. 21,
1895, vol. xxv. p. 1079.
DISEASES OF THE UTERUS. 453
similar way just above the first on the abdominal wall and below it
on the posterior wall of the uterus. Adhesions form at once, but
stretch, so that after a short time the organ is found mobile, with the
fundus well forward in an easy anteflexion and with a marked space
between it and the abdominal wall to which it was attached.
/Severance of Adhesions. In all cases in which the abdominal cav-
ity is opened, adhesions that hold the uterus in its faulty position
should be severed, beginning at the distal end of the broad ligaments.
As a rule, this can be done with the finger alone, but sometimes the
adhesions are so tough that they have to be tied with a double liga-
ture and cut with scissors, or they have to be severed with the thermo-
or electro-cautery. If there is much bleeding from torn adhesions,
it may become necessary to use a provisional intra-abdominal tampon
of iodoform gauze (p. 181).
Examination of Appendages. When the abdomen is opened, the
appendages should be brought into view, and, if seriously affected,
they should be removed. .In the latter case either the stumps or the
fundus uteri may be fastened to the abdominal wall.
Pessary. In all cases of abdominal hysteropexy a Hodge's pessary
should be introduced and worn for several months.
The bladder soon accommodates itself to its new relations with the
uterus. Pregnancy and childbirth at term have been observed after
hysteropexy, but in some cases abortion has occurred. Strangulation
of the intestine or the omentum in the slits might take place, but this
danger does not seem to be great. It is, however, serious enough
to be a point in favor of other operations by which the uterus is not
fastened to the abdominal wall.
7. Intraperitoneal Shortening of Ligaments a. Wylie's Method. 1
The round ligaments are pulled up into the abdominal wound, scraped
on their inner surface so as to make them raw, folded upon themselves,
and the loop tied with three silk sutures, so as to hold the uterus over
the bladder near the pubic bone. Then the abdominal wound is closed.
b. Polk's Method. 2 The round ligaments are caught up about
three-quarters of an inch from the cornua, are approximated in front
of the uterus, and are tied together by one suture. Should further
shortening be needed, one or two more sutures may be passed in front
of the first at a distance of a quarter or half an inch each.
c. Tait?s Method produces a shortening of the round ligaments by
passing the ligature for removal of the appendages (see Diseases of
the Tubes) under the ligament, so as to comprise a loop of it in the
part that is cut away.
d. Eode's Method. The intra-peritoneal shortening is performed
from the vagina. A transverse incision is made in front of the cer-
1 Gill Wylie, Amer. Jour. Obst., May, 1889, vol. xxii. p. 484.
2 W. M. Polk, Oyn. Trans., 1889, vol. xiv. p. 262.
454 DISEASES OF WOMEN.
vix. (See below, Anterior Colpotomy, under Uterine Fibroids and
Salpingitis.) The uterus is turned into the vagina by inserting
bullet-forceps one above the other, in the anterior wall of the uterus.
After examining and treating the appendages, a silk ligature is car-
ried with a needle through or behind the round ligament, half an inch
from its uterine end, from right to left, then tied. Next, the thread
is carried about two inches from the uterus, from left to right, through
the same round ligament. The ends of the thread are secured with
pressure-forceps till the other round ligament has been treated in the
same way. Then the uterus is replaced and the threads tied and cut
short. The wound in the peritoneum is closed with catgut sutures.
The vaginal wound may be closed transversely or longitudinally. In
so doing the bladder is again united to the cervix.
Others have attacked the sacro-uterine ligaments and the infundi-
bulo-pelvic ligament.
In regard to the laparotomy forming part of most of the above-
mentioned methods the reader is referred to the description of
Ovariotomy.
In the writer's opinion it is hardly warrantable to perform laparot-
omy for retroflexiou alone, but if the appendages have to be removed
or if adhesions cause great pain and cannot be disposed of otherwise,
it may be useful to attend to the retroflexion at the same time in one
of the ways mentioned.
E. Lateroversion and Latei*oflexion.
Lateral deviations of the uterus, unaccompanied by other patho-
logical conditions, are rare. They may be congenital (p. 394) or due
to inflammation later in life. The displacement is often produced by
inflammatory exudations in the pelvis or tumors in the broad liga-
ments. The diagnosis is made by bi manual palpation or the sound.
These displacements are apt to cause sterility. No direct treatment
is applicable.
F. Prolapse.
Prolapse, Prolapsus, Descent, Procidentia, popularly called Falling
of the Womb, is that displacement of the uterus in which it sinks
down to a lower position than normal. Some authors reserve the
term " prolapse " for the lesser degrees of descent, in which the uterus
is inside of the vagina, and designate by " procidentia " only the
highest degree, in which the uterus sinks more or less completely out
of the body and hangs between the thighs. Others call the first
degree incomplete, and the second complete prolapse.
Prolapse is sometimes acute ; that is to say, it may occur suddenly
in an otherwise healthy person, even a virgin, while making a mus-
cular effort, but this is rare. It has also been observed in a child,
DISEASES OF THE UTERUS. 455
in consequence of diarrhea, a few days after birth. Commonly it is
chronic; that is to say, it is developed slowly and gradually. In
the latter case it is combined with more or less hypertrophy and
metritis.
Pathological Anatomy. The vagina becomes inverted, as in supra-
vaginal hypertrophy (p. 426), but in prolapse the peritoneal pouches
in front and behind the uterus are dragged down with it (Fig. 252).
FIG. 252.
Procidentia Uteri, with pared surfaces for Lefort's operation: A, anterior denudation; B,
posterior denudation ; U, fundus uteri ; UH, meatus urinarius; .R, rectum.
HJtiology. As just stated, the acute prolapse is due to a muscular
effort in carrying a heavy weight, such as a tub with water, in front
of the body. The chronic is mostly referable to childbirth. The
vaginal entrance being ruptured (pp. 302 and 305), the uterus does
not find its usual support from below. It becomes retroverted
and then retroflexed (p. 443). Intra-abdominal pressure drives
it like a wedge down through the vagina. The sacro-uterine liga-
ments (p. 55) become weakened and elongated, the pelvic connective
tissue loses its touus, and the weight of the subinvoluted vagina drags
the uterus down (p. 336). Finally, the uterus sinks by its own
weight. Thus lack of support from above and below combines with
weight, pressure, and dragging to displace the uterus.
The descent may also be due to tumors in the uterus, which increase
its weight, or in the abdomen, which press on it. The increase in
weight and succulence of all pelvic structures caused by pregnancy
may also result in prolapse.
456
DISEASES OF WOMEN.
Symptoms. The symptoms of chronic prolapse are identical with
those of hypertrophy of the cervix (p. 427). The acute form is
accompanied by sudden severe pain, faintness, and peritonitis.
Diagnosis. A polypus and an inverted uterus form tumors with-
out the opening at the lower end leading into the interior of the tumor.
Prolapse differs from supravaginal hypertrophy by the low position
of the uterine body and the normal or only slightly increased depth
of the cavity. The lesser degrees of prolapse become more apparent
in the erect posture (p. 138).
Treatment. As a rule, common pessaries cannot be retained, on
account of lack of support from the perineum. A large soft-rubber
ring, an inch thick (Mayer's pessary), will sometimes retain the uterus
in the pelvis by distending the upper part of the vagina. Breisky
recommends large ovoid bodies of hard rubber. Gariel's air-pessaiy
consists of a soft-rubber bag, which the patient can introduce herself
into the vagina and fill with air. In most cases of complete prolapse
it is necessary to use supporters composed of a cup and stem pressing
against the vaginal portion and fastened to an abdominal belt (Fig.
FIG. 253.
Uterine and Abdominal Supporter.
253). This apparatus is removed during the night, and the cup
cleansed with some disinfectant.
Brandts method of combined massage and gymnastic movements
(p. 191) claims great triumphs in the cure of prolapsus. 1
may be found in Boldt's
DISEASES OF THE UTERUS.
457
Operations. As a rule, combined operations are required, and even
they may not always prevent a return of the evil. 1
Emmet's or other operations are used for reducing the bulk of the
uterus (p. 418) ; Alexander's operation (p. 448) is combined with peri-
neorrhaphy (p. 307) ; vaginal or abdominal hysteropexy (pp. 451-453)
Leforl's Prolapsus Operation : A, anterior denudation ; B, posterior denudation ; C ', upper
right lateral sutures ; D jy, upper left lateral suture.
is also used to hold the uterus up, in order to fasten the uterus above
and support it from below.
Le/orfs Operation. For complete prolapsus Lefort's operation of
partitioning the vagina is valuable by providing a solid column of tis-
sue right in the middle of the vagina for the uterus to rest on.
In the middle of the anterior surface of the tumor hanging in
front of the vulva a parallelogram three-quarters of an inch wide and
over two inches long is denuded close up to the vulva. Next, the
tumor is held up and a corresponding denudation is made on the pos-
terior surface. Then the uterus is replaced sufficiently to bring the
two upper ends of the pared surfaces in contact, and to unite them
with three or four sutures. After having tied these sutures, one is
inserted on either side of the parallelogram (Fig. 254), and these two
1 I combined in one case removal of the appendages, ventrofixation of the uterus,
Tail's perineal flap operation, and Stolz's cystocele operation. For a time the suc-
cess was complete, but a year had not elapsed before the uterus was prolapsed again.
458 DISEASES OF WOMEN.
also tied, by which the uterus is lifted still more. Thus one stitch is
placed below the other, half a dozen on either side, and finally the
transverse lines forming the lower ends of the parallelograms are
brought together with sutures.
Lefort uses silver wire sutures throughout, leaving them long
enough to hang out through the vulva, but the upper ones are diffi-
cult to remove. It is probably a good plan to combine a perineor-
rhaphy with this operation. 1
An improvement by Coe 2 consists in introducing several rows of
buried catgut sutures in the middle of the wound, each row covering
the preceding one. Chromicized catgut is particularly well adapted
for this operation, since the sutures cannot be removed, and ought to
resist dissolution for some time (p. 204).
This operation does not interfere with coition, since it only forms a
double vagina; but in case childbirth should take place the artificial
septum would probably be destroyed. The operation is, therefore,
particularly indicated after the menopause.
In women who are beyond the child-bearing period, or who are
absolutely incurable by any of the conservative methods, Munde' 3
has resorted to the high amputation of the cervix by making a circu-
lar incision around the cervix, pushing up the vaginal walls with
finger and seal pel -handle, and removing the bladder and the perito-
neum of Douglas's pouch from the seat of operation. Having thus
exposed an inch to an inch and a half of the raw cervix, he ampu-
tated it with the galvano-caustic wire. Passing a tent of iodoform
gauze into the cervix to prevent the closure of that canal, he returned
the uterus into the pelvic cavity and packed the vagina with iodoform
gauze. The cicatricial contraction of the vaginal vault resulted in
forming so firm an attachment that the uterus was retained in its
normal position.
Freund's operation 4 is mentioned only in order to warn against it.
It consists in the insertion of three or four silver wire rings under the
mucous membrane of the vagina, one below the other. It can only
be used in old women, since it excludes connection. It is said to be
so painless that it can be performed without anesthesia, but it is decep-
tive, since the wires soon cause suppuration and come out.
Vaginal Hysterectomy, In those very rare cases of prolapse that
have resisted all other methods, the extirpation of the prolapsed uterus
is justifiable. In performing it a considerable part of the vagina must
also be removed. The modus operandi by Fritsch's method 5 is the
following : The patient is in the breech-back position (p. 368). The
1 Fanny Berlin of Boston, Amer. Jour. Obst., Oct., 1881, vol. xiv. p. 870.
2 H. C. Coe, Annals of Gynecol. and Pcediatry, May, 1890, vol. iii. p. 374.
3 P. F. Munde", Amer. Jour. Obst., Nov., 1891, vol. xxiv. p. 1291.
4 H. W. Freund, Centralbl. f. Gyndk., 1893, No. 47, vol. xvii. p. 1081.
5 Asch, Archivfiir Gynakologie, 1889, vol. xxxv. p. 206.
DISEASES OF THE UTERUS. 459
base of the tumor is constricted with a rubber tube in order to pre-
vent hemorrhage. The vaginal portion is seized with a volsella, and
pulled well upward (Fig. 255). Xow an incision is made on the
posterior vaginal wall, between the middle and upper third, in the
shape of an acute angle, the top of which is situated in the median
line and points backward toward the posterior commissure. This
incision opens Douglas's pouch. The next step is to stitch the peri-
toneum to the posterior vaginal wall. The fundus uteri is easily
FIG. 255.
Fritsch's Hysterectomy for Prolapsed Uterus.
pulled out, and a sponge with attached thread placed so as to retain
the intestines. Now the broad ligaments are gradually tied in sections,
proceeding from their upper end to their base, with a half-sharp
aneurism-needle bent to the side (Fig. 269, p. 487) and threaded with
stout silk. If possible the tubes and ovaries are comprised in the parts
to be removed. As soon as a section is tied, it is cut between the liga-
ture and the uterus. Next, the vaginal portion is carried far down,
and an incision similar to that on the posterior wall is made on the
anterior wall of the vagina (Fig. 256), but only through the vaginal
wall, without entering the bladder. This triangle is separated from
the bladder, partly with blunt instruments and partly with the knife,
and the edges of the wound united by means of transverse sutures.
By pulling the fundus uteri again forward and upward, the line where
460
DISEASES OF WOMEN.
the peritoneum passes from the bladder to the anterior surface of the
uterus is brought into view and incised ; and then the posterior wall
of the bladder is dissected from the uterus from above and from below.
Spurting vessels are caught and later tied. Finally, the peritoneum
of the bladder is stitched to the rest of the anterior vaginal wall, or
rather the lateral walls, which have been stitched together in the
Fritsch's Hysterectomy for Prolapsus Uteri. ,
median line, and the stumps of the broad ligaments are also fastened
to the vagina.
G. Elevation.
The uterus may be raised by tumors in the pelvis, or ascend by its
own size, as in pregnancy, or be pulled up by contracting inflamma-
tory adhesions. Sometimes the whole vaginal portion disappears.
H. Inversion.
Inversion consists in a turning inside out of the uterus (Fig. 257).
Jt may be total or partial. As a rule, the inversion begins as an
DISEASES OF THE UTERUS.
461
indentation at the fundus, but it may also begin in the cervix, subse-
quently dragging down the body. We distinguish three degrees. In
the first degree the inverted part is found inside of the uterus ; in the
second, it has descended into the vagina; and in the third it is
combined with prolapse and hangs outside of the vulva.
Inversion comes under observation at three different periods:
Section of the Second Degree of Inversion of Uterus (Crosse): a, vagina: b, fundus uteri; c,c,
angles of inflection ; c,c, d,d, extent of nninverted cervix ; e, vaginal wall ; /, the perito-
neal cul-de-sac of the inverted uterus : g,g, Fallopian tubes passing down into the in-
verted uterus ; h,h, ovaries ; i,i, broad ligaments ; k,k, round ligaments.
immediately after the occurrence of the accident, especially during or
immediately after childbirth, in regard to which the reader is referred
to works on obstetrics ; about six weeks after labor, when hemorrhage
or other symptoms induce the patient to seek advice; and, finally, a
long time, often many years, after its formation.
Etiology. Inversion is a very rare accident, only one case having
occurred in about 1 50,000 cases of delivery. Thue most common cause
is childbirth, especially if it takes place in the erect posture, if the
cord is too short, if the accoucheur or the midwife pulls on it in order
to remove the placenta, and if it is inserted on the fuudus. But the
inversion may also take place some time after the birth of the child,
especially at the time of getting up, although the lying-in period lias
been normal in every respect. Laceration of the cervix may predis-
pose to it. After abortion it is still rarer than after childbirth. It
has also been observed in connection with a vesicular mole.
Secondly, a tumor of the fundus uteri, especially a fibroid, being
expelled, drags the uterus along.
Thirdly, inversion may occur when the uterus is enlarged and its tis-
sue softened, independently of pregnancy and the presence of a tumor.
Where there is no tumor, the mechanism is the following : A part
of the uterine wall, most frequently the placental site, becomes par-
alyzed and sinks down, while the surrounding parts contract above it.
462 DISEASES OF WOMEN.
Thus a kind of peristaltic movement is set up, proceeding from above
downward. But if the inversion begins at the cervix, the movement
takes place in the opposite direction, from below upward.
Pathological Anatomy. The inverted part of the uterus may only
be a cup-shaped depression near the fundus ; or it may form a pear-
shaped body, the lower end of which does not pass the internal os ;
or it may hang in the vagina, the pedicle being surrounded by a ring
formed by the cervix ; or the whole cervix and part of the vagina
may have become inverted in their turn. If the tumor is yet retained
in the body of the uterus, it is covered with a dark-red, swollen
mucous membrane that easily bleeds. On the lower end may be
seen two minute openings, admitting a bristle, which are the uterine
apertures of the Fallopian tubes.
When the inverted part lies in the vagina, its mucous membrane
sometimes loses its glands and becomes like that of the vagina. If
it is expelled outside of the patient's body, it often ulcerates and
cicatrizes, which gives it a cutaneous appearance.
Seen from the peritoneal cavity, the inverted uterus forms a funnel-
shaped depression, into which descend the Fallopian tubes, the round
ligaments, and sometimes the ovaries. In old cases this funnel may
be impervious, the contiguous sides of the peritoneum having grown
together.
Symptoms. In most cases the inversion of the uterus, taking place
suddenly in connection with childbirth, is accompanied by marked
symptoms hemorrhage, pain, collapse, and the formation of the
characteristic tumor in the vagina and the funnel above the symphy-
sis. But in exceptional cases all alarming symptoms may be absent. 1
In the subacute and chronic forms the chief symptom is again hem-
orrhage, which may undermine the constitution by its frequent recur-
rence or profuseness, to which are added leucorrhea, dragging pain,
difficulty in walking, and different nervous reflexes. Physical exam-
ination reveals the peculiar shape of the fuudus and the presence of
a tumor in the vagina.
Diagnosis. The diagnosis of inversion, apart from obstetric cases,
may be very difficult, and is of the utmost importance in regard to
treatment. Only great carelessness could fail to distinguish common
prolapse and hypertrophy of the cervix from inversion, the distinctive
feature being the presence of the os uteri at the lower end, through
which the sound can be entered more or lass deeply. The tumor
in prolapse is broader at the upper end than at the lower, whereas
the opposite is the case with an inverted uterus. A catheter goes
downward into the cystocele accompanying prolapse, but upward in
case of inverted uterus. A polypus may offer entirely similar symp-
1 John C. Reeve has contributed a paper full of instruction, on Inversion, in Gyn.
Trans., 1884, vol. Lx. p. 69.
DISEASES OF THE UTERUS. 463
toms, and a tumor of the same shape and appearance may be found
in the same place ; but if it is a polypus the sound can be introduced
to the depth of a normal uterus or deeper between the tumor and the
cervix, while in inversion it is soon arrested at the place where the
uterus is inflected. Bimanual examination shows, when we have to
do with a polypus, that the uterus is in its place. If, especially in
stout women, the uterus cannot be felt through the abdominal wall,
recourse may be had to rectal examination (p. 142). A catheter held
in the bladder may help to settle the diagnosis, and if there is any
doubt the urethra should be dilated (p. 142), and the index-finger
introduced into the bladder, from which it can palpate the uterus.
If it is a case of inversion, these same manipulations will show that
the uterine body is not in its place, and that instead there is a funnel-
shaped depression. It is also claimed that if a needle is thrust into the
tumor, it will cause pain in an inverted uterus, but not in a polypus.
If we have a fibroid as cause of the inversion, and it is yet in the
uterus, the differential diagnosis may be particularly difficult. Under
such circumstances the sound enters to its usual depth, but the depres-
sion of the fundus can be made out by the above-named means.
If the fibroid has dragged the uterus down with it, the sound does
not enter, but it becomes necessary to distinguish which part of the
tumor is the uterus proper and which the fibroid. In this respect the
fact that the fibroid is harder, nodulated, and painless on acupuncture
is an aid to diagnosis.
If adhesion takes place between the pedicle of a polypus and the
cervix, the sound cannot enter, but then the uterus is found in its
normal place and of normal shape.
A similar condition obtains when it is a so-called hollow polypus* an
exceedingly rare disease, the pathology of which is not quite settled.
There is found a tumor in the vagina as in common polypus and inver-
sion, but the sound cannot be made to enter anywhere between the
pedicle and the cervix without violence. This tumor is soft and con-
tains fluid, which distinguishes it from a fibroid polypus adherent to
the cervix. One theory is that a plastic deposit is produced on the
endometrium, and that blood or other fluid accumulates between it and
the uterine wall, lifts it up, and forms the polypoid tumor that is ex-
pelled through the os. Another theory is that it is the endometrium
itself that becomes detached and peeled off down to the cervix. A
third possibility and, in my opinion, more likely than either of the
others would be that a common fibroid polypus contracts adhesions
with the cervix; that its interior becomes myxomatous and melts,
forming a cyst in the way we shall see in studying the formation of
fibro-cysts, which cyst later communicates with the uterine cavity by
absorption of the partition. However this may be, the fact is that
1 Sussdorff, Jour, Obst., 1877, vol. x. p. 553.
464 DISEASES OF WOMEN.
we have a sac filled with fluid protruding through and attached to the
cervix. The sound does not enter, but the tumor is softer than an
inverted uterus. By pulling on it, the relations between it and the
cervix remain unchanged, whereas in inversion the cervix becomes
more inverted or disappears altogether. Examination through the
rectum practised while this traction is made will show that the ute-
rus is in its place and has its normal shape. If the sound is made
forcibly to penetrate the obstacle round the pedicle, it enters a cavity
of the normal depth of the uterus.
Prognosis. Inversion of the uterus is a very dangerous condition,
accompanied by great mortality. The total mortality is 20 per cent.,
but it is far less in chronic cases than in obstetric practice. Spon-
taneous replacement is possible, but rare. Another spontaneous cure,
accompanied by the dangers of septicemia, is occasionally brought
about by gangrene of the inverted mass. Most of the measures
adopted for the cure of inversion are more or less dangerous.
Treatment. The measures to be taken for the inversion occurring
during labor are taught in works on obstetrics. Here we treat only
of more or less old cases. Experience has shown that the best treat-
ment is that with elastic pressure. The vagina is disinfected and
Aveling's repositor applied. It is made of hard rubber, aud consists
of a little cup which presses on the inverted fundus, and an S-shaped
rod, which protrudes from the vulva and carries pressure made at its
lower end upward in the direction of the pelvic axis. To the lower
end are attached four elastic tapes, which are drawn through rings
fastened to a belly-binder. Two of the tapes are brought forward
and two backward, and they enable us to give the rod the desired
direction. A pressure of two and a half pounds is sufficient. This
method is safe, hardly ever fails, and leads to replacement in a short
time from nine to fifty-four hours by starting an antiperistaltic
movement, so that the part forming the pedicle is first replaced, and
the fuudus last.
The same principle of elastic pressure may be applied in different
ways. A soft-rubber cup is attached to a curved hard-rubber stem,
from the end of which tapes go to rings in a belt round the abdomen
(Barnes). The uterus is surrounded with cotton pledgets soaked in
glycerin ; then a soft-rubber bag is introduced into the vagina, upon
which pressure is obtained by passing a strap of adhesive plaster from
the lumbar region over the genitals to the umbilicus (Thomas). The
common German way is to use the colpeurynter, a large rubber bag
distended with air or water ; by its great side pressure it causes con-
siderable pain, and can hardly be borne for more than five" or six
hours a day, wherefore the treatment may take a month or more.
Between the applications, the vagina is treated with warm disinfectant
injections. Another way that dispenses with the use of any particular
DISEASES OF THE UTERUS. 4G5
instrument, is to pack the vagina firmly with iodoform gauze, which
is renewed every two or three days.
During all these treatments the patient is kept in bed, and if neces-
sary the pain relieved by hypodermic injections of morphine.
If the elastic pressure does not succeed, recourse is had to one of
the following methods of manual replacement, which are used on the
anesthetized patient.
Emmet surrounded the tumor with the fingers of the left hand and
pressed at the base, making counter-pressure through the abdominal
wall on the ring in the peritoneum.
Noeggerath applied the thumb and middle finger to the horns of
the uterus, replaced first one of them, then the other, and finally the
fundus ; counter-pressure was made as in Emmet's method.
Courty introduced two fingers of the left hand into the rectum,
which allows pressure on the cervical ring with greater effect, while
the fingers of the right hand press at the base of the tumor in the
vagina.
Tate of Cincinnati dilated the urethra, introduced the right index-fin-
ger into the bladder, and pressed on the ring from this side, at the same
time using the left index- and middle finger in the rectum, as Courty
did, and applying both thumbs to the horns as in Noeggerath's method.
Instruments for replacing the inverted uterus have been devised by
White of Buffalo and Byrne of Brooklyn.
If a partial rein version is obtained in any way, Emmet's device, of
pulling the lips of the cervix together over the still inverted fundus,
and uniting them with deep silver-wire sutures, may be followed.
Thus an elastic pressure is obtained that may lead to complete
replacement.
The efforts to reduce the inversion must be continued as long as
possible, say for half an hour, different operators relieving one
another. If one method does not succeed, and her condition war-
rants delay, the patient should be given a few days rest, and another
method tried. In the mean time, the tumor may be softened with
warm vaginal injections and sitz-baths.
Conservative Cutting Operations. Thomas performed laparatomy
and dilated the cervical ring with an instrument like a glove-stretcher.
This method would probably be the best in old cases in which adhes-
ions have formed between the walls of the internal ring.
Barnes pulled the tumor well down with a tape, and made three
longitudinal incisions in the cervix. After that he could easily replace
the tumor by manipulation.
Amputation. When all conservative measures fail, the tumor must
be removed. The chief danger of this method is the possibility of
the presence of the intestine in the inverted part. An elastic Uyatirre
may be applied round the base, and tightened every day. The stran-
30
466 DISEASES OF WOMEN.
gled tumor falls off in twelve to eighteen days. Before applying the
ligature a bed is made for it by burning a groove with the thermo-
cautery (p. 182).
Some prefer to remove the mass by means of the galvano-caustic
wire, or Paquelin's thermo-caute?'y, which does away with the dangers
of septic infection from the putrefying tumor ; and if reinversion of
the stump should take place, the cut surface forms a hollow cone from
which discharge can escape into the vagina.
The tumor may also be cut away with knife and scissors, but then
silver sutures should be drawn through the base before the ablation,
so as to be able to close the peritoneal cavity. On each side one suture
should be brought out transversely, so as to encircle the lateral blood-
vessels, while three middle sutures bring the cut surfaces together.
Destruction of the Mucous Membrane. In irreducible cases in women
near the climacteric, the dangers of amputation may sometimes be
avoided by destroying the mucous membrane and producing cicatri-
zation by means of potassa cum calce or the ther mo-cautery.
If inversion is produced by a fibroid, this must be removed before an
attempt is made to reduce the inversion. It is sometimes difficult to
find the line of demarkation. The safest is to make an incision
over the end of the tumor and enucleate it with Thomas's serrated
scoop (Fig. 264), which will be described in treating of fibroids.
When once the tumor is removed, perhaps parts of the tissue in which
it was imbedded have to be cut away. Next, the uterus is to be rein-
verted and packed with iodoform gauze.
If the tumor is malignant, the whole uterus should be extirpated
by vaginal hysterectomy, as detailed under Cancer of the Uterus.
If we have to deal with a hollow polypus, it should 'be pulled
down, which is best done by surrounding it with a noose. If there
is any difficulty in applying it, a sling-carrier in the shape of a uterine
sound with a small crescent at the end will easily bring it up. A small
incision is made in the pedicle, through which the sound is passed, and
only enters to a depth corresponding to the size of the uterus. The
diagnosis thus having been completed, the protruding tissue is removed
by ligature, thermo-cautery, or galvano-caustic wire.
I. Hernia Uteri.
Hernia uteri, or hysterocele, is that displacement of the uterus in
which it is found lying outside of the pelvis in a sac formed by the
peritoneum. The uterus has been found in an inguinal and in a
crural hernia. Such cases are extremely rare. They are nearly
always congenital malformations. (See p. 394.)
DISEASES OF THE UTERUS. 467
CHAPTER XIII.
NEOPLASMS.
A. Cysts of the Uterus; Adenoma Uteri; Mucous Polypi ; Myxoma.
In regard to cysts of the cervix and o villa of Naboth we refer to
what has been said above under Lacerated Cervix (pp. 396 and 399)
and Chronic Endometritis (pp. 407 and 413). These cysts, being
formed by occluded glands, are a kind of adenoma.
Cysts of the corpus uteri are very rare. Sometimes they are multi-
ple. They are supposed to owe their origin to a detachment of the
bottoms of uterine glands, or to be developments of Gartner's canal.
(Compare Vaginal Cyst, p. 358.)
In speaking of hyperplastic eudometritis (p. 408) we have men-
tioned another kind of adenomas, small benign tumors formed by a
conglomeration of hyperplastic uterine glands. They may be sessile
and do hardly ever become larger than a walnut, but have a tendency
to become pedunculated and form so-called glandular polypi. Such
polypi start very frequently from the mucous membrane of the cervix,
and hang out from the os, where sometimes they may acquire so con-
siderable a size as to fill the vagina ; but that is rare. Most of them
come under treatment when they are not larger than a cherry, a
pigeon's egg, or a small oyster. They are soft, covered with a dark
red mucous membrane. They are full of cavities, the contents of
which are thin or thick, clear or dark.
Sometimes the polypi are formed of myxomatous tissue consisting
of a delicate fibrous network, with slight thickening at the points
of intersection, and a hyaline or finely granular mucoid basis sub-
stance in the meshes, in which we find imbedded single or multiple
granular corpuscles. Glandular formations are rare or absent. 1
The name " adenoma " is also taken in a narrower sense, and used
to designate a tumor formed by an exuberant growth of utricular
glands, while the connective tissue between the epithelial tracts is
extremely scanty and fibrous, only a small number of medullary cor-
puscles being present.
In contradistinction from this benign adenoma, some authors speak
of a malignant adenoma, which is only the first stage of carcinoma.
The microscopical appearance which characterizes it is described as
follows : The gland-spaces are very much enlarged, very irregular,
and are frequently seen to break through into other gland-spaces. The
columnar epithelial cells are attached to the stroma, as a rule, and
they are often converted into cuboidal or even squamous cells. These
1 Louis Heitzmann, " The Differential Diagnosis between Fungous Endometritis
and Tumors of the Mucosa of the Uterus," Amer. Jour. Obst., Sept., 1887, vol. xx.
p. 897.
468 DISEASES OF WOMEN.
cells are frequently seen filling up a gland-space. They, however,
never infiltrate the interstitial or stroraa tissue. The neoplasm ex-
tends to, and appears to progressively destroy, the muscular wall by
atrophy or, perhaps, fatty degeneration. It persistently progresses as
an atypical, glandular, epithelial type of disease. 1
Symptoms. Mucous polypi cause hemorrhage, leucorrhea, and
sometimes pelvic pain, backache, or dyspareunia. When situated
above the internal os, they may work like a ball- valve and cause
great dysmenorrhea.
The treatment of mucous polypi and benign adenoma must begin
with the removal of the growths. In the interior of the uterus this
is done with the curette (p. 176). From the cervix they may be torn
off by seizing them with forceps and turning the instrument until the
pedicle is severed (torsion). Or they may be cut off with scissors,
but then it is well to have a therrno-cautery in readiness, as there may
be some hemorrhage. They may also be removed with the galvano-
caustic wire or a simple cold wire ecraseur. 2
After removal of the growth the accompanying chronic endome-
tritis should be treated as described above (pp. 412415).
Malignant adenoma is an indication for speedy vaginal hysterec-
tomy.
B. Cavernous Angioma of the Uterus.
This neoplasm is very rare. It consists of a tumor formed of
ectatic veins filled with blood.
Pathological Anatomy. The tumor varies in size from a hickory
nut to an English walnut. It is situated in the muscular coat and
covered with the endometrium and the peritoneum. The inner sur-
face is nodular. The tumor is either spongy or harder than the sur-
rounding uterine tissue. On incision the cut surface is covered with
dark, fluid blood, and after this has been removed a delicate frame-
work with thicker nodules appears. The cavities of the framework,
which differ in size and intercommunicate, are filled with fluid
blood. The framework consists of smooth muscle-fibers covered
with fibrillae of connective tissue with an endothelium. In some
places are seen outgrowths of connective tissue forming papillae.
The cavities of the tumor communicate with the veins of the
neighborhood.
Etiology. The cause of the formation of uterine angioma is un-
known. Perhaps it sometimes originates in a subiuvolution of the
placental site.
1 H. D. Beyea, Amer. Jour. ObsL, Feb., 1896, vol. xxxiii. p. 200.
2 Fibrinous polypi are pedunenlated growths formed by layers of fibrin deposited
over a remnant of the after-birth left in the interior of the womb after childbirth or
abortion. The symptoms and treatment are like those of intra-uterine glandular
polypi.
DISEASES OF THE UTERUS. 469
Symptoms. This kind of tumor gives rise to recurrent and pro-
fuse hemorrhage.
The diagnosis can only be made by microscopical examination of
the scrapings obtained by curetting.
Treatment. Since this neoplasm may occupy the whole thickness
of the uterine wall, curetting may lead to perforation.
In the only case observed clinically, the uterus was removed by
vaginal hysterectomy. 1
C. Uterine Fibroids ; Fibroid Polypi ; Fibro-cysts of the Uterus.
Fibroid tumors, or fibroids of the uterus, fibromata, are more exactly
called myomata i. e. muscular tumors or myofibromata, or fibro-
myomata names denoting a mixture of muscular and fibrous connec-
tive tissue in their composition.
Pathological Anatomy. Fibroids are so common that they are
found in the body of one out of every five women over thirty-five
years of age. They are globular tumors composed of several nodules,
and may attain enormous dimensions, weighing up to 140 pounds.
They are mostly harder than normal uterine tissue, but may be so
soft that they impart a sensation which cannot be distinguished from
fluctuation. On the cut surface they appear white or pinkish, show
an irregular concentric arrangement of the fibers around different
<;entres, and bulge out beyond the surrounding parts. In most cases
the tumor is separated from the uterine tissue by a layer of loose
connective tissue, the so-called capsule, so that it is easily shelled out,
but often this capsule is incomplete, and the tumor is a direct continua-
tion of the surrounding muscular wall. As a rule, the substance is
compact and contains less fluid than the surrounding tissue, but some-
times it is full of dilated arteries, veins, or lymph-spaces (cavernous
myoma, myoma teleangiectodes and lymphangiectodes). Nerves can
be followed into the interior. The uterus grows with the tumor,
so that its cavity becomes larger; as a rule, the muscular tissue
becomes hyperplastic, and numerous blood-vessels are developed in
it. But in exceptional cases, on the contrary, the normal muscular
tissue nearly disappears, and the uterus forms only a bag filled with
<3alcified tumors.
Fibroids may be developed in the body or in the neck of the womb,
but the cervical are much rarer than the corporeal. In non-pregnant
women only 5 per cent, are situated in the cervix ; in pregnant women
20 per cent, have this situation, the relative frequency in the state of
gravidity being due to the fact that cervical fibroids are likely to
cause serious complications of pregnancy and childbirth, which bring
the patients under medical observation.
1 H. J. Boldt, Amer. Jour. Obst., Dec., 1893, vol. xxviii. pp. 834-846. Klob, Patho-
Jogische Anatomie der weiblichen Sexualorgane, Wien, 1864, p. 173.
470
DISEASES OF WOMEN.
They are either sessile or pedunculated, and the latter may again
either hang from the cervix and develop into the vagina, or spring
from the interior of the corpus or fundus ; or they may spring from
the outer surface of the corpus and fundus and develop into the peri-
FIG. 258.
Transition from Imbedded to Pedunculated Uterine Fibroid. Smooth right end free, the
remainder imbedded. 1
toneal cavity. Those which spring from the cervix and the uterus
proper and are covered with mucous membrane are called fibroid polypi
(compare glandular and fibrinous polypi, pp. 408 and 467, 468), the
word " polypus " being used as a general term for any pedunculated
tumor attached to the mucous membrane of the uterus.
Sometimes a fibroid may be partly imbedded in the uterine wall
and partly form a polypus, thus forming a transition from a sessile to
a pedunculated tumor (Fig. 258).
FIG. 259.
Pednnculated Submucous Fibrous Tumor (fibroid polypus) enclosed in Uterus (Cruveilhier) :
F, fundus of uterus ; O,O, ovaries ; L,L, round ligaments : C, cervix ; V, vagina; P, polypus.
Fibroids are called submucous (Fig. 259) when a part of them
is only covered with mucous membrane; subperitoneal (Fig. 260)
if they are partly situated immediately under the peritoneum;
and interstitial or intramural (Figv 261), if they are surrounded by
1 Specimen from my operation on Mrs. S., March 24, 1894.
DISEASES OF THE UTERUS. 471
a layer of muscular tissue. This latter variety has a tendency
FIG. 260.
Pedunculated Subperitoneal Fibroid (Hofmeyer).
to work its way outward or inward, so as to pass into one of
FIG. 261.
Intramural Fibroid (Gusserow).
the two other varieties, and may even become pediculate.
472
DISEASES OF WOMEN.
Sometimes there is only a single tumor, but quite frequently
fibroids are multiple. In the latter case the uterus with its tu-
mors may form a mass of fantastic shape, often reminding one
of certain forms of cactuses (Fig. 262).
FIG. 262.
Large Cactus-shaped Uterus full of Fibroids.'
If the fibroid is developed in the infravaginal part of the cervix,
it may form a polypus attached to one of the lips, but from the upper
part it may develop upward into the wall of the body or into its
cavity or into the connective tissue of the parametrium, the broad
ligaments, and the pelvis in general, separating the layers of the
mesorectum.
Microscopical examination shows that fibroids originate from round
cells surrounding capillaries which are undergoing obliteration. The
well-developed tumor consists of uustriped muscle-fibers, mixed with
more or less fibrous connective tissue and fusiform cells.
Fibroids are not so apt to be bound to the peritoneum of the
abdominal wall or other organs as ovarian cysts, but if they do form
such adhesions, these are often broad and contain very large blood-
vessels ; so much so that the tumor to a great extent derives its nour-
ishment from the adhesions; nay, in course of time it may be severed
altogether from the uterus, and be found attached exclusively to an-
other part of the abdomen. Such pediculate tumors may even be
torn off from the uterus and lie loose in the abdomen as necrobiotic
masses, without forming new adhesions. Fibroids are very fre-
quently accompanied by local peritonitis, and may also cause cellu-
1 Specimen from my operation on Miss B. M., in St. Mark's Hospital, March
13, 1894.
DISEASES OF THE UTERUS. 473
litis. They are often the cause of ascites, usually serous, sometimes
chylous, and rarely bloody.
Fibroids are apt to undergo changes in their constituent elements.
Some of them soften and swell at each menstruation, and if they are
pedunculated the tumor at that time may be driven out through the
cervical canal and appear in the vagina. After the menstrual period
the swelling subsides, and the tumor recedes again into the interior
of the womb, forming what is called an intermittent polypus.
A similar softening and swelling take place on a larger scale during
pregnancy, but, on the other hand, the tumor partakes of the general
involution after the birth of the child, and may disappear entirely.
Such disappearance has also been observed after inflammation and
under circumstances where no simultaneous process could be sup-
posed to be the cause. 1 And quite frequently fibroids remain of
small dimensions and give rise to no symptoms during the bearer's
whole life.
After the menopause fibroids, as a rule, become smaller and harder,
but they may continue growing. Even apart from menstruation and
pregnancy fibroids are apt to become edematous. Sometimes tnyxo-
matous tissue is found in their interior.
Cysts may be developed either by simple accumulation of serum in
the meshes of the tumor, or by resorptiou of myxoid tissue, or by
dilatation of lymph-spaces. The latter kind has an endothelial lin-
ing. 2 Often these cysts first appear spread as small hollows, so-called
geodes, throughout a fibroid, but subsequently the intervening tissue
is absorbed, and finally one large cyst is formed. Such cysts increase
rapidly in size, and may become very large, twenty quarts having
been evacuated from one.
The fluid contained in fibro-cysts, as might be expected from their
different nature, differs very much. Sometimes it coagulates by
exposure to the air, and more frequently it is a serous, non-coagulat-
ing fluid. In small cysts it is citrine, viscid, or serous, but in larger
cysts it contains more or less blood and becomes yellow, bloody, dark
brown, or chocolate-colored. Sometimes the contents are purulent.
The fluid is alkaline, and coagulates entirely on boiling and with
acids. It contains always much albumin, and sometimes fibrin.
The microscope reveals sometimes detached unstriped muscle-cells
from the surrounding tissue.
When a considerable bloody extravasation takes place into the
cyst, it may rupture, and the contents be poured into the peritoneal
cavity.
1 Doran, " On the Absorption of Fibroid Tumors of the Uterus," Trans. London
Obst. Soc., 1893, p. 250.
* A specimen of this kind is described in detail in Garrigues's Diagnom of Ovarian
Cysts by Means of the Examination of their Contents, Wm. Wood & Co., New York,
1882, pp. 60-63.
474 DISEASES OF WOMEN.
The fibroid may slough, either spontaneously or after operations
or after the use of ergot. In this way a cure may be effected, but the
patient may also succumb to septicemia.
By deposit of calcareous matter in their interior fibroids may
become calcified and form a stone-hard mass. They may also un-
dergo sarcomatous or carcinomatous degeneration.
Etiology. The causes of fibroids are unknown. The tumors are
developed during the fruitful age of the woman. They are found
more frequently in sterile women than in those who have borne chil-
dren. Celibacy may perhaps predispose to their formation, but in
most cases the sterility is probably the effect and not the cause of
the fibroid. It is stated nearly everywhere that the negro race is more
liable to fibroids than white people, but of late this has been denied
by an American physician, who has had exceptional opportunities for
personal observation of the fact. 1
Symptoms. Fibroids, especially polypi and the submucous variety,
cause menorrhagia (p. 245) and metrorrhagia (p. 247), leucorrhea (p.
250), hydrorrhea (p. 410), and pain. The pain may be located in the
abdomen, and be due to accompanying peritonitis, to the distension
of the abdominal wall, or to the weight of the tumor. By pressure on
the sacral plexus severe neuralgia may be caused in the pelvis, and
shoot down through the legs. A polypus that is being expelled
through the cervix gives rise to " cramps" or labor-like pain. The
circumference of the abdomen may increase enormously. A tumor
is felt entering the vagina, from the uterus, or imbedded in the
uterine wall, or extending from it into the peritoneal cavity or into
the broad ligaments or the pelvic floor. If it is a solid fibroid, it is
generally more or less hard, globular, nodular, but may be quite soft,
as we have seen in the anatomical description. If it is a fibre-cystic
tumor with large cysts, it is fluctuating.
The presence of the tumor may oppose an obstacle to micturition
or make it frequent. If it presses on the ureters, it may cause pye-
litis and hydronephrosis. By pressing on the rectum it may be the
cause of constipation and hemorrhoids. The presence of the tumor
may interfere with the free circulation of the blood, causing edema,
ascites, dilatation of the heart, or myocarditis. It may push the
uterus down and cause prolapse (p. 454). If attached to the fundus,
a fibroid polypus in descending may drag the uterus along and cause
inversion (p. 460). In rare cases it produces diastasis of the linea
alba, and lies partly in a ventral hernia. By pressure on the uterine
vessels, fibroids may cause a sound like the uterine souffle of preg-
nancy, and in very rare cases a thrill like an aneurism.
The intraligamentous variety forms a tumor in the iliac fossa ; that
in the pelvic floor may be traced to the cervix.
1 Dr. Middleton Michel of Charleston, S. C., Med. News, Oct. 8, 1892.
DISEASES OF THE UTERUS. 47 5
Diagnosis. In most cases the diagnosis is easy, but it may be very
difficult or impossible. From hemorrhagic metritis sessile fibroids
differ by the presence of a tumor, which can be felt imbedded in
the wall. A polypus in the vagina is felt with the finger ; in the
interior of the womb with the sound or, after dilatation (p. 1 54),
with the finger. One examination, at least, ought to be made at the
time of menstruation, since we have seen that the so-called intermit-
tent polypus at that time becomes accessible to touch, and may be
seen in a speculum.
In cancer of the cervix soft masses can be scraped oif with the
nail. There soon appears a hard ring around it ; it ulcerates at an
early date ; and the discharge has an offensive odor. Cancer of the
body gives rise to greater pain than a fibroid ; the constitution suffers
much more and sooner ; the patient becomes emaciated, the skin has
an ashy-yellowish color, while those affected with fibroids preserve
for many years a florid hue and are in fairly good health. The
lymphatic glands corresponding to the part affected with cancer
become swollen. Ascites is more common with cancer, and a bloody
ascitic fluid is nearly always associated with malignant disease. A
sloughing fibroid polypus may resemble an epitheliomatous growth
of the cervix, but the microscopical examination shows an entirely
different structure.
A fibroid polypus is distinguished from a glandular by its hardness.
It may not be possible to differentiate it from a fibrinous polypus
until it has been removed and examined microscopically, but the fact
that the trouble has begun after childbirth or abortion would make it
likely to be the fibrinous variety.
A fibroid in the posterior wall may from the vagina feel like a
retroflexion, but by bimanual examination the fundus may be felt
turned forward, or the direction of the uterine canal may be ascer-
tained with the sound, and the greater thickness of the same between
the sound and the posterior fornix of the vagina may be felt. A
fibroid in the anterior wall may be taken for an anteflexion, but the
diagnosis is made by judging of the thickness of the wall between the
sound and the anterior fornix of the vagina.
A uterus bicornis may be taken for a single uterus with a fibroid,
but the contour is more regular, the consistency normal, and the sound
can be introduced into both horns.
In regard to the often difficult and very important differential dia-
gnosis between polypus and inversion of the uterus the reader is
referred to what has been said above (p. 463).
Another diagnostic feature of the utmost importance is the distinc-
tion between a sessile fibroid and pregnancy. As a rule, menstruation
stops in the latter, while in the former it goes on, or is even increased
in regard to the amount of the secreted blood and the duration of the
476 DISEASES OF WOMEN.
discharge. The development of the swelling is regular and more
rapid in pregnancy. Softening of the cervix and lower uterine
segment, fluctuation, ballottement, and recognizable parts of the fetus
are felt. The fetal heart may be heard, and fetal movements both
felt and heard. The mammary and stomachal signs of pregnancy are
not found in connection with fibroids. In hydramnion we have
besides the history of pregnancy an open cervical canal, through
which the ovum can be touched.
Fibroid tumors may be combined with pregnancy, and the detection
of such a condition may be of great practical importance in regard to
treatment. A suspicion of such a condition should always be awak-
ened by hemorrhages during pregnancy. The sound is, of course, not
available. The physician must rely on the history, the stethoscope,
and a careful palpation.
A small subperitoneal fibroid may form a tumor somewhat like that
formed by swollen appendages adherent to the uterus, but, as a rule,
the latter swelling will be softer and much more tender, and the ute-
rine cavity is not enlarged. Accompanying peritonitis may, however,
make a fibroid quite tender, and, on the other hand, old inflammatory
masses around the appendages may form a very hard tumor.
Before making any diagnosis of abdominal tumors the physician
should be sure to have the bowels well emptied with aperients and
enemata, and the urine drawn with a catheter. Otherwise he might
be deceived by seybala or a full bladder.
A pedunculated subperitoneal fibroid may be so like a solid ovarian
tumor that the distinction becomes impossible, and the same holds
good in regard to the diagnosis between a fibro-cyst and a multilocular
ovarian cyst. In trying to differentiate them the following points
should be considered. Fibro-cysts are rather rare ; ovarian cysts very
common. Fibro-cysts are hardly found in women below thirty-five
years of age ; ovarian cysts are frequent in young persons. Fibro-
cysts develop more slowly. Patients with fibro-cysts preserve long a
good general health and have a florid face, while in those with a mul-
tilocular ovarian cyst the constitution soon suffers. With a fibro-cyst
the abdominal veins rarely become dilated ; with an ovarian cyst it is
quite common. Hard masses are felt above the fibro-cyst ; in ovarian
cysts they are found nearer the base if at all. A fibro-cyst draws the
uterus up ; an ovarian cyst pushes it down and backward or forward.
With a "fibro-cyst the uterine cavity becomes often considerably
elongated; with an ovarian cyst it remains of normal length or is
only slightly deepened. By means of the sound it may be possible
to move the uterus independently of an ovarian tumor, while a
fibro-cyst follows the movements of the uterus. Ascites is more com-
monly found with fibro-cysts than with ovarian cysts. Now-a-days
we avoid aspiration and tapping, but if for some reason one of these
DISEASES OF THE UTERUS. 477
operations has been resorted to, coagulability of the fluid and the
presence of muscle-cells in it militate strongly in favor of a fibre-cyst,
while the presence of numerous small round bodies with several
shining granules speaks as strongly in favor of an ovarian cyst. 1
Fibro-cysts of the uterus can only be distinguished from fibro-cysts
of the ovary by the circumstance that the former move with the uterus,
while the latter may be movable independently. The fluid is
identical.
In plain ascites there is a swollen, fluctuating abdomen, but no
tumor. In ascites combined with a fibroid the tumor is felt on dis-
placing the fluid. Hematocele and exudative peritonitis are acute
diseases with a sudden start.
Prognosis. The majority of fibroids give rise to no symptoms and
are harmless. They are in themselves benign, but may endanger life
in different ways. After the menopause their development is, as a
rule, arrested ; they begin to shrink and the patient suffers less ; but,
on the other hand, the change of life is often postponed in women
affected with fibroids, and some fibroids continue growing, pursue a
more disastrous course than before, and frequently become cystic,
calcareous, or have abscesses develop in them. 2 A spontaneous cure
may occasionally be effected by involution after pregnancy or expul-
sion of a polypus.
Hemorrhage rarely becomes directly fatal, but through the repeated
losses of blood and the drain caused by leucorrhea the constitution
finally suffers. Pain, worry, and disturbed sleep have a similar effect.
Mechanically, the tumor may cause death by closing the ureters or the
intestine. The heart suffers in consequence of the increased work
thrown upon it. Large tumors press on lungs and liver, interfering
with respiration and digestion.
The tumor itself has some tendency to sarcomatous or carcinomatous
degeneration. The peritoneum becomes the seat of chronic inflam-
mation, and sometimes palpillomatous degeneration.
In rare cases a fibroid becomes the cause of embolism and paralysis.
For the treatment of these tumors sometimes operations are required
that belong to the most difficult and most hazardous.
Treatment. In treating a case of fibroid tumor of the uterus the
therapeutical resources at our command should, in the opinion of the
writer, be considered in the following order :
Cut off polypi ;
Tie and cut pedunculated subperitoneal tumors ;
Lift tumor ;
Hemostatic and anticatarrhal remedies ;
1 Exceptions are treated of in my above-named wock on Ovarian Cyst*, pp. 63-i>7.
* Joseph Taber Johnson of Washington, D. C., "Growth of Fibroids after the
Menopause," Amer. Jour. Obst., Dec., 1891, vol. xxiv., p. 1420.
478 DISEASES OF WOMEN.
Galvauo-chemical cauterization ;
Curetting ;
Vaginal enucleation ;
Oophorectomy ;
Ligation of ovarian and uterine arteries ;
Total extirpation of uterus ;
Supravaginal amputation
(a) with retroperitoneal treatment of pedicle ;
(6) with extraperitoneal fixation of the stump ;
Abdominal euucleation
(a) from broad ligament ;
(6) from pelvic floor;
(c) from uterine W 7 all.
For a polypus there is no other treatment than to remove it as soon
as possible. If it lies in the vagina, this is a very simple matter.
The anesthetized patient is placed in the dorsal position, the legs fast-
ened with Robb's leg-holder (p. 197), the vagina disinfected, the tumor
brought into view with speculum and retractors, the cervix dilated
with a steel dilator, the tumor seized with a volsella and pulled down,
while an assistant presses on the fundus uteri. If the tumor is not
very small, a better hold of it is secured by passing the noose of a
linen tape around it above the volsella. If necessary, the tape may be
pushed up by means of a crutch, an instrument exactly like a uterine
sound ending in a little fork (Fig. 263). This loop allows us to pull
FIG. 263.
Tape-carrier.
the polypus considerably down, and its pedicle is cut off with a few
rotary movements of Thomas's spoon-saw (Fig. 264), a shallow spoon
FIG. 264.
Thomas's Spoon-saw.
with dull serrated margin. 1 The pedicle may be cut near the tumor,
and it is safer to do so. Subsequently the stump is drawn into the
substance of the uterus and disappears.
1 Many instrument-makers make it too hollow and with too sharp teeth, which
changes it from a safe and valuable instrument into a dangerous one.
DISEASES OF THE UTERUS. 479
If the polypus is situated in the interior of the yet closed uterus,
the cervix must first be dilated with aseptic laminaria (p. 154) or
iodoformed cotton balls (p. 156). If it spring from the fundus, a pair
of strongly curved scissors may be needed for removing it (Fig. 265).
FIG. 265.
Bozeman's Double-curved Scissors.
An intermittent polypus should be removed during menstruation,
when it can be seized in the vagina.
Very large polypi may be brought out, after the pedicle is severed,
by means of the obstetric forceps. Wedge-shaped pieces may be cut
out of the lower part of the tumor in order to make it smaller, a pro-
cedure called morcellation ; or a spiral incision may be carried around
it, right into its substance, while it is being pulled down, which is
called allongement.
As there often are other fibroids imbedded in the uterine wall, which
in course of time become pedunculate, the operation may have to be
repeated, although it is radical in regard to the tumor it is applied to.
Subperitoneal tumors can only be reached by laparotomy (see Ova-
riotomy). If they have a well-developed pedicle, it should be trans-
fixed, and a double silk ligature of proportionate strength drawn
through and cut into two halves, which are made to cross one another
so as to form two interlocked loops, each of which is tied on opposite
sides (Fig. 260). The object in dealing with the pedicle in this way
is to prevent the ligature from slipping, which may cause fatal hem-
orrhage.
Great relief from pressure on rectum, bladder, or nerves, or from
pulling on ligaments, may be afforded by lifting the tumor up, and
sometimes it may be prevented from falling down again by a pessary,
such as a large-sized Gehrung's (Fig. 246, p. 436) or Thomas's (Fig.
244, p. 435), or an abdominal belt with vaginal cup (Fig. 253,
p. 456).
Medical Treatment. Alone or as an adjuvant to other measures
medicinal treatment is of considerable value in combating symptoms,
and may even occasionally effect a radical cure. The chief symptoms
that call for medicinal treatment are hemorrhage and leucorrhea, and
we refer to what has been said on this subject in the general part
480 DISEASES OF WOMEN.
under Hemostaties (p. 227), Menorrhagia (p. 245), and Leucorrhea
(p. 251). The writer would particularly call attention to the value
of gossypium for combating hemorrhage and pain. Ergot may be
given by the mouth, in suppositories (extr. ergotae, gr. ij v in each,
one, two, or three times a day), or hypodermically. For the latter
purpose ergotin (gr. ij or iij) or sclerotinic acid (gr. f) is preferred.
Some years ago, before the Apostoli treatment was introduced, I
used such injections and saw good effect from them. The formula was
U. Acidi sclerotinici, gr. x ;
Glycerini, 3ss;
Aq. dest. q. s. ad sij.
M. Sig. Eight minims hypodermically.
The injections are made in the abdominal wall in front of the tumor,
and they should be very deep. The syringe must be clean and the
skin made aseptic. By so doing I have never seen an abscess form,
but each injection is accompanied by considerable pain, redness, and
swelling, and leaves a knob slow to disappear. The injections were
repeated three times a week. This treatment has afforded so good
results in the hands of many observers besides myself, leading even
in some cases to the total disappearance of the tumor, that under
circumstances it is well worth trying. As a rule, the method is safe.
Too large doses of ergot have, however, caused symptoms of pois-
oning; and a case has been reported in which the tumor became
gangrenous, and the patient died of septicemia. 1
Instead of sclerotinic acid, ergotin (gr. iij pro dosi) may be used
dissolved in five parts of water :
!$$. Ergotini (Squibb), 3ss;
Aq. dest., 3jjss ;
Acid, carbol., TTLij.
M. Sig. Eighteen minims for each injection.
To inject ergot preparations into the substance of the uterus is dan-
gerous and offers no advantage.
Among mineral waters, Kreutznach, used both internally and in
fomentations and baths, has the best reputation for its effect on
fibroids.
With the exception of polypi, pedunculate subperitoneal fibroids
and fibrocysts, most other fibroids should, if possible, be treated with
galvano-e.hemical cauterization after Apostoli's method (p. 233). In
cases of hemorrhage and leucorrhea the positive pole is used in the
uterus ; in more dry cases the negative. If the electrode can be intro-
duced into the canal, there is hardly any danger. I allow even the
patient to go home by street-car and elevated railroads immediately
1 W. T. Lusk, N. Y. Med. Jour., July, 1882, vol. xxxvi. p. 30.
DISEASES OF THE UTERUS. 481
after the application, which I prefer to make in the office, where more
perfect apparatus is available. The first effect is to assuage pain,
which gains the patient's confidence. In the vast majority of cases
the tumor will become smaller, and in some it disappears. Hemor-
rhage will nearly always cease. The softer the tumor is that is to
say, the less connective tissue and the more serum are contained in
the muscular bundles the better are the prospects. In some cases
I have seen parts of the tumor gradually pushed out, so as to
form prominences in the peritoneal cavity. The method is compara-
tively safe and promises so much, and, on the other hand, the cutting
operations are so dangerous, that, as a rule, electricity should be given
a fair trial before resorting to the latter. 1 The method is, however,
not devoid of danger. Sometimes local peritonitis may follow the
application, and some uteri are so distorted by the fibroids they con-
tain that some places of the wall may become very thin. If it should
happen that the intra-uterine electrode were applied to such a place,
the cauterization might go through the whole thickness of the wall.
Many patients, however, cannot get the tedious galvanic treatment,
and, moreover, the experience of later years has shown that by ope-
rating early the prognosis for the operation like that for ovariotomy
has become much better.
Hemorrhage may be checked by curetting (p. 176). Perhaps, it
only gives relief for some months, but may then be repeated. By
thus scraping off the hypertrophied endometrium the patient may
sometimes be kept alive until the menopause arrives and brings per-
manent relief. 2 Properly performed, the operation is, as a rule, harm-
less; the writer has, however, had a case in which it was followed
by gangrene. 3
Vaginal Enucleation by Means of the Spoon-saw. Large sessile
myomas, weighing up to three pounds, 4 have been successfully re-
moved through the vagina. The method is applicable to both cervical
and corporeal fibroids. The patient is placed in Sims's position, and
his largest speculum is introduced. If the cervix is partially open,
and the tumor offers a free end near it, the cervix is seized with a
1 Thomas Keith, who, at a time, was by far more successful than all contempora-
neous operators, who had a mortality of only 8 per cent, in hysterectomy, and only
lost 1 patient in almost 100 cases of oophorectomy for uterine fibroma, rejects even
the minor operation in favor of Apostoli's method (" Contributions to the Surgical
Treatment of Tumors of the abdomen, Part II.," Electricity in the Treatment of Ute-
rine Tumors, Edinburgh, 1889, p. viii.). Only when the galvanic treatment fails does
he perform hysterectomy (Gyn. Trans., 1890, vol. xv. p. 143).
2 An instructive paper on this subject was published by Henry C. Coe in The Med-
ical Record, Jan. 28, 1888.
3 The patient recovered, and was radically cured, but another time the result might
be less favorable. I scraped away what I could with the finger, tore dead shreds off
with forceps, and used carbolized intrauterine and vaginal injections.
4 Thomas, Amer. Jour. Med. Sc., April, 1880, vol. Ixxix. p. 405 ; Munde", Amer. Jour.
Obst., 1885, vol. xviii. p. 189.
31
482 DISEASES OF WOMEN.
tenaculum-forceps and severed bilaterally up to the vaginal vault. A
volsella is fixed in the lower end of the growth, and the uterine
attachments severed with the spoon-saw. The cavity should next be
washed out with disinfectant fluid and packed with iodoform gauze
(p. 180).
If the cervix is open and the tumor entirely imbedded in the wall
of the body or situated in the cervix, a strong tenaculum is plunged
into it, and a hole is cut with scissors in the lowest part of the pre-
senting mucous membrane covering the tumor. This is extended on
a director, the mucous membrane detached with the finger, a vol-
sella fastened in the white tissue of the myoma, and the spoon-saw
introduced and swept all around, detaching the tumor from its uterine
bed for about an inch and a half or two inches, while traction is
kept up. If the tumor is too large to be dragged down as a whole, it
is removed piecemeal. For this purpose pieces large as hen's eggs
are cut out, one after the other, from the detached part of the tumor.
Then the tumor is again seized with the volsella, a new zone de-
tached and removed piecemeal in the same way, and so forth until
the remainder can be removed with the spoon-saw in one piece. It
is only the first incision that is accompanied by serious hemorrhage ;
the tumor itself has few vessels, and the spoon-saw with its blunt
serrated edge peels it out from its bed without much bleeding.
If the cervix is closed, it must be thoroughly dilated before enu-
cleation is begun. For this purpose it is split up to the vaginal
junction with Kiichenmeister's scissors, and the internal os incised
bilaterally with Simpson's metrotome (p. 423), until all resistance is
overcome, and finally full dilatation is obtained by using tents or
cotton balls impregnated with iodoform, procedures which take days
and weeks, and during which I more than once have seen the
patients succumb to septicemia.
Greater than the danger from hemorrhage is that of perforating the
uterus. It is impossible to know if the tumor has more than a peri-
toneal covering. At all events, the spoon-saw must be kept close up
to the tumor. In pulling the uterus down it may become inverted
(p. 466), and the inverted part must be replaced as soon as the fibroid
is enucleated. The danger from septicemia after the operation is also
considerable. In fact, the dangers are so great that this method can-
not be recommended for entirely imbedded tumors, but for partially
polypoid fibroids I think it is less dangerous than oophorectomy and
hysterectomy, and unlike them it preserves the possibility of impreg-
nation.
In exceptional cases, the fibroid starting from the posterior surface
of the uterus presses against the vagina, and may be enucleated through
an incision there.
Emmet's Traction Method is, in some respects, like the preceding
DISEASES OF THE UTERUS. 483
method of enucleation, but the capsule is never opened, and all is done
in the vagina, not in the interior of the uterus. The tumor is seized
with a volsella, pulled down, and removed piecemeal as it emerges
from the os. In this way muscular contraction is induced, and the
surrounding tissue gradually closes upon the removed tumor, so that
it becomes pedunculate and leaves only a small raw surface.
Oophorectomy. With the hope of bringing about the menopause
prematurely, and diminishing the size of the tumor, the ovaries and
tubes may be removed. The first part of this operation consists in
laparotomy, which will be described under Ovariotomy. In regard
to the next part, the removal of the ovaries, the reader is referred to
Diseases of the Tubes. If the tumor is a large one, it may be very
difficult to reach the ovaries. The uterus must not be tilted out
of the abdominal cavity, as it may suddenly become so congested
that it cannot be replaced. It may, however, be advantageously
turned on its longitudinal axis. But the ovaries may be so im-
bedded in adhesions and inflammatory masses that it proves impossi-
ble to remove them. Gangrene of the myoma has followed the
removal of the ovaries. If the cavity of the uterus measures over
six inches, there is little hope that the operation will be of avail.
On account of hemorrhage it is not safe to tear adhesions which
cannot be brought into view.
Oophorectomy for fibroids is practised much less now than some
years ago, hysterectomy having become much less dangerous than it
was at that period.
If it is impossible to remove the ovaries, or if the patient is so
weak that she cannot stand the greater operations, the menopause may
perhaps yet be brought about by tying the ovarian blood-vessels, or,
better, all six arteries supplying the uterus with blood. 1
Hysterectomy, or complete extirpation of the uterv^, may be per-
formed through the vagina vaginal hysterectomy or through the
abdominal wall abdominal hysterectomy or by both ways combined
vagino-abdominal hysterectomy.
Vaginal hysterectomy" may be performed with pressure-.forceps, liga-
tures, or without either.
Modus Operandi. Clamp Method. The patient lies on her bade,
the legs held up with a suitable leg-holder (p. 197). The lower end
of the table is raised about four inches. The genitals having been
shaved and disinfected, and the vagina disinfected (p. 196), Garrigues'
self-retaining weight speculum (Fig. 177, p. 211) is introduced, and
1 C. C. Frederick of Buffalo reports good results, especially enormous shrinkage of
the uterus, by tying both uterine arteries, either from the vagina or after laparotomy
(Amer. Jour. Obst., Sept., 1895, vol. xxxii. p. 348). Rydygier, who was the first to pro-
pose this treatment, publishes, however, a case in which he tied all six arteries, and
yet hemorrhage returned after ten months (Centralbl. f. Gyndk., 1894, vol. xviii. p.
297).
484
DISEASES OF WOMEN.
depresses the posterior wall of the vulva and vagina, or this is done
with a univalve speculum held by an assistant (Fig. 266, 6). The
anterior wall is held up with a short, broad, univalve speculum (Fig.
266, a). The cervix is seized laterally with a bullet-forceps, and dilated.
The uterus is curetted and wiped with sterilized gauze wound around
a pair of forceps. Next, a four-pronged traction-forceps (Fig. 181, p.
212) is inserted in the middle of the posterior lip and another oppo-
site to it in the anterior lip. With these the cervix is moved up and
down so as to show the utero- vaginal junction. The cervix is then
drawn forward toward the symphysis, exposing the posterior cul-de-
sac well. A transverse incision is made with a scalpel, at the utero-
vaginal junction, about an inch above the end of the vaginal portion.
FIG. 266.
Segond's Speculum : a, anterior blade ; 6, posterior blade.
Next, the cervix is drawn back and a similar incision is made in
front, just below the bladder, about half an inch above the end of
the vaginal portion. This is carried round the cervix till it merges
in the posterior incision, the two forming one circular incision close
up to the cervix. Next, a longitudinal incision, two-thirds of an
inch long, is made on both sides corresponding to the transverse
diameter of the os, and carried through the mucous membrane so as
to unite at right angles with the circular incision. This enables the
operator to make a larger anterior flap and carry the bladder and
ureters well out of the way. It is used in all vaginal hysterectomies
in which the cervix is small or the uterus large. Once the incisions
made, the operator pulls steadily down on the cervical volsella3, cut-
DISEASES OF THE UTERUS. 485
ting with small nicks of scissors and using the nails of his thumb
and forefinger as much as possible. Behind, the peritoneal cavity is
soon reached, and the opening is enlarged by pulling the peritoneum
apart from side to side with the two forefingers, while the posterior
speculum is temporarily removed. This posterior opening is large
enough to admit two or three fingers. In front the operator proceeds
in a similar way, exposing as much of the uterus as he can and with-
out paying any attention to the peritoneum. On the sides he can
push up the parametria almost without cutting until he is near the
broad ligament. No retractor should ever be inserted between the
bladder and the uterus, as it draws the ureters together and might
wound them or the bladder. The retractor should only be held flat
against the mons Veneris, at right angles to the uterus, and push the
bladder up.
So far no attention whatsoever is paid to hemostasis, but when the
operator has proceeded in front as far as he can and on the sides is
nearly through the parametriuni, he places a pair of strong hemostatic
forceps (Fig. 267) on the lower part of the broad ligament, including
FIG. 267.
Long Pressure-forceps.
the uterine artery. The forceps is put on in a peculiar way. The
operator holds it close up to the cervix, holds the open jaws in front
and behind the uterus and moves the point outward, describing part
of a circle, by which he is sure to push the bladder and ureter out of
the way, before he clamps the artery. Next, he closes the forceps
just outside the uterus and cuts with scissors the tissue close up to
the clamps and near up to their end, which makes the uterus much
more mobile. The posterior speculum is then removed for good. The
anterior wall of the uterus is pulled down. As soon as feasible the
uterus is anteflexed and the fundus brought into the wound, for which
purpose, as a rule, the uterus is incised or pieces cut out of it, which
procedure presently will be described. The adnexa are pulled out
into the wound, if necessary after loosening adhesions with two fingers
introduced into the pelvis. This is the only step that is done by feel-
ing alone; otherwise all is done in the wound under the control of the
486 DISEASES OF WOMEN.
eye. When the appendages of the left side are brought out, a pair
of hemostatic forceps are placed from above over the broad ligament,
outside of the appendages, and brought in contact with the forceps com-
pressing the lower part of the same. This compresses the ovarian vessels.
The uterus is then cut loose on this side, and .the broad ligament of
the other side is clamped and cut in a similar way. If there is any
bleeding from the cut surface, another clamp is placed outside of the
first and this one removed. Thus, in a typical case, only four clamps
will be left in the vagina, but if needed more are added. When the
uterus has been removed, the operator should look carefully for any
bleeding. For this purpose a pair of Plan's long narrow retractors
are introduced, one in front aud one behind, by means of which a
view is obtained deep into the abdominal cavity, so that even the
appendix vermiformis of the caecum may become visible. These
retractors are much like Schroeder's (Fig. 178, p. 212), but longer
and broader, the blade measuring five by one and a quarter inches.
In searching for bleeding points, real sponges as large as hens' eggs,
on account of their great porosity, are preferable to gauze pads.
When all bleeding points have been secured, the wound is tamponed
with long strips of dry sterilized gauze. Each strip is a quarter of a
yard wide and several yards long. It is folded in several layers
lengthwise, so as to be about two inches wide, and this pad is again
folded transversely in zigzag at the top, and carried in just beyond
the jaws of the clamps. If there is any suppuration, iodoform gauze is
used instead of sterilized gauze. The vagina is packed loosely out-
side of the handles of the clamps with iodoform gauze. For safety's
sake the rings of each forceps may be tied together separately. The
handles are surrounded with absorbent cotton held together with a
string. A self-retaining soft-rubber catheter (Fig. 268) is left in the
FIG. 268.
Petzer's Self-retaining Soft-rubber Catheter : a, bulb ; 6, flange.
bladder and closed with a small pressure- forceps. It is introduced
by entering a uterine sound through the central opening of the bulb
A, and pressing it up against a point in the periphery. The bladder
is emptied every two hours.
The clamps as well as the surrounding dressing are removed forty-
eight hours after the operation. If there is no fever, the pelvic tam-
pon is left in for six or eight days. It becomes very offensive, but
is removed more easily than at an earlier date. If the patient be-
comes feverish, the packing is removed at once.
DISEASES OF THE UTERUS.
487
If the omeutum sinks down, cither during the operation or after
removal of the tampon, it must be pushed high up with a sponge or
pad on a holder so as to prevent its agglutination to the wound.
If the intestine is adherent, a reasonable amount of adhesive tissue
should be left on it to go off by suppuration.
The tampons are removed gradually by pulling down and cutting
off a piece every day. 1
Ligature Method. If we want to use ligatures, the two transverse
incisions in the vagina are not united, but a bridge, half an inch wide
and two-thirds of an inch long, is left on each side of the cervix.
The posterior cul-de-sac is opened as described above. As soon as
the peritoneum of the utero-vesical pouch is reached, it is incised and
torn from side to side, so that we have one opening behind and one
in front of the uterus.
The parametrium on the left side is surrounded with a strong liga-
ture carried with a half-blunt, handled needle, bent to the side (Fig.
269), or with Folk's hinged needle (Fig. 270), a curved, blunt needle,
FIG. 269.
Schroeder's Needle.
with the eye near the point and a movable joint which is fixed by a
button on the side. 2 After having cut the tissue between the ligature
FIG. 270.
Folk's Needle : A, movable needle ; B, B, the needle brought backward and forward ; C,
button for stopping movement.
and the uterus, another ligature is carried over the tissue situated
above that comprised in the first ligature. Next, similar ligatures are
placed on the right parametrium, which is also cut. Then we return
1 The operation here described is in all essentials that of Dr. Paul Segond of
Paris, an adherent of Pean.
2 W. M. Polk, Amer. Jour. Obst., 1887, vol. xx. p. 294.
488 DISEASES OF WOMEN.
to the left side, tying and cutting until the whole broad ligament has
been tied in small portions, which, when tightened, ought not to exceed
the thickness of a lead pencil. The application of the upper liga-
tures is very much facilitated by throwing a strong silk thread over
the ligament by means of J. B. Hunter's needle, which is constructed
on the principles of Bellocq's tube for plugging the posterior nares.
If possible, the tube and ovary should be drawn inside of the upper-
most ligature, or they may be tied separately and removed.
When the left side of the uterus is free, the right broad ligament
with the appendages becomes much more easy to handle, and is se-
cured with a few ligatures passed from above downward.
In regard to the material to be used for the ligatures tastes diifer.
If silk is used, the threads should be left long, and pulled out when
they become loose. If catgut is used, which is just as well in other
respects, it is cut short, and is expelled together with the tissue form-
ing the button of the ligature during the healing process.
If there is hemorrhage from the cut surface of the parametrium
behind or in front of the cervix, it may be checked by uniting the
edge of the peritoneum with that of the mucous membrane of the
vagina. If there is still any bleeding from the depth, it may be
checked by means of a Mikulicz tampon (p. 181). Otherwise the
opening at the top of the vagina and the vagina itself are only packed
loosely with iodoform gauze.
Some go a step farther and close the whole wound, drawing the
stumps of the broad ligaments into the vagina. This makes recovery
speedier, avoids the disagreeable odor of decaying tissue, and prevents
prolapse of the vagina, but makes the operation more difficult and
tedious.
Comparison between Ligatures and Forceps. Whether a surgeon
will prefer ligatures or forceps depends often more on personal predi-
lection and aptitude than on anything else. Forceps may be applied
at a depth where ligatures cannot be applied and where there is not
tissue enough to form a button. The application takes less time, and
is perfectly safe unless impatient and reckless operators remove the
forceps too soon. If, however, a serious hemorrhage occurs after the
vagina is partially filled with forceps, it may be very difficult to check
it. The removal of forceps and of the pelvic packing is very pain-
ful. Great care must be taken to avoid pressure-necrosis of the vulva
from forceps. In certain operations, such as those for large fibroids
and for extensive pelvic inflammation, forceps alone are available.
Often it is an advantage to combine both methods, and not to bind
one's self stubbornly to either of them. Especially, it is sometimes
an advantage to use ligatures for the easily accessible parametria,
which leaves more room for the following manipulations of the uterus
and ligaments. It has been contended that unless the vaginal wall
DISEASES OF THE UTERUS.
489
is stitched to the broad ligaments, and unless the vagina is brought
well up toward the peritoneum, prolapsus of the vagina invariably
follows. 1 This is not borne out by the writer's experience, nor does
it seeni possible that such an event can be of frequent occurrence
without having been noticed by those who have reported hundreds
of cases.
Morcellation. If the uterus is too large to be removed in one piece,
at least with preservation of its shape, recourse may be had to morcel-
lation. In its simplest form this operation consists in an incision in
the median line through the whole thickness of the anterior wall,
extending more or less to the fundus, whereby the organ becomes
already much more mobile. Another way is to excise a wedge-shaped
FIG. 271.
Morcellation of Fibroid Tumors of Large Size (Pean).
piece of the anterior wall or to make two incisions, diverging from
below upward, and remove the intermediate tissue piecemeal. Often
it is an advantage to begin by removing the cervix. In cases of
1 Joseph Eastman. Indianapolis, Ind., Amer. Jour. Obst., Feb., 1895, vol. xxxi. p.
214.
490 DISEASES OF WOMEN.
retroflexion the posterior wall is attacked in similar ways instead of
the anterior. Some divide the uterus into an anterior and posterior
flap, which are amputated and thus give better access to the fundus.
Others divide the whole uterus into two halves in the median line, cut-
ting first the anterior \yall, then, after having anteflexed the uterus,
the fundus, and, finally, the posterior wall. Tumors may also be cut
out from the inside of the uterus with long straight or curved knives
and scissors, and pulled out with forceps with teeth like N6laton's
cyst-forceps (see Ovariotomy and Fig. 271).
In all these operations the uterine arteries are first secured, and, if
possible, the broad ligaments too, but often this is impossible, and
hemostasis is then obtained provisionally by pulling the uterus down
all the time, and often by everting the fuudus and thus twisting the
broad ligaments ; besides that the uterine tissue itself does not bleed
much.
Before cutting off any piece of the uterus a good hold on the
remainder must be secured with a bullet-forceps or a four-pronged
(Fig. 181, p. 212) or eight-pronged traction-forceps. Another prin-
ciple is only to cut what can be seen, and to see or feel all tissue that
is being ligated or clamped, so as to be sure of not including the
intestine in the part grasped. With large tumors the principle is to
remove as much as poasible of the tumors, and' deal with the uterus
subsequently. In all cases the uterine cavity should be disinfected.
While a moderate morcellation is easy to perform and very helpful,
it need hardly be said that the last described procedures are dangerous
and require great dexterity. 1
Limits of Vaginal Hysterectomy. P6an removes all uterine fibroids
by the vaginal method, if the fundus is below or even a little above
the umbilicus. In most operators' hands it will probably be safer to
prefer the abdominal section when the uterus is larger than a normal
fetal head at the end of gestation.
Vaginal Hysterectomy without Ligature or Pressure-forceps. The
uterus and the appendages may be removed without securing a single
vessel. This is based on the anatomical fact that the trunks of the
large arteries, the uterine and the ovarian, are situated in the broad
ligaments at some distance from the uterus, tubes, and ovaries, and
only send small branches into these organs. In regard to the uterus
the writer has found and showed in medical societies that each branch
of the uterine artery has a very fine bore and a very thick muscular
coat, so that the very severance of the little vessels makes its thick
muscular wall contract. If, however, a few arteries spurt, they are
seized separately and tied. The advantage claimed for this method
is that we avoid compressing nerves, which we do in using ligatures
1 Details about morcellation may be found in an article by Edgar Garceau, in
Amer. Jour. Obst., March, 1895, vol. xxxi. pp. 305-346.
DISEASES OF THE UTERUS. 491
or forceps. The operation is feasible, but less safe than the other
methods. 1
The writer has successfully removed the uterus in this way in cases
in which the appendages had been removed before, but a case ending
fatally from hemorrhage has been mentioned in a society meeting in
this city.
The opening left at the top of the vagina by hysterectomy closes
by granulation in the course of three weeks. The patient may be
allowed to get up at the end of the second week. As soon as the
wound canal is shut off from the abdominal cavity by granulation,
vaginal antiseptic injections may be used. There is often formed
some wild flesh which does not heal, and may keep up a discharge
indefinitely. These granulations ought to be scraped off with a sharp
curette and the wound touched with lunar caustic.
Vagino-abdominal Hysterectomy. Modus Operandi. 1 . JBarden-
heuer's Method? A circular incision is made around the cervical por-
tion, and the vaginal wall separated from the cervix. A tampon of
iodoform gauze is left in the vagina. Next, laparotomy is performed
with the patient in Trendelenburg's position (p. 138). The incision
will extend from the symphysis pubis to the umbilicus or still farther.
In so doing most operators go to the left of the umbilicus, but Keith
used to go right through it. A corkscrew is bored into the uterus, by
which it is more easily tilted out through the wound and manipulated
later. If the tumor is not very large, the fundus may be seized with a
strong volsella instead of using a corkscrew. After turning out the
uterus the edges of the abdominal incision above it are held together
and covered with a flat sponge or pad. With large tumors extending
far beyond the umbilicus the writer has found it advantageous to in-
sert four sutures through the whole thickness of the abdominal wall
before turning out the uterus, and tie them after it is done and before
commencing the removal of the uterus. The infundibulo-pelvic liga-
ment, including the ovarian arteries, is tied, a long pressure-forceps
(Fig. 267) placed 1 inside of the ligature, nearer the uterus, and the
intervening tissue cut. Then the remaining part of the broad liga-
ments is tied in one portion, and cut loose, the ligatures bein^r passed
with Schroeder's (Fig. 269) or Folk's needle (Fig. 270). Next, a
transverse incision is made a finger-breadth above the bottom of the
vesico-uterine pouch and the bladder separated from the cervix. A
similar incision behind, in Douglas's pouch, separates the rectum from
1 It is an old operation, having been performed as early as 1822, revived in our
days by Dr. E. H. Pratt of Chicago. Jour. Orificial Surg., June, 1894; Geo. Engel-
mann, "History of Vaginal Hysterectomy," Amer. Jour. Obst., Feb., 1895, vol. xxxi.
p. 295.
2 I call it so for brevity's sake. The chief features are Bardenheuer's, and de-
scribed with histories of cases as early as 1881 in his work Die Drainirung <ler Peri-
t&nealhohle, but minor improvements by others are included in the description.
492 DISEASES OF WOMEN.
the uterus, which now hangs only by a band on either side of the cervix,
containing the uterine arteries. Finally, these bands are tied and cut.
On the side first cut the incision should be made between two liga-
tures on account of the anastomosis with the other side. On the other
side only one ligature is needed.
If the tissue containing the uterine arteries can be reached and tied
before opening the pouches in front of and behind the uterus, the
uterus may be cut off at the level of the internal os, which sometimes
facilitates the removal of the cervix.
A piece of iodoform gauze left in the opening serves to prevent
prolapse of the intestines and provides for free drainage. The last
act of the operation is to close the abdominal wound and dress it in
the usual way (see Ovariotomy). A similar antiseptic pad is laid
over the vulva and anus, and fastened with safety-pins to the bandage
surrounding the body.
After-treatment. The abdominal dressing is left undisturbed for a
week, and later changed as after all other laparotomies. The gauze
tampon in the vagina is changed after two days, and a new one put
in once a day. After the first four days the vagina is washed out, at
the time of dressing, with antiseptic fluid. The wound in the vagina
closes in the third week after the operation.
2. Jacobs' method is also a vagino-abdominal method, but is ex-
clusively performed with pressure-forceps. It is only used for large
tumors. Jacobs uses a posterior weight-speculum and two lateral
retractors. The transverse incisions behind and in front of the cervix
are made with a curved thermo-cautery, leaving a bridge of mucous
membrane, half an inch wide, on either side between the two incisions.
When the posterior and anterior culs-de-sac have been opened into the
abdominal cavity and stretched from side to side with the forefingers,
a pressure-forceps is placed on each lateral parametrium and the tissue
cut between the forceps and the cervix. The vagina is then packed
loosely with iodoform gauze, and the patient placed in a level dorsal
position with the head turned to the light. Having opened the abdo-
men in the median line and turned out the uterus, the operator places
a hemostatic forceps just outside of the left appendage, slanting it
down toward the cervix, and another inside of the appendage, close
up to the uterus, and cuts on the inside of the outer forceps. Next,
he places another hemostatic forceps on the lower part of the broad
ligament, securing all tissue between the forceps above and the one
in the vagina, and another close up to the uterus, and cuts inside of
the outer. The same is repeated on the right side. Having removed
the uterus, he places from the vagina hemostatic forceps just 'outside
of the four placed through the abdominal wall, which he takes off, and
cuts away the tissue grasped by them, so as to come close up to the
forceps introduced from the vagina. Then the abdomen is closed, the
DISEASES OF THE UTERUS. 493
patient again turned with the vagina toward the light, and her knees
bent. A long strip of sterilized gauze, two and a half inches wide
and three yards long, boiled for five minutes in glycerin, is packed
into the pelvis above all the forceps. The vagina is packed loosely
all around the instruments with iodoform gauze, and the handles are
surrounded by a mass of absorbent cotton, and the self-holding cath-
eter introduced as described above. The clamps and vaginal dressing
are removed on the third day, the pelvic tampon on the fourth. This
latter is not renewed, while the vagina is packed loosely every day.
The bowels are moved on the fourth day.
Abdominal Hysterectomy. Martin's Method. The whole uterus
with the cervix is removed through the abdominal incision. The
peritoneum is stitched to the vagina. The stumps of the broad liga-
ments are turned into the vagina by means of the ligatures, which are
left long, and finally the peritoneum is brought together with another
continuous suture above the first, so that the pelvic cavity is closed
and covered all over with peritoneum.
Comparison between the Vaginal and the Abdominal Section. When
the vaginal method is feasible, it should be preferred. Many patients
hate to have a large cicatrix on their abdomen on account of its un-
sightliness ; in which respect, however, the operator can do much by
skill and patience in uniting the wound after laparotomy. If we use
tier-sutures, most of them can be placed subcutaneously. Only thin
silk or silkworm-gut sutures are then required on the skin. They
nee.d not go far out to the sides from the edges of the incision. If
aseptic when inserted and removed in time, they will not cause sup-
puration. Finally, the cutaneous sutures may be avoided altogether
by uniting the edges by the subcuticular suture.
This method, invented by Henry O. Marcy of Boston, consists in
carrying the suture only through subcutaneous tissue and the edge of
the skin without perforating the epidermis. An absorbable suture
catgut or kangaroo tendon is introduced through the skin a quarter
FIG. 272.
Subcuticular Suture (Marcy).
of an inch from the end of the incision, carried in the subcutaneous
tissue close up to the skin, in a direction parallel to the edge of the
wound for about half an inch, then brought out at the edge of the skin
and inserted in the other edge right opposite to the point of exit. Here
it is carried subcutaneously in a similar way, crossing from side to side,
at right angles, and finally brought out through the skin a quarter of
494 DISEASES OF WOMEN.
an inch from the end of the wound (Fig. 272). By pulling on the
two ends the edges of the wound are brought into contact. Next, the
wound is dusted with iodoform, and covered with a layer of iodoform
collodion, in which the ends of the suture are fastened. The collo-
dion is strengthened by a few fibers of absorbent cotton, and the whole
covered with a soft cotton pad. 1 The same stitch may be used with
a silkworm-gut suture, the ends of which are tied together over a pad
of iodoform gauze covering the wound, and which is removed when
the wound is healed.
Halsted unites the edges with interrupted sutures of very fine silk.
These sutures do not perforate the epidermis, and when tied they be-
come buried. They are taken from the under side of the skin and
made to include only the deeper layers, those which are not occupied
by sebaceous follicles. The idea is to avoid the pyogenic organisms
present on the surface of the skin and in the follicles. 2
Another and more serious objection to the cicatrice is that it may
yield in the course of time and give rise to a ventral hernia. This
danger is much smaller in the vaginal section on account of the small-
ness of the wound and the thickness of the cicatricial plug in case it
is allowed to heal by granulation. There is much less shock in the
vaginal operation, which is chiefly due to the fact that the intestine is
not handled. The patient need not stay so long in bed as after lap-
arotorny, and the after-treatment is simpler.
On the other hand, the vaginal method is more difficult on
account of the smaller dimensions of the field. Adhesions are
more difficult to separate or cannot be reached at all. Hemorrhage
is more difficult to check. The bladder and the intestine are more
exposed to injury, and if such an accident occurs, it is more dif-
ficult or impossible to repair the injury. The pelvis cannot be ex-
plored so easily for concomitant disease, and the abdomen not at all.
There is usually somewhat higher temperature the first few days after
the vaginal operation, and in most of the methods there is more or less
dead tissue to be thrown oif, during which time it gives rise to an
offensive smell.
Special Difficulties. The bladder may be spread out and adhere to the
front of the tumor. This condition may sometimes be diagnosticated
before the operation by means of a male urethral sound. If so, the in-
cision through the abdominal wall should be made above the upper
limit of the bladder, the contour of the organ made out by the sound, an
incision made corresponding to it, and the bladder dissected off from
the tumor, using as much as possible blunt instruments and the fingers.
1 Henry O. Marcy of Boston, "The Surgical Treatment of Inguinal Hernia,"
Trans. N. Y. State Med. Association, vol. xi., 1894, reprint, p. 12; "The Animal Su-
ture," Trans. Amer. Assoc. of Obstetricians and Gynecologists, 1889, reprint, p. 24.
2 Wm. S. Halsted, Johns Hopkins Hospital Bulletin, 1889, vol. i. p. 13.
DISEASES OF THE UTERUS. 495
In order to avoid wounding the bladder, it is advisable not to
empty it entirely before the operation, but even to inject water into it.
If the bladder has been wounded, it may be disposed of in two
ways : either the wound is closed separately with a catgut tier-suture
(p. 221), or in closing the abdominal wall the whole wall of the blad-
der is included in the stitches. In the first case, the mucous mem-
brane is first closed by one row of sutures, and the remaining tissue is
brought together by one or two rows. For the peritoneum it is well
to use Lembert's intestinal suture.
If in the second case a urinary fistula forms, it closes spontane-
ously. A permanent catheter should be left in the bladder or the
urine drawn frequently.
If there is a persistent urachus, it may be avoided by making the
incision through the abdominal wall at the side of it. If it has been
wounded, the wound may be closed by comprising it in one of the
abdominal sutures.
On the side of the cervix great care must be taken not to comprise
the ureter in a ligature.
The omentum is often attached to the tumor. If the adhesion is
slight, the separation is best made by brushing the omentum away
from the tumor with a sponge squeezed dry. If it is tough, it must
be cut between one or more sets of double ligatures.
Sometimes the intestine is found intimately adherent to the tumor.
If it cannot be peeled off", an incision is made on the tumor, through
the peritoneum around the adhesion, and the peritoneum dissected
off from the tumor and left in connection with the intestine. Next,
FIG. 273.
Method of Closing Peritoneal Flap left on intestine, after separating it from uterine fibroid
(Schroeder) : I, intestine ; P, peritoneal coat of fibroid ; S, catgut suture.
the raw surface is folded together by means of one or more catgut
sutures (Fig. 273).
In order to overcome the difficulties presented by the mere weight
496 DISEASES OF WOMEN.
of large solid abdominal tumors of any kind, and by the assistant who
lifts it being in the way of the operator, Reverdin has invented a
particular lifting apparatus. A pulley is fastened to a beam in the
ceiling of the operating-room above the table. Over it moves a thick
cord, to the lower end of which is attached a metal chain dividing
into two smaller chains, each ending in a hook. These hooks are
inserted into the rings of a strong volsella, with which the tumor is
seized. An assistant, standing at a distance, out of the way of the
operator, raises the tumor on command by pulling on the cord. To
the chain is fastened a ring or hook, through which the free end of
the cord is drawn, so that the assistant is enabled also to pull the
tumor to the side.
Supravaginal Amputation of the Uterus. In this operation the
cervix or a small part of it is left and forms a stump. There are two
chief varieties, with intra-abdominal and with extra-abdominal treat-
ment of the pedicle.
1. Intra-abdominal, Retro-peritoneal Treatment of the Pedicle.
The unquestioned victory won in ovariotomy by the intra-peritoneal
treatment over its rival constantly has impelled surgeons to apply the
same principle to the amputation of the uterus ; but special difficulties
are met with in the contractility of the pedicle and the danger of in-
fection taking place through the cervical canal unfavorable circum-
stances which, however, to a great extent, have been obviated in dif-
ferent ways.
Modus Operandi. A silk ligature is carried round the infundibulo-
pelvic ligament on one side and tied, thereby securing the ovarian ves-
sels. In order to prevent slipping, the ligature is passed a little below
the free edge of the ligament. One of the ends of this ligature is
then carried through the lower part of the broad ligament, near the
uterus and just above the uterine artery. When this has been tied a
third ligature is applied to the upper part of the broad ligament, in-
side of the appendage, which prevent bleeding from the anastomosis
between the ovarian and uterine arteries.
Next, the broad ligament is cut down to the level of the lowest
point of transfixion.
The same is done on the other side.
Then a superficial incision is made through the peritoneum, unit-
ing the lower ends of the two previous incisions of the broad ligament
in front and behind. It is made about a finger-breadth above the
bottom of the vesico-uterine pouch, and is carried in a curved line,
the convexity of which points upward, over the anterior surface of
the uterus. The lower edge is seized with a tissue-forcepsj and an
anterior peritoneal flap containing the bladder and the ureters is sepa-
rated from the uterus by means of the handle of the scalpel. A sim-
ilar flap having been dissected off from the posterior surface of the
DISEASES OF THE UTERUS. 497
Uterus, one end of the ligature on the broad ligament is carried under
the uterine artery, tied and cut short. The same is repeated on the
other side. Then the uterus is cut away on a level with the internal
os, and the cervical canal is touched with undiluted carbolic acid.
Finally, the peritoneal flaps are united over the cervical stump by a
running suture of catgut, which also covers the raw surface of the
broad ligament. The advantage of using a single ligature on the
broad ligament is that it puckers up the end of the ligament and carries
it down alongside of the cervix, so that the raw surface is very easily
covered by the peritoneal flaps. 1
If the fibrous tissue extends into the cervix, this may be elongated
by constant traction made upon the pedicle by the assistant who is
holding the tumor, so that the uterus may be amputated at a lower
level, leaving a cupped surface. Separate fibrous nodules may be
enucleated from the stump.
2. Extra-abdominal Treatment of the Pedicle (Hegar's Method).
When the uterus is turned out, an elastic ligature is thrown around
the cervix, including the broad ligaments. Only in exceptional cases,
if the tension is too great or the mass too voluminous, are the liga-
ments tied first and cut between two rows of ligatures. An elastic
ligature a piece of rubber tubing as thick as the little finger, or a
solid rubber string three-sixteenths or a quarter of an inch thick is
turned twice around the cervix, drawn very tight, and crossed once.
Then the ends are seized in front of the crossing between the blades
of a pressure-forceps, and tied together with a silk ligature behind the
forceps. When this is tied, the ends of the elastic ligatures are pulled
out a little more, and a second silk ligature is placed at some little dis-
tance behind the first, and all ends of rubber and silk ligatures are
cut short.
Another way of securing the elastic ligature is to have an assistant
lay the silk ligature on the top of the first half hitch of the knot at
right angles to the elastic ligature : next, to tie this with a second
hitch ; and, finally, to tie the silk ligature across this second crossing
of the elastic ligature.
Next, the uterus is cut off one and a half to two inches above the
elastic ligature, and the peritoneal covering of the stump stitched
with a fine curved needle and a continuous catgut suture to the peri-
toneum near the lower end of the abdominal incision, under the liga-
ture, so as to close the peritoneal cavity. The remaining peritoneal
edges are stitched together, and the abdominal wound closed as in
other laparotomies, leaving a circular furrow formed of the receding
1 James R. Goffe of New York, Amer. Jour. Obst., 1890, vol. xxiii. No. 4, p. 372 ;
ibid., Aug., 1895, vol. xxxii. p. 180; Chrobak of Vienna, Centralbl. f. Gynak., 1891,
vol. xv. p. 715; Besselmann, ibid., p. 939; B. F. Baer of Philadelphia, Amer. Jour.
Obst., Oct., 1892, vol. xxvi. p. 489.
32
498 DISEASES OF WOMEN.
muscular, fascial, adipose, and cutaneous layers of the abdominal
wall.
The stump of the uterus is transfixed with a pair of steel pins
crossing one another at right angles above the ligature. Small caps
are pushed over the points in order to protect the skin. The cut
surface and the cervical canal are seared with Paquelin's cautery, and
covered, as well as the surrounding furrow, with a mixture of 3 parts
of tannin with 1 part of salicylic acid. Finally, the whole is dressed
as after a common laparotomy, and the dressing need not be changed
for eight or ten days, when the sutures are removed.
It is not rare that a bloody discharge from the vagina appeal's three
or four days after the operation. It is without importance.
The stump falls off after fifteen to twenty days, leaving a deep
funnel-shaped depression, the necrosis extending beyond the elastic
ligature. This funnel is dressed with iodoform gauze, which is
changed daily until the surface is healed.
In leaving the above-described furrow free between the pedicle and
the abdominal wall, except the peritoneum, a great source of infection
and death has been eliminated, but, on the other hand, a weak point
is left in the abdominal wall, and it is necessary for the patient to
wear an abdominal belt.
If the ovaries are left behind, it happens occasionally that the men-
strual flow continues through the pedicle.
This method is not applicable to tumors that have not risen up
from the pelvic into the abdominal cavity ; it entails a tedious conva-
lescence ; and it exposes the patient to ventral hernia ; but it is expe-
ditious and convenient in dealing with very large tumors.
Comparison between Total Extirpation and Sup)avaginal Amputa-
tion of the Uterus. For the treatment of fibroids, in which the cervix,
or at least the lowest part of it, is healthy supravaginal amputation
is preferable to the total extirpation. There is hardly any hemorrhage,
while in the total extirpation, at least when the whole operation is
performed from above, there is often toward the end of the operation
a troublesome hemorrhage from an artery hard to find and to secure at
the bottom of the deep wound. The supravaginal amputation is easier
and can be performed in less time. The stumps of the broad ligaments
and the roof of the vagina hold one another, so that there is no danger
of prolapse of the vagina, as in certain methods of total extirpation, nor
any danger of vaginal hernia (p. 334), which occasionally has been
observed after total extirpation. The vagina retains its depth, while
sometimes it is shortened in the rival operation.
There are numerous modifications of these myoma-operations upon
which the scope of this work does not allow us to enter.
Abdominal Enudeation. A fibroid may be enucleated, that is to
say, separated from the surrounding tissue and removed, from the
DISEASES OF THE UTERUS. 499
broad ligaments, from the pelvic floor, or from the substance of the
uterus.
A. Enucleation from the Broad Ligaments. If possible, it is a pre-
caution against bleeding to tie the ovarian and uterine arteries. But
even without this a transverse incision is made through the peritoneum
over the whole tumor. The peritoneum is stripped back with the
finger, and a volsella inserted into the tumor, which is pulled up-
ward. As a rule, the tumor is enucleated without a pedicle ; in other
cases the tube or the substance of the uterus forms one, which is tied
and cut. The enucleation should be performed from above downward
and from the wall of the pelvis toward the uterus, so as to avoid the
ureter and have the uterine artery in the pedicle if there is one.
A large cavity is left, that may be dealt with in different ways.
1. A. Martin's method is to perforate the bottom so as to enter the
vagina with a forceps which is pushed through to the vulva. Here
a seft-rubber T-shaped drainage-tube is seized, and pulled up till the
transverse bar lies in the bed of the tumor. Then the peritoneum is
stitched together.
2. Fritsch's method is to cut off redundant tissue, stitch the edge of
the pouch to the edges of the abdominal wound, and fill the pouch
with iodoform gauze disposed like a fan, which serves both to check
hemorrhage and to secure drainage.
Another way of packing the iodoform gauze is that of Mikulicz :
a large piece of gauze with a strong silk thread attached to the
middle is introduced into the cavity to be compressed, and is filled
with strips of gauze like a bag. After a day the interior strips are
withdrawn, and finally the outer piece is removed by pulling on the
silk thread.
If it is not possible to stitch the sac to the abdominal wall, it is
stuffed with iodoform gauze, the peritoneum closed over it with a
tobacco-pouch suture, an incision made in the vagina, and the end of
the gauze, which has been marked beforehand by attaching a silk
thread to it, pulled a little down into the vagina. In both cases the
vagina is solidly tamponed with iodoform gauze.
3. A third method (Hofmeier's) is to stop hemorrhage by stitching
the bleeding places with a continuous catgut suture, and let the
walls of the wound fall together. Sometimes it suffices to touch the
bleeding spots with Monsel's solution.
It is also advisable to throw an elastic ligature around the cervix
as soon as feasible, or around the lower part of the tumor, so that a
part of it may be cut off, which facilitates the removal of the remain-
der (so-called morcellation).
B. Enucleation from the pelvic floor, under the broad ligament, is
still more difficult and dangerous. It is carried out according to the
same principles as for intraligamentous tumors.
500 DISEASES OF WOMEN.
C. Enucleation from the Uterus. When a fibroid is shelled out of
the body of the uterus, a capsule is left, the walls of which are hard
to bring together with sutures. The results have been so little satis-
factory that other operations are preferred.
Small tumors springing from the cervix or the lower uterine seg-
ment can sometimes be enucleated from the vagina, either by posterior
colpotomy, as in the first step of vaginal hysterectomy (p. 483), or by
anterior colpotomy, as described in treating of vaginal hysteropexy
(p. 450).
Complication with Pregnancy. Fortunately, most women with
fibroids are sterile, and if they conceive, their pregnancy quite fre-
quently ends in abortion or in premature labor. Labor at term may
be easy, but oftener the fibroid proves a dangerous complication. If
we are consulted as to the advisability for a woman afflicted with a
fibroid of the uterus to contract marriage, it is, as a rule, best to dis-
suade her from it. Pregnancy having occurred, it is in harmony with
nature's own method to induce abortion or premature labor, if the
tumor is situated in such a place or has such proportions that great
trouble may be anticipated by allowing gravidity to go on till full
term.
To perform operations during pregnancy will be likely to lead to
abortion. Unless there be urgent symptoms, such as hemorrhage or
pressure, it is better to delay operative interference till labor sets in.
A pedunculated subserous tumor may sometimes be pushed up out of
the way of the child. A cervical tumor may be enucleated, and on
account of the succulence of the womb and the uterine contractions
present,., the enucleation is both easier and safer than under ordinary
circumstances. But if the tumor extends high up, it may be neces-
sary to perform Cesarean section or Porro's operation or to sacrifice
the child.
If the child has been born, it is better to postpone the consideration
of operation, so much more so as we have seen that the tumor may
disappear during involution.
Sloughing. For some gynecologists the appearance of sloughing
in a sessile fibroid is an indication for hysterectomy. Taking into
consideration the unfavorable condition in which that grave operation
would have to be performed, and the case referred to above (p. 481),
I am inclined to think a more palliative treatment is preferable,
especially if septicemia has already developed.
Mortality. In deciding the question of the advisability of per-
forming cutting operations for the removal of fibroids we should bear
in mind that the disease for which they are to be performed rarely
leads to death ; that, as a rule, improvement takes place after the
menopause ; and that, on the other hand, the operation is followed
by a large mortality. Until the last decade euucleation from the cervix
DISEASES OF THE UTERUS. 501
had a mortality of from 15 to 20 per cent. ; hysterectomy, with extra-
peritoneal treatment of the pedicle, 25 per cent. ; with intraperitoneal
treatment of the pedicle, 33 per cent. ; and in cases of extensive enu-
cleation from the broad ligaments and the pelvic floor the death-rate
was even 57 per cent. 1 But constant progress is being made, and sev-
eral operators have of late reported runs of a score of hysterectomies
without a death. It would not do for the average operator and still
less for the beginner to expect results like those of P6an and Tait,
who have reduced their mortality to 1.5 per cent. The mortality
among good American operators ranges now between 5 and 6 per
cent. 2
Causes of Death. Death after fibroma-operations is due to shock,
hemorrhage, septicemia, embolism, intestinal obstruction, ligation of
the ureters, or tetanus.
Shock plays a very great role in operations that often are very pro-
tracted, 3 and in which the abdominal organs are exposed to much
handling. The danger is so much greater as sometimes, in conse-
quence of the presence of the fibroid or its treatment by ergot, the
patient has a weak heart. In order to avoid shock, the patient
should be kept warm during the operation, in which respect the
above-mentioned woollen leggings (p. 197) may be of use. The
operation should be simplified, and performed as rapidly, as possible.
The intestines should not be exposed or handled more than absolutely
necessary, which is much facilitated by the Trendelenburg posture.
Ether should be used for anesthesia. When the heart flags, hypo-
dermic injections of tincture of digitalis or nitro-glycerin (p. 210)
should be given.
Hemorrhage is now controlled much better than formerly by means
of pressure-forceps and the elastic ligature. If the intra-abdominal
treatment of the pedicle is used, internal hemorrhage may take place
after the operation is finished. This dangerous condition makes itself
known by the restlessness of the patient, a weak, frequent pulse,
pallor, a cold, clammy skin, a swelling of the abdomen, and sometimes
1 Complete statistical tables are found in " A Eeview of the Operation of Gastrot-
omy for Myofibroma," by H. E. Bigelow of Washington, D. C., in Amer. Jour. Obzt.,
1883-84. Geo. W. Johnston of Washington, D. C., has collected a large number of
cases of fibromata of the cervix, Amer. Jour. Obst., 1885, vol. xviii. p. 1280. (See also
"Analysis of Some Statistics on Supravaginal Hysterectomy," by Marie B. Werner,
Annals of Gynecology, Oct.. 1892, vol. vi. p. 56.)
2 Chas. P. Noble, Med. and Surg. Reporter, June 2, 1894, publishes the following
table:
Kelly 57 cases 2 deaths.
Baer 57 " 3 "
Polk 40 " 3 "
Noble J14 " _!_ "
Total 168 cases 9 deaths 5.36 per cent.
3 Plan's operations have often taken three hours. (Pe"an et Urdy, "Hyste'roto-
mie," Paris, 1873.)
502 DISEASES OF WOMEN.
a distinct feeling of the warm fluid being poured out into the abdom-
inal cavity. Under such circumstances the only means of rescue is
speedily to reopen the abdomen, clean out the cavity, find the source
of hemorrhage, tie the bleeding vessel or put in additional sutures,
inject a pint of hot water into the rectum or inject a warm saline
solution (common salt a little over J per cent, will do) into a vein,
into the peritoneal cavity, or under the skin. The best place for this
subcutaneous injection is under the clavicle : .liij-vj are injected every
ten or fifteen minutes, until at least xxiv have been injected. For
any of these injections an apparatus which I described in 1878, and
have used several times with success, will be found convenient. It
Garrigues' Transfusion Apparatus : A, plunger ; B, bulb; C, stopcock ; D, flexible probe-
pointed canula ; E, E, valves.
is essentially a fine Davidson syringe 1 (Fig. 274). In the subcu-
taneous injection a hollow needle is substituted for the blunt flexible
canula. Bottles with hot water are applied all around the patient,
the extremities are rubbed, and stimulants are used freely.
Septieemia may be due to the entrance of pathogenic germs during
the operation, to the use of insufficiently disinfected materials, and
to infection from the pedicle, or perhaps even from the intestine. 2
The more bacteriology progresses, the more difficult it seems to guard
against infection.
Thrombosis beginning in the pelvic veins may extend to those of
the thigh, and from the thrombus a piece may be detached and form
an embolus.
Intestinal Obstruction may be brought about by exudation and
adhesions. The means to avoid it are in supravaginal hysterectomy
to lift the intestines up before dropping the pedicle, to avoid as far as
possible leaving raw surfaces in the abdominal cavity, and to move
the bowels early. (See Ovariotomy.) If obstruction sets in, it should
be combated with large injections of lukewarm water from a fountain
1 Garrigues, " Apparatus for Transfusion," Amer. Jour. Obst., October, 1878, vol.
xi. No. 4, p. 754.
2 Welch, "Wound Infection," Amer. Jour. Med. Scl, Nov., 1891, p. 443.
DISEASES OF THE UTERUS. 503
syringe. The enema with ox-gall, described on p. 174, may also be
tried. Lavage of the stomach with a weak solution of salt, sometimes
combined with the administration of castor oil, has proved very effec-
tive. (See Ovariotomy.) If the obstruction remains, the abdomen
must be reopened and the obstacle removed manually.
The ligation of one or both ureters leads to acute hydronephrosis
and vomiting. If thirty-six hours have elapsed since the operation,
there would be little danger of hemorrhage in removing the ligatures
on the uterine arteries, which are likely to be those that include the
ureters. The situation being desperate, it might be worth trying this
heroic remedy.
Tetanus is an exceedingly rare complication, and its treatment is
probably hopeless. An attempt should, however, be made with
bromide of potassium, chloral hydrate, curare, and the new serum-
therapy.
Indications for Operative Interference. Polypi should always be
removed, at least when they become easily accessible. Subperitoneal
fibroids with a thin pedicle should be removed if they annoy the
patient or grow much. Fibro-cystic and suppurating tumors must be
removed. In all other cases Apostoli's treatment should be employed,
and operations only resorted to in those in which it fails or when it
cannot be obtained. When a fibroid grows in spite of medical and
electric treatment, it or the uterus containing it should be removed as
soon as possible.
In regard to fibro-cysts, it may be safer to desist from a total extir-
pation, and only to make a large incision, evacuate the fluid, stitch the
sac to the abdominal wound, and pack it with iodoform gauze. It
will then shrink, and be filled by granulation.
D. Sarcoma.
Under the vague name of cancer are united neoplasms of different
anatomical structure, having this in common, that they undermine
the constitution and sooner or later, in most cases rapidly, lead to
death.
To this group belong sarcoma, carcinoma, malignant adenoma,
the last being only the first stage of some cases of carcinoma, and
certain papillomas.
Sarcoma. Pathological Anatomy. Sarcoma preferably affects the
body of the uterus. In the neck it is very rare. It appears in three
forms the circumscinbed, the diffuse, and the papillary sarcoma. The
circumscribed forms globular tumors like fibroids, and used to be
called recurrent fibroid, because it developed again after extirpation,
which a genuine fibroid never does. Like a fibroid, it may be sub-
mucous, intramural, or subperitoneal, and it may form a polypus.
It has very rarely a capsule. Its consistency is generally soft and
504 DISEASES OF WOMEN.
brain-like, but it may be as dense as a fibroid. It may start from
the mucous membrane, the muscular tissue, or the peritoneum. Often
it has its origin in a myoma.
The diffuse sarcoma starts, as a rule, from the submucous connective
tissue, invades the mucous membrane, and may spread more or less
deeply into the muscular tissue of the uterus or perforate the whole
wall, so as to form a tumor in the abdominal cavity. It is composed
of a whitish or grayish extremely vascular mass.
Most sarcomas have a fasciculated arrangement, bands of fibrous
connective tissue separating groups of cells a disposition which may
even be seen macroscopically by breaking hardened specimens. The
less fibrous tissue they contain, and the more the cells predominate,
the more malignant they are. In younger portions of the growth a
jelly-like amorphous mass is found between the fibrillse which later
disappears. The cells may be spindle-shaped or round. Sometimes
also so-called giant-cells with many nuclei are interspersed among the
others. The sarcomatous tissue is full of enormously dilated capillaries
with very thin walls, which explains the hemorrhages that form so
prominent a feature among the symptoms.
The diffuse sarcoma, as a rule, contains epithelial cells, so that a
transition is made to carcinoma.
In myxo-sarcoma, also called colloid cancer, there is a preponderance
of the intercellular amorphous substance containing muciu, to which
is due its gelatinous consistency.
Papillary sarcoma starts from the vaginal portion of the uterus.
It arises from a hypertrophy of the papilla3 of the mucous membrane,
consists of fusiform or round cells, and has a hydropic intercellular
substance.
Sarcomas may spread to the neighboring organs the vagina, the
bladder, and the abdominal cavity. They may also give rise to
metastatic deposits at distant places, such as the vagina, lymphatic
glands, the connective tissue of the pelvis, the peritoneum, the liver,
the lungs, the pleura, the vertebrae, and the skin.
A sarcoma may become cystic, and is then called cysto-sarcoma. 1
Etiology. The cause of sarcoma is unknown. It is most common
at the climacteric age, between forty and fifty years, but differs from
carcinoma by being found in persons under twenty years of age, so
that it may be called the cancer of youth. It may even be congenital.
It differs likewise from' carcinoma in this respect, that among those
affected, with it many are sterile, while carcinoma is rarely found in
women who have never borne children. It sometimes follows endo-
metritis or develops in a fibroid.
1 I have described and represented in the New York Medical Journal, August, 1 882,
such a case in which the mucous membrane of the uterus was intact, but a large
tumor composed of cysts and solid masses had been developed in the abdomen.
DISEASES OF THE UTERUS. 505
Symptoms. In the beginning the symptoms hardly differ from those
of fibroid tumors namely, menorrhagia, metrorrhagia, leucorrhea,
hydrorrhea, and pain. The uterus may be enlarged and nodular, and
may become inverted. But the growth is a rapid one. There is soon
established a continuous sero-sanguinolent discharge with offensive
smell. The patient becomes emaciated, exsanguinated, and weak, and
has an ashy color a complex of symptoms called cachexia. The
cervix often becomes dilated. Pieces of a soft brain-like mass may be
expelled from the interior of the womb. The pain may be due to
pressure or to the nature of the disease. Sometimes it is expulsive in
character. The finger introduced after dilatation of the cervix feels
the soft mass in the wall of the uterus.
Diagnosis. The diagnosis of sarcoma is by no means always an
easy matter. An intramural sarcoma offers the same symptoms as a
fibroid similarly situated. The sarcomatous degeneration of the
mucous membrane is somewhat more characteristic by the rapid dis-
integration that takes place and the speedy development of cachexia.
The appearance of a tumor like a fibroid at the time of the meno-
pause, and its growth after the same, and hemorrhage recurring after
the menopause, must awaken a suspicion of its sarcomatous nature.
A sero-sanguinolent discharge, the softness of the tumor, which
often allows the finger to penetrate it or break pieces off from it, a
more agonizing pain, and the rapid emaciation and cachexia, are all
characteristic of sarcoma. In regard to softness, we must, however,
remember that it is likewise found in a gangrenous fibroid.
From hyperplastie endometritis it is differentiated by greater tender-
ness of the body, by the often open cervical canal, by sometimes
forming a polypus that hangs out through the cervix, by the appear-
ance of cachexia, and by the spontaneous expulsion of torn-off pieces
of the tumor, which never takes place in endometritis. Particles ob-
tained by curetting, on the other hand, are deceptive : a sarcoma may
furnish a specimen exclusively composed of healthy mucous mem-
brane, while in endometritis the curette may bring away granulation
tissue that looks entirely like small round-cell sarcoma. The clinical
diagnosis is, therefore, more reliable than the microscopical, but one
may corroborate the other, and sometimes the presence of large cells
separated by intercellular basis substance is conclusive.
As long as the epithelial cells of the utricular glands either origi-
nal or of new formation are unchanged, the diagnosis of chronic
endometritis is admissible, whatever the nature of the interstitial
tissue be. As soon, on the contrary, as the regular arrangement of
the epithelial cells is broken up, and they give way to sarcomatous
tissue, the diagnosis of sarcoma can be made. 1
When a w f hole tumor is removed, its nature may be settled by the
1 L. Heitzmann, Amer. Jour. Obst., 1887, vol. xx. pp. 906, 907.
506 DISEASES OF WOMEN.
microscope; and if it is reproduced in the same place or forms
metastases, its sarcomatous nature is proved.
In this connection it must, however, be remembered that endome-
tritis may produce new fungoid growths after curetting, and that
another myoma may develop in another place after one has been re-
moved.
The differentiation from carcinoma of the body may be impossible,
and, as we have seen above, the two are frequently mixed in the
diffuse form. The discharge in sarcoma is less fetid ; ulceration does
not appear so soon ; extension to the neighborhood is slower, and
sarcoma may form a polypus emerging from the os, which carcinoma
never does.
Prognosis. The prognosis is bad. The disease ends in death, on
an average, in about three years, sometimes as rapidly as four months,
and very exceptionally as late as ten years.
Treatment. On account of the immense danger to health and life,
the best treatment, when once the diagnosis is certain, is to perform
the total extirpation of the uterus, either by the vaginal, the abdom-
inal, or the combined method (pp. 483-496). Morcellation should
not be thought of, on account of the danger of infecting the neighbor-
ing tissue during the operation. Even if the cervix is healthy the
whole organ should be removed.
Since the development of sarcoma is slower and does not implicate
the surrounding parts so soon as carcinoma does, the operation is
oftener indicated than in the latter disease, and the prognosis as to
complete recovery is considerably better.
A polypoid sarcoma may be cut off and the base cauterized. If a
radical operation is impossible, a palliative treatment, similar to that
for carcinoma, especially curetting followed by cauterization with the
thermo- or galvano-cautery or nitric acid, and the application of
diluted liquor ferri chloridi (1 to 10 parts of water), should be insti-
tuted.
In handling sarcomas great care should be taken to avoid mechan-
ical infection of yet healthy parts.
Decidual Sarcoma. Of late several cases have been described of
sarcoma of the uterus which appeared shortly after abortion or child-
birth. The tumors were composed of large decidual cells imbedded
in a mesh work of connective tissue, forming pseudo-alveoli a"nd con-
taining nuclei and giant-cells. The affection caused increase in size
of the uterus, hemorrhage, putrid discharge, metastatic deposits in the
iliac. fossae, the lungs, and other organs; and ended in death in the
course of from six to seven months.
If the diagnosis is made early enough, complete ablation of the
uterus is the only rational treatment, and has been performed success-
fully.
DISEASES OF THE UTERUS.
507
E. Carcinoma.
Carcinoma (Fig. 275) is a neoplasm composed of epithelial cells
often grouped in alveoli formed of connective tissue, with a tendency
to invade neighboring organs and undermine the constitution.
FIG. 275.
Cervical Carcinoma of Uterus extending into Body : l a, body of uterus ; 6, cervix ; c, tube ; d,
ovary ; e, bydatid ; /, piece of wood inserted in order to expose the cavity of the uterus.
Pathological Anatomy. Carcinoma is most common in the vaginal
portion of the uterus. Next in frequency is that of the cervix,
while that of the body is comparatively rare. Upon the whole, the
uterus is very frequently aifected in this way, perhaps oftener than
any other organ, the only question being if carcinoma of the breast
occurs as often or oftener.
Carcinoma of the Vaginal Portion begins in that part which is
covered with flat vaginal epithelium. It does not, however, start
directly from the epithelium, but from new-formed glands, and may
dip deep into the muscular tissue of the cervix without attacking the
cervical mucous membrane or the outer circumference. It may also
form a papillary growth which develops in the direction of the
' Specimen from iny vaginal hysterectomy on Mrs. C. C. , St. Mark's Hos-
pital, March 25, 1891.
508 DISEASES OF WOMEN.
vagina, and may become so large as to fill it down to the vaginal
entrance. From its shape this form has derived the name of cauli-
flower excrescence. A third form is that of a flat ulceration, which
has been described under the name of rodent ulcer.
Cervical carcinoma begins as nodules in or under the mucous mem-
brane of the cervical canal, which coalesce and form an ulcer on the
mucous membrane, whence it may spread outward, forming a deep
cavity in the cervix without showing at the os or invading the corpus.
The carcinomatous degeneration may begin in the glands of the mucous
membrane or in the connective tissue.
Carcinoma of the Body may be primary or secondary. The primary
starts from the epithelium of the surface or from the glands. It
appears in a diffuse and a circumscribed form, the latter forming a
tumor, which may become pedunculated so as to form a polypus.
Often the mucous membrane of the body is affected at an early date
in cases of carcinoma of the cervix.
In regard to differences in structure, several varieties of uterine
carcinoma are distinguished : 1, epithelioma, where flat or cuboidal
epithelial cells are arranged concentrically, so as to form so-called can-
cer nests or pearls a form probably only occurring in the cervix ; 2,
adenoid carcinoma, composed of columnar epithelial cells, and cha-
racterized by the presence of tubular formations, with manifold con-
volutions, arranged in groups or alveoli or exhibiting a plexiform
arrangement, the epithelial cells often breaking up into medullary
corpuscles ; 3, medullary carcinoma, where the cellular element pre-
dominates, forming a soft mass ; and 4, scin'hous or Jibrous carcino-
ma, in which there are larger trabeculaB of fibrous connective tissue,
imparting greater hardness to the growth. Of these varieties the
medullary is the one that grows fastest and soonest leads to a fatal
issue.
Carcinoma of the uterus extends to neighboring parts, especially
the vagina, the bladder, the pelvic connective tissue, the tubes and
ovaries, the peritoneum, the rectum, and very rarely the bones of the
pelvis. When ulceration takes place, a vesico-uterine fistula may be
formed, or, more rarely, a rectovaginal fistula. The internal iliac, sacral
and lumbar, or the obturator and inguinal glands become infiltrated ac-
cording to the part of the uterus that is affected (p. 62). Of the above-
named varieties, the epithelioma is least apt to spread to the glands. If
the bones are affected, the growth may enter the hip-joint and dislocate
the femur; the tumor may compress the ureters, causing hydronephrosis.
Compression of an artery may be followed by the formation of an
arterial thrombus, but thrombi are much more commonly found in
the veins of the pelvis and the thighs. They may be due to direct
pressure or be caused by the general marasmus and weak heart-
action.
DISEASES OF THE UTERUS. 509
Secondary carcinoma of the body may attack the uterus by exten-
sion of a primary carcinoma from the bladder, the rectum, the ovary,
or the peritoneum of Douglas's pouch.
Metastases from uterine carcinoma are rare, but have been found
in the liver, the stomach, the lungs, pleurae, kidneys, the peritoneum,
the brain, and other parts.
Etiology. Carcinoma of the uterus is a disease of advanced age.
It is very rarely found below the age of twenty, in which respect
it differs from a sarcoma. It is most common during the first five
years following the menopause. It is much more frequent in the
lower classes than in the higher walks of society, probably because
poor women, as a rule, have more frequent childbirths, because they
are much less cleanly, and because worry and want favor the malig-
nant degeneration.
It is to some extent hereditary, and is frequently found in families
other members of which are tuberculous. Perhaps also syphilis in
ancestors, by giving rise to a deteriorated constitution, may predispose
to it.
Carcinoma of the neck is usually found in women who have borne
a large number of children or had difficult labors. Lacerations of
the cervix (p. 396), with the concomitant eversion, glandular devel-
opment, and erosions, are apt to become the starting-point of it.
Carcinoma of the body, on the other hand, is comparatively com-
mon in nulliparous women. Benign tumors may in the course of
time become carcinomatous.
It has been very generally repeated that while the negro race was
much more liable to fibroma of the uterus than white people, it was
free from carcinoma. The first is denied by a competent judge, and
the latter disproved by the public statistics for fourteen consecutive
years of the city of Charleston, S. C., which shows that there is
hardly any difference between the two races. 1
Symptoms. The first symptom that brings the patient to seek advice
is loss of blood. Often it is only a slight bleeding following coition.
In other cases it is a return of bloody discharge after the menopause.
In others, again, the menstrual flow becomes too abundant or pro-
tracted, or there is loss of blood in 'the intermenstrual period.
Another early symptom is a common leucorrheal discharge streaked
with blood. Sometimes a shooting pain or a dull ache occurs at inter-
vals in the sacral or hypogastric region, or the patient may have
sciatica.
If the carcinoma is developing in the collurn, we in most cases
find a laceration with eversion. The mucous membrane is swollen,
bleeds easily, and contains hard nodules. The cervix is indurated in
its totality, and not only at the angle of the tear, where a cicatricial
1 Middleton Michel, Med. News, Oct. 8, 1892.
510 DISEASES OF WOMEN.
plug (p. 397) is so common an occurrence. At the same time, the
tissue is friable, so that a part may be scraped off with the nail.
Sometimes the uterus is tender on pressure.
In carcinoma of the body there are no other early symptoms than
hemorrhage and leucorrhea.
As the disease progresses these symptoms may become more
marked and new ones are added. The hemorrhage often becomes
profuse. After nlceration has taken place there is at times a profuse
watery discharge with a penetrating, most disagreeable odor, and in
the interval a fetid muco-purulent discharge. The pain becomes
more constant and intense. In carcinoma of the body paroxysms of
expulsive pain are caused by detached pieces of the neoplasm which
cannot pass out through the closed cervix. Finally, the whole body
aches. In other cases the pain may be due to peritonitis or to the
direct affection of the nerves in the uterus. The acrid discharge is
apt to cause pruritus vulvse and excoriations of the skin on the inside
of the thighs.
In some cases different forms of dysuria are present. Cystitis,
causing frequent and painful micturition, is common. If one of
the ureters is compressed or invaded by the new growth, hydrone-
phrosis is developed on the corresponding side. The amount of
urine that is excreted is diminished. The patient complains of pain
in the lumbar region, nausea, and headache. If both ureters become
obstructed, complete anuria sets in, followed by uremic convulsions
and death. In other cases the uremic symptoms become less toward
the end, the obstruction being removed by the extension of the ulcer-
ation.
In regard to the alimentary canal, the patient frequently complains
of a bad taste, thirst, loss of appetite, eructations, nausea, vomiting,
and constipation. The hemorrhoidal veins surrounding the anus
often swell. She loses flesh and strength, and her skin has a peculiar
ashy yellowish hue.
If venous thrombi form in the pelvis and thigh, the corresponding
extremity becomes swollen and unwieldy.
Sometimes the abdomen is swollen, some ascitic fluid may collect,
and the cutaneous veins in the abdominal wall become distended.
Peritonitis is of frequent occurrence. Inflammation of the lungs,
pleura?, and kidneys is less frequent. Sometimes dysentery sets in.
A detached embolus may be driven into the pulmonary artery and
put a sudden stop to the sufferings of the patient. Septicemia is rare,
the inflammatory exudations serving as a barrier against the entrance
of the products of decay into the circulation. The glands in the
groins and in the depth of the pelvis are felt to be enlarged.
By vaginal examination we find the uterus to be immovable. The
vaginal vault is as hard as a board. From the cervix we may find
DISEASES OF THE UTERUS. 511
hanging a soft polypoid tumor, which may fill the whole vagina. It
is friable and bleeds easily. Or the finger enters a crater-shaped
ulceration surrounded by hard walls. Often the infiltration with car-
cinomatous tissue can be felt as hard nodules in the broad ligaments
or as a hard string following the course of the uterine vessels out to
the pelvic wall.
Although cancer undoubtedly is transmissible from one part of the
body to another with the current of the vital juices, there is no evi-
dence that it can be inoculated into another individual, and the great
rarity of carcinoma of the penis compared with the very common
occurrence of the disease in the cervix uteri goes far to show that
the disease is not transmissible by coition.
Diagnosis. A sponge left in the vagina and forgotten has given
rise to such hemorrhage and offensive discharge that it has been taken
for a cancerous growth. An examination with the finger and the
eye and the removal of the foreign body will soon settle that error.
The distinction from erosions may be difficult. A papillary ulcer
surrounded by follicles is likely to be benign. On the other hand,
we find in carcinoma of the cervix a sharp line of demarkatiou be-
tween the diseased and the healthy tissue : the former is elevated, has
a yellowish tint, and contains glistening yellowish-white nodules.
The carcinomatous tissue is more friable than the healthy or simply
inflamed, so that a piece may be broken off with the nail of the exam-
ining finger. The result of treatment as a diagnostic measure is valu-
able : erosions heal in a short time if they are treated with sulphate of
copper or some other astringent (p. 414), whereas carcinoma spreads
in spite of the treatment. Microscopical examination may be entirely
negative, but in many cases it gives positive information in regard to
the malignancy of the tissue. For this purpose a wedge-shaped piece
must be cut out of the cervix, choosing the most affected spot and
going deep enough to include in the excision part of the muscular
tissue. The wound is united by a suture. The operation is so little
painful that general anesthesia is superfluous. A strong solution of
cocaine may, however, be applied to advantage. The excised part
should be hardened, cut, and stained. The diagnosis of carcinoma is
only warranted if atypical epithelial pegs dip into the muscular tissue.
A carcinomatous ulceration must be, and in most cases is easily,
distinguished from the other kinds of ulcers found on the cervix
(p. 424).
Chancroid is an acute affection characterized by sharp edges, a yel-
low bottom, a red halo, and an abundant secretion of pus of a different
odor. Chancre may give rise to doubt, but the history, the presence
of other syphilitic symptoms, the result of an antisyphilitic treatment,
and microscopical examination furnish abundant means of dispel-
ling it.
512 DISEASES OF WOMEN.
Tuberculous ulcers are surrounded by tuberculous nodules ; are, as
a rule, combined with tuberculosis of other parts, especially the lungs ;
and show the characteristic bacillus.
The simple friction ulcer found where the cervix protrudes in front
of the vulva is surrounded by bluish tissue, and heals easily under
proper care. The glands are not affected.
Corroding ulcer l has not so hard surroundings, and can be diagnos-
ticated by means of the microscope, which shows absence of epithelial
proliferation.
Papillary hypertrophy may give rise to small benign growths, but
they have a narrow base ; when seated on a broad base a papillary
growth is carcinomatous.
Carcinoma of the body has to be differentiated from hyperplastic
endometritis, fibroma, and products of conception. In regard to hyper-
plastic endometritis the reader is referred to what has been said above
(p. 411). Here we will only add a few words about the microscopical
examination. The diagnosis of scrapings removed by the curette as
being carcinomatous is only warranted if we meet with encephaloid
masses which show, not a glandular structure, but atypic epithelial
pegs. Fungous endometritis is characterized by the presence of a
varying number of tubular glands, the epithelium of which is un-
broken. The interglandular tissue may be crowded with lymph-
corpuscles, or it may be myxomatous or fibrous in character. 2
A fibroid follows a benign course. It develops very slowly, no
particles are expelled, there is no bad odor, the uterus is freely mov-
able, the patient has no fever, and her constitution does not suffer
except from loss of blood. She may be pale, but she has not the
yellowish color of carcinoma. It is true, a fibroid may slough, and
then there may be high temperature and fetid discharge, but this is
a condition that comes on suddenly, and ends in a short time in death
or recovery.
Pieces of secundines may be retained in the uterus for years and
cause considerable hemorrhage, pain, and leucorrhea. When they
are removed with the curette the microscope clears the diagnosis, and
the patient recovers.
The diagnosis from sarcoma can only be made by a microscopical
examination of expelled, scraped-off, or excised parts. It is in so far
of importance as the prospects for success in a radical operation are
greater in sarcoma than in carcinoma.
If the early recognition of carcinoma may be difficult, in its ad-
1 Corroding ulcer is the term used by Dr. Williams for the one he ascribes to senile
gangrene caused by calcification of the internal iliac arteries, while rodent ulcer is
the old classical name that may yet be retained for very flat ulcerations of the
vaginal portion, which extend very slowly to the sides, and very late dip into the
depth of the cervix, but are microscopically proved to be carcinomatous.
* Louis Heitzman, Amer. Jour. Obst., September, 1887, pi 919.
DISEASES OF THE UTERUS. 513
vanced stage the disease presents so uniform a picture that it is easily
recognized, the most striking features being the hemorrhage, the
offensive watery discharge, the immobility of the uterus, the implica-
tion of neighboring organs, the crater-like ulcer, the large, friable,
soft mass springing from it, the pains, and the cachectic condition.
The ascitic fluid accompanying carcinoma of the body and obtained
by aspiration contains sometimes large round or pear-shaped endo-
thelial cells with large nuclei, either isolated or in groups. This sign
is of some positive value, but not of negative i. e. if these malig-
nant cells and cell-groups are found, it is very likely that the disease
is malignant (carcinoma, sarcoma, or papilloma), but their absence
does not prove anything. 1
Prognosis. The disease is fatal. Even the most radical treatment
effects only quite exceptionally a permanent cure, and it is even
doubtful if, upon the whole, it prolongs life. Under palliative treat-
ment patients affected with carcinoma of the cervix may live three or
four years. When the disease is in the corpus they live rarely more
than one or two.
Treatment. Prophylaxis. Cervix lacerations, if they give rise to
eversion and consequent irritation of the mucous membrane, should
be operated on (p. 399), and endometritis treated as stated above
(pp. 413, 414).
Coe 2 recommends the excision of the cervix in cases of extensive
erosion with general induration, whether cancer has actually developed
or not. He cuts out a cone, the apex of which may be as high as the
os internum, the mucous membrane of the entire canal being removed
with the cone, but leaves the vaginal mucous membrane. He then
introduces a plug of glass or iodoform gauze, and closes the cervix
with deep silver-wire sutures.
Palliative Treatment. By far the greater number of patients do
not come under observation before the disease has spread so much
that a radical treatment, aiming at the complete removal of the
affected part, cannot be instituted with any hope of benefiting the
patient. But very much may be clone to relieve her, prolong her
life, and make her a less objectionable companion for others. The
chief indications are to relieve pain, combat hemorrhage and bad
odor, and keep up the patient's strength.
The disease being fatal, and having only a duration of a few years,
we need not be afraid of making opium-eaters of our patients
(p. 226). There are no other drugs that will relieve the pain of
cancer as opiates do, and the patient should simply have as much of
them as is needed to make her comfortable. In cancer of the cervix
small doses will suffice for a long time, and need only be increased
1 For details see Garrigues' Diagnosis of Ovarian Cyst. pp. 94-97.
2 H. C. Coe, Med. News, Feb. 16, 1889.
33
514 DISEASES OF WOMEN.
very gradually. In the beginning four drops of Magendie's solu-
tion, two or three times a day, are enough, and I have not found it
necessary to go beyond ten or twelve drops three or four times a
day in the later stages. The hypodermic injection is most efficaci-
ous, but for obvious reasons most patients take their morphine by
the mouth. In cancer of the body larger doses are required to dull
the pain.
Moderate hemorrhage may be kept in check by means of injections
with chloride of iron (p. 172). In more profuse hemorrhage, or if
the seat is in the body, curetting (p. 176) is of great value. In
removing large sprouting masses from the cervix I have found
Thomas's spoon-saw (p. 478) a very useful instrument. The patient
is placed in the dorsal or left-side position, Garrigues' weight-speculum
or a Sims speculum is introduced, the tumor is seized with a volsella,
and as much of the friable tissue as possible is removed with the
spoon-saw, followed by Simon's sharp spoon. Jagged edges may be
cut off with curved scissors. Most operators use the thermo- or gal-
vano-cautery as supplemental to curetting in order to arrest hemor-
rhage and destroy infiltrated tissue. Others object to the cautery,
because it destroys the tissue that is not yet affected, and thus hastens
the process of destruction. Whether the cautery be used or not, the
cervix is packed with pledgets wrung out of a solution of chloride of
iron (p. 179), and the vagina with an antiseptic plug (p. 179).
After having removed this tampon the next day, some apply pled-
gets wrung out of a solution of chloride of zinc (^v to distilled water
3j, or, if there is a wall more than a quarter of an inch thick around
the cancerous tissue, even equal parts). The vagina is protected by a
tampon of cotton balls wrung out of a solution of bicarbonate of
soda (1 part to 2 of water), which is left in for two or three days.
If the zinc pledgets do not come off easily, they are left for a day or
two longer. This treatment produces a thick slough, leaving a vel-
vety surface, and is followed by considerable contraction. It may
even effect a permanent cure, but is not quite safe, since the action of
the caustic may involve healthy tissue or the cancerous degeneration
go deeper than anticipated.
Some substitute excision with knife and scissors for curetting as the
first step in the chloride-of-zinc treatment, cutting out a cone from
the vaginal junction to the internal os. During the separation of the
slough and cicatrization disinfectant injections are used.
Nobody should undertake curetting for a large cancerous mass
without being prepared to ligate the uterine artery from the vagina
(p. 182), or even to extirpate the uterus if necessary. 1
1 I did so in a case in which I had refused to perform the radical operation on
account of infiltration of the broad ligament on one side. The curetting entailed a
large opening in Douglas's pouch. I then performed vaginal hysterectomy. The
DISEASES OF THE UTERUS. 515
It is also recommended to scrape off all diseased tissue and dress
the wound with a saturated solution of soda.
Hemostatic drugs are not of much avail. Gossypium (p. 227),
however, is useful as an adjuvant.
Injections with creolin (p. 173) are very valuable, both as a hemo-
static and an antiseptic. The odor of the drug itself is by no means
disagreeable. Still more astringent is liqu. ferr. chloridi (p. 172).
Permanganate of potassium (enough to give the water a dark purple
color) has no odor at all, but stains the linen. . Peroxide of hydrogen
has neither odor nor color, and has a high disinfecting power. Small
tampons dipped in terebene and olive oil, equal parts, may be left in
place for two or three days. Equal parts of iodoform and charcoal
applied as a powder on the ulcer relieves pain, cleanses the ulcer, and
combats the odor, but has a smell of its own that to many persons is
objectionable. All these benefits may also be derived from the daily
application of the odorless aristol. Suppositories with chloral and
tannin (da gr. xv 5ss) combat hemorrhage, pain, and odor.
Occasionally the use of a styptic tampon (p. 179) may become
necessary.
For carcinoma of the body Vulliet's dilatation (p. 156), followed
by curetting and chloride of zinc, may be used. Simple curetting,
although less exact and powerful, is also very useful ; repeated
every three to six months, it prolongs life considerably.
In using tonics the reader should remember the warning (p. 228)
against giving iron when there is any hemorrhage.
So far, no drug has been found that will cure cancer, although from
time to time some new specific is praised even by good observers.
Some years ago it was condurango-bark ; then came Chian turpen-
tine ; next methyl blue enjoyed a short-lived celebrity. I have not
seen any effect from the use of these substances ; but since others have
claimed success, and since we must sometimes prescribe something, I
add the following formulae :
fy. Extr. condurango, fl. ss ;
Aqu., ad Sviij. M.
Sig. A tablespoonful four times a day.
1^. Extr. condurango, Iss;
Vaselini, iss. M.
Sig. To be applied daily on tampons to the ulcerated surface.
1^. Terebinthinse Chiensis, 3ss:
Sulphuris sublimati, siiss ;
Had. glycyrrhizse, q. s.
Ft. pil. No. c.
Sig. Three pills every four hours.
patient made an excellent primary recovery, but the cancer, of course, continued
-developing.
516 DISEASES OF WOMEN.
To those who cannot swallow pills it may be given as an emulsion
with mucilage, a yolk of an egg, syrup, and sherry wine.
Methyl blue is given in doses of 3 to 4 grains, once or twice a day,
in capsules, by the mouth, or by the rectum. It is also injected into
the tumor (fllxx to 3) of a solution of 1 part to 300 parts of water),
or the ulcer is covered with it in substance. As it stains every-
thing, it is a disagreeable stuff to handle and to take.
Injections of one-eighth of a grain of bichloride of mercury into
the tissue retard the extension of the disease and clean ulcers, prob-
ably by obliterating lymph-vessels and killing some microbe :
1^. Hydrarg. chloridi corros., gr. iij ;
Sodii chloridi, 3j ;
Aq. destill., 3j.
M. S. 20 minims for parenchymatous injection, three times a
week. 1
Radical Treatment. Although some of the heretofore-mentioned
methods have been claimed to have effected a complete and perma-
nent cure of cancer, we restrict the term " radical " to methods in
which a cure is sought by surgical operations in the healthy tissue
surrounding the diseased part. In this connection we have to con-
sider the supravaginal amputation of the cervix, and total extirpa-
tion of the uterus.
The high cervix amputation (Schroeder's method) has been described
on p. 428. It is not an easy operation, exposes to the danger of con-
siderable hemorrhage, and is less rational than the total extirpation
of the uterus, since we have seen that cervical carcinoma often is
combined with a beginning of the same disease in the body of the
womb.
The whole cervix has also been cut out with the thermo-cautery, by
which means hemorrhage is avoided, but neighboring organs may be
implicated.
Thermal galvano-cauterization seems to have given better results,
both in regard to mortality and the length of time before a relapse oc-
curred, than any other method. 2 It is performed with the cautery
loop, the cautery knife, and the dome-shaped burner (p. 235). At
least the whole cervix should be removed. If the uterus is immo-
bile, the supravaginal amputation is made with the cautery knife, not
the loop (Fig. 276), and thorough cauterization of the bottom, sides,
and edges of the excavation is added. 3
The need of a costly instrumentarium and its liability to get out
1 Schramm, Centralbl. f. Gyndk., 1888, vol. xii. p. 213.
2 Statistics of a large personal experience have been published by Pawlik of Vienna
and John Byrne of Brooklyn, N. Y., Gynecol. Trails., 1889, vol. xiv. p. 90. Dr. Byrne's
battery and instruments may be obtained from Mr. Kaysan, 34 Bond St., Brooklyn.
3 John Byrne, Amer. Jour. Obst., Oct., 1895, vol. xxxii. p. 559.
DISEASES OF THE UTERUS.
517
FIG. 276.
of order have undoubtedly prevented this method from becoming
more popular.
The total extirpation, or hysterectomy, may be performed by the
vaginal, abdominal, vagino-abdominal, sacral,
perineal, or perineo-vaginal section.
Vaginal hysterectomy is a German operation
that has met with much opposition in this
country. 1
The bad results are, however, probably due,
in a great measure, to the fact that it has been
undertaken when the disease had progressed too
far. It is contraindicated if the carcinoma is
not strictly confined to the uterus proper. The
uterus should be freely movable, and an exam-
ination under anesthesia should not reveal any
infiltration of the broad ligaments or of the
pelvic glands. But even with these restrictions
relapses, as a rule, come sooner or later, the
probable explanation being that at the time of
the operation there is already an infiltration of
the surrounding parts which cannot be felt. A. Martin has, how-
ever, tried to prove by statistics that the permanent or rather final
results are as good after extirpation of the cancerous uterus as in
operation for cancer in any other part of the body.
Modus Operandi. The operation may be performed with ligatures,
pressure-forceps, thermo-cautery, or galvano-cautery. In order to
FIG. 277.
knif.
Supravaginal Amputation
of Cervix with the gal-
vano-caustic knife.
Bernays' Utero-tractor.
avoid infection of the wound from the cervix or the interior of the
wound the latter should be cleaned with a disinfectant injection and
the former cauterized.
The ligatures and forceps may be used as described for the removal of
the fibroid uterus (pp. 483-488). As the cervix usually is most affected
1 J. Byrne, Gyn. Trans., 1889, vol. xiv. p. 90; ibid., 1892, vol. xvii. p. 3; Baker,
ibid., 1891, vol. xvi. p. 170; Keamy. Oyn. Trans., 1888, vol. xiii. p. 183; Jackson,
Med. News, Jan. 18, 1890; Coe, Amer. Jour. Obst., June, 1890, vol. xxiii. p. 587.
518 DISEASES OF WOMEN.
and offers a bad hold for the traction-forceps, some instrument is
needed that can take hold of the uterus from within. For this pur-
pose Bernays' utero-tractor (Fig. 277), with its series of thick lateral
projections, has proved very satisfactory in my hands. It is intro-
duced closed into the cavity of the body of the uterus, opened, and
traction made with it, in order to make the hooks penetrate the flesh.
The use of pressure-forceps instead of ligatures is often necessary
on account of lack of space, and is by many preferred under all cir-
cumstances. 1
In order to avoid inoculation of cut surfaces with cancer germs,
hysterectomy for carcinoma of the uterus is of late often done with
pressure-forceps and the thermo-cautery so called thermo-cauter-
ectomy of the uterus. First, the cancerous surface is cauterized with
Paquelin's instrument and the vagina disinfected. Next, a trans-
verse incision is made with the cautery just below the bladder, the
latter separated from the uterus with blunt instruments and fingers,
and the wound cleaned with a strong solution of corrosive sublimate
before the peritoneum of the vesico- uterine pouch is severed. Next,
the posterior fornix of the vagina is opened with the thermo-cautery,
and the mucous membrane of the lateral fornix incised with the same.
Pressure-forceps are placed on the parametria and broad ligaments as
described above, and the uterus cut loose with the thermo-cautery. 2
Still better than the thermo-cautery is the galvano-cautery. This
instrument gives off much less radiating heat, so that the neighboring
parts are not so easily injured, and, on the other hand, it seems to exert
a remedial influence on the tissue even at some distance. It is claimed
that this method not only is characterized by absence of fever and
pain, but that the scar shows a particular immunity from reappear-
ance of the disease, and that there is an unusually long period of
exemption before the disease reappears in remote organs. 3
Mackenrodt goes so far as to demand the extirpation of the upper
half or the whole of the vagina in all cases in which the uterus is
being removed on account of carcinoma. The reason is that there is
great suspicion of the vagina being in a state of latent infection, and
there is no means of distinguishing a healthy vagina from one thus
affected. He uses the galvano-cautery. He begins the operation with a
lateral incision with the cautery-knife through the left vaginal wall and
the perineum. Next, he seizes the edge of this incision with a forceps
1 I do not know if it is more than an accident that I lost a patient by tetanus who
had been doing excellently until the ninth day after the extirpation by the clamp
method. Still, it has been surmised that similar occurrences after ovariotomy and
the extraperitoneal treatment of the pedicle after abdominal hysterectomy for fibroids
stood in some relation to the use of clamps and pins. The forceps has also caused
the formation of a fecal fistula.
2 Cenlralbl. f. Oynak., 1895, No. 21, vol. xix. p. 560.
3 John Byrne, Amer. Jour. Obst., Oct., 1895, vol. xxxii. pp. 565, 566.
DISEASES OF THE UTERUS. 519
and dissects it off with the cautery up to the vaginal portion, rolls the
vagina around the forceps, and burns it loose from the vaginal por-
tion, proceeding first toward the rectum, then to the right side, then
to the bladder, and finally back to the starting-line.
If only the upper half of the vagina is to be removed, a circular
incision is made with the cautery between the upper and lower half
through the whole thickness of the vagina, and then the upper half
is removed as described above. 1
This method may, perhaps, be of value in preventing relapse, but
it must entail a tedious convalescence, and lead to atresia or consider-
able stenosis of the genital tract, and can, therefore, not be followed
if the vagina is yet needed as an organ of copulation.
The pelvis and vagina are packed as described above (p. 486).
The pregnant cancerous uterus has repeatedly been successfully re-
moved in the second and third month by vaginal hysterectomy, which
is particularly indicated under these circumstances.
An accident that is not very rare in separating the bladder from the
uterus is the formation of a vesicovaginal fistula. If such a thing
happens, the opening in the bladder should be closed at the end of the
operation, and all precautions taken to insure healing (pp. 367, 369).
If the attempt fails, and spontaneous closure does not occur, and there
is no relapse, the fistula should be closed later.
In order to gain room for the extirpation of the uterus, the peri-
neum and the whole rectovaginal septum has been cut through in the
median line, and healing by first intention has been obtained by
means of silkworm-gut sutures (Winckel).
Sacral Hysterectomy. 1. Kraske's Method. Kraske's operation for
cancer of the rectum has been adapted to the removal of the cancer-
ous uterus. The patient is placed in Sims's position. A curved
incision is made from the iliosacral synchondrosis on the right side
to the tip of the coccyx. Then the gluteus maximus muscle and the
great and lesser sacrosciatic ligaments are detached from the sacrum.
The coccyx is freed all around, and removed, together with the lower
end of the sacrum, by sawing the latter bone through from between
the third and fourth posterior sacral foramina on the right side to
the left cornu. The rectum is loosened and pushed over to the left
side. The peritoneum is incised close to the margin of the rectum,
exposing the posterior surface of the uterus. The ligaments may now
be tied and severed, and the uterus separated from the bladder.
This operation is recommended in cases in which the uterus is large
and the body of the organ fills up the pelvis, or in which the ova-
ries and tubes are the seat of prior disease and are adherent. 2 The
1 Mackenrodt, Ceniralhlf. Gyuak., 1896, vol. xx. No. 5, p. 129.
2 Details may be found in a paper by E. E. Montgomery of Philadelphia in The
Trans, of the Amer. Assoc. of Obstetricians and Gynecologists, 1891.
520 DISEASES OF WOMEN.
mortality is very great, and the wound heals very slowly, and is apt
to leave fistulae.
2. Hegar's Method. Hegar makes on the posterior surface of the
sacrum a V-shaped incision with the base turned upward, cuts muscles
and ligaments on the edges of the bone, detaches the rectum, and cuts
the sacrum with a chain-saw between the third and fourth sacral
foramina in a slanting line, preserving the periosteum on the posterior
side. The end of the sacrum is not detached, but only thrown
upward, and later replaced.
In regard to the whole procedure of sacral hysterectomy it may be
said that a cancerous uterus that cannot be removed by the vagina is
not fit for extirpation.
Perineal Hysterectomy (Zuckerkandl's Method) opens the way to the
uterus by a transverse perineal incision from one tuberosity of the
ischium to the other, and by separating the vagina from the rectum.
Abdominal Hysterectomy (Freund's Method) for carcinoma was at
first attended with such extreme mortality that the operation was uni-
versally abandoned, and was only used as a necessary addition to
vaginal hysterectomy (vagino-abdominal hysterectomy) when difficul-
ties were encountered which could not be overcome in any other way.
Still, by the easy access it gives to all the pelvic organs it is prefer-
able to the sacral and the perineal methods. jAnd the great success
obtained with abdominal hysterectomy for fibroids of the uterus has
brought some operators back to abdominal hysterectomy for cancer
also. It offers the advantage that one can remove more of the broad
ligaments, and thus come farther away from the seat of the disease.
By previous introduction of flexible catheters into the ureters by
Kelly's method (p. 163) these organs may be avoided.
Perineo-vaginal Hysterectomy (KchuchardCs Method). 1 The same
advantages are, however, claimed for the peri neo- vaginal method,
which is particularly adapted to cases in which one of the broad
ligaments is involved in the cancerous degeneration. The patient is
placed in the dorsal position with drawn-up feet. On that side on
which the ligament is affected an incision is made from a point be-
tween the middle and posterior third of the labium majus, encircling
the anus at the distance of two finger-breadths, and ending about the
level of the tip of the coccyx. This incision is deepened, especially
in its anterior part, in the adipose tissue of the ischio-rectal fossa,
until the wall of the vagina is exposed. Next, the whole vaginal
wall is split from below up to the cervix, and after that the operation
is the same as in common vaginal hysterectomy with ligatures cir-
cular incision around the cervix, opening of the pouch of Douglas,
severance of the ligaments, separation of the bladder from the uterus,
only with this difference, as it is claimed, that everything is done
1 Centrcdbl.f. Chirurgie, 1894, No. 30, Beilage, p. 61.
DISEASES OF THE UTERUS. 521
with the greatest ease, and that all ligations are made under the
guidance of the eye. Both ureters can be extensively laid free, and
even diseased parts of the bladder may be cut out. The incisions
are only made on one side, and the wound heals by granulation in
three weeks.
If the uterus is movable and any part of it is cancerous, the whole
organ, in my opinion, should be removed, together with the append-
ages. If it is immobile, a suitable palliative treatment up to extir-
pation of the cervix is indicated.
In order to be able to extirpate cancerous glands from the pelvic
floor it has been advised to ligate the anterior division of the internal
iliac artery, which normally gives off the superior vesical, the vaginal,
the uterine, the obturator, the middle hemorrhoidal, the internal
pudic, and the sciatic arteries, and by the ligation of which the sur-
geon would be enabled to work in a bloodless field. But the internal
iliac artery and its branches are subject to many variations. Frequently
there is no separation into an anterior and a posterior division, or the
anterior division may be so short that it cannot be ligated. It would,
therefore, be necessary to tie the whole trunk of the internal iliac,
which can be done. It lies between the upper end of the sacrum and
the upper end of the great sacro-sciatic notch, and is usually an inch
to an inch and a half in length, but sometimes it is only half an inch
long. 1 It lies at the inside of the psoas muscle, under the peritoneum.
The vein lies behind it and somewhat to its inner side, the ureter in
front and to the outer side (Fig. 83, p. 82).
The obturator artery is especially erratic, not unfrequently arising
from the posterior division of the internal iliac, and sometimes from
the external iliac or the epigastric, which is of so much more import-
ance as the obturator gland is more liable to be affected than any
other. But when once glands are affected there is no telling how far
the infiltration extends, and under such circumstances it is better to
desist from operation.
F. Papilloma. '
Under the name of papilloma many different tumors have been
described which have in common a dendritic, digitate, or villous
shape. Most of them are simply a form of carcinoma of the cervical
portion Clarke's cauliflower excrescence (see p. 508). Others are
fibroid polypi (p. 470), formed by increase in size of the papillae of
the cervix, and are generally covered with stratified flat epithelium.
They have a pedicle composed of connective tissue and muscular fibers.
Others, again, contain glands, and belong, therefore, to the mucous
polypi (p. 408). Others, again, are sarcomas that have taken the
papillomatous form (p. 504).
1 " Quain's Anatomy," 9th ed., 1882, vol. i. p. 451.
522 DISEASES OF WOMEN.
Some, finally, are true papittomas. In these the tumor is formed
by hypertrophy of the papillae of the vaginal portion. It contains
highly dilated capillaries and larger vessels with very thin walls, but
no epithelial elements. It gives rise to a profuse watery discharge
and hemorrhage, but the general health does not suffer much, and if
the growth is removed by an operation in the healthy tissue, no
relapse follows. But when these tumors become old, epithelial ele-
ments appear in them, and they take on the structure of epithelioma.
This true papilloma is likewise found springing from the mucous
membrane of the body of the uterus, but is exceedingly rare in that
locality.
Treatment. True papilloma is to be treated by amputation of the
cervix, or, if situated in the cavity, by curetting and cauterization.
G. Enchondroma.
Enchondroma has been found in the cervix, but is very rare. It
should be removed by amputating the cervix.
H. Tuberculosis.
Next to the tubes, the uterus is the part of the genital tract which
is most commonly the seat of tuberculosis. It may be primary or
secondary, and the latter may again spread from neighboring organs
or be due to infection through the blood. The disease is usually
limited to the mucous membrane. It occurs in three forms the
acute miliary, chronic diffuse, and chronic fibroid form. Of these,
the chronic diffuse is by far the most common, and is characterized
by the formation of cheesy masses. Tuberculosis is nearly always
limited to the body of the uterus ; and, on the other hand, in a con-
siderable portion of the few cases of cervical tuberculosis on record
the disease did not invade the body. 1
Diagnosis. Besides offering the symptoms of endometritis, the
uterus is considerably enlarged, which is partly due to tuberculous
infiltration, partly to hyperplasia of the normal elements. Knobs
may be felt near the cornua. If the os is closed, pus may accumu-
late, so as to form a fluctuating tumor (pyometra, p. 326). If it is
open, caseous masses may be expelled from it. Shreds removed with
the curette and examined microscopically may show bacilli and cells,
as described on p. 288. As a rule, a tubercular affection is at the
same time found in the tubes and the lungs.
Tuberculous ulceration of the cervical portion may be mistaken for
carcinoma. Microscopical examination of a piece cut out from the
1 J. Withridge Williams, " Tuberculosis of the Female Generative Organs," Johns
Hopkins Hospital Report in Pathology, ii. Baltimore, 1892, p. 126.
DISEASES OF THE UTERUS. 523
neighboring tissue shows, however, an entirely different structure in
the two diseases.
Treatment. As to general treatment, the reader is referred to what
has been said in speaking of tuberculosis of the vulva (p. 288). The
local treatment consists in curetting and the application of iodoform.
If the disease relapses and the general condition of the patient is not
too bad, the uterus, together with the appendages, should be removed
by vaginal hysterectomy.
PART V.
DISEASES OF THE FALLOPIAN TUBES.
CHAPTER I.
MA INFORMATIONS.
THE tubes are sometimes unusually large. In most cases this
increase in size is due to the presence of some abdominal tumor, with
which the tube is connected and grows in length and width. But
even apart from any such complication it has been found to measure
six inches and a half in length. One tube may be longer than the
other.
They may be wound in a spiral or be abnormally contorted, condi-
tions which predispose to retention of fluid, inflammation, and extra-
uterine pregnancy.
There may be from one to three accessory abdominal ostia. They
are surrounded by fimbrise and situated near the abdominal end of
the tube, on the upper part of the wall.
There may also be accessory tubes, either as cystic diverticula
starting from the tube, but without communication between the two
cavities, or as independent tubes with fimbrise starting from the meso-
salpinx. In the latter variety ectopic gestation may take place
paratubal pregnancy. 1
The tubes may be absent, on one or both sides, which is due to a
destruction of the corresponding part of the Miillerian ducts in the
embryo.
In other cases there may be a partial or total absence of tunneling
of the tubes, the result of an arrest of development (p. 30). In others,
again, the tube is normal near the uterus, but is soon lost in the con-
nective tissue of the broad ligament. The corresponding ovary is
usually absent or little developed.
Deficient development of the tube may be the cause of pain at the
menstrual period, and local peritonitis, when ovula and blood from
the Graafian follicles fall into the abdominal cavity.
At the fimbriated end of the tube is often found a little cyst called
the hydatid of Morgagni. Its inside has a ciliated epithelium, and it is
filled with a clear fluid. As a rule, it has only the size of a pea, but
it may acquire that of an English walnut. It is not of surgical
interest.
1 Sanger, Monatsschr. f. GeburtshiUfe und Gynakologie, 1895, vol. i. No. 1, p. 25.
524
DISEASES OF THE FALLOPIAN TUBES. 525
CHAPTER II.
SALPINGITIS.
SALPINGITIS is the inflammation of the Fallopian tubes.
Different Forms. It may be acute catarrhal or acute purulent, both
of which are seated in the mucous membrane, and are, therefore,
called endosalpingitis ; or it may be chronic interstitial, which is also
called pachy salpingitis, mural salpingitis, or parenchymatous salpin-
gitis, and is located in the muscular coat. Salpingitis may be cystic,
and according to the character of the fluid contained in the dilated
tube it is called pyosalpinx, which is filled with pus, hydrosalpinx,
which contains a watery fluid, and hematosalpinx, the contents of
which are bloody.
Perisalpingitis is the inflammation of the peritoneal covering of
the tube, a condition which only occurs as part of a more extended
pelvic peritonitis.
Prqftuent salpingitis is only a variety characterized by the discharge
of a watery fluid, pus, or blood from the tube through the uterus and
vagina. When the fluid is watery the disease is also called hydrops
tubas prqfluens or intermittent hydrocele of the ovary (Bland Button.
See Tubo-ovarian Cysts in the pathology of the Ovaries.)
Under the name of Salpingitis isthmica nodosa has been described
a form of chronic salpingitis in which nodules can be felt at the cor-
ners of the uterus. In their interior is found the tubal canal, hyper-
plasia and hypertrophy of the muscular elements of the wall, and
sometimes cysts.
Pyosalpinx saccata is a variety of pyosalpiux in which the lumen
of the tube is partitioned off into a series of pus-filled sacs, which
partitions may subsequently become absorbed, so as to form one
cavity.
Taking the etiology as base for a classification, salpingitis may be
divided into infectious and non-infectious. The non-infectious is
always catarrhal ; the infectious is nearly always purulent, but may
in the beginning or toward the end of the disease be catarrhal.
Pathological Anatomy. One or both tubes may be diseased. The
infectious form is usually bilateral. The tube is swollen to a thick-
ness varying from that of a little finger to that of a thumb. In
catarrhal salpingitis the aifection is chiefly limited to the mucous
membrane. The folds are edematous and hyperemic or slightly infil-
trated with small round cells.
The epithelial cells are swollen, show slight increase in size of their
nuclei, and vacuoles form in their protoplasm. Side-branches grow
out from the folds, and these, as well as the original folds, may grow
together, forming closed cavities. The muscular coat does not
526 DISEASES OF WOMEN.
participate much in the inflammatory process. The secretion is in-
creased, and contains mucus, albuminoids, and thrown- off epithelial
cells.
In purulent salpingitis the process is more destructive. The tubes
are swollen, often distorted, adherent to neighboring organs, and
sometimes divided by internal partitions or external bands into a
series of compartments, which give them a beaded appearance. The
epithelial cells lose their cilia. The epithelium is thrown off over
large areas, and the underlying tissue is crowded with small round
cells, which are thrown off as pus-corpuscles. The mucous membrane
is the primary seat, but by extension the inflammation invades the
muscular coat, and the connective tissue between the muscle-bundles
becomes infiltrated with pus-corpuscles. The fimbrise become agglu-
tinated to one another or to the ovary. In the beginning the ostium
uterinum may remain open, constituting a profluent purulent salpin-
gitis. If purulent salpingitis is cured, it leads to a temporary or
permanent hypertrophy of the wall by formation of new connective
tissue. The vegetations springing from the folds grow together, form-
ing a whole layer of new formation lining the original tube.
Interstitial salpingitis is a chronic disease which has its seat in the
muscular coat. 1 It may follow either catarrhal or purulent salpin-
gitis. The extension from the mucous membrane to the muscular
layer takes place through the connective tissue. In the first stage the
connective tissue between the muscle-bundles is edematous. Next, a
large number of inflammatory corpuscles (small round cells) form in
it, and even the smooth muscle-fibers themselves break down and are
transformed into such cells. Later, the interstitial inflammation may
lead to the formation of new connective tissue. It is doubtful if
muscular tissue is also formed. In this way the wall is thickened,
and the process may end in a permanent hypertrophy (Fig. 278).
On the other hand, interstitial salpingitis may lead to atrophy of the
tube. Here the wall is thin, the caliber small, and the epithelium
partially lost. The muscle-tissue is to some extent replaced by con-
nective tissue.
The different forms of salpingitis, especially the purulent, are often
accompanied by pelvic peritonitis, due to an extension of the inflam-
mation through the wall of the tube to its peritoneal covering, or to
the entrance of irritating fluid into the peritoneal cavity through the
ostium abdominale. In most cases the ovary becomes implicated in
the inflammation. It is full of small cysts or may form an abscess.
An exudation is formed in Douglas's pouch or around the tube and
ovary, which are then matted together into one globular mass. Ad-
1 H. J. Boldt has made a special study, illustrated by instructive drawings, of the
microscopical changes characteristic of this form in Amer. Jour. Obst., Feb., 1888,
vol. xxi. p. 122.
DISEASES OF THE FALLOPIAN TUBES. 527
FIG. 278.
Hypertrophy of Fallopian Tube due to Interstitial Salpingitis. The tube is cut open, showing
the lumen, a, in the middle of the thick hard wall, b. 1
FIG. 279.
Salpingitis: a, tube finger-thick at lower end, narrowed in many places ; b, cyst as large as
a chestnut situated in the wall of the tube ; c, ovary containing a recently ruptured
Graanan follicle, the size of a large hazelnut; d, torn adhesions. 2
1 Specimen from my salpingo-oophorectomy on Mrs. S., in St. Mark's Hospital,
on July 24, 1890.
2 Specimen from my salpingo-oophorectomy on Mrs. L. S., in St. Mark's Hospital,
on August 29, 1890.
528
DISEASES OF WOMEN.
hesions are formed to the intestines, the omen turn, the bladder, the
uterus, the broad ligament, or the wall of the pelvis.
The loss of epithelium and growth of new folds springing from those
normally formed by the mucous membrane may lead to closure of the
FIG. 280.
1. Left Tube cut open, Catarrhal and Interstitial Salpingitis : a, closed fimbriae ; a b, a c,
thickness of wall ; d, central cavity.
2. Right Tube cut open, Pyosalpinx : a, closed fimbriae ; 6, cavity filled with pus ; c, c, c,
smaller cavities communicating with central canal.
3. Small round body found loose in pelvic cavity, probably atrophic right ovary. 1
ends of the tube or coalescence between the walls in one or more
places in their course. As a rule, the abdominal opening is first
closed by agglutination between the fimbriae or between them and
the ovary. Later, agglutination may also take place at the uterine
end. If both ends are closed, the fluid accumulates, forming a cyst,
filled with a serous, mucous, pultaceous, purulent, or bloody fluid.
The wall is in most places thickened, but through distention or
ulceration in the interior it has thin places liable to rupture. Most
frequently this thinning is found in the upper and posterior part of
the tube, so that the fluid, in case of rupture of the wall, flows into
the peritoneal cavity. In rarer instances the rupture takes place
downward between the folds of the broad ligament and produces
pelvic cellulitis and abscess.
These tubal cysts are mostly club-shaped, with a thinner inner end
and a thicker outer. Sometimes they are more pear-shaped or round,
or form a string of alternating wide and narrow parts, like a string
1 Specimen from my salpingo-oophorectomy on Mrs. F. K., in St. Mark's Hospi-
tal, on May 19, 1894.
DISEASES OF THE FALLOPIAN TUBES. 529
of sausages (Fig. 279). Different forms may be found simultaneously
in the same individual. Thus I have seen pyosalpinx in one tube,
the fluid being purulent with a few columnar cells, while the other
tube showed marked interstitial and catarrhal salpingitis, the much
distended canal being filled with a putty-like mass exclusively com-
posed of ciliated columnar epithelial cells (Fig. 280).
Frequency. Salpingitis is a very common disease.
Etiology. Salpingitis is hardly ever a primary disease. As a rule,
it is secondary to inflammation of the uterus or the peritoneum. The
inflammation may follow the mucous membrane or be propagated from
the uterus through the lymphatics of the broad ligament.
The disease is nearly always limited to the period of genital activity.
It is quite frequent in prostitutes, causing colica scortorum ; and unfor-
tunately, it appears often in newly-married pure women.
Malformations, such as atrophy, a spiral twist, and angles in the
course of the tubes, predispose to their inflammation.
Salpingitis may be due to infectious and exanthematous diseases,
such as cholera, typhoid fever, scarlet fever, and smallpox. It
may be brought on by flexion, myoma or carcinoma of the uterus,
and perhaps stenosis of the os, with retention of mucus in the cavity,
or by ovarian disease. It may be caused by exposure to cold, violent
exercise immediately before menstruation, or too frequent coition.
But in the large majority of cases salpingitis, and that in its worst
form, the purulent salpingitis, is either gonorrheal or puerperal. If
gonorrhea once invades the uterus, it has a great tendency to spread to
the tubes. Puerperal salpingitis is found as part of the affections cha-
racteristic of puerperal infection or of incomplete abortions, in which
the ovum or the spongy decidua is allowed to remain in the uterus.
Purulent salpingitis may also be due to gynecological treatment,
not only operations, such as incision of the cervix ; but the mere intro-
duction of a sound or the administration of an intra-uterine douche
may, in rare cases, lead to salpingitis or change a comparatively harm-
less catarrhal into a purulent inflammation.
Symptoms. There is no pathognomonic symptom. Even a dan-
gerous puerperal salpingitis, calling for removal of the pus-filled tubes,
need not cause any other symptom than emaciation and recurrent
fever. A symptom, however, that must awaken great suspicion is
an intermittent outflow of mucous or purulent fluid from the genitals,
but the same may sometimes be due to endometritis. The patient is, as
a rule, sterile, or has had one child, so-called secondary sterility. The
disease is, in most cases bilateral or, if only found on one side, the left
is more likely to be affected, a peculiarity which may have its cause
in the preponderance of cervical tears on this side (p. 396) or the
absence of a valve in the left ovarian vein (p. 74).
Pain may be insignificant or excruciating. It is felt in one or both
34
530 DISEASES OF WOMEN.
iliac fossa and in the sacral region. It often has a colicky character, and
may be due to contraction of the inflamed muscular coat or to pressure
on the ends of nerve-filaments. In other cases the pain is burning. If
only one side is affected, the pain is sometimes felt in the opposite side.
It is increased by any kind of exertion, so that the woman becomes
unable to do any kind of work ; and it is much enhanced by coition.
It is worst at the menstrual period.
Leucorrhea is common. Often the patient suffers from inenoivha-
gia or metrorrhagia, the hemorrhage taking place in the diseased
tubes themselves or in the uterus, the endometrium of which may be
inflamed. Periods of menorrhagia may alternate with others of amen-
orrhea. The general health suffers, the patient loses flesh and strength,
becomes nervous, and often has fever.
By vaginal examination the tubes are found tender, thickened,
often distorted and either movable or adherent to neighboring organs,
Very often the ovary is felt enlarged and tender, or there may be an
exudation or new-formed connective tissue matting it and perhaps a
knuckle of intestine and a part of the omentum, together with the
tube, into one shapeless mass.
A unilateral mass of this kind may so fill the pelvis as to push the
uterus over toward the other side, at the same time canting it forward.
In case the masses are bilateral and large, they push the uterus with
the broad ligaments from behind forward up against the anterior wall
of the pelvis, or press on it more from above, tipping it forward into
complete anteversion. In other cases again the uterus is found retro-
flexed and often adherent to the posterior wall of the pelvis.
Diagnosis. The diagnosis of salpingitis may be very difficult, the dis-
ease being so often combined with oophoritis, peritonitis, and cellulitis.
The intermittent spontaneous outflow of mucus or pus preceded by
a burning sensation or cramps makes the presence of salpingitis very
probable. This symptom acquires still more weight if the examiner
by gentle pressure exerted on the tubal region can make the fluid
appear at the os uteri.
Oophoralgia is only found as a part of general hysteria ; lumbo-
abdominal neuralgia is elicited by pressure on the skin over the iliac
region, but not by pressure from the vagina, and in none of these
purely nervous affections is there any swelling.
From oophoritis the inflamed tube is distinguished by its shape,
and sometimes the ovary can be felt beside the swollen tube in a
normal condition, or only slightly enlarged and tender compared with
the swelling formed by the tube.
Cellulitis forms a swelling situated lower down than the swollen
tube.
Peritonitis forms, as a rule, a larger exudation of more globular
shape extending from Douglas's pouch to one of the iliac fossse.
DISEASES OF THE FALLOPIAN TUBES. 531
Sometimes it is hard to tell a swollen tube from an intestinal knuckle
felt in Douglas's pouch, but the latter is not particularly tender, is
not always present, and is sometimes empty, while at other times
it contains feces.
In order to obtain full knowledge of the condition of the tubes, it
is necessary, besides the common examination in the dorsal and
Sims's positions and by rectal touch (p. 142), to anesthetize the patient,
place her in lithotomy position, let the legs fall out, so as to put the
psoas muscle on the stretch, introduce the fore- and middle fingers of
one hand into the lateral vault of the vagina, and depress the ab-
dominal wall with the other. The vaginal examination is performed
with the left hand for the left side of the pelvis, and the right hand
for the right side.
A purulent salpingitis may be surmised if the history reveals gon-
orrheal or puerperal infection, and the purulent nature of the fluid in
the tube, together with the permeability of the ostium uterinum, is
proved if pus can be made to appear at the os uteri by the above-
mentioned manipulation.
Prognosis. Salpingitis is a serious disease. Its course is usually
a tedious one. It may end fatally from exhaustion ; it may cause
sudden death or make the patient an invalid for life, and it very often
entails sterility. It is especially the purulent form the prognosis of
which is so doubtful ; the catarrhal is more amenable to treatment,
less protracted, and less dangerous.
Treatment. Prophylaxis. Women should be sufficiently clad (see
p. 128) and avoid sudden refrigeration when heated, especially during
the menstrual period.
As far as possible they should avoid marriage with a man who has
or has had a gonorrhea which is not perfectly cured ; or to put it the
other way, a man with gouorrheal threads, designated with the Ger-
man name " tripper faden," in the urine, or at whose meatus urina-
rius appears a little secretion in the morning, should not marry unless
the discharge is free from pus, and when even a purulent discharge,
artificially produced by injection with nitrate of silver or corrosive
sublimate, does not contain gonococci (see latent gonorrhea, p. 131).
Childbirth should be surrounded by all antiseptic precautions. 1 In
cases of incomplete abortion the uterus should be emptied immedi-
ately.
If salpingitis is present the doctor should abstain from making an
incision in the cervix, introducing an infra-uterine pessary, using in-
tra-uterine injections, nay, even from carrying a sound into the uter-
1 Full information in this respect is found in the writer's Practical Guide to A nti-
septic Midwifery in Hospitals and Private Practice, Detroit, Mich., 1886, and in his
articles on " Puerperal Infection " in Amer. System of Obstetrics, Phila., 1889, vol. ii.
pp. 327-361, and in Amer. Text-book of Obstetrics, Phila,, 1895, pp. 708-719.
532 DISEASES OF WOMEN.
me cavity, as all these interferences may give new impetus to the
disease or change a catarrhal salpingitis into a purulent, and lead to
death.
Curative Treatment. In acute salpingitis we prescribe absolute rest
in bed, fluid diet, an ice-bag on the lower part of the abdomen, opium
suppositories (p. 226), hot vaginal douches (p. 171), and, if necessary,
a saline aperient (p. 225). Hot rectal injections serve both to move
the bowels and combat the inflammation. If the inflammation is
unmistakably purulent and gives rise to serious symptoms, it is safer
to remove the appendages immediately without losing any time in
palliative treatment.
In the chronic form much may be accomplished by mild treatment
if the patient can take care of herself. It is often well, even in this
form, to begin with confining the patient to her bed for three or four
weeks. Painting internally and externally with tincture of iodine
(pp. 170 and 188), pledgets soaked in ichthyol-glycerin (p. 178), gal-
vanism with one pole against the vaginal vault (p. 232) or in the
uterine cavity (p. 231), preferably the former, scarification of the
cervix (p. 186), intra-uterine applications of chloride of zinc (p. 170),
blisters applied over the inguinal fossa, superficial cauterization of
the same region with Paquelin's cautery, poultices, hot-water bags,
Priessnitz compresses (p. 187), and warm entire baths, are all very
effective remedies, which, combined with substantial food, mild stimu-
lants (p. 224), and tonics (p. 225), may effect a cure. In milder cases
of swollen tubes and ovaries, curetting (p. 176), followed by packing
of the uterine cavity with iodoform gauze (p. 180), has proved very
beneficial in the writer's hands an effect which probably must be
attributed to the depletion from the surroundings due to the drainage
from the uterus.
Others think they can evacuate fluid from the tube by dilating the
uterus, curetting, especially around the openings of the tubes, and
packing with iodoform gauze, to be removed every day or two.
Massage (p. 190) has also been praised, but seems to me to be sur-
rounded by too great dangers. The only indication I see for it is the
cases in which the abdominal opening of the tube is closed, and the
uterus remains open. Under such circumstances a very gentle press-
ure following the course of the tube from without inward toward the
uterus may press out the fluid which has accumulated in the tube.
But the diagnosis is not easy to make on the living, and if the abdom-
inal ostium was just a little agglutinated, the pressure might reopen it
and drive the contents of the tube into the peritoneal cavity.
Intra-uterine injections should be avoided, as they are apt to increase
the inflammation of the tubes.
If these milder measures do not succeed, the tube may be attacked
surgically from the vagina or through the abdominal wall.
DISEASES OF THE FALLOPIAN TUBES. 533
Catheterization of the tube is in normal cases, and in most patho-
logical ones, impossible. It has only been performed when the ute-
rus was lateroflexed, and the ostium internum much dilated. In
other cases of supposed catheterization the sound has perforated the
uterine wall, which is easily done, and, as a rule, has no bad conse-
quences (compare p. 177).
Aspiration through the vaginal vault is not devoid of dangers, not
only on account of the organs that may be wounded with the needle,
but still more on account of the nature of the fluid that after its
withdrawal may drip into the peritoneal cavity. It should, therefore,
only be used if the swelling is situated in the posterior half of the
pelvis, so low down that it is within easy reach, and when it seems so
firmly adherent in Douglas's pouch that we have reason to hope that
no fluid will escape into the peritoneal cavity. Besides, as a rule,
aspiration will have greater value from a diagnostic standpoint than
from a curative. It is most likely that the diseased mucous mem-
brane of the tube will reproduce a similar fluid.
An incision may be made from the vagina, and a drainage-tube of
glass, hard rubber, or silver introduced and fastened to the vaginal
vault with silver wire drawn through holes in the vaginal end of the
tube. 1 We may also use a soft-rubber tube with cross-bar, and long
enough to protrude from the vagina. A safety pin is inserted at the
lower end, and iodoform gauze wound round tube and pin, so as to
close the tube without preventing drainage. This method should,
however, only be used if the conditions mentioned in speaking of
aspiration are present ; and, upon the whole, if the diagnosis is
sure that is, if the fluid is in the tube and not in the peritoneal
oavity or the connective tissue of the pelvis the tube should be
removed.
In all cases that have withstood the palliative treatment for four
months or longer, an exploratory laparotomy or colpotomy is indicated,
which may lead to the removal of the uterine appendages or to their
preservation by different means.
Laparotomy, or abdominal section, is described under Ovariotomy.
Colpotomy, or vaginal incision, may be made either in front of the
cervix anterior colpotomy or behind it posterior colpotomy. The
modus operandi is exactly the same as for the first steps of vaginal
hysterectomy (p. 484). The conservative treatment is now mostly
carried out by vaginal section.
Conservative Treatment. In some cases it suffices to separate adhe-
sions, run a probe through the whole length of the tube, wash it out
from the fimbriated end with a weak solution of bichloride of mer-
cury (1 : 5000), and stitch the fimbrias to the peritoneum near the
ovary so as to prevent them from curling in and closing the abdom-
1 T. G. Thomas, Diseases of Women, 6th ed., 1891, p. 763.
534 DISEASES OF WOMEN.
inal opening again. If the fimbriae cannot be separated, the end of
the tube may be cut off, and the raucous membrane stitched to the
peritoneal coat with a few catgut sutures. By tying the rnesosalpinx
without comprising the tube in the ligature, more or less of the latter
may be removed and yet a passage left for an ovulum from the ovary
to the uterus. Several cases of pregnancy under such circumstances
have been reported. At the same time it may be necessary, in order
to prevent reformation of torn adhesions, to perform abdominal hys-
teropexy (p. 452) or shortening of the round ligaments (p. 448). Such
conservative measures have even been successful when the tube con-
tained from a half to a whole fluid rachm of pus. Where there is a
large collection of fluid the tubes should be removed.'
Salpingo-oophorectomy. Indications. In acute salpingitis the re-
moval is contraindicated except when a purulent salpingitis extends
to the peritoneum and threatens to become generalized. Under such
circumstances the extirpation should be performed immediately, with-
out losing time with palliative measures. If at the same time there
is a purulent discharge from the uterus, this organ ought to be cu-
retted or removed.
The removal of the appendages is also indicated for interstitial sal-
pingitis, if the patient suffers much pain and has repeated attacks of
pelvic peritonitis, and for most cases of cystic salpingitis, especially
pyo- and hematosalpinx.
It is true, numerous autopsies have proved that pus can become in-
spissated in the tubes to a puttylike mass, and, on the other hand, it
can probably, by a process of clarification, be changed into a serous
or mucous fluid, but such favorable events are too uncertain, and it
is, therefore, safer to remove the tube if it contains more than a very
small amount of pus.
If the endometrium shows signs of infection, it is advisable first
to curet and drain (p. 179) before performing salpingo-oophorectomy,
and in this way the latter operation may sometimes be avoided.
On the other hand, in general, the removal should not be under-
taken as long as the uterine ostium remains open.
Under all circumstances the consent of the patient must be
obtained. The off-hand way in which some operators spay a
woman without her knowing it is not only unjustifiable on moral
grounds, but exposes the operator to a suit for mayhem and heavy
damages.
Modus Operandi. The appendages may be removed through the
abdominal wall or through the vagina : the former method is called
1 Polk has done much in the line of conservatism, and described his procedures
in Medical Record, Sept. 18, 1886 ; Amer. Jour. Obst., 1887, vol. xx. p. 630 ; Trans.
Amer. Gyn. Soc., 1887, vol. xii. p. 128; Jour. Obst., Dec., 1890; ibidem, Sept., 1891;
Tram. Amer. Gyn. Soc., 1893, vol. xviii. p. 175; Med. News, Jan. 4, 1896.
DISEASES OF THE FALLOPIAN TUBES. 535
Tail's operation, the latter Battey's operation. 1 The reader is referred
to the general description of laparotomy given under Ovariotomy.
Here we shall add a few points with regard to salpingo-oophorectomy.
A. Abdominal salpingo-oopliorectomy. The incision is made in the
median line, so low down that the lower end is half an inch above
the symphysis. The upper end varies according to circumstances.
In easy cases only room for two fingers is needed ; in difficult it may
become necessary to introduce the whole hand, push the intestines up,
and expose the whole pelvic cavity to view.
When the small incision is made in the abdominal wall, the left
fore- and middle fingers are introduced into the abdominal cavity.
Pushing omentum and intestines up, the fingers are placed on the
fundus uteri, and moved out along one of the tubes to the ovary. If
there are no adhesions, the tube and ovary are lifted between these two
fingers up through the abdominal wound. If necessary this proce-
dure may be facilitated by having the uterus lifted from the vagina
by means of a dilator introduced into the cervix or simply with the
fingers of an assistant.
In this and other operations in the depth of the pelvis the manipu-
lations may also be much facilitated, especially on the left side, by
introducing a colpeurynter, i. e. a rubber bag, into the rectum, and
distending it with water. If oozing points are left in the pelvis
after the operation, this same bag filled with ice-water and combined
with abdominal compression may serve as a hemostatic plug working
both by pressure and refrigeration.
If the broad ligament does not yield, Tait gains room by making
small tears in it with his nails near the pelvic wall. The peritoneum
and connective tissue are torn, but the stronger vessels resist. The
parts to be removed may also be seized beneath the surface of the
body with suitably curved forceps, and ligated there, without being
brought out through the incision.
If there are adhesions they are cautiously torn, the surgeon, if pos-
sible, relying on his sense of touch alone. Otherwise, they are lifted
up into the wound and separated there. Sometimes it is necessary
to enlarge the incision so as to make the whole pelvis accessible to
the eyes and hands. The intestines are pressed up under the abdominal
wall, and held there with a flat sponge or a gauze pad. In very ex-
ceptional cases they are even pulled out through the opening, laid on
the upper abdomen, and covered w r ith a cloth wrung out of hot nor-
mal salt solution (6 : 1000). Trendelenburg's position helps much to
avoid the handling of the intestines, which is apt to cause shock and
predisposes to adhesions after the operation.
1 Battey's operation was originally devised for the " extirpation of the functionally
active ovaries for the remedy of otherwise incurable diseases" (Trans. Amer. Gyn.
Soc., 1876, vol. i. p. 101), but has been much extended both as to object and method.
536 DISEASES OF WOMEN.
If the tube and ovary are imbedded in a whole mass of resistant
new-formed tissue it may be necessary to desist from their removal,
but with increasing experience and skill a man will be able to remove
organs which, at an earlier stage of his career, it was wise to leave
undisturbed.
Tait does not give up the operation even if it is necessary to wound
bladder and intestine in order to finish it. The ensuing fistula heals
spontaneously. 1
Sometimes serous fluid accumulates in the interior of adhesions by
which they become tubular, and look much like a Fallopian tube or
the appendix vermiformis.
Vascular bands are often cut between two ligatures.
When the tube and ovary are lifted up, a dull handled needle
(Fig. 185, a p. 2 15) threaded with a strong silk ligature (braided, No.
12), 20 inches long, is pushed from the front backward through the
broad ligament, half to three-fourths of an inch under the ovary. An
assistant seizes the ligature with a pair of forceps and his fingers and
holds it while the operator withdraws the needle. Next, the loop
is brought forward over the ovary and tube, comprising as much
of the latter as feasible. One of the free ends is carried through
this loop, the other remains above it. The operator seizes both ends
with the fingers of his right hand and pulls on them, and presses
with his left thumb and index finger against the tissue to be li-
gated. He may also pull on one end alone, and have his assistant
pull on the other, or, preferably, he may combine both these manipu-
lations. The ligature is pulled very tight,
FIG. 281. but slowly, so as not to break it, and then
tied with a reef knot. This way of tying the
ligature is called the Staffordshire knot (Fig.
281), because it is the badge of the county of
Stafford in England. It is, however, safer
and allows us to get closer up to the uterus
Staffordshire Knot (Tait). to cut the ligature in the middle and cross
the halves twice, as described under Ovariot-
omy. From each side a pressure-forceps is put on the pedicle just
above the ligature, and tube and ovary are cut off with small cuts
made with a pair of scissors curved on the flat, taking care to remove
all of the ovary and as much as possible of the tube ; and, on the
other hand, to leave enough of the pedicle to prevent the ligature
from slipping. Next, one of the pairs of forceps is removed, and a
strong tenaculum or tenaculum -forceps inserted in its stead. Then
the second forceps is taken off. If there is no bleeding from the
stump, the ends of the ligature are cut short. If there is bleeding,
the ligature is carried round the pedicle and tied on the other side.
1 Lawson Tait, Centralblatt. fiir Gynak., Feb. 4, 1893, vol. xvii. p. 93.
DISEASES OF THE FALLOPIAN TUBES. 537
The cut surface is powdered with iodoforra or aristol, or seared with
the thermo-cautery, taking great care not to burn the ligature. Fi-
nally, the tenaculum is removed, and the pedicle dropped into the pel-
vic cavity. If there is too much tissue, it may be cut off under the
tenaculum.
Instead of thus including a large part of the broad ligament in the
ligature, two separate ligatures may be placed, one on the ovarian
vessels in the infundibulo-pelvic ligament and the other on the anas-
tomosis between the ovarian and the uterine artery, just outside of
the corner of the uterus. Then the ovary and the tube may be cut
off. If, exceptionally, there is any bleeding, the bleeding point is
secured by a special ligature. This method offers the great advan-
tages that there is less danger of the ligatures slipping, that very little
tissue is compressed in the ligature, that all ovarian tissue can be re-
moved, and that there is no traction on the scar. 1
It should be remembered that the ovarian vessels at the brim of
the pelvis cross in front of the ureter, and care should be taken not
to embrace this tube in the ligature.
If the tumor is situated in the broad ligament, leaving the lower
part of the same free, this may be tied in small bundles, between two
ligatures, gaining access to the deeper portion by gradually cutting
what has been tied. If there is no pedicle at all, the peritoneal cov-
ering of the tumor must be split, and the tumor enucleated. This
leaves a sac which is treated as described above (p. 499) under Fib-
roids of the Uterus.
As to the treatment of the appendages of the other side there is
much difference of opinions. Tait recommends to remove them even
if they are healthy, because they will be affected later, and the second
operation has a mortality altogether disproportionate to the first pro-
ceeding, while many die for want of a second operation. Other ope-
rators, on the contrary, have even tried to save the second set of adnexa
w r hen they were found diseased. This has the advantage of preserv-
ing menstruation, and of avoiding the mental depression sometimes
following the removal of the appendages on both sides, and has even,
in rare cases, led to pregnancy and childbirth. When offspring is
particularly desirable this method should, therefore, be considered. 2
The ovary may be cut open, cysts enucleated or part of the ovary
cut out, and tiie edges united by a continuous catgut suture. A piece
of the tube may be cut off, and hemorrhage arrested by ligating the
ala vespertilionis without interfering with the vessels nourishing the
ovary. An opening may be cut in the tube, and the mucous mem-
brane stitched to the peritoneum around it (p. 534).
1 C. B. Penrose, Amer. Jour. Obst., 1895, vol. xxxii. p. 221.
2 Details are found in papers by A. Martin, Centralblatt fur Gynak., June 20, 1891,
vol. xv. No. 25, p. 515, and Polk, Amer. Jour. Obst., Dec., 1890, vol. xxiii. p. 1375.
538 DISEASES OF WOMEN.
While the removal of non-adherent appendages is a comparatively
easy operation, it becomes one of the most difficult when there are
many extensive and unyielding adhesions. Great benefit may, under
these circumstances, be derived from the Trendelenburg position (p.
138). In trying to free the adherent appendages we must try to find
natural lines of cleavage. Remembering that the ovary springs from
the posterior layer of the broad ligament, and that the tube is situated
at the upper border of the ligament and forms a curve around the
ovary (pp. 63, 65), we must try to free them by going in between
them and the sacrum behind the broad ligament. If possible the
ligature should be passed below the round ligament, which lessens the
danger of its slipping. For the same reason the broad ligament is
slackened in drawing the ligatures tight. If the tissue is so friable
that the ligature cuts through the tube and ligament, it may become
necessary to form a pedicle of the cornu of the uterus itself, and tie
the ovarian artery separately, as just described.
If the tube or ovary or both contain much fluid, it may be well to
remove it with the aspirator, in order to avoid rupturing the append-
ages, but if feasible the removal of the filled organs is easier. If a
rupture occurs, which most frequently takes place in the upper poste-
rior part of the wall of the tube, the fluid should be carefully wiped
off and a drain of iodoform gauze carried out from the soiled place
through the abdominal wound or the vagina. Only if the fluid
spreads far among the intestinal knuckles, the whole abdominal cavity
should be washed out with copious irrigations of hot salt solution, and
a drain left in. If there is much oozing, a drain is likewise indicated,
or it may be necessary to apply a Mikulicz tampon (p. 181).
If both appendages must be removed, it is better to remove the
uterus too. This organ is often the source of the infection of the
others. It is not only useless after their removal, but often hemor-
rhage and pain continue after the removal of the appendages. Under
such circumstances I have repeatedly been obliged to remove the
uterus after months or years.
If only one set of appendages is removed, it is, as a rule, well to
curet the uterus at the same time.
The mortality after salpingo-oophorectomy has, in Tait's hands,
only been 2.5 per cent. The objection that the operation deprives the
patient of the possibility of becoming a mother has not much weight,
since in the large majority of cases she has proved to be or would
be sterile on account of the condition of the ovaries and tubes.
Her sufferings may be intolerable, and render it impossible for her
to earn a living or perform any useful work. Often they make an
opium-eater of her. Now, in most cases, but, it must be admitted,
not in all, the operation restores her to health and makes her again a
useful member of her household and the community at large.
DISEASES OF THE FALLOPIAN TUBES. 539
Immediate and demote Results, In 86 per cent, the operation
brings on the menopause at once or after a few months (compare
p. 119). When menstruation continues it may be due to incomplete
removal of the appendages, irritation of the stumps, or disease of the
uterus. As a rule, there is a discharge of blood for several days fol-
lowing the operation, which is accounted for by the unusual congestion
caused by the ligature cutting oif the normal roads of circulation.
In some cases a hematoma is developed in the broad ligament. Some-
times, during convalescence, or later, an encysted collection of serous
fluid takes place in pseudomembranes. Many complain of vertigo
and fulness in the head, which may be relieved by bromides or
cauterization with Paquelin's ther mo-cautery on the nape of the neck,
or which may even necessitate repeated venesection.
Purpura hemorrhagica has been observed at the time when men-
struation was due, but the operation does not give rise to vicarious
menstruation.
During the first week after the operation most patients complain
of pain in the pelvis, which probably is due to the constriction of
the pedicle. In some this pain disappears soon, and they feel relieved
from their sufferings and bless the day they submitted to the opera-
tion. In others this happy event does not occur before the lapse of
several months, and in a few the pain persists indefinitely. This
sad condition may be accounted for in different ways. The chronic
peritonitis had extended beyond the tubes and ovaries, and part of it
remains, therefore, after their removal. The operation itself may
lead to new peritonitis. New adhesions may form between the
stump and its surrounding parts. In several cases a secondary ope-
ration has shown that a cyst had formed near the stump on one or
both sides. Adhesions to the bladder may cause a troublesome desire
to urinate. Those to the intestines may cause pain, or give rise to
intestinal occlusion. In some cases there is congestion of the uterus
causing pain, leucorrhea, or hemorrhage. The persistent pelvic pain
is best treated with counter-irritation or galvanism, and sometimes a
second laparotomy is performed and adhesions disposed of, or the
uterus has to be removed, if it was not done when the appendages
were taken out.
The sexual appetite may remain unchanged, increase, diminish, or
disappear. Many become fat and dyspeptic.
In a large percentage melancholia has developed, but alienists
think they can account for it in other ways than by charging it
directly to the loss of the genital glands and the cessation of men-
struation. Even if the mental disturbance does not go so far as
insanity, despondency, irritability, and laziness are quite frequently
observed.
Congestions of the head and thoracic organs and perspiration
540 DISEASES OF WOMEN.
appear soon after the operation, and may continue with lessening fre-
quency for years. 1
Like other laparotomies this operation may cause injury to a ureter,
ventral hernia, fecal fistula, an abdominal sinus following the use of
the drainage-tube, and intestinal obstruction ; or it may aggravate pre-
existing diseases in other organs, all of which has to be considered
before determining on the operation.
B. Vaginal Salpingo-oophorectomy presents the advantage that there
is less shock and less risk of causing a hernia, but it has the draw-
back that the field of operation is so narrow and deep-seated. Now,
the frequency of ventral hernia following laparotomy was due to the
hasty and imperfect way in which the abdominal wall used to be
closed, and can to a great extent be avoided by proper care. On the
other hand, the abdominal section offers the immense advantage that
if necessary every part of the pelvic cavity can be made visible and
accessible, and, taking into consideration how r uncertain the diagnosis
is in these deep-seated affections, and how often there are adhesions
to the intestine and its appendix, that is a point of paramount import-
ance. If we enter through the abdominal wall, the incision may be
enlarged, and we are able to cope with every arising difficulty, while
when entering through the vagina we have to work through a small
opening at the bottom of a long tube. Without speculum and retract-
ors we do not see anything at all, and if we use them, they block the
passage for our fingers. This method was excellent for the removal
of healthy ovaries and at a time when lack of antiseptic surgery made
the opening through the abdominal wall much more dangerous than
that through the vagina, but for the needs of the present day, when
we especially wish to remove diseased tubes, and with our present
resources in regard to hemostasis and drainage, the abdominal method
is preferable. If the appendages of both sides are so diseased that it
is sure they must be removed, much space is gained by first extirpat-
ing the uterus by vaginal section. The situation of the appendages
and the shape of the pelvis ought also to have great weight in the
choice of method : if the parts to be removed are situated near or
above the brim of the pelvis, or if the pelvic cavity is deep and nar-
row, the abdominal method may be the only available one. If, on the
other hand, the uterus is retroverted, or the cervix can be pulled for-
ward and the fundus is easily forced down into Douglas's pouch, the
appendages may be safely removed by vaginal section. Under these
circumstances there will seldom be trouble from intestinal adhesions. 2
The vagina is opened by anterior or posterior colpotomy or both,
1 The results of salpingo oophorectomy have been discussed by Coe, Medical
Record, April 19, 1890; by Boldt, ibidem, May 17, 1890; and Lusk, Amer. Jour.
Obst., Nov., 1891.
2 Henry T. Byford of Chicago, Amer. Jour. Obst., March, 1892, p. 337.
DISEASES OF THE FALLOPIAN TUBES. 541
and in order to gain more room an incision in the median line may
be carried from the posterior transverse incision as far down as the
bottom of the pouch of Douglas, after which the operator works
mostly witli his forefinger, until he can plunge it into the peritoneal
cavity. Adhesions are torn and the appendages brought down and
ligated. Hemorrhage is stopped by the same means as when laparot-
omy is performed, and the wound is closed or left open. (See Hys-
terectomy for Uterine Fibroids.)
Cystic Salpingitis.
When a considerable amount of fluid distends the tube, it forms a
cyst. The abdominal ostium is closed, the uterine may yet remain
open. The cyst forms a tumor situated to the side of and above the
uterus, whence it may extend up into the abdominal cavity or down
between the layers of the broad ligaments. The swelling may be
club-shaped, with a narrower inner and a wider outer end ; or it may
be more globular and be bound to the uterus with a narrow pedicle,
corresponding to the inner undilated part of the tube ; or it may be
divided by external bands or inner partitions into a series of com-
partments, which gives it the appearance of a string of sausages.
The contents vary much, but may be divided into three chief classes
according to the preponderating element namely, pus, blood or serum.
Often different kinds are found in the same individual.
Symptoms. When salpingitis leads to the formation of a cyst, pres-
sure-symptoms are added to those due to inflammation. The patient
complains of heaviness and a bearing-down sensation, meteorism, con-
stipation, often combined with a frequent desire for defecation and
micturition, which is an inconvenience in daytime and disturbs her
rest at night. Sometimes there is a constant slight discharge of blood
from the uterus. She has pain in the inguinal and sacral regions, and
repeated attacks of peritonitis.
By bimanual examination a tumor of the description just given is
felt which may be movable or immovable, more frequently the latter.
Diagnosis. The diagnosis between cystic salpingitis and certain
other diseases may be difficult or impossible. Tubal pregnancy forms
a similar globular tumor fastened to the cornu of the uterus. The
history, the presence of signs of pregnancy, the expulsion of shreds
of a decidua, and attacks of sudden pain so violent as to make
the patient scream and sink down on the floor may, however, enable
us to make the diagnosis of tubal pregnancy.
An ovarian cyst, be it pedunculated or intraligamentous, may be
entirely like cystic salpingitis; but sometimes the ovary may be felt
beside the cystic tube, and the history of the case may give useful
information.
Cysts of the broad ligament are less painful, hardly tender, immov-
542 DISEASES OF WOMEN.
able, and tip the uterus to the opposite side. A peritonitic exudation
causes a constant pain, is immovable, and pushes the uterus forward
and downward, but all this may also be found in cystic salpingitis.
A uterine fibi'oid may form a similar tumor either in the abdominal
cavity or between the layers of the broad ligament, but it is harder,
never fluctuating, and the depth of the uterine cavity is increased.
A uterine fibro-cyst is in closer connection with the uterus, and the
sound reveals an increased depth of the uterine canal. Swollen pelvic
glands may give a similar history and form a similar tumor. Aspi-
ration may give information about the presence and nature of fluid,
but ought not to be used unless the tumor is adherent to the abdomi-
nal w r all or the vaginal vault.
The differential diagnosis between the three kinds of cyst may also
be very obscure, although certain circumstances may point more dis-
tinctly to one rather than to the others. Thus pyosalpinx is by far
more common, follows gonorrheal or puerperal infection, is very adher-
ent and tender, often causes fever, and is apt to form fistula. Like
hydrosalpinx it is usually bilateral.
Hydrosalpinx may form a tumor of much larger size. As a rule,
it is less adherent and less tender, and causes less constitutional
disturbance.
Hematosalpinx is exceedingly rare, is often unilateral, and may be
accompanied by a constant bloody discharge from the uterus. Some-
times it is combined with hematocolpos and hematometra.
Treatment. As a rule, the cystic tube with the ovary should be
removed. An exploratory laparotomy should be performed. If the
cyst is large, it is well to empty it with trocar or aspirator, and close
the opening with pressure-forceps before extirpating the tumor. If
it is small, it may be removed in toto. Some prefer the removal
through the vagina, which also may begin as an exploratory incision.
The arrest of hemorrhage may be very troublesome. It has become
necessary to leave pressure-forceps in the abdominal cavity till the
next day, and even to perform hysterectomy, but as a rule the opera-
tor will be able to control bleeding by the usual means : tying of
arteries, temporary compression with forceps, sponges, or compresses,
flushing the abdominal cavity with hot water (p. 182), uniting perito-
neal edges with a continuous suture of catgut, stitching other bleeding
places in a similar way (p. 499), and permanent compression with
iodoform gauze with or without counter-pressure in the vagina
(p. 181). (Compare Treatment of Intraligamentous Ovarian Cysts.)
Broad adhesions are often better separated with a sponge than with
the fingers. Band-like adhesions should be tied near both- ends and
cut away, as their presence later might give rise to intestinal obstruc-
tion. If there are many adhesions, the removal of the cyst is some-
times facilitated by cutting the tube between two ligatures near the
DISEASES OF THE FALLOPIAN TUBES. 543
inner end, and proceeding outward instead of going from the infundi-
bulopelvic ligament and the pelvic wall toward the uterus. In
order to guard against infection it is best to cut the tube with
Paquelin's thermo-cautery or sear the ends after having cut with
knife or scissors.
The prognosis for the operation is better in hydro- and hematosal-
pinx than in pyosalpinx.
Besides these considerations applying to cystic salpingitis in general,
each of the three varieties offers some peculiarities.
Pyosalpinx.
Pyosalpinx is that form of cystic salpingitis in which the contents
are purulent. The name is only used if an appreciable cyst has
been formed, while a small amount of pus in the tube simply
constitutes purulent salpingitis. The cyst has in most cases the size
of a Bartlett pear, but may be as large as a fetal head at term or
even a cocoanut. The wall is in general thickened, but has thin
places, especially upward and backward, where the cyst is apt to
burst during the operation for its removal. The abdominal ostium is
closed by agglutination of the fimbria3 among themselves or to the
ovary. The uterine ostium may yet be open. As a rule, the cyst is
adherent 'way down in Douglas's pouch. The uterus is often retro-
flexed.
The fluid is thick pus, sometimes of a dirty color and offensive
odor, due to the neighborhood of the intestine. In the course of
time it may change, blood being admixed with it by hemorrhages
from the wall, or it may become inspissated to a putty-like mass, or
the cellular elements may be absorbed, leaving a more serous or
mucoid fluid.
If left alone, the cyst may. rupture and discharge its contents into
the peritoneal cavity, causing sudden death, or in between the layers ^
of the broad ligament, whence it may find an outlet through the
rectum, the vagina, the bladder, or the skin, either above or below
Poupart's ligament, or in the gluteal region. Such rupture often
leaves a fistulous tract with no tendency to heal, the continued dis-
charge exhausting the patient.
Treatment. Some puncture with the aspirating needle from the
vagina, the rectum, or the skin, according to the situation of the cyst,
and when pus appears they follow the puncture up with an incision.
This method only deserves consideration if the cyst is situated in the
bottom of Douglas's pouch, and is firmly adherent, and the other set
of appendages seems to be healthy. It may be drained, as stated
above (p. 511), irrigated with antiseptic fluids, injected with tincture
of iodine, touched with a stick of nitrate of silver, or painted with
544 DISEASES OF WOMEN.
iodized phenol (a mixture of iodine 1 part and crystallized carbolic
acid 4 parts), but the absce&s may continue to discharge for many
months.
Most operators prefer laparotomy, either in one sitting or in two
acts. By the latter method the sac is made to adhere to the abdomi-
nal wall before it is opened. The common way is to operate in one
sitting, guard the peritoneal cavity against the entrance of pus by
means of large sponges or gauze compresses, and, if it has entered,
wash it out with plenty of warm normal salt solution and extirpate
the sac.
Some prefer the vaginal extirpation, as a rule, beginning with hys-
terectomy. By this method, however, it is often impossible to remove
the cyst. Then a large incision is made into it, and it is packed with
iodoform gauze, which acts as a drain, and later may be replaced by
a double-current soft-rubber drain.
Hydrosalpinx.
In hydrosalpinx the fluid is serous, mucous, or pultaceous. Some-
times it contains cholesterine. The wall is, as a rule, thin and trans-
lucent. This variety of cystic salpingitis is less apt to become adhe-
rent and is, therefore, often movable. Like pyosalpinx it is in general
bilateral, but it develops more slowly, gives rise to less pain, and
may become larger. In most cases it is not larger than a pear, but
it sometimes reaches the size of a fetal head at term, and may even
form a very large cyst (Fig. 282). Even if only one side is aifected
the patient is, as a rule, sterile. Often hydrosalpinx is accompanied
by a cystic degeneration of the ovary, and through inflammation it
may become adherent to an ovarian cyst, which may make an im-
pression as if the hydrosalpinx itself were of unusual size. Rupture
of the sac is an exceedingly rare event, and the general condition is
much better than in pyosalpinx. It is probably the remnant of an
old catarrhal or, perhaps, even a purulent salpingitis. The diagnosis
might, perhaps, be made surer by aspirating the fluid, but, being less
adherent, hydrosalpinx is less fit for this operation. We might find
ciliated columnar epithelium in the fluid, but that may also be found
in certain ovarian cysts.
Treatment. A small cyst of this kind may give so little trouble
that it may be left alone. Sometimes aspiration through the vagina
may effect a cure. The tumor may be emptied by means of an incis-
ion made in the vagina and drained, but this process may prove a
tedious one. In most cases laparotomy is performed and the tumor is
removed. If the tumor is not very large, and the ovaries are in a fair
condition, an attempt may be made to save one or both sets of append-
ages (p. 533).
DISEASES OF THE FALLOPIAN TUBES. 545
FIG. 282.
Hydrosalpinx.
Hematosalpinx.
Hematosalpinx is the name of a cyst formed by the tube and filled
with blood. There are two forms : in one the blood is not coagulated,
but kept fluid by admixture with alkaline secretion from the inside of
the tube; in the other is found a laminated fibrinous clot due to
successive hemorrhages. In the former the wall need not undergo
much change, and the blood may be reabsorbed ; in the latter the
wall is much thickened. The effused blood may be inspissated to a
syrupy mass or changed to pus, and the wall may ulcerate and finally
rupture, an accident which is much more common with hematosalpinx
than with hydrosalpinx, and has to be guarded against in operating
for atresia of the genital canal (p. 327).
Etiology. Exaiithematous and infectious diseases, phosphorus-poi-
1 Specimen from my operation on Mrs. A. N in St. Mark's Hospital, on April
30, 1892. In this case a unilateral hydrosalpinx formed a tumor filling the pelvis
and reaching to the level of the umbilicus.
35
546 DISEASES OF WOMEN.
soniug, extensive burns, and diseases of the heart, lungs, and kidneys,
may cause ecchyraosis or slight hemorrhage into the tubes.
In pyosalpinx hemorrhage may take place from the wall, and blood
mix with the pus.
When there is an occlusion of the genital canal, the menstrual blood
which normally is secreted in the tubes (p. 118) is retained and forms
hematosalpinx combined with hematocolpos and hematornetra, al-
though the communication between the tube and the uterus may be
interrupted (p. 326).
Hematosalpinx may also be due to a uterine fibroid or an inflamed
ovary, causing salpingitis by extension of the inflammation of the endo-
metrium or the ovary and closing the tube, or it may be a reflex effect
of an extra-uterine pregnancy in the other tube.
Treatment. Small tumors need no treatment. In that form which
contains fluid blood, laparotomy or colpotomy may be performed, the
tube cleaned out, made perviable, and allowed to remain (p. 533). If
the cystic tube has developed down between the layers of the broad
ligament, which may be supposed when it is low down and immovable,
an incision may be made in the vaginal vault and the cyst drained.
Large tumors filled with clots or* blood mixed with pus should be
removed by laparotomy. The same procedure becomes necessary
after the operation for atresia of the genital canal, if it has not pre-
ceded it (p. 327).
CHAPTER III.
DISPLACEMENTS.
THE tube may be found in a crural or inguinal hernia, and is then
generally accompanied by the ovary.
In the higher degrees of inversion of the uterus the tubes are
always drawn into the sac formed by the inverted uterus (p. 462).
CHAPTER IV.
NEOPLASMS.
THE neoplasms of the tubes are not of much practical interest, as
they often cannot be diagnosticated, are so small that they do no harm,
or appear together with affections of greater importance in the neigh-
boring organs.
A. Cysts. Real cysts, which are something entirely different from
cystic salpingitis (p. 541), may be found in all three layers composing
the wall of the tube. They range in size from a millet-seed to a wal-
nut, and contain a citrine, serous fluid. They are seen very frequently
DISEASES OF THE FALLOPIAN TUBES. 547
in laparotomies and autopsies. One of them situated at the abdominal
end of the tube is so common that it is described in works on normal
anatomy under the name of the hydatid of Morgagni (p. 30). Some
of these cysts are doubtless remnants of the Wolffiau body (p. 20), and
others are the result of extravasations of blood. 1
The fluid contained in them is so bland that, even if through a
rupture in the wall it should find its way into the peritoneum, it
could hardly do any harm.
B. Fibroma. Myomatous and fibrous tumors like those of the
uterus (p. 468) are formed in the muscular coat, but do not, as a rule,
acquire surgical dimensions. In one case, however, the growth had
reached the size of a fetal head at term.
C. Lipoma. Fatty tumors of the size of a bean to that of a walnut
have been found at the lower side.
D. Papillomu, a real neoplasm, must not be confounded with the
growth of the mucous membrane due to simple hyperplasia and
hypertrophy accompanying salpingitis (p. 525). Papillomatous tumors
may close, dilate, and even rupture the tube, in which latter case a
papillomatous infection would be likely to take place in the peri-
toneum. They are commonly small, but may reach the size of an
orange.
E. Cancer, either carcinoma or sarcoma, may occur primarily in
the tubes, but is nearly always secondary to cancer of the uterus or
the ovary.
The disease makes its appearance about the time of the menopause,
and develops slowly. It gives rise to a sanious discharge from the
vagina, which, in connection with the presence of a tumor and the
absence of signs of uterine or vaginal cancer, may lead to a diagnosis.
As a rule, it is not recognized before an autopsy is made.
If it can be diagnosticated in life, the, tube and ovary should be
removed by laparotomy.
F. Tuberculosis. The Fallopian tube is more apt than any other
part of the genital apparatus to be the seat of tuberculosis. In fact
the tubes are affected in nearly all cases of tuberculosis of the genital
tract, and genital tuberculosis is much more common than was for-
merly surmised.
It may be primary in this locality, and is then probably due to
infection through the semen of a tuberculous man. Much more fre-
quently, however, it is secondary, following tubercular peritonitis or
being the effect of infection through the blood in persons suffering
from phthisis. As a rule, both tubes are affected.
The wall is swollen, its epithelium is thrown off, the ostia are
generally closed, the caliber is enlarged, and the tube is filled with a
1 This was so in a case of chronic oophoritis and salpingitis operated on by me and
examined miscroscopically by Charles Heitzmann.
548 DISEASES OF WOMEN.
caseous mass. The microscope reveals the characteristic formation of
tubercles in the wall nuclei centering around giant cells and the
presence of Koch's bacillus in the tissue and in the secretion. Often
the peritoneum in the vicinity is studded with miliary tubercles. In
advanced cases the whole mucous membrane is destroyed. The tubes
are in general out of place, often drawn down along the edges of the
uterus, and bound to neighboring parts by adhesions. They may
form tumors as large as a goose-egg, the shape of which is that of a
sausage, a club, or most frequently a string of 3 to 5 beads, the
single knobs of which are round or oval and hard, while in pyosal-
pinx they are soft. Another point of difference between the two is
that in pyosalpinx the part of the tube situated near the uterus is
nearly always free, while in tuberculosis the disease affects this part
and even the intramural portion as well.
Sometimes tubes, ovaries, and uterus are all matted together by
exudation into one large mass.
The disease is very rarely acute; in general it has a chronic course.
The symptoms are like those of salpingitis.
The diagnosis is often obscure ; but occasionally it may be made by
reference to hereditary predisposition ; by finding signs of tuberculosis
in other parts, especially the lungs ; by finding caseous masses and
bacilli in the vaginal secretion ; and by the peculiarities of the tumor
just mentioned.
Treatment. As a prophylaxis connection with a man affected with
tuberculosis should be avoided. The hygienic and medical treatment
is the same as for tuberculosis in general. If the general condition
of the patient is not too bad, saipingo-oophorectomy may perhaps
effect a cure; but on account of the adhesions the operation is
often difficult and sometimes impossible. If the uterus participates
in the degeneration, this may be removed together with the tubes and
ovaries. But as it is uncertain if all affected tissue has been removed,
and as the operation itself by rupture of the tube and entrance of its
contents into the peritoneal cavity may spread the infection, the treat-
ment, upon the whole, is unsatisfactory. The presence of tubercular
peritonitis or a mild degree of phthisis is no contraindication for the
operation. 1
1 An exhaustive monograph by J. W. Williams on " Tuberculosis of the Female
Generative Organs" is published in Johns Hopkins Hospital Report in Pathology,
ii., Baltimore, 1892, pp. 85-144.
PART VI.
DISEASES OF THE OVARIES.
CHAPTER I.
MALFORMATIONS.
Excessive Growth. The ovaries of new-born children may have
twice the normal size, which may either be due to a uniform hyper-
plasia of all the constituent parts, or, more frequently, to fetal inflam-
mation, resulting in a preponderance of connective tissue and a partial
or total disappearance of the Graafian follicles.
Supernumerary Ovaries. Small globular, pedunculated bodies of
the same structure as the normal ovaries, and varying in size from
that of a pea to that of a hazelnut, are found in 5 per cent, of all
bodies of women. These small ovaries are situated near the peri-
toneal border of the normal ovaries.
An ovary may be more or less completely divided into two parts
by fissures. In a unique case there were even found three large
ovaries, each bound to the uterus with a separate ligament.
The possibility of supernumerary ovaries must be kept in mind
in order to explain the persistence of menstruation after the extir-
pation of both ovaries (pp. 119 and 539), the presence of two nor-
mal ovaries besides an ovarian cyst, and the occurrence of pregnancy
after double ovariotomy phenomena which have actually been
observed. 1
Absence or Rudimentary Development. Both ovaries may be absent,
a condition which usually is combined with absence of the uterus.
One ovary may be absent in cases of uterus unicornis.
More common than the total absence is a rudimentary development
of the ovary. Such rudimentary ovaries may or may not contain
Graafian follicles. In the latter case they consist, only of connective
tissue and smooth muscle-fibers.
As a rule, the rudimentary condition is found in connection with
an arrest of development of the uterus, but it may also be found when
1 For details see my article on " Malformations of the Female Genitals," in Ame>:
System of Gynecology, edited by Mann, vol. i. p. 236.
549
550 DISEASES OF WOMEN.
the uterus is normal. Women without Graafian follicles do not men-
struate, and are sterile, but may have sexual desire and a perfect female
type.
Rudimentary ovaries are often found together with an imperfect
development of the large blood-vessels, especially -the aorta, or of the
central nervous system, especially in idiots and cretins.
CHAPTER II.
DISPLACEMENTS.
ONE or both ovaries may occupy an abnormal position. In its
unusual place the ovary may have preserved its normal connections,
or it may have been cut off altogether from the broad ligament by an
inflammatory process in fetal life. It may then either float about as
a small hard body in the abdominal cavity or it may become fastened
to the lower border of the omentum.
If the displaced ovary retains its normal connections with the ala
vespertilionis and the tube, it may be found outside the pelvis or
remain in it.
Extrapdvic Displacements. It may be found in the lumbar region,
or, passing through the same openings as other hernise, it may occupy
the inguinal canal or the labium majus (inguinal hernia) ; the ante-
rior side of the thigh below Poupart's ligament (o-ural hernia) ;
the gluteal region (gluteal hernia) ; the depth of the anterior wall of
the pelvis (obturator hernia), or the anterior surface of the abdomen
(ventral hernia).
The position of the ovary in the lumbar region is very rare. It is
due to a lack of descent (p. 23), and is only found together with a
considerable arrest of development in other respects.
Inguinal hernia of the ovary may be congenital or acquired. The
congenital may be due to a deficient development of the round liga-
ment, by which the ovary, tube, and sometimes one horn of a uterus
bicornis and part of the omentum are pulled through the canal of
Nuck.
More rarely the ovary alone is found in a congenital inguinal her-
nia, into which it easily drops during intra-uterine life on account
of being much smaller than the caliber of the canal of Nuck.
The acquired form can only occur if the tube and the infundi-
bulopelvic ligament are unusually elongated and lax, and may
then be produced by a fall or similar violence.
In its abnormal place the ovary may become inflamed or undergo
cystic or cancerous degeneration.
Congenital inguinal hernia cannot be replaced. It may be pro-
DISEASES OF THE OVARIES. 551
tected by a hollow pad or, if it gives trouble, it may be extirpated.
The acquired form may be brought back through the canal and kept
back by means of a truss or the radical operation for hernia. If it
cannot pass the canal, herniotomy should be performed. If the ovary
is seriously diseased, it should be extirpated.
Crural ovarian hernia is always acquired. If the ovary cannot be
replaced by taxis, herniotomy should be performed, after which a
truss should be applied. It should only be removed, if it is so seri-
ously affected that medical and palliative treatment must be without
avail.
The other herniae through natural openings are exceedingly rare.
The ovary may be found in a ventral hernia after laparotomy, and
would offer a special indication for operating on the hernia.
The ovaries may also be drawn with the tubes into the funnel of
an inverted uterus (p. 462).
While the preceding displacements are anatomical or surgical curi-
osities, the intrapelvic displacement or prolapse of the ovary, is a com-
mon disease of considerable practical importance. 1
The normal ovaries may frequently be palpated in their normal
situation by bimanual vagi no-abdominal examination. They may
likewise be felt by recto-abdominal examination, but the latter
offers no advantage except in intact virgins or women with atresia of
the vagina.
When the ovary becomes displaced it sinks backward, downward,
and inward, describing an arc with the ligament of the ovary as a
radius and its insertion on the uterus as a center. Thus it sinks
first down on the retro-ovarian shelf (p. 91), and next into Doug-
las's pouch, and may sink as low down as the level of the os
uteri.
Etiology. The left ovary is much more frequently prolapsed than
the right, the cause of which is probably to be sought chiefly in the
absence of a valve in the ovarian vein on this side, and its opening
into the renal vein under a right angle circumstances that favor
passive hyperemia in the gland and predispose to disease (p. 74).
The presence of the rectum on the left side and the motion of hard
fecal lumps downward help also to dislodge the ovary.
The mere increase in weight of the ovary is sufficient to cause it
to prolapse, as is proved by cases in which, after the subsidence of
swelling, the organ returns to its normal place. It may be pushed
out of place by tumors or drawn down by a retroverted or retro-
flexed uterus or by adhesions remaining after pelvic peritonitis. It
may also sink on account of insufficient support from below, espe-
cially rupture of the vaginal entrance (p. 305).
1 This disease has been treated of in an exhaustive way by P. F. Munde, Trans.
Amer. Oyn. Soc., 1879, vol. iv. p. 164 et seq.
552 DISEASES OF WOMEN.
Prolonged sexual irritation may cause the prolapse by producing
hyperemia.
Pregnancy offers particularly favorable circumstances for the pro-
duction of prolapse, since the ovaries are enlarged and ascend into
the abdomen, and their attachments become softened and elongated.
Inflammation and beginning cystic degeneration increase the weight,
and are often the cause of adhesions.
Whether a normal ovary can become prolapsed by a fall or similar
injury, as is the case with the uterus (p. 454), is doubtful, but if it
is enlarged beforehand, such a traumatic impulse is enough to cause
the displacement.
Prolapse of the ovary is frequently associated with acquired ante-
flexion of the uterus, the cause of both troubles being probably sub-
involution after pregnancy and the concomitant lack of tonus in the
tissues.
It is also often combined with tubal disease.
Symptoms. The symptoms are those of chronic oophoritis com-
bined with those due to the abnormal position of the ovary. Hypere-
mia, edema, and inflammation may be both the cause and the effect
of the displacement. The patient complains of pain in the sides of
the pelvis, the sacral region, or the rectum, often shooting down to
the knee and up into the hip. It gets worse when she walks, pre-
vents her from standing for any length of time, and is sometimes
aggravated by sitting down. It is also increased very much by pal-
pation, and may continue through the whole day upon which the ex-
amination has been made. This great tenderness also renders coition
painful or impossible, and causes great pain during the passage of
hard fecal masses, and often painful tenesmus after they have been
expelled.
Menstruation is, as a rule, painful and often too profuse.
Nausea and vomiting are not rare. The whole nervous system
suffers much. The patient is tired, despondent, and irritable. Some-
times she may even have attacks of epilepsy.
Diagnosis. The diagnosis is, as a rule, easily made by bimanual
examination, when the ovary is recognized by its shape, its connection
with the uterus, its great sensitiveness if it is inflamed, or at least a
sickening feeling on pressure if it is normal. If the ovary is situated
on the retro-ovarian shelf, it is felt best by examining the patient in
the left-side position and pressing the perineum well back.
The swollen tube has a more sausage-like shape. A small pedun-
culated fibroid of the uterus is harder and not sensitive. Remnants
of pelvic inflammation are more diffuse and less tender. Sci/bala are
less tender, may often be indented or crushed, and may be removed
by enemas and aperient medicines.
Prognosis. The displaced ovary is liable to become inflamed or
DISEASES OF THE OVARIES. 553
cystic. If it is movable, the prognosis is comparatively good ; but if
it is bound in its new position by adhesions, the treatment will at best
be a very protracted one, and a cure is doubtful.
Treatment. The two chief indications are to combat hyperemia
and inflammation and to replace and retain the ovary in its normal
place. The first is aimed at by rest, keeping the bowels open (p. 225),
prohibiting sexual connection, prescribing hot vaginal douches (p.
171), using scarification of the cervical portion (p. 186), making
applications of iodine (p. 170), or inserting pledgets with ichthyol-
glycerin (p. 178) into the vagina, or by means of galvanism with the
positive pole in the vagina (p. 232).
The displaced organ should be replaced as soon as feasible, but
sometimes the above-mentioned measures must be taken first before
the ovary recovers sufficiently to be able to bear the pressure of a
pessary.
The ovary is best replaced in the genu-pectoral posture (p. 138),
and if it cannot be replaced or retained at once, the daily use of this
posture and a glass tube admitting the air into the vagina (p. 447)
may prepare the way for its final replacement.
If the ovary is adherent, it is necessary first to try to bring about
the stretching and absorption of the adhesions. This is done by
packing the vagina (p. 178). If the ovary is very tender at first,
perhaps only a single cotton ball will be tolerated, but gradually
more are put in, so as to lift the ovary up in the pelvis.
Massage (p. 190) is also a powerful means of stretching and break-
ing up adhesions.
The galvanic current has, in consequence of its electrolytic property
(p. 232), a similar effect. ,
Schultze's method is somewhat similar to that used by the same
author for uterine adhesions (p. 450). The forefinger is introduced
into the rectum of the anesthetized patient in the lithotomy position,
and bored in between the ovary and its surroundings, while the uterus
is grasped with the other hand through the abdominal wall and pulled
upward.
The retention of the ovary in its normal position is often more
difficult than its replacement. Sometimes Thomas's hard-rubber bulb-
pessary, essentially a Hodge pessary (Fig. 250, p. 446) with a
thickened upper arch, answers a good purpose. Special pessaries of
hard rubber with a crossbar of unusual width, or with a notch in the
middle or a corner cut off, have been constructed for this condition. 1
In cases in which no hard pessary can be tolerated, one of whale-
bone covered with soft rubber (p. 447) may be tried.
If these measures fail, we may have recourse to cutting operations.
If the uterus is retroverted or retroflexed, it may be brought forward
1 See the above-mentioned article by Munde.
554 DISEASES OF WOMEN.
by shortening the round ligaments (p. 448) or fastening the fundus
uteri to the abdominal wall (p. 452).
If the uterus is not displaced, but the ovarian displacement is due
to an elongation of the infundibulopelvic ligament, that may be
shortened by taking a reef in it (p. 453).
But if the ovary, besides being prolapsed, is diseased, the proper
thing to do is to perform salpingo-oophorectomy, especially by vagi-
nal section (p. 453).
CHAPTER III.
HYPEREMIA AND HEMATOMA.
A NORMAL hyperemia doubtless takes place in the ovary during
coition in consequence of contraction of the unstriped muscle-fibers
of the broad ligament (p. 57), and contributes to the expulsion of the
ovum (p. 74). A similar normal hyperemia probably returns at
regular intervals, -corresponding to menstruation. At least the gen-
eral blood-pressure of the whole system is increased before menstrua-
tion sets in (p. 117), and in some women a very considerable increase
in size may be found alternately in one ovary or the other at the
menstrual periods (p. 120). An effusion of blood also takes place
normally into the ruptured follicle after the expulsion of the ovum
(p. 71).
Pathological Anatomy. Abnormal hemorrhage may take place
into the Graafian follicles or into the stroma of the ovary, the fol-
licular being much more common than the stromal. Follicular hem-
orrhage forms a tumor that is rarely larger than a hazelnut (Fig. 283),
but may reach the size of a walnut.
The ovary is only moderately enlarged and a little more resistant.
If many follicles are filled with blood at the same time, it is dark and
studded all over the surface with small protuberances. The sac is
thinned on the side nearest the surface. The contents are dark, thin
blood mixed with clots. In the course of time it may change into
a thick chocolate-colored fluid, which may be of the consistency of
honey. The fluid part may be absorbed altogether, leaving a granular
pigment ; or the solid parts may be absorbed, so that only a cyst filled
with serous fluid remains ; or suppuration may set in. As a rule, the
follicle does not burst, but the ovum is destroyed.
Stromal hemorrhage may cause so small an extravasation of blood
that it can only be seen with the microscope, but it may impart a red-
dish color to the ovary, and even show as minute red points oh the cut
surface. On the other hand, it may gradually, by repeated new escapes
of blood, destroy the whole tissue of the ovary, and form a hematoma
as large as a man's fist or a child's head. In other cases the tissue is
DISEASES OF THE OVARIES. 555
preserved, but so infiltrated with blood that the whole ovary is like a
sponge soaked in blood. Such enlarged ovaries are bound by adhes-
ions to the neighboring organs. The stromal hemorrhage may be
primary or follow as a secondary event after follicular apoplexy.
FIG. 283.
Hematoma of Ovary (a little less than natural size) : a, follicular hematoma, 12 millimeters
in diameter, inner measure ; fresh blood -clot easily separated from the surrounding wall,
situated in the outer end of the ovary, one-half of it touching the stroma, the other half
covered with a layer varying from 2 to 3 millimeters in thickness, without any opening;
W>, dilated follicles with serous contents ; c, Fallopian tube. 1
Any extensive hemorrhage may cause rupture of the ovary, the
blood pouring into the peritoneal cavity or penetrating between the
two layers of the broad ligament. The extravasated blood under-
goes changes similar to those just described for the follicular form.
Etiology. Hyperemia and hematoma of the ovary may be due to
any thing that causes venous stasis, such as masturbation or venereal
excesses, heart disease, pulmonary phthisis, cerebral apoplexy, tumors,
adhesions compressing the veins, or torsion of the ala vespertilionis.
Secondly, they may be referable to dissolution of the blood, such as
occurs in severe burns, phosphorus-poisoning, typhoid fever, puer-
peral septicemia, scurvy, etc.
1 Left ovary from my salpingo-oophorectomy on Mrs. P in St. Mark's Hospital,
Nov. 29, 1892. The right ovary contained a serous cyst measuring 2 cm. in
diameter.
556 DISEASES OF WOMEN.
Thirdly, hematoraa may be developed from gyroma, 1 which is the
same as corpus albicans (p. 74), and may be the terminal stage of a
corpus luteum, or tinder influence of chronic oophoritis may represent
the first stage of an endothelioma, an abnormal formation, which will be
described under Oophoritis. Gyroma may occasionally lead to the
formation of a hematoma, and endothelioma does so quite frequently.
Symptoms. A patient affected with hyperemia of the ovary is
liable to suffer from menorrhagia. At the time of menstruation she
is seized with sudden pain in the region of the ovaries, extending
down the thighs, and sometimes accompanied by neuralgia of the
breasts. She has no fever.
Hemorrhage in the ovary may take place without giving rise to
symptoms. If the collection is large, it causes pain, nausea, vom-
iting, and the ovary is felt to be enlarged. If rupture occurs, the
usual symptoms of internal hemorrhage are present, such as shock,
pallor, abdominal pain, a cold clammy skin, and a weak, rapid pulse.
If a large hematocele is formed, a fluctuating swelling can be felt
through the abdominal wall and the vagina.
Diagnosis. Hyperemia or apoplexy may be diagnosticated, if in a
healthy person one or both ovaries suddenly become enlarged and
tender without fever. In a patient affected with blood-dissolution
the apoplexy may be inferred, if she suddenly is seized with ovarian
pain, and a movable tumor can be felt in the pelvis.
A periodical increase of suffering at the time of menstruation in a
person with diseased ovaries is a sign of congestion.
The sudden appearance of the signs of internal hemorrhage in
such a person denotes that rupture of the ovary has taken place.
An extravasation of blood into the broad ligament does not extend
so high up as the tumor formed by intraperitoneal hemorrhage; indeed,
it often forms a tumor at the base of the broad ligament.
A swollen Fallopian tube often is more sausage-shaped, whereas
the ovary is more round.
Sometimes an aspirating needle may be thrust in through the vagi-
nal roof, and the bloody fluid will then help to establish a diagnosis.
Prognosis. Hyperemia can, as a rule, be cured. Hematoma may
also be absorbed, but occasionally a rupture occurs, which may end
fatally. If due to endothelioma, the whole constitution suffers, and
grave nervous symptoms are developed. The normal ovarian tissue
disappears gradually, and the ova are destroyed.
Treatment. In hyperemia, rest, inclusive of physiological rest
1 This subject was first treated by Dr. Mary Dixon Jones, and later by Dr-
Francis Foerster and Dr. H. J. Boldt, all working under the egfs of Dr. C-
Heitzmann: Jones, N. Y. Med. Jour., Sept. 28, 1889, May 10-17, 1890; Times
and Register, Apr. 30, 1892; Foerster, Amer. Jour. Obst., May, 1892, vol. xxv. p.
577 ; Boldt, International Med. Congresx, Berlin, 1890, and Deutsche med. Wochenschr.,
1890.
DISEASES OF THE OVARIES. 557
that is to say, abstinence from sexual excitement is of great import-
ance.
The general health should be improved by means of hygienic
measures and tonics (p. 225). The nervous system may be quieted
by the use of bromides. A derivation to the skin by means of blis-
ters may be useful. The bowels should be kept open. In girls of
ardent temperament or with bad habits marriage may answer a good
purpose. The usual treatment for pelvic inflammation, such as the
use of hot douches, painting with tincture of iodine, tampons with
ichthyol-glycerin or plain glycerin, or the galvanic current, should be
instituted. If there is an acute attack, the patient should stay in
bed, have an ice-bag on the hypogastric region, and be given mor-
phine enough to combat pain. If the ovaries have suffered much in
their structure, it may even become necessary to remove them. When
symptoms of rupture are present, laparotomy should be performed at
once, and the ovary from which the hemorrhage comes should be
extirpated together with its tube. The other ovary should be left,
if it is not seriously diseased.
CHAPTER IV.
OOPHORITIS.
OOPHORITIS, the inflammation of the ovary, may be acute or
chronic.
A. Acute Oophoritis and Ovarian Abscess.
The inflammation may begin on the surface, -perioophoritis, which
is identical with local peritonitis (although the ovary has no perito-
neal covering, p. 65), in the follicles, -folllcular oophoritis, or in
the stroma, interfollicular oophoritis, -just as we have seen in regard
to hemorrhage, with which it is in many cases connected in such a
way that it is difficult to say which has preceded the other. The
distinctive anatomical feature is here, as in the inflammation of other
parts of the body, the infiltration of the tissue with small round cells,
and, if suppuration supervenes, the presence of pus-corpuscles. To
the naked eye the condition is in the beginning much like hyperemia ;
the ovary is enlarged and impregnated with a reddish fluid ; later
yellow points and streaks appear; and finally these melt together,
and an abscess is formed. Of these there may be one or more. In
puerperal and gonorrheal cases usually both sides are affected ; in
others, as a rule, only one ovary is inflamed.
558 DISEASES OF WOMEN.
Before pus is formed the inflammation may end in resolution, but
the ovary rarely returns completely to its pristine condition. As a
rule, it remains enlarged by formation of new connective tissue or
becomes smaller by subsequent cicatricial retraction cirrhosis.
The ovum and the epithelium of the follicles undergo fatty degen-
eration. Sometimes they are transformed into small cysts with thick-
ened walls, or they are destroyed, leaving a cicatrix. An abscess
may destroy the whole ovary. As a rule, plastic lymph is thrown
out as a superficial covering over the abscess in the depth of the
ovary, and thus the organism is protected, but rupture may take
place into the peritoneal cavity and cause general peritonitis. The
pus in an ovarian abscess may be " laudable" or have an offensive
odor due to absorption of gas from the rectum. It may become
inspissated, and finally form an innocuous calcareous mass.
Etiology. Extensive oophoritis is a rare disease outside of the
puerperal state. It may be primary or secondary. The primary
may be caused by hyperemia and hematoma of the ovary (p. 554),
by sexual excesses, or by sudden suppression of the menstrual flow
(pp. 129, 238). It may also appear as part of a constitutional dis-
ease, such as the eruptive fevers, cholera, septicemia whether puer-
peral or not and poisoning with phosphorus or arsenic. It may
follow minor operations, such as the use of the sound, the incision
of the cervix, trachelorrhaphy, etc. The common course is that the
inflammation first attacks the endometrium, then the tubes, and finally
extends to the ovary ; but it may also reach the ovaries directly through
the lymphatics.
An ovarian abscess may even be due to a needle finding its way
from the intestine into the ovary. 1
Secondary oophoritis may also follow after peritonitis, and most
frequently it is due to gonorrheal infection, which latter works its
way up from the vagina through the uterus and tubes.
Symptoms. In most cases the symptoms are obscured by those of
the accompanying disease, especially salpingitis or peritonitis. But
sometimes it is possible to feel the ovary to be enlarged. It is the
seat of a burning pain, radiating down to the knee, to the bladder,
and the rectum, and it is exceedingly tender to the touch. The
knee on the affected side is sometimes drawn up ; occasionally there
is a reflex pain in the breast, and nearly always nausea. Like
orchitis in the male, oophoritis may alternate with mumps.
An ovarian abscess gives rise to recurrent attacks of chills and fever.
Sometimes the swollen ovary can be felt, and perhaps even fluctuation
can be made out. The abscess may open into the peritoneal cavity,
the intestine, especially the sigmoid flexure, the bladder, less fre-
quently into the vagina, and rarely even through the abdominal wall.
1 Frank W. Haviland, New York Med. Record, Oct. 2, 1892, vol. xlii. p. 398.
DISEASES OF THE OVARIES. 559
Diagnosis. It is seldom possible to make an entirely sure diag-
nosis. This can only be done if we feel the enlarged and tender
ovary. In a suppurating ovarian cyst the symptoms are less acute.
Salpingitis and pyosalpinx are sausage-shaped, the inflamed ovary and
ovarian abscess globular. Pelvic abscess is situated lower down and
absolutely immovable, while the ovarian abscess may be more or less
movable.
Prognosis. The prognosis in the common non-septic, acute oopho-
ritis is, upon the whole, favorable as to life, even if the disease rarely
ends in complete resolution. The inflammation may subside in four or
five days. The septic form is apt to form an abscess, and it is not
rare that the abscess bursts into the abdominal cavity and causes death
from septic peritonitis. If the abscess opens into the gut, the opening
may close speedily, but sometimes a fistulous communication remains,
which may give rise to exhausting fever. Since we have seen that
the ova are liable to degenerate, we can understand that oophoritis
often leads to sterility. One attack is frequently followed by others,
so-called chronic oophoritis.
Treatment. The patient must be kept quiet in bed. An ice-bag
is applied over the affected part (p. 1 87). The bowels should be kept
open with saline aperients (p. 225). Pain is to be combated with opi-
ates, preferably hypodermic injections of morphine.
If the symptoms indicate the presence of an abscess, the ovary
should be removed, either by abdominal or vaginal section. Even
if the ovary is adherent, the adhesions are fresh and can in all
likelihood be separated. Some prefer, however, under these cir-
cumstances, if the ovary is within easy reach, to aspirate, make an
incision, and drain from the vagina.
B. Chronic Oophoritis.
By chronic oophoritis is understood a chronic condition charac-
terized by the remains of acute inflammation of and in contact
with the ovary, congestion, and repeated attacks of acute inflam-
mation.
Pathological Anatomy. In most cases the ovary is enlarged to two
or three times its normal size, and has an oval or globular shape.
In others it is smaller than normal, forming an irregular shriveled
mass. Very frequently it is more or less cystic (Fig. 284). The
capillaries increase in size from the periphery toward the center, form-
ing a structure like that of erectile bodies. The anastomosis between
the ovarian and the uterine artery is dilated, which may explain the
endometritis so often found combined with chronic oophoritis. The
ovisacs and the ova are often diseased or disappear. First medullary
corpuscles are developed, and the yolk and the gerrainative vesicle
560
DISEASES OF WOMEN.
break down, leaving a granular mass ; later fibrous connective tissue
replaces the whole structure.
Sometimes the ovum undergoes colloid or waxy degeneration. The
FIG. 284.
FIG. 285.
'-a
Chronic Oophoritis : a, cut surface of ovary studded with cysts ; b, tube ; c, pedunculated
cyst hanging from the mesosalpinx. 1
follicles may be transformed into cysts with a thickened wall and
surrounded by indurated tissue. The albuginea is thickened, and
often covered with an adhesive layer
of peri tonic origin. A single cyst may
reach the size of an English walnut,
and cause the absorption of the rest of
the organ, so that the ovary is changed
to an ovarian cyst. The fluid is se-
rous and yellowish, or may by admix-
ture of blood become thick and brown.
The stroma of the ovary is harder, of
a white color, and shows hyperplasia
of fibrous connective tissue. The
hyperplastic ovary is generally free ;
the atrophic, on the contrary, im-
bedded in adhesions, to the pressure
of which its dwindling probably is due.
The formation of cysts is probably caused by congestion at the men-
strual period, if the blood-pressure is insufficient to rupture the fol-
licle or the rupture is prevented by the thickening of the, albuginea,
perioophoritic adhesions, or the too deep situation of the follicle in the
c-
Chronic Oophoritis (natural size) : a, cor-
pus luteum changed into cyst ; b,b, yel-
low masses with remnant of central
cavity ; c,c, corpora nigra : d, albuginea.
1 Specimen from my salpingo-oophorectomy on Mrs. C.
pital, on June 9, 1891.
in St. Mark's Hos-
DISEASES OF THE OVARIES. 561
stroma. Sometimes it can be seen that the cyst has formed in a
corpus luteum (Fig. 285). 1
Etiology. Chronic oophoritis is by far more common than acute.
Often the acute inflammation forms the starting-point, and the reader
is, therefore, referred to what has been said above (p. 558) in regard
to the causes of that aifection.
The disease is found most commonly in young women between
twenty and thirty years of age. The left side is oftener affected
than the right for the same reasons that we have given for the
greater frequency of prolapse on this side (p. 551). A misplaced
ovary is indeed more liable to the development of chronic oophoritis
than one in its normal situation. For the same reason retroflexion
of the womb predisposes to it. It is often found together with an
ovarian cyst on the other side.
Ordinarily, chronic oophoritis is due to puerperal or gonorrheal
infection. Other factors are venereal excesses, masturbation, and
perhaps, unsatisfied desire. The abuse of alcoholic beverages seems
also to produce the disease. Working on sewing-machines causes
pelvic congestion, and may, therefore, become a cause of chronic
oophoritis. Syphilis has also been thought to be a cause of the dis-
ease a supposition that has much to recommend it when we think
of the frequency with which that disease localizes in other glands,
and especially of the analogy with syphilitic orchitis.
Nothing is more common than to find extra vasated blood by
microscopical examination of even apparently healthy ovaries, and
larger collections of this kind can hardly fail to elicit an inflammatory
reaction in the surrounding tissue. Thus hyperemia and hematoma
may lead to chronic inflammation of the ovarian tissue, and to the
formation of cysts (p. 559).
Symptoms. The symptoms are, as a rule, more or less masked by
inflammation in the surroundings, especially salpiugitis and local
peritonitis, as well as retroflexion of the uterus.
Very frequently both ovaries are affected.
The patient complains of pain in one or both iliac fossa?, to which
often sacral pain is added. At times it extends with a neuralgic
character to the rectum, the bladder, the hip, and down to the knee.
1 Besides the large corpus luteum which has been transformed into a cyst are
found numerous small, generally oblong, yellow masses, in the centre of which traces
of a cavity are still discernible, and two corpora nigra (p. 74).
For want of a more suitable place, I wish here to refer to the calcification of cor-
pora IvJLe/a. Concretions of the bright yellow color characteristic of the recent corpus
luteum have been found imbedded either directly in the stroma of the ovary or sur-
rounded by a cyst-wall. They consist of a dense tissue impregnated with lime-salts.
Occasionally these hard bodies may even be felt through the vaginal wall, and give
rise to the impression that one has to deal with the sac of extra-uterine gestation,
containing fragments of bone (Bland Sutton, Amer. Jour. Obst., Dec. 1892, vol. xxxvi,
p. 908, and H. C. Coe, ibidem, Feb., 1892, vol. xxv. p. 246).
36
562 DISEASES OF WOMEN.
The whole leg may feel heavy. The pain is always increased at the
approach of the menstrual period, and often during intercourse espe-
cially if the uterus is retroflexed and the ovaries prolapsed or during
defecation and micturition. Any kind of exertion is badly borne.
Some patients can hardly stand or walk for any length of time. In
rare cases the pain appears regularly in the middle of the intermen-
strual period. (Compare p. 417.)
Menstruation is often irregular and too profuse. When the follicles
and ova are destroyed, there follows, on the contrary, a stage of
amenorrhea.
Very often these patients are sterile or become so secondarily after
the confinement or the abortion that gave rise to the disease.
Leucorrhea is quite common. The digestion suffers, the patient
loses flesh, and the nervous system is much upset disorders which
may end in hysteria or hystero-epilepsy.
A woman of the laboring class affected with this disease undergoes
an enormous amount of suffering, and her wealthy sister may by
invalidism be confined to her bed or her room for months or years.
Diagnosis. Often it is very difficult or impossible to tell if a mass
we feel through the roof of the vagina is an ovary or a tube, or
both matted together in one mass by peritonitic exudation. Some-
times we can, however, distinctly feel the enlarged or prolapsed ovary.
It lies more laterally and backward, and is of oval shape, while the
swollen tube is sausage-shaped and lies nearer the edge of the uterus.
The ovaries, or at least one of them (p. 120), swell regularly before
each menstrual period, and decrease after menstruation. The tender-
ness of the inflamed ovary is greater than that of any other part of
the pelvis. The pain usually gets worse at the approach of the menses.
How the examination should be made in difficult cases is described
on p. 531.
Prognosis. Chronic oophoritis rarely leads to death, although it
may do so when an abscess forms and ruptures. On the other hand,
it rarely ends in perfect recovery. It is at best a very tedious dis-
ease, causing much pain for months or years, and it may even affect
the mental condition, making the patient irritable, despondent, hys-
terical, epileptic, and weak-minded. It often entails sterility.
Treatment. The treatment coincides in most respects with that for
chronic salpingitis (p. 532). The patient should abstain as much as
possible from sexual intercourse, and stay in bed during menstrua-
tion. A depletion and much relief from pain are obtained by giving
hot vaginal douches (p. 171), painting the vaginal vault \vith iodine
(p. 170), and applying cotton tampons with ichthyol glycerin (p. 178).
If this does not effect a cure, the galvanic current should be tried.
I use it, as a rule, in the vagina (p. 232), and make the current
as strong as the patient can stand, which in most cases is up to
DISEASES OF THE OVARIES. 563
50 milliamperes. Often scarification of the cervix (p. 186), or the
application of a fly-blister, 2 to 4 square inches in size, every evening,
to the iliac region, has a good effect. Massage (p. 190) has been
much praised, and may undoubtedly do good by causing absorption
of perioophoritic adhesions that compress or pull on the ovary. But
if the ovarian inflammation is combined with pyo- or hematosalpinx,
there would be the danger of pressing the contents of the tubes into
the peritoneal cavity.
The medicinal treatment should above all consist in the administra-
tion of tonics (p. 225). The nervous troubles are often greatly bene-
fited by the use of bromides. Chloride of gold has frequently seemed
to me to reduce the size of the swollen ovary (p. 227). Rubbing
with chloroform oil (p. 226) affords temporary relief from pain. A
warm entire bath should be taken twice a week. For those who can
travel a treatment with the strong iodine brine of Kreuznach or the
iron mud of Franzensbad, Marienbad, or Schwalbach, combined with
the effects resulting from the change of air, new impressions, and
the interruption of marital relations, is often followed by decided
improvement.
This palliative treatment, carried out methodically and patiently,
is of great value, but in some few cases nothing short of an operation
will cure the patient. Even when laparotomy or colpotomy is per-
formed, the ovaries need not always be removed. If the tubes are in
a fair condition, the ovaries may be incised, diseased parts cut away,
cysts enucleated, and the wound closed again with a continuous suture
of catgut. If the ovaries are prolapsed, they may be lifted up and
fastened in a better position by stitching the round ligaments to the
anterior abdominal wall. 1
But if the ovaries are much diseased, and if the tubes are in a bad
condition, the appendages should be removed on one or both sides
(p. 534).
Appendix. Gyroma and Endothelloma. It is a peculiarity of the
ovary that, examined microscopically, it shows so many variations
that hardly two ovaries are alike, and it is, therefore, difficult to decide
what is a normal structure and what represents an abnormal process.
(See p. 72, foot-note.)
Two conditions have been described as diseases under the names
of gyroma and endothelioma, 2 which are intimately connected with
1 Polk, Amer. Jour. Obst., Sept., 1891 ; Trans. Amer. Gyn. Soc., 1893, vol. xviii.
p. 175.
* M. A. Dixon Jones, " A Hitherto Undescribed Disease of the Ovary, Endothe-
lioma changing to Angioma and Hematoma," N. Y. Med. Jour., Sept. 28, 1889,
and " Another Hitherto Undescribed Disease of the Ovaries, Anomalous Menstrual
Bodies " (Gyroma), ibid., May 10 and 1 7, 1 890. Compare foot-note on p. 72. Gyroma
is, however, doubtless the same that has been described by Patenko under the name
of corpus fibrosum in Virchovfs Archiv, vol. Ixxxiv. p. 193.
564 DISEASES OF WOMEN.
each other, and one of which, endothelioma, under some circum-
stances, is a normal development.
Gyromas (Fig. 286) are convoluted, highly refracting masses, which
in many instances replace most of the ovarian tissue. They are found
both in the cortex and in the medulla (p. 67). In the former locality
they are transformed corpora lutea abnormal menstrual bodies or
corpora lutea of pregnancy (p. 71) ; in the latter they arise from
FIG. 286.
-
Ovary containing Corpus Luteum changed into Gyroma : a, cut surface of ovary ; 6, tube ;
c, c, gyroma. 1
arteries which become obliterated by endarteritis. The convolu-
tions of gyromas are in the former case due to the convoluted figure
of the structureless membrane of the follicular wall after it has
ruptured ; in the latter they arise from the tortuous course of the
arteries (Fig. 287).
Those that are developed from the corpora lutea are due to a trans-
formation of the medullary corpuscles which are found outside and
inside of the ruptured Graafian follicle (p. 72, foot-note). Instead
of being absorbed or transformed into connective tissue, these med-
ullary corpuscles become infiltrated with an elastic or colloid sub-
stance.
In the vicinity of a gyroma the blood-vessels are in an abnor-
mal condition : the capillaries are large and straight, the veins di-
lated, and the arteries not infrequently suffering from obliterating
endarteritis and waxy degeneration. Gyromas are not found iu
the cow, pig, or sheep, and are probably always a pathological pro-
duction. 2
1 Specimen from my salpingo-oophorectomy on Mrs. M , in St. Mark's Hos-
pital, on Dec. 14, 1889.
2 Dr. Dixon Jones thinks that what has been described as corpora lutea vera or
DISEASES OF THE OVARIES.
565
Gyroma is found in all cases of endothelioma, but may also be
found independently of the latter. Clinically gyroma is character-
FIG. 287.
Gyroma X 100 (Fr. Foerster): GG, gyroma traversed by delicate tracts of fibrous connective
tissue: CC, newly-formed inflamed fibrous connective tissue; AA, arteries with slight
sclerosis and hyaline degeneration ; V. vein in transverse section ; B, capillaries.
ized by pain in the ovarian region, exhaustion, and marked nervous
disturbances, which last may proceed so far as hysteria and mental
aberration.
Endothelioma (Fig. 288) is always an outcome of ovulation, a
growth of the structureless membrane of the follicular wall (p. 69).
Similar formations are found in the pregnant cow, pig, and sheep.
Some endotheliomas are, indeed, nothing but corpora lutea of preg-
nancy, but others are transformed gyromas, which, as we have seen,
are always a pathological product. While gyromas may be found
in an ovary in varying numbers, endothelioma is invariably single.
It is composed of large alveoli, or closed spaces, filled with endo-
corpora lutea of pregnancy (p. 71) is nothing else but anomalous menstrual bodies,
gyromas and endotheliomas changing into angiomas and hematomas ( " Another
Hitherto Undescribed Disease," reprint, p. 24) a rather startling supposition (see
p. 72).
566
DISEASES OF WOMEN.
thelial cells. The wall of the alveoli consists of coarse fibrous con-
nective tissue, richly supplied with blood-vessels. The endothelial
cells are globular, fusiform, or polyhedral corpuscles, mainly arranged
FIG. 288.
Endothelioma of Ovary (Jones): C, coarse connective tissue containing V, large blood-vessels,
mainly venous in character; S, septum or prolongation of connective tissue into a closed
space filled with globular and angular corpuscles in rows ; between the rows there are
fat-globules and empty slits ; A, cellular elements.
in rows and intermixed with dark brown fat-globules and pigment-
granules.
The rows are in many places interrupted by light gaps, probably
caused by liquefaction of some of these cells.
In the vicinity of an endothelioma there are large varicose veins
and often aneurismatic arteries, which occasionally rupture, and cause
hemorrhage under the albuginea or into adjacent cysts.
Sometimes some of the cells are transformed into red blood-cor-
puscles, while others fuse together, forming vessels around the new-
formed blood. (See Hematoma, p. 556.) The endothelial growth
replaces gradually the normal ovarian tissue, and may occupy the whole
DISEASES OF THE OVARIES. 567
ovary, which, however, is not much increased in size, and sometimes
even smaller than normal. The ova are diseased or destroyed.
The clinical features of endothelioma are lancinating pain in the
region of the ovary, progressive emaciation, pronounced pallor, and
great weakness.
By destroying the patient's health and rendering her sterile the
affection is of great importance.
Both gyroma and endothelioma originate in chronic oophoritis, and,
again, they cause inflammation in the surrounding tissue. Some path-
ologists take endothelioma to be a variety of carcinoma, which fits
well with the clinical aspect.
As the presence of these conditions can only be proved by micro-
scopical examination, they cannot be a guide in regard to treatment,
but when, after oophorectomy, they are found in the removed ovaries,
they bear witness to the justifiableness of performing the operation.
CHAPTER V.
NEOPLASMS.
THE ovaries are very frequently the seat of neoplasms. Some are
cystic, others are solid.
A. Cysts.
Pathological Anatomy. Ovarian cysts offer a great variety in their
anatomical structure, but they may, nevertheless, be reduced to a few
types :
I. Dropsy of the Graafian follicle (hydrops folliculi), assuming one
of three forms : 1, a conglomeration of many small cysts in the interior
of the ovary ; 2, a similar formation, but with pedunculated cysts, by
which the whole ovary may become like a bunch of grapes (Roki-
tanski's tumor") ; and 3, the development of a few or one large cyst ;
II. Proliferating cysts, occurring in three varieties: 1, glandular,
2, papillary, and 3, mixed: III. dermoid cysts; and, IV. tubo-ova-
rian cysts. 1
1 While the author was collecting materials for his work on Diagnosis of Omrian
Oysts by means af the Examination of their Contents, he had the advantages of wit-
nessing all the ovariotomies performed in the Woman's Hospital in the State of
New York during eighteen months, and of obtaining a part of the fluid and the sac
and the ovary of the opposite side when it was diseased. Not only was the fluid
examined chemically and microscopically in every case, but many hundreds of
specimens were cut from the hardened sacs or small ovaries. In that work he refers
also in many places to the solid part of ovarian cysts, and if other occupations have
prevented him from increasing the material and utilizing it for a special essay, his
personal acquaintance with all stages of cystic degeneration of ovaries has enabled
him to better understand and value the work of other investigators in this domain.
568
DISEASES OF WOMEN.
I. Dropsical Graafom Follides.
In studying chronic oophoritis we have seen (p. 559) that often in
that disease many small follicles may be transformed into cysts, and
FIG. 289.
Ovary with many Dropsical Follicles (Leopold).
that a single follicular cyst may cause the absorption of the rest of
the ovary. Thus there is # gradual transition from oophoritis, an
FIG. 290.
Bilateral Oligocystic Ovarian Tumors (Hooper).
in
inflammatory disease, to cystic degeneration, a neoplasm, and it is
reality, in some cases, only the size of the specimen which decides us in
calling the disease by one or the other name. The proof that a cyst
is of follicular origin is the presence of the ovum ; and by the con-
formity of the structure and the fluid we are led to regard larger cysts,
DISEASES OF THE OVARIES. 569
even when the ovum has disappeared, as being developed from
follicles.
If many follicles are affected simultaneously (Fig. 289), the ovary
does not obtain very large dimensions, indeed hardly more than the
size of an hen's egg. The stroma may be unchanged or infiltrated
with medullary elements. Gradually it is absorbed.
FIG. 291.
Rokitanski's Tumor, one-third actual size (Tait) ; on the right is seen the adherent omentum.
Sometimes a few follicles become cystic, forming what is called an
oligocystic tumor (Fig. 290). Very rarely the partition between two
570
DISEASES OF WOMEN.
such cysts ruptures, so that they communicate. As a rule, only one
is developed ; or, predominating in its development, causes the atrophy
and disappearance of the others.
If only one follicle undergoes cystic degeneration, it may form a
tumor of the size of a man's head or even a uterus at term. 1
Such a large cyst is strictly monocystic. Nowhere are found rem-
nants of partitions. The wall is white, and consists of two layers of
dense fibrous connective tissue held together with a layer of loose
connective tissue, in which run blood-vessels. The arteries are thick-
ened in consequence of endarteritis. These two layers correspond
probably to the tunica propria and the combined tunica fibrosa and
albuginea (p. 68). The outside is covered with a short columnar
epithelium ; the inside has a similar epithelium with somewhat longer
cells.
The fluid is serous, alkaline, and almost colorless. It does not coag-
ulate spontaneously nor by heat. It contains paralbumin, the presence
FIG. 292.
Ovaries with Pedunculated cysts (Wiiikel) : a, anterior wall of uterus cut open, showing a
primary sarcoma of the body; 6, c, ovaries with multiple pedunculate cysts; d,e, tubes ;
/, posterior wall of bladder.
of which is characterized by its precipitation when the fluid is boiled
with a small amount of acetic acid, the precipitate being redissolved
by adding an excess of the same reagent. It contains only a few
granules and no cellular elements.
These mouocystic and oligocystic tumors are much rarer than the
proliferating and dermoid cysts.
Rokitanski's Tumor (Fig. 291). Much rarer still is that species
1 I have seen it contain a pailful of fluid (Diagnosis, p. 9).
DISEASES OF THE OVARIES.
571
of ovarian cystic tumor which from the name of the man who first
described it is called Rokitanski's tumor. In fact, only a few cases
are known. This seems always to be a bilateral affection. The
tumors grow slowly. They are of moderate size, between that of the
fist of a man and that of the head of a four-year old child. They are
composed of innumerable cysts varying from the minutest size to that
of an orange. The wall is thin and lined with columnar epithelium ;
the contents are limpid ; and the ovum is nearly always found in
every cyst.
The cysts may become more or less pedunculated, so as to impart
to the whole tumor the appearance of a bunch of grapes.
FIG. 293. A.
FIG. 293. B.
A. Inner Surface of Glandular Ovarian Cystoma (partly diagrammatic) x 120: a, connective
tissue; b, epithelium ; c, bowl-shaped depression witli small opening ; d, a similar one, the
opening closing up; ej, buds of epithelium, growing from the bottom of the bowl ; gg.
depressions in the connective tissue, from which the epithelium has been removed.
B. Same as c in Fig. 276 A, enlarged 360 times. It is composed of two pouches uniting: at the
top. The centre of each is undergoing liquefaction. A kind of thready material is seen
extending from the periphery into the interior of the pouch between the epithelial cells
(cement substance).
Fig. 292 shows the ovaries with a few pedunculated cysts on the
surface.
II. Proliferating Cysts. Proliferating cysts are also called myxoid
cystomas, in opposition to the dermoid cystomas, because their inner
surface resembles a mucous membrane. The epithet "proliferating"
572
DISEASES OF WOMEN.
has been given them because they, differing entirely from the above-
described large cysts due to dropsy of the follicle, which are strictly
monocystic with a smooth inner surface, produce new cysts or papil-
lary growths from their inner surface. With regard to these two
different kinds of proliferations the myxoid cystomas are again sub-
divided into two groups glandular myxoid cystoma and papillary
myxoid cystoma.
a. Glandular ovarian cysts have a wall composed of the same two
layers we found in the case of follicular dropsy, and a similar external
epithelium, but the internal epithelium undergoes a remarkable pro-
liferation, which results in the development of gland-like growths.
This epithelium is polymorphous ; that is to say, different forms
of cells columnar, goblet-shaped, and flat are found in it, but the
long columnar is the predominating variety. It is stratified and
forms pouches, which at first are placed regularly side by side,
and are of about the same size (Fig. 293); but in consequence
of the continued proliferation of the epithelial cells some of these
pouches become closed, thus forming a secondary cyst in the wall
of the primary cyst. At first, it is a nearly solid mass of epithe-
lial cells, but soon the cell-body begins to melt, setting the nucleus
free (Fig. 294), and forming a fluid in the secondary cyst. This
.FIG. 294.
Melting of Epithelial Cells in Secondary Cyst in the Wall of an Ovarian Cyst.
process can be followed under the microscope, and, by analogy, we
may infer that the same takes place in the primary cyst. When
the secondary cyst is formed, the same process of proliferation is
repeated, so that continually one generation of cysts is formed in
the wall of another.
Simultaneously with this production of new cavities a reduction in
their number takes place by the absorption of the partition which
separates two cysts from one another. At first there is only a small
hole of communication between the two sacs, but gradually the open-
DISEASES OF THE OVARIES.
FIG. 295.
573
Small Glandular Ovarian Cyst, with beginning absorption of partition. Slightly reduced
from natural size (Doran).
FIG. 296.
Large Glandular Ovarian Cyst, showing numerous secondary cysts and ridges as remnants
of absorbed partitions: a, primary cyst turned inside out and stuffed with cotton; 66,
secondary cysts ; cc, remnants of absorbed partitions. 1
-, at St. Mark's Hospital,
1 Specimen from my ovariotomy on Mrs. M. S-
Aug. 14, 1890. It contained sixteen quarts of fluid.
574
DISEASES OF WOMEN.
ing increases in size until, finally, only a low ridge remains as a rem-
nant of the former partition (Figs. 295 and 296).
By this continual proliferation of epithelial cells, formation of new
cysts, and absorption of partitions very large tumors are formed, in
which, as a rule, one cyst predominates, but there are invariably found
a greater or smaller number of secondary cysts in its wall. These
cysts are, therefore, always multilocular from a pathological standpoint,
even if from a surgical they may be regarded as unilocular.
The healthy ovarian tissue disappears entirely as soon as the tumor
reaches a few inches in diameter.
The glandular variety is by far the most common, and forms the
largest tumors of all. Their growth may, indeed, become so enor-
mous that they weigh more than the rest of the body (Fig. 297). 1
FIG. 297.
Enormous Glandular Ovarian Cystoma (Rodenstein).
Fig. 298, on the other hand, represents such a glandular cystoma
found in a new-born child, and enlarged thirty times.
The outer layer of the wall corresponds to the albuginea, is smooth,
of dense texture, a pearl-gray or white color, and takes no part in the
formation of secondary cysts, which exclusively takes place in the
inner layer.
The inner layer furnishes the connective tissue which, together with
the inner epithelium, enters into the composition of the secondary cysts.
It is -of a reddish color, slightly uneven, and velvety like the inside
1 The figure represents the patient after death at the age of forty-five years. The
tumor stood three feet high, covered the breasts, went down to the knees, and weighed
146 pounds (Dr. L. A. Rodenstein, Amer. Jour. Obst., 1879, vol. xii. p. 315).
DISEASES OF THE OVARIES.
575
of the stomach. Often it is brown from impregnation with extrava-
sated blood, or yellow in consequence of fatty degeneration. Some-
times it has hard spots, due to calcareous infiltration.
FIG. 298.
Congenital Multilocular Cystoma, X 30 (Winckel).
From the outer layer may grow small excrescences, covered with
the common short columnar epithelium (Fig. 299).
FIG. 299.
Papilloraatous Excrescence on Outer Surface of Myxoid Proliferating Glandular Cystoma of
Ovary (natural size): A, seen from above; B, sagittal section of tbe same, with part of
cyst-wall, showing that the papilloma was only connected with the outer part of the
wall, and did not spring from the interior of the cyst : a, papilloma, sagittal section
through pedicle; 6, main cyst; c, secondary cyst, partially filled with cheesy contents,
partially; empty ; d, secondary cyst with cheesy contents.
In the loose connective tissue between the two layers of the wall
are found plain muscular fibers, especially near the ligament of the
ovary. Sometimes cysts have been found there, and even a corpus
luteum.
The glandular cystoma has, as a rule, a pedicle.
Relation to Cancer. Being a neoplasm chiefly composed of epi-
576 DISEASES OF WOMEN.
thelial cells and a stroma of connective tissue, the glandular cystoma
approaches the structure of carcinoma. The difference is that glandu-
lar cystoma does not affect the lymphatic system, does not give rise
to relapse after extirpation, and has the tendency to produce more or
less fluid in its compartments. If, however, the epithelial prolifera-
tion predominates much, and the formation of cysts stops, the condi-
tion is passing into that of carcinoma. The appearance in the wall
of epithelial cells of much larger size than those commonly found in
the wall of ovarian cysts is likewise characteristic of beginning car-
cinoma.
Contents of Glandular Cysts. In microscopical new-formed cysts
nearly the whole body is one solid mass of epithelial cells. As a
rule, the contents become more fluid as the cyst grows, but there are
tumors called parviloeular, in which each compartment never reaches
any considerable size. The whole tumor is like a honeycomb, and
the contents never become more fluid than a thick gelatinous mass,
in which even the microscope fails to find any structure.
The fluid in common ovarian cysts is of a gray, yellow, or brown
color. It may be limpid as spring- water, or so filled with solid bodies
as not even to be translucent. Usually it is more or less viscid. The
specific gravity of the specimens examined by me varied from 1013
to 1062. Its reaction is alkaline. As a rule, it does not foam much,
if at all, on being withdrawn from the cyst.
Generally ovarian fluid does not coagulate sponta-
IG * neously ; but by being boiled, as a rule, the contents
are more or less completely turned into a solid mass.
*r ^b Ovarian fluid possesses a remarkable degree of resist-
ance to decomposition : while in ascitic fluid all form-
^ elements are destroyed within a few days, in ovarian
fluid they are sometimes preserved for weeks or months,
gfe , The fluid contains nearly always paralbumin.
& As a rule, ovarian fluid is full of a variety of form-
elements : red blood-corpuscles, epithelial cells (either
' intact or metamorphosed), nuclei, pigment-granules,
J O O finely granular globular bodies like lymph-corpuscles
Red Biood-cor- or colorless blood-corpuscles, pus-corpuscles, spindle-
shaped cells, crystals of cholesterin and of indican.
Figures 300-313 show most of these bodies. A few remarks about
them will suffice.
Besides the well-known common shape of red blood-corpuscles we
find crenated, rosette-shaped, thorn-apple-shaped, and hematoblasts
(Fig. 300).
Epithelial cells (Fig. 301) are almost constantly found. They are
columnar seen in side view, and multangular in front view. All show
signs of fatty degeneration. When this process reaches a high degree,
DISEASES OF THE OVARIES.
FIG. 301.
577
Epithelial Cells, single and grouped, in front and side view.
the epithelial cells appear as so-called gorged corpuscles, or Bennett's
large corpuscles (Fig. 302). Often vacuoles are formed in epithelial
FIG. 302.
Bennett's Large Corpuscles, or Nunn's Gorged Corpuscles i. e. epithelial cells in fatty
degeneration,
cells, which probably are a kind of disintegration leading to the
destruction of the cells.
FIG. 303.
Colloid Corpuscles.
578
DISEASES OF WOMEN.
Colloid corpuscles (Fig. 303), large and small, are probably either
parts detached from epithelial cells or a transformation of the whole
cells.
FIG. 304. FIG. 305.
Horn-cells.
Proliferating Cells.
Horn-cells (Fig. 304) are epithelial cells that have lost their proto-
plasm, have sharp ridges, and look horny.
FIG. 306. FIG. 307.
Ameboid Bodies.
A Large Bennett Cor-
puscle with ame-
boid movements.
Proliferating cells (Fig. 305) are large cells containing a brood of
younger ones in their interior, from which they escape to lead an inde-
pendent existence.
FIG. 308.
Bennett's Small Corpuscles, or Drysdale's Corpuscles i. e. nuclei in fatty degeneration.
FIG. 309. FIG. 310.
Cells with nucleus and fine dark granules
(enlarged colorless blood-corpuscles?)
Flakes of epithelium, the cells melt-
ing and setting the nucleus free.
In quite fresh fluid it is not rare to find cells with ameboid move-
ments. In Fig. 306 we see the same two cells in three different
stages of separation and amalgamation.
DISEASES OF THE OVARIES.
FIG. 312.
579
FIG. 311.
Fat-granules.
Spindle-cells from a myxofibromatous ovarian cyst.
Drysdale's corpuscles (Fig. 308) are small globular or polyhedral
clear bodies with a small number of shining granules. My inves-
Fio. 313.
Cholesterin.
tigations have led me to believe that these bodies are nuclei of epi-
thilial cells in fatty degeneration (Fig. 310).
Ovarian fluid contains also round cells with a nucleus and finely
Papillary Ovarian Cyst springing from the hilum of the ovary, the greater part of which is
not involved in the morbid growth. The cyst has forced its way between the layers of
the broad ligament as far as the Fallopian tube (Doran).
granular protoplasm (Fig. 309), the nature of which is uncertain.
Perhaps they are enlarged colorless blood-corpuscles.
580
DISEASES OF WOMEN.
b. Papillary Ovarian Cysts are by far not so common as glandular,
being found in only one out of ten ovariotomies, and do not acquire so
large proportions. They contain a comparatively small number of sec-
ondary cysts. From their inside spring dendritic or cauliflower-shaped
growths, called papillomas (Fig. 314), which may fill the secondary
cyst in which they grow, and break through its wall into a neighbor-
ing cyst, or perforate the wall of the primary cyst, so as to come to
lie in the peritoneal cavity, where they may cover the outside of the
ovary and neighboring parts.
They may even penetrate the uterus, the bladder, the rectum or
other viscera, so as to form one mass with them. The ends of papillo-
matous growths may also coalesce in the interior of the cyst, thus
forming a separate compartment or secondary cyst.
The papillae range in size from that of a pea to that of a small
orange. They are sessile or pedunculated, white, dark red, or black.
The inside of papillary cysts is usually lined with a ciliated epithe-
lium, and the fluid in their interior is not viscid or colloid, but more
watery.
This kind of tumors is often bilateral, and develops in a consider-
FIG. 315.
pmt
Superficial Papillomata on both ovaries (Coblenz) : RO, right ovary ; LO, left ovary ; /, fun-
das uteri ; nc, hyaline cyst ; pv, papillary vegetations ; cy, cystic tumors ; bg, blood-vessels ;
km, hydatid of Morgagni ; old, abdominal orifice of right tube : ots, abdominal orifice of
left tube ; lee, calcareous deposits; 11, broad ligament; Ir, round ligament ; at'; infundibulo-
pelvic ligament; ut, uterus; pru, vaginal portion of uterus; vw, vaginal wall laid open.
able number of cases between the folds of the broad ligaments. The
development is much slower than that of the glandular variety. It
DISEASES OF THE OVARIES. 581
is often accompanied by ascites, and, if removed by tapping, the fluid
reaccumulates in a short time.
It is not rare to find grains of a sand-like substance in the papillo-
matous masses, so-called corpora arenacea, or sand-bodies, like those
forming in the brain the tumor called a psammoma.
In this variety normal ovarian tissue is preserved longer than in
the glandular.
Superficial Papillomata. Papillomata on the outside of an ovary
are not always due to rupture of a papillomatous cyst. They may
also develop originally on the surface (Fig. 315).
c. Mixed Proliferating Ovarian Cysts. In one and the same cys-
toma some cavities may be of the glandular type, others of the papil-
lary. Thus there seems not to be any radical difference between the
FIG. 316.
Portion of the Wall of a Dermoid Ovarian Cyst (Ziegler) : a, wall ; 6, elevation composed of
of fatty and cutaneous tissues ; c, hairs ; d, teeth.
two varieties a point to which we shall come back in speaking of the
origin of ovarian cysts. From the history of the development of the
ovaries (p. 26) we know that from a very early period these bodies are
built up of two elements epithelial cells and connective tissue.
In the glandular cystoma the former predominates, in the papillary
the latter.
III. Dei-moid Cysts. Dermoid cysts differ entirely from all those
582 DISEASES OF WOMEN.
hitherto described, both as to sac and contents. While in the other
kinds of cysts the inner surface reminds one of the mucous membrane
of the intestinal canal, in the dermoid variety it is like skin, not only
in general appearance, but in regard to the elements that enter into
its composition (Fig. 316). Thus the inside is covered with a thick
layer of stratified epidermal cells, the most superficial flat and
without nuclei, the deeper round or polyhedral. Outside of this comes
a layer like derma, then one of subcutaneous adipose tissue, and
finally a layer of fibrous connective tissue corresponding to the outer
layer of other ovarian cysts. The derma is often raised in more or
less regular papillae. It may contain sudoriferous glands, with ducts
opening on the inner surface, or sebaceous glands opening into the
sheaths of hairs. Such hairs spring often from a small prominence
and may form a switch several feet long, rolled up into a ball, and
usually of a reddish yellow color. In other places may be seen teeth,
often in large number (up to three hundred have been found in one
cyst). Sometimes several teeth together are inserted in one piece of
bone. Even a kind of shedding may go on, a tooth with a decaying
root sitting over a young healthy one, just as in the mouth the milk-
teeth are eroded and thrown off by the permanent teeth.
If there are many teeth, the bicuspid form predominates. If there
are only few, they are generally like the incisors or canines.
Besides these attributes of the skin, many other tissues, or even
simulacra of organs, have been found in the wall of dermoid cysts :
bones (usually of the flat type), cartilage, striped and plain muscle-
fibers, gray brain matter, nerves going to the teeth, mucous membrane
like that of the intestine, a body like the submaxillary gland, a breast
with papilla, a metacarpus with articulations, a trachea, a heart with
mitral valve, columnae carneae and chordae tendinese, 1 and even an eye.
The outer surface of a dermoid cyst is, as a rule, of a dull gray or
greenish color with orange or ocherous patches.
Dermoid cysts are small or of medium size, rarely exceeding that
of the head of an adult.
Commonly only one ovary is affected, but the occurrence of the
disease on both sides is not rare.
Two or three dermoid cysts may develop in the same ovary. In
the course of time, when the separate cysts grow, the partitions
between them are absorbed, and they are blended into one.
A dermoid cyst may form adhesions and rupture into another
organ or on the surface of the body. If it opens into the bladder,
hairs may be eliminated with the urine (pUimiction).
Dermoid cysts may give rise to metastasis in the shape of small
yellow nodules on the peritoneum, of characteristic composition.
A dermoid cyst in one ovary may be combined with a proliferating
1 A. W. Johnstone, Trans. Amer. Gyn. Soc., 1893, vol. xviii. p. 305.
DISEASES OF THE OVARIES. 583
myxoid cystoraa in the other. In the same ovary some compart-
ments of a cyst may have the dermoid and others the myxoid type,
and the two kinds may even be represented in one and the same
small secondary cyst.
Contents of Dermoid Cysts. The fluid contained in dermoid cysts
is characterized by its richness in fat-globules and cholesterin. It
may be so thick that it hardly can pass through a canula, and
solidifies as soon as it is exposed to the air. It contains often lumps
of solid fat, and in a few cases this has been found in the shape of a
large number of balls of the same size and as round as billiard-
balls.
This fluid has a nauseating odor. It does not give the reaction of
paralbumin. It contains cholesterin, urea, oxalic acid, leucin, tyrosin,
and xanthin.
Dermoid cysts are much rarer than proliferating cysts, less than 4
per cent, of ovarian tumors having this type.
Before puberty this is, however, the predominating variety. Fre-
quently its occurrence is combined with an imperfect development of
the genitals.
Similar cysts have been found in other parts of the body, such as
the head, the neck, the sacrum, the pit of the stomach, the perineum,
the testicle, the uterus, 1 the organs of the chest, and other abdominal
organs, etc. ; but they are more frequent in the ovary than anywhere
else.
IV. Tubo-ovarian Cysts, or Hydrocele of the Ovary. Tubo-
ovarian cysts consist of a combination of a cystic salpingitis (p. 541)
with a cyst of the ovary. They have the shape of a retort. The
line of demarkation between the two organs is, as a rule, distinctly
visible. The fimbria? may have disappeared altogether or may be
spread over the outer surface of the ovarian cyst ; or we may find
them inside, floating from the inner surface or attached to it from
end to end.
The tubal part is covered with peritoneum, and the inner surface
has in the beginning ciliated columnar epithelium, but later the cilia
disappear, and the cells may become flattened.
The uterine opening commonly remains pervious, so that the con-
tents may from time to time, when pressure increases, be evacuated
through the vulva.
Bland Button 2 calls tubo-ovarian cysts hydrocele of the ovary, and
says there is good reason to believe that they arise in a tunic of the
peritoneum that occasionally invests the ovary, much in the same way
that the tunica vaginalis clothes the testis. The ovary is replaced by
1 W. W. Stewart of Columbus, Ga., Med. Record, Nov. 11, 1893, vol. xliv. No. 21,
p. 648.
2 Bland Sutton, Diseases of the Ovaries and Tubes, Philadelphia, 1891, p. 111.
584 DISEASES OF WOMEN.
a cyst which communicates with a distended tube, but the orifice of
communication is an adventitious opening, and does not represent the
abdominal ostium of the tube. What is usually called hydrops tubae
profluens this author calls intermitting ovarian hydrocele.
As a rule, the affection is unilateral.
All kinds of ovarian tumors may undergo this blending with
cystic salpingitis. All that has been said above about the size of the
tumor and the nature of the fluid of ovarian tumors applies, there-
fore, to tubo-ovarian cysts.
Probably a catarrhal salpingitis (p. 525) is a forerunner for the
formation of this kind of cyst. A hydrosalpinx (p. 544) is formed,
adhesion to the cystic ovary follows, the partition becomes atrophied,
and finally the two cavities form one.
All ovarian cysts may be unilateral or bilateral. Dermoid cysts
are oftener only found on one side ; proliferating papillary cysts and
Rokitanski's tumor, on the other hand, are nearly always bilateral.
Even in unilateral cases of ovarian cysts the other ovary very fre-
quently shows beginning cystic degeneration.
Pedicle. Ovarian cysts in most cases rise up into the abdomen,
and are connected with the uterus by means of a pedicle, which facil-
itates their removal. In some cases, however, and we have seen that
this applies particularly to the papillary variety, the development
takes place downward, so that the cyst is situated between the layers
of the broad ligament, more or less close up to the uterus, and has no
pedicle.
The pedicle of ovarian cysts varies much in size and composition.
It may be long or short, thick or thin, broad or narrow. It contains
always the ligament of the ovary and part of the broad ligament, and,
as the tumor grows, the Fallopian tube is drawn in, so as to form part
of it. The tube, as a rule, is both elongated and thickened. The
arteries may become as thick as the radial, and the veins as a finger.
Besides there are lymphatics, nerves, smooth muscle-fibres, and con-
nective tissue, all forming a bundle covered by a peritoneal sheath.
Torsion of Pedicle. The longer and thinner the pedicle is, the
more easily it may become twisted, the tumor rotating around its
perpendicular axis. Such rotation can only occur, if there are no
adhesions, and the tumor is of moderate size. It is probably due to
the peristaltic movement of the intestine, the differences in the state
of emptiness and fulness of intestine and bladder, the irregular
development of secondary cysts, by which the centre of gravity
changes, and to the movements of the patients. It is often caused by
the development of the pregnant uterus. It is much more ' frequent
with dermoid than other ovarian cysts.
Sudden twisting of the pedicle leads to gangrene and fatal peri-
tonitis. If it develops slowly, it causes edema and hyperemia of the
DISEASES OF THE OVARIES. 585
wall, hemorrhage into the wall and the cystic cavity, or suppuration.
The cyst-wall is dark red, nearly black. If the torsion continues,
the whole pedicle may be severed, but in the mean time, as a rule,
adhesions form with other organs, from which the tumor henceforth
draws its nourishment. Even the uterus has been found as part of
the severed mass.
The rotation of the tumor and twisting of the pedicle may involve
the intestine, and cause its occlusion. On the other hand, the twist-
ing may effect a cure of the cyst by causing atrophy, fatty degenera-
tion, and calcification of the diminished tumor.
Adhesions. As long as the ovarian cyst is covered by its columnar
epithelium, it slides freely over the surfaces with which it comes in con-
tact ; but, when the epithelium is rubbed off or covered by inflamma-
tory exudation, adhesions to the surroundings, such as the bladder, the
uterus, the intestine, the omentum, the liver, the abdominal wall, etc.,
are easily formed. These adhesions may be like long strings, which
are easily torn or divided between two ligatures; or extend over a
large surface, when they may place considerable difficulties in the
way of the removal of the tumors. By extending downward between
the layers of the broad ligament and into its base, the tumor may be-
come adherent to the ureter and the large blood-vessels of the pelvis.
Aseites. An accumulation of ascitic fluid in the peritoneal cavity
sometimes accompanies an ovarian cyst, especially the proliferating
papillary variety. The fluid may be mixed with blood, which is a
sign of a deteriorated constitution.
Fusion. When an ovarian tumor develops in each ovary, the two
may become adherent to each other in the abdomen ; the common par-
tition may be absorbed, and the two form one tumor with this peculi-
arity that it has two pedicles, one attached to each cornu of the uterus.
Intraligamentous and Extraperitoneal Development. We have seen
that while most ovarian cysts have a pedicle, some are sessile. They
develop downward between the layers of the broad ligament, and
may extend far away from their base outside of the peritoneum,
going in between the uterus and the rectum or the uterus and the
bladder, and reaching the caecum, colon ascendens, and even the
kidney.
All kinds of ovarian cysts are liable to become retroperitoneal in
this way, but this development is found most frequently in papillary
proliferating cysts.
Hemorrhage. At times more or less considerable amounts of
blood may be poured into the cystic fluid, with which it mixes,
and to which it imparts a dark red or brown color. This hemor-
rhage may come from erosion of vessels in the partitions which are
being absorbed, from ulceration of the wall, or torsion of the
pedicle.
586 DISEASES OF WOMEN.
Suppuration. The wall of a cyst may become inflamed, and the
contents changed to pus. This grave accident may be due to torsion
of the pedicle, but is most frequently attributable to puncturing of
the cyst without sufficient antiseptic precautions. It may be caused
by puerperal infection or occur spontaneously. In the latter case
pyogenic bacilli are supposed to have worked their way in from the
outer world through the genital canal or the intestine.
Rupture. An ovarian cyst may burst and pour part of its con-
tents into the peritoneal cavity, where a bland fluid is absorbed and
eliminated, especially by the kidneys. Even thick colloid con-
tents of cysts, if not mixed with blood or pus, do not irritate the
peritoneum, although their absorption requires more time. But bloody,
purulent, or ichorous fluid, as well as the contents of dermoid cysts,
causes more or less violent peritonitis or death from shock.
The rupture into the peritoneal cavity may give rise to the for-
mation of a metastatic tumor of the peritoneum, of which more will
be said presently.
Rupture may also occur into the intestine, the stomach, the vagina,
the bladder, the Fallopian tube, or through the abdominal wall,
especially the umbilicus.
Under favorable circumstances the rupture may effect a cure of the
disease.
Evidence of rupture is found in 8 or 10 per cent, of all ovarioto-
mies. This accident may be due to a fall, a blow, a kick, or similar
violence. It may also be caused by torsion of the pedicle, by great
thinness and brittleness of the wall, by the development of unusu-
ally numerous secondary cysts or perforating papillomata, fatty de-
generation, or hemorrhage into the cyst.
Calcification and Ossification. We have mentioned above (p. 575)
that frequently calcareous incrustations form hard plates in the cyst-
wall. This process may acquire such proportions that the whole
tumor is changed into a hard shell, in which even bone-corpuscles
may be found.
Cancerous Degeneration. "We have seen above (p. 576) that the
proliferating glandular myxoid cystoma may become malignant. The
same is the case with dermoid cysts, and when once degeneration into
sarcoma or carcinoma has taken place, not only neighboring organs
may be involved, but metastatic deposits may form in remote parts
of the body. It has been found that 20 per cent, or more of all
ovarian tumors become cancerous.
Metastasis. Papillomatous cysts have a tendency to cause the pro-
duction of small yellow nodules on the peritoneum. After removal of
the tumor these may disappear or become innocuous by becoming
calcified.
Glandular and dermoid cysts are much less liable to form such
DISEASES OF THE OVARIES. 587
metastases, except the glandular variety with gelatinous i. e. serai-
solid contents. When in consequence of rupture of the cyst before
or during operation part of the contents enters the peritoneal cavity,
it has in some rare cases given rise to the formation of large gelat-
inous masses covering the peritoneum ; which condition is called
pseudomyxoma of the peritoneum (Werth) or gelatinous disease of
the peritoneum (Pean). 1
The gelatin is held in the meshes of fine membranes of connec-
tive tissue, which may be covered with endothelium or columnar epi-
thelium, and carry fine blood-vessels. In, some cases this formation
may be explained as a transformed peritonitis, but in others it is cer-
tainly a growth of small solid particles of the tumor which go on
forming a tumor in the peritoneum similar to the one in the ovary,
from which they Avere broken loose at the time of the operation.
The Origin of Ovarian Cysts. In speaking of the division of
ovarian cysts into different classes (p. 567) we have seen that one
class, the so-called dropsy of the Graafian follicles, is indisputably
formed by a pathological development of one or more of such folli-
cles. It is likewise sure that a corpus luteum may be converted
into a cyst. As a rule, the cysts of this origin remain small as a
hazelnut ; but they may attain the size of an adult's head.
As to the second class, the proliferating cysts, there reigns yet con-
siderable diversity of opinion in regard to their origin, and it is very
likely that it differs in different cases. Microscopical examination
has shown that both the glandular and the papillary variety may de-
velop from a Graafian follicle. Another source may be the germinal
epithelium, which in some ovaries, even of adults, forms pouches
extending into the stroma of the ovary, much like the columns of
epithelial cells giving rise to the primordial ova and primary folli-
cles (p. 28). Even those tumors which have ciliated epithelium
may have this origin, as part of the ovary, probably by extension
from the tube, may have ciliated external epithelium instead of plain
columnar. Some claim that the papillary cystomas are developed
from remnants of the Wolffian body growing into the ovary from
the hilum, 2
The source of the glandular variety is by some thought to be a de-
generation of the intima of the arteries in the ovary. Colloid deposits
are often found in the stroma, the Graafian follicles, or a corpus
luteum ; but there is no evidence that they are the starting-point of
proliferating cysts. We find, likewise, frequently small cysts without
epithelium in the ovaries, but it is unlikely that formations of so epi-
1 A case of the kind is described on p. 46 of my Diagnosis.
2 In regard to the histogenesis of the papillary cystomata of the ovary a good
synopsis of known facts and valuable new observations are found in articles by J.
Whitridge Williams in Johns Hopkins Hospital Bulletin, No. 18, December, 1891, and
Report in Pathology, II., Baltimore, 1892.
588 DISEASES OF WOMEN.
thelial a character as proliferating cystomas originate in them. It is
not proved that connective tissue can be transformed into epithelium,
and it is, therefore, unlikely that proliferating cystomas can develop
from the stroma of the ovary.
As to the origin of dermoid cysts, the generally accepted theory is
that of invagination. The ovary is developed from the axis-cord, in
which it is impossible to distinguish the individual blastodermic layers.
In the collection of mesoblastic cells destined to form the ovary may be
included cells belonging to the epiblast, to the hypoblast or to other
parts of the mesoblast than those required for the ovary. This hap-
pens most commonly with the epiblastic cells, which form epidermis,
teeth, nails, hair, the cutaneous glands, and the central nervous sys-
tem ; more rarely with the mesoblastic cells, forming bone, cartilage,
and muscle-tissue; and least frequently with the hypoblastic cells,
whose role it is to form the epithelium of the intestine and the glands
connected with it.
When not only extraneous tissue, but more or less perfectly formed
organs are found in a dermoid cyst, it is, however, a question if this
must not rather be looked upon as a case of foetus in fcetu ; that is,
two fetuses, one of which has hardly developed and is included in
the other.
Etiology. Little or nothing is known about the circumstances that
cause the development of ovarian cysts. They are met with at all
ages. Simple cysts have been found in the ovaries of fetuses. In
young children even multilocular cystomas have been found in a small
number of cases, and Fig. 298 (p. 575) represents a congenital cystoma
of this kind. Before puberty the dermoid variety predominates.
Commonly ovarian cysts appear, however, during the period of
greatest sexual activity, between the ages of twenty and fifty years.
Single women are proportionately much more liable to the disease
than married, the reason for which may be sought in the physiolog-
ical rest which the ovaries enjoy during pregnancy and lactation.
Sometimes several members of one family are affected, which points
to a hereditary disposition.
Some think chronic oophoritis is the cause ; others have taken
chlorosis to be a factor in the production of ovarian cysts : the
monthly congestion in these patients is insufficient to cause a men-
strual discharge, but strong enough to produce hypertrophy of the
walls of the follicle, and thus start the development of a cyst.
Symptoms. If the tumor can rise freely into the abdominal cav-
ity, it may pass unnoticed until it is large enough to give the patient
the appearance of being in a state of advanced pregnancy. ' But, as
a rule, it gives rise before that to diverse abnormalities.
Quite commonly she complains of pain in one or both sides of the
pelvis or the sacral region. In some patients each menstruation is
DISEASES OF THE OVARIES. 589
accompanied by pain, fever, and increase in size of the tumor, which
symptoms are doubtless due to congestion. Sometimes the pain occurs
regularly about a week after menstruation as a kind of intermenstrual
pain (p. 417).
As a rule, the patient has an abnormal sensation in walking, sitting
down, or rising. Often she complains of cold feet, probably due to
an imperfect circulation.
In the beginning there are no menstrual disturbances ; but, when
the tumor becomes large, it is often accompanied by menorrhagia,
especially if it is intraligameutous ; and still later, when all ovarian
tissue has disappeared, menstruation often ceases altogether. On the
other hand, even after the menopause new hemorrhagic discharges
from the uterus may occur.
Even if menstruation takes place, and only one ovary is affected,
the patients are often sterile, which may be due to the diminished
number of ovules, a more difficult ovulation, inflammatory deposits,
tubal disease, the displacement of the uterus, or endometritis. On
the other hand, women with two large ovarian cysts may yet occa-
sionally become impregnated, but their pregnancy is often cut short
by abortion.
Like other abdominal tumors, and, on account of the enormous size
they sometimes attain, in a higher degree than most others, ovarian
tumors give rise to a series of symptoms, all of which are referable
to pressure.
If the tumor is prevented by intraligamentous development, adhe-
sions, or shortness of the pedicle from rising up into the abdominal
cavity, symptoms of this class begin as soon as the tumor reaches the
size of a fetal head. If, on the other hand, it leaves the pelvis, they
come much later. Pressure on the bladder causes frequent micturi-
tion ; that on the rectum, constipation. Moderate compression of the
ureters leads to a scanty excretion of urine. If one of them becomes
closed, the urine accumulates above the stricture and in the pelvis of
the corresponding kidney, causing hydrouephrosis and uremia. Press-
ure on the hemorrhoidal veins or on the trunks to which they carry the
blood the internal iliac and the superior mesenteric is conducive to
the formation of hemorrhoids. The pressure on the internal iliac
veins and the vena cava inferior may become so great that these chan-
nels practically become impervious. Under such circumstances the
blood finds an outlet through the deep and the superficial epigastric
veins, the roots of which anastomose with those of the internal mam-
mary vein ; but, as a result of the increase of the blood carried, the
veins on the lower part of the abdomen become much enlarged.
The uterus is pushed over to the opposite side by a lateral cyst.
If both ovaries are cystic, they push the uterus forward. In the begin-
ning the uterus lies, as a rule, in front of the ovarian cyst, but later
590 DISEASES OF WOMEN.
behind it. The pressure may become so great that it becomes pro-
lapsed.
Pressure on the stomach is accompanied by nausea, vomiting, and
anorexia. The liver may become flattened, and in rare cases jaundice
appears as a sign of compression of this organ or the excretory ducts
destined to convey the bile to the intestine. The apex of the heart
may be pressed outward and upward, so that the whole organ occu-
pies a more horizontal position.
Even the substance of the heart is apt to undergo fatty degener-
ation or brown induration, which may become a cause of sudden
death. The compression of the lungs gives rise to rapid and super-
ficial respiration. In rare cases a serous exudation takes place into the
cavity of the pleura. Even the lower ribs and the ensiform process
may be turned outward.
Interference with the free circulation in the femoral and ex-
ternal iliac veins causes varicosities and edema of the legs and labia
majora, which are still more increased, when the stagnation results in
the formation of a thrombus in those large venous trunks. Rarely
neuralgia appears in the legs in consequence of pressure on the sacral
plexus or the large trunks innervating the lower extremities. Some-
times a certain variability is observed in the pressure-symptoms.
They increase during congestion of the tumor and diminish in conse-
quence of profuse menstruation, diarrhea, and abundant diuresis.
In some cases a blowing sound may be heard with the stethoscope
on the abdomen, like the uterine souffle of pregnancy. It is probably
due to compression of the large blood-vessels of the pelvis. The
abdominal wall becomes thin, the umbilicus protrudes, and the skin is
the seat of striae, due to rupture of the corium. This tension of the
skin may be accompanied by painful burning and exasperating itch-
ing, which disturb the sleep of the patient.
A symptom that often is the first to bring the patient to the phy-
sician is the increase in size of the abdomen. Sometimes she can
distinctly tell that the swelling has begun in one iliac fossa ; and, per-
haps, we can yet feel it there ourselves ; but when the tumor grows
large, it becomes central and fills the abdomen. The rapidity with
which it grows varies much. The glandular variety grows fastest of
all, and becomes largest ; the papillary grows more slow T ly, and does
not acquire such large proportions; the paucilocular dropsy of the
Graafian follicles and a monocystic dermoid cyst develop most slowly
and remain smallest of all.
The larger the tumor becomes, the more the patient leans backward
in order to move the center of gravity into a more favorable .position,
just as a pregnant woman does. When the growth becomes too heavy
and unwieldy, she cannot walk at all. She cannot even lie on her back,
but only on the side, and can only turn with the assistance of others.
DISEASES OF THE OVARIES.
591
In the beginning the general health is good, but soon the patient
begins to lose flesh and strength. Digestion, respiration, circulation,
innervation, all suffer. Sleep is often disturbed. Pain, anxiety, and
loss of adipose tissue give her face a peculiar expression, the so-called
fades ovariana (Fig. 317), characterized by pinched features and deep-
ening furrows.
FIG. 317.
Fades Ovariana (Spencer Wells).
In rare cases the breasts may undergo a development similar to
that of pregnancy. Sometimes aphthous stomatitis develops toward
the end.
As a rule, the disease ends fatally, and many are the ways in which
death is incurred. It may be due to lack of nutrition, dyspnoea,
hydrothorax, pleurisy, pneumonia, insomnia, exhaustion, heart-dis-
ease, hydronephrosis, nephritis, uremia, hemorrhage into the cyst,
inflammation and suppuration of the cyst, rupture into the peritoneal
cavity, twisting of the pedicle, acute or chronic peritonitis, cancerous
degeneration, etc.
By physical examination the presence of a tumor is made out. If
the patient is nervous and contracts her abdominal muscles, it may be
necessary to anesthetize her (p. 161), and certain details in regard to
the pedicle can only be ascertained in this condition.
592 DISEASES OF WOMEN.
A complete examination is to be made both of the pelvis and the
abdomen (pp. 139, 157, et seq.).
By bimanual examination (p. 141) we may find the womb dis-
placed, as described above in speaking of pressure, or we may find
the vagina elongated by being pulled up by the tumor and ending as
a funnel-shaped canal, the vaginal portion of the uterus having dis-
appeared. If the tumor is confined to the pelvis, we will feel it as
a globular elastic mass to one side of or behind the uterus. As a
rule, the tension of the cyst is too great to allow fluctuation to be
felt.
Even when the tumor is developed in the broad ligament, close up
to the edge of the uterus, a shallow furrow between the two indicates
the line of demarkation. In cases of large tumors part of the cyst
may be felt in the pelvis.
The independence of the uterus is also made out by introducing a
sound and moving the uterus. The cavity of the uterus is often
somewhat deeper than normal. Often a larger part of the tumor
may be felt through the rectum than through the vagina. Some-
times external papillomata may be felt through the rectum or the
vaginal roof.
If the tumor extends into the abdomen, we notice by inspection
that the abdomen is more prominent than usual. By palpation we
feel the resistance offered by the tumor, judge of the mobility or im-
mobility of the same, and in most cases feel fluctuation. We fold the
abdominal wall in front of the tumor, and move it in different direc-
tions, and move the tumor from side to side and up and down. In
order to feel the pedicle, one assistant pulls the uterus down with a
volsella, another lifts the tumor, and the surgeon tries to feel the hard
string extending from one to the other.
In palpating an ovarian tumor we sometimes hear and feel a super-
ficial crepitation, which is explained in different ways. I believe it to
originate in fresh adhesions between the tumor and the abdominal
wall, as I have noticed almost identically the same sensation in peel-
ing off the membranes from the inside of the uterus in performing
Cesarean section.
Percussion elicits a dull sound over the tumor, surrounded on
both sides and above by an area of tympanitic resonance due to the
intestine.
Auscultation permits us sometimes to hear a blowing sound in
enlarged and partially compressed blood-vessels.
The following measures should be taken with a tape measure :
the circumference at the level of the umbilicus and at the most prom-
inent point, if that measure differs from the first ; the distance from
the symphysis to the umbilicus and from the umbilicus to the ensi-
form process, and to both anterior superior spines of the ilium. In
DISEASES OF THE OVARIES. 593
tumors of moderate size the distance from the symphysis to the
umbilicus is longer than from the latter to the ensiform process, and
the distance from the umbilicus to the anterior superior spine of the
ilium is greater on that side where the tumor is situated. In very
large tumors these differences disappear.
In the course of the development of ovarian cysts some accidents
may occur, the clinical aspects of which would require special
attention namely, hemorrhage, inflammation, suppuration, twist-
ing of the pedicle, rupture, ascites, peritonitis, and intestinal
obstruction.
Hemorrhage. Small amounts of blood are frequently mixed with
the cystic fluid without giving rise to any symptoms, but if the intra-
cystic bleeding is considerable, it may even jeopardize the patient's
life. This occurrence is marked by a sudden increase in the size of the
tumor, a weak pulse, dyspnoea, fainting, pallor, and a cold, clammy
skin. While a moderate bleeding may, perhaps, be arrested by means
of an ice-bag placed on the abdomen, signs of serious internal hemor-
rhage call for immediate ovariotomy.
Inflammation and Suppuration. The cyst may become inflamed,
which is accompanied by fever, pain, and tenderness of the tumor.
If the inflammation passes into suppuration, the patient is seized with
more or less regularly recurring rigors, followed by profuse perspira-
tion and high temperature. Simple inflammation is treated success-
fully with ice-bags, while suppuration is an indication for immediate
removal of the cyst.
Torsion of the Pedicle. If torsion takes place very slowly, it may
develop without appreciable symptoms, except a gradual diminution
of the tumor, but if it occurs suddenly, it is accompanied by rapid
enlargement of the cyst, pain, tenderness, incessant vomiting, the
vomit soon becoming green in color, and acceleration of the pulse.
The torsion may be temporary. With its cessation the symptoms
stop. If it continues, it may lead to ascites, internal hemorrhage,
rupture of the cyst, suppuration, peritonitis, or gangrene of the
tumor. But it may also follow a more chronic course, and end the
patient's life by slow infection and marasmus. If the diagnosis of
torsion of the pedicle can be made, ovariotomy should be performed
at once.
Rupture of the Oyst. Rupture into the peritoneal cavity of small
cysts with serous contents need not produce any symptoms. If the
cyst is large and the contents watery, the fluid is soon absorbed and
disposed of by increased diuresis and perspiration. Colloid fluid may
remain for months in the peritoneal cavity.
The rupture of a cyst with bloody contents may be followed by
the development of a retro-uterine hematocele.
If pus or other irritant fluid is poured into the peritoneal cavity,
594 DISEASES OF WOMEN.
it sets up general peritonitis. Smaller amounts of fluid may, how-
ever, only cause local peritonitis and adhesions.
If a large cyst ruptures into the peritoneal cavity, the patient has
a sensation of something giving way, is seized with sudden severe
pain and faiutness. The surgeon can feel the fluid move freely in the
peritoneal cavity. In rare cases a new large tumor may form in the
peritoneal cavity (p. 587).
In some cases rupture occurs repeatedly, each time accompanied
by temporary diminution of the cyst and symptoms of peritonitis.
The effects of rupture being so very different, the appropriate
treatment must be decided on in each case according to circumstances.
If the symptoms are at all alarming, ovariotomy should be per-
formed at once.
The rupture into the stomach is marked by vomiting of cystic fluid.
That into the intestine is evidenced by evacuation of the fluid through
the anus, and diarrhoea. When rupture takes place into the bladder,
cystic fluid, hairs, and teeth may be evacuated with the urine. If
the cyst ruptures into the vagina, the contents are evacuated through
the vulva.
The evacuation through a hollow organ or through the skin, like
that into the peritoneal cavity, may be intermittent. If the com-
munication has taken place with the intestine, no infection need take
place, the opening being small and valvular, or being kept temporarily
closed by the inside of the cyst-wall applying itself against it.
The rupture through a hollow organ may effect a spontaneous cure.
It is, therefore, wise to await developments before undertaking any
dangerous operation.
Ascites. -Serous fluid may accumulate in the peritoneal cavity,
outside of the tumor, in consequence of chronic peritonitis, torsion
of the pedicle, rupture of the cyst, hydronephrosis, and, perhaps,
pressure on the vena porta. Papillary cystomas are particularly apt
to be surrounded by ascitic fluid.
A moderate amount of such fluid may be looked upon as bene-
ficial, as it prevents the formation of adhesions, and, therefore, facili-
tates the removal of the tumor. A large collection increases, of
course, the gravity of all the pressure-symptoms.
Peritonitis. Local or general peritonitis, characterized by the
usual symptoms, fever, vomiting, pain in the abdomen, great tender-
ness, exudation, and tympanites, is a very common accompaniment
of ovarian cysts. It may be caused by friction, torsion of the pedi-
cle, or rupture of the cyst. It leads to the formation of adhesions
which render the removal of the cyst more difficult or impossible.
As a rule, its occurrence should, therefore, be met by immediate
ovariotomy.
Intestinal Obstruction. As the result of pressure of a large tumor
DISEASES OF THE OVARIES. 595
on the intestine, or the formation of adhesive bands, or the torsion
of the pedicle, involving the intestine in its convolutions, the latter
may become impervious an accident characterized by the usual
symptoms, constipation, gaseous distention, pain, and vomiting,
which finally becomes stercoraceous. This grave condition calls for
immediate ovariotomy.
Explorative Puncture. The practice of withdrawing some fluid
from the tumor by thrusting the needle of an aspirator through the ab-
dominal wall, which in most cases gave valuable information about
the nature of the tumor, has practically been abandoned. The reasons
of this change are that a blood-vessel might be wounded ; or cystic
fluid find its way into the peritoneal cavity, and cause peritonitis or
metastases, especially in case of a papillary cystoma ; or suppuration
be brought on in the cyst, which, however, can be avoided by using
an aseptic syringe and disinfecting the skin ; or adhesion be caused
between the cyst and the wall. I believe, however, that the chief
explanation is to be found in the development of abdominal surgery :
while fifteen or twenty years ago most surgeons avoided operating
on other tumors than ovarian cysts, they are now prepared to attack
whatever they may find after opening the abdomen.
Aspiration through the vagina is yet frequently used in different
pelvic disorders, and thus familiarity with the fluid of ovarian cysts
is still of importance, both for diagnostic and curative purposes.
Diagnostic Value of the Examination of the Fluid. By studying
the physical, chemical, and microscopical characters of the fluid, it is
almost always possible to diagnosticate ovarian cysts from others.
Myxoid ovarian fluid has in most cases a certain appearance by
which it can be recognized at once simply by looking at it.
Viscidity is the most important physical character when present,
but it may exceptionally be wanting in ovarian and present in non-
ovarian fluid.
No chemical product peculiar to ovarian cysts has been found.
As a rule, the fluid of an ovarian cyst does not coagulate sponta-
neously, and, when it does, the coagulation takes place slowly. As-
citic fluid, as a rule, coagulates spontaneously and slowly, forming a
small coagulum. The fluid of uterine fibrocysts sometimes coagu-
lates, and then immediately after being evacuated and en masse.
Ovarian fluid, as a rule, coagulates to a great extent or entirely by
heat. That of the cysts of the broad ligament does not coagulate
by heat, unless an acid is added.
There is no pathognomonic morphological element in ovarian fluid.
The most important element in regard to diagnosis is columnar epi-
thelial cells seen in side view. Their presence excludes all other
tumors than those of the ovary, the Fallopian tube, and the broad
ligament (perhaps with the exception of the rare pancreas-cysts).
596 DISEASES OF WOMEN.
Although the small granular bodies described above, and represented
in Fig. 308, may be found in very different fluids, the presence
of very many of them in an abdominal cyst is a strong presumption
in favor of its ovarian origin.
If a cystic fluid contains hair or epidermis-cells or is composed of
fluid fat, it comes from a dermoid cyst ; but we can only conclude
that it is ovarian, if besides it contains the just-mentioned form-
elements.
A fluid as clear as spring-water and containing very few histolog-
ical elements may be found in ovarian cysts, both in true monocysts
(hydrops folliculi) and in multilocular cysts with ciliated epithelium.
Both ovarian cysts and cysts of the broad ligament may have
serous or colloid contents, but the latter is common in ovarian cysts,
rare in extra-ovarian, while a watery fluid is common in extra-ovarian,
rare in ovarian cysts.
Besides the information gained by the examination of the abstracted
fluid, explorative puncture offers the advantage that many relations
of a cyst, which were masked as long as it was full, may be felt after
it is emptied. As to the modus operandi, see p. 157.
Explorative Incision. If the symptoms and signs of an abdominal
tumor yet leave the surgeon in doubt as to its being ovarian or as to
the possibility of its removal, resort should be had to explorative
laparotomy (p. 159).
Differential Diagnosis. The diagnosis of abdominal tumors is
often so difficult, and so many mistakes have been made, that an
operator before coming to a final conclusion, and especially before
beginning an operation, should bear in mind the mistakes that have
been recorded and the means of avoiding them.
It is convenient to consider separately the diagnosis as long as the
tumor is confined to the pelvis, and when it has become abdominal.
A. Pelvic Tumor.
An ovarian tumor in the pelvis should be differentiated from 1,
cellulitis ; 2, peritonitis ; 3, hydro- and pyosalpinx ; 4, a cyst of the
broad ligament ; 5, hematoma of the broad ligament ; 6, a retroflexed
gravid uterus ; 7, extra-uterine pregnancy ; 8, retro-uterine hemato-
cele ; 9, fibroid and fibrocystic tumor of uterus ; and 10, solid ovarian
tumors.
1. Cellulitis gives the history of inflammation, and as a probable
cause, labor or abortion. The swelling is hard unless an abscess has
formed, when it is softer than a cyst. It is immovable. The limits
are less distinct.
2. Peritonitis gives a history of inflammation, and is generally
caused by the use of the sound, some operation performed on the
DISEASES OF THE OVARIES. 597
uterus, or gonorrheal infection. It is often combined with endo-
metritis and salpingitis. The swelling is immovable. The fluid is
serous, never viscid or ropy, and does not contain columnar epithelial
cells.
3. Hydro- and Pyosalpinx are usually bilateral, and form long
sausage-shaped tumors.
4. Cysts of the broad ligament have very distinct fluctuation, are
less tender, and contain, as a rule, a fluid that is thin, colorless, and
does not coagulate by heat before the addition of an acid.
5. Hematoma of the broad ligament appears suddenly, is accom-
panied by pallor and fainting, and is soon reabsorbed.
6. The retroflexed gravid uterus is accompanied by signs of preg-
nancy, and often constipation and retention of urine. The mass in
Douglas's pouch is continuous with the cervix, and can often be
replaced.
7. Extra-uterine pregnancy gives the signs of pregnancy. A
tumor is felt either independent of the uterus or attached to it.
The patient has attacks of sudden, violent pelvic pain. Sometimes
there is a bloody discharge from the uterus containing decidual
shreds.
8. Retro-uterine hematocele gives a history of sudden abdominal
pain at a menstrual period or of menorrhagia, followed by inflamma-
tion. The tumor, at first very soft, soon becomes hard.
9. Fibroids of the uterus are hard, situated in the uterus or inti-
mately connected with it. The uterus has an irregular shape. Hard
nodules are often felt.
Fibrocystic tumors may be fluctuating, but form one mass with the
uterus, and hard nodular masses are likely to be felt.
10. Solid ovarian tumors are much rarer than cysts, are hard, often
nodular, frequently accompanied by ascites, the fluid of which may, if
the tumor is cancerous, contain large round or pear-shaped cells,
isolated or in groups, and with single large nuclei.
B. Abdominal Tumor.
If the ovarian tumor has risen into the abdominal cavity, it should
be differentiated from the following swellings: 1, pregnancy (normal,
with excess of liquor amnii, with dead child, or extra-uterine) ; 2, hy-
datiform mole ; 3, hematometra, hydrometra or physometra ; 4, fibroid
or fibrocystic tumor of the uterus; 5, ascites ; 6, hematocele ; 7, encysted
peritonitic exudation ; 8, tuberculosis of the peritoneum ; 9, cancer of
the peritoneum ; 10, a cyst of the broad ligament ; 11, an omental cyst
or solid tumor; 12, hydronephrosis; 13, a renal cyst ; 14, a floating
kidney; 15, a hydatid; 16, a liver-cyst; 17, a floating liver; 18,
a pancreas-cyst; 19, a cyst or solid tumor of the spleen; 20, a cyst
598 DISEASES OF WOMEN.
of the mesentery ; 21, a cyst of the abdominal wall ; 22, a solid tumor
or swelling of the abdominal wall; 23, hydrosalpinx ; 24, spiua
bifida ; 25, dilatation of the stomach ; 26, a distended bladder ; 27,.
impacted feces; 28, tympanites; and 29, a phantom tumor.
1. Pregnancy is characterized by numerous signs, especially the fetal
heart-sound, fetal movements to be heard and felt, parts of the fetu&
to be felt by vaginal or abdominal examination, ballottement, purple
color of the vagina, and softening of the cervix and lower uterine
segment. The tumor forms one mass with the cervix and is con-
tractile.
In hydramnion the fetal heart-sounds may be inaudible and the
fetal parts may be difficult to feel, but we have the history and other
signs of pregnancy, unusual distention of the lower uterine segment,
and sometimes an open cervix, allowing the examiner to place the
finger right on the ovum.
Amniotic fluid differs from all others by containing large flat cells
filled with fat, and free masses of fat.
If the child is dead, we have, of course, no fetal sounds or move-
ments; but the history and other signs of pregnancy remain, and.the
fetus can be felt.
Extra-uterine pregnancy rarely advances so far as to form a large
abdominal tumor. We have the history and the signs, not only of
pregnancy, but of ectopic gestation (p. 597), and the fetus is even felt
more easily than in intra-uterine pregnancy.
2. A hydatiform mole may be very like an ovarian cyst, but it
differs from it by the condition of the cervix during pregnancy, the
contractility of the uterus, and the discharge of a bloody fluid con-
taining debris of the vesicles of the chorion.
3. Hematometra, hydrometra and physometra (p. 421) are all sit-
uated in the uterus, follow atresia of the genital canal, give rise to-
menstrual molimina, and do not affect the constitution.
4. Sessile fibroids are hard, nodular, and situated in the wall of the-
uterus. Pediculated fibroids may be much like an ovarian cyst, but
are harder.
Fibrocystic tumors of the uterus may be so like multilocular, colloid,,
sessile ovarian cysts that the most experienced gynecologists may be
deceived in differentiating them. The points to keep in mind are that
fibrocysts are rare, that they usually appear in persons over thirty
years of age, that the uterine cavity commonly is considerably enlarged,
that the tumor, as a rule, forms one mass with the uterus, that it*
consistency is harder, that hard masses are often felt in the upper part
of the tumor, that the patient often suffers from profuse menorrhagia,
that the development is slow, and that the constitution suffers less.
If the fluid coagulates spontaneously, rapidly, and in toto, it is proof
that the tumor is a fibrocyst.
DISEASES OF THE OVARIES.
599
5. Ascites. The abdomen appears flat, and no tumor is felt. The
fluctuation is very marked. The percussion is tympanitic on the part
of the abdomen turned upward, and dull in the dependent parts in
whatever position we place the patient. In Fig. 318 the shaded
FIG. 318.
Percussion-sound in Ascites to the left and in Ovarian Cyst to the right when the patient
lies on her back (Spencer Wells).
parts mark the dull percussion. The fluid is not viscid, forms a small
coagulum by exposure to the air, and contains flat endothelial cells and
lymph-corpuscles with ameboid movements. As a rule, the condition
is found to be due to diseases of the liver, heart or kidneys.
If the ascitic collection is so enormous as to distend the whole
abdomen, it may, however, be impossible to elicit the above-described
signs ; but then such a mass of fluid may accumulate in the 00111*86
of a few months in ascites, while an ovarian cyst takes years to grow
to such enormous proportions. The uterus is easily movable in ascites,
immovable in cases of very large cysts.
6. Hematocele (see above under Pelvic Tumor).
7. Encysted peritonitic exudation gives a history of inflammation.
The fluid is serous, like that in ascites.
8. Tuberculosis of the peritoneum is accompanied by free fluid, and
often by a tumor formed by agglutinated intestinal knuckles and
omentum, that may be hard to differentiate from an ovarian cyst.
These pseudotumors, however, are much more common in young
women than later in life, and grow much more rapidly than ovarian
cysts. Sometimes the central part of the abdominal wall is the seat of
a red blush and edema. The fluid is straw-colored, and coagulates, at
least partially, by exposure to the air. The presence of tubercles in
the lungs, pleurisy, great tenderness, on pressure, of the intestines, and
a rise in temperature in the evening, also go far to establish the diagno-
600 DISEASES OF WOMEN.
sis of tuberculosis of the peritoneum ; and as laparotomy has proved a
cure for this disease, no harm is done, if a mistake should be made. 1
9. Cancer of the peritoneum is accompanied by rapid cachexia.
The fluid often contains characteristic cells (p. 513). Large, hard,
irregular masses can be felt in the abdominal cavity.
10. Oysts of the broad ligament are much rarer than ovarian cysts,
seldom larger than an adult's head, immovable, and dip deep into the
pelvis, where they are situated close up to the uterus. As a rule,
they develop slowly. The fluid is as described above under Pelvic
Tumor. When evacuated, the tumor is slow to refill.
11. Omental cysts are situated higher up in the abdomen, and have
no connection with the pelvic organs. The fluid is serous like that
of ascites.
There may also be a solid tumor of the omentum, especially a carci-
nomatous tumor.
12. Hydronephrosis lies behind the intestine, and occupies a more
lateral position. There is a history of urinary trouble. The fluid may
contain columnar epithelial cells and a large amount of urea, but is
very unreliable, and even deceptive. Perhaps, it may be reached by
means of catheterization of the ureter (p. 165).
13. Renal cysts are rare. There is a tympanitic percussion-sound,
because the intestine lies in front of it. There is a history of urinary
trouble. These cysts develop from above downward. Sometimes the
peculiar shape of the kidney can be recognized. The fluid con-
tains much urea.
14. A floating kidney or one fastened in the iliac fossa has also
been mistaken for an ovarian cyst. In this case the characteristic
shape is still better preserved than when the organ is the seat of cystic
degeneration.
15. A hydatid of the liver develops downward from the right hypo-
chondrium, and can be felt to be continuous with the liver. The dull
percussion-sound extends uninterruptedly to the liver region. Some-
times hydatid vibration can be felt. The fluid is clear as spring-
water, does not coagulate by heat, and may contain booklets of echi-
nococci or shreds of cuticula, the parallel striatiou of which is pathog-
nomonic. In its chemical composition enter succinic acid, leucin,
grape-sugar, and inosite, but never paralbumin. (Hydatids of the
Pehns will be described in Part vii., Chap. ix).
16. Liver-cysts, other than hydatid cysts, are exceedingly rare.
They develop from the right hypochondrium. The fluid may con-
tain bile or liver-cells, and does not contain the bodies usually found
in ovarian tumors.
17. A floating liver is recognized by its shape, the clear percussion
1 Encysted tubercular peritonitis has been lucidly discussed by W. T. Howard of
Baltimore in Trans. Amer, Oyn. Soc., 1885, vol. x. pp. 41-62.
DISPOSES OF THE OVARIES. 601
in the liver region, and the possibility of replacing the liver in its
normal position.
18. Pancreas-cysts are rare and develop downward. The fluid is
acid and contains small nuclei and peculiar thready bodies. 1
19. Cysts of the spleen are very rare, develop from the left hypo-
chondrium, and the fluid is rich in leucocytes.
Solid splenic tumors retain the peculiar shape of the spleen, and are
harder.
All tumors coming from above leave for a time a resonant space
above the symphysis. The production of gas in the stomach and in-
jection of water into the intestine drive a tumor in the direction
from which it has started (p. 158).
20. Cysts of the mesentery are very rare. Perhaps both ovaries can
be felt. The tumor is sometimes freely movable in an upward direc-
tion. A kind of pedicle formed by the mesentery may extend to it
from above. The fluid is serous, without epithelial cells.
21. Cysts of the abdominal wall have no connection with the uterus.
The fluid is serous, and does not contain cellular elements.
Cysts of the urachus contain flat epithelial cells.
22. A solid tumor of the abdominal wall, especially a fibroma of
the fascia transversalis with partial cystic degeneration, has been
taken for an ovarian cyst. 2 The lack of menstrual disturbance and
of pain may give rise to a doubt, which may be cleared by examina-
tion under ether.
A thick layer of subcutaneous adipose tissue has given rise to the
same mistake, but it may be raised between the fingers, and on deep
percussion we get a clear sound.
Edema of the anterior wall is characterized by the pitting left by
pressure.
23. Hydrosalpinx very seldom forms a large tumor (p. 544). It
is, as a rule, bilateral, always monocystic, and not very tender. The
fluid is serous, and does not contain the bodies commonly found in
ovarian tumors. The presence of ciliated columnar epithelial cells
does not decide the question (p. 580).
24. Spina bifida very rarely forms a tumor in the pelvis and abdo-
men, but in one case it contained some three quarts of fluid. 3 This is
watery, colorless, limpid, without form-elements, and contains only
traces of albumin. After evacuation of the fluid the fissure in the
sacrum through which the cyst entered the pelvis may be felt.
25. Dilatation of the Stomach. Incredible as it may seem, even a
dilated stomach has been mistaken for an ovarian cyst and operated
1 Garrigues, Diagnosis, p. 86.
J An interesting case of the kind was reported by Rob. Weir, in the Med. Record,
Dec. 3, 1887, xxxiii. 703.
3 Emmet, Gynecology, 2d ed. p. 791.
602 DISEASES OF WOMEN.
on. 1 The chief points which are to be borne in mind in order to
avoid a similar mistake are the great variations in the size of the
tumor ; the change in the distribution of the tympanitic and the dull
percussion-sound, according to the presence of gas or food in the
stomach ; and the large quantities of food vomited at times, rep-
resenting nearly all that has been ingested for several days. Once
on the alert, the diagnosis can be made clear by the introduction of
an esophageal sound or the production of gas in the stomach (p. 158),
26. Distention of the Bladder. A bladder may be overdistended
with urine although the patient urinates (ischuria paradoxa), and
may form a very large tumor in the abdomen. 2 Before making his
examination the doctor should, therefore, introduce the catheter, and
empty the bladder.
27. Impaction of Feces. A patient may likewise suffer from diar-
rhea, and still carry large masses of feces in her intestines, which
may be mistaken for tumors. Before a diagnosis is made, the bowels
should be emptied with aperient medicines and large irritating enemas
(p. 174).
28. Tympanites gives tympanitic percussion-sound.
29. A phantom tumor is a curious condition sometimes met with in
hysterical patients and in those affected with caries of the vertebra?.
Through a combination of adipose tissue in the wall and tetanic con-
traction of the abdominal muscles a protuberance is formed on the
abdomen, which even may give a somewhat dull percussion-sound.
The moment the patient is anesthetized the supposititious tumor sub-
sides and disappears, leaving an area yielding the normal tympauitic
sound of the intestine.
Large extraperitoneal ovarian cysts are particularly difficult ta
diagnosticate. They have no pedicle.
Other signs, that, taken conjointly and not singly, may give rise
to a more or less strong suspicion of the existence of this kind of cyst,
are the following : 1, close adherence to the enlarged and laterally
displaced uterus; 2, elongation of the bladder, as proved by the
introduction of a steel sound ; 3, pressure on the rectum and bulging
out of the posterior vaginal cul-de-sac; 4, embarrassed defecation
and micturition ; 5, spontaneous rupture of the cyst ; 6, unusual pain
caused by the growing cyst ; 7, tympanitic percussion-sound in front
of the tumor, like that found in renal tumors; 8, an unsymmetrical
shape and preponderating development in one side of the pelvis of a
firmly fixed cyst. 3
Complications. Ovarian cysts may be complicated by many dis-
eases, some of which may be directly referable to the pressure
1 Beeves Jackson, Detroit Lancet, 1880 ; Centralblatt. fir Gynak., 1880, vol. iv. p. 368.
2 I have myself withdrawn three quarts of urine from the bladder.
8 \Vm. Goodell, Amer. Syst. of Gynecol., vol. ii. p. 830.
DISEASES OF THE OVARIES. 603
exercised by the tumor itself, while others are mere coincidences,
which, however, may have considerable influence on the prognosis
and treatment. Thus we would not perform ovariotomy, if the cyst
is accompanied by cancer of the uterus, unless the latter organs could be
extirpated at the same time an addition to the operation which, of
course, would cast a deep shadow over the prognosis. In advanced
tuberculosis or any other serious chronic disease it may also be deemed
inadvisable to subject the patient to the risks of a capital operation,
which at best will fail to prolong her life.
The complication with pregnancy is of particular interest, since it
is not so very rare, and may influence the treatment very much. It
may occur even when both ovaries form large tumors, and so much
the more so when only one is affected. The diagnosis is made from
the history and the objective find, the presence of an ovarian tumor
having been known before the patient became pregnant, or being
made out in connection with the gravid uterus. When the pres-
ence of one child is ascertained, the investigation must next be di-
rected toward the second mass, with a view to decide whether the case
is simply one of twins or of uterogestation combined with a tumor.
The simultaneous pressure of a growing uterus and an ovarian cyst
will in most cases cause so much discomfort, or even be attended with
such danger, that interference is called for. Three methods are then
at our disposal : 1, artificial abortion or premature labor; 2, tapping
of the cyst ; or, 3, ovariotomy. If possible, we would wait till the
child is viable, and then induce premature labor. Tapping has given
excellent results, and there is no serious objection to it, if performed
by a man prepared to let ovariotomy follow if untoward sequences
should develop. Ovariotomy has been performed many times during
pregnancy. The dangers of the operation are very slightly increased,
but sometimes it is followed by abortion.
Prognosis. A spontaneous cure of an ovarian cyst may take
place by means of slow torsion of the pedicle, followed by atrophy,
fatty degeneration, or calcification. Or it may be brought on by
rupture of the cyst. The tumor may also shrivel up after one or
more tappings. It may also become stationary and stop growing.
But all these occurrences are so rare, that they must be left entirely
out of consideration when the question of treatment is raised.
A patient may live twenty years with an ovarian cyst, but in the
vast majority of cases a speedy death awaits the woman affected with such
a tumor. Of those having a proliferating cystoma, 60 to 70 per cent.
die within three years, and 10 per cent, additional in the fourth year.
Treatment. Medical treatment is of no avail, and galvanopuncture
is more dangerous than ovariotomy. Noeggerath * claims that a
1 E. Noeggerath, Centralblf. Gynak., 1890, vol. xiv., "Report of Tenth Inter-
national Congress," p. 86.
604 DLSEASES OF WOMEN.
weak faradic cwrent applied three times a week for from one-half to
one hour makes a glandular proliferating ovarian tumor of small or
medium size disappear in six to eight weeks, so that only small rem-
nants of it remain. He uses the secondary current, the negative
pole, covered with a sponge, in the vagina, the positive, in the shape
of a sponge-covered plate of the size of a hand, on the abdomen. As
the procedure is innocuous, it might be tried.
Two kinds of treatment only are generally recognized namely,
tapping and ovariotomy; and it maybe stated from the beginning
that ovariotomy should be performed whenever it is practicable.
Tapping.
Tapping as a therapeutic measure is objectionable for several
reasons. It may cause hemorrhage, a danger which, however, is con-
siderably reduced by using a fine needle or trocar and canula con-
nected with an aspirator. It may cause suppuration of the cyst ; but
that may be entirely obviated by using a clean instrument, and
disinfecting the patient's skin and the operator's hands carefully.
Acrid fluid may find its way through the opening in the cyst into the
peritoneal cavity, and set up peritonitis. This may also, to a great ex-
tent, be prevented by emptying the opened cavity entirely ; but nobody
ought to tap without being prepared to have an ovariotomy follow in
case of supervening peritonitis. A malignant infection of the peri-
toneum may take place, if the tumor happens to be of the papillary
variety, and particles of the papillomatous growths are carried out into
the peritoneal cavity on withdrawing the instrument. As nearly all
ovarian cysts contain secondary cysts, these will, on removal of the
pressure from the emptied compartment, only develop so much the
faster. The tapping has to be repeated again and again, with ever
shorter intervals, thus constituting a serious drain on the strength of
the patient. The sudden evacuation of a large amount of fluid may
so change the shape of the tumor that a rotation is induced, accom-
panied by torsion of the pedicle (p. 584).
In spite of all real and imaginary dangers connected with tapping,
there are, however, circumstances under which it is perfectly proper
to have recourse to it :
1. If a patient absolutely refuses to have ovariotomy performed,
tapping may yet offer relief, and sometimes even prolong her life.
2. We have seen above (p. 603) that during pregnancy tapping has
in many cases given excellent results as a palliative measure. If the
physician is first called during actual labor, and the cyst offers an
obstruction to its progress, tapping is in many instances preferable to
any other treatment.
3. The removal of very large tumors has been attended by sudden
death on account of anemia of the brain caused by the rush of blood
DISEASES OF THE OVARIES.
605
to the abdominal organs at the cessation of the pressure exercised on
them by the tumor. Other vital organs, such as the heart, the lungs,
and the kidneys, may be so compressed by the cyst that they are not
in a condition to perform their functions properly. It
is, under such circumstances, a good plan to prepare FIG. 319.
the system for the radical operation by the preliminary
slow evacuation of some of the fluid contained in the
cyst.
4. Tapping may be indicated by the presence of an
acute disease, such as pneumonia, bronchitis, typhoid
fever, smallpox, etc., which makes it desirable to re-
move pressure, but excludes the immediate perform-
ance of ovariotomy.
5. It is also indicated in advanced chronic diseases,
such as tuberculosis, Bright's disease, and cancer.
6. Finally, in the rare cases in which ovariotomy is
impossible.
Tapping may be performed through the abdominal
wall or through the posterior vault of the vagina. It
may be performed with a large trocar, such as that
used for ascites, or by means of an aspirator. The
former is more expeditious, and, if the fluid is thick, the
only available method ; the latter is considerably safer.
If a large trocar is used, it is well to prevent the possible
entrance of air by having a soft-rubber tube attached to
it, the other end of which is kept under the surface
of some fluid in the receptacle. The instrument repre-
sented in Fig. 319 offers the further advantage that,
in case of obstruction of the canula, the trocar can be
pushed forward again.
Modus Operandi. The patient should lie on her
back. The puncture is usually made in the median
line, midway between the symphysis pubis and the
umbilicus. With a hypodermic injection of cocaine
(p. 209) the skin may be made insensible, and a small
longitudinal incision, large enough to admit the trocar,
be made through it, which leaves a better wound for
healing than if the trocar is thrust through the skin.
If an aspirator is used, the pain is so insignificant and
the opening so small that neither cocaine nor the
cutaneous incision is called for. If the canula becomes i T cr
blocked up during the flow of the fluid, a disinfected
stylet should be used to clear it without removing it. Sometimes the
obstruction is due to contact with the inside of the cyst-wall, and is
overcome by changing the direction of the canula. It is risky to open
606 DISEASES OF WOMEN.
more than one cyst at a time, as large blood-vessels may run in the
deeper parts of the cyst. After the operation the wound is closed, the
abdomen covered with a thick pad of cotton, and surrounded with a
binder, so as to counteract the loss of pressure caused by the removal
of the fluid. If there is any bleeding, which is very rare, a hare-lip
pin may be passed deep in under the lips of the wound and surrounded
by a figure-of-eight ligature. The patient should be kept in bed for
four days. (For further particulars see p. 159.)
Tapping through the vagina is much more hazardous, and likely to
give less relief, since the large compartments of a cyst are found in
the abdominal part of an ovarian cyst. If the operation is followed
by suppuration, ovariotomy must be performed or the opening in the
vagina and cyst enlarged by incision, so as to make room for a
T-shaped soft-rubber drainage-tube, through which disinfectant fluid
should be injected daily, until the discharge ceases.
Ovariotomy.
Ovariotomy is the operation by which an ovarian tumor is re-
moved from the body, while the term oophorectomy is used to desig-
nate the removal of ovaries which do not exceed the normal size of
the organ very much (p. 559).
Indications and Contraindications. In a general way it may be
said that ovariotomy is indicated in every case of ovarian cyst, and
as soon as its presence is discovered.
Small tumors may be more difficult to remove because the pedicle
is less developed, but, on the other hand, there is less danger from
adhesions. The patient is spared all the accidents to which such
tumors are liable in the course of their development (pp. 593-95).
Finally, we must take into consideration the pronounced tendency
ovarian tumors have to become malignant (p. 586).
Special indications for immediate operation are serious hemorrhage
into the cyst, suppuration of the cyst, torsion of the pedicle, rupture
into the peritoneal cavity followed by alarming symptoms, and the
occurrence of peritonitis or of intestinal obstruction.
The age of the patient need not be taken into consideration : ova-
riotomy has been performed with success in young children and in old
women over eighty years of age.
Even hemophilia is no contraindication, since the operation has
been successfully performed under such circumstances.
On the other hand, the surgeon should abstain from so capital an
operation, if the patient is in an advanced stage of tuberculosis or
ohronic nephritis or suffers from cancer in any other organ than the
ovary, unless the cancer can be removed at the same time or by a
separate operation. Cancer in the ovarian cyst itself also forms a
DISEASES OF THE OVARIES. 607
contraindication, if the disease has invaded the surroundings or in-
'fected the constitution. The same applies to any other wasting dis-
ease that may be expected soon to put an end to the patient's life.
Ovariotomy may be performed through the abdominal wall or
through the vagina, the former of which methods is by far the more
common and important.
Vaginal ovariotomy should be limited to cases of small, especially
freely movable cysts. The drawbacks in entering the abdomen from
the vagina have been set forth in speaking of oophorectomy (p. 540),
and the great frequency of adhesions of ovarian cysts recommends
particularly the abdominal section for tumors that have risen into the
abdomen. Small cysts behind the broad ligaments may be removed
by posterior colpotomy, but small intraligamentous cysts are best
reached through anterior colpotomy (p. 450).
In the following we consider only abdominal ovariotomy.
Preparatory Treatment. If the patient is weak, and has been living
in unfavorable circumstances as to food and shelter, it is advisable to
give her a chance of gaining in health and strength by proper diet
and regimen. Under all circumstances the skin is cleaned, the bowels
are emptied, and, if necessary, the functions of the kidneys regulated
(p. 196).
Some surgeons give ten grains of quinine for several days in order
to ward oif fever, which, however, is hardly necessary, unless the patient
is subject to malaria. Others praise bromides as a preventive of vom-
iting.
In regard to season, the time of the day, menstruation, lactation,
the arrangement of the room and table, the presence of spectators, the
administration of the anesthetic, the patient's dress, and disinfection,
the reader is referred to what has been said in speaking of operations
in general (pp. 192-224).
Instruments, Sponges, etc. In a simple ovariotomy very few instru-
ments are required ; but, as it is impossible to foretell with certainty
what difficulties may arise, a rather large armamentarium must be
prepared to overcome them. The following paraphernalia ought to
be within reach :
4 large flat sponges ;
4 large round sponges ;
8 small round sponges (p. 200 ; about the substitution of gauze,
see p. 201) ;
4 sponge-holders (Fig. 183, p. 213) or forceps;
1 sharp-pointed bistoury ;
1 probe-pointed bistoury ;
1 pair of long straight blunt-pointed scissors ;
1 pair of blunt-pointed scissors curved on the flat ;
1 dissecting-forceps ;
608 DISEASES OF WOMEN.
1 mouse-tooth thumb-forceps ;
1 director ;
12 pairs of small pressure-forceps (Fig. 157, p. 184);
3 pairs of small pressure-forceps with T-shaped jaws ;
6 pairs of long pressure-forceps (Fig. 267, p. 485);
2 pairs of Nelaton's cyst-forceps (Fig. 321, p. 612) ;
2 volsella (Fig. 180, p. 212) ;
2 pairs of Spencer Wells's pedicle-forceps (Fig. 322, p. 613) ;
1 male metal catheter ;
1 female metal catheter ;
1 male urethral steel sound, No. 25 French ;
2 small tenacula (Fig. 180, p. 212) ;
1 Simon's sharp spoon (Fig. 133, p. 154);
1 tenaculum-forceps ;
1 large curved trocar (Fig. 320, p. 612) ;
1 small curved trocar (Fig. 164, p. 190);
1 aspirator (Fig. 138, p. 160) ;
2 retractors ;
1 cautery-clamp (Fig. 323, p. 613) ;
1 thermo-cautery (Fig. 156, p. 183);
1 yard of rubber cord for temporary compression ;
drainage-tubes of glass and soft rubber, one of the latter T-shaped ;
1 uterine sound ;
1 dull handled needle (Fig. 185a, p. 215) ;
1 Schroeder's needle, bent at right angles (Fig. 269, p. 487) ;
1 Folk's needle (Fig. 270, p. 487) ;
2 strong curved Hagedorn needles for closing incision ;
2 smaller curved needles for passing ligatures ;
2 fine curved needles ;
6 cambric needles for the intestine ;
1 Hagedorn needle-holder;
1 common needle-holder;
Silk for ligatures and sutures, fine, medium, and strong ;
Catgut ;
Silkworm gut.
A movable electric lamp is sometimes very useful ;
For dressing : lodoform ;
lodoform gauze ;
Gutta-percha tissue ;
Salicylated, borated, or plain aseptic absorbent cotton ;
Rubber adhesive plaster ;
Flannel binder or many-tailed muslin bandage ;
6 large safety-pins.
Ovariotomy begins with laparotomy.
DISEASES OF THE OVARIES. 609
Laparotomy, 1 or abdominal section, is an operation consisting in an
incision through the abdominal wall into the peritoneal cavity. In
ovariotomy the chief steps are
1, the abdominal incision ;
2, the removal of the cyst ;
3, the closure of the wound ;
4, the dressing.
With few exceptions laparotomy is performed in the median line,
between the umbilicus and the symphysis pubis. According to dif-
ferent circumstances the incision is made longer or shorter, more or
less near the symphysis, and may be extended beyond the umbilicus
all the way up to the ensiform process.
The patient is placed on her back, extended at full length on a table,
with her feet toward the window. The necessary preparations have
been described in the general division (pp. 193-224). The operator
stands on the right side. At least one assistant besides the one who gives
the anesthetic is needed, and stands on the left side of the patient, facing
the operator. Many operators prefer, in order to avoid sources of
infection, to have as little assistance as possible, and take the instru-
ments from the tray themselves.
For operations in the pelvis Trendelenburg's position (p. 138) offers
great advantages, the organs being more exposed to view and easier
to reach. For this position the patient is turned with the head toward
the light. The operator may stand on her right, which affords him
better light, if the light comes from the side only, but has the draw-
back that he must lift his arm in a somewhat fatiguing way ; or he
may stand on her left. Often he has to change his position from one
side to the other, the principle being that, when there is any trouble,
he must stand on the opposite side to the one where he wants to see.
Plan's Position. Some surgeons prefer to operate sitting, which
becomes a necessity in very protracted operations. Pean has con-
1 Dr. Robert P. Harris of Philadelphia published in 1890 a pamphlet entitled
" Ooeliotomy. This, and not laparotomy, is the proper Greek synonym of ' abdominal
section? laparotomy being an incision of the flank only." Unfortunately this name has
been adopted to some extent.
First, it is to be regretted that the euphonious word laparotomy, with its beautiful
liquids and open vowels, should be driven out by "celiotomy" for that is not only
the pronunciation, but the modern spelling with its sharp sibilant and thin sound
of e. Secondly, when a word has existed for nearly a hundred years, has passed into
all languages, and forms the root of numerous derivatives and part of compound
words, it causes only confusion to substitute another for it. Finally, even the argu-
ment drawn from philology in favor of the new word, is to say the least, doubtful.
If it must be admitted that rj ^anapa means the soft part between the ribs and the
crest of the ilium, it is only a very slight extension to apply it to the whole abdominal
wall, and it has no other sense; whereas 77 KOIAIU means, 1, the abdominal cavity;
2, the stomach ; 3, stools; 4, the pulp of the finger ; 5, any cavity ; and consequently
the word celiotomy does not convey even approximately an idea of what is going to
be cut.
. 39
610 DISEASES OF WOMEN.
structed a special table for this purpose. The operator sits between
the patient's legs, which rest in movable hollow supports or hang
down over the operator's own thighs. For this position the operator
sits on a high chair, and the patient lies on a low table, so that he
can bend over the abdomen, and look into the peritoneal cavity.
Behind and to the left of the operator is the instrument table ; to
the right, a basin with corrosive-sublimate solution (1 : 2000), and
another with plain boiled water.
I. Incision. In many laparotomies it suffices to make an opening
large enough to admit the index- and middle fingers. If Trendelen-
burg's position is to be used, a much larger incision is needed. In
order to inspect the pelvic cavity, an incision extending from the sym-
physis pubis to the umbilicus is required. The first incision is made
with a medium-sized scalpel through the skin and subcutaneous tissue.
Bleeding vessels are secured with pressure-forceps. The next incision
severs the linea alba. If the operator misses it and goes a little out
to one of the sides, no harm is done. The only difference is that he
will see and perhaps cut through the inner fibers of the pyramidalis
or rectus muscle. The septum between the two recti is, however,
easily found by pushing a director from the opening made in the
sheath to- the sides, a resistance being met with in the median line.
Instead of this incision in the median line it has been recommended
to make the incision half an inch to the side of the median line,
whereby it is claimed that ventral hernia is avoided. 1 I have tried
it several times, but found the adaptation of the edges less accurate
than with the median incision.
In this part of the operation there is no danger, and it may be
executed rapidly, simply cutting down on the tissues. But under the
fascial and muscular tissue lies a layer of adipose tissue, the preperi-
toneal fat, 2 which forms an important landmark, for immediately
behind it is found the peritoneum.
This preperitoneal fat is, therefore, best torn with pressure-forceps
or the handle of the scalpel, until the peritoneum itself is exposed.
When the abdomen is distended by a tumor, its wall is on the
stretch, and the tissues separate more easily than in other laparoto-
mies, and in consequence of the pressure exercised on it the preperi-
toneal fat may become very much reduced. Greater care is, therefore,
needed under these circumstances in making the abdominal incision
than, for instance, in oophorectomy, or the operator risks plunging
his knife right into the cyst from the start, not to speak of wounding
organs, such as the omentum, the intestine, or the bladder, that
might be in the way.
1 Abel, Archiv fur Gyndk., xlv. 3; Flatau, Centralbl. fur Qyntik., 1894, No. 12, p.
278.
* It is sometimes called the subperitoneal fat, an expression that is apt to mislead.
DISEASES OF THE OVARIES. 611
The exposed peritoneum is seized with two pairs of pressure-for-
ceps or with a tenaculum, and lifted up in a fold, in which a small
opening is cautiously made with the knife. Before doing this all hem-
orrhage should be stopped by grasping bleeding vessels with pressure-
forceps, which are left on during the following steps of the operation,
until they are in the way, and bleeding has stopped. Now the left
index-finger is introduced, and the knife held against it and made to
cut the peritoneum from within outward until the hole is large
enough. If after a digital exploration the operator deems it neces-
sary to enlarge the opening, it is done with a pair of strong straight
scissors, one blade of which is placed inside of the abdominal cavity,
between the middle and index-fingers, which keep intestine and omen-
turn out of the way and protect the bladder ; and the other touches
the skin. Thus the whole thickness of the abdominal wall is cut
through, and bleeding vessels are caught with pressure-forceps. As
to the length of the incision, we can only say that it should not be
longer than required, but long enough to allow of all necessary
manipulations. A pressure-forceps is put on the peritoneum on either
side of the incision, so as to facilitate finding it again when the wound
is to be closed. Instead of that, the peritoneum may be sutured to
the skin in one or more places on either side. These sutures are tied
loosely and left long, so that they may serve as retractors. In closing
the wound they are gradually removed as they are reached in insert-
ing the permanent sutures.
The lower end of the incision ought, finally, to be half an inch
above the symphysis ; the upper varies according to the size of the
mass to be removed. If the incision extends beyond the umbilicus,
most operators avoid this place, as being thinner and less favorable
for healing, and go to the left of it ; but some of the best ovariotomists
cut right through it.
2. Removal of Cyst When the peritoneal cavity is opened, the
cyst appears in the wound as a pearl-gray glistening body. In order
to reduce its size the patient is turned on the side facing the operator.
Emmet's trocar (Fig. 320) is pushed into it near the upper end of the
incision, and the fluid directed down into a tub standing under the
table. Many operators prefer to let the patient stay on her back and
to use a trocar with a rubber tube attached, leading the fluid down
into the vessel destined to receive it. Howard Kelly has devised one
of glass, which is cheap and easily rendered aseptic by boiling with
soda (p. 199). 1 As soon as the cyst begins to collapse, it is seized
with a Nelaton forceps (Fig. 321) and pulled out. If there is
much fluid, the operation is considerably expedited by withdrawing
the trocar and enlarging the opening with scissors. After a little
while room will be gained for the application of a second Nelaton
1 Kelly, Amer. Jour. Obst., April, 1893, vol. xxvii. p. 581.
612
DISEASES OF WOMEN.
forceps, and sometimes even one or two volsellae may answer a
FIG. 320.
FIG. 321.
Emmet's Ovariotomy Trocar.
good purpose in pulling out the tumor. If there are several large
compartments, they are opened one after the other with trocar, scis-
sors, or fingers, from that first entered.
During the removal of the cyst the assistant
compresses the abdomen, and is particularly
careful to prevent the protrusion of the intes-
tine. He should also, during the following
steps of the operation, always keep the abdo-
men closed as much as possible by approx-
imating the edges, and covering the incision
with a sponge or a gauze pad.
If the mass of the cyst left after evacuation is
still heavy or bulky, it is best to get rid of it
by seizing the pedicle in a temporary ligature
of rubber tubing or strong silk, or with Spen-
cer Wells's pedicle-forceps (Fig. 322), or a
cautery-clamp (Fig. 323), and cutting it off at
a distance of about two inches above the com-
pression. If, on the other hand, the cyst is
collapsed and light, the pedicle is simply seized
with the fingers. As described under salpingo-
oophorectomy (p. 536), a blunt handled needle
is used to carry the pedicle ligature through,
and the Staffordshire knot (p. 536) may be
Neiaton-s cyst-forTeps?^, u ed ; but in ovariotomy it is more convenient
circular jaws with holes to cut the pedicle-silk in two halves, cross
and pegs ; B, catch. ,.-r ,,,/, , -\ . i /
them, and tie each half separately, thus form-
ing two links of a chain perforating and surrounding the pedicle.
DISEASES OF THE OVARIES.
613
As the stump of the Fallopian tube might suppurate, it ought to
be tied as close up to the uterus as convenient. When the pedicle
FIG. 322.
Spencer Wells's Pedicle-forceps.
has been tied, it is cut three-quarters of an inch above the ligature,
and treated just as the stump in salpingo-oophorectomy. Finally, it
is dropped, the intestine kept back, and the omentum spread over it.
FIG. 323.
Smith's Cautery-Clamp.
Some draw the peritoneum together over the stump and close it
with a continuous suture of catgut, expecting thereby to ward off
infection and adhesions to the intestine ; but the first may just as well
take place through the peritoneal covering, and, since the peritoneal
endothelium must be handled in stitching, it is just as liable, or per-
haps more liable, to form adhesions than the raw surface dusted with
a powder like iodoform or aristol.
Others sear the stump over the ligature, which is a good means of
preventing absorption and adhesion, but which shortens the stump
and invites the risk of burning the ligature, unless a cautery-clamp
is used.
On the other hand, it is a double assurance against hemorrhage to
seize large arteries in the stump and tie them separately.
614 DISEASES OF WOMEN.
The distal end of the stump does not slough, because new capil-
laries are speedily formed around the ligature, which carry nourish-
ment enough to the part beyond.
The silk becomes encapsulated, and is slowly absorbed ; but it has
been found as late as two years after it had been put in. If aseptic,
it is entirely innocuous.
After having dropped the pedicle, the second ovary should be brought
into view and examined. In a young woman it ought to be saved if
possible. If it is healthy, nothing is done to it. If it only shows a
few small serous cysts, they should be pricked open. A larger cyst
may be cut out and the edges united with a continuous catgut suture.
In women who have passed the climacteric or are near that period it
is safer to remove the second set of appendages, so as to prevent the
formation of a cyst on this side. The same rule applies, if the cyst
is cancerous, as experience has shown that in such cases the second
ovary is predisposed to become affected in the same way. It should
also be removed, if the uterus is the seat of a fibroid (p. 483) or
if for any other reason it is advisable to hasten the menopause.
If no blood or other fluid has escaped into the peritoneal cavity,
no attempt should be made to clean it, but the wound should simply
be closed when the rest of the operation is finished.
A separate nurse should have care of sponges and gauze pads, and
before the operator proceeds to the closure of the wound the sponges,
pads, and artery-forceps should be counted, as it has happened that
such objects have been left in the abdominal cavity, from which place
they often have been removed after a long time, and after much injury
had been caused.
3. Closure of the Abdominal Incision. In closing the wound after
laparotomies great care should be taken to unite the different layers,
and especially the fascial and aponeurotic structures, as otherwise a
ventral hernia is very apt to form. The best practice is first to close
the peritoneum with a continuous suture of thin catgut, put in either
as in simple sewing or as for buttonholes, by passing the needle
through each loop of the thread the so-called glover's suture. The
second row of sutures should unite the aponeurotic and muscular struc-
tures. This may be done with interrupted sutures or a running suture
of strong catgut. A particularly solid, but a little more tedious, way
is to use the cobbler's stitch, inserting a stitch for every quarter of an
inch with a curved handled needle, which is unthreaded and threaded
again with the other end of the thread for every stitch, so that the two
ends pass through the same hole (Fig. 327), the loops lying on both
sides and crossing under, not above, the edges. Catgut or kangaroo
tendon should be used. 1 The suture should be tightened for every
1 Henry O. Marcy, Trans. Amer. Assoc. Obstetricians and Gynecologists, 1889, re-
print, p. 23.
DISEASES OF THE OVARIES. 615
two or three stitches sufficiently to cause apposition of the lateral sur-
faces, but no constriction. Finally, the skin and subcutaneous adipose
tissue are united by deep and superficial silk sutures, or preferably by
a subcuticular, absorbable running suture, inserted parallel to the
edges of the wound and crossing from side to side, at right angles,
under the surface (Fig. 272, p. 493). Before closing the two upper
rows of sutures the wound should be irrigated with some antiseptic
fluid (p. 205).
4. Dressing. When all the sutures have been tied and cut off, the
abdomen is washed with a solution of corrosive sublimate, the wound
dusted with iodoform, a compress of iodoform gauze laid over it, and
a piece of gutta-percha tissue, an inch wider than the compress in all
directions, placed outside of it. Next, the whole anterior surface of
the abdomen is covered with a thick layer of sterilized dry absorbent
cotton ; this is held in place by two-inch-wide straps of rubber ad-
hesive plaster ; and, finally, a flannel binder or a many-tailed muslin
bandage is put around the whole abdomen and pinned in front with
safety-pins.
5. After-treatment. After the operation the patient is placed in
her bed, and surrounded by half a dozen bottles filled with hot
water. If there is no shock, she is allowed to sleep till she awakes
spontaneously. If she vomits, the measures recommended on p. 241
are taken. The urine should be drawn with a catheter three or four
times a day, if she is unable to pass it herself. Opiates should be
avoided as much as possible on account of the danger of their para-
lyzing the intestine. Pain may often be considerably relieved by
applying an ice-bag to the abdomen ; but great pain is weakening and
calls, in my opinion, for a hypodermic injection of one-eighth of a
grain of morphine.
If there is no special indication for doing it earlier, the bowels
should be moved by a gentle aperient on the third day. I prefer for
this purpose a heaping teaspoonful of sulphate of sodium, to be repeated
every four hours if needed. This salt tastes much better than sul-
phate of magnesium and does not gripe. To allow the bowels to be
at rest too long is dangerous, because it may give rise to occlusion of
the intestine by adhesions. Before the bowels are moved much relief
from flatulence is afforded by introducing a soft-rubber rectal tube.
During the first day no food is given. Thirst is relieved by very
small quantities of hot or ice-cold water or an enema of a pint of
tepid water. The following days the patient may have tea, milk,
thin oatmeal gruel, and beef-tea, in small, frequently repeated portions
(not over two ounces at a time). After the first week she may have
common food.
If everything goes well, the dressing is not touched for a week.
Then the sutures are removed as described on p. 220. The abdomen
616 DISEASES OF WOMEN.
is washed with a solution of corrosive sublimate, the sutures are
replaced by strips of rubber plaster, half an inch wide and cut out in
the middle so as to leave free exit for any discharge from the edges
of the wound. Then a similar dressing is applied as at the time of
the operation. In this way the wound is dressed once a week, and
the patient should stay in bed for three weeks.
As the broad straps of plaster adhere to the skin, and their removal
causes some pain, it is better to cut them just outside of the cotton,
leaving the ends, and fastening the new straps to them, until finally,
after three weeks, all is removed. Another way is to sew pieces of
tape to straps of adhesive plaster. The latter are fastened to the side
and part of the back of the patient, and remain undisturbed, while
the tapes cross the dressing and can be tied or untied as needed. After
removal of the plaster the abdomen is cleaned with chloroform, which
dissolves rubber plaster, and, after having been up a few days the
patient may be dismissed. She should, however, wear an abdominal
belt for at least three months.
Difficulties met with during the Operation. If an ovarian cyst does
not contain much solid matter, has no adhesions, and has a long and
strong pedicle, ovariotomy is one of the easiest operations. But numer-
ous and manifold are the difficulties which may arise, which often
cannot be foreseen, and for which the operator must be prepared.
Bladder in Front of Tumor. Just as we have seen that the blad-
der may be spread over the front of a uterine fibroid (p. 494), so this
may be the case with an ovarian cyst.
Pei'sistent Uraehus. See p. 495.
Peritoneum taken for Cyst-wall. In consequence of the irritation
caused by the tumor the peritoneum is often much thickened, and,
taking it for the adherent cyst-wall, the operator has sometimes peeled
it off from the abdominal wall. If this is only done over a small space,
it is immaterial ; but if a large surface has been denuded, the peri-
toneum, in order not to lack nourishment, and to prevent suppura-
tion, must be stitched to the abdominal wall either by a continuous
catgut suture or by the so-called mattress-suture i. e. interrupted
sutures going through the whole thickness of the abdominal wall
and tied over a quill or a small roll of adhesive plaster.
If the operator is in doubt whether he has to do with the perito-
neum or the adherent cyst-wall, it is better to continue cutting cau-
tiously, even at the risk of extending the incision into the cyst.
Adhesions may cause great trouble or even render the extirpation
impossible. . ..
Adhesions to the abdominal wall may often be easily severed by
pushing a male urethral steel sound between the abdominal wall and
the cyst before tapping. If there is much resistance, the flat hand is
introduced, and the ulnar edge of it used in the way a paper-cutter
DISEASES OF THE OVARIES. 617
separates the leaves of a book. On account of bleeding it is, how-
ever, not safe to go too far out, and more resistant adhesions should
be left till the cyst has been emptied.
If the adhesion is found in the line of incision, this should be
extended upward above the adhesion, until a point is reached where the
abdominal cavity is opened, and then the adhesions should be attacked
from this point. If this cannot be done, the operator should cut into
the sac and invert it.
Long and resistant adhesions are cut between two ligatures. If
they are too short for that, they should simply be cut and the bleed-
ing points caught with pressure-forceps.
Adhesions to the intestine are very serious. If an adhesion is string-
shaped, it may be torn or tied between two ligatures. If it is broad,
it may be severed by pulling on the sac or pushing this away from
the intestine by means of a sponge on sponge-holder. If it does not
yield readily, a piece of the outer layer of the sac is cut out, and left
on the intestine (p. 495). If the adhesion is very extensive, it is bet-
ter not to try to separate it at all, but either to desist altogether from
the operation or be satisfied with an incomplete operation by marsu-
pialization, as will presently be described.
If the intestine has been injured, it must be attended to, as even
the smallest puncture may allow the contents to enter the peritoneal
cavity, and as any place deprived of its peritoneal coat is apt to
rupture.
A mere puncture may be seized with forceps and surrounded by a
ligature. The edges of a longer tear must be brought together : if it is
only peritoneal, they may be united with a continuous suture; but
if the whole wall is torn through, the edges should be united by
a Czerny-Lembert suture ; that is, a double row, the inner comprising
the muscular layer and the peritoneum, but not the mucous mem-
brane, the outer the peritoneum alone a quarter of an inch outside of
the first. A fine cambric needle, threaded with the finest iron-dyed
black silk, is used for this delicate work. The inner suture may be
interrupted or continuous ; the outer is always continuous.
If the intestine has suffered much, it may become necessary to
excise a portion of it.
Small bleeding surfaces on the intestine may be seared by holding-
a Paquelin cautery at a short distance from them, or they may be
touched with Monsel's solution. The injured part should be kept
near the incision, so as to favor the formation of a fecal fistula in case
healing fails to take place. Serious injury to the intestine is commonly
fatal.
Special attention should be paid to the appendix vermiformis. If
it is adherent to the cyst, and not easily detached, it should be cut off
between two ligatures, and the surface remaining in the body thor-
618 DISEASES OF WOMEN.
oughly disinfected, or the stump of the appendix may be inverted and
the peritoneum united with a running suture.
Adhesions to the mesentery are vascular. If possible, they should,
therefore, be tied before cutting. If that is not feasible, they must be
cut, and a suture passed under the bleeding part. As much as possi-
ble blunt instruments, such as a pair of closed blunt scissors or the
finger-nails, should be used. If a large surface has been denuded, the
edges should be united with a running suture.
Adhesions to the omentum are common and bleed easily. They
are best separated with a sponge squeezed dry. If they are exten-
sive, a part of the omentum must be cut off, for which purpose it
must be ligated in sections. A larger mass, however, can safely be
tied by using the elastic ligature (p. 496). Large veins may extend
all alone without being accompanied by other tissue from the omen-
tum to the abdominal wall or down into the pelvis. They are easily
torn, and must be severed between two ligatures. No rent should
be left in the omentum, as the intestine may be caught in it and
become strangulated. Its edges should be united with continuous
catgut sutures or the whole cut off.
Adhesions to the liver and the spleen may cause severe hemorrhage.
If they are not easily separated, it is better to leave part of the cyst-
wall on the viscus. Bleeding from these organs may sometimes be
stopped with Paquelin's cautery or Monsel's solution, and, best of all,
with a current of steam directed for half a minute against the bleed-
ing surface. 1
The operator should be careful not to tear the gall-bladder. If the
accident happens, the tear must be comprised in the sutures closing
the abdominal incision, temporarily establishing a biliary fistula. If
this organ is badly torn, it is necessary to remove it entirely.
Adhesions to the pelvis are the worst of all, as they are broad,
deep-seated, and may implicate the ureter or large vessels. If the
tumor is small, it is best to sever them before emptying it. It may
be necessary to do so guided by the touch alone, although a great help
has been secured just for such cases in Trendelenburg's position (p.
138). It may be better to leave the outer layer of the cyst where it
is adherent or to cut off the free part of the cyst and stitch the
remainder to the abdominal wound.
The ureter may have to be dissected out in order to free it from
adhesions.
If the ureter is injured during a laparotomy, the injury is to be
remedied in one of the following ways : if the wound is lateral, the
edges should be united by suture over a catheter introduced through
the wound, partly up in the direction of the kidney and partly down
into the bladder, whence it is pulled out with a forceps through the
1 Snegireff, Berliner Klinik, April, 1895.
DISEASES OF THE OVARIES. 619
urethra; or, if that is not practicable, an iodoform tampon, made
according to Mikulicz (p. 181), should be left in contact with the
sutured wound in order to save the peritoneal cavity, if the wound
does not unite.
If the ureter is torn transversely, but the ends remain in contact
with each other, the same course should be pursued.
Sometimes it is possible to introduce the upper end into the bladder
and stitch it there bv intra-peritoneal or extra-peritoneal cystostomy
(p. 375).
If no conservative method is available, nephrectomy should be per-
formed at once, provided the patient appears able to stand the shock.
If she is too weak, a provisional urinary fistula should be established
by making an incision in the lumbar region, suturing the upper end
of the ureter to it, and leaving a catheter in it. The other end is
ligated and sutured to the lower end of the abdominal wound. If a
fistula forms here, another catheter is introduced and left in it. A
third is introduced through the urethra into the bladder. From all
three catheters rubber tubes go into vessels containing a solution of
boric acid. When'the patient has recovered, the kidney is extirpated. 1
If the uterus has been wounded, the bleeding may usually be
stopped by passing a ligature under the bleeding point, by stitching
some loose tag of peritoneum to it, or by searing it with the thermo-
cautery. If, however, the hemorrhage cannot be checked in any
other way, the uterus must be removed.
The cyst may be so adherent everywhere that it cannot be extirpated.
In making the first incision the operator enters it, and the sac cannot
be inverted. Then there is nothing to be done except to empty it,
stitch it to the abdominal incision, wash it out, and pack it with iodo-
form gauze, which is changed every four or five days. Under this
treatment the sac shrinks and fills with granulations.
If an irremovable cyst has colloid contents contained in numerous
small compartments, the upper and lower ends of the incision should
be seized with volsella3 and held up against the abdominal wall. The
compartments should be broken up with one or more fingers or the
whole hand.
Sometimes adhesions in the upper part may be overcome by seizing
the lowest part from within and inverting it. In other cases it
suffices to let an assistant introduce his hand into the sac and put it
on the stretch, while the operator severs it from its surroundings.
If the cyst contains much solid matter, it is best to tie the pedicle
and extract the lower end first. If the solid matter is found below,
while the upper part forms a large cyst, the trocar should be pushed
through the lower solid part into the upper cystic part, thus giving
1 Pozzi, Centrcdbl. f. Gyndk., Feb. 4, 1893, vol. xvii. p. 98.
620 DISEASES OF WOMEN.
an outlet to the fluid, and then the upper part should be pulled out
first. If it becomes necessary to pull the intestine out of the abdom-
inal cavity in order to sever adhesions or stanch bleeding;, it should be
laid on the upper part of the abdomen, and covered with cloths wrung
out of warm salt water (p. 502). Treudelenburg's position has, how-
ever, rendered this evisceration superfluous in most cases.
Intraligamentous Development. Ovarian tumors that develop in
the broad ligament are usually papillary (p. 580). They are
smaller, grow more slowly, and have fewer daughter-cysts. Their
papillomas may rupture the cyst- wall and lie free in the peritoneal
cavity or grow into neighboring organs. They are more malignant,
and are very apt to cause metastatic infection of the peritoneum. They
are difficult to remove, and special care must be taken to avoid infec-
tion. The uterus is at first pushed over to the other side by the tumor,
later elevated and immovable. When the lower limit of the broad liga-
ment is reached, the tumor may develop forward or backward. If it
goes forward, it strips off the peritoneum from the abdominal wall, and
thus it is reached in making the abdominal incision before the peritoneal
cavity is opened. Such tumors may occasionally be removed without
entering that cavity at all, but, as a rule, it becomes necessary to do
so at a later stage of the operation. If the development takes place
backward, the tumor separates the layers of the mesentery and comes
to lie behind the large and small intestine.
The intraligamentous tumor may also burst through its peritoneal
covering, so as to present an upper intraperitoneal and a lower extra-
peritoneal part. That portion which is free from the peritoneum has
the usual pearl-gray color of ovarian cysts, while that which is cov-
ered with peritoneum is pink. In exceptional cases the tumor is even
covered with a thick layer of unstriped muscle-fibers, which gives it
the appearance of a uterine tumor.
The ovarian vessels enter the tumor at ite outer border ; the uterine
follow the Fallopian tube and enter on the middle of the surface.
The intervening part of the broad ligament may give way, so that
the tumor has a double pedicle.
Smaller cysts with thin walls are often present, and the uterus usu-
ally lies in the angle between the chief cyst and the smaller ones.
Rarely the whole encapsulated cyst can be drawn out and re-
moved entire by forming a pedicle of the broad ligament. If the
outer and lower parts of the ligament are free, the surgeon may put
in a double row of sutures, beginning at the infundibulopelvic liga-
ment, and cut the tissue that lies between each two sutures, whereby
the deeper parts become more accessible. The following suture must
always embrace part of the mass comprised in the preceding one, in
order to avoid hemorrhage. (Compare Vaginal Hysterectomy, p.
487). Proceeding in this manner we get under the cyst and diminish
DISEASES OF THE OVARIES. 621
its attachment, until finally the tube and the rest of the broad liga-
ment can be enclosed in one ligature.
If the cyst extends down to the lower edge of the broad ligament, it
can only be removed by enucleation (Miner's method), 1 which consists
in stripping the cyst of its peritoneal covering, and leaving this- or
part of it as an empty sac. If the tumor does not rise much above
the superior strait of the pelvis, this is done by making an incision
through the peritoneum at the upper end of the tumor and pushing
it down with fingers and blunt instruments. If, on the other hand,
the cyst is large, it should be emptied and pulled out to the level of
the abdominal wall. On account of the dangerous character of the
fluid and the inner wall, the opening in the cyst should not be en-
larged with the knife nor papillomata broken off, but the hole left
by the trocar should be closed with forceps. Next, a small incision
is made on the anterior surface in a transverse direction. The peeling
is begun here, and it is gradually extended all around the circum-
ference.
Before doing so the ovarian vessels should, however, be tied be-
tween two ligatures and cut ; and if large veins are found in the invo-
lucrum, they must be disposed of in the same way. Branches of
the uterine artery which are severed in cutting the peritoneum are
also tied. When the ovarian ligament and the Fallopian tube come
within reach, they should be tied and cut; and, finally, the uterine
attachment is tied with one or more mass-ligatures. They include
sometimes a part of the uterus itself, and it may even become neces-
sary to perform supravaginal hysterectomy (p. 496).
Often a large part of the uterus is left without peritoneal covering,
and may bleed ; which hemorrhage may be checked by passing a con-
tinuous catgut suture under the bleeding surface or inserting inter-
rupted sutures under it or touching it with the thermocautery.
It often happens in operations involving the broad ligament, the
cornu, or the lateral edge of the womb that the tissues are extensively
torn or so decomposed as to break down under the fingers, forceps, or
ligatures. In such cases hemorrhage may be controlled by tying one
or both uterine arteries and one or both ovarian arteries. For the
purpose of tying the uterine artery the uterus should be drawn toward
the opposite side. A stout curved needle armed with strong silk or
catgut, a foot long, is carried a quarter to half an inch below the lower
limit of the tear, just entering the substance of the uterus. It is car-
ried back through the broad ligament about half an inch outside of
the uterus and tied. The ovarian artery is easily secured in the in-
1 Julius Francis Miner of Buffalo, N. Y., performed the first operation of this
kind in 1869, and in the following year published the method (Atkinson Biographi-
cal Dictionary of Contemporary American Physicians and Surgeons, Philadelphia, 1880,
p. 45).
622 DISEASES OF WOMEN.
fundibulo-pelvic ligament. When a large piece of the broad liga-
ment has been removed, the raw surface may be disposed of by
uniting the inner edge near the uterus with the outer near the pelvic
wall by a few sutures, thus producing an artificial latero-version. 1
The development into the mesentery gives rise to considerable hem-
orrhage, which must be overcome by mass-ligatures. Pieces three or
four inches wide may be ligated without causing gangrene of the
intestine.
If a part of the cyst is imbedded in the pedicle, its inner layer
should be scraped out with a sharp curette or seared with Paquelin's
cautery.
Sometimes, as a result of inflammatory processes, the peritoneum is
so adherent to the intraligamentous ovarian cyst that in places it
cannot be stripped off, but has to be dissected off from the tumor
with a knife, or the separation made within the limits of the tumor
itself. In these difficult cases the peritoneal covering is often torn,
and severe hemorrhage may take place.
If papillomas have grown from the ovarian cyst into other organs,
these parts are temporarily left, and after removal of the tumor they
are, as far as possible, scraped out with nail or curette or cut out
with the knife, to which treatment the uterus lends itself more
readily than other organs.
At the base of the tumor a sharp lookout should be kept for the
ureter, which runs in a nearly antero-posterior direction, and is rec-
ognizable by its hardness. Great care must be taken not to tear it,
cut it, or comprise it in a ligature.
After the enucleation a large raw surface is left, which may be
treated in different ways, as described in speaking of Fibroids (p. 499).
Pseudo-intraligamentous Ovarian Tumors. 2 There is a kind of
ovarian tumor which simulates intraligamentous tumors, but in reality
is adherent to the posterior surface of the broad ligament, which it
draws up in front, sometimes high up in the abdominal cavity. The
upper end and the posterior surface of the tumor may be free or
covered with a pseudo-membrane of peritonitic origin, which is
entirely like the peritoneum. The bottom adheres to Douglas's
pouch. These pseudo-intraligamentous tumors can hardly be diag-
nosticated clinically from the intraligamentous, except when the latter
adhere with a broad surface to the vagina proper, situated laterally
to and behind the uterus. The vagina is then immovably fastened
to the lower pole of the tumor. A history of gonorrheal or puerperal
peritonitis makes it likely that the tumor is pseudo-intraligamentous.
Even when the abdomen is opened, it may be quite difficult to
1 H. A. Kelly, Johns Hopkintf Hospital Reports, Gynecoloqy 1, Baltimore, Md.,
Sept., 1890, pp. 220-223.
* K. Pawlik, Ueber Pseudo-interligameniose Eierstocksgeschivulite, Wien, 1891.
DISEASES OF THE O VARIES. 623
recognize the true condition, and still it is of great importance, since
it complicates the operation very much if the operator enters the space
between the- layers of the broad ligament.
Sometimes the tube may be separated from the tumor, and the
separation continued along the posterior surface of the broad ligament,
or one succeeds in getting behind and under the tumor and loosen-
ing it from the peritoneum in Douglas's pouch. The best way of
removing the lower end of the tumor is to pull on the sac after free-
ing it from adhesions above, and tying the tube with a double ligature
near the uterus, and severing it with the thermocautery.
Incomplete Operations. Sometimes it is impossible to remove the
tumor, even by enucleation. Then three methods are at our com-
mand viz. : 1 , marsupialization ; 2, to leave the remainder and
close the abdomen ; 3, drainage through the vagina. But if it is
evident that the operation cannot be finished, it is better not to ope-
rate at all. The conditions which make it impossible to perform a
complete extirpation are general adhesion all over, subserous devel-
opment in its worst forms, and cancer which has spread to the sur-
roundings.
Marsupialization consists in stitching the edges of the tumor to
those of the abdominal wall, so as to leave a pouch which has been
likened to that in which marsupialian animals carry their young.
This method is particularly indicated in monocystic tumors. If it is
a papillomatous cyst, all vegetation and, so far as possible, the whole
mucous layer on the inside of the cyst, should be scraped off. Some-
times the whole tumor is left in the abdominal cavity ; in other cases
as much as possible is removed, and the rest stitched to the abdomen.
If the opening in the cyst is larger than that of the abdomen, the cyst-
wall must be folded so as to adapt itself to the abdominal incision. The
interior of the cyst is packed with iodoform gauze, which is changed
every few days. After a week when adhesion has taken place, the cyst
may be injected with antiseptic solutions. The sac almost invariably
suppurates, healing may take many months or even a year, the patient's
strength may give out, a fistula may remain, or a relapse may occur.
If the tumor is papillomatous, proliferation usually continues and
puts an end to the patient's life in a few months. If, on the other
hand, everything goes favorably, the sac fills gradually with granula-
tions, and shrinks until the wound closes.
If the tumor is polycystic, it is better to leave what cannot be re-
moved and close the abdomen. 1
If the tumor has an involucrum so full of large blood-vessels that
the operator deems it impossible to remove the cyst, he may puncture
it from the vagina with blunt scissors, dilate the opening with an
expanding dilator, empty the cyst, and leave a drainage-tube in it.
1 Olshausen in Billroth and Liicke's Frcmenkrankheiten, vol. ii. p. 591.
624
DISEASES OF WOMEN.
But this vaginal treatment, like the abdominal, may give rise to an
interminable secretion.
It has been suggested x to cut off the blood-supply of the tumor
by tying the ovarian artery in the infundibulopelvic ligament, and
the uterine by passing a ligature round it with a curved needle from
the vagina and again at the corner of the uterus. If possible, the
cyst should then be stitched to the wall, opened, and drained. If the
cyst is papillomatous or suppurating, it is, however, not desirable to
proceed in this manner, on account of the danger of infection in
passing the sutures. In such cases, and if it is not possible to stitch
the cyst to the wall, the abdomen is closed, the dressing applied, the
patient's feet are lifted up, and the tumor tapped from the vagina.
This is done by thrusting a pair of pointed scissors into the cyst and
opening them widely on withdrawal, or, better, by using a half sharp-
pointed expanding instrument like a dilator (Fig. 324), and introduc-
FIG. 324.
Half Sharp-pointed Pelvic Puncturing Dilator.
ing a strong blunt dilator (Fig. 325), into the opening made with the
first, and expanding it. This will give us a free opening, by which
FIG. 325.
Blunt Expanding Pelvic Dilator.
we can both empty the sac and ensure free washing and drainage. A
rubber tube should be stitched in the wound, or, better, the sac packed
with iodoform gauze. Later on, from day to day, the mass may be
broken down with a dull curette and the sac injected with diluted
tincture of iodine of increasing strength, or peroxide of hydrogen.
1 B. McE. Emmet, Amer. Jour. Obst., July, 1890, vol. xxiii. p. 706.
DISEASES OF THE OVARIES.
625
The Pedicle. If the pedicle is thick and short, there is danger of
the outer part of the ligature slipping. This may be obviated by
repassing it near the edge before tying it, or by first making a notch
by passing a finer silk ligature around the pedicle one-third of an inch
from the edge, and tying it before tying the thick pedicle-ligature.
FIG. 326.
Wallich's Chain-ligature:!. P, pedicle; ppp, pressure-forceps; aa, loops; 2, ligatures cut.
crossed, and tied loosely.
If the pedicle is so short that the ligature encroaches on the
uterus, it is a protection against hemorrhage to unite the edges of the
peritoneal covering of the stump with sutures. If it is very thick,
it is necessary to tie it in more than two parts by means of a chain-
ligature. A long thread is carried with a handled needle through
40
626
DISEASES OF WOMEN.
part of it, and seized with a pressure-forceps. Next, the long end of
the same thread is carried through in one or more other places, and
the loops secured in the same way. When all are in place, the loops
FIG. 327.
Cobbler's Stitch for Ligation of Pedicle.
are cut, one after the other, near the forceps, and the halves crossed
and tied, so that finally the whole mass to be ligated is enclosed in
threads, forming together a chain (Fig. 326). The pedicle may be
cut gradually, leaving at least half an inch of tissue above the liga-
ture, and for greater safety it is advisable to tie arteries visible on the
cut surface with silk or catgut.
Marcy's Method 1 (Fig. 327). A handled needle, carrying a long
tendon or catgut thread, is inserted through the part of the pedicle
1 Henry O. Marcy reported this method at the International Congress in London,
1881, and claims to he the inventor of the shoemaker's stitch: "The Surgical Ad-
vantages of the Buried Animal Suture," Jour. Amer. Med. Assoc., July 21, 1888,
reprint, p. 6.
DISEASES OF THE OVARIES. 627
farthest away from the operator (1). One end, A, is held by the assist-
ant ; the other end, B, is pulled out from the stitch-canal and the eye
of the needle (2), the needle threaded with A (3), pulled back (4), and
then pushed with A through another part of the pedicle. Now A is
pulled out from the eye, B inserted (5), and the needle pulled back
with B. Finally, the two ends are tied with a surgical knot over the
last part of the pedicle (6). This does not tear the tissue, and com-
presses the whole pedicle tightly. It is only another way of making
a cobbler's stitch.
In dealing with thick pedicles it is also useful to compress them
with Spencer Wells's forceps, so as to form a notch before tying.
If a hematoma forms under the ligature of the pedicle, another
ligature should be placed nearer the uterus. The blood between the
two ligatures is left to be absorbed.
If the tube appears inflamed or if the stump contains parts of the
cyst, the cut surface should be cauterized. If in combination with a
pedunculated tumor we find metastatic masses behind the peritoneum,
the latter must be left alone.
If the pedicle is so friable that the ligature cuts through, the single
vessels must be secured with forceps left in the wound.
After the removal of a large tumor which has caused great dis-
tention of the abdominal wall, part of the skin and peritoneum
inside of the recti muscles should be trimmed off before closing
the wound.
Toilet of the Peritoneum. If adhesions have been torn, and blood
or other fluids, such as pus, cyst-contents, etc., have found their way
into the peritoneal cavity, it must be cleaned, the technical term for
which procedure is the toilet of the peritoneum. Sometimes it is enough
to introduce a few sponges or pads on sponge-holders into Douglas's
pouch. If the bleeding is more profuse or more objectionable fluids
have found their way into the abdominal cavity, it should be flushed
with hot water to which table-salt has been added in the proportion
of 6 : 1000. This is poured into it from a pitcher or through a finger-
thick glass tube. This saline solution comes very near the composi-
tion of serum, and attacks the epithelium less than plain water or an-
tiseptic fluids. If there is still some oozing, the abdominal packing
with iodoform gauze (p. 181) may be used. Only if there seems to
be a decided hemorrhage, it is necessary to hunt for its source and tie
the bleeding vessel. Experience alone can guide the operator in this
respect.
Hemostasis. For arresting hemorrhage four methods are avail-
able pressure, ligature, cauterization, and styptics.
A small hemorrhage may be arrested by simple pressure with a
finger or sponge. A liberal use of pressure-forceps saves much time
by avoiding many ligatures. Bleeding from larger surfaces in the
628 DISEASES OF WOMEN.
pelvis may be arrested by packing it with sponges, pads, or cloths,
which should be left in sometimes as much as fifteen minutes, while
counter-pressure is being made from the vagina, and removed very
cautiously, so as not to tear off newly formed coagula.
Sometimes long forceps have to be left in the wound till the next
day, but this should be avoided as much as possible. It is better to
pack the peritoneal cavity with iodoform gauze (p. 181). After the
abdomen has been closed, pressure may yet be used to arrest oozing by
means of a tightly 'fitting bandage or two bricks placed outside the
dressing, combined with packing of the vagina and a bag filled with
ice-water in the rectum (p. 464).
Bleeding from a large surface on the anterior abdominal wall may
be checked by folding that part of the wall and excluding it from
the abdominal cavity by passing some -quilled sutures at the base of
the fold, which are left in place for two days (Kimball's l method).
When blood may be expected to flow from both ends of a divided
vessel, it is, if possible, cut between two ligatures. If this is not
possible, it is cut, and both ends are seized and tied or compressed
with artery-forceps. It is safest to tie the isolated vessel that bleeds,
but often this cannot be done, and we must be satisfied with a mass-
ligature embracing the surrounding tissue. Bleeding from a sur-
face may be arrested by passing a continuous suture under it and
drawing it together. Sometimes loose tags of peritoneum are used as
a patch. Bleeding from the anterior abdominal wall may sometimes
be arrested by tying the corresponding epigastric artery.
Cauterization has become quite convenient since Paqueliu invented
his thermocautery. It can be applied to bulky organs, such as the ab-
dominal wall, the uterus, the spleen, and the liver ; it can be used for
cutting ; and, held at a distance, it has even proved successful in deal-
ing with hemorrhage from the intestine.
Tincture of iodine or Monsel's solution may be used as a styptic to
smear on small surfaces of delicate organs, such as the intestine or
bladder, but their use ought to be avoided whenever possible, as they
form coagula which may become a source of inflammation or sepsis.
Hot water is an excellent hemostatic, which operates by causing con-
traction of the capillaries. A current of overheated steam led through
a tube ending in a perforated nozzle like the rose of a watering-pot is
said to be effectual in arresting hemorrhage even from large arteries
(p. 618).
In order to find the bleeding spot, it is sometimes necessary to
enlarge the incision and even to draw out the intestine (p. 535).
The search may be facilitated by throwing light into the abdominal
cavity with a concave mirror, a large plane mirror, or, still better,
with a portable electric lamp.
1 Oilman Kimball of Lowell, Mass.
DISEASES OF THE OVARIES. 629
Much hemorrhage may be avoided by tying the pedicle as soon as
possible, before beginning to separate adhesions.
Complications. If a small myoma is seen in the uterus, it should
be let alone, but its presence may be an inducement to remove
the second ovary (p. 483). A large myoma may be in the way,
and have to be removed according to circumstances (p. 483, et seq.).
If the ovarian cyst is accompanied by ascites, nothing should be
done to remove the latter before the cyst is taken away, for the fluid
serves as a diluent for cyst-fluid that may enter the peritoneal cavity.
If the patient is affected with an umbilical or ventral hernia, its sac
should be dissected out, and the thinned and superfluous tissues cov-
ering it be cut away.
Complication with pregnancy has been considered above (p. 603).
If the patient is not seen before labor has set in, and an ovarian tumor-
obstructs the parturient canal, the operator should try to push it up
into the abdominal cavity in the genupectoral position a treatment
which is, however, only applicable to small tumors. A large tumor
should be tapped from the vagina (p. 606). If it does not collapse
sufficiently, an incision may be made in the vagina, and the tumor
removed or diminished in this way. If it contains much solid matter,
craniotomy or Cesarean section may be preferable. In the latter case
ovariotomy should be added.
Drainage. We have seen in the general part of this work (p. 186)
that the most experienced laparotomists entertain very divergent
views as to the use of drainage. While some look upon it as a fifth
emunctory, of Avhich they are very willing to avail themselves, others
are loth to have recourse to it. In a general way it may be stated
that it is indicated when pus or other irritant fluid has entered the
peritoneal cavity during the operation ; when sepsis or peritonitis is
present; when there is much ascites, especially in connection with
papillomata ; when there are many or large raw surfaces left ; when
the bladder or intestine has been wounded during the operation or is
found in a sloughy condition ; and when the operator is in doubt
about the efficacy of his hemostasis. In the last case, if a tube is
used, it should be kept pumped out, as coagulation then takes place
more readily than when blood accumulates in it.
If a tube is used, it should be without side holes, granulations being
apt to grow into them ; and even if the tube has no lateral openings, it is
well to turn it on its axis once a day in order to prevent too firm adhe-
sion. It is also well to lift the tube half an inch and let it drop back
by its own weight, so as to avoid too much pressure and the formation
of a fecal fistula. 1 But, as a rule, it is enough to leave the tube for one
or two days in the peritoneal cavity or an empty pouch. When only
a teaspoonful of fluid accumulates in several hours, the tube can safely
1 Wm. Goodell, Mann's Amer. Syst. of Gynecol., vol. ii. p. 819.
630 DISEASES OF WOMEN.
be withdrawn. If it is used in incomplete operations, it should be
left in as long as there is secretion of pus. In the latter case injection
with antiseptic fluid is made through it, whereas in completed operations
no injections should be used, as they are apt to tear protective adhesions.
A hole is cut for the tube in the dressing ; a piece of gutta-percha
tissue is drawn tight up to the flange of the tube and folded over
some loose iodoform gauze outside the dressing, which allows us to
change the gauze and empty the tube without disturbing the dressing.
In order to avoid secondary infection of the sutures, it is well to use
silver wire for the two that are in direct contact with the tube. One
of them should be left open until the tube is removed.
The tube has to a great extent been replaced by iodoform gauze,
which has the advantage of being soft and of helping to check hem-
orrhage. It may be left in place from three days to a week.
The objections to the use of drainage in the peritoneal cavity are
that it irritates the peritoneum, may cause uncontrollable vomiting,
interferes with free movements of the intestine, predisposes to intes-
tinal obstruction, the formation of fecal fistula and ventral hernia,
and maintains a danger of infection. 1
Some prefer drainage through the vagina, a method which has
already been referred to in speaking of enucleation of fibroids from
the broad ligaments (p. 499), which is particularly indicated in cases
in which the tumor extends far down into Douglas's pouch, and by
which ventral hernia is avoided. It is established by means of iodo-
form gauze or a soft-rubber drainage-tube. Two fingers are passed up
through the disinfected vagina to the posterior vault. An opening
is made from above through the bottom of Douglas's pouch with
scissors or trocar, and dilated with forceps or an expanding dilator,
until a finger can easily be passed through it. A strip of iodoform
gauze, four inches wide, is passed through from above into the vagina,
and packed in or around the part from which one wishes to drain.
After closure of the abdominal cavity the vagina is packed with iodo-
form gauze. If there is a rise in temperature, the vaginal packing
should be removed, and the abdominal gauze pulled out a few inches,
which produces free drainage. At the expiration of from eight to
twelve days the last of the abdominal gauze should be withdrawn.
If there yet is a purulent discharge, a soft-rubber drainage-tube with
crossbar should be introduced instead. 2 Such tubes cause, however, a
good deal of irritation, make the vagina very tender, and may pro-
duce ulcers, a condition which is successfully combated by injecting
stearate of zinc with a powder-blower into the vagina, after having
1 A strong plea in its favor is made by E. W. Gushing of Boston, Mass., supported
by Lawson Tait and Bantock, in Annals of Gynecology, Nov., 1890, vol. iv. p. 69.
1 H. T. Hanks, "Counter-drainage after Cceliotomy," The Post- Graduate, No. 4,,
1893.
DISEASES OF THE OVARIES. 631
injected a saturated solution of boric acid through the tubes and into
the vagina.
Shock. The sudden giving out of vitality called shock is very
dangerous, and calls for immediate attention. We have already
spoken of this condition in treating of the operations for uterine
fibroid (p. 501). Much may be done to prevent it, not only by
proper attention to the anesthesia, but by preventing hemorrhage,
by keeping the patient warm, by avoiding as much as possible
handling the intestine, 1 and by abbreviating the duration of the
operation as much as other considerations allow us to do.
If it threatens, death may yet be averted by 'the hypodermic injec-
tion of digitalis, nitroglyceriu, and strychnine, the intramuscular in-
jection of camphor (p. 210), the rectal injection of hot water, injection
into the peritoneal cavity of a hot saline solution (p. 502), or rapidly
interrupted compression of the heart (p. 207), and by finishing the
operation in the shortest possible time.
Complications during After-treatment.
Shock. If shock is present after the patient has been brought to
bed, she should be roused (p. 223) and stimulated as just described.
Vomiting. If the patient vomits, the medicine with hydrocyanic
acid mentioned on p. 211 should be administered. Deep inspirations
may be tried, by which air containing remnants of the anesthetic is
expelled from the deeper part of the lungs. If vomiting continues
at a time when the patient should take food, the different modifica-
tions of milk peptonized milk, kumiss, or matzoon can often be
retained when everything else is ejected. If the patient vomits
everything ingested, she must be fed by rectal alimentation, for
which milk, eggs, and beef extracts are particularly useful. As a
rule, an ounce of brandy should be added. The whole enema, in
order to be retained, should not be more than four ounces.
If vomiting accompanies intestinal obstruction, calomel is the best
remedy.
Internal Hemorrhage. After bloody operations the patient may be
very weak and restless, with a weak, rapid, and irregular pulse ; but
if there is no bleeding, this condition will yield to the free use of
stimulants.
Real hemorrhage comes nearly always from the pedicle, rarely from
large raw surfaces. If a drainage-tube has been left in the abdomen,
the continuous reproduction of pure blood furnishes the diagnosis.
Otherwise it must be made by the general condition of the patient
weakness ; restlessness ; weak, rapid pulse ; cold, clammy skin ; and
1 Goltz has shown that a continuation "of small, insignificant raps on the belly of a
frog kills it. ,
632 DISEASES OF WOMEN.
swelling of the abdomen. Then only two sutures should be removed,
which will suffice to ascertain the presence of blood in the abdominal
cavity. If it is found, the whole wound must be reopened, and the
source of the hemorrhage first of all, the pedicle looked for.
When found, the bleeding is arrested by means of ligatures, and the
cavity cleaned and closed again. If the patient has lost much blood,
a subcutaneous injection of saline solution (p. 502) may prove of
great value.
Tympanites without inflammation is much relieved by the introduc-
tion of a soft-rubber rectal tube ; by enemas with turpentine (gss to
Oj), sulphate of qiu'nine (gr. v every four hours), or mentha viridis
(3ij to aquse Oj) ; by the administration of tinct. nucis vomicae or
tinct. capsici (ITtv every hour), or large doses of subnitrate of bismuth
(gr. xxx-xl) ; by standing the patient on her head ; by nicking the
plaster straps crossing the abdomen, drawing up her knees, using
faradization, or puncturing the transverse colon.
Elevation of Temperature. The temperature should not rise above
100 Fahr. As soon as it does, the cause should be looked for,
which may be constipation, emotions, suppuration of a stitch-canal, a
mural abscess, peritonitis, or sepsis. An ice-bag or rubber coil with
running ice-water should be applied outside of the dressing. Anti-
pyretic drugs should be administered. One or more sutures may be
removed to give exit to pus.
If the temperature rises more than two degrees above the normal
average, and swelling of the abdomen announces approaching peri-
tonitis, the bowels should be moved at once, which may be done with
sulphate of sodium, a teaspoonful every hour, and an enema with
ox-gall (p. 174) given in the mean time.
/Suppression of Urine. If the secretion of urine stops, it should
be promoted by giving digitalis and acetate of potassium.
If a ureter has been tied or injured, a urinary fistula may form
in the vagina, which should not be interfered with until the pa-
tient has recovered. Hydronephrosis has developed, and been
cured by extirpation of the corresponding kidney. In another case
a cure was effected by pushing a trocar through the urethra and
bladder into the abnormal reservoir, and leaving the canula till heal-
ing had taken place. Perhaps it might suffice to remove the ligature
from the uterine artery (p. 503). If not, the ureter may be cut above
the ligature and implanted into the bladder by intra- or extra-perito-
neal uretero-cystostomy (p. 375).
Intestinal obstruction is marked by constipation, vomiting, and tym-
panites. It is often due to adhesion between the stump of the pedicle
and the intestine, and is now-a-days, as a rule, avoided by moving the
bowels early. If this grave complication occurs, large ox-gall enemas
(p. 174) should be given. By using a fountain syringe and low press-
DISEASES OF THE OVARIES. 633
ure (p. 175) several quarts may be injected. Calomel is the best ape-
rient, because it is least likely to be vomited. Tinct. belladonnas or
atropine may help to relax the bowel.
A very efficacious remedy is to wash out the stomach with five or
six quarts of lukewarm solution of table-salt, which produces strong
peristaltic movements of the intestine. If this does not give relief,
a second lavage is made, followed by the introduction of nearly two
ounces of castor oil through the stomach-tube. 1
If these milder means fail, the abdomen must be reopened and the
obstruction removed manually.
Septic Peritonitis. In spite of all antiseptic precautions, some pa-
tients develop peritonits, which is probably always of septic origin,
and may lead to general septicemia and death. The infection cannot
.always be blamed on the operator, as it would seem that pathogenic
microbes can find their way through the wall of the intestine to the
peritoneal cavity (p. 502), where they find an excellent soil in blood
and serum. Often the drainage-tube has been the door through which
infection has entered.
Peritonitis develops, as a rule, within four days. It is character-
ized by green vomit, tympanites, tenderness of the abdomen, and
a frequent pulse. Often there is no rise in the temperature, which,
on the contrary, may be subnormal.
The bowels should be moved at once, five grains of quinine or
salophen given every four hours, brandy administered freely, and an
ice-bag or ice-water coil applied to the abdomen. Finally, the wound
may be reopened and the peritoneal cavity washed out with peroxide
of hydrogen, but the chance of recovery is then slim indeed. I have
seen a patient who evidently was dying of septicemia saved by merely
taking out a couple of sutures from the abdominal incision, which
gave exit to a great amount of gas. Nothing was injected, and the
abdomen was closed again.
If peritonitis supervenes as late as ten to fifteen days after the
operation, it is probably due to mortification of the pedicle or other
large masses that have been ligated, and treatment is then nearly
powerless.
A mural abscess is recognized by hardness and tenderness of the
affected part. A small opening should be made, a drainage-tube in-
serted, and the abscess-cavity washed out daily with peroxide of hy-
drogen. If the abscess has formed around a suture, this should be
removed, the pus pressed out, and the dressing changed daily.
A deep abscess may be made out by bimanual examination. If it
lies close up to the vagina, it should be opened and drained from that
point. If not, the abdomen must be reopened, cleaned, and drained
either through the skin or through the vagina.
1 Klotz, Centralblatt f. Gyndk., 1892, vol. xvi., No. 50, p. 977.
634 DISEASES OF WOMEN.
Emphysema of the abdominal wall is rare, but is of importance, in
so far as it predisposes to the formation of an abscess.
Spontaneous reopening of the wound is an unfortunate occurrence
that may to a great extent be prevented by keeping the bowels open,
by not removing the sutures too soon (some think they ought even to
be left in for ten days), and by replacing them by plaster strips, as
recommended above (p. 616). If it happens, the patient should be
anesthetized, and new sutures put in. It may be so difficult to
replace the intestine that it becomes necessary to puncture it and
let the gas escape. Before replacing it, it should be washed with the
normal solution of chloride of sodium.
Sometimes a fistulous tract leads into the abdominal cavity, and
resists healing for a long time. Patients affected with tuberculosis,
syphilis, or cancer are predisposed to this untoward accident. In
most cases it is due to the mechanical irritation caused by a drainage-
tube or suture- and ligature-material. Sometimes the cause is sepsis.
It not only protracts convalescence, but may lead to the formation of
a fecal or urinary fistula, nephritis, and exhaustion. Many such
fistula? heal by nature's sole efforts under favorable hygienic circum-
stances, and the use of nourishing food. Daily irrigation with hot
water or mild antiseptic fluids, especially the peroxide of hydrogen,
contributes, however, much toward a favorable result. Sometimes
much time can be saved by dilating the fistulous canal sufficiently
to introduce a fine pair of forceps and pulling out a ligature from
the bottom. Packing with iodoform gauze or marine lint soaked in
balsam of Peru is also often useful. Strong fluids and severe ma-
nipulations must be avoided, as they may make the condition worse
by wounding the intestine. 1 In protracted cases the best treatment
is to make an incision in the abdominal wall at the opening of the
fistula, and dissect out the whole wall of the same, whether it becomes
necessary for that purpose to enter the peritoneal cavity or not. A
rubber drainage-tube or a strip of iodoform gauze is left in for a few
days, and then replaced by catgut strands, which contribute to the
healing.
Fecal fistula is a rare complication. It is due to injury of the
intestine during the operation or to pressure from a drainage-tube.
It may occur as late as two or three weeks after the operation.
The accident may be prevented by enlarging the abdominal incis-
ion, if there are many adhesions, and using Trendelenburg's position,
so as to obtain a view of adhesions that implicate the intestine ; by
using iodoform gauze as a drain instead of hard tubes ; and by using
silk, not catgut, in repairing injury to the intestine.
To operate for fecal fistula is dangerous and unnecessary, for, as a
1 A valuable paper on this subject by Andrew F. Currier of New York is found
in Annals of Gyncecology, July, 1892, vol. v. No. 10, p. 577.
DISEASES OF THE OVARIES. 635
rule, it closes spontaneously within a year. The fistula should be
tamponed with marine lint soaked in Peruvian balsam, or gauze
impregnated with iodoform, aristol, or dermatol, and the dressing
renewed daily. When the opening in the bowel becomes very small,
the intestines should be emptied by a cathartic, then kept at rest
for a week, and then again moved by enemas. When the hole in the
intestine is closed the same dressing should be kept up until the sinus
heals up from the bottom. 1
Tetanus is also a rare complication, and the prognosis is very bad.
It should be treated with chloroform, chloral, and curare, or a sub-
cutaneous injection of a specific antitoxin.
Phlebitis occurs sometimes. The affected leg should be raised on
pillows, painted with tincture of iodine, wrapped in cotton batting
and slightly compressed with a roller-bandage.
Great care should be taken not to press much on the swollen vein,
as a clot may be detached, and cause sudden death by embolism of the
pulmonary artery.
Parotitis is a rare occurrence. The swelling of the parotid gland
may simply be due to the mysterious consensus between that organ
and the genital gland, also frequently observed in man. It is then
of slight importance, and soon ends in resolution. But it may also
be part of a septic infection, and then it has a tendency to suppurate,
and is a serious complication.
Mental Aberration. In rare cases ovariotomy is followed by
mania, melancholia, and temporary or permanent insanity. This
complication is most apt to arise in patients with an hereditary
predisposition.
If both ovaries have been removed, menstruation stops, as a rule,
but may continue for a few months. (Compare pp. 119 and 539.)
If one ovary has been left behind, pregnancy may occur, and it, as
well as the ensuing childbirth, offers nothing abnormal, except that
the cicatrice is subjected to such a strain that it needs protection by
means of an abdominal belt.
If both ovaries have been removed, the patient is, as a rule, sterile.
(In regard to an exception to the rule and its explanation, see p.
549.)
Prognosis. The technique of ovariotomy has been brought to such
a degree of perfection that in the hands of the most skillful operators
the mortality has been reduced to 5 per cent. Circumstances that
make the prognosis good are a good constitution, a hopeful disposi-
tion, absence of disease in other organs, a unilocular or paucilocular
cyst, a good pedicle, and absence or easy separability of adhesions.
Death is commonly due to shock, hemorrhage, peritonitis, or septi-
1 An interesting paper on fecal fistula? after laparotomy by A. Palmer Dudley
is found in Amer. Jour. Obst., Feb., 1892, vol. xxv. pp. 145-163.
636 DISEASES OF WOMEN.
cemia, to which are added the rarer causes, such as exhaustive sup-
puration, uremia, tetanus, or embolism. 1
B. Solid Ovarian Tumors.
Solid ovarian tumors are much rarer than cystic tumors of the
ovary and solid uterine tumors. They may be fibroids, papillomas,
sarcomas, endotheliomas, carcinomas, or tuberculous.
I. Fibroma.
Pathological Anatomy. Fibroids of the ovary are usually small,
not larger than a hen's egg or an orange, but may reach the size of an
adult's head, or even become enormous, weighing over sixty pounds.
They are smooth, globular, and nodular, like uterine fibroids ; but,
unlike them, if they do not comprise the whole ovary, they are inti-
mately connected with the surrounding tissue, and cannot be shelled
out. They may be hard or so soft as to become fluctuating. They
are most frequently found on one side only, but may be bilateral.
They may be diffuse i. e. comprise the whole ovary or circumscribed,
occupying only a part of it, and then generally the outer end, while
the remainder is in a condition of chronic oophoritis (p. 559).
The cut surface shows translucent gray or yellowish places alter-
nating with opaque white ones. The follicles have disappeared. The
tissue is composed of fine fibrillar connective tissue, peculiarly rich
in long spindle-cells. Sometimes it contains smooth muscle-fibers,
in other cases none.
As a rule, the mesoariurn is preserved, forming a pedicle to the
tumor, but when this grows large it may invade the broad ligament,
and become sessile. The tube is not implicated in the pedicle, unless
the tumor becomes very large. The tumors are generally accompanied
by ascites, which prevents the formation of inflammatory adhesions as
long as they remain small. Sometimes they are found together with
myoma of the uterus.
They may undergo the same changes as uterine fibroids. They
may become cystic, a transformation which is due to the dilatation
of lymph-spaces in the connective tissue, so-called geodes, hollows
filled with a coagulable serous fluid. Such cystic fibroids are called
cystofibromas or fibrocysts. Fibroids may undergo mucoid, fatty,
or cancerous degeneration, or become calcified or ossified- or cartilag-
inous. Internal hemorrhage, suppuration, and gangrene may occur
in consequence of torsion of the pedicle or pressure during child-
birth.
1 H. 'C. Coe has in a most excellent paper in Trans. Amer. Gyn. Soc., 1889, vol.
xiv. pp. 170-191, based on personal observation, discussed "Death from Visceral
Affections after Ovariotomy."
DISEASES OF THE OVARIES. 637
Origin. The fibroma may originate in the albnginea or in a corpus
luteum. 1
Etiology. The etiology of ovarian fibroids is unknown. They are
more common in young women than later in life.
Symptoms. Commonly there are menstrual disturbances, such as
amenorrhea, dysmenorrhea, or irregular menstruation. The tumor
causes more pain than uterine fibroids. It grows very slowly. As-
cites develops frequently and early. If the tumor acquires large
proportions, all the pressure-symptoms described in speaking of ute-
rine fibroids (p. 474) may be developed. As a rule, the tumor is
freely movable.
Diagnosis. It may be difficult or impossible to distinguish an
ovarian fibroid from a pedunculated uterine fibroid, unless both ovaries
can be felt, which, of course, excludes an ovarian tumor. The
ovarian tumor causes more pain. A malignant tumor grows more
rapidly. A fibrocyst of the ovary, if not movable, closely resembles
a uterine fibrocyst. In the latter the sound will, however, generally
show a greater depth of the cavity. A fibrocyst of the ovary can
hardly be distinguished from other ovarian cysts. It may, therefore,
often be necessary to perform exploratory laparotomy before a positive
diagnosis can be arrived at.
Prognosis. The tumor may become dangerous by its size. It may
oppose an insurmountable obstruction to childbearing, and necessitate
Cesarean section. It may undergo dangerous changes, as mentioned
above. Death may result from peritonitis, nephritis, uremia, intes-
tinal obstruction, or an embolus in the pulmonary artery.
Treatment. Electrolysis is said to have caused a diminution of the
tumor, but it is not known if the result is permanent. It should
only be used if an operation is absolutely refused. The true treat-
ment called for is abdominal or vaginal ovariotomy (compare Hyste-
rectomy, p. 483), which ought to be performed as soon as the tumor
is found.
II. Papilloma.
We have seen above (p. 580) that a whole class of ovarian cysts is
characterized by the presence of papillary growths in the interior,
which may perforate the wall, and enter the peritoneal cavity. Simi-
lar papillary growths may develop on the surface of a solid ovary
or the wall of a glandular cyst.
They are, as a rule, accompanied by ascites. They may be small
like warts, or become as large as a fist, and extend to neighboring
organs.
1 Those who are more particularly interested in the pathology of ovarian fibroids
will find an interesting monograph on the subject by H. C. Coe in the Amer. Jour.
Obst., July and Oct., 1882, vol. xv. p. 561, et seq.
638 DISEASES OF WOMEN.
Etiology. Gonorrheal salpingitis has in several cases preceded this
formation.
Prognosis. It has a tendency to become malignant.
Treatment. The treatment consists in early ovariotomy.
III. Sarcoma.
Sarcoma of the ovary is a rare affection.
Pathological Anatomy. It may be primary or develop secondarily
in an ovarian cystoma. It is often bilateral. It forms pink tumors
ranging in size from that of a child's fist to that of a man's head, or
may even acquire enormous proportions. It is globular or oval, and
has a smooth surface, with varying consistency according to the com-
position, the pure sarcomatous growth and cystosarcomas being much
softer than fibrosarcomas. Often small cysts project slightly from the
surface. Like other solid ovarian tumors, it is commonly, and at an
early date, accompanied by ascites, which prevents the formation of
adhesions.
It is rich in blood-vessels, and may become cavernous, forming
large cysts. The follicles are destroyed. It may be combined with
sarcoma of the uterus.
Spindle-celled sarcoma is the most common variety, but round-
celled and mixed-celled sarcomas are also found. The variety known
as alveolar sarcoma has likewise been observed. The sarcomatous tis-
sue may be combined with myxomatous, fibrous, or carcinomatous tissue
(myxosarcoma, fibrosarcoma, sarcoma carcinomatosum) or a new for-
mation of glands (adenosarcoma).
The sarcomatous tissue may undergo changes, especially fatty degen-
eration, by which hollows are formed without separate walls and filled
with a fatty fluid. 1 A sarcoma may also become calcified. Torsion
of the pedicle may lead to internal hemorrhage, suppuration, or
gangrene.
Etiology. Sarcoma has been found in new-born children, and is,
like fibroids, usually found in young persons. It may develop in
a fibroid.
Diagnosis. It grows more rapidly than fibroids, and especially a
cystosarcoma may in a short time acquire very large dimensions.
Prognosis. It is a malignant disease, ending in death, which may
be due to marasmus, peritonitis, metastasis in other organs, or an
embolus in the pulmonary artery.
Treatment. As soon as discovered the growth should be removed
by ovariotomy. The danger of relapse is less than with carcinoma.
1 I have described a case of sarcoma composed of cysts with transparent walls,
formed of spindle-cells, and containing a bloody fluid, in Amer. Jour. Obst., 1881, vol.
rxiv. p. 890
DISEASES OF THE OVARIES. 639
IV. Endothelioma (Ackermann). 1
Endotheliomas are malignant tumors which start as a prolifer-
ation of the endothelial cells of the blood- or lymph-vessels of the
ovary. They may acquire considerable size, and have a smooth sur-
face studded with tuberosities formed of a brain-like or spongy tissue.
In other places is found dense connective tissue. They cannot be
diagnosticated from other solid tumors before their removal.
Treatment Ovariotomy.
V. Carcinoma.
The ovary may be the seat of medullary, scirrhous, or alveolar
(colloid) carcinoma, the first of which varieties is by far the most
common.
Carcinoma may be primary that is to say, beginning in the ovary
or secondary, invading the ovary from another organ, especially the
uterus. The primary is much more common than the secondary, and
may either attack the healthy ovary or an ovarian cystoma, in which
latter case the result is a carcinomatous cystoma. Any kind of cys-
toma, myxoid or dermoid, may undergo carcinomatous degeneration,
and the liability to this transformation is even considerable (p. 586).
We have seen above that especially the glandular variety is so nearly
related to the carcinomatous formation that it may be very difficult
to draw the line of demarkation between the two (p. 576).
Primary carcinoma forms a tumor varying in size from a hen's
egg to an adult's head. It is frequently bilateral. In the beginning
the tumor preserves the oval form of the slightly enlarged normal
ovary, but later it becomes more globular. It has a nodular sur-
face, a whitish color, and varies in consistency from considerable
firmness to brain-like softness (Fig. 328).
At first the mesoarium forms a pedicle, but later this may become
infiltrated, thickened, and hard, and finally the tumor may be entirely
sessile. At an early date ascitic fluid accumulates, which is often mixed
with blood ; local peritonitis is of frequent occurrence ; and the degen-
eration extends to neighboring organs, such as the peritoneum, the
pelvic connective tissue, the bones, the lymphatic vessels or glands,
especially those of the lumbar region, or to the uterus; or metastases
appear in the liver, the lungs, the spleen, and other remote parts of
the body.
It seems that the carcinomatous degeneration originates in an atypic
proliferation of the epithelium of the Graafian follicles or pouches
extending from the germinal epithelium into the interior of the ovary
(p. 587).
Secondary carcinoma of the ovary is brought through the lym-
1 The name has been used in another sense by Dr. Dixon Jones (p. 564).
640 DISEASES OF WOMEN.
phatics, cancerous epithelial cells being carried into these vessels, in
FIG. 328.
Carcinoma of Ovary. 1
which they cause thrombosis and infection of the surrounding tissue. 2
Like other tumors, carcinoma of the ovary may undergo secondary
FIG. 329.
Patient with Carcinoma of Ovary, Ascites, Anasarca, and Marasmus.
changes, especially fatty degeneration, which leads to the formation
1 Photograph of specimen from my operation on Mrs. L., in St. Mark's Hospital,
on April 12, 1894.
2 This is proved by actual observation of microscopical specimens from a carcino-
matous tumor of tbe pelvic floor and the ovaries belonging to it, by M. Dixon Jones,
Med. Record, March 11, 1893, vol. xliii. No. 10, p. 295, el seq.
DISEASES OF THE OVARIES. 641
of cystic cavities with ragged walls of carcinomatous tissue a condi-
tion called cystocarcinoma.
Etiology. Carcinoma rarely attacks the healthy ovary, while,
as we have seen, it often occurs in ovarian cystomas. Its cause is
unknown. It is found in young women, and even in children, most
commonly near the two ends of menstrual activity, puberty or the
menopause.
Symptoms. The disease may begin as an acute inflammation or
develop gradually. It is characterized by amenorrhea, pain, rapid
growth, local peritonitis, ascites, edema of the thighs, and general
marasmus (Fig. 329).
Diagnosis. It is distinguished from fibroid and sarcomatous tumors
by the unusually rapid development, greater pain, edema of the
thighs, and the presence of tumors in Douglas's pouch, the lumbar
region, the omentum, stomach, liver, or spleen.
The ascitic fluid accompanying malignant ovarian tumors (carci-
noma, sarcoma, or papilloma), obtained by aspiration, contains some-
times large round or pear-shaped cells, with a large nucleus, either
isolated or in groups. 1 Much more conclusive than aspiration is, how-
ever, exploratory incision, which enables us to feel the nodules on the
tumor, and perhaps on other parts, and to judge whether an extirpa-
tion should be attempted or not.
Treatment. If performed early, ovariotomy may effect a radical
cure. If the neighboring organs are implicated, it may yet give
relief from painful tension for several months. But if other tumors
are felt beside the ovary, the operation is contraindicated.
VI. Tuberculosis.
Next to the tubes and the uterus, the ovary is the part of the geni-
tal tract most commonly affected by tuberculosis. It may be primary 2
or secondary. It may be part of general tuberculosis, and is then
brought to the ovary through the blood, but it may also reach the
ovary through the genital canal.
Pathological Anatomy. Miliary tubercles are rarely found. The
affection may be limited to the surface or invade the whole organ.
The ovary is then somewhat enlarged, soft, and contains cheesy de-
posits ranging in size from that of a millet-seed to that of a marble.
These tuberculous nodules may soften and rupture into the peritoneal
cavity, causing peritonitis. The surface of the ovary is commonly
covered with layers of inflammatory exudation and adhesions.
Symptoms. The symptoms are those of chronic oophoritis.
Diagnosis. The disease can only be diagnosticated, if swelling of
1 Garrigues, Diagnosis of Ovarian Oysts, pp. 94-97.
2 Dr. G. M. Tuttle of New York has reported a case of apparently primary tuber-
culosis of the ovary in Aimer. Jour. Obst., Jan., 1890, xxiii. p. 68.
41
642 DISEASES OF WOMEN.
the ovary is combined with pulmonary tuberculosis or local tuber-
culosis of the visible part of the genital canal, or if the discharge
from the uterus contains cheesy masses and tubercle-bacilli.
Treatment. If the affection is primary, salpingo-oophorectomy may
lead to a cure. If it is combined with pulmonary tuberculosis, and
the disease has been checked in the lungs, the removal of the append-
ages is still indicated. If it is allied to a similar affection of the
tube and the uterus, hysterectomy may be added (p. 491). Even
tubercular peritonitis may be cured by the operation. On the other
hand, the operation is contra-indicated as long as the disease spreads
in the lungs. If no radical cure is possible, the usual medical and
hygienic treatment is all we have to rely on.
CHAPTER VI.
OOPHOBALGIA.
THE ovary may be the seat of neuralgia. In most cases this forms
only part of hysteria, but the disease may be found in women who show
no other symptoms of that affection. It may be of malarial origin.
The left ovary is affected much more frequently than the right, for
which circumstance we may, perhaps, find an explanation in its con-
tact with the rectum, the contents of which are apt to press on the
ovary on this side, or the different disposition and construction of the
ovarian vein on this side (p. 74). Sometimes the affection is bilateral.
The pain is spontaneous, or may be produced by pressure on the
ovary. It is felt in the hip, shooting back to the lumbar region or
down the leg, and is so severe that the patient can neither be moved
nor stand. Very often it is combined with hemianaBSthesia of the
corresponding side and hystero-epileptic seizures. Pressure on the
ovary produces, first, cardialgia and vomiting ; next, palpitations, with
frequent pulse and globus hystericus; and, finally, often a hissing
sound in the corresponding ear, pain in the temple, darkening of the
eyesight, loss of consciousness, and convulsions.
While pressure on the ovary may produce such an attack, it can
also check a spontaneous one.
Diagnosis. In chronic oophoritis the ovary is enlarged, and often
uneven and fastened by adhesions.
Treatment. The treatment consists in rest, anodynes, galvanism,
faradization with the secondary current of high tension (p. 230), and
tonic and antihysteric remedies. If the disease is malarial, it yields
to large doses of quinine. 1 Oophorectomy has sometimes a marked
beneficial effect, but is in many cases fruitless.
1 Case of H. C. Coe, Amer. Jour. Med. Sci., April, 1891, vol. ci. p. 365.
PART VII.
DISEASES OF THE PELVIS.
UNDER this title we describe the affections of the peritoneum, the
connective tissue, and the blood- and lymph- vessels of the true pelvis,
including the ligaments of the uterus.
CHAPTER I.
MALFORMATIONS.
IN speaking of the uterus (p. 394) we have mentioned that latero-
position is due to an uneven development of the two broad ligaments,
anteposition to defective development of the parts situated in front
of the uterus, and retroposition to a similar defect in those behind it.
Perhaps some cases of congenital anteflexion and anteversion orig-
inate in too great shortness of the round ligaments.
The peritoneal pouch, which in the fetus forms the canal of
Nuck, and normally is transformed to a fibrous string, may remain
open. It may either remain in connection with the abdominal cavity
or be closed at the upper end and become the seat of hydrocele, or
form a sheath around the round ligament, which must be pushed back
in Alexander's operation (pp. 59, 262, and 449).
CHAPTER II.
ANEURYSM OF THE UTERINE ARTERY.
I AM not aware that more than one case of aneurysm of the ute-
rine artery has been reported. 1 Upon vaginal examination there was
found a pulsating tumor in the pelvis of the size of a hazelnut,
which was diminished by pressure, but refilled again each time press-
ure was discontinued. It gave a subjective sensation of throbbing.
It was supposed to be due to the use of leeches in the vagina, and
1 Mare, Excerpta Medica. No. 2, Nov., 1891.
643
644 DISEASES OF WOMEN.
might, perhaps, also be due to childbirth. The treatment recom-
mended is galvanopuncture, with the positive pole in the tumor,
or forcipressure.
CHAPTER III.
DISEASES OF THE BROAD LIGAMENT.
A. Varicocele of the Broad Ligament, or Parovarian Varicocele.
VARICOCELE in the female corresponds to the same condition in the
male, but the different anatomical relations constitute rather consider-
able differences between the two. While in man the veins of the
testis follow an almost perpendicular course, those of the ovary are
nearly horizontal. The spermatic veins soon form a single trunk,
whereas the pampiniform plexus in woman communicates freely with
the uterine, the vaginal, and the vesical plexus. There will, therefore,
be less tendency to the disease in woman than in man. As a matter
of fact, it is about three times less common in female cadavers than
in male, and is rarely recognized in the living subject, although we
may be sure that the swelling must have been much larger during
the patient's lifetime than after death.
By varicocele we do not mean the enlargement of veins in the
broad ligament which accompanies tumors, especially uterine fibroids,
but an isolated swelling of the ovarian veins, implicating more or less
the other veins of the broad ligament, It has been divided into supe-
rior parovarian varicocele when it is situated between the ovary and
the tube, and inferior parovarian varicocele, when it is found below the
ovary. It may reach the size of a hen's egg, and is composed of a
conglomeration of veins, the walls of which are often thickened, and
which may contain phleboliths. It is much more common on the left
side, but may be found on the right or on both, the preponderance on
the left side being without doubt due to the lack of a valve in the
left ovarian vein, and to the fact that it opens at right angles into the
renal vein (p. 74).
Etiology. The condition is probably due to stibin volution after
confinement ; a relaxed condition of the tissues following a low state
of the general health ; an original weakness of the walls of the veins ;
pressure from fecal accumulation in the sigmoid flexure, which lies in
front of the ovarian vein ; or displacements of the uterus, especially
retroversion and retroflexion, which interfere with the free return of
the blood througli the infundibulopelvic ligament.
Symptoms. The most prominent symptom is pain of a peculiar
dull, aching character, extending up the side to the region of the kid-
iiey. The pain disappears when the patient is in the horizontal posi-
DISEASES OF THE PELVIS. 645
tion, and is increased by standing erect. By bimanual examination
with one finger in the rectum a distinct doughy tumor or knotted
swollen vessels may be felt in the broad ligament.
Prognosis. Some patients suffer so much that they are unable to
stand or walk, and are bedridden invalids for years. The dilated
veins may rupture, and form a hematocele or hematoma (see below).
Diagnosis. Salpingitis causes a sausage-shaped tumor ; odphoritis
is harder and more painful ; cellulitis and pelvic peritonitis have more
diffuse contours, and none of them becomes smaller in the recumbent
position. A swollen vein may be confounded with a swollen ureter,
but in the latter condition other symptoms of a pathological state of
the uropoietic organs are present.
Treatment. If the condition is recent, hot douches, tincture of iodine,
ichthyol glycerin, or faradic electricity, combined with frequent rest
in a recumbent position and attention to the bowels, may effect a cure.
If it is old enough to have produced permanent dilatation of the
veins and thickening of their walls, nothing is likely to be of avail
except an extirpation of the affected part of the broad ligament,
together with the tube and ovary ; which may be done by tying it
with the cobbler's stitch or some other form of a chain-ligature, and
cutting the parts away above the ligature. 1
B. Cysts of the Broad Ligament.
Not every cyst situated in the broad ligament is a cyst of the broad
ligament. We have seen above (p. 585) that ovarian tumors may
develop downward into the broad ligament and even far beyond its
base. A Graafian follicle or a corpus luteum may form such a cyst.
By a cyst of the broad ligament is meant a cyst developed in the
broad ligament outside of the ovary. Such cysts are sometimes
called parovarian cysts, but this name is not quite correct, for the
parovarium is a definite organ found in a definite locality, and, if it
is true that such cysts may develop in it, it is no less true that they
may develop in any other part of the broad ligament. The schematic
figure 330 gives a good idea of the locality of such cysts.
Cysts of the broad ligament are much rarer than ovarian cysts.
As a rule, they are monocystic, but exceptionally polycystic tumors
of this origin have been found. Commonly, they do not exceed the
size of a pregnant uterus at six months' gestation, but exceptionally
they may become enormous.
1 The disease has been described, with report of four cases in which Inparotomy
was performed successfully, by A. P. Dudley of New York in the N. Y. Med. Jour.,
Aug. 11 and 18, 1888 a paper that has been severely, and in my opinion rather
unjustly, criticised by Coe in Amer. Jour. Obst., May, 1889, vol. xxii. p. 504. I have
myself operated on a case of this kind Mrs. H., St. Mark's Hospital, Feb. 19, 1894.
The left broad ligament formed a conglomeration of tortuous dark bine, almost black
veins, each as thick as a lead pencil, situated between the uterus and the tube.
646
DISEASES OF WOMEN.
As a rule, the wall is so thin as to be translucent or transparent,
but in exceptional cases the cyst may look like a uterine growth on
account of a thick layer of smooth muscle-fibers. The wall is com-
posed of the peritoneum with its endothelium ; a layer of connective
tissue containing some plain muscle-fibers ; often glands, which do not
open into the interior ; and very few blood-vessels, which gives it a
Diagram of the Structures in and adjacent to the Broad Ligament (Doran) : 1, framework of the
parenchyma of the ovary, seat of 1 a, simple or glandular multilocular cyst ; 2, tissue of
hilum with 3, papillary cyst l ; 4, broad-ligament cyst independent of parovarium and Fallo-
pian tube ; 5, similar cyst in broad ligament, above the tube, but not connected with it ;
6, similar cyst developed close to 7, ovarian flmbria of tube ; 8, the hydatid of Morgagni ;
9, cyst developed from horizontal tube of parovarium ; 10, the parovarium : the dotted lines
represent the inner portion, always more or less obsolete in the adult ; 11, small cyst devel-
oped from a vertical tube : 12, Gartner's duct ; 13, track of the same in the uterine wall.
white color. Its interior surface is smooth or wrinkled, but has no
glandular formations, and is covered with a single layer of vibratile,
low columnar or flat epithelium. As a rule, these cysts extend right
up to the tube, that becomes imbedded in the wall without mesosal-
pinx. Like ovarian tumors, they may develop below the broad liga-
ment, and come to lie below, in front of, or behind the peritoneum.
They may become so large as to be much more abdominal than pelvic
tumors.
The fluid is normally watery, nearly colorless, and alkaline or
neutral. It does not coagulate spontaneously, nor to any extent by
heat before adding an acid. It contains a few cells and Bennett's large
and small corpuscles (Figs. 301, 302, and 308, pp. 577, 578). But
in exceptional cases a thick colloid fluid has been found in such cysts.
Papillary and dermoid cysts may also develop in the broad ligament.
As a rule, cysts of the broad ligament are sessile, but sometimes
1 This theory about the origin of the two kinds of ovarian cysts is not generally
admitted.
DISEASES OF THE PELVIS. 647
the ligament forms a pedicle, which may even become twisted, an
accident that may lead to gangrene of the tuinor.
These tumors are found in the period of sexual maturity. They
grow very slowly. 1 They do not impair the general health, and give
rise to no symptoms except by their bulk.
Diagnosis. A small cyst of the broad ligament may be felt in the
pelvis separate from the ovary and tilting the uterus over to the
opposite side. It may be so like hematoma that it cannot be distin-
guished from it except by the history, the latter developing rapidly,
and being reabsorbed after some time. The distinction from ovarian,
especially intraligamentous, and other abdominal cysts may be very
difficult. The leading points are the slow development, slight pain,
absence of cachexia, the low seat, absence of solid masses, a very dis-
tinct fluctuation- wave, flatness in front, and greater fullness in the
flanks.
It is impossible to tell for sure, by the fluid alone, whether a tumor
is ovarian or a cyst of the broad ligament, although the presumption
may be strongly in favor of one or the other 2 : both ovarian cysts and
cysts of the broad ligament may have serous or colloid contents, but
the latter is common in ovarian cysts, rare in extra-ovarian, while the
watery is common in extra-ovarian, rare in ovarian cysts. Still, it
may be found, not only in true monocysts, but in multilocular
cystomas of the ovary.
Treatment. Small tumors of this kind should be let alone. When
by their bulk they become troublesome, the best thing to do is to re-
move them exactly like an ovarian tumor. Sometimes there is a pedicle,
and sometimes one can be made of the peritoneal covering during the
operation. Enucleation is, as a rule, easy. If it meets with difficul-
ties, the sac should be cut open and the left hand introduced to help
the right hand separate the cyst from the peritoneum. After the enu-
cleation the empty shell may be tied as a pedicle in one or more sec-
tions, or the edges may be stitched together with catgut, or they may be
brought together as a purse and fastened to the abdominal wound.
The cavity is packed with iodoform gauze, ancf will fill by granula-
tion, but, as a rule, only with suppuration. If the tumor cannot be
enucleated, the whole sac may be fastened to the abdominal wound
(marsupialization). Redundant tissue is, of course, cut away in all
these procedures.
Another way of operating is simply to cut out a large circular
piece of the wall and close the abdomen.
These cysts used to be treated by tapping or aspiration, and their
1 1 have, many years ago, assisted in aspirating one that had been tapped five years
before by W. L. Atlee, and in that time had not become larger than the uterus at the
end of six months' gestation.
2 Garrigues, Diagnosis, etc., pp. 49-55.
648 DISEASES OF WOMEN.
innocuous nature and the slowness to refill of most of them are indeed
great inducements to use that kind of treatment ; but since it has been
discovered that some of them are papillomatous, and the radical ope-
ration in most cases easy and safe, extirpation is preferred by most
gynecologists.
If the ovary and tube are healthy and placed so that they need not
be removed, they should be left behind.
C. Solid Tumors of the Broad Ligament.
Besides uterine fibroids which grow in between the layers of the
broad ligament, and of which enough has been said in speaking of
that disease, the broad ligament is occasionally the seat of solid tumors
which take their origin in the ligaments themselves. Thus, myomas,
fibromas sometimes melting to fibrocysts lipomas, and sarcomas,
have been observed. Such tumors may push the vagina before them
and protrude into the vulva, or grow out through the greater sciatic
foramen, simulating a hernia.
All solid tumors of the broad ligament should be removed by
laparotomy as soon as discovered.
CHAPTER IV.
DISEASES OF THE ROUND LIGAMENT.
IN an earlier part of this work (p. 256) we have said that any
part of the round ligament may become the seat of a fibroma, and
that this occurs more frequently outside than inside of the pelvis.
The fibrous tissue is commonly blended with muscular, myxomatous,
or sarcomatous tissue, constituting a myofibroma, myxofibroma, or
fbrosarcoma. In one case the lymphatics were much distended
(fibroma lymphangiectodes).
The affection is much more common on the right side than on the
left. The diagnosis may be very difficult. The treatment consists
in early extirpation.
CHAPTER V.
DISEASES OF THE SACRO-UTERINE LIGAMENT.
WE have seen above (p. 426) that inflammation of the sacro-uterine
ligament is a chief cause of anteflexion of the uterus. One or both
ligaments are swollen, tender on pressure, and become shortened
through cicatricial contraction.
DISEASES OF THE PELVIS. 649
The usual antiphlogistic treatment, especially ichthyol glycerin,
tincture of iodine, hot douche, and the galvanic current, is indicated,
and often yields good results in fresh cases ; and even a chronic short-
ening may be overcome by means of vaginal packing (p. 178).
Since these ligaments form the chief support of the uterus (p. 55),
their loss of tonus and elongation, usually due to childbirth, are prin-
cipal factors in the production of prolapse of the uterus (p. 454). The
loss of tonicity may perhaps be remedied by the use of the faradic
current or massage. If not, recourse must be had to pessaries, sup-
porters, or the operations indicated for prolapse (p. 457).
CHAPTER VI.
PELVIC HEMORRHAGE.
INTERNAL hemorrhage from the genitals and the parts near them
takes place in three ways, differing widely from one another as to fre-
quency, anatomy, danger, and treatment, and which it is, therefore,
appropriate to designate by three different names and to describe
apart from one another. Since, however, most authors follow
a different course in this respect, it is necessary to add the other names
under which the described conditions are known.
The blood may be poured freely into the peritoneal cavity. We
call this simply intraperitoneal hemorrhage, but most writers class it
with the second condition, and call it non-encysted hematocele or
cataclysmic hematocele. Secondly, the blood may enter the peri-
toneal cavity, and become limited by inflammatory exudation, so as to
form a tumor. We call this hematocele, but it has been designated
as pelvic hematocele, intraperitoneal hematocele, or true hematocele
(always comprising the free intraperitoneal hemorrhage). Finally,
the extravasated blood may be situated in the connective tissue of
the broad ligaments, the pelvis, and the abdomen. This condition we
designate as hematoma, but it is also called extraperitoneal hematocele,
false hematocele, pseudohematocele, or thrombus. (Compare Throm-
bus of the Vulva, p. 276.) 1
A. Intraperitoneal Hemorrhage.
If a large amount of blood is poured rapidly into the healthy peri-
toneal cavity, it meets with no resistance, the intestines are pushed
aside, and the abdominal wall becomes distended.
Etiology. Most cases of abdominal hemorrhage are traumatic and
1 Kosenwasser of Cleveland, Ohio, unites the two last condition, under the name of
circumscribed or limited, hemorrhage, opposed to the first, which he calls free hemor-
rhage (Trans. Amer. Obstetricians and Gynecologists, 1893).
650 DISEASES OF WOMEN.
due to rupture of the liver, or they may be caused by the rupture of
an aneurysm of the abdominal aorta or the celiac axis. In gyneco-
logical practice they are nearly always brought about by tubal preg-
nancy with, or oftener without, rupture of the tube, and sometimes
by rupture of a dilated vein, such as those forming a varicocele or
accompanying a uterine fibroid, or by hemorrhage from a badly
secured pedicle, or by adhesions torn during laparotomy.
Symptoms. The condition is characterized by sudden pain in the
abdomen ; a sensation of a warm internal current ; faiutness ; nausea ;
vomiting ; a frequent, small, or imperceptible pulse ; a subnormal tem-
perature ; difficult respiration ; pallor ; a cold, clammy skin ; and often
discharge of blood from the vagina. Consciousness is preserved and
the patient feels that she is dying.
Diagnosis. We have only these rational symptoms of internal
hemorrhage to go by. No tumor can be felt, and we cannot wait for
a dull percussion-sound or the feel of fluctuation.
Prognosis. The condition is absolutely fatal unless the hemorrhage
is arrested by surgical means.
Treatment. The indication is the same as for any other serious
hemorrhage accessible to the surgeon's knife : laparotomy offers the
only chance of rescue for the patient. Clots, fluid blood, and foreign
substances, such as a fetus, must be removed from the peritoneal cav-
ity, bleeding vessels tied, or diseased appendages removed on the
affected side. It is even recommended, in cases of a ruptured fetal
sac, not only to stitch up the tear in the tube, but to combine with it
the ligation of both the ovarian and uterine artery in their continuity.
B. Hematocele.
Hematocele is an encysted effusion of blood in the peritoneal cav-
ity of the pelvis.
Pathological Anatomy. As a rule, the blood is found in Douglas's
pouch, but if the amount is large, it rises more or less above the
brim of the pelvis, and may reach as far up as the umbilicus. At
first it lies behind the uterus, and is, therefore, called a retro-uterine
hematocele. If later it surrounds that viscus, it is designated as
circumuterine. If Douglas's pouch is closed by adhesions, the blood
accumulates in front of and above the uterus, which condition is
named ante-uterine hematocele, and is, of course, much rarer than the
other varieties.
The blood is at first pure and thin, but becomes coagulated, in-
spissated, tarry, and, still later, sometimes mixed with pus or sanies.
Through adhesive peritonitis the intestinal knuckles are glued to-
gether, and plastic lymph is poured out and converted into tissue,
forming a roof over the extravasated blood, which in places is finger-
thick and shuts it off from the peritoneal cavity.
DISEASES OF THE PELVIS. 651
The blood may be derived from the ovaries, the tubes, the uterus,
the broad ligaments, the peritoneum, or a fetal sac.
If it is a case of tubal pregnancy, the fetus is found only in a
small minority of cases, which shows that it becomes absorbed ; but
on microscopical examination we always find villi chorii, which are
entirely characteristic of an impregnated ovum.
Sometimes peritonitic adhesions exist before the hemorrhage takes
place, or repeated hemorrhage may occur under the already formed
roof.
Etiology. Hematocele is a rather rare disease. It is found at the
age of sexual maturity, most frequently in persons between twenty-five
and thirty-six years of age. We may distinguish two chief forms, of
which one is brought about by rupture of some organ, while the other
is due to menstrual fluid entering the peritoneal cavity through the
abdominal ostium of the tube. By far the most common cause is a
tubal pregnancy rupturing into the peritoneal cavity. Hematosal-
pinx is more apt to cause fatal hemorrhage in rupturing than the
formation of a tumor. Hemorrhagic salpingitis may furnish the
blood. There may be closure of the uterine end of the tube or atresia
of the uterus or vagina. In rare cases the hematocele is caused by
bleeding from an apoplectic Graafian follicle or a hematoma in the
stroma of the ovary (p. 554). A hematoma of the broad ligament
may secondarily burst, and pour its contents into the peritoneal cavity.
A ruptured vein is more likely to cause a speedily fatal hemorrhage.
Torn peritonitic adhesions may cause hematocele e. g. when an
adherent retroflexed uterus is forcibly replaced (p. 449), or the adhe-
sions may give rise to a bleeding in their interior by the same process
as that which in pachymeningitis leads to the formation of a hema-
toma of the dura mater. This condition is called hemorrhagic pachy-
peritonitis.
The formation of a hematocele is often closely allied to menstrua-
tion. It is not only when the genital canal is closed that regurgita-
tion takes place, but lifting of heavy weights, violent exercise, coition,
and exposure to cold during the menstrual period may have the same
effect.
Systemic diseases, such as scarlet fever, small-pox, purpura, and
icterus gravis, may cause such changes in the composition of the
blood, and weaken the walls of the pelvic blood-vessels so much, that
they give way and allow the blood to escape into the peritoneal cavity.
Symptoms. Sometimes there are premonitory symptoms. If the
hematocele is due to ovarian or tubal disease, there will, as a rule, be
a history of dysmenorrhea and pain in the pelvis. If the genital
canal is closed, the patient has never menstruated, or at least not for
a long time, and may have had monthly molimina. In extra-uterine
pregnancy there may be signs of pregnancy, expulsion of decidua, and
652 DISEASES OF WOMEN.
previous attacks of pain. Metrorrhagia or menorrhagia may have
been present as a sign of some abnormal condition of the internal
genitals ; or the patient may recently have gone through one of the
above-named systemic diseases. In other cases the onset may be sudden
and without warning. How severe it will be depends on the amount
of blood that has extravasated, and the rapidity with which it escapes.
There is always a sudden pain in the pelvis, to which may be added
faintness, nausea, vomiting, a more or less rapid and weak pulse, and
swelling of the abdomen, due to tympanites. Instinctively the patient
avoids all movements, and lies, as a rule, on her back. If she is
menstruating, the flow may stop, or, on the other hand, outside of
the menstrual period there may come a bloody discharge from the
vagina.
This stage of hemorrhage is the next day followed by one of
inflammatory reaction, with a chill, a pulse beating 100 to 140 in the
minute, and a temperature of 102 104 F. But this stage is like-
wise of short duration. As soon as the fluid is well encysted pulse
and temperature return to the normal standard, and the pain abates.
The third stage is that of absorption, in which the coagulated and
inspissated blood is gradually liquefied and taken up into the circu-
lation. Only in exceptional cases suppuration or septicemia super-
venes. If rupture occurs, the contents are most frequently evacuated
through the rectum, more rarely through the vagina, and still more
so through the bladder. They may also enter the free peritoneal
cavity. During the time of resorption there is often a discharge of
thick, dark blood from the vagina, which probably is some of the
extravasated blood that finds its way out through the tube and uterus,
while others think it is of uterine origin and due to hyperemia.
If the amount of blood in the peritoneal cavity is large, it may
give rise to pressure-symptoms, such as constipation, retention of
urine, tenesmus, uremia, neuralgia, edema of the legs, and rarely
phlebitis. Sometimes jaundice is developed, and the urine contains
urobilin, causing green fluorescence when chloride of zinc in ammo-
niacal solution is added.
By vaginal examination at first a soft mass, and later a tumor, is
felt filling Douglas's pouch and extending more or less upward toward
the umbilicus. The examination is best made with one finger in the
rectum, one in the vagina, and the other hand on the abdomen.
Parts of the tumor may be hard and others fluctuating. It bulges
with a round end into the vagina, which, as well as the vaginal portion,
may be seen to be in an anemic condition. The uterus is pushed for-
ward and upward against the symphysis. By means of the sound it
can be ascertained that the fundus lies upward and forward. If
Douglas's pouch was closed before the attack, the tumor is situated
in front of the uterus, and tilts it backward against the sacrum. If
DISEASES OF THE PELVIS. 653
it was partially closed by adhesions, the lower end of the tumor is
irregular.
In the cachectic form of hematocele the bleeding may take place
slowly, and in certain cases, depending on menstruation, there may
be a monthly exacerbation, with increase in the size of the tumor.
Diagnosis. The diagnosis is, as a rule, not difficult. The general
condition is not so alarming as' in unlimited intraperitoneal hemor-
rhage. Hematoma does A iot form so large a tumor, is not accom-
panied by vaginal discharge or peritonitis, is lateral and pushes the
uterus over to the opposite side, and is absorbed sooner. Pelriperito-
nitis is ushered in with fever, while in hematocele it comes a day
later. The well-defined tumor is formed later in peritonitis. It is
often situated more laterally. The exudation remains fluid longer.
But in the last stage it may be impossible to distinguish them. A
retroflexed gravid uterus is accompanied by signs of pregnancy, a
peculiar elasticity of the body of the uterus, softness of the lower
uterine segment and the cervix, and a distinct angle between the two.
Extra-uterine pregnancy is accompanied by signs of pregnancy, and
is rarely developed in Douglas's pouch. As we have seen above, the
two are frequently combined.
Prognosis. The prognosis is much better than in cases of free
hemorrhage. Most patients recover if not interfered with, but the
process is a slow one. Absorption takes from three weeks to six
months. Some succumb, however. The rupture into the peritoneal
cavity ends speedily in death from shock or septic peritonitis. After
rupture through the rectum suppuration may continue and slowly ex-
haust the patient's vitality.
Treatment. During the first stage the indications are to arrest
hemorrhage, combat shock, and relieve pain. The patient should be
moved as little as possible ; her head should be low ; bottles with hot
water should be applied to the extremities ; morphine should be
given hypodermically, and brandy by the mouth. An ice-bag should
be placed over the symphysis, and ice-water injected into the vagina
and rectum, unless the vitality is low, when very hot water is to be
preferred.
In the inflammatory stage ice-bags, hot- water injections, and opium
are indicated.
In the third stage absorption should be promoted by the use of
Priessnitz's compress (p. 187), ichthyol, iodine (internally and exter-
nally), mercury ointment or plaster, and the galvanic current, with a
large negative pole in the vagina and Engelmann's electrode (p. '2.31)
on the abdomen. The vagina should be kept clean by means of an-
tiseptic injections, in order to avoid possible infection.
In fresh cases all operative interference is absolutely contra-indi-
cated. If there is any likelihood of a fluid collection in the pelvis
654 . DISEASES OF WOMEN.
being a hematocele, the doctor should abstain even from a puncture
with a hypodermic syringe. Even if his instrument is aseptic and
he disinfects the vagina, germs of suppuration and putrefaction may
enter into this mass, which is so particularly favorable for their prop-
agation, and cost the patient her life.
If, on the other hand, softening of the tumor, with high tempera-
ture, frequent pulse, dry skin, chills, and pain in loins and legs
denote that suppuration has taken place, an opening should be made
in the vagina large enough to introduce one or two fingers ; the sac
should be emptied and washed out with antiseptic fluid, and a finger-
thick T-shaped soft-rubber tube introduced. If there is any bleed-
ing, the cavity is packed with iodoform gauze for forty-eight hours
before using the tube. The end of the tube is surrounded with iodo-
form gauze and rubber tissue, and the vagina packed loosely with
gauze. Once or twice a day mild antiseptic injections are made
through the tube (thymol is particularly appropriate on account of its
blandness).
The incision in the vagina may be made in the median line, where
there is the least chance of wounding vessels and the accumulated
blood keeps the rectum away; but of late most operators prefer
a transverse incision just behind the cervix (p. 484).
If the blood-cyst has ruptured into the rectum, and suppuration
continues, exhausting the patient, it is best to make a counter-opening
in the vagina and insert a drainage-tube. The sac may be so thick
and stiff that a soft tube is compressed. Then it is necessary to have
one of hard rubber closed with a stopcock.
Another indication for operation is a very slow absorption. If the
collection is large, and at the end of a month no perceptible diminu-
tion has taken place, the patient may be spared the annoyance of
spending many months in bed by evacuating the contents of the sac.
Operation is also indicated in repeated relapses. As in such a case
we may expect some bleeding, the sac should be tightly packed with
iodoform gauze, which may be left in for a week.
Vaginal incision is much safer than abdominal, on account of the
danger of septic peritonitis in the latter. But if the extravasation
cannot be reached from the vagina, laparotomy is indicated. The in-
cision may be subperitoneal or transperifoneal. For the former an
incision is made above and parallel to Poupart's ligament, the peri-
toneum lifted up, and an incision made into the sac without opening
the peritoneal cavity. If this is accidentally opened, the opening
should be enlarged and tamponed with iodoform gauze for twenty-
four hours, until adhesions have formed. Then the gauze is removed
and the tumor opened. The cavity once emptied, a counter-opening
is made in the vaginal vault and through-drainage established.
Transperitoneal laparotomy is performed in the median line. If
DISEASES OF THE PELVIS. 655
possible, the sac should be stitched to the abdominal wall, and drainage
established in that way ; but often it is impossible because there is no
separate wall. Then we can only wash the cavity out with an anti-
septic solution, and drain with iodoform gauze through the wound in
the abdominal wall.
C. Hematoma.
Pelvic hematoma, or hematoma of the broad ligament, is an effusion
of blood in the pelvic connective tissue above the levator ani muscle,
most frequently between the layers of the broad ligament, whence it
may extend under the pelvic peritoneum, up under the abdominal
peritoneum, and down on the side of the vagina. 1
Pathological Anatomy. The blood is situated in the loose connec-
tive tissue between the two layers of the broad ligament and between
the peritoneum and the underlying fascia. In most cases it is not a
very large collection, but the sac may contain several pints of blood,
and form a tumor that nearly mounts to the umbilicus. As a rule, it
is unilateral, but both sides may be affected, and then the two lateral
tumors are united by an isthmus in front of and behind the uterus, and
the rectum is narrowed by a ring-shaped stricture. The flow is arrested
by the resistance offered by the surrounding sac, and the blood does
not coagulate so rapidly as in hematocele. There may develop some
peritonitis, but less than in hematocele. The sac may rupture, with
the formation of a secondary hematocele, or it may suppurate, so as
to become a pelvic abscess. (See Cellulitis.)
Etiology. Since the connective tissue of the pelvis becomes laxer
by pregnancy, multiparous and pregnant women, as well as puerperse,
are more apt to be affected. A varicocele or the fetal sac in tubal preg-
nancy may rupture in such a place that the blood escapes between the
layers of the broad ligament, and not into the peritoneal cavity. Ex-
cessive coition may be the exciting cause. The accident happens
most frequently during menorrhagia or the pseudo-menstruation fol-
lowing oophorectomy and ovariotomy. The patient may be in perfect
health.
Symptoms. Suddenly the patient feels pain in the pelvis, with
faintness and rapid, small pulse, but the attack is less alarming than
in hematocele.
The vagina, and even the skin, may have a bluish color. A
doughy tumor is felt on one side of the uterus, which it pushes over
to the opposite side and upward. If the affection is bilateral, the
uterus is lifted up. The tumor is in close connection with the uterus,
1 According to W. A. Freund (Qynakologische Klinik, Strasburg. 1885, vol. i. p.
219) the pelvic hematoma may in non-puerperal cases form between the rectum and
the vagina, and in puerperal cases extend from the sides of the vagina to the ante-
rior abdominal wall, the kidneys, and into the mesentery, without entering the broad
ligament.
656 DISEASES OF WOMEN.
which is rendered immobile. As a rule, the tumor does not rise
beyond the pelvic brim, but it may, as stated above, ascend to the
neighborhood of the umbilicus and be distinctly fluctuating.
Diagnosis. The effusion is less rapid, causes less pain and shock,
and forms a distinct tumor sooner than in hematocele. In large bilat-
eral collections in the connective tissue the upper surface is convex,
the lower more or less irregularly concave, so that the whole reminds
one of a jellyfish, while hematocele bulges into the vagina with a con-
vex end like a dilated bag. The ring-shaped stricture of the rectum
is characteristic. The tumor is found just within the vulva, while in
most cases of hematocele its base is situated higher up. It is found
on one or both sides of the vagina in hematocele, behind. It re-
mains longer fluid. The uterus is sooner rendered immobile. Fever
sets in later. In ceUutitis the fever precedes the formation of the
tumor, the uterus is not immobilized so soon, and the inflammation
is referable to childbirth, abortion, or operative interference.
Prognosis. Nearly all patients recover in from ten to fourteen
days. Only when occurring in pregnancy, childbirth, or the puer-
perium is it dangerous. As a rule, the blood, and even the fetus in
extra-uterine pregnancy, is absorbed. Suppuration is rare. But the
sac may rupture into the peritoneal cavity, and in extra-uterine preg-
nancy the fetus may continue to grow.
Treatment. As a rule, no operation should be performed, but the
same measures be adopted as for hematocele. If the bleeding is
severe or the tumor very large, and does not become absorbed or is
changed into an abscess, one of the operations described under Hema-
tocele should be performed.
In laparotomy the sac, if possible, should be stitched to the abdom-
inal incision, but it may be so brittle that it cannot be lifted so far
even when pressure is made against the vaginal roof. In such cases
the uterus may sometimes be used to fill the gap. A suture is carried
through the abdominal wall, the edge of the sac, the peritoneal cover
of the uterus, the other edge of the sac, and the other side of the
abdominal wall. If it appears desirable, a second suture may be
inserted in a similar way. When these sutures are drawn taut, the
sac is closed by the uterus, and the latter brought in contact with the
abdominal wall. 1
Galvanopuncture through the vagina, with a fine platinum-pointed
needle connected with the positive pole, and with a current of 50
milliampres, used from five to ten minutes, has been recommended.
In a small hematoma one application suffices ; in larger it may be
repeated in from three to six days. 2
1 Marcus Rosenwasser of Cleveland, O., Annals of Gynecoloyy, March, 1891, vol.
iv. p. 325.
2 A. H. Goelet, N. Y. Med. Record, March 8, 1890, vol. xxrvii. p. 279.
DISEASES OF THE PELVIS. 657
CHAPTER VII.
PERIMETRIC INFLAMMATION.
BY " perimetric inflammation " is understood the inflammation of
the pelvic peritoneum, the pelvic connective tissue, the veins, and the
lymphatic vessels and glands in the pelvis. On account of the inti-
mate connection between these different structures and with the
neighboring organs, it is quite common that more than one of
them is affected at a time, and it is evident that there must be a cer-
tain similarity between all pelvic inflammations; but according to
the tissue from which the inflammation starts or the one that is most
affected we distinguish perimetric inflammations by different names,
and these different diseases present also sometimes peculiarities as to
frequency, physical signs, prognosis, and indications for treatment.
Our old knowledge, based only on clinical observations and post-mor-
tem examinations, has been greatly extended and corrected by the
numerous laparotomies that have been performed of late years in these
conditions. Thus we describe separately pelvic peritonitis, pelvic cellu-
litis, pelvic lymphangitis, and pelvic phlebitis.
A. Pelvic Peritonitis.
Pelvic peritonitis is the inflammation of that part of the peritoneum
which covers more or less of the uterus, the tubes, the bladder, the
rectum, the vagina, and the walls of the pelvis, and which forms the
broad ligaments.
Pelvic peritonitis is sometimes called perimetritis as a companion
name to parametritis, which is used to designate inflammation of the
connective tissue ; but since these names are not very characteristic in
regard to their derivation, -peri meaning " around," and para, " at
the side of," since their sound, especially in English, is so much alike
that there is little for the memory to take hold of, and since most
excellent treatises have been written about them under their old
names, we take it to be more practical to preserve the words " peri-
tonitis" and " cellulitis," although the latter leaves much to be desired
from an etymological standpoint, being a combination of a Latin root
and a Greek suffix, and the root itself being a remnant from the time
when what we now call connective tissue was designated as cellular
tissue.
Of all the perimetric inflammations, peritonitis is by far the most
common.
Pathological Anatomy. Different forms of pelvic peritonitis have
been distinguished namely, the serous, the adhesive, and the suppn-
rative which are sometimes only different stages of the same disease.
The inflammation may be acute or chronic.
42
658 DISEASES OF WOMEN.
In nearly all these cases are found diseased tubes, and usually the
ovary is implicated. Often the inflammation of the tubes can be
traced back to the corresponding condition in the uterus. First the
peritoneum becomes injected, its endothelium is lost, and serum is
secreted from the denuded surface. The neighboring organs are
agglutinated by a yellow tibrinous mass that becomes organized, and
forms a false membrane which encapsulates the serous exudation.
Serum may also be enclosed in the meshes of the adjacent connective
tissue, forming an inflammatory edema. The serum may gravitate
down into Douglas's pouch or be found in one of the para-uterine
fossae, or the quantity may be large enough to fill the whole pelvis,
and even surmount the iliopectineal line. As a rule, the fluid is
found behind the uterus and pushes it forward, sometimes also to
one side, but in exceptional cases the uterus being already bound
down with adhesions, the fluid is found above and in front of it.
Later this serum in the peritoneal cavity becomes inspissated, form-
ing a yellow mass like orange-jelly, 1 the more watery part being
reabsorbed and connective tissue being formed. Finally, the whole
may be absorbed, or, as it is called, the disease ends in resolution.
Even solid adhesions can probably disappear without leaving any
trace ; at least a uterus that at one time is immovably moored to the
surroundings may regain entire mobility. This absorption is doubt-
less favored by the constant movement in which the pelvic organs are
kept by respiration, the different degrees of fullness of the bladder
and intestine, their evacuation, sneezing, coughing, muscular exer-
tion, and sometimes an intervening pregnancy in which the adhesions
are softened and stretched. But, as a rule, adhesions remain indef-
initely. The serous cyst may remain unchanged for many months.
Sometimes the contents become bloody in consequence of rupture of
vessels in the adhesions, and in rare cases they become purulent. In
the adhesive form we find on one or both sides of the uterus a tumor
composed of the tube, the ovary, and, perhaps, a knuckle of intestine or
a part of the omentum, all matted together with plastic lymph or
organized adhesions. As a rule, this mass is bound in the same way
to the posterior surface of the broad ligament, or, more rarely, to the
posterior surface of the uterus, the anterior surface of the rectum,
the superior surface of the bladder, or the pelvic wall. Serum may ex-
tra vasate into such a mass. The ovary is covered with a false membrane.
The tube is contorted, and its sinuosities bound together ; the abdominal
ostium is often closed ; the fimbriae may have grown together ; bands
of adhesions form constrictions which cause adhesive salpingitis and
strictures or total partitions in the interior of the tube. The uterus may
be retroflexed or retroverted, and bound to the rectum, or, more rarely,
anteflexed or anteverted, and bound to the bladder. The condition
1 John Williams, Obst. Trans, of I<ondon, June 3, 1885, vol. xxvii.
DISEASES OF THE PELVIS. 659
we here describe, as it presents itself in laparotomies, is in most cases
probably a late stage of the preceding form, but in some cases there is
little serous effusion from the beginning, and the exuded fibrinous
lymph is soon transformed into connective tissue by a process similar
to that causing dry pleurisy. This dry chronic form is particularly
frequent in connection with tuberculosis, while the common acute form
is ordinarily accompanied by more or less serous exudation.
Pelvic peritonitis may be suppurative from the beginning, as
when gonorrhea extends through the uterus and tubes, or a serous
exudate may in the course of time, instead of being absorbed, become
purulent. Fortunately, this is a comparatively rare occurrence.
Pus in the pelvis may be found in the tube (pyosalpinx), in the
ovary (ovarian abscess), in the peritoneal cavity, or in the subperito-
neal connective tissue. Often it is found in all these localities at the
same time. We have described the first two in dealing with the
Diseases of the Tube and the Ovary. Here we will only add that
the pus-filled tube may become so distended that it occupies the
whole pelvis, where it may adhere, so that it cannot be separated from
the peritoneum. The pelvic abscess of the connective tissue will be
described below. Here we have only to do with the intraperitoneal
collection of pus. On account of the preexisting wall formed by
adhesions and the new irritation caused by the acrid contents, this
abscess, although situate in the peritoneal cavity, is in reality, as a
rule, separated from it by a complete partition of varying thickness.
This intraperitoneal abscess may open into a hollow organ, most fre-
quently the rectum, less often the vagina, and rarely the bladder. It
may rupture into the peritoneal cavity, which, fortunately, is a rare
occurrence, and it may find its way out through the peritoneum, the
connective tissue, and the skin above or below Poupart's ligament, or
burst in the gluteal region, which it reaches through the great sacro-
sciatic foramen. 1
Often the abscess is only partially emptied through a long, narrow,
and devious canal surrounded by indurated tissue, or refills again
when the outlet becomes blocked up. Such fistulous abscesses may
remain indefinitely as a source of fresh attacks of peritonitis or as a
drain on the patient's constitution, which makes her an invalid or
causes death by exhaustion.
In contact with the purulent collection the muscular fibers of the
uterus are apt to undergo fatty degeneration. The inflammation may
follow the lymphatics through the infundibulopelvic ligament up to
1 W. M. Polk thinks this is brought about by agglutination of the fimbriated end
of the tube to some point of the peritoneum, which yields and allows the migration
of the pus (" Peri-uterine Inflammation," N. Y. Med. Record, Sept. 18, 1886, vol.
xxx. p. 315).
660 DISEASES OF WOMEN.
the diaphragm, and cause diaphragmatic pleuritis ; but this is of the
dry variety and of minor importance.
Microscopical investigations 1 have shown that in peritonitis the en-
dothelia of the peritoneum and blood-vessels, the epithelium of the
ovary, the fibrous connective-tissue bundles, and the smooth muscle-
fibers all break up, forming inflammatory corpuscles i. e. small round
cells which, if they continue in connection with one another, become
spindle-shaped and form new connective tissue (adhesive peritonitis),
or, if the connection between them is interrupted, form pus-corpuscles
(suppurative peritonitis). The latter is due to the influence of gono-
cocci, staphylococci, or streptococci. The most common cause is
gonococci. The other microbes may be introduced by unclean fingers
and instruments, or may be due to rupture of vessels in injuries, since
they circulate in the blood, or may be derived from a suppurating
surface in a remote part of the body.
False membranes consist of connective tissue with interspersed
cells and blood-vessels, and contain sometimes miliary abscesses.
According to the bacteriologists, 2 gonococci do not affect the lym-
phatics, but travel along the mucous membrane of the uterus and the
tubes, while staphylococci are carried more rapidly by the lymphatics
than in following the mucous membrane, and do not invade the veins
until the lymph-vessels are choked. Streptococci are only found ex-
tensively in puerperal cases, and are transmitted in the same manner
as the staphylococci.
Etiology. Pelvic peritonitis may develop in the fetus. In adults
it is in most cases added to preexisting disease of some pelvic organ,
especially salpingitis. A serous peritonitis may accompany purulent
salpingitis, for which an explanation may be sought by supposing the
adhesions to serve as a filter, retaining the pyogenic microbes. Me-
tritis may spread from the endometrium through the muscular wall
out to the peritoneum, or it may first reach the connective tissue, the
lymphatics, or veins of the broad ligament, and secondarily the peri-
toneum. Enlargement, displacement, fibroids, and cancer of the
uterus are all very apt to be accompanied by peritonitis. Hematocele
is limited by adhesive inflammation. Peritonitis may be due to rup-
ture of a tubal pregnancy or an ovarian hematoma or abscess.
Tubercular peritonitis is usually propagated from the same affection
in the tube. It is commonly preceded by simple peritonitis.
Peritonitis is chiefly the result of gonorrhea, trauma, childbirth, or
disturbance of the menstrual flow, in all or most of which cases the
real morbific cause is infection with microbes.
Traumatic peritonitis is often brought about by gynecological treat-
ment, such as the passing of the uterine sound, application of caustics,
1 Dr. M. Dixon Jones, Medical Record, May 28, 1892, vol. xli. p. 599.
2 W. R. Pryor, Amer. Jour. Obst., May, 1891, vol. xxv. p. 603.
DISEASES OF THE PELVIS. 661
curetting, intra-uterine injections, tents, stem-pessaries, 1 incision
of the cervix, or trachelorrhaphy.
Puerperal peritonitis may be gonorrheal or traumatic, in the latter
case beginning as a hematoma or being due to microbes deposited on
wounds by unclean lingers or instruments and similar carriers of
infection.
Menstrual peritonitis may be due to a malformation of the tubes
or to flexion or stenosis of the uterine canal, but is in most cases brought
on by exposure to cold or by coition. It is not rare in washerwomen
who get wet feet, or prostitutes who bathe the genitals with cold
water in order to stop the inconvenient flow.
Perhaps also masturbation may cause peritonitis.
Symptoms. The symptoms of an acute attack of pelvic peritonitis
are much like those of acute inflammation of the pelvic organs. The
patient experiences a sudden severe pain in one side of the pelvis,
which may extend over to the opposite side or down the anterior sur-
face of the thigh. She feels faint and sometimes nauseated, and may
vomit. As a rule, she has a chill, followed by rise in temperature,
and a frequent small pulse. Very commonly she complains of rectal
and vesical tenesmus. Her face has an expression of anxiety, and
she may become delirious. The abdomen is distended and tender.
Metrorrhagia is of frequent occurrence. On vaginal examination is
found an exquisitely tender swelling occupying Douglas's pouch or
situated to one side of the uterus, and pushing the latter up against
the symphysis, and sometimes over to the opposite side, but at the
same time canting the edge forward. It is immovable. Sometimes
crepitation is heard and felt, but the swelling is too tense to give
fluctuation.
As a rule, the fluid is absorbed, the tumor becomes smaller and
disappears, and the uterus may regain its normal mobility. In other
cases induration and adhesions remain, and the uterus continues more
or less immobile. In other cases, again, recurring fever, chills, night-
sweats, and a yellowish hue of the skin indicate the formation of pus ;
but all these symptoms may be absent and, nevertheless, the exudate
become purulent. Sometimes the transformation is marked by an
extension of the inflammation up into the abdomen, by the occurrence
of persistent diarrhea due to ulcerative enteritis, or by bronchopneu-
monia with mucopurulent expectoration.
While the above description applies to most cases of acute pelvic-
peritonitis, there are others that present some peculiarities. Thus
the temperature may be normal, or even subnormal, or fluctuate be-
tween a high and a low mark ; which are bad signs. Pain and tumor
may be absent in particularly dangerous cases. The tumor may fill
1 I have described a case of this last kind in Amer. Jour. Obst., 1870, vol. xii.
p. 756.
662 DISEASES OF WOMEN.
the whole pelvis, extend considerably above the brim, or be as small
as a pigeon's egg. It may change in position and size on account of
the presence or disappearance of the accompanying edema or con-
gestion.
The chronic form may be really chronic from the beginning, but
oftener it is a succession of acute attacks brought on by bodily exertion,
trickling of tube-contents into the peritoneal cavity, rupture of a fol-
licular cyst or a distended tube. In this form the patient is often
able to be up and about, and even to do some work, but she has more
or less constant pain, with menstrual exacerbations. Menorrhagia or
amenorrhea is common. By bimanual examination we feel on the
side of the uterus the tumor described above in speaking of the
pathological anatomy, or a large tumor that mounts into the abdomen
simulating an ovarian cyst. Sometimes a fibrinous discharge from
the uterus accompanies a serous collection in the pelvis.
Prostitutes suffer often from a condition called colica scortorum.
Its symptoms are pelvic pain, fever, and purulent discharge, and it
is due to slight attacks of peritonitis, and probably to painful con-
tractions of the inflamed tubes.
Diagnosis. It may be impossible to differentiate pelvic peritonitis
from other conditions, but in most cases the diagnosis is easy. In
fresh cases the bulging tumor filling Douglas's pouch and pressing
the uterus up against the symphysis is characteristic. Hematocele
occupies, however, the same position, but it begins more suddenly and
with greater violence, and the tumor is at first fluid, and becomes
harder (p. 650), whereas peritonitis takes an opposite course. Hemor-
rhage may take place into a serous pseudocyst, but the red blood-
corpuscles are then changed into pale spherical bodies, while in hema-
tocele the fluid is pure blood with well-preserved or shrunken blood-
corpuscles. In cettulitis the symptoms are less severe, the tumor is
situated close up to the side of the uterus, and pushes it, together
with the cervix, over to the other side. It may form two tumors,
one on either side, connected by a bridge in front and behind the cer-
vix. In peritonitis the whole vaginal vault presents one smooth,
hard mass. The immobility of the uterus is less pronounced than
in peritonitis. If cellulitis extends above the brim, it always follows
the bone closely, while the peritonitic tumor, as a rule, is situated far-
ther in, and allows us to insert the fingers between it and the bony pel-
vis. If cellulitis involves the psoas and iliacus muscles, relief is found
by flexing the corresponding limb ; in peritonitis both limbs must be
drawn up to obtain the same effect. In chronic oophontis the ovary
may be movable, its shape is more or less recognizable, and it shows
an unusual tenderness. In salpingitis the tumor is sausage-shaped,
often bilateral, and follows the edge of the uterus. In cases of long
standing the tube, may, however, be so distended as to fill the pelvis,
DISEASES OF THE PELVIS. 663
and adapt itself to the peritoneum, and then the diagnosis between
this condition and a collection situated directly in the peritoneal cav-
ity becomes impossible. In extra-uterine pregnancy there are signs of
pregnancy, and the tumor is situated laterally. In cases of fibroid or
fibrocystic tumors of the uterus this is, as a rule, movable, and the
tumor moves with it. Fibroids are felt as solid nodular masses, and
there is no history of acute inflammation. The uterine cavity is, as
a rule, enlarged. In oophoralgia there is neither tumor nor inflamma-
tion. An old encysted serous collection is easily mistaken for an
immovable ovarian cyst, but there is the history of the acute begin-
ning, and exploratory puncture shows a citrine fluid containing leuco-
cytes and forming a small coagulum by exposure to the air. In the
same way a peritonitic cyst is distinguished from a cyst of the broad
ligament or a hydatid. In tubercular peritonitis the lungs are, as a
rule, affected.
Prognosis. When the disease is of traumatic or menstrual origin
the prognosis is good, both as to life and complete recovery, but
absorption may be very slow. The gonorrheal form is much more
dangerous, and may in short time lead to death by general peritonitis
or give rise to chronic peritonitis, which may end fatally through
exhaustion, embolus, or tuberculization. The puerperal form is
very grave.
Often the patient is left with impaired health. Uterine displace-
ments are a common sequel. Hematocele may develop in the adhe-
sions (p. 651). Intestinal adhesions may cause constipation, alternat-
ing with dianrhea, or occlusion of the bowel. Pressure on the nerves
of the pelvis may cause sciatica or reflex paralysis. Sterility is very
common, the ovary being covered with a false membrane that prevents
the ovum from escaping, or the tubes being sealed by adhesions. If
impregnation takes place, there is danger of the ovum being arrested
in the tube, or if it reaches the uterus, the presence of a layer of old,
unyielding false membrane around this organ or its fixation by
adhesions in an untoward position may. lead to abortion.
Treatment. In regard to prophylaxis the reader is referred to
what has been said in speaking of Salpingitis (p. 531). The patient
must lie quietly in bed, and be kept on fluid diet (p. 224). Often a
pillow rolled up, tied, and placed under her knees is grateful to her.
In the acute stage an ice-bag or ice-water coil should be applied over
the uterus, or, if cold is not well borne, a hot poultice or stupe (p. 1S7)
may be substituted. Frequent hot vaginal injections should be ordered,
to which in infectious cases antiseptics should be added (p. 172).
Heat may be used continually by combining the poultice on the
abdomen with one in the vagina, or placing a colpeurynter with hot
water in the latter. Pain should be subdued by opiates. If it is
severe, it is charitable to begin with a hypodermic injection of to
664 DISEASES OF WOMEN.
of a grain of morphine. Later, the drug is given by the mouth in
doses of ^ of a grain, repeated often enough to keep the patient com-
fortable, for which purpose iu most cases not much is required, 1 or
suppositories with J grain of pulvis opii are administered by the rec-
tum every two or three hours.
I prescribe in this as in all inflammations 5 grains of quinine every
four hours, not as an antipyretic, but as an antiphlogistic. If the
temperature rises above 102 Fahr., antipyretics (p. 228) are indi-
cated. Bacteriological researches having shown that bacilli find their
way from the intestine, and change a comparatively harmless simple
peritonitis into a dangerous septic one, it is a wise precaution to keep
the bowels open from the beginning with enemas (p. 174) or aperients,
preferably sulphate of sodium (a heaping teaspoonful, repeated, if
necessary, every three hours), or, if salts cause vomiting, calomel
(gr. j every hour until the bowels move).
When the disease after eight or ten days enters on a more subacute
stage, that is to say, when spontaneous pain and fever have ceased
and the tenderness is diminished, the patient is allowed more sub-
stantial food, and Priessnitz's compress (p. 187) should replace the
ice. A few days or a week later the abdomen should be painted with
tincture of iodine, followed by a glycerin compress (p. 188). When
the tenderness has abated sufficiently to warrant the introduction of a
speculum, the iodine is applied with greater effect to the vaginal roof
every three days (p. 170), and combined with pledgets with ichthyol-
glycerin (p. 178), abdominal inunction with ichthyol ointment (10
per cent.), and the internal use of iodide of potassium. ..By this time
about three weeks since she was taken sick the patient will, as a
rule, be well enough to get up cautiously and spend most of the day
on a lounge. Still later, when she is well enough to be on her feet,
galvanism with the negative pole in the uterus or vagina (p. 232).
faradization with the high tension secondary current for ten minutes
every day (p. 230), massage (p. 190), warm entire baths, sitz-baths
(p. 187), and the constant use of a wet abdominal bandage well covered
with water-proof material, are valuable means of causing absorption
of exudation and inflammatory tissue. Finally, the treatment in
places where they have mineral mud, so-called " moor," such as Fran-
zensbad or Marienbad in Germany, and Sandefjord in Norway, may
be recommended.
If serous pseudocysts remain after the acute symptoms have sub-
sided, and do not yield readily to the absorbent treatment described,
much time may be saved by aspirating the fluid (p. 159) from the
1 In this respect, as in many others, pelvic peritonitis differs from general peri-
tonitis, in which often enormous doses are not only well borne, but beneficent. (See
Garrigues, " The Opium Plan in Puerperal Peritonitis," N. Y. Med. Jour., Jan. 24,
1885, vol. xli. p. 98.)
DISEASES OF THE, PELVIS. 665
vagina; but the utmost care should be taken in disinfecting both
aspirator and vagina, as otherwise the inoffensive serum may be fol-
lowed by pus; and bladder, ureters, and blood-vessels must be care-
fully avoided, which limits the safe field to the posterior part of the
pelvis and a moderate distance, say an inch, from the median line.
In the chronic form of peritonitis, or when the acute and subacute
stages have passed, the patient is allowed moderate exercise ; her diet
should be nutritious and mildly stimulating (p. 224) ; but sexual
intercourse should be avoided or restricted within narrow limits.
To the therapeutic measures already mentioned may be added pack-
ing of the vagina (p. 178), which may help to stretch adhesions and
further their absorption. The internal use of resolvents (p. 226) has-
tens absorption, and an abdominal belt (p. 190) often gives comfort
by removing pressure from the inflamed peritoneum.
Pelvic Abscess. 1 If the fluid in the sac formed by the perito-
neum, pelvic organs, and false membranes is purulent, it should be
evacuated ; and the question arises, from what side is it best to attack
the sac from the rectum, the vagina, or the abdominal wall? To
make an opening in the rectum, be it with trocar, aspirator, or knife, is
not advisable, as the abscess inevitably becomes infected with the con-
tents of the bowels. If there already is a communication with the rec-
tum, opinions about the best way of treating the abscess differ. Some 2
anesthetize the patient, dilate the sphincter ani muscle to over-disten-
tion, tear the opening in the rectum down to the bottom of the abscess,
scoop out with finger or curette all granulations and old bands, wash
out the cavity, and treat it exclusively through the anus till it is
healed, which often necessitates a repetition of the operation and the
use of sponge tents to keep open the entrance to the abscess. Most
operators prefer to introduce a sound through the opening in the rec-
tum, bend it well down against the vaginal roof, and make a counter-
incision there, through which a drainage-tube may be drawn, and left
until the cavity is closed. It is, of course, kept clean with daily injec-
tions of antiseptic fluid. More rarely the counter-opening is made
in the abdominal wall.
If the purulent collection is near the vaginal roof, and does not
contain over two ounces of pus, some advise to aspirate. Others use
a trocar and canula. But it is better to make a large opening, so as
to be sure to have a free outlet and be able to insert a drainage-tube.
Some make this opening by plunging a pointed curved pair of scissors,
1 The term ."pelvic abscess" is taken in different senses by different authors.
Some use it for a collection of pus anywhere in the pelvis ; others restrict it to col-
lections the sac of which cannot be removed (Pozzi) ; and others, again, use it only
to designate the suppuration of the connective tissue of the pelvis (Thornas-Munde').
1 use it for intra- or extra-peritoneal purulent collections in the pelvis, except those
situated in the tube or the ovary.
2 H. T. Byford, A Case of Pdvic Abscess, Chicago, 1886.
666 DISEASES OF WOMEN.
through the posterior vault of the vagina into the abscess and with-
drawing them open. Then they enlarge the opening with an expanding
dilator, clean out the cavity with finger and curette, removing granu-
lar masses, tags, and partitions, wash out, and leave a stiff soft-rubber
drainage-tube with cross-bar. Special forceps have been made with
which the abscess may be opened and the drainage-tube carried in. 1
The puncturing dilator (Fig. 324) and the blunt dilator (Fig. 325)
are also serviceable instruments in such cases. This method is simple
and effective, and, as a rule, successful, but has the drawback that one
is never sure of not wounding a blood-vessel or the intestine. It is
much safer to cut layer after layer with a scalpel, arresting hemor-
rhage, if necessary, by carrying a suture round the bleeding vessels.
(Compare Hematocele, p. 666.) As to the direction of the incision, if
the collection is central, it may be made in the sagittal or coronal
plane. If it is lateral, the incision should go outward and backward,
never passing the prolongation of a transverse line drawn from side
to side through the cervical canal, in order to steer clear of the ureter
and the uterine artery.
If the abscess points near Poupart's ligament, a large incision is
made parallel to the ligament, cutting layer by layer, and when an
opening has been made a finger is introduced to the bottom, counter-
pressure is made from the vagina, and, if there is not too much tissue,
a counter-opening is made here and a soft rubber drainage-tube with
side holes drawn through the cavity.
This incision may even be used if the abscess does not point, but is
at some distance from the ligament : the peritoneum is then lifted
until the abscess can be entered from behind without opening the
peritoneal cavity.
When the pus extends upward and backward (in puerperal cel-
lulitis), the most favorable point at which to cut deep is above the
crest of the ilium, between the attachments of the latissimus dorsi
and obliquus abdominis externus muscles (Petit's triangle). Here
a vertical incision is made, which leads to the external border of the
quadratus lumborum muscle.
With the increasing familiarity with laparotomy it becomes, how-
ever, more and more customary to perform that operation. It has
the great advantage of allowing the operator to see, of giving him
room to tie bleeding vessels, to remove the appendages if they are
found to be the source of the suppuration, and to empty separate pus-
foci wherever they may be, and of preventing subsequent infectioiii
The pus should be aspirated and the abscess-cavity washed out with
antiseptic fluid before opening it. Even then the place where the
incision is to be made should be surrounded by sponges or gauze pads
1 Dr. Bache Emmet has described and delineated one in N. Y. Med. Record, March
19, 1892.
DISEASES OF THE PELVIS. 667
in order to catch the contents. If the abscess unfortunately bursts
and pus enters the peritoneal cavity, it should be wiped off with gauze
pads, and a drain of iodoform gauze be carried from the contaminated
part through the wound in the abdominal wall or the one in the vagi-
nal roof. Only if the pus has spread far away among the intestinal
knuckles, the cavity should be flooded with a warm solution of salt
(p. 502) or thymol, or with Thiersch's solution (p. 206). If pos-
sible, the sac is stitched to the edges of the incision ; if not, an
opening is made in the vaginal vault, drainage is established in
that way, and the abscess-cavity is closed over it ; and if that too
is impossible, the focus is simply opened and disinfected, and a
drainage-tube or iodoform-gauze drain is brought out through the
abdominal incision.
Even when laparotomy is performed, it may be found to be advan-
tageous to open the abscess above Poupart's ligament by lifting the
peritoneum and getting in from behind, so that it does not connect
with the peritoneal cavity.
It has been advised to open abscesses in two sittings (Hegar's
method). An incision is made down to the sac without opening it ;
the wound is packed with iodoform gauze, which is left in for four
or five days until strong adhesions have formed all around, and then
the abscess is opened. This method is applicable both to abdominal
and vaginal incision.
Of late laparotomy has again to a great extent been replaced by
vaginal hysterectomy and, if possible, removal of the appendages. If
these cannot be removed and contain pus, they should be incised and
drained through the vagina. This method presents the advantage
that the protecting partition which nature has placed between the
abscess and the upper part of the peritoneal cavity need, perhaps, not
be broken, and that there is established free drainage through the
vagina. On the other hand, the removal of the uterus does not al-
ways succeed, and still less that of the appendages. There is also
considerable danger of wounding the intestine or bladder, and the
parts are so little accessible between the hemostatic pressure-forceps
filling the .vagina that repair becomes impossible. Often the re-
moval of the uterus is facilitated by morcellation. (Compare Uter-
ine Fibroid, pp. 483-491.)
Other methods have been proposed in order to reach deep abscesses
from the perineal or sacral region, such as vertical perineotomy, trans-
verse perineotomy, and sacrotomy.
Vertical Perineotomy. An incision is made from a point between
the posterior and middle third of the labium majus, going midway
between the anus and the tuberosity of the ischium, and ending
somewhat beyond the tuberosity. In this way the levator ani muscle
is exposed and incised in order to reach the abscess.
668 DISEASES OF WOMEN.
Transverse Perineotomy. An incision is made from one tuberosity
to the other, and carried up through the rectovaginal septum.
Sacrotomy. This is Kraske's method for extirpation of the rec-
tum or Hegar's modification of it applied to the opening of a deep
abscess. (See Hysterectomy, pp. 519, 520.)
None of these methods allows the operator to explore the pelvis
to any great extent, and still less to remove diseased tissues or organs
with anything like the facilities afforded by laparotomy.
To use the blunt curette in the abscess, except in cases of old
standing, is hazardous, since we have seen above that the thickness
of the sac varies much in different parts, and a perforation might be
made unawares into the peritoneal cavity.
If the abscess has opened into the bladder, a counter-opening has
been made in this viscus, either by suprapubic cystotomy (Schroeder)
or from the vagina (Buckmaster x ), in order to establish good drain-
age. But it often closes without operation by simply washing out
the bladder.
If the abscess opens into the ureter, it may perhaps be possible to
repair the defect by laparotomy (p. 375).
After an abscess has been emptied and well drained, the surround-
ing hard masses soon disappear.
Fistulous Tracts. After spontaneous opening into the vagina the
abscess heals in most cases, but if a fistula remains and constant suppu-
ration exhausts the patient, it must be dilated with the knife, dilator,
or tents ; or perhaps a laparotomy may give the best access to the
cavity. Spontaneous opening near Poupart's ligament or the iliac
crest often leaves long sinuous fistula? that have to be dilated with
laminaria or laid open with the knife, and good drainage established,
sometimes by means of a counter-opening in the vagina, before recov-
ery can take place.
Sometimes it suffices to curette the fistulous tracts and old abscess-
cavities that will not close, and inject them daily with peroxide of
hydrogen, carbolized water (2 per cent.), Labarraque's solution diluted
with 8 or 10 parts of water, Villate's solution 2 mixed with 2 parts of
water, or to use two or three times a week injections with tincture
of iodine, in the beginning mixed with water, or a solution of nitrate
of silver (2 per cent.).
In some cases of adhesive peritonitis laparotomy is performed with
the sole aim of breaking up adhesions (compare Salpingitis, p. 533) ;
but if it is done for a pelvic abscess, the tubes and ovaries should, if
possible, be removed as the source of the suppurative peritonitis.
1 A. H. Buckmaster, "Pelvic Abscess," Brooklyn Med. Jour., April, 1891.
2 R. Cupri sulphat, \ da ISO-
Plumbi sulphat., (
Liq. plumbi subacetat., 30.0 ;
Aceti, 200.0. M.
DISEASES OF THE PELVIS. 669
B. Pelvic Cellulitis.
Pelvic cellulitis is the inflammation of the connective tissue in the
pelvis above the pelvic diaphragm. We have seen in the anatomi-
cal part (p. 93) that there is a large amount of such tissue in this
locality, and especially around and in the broad ligaments, and that
it is in direct connection with the same kind of tissue outside of the
abdominal peritoneum and under the skin. Some modern gynecolo-
gists would have us believe that inflammation is rare in this tissue,
and that, when it does occur, it rarely runs into suppuration. It is
an unfortunate, but common, quality of the human mind to be en-
grossed by one idea to the exclusion of others. When a new discovery
is made we are apt to be dazzled by it to such a degree that we over-
look other equally well-established facts. There was a time when
every pelvic inflammation was looked upon as cellulitis; then there
came a reaction and it was all peritonitis ; and of late many exclusively
lay stress on salpingitis.
As a matter of fact, connective tissue in the pelvis, just as anywhere
else in the body, is prone to become inflamed ; but, as a rule, we have
only clinical evidence of its existence. Since the patients usually
recover, we have only few autopsies to fortify our argument with. Yet
we have some performed on women in which the inflammation was
strictly confined to the connective tissue, without implicating perito-
neum, tube, or ovary ; and there is the still more convincing case of
a man who fell asleep on a wet bridge, and in whose pelvic connective
tissue a large abscess formed, while the peritoneum was entirely free. 1
In this case certainly no puerperal influence could be invoked, nor
could the cellulitis be attributed to uterus, tubes, or ovaries.
Some gynecologists express themselves as if the disease did not
concern them when it is connected with childbirth and abortion ; but,
even if they do not practice obstetrics, they are very likely to be called
in when an operation has to be performed, and science is one inde-
pendently of the limits within which the physician may find it con-
venient to confine his work. But, even independently of puerperal
influences, cellulitis exists, and if we do not see it in laparotomies as
often as we find peritonitis, it is for the simple reason that few lapa-
rotomies are performed when the inflammation is limited to the pelvic
connective tissue. 2
1 T. H. Burchard, " Pelvic Abscess in the Male," paper read before the X. Y.
Academy of Medicine, April 15, 1886.
2 It is beyond the scope of this work to enter into controversies or to give a com-
plete bibliography, but those who want to study the question of pelvic inflammation
more in detail will find it to their advantage to examine, among others, besides
those already quoted, the following papers: " On the Character and Types of Pelvic
Inflammations in the Female," by Henry S. Stark, Me<l. Record, Aug. 15, 1891 ;
" Perimetric Cysts," by John Schmitt, Amer. Jour. Obst., Jan., 1892, vol. xxv. p. 18 ;
" Peritonitis hervorgerufen durch Ruptur eines Ovarialhiimatoms," by II. J. Boldt,
670 DISEASES OF WOMEN.
Cellulitis not only exists, but it is a rather common occurrence,
and used especially to be so before antiseptic midwifery and sur-
gery were so much practised as they are now-a-days. Certain
localities are more liable to be affected than others, because they con-
tain a larger amount of connective tissue, and because they are more
exposed to injury viz. the broad ligaments, the surroundings of the
lower uterine segment and the fornix of the vagina, the sacro-uterine
ligaments, and the space between the cervix and the bladder.
Cellulitis may be acute or chronic.
Acute cellulitis may arise by propagation of the inflammation from a
tear or ulcers in the cervix or from corporeal endometritis, the inflam-
mation spreading through the intermuscular connective tissue. It may
also begin directly in a tear extending into the parametrium, or it may
begin anywhere in the depth of bruised tissue. In most cases it is
combined with pelvic peritonitis, lymphangitis, or phlebitis.
That peritonitis and cellulitis go together, whether one or the other
is the primary affection, is easy to understand, since the peritoneum
and the connective tissue are not only in contact, but the peritoneum
is only a modification of connective tissue.
When cellulitis is combined with lymphangitis, the latter is the pri-
mary lesion, the lymph-vessels becoming inflamed in the uterus or in
Deutsche med.Wochenschrift, 1891 ; "Unusual Cases of Abdominal Section." by Henry
T. Byford, Chicago Med. Recorder, Dec. 7, 1891 ; " Pus in the Pelvis, and How' to Deal
with It," by Joseph Price, Southern Surgical and Gynecological Trans., vol. ii. ; " Ob-
servations on the Medical and Surgical Treatment.of Peritonitis," by T. H. Burchard,
N. Y. Med. Jour., Aug. 15, 1885 ; " Recurrent Pelvic Peritonitis," by B. F. Baer,
Med. and Surg. Reporter, Oct. 13, 1888 ; " Chronic Adhesive Perimetritis," by James
H. Etheridge, Chicago, 111. (pamphlet without date) ; " Remarks on Peri-uterine Cel-
lulitis and Peri-uterine Peritonitis," by H. T. Hanks, Albany, 1885 ; " Electrolysis in
Peritoneal Adhesions," by W. E. Ford, Med. Press of Western New York, April, 1888 ;
" The Treatment of Local and General Peritonitis," by W. E. B. Davis, Med. Asso-
ciation of the State of Alabama, April 13, 1890 ; "Early Operations in Purulent Peri-
tonitis," by Joseph Price, Amer. Med. Assoc., May, 1890; "The Exaggerated Im-
portance of Minor Pelvic Inflammations," by H. C. Coe, N. Y. Med. Jour., May 15,
1886 ; " The Dangers of Leaving the Products of Inflammation in the Female Pel-
vis," by Chas. P. Noble, Annals of Gynecology and Paediatrics, July, 1891 ; "Cases
of Neglected Pus-tubes," by the same author, ibid., June, 1893, p. 535 ; " Cases of
Post-partum Pelvic Abscess," by T. Johnson Alloway, Canada Med. and Surgical
Jour., Montreal, 1887 ; " Traumatic Pelvic Cellulitis," by Thomas H. Allen, Gail-
lard's Med. Jour., Sept., 1889 ; "Some Observations upon Pelvic Cellulitis," by Vir-
gil O. Hardon, Atlanta Medical and Surgical Jour., 1887 ; " Pelvic Abscess," by A.
H. Bnckmaster, Brooklyn Med. Jour., April, 1891 ; " Case of Pelvic Abscess," by H.
T. Byford, Chicago Gyn. Soc., Dec. 18, 1885, Chicago, 1886; "Treatment of Pelvic
Abscess in Women," by P. F. Mtinde", Amer. Jour. Obst., 1886, vol. xiz. p. 113;
"Peri-uterine Inflammation," by W. M. Polk, Med. Record, Sept. 18, 1886, vol.
xxx., p. 309 ; Pelvic Peritonitis Microscopical Studies," by Mary Dixon Jones, Med.
Record, May 28, 1892 ; " Septic Endometritis and Peritonitis," by W. R. Pryor, Amer.
Jour. Obst., vol. xxv. p. 598, May, 1892; " Remarks upon Parametritis," by Geo. T.
Harrison, Amer. Jour. Obst., April, 1891, vol. xxiv. p. 460 ; " How shall we Treat
our Cases of Pelvic Inflammation?" by Richard B. Maury, Amer. Jour. Obst., vol.
xxiv., Jan., 1891.
DISEASES OF THE PELVIS. 671
the tear of the cervix, and carrying the infection through and into the
connective tissue.
Phlebitis may be primary, extending from inflamed uterine sinuses,
or secondary, beginning as periphlebitis by contact with inflamed
connective tissue, and gradually gaining the deeper coats of the vein.
Cellulitis is seldom bilateral.
We may distinguish between a simple traumatic form and a septic
form. Both are due to infection with bacteria, but in the first simple
bacteria of putrefaction are at work ; in the second we have to deal
with specific pathogenic bacteria.
Either of these forms may, again, be puerperal or non-puerperal.
The traumatic extends in the loose connective tissue, following the
interstices between sheets of hard connective tissue; the septic
respects no boundaries.
As in other inflammations, we may distinguish different stages, one
of infiltration, followed by one of resolution, suppuration, or organ-
ization.
During the stage of infiltration the connective tissue is swollen by
exudation of serum and formation of small round cells, which change
the tissue into a gelatinous yellow mass. In most cases the serous fluid
and the form-elements disappear again in the course of two or three
weeks. In others pus is formed, and of all perimetric inflammations
cellulitis is the one which most frequently ends in suppuration.
Often the melting into pus takes place at several distinct points, and
it is only in the course of time that these separate foci unite into one
large abscess-cavity. As to the routes followed by the pus and the
point where the abscess breaks, the reader is referred to what has been
said above in speaking of pelvic abscess in general (p. 659). Here
we shall only add that while a puerperal abscess commonly finds an
outlet through the skin ; breaking above Poupart's ligament or, more
rarely, below the same; following the vagina down to the labium
majus and the anus; going through the obturator foramen or the
greater sacro-sciatic foramen ; or following the round ligament through
the inguinal canal ; the non-puerperal very rarely perforates the skin,
and is usually discharged into one of the hollow organs in the pelvis.
The abscess in the connective tissue rarely ruptures into the peri-
toneal cavity, fatal peritonitis being, as a rule, due to simple extension
of the inflammation to the peritoneum.
Cellulitis often leads to uterine displacement, cicatricial retraction
of the sacro-uterine ligaments causing anteflexion (p. 439), and that
of the broad ligament lateroversion (p. 454).
If the inflammation ends in organization, pus may still form in the
indurated tissue after a long time.
Chronic Cellulitis. Chronic cellulitis is found as a remnant of the
acute form in the shape of cicatrices, indurated bands, discharging
672 DISEASES OF WOMEN.
abscesses, and fistulous tracts. It may also be an originally chronic
cirrhosis (atrophic chronic cellulitis), which will be described later.
Etiology. Acute cellulitis is not found in childhood, and is rare
after the menopause. It is confined to the age of sexual maturity, and
especially to the puerperal state.
Puerperal cellulitis may be due to a tear in the cervix in an other-
wise normal labor; but is especially caused by obstetric operations,
such as forced dilatation of the cervix or the extraction of the child
with forceps through a narrow pelvis. It may join inflammation of
the uterus, tubes, and ovaries. Sometimes a hematoma puerperal or
non-puerperal is first formed, which later suppurates.
Non-puerperal cellulitis is due to the use of tents, over-distention
and other operations on the cervix, enucleation of tumors, or the
presence of a non-puerperal hematoma. But, finally, all these cases
are due to infection, and the difference in their course depends on the
different kinds of microbes at work, especially the difference between
common bacteria of putrefaction and specifically pathogenic micro-
cocci.
Cellulitis may also be brought on by exposure to cold.
Symptoms. The symptoms are much like those of peritonitis, but
with certain differences. The patient may have a chill ; there is a
rise in temperature ; her pulse becomes frequent ; her tongue is
furred ; she feels weak ; she has no appetite ; she has pain in the lower
part of the abdomen, and, perhaps, vesical or rectal tenesmus ; but the
pain is not so sudden nor so severe as in peritonitis ; there is less
tendency to vomiting, and no distention of the abdomen. On vaginal
examination we find heat, swelling, and considerable tenderness. If
the broad ligament is the seat of the disease, we feel a tumor varying
in size between a walnut and an apple. If sufficiently large, it pushes
the uterus over to the opposite side. If the inflammation is bilateral,
the uterus is lifted up, and often the two lateral tumors may be felt
connected by a bridge in front and behind the cervix. If the con-
nective tissue around the sacro-uterine ligaments is affected, we feel
the semilunar fold forming the upper limit of Douglas's pouch
swollen on one or both sides. Occasionally the swelling may be
limited to the connective tissue behind or in front of the cervix
(posterior or anterior cellulitis). If the inflammation extends to the
iliac fossa, the corresponding leg is drawn up.
Transition to pus is marked by the swelling becoming soft, but
hardly distinctly fluctuating.
Induration of the tissue may last for many months. Often irrita-
bility of the bladder continues after the fever and swelling have sub-
sided a symptom which is referable to shortening of the sacro-ute-
rine ligaments, which pull on the cervix and indirectly on the base of
the bladder, which is bound to it with a thin layer of connective tissue.
DISEASES OF THE PELVIS.
673
As to other sequels, we may find amenorrhea, menorrhagia, or
dysmenorrhea.
Diagnosis. Enough has been said under the Symptomatology and
in speaking of pelvic peritonitis (p. 662) about the difference be-
tween cellulitis and the latter disease. Hematoma begins suddenly
without fever and with great pain. An inflamed ovarian tumor may
be very hard to differentiate except by the history and later course of
the disease. A common ovarian tumor is movable. A uterine fibroid
forms one mass with the uterus and moves with it, whereas in cellu-
litis it is possible to feel a groove between that organ and the swelling
in the broad ligament, and the uterus is more or less immovable.
Retroperitoneal sarcoma is a chronic disease, in which the constitution
soon suffers.
Prognosis. The prognosis of cellulitis is less grave than that of
peritonitis. It may, however, become fatal in a short time through
septicemia or develop into the more dangerous peritonitis. As a
rule, the prognosis is good as to life, but very uncertain as to time
and complete recovery.
Treatment. All that has been said above about the treatment of
peritonitis (p. 663, et seq.) applies to cellulitis, whether an abscess is
formed or not. I shall, therefore, limit myself to a few additional re-
marks bearing especially upon cellulitis.
Prophylaxis consists in avoidance of refrigeration and in antiseptic
midwifery and surgery. Slowly dilating tents should, as far as possi-
ble, be discarded, and replaced by rapid dilatation with steel dilators.
Instead of the hot douche, some recommend a continuous current
of ice-water, beginning at a pleasantly warm temperature and dimin-
ishing the heat gradually ; and, to judge by the superiority of the
ice-bag over the poultice in other inflammations, the advice seems
worthy of trial. This injection can easily be administered through
FIG. 331.
Frost's Vaginal Syringe.
Frost's vaginal syringe (Fig. 331), which plugs the vagina and has
an efferent tube leading down to a vessel under the bed.
If pus begins to form, the maturation of the abscess should be fur-
thered by the use of warm abdominal poultices and vaginal injections.
674 DISEASES OF WOMEN.
Some recommend early aspiration in several places through the
vaginal roof, by which a small amount of bloody serum is with-
drawn, but the discomfort unavoidably connected with the operation
and the danger of infection make other means of promoting absorption
preferable. If pus is formed, aspiration is hardly radical enough to
produce a cure.
When pus begins to form in several foci, it is best to give them
time to unite before opening the abscess.
If pus follows the round ligament, the operator may succeed in
introducing a glass drainage-tube through the inguinal canal.
If an abscess forms between the uterus and the bladder, it must be
opened very cautiously by a T-shaped incision in the vagina.
An abscess in the broad ligament may be reached by partial excis-
ion of the uterus. 1 First the cervix is removed, and then so much
of the body cut away that the finger can be introduced into the
abscess-cavity. Hemorrhage is exclusively controlled by hemostatic
forceps, which are left in place for forty-eight hours. This method
would only be available in women with a large vagina.
Some go even so far as to perform total vaginal hysterectomy in
order to reach a purulent collection in the pelvis, whether situated in
the connective tissue or elsewhere. 2 It was doubtless a great progress
when Pean in 1890 introduced vaginal hysterectomy for large puru-
lent collections in the pelvis, and invented a new technique for its
performance. This was the starting-point of the new vaginal method
as opposed to the abdominal section, which had reigned since 1872.
But, as in the beginning, many appendages were extirpated which
might have been cured or were not diseased ; doubtless many uteri
now share their fate, and the vaginal method is probably sometimes
more used for display of the surgeon's dexterity than because the ope-
ration is done better and more safely by that method than by lapa-
rotomy. (Compare Pelvic Abscess, p. 667.) In regard to the technique
the reader is referred to the description of vaginal hysterectomy by
the clamp method (p. 483).
In a case of pelvic abscess that had opened into the bladder recov-
ery was obtained by making an artificial vesico-vaginal fistula, dilat-
ing the opening between the bladder and the abscess, thrusting a pair
of scissors in front of the cervix into the abscess, dilating the opening
thus made, and fastening a drainage-tube there. 3
Chronic Atrophic Cellulitis* It consists in a cirrhotic contraction
1 Landau, CentraJblatt fur Gyndkologif, 1892, No. 35, vol. xvi. p. 689.
2 Pe"an, Bulletin de I' Academic de Medecine, No. 27, 1890 ; Segond, " De 1'Hystdrec-
toniie vaginale dans le Traitement des Suppurations pelviennes," Revue de Chirurgie,
1891, No. 4,
3 A. H. Buckmaster, Brooklyn Med. Jour., April, 1891.
4 This disease has been described by Wilhelm A. Freund in Gynak. Klinik, vol. i.
pp. 239-326, Strassburg, 1885.
DISEASES OF THE PELVIS. 675
and hardening of the pelvic connective tissue, like that taking place
in the kidneys, liver, spleen, lungs, and other organs. It appears in
a circumscribed and diffuse form. The circumscribed is due to ulcers
in the bladder and the rectum, laceration of the cervix, or chronic
raetritis. The induration is situated on a level with the so-called
superior sphincter. On the anterior wall of the vagina, correspond-
ing to the base of the bladder, is found a stellate cicatrice, from which
the induration can be followed more or less far into the surrounding
parts. This condition is combined with congestion of the hemor-
rhoidal veins. The diffuse form starts from the base of the broad
ligament, and may extend through the whole pelvis. The Arteries
are diminished in size ; the veins are either narrowed or dilated, and
contain often thrombi or phleboliths. It leads to venous congestion
and varicosities, atrophy and sclerosis of the uterus, and synechise
between the walls of the cervix. The vagina is shortened, and often
funnel-shaped. The cervical ganglion (p. 62) is covered and inter-
spersed with cicatricial tissue.
The causes of the diffuse form are the same as those of the circum-
scribed or too great or too frequent sexual excitement, especially mas-
turbation, and losses through hemorrhage and leucorrhea. Chlorotic
women with hypoplasia of the genitals and the circulatory system are
particularly predisposed to it.
Symptoms. Patients affected with chronic atrophic cellulitis have
a decided propensity to masturbation, with indifference, or even aver-
sion, for coition. They suffer often from erotic dreams, with emis-
sions of mucus. They complain of pain in the iliac fossa, dyschezia,
dysuria, dysmenorrhea, often intermenstrual pain (p. 417), and always
present hysterical symptoms, among others copiopia hyst erica (p. 247).
Prognosis. The circumscribed form may be cured when the cause
is removed, and especially if pregnancy supervenes. The diffuse is
incurable, but may remain stationary for long periods.
Treatment. The causes must be removed, the vagina treated with
iodine glycerin or ichthyol glycerin and packing, and cicatrices cut out
or incised and stretched (p. 354). The many reflex neuroses are treated
as hysteria, especially with nitrate of bismuth, nitrate of silver, acetate
of zinc, ammonia, castoreum, and valerian. During the hysterical
attack nothing should be done, as any interference only serves to
make the condition worse. 1
C. Pelvic Phlebitis.
Pelvic phlebitis is a rare disease. It. is primary in puerperal cases,
the inflammation starting in the sinuses of the uterus. In this
1 In this connection it is quite interesting that Freund states that in Strasshurg they
do not see the attacks described by Charcot in Paris an experience which is shared
by many others in other places.
676 DISEASES OF WOMEN.
variety the inflammation begins in the internal coat, and soon a
thrombus forms in the lumen. The inflammation spreads outward,
and may implicate the connective tissue.
In non-puerperal cases it is exceedingly rare, and begins as peri-
phlebitis, an affection following secondarily on acute cellulitis.
Congestion of the pelvic veins is very common, and the presence
of phleboliths in the veins at the base of the broad ligament is not a
rare occurrence. This congestion, which must not be confounded
with phlebitis, is often much relieved by lifting the uterus with a
pessary, and thereby giving a straighter course to the veins.
Pelvic phlebitis blends always with cellulitis, and clinically they
cannot be distinguished.
, D. Pelvic Lymphangitis and Lymphadenitis.
In the anatomical part (p. 62) we have seen that the uterus is
exceedingly rich in lymph-spaces and lymph-vessels, uniting in trunks
which traverse the broad ligament and lead to the different glands
in the pelvis. The lymphatics from the upper three-fourths of the
vagina go the same way, while those from the vulva and the lower
fourth of the vagina go to the superficial inguinal glands, that com-
municate with the deep inguinal glands, from which other vessels go
to the external iliac glands. Those from the tube and the ovary
traverse the broad ligament, and go through the infundibulopelvic
ligament to the lumbar glands.
The inflammation may extend from any part of the genital tract
into the broad ligament and the peritoneum, causing lymphangitis,
lymphadenitis, cellulitis, or peritonitis.
The lymphatic vessels play a very important part in the propaga-
tion of infection in the puerperal state, 1 and the inflammation follow-
ing is then acute.
In non-puerperal cases lymphangitis and lymphadenitis also exist,
but seem to be rare, or so blended with other pelvic inflammations
that they seldom can be discovered. Many authors do not mention
the affection at all ; others have little to say about it or are doubtful as
to its existence. In a gynecological practice extending over more than
twenty years, in which I have examined I do not know how many thou-
sand women, I have never found a case myself, unless a few in which
the gland on the side of the isthmus was swollen belonged to this cate-
gory. One was kindly demonstrated to me by Dr. P. F. Munde' in
1883, but, although I felt the small tumors behind the uterus, I am
not sure that they were swollen lymphatic glands. But the disease
having been described by such excellent observers as Courty, Cham-
pionnire, Munde", A. Martin, and others, each of whom claims to
1 See Garrigues, " Puerperal Infection," Hirst's Amer. System of Obstetrics, vol. iL
pp. 290-378.
DISEASES OF THE PELVIS. 677
have seen, if not many, at least a certain number of cases, I do not
doubt its existence, and shall here give a resume* of their descriptions.
The non-puerperal form is either acute or chronic, more frequently
the latter. Lymphadenitis is characterized by the occurrence of small,
rounded, irregular, uneven tumors, varying in size from a pea to a
small hazelnut, and situated to the sides of the isthmus of the uterus,
more frequently on the right, or on the posterior surface of the uterus.
They are loosely connected with the latter and the vagina. Most
authors claim only to have felt from one to three such tumors, but
Munde* has found at least twenty 1 on the posterior surface of the
uterus, and Martin speaks of glands in the broad ligaments forming
rows like strings of pearls of moderate size. 2
Now, there is this objection to the theory of looking upon these
tumors as glands, that only those glands which I have mentioned in
the anatomical part have been found in the pelvis by anatomists
namely, Charnpionni&re's gland at the side of the isthmus, the obtu-
rator gland, the external iliac glands, the internal iliac glands, and
the sacral glands. On the posterior surface of the uterus there are
none ; but, on the other hand, there are large plexuses of lymphatic
vessels ; and those small tumors felt clinically above the posterior
vault of the vagina are probably clusters of swollen lymph-vessels or
pouch-like dilatations of such vessels, just as we find them in puer-
peral cases, in which they may reach the size of a cherry. The same
explanation holds good for the rows of swellings felt in the broad
ligament.
A third possibility is that the small tumors may be due to local-
ized perilymphatic inflammation.
A. Martin thinks that cellulitis often begins as lymphadenitis, the
gland suppurating and pouring its contents into the connective tissue
of the broad ligament. Even without such suppuration and rupture
it is very likely that cellulitis often starts from perilymphangitis.
Etiology. The inflammation of the lymphatics is caused by endo-
metritis either catarrhal or non-specific purulent or gouorrheal.
Lymphadenitis may also be due to syphilis or scrofula, when it is
apt to be combined with adenitis in other parts of the body.
Symptoms. The patient complains of a pain deep in the pelvis,
rather to one side, especially the right, extending to the pubes and the
obturator foramen or downward and backward to the coccyx, and of
a tenderness rendering coition painful. There is no rise in tem-
perature. The parametrium is swollen and tender, but without
effusion. The uterus is movable, but its movement causes pain. It
is enlarged, tender, and often retroflexed. The ovaries are also
swollen and tender. Behind and to the sides of the uterus are felt
1 P. F. Mund, Amer. Jour. Obst., 1883, vol. xvi. p. 1018.
2 A. Martin, Frauenkrankheiten, p. 323.
678 DISEASES OF WOMEN.
the above-described small tumors, which are very tender and some-
what movable, or a bundle of tender, movable cords which impart
a feeling like a bunch of angle-worms. 1
Diagnosis. The tumors are much smaller and situated lower down
than the ovary, not so movable, and when pressed do not cause the
sickening pain elicited by pressure on the sexual gland.
Their own mobility and the mobility of the womb distinguish
them from cellulitis.
The movable, worm-like cords are pathognomonic of lymphangitis.
Treatment. When endometritis is the cause, it should be treated
according to the rules laid down for that disease (pp. 405 and 412).
Iodine (p. 170) and ichthyol glycerin (p. 178) should be used in the
vagina. Packing of the vagina (p. 178) gives much relief and makes
the swelling disappear. lodoform suppositories (p. 226) are useful
both as anodynes and as resolvents. It is recommended to use inunc-
tions of Ung. hydrargyri (20 parts) and Ext. belladonnse (1 part) on
the hypogastric region. Galvanism has also proved beneficial. In
extreme cases it may be justifiable to try to favor involution of the
hyperplastic uterus by amputation of the cervix (p. 418). If the
patient is affected with scrofula or syphilis, the usual remedies for
those diseases should be combined with the local treatment.
CHAPTER VIII.
SARCOMA AND CARCINOMA OF THE PELVIC PERITONEUM AND
CONNECTIVE TISSUE.
CANCER of the pelvis is usually only part of a similar affection
spread over a larger territory or a direct propagation by continuity
from neighboring organs. Thus, carcinoma of the broad ligament
appears in connection with the same affection in other parts of the
peritoneum, or begins as carcinoma of the uterus or the ovary. But
both sarcoma and carcinoma may start as a primary disease in
Douglas's pouch, and carcinoma may begin in the lymphatic glands.
Sarcoma may form a large tumor behind the uterus, pushing this
organ forward. Medullary carcinoma often appears as a relapse in
the cicatrix after removal of the carcinomatous uterus.
The malignant nature of these affections is proved by the cachexia
which rapidly follows their advent. It is rarely possible to do any-
thing of therapeutical value for them, except in the cases of relapse
1 The great tenderness of the tumors, even in chronic cases, speaks also against
their being glands, for chronically inflamed lymph-glands, which are so common in
scrofula and syphilis, are not sensitive to touch.
DISEASES OF THE PELVIS. 679
after hysterectomy. A patient who has had her uterus extirpated
should be examined every few months for many years, and as soon as
a local relapse appears the diseased tissue should be cut away and the
wound cauterized. 1
CHAPTER IX.
HYDATIDS (Ecmxococci) OF THE PELVIS.
HYDATIDS are so rare that few physicians have had opportunity to
see a case, 2 but of the entire number reported 4 per cent, were situated
in the pelvis ; and the disease is by far more common in women than
in men. 3
Pelvic hydatids are most common in the connective tissue of the
posterior part of the pelvis near the rectum, but are also found in the
uterus, the ovaries, the broad ligaments, the anterior part of the pel-
vis, and anywhere in the bones. As- a rule, the animal consists of a
mother-cyst with endogenous or exogenous daughter-cysts. The mul-
tilocular, or alveolar, form has never been found in the pelvis.
The echinococcus may enter the pelvis as a germ or reach it by
extension from another part of the abdomen. Beginning in the pel-
vis, the cyst may rise above the superior strait or follow the connect-
ive tissue of the pelvis, press down on the perineum, grow out through
the great sacro-sciatic foramen or the crural canal, and extend up on
the anterior wall of the abdomen. In consequence of pressure from
neighboring organs the animal may die, the fluid become turbid, puru-
1 Dr. M. D. Jones has reported a case in which a carcinomatous tumor of the size
of an orange in the pelvic floor was combined with a similar affection of the ovaries.
She removed all the diseased tissue, and made a microscopical examination that is
of great interest, because it proves that the so-called inflammatory infiltration that
surrounds a carcinoma to a distance of a quarter to half an inch is in reality a pre-
cursory stage of carcinomatous infiltration, the inflammatory corpuscles shaping them-
selves into the epithelial cells characteristic of carcinoma, and that the disease spreads
by such cancer-cells being transmitted into the lymphatics and causing thrombosis
of, and carcinomatous infection around, them (Medical Record, March 11, 1893, vol.
xliii. p. 292).
2 Personally, I have only seen one case, and that was in the liver (Proceeding* of
the Medical Society of Kings, Brooklyn, N. Y., 1876, vol. i. No. 5, p. 123V In the
above description I chiefly follow W. A. Freund, who, living for many years in an
echinococcus district, has had the rare opportunity of treating eighteen cases of
hydatid disease in the true and false pelvis, and who has described them in his
Klinik der Gyntikologie, vol. i. pp. 299-326. Four of these he has previously described,
conjointly with J. K. Chadwick of Boston (Amer. Jour. Obst., Feb., 1875, vol. vii. pp.
668-679).
3 The Icelandic physician Jon Finsen personally treated 245 cases of echinococcus
disease. Of these, 172, or more than 70 per cent., were in the female sex ( Ugeskrift
for Lceyer,3d series, 3d vol. Nos. 5-8, Copenhagen, 1867). A French translation,
made by myself from the Danish original, is found in Archives generales de Medentie,
Jan. and Feb., 1869, vol. i. pp. 23-46 and 191-210).
680 DISEASES OF WOMEN.
lent, or sanious, and the vesicles be broken up into shreds. Rupture
may take place into the bladder, or exceptionally into the uterus or the
vagina, but never into the peritoneal cavity the peritoneum, on the
contrary, always becoming thickened. Such rupture may lead to a cure.
Etiology. The disease is due to the entrance into the body of the
eggs of the Tcenia echinocoecus of the dog. As a rule, the entrance
takes place through the mouth, but some women allowing their geni-
tals to be licked by dogs for libidinous purposes, it is not impossible
that the germs might be brought directly into the genital tract instead
of passing through the alimentary canal. The disease is endemic in
certain parts of the world, such as Australia, Iceland, Mecklenburg,
and Silesia.
Symptoms. The disease may exist for years without impairing the
general health or even causing much local trouble. Attention is first
called to it when it causes dyschezia, dysuria, or dystocia, and often
it gives rise to leucorrhea or menorrhagia. Later the nutrition suf-
fers, the patient loses flesh, and she may become feverish, either when
suppuration sets in or when the constitution becomes undermined. In
consequence of pressure her feet may swell, her legs become paralyzed,
she may have sciatic neuralgia or hydronephrosis, and even intestinal
obstruction may develop. Death is often due to the presence of an
echinocoecus cyst in another organ.
Diagnosis. The disease being nearly exclusively limited to certain
regions, geographical considerations may give a hint as to its exist-
ence. Early in its course the presence of one or more round, remark-
ably smooth, tensely elastic tumors in the connective tissue of the
posterior part of the pelvis, with a thin homogeneous wall, little
movable, insensitive, unconnected with the uterus or the ovaries, and
not causing any local or general disturbance, makes it very likely
that one has to deal with one or more echinocoecus cysts in the con-
nective tissue. The last point is the basis of the differential diagnosis
from intraligamentous ovarian cysts, which very early become the source
of such disturbances. The cervix is also very characteristic in hyda-
tids, being situated in a depression surrounded by an elastic mass like
an air-cushion.
The fluid contained in the cyst is colorless, opalescent, or yellow ;
clear or turbid. It does not contain albumin or only traces of it, but
succinic acid, leucin, grape-sugar, inosite, and sometimes urea and uric
acid. A single booklet from the scolices (young tape-worms) or the
smallest piece of cuticula (the tunica propria of the sac) which shows
parallel structureless layers arranged with the utmost regularity, and
which is not affected by acetic acid, is pathoguoraonic of a hydatid. 1
If exploratory puncture is resorted to, it must, however, be made
with the strictest antiseptic precautions.
1 Garrigues, Diagnosis of Ovarian Cysts, p. 74.
DISEASES OF THE PELVIS. 681
A vesicular mole always forms one continuous body, and has cha-
racteristic appendages, while the echinococcus often is multiple, and
has a smooth surface. Fibroma is harder and nodular.
The hydatidic thrill cannot be utilized for the diagnosis, as it cannot
be felt in pelvic hydatids.
Treatment. If the tumor is confined to the pelvis, and does not
cause much discomfort, it is better to leave it alone. But if it is
necessary to interfere, it is best to make a large incision in the vagina.
If there are numerous tumors, the internal use of potassium iodide
and tincture of kamala (3j-3ss) lias been recommended. Electrol-
ysis may, perhaps, kill the animal and cause absorption. A submu-
cous uterine hydatid may be treated with ergot in the hope of its
becoming pedunculated like a fibroid polypus. If the tumor rises
into the abdominal cavity, laparotomy should be performed, the tumor
enucleated, and the cyst- wall of connective tissue formed around the
animal, the so-called ectocyst, treated as after enucleation of a fibroid
(p. 499). Often it is not possible to remove the whole mother-cyst,
and then the edges of the opening made in the cyst should be stitched
to those of the abdominal incision and packed with iodoform gauze.
After spontaneous rupture of an echinococcus cyst it is necessary to
dilate the opening or make a counter-opening.
APPENDIX.
I. STERILITY.
JUST as I found it proper to begin the description of the diseases
of women by special chapters on the two symptoms hemorrhage and
leucorrhea, I deem it advisable for practical purposes to finish with
one on sterility, since it is a symptom that often impels the patient
to seek medical advice, depends upon a great variety of conditions,
and calls for special treatment, part of which has not been described
in the foregoing pages.
We have seen in the physiological part of this work (p. 121) that
fecundation consists in the union of the male and the female genera-
tive elements ; but many obstacles may prevent such union or, if it
takes place, prevent the development that results in the formation of
a fetus. The premature expulsion of the fetus by abortion or mis-
carriage, which also leads to childlessness, belongs to the domain of
obstetrics.
By sterility, barrenness, or infecundity we understand the lack of
capacity for conception or impregnation. One marriage out of every
eight is childless. It is commonly believed that the fault is always
or nearly always to be found in the wife, and with some people it has
been deemed a sufficient cause for repudiation ; but modern investiga-
tion has shown that the husband is at fault in about one case out of
every six. 1
Sterility in the Male. Infecundity in man may be due to impotence,
or inability to perform the sexual act ; to aspermatism, absence of
ejaculation ; or to azoospermia (also called azobspermatism or azoo-
spermism), the condition in which the ejaculated semen does not con-
tain any spermatozoids, and, therefore, has no fertilizing power. It
even seems that the man may produce healthy semen in his testicles,
but that by admixture with abnormal secretions during the passage
through the vas deferens, the canalis ejaculatorius, and the urethra a
change takes place, in consequence of which the spermatozoids soon die.
The chief cause of sterility in the male is latent gonorrhea. A
man may have been free from gonorrhea! discharge for years, and
1 Samuel W. Gross, Impotence, Sterility, and Allied Disorders in the Male Sexual
Organs, Philadelphia, 1881, p. 88.
682
APPENDIX. 683
still an olive-pointed bougie may discover wide strictures in the mem-
branous part of the urethra, and bring to light a drop of muco-pus,
while at the same time spermatozoids are absent, a condition which
is supposed to be due to the action of micrococci. 1
Sterility in the Female. The female genital tract being so much
longer than that of the male, and subject to such numerous diseases,
it is quite natural that the cause of barren marriages is found so much
more frequently in woman than in man.
It should be borne in mind that fecundity in women is limited to
a certain period of their lives. Before puberty and after the climac-
teric sterility is normal.
Sterility may be primary or secondary. It is primary when a
woman, in spite of frequent intercourse, never conceives ; it is sec-
ondary if it appears after she has had one or a few children.
The sexual element (the ovum) may be absent or it may be pre-
vented from contact with the male element, the spermatozoid, by
incapacity for copulation, which, again, may be mechanical or nerv-
ous; by incapacity for conception, which may be due to local tis-
sue-changes or constitutional disturbances; or by incapacity for ges-
tation.
1. Absence of Ova. In chronic oophoritis the ovisacs and ova are
often diseased and disappear (p. 560). 2 By the development of.
cysts and solid tumors of the ovaries the ovisacs may disappear,
but the sterility so common in these cases is often due to other causes
(p. 589).
2. Incapacity for Copulation. Incapacity for copulation may be
mechanical or nervous.
(a) Mechanical incapacity may either be absolute, as in cases of the
absence of the vulva (p. 255), coalescence of labia (p. 258), or atre-
sia of the hymen (p. 326) or vagina (p. 328) ; or it may only be
relative, opposing a more or less important obstacle to the perfect
union of the sexes, such as solid or cystic tumors of the vulva
(pp. 275-287), kraurosis (p. 288), or cysts, fibroids, mucous polypi,
or carcinoma of the vagina (pp. 358, 359, 361). A tear of the peri-
neum, allowing the semen to flow out, may also be a cause of steril-
ity, but is of comparatively small importance.
(6) Nervous incapacity is connected with hyperesthesia of the vulva
(p. 275), painful urethral caruncle (p. 282), and, in its worst form,
with vaginismus (p. 355).
3. Incapacity for conception may either be local or constitutional,
(a) Local incapacity may, again, constitute an absolutely instir-
1 E. Noeggerath was the first to call attention to latent gonorrhea in both sexes,
and its influence on fertility (Trans. Amer. Gyn. $oc., 1876, vol. i. p. 268, et seq.).
2 These retrograde processes have been carefully studied and delineated by Mary
Dixon Jones (Med. Record, Sept. 19, 1891, vol. xl/p. 324).
684 APPENDIX.
mountable obstacle to conception, as in cases of absence of the uterus
(p. 387), a rudimentary uterus (p. 388), atresia of the genital canal
(pp. 326, 328, 391, 420), or only a more or less serious hindrance.
Vaginal catarrh (p. 344) may cause sterility through the hyperacidity
of the discharge, which kills the spermatozoids. Women with urinary
fistula rarely conceive, partly on account of mutual disinclination to
copulation, partly in consequence of concomitant diseased conditions.
Most of the malformations and diseases of the uterus, tubes, ovaries,
and pelvis are accompanied by or have a tendency to produce sterility,
such as the fetal, infantile, or pubescent uterus (pp. 392, 393), congen-
ital or acquired displacements of the uterus (pp. 394, 433-466),
elongation and hypertrophy of the cervix (pp. 381, 411), stenosis
of* the cervical canal (pp. 394, 421), superiii volution of the uterus
(p. 431), chronic endometritis (p. 407), or a polypus obstructing the
cervix or the tube (p. 467). Women with sessile fibroids are, as a
rule, also sterile, and their barrenness is probably due more to the
accompanying catarrh than to the mechanical obstruction. In car-
cinoma of the cervix (p. 507) infecundity may be due to the consti-
tutional disturbance as well as to mechanical obstacles.
In regard to the Fallopian tubes congenital contortions (p. 524) or
acquired displacement (p. 546) may oppose an impediment to the free
movement of the ovum or the spermatozoids. They may be imper-
vious (p. 524), or their inflammation (p. 528) or neoplasms (p. 546)
may prevent conception.
The surface of the ovaries may be so covered with inflammatory
products that the ovum cannot escape (p. 560).
The presence of hydatids in the pelvis (p. 678) or a mole in the
uterus, uterine hemorrhage, or leucorrhea from whatever cause, may
render the woman sterile.
(6) Constitutional Incapacity. Anemic women are less likely to
conceive than healthy women. Great obesity is quite frequently
accompanied by barrenness. Tuberculosis, syphilis, and cancer,
all diminish fecundity. The same applies to masturbation (p. 300)
and to too frequent or violent coition, as in prostitutes. It is not
unlikely that in the last-named" condition impregnation often takes
place, but that the ovum is expelled at so early a date that not even
menstruation is interrupted.
Bisulphide of carbon seems to exercise a highly deleterious influence
on procreation in both sexes among those whose calling exposes them
to its influence. It is used much in the arts as a solvent for vegetable
oil and rubber. In the male it lessens the desire and the power for
sexual intercourse. In females conception is rare, and, when it takes
place, they almost always abort.
4. Incapacity for Gestation. This condition is often combined with
the incapacity for conception, barrenness alternating with abortions
APPENDIX. 685
and miscarriages. An inflamed endometrium, for instance, offers a
poor soil for the growth of an ovum, so that fetal development is
likely to be arrested, the pregnancy ending in a miscarriage ; but the
ovum may also be washed out by hemorrhagic and leucorrheal dis-
charges, before it ever becomes imbedded, and perhaps before it is
fertilized.
Diagnosis. 'Fecundity depending upon the union of elements
derived from two individuals, it is proper in a case of sterility to look
for the cause or causes in both persons concerned ; but, unfortunately,
it happens that the husband, while he is quite willing to submit his
wife not only to the most searching physical examination, but even to
operative procedures, absolutely refuses to be examined himself.
There is, sometimes, a lingering doubt in his mind that the fault
might be on his side, and he dreads above all to acquire this certainty,
or at least to let his wife know it. If he is willing to give the neces-
sary information, he should, first of all, be questioned in regard to
copulation, ejaculation, syphilis, and gonorrhea. The proper position
of his meatus urinarius should be ascertained. His urethra should
be carefully examined with a bougie-a-boule or an endoscope as to
caliber and small pus-secreting surfaces lurking behind strictures.
Finally, his semen must be examined microscopically. The proper
way of obtaining it unmixed with foreign substances is to let him
have intercourse with his wife, using a condom. Immediately after
copulation this bag with its contents is thrown into a wide-mouthed
bottle and brought to the physician, who examines it without delay.
If the man's semen is full of living spermatozoids, the examination
may be extended to the woman, in order to find out if there is any
discharge in the vagina that kills the spermatozoids. For this pur-
pose the husband should be allowed to have normal intercourse with
his wife, and shortly after the act a little semen should be removed
from the posterior vault of the vagina with a Simon's spoon and
examined microscopically. Often it suffices, however, to examine
the woman without having recourse to this somewhat repugnant
procedure.
In examining the woman the physician will bear in mind all the
malformations and diseases just enumerated that may entail sterility.
The vaginal secretion should be tested with litmus-paper. It is nor-
mally acid, but it may be so to such a degree that it kills the sperma-
tozoids. It should also be examined microscopically for pus-corpus-
cles, the presence of which always shows inflammation. The utero-
tubal mucus is obtained by introducing a speculum and taking the
mucus directly out of the cervical canal. This is normally alkaline,
and any acid fluid is deleterious to the spermatozoids.
Treatment. In regard to the treatment of the man the reader is
referred to works on venereal diseases.
686 APPENDIX.
Ofteii a certain mutual adaptation seems to be necessary. Nothing
is more common than that impregnation does not take place immedi-
ately upon entering upon marital relations. Many months may even
elapse before it occurs between perfectly healthy individuals. A little
patience is, therefore, always to be recommended. But, on the other
hand, accurate statistics have shown that three-fourths of married
women get a child in the course of the first year of their marriage,
and that if three years elapse without offspring the chances of hav-
ing children become very small. As a practical rule, we may say
that if a woman does not conceive during the first year of her
marriage, and wishes to become a mother, she had better seek med-
ical advice.
The entrance of the semen into the uterus may be favored by rais-
ing the pelvis during copulation or by coition modo brutorum. Trav-
eling has a marked influence, which may be due to climatic influ-
ences, change of diet, or, more likely, the diversity of couches.
The causes of sterility in the female being so manifold and com-
prising most of the malformations and diseases treated of in this
work, the treatment will, of course, also vary much, the general rule
being to remove, if possible, whatever cause or causes we may find by
the means indicated in the preceding chapters.
Anemia is treated with iron, manganese, strychnine, cod-liver oil,
terraline, and a diet in which albuminoids preponderate, and into
which enters the use of milk, beer, or wine. Adipose tissue is
reduced by iodine, fucus marina, exercise, massage, Turkish baths,
and a diet from which sweets and cereals are nearly excluded, and
in which liquids are limited as much as possible. 1
A too small uterus may sometimes be enlarged by the galvanic
current.
Many different operations may be called for in order to remedy
sterility. The labia may have to be separated ; a resistant hymen
removed ; a painful caruncle destroyed ; a vagina made ; or an elon-
gated cervix amputated. The cervical canal may require dilata-
tion, which may be kept up by the use of Outerbridge's permanent
dilator (p. 184) ; a polypus may have to be cut off; a spongy endo-
metriuin may need curetting, etc. Sometimes the operation required
is not one of division, but of union, as when a torn perineum and
vagina are repaired or trachelorrhaphy is performed. A torn cer-
vix would seem to favor impregnation by offering freer entrance to
1 Such a diet should be composed of beef, mutton, veal, pork, game, poultry,
eggs, fish, lobsters, crabs, shrimps, oysters, clams, scollops, muscles, cheese, green
vegetables, lettuce salad, and a small amount of juicy fruit, with a pint of claret or
Moselle wine, a cup of black coffee, a cup of tea without milk, and four ounces of
bread per day. Butter and other fats are harmless. Forbidden, on the other hand,
are soups, water, milk, beer, potatoes, beets, puddings, pies, and other sweet dishes,
as well as bananas.
APPENDIX. 687
the interior of the womb ; but, on the other hand, the endometritis
following the tear is a barrier to conception ; and, as a matter of
fact, I may state that I have repeatedly removed sterility by this
operation.
Laparotomy or colpotorny will hardly be undertaken for sterility
alone, since it would risk an existing life in the uncertain hope of
rendering another possible ; but when it is undertaken for legitimate
causes, it may perhaps even cure sterility, if the operator finds it pos-
sible to leave one or both ovaries and render the tubes permeable
(p. 533).
When all other means fail, or no cause for the sterility can be
found, or the woman refuses any kind of cutting operation, we may
yet try artificial impregnation. Since the fundamental condition of
fecundity is the union of a spermatozoid and an ovum (p. 121), since
in most cases it is an easy matter to introduce semen all the way up
to the fundus of the uterus, and since artificial fertilization is used on
a large scale in pisciculture, one would think that artificial impregna-
tion of a woman could likewise be performed without difficulty. But
it is not so. It has been tried many times, but has nearly always
proved a failure.
The operation is very simple. The semen of the husband having
been found normal, and especially after ascertaining that it does not
contain pus-corpuscles, he has intercourse with his wife, using a con-
dom. This he brings to the physician waiting in another room.
The latter has in readiness an intra-uterine syringe (p. 172), properly
disinfected and kept warm. He sucks a small amount of semen up
with the syringe, exposes the os uteri with a speculum, wipes it off
with cotton dipped in some antiseptic fluid, introduces the nozzle up
to the fundus, and expresses a few drops slowly into the interior of
the womb. The woman should stay in bed on her back, and if she
feels any pain an ice-bag should be applied to the hypogastric region.
The most favorable time for performing the operation is shortly
before menstruation is expected, and the next best period is imme-
diately after the catamenia (p. 119). It may, of course, be repeated
during several months, if the first attempt does not succeed.
II. LACK OF ORGASM.
A CONDITION for which we are not infrequently consulted is lack
of the normal feeling of the highest sexual excitement called orgasm
(p. 121). Both the husband and the wife deplore a defect which
deprives the marital relation of its highest physical satisfaction, and
some knowing women, in order to retain their husbands' affection,
688 APPENDIX.
simulate a state which does not exist in reality. Some women have
never felt this sensation. With them the fault is congenital, and is
probably due to some imperfection in the central nervous system.
Others know the sensation from previous experience, but have lost
the faculty of feeling it. Some feel it dreaming, but never during
intercourse. The lack of orgasm, both the primary and the second-
ary, may be found in otherwise perfectly healthy women, and is not
a barrier to conception.
Primary lack of orgasm is incurable, and it is very doubtful if the
acquired form allows us to give a better prognosis. In my own
practice I have constantly failed with the use of tonics, the galvanic
current, and aphrodisiac drugs, such as damiana, phosphorus, and
cantharides.
III. INTESTINAL SURGERY.
IN operations on the internal genitals, especially ovariotomy and
salpingo-oophorectomy, the gynecologist is sometimes incidentally
forced to operate on the intestine. A short description of the chief
operations of this kind, such as resection, lateral anastomosis, end-to-
end approximation by artificial invagination, the use of the intestinal
button, and the removal of the appendix vermiformis, may, therefore,
not be out of place here.
A. Resection of Intestine. The bowels are squeezed empty for five
or six inches in either direction from the part to be removed and
compressed with special forceps (Murphy), a safety-pin and sponge
(Maunsell), a strip of gauze, or an elastic ligature carried through a
hole in the mesentery and tied round the intestine. The intestine is
cut across, and the mesentery is treated in one of two ways, either by
excision or by folding. Either a wedge is cut out, the base of which
corresponds to the piece of intestine to be removed, and the apex to
the root of the mesentery ; next, the two edges are stitched together,
according to the thickness of the mesentery, by a single running su-
ture or by a double, stitching each layer of the mesentery separately.
Or the mesentery is cut along the piece of intestine to be removed,
using blunt scissors, and separating the peritoneum as much as pos-
sible from the intestine before cutting it. When the ends of the
intestine have been brought together, the edge of the mesentery is
doubled up and stitched together, and the flap formed in this way is
itself fastened to the remainder of the mesentery with a few stitches.
B. Lateral Anastomosis. 1 A part of the intestine having been
resected, each end of the inverted gut is closed with a double row
of continuous sutures with fine black silk. Next, the mesentery is
1 Eobert Abbe, Med. Record, April 2, 1892, vol. xli. p. 365.
APPENDIX. 689
divided sufficiently to draw the ends of the severed gut past each
other, so as to make them overlap for six inches (Fig. 332). In this
position they are sutured together by two rows of Lembert sutures, a
quarter of an inch apart, carrying a running suture of finest black
embroidery silk with a cambric needle. Half a dozen such needles
should be threaded with silk threads twenty-four inches long, and
the silk tied to the eye of the needle with a simple knot, leaving a
short end two inches long. The lines of sutures are made about five
inches long, and the two needles are left on their silk threads. Next,
an incision four inches long is made with scissors in both ends of
intestine, a quarter of an inch from the nearest of the two sutures,
applying hemostatic forceps to bleeding points. Next, another over-
hand suture is started at one end of the incision, uniting the two
edges nearest the previous sutures, and penetrating both serous and
mucous coats, which arrests hemorrhage. This suture is then contin-
ued round each of the two free edges separately. Finally, the needles
FIG. 332. FIG. 333.
Maunsell's Intestinal Imagination: a,
a, temporary sutures ; b, needle carry-
Abbe's Intestinal Anastomosis. ing horsehair.
of the first two sutures are taken up one after the other, and used to
complete the double row of Lembert sutures around the opening
made in the intestine.
There is no doubt of the excellence of this operation, but in order
to be performed within a reasonable time it demands a hand used to
that kind of work.
C. End-to-end Approximation by Artificial Imagination. 1 - Two
temporary sutures are placed, one at the mesentery and one just oppo-
site, carrying them through all three coats of the two ends of the
severed intestine. Next, a longitudinal hole, one and a half inches
long, is cut in the larger part of the intestine one inch from the end,
and the two temporary sutures are hauled out through this opening,
carrying the end of the intestine after them. Ten horsehair or s
worm-gut sutures are now carried through both walls of intestine
(Fig. 333), picked up in the middle, and cut, thus forming twenty
H. Widenham Maunsell, Amer. Jour. Med. Sci, March, 1892, p. 245.
i
44
690
APPENDIX.
sutures, which then are tied. The temporary sutures are removed.
Next, the invaginated portion of intestine is hauled back, and the
longitudinal opening closed with a running silk suture through the
serous and muscular coats only.
This is a reliable operation, and not particularly difficult.
D. Murphy's l Button (Fig. 334). Through the ingenious device
of Dr. Murphy of Chicago we are now enabled to do away with
enterorrhaphy altogether. It consists of a
set of four button-like contrivances, one of
which is chosen according to the diiferent
sizes of the intestines to be united. Each
button consists of a male and a female half.
The female half, again, is composed of a cen-
tral cylinder that has a shallow screw thread
on its inner surface and a wide bowl-shaped
flange with five large holes for the passage
of gas. The male half is composed of a
similar central cylinder with two small fe-
nestrae, through which pass two small pro-
tuberances fastened with springs to the in-
side of the cylinder. The tube has a similar
perforated bowl-shaped flange to that of the
female half, but besides that it has a mov-
able ring surrounding the central cylinder
and fastened to the bottom of the bowl with
a spiral spring. This male half fits in the
female, the lateral prominences adapt them-
selves to the screw thread, and the ring ex-
ercises a pressure on the rim of the intestine
comprised between the two halves of the
button, producing constant approximation
and ultimate absorption, while adhesive in-
flammation closes the line of union between
the two pieces of intestine. When this pro-
cess is finished, the button is carried down
through the intestine and expelled through the anus. There is a
linear cicatrice, and the bowel retains an opening as large as that of
the button used.
The Murphy button can be used both for lateral anastomosis and
for end-to-end adaptation. For lateral anastomosis the ends of the in-
testine are closed with a double row of Lembert sutures, as in Abbe's
operation. A needle with a silk thread, fifteen inches long, is inserted
in the bowel opposite the mesentery, and a stitch taken longitudinally
1 John B. Murphy of Chicago, 111., North American Practitioner, Nov. and
1892 ; New York Med. Record, May and June, 1894.
Murphy's Intestinal But-
ton (enlarged) : A, open ; B,
closed.
APPENDIX.
691
Fio. 335.
through the entire wall of the gut one-third the length of the incis-
ion to be made. The needle is again inserted one-third the length of
the future incision from its outlet, in a line with the first. A loop
of the silk, three inches long, is held here, and the needle is again in-
serted, making two stitches parallel to the first two, a quarter of an
inch from them and going in the reverse direction. This forms the
running thread, which when tightened draws the incised edge of the
gat within the cup of the button. A similar running thread is placed
on the other end of the gut. A hole is cut inside of the suture, which
hole should not be longer than two-thirds of the length of the diam-
eter of the button used. The ligatures are tightened round the cen-
tral cylinders, the two halves of the button are pressed together, and
the intestine dropped into the abdominal cavity. In inserting the
male half into the intestine the movable
ring should be pressed down to a level with
the flange, and this should be grasped with
a forceps and held while the first half of the
knot is being made. When the gut is drawn
close about the central cylinder, the forceps
is changed to the edge of this cylinder and
the knot is completed.
In the end-to-end adaptation each half
of the button is inserted in one end, but
before so doing a running suture is intro-
duced in such a way as to prevent the ever-
sion of the mucous membrane and insuring
the overlapping of the mesentery. This is
obtained by beginning at a opposite the mes-
entery, using a top stitch along the incised
edge, taking a return over-stitch (6) at the
mesentery, and continuing the top stitch on
the opposite side, back to the starting-point
(Fig. 335).
This method is the simplest and most ex-
peditious of all.
E. Ecphyadectomy, or removal of the ap-
pendix vermiformis. If in performing lap-
arotomy the appendix vermiformis is found
diseased, it is proper to remove it. A con-
tinuous Lembert suture of silk is made to
surround the appendix, running like a purse-
string in the superficial layers of the cecum
one-fourth of an inch from the appendix.
The suture is not tightened, but only half of a surgeon's knot i?
made. Next, the appendix is divided, leaving a stump at least half
Manner of Inserting Running
Su'nre in End of Intestine
(Murphy): a, starting-point;
b, return over-stitch at mes-
entery.
692 APPENDIX.
an inch long. This stump is stretched by introducing a fine pair of
forceps through it into the cecura and opening it gently. With
another pair of fine mouse-toothed forceps the stump is invaginated
and carried into the interior of the cecum. And, finally, the suture
around its base is tightened over it. 1
1 Dawbarn, Inteniatiorud Journal of Surgery, 1895, vol. viii., No. 8.
INDEX.
A.
Abbe, intestinal anastomosis, 688
Abdominal hysterectomy, 431, 493, 520
regions, 113
section, 609
wall, adherent to ovarian cyst, 616
Abortion, cause of disease, 130
Abortionist. 395
Abscess
after ovariotomy, deep, 633
mural, 633
of vulvovaginal gland, 290
ovarian, 557
pelvic, 665
Accessory abdominal ostia of Fallopian
tube, 524
A. C. E. mixture, 206
Acid
carbolic, 181, 188, 205, 272, 293
hydrocyanic, 211, 269
sclerotinic, 480
Adenoma
benign, 408, 467
malignant, 408, 467
uteri, 467
Adhesions
ovarian, 553, 585, 617
severance of uterine, 453
tearing of, 450
After-treatment, 223
after ovariotomy, 615
complications during, 631
Air-pressure, 445
Ala vespertilionis, 26, 64
Albuginea, 27, 67
Alcohol for disinfection, 199
Alexander's operation, 448
Alimentation, rectal, 225
Allantois, 32
Allis, inhaler, 207
Allongement of polypus, 479
Aloes, 225
Ameboid bodies, 578
Amenorrhea, 238
proper, 239
Ampulla of Fallopian tube, 63
Ampulla
rectal, 85
Amputation
of cervix, 418, 428, 429, 442
of inverted uterus, 465
supravaginal, of uterus, 496. (See
Hysterectomy. )
Anal region, 99
Anatomy, 35
Anesthesia, 206
causing paralysis, numbness or pain,
198
in Trendelenburg's position, 209
Aneurysm of uterine artery, 643
Angioma
of uterus, 468
of vulva, 282
Anodynes, 226
Anteflexion, 394, 438
acquired, 439
cervical, '438
cervicocorporeal, 438
congenital, 439
corporeal, 438
developmental, 439
Dudley's operation for, 442
irreducible, 438
reducible, 438
salpingo-oophorectomy, 442
Sims's operation for, 441
Anteposition, 394
Anterior commissure, 36
Anteversion, 433
operations for, 437
Antiblennorrhagic drugs, 348
Antidysmenorrheal drugs, 243
Antipyretics, 228
Antisepsis, 199
Antiseptic
fluids, 205
material, 199
Anna, preternatural, 381
Aperients, 225
Apostoli, electrode, 230, 231
method, 233
Applications, 170
Applicator, 170
693
694
INDEX.
Arbor vitae, 49
Arch, tendinous, 94
Aristol, 205
Arnold, sterilizer, 199
Arteries
helicine, 60
ligation of internal pudic, .183
of uterine, 182
of perineal region, 105
of uterus, 60
Artificial impregnation, 687
Ascites, 585, 594, 599, 629
Asepsis, 199
Ashton, speculum, 150
Aspermatism, 682
Aspiration, 159, 188
exploratory, 159, 595
through vaginal vault, 533, 595
Aspirator, 159
Dieulafoy's, 159
Emmet's, 159
Potain's, 159
Assistants, 195
Asthenopia, 134, 409
Atresia
acquired, of uterus, 420
of vagina, 329
ani vaginalis, 333
vestibularis, 333 ,
case of, 331
hymenalis, 326
of urethra, 372
of uterus, 391, 420
of vagina, 328
acquired, 329
combined with double vagina, 333
complete, 328, 333
congenital, 329
incomplete, 328
Atrophy of uterus
acquired, 431
puerperal, 431
senile, 431
Atropine injected subcutaneously before
anesthetizing, 197
Auscultation, 158
Aveling, repositor, 464
Azoospermatisrn, 682
Azoospermia, 682
Azoospermism, 682
B.
Bacilli, 171
Ballooning, 146
Bandl, operation for ureterovaginal fistula,
373
Bardenheuer, hysterectomy, 491
Barnes, ointment-carrier, 171
Barnes, operation for inversion, 465
replacement of inverted uterus, 464
Barton, Rhea. operation for rectolabial
fistula, 382
Base of bladder, 78
Baths, 187
general, 187
Russian, 187
sea-, 188
sheet-, 188
shower-, 188
sitz-, 187
sponge-, 188
steam-, 187
towel-, 188
Turkish, 187
Bath-speculum, 187
Battey's operation, 535
Bed, 194
Bed-pan, 171
Belladonna, 269, 413
Belt, abdominal, 190
Bern ays, uterotractor, 518
Bichloride of mercury
for parenchymatous injection, 51&
internally, 226
standard solution, 205
Bimanual examination, 141
replacement of uterus, 445
Bipolar electrodes, 229
Bismuth, 225
Bisulphide of carbon, 684
Bladder-
adherent to tumors, 494, 616
anatomy, 77
catheterization, 39, 161
distention, 602
function, 81
irrigator, 175
irritable, 409, 413
Blasius, operation for fistula, 369
Blind canals in vagina, 333
Blister, 188
Bloodletting, 186
Blood-pressure increased before menstrua-
tion, 117
Bode, vaginal shortening of round liga-
ments, 453
Bodies, ameboid, 578
Body, perineal, 104
of womb, 47
Boldt, table, 195
Bougies with iodoform, 406
Bozeman, button, 368
operation for fistula, 368
scissors, 479
speculum, 368
table, 368
urinal, 375
INDEX.
695
Brandt, Thure, 911
cure for prolapse, 456
cure for retronexion, 450
Braun, syringe, 172
Breisky, pessary, 456
Brewer, speculum, 144
Broad ligament
cysts of, 645
diseases of, 644 t
during pregnancy, 57
solid tumor, 648
varicocele, 644
Broca's pouch, 37
Bubo, 293
Budd, applicator, 170
Bureau, operation for fecal fistula,
384
Burning sensation in genitals and abdo-
men, 274
Burrage, speculum, 150
Buttle, scarificator, 186
Button, Bozeman's, 368
Murphy's, 690
Byrne, inversion, 465
carcinoma uteri, 516, 517
C.
Calcification
of corpus luteum, 561
of ovarian cyst, 586
of uterine fibroid, 474
Calculus due to suture, 371
Camphor
emulsion, 351
in collapse, 210
Canal
anal, 84
Gartner's, 20, 358
of Nuck, 37, 59, 643
hematocele of, 263
Canals, blind, in vagina, 333
Cancer
carried through lymph-vessels, 639
definition, 503
of Fallopian tube, 547
of peritoneum, 600
of vulva, 283. (See Carcinoma and
/Sarcoma.)
Cancer-cells in ascitic fluid accompanying
malignant tumors, 513
Capsule of fibroid tumors, 469
Carbon bisulphide, 68
Carcinoma
in negro race, 509
not transmissible by coition, 511
of body of uterus, 508
of cervix, 508
of Fallopian tube, 547
Carcinoma
of ovarian cyst, 576, 586
of ovary, 635
of pelvis, 678
of uterus, 507
of vagina, 361
of vaginal portion, 507
of vulva, 283
Caruncle, urethral, 282
Carunculffi myrtiformes, 47
Catarnenia, 115
Cataphoresis, 233
Catarrh
of tite/us, 410
of vagina, 344
Catgut, 202
buried, 314
chromicized, 204
Catheter
double-current, 175
self-retaining, Petzer's, 486
Sims' s, 367
Catheterizatiou
of bladder, 39, 161
of Fallopian tube, 533
of ureter, 165
Cauliflower excrescence, 508
Cauterization, 182
galvanochemical, 233, 234
galvanothermal, 237
hemostatic, 182, 628
of fistula, 365, 382
Cautery-clamp, 612
Cavity-
of uterus, 49
pelviperitoneal, 94
Celibacy
in relation to disease, 129
to uterine fibroid, 474
" Celiotomy," 609
Cells, proliferating, 578
Cellulitis, 596
anterior, 672
chronic atrophic, 674
pelvic, 669
posterior, 672
Cervical canal, 49
carcinoma, 508
ganglion, 62
speculum, 150
stenosis, 394
Cervicitis, 404
Cervix, 47
amputation, 418, 428, 429, 444
cone-mantle-shaped excision, 419
congenital cleft, 398
conical. 421
cysts, 413, 467
discission of posterior lip, 441
696
INDEX.
Cervix
elongated, 394, 425
funnel-shaped excision, 427
high amputation, 428, 429
laceration, 396
single-flap excision, 420
stenosis, 394, 421
supravaginal amputation, 428, 429
ulcers, 424
wedge-shaped excision, 418
for retroflexiou, 448
Chain-ligature, 625
Chancre, 293
hard, 293, 424
mixed, 294
soft, 291
Chancroid, 291, 424
chronic, 285, 292
Change of life, 123
Charts, 158
Chian turpentine, 515
Childbirth, cause of disease, 130
Chloral hydrate, 269
Chloride of zinc, 170
for cauterizing carcinoma of uterus,
514
Chloroform, 208
embrocation, 226
-mask, 208
Cholesterin, 579
Cicatrices in vagina, 353
Circular artery, 60
Cirrhosis of ovary, 558
Clamp
compared with ligature, 488
Kceberte's, 184
method for hysterectomy, 483
Cleanliness, 140
a cure for fistula, 365, 382
Cleisis, 378
Cleveland, ligature-carrier, 217
suture, 319
table, 195
Climacteric, 123
treatment, 125
Clitoridectomy, 292, 300
Clitoris, abnormal, 256
absent, 256
amputation, 292, 300
anatomy, 37
development, 34
enchondroma, 281
function, 39
horn, 282
Cloaca, 32
persistent, 333
Cloacal opening, 33
Closure of uterus, 420
Clover's crutch, 197
Clysters, 174
Coalescence of labia, 258
Cobbler's stitch, 614, 627
Cocaine, 209
bougies, 356
Coccygectoiny, 324
Coccygodynia, 333
Coccyx
anatomy, 325
extirpation, 324
Coe, improvement on Lefort's operation,
458
preventive excision of cervix, 513
Coffee against vomiting, 210
Coil, 187
Coition
during menstruation, 130
modo brutorum, 686
Cold, 187
Colica scortorum, 529
Collapse, 207, 210, 501
Collector, 232
Colpeurynter, 464, 535
Colpitis, 343
Colpocleisis, 378
Colpohyperplasia cystica, 349
Colpoperineorrhaphy, 311
Colporrhaphy
anterior, 336
bilateral, 338
lateral, 338
median, 336, 337
posterior, 340
Colpotomy, 533
anterior, 450, 484, 487
posterior, 484, 487, 666
Columns
of Morgagni, 87
of vagina, 43
Comparison between ligature and forceps
in vaginal hysterectomy, 488
between total extirpation and supra-
vaginal amputation of uterus,
498
between vaginal and abdominal section,
for carcinoma of uterus,
520
for fibroid of uterus, 493
for salpingo-oophorectomy,
540
Conception, incapacity for, 683
Condurango, 515
Condylomata acuminata, 277
Cone-mantle-shaped excision of cervix,
419
Conium pills, 243
Connective tissue, pelvic, 93
Consent of patient necessary for opera-
tions, 534
INDEX.
697
Conservative treatment of appendages,
533, 562
Copeland, method of arresting vomiting,
192
Copiopia, 247
Copulation, 121
incapacity for, 683
Corpora arenacea, 581
Corpus
albicans, 74
cavernosum of clitoris, 38
luteurn
calcined, 561
changed into cyst, 561
into gyroma, 564
false, 73
of menstruation, 70
of pregnancy, 71, 565
ossified, 561
verum, 565
nigricans, 74
uigrum, 74
uteri, 47
Corpuscles
Bennett's large, 576
small, 578
colloid, 578
Drysdale's, 579
gorged, 577
Nunn's, 577
Corroding ulcer of cervix, 424
different from rodent ulcer, 512
Corset, 129
Cortical substance of ovary, 67
Cotton, styptic, 182
Counter-irritation, 188
Counter-pressure hook, 219
Courses, 115
Court}', inversion, 465
Cramps, 404
Creolin, 173, 205
Crosby, needle-holder, 215
Crus of clitoris, 38
Curette, 153
Kecamier's, 177
Simon's, 153
Sims's, 153
Thomas's dull-wire, 153
Curetting, 176
for uterine fibroids, 481
Current
constant, 232
interrupted, 232
Cusco, speculum, 144
Cyst
of abdominal wall, 601
of broad ligament, 597, 600, 645
of cervix, 413, 467
of Fallopian tube, 546
Cyst
of liver, 600
of mesentery, (501
of omentum, 600
of ovary, 567
of pancreas, 601
of spleen, 601
of uterus, 467
of vagina, 358
of vulva, 283
of vulvovaginal gland, 289
ovarian, 567
parovarian, 645
renal, 600
tubo-ovarian, 583
Cystocarcinoma of ovary, 639, 641
Cystocele, 335
Cystoma of ovary
dermoid, 581
glandular, 572
myxoid, 571
papillary, 572, 580
Cystopexy, 339
Cystosarcoma of uterus, 504
Cystoscope, 152, 162
Czerny, ventrofixation, 452
Czerny-Lembert suture, 617
D.
Davidson, syringe, 171
Death
after hysterectomy, 501
after ovariotomy, 635
from chloroform, 208
Decidual sarcoma, 506
Depressor
Garrigues', 149
Hunter's, 147
Sims's, 147
vaginal, 147
Dermoid cyst
of ovary, 581
outside of ovary, 583
Descent
of ovary, 23
of uterus, 454
Detrusor of rectum, 87
Development
arrest of, of uterus, 387
excessive, of uterus, 387
irregular, of uterus, 394
of the female genitals, 19
Diaphragm, pelvic, 97
Diet-
after operations, 224
fluid, 224
for reducing fat, 686
Dieulafoy, aspirator, 159
698
INDEX.
Digital pressure for replacing uterus, 446
Digitalis for reviving, 210
Dilatation
of cervical canal, 154, 184
of urethra, 142, 163
of uterus, 156
Dilator-
blunt pelvic, 624
Garrigues', 155
Hanks's, 155, 156
Outerbridge's, 184
sharp-pointed pelvic, 624
Discus proligerus, 28, 69
Disease, gelatinous, of peritoneum, 587
Diseases
exanthematous, 271
of broad ligament, 644
of Fallopian tube, 524
of ovary, 549
of pelvis, 643
of perineum, 301
of round ligament, 648
of sacro-uterine ligament, 648
of uterus, 387
of vagina, 326
of vulva, 255
of vulvovaginal gland, 289
venereal, 291
Disinfection, 198
by steam, 199
internal, 385
of instruments, 215
of laminaria tents, 154
with boiling soda solution, 199
Displacement
of Fallopian tube, 546
of ovary, 550
of uterus, 433
Distribution of organs between perineal
fasciae, 109
Douche-can, 171
Douglas's pouch, 91
prolapse of intestine into, 335
Dowd, sterilizer for catgut, 203
Drainage
abdominal, 181, 185, 629
after ovariotomy, 629
of uterus, 180, 184
-tube, 185
vaginal, 630, 665
Dress, 128
Drink, 224
Dropsy of Graafian follicle, 568
Dudley, E. C., operation for anteflexion,
442
Dysmenorrhea, 242
membranous, 242, 415
nervous, 242
obstructive, 421
Dyspareunia, 121
Dyspepsia, 225
E.
Echinococci, 679
Ecphyadectomy, 691
Ectropium, 396, 407
Edebohls, table, 195
Edema
indurating, 285
of abdominal wall, 601
of lacerated perineum, 305
Education, 127
Ehrich, speculum, 148
Elastic ligature, how to tie, 497
pressure, 464
Electricity
Apostoli's method, 233
bipolar electrode, 229
chemical, 230
galvanocauterization of the cervix,.
234
different qualities of poles, 233
frictional, 229
high-tension coil, 230
inductional, 229
molecular movement, 233
Electrode
aluminium, 231
Apostoli's, 230, 231
bipolar, 229
Engelmann's, 231
Fry's, 423
Garrigues', 231
gas-carbon, 232, 233
Goelet's, 231
Martin's, 231
platinum, 231
Electrolysis, 232
for stenosis of cervix, 423
metallic interstitial, 236
Elephantiasis of vulva, 279
Elevation of uterus, 460
Elytritis, 343
Emmenogogues, 240
Emmet, Bache, trocar-forceps, 666
Emmet, T. A., aspirator, 159
button-hole operation, 297
counter-pressure hook, 219
operation for fecal fistula, 384
for inversion, 465
for lacerated cervix, 399
for uterine fibroid, 482
for vaginismus, 357
for vesico-uterine fistula, 37fr
perineorrhaphy, 316, 320
pessary, 446
tenaculum, 212
INDEX.
699
Emmet, T. A., trocar, 611
wire-twister, 219
Emphysema, 634
Ems, 188
Emulsion of camphor, 351
Enchondroma
of clitoris, 281
of uterus, 522
Encysted peri ton itic exudation, 599
Endocervicitis, 404
Endometritis, 403
atrophic, 409
catarrhal, 407
chronic, 407
decidual, 409
exfoliating, 415
fungous, 408
hemorrhagic, 409, 420
hyperplastic, 408
menstrual, 415
Endosalpiugitis, 525
Endothelioma (Ackermann) of ovary, 639
(Jones) of ovary, 563, 565
Enemas, 174
Eogelmann, electrode, 231
retractor, 211
Enterocele, vaginal, 334
Enucleation
abdominal, 498
from broad ligament, 499
from pelvic floor, 499
from uterus, 500
Miner's method, 621
of uterine fibroids, 481, 498, 499
vaginal, 481
Enuresis, operations for, 339, 379
Epididymis, 22
Episiocleisis, 378
Epispadias, 256
Epithelial coalescence of vulva, 258
Epithelioma of vulva, 283
Erection, 121
of internal genitals, 57
Ergot, hypodermically for fibroids, 480
Ergotine, 480
Erosions, 408, 413, 424, 513
Erysipelas of vagina, 353
Esmarch, mask, 208
Esthiomene, 285
Ether, 206
chloric, 210
Ethyl chloride, 210
Examination
bimanual, 141
chemical, 161
combined, 141, 142
digital, 139
for sterility, 686
in general, 132
Examination
in regard to operations, 196
intestinal, 142
microscopical, 161
of abdomen, 157
of bladder, 161
of pelvis, 139, 531
of ureters, 159
of urine, 160
of uterine appendages, 531
of virgins, 156
physical, 135
rec'tal, 142
under anesthesia, 161
vaginal, 140
verbal, 132
vesical, 142
Exanthematous diseases, 271
Excitor
bipolar, 229
uterine, 229
vaginal, 229
Excretions, 128
Exercise, 127
Exploratory
aspiration, 159, 595
incision, 159, 596
laparotomy, 533
puncture, 595
Extraperitoneal shortening of the round
ligament, 448
Extra-uterine pregnancy, 597
F.
Facies ovariana, 591
Falling of the womb, 454
Fallopian tubes
absence of, 524
accessory, 524
anatomy, 62
cancer, 547
carcinoma, 547
catheterization of, 533
cysts, 546
development, 30
diseases of, 524
displacement, 546
examination of, 531
fibroma, 547
function, 64
lipoma, 547
malformation, 524
neoplasms, 546
palpation, 531
papilloma, 547
relation to menstruation, 118, 120
sarcoma, 547
tuberculosis, 547
700
INDEX.
Faradism, 229
Faradization of diaphragm, 210
Fascia
anal, 95, 101
deep perineal, 100
distribution of organs between perineal
fasciae, 109
levator, 101
obturator, 94
pelvic, 94
perineal, 100
pyriformis, 94
superficial perineal, 100
vesicorectal, 94
Fat
-granules in ovarian cysts, 579
preperitoneal, 610
retropubic, 93
Fecal fistula after ovariotomy, 634
Feces, impacted, 602
Fecundation, 121
Fergusson, speculum, 144
Fertilization, 121
Fibrocyst of ovary, 536
of uterus, 573
diagnosis, 598
treatment, 503
Fibroid
of uterus, 469, 597
calcification, 474
causes of death from operations, 501
complication with pregnancy, 500
diagnosis from ovarian cyst, 598
indications for operations, 503
mortality after operations, 500
sloughing, 500
of vagina, 359. (See Fibroma, Myoma..)
Fibroma
molliiscum, 281
of Fallopian tube, 547
of ovary, 636
of round ligament, 264
of uterus, 469
of vagina, 359
of vulva, 280
case of pedunculated, 281. (See Fi-
broid, Myoma.)
Fibromyoma
of uterus, 469
of vagina, 359. (See Fibroid, Fibi-oma.)
Plbrosarcoma of ovary, 638
Fimbria ovarica, 63
Fimbrise
anatomy, 63
development, 30
Fistula, 363
abdominal method, 371
Bandl's method, 373
Barton's method, 382
Fistula
Blasius's method, 369
Bozeman's method, 368
Bureau's method, 384
combination of methods, 372
congenital rectovaginal, 334
denudation, 366
Emmet's method, 376
entero-vaginal, 380, 385
fecal, 380, 634
flap-splitting methods, 369, 384
Follet's method, 376
Fritsch's method, 384
ileo-uterine, 380
ileovaginal, 380
Pozzi's method, 375
produced by coition, 265
rectolabial, 380
rectovaginal, 380, 382
rectovtilvar, 265, 380
Schede's method, 374
Simon's method, 368
Sims's method, 366
suprapubic method, 369
Taylor's method, 383
Trendelenburg's method, 369
uretero-uterine, 377
ureterovaginal, 371, 373
ureterovesicovaginal, 377
urethrovaginal, 372
urinary, 363
uterovaginal, 397
vesico-uterine, 376
vesico-uterovaginal, 377
vesico vaginal, 363
Vignard's method, 384
Walcher's method, 370
Fistulous tract, 634, 668
Flap-operation for atresia, 331
Flap-sliding method for rectovaginal
fistula, 384
Flap-splitting perineorrhaphy, 307
Flatus vaginalis, 323
Fluid
in cysts of broad ligament, 646
in ovarian cysts, 570, 576, 583, 595
in uterine fibrocysts, 473
Fluids, antiseptic, 205
Foerster, table, 195
Fostus in foetu, 588
Follet, vesico-uterine fistula, 376
Folsom-Skene, speculum, 151
Fomentation, 187
Food, 128, 224
Forceps
artery-, 184
compared with ligature, 488
cyst-, 611
dressing-, 150
INDEX.
701
Forceps
hemostatic, 184, 485
intra-uterine, packing-, 180, 181
pedical-, 612
pressure-, 184, 214,485
tenaculuin-, 213
tissue-, 213
tongue-, 209
traction-, 212
trocar-, 666
Forcipressure, 184
used in hysterectomy, 485
Foreign bodies
in uterus, 403
in vagina, 342
Fornix of vagina, 42
Fossa
ischiorectal, 101
navicularis, 40
Fourchette, 36
Fowler, pessary, 447
Franklinism, 229
Franzensbad, 188
Frenulum of clitoris, 37
Freund, hysterectomy, 520
operation for prolapse of uterus, 458
Fritsch, enucleation, 499
hysterectomy for prolapse, 458
operation for fecal fistula, 384
Frost, vaginal syringe, 673
Fry, electrode, 423
Fund us
of bladder, 78
of uterus, 47
Fusion of ovarian cysts, 585
G.
Gall-bladder torn in ovariotomy, 618
Galvanism, 230
Galvanocauterization
chemical, 233, 234, 480
for carcinoma of uterus, 516, 517
for extirpation of uterus, 518
thermal, 235
Galvanochemical cauterization for uterine
fibroids, 480
Galvanopuncture, 235
Ganglion, cervical, 61
Gangrene
of uterus, 432
of vagina, 352
of vulva, 270
Gariel, air-pessary, 456
Garrigues, apparatus for transfusion and
infusion, 502
colpoperineorrhaphy, 311
dilator, 155
intra-uterine electrode, 231
Garrigues, intra-uterine pack ing- forceps,
curved, 180; straight, 181
tube, 173
perineal pad, 304
serrefines, 303
weight speculum, 211
Garrulity of vulva, 323
Gartners canal, 20, 358
Gas artificially developed in stomach, 158
Gauze
balls, 201
pads, 201
sponges, 201
Gehrung, pessary, 435
Gelatinous disease of peritoneum, 587
Genital
cleisis, 378
cord, 31
corpuscles, 39
folds, 33
furrow, 34
tubercle, 33
Genitals
external, 35
internal, 35
Geode, 463
Germ-epithelium, 28
Germinal
spot, 70
vesicle, 70
Gestation, incapacity for, 684
Glands
Bartholin's, 40
C'hampionniere's, 61, 677
coccygeal, 103
Littre's, 76
mammary, 114
of isthmus, 61, 677
pelvic, 62, 508
Skene's, 76
utricular, 50
vulvovaginal, 40, 289
Glandulae vestibulares majores, 41
minores, 39
Glass plug for vagina, 330
Glycerine tampon, 178
Glycerite of tannin, 178
Goelet, electrode, 231
intra-uterine tube, 173
Gold, 226
Goltz's experiment, 631
Gonococcus, 344, 347
Gonorrhea, 131, 267, 269, 291,346,406,
529, 558, 659
danger of, 131
latent, 131, 682
Gordon, S. C., excision of cervix. 418
operation for chronic metritis, 418
Gossypii radicis cortex, 227
702
INDEX.
Graafian follicl
anatomy, 67, 68
development, 26
dropsy, 568
Gram's method of finding gonococcus, 344
Granular os, 408, 424
Greenhalgh, metrotome, 422
Gymnastics, 191
Gynecological treatment, cause of disease,
131
Gyroma, 563
H.
Hagedorn, needles, 214
needle-holder, 215
Hallucinations due to lacerated cervix,
397
Hanks, dilators, 155, 156
Heart-
artificial contraction, 207
examination in regard to operation, 196
Heat, 187
Heels, high, 128
Hegar, amputation of cervical portion,
418
colpoperineorrhaphy, 311, 314
extra-abdominal treatment of pedicle
in hysterectomy, 497
funnel-shaped excision of cervix, 427
operation for chronic metritis, 418
for fecal fistula, 385
for pelvic abscess, 657
sacral hysterectomy, 520
Helicine arteries, 59
Hematocele, 597, 649, 650
of the canal of Nuck, 263
Hematocolpos, 326
Hematoma
of broad ligament, 597, 655
of ovary, 554
of round ligament, 263
of vagina, 342
of vulva, 276
pudendal, 265
Hematometra, 326, 389, 421
Hematosalpinx, 326, 525, 545
Hemorrhage
at climacteric, 126
from torn hymen, 341
from wound in vulva, 41
in hysterectomy, 501
in ovarian cysts, 585, 593
in perineal region, 108
internal, after ovariotomy, 631
intraperitoneal, 631
pelvic, 649
Hemostasis, 181
after ovariotomy, 627
Hemostatic
drugs, 227
vaginal plug, 179
j Heredity, 127
Hermaphrodism, 258
, Hermaphroditism, 258
Hernia
anterior labial, 260
crural, of ovary, 550
in the canal of Nuck, 261
inguinal, of ovary, 550
inguinolabial, 260
posterior labial, 261
umbilical, complicating ovarian cyst,
629
uteri, 394, 466
vaginal, 334
vaginolabial, 261
Herpes progenitalis, 271
Hewitt, cradle pessary, 435
High-tension current, 230
Hilum, 66
Hodge, pessary, 446
Hofmeier, enucleation, 499
Horn of clitoris, 382
Horns of uterus, 31
Horn-cells, 578
Horsehair, 204
Hot water, 182
Hot- water bag, 187
Hottentot apron, 37
Houston's valves, 87
Hunter, J. B., needle, 488
Hydatid
of liver, 600
of Morgagni, 30, 524
of pelvis, 679
Hydramuion, diagnosis from ovarian
cyst, 598
Hydrobromate of hyoscine, 226
Hydrocele, 262
of ovary, 583
intermittent, 525, 584
Hydroleine, 252
Hydrometra, 125, 392, 421, 598
Hydronaphthol, 206
Hydronephrosis, 600
Hydrops
folliculi, 567
tubae profluens, 525, 584
Hydrorrhea, 410
gravidarum, 410
puerperal, 410
Hydrosalpinx, 525, 544, 597, 601
Hydrotherapy, 188
Hygroma, 325
Hymen
abnormal openings in, 328
absent, 326
INDEX.
703
Hymen
anatomy, 46
atresia, 326
bifenestratus, 328
biforis, 328
cribriformis, 328
development, 33
double, 328
fleshy, 328
hemorrhage from torn, 341
malformations, 326
septus, 328
subseptus, 328
Hyperemia
of ovaries, 554
of pelvis, 127
Hyperesthesia of vulva, 275
Hyperplasia of vulva, 275, 285
Hypertrophy of uterus, 425
infravaginal, 425
supravaginal, 426
Hypnotics, 226
Hypospadias. 255
Hysteralgia, 432
Hysterectomy, 483
abdominal, 431, 493, 520
compared with vaginal method, 493
Bardenheuer's method, 491
causes of death, 501
extra-abdominal treatment of pedicle,
497
for carcinoma uteri, 517
for hemorrhagic endometritis, 420
for prolapse, 458
for supravaginal hypertrophy of cer-
vix, 431
for uterine fibroid, 483
intra-abdominal treatment of pedicle,
496
Jacobs's method, 492
Martin's method, 493
mortality, 500
perineal, 520
perineovaginal, 520
Pratt's method, 491
retroperitoneal treatment of pedicle, 496
sacral, 519
. special difficulties, 494
supravaginal amputation compared
with total extirpation, 498
vaginal, 431, 458, 483, 490, 674
compared with abdominal, 493
vagino-abdominal, 491
with galvanocautery, 518
with ligatures, 487, 517
with pressure-forceps, 483
with thermocautery, 518
without ligature or forceps, 490
Hysteria, 247
Hysterocele, 466
Hysterocleisis, 378
Hysterocystocleisis, 378
Hystero-epilepsy, 247
Hysteropexy, 450
abdominal, 452
vaginal, 450
Hysterotrachelorrhaphy, 399
I.
Ice-bag, 187
Ichthyol glycerine, 178
Impotence, 682
Impregnation, artificial, 687
Incision
exploratory, 159, 596
of vaginal vault, 533
Incontinence of urine, operation for, 339,
379
Incubation, 294
Indurating edema of syphilis, 285
Induration, absent, 294
Inflammation, perimetric, 657
Infusion of salt solution, 502
Inhaler
Allis's, 207
Esmarch's, 208
Ormsby's, 208
Injections, 171
antiseptic, 172
astringent, 172
cleansing, 172
emollient, 172
hot-water, 182
hypodermic, before operations, 197, 208,
209
intestinal, for diagnosis, 158
intraperitoneal, 176
intra-uterine, 172
intravenous, 176, 207
rectal, 174
subcutaneous saline, 176, 502
vaginal, 171
vesical, 175
Injuries
of body of uterus, 394
of cervix, 396
of intestine, 617
of perineum, 301
of uterus, 394
of vagina, 341
of vulva, 265
Insanity, 247
Inspection
of abdomen, 157
of genitals, 139
Instruments
common, 211
704
INDEX.
Instruments
disinfection of, 199
how to clean, 223
needed in all operations, 211
in ovariotomy, 607
selection of, 223
Intermenstrual pain, 404
Intermittent hydrocele of ovary, 503
Interpolar effect, 232
Intestinal
obstruction, 502, 594, 632
surgery, 688
Intestine
adherent to tumors, 495, 617
anastomosis, 688
button operation, 690
injury during ovariotomy, 617
invagination, 689
laid on abdominal wall, 535, 620,
628
resection, 688
Schroeder's method of repairing,
495
surgery, 688
Invagination theory, 588
Inversion
instrumental replacement, 465
manual replacement, 465
of uterus, 460
of vagina, 340
operations for, 465
partial, 460
total, 460
lodoform, 205
bougies, 407
ointment, 178
solution with tannin, 412
suppositories, 226, 324, 407
lodol, 218
Iron contraindicated in uterine hemor-
rhage, 228
pills, 225
Irrigation with hot antiseptic solution,
182, 222
Irrigator for bladder, 175
Irritable
bladder, 409, 413
vascular excrescence of the urethra,
282
Ischuria paradoxa, 602
Isthmus
of Fallopian tube, 63
of uterus, 49
J.
Jacobs, hysterectomy, 492
Jackson, speculum, 150
Jay, urinal, 379
K.
Kaltenbach, supravaginal amputation of
cervix, 429
Kangaroo tendon, 204
Keith, opinion about Apostoli's method,
481
Kelly, catheterization of ureter, 163
rubber cushions, 194
suspensio uteri. 452
trocar, 611
ventrofixation, 452
Kelsey, speculum, 150
Keyes, irrigator, 175
Kidney
extirpation, 619
floating, 600
Kleptomania, 247
Knives, 213
uterine, 422
Knot, surgical, 217
Staffordshire, 536
Koeberle", artery clamp, 182
Koenig, method of reviving, 207
Kraske, hysterectomy, 519
Kraurosis vulvse, 288
Kreuznach, 188
Kiichenmeister, scissors, 422
Kiistner, flap-operation for atresia, 331
L.
Labarraque, solution, 668
Labia majora
abnormal, 258
anatomy, 36
function, 37
Labia minora
anatomy, 37
function, 37
Labor, ovarian cyst during, 629
Laceration
of cervix, 396
of perineum, 301
complete, 302, 305, 310, 314, 320
incomplete, 302, 303, 307, 311, 316
intermediate operation, 307
primary operation, 303
secondary operation, 307
of vaginal entrance, 305
Lack of orgasm, 687
Latninaria, disinfection of, 154
Lamp, electric, 628
Laparotomy, 609
compared with vaginal section, 493,
520, 540
for sterility, 687
Late hours, 129
Lateroflexion, 394. 454
Lateroposition, 394
INDEX.
705
Lateroversion, 394, 454
Lauenstein, suture, 316
Leavens, sutures, 200
Leech, artificial, 186
Leeches, 186
Lefort's operation for prolapse of uterus,
457
Leg-holder, 198
Leggings, 197
Leopold, ventrofixation, 452
apparatus for Trendelenburg's position,
139, 195
Leptothrix vaginal is, 349
Leucorrhea, 250
in phthisis, 252
Ligaments
broad, 56, 644
infundibulopelvic, 25, 64
intern reteric, 81
of bladder, 80
anterior true, 80, 95
false, 80
lateral false, 80
true, 80, 95
posterior false, 80
superior false, 80
suspensory, 80
true, 80
vesico-uterine, 55, 80
of ovary, anatomy, 65
development, 23
of rectum, 96
of uterus, 54
perineal, 100
pubovesical, 76, 95
round, 58
sacro-uterine, 55
subpubic, 100
superior round, 57
suspensory, of clitoris, 38
transverse, of pelvis, 100
triangular, of urethra, 100
vesico-uterine, 55, 80
Ligamentum suspensorium of bladder,
80
Ligation of pedicle of ovarian cyst, 612,
625. (See Ligature.)
Ligature
-box, 202
-carrier, 217
chain-, 625
compared with forceps, 488
elastic, 217, 465, 496
for fecal fistula, 383
in ovariotomy, 628
mass-, 182
material, 217
method for hysterectomy, 487
of arteries, 182
45
Ligature
of internal iliac artery, 521
of internal pudic artery, 183
of uterine artery, 182
Li pom a
of Fallopian tube, 547
of vulva, 281
Lips of cervical portion, 48
Liquor
ferri chloridi, 179
folliculi, 28, 70
Liver -
adhesions, 618
floating, 600
Lotion to be used with tincture of iodine,
188
Lotions
carbolic acid, 188, 272, 293
chloral hydrate, 269
hydrocyanic acid and lead, 269
Lubricant, 140
Lungs, examination in regard to opera-
tions, 196
Lupus of vulva, 285
Lymphadenitis, pelvic, 676
Lymphangitis, pelvic, 676
Lymphatics
of perineal region, 108
of uterus, 62
Lysol, 206
M.
Malformations
of Fallopian tubes, 524
of hymen, 326
of ovaries, 549
of pelvic peritoneum, 643
of uterus, 387
of vagina, 326, 328
of vulva, 255
Malignant tumor diagnosticated by
cancer cells in ascitic fluid, 513
Malposition of uterus, 394
Afammary gland, normal development
simulating tumor, 114
Manual replacement of inverted uterus,
465
Marcy, cobbler's stitch, 626
needle, 215
subcuticular suture, 493
Marienbad, 188
Marriage
as a cure, 244
in relation to disease, 129
Marsiipialization, 623, 647
Martin, A., enucleation, 499
hysterectomy, 493
Martin, E., pistol, 171
706
INDEX.
Massage, 190
for adhesions, 450
Masturbation, 297
Maunsell, artificial invagination of in-
testine, 689
Mayer, pessary, 456
Mayhem, 534
McNaughton, apparatus for Trendelen-
burg's position, 195
Meatus urinarius, 39
Medullary substance of ovary, 67
Metnbrana granulosa, 28, 69
Menopause, 123
treatment, 125
Menorrhagia, 245
Menses, 115
suppression of, 238
Menstrual
disorders, 247
period, 115
Menstruation, 115
abnormal, 238
coition during, 130
influence of operation, 119, 539
neglect during, 129
operations during, 192
precocious, 244
scanty, 241
supplementary, 241
tardy, 245
theory of, 120
vicarious, 241
Mensuration, 158
Mental aberration after ovariotomy, 635
Mercury, bichloride, 205, 516
Mesentery, adhesions, 618
Mesoarium, 23
Mesorchium, 23
Mesorectum, 86
Mesosalpinx, 25, 64
Metastasis
from ovarian cysts, 586
from uterine carcinoma, 509, 511
Methyl blue, 515
Metritis, 403
acute, 403
chronic, 407
parenchymatous, 416
diphtheritic, 406
dissecting, 406
gonorrheal, 406
operations for, 418
parenchymatous, 403
Metrorrhagia, 247
Metrotome
Greenhalgh's, 422
Simpson's, 422
Mikulicz, abdominal tamponade, 181, 499
Milliampereraeter, 232
Miner, enucleation, 621
Mirror, concave, for throwing light into
abdominal cavity, 628
Mitchell, Hubbard, speculum, 147
Mitchell, S. Weir, rest-cure, 225
Mixtures
A. C. E., 206
condurango, 515
hydrocyanic acid, 211
pepsin, 225
potash and belladonna, 269, 413
strychnine, 226
Molecules moved by electric current, 233
Molimina, 133, 139"
Mons Veneris
anatomy, 35
function, 35
Monsel's solution
in enucleation of fibroid, 499
in ovariotomy, 628
Monthly
flow, 115
sickness, 115
Morcellation, 479, 489
Morgagni, hydatid of, 30, 524
lacunae of, 76
Morphine injected subcutaneously before
anesthetizing, 208
Miillerian duct, 29
Munde", speculum, 147
Murphy, button, 690
Muscles
bulbocavernosus, 102
coccygeus, 97
compressor urethra 3 , 103
constrictor urethra 3 , 103
vaginae, 104
deep trans versus perinsei, 104
depressor urethne, 103
detrusor recti, 87
external sphincter ani, 87
Giithrie's, 103
internal sphincter ani, 87
ischiocavernosus, 102
ischiococcygeus, 97
Jarjavay's, 103
levator ani, 97
obturatococcygeus, 97
perineal, 102
pubococcygeus, 97
superficial transversus perinaei, 103
third sphinter of rectum, 87
transversus urethrse, 103
Myofibroma
of uterus, 469
of vagina, 359. (See Fibroid, Fibroma,
Fibromyoma, Myoma.)
Myoma
cavernous, of uterus, 469
INDEX.
707
Myoma
complicating ovarian cyst, 629
lymphangiectodes, 469
of uterus, 469
of vagina, 359
of vulva, 281
teleangiectodes, 469. (See Fibroid. Fi-
broma.)
Myxoid cystoma, 571
Myxoma
of uterus, 467
of vulva, 281
Myxosarcoma
of ovary, 638
of uterus, 504
ir.
Naboth, ovula of, 407, 410
Neck of womb, 47
Needles, 214
handled, 216
Hunter's, 488
Marcy's, 215
perineum, 417
Folk's, 487
Rchroeder's, 487
Needle-holder
Crosby's, 215
Hagedorn's, 215
Sims' s, 215
Neglect of skin, 127
Negro, carcinoma, 509
uterine fibroid, 474
Ne"laton artificial respiration, 207
cyst-forceps, 611
Neoplasms
of Fallopian tube, 547
of ovary, 567
of uterus, 467
of vagina, 358
of vulva, 277
Nerves of perineal region, 108
Neuralgia
lumbo-abdominal, 411
of uterus, 432
Neuroma of vulva, 282
Nitroglycerin, 210
Noeggerath, inversion, 465
latent gonorrhea, 131
Nott, catheter, 175
Nozzle with stopcock, 198
Nubility, 114
Nuck, canal of, 37, 59, 263, 643
Nunn's gorged corpuscles, 577
Nussbaum, suprapubic urethra, 378
Nymphae
anatomy, 37
progressive atrophy, 288
O.
Obliquity of uterus, 384
Occlusion dressing, 304
Oi'dium albicans, 349
Ointments
chloral hydrate, 269
condurango, 515
iodoform, 178
Ointment-carrier, 171
Olshausen, ventrofixation, 452
Omentum adherent to tumors, 495, 618
Oophoralgia, 642
Oophorectomy
for atresia, 332
for uterine fibroids, 483. (See Salpingo-
oophorectomy.)
Oophoritis, 557
acute, 557
chronic, 559
follicular, 557
interfollicular, 557
transition to cyst, 560
Oozing tumor, 278
Operating-room, 193
Operating-table, 194
Boldt's, 195
Bozeman's, 368
Cleveland's, 195
Foerster's, 195
Operations
after-treatment, 323
Alexander's, 448
assistants, 195
combined, 223
diet after, 224
disinfection, 199
during hot season, 192
during lactation, 193
during menstruation, 192
during pregnancy, 192
for incontinence, 379
in general, 192
instruments which are used in nearly
all, 211
preparation for, 193
of patient, 196
room, 193
rubber cushions, 194
spectators, 196
table for, 194
time of day for, 183
vessels needed in, 198
Opium
pills, 243
suppositories, 226
Organ of Giraldez, 22
Orgasm, 121
lack of, 687
708
INDEX.
Ormsby, inhaler, 208
Os
externum, 48
granular, 408, 424
internum, 40
pinhole, 421
tincne, 48
uteri, 48
Osmosis, electrical, 233
Ossification
of corpus luteum, 561
of ovarian cysts, 586
Ostium
abdoininale of Fallopian tube, 63
accessory abdominal, of Fallopian
tube, 524
uterinum of Fallopian tube, 63
Outerbridge, instrument for uterine dila-
tation and drainage, 184
perineorrhaphy, 318
Ova-
absence of, 683
anatomy, 70
development, 26
expulsion, 74, 117
formation, 26
primordial, 28
Ovarian
abscess, 557
cyst
adherent everywhere, 619
adhesions, 585, 616, 619
ascites, 594
blood corpuscles in fluid of, 576
calcification, 586
cancerous degeneration, 576, 586, 639
cholesterin in, 579
complicated with labor, 629
complications, 602, 629
congenital, 574
contents, 576, 583
cut off blood-supply from, 624
dermoid, 581
diagnostic value of examination of
fluid, 595
differential diagnosis, 596
epithelial cells in fluid of, 577
etiology, 588
explorative
incision, 596
puncture, 595
extraperitoneal, 585
diagnosis, 602
fluid, 570. 576, 583, 595
fusion, 585
glandular, 572
hemorrhage, 585, 593
in mesentery, 622
inflammation, 593
Ovarian cyst
intestinal obstruction caused by, 594
intraligamentous, 585, 620
irremovable, with colloidcontents, 691
metastasis, 586
mixed proliferating, 581
multilocular, 574
myxoid, 771
origin, 587
originating in chronic oophoritis, 560
in corpus luteum, 560
ossification, 586
papillary, 580
parvilocular, 576
part of, imbedded in pedicle, 621
pedicle, 584, 625
peritonitis caused by, 594
prognosis of, 603
proliferating, 571
pseudo-intraligamentous, 622
relation to carcinoma, 576
retroperitoneal, 585
Kokitanski's, 570
rupture of, 586, 593
spindle-cells in fluid of, 579
suppuration of, 586, 593
symptoms of, 588
torsion of pedicle, 584, 593
treatment, 603
tubo-ovarian, 583
unilocular, 570
wall of, 570, 574, 582
with pregnancy, 603
tumor
intraligamentous, 585, 620
oligocystic, 569
'solid, 597, 636
(See Ovarian Cyst.)
Ovaries
abscess, 558
absence, 549
adenosarcoma, 638
alternate swelling at menstruation, 120
anatomy, 65
carcinoma, 639
carcinomatous cystoma, 639
cirrhosis, 558
cystocarcinoma, 639
cysts, 567
descent, 23
development, 22
diseases of, 549
displacement, 550
endothelioma (Ackermann) 639
(Jones), 565
excessive growth, 549
fibroma, 636
fibrosarcoma, 638
function, 74
INDEX.
709
Ovaries
gyroma, 563
hem atom a, 554
hernia, 550
hydrocele, 583
hyperemia, 554
inflammation, 557
intermittent hydrocele, 525
malformations, 549
myxosarcoma, 638
neoplasms, 567
neuralgia, 642
palpation, 531
papilloma, 637
prolapse, 551
rudimentary, 549
sarcoma of, 638
carcinomatosum, 638
second ovary in ovariotomy, 614
supernumerary, 120, 549
tuberculosis, 641
with pedunculated cysts, 571
Ovariotomy, 606
abdominal, 607
after-treatment, 615
causes of death after, 635
complications during after-treatment.
631
during operation, 616, 629
contraindications, 606
difficulties, 616
drainage, 629
heinostasis, 627
incomplete, 623
indications, 606
injury of gall-bladder, 618
of intestine, 617
of uterus, 621
instruments, 607
opiates, 615
papilloma extending into other organs,
622
parotitis after, 635
preparatory treatment, 607
prognosis, 625
second ovary, 614
shock, 631
temperature, 632
toilet of peritoneum, 627
vaginal, 607
Ovula of Naboth, 407, 410
Ovulation, 118
Ovisacs, 67
Ovum. (See Ova.)
Ox-gall, 174
P.
Pachyderm ia of vulva, 279
Pachyperitonitis, hemorrhagic, 651
Pachysalpingitis, 525
Pack; hot, 187
Packing, vaginal, 178
Pad, perineal, 304
Pain, 134
intermenstrual, 417
Palm se plicatse, 49
Palpation
of abdomen, 57
of ureters, 167
Papilloma
growing from ovarian cyst into other
organs, 622
in ovarian cyst, 580
of Fallopian tubes, 547
of ovary, 637
of uterus, 521
of vulva, 277
on outer surface of myxoid proliferat-
ing cystoma of ovary, 575
on outer surface of ovary, 581, 637
Paquelin's thermocautery, 182
Parametric connective tissue, 56
Parametritis, 657
Parametrium, 56
Parenchymatous zone of ovary, 67
Paring, 213
Parotitis after ovariotomy, 635
Parovarian varicocele, 644
Parovarium
anatomy, 74
development, 22
Partitioning the vagina, 457
Parturition
pelvic floor during, 112
results in regard to pelvic floor,
113
Patch, mucous, 295
Patient, preparation of, for operations,
196
Pawlik, catheterization of ureter, 165
operation for incontinence, 379
Pan, position, 609
retractor, 486
traction-forceps, 212
vaginal hysterectomy, 674
Pectiniform septum, 38
Pedicle of ovarian cyst
composition, 84
ligation, 612, 625
torsion, 584, 593
Pelvic
abscess, 665
hysterectomy for, 675
opening in two sittings, 667
carcinoma, 678
diaphragm
anatomy, 97
function, 97
710
INDEX.
Pelvic floor
anatomy, 94
during parturition, 112
entire displaceable portion, 110
entire fixed portion, 111
function, 111
projection, 105
pubic segment, 110
results from parturition, 113
sacral segment, 110
sarcoma, 678
structural anatomy, 110
hematoma, 655
hemorrhage, 649
lymphadenitis, 676
lymphangitis, 676
peritonitis, 657
phlebitis, 675
sarcoma, 678
Pelvis
adhesions in, 618
diseases of, 643
hydatids, 679
malformations of, 643
three spaces of, 94
Penis captivus, 355
Pepsin, 225
Percussion, 158
Perimetric inflammation,- 657
Perimetritis, 657
Perineal
body, 104
cystic hygroma, 325
hysterectomy, 520
pad, 304
region, 99
Perineorrhaphy
after-treatment, 322
Cleveland's, 319
Emmet's, 316
for retroflexion, 348
Garrigues', 311
intermediate, 307
Outerbridge's, 318
preparation for, 322
primary, 304
secondary, 307
Tail's, 307
Perineotomy
transverse, 668
vertical, 667
Perineum
complete laceration, 305
development, 31
diseases, 301
incomplete laceration, 303
injuries, 301
needle, 217
old lacerations, 307
Perineum
recent lacerations, 301
Perioophoritis, 557
Perisalpingitis, 525
Peritoneum
function, 92
gelatinous disease, 587
pelvic, 90
pseudomyxoma, 587
taken for ovarian cvst-wall, 615
toilet, 627
Peritonitis
diagnosis from ovarian cyst, 596
pelvic, 657
septic, 633
with ovarian cyst, 594
Pessary
after ventrofixation, 453
Breisky's, 456
Emmet's, 446
Fowler's, 447
Gariel's, 456
Geh rung's, 435
general remarks, 436
Hewitt's cradle, 435
Hodge's, 446
Mayer's, 456
retrotiexion, 446
stem-, 441
Thomas's anteversion, 185, 435
retroflexion, 553
vaginal, 435
Vienna, 435
whalebone, 447
Petit's triangle. 666
Petzer, catheter, 486
Phagedena, 292
Phantom tumor, 602
Phlebitis-
after ovariotomy, 635
pelvic, 675
Physiology, 114
Physometra, 125, 392, 421, 598
Pilimiction, 582
Pills-
aloes and iron, 225
antidysmenorrheic, 243
Chian turpentine, 515
conium, 243
emmenagogue, 240
Pinhole os, 421
Pinworms, 273
Pistol, E. Martin's, 171
Platysma, 57
Pledgets, vaginal, 178
Plicae palmate, 49
Plombieres, 188
Plug, vaginal, 179, 330
Poles, qualities of, 233
INDEX.
711
Polk, needle for hysterectomy, 487
shortening of round ligaments, 453
Polypus
fibrinons, 468
fibroid, uterine, 469
vaginal, 360
glandular, 467
hollow, 463, 466
intermittent, 473
mucous, of uterus, 408, 467
vaginal, 361
myxomatous, 467
Position, 136
breech-back, 137, 197, 198, 368
dorsal, 136
erect, 138
genupectoral, 138
high pelvic. (See Trendelenburg's.)
Simon's, 197, 368
Sims's, 137
Trendelenburg's, 138, 195
ventral, 139
Posterior commissure, 36
Postural treatment of retroflexion, 447
Potain, aspirator, 159
Potassa, 269, 413
Pouch
Douglas's, 91
obturator, 91
para-uterine, 91
paravesical, 91
recto-abdominal, 91
recto-uterine, 91
utero-abdominal, 91
vesico-abdominal, 91
vesico-uterine, 91
Poultice, 187
Powders
headache, 249
phenacetine compound, 249
Pozzi, injecting cysts with spermaceti, 290
injury to ureters, 619
operation for ureterovaginal fistula,
375
ventrofixation, 452
Pratt, hysterectomy, 491
Precocity, 387
Pregnancy
diagnosis from ovarian cyst, 589
in relation to uterine fibroids, 500
operations during, 192
with cancerous uterus, 519
with ovarian cyst, 603
Pregnant cancerous uterus removed by
vaginal hysterectomy, 519
Prepuce, 37
adherent, 257
Pressure
as hemostatic, 627
Pressure
-forceps, 184, 214, 485
symptoms, 474
Priessnitz's compress, 187
Primary follicles, 28
Primordial ova, 28
Probe, 153
Procidentia of uterus, 454
Progressive atrophy of nymphse, 288
Prolapse-
acute, of uterus, 454
Brandt's method, 456
chronic, 455
complete, 454
incomplete, 453
Lefort's operation, 457
of anterior wall of vagina, 335
of intestine into deep Douglas' pouch,
335
of ovaries, 551
of posterior wall of vagina, 340
of urethra, 296
of uterus, 454
of vagina, 340
operations, 457
Prolapsus of uterus, 454
Proliferating cyst, 571
Pruritus, 272
Pseudohermaphrodism, 259
Pseudo-intraligamentous tumors, 622
Pseudomyxoma of peritoneum, 587
Puberty, 114
different from nubility, 114
Puncture, explorative, .595
Pus, inspissation of, 534
Pyocolpos, 326
lateral, 333
Pyometra, 326, 392, 421
Pyosalpinx, 525, 543, 597
saccata, 525
Pyroinania, 247
R.
Raphe
ano-coccygea, 97
perineal. 101
Receptaculum seminis, 63
Rectal-
alimentation, 225
ampulla, 85
speculum, 150
Rectocele, 340
Emmet's operation, 316
Rectum
anatomy, 83
function, 89
Reese, artificial leech, 186
Regions
abdominal, 113
712
INDEX.
Regions
anal, 99
perineal, 99
urogenital, 99
Repositor
Aveling's, 464
Byrne's, 465
White's, 465
for inversion, 464
for retroflexion, 446
Resolution, 226
Resolvents, 226
Respiration, artificial, 207
Rest-cure, 225
Retractor muscles of uterus, 55
Retractor-*
Engelmann's, 211
Plan's, 486
Schroeder's, 211
vaginal, 211, 486
Retroflexed gravid uterus, 597
Retroflexion, 443
Retro-ovarian shelf, 91
Retroposition, 394
Retroversion, 442
Reverdin, apparatus for lifting large
tumors, 496
Reviving from anesthesia, 207, 210
Rheophores, 232
Rheostat, 232
Richardson's bellows, 207
Rima pudendi, 36, 43
Robb, leg-holder, 198
Rodent ulcer, 508
different from the corroding ulcer,
512
Rokitanski's tumor, 570
Roof of vagina, 42
Room, operating-, 193
Rosenmiiller's organ, 22
Round ligament
anatomy, 58
diseases, 648
fibroma, 264
function, 50, 60
hematoma, 263
shortening, 448, 453
tumors connected with extrapelvic
portion, 262
Rubber
bag for injecting bladder, 176
cushions for operations
Kelly's, 194
Marcy's, 194
ligatures, preservation of, 207
Rudimentary horn of uterus, 389
Rugfe of vagina, 43
Rupture of ovarian cyst, 586, 593
Ruptures (hernise), 260
S.
Sacral hysterectomy, 519
Sacrotomy, 668
Sacro-uterine ligament, 55
diseases of, 648
Salpingitis, 525
acute catarrhal, 525
purulent, 525
chronic interstitial, 525
conservative treatment of, 533
cystic, 525, 541
infectious, 525
interstitial, 526
isthmica nodosa, 525
mural, 525
non-infectious, 525
parenchymatous, 525
profluent, 525
Salpingo-oophorectomy, 534
abdominal, 535
for anteflexion, 442
for hemorrhagic endometritis, 420
mortality, 538
results, 539
vaginal, 540
with ventrofixation, 453
Salt, solution of, 502
Sand-bodies, 581
Sarcoma
carcinomatosum of ovary, 638
decidual, 506
of Fallopian tube, 547
of ovary, 638
of pelvis, 678
of uterus. 503
of vagina, 561
of vulva, 283
Scarification of vaginal portion, 186
Scarificator, Buttle's, 186
Schede, operation for ureterovaginal fis-
tula, 374
Schimmelbusch, sterilization-box, 202
Schroeder, needle for hysterectomy,
487
operation for vaginal cyst, 359
repair of intestine, 495
vaginal retractor, 211
Schuchardt, hysterectomy, 520
Schultze, disinfection of laminaria tents,
154
method of tearing adhesions of ovary,
553
of uterus, 450
Scirrhus of vulva, 283
Scissors, 213
Bozeman's, 479
Kiichenmeister's, 422
Searcher, ureteral, 165
INDEX.
713
Section, vaginal, compared with abdomi-
nal, 493, 540
Sedatives, 226
Segmental vesicles, 21
Segond, speculum, 484
vaginal hysterectomy, 483
Septicemia, 502, 633
Septum
pectiniform, 38
retrohymenale, 328 ,
transverse perineal, 101
Serrefines, 303
Shelf, retro-ovarian, 91
Shock, 501, 631
Shortening of round ligament
extraperitoneal, 448
intraperitoneal, 453
vaginal, 453
Shouldering, 219
Silk, 201
Silkworm gut, 204
Silver wire, 204, 217
Simon, cone-mantle-shaped excision of
cervical portion, 419
curette, 153
intestinal examination, 142
operation for fistula, 368
position, 368
Simpson, J. Y., metrotome, 422
Sims, Marion, catheter, 367
discission of posterior lip of cervix,
441
needle-holder, 215
operation for anteversion, 437
for cystocele, 336
for rectovaginal fistula, 366
for urinary fistula, 366
speculum, 145
sponge-holder, 213
suture-shield, 218
uterine knife, 422
Sinus copularis, 30
Sinuses of Morgagni, 87
Skene's glands, 76
Smith, cautery-clamp, 612
Smith, Greig, ligature-box, 202
Sodium sulphate, 228
Solution
borosalicylic, 206
ergotine, 480
Labarraque's, 668
Monsel's, 499, 628
normal salt, 502
sclerotinic acid, 480
sodium carbonate, 199
tannin-iodoform, 412
Thiersch's, 206
Villate's, 668
Solutions, antiseptic, 205
Souffle, uterine, 158
Sound, uterine, 152
Space
subcutaneous, of pelvis, 94
subperitoneal, of pelvis, 94
Spanish-fly blister, 188
! Spectators, 196
I Speculum
Ashton's, 150
bath-, 187
bivalve, 145
bladder-, 163
Bozeman's, 368
Brewer's, 144
Barrage's, 150
cervical, 150
Cusco's, 144
Ehrich's, 148
Fergusson's, 144
Folsom-Skene's, 151
Garrigues', 211
Jackson's, 150
Kelly's 163
Kelsey's, 150
Munde's, 147
Mitchell's, 147
pi uri valve, 144
rectal, 150
self-holding, 147
Segond' s, 484
Sims's, 145
tubuliform, 144
univalve, 145
urethral, 150
vaginal, 144
Sphincter
ani, how to unite broken, 320
muscles of urethra, 76
of rectum, third, 87
Spina bifida, 601
Spiritus glonoini. 210
Spleen
adhesions, 618
cyst, 601
tumor, 601
Sponge taken for carcinoma, 511
Sponges, 200
Sponge-holder, 213
Sponging, 222
Spontaneous opening of wound after
ovariotomy, 634
Spoon, sharp, 153
Spoon-saw, 478
Springs, mineral, 188
Staffordshire knot, 536
Steam as disinfectant, 195
as hemostatic, 618
Stearate of zinc, 630
Stem-pessary, 441, 447
714
INDEX.
Stenosis
of cervical canal, 242, 394, 421
acquired, 421
congenital, 421
of vagina, 328
Sterility, 682
after double ovariotomy, 635
in the female, 683
in the male, 682
primary, 683
secondary, 683
Sterilization of catgut, 202
Sterilizer, 199, 202
Arnold's, 201
Schimmelbusch's, 202
Stimulants, 210, 224
Stitch, cobbler's, 614, 627
Stomach, dilatation of, 601
Stramonium pills, 243
Structureless membrane of Graafian folli-
cle, 69
Strychnine
in collapse, 210
mixture, 226
pills, 240
Stupe, 187
Styptics, 182, 602
Subinvolution of uterus, 416
Summit of bladder, 78
Superfetation, 391
Superinvolution of uterus, 431
Supporter
abdominal, 190
uterine, 456
Suppositories
with iodoform, 324, 407
with morphine, 324
with opium, 226
Suppuration of ovarian cyst, 586
Supravaginal amputation compared with
total extirpation of uterus, 498
Suspensio uteri, 452
Suture, 217
buried catgut, 314, 316
button-, 368
chain-, 222, 625
Cleveland's, 319
cobbler's stitch, 614, 627 ^
continuous, 220
Czerny-Lembert's, 617
for fecal fistula, 383
for hemostasis, 184
for inversion, 465
for urinary fistula, 365
forming nucleus of stone, 371
Glover's, 614
Halsted's, 494
horsehair, 204
how to remove, 222
Suture
interrupted, 220
kangaroo tendon, 204
Lauenstein's, 316
Marcy's, 494
material, 200, 217, 304
mattress-, 184
quilled, 184, 220
removal of, 222
secondary infection of, 217
-shield, 219
shouldering, 219
silk, 201, 217
silkworm gut, 204
silver wire, 204, 218
sterile, 200
subcuticular, 493
submucous, 316
tier-, 221
twisting, 220
Swedish movement cure, 191
Sylvester's artificial respiration, 207
Syphilis, 293
indurating edema, 285
initial lesion, 293
secondary, 295
tertiary, 296
Syringe
Braun's, 172
bulb-nnd-valve, 171
Davidson's, 171
for bladder, 175, 176
fountain, 171
Frost's, 673
uterine, 172
T.
Table
Daggett's, 135
examining-, 135
operating-. (See Operating-table.}
Tail, flap-splitting operation for perineal
laceration, 307
operation for fecal fistula, 384, 385
for urinary fistula, 369
salpingo-oophorectomy, 535
shortening of round ligaments, 453
"Tait's operation," 535
Tampon
abdominal, 181
vaginal, 178
Tamponade, 177
of uterus, 180
Tannin
glycerite, 178
solution with iodoform, 418
Tape-carrier, 478
Tapping, 188, 604
INDEX.
715
Tate, inversion, 475
Taylor, I. E., operation for rectolabial
fistula, 382
Temperature after ovariotomy, 632
Tenaculum, 212
Emmet's, 212
-forceps, 213
Tendinous arch, 94
Tents, 154
Tent-carrier, 155
Tetanus, 503, 635
Thermal galvanocauterization for cancer
of uterus, 516, 517
Thermocauterectomy of uterus, 518
Thermocautery, 182
Thiersch's solution, 206
Thirst, 223
Thomas, anteversion pessary, 435
classification of anteflexion, 438
enucleation of uterine fibroids, 481
inversion, 464, 465
operation for vaginismus, 357
retroflexion pessary, 553
stem-pessary, 441
spoon-saw, 478
Thompson, bladder-syringe, 176
Thrombosis, 502
Thrombus
of vagina, 341
of vulva, 276
Thymol, 206
Tincture of iodine
in ovariotomy, 628
on the skin, 148
in the vagina, 170
Tissue-forceps, 213
Toilet of peritoneum, 627
Tongue-forceps, 209
Tonics, 226
Trachelorrhaphy, 399
for retroflexion, 448
Trachelotomy, 422
Traction, for removing uterine fibroids,
482
Transfusion, 502
Travelling, cure for sterility, 586
Treatment
electric, 229
external, 170
in general, 168
internal, 224
preventive, 168
Trendelenburg, operation for fistula,
369
position, 138
anesthesia in, 209
apparatus for, 139, 195
Trichiasis, 272
Trichomonas vaginalis, 344
Trigone
Lieutaud's, 78
Pawlik's, 165
Tripperfaden, 531
Trocar
Emmet's, 611
Kelly's, 611
vaginal, 189
Warren's, 605
Tubercle of vagina, 43
Tuberculosis
of Fallopian tube, 547
of ovary, o'41
of peritoneum, 599
of uterus, 522
of vagina, 362
of vulva, 288
Tubes
double-current uterine, 173
drainage-, 185
Fallopian, 62, 548
single-current uterine, 173
Tubo-ovarian cyst, 583
Tumeur fluxionnaire, 417
Tumor
fibroid, of uterus, 468
of abdominal wall, 601
of broad ligament, 648
of round ligament, 262
of spleen, 601
of vulva, 275.
(See Cancer, Cyst, Carcinoma, Fi-
broid, Sarcoma, etc.)
oligocystic, 569
oozing, 278
painful, of urethra, 282
phantom, 602
Rokitanski's, 570
solid ovarian, 636
vascular, of urethra, 282
Tunica
fibrosa of Graafian follicle, 68
propria of Graafian follicle, 68
Turns, 115
Turpentine, Chian, 515
Tuttle, fibroma molluscum, 281
Tympanites, 174, 602, 632
U.
Ulcer-
corroding, 424, 512
of cervix, 424
rodent, 508
simple, 424
tuberculous, 288, 362, 424
venereal, 291, 293
Urachus, 31, 80
persistent, 495, 616
716
INDEX.
Ureter
anatomy, 81
at base of intraligamentous tumors, 622
catherization, 165
course during pregnancy, 82
examination, 161
function, 83
implantation, 375
injury, 371, 373, 537, 618
ligation, 371, 503, 537
opening into vagina, 334
palpation, 167
Ureterocystostomy, 375
extraperitoneal, 375
intraperitoneal, 375
Urethra
anatomy, 75
atresia, 372
caruncle, 282
dilatation of, 142
ducts, 76
inflammation of, 270
function, 77
irritable vascular excrescence, 282
painful tumor, 282
prolapse, 296
suprapubic, 378
vascular tumor, 282
Urethral
ducts, 76
inflammation of, 270
speculum, 150
Urinals, 378
Bozeman's, 375
Jay's, 379
Urinary analysis, 160
Urine
alkaline, 355
examination with regard to operations,
196
suppression of, 632
Urogenital region, 99
sinus, 20, 31
persistent, 334
Uterine appendages of the other side
in ovariotomy, 614
when one set is removed, 537
artery
aneurysm, 643
during pregnancy, 61
ligature of, 182
cancer, 503
radical treatment, 516
carcinoma, 507
fibrocyst, 473
treatment, 503
fibroid
abdominal enucleation, 498
apparatus for lifting, 496
Uterine fibroid
cervical, 468
changes, 473
combined with pregnancy, 500
corporeal, 468
curetting, 481
galvanochemical cauterization, 480
hypodermic injection of ergot, 480
indications for operations, 503
in negro race, 474
interstitial, 470
intramural, 470
mortality of operations, 500
multiple, 472
oophorectomy, 483
pedunculated, 470
sessile, 470
single, 472
sloughing, 500
submucous, 470
subperitoneal, 470
supravaginal amputation, 496
traction method, 482
vaginal enucleation, 481. (See
Uterus.)
Uterotractor, 518
Uterus
absence of, 387
acollis, 393
acquired atrophy, 431
adenoma, 467
anatomy, 47
anteflex'ion, 394, 438
anteposition, 394
ante version, 433
apoplexy of, 125
arrest of development, 387
artificial prolapse, 143
atresia, 391, 420
bicameratus vetularum, 125
bicornis, 390
bilocularis, 390
bimanual replacement, 445
cancer, 503
carcinoma, 507
of body, 508
of cervix, 508
of vaginal portion, 507
catarrh, 410
cavernous angioma, 468
cervical carcinoma, 508
closure, 420
congenitally atrophic, 393
cysts, 467
cystosarcoma, 504
descent, 454
development, 31
excessive, 386
didelpliys, 388
INDEX.
Ill
Uterus-
digital replacement, 446
dilatation, 154
diseases, 387
displacement, 433
duplex separatus, 388
elevation, 460
enchondroma, 522
erosions, 408, 413, 424, 513
excessive development, 387
extirpation, 483
fetal, 392
fibrocysts, 473, 598
fibroid, 469
tumor, 469
fibroma, 469
fibromyoma, 469
foreign bodies, 403
function, 62
gangrene, 432
hernia, 394, 466
horns, 31
hypertrophv, 424
infantile, 392
inflammation, 403
injuries, 394
inversion, 460
irregular development, 394
lateroflexion, 394, 454
lateroposition, 394
latero version, 394, 454
ligaments, 54
male, 30
malformations, 387
malposition, 394
myofibroma, 469
myoma, 469
myxoma, 467
myxosarcoma, 504
neoplasms, 467
neuralgia, 432
obliquity, 394
papilloma, 521
parvicollis, 393
polypus, 467
glandular, 467
hollow, 463, 466
mucous, 467
myxomatous, 467
procidentia, 454
prolapse, 454
prolapsus, 454
pubescent, 393
repositors, 446
retractor muscles, 55
retroflexion, 443
retroposition, 394
retroversion, 442
rudimentary, 388
Uterus
rudimentary horn, 389
sarcoma, 503
senile atrophy, 431
septus, 390
severance of adhesions, 453
shape and position, 51
subinvolution, 416
subseptus, 390
superin volution, 431
supravaginal amputation, 496. (See
Hysterectomy.)
suspension of, 452
tamponade, 180
thermocauterectomy, 518
total extirpation, 483
compared with supravaginal ampu-
tion, 498
tuberculosis, 522
tumeur fluxionnaire, 417
unicornis, 389
vaginofixation, 450
ventrofixation, 452
wounded in ovariotomy, 618, 621
V.
Vagina
anatomy, 41
atresia, 328, 333
blind canals, 333
carcinoma, 361
cicatrices, 353
cysts, 358
development, 31
diseases of, 326
double, 332
entrance, 43
erysipelas, 353
extirpation, partial or total, in carci-
noma of uterus, 518
faulty communications, 333
fibroid polypus, 359
tumor, 359
fibroma, 359
fibromyoma. 359
foreign bodies, 342
function, 45
gangrene, 352
glass plug, 330
hematoma, 342
how to keep open after atresia opera-
tion, 330, 331
incision, 450, 484, 487, 533, 666
injuries, 341
inversion, 340
laceration of entrance, 305
malformations, 326, 328
mucous polypus, 361
718
INDEX.
Vagina
myofibroma, 359
narrowness, 329
neoplasms, 358
partitioning, 457
prolapse, 340
of anterior wall, 335
of posterior wall, 340
sarcoma, 361
stenosis, 328
tamponade, 179
thrombus, 341
tuberculosis, 362
Vaginal
enterocele, 334
case of, 334
glass plug, 185
hernia, 334
hysterectomy, limits, 490
portion
anatomy, 47
development, 32
subinvolution, 416
speculum, 144
Vaginismus, 328, 355
deep, 355
superficial, 355
Vaginitis, 343
acute, 343
adhesive, 344
catarrh al. 344
chronic, 343
diagnosis between simple and gonor-
rheal, 346
diphtheritic, 350
dissecting, 351
due to burrowing pus from pelvic ab-
scess, 352
dysenteric, 351
emphysematous, 349
epithelial, 348
exfoliative, 348
exudative, 350
follicular, 344
glandular. 344
gonorrheal, 346
granular, 344
mycotic, 349
phlegmonous, 351
primary, 343
secondary, 343
simple, 344
Vaginofixation of retroflexed uterus, 450
Valves
Houston's, 87
of rectum, 87
Varicocele
of broad ligament, 644
parovarian, 644
Vascular zone of ovary, 67
Vegetations of vulva, 277
Veins
of perineal region, 108
varicose, of vulva, 276
Venereal diseases, 291
Ventrofixation of uterus, 452
Vesicula prostatica, 30
Vessels needed for operations, 198
Vestibule
anatomy, 39
development, 32
function, 40
Vestibulovaginal bulb, 39
Vignard, operation for fecal fistula, 384
Villate, solution, 668
Virgins, examination of, 156
Vitelline membrane, 70
Vitellus, 70
Volsella, 212
Vomiting, 192, 211, 225, 226, 631
Vuillet, method of dilatation, 156
Vulva
absence of, 255
anatomy, 36
angioma, 282
atrophic carcinoma, 283
cancer, 283
carcinoma, 283
chronic infiltration, 285
inflammation, 285
ulceration, 285
cysts, 283
development, 33
diseases of, 255
elephantiasis, 279
epithelial coalescence, 258
epithelioma, 283
exanthematous diseases, 271
fibroma, 280
gangrene, 270
garrulity, 323
hematoma, 276
hyperesthesia, 275
hyperplasia, 275, 285
injuries, 265
kraurosis, 288
lipoma, 281
lupus, 285
malformations, 255
medullary carcinoma, 283
melanosarcoma, 283
myoma, 281
myxoma, 281
neoplasms, 277
neuroma, 282
oozing tumor, 278
pnchydermia, 279
papilloma, 277
INDEX.
719
Vulva
pruritus, 272
sarcoma, 283
scirrhus, 283
thrombus, 276
tuberculosis, 288
tumors, 275
varicose veins, 276
vegetations, 277
warts, 277
Vulvitis, 266
Vulvovaginal gland
abscess, 290
anatomy, 40
catarrh^ 289
cysts, 289
diseases of, 289
Vulvovaginitis in children, 352
W.
Walcher, operation for fistula, 370
Wallich, chain-suture, 625
Warren, trocar, 605
Warts of vulva, 277
Water, hot, 182
Watkins, operation for cystocele, 338
Wells, pedicle-forceps, 612
White, Jas. P., inversion, 465
White line
at anus, 87
of labia minora, 37
Whites, 250
Wiley, Gill, shortening of round liga-
ments, 453
Wire-twister, 219
Wolffian
body, 20
duct, 19
Woman's dartos, 37
Womb, falling of, 454
Xenomenia, 241
X.
Z.
Zona pellucida, 70
Zuckerkandl, hysterectomy, 520
ILLUSTRATIONS.
DEVELOPMENT.
FIG. PAGE
1. Wolffian Ducts 19
2. Urogenital Sinus ; . . 20
3. Wolffian Bodies 21
4. Beginning of the Bound Ligament 22
5. Lateral Canals of Wolffian Body 23
6. Transformation of the Wolffian Body in the Male 24
7. Transformation of the Wolffian Body in the Female 24
8. Transverse Section of Ovary of Human Embryo three months old .... 24
9. Transverse Section through Eegion of Ovary of Human Embryo five months
old 25
10. Ovary of Human Fetus ten to eleven weeks old 25
11. Part of Ovary of Human Fetus sixteen weeks old 26
12. Part of Ovary of Human Fetus twenty-eight weeks old 26
13. Part of Ovary of Human Fetus thirty-six weeks old '26
14. Part of Ovary of a Girl three days old 27
15. Perpendicular Section of Ovary of a Bitch six months old, showing tubes with
primordial ova 28
16. Graafian Follicles of New-born Girl 28
17. Graafian Follicle of a Girl seven months old 29
18. Primordial Ova undergoing Division 29
19. Transverse Section of Embryo of Eabbit fourteen days old, showing the for-
mation of the Miillerian Ducts 30
20. Transverse Section through the Genital Cord of Embryo of Cow 31
21. Ovaries, Tubes, and Horned Uterus of Human Embryo in the tenth week . . 31
22. Entrails of Abdomen and Pelvis of a Female Human Embryo five months old 32
23. 24, 25. Formation of Anus, Cloaca, and Urogenital Sinus 32
26. Urogenital Sinus and Organs opening into it 33
27. Development of the External Sexual Organs in the Male and the Female . . 34
ANATOMY.
28. External Genitals 36
29. Hottentot Apron (colored plate ) 37
30. Front View of Perineal Septum, showing entire Clitoris 38
31. Nerves of Pelvic Viscera (colored plate) 39
32. The Vestibulovaginal Bulbs 40
33. The Vulvovaginal Gland 41
34. Sagittal Section of Pelvis 42
35. Horizontal Section of the Soft Parts in the Inferior Strait of the Pelvis ... 43
46 721
722 ILLUSTRATIONS.
FIO. PAGE
36. Microscopical View of Longitudinal Section of the Vagina of a Girl twenty-
four years old 44
37. Transverse Section of the Same 44
38. The Arteries of the Uterus, the Ovaries, and the Vagina (colored plate) ... 44
39. The Venous Plexuses of the Vagina and Vulva, as seen in mesial section . . 45
40. Hymen with Linear Opening 46
41. Annular Hymen 46
42. Crescent-shaped Hymen 47
43. Indented Hymen 47
44. Virgin Uterus 48
45. The Utricular Glands 50
46. Section of the Mucous Membrane of the Uterus, parallel to the surface ... 51
47. Fiber of Endometrium, showing different degrees of corpuscular development 52
46. Uterine Epithelial Cells 52
49. Mesial Section of the Pelvis of a Girl seventeen years old 53
50. Diagram of Mesial Section of the Pelvis of a Living Woman 54
51. Endometrium of a Woman sixty years old 54
52. Diagram of the Ligaments of the Uterus 55
53. The Pelvic Viscera, seen from above 56
54. The Eight Wall of the Pelvis, showing insertion of the broad ligament ... 57
55. The Vessels of the Vagina and the Internal Genitals in their relation to the
superficial muscular structures 58
56. The Uterine Artery in its Belation to the Ureter 60
57. The Uterine Veins and the Ureter 61
58. Fallopian Tube, Ovary, and Parovarium 62
59. Fallopian Tube laid open 63
60. Tube and Ovary of a Woman who died during Menstruation 65
6L Ovary and Tube of Girl nineteen years old 66
62. Ovary and Tube of Girl twenty-four years old 67
63. Section of Ovary of Cat 68
64. Part of the Same, more highly magnified 69
65. Diagram of Zones in Human Ovary 69
66. Graafian Follicle of Adult Woman 70
67. Ovum of Babbit 71
68. Microscopical Structure of Corpus Luteum of Pregnancy ten to twelve days
after rupture 72
69. Corpus Luteum of Woman two days after menstruation (colored plate) ... 73
70. Corpus Luteum of Woman twenty days after menstruation (colored plate) . . 73
71. Cicatrice of Corpus Luteum nine days after menstruation (colored plate) . . 73
72. Corpus Luteum at term of pregnancy (colored plate) 73
73. False Corpus Luteum (colored plate) 73
74. Normal Menstrual Body 73
75. Ovary of Woman filled with Yellow Masses 75
76. Ovary of Woman with Cystic Corpus Luteum and Numerous spread Yellow
Masses 76
77. Ovary of Woman with Cystic Corpus Luteum and Numerous Yellow Masses
with Bemnant of Central Cavity 76
78. Parovarium .7 77
79. Urethral Ducts (Skene's glands) 78
80. Uterus, Ureters, Bladder, and Upper Part of Vagina 79
ILLUSTRATIONS. 723
FIG- PAGE
81. Superficial Layer of Bladder Epithelium 80
82. Deep Layers of Bladder Epithelium 80
93. The Course of the Ureters 82
84. Epithelium of Pelvis of Kidney , 83
85. The Eectum inflated with Air 84
86. Vertical Section of lower end of Eectum 85
87. Muscles of Perineum 86
88. Muscular Coat of Rectum 88
89. Mesial Section of Peritoneum with Empty Bladder 89
90. Mesial Section of Peritoneum with Full Bladder 90
91. Position of Viscera at the Pelvic Brim 92
92. Coronal Section of Pelvic Cavity 93
93. The Pelvic Fascia 95
94. Levator Ani, seen from below 96
95. Side View of Levator Ani 98
96. Pelvic Floor in mesial section 99
97. Transverse Section of Pelvis through Axis of Vagina ... 100
98. The Muscles of the Perineum 102
99. Sagittal Section of Perineal Body 105
100. Superficial Structures of the Female Perineum 106
101. Deep Structures of the Female Perineum 107
102. Horizontal Section of Pelvis Ill
103. Coronal Section of Body 112
PHYSIOLOGY.
104. Uterus during Menstruation 116
105. Endometrium of Menstruating Woman 117
106. Fusion of Spermatozoid and Ovum 122
107. Fertilized Ova of Echinus 122
EXAMINATION.
108. Daggett's Table 135
109. Dorsal Position 136
110. Sims's Position .... 137
111. Genupectoral Position 138
112. Trendelenburg's Position .139
113. Combined Vaginal and Abdominal Examination .141
114. Simon's Urethral Dilators .143
115. Fergnsson's Speculum
116. Brewer's Speculum
117. Sims's Speculum
118. Introduction of Sims's Speculum
119. Sims's Depressor
120. Hunter's Depressor
121. Munde's Speculum
122. Mitchell's Speculum
123. Ehrich's Speculum
124. Garrignes' Depressor
125. Bozeman's Dressing-forceps
724 ILLUSTRATIONS.
FIG. PAGE
126. Barrage's Cervical Speculum 150
127. Ashton's Eectal Speculum 150
128. Kelsoy's Kectal Speculum 150
129. Jackson's Urethral Speculum 151
130. Folsom-Skene Urethral Speculum 152
131. Simpson's Uterine Sound 152
132. Sims's Sharp Curette 154
133. Simon's Sharp Curette 154
134. Thomas's Dull Wire Curette 154
135. Barnes's Tent-carrier 155
136. Hanks's Small Uterine Dilators 155
137. Garrigues' Uterine Dilator 155
138. Potain's Aspirator 160
139. Epithelial Cells found in Urine 162
140. Kelly's Urethral Dilators 163
141. Kelly's Vesical Speculum 163
142. Kelly's Suction Apparatus 164
143. Pawlik's Furrows on the Anterior Vaginal Wall, corresponding to the trigone 166
144. Pawlik's Ureteral Catheter 166
TREATMENT.
145. Budd's Uterine Applicator 170
146. Bed-pan 171
147. Braun's Uterine Syringe 173
148. Garrigues' Single-current Uterine Tube 173
149. Goelet's Double-current Uterine Tube 174
150. Keyes's Irrigator for Bladder . . . . , 175
151. Nott's Double-current Catheter 176
152. Thompson's Rubber Bag for Injection into Bladder 176
153. Re"caniier's Curette 178
154. Garrigues' Curved Intra-uterine Packing-forceps 180
155. Garrigues' Straight Intra-uterine Packing-forceps 181
156. Paquelin's Thermocautery 183
157. Kceberl6's Artery-clamp 184
158. Onterbridge's Permanent Dilator of Cervix 185
159. Carrier for the Same 185
160. Abdominal Glass Drainage-tube 185
161. Reese's Artificial Leech 186
162. Buttle's Uterine Scarificator . 186
163. Bath-Speculum .-. 187
164. Trocar with Blunt Stylet 189
165. Abdominal Belt . . . . 190
166. Fitch's Abdominal Supporter 191
167. Inflatable Surgical Rubber Cushions 194
168. Clover's Crutch 197
169. Robb's Leg-holder . . '. 198
170. Nozzle with Stopcock 199
171. Leavens's Suture-tubes . 200
172. Schimmelbusch's Ligature-box 201
ILLUSTRATIONS. 725
FIG. PAGE
173. Greig Smith's Ligature-box (modified) 202
174. Dowd's Condenser 203
175. Allis's Ether Inhaler 207
176. Esrnarch's Chloroform Mask 209
177. Garrigues' Weight Speculum 211
178. Schroeder's Vaginal Ketractors 212
179. Emmet's Tenaculum 212
180. Volsella 212
181. Pean's Traction-forceps 212
182. Tissue-forceps 213
183. Sims's Sponge-holder 213
184. Needles 214
185. Needles with Handles 215
186. Sims's Needle-holder 216
187. Hagedorn's Needle-holder 216
188. Crosby's Needle-holder 216
189. Cleveland's Ligature-carrier 217
190. Bringing Pared Surfaces together with Sutures 218
191. Emmet's Counter-pressure Hook 219
192. Emmet's Wire-twister 219
193. Shouldering Wire Sutures 220
194. Sims's Suture-shield 220
195. Beginning a Catgut Tier-suture 221
196. Second Deep Row of Tier-suture 222
197. Apostoli's Bipolar Vaginal and Uterine Exciters 229
198. Garrigues' Intra-uterine Electrode 231
VULVA.
199. Hypospadias 256
200. Epispadias 257
201. Follicular Vulvitis 267
202. Epithelioma of Vulva 284
203. Lupus of Vulva 286
PERINEUM.
204. Vidal-Garrigues' Serrefines 303
205. Recent Tear of the Vaginal Entrance -306
206. Tait's Flap-splitting Operation for Incomplete Laceration of Perineum . . 308
207. Tait's Flap-splitting Operation for Complete Laceration of Perineum . . . 309
208. Diagrams Illustrating Incisions and mode of Suturing in Tait's Operation . 310
209. Hegar-Garrigues' Colpoperineorrhaphy for Incomplete Laceration . . . 313
210. Hegar's Colpoperineorrhaphy for Complete Laceration . 314
211. Submucous Sutures
212. Emmet's Operation for Incomplete Laceration (Rectocele) -
213. Emmet's Suture for Lifting Pelvic Floor 318
214. Outerbridge's Suture
215. Cleveland's Suture
216. Diagrams showing Retraction of Fibres after Rupture of Sphincter Ani Muscle 320
726 ILL USTRA TJONS.
FIG. PAGE
217. Sutures for Kepair of Torn Sphincter Ani 321
218. Diagram of Emmet's Operation for Complete Laceration of the Perineum . 321
VAGINA.
219. Vaginal Glass Plug 331
220. Sims's Operation for Cystocele 337
221. Stolz's Operation for Cystocele 338
222. Bozeman's Operating-Table 367
223. Bozeman's Speculum 368
224. Bozeman's Button 368
225. Walcher's Fistula- Operation 370
226. Bandl's Operation for Ureterovaginal Fistula . . 374
227. Pawlik's Operation for Incontinence 379
228. I. E. Taylor's Operation for Rectolabial Fistula 383
UTERUS.
229. Uterus Didelphys 388
230. Uterus Unicornis 389
231. Uterus Bicornis 390
232. Trachelorrhaphy 400
233. Dissecting Metritis ... 406
234. Hegar's Amputation of the Vaginal Portion 418
235. Simon's Coue-mantle-shaped Excision of the Vaginal Portion 419
236. Schroeder's Single-flap Excision of the Vaginal Portion 419
237. Kuchenmeister's Scissors 422
238. Simpson's Metrotome 423
239. Hegar's Funnel-shaped Excision of the Supravaginal Cervix 428
240. Schroeder's Supravagiual Amputation of Cervix 429
241. Kaltenbach's Supravaginal Amputation of Cervix 430
242. Anteversiou of the Uterus 434
243. Graily Hewitt's Cradle Pessary 435
244. Thomas's Auteversion Pessary 435
245. Thomas's Horseshoe-shaped Anteversion Pessary 436
246. Gehrung's Anteversion- Pessary 436
247. Anteflexion 438
248. Intra-uterine Stem-Pessary 441
249. Eetroflexion of the Uterus 443
250. Hodge-Emmet Pessary 446
251. Fowler's Pessary 447
252. Procidentia Uteri 455
253. Uterine and Abdominal Supporter 456
254. Lefort's Prolapse-Operation 457
255. 256. Fritsch's Vaginal Hysterectomy for Prolapsus of Uterus 459, 460
257. Section of Extreme Inversion of Uterus 461
258. Transition from Imbedded to Pedunculated Uterine Fibroid 470
259. Pedunculated Submucous Fibroid Tumor enclosed in Uterus 470
260. Pedunculated Subperitoneal Uterine Fibroid 471
261. Intramural Uterine Fibroid 471
262. Large Cactus-shaped Uterus full of Fibroids 472
ILLUSTRATIONS. 727
FIG- PAGE
263. Tape-carrier 478
264. Thomas's Spoon-saw 478
265. Bozeman's Double-curved Scissors 479
266. Segond's Speculum 484
267. Long Pressure-forceps 485
268. Petzer's Self-retaining Soft-rubber Catheter 486
269. Schroeder's Hysterectomy Needle 487
270. Folk's Needle 487
271. Morcellation of Fibroid Tumors 489
272. Subcuticular Suture 493
273. Closing Peritoneal Flap left on Intestine 495
274. Garrigues' Transfusion and Infusion Apparatus . . 502
275. Cervical Carcinoma extending into Body of Uterus , . 507
276. Supravaginal Amputation of Cervix with the Galvanocaustic Knife . . . 517
277. Bernays' Uterotractor 517
TUBES.
278. Hypertrophy of Fallopian Tube due to Interstitial Salpingitis 527
279. Tube with Alternating Wide and Narrow Places due to Salpingitis .... 527
280. Pyosalpinx on One Side, Catarrhal and Interstitial Salpingitis on the Other 528
281. Staffordshire Knot 536
282. Hydrosalpinx . . 545
OVAKIES.
283. Hematoma of Ovary 555
284. Chronic Oophoritis, the enlarged Ovary filled with Minute Cysts 560
285. Ovary with Cystic Corpus Luteum 560
286. Ovary containing a Gyroma 564
287. Gyroma Magnified 565
288. Endothelioma (Jones) .566
289. Ovary with many Dropsical Follicles . 568
290. Bilateral Oligocystic Ovarian Tumor . 568
291. Eokitanski's Tumor '
292. Ovaries with Pedunculated Cysts - 570
293. Epithelial Pouches on the inside of a Glandular Ovarian Cystoma .... 571
294. Melting of Epithelial Cells by which the nucleus is set free and fluid formed 572
295. Small Glandular Ovarian Cystoma, with beginning absorption of partition
between two cysts
296. Large Glandular Ovarian Cystoma, with numerous secondary cysts and
remnants of absorbed partitions
297. Enormous Glandular Cystoma
298. Congenital Ovarian Cystoma
299. Excrescence on outer surface of Glandular Cystoma .
300-313. Form-elements in Ovarian Cyst-fluid
300. Red Blood-corpuscles
301. Epithelial Cells
302. Bennett's Large Corpuscles, or Nunn's Gorged Corpuscles .
303. Colloid Corpuscles '.
304. Horn Cells r> ~ 8
728 ILL USTRA TIONS.
FIG. PAGE
305. Proliferating Cells 578
306. Ameboid Bodies 578
307. Large Bennett Corpuscles with Ameboid Movement 578
308. Bennett's Small Corpuscles, or Drysdale's Corpuscles 578
309. Cells with Nucleus and Fine Dark Granules 578
310. Flake of Epithelium, the cells melting and setting the nucleus free .... 578
311. Fat-granules 579
312. Spindle-cells from Myxofibromatous Ovarian Cyst 579
313. Cholesterin 579
314. Papillary Ovarian Cyst 579
315. Superficial Papillomas on both Ovaries 580
316. Dermoid Ovarian Cyst 581
317. Facies Ovariana 591
318. Percussion in Ascites and Ovarian Cyst . 599
319. Warren's Ovariotomy Trocar ' 605
320. Emmet's Ovariotomy Trocar 612
321. N61aton's Cyst-forceps 612
322. Spencer Wells's Pedicle-forceps 613
323. Smith's Cautery-clamp 613
324. Puncturing Pelvic Dilator 624
325. Blunt Expanding Pelvic Dilator ' 624
326. Wallich's Chain-ligature 625
327. Marcy's Method of Ligating Pedicle 626
328. Carcinoma of Ovary 640
329. Patient with Carcinoma of Ovary 640
PELVIS.
330. Diagram of the Structures in and adjacent to the Broad Ligament .... 646
331. Frost's Vaginal Syringe 673
332. Abbe's Intestinal Anastomosis 689
333. Maunsell's Intestinal Invagination 689
334. Murphy's Button 690
335. Eunning Suture placed in End of Bowel 691
I
PUBLISHED BY
<M
1 W.
2 r Walnut
MR. SAUNDERS, in presenting to the profession the fol-
lowing list of publications, begs to state that the aim
has been to make them worthy of the confidence of
medical book-buyers by the high standard of authorship
and by the excellence of typography, paper, printing,
and binding.
The works indicated in the Index (see next page) with
an asterisk (*) are sold by subscription (not by booksellers),
usually through travelling solicitors, but they can be ob-
tained direct from the office of publication (charges of ship-
ment prepaid) by remitting the quoted prices. Full descrip-
tive circulars of such works will be sent to any address upon
application.
All the other books advertised in this catalogue arc
commonly for sale by booksellers in all parts of the United
States; but any book will be sent by the publisher to any
address (post-paid) on receipt of the price herein given.
CONTENTS.
Anatomy. PAGE
Haynes, Manual of Anatomy 24
Nancrede, Anatomy and Manual of Dissection . 16
Nancrede, Essentials of Anatomy 26
Bacteriology.
Ball, Essentials of Bacteriology 26
Crookshank, A Text-Book of Bacteriology ... 13
Frothingliam, Laboratory Guide 20
.McFarland, Text-Book of Pathogenic Bacteria . 15
Botany.
Bastin, Laboratory Exercises in Botany 20
Chemistry and Physics.
Brockway, Essentials of Physics 26
Wolff, Essentials of Chemistry 26
Children.
*An American Text- Book of Diseases of Children 8
Griffith, Care of the Baby 21
Powell. Essentials of Diseases of Children ... 26
Clinical Charts, Diet, and Diet Lists.
Hart, Diet in Sickness and in Health 22
Keen, Operation Blank 19
Lain6, Temperature Chart 16
Meigs, Feeding in Early Infancy 14
Starr, Diets for Infants and Children 22
Thomas, Detachable Diet Lists, etc 22
Diagnosis.
Cohen and Eshner. Essentials of Diagnosis ... 26
MacDonald, Surgical Diagnosis and Treatment . 29
Vierordt and Stuart. Medical Diagnosis .... 10
Corwin, Essentials of the Physical Diagnosis of
the Thorax 18
Dictionaries,
Keating and Hamilton, New Pronouncing Dic-
tionary of Medicine 10
Morten, Nurses' Dictionary of Medical Terms . 22
Saunders' Pocket Medical Lexicon 17
Ear.
Gleason, Essentials of Diseases of the Ear ... 26
Electricity.
Stewart and Lawrance, Essentials of Medical
Electricity '26
Embryology.
Heisler, Text-Book of Embryology 29
Eye, Nose, and Throat.
De Schweinitz, Diseases of the Eye ...... 14
Jackson and Gleason, Essentials of Diseases of
Eye, Nose, and Throat 26
Kyle, Manual of Diseases of Nose and Throat . . 24
Genito-uriiiary.
Hyde, Syphilis and the Venereal Diseases ... 24
Martin, Essentials of Minor Surgery, Bandaging,
and Venereal Diseases 26
Saundby, Renal and Urinary Diseases 27
Gynecology.
*An American Text-Book of Gynecology .... 9
Cragin, Essentials of Gynecology 26
Garrigues, Diseases of Women Ib
Long, Syllabus ol Gynecology 19
Histology.
Clarkson, Text-Book of Histology 15
Life Insurance.
Keating, How to Examine for Life Insurance . . 21
Materia Medica and Therapeutics.
*An American Text Book of Applied Therapeu-
tics 4
Butler, Text-Book of Materia Medica, Therapeu-
tics, and Pharmacology 27
Cerna, Notes on the Newer Remedies 17
Griffin, Manual of Materia Medica and Therapeu-
tics 24
Morris. Essentials of Materia Medica, etc. ... 26
2
PAGE
Saunders' Pocket Medical Formulary 17
Stevens, Manual of Therapeutics 17
Thornton, Dose-Book and Prescription- Writing . 24
Warren, Surgical Pathology and Therapeutics . 11
Medical Jurisprudence.
Chapman, Medical Jurisprudence and Toxi-
cology 24
Semple, Essentials of Legal Medicine, etc. ... 26
Medicine.
*An American Text-Book of Practice 7
*Gould and Pyle, Anomalies and Curiosities of
Medicine 28
Lockwood, Manual of the Practice of Medicine 24
Morris, Essentials of the Practice of Medicine . 26
Saunders' American Year-Book of Medicine and
Surgery 30
Stevens, Manual of the Practice of Medicine . . 16
Nervous Diseases and Insanity.
Burr, Manual of Nervous Diseases 24
Shaw.Essentials of Nervous Diseases and Insanity 26
Nursing.
Griffith, Care of the Baby 21
Hampton, Nursing: its Principles and Practice 21
Stoney, Practical Points in Private Nursing ... 13
Obstetrics.
*An American Text-Book of Obstetrics 5
Ashton, Essentials of Obstetrics 26
Boisliniere, Obstetric Accidents 20
Dorland, Manual of Obstetrics 24
Norris, Syllabus of Obstetrical Lectures 19
Pathology.
Semple, Essentials of Pathology and Morbid
Anatomy 26
Senn, Pathology and Surgical Treatment of
Tumors ; 11
Stengel, Manual of Pathology 24
Warren, Surgical Pathology and Therapeutics . 11
Pharmacy.
Sayre, Essentials of Pharmacy 26
Physiology.
*An American Text-Book of Physiology .... 3
Hare, Essentials of Physiology 26
Raymond, Manual of Physiology 24
Stewart, A Manual of Physiology 15
Skiagraphy.
Rowland, Archives of Clinical Skiagraphy ...
Skin.
*Pictorial Atlas of Skin Diseases ........
Stelwagon, Essentials of Diseases of the Skin . .
Surgery.
*An American Text-Book of Surgery ......
Beck, Surgical Asepsis ..............
DaCosta, Manual of Surgery ...........
Keen, Operation Blank .............
MacDonald, Surgical Diagnosis and Treatment .
Martin, Essentials of Surgery ..........
Martin, Essentials of Minor Surgery, etc .....
Pye, Elementary Bandaging and Surgical Dress-
ing .....................
Saunders' American Year-Book of Medicine and
Surgery ...................
Senn, Pathology and Surgical Treatment of
Tumors ...................
Senn, Syllabus of Surgery ............
Warren, Surgical Pathology and Therapeutics .
Urine.
Wolff, Essentials of Examination of Urine
12
26
Miscellaneous.
Gross, Autobiography of ............ 12
Saunders' New Aid Series of Manuals .... 23, 24
Saunders' Question Compends ........ 25, 26
Thresh, Water and Water Supplies ....... 15
CATALOGUE OF MEDICAL WORKS.
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by
WILLIAM H. HOWELL, PH. D., M. D., Professor of Physiology in the Johns
Hopkins University, Baltimore, Md. One handsome octavo volume of 1052
pages, fully illustrated. Prices: Cloth, $6.00 net; Sheep or Half-Morocco,
$7.00 net.
This work is the most notable attempt yet made in America to combine in one
volume the entire subject of Human Physiology by well-known teachers who have
given especial study to that part of the subject upon which they write. The
completed work represents the present status of the science of Physiology, par-
ticularly from the standpoint of the student of medicine and of the medical
practitioner.
American teachers of physiology have not been altogether satisfied with the
text-books at their disposal. The defects of most of the older books are that they
have not kept pace with the rapid changes in modern physiology, while few if any
of the newer books have been uniformly satisfactory in their treatment of all parts
of this many-sided science. Indeed, the literature of experimental physiology is
so great that it would seem to be almost impossible for any one teacher to keep
thoroughly informed on all topics.
The collaboration of several teachers in the preparation of an elementary text-
book of physiology is unusual, the almost invariable rule heretofore having been
for a single author to write the entire book. One of the advantages to be derived
from this collaboration method is that the more limited literature necessary for
consultation by each author has enabled him to base his elementary account upon
a comprehensive knowledge of the subject assigned to him ; another, and perhaps
the most important, advantage, is that the student gains the point of view of a
number of teachers. In a measure he reaps the same benefit as would be obtained
by following courses of instruction under different teachers. The different stand-
points assumed, and the differences in emphasis laid upon the various lines of pro-
cedure, chemical, physical, and anatomical, should give the student a better insight
into the methods of the science as it exists to-day. The work will also be found
useful to many medical practitioners who may wish to keep in touch with the
development of modern physiology.
The main divisions of the subject-matter are as follows : General Physiology of
Muscle and Nerve Secretion Chemistry of Digestion and Nutrition Movements
of the Alimentary Canal, Bladder, and Ureter Blood and Lymph Circulation
Respiration Animal Heat Central Nervous System Special Senses Special
Muscular Mechanisms Reproduction Chemistry of the Animal Body.
CONTRIBUTORS:
HENRY P. BOWDITCH, M. D.,
Professor of Physiology, Harvard Medical School.
JOHN G. CURTIS, M. D.,
Professor of Physiology, Columbia University, N. Y.
(College of Physicians and Surgeons).
HENRY H. DONALDSON, Ph.D.,
Head-Professor of Neurology, University of Chicago.
W. H. HOWELL, Ph. D., M. D.,
Professor of Physiology, Johns Hopkins University.
FREDERIC S. LEE, Ph. D.,
Adjunct Prof, of Physiology, Columbia University,
N. Y. (College of Physicians and Surgeons).
WARREN P. LOMBARD, M. D.,
Professor of Physiology, University of Michigan.
GRAHAM LUSK, Ph.D.,
Professor of Physiology, Yale Medical School.
W. T. PORTER, M. D.,
Assistant Professor of Physiology, Harvard Medical
School.
EDWARD T. REICHERT, M. D.,
Professor of Physiology, University of Pennsylvania.
HENRY SEWALL, Ph.D., M. D.,
Professor of Physiology, Medical Department, Uni-
versity of Denver.
W. B. SAUNDERS' ILLUSTRATED
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU-
TICS. For the Use of Practitioners and Students. Edited by
JAMES C. WILSON, M. D., Professor of the Practice of Medicine and of
Clinical Medicine in the Jefferson Medical College. One handsome octavo
volume of 1326 pages. Illustrated. Prices: Cloth, $7.00 net; Sheep or
Half-Morocco, $8.00 net.
The arrangement of this volume has been based, so far as possible, upon mod-
ern pathologic doctrines, beginning with the intoxications and following with
infections, diseases due to internal parasites, diseases of undetermined origin, and
finally the disorders of the several bodily systems digestive, respiratory, circu-
latory, renal, nervous, and cutaneous. It was thought proper to include also a
consideration of the disorders of pregnancy.
The list of contributors comprises the names of many who have acquired dis-
tinction as practitioners and teachers of practice, of clinical medicine, and of the
specialties.
CONTRIBUTORS:
Dr. I. E. Atkinson, Baltimore, Md.
Sanger Brown, Chicago, 111.
John B. Chapin, Philadelphia, Pa.
William C. Dabney, Charlottesville, Va.
John Chalmers DaCosta, Phila., Pa.
I. N. Danforth, Chicago, 111.
John L. Dawson, Jr., Charleston, S. C.
F. X. Dercum, Philadelphia, Pa.
George Dock, Ann Arbor, Mich.
Robert T. Edes, Jamaica Plain, Mass.
Augustus A. Eshner, Philadelphia, Pa.
J. T. Eskridge, Denver, Col.
F. Forchheimer, Cincinnati, O.
Carl Frese, Philadelphia, Pa.
Edwin E. Graham, Philadelphia, Pa.
John Guiteras, Philadelphia, Pa.
Frederick P. Henry, Philadelphia, Pa.
Guy Hinsdale, Philadelphia, Pa.
Orville Horwitz, Philadelphia, Pa.
W. W. Johnston, Washington, D. C.
Ernest Laplace, Philadelphia, Pa.
A. Laveran, Paris, France.
Dr. James Hendrie Lloyd, Phila., Pa.
John Noland Mackenzie, Bait., Md.
J. W. McLaughlin, Austin, Texas.
A. Lawrence Mason, Boston, Mass.
Charles K. Mills, Philadelphia, Pa.
John K. Mitchell, Philadelphia, Pa.
W. P. Northrup, New York City.
\Villiam Osier, Baltimore, Md.
Frederick A. Packard, Phila., Pa.
Theophilus Parvin, Philadelphia, Pa.
Beaven Rake, London, England.
E. O. Shakespeare, Philadelphia, Pa.
Wharton Sinkler, Philadelphia, Pa.
Louis Starr, Philadelphia, Pa.
Henry W. Stelwagon, Phila., Pa.
James Stewart, Montreal, Canada.
Charles G. Stockton, Buffalo, N. Y.
James Tyson, Philadelphia, Pa.
Victor C. Vaughan, Ann Arbor, Mich.
James T. Whittaker, Cincinnati, O.
J. C. Wilson, Philadelphia, Pa.
The articles, with two exceptions, are the contributions of American writers.
Written from the standpoint of the practitioner, the aim of the work is to facili-
tate the application of knowledge to the prevention, the cure, and the alleviation
of disease. The endeavor throughout has been to conform to the title of the
book Applied Therapeutics to indicate the course of treatment to be pursued
at the bedside, rather than to name a list of drugs that have been used at one
time or another.
While the scientific superiority and the practical desirability of the metric
system of weights and measures is admitted, it has not been deemed best to
discard entirely the older system of figures, so that both sets have been given
where occasion demanded.
CATALOGUE OF MEDICAL WORKS.
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by RICH-
ARD C. NORRIS, M. D.; Art Editor, ROBERT L. DICKINSON, M. D. One
handsome octavo volume of over 1000 pages, with nearly 900 colored and
half-tone illustrations. Prices : Cloth, $7.00 ; Sheep or Half-Morocco, $8.00.
The advent of each successive volume of the series of the AMERICAN TEXT-
BOOKS has been signalized by the most flattering comment from both the Press and
the Profession. The high consideration received by these text-books, and their
attainment to an authoritative position in current medical literature, have been
matters of deep international interest, which finds its fullest expression in the
demand for these publications from all parts of the civilized world.
In the preparation of the "AMERICAN TEXT-BOOK OF OBSTETRICS " the editor
has called to his aid proficient collaborators whose professional prominence entitles
them to recognition, and whose disquisitions exemplify Practical Obstetrics.
While these writers were each assigned special themes for discussion, the correla-
tion of the subject-matter is, nevertheless, such as ensures logical connection in
treatment, the deductions of which thoroughly represent the latest advances in the
science, and which elucidate the best modern methods of procedure.
The more conspicuous feature of the treatise is its wealth of illustrative matter.
The production of the illustrations' had been in progress for several years, under
the personal supervision of Robert L. Dickinson, M. D., to whose artistic judg-
ment and professional experience is due the most sumptuously illustrated
work of the period. By means of the photographic art, combined with the
skill of the artist and draughtsman, conventional illustration is superseded by
rational methods of delineation.
Furthermore, the volume is a revelation as to the possibilities that may be
reached in mechanical execution, through the unsparing hand of its publisher.
CONTRIBUTORS:
Dr. James C. Cameron.
Edward P. Davis.
Robert L. Dickinson.
Charles Warrington Earle.
James H. Etheridge.
Barton Cooke Hirst.
Henry J. Garrigu.es.
Charles Jewett.
Dr. Howard A. Kelly.
Richard C. Norris.
Chauncey D. Palmer.
Theophilus Parvin.
George A. Piersol.
Edward Reynolds.
Henry Schwarz.
" At first glance we are overwhelmed by the magnitude of this work in several respects, viz. ;
Fir?t. by the size of the volume, then by the array of eminent teachers in this department who have
taken part in its production, then by the profuseness and character of the illustrations, and last, but
not least, the conciseness and clearness with which the text is rendered. This is an entirely new
composition, embodying the highest knowledge of the art as it stands to-day by authors who occupy
the front rank in their specialty, and there are many of them. We cannot turn over these pages
without being struck by the superb illustrations which adorn so many of them. We are confident
that this most practical work will find instant appreciation by practitioners as well as students. "-
New York Medical Times.
Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical
work that I have ever seen. I congratulate you and thank you for this superb work, which alone is
sufficient to place you first in the ranks of medical publishers.
With profound respect I am sincerely yours,
ALEX. J. C. SKENE.
W. B. SAUNDERS 1 ILLUSTRATED
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF SURGERY. Edited by WIL-
LIAM W. KEEN, M. D., LL.D., and J. WILLIAM WHITE, M. D., PH. D.
Forming one handsome royal-octavo volume of 1250 pages (10x7 inches),
with 500 wood-cuts in text, and 37 colored and half-tone plates, many of
them engraved from original photographs and drawings furnished by the
authors. Prices : Cloth, $7.00 ; Sheep or Half- Morocco, $8.00 net.
SECOND EDITION, REVISED AND ENLARGED,
With a Section devoted to "The Use of the Rbntgen Rays in Surgery."
The want of a text-book which could be used by the practitioner and at the
same time be recommended to the medical student has been deeply felt, especially
by teachers of surgery ; hence, when it was sug-
gested to a number of these that it would be
well to unite in preparing a text-book of this
description, great unanimity of opinion was
found to exist, and the gentlemen below named
gladly consented to join in its production.
Especial prominence has been given to Surg-
ical Bacteriology, a feature which is believed to
be unique in a surgical text-book in the English
language. Asepsis and Antisepsis have received
particular attention. The text is brought well
up to date in such important branches as cere-
bral, spinal, intestinal, and pelvic surgery, the
most important and newest operations in these
departments being described and illustrated.
The text of the entire book has been sub-
mitted to all the authors for their mutual criti-
cism and revision an idea in book-making
that is entirely new and original. The book as
a whole, therefore, expresses on all the im-
portant surgical topics of the day the consensus
of opinion of the eminent surgeons who have joined in its preparation.
One of the most attractive features of the book is its illustrations. Very many
of them are original and faithful reproductions of photographs taken directly from
patients or from specimens, and the modern improvements in the art of engraving
have enabled the publisher to produce illustrations which it is believed are superior
to those in any similar work.
CONTRIBUTORS:
Specimen Illustration (largely reduced).
Dr. Charles H. Burnett, Philadelphia.
Phineas S. Conner, Cincinnati.
Frederic S. Dennis, New York.
William W. Keen, Philadelphia.
Charles B. Nancrede, Ann Arbor, Mich.
Roswell Park, Buffalo, N. Y.
Lewis S. Pilcher, Brooklyn, N. Y.
Dr. Nicholas Senn, Chicago.
Francis J. Shepherd, Montreal, Canada.
Lewis A. Stimson, New York.
William Thomson, Philadelphia.
J. Collins Warren, Boston.
J. William White, Philadelphia.
" If this text-book is a fair reHex of the present position of American surgery, we must admit
it is of a very high order of merit, and that English surgeons will have to look very carefully to
their laurels if they are to preserve a position in the van of surgical practice." London Lancet.
" The soundness of the teachings contained in this work needs no stronger guarantee than is
afforded by the names of its authors." Meiical News, Philadelphia.
CATALOGUE OF MEDICAL WORKS.
For Sale by Subscription.
AN AMERICAN TEXT-BOOK ON THE THEORY AND
PRACTICE OF MEDICINE. By American Teachers. Edited
by WILLIAM PEPPER, M. D., LL.D., Provost and Professor of the Theory
and Practice of Medicine and of Clinical Medicine in the University of
Pennsylvania. Complete in two handsome royal-octavo volumes of about
1000 pages each, with illustrations to elucidate the text wherever necessary.
Price per Volume: Cloth, $5.00 net ; Sheep or Half- Morocco, 6.00 net.
VOLUME I. CONTAINS:
Hygiene. Fevers (Ephemeral, Simple Con- \ Hydrophobia, Trichinosis, Actinomycosis, Glan-
tinued, Typhus, Typhoid, Epidemic Cerebro- ders, and Tetanus. Tuberculosis, Scrofula,
:>inal Meningitis, and Relapsing). Scarlatina, Syphilis, Diphtheria, Erysipelas, Malaria, Choi-
Measles, Rotheln, Variola, Varioloid, Vaccinia, j era, and Yellow Fever. Nervous, Muscular, and
Varicella, Mumps, \Vhooping-cough, Anthrax, i Mental Diseases.
VOLUME II. CONTAINS;
Urine (Chemistry and Microscopy). Kidney Liver, and Pancreas. Diathetic Diseases (Rheu-
ittd Lungs. Air-passages (Larynx and Bronchi) . matism, Rheumatoid Arthritis, Gout, Lithaemia
and Pleura. Pharynx, CEsophagus, Stomach and Diabetes). Blood and Spleen. Infiamma
and Intestines (including Intestinal Parasites), tion, Embolism, Thrombosis, Fever, and Bacte
Heart, Aorta, Arteries and Veins. Peritoneum, riology.
The articles are not written as though addressed to students in lectures, but are
exhaustive descriptions of diseases, with the newest facts as regards Causation,
Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number
of approved formulae. The recent advances made in the study of the bacterial
origin of various diseases are fully described, as well as the bearing of the know-
ledge so gained upon prevention and cure. The subjects of Bacteriology as a
whole and of Immunity are fully considered in a separate section.
Methods of diagnosis are given the most minute and careful attention, thus
enabling the reader to learn the very latest methods of investigation without con
suiting works specially devoted to the subject.
CONTRIBUTORS:
Dr. J. S. Billings, Philadelphia.
Francis Delafield, New York.
Reginald H. Fitz, Boston.
James W. Holland, Philadelphia.
Henry M. Lyman, Chicago.
William Osier, Baltimore.'
Dr. William Pepper, Philadelphia.
W. Oilman Thompson, New York.
W. H. Welch, Baltimore.
James T. Whittaker. Cincinnati.
James C. Wilson, Philadelphia.
Horatio C. Wood, Philadelphia.
" We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best text-
!x>oks on the practice of medicine which we possess.' A consideration of the second and last
volume leads us to modify that verdict and to say that the completed work is, in our opinion, the
BEST of its kind it has ever been our fortune to see. It is complete, thorough, accurate, and clear.
It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of
what the modern text-book should be." New York Medical Journal.
" A library upon modern medical art. The work must promote the wider diffusion of sound
knowledge." American Lancet.
." A trusty counsellor for the practitioner or senior student, on wh : ch he may implicitly rely."
Edinburgh Medical Journal.
W. B. SAUNDERS ILLUSTRATED
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL-
DREN. By American Teachers. Edited by Louis STARR, M. D. f
assisted by THOMPSON S. WESTCOTT, M. D. In one handsome royal-8vo vol
umeof 1190 pages, profusely illustrated with wood-cuts, half-tone and colored
plates. Prices: Cloth, $7.00 net; Sheep or Half-Morocco, $8.00 net.
The plan of this work embraces a series of original articles written by some
sixty well-known podiatrists, representing collectively the teachings of the most
prominent medical schools and colleges of America. The work is intended to be
a PRACTICAL book, suitable for constant and handy reference by the practitioner
and the advanced student.
One decided innovation is the large number of authors, nearly every article
being contributed by a specialist in the line on which he writes. This, while
entailing considerable labor upon the editors, has resulted in the publication of a
WOrk THOROUGHLY NEW AND ABREAST OF THE TIMES.
Especial attention has been given to the consideration of the latest accepted
teaching upon the etiology, symptoms, pathology, diagnosis, and treatment of the
disorders of children, with the introduction of many special formulas and thera-
peutic procedures.
Special chapters embrace at unusual length the Diseases of the Eye, Ear, Nose
and Throat, and the Skin ; while the introductory chapters cover fully the important
subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of Food. Trache-
otomy, Intubation, Circumcision, and such minor surgical procedures coming
within the province of the medical practitioner, are carefully considered.
CONTRIBUTORS:
Dr. S. S. Adams, Washington.
John Ashhurst, Jr., Philadelphia.
A. D. Blackader, Montreal, Canada.
Dillon Brown, New York.
Edward M. Buckingham, Boston.
Charles W. Burr, Philadelphia.
W. E. Casselberry, Chicago.
Henry Dwight Chapin, New York.
W. S. Christopher, Chicago.
Archibald Church, Chicago.
Floyd M. Crandall, New York.
Andrew F. Currier, New York.
Roland G. Curtin, Philadelphia.
J. M. DaCosta, Philadelphia.
I. N. Danforth, Chicago.
Edward P. Davis, Philadelphia.
John B. Deaver, Philadelphia.
G. E. de Schweinitz, Philadelphia.
John Doming, New York.
Charles Warrington Earle, Chicago.
Wm. A. Edwards, San Diego, Cal.
F. Forchheimer, Cincinnati.
J. Henry Fruitnight, New York.
London Carter Gray, New York.
J. P. Crozer Griffith, Philadelphia.
W. A. Hardaway, St. Louis.
M. P. Hatfield, Chicago.
Barton Cooke Hirst, Philadelphia.
H. Illoway, Cincinnati.
Henry Jackson, Boston.
Charles G. Jennings, Detroit.
Henry Koplik, New York.
Dr. Thomas S. Latimer, Baltimore.
Albert R. Leeds, Hoboken, N. J.
J. Hendrie Lloyd, Philadelphia.
George Roe Lockwood, New York.
Henry M. Lyman, Chicago.
Francis T. Miles, Baltimore.
Charles K. Mills, Philadelphia.
John H. Musser, Philadelphia.
Thomas R. Neilson, Philadelphia.
W. P. Northrup, New York.
William Osier, Baltimore.
Frederick A. Packard, Philadelphia.
William Pepper, Philadelphia.
Frederick Peterson, New York.
W. T. Plant, Syracuse, New York.
William M. Powell, Atlantic City.
B. Alexander Randall, Philadelphia.
Edward O. Shakespeare, Philadelphia.
F. C. Shattuck, Boston.
J. Lewis Smith, New York.
Louis Starr, Philadelphia.
M. Allen Starr, New York.
J. Madison Taylor, Philadelphia.
Charles W. Townsend, Boston.
James Tyson, Philadelphia.
W. S. Thayer, Baltimore.
Victor C. Vaughan, Ann Arbor, Mich.
Thompson S. Westcott, Philadelphia.
Henry R. Wharton, Philadelphia.
J. William White, Philadelphia.
C. Wilson, Philadelphia.
CATALOGUE OF MEDICAL WORKS.
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL
AND SURGICAL, for the use of Students and Practitioners.
Edited by J. M. BALDY, M. D. Forming a handsome royal-octavo volume,
with 360 illustrations in text and 37 colored and half-tone plates. Prices:
Cloth, $6.00 net; Sheep or Half- Morocco, $7.00 net.
In this volume all anatomical descriptions, excepting those essential to a clear
understanding of the text, have been omitted, the illustrations being largely
_ depended upon to eluci-
jj?/ / 'date the anatomy of the
parts. This work, which
is thoroughly practical in
its teachings, is intended,
as its title implies, to be
a working text-book for
physicians and students.
A clear line of treatment
has been laid down in
every case, and although
no attempt has been made
to discuss mooted points,
still the most important
of these have been noted
arid explained. The ope-
rations recommended are
fully illustrated, so that
the reader, having a pic-
ture of the procedure de-
scribed in the text under
fail to
All ex-
traneous matter and dis-
cussions have been care-
fully excluded, the attempt
being made to allow no
unnecessary details to cumber the text. The subject-matter is brought up to date
at every point, and the work is as nearly as possible the combined opinions of the
ten specialists who figure as the authors.
The work is well illustrated throughout with wood-cuts, half-tone and colored
plates, mostly selected from the authors' private collections.
his eye, cannot
grasp the idea.
Specimen Illustration.
CONTRIBUTORS:
Dr. Henry T. Byford.
John M. Baldy.
Edwin Cragin.
J. H. Etheridge.
William Goodell.
Dr. Howard A. Kelly.
Florian Krug.
E. E. Montgomery.
William R. Pryor.'
George M. Tuttle.
" The most notable contribution to gynecological literature since 1887, .... and the most com-
plete exponent of gynecology which we have. No subject seems to have been neglected and
the gynecologist and surgeon and the general practitioner, who has any desire to practise diseases
of women, will find it of practical value. In the matter of illustrations and plates the book sur
passes anything we have seen." Boston Medical and Surgical Journal.
io W. B. SAUNDERS' ILLUSTRATED
A NEW PRONOUNCING DICTIONARY OF MEDICINE, with
Phonetic Pronunciation, Accentuation, Etymology, etc. By JOHN
M. KEATING, M. D., LL.D., Fellow of the College of Physicians of Phila-
delphia ; Vice- President of the American Paediatric Society ; Ex-President
of the Association of Life Insurance Medical Directors ; Editor " Cyclopaedia
of the Diseases of Children," etc. ; and HENRY HAMILTON, Author of a "A
New Translation of Virgil's ^Eneid into English Rhyme;" Co-Author of
"Saunders' Medical Lexicon," etc. ; with the Collaboration of J. CHALMERS
DACOSTA, M. D., and FREDERICK A. PACKARD, M. D. With an Appendix,
containing Important Tables of Bacilli, Micrococci, Leucomai'nes, Ptomaines ;
Drugs and Materials used in Antiseptic Surgery ; Poisons and their Antidotes ;
Weights and Measures ; Thermometric Scales ; New Official and Unofficial
Drugs, etc. One volume of over 800 pages. Second Revised Edition.
Prices: Cloth, $5.00; Sheep or Half-Morocco, 6.00 net ; Half- Russia, $6.50
net, with Denison's Patent Ready- Reference Index ; without Patent Index,
Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net.
" I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it
to my classes."
HENRY M. LYMAN, M. D.,
Professor of Principles and Practice of Medicine, Ruth Medical College, Chicago, III.
" I am convinced that it will be a very valuable adjunct to my study-table, convenient in size
and sufficiently full for ordinary use."
C. A. LINDSLEY, M. D.,
Professor of Theory and Practice of Medicine, Medical Depl. Yale University ;
Secretary Connecticut State Board of Health, New Haven, Conn.
MEDICAL DIAGNOSIS. By Dr. OSWALD VIERORDT, Professor of Medi-
cine at the University of Heidelberg. Translated, with additions, from the
Second Enlarged German Edition, with the author's permission, by FRANCIS
H. STUART, A. M., M. D. Third and Revised Edition. In one handsome
royal-octavo volume of 700 pages, 1 78 fine wood-cuts in text, many of which
are in colors. Prices: Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net;
Half- Russia, $5.50 net.
In this work, as in no other hitherto published, are given full and accurate
explanations of the phenomena observed at the bedside. It is distinctly a clinical
work by a master teacher, characterized by thoroughness, fulness, and accuracy.
It is a mine of information upon the points that are so often passed over without
explanation. Especial attention has been given to the germ-theory as a factor in
the origin of disease.
This valuable work is now published in German, English, Russian, and Italian.
The "issue of a third American edition within two years indicates the favor with which
it has been received by the profession.
" Rarely is a book published with which a reviewer can find so little fault as with the volume
before us. All the chapters are full, and leave little to be desired by the reader. Each particular
item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of
any disease of that organ, is mentioned ; nothing seems forgotten. The chapters on diseases of the
circulatory and digestive apparatus and nervous system are especially full and valuable. Not-
withstanding a few minor errors in translating, which are of small importance to the accuracy
of the rest of the volume, the reviewer would repeat that the book is one of the best probably,
the best which has fallen into his hands. An excellent and comprehensive index of nearly one
hundred pages closes the volume." University Medical Magazine, Philadelphia.
CATALOGUE OF MEDICAL WORKS.
PATHOLOGY AND SURGICAL TREATMENT OF TUMORS.
By N. SENN, M. D., PH. D., LL. D., Professor of Surgery and of Clinical
Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ;
Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. Joseph's
Hospital, Chicago. 710 pages, 515 engravings, including full-page colored
plates. Prices: Cloth, $6.00 net ; Half-Morocco, $7.00 net.
Books specially devoted to this subject are few, and in our text-books and
systems of surgery this part of surgical pathology is usually condensed to a degree
incompatible with its scientific and clinical importance. The author spent many
years in collecting the material for this work, and has taken great pains to present
it in a manner that should prove useful as a text-book for the student, a work
of reference for the busy practitioner, and a reliable, safe guide for the surgeon.
The more difficult operations are fully described and illustrated. More than one
hundred of the illustrations are original, while the remainder were selected from
books and medical journals not readily accessible to the student and the general
practitioner.
" The appearance of such a work is most opportune. ... In design and execution the work is
such as will appeal to every student who appreciates the logical examination of facts and the prac-
tical exemplification of well-digested clinical observation." Medical Record, New York.
" The most exhaustive of any recent book in English on this subject. It is well illustrated, and
will doubtless remain as the principal monograph on the subject in our language for some years.
The book is handsomely illustrated and printed, .... and the author has given a notable and
lasting contribution to surgery." Journal of American Medical Association, Chicago.
SURGICAL PATHOLOGY AND THERAPEUTICS. By JOHN
COLLINS WARREN, M. D., LL. D., Professor of Surgery, Medical Depart-
ment Harvard University ; Surgeon to the Massachusetts General Hospital,
etc. A handsome octavo volume of 832 pages, with 136 relief and litho-
graphic illustrations, 33 of which are printed in colors, and all of which were
drawn by William J. Kaula from original specimens. Prices: Cloth, $6.00
net; Half-Morocco, $7.00 net.
" The volume is for the bedside, the amphitheatre, and the ward. It deals
with things not as we see them through the microscope alone, but as the practitioner
sees their effect in his patients ; not only as they appear in and affect culture-
media, but also as they influence the human body; and, following up the demon-
strations of the nature of diseases, the author points out their logical treatment"
{New York Medical Journal}. "Indeed, the volume maybe termed a modern
medical classic, for such is the position to which it has already risen " (Medical
Age, Detroit), " and is the handsomest specimen of bookmaking * - ; * that has
ever been issued from the American medical press" {American Journal of the
Medical Sciences, Philadelphia).
Without Exception, the Illustrations are the Best ever Seen in a Work of
this Kind.
" A most striking and very excellent feature of this book is its illustrations. Without exception,
from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind.
* * * Many of those representing microscopic pictures are so perfect in their coloring and detail as
almost to give the beholder the impression that he is looking down the barrel of a microscope at a
well-mounted section." Annals of Surgery, Philadelphia.
12 W. B. SAUNDERS' ILLUSTRATED
AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus
Professor of Surgery in the Jefferson Medical College of Philadelphia, with
Reminiscences of His Times and Contemporaries. Edited by his Sons,
SAMUEL W. GROSS, M. D., LL.D., late Professor of Principles of Surgery
and of Clinical Surgery in the Jefferson Medical College, and A. HALLER
GROSS, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross,
by the late Austin Flint, M. D., LL.D. In two handsome volumes, each con-
taining over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontis-
piece engraved on steel. Price, $5.00 net.
This autobiography, which was continued by the late eminent surgeon until
within three months before his death, contains a full and accurate history of his
early struggles, trials, and subsequent successes, told in a singularly interesting
and charming manner, and embraces short and graphic pen-portraits of many of
the most distinguished men surgeons, physicians, divines, lawyers, statesmen,
scientists, etc. with whom he was brought in contact in America and in Europe ;
the whole forming a retrospect of more than three-quarters of a century.
" Dr. Gross . . . was perhaps the most eminent exponent of medical science that America has yet
produced. His Autobiography, related as it is with a fulness and completeness seldom to be found
in such works, is an interesting and valuable book. He comments on many things, especially, of
course, on MEDICAL MEN AND MEDICAL PRACTICE, in a very interesting way. Details of profes-
sional life have also much in them that will be new." The Spectator, London, England.
THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPH-
ILITIC AFFECTIONS (American Edition). Translation from the
French. Edited by J. J. PRINGLE, M. B., F. R. C. P., Assistant Physician
to, and Physician to the department for Diseases of the Skin at, the Middle-
sex Hospital, London. Photo-lithochromes from the famous models of der-
matological and syphilitic cases in the Museum of the Saint-Louis Hospital,
Paris, with explanatory wood-cuts and text. In 12 Parts, at $3.00 per Part.
Parts i to 8 now ready.
" The plates are beautifully executed." JONATHAN HUTCHINSON, M. D. (London Hospital).
"I strongly recommend this Atlas. The plates are exceedingly well executed, and will be
of great value to all studying dermatology." STEPHEN MACKENZIE, M. D. (London Hospital).
"The plates in this Atlas are remarkably accurate and artistic reproductions of typical ex-
amples of skin disease. The work will be of great value to the practitioner and student."
WILLIAM ANDERSON, M. D. (St. Thomas Hospital).
" If the succeeding parts of this Atlas are to be similar to Part I, now before us, we have no
hesitation in cordially recommending it to the favorable notice of our readers as one of the finest
dermatological atlases with which we are acquainted." Glasgow Medical Journal, Aug., 1895.
"Of all the atlases of skin diseases which have been published in recent years, the present one
promises to be of greatest interest and value, especially from the standpoint of the general practi-
tioner." American Medico- Surgical Bulletin, Feb. 22, 1896.
" The introduction of explanatory wood-cuts in the text is a novel and most important feature
which greatly furthers the easier understanding of the excellent plates, than which nothing, we ven-
ture to say, has been seen better in point of correctness, beauty, and general merit." New York
Medical Journal, Feb. 15, 1896.
" An interesting feature of the Atlas is the descriptive text, which is written for each picture by
the physician who treated the case or at whose instigation the models have been made. We pre-
dict for this truly beautiful work a large circulation in all parts of the medical world where the
names St. Louis and Baretta have preceded it." Medical Record, N. Y., Feb. I, 1896.
CATALOGUE OF MEDICAL WORKS. 13
PRACTICAL POINTS IN NURSING. For Nurses in Private
Practice. By EMILY A. M. STON T EY, Graduate of the Training-School for
Nurses, Lawrence, Mass. ; Superintendent of the Training-School for Nurses,
Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated
with 73 engravings in the text, and 9 colored and half-tone plates. Cloth.
Price, $1.75 net.
In this volume the author explains, in popular language and in the shortest
possible form, the entire range of private nursing as distinguished from hospital
nursing, and the nurse is instructed how best to meet the various emergencies of
medical and surgical cases when distant from medical or surgical aid or when
thrown on her own resources.
An especially valuable feature of the work will be found in the directions to
the nurse how to improvise everything ordinarily needed in the sick-room, where
the embarrassment of the nurse, owing to the want of proper appliances, is fre-
quently extreme.
The work has been logically divided into the following sections :
I. The Nurse : her responsibilities, qualifications, equipment, etc.
II. The Sick-Room : its selection, preparation, and management.
III. The Patient : duties of the nurse in medical, surgical, obstetric, and gyne-
cologic cases.
IV. Nursing in Accidents and Emergencies.
V. Nursing in Special Medical Cases.
VI. Nursing of the New-born and Sick Children.
VII. Physiology and Descriptive Anatomy.
The APPENDIX contains much information in compact form that will be found
of great value to the nurse, including Rules for Feeding the Sick ; Recipes for
Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for Com-
puting the Date of Labor ; List of Abbreviations ; Dose-List ; and a full and com-
plete Glossary of Medical Terms and Nursing Treatment.
" There are few books intended for non-professional readers which can be so cordially endorsed
by a medical journal as can this one.'' Therapeutic Gazette, Aug. 15, 1896.
" This is a well-written, eminently practical volume, which covers the entire range of private
nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various
emergencies which may arise and how to prepare everything ordinarily needed in the illness of her
patient." American Journal of Obstetrics and Diseases of Women and Children, Aug., 1896.
" It is a work that the physician can place in the hands of his private nurses with the assurance
of benefit." Ohio Medical Journal, Aug., 1896.
A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and
Prevention of Infective Diseases and an account of Yeasts and
Moulds, Haematozoa, and Psorosperms. By EDGAR M. CROOK-
SHANK, M. B., Professor of Comparative Pathology and Bacteriology, King's
College, London. A handsome octavo volume of 700 pages, illustrated with
273 engravings in the text, and 22 original and colored plates. Price,
$6.50 net.
This book, though nominally a Fourth Edition of Professor Crookshank's
"MANUAL OF BACTERIOLOGY," is practically a new work, the old one having
been reconstructed, greatly enlarged, revised' throughout, and largely rewritten,
forming a text-book for the Bacteriological Laboratory, for Medical Officers
of Health, and for Veterinary Inspectors.
W. B. SAUNDERS' ILLUSTRATED
DISEASES OF THE EYE. A Hand-Book of Ophthalmic Practice.
By G. E. DE SCHWEINITZ, M. D., Professor of Ophthalmology in the Jeffer-
son Medical College, Philadelphia, etc. A handsome royal-octavo volume
of 679 pages, with 256 fine illustrations, many of which are original, and 2
chromo-lithographic plates. Prices: Cloth, $4.00 net; Sheep or Half-
Morocco, $5.00 net.
The object of this work is to present to the student, and to the practitioner who
is beginning work in the fields of ophthal-
mology, a plain description of the optical
defects and diseases of the eye. To this
end special attention has been paid to the
clinical side of the question ; and the
method of examination, the symptoma-
tology leading to a diagnosis, and the
treatment of the various ocular defects
have been brought into prominence.
SECOND EDITION, REVISED AND
GREATLY ENLARGED.
The entire book has been thoroughly
specimen illustration. revised. In addition to this general re-
vision, special paragraphs on the following
new matter have been introduced : Filamentous Keratitis, Blood-staining of the
Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis,
Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies in the
Papilla, Monocular Diplopia, Subconjunctival Injections of Germicides, Infiltra-
tion-Anaesthesia, and Sterilization of Collyria. Brief mention of Ophthalmia
Nodosa, Electric Ophthalmia, and Angioid Streaks in the Retina also finds place.
An Appendix has been added, containing a full description of the method of deter-
mining the corneal astigmatism with the ophthalmometer of Javal and Schiotz,
and the rotations of the eyes with the tropometer of Stevens. The chapter on
Operations has been enlarged and rewritten.
"A clearly written, comprehensive manual. . . . One which we can commend to students as a
reliable text-book, written with an evident knowledge of the wants of those entering upon the study
of this special branch of medical science." British Medical Journal.
" The work is characterized by a lucidity of expression which leaves the reader in no doubt as
to the meaning of the language employed. . . . \Ve know of no work in which these diseases are
dealt with more satisfactorily, and indications for treatment more clearly given, and in harmony with
the practice of the most advanced ophthalmologists." Maritime Medical News.
" It is hardly too much to say that for the student and practitioner beginning the study of
Ophthalmology, it is the best single volume at present published." Medical News.
" The latest and one of the best books on Ophthalmology. The book is thoroughly up to date,
and is certainly a work which not only commends itself to the student, but is a ready reference for
the busy practitioner." International Medical Magazine.
FEEDING IN EARLY INFANCY. By ARTHUR V. MEIGS, M. D.
Bound in limp cloth, flush edges. Price, 25 cents net.
SYNOPSIS: Analyses of Milk Importance of the Subject of Feeding in Earlj
Infancy Proportion of Casein and Sugar in Human Milk Time to Begin Arti-
ficial Feeding of Infants Amount of Food to be Administered at Each Feeding
Intervals between Feedings Increase in Amount of Food at Different Periods of
Infant Development Umuitableness of Condensed Milk as a Substitute for Moth-
er's Milk Objections to Sterilization or "Pasteurization" of Milk Advances
made in the Method of Artificial Feeding of Infants.'
CATALOGUE OF MEDICAL WORKS. 15
A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC-
TICAL. For the Use of Students. By ARTHUR CLARKSOX, M. B.,
C. M., Edin., formerly Demonstrator of Physiology in the Owen's College,
Manchester; late Demonstrator of Physiology in the Yorkshire College,
Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174
beautifully colored original illustrations. Price, strongly bound in Cloth,
$6.00 net.
The purpose of the writer in this work has been to furnish the student of His-
tology, in one volume, with both the descriptive and the practical part of the
science. The first two chapters are devoted to the consideration of the general
methods of Histology ; subsequently, in each chapter, the structure of the tissue
or organ is first systematically described, the student is then taken tutorially over
the specimens illustrating it, and, finally, an appendix affords a short note of the
methods of preparation.
TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe-
cially written for Students of Medicine. By JOSEPH MCFARLAXD,
M. D,, Professor of Pathology and Bacteriology in the Medico-Chirurgical
College of Philadelphia, etc. 359 pages, finely illustrated. Cloth. Price,
$2.50 net.
The book presents a concise account of the technical procedures necessary in
the study of Bacteriology. It describes the life-history of pathogenic bacteria, and
the pathological lesions following invasions.
The work is intended to be a text-book for the medical student and for the
practitioner who has had no recent laboratory training in this department of med-
ical science. The instructions given as to needed apparatus, cultures, stainings,
microscopic examinations, etc. are ample for the student's needs, and will afford
to the physician much information that will interest and profit him.
" The author has succeeded admirably in presenting the essential details of bacteriological
technics, together with a judiciously chosen summary of our present knowledge of pathogenic bac-
teria. . . . The work, we think, should have a wide circulation among English-speaking students
of medicine." N. Y. Medical Journal, April 4, 1896.
A MANUAL OF PHYSIOLOGY, with Practical Exercises. For
Students and Practitioners. By G. N. STEWART, M. A., M. D., D. Sc.,
lately Examiner in Physiology, University of Aberdeen, and of the Xew
Museums, Cambridge University; Professor of Physiology in the Western
Reserve University, Cleveland, Ohio. Handsome octavo volume of Soc
pages, with 278 illustrations in the text, and 5 colored plates. Price,
Cloth, $3.50 net.
" It will make its way by sheer force of merit, and amply deserves to do so. It is one of the
very best English text-books on the subject." Lancet.
"Of the many text-books of physiology published, we do not know of one that so nearly
comes up to the ideal as does Prof. Stewart's volume." British Medical Journal.
WATER AND WATER SUPPLIES. By JOHN C. THRESH, D. Sc.,
M. B., D. P. H., Lecturer on Public Health, King's College, London;
Editor of the "Journal of State Medicine," etc. i2mo, 438 pages, illus-
trated. Handsomely bound in Cloth, with gold side and back stamps
Price, $2.25 net.
16 W. B. SAUNDERS' ILLUSTRATED
ARCHIVES OF CLINICAL SKIAGRAPHY. By SYDNEY ROWLAND,
B. A., Camb., late Scholar of Downing College, Cambridge, and Shuter
Scholar of St. Bartholomew's Hospital, London ; Special Commissioner to
"British Medical Journal" for the Investigation of the Applications of the
New Photography to Medicine and Surgery. A series of collotype illustra-
tions, with descriptive text, illustrating the applications of the New Photog-
raphy to Medicine and Surgery. Price, per Part, 1.00. Parts I. to III.
now ready.
The object of this publication is to put on record in permanent form some of
the most striking applications of the new photography to the needs of Medicine
and Surgery.
The progress of this new art has been so rapid that, although Prof. Rontgen's
discovery is only a thing of yesterday, it has already taken its place among the
approved and accepted aids to diagnosis.
ESSENTIALS OF ANATOMY AND MANUAL OF PRACTICAL
DISSECTION, containing "Hints on Dissection." By CHARLES B.
NANCREDE, M. D., Professor of Surgery and Clinical Surgery in- the Uni-
versity of Michigan, Ann Arbor; Corresponding Member of the Royal
Academy of Medicine, Rome, Italy; late Surgeon Jefferson Medical Col-
lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with
handsome full-page lithographic plates in colors, and over 200 illustrations.
Price : Extra Cloth (or Oilcloth for the dissection-room), $2.00 net.
No pains nor expense has been spared to make this work the most exhaustive
yet concise Student's Manual of Anatomy and Dissection ever published, either in
America or in Europe. The colored plates are designed to aid the student in
dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been
specially drawn and engraved, and an Appendix added containing 60 illustrations
representing the structure of the entire human skeleton, the whole being based
on the eleventh edition of Gray's Anatomy.
A MANUAL OF PRACTICE OF MEDICINE. By A. A. STEVENS,
A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsyl-
vania, and Demonstrator of Pathology in the Woman's Medical College of
Philadelphia. Specially intended for students preparing for graduation and
hospital examinations. Post 8vo, 512 pages. Illustrated. Price, $2.50.
FOURTH EDITION, REVISED AND ENLARGED.
Contributions to the science of medicine have poured in so rapidly during the
last quarter of a century that it is well-nigh impossible for the student, with the
limited time at his disposal, to master elaborate treatises or to cull from them that
knowledge which is absolutely essential. From an extended experience in teach-
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TEMPERATURE CHART. Prepared by D. T. LAINE, M. D. Size
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method of Brand in the treatment of Typhoid Fever.
CATALOGUE OF MEDICAL WORKS.
MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By
A. A. STEVENS, A. M., M. D., Instructor of Physical Diagnosis in the Uni-
versity of Pennsylvania, and Demonstrator of Pathology in the Woman's
Medical College of Philadelphia. 445 pages. Price, Cloth, $2.25.
SECOND EDITION, REVISED.
This wholly new volume, which is based on the last edition of the Pharma-
copoeia, comprehends the following sections : Physiological Action of Drugs ;
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eases ; the treatment being elucidated by more than two hundred formulae.
NOTES ON THE NEWER REMEDIES: their Therapeutic Appli-
cations and Modes of Administration. By DAVID CERNA, M.D., PH.D.,
Demonstrator of and Lecturer on Experimental Therapeutics in the Univer-
sity of Pennsylvania. Post 8vo, 253 pages. Price, $1.25.
SECOND EDITION, RE- WRITTEN AND GREATLY ENLARGED.
The work takes up in alphabetical order all the newer remedies, giving their
physical properties, solubility, therapeutic applications, administration, and chem-
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SAUNDERS' POCKET MEDICAL FORMULARY. BY WILLIAM
M. POWELL, M. D., Attending Physician to the Mercer House for Invalid
Women at Atlantic City. Containing 1750 Formulae, selected from several
hundred of the best-known authorities. Forming a handsome and convenient
pocket companion of nearly 300 printed pages, with blank leaves for additions;
with an Appendix containing Posological Table, Formulae and Doses for
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Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Dis-
eases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia
from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive
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unusually reliable." New York Medical Record.
SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of
Terms and Words used in Medicine and Surgery. By JOHN M.
KEATING, M. D., Editor of "Cyclopaedia of Diseases of Children," etc. ;
Author of the "New Pronouncing Dictionary of Medicine," and HENRY
HAMILTON, Author of "A New Translation of Virgil's ^Eneid into English
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W. B. SAUNDERS" ILLUSTRATED
DISEASES OF WOMEN. By HENRY J. GARRIGUES, A. M., M. D., Pro-
fessor of Obstetrics in the New York Post- Graduate Medical School and Hos-
pital ; Gynaecologist to St. Mark's Hospital, and to the German Dispensary,
etc., New York City. One octavo volume of nearly 700 pages, illustrated
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A PRACTICAL work on gynaecology for the use of students and practitioners,
written in a terse and concise manner. The importance of a thorough knowledge
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author, and considerable space has been devoted to the subject. The chapters on
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EXCERPT OF CONTENTS.
Development of the Female Genitals. Anatomy of the Female Pelvic Organs. Physiology.
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Diseases of the Pelvis. Sterility.
The reception accorded to this -work has been most nattering. In the
short period which has elapsed since its issue, it has been adopted and
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Universities of the United States and Canada.
" One of the best text-books for students and practitioners which has been published in the
English language ; it is condensed, clear, and comprehensive. The profound learning and great
clinical experience of the distinguished author find expression in this book in a most attractive and
instructive form. Young practitioners, to whom experienced consultants may not be available, will
find in this book invaluable counsel and help."
THAD. A. REAMY, M. D., LL.D.,
Professor of Clinical Gynecology, Medical College of Ohio ; Gynecologist to the Good
Samaritan and to the Cincinnati Hospitals.
ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THO-
RAX. By ARTHUR M. CORWIN, A. M., M. D., Demonstrator of Physical
Diagnosis in the Rush Medical College, Chicago ; Attending Physician to
the Central Free Dispensary, Department of Rhinology, Laryngology, and
Diseases of the Chest. 200 pages. Illustrated. Cloth, flexible covers.
Price, $1.25 net.
This book was originally published for the use of students, but its rapid absorp-
tion by the practitioner made it appear that a wider field had been reached. In
this edition the author has added to his revision of the text a section setting forth
the signs found in each of the diseases of the chest, thereby increasing its value to
the general practitioner for post-graduate study.
" It is excellent. The student who shall use it as his guide to the careful study of physical
exploration upon normal and abnormal subjects can scarcely fail to acquire a good working know-
ledge of the subject." Philadelphia Polyclinic.
CATALOGUE OF MEDICAL WORKS. 19
SYLLABUS OF OBSTETRICAL LECTURES in the Medical
Department, University of Pennsylvania. By RICHARD C. NORRIS,
A. M., M. D., Demonstrator of Obstetrics in the University of Pennsylvania.
Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth,
interleaved for notes, $2.00 net.
"This work is so far superior to others on the same subject that we take
pleasure in calling attention briefly to its excellent features. It covers the subject
thoroughly, and will prove invaluable both to the student and the practitioner.
The author has introduced a number of valuable hints which would only occur
to one who was himself an experienced teacher of obstetrics. The subject-matter
is clear, forcible, and modern. We are especially pleased with the portion devoted
to the practical duties of the accoucheur, care of the child, etc. The paragraphs
on antiseptics are admirable ; there is no doubtful tone in the directions given.
No details are regarded as unimportant ; no minor matters omitted. We venture
to say that even the old practitioner will find useful hints in this direction which
he cannot afford to despise." Medical Record.
A SYLLABUS OF GYNECOLOGY, arranged in conformity with
"An American Text-Book of Gynecology." By J. W. LONG, M. D.,
Professor of Diseases of Women and Children, Medical College of Virginia,
etc. Price, Cloth (interleaved), $1.00 net.
Based upon the teaching and methods laid down in the larger work, this will
not only be useful as a supplementary volume, but to those who do not already
possess the Text-Book it will also have an independent value as an aid to the prac-
titioner in gynecological work, and to the student as a guide in the lecture-room,
as the subject is presented in a manner systematic, succinct, and practical.
A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR-
GERY, arranged in conformity with "An American Text-Book
of Surgery." By NICHOLAS SENN, M. D., PH. D., Professor of Surgery in
Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00.
This excellent work of its eminent author, himself one of the contributors to
"An American Text-Book of Surgery," will prove of exceptional value to the
advanced student who has adopted that work as his text-book. It is not only the
syllabus of an unrivalled course of surgical practice, but it is also an epitome of,
or supplement to the larger work.
AN OPERATION BLANK, with Lists of Instruments, etc. re
quired in Various Operations. Prepared by W. W. KEEX, M. D.,
LL.D., Professor of Principles of Surgery in the Jefferson Medical College,
Philadelphia. Price per pad, containing Blanks for fifty operations, 50
cents net.
SECOND EDITION, REVISED FORM.
A convenient blank (suitable for all operations), giving complete instructions
regarding necessary preparation of patient, etc., with a full list of dressings and
medicines to be employed. On the back of each blank is a list of instruments
used viz. general instruments, etc., required for all operations; and special in-
struments for surgery of the brain and spine, mouth and throat, abdomen, rectum,
male and female genito-urinary organs, the bones, etc. The whole forming a neat
pad, arranged for hanging on the wall of a surgeon's office or in the hospital
operating-room.
20
W. B. SAUNDERS' ILLUSTRATED
LABORATORY EXERCISES IN BOTANY. By EDSON S. BASTIN,
M. A., Professor of Materia Medica and Botany in the Philadelphia Col-
lege of Pharmacy. Octavo volume of 536 pages, with 87 plates. Price,
Cloth, $2.50.
This work is intended for the beginner and the advanced student, and it fully
covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers,
bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross
and microscopical structure of plants, and to those used in medicine. The illus-
trations fully elucidate the text, and the complete index facilitates reference.
Trailing Arbutus (Epigea repens)
Specimen Illustration.
LABORATORY GUIDE FOR THE BACTERIOLOGIST. By
LANGDON FROTHINGHAM, M. D. V., Assistant in Bacteriology and Veterinary
Science, Sheffield Scientific School, Yale University. Illustrated. Price.
Cloth, 75 cents.
The technical methods involved in bacteria-culture, methods of staining, and
microscopical study are fully described and arranged as simply and concisely as
possible. The book is especially intended for use in laboratory work.
OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA-
TIONS. By L. CH. BOISLINIERE, M. D., late Emeritus Professor of Ob-
stetrics in the St. Louis Medical College. 381 pages, handsomely illustrated.
Price, $2.00 net.
" For the use of the practitioner who, when away from home, has not the
opportunity of consulting a library or of calling a friend in consultation. He
then, being thrown upon his own resources, will find this book of benefit in
guiding and assisting him in emergencies. >f
CA TALOGUE OF MEDICAL WORKS.
HOW TO EXAMINE FOR LIFE INSURANCE. By JOHN M.
KEATING, M. D., Fellow of the College of Physicians and Surgeons of Phila-
delphia; Vice-President of the American Poediatric Society; Ex- President
of the Association of Life Insurance Medical Directors. Royal 8vo, 211
pages, with two large half-tone illustrations, and a plate prepared by Dr.
McClellan from special dissections ; also, numerous cuts to elucidate the text.
Price, in Cloth, $2.00 net.
" This is by far the most useful book which has yet appeared on insurance examination, a sub-
ject of growing interest and importance. Not the least valuable portion of the volume is Part II.,
which consists of instructions issued to their examining physicians by twenty-four representative
companies of this country. As the proofs of these instructions were corrected by the directors of
the companies, they form the latest instructions obtainable. If for these alone the book should be
at the right hand of every physician interested in this special branch of medical science." The
Medical News, Philadelphia.
THE CARE OF THE BABY. By J. P. CROZER GRIFFITH, M. D., Clftii-
cal Professor of Diseases of Children, University of Pennsylvania ; Physician
to the Children's Hospital, Philadelphia, etc. 392 pages, with 67 illustrations
in the text, and 5 plates. i2mo. Price, $1.50.
A reliable guide not only for mothers, but also for medical students and prac-
titioners whose opportunities for observing children have been limited.
" The whole book is characterized by rare good sense, and is evidently written by a master
hand. It can be read with benefit not only by mothers, but by medical students and by any prac-
titioners who have not had large opportunities for observing children." American Joiirnal of
Obstetrics, July, 1895.
"The best book for the use of the young mother with which we are acquainted. . . . There
are very few general practitioners who could not read the book through with advantage." Archives
of Pediatrics, Aug., 1895.
" No better book of its kind has come under our notice for some time. Although intended
primarily for mothers and nurses, it will well repay perusal by medical students." Birmingham
Medical Review, Oct., 1895.
" This is one of the best works of its kind that has been presented to the people for many a
day." Maryland Medical Journal, Aug. 13, 1895.
NURSING: ITS PRINCIPLES AND PRACTICE. By ISABEL ADAMS
HAMPTON, Graduate of the New York Training School for Xurses attached to
Bellevue Hospital; Superintendent of Nurses, and Principal of the Training
School for Nurses, Johns Hopkins Hospital, Baltimore, Md. ; late Superin-
tendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one
very handsome xamo volume of 484 pages, profusely illustrated. Price,
Cloth, $2.00 net.
This original work on the important subject of nursing is at once compre-
hensive and systematic. It is written in a clear, accurate, and readable style, suit-
able alike to the student and the lay reader. Such a work has long been a deside-
ratum with those intrusted with the management of hospitals and the instruction
of nurses in training-schools. It is also of especial value to the graduate nurse
who desires to acquire a practical working knowledge of the care of the sick and
the hygiene of the sick-room.
22 W. B. SAUNDERS' ILLUSTRATED CATALOGUE.
NURSE'S DICTIONARY of Medical Terms and Nursing Treat-
ment, containing Definitions of the Principal Medical and Nursing Terms
and Abbreviations ; of the Instruments, Drugs, Diseases, Accidents, Treat-
ments, Physiological Names, Operations, Foods, Appliances, etc. encountered
in the ward or in the sick-room. Compiled for the use of nurses. By
HONNOR MORTEN, Author of "How to Become a Nurse," "Sketches of
Hospital Life," etc. i6mo, 140 pages. Price, Cloth, $1.00.
This little volume is intended merely as a small reference-book which can be
onsulted at the bedside or in the ward. It gives sufficient explanation to the
i.iirse to enable her to comprehend a case until she has leisure to look up larger
and fuller works on the subject.
DIET IN SICKNESS AND IN HEALTH. By MRS. ERNEST HART,
formerly Student of the Faculty of Medicine of Paris and of the London
School of Medicine for Women ; with an INTRODUCTION by Sir Henry
Thompson, F. R. C. S., M. D., London. 220 pages; illustrated.' Price,
Cloth, $1.50.
Useful to those who have to nurse, feed, and prescribe for the sick. ... In
each case the accepted causation of the disease and the reasons for the special
diet prescribed are briefly described. Medical men will find the dietaries and
recipes practically useful, and likely to save them trouble in directing the dietetic
treatment of patients.
" We recommend it cordially to the attention of all practitioners ; . . . . both to them and to
their patients it may be of the greatest service." Medical Journal, New York.
DIETS FOR INFANTS AND CHILDREN IN HEALTH AND IN
DISEASE. By Louis STARR, M. D., Editor of "An American Text-
Book of the Diseases of Children." 230 blanks (pocket-book size), per-
forated and neatly bound in flexible morocco. Price, $1.25 net.
The first series of blanks are prepared for the first seven months of infant life ;
each blank indicates the ingredients, but not the quantities, of the food, the latter
directions being left for the physician. After the seventh month, modifications
being less necessary, the diet lists are printed in full. Formula for the prepara-
tion of diluents and foods are appended.
DIET LISTS AND SICK-ROOM DIETARY. By JEROME B. THOMAS,
M. D., Visiting Physician to the Home for Friendless Women and Children
and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County
Hospital ; Assistant Bacteriologist, Brooklyn Health Department. Price,
$1.50. Send for sample sheet.
There is here offered, in portable form, as an efficient aid to the better practice
of Therapeutics, a collection of detachable Diet Lists and a Sick-room Dietary.
It meets a want, for the busy practitioner has but little time to write out Systems
of Diet appropriate to his patients, or to describe the preparation of their food.
Compiled from the most modern works on dietetics, the Dietary offers a variety
of easily-digested foods.
"A convenience that will be appreciated by the physician." Medical Journal, New York.
" The work is an excellent one, and ought to be welcomed by physician, patient, and nurse
alike/' Indian Lancet, Calcutta.
Practical, Exhaustive. Authoritative.
SAUNDERS'
NEW AID SERIES OF MANUALS.
FOR
STUDENTS AND PRACTITIONERS.
MR. SAUNDERS is pleased to announce the successful issue of several volumes
of his NEW AID SERIES OF MANUALS, which have received the
most flattering commendations from Students and Practitioners and
the Press. As publisher of the STANDARD SERIES OF QUESTION COMPENDS,
and through intimate relations with leading members of the medical profession,
Mr. Saunders has been enabled to study progressively the essential desiderata in
practical " self-helps " for students and physicians.
This study has manifested that, while the published "Question Compends"
earn the highest appreciation of students, whom they serve in reviewing their
studies preparatory to examination, there is special need of thoroughly reliable
handbooks on the leading branches of Medicine and Surgery, each subject being
compactly and authoritatively written, and exhaustive in detail, without the intro-
duction of cases and foreign subject-matter which so largely expand ordinary text-
books.
The Saunders Aid Series will not merely be condensations from
present literature, but will be ably written by well-known authors
and practitioners, most of them being teachers in representative
American Colleges. This new series, therefore, will form an admirable col-
lection of advanced lectures, which will be invaluable aids to students in reading
and in comprehending the contents of " recommended " works.
Each Manual will further be distinguished by the beauty of the new type ; by
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attractive binding in cloth; and by the extremely low price at which
they will be sold.
23
Saunders New Aid Series of Manual*
0.
VOLUMES PUBLISHED.
PHYSIOLOGY, by JOSEPH HOWABD RAYMOND, A. M., M. D., Professor of Physi-
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pital ; Director of Physiology in the Hoagland Laboratory ; formerly Lecturer on
Physiology and Hygiene in the Brooklyn Normal School for Physical Education;
Ex- Vice- President of the American Public Health Association ; Ex-Health Commis-
sioner, City of Brooklyn, etc. Illustrated. $1.25 net
SURGERY, General and Operative, by JOHN CHALMERS DACOSTA, M. D., Demon-
strator of Surgery, Jefferson Medical College, Philadelphia; Chief Assistant Sur-
geon, Jefferson Medical College Hospital ; Surgical Registrar, Philadelphia Hospital,
etc. 188 illustrations and 13 plates. (Double number.) $2.50 net
DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING, by E. Q.
THORNTON, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Phila-
delphia. Illustrated. Price, cloth, $1.25 net
SURGICAL ASEPSIS, by CARL BECK, M. D., Surgeon to St Mark's Hospital and
to the New York German Poliklinik, etc. Illustrated. Price, cloth, $1.25 net.
MEDICAL JURISPRUDENCE, by HENRY C. CHAPMAN, M. D., Professor of Insti-
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of
Philadelphia; Member of the College of Physicians of Philadelphia, of the Acade-
my of Natural Sciences, of the American Philosophical Society, and of the Zoologi-
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SYPHILIS AND THE VENEREAL DISEASES, by JAMES NEVINS HYDE,
M.D., Professor of Skin and Venereal Diseases, and FRANK H. MONTGOMERY,
M. D., Lecturer on Dermatology and Genito-Urinary Diseases, in Rush Medical
College, Chicago. Profusely Illustrated. (Double number.) $2.50 net.
PRACTICE OF MEDICINE, by GEORGE ROE LOCKWOOD, M. D., Professor of
Practice in the Woman's Medical College of the New York Infirmary ; Instructor
of Physical Diagnosis of the Medical Department of Columbia College; Attending
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of the New York Academy of Medicine, of the Pathological Society, of the Clinical
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MANUAL OF ANATOMY, by IRVING S. HAYNES, M.D., Adjunct Professor of
Anatomy and Demonstrator of Anatomy, Medical Department of the New York
University, etc. Beautifully Illustrated. (Double number.) Price, $2.50 net.
MANUAL OF OBSTETRICS, by W. A. NEWMAN DORLAND, M. D., Asst. Demon-
strator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dispen-
sary, Pennsylvania Hospital ; Member of Philadelphia Obstetrical Society, etc.
Profusely illustrated. (Double number.) Price, $2.50 net.
DISEASES OF WOMEN, by J. BLAND SUTTON, F. R. C. S., Asst. Surgeon to Mid-
dlesex Hospital, and Surgeon to Chelsea Hospital, London ; and ARTHUR E. GILES,
M. D., B. Sc. Lond., F. R. C. S. Edin., Asst. Surgeon to Chelsea Hospital, London.
436 pages, handsomely illustrated. (Double number.) Price, $2.50 net.
VOLUMES IN PREPARATION.
NOSE AND THROAT, by D. BRADEN KYLE, M.D., Chief Laryngologist of the St
Agnes Hospital, Philadelphia ; Bacteriologist of the Orthopaedic Hospital and
Infirmary for Nervous Diseases ; Instructor in Clinical Microscopy and Assistant
Demonstrator of Pathology in the Jefferson Medical College, etc.
NERVOUS DISEASES, by CHARLES W. BURR, M. D., Clinical Professor of Nervous
Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopaedic
Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph
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*** There will be published in the same series, at close intervals, carefully-prepared works on
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24
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their special line, well and authoritatively written by able men, who, as teachers in the large col-
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25
26 W. B. SAUNDERS ILLUSTRATED
Saunders' Question-Compend Series.
&&~ Price, Cloth, $1.00 per copy, except when otherwise noted.
1. ESSENTIALS OF PHYSIOLOGY. 3d edition. Illustrated. Revised and enlarged.
By H. A. HARE, M. D. (Price, #1.00 net.)
2. ESSENTIALS OF SURGERY. 5th edition, with an Appendix on Antiseptic Surgery.
90 illustrations. By EDWARD MARTIN, M. D.
3. ESSENTIALS OF ANATOMY. 5th edition, with an Appendix. 180 illustrations. By
CHARLES B. NANCREDE, M. D.
4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC.
4th edition, revised, with an Appendix. By LAWRENCE WOLFF, M. D.
5. ESSENTIALS OF OBSTETRICS. 3d edition, revised and enlarged. 75 illustrations.
By W. EASTERLY ASHTON, M. D.
6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 6th thousand.
46 illustrations. By C. E. ARMAND SEMPLE, M. D.
7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE-
SCRIPTION-WRITING. 4th edition. By HENRY MORRIS, M. D.
8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By HENRY MORRIS, M. D.
An Appendix on URINE EXAMINATION. Illustrated. By LAWRENCE WOLFF, M. D.
3d edition, enlarged by some 300 Essential Formulae, selected from eminent authorities,
by WM. M. POWELL, M. D. (Double number, price 2.00.)
10. ESSENTIALS OF GYNAECOLOGY. 3d edition, revised. With 62 illustrations.
By EDWIN B. CRAGIN, M. D.
11. ESSENTIALS OF DISEASES OF THE SKIN. 3d edition, revised and enlarged.
71 letter-press cuts and 15 half-tone illustrations. By HENRY W. STELWAGON, M. D.
(Price, $1.00 net.)
12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL
DISEASES. 2d edition, revised and enlarged. 78 illustrations. By EDWARD
MARTIN, M. D.
13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.
130 illustrations. By C. E. ARMAND SEMPLE, M. D.
14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124
illustrations. 2d edition, revised. By EDWARD JACKSON, M. D., and E. BALDWIN
GLEASON, M. D.
15. ESSENTIALS OF DISEASES OF CHILDREN. 2d edition. By WILLIAM M.
POWELL, M. D.
16. ESSENTIALS OF EXAMINATION OF URINE. Colored " VOGEL SCALE,"
and numerous illustrations. By LAWRENCE WOLFF, M. D. (Price, 75 cents.)
17. ESSENTIALS OF DIAGNOSIS. By S. SoLis-CoHEN, M. D., and A. A. ESHNER,
M. D. 55 illustrations, some in colors. (Price, $1.50 net.)
18. ESSENTIALS OF PRACTICE OF PHARMACY. By L. E. SAYRE. 2d edition,
revised and enlarged.
20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustrations. By M. V.
BALL, M. D.
21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations.
2d edition, revised. By JOHN C. SHAW, M. D.
22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised-
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23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By DAVID D.
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A TEXT-BOOK OF MATERIA MEDICA, THERAPEUTICS,
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LECTURES ON RENAL AND URINARY DISEASES. By
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MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE.
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SENN'S GENITO-URINARY TUBERCULOSIS.
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SUTTON AND GILES' DISEASES OF WOMEN.
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AN AMERICAN TEXT-BOOK OF GENITO-URINARY AND SKIN DISEASES.
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THROAT.
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Surgical Diagnosis and Treatment. By J. W. MACDONALD, M. D., Graduate of
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Edinburgh; Professor of the Practice of Surgery and of Clinical Surgery, Minneapolis
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HIRST'S OBSTETRICS.
A Text-Book of Obstetrics. By BARTON COOKE HIRST, M. D., Professor of Obstet-
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MOORE'S ORTHOPEDIC SURGERY.
A Manual of Orthopedic Surgery. By JAMES E. MOORE, M. D., Professor of
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of Medicine and Surgery.
HEISLER'S EMBRYOLOGY.
A Text-Book of Embryology. By JOHN C. HEISLER, M. D., Prosector to the Pro-
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NOW READY VOLUMES FOR 1896 AND 1897.
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Garrigues, Henry J
A text-book of the diseases of
wor en 4
MEDICAL SCIENCES LIBRARY
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