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