PRESS NOTICES OF THE FIRST EDITION.
" While written in .1 concise way, it is excccdin;;ly full, and covers the whole ground
of gynecology." — Boston Medical and Surgical Journal.
" The chapter on the Anatomy of the Female I'clvic C)rgaiis 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.
" A useful work. A capital index makes consultation easy." — Edinburgh Medi-
cal Journal.
" Tiie chapter on Diseases of the FalIo])ian Tube> 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 ]")ages for hurried
consultation niucli oftener tlian to some of the more elaborate ' text-books ' and ' sys-
tems.' " — ^Journal of the American Medical Association.
"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 complete with technique and fairly detailed
instructions." — Chicago Clinical Review.
PRESS NOTICES OF THE SECOND EDITION.
" It has, by the sheer force of its intrinsic merit, shouldered its way through a crowd
of more ambitious works, up to the front rank." — Medical Record, New York.
" The book has already taken its place among the best works of its kind. ... It
is one of the most complete treatises on gynecology which we have." — American
Journal of the Medical Sciences.
" It is in every respect a good guide for the physician and a first-class book of refer-
ence for the gynecologist." — Annals of Gynecology and Pediatrics.
"Eminently jjractical and susceptible of practical ajiplication by him who is in need
of just such information as it furnishes." — St. Louis Medical and Surgical Journal.
" It is in every way a good and safe boolc for both students and practitioners." —
Canadian Practitioner.
PROFESSIONAL COMMENTS.
•'One of the best text-books for students and practitioners which has been published
in tlie English language; it is condensed, clear, and comjMehensive. The jirofound
learning and great clinical experience of the distinguished author find expression in this
book in a most attractive and instructive form. Young ]:>ractitioners, to whom exj)e-
rienced consultants may not be available, will find in this book invaluable counsel and
help." — Thad. A. Re.\my, 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 tliis sub-
ject, and among them all I find none better fitte<l 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.
Streetkr, Professor of Gynecology, Chicago Homeopathic Medical College.
A TEXT-BOOK
DISEASES OF WOMEN
BY
HENRY J. GARRIGUES, A.M., M.D.
GYNECOLOGIST TO ST. MARk's HOSPITAL IN NEW YORK CITY; GYNECOLOGIST TO THE GERMAN DISPENSARY
IN THE CITY OF NEW YORK; CONSULTING OBSTETRIC SURGEON TO THE NEW YORK MATERNITY' HOS-
PITAL: CONSULTING PHY'SICIAN TO THE NEW YORK MOTHERS' HOME AND MATERNITY HOSPITAL ;
EX-PRESIDENT OF THE GERMAN MEDICAL SOCIETY OF THE CITY' OF NEW Y'ORK ; FELLOW OF
V THE AMERICAN GYNECOLOGICAL SOCIETY; FELLOW OP 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.
WITH 367 ILLUSTRATIONS
THIRD EDITION, THOROUGHLY REVISED
I'JIILADELI'IIIA
W. B. SAUNDEKH & COMPANY
It)
(^
p(
Copyright, 1900, by
W. B. SAUNDERS & COMPANY.
PRESS OF
\V. B. SAUNDERS k COMPANY.
TO
ABRAHAM JACOBI, M. D.,
PaOFESSOB 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 TO THE THIRD EDITION.
When, after the brief space of two years, I had the pleasure of
being informed by the publisher that a third edition of my Text-
book of Diseases of Women was called for, I resolved to make it
in every respect as perfect as was in my power. The entire work
has been carefully and thoroughly revised ; what seemed antiquated
or of minor importance in a text-book has been left out ; consider-
able new material has been admitted, bringing the work up to date
as far as it was deemed safe to do so in a text-book, which, first of
all, must aim at soundness of doctrine. Many new illustrations have
been added. Instead of making a new index, which is a compara-
tively easy matter, that which has gradually been developed by use
of the two preceding editions has been retained, improved, and
increased, facilitating research in a work containing information
upon so many different subjects.
By these improvements I have tried to make the book worthy
of the kind reception accorded it by the profession and the press,
and I trust that this edition will be found a still more reliable
guide and handy counsellor than its predecessors.
In the preparation of this third edition for tlie press I have
been assisted by Drs. Evelyn Garrigue, r^eon F. (Jarrigues, and
Harry G. Watson ; and new drawings have been made by Mrs.
Editii Ilutchins.
107 East Sixty-Second Street, New York,
June, 1900.
PREFACE TO THE FIRST EDITION.
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 nut had the advantage of hospital training,
and loho 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 loho
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 wlio 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 w^here 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
PREFACE. 9
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 treate<l so discursively of the auatomy 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 Avorks of an encyclo-
pedic character or in articles in journals to which many have not
access.
I exjject to be criticised for having devoted special chapters to
Hemorrhage and Leucorrliea. I know well that they are not dis-
eases ; but they are symptoms that ])lay so great a j)art in tlie diseases
of women, and so often require symptomatic treatment, that I take
it to be in the interest of tlie general ])ractitioner to treat them sep-
arately ; and besides, by so doing infinite repetitions are avoided.
This l)eing a text-book for beginners and a manual foi- 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
10 PREFACE.
different metJiixls 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 arc 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.
CONTENTS.
GENERAL DIVISION.
PART I.
PAGE
DEVELOPMENT OF THE FEMALE GENITALS 19
PART II.
ANATOMY OF THE FEMALE PELVIC ORGANS 35
PART III.
PHYSIOLOGY 116
CHAPTER I.
Puberty 116
CHAPTER II.
Menstruatiox and Ovulation 117
CHAPTER III.
Copulation 12.3
CHAPTER IV.
Fecundation 123
CHAPTER V.
The Climactekic 125
PART IV.
ETIOLOGY IN GENERAL 129
PART V.
ILXAMLVATION IN GENERAL l.'M
Verbal Eraminntion l.'M
Physical ICxaminntiou l.'i"
I. Positions ];5S
11. Examination of the Pelvis 1 II
in. Examination of the Alxlomcn KiO
IV. Other .Means of Investigation eommon for Pelvic and Ahdominul Diseases ](!!
11
12 CO^^TENTS.
PART YI.
PAGE
TREATMENT IN GENEEAL 172
CHAPTER I.
Preventive Treatment 172
CHAPTER II.
External Treatment 174
A. Applications 174
B. Injections 175
C. Curettage 180
D. Tamponade 182
E. Hemostasis 186
F. Dilatation 191
G. Drainage 191
H. Bloodletting 194
I. Heat and Cold 195
J. Counter-irritation 196
K. Tapping and Aspiration 197
L. Abdominal Belt 199
M. Massage 199
N. Gymnastics 200
0. Operations in general 201
1. Time for Operating 202
2. Preparation 202
Disinfection, Asepsis, and Antisepsis 209
3. Anesthesia 218
4. Shock 224
5. Common Instruments and their Use 226
6. After-treatment 239
CHAPTER III.
Internal Treatment 240
CHAPTER IV.
Electric Treatment 246
PART VII.
ABNORMAL MENSTRUATION AND METRORRHAGIA 255
CHAPTER I.
Amenokrhka 255
CHAPTER II.
Vicarious Menstruation 258
CHAPTER III.
Dysmenorrhea 259
CHAPTER IV.
Precocious and Tardy Menstruation 261
CONTENTS. 13
CHAPTER V.
PAGE
Menoeehagia 262
CHAPTEE VI.
Meteoeehagia 264
CHAPTEE VII.
Geneeal Menstetjal Disoedees 264
PART VIII.
LEUCOEEHEA 268
SPECIAL DIVISION.
PART I.
DISEASES OF THE VULVA 273
CHAPTEE I.
Malfoemations 273
CHAPTEE II.
EuPTUEES (Heenije) 273
CHAPTEE III.
TuMOES Connected with the Extrapelvic Portion of the Eound Lig-
ament 280
CHAPTEE IV.
Injuries 283
CHAPTEE V.
Vulvitis 285
CHAPTER VI.
Inflammation of the Urethral Ducts 289
CHAPTER Vn.
Gangeexe of the Vulva 289
CHAPTEE VIII.
Exanthematous Diseases 290
Herpes Progenitalis 290
CHAPTEE IX.
Teichiasis 291
CHAPTER X.
Pburitus Vulv^ 291
Burning Sensation in the (ienitjils and the Abdomen 29.'J
CHAPTER XI.
Hvperestuesia of tup; Vulva 291
14 CONTENTS.
CHAPTER XII.
PAGE
Tumors of the Vulva 294
CHAPTEK XIII.
Tuberculosis 306
CHAPTEK XIV.
Progressive Atrophy of the Nvmpikk, ok Kraurosis 307
CHAPTEE XV.
Diseases of the Vulvovaginal Glands 308
CHAPTEE XVI.
Venereal Diseases -. 310
CHAPTEE XVII.
Prolapse of the Urethra 315
CHAPTEE XVIII.
Masturbation 316
Clitoridectomy 319
PART II.
DISEASES OF THE PEEINEUM 320
CHAPTEE I.
Injuries 320
CHAPTEE II.
Garrulity of the Vulva, ok Flatus Vaginalis 342
CHAPTEE III.
COCCYGODYNIA 342
CHAPTEE IV.
Hygroma Perin^ei 344
PART III.
DISEASES OF THE VAGINA 345
CHAPTEE I.
Malformations 345
A. Maltbrmatious of tbe Hymen 345
B. Malformations of the Vagina 347
CHAPTEE II.
Vaginal Entekocele 354
CHAPTEE III.
Pkolapse of the Anterior Wall of the Vagina ; Cystocele 356
CHAPTEE IV.
Prolapse of the Posterior Wall of the Vagina ; Eectocele 359
r^ENERAL PEOLAP.se AND INVERSION 359
CONTENTS. 15
CHAPTEK Y.
PAGE
Injueies; Thrombus, oe Hematoma 360
CHAPTEE VI.
FoEEiGN Bodies 362
CHAPTER VII.
Vaginitis 363
CHAPTEE VIII.
Gangeene 372
CHAPTEE IX.
Eeysipelas 373
CHAPTEE X.
CiCATEICES 373
CHAPTEE XI.
Vaginismus 375
CHAPTER XII.
Neoplasms 378
CHAPTEE XIII.
FiSTULiE 383
A. Urinary Fistulse 383
Genital Clcisis 3!)7
Urinals 397
Operations for Incontinence 3i»8
B. Fecal Fistula 3it!»
PART IV.
DLSEASES OF THE UTERUS 106
CHAPTER I.
Malfor.mations 106
A. Exce.s.sive DcvelopineTit and Precocity 106
B. Arrest of Development during tlie First Half of Intra-utcrine Life . . . 406
C. Arrest of Development during the Second Half of Intra-uterine Life . .111
D. Irregular Development 113
rilAPTEU II.
Ix.hkiks -Ill
rilAPTKR III.
FoKKHJN Bodies 122
CII.M'TKR IV.
Metritis I-,'.'!
CII.M'TKK V.
Closukk ok the T'ti;iu« L\(uriuKi) Atuksia) 1 in
CHAPTKi: VI.
Stk.nosis of iiiK Ckkvix Ill
16 CONTENTS.
CHAPTER VII.
PAGE
Ulceks op the Cervix 444
CHAPTER VIII.
Hypertrophy of the Uterus 444
CHAPTER IX.
Acquired Atrophy of the Uterus (Superinvolution) 451
CHAPTER X.
Gangrene of the Uterus 452
. CHAPTER XI.
Hysteralgia 452
CHAPTER XII.
Displacements of the Uterus 453
CHAPTER XIII.
Neoplasms of the Uterus , 492
PART V.
DISEASES OF THE FALLOPIAN TUBES 553
CHAPTER I.
Malformations 553
CHAPTER II.
Salpingitis 554
CHAPTER III.
Displacements 578
CHAPTER IV.
Neoplasms 578
PART VI.
DISEASES OF THE OVARIES 581
CHAPTER I.
Malformations 581
CHAPTER II.
Foreign Bodies 582
CHAPTER III.
Displacements 582
CHAPTER IV.
Hyperemia and Hematoma 586
CHAPTER V.
Oophoritis 590
Gvroma and Endothelioma 597
CONTENTS. 17
CHAPTER VI.
PAGE
Neoplasms 601
A. Ovarian Cysts 601
I. Dropsical Graafian Follicles 602
Rokitanski's Tumor 604
II. Proliferating Cysts 605
a. Glandular 606
b. Papillary 614
c. Mixed 615
III. Dermoid Cysts 615
IV. Tubo-ovarian Cysts, cr Hydrocele of the Ovary 617
B. Solid Ovarian Tumors 671
CHAPTER VII.
Oophoralgia 678
PART VII.
DISEASES OF THE PELVIS 679
(The Peritoneum, the Connective Tissue, the Vessels of the Pelvis, and the Liga-
ments of the Uterus.)
CHAPTER I.
Malformations 679
CHAPTER II.
Aneurysm of the Uterine Artery 679
CHAPTER III.
Diseases of the Bkoad Ligament 680
CHAPTER IV.
Diseases of the Roind Ligament 684
CHAPTER V.
Diseases of the Sacro-uterine Ligament 684
CHAPTER VL
Pelvic Hemorrhage 685
CHAPTER VII.
Perimetric Inflammation 693
CHAPTER VIII.
Sarcoma and Car( i.voma of the Pelvic Peritoneum and Connective
Tissue 714
CHAPTER IX.
Hydatids (Echinococcii of the Pelvis 715
APPENDIX.
L STERILITY 718
II. LACK OF ORGASM 723
IIL INTE.STINAL SURGERY 724
2
DISEASES OF WOMEN
OR
aYi^ECOLO GY.
GENERAL DIVISION.
DISEASES OF 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 im|)()rtancc in regard
to life and happiue&s, we give here a resume of the same.*
The Wolffian Ducts.
The first organs belonging to the genital si)here, whicii 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-
FlG. 1.
Tniiisverse Section throiiRli the Mcdiiui I'lirt of the Rodv of the Kmhrvo of a Katibil o
days and two hours (enlarged 158 times); r/r/. hvpohlast ; i/r, intesiiiial u'roove; rh.
chord : no, deseendiiit; aorta; un, protovertelmi ; mr, inednllarv tube : inui, WoKlian
(Uu. visceral division of the mesohlast : <i, vessels in the deeper'ijarlsof the visceral
blast: h]), parietal mesohlast ; h, epihiast ; ;</>, pleuro-peritoiical cavity (I\'(>llil;eri.
vertebral column and the lateral plates (Fig. 1). Originally it
* Tliis is an abstract of the author's more ('lal)or;ite articile on tlie siiKjcct
Sj/sirm of Gynecolot/i/ by American Authors, edhed hv M. I ). Mann, I'liiladel
1887.
f nine
. nolo
duel;
in I
pliia,
20
DISEASES OF WOMEN.
solid cord, 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 soon
conneets with the Wolffian body, forming its outlet. The lower
end opens into that part of the alluntois 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 Wolf-
fian duct ends in the urogenital sinus (Fig. 2).
Fig. 2.
Sagittal Section through the Posterior Part of tliu P)0(ly of the Embryo of a Rabbit of eleven
days and ten liours (enlarged 45 times) : w(/, Wolflian duct: n, ureter; Ji', beginning formation
of the kidney ; urj, urogenital sinus ; cl, cloaca ; h</, region in which, in the mesial plane,
the hind-gut opens into the cloaca ; erf, post-anal gut ; a, anus, or fissure of the cloaca ; s,
tail : r, perineal 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 Wolffiax Bodies.
Shortly after the AVolffiian ducts the Wolffian bodies appear.
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 eudothelium of the peritoneum,
and form at first a long row of pear-shaped solid bodies. Later,
Fig. 3.
Human Kmhryo of thirty-five days (front viowi: 3, Ifft fxtcrnal nasal iiniccss; I, siijiorior
maxillary process: z. t<ini.'ue: b. aortic hiilb: b , lirst ju'riiiunt'iit aortic arch ; b", scconii
aortic arcli ; '; ". thinl aortic arcli, or <liictns Botalli : //. tlic two tilamciits to the riuht anil
the left of tliis letter ate the imlmonary arteries, wliicii jus! betiiii to he <levi>lo])c(l ; r. the
trunk of the sn|H-rior vena cava ami ris,'ht azvLros vein ;' <•'. the conuiion venous siiiu> of
the lieart : r", the common tiiink of tlie left ve'na cava anil left azy<.,'os vein ; n, left anriele
of the lieart; ?'. rij,'ht ventricle : r', left ventricle; (i», liin}.'s ; r, stomach :./. left omiihalo-
mesenlcric vein ; x, continuation of tlie >ami- behiml the I)ylonl^, whieli afterward
becomes the vena porta; x, vilello intestinal ihict ; u. riL'hl omiihalo-mesenterie artery;
//'. W'olllian liody ; /, ^nt : /(, nml)ilie:il artery : n. umliilieal \eiii ; >, tail : .'', anterior limii ;
.'' , posterior limb. The liver ha- been reini'>vi(l. 'I be u liiie b.-iml at the inner side of tlie
Woltliaii body is tin- genital uland. ,-11111 the two while liaiid- at its niiier >idi' are ilie .Mul-
leriaii and the Wolllian duels (Co^tc).
tii('.«;(; are .s(,'|)aratcd from the jx'ritoncnin luid hccniiic hollow. Innii-
iiio; a row of vesicles called the sci/uii'tildl rcsic/is, each of whii'li soon
coiiiiccls with the Wolllian duct by the absorption ol'tlic tissue iuter-
veiiiu'' between their cavities and the lumen of the ilnd. The Ioihk r
22
DISEASES 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
siune way :is the uriniferous ducts and the Malpighiau tufts in the
kidneys.
In the male the Wolffian body is later transformed into the epidi-
didymiH and the organ of Gindd^s (Fig, 0) ; in the female into Rosen-
FiG. 4.
The Genital and Urinary Organs of the Embryo of Cattle :
1, from a female embryo IJ/^ inches long (double size) : w, WolflBan body : wr/, WolflBan and
Miillerian ducts ; i, ineuihal ligament of Wolffian body ; o, ovary with an upper and lower
peritoneal fold; n, kidney ;nM, suprarenal body; g, genital cord, composed of the united
Wolffian and Miillerian ducts.
2, from a male embryo 2)/, inches long (nearly three times natural size) : one of the testicles
has been removed. Letters as in Fig. 1, and, besides, to, Miillerian duct ; m', 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.
3, 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 Miiller's duct ; o', lower ovarian ligament ; ti, thiclj-
eued part of Miillerian duct, which later becomes the uterine horn (Kolliker).
rauller's 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 tlie testicle l)egiu to
diffiir from each other, the testicle be(;oming broader and sliorter,
while the ovary remains long and narrow. The ovary has a much
more developed columnar epithelium than the testicle. An early
difference is also said to be found in the distribution of the l)l()od
vessels. The testicular circulation is peripheral, the main artery
DEVELOPMENT OF THE FEMALE GENITALS.
23
coursing ov^er the dorsal aspect of the organ, and giving off rib-like
branches, which in turn send penetrating branches into the gland.
Between the arteries are situated the
collecting veins, which unite at the
base of the testicle to form the sperm-
atic plexus. In the ovary, on the con-
trary, the arteries with their accom-
panying veins enter the center of the
organ, where they branch tree-like,
and terminate as a fine capillary anas-
tomosis in the tunica albuginea.'
The sexual glands are situated on
the inner side of the Wolffian body
(Fig. 4), to which tliey are fastened by
a fold of the peritoneum called the
mesorc'hiiDii in the male and the meso-
ariuni in the female. At the upper
end is a ligament which unites with
the diapliragmatic ligament of the
Wolffian body ; at the lower end is
another ligament, which is fastened
to the Wolffian duct, opposite the
starting-])oint of the inguinal liga
ment of the Wolffian body, and which
Posterior End of tlic Embryo of a Dog,
with buddinjr allanloid. Tliemeso-
blast and the liypdblast, or the begin-
ning of the intestine and the neigh-
boring parts of tlie blastodermic
vesicle, are thrown back in order to
show tlie Wolflian bodies (enlarged
10 times) : o, Wolflian bodies, with
the duct and the simple blind canals;
b, protovertebrai ; c, spinal marrow;
d, entniiice to the pelvic intestinal
cavity iBif-ehoff).
later becomes tlie permanent li(/(iinciit
of the ovary.
Tlie sliape of the ovary undergoes
threat chano^es. At first it is a lono:
flat body. Later it grows, especially at the edges, so that a trans-
verse 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 c/csw/j^ just as the testicle. At the birth
of the child the ovaries are yet situated above the ileo-jx'ctinetd line,
and descend into the true pelvis during the first two or tliree months
of the child's life. This descent is partly apparent and partly real:
it is chiefly due to the greater growth of the jiarts above the ovaries ;
l)ut, besides that, a shrinking of the round ligament of the uterus
tak(.'s j)Iace, by which the ovaries indirectly are pulled down. At the
SJime time there is a (•hang(! in ])osition by whicii 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 hiluni is; the outer becomes the upj)er, free edge; the anterior
surface becomes the inner, the posterior becomes the outer. The
relations to the l^'allopian tube are changed in such a way that the
' J. (i. (lark, .luliiui JL/pkins Jloapilid Bulletin, Nos. 94— IH), Jan., I'd)., Mar., iS'.ti*
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
E
Fig. 6.
-H
U u ■ -
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 Giraldes (uropoetic part of
Wolffian body) ; G, 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, ovarv ;
T, tube ; abd., abdominal ostium of tube ; E. parovarium ; U, uropoetic part of the Wolff-
ian bodv remaining as tubes between parovarium and uterus ; Y. Wolffian duct disap-
pearing lower down; Mp., Malpighlan bodies iWaldeyer).
The ovarian vessels enter originally at the upper end of the
Fig
'rian<:verse Section of Ovary of Human Embryo of three months (enlarged 43 times • a.
mesoarium ; a', stroma of the liiluni (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 fimbriae of the tube to
Fig. 9.
* mt
Transverse Section through the Ovarian Region of a Human Embryo of five months; lower
surface seen from above (enlarged 3 times) : oi, os iliura ; s, sacrum ; mo, mesoarium and
hilum of ovary, bounded by two lii)s ; o, cut surface of the ovary ; v, free ventral surface,
or lateral jmrt of the ventral surface, of the ovary ; 7(i, rectal surface of ovary, or medial
part of its ventral surface: t, tube; vd, mesentery of tube (later ala vespertilionisi; r,
rectum; «, uterus; vr. ureter; o;(, umbilical artery; ie, external iliac vessels ; nc, ante-
rior crural nerve (KoUikei ;.
the wall of the pelvis. To the outer side of the mesoarium is attached
the mesosaljjinx (Fi^. 9), or mesentery of the tube, which later is called
Ovary of a Human Fetus of ten or cli'ven week- : '/, ^uperficial stratum of ci
connective tissue: '•, trabeculii: of CDiineclive tissue, the cells having bee
mesoarium : e, i)art near surface seen with liigher power, n, naiurul size o
(H. Meyer;.
■lis: /<, lay
n reiuuve
f the siiec
i; (/,
iiiu'u
26
DISEASES OF WOMEN,
ala vespertilionis (the bat's wing), and contains the remnants of the
Wolffian body, especially the parovarium, 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 covering 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-
FlG. 11.
Part of Ovary near Surface, from Human Fetus of sixteen weeks, showing formation and
separation of ova (H. Meyer).
Fig. 12.
Part of Ovarv 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
(H. Meyer).
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, 13); 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 Surfaoc to Hilum of Ovary of (iirl tiireu days old : s, single layer of epi-
thelium yet in eoniiection with cluster of primordial ova. All ova have disappeared from
the surface. A broad layiT of stroma separates in most ])laces llu- ei>ithelinni from the
follicular zone. The far'tlur we go froin the surface toward the hilum. the fewer ova are
there in one nest, until, finally, there is only one in its primary follicle ; n, natural size
of the wliole ovary ill. Meyeri.
surrounded by smaller cells, until liiially all these clu.sters and col-
umns are broken up into small compartments, each containing one
28
DISEASES OF WOiMEN.
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 : b, 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 primordial ova ; and the small cells multiply and form the
epithelium of the j)^'i'>nary 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 begrinning
of the future liquor j'ollicidi. The outer
layers form the epithelium of the Graaf-
ian follicle, the so-called viembrana
granulosa; the inner continue to sur-
round the ovum, forming the discus
prolifjerus (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-
scri])tion 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 AVolffian body.' As mother to so
many epithelial formations, this is called the r/enn-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
' According to J'oulis and his followers, the germinal epithelium only forms the
ova. while the epithelium of the primary follicles is derived from the connective-
tissue stroma.
Three Graafian Follicles from the
Ovary of a Xew-born Girl (en-
larged 350 times) : 1, natural condi-
tion ; "2, treated with acetic acid ;
a. structureless membrane ; 6, epi-
thelimn (memlirana granulosa) ; c,
yolk : d. germinal vesicle, with ger-
ininal spot ; e. nuclei of the epi-
thelial cells ;/, vitelline membrane
(Kolliker).
DEVELOPMENT OF THE FEMALE GENITALS.
29
month, but it seems that the ova themselves multiply by division
(Fig. 18). Their number is enormous: it has been computed that
the two ovaries together contain 72,000 ova.
The Mullerian Ducts.
The Mullerian ducts appear shortly after the Wolffian body as a
funnel-shaped invagination 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 :
h, discus prfiligerus, 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 surnninding stroma (Kolliker).
at the inner side of the upper end of the Wolffian body (Fig. 19).
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.
1 m
Primordial Ova undergoing division, from a Human Kmbryo of si.x months (enlarged I'K)
times) : 1, two primordial ova surroiiiideil by a conmion layer of eiiithelium, one of which
- has a prolongation by iiuans of which it prolnilily was attached to aiiotlier ovum, as in 2,
where two jirimordial ova are linkeil tosrctlier by a band of protoplasm, the whole sur-
rounded by one epithelial layer; 3, primordial ovum with two nuclei (germinal vi.'sicles)
(KiiUiker).
30
DISEASES OF WOMEN.
pass in front of it, and finally lie behind it. The lower part is at
firet formed by a solid column of cells, which later is tunnelled so as
to form a tube.
The JMiillerian 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 trom 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 JMiillerian ducts soon disappear, leaving as rem-
nants the hydatid of Morgagni on the epididymis and the vesieula
Fig. 19.
Transverse Section through the upper end of the Wolffian Body of the Ernbryo of a Rabbit of
fourteen days (enlarged 114 times): w^r, Wolffian duet; ??!, connection between a tubule
of the Wolffian body with a Malpighiari 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; I!', surface of the liver; hb, posterio'r abduminal wall; 7)iff, lateral part
of the Miillerian duct (KoUiker).
prostatica (sinus copularis, or male viern^). In the female they form
the Fallopian tubes, the uterus, and the vagina.
The Fallopian Tubes. — The Fallopian tubes arc formed of that
part of the ^liillerian ducts which lies above the round ligament of
the uterus (the inguinal ligament of the Wolffijin body, Fig. 4).
The cells of the Mall form the fibrous, muscular, and mucous coat of
the fully-developed tube, and fringes grow out around the abdominal
opening, forming the fimbrke. 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 Uteinis and the Vagina. — The part of the Miillerian ducts
below the round ligament forms, together with the lower ends of the
Fig. 20.
Fig. 21.
Transverse Section of the Genital Cord of the Embryo of a Cow, 1]4 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 ; wg,
WolflBan duct (KoUiker;.
Wolffian duets, a quadrangular cord with rounded edges, the gcmtal
cord (Fig. 20). The tissue that separates the two Miillerian ducts is
gradually absorbed until there is one canal instead
of two at the end of the second month. Tlie
genital cord is developed so as to form the uterus
above and the vagina below. While the fusion of
the Miillerian ducts is incomplete, they are yet
separated above, forming the two horns of the
uterus (Fig. 21). About the middle of pregnancy
t'ne uterus forms one sac without horns (Fig. 22).
The ]Miillerian ducts o])en into the lower part
of the uraclius, that ])art of tlie allantois whicli is
included in the body, and later forms the bladder
(Fig. 23). Tliis lower part, situate below the
openings of the Miillerian and Wolffian ducts, is
called the urogenWd .sinus (Fig. 2). Originally
this sinus opens into tlie cloaca (Fig, 24). Fiater
a septum is formed, dividing the cloaca and then^by
separating the sinus urogenitalis from the rectum,
and the urogenital o])ening from the anus, and
forming tlie prr'riieum (Fig. 25). The urogenital
sinus grows much less than the other |)arts. The
urethra is differentiated as a sj)e('ial organ from the
bladder, with which it heretofore formed one sac call
Tubes, and
of Htnnan
Embryo from tlie
toiitli weelc, 'it'i mm.
long: 1. natural size;
2. enlargeil 4 times;
n. round ligament ;
6, reclum(H. Meyer).
d tl
ic uraclin
and the vagina is undergoing a great development. Thus the change
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.) :<, tube; r, round ligament; v, bladder; u, umbilical artery; ur, urachus; c, cacum;
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,
®
Fig. 2S.—al!, allantois. which becomes the bladder : r, rectum : m, Miillcr's duct, which later is
transformed into the vagina; a, indentation of the skin, which forms the anus (Schroeder).
Fig. 24.— d, cloaca ; all, allantois; m, Miillcr's duct ; r, rectum (Schroeder).
Fig. 25.— sm, urogenital sinus ; r. rectum, separated from the former by the perineum ; v,
vagina (lower part of Miillcr's duct) ; b, bladder ; u, 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; this increase in size con-
tinues until the rest of the body has attained the limit of its growth..
Fig. 26.
1
"3.
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' ; b, bladder ; h, urethra ; ug,
urogenital sinus ; g, genital canal (common rudiment of vagina and uterus) ; s, vagina ;
u, uterus (KoUiker).
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-
ojHiient of the posterior wall of the vagina.^
' In tlie above description of the formation of tlie female genitals, I have chiefly
followed KoUiker and Waldeyer. According to I). IJerry Hart {Trans. Edinburgh
Ohsl. Soc, 1895-'yG), .several points would have to be added or corrected. The
ducts of Miiller arise probably from the mesobiast, the Wolffian ducts from the
epiblast. JJefore the hymen is developed — i. e., up to the second and third month
of fetal life — the vagina is formed by the coalesced ducts of Miiller, but the lf)wer
end has no opening. At the beginning of the third month, two bulbs form from the
lower ends of the Wolffian ducts, the perij)hery of these bulbs being formed of the
more active cells, the center of cells of a more .scpiamous type. Jiy the j)n>lifera-
tion and sj)read of these cells the Miillerian vagina has its lumen blocked, the
fornices and vaginal portion mapped out. The Wolffian bulbs coalesce, break down
in the center, and as the Wolffian cells in the center of the Miillerian vagina do the
same, the normal vaginal lumen is formed. Tlie hymenal o|)ening is brought al)(>ut
by the epithelial involution of the sinus urogenitalis from below meeting the dis-
tending Wolffian bulbs above. The Wolffian ducts thus supply the epithelium of
the vagina and develop the hymen.
3
34
DISEASES OF WOMEN.
The Vulva.
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 cloaca! opening. In front of this opening there appears in
the sixth week a protuberance called the f/enif(d tubercle, which soon
thereafter is surrounded by two lateral folds called the genital folds.
Tiie genital tubercle grows, and toward the end of the second month
there is formed a groove on its lower surface which extends to the
cloacal opening, and is called the genital furroiv (Fig. 27). So far,
the external genitals 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-
arius.
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.
Development of the External Sexnal Organs
in the Male and the Female from the in-
different type : A, the external sexual or-
gans in an embryo of about nine weeks,
in which external sexiial 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 ; cl, cloacal opening ; vp. urogenital
opening ; a, anus : Is, cutaneous elevation
which becomes the labia or the scrotum,
genital folds; I, labium; .s, scrotum; co,
caudal or coccygeal elevation (Ecker).
PART 11.
ANATOMY.i
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 Veneris (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 erect. 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 i)art 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
' Those who wish further information than tliat warranted by the limits of this
work are referred to the excellent articles by Henry C. Coe in the Si/Htrm of (ii/ne-
colof/y, and Ambrose L. Kannev, Am. Jour. Ob.'itetrics, March, April, ^lay, June,
1883.
My own special investigations on anatomical questions are found incorporated in
the following pajiers: " Gastro-elytrotomy," A. Y. Med. Jour., Oct. and Nov., 1S78;
"The Obstetric Treatment of the Perineum," ^h). ./owe. O/w/., April, 1880; "Rest
36
DISEASES OF WOMEN.
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 minora, with the
^^"- ^^- clitoris ; the vestibule, with the bulbs ;
^ ^«=*sssfs^^iiis^'p^^ the fossa navicularis ; and the vulvo-
II vaginal glands.
;^|g^ ^jy; The labia majora (larger lips, Fig.
**"'^^^^ ^ ^^' '^^ ^^^ ^^^ prominent ridges, one
l^y ^^k ^^ either side of the median line. A
MIk \im&^ transverse incision shows a triangular
^ "^S^'-' flUm ' ^^^ surface. They are situated in front
J '^F , j UmRSjl "^sM : ^f the descending ramus of the pubes
^ ' ''^ "J ^M ^^Ir^ J^B ^^*^ t^i^ ascending ramus of the
6- ^ WW'T^ml^ "^^fc ischium. Theouter surface is convex,
^ M( IILJ^b I ^^^: ^^ darker color than the rest of the
^ ^ ^ ^^B ^Wp ^KH skin, covered with a continuation of
8-- ■' " ■ ^- ^^^^ '' ^Wii the hair on the mons Veneris, and has
ft^ZZZ3^r-%g^£^^ ^^"'111: numerous and large sebaceous and
- ' ^rm^^^^i ^^ sudoriferous glands. The inner sur-
i^tai'llii' *^' ' ■-■■ "^^^ ^'^ rose-colored, and forms a transi-
ii iJlllli ii i tion from skin to mucous membrane,
tt / ' '''wJMB lr ' having the same glands as the outer
Jij/I II^^M^m '1 surface, and even a few downy hairs.
^^^Br ^^W^IN^^-^ "^^^ place where they unite anteriorly
■..,:^^^^ ^^^^^^^: is called the anterior commissure, and
Virginal Vulva: 1, labia majora; 2, 4.},p r>lopp wliprp thpv iinitp lipln'nrl i<*
fourchette; 3, labia minora; 4, glans '^"^ pjace Wneie luey uniie ueuinu IS
ciitoridis ; 5, meatus urinarius ; 6, ves- called the posterior commisswe. Here
tibule; 7, entrance to the vagina ; 8, , . -f, ji • i i
hymen; 9, orifice of Bartholin's the tlSSUe bcCOmeS VCrv thin by the
f;lanci; 10, anterior commissure of j- v j-i r "i \ • 'i £•
abia majora; 11, anus; 12, blind re- disappearance of the fat which forms
cess; 13, fossa navicularis; 14, body „ (yrpnt r^nrf nf thp Inhin mninrn Thn«5
of clitoris (modified from Tarnier). ^ gieai parr 01 tne laoia majoia. ±nus
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 u})per
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 pudendi. In the new-born
child, in whom the labia majora are incompletely developed, the labia
ANA TOMY. 37
minora 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 mons
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 woman's dartos. Under the dartos
is found a layer of adipose and connective tissue, and under that,
again, a pear-shaped sac called Broca's 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 deejier parts, lead the
male organ to them, and serve as buffers durino- coition.
The Labia Minora (small lips) or Xipnpha'. — 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 frenulnm, and the upper ]>assing above the clitoris,
forming \ts 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 down
to the knees, forming the so-called Hottentot apron.
The labia minora are covered with several layers of ej)idermic
cells. Ijeneath the epidermis they are composed of connective tissue,
elastic fibres, and smooth muscular fibres, and contain large venous
plexuses. They have no hairs nor i'at, 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 a(!t as an irritant for the nerves of the
male member at the same time that th(;ir own nerves are acited on.
During pregnancy they participate in the general softening of the
parturient canal, and by becoming to some extent unlolded during
the passage of the child, they facilitate labor.
38 DISEASES OF WOMEN.
The Clitoris. — This corresponds to the penis in the male, but the
urethra and the corpus spongiosum are separated from it. It is a
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 pectlniform septum. These corpora cavernosa consist
of fibrous trabecular, elastic fibres, unstriped muscular fibres, and
venous plexuses, with numerous anastomoses. The body is attaclied to
the anterior surface of the symphysis pubis by the suspensory liga-
ment. Arrived at the pubic arch, the body separates into two crura
(Fig. 29), small fibrous cylinders attached to the rami of the pubes
Fig. 29.
Front View of the Perineal Septum, showing entire clitoris : 1, glans ; 2, suspensory ligament ;
3, crura of clitoris; 4, subpubic ligament; o, 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 tiiey 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 the corpus cavernosum in the
depth of that body. The veins go to the dorsal vein, running in the
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; P, symphysis pubis (the whole body
being inclined forward, it has become horizontal) ; T, fimbriated end of Fallopian tube ;
1, Lumbar nerves, 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 syniphy^'is, and ends as
the dorsal nen'e 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 vertebrse ; 8, continuation of
the sympathetic in front of the sacrum ; 9, aortic plexus ; 10, hemorrhoidal plexus, following
the arteries of the same name ; 11, superior hypogastric plexus, or ilio-hypogastric plejcus,
which receives many spinal and sympathetic branches ; 12, inferior hypogastric 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 ; 15, 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).
Fig. 30.
ANATOMY. 39
middle line between the two arteries, and ending in the pudic plexus,
which surrounds the upper part of the urethra. Those of the glans
commui^ioate with the bulbus vaginge.
The lymphatics go to the superficial inguinal glands.
Nerves. — The clitoris has a rich nerve-supply (Fig. 30) 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
dorsum 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, 12j. As these recesses are always plainly visible, and the urethral
opening sometimes does not appear, the former become valuable land-
marks in catheterization. By placing the catheter just midway
between the two blind sacs we cannot miss the urethra. In cathe-
terization 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 vestil)ule, which are the oj)enings of compound
racemose glands {glandulce vestibulares minores) that secrete a mucous
fluid. Sebaceous glands are absent.
The vestibulo-vaginal bulbs (Fig. 31) are two leech-shaj)ed 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 tiie nuicous membrane and tiie
superficial fascia of tlie ])erineum, 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 nuis-
cular fibres, and connective tissue. The veins have numerous com-
munications with those of tlu; surrounding parts. Near the anterior
eiid f)f the bulbs they go from one side to the other, miiting the two
40
DISEASES OF WOMEN.
both behind and in front of the meatus urinarius, forming the joars
intermedia, and from here they communicate with the corpora cav-
ernosa of the clitoris.
The fossa tiavicularis 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. 31 .
Front View of the External Erectile Organs : a, vestibulo-vaginal bulb ; b, sphincter vaginse
muscle; ce, pars intermedia; /, ghxns 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 wlieu 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 Avithout
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
tlie surroundings, and being conifurm, 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 BarthoVui's glands (Fig. 32, b), are
two small oval bodies, from the si/.e of a bean to that of an almond,
situated 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
ANATOMY.
41
Fig. 32.
transversus perinsei 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 (i. e.,
above in the erect posture) the deep layer.'
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. Wlien not artificially
spread out, the two lateral halves are in
contact in the normal adult woman.
The vulva receives its arteries from the
superficial jierineal 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 perineal nerve, which
is a branch of the pudic, the inferior jiudendal 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. 33, A), having a slanting direction from above and
' Ambrose L. Ranney found in every rase Bartholin's glands lying posterior to
triangular ligament ("The Female Perineum," N. Y. Med. Jour., July-August,
1882, vol. xxxvl. p. 45).
Vulvo-vaginal Gland. Thelabium
majus and minu.s, the sphincter
vaginae muscle, and the bulb
have been partly removed on the
right side in order to expose the
gland : AA', section of labium
majus and minus; B, gland; C,
excretory duct ; C, stylet intro-
duced into the duct; D, glandu-
lar end of duct ; E, free end of
duct ; F, section of bulb ; O, as-
cending ramus of ischium (Hu-
guier).
42
DISEASES OF WOMEN.
behind downward and forwaixl, at an angle of 60° with the horizon,
situated between the bladder and the urethra in front and the rectum
Fig. 33.
Sagittal Section of Pelvis (Waldeyer): a, symphysis pubis; b, bladder; c, small intestine; d,
large intestine; e, anus ; /, perineal Dody ; 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, correspouding 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. 34, vo). 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 ujiper, broader end is
called the roof or fornix, and in its adaj^tation 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 tiie difference between the two openings at its beginning.
The entrance to the vulva is formetl 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 2i inches long, and the
width near the upper end about Ih
inciies. 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 pa&s, 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. 35, 3G) 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 j)erineal 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 rur/ce, 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 (Ulterior and posterior rohdnu.s.
The anterior often ends below in a round protuberance, called the
tubercle of the vaf/iua, which is situated inunediatcly behind the
meatus urinarius. Often the anterior column is divided bv a lon-
Horizontal Section of the Soft Parts
in the Inferior Strait of the Pelvis
(Henle) : I'u, vagina ; Lr. urethra;
H, rectum ; L, levator ani.
44
DISEASES OF WOMEN.
gitudinal furrow into two halves. The rugae are covered with micro-
scopical papillae. The columns and the rugae disappear in the upper
part of the vagina. They are organs of sexual excitement, and cou-
FiG. 35.
Fig. 36.
Fig. 35.— Longitudinal Section of the Posterior Wall of the Vagina of a girl twenty-four years
old.
Fig. 36.— Transverse Section of the Same (Breisky) : a, mucous membrane; b, muscular layer,
with a, circular, and p, longitudinal fibres; c, fibrous layer containing adipose tissue.
tribute probably to the eulargement of the vagina during pregnancy and
childbirth. After the latter they are much less prominent or disappear
entirely. Tiie presence o^ glands in the mucous membrane is disputed.'
The vagina posses.ses the power of absorption. This faculty is in-
creased in pregnant, puerperal, and feverish women. ^
The vagina has a rich vascular su])ply. The arteries (Fig. 37) come
from the anterior division of the internal iliac or one of its branches,
the vaginal, the uterine, the vesical, the middle hemorrhoidal, and the
1 In a woman in the fifth month of pre<,Miancy 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.
^ Coen and Levi : Centralblatt fur Gyndkolorjie, 1894, No. 49, p. 1261.
P
o
:«
3-
-^
►^
£ ^
"
,-f
O
C
^
^
S.""
5
tr
o
ra
<
s.
JQ
rs
H
2"
—
3"
^.
^'
c
c
D-
SO
-1
a
p 3.
^
ZT
5
s
5"
re
S
2.
ra
2
m
^
a
—
o-
2
P <l:
:^
^
_
O
s
3
t3'
-
o'
H>
Oi
2,
ifT
2
3*
S"<
D-
S
S'
r-^
«j=i 2 P - "-^ o- o
s S '^ t^ -
'i{^ '^ ^ £.-^ c-j
ANATOMY.
45
internal pudic. There are two or three vaginal artories on either
side, which anastomose with the circular artery of the uterus, and
form a perpendicular branch in the median line, back and front,
called the azygos artery of the vagina.
The veins form a dense network (Fig. 38), and communicate with
those of the vulva, the bladder, the rectum, tlic uterus, and the broad
ligament. Finally, the blood is carried to the internal iliac veins.
The lymphatics from the lower tliird, go to the superficial inguinal
glands, as do those from the vulva ; those from the middle third
Fig. 38.
The Venous Plexuses of the Vaprina and the Vulva, as seen in mesial section (Savage) : B,
bladder partially inflated ; h, ureter : V. vagina ; P, section of pubcs ; /?, 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; a, pyri-
formis muscle; 6, greater sacro-sciatic ligament; c, levator ani and eoccygeus muscles;
d, OS eoecygis; e, suspensory ligament of clitoris; i-; vulvo-vaginal gland; ggg roots of
sacral plexus of nerves.
form two trunks, which follow oue of the vaginal arteries to one or
two glands situated between the rectum and the sciatic nerve, near
the origin of the vaginal, hypogastric, and internal ptidic arteries, on
a level with the middU; part of the great sciatic notch. Tiicy con-
stitute the lowest of the internal iliac glands. The lyin])liaties from
the upper third of the vagina combine with those from the cervix
The nrn^fts (Fig. 30) come from the syinj)athetic, and form a vaginal
» Poirier, Progris Medical, 1889, Nof*. 47, 48, 49, ol, and 1890, Nos. .'i, 4.
46 DISEASES OF WOMEN.
plexus on either side of tlie vagina, communicating with the inferior
hypogastric. Their final fibrillae terminate in end-bulbs.
Function. — The vagina has a triple physiological function. Dur-
ing copulation it receives the penis, and during parturition it helps
move the child forward along tlie curve of Cams. To this must be
added the power of the normal vaginal secretion to kill bacteria and
thus protect the woman against the numerous cocci and bacilli that
in various ways find entrance into the vagina. Even when pyo-
genic staphylococci and streptococci are introduced experimentally
into the vagina, they disappear within two days. 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
finger with the patient lying on her back, and in nulliparae 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 ca.ses it is more developed behind than in front. The
Fig. 40.
Fig. 39.
illi
|i^'"""
pp/"
Hymen with Linear Opening (Tardien). Annular Hymen (Tardieu).
most common shape, especially in childhood, is that of a strip of
tissue bent so as to form two lateral halves touching each other in a
ANATOMY.
47
straight middle line (Fig. 39). In other cases it forms a ring with a
round opening (Fig. 40). In others, again, it has the shape of a
crescent (Fig. 41). Often the border is indented (Fig. 42), 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 pass
the finger. Sometimes the hymen is only represented by a low circu-
lar or crescentic ridge. The u])per surface shows a continuation of
the rugfle of the vagina, of whicii 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 flajis, but there is no loss
of substance. By putting the flaps in contact we can reproduce its
Driginal shape. In childbirth, on the contrary, it suffers so much
that only three or four roundish prominences are left of it, the
so-called carunculoe myiiijorvies.
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-
FiG. 4L
Fig. 42.
Crescent-shaped Hymen (Tardieu).
Indented Hymen.
bility to the vagina without laceration of the hymen is due to a
gradual dilatation l)y a comparatively small body. It must be borne
in mind tliat this not always means mastiirbation. It may be the result
of carci'ui gynecological treatment, while a careless examination may
ru])ture the membrane, producing a result similar to that of coition.
48
DISEASES OF WOMEN.
It has been asserted that there is a folding or yielding kind of
hymen, which folds back when a specuhim is introduced or during
copulation. I think this can only be the effect of gradual dilata-
tion. Some pretend that such a pliable hymen goes unscathed even
through child-birth — a statement so entirely at variance with the
common experience that its accuracy seems doubtful.
The Uterus.
The items (Fig. 43) 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 coi'piis. A subdivision of the neck is
the vaginal po7'tio7i (Fig. 43, A, a), which dips into the vagina; and
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, os externum ; d, os internum ; /,
fundus, the letter placed just above uterine opening of Fallopian tube.
a subdivision of the body is the fundus (Fig. 43, C,f), whicli 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 to the bladder.
ANATOMY. 49
The vaginal portion or infravaginal 'part of the cei'vix 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.
The anterior lip di])S lower down than the posterior, but the pouch
formed by the vagina being much deeper behind than in front (Fig.
43, B) the posterior lip goes much higher up, so that it is longer than
the anterior, 'i'he 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 -J inch long, and is
bound with rather loose connective tissue to the bladder in front, and
on the sides to the mass forming tiie base of the broad ligaments of
the uterus, and called the parametrium. Behind, it is free, being
separated from the rectum by a ])art 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
are a little convex (Fig. 43, ^1). 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. 43, B and C).
The interior of the womb contains a cavity (Fig. 43, 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 tiie cavifij of the bodij. The cervical canal is
about 1 inch long, is spindle-shaped, and on the anterior and ])osterior
wall there is found a longitudinal ridge from which branches go out-
ward and upward, se])arated by deep pouches. The whole Ibrmatiou
is called arbor vita'., iiahiuv. plicatcc, or plicce pahnatai. The isthmus,
or OS interuuui, is the narrowest j)art of the cavity, r.early cylindrical,
about \ inch long and ^- inch in diameter. The median ridge of the
arbor vitcn extends to its uj)j)er 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 fbiuid the uterine apertures of
the Fallopian tubes.
The wall is about ^ of an in(;h thick in the thickest parts, which
are the middle of the edges of the body, the; middle of the fundus,
and th(! middle of the cervix. It is thinnest at the entrances to the
Fallopian tubes and at the external os.
4
50
DISEASES OF WOMEN.
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 nullipane 2 to 2| inches, in multiparae 2^ to 3
inches. The width on the level of the Fallopian tubes, the broadest
part, is in virgins 1^ to If, in nulliparae the same, in multiparse 1^ 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 l^^- inches from side to side in the middle, and
a little less at the ends.
Fig. 44.
Vertical Section through the Mucous Membrane of the Human Uterus (Turner) : e, columnar
epithelium ; the cilia are not represented ; g,g, utricular glands ; ct, interglandular con-
nective tissue ; v,v, blood-vessels ; mm, muscular layer.
The body is only a little longer than the neck in nulliparae ; 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.
ANATOMY.
51
il^lirt
the tubes, and the sacro-uterine ligaments ; a middle layer of inter-
lacing 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 the internal os, in which lat-
ter place it forms a sphincter. It
enters also the folds of the plicae pal-
raatse. The middle layer is the thick-
est and contains the vessels.
The mucous membrane (Fig. 44)
lines the whole cavity. In the body
it is thin and intimately connected
with the muscular layer, bundles of
the muscles and connective tissue ex-
tending from one to the other. When
fresh it is pink. It consists of fine
threads of connective tissue and round
or oblong cells (Figs. 45 and 46), and
is perforated by numerous tubes, com-
posed of a basement membrane and a
layer of ciliated columnar 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.*
In the" cervix the mucous membrane is thicker, is composed of
fibrous connective tissue without adenoid structure, has racemose
glands, and is separated from tlie muscular layer by a distinct sub-
mucous layer of looser connective tissue. The epithelium is col-
umnar and ciliated on the free surface of the body,^ in tlie utricular
glands, and on the edges of tlie branches of the arbor vita?. In the
^ According to Dr. Arthur W. .Johnstone of Danville, Ky., the mucous membrane
is an adenoid tissue, like that of the tonsils, the tliyroid body, the spleen, the thy-
mus, the lymphatic glands, and the lymph-tiss>ies 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. Soc, June 23, 1886).
* 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 a-s De Sinety (Manuel pratiijite de Gynerolof/te, Paris, 1879, [). 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 diflerence of opinion is that the ei)ithelium on the free
surface of the corporeal endometrium is shed every twenty-eight days, and the difU'r-
ent observers have each described a diflerent stage of its regeneration. I have seen it in
all conditions, from a simple round cell up to a fully-developed colimniar e])ithelium,
and in a few inst'inces have seen what looked like cilia. Hut before they become
perfect the menstrual flow strips off the epithelial coat, and the cycle repeats itself."
Section of the Mucous Membrane of
the Uterus parallel to the surface,
enlarged 150 times (Heiile) : 1, 2, 3,
glands (the epithelium has fallen
out from 2) ; 4, blood-vessel.
5^
DISEASES OF WOMEN.
depressions between them it is goblet-shaped, without cilia. In the
glands of the cervix it is cuboidal, without cilia. The direction of
the ciliary movement is from the fundus to the os.^
Shape and Position. — Opinions as to the normal shape and posi-
tion of the womb differ so nuK;h that it has almost become a con-
fession of faith to say anything about it ; but, since I have made
gynecological examinations for many years, and have paid special
attention 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
Fig. 46.
Fibre of Endometrium, showing different degrees of corpuscular development. Enlarged
3000 times (Johnstone).
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-
ara, is apt to sink, so that the fundus of the uterus comes to lie
considerably deeper than in the living woman,^ 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 Ludwig Mandl, Centralbl. fur GyndL, 1898, No. 13, p. 327.
* According to Sappey, it should lie | incii to 1 inch below the superior strnit.
ANATOMY.
53
other hand, examinations of the living do not admit of the same
degree of accuracy as those of dead bodies.
Epithelial Cells from the Uterus of a Womaii 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 plicfc palmata: 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.
Fig. 48.
Mesial Section of the Pelvis of a Girl seventeen years old, luilf natural size (Kolliker): ur,
ureter opening into blud<ier; ii, vesical opening of uretlira; <■/, clitoris; /;, hymen.
The canal of the normal uterus is straight or sliglitly curved, with
the concavity turned forward (Fig. 4^), or S-shapcd. Tlie ])re.->en(c
64
DISEASES OF WOMEN.
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
the brim of the pelvis (Fig. 41)), 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.
IMagram of a Supposed ^Mesial Section of the Pelvis of a living woman (Foster-Ranney) : a,
anal canal; r, rectum; v, vagina; c, clitoris; b, bladder wlien collapsed; u, uterus; d,
valve of rectum (Houston) ; 8, symphysis pubis ; 6 ', sacrum ; C, coccyx.
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 M'ay as to form a Y
(Fig. 33), 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. 48).
During pregnancv the uteras 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 disa])pears altogether, and the mucous mem-
brane of the body loses nearly all its cells and consists of common
connective tissue (Fig. oOj.
ANATOMY.
Fig. 50.
55
Endometrium of Woman sixty years old x 800 (Jolinstone).
Fig. 51.
Diagram of the I,ie:aniciits <if tlie I'tcrns (Ilodge).
56
DISEASES OF WOMEN.
The Ligaments of the Uterus. — There are eight ligaments (Fig.
51) 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.
The vesico-utei'ine Ugaments are two small semilunar folds, one on
either side of the median line formed by the peritoneum, when from
the bladder it passes to the uterus, on the level of the internal os.
Fig. 52.
Superior View of the Pelvis and its Organs (Savage) : B, bladder; U, uterus (drawn down by
loopc); j; Fallopian tubes ; O, ovaries; L, round ligaments ; £r, ureter; a, ovarian vessels,
often prominent under their peritoneal covering (the infundibulo-pelvic ligament) ;
8 S, sacro-uterine ligaments.
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. 62),
and forms the upper border of Douglas's pouch. They contain
unstriped muscle-fibres, a direct continuation of those of the woml),
and have been called the retractor muscles of the uterus (Luschka).
Besides, they contain loose and fibrous connective tissue. They form,
toijether with the anterior vaginal wall, an elastic beam on wiiich the
uterus is suspended.^ They prevent the uterus from being pulled
down in the normal condition beyond the entrance to the vagina.
Working together with the round ligaments, their shortening produces
anteflexion.
1 Frank P. Foster, Trans. Am. Gyn. Soc, 1881, vol. vi. p. 434.
ANATOMY.
57
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.
The Right Wall of the Pelvis (Polk): .^.internal ilinc artery; 5, uterine artery; f, ovarian
artery ; JJ, course of the ureter, projected on pelvic wail ; JC. 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.
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 .'^j)ine
of the i.schium (Fig. 5;5). The upper edge is formed by the Fallo])ian
tube inward and tlu; infundibulo-pclvic! ligament outward. The
lower edge is attached to the mass of connective tissue lying to the
side of the cervix, and called paramvtriHiii or jxiravufru' connective
tit<Hne. The upj)cr edge is free ; the three other edges are continuous
with the peritoneal covering oi" 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 po.sterior layer contains
an opening, in which the l)as(' of the ovary is inserted. Px'lween
these two layei's lie loose connective ti.ssue, unstrijK'd muscular fibres,
bliKxl-ve.s.'^els, lymphatics, and nerv(!S. 'Hie mu.scular fibres are a
continuation of the outer layer of tlie uterine muscular coat, and form
58 DISEASES OF WOMEN.
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. 54, LS). This whole muscular expansion is capable of" producing
a kind of erection of the internal genitals, and it is probably also
instrumental in adapting the fimbriae of the tube to the ovary during
ovulation (Fig. OO).
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-pectineal emi-
nence to the sacro-iliac articulation.^ 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
elasticity, the broad ligaments, as well as the pelvic connective
tissue, are put on the stretch by ])ulling the uterus down.
The round ligaments (Fig. 54, LI) are two cords, one on either side,
springing from the anterior surface of the uterus immediately beloAV
and in front of the Fallopian tube, and going in a curve first upward
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-
cular fibres from the uterus, and striated fibres coming from the
transversalis muscle and the pubic spine. The funicular artery, a
branch of the superior vesical, runs through its centre and anasto-
moses at the upper angle of the uterus with the uterine and the
ovarian arteries, and in the labium majus with branches of the ex-
ternal pudic artery. The artery is accompanied by veins. The
genital branch of the genito-crural nerve lies in front of the liga-
ment at the external ring. Other veins and nerves join it from
below. At first it lies under the anterior layer of the broad liga-
ment. When it leaves the broad ligament it has a peritoneal cover-
ing of its own, which, as a rule, stops at the internal ring in the
adult. During the fetal life the peritoneum forms a pouch which
accompanies it through the inguinal canal, and is called the canal of
^ W. M. Polk, " Landmarks in the 0])eration of Gastro-elytrotomy," N. Y. Med.
Jour., May, 1882, vol. XXXV. jip. 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 anywliere else, to my knowledge.
ANATOMY.
59
Nuck, and corresponds to the processus vaginalis in the male. This
pouch normally grows together, forming a fibrous cord; but abnor-
mally it may persist and give rise to female hydrocele, or be found
as a sheath of the ligament in Alexander's operation. (See Retro-
flexion of Uterus.)
Fig. 54.
b
The vessels of the vagina and the internal genitals in their relation to the superficial muscu-
lar structures (Rouget). The specimen i.s seen from behinfl. Vascular system: VP,
vaginal plexus ; PC, cervical plexus ; PU, uterine plexus ; JIJ', helicine arteries of uterine
bcxiy; h, helicine arteries of hilum of ovary. Muscular system: 17', 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; L'S, uterine muscle-bundles which
accompany the preceding, and constitute to a great extent the posterior layer of the broad
ligament; VP, recto-uterine or sacro-uterine ligaments; J J, inguinal or pubic round
ligament, spreading over the whole anterior surface of the uterus ; LO, ovarian ligament ;
L>, superior or lumbar round ligament, which accompanies and envelops the internal
spermatic, or ovarian vessels; a, muscular bundles coming from the ovarian ligament
(7,0), spreading and interlacing with the bundles, 6, coming from the superior or lumbar
ligament (LS), in tlie interior of the ovary, and beyond in tlie ala vesperlilionis, liefore
they insert themselves on the tube and the fimbriae ; a', bundles starting from tlie ovary,
which, together with others coming directly from the superior ligament, form tlie
fimbria ovarica.
During pregnancy the round ligament becomes finger-tliick. It is
only found in women and the higher aj)(;s, who occasionally take the
erect position. It contracts when stimulated by electricity like other
mu.scles. JJoth 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'
' J. II. Kellogg, of Battle Creek, IMicli., Tran.'^. Am. Assoc. Obshi. and Cijn., 1889,
vol. ii. p. *2GG.
60
DISEASES OF W03IEN.
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.
srustomosfs
Sagittal section of uterus, showing the scheme of the arterial distribution (Clark).
The arteries of the uterus come from three chief sources : tlio
uterine artery from the internal iliac ; the ovarian from the aorta ;
and the small artery of the round ligament from the superior vesi-
cal. The uterine artery starts from the internal iliac about |r of an
inch below the brim of the pelvis, goes behind the ])critoncum on
the posterior wall of the pelvis, down into the parametrium, and
forms a loop in front of tiie ureter, a short distance from the an-
terior lateral fornix of the vagina (Fig. 56). (Compare Fig. 53.)
Hence it goes up between the two layers of the broad ligament,
ANATOMY.
61
following the edge of the uterus to the corner of the same, where it
anastomoses with the ovarian artery, one being simply a continuation
of the other (Fig. 37, p. 45). It sends numerous branches off at
right angles to the uterus, where they anastomose with those from
the other side. At the level of the internal os such anastomosing
branches in front and behind form the circular artery. In the outer
layer of the musculature the arteries have a longitudinal direction,
running parallel to one another, but freely anastomosing with one
another. From the innermost of these branches others go off at
riglit angles, penetrate the dee])er layers of the musculature, supply-
Fro. 56.
The Uterine Artery in its lU'lntion to the Ureter: a pliotographic reprortuetion of a section of
the pelvis, extending from the pectineal eminence above to tlie lesser saero-sciatic fora-
men below (l'(jlk). On the right .side the broad ligament has been removed : U. nterus,
right side freed of peritoneum: O, ovary ; (', base of bladder sliowing urethral orifice,
the organ having been cut away on a level with the utero-vesical peritoneal fold : the
doited line running acro.ss its iipper edge corresponds to the ntero-vaginal junction;
above this, at F, we have the ctircular artery of the cervix; .1, uterine artery : BB. ureter,
with a probe passing through it : />, nvariim artery ; E, round ligament, held up to show
the ovary and vessels behind it ; li, rectinn.
ing them with numerous anastomosing nutrient vessels, and finally
terminate in a rich cajiiliarv network in the endometrium (Fig. 5;")).'
Tlie trunk has a very tortuous course, and the branches are wound
like corkscrews, Jidicine ayirrics (Fig. 54, JIJ^). These branches
have so small a lumen and so thick a mu.-^cular coat that in many
cases the whole ut(n'us can be cut loose from the broad ligament
witliout using ligatures or elamj)s f(»r arresting hemorrhage.
During pregnancy the uterine artery remains comj^aratively small,
its calii)re equalling that of the ureter, while the ovarian is much
thicker.
'.]. (i. Clark, JohuK Ihpkim liulldhi, No. 91, Jan., 1S99.
62
DISEASES OF WOMEN.
Besides the six arteries of the uterus described above, it receives
the anterior and posterior azygos arteries from the vagina.
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 oiirry the blood to the internal iliac vein. At its
upper end this plexus anastomoses with the branches of the ovarian
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 tlie 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 tlie bladder is full ; h, portion of supravaginal part of
cervix covered by the bladder ; c, vaginal portion of uterus ; d, vault of vagina ; e, 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.)
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.
ANATOMY.
63
The Lymphatics. — The uterus is exceedingly rich in lymphatic
vessels. They begin in the mucous membrane between the bundles
of connective tissue. In the muscular layer are found similar ves-
sels, and they all communicate with a superficial network of vessels
in the serous membrane. From the uterus the lymphatics go through
the edges of the broad ligament. Those from tiie cervix form from
two to four large trunks which follow the uterine artery and veins
outward, and lie in the lower, and later in the outer edge of the
Fig. 58.
The lymphatics of the litems (Poirier) : 1, lymphatics from the body and fundus ; 2, ovary ;
3, vagina; 4, Fallopian tube : .">, lymphatics from the cervix; 6, trunks goiiifjr from the
cervix to the iliac glands; 7, trunks going from tlie body and fundus to the lumbar
glands; 8, anastomosis between cervical and corporeal lymphatics; 9, small lymjih-
vessel In the round ligament, going to the inguinal glands; 10, 11, lymphatic vessels
from the tube, which empty into the large vessels coming from the body of the uterus ;
12, ovarian ligament.
broad ligament. They arc as wide as the uterine artery, and go to
the iliac glands. Those from the body and fundus form two trunks
on either side, which lie in the upjxn' border of the broad ligament,
passing close to the hilum of the ovary. They follow the ovarian
artery, going out to the pelvic wall and then turning upward to the
lumbar glands, which lie in front of the lMinl)ar vertebne. On the
anterior surface of the sacrum are the sacral glands, which (•onncct
with the iliac and lumbar. The obturator gland at the inner opening
of the obturator canal is rarely found and stands in no relation to
64
DISEASES OF WOMEN.
the uterine lymphatics. Some lymphatics go from the uterus through
the broad ligament to the inguinal glands. The lymphatics of the
cervix and those of the body anastomose, both in the interior of the
The nerves of the pelvic organs of woman (Frankenhiiuser) : 1, nerves to fundus of uterus;
2, right Fallopian tube; 3, right round ligament; 4, nerves to Fallopian tube; 5, com-
munication between uterine and ovarian nerves ; 6. ovarian plexus of veins ; 7, ovarian
vein ; 8, nerve passing to ovarian plexus ; 9, fimbriated extremity of Fallopian tube ;
10, reflected peritoneum ; 11, uterine nerves; 12, superior hypogastric plexus ; 13, branches
from hypfigrastic plexus to uterus; 14. inferior hypogastric plexus; 15, vesical nerves;
16, communicating branches to vesical plexus; 17, cervical ganglion: ]<S, branches from
hypogastric plexus to cervical ganglion; 19, first sacral nerve; 20, branches passing to
bladder; 21, branches passing between bladder and rectum ; 22, communicating branches
from second sacral to cervical ganglion ; 23, branch from third sacral nerve to cervical
ganglion; 24, second sacral nerve : 25, branches from third sacral nerve to vagina and
bladder ; 26, branches passing from fourth sacral to cervical ganglion.
uterus and through a large vessel running in the broad ligament,
along the edge of the uterus.
The Nerves (Fig. 59). — Branches from the second, third, and
ANATOMY. 65
fourth sacral (spinal) nerves meet with others from the hypogastric
plexus (sympathetic) in a large ganglion on either side of the cervix,
from which cervical ganglion branches go the uterus, the vagina,
and the bladder. 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.' 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.^
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. 60), are two long, slender,
round tubes connected with the upper angles of the uterus. Their
Fig. 60.
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; 0, broad
ligament; 7, ovarian ligament; 8, infundibulo-pelvic ligament.
length varies between 3 and 5 inches. Tlio tube starts from tlio
' Joseph R. Beck, Am. Jour. Ohnf., 1H74, vol. vii. p|). 353-391.
'Several oases are on record of women with a fracture of ttip spine, eausinf^ coin-
(>lete paralysis of the aMoniinal muscles, in whom the child was expelled hv the
mere contractions of the womb.
66 DISEASES OF WOMEN.
highest point of tlie corner of the womb, above the round ligament
in front and the ovarian ligament behind, whence it goes first out-
ward, and then turns backward, lying near the wall of the pelvis,
above and in front of the ovary, and 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 fimbriae. The isthmus comprises about the inner third. It begins
Fig. 61.
Fallopian Tube laid open (from Playfair, source unknown) : ab, uterine portion of tube ; cd,
folds of mucous membrane ; e, tubo-ovarian ligament, or fimbria ovariea ; /, ovary ; g,
round ligament ; h, Graafian follicle.
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 fimbriae are the outermost part. They sur-
round the outer end of the ampulla like a collar with long flaps.
One of these, the fimbria ovariea, is attached to the free end of the
ovary, and forms a channel. In the middle of the fimbriae is the
ostium abdominale, which again is a very fine opening, leading into
the peritoneal cavity. Often a pedunculated hydatid is found at the
abdominal end. This was originally the end of the Miillerian 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
ANATOMY. 67
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
Fig. 62.
Transverse section of the Fallopian tube (Ahlfeldt), showing the complicated arrangement
of the longitudinal UAds (enlarged about twelve times).
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 a(a vcspertiUonh (bat's wing). The mesosalpinx
is continued beyond the end of the tube as the so-called {iifundibulo-
pelvic ligament, which goes from the fimbria? outward and backward
to the iliac fossa, whence it carries the utero-ovarian vessels (internal
sj)ermatic) to the tube and ovary.
The nmscular coat consists of an outer longitudinal, an inner circu-
lar layer, and near the uterus another longitudinal layer.^ It contains
most of the blo(xl-vessels.
The mucous membrane forms large and small longitudinal folds
(Figs. 01, 63). It covers the inner side of tiie fimbriie, while the outer
side is covered with peritoneum. It has a single layer of ciliated
' J. Whitridge Williams, Avi. Jour. Med. Sci, Oct., 1891, vol. cii. p. 378.
68 BTSEASES OF WOMEN.
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.*
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
Fig. 63.
Tube and Ovary of a Woman who died during menstruation, natural size (Farre) : I, broad
ligament ; o, ovary ; rr, old corpora lutea ; /, isthmus of tube ; i, fimbriated end spread
over ovary.
connected with a movable ovary, and the infundibulo-pelvic liga-
ment.
The arteries of the Fallopian tubes come from the ovarian artery
(Fig. 37).
The veins go to the pampiniform plexus iu tlie broad ligament.
The lymjyhatics 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 iu 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
^ Otto Cohen, Med. Moiiatsschr., New York, Sept., 1890, vol. ii. p. 413.
ANATOMY. 69
ovary, so as to catch the ovum when it leaves the Graafian follicle
(Fig. 63). 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,
is absorbed. If copious, it forms periuterine hematocele. The ova
perish or give rise to abdominal pregnancy. Some may also be sec-
ondarily attracted to the Fallopian tubes by the current produced
by the movement of the cilia of the latter.
The Ovaries.
The ovaries (Fig. 64) 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 1 J inches long, 1 inch wide,
and I 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
Ovary and Tube of a Nineteen-year-old Girl, seen from behind (Waldeyer) : U, uterus ; T,
tube; LO, ovarian ligament (of uinisual length); o, ovary; x, limit of peritoneum. (The
inner end of the ovary is too high.)
epithelial cells,^ 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 po-sterior end, an anterior outer edge, a
posterior inner edge, an upper anterior outer surface, and a lower
posterior inner surface.^ The inner end is fastened to the corner of
' As some authors deny tlie fact, first pointed ont by Waldeyer, that the ovary is
not covered with peritoneum, I wish to state tliat I have satisfied myself hy numer-
ous examinations of ovaries of women of the correctness of the above.
* The reader will understand this mudi more readily if he takes an oblong box
and gives the surfaces, ends, and edges tlie above indicated directions.
70
DISEASES OF WOMEN.
the uterus, behind and below the tube, by means of the Ugammt of
the ovary, a round cord, 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 continu-
ation of the outer layer of the uterine muscular tissue. This inner
Fig. 65.
Ovary and Tube of Girl twenty-four years old, seen from behind (Waldeyer): f7, uterus; T,
tube ; LO, ovarian ligament ; o, ovary ; x, limit of peritoneum ; b, cicatrice after ruptured
Graafian follicle.
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. 64). The anterior edge is
nearly flat, and bound to the posterior layer of the broad ligament.
The place where the vessels and nerves entei' 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.^ 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.
* 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 very different
positions, so that expressions like upper and lower, inner and outer, are taken in
the opposite sense by different authors.
ANAT03IY. 71
In a young girl the surface of the ovary (Fig. 64) is even, smooth,
velvety, of pearl-gray color.
Later, each ovulation leaving a little puckered cicatrix, the sur-
face becomes harder and shows irregular depressions (Fig. 65), and
in old age it becomes nearly cartilaginous and loses part of its epi-
thelium.
As to its composition, the ovary may even macroscopically be
divided into an outer part, called the parenchymatous zone, or coi'ti-
FiG. 66.
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 ; y, a follicle from which the ovum has accidentally escaped ; 10, corpus
luteum.
cal 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 albwjinca (Figs. 66 and 67). 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 ali)uginea 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
foun<l another with much larger Graafian follicles. The tissne in
which tiiese tbllicles are inii)e(l(led consists chieHy of unstri])ed mus-
cle-fil>res and connective tissue, which are arrang('<l in circles around
each follicle. The centre is formed by the so-caiUid vwdullari/ .sub-
stance, or vascular zone. Here the connective tissue is much looser
than in the parenchymatous zone, but it is full of uiistrij)e(l muscle-
72
DISEASES OF WOMEN.
fibres, as well as the parenchymatous zone. The largest vessels are
found most centrally and nearest the hilum. Nearer the surface and
Fig. 67.
Part of the Same Section as represented in Fig. 66, 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; 6, discus proligerus; c, ovum; d, germinal
vesicle; e, germinal spot.
Fig.
J layers
Zone ofsmalll
follicles
Zone oflargi
follicU
Columnar'
mlthdium
Zone of ^ne
vessels
Loose connect-
ii/e (issue ivtth
large t^essels.
ffilmn
Diagram of Zones in Human Ovary.
the free end they are smaller. A diagram (Fig. 68) 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
ANATOMY.
73
being narrower near the* hilura and increasing in width toward the
free border.
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. 69.
Graafian Follicle of Adult Woman, 40 : 1 (De Sin6ty) : 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.
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. 69) consists of two layei*s, 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 ti.ssue, they are easily pulled out. Inside
of the tunica propria are found several layers of ej)ithelial cells, together
called the memhraiia gramihsa. On one side these epithelial cells
form a mass protruding into the cavity of the follicle, and called
(Hmchh proligerus (Fig. 67, h). The outermost layer of cpitlielial
cells of the Gnuitfian follicle has a regular columnar shaj)e ; tlie
74 DISEASES OF WOMEN.
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 folUculi, which contains a few cells, albumin, and paralbumin.
It is formed by liquefaction of the cells of the membrana granulosa.
Fig. 70.
r**^
Mature Ovum of Rabbit, Hartnack f (Waldeyer) : a, cells from the discus proligerus (epi-
thelium of ovum); 6, zona pellucida; c, vitellus; rf, germinal vesicle; e, germinal spot;
/, large globules with dull lustre in the germinal vesicle.
In the discus proligerus is imbedded the ovum (Fig. 70). 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 stripe, the zona pellucida, or vitelline
membrane} The interior is filled with a semifluid mass called the
vitellus. 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.
Corpus Luteum of 3Ienstr nation. — The Graafian follicle undergoes
certain changes. As a rule, one attains during the intermenstrual
^ The vitelline membrane is something entirely different from the yolk-sac,
although one name might seem to be a translation of the other.
Fio. 74.
Fkj.
Fio. 71.— Ovary nf Woman two days after Menstruation fDalton), showing carlitst sta^e of
a ruiitureil ami bloody (inuitlan follirlc into a corpus liitcuni.
Fl<j. 72.— Ovary of Woman twenty days after Menstruation < Kalton). JJesides larvre fresli
Been two smaller old on»-s. ami (iraafian follicles of ditl'crent size.
Kio. 73.— Ovary of Woman nine days after Menstruation ilmlloin. Tlie dark s|iot Is the
roundiUK yellow circle is the corj)U» luteum shining throutrli the traiisjiarenl tisstie.
Fio. 74.— Ovary of Woman at Term of I'reKiianey iDaltoii), showing corpus luteum with tirm
Vui. 75.— False Corpus Luteum (I)alton).
transfo
corpus
ciciitri(
white c
rmalion of
luteuiri arc
•e ; the sur-
entnil (•l(.t.
ANATOMY. 75
period the size of a hazelnut (^ 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. 71). 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
follicle (Fig. 72). 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. 73). 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 seklom liappens that we do not find three or
more corpora lutea in different 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 month 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
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 iu the centre of the
yellow ring (Fig. 74). Sometimes this clot has itself a central cavity
filled witli 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 freslmess of its yellow hue. At the end of
pregnancy it is reduced to about one-half of a cubic centimeter.
There is up to this date great diversity of opinion among diiferent
observers of equally high standing as to the origin of the corpus
luteum. According to von Baer, it arises from the internal layer
of the wall of the fTniaflian follicle, while, according to liischoff, it
arises from the epithelium of the follicle — the membrana granulosa.
Dr. J. G. Clark, who has used new methods of investigation,
declares himself in favor of the first theory. He says that the lutein
cells — those characteristic of the corpus luteum — are specialized
connective-tissue cells, which appear in tlu; inner layers of the I'olli-
cle-wall at the time when it begins to show a differentiation into
two layers — the theca interna and externa. In tlu' mature follicle
is found a fine reticulum stretching from the theca externa among
the lutein cells, beyond whi(;h it is woven into a more or less fine
76
DISEASES OF WOMEN.
line known as the membrana j)ropria — not to be confounded with
the above-mentioned tunica propria, which is the same as the
theca interna. At the time of the rupture of the follicle, this
membrana propria is broken through in several places by the
advancing lutein cells and blood-vessels, but quickly a connect-
ive-tissue line reforms in front of the lutein cells, which ])ush it
toward the centre, where it finally forms a dense core of inter-
lacing fibres.
The retrogression of the corpus luteum is characterized first by
the fatty degeneration of the lutein cells, followed by the shrinking
Fig. 76.
Fig. 77.
Fig. 76.— Ovary of Woman thirty-six years old (natural size) : a, albuglnea ; h, red zone ; c,
rf, e. Graafian follicles situated in the red zone, which here broadens;/, all the remainder
is taken up by yellow tissue indistinctly divided into several parts, probably corpora
lutea of menstruation in retrograde metamorphosis.
Fig. 77.— Ovary of Woman forty-seven years old (natural size): a, corpus luteum with cen-
tral cavity ; 6, another corpus luteum ; c, a third small one ; besides this thirteen yellow
bodies could be counted on the cut surface, and there were perhaps more in the" invis-
ible p«rts of the ovary.
Fig. 78.— 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 ; d, albu-
ginea.
of the connective-tissue net into a compact body (corpus jihrosum),
after which it is gradually removed through hyaline changes until
a very fine scar-tissue is left, which is at last lost in the ovarian
stroma. Cessation of ovulation is induced through the densification
of the ovarian stroma and a destruction of the peripheral circula-
tion, which prevents the development of follicles.^
False Corpora Lutea. — Sometimes Graafian follicles degenerate.
The wall becomes thick, opaque, whitish, and assumes a slightly car-
tilaginous consistency. The fluid in the interior disappears, and the
opposite surfaces come in contact M'ith each other. Tlie ovum dis-
appears also. These follicles lie in the deeper parts of the ovary, and
do not communicate with the surface (Fig. 75, colored plate, p. 76).
' J. G. Clark, "The Origin, Growth, and Fate of the Corpus Luteum of the Pig
and Man," Johna Hopkins Hospital Eeport.% vol. vii, 1898. Several points in this
article had already been elucidated by Dr. Mary Dixon Jones in the New York Med.
Jour., May 10 and 17, 1890.
ANATOMY. 77
They may be called false corpora lutea.^ 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.^
Quite frequently large or small extravasations of blood are found
in the tissue of the ovary .^
The ovary has a rich supply of blood- and lymph-vessels, which
enter at the hilum. The arteries (Fig. 37, colored plate, p. 45) 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 tlie 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. 62). 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 hypogastric
plexus (Fig. 30, 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 ovaries, like
other glands, probably have an internal secretion that plays u great
role in tiie general economy of the body. (See Results of Salpnigo-
oupiiorectoniyj.
The Parovarium.
The parovarium (Fig. 79) is a remnant of the Wolffian body (see
p. 22). It is situated in the connective tissue between the two layers
^ The term " false corpus luteum " is often, but less properly, used in the sense
of corpus luteum of menstruation.
'^ John C. Dalton, "Report on the Corpus Luteum," Am. Gyn. Trans., 1877, vol. ii.
pp. 111-160.
^ In 1879-80, while investigating abdominal fluids, I made numerous sections of
apparently normal human ovaries. In so doing I got the ini{)ression that there are
many jirocesses going on in the ovaries which are not yet described. Other work
has prevented me from following this track, Init it may be permissible here to jioint
out the large numljer of yellow masses we find in seemingly normal ovaries of
women. Fig. 7(5 is drawn in natural size from tlie ovary of a woman ihirty-six
years olil, cut open lengthwise. I'nder tlie albuginea was found a red zone with
three Gra-atian follicles, and the whole interior was taken up by yellow tis.-ue indis-
tinctly divided into several jiartc.
Fig. 77 is likewi.* drawn from nature, in the exact size. It represents the ovary
78 DISEASES OF WOMEN.
of tlie 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 light. It is a small, flat, triangular
organ, the apex of which touches the attached edge of the orary.
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 and cord
correspond to Gartner's canal in certain animals (see p. 20), and are
Fig. 79.
Adult Ovary, Parovarium, and Fallopian Tube (Kobelt) : aa, parovarium ^or epophoron) ; 6,
remains of the uppermost tubes of the Wolffian 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 Wolffian duct; ft, the Fallopian tube; i,
hydatid of Morgagni ; I, ovary.
a remnant of the Wolffian duct. The tubules have a wall com-
posed of connective tissue, unstriped muscle-fibres, and a ciliated
columnar epithelium. At the outer side there are some tubules
which do not reach the ovary, and one of them, the end of the
transverse tube, terminates often in a small cyst similar to the
hydatid Morgagni (p. 30). At the inner side there are some tubules
which have lost their lumen and become fine cords.
The parovarium has no function, but is liable to become the seat
of cystic degeneration.
of a woman forty-seven years old. It shows a corpus luteum, a large yellow mass,
and thirteen distinct small yellow masses. Examined under tlie 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. 1
am inclined to think that all this yellow pigment is a remnant of old corpora
lutea.
Fig. 78 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.
ANAT03IY.
79
The UiiiNARY 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 rdsum^ of their
anatomy would seem indispensable.
Fig. 80.
> i^f
The Urethra.
The urethra is a canal leading from the bladder to the vulva. It
is from 1 to IJ 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
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 wliich it is surrounded by the compressor
urethrse muscle, or Guthrie's muscle. An-
other sphincter muscle surrounds the urethra
and the vagina togctlier as a narrow belt just
behind the vestibulo-vaginal bulbs.
The urethra has an outer layer of circular
unstrij)ed muscle-fibres, an inner longitudinal
layer, and a mucous membrane.
Tlie meatus urinarhis has already been de-
scril)ed in speaking of the vulva (see p. 39).
The mucous membrane, when not distend-
ed, forms longitudinal folds. It has many
dej)ressions and blind canals, so-called J/or-
f/fff/ni's lacunce, and racemose glands (IJttrc's^
glands). Near the floor, just inside of the
meatus, are found two canals, Skoie's r/Iands,^
or urethral ducts (Fig. HO), one on either side,
probe of the French scale, and extend upward, ])arallel to the long
axis of the urethra, from ^ to -} of an inch, in tlu^ nuiscular tissue,
below the mucous membrane. The mouths of these tubules are
' This name is often erroneously spelt Littr(?, which is that of the author of a
dictionary, just as (Jartner almost invariably is called (iiirtner, and Bartholin often
Rartholini. Hoth were Danes.
'Skene, "The Anatomy and I*afholop;y of Two Important Glands of the Feninle
T'rethni," Am. Jour. Obstet., 1880, vol. xiii. p. 205. Their glandular nature has
been contested.
The Urethra laid open from
behind ; probes introduced
into the urethral ducts
(Skene).
They admit a No. 1
80 DISEASES OF WOMEN.
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, sur-
rounded by a rich network of veins, and has a stratified flat
epithelium.
Vessels and nerves are derived from those of the vagina.
Functions. — The function of the urethra is to serve as an outlet
from the bladder. Its muscular tissue works probably as a sphinc-
ter for the same.
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 ; when distended, it
reaches more or less into the abdominal cavity, lying close against
the abdominal wall. When empty, it has been found in two dif-
ferent shapes — either so that the upper part falls against the lower,
the cavity combined with the canal 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.^
The female bladder is shorter than the male in the antero-posterior
direction, but more than makes uj) 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
surfaces, and two sides. The base or fundus ^ 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 0])enings are
found on it. In front is the internal opening of the urethra, wliich
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
^ 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.
' 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.
ANATOMY.
81
where the ureters open into the bladder. The triangle between
these three openings is called the trigone (Fig. 81). Each of its
sides measures about an inch. The base is formed by the intra-
ureteric ligament. The distance from this to the cervix uteri varies.
Fig. 81.
Uterus, Ureters, and Upper Part of Varina of Woman forty years old, J natural size. All
measurements were made in mtu with compasses, and then marked on the paper without
regard to foreshortening : a, ureters ; b, uterus ; c, Fallopian tube ; d, ovary ; e, round liga-
ment; i*', broad ligament; g, connective tissue; h, bladder (the antero-superior part re-
moved to show attachment to cervix and vagina); t, vesical opening of ureters; j', inner
aperture of urethra; k, urethra ; I, vagina ; m, incision and rent in the operation called
gastro-elytrotomy as originally jKjrformed by I3audelo(;que.
I have found it immediately under the os and half an inch below it.
AV^hen 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 | inch on the cervix.
«2
DISEASES OF WOMEN.
From tlie summit the uraclms, one of the false ligaments of the blad-
der, goes to the umbilicus. The anterior surface lies against the body
of the pubic bones and the anterior abdominal wall. It has no peri-
toneal covering. The posterior wall is covered with peritoneum
down to the level of the internal os, where it passes to the uterus.
Fig. 82.
Fig. 83.
X 350.
X 350.
Fig. 82.— Superficial Layer of the Epithelium of the Bladder, front view, composed of poly-
hedral cells of various sizes, witn one, two, or three nuclei (Klein and Noble Smith).
Fig. 83.— Deep Layers of Epithelium of Bladder, side view, showing large club-shaped cells
above and snialler, more spindle-shaped, cells below, each with an oval nucleus (Klein
and Noble Smith).
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 stri])ped of its peritoneal coat. The muscular
coat has an outer longitudinal and an inner circular layer of unstripetl
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 o])ening to the urethra, which disposition prob-
ably serves to press out the last drops of urine during micturition.
The mucous membrane, examined with the galvanic cystoscope,
has a bright pink color. In general it is loosely attached to the
muscular layer, and forms folds when the bladder is empty. But at
the trigone it is attached more solidly. It contains numerous lacuna3
and racemose glands. It is covered with transitional epithelium, in
which several layers are discernil)le, an upper of flat and several
deeper of large and small pear-shaped cells (Figs. 82, 83). The
raucous membrane seems to be able to absorb substances injected
into the bladder.
Between the mucous membrane and the muscular coat there is,
with the exception of the trigone, a well-developed submucous layer
composed of connective tissue, elastic fibres, vessels, and nerves.
ANATOMY. 83
Ligaments. — The bladder has four true aud five false ligaments.
The ti-ue 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-
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 sujierior. The posterior are
the vesico-uterine ligaments (see p. 56); the lateral false ligaments
extend from the iliac fossse to the sides of the bladder, each separated
from the posterior ligament by the obliterated hypogastric artery.
The superior false ligament (ligamentum snspensorium) 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 snspensorium.
The urachus is a remuant of the allantoid 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.
Very rarely the whole bladder is found in the adult woman
extending up to the umbilicus between the aponeuroses of the
abdominal muscles and the peritoneum (see Hysterectomy).
Vessels and Nerves. — The a/'^mcs come directly from the internal iliac
{i\\Q superior, middle, and inferior vesical arteries) or from its branches,
the sciatic, internal pudic, middle hemorrhoidal, and uterine arteries.
The re/T^.s form large plexuses comnnniicating with those of tlie uterus,
vagina, vulva, and rectum, and sending their blood to the internal
iliac vein. The lympJiatics follow the veins and open into the in-
ternal iliac glands. The nerves come from the hypogastric plexus
of the sympathetic and the sacral nerves (cerel)ro-sj)inal).
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.
84 DISEASES OF W03IEN.
The Ureters.^
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 bcr
tween their two ends. At their upper ends the distance between them
is 21 inches. From this point they go, with the exception of slight
windings, parallel with each other, 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 in front ; the right lies
close to the outer side of the inferior vena cava, behind the ileum.
The left lies behind the sigmoid flexure 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 internal iliac (Fig, 84),
which lie behind them, 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. 62), behind
the loop formed by the uterine artery (Fig. 56, p. 61). 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.
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 gi'eat
change. Its middle part, that which in the unimpregnated condition
^ 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
Remarks on Gastro-elytrotomy," Amer. Jour. Obstet., 1883, vol. xvi. pp. 45-49).
ANATOMY.
85
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. 84.
The Course of the Ureters, from a woman fifty-seven years of age, with atrophic uterus, J 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 of 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 ])asses under
the broad ligaments, and in front of the.se it lies again immediately
under the peritoneum. From the point where it opens into the blad-
der to the po.stcrior surface of the pubis behind the spine is a dis-
tance of 3 inches. It will thus be seen that while the posterior ])art
of the course of the ureter through the pelvis is lifted to so high a
level, the anterior end retains its position.
Structure. — The ureters have a fibrous coat, a muscular coat, M'ltii
86
DISEASES OF WOMEN.
Fig. 85.
an outer circular and an inner longitudinal layer, and a mucous
membrane, with transitional epitliclium composed of an inner short
layer, a middle columnar with long processes, and a deep layer of
rounder and smaller cells (Fig. 85). The cells of the deeper layers
very much resemble those in the deeper
layers of the bladder epithelium. When
not distended the mucous membrane
forms longitudinal folds. It has no
glands.
Vessels and AWves. — 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 wnth
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 wiiich 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 illo-sacral articulation (Fig. 52, p. 56), goes
first downward, backward, and inward, in front of the third or fourth
sacral vertebra, to the median line ; here it turns forward and lies in con-
tact with the cervix and the vagina (Fig. 49, ]). 54) ; finally, an inch
from its end it turns rather sharply downward and backward at a
right angle with the second part. This last part is called the anal
canal (Figs. 33, p. 42, and 49, p. 54), and is the narrowest por-
tion, while the part situated immediately above it is the widest, and
Epithelium of Pelvis of Kidney of
man X 350 (Kolhker): A, single
cells ; iJ, 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.
ANAT03IY.
87
is called the rectal ampulla. From here the gut tapers gradually to
the upper end (Fig. 86). It is about 8 inches long, and when empty
Fig. 86.
Rectum inflated with Air (Chadwick) : D, D', anterior and posterior segments of the superior
detrus(jr fsecium (so-called third sphincter) ; Ji, rectal ampulla ; t "ud *> the same points
80 marked in Fig. 8U.
about 1| inches from c(\<2;q to cdt^c, but capable of such a distention
that it sometimes nearly fills tlie pelvic cavity. Tlie way in which
it collapses when empty depends probably on the condition of the
vagina and the bladder. If those are empty, the rectum collajiscs
from side to side (Fig. 34, p. 43), but if the other cavities arc dis-
tended, it becomes compressed in an antero-})()stcrior direction.
Structure. — The rectum is composed of" a ])eritoneal 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 upj)er is completely
covered, and has even sometimes a mcsorcctuia ; tlie middle is cov-
ered with peritoneum in front only (Douglas's pouch); and tlic third
88
DISEASES OF WOMEN.
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. Tlie longitudinal layer is spread all over, and does not form
such bands as on the colon. Besides this, the mucous membrane con-
FiG. 87.
The Lower End of the Rectum in Vertical Section (Rvdvpier) : ], 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 niuscularis mucosae.
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. 87).
ANATOMY.
The external sphincter ani muscle (Fig. 88, 13) is an elliptic layer
of striped muscular fibres which surround the anal opening and lie
directly under the skin. Behind it is attached by a tendon to the
tip of the coccyx ; in front it blends with the transversus perinei
Fig
Muscles of the Perineum (Breisky): 1, glans clitoridis; 2, corpus clitoridis; 3, meatus urln-
arius; 4, tendon of ischio-caveruosus muscle; 5, bulb; 0, ischio-cavcrnosus muscle; 7,
vaginal entrance ; 8, sr)hincter vagina; or bulbo-cavernosus muscle ; 9, fossa navicularis;
10, Bartholin's gland; 11, superficial transversus perina-i muscle; 12, anus; 13, sphincter
ani externus; M, 15, levator ani muscle; 10, coceygeus muscle; 17, great sacro-sciatic
ligament; 18, obturator iuternus muscle ; 19, gluta.'us maximus ; 20, os coccygis.
and sphincter vaginae muscles. It is the true vohmtary sphincter
by which feces and gases are kept back.
The internal sphincter ani muscle is only a thicker ])art of the cir-
cular layer of the rectum situated inside of the external sphincter,
and consi.sts of unstriped muscle-fibres, with a considerable admix-
ture of striped fibres. It receives fibres from the deep layer of the
90 . DISEASES OF WOMEN.
deep perineal fascia, from the superficial transversus perinei, and
from the bulho-cavernosus muscles. It surrounds the anal canal,
and is an inch hi(;h. It contracts and relaxes by reflex action, and
is not subject to the -will.
Tiie levator anl muscle (Figs, 88, 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
colunms of Morgagni, and the depressions between them are called
the sinuses of Morgagni. In the u}>per 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. 89), 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.'
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 ivhite line.
Melatipns. — 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
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
of the perineal body, which separates it from the entrance to the
vagina and the vulva.
Vessels and Nei'ves. — The rectum has an abundant blood-supply.
The arteries are the superior hemorrhoidcd 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
from the internal pudic. The veins form a rich plexus, and lead the
blood tiiroutrh 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
^ J. K. Chadwick, "The Functions of the Anal Sphincters, so-called, and the Act
of Defecation," Tran-s. Am. Gyn. Soc, ii. pi>. 43-56. I have, however, frequently
palpated these folds on patients, and do not find that it causes any expulsive eflbrt
ANATOMY.
91
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
Fig. 89.
RectiiTti cut open lonKitudinallv, find tlie mucous in(.nitjrane dissected off, so as to show the
circular muscular fibres 'Ctiadwick) : J)jy, anteridr aud posterior segment of the superior
detrusor (Veciuin (or third sphincter); .S", inferior detrusor fkcium (or internal spliincter);
A, aims; + and * correspond to the same points in Fip. 8."). This drawing shows the mus-
ctilar fibres passing from the anterior to the posterior segment of tlie superior detrusor, by
the action of whicli they may be approximated to eacli other.
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, aiul
pulling the relaxed part of the intestine up over the fecal mjLss. The
internal s[)hiiu;ter can, by its contraction, push the nnicous membrane
out through the anus, and thus bctjomes an expulsive muscle, as is
very apparent in the horse. Tin; mucous membrane is ca|)able of
92 DISEASES OF WOMEN.
absorbing, which explains many bad eifects 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.
Pelvic Peritoneum with Empty Bladder ; mesial section of frozen body, J (Fiirst). The dotted
line indicates the peritoneum ; a, rectum ; b, vagina ; c, bladder ; d, uterus ; e, below pouch
of Douglas ; /, symphysis pubis.
It has been likened to a cloth which is being lifted up by pushing
the organs from below u]) under it, by which they themselves acquire
ANAT03IY.
93
a covering and certain folds and pouclies 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
it. Beginning in front, the peritoneum passes from the anterior
abdominal wall at the upper end of the symphysis pubis to the top
of the bladder (Fig. 90), covers its posterior wall down to the level
of the internal os of the uterus, and its sides behind the obliterated
hypogastric artery. When the bladder is much distended it rises
into the abdominal cavity, and the peritoneum forms a pouch be-
Diagram designed to show the antero-posterior outline of the pelvic peritoneum in the mesial
pelvic plane, with distended bladder (Ranney): P/', peritoneum ; Ji, rectum; t/, uterus;
B, bladder; S, symphysis pubis. The vesico-abdominal, the vesico-uterine, and Douglas's
pouch are made very apparent.
tween the abdominal wall and the bladder (the vcmcn-ahdomimd
pouch), the deepest point of which lies an inch above the symphysis
(Fig. 91).
From the posterior surface of the bladder the pcvitoiieum ])n.<ses
to tiie anterior wall of the uterus, covering it entirely above the
cervix, and leaving a ])ouch between the two called the rrs-iro-iiferhie
pouch. When the bladder is over-di.'^tended, the bottom of this
])ouch is raised a little, as represented in tiie figure Next, tlu^
peritoneum covers the whole posterior surface of the uterus, and
94 DISEASES OF WOMEN.
generally it goes even an inch behind the posterior wall of the vagina,
and thence it passes to 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-vaginal
junction, and in other cases extending down as far as the entrance
to the vagina. Tlic peritoneum covers the anterior surface of the
middle portion of the rectum, surrounds the whole upper portion of
the same, and passes to the sacrum as the meso-rectum.
From the sides of the uterus the peritoneum passes 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. 51, p. 55). The anterior compartment as a whole
is called the utcro-abdominal pouch. In it we notice the utero-
vesical ligaments and the round ligaments of the uterus. It is
filled by the bladder, and, Avhen this is empty, by loops of the small
intestine. Laterally, near the entrance to the obturator canal, it
has been designated as the obturator pouch, or paravesical pouch
(Fig. 52, p. 56). 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
portion — i. e. Douglas's pouch — and two shallower lateral portions
called para-uterine pouches. The bottom of this para-uterine pouch
has been specially designated as the retro-ovarian shelf (Polk). The
sacro-uterine ligaments form the boundary -line between these three
portions. On tlie side walls of the para-uterine pouch the ureters
are seen running under the peritoneum (Fig. 52, p. 56). The ovaries
project into the lateral pouches, which also contain loops of the
small intestine. Tliese are likewise found in the upper part of
Douglas's pouch.
In reference to the elevation of the peritoneum during pregnancy,
see the description of the broad ligaments and the ureters (pp. 57
and 84). The para-uterine pouch is lifted up to the pelvic brim ; the
para-vesical poucli 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.
95
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 forms one continuous layer, which is a continuation
of the corresponding layer of tiie 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. y2.
Coronal Section of Pelvis, showing- tlie three cavities of the pelvis: the peritoneal, the sub-
peritoneal, and the subcutaneous (I^usehlia).
rotomy. It is continued behind the symphysis as rctro-puhh fat
(Fig. 89), and lies here in front of the l)ladder. Between the base
of the bladder and the vagina the connective tissue is rather tight.
On the posterior surface; of the vagina tliere 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 little connective tissue without fat, but during pregnancy
it becomes much looser and increases in bulk. The reetiun and the
vagina are again imbedded iu considerable masses of fatty connective
96 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 subperitoneal connective tissue forms a fun-
nel-shaped mass around the cervix and downward around the vagina
to the insertion of the levator ani nmscle (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).^
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-pectiueal 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 intern us muscle, and is also called
the obturator fascia. It sends a thinner prolongation backward,
covering the pyriformis muscle, and called the pyrifo7'mis 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
^ The distinction was made by Luschka, but his names, cavum peritoneale, oavum
subperitoneale, and cavum subcutaneum are bewildering, the two latter " cavities "
being filled with solid tissue.
ANATOMY.
97
the obturator internus 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 (Savaprc): B, bladder: V, vapiiia ; /?, rectum; P. symphysis pubis;
S, sacrum ; a. fascia covering psoas muscle; 6, obturator fascia; r, tendinous arch; d,
reflection of fascia on to the rectum, vagina, and bladder; e. posterior portion of fascia
covering sacral vessels and nerves; f, iliac fascia covering iliac vessels; (7, gluteal ves-
sels ; h, sciatic vessels ; i, internal pudic vessels ; k, obturator vessels.
From its insertion on the ])elvic wall the vcsico-roetal fa.scia goes
inward and downward, covering the upper ,'^urfaco of the levator ani
muscle, to the base of the bladder, the; vnginn, and the rectnni. In
front, near the middle lino, a thicker, narrow ])art of this fascia forms
the anterior true lujaracnh of (he Uaddcr, or the piiho-rc.sical lU/amcnfs
(see p. 83).
I^tween the two ligaments tlu; fascia is thin and depres.'^ed. Out-
side of this ligament lies another, thicker band, the /dfcral tnie Ilf/n-
merii of the bladder, which is attached to the side of the bladder.
98 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 a band goes to the side of the rectum, which
is called tiie 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
Fio. 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 ])ouch 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 ])elvic fascia forms a very irregular fibrous layer
under the peritoneal cavity and the underlying loose connective ti.ssue,
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. 99
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-coccygeus, the obturato-
coccygeus, and the ischio-coccygeus (Savage), but not one of the fibers
that start from the pul)es is inserted on tlie 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-coccygem). 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 (71/. obturato-
coccygeus).
The pubic portion (31. pubo-coccygeus) 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 sujiport it from below (Fig. 95). The
muscle goes in between the external and internal sjihincter, 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 ])ortion of the levator ani muscle (M. obfurato-coc-
cygeiui) goes with convergent fibers to the rectum and the coccyx.
It takes part with the pubi(^ portion in the formation of a looj) behind
the rectum, and another i)art of it is inserted on the fourth coccygeal
vertebra.
The ischio-coccygeal muscle (= the cocof/geus) 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 vertebrie of the sacrum.
Function. — The jxjlvic diaphragm strengthens the pelvic floor; in
100
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 sup])ort for
the uterus and the bladder. It is the antagonist of the thoracic
diapliragni, being relaxed under inspiration and contracting under
expiration. By inserting a Sims's speculum it is easy to see the
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) :
rhythmical movement synchronous with respiration. The anterior
wall of the vagina goes downward and backward during inspiration,
and upward and forward during expiration.
The pelvic diaphragm lifts the rectum up during the act of defeca-
ANATOMY.
101
tion, and draws the anus forward in the direction of the symphysis.
It exercises a similar function toward the vagina during childbirth
by 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 on either side by the
descending ramus of the pubic bone, the ascending ranuis and the
tuberosity of the ischium, the lower edge of the gluteus maximus
muscle, and the tip of the coccyx. In depth it comprises all the
Fig. 96.
Diagram of the Fascia of the Pelvic Floor in mesial section, to show how tiie levator anl
muscle is backed by strong and dense sheets of fibrous tissue (Dickinson): 1, superficial
perineal fascia, outer layer (this we call simplv subcutaneo\is adipose tissue) : '2, super-
ficial perineal fascia, inner layer (our superficial perineal fascia); '.i, triauKular liKanient,
or deep perineal fascia, outer layer: 4, triangular ligament, or deep perineal fa.scia, inner
layer; 5, vesico-rectal (part of pelvic) fascia.
ti.ssue lying within these boundary-lines between the surface and the
pelvic diaphragm. It is shorter and broader than in man, and con-
tains more fat. It may be subdivided by a line drawn just in front
of the tuberosity of the ischium on either side into two triangle.^,
an anterior or uro-cjenital region, and a posterior, or (imd region.
102
DISEASES OF WOMEN.
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 attached 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 triangidar 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 pekis
(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, showing
posterior wall; O, ischio-rectal fossa filled,
■with fat; I, ischial tuberosity; B, perito-
neal cavity; D, recto- vesical fascia cover-
ing ujiper surface of levator ani muscle ;
C, anal fascia covering lower surface of
levator ani; N, obturator fascia; P, pos-
terior aponeurosis 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
transvers\is perina'i muscle ; 3, bulb ; 4,
deep perineal muscles.
ANATOMY. 103
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. 96), 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
perineal fascia come together, at the posterior margin of the super-
ficial transversus perinaei muscle, they are fortified by a strong trans-
verse fibrous baud, 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 fascise 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. 88, 12). It is surrounded by
radiating folds of tiie 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 tiie rectum and the ischium is found a space on either
side which is called the isohio-recial fossa, and has the shape of an
irregular triangular pyramid. Its top is at the spine of the iscliium ;
the inner wall is formed by the levator ani muscle, covered by the
anal fascia, the outer by the obturator intcrnus muscle, covered by
the obturator fascia, below the line of dcniarkation between that fascia
and the vesico-rectal fascia covering the upper surface of the levator
ani muscle (p. 90). Its entrance from below is bounded by the
lower edge of the gluteus maximus and the greater sacro-sciatic liga-
ment behind, the transversus j)erinaei superficialis muscle in front, and
the external sphincter ani on the inner side. Posteriorly thes(> two
spaces communicate by means of the loose adipose tissue behind tlu;
rectum and pelvic fascia. In front the fossa is limited by the line
of junction of the superficial and deep perineal fasciic. I Fere it be-
104
DISEASES OF WOMEN.
comes narrow, but may be followed above the deep fascia of the
perineum along the origin of the levator ani muscle. It appeal's
triangular both on perpendicular and horizontal section (Fig's. 92
and 97). . .
The above-mentioned fasciae constitute a frame-work in which lie
imbedded muscles, blood-vessels, nerves, and other organs.
B. Penneal Muscles. — In the uro-genital triangle we find a super-
ficial layer of three pairs of muscles (Fig. 88, p. 89) situated between the
Perineal Muscles (Henle) : CL, clitoris turned over to the left side ; CCC, corpus cavernosum
clitoridis : CCU, corpus cavernosum urethra, or vestibulo-vaginal bulb; CVA, anterior
column of vagina ; CW, vulvo-vaginal gland ; BC, 1, 2, 3, bulbo-cavernosus muscle ; JC, 1, i,
ischio-cavernosus muscle : TPS, transversus perinsei superflcialis ; 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
hulho-cavernosus, or sphincter vagince muscle; and the superficial
transversus pei'inoei muscle.
The vichio-cavernosus muscle is a long, slender muscle which arises
by two slips on the inside of the tuberosity of the ischium and the
ascending ramus 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 tlie external
sphincter ani and levator ani and the superficial transversus perinsei
ANATOMY. 105
muscles, and others originate on the ischio-perineal ligament and
neighboring tendinous tissue. The posterior ends are united by
organic muscular fibers. It goes forward, outside of the vulvo-vagi-
nal bulb, and splits up into three tendons, one inserted 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. It divides the role of a sphincter with the constrictor vaginae,
and, above all, the levator ani muscle.
The superjicial transversus pemnoei 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 })erineum 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. 89).
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
coccygeal gland, a small body of the size of a pea, wiiicli seems to be
a remnant of a more developed middle sacral artery, such as it is
in animals with a tail.' 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-genital region are not well develoj^ed
or clearly soparaterl from one another. They are, therefore, enu-
merated and described ditterently by different anatomists. Most
commonly the following three are recognized : the constrictor urethra',
the de^'p transversius ]>erin<ri, and the constrictor vagince muscles.^
They are all situated between the two layei-s of the deep perineal
fascia.
The constrictor urct}ir(v, or compressor urctJira', or Guthrie's muscle,
' An interesting article on tliis subject, illiistnited witli fipures, was piil)lislu(l liy
Anpustus ('. IJernays of St. Louis in the u^fcdirnl liriij, Nov., ISST, vol. xv. j). ll'.i.
'■'Some descrilte a dfjireKmr nrethnr (or J(irj(ir(ii/'!< muscle), a transver.H' muscle join-
ing the constrictor from helf)w and going from side to side over tlu' urethra, ;uiil ;i
tnuii'irrsm nrrlhrn- mimrli; coming from a})ove and inserted on the upjjer surface of
the same. Tliev are probably only parts of tiie onMriclor urcthnr.
106 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. 79).
The deep transversus perincei muscle arises from the ramus of the
ischium just behind the constrictor urethrae, 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 consi7'ictor vagince 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. 89) and
the levator ani, inclusive of the ischio-coccygeus (p. 99). The ante-
rior part of tiie 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. 86). Much
diversity obtains among authors about its shape — a divergence of
opinion easily accounted for when we 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 wliole 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 Avhich 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 perinsei, 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. 107
mucous membrane of the vulva and sometimes by that of the vagina.
It has no definite Jateral limits, imless we arbitrarily suppose it con-
Fia. 99.
^EAI
NAVICULWy
'levatcrrfttscia-
Jfiansular Ugmtt
JuperficiiUlayer.
•Sup-Penneal faida.
Sagittal Section of the Perineal Body, showing its component structures (life size;
Dicliinson).
tinued to the tuberosity of the ischium. The cutaneous surface is
shorter than in man. It measures J 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, fascioe, and ligaments
come together. They being fastened to the surrounding bones, the
perineal body becomes tlie 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 Projeciion of the Pelcio 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 piil)ic arch {i. e. the antero-posterior diame-
ter of the outlet of the i)elvis) is 1 inch.^
E. The Arteries of the Perineal Region are the infernal 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-
* Foster, Amer. Jour. Obstct., 1880, vol. xiii. pp. 35, 30.
108
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, H inches above the lower end of the tuberosity,
where it lies on the obturator internus 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 termmal branches, the dorsal artery of the
clitoris and the artery of the corpus cavernosum. Before that it gives
off four branches to the perineum — the inferior hemorrhoidal, the
superficial perineal, the transverse peri^ieal, and the artery of the
hxdb (Figs. 100 and 101).
Fig. 100.
Superficial Structures of the Female Perineum (Weisse) : a. external superficial perineal
nerve; b, internal superficial perineal nerve; c, superficial perineal artery; d, inferior
pudendal nerve; e, pudic nerve; /, internal pudic artery; (j, 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
ANATOMY.
109
end between the skin and external sphincter aui, giving branches to
them and the levator aui.
Fig. 101.
Dissection of Female Perineum ; on the ri^ht side the perineal muscles are exposed by the
reflection of the perineal fascia; on the left side the muscles and the superficial layer
of the triangular litrameiit have been removed, thereby exposing the deep layer of the
ligament (modified from Weisse): a, dorsal vein of clitoris; ft, dorsal artery of clitoris;
c, inferior pudendal nerve; d, artery of bulb; c, ])udic nerve ;/, internal i)Udic artery ;
g, inferior hemorrhoidal artery; /;, inferior hemorrhoidal nerve; i, tendinims perineal
center; J, superticial transversus perinrei muscle; k, ischio-cavernosus muscle; S\',
sphincter vagintt; l', vagina; .5.1, sphincter ani.
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 periuici muscle, between the
superficial and the deep perineal fascia, and between tlie ischio-cav-
ernosus and bulbo-cavernosus muscles. It then passes through the
superficial perineal fascia, in wliich respect it differs from tiie corre-
sponding artery in the male. It sends branches to tlie named muscles
and ends in the vulva.
The t7'an8verse perineal artery ])erforates the deep layer of the deep
perineal fascia, follows the superficial transverse jierincal muscle, and
8Uj)plies this nuiscle, the vestibulo- vaginal bulb, and JJartholiiTs gland.
The artery of tlie bulb is smaller than in the opposite sex. It conu's
110 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
ditoins 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 supa'Jicial extamal pudic artei-y 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. 90)
the inferior heraorrhoidal 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. 102), 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 veiiis 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. 83 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.
ANATOMY. Ill
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 infetnor hemorrhoidal, the perineal, and the dorsal
nerve of the clitoris. .
The inferior hefniori'lioidal 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 tiie anus. Its ante-
rior branches combine with those of the superficial perineal 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 tlie 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 infei'ior pudendal na've is a branch of the small sciatic. It
passes under the tuberosity of the ischium, ])ierces the fascia lata,
runs between the skin and the superficial perineal fascia to the labia
majora, comnmnicating with the inferior hemorrhoidal and superficial
perineal nerves.
I. Distribution of Orrjans between the Fascice. — The following table
may help to memorize tlie distribution of the muscles, vessels, nerves,
etc. of the jjerineal region :
External sphincter ani muscle;
Inferior iicmorrhoidal vessels and nerves;
Superficial ju'rincal artery, veins, and nerves;
External pudic arteries ;
Superficial perineal nerves.
Immediately under
the skin.
112
DISEASES OF WOMEN.
Between the super-
ficial perineal and
the deep perineal
fascia.
Between the two
Ischio-cavernosus )
Bulbo-cavernosus v muscles;
Superficial trausversus perinsei )
Pudendal sac ;
Vestibulo-vaginal bulb (in a particular sheath) ;
Artery of bulb;
Dorsal artery of clitoris ;
Artery of corpus cavernosum ;
Venous ])lexuses ;
^ Superficial perineal nerves and vessels.
Constrictor urethrae ^
Deep trausversus perinsei > muscles ;
Constrictor vaginae J
Internal pudic artery with its branches, trans-
verse perineal artery and artery of the bulb ;
layers of the deep ■{ Venous plexuses ;
perineal fascia. Internal pudic veins;
Deep perineal nerves ;
Dorsal nerve of clitoris ;
A^ulvo-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.^ The
portion in front of the vaginal slit has been called the jjubic segment,
and that behind the sacral segment. The pubic segment is com-
posed of loose tissue, and is loosely attached to the sympliysis pubis.
(Compare pp. 89, 90, and 95.) 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. 95), 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.
' 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).
ANATOMY.
113
The entire fixed portion has the shape of a funnel, wide above
and narrow below. It consists of tissue attached to the sacrum
and the rectum, and of all tissue lying outside of the inner aspect
of the levator ani muscle.
K. The Function of the Pelvic Floor. — The pelvic floor counter-
acts the abdominal pressure from above. The loose tissue surround-
ing the bladder and the rectum allows these organs to be distended
and emptied. Itfe role during the act of copulation has been referred
to in describing the vulva and the vagina, and the effect of the con-
FiG. 102.
Horizontal Section of Pelvis at Plane of Hip-joint (Rydygier) : n, coccyx; 6, ischio-rectal
fossa; c, rectum ; (/, vagina; c, bladder; /, retro-pubic fat; g, hip-joint.
traction of the perineal muscles and the levator ani in narrowing
the genital canal is ca.sily understood.
During parturition the entire displaceable portion is pulled up-
ward l)y the contractions of the muscular fibres of the utcru.'^, which
are continued on the vagina (p. 50). The child is pushed tlirough
the vagina, exerting a strong pressure on its posterior wall, on account
of the angle between the uterus and the vagina. The activ(! and
passive counter-pressure exercised l)y muscles and fii.scise (pp. 101,
10.">, 104, 10">) turn the child forward around the pubic arch.
The result of parturition is, first, to dihite tlu! vagina and the vulva ;
second, to tear tlu; ])erineal IkkIv more or less deeply; and third, to
elongate and slacken tlu; hiyer o(" loos(? connective tissue between the
entire displaceable and the entire fixed jxntion of the pelvic floor,
thus predisposing to prolapsus of the vagina and the uterus.
8
114
DISEASES OF WOMEN.
Fig. 103.
Coronal Section of Frozen Body (Kydygier) : 1, right lung; 2, right atritim 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 intestine; 14,
fundus uteri; 15, bladder: 10, obturator internus muscle ; 17, descending colon; IK, sig-
moid flexure; I'J. mesentery; 20, obturator externus muscle; 21, corpus cavernosum
clitoridis ; 22, meatus urinarius; 23, labia minora; 24, labia majora ; 25, femur.
ANATOMY.
115
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 cases. 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-
jjectineal eminence.^
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. 108).
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 cither 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 pelvis (p. 112).
' Different anatomists draw these lines somewliat 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 c(nidition
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
116
PHYSIOLOGY. 117
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.
Mensteuation 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.^ 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, together with a flabby
uterus, in animals whose trunk is horizontal.^
The menstrual flow commences in most women in the temperate
zone between the fifteenth and seventeenth year 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.^ It returns in periods of twenty-eight days,^ and lasts on an
average four days. The amount varies very much. Four or five ounces
are said to be the average.^ It is increased by exercise, corporeal work,
ehalybeates, 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 lias no part in the process
of menstruation. Before its appearance the woman feels a certain
heaviness in the lumbar region, while ])ain is always a sign of an
abnormal condition. Often the breath has an un])leasant odor during
1 Bland Sutton, Brit.Gyn. .Jour., Nov., 1886, Part vii. p. 285.
■■* A. \V. .Johnstone, Arner. Gyn. Tmna., 1889, vol. xiv. p. 284.
'Special statistics are found in Hannover's Om Mcnxlruationens Betydning, Copen-
hagen, 1851, ji. 18; and T. A. Emmet, The Prinriplex and Prarticr of Gynecology, 2d
ed., 1880, p. 153 et mq. In a total of 2.330 cjises, Dr. p]. 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.
* 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 account
himself of the beginning and the end of the periods of those uiuier his treatment.
Tiius many an error is proved, many a complaint settled.
* Funcke, Lehrbuch der Phynioloyie, 4th ed., 180(5, vol. ii, p. '.»',)!.
118
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.^ About a week before menstruation
Fig. 104.
Uterus during Menstruation (Coiirty). 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 mucous membrane of the uterus begins to swell, so that
from 2 or 3 millimeters (^ inch) in thickness it becomes 6 or 7 milli-
meters {I 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 \,avy in consequence of the
^Leopold, Archiv fiir Gyndk., 1877, vol. xi. p. 110 et seq.
PHYSIOLOGY.
119
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 few 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 Endometrimn of a Menstruating Woman, aged twenty, showing
utricular follicles denuded of epithelium, and one still containing the epithelial east
X feOO (Johnstone).
cles, and giant-cells with many nuclei. According to Leopold, these
cells are found in a condition of active proliferation, while, according
to Johnstone, wlio has worked witli nmch more powerful lenses, the
corpuscular elements arc formed from granules in tlie threads of con-
nective tissue forming tiu; bulk of the mucous membrane (Fig. 47,
]). 5.j). J^efore menstruation begins tiie blood-pressure is increased
(Stephenson). Some of the capillaries near the surface burst and the
blocnl escapes, partly into tlie tissue, forming small extravasations ;
partly on the surface, lifting uj) and tearing off the epitlielium. The
ej)ithelium is also shed in that jKii-t of the utricular glands that lies
nearest to the cavity of the ntei-us (1^'ig. 105). Five or six days after
the beginning of menstruation the regeneration of the epithelium
120 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.
AVe 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.
Ovulation. — 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
to that of a menstruating woman, ^ the tissue being full of medullary
elements. If copulation takes place, the ovum meets the sperma-
tozoids 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 ovulation is a periodical process,
and, if so, we"do not know if the cycle is the same as for menstrua-
tion. 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. 75). But this correspondence
is denied by others, who have large experience in the removal of
the uterine appendages.^
We know certainly 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. Tiiis is, among
other things, proved by embryology. In the young embryo the devel-
1 A. W. Johnstone, Brit. Med. Jour.. Nov., 1887, Part xi, p. .S84.
2 Lawson Tait, Diseases of Women, Philadelphia, 1889, pp. 312-317.
PHYSIOLOGY. 121
opment is so rapid that an interval of three Aveeks makes an enormous
ditference in the condition of the organs. In this way it was found
tiiat three-fourths of young embryos corresponded to the first skipped
menstruation, and only one-fourth to the end of the preceding/
The fact that a woman may be impregnated at any time does,
however, not prove that an ovum is detached then, for we know
that both ovum and spermatozoids may be preserved in the genital
canal. The first has been found on the fourth day of menstrua-
tion in the uterine part of the tube (Hyrtl-), and in another case
1^ inches above the internal os (Benham-). 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.^ 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 Operatioiis 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 o])eration.* In some cases tlie hemorrhage occurs from other
organs: I have seen it come from tiie 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 to this rule are by no
means rare. There are cases in which menstruation is repeated \\\i\\
more or less regularity for several months or even years. In other
cases menstruation does not occur during tiie 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.''
' His, Ajuitomie menxcldicher Emhryonrn, Leipzig;, 1882, ii. p. 7.'>. T\\v wliole num-
ber, liowevcr, heiii}^ only Hixtoeii, this argument loses some of its \vcif;lit.
'■' lA'opoJd, /. r., p. 121.
•' K. IVrcy, of >i'W York, Ann'r. Jmir. Med. .91"/., July, ISTfi, p. 1")S.
* In onier to avoid this extra loss of hlood, wliich in anemic patients may turn tiie
fK'ales, Mr. Tail advises to operate immediately before or diirinu; menstruation (7. '.,
p. .H12).
'(ieorge Kngelmann of St. I>ouis, "Menstruation and tin' Removal of itotli
Ovaries," Trmuf. Soidhern Siirf/irtil nud (iifiircul. .{■•<for., Si'pt., LSS'.t; rejirinl, p. 1.
This is not in itself a proof against the ovulation theory,. for if the [iresence of a
122 DISEASES OF WOMEN.
At the time the extra-peritoiieal treatment of the pedicle was yet
in vogue I saw menstruation after ovariotomy accompanied by bleed-
ing from the tul>e in the stump. With the present intraperito-
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.^ 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. 51,
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 i. 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 (/. c, p. .320). Eut can also
occur in animals after complete removal of the ovaries (Barthelemy, Jour, de Mede-
cine reterinaire ; Med. Record, Sept. 27, LS90, p. 368).
^ Johnstone, Brit. Med. Jour., Nov., 1887, p. 387.
PHYSIOLOGY. 123
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-vaginal 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 neverthele&s are capable of being impregnated.
The orgasm is accompt^uied 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 ditference 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 dysparcunia,^ 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, l)y 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 mainnialia the
spermatozoids are found on it within twenty-four hours after coition.
^ Kolx;rt I'>.'irnes, A Cllnmd History of the Medical ami Sur(jical Disensta of Women,
London, 1878, p. Gl.
124
DISEASES OF WOMEN.
In animals the ovum is no longer capable of fertilization when it has
Fig. lOG.
\T v"' d; :co ;j»v!° v «•? ' v.'j ^■
Portions of the ova of Asterias glacialis, showing the approach and fusion of the spermatozoon
with the ovum (Hertwie) : a, fertilizing male element ; b, elevation of protoplasm of egg;
6', 6", 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): ^, 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. 125
fecundated for weeks after it has left the ovary, whilst no fact is
known that would conflict with the supposition that the sperniato-
zoids keep their vitality for weeks in the folds of the ampulla, and,
on the contrary, such possibility is absolutely proved in animals/
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.
Observations on animals make it highly probable that a part of
the spermatozoid enters through the zona pellucida and combines
with the germinal vesicle (p. 74), 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 ns at least one step farther in the comprehension of the won-
derful transmission through heredity of physical and mental
peculiarities, aptitudes, and acquired talents, as well as diseases,
from the father to his offspring.
The ciliary movement is directed from the fimbriae to the internal
OS, so that it pushes the ovum through the tubes and the uterus,
while the spermatozoids move against the current.
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 ])uberty, 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 wiiole system, causing considerable })hysical and mental
changes. It comprises the time when menstruation begins to be
irregular, gradually diminishes, and finally ceases altogetlier. In
most women the menopause suj)ervenes when they are from forty-five
to fifty yeare old, and the length of the fruitful period is in most
women thirty-four years. Those who begin to menstruate early
(under sixteen veal's) continue, as a rule, longer than those who have
their first menstruation late (after sixteen). To tiiis 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 ir
begins and ceases early. Tlie fruitful period is longer in those avohicu
who have borne children and mu'sed them themselves than in nul-
lilKine and those who have not mu'scd their children. On the other
hand, early sexual intercourse and a rapid scciuence of childbirths or
mis("arriages shorten the pericMl of fertility. It is shorter in the labor-
* His, Aiuitomic meiuiclUicher Embnjoncn, Leipzig 1880, i. p. 1()7.
126 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 fii'st 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 intestine, 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 tiie 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
com])lains 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 meiio-
PHYSIOLOGY. 127
pause. Most women become stout, but some lose flesh. Sometimes
gout makes its appearance.
Important 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 bicamei-atv^
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 ((ipoplexy 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 tiie patient, and sometimes the
piiysician, to the erroneous belief that she is pregnant.
Treatment. — Although the climacteric is a physiological j)rocess,
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 j^hysician is often consulted about it. The treatment
of the real diseases conne<'tod with it will be discussed in later chap-
ters, under the diseases of the diflerent organs affected, or must be
looked for in works on the practice of medicine. Here we can only
indicate a few ])oints, especially in reference to hygiene.
A chief point is to keep the bowels open, preferably by means of
aperient Siilts or waters. Sometimes enemas of plain water or muci-
laginous aiid oily substances or glycerin may advantageously be com-
bined with or substituted for the a])erient medicine. Derivation to
the skin by washing the whole body with cold water and rubbing
the skin well with Turkisii t<nvels is both ])leasant and useful. For
the loaded urine it is well to driidv a syphonfnl of Vichy, Rhcns.
or Scltser water in tlie cour-^c of the day, or to take bicarbonate o("
soda (3SS t. i. d.) in a tumblerful of water. The congestion of llir
head and visual disturbance are often much benefited l»v the use oi"
128 DISEASES OF WOMEN.
hot foot-baths, with or without mustard, of the cold eye-douche five
minutes tliree times a day, and of scarification of the cervical portion.
A glycerin pledget introduced morning and evening into the vagina
may also relie\'e 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 ougiit 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 when
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 tlie 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
develo})ment, and preparing for the important functions of womanhood
and motherhood. Too great interest in and practice of music, i'rom
its profound effect on the emotions and the constantly repeated
physical thrill in the nerves, is particulary dangerous.
Everything that causes active or passive hyperemia of tJie pelvic
organs is a source of disease. In tiiis category belongs sexual ex-
citement brought on by reading prurient novels ; l)y looking at
obscene pictures; l)y seeing representations on the stage that aim at
the exposure of so much of the body as existing laws and public
opinion will permit; by masturbation, sa})pliism (tiie same as tribad-
ism), sodomy, and even normal coiton if performed too violently.
Tlie neglect of the skin, by which one of the chief enumctories is
nearly blocked up, is hardly ibund in the better classes in this conn-
try, i)ut is exceedingly common among the jjoorer women, es[)ecially
immigrants, of certain nationalities.'
Ins^ijficirnt exercise and lavl: (f open air are a IVeijuent cause of" dis-
ease, and favor th(! stagnation of blood in the pelvis; l)ut in this
' 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.
9 1 L'l)
130 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 still it is
often necessary to preach 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 Avith 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 Avomen 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 accunuilation 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 eifect 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 unfrequently
is the cause of cystitis and neuralgic pain, besides predisposing to
uterine disease by pushing the womb out of j)lace.
The mode of dress in r/, although changingunder 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 Morn 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.^
^ S. Eusey, Trana. Amer. Gyn. Sue, 1882, vol. vii. pp. 248-261.
ETIOLOGY IN GENERAL. 131
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-.
tine 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
floor is bulged down to the extent of one-third of an inch.^
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,^ 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 Avhich in the course of time result in
liemorrhage, leucorrliea, 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 toucli during a (;areful examination !
If married life has its dangers, celibaci/ does not offer entire pro-
tection. Esi)ecially is the liability to the formaticm of fibromas of
the uterus greater in unmarried and imllijxarous 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.
' The question of the eflert of tlie corset and otlier wearing apparel has been ably
discussed by Dr. Kol)ert L. Dickinson in tiie Nnn York Med. Join:, Nov. 5, ISST,
Hare's Syslcin of Tlimtpi'iilirji, vol. iii. pp. 7o()-7.S4, and Trans. Aiiirr. (lyn. Sue., IS',);-},
vol. xviii. pp. 411-4.>S.
' A carefnl perusal of Genesis xxxviii. 9 will convince the render tliat tlicrfby is
not meant the vice which erroneously lias been named sifter that man, and whicli
properly is called masturbation, but the practice commonly known as " witlidrawul.'^
132 DISEASES OF WOMEN.
In married, as well as unmarried women, the climacteric predis-
])()ses to ilisease — a point wliich has been considered in a previous
chapter (p. 126).
Exciiing causes. — Sometimes a faulty development- of the fetus
constitutes a disease. Too great closure of the two halves forming
the body gives rise to atresia ; too little, results in hypospadias,
epispadias, or extroversion of the bladder. Arrest of development
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 ofteuer 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 nuicous
membrane, leucorrhea, hemorrhage, cystic degeneration of tlie 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. ^ 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 diseases calling for the gynecologist's inter-
ference ; but of by far greater im])ortauce is the criminal abortion so
frequently resorted to by women in all classes of society, in the coun-
try as w'cll 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 intestine
may find its way into the vagina and down between the thighs;^
and it is by no means rare to read in the reports of coroners' autojisies
in suits for malpractice that wounds inflicted with some sliarj) 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
' This question has been considered at length in my article "Eest after Delivery,"
Amer. Jour. Obstetrics, vol. xiii. No. iv. Oct., 1880, pp. Sol-SOS.
^ Cases of this kind were reported by Thomas and Xoeggerath in the Obstetrical
Society of New York, Amer. Jour. Obstet., 1882 (Supplement, pp. 4-6).
ETIOLOGY IN GENERAL. 133
to fungosities of the endometrium, and undermines the most robust
constitution.
The more remote eiFects of abortion are similar to those of too early
rising after childbirth, especially subinvolutions and displacements.^
Gynecological J/"€a^?>ien^.— 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-uterine treatment Mitli sounds, curettes, tents, dilators,
and pe&saries'^ fraught with danger on account of the absorption of
septic material, which so easily takes place through the lymphatics
Df 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 yeare ago which has not been thoroughly cured. AVhile a
gonorrhea in man in most cases is a trifling disorder, although excep-
tions, in 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 affects 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-
metritis in every confinement.
Under the name of Intent r/onorrhca has been described a condition
in which a woman is infected by a man who had a gonorrhea months
or years before. Xo acute gonorrhea is pnxlueed, but the women
become ailing, remain sterile, and are affected with chronic, subacute,
sometimes acute, very often relaj)sing, inflammation of the internal
genitals.^
' An interesting paper on "Abortion and its Eflects" was read by Dr. J. T. John-
son of Washington, D. (;., l)efore the Medical and Chirurgioal State Faculty of
Maryland, on Aj)ril 23, 1890 {Marj/lnnd Miil. Jour.).
'(Jarrigues, "Danger of Stem Pessaries," Amer. Jour, ObMct., Oct., 1879, vol. xii.
p. 756.
' 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 tlie 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.
ChildbirtJi and 3Iiscarriages. — 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 or
an instrumental delivery. If she is sterile, we must find out if it
134
EXAMINATION IN GENERAL. 135
is a natural condition or due to the use of preventives. If we find
sterility combined with dysmenorrhea, we nearly always find a
Hexion of the womb, and most frequently an anteflexion, often com-
bined with a narrow os. If there have been many miscarriages, we
must ask if they were spontaneous or induced. If criminal abor-
tion has been performed, that often gives the clue to the origin of
the disease, while, on the other hand, repeated spontaneous miscar-
riages are generally 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. 117). 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 najikins, the number of which often is 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. 117) and ascertain if she has molhainn — /. e. if at regular intervals
of four weeks she suffers from abdominal pain, cerebral congestion,
and general malaise. If tiie patient has reached the age of puberty,
is otherwise well developed, and has monthly moliniina, 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 nnist 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 n)enstruation 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 lias been suddenly suppressed, and if
any cause for such suj)pression is known — r. 7. exj)osure to cold.
Under all circumstances of disapj)earance of the menstrual flow the
physician must think of the possibility of pregnancy, and iiKpiire
about nausea and vomiting, and if tiie pati(Mit is unmarried, under
136 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 is generally a hemorrhage caused by
cancer.
Discharge. — We ask the patient if she has 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
ulcere 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 oifensive one often is a sign of cancer.
3Iicturition 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 (dyspareunia). When a pain is felt on
one side of the body, it is, as a rule, on the aifected side ; but some-
times it is referred to the opposite side.
Other al)normal sensations, such as itching or burning, are some-
times worse than real pain.
Sometimes patients suifer 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 l)efore they were taken sick.
Family History. — Sometimes the family history helps to a diag-
nosis, especially in regard to hereditary predisposition to such dis-
eases as tuberculosis and cancer.
EXAMINATION IN GENERAL. 137
Special Questions. — 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
tiie patient has a normal sexual appetite and feels 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 (ulcei-s, 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 hereelf, and so forth. But all such special questions will,
as a rule, best be put during or after the j^hysical 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 })os-
ture. A common table with a hard
mattress may be used, but it is a Fig. 108.
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.
106). Whatever table is used
shoukl be jilaccd near a window,
with the foot end turned toward as
g(x>d a light as can be obtained. Daggett's ruble.
The bladder and the rectum must
be empty. If the bladder is more or less full, the urine in;iy be
drawn when the patient is on the tal>le. If the rectum is loaded, it
138
DISEASES OF WOMEN.
is better to postpone the examination until the intestine has 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 to disappear with
a movement of the bowels.
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, the ventral, and the elevated-pelvis
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.
139
If no inspection is intended, but only a digital examination, the
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
under " Urinary Fistulse."
Sims' s position (Fig. 110) is a position on the left side, but every
left-side position is by no means Sims's. In the later 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.
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, tlie riglit fore-
arm and hand may rest on the cusliion in front of the face ; the nates
form an inclined plane, the right being a little nearer tlie head and in
front of the left; the riglit 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 ])osition is the b(!st for bimanual examination,
for the use of the j)lurivalve specnlum, and for the examination of
the alxlomen. Sims's position allows ns to introduce one or two fin-
gers much higher up behind the uterus than when the j)atient is in
the dorsal position. Kven things in the anterior j)art of the pelvis
140
DISEASES OF WOMEN.
are sometimes felt better ; for instance, an anteflexion which cannot
be made out while the patient is on lier back, may become quite plain
when the l)eut 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
cf her and introduces the index-finger into the vagina.
The elevated-pelvis 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, the knees are bent and her legs are tied
to a flap, forming a right angle with the table. This position, which
rarely is used for diagnostic purposes, is of the higliest value in
operations in the depth of the pelvis. In protracted operations in
this position the pelvic organs become comparatively anemic, and
when the patient is brought back to the horizontal position, a con-
' This position is in this country often called Trendelenburg's (tlie accent is on
the first syllable — Tren'dei-en-burg). In Germany, where it was invented, it is
known as Berkenhochlage. Trendelenburg has contributed much to tiie populariza-
tion of the position ; but years before, it was used and described by Bardenheuer
( Drainirunf) der Peritonealhohle, Stuttgart, 1881, p. 276), and is said to have been
used still earlier by Billroth in Vienna.
EXAMINATION IN GENERAL.
141
gestion takes place, wliich may cause hemorrhage corresponding
to what takes place after the artificial anemia brought on by
Esmarch's method. It is, therefore, a wise precaution to raise
Fig. 112.
Klcvatod-pclvis position.
the foot of the bed during the first two or throe hours after the
operation.^
The ventral position is needed when we want to use percussion on
the lumbar region ; e. g. 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
e.xamine her, and, in order not to overlook anything, we will consider
separately the examination of the 2)clvis, 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
utenis ; specula; the uterine sound ; the probe; and dilatation of the
cervical canal.
A. Inspection is peribrmed while the })atient is in the dorsal posi-
tion. Having in mind the normal anatomy of the external genitals
(pj). 35 to 47), we })ay attention to every deviation from the stiintlanl.
15. Digital Krarninfdion. — The fingers, esj)ecially the two index-
fingers, are instriiments of exj)loration of the very greatest value.
The touch can to a great extent replace vision, and is soiiictinies
superior to it — e. g. in judging of the extent of a cervical laceration —
but a good deal of practice is needed before the limit of all (he ))n.-si-
' il. C. C'oe, New York I'didlnic, Sept., ISUIJ.
142 DISEASES OF WOMEN.
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 jiatient, 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 Ls
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 and of the
gynecologist in performing operations, 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 M'ith 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
used in the vagina. It is stretched, the last three fingers are bent
flat in a<2:ainst the hand, so that one riffht ang-le 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 M"ith 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 ])enetrate fully an inch deeper, but causes
some pain. In entering it is well first to ascertain the condition of
the vaginal entrance, especially tlie 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, we j)lace the
tip of the finger on the os, and examine its size, shape, and direction.
EXAMINATION IN GENERAL.
143
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 fingei-s 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 E.xamiimtion (Schroeder).
upward and backward, a little otit.'^ide of the edge of the uterus, we
are sometimes eual)l(Hl to feci the ovaries, the tul)es, the sacro-uterine
ligaments, cy.sts of the broad ligaments, exudations, infiltrations, pel-
vic abscesses, etc. Finally, we examine the right side of the pelvis
in the same way.
144 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. 90), and in so doing he pays attention to tumors,
ulcers, or strictures of the intestine itself, and to the condition of
the genitals in front, and the sacro-uterine liagments laterally. 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. In virgins it
may sometimes replace vaginal examination. 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 jiainful than a vaginal examination in a woman who
has had sexual intercourse, it is by no means used in every case.
In regard to its combination with artificial prolapse of uterus, see
below.
In children, rectal examination, combined with abdominal, is of
great value, but demands anesthesia. Xot only the pelvis, but
nearly the whole abdomen may be explored in this way.
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,^ 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.^ 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
several of the above-mentioned methods. Thus, a good mode of
examining the perineal body is to introduce the index-finger into the
rectum and the thumb into the vagina simultaneously. In other
cases tin middle finger is introduced into the intestine, the index-
finger into tiie vagina, while the four fingers of the other hand
palpate through the abdominal wall.
' T. A. Emmet, Principles and Practice of Gijnecolocjy, 2d ed , 1880, p. 732.
^ I have, for instance, done it successfully in an old lady with a large cancer-
ous mass situated on the base of the bladder, and precluding incision from the vagina.
EXAMINATION IN GENERAL.
145
C. Artificial Prolapse of the Uterus, by which this organ is pulled
down by means of a volsella to the entrance of the vagina, is much
practiced in Germany, and has some advocates. in this country.^
By handing the forceps to an assistant, introducing one or two fingers
into the rectum, and depressing the abdominal wall with the other
hand, if the uterus is of normal size, its whole posterior wall up to
the fundus may be palpated, and likewise the broad ligaments,
tubes, ovaries, and the pedicle of an ovarian tumor. The method
is not without danger, as it is liable to set up an acute peritonitis
or cellulitis where there are remnants of old similar aifections, and
even endanger the integrity of the tubes or large veins in the broad
ligaments if, perhaps, they are bound by old adhesions which es-
cape our attention. It is better not to be too zealous a diagnostician
Fig. 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 preci.se character.^
D. Specula. — In order to see the deeper parts of the canals leading
to the pelvic org-ans we have iii.struments called "specula," which at
the same time an; of great importance for treatment, since they render
it p<^)ssible to make applications to, or perform o})erati()iis on, tiie
' Howard Kellv has construrted a sj)efial kind of liook for tlie purpose (Amrr. Jimr.
ObMct., \m\, vol. xxiv. No. 2, j). 141 i.
* For details tlie remler is referred to a pai)er liy II. ('. Coe, Mid. Ilcrord, Autr. '•*,
1890, vol. xxxviii. No, 6, p. 141.
10
146 DISEASES OF WOMEN.
parts exposed. We liave vaginal, cervical, rectal, urethral, vesical
specula, and the (jalvanic ci/stoscope.
Vaginal SpecuUi. — Of these there are a great variety, but virtually
they may be reducal to three types : the tubulifoiin, the pluHvalve,
and the univalve specula.
Of the tuhuliform specula, Fergiisson'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
point of the end is introduced through the vagina, pressing on the
perineal body. The anterior and posterior walls of the vagina should
be seen all the time touching each other 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 be
overlooked;^ it cannot be used for the inspection of the fornix 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 spwula, 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 M'ithout 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 j)ain
there. The blades should be of the same length : if the anterior is
' The almost exclusive use of this speculum in Enfrliind accounts in a great meas-
ure for the tiirdiness with which Emmet's laceration and its cure by operation were
recognized there.
EXAMINATION IN GENERAL.
147
half an inch shorter than the posterior, as in some instruments of
this kind, the os cannot be seen if the uterus is auteverted.
Fio. 116.
Brewer's Speculum : A, open ; B, closed ; C, handles ; 1), set-screw.
The bivalve specuhim is used to greatest advantage in the dorsal
position. Before introducing it tlie physician ascertsiins by touch the
position of the os, and dir<!cts the instrument, closed, in that direction
to its full length or till he reaches the vaginal portion. Then the
branches arc separated by pressing on the handle (C), turning ^he
screw, and the instrument pushed a little farther in, so as to reach
tlie fornix of the vagina.
The univalve or tSinis speculum (Fig. 117) is the only one that
Fk;. 117.
Slms's Speciilum.
shows the uterus and the anterior wall of the vagina in their normal
position and relation, since all it (hx'S is to pull back the |K!rineal bcxly
and the posterior vaginal wall. It covers a smaller part of the vagina
than the other two. Jt alone allows us to combine touch with sight,
148 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
siime time, in the dorsal decubitus. Generally, two Sims's specula,
of diiferent 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. (See Vaginal Hysterectomy,)
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-
ment 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
w^eight, 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 haUooning. This 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.
149
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 Avail of the cavity in question
to fixed points in the surroundings (p. 43 and Fig. 55, p. 60).
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. Himter^s, a silver-plated copper rod ending in a S})oon
at each end (Fig. 120;', cr my ov.n, which will presently be described.
Fig. 120.
Hunter's Depressor.
ModificMions of Sims's Speculum. — Jhmde's speculum (Fig. 121)
is a Sims's speculum to whicli is added a flange that holds the u])per
nates out of the way. Jfiibhard W. M'dclieirs speculum, (Fig. 122) is
a single Sims's sj)eculum with jMundc's flange and wings, which give
a good iiold for the index- and middle fingers.
Self-hold i)ir/ Sims Sjtecula. — If one holds one of these flaiig(Ml
specula or a common Sims speculum in his left hand, re(|uesting
tli(! patient to lift the ni)j)ei* nates herself, and he holds the depressor
in the right hand, Ik; can see well enough, but no hand is left for
treatment. Tin; consequence is, that he nnist have an assistant. The
])resenee of a third ))erson, especially a female mu'se, ofl'ei-s many
advantages, but not overvbody who wants to ns(> Sims's sjK'culum,
has suflieient gvnee(»logieal jtraetice to make it pay to keep one for
the j)iu*j)osc. A luunber of instnnnents have, tlieref"oi-e, l)e<Mi con-
structed with the aim of making the a.ssistant superiluous ])y render-
150
DISEASES OF WOMEN.
ing Sims's speculum self-holdiug. 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 Fig- 122.
hand of an exjierienced
nui*se, 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.
Mundt>'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 frighten the patient, and take much more time to apply than a
common Sims speculum. In order to have all the advantages of
EXAMINATION IN GENERAL.
151
the latter without being obliged to have an assistant for a mere appli-
cation, curetting, and
similar manipulations, I Fig. 123.^
have had a vaginal de-
preasor 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.
(iarrigues' Vuginal Depressor.
' This {\frine represents tlie speeulnm so modified lliat flie vnf^iiKil l)lade is divided
into two lateral liaives, wliicli can he se|)arated and M])i)roxiinat('d l>y means of a
s<'re\v. It lias also a depressor for tin- anterior wall wJiieli is fastened to tiie nppev
flange. This depressor prevents one from pnlling tiie uterus down and lias not ap-
peared praetieal to me.
^ II. .J. (iiirrignes, "A Vaginal Depressor," Med. lironl, 1881, vol. xx. p. (IDS.
152
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. 142). 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 antise])tic 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 iitting 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 ])ain, 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. AsJdon's rectal S])eculum is constructed on the same prin-
ciples as Fergusson'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).
Uretln-al 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.
153
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
Fig. 128.
Kelsey's Rectal Speculum.
inches long and half an inch in outside diameter will be suitable for
most cases.' Skene has adapted Folsom's nasal speculum to the
Fig. 129.
Jackson's Uretliral Speculum.
urethra (Fig. 130). It consists essentially of two oblong rings of
' A. Reeves Jac-k.son, Amer. Gyn. Trans., 1877, vol. ii. p. oT-'i.
154
DISEASES OF WOMEN.
Fig. 130.
metal wire separated by sprinji^ 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, a reflected light is
necessary.
Vesical specula Mill be described below in
speaking of Examination of the Bladder- and
Ureters.
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 depth to which the sound enters is
easily read off.
The sound is a very useful, aud, when properly used, harmless,
instrument, but in handling it we must never forget that it is a metal
Fro. 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 pi'ccautions 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 ])athogenic 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 u.sed in the dorsal or in the lateral posi-
tion, with or without speculum. As a rule, I think the intro<luction
in the left lateral position without speculum is the best. The sound
EXAMINATION IN GENERAL. 155
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 2J inches in order to introduce it more
easily into the canal, which forms an angle with the vagina (p. 54).
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
intro<luction 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. 50) ; 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 fundus 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 difierent directions,
and thus ascertaining; the relation of this ormui to tumors in its
vicinity.
F. The Probe. — The ])r(^be 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 rul)ber, or whalebone.
G. The C'lirrlfe. — The cui-ette is an instrument used for scraping
something off the inside of th(» uterus or other cavities. It is mostly
used as a therapeutic agent, but sometimes it is employiMl in the ser-
vice of diagnosis in order to obtain a specimen for nii('roseo])ieal
examination. The chief curettes are Sims's (V\^. MVI) and Simon's
(Fig. ]'>')) sharp and stiff, and Thomas's dull and flexible curettes
(Fig. l.'>4). In the choice of a '^riiom.'is dull-wire ciu'ctte the j)nr-
ehaser should take good care not to buy one that is so flexil)l<' that
156
DISEASES OF WOMEN.
it bends while being 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 seems to me the best instrument for the cervix,
and of late years I use it also exclusively in the body of the uterus.
In curetting great care should be taken to disinfect the instrument, the
vagina, and the interior of the womb both before and after operating.
Fig. 132.
Sims's Sharp Curette.
H. Dilatation. — Sometimes it becomes necessary for diagnostic
purposes to dilate the cervical canal suificiently to introduce the
curette or the finger. This may be done slowly by means of teiits,
or rapidly by means of cones or diverging rods working on the
principle of a glove-stretcher.
Except during or shortly after pregnancy, it is hardly feasible to
dilate the cervical canal by rapid dilatation to such an extent that
Fig. 133.
Simon's Sharp Curette.
the finger can be introduced. If this is necessary, laminaria tents
should be used for from twelve to twenty-four hours. They not only
dilate the cervix, but soften it so much that rapid dilatation there-
after may be able to accomplish what it could not before.
Tents are cones made of substances that swell by ab.sorption of fluid,
especially sponges, sea-tangle (laminaria), tupelo root, and slippery-
FiG. 134.
Thomas's Dull Wire Curette.
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 ca.ses, especially for tiie 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.
EXAMINATION IN GENERAL.
157
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. Such tents
may be kept in a solution of bichloride of mercury in absolute
Fig. 135.
Barnes's Tent-Tntrorliiper. A tent is seen fitted to the end ready for introduction. Whien it
has been placed, the stylet on which it is mounted is withdrawn tlirough the tubp, with
which the tent is steadied till the stylet is quite free from the tent.
alcohol, 1 to 100. Just before insertino: them they arc dipped in
corrosive sublimate glycerin (1 to 1000). The patient mu.st keep
absolutely quiet for a few hours imtil the tent is sufficiently swollen
to be retained. The labor-like pain produced by the swelling
Fig. 136.
Hanks's Uterine Dilator.
may be relieved by applying a hot-water bag, cloths wrung out of
hot water, or a hot poultice to the alxlomen. If needed, four
or more tents may be introduced, one after the other, changing
Fi(i. 137
Garrigues' Uterine Dilator.
them twice in twenty-four hours, and wasliing out the uterus at the
same time.'
The tent is introduced with a pair of dressing forceps or Jiarnes's
tent-carrier (Fig. 1.35).
For diagnostic purposes, and as ])art of treatment, dilatation is
much safer when jx'rformcd rapidly. For the lower degrees of
' ThLs is the method of 15. S. Schultze, ChilmMut fiir (hjiuikoL, 1S7S, vol. ii.
p. 150.
158
DISEASES OF WOMEN.
dilatation a few of Hanks's coniform hard-rubber dilators (Fig. 136),
a moditieation of Hegar's, are 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 dila-
tation, up to Ij inches, a strong instrument of the diverging kind is
required. I have had one made which I think unites the best
features of the different instruments of this class (Fig. 137). It
lias EUinger's parallelogram ; only one handle, in order not to
Fig. 138.
Goelet's fourbladed dilator.
obscure 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.
A strong and even dilatation is obtained by means of Goelet's
four-bladed dilator (Fig. 138).
For the very highest degrees of dilatation — which, however,
scarcely are needed for mere diagnosis — the writer has had a series
Fig. 139.
Olive-shaped dilators.
of ten hard-rubber olives made, which can be screwed on a metal
shaft (Fig. 1 39). One of the balls .serves as a handle, while anotlier
is slowly pressed through the cervix. They correspond to num-
bers 22 to 45 of the American scale (33 to 67.5 millimeters in
circumference).
EXAMINATION IN GENERAL. 159
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 (Yulliet'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. W the cervical canal is too narrow, it
is fii*st dilated by means of the above-mentioned dilators. The tam-
pons are left in for forty-eight hours.
In order to dilate the cervix and lower uterine segment, it is
sometimes necessary to combine the use of these cotton balls with a
bundle of laminaria tents, the cotton ball being pnshed 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 tiiis way, only cotton
balls are used and the packing renewed. Occasionally this method
might prove valuable both tor diagnostic purposes and for the re-
moval of tumors from the cavity of the body of the Momb.
The cervix having been dilated, the interior of the uterus may
also be inspected by means of Goelet's uterine sjx'culum, an instru-
ment similar to Kelly's bladder-speculum (Fig. 141).
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 leucori'hea, 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
ought only to i)e undertaken with great care and deliberation. Un-
fortunately, many girls an; easy enough to examine, but in a really
intact girl the introduction of the finger meets Avith considerable
resistance, and the sharp edge of the hymen is felt like a fine steel
cord on the l)ulp of the finger. With the excej)tion of a few urgent
cases, in which it is necessary for treatment's sake to make a spe(Hly
diagnosis, it is better first to prepare the hymen by the introduction
twice daily of a small tamj)on of absorbent cotton soaked in glycerin.
\\y gradually increasing the size of the tampon at every change the
parts will in a few days be sufficnentiy softened and dilated to allow
the index-finger to ])ass. It should be carefully lubricated all over
and intr(xlu(;ed very slowly, in order to avoid causing unnecessary pain
' ViiUiet et Liitaiul, Lt;(;ons de Gynccologie operafoire, Paris, 1890, p. 75.
160 DISEASES OF WOMEN.
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
doi*sal 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 {strioe 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 then that it is the gravid
uterus.
If a patient make 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.^
In palpating tumors the bimanual examination (Fig. 113, p. 143)
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
in one place and pressing on another with those of the other liand, we
ascertain if there is diXxy 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 Percussion. — By means of percussion we find out whether we
have the normal tympanitic sound of the intestine 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 we use percussion. If the fluid sinks down, leaving a
^ Naunyn, reported by Minkowski, Centrcdblalt fiir Gyndkologie, 1888, vol. xii.
p. 790.
EXAMINATION IN GENERAL. 161
tympanitic area above, we conclude that the fluid moves freely in
the abdomen (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 souffie) 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. 3Ieusu7-ation. — 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 trater into
the intestine have recently been recommended for diagnostic purposes.
The stomach is expanded by giving bicarbonate of sodium and tar-
taric acid, which together develop carbonic acid. Later the stomach
is evacuated by introducing a soft- rubber oesophageal 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.'
G. Charts. — It saves much time and contributes to a precise diag-
nosis to use printed charts representing tlie outline of the abdomen
and pelvis in front and side view, and mark on them the location of
any swelling found by examination.^
IV. Other Means of Investigation Common for Pelvic and Abdom-
inal Diseases. — Such are exploratory aspiration, cvploratonj incision,
urinary awdysis, microscopic e.vanunation, chemical examination, ex-
amination under anesthesia, and e.vamin<dion of the ureters.^
A. IJrimtry analysis ought to be made in every case before an ojie-
ration is uiidertnUen, 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
' Naunvn, CrnlmlhlnU f. Cyn., ]8s,-<, vol. xii. ]). 7!)0.
ing Co,
Rubber stamps for recording' cases are manufactured by tlie I'.arton Manufacfi
., No. I^.'iS I'.roadwav, New York.
II
162 DISEASES OF WOMEN.
gynecology the examination of the urine often gives vahiable hints as
CO diagnosis or treatment. The urine should be examined chemically
and microscopically.
B. 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 lubricated by immersion in water containing 1 per cent, of lysol,
creolin, or carbolic acid, and introduced in a curve hugging the
symphysis pubis.
C 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. 140), to casts characteristic of
nephritis, and to the different crystals abnormally seen in urine.^
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.
D. Chemical Examination. — Chemical reactions are esj^ecially used
to reveal the presence of sugar, albumin, or gall in urine or other
fluids.
E. Examination of the Bladder and the Ureters. — The size, sensi-
tiveness, and elasticity of the bladder can be tested with a metal
catheter.
Howard Kelly's bladder-speculum^ 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.
' For details the reader is referred to the work of Charles Heitzmann, Microsmpic
Morpholocjy of the Animal Body in Health and Disease, New York, 1883, with its
excellent illustrations.
'^ 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).
EXAMINATION IN GENERAL.
163
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.
Epithelinl Cells found in Urine X '''W (C. Ileiuniunn): B, from bladder, superficial layer;
HM, from middle layers of bladder; III), from deepest layer of liladder; P, from tlie
prostate; K, from the ejaculatory duet; V, from superficial layer of vagina; \'M, from
middle layers of va^'ina ; VI), from deei>est layer of vagina : <'. from the outer surface of
the cervix uteri ; II, from the cavity of the uterus; J'K, from pelvis of kidney ; KC, from
the convoluted tulxis of the kidney ; KS, from tlie struiglit tuljcs of the kidney.
introduced into the urethra as far as it will readily go, tlu^ measure
of the meatus uriiiarius is taken. A dilator (Fig. HTj) of the same
size is inserted instead of the calibrator, and gradually rcplacetl by
thicker ones. The average female urethra can easily l)e dilated up to
164
DISEASES OF WOMEN.
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
its obturator removed. The hips of the patient are now elevated on
cushions 8 to 16 inches above the table. The examiner puts on u
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
EXAMINATION IN GENERAL. 165
balls of absorbent cotton grasped with a long mouse-toothed forceps.
In some inflammator}'^ cases the bladder will not balloon out in the
ordinary position, owing to its thickened walls. Then the genu-pec-
toral position (p. 140) 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 j>er cent, solution of cocaine and left for five minutes in the urethra
greatly facilitates the dilatation and is often the best form of anesthesia.^
The ureters may be examined by inspection, by catheterization, and
by palpation.
With the galvanic cystoscope the ureteral 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 sharj)ly, 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 introducetl 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 Avith-
out elevating the pelvis. Commonly a s})eculum 10 millimeters in
diameter suffices for inspection, catheterization, and treatment of the
ureters.
On withdrawing the stopper of the catheter a few droj)s of urine
run out, and then cease, keeping up an intermittent discharge en-
tirely characteristic!. 'J'he catheter can l)e ])ushed beyond the brim
of the pelvis, up to the pelvis of the kidney, by introducing an
' Howard Kelly, Amcr. Jour. (Jbd., January and July, 1S<J4.
106 DISEASES OF WOMEN.
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.
Galvanic Cydoscopy. — By means of Casper's cystoscope (Fig.
143),' a minute electric lamp is carried into the interior of the blad-
FiG. 143.
li
Casper s ureter cystoscope : li, movable lid covering groove in which moves c, the ureteral
catheter; d, handle of lid; o, ocular end; p, prism; I, lamp; s, screw for making and
breaking connection with the battery; vi, mandril.
der, which it illuminates to perfection, and not only allows one to
see the openings of the ureters but to catheterize them, and thus
obtain the urine separately from each kidney. This instrument has
somewhat the shape of a lithotrite and is introduced without dilating
the urethra.
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 Sinis's position. In botli 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.
Many attempts have been made to accomplish this end, but they
were either unreliable, or necessitated bloody operations, or a dan-
gerous distention of the urethra, or exposed the patient to the risk
of having a healthy ureter infected by carrying germs from' the
bladder into it, when the latter was itself infected from the other
diseased ureter. All those evils are avoided by the simple and in-
genious method invented by Dr. liose, of Hamburg.^ He uses a
^ The instrument and its use are described by Willy Meyer in the New York Med.
Jour., Mar. 21, 1896.
^ H. Rose, " Ein Neues Verfahren, bei der Frau den Urin beiden Nieren gesondert
empzufangen," Centralbl. f. OyndL, vol. xxi, No. 5, p. 121, Feb. 6, 1897.
EXAMINATION IN GENERAL.
167
steep elevated-pelvis position, in which the bladder, and especially
the region next to the inner opening of the urethra, becomes the
highest point of the abdominal cavity. The symphysis pubis and
the recti muscles prevent the bladder from ascending, and when it
becomes distended by air it is driven downward. Therefore, the
inner urethral opening and the openings of the ureters lie near it,
remain the highest points, and the urine must sink into the air-filled
bladder until the latter is tilled with urine. In the meantime, the
examination of the ureters takes place by means of a specially con-
structed speculum (Fig. 144), cut off slantingly, so as to adapt itself
Fig. 144.
Rose's vesical speculum, one-hnlf natural slzo.
better to the opening of the ureter. It has an obturator and a handle.
It is made of nickel-plated German silver, and comes in tAvo sizes,
one 2 centimeters longer than the other. In fat patients the longer
one is the better. The longer instrument may also be used in
lean persons, but here a shorter one is more convenient. In order
to avoid too great a distention of the urethra, the lumen of the
speculum is 1 centimeter. On the shorter side is a scale, which may
be read off by an assistant. The urethra i)eing 2^ to 3 centimeters,
and tlie distance from the inner ojxMiing of the urethra to the o])(!n-
ing of tiie ureter about the same, the de])th to wliich the speciihim
should be introduced is about o.L centimeters on the scale. It is
necessary to anesthetize the urethni and l)hidder with cocaine (a 5
per cent, sohition applied for five minutes), and to dihite the urethra
with conical dilators, either Simon's (Fig. Ill, |>. 145) or Kellv's
(Fig. 145).
Jt is best to shave the hairs off next to the meatus, "^fhe pliysi-
cian stands between the legs of the patient, which are separated as
much as possible. Tiie labia are lield apart by an assistant, who
stands on the side wliere the ureter is to be insj)ected. At first the
168
DISEASES OF WOMEN.
handle is pointed straight upward. The outer end of the speculum
is somewhat lowered, and the speculum introduced 5^ centimeters.
Upon removal of the obturator, one sees plainly, by good daylight
or by gas-light and a head-reflector, or by an electric head-lamp, the
lower part of the anterior wall of the bladder. Next, the instru-
ment is applied to the wall of the bladder, and the outer end moved
in the direction opposite to that of the ureter that is to be examined,
at the same time lifting it a little and rotating it so as to turn the
handle outward to the side where the ureter is, and then downward
until it comes to stand about in the middle of the lower quadrant
Fig. 145.
Kelly's Urethral Dilators.
of the urethra, on the side where the ureteral opening is to be
inspected.
The ureteral opening is recognized by its form, which is that of
a little mound with a depression. Sometimes the mound is absent,
and one sees only with great difficulty a fine semicircular slit.
Finally, there are cases in which nothing denoting the presence
of the ureter is visible, and then the only w'ay of finding it is to
look for the periodical spurting of the urine through the opening.
Another and still simpler method of obtaining the urine separately
from the two kidneys, in either sex, is that of Harris, of Chicago.'
Harris's instrument (Fig. 146) consists of tw^o catheters partly
enclosed in a common sheath, and movable on their longitudinal
axis within the .sheath. At the proximal end of each catheter (in
regard to the patient) are three or four small holes ; to each distal
end is attached a rubber tube leading to a separate vial, the stopper
of which is perforated by two tubes, one in connection with one of the
catheters, and the other with another rubber tube leading to a single
exhaust-bulb. The patient being in the litliotomy position, the
double catheter is introduced just as any other catheter, but as
soon as it enters the bladder, which can be seen by the scale on the
' M. L. Harris, "A New and Simple Method of Obtaining the Urine Separately
from the Two Kidneys in Either Sex," Jour. Amer. Med. Assoc, Jan. 29, 1898, vol.
XXX., p. 236.
EXAMINATION IN GENERAL.
109
upper surface of the sheath, each catheter is turned so that the inner
end points backward and outward, the angle between the outer ends
subtending an arc of 120 to 140 degrees, in which position they are
held by a spiral spring. The inner ends will then be in the neigh-
borhood of the openings of the ureters. Next, a metal rod is intro-
duced into the vagina (or into the rectum of the male). By gentle
Fig. 146.
Harris' instrument for collecting the urine separately from the two kidneys; «, catheters
turned down; b, sheath with scale; c, vaginal rod; dd, vials fur collecting urine ; e,
exhaust-pump.
pressure forward in the medium line the base of the bladder is
raised into a longitudinal fold between the ureteral openings,
forming a water-shed between tiie two, so that each catheter lies at
the bottom of a separate ])()eket. IW producing a gentle exhaustion
of the air in the vials by means of the bulb, the urine, as fast as it
escapes from the ureters, drops directly into the ends of the catheters,
and flows at once into the vials, right and left, respectively.
F. Examination nmler anesthesia is, of course, only used in more im-
portant cases, since the j)rocess 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 nuiscles so })ersistently that it is imj)ossible 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.
G. Explnratorn aspiration is used less now than it was some years
ago. It is done in order to ascertain tlie presence of a fluid oi' to
obtain a sann)le of sucli fluid for examination. If the Huid is IJiin,
it may be drawn out by the common hyjXKlcrmic syringe. l*^)r use
in the vay-ina such a svrin<i:e has been made with a lonwr needle and
170 DISEASES OF WOMEN.
an attachment by which the piston can be pulled out (Fig. 147).^ In
most cases it is preferable to use a real aspirator, such as Dieulafoy's,
Potain's (Fig. 148), or Emmet's. Even the finest hypodermic nee-
FiG. 147.
Exploratory vaginal syringe.
die 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 les.«en 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.)
H. Exploratory Incision. — With the increasing innocuousness 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
' Campbell, southwest corner Lexington Avenue and Thirty-fourth Street, has
made such a syringe for me.
EXAMINATION IN GENERAL.
171
pelvis, and, this being the simpler operation, it should, as a rule, be
preferred.^ 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 Kraduatod scale showing
the amount of fluid contained. It is closed by a rubber stopper. ihrout;h the centre of
which a double-current tube, 2, passes. It is attached to an elastic hose, 3, with iin ex-
hausting pump, 4, and another elastic hose, 5, with a stopcock, G. On the top of the latter
tit needles ana trocars, 7, of difl'erent sizes.
It goes without saying that the pvhe should be counted and its
character noted, the fenipr rati ire measured with a clinical thernionietci-,
and sucli other investigation.s made in regard to the condition of of/ier
or(/anfi and the (/aieral Jicdltli of the patient as the case may call for.
* Garrignes, "Vaginal Hvsterectoniv and ( )()i)liorectomy after Svni])hvsiotomv,"
Mc(l. Record, Feb. 2'.'>, 1895, vol. xlvii. No. 8, p. 'IM.
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
172
TREATMENT IN GENERAL. 173
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,^ 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.
^ 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 2d, 1S83, 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 TransuetionK, Amer. Gynecol. Soc, vol. x. 1885, pp. 9H-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 nj 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 antL'^epsis is now used everywhere, but in private ])rac-
tice we lag yet in a deplorable way behind other coinitries, and the result is to be
found in fre(iuent disea.se and death among the well-to-do, which have marly dis-
apjx'ared from the lying-in hosjiitals. It is to be hoped that the general i)ra(titioncr
soon will follow the lead of the expert obstetrician m this field. On motion by the
writer the following resolution was unanimously adn|)t((l on October '27, 1S92: "In
the opinion of the .'^ei'tion on Oi)stetrics and ( Jynccolo^'v of the New York .Academy
f>f Medicine, it is the duty of every f)hysician practicini,' midwifery to surround
sucii cases in private practice with the same safeguards that ;ire used in lios|iitais"
((Jarrigues, " Keprehensibic, Dei)atable, and Necessary Antiseptic Midwifery,"
Med. News, Nov. 26, 1892).
174 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, or better, a small ball of
absorbent cotton held in a forceps. As the iodine smarts when it
reaches the vulva, care should be taken not to use 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 application to the interior of the uterus an applicator is needed.
Most of the instruments offered for sale are either too elastic or too
flexible, which makes it difficult to introduce them, or they have
a shape that makes it hard to remove the cotton after the applica-
tion. I have, therefore, had one made (Fig. 149) of rather thick
Fig. 149.
Garrigues' intra-uterine applicator.
hard-rubber, which has just the desired degree of elasticity and is
conical, which renders the removal of the cotton very easy. As the
cotton occasionally will come off, while the applicator is withdrawn
from the uterine cavity, it ought always to be so long that part of it
remains outside of the cervix. By seizing this end wnth a pair of
dressing- forceps and rotating the cotton, it is easily pulled out.
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 wiped off with dry cotton, or, if
this proves impossible, it is coagulated by ajiplying 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. 152).
TREATMENT IN GENERAL.
175
If the canal is too narrow, it must be dilated (p. 156). For the
endometrium, I use mostly Churchill's tincture of iodine, liquor ferri
chloridi undiluted, chloride of zinc (20 per cent.), and occasionally
sol. argent, nitrat. 1 to 12, or pure carbolic acid.
As some patients are extremely sensitive to intra-uterine appli-
cations, it is best to restrict the first application to the cervix,
and gradually penetrate into the cavity of the body up to the
fundus.
Uterine and vaginal applications are, as a rule, repeated twice a
week.
Medicinal applications are also made to the skin of the abdomen,
especially tincture of iodine or an ointment of equal parts of ichthyol
and lanolin. These applications
are repeated once a day. In ^Jg- 150.
septicemia, inunction once a day
with unguentum Crede, which
contains soluble silver, has ac-
quired great reputation.
B. Injexitioiis. — 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
position on a douche-pan (Fig.
150). A good douche-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 l)ed. If it does not have
such a contrivance, and is not
large enough, the water may be
gradually pumped out by means
of a bulb-and-valve syringe (Davidson's syringe) while running into
the douche-pan.
Patients who arc obliged to help tlicmsclves may also take their
vaginal douche sfcmding over a vessel placed on a cliair, or sitting
on a bidet.
It is best to use a foimfain ftj/rinf/e ; that is, a bag of soft rubber,
or a metal pail, a so-called donohe-can with a long soft-rubber tube
and a nozzle of metal or, perferably, hard rubber. The nozzle should
have holes only at or near the v.\u\, and it should be pushed in so far
that the openings are behind and above the os uteri. If there are
Douche-pan: A, tube closed unless used to
make connection with rubber hose leading
to vessels jjlaced under the bed.
17G 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 can just hold her hand in it (110° to 120° 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.), creolin,
or lysol (^ to 1 per cent.) is used. Creolin 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,^ 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 nne openings near the end (Fig.
151). Having seen several cases of alarming colla])se 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 debris. For this purpose
' Garrigues, "Corrosive Sublimate and Creolin in Obstetric Practice," Amer. Jour.
Med. Sci, Aug., 1889, vol. xcviii. pp. 109-128.
TREATMENT IN GENERAL. Ill
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. 151.
Brauii's Uterine Syringe.
syringe (Fig. 152), If the cervical canal is not so wide, a double-cur-
rent uterine tube (Fig. 153) should be used. AVhen it is of import-
ance to bathe the whole inside, cervix and body, it is best to use two
Fio. 152.
< ^r . -..—■: . ^ .
Garrigues' Single-current Intra-uterine Tube.
single-current catheters, a thinner afferent and a thicker eiferent.
The fluid then comes out partly through the thick tube and partly
between and around both.
The patient is placed on a tabic, 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
leg nearest the edge 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 iier buttocks, and })inned witli two ])ins so as to form a
funnel, the lower end of which o])ens into a pail. If the patient is
placed on a table, the inflatabk; rul)ber cushions mentioned on page
203 may also be used. Intra-uterine injections ought only to be
given in the dorsal position in order to avoid the entrance of the fluid
througii 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. Cu.sco's specnhim is introduced. Tlie intra-uterine tube
is attached to the tubing of the iountain .syringe, and, all air having
l)een exj)elled, is pushed up to the fundus of the uterus while the
fluid is turned on. The physician watciies tiie flow all the time to
make sure that there is no ob.struction. I use about a quart for the
vagina and from a j)int to a quart for the uterus. When the uterus
is deemed to be sufliciently wa.'^hed out, it is .squeezed in order to
remove all fluid from its cavity. Finally, the vagina is again douched,
and the perineum (lej)ressed so as to allow all fluid to flow oil".
For these injections I prefer crcolin (1 per cent.), as it is a non-
12
178 DISEASES OF WOMEN.
poisonous reliable disinfectant and an excellent hemostatic. Lysol is
also good, and has the advantage of forming a nearly clear mixture
Glasgow'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. 152), and introduce an intra-uterine tube
through the speculum all the way up to the fundus.
Rectal injections, enemas, or clysters are used for emptying the lower
part of the bowels, or as a vehicle for medicinal substances to be ap-
plied to the diseased mucous membrane, or to overcome an obstruction
in the intestine, or to mark the course of the intestine (p. 161). If the
object is only to cause a movement of the bowels, plain lukewarm
water may be used, or a teaspoonful 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 impaction 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-gaJl 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 ( .5j to .5iv).
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 arc best given with the patient lying on her
left side. Evacuant enemas are preferably administered by means of
a bulb-and-valve-syringe (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.
Ordinarily, enemas are administered through a hard-rubber or
TREATMENT IN GENERAL.
179
metal nozzle about two inches long ; but when it is desirable to
carry the fluid higher, a children's nozzle is inserted into a soft-
rubber rectal tube a foot long. If the object is not only to inject a
certain amount of fluid, but to irrigate the intestine, Dr. Kemp's
double-current tubes will be found useful. They are respectively
five or twelve inches long. The shorter is made of hard or soft
rubber, the longer one of soft rubber only.^
Vesical injections are used very much in diseases of the bladder.
The patient occupies the dorsal position. For large injections Keyes's
Fig. 154.
Kfvuj^'s Irrigator for Bladder.
irrigator (Fig. 154) may be used. It is essentially a fountain-syringe
with a two-way stop-cfK'k, which allows alternately to fill and ein])ty
the bladder simply by turning the stopcock. It may be used with
any hard or soft catheter. Another good and simj)le apparatus for
washing ont the bladder consists of a catheter, an intermediate piece
of rublxsr 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 cstabli'^hing a si-
phonage. Care should be taken to let as little air as ])ossible
enter the bladder. Where shreds are to be washed out, Xotf's
(louhfe-ciirrciif (•(ifhcfrr (Fig. loo) with its large eves will be found
' Kol)C'rt ('(.Icman Kt-nii), Xnr York Midiml Riro.-d, Doc. 7 and 11, IS!*.").
180
DISEASES OF WOMEN.
to answer a good purpose. For smaller injections, Thompson's rubber
bag with stopcock (Fig. 156), inserted into a soft catheter Avith hard
Fig. 165.
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 (^ to 3 per cent.), tannin (^ to 1 per
Fig. 156.
Thompson's Rubber-bag with Stopcock.
cent.), carbolic acid (^ per cent.), creolin (^ per cent,), permanganate
of potassium (^ 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. Gen-
erally the fluid should be lukewarm (95° F.), but as a hemostatic it
should be hot or ice-cold. The irrigation of the bladder is repeated
once, twice, or three times a day.
Intravenous, subcutaneous, or intraperitoneal injedion of a hot solu-
tion of 6 parts of chloride of sodium in 1000 parts of hot water
(110° to 120° F.), or al)oiit a flat teaspoonful to a quart, is used with
great benefit to counterbalance loss of blood in operations. (See
Uterine Fibroids.)
C. Curettage. — The instruments needed for scraping the inside of the
uterus have been described in the preceding chapter fp. 155). The
patient is placed on a table arranged forintra-uterine injection (p. 177).
As the procedure is often protracted and painful, she ought to be
TREATMENT IN GENERAL. 181
anesthetized.^ The vagina and uterus are disinfected with creolin
(p. 177). The cervix is dilated (p. 156). The condition of the in-
side of the uterus is ascertained by sound (p. 154) or finger. The
index-finger is preferable if the cervix admits it. In introducing it
counter-pressure is made on the fundus with the other hand. The
nail of the finger is often used itself as curette. It is safer than
instruments, but not so efficient. In gynecological cases I use the dor-
sal position and introduce the curette through Cusco's speculum (p.
146j ; or if the patient is anesthetized, I pull the uterus down to the
vulva with a tenaculum-forceps while the j)erineum and the posterior
vaginal wall are being pulled back with a Garrigues 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 simultaneously with the
left index-finger and a large dull-wire curette (Fig. 157).^ The
Fig. 157.
Large dull-wire curette.
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 disin-
fected, and a tampon is put in the latter until the following day.
The iiemorrhage is not very considerable. It is very rarely neces-
sary 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 discharge. The ])atient is kept in bed
for four days. If then; is any pain, which is an exception, an ice-
bag is applied over the symphysis and the patient is given an opiate.
The curette should only ])e used for scraping in the direction from
the fundus to the os and along the fundus, but never in going from
below u])ward. In moving the curette u]) toward the fundus great
gentleness should be used, as otherwise the instrument may ])er-
forate the uterus. If this should happen, the beginner need not be
particularly alarmed. It has happened twice to me, and no bad
consequences were observed, but in such a case it is necessary to
desist from washing out the ut(!rus, an omission whi(^h, of course,
in other respe(;ts is undesirable. The smaller the loo]) of tlu^
curette, tlu; greater is the danger of ])erforation. AVe should,
' This ap[)lieM to strictly pynccdloirieal cases; in cases of licmorrliajre due to recent
abortion, anesthesia may be (iisi>(;iise(l with except in very nervous women.
' I call ail dull-wire curettes Thomas's, whether they are jarj^e or small ; hut the
instrument is also known as ^f un(l<'''s (see Ciarrigues, " 'I'he 'Ireatment of Abortinn'),
Medical Newx, Nov. 6, 1897, and .Jan. 1, I89H.
182 ' DISEASES OF WOMEN.
therefore, always use as large an instrument as will enter the cer-
vix and is in reasonable 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, Becrnnier\s curette
(Fig. 158) is sometimes useful. It is made of steel, and has either
dull or cutting edges.
Physicians wlio are not quite familiar with the aseptic and anti-
septic treatment, or who have not an educated sense of touch, had
better abstain from performing curettage. Simple as the o])cration
is, it has cost more than one woman her life. Large j)elvic abscesses
have been produced, and the most fearful direct injuries have been
inflicted. Unskilful hands have not only perforated tlie uterus,
but have taken hold of the intestine and torn it loose from its mes-
entery or severed it, causing gangrene of the intestine, and death.
The only remedy is prompt laparotomy, repair of the intestinal
injury (see Appendix), and suturing of the wound in the uterus.^
D. Tamponade. ^-Thc word tampon is French, and means a small
mass of cotton or other soft material which is carried into a wound or
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 such very different purposes, becomes a very different thing,
and we will, therefore, consider separately the application of medi-
FiG. 158.
R^camier'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 uj) 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
witli different substances. The best in my experience is ichtiiyol
dis.solved in glycerine (5 per cent.) ; but in some cases the ichthyol
irritates the vagina, so that it becomes red and smarts. Then plain
'M. D. Mann, Amer. Jour. Obs., May, 1895, vol. xxxi, p. 603. H. .T. Boldt,
Moruilsschrift fiir Geburtshiilfe und Gyndkoloqii', vol. ix, p. 360. Albert!, Centrulbt.
f. Gyndk., 1894, No. 39, vol. xviii, p. 939.
TREATMENT IN GENERAL. 183
glycerine must be substituted. Another good resolvent combina-
tion is :
^. Potassii iodidi, gr. xxx ;
Acidi borici, gr. xl ;
Glycerini, q. s. ad siij.
As an astringent, for instance, for a spongy cervix, tannin-glycerine
(10 per cent.) is very efficient. Others prefer lioroglyceride or sul-
phate or acetate of aluminium, in the proportion of .5J to glycerine
Oj.' All these applications containing glycerine produce a watery
discharge, relieve pain, and scatter swelling. If the discharge is
free, and especially if ichthyol or tannin is used, which stain the
linen, some kind of napkin or pad should be used.
Packing of the vagimi differs from the application of a pledget, as
heretofore considered, in being a combination of medicinal action and
pressure in the treatment of diseases of the uterus, ovaries, and peri-
uterine 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 posterior cul-de-sac and resting on the pubic arch and the peri-
neum below. The uppermost pledget, which covers the cervical
portion and part of the vaginal roof, should be saturated with pure
glycerine, or better, the above mentioned solution of iodide of potas-
sium. The others are rolled into cylinders and put in dry. 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.^
It is claimed that by this method adhesions may be lengthened,
cicatrices stretched, exudations absorbed, congestion relieved, and
the vagina lengthened ; but the writer is somewiiat skeptical as to
the possibility of exerting any pressure in this way, and thinks that
the same results are obtained in an easier way by the use of medi-
cinal pledgets, by painting the vaginal roof with the tincture of
iodine, or by electrolysis.
TJic Jfnnosf((fie 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-si/ed j)ieces of cotton are necessary.
One or two sheets of al)sorl)ent coftou, a foot S(juare, shotdd be im-
mersed in a 1 ])er cent, emulsion of creolin, s(jueezed dry, and torn
into strips, which arc folded so as to form flat scpiares which may
be packed very tightly. The creolin imj)arts both styptic and anti-
septic ])roperties. The first may also be obtained by immersion in
'Wiley, M>'(1 RrronI, October, 8, 1SS7. vol. xxxi, p. AHli.
^ Natlinii Hozemanii, "The Wiliie of (inidiiatcd Pressure in the Treatinetit of
Diseases of the N'agiiia, Uterus, (^varies, and other Appendages," All'tntu Midiad
Retfinter, January, ISSI}.
184 DISEASES OF WOMEN.
an alinn solution, the latter by using carbolized water (1 per cent.).^
When there is much bleeding from an accessible surface — e. g. after
curetting a cancerous cervix — the tlu'ce 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 ])ainful. 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 Avhich 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 relv on it in severe hemorrhaa-e.
The vaginal tampon is best a])j)lied 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 princijile should be followed if a continuous long strip of some
kind is used. Whatev^er we use should be evenly and tightly put in
with a strong pair of dressing-forceps until the vagina is filled all
tiie way down to the entrance (but not the vulva). If the patient
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, W'hen it may stay in for five or six days if necessary.
In exceptional cases of severe hemorrhage the vulva, too, must be
filled and two tightly-rolled towels placed on the ])erineum and held
tightly pressed against it by means of a bandage which surrounds the
])elvis, 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 ])ull 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 ])ushed farther in
until the whole tampon has been removed. Then the patient is
turned on her back and given a vaginal injection with creolin.^
' A stronger solution takes off the whole epithelium.
^ 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.
185
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
tissue, especially in chronic endometritis and metritis, and even in
order to cause depletion from intlamed appendages. 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 aj)plication through an undi-
lated cervix (Fig. 159).^ But, as a rule, the cervix should be pulled
Fiu. 159.
Garrigues' cnrved intra-uterine packing-forceps.
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 Burrage's cervical speculum (Fig. 12(j, p. 152), with a
single-current tube (Fig. 152, p. 177) reaching to the fundus, and the
uterine cavity packed with a strip of iodoform gauzt; 2 inches wide
and folded so as to form four layers ^- inch wide, the end of which
Fk;. ino.
(iarrigucs' straiglit iiitra-uteriiic packiiig-fnrcciis.
strip is left hanging in the vagina, and a pad of the same inatcriMl
is placed in the vagina. The gauze is pusiied through the spccuhini
by means of a straight forceps (Fig. KiO).
' Amer. Jour. ()hs(., vol. .xxv. No. 1, Jamiarv, 1 N'Jl*.
186 DISEASES OF WOMEN.
Abdominal Tampon. — The iodoforra-gauzc 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 eifectually by packing the pelvis with iodoibrm gauze
through the abdominal wound. The end is left hanging from the
lower end of the woimd, 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 suflficient adhesive matter has been formed
to shut off the abdominal cavity from that part where the tam])on
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 Avhich remain outside (jSIickulicz'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 timipon, 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. Hemostasis. — Besides the hemostatic tampon, of which we have
just spoken, other means of preventing or checking hemorrhage are
available: hot loater, styptics, cauterization, ligature, suture, and ford-
pressure.
Hot water is used to check hemorrhage during operations. Thus
a stream of some hot antiseptic solution or plain sterilized water
may be kept continually flowing over the field of operation' or may
occasionally be directed against the bleeding surface. At the end
of laparotomy hot water is often poured from a pitciier or through
a glass tube, as thick as a finger, right into the peritoneal cavity.
Hot-water injections are also used as a hemostatic independently of
operations, both in the vagina and in the uterus (pp. 176, 177).
Styptics, especially alum, tannin, and chloride, persulphate or sub-
sulphate of iron (Monsel's solution), are used as applications (p.
174), on tampons (p. 181), or in injections (p. 176). The undiluted
liq. ferri chloridi or subsulphatis may be applied with cotton to
small bleeding surfaces. Diluted with 10 parts of water, it may
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 stypdic
cotton as sold in the drug stores. Ferripyrine (p. 174) may be used
as dry powder or in strong solution (20 per cent.).
Cauterization is an excellent hemostatic and, at the same time, an
'Geo. Engelmann, of Boston, Trans. Amer. Med. Assoc, 1885.
TREATMENT IN GENERAL.
187
antiseptic; but as it leaves an eschar, it cannot be used where heal-
ing by first intention is aimed at (nor can styptics). 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. 161), in which a tip of platinum may be kept at different
degrees of heat by a more or less abundant supply of benzine vapor.
Fig. IGl.
Thermo-cautery.
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. Some use it, for instance, on the stumps left after
removal of the ovaries or the uterus.
Cauterization by means of the r/dhano-cautery will be described
under Electric Treatment.
Vaporization. — Steam may be led from an apparatus like a steam
atomizer, through rubber tul)ing and a metal nozzle with fine holes,
into the interior of the uterus for half a minute or a minute. This
method, called vaporization, is highly recommended as a preventive
in all operations in which th<; uterine cavity may become a source
of infection — e. r/., hysterectomy or myomectomy.'
Vaporization niay also be used to check hemorrhage in other locali-
ties, especially tiie liver or tlu; spleen. For the uterus I have found it
efft'ctive after curetting ; but it sometimes gives rise to protracted
puruh'ut discharge, and has caused atro])hy and atresia of tiie uterus. -
Even a fatal case, du(! to secondary perforation and se])ti(^ peritonitis,
has been reported.^
Lir/aftirc. — Spurting arteries or, more rarely, bleeding veins, may
be ligated Avith silk or catgut, according to the general rules of sur-
gery, but in gynecological ])raeticc we are oftener tiian in any other
departments obliged to tie, not the isolated ]>leeding vessel, l)ut a
more or less considerable inass of the surroiuidiiig tissue with it
' i'"erK)Tiicn()W, f'rulnilbLf. Gi/riiilc., ISOS, vol. xxii, No. '2.'), ]>. (iO'.>.
'■^ SncRirefr, Jirrliinr Klinik; Apr., ]S9."). Jianicli, (Vnlntlhl. f. diiiiiik., Kcl). •"),
189S.
■'()|K'ration perforiiu'd l)v Treiil), reportfd liv \':iii de Veliie, Crvlni/hl. f. (hiniik.,
Dec. 31, 1898, vol. -x.xii, .No. W, j). 1 tOU.
188
DISEASES OF WOMEN.
(wuws ligature). Arteries may be tied wliere they are severed or in
continuity.
Ligature of the Uterine Artery. — The uterine artery may be tied
from the vagina.
Modus Operandi. — Two assistants are needed besides the anes-
thetist. The patient is phiced in the dorsal position witii raised knees
or in the breech-back position (see Urinary Fistuhi). The cervical
portion is exposed by means of short, broad, posterior, and anterior
specuhi (see Hysterectomy), and seized with a bullet-forceps. A
strong thread is carried through both lips in the median line. Before
tying it, a strip of iodoform gauze may be introduced into the
uterus, in order to keep all discharge from this organ away from the
wound. By means of this ligature the uterus is pulled down and
over to the side opposite that on which the operation is to be per-
formed. The anterior blade is now removed, and a Schroeder lat-
eral retractor (Fig. 193) is held against the wall of the vagina, so
as to fully expose the lateral vault. At a distance of f inch outside
of the utero-vaginal junction a fold of the vaginal wall is lifted
with a tenaculum and cut (with blunt-pointed scissors, curved
on the flat) in an antero-posterior direction at right angles with the
base of tlie broad ligament. Next, one blade of the scissors is in-
serted through the wound, and used to extend the incision backward
and forward in a slightly curved line, the convexity of which
points toward the side wall of the
Fi(i. 1C)2. vagina, until the incision measures
1^ to 2 inches in length (Fig. 162).
With both index-fino;ers the vag-inal
tissue is separated laterally from the
parametrium to the extent of nearly
2 inches. In a similar way the para-
metrium is separated from the bladder
and ureter in front and the rectum
behind. By passing one finger be-
hind and one in front of the para-
metrium the whole mass, in which the
main trunk and several branches of
the uterine artery are felt throbbing,
is grasped. The wound is kept well
open by means of two lateral retrac-
tors, and a strong silk ligature is car-
ried with a Schroeder needle (Fig.
295), guided by the left index-finger, from behind forward, around
the whole parametrium. The thread is seized with an artery-
forceps, freed from the needle, tied tightly, and cut short. The
ligature should be passed as far out to the side as convenient,
■ •'^v
Ligation of Uterine Artery from th ■
Va<rina: a, vaginal portion; b,
vaginal incisions sutured.
TREATMENT IN GENERAL.
189
so as to include all branches of the artery. After irrigating
the vagina with an antiseptic solution, the edges of the wound
are united with a running suture of fine catgut, completely
burying the silk ligature. To tie the ligature at such a great
distance from the surface may be so difficult that catgut, in
most cases, will be less appropriate. The handling-string and the
gauze are removed from the uterus, and the vagina is packed loosely
with iodoform gauze, which is removed after three or four days, and
either renewed or replaced by antiseptic injections.
The uterine artery may also be tied from the abdominal cavity
after performing laparotomy (see Uterine Fibroids).
Ligature of the Internal Pudic Artei-y. — As a rule, this artery
should be cut down upon where it bleeds, making an incision in the
Fig. 163.
Lifjiition of the internal pudie artery in tlie Bluteal region : <i, skin; 6, fiiseia; r, Khiteiis
innximus ninsele ; (/, pyriforinis nmsele; c, intorniil )ni(lic artery; /, interiml pudic
nerve; (t, superlieial brimeli of gluteal artery; h, seiiitie artery; /, sciatic nerve;
j, sciatic vein.
jX'riiuMim parallel to the inner margin of the rami of the pul)is and
ischium. Pxtth ends must be tied. It may also be tied in con-
tinuity in the gluteal region, in the place wher(> the arterv runs
i)ehin(l the spine of the ischium ( I'^ig. KJo). An incision H inches
long is mad(! on a line extending from the middle of the spine of
190
DISEASES OF WOMEN.
Fig. 164.
the sacrum over the spine of the ischium to the trochanter. The
fibers of the ghiteus maximus muscle are separated bhmtly and
held apart with retractors, and the deep fascia is torn. The lower
edge of the pyriformis muscle and the spine of the ischium must
be well exposed. Under the edge of the muscle emerge both
the internal pudic and the sciatic arteries. The latter is more
superficial and passes outward. It is accompanied by the sciatic
vein on the inner side and the sciatic nerve on the outer. The
internal pudic artery is accompanied by the nerve of the same
name on its inner side, and crosses behind the spine of the ischium
to gain the lesser sciatic foramen, by which it re-enters the
pelvic cavity. On account of the depth of the wound and the
bleeding, this operation is, however, so difficult, that the great
English surgeon Fergusson has stamped it as " an ingenious dis-
secting-room proceeding." *
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-
h-ess suture). These sutures may be made more
efficacious by using quills, a couple of lead-pen-
cils or pen-holders serving as such.
Foreipressure. — Much time is saved by sub-
stituting a temporary strong pressure with Koe-
berl^'s clamp (Fig. 104), 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 (Fig. 165) and
left for twenty-four hours or longer, 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 re-
moved toward the end of the operation Avhcn
the bleeding is stopped. If, exceptionally, a
vessel still bleeds, it may, of course, be seized again with the forceps
and secured with a ligature.
^William Fergusson : "A System of Practical Surgery," fourth edition, London,
1857.
Koeberle's artery-clamp
(modified by Pean).
TREATMENT IN GENERAL.
191
Angiotripsy is a peculiar development of forcipressure. An angio-
tribe is an exceptionally strong pair of forceps, in which pressure is
Long Pressure-forceps.
exercised by means of a screw with a large head (Fig. 166). With
it the tissue containing the artery to be closed is crushed, whereupon
the instrument is removed. The angiotribe was originally used in
vaginal hysterectomy to crush the broad ligaments. If (lifficulties
are met with, especially when morcellation is needed, the inventor,
Fig. 166.
Tuflier's angiolribe.
Tuffier, of Paris, uses first common compression-forceps, but at the
end of tiie oj)eration he removes them all one after the other, and
crusiios the tissue held by each with the angiotribe.' Others have
used the instrument for other operations involving small or medium-
sized arteries. It insures ])erfect hemostasis, and leaves no foreign
body in tlie wound.^
F. J)il(ii(iii<)ii and (i. J)rain<i(/e art; .so intimately connected that
we will treat of tiiem together. In regard to dihitation of the cer-
vix the reader is referred to what has been said on tlie subject in
the cha|)ter on Fxamination (pp. 1 56-15!*).
Dr. Outerbridge of New York has constructed an ingenit)us insfrii-
'Tiiflier, Si-mninc Mvdimle, lKii7, p. 472, and ]8!)S, p. 'J3.',.
• W. F. SchuItC'n, Ibiil., p. i:i)3.
192
DISEASES OF WOMEN.
ment for pei'manent dilatation of the cervix and drainage of the
uterus. It consists of a silver- or gold-plated steel wire (Fig. 167),
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 cnrvatnre. 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. 168). It consists of a fork with a movable ball and spiral
spring sliding up and down a metal rod with handle. The dilator is
introduced five or six days before expected menstruation, left in
Fig. 167.
Fig. 168.
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 tenaculum or a blunt
hook.^
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.
Iodoform gauze is used extensively for drain-
age, either through the abdominal wall or the
vagina. If there is much oozing from raw
surfaces, or if pus or acrid cyst-fluid has found
its way into the peritoneal cavity, it is ordi-
narily best not to close the wound entirely
after la])arotomy, but to leave one or two su-
tures at the lower end untied, and to carry a long strip of iodoform
ip. E. Outerbridge, Med. Record, April 20, 1889, vol. xxxv, p. 430.
Carrier for Outerbridge's
Dilator.
TREATMENT IN GENERAL.
193
gauze from the bottom of the pelvis out through the lower end of the
abdominal wound. If hemostasis is called for, the above-mentioned
Mickulicz tampon is excellent, and will, at the same time, serve as
drain, especially when part of its contents are removed (p. 186).
Sometimes the pelvic floor is perforated, and the iodoform-gauze
drain pressed into the vagina. Its upper end may be free in the
abdominal cavity, or may lie in a pouch that does not communicate
with the peritoneal cavity. It may be left in from two to eight days.
If there is no contamination with pus, some prefer plain sterilized
gauze. If there is no hemorrhage, soft-rubber tubes are also very
useful as drains.
Superficial abscesses may be drained through short thin tubes
with side holes. A longer and thicker tube of this kind may be
carried from an incision above Poupart's ligament into the vagina.
If the drainage-tube is only introduced through an opening in the
vagina into a space shut off from the peritoneal cavity, the drain
Fig. 169.
Single soft-rubber drainage-tube.
Fig. 170.
Double soft-rubber drainage-tube.
Fig. 171.
■^ky rocket ilrainagc-tube.
siiould have a T-shapo, the nj)p('r bar of the T serving as wings to
retain the tiil)e in situ (Fig. KID). It is well to have a double tube,
which facilitates washing out the cavity H'^ig. 170). The afferent tulx!
should be thinner tiian the elferent and not have anv side holes. In
large pelvic abseesses, the s/:i/ro<-/:<t <lr(ti)ui</(-liibc {V\\i. 171) is very
1:1
194
DISEASES OF WOMEN.
useful. It consists of a short tliick tube, with lateral openings, and
a long thin one without side lioles. The former has a lumen of f
inch, and is 2^ inches long ; the latter has a lumen of ^ inch, and
is 10 inches long. They are stitched together in three places.
After the abscess has been opened from the vagina, the tube is in-
troduced and the lower end of the short one is fastened with four
silver wire sutures to the edges of the wound. The long tube may
be closed with a clamp and is used for injections. The T-tubes are
found in the instrument stores, but are rather expensive, and fairly
good ones may be improvised with tubing.
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.
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. 1 72).
Fig. 172.
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 enter.s. 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. 1 73) is pushed to the depth of three-quarters of an
Fig. 173.
Garrigues' uterine scarifier: a, spear; b, button and side slot; c, main slot; d, shaft.
inch into the vaginal portion in three or four places, and blood to
the amount of from htdf an ounce to two ounces is withdrawn
twice a week. Fig. 173 represents such an instrument, wliicii
finds room in a pocket-case, the needle being pushed forward and
TREATMENT IN GENERAL.
195
fastened like a bayonet. 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.
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 ]>ain.
I. Heat and Cold. — We have spoken above of hot, lukewarm, and
cold injections (pp. 175-180 and 186). 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.
These warm fomentations must be covered with
some waterproof material, such as oiled muslin, Fig. 174.
rubber sheeting, enamel (/. c. thin oilcloth). Spon-
giopiline is felt covered with guttii-percha, and is
merely wrung out of hot water. Aiifij)/ilo(/i.sti)ie is
a putty-like combination of glycerine, boric acid,
salicylic acid, iron carbonate, peppermint, gaulthe-
ria, eucalyptus, iodine, and dehydrated silicate of
aluminum and magnesium, which is warmed and
smeared in a layer i of an inch thick directly on
the skin, covered with a cheese-cloth jacket or
bandage, and left in place for twenty-four hours.
Poultices or a small rubber l)ag with hot water
may also be used in the vagina.
In acute inflammation an icc-haf/ or a coil with
running ice-water is a more expeditious remedy,
and checks in most cases the pain more efficaciously.
Ff)ur layers of muslin should be inserted b(>tween
the ice-bag and the skin in order to avoid local
freezing.
When the acute stage is ])assed, J*i'irssnitz\'< com-
press — /. e. a towel wrung out of cold water and covered with some
waterproof material and held in j)lace with a flannel binder — is
])rererable 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 ]>owerfnl absorbent.
A great variety of hdf/i.s may l)c used as valu:ibl(> adjuvants in
gynecological diseases. Tiu; effect on the pelvic organs may be
enlianced by the uso. of a hath-sjicmhim (I^ig. 174), which is intro-
<liic('d into the vagina and allows the water to fill the same. A
tc\m\ (p'n<r<d hafJi^i)^ ix temperature slightly below blood-heat, taken
Batli-spcculiiin.
196 DISEASES OF WOMEN.
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.
'Turkish and liussian baths may sometimes be substituted for warm
baths, but are often too irritating 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 covering all well with blankets and
waterproofs. If the patient is well enough, she may sit on the
chair covered 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.
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. For this three Turkisli towels and a large basinful of
cold water will suffice. 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 comi)laints, such as Franzensbad and IMarien-
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-
TREATMENT IN GENERAL. 197
dermis is hardened a little, it is well, in order to avoid cracking, to
cover it with a compress soaked in the following wash :
^. Acid, carbol, ITlxl ;
Glyeerini, 5ss ;
Aquse, q. s. ad siv.
This allows one to coutiime the use of the iodine indefinitely.
(Compare p. 174.)
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 mo if it is any better than other means ;
but half a dozen small blisters, 2-4 square inches, one of which is put
on every evening, often relieve pain in chronic cases.
K. tapping and Aspiraiion. — 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 asjM-
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 sim])le tapping. The
object is to remove a fluid collected in a normal cavity or a cyst.
Tapping is used much less no\v-a-days as a se})arate and complete
gynecological operation than a decade or two ago. Tumors are sel-
d(jm tapped, the more radicjil operation of removal being ])referred ;
but ascitic fluid has often to be evacuated by tapi)ing. Tapping is
used during ovariotomy to diminish the cyst, and aspiration is often
used as part of a more comprehensive o])eration — e.g. in removing a
pyosalj)inx or opening a pelvic abscess. Asjiiratioii 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 l)e needed. We have already spoken of the
use of the aspirator for diagnostic purj)oses (p. 3G9).
A ])atient who is going to be ta])j)e(l through the abdominal wall
should sit on a chair or lie on her side with the abdomen turned to-
ward the o])erator. The abdomen should be surroinided above and
below the point selected for the o])eration with a sheet, the ends of
which are crossed in front and pulled upon during evacuation. The
<)l)je(;t thereof is not only to ])roduce the necessary jiressure for the
evacuation, but to avoid a sudden suction of blood (o the abdominal
viscera, which might cause syncope. A quarter of a grain of cocaine
sliould be injected with a hyjXKlcrmic syringe into the skin at the
place selected, which, as a rule, should be in the mesial line, nn'dwav
l)etween the symphysis jmd the umbilicus. Full antiseptic |)rec;ui-
ti(»ns should be used. The bladder should be emptied with the
ciuheter. The trocar is thrust in, the stylet withdrawn, and the fluid
directed into a pail placed on the floor. When all has been removed,
198
DISEASES OF WOMEN.
tlio abdominal wall is lifted in a fold around the canula, the latter
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 holes or rings 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
Fig. 175.
Trocar, composed of canula with cap, pointed stylet, and blunt stall'.
substituted. The canula is withdrawn and a knife is slid along the
furrow in the guide (Fig. 175).
F'lG. 17().
Garrigues' blunt expanding perforator.
Instead of this method it will in most cases bo found preferable
to use a perforating dilator (Fig. 176), sometimes followed by a
TREATMENT IN GENERAL.
199
blunt expanding dilator (Fig. 177), and to drain by means of iodo-
form gauze or a soft-rubber tube.
Fig. 177.
Blunt Expanding Pelvic Dilator.
L. Abdominal Belts. — An elastic abdominal belt (Fig. 178) is often
useful, especially in fat women, to take off some of the pressure on
the pelvic organs, and is used during the first three months after
laparotomy to take off the strain on the cicatrix.
Fig. 178.
Teufel's ab
porter.
When a special pressure above the symphysis is required, an ali-
dominal sup))()rter, with a solid hy])()gastric j)a<l, is used. A good ap-
paratus of this class is the so-called natural body brace' (Fig. 17J)).
M. 3fasH(u/e. — Certain manipulations inside of tiie ]>elvis and
through the abdominal walls constitute a valuable mode ol" treatment
in many diseases of wouk-ii, especially chronic metrilis, cellulitis,
peritonitic exudations, adhesions, hematoma, and (Mjphoritis. ( )f"teii a
general massage of other parts of the body or the whole body is
added. In this way exudations, infiltrations, liy|)ertrophies, nnd
adhesions are made; to disa|)])ear, weak ligaments and muscles
strengthened, and disj)laced organs brought bark and kept in (lieir
normal positicm. The j)roeednres being rather ])ainful, tliere is no
danger of causing sexual excitement. ( )ne or two fingers are inserted
' Natural I'ody I'race Company, National Hotel I'luek, Salina, ]\a.
200
DISEASES OF WOMEN.
into the vagina and kept pressed against the part to be massaged,
while the otlier liand seizes it throngh the abdominal wall and rubs
and squeezes it. This is done for ten minutes three times a week.'
If blood or pus has accumulated in the Fallopian tube, massage
Fig. 179.
Nickel-i)lated, perforated hypogastric pad, forming part ot the "natural body brace."
is contraindicated, as there is danger of the fluid being pressed into
the peritoneal cavity.
N. (ri/mnastics. — The Swedish movement cure may be a valual)lc
adjuvant, combined with other methods, and even common gymnas-
^ The limits of this work forbid me even to give an outline of tlie different mani-
pulations used in massage. Those interested in it are referred to the ji;iper by A.
Reeves Jackson, of ('hicago, on "Uterine Massage as a Means of Treating certain
Forms of Enlargement of the Womb," Trans. Amer. Gym. Soc, 1880, vol. v. j). 80;
to that by H. J. Boldt of New York, on the " Manual Treatment in Gynecology,"
Amer. .Tour. Ohst., June, 1887, vol. xxii. p. 579 ; to that by H. X. Vineberg on '' The
Treatment of Retrodisplacements of the Uterus with Adhesions by Brandt's Method,"
N. Y. Med. Record, July 11, 1891 ; and to Profanter's pamphlet, Die Maxsar/e in der
Gynakolor/ie, Vienna, 1887. The application of massage in diseases of women is due
to Thure Brandt, a Swedish layman, and the method is known under his name.
TREATMENT IN GENERAL. 201
tic exercises, if not too violent, are not only an excellent preventive
of pelvic diseases, but may be used to advantage toward the end of
a cure begun on other lines.'
Bicycling is contraindicated in pelvic disease, but is an excellent
exercise for healthy women or those afflicted with anemia, nervous-
ness or dyspepsia.^
O. Opei-ations in General. — 1. Time for operating. If we have a
choice, opemtions 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 icomen,
on account of the danger of ]>roducing 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 })e treated successfully by apj)lying
nitrate of silver in sul)Stance or in solution to a granular os, or by
stretching the os and lower part of the cervical canal (CopehiruVs
method) with the index-finger. Large polypi hanging from the cervix
may be the source of hemorrhage or become an obstruction during
labor. It niay, therefore, be wise to remove them with the galvano-
caustic wire. Ovarian cysts should be removed if discovered early.
If pregnancy is far advanced, or labor has commenced, ta])ping may
1)0 j)referable. 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 ra])i(lly during pregnancy, and may cause an obstruction
during laixtr that may cost the life of both mother and child.'
As a rule, we avoid operations during or near menfttruaiion, on
account of the great cong(>stion of the pelvic organs. As the re-
moval of the ovaries, or j)rol)ably rather the tying of the pedicle,
very commonly brings on a l)U)o<ly flow, even if the ])atient has just
gone through her menstrual jx-riod fp. 121), it may, however, be
pr('f('ral)le in anemic ])atients, in order to avoid this extra loss of
blood, to operate immediately before or during menstruation.
' llie value of pymimstics as prevent ivi; of and cure for ])elvic disorders lias lieen
inciilcate<l hy .loliii" H. Keliotrp, .W'<l. Nnr.-<, Noveiuher S, 1890. No. '.»:50, p. JOS.
' (larrimies, '" Woriiati and the IJicvcle," Tlir Forum, .Jan., IH'Ji), pp. 578-r)S7.
" Further information may he found in a ])aper hy M. I). Mann of Bufliilo, N. Y. :
"Surj,n(!il Operations on the Pelvic Organs of Pregnant Women," Traim, Amcr. (Jyn.
Soc, 1882, vol. vii. p. ;}40.
202 DISEASES OF WOMEN.
For ovariotomy the presence of menstruation is of no importance.
In oases of myomectomy and hysterectomy it is better to avoid the
period.
PhL-^tic operations ought always to be performed shortly after
menstruation, as the occurrence of this flow might be mistaken for
hemorrhage 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 day most suitable for serious operations is the morn-
ing, 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 considera-
tions often prevail, and many operate in the afternoon. Day-time
should always be preferred, as no artificial light can replace good
daylight. If it is necessary to operate, at night, care should be taken
to obtain as perfect an illumination as possible. The electric light
and gas-jets with Welsbach hoods are the best.
2. Preparation for Operations. — The more thought the operator
and his assistants bestow beforehand on every detail of a contem-
plated operation, the more smoothly it will come oflP, and, other
things being equal, the better the result will be.
Boom. — If we have the choice, we should select a large room
with a good light for operating, and, if possible, this should be
another than the one in which the patient shall lie after the opera-
tion, 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
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 M'arm, 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
TREATMENT IN GENERAL.
203
should be pinned together, so as to form a funnel leading at the
lower end of the table down into a pail. Instead of the latter arrange-
FiG. ISO.
Inflatable Surgical Rubber Cushions.*
nient inflatable rubber cushions (Fig. 180) 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 tiie three sides of a square,
and in the latter case tied with strings at the corners. This frame is
covered with a rubber sheet. Tlie first i)art of tliis arrangement may
be improvised, and the latter is easily carried in a satchel. A pillow
is j)laced at the head of the table, and this end is slightly raised
so that fluids may gravitate down into the ])ail. For laparotomy it
is better to have the table level with drainage to the side where the
operator stands or under the table.
In hos])itals, tables are preferably used that can be thcM'oughly
disinfected. Good tables for this ])urp()se, and Avith facility for
elevated-pelvis ])osition fp. 140), have been constructed l)y Cleve-
land, f^dcbohls, Foerster, and lioldt.
Leopold uses for the elevation of the pelvis an apparatus that has
the advantage of being inexpensive and so simple that any carjK'utcr
can make it. It consists of a frame 50 inches long and 20 inches
wide, with a hinged flap that can be raised. The shorter, lower
part of the flap, uj)on which the legs rest, can be bent downward, so
as to form a right angle with the up])er part, upon which lie the
thighs and the jx'lvis, and which is a yard lon<r. I>y means of a
sup]K»rt the flap can be raised as much as 20 inches above the frame,
so that tlie sujjport forms an angle of about '>0° with the upjier ])art
' DescriiKid by Howard Kelly, Amer. Jour. Oh."/. 1SS7, vol. xx. p. lOI'.O, l.iif II. <).
Marey of lioston claims many years' priority {Tnins. Aiiicr. Ax.wridlioji af l)hxlfln-
ciann and Gynecylo(jixls, ]89.'5, reprint, p. 13).
204
DISEASES OF WOMEN.
of the flap. The frame is fastened with iron clamps to a table
(Fig. 181).
MoNaughton ' has had made of galvanized iron a portable attach-
ment that also can be nsed on common kitchen tables. In hospitals
two long wooden foot-stools, about six inches high, should be in
readiness to be nsed when the patient is brought into the elevated-
pelvis position.
A fairly good apparatus for the elevated-pelvis position may be
improvised by placing the patient on the back of a chair. It should
be properly padded and the patient's legs tied to it (Fig. 182).
Assistants. — For most operations three, four, or even five assist-
ants are needed, and each of them should have his part distinctly
Fig. 181.
Elevated-pelvis position (Leopold's apparatus): «, adjustable flap; 6, supporter: c, wooden
frame fastened with clamps to table.
allotted and explained to him beforehand. One should be in charge
of the anesthesia exclusively ; and as the patient's life in most
cases depends mucii more on him than on the oj)erator, this function
should be confided to the most experienced ])er.son 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 tenaculum, or for such other
assistance as may be needed. If a leg-holder is used (see below),
in simpler operations, such as curetting, only one assi.stant is needed.
' McXaujjliton's attachment is sold by 11. A. Kaysan, 36 Bond .street, Brooklyn,
N. Y., for $12.00.
TREATMENT IN GENERAL.
205
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
rule, the assistance of a nurse is required to hand gauze, sponges,
and attend to fluids, basins, pitchers, syringes, dressing-material, etc.
Spectators. — There can hardly be any doubt that the fewer persons
present in the operating-room, the better, other things being equal,
are the chances of the patient. Particularly in laparotomies the
presence of persons coming from a case of erysipelas, scarlet fever,
Fig. 182.
Elevation of nulvis bv iiu'iuis of a fhair.
diphtheria, or other zymotic disease constitutes an element of danger.
On the other hand, nolxxly can learn to operate by reading descrip-
tions of operations. The; accumulated exi)erienc(^ of mankind in
this line can only be accjuired 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 i)e done
depends on many circumstances which cannot Ix; considered her(\
Kx[)erinients have shown that by loud talking and still more by
coughing and sneezing minute drops of the secretion of the mouth
and nose mav be carried to a distance of several vards, and there cause
20G DISEASES OF WOMEN.
infection by bacteria contained in those secretions, which is a serious
matter, since entirely healthy persons frequently have staphylococci
and streptococci of complete virulence in their mouths.^
Patient. — The patient's urine shoilld be examined witU special
reference to the presence of albumin in the same, as it may be
deemed necessary to postpone the operation or desist from it alto-
g:ether, if the kidneys are in a bad condition, or, at least, to prefer
chloroform to ether as an anesthetic, the latter having ])roved partic-
ularly dangerous in patients with inflamed kidneys,^ or to use opium
or cocaine, or operate without an anesthetic. If there is albumin in
the urine, it should also be examined miscroscopically for casts. If
there is an excess of pigment and salts in the urine, it is well to pre-
pare the patient for an importiint operation by the use of Vichy, or
lithia, or Poland 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 contraindication 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. In order to loosen
old epidermis-cells and kill microbes still more effectively, it is M'ell,
before laparotomies, to apply a poultice of potassa soap to the abdo-
men for twelve hours ; then to wash the skin with water and with
alcohol, and finally to apply for another twelve hours a bichloride
of mercury poultice (1 : 2000) covered with rubber sheeting and
held in place with a bandage. 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 coffee or beef tea.
Six hours before the operation she should be given an enema of a
quart of soap-suds.
Twenty minutes before anestliesia 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 to diminish the amount
of the anesthetic needed, and the second strengthens the heart. In
timid patients this administration of narcotics may even be con-
ducive to safety by tranquillizing the nervous system.
»C. Flucrge, "Ueber Luftinfektion," Cevtralbl.f. Gmak:, 1898, vol. xxii, p. 350.
'T. A. P^mmet, /. c, p. 745. Some later observers claim, however, that chloro-
form is still worse than ether when the kidneys are affected (see Anesthesia).
TREATMENT IN GENERAL.
207
Immediately before the operation begins, the bladder should be
emptied with the catheter, even if the patient says she has just
urinated.
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 private 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 opera-
tion.
For abdominal operations, the skin should be shaved, scrubbed
with tinctura saponis viridis and plenty of water, then washed with
alcohol and bichoride of mercury (1 : 2000).
The field is surrounded with four sterilized towels pinned together
and to the clothes. Even in laparotomies the genitals should be
Clover's Crutch.
shaved and disinfected, and the vagina carefully disinfected by
swabl)ing with tinctura saj)ouis viridis, followed by corrosive-subli-
mate solution, and thereafter lysol (1 ])er cent.), in order to counter-
act the roughness left by the corrosive-sublimate. lM)r operations
of the external genitals, similar ]>r(>cautions are taken and the but-
tocks are covered with a large j)iece of sterilized gauze in which a
hole is cut in front of the vulva.
For perineal and vaginal operations the knees are lifted more or
h'ss uj), and kej)t sepanite bv means oi' C/orrr^s cnifc/i ( I"'ig. ls;|), :in
208 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. 184). It is easily
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. Good operating-tables have special uprights with stir-
rups, to which the feet are attached in an elevated position.
Anesthetists should pay much more attention than is usually done
to the prevention of that more or less complete paralysis that may
follow an operation. Anesthesia parali/sis may be of central or
peripheral origin. The former is very rare and is due to cerebral
apoplexy or to eml)oli or softening of the brain. It takes the form
of hemiplegia or hemiparesis, and probably some cases of so-called
ether or chloroform death are caused by it. The peripheral form is
more frequent and is always due to pressure, either on single nerves,
such as the musculo-spiral at the lower end of the deltoid muscle,
or on the brachial plexus, the pressure occurring between the clavicle
and the anterior surface of the first rib. This pressure is a])t to
take place when the arm is elevated alongside of the head or
TREATMENT IN GENERAL. 209
brought out from the body. In most cases of periplieral paralysis
the prognosis is good, but it may take many months or even years
before a cure is effected. Pressure on the special nerves should be
avoided, and the arms should never be raised above the head, but, as
far as possible, placed in an easy position on the chest. In using
leg-holders, the parts exposed to pressure should be carefully
padded with cotton batting. The head should be supported on a
pillow, and if the patient vomits, and the arm is raised, the head
should be bent toward the arm, and not away from it. In regard
to curative treatment, faradization is best of all, but massage,
strychnine, and hydrotherapy may also answer a good purpose.^
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. 185).
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
to the rules of aseptic surgery, but in private practice this is some-
times not feasible, and then a high degree of safety is still obtainable
by strict adherence to antiseptic measures. Common to 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. 185.
Xozzle 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 arc found
more or less costly apj)aratus for rendering instruments, gauze pads,
towels, coats, etc., a.sej)tic, but the same may be obtained at small exj)ense
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 live minutes in a solution of crudt;
' H. J. (Jarrigufs, " Anesthesiii Paralysis," Aiwr. Jdhv. Mnl. Sri., .Jan., IS'.iT.
14
210 DISEASES OF WOMEN.
carbonate of sodium, that is, common washing soda — a tablespoon-
ful to the quart. Even cutting and pricking instruments are disin-
fected in this Avay, but shouhl 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.
Rubbing the hands with equal parts of chlorinated lime and car-
bonate of potassium, by which chlorine gas is generated, adding
M'ater enough to form a paste, may to great advantage be made part
of the disinfection between the use of soap and alcohol. It is con-
venient to put on a rubber apron covering the whole front of the
body from tiie 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. Some operators cover
their hands with disinfected gloves. To use cotton gloves for the
surpose seems nugatory, when we take into consideration the com-
parative size of microbes and the meshes of woven tissue. Much
more rational is the use of fine rubber gloves, l)ut it is a question
whether the loss in delicacy of touch does not counterbalance the
advantage of keeping back the few bacteria that have resisted the
disinfection of the hands. On the other hand, the advice to use a
separate knife for incision of the skin only, is excellent and deserves
general adoption, since there is no means of reaching the microbes
located in the deeper parts of the glands of the skin.^
For dressing, the antiseptic materials, such as iodoform gauze or
corrosive-sublimate gauze, sold by druggists and instrument-makers,
may be used, but much of so-called aseptic ligatiu-e and suture
material and sponges found on the market is unreliablo.-
Entirely reliable sterile suture material — plain and chromicized
' Dr. Carl Beck, "On Some Important Points Regardinj; Perfection of Asepsis,''
Kew York Med. Recnnl, Oct. 7, 1899, vol. Ivi., No. lo, p. oOo.
* Aseptic material may Ije prepared in many ways ; I describe only tlie one I
follow myself.
TREATMENT IN GENERAL.
211
catgut, silk, silkworm gut, and horseliair — is prepared by Geo. St.
John Leavens, 72 Bible House, New York. It comes in sealed
glass tubes, and is sterilized by boiling in absolute alcohol at 250°
Fahr. for forty-five minutes after sealing. At the time of ope-
rating, the tubes are broken (Fig. 186). If catgut is used, it must
be immersed in sterilized Avatcr in a sterilized tray for a few
minutes, in order to make it pliable.
Leavens' Suture-tubes : A, sterilized at 25(P F. after sealing ; B, opened at operation.
Sponges. — The raw sponges are beaten in order to soften them and
remove sand, and then immersed in acidulated water (acid, hydro-
chlor. .Ij to each quart of water) in order to di.ssolve the calcareous
matter. Part of this trouble may be avoided by buying the sponges
already pre])ared ; 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 l)een 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 jwtassa (liqu(jr. potassa> 5J to each quart of water) whicii 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 lor an hour in a solution of bichloride of mercury
(1 : 1000), wrung out, drii^d in the sun or in front of a fire, and kept
in a muslin bag. By kee])ing them in this dry way th(y do not be-
come rotten so soon as when kept in an antiseptic fluid. Jiefore
using th(.'iu the next time th(y are left for five or ten mimites in a
sirnilar solution of bichloride, after having soaked them well i)v
pressing all the air out of them, wrung out, and kept in cMrliolizcd
212
DISEASES OF WOMEN.
water (2 or 2^ 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, ^ inch thick.
Most operators, in order to avoid infection from sponges or the
trouble of disinfecting them, have discarded them altogether, and use,
iustead 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 thickne&ses are needed: Nos. 1, 2, 5, and 12 of the braided.
In hospitals it is sterilized immediately before each operation by
being placed for an hour in the sterilizer. Schimmelbusch of Berlin
has constructed a practical metal box for this purpose (Fig. 187).
Fig. 187.
Schimmelbusch's Metal Box for Sterilizing Silk and Keeping it Sterile: yl.box opened in
order to expose the silli to the circulating steam of the sterilizer ; B, partly closed as
when in use.
Since we have obtained reliable catgut, I have given up using silk
for most purposes. It dissolves very slowly, and if it become in-
fected, it will cause the formation of fistulous tracts that do not
heal until the offending ligature has been removed, which may take
weeks or months. At all events no ligature should be made of
heavier material than needed ; nor should more of it be used than
is required.
(htr/ut, so called, is in reality sheep's gut — the strong air- and
water-tight layer found between the mucous membrane and the
muscular coat of the gut of sheep, being cut in long shreds and
twined. It is hard to render it aseptic and keep it so, but its ab-
sorbabilitv makes it verv valuable for ligatures and buried sutures.
TREATMENT IN GENERAL.
213
A simple and excellent way of preparing it is to boil it an hour
in so-called absolute alcohol (97 per cent., or even in the common 95
per cent.) in a closed glass placed in a water-bath, and keep it in
the same alcohol.'
Fig. 188.
Dowd's Apparatus for the Sterilization of Catgut.
This method has been made easy, inexpensive, and safe by means
of Dowd's condenser, represented in Fig. \Sd>.^ The catgut is wound
on glass reels enclosed in small glass jars, which are immersed in
alcohol in a larger jar j)laced 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 tiie catgut may simply be
l)<»iled in a common fruit-jar with ak'ohol, witii the metal t(»p
screwed tight and standing in a casserole with water during the j)rc-
paration for the operation.
' CJeorge K. Fowler of lirooklvn, N. Y. ^f^•(^. Rcrnrd, 1890, vol. .\.x.\viii., \>. ITS.
' Charles N. Dowd, of New York, Mai Record, Dec. 3, 1892.
214 DISEASES OF WOMEN.
Another excellent way of disinfecting catgut — Reverdin's method
— is by means of dry heat. For this purpose an ov'en with double
copper walls covered with a layer of asbestos is needed. The air is
heated by means of a Bnnsen gas-lamp, and an automatic arrange-
ment regulates the gas supply, so as to avoid overheating, which
makes the catgut brittle. The catgut is rolled in small hanks like
violin cords, placed in test-tubes, which are closed with cotton and
placed in the oven. For an hour, the heat should only be 70-80° C.
in order to drive all moisture out of the catgut, which otherwise is
changed to glue and becomes unfit for use, and thereafter it is ex-
posed for two hours to a temperature of 130° C. Immediately
before use, it is immersed in hot boiled water in order to make it
pliable.
A modification of this method is to use wide-mouthed vials with
glass stoppers, instead of test-tubes, take the stoppers off while the
catgut is heated, and to keep the catgut in absolute alcohol to which
is added yfoT ^^' corrosive sublimate.
By the same method chromicized catgut that is slow to absorb
may be obtained — Doderlein's method.^ The catgut is immersed
for ten minutes in a solution of chromic acid (1 : 10,000), and then
dried and heated in test-tubes, as described above. This catgut
withstands absorption for over four weeks. A tube that once has
been opened cannot be used again.
A third, very simple and inexpensive method of disinfecting cat-
gut is by means of formalin, that is, a 40 per cent, solution of for-
malhyde — Kossmann's method. The raw catgut is wound on glass
spools and immersed for twenty-four hours in a 2 per cent, solu-
tion of formalin — 1 part of the commercial formalin to 20 parts
of water. In order to avoid the irritation caused by the chemical,
and at the same time to avoid swelling of the catgut the spools are
washed with normal salt solution according to the formula : — sodium
chloride 7.5, sodium carbonate 2.5, and distilled water 1000. The
spools are shaken lightly, changing the solution two or three times.
The catgut thus prepared is kept in glass vials with the same salt
solution. It may also be kept in a dry state. For this purpose the cat-
gut is rolled into hanks, each packed in blotting paper. After im-
mersion in formalin solution as ahove stated, each package is pressed
between two layers of blotting-])aiier and then ex])osed to moderate
dry heat, about 60° C until it is perfectly dry, in which state it
keeps indefinitely. Before using it, it is placed for a few minutes in
sterile salt solution.^
A fourth and good way of disinfecting catgut is by means of
' Doderlein, Miinchener Medicinische Wochenschrifl, 1890, No. 4.
* Kossmann of Berlin, Centrnlhl. f. Gyndh., 1895, vol. xix., No. 20, p. 545, and
his assistant, Vollraer, ibid, No. 46, p. 1219.
TREATMENT IN GENERAL.
215
cumol — Kroenig's method.' Cumol is a fatty, yellowish fluid found
in Roman cumin oil and obtained artificially by distillation of cumic
acid. It has a very high boiling-point, between 168 and 178° C.
Each catgut thread is wound into a hank with a diameter of four
finger-breadths, and the shape of the ring preserved by tying it with
a thread in three or four places. The hygroscopic water contained in
the catgut is driv^en out by exposure to moderate heat, as stated above,
slowly raising the temperature to 70° C. and keeping it there for
two hours. Next, the catgut-rings are immersed in a graduate with
cumol, two-thirds of which is surrounded by a sand-bath, consisting
of an enamelled pot filled with sand, heated to from 155 to 165° C.
by two Bunsen burners. The glass containing the cumol is covered
with a metal net, in order to avoid the danger of its ignition by the
approach of a flame. The catgut is
kept in the cumol for an hour. When
the cumol has reached a temperature
of 155° C, one burner is turned ofl',
and then the temperature remains for
an hour between 155 and 165° C. The
same cumol may be used over and over
again. In order to remove the cumol
from the catgut, this is seized with a
disinfected forceps and placed for three
hours in a disinfected goblet witli pe-
troleum benzin, and then kept in dis-
infected Petri dishes, glass dishes with
overlapping covers, in which it keeps
aseptic for weeks. This catgut is, ac-
cording to its thickness, absorbed in
from 7 to 13 days.
For the intestine the very finest is
required ; but here silk is preferable.
For closing the ])eritoneum in lapa-
rotomies a somewhat thicker one is
ne(Hled ; fi)r the abdominal aponeuroses,
ligaments, fiiseifc, the cervix, the vagina
and the ])erineum a medium siz(> is
used; and i'or the j)e<licles of tumors a
very thick one. Diflerent manufac-
tuHTs use diflerent mnnbers, so that I
cannot designate the size in that way.
Whetiier caigut is disinfected in one
of these ways or another is of minor importance. The (;hief point is
to avoid handling after the disinfection. It should be wound on
' Krocnit,', Lciir/.i^, Centmlhl. f. Gyniik., 1894, vol. xviii., ?.'(). 27, p. G.')0.
Glass reels for svitiire ninteriuls, kept
in aseptic test-tubes.
216 DISEASES OF WOMEN.
glass-reels (Fig. 189) or fashioned into small hanks before disinfect-
ing it. At the time of the operation what is needed should be taken
out of the vessel in which it is kept, with a disinfected forceps, and
never should any spool or hank be replaced in the vessel from
which it has been taken.
In private practice the surgeon saves himself a good deal of
trouble and anxiety by using Leaven's plain and chromicized catgut.
Catgut has the advantage over silk that it is soon di&solved 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 wdth chromic acid.
Silkworm gut is sold " prepared " in a long bundle tied at both ends.
It may be disinfected by boiling it in water for ten minutes, or ex-
posing it like silk, for an hour to steam in motion. For most cases the
following precautions suffice : 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.) or
some other disinfectant during it. It is, of all materials, the best
for oj)erations on the perineum. It does not absorb fluid like silk,
does not become corroded like" catgut, and does not hurt in reijioval
like silver wire.
Horsehair is an excellent material for many purposes, especially for
enterorrhaphy according to Maunsell's method.^ The hair should be
taken from a male animal. The longest and strongest hairs without
a flaw should \)G selected, tied at one end, brushed up with soap and
water. Next they should be immersed in bichloride-of-mercnry 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 absorption for a longer time, 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 is made aseptic like instrimicnts by
boiling in a solution of carbonate of sodium (p. 209) or by drawing
' Maunsell, Amer. Jour. Med. Sci. March, 1892. (See Appendix.)
TREATMENT IN GENERAL. 217
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, Xo. 27 for the cervix, and No. 28
for the vagina. The thickest of these may also be used for the
closure of the abdominal wound in laparotomies. Some prefer it,
even, on account of the antiseptic property of silver, but upon the
whole it is used much less now than some years ago.
Iodoform is not, in itself, an antiseptic; but it seems that it is de-
composed by the very appearance of piis-cocci and the formation of
ptomaines in such a way as to become a germicide. HoAvever 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.^ A chemical
combination of the two has been introduced under the name of
aristol. Coumarin, the oderiferous principle in Tonka beans (1 part
to 5), and ground coffee are also recommended for the purpose of
covering the smell of iodoform. Iodoform gauze may be disin-
fected 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 liv-
ing 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.^ I liave, 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 tlie doctors and nurses. It is
convenient to have a solution of 1 : 1000, which may be diluted by
adding hot water.
Ovrbolic acid is used for instruments and sponges where asepsis
is not ol)tainable. It is best to have a 5 per cent, solution, and add
hot water so as to get a 2^ or 2 per cent, solution.
Creolin forms no solution, but an emulsion, with water. This
emulsion should l)e pre])an'd by pouring the creolin into <'old water,
stirring it, and adding the same amount of hot water. The strength
that answers Ix'st in most cases is a 1 per cent, emulsion (2 table-
spoonfuls to .J quarts of water), but both i per cent, and 2 per cent,
solutions are used. The enmlsion looks like milk with a little
^MfdWorUl, 1H8G, )). 89.
'Details may he foun<i in my article on "Corrosive Sublimate and ( 'reoliii,"
Avier. Jour. Med. Set., 1889, vol. xcviii.
218 DISEASES OF WOMEN.
coffee. It lias the fault of being opaque and of producing a smart-
ing sensation in tlie vagina of some patients. It is not so powerful
an antiseptic as bichloride of mercury ; but, compared with carbolic
acid, it has the advantage of being an excellent hemostatic, of being
almost innocuous, of making the tissue slippery, of having a rather
pleasant odor, and of not affecting the operator's skin and nerves.
I use it after curetting, especially for cancer, where its hemostatic
powers prove of great value.
Li/sol 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 tilled with this solution with perfect impunity." ^
Boro-mlici/lic i^olidion, or Thiersch''^ solution (K : Acidi borici 12,
Acidi salicvllci 2, AqUcT 1000), is a bland fluid that likewise may be
used in the peritoneum or for irrigation of wounds.^
Thymol (1 : 1000) is also a bland disinfectant.
For wetting pads, keeping instruments immersed, irrigating
wounds, and cleaning blood-stained hands during operations, ster-
ilized water — that is, water that has been boiled for from two to five
minutes — is used. It should be prepared fresh daily.
.3. Anesthesia. — The two chief anesthetics used are ether and
chloroform. Ether, as the safer of the two, should be preferred,
except when 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. In regard to
the kidneys the most divergent views are entertained. Schleich^
holds that chloroform is particularly dangerous for the kidneys,
because on account of its high boiling-point — 149° Fahr. — it can
only be eliminated through these and not through the lungs, as
ether is. On the other hand, Drs. Wm. H. Thompson and R. C.
Kemp, basing their views on their experiments on dogs and rabbits
with the onchometer, an instrument which shows the circulation in
the kidney, compared with that in the general system, declare that
chloroform has no effect on the kidney, while, according to them,
' Clinton Ciishing, Pacific Med. Jour., July, 1890, reprint, p. 7. First recom-
mended by Geo. R. Fowler of Brooklyn, X. Y., Sew York Med. Jour., 1885, vol.
xiii. p. 374 et ■•^ee/., and endorsed by R. J. Levis of Philadelphia, ibid., p. 593.
*A convenient way of making this solution is by dissolving Thiersch's tablets in
water, 1 tablet to each quart.
•* C. L. Schleich, Schmerzlose Operationen, 3d. ed., Berlin, 1898, p. 60.
TREATMENT IN GENERAL. 219
ether is contraindicated in kidney disease, especially albuminuria
with tendency to pulmonary edema. Chloroform depresses the
heart, which ether strengthens.^ If heart trouble is combined with
lung disease, ether is more contraindicated than chloroform. 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.
I have had one patient who stopped breathing as soon as the first
dimming of consciousness began. We tried in vain ether, Schleich's
mixture,- A. C E. mixture, and the simultaneous administration of
ether and oxygen.
Some prefer mixtures of ether and chloroform in different pro-
portions, usually combined with absolute alcohol. A combination
of this kind is known as the A. C. E. mixture :
I^. Alcohol absoluti, 3J ;
Chloroformi purificati, .sij ;
^theris fortioris, 5iij.
M. S. — A. C. E. mixture for inhaling.
Personally I have been much pleased with this mixture.^
A very good method of producing anesthesia is to begin with
nitrous oxide gas, and when unconsciousness has been achieved, to
continue with ether — the so-called (jdx-dher method. It is verv
expeditious, and saves the patient all tiic unpleasantness of getting
under the influence of ether.
On the other hand, it is said to be particularly dangerous to start
witii chloroform and then continue with ether, because when })ar-
tially under the infiuenee of chloroform the glottis allows a higher
percentage of ether to pass, and if the lung-circulation be slow, as
is likely to be the case, the blood may be so highly charged with
etiier as to depress rather than to stimulate the heart.'
'Thompson and Kemp, Mi'd. Record, Sept. 3, 1898.
'Chloroform, fi.^iss. ; .'ether petroh-i, .^ss. ; a-tlier sulpluir., ,^vi. This mixture
lia.s many excellent qualities (see (iarripues' "Clinical Observations in Keiranl to
General Anesthesia by the Schlcich Mixtures," GijnecoL Tnms., 1S9S, vol. xxiii., jip.
II0-I27, and Med. Nevn, Nov. \2, '9*^,), l)ut unfortunately it is dangerous, owiny; to
its effect on respiration (see (iarrimies, M<<1. Nev.^, .Jan. 7, 1S99). My clinical
experience in this respect coincides with the experimental studies of H. C. Wood,
Jr.. of Philadelphia, " Benzine in Anesthetic Mixtures," I'liild. Med. Jmn:, April I'),
1H99.
"It is much praised by .John C. Reeve, Davton, O. {Tnni.*. .imrr. Gj/iierol. Sor.,
1891, vol. xvi., p. 20); and Lawson Tait declares the combination to be a ;:rcat
advance over either ether or chloroform iiseii separately {Ihi(f(do Mi<l.-ti\n-<i. ■Jmir..
quoted in Med. Brief, May, 1894, p. G.'JO).
*.I. T. Clover, quoted bv II. .J. lioldt, Med. Review of Reviews, April, 1S97, rcjjrint,
p. 16.
220 DISEASES OF WOMEN.
Both chloroform and ether produce in protracted operations acute
nephritis with casts and albuminuria.^
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 bel-
lows may be instituted. Laborde's method of reviving has, how-
ever, appeared to me more efficient than anything else. It consists
in seizing the tip of the tongue with a cloth or a forceps and pulling
it forward so as to raise its root rhythmically fifteen to twenty times
a minute.
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 col-
lapse during chloroformization, the best treatment is the combina-
nation of artificial respiration with Nelaton's method, which consists
in suspending the patient by holding her knees over the shoulders
of an assistant or the edge of the table 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.
The application of a towel dipped in hot water to the precordium is
also very effective.
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) mav vet save the patient's
life.
Ether may be given with Goldan^s inhaler'^ (^^ig- 190), which
may be used as an open or closed inhaler — that is, without or with
the bag. If used without the bag, it need not be removed during
the administration. At first, only a few drops of ether should be
sprinkled on the gauze in the cone. A few seconds later a few
more drops are added, and within a minute it may be dro]iped
more constantly, and soon a small stream is substituted, carefully
avoiding irritation of the larynx. "In this way the patient is grad-
' J. B. Ogden (Journal of Boston Society Med. Sciences, No. 15, June, 1897, p. 22)
found albumin, or an increased amount of albumin in nearly 70 per cent, of cases
anesthetized witli ether, and nearly 62 per cent, showed casts, or an increased
number of casts. Strangely enough, there were generally as many casts after asmall
operation and wlien a small amount of ether was used as after a great operation and
the use of a large amount of ether. I have, however, no doubt that this is one of
the causes of the success in rapid operations, compared with tedious ones.
'■' .S. Ordmond Goldan, " Practical Anesthesia," Medical News, July 16, 1898.
TREATMENT IN GENERAL.
221
ually brought under the full influence of the anesthetic in from
three to ten minutes, and a slight dripping will suffice to prolong
the effect. If the instrument is used in connection with the bag,
it must be removed to pour on ether. By using closed inhalers,
we expose the patient simultaneously to the action of ether and
carbonic acid found in the expired air, a combination which works
Fig. 190.
Goldan's inhaler.
well and has the advantage of counteracting the great refrigeration
of the lung caused by the evaporation of the ether.
Often a substitute is improvised by folding a newspaper and a
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.
Of late a practical and cheap ether-cone made of felt has been
brought on the market. It can be disinfected by boiling it in
water, and takes very little room in a satchel.
As often a considerable amount of ether is used, it is best to have
a pound of it on hand, Init divided into cans holding 100 granmies
each. Even in hospitals it is better to have these small cans,
because etl»er undergoes some change as soon as the can has been
opened, in consequence of which it lo.ses 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 (p. 206) does not abridge the time required to induce anes-
thesia, but offers the advantage that very little is needed to keep up
the effect.
The vapor of ether is inflaninial)le. Great care must, therefore, i)e
tiiken not to bring the ctlicr-coue or bottle too near the flame or in-
candescent body when a cautery is used, or when tlie operaticm is
performed with artificial liglit, or in a room with an open fire. It is
safe to have gas-lights a yard above the operating tabh\' My own
' J. R. f'onite, " Ether et Chlorofornie," /ierut' mcdkalc de In Sui.-'si' liomdiide, 20
F^vrier, 1800, p. ST.
222
DISEASES OF WOMEN.
experiments have, iudeed, proved that a compress saturated with ether
does not cjitch 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. 191), consisting of a wire frame cov-
ered with Canton flannel. The mask 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.
The above-mentioned inhaler of Goldan may also be used for
chloroform by removing the bag from the short cylinder of the
instrument and covering it with four layers of gauze. Chloroform
should be given in the dose of 5 to 10 drops poured on the mask at
intervals of half a minute, or continuously drop by drop. The
inspired air should never contain more than 4 per cent, of chloro-
form vapor. Death from chloroform appears in four modes : (a)
By syncopal apnaea ; (6) by epileptiform syncope ; (c) by paralysis of
the heart with paralysis of the muscular system generally ; (d) by a
combination of the effect of the anesthetic with surgical shock.^
Fig. 191.
Esmarch's Chloroform-Mask.
Since in chloroformization there is so much danger of paralysis of
the heart, it is well to add -V 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
'Benjamin Ward Kichardson, "On Death by Chloroform," The Asclepiad. 1st
quarter," 1890.
TREATMENT IN GENERAL. 223
instrument-stores. The tongue should not be pinched -vvitli artery-
forceps, which causes bad-looking and painful ulcerations.
Particular care should be taken when the elevated-pelvis position
is used, as it tends to produce congestion of the brain. At all events,
the patient should be anesthetized in the horizontal position, not
kept inclined longer than necessary, and brought back to the hori-
zontal position, at least temporarily, 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. Mere fright caused
by seeing or hearing the surgeons at work may be fatal.
It is, however, in many cases, a great advantage to dispense with
general anesthesia, and it has been noticed that the dangerous collapse
is less likely to occur the farther away from the liead 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 have been placed
for five minutes around it, and in its cavity, if it is sufticiently wide
to allow it. Beta-eucaine may also be used.
In cases in which general anesthesia was deemed to be too danger-
ous on account of heart disease, even the largest oj)erations, 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
sfimnlants should be kept ready. A few drops of nitrite of amyl are
good where there are signs ot" anemia of the brain (chloroform, cocaine).
Hypodermic injections of 10 miuitns of tincture of digitalis often in-
crease the volume of a sinking j)ulse or bring it back when it is in-
discernil)le.' .Sj)iritus glonoini (/. e. nitroglycerin), Til i to iv, is also
a reliable heart tonic :
I^. Spts. glonoini, Vt\y ;
A(juie (lest. HJ.
M. S. — One or two hy[)(>(l('rmi(' syriugefids 0> twenty minims.
' The injection of camphor dissolved in acetic ether, used in several hosj)itals of
this city !is well as clscwiiere, ought to he discarded, as it in sevi-ral cases lias pro-
duced paralysis.
224 DISEASES OF WOMEN.
Strychnine has a powerful effect on respiration.^ Injection of TTL xxx
of a solution of 1 part of camphor in 4 parts of sterilized olive oil
into the deltoid or vastus externus muscle is efficacious and harmless.^
Faradization of the diaphragm may occasionally prove useful.
Against the collapse caused by cocaine, inhalation of nitrite of
amyl, subcutaneous injections of ether or caffeine, or a warm or cold
infusion of coffee by the mouth have been recommended.
Both ether and chloroform are very apt to cause vomiting. The
patient should, therefore, not have any solid fo(xl the day of the opera-
tion. When 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 :
I^i. Acidi hydrocyanici dil., .5ss ;
Acidi citrici,
Sodii bicarbon, da. 5ij ;
Syr. rubi Idsei, sss;
Aquae, ad 3vj. — M.
Sig. A tablespoouful every one, two, or three hours.
Shock. — A common and exceedingly dangerous occurrence during
or after operations is shock, or collapse, the sudden giving out of
vital force. This condition may appear with two different types, the
erethistic, in which the functions of the sympathetic nervous centers
are partially abrogated, and the torpid, or apathetic, in which the
cerebrospinal nervous centers are affected as well as the sympathetic.
In the first the cardiac ganglia become weak, and the blood-vessels
lose their tone, the effect of which is that the blood accumulates in
the veins, and virtually an internal bleeding takes place. The
patient retains consciousness, but is restless, thirsty, and often nau-
seated. She sighs for more air, the skin is cold and clammy, her
pulse rapid and feeble. In torpid shock we have a similar condition
of the skin and pulse, but no dyspnea, thirst or nausea, symptoms
which demand an active brain. Often the patient loses control of
her sphincters. Sometimes she is a little delirious or has convulsions,
^ 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 1S9U [Abstract in Practice, Feb., 1891, p. 58-59). According to
him, alcohol is inetrective 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.
^ H: C. Coe, The Sew York Polyclinic, vol. i. No. 1, p. 20.
TREATMENT IN GENERAL. 225
more commonly she is in stupor. As a predisposing cause of shock
must first of all be mentioned fear, which sometimes has proved
fatal before an operation or anesthesia was begun. In this respect
we cannot impress too strongly upon the mind of operators and anes-
thetists the importance of cheering the patient up and of inspiring
her with confidence. AViieuever possible the patient should be
anesthetized in another room than the one in which the operation is
performed, so as to spare her the view of instruments and of appa-
ratus needed during the same, which especially since the introduc-
tion of antisepsis and asepsis often have an appearance out of all
proportion to the magnitude of the operation itself. Any other thing
that weakens the constitution or the momentary condition of the
patient, likewise predisposes to shock. The exciting causes are loss
of blood, too deep anesthesia, length of operation, refrigeration, ner-
vous reflex, and idiosyncrasy. By means of pressure-forceps, the
preventive elastic ligature or digital pressure, ligation of vessels,
either speedily after their severance or before cutting them, hemo-
static suture, tamponing, hot water, cauterization and styptics, loss of
blood is prevented or checked. The best man available should be
chosen to administer the anesthetic, and he should be thoroughly
conversant with the dangers attending anesthesia, a condition verg-
ing on death. Many more deaths are due to anesthesia than to tlie
work of the operator. A loss of animal heat is exceedingly dan-
gerous, the room in which an operation, especially one in which the
large abdominal cavity is exposed, should be at a temperature be-
tween 70° and 80° F. The above-mentioned leggings (p. 207) may
be of use. The operation should be simplified and abbreviated as
much as other considerations allow us to do. Handling of the in-
testine siiould l)e avoided as much as possible, which is much facili-
tated by the elevated-pelvis position.' The removal of the uterus
seems to expose much more to shock than that of the appendages.
Some individuals cannot take any kind of anesthetic, since they stoj)
breathing as soon as consciousness becomes slightly dimmed.
If a j>r()tracted and bloody operation may be auticij>ated, it is
well to (•()mpress all four ('xtremiti(?s at their base with i)ieces of a
roller-bandage, so as to Ibrm reservoirs of blood which may grad-
ually be opened when the pulse weakens. Strychnine (gr. -r^^J uj) to
j',j), tincture of digitalis (ITI x u]> to 3 ss), and nitroglycerin (gr. y/j,,
up to Jjj- ) should be injected under the skin, the above-mentioned
camjihor solution into a muscle. Hot saline solution ((] parts ol'
chloride of sodium to 1000 parts of water, or a flat teas])oonfiil dis-
solved in a (juart of water) at a temperature of 120° V.. ouo to two
f[narts are, during tho operation, and while the patient is anesthetized,
' (loltz ha.s shown that a contimiatinn of small, ii).sigiii(ic'aiit raps on tlif Ijoliy of
.1 frog kills it.
15
226
DISEASES ^F WOMEN.
Fig. 192.
injected slowly, not faster than a quart in ten minutes, into the basilic
vein. If a juore prompt effect is not needed, the same fluid may be
injected into the rectum, and this way is used for the repetition of
the injection, whicli is adnn'nistered for an hour at the time, with an
hour's interval until the pulse at least has come down to 120 per
minute.^ The operation should be finished in the shortest possible
time, leaving out measures which are not absolutely necessary.
If the abdominal cavity is open, the saline solution may be poured
from the pitcher into it. After the operation the patient should be
handled very carefully, and the head should never be raised above
the trunk in removing her from the operating table. She should be
placed in a warm bed, and surrounded by half a dozen bottles or
bags filled with hot water. Great care should, however, be taken
not to have the water so hot that it burns. The nurse, must try the
temperature by holding the vessel in contact with the back of her
hand. If the water is too hot, the bottle may be wrapped in a towel
or placed outside of the blanket. The foot of the bed should be
raised on a chair, so as to keep the
blood gravitating toward the brain.
No pillows are to be placed under the
head. The hypodermic injection of
the above-mentioned stimulating drugs
is repeated according to circumstances
and within the limits indicated. Kub-
bino' of the skin and kneading of the
muscles of the extremities are useful
measures in bettering the peripheral
circulation. Strong spirits of ammonia
held under the nose stimulates the
nervous system. The saline solution
may also be injected under the skin
(hypodermoclysis). The best place for
this subcutaneous injection is between
the clavicle and the breasts. A pint
of fluid is injected, and the injection
repeated when needed. To further
absorption, the region sh(nild be mas-
saged during injection ; still, it is a
rather slow process.
Common Instruments and Their Use.
— Some instruments are so generallv
Garriimes' Weight Speculum, i^ i ^.i j. xi i i /> ^'
r, r useiul tliat they are needed lor nearly
all gynecological operations, and should always be on hand. Such
are a uterine sound (p. 154), bivalve and univalve specula (pp. 146
' Robert H. M. Dawbarn of New York, Med. News, Feb. 25, 1899.
TREATMENT IN GENERAL. 227
and 147, a vaginal depressor (p. 149), tenacula, volsellse) sponge-
holders, knives, scissors, several pairs of artery-forceps (pp. 190,
191) needles, a needle-holder. With some of these we are already-
acquainted from the chapter on Examination. In regard to the
others I shall make a few remarks.
Fig. 193.
Schrocdcr's Vaginal Retractor.
Weight Speculum. — For certain operations which are best per-
formed with the patient in the dorsal posture, such as traclielor-
rhaphy and vaginal hysterectomy, 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. 192).
Fig. 194.
Eugelmanii's vaginal retractor.
Vnf/inal Retractors. — Besides the specula and depressors described
in speaking of how to make an examination, Idteral retractori<, sucli
as Schroeder's (Fig. 193) or Eiigelmann's (Fig. 194) are often needed
in operations in the dorsal position.
Fig. 195.
L
3
Emmet's Tenaculum.
Tenacula. — A tenaculum is a sharjvpointed steel hook with
handle, which should be made of one piece of metal. Two sliajM'S
of iiooks are most convenient : oiu; is simply bent .so as to lorm a
little less than a right angle ; in the other the j)oint has a second
flexure in the direction of the handle (Fig. 19o).
228
DISEASES OF WOMEN.
Tenacula are used to put tissue on the stretch, to lift up tissue to
be cut, to manipulate silver sutures, etc.
Volsella.
A volsella (Fig. 196) is a pair of forceps, each blade of which ends
in a double hook. It is used for seizing and pulling tissue. For
Fig. 197
plan's Traction-forceps.
vaginal hysterectomy Pean's traction-forceps (Fig. 197) is excellent
and almost indispensable.
A tenaculum-forceps is a modified volsella with single or double
hooks, and, as a rule, of more slender build.
A tissue-forceps (Fig. 198) is a pair of forceps with side teeth, con-
venient for holding a strip of tissue while cutting it off.
Fig. 198.
Tissue-forceps.
Another tissue-forceps which I have found superior to any other
instrument for holding flaps of peritoneum and similar delicate tis-
sues is that of Kocher (Fig. 199), which ends in two teeth on each
branch, with comparatively large seizing-surfaces, by which arrange-
ment they are much less apt to tear the tissue grasped than other
instruments are.
A sponge-holder (Fig. 200) is an instrument formed like a for-
ceps, with ring-shaped ends between which the sponge or pad is
held. It may be replaced by any other forceps of suitable length
and grip.
TREATMENT IN GENERAL.
229
Knives are used much less than in general surgery. A medium-
sized scalpel is about all that is needed.
Fig. 199.
Kocher's tissue-forceps.
Scissors are in- most cases used to great advantage as cutting instru-
ments. They cause less hemorrhage than knives, are more expedi-
FiG. 200.
Hunter's sponge-holder.
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 ])arod a tenaculum is passed into the
mucous membrane at the end nearest to the operator and at the lowest
part of the field to l>e denuded, so as to avoid having l)lood running
over the upper part that is to be denuded later. The mucous mem-
brane is lifted a little, and the scissors arc made to cut off a thin strip
of tissue under the teuacuhim in such a Avay tiiat the tenaculum stays
in the loo.sened strip. When once tlie strip is cut loo.se, it is often
more convenient to exchange the tenaculum for a tia'^ue-forceps. The
strip shoidd be cut of as uniform breadth and thickne.'NS as possible,
and from one end of the surface to be denuded to the otiier. If this
is wider than the strij), one or more similar strips are cut off ])arallel
t^) the first, taking great care not to leave any j)art inideinided. While
this is in process, tiic denuded surface is kept free from blood by irri-
230
DISEASES OF WOMEN.
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-
FiG. 201.
Needles : a, short straight round ; 6, 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. 201 and 202) 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. In soft tissue, such as the intestine, straight or
curved English sewing needles are used. But where the tissues offer
much resistance it is necessary to make the round needle cutting
near the point by grinding it 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 particularly useful when catgut is used.
When the suture inserted with Hagedorn's needles is tightened, the
TREATMENT IN GENERAL.
231
edges of the wound made by the needle are drawn together from
side to side, instead of being pulled apart, as is the case when a
needle is used that cuts at right angles to the direction of the suture.
Fig. 202.
Needles with Handles : a, slightly curved, sharp-pointed or dull : b and c, strongly curved,
dull ; d, Marey's needle, sharp-pointed, with eye from side to side.
In order to avoid turning or breaking of the curved needles when
grasped by the needle-holder, the part nearest the eye should be
Fia. 203.
Uagedorn'B Needle-holder.
straight and fiat. For operations on the intestines long Englisii
<'anii)ric needles, about No. 7, or tine curved ones are used.
232
DISEASES OF WOMEN.
Needle-holder. — For all these needles a needle-holder is needed.
Hagedorn's (Fig. 203) is adapted to his needles, and Crosby's can be
used for any needle, opens by mere pressure, and is easy to disinfect
(Fig. 204).
As a rule, the needle-holder should be applied to the needle just
in front of the eye, for if the latter is comprised in the grasp of the
forceps, the needle is very liable to break.
Mucli time is saved and a good adaptation more easily obtained by
using handled needles (Fig. 202), but in order to be strong enough to
pass through resistant tissues they must be made so thick that they
make a large hole, Avhich, however, immediately contracts, and, there-
FiG. 204.
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-
ularly useful for closing wounds in the perineum or the abdominal
wall, and are often called perineum-needles (Fig. 202, 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. 205)
may sometimes be used with advantage. It is a half sharp-pointed
Fig. 205.
Cleveland's Ligature-carrier.
curved forceps, between the jaws of which the ligature is seized and
carried around the tissue to be ligated. It makes large holes, and I
TREATMENT IN GENERAL. 233
prefer therefore, Schroeder's needle. Mallett's ligature-carrier (Fig.
206) has the advantage of being automatic.
Fig. 206.
MaUett's ligature-carrier.
Ligatures. — For ligatures silk or catgut is used (pp. 212—216).
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 (sec Lupus Vulvte, Fecal Fistulae,
Fibroids of the Uterus, etc.) the elastic ligature of rubber is used.
It consists in solid round strings varying in diameter from less than
jlg- 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 kej)t in a 4-per-thousand
solution of bichloride of mercury in alcohol.'
l^utaroi. — The chief materials used for sutures are silk, catgut,
silver wire, silkworm gut, and kangaroo tendon (pp. 212-216). 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 Ixiing tied. Silk sutures may be left in the abdominal
wall for a week.
Silk sutures placed near a drainage-tube or a tampon, from Mhich
septic material may come, are apt to become secondarily infected.
In order to avoid this, they should not be used in such places, but
pref<!ren(H' given to silver wire or silkworm gut, wliicli do not al)s()rb
fluids. In tlu; vagina I have often left silk sutures for a month
without causing suppuration or cutting through.
' Fiisola and Martinetty, Cnilmlblalt /. (iyndk., ISUl, Nov. 24, p. 50t;.
234
DISEASES OF WOMEN.
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 often is 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 ivire-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. 207.
Two Denuded Surfaces, showing where the sutures lie.
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 oif. When
one pared surface is to be applied against the other, the needle is, as
a rule, inserted from 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 ju.st on the inner line between pared and unpared tissue,
reinserted at the corresponding point on the other side, and pushed
out from a quarter to half an inch beyond the pared surface (Fig. 207).
When the point of the needle emerges from the tissue, a dull hook^
TREATMENT IN GENERAL.
235
much like a button-hook and called a counter-pressure hook (Fig.
208), is inserted under the point and pressed against the tissue, while
Fig. 208.
fV.
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 aud 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 paasing 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 tlie wire-twister (Fig.
209), the long free end cut off, the suture drawn taught and shouldered
— /. e. belit with a tenaculum at the point that will come to lie just
Fig. 209.
Emmet's Wire-twister.
at the line of union when the edges are brought together (Fig. 210).
Next, the suture-Hhield (Fig. 211) is placed around both wires and
pushed gently down to the tissue. Tiie wires are now bent against
the siiarp inner edge of the shield, and turned round until the twist(<l
part thus formed just reaches the shield.
This is the nicest point in the whole procedure. If you do not
236
DISEASES OF WOMEN.
Fig. 210.
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 still 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.
Shouldering Wire Suture:
a, twisted suture bent to
a side and cut short; b,
shouldered suture.
Fig. 211.
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 each other, 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 quilled suture is required. The continuous, or
running, suture is often used in laparotomy, in bringing together the
TREATMENT IN GENERAL.
237
edges of the peritoneum, aponeuroses, or fasciae. Some use it also
much in plastic operations for lacerated cervix, cystocele, or pro-
lapse of the uterus. A particular modification of this suture is the
so-called continuous tier-suture (Fig. 212).
Fi«. 212.
Beginning of a Catgut Tier-suture (A. Martin).
Suppose an oval denudation has been made on the anterior vaginal
wall. The needle, armed with a catgut tliread 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 uj) witli a i)ressure-forceps. Then several
turns are made in the same way below the first, but with a continuous
suture, always drawing the thread taut. Wiien 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 l)ott<)m of the wound. Wiien the operator
reaches the lower narrow part of the oval, he comprises again the
edges in the suture, l^ necessary, a second tier ol" buried sutures
may l)e placed over the first (Fig. 213), avoiding interference with
it, and finally the superficial tier is inserted. The best way of knot-
238
DISEASES OF WOMEN.
tiug 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 witli each other.
Interrupted sutures may also be placed in tiers above one another
— e. g. in closing the abdomen after laparotomy.
Fig. 213.
Second Deep Row of Tier-Sutures (A. Martin).
The looped, or glover's, suture is a continuous suture in which each
loop is closed bv passing the needle through it. This suture is
valuable for arresting hemorrhage and diminishing the length of
the line of suturing.
Chain-suture is used to secure thick pedicles, and will be described
under Ovariotomy.
Sponging and Irrigation. — During most plastic operations veiy
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 rnay advantageously be substituted for sponging (pp.
TREATMENT IN GENERAL. 239
186 and 209) ; 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.
Haw to Clean and Disinfect Instruments. — Instruments should be
boiled in a solution of soda before every operation (p. 209). After an
operation they should be scrubbed with soap, lukewarm water, and
nail-brush, rinsed with clear water, and wiped perfectly dry M'ith at
least two towels. During the operation they should be innnersed
in sterilized water or a 2| 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 his mind, and take out all instruments that are
sure to be used ; but, besides, he ought, within reasonable limits to
prepare himself 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, pressnre-forcejis, etc.
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. 220) 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 docs not quench thirst. An injection of tepid
water into the rectum has sometimes proved useful (p. 174).
No food is given as long as nausea continues. As a rule, a fluid
diet of peptonized milk, buttermilk, kumyss, matzoon, l)eef-tea, 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 grapliically
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.
240 DISEASES OF WOMEN.
CHAPTER HI.
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 Avill 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. jVIild alcoholic drinks, such as beer, Johann Hoff' s
malt extract, Liebmann's Teutonic, Anheuser-Busch's nutrine,
Pabst's Best tonic, Rhine wine. Moselle wine, French or Hungarian
claret, Burgundy, vin Mariani, port, or tokay,^ should be taken with
meals unless especially contraindicated.
Beef-tea may be made of extracts or of fresh meat. A pint of
cold water acidulated with a tcaspoonful of dilute hydrochloric acid
is poured on a pound of minced lean beef. The mixture is stirred
once every quarter of an hour for an hour and a half. Then it is
put over a fire until it reaches the boiling point. Strain, and add
salt to taste.
A still more nourishing preparation of beef may be obtained by
mincing a pound of lean meat, mixing it with a pint of cold water
and two teaspoonfuls of dilute hydrochloric acid. The mixture is
put on ice for an hour and during that time off and on pressed with
a wooden spoon. It is then strained and replaced on ice. About
two ounces should be taken every two hours.
' Where economy is an object, the strong California wines, such as port, sherry,
angelica, and tokay, are to be recommended. Good wines such as the '' Sunset " tokay
can be obtained for 50 cents a bottle. These wines are certainly much to be pre-
ferred to the cheap mixtures often sold as imported wines.
TREATMENT IN GENERAL. 241
If the patient is unable to dispose of so large a bulk, the beef
may be boiled without water in a bottle immersed in water. A few
teaspoonfuls of the strong juice obtained in this way is given at a
time.
Strong bef^f-juice is also secured by broiling slices of beef and
pressing them in a little machine made for the purpose.
Weir MitcheWs rest cure, in which the patient is removed from
her friends, put to bed, fed by a nui-se to the limit of her digestive
powers, and treated w^th massage and electricity,^ may be indicated
in exceptional cases, but, as a rule, gynecological patients should be
encouraged to take as nuich exercise in the open air as they can with-
out increasing their sufferings.
If the patient cannot digest her food, slie should take pepsin and
hydrochloric acid after each meal :
I^. Pepsins, Sij ;
Acid, hydrochlor. dilut., ^ij ;
Syr. aurant., Sss ;
Aquae, q. s. ad oviij. — M.
Sig. Shake well. A tablespoonful after meals.
I have also found Parke, Davis & Co.'s pepsin cordial, a tea-
spoonful three times a day, very beneficial.
In severe cases of indigestion even redal alimentation may become
necessary.^ Xutrient enemas ought not to exceed six ounces in
bulk, as otherwise they are apt to be ejected. The bowel ought
first to i)e emptied by a [)laiu salt-water injection, and the nutrient
enema ought to be injected very slowly, so as to avoid irritating the
bowel. Appropriate mixtures for rectal feeding are an egg beaten up
with four ounces of milk, with or without addition of an ounce of
whisky ; l^eef-tea, witli addition of one of the extracts found in the
stores, such as Licbig's, Armour's, etc. ; or four ounces of lean beef
finely chopped togetiier, witli one ounce of "white liver" — /. c.
pancreas — adding water enough that the mixture can be injected
with a Davidson's syringe.
Very commonly gynecological patients suffer from constipation
and need some (ipericnt. A heaping teaspoonful of Carlsbad salts'
or sulphate of sodium, dissolved in a tumblerful of hot water and
taken on an em|)ty stomach in the morning, often effects a cure in
the course of six we«'ks. A heai)ing teasj)oonf'ul of conij)ound licorice
powder, tiiken in the evening, gives a passjige the next morning, and
' S. Weir Mitdiell, /•'(/ mid lilood, and how to M<tl;e tlinn, 2d vd., I'liiladelplii.-i
1K78.
'•' An important paper on this snhjecf, \>y TIcnry F. ('aniplR'll of Aiit^iista, (ia., is
found in 7Va7M. Aim-r. Gyn. Soc, 187H, vol. iii. p. 'JtiS, <•! sn/.
* Tlie artificial salt seems to be jimt as ^"'"1, 'IikI t-osts only one-foiirtli of tlie im-
ported.
1«
242 DISEASES OF WOMEN.
many like that powder. As a rule, I combine the aperient with a
tonic by giving Bland's pills with aloes :
Iji. Ferri sulph.,
Potass, carb., aa 3ij ;
Aloes Socotrinse, 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 :
^i. Bismuthi subnitr., sij ;
Magnesias carb.,
Sacchari albi, da. §ss. — M.
Sig. A heaping teaspoonful three times a day, between meals ;
or Liq. iodi co. (Ttlj every two hours) ; creasote (TUj every three
hours) ; ac. hydrocyan. dilut. (Tlliij every one to three hours) ; tinct.
nuc. vom. (TTLiij every three hours), each diluted with a tablespoon -
ful of water ; cocaine hydrochlorate (gr. ^ every two or three hours) ;
cerium oxalate, oroxine hydrochlorate (gr. iij to v, t. i. d., in pills or
capsules).
Tonics are nearly always needed, especially iron, quinine, strych-
nine, arsenic, and phosphorus. Clinical experience shows that the
solution of ferrous malate (American Pharmaceutical Manufacturing
Company) and the compound tincture of cinchona, equal parts, in
spite of the chemist's protest, is an excellent tonic. — M. Sig. A
teaspoonful three times a day.
Another valuable combination is the following :
I^. Strychninae sulph., gr. j ;
Ferri et quininae citrat., sij ;
Syr. aurant., 5ss ;
Aquae, q. s. ad siij. — M.
Sig. A teaspoonful in a wine-glass full of water, three times a
day, after meals.
Plain Blaud's pills are also good. If a malarial element is pres-
ent, full doses of quinine and other antipcriodics are required.
In carnogen, the extract of red bone-marrow, given in teaspoonful
to tablespoonful doses, either alone or in combination with other
tonics, we have a new and powerful remedy against anemia :
I^'. Liq. Fowleri, 3J ;
xVc. phosphor, dilut., .^ss ;
Carnogen, q. s. ad 5iv. — M.
Sig. A desserts])oonful three times a day after meals.
TREATMENT IN GENERAL. 243
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 pulvis opii
every three hours, are the most common anodynes. Hydrobromate
of hyoscine, gr. j^-^, has been much praised of late. I find phenac-
etine, in doses of 7^ 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, t. i. d., is also
good. Iodoform or aristol, 5 grains, in suppositories, t. i. d., often
dulls pain.
Headache is often banished with almost magic promptness by
the following powder :
I^. Phenacetini, 3j ;
Caffeinae, gr. xxiv ;
Sodii bromidi, .^ij. — M.
Div. in chart, cerat.. No. xii.
Sig. One powder, repeated, if needed, after one and three hours.
Among sedatives, the bromides of ])otassium, sodium, and ammo-
nium, single or combined, are often required. An embrocation with
chloroform (1 ])art) 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 iiave
been ])articularly pleased with sulphonal (gr. x), chloralamid (gr. xlv),
or trional (gr. xv).
Resolvents are often called for in chronic inflannnations. The most
important are iodine, gold, and mercury. We have spoken in another
place (pp. 174 and 106) of tiie application of tincture of iodine to
the vaginal roof and the abdominal wall. Internally, iodine is best
given as iodide of ])otassium, 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 oophoi-itis. It is given in the dose of gr. I to ^,
t. i. d., after meals. Tiic bichloride of mercury (gr. ^,j, f. i. d.) has
been recommended in chronic metritis.
HaiwxUdicH. — In acute hemorrhages from the womb, menstrual or
intermenstrual, ergot is the best drug (Extr. ergotse fl. .^j, i. i. d., or
so-called ergotin, gr. ij, /. /. '/.). It works by causing contraction
of the unstrip(Ml mnscU^-fibcrs c()mj)osing the l)ulk of the W(tmb and
those found in the walls of the arteries. It is also useful in subin-
volution, chronic metritis, active or j)a.ssive hyj)eremia, in intranuiral
244 DISEASES OF WOMEN.
and submucous fibroids, but not in polypi, in which it is apt to
increase the hemorrhage.
In chronic cjises cotton-root is in my experience superior to all
other remedies, whatever the cause of the hemorrhage may be/ 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 (I^. Gossypii radicis corticis raspati, 5iv).
This decoction not only checks hemorrhage when present, but seems
to have a tonic influence on tlie 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 arrestino; 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 {^,. Extr. visci albi
fl, oij- Sig. A teaspoouful 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 arsenio (Liq. potass, arsenitis, gtt. iij to v, t. i. d.), is
indicated. Ar.-^enic 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 (I^. Tinct. cannabis Indies, .Ij. — Sig. 20-40
drops three times a day). It has been especially extolled in the hem-
orrhaojes of the climacteric. Witch-hazel has been accorded a high
position on the scale of uterine hemostatics in passive engorgement '"
(I^. Extr. hamaraelis 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, t. 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 pruuifolium (Extr. fl., 3j, t, i. d.) ; hydrastis Canadensis
' Garrigues, The Post-Graduate, Jan., 1887, vol. ii. No. 2, p. 117, and New Yorker
Medicini.The PreHSc, Nov., 1886, vol. ii. No. 0, p. 231.
^ Chauncey D. Palmer of Cincinnati, O., Trans. Amer. Gyn. Soc, 1887, vol. xii.
p. 182.
TREATMENT IN GENERAL. 245
(Extr. fl., gtt. XX, t. i. d.), or hydrastiuinse liydrochloras (gr. J, in a
capsule, four times a day); terebinthiua Chiensis (gr. vj, t. i. d.^);
tinct. capsici (5 drops in a tablespoonful of* water every hour); smut
of Indian corn (Extr. ustilagiuis maidis fl., 3j, t. i. d.), and the root
of Caulophyllum thalictroides (5J-5ij of the infusion or decoction
made with an ounce of the root to a pint of water, or .^j-3ij of the
tincture made with four ounces to the pint), which both cause uterine
contraction ; the nettle (Urtica urens and U. dioica, as decoction,
sj to Oj of water. — Dose, a cupful several times a day) ; senecin
(gr. i-iij), or extractum senecionis aurei fl. (3 i-ij, /. i. d.). Chlorate
of potassium, given together with ergot, is also regarded with much
favor.
Very gratifying results have been reported of the use of the
desiccated mammary gland of the sheep. The dose is from 3 to
6 tablets a day, each tablet containing 2 grains of the dry powder,
and 3 of an excipient.^
In cases of uterine hemorrhage the bowels should be kept open,
so as to avoid congestion of the pelvic organs. Sulj)hate 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 fii-st 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.
Antipi/retics. — In acute cases there are often indications for reducing
the temperature. If ice-bags and sponging with equal ])arts 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.
* J. R. Chaflwjck, Boston, Tram. Amer. Grfn. Soc., xii. p. 88.
'.John K Sliober, Philadelphia, Amrr. Jour. Ohsletrm, Feb., 1809, vol. xxxix, p.
175. The tal)lets are made hy the Armour Company, of Chicago, and the H. K.
Mulford Company, of Philadelpliia.
24(>
DISEASES OF WOMEN.
CHAPTER IV.
Electric Treatment.
Electricity is of great value in gynecology. The diiferent kinds
of electricity and differently constructed machines and batteries have
very different effects, and nnist, therefore, be considered separately.
We distinguish between frankliniion, Jaradism, and galvanism, and, as
a subdivision of the last named, galvano-cautcrization.
1. Franklinism, or frictionai elevtriciiy, 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 sjiarks drawn from her by the ap-
proach of a metal rod to different ])arts of her body. Another way
of using frictionai electricity is by means of sparks and shocks from
a Ijcyden jar. This kind of electricity is little used, and can hardly
have any other effect than that of a stimulant in neurasthenia and
of a counter-irritant in hyperesthesia
and neuralgic pain.
2. FaracUsm, or indudioral e/edricitt/,
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 primari/
coil, in such a way that the current is
broken and closed at short intervals. The
effect is much enhanced by placing a buu-
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 secondari/ 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 tlie
abdominal wall over the fimdus of the uterus, or both poles may be
Apostoli's Bi-poli\r Uterine niifl Va-
ginal Exoitors: 1, small uterine;
2. medium uterine; o, lar^e ute-
rine ; 4, vaginal, used in the ute-
rus after confinement.
TREATMENT IN GENERAL. 247
combined in one uterine or vaginal electrode (Fig. 214). The ad-
vantages of the bipolar method are that it is less painful, the sensi-
tive 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} Such a current of tension lias great power in subduing pain
(ovaralgia, abdominal pain in hysterical women, vaginismus, and pain
arising from pelvic inflammations). It is also an emnienagogue.
The faradic current is, as a rule, applied three times a week, some-
times daily ; each sitting lasts from ten to thirty miuutes. 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 strengtli
applied. Finally, the current is gradually weakened and stopped
before the electrodes are withdrawn. Tlie reason for so doing is
that the vulva is much more sensitive than the vagina and uterus,
and tliat a strong current is more endurable when it is increased
and decreased gradually than when it begins and ceases suddenly.
The cervix is also mucli more sensitive than the body of the womb.
3. Galvanism, or chemical electricity, is produced in a so-called
battery, a combination of jars containing tiie elements and the exciting
fluids. As strong currents often are needed, it is necessary to have
a powerful battery.^
One of the electrodes is applied to the alidonien or, exceptionally,
to tlie back. It ought to be very large, so as to distribute the current
over a large surface, and thereliy diminish its density. Apostoli's'^
external electrode consists of wet clay^ in a bag of nmslin 10 or 12
' Rockwell has constnuteil an apparatus which is made by the Jerome Kidder
Manufacturing Company, 81^0 I'roadway, New York (Aow York Med. Jour., May
13, lS'J3i. With the latest iinprnveinents this battery consists of a fixed coil oif
Xo. 21 wire, 02 to 05 feet lon<^, lor tlie primary current, and a movable secondary
coil, operated hy a rack-muvcmeut. The total len<,^th of this secondary coil is
7,9ti2 feet, with the following suixlivisions : 72') feet of \o. 21 wire, tap|)ed at
252 and 474 feet; 2,574 feet of Xo. 32 wire, tapjied at 1,224 .-ind 1,350 feet; and
4,002 feet of Xo. 30 wire, tajjpcd at 1,032 and ;{,030 feet. The maciiine is provided
with a circle-switch, allowing the .selection of the total length of the wire, or any
part, iir any suhdivisiDU of any part, of the coil, and with a rheostat for modifying
minutely tlie strength of the current.
' A battery of tbrly lai'ge I,eclaiich<' ctdis, i'a<'li with an electro-motor power of one
and a half volts, or one of thirty acid cells, i ach producing two volts, is much used here.
"Electricity has been u<ed in gynecolngy as long as it has existed as a s])ecial
branch of medicine, and important woik li;is been dnue in this line also in this
country by Kimball of Lnwell, Mass., Ilphraim Cutter of New York, .J. X. Ireeman
and .John Byrne of Brooklyn, X. Y., and others. J{ul sinc(! 1SS4, Apostoli of I'aris
has given this kind of treatment such au imjietus by o|)ening new and large lields
for it, and introducing trreat improvements in its application, that his name is on
all lips, and, therefore, this historical note may be pardoned as an exception.
* In order to j)revent it from getting dry, it is a good jilan to add glycerin to the
water fLapthornSmitii of .Montreal, .l/((<'r. .fmir. fjlj.</rt., .Vug., ISS'.t, vol. xxii. p. 7'JSj.
248 DISEASES OF WOMEN.
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 En(felmann''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 3Iartin's electrode, which 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 such strong currents as without it.^ The inner
electrode is, as a rule, applied in the cavity of the uterus all the
way up to the fundus.
Apostoh'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
disadvantage that it is stiff, has a tube hard to clean, and is very
expensive. Aluminium cannot replace platinum, as it becomes
corroded. I have had one made with a tip of platinum. No. 9, of
the French bougie scale, 2 inches long, mounted on a brass rod
covered with hard rubber (Fig. 215). The anterior 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.^ The burning
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.
The stiff electrode should be introduced without speculum after
disinfecting the vagina.^
If the inner pole is applied to the vaginal roof, a ball of metal or
^ A. H. Buckmaster, New York, " The Galvanic Treat.ment of Fibro-rayomata,"
Brooklyn Med. Jour., Nov. and Dec, 1888.
* It was made by Waite & Bartlett, 108 East Twenty-third street, New York.
^ 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 milliamperes (F. H. Martin, Trcaw. Amer. Gyn. Soc, 1888, vol. xiii. p. 2751.
Apostoli has a series of seven intra-uterine electrodes made of gas-carbon, which
conducts readily, is little suVjject 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 (] to h 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 eliect is extended from one
part to the other (Apostoli, "Novelties," B7-it. Med- Ass., August, 1888, reprint,
p. 26).
TREATMENT IN GENERAL. 249
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
thorougiily 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 silk,
Avith metal tips at the ends, which are easily adapted and kept in
their place by a set-screw or by the elasticity of a cleft in the
electrode.
To measure the strength, or so-called intensity, of the current a
milhamph'cmeter 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 oif 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 or 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 an apparatus that controls the current coming from the
whole battery. The one I use consists of a hollow glass cylinder
^vith a wooden bottom, into which are inserted two set-screws for the
rheophores. The posts connected with the screws lead the electric
current through metal columns up to the metal cover of the cylin-
der, in which cover a metal screw-rod turns, carrying at its lower
end a cone of carbon, which is arrested on the edge of a well of
Fig. 215.
Garrigues' Intra-uterine Electrode.
similar material placed at the bottom of the glass cylinder. This
cylinder is partially filled with water. When the cone is out of the
water there is no current, and by gradually immersing it the cur-
rent 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 cau.scs a shock and muscular con-
traction, but is more or less painful, and with strong currents even
dangerous.
Bv using large and wet electrodes we chiefly get the interjwhtr
effect, which is tliat oi' electroly.sis. By using small and dry electrodes
we cliiefly obtain the polar eifect, which, when the cm-rent is strong
'The ahove-(lpscriho«l rheostat is that of the Galvanofaradic Company, Fourtli
Avenue, near Twenty-third Street, New York.
250 DISEASES OF WOMEN.
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. Wlien it is applied to the heart, and the part en-
compassed between the poles is examined under the microscope, the
striic of the muscular fibrillar are found in a granular condition — a sign
of beginning disintegration.'
That the molecules are moved by the galvanic current can even
be seen in a physical experiment. When a vessel is dK'ided 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 com])artment in which the
negative pole is. This electric osmosi.s, or so-called cataphoresis, may
be used for introducing drugs, such as cocaine or iodide of ])otassium,
into the body by applying a solution of them to the anode.^
Different Qualities of t/ie Poles. — The two poles of the battery have
different })hysical and physiological effects. The positive pole attracts
acids, while alkalies collect at the negative. The eschar produced by
the positive j)ole is dry ; that at the negative is softer, larger, and lets
the galvanic current ])enetrate through it. Tiie 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 ojieration 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 milliampereraeter.
The patient should remove her corset.^ 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 Buckniiibter. /. c, pp. 12-14.
^Frederic Peterson, "Electric Cataphoresis as a Therapeutic Measure," jN^. Y,
Med. Jour., April 27, 1889.
^ In using Kngelmann's electrode it is enough to open the lower part of it
TEEATMEyr IN GENERAL. 251
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 offered by the epidermis.
Then we wait till it has ceased before increasing; the streno-th 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 millianiperes is used, but -when there is
a subacute inflammation of the parts situated near the uterus, and in
hysterical patients, only 40 to 50 millianiperes can be tolerated
Under all circumstances it is advisable not to go too fsir at the first
sitting, but to stop, say, at 50 M. There must never be any severe
pain felt in the uterus. In hirge uteri the intensity must be increased
or the surface of the intra-uterine 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 ])raetice the
a})pIications are made two or three times a week. J3ut lieniorrhage
may call for treatment every day ; and, on the other hand, Mhere
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 efl'ect a cure.
Immedidte 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 })atient may lose a little
dark blood, and on the following days, when the eschar i,s being
thrown off, there is always somesero-])uruleiit discharge. JOxception-
ally, even enormous amoinitsof a watery fluid are discharged through
the vagina. It is therefore by no means rare that the synii)toms, on
the whole, get worse during the first five or six sittings before im-
provement begins. Sometimes fever and other signs of iuflannnation
may necessitate the tem])orarv interruj)tion of tlu; galvanic treatment.
Chnaical (iahyino-cduterhdtioii of (he C'crvi.v. — .\))os(oli has con-
structed a sj)ecial bi])olar electrode of carbon, to be used f()r cautei-iz-
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 cari)on electro<le wound with very little, nearly
252 DISEASES OF WOMEN.
dry cotton, forming; the positive pole, while the negative was an
Eugelniann electrode applied to the abdomen (see Chronic Endo-
metritis).
Galvano-puncture. — If a tnmor 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 })latinum 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 j)ulsating 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 the needle goes
simply into the tissue of the uterus and perhaps a tumor situated in
its wall. Hemorrhage 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
wdiole, galvano-puncture is more dangerous than other methods that
will be described in treating of uterine fibroids, and cannot be rec-
ommended.
Thermal Gnlvano-cauierization. — 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 — c. g. the cervix uteri.
The latter is shaped into knives and domes for cutting and burning.^
* The best instrument of this class is that of John Byrne of Brooklyn, N. Y., who
has also constructed a special speculum for galvano-caustic operations {Clinical
Notes on the Electric Cautery in Uterine Surgei-y, New York, 1873, and Trans. Amer.
Gyn. Soc, 1892, vol. xvii. pp. 42-46).
TREATMENT IN GENERAL. 253
By means of these galvano-eauteries 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 ap])lied, 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 tnuteries (p. 187) 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 aj^plication to
germ-cultures.
AVliere 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-cauterv. But then bleeding nuist
first be stanched by irrigation with creolin, sponging, and the appli-
cation of the cautery to ()j)en vessels. After that every })art of the
cavity is gone over repeatedly with the dome-shaped galvano-cautery,
and each time tiiat blood oozes from tlie 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 escai)e the cautery. Finally, the cavity and
the vagina are tamponed with iodoform gauze (pp. 183—185).
Dr. Skene has substitut(!d the combination of pressure and gal-
vano-cauterization for sutures or clamps.'
Metallic hderdllial Electrohji^h. — Under this name has been de-
scribed a ])rocedure whicli in reality is a cataphoresis of drugs formed
by the electric current itself Jiy using an intra-uterine electrode of cop-
per, connected with tiie positive pole, oxychloride of copper is formed,
and is, by the electric osmosis or cataplioresis, driven into the tissue.
A current of" 20 to 30 .M. is used Cor from five to ten mijiiites. l)ui--
ing the ap|)li('ation the clectnKle siiould be kej)t in motion in order to
avoid its sticking to the wall. If this, however, should hap|K>n, all
that is needed to loosen it is to reverse the direction of the current
for a few minutes. The cervical canal must be patulous for sul)S(!-
' Alexander, J. f\ Skene, of Brooklyn, N. Y., New Yurk Mid. Jour., .M;ir(li 27,
1897; Tram. Atncr. (Jyn. Soc, 1808, vol. xxiii.
254 DISEASES OF WOMEN.
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.^
In 1898 the American Gynecological Society had invited four of its
members, Drs. Geo. Engelmann, of Boston ; W. E. Ford, of Utica,
N. Y. ; E. H. Grandin, of New York, and myself, to discuss the
question of electricity in gynecology. Of the four papers, three
were in favor of electricity as a therapeutic measure.^
' A. H. Goelet, The Times and Register, 1893. pt. 2, p. 743.
■^ Garrigiies, " Electricity in Gynecology," Trans. Amer. Gynecol. Soc, 1898, vol.
xxiii, p. 78, and Med. News, June 11, 1898.
PART YII.
ABNORMAL MENSTRUATION AND METRORRHAGIA.
The normal process of menstruation has been considered in Part
III. (pp. 117-122). 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 {dysmenori-hea) ; it may begin too
early in life {precocious menstruation) ; or it may be profuse {men-
orrhagifi).
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, of which
there are two varieties, suppression of menses and amenorrhea
proper.
1. Suppression of menses is the condition in which the flow after
having begun is suddenly arrested.
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. 131) ; to emotions, especially a fright; or to the
appearance of an acute inflammation, such as pneumonia or ery-
sipelas.
Symptoms. — The symptoms are sometimes slight or none, and tlie
courses reapjicar at the next period ; but sometimes the sudden su])-
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 tissu(>, and tiie
amenorrhea may last h ng or be final.
Treatmenf. — It is pr'-j)er to try to bring the flow l)aek by hot a|>pli-
cations to the alxlom in, hot hip-l)aths, hot vaginal and rectal injec-
256 DISEASES OF WOMEN.
i
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 tiie 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. — W^ 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. 1 21.
Syinptoias. — 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 non-appear-
ance of the 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 or
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 softdning of the lower uterine
segment, the increased diameter of the uteru.> in the antero-posterior
direction, morning sickness, and small tongues of brown pigmentation
ABNORMAL MENSTRUATION AND METRORRHAGIA. 257
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 may be skipped. If the girl is other-
wise 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. 242), moderate exercise
in the open air, horseback riding, mild gymnastics, or massage.
Aperients haV'C some influence in bringing on the flow, and the
one most credited with emmenagogue ])Ower is aloes. In malaria
quinine and arsenic are the chief remedies. If the nervous system
is upset, bromides, antipyrin, or })henacetin 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 liave the same effect. Elec-
tricity in all its forms (p. 246) is a powerful remedy, especially
bijjolar intra-uterine faradization, witii secondary current, or, best,
of all, galvanism, with the negative ])ole in the uterus.
Besides iron, quinine, stryciminc, and aloes, the following drugs have
more or less well-founded re|)utation as emmenagogue.^: Manganese in
the form of the permanganate of potassium or tiie binoxide (gr. ij to
iv, /. /. (1.)', chlorate of potassium (gr. v to xx, t. i. d.) in combi-
nation witli iron ; santonin (gr. ij or iij, t. i. d.) ; oleum sabina3 (TTtiij
to vj, t. i. d.); oleum ruttc (Tlliij to vj, f. i d.); oleum tanaceti (TTliij
to vj, t. L d.) ; oleum hedeonue (THU to x, /. /. d.) or a warm infusion
made of the herb; ergot (p. 243); radix gossypii (]). 244); tinct.
cantharidis (TTtx, xx, uj) to foj, t. i. d.) ; tinct. hcllebori nigri (THxx to
xl, t. i. d.) ; senecin, or fluid ('xtnK;t of" senecio (p. 245). As their
effect is very uncertain, it is wise to combine several in one })re-
scription — e. g. :
I^. Strychninie sulj)h., ^^- } ',
Aloes Socotr., 9j ;
Quininte sulph., .^ij ;
Fcrri sulphat. cxsiccat., Bij ;
()1. sabiuic, .^j ;
Extr. gentian, co., q. s.
Ft. pill. No. Ix.
Sig. Three i»ill^ three; times a day.
It is also well to combine the use of drugs with tiie other remedial
agent.s recommended.
17
258 DISEASES OF WOMEN.
If in cases of rudimentary uterus the development is so insufficient
that there is no liope 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 amenorrhea 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.
Scanfi/ menstruation, the condition in -which the menstrual flow is
insufficient in amount, is treated on the same principles as amenor-
rhea, especially with tonics and electricity.
CHAPTER 11.
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 apj^ear
at the menopause.^
Vicarious menstruation is a rather rare condition. It is mostly
found in weak, nervous, hysterical women. Wounds, ulcers, and
varicose veins ])redispose to it.
Symptoms. — Generally tlie 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. 257). The ectoj)ic bleeding
calls only for treatment if it becomes excessive, and is then treated
' Garrigues, ximer. Jour. Obst., 1884, vol. xvii. p. 524.
ABNORMAL MENSTRUATION AND METRORRHAGIA. 259
according to the general rules of medical and surgical practice. Dr.
Frank V. Cantwell, of Trenton, N. J., in a case of excessive hema-
temesis, accompanying normal menstruation, removed the healthy
uterus and appendages, and obtained a perfect cure.^
CHAPTER III.
Dysmenorrhea.
Dysmenorrhea 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, it apj)ears, 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. 119). The pain is situated in tiie sides
of the pelvis or the iliac fossae. Sometimes it seems to be due merely
to a toughness in the texture of tlie ovary which interferes with the
free development of the Graafian follicle.
If the aysmenorrhea is of uterine origin, it may be due to
inflammation of the mucous meml)rane or the muscular tissue (en-
dometritis or parenchymatous metritis). There may be an intra-
uterine j)olypus playing the role of a ball valve, or the simple swell-
ing of the nuu'ous membrane, esj)e('ially at the internal os, may pre-
vent the escape of the blood from the cavity, or tiie 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 eflect. The
cervical canal may be too narrow, especially at the internal or external
OS (.sfoioslay Sfjinetimes clots are formed in the uterus, the exi)ulsion
of which causes labor-like ])ain in the back and behind the symphysis.
Sometimes the whole nnicous membrane is thrown off and expelled
with similar ])ains — a condition called vinnhnniniis- di/smoiorr/icd.
Uterine dysmenorrhea is felt more centrally and appears a shorter
tiuK! before the app<'arance ol" the flow, and contiimes often for several
days after it has begun.
Tiiat dysmenorrhea which is due to closiu'e of the genital canal
' .!/•<■'/. Rrrorrl, Nov. 19. I SOS, j). 748.
2G0 DISEASES OF WOMEN.
and retention of the menstrual blood has already been mentioned in
the chapter on Amenorrhea (p. 256).
Nervous dysmenorrhea may be due to over-sensitiveness of the
nerves, so that the normal congestion of menstruation is perceived as
a painful pressure, or 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.
Pro(/nosis. — The prognosis varies, especially with the etiology. In
most cases we may promise relief, if not a cure.
Treatment — The treatment \'aries likewise very much with the
causes. In young, undeveloped girls, without any inflammatory
complications, mc try to avoid a vaginal examination. Even a rectal
one may be dispensed with for some time. Tonics (p. 242), exercise
in open air, gymnastics (p. 200), general massage (p. 199), towel baths,
shower-})aths, and sea-bathing (p. 196) are the chief remedies. "Where
there is any form of inflammation exercise can only be taken with
great caution and Avithin 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 dilierent organs, but for convenience's sake we will briefly
refer to it here.
In all inflammatory conditions we use hot vaginal injections (p.
175), painting of the vaginal roof with tincture of iodine (p. 174),
pledgets with glycerin, iodine-glycerin, or ichtliyol-glycerin (p. 182),
faradization with the secondary current (p. 246), galvanism or scar-
ification of the vaginal portion (p. 194). In endometritis we make
applications to the endometrium (p. 175).
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. 191) mav prove useful. For flexions or mere stenosis the cervical
canal is dilated with Hanks' and Garrigues' dilators (p. 157), 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 desjierate cases of dysmenorrhea due
to inflammation of the ovaries and tubes salpingo-oophoreetomy is
the last resort.
The purelv nervous dvsraenorrhea is treated with tonics and seda-
tives (p. 242).
During the attack all forms need some immediate relief. Since
these conditions often last long and a baneful habit might be acquired,
ABNORMAL MENSTRUATION AND METRORRHAGIA. 261
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 :
I^. Extr. couii ale, Bj ;
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,
and hot driid\S, such as hot tea or hot brandy and water or an infu-
sion of anthemis or matricaria, may suffice. Antij)yriu (gr. x),
antifebrin (gr, v), and pheuacetin (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 horn's.
Viburnum prunifolium is also a uterine sedative : since the taste and
odor of the fluid extract are most offensive to many ])atients, 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), ])ulsatilla (TTl.ij-iij of the fluid extract iu 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 still praised.
There is a widespread popular belief that marriage is a panacea
for all a girl's sufferings, 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 ])r(xluced by coition and the stretch-
ing of all the organs unavoidably connected with pregnancy and
childbirth (p. l.'U).
CHAPTER IV.
pREcociors AM) Taiidy Menstruation'.
A sixcjLE discharge of blood from the genitals is sometimes found
in little ehildfen, even in the new-born, without any a|)])arent disease.
Irregular bleeding may tak<! |)laee from a Siireoma. Hut we can only
sjK'ak of pre(;ocious menstruation when there is a regular retinii of
the bleeding from the genitals every four weeks in children bel(»w
the age of puberty. This is a very rare afl'eetion. It has been
262 DISEASES OF WOMEN.
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 excej^t to try to combat the general weakness,
keep them quiet at the time of menstruation, and watch them in
regard to masturbation. Perhaps clitoridectomy may put an end
to the unfortunate habit. (See Masturbation.) To check the flow
might lead to vicarious menstruation.
Tardy menstruation is the first appearance of th(; menstrual flow at
an unusual! V adv^anced ao-e. 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 intermenstrual 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 way where menorrhagia
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 dis{)lacements
of the uterus. Secondly, it may be due to ovarian diseases, especially
oo])horitis and small ovarian tumors. Thirdly, certain general acute
infectious diseases are a])t to cause profuse menstruation, esj)ecially
cholera, small-pox, scarlet fever, typhoid fever, and inflammatory
rheumatism. x\mong 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.
The menorrhagia not infrequently foinid in young girls at the
beginning of menstrual life is due to anemia, that })revents coagulation
of the blood in the capillaries, or to an overtaxed nervous system,
which loses its normal control over the vasomotor nerves and the
ABNORMAL MENSTRUATION AND METRORRHAGIA. 263
muscular tissue of the uterus. Similar causes are apt to give rise
to a menstrual subinvolution in somewhat older girls, say between
seventeen and twenty-four years of age, and this again is apt to
result in menorrhagia.^
Symptoms. — Besides the increased loss of blood, there are other
symptoms due to raenorrhagia. 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 characterized by pallor, weakness, asthenopia, and backache.
Diagnosis. — The diagnosis between menorrhagia and metrorrhagia
— i. e., uterine hemorrhage occurring independently of menstruation
— is sometimes difficult or impossible when sucli 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
admixture of mucus with the blood, and by the gradual way in
which the blood 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 Ave prescribe ergot and other
internal hemostatics (p. 24-3), rest, cool diet, and abstinence from
alcoholic drinks and coffee. The bowels should be kept open with
saline aperients (p. 142). If there is any excitement, bromides
and opiates, especially opium suppositories (p. 243), are indicated.
If this treatment does not have tiie desired effect, vaginal injections
with hot water may be added. If they do not check the hemor-
rhage, we add liq. ferri chloridi to the water (p. 186). If the bleed-
ing continues, an intra-utcrine injection of hot water with or without
li(l. ferri is given (p. 176). Vaporization is effective ; but not with-
out drawbacks and dangers (see p. 187). A bag with hot water
applied to tht^ lumbar region is sometimes effective. An ice-bag is
placed over the sympliysis (p. 195). If all this is ineffectual, or if
the hemorrhage is alarmiiiii;, we tampon the vagina (p. 183) or the
uterus (p. 185).
In the intermenstrual period a treatment is instituted according to
tlu! caus(! of the menorrhagia. If the endometrium is affected, the
uterus is treated with a])plieati()ns of li<juor ferri ()). 175), curetted
(p. 180), or eauterized by means of cliemical galvano-eauterization
(p. 250), with the ))i)sitive pole in the uterus. (Jranulations are de-
stroyed, a torn cervix united, a polypus removed, and a fibroid
treated as taught under the (lis(;ussion of that disease. Ovarian
' W. H. Haker, address at the animal meeting of the Middlesex South Medical
Society, April 20, 18'J8.
264 DISEASES OF WOMEN.
inflammation is treated with injections, applications, resolv^ents (p.
243), 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. 240-245). In cases of deficient nerve
force and muscular contraction, faradization, hydrotherapy, sea-
baths, general and local massage, gymnastics, and open-air sports
are of the greatest value.
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
euouymin (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 meuorrhagia 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.
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 meuorrhagia, 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 oulv
ABNORMAL MENSTRUATION AND METRORRHAGIA. 265
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 Net'vous 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. 126).
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^ acquires generally increased
intensity. Blood may be extravasated into the anterior camera or
behind the retina. Papillary inflammation, optic neuritis, neuro-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-
neas 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, iier]>es, etc. The latter appears not
infrequently on the genitals, which also are liable to become the prey
^ This disease, described by P'oerster, is characterized by pain in the region of tlie
conjiiiictiv;il fold, in or Ix'hiiui the eye, the foreliead, less frequently in the inahir
hones or the superior maxilla, and hy a peculiar kind of photophobia experienced
in regard to artificial light in a dark room, ix'sides a great variety of hyperesthctic
phenomena. It attacks both eyes. It is incurable, Imt disappears spontaneously,
often after many years. It is frecpient in the higher classes, and is by far more
common in women than in men. It is said in the former to be a retlex neurosis
from chronic parametritis. As treatment it is recommended to let the patient take
I draciim of Canadian castoreum and 1 drachm of extract of valerian in the
course of four days, which gives relief for several wei'ks. At the .same lime the
patient should u.se eve-<Irops with acetate of zinc (W. A. Frennd, GijnukobKjmhe
Klinik, Strasburg, LSSo, vol. i. pp. 'J»;.")-272).
266 DISEASES OF WOMEN.
of pruritus. The legs aud the face may become edematous. Some-
times tliere is free pei*spiration, witli or without an unpleasant smell,
or seborrhea of the scalp. Besides vicarious menstruation in the
shape of blood trickling out through tissures forming in the skin,
there are sometimes minute ee(;hynioses 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 hypochondrium betokens a congestion of the
liver, which may even lead to jaundice.
The Respiratory !Si/stem. — 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 ])redilection for vi(;arious 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 Avorse during the congestion preceding menstruation. Tliere is
a frequent desire to evacuate the urine, and the bladder may be the
seat of vicarious menstruation.
The Genitals. — Displaced ovaries may become particularly painful,
and the swelling of the ovary enclosed in a hernia may give rise to
strangulation. Fibi'oids often grow larger, aud intra-uterine polypi
may be pushed down into the cervix or the vagina. In cases of
atresia we have seen that the |)ain 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.
Treutment. — In all affections connected with amenorrhea 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
deVjility that, presumably, would be made worse by any loss of blood.
Under these latter circumstances the first thing to do is to strengthen
ABNORMAL MENSTRUATION AND METRORRHAGIA. 267
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. d.), or the combination called effervescent granulated bromo-caf-
feine (a heaping teaspoonful), pulv. paullinise (gr. xx, t. i. cL), extr.
cannabis (gr. ^ to h, or 20 to 40 minims of the tincture, t. i. d.). A
favorite combination of mine is phenacetin, caffeine, and sodium
bromide (p. 243).
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.^
' Those familiar with German may find much valuable information in Leopold
Meyer's Der Menstruation sprozess unci seine Krankhajten Abiveichungen, Stuttgart, 1890.
PART VIII.
LEUCORRHEA.
Normally, the genital ti*act 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. 52), 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. The fluid 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 vitse (p. 51).
Leucorrhea 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.^ — 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, es})ecially
of a depressing kind, and insuflicient nourishment. It occurs fre-
queiitly in persons predisposed to pulmonary phthisis. It is some-
' Fordyce Barker's paper, " Leucorrhea considered in Eelation to its Constitutional
Causes and Treatment," Trans. Amer. Gyn. Soc, 18S2, vii. pp. 130-141, contains
manv valuable hints on this topic, which has disappeared from many modern treatises
on gynecology.
268
LEVCORRHEA. 269
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, hemor-
rhoidal flow, diarrhea, and other discharges.
2. The specific leucorrhea due to gouorrheic 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.
Si/mptoras. — The leucorrhcic discharge is a drain on the system,
which lias given rise to the po})nlar belief that the Mhite stuff coming
out of the genitals is the spinal marrow which melts. AVhile it may
be brouglit on by anemia, it may also lead to it. The patients com-
plain of weakness, backaelie, neuralgia in different parts of the body,
and often an irrital)]e bladder. Commonly they sutler from anorexia
and dyspepsia. Frequently there are menstrual disturbances, csj)e-
cially too frequent, 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 aj)])lies 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 successful it is ; the
more local disease; predominates, the more actively must the leucor-
rhea be comljated in its seat.
The most substantial food and invigorating drinks that the stom-
ach can digest nnist be given ( p. -40), and dig(;stion is to be helped
artificially if necessary. Tlu- [)atient nnist liavc a movement of the
bowels once in twenty-four hours. She must wear sufficiently warm
clothes, especially woolen underwear (pp. l.'JO and 172). Toni(;
medicines (p. 242), general massage(p. 199), gymnastics (p. 200), and
exercise in the opc^n air, are useful. A great In^lp is found in change
270 DISEASES OF WOMEN.
of climate, locality, and surroundings. The patient should, if pos-
sible, be sent to a warm, dry climate or higli up in the mountains,
but at the same time pleasant company should be provided. A cold
and damp dwelling must be exciuinged for a dry and sunny one. Dif-
ferent kinds of baths (p. 195) are to be recommended : warm hip-
baths, tepid general baths, Turkish or liussian baths, are especially
indicated where there is a rheumatic diathesis. Otherwise, it is
better to strengthen the nerves and liarden the skin by means of
towel-, sheet-, or sponge-baths, shower-baths, hydrotherapy, or sea-
baths. Bicycling and lawn-tennis may answer a good purpose. 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 impera-
tive addition to the general treatment. Applications of tincture of
tincture of iodine, solution of nitrate of silver, carbolic acid, chloride
of iron, ferripyrine, chloride of zinc (20 per cent.), etc., are made to
the affected parts (p. 174). If tlicre is no free drainage from the
uterus, the cervical canal should be dilated (p. 157). Vaginal in-
jections with hot water or astringents are beneficial in most cases
(p. 175). It may become necessary to remove granulations from
the cervix or fungoid growths from the inside of the corpus and
fundus, by scraping the endometrium with the curette (p. 156), or
to burn the cervical canal with the thermocautery (p. 187), or by
means of thermic or chemical galvano-cauterization (pp. 252 and
248). 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, 3j t. i. d.), hydras-
tis (fluid extract, gtt. xx, t i. d.), cimicifuga (fluid extract, 3ss to 3j),
inula (a decoction of the root, ^iij to water q. s. ad Biv, 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 tlie 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, hydroleino,^ etc., only
strengthen the whole constitution, and thus benefit the lungs indi-
rectly, and the leucorrhea, if abundant, being in itself a drain on tiie
physical strength, can hardly fail to have a bad influence on the
pulmonary aft'ection.
* Terraline is a product gained from petroleum. Ilydroleiue is a mixture of
cod-liver oil, boracic acid, and other substances. I5otli of these medicines have
seemed to me to have so decided an effect in wasting disenses that I do not hesitate
to mention them here.
DISEASES OF ^S\^0]SlEISr,
II.
SPECIAL DIVISION.
SPECIAL DIYISIOK
PART I.
DISEASES OF THE VULVA.
CHAPTER I.
Malformations.^
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, liie may be continued without external geni-
tals, the urine being evacuated through the navel. Such a case is
on record, and wiis cured by tlie formation of an artificial urethra
and closure of the opening of tiie urachus at the umbilicus.
2. Ili/pospadid.s. — In consequence of an insufficient closure in the
median line the lower wall of the urethra may be split more or less
deeply (Fig. 216). If tlie defect extends very deeply, so as to divide
the ditfcrent spliincters of the urethra (p. 82), 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 hyj)ospadijLS has been successfully treated by
paring and uniting the surrounding nnicous 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."
' In this chapter T li.ivc to some extent used my article on tliis subject in Aiiirri-
cxin Si/Klcm of (Ij/tirrnlDi/if, e<lifeil l>_v Marui, I'liiladelpliia, 1SS7, vol. i. pp. 'J.)")-l!SL'.
' For details the reader is referred to T. A. Emmet's (ti/iiccoloiji/, 'Jd ed., pp. »i49-C")t.
18 "" -7;i
274
DISEASES OF WOMEN.
3. Epispad{as.-^l£.Y>\spad\as (Fig. 217) is the name for the condi-
tion characterized by a hick of union of the upper wall of the urethra.
It is generally combined with a similar defect in the anterior wall of
the bladder (e^i'troverslon). The clitoris and the symphysis pubis
may be cleft or not. These defects are due to the intracorporeal part
Fig. 216.
Hypospadias (Mosengeil) : a, open canal, formed by the anterior wall of the urethra; b, pos-
terior, closed part of tlie urethra ; c, entrance to vagina ; (/, 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 o])en
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.
275
be remedied by amputation witli the galvano-caustie wire (p. 252),
with the §craseur, or with Paquelin's thermo-cautery (p. 301).
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. The child is anesthetized, or two or three drops of
Fig. 217.
Epispadias (Kleinwachtcr) : a, fissure in tlic bladder; b, labium majus; c, clitoris; d, labium
minus; e, liynien ; /, vaginal entrance.
a 2-per-cent. solution of cocaine arc tlirown into tlic glans clitoridis
with a hypodcrniic syringe, and four or five drops more are thrown
into the prepuce, li' one margin of the prepuce is then .seized with
a pair of forceps, the thumb-nail will easily complete tiu; work of
clearing the glans. Raw surfaces are sprinkled with iodoform and
the prepuce packed with a little ball of iodoform gauze. As there
276 DISEASES OF WOMEN.
is a marked tendency to recurrence of the adhesions, and the conse-
quent 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 them-
selves.
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
phvsiologicallv in whole tribes. (See, for instance, Hottentot apron.
This condition may interfere with coition, and may then be reme-
died by cutting away the superfluous tissue and uniting the edges of
tlie wound, which will heal by first intention.
6. Abnormalities of the Labia 3Iojora. — 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 suturing.
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 Miillerian), and, finally, the external
genitals (pp. 20, 22, 30, and 34). It is, therefore, not so difficult to
undei"stand how one of these parts may be developed according to a
sexual type diflering from that of the others.
DISEASES OF THE VULVA. * 277
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 Avhile 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. 122), and the same is claimed in regard to testicles, although it is
infinitely rarer with them than with ovaries.
Herraaphrodism 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 —
i. e. two ovaries and two testicles (true bilateral, hermaphrodiwi) ; 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 lateral Jirrmaphrodism).
True hermaj)lirodism is at best exceedingly rare, and its existence
is not even universally admitted.
Spurious hermaphrodism, or pseudo-hermaphrodism, is that condi-
tion in which the sexual glands belong to one sex, cither masculine
or feminine, and the passages leading from them, as well as the exter-
nal parts, approach more or less the otlier. S])urious hermaj)hrodism
is subdivided into male or female according to tlie 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 op])o-
site sex [internal male or female pseudo-hermaphrodism) ; the second,
by those in which tlie external ])arts alone re})resent the opposite sex
{external male or female pseudo-her)na])hrodi.wi) ; and the third, those
in wiiicli both the ducts and tlie external ]>arts approach tlie tyj)e of
the other sex (internal and e.rtcrnal — or complete — male or female
pseudo-liermaph rodism ).
Pseu(lf>-hermaphro(lism, as well as true hernia])hro(lisin, is a mal-
formation that dates from the earliest periods of i'oti\\ devclojtment.
It is much more fre(|U('ntly found in the male than in the female! sex,
and reaches also a nuicli iiighcr degree in the fonncr, so that a vagina,
ut(^'rus, and tubes may Ik; found more or less developed in an indi-
vidual with testicles, vasa def<'rentia, 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
278 ^ DISEASES OF WOMEN.
take place from normal male genitals, and especially in males suffer-
injr from hypospadias.
The external genitals being formed in both sexes of the same sub-
stance, it would seem impossible to have a double set of them, one
male, the other female, although some portions may assume more
the male; others more the female, type. Still, a case has occurred
in which a woman who had recently given birth to a child presented
in the median line, between an entirely normal vulva with clitoris
and the anus, an erectile penis 2^ inches long.^
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 marry without knowing that she, from a physical standpoint, is
an unsatisfactory mate. Even otherwise well-informed physicians
are apt to be led into error in regard to the determination of a per-
son's sex, if they allow themselves to found their opinion upon such
unreliable signs as the character of the voice and the presence of
the mammarv olands."
CHAPTER II.
Ruptures (Hernia).
Two kinds of hernise find their way into the labia majora — viz.
the anterior, or inguino-lahial, hernia and the posterior, or vagino-
labial, hernia .
1. The anterior labial, or inguino-labial, hernia in women corre-
' Franz Gebaiier, Centralbl. J. Gyndk., vol. xxiii. No. 5, p. 139, Feb. 4, 1899.
* See Garrigues' "Supposed Hermaphrodite. — Sexual inversion," The Clinical
Recorder, vol. ii. No. 2, pp. 4-7, April, 1897.
DISEASES OF THE VULVA. 279
spends 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-siiaped. It may contain the gut, the omentum, the
ovary, and the uterus, and when impregnation takes place even a
fetus in the uterus.
iJiagnosis. — When near the external inguinal ring, it may be mis-
taken for a tumor of the round ligament, or hydrocele. In the
labium it may be mistaken for an abscess, cyst, or tumor. As a
rule, it will be possible to make the <listinction 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 the swelling 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 inflammation, 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 — either by
means of a truss, or preferably, by the radical operation. When
the hernia is strangulated and cannot be reduce-d, herniotomy is im-
jxTative. It may become necessary to extirpate an ovary found in
the sac and, when pregnancy occurs in the imprisoned uterus, to
perform Cesarean section, or, preferably, supravaginal amputation,
or total extirpation of the uterus,
A variety of inguinal hernia found in little girls is the hernia in
the canal of the Xiich, corresponding with the hernia of the tunica
vaginalis in the male. It is extremely rare. The treatment is the
same as for other inguinal hernia?.
2. Posterior Labial, or Vat/i no-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 mu>;cle, 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 l)een found
in it.
Diagnosis. — It differs from anterior labial hernia by its positi(»n
farther back, by the freedom from swelling of the sj)ace between it
and tlie inguinal canal and of the latter itself, and by l)eing reduci-
ble, not in the direction of the external inguinal ring, but in that of
the vatrina.
280 DISEASES OF WOMEN.
The diagnosis from other affections is made in th'e same way as
just pointwl out for the anterior variety.
Treatment. — It is hard to hold this kind of hernia back, but, as it
may become very hvrge, tlie attempt should be made with vaginal
pessaries, of which an inflatable rubber bag would be most likely to
answer, or a truas. 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.'
CHAPTER III.
Tumors connected with the Extrapelvic Portion of the
Round Ligament.
In connection with the extrapelvic portion of the i"ound 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 comnmnicate 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
suj)erficial fascia, and the fascia transversal is. 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 inflanunation 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 corrcs])onding affection of the tunica
vaginalis in man. Jt may become as large as a child's head at tern),
and may interfere with locomotion, render coition impossible, and
opj)Ose a serious obstacle to childbirth.
' Winckel, Die Pathologie der Weiblichen Sexualorgane, Leipzig, 1881, p. 284.
^ A comprehensive article on this subject bv \Vm. C. Wile is found in Amcr. Jour.
ObsL, 1881, vol. xiv. p. 584.
DISEASES OF THE VULVA. 281
Diagnosis. — The diagnosis is sometimes difficult, particularly in re-
gard to inguinal hernia. The characteristic points are the slow devel-
opment ; the disappearance on pressure, if there is communication
with the peritoneal cavity, without the sensation of any solid body
being displaced ; the elasticity if the sac is closed ; and the translu-
€ency. 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,
simple aspiration has effiicted some cures. If that does not suffice, a
few drops of tincture of iodine or ciarbolic 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, All 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 nmst be laid open and thoroughly washed
with disinfecting fluids (p. 217).
2. Hematocele of the Canal of Kuck. — If hydrocele of the canal of
Kuck is rare, hematocele of the same is unique.' 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 ranuis 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 cougii, and gave a
dull sound on percussion. From its upper end a ratiicr liurd pedicle
could be traced into the inguinal canal. It contained a thick choco-
late-colored mass of tiie 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 laci-c of increase during cough ; from hernia
of the orarj/ by its lack of sensitiveness ; from h i/drocclc by being less
soft and l)y not being translucent ; from hemafoina of the vnlra bv the
even surface and its clir()nic course, whereas hematoma of the vulva
is soon al)Sorl)ed or forms an al)sc(!ss.
Eliologij. — Injury (childbirth) in a person with a canal of 'Snvk
the lower part of which lias remained oj)en, may cause an extravasa-
tion of blood into that cavity. The ii-ritation of the foreign body
<3auses the tiiickeiiing of tlie sin-rouiiding membrane.
Treatment. — In the case on record a long incision was made, the
' Robert Koppe, V'nlnilblaUf. Gymik., 188G, vol. x. p. 17'J.
282 DISEASES OF WOMEN.
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.^ 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 e^g, and had been taken for a hernia. The surface
was smootii, the consistency tense and elastic, the skin normal and
movable over the tumor. From the uj^perend a pedicle lialf an inch
in diameter could be traced into the inguinal canal. The tumor was
not diminished by pressure, nor could it be pushed up into the
inguinal canal. It gave a dull percussion-sound, 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
prove<l 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 already been said is only to be added
that tlie pedicle ought to be comprised in' the sutures, so as to avoid
a displacement backward of the womb.
4. Fibroma of the Mound Ligament. — The round ligament may
become the seat of the formation of a fibrous tumor anywhere in its
course from tlic 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. Tlie 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, j)ainless, 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
^ Sigraund Gottschalk, CentndblaU f. Gyndk., 1887, vol. xi. p. 329.
DISEASES OF THE VULVA. 283
lack of increase during cough ; from hydrocele, by its hardness and
lack of pelhicidity ; from hematocele, by its hardness ; from hematoma,
by its chronic course. Chronic inflammation or lymph o-sarcoma of
an inguinal gland forms an immovable tumor, without pedicle, and
affects, as a rule, several glands. Difuse fibroma of the vidva 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 unitins: the edires.
CHAPTER IV.
Injuries.
The vulva may be tlie 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 ranuis 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 traumatism 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.^
Cliil(h*en 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 ([uite conmion, but need no special atten-
tion, if my antiseptic occlusion-dressing is used.^ Sometimes a tear
occurs in the vestibule, n^ar the clitoris, which may give rise to
dangerous or fatal hemorrhage.'
The sijinpfoins vary according to the cause and the degree of the
violenre. If the skin remains imbroken, there are pain, soreness,
swelling, discoloration, or perhaps subcutaneous extravasation of
blood (pndenddl hrinafoma). The hematoma may consist in a swell-
ing of the size of a hazel-nut or ac(|uire the dimensions of a fist
or a fetal head at term. It is of dark blue or j)urple color and
' .loseph I'rice, Amer. Jovr. Ohst., IgSO, Tf.l. xix. p. 832.
'GarriKiies, Pmrtiml (hiiilc to Attli.vjitir Miihrifrtji, Detroit, Michigan, 188*'), p. 27.
■* Mund*'', Amn-. Jour. OhM., 187.'), vol. viii. p. •").'57.
284 DISEASES OF WOMEN.
tender on pressure. The blood may be absorbed or the tumor may
become inflamed, suppurate, and even fall a prey to gangrene.
When inflanmiation sets in, swelling, tenderness, 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 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. 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 5j). After that lead-and-opium stupes (tinct. opii, liq. plumbi
subacetat., da 3j ; aquae, ,?viij) 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
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 :
I^. lodoformi,
Bals. Pcruviani, da, 3J ;
Vaselini, ,5j. — M.
If there is any hemorrhage, a careful examination should be made
for its source. Spurting arteries are twisted or tied. Bleeding sur-
faces are brought into contact and miited by deep sutures. If this
does not check the hemorrhage, the wound should be covered with
styptic cotton (p. 186), the vagina tamponed (p. 183), and the ex-
ternal 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 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 demarcation has formed,
and the wound dressed with iodoform ointment.
DISEASES OF THE VULVA. 285
CHAPTER V.
Vulvitis.
Vulvitis is inflammation of the vulva. It appears under five
different forms : the catarrhal, the follicular', 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 afilicted 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. Tlie diphtlieritic 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 Avith a muco-purulcnt secretion. Tliere 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
the papillae are hypcrtrophied 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 excoriatt'd patches
becoming inflamed.
In foUicjilar vnli-ifis the scat of the inflammation is in the hair-folli-
cles, the sebaceous and sudoriparous glands, and, less fre((uently, the
mucous follicles, the intervening mucous membrane remaining healthy.
This gives a peculiar ap[)earance to the vulva, the labia majora and
minora being studded with small round red j^rotuberances of the si/e
of a millet-seed to a hemp-seed (Fig. 218). Often a hair comes out
from the mifldic, and a drop of pus may be ])ressed 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
ncxlules remain after the inflammation has run its course.
In phlegmonous vulvitis tin; iiiHammation extends to the submucous
and sulx'Utaneous connective tissue. J)('('p abscesses and sloughs may
form, aud end in permanent fistulous tracts if" not properly treated.
286
DISEASES OF WOMEN.
Gono)'rheal vulvitis is much like the sini])le acute catarrlial ; but
redness and swelling are more intense, the discharge is more purulent,
Fig. 218.
Follicular Vulvitis (Huguier).
and the inflammation has a tendency to inij)licate the urethra, and is
usually accompanied by gonorrheal vaginitis. ^licturition 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 pathognomonic
that, called as expert in a lawsuit, the physician should not be careful
not to be too positive in his as.sertions.' (See below under Vaginitis.)
C/Mncroids and chancres will be considered under A^enereal Disea.ses.
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 .sy.stem.
Prognosis. — The acute catarrhal and follicular forms are of little
' The reader is referred on this point to the timely warning of so liigh an autliority
as Kobert W. Tavlor, Atlas of Venereal and Skin Diseases, Philadelphia, 1888, pp.
57-58.
DISEASES OF THE VULVA. 287
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 jiatient's
life, it may lead to more or less complete destruction of important
parts, coalescence, and atresia of the genital canal.
Treatmmt. — 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 and strychnine. The genitals should be carefully
cleansed, lukewarm or hot sitz-baths given two or three times
daily; vaginal injections with carbolized water (p. 176) should be
used as often. The genitals ^should be covered with fomenta-
tions moistened with a weak antiseptic fluid. The genitals should
be covered Avith fomentations of the same description, j)art 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 tiie gonorrheal form hydrargy-
riun bichloride is preferable ibr injections and fomentations (p. 17G).
Later, the mucous membrane of the vulva may be painted several
times daily with Monsel's solution of subsulphate of iron or the liq.
ferri chloridi, each of them diluted with eight parts of glycerin. If
this does not effect a cure, the inflamed ]>arts should be ])ainted every
other day with a solution of nitrate of silver (gr. x— 5j) or tinct.
iodinii co., diluted with two parts of water. When the nuicous mem-
brane has nearly recovered, dry jxnvders, such as oxide of zinc, sub-
nitrate of bismuth, iodoform, or even inert powdere, as lycopodium,
talcum, or corn starch, often hasten the process. Tliese same powdei"s
are used for the accompanying intertrigo.
W the urine is alkaliue, benzoate of ammonium or sodium should l)e
given (gr. x-xx every four iiours). When, on the other hand, the
urine is too acid, bicarbonate of sodium or liijuor potassa' are indi-
cated :
I^. Tinct. belhulonn.ie, oij ;
Li(l. potass., .^J ;
Acpue, ad ^iv.
M. Sig. A tcasjxionfiil in a wineglassful of water, /. /. <L
In gonorrheal un'fhrifi.s tlu! uretln'a sliould be washed out with iiot
water or flaxseed tea l)y means of a reflux catheter. WIhmi the
inflammation subsides somewliat, carbolized water (.1 per cent.) or
corrosive sublimate (j\j gr. to .5j), or nitrate of silver (^ gr. to .sj), oi-
288 DISEASES OF WOMEN.
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-5j) may be in-
jected or applied with an applicator through an endoscope. Fritsch's
syringe is quite convenient for the injections. It consists of a hypo-
dermic syringe and a silver tube with a small bulb at the end and
perforated with several fine holes (Fig. 219). Antiblennorrhagic
Fig. 219.
Fritsch's urethral cannula.
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 :
I^. Chloral, hydrat., 3j-ij ;
Vaselini albi, §ij. — M.
^i. Chlorali hydrat.,
Camphorse, da. 3j ;
Vaselini albi, §ij. — M.
^i. Acid, hydrocyan. dil., 3ij ;
Plurabi acetat., 9ij ;
Glycerini, §ij. — M.
I^. Chlorali hydrat.,
Camphorse, da. 3ij ;
Acidi oleici, lij. — M.
When nothing else will help, the whole mucous membrane must
be excised.
In the phlegmonous form abscesses should be laid open by free
incisions, washed out with disinfectants, and filled with iodoform
gauze.
Parts aiFected with diphtheritic infiltration should be cauterized
with chloride of zinc dissolved in equal parts of distilled water.^
The healing process should be carefully watched, so as to avoid sec-
ondary deformities.
' For the details of this treatment I must refer the reader to my other writings:
" Puerperal Diphtheria," Trans. Ajiier. Gyn. Soc, 1885, vol. x. p. 109; "Puerperal
Infection," Amer. Syst. Obst., ii. p. 363 ; Antiseptic Midwifery, p. 61.
DISEASES OF THE VULVA. 289
CHAPTER VI.
Inflammation of the Urethral Ducts.
The urethral ducts described on p. 79 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. 187).
CHAPTER VII.
Gangrene of the Vulva.
The vulva mav 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. 184). Gangrene
may also be caused by inflammation, especially diphtheritic infiltra-
tion. It occui-s sometimes in ('ruj)tive fevers. An idiopathic gan-
grene identical with noma is found in young children, and is said to
\)c 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.
Treatment. — The afflrtcd ])iirt shoidd be cauterized with a 50 per
cent, solution of chloride of zinc, oi* with the thermo-cautery, and
covered witli iodoform or compresses dipjx-d into a saturated solution
of chlorate of potash, 'iconics and stimulants should be used freely.
As soon as a line of demarkation is formed, the dead tissue should
be removed.
290 DISEASES OF WOMEN.
CHAPTER VIII.
EXANTHEMATOUS DISEASES.
In exantheinatoiis 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 on skin diseases. Only one exudative
skin disease shall be described here, on account of its frequent occur-
rence and great diagnostic importance — viz., herpes.
Herpes Frogenitalis. — 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 ca.ses 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 siiarj^ly 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, MMthout 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
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.
IVIildcr cases get speedily well when covered with lint soaked in —
R. Acidi carbol..
mxi;
Glycerini,
5ss;
Aquse,
ad 5iv.
DISEASES OF THE VULVA. 291
The dry powders mentioned above (Vulvitis, p. 285) hasten the
healing, and the iodoform ointment (p. 284) 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.^
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 Yulv^.
Pruritus vulvae 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. AVhen 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 rcfiex symptom of disease
in other organs, such as hemorrhoids, pin-worms in the rectum, diseases
of the kidneys, ureters, bladder, or urethra, congestion of tlie pelvic
organs, etc.
Predisposinc/ canscs are pregnancy, menstruation, the menojxuise,
old age, the gouty diathesis, or general nervousness. Sometimes the
itching is due to direct irritation by parasites (lice or aearus seabiei),
acrid disciiarges from the vagina or uterus, or urine containing sugar.
In other cjises no cause, near or remote, can be found, and then it
has been surmised that the disease is located in the tiervous centers.
Symptoni.H. — 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 pnxluces excoriations and intlanimatory conditions, especially
(K!zetna, which, again, contribute to the morbid sensation.
' For further details the reader is refcrre<l to Robert W. Taylor's ,!//'/.•< ';/' Vfinifdl
and Shin Dmcu^ex, Philadelphia, 1S8S, p. 7'J.
292 DISEASES OF WOMEN.
In its higher degrees the disease is a very serious one. The patient
scratches so that she wears off the liair of the mons A^eneris and
Libia niajora ; she avoids company ; she becomes melancholy and
morose ; she loses her appetite ; her sleep is disturbed ; she becomes
the victim of an abnormally increjised 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.
Prog)iosis. — 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 balsam of Peru, or washed with a strong solution of corrosive
sublimate (1 gr. to alcohol and water ad. .^ss), 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 5J) or sulphur ointment should be rubbed in.
Inflammation of the vulva must be treated as described above
(p. 279). Eczema is treated with unguent.diachyli. Pin-worms are
removed from the rectum by means of extr. sennse et spigeliise fl. (.sss,
t. i. d.), given by the mouth, and rectal injections of a strong infusion
of quassia (.lij-Oj) or corrosive sublimate (gr. | in .oviij 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 «uises 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 (oj-ij daily) is often very valuable. Tinct.
cannabis Indica (20 to 40 drops, t. i. d.) is preferable to opium. It
may be necessary to procure sleep by means of chloralamid, suljihonal,
urethane, trional, or the other modern hypnotics (p. 24.">).
The local treatment is of the greatest ini{)ortance. Vaginal injec-
tions and affusions of plain hot water, solutions of carbolic acid,
DISEASES OF THE VULVA. 293
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 (8:1), hydrocyanic acid (p. 288),
or morphine (gr. ij or iij to 5J) ; or the parts may be painted at longer
intervals with a 10 per cent, solution of cocaine in water, or a simi-
lar solution of carbolic acid, followed by cold applications. For
base of ointment vaseline is the best. It may be mixed with
acetate of lead, chloral, camphor (p. 288), or chloroform (of each
3j-§j). The affected part may be rubbed with a menthol stick or
solid nitrate of silver. In nearly every case 1 have obtained a cure
by painting the whole inside of the vulva two or three times a week
witii a solution of nitrate of silver (5 per cent.) and letting the
patient use the wash comy)osed of lead, hydrocyanic acid, and gly-
cerin (p. 288), on fine muslin, changing it half a dozen times a day.
In cases complicated with diabetes this treatment docs not cure, but
even then it gives considerable relief. Some claim to have success-
fully applied the galvanic current.' As a last resort, when every-
thing 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 al)ove-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
wiiich tobacco-smoking gave relief.
Burnwfj Sensation in t/ic Genitah mid the Abdomen. — This affec-
tion is probably nearly related to pruritus, but dili'ers 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 c()ni])resses
soaked in cold water to the abdomen, the above-mentioned vaginal
injections, and bromidi! of ])otassium internally have given me the
best results.
' W. Blackwood, PohjcUnic, Philadelphia, 1885, No. 9, vol. ii. p. 141.
294 DISEASES^ OF WOMEN.
CHAPTER XI.
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.^ 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. 123).
Tiie 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 })roduee a permanent cure.
Sexual intercourse should be absolutely forbidden. If feasible, the
patient should be sent away from home to a place offering healthy
surroundings and cheerful company. The general treatment should
consist in tonics, sea-baths or M-arm general baths, and massage.
The local affection siiould 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 Yulva.
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. 274).
' T. Gaillard Thomas, A Practical Treatise on the Diseases of Women, 6th ed.-,
Philadelphia, 1891, p. 150.
DISEASES OF THE VULVA. 295
2. Varicose Veins. — The veins of the vulva, especially of the labia
majora, may swell so as to ibrm 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 ])regnancy the ])atient 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
dangei-s of hemorrhage, and instructed how to check it by compression
till she can get helj). AVhen 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. 183, 184), combined
with ])ressure 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-bandage.
3. Hnnafoma, or thmmhus, 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 iiematoma. The exciting causes are
external violence, such as a blow or a fall, and straining, esjiecially
during childbirth. (See p. 283.)
4. Papilloma is a tumor produced by hyperplasia of the pa])ill8e
of the skin or nnicous nicmljranc, with corres]X)nding develo])uu'nt
of the blood-vessels and epidermis. It appears on the female genitals
in three well-marked forms: common wartx, vegetations, and vikcoiis
patches.
Warts, generally of round form, more or less pediculated, of the
size of a j)ea or a i)ean, witii a dry, uneven surface of dark brown
color, are oc(y»sionally found on the skin of the vulva, especially the
296 DISEASES OF WOMEN.
mons Veneris, as in other parts of the body. They are insignifi-
cant, 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 they may also be entirely indej^endent of any
venereal atfectiou, and are then due to lack of cleanliness or to friction.
They are most common on the fourchette, at the vaginal entrance,
and the labia minora or majora, 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,
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 coUodium (oSS-.lj) or sali-
cylic acid dissolved in collodium (.^j-.lj), glacial acetic acid, lactic,
nitric, or chromic acid, and other caustics. The tincture of Thuya
DISEASES OF THE VULVA. 297
occidentalis is said to be a specific for these growths. They should
be constantly moistened with it. In my experience the thermo-
cautery and nitric acid have given the best results.
If the tiimors 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.^ 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 ])resent a double danger for
mother and child. Minor operations may be performed with cocaine
(1 : 8 or 10); the larger require general anesthesia.
Mucoiis patches will be considered later.
The disease which has been described under the name of oozing
tumor is probably a kind of papilloma. It is a very rare disease, if
it is not simply the same as large fiat vegetations. It is said to
occur mostly in middle-aged fat women. It forms a large fiat tumor
on one or both labia majora, divided by deep fissures, and is char-
acterized by discharging a large amount of an acrid, offensive fluid.
In a case operated on by Dr. Emmet ^ with knife and sutures the
hemorrhage was profuse. It is therefore preferable to remove the
mass with the thermo-cautery or galvano-cautery.
5. Elephantiams, or jxtchydermia, is a chronic recurring inflamma-
tion of lymph-ve&sels accompanied by hyperplasia of the connective
tissue, the skin, mucous membrane, and epidermis, leading to the
formation of large tumors.
Etioloffy. — Sj)oradic eases are very rarely found in North America
and I]urope, but the disea.se 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-
hoo<l. 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 jmrasite called fi/firia saiupdnis in the bloo<l, in
which it is sup])()sc(l to Ix' introduced through mosquito-bites. It
may also be due to ])rimary occhision of lym])hatics and destruction
of the lymphatic glands of the groin.
HymptoiiiH. — The endemic form begins with all the symptoms of
' i:. W. Tavlor, /. c, p. 30.
» L. c, p. 003.
298 DISEASES OF WOMEN.
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
tumore 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 lympliatics are dilated and the
papillae enlarged. The underlying subcutaneous connective tissue and
the epidermis are also increased in thickness. In the tissue compos-
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 ^6roK/ 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. AVhen tiie 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 pyemia.
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|, twice a day) is chiimed to have effected
a cure in a month or two. Massage and electrolysis may, under
similar circumstances, prove useful and may be combined with
the sulphide of calcium. In cases of long standing, amputation is
the only remedy. This may be performed in different ways :
DISEASES OF THE VULVA. 299
a. Scbroeder'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.
b. Munde introduced long pins through the base of the tumor,
surrounded it with a temporary elastic ligature, cut the tumor oif,
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 M-ire 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 fibroma 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-oif pedunculated portions.
The skin covering them is 2)ink, whitish, or brownish. They have
no intrinsic tendency to ulceration, but through friction superficial
ulcers may form, and again heal up, leaving cicatrices. These
tumors are not sensitive nor the seat of sj)ontaneous pain, except
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 dyspareunia.
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. — Amputiition is the only remedy, and is carried out as
stilted under Elephantiasis.
The circmiiHcrihed fibroma is a rare affection. It is composed of
the same tissue as the diffus(! form, but soon becomes pedunculated,
and hangs down from the labiiun majus.
The trecdment 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 Ik; formed of unstrij)ed nniscle-fibers (myoma); of a delicate
fibrous reticulum, the meshes of wiiich contjiin a homogeneous basis-
300 DISEASES OF WOMEN.
substimce and cells {myxoma) ; or of adipose tissue {lipoma). Quite
eominonly the different kinds of tissue are intermingled with more
or less fibrous tissue, forming mi/o-Jibromas, myxo-fibromas,^ etc. They
are all benign, but the only treatment is amputation.'^
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-
oris, and composed of a cartilaginous ma&s, 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 galvauo-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 vascidar 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 without causing any symptoms, is often seen
accidentally in patients examined for other complaints. 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
* On account of the great rarity of these tumors, I may be pardoned for stating
that on !Marcli 12, 1884, I removed one from a Swedish cook, jet. 34: it had been
first noticed nine years l)efore. It hung from the middle of tlie 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
oflTensive 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 p:iin, nor was it tender on pressure. I put a clamp on the base of the
fedicle, formed two small flaps, tied the artery, and united the edges with catgut.
t healed by first intention. When cut open a moderate amount of blood flowed
from the tumor ; the surface Avas smooth, the skin not thickened, but so intimately
connected with the tumor that it could not be dissected oflf". Microscoj)ical 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.
^ Geo. M. Tuttle of ]!sew York has removed a large fibroma molluscum from the
labium majus. It measured 17j in. in circumference ; had a thick capsule, in cut-
ting through which the appearance was strikingly like gut: thin, translucent, gas-
eous in .feeding, and very resonant on percussion {Amer. Jour. Obslet., June, 1891,
vol. xxiv. p. 715).
■* Tumors of the clitoris are extremely rare. Grace Peckham has described a cyst
as large as a hen's egg, and collected twenty cases of diflferent kinds of tumors of this
organ [Amer. Jour. ObMet., Oct., 1891, vol. xxiv. pp. 1153-1172).
DISEASES OF THE VULVA. 301
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 le&s high up in the urethra. They are sessile or j)ediculated, 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 arc 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-fibres, 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 lumors (neuromata) form
in rare cases small tumors on otlier 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 ver/ctations.
Treatment. — The only thing that affords help is the removal of the
tumor. If there is a tliin ])edicle, it needs only to be twisted off M'ith
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.) mav be used for local anesthesia. I^argcr sessile tumors are
best removed with the thcrnio- or galvano-cautery under general
anesthesia. In the interior of the urethra they must be exposed witii
a uretliral speculum (p. 152), especially Jackson's, and cut or scraped
off or destroyed with ctuistics. The latter should even be used on
the base after cutting or scraj)ing, in order to prevent recurrence.
11. Ci/sti^. — 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. Tluy dilTcr nuieh in origin. Some are dcnaoid
cyd-H, with the characteristic hairs, bones, and teeth in the interior.
Others are atlieroiudu, ibrmed 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 extra vasati(jn of blood or to
expansion of lyin])liatic vessels.
Jf small, they do not give rise to anv symptoms, but if thev accpiire
large proj)ortions, tiny may incommode the |)atient by i\\v\\' weight
and size, and cause dyspareunia. If they become inflamed, they are
j)ainful, and are accompanied i)y fever and other systemic (listnrl)an(;es.
Tredliiicnt. — As th(y are intimately connected with tlie surrounding
tissue, it may i)e diflicult to enucleate! tluiin. If so, a part of the wall
302
DISEASES OF WOMEN.
is excised, the interior cauterized, packed witli 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. 220) is in so far less malignant than the other
varieties of cancer as its course is slower.
Fig 220
f.-^-=^)l(^^.
Epithelioma of Vulva (P. Zweifel): a, clitoris; 6, fossa navicularis; c, vaginal entrance; rf,
torn perineum ; t/g, cancerous nodules in the skin.
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 tiie cause is unknown.
^Symptoms. — The most common starting-point is the sulcus between
the labium 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, whicli often causes distressing itching. Later,
DISEASES OF THE VULVA. 303
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
ojienings may become obstructed.
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
inguinal glands swell late or not at all. The general health remains
good. Chanci'oid is not indurated, has sharply-cut, perpendicular
edges, and the inguinal glands are imj^licated much sooner. Chancre
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 po&sible, it sliould be done with knife and scissors, and the edges
united by deep sutures, which allows of union by first intention ;
otherwise the thermo- or gal va no-cautery is used. If the urethra
is implicated, as much of it as feasible should be left, in order not to
interfere with the retentive power. If the inguinal glands are
affected, they nuist be enucleated, but even if they are removed en-
tirely, the disease cannot be arrested permanently.
13. Lupus, Esthiomhie (Huguier); Chronic Liflamraation, 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 184!), Huguier, a French piiysician, de-
scrilKxl a disease of the vulvo-anal region under the name of esthio-
mP.ne, which was claim<'d to be identical with lu])us as found especially
on the face. The name '' lu|)us" has prevailed, and a certiiin number
of cases have been reported in (Ufferent countries.'
The pathologi/ of luj)us itself is not yet settled, and so much tlu;
less can we de(Mdc whetiier the disease attacks the external female
'Grace rcckham, in an excellent paper fortified by microscopical examinations
by II. ('. Co.! i Am»;: Jour. OhM., 1HS7, vol. xx. p. THo), lia,s collected 18 cases, of
whicb slie eliminates some as tuhercnlar, carcinomatous, or not ulcerative, and
retains 15.!, iiu-lusive of lier own.
304 DISEASES OF WOMEN.
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 fur been looked for in vain in lupus vulvae. Others
claim that an infiltration with small round cells, clustering together in
nodules, esi)ecially 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 iuHammation with formation of granulation tissue
and proliferation of the cells of the connective tissue.' R. W.
Taylor^ denies altogether the existence of lupus in the female geni-
tals. Based on his large experience in Charity Hos{)ital, he includes
all the inflammations and infiltrations of the vulva of non-malignant
origin in the following categories :
1. Small hyperplasije, caruncles, and papillary growths;
2. Large hyperplasia.
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-
stituting the condition commonly called lupus vulvae, that have come
under my own observation, were all developed on a foundation of
recent or old syphilis.
What has been called lupus vulvae (Fig. 221) consists in ulcera-
tive lesions of the vulva characterized by their slow development,
absence of pain, a purple color, thickening, induration, and forma-
tion of detached tumors. Hyperplasia and destruction go hand in
hand, but the hyperplastic process ])reponderates. 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
and around the rectum, and fistulae may open into tlie urethra, the
bladder, or the rectum. Fortunately, this destructive hyperplastic
affection of tiie vulva is a rare disease.
Etiology. — Those who do not look upon the ulcerative hyperplasia
^ Coe, I. c, Ira Van Gieson in R. W. Taylor's paper.
2 R. W. Taylor, iV. 1^ Med. Jour., Jan. '4, 1890.
DISEASES OF THE VULVA.
305
of the vulva as a disease sui generis, attribute it to the large vascular
and nervous supply of the genitals, to the injuMes they are frequently
Fig. 221.
Lupus of Vulva (Iliibcrlin).
exposed to, to tiieir dependent position between the thighs, to lack of
cleanliness and care, and the irritation cau.sed by uterine or vaginal
disciharges.
IHar/noHlH. — EjntheliohKi is usually more localized, of niucii greater
density — even to stoniness — is pHxluctive of a large warty or papilla-
niatous and ulcerated surface, and is very soon acconij^anied by
enlargement of the inguinal lymphatic glands. The ulcerations of
epithelioma are upon the surface, while those in so-called lupus are
mostly foiuid in interstices, tissurcs, and at the b;use of tumors. Epi-
thelioma gives ris<! to lancinating pain ; lupus is painless or causes
only smarting or pruritus, esjK;cially after micturition. The discharge
20
306 DISEASES OF WOMEN.
that emanates from the ulcei's 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-uests of concentrically arranged cells of
the epithelial type.
Prof/nosis. — 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. Oftcm
a tonic treatment with iron, quinine, cod-liver oil, etc., or local or
general antisyphilitic treatment, may be called for in combination
with the local mechanical treatment.
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
DISEASES OF THE VULVA. 307
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, fresh air, and, per-
liaps, one of the modern hypodermic injections. 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, mere palliative treatment with the curette
and iodoform or aristol is all that should be attempted.
CHAPTER XIV.
Progressive Atrophy of the Nymphs (L. Tait), Kraurosis
YuLV.Tc (Breiskyj.
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 serplginously. J^ater,
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 ])ainful,
and childbirth is accompanied by tears of the tissues. When the dis-
ea.se is fully developed, the labia minora seem to be absent. The
raucous meml)rane appears dry, smooth, and cicatricial. Sometimes
there is a slight yellow discharge. In many cases itching or burn-
ing is complained of.
The cause of the disease is unknown. Perhaps it is due to infec-
tion from trachoma.' Its course is very slow.
Patholofjical Anafotni/. — Microscopical examination of the red
spots shows dilated ca])il!arics, with thinned walls, and ncrve-tibres.
AH ov(!r the affected i)art of the mucous inenil)rane the rete niucosum
is thin, so that in many phices tlu.' horny epidermis-cells lie directlv
on the papiiUe. These are mostly siiort and of" luxven leiigtii ; the
papillary layer is composed of straight fil)res lii<e a cicatrix, and
the sebaceous and sudoriferous glands disa])j)ear.
Treatment. — Kraurosis vuivie is a very intractable disease. ( 'ocaine
is said to increasi; the sufferings. Aj)])lications of strong carbolic acid
' I)r. A. W. Johnstone, of Ciiicitiiiati, found that in every case whieli liad come
under liis ol)scrvati<>n, some member of tlie patient's family \v:is alii'ctcd willi
traclioma of the eyelid«, Mcil. Uncord, June .'5, 1S9'.».
308 DISEASES OF WOMEN.
and a pledget steeped in a saturated solution of acetate of lead are rec-
oniniended. Dr. Johnstone recommends yellow oxide of mercury
ointment (gr. iv to vaseline .^j). A cure has been obtained by cutting
away the affected part of the mucous membrane 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, cystio
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. Cysts. — 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 imder the mucous membrane, just outside the vaginal
entrance. It may vary in size from that of a hazelnut 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
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. — Hydrocele 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 heryiia 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
DISEASES OF THE VULVA. 309
(1 to 10). The contents may be withdrawn entirely, aixl 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. Modus
operandi: The patient is in dorsal position. By seizing the labium
between thumb and index-finger, the operator makes the swelling
protrude. Now he makes a longitudinal incision, about 1^ inches
long, through the mucous membrane covering the cyst, and another
in the same direction through the fascia. Xext, he seizes the gland
with a tenaculnm-force])s and pulls cnit all the time while he sepa-
rates the gland from its surroundings, partly with closed scissors or
the nail, partly by dissection. Three or four small arteries may
spurt and "are clamped. A large and deep hole is left with an
oozing: surface. Under this whole surface is carried a runnintr
suture of medium-sized catgut, which arrests hemorrhage and
abridges the after-treatment very mucli. Exceptionally it may be
advisable to use tier-sutures of catgut (p. 237).
3. Abscess. — With or without preliminary formation of a cyst the
gland may suppurate and form an abscess. Tiic left gland is more
frequently affected. The process is accompanied by the usual signs
of inrtammation — pain, swelling, redness, heat, and considerable
systemic disturbance. Tiie inguinal glands are commonly impli-
cated. If left to Nature's sole eiforts, the abscess breaks on the
inside of the labium majus in one or more places, and often fistulous
tracks remain. Tiierc is in many women a tenih'ncy to repetition
of such absc(!sses. Tiie pus lias the same offensive odor as abscesses
in the ischio-rectal fossa or near the i'auces. Cronococci have been
found in the pus-cells.
The abscesses may l(!ave a c/ironlr suppuraiion of the gland, or such
a condition may (h^velop without abscess. There is then little swell-
ing and tenderness, but a continual discharge of a purulent fluid
through the duct of the gland. This suj)puration is perhaps alwavs
brought on by gonorrhea, and contimially gives rise to new infection.
I)i(ir/no.^is. — Fiiriinr/ts are situated in the skin. P/def/iiioxoxs
ru/rHi.s has not the dislliiet limits and the ])eeuliar situation of the
abscess of the gland. A xfercoral (thsref^x originates nearer the amis.
Trefduicnt. — The al)se((ss must be laid oi)en by a long incision on the
inner side of the labium majus, disinfected, and packed witii iodolbnn
gauz(.'. The oj)ening may conveniently be made with J*a(juelin's cau-
tery. \i there is fre(|uent recurrence of the formation of such abscesses
or a chronic suppuration, it is best to extirj)ate tlu; gland in ioto. It is
not worth while trying primary union. It rarely succeeds, and it Ls
310 DISEASES OF WOMEN.
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 fjiscia. Wounding the bulb might give rise to hemorrhage.
The incision should, therefore, always be made from the bulb
backward. Instead of incision or extirpation, injection with a
saturated solution of salicylic acid in alcohol has been praised in
cases of recurrent Bartholinitis. If the contents are purulent, it
may be necessary to repeat the injection.'
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 resume 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. 286). 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, givnng rise to oophoritis and peritonitis — conditions tliat 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 tiie 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. 287) 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,
^ Cordier, LyoJi Medical, Dec. 19, 1S97.
DISEASES OF THE VULVA. 311
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 jienetrating 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, led
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 tiie 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 hy[)erplasia of the surrounding j)arts. (See Lupus, p. 303.)
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 ])roof
that it began as a typical acute ciuuicroid.' For years women affected
with such ulcers and hyperplastic formations may feel well, but in
the course of time the ulcers may perf"orate the urethra, the bladder,
and the rectum, or i)urro\v far away under the skin, forming lai'ge
cavities, which may open by fistulous tracts about the buttocks or the
thighs. Hemorrhages of greater or less severity may take place, or
erysi|M'las start from tin; genitals. In the course of years such women
mjiy fall a pr(;y to pulmonary |)hthisis or succumb to kidiuy and
liver complaints. Some; an; subject to chronic diarrhea and dys-
entery, or are finally c:irri<'d off by jwemic infection.
Treatment. — The acute chancroid should he. destroyed with nudi-
' K. W. Taylor, S. Y. Med. Jmr., .Jan. 4, iS'.tO.
312 DISEASES OF WOMEN.
luted carbolic acid, nitric acid, or Paquelin's thermo-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.,
^i. Acidi carbolici, TTLxx to xl ;
Glycerini, Sss ;
Aquse, q. s, ad siv,
or smeared with the iodoform-balsam-of-Peru ointment (p. 284).
A^aginal injection with bicarbonate of soda or borax, followed by cor-
rosive sublimate (1 : 5000), should be used several times daily. The
substance tiiat makes tlie ulcei-s 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. argeuti nitrat, (gr. j-5iv), liq. sodii chlorinat.
(sij-.siv), 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. Tlie
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 eigiit
to twelve hours daily.
Bubos are painted with tincture of iodine. If they suppurate, they
must be o])ened 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 sj^ica 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 .Ij) hastens the process of
healing. Pure boracic acid is also excellent for dressing. In more
chronic cases the glands may be removed by enucleation.
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. Tiie syphilitic neo-
DISEASES OF THE VULVA. 313
plasm is there, but the new-formed cells are so few in number or so
loosely patched together that the characteristic sclerosis is not devel-
oped. When, furtliermore, 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 undei'stood that sometimes
it is entirely overlooked, and that secondary and tertiary symptoms
may appear althougii 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 incuhaiion — that is, the time elapsing between
the infection and the ap})earance 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 sy})hilis — occui)ies 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 live to ten
days after tiie 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 major, some-
times (m tiie cervix uteri, and very rarely on the walls of the vagina.
It begins as a superficial, Hat, reddish erosion, which soon forms a
round or oval flat ulcer of dark-rc<l 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
witii the introduction of the syphilitic virus. Then the secretion of
tiie ulcer becomes more ])urul('nt and the floor shows local gangrene.
Exceptionally, a syphilitic lesion may become phagedenic. If a
doul)l(! infection with sy|)liilitic virus and that from a chancroid
takes place sinuiltaneously, the chan<;roi(l is first developed, and
changes its a])jK'arance in the course of time, so as to form a syphil-
itic chancre {mixed chancre).
The primary lesion is commonly single, but may be multi])le an<l
may be combined with soi't chancres. It stays a variaide length ol
time — even several months — but, as a rule, heals readily, and may dis-
appear without leaving any trace.
The inguinal glands form a duster of indolent swellings. IJut
where there is a suppurating ulcer, there may also occur inflammation
and abscess of the inguinal glands.
Didf/noHi.s. — Since the characteristic induration is often absent, the
diagnosis of the ])rimary lesion becomes more diflicult in women than
314 DISEASES OF WOMEN.
in men. The following points ' may occasionally be found useful in
making a differential diagnosis : In herpes pr'ogeiiitalis the inguinal
glands are not aifected ; the base is soft ; the contour is poly cyclic —
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 Si/philis. — 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-sliaped tumors like vegetations, and may, like them, be-
come gangrenous. On the vaginal portion mucous patches appear as
' A. Fournier, Lemons sur la Syphilis etudiee particidiiremeni chez la Femme, Paris,
1873, pp. 261, 281.
DISEASES OF THE VULVA. 315
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. — Ginumous nodes are not rare in the labia
majora. They form first deep-seated globular tumors, which may
break and leave ulcei-s. 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 tiie uretlira and the bladder would
require more space than we can aiford, and they do not strictly be-
long to those organs the diseases of Avhich 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
tiie normal mucous membrane, but later it becomes darker and denser,
and is sometimes excoriated.
J)i(i(/vos/s. — When the prolapse is total, the presence of the lumen
of the canal in its center settles at once the diagnosis, li' it is j)artial,
it may be taken for a ccni.nc/c, \mt it diflcrs from ihv. latter by always
having a broad base and by being easily reduced,
Trcdtinrnt. — Simple reduction with a finger or sound, followed by
the use of a cup|)ed bougie, with tannin or the application of tincture
31G DISEASES OF WOMEN.
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
ciises — 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 (an
act called withdrawal). It is not usual to treat of this subject in
works on gynecology, but since the thing exists, since it appears in
innocent childhood, since it produces certain symj)toms, since it may
be the cause of the most serious diseases, since the })hysician 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, proj)er
to give some information about it here.
Ma.sturbation may be indulged in by infants of either sex who
have no idea what they are doing.^ 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-
' A. .Taoobi, " On Masturbation and Hysteria in Young Children," Amer. Jour. Obst.,
vol. viii. No. 4, 1875, and vol. ix. No. 2, 187G.
DISEASES OF THE VULVA. 317
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 oifspring. There
are several reasons for it, one of which is the less degree of orgasm
felt by women daring normal sexual intercourse (p. 123). This, at
least, would seem to explain the fact that many married women are
given to this vice — a thing that 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 tliat of another, or In- 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 i)i Infanci/. — Masturbation in early childhood
being in many respects ])eculiar, we must c-onsider 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 iis 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 tiie rectum, they should be
removed (p. 292). If the c()mj)osition of the urine is abnormal, it
should be remedied l)y j)ro])er medicine, especially alkalies and ano-
dynes. The couch should l)e hard, the cover not warmer than what
is necessary to j)rotect the child. It should not have too rich food:
large quantities of meat, eggs, spices, salt, and beer are injurious.
Drugs that irritate the lu'opoietic system, such as cantharides or nitrate
or chlorate of potash, sh<»uld be avoided or handled with care.
During the act the child should be taken up, her thighs sej)arated,
her hands removed from her alxlomen, and her mind diverted. J'he
anemia and nervousness should be treated with strychnine, iron, and
arsenic. When every other remedy has failed, clitoridectoiiii/ may
still effect a cure.'
' At the request of I)r. Louis Fischer, I i)erforme<l (lie operation on a tliree-
months' old child, who masturbated nearly ail the day. All known inedieal reme-
dies and mechanical contrivances having; been nsed in vain by this distin^riiisiied
pediatric, 1 anesthetized the child, seized the clitoris with a pair of forceps, and
318 DISEASES OF WOMEN.
2. Masturbation in Older Children and Adnltn'i. — Sipnptoms. — The
froquontlv repeated act of self-abuse or masturbation with another
})erson leaves certain local changes in the genitals which it is useful
to know. It is true that not one of them is pathognomonic, but the
presence of several of them must, to say the least, awaken suspicion
and may help to determine the truth. The clitoris is both thickened
and elongated. The glans is red and protrudes beyond the pre-
puce. Tiie 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. 285)
are present. The vulvo-vaginal glands may be inflamed. The vulva
may show fresh scratches or old cicatrices, and the clitoris has been
found Mounded 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 pneumpuia, 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 sulFers 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 ;
removed glans and body with the thermocautery. The after-treatment consisted in
the application of a weak solution of carbolic acid, and the child was entirely and
permanently cured of its bad habit. Archives of Pediatrics, May, 1899.
DISEASES OF THE VULVA. 319
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 who, when she married
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 — or the for-
eign bodies themselves may cause pain and endanger the bladder.
The sphincter of the anus may become relaxed and give rise to pro-
lapse 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 palpal)le
cause of irritation, such as j)in-worms, accumulated smegma, adhe-
sion of the prepuce to the glans of the clitoris, bladder catarrh,
calculi, or hemorrhoids, nuist be removed. The focxl should be
bland ; alcoholic beverages and spicy dishes should be forbidden.
The body should be tired with manual work, gynmastics, 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. 'J'he patient should lie on a hard matti'ess, lightly covered,
with the arms al)ove the cover, and in a cool room. The nervous
system must be (piieted with camphor, lupulin, the bromides of
anunonium, pot;issium, and Sixlium, or monobromide of camphor.
In the worst cases clitoridectomy is indicated, and has eflected some
remarkable cures. It is a simple o])eration, but, as it has led to sej)-
tic peritonitis and death, it ought to be performed with antise])tic
precautions. It is only the glans and body that are removed. This
may be done with a bistoury or curved scissors and sutures ap})lied,
or one may use the therino- or galvano-cautery. Tiiere is no reason
why this little bit of flesh should not i)e removed, and, as it certainly is
the Tuost excitiiblc! j)art 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 have to deal with only tlie anal part of the perineal re-
gion, the injuries to the vulva having been considered above (p. 283).
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 WitJiin. — 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.^ Here we will only briefly allude to a few points which
are necessary in order to understand the old lacerations, or which
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 rima
pudeudi, the first of which is circular from the beginning, while the
second becomes so when distended by the child being pushed through
^ 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. News, April,
1891, vol. Iviii. p. 454, et seq.
320
DISEASES OF THE PERINEUM. 321
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 su})erficial 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 fascife (pj). 96, 97),
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 i)ad 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 tiie genital canal,
while the forehead is pressed against the posterior wall of the vagina.
The external ring, formed by the expanded vulva, often escapes
all injury through ciuldbirth, so that even the thin edge of the four-
chette may ])e found entire in women who have borne children. It may,
however, suffer in different places. The most conmion is a tear in
the median line, beginning at the j)osterior commissure, from which
it may extend down to and into the anus and up to and through the
vaginal entrance. More rarely this perineal ru})ture begins in the
center of the ])erineiun, 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 suiliclently
large to admit of the ])nssage of the child through it without impli-
cating the rima pudendi or the anus {ccniral laceration).
If the perineum escapes or suffers little, the injiny often takes the
shape of superficial tears on the labia majora or deeper tears in the
lal)ia minora and vestibule near tiie clitoris (p. 283).
Nearly all tears i)eing due U^ circnlMr ex[>ansion, the })arts separate
laterally, and the rents have a longitudinal dii-ection more or less
parallel to the axis of the parturient canal ; but if the severed halves
of the perineum do not unite l)y first intention, they heul separately,
each forming one-half of a cicatrice, in which way cicatrices with a
transverse direction ar(! formed. This has given rise to the erroneous
conception that the fn.-h tear also had lieen transverse, which it
hardly (!ver is.
Sometimes nature can elfect comj)let(,' agglutination and coalescence
by first intention of any tear. I have myseli' seen this in inconij)lete
laceration where the whole j)erineal body was s( vered to the rectum,
and I have heard of the same lucky result in cases of coM)|)lefe lace-
ration, in which nothing was done except to ti<! the patient's knees
together, J5ut such a pnK-ess is (»i" so extreiiielv I'are occui reiice that
21
322 DISEASES OF WOMEN.
it is fbolhardineas to wait for it. In the great majority of cases the
natural healing is altogether insufficient. An 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 jielvic 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 perineorrhaphy).
Rupture of the Outer Ring. — If the tear begins at the posterior
commissure and extends more or less far toward the
Fig. 222. anus without implicating it {incomplete laceration), and
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
serrejines (Fig. 222) — fine self-holding clamps working
on the principle of clothes-pins. These little in.stru-
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-
bracino; it with the legs of the serrefine. The first is
j)laced half an inch from the end of the tear, the fol-
lowing with half an incii interval, and the last at the
anterior end of the tear. Good serrefincs 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 nni.st be half an inch long beyond the cro.ssing.^
' Serrefines were invented \>y the French surgeon Vidiil. Most of those on tlie
market are of very inferior make, but Geo. Tiemann & Co. keep some good ones
under my name.
DISEASES OF THE PERINEUM. 323
In fat women tlio perineum cannot be folded as described, and
therefore the serrefines cannot be used, and recourse must be had
to sutures.
Serrefines are inferior to sutures, but they have the g:rcat advan-
tage that they may be used wlien the "operation" of stitcliing the
torn perineum wouhl be declined or would do harm to the obstetri-
cian's reputation. They may be put on without speaking of it,
while the patient is lying on her left side in order to be cleaned.
They are, therefore, of particular value to the young practitioner
who has not such a command over his patient that she takes his
word for good when he tells her that it is quite natural her peri-
neum should be torn on account of the disproportion between the
opening and the child that passes through it, and who nevertheless
will blame him when the consequences of her tear make themselves
felt.
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 Avitli 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 tamj)on with an attached thread is
pushed up into the vagina above the tear, in order to keep blood
away from the field of o])eration. Siireds that hang loose by a pedicle
are cut off. The left index-finger is introduced into the rectum,
while the a&sistants 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 j)()st(ri()r end of tli(! tear, and carried under the torn
surface over to the corresponding i)oiiit on the otiier side. The sec-
ond suture is placed about halt an ineh farther forward, j)arallel to
the first, and is likewise entirely imbedded. It embraces often the
lower end of tin; nuicous niembranc; above the tear. The third and
last is ])laced a little Ixlow the posterior commissure. It goes only
under the tear in the left labium majus ; the needle emerges on the
line of demarkation Ix-tweeu this torn surface and the nuiet)ns niem-
l)rane, is again entered on the eorresi>ouding point on the light
lal)ium, and is |)uslie(l out on the eoi-respoiiding point ol" the skin.
'I'hese three sutui-es eorresixtud to sutures 2, 4, and G in Fig. 'I'-Uk
I'Lxeetited with j)roper antiseptic ])recautions, this operation is nearly
alwavs suecessf'ul.
324 DISEASES OF WOMEN.
Before closing the sutures, the tampon is pulled out and the parts
are again irrigated. My perineal pad, or antiseptic occlusion dress-
ing, is applied. This consists of (1) a piece of absorbent lint, 12
by 8 inches, folded twice lengthwise, so as to become 3 inches wide,
the average distance from one gen i to-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
by 4 inches ; (3) a large pad of cotton batting ; and (4) a piece of
unbleached muslin ^ yard square. The lint or absorbent cotton is
wi'ung out of some antiseptic fluid and carefully applied over the
vulva and the anus. The gutta-])erciia is washed with the same
solution and ])laced over the first layer, turning the edges forward
against the thighs. The outer layer of cotton batting serves only
to give bulk, and is pressed up against the genitals by the muslin,
which is fokled like a cravat 5 inches wide, and fastened to an
abdominal bandage, so-called binder, in front and behind. This
dressing is changed three or four times in twenty-four hours, or
oftcner if the patient has a movement from the bowels or passes her
urine in the meantime. 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.^ The knees are bound loosely togetlier, 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 oj)en 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. Sjiecial care should be taken to unite the ends of
the sphincter ani nuiscle on the principle that will be described below
in speaking of Emmet's operation for the old rent.
' More details and an illustration are found in Garri.Lrues' Antiseptic Midnifery, p.
27, and Amcr. Syd. of Obst., ii. p. 351.
DISEASES OF THE PERINEUM.
325
It" 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 foiuid 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 oif.^ 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
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 and cutaneous crown-suture in
place ; D, all sutures tied.
of the outer ring, except when the latter implicates the S])hincter
muscles of the rectum, medical science ctdls for its immediate treat-
ment; but in most cases me(lit"al diplomacy and other considerations
will throw their weight into tlie other scale. These tears are mostly
])roduced by an unskilful conduct of labor, such as the administration
of oxyt(K3ics, manual exjjulsion of tiie child by {)ressure on tlie fundus,
a precipitate use of the ft)rce})s, or, at tlie very least, tlie omission ot"
means to ensure a slow dihitation of tlie vaginal entrance and the
vulva during the birtli of the child ; and noaccouclieurs who will com-
mit such faults and no midwives are likely to examine for a tear that
is not visible on the skin, and, if they did,thev would liardly be compe-
tent to remedy the injury. It will also be hard for the general })rae-
' J. II. Carsten.s, Detroit, Midi., Amrr. Jour. Ohsl., 1884, vol. xvii. j). 'J41.
326 DISEASES OF WOMEN.
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 cir(!um stances 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 j)elvic 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 dis})oses of what is not united
by the preceding sutures (Fig. 223). For the latter silkworm gut
or silver wire is preferable.
If the sphincter ani is torn, its ends should be brought together
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.
Serrefiues are removed on the fifth day, sutures in the incomplete
laceration on 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 Perineorrhaphy. — If several days have passed since
the laceration took place and the surface lias begun to granulate, it
may yet be made to grow together. It is for this purpose scraped
with the edge of a knife, washed with lysol water, and united as
described above with serrefiues 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. ]>ut, so far as I know, nobody has undertaken this at
the time of delivery, and I think such a procedure would meet with
considerable opposition, not only in the public, but even in the pro-
fession. This accident is therefore left until injurious consequences
develop, and is tiien 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 meantime 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 Ijroad surfaces corre-
DISEASES OF THE PERINEUM. 327
spending to each other, 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 each other 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 our opinion, will give satisfaction in any case :
1. Incomplete Laceration. — a. Colpoperineorrhaphy.^ — The patient
is in the dorsal posture. The object is to remove the whole vaginal
wall and the mucous membrane of the vulva over a surface on the
posterior part of the vagina and vulva, bring tlic two halves together
from side to side, and at the same time lift the })osterior wall of the
vagina uj) against the anterior.
According to the amount of tear and relaxation of the vaginal
entrance and the perineum, a point (Fig. 224, 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 ])air of bullet-forceps with
catch. A small nick is made on the inside of each labium majus
near the edge at such a distance from tiie clitoris that there will be
left proper space for c<)})uhiti()n {/> and c). Imaginary lines are
drawn from tliese two jioints to the first, and another j)air of buUet-
forcej)S is introduced where the line intersects the furrow on either
side of the vagina (d and e). A blunt-pointed pair of scissors, bent
on the flat, and with the concave side turned toward the operator,
are then introduced at c, the nick made on the left labium, and ])ushed
up to e and down to tiie line of demarcation between the mucous
membrane and the skin and over toward the other side. Next,
they are introduced at h, the nick made on the right labium, and
used in a similar way until this lower ])art, somewhat shaped like
a trapezoid, is denudecK The uiore we a])proa('h the base (h c) the
more the miu'ous membrane adheres, and it may be bound to the
miderlying parts by cicatricial tissue, which may recpiire small nicks
with the scissors. The fin)) is cut off along the lines e r, c h, and
b (1. The scissors are now turned upward from e and <l to a, and
from one side to another, loosening the wiiole vaginal wall irom
the underlying conne(;tive tissue and rectum in the sha])e of a dome.
This is very easily done by taking hold of the lower part of" the
flap. Finally, tlu; uj)per ])art is cut loose by carrying the scissors
in a curved line with the convexity turned outwiinl. ( )n account
of the foreshortening, it is dillicult to represent in a draw ing the
' TJiin ()j)or;itioii Iki^; Iiccii pra'itially (icvolopccl in (he course of a Cfntury. lloiix,
niefPenhach, \\v^:\r, and many otiiors liavecontrilmtcd to it. 'I'lic writer lias also tn-eii
much int«'reste<l in it, as will bo seen by compariiif^ tlu; tiirec niitions of tliis work
— the description dillerin;? in all of them. I desorihe it here as 1 now perform it.
328
DISEASES OF WOMEN.
Fig. 224.
^.Garrigues' Colpoperineorrhaphy : the four lower turns of the suture slant downward
toward the entrance : 2J, the dome- shaped part of the wound shown in A having been
closed, the perineal sutures are inserted— 2 is all buried; 3 and 4, partly free— all in a
.slanting direction ; C, deep and superficial perineal sutures tied.
DISEASES OF THE PERINEUM. 329
shape of the denudation. It somewhat suggests a policeman's hel-
met. The wound is closed by a running suture of medium-sized
catgut, going ^ of an inch out from the edge and under the whole
surface. The first few turns are carried horizontally, but the fol-
lowing are made to dij) a little toward the perineum, so that when
tightened they will raise the posterior wall of the vagina forward
and upward. This suture is continued until the lines / c and / b
(Fig. 224, B) have the same length us g c and ff b.
Then a silkworm-gut suture (2) 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 surface 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 (3)
is inserted midway between the first and the point c, brought out on
the edge of the denuded surface at h, between the inner and middle
third of c, reinserted on the other side at i, and brought out on the
skin. Finally, the last suture (4) is inserted near the outer edge 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 b. These three sutures are not tightened until all
are put in and the surface well irrigated. Tlie direction given to
the sutures ensures a perfect adaptation of the edges, and makes
the surfaces that come in contact sufficiently broad to form an ex-
cellent substitute for the original perineal body. In order to pro-
tect the rectum from being wounded, it is necessary to keep the left
index-finger in it while passing the sutures.
A large curve<l Hagedorn needle can be used in most cases.
Finally, in order to ensure perfect adaptation of the edges, a couple
of fine superficial silk sutures arc introduced on the perineum,
between the deep sutures (Fig. 224, V).
At the end of the ojx'ration, all inner (vaginal and })erincal)
sutures lie in one C-shaped line. 'J^lie effect is to narrow the vagina
and vulva, lift the ])()steri()r wall, and interpose a strong perineal
body between the vagina and the rectum, much in the siiajK' of the
one shown in Fig. 49, ]). 54, whi(;h body is suspended from above
by its indirect attachment to the bones of the ])elvis. After some
time tiie ])arts look so natural that one can liardly see that an ()])er-
ation has b<'en jtcrfonued, and the ])erineum may even stand the test
of (!hildbirth. I reiii(»ve the niiddhi j»erineal suture on the fifth
day, as there is danger of a fistula forming, the others on the eighth.
Jhirird Cfifi/iif Siifin-cs. — Some ])refer to (!h)se the whole wound
with buried catgut sutures, either int(>rrupted or continuous. Tiie
latter is begun at the uj>|)» r en<l of the triangle, and the first circle
closed with a knot, leaving the end .'> inches long. '^Fhis end is
seized with a j)aii of fbrcej)s and ])ulled u])ward by an assistant,
330
DISEASES OF WOMEN.
which facilitates the introduction of the remaining sutures very
niucli. 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 nuicous membrane, and finally doAvn the perineum.
It is tied as stated in describing tier-sutures (p. 237).
b. Tail's Flap-xpllitlnrj Operation} — The j>atient is placed on
the table in the dorsal position, with knees drawn up by Clover's
Fk;. 22").
yiS^.
Tail's Perineal Flap-splittmp; Opt ration for Incomplete Laceration (MacPhatter).
crutch or Robb's leg-holder (p. 208). The left index- and mid-
dle 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
^ Tail's priority has ))een contested, and I nnyself saw Demarqiiay operate by the
flap-method, in Paris, in 1872. many years before anybody had heard of Tait's opera-
tion of this kind ; but tliere can be no doubt that revival and simplification of the
operation are due to the great gynecologist of Birmingham.
One difficulty in describing his operation arises from the fact (hat he has per-
formed it in different ways, and that those who have seen him operate have given
very different descriptions of it — c. ;/. Maephatter (Amer. Jour. ObsL, Nov., 1889, vol.
xxii. p. 1146) and Munde {ibidem, July, 1889, p. 673). In tlie text I describe it as
I have performed it myself with good results.
DISEASES OF THE PERINEUM. 331
depth of about | 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. Tiie wound gapes, and is made
to gape wider by pulling the cut surfaces apart. If arteries spurt,
thev are caught with pressure-forceps and may be tied with catgut
(Fig. 225).
A handled needle, slightly curved near the end, is pushed through
the skin yV inch outside of tlie wound, and about ^ inch behind
the anterior end of the incision,^ 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 -^^ inch outside of the wound. A
piece of silkworm gut 10 iuclics 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 | 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 each other. The outer flaps of each A on
the two sides are turned outward, and the inner turned inward, and
when the sutures are tightened the flaps are in this way approximated
as plane surfaces, and so tiiey unite. If there is much redundant tis-
sue to dispose of, the vaginal flap is turned forward and a special suture
passed through its whole width, or it may even be necessary to cut
out a V-shaped piece of it before uniting it. Between each two of
the deep sutures a superficial silk suture is put through the skin alone.
The original Tait operation is by far the most expeditious peri-
neorrhaphy, and results in the formation of a thick and broad beam
between the anus and the vulva. If there is not nuicli prolapse of
the posterior wall, it is also sufficient, and its rapid performance
recommends it in cases in wiiich several operations have to be per-
formed in one sitting.
Tait's operation lias been modified by using a scalpel and sej)a-
rating the flaps to greater depth. Then it becomes also necessary
to use a full curved needle and needle-holder.
^ Tait teaches to insert the needle well within the margin of the wound f /)(".vn.vs
of Wovien, i. p. ()7), but in my hands the sutures cut through if placed in that way,
and the skin is not accurately brought together.
332
DISEASfJS OF W03fEN.
c. T. A. Emmet's Operation} — The aim of this operation is to
lift up the pelvic floor and dispose of a so-called reetocele.
The patient is in the dorsal position, with bent knees and with
feet held up by two assistants.
First Step. — The top of the reetocele (Fig. 226, A, a) is caught
with a tenaculum and held by an assistant over to the left side of
the vulva. Another tenaculum is inserted at the caruncula myrti-
formis on the right side (b). A third tenaculum is inserted at the
posterior commissure (c). Finally, a fourtli tenaculum is inserted
at d; that is, a point so far up in tlie side sulcus of the vagina that
Fig. 220.
Diagram of T. A. Emmet's Operation for Incomplete Laceration of the Perineum.
it does not yield on being pulled down. The four tenacula being
pulled in divergent directions, a rhomboidal })art of the mucous
membrane of the vagina is put moderately on the stretch, and the
isosceles triangle, a d b, 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 to]) of which points
down toward the vulva (Fig. 227), the operator guiding himself by
introducing a finger into the patient's rectum. While they are
^ 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 OE THE PERINEUM.
333
Fig. 227.
being passed the assistant ahvays lifts the last, in order to check
hemorrhage.
Second Step (Fig. 226, B). — The top of the rectocele is carried
over to the right side, and the triangle,
afe, on the left side treated in the same
way as the right.
Third Step (Fig. 226, C).— The pa-
tient's feet being lowered to the top of
the table, the surface, a b e g — that is, all
the mucous membrane between tlie top
of the rectocele, the tMo carunculpe myr-
tiformes on the side of the vaginal en-
trance, and a curved line running a quar-
ter of an inch inside of the posterior
circumference of the rima pudendi and
parallel with it — is denuded, and sutures
are put in from side to side. One is car-
ried througli the two caruncles, h and e,
and behind the tip of the tongue of mu-
cous 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.
Emmet's Suture for lifting the
Pelvic Floor: The needle ia in-
trortiK'ed at a, pushed out at 6,
and when it has been pulled
through, it is reinserted at b
and carried to c.
Fig. 228.
Outorbridge's Suture. The BUtures are numbered in the order in wliich lli'V arc tied, not
inserted.
Fniirfli Sff'p. — The sutures are twisted, beginning from thetojisof
the triangles, d and /', and ending at //, cut oil', and ])ent backward
334
DISEASES OF WOMEN.
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 much like the
normal in appearance ; but it requires more time, more skill, and
better assistance than the other operations.
Outerbridge ' has simplified Emmet's operation by using only three
sutures. The first is medium-sized catgut, 10 to 12 inches long, armed
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-
FiG. 229.
'X«'
Tait'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
flap.
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. i!so\v this lower
suture is drawn tight and tied. Finally, tiie silver suture is twisted.
The bowels are moved on the third dav, and the silver suture removed
on the eighth (Fig. 228).
' Outerbridge, Med. Record, April 21, 1894, vol. xlv. p. 493.
DISEASES OF THE PERINEUM.
335
2. Complete Laceration. — a. Tali's Flap-splitting Operation (Fig.
229). — The cicatrix in tiie 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. 230, A), making an incision about | inch
deep, by which are formed a vaginal and a rectal flap. From each
end of this first incision another is carried at an obtuse angle, forward
and outward, into each labium majus for about an inch (Fig. 230,
B, a d and b c), and, again starting from the ends of the first, a
fourth and fifth, one-third of an inch in length, are made backward
Fkj. 230.
A
a b
Diagrams illustrating Incisions and Sutures in Tail's Operation for Complete Laceration of
the Perineum : A, first incision following the cicatricial line between rectum and vagina,
the ijuttoclis being stretcheii (nattiral size); li. incisions to anterior edge of labium majus
and outside of anus (witiiout tension) ; '', flaps thrown upand down and puton the stretch ;
sutures inserted in the order marked : the third c<)rresi>onds to tlie angle lietween tlic flaps
(the bottomof the first incision); the first goes riglit through theendsof tlie lirokcn sjiliinc-
ter ; I), continuous catgut suture carried througli the edges of the wound, now turned into
the vagina (the same as the upper edge of the Hrst incision, li, a b).
and outward (Fig, 230, /*, a f and h r) just outside of- tiie ends of
the torn sphincter.
The vaginal Hap is licld u])\vanl, the angles d a h and r }> a being
pulled by forceps diagonally nj)\vard and inward toward the median
line. Th(! rectal lla|) is held downward, the angles/ a h and v h a
being pulled in a similar manner downward and inward. Thus the
lines f//and re l)ecom(! curved with their convexity turned outward
(Fig. 230, C, (la and hb). The needle is carried as described above,
with this difference, that it is mnde to emerge Mi)ont \ inch iVom
33G
DISEASES OF WOMEN.
the bottom of the wound aud enter at the corresponding point
on the opposite side (except the hindmost closing the spliincter,
which is buried altogetlier). Tlie 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. 230, D).
li 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
aud are hard to find.
For the complete tear, Tait's operation is, in my experience,
superior to all others. It is easy to perform, takes a short time,
and yields perfect results.
b. Hegar^s Operation} — The patient is in the dorsal position.
The buttocks are pulled aside and the anterior vaginal wall lifted
U]) with Sims's speculum. A sponge soaked in antiseptic fluid, or a
pad of iodoforni gauze, may be introduced into the rectum, and
withdrawn before the last rectal sutures arc introduced.
A tenaculum-forceps is introduced at x (Fig. 231) in the median
Fig. 231.
c d
Ilegar'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 b on
tiie lower edge of the labia majora, at tlie 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 })ut on the stretch, and, beginning
' For simplicity's sake I leave tliis operation under lietrar's name, hut it has
evolved gradually in the hands of Dieflenbaeh, Simon, and others.
DISEASES OF THE PERINEUM. 337
at X, the operator draws, with the })oint of a scalpel, a curved line to
6, with the convexity turned toward himself. Next he continues the
line from b to d, 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 ti&sue. 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 force})s 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 an<l curved, 2 inches long, should be used
for the vagina and rectum. 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 ^ inch below the top of the rent, and at the
same distance from the edge, and (!arried under the raw surface above
the rent, pushed out in the malian line, reintroduced with the point
turned down in the same ])lace, 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, intnxluced in the corresponding place on the right side, and
carried down through tlie 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 s|)hincter. The rectal
sutures are (piite close to one another, about -^ incii apart, superficial
alternating with deep. Next, the lines m (i. and n h are l)r(>ught
together witii sutures ^ inch apart, alternately a deej), reaching half-
way under the raw surface", and a superficial. Finally, four or five
are |)la(XHl rather superficially on the perin(Mim. Every suture is tied
and cut imme<liately when inserted, the ends being turned iij) out of
the wav of the follo\vin<r suture.
338
DISEASES OF WOMEN.
If the tear is over 11 inches long, the upper half of it is stitched
from the vagina alone, the se])tuin 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. Tliis may be obviated by using buried submucous
catgut sutures (Fig. 232). 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
Fig. 232.
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.'
Dr. Hirst, of Philadelphia, has modified Hegar's operation (Fig.
233).^ He closes first the rectum, as a rule, with four sutures, tlie
last two of which unite the ends of the broken sphincter. Next,
he inserts a suture surrounding the whole tear in the rectum, which
suture strengthens the rectal sutures and forms a barrier between
them and the vaginal and perineal sutures. Finally, the vaginal
wound is closed with four sutures, and the perineum with three.
He uses silkworm-gut, which is knotted in the rectum and shotted
in the vagina and tlie perineum.
In a very extensive denudation it is often an advantage to wliip
the whole denuded surface together with a two-tier running catgut
suture, beginning at the upper end of the vaginal denudation, run-
ning down the deeper part of the wound, just short of the rectal
mucous membrane, and returning in the vagina to a point opposite
the original insertion, so that the two ends are joined by a single
' f!;irl Lauenstein, Centralhlatt f. Gyndk.. 1886, vol. x. p. 50.
^ 1). ('. Hirst, University Medical Mayazine, Jan., 1899.
DISEASES OF THE PERINEUM.
339
knot. Naturally the catgut suture must be inserted after the inter-
rupted silkworm-gut sutures are all in place.
Fig. 233.
■,i j.--
,'■* 't ■■
1
^M ^ A^*%^
11
J
WmJk^M
T
i
I-mT
r?^
^1
!■
■ — ^
S
"^^
-■^-4W»->»- - ^
y ■sap
'/;
/^Pf
1
4
A
The suture for a foiii])lele laeerutioii nf the perineum: A, A, the barrier or splint suture
(Hirst).
c. r. A. EinmeCs Operation. — Special care is taken to get the entire
Fici. •2:!4.
Diagram of Broken Spliinctcr Ani Muscles (T. A. Emmet): DC. first suture: HA, second
suture.
ends of the broken s{)hincter brought together. The above-men-
340
DISEASES OF WOMEN.
Fig. 235.
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. 234), 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. 235, C, D). The second suture (A, B)
is inserted at the outer end of the broken
sphincter and carrial 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. 236, 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. 236.
Diagram of Broken Sphincter Ani
(T. A. Emmet), showing how the
ends are brought together by
tightening the sutures.
Diagram for Emmet's Operation for Complete Laceration of Perineum : R, rectum : r, vagina ;
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 la.st (6) unites the tops of" the
denuded surfaces on the labia majora.
DISEASES OF THE PERINEUM. 341
If the rent in the recto-vaginal septum is ova^ 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.
Preparaiion 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. 205).
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 oystei-s, and eggs), so as to have as little
lecal 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 laxol ' (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
movement or two are brought on. Thereafter every morning just
enough laxol (about ^ij) is given to have one easy movement. The
urine should be drawn with a catheter. AVhen, after a few days,
there appears some discharge, a vaginal injection of carbolized water
(oSS to Oij) should be given morning and evening, and, in com])lete
laceration, half a ])int of lukewarm water injected at the same time
into the rectum. In consecjuenee of the pressure exercised by the
sutures against the granulation tissue formed around them, it is not
rare to see the discharge be(;ome bloody. Then a vaginal injection
of li(i. ferri chloridi, .^ss to a ])int of water, should be given three
times a day. If the ])atient is troubled with flatus, nuieh relief is
aflorded by the occasional cautious introduction of" a lubricated soft-
rubber rectal tube of the size of the little finger.
As a rule, ])erineal sutures nuist be removed at the end of a week
(comj)are Tait's method) ; vaginal, whi(;h 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 suttu'es a virginal Sims speculum and
' Laxol is prepare<l from castor oil, but is easier to take and just as etieetive.
342 DISEASES OF WOMEN.
Hunter's depressor (p. 149) 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 entmnce
of the stitch-canal. Tiie sutures should be removed from below
upward, and when the rent begins to bleed the removal of the others
siiould be postponed. But by using chromicizcd catgut we avoid
all trouble in removing sutures from the deeper parts.
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 ex])ulsiou with a noise from the same. Another
name for the same ])heuomenon is flatus vaginalis.
Etiology. — It is a rare disease, which can only develop when the
vulva and the vaginal entrance gape. It may be due to tears of the
perineum and vaginal entrance, episiotomy, loss of flesh, and vari-
cose veins in the vulva.
Treatment. — The indication is to diminish the entrance to the
genital canal by the performance of one of the operations describtd
above for laceration of the perineum, or by excision of cicatrices
and union by suture.
CHAP TEE III
COCCYGODYNIA.
Under the name " 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, ankylosis^ 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. 105), with its exceedingly rich nerve-
supply, has something to do with it. Still, this gland is found in
DISEASES OF THE PERINEUM. 343
both sexes and at all ages, while the disease is never found iu 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 tlie most common cause is childbirth. As a rule,
it appears after tedious labor with long-sustained pressure, tears, or
straining of muscles or ligaments, or after instrumental delivery ;
but it may also begin before delivery, and is then probably due to
the })ressure of the head against the last two sacral and the coccygeal
nerves. Tlie 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 eon-
sefjuence of painful caruncle or hemorrhoids.
Symptoms. — 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
tlie ligaments and muscles attached to it, intluced by walking, riding,
defecation, coition, etc., increase the ])ain 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 thuml) 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 venitrine or aconitine; blisters; cauteri-
zation ; and galvanism or fiiradi/ation with the secondary high ten-
sion current (p. 'J40) ; Ix'sidcs treatment of concomitant diseases in
neighi)()ring organs, — have eacii effected cures. Jiut cases that have
resisted all other remedies have yet been cured by the e.xiirpati<m
of the coccyx, whether diseased or healthy. This o])eration, which
may be called coccygectomy, is performed by placing the patient on the
right side or on the alxlomen, introducing the index-linger of the h'ft
iiand into her rectum, pressing it outward, and making an incision in
tlie median line, abf)ut lour inciies long, and reaching from half an
inch below the tip of'the (coccyx toone and a half inchesabove tlie base,
down to the bone. Tlie soft tissues are j)ushed aside with a bhuit in-
strument aiul a few touches of the knife, until the whole bone, inehisive
of the projecting transverse processes of the uppermost vertebra, is laid
bare. The attaciimcnts of the ijone throughout its whok; length are
344 DISEASES OF WOMEN.
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 disengiiged, and, armed Nvith 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,
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
^w. 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. 97). 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 accunnilation 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 be a serious obstacle in the way of childbirth. I^iko similar tu-
mors 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 in-
jected with the fluid. Part of the skin and subcutaneous tissue cover-
ing it may be cut off", the cavity packed with iodoform gauze, and left
to fill by granulation, changing the dressing daily. 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 bistoury,
washed out with disinfectants, and filled with iodoform gauze.
PART III.
DISEASES OF THE VAGINA.
CHAPTER I.
Malformations.*
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-oif 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, heinatometra. If the
blood is changed to pus, the conditions are respectively called pj/ocol-
pos and pyometra. As a rule, the blood forms a thick, dark l)rown,
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 periwl, and
tiie 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 toj) of which is felt the undilated body
of the ut(!rus, until, finally, this also takes part in the dilatation.
The tubes form sometimes large tumors fillwl with blood {hematox(tl-
pinx), which do 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 themselv(>s. ])iverti(!ula may bulge out from them.
They may be divided into a series of three or four compartments by
internal lamella; growing from the wall or i)y bands of peritonitic;
' I have treated tliis siiliji^ct somewhat more extensively in Atrn'riain Sij.<lcm of
Oyiuxolorpj, vol. i. pp. 2o7-278.
.145
346 DISEASES OF WOMEN.
origin, forming constricting rings without, and they may be bound
to the Avail 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. The pent-up blood 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 there is found the
meatus urinarius. This tumor is fluctuating.
Strangely enough, imperforate hymen may be found combined with
pregnancy, wliich can only be explained by supposing that there has
been a minute opening, admitting spermatozoids, which has closed
after menstrual discharge has 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 oj)ening 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 tiirough 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. Xo pressure should be exer-
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 potass^e, oSS— 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
DISEASES OF THE VAGINA. 347
fatal. The two dangers are rupture of the tubes and sepsis, the latter
of which, being so much more common, must cany 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 hiforis 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 cribriformvi.
■ 4. Double Hymen. — The hymen may be double in different Avays.
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 sliape of the hymen interferes with coition or
childbirth, the condition is easily remedied by removing the septum,
making an incision in it, or removing the whole hymen.
5. Fleshy Hymen. — Sometimes the hymen is so thick that it is
not ruptured in attempted coition, but constitutes an insurmountable
obstacle. This may cause considerable pain and become a source
of much nervous irritability (vaf/inismus).
The condition is very easily remedied by cutting the offending
part off with curved scissors and stitching the edges of the wound
together.
B. Malformations of the Vac/ina.
1. Atre.sia and Stenosis. — The word "atresia" means a lack of
lumen, and ought only to be used in speaking of a complete closure
of the vagina, whereas "stenosis" means narrowness, and may
])ropcrly be applied to any condition in which the vagina has not its
proper width. Jiut 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 retrolnpnenale), or one or more solid transverse septa may be
found higher up in the vagina, or, finally, there may be a coinplete
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 tiasue where the vagina (»ught to be.
34xS DISEASES OF WOMEN.
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
deei)er. 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 conunon than this complete closure is the presence in
the vagina of a transverse se})tum with one or more 0})enings. 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 ])roposed 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.
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 tiiere, 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
shall now consider.
If there is an incomplete transverse septum between an up])er
and a lower dilated part of the vagina, the narrow part may be in-
cised longitudinally, in the direction of the axis of the vagina in
several places, the narrow part bluntly dilated, and the edges of
the incisions sutured in a transverse direction, producing a shorter
but wider canal.
DISEASES OF THE VAGINA. 349
In a case of absence of the vagina, the first thing to do is to make
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 a uterus, and the menstrual
flow takes place internally, an operation becomes imperative, in order
to save the patient's life, and by proper care the new-formed vagina
may be kept pervious. If the ovaries are also present, impregna-
tion may take place after the formation of a vagina, but childbirth
would be impossible, or so dangerous that i^ should be prevented by
artificial abortion or abdominal hystero-salpingo-oophorectomy. If
there is only a rudimentary uterus, but ovaries giving rise to moli-
mina, abdominal oophorectomy should be performed.
Modus Operandi. — In order to make an artificial vagina, 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 incisi(m 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 introduces 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, and washes out the uterus with warm solution of bicarbonate
of sodium (.5J-Oj) and after that Avith creolin (1 per cent.).
A hollow glass plug (I ig- 237) in proportion to the size of the new-
formed vagina is introduced into it, covered with antiseptic gauze and
cotton, and held in ])lace by a T-bandage. I think it is an improve-
ment to have a hole {(i) at tlie bottom of the i)kig in order to allow
es(!ape of fluid, and one (h) on each side of the rim from which a
string goes to the bandage surrounding the ]>elvis.'
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
tiiken out and cleansed every day and tiu; vagina disinfected. li'
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-.5J). The patient
should wear tlu; plug daily for at least an hour during a whole year,
but as this is tiresome and somewhat painful, she is liable to neglect
it, and then the canal shrinks again from the uterus downward, and
it b('<!omes necessary to dilate it gradually or rej)eat the ()j)(Tati<)n,
'.fohn Reyndcrs & Co. , cor. Fourth ave. and Twenty-third st., liavo nuuic such
plugs for me.
350
DISEASES OF WOMEN.
which is still more difficult and dangerous than the first time, when
the tissue yields more easily.*
Other Methods for Keeping the Canal Open. — Instead of the per-
manent use of the plug, some prefer, after granulation is well estab-
FiG. 237.
Vaginal Glass Plug.
lished — say, the end of a mouth — 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 raucous membrane have been obtained
from the vulva and used with success. Thus, Kiistner cut loose the
^ On Jan. 25, 1890, 1 operated on Annie K , American, fifteen and a lialf 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 tiie rectum was felt a hard, slightly
elastic swelling, nearly filling the pelvis, especially in tlie left side, and extending
up into the left iliac fossa. 1 had to form a vagina to the full length of my index-
finger, 2h inches, and tliere 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. Tliere 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 j'ellowish mucus, mixed with old blood, flowed out. The tumor
diminished, and was washed out as stated in the text. She imy>roved immediately,
and made a good recovery, and menstruated three times while she was under my
observation. Slie was ordered to use her glass plug one hour every day, but soon
got tired of it. When I saw her again, about a year later, the upper lialf of the
vagina had contracted again to the size of a cervical canal, just admitting the sound.
On May 30, 1895, after slie had grown to be a big, stout woman and had married, I
formed again a vagina in the same way as before. Ten months later there was still
a vagina as long as the index-finger, and beyond that a probe could be introduced 1^
inch farther. Since she had not menstruated for four months, and ha<l pain in the
left side, 1 advised abdominal hysterectomy, but she passed into other hands.
DISEASES OF THE VAGINA.
351
labia minora to their posterior end, split them open by a longitudinal
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 anotlior patient. The new-formed vagina has also
successfully been lined with portions of the vaginae of other patients
upon whom colpoperineorrhaphy had been performed.^
Dr. Burrage, of Boston,- in a case of absence of the uterus,
formed two lateral and posterior flaps, and thus obtained a vagina
4^ centimeters deep, which by use was deepened to 5^ centimeters,
and satisfied both the patient and her husband (Fig. 238).
The orifice of the rudimentary vagina is shown on line ef. An
incision was made along this line and prolonged at each end, so that
Fig. 238.
Formation of a Vagina (Burrapo) : a h f and r <i e, lines of incision for flaps fioni laliia
minora; e rf and /6, lines of incision for perineal flap; r/, line of incision for excava-
tion for new vagina.
it m(;asured about 3 centimeters in length, splitting the riKliiucntary
vagina into halves. With a finger in th<> re<;tum and a .m)Iuu1 in the
urethra for guides, tlie recto-urethral s('])tum was split by dissect-
ing with scissors and finger for a distance of 5 centimeters. At
that point the finger in the wound was aj)))arently sej)ar:ite(l iVom
the intestines by a sheet of jx'i'itoneum only, and it was impossible'
to feel any tissue that might represent the uterus, ovaries, or tubes.
In order to covc-r the raw surfaces fi)rmed by the dissection, fhips
were formed as follows: The nymplue were cut off ;it n li :ui<i
' Mackenro.It, C-ntnilhl. f. Gyiwk., ISyO, No. '1\, p. :A(\.
^ W. L. JUirrage, Aim-r. Jour. M,<l. Sci., Marcli, IS'j;.
352 DISEASES OF WOMEK
e g, and then incisions made through mucous membrane along the
lines hfb and g e d. The two lateral flaps formed in this way
were dissected free, and by so doing the nymphie were split from
their posterior aspect and unfolded. The posterior flap, represented
by the surface enclosed between the letters d e f b, was formed
by dissecting deeply the tissues of the fourchette and perineum, so
that this flap could be dragged upward and inward to cover the
posterior surface of tlie new vagina. The strip of mucous mem-
brane that had been the posterior half of the rudimentary vagina
was dissected away, and the posterior flap anchored by suturing its
tip at the uppermost part of the new vagina with a catgut stitch.
In the same manner the two lateral flaps were disposed of. The
little strip of mucous membrane on the anterior wall was utilized
by stitching the lateral flaj)S to its edges. The operation was com-
pleted by sewing together the edges of the mucous membrane and
the stumps of the nymphae and at the places where the three flaps
came into apposition, with fine interrupted sutures of catgut.
The after-treatment consisted in keeping the vagina packed with
iodoform gauze. After healing, a dilator was made of a rubber
finger-cot stuffed Avith cotton. This was worn constantly, being
kept in place by a T-bandage.
The treatment of general narrowness consists in gradual dilata-
tion 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.
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 Miillerian 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 band as remnant of the original septum between the Miillerian
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 lengtliwise. Both halves are distended wath 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 gal va no-cautery.
DISEASES OF THE VAGINA. 353
A mere band oftener causes dyspareunia and dystocia than a com-
plete partition, 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 preferable to tie near the two ends and cut
out the middle piece.
Double Vagina icith 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 thaa
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 i)urulent or putrid [lateral pyocolpo)^ and
p}loinetra),i\n(\ causes inflammation and uktcration 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 ])ain, a
new discharge takes ])lace through the opening in the septum.
Diaffnosia. — For diagnostic ])urposes, it is of importance tliat
pressure on the vaginal tumor causes a jiurulent discharge through
the OS uteri of the open half of the vagina.
Lateral atresia has been taken for licinatocele, but the history of a
chronic disease with monthly exacerbations, and the shape and ])osi-
tion of the tumor, will help to avoid this mistake. In lateral atresia
the tension of the wall often varies at ditl'crent times, and if it is
not very gnsat, it is sometimes ])ossible to invaginate the lower ])art
of the tmnor and feel the muscular ring formed by the os.
If the septum is situated very high n|), the tumor may also be con-
founded with cij.sl.s adherent to the utei'us or a iiii/oma. in the wall of
the latter. An exploratory puncture may become necessary to settle
the diagnosis.
Treat innd. — Sims's speculum is introduced in the open halt', and
thesej)tiim slit open with knife, scissors, or preferably thermo- or gal-
vano-cautery. In cases of double atresia one side is lir-t opened, as
in atresia of the single vagina, and allerward the septum incised.
.'). lUiiul (jinals. — Imme(li:itely al)ove tli(,' entrance of the vagina,
laterally, are occasionally found l)lind canals, which may be ;ui inch
and a half long and wide enough to admit the little fmger. Tliev are
2.3
354 DISEASES OF WOMEN.
lined with smooth mucous membrane, and are probably only unu-
sually developed lacunae. 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 uece&sary to lay
the canals open.
4. Faulty Communications. — Familiarity with the history of devel-
opment (p. 81) allows us to recognize as consequences of developmental
arrest certain abnormal conditions sometimes met with. Thus we
have complete atresia — i. c. 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.
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 may
be made; but if there is a sphincter, it may lose its innervation,
and the patient be left in a worse condition than she was before.
In very rare cases there is a normal anus, but a communication
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 ope) is into the vagina instead
of the bladder. This may be loosened and fastened with sutiu-es in
the wall of the bladder.'
CHAPTER II.
Vaginal Enterocele.
Vagixae Enterocele, or vaginal hernia, is a tumor formed by
the intestines, and sometimes the omentum or <narv, 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 })rotrusion begins in Douglas's pouch, but it may also
' W. H. Baker, of Boston, New York Medical Jourrud, Dec, 1878.
DISEASES OF THE VAGINA. 355
occur between the uterus and the bladder, or in the scar left by
vaginal hysterectomy. It may extend into the posterior part of the
labium majus, forming a vagino-labial hernia (p. 279).
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 Avhen it is being pushed (lown in front of the presenting
part. On examination, a pear-shaped, soft tumor is found protrud-
ing in the lumen of the vagina or (lescending 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 tympanitic percussion-sound.'
Diagnosis. — It has been mistaken for a uterine poh/pu.-^ — a mistake
that seems impossible except in consequence of unpardonable 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
Hoifmann's, Fowler's, Garriel's, or a globe-sliaped one which will
be described in treating of the uterus. Thomas has pcrlbrmed lapa-
rotomy, inverted the sac, and fastened it in the abdominal wound.
Perhaps colporrhaphy (p. 360) may succeed in retaining the intes-
tines in the pelvic cavity. As a last resort, the sac may l)e opened,
superfluous tissue cut away, and the edges united by interrupted
sutures.
Prolapse of the intestine into an unusually deep Douglas's pouch
(p. 94) is a somewhat kindred condition, which may give rise to
constipation, a sensation of weight, and other discomfort. The intes-
tine may j)erhaps l)e kept up by one of the above-named l)ulky
vaginal pessaries, li' this does not succeed and the condition causes
<.'onsi(leral>le trouble, an incision may be made in tiie posterior fornix
and the pouch closed by a contimious suture of catgut.
' On !ii'coiitit of the preat rarity of this aflection tlie foliowins; notes of the only
case I liave ever met with may be of interest: Kliso V., set. 27, widow, nnipara,
of robust appcaranee and excellent cfmstitutirin, applied at tlie (icrman I)isiiensary
on < )ctol)er l(t, 1H!);>. Slu; had l)een perfectly well until three weeks before 1 saw
lier, when she fell down into a cellar and struck tlu> riuht side of the abdomen
against a wooden box. Since then she had bloody dischar^'e from tiic ulcriis and
alKlominal jiain. I'y vajrinal examination the uterus was found retrotlexed and
very tender, hut it eoidd ea-ily be replaced, in the left and posterior w:dl of the
fornix was found a soft elastic tumor of the size and shape of a hen's cj;j^ and very
tender. It could be i)artially jiushed iiack into the abdominal cavity, wlieu a sharp
oval ring was felt surroun<liiig it, probably an opening in the |(elvie fascia.
356 DISEASES OF WOMEN.
CHAPTER III.
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 nniscle 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 }irola])se 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
always follows the anterior wall of tlie vagina more or less in its
descent.
Causes^ — By far the most common cause of this disj)lacement is
childbirth. During pregnancy all the constituent parts of the vagina
awd the surrounding connective tissue grow and become infiltrated
with serum. During childbirth these parts are bruised and torn.
During tiie lying-in period, and when the patient gets up, the weight
of tiie accumulated urine presses on the yet soft and yielding anterior
vaginal wall. If the perineum has been ruptured or the vaginal
ring (p. 320) is l)roken or over-distended, there is a still greater lack
of support from below. The increased weight of the vagina itself,
due to subinvolution, 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), thC'
bladder forms in front of the uterus, which hangs between the thighs,
a large soft swelling.
Treatment. — Elinor degrees of cystocele may be successfully
treated with astringent su])positories or injections, by electricity, by
rc})airing a torn perineum and a posterior vaginal wall, and by a
general tonic regimen. More pronounced cases call for direct sur-
gical interference. These operations are called anterior co/porr/icip/ij/^
DISEASES OF THE VAGINA.
357
Fig. 240.
It may be median, lateral, or bilateral. The median operation may
be performed according to Sims's method.
Sims's Method (Fig. 239). — The patient is in the dorsal position,
the knees drawn up and separated by means of Clover's crutch or
Kobb's leg-holder (p. 208).
The posterior wall is pulled
down with Garrigues's spec-
ulum, a bullet-forceps is fast-
ened in the median line just
below the point corresponding
to the inner end of tiie urethra,
which is marked by a trans
verse ridge (Fig. 240), and
another at the lowest point
near the cervix. The opera-
tor seizes the mucous mem-
brane of the anterior wall of
Fio. 239.
Diagram of Sims's Cystocclo
OiHsrution : duiiudirtlon by
cnttiiiK 'iff the loiiKiliHliiial
strii)S of mucous membrane
witfi scissors.
Pawlik's Vafrinal TriRone, correspond inp to Lieutaud's ves-
ical trifrone: A. lal)ia minora: O, meatus urinarius ; O'.O',
uretliral lcdf?e ; .S, S, lateral folds correspondingtothesides
of the vesical trigone; /{, fold corresponding to the basis
of the vesical trigone ; V, vaginal portion of uterus.
the vagina somewhere near the lateral sulci with two tenacula, and
draws them together. Thus lie ascertains how much tissue is redun-
dant, and makes a suiji with a pair of scissors on each side, in oi'dcr
to mark the great<'st width of tlu." surface to be denuded. Just out-
side of these |)oints he inserts a tenaeulum-forceps, so that the wlioh;
surface to be ])ared may i)e ]iut on the stretch. With a ])air of scis-
sors curved on tlie flat a strij) of mucous membrane about ] inch
wide, and extending from the lower forceps to the uj)per, is cut olf.
Similar strips are cut ofl' j)arallel to the first on the right side until
358 DISEASES OF WOMEN.
tlie 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, a running suture
of chromicized catgut (Leavens, No. 2) is passed under the whole
denuded surface, uniting the edges. It is very convenient to use
irrigation instead of sponges (pp. 186, 209, and 238). This metliod
leaves a linear cicatrix in the median line.
Walking'' s Method ^ 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.
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 M'all of the vagina, to a point beyond
the prolapse. This point corresponds to the internal opening of the
urethra, or the denudation may extend even as far back as the
lateral aspect of the cervix uteri. The breadth of the denuded sur-
face 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 vcsico-vaginal
septum from tliis point outward 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 which sometimes is a distressing feature of cystocele and
urethrocele. (Compare Pawlik's operation for incontinence, under
Urinary Fistula.)
^ T. J. Watkins of Chicago, 111., Jour, of Gynecology, Toledo, O., Aug., 1891, vol. i.
No. 5, p. 305.
DISEASES OF THE VAGINA. 359
Gersuny's Method. — Experience having shown that in the course
of time the linear cicatrix formed in Sims's operation is apt to give
way, Gersuny has tried to fortify it by the following procedure : A
median incision is made from the cervix to the tuberculum vaginaj.
The flaps are separated from the bladder as far as, or beyond, the
limits of the cystocele. Next, the wound corresponding to the base
of the bladder is closed with three or four tiers of running forma-
lin catgut sutures, which produce a longitudinal ridge in the blad-
der, which can be felt with a sound. Finally, the superfluous tissue
is cut off from the vaginal flaps, and the edges stitched together.
For the last stitch interrupted sutures are preferred.^
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 jiatient should stay in bed three weeks.
Cyntopcxy. — A new French operation for cystocele, by which the
anterior wall of the bladder is fastened to the abdominal wall, has
been performe<l several times with success. Tiie bladder is injected
with Ave ounces of solution of boraoic 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.
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 pmlapse of the vagina. It is commonly
called "rectocele," but this name is only used correctly, if the })ro-
lapse contains the rectum, which, as a rule, is not the case. The con-
nective tissue between the rectum and tlic 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. IJy pinching this fold and by intro-
du(;ing a fing(ir into the rectum we can easily satisfy ourselves that
this is so, JJut in tlie course of time the anterior i-ectal wall, lacking
its normal support in front, may become distended and form a pouch
descending inside of that formed by tlie vagina.
' R. fiersiiny, Centralbl. /. Gyndk., 1897, vol. xxi. No. 7, p. 177.
360 DISEASES OF WOMEN.
Etiology. — The causes are similar to those enumerated for cysto-
cele, except the weight of the bladder, for which here is substituted
constipation.
Si/mptoms. — 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.
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. On account of the
looseness of the connective tissue between the vagina and the rec-
tum, instead of cutting the mucous membrane off in strips, the
whole vaginal wall may be separated bluntly and circumscribed
with curved scissors. As a rule, the perineum and the vaginal
entrance have been injured, and the operation called for is colpoper-
ineorrhaphy. (See pp. 327 and 336.) By a little ingenuity, inter-
mediary forms of denudation between that of posterior colporrhaphy
and colpoperineorrhaphy may be adapted to particular cases.
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-off epithelial cells, if the parts
are not kept clean, form a white, malodorous smegma in tiie 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.
CHAPTER V.
Injuries; Thrombus or Hematoma.
The tear in the hymen produced by the first coition may cause a
severe and even fatal hemoi-rhage. 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. 175 and 176).
In order to prevent its recurrence, the tear should be given time to
DISEASES OF THE VAGINA. 361
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
vaginal entrance to the fornix. Tears are occasionally produced dur-
ing coition with women wlio have had frequent intercourse or even
borne children, but then tliere is a strong suspicion, sometimes cor-
roborated by confession, that some hard object has been introduced
simultaneously witli the pern's. 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 jwstures during tlie act.
During childbirth the vagina is quite frequently torn. In most
cases the lesion extends only through the mucous membrane, and is
then of little importance, but it may ])enetrate through the whole
thickness of the wall into the surrounding connective 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 forccj)s,
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 st(?j) on a staircase has indirectly caused a tear of the nuicous
membrane of the vagina.^
Sipnptoms. — 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
the sympton)s of septicemia may be developed. A permanent recto-
or vesi(;o- vaginal fistula may remain.
J'rof/no.si.s. — Witli proper surgical help the ])rospects are good.
Trcaduent. — The vagina is cleaned of clots, spurting arteries tied
with catgut, the edges of the wound united with sutures, and a few
})le<igets of icKJoform gauze placed over the wound. These are re-
newed ubout every three days,
Thromhui^ or hniKtioiiia is a swelling formed by the extravasation
of l)lood in the coinieetiv(> tissue surrounding the vagina. It is
nearly always due to childbirth, and the reader is, therefore, referred
to works on oi)stetrics for information concerning it.
' Centralbt. fiir (iyniik., 1802, No. ?>\, xvi. p. 014.
362 DISEASES OF WOMEN.
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 divei-se 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.
The writer has found an imperforate shot. 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 hy|)ogastric 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.
Diagnosii. — 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 wnth 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
body and in combating the inflammation and other disorders caused
by its presence. While the first indication in most cases is simple
enoutih to fulfil, in others all the ingenuitv 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 nmst be
remembered that tliev almost invariablv are introduced with the ends
DISEASES OF THE VAGINA. 363
pointing downward to the vulva, which ends must be freed before
the pin can be extracted. Sometime^ 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 witli them
that may be withdrawn without cutting the vagina.'
The second indication will in most cases be met by using antiseptic
and astringent vaginal injections. Sometimes a consecutive endo-
metritis calls for treatment, and in rare cases fistula operations, or
even laparotomy, may be required.
CHAPTER VII.
Vaginitis.
Vaginitis is tlie 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 such very different
conditions that it is necessary to admit certain divisions and sub-
divisions of the subject, which is done in many diffi^rent v.ays by
different authors choosing different standpoints.
Thus we distinguish between acute and c/u'o?i/c vaginitis, the differ-
ence being not only limited to the time the disease lasts, but also to
the greater and lesser intensity of tiie symptoms. Tiie 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 tliis organ from another ])art
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 {diphtheritic vaginitis) ;
and ph/cf/moiious vaginitis, also called dbisectiiir/ vaginitis or jjeri-
va</initix, in which the inflammation has its scat in tlu; connective
tissue surrounding tin; vagina, and leads to the severance; and expul-
sion of^ the whole tube.
As sulxlivisions we unite under tlie term "catarrhal" the following:
* K. J. Levis of Pliiladelphia.
364 DISEASES OF WOMEN.
forms of vaginitis : 1, the granular (also called follicular, or glandu-
lar) ; 2, the .simple ; 3, the adhesive; 4, the gonorrheal; 5, the exfoili-
ative ; and 6, the emphysematous vaginitis. To the diphtheritic
vaginitis belongs the dyseuteric.
A. Catarrhal Vaginitis. — Pathological Anatomy. — In granular
vaginitis the epithelium as a whole becomes thicker, the papillae be-
come larger, and circumscribed groups of small round cells are formed
under tiiem and send proliferations into thera. When tiie papillae
increase in length and width, the ej)ithelial cover immediately over
tliem, 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 toj) form on the surface of
the vagina circular prominences as large as lentils.
In simple catarrhal vaginitis a similar process takes ]ilace on a
smaller scale, so iliat the cell-groups and the swollen papillae remain
under the level of the epithelium. In the chronic form pigment is
imbedded in the deeper cells of the epithelium.
In the lowest portion of the normal vagina are found numerous cocci
and bacilli ; the upper portion is free. The acid secretion of the vagina
kills the microbes or deprives them of their virulence ; but under
favorable circumstances they regain it and may cause inflammation.
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 tlie seat of ecchymoses and superficial
ulcerations, and there is great tendency to coalescence between the
surfaces lying in contact with each other. 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 diplocoecus found in the interior of the
epithelial cells and of pus-c()rj)uscles, and is characterized by becoming
decolorized by Gram's method.^
* Gram's Method. — The cover-glass smeared witli the substance to be examined is
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 cc. of 97 per cent, alcohol and 1 cc. of a saturated alco-
holic solution of gentian violet. The excess of fluid is drained ofi' from the cover-
glass with filter-paper. Next, the cover-glass is placed for five minutes in Gramas
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.) •
DISEASES OF THE VAGINA. 365
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 fistuke, or by an acrid discharge coming down
from the uterus or from a pelvic abscess. The real morbific agent
is, according to modern science, to be sought in infection with bac-
teria. By far the most common cause of the acute form is infec-
tion Avitii gonorrheal discharge in whatever way the infecting
principle may enter the vagina.
Syinptovis. — The patients have a disagreeable sensation of heat in
the vulva and the vagina. They have pain in the j)elvis and the
groins, which increases by walking or any other exercise. They com-
plain of general malaise, and are oft(Mi feverish. Micturition is ac-
companied by a burning sensation. Defecation may also be painful.
The vagina is so tender to the touch tiiat the introduction oi'a specu-
lum causes great ])ain, and sexual intercourse becomes imjjossible.
The mucous meml)nine is red and swollen. At first it is dry, but
in a day or two a discharge begins, mIhcIi first is nuicoid, then muco-
purulent, and finally consists of thick creamy j)us. The vaginal ]H>r-
tion presents a dee|) red arecjla around tiie os, which easily bleeds on
being wnped, and a plug of thick muco-puruU'nt matter is seen in the
cervical canal. J>y |)ressing on the urethra a di"op of pus is commonly
brought out. The inflamiiialion is aj»t t(» remain long in the upper
part of the vagina. Sometimes it sj)reads to the vulvo-vaginal or the
inguinal glands, where it may end in res(»lution or induration, or
cause the formation ol' an abscess. At the menstrual periods the
symptoms of vaginitis are apt to l)ecome more marked, and a decided
exacerbation is caused by pregnancy and chiklbirlh.
In r/iroiilr r(if(irr/i(i( r(i(/iiiili.s the symj»tonis have much less
intensity. The patient may, however, complain of a sensation of
heaviness or smarting. Tiie chief" symptom is the dischai'ge, which
sometimes is mon; 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 niuc(»us membrane is thickened, folded, and often more
or less j»roIapsed.
366 DISEASES OF WOMEN.
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 f7'om the interior of the
icomb due to endometritis, chancer, 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 preseiice of purulent
ophthalmia in children of the family makes the gonorrheal nature
of the vaginitis probable, the germs of the disease having been carried
to the children on 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 ])unishraent. 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 and the
urethra are implicated ; there is greater tendency to inflammation of
Bartholin's glands ; the development of vegetations, if the patient is
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.
DISEASES OF THE VAGINA. 367
The most conclusive proof is thought to be the presence of gonococci,
but there are as yet such great differences between the views of bacteri-
ologists on this subject tliat it would be unjustifiable to base on the bac-
teriological investigation alone an assertion which may cause the con-
viction of an innocent man accused of rape or cast the opprobrium of
infidelity on a faithfid 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 yeare. 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
plicfe j)almatfe of the cervical (^anal, in Bartholin's glands, in the
urcithral ducts, and in the smaller vestibular glands, so that it is
hardly possible to j)rogn()sti('ate 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 cajjital operations,
but it jeopardizes of itself the life of a patient. Kveu in children
it has l)e('oine nccessiiry to remove the appendages of the uterus on
account of pvosalpinx due to gonorrhea. Apart from the danger to
life and health, it is likely to cause sterility by closure of the tulx's or
by imbedding the ovaries in exudative inflammatory masses. If the
woman conceives and gives birth to a child, the chances of her
catching ])uerperal infection are mucli increased, probably because
the presenc(,' of" gonococ(;i facilitate the development of pyogenic
microbes, and there is great danger of ophthalmia develop! nic in
the child.
Trcdliiunt. — I'atients affected with severe acute viiginitis should
stay in bed for eight or ten days, or at least lie quietly on a lounge,
riiey should be given a saline aperient. Their diet should be bland
in (|uality and mcMleiate in amoinit. A'aginal injections of plain hot
water .should be given, and in order to reach all the recesses of" the
368 DISEASES OF WOMEN.
vagina it is best to stretch it by means of a wire speculum — e. g.
Blakeley's resilient speculum. If tlie 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
S(xla 3j to Oj, with addition of tinct. opii 5J). 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 : 2500) or
chloride of zinc (1 : 100) are used. In pregnant women it is better,
on account of the risk of merciu'ial 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 i\ni vagina
with nitrate of silver in substance or in a strong solution (3ss-5j)
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 : \Q), tannin (1 : 8, see p. 183), is introduced, and
changed every day. Iodoform 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 vaginae, and retained by means of a
tampon. In regard to the treatment of the accompanying urethritis,
see p. 287.
AntihlennorrJiagic drugs (ol. santali, bals. copaivse, 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. piui 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 m itli pure
carbolic acid, and dressed with iodoform gauze. For further infor-
mation the reader is referred to the chapter on Leucorrhea (p. 268).
Exfolintive, 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 clianges
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.
Astringents make tlie condition worse. General treatment, espe-
cially with bromide of potassium in large doses, has had better effect.
DISEASES OF THE VAOINA. 369
Emphysematous Vaginitis (Colpohyperplasia Cystica — Winckel). —
Although not very common, this disease is frequent enough to have
been observed by a number of 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 and on the vaginal
portion of the neck of the womb of numerous translucent, pink,
gray, or bluish, soft cysts, varying in size from a millet-seed to a
hazelnut. They are situated superficially, and are filled with gas.
Some have a central depression. Sometimes they give a crackling
sensation like emphysema. When pricked, the gas escapes with a
distinct wiieezing sound and the cyst collapses. The disease is most
common in pregnancy, but has been found in virgins, but only
in women suffering from profuse catarrhal discharge. It does not
give rise to any symptoms, except that the introduction of the
speculum is painful, and it disappears within three months after
cliildbirth.
The gas cysts are formed in the lymphatic vessels or the connec-
tive tissue, and have, therefore, sometimes an endothelial lining, and
in other cases not. The disease is due to a bacillus, which produces
gjis and may be cultivated on gelatin.
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 ])()ur dilute hydrochloric acid
(1 per cent.) through a I\'rgusson speculum on the atfected parts, or
use injections of solutions of boric or carbolic acid, or corrosive
sublimate.
Mycotic, Va(jinitu. — Two kinds of fungi may grow in the vagina
— namely, Leptothrix vaf/inalis and O'idium albicans. I^eptothrix
consists of fine threads with oval spores. Oi'dium lias hair-like
branches. It is pr()bal)ly the same fungus as tiie one forming
tlirush in the mouth.
Syiiipfonis. — Leptothrix iiardly gives rise to any discomfort.
Oi'dium causes sometimes intense pruritus, a burning sensation,
swelling, discharge, and even fever. The disease may end in a few
days, but may also last several weeks or months, especially in ])reg-
naut women. The mucous membrane of the vagina is red, teiidef,
and studded with small white spots, which cau only b(> removed
together with the ej)ilheliiuii, atid luider the microscope prove to be
composed of hy|)iia' and sj)ores.
FJinlof/y. — Vaginitis and j)reguancy predispose to the developnxiit
of fungi. These mav be directly brought in during coition with men
affected with (Iial)et<'s, a disease which fre(|uently is accompanied bv
the presence of finigi between the prepuce and the glaml. 'fli(\ ni:iv
21
370 insEAsr':s of women.
also be carried on fingers that have handled flour — e. g those of mil-
lers or bakei"s.
Proqiiosis. — 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. 217). 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 Vaginitis. — 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.^
It is not settled whether this condition is always identical with
the process that takes place in the throat in the disease called dijih-
theria or not. The Klebs-Loffler bacillus has, however, been found
in the vaginal exudate.^
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.^
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 tiie puerperium, there is imminent danger of
general infection, wiiicli 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-
* For further detnils see Garrigues, "Puerperal Diphtheria," Tram. Amer. Gijn.
Son., 1885, vol. x. p. 9(j.
2 B. C. Hirst, T>'xtbo.>l: of Obstetrics, Philadelphia, 1898, p. 717.
•* Garrigiies, " Corrosive Sublimate and Creolin in ( )bstetric Practice," Amer. .[our.
Med. Sci, 1889, vol. xcviii. p. 115.
DISEASES OF THE VAGINA. 371
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 gai)iug vulva, through which the dysenteric proce&s
extends into the lower part of the vagina. Small gray membranes,
com}X)sed 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 — es]^)e-
cially by regulation of diet, astringent medicines, injection with a
teaspoonful of subnitrate of bisnuith in a cui)ful 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
di«,Hecting vaginitis, in mIhcIi 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 aflection
have been reported. They appeared in the course of severe feverish
diseases, such as typhoid fever, ])neumonia, perhaps gonorrhea, and
the affection in all came on imnicdiately after menstruation.
Symptoms. — The ])atieiit coiiijjlains of more or less intense pain.
There is a sanious discharge. 'J'he lai)ia 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 graiHilati(»n, and considerai)le stenosis is liable to
follow.
Treatment. — A tampon soaked in camj)hor emulsion —
H. Cani|)liora\ 5ss;
Mucilag. acacise, .SJ ;
A(pne, ,5iv.
M.— Sig. Shake well-
should be ke|)t in the vagina until all necrosed tissue is se|)aratod.
The s(!j)aration should be aidecl In* cautious pidling and cutting of
rasistant siiicwv strings. After expulsion the surface should l)c dusted
with {(xloforin or smeared with iodoform ointment, and stenosis should
be guard(Kl against by the use of tampons and the frequent introduction
of a sj)cculum.
372 DISEASES OF WOMEN.
2. Another form of phlegmonous vaginitis is caused by the burrow-
ing of pm from a pelvic abscesfi. 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.
Treaimcnt. — 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 gonorrheal. 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. 184). It may
be due to pressure of the head of the child if, in cases of mechanical
disproportion between it and the pelvic canal, impaction 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. The separation of
the necrosed plug leads 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 trans-
mission of toxic material from the cheek to the genitals. It may
also be brought about l>y diphtheritic vaginitis (p. 370).
Morbid Anatomy. — The whole mucous membrane, inclusive of that
' Aristides Agramoiite, M':(i. Record, Jan. 11, 1896.
DISEASES OF THE VAGINA. 373
covering the vaginal portion of the uterus, may be changed to a black,
pulpy malodorous mass, and the destruction may extend more or le&s
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 tam}>on
with the above-mentioned camphor emulsion (p. 371) or a saturated
solution of chlorate of pota.sh left in it. Dead tissue should be
removed as soon as feasible. The grranulatino; surface should be
dusted with iodoform or smeared with iodoform ointment, and care
taken to obviate stenosis (pp. 349, 350). 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 meml)rane 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 smeared
with ^9-naphtol vaseline (gr. xxv-5J), in conjunction with the general
treatment of erysipelas.
CHAPTER X.
ClCATRICE-S.
The vagina is often the seat of cicatricial tiasue, resulting from
inflammation, ulceration, or gangrene.'
Etiology. — The most common cause is a laceration and sloughing
occurring in childbirth. Cicsitrices may also be formed by the use
of caustics — e. <). chloride of zinc for dij)lithcritic ulcers (j). 370).
Unsuccessful plastic o|)erations, where large surfaces heal by granula-
tions, leave also large seal's.
Symptoms. — The pres<'nce of such cicatricial tissue may give rise to
' A valuable t)aj)er on this subject by Skene, witli important remarks by T. A.
Emmet, is found in Tran.i. Amer. Gyn., 187(), vol. i. p. 91, et scq.
374 DISEASES OF WOMEN.
pain, which, although the lesion is permanent, may be intermittent or
remittent. This })ain is probably due to irritation of fine nervous
fibrillse enclosed in the scjir. By reflex action neighboring organs
often l>ecome 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 tlie 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
fistulffi.
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 })rophylaxis 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 wiiich 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. 350), or better by Boze-
man's vaginal dilators, consisting of cylinders of hard rubber with
rounded ends and attachment for a string. Othei's recommend slip-
pery-elm bark made into a roll and beaten till it is soft. Before
DISEASES OF THE VAGINA. 375
introtluction it is dipped in carbolizal water (I per cent.). It swells
slowly and promotes healiu<r.
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 even be developed in women
who have borne children.
Etiology. — Nearly always some palpable local disease is found in
the genitals or the neighboring organs, such as an inflamed hymen,
irritable caruncuhe 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, endometritis, displacement of the uterus, or pelvic
inHamraation. 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 ])ain in the female. Lead-poison-
ing is also said to produce vaginismus.
HymptomH. — In superficial vaginismus it is not only the attempt at
coition that brings on a spasm of the muscles surrounding the vagi-
nal entrance, and thus prevents the introduction of the penis, but the
spasm is observed when the physician tries to make a digital examina-
tion or introduce a speculum ; even the slightest touch with 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. Sometimes the
sphincter ani muscle may enter into a similar condition, or even
general convulsions of the whoh; body be added. I have seen opis-
thotonos arise which would have suiliced to throw any man aside.
Deep raf/iiiismn.'<, alsoealled peiii-s cftpfirus, is a much rarer alfeetion,
consisting in a similar s|)asm in the (lej)th of the vagina. It occurs
during coition or during a digital examination. Xodifliculty is exj)e-
rienced at the vaginal entraiu^e, but in the depth of the tul)(> a resist-
ance is met with in the shap<' of a tetanically contracted circular band,
which prevents further progress. Jf the spasm occurs after full intro-
376 DISEASES OF WOMEN.
duetiou of the penis, the corona is encircled, and the attempts to
withdraw the penis cause great pain to both participants in tlie
act.
Prognoms. — If neglected, vaginismus is a source of great physical
and mental misery; if pro})erly treated a cure may always be effected.
Treatment. — If one of the above-named causes is found, it nmst
first of all be removed. Fissures of the hymen, vaginal entrance, or
anus are best treated with })ledgets soaked in a 4 jier cent, solution of
chloral hydrate. Others recommend ointments with opium, bella-
donna, or other narcotics. Neuromata, urethral caruncles, and car-
unculoe 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 —
I^. Cocainaj hydrochlorat., gr. xij ;
Ol. theobromatis, 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 aifections 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 5j), and
the application twice a week of a solution of nitrate of silver (gr. x
or XX to 5j) to the vulva and hymen, followed by cold, and later
lukewarm, applications.
The galvanic current, with the soothing positive pole on the aifected
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. Hydrotherajiv and
bicycling are also very useful in drawing away the abnormally con-
centrated 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 pluri valve speculum. As after-treat-
ment a vaginal glass plug (p. 350) 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. 377
plete recovery. In other cases it is necessary 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 scissore 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 ?ine
through the {jerineal body that often takes place in childbirth (T. G.
Thomas).
The deep vaginismus is treated by attention to the cause, especially
a granular os, by the 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 tlie subsidence of the
spasm or of the erection allows an easy withdrawal. If ether is
available, the mere administration of it would probably end the
spasm, even before anesthesia is produced.
378 DISEASES OF WOMEN.
CHAPTER XII.
Neoplasms.
1. Cysts} — 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
e^g 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 (J^ 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 Avithout epithelium.
The contents may also vary very much. They may be serous or
purulent, citrine, yellow^, or chocolate-colored. Sometimes they do
not contain form-elements ; in other cases wc 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 tli rough 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.^ 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-
^ An exhaustive paper on the subject bv Dr. G. W. Johnston of Washington, D.
C, can be found in Arner. Journ. Ohat., 1887, vol. xx. p. 1121.
^ Garrigues's report on a cyst extirpated by Dr. K. Watts, Amer. Jour. ObM., 1881,
p. 849, and a note on Gartner's canals in Xew York Med. Jour., March 31, 1883, vol.
xxxvii. p. 348.
DISEASES OF THE VAGINA. 379
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 tlie
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
layers.
Treatment. — The best way is to extirpate them and unite the
edges by suture. 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.
Tlie most prominent point is seized with tenaculum-forceps or a
volsella and the anterior wall of the cyst cut off' with the cover-
ing 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 exfoliatetl. 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-eautery, and treat the parovarium with
iodized injections and a drainage-tube.'
2. Fibroids {Fibroma, Myofibroma, Fibromyomci). — Fibrous tumors
of the vagina are rather rare, esix'cially when compared with their
frequency in the uterus. Their most common seat is the u|)j>er 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 unstrijied nuiscular
fibers. Their starting-point may be in the subnuicous or perivaginal
connective tissue or in the muscular coat of the vagina. Sometimes
a fibroid in the recto-vaginal partition is in reality a uterine fibroid
' Ainaiid Uouth. VVari.". 0/>.'-7. Soc. London, vol. xxxvi.
380 DISEASES OF WOMEN.
that has developed downward, just as, on the other hand, a true vagi-
nal fibroid may extend into the vulva.
According to the j)redoniinance 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 meshwork 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 tumoi*s are called fibroid vaginal polyjn. 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 6craseur 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.
Lastly the tumor is cut off. Any of these methods prevents hemorrhage.
DISEASES OF THE VAGINA. 381
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,
d part of the mucous membrane covering it is included between two
.nirved 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. If a cautery is used, the
wound must be packed with iodoform gauze.
3. Mucotts Polypi. — Rarer than the hard fibroid polypi are soft
growths of similar shape, in structure like tiie mucous, or glandular,
polypi so common in the cervical canal. They give rise to the same
symptoms as fibroid polypi. They are verj' 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 two forms —
one c/rcuwi.<?cr/6p(^/, forming interstitial globular tumors like fibroids;
the other diff'use, 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 implicjited, and the general health is
undermined. In children the symptoms referable to pressure on the
organs in the pelvis soon iu'coiue pronounced.
I)ia(/)tosis. — The diagnosis i'wnn fibroid and carcinoma can only be
made by microscopical examination.
Treatmcuf. — ('ir(;uniscril)e(l tumors are extirpated like sessile
fibroids. The diffiise form may be kept in check foe a time by
curetting and cauterization with tliermo- or galvano-cautery, or chlo-
ride of zinc as in cancer of the uterus. It might be well to try the
application of caleiiim carbid (see Carcinoma Fteri).
o. CarcinoiiKt. — Priniari/ carcinoma of the vagina is a rare <lis-
ease. As a rule, it is .^('coiithirif, either ])ropagated i)y eonlinuity
from neit^hboriiig organs, esj)eeially the cervix ut<'ri, or a])pearingas
incfa.^ldtir dej)osits from carcinoma in remote ])arts.
Jt is found in two forms, either as a c//vv/y/;.sT/-/7/rr/y>^/yv///rn// growth,
and then it is epithelion)atous in structure, or as a (////W.sy careiiioina-
382 DISEASES OF WOMEN.
tons infiltration, wliieh ao^ain may have the medullary or scirrhous
tyj)e. The difll'use form affects sometimes the shape of a rin^.
The cause is doubtless infection with a hitherto unknown microbe.
The disease is rarely found l)efore 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 conmmnications with other canals
may be formed, tiie most frequent of which is a recto-vaginal fistula.
Tiie lymphatic glands in the ])elvis and at the groin soon swell.
The chief symptom.'^ are the sanious, dirty, ill-smelling discharge
from the ulcer, hemorrhage and })ain, to Avhich may come the common
sym]>toms 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. 295). 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 will both 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
siiould be removed.^
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, the best of all seems to be calcium carbid,
in M-hich respect the reader is referred to the chapter on Carcinoma
of the Uterus.
6. Tuberculosis. — Tuberculosis of the vagina is much more common
' ]Vrackenrodt, Centralbl.f. Gyndk., 1896, vol. xx. No. 5, p. 129.
DISEASES OF THE VAGINA. 383
than that of the vulva, but is still rather rare. It forms ulcers ou
the posterior wall of the vagiua, 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, ulcei'S, 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 easily form fistula? opening into the bladder, the urethra, or
the rectum. The tuberculous nature of these fistulse is revealed by
the presence of notlules and bacilli around their opening.
Such fistulae must be cut out in a wide circumference. Operations
for their closure offer scant hope of success. For further information
the reader is referred to Avhat has been said about the same affection
in the vulva (p. 307).
CHAPTER XIII.
Fistula.
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 a])j)lied to such openings
the edge of wliich 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 fistuhe into the genital canal
they are divided into uritiari/ and feral fistula?.
A. Urinary fi^Htula' are again divided, according to the organs
through which the fistula goes, into (1) vesico-vaginal, (2) urethro-
var/inal, (3) urefero-var/iiial, (4) ve.sico-uferinc, (5) vesico-utero-vac/inal,
(G) uretero-uterine, and (7) nrctero-resiro-vaginal.
There may be one or more fistuL'e, and in size they vary from a
scarcely percej)tible aperture to an opening measuring two indies in
diameter.
1. Vemco-vdffinal Finiula. — The most common urinary fistula is the
ve.sico-va(/i)ia( variety. The following descrij)tion applies, therefore,
more particularly to it, and the jK'ciiliarities of the i-arer forms will
be mentioned later on.
J'J(iolof/i/. — liy far the most common cause of fistula is chihlbirih.
The mechanism maybe twofold. Tlie abnormal eoinnuniication may
be due to a tear, and apj)ear immediately after delivery, or it may be
due to pressure with consequent necrosis, and not be developed bcluic
several days or even weeks have elaj)s('(l sin<'(> parturition tooU place
384 DISEASES OF WOMEN.
Tears are especially found in old primiparje or after the use of ergot or
in eases 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
jiressure if it is exercised for a shorter time, Fistulee 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 midwifery and the much more frequent use of the forceps
fistulfe have become much rarer now than they used to be, and come
mostly from remote localities where proper assistance is not avail-
able.
Fistulse 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 has been due to vaginal hysterectomy — i. e., the
removal of the uterus through the vagina.
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 ammoniacal odor. If tlie 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 raised knees (p. 207).
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. 385
be made visible and accessible before intervening cicatricial bands are
cut and distended (p. 374).
Prognosis. — Small listulse 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 fistulae 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 succe&s is obtained. AVith 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 leas remote point.
1. C/eanUness. — A fresh fistula, even of considerable size, may be
mucli diminished, and sometimes closed altogether, by giving hot vagi-
nal injections and using remedies tliat render the urine normal. As
it has a tendency to become alkaline and deposit phosphates, acids are
indicated, especially benzoic, boric, nitric, and phosphoric.^
Phosphatic incrustations should be removed mechanically, and
the parts lubricated with vaseline or zinc ointment. Raw sur-
face are brushed over with a solution of nitrate of silver (gr. x
to §j) twice a week. 8itz-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 l)y suture. It may, however, be tried for
small fistulffi, and is often used successfully, when a small o])ening
remains or forms in a stiteh-eanal alter the operation by suturing.
The part is rendered insensitive by means of cocaine (p. 223).
The galvano- or thermo-eautery may l)e used. Among clienjical
caustics, the nitratc-of-silver stick, nitric acid, and carbolic acid an;
the best. Tinctun; of caiitharides has also ])rove(l useful. The
cauterization ought not to be reoeated until granulations have de-
veloped, and do not grow any more. The efiect of the cauteriza-
tion is much enhanced by the use of a permanent catheter.
3. ('fo.siire hif Sidnrr <d flic Scat of the Fisfii/a. — This is the
most reliabh; and satisfactory of all tlu; methods. \\'e must con-
sider sej)arat<'ly the |)re})arat()ry treatment, the operation, and the
aller-treatmeiit, all of which are of great importance in effecting
a ciu'c.
Tlu! best time for operating is six or eight weeks after conrmenient.
' Hc'iizoic acid may he fjivcii in capsiiics ( i;r. x, t. i. d.i. Tlie l)(.'iiznatcs of
arniiioniiim, lilliium, or sodiiirii i >;r. v xxxi also foikIit tlit! iiriiK' acid. 1 iiave
likewise seen good eliect from the satiitaied solution of l)oric acid, a tai)U'S|»oon-
fiil four times a day; S dro[)s of dilute nitric acid four times a day; or Ilorsi'ord's
ai-id phosphates, a tcitspoonfn! in a wine;,dass of water, three times a tlay.
25
386 DISEASES OF WOMEN.
Jiofore tliat period'spontaneous closure might take ]>lace or cauteriza-
tion might suffice for the purpose. The lochial discharge would be
luifavorable for healing hy 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 preparatoi'y 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. 374). ^\'hen the first incisions are
healed, new ones may be made and treated in the same way. By tnis
combination of cutting and pressure not only room is gained, which
renders the fistula more accessible ; but the cicatricial 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 nt)t 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 the^or^-
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. 139),
Sims's speculum, or one of the self-holding modifications thereof (p.
150), 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 stri}) 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 enougii, a second strip is cut off from
the vaginal mucous membrane outside of and contiguous to the first
(p. 357). The edges should be brought together in that direction in
wiiich 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 tiie 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.
■ 387
Silver wire is used for sutnrino; (pp. 216 and 234). It is pulled
through with disinfected silk tlireiid. Round, slightly curved
needles made cutting near the point (Fig. 202, d) and 1 inch long
are best. If possible, the needle is seized below the eye ; but if
the fistula is closed in a transverse line, the needle must be seized
at its blunt end and held in the long axis of the needle-holder.
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 tlie bladder, and carried
through the corresponding ])oints on the opposite lip. Five sutures
are put in for each inch of line of union. As to the use of the coun-
ter-pressure hook, twister, suture-shield, and cutting of wires, the
reader is referred to the general rules given above (pp. 235, 236).
The patient is now turned on her back, the bladder washed out
with a double-current catheter, and Sims's relf-retaining, sigmoid,
block-tin catheter with many small side o])enings introduced. This
catheter should be bent so as to move freely l)ehin(l the pubes as a
key turns in a lock. Many now prefer, however, soft-rubber or
glass catheters.
After-ireatmcni. — 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 tiie bowels constipated for three days.
Fig. 241.
T?rizciiiaii''- Opcrnliiifr-Tal
On the fourth dav the bowels are moved by means of an aj)erient
and an olive-oil etiema (.^iv). The sutiu'es are generally removed on
the eighth, ninth, or tenth day.
The catheter is taken out and cleaned several times a day. A
388
DISEASES OF WOMEN.
small flat cup (a bird bathing-tub) is placed under it to catch the
urine dripping from it. It is loft in a few days after the removal of
the sutures. The patient is allowed to sit up some time during the
thii'd week after the operation.
Fig. 242.
Bozeman's Speculum : a, surface of third blade which is applied to the vasrina; h. a sin rt
plate which is pushed under the ends c and d, and thereby kept in place.
Bozemari's Method. — Bozeman places the patient in the knee-elbow
position, in which she is retained by a special apparatus of his (Fig.
241). His speculum (Fig. 242), 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 i)late of
thin lead (Fig. 243) 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.
SUnoti^s Method. — The patient is placed in the
dorsal position, with raised pelvis and the legs
drawn up — so-called hreech-back position, be-
cause the breech presents as in deliveries with breech presentation.
Fig. 243.
Bozeman's Button.
DISEASES OF THE VAGINA. 389
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 liulting 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 prefei-s, 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 Supr'apubic Method. — For fistulfe that cannot be reached in
any other way Trendelenburg makes a transverse incision just above
the symphysis ])ubis, 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.
Blasius's Method. — Tiiis is a flap-splitting operation which has
been revived by Lawson Tait and othei-s. 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 tlie edge to the de])th 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 tobaceo-jwueh
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 septinn in a curved direction, following the
curve of the se])arati()n of the flaps till it comes to the opposite ])()le of
the diameter of tlu! fistulous ojx'ning, and then the |)oint ol' the needle
is made again to emerge into the vagina. I'he needle is now threaded
and withdrawn, one-half of the fistula being thus embraced by the
suture. TIh' needh; is again made to j)ass similarly round the oppo-
site half of the fistula, the points of ingress and egress being identical
with thos(! of the first halt" of the proceeding. The needle is again
threaded and with(b'awn, and in this way the cireiUHvention of the
fistida is eonipleted. When the thread or wire is drawn tight and
s(!cured,it will l)e found that the flaj) of vaginal nuieons membrane is
made to front into the vagina, and that of the vesical mueons mem-
300
DISEASES OF WOMEN.
Fig. 244.
brane to front correspoiulingly into the bladder, whilst the raw sur-
faces between them are brought I'ully 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 sej)-
tuni 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 tlie 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 — /. 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.'
Walcher's Method (Fig. 244). — 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 sujier-
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 M'hole cicatrix as deep as possible.
In some places larger cicatricial masses
have to be removed ; in others, where
healing had taken place by first inten-
tion, the edge is simply s})lit into an
anterior and posterior flap. As long
as there are immovable parts or ])arts
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
like a loose sac. Now the vesical flaps are brought together in a line
by a row of catgut sutures. He introduces the needle on the raw
' L. Tait, The British Gynecological Journal, Nov., 1887, Part xi. p. 368.
Walchor's Fistula ()i)o ration : a, fistula ;
b, bladder; c, vaginal wall rolled out.
DISEASES OF THE VAGINA. 391
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 raera-
brane of the bladder, just comprising the latter in the suture (compare
submucous sutures, p. 338). 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 fistulae 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 se])sis. In operations near the fornix the peritoneal cavity
may be opened — an accident wliieh 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 tiie vaginal wall so as to embrace the bleetling vessel,
which experience has siiown usually comes from the neck of the
bladder or the neck of the womb (T. A. Emmet).
Secondary hemorrhage is vei'v rare. Bloo<lclots in the bladder
should be broken uji with a catheter. Hot and ice-cold injections
should be made. If these measures do not check the hemorrhage,
the sutures must be removed and tiie bleeding vessel looked i'or 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 diiHeult to heal than the original
vesico- vaginal fistula. The ligation of a ureter leads to acute hydro-
nephrosis with high fever an<l vomiting. \{' the field of oi)eration
extends more than half an inch from the median line, the ()[)erator
should look out for tlie ui-eter. Sometimes it can be seen at the edge
of the fistula. Then tiie ureter must first be s})lit open from the
bladder to the extent (»f 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 y\\v. fistula is closed.
The operator should note the mimber of sutures he introduces and
be sure to remove them all, as an overlooked or eut-olf suture may
form the nucleus of a calculus in the bladder.
When there is (ir<(d /o.v.v of suhsldiwe it is often impossible to unite
the edges on one line. It may tlu-n become necessary to give to the
line of union the shape of a Y, a T, or an I.
In large- (istuhe it is also sometimes found advantageous not to
392 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.^
If the fistula is situated near the bone, the fiap-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 loolc; 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. Bozenian's or Simou'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 mucii preferable to any other
material. The largest specidum 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 witii 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. Urethra-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 pari of the urethra may be combined with a
vesico-vaginal fistula. Then tli-i 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.
^ Thomas, Diseases of Women, 6th ed. p. 274.
DISEASES OF THE VAGINA. 393
If the atresia is situated between a urethral and a vesico-vaginal
fistula, the impervious portion is bridged over by uniting the upper
edge of the vesical fistula with tlie 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-vaginal 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.
273).
3. Uretero-vaginal Fistula. — Remembering the relations between
the ureter, the neck of the womb and the fornix of the vagina (p. 84),
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 tiie fistula is ureteral, can be pushed
deep in in the direction of the corresponding kidney, and urine Avill
be secreted in jets from it. Milk injected through the urethra will
come out immediately through the fistula, if it be 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, li' under such circumstances the fistula were closed,
acute hydronephnxsis with all its dangers would l)e the result.
The perviou.sness of the lower portion of the ureter is made out by
introducing one ])rol)e through the fistula and another through the
urethra, which will come in contact in the bladder, if there be
free communi(;ation between the fistula and that organ.
The c(UiseH of uretero-vaginal fistula are pressure during child-
birth, the gnawing of a pessary, hysterectomy, or the o])eration for
a vesico-vaginal fistula, in <'onse(juence oi' 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. Chxure of the Fktnla. — The fistula has been directly closed in
different ways.
a. Baii(I/'s MefJioiJ (Fig. 245). — I'nndl ma<l(> an elliptic incision
around the fistula in the course of the ureter, cut out some tissue at the
lower end of this inci.sion and made an opening into the bladder, press-
394
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. 245.
Diagram of Bandl's Operation for Uretero- vaginal Fistula (the patient is in genu-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 nretero-vaginal fistula ; B, bladder ;
U, vaginal poriion of uterus ; H, right ureter ; H', left ureter opening at « into the vagina;
cc, first incision ; de, flat denudation in the vagina ; b, artificial opening into the bladder.
drew its point with a forceps through the artificial opening made in
the bladder, out into the vagina, and ]>ushed 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 Bozenian's position, speculum, and button, and left
another catheter in the bladder.^
6. Pozzi's Method. — Poz/i used the flap-splitting method in a case
of uretero- vesico-vaginal fistula. He placed the patient in the knee-
chest position, made a ti'ansverse 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 fistulae with three deep silver-wire sutures and three superficial
sutures.^
' Ludwig Bandl, Die Boznnnnsche Methode der Blasem^dieidenfistel- Operation mid
Beilrdge znr Operation der ILtrnleiter- nnd Blnsensc.heidenfiMeln, Wien, 1883, p. 42.
^ Pozzi, Traite de Gynecobgie clinique et operaloire, Paris, 1890, p. 934.
DISEASES OF THE VAGINA. 395
B. Implantation of the Ureter in the Bladder ( Uretero-cystostomy). —
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 (fitting down on a cIoschI forceps introduced
througii the urethra. A thin flexible catheter is introduced into the
ureter and pulled out through the urethra. The ureter is then fast-
ened 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.
C. Nephrectomy. (See below, under Uretero-uterinc Fistula.)
Of these three operatious 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 Fistida. — Fistulous communication between the
urinary system and the uterus can only take ])la('e in the cervix.
The other end of the fistula may be in tiie bladder or in the ureter,
and it is of vital importance to distinguish betweeu 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.
Diar/nosis. — Sometimes a probe can be brought from the bladder
througii 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 be j)luggcd with a
laminaria tent, no systemic disturbance will result; while, if it is a
uretero-cervical fistula, acute hydronephrosis is developed.
P/w//!o.s'/.s'. — This kind of fistula has an unusual tendency to spon-
taneous healing, which jjrobably is due to the thickness of the wall
in which it is situated.
Treatment. — This tendency to spontaneous closure mav be furthered
by (".uiterization. If that does not succeed, closure by suture may be
attcMupted in diflerent ways.
a. h'mmct'.s MctJtod. — The anterior lij) of the cervix is sj)lit open in
the median line, so as to re|)roduce a condition similar to that obtain-
ing when the injiu'v was fresh. In this way the fistula is reached, and
pared, and tlu; woutid united by silver-wire sutures from side to side.
h. F()let\s Method. — The urethra is dilated so as to admit the index-
finger, and the cervix is |)ulled 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 linger in the
urethra aidinir the introduction of (he sutures.
396 DISEASES OF WOMEN.
It seems that even the somewhat risky dilatation of the urethra
(p. 144) may be dispensed with.^
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-%itero-vag'mal Fistula. — This fistula goes from the blad-
der through the anterior lip of the cervix and ends in the vagina.
Treatment. — If there is enough of the anterior lip of the cervix
left, it is denuded and stitched together with a correspondingly pared
surface on the anterior wall of the vagina.
If there is not tissue enough left in front, the ])()sterior lip of the
cervix is pared and bi-ought together with the anterior lip of the
opening in the bladder. \\\ this procedure the cervix is turned into
the bladder, and the menstrual flow is secreted with the urine through
the urethra.
6. Uretcro-tdcrine 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. INEilk injected into the bladder will not come
out through the os. If the cervical canal be plugged, there will soon
appear symptoms of acute hydronephrosis, sucli 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 tiie
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. 166). That
it should be possible to intnKluce a ureter-catheter into the uterus
from the bladder (]). 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 simj^ly 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-var/inal Fistula. — When the ureter has been partly
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 lat-
ter. This condition may be cured in a way similar to a uretoro-
vaginal fistula, but in so doing it is sometimes an advantage to
^ A. Benckisser, Centralblatt f. Gyndk., 1893, vol. xvii. p. 847.
DISEASES OF THE VAGTNA. 397
make a slit leading from the lumen of the ureter to the interior of
the bladder.
Genital Cleins. — 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 (Jiystei'o-
cleisis), the turning in of the cervix into the bladder (Jiystcro-cysto-
cleisis). The vulva may be made the seat of the closure {episio-
cleisis) ; but this is a very objectionable procedure, since it not only,
like the two others, renders impregnation im])ossible, but prevents
coition, causes stagnation of urine, and may giv(! rise to the forma-
tion of stone in the lower part of the vagina. Tiie most common
seat of this closure is the vagina (cnlpoclci.si.'i). In performing this
operation the operator should always keep in view the desirability
of preserving as much of the deptli of the vagina as possible.
Closure should therefore not be made at a lower point than neces-
sary, and often much can be gained by giving the line of union a
slantiug direction.
The patient is ])laced in Simon's position (p. 388). A narrow
strip is cut off' from the mucous membrane of tiie vagina in such a
way that the denuded part of the anterior wall fits to that of tiie
posterior. These are now brought together by sutures accordiug to
general rules (Fig. 207, p. 234). Diiriug the insertion of sutures on
the anterior wall a sound is kept in the bhulder, and while working
on the posterior wall the o[)erat()r uses a finger in the rc(!tum 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 occasionally indicated in eases of
great loss of substance, when tlun-e is much cicatricial tissue around
the fistula ])artly adherent to t\m bone, when the bladder is inverted
and filled with ])art ot" the intestine, and especially in certain cases of
uretero-uterine and vesico-ntero-vaginal fistula. (See above.)
When the urethra had been lost or its lower edge was too Aveak to
be pared and stitched, \'on Nussbaum combined cleisis with the
formation of an artificial siijird-pnhic iirdlmi. He ]>unctured the
bladder above the symj)hysis, and left tiie canula in pl:ic(i for two
weeks. Then the patients were allowed to get up, and directed to
empty the bladder (;verv two or thi'ce hours with a female! catheter.
At the end of a few months the catheter could be dispensed with, the
urine i)eing (h-iven 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.
Urimils. — If for some reason or other no operation can be per-
398 DISEASES OF WOMEN.
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
iutra-vaginal. To the iirst belong rubber bags with a wide opening
covering the vulva, and fastened to the pelvis and the thigh. To the
second belong tlie 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 siuit-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.^
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^ has devised
an operation by which the condition is remedied at once (Fig. 246).
The patient is placed in knee-elbow po-
sition. The urethra is pulled to one side
with a tenaculum as far as })ossible (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 u])per
end near the subpubic ligament. Next,
„ ,., , ^ ° ,. . -, ,. the meatus is pulled as far as possible
Pawlik s Operation for Iiiconti- •wv.wi j | ^ x
nence: H, urethra; A. denuda- tOWard the clltOriS Without USUlg UUduC
tion: o, point .to which the „ t n i • i. t i //\ T^l
nrethracan bepuUed toaside; lOrCC, and that pOUlt niarkec] (0). lllC
fi.point to which it can be pulled i- „ r>f inoI^iVm nro nnw r'ontinnpfl in n
in the direction of the clitoris. llUCS 01 inClSlOU aiC llOW COniHlULU JO a
slightly convergent direction to 6. The
thus circumscribed tissue is cut out in the shape of a Mcdge, and the
^ John C. Jav, Jr., New York Medical Record, Aufj. 2S, 1886, vol. xxx. p. 251.
The urinal is iriade by Parker, Stearns & Sntton, 228 South street. New York.
'■^ Pawlik, Wiener Med. Wochem^chriff, 1883, Nos. 25-26, p. 772, and Zeiischrift fur
Geburtshiilfe und Gyndk., 1882, vol. viii. p. 38.
DISEASES OF THE VAGINA. 399
wound united with deep sutures of sillvAvorm gut and covered with iodo-
form. After seven days tlie sutures are removed, and, the wound hav-
ing healed by first intention, the other side is treated in the same way.
Tlie 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 chtoris,
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 suifers from incontinence without having had a fistula.
Sometimes the cause of incontinence is irritation caused by a band
attached to the urethi-a and spreading itself over the anterior aspect
of the vulvo-vaginal 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 meatus. 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,^ or, better, dusted with stearate of zinc. The patient may
then urinate herself. If the incontinence of urine is due to a cysto-
cele or urethrocele, Watkins's operation (p. 358) may effect a cure.
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 Anatomij. — There may be one or more openings. The
fistulous communication may take [)lace between the rectum and the
vulva — recto-vidvar or recto-lahial Jvitala ; the rectum and the vagina —
recto-vaginal fuitida ; between the ileum or the sigmoid flexure of the
colon and the vagina or uterus — entero-vaginal, ilco-vagimd, and ileo-
nteriiie jldala.
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
connecting tlu; intestine and the vagina, but it is most commonly fi)und
either immediately al)ove the s|)hin(!ter ani nuiscles or at the fornix.
As a rule, it is found on the j)()sterior wall of the genital canal, but the
entero-vaginal variety may exci'jjtionally oj)en in front of the uterus.
Sometimes the length is almost nil, (he rectal and vaginal walls com-
ing in contact in th(! thin s(ij)tum between the two. \n other cases,
when the fistula is the result of an abscess, the inner opening may be
a.s nnich as three inches and a half up the rectum, while the outer is
found on the inside of the labium majus.
' D. Tud (jrilliam of ( 'oIuiiiImis, O., .l»n<T. J<nir. Obd., 189G, vol. xxxiii., Xo. 2, p. 177.
400 DISEASES OF WOMEN.
Etiology. — The ciiuses of fecal fistnlse are in many respects like those
determining urinary fistnlse. The most common is childhirih, 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 ru})ture of tlie 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 fornix it may be due to a sup-
purating dermoid cyst or extra-uterine pregnancy ; at the vulva the
inflammation begins often in Bartholin's glands.
We have mentioned above that direct injury, especially violent
coition, may cause a permanent fistula (p. 283) 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.
Sympto7ns. — The escape of flatus and, Avhen 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 fistulas there are two varieties with very different
symptoms. If the opening is small {ileo-vaf/imd fisfiihi), 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 [preternatural 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 will lose
flesh and finally die from starvation. Her weakness may also cause
amenorrhea.
I^arge 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 knuckle having
been destroyed, there may be two ojx'nings with a so-called .npur
between them.
Prognosis. — Fecal fistula) have in so far a better prognosis than
urinary, as a larger number of them heal sjjontaneously ; but, on the
DISEASES OF THE VAGINA. 401
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 we 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 fistulse
nutrition becomes insufficient.
Treatment. — Preventive Treatment. — ]\Iuch can be done to prevent
the formation of fecal fistulae 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 symphysiotomy, or even Cesarean section.
Pessaries should always })e kept clean with daily vaginal injec-
tions, and removed at least once every two months. If there is
any gnawing, the jx'ssary should be left out for a week and carbol-
ized injections used until all abrasions or ulcers are healed.
It goes without saying that most strenuotis etforts should be made
to prevent syphilitic; ulcers from forming fistula\ Perhaps we shall
soon have in one of the many remedies now being experimented with
a means of checking tuberculous ulcei-s 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 (l('velo])nu'nt 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 ll-cal fistiihe have a decided tendencn' to close
of themselves, this liapju' result should l)e facilitiited l)y scruj)ulous
eleanHne.HH, especially sitz-i)aths, rectal and vaginal injections, and
prevention of eonstijjation, combined with cauterization (p. .'W."}).
H. Lif/ature. — In re(!to-lal)iMl fistula, which we have seen often
extends far up th(; gut, a cutting operation would be liable; to cause
great hemorrliage, and by forming a cloaca leave the patient in a
worse condition than sju; was before. This alfeetion is treated suc-
wissfiilly by changing it into a conunon fistula in ano, and treating
2''.
402
DISEASES OF WOMEN.
that with the elastic ligature.' 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 0|>ening, having the eye 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. 247). The labial orifice is left to itself and closes in a few days,
Fig. 247.
Barton-Taylor's Operation for Recto-labial Fistula: A, anal end of ligature; B, labial fistula;
C, incision in jjerineum. The fine dotted lines mark the coiirse 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
* This method orijifinatedwith Rhea Barton of Philadelphia, and was improved by
I. E. Tavlor of this City, who, on November 18, ISSo, read a paper on Bedo-labial
and ViUvar FUtulce before the New York State Medical Association.
DISEASES OF THE VAGINA. 403
embraced tissue is easily severed with scissors or Paquelin's cau-
tery.
C. Cutting operations may be performed from the perineum, the
vagina, or the rectum.
I. For a rectal fistula situated low doicn three different suture-
operations recommend themselves.
1. Emmefs 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. 340).
2. Tait's flap-splitting method with circular suture (p. 389) 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 fii"st 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^ to the mucous membrane or the skin.
Whichever method be used it is best first to paralyze the sphincter
ani muscle by overstretcliing it.
II. Rectal fi^tulce 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 colpo-
perineorrhaphy.
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.
I^ext, the edges of the vaginal flaps were brought together with a
continuous suture of chromicized catgut. Finally, the relaxation
sutures were tied.^
These fistulaj have strongly l)eveled 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 tlie edges bciuir brought together. In sneli a case it
is necessary to split tlie edges of" the fistula on each side to a depth
sufficient to permit the c{\'^v> of the rectal wall to be brought to-
» IT. Fritsch, CentralblnU f. Gi/vak., 1888, vol. xii. p. 80(5.
' Bureau and Vignard. Ontmlhl. f. Gyniik., 1894, vol. xviii. No. -10, p. 001.
404 DISEASES OF WOMEN.
gether below, leaving the vaginal opening to be filled up by gran-
ulation.*
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-
veree line.
2. Tail's fiap-spUtting with interrupted suture (p. 390) may be
available.
3. German authors recommend a denudation and adaptation from
side to side as in co]po-|)('rineorrhaphia for incomplete rupture of the
perineum (p. 327).
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 ]). 398) it should not be divided. Under such cir-
cumstances the operation is performed from the rectal side.^
The intestine should not only be cleaned out by high enemas of
water and irrigated wltii an antiseptic solution during the operation
(p. 238), but it may even be well to try to combat the germs in the
upper part of the intestine by the internal administration of naplitha-
linc (gr. ij to viij pro dosi, up to gr. Ixxx in twenty-four hours),
salol (gr. X q. two hours), or carbolatc of bismuth (gr. x every two
hours). The sutures are ])ut in near the edge on the rectal side, but
should go out a quarter of an inch from the edge on the v;igiiial side.
Enter o-vaginal Fistulce.^ — 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 s])ur between the two may be
cut by introducing Dupuytren's enterolome, 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 cnterorrhaphy.
If the lower end is closed or too narrow, an anastomosis may be
effected between the upper end and the large intestine.
' T. A. Emmet's (hinecnlorjy, p. GG2.
* Emmet, /. c, p. 6(K;.
^ Tliirty-nine cases have been collected by II. L. Petit, Annales de Gyneeologiey
vols, xviii., xix., xx., 1882-83.
DISEASES OF THE VAGINA, 405
3. It has also been proposed to loosen the wounded part of the in-
testine and insert it in the rectum from the vagina.
4. After having made an artificial rectovaginal fistula, colpocleisis
may be performed under it.
General Remarhs about the Operation for Fecal Fistulce. — In ope-
rations from the vagina or the perineum Simon's position (p. 388)
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, so 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. In low operations it
may be possible to use silkworm gut. The bowels siiould, of course,
be emptied before operating. After the operation they are best let
alone for three days. After that daily loose passages should be se-
cured by means of medicines (pp. 242 and 34l). The patient may
urinate herself.
PART IV.
DISEASES OF THE UTERUS.
CHAPTER I.
Malformations.
Malformations of the uterus may be due to excessive develop-
ment and precocity, to arrest of development or to irregula?- developraent.
Those due to arrest of developraent correspond again either to the fii'st
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.^
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 lias
been said on p. 261.
B. Arrest of Development during the First Half of Intra-uierine
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.
^ 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.,
Syst. of Gynecol; vol. i., pp. 238-257.
406
DISEASES OF THE UTERUS. 407
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 tlie cases of rudimentary uterus authenticated by autopsy
was there any menstrual flow, but often molimina.
3. Uterus Duplex Separatus, or Uterus Didelphys (Fig. 248). — This
variety is produced when the two Miillerian ducts do not even come
Fig. 248.
Uterus Didelphys (Ollivier) : a, right body ; /*, 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, lefl vagina; k, partition between the two vaginse; I, right tube.
in contact with each other in that part of their course in which they
usually merge, forming the uterus. Consequently they arc two
entirely separate uteri, but each of them represents only one-half
of the total organ. Each half lias at its u})per 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 didelpiiys is mostly found in still-born children, but
occurs also in aduhs.' 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.
' I have seen one in performing laparotomy on a girl twenty years old. In this
case the vagina wa.s normal.
408
DISEASES OF WOMEN.
4. Utenis Unicornis (Fig. 249). — The oue-horned uterus is due
to the development of oue of Miiller's ducts, while the other is
Fig. 249.
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 ;
RL/r, 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, the characteristic shape and position being felt.
Pregnancy and childbirth may take their normal course. But
attached to tlie point where the cervix merges into the body of the
unicorn uterus is sometimes found a rudimentary horn. If pregnancy
takes place in that, the condition is a very grave one, the rudiment-
ary horn being incapable of producing the necessary muscular tissue
to form a sac for the growing fetus. The condition is, tlien, practi-
cally the same as in tubal pregnancy, from which it cannot be dis-
tinguished 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 demarcation between the uterus and the Fallopian
tube (p. 58). A tube, be it ever so narrow, 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 and 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 la])an)tomy or colpotomy.
In very rare cases menstrual blood has accumulated in the rudi-
mentary horn, forming a tumor (hematomefra). 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.)
DISEASES OF THE UTERUS.
409
5. Uterus Bicornis (Fig. 250). — When the Miillerian ducts remain
more or less separated from each other 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. 250.
uterus Bicornis (Hunkemiiller) : ur, uretlira cut off; hi, meatus urinarius; vag and v«<7*,
entrance to the double vagina, tlie anterior wall of which has been removed, showing
the two vaginal portions of the two-horned uterus.
fundus inside, while the horns are only separated by a corresponding
slight depreasion 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 bilnculav'is, is a uterus with a complete partition
between the two halves, but with the normal shape of a uterus out-
side, a kind tliat is of nnich rarer occurrence than the corresponding
bicornute variety.
If part of the septnni lias been ab.sorbcd, the uterus is called suh-
septus — i. e. pai'tially partitioned.
In all forms of double uterus, be it horned or not, the vagina may
l)e single or double (p. IV)2). The men.strual flow may come from
one or i)()th halves, and if from i)oth, it may either come from both
sides at the same time or alternately from each half.
I'rexpiancji may take ])!ace in either half or in both at once, i^ven
if it is confined to one side, the other, as a rule, j)artakes in the pro-
410 DISEASES OF WOMEN.
cess, forming a decidua, aud producing muscular hyperplasia and
hypertrophy.
The presence of a double uterus serves to explain many cases of
superfetatlon, 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. 345 and 346)
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 an. external os, or the cervix may be one uninterrupted
muscular mass without lumen. In such cases the vaginal portion
may be well developed or totally absent. In a bicornute 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. 346-349). 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 we 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, in the differentiation of
which the examiner must especially think of pregnancy, fibroma,
and hematocele.
In a case o^ 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, Avhicli pushes the uterus for\vard.
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 aud 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 closetl
horn may become adherent to the anterior abdominal wall, and rup-
ture take place through it. The hematometra may also rupture into
DISEASES OF THE UTERUS. 411
the stomach or the inte-tine, which leads to septicemia and death.
The least daDgerous 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 cousequence of tiie entrance of pyo-
genic bacilli becomes purulent {pyometra). 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. (Compare Lateral Pyocolpos, p. 353.)
Exceptionally, the contents of the closed horn are only mucus
(hi/drometra). If a })urulent collection becomes decomposed, gases
are formed in the cavity of the uterus, a condition called jjhysometra.
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 the cavity should be washed out ^vith
an alkaline and an antiseptic fluid (p. 346), and an iodoform-ganze
drain should be left in the uterus for Ave or six days, and after its
removal a perforated intra-uterine glass stem should be inserted in
order to keep the cervix ()j)en. J^ater, 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 rej)eated, 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, ^^'hen the closed half
has been ])unctured and evacuated it may be possible to dilate the
open half by Vulliet's metho<l (p. 159) and remove a part of the
partition between the two halves of the uterus.
If the swelling cannot be reaciuHl from the vagina, laparotomy
should be performed and the affected horn or the whole uterus re-
moved as for a flbroid,
Jf blood has collected in the Fallopian tube, and there is no com-
nnuiication with the uterine cavity, it is best to let it alone, as it may
perhaps be reabsorbed. It' the tubal sac grows, it may be punctured
from the uterus or tiie vagina, and in the latter j)lace treated with
injection and drainage. Laparotomy and removal of the distended
tube may be tried, but it is liai)le to })r()ve difHcult or imjK)ssible on
account of adhesions.
C. Arrest of Development dnrinf/ the Seeoyid Ihtlf of Infrd-vfertne
Life. — L Fet(d (tnd Jufoidile UteruK. — Some adult women have a
womb that in size and configuration corresponds to that of a fetus
412 DTSEASES OF WOMEN.
toward the end of pregcnancy or that of a young chihl. Sometimes
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 tiie same time be two-horned (p. 409), 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. llie 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 dysmenorrhea, and sometimes vicarious men-
struation (p. 258) takes place. All sorts of disorders in organs out-
side the pelvis (pp. 264-267) 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.
Sometimes the scant development of the uterus is allied with
goiter. There is, indeed, an intimate connection between the uterus
and the thyroid gland. It may be a poetic fiction when Catullus
sings that on the morning following the bridal night the string that
formerly encompassed the girl's neck is found too short ; but medi-
cal observation has found a decided connection between the thyroid
gland and the chief uterine functions. Thus, the thyroid often is
the seat of swelling at approaching pul)erty, and resumes, as a rule,
its normal proportions after the establishment of menstruation. In
many women tlio gland swells before each menstrual period. In many
cases goiter is referable to ])regnancy ; and it is even stated that while
goiter was being treated with electricity, the susceptibility to impreg-
nation was much increased. At the menopause the goiter does not
always diminish or disappear. On the contrary, it may increase.^
Prognosis. — Tin; prognosis, especially in regard to sterility, should
be guarded, but a late develo})ment 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 tiirough the rectum, and the use of the sound.
' Charles R. Dickson, of Toronto, (Ontario, " Observations on the Relations of the
Uterus to the Thyroid Gland," Amer. Jour. Surg, and Gynecol., Oct., 1899, vol. xiii.,
No. 4, p. 63.
DISEASES OF THE UTERUS. 413
Ti'eatment. — If tuberculosis or chlorosis is 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. 240-245).
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-
nienorrlieic disorders outside of the pelvis, she should be treated
according to the rules laid down above (pp. 258, 260, 261, 266) in
discussing those conditions, especially with tonics, a strengthening
regimen, sedatives, electricity, and the uterine sound.
3. Uterus ParvicolUs 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 tiie body is likewise too small, but
the hypoplasia is most pronounced in the neck. These deformities
have more pathological than clinical interest.
4. Anteflexion of the uterus is often congenital, and sim})ly a con-
tinuation of the shai)e 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. Obliquiti/. — The uterus may be con-
genitally bent to one side {later oflexion), the two Miillerian ducts that
formed it not having kept pace with each other. Or a similar con-
dition may be i)ro(luced by fetal peritonitis and cicatricial shrinkage
of one of the broad ligaments.
A normally shaped uterus may be tilted to one side (later over sion),
especially when there is a beginning ovarian hernia.
2. MalpoHilion. — In consecpience 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, latcropo.vtion.
A similar irregular development of the parts situated in front of
and behind the uterus lea<ls to a)Uej)o.'<ition, when the uterus is situ-
ated too near the symphysis, or rvtropositlon, when it is drawn too
near to the sa(!rum.
3. Hernia Uteri. — ^The uterus has been found in a congenital
inguinal hernia. Jn such ca.ses the ovary descends first through
the inguinal canal, just as the testicle descends, or rather is drawn,
into the scrotum. TIk; uterus has also been found in a crural her-
nia. Such herniie are exceedingly rare. The pjitient mav become
impregnated and the ictus develop in the hernia, whence it has to
be removed by Cesarean section with or without hvsterectoniv. If
the condition comes und<'r observation earlier and gives Iroubh'.
hvsterectomy might be jxTlormed.
414 DISEASES OF WOMEN.
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 uninipregnated 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.^
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 j)eople 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.^
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 curette. Sometimes in performing lapa-
rotomy, the gravid uterus has been mistaken for an ovarian cyst, and
a trocar thrust into it.^
In regard to rupture of the gravid uterus during labor the reader
is referred to works on obstetrics.
Frognoids. — With the exception of the simple perforation of the
uterus with soiuid 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 })regnant uterus is ripped o})en by the horn
of cattle the prognosis is better than one would expect from the vio-
' An interesting case of tlie last kind was reported by Dr. George A. B. Hays,
of Plaqueminos, La., in Gaillards Med. Jour., Nov., 1S79, p. 402, ct.seq.
* Ca.ses of tliis kind were mentioned by Thomas, IMunde, and Na'ggeratli in the
N. Y. Obst. Society, April -5, LSSl, Amcr. ,Ioiir. Obst., 1882, Supplement, p. 5.
^ An interesting paper on this subject by Dr. C. C Lee is found in Trans. Amer.
Gyn. Soc., 1883, vol. viii., p. 154.
DISEASES OF THE UTERUS. 415
lence of the injury, which can only be accounted for by the excel-
lent health of the persons wounded in this way.^
Treatment. — In cases of wounds through the abdominal wall, rest,
opium, and antiseptic dressing of the Avound probably offer the best
chances ; but if there are signs of internal hemorrhage, laparotomy
shouhl 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 treat-
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 intestino-iiterine
fistula will form, a condition that not only is compatible with life,
but may be cured by nature's sole efforts (p. 400).
If the gravid uterus is punctured in laparotomy and the ovum
opened. Cesarean section should be performed ; but if the trocar
does not enter the ovum, the opening in the uterus may be closed
with catgut 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, when 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 unilateral,
which is more frequent on the left than on the right side, doubtless
on account of the greater frequency of the left occi pi to-anterior j)osi-
tion of the fetus. The laceration may also be .stellate; that is, the oc-
currence of at least three tears forming a starlike figure. It \h funnel-
shaped when there are several incomplete tears, which result in a
patulous OS. Sometimes it l)ecomes crescentic through the bulging
of a hyperj)lastic anterior lip. In other cases the tear is Ibund in
the posterior or anterior lip alone.^
The tear extends often more or less beyond the vaginal junction and
enters tiie ])arametritim or the connective tissue beiiiiKl the uterus,
or extends into the bladdcir. Often it gives rise to cellulitis in these
l)arts, which through cicatricial contraction may lead to displacements
' Out of 14 cases 9 rccovcrid, K. 1*. Harrison, Amrr. Mai. Jour. Sri., Oct., 1S!)1,
vol. cii., p. 87(i, and .Monograph : Ahdnminal <uid Uterine Tolerance in J'rri/n/tni
Women, Philadelphia, ISD'J, ],\>. iL' lo.
' Most of those varieties are hcaiitifidly represented on colored plates a<'conipaii_v-
in^an excellent article on tin; Indirotiona for Hi/^trro-trachelorrhup/iy by 1'. F. Miindd
in the Amrr. Jour. (JbM., 1879, vol. xii. p. l.'U.
416 DISEASES OF WOMEN.
of the uterus. If the tear implicates the bladder, it may leave a
vcsico-vaginal or vesieo-uteriue fistula (pp. 383 and 390).
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, tiie mucous membrane becomes swollen, red, and rolls
out iectropium), and the lips become separated, a condition which is
increased by pressure against tiie 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
latter case the process 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 also fre-
quently gives rise to abnormal loss of blood, be it menorrhagia
or metrorrhagia (pp. 2G2 and 204) from the cervix or from the
endometrium of the body. In the interval the i)atient suffers
from leucorrhea. This double drain soon produces anemia. The
patient loses her strength. She easily gets tired, becomes nervous
and irritable, and often has neuralgic pain in the localities de-
scribed above (p. 136), and sometimes strangely perverted sen-
sations and hallucinations.^ She loses her appetite, her nutrition
becomes insufficient, she is pale, and lier features have a suffering
expression.
Laceration of the cervix is often accomjianied by secondary ster-
ility, probably in consequence of the uterine catarrh to which it gives
rise. Tlie hyperplastic li})s and the unyielding cicatricial })lug in the
' 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 trachelorrliaphy, and a
case illustrating the obstetric indication for the operation.
DISEASES OF THE UTERUS. 417
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 ectropium 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 into 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 each other.
Diacjnosis. — 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.
Some women have a congenital cleft of the vaginal portion in one
or two places. The lips thus formed may become tiie seat of a chronic
inflammation, and thus a condition may be brought about in a uuUip-
arous woman that is entirely like a bilateral laceration.'
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 tiie 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 pretlispose to cancerous
degeneration. If properly treated the laceration and its consequences
may be entirely cured.
Treatiiicnf. — 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, sudi a.s belladonna, chloral, and antipyrin is beneficial.
The accoucheur should not feel or looU for lacerations of the cervix
' I have treated a <rirl who was ahout twenty years old and liad an antellcxion
of the womb. The liyini'ii was not rnf)tnr('(I, lint very lax, prohahly in consonncnce
of iMastiirl)ation. The anterior vajfinal wall was everted, 'ilie cervix was split into
an anterior and a jiostcrior lip, wliicli were entirely separated, and hent forward and
backward into the fornix. Tlu' openinj^ in the cervical canal formed a transverse
slit \ inch wide. The anterior lip ineasnred 1 inch, the jiosterior ] inch in Ien<rlh.
The everted mucous memlirane was edematouH, tiled easily, and was covered with
abundant jrlairy mucus.
27
418 DISEASES OF WOMEN.
except in case of arterial liemorrhage.^ Otherwise he exposes his
patient to infection, that may do much more harm than lacerations,
most of whidi 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 (p. 185).
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 (^i-si)-^
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 (si— §i), changed morning and evening, and the use of hot
vaginal injections.
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, trachelorrhaphy {i. e. neck-sewing), or, more
explicitly, hystero-trachelorrhaphy {i. 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 (pp. 175,
182, and below under Chronic Metritis). Cysts should be pricked
with a scarifier and painted with Churchill's tincture of iodine.
This preparatory treatment may take several months. If circum-
stances do not warrant so protracted a treatment, the whole mucous
membrane may be excised at the time of the operation.
Trach.elorrhapliy . — The pubic hairs having been shaved off and
the genitals, inclusive of the vagina, disinfected, the patient is
placed in the dorsal ])osition, the legs tied with Kobb's legholder,
and the perineum drawn back with a single Sims speculum or Gar-
gues' weight speculum (Fig. 192). A Schroeder vaginal retractor (ji.
227) helps often consideral)ly in making the parts accessible. I use
strong full-curved trocar-])ointed needles, 1^ inches long, \\ inches
the straight line from end to point (Fig. 201, g), and Crosby's
needle-holder (Fig. 204).
1 Garrigues, "The Immediate Closure of the Laceration of the Cervix," Amer.
Jour. OhKtPt, vol. xxiv. No. 11, 1891.
^ Elwood Wilson, Gynecological Trans., 1886, vol. xi. p. 92.
DISEASES OF THE UTERUS
419
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 tlie 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 versd. 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 ougiit to be about half an inch wide at the os, as con-
traction always takes place later, and would result in too narrow an
Fig. 251.
Diaprnm Illustrating Triichelorrliapliy in a rase of Bilateral Laceration: A, posterior lip; B.
anterior lip; C, cervical canal (apparent os surrounded by reel and swollen iiuieous mem-
brane, which used to bo ri'cariU'd as an ulcer). The numbers mark the order in which
the sutures are inserted. Wlieii Ihey are tied A comes in contact with li and forms the
real os (e.f, r/, k). The render can easily realize the whole ellect of the operation by copy-
Inx tlii.s (iKuVe on a piece of [taper and folding It at a line uniting D and J), which repre-
sents the angle between the lips.
OS, if there had not been tissue enough left. Particular care should
be taken to remove tlu> <'i(;atricial plug from the angle. The cut
surfaces bleed freely, but there is, as a rule, no hemorrhage of
<!onse(juence.
The result of the cutting i.s that we have four denuded surface,-;,
i'aeh two of which are continuous in tlu^ depth of the angle, and
between the denuded surfaces a tnunpet-shaped undenuded ])iece
420 DISEASES OF WOMEN.
of mucous membrane is left on the anterior and posterior lips of the
cervix (Fig. 251).
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
of the posterior lip near the angle. It is passed transversely under
the denuded surface and made to emerge just on the line of deinarka-
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 cor resjwn ding to the first in which the needle
entered. When the point of the needle emerges anywhere, the
assistant holds the counter-pressure hook (p. 235) in under it, and
presses against the tissues in order to facilitate the passage of the
needle. The best suture material is chromicized catgut (Leaven's
No. 2). As a rule, three such sutures are inserted on either side,
and when they all are in place, they are tied and cut off, beginning
nearest the angle.
Before and after closing the sutures I thoroughly irrigate with
lysol.
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
w-e must mention some of the many conditions that call for a modifi-
cation of the operation.
Modifications. — If it has been necessary to cut veiy deep into the
angle between the lips, the wound cannot be closed in a reliable May
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 and a carrier of silkworm gut. One of the needles, threaded
with one end of the suture, is introduced from the cervical canal and
puslied out through the posterior li]) ; the other, attached to a loop
of silkworm gut, is in tlie same way carried from within outward,
through the anterior lip. Next the free end of the suture is passed
through the loop, and the latter pulled out through the anterior lip,
carrying the suture witli it.
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 cy.stic degenera-
tion, it may be necessary to remove the whole mucous membrane
from one or both lips. This may be done at the time of the
operation by omitting to leave an undenuded strip in the centre
for the canal or by curetting it. If this is done on both sideS;
DISEASES OF THE UTERUS. 421
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 sound repeatedly during the heal-
ing process. Others leave a silk thread or reopen the canal by
electrolysis.*
When there is much hy|)erplasia, so that the lips stand far apart,
and when brought together oiler 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 ]>erineum is torn, we are in general com-
pelled to do both operations at one sitting ; but if secondary hemor-
rhage, necessitating tamponade, were to ensue, the perineal work
would be destroyed ; and if menstruatit)n were to come on unex-
pectedly, which sometimes happens, it might be hard to diagnosti-
cate (p.' 239).
As a rule, the loss of blood is so moderate that the operator need
not pay attention to it. If, in very exceptional cases, the circular
artery bleeds considerably, the deepest suture should be inserted im-
mediately on the bleeding sid(\ 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 fornix 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,
serious hemorrhage may follow, which, however, can be controlled
with styptic cotton and u tampon of comm(m cotton, and need not
interf(.'re 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 nec^essary, superficial plain catgut sutures may be
inserted besides the deep sutures.
If the lips of the torn cervix are adherent to the vaginal wall, the
adhesions should be sej>arated sufficiently to allow the lips to be
brought together. The gaj) made by the incision in the vagina should
be i)acked with iodoform gauze.
Upon ti)e wliole, small as the field is, atid free from danger as the
operation is, if performed aseptieally, trachelorrhaphy requires, in my
opinion, as much judgment and skill as any other gynecological
operation I know of.
' fJeoPKe Kngelmaiin of St. Louis, (hjn. Trans., 1S85, vol. x. ]>. "JO'J, and 188{),
vol. xi. p. 90.
422 DISEASES OF WOMEN.
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 hei-self. The bowels are kept open if necessary.
On the fourth and the seventh day tlie tampon is changed and the
vagina swabbed with antiseptic solntion. 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 eifect 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 cervix may, of course, be ruptured in a new labor,
just as the intact cervix was, but very often it goes uninjured through
subsequent childbirths.
CHAPTER III.
Foreign Bodies.
Foreign bodies are by far not so common in the uterus as in the
vagina. Still, occasionally an intra-uterine 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 (p. 194). A hairpin used
to produce abortion has also been found there. A Hodge pessary
slipped from the vagina into the cervix while the patient lifted
another person.^
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 be
a living leech, a strong solution of table-salt injected into the womb
will make it loosen its grip. If there is any hemorrhage, the uterus
1 Henry Heiman, iMed. Record, March 17, 1894, p. 347.
DISEASES OF THE UTERUS. 423
should be tamponed with iodoform gauze, and if that does not
suffice, the vagina too must be plugged (p. 183).
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 l)etween
acute and chronic metritis.
Acute Metritiii. — In the acute inflammation the whole organ — body,
cervix, nnicous membrane, muscular laver, and peritoneal covering — is
more or less implicated. The peritoneal inflammation — so-called peri-
metritis — is, however, not always found, and if found extends gener-
ally to neighboring parts of tiie peritoneum, and will, therefore, be
treated of under Pelvic Peritonitis.
The inflammation of the nnicous membrane is called endometritis,
that of the nuiscular layer pdrenchi/mutoiis laetritiH, that of the cervix
has been designated as cerricitis, and that of the raucous membrane
of the cervix as rndorcrrlciti.s.
Pathological Andtoiinj. — The whole uterus is enlarged and softened,
the cut surface is red wi(h yellow points. The nnicous membrane is
swollen and red. Micn)Scoj)ical examination shows both in the mucous
membrane and between the nuis<;le-fibers an abundant inliltration with
small round cells, dihited biocKl-vessels, and masses of extravasated
blofnl. The inflammation extends sometimes to the pei'itonenin and
the pelvic connective tissue, eitiier through the tubes or through tiu;
lympathics (p. (i3). Sometimes it is combined with vaginitis.
424 DISEASES OF WOMEN.
It is doubtful if ever an abscess be formed in the uterine tissue,
except in ]>uerperal cases, where tiie metritis appears as part of a
more comprehensive infection.
Etiology. — Menstruation being accompanied by a development that
has much in common with that of inflanmiation, 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, slie 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 ])essary. 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 tliese cases has been
found to be the introduction of pathogenic microbes into the uterus,
which normally does not contain microbes.
Acute metritis a])pears sometimes in the exanthomatous fevers,
typhoid fever, cholera, acute yellow atrophy of tlie liver, phos-
phorus-poisoning, and in persons affected Avith syphilis.
As we have seen above (pp. 133 and 310), gonorrheal infection
sometimes invades 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 com])lains of vomiting, diarrhea, dyschezia,
and dysuria. Often she suffers from suppressio meusium or menor-
rhagia, or has a purulent discharge from the uterus. In gonorrheal
metritis there is especially an abundant secretion of thick creamy,
often blood-tinged ))us, 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
uterus.
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 ]>ossibility of the
extension of the inflanmiation to the tubes and the peritoneal cavity.
DISEASES OF THE UTERUS. 425
especially in gODorrheal and septic metritis, must also make us cau-
tious in our prognostication.
Treatment. — Pi'ophyloxis. — A ])erusal 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 carel'ul to avoid too great
bodily exertion and exposure to cold. They should abstain from
sexual intercouree. Obstetricians and gynecologists should use all
antiseptic and aseptic precautions, even in normal deliveries, as well
as small gynecological manipulations and operations.
Curative Treatment. — The j)atient should stay in bed. An ice-bag
or ice-water coil should be applied over the symphysis (p. 195),
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 sim])le scarification (p. 194) 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°-10o° F.) has often a more soothing effect than the hot (110°-
120°). The addition of flaxseed or slij)pery elm increases perhaps
this effed of the douche somewhat (p. 176).
A lukewarm sitz-bath (p. 196) once or twice a day or a general
warm bath every other day is also useful, if the slight movements
insej)arable from these procedures do not hurt the patient. Ano-
dynes are best given as opium suppositories (p. 243). Five grains
of (piinine 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 Prieszuitz's eompress (]). 195), tincture
of iodine may be painted on the abdomen and on the roof of the
vagina (p. 196), and ^lye(;rin tampons (j). 183) may be introduced
into the vagina. If the discharge is purulent, the uterus should l)e
curetted.
Gonorrheal metritis necessitates a more active treatment. The ute-
rus should be washe<l out (p. 176) at least once a day with a solution
of corrosive sublimate (1 : .'>()00), permanganate of potash (1 : lOOOj
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 jier
cent.) or nitrate of silver (1 : 12). 8ome use curetting (p. ISO). A
milder treatment, with a somewhat siuiilar etlect, consists in i)ackiMg
the uterus once or twice with iodoform gauze (p. 1H5) in order to
remove all pus and some of the epithelium, and finally leaving a
426
DISEASES OF WOMEN.
Fig. 252.
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
to puerperal infection, but is also found as
part of general diphtheria. It occurs com-
bined with gangrene of the vagina (p. 372) in
scarlet fever, typhoid fever, cholera, and other
infectious diseases.
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. 252), 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.^
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-
pelled, 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
I^. lodoformi, 3v;
Amyli, 3ss;
Glycerini, fl. gss ;
Acaciee, 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
' Specimen expelled by B. E. at Maternity Plospital, 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.
^Garrigues, " Dissecting Metritis," New York Medical. Journal, 1882, vol. xxxvi. p.
^37 ; Archives of Medicine, April, 1883; and ArchivfUr Gynakologie, 1890, vol. xxxviii,
p. 511.
Dissecting Metritis.i
DISEASES OF THE UTERUS. 427
treatment consists in tlie administration of quinine, stimulants,
strychnine, 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 sup-
puration and disintegration of the broad ligaments. In the writer's
experience these patients are in most cases too w-eak to stand so
serious an operation, and the operation itself often spreads the infec-
tion. In the majority of cases better results may be expected from
medical treatment, opening and draining of abscesses, etc. More
radical operations are often postponed to advantage 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 inflanmia-
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 tlie 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 througli the surface of the vaginal
j)ortion. In olden time these retention cysts were mistaken for the
human ovulum and are yet known under the name of ovula of A«-
Ijiifh. Occasionally these cervical cysts acquire, however, the size of
a c;herry. When pricked open a thick colorless fluid, like tlic raw
white of an egg, flows out from them. The interior of the body has
lost its even smoothness, and is raised in ridges or in pa))illarv
growths, or long club-shaped polypi hang from the finulus and
th(! side walls. This has been (les('rii)ed under the name of hifjier-
plastir or fiinf/oiis riKlonicfrifis. Similar iiikcou.s polypi (Fig. ^ol)
form in the mucous membrane of the cervix, and may hang out
from the OS as pednneulatcd tumors.
Around the os, on the outer surfiiee of the vaginal ])ortioii, is
found a red velvety area, and similar red spots may be found
428
DISEASES OF WOMEN.
Vui. 2o3.
further out on the vaginal ])ortion, apart from the os. They are
oh^nx called erosions, and thev form what is known as a (jranular os.
Thoy used erroneously to be called ulcers
of the cervix, an expression that is yet
often used by patients.
Microscopical examination siiows that
the swelling of the mucous membrane in
chronic endometritis is due to a great de-
velopment of its glands, to iniiltration
with round cells, and to dilatation of the
blood-vessels. The glands penetrate into
the muscular layer. When this consid-
erable development of glands takes place
the condition is sometimes designated as
benign adenoma, as opposed to malignant
adenoma, which is beginning cancer of
the mucous membrane.
The fungoid growths on the inside of
the uterus are sometimes almost exclu-
sively formed by glands ; in others they
consist of round cells like the granula-
tions on a wound ; and in a third variety
they are almost entirely composed of di-
lated blood-vessels. In some places the
formation of connective tissue gets the
upper hand," and the glands become
atrophic or disap])ear. A similar difference is observed on different
parts of the meml)rane, if it remains com])aratively smooth.
The so-called erosions are due to a change in the epithelium cov-
ering the vaginal portion, which normally is Hat like that of tiie
vagina, but becomes columnar. In the interior is found an infiltra-
tion with round cells, as in all inflammations. By invagination the
epithelium forms follicles and tubules, which constitute new glands
and, when they become closed, are transformed into cysts.
Etiology. — Many pointjj have already been discussed in the cha])ter
on Etiology in General (pp. 129-133), 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. 133 and
310, and we have seen how it may cause acute metritis (j). 424),
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-
Intra-uterine polypi (De Sindty)
DISEASES OF THE UTERUS. 429
cervicitis follows. This is especially the case if the cervical portion
is torn (p. 415).
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.
Whether bacteria play any role in chronic metritis is yet unsettled.
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. 136). 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 tiie 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 less severe dysmenorrhea ({). 259).
Secondly, abnormal loss of bkxKl from the uterus is of frequent
(K'currence, and easily explained by the vascular development de-
scribed in the paragraph on morbid anatomy. There may be men-
orrhagia (p. 202) or metrorrhagia (p. 204), or both, and often pro-
tracted menstruation, tiie menstrual process extending over an uiuisual
number of days, although ])erliaps the total loss of blood does not
exceed the normal (juantity. When loss of blood is a prominent
feature the condition has been described as Iicniorrliaf/ic cvdoiiidritis.
In very Mcak patients endometritis is, on the other hand, occa-
sionally accompanied by amenorrhea.
A third symptom that brings the patient to seek help is leucorrhca,
which is easily accounted for l)y the liyper})lasia 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. 208), that from the inteiior of
tiie body is more; milky. I>oth are alkaline, and both may become
pMnilent, which is es|)eci;illy the ease in g(»norrlieal and atrophic
endf)metritis. As to the microscoj)ical composition, see p. 2()S. Ff
the discharge is at all abundant, it weakens the constitution (p. 20(»).
430 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 mnco-serous
fluid, a condition called hydrorrhea. At times the secretion may he
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 rusiies out in a gush, when she feels relieved
until the same process repeats itself. Apart from pregnancy hydror-
rhea is a rare disease.^
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 often gives 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."
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. Hysteria is not more frequent in those affxH'ted
with endometritis than in others ; it is, therefore, doubtful if there
is a causative relation between the two.
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 nuieh is sure that
])atients afflicted with endometritis often are sterile, or if they con-
ceive they have a tendency to abortion. It is also claimed that pla-
centa prsevia 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 {ovula of Nabotli). In nul-
' I have seen a case in which the uterus was purple, slightly tender, and meiis-
ured, when the patient consulted me, 2>\ inches, but before that it had been as inncli
as 5 inches, as measured by other gynecologists of this city. Iler discliargc 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 U."
'■* R. Barnes, Disease-i of Women, London, 1873, p. 81.
DISEASES OF THE UTERUS. -431
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, tiie formation of glands and cysts, and the dila-
tation of the blood-vessels predominate, or too hard, when the hyper-
plasia of connective tiasue 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 jibrvid tumor often causes hemorrhage and leucorrhea, but the
presence of the tumor can be made out by bimanual examination. If
it is Q. 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 off 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 ])eculiar pungent and
offensive o<lor. As to hemorrhage, when the patient is in the prime
of life, has a subiuvoluted uterus, and suffers merely from menorrha-
gia, the probability is in favor of hyj)erplastic cndometrits, and against
malignant disea.se. On the other hand, bleeding after the menopause
is a very suspicious symptom. Many lay much stress upon irregular
bleeding in the intermenstrual periixl, especially after coition, but I
have often seen this in cases of lacerated cervix with ectroj)ion. Pain
is, as a rule, absent in beginning cancer, but sometimes the ])atient has
vague shooting ])ains in the j)elvis. Cancerous tissue is well differenti-
ated from the surroundings, forming a glistening j)rominence not unliUe
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 *'tea.sing" with two neetUes does not furnish conclusive
s|)ecimens.
Prognosis. — Ciironic endometritis is at best a very tedious dise:u-;c,
and it is not safe to promise more than improvement. This applies
particularly to the catarrhal discharge. l]ut even this is sometimes
432 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 pro])hylactic 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 aifected 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 :'
^. Acidi tannici,
lodoformi, ad 3ii ;
Glycerini, 5v. — 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.
241). An elastic belt surrounding the whole abdomen (p. 198) 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. 195) twice a Meek 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. 195) this may still
be enhanced. Sea-bat]iing, shower-, sponge-, sheet-, or towel-baths,
or a regular hydrotherapeutic treatment is excellent in combating
catarrh, hemorrhage, and debility. Certain spas (p. 1 96) have a repu-
tation for being beneficial in chronic endometritis.
The disease being of long duration, we should use anodynes
(p. 243) 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.
^ H. Fritsch in Billroth' s und Luecke's Handb. d. Frauenhr., vol. i. p. 1043.
DISEASES OF THE UTERUS. 433
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. 242).
For irritable bladder I use the following mixture :
^i. Tinct. belladonnse, Sij ;
Liq. potassse, ^j ;
Aquam, ad siv.
M. Sig. 1 teaspoonful in a wineglassful of water 3 times a day,
l)etween meals, or, if the urine is alkaline, a tablespoonful of the
saturated solution of boric acid four times a day.
In regard to hemorrhage the reader is referred to what has been
said on p. 263.
If the measures described there fail to check the uterine hemor-
rhage, the uterine artery may be ligated on both sides (p. 187).
Sometimes salpingo-oophorectomy has been performed, and even
hysterectomy.
If in hyperplastic endometritis the endometrium is studded with
prominences, curetting (p. 180) 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. 257. 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 whieii the curetting was done.
For the treatment of lencorrhea directions are found on ]). 2G9.
Since we have seen above how llie glands of the mucous membrane
become enlarged and dij) into the niu.-cular layer, it is easy to under-
stand how fruitless often all applications pi'ove, and how important it
is to combine general with local trcatnicnt.
Curetting, chemical irritants, the actual cautery, and other powerful
revulsives, work not only by removing diseased tissue, but the tissue is
returned to a niedullaiy state, and taking a new start the new-formed
tissue may bec(»me healthy.
Oppression and ))alpit:itions are treated with bromides, especially
monobromated camphor (gr. i-x, (. i. d, in emulsion oi- capsules).
Ovula Xahothi an; pricked ojx'n and then painted with tincture of
io<lino. Exce})tionally, the whole cervical portion may be one ngsxlom-
eration ot" cvsts, which do not yield to this ti'eatiiient. Then tluy
should gradually be destroyed with a needle-shaped l*a(juelin's cau-
terv or galvano-caut<'rv, or the cervical portion am])ntatcd (see
Chroni(; Parenchymatous Metritis).
For erosions tln-rc is no better treatment than to bathe the vaginal
28
434 DISEASES OF WOMEN.
jK)rtion iu a tubuliform speculum for a couple of minutes with acidum
pyroliguosum rectifieatum 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 ai)plied 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 licpior ferri
chloridi.
I have obtained excellent results by applying to the eroded os,
through Cusco's speculum, the positive j)ole of a galvanic battery iu
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 milliamperes). 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 pur])ose (p. 251).
If the cervix is lacerated, trachelorrhaphy should be performed
(p. 418), or, in very bad cases, the cervix may be amputated.
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 a})})ly them all
on absorbent cotton wound around my applicator (p. 174).
Iodine is the mildest and the most generally useful, especially indi-
cated if the discharge is purulent ; chloride of iron is best in the hem-
orrhagic, chloride of zinc and nitrate of silver in the catarrhal form.
Besides the intra-uterine a})j)lication, I paint the vaginal roof with
tincture of iodine (p. 175), which probably acts as a counter-irritant.
The patient herself introduces a j)ledget with glycerin, with or
without ichtliyol, morning and evening (p. 182). As we want the
iodine to enter the tissue' by endosmosis, and glycerin causes a
powerful exosmosis, it is better not to introduce the pledget imme-
diately after painting the vagina.
As an astringent on a s})ongy cervix, glvcerite of tannin is very
good (p. 183). Duke recommends boracic acid in powder applied
with a tube and piston (p. 175).
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 often gives great relief (p. 194).
If the external os is too narrow, mucus often accunuilates in the
cervix, which is distended in the shape of a barrel. In such cases
DISEASES OF THE UTERUS. 435
the treatment must begin by gradual dilatation of the cervical canal
(p. 156). If the OS is so small that not even a common uterine sound
can enter, it is necessary fii'st 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. 425).
In cases of catarrhal endometritis that had resisted all other
treatment the writer has obtained a cure by cutting off the wliole
mucous membrane of the cervix, and leaving the wound to heal
over an intra-utenne glass stem.
Exfoliating Endometritis. — Exfoliating endometritis, also called
menstrual endometritis, or monhmnov.'i difsmenorrhca, is a rare variety
of endometritis that presents such peculiar features that we are
obliged to treat it separately. It forms a link between acute and
chronic endometritis in so far as it is an acute process that repeats
itself every four weeks.
Pathological Anatomy. — The nuicous membrane of the b(xly of
the womb is swollen and red. It is thrown oif 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 tlie 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 pacivcd so closely
together that little space is left for tlie inter-cellular substance.
Etiology. — Exfoliating endometritis 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 ])liosphorus-
poisoning.
Symptoms. — The disease is characterized by severe pain in the
pelvis recurring at eacli menstrual ])eri()d and followed l>y 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 arc liable to abortion, but may even give
birth to children and then again he affected in the old way.
Diagnosis. — Exfoliating endometritis is, as we have said, a very rare
disease, and assertions to the contrary arc based on errors of diagnosis.
A chief point in the diagnosis is the regularity of the exj)ulsion of
membranes, but even that may Ik; sinuilated for some time by regu-
larly repeated abortions. TIk; microscope alone can positively settle
th(! diagnosis. The j)resence of villi choi-ii is absolute proof that the
specimen is a jnoduct of conception, and even the decidna of preg-
naiKT dilfers from that of meiistiiiatioii i)v the lai'ge size of the cells
of the endometrium.
In ecto])ic gestation a similar ex|)ulsion of the endoiiictriiiiu inav
take place. In order to a\-oid cri'ors as nuich as possible, the pel-
436 DISEASES OF WOMEN.
vis must be examined most carefully for a tumor that* might be the
fetal sac, aud all sigus of pregnancy, genital, pelvic, abdominal, sto-
machic, mammary, cutaneous, and nervous, looked for.
Treatment. — 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 aud 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-vessels 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).^
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 ejaculatod semen, abortion, subinvolution after childbirth, and too
rapidly recurring pregnancies, favor its development. It frequently
accompanies 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. jSIcu-
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 oftcner 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.
' Welch of Baltimore, quoted by A. P. Dudley, N. Y., Med. Jour., Sept. 4, 1886.
DISEASES OF THE UTERUS. 437
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 semiglobulai", 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 JInxionnaires," 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 ])arenchymatous 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.
Treatmait. — In order to avoid needless repetition, the reader is
referred to what has just been said about chronic endometritis, which
always accomj)ani(s the parenchymatous form. Here we will only
add measures ])articularly 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 o^ corrosive siihliraate (p. 244) may succeed here as
in other parts of the bo<ly in reducing the abnormal deposit of con-
nective tiasue.
In cases of subinvolution, Tait ])raises the effect of chlorate of
j)otassiuni, gr. viiss, t. i. d., given in a medicine with a few drops of
dihite hydrochloric acid.
Faradizafioii has a siniihu* effect l)y causing muscular contraction.
The bij)olar intni-utcrine nicthtKl (p. 24(5) is particularly recom-
mendable. Apostoli praises the primary current.
The galraiiic ciirmit (p. 2 Hi) may hclj) to rcihice the bulk of the
uterus by electrolysis.
Massage (p. 195)) causes al)sorption by mechanical manipulations.
Finallv, o{)erative interference not only serves to remove redinidant
438
DISEASES OF WOMEN.
tissue luechauieally, but oxpcrionce has showu that it so modifies the
nutrition of the womb that that organ may shrink considerably in
the course of several montiis following the operation. If the cervix
is lacerated, trachelorrhaphy (p. 418) should be performed. If it is
not torn, but much enlarged, it may be diminished in diiferent ways.
1. Gordon's Method} — If the cerviail canal is so hirge that it
can be done without causing stenosis, a wedge-shaped piece may be
cut out, having the base at tiie os and the apex at or somewhat beyond
the utero-vagiual 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. 147) and side
retractors (p. 227), 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 oil* 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. 254). Sometimes it
Fig. 254.
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
' S. C. Gordon of Portland, Me., Amer. Jour. Obst., 1884, vol. xvii. p. 1205.
DISEASES OF THE UTERUS.
439
Simon's Cone-mantle-shaped Excision of the Vaginal Portion: a, sutures inserted ; 6, sutures
tied. (There ought to be one or two on each lateral incision).
strong, curved, round, cre.scent-ground, or trocar-pointed needles or
the fishhook-shaped needles (Fig. 201,/, g, and /), held in a needle-
holder.'
Fig. 25(5.
A B C
Schroeder's Pinple-flnp Excisidn of the Vaginal Portion : A, excision made, sutures placed
on anterior lip aii<l tic<l mi posterior; 1 and 2, lateral sutures. 1$, longitudinal scciiun
through cervix: i^/ r, transverse incision :/ e, longitudinal incision joining the first and
severing the mucous membrane ami part of the muscular tissm? from the cervix; h c,
course of a suture ; f/, f)vula of Naboth. C, longitudinal section after the sutures are tied.
3. tShnon\'i Mffhnd, the so-called conc-mnnflr-sjiaped excision. —
After having made the two lateral incisions a wcdgc-.shapc<l piece is
cut out with a knife <tf the whole width of each lip from side (o side,
' My traclielorrliapliy needles (p. 418) are cjuite servicciible in this o|)cr:iti<ii).
440 DISEASES OF WOMEN.
Next, the two flaps of eacii lip are united by sutures, and, finally, the
two lateral incisions are similarly closed (Fig. 255).
This method is especially indicated when the cervix is very thick
and hard and the mu(!Ous 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
transveree incision is made through the mucous membrane of the cer-
vix at the base of each lip, and then a wedge-shaj)ed piece is cut off
from the os to the first incision. Each of tlie lips is folded trans-
versely, and the lower end of the cut surface united to the upper.
Finally, the side incisions are closed (Fig. 256). 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 a})pro-
priate than the cutting operations, since it necessitates the healing of
the wound by granulation and may lead to steno.-is of the cervical
canal.
If there is leucorrhea, menorrhagia, or metrorrhagia, it is proper
to combine curetting with the amputation.
If chronic parenchymatous metritis gives rise to persistent hem-
orrhage, salpingo-obphorectomy 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. 410), but the uterus may also become
closed later in life — acquired atresia.
Althougli not so rare as the congenital 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. 251). Ulceration of the cervix, diphtheria, small-pox, and scarlet
lever 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. 441
amenorrhea, abdominal pain, menstrual molimina, and swelling of
the uterus in consequence of accumulation of blood {hematometrci),
mucus (hydromdra), 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 giv^es rise to any symptoms,
unless it is complicated with some other disease of tiie 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-
raetra, 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 cut in four different directions with Simpson's metrotome
(Fig. 258). The uterine cavity should be washed out with an anti-
septic fluid, and packed with iodoform gauze (p. 184), followed by
an intra-uterine glass stem (p. 411). Jn regard to the dangers of
the operation, the reader is referred to what has been said in speak-
ing of atresia in other parts of the genital canal (p. 346).
CHAPTER VI.
Stenosis of the Cervix.
Stenosis, or narrowness, of the cervical canal is somewhat similar
to atresia, but tiie difference is that the cervical canal is o])en, although
the caliber is too small. IJke atresia it may be congenital or acquired.
It is often combined with a conical cervi.T, 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 ojien-
ing, sometimes so narrow that it does not even admit the common
uterine sound ( pinJiole ox). Less freciuently it is found at the inter-
nal OS. Sometime,s the whole cervical canal from end to end takes
part in the stenosis, but in other c«.ses it is, on the contrary, dilated
between the two narrow openings so as to form a l)arrel-shai)ed cavity.
The etiology of the acfjuin-d form is identical with tiiat of atresia.
f^ymptom.s. — If the menstrual l)loo<l is secreted in larger amomit
than what can jkiss in the same linu' through the nan-ow cervix, the
patient has ])ain [oh.sfnicfirr ihismcnorrhea). Often the blood coagu-
442
DISEASES OF WOMEN.
lates, and the clots are expelled with })ainful cramps. Also mucus
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. 429 and 43G) 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 ex-
perience is by no means common. The normal opening 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 different 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 Kiichenmeister's
scissors (Fig. 257), that have a blunt and longer blade for entering
Fig. 257.
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.
443
metrotome (Fig. 258) was used, a sheathed knife, the excursion of
which is regulated by a screw, and which cuts in one direction at a
time, or Greenhafgh^s metrotome, that cuts both sides at the same time.
When it was found tiiat this deep cutting not infrequently was accom-
panied by dangerous or fatal hemorrhage or by not less dangerous
Fig. 258.
Simpson's Metrotome.
and fatal pelvic septic inflannnation, superficial trachelotomy was sub-
stituted.^ 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 excentrically. There is no hemorrhage, and inflam-
mation is avoided by the use of antiseptic precautions (p. 209).
In most other cases I only use dilatation with blunt conical and
diverging instruments (p. 158), 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 I treat the })atient 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 o})en the dilator to full expansion, one and a quarter
inches in all directions. In order to avoid tearing the tissues tiiis must
be done very slowly and gradually. I introduce some iodoform into the
cervix, and cover it with iodoform gauze. The ])atient is kept in bed
for foin- 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 piu'pose 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 Fiigchuaini's electHnle (p. 248), for the former
Fry'sj which has six nickel-plated conical ti|)s, ranging from 11 to 25
millimeters in circumference, to be screwed on tli<' same iiaiidle. I
have, however, not found any advantage in tiie electric treatment over
the mechanical.
' IVaslee, Amcr. Joum. ObM., 1870, vol. ix. ji. 374.
444 DISEASES OF WOMEN.
CHAPTER VII.
Ulcers of Cervix.
AVe have mentioned, in treating of chronic endometritis (p. 408)
that the term ulcer is often erroneonsly applied to eroHio7is and gran-
ulations of the cervix. But the cervix may be the seat of true
ulceration — i. e. an inflannnatory process in whicli there is molecular
loss of substance. Such ulcers may be chancroids, chancres, tubercu-
lar idcers, simple vJcers, 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 idceration takes ])lace Avhen 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 substancic surroHuding 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 jn-olapsed, 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. 266), to be changed morning and evening.
Corroding ulcer looks mucii 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.^
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.
For ulcerated cancer, see Chapter XIIL, Sarcoma and Carcinoma.
CHAPTER VIII.
Hypertrophy of the Uterus.
An increased size of the uterus, apart from neoplasms, is com-
monly due to subinvolution or chronic metritis (p. 436) ; but it may
be due to sim])le hypertrophy, independent of all inflanmiatory action.
The uterus presents abnormally large dimensions, but there is no
change in structure. This hyi)ertrophy may be general or partial.
^ John Williams, Trans. Obd. Soc. of London, vol. xxvii., reprint.
DISEASES OF THE UTERUS. 445
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.*
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. 406) 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 hyi)ertrophy 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-sliaped mass. The
OS is large and forms a transverse slit. Very often the cervix has
sustained bilateral laceration (p. 415), and frequently the condition
is combined with prola])se 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 hy})ertrophy is unknown.
The acquired is evidently due to childbirth.
HymjdonuH. — Sometimes hypertrophy of the cervical portion does
not give rise to any symptoms. In other cases the patient eomj)lains
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. 441).
The friction against the vaginal walls may cause leueorrhea. When
the cervix })rotrudes from tlic vulva it is liable to become ulcerated
(p. 444). li' the hvjK'rtrophy is pronounced, it gives rise to dys-
pareunia, the male nuimlxT meeting Avith an obstruction, which is
pushed forward, causing discomfort and even pain to the female, and
sometimes to tlu; mah; too. The semen, being ejaculated into the deej)
jMHich formwl beliind tlw; cervix, does not easily enter the os, and
sterility is, therefore, (|uite common.
I)itignos-is. — TIk' diagnosis is easy. By vaginal examination the
finger may be carried round the hyj)ertroj)hied cervix, "^riie vaginal
' Schroeder has aiUlcl :is a tliinl catci^ory the hyportroj)liy of what Ik> calls the
inlrrmiylinlf. jxirlloii ; tliat is, that |»art of the corvix that is hound to the hiaddcr in
front, but has iH'hiiid the deep iionch fomii'd liy tlio posterior fornix of tiu' vatjina
(p. 42 ; from a practical standpoint this variety may ho taken toirctiier with the
Btipravjiginal.
440 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-
vereion.
Treatment. — Slight degrees of elongation may successfully be
treated with dilatation (p. 156), 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. 438) is the best ; for hypertrophy with thickening of the cervix
Simon's cone-mantle-shaped excision (p. 439) 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 wath a
few stitches. The common ecraseur has the fiult of having a ten-
dency, w^hile being tightened, to pull in neighboring tissue, 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. 441).
B. Supravaginal hypertrophy consists in the increase, especially
elongation, of that part of the cervix that is situated above the
utero-vaginal junction.
Pathological Anatomj/. — The supravaginal part of the cervix is
felt as a long cylindrical body, somewhat flattened in the antero-
posterior direction, and, as a rule, thinner than normal ; but excep-
tionally it is of normal circumference or even thicker. 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 (cystocele) ;
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 upjier
part of the cervix.
Etiology. — This condition is due to prolapse of the vagina (p. 356).
The body of the womb remaining in its place, and the cervix being
DISEASES OF THE UTERUS. 447
pulled down, the latter 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 tlie vaginal entrance, frequent childbirth, too early get-
ting up after deliv^ery, subinvolution, occupations that keep the woman
in a standing position, and vebereal excesses, lead indirectly to hyper-
trophy of the supravaginal cervix.
Symptoms. — The symptoms are like those of prolapse of the vagina
and uterus, combined with those of infravaginal 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 mucous membrane 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 antefiexed or retroflexed, 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 participates in the inver-
sion, so that the lips of the os uteri are situated far apart, and the
inverted cervi(!al canal a})pears between them, more or less inflamed
or even ulcerated (p. 444).
Diagnosis. — A pohjpus and an inverted uterus have no opening at
the lower end. In the itifr<iv<i(jiii(tl lii/pertrophy the vaginal vault
is normal. The chief })oint in the diagnosis is the distinction from
prolapse of the uterus, with which the supravaginal iiyj)ertroj)hy is
often confounded ; but the fing('r-sha])ed mass formed by the cervix
is easily felt by bimanual ])alpation with one finger in the rectum;
the uterus is felt in its place; tiu; uterine cavity is much deeper
than in simj)le prolaj)s(' ; a catheter introduced into the bladder is not
felt from the rectum, tlie uterus intervening between the two canals.
Frequently, however, the hyj)ertrophy is combined with j)rolapse.
Prognosis. — Xo spontaneous cure is lo be expected.
Tredtment. — In the lesser degrees the uterus may be pushed up,
th(! body becoming strongly nuteverted, and nuich comfort may be
afforded 1)V the use of a cujHshaped su])i)orter attached to an abdomi-
nal belt. (See Pro/ojisr.) IT this j)l;iu does not su('ce(>d, i"eeours(!
nnist be h;id to ;in oper:ition.
1. JI(t/iir''.-< Method, Fit ini< l-.^Jio jted I'lrrixioii (I'^ig. 209). — Dorsal
])Osture. The cervical ))ortion is e.\|)osed with a single Sims or
(iarrigues speciilinn and latei'al retractors, seized with a \olsella,
and pnlled (htwn. A circuhir incision is made below the ntero-
448 DISEASES OF WOMEN.
vaginal junction. From this the knife is carried in a slanting direc-
tion upward and inward to the cervical canal. When the canal has
Fio. 259.
Hegar's Funnel-shaped Excision of Supravaginal Cervix (natural size).
been opened in front and the hemorrhage is considerable, a suture
is passed immediately under the whole wound in the cervix, and so
as to comprise the mucous membrane 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 membrane of the cervix is sutured
all around to that of the vagina, passing the sutures with small,
strongly curved needles under the whole wound — a procedure that is
very difficult. It is, therefore, preferable to apply the thermo-cau-
tery as soon as a part is cut, and continue alternating with the cut-
ting and the searing instrument, or to do the whole operation wdth
the galvanocaustic knife (see p. 450).
2. Schroeder^s Method (Fig. 260) 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. 462) 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
DISEASES OF THE UTERUS.
449
carried through the vaginal wall, the parametral connective tissue, and
the severed cervical wall, and out through the cervical canal. If
necessary to check hemorrhage, several such deep sutures are passed
Fig. 260. A.
Fig. 260, 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 ])eritoneal cavity is opened, the rent may be
clo.sed separately with silk or catgut, or comprised in the sutures fixing
the po.sterior 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.
.'>. KcdfenbdcJi^s Method (Fig. 261). — After emptying the bladder
and pushirig the intestines u|) from Doughis's pouch, the cervix is
constricted at the vaginal entrance with an elastic ligature, which is
stitched to tiie inverted vagina in front and behind, or the uterine
artery is s<'cured on both sides (]). 188). A cireuhir incision is mad<',
and the elongated supravaginal cervix is <'asily separated from the
surrounding tissue with knile and scis.sors, and even partly with blunt
instruments. A\'heii this has been done to the extent deemed iieees-
.SJiry, .sometimes even above the internal os, the cervix is divideci with
Kiichenmeister's scis.sors (p. 442) into an anterior and a ])osterior half,
a transverse incision is made through the mucous meml)ran(! o(" each
iialf, an inch from the lop, and the nnicous membrane; is dissected off,
29
450 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
Fig. 261.
Kaltenbach's Supravaginal Amputation of tlie Cervix.
are stitched to the vaginal wall with three or four deej) sutures, coin-
prising some of the muscular part of the stump. If we go too near
the constrictor, the stumps of the cervix are apt to retract be-
yond 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 tiie 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 tiie ligated blood-
vessels, and affords an excellent adaptation of the fornix to the stun) p.
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 stum}).
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. 253). But even this does not prevent secondary hemorrhage,
and is liable to cause stenosis of the cervical canal (p. 441). Tiie
patient should, therefore, be carefully watched during the healing
process.
Besides primary and secondary hemorrhage, those methods of the
DISEASES OF THE UTERUS. 451
supravaginal amputation which leave a large deep-seated, more or less
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 tlie Uterus.
5. Abdominal Hysterectomy. — If the supravaginal hyi^ertrophy 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 ; Superinvolution.
Atrophy of the uterus may be congenital or acquired. We have
described the congenital form above (pp. 411,412) as the fetal, the
infantile, and the pubescent uterus.
Acquired atrophy is a normal condition after the climacteric (p.
127), — 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. 441).
The writer has also always found atrophy of the uterus in removing
this organ after having previt)usly performed salpingo-oophorectomy
on the same patients.
Patliologicid Anatomy. — In the non-puerperal form the uterus is
small, the vaginal ])ortion (lisai)j)oars 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 blocxl. The cavity of the uterus
is less deep than normal.
The puerperal atrophy differs in some resjM}cts from the non-puer-
peral form. The walls are thin and often very soft, and the uterine
cavity may preserve its normal de|)th.
pjtioUxjy. — Pu(!rperal atroj)hy, or supcrinvolution, is a rare disease.
It is, j)erhaps, oftener ('oiuiected with abortion than with childbirth.
It is caused by loss of I)1o(h1, protracted lactation, debilitating dis-
eases, such as scarlet fever, tuberculosis, chlorosis, syphilis, diabetes,
Bright's disease, and exophthalmic goiter.
Th(! non-j)U('rpcral atrophy can be caused mechanically by press-
ure of a uterine (ii)r()i(l or an ovarian (;yst. It may l)e brought
about bv trachelorrhaphy, ampntution of cervix, or oophorectomy.
Sometimes salpingo-o<')phoritis seems to be tiie cause of it, and it
has been found together with paraplegia.
452 DISEASES OF WOMEN.
Great acquired atrophy of the uterusand ovaries occurring in a young
healthy woman, who never had been pregnant, has been observed/
St/mptoms. — 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 155). 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. 413).
CHAPTER X.
Gangrene.
Gangrene of the uterus may occur as a result of puerperal infec-
tion and is then fatal ; but an inverted uterus, a fibroid, or a cancerous
tumor may slough, and in this way a spontaneous cure may occur.
Treatment, — The patient's strength sliould 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. 175), and
even in the interior of the uterus.
CHAPTER XL
Hysteralgia.
Hysteralgia, or neuralgia of the uterus, 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. — Ilystc^ralgia 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
' Martin Schuli, Med. Record, Dec. 24, 1898, vol. liv. p. 914.
DISEASES OF THE UTERUS. 453
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 tlie 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, according to the etiology, calls for tonics
(p. 242), antiperiodics, or antirheumatic medicines. The galvanic
current, with the positive pole in the vagina or uterus (pp. 248,
249), is very effective, and so is the high-tension faradic current
(p. 246).
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 ])ushed forward and downward,
while the cervix moves upward and backward. During expiration the
opposite movement takes j)lace. During urination and defecation it
is pushed down ; during copulation it is lifted up. It is therefore
clear that the uterus is an umisually mobile organ. But certain ])er-
manent changes and deviations from the normal take place under
certain conditions, and constitute the so-called displacements. These
are antevrrsion. anfcfle.riou, retroversion, retrojle.rion, lateroversion,
laterojlexion, ante position, retro position, lateroposition, prolapsus, ele-
vation, inversion, and hernia.
Anteposition, retroposition, and lateroposition, if not due to press-
ure from a neigliboring tumor, are developmental abnormalities of
merely anatomical interest (p. 413).
A. Antevrrsion.
Anteversion (Fig. 202) is that j)osition of the uterus in which the
fundus points forward, and sometimes downward, to tlie symj)liysis
pubis, the os backward, and sometimes upward, toward the sacrum.
The uterine canal preserves its normal direction in a line tliMt is
stniight or slightly curved forward (p, 52),
l'at}iol()(/ieal Aiidtounj. — The uterus is more or less enlarged ;uid
in a condition ol" chronic metritis. 8()metin)es adhesions are luund
454
DISEASES OF WOMEN.
between the fundus and the peritoneum or signs of celhilitis 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. 262.
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 ; or to a
deficient development of the vaginal portion or its operative removal.
Anteversion is sometimes due to subinvolution after childbirth or
abortion, but is not rare in virgins.
SymjAoms. — These are the same as in chronic endometritis and
parenchymatous metritis (pp. 427 and 436), 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.
455
ehanical 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.
Diagnods. — 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 wiiat has been said above (pp.
432-435 and 437, 438). The remedies especially useful are the hot
douche, glycerin or ichthyol tampon,
Fig. 263. scarification, electrolysis, gold, corrosive
sublimate, massa2:e, and hemostatic meas-
ures (pp. 181, 182 and 243).
The uterus may be lifted up by means
Fig. '204.
iiraily Hewitt's Antevtjrsinn IVs.sary :
ab, anterior bow restiiiK on tlie ante-
rior wall of the vajrina: r <, upjier
end pre-ssint; on tlu; anterior surface
of the uterus ; (/, pcislerior bow going
behind cervix.
Thomas's Anteversion Pessary: ^, lower end rest-
ing just inside the vaginal cTitrance: B, unpen
end to be introduced in tlie posterior pouch of
the fornix: (', anterior, nioval)le bow, which is
to lift the uterus through the anterior pouch of
the f<iriiix.
of vaginal peasarU.s — that is, supporters. Those most used for tliis
purpose are Graily Hewitt's cradle pessiuy (Fig. 203), Thomas's two
kinds (Figs, 204 and 205) of anteversion ])essaries, Gehrung's ])es-
sary (Fig. 200). If the uterus bends over these instruments and
an anteflexion is formed, they do, however, more harm than good.
There is a soft-rubl)er Vienna pes.sary consisting of a tiiick elas-
tic ring which surrounds the cervix, and a straight ])ieee lying
in the canal of the vagina, which I occasionally have found very
u>eful.
456
DISEASES OF WOMEN.
General Remarks about Pessaries. — Some pessaries, such as elastic
rings, work bv pressing excentricallj on the vaginal walls ; others, a
class to which the above-mentioned
Thomas pessary (Fig. 264) belongs, S'lo- 266.
rest against the muscles and fasciae y' \
forming the vaginal entrance;
Gelirung's pessary and Thomas's / i
Fig. 265. /
Thomas's Horseshoe-shaped
Anteversion Pessary.
Gehrung's Double Horse-
shoe-shaped 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 })essary
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
i-ather 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. Hard-rubber pessaries become eroded or incrustcd, and
must then be removed.
Pessaries are introduced while the patient occupies the dorsal or
left lateral position. In aiitedeviations the former is preferable, in
retrodeviations the latter. The uterus ought, as a rule, to be replaced
in the right position with tlie 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. 142).
DISEASES OF THE UTERUS. 457
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 tlie 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 fii*st, rolling over the
perineum, then the middle piece, and finally the upper ring.
Thomas's anteversion 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 the rest of the instrument and
push it in front of the cervix ; finally, the Mhole 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 }>essarv 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 hoi-seshoes 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 ]>osterior
wall and the two horseshoes embrace the cervix anteriorly. In with-
drawing the same movements are gone through in opposite order.
The best-fitting j)essarv 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 ac^id, in order to keep the pessary clean.
She should also be instructed to remove it immediately if it causes
])ain, as neglect in this respect may cause serious pelvic infiammation.
An elastic abdomhutl hell may give comfort by taking off pressure
from above and steadying a large mobile uterus. The latter object
is attaiiKid still better by an abdominal suj)porter witli a solid hyj)o-
gastric; pad, such as tiie one represented in I'Mg. 179, p. 200.
Certain opcmtlonH have proved useful in different ways. If the
cervix is thl(;k, Simon's con(>-mantIe-sliaped excision (p. 4^39) may l)e
performed, and result in a considerabh' reduction in the size of the
bo<ly of th(! uterus (p. 438).
Sims fi)lded the anterior wall of the vagina transversely, denuded
the wlges of the fold just in front of the cervix and an inch and a
458
DISEASES OF WOMEN.
half lower down, and united the two somewhat crescent-shaped sur-
faces with silver- wire sutures (p. 234).
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 anteflexion (Fig. 267).
Fig. 267.
Anteflexion (Orally Hewitt).
Claitsification. — 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-corporcal, 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.'
' T. G. Tlioma-s, Gynecol. Trann., 1888, vol. xiii. p. 142 — a paper of the greatest
value to anyljody who undertakes to treat antellexion.
DISEASES OF THE UTERUS. 459
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-
atefl 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. 436), with enlargement of the
cavity. Frequently the supravaginal portion is elongated (p. 446).
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 at 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 wall
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 time
it is more liable to become anteflexed than after it is fully formed.
The pressure of corsets (p. 131) 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. 130), which again weakens the tissue of the womb. Mastur-
bation (p. 318) causes hyperemia, and thus furthers anteflex-
ion. Exposure during menstruation (p. 131) may have a similar
effect.
The acquired form is, however, mostly due to inflammation of the
uterus or its surroundings : metritis, which makes the uterus heavier ;
cellulitis around the utcro-sacral lig-aments, which pulls the angle
between corpus and cervix uj)ward and l^ackward ; and perimetritis
or inflammation of tiie a])p('ndages, resulting in adhesions pulling
the fundus forward and downward. These inflammations are also
caused by g(morrlical or puerperal infection, or may be simply due
to colds ; that of the sacro-uterine ligaments may also originate in
irritation caused by tiie j)assage of hard scybala.
Anteflexion may also be due to subinvolution following childbirth
or abortion ; pressure from an alxhuninal tiuiior; the presence of a
growth, especially a fil)roi(i, in the wall of the corpus; and softening
of the uterine ])arenciiyma in consequence of wasting diseases or
insufficient nutrition.
Sym/)tomt<. — Sometimes women with pronounced anteflexion enjoy
perfect health, and the only thing that brings them to the ])hysi('ian
is sterility. The svriiptoni next in frequency is (lysiuenonhea (]).
2511), which may be (hie to obstruction at tiie angle with formation
460 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, es])ecially j)ain in the epigastrium, with dys-
pepsia, intercostal neuralgia, headache, backache, asthenopia (p. 229),
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. — AVhen 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
(pp. 154, 155).
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, wliich is often
the case. Otherwise there is tendency to relapse. I have never seen
an anteflexed womb become straight, but the symptoms may dis-
appear and the patient feel well. Irreducible cases have to be
treated by 0})erations, which are, however, not sure to result in
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 kejit open, and
a tonic treatment followed in regard to food, regimen, and medicines
(p. 242).
Congestion and inflammation are combated with hot vaginal
douches (p. 176), glycerin or ielithyol tampons (p. 182), painting
with iodine (p. 175), and scarification (p. 194). When there is a
DISEASES OF THE UTERUS.
461
Fig. 268.
tendency to hemorrhage, curetting (p. 181), with or without intra-
uterine packing with iodoform gauze (p. 185), does a great amount
of good.
The curvature may be attacked directly with sound or fingers.
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 Avitli the concavity back-
ward, establishing a transient retroflexion. The uterus may also be
stretched bimanually by pushing the cervix back with a finger in the
vagina, and pressing, with the other hand, on the fundus 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. 157)
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. 192).
Some praise electrolysis (p. 443).
An abdominal belt or supporter
(p. 199) 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 j)essary may irritate
and cause inflammation, tlie intra-
uterine stem (Fig. 2G8) is still more
dangerous.' It should be of glass,
and half an inch shorter than the
cavity of the uterus. It may be
solid or hollow, straight or sh'ghtly
bent. In order to hold it in place,
it is sometimes coiubiiicd with a vagi-
nal pesHjiry Juiving a little ouj) into
which the plat(! of the stem fits. It siiould iuive a string attaclKd
to it. It is introduced with the fingers or dressing- forceps (p. 152)
through a Sims sjx'cnhiiii.
Irreducible cases may l)e treated by cmj)loying the
opcrati(»n :
' (iarri>^iu's, "(/'ase Illiistratin<^ tlie Danger of Stoin IVssarics," Anitr. Jour. (Jlisl ,
lS7y, vol. xii. p. 7o<).
iiIni-iitiTin(> Slciu aiui Itclnilloxiuu-
Tesi^aiy witli Cup (T. G. 'I'lioiuas).
r..ii
(»\\ iiig
462
DISEASES OF WOMEN.
Garricjues^ Discission of the Posterior Lip} — The patient is placed
in the dorsal position with elevated feet. The cervix is exposed with
Gtirrigues' weight speculum (Fig. 192, p. 226), and pulled down
Fici. 269.
A
Anteflexion OpenitiDn, S|ilitting jjosterior lip of eervix : a, Garrigues' weight speculum ;
?>, transverse furrows of vagina; r, incision in median line of cervix to uturo-vaginal
junction; d, os after dilatation; e, bullet-forceps.
with a l)ullet-forceps applied to the right side of the eanal. As a
rule, there will be indication for curetting, and, at all events, the
' This operation, as I now perform it, is an evohition from Sims' operation, de-
scribed in former editions. The advantaf;;es are absence of hemorrhage, of suppura-
tion, and of danger to life or health, and a speedy recovery.
DISEASES OF THE UTERUS.
46a
uterus is washed out with creolin emulsion (1 : 100). Next, tlie
posterior lip is cut in the median line up to the utero- vaginal junc-
tion (Fig. 269, A) with KUchenmeister's scissors (Fig. 257, p. 442),
and the incision extended up through the internal os with Simpson's
metrotome (Fig. 258, p. 443), until the opening admits the tip of
the finger. A second bullet-forceps is now inserted in the left Hap
of the cervix, and the edges of the first incision are seized with a
tenaculum and brought together with a running suture of chromi-
cized catgut No. 2, uniting the mucous membrane of the vagina
with that of the cervical canal. If there is no hemorrhage, the
cavity of the uterus is packed loosely with iodoform gauze, and the
Fig. 270.
7?.— Cervix split open; n, vagina; b, cut surface: r, anterior wall of Cervical canal. '/,
external os.
C.—a, b, c, (I, as in /// c, runnint; .'^uturo of cliromicizcil catgut, uniting the edges of the lir.vt
incision.
vagina is treated in the same way. If there is some bleeding, tlie
uterus is ])aeked tightly, and under the vaginal gauze is ])hiee(l a
hemostatic tampon of cotton wrung out of creolin (p. IH.'i). In this
ease, the vaginal dressing is removed or changed the next dav.
Otherwise it inav remain undisturbed ibr several days, but by ehaug-
ing the loo.'je vaginal ])acking every day a more elTeetive (b'aiuage
of th(! uterus and its app<'ndages may be secured, if desired. The
wound lieals by first intention ; when the intni-uterine jiaeking
is removed after five or six days, a glass stem is kept in the
uterus during the remainder of the healing process at the inter-
nal OS.
464
DISEASES OF WOMEN.
If the anteflexion is complicated with considerable elongation of
the cervix, the preceding operation may be combined with amputa-
FiG. 271.
D
Z).— Side view of sagittal section : a, vagina ; b, uterus ; c, base of first incision ; d, base of
second incision.
tion of the cervix by cutting off the end of the open cervix before
suturing it.
Salpingo-odphorectomy. — 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 retrojlexioji,
corresponding to anteflexion.
In retroversion tiie uterus as a whole is tipped backward over a
transverse axis. Accordino- to the de2:ree to which the tilting: is car-
ried the os points downward or forward against the symphysis pubis,
and the fundus, just opposite it, turns ujiward or backward toward the
sacrum. The longitudinal axis is straight. In most cases retroversion
is only a transition to retroflexion, or the two are combined ; the
DISEASES OF THE UTERUS.
465
pathology, the symptoms, and the treatment are identical, and since
the flexion is so mnch more common than the version, Ave prefer to
describe them under that heading.
Diagnosis. — We have seen above (p. 460) that the direction of the
cervix might lead one to think of antefiexion, 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.
Fici. 272.
Retrnflcxion of the Uterus (Fritsch).
272). It is often combined with retroversion, when the os points
downward and forward.
30
466 DISEASES OF WOMEN.
Pathological Anatomy. — Besides the peculiar shape of the uterus,
we find, as a rule, signs of chronic metritis, 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; otiiei-s 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 subinvolution 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 auteflexed position ; but vyhen 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 shallowness 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 salpingitis, 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 metritis 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. 436) : 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 are, as a rule, prominent
features.
DISEASES OF THE UTERUS. 467
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-tle-sac of the vagina. That might 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, tlie
direction of the uterine cavity may be ascertained with the sound or
probe.
There are cases of flabby uterus without adliesions in which the
corpus moves at tiie 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 adliesions 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 tlie 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, and the
uterus does not rise spontaneously out of the pelvis, a serious con-
dition may be brought al)out. In some cases operations are neces-
sarv in order to procure relief, and in the laboring classes, in which
harder work is combined with less cleanliness and care, they are
j)referable to pessaries.
Treatment. — If the uterus and its surroundings are tender, the
inflammation should be combated with hot vaginal douches (p. 176),
painting with iodine (p. 175), and iciithyol or glycerin tampons (p.
182) before any attempt is made to replace and retain the uterus in a
i)etter position. If there are signs of chronic metritis, curetting (p.
181) and packing with iodoform gjuize (p. 185) 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 tin; patient in the genu-pectoral
position (p. 140) an<l introduce Sims's speculum. In rare cases this
may suffice to make the fundus uteri sjwntaneously sink l<)rward.
The pressure may be increased by means of a sponge on a sponge-
holder or a cotton tampon held in a dressing- forceps ap])lied against
the posterior vaginal vault.
Bimannal Maniprdation. — Another way is to place the patient in
the dorsal decubitus, intnxluce one or two fingers into the vagina, ami
4G8
DISEASES OF WOMEN.
press their tips, with the volar surface turned up, into the posterior
vault. The four finders of the other hand are inserted above the
symphysis pubis and press the abdominal wall down until the fundus
Fig. 273.
Bimanual replacement of retrofloxed uterus.
of the uterus is reached and can be pulled forward, while the fingers
in the vagina push in the same direction (Fig. 273). This method
can only be used on rather lean patients.
Digital Pressure. — A good Avay 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 .«acro-iliac synchondrosis.
depositors. — 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. 154, 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 circum.scril)e 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-
DISEASES OF THE UTERUS. 469
finger of the left hand helping to tilt the uierus forward by pressing
ou its posterior .surface. As soon as a resistance is felt or the reposi-
tion causes pain, the o])eration should be discontinued.
Pessaries. — When the uterus is replaced, it is kept in the normal
position by means of a pessary. Tiie best is Emmet's modification
of Hodge's (Fig, 274). It is made of hard rubber, and is introduced
Fig. 274.
Hodge-Emmet Pessary.
in the following way : The patient being in Sims's position, and
the doctor standing behind her back, the j>essary 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
pe&sary is pushed tiirough the vaginal entrance pressing upward
toward the j)romontory and backward against the ])erineum.
When the broadest part has j)asse(l the vaginal entrance, the pessary
is turned into the coronal plane. Next the lower end is seized from
the point with tiie left thumb and index-finger, and the right index-
finger is applied to the inside of tiic u})p('r arcii, which, by a com-
bined movement with both iiands, is brought uj) l>ehind the cervix
as high as possible. Finally, the right index-iinger is inserted in
front of the lower arch and pushes it back, the effect of which is
to pusli the up[)er arch well forward ag-.iinst the posterior surface of
the uterus. Beginners arc ai)t 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 ])('ss:iry may be introduced while ])ull-
ing the perineum bac-k with Sims's speculum, a method which oilers
the advantage that th(; hand is guided by the eye.
Most pessari(>s on the market have too strong a curvature. This
may i)C remedied by dipping them in oil and heating them in the
flame of an alcohol lamp, when the hard rubber becomes soft and
("an l)e shajxnl at will. A well-fitting jx'ssary extends from the dej)th
of the posterior cul-de-sac to the vaginal entrance, and takes its sup-
port th<'re. It follows the normal curvature of the vagina. The
470 DISEASES OF WOMEN.
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
Fig. 275. backwarcf over the pessary, which then
does more harm than good. To obviate
this the vagina may he deepened by meth-
odical packing (p. 183). In e.xceptional
cases 1 have succeeded with Fowler's
pessary (Fig. 275) wlien others failed.
Some use the intra-uterine stem with or
Fowler's Pe>,sary. without Vagiual SUpport (p. 461).
Postural Treatment. — Some help may
be derived in the treatment of movable retroflectcd uteri by direct-
ing 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 recommended 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.^
In some women it is only necessary to use the Hodge pessary for
some time, say from three to six months. Others need it all their
lives.
General remarks about pessaries are found on p. 456. An
elastic abdominal belt (p. 199) 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-
rhaphv, 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, in addition to the other opera-
tions, the perineum should be repaired (p. 327).
2. Trachelorrhaphy and Wedge-shaped Exeision of Cervix. — If the
cervix is torn, it should be brought together (p. 419) ; and even -if it
is not torn, but bulky and presenting a large canal, Gordon's operation
(p. 438) should be performed. The involution caused in the body
1 H. F. Campbell, Gyn. Tranx., 1885, vol. x. p. 305.
DISEASES OF THE UTERUS. 471
of the uterus by operations on the cervix (p. 438) is in many cases,
together with postural and astringent treatment, sufficient to ensure
the reposition of the displaced womb.^
3. Extraperiioneal Shortening of the Round Lkjaments {Alex-
ander's Operation). — This operation is chiefly indicated in cases where
there are no adhesions. Its object is to keep the fundus forward bv
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.
3Iodu8 Operandi. — The pubic hairs having been shaved off, and
the vagina having been disinfected, the womb is replaced with a
uterine sound, and in cases of retroversion a small easy-titting Hodge
pessary is introduced. In cases of retroflexion this is combined with
an intra-uterine stem. The patient is then stretched at full length
on her back. The operator stands on the side of the table oppo-
site the ligament to be operated upon. He feels for the spine of
the pubis, and makes with his nail a little dent in the skin over it.
An incision is made approaching tlie j)erpendicular line a little more
tlian Poupart's ligament, just in the direction of the slit between
the pillars of the external ring, but so as to stay within the region
covered by pubic hair, which covers the cicatrices entirely, 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 exteruus alxiominis muscle. Beginners
should, however, first cut through the skin with one incision, then
sever the sul)cutaneous connectivt! tissue with several smaller cuts
in the same direction, until the superficial fascia is exposed, n(>xt
divide this with one in(Msion and lay bare the ])illars in their full
length and the intcrcolumnar fascia with its transverse fibers, ])artly
witii the edge aud partly with the iiaudh' of th(! scalpel. The ring
is situated immediately abov(; and a little outside of the s])ine.
Bleeding vessels are tied or (■om|)ressed. From the ring emerges
a bunch of adij)Ose tissue that contains the ends of the round liga-
ment, which sprea<l out in fine filaments often hard to distinguish.
Tiiis who/r nid.ss is seized with a pressure-f()rcej)s, and an aneurism-
needh; inserted under it c/omc to the hone. Next we })idl on the m;iss,
and see tlie white genital branch of the genito-crural nerve, which lies
just in front or to one side of the ligament. If it is in tliewav.it is
severed with knife or scissitrs, and so are some fine tendinous fil)(>rs
runuintr fnxu the liif:im<iit to the wall of the canal. Sometimes the
p!-ritoueum is in\!igin;ite(l and accompanies the ligament, from which
it must i)e stripj)e<l with the fin<j:ers and pushed back. When the
' fiordon and Kiitrflmaiin, Iiitfrnational M('(li<'al Concrn'ss, l-^Sl ; Onnptf-irwln iks
Irnvdux (Ik la St-r/ion 'T (Jhstt'lrii/w ct dn (lijncrdbujir^ pp. 157-1()0.
472 DISEASES OF WOMEN.
li«^amont begins to peel out easily, this side is covered with an anti-
septic or sterilized pad.
The operator now steps over to tiie other side of the table, and
repeats the operation on the other ligament.
^^'hen both ligaments are free, they are pulled out from 2 to 4
inches, until a decided resistance is met.
Next, the ligaments are secured in their new position by passing
two or three sutures of chromicized catgut through the pillars and
the ligament, and in so doing we should keep outside of the center
of the ligament in order to avoid tying the artery (p. 60), which
might lead to slonghing. 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
external wound closed with interrupted silk or silkworm-gut sutures.
In very fat women, or if the tissues have l)een 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 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 breaks or cannot be found, it is necessary to split
the anterior wall of the inguinal canal.
Xobody should undertake this operation M'ithout having tried it
several times on the cadaver, since even experienced surgeons have
found it difficult or impossible to find the ligaments. The structures
mentioned above should be distinctly seen, but no muscular tissue
is at any time visible. If any apjiears, it is a sign that the opera-
tor has gone too deep, and he should try to find the ligament more
superficially. In case no ligaments were found or that they tore,
the operator should search for them from the vagina and fasten
them there (p. 475).
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 0])eration are on record.
If the fundus is held back by adhesions which cannot be disposed
of by manipulation, hqiarotoniy should be performed, the adhesions
severed, and the uterus kept forward by one of the methods presently
to be described.
Instead of the buried sutures, one or more silkworm-gut sutures
may be inserted through the skin, the superficial fascia, the pillar,
and the ligament, and left for two weeks. The intra-uterine stem
is withdrawn at the end of three weeks. The Hodge pessary should
be worn nine weeks or lono-er.
DISEASES OF THE UTERUS. 473
Alexander lays such stress upon the use of pessaries that he
declares the operation is not properly performed without them.^
The intra-uterine stem should always be used in cases of retro-
flexion ; but as I as a rule combine the Alexander operation with
colpoperineorrhaphy, it is not feasible to use the Hodge pessary at
the time of operation.
4. Forcible Tearing of Adhesions {Schultze's Method). — When the
uterus is bound down with adhesions, Schultze dilates the cervical
canal with aseptic laminaria (p. 157). He introduces the index- and
middle fingers into tiie 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 aixlominal wall. When the uterus is replaced, it is
kept in situ witli a })essary. 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.^ It is much safer to open
the cul-de-sac.
In a modified form Schultze's method may, however, be recom-
mendable. The cervical canal is not dilated, the patient is anes-
thetized, and if there is not found any marked enlargement of the
tubes and ovaries, and the adhesions are not unusually dense, they
are torn by bimanual manipulations in the vagina and through the
abdominal wall.
5. M(tssar/e ( Hr<rrid1\^ Method). — Not less efficacious and safer than
Schultze's is Brandt's method, that obtains similar results by means
of manipulations dircrtcd through the aixlominal wall and the vagina
(p. 199). By this method the adlicsions are stretched gradually, and
made to be absorbed by increase in vital processes.^ If, however,
there is a pyosalpinx or other |)urulent collection in the ])elvis, the
])us may be pressed into the peritoneal cavity and cause an acute
indamniation that may end fatally.
0. Jft/steroj}e.rl(t, or Wdinh-fitsleiiiiui.* — There are tliffereut opera-
tions by which the uterus is stitched to other ])arts in order to
mfike it adhere in a position that prevents it filling back again.
They may be <livide(l into two classes, according to the ])oint
chosen for the adhesion — viz. rdt/imtl hijsteropexid and (ibdotni)ud
hifxteropcrid.
A. Vaf/i)iaf IFi/.sfrrojx.rid. — In this operation the anterior wall or
' Willium Aleximiit r, I\nrlic<il Gi/iu'roloip/, I'Miiiburjjli, 1890, p. nO.
' Kricii of I'.Mltimorc, Aam: .fonr. OhM.', Oct., 18S0, vol. xiii. p. 83() ; Van de
Warker of Syracuse, (iiju. 'I'mnx., 1881. vol. vi. p. 18').
' lu)r {Ictails tlu- reader is referre<l to |)r. V'inebertr's pa|)er, (juoted on ]>. ISS.
* Hysftcrd, wonil) ; ju'tptiimi, i fastcTi. Tlii.s name i.s more correct than liystcnirifi(ipfii/,
which means oniv womh-sewin''.
474 DISEASES OF WOMEN.
the fundus of the uterus is made to adhere to the anterior wall of
the vagina by the introduction of temporary sutures.*
It ox})oses 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,
Avhich prevented engagement of the fetus. Other operations should,
therefore, be preferred.
B. Abdominal Hystcropexia, or Ventro-fixation of the Uter'us. — In
this operation the uterus is attached to the abdominal wall. There
are many varieties, but wc shall describe only one.
Kclli/'s 3Ietho(h'^ — An incision is made in the median line, be-
tween three and four inches in length, beginning about one and a
half inches above the symphysis pubis. The uterus having been
lifted up, a ligature is carried through the parietal peritoneum and
adjacent tissue one-eighth of an incli deep and a third of an inch
wide, and througli the posterior wall of the uterus below the fundus,
and finally through the peritoneum and adjacent tissue on the other
side. When this suture has been tied, a second is carried in a
similar way just above the first on the abdominal wall and below it
on the ])ostcrior 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. In a
subsequent laparotomy the adhesions have been found drawn out to
a cord two inches long, extending from the abdominal wall to the
fundus of the uterus. Such a cord contains an clement of danger
in regard to intestinal obstruction ; but so far no such case has
been reported, although the operation is extensively performed.
C Desmopexia, or FaHfcniv<j of the Rouvd Lic/aments. — Instead
of attacking the uterus itself, the round ligaments may be used to
correct its position.
a. Ventrofixation of the Round Ligaments. — a. Olshausen's Method.. —
After having opened the abdomen as described, and lifted the uterus
up, three sutures of chromicized catgut (Leaven's No. 1) are carried
on each side with a curved needle through the round ligament and
the peritoneum, transversalis fascia, and part of the rectus abdominis
or pyramidalis muscle, at intervals of about half an inch, the upper-
most being inserted near the cornu of the uterus. The needle
should not be carried so deep into the ligament as to interfere with
the funicular artery (p. 59). All six sutures are inserted before any
' Mackenrodt, Deutsche med. Wochensc.hr., 1892, No. 22, with improvements I'V
Winters (Centralbl.f. Uynak., 1893, No. 27, p. 627), Diihrssen {ibid., No. ;^0, p. ti90),
Orthmann {ibid., No. 45, p. lOoS), and others.
■■'Howard Kellv, " Siis[)ension of the Uterus," Jour. Amer. Med. Ashoc, Dec. 21,
1895, vol. XXV. p." 1079.
DISEASES OF THE UTERUS. 475
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.
/9. Beck's Method^ is an adaptation of Bassiui's operation for
inguinal hernia. The abdomen is opened in the median line and
the uterus lifted up by means of a volsella or a temporary suture
through the fundus. One of the round ligaments is separated from
the broad ligament, near the uterus, and a loop about one and a
half inches long pulled out of the peritoneal cavity. Next, the
peritoneum is united behind the loop, and in a second layer tlie
aponeurosis of the ol)liquus externus muscle, piercing the loop at
both ends. Finally the abdominal wound is closed.
6. V(i(final Fixation of the Round Ligamentn ( Vineberg's 3Iethod).^
— The operator seizes the anterior lip with two volsellsn and draws
the uterus down to the vulva. Another volsella is inserted into the
anterior vaginal wall, just beyond the urethral mound, and the ante-
rior wall put on the stretch. Next an incision is made from the
urethral mound to the cervical attachment of the cervix, and the
two flaps are separated from the bladder, using partly the handle
and partly the edge of the knife. The sej)aration should be gener-
ous, in order to gain room. The two flaps are then held asunder
by tenacula near the cervix ; Avitli a stroke of the knife the vesico-
vaginal septum is divided, and the bladder separated from the
uterus with the iudex-tiugcr.
It is well to insi'rt the two in(l(\\-tiugers into the opening between
the bladder and the uterus and dilate it as much as possil)le, avoid-
ing undue force.
The cervix is now pushed backward with the two volselije, and
Enghsmaun's retractor is inserted into the op(>ning, so as to hold the
bladder out of the wav. liy this nuuneuvre the lower part of the
anterior surface of the uterus is exj>osed. A traction suture is car-
ried through the anterior wall as high as one conveniently can, by
means of a short, stout curved needle. With this suture the Ixxly
of the uterus is drawn downward and forward into the incision.
Now is a convenient time to snip open the peritoneum and enlarge
the opening with the fingers, providecl an opening lias not already
been made in it in the elfort to strip the bladder from the uterus.
If no adhesions exist and the uterus is not overlarge, it mav now
be ti))ped outside the woutxl by hookintr two fingers over the lundus.
If th(! direct palpation shows that the adnexa are normal, tiie uterus
need not be pulled out in /o/o, i)uf the two fingers are hooked Ix'hind
Tarl r.t'ck of New \i,rV, ('.•nlnilhliill flir (ii!niri/lr. 1897, No. .'?.''..
^ Hiram N. N'iiiflicrt,', Ainrr. Jom; Obnl., vol. xxxvi., No. 1, 1S!)7, ami 7';yhi.s.
Artwr. (lyn. Soc, 1S'.*7, vol. xxii. pp. 2*>9-2H2.
47G DISEASES OF WOMEN.
one horn and the corresponding end of the tube, and the round
hVanient is drawn well into the incision. If inspection of the
adnexa is desired, tiie uterus is brought outside the wound either
by the lingers, as just described, or by traction sutures, inserted one
above the other on the anterior wall. Bullet-forceps are less recom-
niendable, as they are likely to tear the uterine tissue.
Cases are met with in which the adhesions are so extensive or the
infundibulo-pelvic ligan)ent so short that the a])pendages cannot
safely be brought out. Then it is better to adopt the suprapubic
method.
If the round ligaments can be brought well within reach, a silk-
worm-gut suture is carried around it from behind forward, about an
inch and a half from its uterine end. A similar suture is passed
half an inch nearer the uterus. The four ends are carried through
the vaginal flap by means of a silkworm-gut carrier, which has the
advantage over silk of being stiff and not becoming ravelled. The
same is done on the opposite side, the uterus replaced, the traction
sutures removed, the vaginal sutures tied, and the slit in the peri-
toneum closed with a running catgut suture. Finally, the vaginal
flaps are united with the same kind of suture. If there is a cystocele,
they are first shortened. The last couple of stitches are made to enter
the cervical tissue so as to attach the vaginal wall to the cervix.
D. Dcsmorrhaphy. Intrdperitoneal Shortening of the Round Lig-
aments. — The ligament is folded on itself, forming a single ( Wylie^s
method ^) or a double (Mann's method') loop. The peritoneum is
scraped off where the folds of the ligaments touch one another, and
the latter stitched together w-ith chromicized catgut.
Taifs 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 include a loop of it in the
part that is cut away.
Gaffe's Method.^ — While in all these methods the ligaments are
reached by lajiarotomy, Goffe obtains access to them through the
vagina much like Vineberg; but he shortens the ligaments by fold-
ing and stitching them together, and does not fasten them to any
other organ, in which respect he follows a method described by Bode ;*
but he secures much more room than that operator, and he avoids
the use of traction sutures or l)ullet-forceps on the body of the uterus.
He drags the cervix strongly down with a volsella, and makes a
transverse incision on the anterior wall of the vagina one inch in
>Gill Wylie, Am^r. Jour. OhM., May 18S9, vol. xxii. p. 484.
*M. D. Mann, Trnns. Amer. (h/n. Snc.. 1897, vol. xxii.
M. R. Goffe, Trans. Amer. Gyn. .^V., 1897, vol. xxii. pp. 2.S4-241, and 1898, vol.
xxiii. p. 71.
* Bode of Dresden, Centralhl. f. Gyndk., 1896, No. 13, p. 358.
DISEASES OF THE UTERUS. 477
front of the cervix, the low position of the incision facilitatin<^ the
swinging back of the cervix when the fundus is being delivered into
the vagina. By blunt dissection, as in hysterectomy, the bladder is
dissected from the uterus up to the peritoneum. The lower edge of
the transverse incision is then caught with two artery forceps near
to the median line, and a longitudinal incision is made at right angles
to the first, through the vaginal wall, down to the origin of the
urethra. The two lateral flaps are dissected from the bladder an
inch or an inch and a half on each side. The ])eritoneum is now
opened and torn freely toward each side by passing the two index-
fingers through the opening and making lateral pressure. The uterus
and appendages may now be pulled into the vagina with a finger
hooked over them. The round ligauient is caught with an artery
forceps as far out from the corner of the uterus as will permit the
point at which it is caught being drawn to the site of origin of the
round lijniment — a distance varviny: from two and a half to three
inches. A fine silk suture is drawn through a point midway between
the forceps and the corner of the uterus, and through another point
at the same distance from the forceps on the distal side of the liga-
ment. When this suture has been tied, another suture fastens tiie
point held l)y the forceps to the origin of the ligament. The other
ligament is treated in the same way, the uterus replaced, and the
peritoneum and vaginal wound closed.
Severance of Adhemoiia. — In all cases in which the abdominal cav-
ity is opened, adhesions that hold the uterus in its faulty i)osition
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 tiie
adhesions are so tough that they have t«» be tied with a double liga-
ture and cut witii 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. 18(J).
Kramiiififion of Aj>pe)i(l(i(/cs. — When the abdomen is op(Mied the
appendages should be brougiit into view, and, if seriously affe('t(>d,
they should l)e removed. In the; latter ease (Mth(T the stumj)s or the
fundus uteri inav be fastened to the abdominal wall. The a])|)end-
ages may also b<' treated in any way desired, through the vaginal
incision.
7V.s.sr//-//. — In all eases of direct or indirect hvsteropexia a Hodge
]K'ssarv should be introduced and worn for several months.
The bladder soon ae<'oniino(lates itself to its new relations with
the ut<'rus.
Shortening of the saero-uterine and the infundibulo-pelvic liga-
ments has also been attempted for the correction of retroflexion, but
without success.
478 DISEASES OF WOMEN.
In regard to tlie 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 retroflexion alone; bnt if the appendages have to be removed,
or if adhesions canse great pain and cannot be disposed of otherwise,
it may be nsefnl to attend to the retroflexion at the same time in one
of the ways mentioned.
Comparison between the Different Operations for Retroflexion. —
Alexander's operation offers the great advantage that the peritoneal
cavity is not entered, and that the scars, covered by hair, become
practically invisible. If tlie uterns is movable and the appendages
healthy, and the patient is not so old that the ligaments arc atro-
phied, that ought to be the operation of choice. If the appen-
dages are diseased, they may be examined, treated, or removed
by either the abdominal or the vaginal section, the first of which
gives more room and is always available ; the second leaves no
abdominal scar, but is more diflficnlt and has sometimes to be
abandoned. (See p. 476.) All operations that are directed against
the round ligaments are preferable to those that fasten the uterus
to other structures, because they present no danger of intestinal
obstruction or dystocia.
E. Lateroversion and Lateroflexion.
Lateral deviations of the uterus, unaccompanied by other patho-
logical conditions, are rare. They may be congenital (p. 413) 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 bimanual palpation or the sound.
These displacements are apt to cause sterility. No direct treatment
is applicable.
F. Prolapse.
Prolapse, Prolajisus, 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.
479
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. 446), but in prolapse the peritoneal pouches
in front and behind the uterus are dragged down with it (Fig. 276).
Fig. 276.
Procidentia Uteri, with pared surfaces for Lefort's operation: A, anterior denudation; B.
posterior denudation ; I/, fundus uteri; L'/J, meatus urinarius; if, rectum.
Etiology. — As just stated, the acute prolapse is due to a muscular
eifort in carrying a heavy weight, such as a tub with water, in front
of the body. The chronic is mo.stly referable to childbirth. Tiie
vaginal entrance being ruptured (pp. 821 and 324), the uterus does
not find its usual suj)p()rt ironi below. It becomes retroverted and
then retroflexed (pp. 464 and 465). Intra-abdominal ])ressure drives
it like a wedge down through the vagina. The sacro-uterine liga-
ments (p. 55) become weakened and elongated, tlie pelvic c(mnective
tissue lo.ses its tonus, and the weight of the subinvoluted vagina drags
the uterus down (p. .356). Finally, the uterus sinks by its own
weight. Thus lack of .<uj)|)ort from above and below combines with
v/eight, pressure, and dragging to displace the uterus.
Thedes<x'nt may also b(! (hu; to tum(»rs in the uterus, which inerea.se
its weight, or in the alxlomen, which j)ress on it. The incre:i.se in
weight and succulence ol' all pelvic structures caused by pregnancy
may also result in prolap.se.
480
DISEASES OF WOMEN.
Symptoms. — The symptoms of chronic prolapse are identical with
those of hypertrophy of the cervix (p. 447). 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 dift'ers 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.— If there is an ulcer, it ought to be treated with the
ointment of iodoform and balsam of Peru (p. 284) ; and secondly the
uterus should be replaced and retained. As a rule, common pes-
saries cannot be retained, on account of lack of support from the
perineum. A large soft-rubber ring, an inch thick (Mayer's pes-
sary), will sometimes retain the uterus in the pelvis by distending
the upper part of the vagina. Breisky recommends large ovoid
Fig. 277.
uterine and Abdominal Supporter.
bodies of hard rubber. Gariel's air-pessary 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. 277). This appa-
ratus is removed during the night, and the cup cleansed with some
disinfectant.
DISEASES OF THE UTERUS.
481
Operations. — As a rule, combined operations are required, and
even they may not always prevent a return of the condition.^
Trachelorrhapliy, excision of a piece, or complete amputation, of
the cervix, is used for reducing the bulk of the uterus (p. 418) ;
Alexander's operation (p. 471) is combined with colpo-perineor-
rhaphy (p. 327) ; abdominal hysteropexia (pp. 474-477), or abdom-
inal or vaginal desraopexia (p. 477), or vaginal shortening of the
round ligaments, is also used to hold up the uterus, in order to
fasten it above and support it from below.
Fig. 278.
Lefort's Prolapsus Operation: ^.anterior (Kiiiuiaiioii ; 7;, posterior denudation; C C, upper
right lateral sutures ; J> J/, upper left lateral suture.
Leforf'i^ Oprrfifioii. — For complete ])rolapsus I^efort's operation of
pardfionirir/ t/ir rnr/itift is vahial)U' by ])roviding a solid cohmin of tis-
sue right ill the middle of the vagina for the uterus to rest on.
In the middle of the anterior surfiice of the tumor hanging in
front of the vulva a ])arallelogram three-tjuarters of an inch wide and
over two inches long is denuded close up to the vulva. Next, the
tumor is held up and a (•orresj)ondiug denudation is made on the pos-
terior surface. Then the; uterus is replaced sufficientlv to bring the
two u|)per ends of the jiared surface.-^ in contact, and to unite them
' I (iiiiibiiicd ill one case rein ival of tlie ap])eii(Iaf;:es, ventrofixation of tlic iitonis,
Tail's perineal flap operation, and Stol/.'s cvstoeele operation. I"'or a lime tlic snc-
eess was coinpiete, but a year had not elapsed before the uterus was i)r()iapsed a^airi.
31
482 DISEASES OF WOMEN.
with a riinninj; suture of ehromicized catji;ut, whicli is continued
tier after tier until the entire surfaces are brought together (Fig.
278). It is a good plan to combine a perineorrhaphy with this
operation.*
An improvement by Coe 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. 216).
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, Mund^^
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 scalpel-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 iialf of the raw cervix, he am})u-
tated it with the galvano-caustic wire. Passing a tent of iodoform
gauze into tlie 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'^ 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 Mires soon cause suppuration and come out.
Vaginal Tli/deredomy. — In those very rare cases of jirolapse that
have resisted all other methods, or when the uterus is diseased, and
the woman has passed the mcnojiause, the extirpation of the ])ro-
lapsed uterus is justifiable. In performing it, a considerable part of
the vagina must also be removed. The modus ()))eran(li^ is the fi)l-
lowing : The patient is in the breech-back position (]). 388). The
uterus is curetted and disinfected. Each lip of the vaginal ])()rti()n
is seized with a traction f()rce})s (p. 228), and the cervix is j)nlled
^Fannv Berlin of Boston, Aiupr. Jour. Ohf<L, Oct., 1881, vol. xiv. p. 870.
•' P. F.'Mundo, Amer. Jour. OhM., Nov.. 1891, vol. xxiv. p. 1291.
^ H. W. Frcnnd, Centralhl.f. Oynuf:., 189.'5. No. 47. vol. xvii. )). lOSl.
* I have evolved this method from the description of H. Fritsche's operation
given hy Asch, Archiv/iir Gyndkologie, 1889, vol. xxxv. p. 20(5.
DISEASES OF THE UTERUS.
483
well upward (Fig. 279). Now an incision i.s 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, whereas the sides
extend to the side of the cervix. The incision goes through the
whole thickness of the vaginal wall, and is deepened with tiie finger
and closed with blunt scissors, until the peritoneum in Douglas's pouch
is exposed. The peritoneum is seized with two pairs of Kocher's
tissue-forceps (Fig. 199, p. 229) and cut transversely with scissors.
Fig. 279.
HysterertDiiiy fur proliipsod uterus.
The next ste|) is to stitch the posterior flap of the peritoneum to the
posterior vaginal wall, and to ins(>rt a sponge with attaclied thread >o
as to retain the intestines. Next, the vaginal ])ortion is carricnl i'ar
down, and an incision similar to that on the posterior wall is ina<l(>
on the anterior wall of the vagina (Fig. 2.S0), but only tlirough the
vaginal wall, without entering the bladder, and, if there is a large
cvstoeele, extending to the mound of the urethra and joining the ends
of the posterior incision on the sides of the cervix. This trianguhir
flaj) is separated IVoiii the bladder, partly with blunt instruments
and partlv with the knife ; a transverse incision is made just below
484
DISEASES OF WOMEN.
the bladder. This organ is separated from the uterus, and the
peritoneum of the vesico-utcrine pouch incised, after having secured
the anterior flap with a silk thread.
The uterus is easily retroflexed and pulled out. The intestines
and the omentum are kept back by a pad with a string attached to
ir. The broad ligaments are tied in portions from their upper edge
downward to the point where the incisions meet on the sides of the
cervix. This is done with a half-sharp-pointed needle (Fig. 270,
Fig. 280.
Hysterectomy for prolapsus uteri.
p. 463). As soon ais a portion is tied, it is cut between the ligature
and the uterus. If the ovaries are healthy, one or botli should be
left in. AVhen the uterus has been removed, the edges of the
wound on the anterior wall are whip])ed together with a running
catgut suture ; the stumps of the broad ligaments are fastened in
tlie vagina ; and finally the peritoneum of the; bladder stitched to
the anterior ciniumfcrence of tlie vagina and the opening in the
vagina packed with iodoform gauze.
DISEASES OF THE UTERUS.
G. Elevation.
485
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
Fig. 281.
Supra- and infra-vapinal hypertrophy of the cervix. Specimen removed by vajiinal hys-
terectomy': ri, hypertroj)hied vafriiiiil i)ortioii; /j, tumor full of cysts ; r, jiiirt of the vatfina
removed; d, hypertrophied supravaKiual cervix; r, corpus uteri;//, KalJoi)iaii tubes; ;/ ,'/,
ovaries.
inflammatory adhesions. Sometimes the whole vauinal portion
disappears.
11. InrerKion.
Inversion consists in a turning inside out of th(> uterus (Fig. 2S2).
It may be fofal or jxirtu/f. As a rule, tlie inversion begins as an
'Specimen obtained from mv openition on Mrs. II. at St. Mark's Hospital.
Aug. 8, 1898.
486 DISEASES OF WOMEN.
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 uninverted cervix ; e, vaginal wall ; /, the perito-
neal cul-de-sac of the inverted uterus ; g,g, Fallopian tubes passing down into tne 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 referre<l
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. The 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 fundus. 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 has
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, indej)end('ntly of pregnancy and the presence of a tumor.
Where there is no tumor, the mechanism is the following : A part
of tlie uterine wall, most frequently the placental site, becomes par-
alyzed and sinks down, while the surrounding parts contract above it.
DISEASES OF THE UTERUS. 487
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 ]iass 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
ajjertures 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 ])atient's body, it often ulcerates and
cicatrizes, which gives it a cutaneous a})pearance.
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.
tSi/mptoms. — 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
cliaracteristic tumor in the vagina and the funnel above the symphy-
sis. But in exceptional cases all alarming symptoms may be absent.^
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 Icucorrhea, dragging pain,
difficulty in walking, and different nervous reflexes. Physical exam-
ination reveals the peculiar shape of the fundus and the })resence of
a tumor in the vagina.
DiafjiKix'ix. — Tile diagnosis of inversion, apart from obstetric cases,
may be very difficult, and is of the utmost importance in regard to
treatment. Only great careleasness could fail to distiuguish common
prolapse and In/pcrtrophi/ of the cervix from inversion, the distinctive
feature being the j)resence of the os uteri at llie lower end, through
which the soiuid can be entered more or less 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 prolaj)se, but upward in
rase of inverted uterus. A />oli//)U.s may offer entirely similar symj)-
' .John ('. lieeve has contributed a paiier full of instruction, on Inversitui, in ('t/n.
TrartK., 1884, vol. ix. p. 69.
488 DISEASES OF WOMEN.
toms, and a tumor of the same shape and appearance may be found
in the same ])laee ; but if it is a j)olvpus 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 j^lace. If, especially in
stout women, the uterus cannot be felt through the abdominal wall,
recoui'se may be had to rectal examination (p. 144). A catheter held
in the bladder may help to settle the diagnosis, and if there is any
doubt the urethra should be dilated (p. 144), 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 Avhicli 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 holloio 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 ])oly])oid tumor tliat 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 })olypus 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
' Sussdorff, Jour. Obat., 1877, vol. x. p. 553.
DISEASES OF THE UTERUS. 489
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 eases. Experience has shown that the best treat-
ment is that with elastic pressure. The vagina is disinfected and
Aveliru/s repositor applied. It is made of hard rubber, and consists
of a little cup which presses on the inverted fundus, and an S-shaped
rod, which protrudes from the vuK'a and carries pressure made at its
lower end u})\vard in the direction of the pelvic axis. To the lower
end are attached four elastic tapes, which are drawn through rings
fastened to an abdominal binder. Two of the tapes are brought for-
ward and two backward, and they enable us to give the rod the
desired direction. A pressure of two and a half pounds is sufficient.
Tiiis method is safe, hardly ever fails, and leads to replacement in
a short time — from nine to fifty-four hours — by starting an anti-
peristaltic movement, so that the part forming the pedicle is first
replaced, and the fundus last.
The same principle of elastic pressure may be applied in difi'crent
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). Another way, that disjK'Uses with the use of any ])Mr-
ticular instrument, is to i)a('k the vagina firmly with iodoform gauze,
which is renewed every two or three days.
During all these treatments the |)atient is kept in bed, and if ne('(>s-
sary the pain relieved by hypo(lermi(; injections of morj)liiue.
If the elastic ])ressure does not succeed, recourse is had to onv. of
the following methods of manual rcphtccmcnl, which are used on the
an<!sthetized patient.
Kmmet surrounded the tumor with the finwrs of the lefi IimikI and
490 DISEASES OF WOMEN.
pressed at the base, making counter-pressure through the abdominal
wall on the ring in the peritoneum.
Xoeggerath applieil the tliumb and middle finger to the horns of
the uterus, replacetl first one of them, then the otiier, 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 eifect, 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. It must, however, be borne in mind that such dilata-
tion of the urethra occasionally has led to incontinence of urine
(p. 1-44).
If a partial reinversion 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-icire 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 meantime, the tumor may be softened with
warm vaginal injections, sitz-baths, and glycerin tampons.
Conservative Cutting Operations. — Thomas performed laparotomy
and dilated the cervical ring with an instrument like a glove-stretcher.
This method would probably be the best in old cases in which adhe-
sions have formed between the walls of the internal ring.
Barnes pulled the tumor well dow^n with a tape, and made three
longitudinal incisions in the cervix. After that he could easily
replace the tumor by manipulation.
Kiistner performs posterior transverse colpotomy (p. 171), intro-
duces the left index-finger into the funnel-shaped depression formed
by the inverted uterus, and tries reposition. If it does not succeed,
he makes a longitudinal incision in the median line, through the
whole posterior wall of the uterus, when the reposition becomes very
easy. Next, the uterus is rctroflexed and drawn into the wound in
the vagina, the incision in the uterus closed with a running suture
of catgut, the uterus replaced, and finally the w'ound in the vagina
closed. This method has given such excellent results that it should
be resorted to as soon as elastic pressure by Aveling's method and
manual taxis according to Noeggerath and Courty have failed.
DISEASES OF THE UTERUS. 491
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.
The mass may be removed by means of the f/alvano-caustie u-ire
or Paquelin^s thermo-cautery. 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 thermo-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. 290), 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 cresccint at the end will easily bring it up (Fig.
26.3, p. 455). A small incision is made in the pedicle, through
which the sound is ])ass('d, and only enters to a depth corresponding
to the size of the uterus. The diagnosis thus having l)een comj)leted,
the protruding tissue is removed by the thermo-cautery or the gal-
vano-caustic wire or knife or scissors, followed by a hemostatic
running suture.
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 bv the
peritoneum. The uterus has been found in an inc/uinal and in a
n'ur(d hernia. Sucii cases are extremely rare. Thev are iiearlv
always congenital malformations. (See p. 41.'}.)
492 DISEASES OF WOMEN.
CHAPTER XIII.
Neoplasms.
A. Oysts of the Uterus; Adenoma Uteri; 3Iiicous Polypi ; Myxoma.
In regard to cysts of the cervix and ovula, of Naboth we refer to
what has been said above under Lacerated Cervix (pp. 396 and 318)
and Chronic Endometritis (pp. 427 and 433). Tliese 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. 378.)
In speaking of hyperplastic endometritis (p. 427) 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 waliuit, 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 Qg^, 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 myxomcdous 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.^
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 aj^jiearance 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
^ 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.
DISEASES OF THE UTERUS. 493
cells are frequently seen filling up a gland-space. They, however,
never infiltrate the interstitial or stroma tissue. The neoplasm ex-
tends to, and appears progressively to destroy, the muscular wall by
atrophy or, perhaps, fatty degeneration. It persistently progresses
as an atypical, glandular, epithelial type of disease.^
Fibrinous polypi are pedunculated 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.
Symptoms. — ]\Iucous polypi cause hemorrhage, leucorrhea, sterility,
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. 178). From the cervix they may be torn
off by seizing them with forceps and turning the instrument until the
j)edicle is severed (torsion). Or they may be cut off with scissors,
but then it is well to have a thermo-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.
After removal of the growth the accompanying chronic endome-
tritis should be treated as described above (pp. 432-435).
Malignant adenoma is an indication for speedy hysterectomy.
B. Cavernous Angioma of the Uterus.
This neoplasm is very rare. It consists of a tumor formed of
ectatic veins filled with blood.
Patholof/ieal 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 fram(>-
wr)rk with thicker nodules appears. The cavities of the framework,
which differ in size and intercomnuniicate, are filled with fluid
blood. Th(^ framework consists of smooth muscle-fibers covered
with fibrill.'o of connec'tive tissue with an endothelium. In some
])laees are seen outgrowths of connective tissue forming })a|)ill;e.
The cavities of the tumor comnnmicate with the veins of the
neighboihood.
Ktiolo(jy. — TJie cause of the formation of uterine angioma is un-
known. Perlia[)S it sometimes originates in a subinvolution of the
placental site.
' II. I). Ik-yea, Amrr. .Jour. OliM., Feb., 189*!, vol. xxxiii. p. 200.
494 DISEASES OF WOMEN.
Sj/mptoms. — This kind of tumor gives rise to recurrent and pro-
fuse heniorrhatje.
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.^
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
centres, 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-vessels {cavernous
myoma, myoma teleangiectodes and lymphangiectodes). Generally the
tumors themselves have scant blood-supj)ly, but are surrounded by
a zone rich in arteries.^ 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 the nor-
mal muscular tissue nearly disappears, and the uterus forms only a
mass of fibroids held together with a small quantity of connective
tissue, as in the case represented in Fig. 283, or a bag filled with
calcified 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-
> II. J. Boldt, AvKT. Jour. ObsL, Dec, 1893, vol. xxviii. pp. 834-846. Klob,
Paiholnfjhche Anatnmie der weiblichen Sexualorgane, Wien, 1864, p. 173.
'J. (r. Clark, Johns Hopkins Hospital Bulletin, Marcli, 1899, No. 96.
DISEASES OF THE UTERUS.
495
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
Fig. 283.
rtonis in which all muscular tissue was replaced by connective tissue and fibroids, nine
f)f which were enucleated before the uterus could be delivered : a, vaginal llaps; /), su]ira-
vut,'inal liy pertrophied cervix ; c, body of uterus still full of fibroids ; d, vaginal portion.'
o('rvi(;al fibroids are likely to cause serious complications of preg-
nancy and childbirth, wiiich bring the patients under medical
observation.
They are either srssi/c or pedunculated, and the latter may
either hang from the cervix and develop into the vagina, or spring
' I)r;iwinj( of specimen Iroin the writer'^ (ii)eratiua on ^Irs. li. iit 6t. Mark's
IIoHpitul, .June 11, IHOS.
49G
DISEASES OF WOMEN.
from the interior of tiie corpus or fundus ; or they may spring from
the outer surface of the corpus and fundus and develop into the peri-
FiG. 284.
Transition from Imbedded to Pedunculated Uterine Fibroid. Smooth right end free, the
remainder imbedded.^
toneal cavity. Those which spring from the cervix and the uterus
proper and are covered with mucous membrane are caUed fibroid polypi
(compare glandular and fibrinous polypi, pp. 427 and 492, 493), the
word " polypus " being used as a general term for any pedunculated
tumor attaclied to a mucous membrane.
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, 284).
Pedunculated Submucous Fibrous Tumor (fibroid polvpus) enclosed in Uterus (Cruveilhier) :
F, fundus of uterus; 0,0, ovaries; L,L, round ligaments; C, cervix; U, vagina; P, polypus.
Fibroids are called submucous (Fig. 285) when a part of them
is only covered with mucous membrane; subperitoneal (Fig. 286)
if they are partly situated immediately under the peritoneum;
and interstitial or iy\tramural (Fig. 287), if they are surrounded by
* Specimen from my operation on Mrs. S., March 24, 1894.
DISEASES OF THE UTERUS 497
a layer of muscular tissue. This latter variety has a tendency
Fig. 286.
Pedunculated Subperitoneal Fibroid (Hofmeyer).
to work its way outward or inward, so as to pass into one of
Fig. 287.
Intrniniiriil Fibroid ((iu.sscrow).
the two other varieties, and may even become podiciilnte.
:i2
498 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. 288).
Fig. 288.
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, and 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
meso rectum.
Microscopical examination shows that fibroids originate from round
cells surrounding capillaries which are undergoing obliteration. The
well-developed tumor consists of unstriped muscle-fibers, mixed with
more or less fibrous connective tissue and fusiform cells.
Fibroids are not so apt to be bound to the ])eritoneum of the
abdominal wall or other organs as ovarian cysts, but if they do form
such adhesions, these ai'e 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 exclusivelv to an-
other part of tiie abdomen. Such pediculate tumors may even be
torn off from the uterus and lie loose in the abdomen as necrobiotic
ma.s.ses, without fi)rming new adhesions. Fibroids are very fre-
quently accompanied by local peritonitis, and may also cause cellu-
* Specimen from my operation on Miss B. M., in St. Mark's Hospital, March
13. 1894.
DISEASES OF THE UTERUS. 499
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 througii 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 tlie geneml
involution after the birth of the child, and may disappear entirely.
Such disappearance has also been observed after inflammation or
under circumstances where no simultaneous process could be sup-
})osed to be the cause.^ 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
j)regnauey fibroids are apt to become edematous. Sometimes myxo-
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 resorption of myxoid tissue, or by
dilatation of lymph-spaces. The latter kind has an endothelial lin-
ing.^ Often these cysts fii*st appear spread as small hollows, so-called
c/eodes, throughout a fibroid, but subsequently the intervening tissue
is al)sorbcd, 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 Jiuid contained in fibro-cysts, as might be expected from their
different nature, diffei-s very much. Sometimes it coagulates by
exposure to tiie 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 arc jiurulent.
The fluid is alkaline, and coagulates entirely on boiling and with
acids. It contains always much albuuiin, and sometimes fibrin.
Tile microscope reveals sometimes detached unstriped muscle-cells
from the surrouuding tissue.
When a consid(!ra))le bloody extravasation takes place into the
cyst, it may rupture, and the contents be poured into the peritoneal
cavity.
' Doran, "On the Alworptioii of Fibroid Tumors of the Uterus," 7V((/i.s. Lon<l<>n
Oh.il. S(>r., 1S'J:j, p. 2.')0.
' A specimen of this kind is desoril)ed in detail in (}arripucs's I)i(i()ii().ii.< of Ovtrinn
Cifil-t hy Meaiui of the Etaminatiim of their Contents, V\'m. Wood & Co., New York,
1882, pp. 60-03.
500 DISEASES OF WOMEN.
The fibroid may slough, either spontaneously or after operations
or the use of ergot. In tiiis 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 stony mass. They may also undergo
sarcomatous or carcinomaiaus 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.^
Symptoms. — Fibroids, especially polypi and the submucous variety,
cause menorriiagia (p, 262) and metrorrhagia (p. 264), leucorrhea (p.
268), hydrorrhea (p. 430), and pain. The bleeding is partly of venous
origin, the tumor causing stasis in the veins of the endometrium ;
and partly it is arterial, the arteries between the tumor and the en-
dometrium changing their direction from one perpendicular to the
endometrium (p. 59) to one parallel Avith it, and giving off twigs at
right angles to the endometrium. The mucosa itself atrophies, and
finally disappears over a large area, laying bare the capsule of the
myoma. The blood-vessels themselves undergo changes which
lead to the occlusion of some, to the widening of others, and to the
rendering of their loops brittle.^ 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 descri})tion. If it is a fibro-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
J Middleton Michel of Charleston, S. C, Mexl. News^. Oct. 8, 1892.
* J. G. Clark, "Tlie Cause and Sifrnificance of Uterine Ilemorrliajje in Cases of
Myoma Uteri," Johns Hopkins Hospital Bulletin, Nos. 94-90, Jan. -Mar., 1899.
DISEASES OF THE UTERUS. 501
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. 478). If attached to the fundus,
a fibroid polypus in descending may drag the uterus along and cause
inversion (p. 485). 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.
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. 156),
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 through a speculum.
In cancer of the cervix soft masses can be scraped off" with the
nail. There soon appears a hard ring around it ; it ulcerates at au
early date; and the discharge has au offensive odor. Cancer of the
body gives rise to greater pain than a fibroid ; the constitution suffers
much more and sooner ; the jwtient 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 be-
come infiltrated. 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 po/i/pus
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
retroflcxiov , but l)y bimanual examination the funihis may be felt
turned forward, or the direction of the uterine canal may be ascer-
tained with the sound, and the greater tliickness of the same between
the sound and the ])osterior fornix of the vagina may be felt. A
fibroid in the anterior wall may i)e taken for an antcjicxion, but the
diagnosis is made by judging of tiie thickness of the wall between the
sound and the anterior fornix of the vagina.
502 DISEASES OF WOMEN.
A ntenis 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. 487).
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 tlie former it goes on, or is even increased
in regard to the amount of the secreted blood and the duration of the
discharge. The development of the swelling is regular and more
rapid in pregnancy, k^oftening 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 aud 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 scyhcda 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
gootl 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
common. Fibro-cysts are seldom found in women under 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
DISEASES OF THE UTERUS. 503
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
operations has been resorted to, coagulability of the fluid and the
presence of muscle-cells in it militate strongly in favor of a fibro-cyst,
while the presence of numerous small round bodies with several
shining granules speaks as strongly in favor of an ovarian cyst.^
Fibro-cysts of the uterus can only be distinguished from fibro-cysts
of (he ovary by the circumstance that the former move with the uterus,
while the latter may be movable independently. The fluid is
identical.
Myomas of the knr/e intestine have in a few cases reached con-
siderable size, and may be much like uterine tumors of the same
kind; but as a rule it is possible, at least under anesthesia, to find
that they are not connected with the uterus.^
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 tlie fluid. Iloiiatoccle 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 ; tiiey begin to shrink and the ])atient suffers less; but,
on the other hand, tlie change of life is often postponed in women
affl'cted with fibroids, and some fibroids continue gnnving, jnirsue a
more disastrous course than before, and frequently become cystic,
calcareous, or have abscesses develop in them.* A spontaneous cure
may occasionally be effected by involution after pregnancy or by
expulsion of a })olyj)us.
Hemorrhage' rarely l)e<'omes directly fatal, but through the repeated
losses of blood and the drain caused by leucorrhea the constitution
finally suffers. Pain, worry, and disturbed sleep iiave a similar effect.
Meciianiciilly, the tumor may cjiuse death by closing the ureters or the
intestine. The heart sufftTS in consequence of the increase<l work
• Exceptions are treated of in my al)<)ve-nanie(l work on Ovarian C>isl.^, pp. G3 G7.
'Richard Krukeiiliern, ('iiilralhl. f. (ii/niik:, 1S97, No. '(2, vol. x.xi. j). i.')l").
'Joseph Taher .Johnson of \Va.shin<,'ton, I>. C, "(Jrowth of Filiroids after tlie
Menopause," Amer. .Jour. (M)M., l)ec., IS'JI, vol. xxiv. p. M'JO.
504 DISEASES OF WOMEN.
thrown upon it. Large tumoi-s 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 papillomatous 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 ;
Galvano-chemical cauterization ;
Curetting ;
Vaginal enucleation ;
Ligation of ovarian and uterine arteries ;
Abdominal enucleation —
(a) from the uterine wall ;
(6) from the broad ligament ;
(c) from the pelvic floor ;
Supravaginal amputation —
(a) with retroperitoneal treatment of the pedicle ;
(6) with extraperitoneal fixation of the stump ;
Total extirpation of the uterus.
Fig. 289.
Tape-carrier.
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. 208), the vagina disinfected, the tumor
brought into view with s])eculum and retractors, the cervix dilated
with a steel dilator, the tumor seized with a volsella and pulled down,
M'hile an assistant pre.s,ses 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. 289). This loop allows us to pull
DISEASES OF THE UTERUS. 505
the polypus considerably down, and its pedicle is cut oiF with a few
rotary movements of Thomas's spoon-saw (Fig. 290), a shallow spoon
Fig. 290.
Thomas's Spoon-saw.
with dull serrated margin.^ 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.
If the polypus is situated in the interior of the yet closed uterus,
the cervix must first be dilated with aseptic laminaria (p. 156) or
iodoforraed cotton balls (p. 159). If it spring from the fundus, a pair
of strongly curved scissors may be needed for removing it (Fig. 291).
Fig. 291.
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 marcel lation^; or a sj)iral 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 c»nrse of time become jK'dunculate, the operation may have to be
rejx;ated, although it is radical in regard to tiie tumor it is ap})lied to.
.Subperitoneal tumors ciui only be I'cached by laparotomy (see Ova-
riotomy). If they have a well-developed pedicle, it should be trans-
' Many instrurnent-niakcrs make it too liollow and witli too .Hliarp teetli, wliicli
clwiiitfes it from a .safe and vaiiuihlc iiistrmiK'iit into a (ianu'iTous otie.
' I removed in tliis way a tiiiroid weifrhintr twenty-eiL;Iif ounces, from the ntiTiis
of Mrs. M., in St. Mark's Hospital, on Dec. 1<), l.sys. 2>'eue I'Drken DU'dicinischc
Monataachrift, vol. xi. No. .'!, p. r.'o, March, 1899.
506 DISEASES OF WOMEN.
fixetl, 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. 286). Tlie 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. 266, p. 456) or Thomas's (Fig.
264, p. 455), or an abdominal belt with vaginal cup (Fig. 277^
p. 480).
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
under Hemostatics (p. 243), Menorrhagia (p. 262), and Leucorrhea
(p. 268). 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. ergotse, 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
R. Acidi sclerotinici, gr. x ;
Glycerini, 3ss ;
Aq. dest. q. s. ad 3ij.
M. Sig. Eight minims hypodermically.
The injections are made in the abdominal wall in front of the tumor,
and they should be very deej). 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 such 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.'
Instead of sclerotinic acid, ergotin (gr. iij pro dosi) may be used
dissolved in five parts of water :
» W. T. Lusk, N. Y. Med. Jour., July, 1882, vol. xxxvi. p. 30.
DISEASES OF THE UTERUS. 507
I^. Ergotini (Squibb), Hss;
Aq. dest., Sijss ;
Acid, carbol., TTLij.
M. Sig. Eighteen minims for each injection.
To inject ergot preparations into the substance of the uterus is
dangerous and oifers no advantage.
Desiccated mammary gland of sheep, three to six tablets a day,
each containing two grains of the dry gland powder, is praised.
Under its influence the tumors are said to decrease, hemorrhage to
stop, and the general health to improve.^ Compare p. 245.
Among mineral watei-s, 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-c.hemical cauterization after Apostoli's method (p. 250). 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 even allow the
patient to go home by street-car and elevated railroads immediately
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, most of
the cutting operations are so dangerous, that, as a rule, electricity
should be given a fair trial before resorting to the latter.'' The
method is, however, not devoid of danger. Sometimes local peri-
tonitis may follow the application, and some uteri are so distorted
by the fibroids they contain that some j)laces of the wall may be-
come very thin, li it should happen that the intra-uterine elec-
trode were applied to such a place, the cauterization might go
through the whole tiiickness of the wall.
Many ])atients cannot get the tedious galvanic treatment, and,
^ J. B. Hhoher of I'iiiladelpliia, Tnins. Amer. Gpier/d. Sf>c., 1898, vol. xxiii. p. 204.
'ThorTi;i.s Keith, wIk) in his time was by far more successful than all ('oiitempo-
raneous operators, strongly reconirnciHicd Apostoli's method (" ( outriljutions to tlie
8urj(ical Treatment of Tumors of the Al)domen," I'art II,, Klcrtririttj in the TratlmnU
Ulerinr Tumorfy I']<linhurgh, 1889, p. viii.). Only wlien the tjalvanic treatment
led did he perform hysterectomy {(lynccoL Traris., 1890, vol. xv. p. 148).
of U
ftiilec:
608 DISEASES OF WOMEN.
moreover, the experience of later years has shown that by operating
early the prognosis for the operation — like that for ovariotomy —
has become much bettor.
Hemorrliage may be checked by curetting (p. 180). Perhaps it
gives relief only for some months, but may then be repeated. By
thus scraping off the endometrium with its dilated veins the patient
may sometimes be kept alive until the menopause arrives and brings
permanent relief.^ Properly performed, the operation is, as a rule,
harmless ; the writer has, however, had a case in which it was fol-
lowed by gangrene.^
Vaginal Enucleation by 3Ieans of the Spoon-saw. — Large sessile my-
omas, weighing up to three pounds,^ have been successfully removed
through the vagina. The method is applicable to both cervical and
corporeal fibroids. The patient is placed in Sims's position, and the
largest Sims speculum is introduced. If the cervix is partially open,
and the tumor offers a free end near it, the cervix is seized with a
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. 185).
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 dowu 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-
^ An instructive paper on this subject was published by Henrv C. Coe in The Med-
ical Record, Jan. 28, 1888.
' The patient recovered, and was radically cured, but another time the result might
be less favorable. 1 scraped away what I could with the finger, tore dead shreds off
with forceps, and used carbolized intrauterine and vaginal injections.
' Thomas, Amer. Jour. Med. Sc, April, 1880, vol. Ixxix. p. 405 ; Munde, Amer. Jour.
ObsL, 1885, vol. xviii. p. 189.
DISEASES OF THE UTERUS. 509
cleation is begun. For this purpose it is split up to the vaginal
junction with Kuchenmeister's scissors, and the internal os incised
bilaterally with Simpson's metrotome (p. 443), 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. The danger from septicemia after
the operation is also considerable.
Greater than the danger from hemorrhage or septicemia is that of
perforating the uterus. It is impossible to know if the tumor has
more than a peritoneal 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. 491), and the inverted part must be replaced as
soon as the fibroid is enucleated. In fact, the dangers are so great
that this method cannot be recommended for entirely imbedded
tumors, but for partially polypoid fibroids I think it is less danger-
ous than oophorectomy and hysterectomy, and unlike them it pre-
serves the possibility of impregnation.
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.
Kmmeffi Traction Method is, in some respects, like the preceding
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, ])ulled down, and removed piecemeal as it
emerges from tlie os. In this way muscular contraction is induced,
and the surrounding tissue gradually closes ujwn the removed
tumor, so that it becomes jx'dunculate and leaves only a small raw
surface.
Ligation of Blood -rc.^^cln. — I^igation of both uterine arteries from
the vagina (Franldin Marti n^x nnfliod, ■\). 1H8) has given good re-
sults, both MS to hemorrhage and shrinkage of the tumor.'
(loelet isolat<'s the artery, seizes it with a long pressnre-foree])s,
ties it with stroiiir e:itti:nt outside and inside of this forceps, re-
moves the forceps, and cuts the artery between the liiratures. The
peritoneal cavity is not entered.^ 'I'his nu'thod, nlthoiiLih the trunk
of" the uterine artery is cut, is less effective than I^'ranklin M;irtin's,
because there are side; branches iroinsi; off from the uterine artery,
which would facilitate the formation of a collnteral circnhition.
Perhaps th'' nerx'c-siipply is also of some importance. It is, there-
fore, better to tie the whole jtaramctrium by a mass ligature.
' I-'ranklin Martin of ( liicatro, Amrr. Jonr. ()h^l„ Apr., IS'.i:], vdl. xxvii. |)p. 481 40'J ;
ihitlnii, .]:\n., IH'.ll. vol. xxix. pp. li'J-.''?. Nortli Ainrrirnn I'rddiliimrr, isy4, veil. vi.
pp. -") 14; .I'Kir. Avirr. Mril. Afivtr., 1S94, vol, xxiii. pf). '21.'>-217.
' .\. H. (loolot, Avwr. (Jyn. and Obgt. Jour., Kel)., IH'.tT.
510
DISEASES OF WO 31 EN.
C. C. Frederick ' of Buffalo reports good results, especially
enormous shrinkage of the uterus, by tying the uterine arteries
either from the vagina or after laparotomy. Others have tied the
ovarian blood-vessels, and Rydygier^all six arteries supplying the
uterus with blood, and yet the hemorrhage returned after ten months.
In such a case the uterus and its tumor are supplied with blood
through other normal arteries — the anterior and posterior azygos, or
the middle hemorrhoidal (p. 60) — or through new-formed arterial
connections imbedded in adhesions. The ligation of the uterine
arteries from the vagina seems to be worthy of more attention than
it has received. It is particularly applicable if the uterus does not
rise much above the umbilicus, and in women who have born chil-
FiG. 292.
Segond's Speculum : a, anterior blade ; b, posterior blade.
dren. It is safe, and, if it fails, it in no way interferes with a fol-
lowing hysterectomy.
Hysterectomy, may be performed through the vagina — vaginal Jiy.s-
terectomy — or through the abdominal wall — abdominal hystei'ectomy.
Vaginal hysterectomy may be performed with pressure-forceps,
ligatures, or without either.
Modus Operandi. — Clamp 3fethod, or l-'ean's Operation. — The pa-
tient lies on her back, the legs held up with a suitable leg-holder (p. 207).
The lower end of the table is raised about four inches. The exter-
nal genitals having been shaved and disinfected, and the vagina
^ Amer. Jour. Obst,, Sept., 189o, vol. xxxii. p. 348.
^Cenlralbl./. Gyndk., 1894, vol. xviii. p. 297.
DISEASES OF THE UTERUS. 511
disinfected (p. 207), Garrigues' self-retaining weight speculnm (Fig.
192, p, 226) is introduced, and depresses the posterior wall of the
vulva and vagina, or this is done with a univalve speculum held by
an assistant (Fig. 292, 6). The anterior wall is held up with a short,
broad, univalve speculum (Fig. 292, 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, or, better, dis-
infected by means of vaporization (p. 187). Next, a four-pronged
traction-forceps (Fig. 197, p. 228) is inserted in the middle of the
posterior lip and another opposite to it in the anterior lip. With
these the cervix is moved up and down so as to show tlic utero-
vaginal junction. Tiie 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. 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 in-
cision, the two forming one circular incision close up to the cervix.
Next, a transverse 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 are made, the operator
pulls steadily down on the cervical volsella, cutting 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, wiiile the posterior speculum
is temporarily removed. This posterior opening is large enough to
admit two or three fingers. In front the operator ])roceeds in a
similar way, exposing as much of the uterus as he can and without
paying any attention to tlie peritoneum. On the sides he can push
up the parametria almost without cutting until he is near the broad
ligament. No retractor should (!ver he inserted between the bladchn*
and the uterus, as it draws the ureters together and might wound
them or the bladd(>r. It siioidd only be iield 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 tiirough the parametrium, he places a pair of strong hemo-
statics forc(>j)s (Fig. 29.'>) on the lower part of the broad ligament on
i)oth sides, inchiding the uterine artery. The forceps is j)ut on in
512 DISEASES OF WOMEN.
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
Fig. 293.
Long Pressure-forceps, closing from point backward,
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 nterus much more mobile. The posterior speculum
is then removed for good. The anterior wall of the uterus is pulled
doM'n. 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 feeling alone ; otherwise all is
done in the wound under the control of the eye. AVhen 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 appen-
dages, and brought in contact with the forceps compressing the
lower part of the ligament. This compresses the ovarian vessels in
the infundibulo-pelvic ligament. 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 tlie 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 pur-
pose a pair of Pean's long narrow retractors, so-called ecarteurs,
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. 193, p. 227), 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.
DISEASES OF THE UTERUS. 513
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. 294) is left in the
Fig. 294.
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 j)aeking is removed at once.
If the omentum sinks down, either during the operation or after
removal of the tam])on, 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 to the uterus, a reasonable amount of
adhesive tissue should be left on it to go off by suppuration.
The abdominal tampon is removed gradually by pulling down
and cutting olf a piece every day.'
Lif/aturc Mrfhod, or Schrocdo^s Oj)rr(d!on. — If we want to use
ligatures, the two transverse incisions in the vagina are not united,
l)ut a bridge, half an inch wide and two-thirds of an inch long, is
left on each side of the cervix. The ])()steri(>r cul-de-sac is ojxiied
as descrii)ed nbove. As soon :is the peritoneum of the utero-vesical
pouch is reached, it is incised and torn from side to side, so tiiat we
liave one opening behind and one in front of the uterus.
The parametriinn on the left side is surrounded witii a strong
'The operation hero (iewrilwd is in all t>Hsentials that of Dr. Paul Sofroiid of
Paris, an adherent of I'i'an, who was the inventor of vaginal liysterectoiny hy the
clamp nieth(Kl.
33
514 DISEASES OF WOMEN.
lifjaturc carried with a half-blunt handled needle, bent to the side
(Fig. 295). After having cut the tissue between the ligature and
KiG. 295.
Schroeder's Needle.
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
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 tlie 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 po.ssible, the tube and ovary should be drawn inside of the upper-
most ligature, or they may be tied separately and removed (see
below).
When the left side of the uterus is free, the right broad ligament
with the appendages becomes much more ea.sy 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 differ.
If silk is used, the threads should be left long, and pulled out when
they become loose, or they may be removed any time after two days
1)V using the ingenious device of Dr. (irad.' For each ligature two
or three traction strings, strong silk loops marked with one, two, or
three knots respectively, so as to be able to distinguish them from
one another, are used. One of these strings is inserted in each loop
of the knot, and by pulling on them each can be opened at the time
the ligature is to be removed. If catgut is used, which is just as
well in other respects, it is cut short, aiul is expelled together with the
tissue forming the button of the ligature during the healing process.
If there is hi'inorrhage from the cut surface of the parametrium
behind or in front of the cervix, it may be ciiecked by uniting the
edge of the peritoneum with tliat of the mucous membrane of the
vagina. If there is still any bleeding from the dej)th, it may be
checked by means of a Mikulicz tampon (p. 186). Otherwise the
opening at the top of the vagina and the vagina itself are only parked
loosely with iodoform gauze.
* Herman Grad of New York, Amer. Gynec. and Obst. Join:, Feb., 1897.
DISEASES OF THE UTERUS. 515
Some go a step farther and close the whole wound, drawing the
stumj)s 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 ojieration more difficult and
tedious.
It has been stated above, how the appendages should be removed ;
but if the ovaries are healthy, it is better to leave them ; and the
same rule applies to one of them, if that is healthy and the othc
diseased. This rule has been evolved from observation of the mani-
fold and serious disturbances following double oophorectomy (see
J^csults of Salpingo-oophorcctomy), while single hysterectomy is
tolerated much better. This rule does not, however, ap}>ly to cases
of carcinoma of the uterus, because the ovaries are very liable to be
involved in the cancerous degeneration.
Comparison between Ligatures and Forceps. — Whetlier a surgeon
will prefer ligatures or forceps depends often more on personal predi-
lection and aptitude than on anything else. Forcejis may be applied
at a depth whore ligatures cannot be ap])lied 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 nuist be taken to avoid ])ressure-uecrosis 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. Esj)ecially, 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.
jrorcelldtioti. — 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 sim[)lest 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 bcconuN
already much more mol)ile. Another way is to excise a wedge-siiaj)ed
\)iQ('Q of the anterior wall or to make two incisions, diverging fioin
below upward, and remove the intermediate tissue piecemeaL Often
it is an advantage to begin by removing the cervix. In cases of"
retroflexion the posterior wall is attacked in similar ways instead of
tile anterior. Some divide the uterus into an anterior and posterior
flap, which are amj)utatcd and thus give i)etter access to the fundus.
Others divide the whoh; uterus into two halves in the median line, cut-
ting first the anterior wall, then, after having anteflexed the uterus.
516
DISEASES OF WOMEN.
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 N^laton's
cyst-forceps (see Ovariotomy and Fig. 296).
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 fundus and thus twisting the
Fig. 296.
Morcellation of Fibroid Tumors of Large Size (P6an).
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. 197, p. 228) 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 clanaped, 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 possible of the tumors, and deal with the uterus
DISEASES OF THE UTERUS. 517
subsequently. In all eases 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.^
Limits of Vaginal Hysterectomy. — P^an removes all uterine fibroids
by the vaginal method, if the fundus is below or even a little above
tiie 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 send
only small branches into these organs. In regard to the uterus, the
writer has found and shown before medical societies that each branch
of the uterine artery has a very fine lumen 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
or forceps. The operation is feasible, but less safe than the other
methods.^
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 to]) of the vagina by hysterectomy closes
by granulation in the course of three weeks. The patient may be
allowed to get uji at the end of the second week. As soon as the
wound canal is shnt off from the abdominal cavity by granulation,
vaginal antiseptic injections may be used. There is often formed
some proud iiesh which does not heal, and may keep up a discharge
indefinitely. Thos(! granuhitions ought to be scraped off witli a
sharp curette and the wound touched with lunar caustic.
Abdominal Hysterectomy is done either by sujiravaginal ampnta-
iion or by total e.vtirpation of the uterus.
Su])ravaginal Amputation of the Uterus. — In tiiis operation the
cervix or a small part of it is left and forms a stump. There are two
chief varieties, with intra-abdoviinal and witii e:ctra-alxlominal treat-
ment of the pedicle.
' Details about ninrcollation niav hi- fouiul in an article by Edgar (rarceaii, in
Amer. Jour. ObM., March, 1895, vol." xxxi. pp. 305-346.
' It is an old operation, having been performed as early a.s 1^22, revived in our davs
by Dr. K. H. Pratt of Chicago, .Jour. Orificinl Surf/., .Jiuie, lS!t4; (ieo. Knpelniann,
"History of Vaginal Hysterectomy," Anrr. Jour. (Jbst., Feb., 1895, vol. xxxi. p. 295.
518 DISEASES OF WOMEN.
1. Intra-abdominal, Retro-peritoncdl Treatment of the Pedicle. —
Tlie unquestioned victory won in ovariotomy by the intra-peritoneal
treatment over its rival the extra-peritoneal constantly has impelled
surgeons to apply the same ])rinciple to the amputation of the uterus;
but special difficulties are met with in the contractility of the pedicle
and the danger of infection taking place through the cervical canal
— unfavorable circumstances, which, however, have been obviated in
different ways.
Modus Operandi. — An incision is made through the abdominal wall,
extending from the sym})hysis pubis to the umbilicus or still farther.
In so doing, most operators go to theleftof the umbilicus. Acorkscrew
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 insert 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 ligament, including the ovarian
vessels, is tied, a long pressure-forceps (Fig. 293) placed inside of
the ligature, nearer the uterus, and the intervening tissue cut. In
placing this ligature it is well to carry the needle around the vessels
at a little distance from the free border of the ligament, by which
slipping of the ligature is prevented. Next, the round ligament
with the funicular artery is ligated, a pressure-forceps placed on it
nearer the uterus, and the first incision continued between the
forceps and the ligature. From the point where this incision ends,
just below the round ligament, a superficial transverse incision is
made a finger-breadth above the bottom of the vesico-uterine pouch
through the peritoneum to the corresponding point on the otlier side,
and the bladder separated from the supravaginal cervix. A similar
incision behind, in Douglas's pouch, separates the rectum from the
uterus. The uterus is pulled well over to the opposite side by an
assistant, and the operator goes with thumb and index-finger down
between the two layers of the incised broad ligament until he can
see or feel the uterine artery at the upper end of the cervix, where
it ascends alongside of the edge of the body of the uterus. Here it
is tied and cut after a pressure-forceps has been placed above the line
of incision. Xext, the cervix is cut across,' and when the last fibres
are cut or torn, the uterus simultaneously being ])ulled well up and
rolled ov^er to the other side, the second uterine artery comes into
' H. A. Kellv uses a special spud for this purpose {Bulletin of Johns Hopkins Hos-
pital, Feb.-Mar., 1896j.
DISEASES OF THE UTERUS. 519
view. It is tied and cut about an inch above the cervical stump, so
as to be sure not to include the ureter, which lies below and outward.
Next, the second round ligament is reached from below, tied and
cut, and finally tlie ovarian vessels. This leaves the uterus with
appendages as one piece, to which on the first side are attached three
pairs of forceps, which prevent recurrent hemorrhage. Next, the
cervical stump is hollowed out a little and its edges sutured together.
The anterior peritoneal flap is drawn over the wound and stitched to
the posterior flap with a running suture. Instead of ligating the
infundibulo-pelvic and round ligaments, they may be caught with
pressure-forceps, and the single arteries picked out on the cut sur-
face and tied. This may also be done as a particular precaution if
the ligaments are ligated. Catgut may be used for all sutures and
ligatures. The latter may \)o carried with the Schroeder needle
(Fig. 269, p. 462). Finally, the abdominal wound is closed and
dressed (see Ovariotomy).'
If the myoma 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 bo
enucleated from the stump.
2. Extra-abdominal Treatment of the Ped'u-Ie. — a. ITef/ar's Jllethod.
— When the uterus is turned out an elastic ligature is thrown around
the cervix, including the broad h'gamonts. Only in exceptional cases,
if tiie tension is too gn.'at or the mass too vohuninons, are the liga-
ments tied first and cut betw(;en two rows of ligatures. An elastic
ligature — a piece of ruljber tubing as thick as the little finger — is
turned twice around the cervix, drawn very tight, and crossed once.
Then tiie ends are seized in front of tiie crossing between the blades
of a pressure-tbrceps, and tied togetlier with a silk ligature behiud the
forceps. When this is tied, the ends of the elastic ligatures are j)ulled
out a little more, aud a second silk ligature is placed at some little dis-
tance i^ehind the first, aud 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 clastic ligature; next, to tie this with a second
hitch ; and, finally, to tie the silk ligature across this second crossing
of the elastic ligature.
' Tliis method lias hoeii fvolvcd by Anicriran surpeons, and lias liv Sotrond heon
called the Ainerirnn virllioil in contradistinction from the vajiiiial claiii]) iii(tho<l,
which is the invention of IVan. The chief points in the Aiiieri<'an operation are
the retroperitoneal method of trealinf? the stump (T. A. Emmet, IHSl), the separate
ligation of vessels instead of mas^s liualiires ( L. A. Stimson, A'. )'. MkI. Jmir., Mar.
1», 1889, vol. xlix. p. '277), and the side-to-side incision ( \V. K. I'ryor, Mrd. Xrws,
Dec. 1, 1894, and TntriK. .V. )'. OhM. S„r., Dec, 1891j.
620 DISEASES OF WOMEN.
Next, the uterus is cut off oue 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
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 iu 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 appears 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 cr.vity ; it entails a tedious conva-
lescence ; and it exposes the patient to vcntrnl hernia ; but it is expe-
ditious and convenient in dealing with very large tumors.
b. Senn's Method. — Extraperitoneal hysterectomy has been much
improved by Dr. 8enn of Chicago.^ He does away with the elastic
ligature, ligates the uterine arteries, sutures tlis cut surface, and ob-
tains healing by first intention. A circular incision is made through
the peritoneum, at a point corresponding to that at which the broad
ligaments have been divided. The peritoneum is then with the
fingers and blunt instruments peeled from the pedicle, which is
then (;ut transversely. The uterine arteries are tied immediately
after they are divided, and parenchymatous oozing is arrested by
^ Nicholas Senn, Pathology and Surgical Treatment of Tumors, Phila., 1895, pp.
509-511.
DISEASES OF THE UTERUS.
521
suturing the stump with several rows of catgut sutures. A small
strip of mucous membrane is then excised, after which the cut sur-
faces are brought together with several rows of catgut sutures. The
stump is stretched to the ^parietal peritoneum, as in Hegar's opera-
tion. The pedicle is accessible at all times in case of hemorrhage.
The space around the sutured pedicle is packed with iodoform
gauze. Secondary sutures are in place, and provisionally tied in a
Fig. 297.
Extraperitoneal Abdominal Hysterectomy without the use of the elastic constrictor or the
wire loop: operation completed (Senn).
loop over the packing. On the second day the gauze is removed
and the sutures tied ( Fig. 297).
While this method is an advance from Hegar's, it is inferior to
the intra-alxlominal methcxl as (h'seril)ed above, whicli gives rise to
no hemorrhage, is simph', expeditious, and finished at once, and
leaves the alxlominal wall free from any unnatural attachment.
Total Ah(lomh\(il Krflrpdfinn of the P/o-z/.s. — When th(> body of
the uterus with its appendages has been removed as described under
Su|)ravaginal ATn])ntation it is not difficult, if so desired, to remove
the stump of the cervix. It is seized with traction-forceps and
Revered all around partly with closed, partly with cutting scissors.
522 DISEASES OF WOMEN.
Even when all throe chief arteries of the uterus are tied on both
sides there may be, and commonly is, severe hemorrhage from one or
more arteries in removing the cervix. This is due to the fact that
the internal iliac often continues below the departure of the uterine
artery, and gives ott* the vaginal arteries, either as one or separately
as two or three branches (Fig. 37, p. 45). The anterior and superior
azygos artery and one or more of the lateral vaginal branches
normally anastomose with the circular artery of the uterus, and the
origins of the vaginal arteries vary much (p. 45). It happens some-
times that the operator, without knowing, cuts into the vaginal vault
instead of the cervix. The opening in the vagina may either be
left open for drainage or closed.
Special Difficulties met with in Abdomined Ili/sterectomy. — The
bladder may be spread out and adhere to the front of the tumor.
This condition may sometimes be diagnosticated before the opera-
tion by means of a male urethral sound. If so, the incision through
the abdominal wall should be made above the upper limit of the
bladder, the contour of the organ made out l)y the sound, an incision
made corresponding to it, and the bladder dissected oif from the
tumor, using as much as possible blunt instruments and the fingers.
If during the operation the operator is in doubt about the upper
limit of the bladder, the uncertainty may be dispelled by directing
an assistant to introduce a catheter or a uterine sound into that
viscus through the urethra.
If the bladder has been wounded, the wound is closed separately
wdth a catgut tier-suture (p. 237). The mucous membrane 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.
A catheter should be left permanently in the bladder or the urine
drawn frequently.
If there is an open uracJnis, 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 applying a double tier suture.
The writer once, in performing supravaginal amputation for uter-
ine fibromyoma on a woman forty-five years old, found the whole
fetal bladder preserved, as shown in Fig. 298.^
^ Specimen from my operation on Miss S. at vSt. Mark's Hospital on Feb. 13, 1899.
The bladder presented itself in tlie line of incision after division of the aponeuroser.
of the abdominal muscles as a triansjular body, being a. full-width continuation of
the lower part of the bladder and ending in a point at the umbilicus. It lay between
the transversalis fascia and tlie peritoneum, surrounded by somewhat tliickoned
connective tissue, from wliicli it was separated bluntly. The top was tied and cut
loose from the umbilicus, and tlie wliole organ dropped into the pelvis. On either
side the In'pogastric artery was seen as a hard, solid white cord, one-eighth of an
inch in diameter, outside of which the separation was made. The patient succumbed
to nephritis ten days after the operation.
DISEASES OF THE UTERUS.
523
On the side of the cervix great care should be taken not to
include 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 dry sponge. 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
Fig. 298.
Kt'tal Ijladdor in adult woiiiuu: (i, bladder; hb, hypogastric artcrios as solid Lurds;
ureters; '/, urethra; r, vHK'inn.
the jH'ritoneum around the a<lh('sion, and the jK'ritoneum dissected
off from the tumor and left in (ionncction with the intestine. Next,
the raw surfa(!e is fielded together by means of one or more catgut
sutures (Fig. 'I'M)).
In order to overcome the diniculties presented bv the mere weight
of large soli<l abdominal tumors of any kind, and by tlie assistant who
lifts it being in the way of the operator, Reverdin has invented a
524 DISEASES OF WOMEN.
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 draw-n, so that the assistant is enabled also to pull the
tumor to the side.
Fig. 299.
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.
Comparison between the Vaginal and the Abdominal Section. — When
the vaginal method is feasible it should be preferred. Many patients
dislike to have a large cicatrix on their abdomen on account of its
unsightliness ; 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 arc tlien required on the skin. They
should not extend far from the edges of the incision. If aseptic
when inserted and removed in time, they will not cause suppuration.
Finally, the cutaneous sutures may be avoided altogether by uniting
the edges by the subcuticular suture (see Ovariotomy).
Another and more serious objection to the cicatrice is that it may
yield in the cour.se 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 thickne.'^s 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-
arotomy, and the after-treatment is simpler.
On the other hand, the vaginal method is more difficult on
DISEASES OF THE UTERUS. 525
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 off, during which time it gives rise to an
offensive odor.
Comparison between Total Extirpation and Supravaginal 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 oflc i 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 le.-s 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 nor any danger of vaginal hernia (p. 354),
which occasionally has been observed after total extirpation. The
vagina retains its depth, while sometimes it is shortened in the rival
operation. The mortality is little more than one-half of that of
total extirpation.'
There are numerous modifications of these myoma-operations, upon
which the scope of this work does not allow us to enter.
Abdominal Enucleation or Jfi/omcctomi/. — A fibroid may l)e enu-
cleated ; that is to say, separated from the surrounding tissue and
removed from the substiuice of the uterus, from the broad ligaments,
or from the pelvic floor.
A. Ewu'tvation from the Uterine Wall. — When the uterus is not
studded with fibroids or their size is too large, and if there is reason
to iielieve they are intrair.ural, enucleation of the tumors is to be
preferred to hysterectomy, as thereby the genital organs ar<' preserved
in their integrity. In order tf) avoid hemorrhage an elastic con-
stri(;tor may 1)0 aj)j)li(!d around the cervix and the broad ligaments.
An incision is carried right through the muscular tissue covering
the tumor. This is shelled out of its eapsule, and the cavity closed
with rniining tier-sutures of catgut. If there are several myomas, it
may be necessary to make nHiltij)le incisions. That the tumors are
not submucous may i)e inferred from the fact that they have only
' Olshansen lia.s coUectt'd the following; statistics: supravaginal aiiipiitatiou, 806
cases, 45 deaths 5.6 j)er cent. ; total extirpation, 520 cases, 50 deaths [KG per
cent., Veil's Handbuch dcr dynakolorjie, vol. ii. p. 713, Wiesbaden, IfS'JT.
526 DISEASES OF WOMEN.
caused some increase in the menstrual flow, no serious liemorrhage
nor intermenstrual loss of blood. If the uterine cavity is opened,
the operation may still be continued ; but in that case the endo-
metrium siiould be brought together by a separate suture. If it is
impossible to arrest hemorrhage in any other way, supravaginal
amputation should be resorted to.
In ease it is found impossible to unite the walls of the cavity left
after the enucleation of a libroid by suture, Alexander's method might
offer a means of ending the operation before recourse is had to supra-
vaginal amputation of tlie uterus. After having temporarily clamped
bleeding vessels, he packs the cavity with iodoform gauze and closes
the edges of the wound in the uterus by suture, leaving each end of
the gauze hanging out at the ends of the incision. Kext, he closes
the abdominal wound and draws the gauze out through the two ends
of the wound. This gauze serves the double purpose of a plug and
a drain. It is gradually withdrawn, the cavity closes, and, finally,
the uterus drops down to its normal place.'
B. Enucleation from the Broad Ligaments. — If possible, it is a j^re-
caution ag-ainst bleediuo- 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 diflFereut 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 soft-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 tlie edges of the abdominal wound, and fill the pouch
with iodoform gauze disposed like a fan, Avhich 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
^William Alexander, Practical Gynecolorjy, Edinburgh, 1899, p. 112.
DISEASES OF THE UTERUS 527
packed with iodoform gauze, tlie 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 bv 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 (Hofnieier'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 or the thermocautery.
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).
C. Enucleation from the pelvic floor, under the broad ligament, is
still more difficult and dangerous. Ifis carried out according to the
same principles as for intraligamentous tumors.
Small tumors springing from the cervix or lower uterine segment
can sometimes l)e enucleated from the vagina, either by posterior col-
potomy,as in the first step of vaginal hysterectomy (p. 510), or by ante-
rior colpotomy,as described in treatingof vaginal hysteropexy (p. 473).
Complication with Pre(/)}((uci/. — Fortunately, most women with
fibroids are sterile, and if they conceive, their })regnancy quite fre-
quently ends in abortion or in premature labor. Labor at term may
be easy, but oftener the fibroid j)roves a dangerous com])lieation. 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 j)rematurc labor, if the
tumor is situated in such a place or has such ])roportions that great
trouble may be anticipated by allowing gravidity to go on to full term.
To perform operations during ])regnancy will be likely to lead to
abortion. Unless there be urgent symj)toms, such as hemorrhage or
pressure, it is better to delay ()|)erative interference till labor sets in.
A pedunculated subserous tumor may sometimes be ])us]ied up out of
the way of the cjiild. A cervical tiunor may be enucleated, and on
account of the succulence of the womb and the uterine contractions
]>resent, the enucleation is both easier and safer than under ordinary
circumstances. But if the tumor extends high uj), it may be neces-
sarv to perform (VsarcMii section, supravaginal amputation, or total
extirpation, or to .sicrifice the cliild.
If the child has been horn, it is better to j)ostj>one the consideration
of o))eration, so much moi"<' so as we have seen that the tumor may
(lisa|»pear during involution.
Sloiif/hitif/. — l''or some gynecologists the appearance of sloughing
in a sessile filtroid is an indication for hvstcrectomv. 'I'akini:- into
528 DISEASES OF WOMEN.
consideration the unfavorable condition in which that grave operation
would have to bo performed, and the case referred to above (p. 508),
I am inclined to think a more palliative treatment is preferable,
especially if septicemia has developed.
Decubitus Aeutus sive Ncuriticus, Acute Bedsore. — This is a uni-
lateral gangrene which sometimes complicates operations in which
the nerves of the j)elvis are pinched or otherwise irritated. Segoud
has observed its occurrence in nearly 1 per cent, of his vaginal
hysterectomies. AVomen who suffer from old perimetric inflamma-
tion seem to be predisposed to this occurrence. On one side of the
crest of the sacrum and the corresponding part of the nates appears
suddenly an erythematous spot with a more or less regular contour,
rather sensitive to touch, and accompanied by a pronounced swelling
of the derma and subjacent tissues. There is a rise in temperature,
and the general condition is bad. In the course of a few hours
blebs filled with a reddish fluid are produced on the erythematous
area, and in two or three days an eschar is formed as large, at least,
as the hollow of the hand and implicating all the soft parts down to
the bone. All the patients thus affected have recovered, the eschar
being thrown off and the wound filling up slowly.^
3Iortality. — In deciding the question of the advisability of per-
forming cutting operations for tlie 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, tlic operation is folloAyed
by a large mortality. Until recent years operations were very fatal. -
But constant progress is being made, and several opei'ators have of
late reported long series of hysterectomies without a death. Early
recourse to operation, as well as an improved technique, has had
great influence in diminishing the mortality. It would, however,
not do for the average operator, and still less for the beginner, to
expect results like those of Pean and Tait, who reduced their mor-
tality to 1.5 per cent. The mortality among good American opera-
tors ranges now between 5 and 6 per cent.^
^ Paul Segond, Revue de Gynecologie, No. 1, pp. 59-66, Jan.-Feb., 1897.
^ Complete statistical tables are found in "A Review of the Operation of Gastrot-
oruy for Myofibroma," by II. R. Bigelow of Washington, D. C, in Ame): Jour. Obst.,
1883-84. <leo. W. Johnston of Washington, D. C, has collected a large number of
cases of fibromata of the cervix, Amer. Jour. Ohi<t., 1885, vol. xviii. p. 1280. (See also
"Analysis of Home Statistics on Supravaginal Hysterectomy," by Marie B. Werner,
Annals of Gynemlogi/, Oct., 1892, vol. vi. p. 56.)
s Chas. P. Noble, Med. and Surg. Reporter, June 2, 1894, publishes the follo\¥ing
table :
Kelly 57 cases 2 deaths.
Baer 57 " 3 ''
Polk 40 " 3 "
Noble 14 " 1 "
Total 168 cases 9 deaths = 5.36 per cent.
DISEASES OF THE UTERUS.
529
Causes of Death. — Death after fibroma-operations is due to shock,
hemorrhage, septicemia, nephritis, embolism, intestinal obstruction,
ligation of the ureters, or tetanus.
Shock plays a very great role in operations that often are very pro-
tracted,' 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. (See p. 244).
HemorThar/e is now controlled much better than formerly by means
of pressure-forceps and tlie 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 tlie patient, a weak, frequent pulse,
pallor, a cold, clammy skin, a swelling of the abdomen, and sometimes
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 tlie abdomen, clean out the cavity, find the source
of hemorrhage, tie the bleeding vessel or put in additional sutures,
inject warm saline solution (common salt, a little over ^ per cent.,
will do) into a vein, into the peritoneal cavity, into the rectum, or
under the skin. (See p. 220.) For any of these injections an apjKi-
ratus which I descrilxd in 1878, and have used many times with
success, will be found convenient. It is essentially a fine Davidson
'iarritrncs' Transfusion nrul Inftision Apparatus : /I, pluntjcr ; /;, bulb ; r, st(ii)C()ck ; /^ flex-
ible probo-iKjiiitfd cunula; K, K, valvis.
syringe- (I'ig. .'>()()). For the subcutaneous injection a hollow needle
is substituted for the blunt flexible camda. JM)r subcutaneous injec-
tions, instead of the valve-syringe, the needle may be cotnie(!ted
with tlie tubing of a fountain syringe, which needs less attention.
Scjificciiiia may be due to the entrance of path(»genic germs (hiring
' I'l'an's operations have oficn taken tliree hours. (lYanet Uniy, " Ilysteroto-
niie," Paris, l>^~'.'>.)
'^(iarrij^ues, " Aiijiaratus for Transfusion," Atmr. Jmir. 0/>^7., October. l>7s, vol.
xi. No. 4, p. 7o4.
U
530 DISEASES OF WOMEN.
tlie operation, to the use of insufficiently disinfected materials, and
to infection from the pedicle, or perhajis even from the intestine.^
The more bacteriology progresses the more difficult it seems to guard
against infection.
JVcphriiis. — AVe have seen (p. 218) that- anesthetics produce acute
nephritis. As a rule, this is only a transient phenomenon that dis-
ap})ears in a day or two ; but occasionally, especially if the kidneys
were affected before the operation, the inflammation may become
permanent and cause the ])atient's death.
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.
Infesfina! Obstruction may be brought about by exudation and
adhesions. The means to avoid it in supravaginal hysterectomy are
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 salt solu-
tion from a fountain syringe. The enema with ox-gall described
on p. 178 may also be tried. I^avage of the stomach with a weak
solution of salt, sometimes combined with the administration of
castor oil, has proved very effective. (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 danwr of hemorrhao;e in removino- the lio-atures
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. It has been suc-
cessfully treated with tetanus antitoxin. If that fails, an attempt
should be made with bromide of potassium, chloral hydrate, and
curare.
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
|)atient or grow miieli. Fibro-cystic and snj^purating tumors nuist be
removed. In all other cases Apostoli's treatment should be employed,
and o})erations only resorted to in those in which it fails or when it
cannot be obtained. When a fibroid grows in s]>ite 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-
* Welcli, "Wound Infection," Amer. Jour. Med. ScL, Nov., 1891, p. 443.
DISEASES OF THE UTERUS. 531
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 cancel- 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 impillomas.
Sarcoma. — Pathological Anatomy. — Sarcoma preferably aifects the
body of the uterus. In the neck it is very rare. It appeal's in three
forms — the circumscribed, 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
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
ti.ssue, 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 l)reaking hardened s|)ecimens. The
less fibrous tissue they contain, and the more the cells ]>rcdominate,
the more malignant tluy are. In younger ])ortions of the growth a
jelly-like amor{)li()us mass is found between the fibrilla) whicli 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 ca])illaries
with very thin walls, which exj)lains the hemorrhages that form so
prominent a featun; among the symptoms.
The diffuse sarcoma, as a rule, contains cpitiielial cells, so that a
transition is made to carcinoma.
SarcoTuas ar(! Ui)t \mmv to ulcerate so soon as carcinomas. As
a rule, the tumor (htcs not l)C(!omc decomposed until parts of it
descend into tlu; vagina or are removed artificially.
In myxosarcoma, also called colloid cancer, there is a })repondcrance
532
DISEASES OF WOMEN.
of tlie intercellular amorphous substance containing mucin, to Nvliich
is due its gelatinous consistency.
Papillary san'oma starts from the vaginal portion of the uterus.
It arises from a hypertrophy of the papillae 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
Fig. 301.
Cj'Stosarcoma of rterus, seen from behind (hall size) : «, uterus: 5, risrlit Fallopian tube ;
c, right (jvary ; </, largest cyst cut open ; e, small solid tumor cut open.
metastatic deposits at distant places, such as the vagina, lym])hatic
glands, the connective ti.ssue of the pelvis, the peritoneum, the liver,
the lungs, the pleura, the vertebne, and the skin.
A .sarcoma may become cystic, and is then called cysto-sarcoma}
Etiology. — The cause of sarcoma is unknown. It is most common
at the climacteric age, between forty and fifty years, but differs from
' I have described and represented in the Nev; York MedicalJoumaJ, Angust, 1882,
such a case in which the mucous membrane of the uterus was intact, but a large
tumor composed of cy.sts and solid masses had been developed in the abdomen.
DISEASES OF THE UTERUS. 533
carcinoma by being found iu persons under twenty yeare 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 folloM'S endo-
metritis or develops in a fibroid.
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
odor. 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 Avomb. 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 ])lace and the speedy development of cachexia.
The appearance of a tumor like a fibroid at the time of the mono-
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 hyperplcuHtic endometritis it is differentiated by greater tender-
ness of the b(xly, by the often open cervical canal, by sometimes
forming a polypus that iiangs out through the cervix, by tiic apjiear-
ance of cachexia, and l)y the spontaneous expulsion of torn-off pieces
of the tumor, which never takes j)lace in endometritis. Particles ob-
tained by curetting, on the other liand, are deceptive : a sarcoma may
furnish a specimen exclusively composcHl 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 j)resenee of large cells
separated by intercellular ba<is siiljstance is coifclnsivc;.
As long as the epithelial cells of the utricular glands — either origi-
nal or of" new formation — arc unchanged, the diagnosis of chronic
534 DISEASES OF WOMEN.
endometritis is admissible, whatever the nature of the interstitial
tissue be. As soon, on tiie 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.'
When a whole tumor is removed, its nature may be settled by the
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 endon^-
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, tlie 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, wlien once the diagnosis is certain, is to perform
the total extirpation of the uterus, either by the vaginal or the ab~
dominal method (pp. 510-517). Morcellation should not be thought
of, on account of the danger of infecting the neighboring 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 ])arts 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. The application of calcium carbid may also be tried (see
Carcinoma).
In handling sarcomas great care should be taken to avoid mechan-
ical infection of yet healthy parts.
Decidual ^arcoma."^ — Of late several cases have been described of
sarcoma of the uterus which appeared shortly after abortion or cliild-
1 L. Pleitzmann, Amer. Jonr. Ohst., 1887, vol. xx. pp. nOfi, 907.
^ Aocordinj? to Pfannenstiel, " drrlduomn maJignum" is not a sarcoma, but an en-
dothelioma, starting from the endotlielium of the capillaries of the decidua.
DISEASES OF THE UTERUS.
535
birth. The tumors were composed of large decidual cells imbedded
in a meshwork of connective tissue, forming pseudo-alveoli and con-
taining nuclei and giant-cells. The aifection 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
coui"se 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.
E. Carcinoma.
Carcinoma (Fig. 302) 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. 302.
Cervical Curciiioiim of Uterus cxtciidinj; into IJody :' a, body of uterus ; h, cervix ; r, mbe ; d,
ovfiry ; c, liylutid ; /, piece of wood inserted in order to expose tlie ciivity of tlie \itcni^.
Pfifhohf/ical A)i(tf(iiiii/. — Carcinoma is most common in the VMgiiial
portion of the utrrus. Next in fre(|uency is that of ihc ccivix,
while that of" the h(Miy is comparatively rare. Uj)on the whole, th(>
' Specimen from my vaj,'iiiiil iivsterectomy on Mrs. C. C.
nital, March 25, ISUl.
-, St. Mark's llos-
.536 DISEASES OF WOMEN.
uterus is very frequently aifected in this way, perhaps oftener than
any other organ, the only question being if carcinoma of the breast
ocoui's as often or oftener.
Carcinoma of flic VaghiaJ Portion begins in that part which is
covered with flat vaginal ej)ithelium. It does not, however, start
directly from the epithelium, but from new-formed glands, and may
dip deep into the muscnlar 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
vagina, and may become so large as to fill it down to the vaginal
entrance. From its shape this form lias derived the name of canli-
floiccr crcrcaccnce. 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, tlie latter forming a
tumor, which may become pedunculated so as to form a polypus.
Often the nmcous membrane of the body is aflected 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 nest^ 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 plexiforra
arrangement, the epithelial cells often breaking up into medullary
corpuscles; S, medullary carcinoma, \vheve the cellular element pre-
dominates, forming a soft mass ; and 4, scirrhous or fibrous caraino-
ma, in which there are larger trabecule 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, sa-
cral and lumbar, or the inguinal glands become infiltrated according
DISEASES OF THE UTERUS. 537
to the part of the uterus that is aifected (p. 62). Of the above-named
varieties, the epithelioma is least likely to spread to the glands. If
the bones are aifected, the growth may enter the hip-joint and dislocate
thefemur; 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
tlie veins of the pelvis and the thighs. They may be due to direct
pre&sure or be caused by the general marasmus and weak heart-
action.
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.
Jt is very rarely found below the age of twenty, in which res])ect
it diifers 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, ])robal)ly 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 f)f which are tuberculous. Perhai)s also syphilis in
ancestors, by giving rise to a deterioi-ated constitution, may jwedispose
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 (j). 415), with the concomitant eversion, glandular devel-
opment, and erosions, are apt to become the starting-))()int 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.
Carcinoma of th<; placental site is mon; common than sarcoma
(p. 534), and originates from the syncytium of the villi chorii (('(trci-
iiotiuf .syncytidlc). The syncytial character is even repnuluccd in
metastases.'
Carcinoma in general is found twice as often in brunettes as in
blondes, but, in the United States, twice as often among whites as
among blacks.
Carnivorous animals arc more ])rone to cancer than herbivorous,
just the reverse being the case concerning tuberculosis. W omen
are nujch more the subject of cancer than men. It is more preva-
' Jlirst, Tift-l'xiok <ij (//jxlflrirs. p. 129.
538 DISEASES OF WOMEN.
lent in certain localities than in others. Thus Buffalo, N. Y., is near
the center of an area with a radius of two hundred miles where
the death-rate from cancer is greater than in any other part of the
States. Malignant tumors are more frequent in habitations sur-
rounded by or near W(jods and in persons who are occupied in
woods.
Although carcinoma undoubtedly is transmissible from one part
of the body to another with the current of the blood and lymph,
there is no evidence that it can be inoculated into another individual,
and the great rarity of carcinoma of the penis compared with the
very common appearance of the disease in the cervix uteri goes far
to show that the disease is not transmissible by coition. Still, much
evidence is accumulating in favor of cancer being a germ disease.
Sanfelice, Roncali, and their pu])ils have proved experimentally that
certain blastomycetse are capable of being isolated by culture from
certain carcinomas and sarcomas, and of producing in animals into
which they arc injected tumors strikingly analogous or identical
with those from wliicli the cultures were made, from which artificial
tumors the germs can again be isolated and used for farther inoc-
ulations.'
Statistics in Enghmd and America show that cancer has increased
alarmingly of late. According to the returns of the Board of Health,
the number of cases in New York State has nearly doubled during
the decade 1885-1895.
Si/mptoms. — 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 collum, 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
plug (p. 416) 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 ])ressure.
In carcinoma of the body there are no other early symptoms than
hemorrhage and leucorrhea.
As the disease progresses these symptoms may become more
1 Koswell Park, " An Inquiry into the Etiology of Cancer," Amer. Jour. Med. Sci.,
May, 1898.
DISEASES OF THE UTERUS. 539
marked and new ones are added. The hemorrhage often becomes
profuse. After ulceration 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 vulvae 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 compressetl 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 ])elvis 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,
pleurie, and kidneys is less frequent. Sonietimes dysentery sets in.
A detached embohis may be driven into the pulmonary artery and
put a sudden sto}) to the suflerings of the ])atient. Septicemia is rare,
tlie inflammatory exudations serving as a barrier against the entrance
of the products of decay into the circulation. The glands in the
groins and in tiie depth of the pelvis are felt to be enlarged.
By vaginal examination we find the uterus to be immovable. "^I he
vaginal vault is as hard as a board. From the cervix we may find
hanging a soft j)olv|)oid tumor, which may fill the whole vagina. It
is friable and bleeds ea-ily. Or the finger enters a crater-shaj)ed
ulee'nition surrounded hy hard walls. Often the infiltration with car-
cinomatous tissue can l)e 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.
540 DISEASES OF WOMEN.
Diagnosk\ — A sponge left in the vaj^ina and forgotten lias 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 papillarj^ ulcer
surrounded by follicles is likely to be benign. On the other hand,
we find in carcinoma of the cervix a sharp line of demarkation be-
tween the diseased and tiie 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 ])iece 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. 434), whereas carcinoma spreads
in spite of the treatment. Microscopical examination maybe 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. 444).
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 microscopiciil examination furnish abundant means of dispel-
ling it.
TubercuIoHS ulcers are surrounded by tuberculous nodules ; are, as
a rule, combined with tuberculosis of other parts, especially the lungs ;
and sliow the characteristic bacillus.
The simple friclion ulcer found where the cervix protrudes in front
of the vulva is surrounded by bluish tissue, and heals easily under
proper care. The lymphatic glands are not affected.
Corroding nicer ' has not such hard surroundings, and can be diag-
^ Corrodinrj ulcer is the term used bv Dr. AVilliams for tlie one lie ascribes to senile
gangrene caused by calcification of the internal iliac arteries, while rochnt nicer 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.
DISEASES OF THE UTERUS. 541
nosticated by means of the microscope, which shows absence of
epithelial proliferation.
Papillary hypertrophy may give rise to small benign growths, bnt
they have a narrow base ; w^ien 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 tlie reader is referred to what has been said above
(p. 431). 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.^
A fibroid follows a benign course. It develops very slowly, no
particles are expelled, there is no l)ad 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 higli temperature and fetid discharge, but this is
a condition tiuit comes on suddenly, and ends in a short time in death
or recovery.
Pieces of secundine.s 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 microscojiical
examination of expelled, scraped-off, or excised parts, carcinoma
being comjwscd of rpithclial angular cells, sarcoma of round or
spindle-shaped. The diagnosis is in so far of imjiortance, as the
prospects for success in a radical operation are greater in sarcoma
than in carcinoma.
H' the early recognition of carcinoma may Ix; difficult, in its ad-
vancc<l stage the disease presents so uniform a picture that it is easilv
recognized, tlie most striking featiu'es 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, tlu; pains, and the cachectic condition.
The ascitic fluid accomj)anyiiig ean-inoma of the body and obtained
by aspiration contains sometimes large round or peai'-shajx'd endo-
thelial c(!lls with large nuclei, either isolated or in groups. This sign
is of some positive value, but not of negative — /. r. if' these malig-
* Louis Heit/.Dianii, Ainrr. ,Jonr. ObM., St'j)t<.'ml)i'r, 1SS7, p. \)\\).
542 DISEASES OF WOMEN.
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.^
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. — Prophyla.ris. — Cervix lacerations, if they give rise to
eversion and consequent irritation of the mucous membrane, should
be operated on (pp. 418, 419), and endometritis treated as stated above
(pp. 433, 434).
Coe^ 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 raucous 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 wath any hope of benefiting the
patient. But very much may be done 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. 244). 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
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 (Iroj)s 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. 176). In more profuse hemorrhage, or if
' For details see Garrigues' Diagnosis of Ovarian Cyst, pp. 94-97.
2 H. C. Coe, Med. Neivs, Feb. 16, 1889.
DISEASES OF THE UTERUS. 543
the seat is in the body, curetting (p. 180) is of great value. In
removing large sprouting masses from the cervix I have found
Thomas's spoon-saw (p. 505) a very useful instrument. The patient
is placed in the dorsal or left-side p()sitit)n, 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 pr(x;ess 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. 184), and the vagina with an antiseptic plug (p. 184).
After having removed this tam])on the next day, some ap]dy pled-
gets wrung out of a solution of chloride of zinc (.^v to distilled water
^j,or, if there is a wall more than a quarter of an inch thick around
the cancerous tissue, even equal ])arts). 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. During the separation of the slough
and cicatrization disinfectant injections are used.
Some substitute excision with knife and scissors for curetting as
the first step in the chloride-of-zin<; treatment, cutting out a cone
from the vaginal junction to the internal os.
Nobody should undertake curetting for a large cancerous mass
without being ])rej)ared to ligate the uterine artery from the vagina
(p. 188), or even to extirpate the uterus if necessary.^
It is also recommended to scrape off all diseased ti.ssue and dress
the wound with a sjiturated solution of soda.
Hemostatic drugs ni\> not of much avail. Gossypium (p. 214),
however, is useful as an adjuvant.
Injections with crcolin (j). 177) are very valuable, both as a hemo-
static aud an autiseptie. Tiie odor of the drug itself is by no means
disagreeable. Still nioi-<! astringent is li(ju. ferr. chloridi (p. 17(J).
' T (lid so in a rase in wliich I liad refused to jx'rfnrin the radical operation on
account of infiltration of the liroad lif^aniont on one side. The enrettinji; entailed a
larpe openintr in Donirlas's poudi. I then jHirfornied vajjinal hvsterectoniv. The
patient made an excellent primary recovery, but the cancer, of course, continued
developing.
544 DISEASES OF WOMEN.
Periiianganate 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 wlor 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-.^ss) combat hemorrhage, pain, and odor.
Occasionally the use of a styptic tampon (p. 184) may become
necessary.
For carcinoma of the body Yulliet's dilatation (p. 159), 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.
The local use of calcium carbid is an important addition to our
palliative resources, which in cases that have not progressed too far
may even effect a permanent cure. Calcium carbid is one of the
new combinations effected by Masson's electric stove. It is a
brownish stone-like, very hard mass. A piece varying in size from
that of the last ])halanx of the little finger to that of the thumb is
placed in contact with the cancerous tissue in the vagina or in the
uterus. A bubbling sound is heard and a foam seen, due to the
development of acetylene gas. The vagina is rapidly packed with
iodoform gauze, which may be left in place three or four days.
Then it is removed. The calcium carbid is found transformed to a
calcareous, clayish mass, which is scraped out with Kecamier's dull
curette (p. 182) and incrustations removed with the finger. The
sore is irrigated with lysol and dried carefully, and then a fresh
piece of calcium carbid is applied.
The three chief symptoms — pain, hemorrhage, and odor — are
checked, and occasionally the whole cancerous cavity heals and
contracts.^
In using tonics the reader should remember the warning (p. 245)
against giving ii-on 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 bine enjoyed a short-lived celebrity. I have not
seen any effect from the use of these substances ; but since others have
' Aime Giiinanl of Paris, Tribune Medirale, 1896, vol. xxvii. p. 827. J. IT. Ktlier-
idwe, Jour. Ampr. Med. .i.s.wr., July 9, 1898, befran hy curetting and cauterization;
but tlie original method of the inventor, Guinard, has the great advantage that it
may be used in dispensary practice.
DISEASES OF THE UTERUS. 545
claimed success, and since we must sometimes prescribe something,
I add the following forrauhie :
^,. Extr. condurango, fl. 5ss ;
Aqu., ad Sviij. — M.
Sig. A tablespoonful four times a day.
^i. Extr. condurango, iss;
Vaselini, §iss. — M.
Sig. To be a])plied daily on tampons to the ulcerated surface.
^i. Terebinthinfe Chiensis, sss:
Sulphuris sublimati, Siiss;
Rad. glycyrrhizse, q. s.
Ft. pil. No.' c.
Sig. Three pills every four hours.
To those who cannot swallow pills it may be given as an emulsion
with mucilage, a yolk of an eg^, 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 (TTLxx to .^j of a solution of 1 part to 300 pails 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, proD-
ably by obliterating lymph-vessels and killing some microbe:
]^. Ilydrarg. cliloridi corros., gr. iij ;
Sodii chloridi, oj ;
Aq. destill,, 5j.
M. S. — 20 minims for parenchymatous injection, three times a
week.'
Radicfil Tredhacnt. — Although some of the heretofore-mentioned
methods have been claimed to have eflected 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 disejiscd j)ai"t. In this connection we have to con-
sider the supravaginal aiiii)utation of the cervix, and total extirpa-
tion of the uterus.
Tke high cervix ampndition (Schroeder's method) has been described
on p. 448. It is not an easy ()j)cration, exposes to the danger of con-
si(l(!rable hemorrhage, and is less rational than the total extirpation
of tlie uterus, since we iiave seen that cervical carcinoma often is
(•oini)ined with a beginning of the same disease in the bodv of the
womb.
Tlie whole cervix has also been cut out with the fhcnno-cdiilcri/, by
' Scliiiiiiiiii, Ct-ntntlbl./. (iijndk., 1>S8S, vol. xii. p. 'Jl.'!.
546
DISEASES OF WOMEN.
which means hemorrhage is avoided, but neighboring organs may be
implicated.
Thennal galvano-cauterizafion seems to have given better resuhs,
both in regard to mortality and the length of time before a relapse oc-
curred, than any other method.' It is performed with the cautery
loop, the cautery knife, and the dome-shaped burner (p. 252). At
least the whole cervix should be removed. If the uterus is immo-
bile, the supravaginal amjiutation is made with the cautery knife, not
the loop (Fig. 303), and thorough cauterization of the bottom, sides,
and edges of the excavation is added.^
The need of a costly instrumentarium and its liability to get out
of order have undoubtedly prevented this method from becoming
more popular.
The total extirpation, or hysterectomy, may be jierformed by the
vaginal, abdominal, vagi no-abdominal, sacral,
perineal, or perineo-vaginal section.
Vaginal hysterectomy is a German operation
that has met with much opposition in this
country.'^
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. jNIartin 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, but at the end
of five years all his patients were dead.
Modus Operandi. — The operation may be performed with ligatures,
pressure-forceps, thermo-cautery, or galvano-cautery. In order to
' Statistics of a large personal experience have been published by Pawlik of
Vienna and John Byrne of Brooklyn, N. Y., Gynecol. Tran.'<., 1889, vol. xiv. p. 90.
Dr. Bvrne's batterv and instruments niav be obtained from Mr. Kaysan, 34 Bond
St., Brooklyn, N. Y.
'■^ John Bvrne, Amer. .Jour. Ob.4., Oct., 1895, vol. xxxii. p. 559.
^ J. Bvrne, Gyn. Trans., 1889, vol. xiv. p. 90; ibid., 1892, vol. xvii. p. 3; Baker,
ihi'l., 1891, vol. xvi. p. 170; Resimy, Gun. Trans., 1888, vol. xiii. p. 183; Jackson,
Med. News, Jan. 18, 1890; Coe, ^Imer. Jour. ObsL, June, 1890, vol. xxiii. p. 587.
Supravaginal .Xmputation
of Cervix witli tiie gal-
vano-caustic knife.
DISEASES OF THE UTERUS. 547
avoid infection of the wound from the cervix or the interior of the
uterus 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. 509-51 5). As the cervix usually is most affected
Fig. 304.
Bernays' Utero-tractor.
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. 304), 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.'
In order to avoid inoculation of cut surfaces with cancer germs,
hysterectomy i'ov carcinoma of the uterus is of late often done with
pressure-for<'cj)s and the thcrmo-cautery — so called tliermo-cduter-
eviomy of the ntcriUH. First, the cancerous surface is cauterized with
Paquelin's instrument and the vagina disinfected. Next, a trans-
verse incision is made witii 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 j)ouch is severed. Next,
tlie 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 aie placed on the parametria and broad ligaments as
described above, and the uterus cut loose with the thermo-cautery. -
Still Ixitter than the th(M'mo-caiitery is the (/(ilirnio-cdiifcri/. This
' I do not know if it is ninre tlian ;tn :ic<i(lont tli:it I lost a ))ati('tit l)y totaiins who
ha<l been doini; oxceilcntly until llif nintii day after tlu' i'Xtir|iatioii liy tlie ciainp
method. Still, it has been siiriniscd that similar occiirrenrcs after ovariotomy and
tlie extraperitoneal treatment of tlie pedicle after alKlominal hystereelomy for fibroids
stood in some relation to the use of clamps and pins. 'J'he forceps has also caused
the formation of a fecal fistula. Compare decubitus acutiis (p. 528).
' ('nitraWl. f. Gyniik., \H'J'), So. 21, vol. .xix. p. 5GU.
548 DISEASES OF WOMEN.
instrument gives off much less nuliating 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.^
Mackenrodt goes so far as to demand the extirpation of the upper
half or the who/e 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 tlie galvano-cautery. He begins the operation witli a
lateral incision with tlie cautery-knife through the left vaginal wall and
the perineum. Next, he seizes the edge of this incision with a forceps
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 tlie 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.^
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.
After hysterectomy the pelvis and vagina are packed as described
above (p. 513).
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 shoukl be closed at the end of the
operation, and all precautions taken to insure healing (pp. 383, 385).
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 (WincUel).
Sacral Hijsterectomy. — 1. Kraske's Method. — Kraske's operation for
' John Byrne, Aiiu:r. Jour. Obttt., Oct., 18i)-'), vol. xxxii. pp. 5G5, 566.
^ Mackenrodt, Centralbl.f. Uyndk., I>9(i, vol. xx. ^'o. 5, p. 129.
DISEASES OF THE UTERUS. 549
cancer of the rectum has been adapted to the removal of the cancer-
ous uterus. The patient is placed in Sinis's position. A curved
incision is made from the iliosacral synchondrosis on the right side
to the tip of the coccyx. Then the gluteus maxiraus muscle and the
great and le&ser 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 tlie bladder.
This operation is recommended in cases in which the uterus is large
and the body of the organ fills up the j)elvis, or in which the ova-
ries and tubes are the seat of prior disease and are adiierent.' The
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 tlie bone, detaclies 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.
Abdominal iri/derectomj/ (Freund's 3fethod) for carcinoma was at
first attended with such extreme mortality that the operation was
universally abandoned, and was only used as a necessary addition to
vaginal hysti.'rcctomy (rdf/ino-ahdoinina/ hyHtcrcdomy) when dillicMil-
ties were encomitered which could not be overcome in any other way.
Still, from the ready ac(!ess it gives to all the pelvic organs, it is ])re-
f(!nihle to the sacral mc^thod. And the great success ()btaine(l with
abdominal hysterectomy for fibroids of the ut(!rus has induced some
operators to j)erform abdominal hysterectomy for cancer also. It
offers the advantage that one can remove more of the broad ligaments,
and thus come further away from the seat of the disease. It has
(!V('n i)('(>n recommended as routine pra(!tice to extirpate the iliac
glands, in analogy with what -is (lon(! with th(> axillary glands in
amputation of the i)reast.^ \\y ])reviotis iutrodnction of llexible
' Details may he foiiiKi in a paper hv E. K. Moiitgonierv of I'liiladeliiiiia in llie
Trmnt. of llif Amrr. Akxhc. nj ()hKh'triritinH and (ii/iK'niliiiilsttt, IfSDI.
" K. iiii'ii, Zeitscli. /. G»-buiUfi. u. Gyniik., vol. xxxii. No. 2.
550 DISEASES OF WOMEN.
cathotors into the ureters by Kelly's method (p. 163) these organs
may be avoided.
Fennco-caginal Hysterectomy {Sclmchardf s Method)} — The same
advantages are, iiowever, claimed for the perineo- vaginal method,
which is particularly adapted to cases in which one of the broad
ligaments is involved in the cancerous degeneration. The patient is
})laeed 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 w\all of the vagina is exposed. Next, the whole vaginal
Mall is split from l>elow 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
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 wiiich the sur-
geon would be enabled to work in a bloodless field. But tlie 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.^ 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. 84, p. (So).
' Centralbl.f. Chirun/ie, 1894, No. 'di), Beilage, p. 61.
* " Quain's Anatomy," 9th ed., 1882, vol. i. p. 451.
DISEASES OF THE UTERUS. 551
The obturator artery is especially erratic, not unfreqnently 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 aifected 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. 536). Others are
fibroid polypi (p. 496), formed by increase in size of the papillae of
the cervix, and are generally covered with stratified flat epithelium.
They have a pedicle comj)osed of connective ti&sue and muscular fibers.
Others, again, contiiin glands, and belong, therefore, to the mucous
polypi (p. 427). Others, again, are sarcomas that have taken the
papillomatous form (p. 532).
Some, finally, are t7'ue papillomas. In these the tumor is formed
by hypertrophy of the papilla? 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 a})pear in them, and they tai<e on the structure of epithelioma.
This true papilloma is likewise found springing from the nuicous
membraue of the body of the uterus, but is exceedingly rare in that
locality.
Treatment. — True ])apilloma is to be treated by amputation of the
cervix, or, if situated in the cavity, by curetting and cauterization.
G. Dnchondroma.
Enchondroma has been found in the cervix, but is very rare. It
should be removed by amputating the cervix.
H. Tuberculosis.
Next to tho tul)es, the uterus is the part of the genital tract which
is most commonly the seat of tulu'rculosis. It may be j>rimary or
.'<econ(Jary, and the latter may again spread from neighboi'ing organs
or hc: due to infection through the blood. The disease is usually
limited to the mucous membrane. It occurs in three forms — llic
552 DISEASES OF WOMEN.
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 tuberculasis on record
the disease did not invade the bcxly.^
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. 349). 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. 307. 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
neighboring tissue shows, how^ever, an entirely different structure in
the two diseases — in carcinoma epithelial cells ; in tuberculosis small
round cells, giant-cells, cheesy masses, and the bacillus tuberculosis.
Treatment. — As to general treatment, the reader is referred to what
has been said in speaking of tuberculosis of the vulva (p. 307). 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.
^ J. Withridge Williams, " Tuberculosis of the Female Generative Organs," Johns
Hopkins Hospital Report in Pathology, ii. Baltimore, 1892, p. 126.
PART Y.
DISEASES OF THE FALLOPIAN TUBES.
CHAPTER I.
Ma lform ations.
The tubes are sometimes unusually large. In most cases this
increase in size is due to the presence of some aMominal 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. Sometimes the lumen is so large that a uterine sound can
pass it, and then, of course, also fluid. Intra-uterine injections should,
therefore, be administered in the dorstil position only, and with
sufficiently dilated cervical canal, unless a double-current tube is
used (p. 178).
They may be wound in a spiral or be abnormally contorted, condi-
tions which predispase to retention of fluid, inflammation, and extra-
uterine pregnancy.
Tliere may lie from one to three accessory abdominal ostia. They
are surrounded by fimbriae and situated near the abdominal end of
the tube, on the uj)per part of the wall.
There may also be ticccssori/ tubes, either as cystic diverticula
starting from the tube, but without communication between the two
cavities, or as independent tubes with fimbria? starting from the meso-
salpinx. In the latter variety ectopic gestation may take place —
paratubal pregnancy}
The tulx!S 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 l)e a partial or totiil absence of tunneling
of the tubes, the result of an arrest of development (p. 30). In otliers,
again, the tube is normal near the uterus, but is soon lost in the con-
nective tissue of tlie broad ligament. The corres[)onding ovary is
usually absent or little developetl.
Deficient development of the tube may be the cause of })ain at the
menstrual j)eriod, and hw-al peritonitis, when ovula and 1)1(xk1 from
the Graafian follicles fall into tiie alxlominal cavity.
' yiinger, MomitJischr. f. GeburhMil/e uiul Gyruikologie, 189o, vol. i. No. 1, p. 25.
554 DISEASES OF WOMEN.
At the fimbriatetl end of the tube is often found a little cyst called
the hydatid of Morcfagni. 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.
CHAPTER II.
Salpingitis.
Salpingitis is the inflammation of the Fallopian tubes.
Diffei'ent Forms. — ^^It may be acute catarrhal or acute purulent, both
of which are seated in the mucous membrane, and are, therefore,
called endosalping'dis ; or it may be chronic interstitial, which is also
called pacht/salpinc/itis, mural salpingitis, myosalpnngitis productivay
or parenchymatous salpingitis, and is located in the muscular coat.
Salpingitis may be cystic, and according to the character of the fluid
contained in tlie dilated tube it is called pyosalpinx when the tube
is filled with pus, Jiydrosalpinx when it contains a watery fluid, or
hematosalpinx when the contents 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.
Proflucnt salpingitis is only a variety characterized by the discharge
of a Matery fluid, pus, or blood from the tube through the uterus and
vagina. When the fluid is watery the disease is also called hydrops
tubce prqfluens or intermittent hydrocele of the ovary (Bland Sutton.
See Tubo-ovarian Cysts in the pathology of the Ovaries.)
Under the name of Scdpingitis 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 pyosalpinx in which the lumen
of the tube is partitioned ofl" 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.
Paihologiccd Anatomy. — One or both tubes may be diseased. The
infectious form is usually bilateral. The tube is swollen to a thick-
DISEASES OF THE FALLOPIAN TUBES 555
ness varying from that of a little finger to that of a thumb (com-
pare below, cystic salpingitis). In catarrhal salpingitis the aifection
is chiefly limited to the mucous membrane. The folds are edematous
and hyperemic, or slightly infiltrated with small round cells.
The epithelial cells are swollen, show slight increase in size of their
nuclei, and vacuoles form in their protoplasm, Side-b randies grow
out from the folds, and these, as well as the original folds, may grow
together, forming closed cavities. The muscular coat does not
participate much in the inflammatoiy process. The secretion is in-
creased, and contains mucus, albuminoids, and thrown-oif 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 e])ithelium is thrown oif over
large areas, and the underlying tissue is crowded with small round
cells, which are thrown oif as pus-corpuscles. Commonly the mucous
membrane is the primary seat, but by extension the inflammation
invades the muscular coat, and tiie coinicctive tissue between the
muscle-i)undles becomes infiltrated with pus-corpuscles. Probably
tears of the cervix and pelvic cellulitis may also lead through the
lymph-vessels to infiltration of the tube. The fimbriic 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 perma-
nent hypertrophy of the wall by formation of new connective tissue.
Interstitial salpingitis is a chronic disease which has its scat in the
muscular coat.^ It may follow either catarrhal or purulent sal})in-
gitis. The extension from the nuicou-^ membrane to the muscular
layer takes place through the connective tissue. In the fii'st stage the
connective tissue between tlie muscle-bundles is edematous. Next, a
large number of inHammatory corpuscles (small round cells) form in
it, and even the smooth nuiscle-fibers themselves break down and are
transformed into such cells. Later, the interstitial inflammatif)n may
lead to the formation of new connective tissue. Jt is doubtful if
iiniscular tissue is also formed. In this way the wall is thickened,
and the prwess may end in a permanent hypertrophy (Fig. .')();")).
On the otlier hand, interstitial salpingitis may lead to atrophi/ of the
tube. Here the wall is thin, the caliber small, and the e})ith('lium
partially lost. The muscle-tissue is to some extent replaced by con-
nective tissue.
' II. J. T>oI(lt lias iiiiulc a sj)e(ial study, illiisf ratid by instriiclivc dr.iwiiifrs, of tlio
microscopical changes characleristic of this form in Ama: Jour. Ohft., I'ch., 188S,
vol. xxi. p. Vl'l.
556
DISEASES OF WOMEN.
Fig. 305.
Hypertrophy of Fallopian Tube due to Interstitial Salpingitis. The tube is cut open, showing
the lumen, a, in the middle of the thiclc hard wall, 6.1
Fig. 306.
Salpingitis: a, tube finger-thick at lower end, narrowed in many places ; 6, cyst as large as
a chestnut situated in the wall of the tube ; c, ovary containing a recently ruptured
Graafian follicle, the size of a large hazelnut; d, torn adhesions.^
' Specimen from my salpingo-oopliorectomy on Mrs. S., in St. Mark's Pfosiiital,
on July 24, 1890.
^ Specimen from my salpingo-oojiliorectomy on Mrs. L. S., in St. Mark's liostatal,
on August 29, 1890.
DISEASES OF THE FALLOPIAN TUBES.
557
The different forms of salpingitis, aspeeially the purulent, ai'e 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-
hesions are formed to the intestines, the omentum, 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. 307.
1. Left Tube cut open, f'atarrlial and Interstitial Salpingitis: a, closed fimbria'; a h, a c,
thickness of wall ; d, central cavity.
2. Right Tube cut oirti, I'yosalpiiix : a, closed fimbriic; b, cavity filled with pus; c, c, r,
smaller cavities coinmunicatiMK with central canal.
S. Small round body found loose in pelvic cavity, probably atrophic right ovary .i
ends of the tube or coalescence between the walls 'u\ one or more
places in their cour.-e. As a rule, the abdominal opening is first
closed by agglutination between the fiml)ria3 or between them and
tlie ovary. Later, agglutination may also take place at the uterine
end. If both ends are closed, the fluid ac(;umulates, forming a cyst,
filled with a serous, mucous, pultaceous, purulent, or l)Io(Kly fluid.
The wall is in most j)laces thickened, but through distention or
ulceration in the interior it has thin })laces liable to rupture. Most
' Specitrieii from mv salpingo-tx'ppliorectomy on Mfh. F. K., in St. M:nl< .« Ilospi-
tal, on May 19, 1894. '
558 DISEASES OF WOMEN.
frequently this thinning is found in the upper and posterior part of
the tube, so that the fluid, in ease of rupture of the wall, flows into
the peritoneal cavity. In rarer instances the rupture takes place
downward between tiie folds of the broad ligament and produces
pelvic cellulitis and abscess.
These tubal cysts are mostly club-shaped, Avith 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
of sausages (Fig. 306). Diflferent 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. 307).
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.
In rare cases the presence of actinomyces is the cause of sal-
pingitis.
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.
Symptovis. — There is no pathognomonic symptom. Even a dan-
gerous puerperal salpingitis, calling for removal of the pus-filled tubes.
DISEASES OF THE FALLOPIAN TUBES. 559
need not cause any other symptom than emaciation and recurrent
fever. A symptom, however, that must awaken great suspicion is
an intermittent outjiow of mucous or purulent fluid irom tlie 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 aifected, a peculiarity which may have its cause
in the preponderance of cervical tears on this side (p. 415) or the
absence of a valve in the left ovarian vein (p. 77).
Pain may be insignificant or excruciating. It is felt in one or both
iliac fossa and in the sacral region. It often has a colicky character, and
may be due to contraction of the inflamed nuiscular 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 ])atient suffers from menorrha-
ffia or metrorrhagia, the hemorrhage taking place in the diseased
tubes themselves or in tlie 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 tlie tubes are found tender, thickened,
often distorted and either movable or adlierent 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 ])erliaps a
knuckle of intestine and a part of the omentum, together with the
tube, into one sliajx'less mass.
A unilateral mass of this kind may so fill the pelvis as to push the
uterus over towardthe other side, at tlie same time canting it forward.
In ca.se the masses are bilateral and large, they ])ush the uterus with
the broad ligaments from behind forward up against tlie anterior wall
of the pelvis, or j)ress on it more from above, tipj)ing 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.
JJiar/notiiH. — The diagnosis of salpingitis may be very diflicult, the di>-
ease being so often combined with oophoritis, peritonitis, and cellulitis.
The intermittent spontaneous outfiow of nuicus or ])us ])receded by
a burning sensation or cramps makes the })resence of salpingitis veiy
probaiile. Tiiis symj)tom actpiires still more weigiit if the examiner
by gentle pressure exerted on the tui)al region can make the fiuid
appear at th<; os uteri.
(Jophoral(/i(f is oidy found as a ])art of general hv>teria ; luinho-
ahdoniinal 7U'iir(il(/i(i is elicited by j)ressure on the skin over the iliac
5G0 DISEASES OF WOMEN.
region, but not by pressure from the vagina, and in none of these
purely nervous affections is there any swelling.
From oophoritis the inflamed tul^e 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 form?, as a rule, a larger exudation of more globular
shape extending from Douglas's pouch to one of the iliac fossse.
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
Sinis's positions and by rectal touch (p. 144), to anesthetize the patieiit,
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
W'ith 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 am 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. 130) 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 gonorrheal threads, designated with the Ger-
man name " tripj>er 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. 133).
DISEASES OF THE FALLOPIAN TUBES. 661
Childbirth should be surrounded by all antiseptic precautions.^ 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 intra-uterine pessary, using in-
tra-uterine injections, nay, even from carrying a sound into the uter-
ine 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. 243), hot vaginal douches (p. 176), and, if necessary,
a saline aperient (p. 242). 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. 174 and 196), pledgets soaked in ichthyol-glyccrin (p. 182), gal-
vanism with one pole against the vaginal vault (p. 249) or in the
uterine cavity (p. 248), preferably the former, scarification of the
cervix (p. 194), intra-uterine applications of chloride of zinc (p. 175),
blisters applied over the inguinal fossa, superficial cauterization of
the same region with Paquelin's cautery, poultices, hot^ water bags,
Pricssnitz compresses (p. 195), and warm entire baths, — are all very
eff<'ctive remedies, which, combined with substantial food, mild stimu-
lants (p. 241 ), and tonics (p. 242), may efl'ect a cure. In milder cases
of swollen tubes and ovaries, curetting (p. 180), followed by pac^king
of the uterine cavity with iodoform gauze (p. 185), 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 tlie tubes, and
packing with iodoform gauze, to be removed every day or two.
MuHHage (|). 199) has also been praised, but seems to me to be sur-
rounded by too great dangers. '\\\i\ only indication I see for it is the
cases in which the abdominal opening of the tube is closed, and the
' V\\\\ information in this respect is found in the writer's Prartiml fhiiilr In Aiill-
Sfjylir Midviff-ni in IIuspilnlH and I'rivdtr I'rnrHcf, Hetroit, Mich., 1SS(>. jiixi in his
articit^ on " I'iier[)eral Infection" in Amrr. Si/slrvi of Ohxlt'lrint, I'hiia., iSSit, vol. ii.
I){). 3'.i7-;'>f)l, and in Avur. Text hook of OhsMnrs, I'fiiia., IS!)."), i)|.. TOS 719.
36
562 DISEASES OF WOMEN.
uterus renmius opeu. Uudcr such cirounistanees a very gentle press-
ure followiug the course of tlie tube froui without inward toward the
uterus may press out the fluid whicli has accunuilated in tjie 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 wixW.
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 Literoflexed and the ostium internum much dilated, or in
cases of abnormal width of the tube (p. 553). In otlnir cases of
supposed catheterization the sound has perforated the uterine wall,
which is easily done, and, as a rule, has no evil consequences (com-
pare p. 181).
Aspiration through the vaginal vaidt is not devoid of danger, 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
flrmly adherent in Douglas's pouch that we have reason to hope that
no fluid will escape into the j)eritoneal 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.
xVn incision may be made from the vagina, a method es])ccially
indicated in acute puerperal cases, where the patient is too weak to
stand salpingo-oo])horcctomy or hysterectomy.' A transverse in-
cision is made behind the cervix as for hysterectomy. With the
finger and l)lunt instruments the operator approaches the tubal swell-
ing as much as possible, and then opens it with the expanding per-
forator (Fig. 177, p. 199). The cavity is either ])acked with iodo-
form gauze, or a soft-rubber drainage-tube with cross-bar (Fig. 169,
p. 193), and long enough to protrude from the vulva, is placed in
the tube. A safety-])in 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 ])r(>s(nt ;
and, as a rule, if the diagnosis is sure — that is, if the fluid is in the
^ The writer has successfully opened five distinct pus collections in a puerper;i,
corresponding to abscesses in tioth tubes, both ovaries, and encysted peritonitis, from
the vagina.
DISEASES OF THE FALLOPIAN TUBES. 563
Fallopian tube, and not in the peritoneal cavity 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 exj)lot'atory laparotomy or colpotomy is
indicated, whicii may lead to the removal of the uterine append-
ages with or without the uterus, or to their preservation by diifer-
ent 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. 511), or, so far as anterior colpotomy is concerned,
more room may be gained by following the rules laid down for
vaginal fixation of the round ligaments (p. 475). The conservative
treatment is now mostly carried out by vaginal section.
Conservative Treatment. — In some cases it suffices to separate adhe-
sions, ]>ass a probe tlirough 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 stitcli the fimbriae to the peritoneum near the
ovary, so as to prevent them from curling in and closing the abdom-
inal opening again. If the fimbriae cannot be separated, the end of
the tul^e may be cut off, and the mucous membrane stitched to the
peritoneal coat with a few catgut sutures. By tying the mesosalpinx
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-
tero])exy (p. 474) or shortening of the round ligaments (p. 471). Such
conservative measures have even Ix'en successful wh(>n the tube con-
tained from a half to a whole fluidrachm of pus. Where there is a
large collection of fluid, the tubes should be removed.'
Halpiwjo-o'nphorectomji. — Indications. — In acute sal))ingitis the re-
moval is contraindicated excej)t when a purulent salpingitis extends
to tiie peritoneiun and threatens to l)Of!ome generalized. Under such
circumstances tiie extirpation should l)e performed immediatelv, with-
out losing time with j)alliative measures. If at the same time tiiere
is a ])urulent discharge from the uterus, this organ ought to be cu-
retted or removed.
Tlie removal of tlie apj)endages is also indicated fi)r interstitial sal-
pingitis, if the j)atient sufl'ers much pain and has repeated attacks of
' I'olk has (lone miidi in tho line of conservatism, and descrihed his i)roc(>(iiire8
in Mediml Rermd, Sept. 1«, IHSO; Amn\ Jour. ()I>M., 18«7, vol. xx. |). ti.SO; Tmn^.
AviPT. Gyn. Sor., 1H87, vol. xii. p. 128; Jonr. OhxI., Dec, IS'.tO; i7>i(/(?/i, Sept., IS'.tl;
IVaim. Amer. Gyn. Soc., Wfd, vol. xviii. p. 175; Med. Neua, Jan. 4, 189(1.
564 DISEASES OF WOMEN.
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. 180) l^efore 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 oif-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.
3Iodus Operandi. — The appendages may be removed through the
abdominal wall or through the vagina : the former method is called
Tail's operation, the latter BaMey's operation.^ 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-oophorectomy. — The incision is made in tiie
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 nece&sary 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
tliere are no adhesions, the tube and ovary are lifted between these two
fingers up through the abdominal wound. If necessary, this proced-
ure 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, or by packing the vagina before the operation
with gauze.
In this and other operations in the depth of the pelvis the manij)-
nlations may also be much facilitated, especially on the left side, l)y
introducing a eolpeuryiiter — /. e. a rubber bag — into the rectum, and
* Battev'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.
DISEASES OF THE FALLOPIAN TUBES. 565
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 pre&sure 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 with a cloth wrung out of hot nor-
mal salt solution f() : 1000). The elevated-pelvis ])()sition lielj)s
much to avoid handling of the intestines, which is likely to cause
shock and predisj)oses to adhesions after tiie ojK'ration.
If the tube and ovary are imbedded in a mass of resistant new-
formed tissue, it may be ne(!essary to desist from their removal ;
but with increasing experience and skill an ojicrator will be able to
remove organs which, at an earlier stage of his career, it was wise
to leave undisturbed.
Tait did not giv(; up the oj)eration even if it was necessary to
wound bladder and intestine in order to finish it. The ensuing
fistula heals spontaneously.'
Sometimes serous fluid accumulates in the interior of adh(>sions, by
whi(;h thev become tubular, and look much like a Fallopian tube or
the appendix vermiform is.
Vascular bands arc; often cut Ix^tween two catgut ligatures.
When the tube; and ovary are lifted up, a dull handled needle
(Fig. 202, p. 2?>\) threaded with a strong silk ligature (braided, No.
12), 20 inches long, is pushed from the front backward through the
broad Iigan)ent, half to three-fourths of an inch under the ovaiy. An
assistant seizes the ligature with a ])air of fbreej)s and his finders and
holds it while the oj)erator withdraws the needle. Next, the loop
is i)rought forward over the ovaiy and tube, comj)risiiig as nnKJi
of the latter as feasible. One of the fre(^ ends is carried through
this loop, the (jther remains above it. I'he opei'ator seizes both ends
with the fingers of his right hand and ])ulls on them, and j)resses
with his left thum!) and index finger against the tissue to be li-
' Lawson Tait, t'adratbldtt. Jar (lyndk., Keb. 4, 1893, vol. xvii. p. IKJ.
566 nrSEASES OF WOMEN.
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. 308. 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.
308), 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 tliere is bleeding,
the ligature is carried round the pedicle and tied on the other side.
The cut surface is powdered with iodoform 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 sj^cial ligature. This method offers the great advan-
tages that there is less danger of the ligatures slipping, that very little
tiasue is compressed in the ligature, that all ovarian tissue can be re-
moved, and that there is no traction on the scar.*
Another good way is to place clamps inside and outside of
the appendages, cut those out, tie the ovarian and the uterine
arteries separately on the cut surface, and close the whole in-
cision with a running catgut suture. If there is any bleeding,
more clamps are provisionally put on and removed Avhcn they are
reached by the suture. Then it is best to loop this for every
stitch (p. 238).
It should be remembered that the ovarian vessels at the brim of
' C. B. Penrose, Amer. Jour. Obst., 1895, vol. xxxii. p. 221.
DISEASES OF THE FALLOPIAN TUBES. 567
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. 526) under Fib-
roids of the Uterus.
As to the treatment of the appendages of the other side there is
much difference of opinion. Tait recommended to remove them
even if they were healthy, because they would be affected later, and
the second operation had a mortality altogether disproportionate to
the first proceeding, while many die for want of a second operation.
But experience having shown that tiie removal of both ovaries often
gives rise to great mental depression and piiysical disturbance (see
J). 569), it is better, if the otlier set of appendages is healthy, and
even if it is only moderately diseased, to try to save it, or part of it,
so much more so as tliis has in rare cases permitted of pregnancy
and childbirth.'
The ovary may be cut open, (ysts enucleated or part of the ovary
cut out, and the e<lges united by a continuous catgut suture. A piece
of the tube may be cut off, and hemorrhage arrested by ligating the
ala vesjK'rtilionis without interfering with the vessels nourisiiing tiie
ovary. An ojxiuing may be cut in the tube, and the mucous mem-
brane stitched to the peritoneum around it (p. 563).
While the removal of non-adherent appendages is a comparatively
easy oj)('rati(»n, it becomes one of tlie most dlflicnlt when there are
many extensive and unyielding adhesions. Great benefit may, under
these circnmstances, be derived from tiie elevated-pelvis position (p.
141). In attempting to free the adiierent a])pendages, we nuist try to
find natural lines of ch'avage. Remembering tiiat the ovary s})rings
from the posterior layer of the broad ligament, and that the tube is sit-
uated at the u|)per border of the ligament and forms a ciu've around
the ovary (pp. (j;3, 65), we nuist try to free them l)y going in Ix'tween
them and the sacrum, behind the broad ligament. M' j)()ssible, the
ligature shoidd be |)asse(l ix'low the round ligament, which lessens the
danger of its slij)|)ing. For the same reason the broad ligament is
shurkened in drawing the ligatures tight. If the tissue is so friable
that the ligature cuts tiirough the tube and ligament, it may become
necessary to tie the ovarian artery sej)arateiy and close the wound in
the uterus with a nuuiing sutun; of" catgut. If" hemorrhage cannot
l)e checked in this way, the uterine artery nnist be tied below, at
' Details arc found in papers l>y A. Martin, (Vntralhlatt jiir (ij/nii/:., Anno 20, 1891,
Vol. XV. No. lio, J), ol"), and I'olk, Avkt. Jour. Obst., Dec, 1S9(), vol. .\xiii. ]>. i;?7r>.
568 DISEASES OF WOMEN.
the upper end of the cervix on one or both sides, or the uterus itself
removed.
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
ofl^*, and a drain of iodoform gauze carried out from the contaminated
area tiirough the abdominal wound or the vagina. If much of the
pelvis becomes infected, the best plan is to fill the cavity with a
Mikulicz tampon (p. 186), the eflect of which is that by exudation
and organization of plastic lymph a temporary partition is formed
between the pelvic and the abdominal cavity. If the fluid spreads
widely 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 indi-
cated ; or it may be necessary to apply a Mikulicz tampon (p. 186).
If both appendages must be removed, it is best to remove the
uterus also. This organ is often the source of infection of the
others. It is not only useless after their removal, but often hemor-
rhage and pain continue after removal of the appendages. Under
such circumstances I have repeatedly been obliged to remove the
uterus after months or years.
The uterus may be removed by one of the methods descrilied
above under Uterine Fibroid (p. 494 seq.), but Faure^s method is
particularly adapted to cases of suppuration of both sets of adnexa
with a small uterus. It is based on the principle that enucleation
from below is easier than that from above, and applies it to both
sides.
After having opened the abdomen, the fundus uteri is seized
with two pairs of traction- forceps, one on either side of the middle
line. A transverse incision is made above the vesico-uterine pouch,
and the bladder pushed down. Next, the fundus is divided in the
median line with strong straight scissors, and with three or four
clips the whole uterus is divided into two halves, whereby the
vagina is opened in the median line in front and behind. Then
one half of the cervix is seized, beginning with the side that seems
easiest. If there is no difference, the right is taken first. This is
pulled on, until a strong resistance is felt, formed by the correspond-
ing half of the vagina. This is cut close up to the cervix, and half
the uterus removed with its set of appendages. Afterward the same
is done with the second half. The uterine artery is seized with a
clam]) either before or after cutting it. The round ligament and the
ovarian artery are seized and tied. If there are intestinal adhesions,
they are separated last. By going from below upward the enuclea-
DISEASES OF THE FALLOPIAN TUBES. 569
tion of the adnexa boconios mucli easier. The arteries are tied with
catgut. The vagina may be closed or left open. Faure prefers the
latter, and uses a thick tube and a strip of iodoform gauze for drain-
age. For sterilizing the uterus, when opened it may be touched
with Paquelin's cautery ;' or, preferably, it should be vaporized before
opening the abdomen. If the vagina is closed, the whole wound in
the peritoneum should also be closed as in supravaginal amputation
of the uterus (p. 517).
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 salpiugo-oophorectoray 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 impo&sible for her
to earn a living or perform any Jiseful work. Often they make an
opium-eater of hei-. 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 comnuinity at large.
Immediate and Remote RcHiUta. — In 8G per cent, the operation
brings on the menopause at once or after a few months (compare
p. 121). When menstruation continues it may be due to incompK'te
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 off the normal roads of circulation.
In some cases a hematoma is developed in the broad ligament. Some-
times, during convales(;enc(', or later, an encysted collection of serous
fluid takes place in ])seudoniembraiies. Many complain of vertigo
and fulne-s in the head, which may be relieved by bromides or
cauterization with Patjuelin's thermo-cautery on the nape of the neck,
or which may even necessitat<! repeated venesection.
Purpura heiuorrhagica 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 c()in])lain
of pain in tlu; pelvis, which probably is due to the constriction of
the pedicle. In some this j)ain disaj)pears soon, and they feel relieved
from their sufferings and bless the day they submitted to the opera-
tion. In others this Iiapj)y event does not o(;cur before the la{)se of
several moiuhs, and in a lew the j)ain j)ersists indeliniU'ly. This
sad condition may be accounted for in ditl'erent ways. The chronic
peritonitis had extende<l beyond the tui)es and ovaries, and part of it
' 1. L. I'aure, I'rc.isn mc'lirak, Urt. I'J, ISUT, vol. ii. p. 'S.i~.
570 DISEASES OF WOMEN.
remains, therefore, after their removal. Tlie 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
cjiusing 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. Experiments on
animals have shown that removal of the ovaries has a marked in-
fluence on the metabolism. The phosphates eliminated in the urine
and the carbonic acid contained in the expired air diminish, while
tlie weight of the body increases. Whether the uterus is removed
or not has no influence on metabolism.^
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 lo&s 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
appear soon after the operation, and may continue with lessening fre-
quency for years.^ Other disturbances that have been noticed are
loss of memory, irritability of temper, diminution of the power of
vision, a more masculine voice, skin aflfecticms, nightmare, and in-
somnia.'*
The functional troubles following the removal of both ovaries
may sometimes l)e successfully treated by the internal administra-
tion of powdered desiccated ovarian tissue — gr. ij in a capsule at
midday.
Perhaps even a radical cure and pregnancy may be obtained by
the implantation of a piece of ovarian tissue either from the patient
herself or from another patient into the fundus uteri or a Fallopian
tube. A piece of ovarian tissue as largo as a pea is excised and kept
in warm normal salt solution. The fundus uteri is reached by
* Curatulo and Tunilli, La Secrezione Interna delle Ovaie, Home. 1896.
^The results of salpingo-oopliorectoiny have been discussed by Coe, Medical
Record, April 19, 1890; bv Jjoldt, ibidem, May 17, 1890; and Lusk, Amer. Jour.
Oh.«t., 1891.
^Sherwood-Dunn, Annals of Gynecol., Nov., 1897, Mar., April. 1898, vol. xi.
DISEASES OF THE FALLOPIAN TUBES. 571
laparotomy or, preferably, posterior or anterior colpotoray. An
incision is made in the median line of the fundus to the cavity.
The ovarian graft is inserted in such a way that its epithelial sur-
face protrudes into the uterine cavity, and the raw surface is in con-
tact with the raw surface in the fundus, where it is fastened by a
single stiteh of fine catgut, which also, as well as other sutures,
serves to close the incision in the fundus. A gauze drain, inclosed
in a rnbber tube, is placed in the uterus against the place of grafting
and let out through the vulva. After forty-eight hours it is re-
moved. If the tube is chosen, a probe is inserted, the wall cut on
this ; and in one point of the circumference the mucous membrane
and the peritoneum stitched together, in order to prevent protrusion
of the former. Xext the tube is dilated and the graft inserted with
the epithelial surface turned into the lumen, and the raw surflice
stitched to that of the tube ; and finally the tube is closed by suture
over the graft. ^
Like other laparotomies, this operation may cause injury to a ureter,
ventral hernia, fecal fistula, an abdominal sinus following the use of
a drain, 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 Salpingn-odphorccfoviy 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 w'ay 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 uncertain the diagnosis
is in these dee])-seated affections, and how often there are adhesions
to the intestine and its appendix, that is a point of ])aramount im])ort-
ance. If we enter through the abdominal wall, the incision may bo
enlarged, and we are able to coj)e 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. 'J'his method was excellent for the removal
of healthv ovaries and at a time when lack of antise|)tic surg<'rv made
the opening through the abdominal wall much more dangerous than
that thn)Ugh the vagina, but for the needs of tiie present day, when
W'e es|K'ciallv wish to i-emove diseased tubes, and witli our ])resent
H'sources in regard to heniostasis and drainage, the abdominal method
is ])referiibl('.
' KobtTt T. Morrihoii, Lrrture.t an Ajipnulicitis, New York, IS'.ifi, |>. ITjG.
672 DISEASES OF WOMEN.
In the vaginal operation the vagina is opened by anterior or pos-
terior colpotoniy, or both ; and in order to gain more room an incision
in the median line may be carried from the posterior transverse in-
cision as far down as tiie bottom of the pouch of Douglas, after
which the operator works mostly with liis forefinger, until he can
plunge it into the peritoneal cavity. Adhesions are torn and the
appendages brought down and ligated, or treated otherwise and re-
placed. Hemorrhage is stopped by the same means as when lapa-
rotomy is performed, and the wound is closed or left open. (See
Hysterectomy for Uterine Fibroids.)
If the appendages of both sides are so diseased that they must
be removed, much space is gained by first extirpating the uterus
by vaginal section. But since it is so much better to leave even
only part of an ovary (p. 570), and since this cannot be done if
we begin by performing hysterectomy and tear out the appendages
in the dark (p. 567), either laparotomy or colpotomy should be pre-
ferred to hysterectomy. 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 narrow, the
abdominal method may be the only available one.
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
betweeu 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
DISEASES OF THE FALLOPIAN TUBES. 573
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-
able, and tip the uterus to the opposite side. A periionitic 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 fibroid 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 wall or tiie vaginal vault.
Tiie 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 tiie others. Thus pyosalpinx is by far
more common, follows gonorrheal or puerperal infection, is very adher-
ent and tender, often rauses fever, and is apt to form fistula?. Like
iiydrosalpinx it is usually bilateral.
Hydrosalj)iiix may form a timior of much larger size. As a rule,
it is less adherent and less tender, and causes less constitutional
disturbance.
Hematosalpinx is cxcccdiiigly rare, is often unilateral, and may be
accompanied by a (constant bloody discharge from tiie uterus. Sonie-
tinies it is combined with hetnatocolpos and hematonietra.
Treatment. — As a rule, the cystic tube with the ovary should be
removed. An (-xploratory 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 bef"ore extirj>ating the tumor. If
it is small, it may be removed in tofo. Some jirefcr the removal
through the vagina, wliich also may begin as an exploratory incision.
The arrest (A' /icmorrliagr may l)e very troublesome. It lias become
574 DISEASES OF WOMEN.
necessary to leave pressure- forceps in the abdominal cavity till the
next (lay, 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. 186), uniting perito-
neal edges with a continuous suture of catgut, stitching other bleeding
places in a similar way (p. 526), and permanent comj)ression with
iodoform gauze with or without (iounter-pressure in the vagina
(p. 185). (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
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 fimbriae 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 ])us, 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
DISEASES OF THE FALLOPIAN TUBES. 575
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. — If the cyst adheres to the abdominal wall, an incmon
should be made parallel to Poupart's ligament, and, if possil)le, a
counter-opening made in the vagina, establishing through-drainage
with a soft-rubl)er drain. If tiie cyst adheres to Douglas's pouch, the
incision may be made in the vagina. If situated higher up, it may
still be reached through incision and puncture (p. 562). It may be
drained, as stated above (p. 562), irrigated with antiseptic fiuids,
injected with tincture of iodine, touched with a stick of nitrate of
silver, or painted with iodized phenol (a mixture of iodine 1 part
and crystallized carbolic acid 4 parts), but tlie abscess may continue
to discharge for many months.
Some operators perform kiparotomij 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,
to wipe it off, drain or pack the pelvis or irrigate the abdominal
cavity with plenty of warm normal salt solution and extirpate the
sac (p. 567).
Boinet found that j)us from an old pyosalpinx does not contain
bacteria; and even from recent cases pus containing streptococci may
be injected into animals without causing disease. Jiut if these same
cocci are cultivated on agar bouillon, they become very virulent; and
as raw surfaces left by operations have a similar elfect, he advocates
drainage of the ])eritoneal cavity in these cases. ^
Many prefer the rayiudl <:vtirp(iti()V,x\'> a rule, beginning with hys-
t(!reetomy. \\\ this method, however, it is often impossible to re-
move the cyst. 'J'hen a large incision is made into it, and it is j)acked
with iodoform gauze, which acts as a drain, and later may be replaced
by a double-current soft-rubber drainage-tube.
ILjdroHalpbix.
In hydrosalj)inx the fluid is sentus, mucous, or pultaceous. Some-
times it contains cholesterine. The wall is, as a rule, thin and trans-
lucent. This variety of (ystic; 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
» Boinet, Macredi Mcdiml, 1894, No. 47.
576
DISEASES OF WOMEN.
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. 309). Even if only one side is affected
Fro. 309.
Hydrosalpinx.!
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, perhap.s, be made surer by aspirating the fluid, but, being less
adherent, iiydrosalpinx is less fit for this operation. We might find
' 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.
DISEASES OF THE FALLOPIAN TUBES 577
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. 663).
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 nmch more common with hematosalpinx
than with hydrosalpinx, and has to be guarded against in operating
for atresia of the genital canal (p. 347).
Etiolocjy. — Exanthematous and infectious diseases, phosphorus-poi-
soning, extensive burns, and diseases of the heart, lungs, and kidneys,
may cause ecchymosis or sligiit hemorrhage into the tubes.
In pyosalpinXjhemorrliage may take place from the wall, and blood
mix with the pus.
Wlien there is an occlusion of the genital canal, the menstrual blood
which normally is secreted in the tubes (p. 118) is retained and forms
hematosiUpinx coml)ined with hemato<"()lpos and hematometra, al-
though the comnnuiication between the tube and the uterus may be
interrupted (p. 345).
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 eflect
of an extra-uterine |)regnancy in the other tube. The most common
cause of hematosalpinx is, however, extra-uterine pregnancy in the
same tube.
Ircatmnif. — Small tumors need no treatment. In that lorni which
contains fluid bloml, laparotomy or colpotomy may be performed, the
tube; cleaned out, made perviabh;, and allowed to remain (]>. 563). If
the cystic tui)e has deveio|M'd down between the layers of the l)road
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.
578 DISEASES OF WOMEN.
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. 347). Hematosalpinx due to ectopic gestation is treated
by extirpation of the tube in which the ovum is developed through
either an abdominal or a vajjinal section.
CHAPTER HI.
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 invereion of the uterus the tubes are
always drawn into the sac formed by the inverted uterus (p. 487).
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. Ci/sts. — Real cysts, which are something entirely different from
cystic salpingitis (p. 572), 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
in laparotomies and autopsies. One of them situated at the ab-
dominal end of the tube is so common that it is described in works
on normal anatomy under the name of the hydatid of Morgagni. It
is a development of the up])er end of the Miillerian duct (p. 30).
Some of these cysts are doubtless remnants of the Wolffian body (p.
20), and others are the result of extravasations of blood. ^
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. 49.3) are formed in the muscular coat, but do not, as a
rule, acquire surgical dimensions. One case, however, has been
reported in which the growth reached the size of a fetal head at
term.
' This was so in a ca.se of chronic oophoritis and salpingitis operated on by me and
exaniiiud niiscroscopically by Charles Heitztnann.
DISEASES OF THE FALLOPIAN TUBES. 579
C. Lipoma. — Fatty tumors of the size of a bean to that of a wal-
nut have been found at the lower side.
D. Papilloma, a real neoplasm, must not be confounded with the
growth of the raucous membrane due to simple hyperplasia and
hypertrophy accompanying salpingitis (p. 55-1), nor with malignant
growths, all new growths of the Fallopian tubes having a tendency
to assume the papillary appearance. True papillomata of the Fal-
lopian tube are rare, only seven cases having been reported.^ Cysts
are formed either by fusion of the papillomatous excrescences or in
the wall of the mother cyst. Papillomatous tumors may close, dilate,
and even rupture the tube, in which latter case a papillomatous in-
fection would be likely to take place in the peritoneum. They are
commonly small, but may reach the size of a child's head.
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 eti'ect of infection through the blood in persons sulfei'ing
from phthisis. As a rule, both tubes are affected.
The wall is swollen, its epitiielium is thrown off, the ostia are
generally closed, the caliber is enlarged, and the tube is filled with a
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 tlie secretion. Often
the peritoneum in the vicinity is studded with miliary tubercles. Jn
advanced cases the whole nuicous membrane is destroyed. Tiie 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 larg<' as a goose-egg, the shape of which is that of a
sausage, a club, or most frequently a string of 3 to o beads, the
'J. G. Clark, Johns Hopkins Hospital Bidldin, July, 1898, No. 88.
580 DISEASES OF WOMEN.
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 tuberculo.sis 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 si/mpto7ns 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, salpingo-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.^
^ An exhaustive monograph by J. AV. Williams on "Tuberculosis of the Female
Generative Organs" is published in Johns Hopkins Hospital Report in Pathology,
ii., Baltimore, 1S92, pp. 85-144.
PART VL
DISEASES OF THE OVAEIES.
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 tlie Graafian follicles,
Supernumerari/ 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 unicpie case there were even found three large
ovaries, eacii bound to tiie uterus with a separate ligament.
The possil)ility of supernumerary ovaries must be kept in mind
in order to explain the persistence of menstruation after the extir-
pation of both ovaries (j)p. 121 and 569), the presence of two nor-
mal ovaries l)esides an ovarian cyst, and the occurrence of pregnancy
after double ovariotomy — phenomena which have actually been
observed.'
Absence or liudimentavy 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 unieornis.
More common than the total absence is a rudimentary develo])ment
of the ovary. Such rudimentary ovaries may or may not contain
Graafian fi)llicles. In the latter case they consist only of connective
tissue and smooth muscl(!-fi bet's.
As a rule, the rudimentary condition is found in connection with
an arrest of development of the uterus, but it may also be foiuid when
' F'or details st>e my article on " Mallonnations of the I'Vinak' (Jiiiitals," in Atiwr.
System of Gifnecoloyy, edited by Mann, vol. i. p. 23G.
5HI
582 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
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.
Foreign Bodies.
In rare cases a needle has been found in the ovary. A sewing-
needle may enter the ovary after wandering a more or less long dis-
tance through the soft tissues of the body, or more directly from the
intestine.^ A darning-needle, found partially in the uterus and
partially in the ovary, had probably been introduced through the
OS with the intention of producing abortion.^
The foreign body causes pain and inflammation, and should be re-
moved. If part of the body is situated in the uterus, it will prob-
ably be possible to reach it by dilatation, and withdraw it. If it is
all imbedded in the ovary, anterior colpotomy or laparotomy will
probably allow one to remove it by cutting down upon it and to
sew the ovary up again ; but if it has formed an abscess, it may be
necessary to remove the ovary.
CHAPTER III.
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 oflp altogether from the broad ligament by an
inflammatory process in fetal lite. It may then either float about as
a small hard body in the abdominal cavity or it may become fastenal
to the lower border of the omentum.
If the displaced ovary retains its normal connections w'ith the ala
vespertilionis and the tube, it may be found outside the pelvis or
remain in it.
Extrapehic 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-
1 Frank W. Haviland, New York Med. Record, Oct. 2, 1892, vol. xlii. p. 398.
'C. Liebmann, Cenlraibl. f. Gyndk., 1897, vol. xxi. No. 16, p. 421.
DISEASES OF THE OVARIES. 583
rior side of the thigh below Poupart's ligament (a-ural hei-nia) ;
the gluteal region [gluteal hernia) ; the depth of the anterior wall of
the pelvns (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-
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 shoidd 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 hernine througii natural openings are exceedingly rare.
The ovary may he found in a ventral hernia after laj)ar()tomy, and
would offer a special intlication for operating on the hernia.
The ovaries may also be drawn with the tubes into the funnel of
an inverted uterus (p. 487).
Intrapelric DiKplacnncnta. — While the preceding displacements
are anatomical or surgical curiosities, the infraprlrir <li-y)lacanenf, or
prolap.^e, of the ovarij is a common disease of considerable practical
importance.'
The normal ovaries may frecpiently be palpated in their normal
situation by bimanual vagino-abdominal examination. Thev mav
likewise be felt by recto-abdominal (examination, but the latter
' This disease lias lu'en treated of in an exhaustive way hy P. 1'. Mund<^, 7V((n,<t.
Avirr. (iijn. Sor., 1871*, vol. iv. p. 1G4 el ne<j.
584 DISEASES OF WOMEN.
offers no advantage, except in intact virgins or women with atresia
of the vagina, unless the uterus is pulled down at the same time
(p. 143).
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. 94), 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 tiie 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. 77).
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 retro verted or retro-
flexed uterus or by adhesions remaining after ])elvic peritonitis. It
may also sink on account of insufficient support from below, espe-
cially rupture of the vaginal entrance (p. 322).
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.
AA hether a normal ovary can become prolapsed by a fall or similar
injury, as is the case with the uterus (p. 478), 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 ^\•ith tubal disease.
Symptoms. — The symptoms are those of chronic oophoritis com-
bined with those due to the abnormal position of the ovary. Plypere-
mia, edema, and inflannnation may be both the cause and the effect
of the displacement. The patient com])lains of pain in the sides of
the pelvis, the sacral region, or the rectum, often shooting down to the
knee and up into the hi]). The pain gets worse when she walks, pre-
DISEASES OF THE OVARIES 585
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 u])ou 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
suifers much. The })atient is tired, des])ondent, 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 slia})e. 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
cystic. If it is movable, the prognosis is comi)aratively 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. 241),
prohil>iting sexual connection, prescribing hot vaginal douches (p.
170), using scarifiation of the cervical portion (p. 15)4), making
a])plications of iodine (p. 17")), or inserting j)ledgets with iehthyol-
glycerin (p. 182) into the vagina, or by means of galvanism with the
positive pole in tlu; vagina (j). 248).
Tile displaced organ should be rej)laced as soon as feasible, but
sometimes the above-mentioned measures must be taken lirst befon*
the ovary recovers sullieiciitly to l)e able to bear the pressure (»!" a
pessary.
The ovary is best rej)laeed in the genu-pectoral posture (j). 1 10),
and if it <'anuot b<' I'eplaeed or retained at once, the dailv us(> of this
])osture and a glass tube admitting the air into the \agina (p. 17<>)
may j)repare the way for its final replaeemetu.
I f the ovary is adherent, it is necessary first to trv to bring about
the stretching and absorption of" the adhesions. This is douc liy
packing the vagina (p. 182 1. If" the o\ary is \-ery tender at lii'st,
58G DISEASES OF WOMEN.
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. 199) is also a powerful means of stretching and break-
ing up adhesions.
The gtilvanic current has, in consequence of its electrolytic property
(p. 248), a similar effect.
Schultze's method is somewhat similar to that used by the same
author for uterine adhesions (]). 473). 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
bulh-peKsai'i/, essentially a Hodge pessary (Fig. 274, p. 469) with a
thickened upper arch, answers a good purpose. Special pessaries of
hard rubber with a cross-bar of unusual width, or with a notch in the
middle or a corner cut off, have been constructed for this condition.^
In cases in which no hard pessary can be tolerated, one of whale-
bone covered with soft rubber (p. 470) may be tried.
If these measures fail, we may have recourse to cutting operations.
If the uterus is retroverted or retroflxed, it may be brought forward
by shortening the round ligaments (p. 471), suspensio uteri (p. 474),
or fastening of the round ligament to the abdominal wall or the
vagina (p. 475).
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. 577).
The ovary may also be sutured directly to the peritoneum of the
pelvis.
But if the ovary, besides being prolapsed, is diseased, the pr()])cr
thing to do is to ])erform salpingo-oophorectomy, especially by
vaginal section (p. 576j.
CHAPTER IV.
Hyperemia and Hematoma.
A normal hyperemia doubtless takes place in the ovary during
coition in consequence of contraction of the uiistriped muscle-fibers
of the broad ligament (p. 57), and contributes to the expulsion of the
ovum (p. 77). A similar normal hyperemia probably returns at
regular intervals, corresponding to menstruation. At least the gen-
' See the above-mentioned article by Munde.
DISEASES OF THE OVARIES.
587
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. 75).
Pathological Anatomy. — Abnormal hemorrhage may take place
into the Graafian follicles or into the stroma of the ovary, the fol-
FiG. 310.
Hematoma of Ovary (a little less than natural size): a, follicular hematoma, 12 millimeters
in diameter, inner measure ; fresh bloo<lclot easily separated from tlie surrounding wall,
situated in the outer end of the ovary, one-half of it touching tlie stroma, the other half
covered with a layer varying from 2 to 3 millimeters in thickness, without any opening;
66, dilated follicles with serous contents ; c, Fallopian tube.'
licular being much nioic coininoii than tiic stromal. Follicular hem-
orrhage forms a tumor that is rarely larger than a hazelnut (Fig. 310),
but may reach the size oi" a wahiut.
Tlie ovary is only moderately eularg-ed and a little nK)re resistant.
If manv follicles are filled with blood at the .same time, it is dark and
studded all over the suriiice with small ])rotul)erances. The sac is
thinned on the side nearest the surface. The contents ai'c dark, thin
l)lood mixed with clots. In the course of time it may change into
' Loft ovary from my Haliiinf^o-fMiphnrectomy on Mrs. 1* in St. Mark's Ilospitiil,
Nov. 29, 1892. Tlie rij^ht ovary contained a serous cyst ineasuriiiL,' 2 cm. in
diameter.
688 DISEASES OF WOMEN.
a thick chocolate-colored fluid, M-hicli may l)e of the consistency of
honey. Tlie fluid part may be absorbed altog;ether, 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 bui-st, but tiie ovum is destroyed.
Stromal hemorrhage may cause so small an extravasation of blood
that it can only be seen Avith the microscope, but it may impart a red-
dish color to the ovary, and even show as minute red points on 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
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.
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
occui*s in severe burns, phosphorus-poisoning, typhoid fever, })uer-
peral septicemia, scurvy, etc.
Thirdly, hematoma may be developed from gyroma,^ which is the
same as corpus albicans (p. 77), and may be the terminal stage of a
corpus luteum, or under 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 tlie
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
^ This subject was first treated In- Dr. Mary Dixon Jones, and later bv Dr.
Francis Foerster and Dr. II. J. Doldt, all workinjj nnder the egis of Dr. C.
Heitzmann: Jones, X Y. M>(1. Jour., Sept. 28, 1889. May 10-17, 1890; Timea
and Jifrpster, .Apr. 80, 1892; P^oerster, AmiT. Jour. Obst., May, 1892, vol. xxv. p.
577 ; Boldt, International Med. Congresx, Berlin, 1890, and Deutsche med. Wochenschr.,
1890.
DISEASES OF THE OVARIES. 589
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 —
that is to say, abstinence from sexual excitement — is of great imj)ort-
ance.
The general health should be improved by means of hygienic
measures and tonics (p. 241). The nervous system may be quieted
by the use of bromides. A derivation to the skin by means of blis-
t<irs may bo useful. The bowels should he kept open. Scarification
of the vaginal portion ([). 194) may give great relief In girls of
ardent temperament or with l)ad habits marriage may answer a good
purpose. The usual treatment for jx-lvic inflammation, such as the
use of hot douches, painting with tincture of iodine, tampons with
i(!litliyol-glycerin or plain glycerin, or the galvanic current, should
be instituted. If then; is an acut(! atta(d<, tlie patient should stay in
l)ed, have an i(;e-bag on the hypogastric region, and be given mor-
j)liine enough to combat pain. If th(! ovaries have suffered much in
their stru(;ture, it may even become necessary to remove them.
When symj)toms of ru|)ture are present, laparotomy shotdd be per-
formed at once, and the ovary from which the hemorrhage comes
should b(! extirj)ated together with its tube. The other ovary should
be left, if it is not seriously diseased.
590
DISEASES OF WOMEN.
In a case operated on by the w ritor the hematoma was due to a
solid, imperforate uterus and atresia of tlie u})permost part of the
vagina. The left ovary was transformed into a sac larger than a fist,
and filled the pelvic cavity behind the uterus. It was uniformly
adherent all over to the intestines and the pelvic organs, and con-
tained eight or ten ounces of inspissated chocolate-colored blood.
The left tube was the site of interstitial salpingitis ; the right tube
Fig. 311.
Large hematoma of left ovary : a, imperforate uterus with cervix ; b, right ovary with
ruptured Graafian follicle; e, right Fallopian tube with part of broad ligament ; d, left Fal-
lopian tube swollen ; e, serous cvst ; /, left ovarv transformed into sac filled with inspissated
blood.i
and ovary were normal, the latter showing a ruptured Graafian
follicle the size of a hickory-nut (Fig. 311). The patient had
been suffering for four years from severe molimina, preceded and
often followed by epileptic fits.
CHAPTER V.
Oophoritis.
OoPHOEiTis, the inflammation of the ovary, may be acute or
chronic.
'Specimen from my abdominal hvsterectoinv on Miss M. B., at .St. Mark's Hos-
pital, Oct. 25, 1899.
DISEASES OF THE OVARIES. 591
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. 69), in the follicles, — -follicular 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 hais 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 pns-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 aj^pear ; 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.
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 the follicles are transformed into small cysts
with thickened walls; or they are destroyed, leaving a cicatrix. An
abscess may destroy the whole ovary. xVs a rule, })lastic lymph is
thrown out as a superficial (;overing 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 j)eritonitis.
The pus in an ovarian al)scess may be " laudable " or have an off^en-
sive odor due to absorj)tion of gas from the rectum. It may become
insj)issated, and finally form an innocuous calcareous mass. The
niajority of abs(;esses of the ovary arc the work of staphylococci.
A few contain bacillus coli communis, and a few otluT ])yogcnic bac-
teria have been found in ovarian abscesses. In three cases Kth-
ridge found the pneumococcus to be the sole bacterium pn^sent.*
The coccus may rea<'h the ovary from the external g<'nitals, from the
intestine — where it ai>oun(ls — or through the general circulation.
J'Jtiolof/i/. — Extensive cx'iphoritis is a rare disease outside of the
puer|x,'ral state. It may be jirinuiri/ or sccondarj). The primary
may be caused by hyperemia and hematoma of the ovary (p. oHO),
by sexual excesses, or by sudden su})j)ression of tiie menstrual flow
(pp. 128, 256). It may also appear as part of a constitutional dis-
ease, sucli as the eruptive levers, cholei-a, sej)ticemia — whether puer-
peral or not — and poisoning with phosphorus or arsenic. It may
' .1. H. Kthridge of (.'liicago, Amcr. Jour. Med. Sci., April, 18'J(J.
592 DISEASES OF WOMEN.
follow minor operations, such as the use of the sound, the incision
of the cervix, trachelorrliaphy, etc. The common course is that the
inflammation fii-st attacks the endometrium, then the tubes, and finally
extends to the ovary ; but it may also reach the ovaries directly through
the lymphatics.
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.
Si/nij)toms. — In most cases the symptoms are obscured by those of
the accompanying disease, especially salpingitis or peritonitis. But
sometimes it is possible to feel tlie 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 aflPected 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 wail.
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. — Tlie 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 speedil^v, 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. 195). The bowels should be kept
open witii saline aperients (p. 241). 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
DISEASES OF THE OVARIES.
593
if the ovary is adherent, the adhesions are recent and can in all
likelihood be separated. If the ovary is within easy reach it is,
however, better to make a transverse incision behind the cervix,
separate the tissues bluntly, plunge the expanding perforator (Fig.
177, p. 199) into the abscess, dilate, as recommended for py ©salpinx
(p. 533), 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 ov'al or globular shape.
In others it is smaller than normal, forming an irregular shrivelal
mass. Very frequently it is more or less cystic (Fig. 312). The
Fig. 312.
Chronic Oophoritis : a, cut siirfaro of ovary sttiddod with cysts ; b, tube ; <*, pedunculated
cyst hiinniiit,' from tlic nicsof^iilpiiix.'
capillaries increase in size from the poripliery toward the center, form-
ing a structure like that of erectile bodies. The ana-^tomosis between
the ovarian and the uterine artery is dihited, whicli may explain the
endometritis so often found combined with ehronie ()Oi)horitis. The
ovisacs and the ova are often diseased or disappear. First medullary
corpuscles are developed, and the yolk and the genninative vesicle
' Specinicn from my salpingo-oophorectoniy on Mrs. ('. C , in St. Mark's IIos-
piUiI, on .June 9, IS'JI.
.■J8
594
DISEASES OF WOMEN.
Fig. 313.
y
Chronic Oophoritis (natural size) : a, cor-
pus luteum changed into cyst ; 6,6, yel-
low masses with remnant of central
cavity ; c,c, corpora nigra : d, albuginea.
break dovvu, leaving a granular mass ; later fibrous connective tissue
replaces the whole structure.
Sometimes the ovum undergoes colloid or waxy degeneration. The
follicles may be transtbrnied into cysts with a thickened wall and
surrounded by indurated tissue. The albuginea is thickened, and
often covered with an adhesive layer
of peritonic 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,
])erioophoritic adhesions, or the too deep situation of the follicle in the
stroma. Sometimes it can be seen that the cyst has formed in a
corpus luteum (Fig. 313).^
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. 592) in regard
to the causes of that affection.
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. 584). A misplaced
ovary is indeed more liable to the development of chronic oophoritis
than one in its normal situation. For the same reason retroflexion
^ Besides the large corpus Inteiim which has heen 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. 77).
For want of a more suitable place, I wish liere to refer to the calcification of cor-
pora lutea. 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, Amcr. Jour. ObsL, Dec. 1892, vol. xxxvi.
p. 908, and H. C. Coe, iiiclem, Feb., 1892, vol. xxv. p. 246).
DISEASES OF THE OVARIES. 595
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 extravasated 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. 593).
Symptoms. — The symptoms are, as a rule, more or less masked by
inflammation in the surroundings, especially salpingitis and local
peritonitis, as well as retroflexion of tiie uterus.
Very frequently both ovaries are affected.
The patient complains of pain in one or both iliac fossae, 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.
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. (Con)j)ar(' p, 437.)
Menstruation is often irregular and too profuse. When the follicles
and ova are destroyed, there Ibllows, on the contrary, a stage of
anjcnorrhea.
Very often these patients arc sterile or become so secondarily after
the confinement or tiie abortion that gave rise to the disease.
T^eucorrhea is (juite common. The digestion sufli'rs, the j)ationt
loses flesh, and the nervous system is nnieh 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 b(! confined to her bed or her room Ibi' months or vears.
Viarpiosi.s. — Often it is very difficidt oi- 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-
596
DISEASES OF WOMEK
times we can, however, distinctly feel the enlarged or prolapsed ovar}\
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. 122), 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
ou p. 561.
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. 562). 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. 176), painting the vaginal vault with iodine
(p. 175), and applying cotton tampons with ichthyol glycerin (p. 182).
If this does not effect a cure, the galvanic current should be tried.
I use it, as a rule, in the vagina (p. 248), and make the current
as strong as the patient can stand, which in most cases is up to
Fig. 314.
Garrigues' vaginal electrode.
50 milliamperes (Fig. 314). If, besides the ovary, the cervix is
inflamed, I apply the current there. For application in the in-
FiG. 315.
darrigues' cervical electrode.
tcrior of the cervix I have had made cylindrical and slightly-
curved electrodes of carbon (Fig. 315) in three thicknesses (y^, \,
^ -inch).
Often scarification of the cervix (p. 194), or the application of
a fly-blister, 2 to 4 square inches in size, every evening, to the iliac
DISEASES OF THE OVARIES 597
region, has a good effect. Massage (p. 199) has been much praised,
and may undoubtedly do good by causing absorption of perioophor-
itic adhesions that compress or pull on the ovary. But if the
ovarian inflammation were 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 adminis-
tration of tonics (p. 241). Tiie nervous troubles are often greatly
benefited by the use of bromides. Chloride of gold has frequently
seemed to me to reduce the size of the swollen ovary (p. 243).
Desiccated parotid gland substance of sheep (3 to 6 tablets daily, each
containing 2 grains) is praised. Rubbing with chloroform oil (p.
242) affords temporary relief from ])ain. A warm entire bath
should be taken twice a ^\■cek. For those who can travel a treat-
ment 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 interrui)tion of marital relations, is often followed by decided
improvement.
The palliative treatment, carried out methodically and patiently,
is of great value, but in some few cases nothing short of an operation
will cure tiie 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 with a continuous
suture of catgut. If tiie ovaries arc prolapsed, th(>v may be lifted
up and fastened in a bett(>r position by stitching the round ligaments
to the anterior abdominal wall ' (pp. 471, 470-478).
But if the ovaries are much diseased, and if the tubes arc in a bad
condition, tiie appendages should l)e removed on one or both sides
(p. 563).
Appendix. — Gijronia and Endofheliomn. — It is a peculiarity of the
ovary that, examined microscopically, it shows so ni;iiiy variations
that hardly two ovaries are alike, and it is, therefore, difficult to decide
wliat is a normal structure and what represents an abnormal j)r()i -ess.
(See p. 77, foot-note.)
Two conditions have l)een described as diseases under the names
of (jijroiivi and endof/ic/ioiiid,' which are intimately connected with
* Pnlk, Aiiwr. Jour. Ob.tl., Sopt., 18',»1 ; Trans. Amer. Gyn. Soc, ]S'j;5, vol. xviii.
p. 175.
' M. A. Dixon .Jones, "A IlitlitTto UndescrilR'd Disease of tiie Ovarv, Kndollie-
lionia ciian{,'in,t^ to Anj^iotna :in<l Hetnatoina," X. Y^. Mfd. .lanr., Sept. -X, ISSU,
and ''Anotiier Ilitlierto I 'ndts(iil)ed Disease of the Ovaries, Anomalous Menstrual
BmJies" ((iyroma), ihiti, May 1(1 ami 17, ls;»0. t'onipare foot-note on p. 77. (Tvronia
i.s, however, doubtless the same that has been descriited by I'atenko under the name
of corpu.i Jibromm in Virchoiv's Arcliir, vol. Ixxxiv. p. 193.
598 DISEASES OF WOMEN.
each other, aud one of which, endothelioma, under some circum-
stances, is a normal development.
Gyromas (Fig. 316) 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. 71). In the former locality
they are transformed corpora lutea — abnormal menstrual bodies — or
corpora lutea of pregnancy (p. 74) ; in the latter they arise from
Fi(3. 316.
Ovary containing Corpus Luteum changed into Gyroma: a, cut surface of ovary; b, 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 — the membrana propria — of the fol-
licular wall after it has ruptured ; in the latter they arise from the
tortuous course of the arteries (Fig. 317).
Those that are developed from the corpora lutea are due to a
transformation of the medullary corpuscles which are found out-
side and inside of the ruptured Graafian follicle. Instead of
being absorbed or transformed into connective tissue, these me-
dullary corpuscles become infiltrated with an clastic or colloid
substance.
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 sufiering from obliterating
endarteritis and waxy degeneration. Gyromas are not found in
the cow, pig, or sheep, and are probably always a pathological pro-
duction.^
* Specimen from my salpingo-oophorectomy on Mrs. M , in St. Mark's Hos-
pital, on Dec. 14, 1889. _
* Dr. Dixon Jones tliinks that what has been described as corpora lutea vera or
DISEASES OF THE OVARIES.
599
Gyroma is found in all cases of endothelioma, but may also be
found independently of the latter. Clinically gyroma is character-
FiG. 317.
Gyroma X I'K) (Fr. Foerster): GO, gyrorna traversed by delicate tracts of fibrous connective
tissue: CO, newly-formed inflamed fibrotis connective tissue; AA, arteries witli sligbt
sclerosis and hyaline degeneration ; V. vein in transverse section; B, capillaries.
izcd by pain in the ovarian region, exhaustion, and marked nervous
disturbances, which last may proceed so iar as hysteria and mental
aberration.
EwlotheJioiiKi (Fig. 318) is always an outcome of ovuhition, a
growth of the structureless membrane of tlie follicular wall ([). 71).
Simihir formations are found in the pregnant cow, pig, and sliecp.
Some endotheliomas arc, indeed, nothing but c()rj)<)ra lutea of i)reg-
nancy, but others are transformed gyromas, which, as we have seen,
are always a j)athol(»gical product. Wliile gyromas may be found
in an ovary in varying numbers, endothelioma is invariably single.
It is eomj)oscd of large alveoli, or closed spaces, filled with endo-
oorpora lutea of prcsmaiicy (p. 74) is nothing else hut auotnaloiis menstrual hodies,
gyromas and endotheliomas changing into angiouui-s and lu'nuitonias (".Vnother
liitherto L'ndeacribed Dise:i.se," reprint, p. 24) — a rather startling supposition (see
p. 7Tj.
600
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. 318.
Endotheliomaof Ovary (Jones) : C, coarse connective tissue containing r, 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 liglit 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 ve.'^sels around the new-
formed blood. (See Hematoma, p. 586.) The endothelial growth
replaces gradually the normal ovarian tissue, and may occupy the whole
DISEASES OF THE OVARIES. 601
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 VI
Neoplas]ms.
The ovaries are very frequently the seat of neoplasms. Some are
cystic, others are solid.
A. Ci/sts.
Pathological Anatomy. — Ovarian cysts offer a great variety in their
anatomical structure, but they may, nevertheless, be reduced to a few
I. Dropsy of the Graafian Jollick {hydrops folUculi), assuming one
of three forms : 1, a conglomeration of many small cysls 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 (Jkohi-
tanski's tumor) ; and S, the develo])ment of a few or one large (yst ;
11. Proliferating cysts, occurring in three varieties: 1, glandidar,
2, papillary, and 3, mixed: III. dermoid cysts; and, lY. tubo-ova-
rian cysts.'
' While the aiitlior was collecting materials for his work on I)iit(i)iii.<i.< nf Ontrlmi.
(,)/!<ln 1)1/ m^'iiis (if till- J'JjdtiiiiKitiDii of tlicir (''i)iti'iil.<, 111' had the advantat^es of wit-
nessing all tile ovariotomies performed in tiie Woman's Hospital in the State ol'
New York during eif^hteen months, and of ohtaiiiiiif,' a jiart of the Ihiid and tiie sac
and the ovary of the opposite side when it was diseased. Not only was the flnid
examined ehemieally and nneroseo])ically in every ease, hut many hundreds of
specimens were cut from the hardened sacs or small ovaries. In that work he refeix
also in many places to the solid part of ovarian cysts, and if other occupations have
prevented him from increasing? the material and utilizin<r it for a speeial essay, his
1)ersonal aeqiiaint.ance with all slaves of cystic defjeneratioii n\' ovaries has eiial>l<'(l
lim to better understand and value the work of other investigators in this domain.
602
DISEASES OF WOMEN.
I. Dropsical Graafian Follicles.
In studying chronic oophoritis we have seen (p. 559) that often in
that disease many small follicles may be transformed into cysts, and
Fig. 319.
Ovary with many Dropsical Follicles (Leopold).
that a single follicular cyst may cause the absorption of the rest of
the ovary. Thus there is a gradual transition from oophoritis, an
Fig. 320.
Bilateral Oligocystic Ovarian Tumors (Hooper).
inflammatory disease, to cystic degeneration, a neoplasm, and it is in
reality, in .some cases, only the size of the specimen which decides us in
calling tlie 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.
603
even when the ovum has disappeared, as being developed from
follicles.
If many follicles are affected simultaneously (Fig. 319), the ovary
does not obtain very lai'ge dimensions, indeed hardly more than the
size of a hen's egg. The stroma may be unchanged or infiltrated
with medullary elements. Gradually it is absorbed.
Fig. 321.
Rokitanski's Tumor, one-third actual size (Tail) ; on the right is seen the adherent omentum.
Sometimes a f(;\v follicles become cystic, forming what is called an
oligocystic tumor (Fig. .'>20). Veiy rarely the partition between two
604
DISEASES OF WOMEN.
such cysts ruptures, so that they communicate. As a rule, only one
Is developed ; or, predominating iu 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.^
Such a large cyst is strictly monocystic. Nowhere are found rem-
nants of partitions. The icall is white, and consists of two layers of
dense fibrous connective tissue held together with a layer of loose
connective tissue, iu 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. 71). The outside is covered with a short coluiunar
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. 322.
Ovaries with Pedunculated cysts (Winkel) : 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, tlie })recipitate being redissolved
by adding an excess of the same reagent. It contains only a few
granules and no cellular elements.
These monocystic and oligocy.stic tumors are much rarer than the
proliferating and dermoid cyst.s.
RohUanski^s Tumor (Fig. 321). — Much rarer still is that species
' I have seen it contain a i)ailful of fluid [Diagnosis, p. 9).
DISEASES OF THE OVARIES.
605
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. 323 A.
C V^A ^K
A. Inner Pnrfaoc of filandular Ovarian Cystoma ( [lartly fliaprainmatic) x 120: (7, connective
tissue; ^, ('f)itlieliiim ; <■, howl-shaped 'Icpression witli STuall oiteniii},''. '/, a similar one. the
opeiiint,' cIosiiiK up; r.f, huds of epithelium, growing from tlie bottom of tlie howl: ,'7.7.
depressions in the conneelive tissue, from which the epithelium lias been removed.
i5. Same a.s r in FIr. -SlCi A, enlarRed :W) times. It is comi)osed of two pouches unitintr at the
top. The centre of each is uudertroinK Ii(|uefaction. A kind of tliready nuiterial is seen
exten<lintr from the periphery into tlie interior of the pouch Ijctween the epithelial cells
(cement sulistauce).
Fig. 322 .'^liows the ovaries with a few pcdunciilatod cvsts on the
surfice,
II. Prolifrrafhif/ Ojixts. — Proliferating cysts are also called myxoid
cj/sforiuift, in opposition to the dermoid cystomas, bcranse their inner
surface re-sembles a mticous membratie. The epithet "proliferating"
606
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 snKX)th 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-
dividt^l 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. 323) ; 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. 324), and forming a fluid in the secondary cyst. This
Fig. 324.
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 })lace by the absorption of the partition which
separates two cysts from each other. At first there is only a small
hole of communication between the two sacs, but gradually the open-
DISEASES OF THE OVARIES.
Fig. 325.
607
Small Glandular Ovarian Cyst, with beginning absorption of partition. Slightly reduced
from natural size (Dorani.
Fig. 326.
Lar^;< i .,ai,.iiilar Ovarian Cyst, sliowiiig nuiiicnius .secondary cy.^ls and rid^'t's as remnants
of absorbed partitions; n, primarv cyst turiieii insi<lc oi'it iind stulVcd witli cuiton ; hb,
secondary cysts; cr, reiniianls of iibsorljed panilions.'
' Sj)e<inicn from my ovariotomy on Mrs. M. S-
Aug. 14, 18'J0. It contained si.xtcen quarts of liiiid.
-, at St. .Mark's llospit.ii,
(508
DISEASES OF WOMEN.
ing increases in size until, finally, only a low ridge remains as a rem-
nant of the former partition (Figs. 325 and 326).
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 muUiloeular 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. 327).^
Fig. 327.
Enormous Glandular Ovarian Cystoma (Rodenstein).
Fig. 328, on the other hand, represents sucli a glandular cystoma
found in a new-born child, and enlarged thirty times.
The outer layer of tlie wall corresponds to the albnginea, 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
' 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.
609
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. 328.
Congenital Mnltilocular Cystoma, X 30 (Winckel).
From the outer layer may grow small excrescences, covered with
the common short columnar epithelium (Fig. 329).
Fig. 329.
PaplUoraatous Excrescence on Outer Pnrfacc of Myxoid Proliferating Glandular Cystoma of
Ovary (natural size): A, seen from above; B, sagittal section of the 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, sagittJil section
through pedicle; I), main cyst; c, secondary cyst, partially filled with cheesy contents,
partially empty ; d, secondary cyst with cheesy contents.
In the loose connective tissue betwoon the two layers of the wall
are found ])lain muscular fibers, osj)ocially near the ligament of the
ovary. Sometimes cysts have boon found there, and even a corpus
luteum.
The glandular cy.stoma has, as a rule, a pe<liclo.
Relation to Omcer. — licing a neoplasm ciiiefly composed of epi-
30
610 DISEASES OF WOMEN.
thelial cells and a stroma of connective tissue, the glandular cystoma
approaches the structure of carcinoma. The diiference is that glandu-
lar cystoma does not affect the lymphatic system, does not give rise
to relapse after extirpation, and has tlie tendency to produce more or
less fluid in its compartments. If, however, the epithelial prolifera-
tion predominates nuich, and the formation of cysts stops, the condi-
tion is passing into tiiat of carcinoma. The appearance in the wall
of epithelial cells of nmcli 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 parvilocular, 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-
neously; but by being boiled, as a rule, the contents
^ are more or less completely turned into a solid mass.
0i ^ 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.
^ „ The fluid contains nearly always paralbumin.
n^ As a rule, ovarian fluid is full of a variety of form-
elements: red blood-corpuscles, epithelial cells (either
O O intact or metamorphosed), nuclei, pigment-granules,
w ® ^ finely granular globular bodies like lymph-corpuscles
Red Biood-cor- or colorlcss blood-corpusclcs, pus-corpuscles, spindle-
shaped cells, crystals of cholesterin and of indican.
Figures 300-31 3 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. 330).
Epithelial cells (Fig. 331) 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. 331.
611
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. 332). Often vacuoles are formed in epithelial
Fio. .S.32.
Bennett's Large Corpuscles, or Nunn's Gorged Cori)uscles— i.e. epithelial cells in fatty
degeneration,
cells, which probably are a kind of disintegration leading to the
destruction of the cells.
Fig. 333.
Colloid Corpuscles.
612
DISEASES OF WOMEN.
Colloid corpuscles (Fig. 333), large and small, are probably either
parts detached from epithelial cells or a transformation of the whole
cells.
Fig. 334. Fio. 335.
Horn-cells.
Proliferating Cells.
Horn-cells (Fig. 334) are epithelial cells that have lost their proto-
plasm, have shai'p ridges, and look horny.
Fig. 336. Fig. 337.
Ameboid Bodies.
A Large Bennett Cor-
puscle with ame-
Doid movements.
Proliferating cells (Fig. 335) are large cells containing a brood of
vounger ones in their interior, from which they escape to lead an inde-
pendent existence.
Fig. 338.
Bennett's Small Corpuscles, or Drysdale's Corpuscles— i. e. nuclei in fatty degeneration.
Fig. 339. Fig. 340.
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. 336 we .see the same two cells in three different
stages of separation and amalgamation.
DISEASES OF THE OVARIES.
Fig. 342.
613
Fig. 341.
Fat-granules.
Spindle-cells from a myxofibromatous ovarian cyst.
Drysdale's corpuscles (Fig. 338) are small globular or polyhedral
clear bodies with a small number of shining granules. My inves-
FiG. 843.
fP
Cholesterin.
tigations have led me to believe that these bodies are nuclei of epi-
thilial cells in fatty degeneration (Fig. 340).
Fig. 344.
rajdllary Ovarian Cyst sprinnintr from tlio liiliim of tlio ovnry, ttic preater part of wliich is
not involved in tno niortiifl jtrowtli. Tlit- fvst lias forot-d its way betwoun the layers of
the broad liKanient as far as the Fallopian lube (Doran).
Ovarian Ihiid contains also round cells, each with a nucleus and
finely granular ])rotoplasin (1^'ig. 339), tlie nature of" which is un-
certain. Perhaps they an,' enlarged colorless blood-corpuscles.
614
DISEASES OF WOMEN.
b. Papillari/ Ovarian Ci/sts are not so common as glandular, being
found in only one out of ten ovariotomies, and they do not ac-
quire such large proportions. They contain a comparatively sniall
number of secondary cysts. From their insid(i spring dendritic or
cauliflower-shaped growths, calksd papillomas (Fig. 344), which may
fill the secondary cyst in wiiich they grow, and break through its
wall into a neighboriug 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 eveu penetrate tiie 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. 345.
pvu
Superficial Papillomata on both ovaries (Coblenz) : RO, right ovary ; LO, left ovary ; fu, fun-
dus uteri ; he, hyaline cyst ; pv, papillary vojretations ; cy, cystic tumors ; hg, blood-vessels „
hm, hydatid of "Morgaftni ; old. abdomiiia! orifice of right tube: o^v, abdominal orifice of
left tube ; kc, calcareous deposits; //. broad ligament; Ir, round ligament ; av, Infundibulo-
pelvic ligament; id, uterus; ;jri(, vaginal portion of uterus; inv, 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
DTSEASES OF THE OVARIES.
615
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. 345).
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. 346.
Portion of the Wall of a Dermoid Ovarian Cyst (Ziegler) : a, wall ; ft, elevation composed of
(if fatty and eiitaiieoiis tissues : c, liairs ; (/, tectli.
two varieties — a point to wl)ich we shall come back in sj)caking of tlie
origin of ovarian cysts. From the liistoiy of the <l('V('loj)ment of the
ovaries (p. 20) we know that from a very <'arly period these bodies are
l)uilt up of two ehiinents — epithelial (;ells and connective' tissue.
In the glandular cystoma tiie Ibrnier ))re(lominat<'s, in tiie papillary
the latter.
III. Dermoid C^.sis. — Dermoid (;ysts diller entirely from all those
616 DISEASES OF WOMEN.
liitherto 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. 346). Thus the inside is covered with a thick
layer of stratified epidermal cells, the most superficial, flat and with-
out 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, columnse carnese and chordae tendineae,^ 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 ])atches.
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 ru])ture into another
organ or on the surface of the body. If it opens into the bladder,
hairs may be eliminated with the urine (piliniiction).
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
' A. W. Johnstone, Trans. Amer. Gyn. Soc, 1893, vol. xviii. p. 305.
DISEASES OF THE OVARIES G17
myxoid cystoma 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 ])uberty this is, however, the })redominating 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 ])it of the stomach, the perineum,
the testicle, the uterus,' the organs of the chest, and other abdominal
organs, etc. ; but they are more frequent in the ovary than anywhere
else.
IV. — Tabo-ovarian Cysts, or Hydrocele of the Ovary. — Tubo-
ovarian cysts consist of a combination of a cystic salpingitis (p. 572)
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 fimbriae may have disiippeared altogether or may be
spread over the outer surface of the ovarian cyst ; or Ave may find
them inside, floating from the inner surfiu-e 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 ej)ithelium, but later the cilia
disappear, and the cells may become flattened.
Tiie uterine oj)ening commonly remains pervious, so that the con-
tents may from time to time, when pressure increases, be evacuated
through the vulva.
Bland Sutton^ calls tubo-ovarian cysts hydrocele of the ovary, and
says there is good reason to believe that tiiey 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 oviii'v is replaced by
' W. W. Stewart of ('oliinil)us, Ga., Med. Record, Nov. 11, iS't:',, vol. xliv. No. 21,
p. 648.
' IJIaiKl Sutton, J tisf'tuieis of the Ovaries and Tiibex, Philadelphia, 1S91, p. 111.
618 DISEASES OF WOMEN.
a cyst which communicates with a distended tube, but the orifice of
oommunication 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. 555) is a forerunner for the
formation of this kind of cyst. A hydrosalpinx (p. 575) is formed,
adhesion to the cystic ovary follows, the partition becomes atro})hied,
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
RoUitanski'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 tiie pedicle leads to gangrene and fatal peri-
tonitis. If it develops slowly, it causes edema and hyperemia of the
DISEASES OF THE OVARIES. 619
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 meantime, as a rule,
adhesions form with other organs, from which the tumor henceforth
derives its nourishment. Even the uterus has been found as part of
the severed mass. Large cysts have also been found lying loose in
the abdominal cavity, without any kind of attachment.^
Tiie 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 whicli it comes in con-
tact; but, when the epithelium is rubbed off or covered by infiamma-
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 cords, 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 downuanl between
tiie layers of the broad ligament and into its base, tlie tumor may be-
come adherent to tlie ureter and the large blood-vessels of the pelvis.
Ascites. — An accunmlation of ascitic fluid in the peritoneal cavity
sometimes accompanies an ovarian cyst, especially tlie proliferating
papillary variety. Tiie fluid may be mixed witli blood, wliieli 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 conunon ])ar-
tition may be absorbed, and the two form one tumor with this ]K'culi-
arity that it has two pedicles, one attaciicd to each cornu of the uterus.
IntraUfjameiitoHs and E.vtraperilone(d Developinenf. — 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 th<! uterus and rectum or the uterus and bladder,
and reaching the; ciccum, 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 frecpiently in ])aj)illary
proliferating (ysts.
lleinorrhaf/e. — At times more or less considerable amounts of
blofxl may Ix' poun-d into the cystic fluid, with which it mixes,
and to which it imj)arts a dark red or l)rown color. Tiiis hemoj'-
rhage may come from erosion of vessels in the partitions which aie
being al)sorbe(l, from ulceration of the wall, or torsion of" the pedicle.
' I. 1^. Stoiu', \Vasliiii),'t(>n, I). ('., Mi'/niul Tiiiiinr, \>\i. S jirid Id.
620 DISEASES OF WOMEN.
Suppuraiion. — The wall of a cyst may become inflamed, and the
contents changed to pus. This grave accident may he 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 al^sorbed 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. 609)
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. 610) 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 l)e 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. — Pa})illomatous cysts have a tendency to cause the pro-
duction of small yellow nodules on the peritoneum. After removal of
the tumor these may disai)|)ear or become innocuous by becoming
calcified.
Glandular and dermoid cvsts are much less liable to form such
DISEASES OF THE OVARIES. 621
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 tiie peritoneum ; which condition is called
pseudomyxoma of the peritoneum (\yerth) or gelatinous disease of
the peritoneum (Pean).^
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 tlie tumor which go on
forming a tumor in the peritoneum similar to the one in the ovary,
from wiiich they were 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. 601) 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 tiie 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 ])apillary 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 e|)itheliuin instead of ])lain
columnar. Some claim that the papillary cystomas are developed
from remnants of the Wolffian body growing into the ovary from
the liilum ^
The source of the glandular variety is by some thought to be a de-
generation of the intima of tiie arteries in the ovary. ( 'olloid deposits
an; often found in the stroma, the Gnuifian follicles, or a corpus
lut(!um ; but there is no evidence that they are th<' starting-])oint of
proliferating cysts. We find, likewise, frequently small (ysts without
epithelium in the ovaries, but it is inilikely that formations of so'epi-
' A ca-se of the kind is described on p. 4() of my Dinffjinsin.
' In n'lfani to the liis'ofienosis of the pajjilhiry cystomata of the ovary a pood
Bvnopsis of known facts and vahiahle new observations are found in articles by .T.
WhitridRc Williams in ./oA/is [[iipkinn IFoMpilal liulletin, No. 18, December, lS9I,and
Report in Patholofjij, II., Baltimore, 1892.
G22 DISEASES OF WOMEX.
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 ti)e 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, tiie 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 fostu; 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. 328 (p. 609) 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 tlie 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 tiie production of ovarian cysts : the
monthly congestion in these patients is insufficient to cause a men-
strual disciiargo, but strong enough to produce hypertrophy of the
walls of the follicle, and tiuis start the development of a cyst.
Symptom.'!. — 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 ride, it gives rise before tiiat 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. 623
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. 429).
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 meuorrhagia,
especially if it is intraligamentous ; and still later, wlien 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 preguancy 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 i)ressure.
If the tumor is prevente<l by intraligamentous development, adhe-
sions, or shortness of tiie pedicle from rising up into the abdominal
cavity, symptoms of this class begin as soon as the tumor reaches the
size of a fetal iiead. If, on the other hand, it leaves the pelvis, they
come much later. Pressure on the bladder causes frerpient 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; a('(;umulates above the stricture and in the jielvis of
the corrcspouding kidney, eausing hydroucphrosis and uremia ; but
sometimes the organism adapts itself to the new relations, and secre-
tion ceases in the <'orresj)onding kidixy, the pressure from below
being greater than that in the interior of the kidney.^ I'ressure 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 becotne so great that these chan-
nels |)ractieally become impervious. Under such circumstances tin;
blood finds an outlet through the deep and the su|)erfici;il ej)igastric
veins, the roots of which anastomose with those of the internal mani-
'.I. W. Hovc^c, " rrctero-iirctrnil Anastomosis." /In7i. o/A'j/n/., .Jan., 1S97, reprint,
p. '2-"), referring to .James, I'liy.^iohnjirdl imtl Clinirnl Study, Kdinlmrgli, 1S88, p. 41).
624 DISEASES OF WOMEN.
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 tiie 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
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. Tlie 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 \vitli 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 strijc, due to rupture of the corium. This tension of the
skin may be accom])anied 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 slowly, 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.
DISEASES OF THE OVARIES.
625
The larojer 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 Avalk at all. She cannot even lie on her back,
but only on the side, and can only turn with the assistance of others.
In the beginning the general health is good, but soon the patient
begins to lose flesh and strength. Digestion, respiration, circulation,
innervation, all suifer. Sleep is often disturbed. Pain, anxiety, and
loss of adipose tissue give her face a pe<;uliar expression, the so-called
fades ovariana (Fig. 347), characterized by pinched features and deep-
ening furrows.
Fig. 347.
Facies ovariana (SpeuctT 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 incurrcKl. It may be due to lack of nutrition, dyspnoea,
hydrothorax, pleurisy, pneumonia, insomnia, exhaustion, heart-dis-
ease, hydroMcpiirosis, nephritis, uremia, hemorrhages into the cyst,
inflammation and suppuration of the; cyst, rupture into the jx'ritoneal
cavity, twisting of the pedicle, acute or chronic peritonitis, cancerous
degeneration, etc.
By physic.il examinati<tn the presence; of a tumor is made out. If
the patient is nervous and contracts her abdominal muscles, it may be
neeessjiry to anesthetize her (|). lOo), and certain details in regard to
the j)edicle can only be a^^certained in this condition.
40
626 DISEASES OF WOMEN.
A complete examination is to be made both of the pelvis and the
abdomen (pp. 141, 160, cf i>e(j.).
By bimanual examination (p. 143) we may find the womb dis-
placed, as described above in spealving 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 ins})ection
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. "SVe 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 nienil)ranes 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 627
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 asp^'ts of which would require special
attention — namely, hemorrhage, inflammation, suppuration, twisting
of the pedicle, ruj)ture, 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 tiie
tumor, a weak ])ulse, 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 inmiediate ovariotomy.
Inflammation and Suppuration. — The cyst may become inflamed,
which is accom])anied 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 (Xicui's suddenly, it is accompanied by ra])id
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. AVith its cessation the symptoms
stop. If it continues, it may lead to ascites, internal hemorrhage,
rupture of the cyst, suj)puration, peritonitis, or gangrene of the
tumor. I?ut it may also follow a more chronic course, and end the
j)atient's life by slow infe(;tion and marasiiuis. If the diagnosis of
toi'sion of the j)e<licle can be made, ovariotomy should i)e performed
at once. Wy means of artificial prola})se of the uterus (p. 145) the
torsion may be directly felt.
Rupftire of thr Ci/sf. — Rupture into th(> peritoneal cavity of small
cysts with serous contents need not produce any symptoms. If the
cyst is lai'ge and the eontcMits watery, the fluid is soon absorbed and
dispose<l of by increased diuresis and pei-spiration. Colloid fluid may
remain for months in the peritoneal ("avity.
The ruj)ture of a cyst with bloody contents may be followed by
the development of a retro-uterine hematocele.
If pus or other irritiint fluid is poured into the ])eritoneal cavity.
628 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 faintness. 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. 620).
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, fiicili-
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 ])edi-
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. 629
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 twenty-five 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 ap})carance by
which it can be recognizal at once simply by looking at it.
Viscidity is the most important ])hysical character when present,
but it may exceptionally be wanting in ovarian and present in non-
ovarian fluid.
No chemical prmluct peculiar to ovarian cysts has been found.
As a rule, the fluid of an ovarian cyst does not coagulate sjwnta-
neously, and, wiien it does, tiie coagulation takes place slowly. As-
citic fluid, as a rule, coagulates spontaneously and slowly, forming a
small coaguhiin. The fluid of uterine fibrcxysts sometimes coagu-
lates, and then immediately after Ijeing evacuated and en max.se.
Ovarian fluid, as a rule, coagulates to a great extent or entirely by
heat. That of the cysts of the broad ligament does not coagidate
by heat, unless an acid is added.
There is no j)atliognomonic morj)hological (element in ovarian fluid.
The most imj)ortant (ilement in regard to diagnosis is colunniar ('j)i-
thelial cells se(;n in sich; vi(!W. Tlicir presence exchides all other
tumors than those of the ovary, the Fallo|)ian tube, and tiie broad
liganjent (perhaps with the exception of the rare pancreas-cysts).
630 DISEASES OF WOMEN.
Although the small granular bodies described above, and repre-
sented in Fig. 338, may be found in very different fluids, the pres-
ence of 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 veiy 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. 169.
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. 170).
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. Pehic 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 VARIES. 631
utenis, 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 tiiat 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 retrqflexed 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 ])elvic pain. Sometimes
there is a bloody discharge from the uterus containing decidual
shreds.
8. Retro-uterine Iiematocele gives a history of sudden abdominal
pain at a menstrual period or of menorrhagia, followed by inflamma-
tion. The tuMKjr, at first very soft, soon becomes hard.
9. Fibroids of the xderus are hard, situated in the uterus or inti-
mately connected with it. The uterus has an irregular shape. Hard
nodules are often feU.
Fibrocystic tumors may be fluctuating, but form one mass with the
uterus, and hard nodular masses are likely to l)e felt.
10. So/ id ovarian tumors are nmeii rarer than (ysts, are hard, often
nodular, frecjuently accompanied by ascites, the fluid of which may, if
the tumor is cancerous, contiiin large round or pear-shaped cells,
isohited or in groups, and witli single large nuclei.
B. Abdominal Tumor.
If the ovarian tumor has risen into the abdominal cavity, it should
be differentiated from the; foHowing swellings: 1, pregnancy (normal,
with excess of iicpjor amnii, with dead child, or extra-uterine); 2, hy-
datiform mole; 3, hematometra, hydrometra or j)hysonietra ; 4, fibroid
or fibrocystic tumor of the uterus; o, ascites ; (5, hcniatocele ; 7, eiuysted
peritonitic exudation ; 8, tui)erculosis of the j)eritoneum ; !), cancer of
tiie p(;ritoneiiui ; 10, a cyst of the broad ligament ; 11, an omental (yst
or solid tumor; I 2, hydronephrosis ; 1 .'>, a renal (yst ; 14, a floating
kidiujy ; 1"), a hydatid; IG, a liver-(yst ; 17, a floating liver; 18,
a pancreits-(yst ; 19, a (yst or solid tumor of" the spleen; 20, a (yst
C'i2 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, spina
bifida ; 25, dilatation of the stomach ; 2G, 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 fetus
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. 631), 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 ddbris of the vesicles of the chorion.
3. Hennatometra, hydrometra and physometra (p. 441) 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 keej) 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 its
consistency is harder, that hard masses are often felt in the up])er 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 sj)ontaneoHsly, rapidly, and in toto, it is proof
that the tumor is a fibrocyst.
DISEASES OF THE OVARIES.
633
5. Ascites. — The abdomen appeal's 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. 348 the shaded
Fig. 348.
Percussion-sound in Ascites to the left and in Ovarian Cyst to the right when the patient
lies on her baclc (Spencer Wells).
parts mark the dull percuasion. 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. .Vs a rule, the condition
is found to be due to di.seases of the liver, heart or kidneys.
If the ascitic collection is so enormous as to distend the whole
abdomen, it may, however, be impo.ssible to elicit the above-described
signs ; but then such a mass of fluid may accumulate in the course
of a few months in ascites, while an ovarian cyst takes years to gi'ow
to such enormous proportions. The uterus is easily movable in ascites,
immovable in cases of very large cysts.
6. Hematocele (see al)ove under Pelvic Tumor).
7. EnnjHted perifonitic ej-udation gives a history of inflammation.
The fluid is serous, like that in a.scites.
8. Tiihcreu/osis of the peritoneum is accom])anied by free fluid, and
often i)y a tumor formed by agglutinated intestinal knuckles and
omentum, that may be hard to diflcrentiate from an ovarian tyst.
These jiseudotiunors, howeviM", are much more common in voung
women than later in life, and grow much more rapidly than ovarian
cysts. iSometimes 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 tul)ercl(>s in
the lungs, pleurisy, gn'at tenderness, on pr(>ssure, of the intestines, and
a rise in temperature in the evening, also go far to establish the diagno-
634 DISEASES OF WOMEN.
sis of tuberculosis of the peritoneum ; and as laparotomy has proved a
cure for this disejise, no harm is done, if a mistake should be made.^
9. Caticer of the peritoiwuia is accompanied by rapid cachexia.
The fluid often contains characteristic cells (p. 540). Large, hard,
irregular masses can be felt in the abdominal cavity.
10. Cysts of the broad ligament are much rarer than ovarian cysts,
seldom larger than an adult's head, immovable, and dip deep into the
j)elvis, where they are situated close up to the uterus. As a rule,
they develop slowly. Tlie fluid is as described above under Pelvic
Tumor. AVhen 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
these features are 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 tlie liver. The dull
percussion-sound extends uninterruptedly to the liver region. Some-
times hydatid vibration can be felt. The fluid is clear as spring-
Avater, does not coagulate by heat, and may contain booklets of echi-
nococci or shreds of cuticula, the parallel striation of which is pathog-
nomonic. In its chemical composition enter succinic acid, leucin,
grape-sugar, and inosite, but never paralbumin. [Hydatids of the
Pelvis 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
' Encysted tubercular peritonitis has been lucidly discussed by W. T. Howard of
Baltimore in Trans. Amer. Gyn. Soc, 1885, vol. x. pp. 41-62.
DISEASES OF THE OVARIES. 635
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.^
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. 160).
20. Q/.s'fe of the rnesentertj 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 tiie 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.
Cysbi of the nrachus contain flat ej)ithelial cells.
22. .1 solid tumor of tlie abdominal wall, especially a fibroma of
the transversalis fascia with partial cystic degeneration, has been
taken for an ovarian cyst." 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 tlie
same mistake, but it may be raised between the fingei-s, 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. 575). It
is, as a rule, bilateral, always monocystic, and not very tender, Tlie
fluid is serous, and does not contain tlie bodies coinmonlv found in
ovarian tumors. Tlie presence of ciliated columnar ei)ithclial cells
does not decide the (piestion (p. 614).
24. Spina bifida very rarely forms a tumor in the jK'lvis and abdo-
men, i)ut in one case it contained some three (juarts of fluid.^ This is
watery, colorless, limpid, without form-elcmciits, and contains only
traces of albumin. Alt<'r evacuation of the fluid the fissiu-e in the
sacrum through which the cyst entered the jxilvis may be felt.
25. Dilatation of flic Stomacli. — Tnci'edible as it mav seem, even a
dilated stomach has been mi>lak('n for an ovarian cyst and <)j)erate(l
' fJarrigiK's, Ditif/nfiKln, p. 8G.
* An intiTcstiiiK case of tlie kind wjts reported bv Kob. Weir, in llu! Med. Record,
Dec. n, 18.S7, xxxiii. TO."..
' Kinmel, (iipircolo</ij, 2d ed. p. 791.
C36 DISEASES OF WOMEN.
on.^ The chief points which are to be borue 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. 160).
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.^ 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. 178).
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 vertebrte.
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 tympanitic
sound of the intestine.
Large extraperitoneal ovarian cysts are particularly difficult to
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 ])ain
caused by the growing cyst; 7, tympanitic percussion-sound in front
of the tumor, like that found in renal tumors; 8, an unsynnnctrical
shape and preponderating development in one side of the pelvis of a
firmly fixed cyst.^
Complications. — Ovarian cysts may be complicated by many dis-
eases, some of which may be directly referable to the pressure
^ Reeves Jackson, Detroit Lancet, 1880 ; Cevtralblatt. fdr Gyndk., 1880, vol. iv. p. 368.
^ I have myself withdrawn three quarts of iirine from the bladder.
' Wm. Goodell, Amer. Syst. of Gynecol., vol. ii. p. 830.
DISEASES OF THE OVARIES. 637
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 organ 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 nmch
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
or of uterogestation combined with ectopic gestation.
The simultaneous pressure of a growing uterus and an ovarian cyst
will in most ca^es cause so much discomfort, or even be attended with
such danger, that interference is called for. Three methods are tiien
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 se(|ucnces
should develoj). 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 ])edick', followed by atrophy,
fatty degeneration, or calcification. Or it may be brought on bv
ruptiu-e of the (yst. The tumor may also shrivel uj) after one or
more tappings. It may also become stationary and stoj) growing.
But all these occurrences are so rare, that they must he left entirely
out of consideration when the question of treatment is raised.
A patient may live; twenty years with an ovarian (yst, but in the
vast majority of ejises a speedy death awaits the woman aflected with such
a tumor. Of those having a |)roliferating cystoma, GO to 70 per cent.
die within thre(! years, and 10 per c(!nt. additional in the fourth year.
Treatment. — Medical treattnent is of no avail, and galvanopuncture
is more dangerous than ovariotomy. Noeggerath ' claims that a
' E. Noo^jrenitfi. Crnlralhl.j. (iifniilc., 1890, vol. xiv., "Report of Tontli Iiitor-
national CongrcsH," p. 8CJ.
638 DISEASES OF WOMEN.
yvenk faradic cmrent 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 may be stated from the beginning
that ovariotomy should be performed whenever it is practicable.
Ta2)ping.
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. 618).
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. AVe have seen above (p. 637) 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 oifers 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.
639
Fio. 349.
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
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 eases 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 wiiich is kept under the surface
of some fluid in the receptacle. The instrument rejire-
sented in Fig. 349 offers the further advantage that,
in case of obstruction of the canula, the trocar can J)e
pushed forward again.
3fodiis Operandi. — The patient should lie on her
back. The puncture is usually made in the median
line, midway between the symphysis pubis and tlie
umbilicus. With a hypodermic injection of cocaine
(p. 223) 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 asj)irat()r is usfid, the pain is so insignificant and
the opening so small that neither cocaine nor the
cutaneous incision is called for. If the canula becomes
bhx^ked up during the flow of the fluid, a disinfected
stylet should be used to clear it without i-emoving 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
Warren's Ovarian
Trocar.
640 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 furtlier particulars see p. 191.)
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 alxlominal 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
shotdd 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. 593).
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, ou 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. 627-629).
Finally, we must take into consideration the pronounced tendency
ovarian tumors have to become malignant (p. 620).
Special indications for immediate operation are serious hemorrhage
into the cyst, sup])uration of the cvst, torsion of the pedicle, rupture
into tiie 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-
rif)tomy 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 tiie patient is in an advanced stage of tuberculosis or
chronic nephritis or suffers from cancer in any other organ than the
ovary, unless the cancer cjm be removed at the same time or by a
separate operation. Cancer in the ovarian cyst itself also forms a
DISEASES OF THE OVARIES. 641
contraindication, if the disease has invaded the surroundings or in-
fected tlie 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. 570),
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 colpbtomy, but small intraligamentous cysts are best
reached through anterior colpotomy (p. 475). Vaginal ovariotomy
has received a new im])ulse by being combined with hysterectomy
by Pean's method (p. 510). It is claimed by those who advocate
this method that it is indicated (1) for tumors of the appendages
reaching or even passing a little the umbilicus, whether cystic or
solid, but bilateral and perfectly movable ; and (2) for tumors that
are less voluminous and situated low down, whether mobile or im-
pacted, complicated with ascites or not, but decidedly bilateral.^
But in the author's opinion the diagnosis is often so uncertain, and
the execution of the operation often so difficult, that, while it may
be true that in the hands of surgeons who have had exceptional
experience in vaginal hysterectomy, that method is to be preferred,
the average surgeon is likely to serve the interests of his patient
better by following the abdominal route. The stress laid upon
avoidance of the abdominal scar seems under such grave circum-
stances to be nither misplaced, but it emphasizes tlie importance
of using the greatest possil)le care in closing the abdominal wound.
In tiie following exposition we consider only abdominal ovari-
otomy.
Prrjxirafory Treatment. — If the patient is weak, and. has been
living under unfavorable circumstances as to food and shelter, it is
advisal)le to give her a elianee to gain in health and strength by
proper diet and regimen. Under all circumstances the skin is
cleaned, the bowels are em|)tie(l, and, if necessary, the functions of
the kidneys regidated (p. 205).
Some surgeons give ten grains of quinine for several days, in order
to ward ofl' fever; which, however, is hardlv necessary, unless the
patient is subject t(i nialaria. Others giv(^ strvchiu'iic to bnice her
against shock. Otiiers |)raise bromides as a preventive of voiTiiting.
In regard to season, the time of the day, menstruation, laetiition,
the arrangement of tlie room and table, the ])reseuce of spectiitors,
' Paul Segond, Jin-iie de (lym'col. et dr Cliir. >il,<h„nii„di\ 1897, No. 2, p. ^aH.
41
642 DISEASES OF WOMEN.
the administration of the anesthetic, the patient's dress, and disin-
fection, the reader is referrtnl to what has been said in speaking of
operation in general (pp. 201-233).
Instruments, Spongi\'<, 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
kept in readiness to overcome them. The following paraphernalia
ought to be within reach :
4 large flat sponges or half a dozen large pads ;
4 large round sponges or a dozen mediimi-sized pads ;
8 small round sponges or two dozens of small pads (p. 210;
about the substitution of gauze for sponges, see p. 211) ;
4 sponge-holders (Fig. 199, p. 229) or forceps;
1 sharp-pointed bistoury ;
1 pair of knee-bent, blunt-pointed scissors ;
1 pair of blunt-pointed scissors curved on the flat ;
1 dissecting- forceps ;
1 mouse-tooth thumb-forceps ;
1 director ;
12 pairs of small pressure-forceps (Fig. 164, p. 191);
6 pairs of long pressure-forceps (Fig. 293, p. 512) ;
2 pairs of Nelaton's cyst-forceps (Fig. 352, p. 647) ;
2 volsella (Fig. 196, p. 228);
2 pairs of Spencer Wells's pedicle-forceps (Fig. 353, p. 647) ;
1 male metal catheter ;
1 female metal catheter ;
1 male urethral steel sound. No. 25 French ;
2 small tenacula (Fig. 195, p. 227);
1 Simon's sharp spoon (Fig. 133, p. 156) ;
1 tenaculum-forceps ;
1 large curved trocar (Fig. 351, p. 646);
1 small curved trocar (Fig. 175, p. 197) ;
1 aspirator (Fig. 148, p. 171) ;
2 retractors ;
1 cautery-clamp (Fig. 354, p. 648) ;
1 thermo-cautery (Fig. 161, p. 187);
1 yard of rubber cord for temporary compression ;
drainage-tubes of glass and soft rubber, two of the latter T-shaped ;
1 uterine sound ;
1 dull handled needle (Fig. 202, p. 231) ;
1 Shroedor needle (Fig. 295, p. 514) ;
2 strong curved Hagedorn needles for closing incision ;
3 smaller curved needles for passing ligatures ;
3 fine curved needles ;
6 cambric needles for the intestine ;
DISEASES OF THE OVARIES 643
a set of 4 iVIurphy buttons (see Appendix) ;
1 Hagedoru 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 : Iodoform ;
Iodoform gauze ;
Gutta-percha tissue ;
Aseptic absorbent cotton ;
Rubber adhesive plaster ;
Flannel binder or many-tailed muslin bandage ;
6 large safety-pins.
Ovariotomy begins with laparotomy.
Laparotomy^ 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 beyoivd the umbilicus
all the way up to tiie ensiform process.
The })atient is placed on her back, extended at full length on a tiible,
with her feet toward the window. The necessary preparations have
been described in the general division (pp. 206-237). The operator
' Dr. Robert P. Harris of Philadelphia published in 1890 a pamplilet entitled
" Oieli»to)iii/. This, (iiul nt)t l/iparotnnii/, is the proper Grrek fti/noiiipa of ' abdominal
licrtioii,' laparotoini/ hfinij an iivcinion of the flank onli/." Unfortunately this name has
been adopted to some extent.
First, it is to l)e regretted that the euphonious word lai)arotomy, with its beautiful
liquids and npen vowels, should be driven out by "celiotomy" — for that is not only
the [)ronuuciation, liut the modern spelling — with its sharp siliilant and thin sound
of e. Secondly, when a word has existed for nearly a hundred years, has i)assed into
all languages, atul forms the root of numerous derivatives .'uid part of compound
words, it cjiuses only confusion to substitute another for it. I'inally, even the argu-
ment drawn from i)hiloli)gy in favor of the new word, is to say the least, doubtful.
If it must be admitted that v /a:rdf>(i means the soft part between the ril)s and the
crest of the iliinn, it is oidy a very slight extension to apply it to the whole abdominal
wall, and it has no other sense; whereas // /<'»//« means, 1, the abdonunal cavity;
2, the stomach ; .'5, stools; 4, the pulp of the fmger ; o, any cavity ; and cousc(|uently
the word o-liotomy does not convey even approximately an idea of what is going to
be cut.
644 DISEASES OF WOMEN.
stands ou 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 operatoi-s 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 the elevated-pelvis position (p. 141)
oifers groat advantages, the organs being more exposed to view and
easier to reach. For this position the patient is turned with the
head toward the ligiit. The operator may stand on her right, which
affords him better light, if it comes from the side only, but has
the drawback 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 difficulty, he must stand on the opposite side to the one
where he wants to see.
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.
1. I)icif<io)i. — In many laparotomies it suffices to make an opening
large enough to admit the index- and middle fingers. If the ele-
vated-pelvis position is to be used, a much larger incision is needed.
In order to inspect the pelvic cavity, an incision extending from the
symphysis pubis to the umbilicus is required. The first incision is
made with a medium-sized scalpel through the skin, the next, after
changing knife, through the subcutaneous tissue. Bleeding vessels
are secured with pressure-forceps. Then the linea alba is severed.
If the operator misses it and goes a little out to one of the sides,
no harm is done. The only diffi^rence is that he will see and per-
haps separate 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,
resistance being met with in tiie 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.' I have tried
it several times, but found adaptation of the edges less accurate
than with the median incision. This can, however, be avoided by
holding the nniscle aside instead of going through it, and to unite
the edges of the cut aponeurosis only, without including the nuiseu-
lar tissue in the suture.
In tliis part of the operation there is no danger, and it may be
executed rapidly, simply cutting down on the tissues. But under
the muscular, fascial, and aponeurotic tissue lies a layer of adipose
* Abel, Archiv fiir Gijudk., xlv. 3; Flatau, Cenlralbl. fur Qyndk., 1894, No. 12, p.
278.
DISEASES OF THE OVARIES. 645
tissue, the preperitoneal fat^ which forms an important landmark,
for immediately behind it is found the peritoneum.
This preperitoneal fat is, therefore, best torn -with ])ressure-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 j)ressure exercised on it the prejjeri-
toneal fat may become very nnicli reduced. Greater care is, therefore,
needed under these circumstances in making the abdominal incision
than, for instance, in oophorectomy, or the operator risks ])lunging
his knife right into the cyst from the stai't, not to sj)eak of Mounding
organs, such as the omentum, the intestine, or the bladder, that
might be in the way.
The exposed peritoneum is seized with two pairs of pressure-for-
ceps or with a tenaculum, and lifted uj) in a fold, in which a small
opening is cautiously made with the knife. Before doing this all
hemorrhage 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 ])eritoneum from within outward until the
hole is large enough. If after a digital ex]>loration the. operator
deems it necessary to enlarge the opening, it is done with a pair of
strong knee-bent scissors, one blade of which is })laced inside of the
abdominal cavity, between the middle and index-fingers, which keep
intestine and omentum out of the way and protect the bladder; and
the other touches the skin. Thus the whole thickness of the ab-
dominal wall is cut through, and bleeding vessels are caught with
pressure-fi)rceps. Most such scissors, designed to follow the groove
of a director, have an inner pointed blade and an outer blunt one,
which does not answer our purpose. The inner blade should be the
blunt one, so as not to prick the abdominal oi'gans ; on the skin there
is no danger, and it is immaterial whether the blade is j)ointe(l or
blunt. As to the length of the incision, it should not be longer than
required, but long enough to allow of all necessary manij)ulations.
A pressure-fi)rceps is put on the jieritoneum on either side of the
incision, .so as to facilitate finding it when the wound is to be closed.
Instead, the peritoneum may be sutured to the skin in one or more
phuM's 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 reacluMl in inserting the perma-
nent sutures. It is, however, much better to use a pair of the large
cnrv(Ml side retnictors re|)resented in Fig. .'ioO. They give more
room and n^fiect light into the iwlvic cavity.
' It is sometimes tailed the subperitoneal fat, an txprossion that is apt to misUad.
646
DISEASES OF WOMEN.
The lower end of the incision ought, finally, to be half an inch
above the symphysis ; the upper varies according to size of the
mass to be removed. If the incision extends beyond the umbilicus,
Fig. 350.
Landauer's Laparotomy Retractor.
most operators avoid this point, as being thinner and less favorable
for healing, and go to the left of 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. 351) is pushed into it near the upper end of the
Fig. 351.
Emmet's Ovariotomy Trocar.
incision, and the fluid directed into a tub under the table. Many
operators prefer to let the patient remain on her l)ack and to use a
trocar with a rubber tube attached, conducting the fluid into the
vessel destined to receive it, or to have a basin covered with an
aseptic towel held under the trocar. As soon as the cyst begins to
collap.se it is .seized with a Nclaton forceps (Fig. 352) 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 sec-
DISEASES OF THE OVARIES.
647
Fig. 352.
ond Nelaton forceps, and sometimes even one or two volsellae may
answer a good purpose in pulling out the tumor. If there are sev-
eral large compartments, tiiey are opened one after the other with tro-
car, scissors, 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 j)edicle in a temporary ligature
of rubber tubing or strong silk, or with Spen-
cer Wells's pedicle- forceps (Fig. 353), or a
cautery-clamp (Fig. 354), and cutting it off at
a distance of about two inches abov'e 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-
oopiiorectomy (p. 563), a blunt handled needle
is used to carry the pedicle ligature through,
and the Staffordshire knot (p. 566) may be
used; but in ovariotomy it is more convenient Naatons Cyst-f(m>eps : a,
to cut the pedicle-silk in two halves, cross cir^'i'ir jaws with holes
.1 111," Tin ^^'^ P*^SS ; B, catcli.
them, and tie each half separately, thus form-
ing two links of a chain perforating and surrounding the pedicle.
Fig. 353.
Spencer Wells".s redicle-Rirceps.
As the stum]) of the Fallopian tube might su])purate, it ought to
be tied as close up to the uterus as convenient. W'lien the pedicle
648
DISEASES OF WOMEN.
lias been tied, it is cut three-quarters of an inch above the ligature,
and trt>ated just as the stump in salpingo-ooj)horectoniy. Finally, it
is dropped, the intestine kept back, and the omentum spread over it.
Fig. 354.
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 Avell
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 use<^l.
On the other hand, it is a double assurance against hemorrhage to
seize large arteries in tiie stump and tie them separately.
The distal end of the stump does not slough, because new capil-
laries are speedily formed around the ligature, which convey nour-
ishment 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,
Fig. 355.
Noyes's Alligator-forceps.
it is innocuous ; but often a secondary infection takes place and a
fistulous tract is formed, which will not clo.se till the ligature is ex-
DISEASES OF THE OVARIES. 649
pelled or withdrawn. This is done best with the alligator-forceps
of the otologists (Fig. 355), which takes up little room and has a
good grip. It is better to use catgut ; but as this material is likely
to become loose at the knot, particular care should be taken in tying
it. AVhere larger masses are tied, as in a pedicle, a triple knot is
required.
After having dropj)cd 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, notiiing 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 aj)plies, 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. 494) 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 ])ads, and
before the ojjcrator proceeds to the closure of the wound the s})onges,
pads, and artery-forceps should be counted, as it has ha])})ened that
such obje(!ts have been left in the abdominal cavity, from which place
they often have l)eeu removed after a longtime, and after much injury
had been caused. Another precaution is to liave a cord attached to
a corner of each of the large pads which are packed into the ab-
dominal cavity to cover intestinal knuckles, etc., and to leave the
ends of the cords outside the wound.
8. Closure of the Abdominal IncLnon. — ]>efore closing the abdomen,
the omentum sJiould be drawn down over tiie intestines. Great care
should ho taken to unite tiie dilferent layers, and especially the
fascial and aponeurotic structures, as otherwise a ventral hernia is
very apt to form. The best practice is first to (^lose the pi^ritoncum
with a contimums suture of thin catgut. The second row of su-
tures should unite the aponeurotic structures. This may i)e done
with interrupted sutures or a rumiing sutures of strong catgut. A
particularly sf)lid union may be obtainecl by using the cobbler's
stitch, inserting a stitch for every (piarter of an inch with a curved
hainlled neeclle, which is unthreadecl and tlire:i(le<l again with the
other end of the thread for every stitch, so that the two ends pass
through the same hoh; (I'ig. 35!)), the loops lying on both sides and
crossing under, not above, th(> edges. Catgut or kangaroo teiidon
should be used. The suture should i)e tightened after everv two or
650
DISEASES OF WOMEN.
three stitches sufficiently to cause apposition of the lateral surfaces,
but no constriction. Of late years I avoid includino; the muscle-fibers
in the stitches. In themselves they are soft and friable, and do not
give a strong cicatrice, and they prevent the sinewy tissues from
growing together, which form the natural material where a per-
manent resistance is Avanted. On the other hand, a muscle in its
natural condition, not invaded by sutures, may be used as a pad out-
side of the cicatrix, which it then serves to strengthen. Finally,
the skin and subcutaneous adipose tissue are united by deep silk-
worm gut and superficial silk sutures, or by a subcuticular, absorb-
able running 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. 356.
^-^
-Sii^^
Marcy's Subcuticular Suture.
of an inch from the end of the incision, carried in the subcutaneous
ti>sue 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 in.serted in the other edge riglit 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
an inch from the end of the wound (Fig. 356). 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 whicii 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.^ The same stitch may be used with
a silkworm-gut suture, the ends of which are tied together over a ]>ad
of iodoform gauze covering the wound, and which is removed wlien
the wound is healed.
Plalsted unites the edges with interrupted sutures of very fine silk.
These sutures do not perforate the epidermis, and when tied they be-
' Henry O. Marcy of Boston, "The Surgical Treatment f)f Inguinal Hernia,"
Trans. N. Y. Stale Med. Association, vol. xi., 1894, reprint, p. 12; "The Animal Su-
ture," Trans. Amer. Assoc, of Obstetricians and Gynecologists, 1889, reprint, p. 24.
DISEASES OF THE OVARIES. 651
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.^
If the incision is long, two or three sutures should be used, meeting
one another at their ends. Before closing the two upper rows of su-
tures the wound should be irrigated with some antiseptic fluid (p. 217).
If the patient is in a low condition, the operator should, however,
abstain from all these niceties and close the abdomen in the speediest
way, which is to insert silkworm-gut sutures through the whole ab-
dominal wall, inclusive of the peritoneum, one for each inch.
4. Dressinc/. — 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-pcrclia tissue, an inch wider than the com-
press in all directions, placed outside of it. Next, the whole an-
terior surface of the abdomen is covered with a thick layer of
sterilized dry absorbent cotton ; this is held in place by six two-inch-
wide straps of rubber adhesive plaster, six inches long and sewed to
tapes, the first of which are fastened on the skin outside of tiie
dressing and the latter tied over it ; and, finally, a fiannel 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. I'i there is no shock, she is allowed to sleep till she awakes
spontaneously. If slie vomits, the measures recommended on p. 242
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 sliould be
avoided as much as possible on account of the danger of their para-
lyzing the intestine. Pain may often be considerably relieved by
ap|)lyiiig ail i('c-l)ag to the abdomen ; but gn^it pain is weakening,
and calls, in my opinion, fi»r a hvpodermic injection of one-sixth to
one quarter of a grain of morphine.
If there is no s])ecial indication for doing it earlier, tlie bowels
should l)e moved l)y a gentle aperient on the third day. I |)rcicr
for this purj)ose a heaping teaspof»nfnl of sulj)liate of sodium or t.ii'-
tratc of ])otassinm and sodium, to be repeated evcrv four hours if
needed. T(» allow tlie bowels to i)e at rest too long is dangerous,
because it mav give rise to occlusion of the intestine bv adhesions.
Hefi/re the bowels ;ire moved much relief from flatulence is afl'onled
by inti'oducing a soft-rubber rectal tube. If" salts are vomited, I
substitute calomel (gr. j evcrv hour) ; and if that does not operate
when ten doses are given, I give an ox-gall enema (j). 17H).
' Will. S. Halsttnl, .Johns Hopkins HoxinUd Bulletin, 1889, vol. i. p. 13.
652 DISEASES OF WOMEN.
During the first day no food is given. Thirst is relieved by very
small quantities of hot or ice-cold \vater or an enema of a pint of
tepid water. The following day the patient may have tea, milk,
thin oatmeal gruel, and beef-tea, in small, frequently repeated por-
tions (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. 236. The abdomen
is washed with a solution of corrosive sublimate, the sutures are
replaced by strips of rubl)er 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.
After removal of the plaster straps the abdomen is cleaned Avith
chloroform, which dissolves rubber plaster, and after having been
up a few days the ])atient may be dismissed. Slie should, however,
wear an abdominal supporter (p. 199) for at least three months.
Some gynecologists dispense with the bandage, just as some ob-
stetricians have abandoned the binder after confinements. But there
is no doubt that after the removal of a large tumor or the expulsion
of the child an abdominal supporter helps to avoid that relaxation
of the abdominal wall which is so unseendy, and may give rise to a
numlxn' of more or less serious symptoms, such as loosening of the
abdominal organs from their moorings, atony of the stomach, slug-
gish blood circulation in the abdomen with consequent hyperemia,
giving rise to metrorrhagia, menorrhagia, hematocele, hematoma,
hemorrhoids, inflammation of the uterus and its appendages, stasis
of the gall in the gall-bladder, constipation, and weakness of the
heart.'
Difficulties md vith during the Operation. — If an ovarian cyst does
not contain much solid matter, has no adhesions, and lias a long and
strong pedicle, ovariotomy is one of the easiest operations. But numer-
ous and manifold are the difficulties which may arise, wliich often
cannot be foreseen, and for which the operator must be pre])ared.
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. 511), so this
may be tlie case with an ovarian cyst.
I-*ersistent Urachu.s. — See j). 522.
Peritoneum taken for Ci/st-iraU. — 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 aI)dominal Avail. If this is only done over a small space,
'Compare the excellent paper by Dr. Illoway, Amer. Jour. Obst., Sept., 1898, vol.
xxxviii. p. 331.
DISEASES OF THE OVARIES. 653
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 loall may often be easily severed by
pushing a male urethral steel sound between the abdominal wall and
the cyst before tapping. If tliere is much resistance, the flat hand is
introduced, and the ulnar edge of it used in the way a paper-cutter
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.
I-iong 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 bo 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. 513). If the adhesion is very extensive, it is bet-
ter not to try to separate it at all, but either to desist altogether from
tlie operation or be satisfied with an incomplete operation by marsu-
pialization, as will presently be described.
If the intestine has been injured, it nnist i)e attended to, as even
the smallest puncture may allow the contents to enter the ])eritoneal
cavity, and as any place deprived of its peritoneal coat is apt to
rupture.
A mere puncture may be seized with foreej)s and surrounded by a
ligature. TIh' edges of a longer tear must be brought together : if it is
onlv peritoneal, they may be united with a continuous suture; but
if th(! whoh; wail is torn through, the edges should be united by
a rV.ernv-Lembert suture ; that is, a donbh' row, comprising the
iniiscular layer and the peritoneum, l)Ut not the nineous membrane.
654 DISEASES OF WOMEN.
the outer a quarter of an incli outside of the first. A fine cambric
needle, threaded witli the finest iron-dyed black silk, is used for
this delicate "svork. The inner suture may be interrupted or con-
tinuous ; the outer is always continuous. If a rectangular suture is
used, one row suffices.
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 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, the stump inverted, pushed into the caecum,
and the peritoneum united with a running suture. (See Appendix.)
Adhemons 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
possible, 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. Large veins may extend all alone
without being accompanied by other tissue from the omentum to the
abdominal wall or down into the pelvis. They are easily torn, and
must l)e 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.
Adliesions 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
bleeding surface.'
The operator should be careful not to tear the gaJl-t)lnddei\ If
the accident happens, the tear must be comprised in the sutures
closing the abdominal incision, temporarily establishing a biliary
fistula which closes spontaneously. If this organ is badly torn, it is
necessary to remove it entirely.
'Snegireff, Berliner Klinik, April, 1895.
DISEASES OF THE OVARIES. . 655
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
lielp has been secured in the management of such cases by the in-
vention of the elevated-pelvis position (p. 141). 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 abdom-
inal 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 without penetrating the mucous
membrane.
If the ureter is torn transversely, but the ends remain in contact
with each other, the same course should be pursued or tlie ends
should be cut in a slanting direction before uniting them end to end
(Bov6e).'
Sometimes it is possible to introduce the upper end into the blad-
der and stitch it there by intra-peritoneal cystostomy (p. 395).
A sim])ler method and one which has given excellent results is that
of Van Hook. The end of the lower portion of the ureter is closed
with suture ; a longitudinal incision a quarter of an inch long is made
into its wall below the closed end. A slit is also made in the end
of the upper portion, in order to make the opening larger; a catgut
thread, with a needle at each end, is carried through tlie wall from
within outward, opposite the slit. Next the needles are inserted
through the opening in the lower portion and ]>ushed tlirougli the
wall, half an inch below the slit. ]iy gentle manij)ulation the upper
extremity is dniwn into the lower tube, and the suture being tightened
and tied the slit is entirely occluded.^
If no conservative method is available, nephrectomy should be ])er-
formed at once, provided tlu; patient ap])ears able to stand the sliock.
If she is too weak, a provisional urinary fistula should be established
by making an incision in the lumbar region, suturing the up})er end
of the ureter to it, and leaving a catheter in it. Tlie other end is
lilJated and sutured to the lower end of tiie abdominal wound. If a
'.T. Wesley Bovtje of Washinjifton, D. C, " TTrotero-iireteral Aiiastotnosis," Annals
of Saiy/r.ri/, .Jan., 1S97. He re<-()iiiinonds silk in preference to catfiut, t)eratise it
knots more firmly, siu-h long ends neetl not he left, and it occnpies less space in the
ureteral wall. He re(;ommends also to use rectany;nlar sutures aitcrnaliiifj with ihe
sin^^le interrui)ted. He thinks drainage should he used only in cases in wliich there
is pus.
' Weller Van Hook of Chicago, "The Surgerv of the ^reter.^'' Jour. Aincr. Med.
Assoc, 1893, vol. xxi. pp. !»1], Wo.
656 , DISEASES OF WOMEN.
fistula forms here, another catheter is introduced and left in it. A
tiiird is introduced throuoh 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.*
If the litems has been Avounded, 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, hoAvever, the hemorrhage cannot be checked in any
other way, the uterus must be removed.
The cyst may be so adhevcyd 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
iodoform gauze, which is changed every four or five days {mar-
supiaUzaiion). 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 volsellse 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
an outlet to the fluid, and then the upper ])art should be pulled out
first. If it becomes necessary to pull the intestine out of the abdom-
inal cavitv 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. 531). The elevated-pelvis posi-
tion has, however, rendered this evisceration superfluous in most
cases.
Intrnlif/amentous Development. — Ovarian tumors that develop in
the broad ligament are usually papillary (p. 614). They are
smaller, grow more slowly, and have "fewer daughter-cysts. Their
papillomas may rupture the cyst- wall and lie free in tli^ peritoneal
cavity or grow into neighboring organs. They are more malignant,
and are very apt to cause metastatic infection of the peritoneum. They
are diffi(.'ult 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,
' Puzzi, Centralbl f. Gynulc, Feb. 4, 1893, vol. xvii. p. 98.
DISEASES OF THE OVARIES. 657
later elevated and immovable. When the lower limit of the broad liga-
ment is reache<l, 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 tumoi^s 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 inti'aligamentous 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 ca^^es 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 itfi 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 tiie 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 tlie tissue that lies between each two sutures, whereby
the deeper parts become more accessible. The following suture must
always eml>race part of the mass comj)rised in the preceding one, in
order to avoid hemorrhage. (Comj)are Vaginal Hysterectomy, p.
510). Proceeding in this manner we get under the cyst and diminish
its attachment, until finally tiie tube and the rest of the broad liga-
nient can be enclosed in one ligature.
If the cyst extends down to the lower edge of the broad ligament, it
can only i)e removed by enucleation (Miner's method),' which consists
in stri|)ping the cyst of its j)erit()neal covering, and leaving this or
part of" it as an empty sac. If the tumor does not rise much above
the superioi- strait of the pelvis, tiiis is done by making an incision
through the peritoneiun at the upper end of llu; tuni<»r and pushing
it down with fingers and blunt instruments. If, <tn the other hand,
the cyst is large, it should be emptied and pulled out to the level of
' JtiliiiK Francis Miner of I'liflhio, N. Y., jierforincd tlic (irst operation of this
kind in 1H(;9, and in tlic follow inj: year piihlislicd tlic inctliod (Atixinson Iii<>(ii(i])hi-
<(d hirtiinuiri/ of (oiilimixirary Amrrlrun I'hyxiridns (tnd Siirijfnns, I'liiladclpliia, ISSO,
p. ir,,.
42
658 DISEASES OF WOMEN.
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 })a|)illomata broken oft', 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 and
the anastomosis between the uterine and the ovarian, that lies just
under the inner end of the 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 necessary to perform supravaginal
hysterectomy (p. 517).
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 ^vith 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 throup-h the broad lirament about half an inch outside of
the uterus and tied. The ovarian artery is easily secured in the in-
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.^
The development into the mesentery gives rise to considerable hem-
orrhage, Avhich must be overcome by mass-ligatures. Pieces three or
four inches wide may be ligated without causing gangrene of the
intestine.
If 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.
* H. A. Kellv, Johns Ilopkms' Hospital Reports, Gynecology 1, Baltimore, Md.,
Sept., 1890, pp. 220-223.
DISEASES OF THE OVARIES. 659
Sometimes, as a result of inflammatory processes, the peritoneum is
so adherent to the intraligamentous ovarian cyst that in places it
cannot be stripped oif, 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 describetl in speaking of Fibroids (p. 526).
Pseudo-intraligamentous Ovarian Tuviors.^ — 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
recognize the tru(! condition, and still it is of great imj)ortance, 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 ])eritoneum in Douglas's pouch. Th(^ best way of
removing the lower end of the tumor is to j)ull on the sac after free-
ing it from adhesions above, and tying the tube with a double ligutui'e
near the uterus, and severing it with the thermocantery.
Incomplete Operations. — SoiTK.'times 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
' K. Pawlik, Ueber I'seudo-i»Jeiii;/<imriitiJxi' Eirrslock-KffeschwiilMe, Wieii, 181)1.
660
DISEASES OF WOMEN.
close tlie abdomen ; 3, (lrainap:e through the vagina. But if it is
evident that the operation cannot be finished, it is better not to
operate at all. The conditions which make it impossible to per-
form a complete extirpation are general adhesions, subserous devel-
opment in its worst forms, and cancer which has spread to the
surroundings.
Jlarsupialization 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 oif. 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 leav^e what cannot be re-
moved and close the abdomen.^
If the tumor has an involucrura so full of large blood-vessels that
the operator deems it impossible to remove the cyst, he may puncture
Fig. 357.
Boldt's Blunt Expanding Pelvic Dilator.
it from the vagina with lioldt's blunt expanding dilator (Fig. o-")?),
empty the cyst, and leave a drainage-tube in it. But this vaginal
treatment, like the alxlominal, may give rise to an interminable
secretion.
' Olshaiisen in Billrotli and Liicke's Frauenkrankheilen, vol. ii. p. 591.
DISEASES OF THE OVARIES. 661
It has been sugji^ested ^ to cut off the blood-supjily of irremovable
tumors by tying the ovarian artery in the infundibidopelvie liga-
ment, and the uterine by passing a ligature round it with a curved
needle from the vagina (p. 188) and again at the corner of the uterus.
If possible, tlie 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 in
others in which 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 opened from the vagina in the way just de-
scribed. This is done bv thrustino; a stroup; blunt dilator into the
opening made with the first, and expanding it. This will give a
free opening, by which we can both emj^ty the sac and ensure free
washing and drainage. A rubber tube with wings should be inserted
into the cyst, 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 increas-
ing strength, or peroxide of hydrogen.
The Pedicle. — If the ])edicle 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 t\ing 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.
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 duiin-
ligature. A long thread is carried with a handled needle through
part of it, and seized witii a pressure-forcejvs. Next, the long end ot
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
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. ^58). The })edi('le mav be
cut gradually, leaving at least half an inch of tissue above the liga-
ture, and for greater safety it is advisable U) tie arteries visible on the
cut surface with silk or catgut.
}f(frcjfs Mcfliod' (Fig. ^359). — A handled needle, carrying a long
tendon or catgut thread, is inserted through the j)art of the judicle
' \i. McK. p:nin)ctt, Aiwr. Jour. Ob.<t., .Inly, 1^90, vol. xxiii. j). TOO.
' Henry (). Marcy roixirtcil tliis nu'tliixl :it tlio Ititeriiational ('(iiiL'ress in l^niuloii,
1881, aixl rlaiins to lie tlic inventor of ilic slioeinakiT's stitcli : " Tlio Surpical Ad-
vantages ot" the Buried Animal Suture," Jour. Aincr. Med. .twir., .Inly '2\, 1888,
reprint, p. <>.
662
DISEASES OF WOMEN.
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 tlie 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
Fig. 358.
Wallich's Chain-ligature :— 1. P, pedicle : ppp, pressure-forceps ; aa, loops ;— 2, ligatures cut,
crossed, and tied loosely.
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
la.st part of the pedicle (6). This does not tear the tissue, and com-
pre.s.ses the whole pedicle tightly. It is only another way of making
a cobbler's stitch.
DISEASES OF THE OVARIES.
663
In dealing with thick pedicles it is also useful to compress them
with Spencer Wells's forceps, so as to form a notcli 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 appeal's inflametl or if the stump contains parts of the
cyst, the cut surface should be cauterized. If in combination with a
\^
Cobbler's Stitch for I.igntioii of Pedicle.
pcdiinctihited tumor we find metastatic masses behind the ])critoneuni,
tlie hitter must be left alone.
H the pedicle is so frial)le that the ligature cuts through, the single
vessels must be se<'ure<l with forceps left in the wound.
After the removal of a large tum(»r which has caused great dis-
tention of the abdomiii.d wall, part of the skin and peritoneum
insid(! of the recti muscles should be trinnned off before closing
the wound.
664 DISEASES OF WOMEN.
Toilet of the Peritoneum. — If adhesions have been torn, and blood
or other fluids, such as pus, oyst-conteuts, etc., have found their way
into the peritoneal cavity, it must be cleaned, the technical term for
which procedure is the toUet 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 flusiied
M'ith 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
thick glass tube. This saline solution comes very near the composi-
tion of serum, and attacks the epithelium less than jilain water or an-
tiseptic fluids. If there is still some oozing, the abdominal packing
with iodoform gauze (p. 186) 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
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. 186). 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. 484).
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 fi)r two days (Kimball's^ 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 com])reased
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
' Oilman Kimball of Lowell, Mass.
DISEASES OF THE OVARTES. 665
a patch. Bleeding from the anterior abdominal wall may sometimes
be arrested by tying the corresponding epigastric artery.
Cauterization has become quite convenient since Paquelin 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, iield 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. 054).
In order to find the bleeding spot, it is sometimes necessary to
enlarge the incision and even to draw out the intestine (p. 565).
The search may be facilitated by throwing light into the abdominal
cavity with a concave mirror, a large })lane mirror, or, still better,
with a portable electric lamp.
Much hemorrhage may be avoided by tying the pedicle as soon as
possible, before beginning to separate adhesions.
CompUcatioHK. — 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. 503). A large myoma may be in the way,
and have to be removed according to circumstances (p. 503, d seq.).
If the ovarian cyst is accompanied by at^cites, nothing should be
done to remove the latter before the cyst is taken away, for the fluid
serves as a diluent for any cyst-fluid that may enter the })eritoneal
cavity.
If the jKitient is afl'ected with an iiinhUh-dl or irnfntJ hernia, its sac
shotdd b(! dissected out, and the thinned and superfluous tissues cov-
ering it be cut away.
Complication with jji-ef/nancj/ has i)een considered above (p. 637).
If the j)atient is not seen l)efore /abor has set in, and an ovai'ian tumor
obstructs the ])arturient canal, the oj)erator should try to ])usii it u))
into the abdominal cavity in tiie genupectoral position — a treatment
which is, however, only applieal)le to small tumors. A large tumor
should be ta|)pe<l from {\iv vagina (j). 640). li it does not collapse
sutlieientlv, an incision may l>e made in the vagina, and the tumor
removed or diminishr'd in this way. If it contains nuicli solid matter,
craniotomy or Cesarean section may be ])referal)le. In the latter case
ovariotomy should l)e added.
J)r(iiii(i</c. — We have seen in the general i)art of this work (]). li>5)
666 DISEASES OF WOMEN.
that the most experienced laparotomists entertain very divergent
views as to the use of drainage. While some look upon it as a fifth
emunctorv, of which thoy are very willing to avail themselves, others
are loth to have recoui-se 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 nmch 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.
Drainage-tubes have to a great extent been replaced by iodoform
gauze, which has the advantage of being soft and of helping to check
hemorrhage. 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.^
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. 526), 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 Avith forceps or an expanding dilator,
until a finger can easilv 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 j)acked Avith 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
tAvelve 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.^ Such tubes cause, however, a
good deal of irritation, make the vagina very tender, and may pro-
duce ulcers, a C(jndition which is successfully combated by injecting
stearate of zinc with a powder-blower into the vagina, after having
' A strong plea in its favor is made by E. W. Cnsliing of Boston, Mass., supported
by Lawson Tait and Bantock, in Annah of Gynecolorfy, Nov., 1890, vol. iv. p. G9.
' H. T. Hanks, "Counter-drainage after Cceliotomv," The PoM- Graduate, No. 4,
1893.
DISEASES OF THE OVARIES. 667
injected a saturated solution of boric acid through the tubes and into
the vagina.
It ought to be distinctly understood that the more perfect asepsis
is, the less drainage is needed ; and except in the conditions enu-
merated it is nuicli better to do without it.
Shock. — The sudden giving out of vitality called shock is very
dangerous, and calls for immediate attention (see p. 224).
Complications during After-treatment.
Shock. — If shock is present after the patient has been brought to
bed, she should be roused (p. 239) and stimulated as just described.
Vomiting. — If the patient vomits, the medicine with hydrocyanic
acid mentioned on p. 224 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 diiferent 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 (p. 241).
As a rule, an ounce of brandy shoidd be added. The whole enema,
in order to be retained, should not be more than six ounces.
If vomiting accompanies intestinal obstruction, calomel is the best
remedy.
Internal Hemorrhage. — After bloody ojicratlons the patient may
be very weak and n-stlcss, with a weak, rapid, and irregular pulse ;
but if tlicrc is no bleeding, this condition will yield to the free use
of stimulants, or injection of hot water into a vein or the rectum or
under the skin (p. 224).
IlemorrliMgc conies nearly always from the pedicle, rarely from
large raw surl'aces. If a (lrainage-tub<> has been left in the abdo-
men, the continuous appearance of pure blood after the tube has
been emptied furnishes the diagnosis. Otherwise it must be made
by the general condition of the patient — weakness; restlessness;
weak, raj)id pulse ; cold, clammy skin ; and swelling of the abdomen.
Then only two sutures should be removed, which will sutHce to as-
certain the |)resence of blood in the abdominal cavity. If it is
found, the whole wound must be reopened, and th(> source of the
hemori"h;i^'e — first of all, the pedicle — looked for. When found, th(>
l)lee(ling is arrested by means of ligatures, and the cavity cleaned
and closed again. If the |)atieMt has lost nnich blood, injection of
saline solution may prove of great value.
TiiiiijX'nitrs with(»iit inflammation is nnich relieved bv the intro-
duction of a soft-rubber rectal tube ; by enemas with turi)entine (,sss
668 DISEASES OF WOMEN.
to Oj), with sulpliate of quinine (gr. v every four hours), or with
infusion of nientha viridis (sij to aquoe Oj) ; by the administration
of tinct. nucis vomicfe or tinct. capsici (V(lv every hour), or large
doses of sul)nitrate of bismuth (gr. xxx-xl) ; by standing the patient
on her head ; by loosening the t<apes crossing the abdomen, draw-
ing up her knees, using faradization, or puncturing the transverse
colon.
Ekvaiion of Temperaixre. — 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 aj)proaching 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. 178) 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, M'hicli sh.ould 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 cui'e 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. 530). If not, the ureter may be cut above
the ligature and implanted into the bladder by intra-peritoueal
uretero-cystostomy (p. 395).
Intestinal obstruction is marked by constipation, vomiting, and tym-
panites. It is often due to adhesions 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. 178) should be given. By using a fountain syringe and low press-
ure (p. 179) several quarts may be injected. Calomel is the best ape-
rient, because it is least likely to be vomited. Tinct. belladonnse 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.^
^ Klotz, Centralblatt f. Gyndk., 1892, vol. xvi., ^'o. 50, p. 977.
DISEASES OF THE OVARIES. 6Q9
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. 529), where they find an excellent soil in blood
and serum. Often the drainay-e-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 ciiance 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
gjive 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 jimral 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 ai)scess has formed around a suture, this should be
removed, the pus pressed out, and the dressing changed daily.
A deep (thscess may 1)C made out by bimamial examination. If it
lies close up to the vatniia, it should be oj)cned and drained from that
point. If not, the abdomen must be reopened, cleaned, and drained
either tiirongh the skin or through the vagina.
J'Jrtijjln/-'^eiii(i of the alxlominal wall is rare, i)ut is of importance, in
so far as it j)redisposes to the formation of an abseess.
Sijoiifaiuoiis reopciiiiir/ of the wound is an unfortunate occurrence
that mav to a great extent i)e prevented by keeping the bowels o|)en,
1)V not removing the sutures too soon (some think liny ought even to
be left in for ten days), and by rej)la('iug them l)y |)laster strips, as
recommended al)ove(p. <)."»2). W it hapjx'us, the j)atient should be
ane-thetized, and new sutures put in. It may be so diflieult to
rej»lace the intestine that it becomes necessary to piuicture it and
670 DISEASES OF WOMEN.
let the gas escape. Before replacing it, it should be washed with the
normal solution of chloride of sodium.
Sometimes a Jistulotis irad loads 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
fistulae 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 (p. 649). Packing with iodoform gauze or marine lint soaked
in balsam of Peru is also often useful. Strong fluids and rough ma-
nipulations must be avoided, as they may make the condition worse
by wounding the intestine.^ 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 this purpose to enter the peritoneal cavity or not. A
rubber drainage-tube or a strip of iodoform gauze is left in for a fe\v
days, 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 the elevated-pelvis posi-
tion, so as to obtain a view of adhesions that implic.ite 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
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. AVheu 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 luitil the sinus
heals up from the bottom.^
'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.
^ An interesting paper on fecal fistulae after laparotomy by A. Palmer Dudley
is found in Amer. Jour. Obst., Feb., 1892, vol. xxv. pp. 145-163.
DISEASES OF THE OVARIES. 671
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 iu cotton batting
and slightly compressed whh 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. The abscess should be opened at once.
3Iental 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. 121 anil 570.)
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 })rotection by
means of an abdominal belt.
If lx)th ovaries have been removed, the patient is, as a rule, sterile.
(In regard to an exception to the rule and its explanation, see p.
581.)
Prognosis. — The technique of ovariotomy has been brought to such
a degree of perfection that in the hands of the most skillful o[)erators
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 (jr j)aucilocular
cyst, a good pedicle, and al)sen('e or easy s('j)arability of adhesions.
Death is commonly due to shock, hemorrhage, peritonitis, or septi-
cemia, to which are added the rarer causes, such as exhaustive sup-
puration, uremia, tetanus, or embolism.^
B. So/ id Ovarian Tinnors.
Solid ovarian tumors are nuich rarer than cystic tumors of the
ovary and solid uterin(! tumoi's. They may be Jibroidfi, papilhyna.'^,
.sarcomas, endothetioinas, carfinomas, 6v tubercuhms.
^ 11. C. Coe ha.s in :i most exc< Iloiit paper in Trnm. Avirr. di/n. Soc, 1S,S9, vol.
xiv. pp. 170-ini, lia.scd on personal observation, disoussed "Death from Vi.sceral
Affections after Ovariotomy."
672 DISEASES OF WOMEN.
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.
Tiiey are smooth, globnlar, 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 — /. 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. 593).
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 mesoarium 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
cystojibromas or fibrocysts. Fibroids may undergo mucoid, fatty,
or cancerous degeneration, or become calcified or ossified or cartilag-
inous. Internal hemorrhage, suppnration, and gangrene may occur
in consequence of torsion of the })edicle or pressure during child-
birth.
Origin. — The fibroma may originate in the albuginea or in a corpus
lutenm.^
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, dysmenorrliea, 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
' 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.
Obit., July and Oct., 1882, vol. xv. p. 561, et se^.
DISEASES OF THE OVARIES. 673
proportions, all the pressure-symptoms described in speaking of ute-
rine fibroids (p. 500) may be developed. As a rule, the tumor is
freely movable.
Diagnosis. — It may be difficult or impossible to distinguish an
ovarian fibroid from o. pedunculated uterine fibroid, unless both ovaries
can be felt, which, of coui-se, 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 arrivetl at.
Progno.s'is. — The tumor may become dangerous by its size. It may
op}X)se 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 puhnonary 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. 510), wliich ought to be performed a.s soon as the tumor
is found.
11. Papilloma.
AVe have seen above (p. 614) that a whole class of ovarian cysts is
chanicterized 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 a.s large as a fist, and extend to neighboring
organs.
Etiology. — Gonorrheal salpingitis has in several cases precedi.d this
formation.
Prognosi'i. — It has a tendency to become malignant.
Treatment. — The treatment consists in early ovariotomy.
III. Sarcoma.
Sarcoma of the ovary is a rare affection.
P<dhol()gic(d Ancdomy. — It may be primary or develop secondarily
in an ovarian cystoma. It is often bilateral. It forms pink tuinore
ranging in size from that of a child's fist to that of a man's head, or
4.3
674 DISEASES OF WOMEN.
may even acquire enormous proportions. It is globular or oval, and
lias 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 timiors, 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
{inyxosarcoma, fibrosarcoma, sarcoma carcinomatoswii) 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.' 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.
IV. Endothelioma (Ackermann).^
Endotheliomas are malignant tumors which start as a prolifer-
ation of the endothelial cells of the blood- or lymph-vcsscls 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.
* I have described a case of sarcoma composed of cysts with transparent walls,
formed of spindle-cells, and containing a bloodv fluid, in Amer. Jour. Ohst., 1881, vol.
xiv. p. 890
^ The name has been used in another sense by Dr. Dixon Jones (p. 564).
DISEASES OF THE OVARIES.
675
V. Carcinoma.
The ovary may be the seat of malullarv, scirrhous, or alveolar
(colloid) carcinoma, the fii-st 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 ca.se the result h ^ carcinomatous cystoma. Any kind of cys-
toma, myxoid or dermoid, may undergo carcinomatous degeneration,
and the liability to this transformation is even considerable (p. 620).
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 l^etween the two (p. 610).
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
iirmness to brain-like softness (Fig. 360).
Fxo. 360.
Carciiionift of Ovary. >
At fii"st the mesoarium I'orms a pedicle, but later this may become
infiltrated, thickened, and hard, and finally the tumor may be entirely
sessile. At an early date JLscitic fluid accunmlates, which is often mixed
with blood ; local |)eritonitis is of f"re(juent occurrence ; and the dcgcn-
' Photograph of Hi)ecimen from mv operation on Mrs. L., in St. Mark's Hospital
on April 12, 1894. ' '
676
DISEASES OF WOMEN.
eration extends to neighboring organs, such as the peritoneum, the
pelvic connective tissue, tlie 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 ei)itheliuni of the Graafian follicles or pouches
extending from the germinal epithelium into the interior of the ovary
(p. 621):
Secondary carcinoma of the ovary is brought through the lym-
phatics, cancerous epithelial cells being carried into these vessels, in
which they cause thrombosis and infection of the surrounding tissue.'
Like other tumors, carcinoma of the ovary may undergo secondary
Fig. 361.
Patient with Carcinoma of Ovary, Ascites, Anasarca, and Marasmus.
changes, especially fatty degeneration, which leads to the formation
of cystic cavities with ragged walls of carcinomatous tissue — a condi-
tion called cydocai'cinoma.
Etiology. — Carcinoma rarely attacks the healthy ovary, while,
as we iiave seen, it often occiu's 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, i)ain, rapid
' This is proved by acttial observation of microscopical specimens from a cantino-
matons tumor of the pelvic floor and the ovaries belonging to it, by M. Dixon Jones,
Med. Record, March 11, 1893, vol. xliii. ^'o. 10, p. 295, et seq.
DISEASES OF THE OVARIES. 677
growth, local peritonitis, ascites, edema of the thighs, and general
marasmus (Fig. 361).
Diagnosis. — It is clistinguished 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 pa]Mlk)ma), obtained by aspiration, contains some-
times large round or pear-shaped cells, with a large nucleus, either
isolated or in groups.^ 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 mouths. 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 })art of the geni-
tal tract most commonly affected by tuberculosis. It may be primary^
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 xinatomy. — Miliaiy tubercles are rarely found. The
affection may be limited to the surface or invade the whole organ.
The ovary is tiien somewhat enlargetl, 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 tiie })eritoneal
cavity, causing peritonitis. The surface of the ovary is commonly
covered with layers of inflammatory exudation and adhesions.
Syuiptoiiis. — The symptoms are those of chronic oophoritis.
l)iagno.'<ix. — The disease can only be diagnosticated, if swelling of
the ovary is c(H)ii)ined with pulmonary tuberculosis or local tubei-
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-o()phorectomy 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 apjx'ud-
ages is still indicated. If it is alli<'<l to a siinilai- afleclion of the
tube and the lUenis, hvsten'ctoinv niav be added ([>. Aid). I^veu
tui)ercular |)eritoiiitis may be cured by the operation. On the other
' (iarri^'it's, Di^ujnoaU of Onifiim f'l/ulK, pp. 9l-it7.
" Dr. (i. M. Tutllc of N»'w York lia.s reported !i case of apparently primary tul)er-
culosis of the ovary in Amrr. ./nin: OImI., .Jan., IH'.H), xxiii. p. OH.
678 DISEASES OF WOMEN.
hand, the operation is contra-indicated as long as the disease spreads
in the kings. If no radical cure is possible, the usual medical and
hygienic treatment is all we have to rely on.
CHAPTER VII.
Oophoralgia.
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. 77). 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 hemiansesthesia of the
corresponding side and hystero-epileptic seizures. Pressure on the
ovary produces, first, cardialgia and vomiting ; next, palpitations, with
frequent pidse and globus hystericus; and, finally, often a hissing
sound in the corresponding eai', pain in the temple, darkening of the
eyesight, loss of consciousness, and convulsions.
AVhile 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.
TreaUnent. — The treatment consists in rest, anodynes, galvanism,
faradization with the secondary current of high tension (p. 247), and
tonic and antihysteric remedies. If the disease is malarial, it yields
to large doses of quinine.' Oophorectomy has sometimes a marked
beneficial effect, but is in many cases fruitless. Desiccated parotid
gland substance (tablets containing two grains each, from tiiree to
six tablets daily) is said to have given far more prompt and lasting
results than other forms of treatment."
' Case of H. C. Coe, Amer. Jour. Med. Sci., April, 1891, vol. ci. p. 365.
'J. B. Shober, Amer. Jour. ObsL, Feb., 1899, p. 175. Tablets made by Armour
in Chicago and Mulford in Philadelphia.
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.
Ma lform ations.
In speaking of the uterus (p. 406) 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 auteversion orig-
inate in too great shortness of the round ligaments.
The peritoneal pouch, which in the fetus forms the ciuial 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 upj)er 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. 60, 280, and 47 Ij.
ClIAPTEIl 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.' Upon vaginal examination there was
found a j)nlsatiiig tumcjr in the ])elvis of the size of a hazehnit,
which was (liminisjie<l by pressure, but refilled again each time press-
ure was discontimied. It gave; a subjective sensation of thr()l)bing.
It was supposed to be due to the use of leeches in the vagina, and
might, perhaps, also be due to childbirth. The treatment recom-
mended is galvanopuncture, with the positive pole in tiie tumor,
or tbrcipressure.
' Mars, Exrcr,,(a MMua. No. 2, Nov., 1891.
679
680 DISEASES OF WOMEN.
CHAPTER HI.
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 tiie different anatomical relations constitute rather consider-
able differences between the two. While in man the veins of the
testis follow an almost perpendicular coui'se, those of the ovary are
nearly horizontal. The spermatic veins soon form a sinjjjle trunk,
whereas the pampiniform plexus in woman communicates freely with
the uterine, the vaginal, and the vesical ])lexus. 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 tiie
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 ])arovarian 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 phlebolitlis. 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. 77).
Etiolof/j:/. — The condition is probably due to subinvolution 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, esjiecially
retroversion and retroflexion, whicii interfere with the free return of
the blood through the infundibulopelvic ligament.
Symptoms. — The most prominent symptom is pain of a ]>eeuliar
dull, aching character, extejiding up the side to the region of the kid-
ney. The pain disappears when the patient is in the horizontal posi-
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).
DISEASES OF THE PELVIS. 681
Diagnosis. — Salpingitis causes a sausage-shaped tumor ; oophoritis
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 ])ermanent 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.^
B. Ci/sts of the Broad Ligament.
Xot every cyst situated in the broad ligament is a cyst of the broad
ligament. We have seen above (p. 619) that ovarian tumors may
develop downward into the broad ligament and even far beyond its
base. A Graafian follicle or a corpus lutcum 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 arc 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 sudi cysts may develop in it, it is no less true that they
may develop in any other pail of the broad ligament. The schematic
figure .362 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 })()lycvstic tumoi-s
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.
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 nuiscle-fibei's. The wall is com-
posed of the j)eritoneum with its endothelium; a layer of connective
ti&sue containing sonic plain muscle-fibers; often glands, which do not
ojicn into the interior; and very few blood-vessels, which gives it u
' Tlie (lisca'^c has been dt'scrilu'd, with report of fmir rasos in wliicli laj)ar()tomy
%vas |MTforinc<i Hiicccs^fuliy, hy A. I'. Dudley of New York in tiie X. )'. M(<l. Jour.,
Ann. 11 and is, ISSS — a j)a|)er tliat lias heeii srvcnly, and in my ojiinidu ratlier
unjiiHtly, criticisefl by Coe in Amfr. Jour. Ohsl., May, ISS't. vol. xxii. ]>. 501. 1 have
nivseir()j)erate(i on a ea.se ot'tliis kind— Mrs. JI., St. .Mark's Hospital, l"el). 1!», 1S".»4.
The left broad ii),'aineiit tornieii a eon^donieralioii of torlnous dark bine, almost black
vein.H, eacli as thick as a lead pencil, situated between the uterus and the tube.
682
DISEASES OF WOMEN.
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 lie below, in front of, or behind the peritoneum. They may
become so large as to be much more abdominal than pelvic tumors.
Diagram of the Structuresinandadjacentto the Broad Ligament (Doran) : 1, framework of the
Eareut'hyma of the ovary, seat of 1 a, simple or glandular multilocular cyst; 2, tissue of
ilum with 3. papillary cyst 1; 4, broad-ligament cyst independent of parovarium and Fallo-
pian tube : r>, similar cyst in broad ligament, above the tube, but not connected with it;
6, similar cyst developed close to 7, ovarian fimbria of tube; 8, the hydatid of Morgngni;
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.
The Jlilid 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 laro;e
and small corpuscles (Figs. 331, 332, and 338, pp. 611, 612). 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
the ligament forms a pedicle, which may even become twisted, an
accident that may lead to gangrene of the tumor.
These tumors are found in the period of sexual maturity. They
grow very slowly.' They do not impair the general health, and give
rise to no symptoms except by their bulk.
* This theory of the origin of these ovarian cysts is not generally admitted.
■•"Many years ago I assisted in aspirating one that had been tapped five years
before by W. L. Atlee, and in that tinie had not become larger than the uterus at
the end of six months' gestation.
DISEASES OF THE PELVIS. 683
Diagnosis. — A small cyst of the broad ligament may be felt in the
t)elvis 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 veiy
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 ^ : 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 j)edicle 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 j)acked with iodoform gauze, and will fill by granula-
tion, l)ut, as a rule, only with suppuration. If the tumor cannot be
enucleated, the whole sac may be fastened to the abdominal wound
[rnarsiijjid/irjifion). Redundant tissue is, of course, cut away in all
these procedures.
Anotlier 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 tajjpinr/ or aspiration, and their
innocuous nature and the slowness to refill of most of tliem are indeed
great indu<'ements to use that kind of treatment ; but since it has l)eeu
discovered that some of them are papillomatous, and the radical ope-
ration in most cases easy and siife, extirpation is preferred by most
gynecologists.
It' the ovary and tube are healthy and j)!acetl so that they need not
be removed, they should be left behind.
Of late the total extirpation or partial resection of the cyst by the
'Garrigues, iJiaijnoxiK, etc., j)p. 49-56.
684 DISEASES OF WOMEN.
vaginal route has been recommended.* Small tumors of this kind can
easily be removed by anterior colpotomy, but as to large tumors the
writer feels the same hesitation as expressed (p. 641) in regard to the
extirpati(m of adnexial tumors by Pean's method. \Ve must bear in
mind that those who invent or are particularly identified with a cer-
tain method incline to give it the widest possible range of application.
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. 274) 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
fibrosarcoma. In one case the lymphatics were much distended
[fibroma lymphangiectodes) .
The affection is much more common on the right side than on tlie
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. 459) that inflammation of the sacro-uterine
ligament is a chief cause of anteflexion of the uterus. One or botli
ligaments are swollen, tender on pressure, and become shortened
through cicatricial contraction.
The usual antiphlogistic treatment, especially ichthyol glycerin,
tincture of iodine, hot douche, and tiie galvanic current, is indicated.
DISEASES OF THE PELVIS. 685
and often yields good results in fresh cases ; and even a chronic short-
ening may be overcome by means of vaginal packing (p. 182).
Since these ligaments form the chief support of the uterus (p. 55),
their loss of tonus and elonf/ation, usually due to childbirth, are prin-
cipal factors in the production of prolapse of the uterus (p. 478). The
loss of tonicity may perhaps l)e 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. 481).
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 coui*se in tiiis 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 intrajjeritoneal hcmorrliagc, but most writers class it
with the se(;oud 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 lieinafocclc, but it luis 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 ])elvis, and the abdomen. This condition we
designate as henidfoinft, but it is also called extrnperitoneal hematocele,
false iiematocele, pseudohematocele, or thrombus. (( "oinpare Throm-
bus of the Vulva, p. 295.) ^
A. Intra prritoncal Ilcmovrliage.
If a large amoinit of blood is j)oured nipidly into the healthy peri-
toneal cavity, it meets with no resistance, tin; intestines are pushed
asid(,', and the abdominal wall becomes distended,
J'Jfiofof/if. — Most cases of abdominal hemorriiage are traumatic and
due to rupture of" the liver, or they may be caused by the rupture of
an aneurysm of" the aixlominal aorta or the celiac axis. In gyneco-
' Rf)SfnwaHscr of < 'levcl:in<l, ( )hi(>, unites the two last condition, under the name of
circiimsrrllxfl or litiiitcd, hiinitnluii/r, opposed to tlie lirst, whieh lie ealLs fr<x linnai-
rhage [Trans. Amer. Obnldriciurui and (•'i/necoloyi.fl.", iS'J.'Jj.
686 DISEASES OF WOMEN.
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 tlilated 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 ; faintness ; 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 ])atient feels that she is dying.
Diar/nosis. — We have only these rational symptoms of internal
hemorrliage 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. — Tlie 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
otiier 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 roof in places is
finger-thick and shuts it off from the peritoneal cavity.
^ Paul Segond, Revue de Gynecologie et de Chirurgie abdominale, 1897, No. 2, p. 235.
DISEASES OF THE PELVIS 687
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 preguaucy, 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 mre disease. It is found at the
age of sexual maturity, most frequently in persons between twenty-five
and thirty-six yeai'sof age. We may distinguisli 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. 587). A hematoma of the broad ligament
may secondarily burst, and ])onr 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. 468), or the adiie-
sions may give rise to a bleeding in their interior by the same process
as that which in ])achymeningitis leads to the formation of a hema-
toma of the dura mater. This condition is called hemorrhagic pachi/-
peHtonitis.
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 weiglits, violent exercise, coition,
and exposure to cold during the menstrual period may have the same
effect.
Systemic diseases, sucii as scarlet fever, small-pox, purpura, and
icterus gravis, may cause such changes in the composition of the
bloo<J, and weaken the walls of the pelvic blo<xl-vftssels so much, that
tliey give way and allow the bkxKl to escape into the peritoneal cavity.
Hyiajdomx. — Sometimes there are premonitory symptoms. Jf the
hematocele be due to ovarian or tubal disease, there will, as a rule, be
a history of dysmeuorriica and ])ain in the pelvis. If the genital
canal is cIose<l, the patieut 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
688 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, ou the other hand, outside of
the menstrual period there may come a bloody discharge from the
vagina.
This stage of hemorrhage is followed the next day by one of
inflanmiatory reaction, with a chill, a pulse beating 100 to 140 a
minute, and a temperature of 102°-104° F. But this stage is like-
wise of short duratiou. As soon as the fluid is well encysted pulse
aud 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 tiie 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 fing-er in tiie
rectum, one m the vaguia, 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. 689
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 iiot 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. Pelviperito-
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
retrofiexcd 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 nmch 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 vitidity.
Treatnund. — During the first stage the indications are to arrest
hemorrhage, ('()ml)at 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 tiie 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
preferrc<h
In \\\(i inflammatory stage ice-bags, hot-water injections, and opium
are indicated.
In the third stage absorption sjiould l)c promoted by the use of
Priessnitz's compress (p. 195), ichthyol, iodine (internally and exter-
nally), merciuy ointment or j)laster, and the galvanic current, with a
large negative pole in the; vagina and Kngelmann's electrode (p. 248)
on the abdomen. The vagina should l)e l«'j)t clean by means of an-
tise|)tic injections, in order to avoid ])()>sil)l(' inf(>(!tion.
In fresh cases all operative intcsrfi'rence is ai)S()huely contra-indi-
cated. If there is any likelihood of a fluid collection in tiie pelvis
44
690 DISEASES OF WOMEN.
being a hematocele, the doctor should abstain even from a puncture
with a hypodermic syringe. Even it' 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 })acked 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
bland ness).
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. 511).
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.
A nother indication for operation is a very slow absorption. If the
collection is large, and at the end of a month no perceptible diminu-
tion lias 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 rela]>ses. As in such a case
we may expect some bleeding, the sac should be tightly packed with
iodoform gauze, M'hich 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 transperitoneal. 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
shonld be enlarged and tamponed with iodoform gauze for twenty-
four hours, until adliesions 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. 691
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 tiie side of the vagina.^
Pathological Anatomy. — The blood is situated in the loose connec-
tive tissue between the two layei's 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 beiiind 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, Mith
the formation of a secondary hemat(x;ele, or it may suppurate, so as
to become a pelvic abscess. (See Cellulitis.)
Etiology. — Since the connective tissue of the |x?lvis becomes laxer
by pregnancy, multiparous and pregnant women, as well as pucrperae,
are more apt to l)e affected. A varicocele or the fetal sac in tubal preg-
nancy may rui)ture in such a place that the blood escapes between the
layei's of the broad ligament, and not into the peritoneal cavity. Ex-
cessive coition may be the exciting cause. The accident ha])i)ens
most frequently during menorrhagia or the pseudo-menstruation fol-
lowing 0('>phorectomy and ovariotomy. The patient may be in j)erfect
hetilth.
Symptoms. — Suddenly the patient feels ])ain in the ])<'lvis, with
faintness and rapid, small j)ulse, but the attack is less alarming tiian
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 ])ushes over
to the opj)osite side and upward. If the affection is bilateral, the
uterus is lifte<l up. The tumor is in close comiection with the uterus,
' Acforfling tf> W. A. Freiind (Gyii'ikoloifi.'^chf Klinik, Strasburp, 1885, vol. i. p.
21tM till" pt'Ivic liomatoiiia may in iioii-piierperal cases form lu'twecn tlie rcftiim and
the vapina, and in pufrpcral cascH exItMid fmm tlie sides of the vatfina to the ante-
rior alulominal wall, the kidneys, and into tlie mesentery, vilhout enlirinc/ the broad
liyamenl.
692 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 etlusion 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 cellulitis 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.
Proc/nosis. — Xearly 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
tlu'ough the abdominal wall, the edge of the sac, the peritoneal cover
of the uterus, the other edge of the sac, and the otiier 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.^
Galvanopuncture through the vagina, with a fine platinum-pointed
needle connected with the positive pole, and with a current of 50
milliamperes, used from five to ten minutes, has been recommended.
In a small hematoma one application suflices; in larger it may be
repeated in from three to six days.^
* Marcus Rosenwasser of Cleveland, O., Annals of Gynecology, March, 1891, vol.
iv. p. 3-2o.
2 A. H. Goelet, N. Y. Med. Record, March 8, 1890, vol. xxxvii. p. 279.
DISEASES OF THE PELVIS. 693
CHAPTER VII.
Perimetric Inflammation.
By " perimetric inflammation " is undei*stood the inflammation of
the pelvic j>eritoneum, tiie 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 Avith 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 tiie 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 ])ost-mor-
tem examinations, has been greatly extended and corrected by the
numerous laparotomies that have been performed in these conditions.
Thus we describe separately pelvic peritonitis, pelvic cellulitis, 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, tlie 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
connef;tive tissue ; but since these names are not very characteristic in
regard to their derivation, — jicri meaning "around," and j>«;-a, " at
the side of," — since their sound, especiially in Englisii, 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 l>e more practical to j)reserve the woi'ds " peri-
tonitis" and " cellulitis," although the latter leaves much to be desired
from an etymological stan(lj)oint, being a combination of a I>.atin root
and a Greek suflix, and tiic root itself being a remnant from the time
when what we now call connective tissue was di'sjgnated as cellular
ti.s.sue.
Of all the j)erimetric inflammations, peritonitis is In- far the most
common.
Patholof/ical Annfoini/. — Different forms of ])elvi(' pei'itonitis hnve
been distingin'shcd — nanx-ly, the serous, the (id/iesive, and the snpjni-
ratire — which arc sonietimcs only dilTcrcnt stages of the .same disejise.
The inflammation mav be acute or chronic.
694 DISEASES OF WOMEN.
In nearly all these eases 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. Fii'st the
peritoneum becomes injected, its endothelium is lost, and serum is
secreted from the denuded surface. The neighboring organs are
agglutinated by a yellow fibrinous 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
foasse, 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,^ 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 sui)erior surface of the bladder, or the pelvic wall. Serum may ex-
travasate 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 adliesions 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,
' John Williams, Obst. Trans, of London, June 3, 1885, vol. xxvii.
DISEASES OF THE PELVIS. 695
anteflexed or anteverted. and bound to the bladder. The condition
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 the tubes ; or a
serous exudate may in the course of time, instead of being ab-
sorbed, 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
wiiole 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 j)us. 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 In- a complete partition of varying tiiickness.
Tills intraperitoneal al)scess may open into a hollow organ, most fre-
quently the rectum, less often the vagina, and rarely the bladder. It
mav rupture into the peritoneal cavity, which, fortunately, is a rare
occiu'rence, and it may find its way out througli the peritoneum, the
connective tissue, and the skin above or below Poupart's ligament, or
burst in the gluteal region, whicii it reaches tiu'ough the great sacro-
sciatic foramen.
Often the abscess is only partially emj)tied through a long, narrow,
and devious <'anal, surrounded by indurated tissue ; or it 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 Jier an invalid or
causes death by exhaustion.
In contact with the purulent collection the muscular fibers of the
uterus are aj)t to undergo faltv degeneration. The inflanunatlon may
follow the lymj)hatics through the lnfun(lll)ulopelvic ligament up to
the diaphragtn, and cau>e dia|)hragtiiatic pleiu'ltis ; but this is of the
dry varif'ty and of minor importance.
696 DISEASES OF WOMEN.
Microscopical investigations* 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 comiective tissue (adhesive peritonitis),
or, if the connection between them is interru})ted, form pus-corpuscles
(suppurative peritonitis). The latter is due to the influence of gono-
cocci, staphylococci, or streptococci. Gonococci cause it most fre-
quently. The other microbes may be introduced by unclean fingers
and instruments ; since they circulate in the blood, they may be due
to rupture of vessels caused by injuries, or they 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 not uncommonly contain miliary ab-
scesses.
Gonococci do not affect the lymphatics, but travel along the
mucous membrane of the uterus and the tubes, while stajjhylococci
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 found extensively only in
puerperal cases, and are transmitted in the same manner as the
staphylococci.^
Etiology. — Pelvic ])eritonitis may develop in the fetus. In adults
it is in most cases added to preexisting disease of some pelvic oi'gan,
especially salpingitis. A serous peritonitis may accompany purulent
salpingitis, for which an explanation may be sought by sup])osing 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, dis})lacement, 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 ])erit()nitis is usually propagated from the same affection
in the tube. It is commonly preceded by simple })eritonitis.
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 mi(;robes.
Traumatic peritonitis is often brought about by gynecological treat-
ment, such as the passing of the uterine sound, application of caustics,
' Dr. M. Dixon .Jones, Medical Record, Mav 28, 1892, vol. xli. p. 599.
* W. K. Pryor, Amer. Jour. ObsL, May, 1891, vol. xxv. p. 603.
DISEASES OF THE PELVIS. 697
curetting, intra-uterine iujectious, teuts, stem-pessaries/ incision
of the cervix, or traclielorrhaphy.
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 fingers 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. Slie 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 com])lains of rectal
and vesical tenesmus. Her face has an exjn-cssion 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 tlie 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
disappeai's, and the uterus may regain its normal mol)iIity. In other
cases induration and adhesions remain, and the uterus contimies more
or less immobile. In other cases, again, recurring i'cvcr, chills, night-
sweats, and a yellowish hue of the skin indicate the formation of ])us ;
but all these sym])toms may be absent and, nevertheless, the exudate
l)Ccome purulent. Sometimes the transformation is marked by an
extension of the inflammation up into the alxlomen, l)y the oeciu'rence
of persistent diarrhea due; to ulcerative (Miteritis, or by bronehoj)neu-
monia with mucopuruk'nt expectoration.
WiiiJe the above deseri])tioii aj)])lies to most ca'^es of acute pelvic
peritonitis, there are others that pi-esent some jHvuliarities. Tims
th(! temp<'ratnr(! may be normal, (»i' even sui»noi-mal, or fluctuate be-
tween a high and a low mark ; which ai'c bad signs. Pain and tumor
may be al>seiit in particularly dangerous eases. The tumor may fill
' I have described a case of tliis last kind in Awrr. Jour. Obat., 1S70, vol. xii.
p. 7 06.
698 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 maybe 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 coUca 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. 686), whereas peritonitis takes an opposite course. Hemor-
rhage may take place into a serous pseudocyst, but the red blood-
corpuscles are then chauged into pale spherical bodies, while in hema-
tocele the fluid is pure blood with well-preserved or shrunken blood-
corpuscles. In cellulitis 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 situatetl 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 oophoritis the ovary
may i)e 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 tiie uterus. In cases of long
standing the tube, may, however, be so distended as to fill the pelvis,.
DISEASES OF THE PELVIS. 699
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 oop/io^'a/'^ia 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, aflected.
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 mucli 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. 087). Intestinal adhesions may cause constipation, alternat-
ing with diarrlica, or give rise to occlusion of the bowel. Pressure on
the nerves of the pelvis may cause sciatica or reflex paralysis. Steril-
ity is very conmion, the ovary being covered with a false membrane
tliat prevents the ovum escaping, or the tubes l)elng sealed by adhe-
sions. If impregnation takes place, there is danger of the ovum being
arre.ste(l 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.
Trcfd/iirnt. — In regard to prophylaxis the reader is referred to
■what has been said in speaking of Salpingitis (p. 5G0). "^flie ])atient
nnist lie fpiietly in bed, and be kept on fluid diet (p. 240). Often a
pill(»w 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 apjilied over
the uterus, or, if cold is not well borne, a hot ])oulti<'e or.-tiipe(p. 195)
may be substituted. Frequent hot vaginal injections should be ordei'ed,
to which in infectious cases antise|)tics should be added (p. ITd).
Heat may be us<'<l continually by combining the ])oultice on the
abd(»men with one in the va<;;ina. or j>lacing a colpenrynter with hot
water in the latter. Pain should be subdued by opiates. If it is
severe, it is charitable to iK'gin with a hypodermic injection of I to
700 DISEASES OF WOMEN.
1^ of a grain of morphine. Later, the drug is given by the mouth in
doses of ^ of a grain, rej)eated often enough to keep the patient com-
fortable, for which purj)ose in most cases not nmch is required,^ or
suppositories with | grain of pulvis opii are administered by the rec-
tum every two or three hours.
I prescribe in tliis as in all inflammations 5 grains of quiniue every
lour houi*s, not as an antipyretic, but as an antiphlogistic. If the
tem[>erature rises above 102° Fahr., antipyretics (p. 245) are indi-
cated. Bacteriological researches having shown that bacilli find their
way from the intestine, and change a comj)aratively harmless simple
peritonitis into a dangerous septic one, it is a Avise precaution to keep
the bowels open from the beginning with enemas (p. 178) 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, Nvhen spontaneous pain and fever have ceased
and the tenderness is diminished, — the patient is allowed more sub-
stantial food, and Priessnitz's compress (p. 195) should replace the
ice. A few days or a week later the abdomen should be painted with
tincture o£ iodine, folloM'ed by a glycerin compress (p. 196). AVhen
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. 174), and combined with pledgets with ichthyol-
glycerin (p. 182), 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. 248).
faradization with the high tension secondary current for ten minutes
every day (p. 247), massage (p. 199), warm entire baths, sitz-baths
(p. 196), 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
Kreuznach, Franzensbad or ]Marieni)ad 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. 169) from the
' In this respect, as in many others, pelvic peritonitis differs from general peri-
tonitis, in which often enormous doses are not only well home, but heneficent. (See
Garrigues, " The Opium Plan in Puerperal Peritonitis," N. Y. Med. Jour., Jan. 24,
1885, vol. xli. p. 98.)
DISEASES OF THE PELVIS. 701
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. 240) ; 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. 182), which may help to stretch adhesions and
further their absorption. The internal use of resolvents (p. 242) has-
tens absorption, and an abdominal belt (p. 199) often gives comfort
by removing pressure from the inflamed peritoneum.
PelviG Abscess.^ — 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 Mith 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 and it is within reach, a sound should be introduced through
the opening in the rectum, bent well down against the vaginal roof,
and a counter-incision made there, through which a drainage-tube
with wings may be drawn, and left until the cavity is closed. It is,
of course, kept clean witli daily injections of antiseptic fluid. If
the rectal opening cannot be felt, the abscess cavity is entered from
the vagina, as if there w<>re no communication with the int(>stine.
More rarely tlie counter-opening is made in the abdominal wall.
If tlio purulent collection is near tiie vaginal roof, it is best to
make a larg(! ojx'uing, so as to be sure to have a free outlet and be
able to insert a drainage-tube. Special foreejis have been made with
which the abscess may be opened and the drainag(>-tul>e carried in.^
This method is simple and effective, and, as a rule, successful, but
has the drawback that one is never sure of not woiniding a blood-
vessel or the intestine. It is much safer to make a transverse in-
cision beliind the cervix, separate the tissues bluntly from it, per-
forate the abscess wall with my blunt ])erforator (p. 199), exj)and
.lltlit'tl 111 iinj iiiijT^ \fi mi: t/i'<irV,
'' Dr. I'afhe Kriiincl has (Icscrihtd aiui (K-lincilcd one in .V. }'. Mid. Rvcord Marc h
19, 18<J1'. f
702 DISEASES OF WOMEN.
the instrument, enlarge the opening by means of Boldt's blunt
dilator, and insert a sky-rocket drainage-tube (p. 193). If there is
any bleeding, the cavity is tamponed with iodoform gauze, which,
if the bleeding is not easily checked, should be steeped in diluted
liquor ferri chloridi (1 : 10). The vagina is then tamponed with
cotton wrung out of creolin. On the third day a double soft rubber
drainage-tube with cross-bar is inserted instead of the gauze in the
cavity and led out through the vulva. This allows us to inject the
cavity with an antiseptic fluid without hurting the patient. The
tube is removed after two or three weeks, or, if it has been fastened
with silver sutures, when these cut through, which happens from ten
to fourteen days after their insertion. Thereafter the tract should
be washed out with iodized water, beginning with tinct. iodi oj-
Oj, and graduaily increasing the strength till all secretion ceases.
The injection is made with a double-current uterine tube, and if
possible repeated daily.
This operation has to a great extent replaced laparotomy, which
in cases of suppurative pelvic peritonitis is particularly dangerous.
It is especially indicated in puerperal cases, in M'hich the patient's
vitality is so low that she cannot stand the shock of laparotomy or
vaginal hysterectomy.
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 nmscles (Petifs triangle). Here
a vertical incision is made, Avhich leads to the external border of the
quadratus lumborum muscle.
If there is reason to believe that the appendages are aflPccted, and
the patient's general condition warrants the performance of a severe
and tedious operation, the choice lies between laparotomy and vaginal
hysterectomy. The former has the great advantage of allowing tlie
operator to see, of giving him room to tie bleeding vessels, to remove
the a])pendages if they are found to be the source of the sujipuration,
and to empty se])arate ])us-foci wherever they may be, and of pre-
venting subsequent infection. Theijjus should be aspirated and the
DISEASES OF THE PELVIS 703
abscess-cavity washed out with antiseptic fluid before opening it.
Even then the place where the incision is to be made should be sur-
rounded by sponges or gauze pads in order to catch the contents.
If the abscess unfortunately bursts, and pus enters the peritoneal
cavity, it should be wiped oif with gauze pads, and a drain of iodo-
form gauze be carried from the contaminated part through the wound
in the abdominal wall or the one in the vaginal roof. But if the
pus has spread widely among the intestinal knuckles, the cavity
should be flooded with a warm solution of salt (p. 531) or thymol,
or Avith Thiersch's solution (p. 218). If possible, 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.
If both appendages have to be removed, it is best to remove
the uterus too, either by the transverse supravaginal amputation
(p. 517) or Faure's method of total extirpation of the uterus
(p. 568).
Even when laparotomy is performed, it may be found advanta-
geous to open the abscess above Poupart's ligament by lifting the
peritoneum and getting in from behind, so that the abscess does not
connect with the peritoneal cavity.
It has been advised to o[)('n 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 ap})licable to both abdominal
and vaginal incision.
If the al)sccss is adherent to the anterior wall of tlie abdomen, a
vertical incision is made over the most prominent ])()int. If ])os-
sii)le a count(!r-o|)ening is made in the vagina, and under all circum-
stances drainage is established through the openings made.
Of late, laparotomy has to a great extent been rejilaced by vaginal
hysterectomy and, if possible, removal of the a|)peu(lages. If tiiese
cannot be removed and contain pus, they .^-hould be incised and
drained thr(»ugh the vagina. This metliod pn'seuts the advantages
that the |)rotecting partitioii which nature has j)laced between tlie
abscess and the u])|)er part of the peritoneal cavity need, perhaps,
not be broken, and that there is established free drainage through tlu»
vagina. It was indeed for large, bilateral |)urulent coUec^tions in
the pelvis that Pean invented his method of I>eginning with vaginal
hysterectomy. On the other hand, the removal of the uterus does
not always succeed, and still less that of the appendages. There is
also considerable dan<;er of woundintr the intestine or bladder, and
704 DISEASES OF WO.\fEN.
tlie parts are so little accessible between the hemostatic pressure-
forceps fillinp: the vapna that repair becomes impossible. Often the
removal of the uterus is facilitated by morcellation. (Compare
Uterine Fibroid, pp. 494-502.)
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 sacrotoray ; but none of these allows the
operator to explore the pelvis to any great extent, and still less
to remove diseased tissues or organs, as well by laparotomy or
vaginal hysterectomy.
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^), 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 either by implantation of the upper end into the
bladder (p. 395) or by uretero-ureteral anastomosis (p. 650).
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 fistulse 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^ 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
* A. H. Buckmaster, "Pelvic Abscess," Brooklyn Med. Joiir., April, 1891.
2 R. Cupri siilphat., \ ,. „.
Pluinbi sulphat., )' "" ^'^-^ '
Liq. plurabi subacetat., 30.0 ;
Aceti, 200.0.— M.
DISEASES OF THE PELVIS. 705
the sole aim of breaking up adhesions (compare Salpingitis, p. 563).
If it is possible to save the uterus and one set of appendages, it
should be done (pp. 514 and 569) ; but if the tubes and the uterus
are the seat of suj)pu ration, it is best to remove them, as the source
of the suppurative peritonitis.
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. 95) 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 inflanmiation 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 })rone to become inflamed ; but, as a rule, we have
only clinical evidence of its existence. Since the patients usually
recover, we have only few auto})sies 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 Met bridge, and in whose pelvic connective
tissue a large al)sccss formed, while the })eritoncum was entirely free.*
In this case certainly no ])uerj)eral influence could be invoked, nor
could the cellulitis l)e attributed to uterus, tubes, or ovaries.
Some gynecologists exj)ress themselves as if the disease did not
concern tliem when it is connected witii childbirth and abortion ; but,
even if they do not practice obstetrics, they are very likely to be called
in when an ojx'ration has to be performed, and science is one inde-
pendently of the limits witiiin wiiich the j)hysi('ian may find it con-
venient to confine his work. Jiut, even indej)endently of puerj)eral
influences, celhilitis exists, and if we do not see it in laparotomies as
often as we find ])eritonitis, it is for the simple reason that few lapa-
rotomies are j)crf()rmed when the inflammation is limited to the pelvic
connective tissue.
' T. 11. Burclianl, "Pelvic AItw-csr in tlie Male," piipcr read before the X. Y.
Academy of Medicine, April 15, 1880. *
45
706 DISEASES OF WOMEN.
Cellulitis not only exists, but it is a rather common occurrence,
and useti especially to be so before antiseptic midwifery and sur-
gery were so nmch 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 ijeritoneuni
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
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 Avith 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 sej^tic
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 2'>uerperal 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,
Diu'ing 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
DISEASES OF THE PELVIS. 707
it is only in the course of time that these separate foci unite into one
large abscess-cavity. As to tlie 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. 695). 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 i)eritonitis being, as a rule, due to simple extension
of the inflammation to the peritoneum.
C(!llulitis often leads to uterine displacement, cicatricial retraction
of the sacro-uterine ligaments causing anteflexion (p. 458), and that
of the broad ligament lateroversion (p. 478).
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
abscesses, and fistulous tracts. It may also be an originally chronic
cirrhosis (atrophic chronic cellulitis), which will be described later.
Etiologi/. — Acute cellulitis is not found in childhood, and is rare
after the menopause. It is confined to the age of sexual maturity, and
es]>ecially to the jnierperal state.
Puerperal cellulitis may be due to a tear in the cervix in an other-
wise normal labor ; but is especially caused by obstetric o])erations,
such as forcal dilatation of the cervix or the extraction of the child
with forceps through a narrow ])elvis. It may join inflammation of
the uterus, tubes, and ovaries. Sometimes a hematoma — puerj)eral or
non-puerperal — is first formal, which later supj)urates.
Non-puerj>eral 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-pueri)eral hematoma. But, finally, all these cases
are due to infection, and the dill'erence in their course depends on the
difl'ercnt kinds of microbes at work, es})ecially the difterence between
common bacteria of putrelaction and specilically pathogenic micro-
cocci.
Cellulitis may also be brought on by exposure to cold.
Syinptoiiui. — The sym[)toins an; nuich like those of peritonitis, but
with certain differences. The i)atient may have; a chill; there is a
rise in temperature; her [)ulse l)e('omes fre<juent ; her tongue is
furred ; she feels weak ; she has no a|)petite ; she has pain in the lower
part of the alxlomen, and, perhaps, vesical or rectal tenesiinis ; but the
708 DISEASES OF WOMEN.
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 iind heat, swelling, and considerable tenderness. If
the broad ligalnent 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
{iwsterior 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.
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. 698) 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.
Retrojja'itoneal 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 lias been said above about the treatment of
peritonitis (p. 699, 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 antise])tic
midwifery and surgery. Slowly dilating tents should, as far as possi-
DISEASES OF THE PELVIS
709
ble, be discarded, and be 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. This injection can easily be administered
through Frost's vaginal syringe (Fig. 363), which plugs the vagina
and has an efferent tube leading 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 warm vaginal
injections.
When pus begins to form in several foci, it is best to give them
time to unite before opening the abscess.
If an abscess forms between the uterus and the bladder, it must
be opened very cautiously by anterior transverse colpotomy, enter-
ing the space between the bladder, the vagina, and the cervix with
Fig. 363.
Frost's Vaginal Syringe.
the finger and blunt instruments, enlarging the opening cautiously
with my blunt expanding dilator, and draining with a rubber tube or
iodoform gauze.
An abscess in the broad ligament may be reached l)y ])artial exci-
sion of the uterus.' First tlic cervix is removed, and tlien so much
of tlie body cut away that the finger can be introduced into the
abscess-cavity. Hemorrhage is controlled by liemostatic fi)rceps,
wliicli arc left in j)la('e for forty-eight hours. This method would
only be availubh' in women with a hirge vagina ; and tliis muti-
lating oj)eration may pr<)bal)ly l)e avoided l)y ap])roaehing tlie abscess
either bv posterior or anterior colj)otoniy, oj)ening it, and enhirging
the opening as described al)ove ()>. 701 ).
Some? go <'ven so far as to perform total vaginal hysterectomy in
order to reaeii a purulent collection in the pelvis, whether situated in
the conne(;tive tissue or elsewhere.^ It was doubtless a great progress
' Landau, Cmlrnlhlnll fiir G)/iiii/,»l(i'ilr, 1802, No. 3-5, vol. xvi. j). CiSO.
'' lY-an, Hulhtin (k V Artulrmir ,1,- Mdlrrim-, No. 27, 1890 ; Sok<'11<1 " I>e I'JIy.sti'rec-
toniie vaginale dans le Traitt'inent dts Supjuiration.s pelviennes," Revue dc C/iiniryie,
1891, No. 4,
710 DISEASES OF WOMEN.
when P6an in 1890 iutroduocd vagiual 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 fote, and the vagiual 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. 703.) In regard to the technique
the reader is referred to the description of vaginal hysterectomy by
the clamp method (p. 510).
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.^
Chronic Atrophic Cellulitis? — It consists in a cirrhotic contracti<)n
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
metritis. 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 Mhich
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 diifuse 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 ])hleboliths. 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. 65) is covered and inter-
spersed wnth 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 Icucorrhea. Chlorotic
women with hypoplasia of the genitals and the circulatory system are
particularly predisposed to it.
Symptoms. — Patients aifected with chronic atrophic cellulitis have
a decided propensity to masturbation^ with indifference, or even aver-
^ A. H. Buckmaster, Brooklyn Med. Jour., April, 1891.
' This disease has heen described by Wilhelm A. Freund in Gijnak. Klinik, vol. i.
pp. 239-326, hftrassburg, 1885.
DISEASES OF THE PELVIS. 711
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. 437), and always
present hysterical symptoms, among others copiopia hysterica (p. 265).
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. 374). The many reflex neuroses are treated
as hysteria, especially with nitrate of bisnuith, 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 woVse.^
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
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 afl'ection following secondarily after 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 nuist not be confounded
with pldcbitis, is often much relieved by lifting tlie uterus with a
pessary, and thereby giving a straighter course to the veins.
Pelvic phlcliitis blends always with cellulitis, and clinically they
cannot be distinguished.
D. Pelvic Li/mphancjitis and LympliadenHis.
In the section on Anatomy (p. fil), we have seen that the uterus is
exceedingly rich in lymph-vessels, uniting in tnuiks which traverse
the broad ligaments and lead to the different glands in the pelvis.
The lym])hatics from the upper two-thirds of the vagina go the same
way, while those from the vulva and the lower third of the vagina go
to the sup(TficiaI inguinal glands, that communicate with tlu; deep
inguinal glands, from which other vessels go to the external iliac
glands. Tlios<' from the tube and the ovary traverse the broad liga-
ment, and go through the int'uudibulopelvic ligament to the lumlxir
glands.
' 111 thisroniu'ction it is<]uito ititon'stin},' that ]"rcun<l states tliat in Strasshiir;,' tliey
do not see the attacks (ieseril)e(l liy Chareot in I'aris — an experience wiiich is shared
by many others in otiier j)hici's.
712 DISEASES OF WOMEN.
The inflammatiou may extend from any part of the genital tract
into the broad liorament and the peritoneum, causing lymphangitis,
lymphadenitis, cclhilitis, or peritonitis.
The lymphatic vessels jilay a very important part in the propaga-
tion of infection in the puerperal state,^ 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. ]\lany autliors do not mention
the affection at all ; others have little to say about it or are doubtful as
to its existence. In an extended gynecological practice I have met
with only one or two cases. But tlie disease having been described
by such excellent observers as Courty, Championniere, Munde, A.
Martin, and others, each of whom claims to have seen, if not many,
at least a certain number of cases, I 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
Mund^ has found at least twenty^ on the posterior surface of the
uterus, and ]\Iartin speaks of glands in the broad ligaments forming
rows like strings of pearls of moderate size.^
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, the obturator gland, the inguinal glands, the 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 Mhich 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
* See Garrigues, "Puerperal Infection," Hirst's Amer. System of Obstetrics, vol. ii.
pp 290-378.
*P. F. Mund^, Amer. Jour. Obst., 1883, vol. xvi. p. 1018.
' A. Martin, Frauenkrankheiten, p. 323.
DISEASES OF THE PELVIS 713
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 })erilymphangitis.
Etiology. — The inflammation of the lymphatics is caused by endo-
metritis — either catarrhal or non-specific purulent or gonorrheal.
Lymphadenitis may also be due to syphilis or scrofula, when it is
apt to be combined with adenitis in other parts of the body.
Si/mptoms. — 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
the above-described small tumors, which are very tender and some-
what movable, or a bundle of tender, movable cords Avhich imi)art
a feeling like a bunch of angle- worms.^
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 purj)(>sc (pp. 432 and 489).
Iodine (p. 174) and ichthyol glycerin (p. 182) should be used in the
vagina. Packing of the vagina (p. 182) gives much relief and makes
the swelling disaj)pear. Iodoform su])])ositories (p. 243) are useful
both as anodynes and as resolvents. It is recommended to use inunc-
tions of Ung. hydrargyri (20 parts) and Ext. belladonnas (1 part) on
the hypogastric region. Galvanism has also ])rove(l bonefi'-ial. In
extreme cases it may be justifiable to try to favor involution of the
hyper])lastic uterus by amputation of the cervix (p. 438), If the
patient is affecte<l with scrofula or syphilis, the usual remedies for
those diseases should be combined with the local treatment.
' TliP preat tendfrness of the tumors, even in clironic ra«es, speaks also ajjainst
their Injintr kI-'ukIs. for clironically inflamed lymph-glands, wliidi are so common in
Bcrofula and syphilis, are not sensitive to touch.
714 DISEASES OF WOMEN.
CHAPTER VIII.
Sarcom.a 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
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.'
In cases of malignant abdominal tumors that cannot be operated
on, a cure may perhaps be effected by injection of the " Coley mixt-
ure," containing bacillus erysipelatis and bacillus prodigiosus. The
dose is from TTtss to TTLxx, beginning with the smallest and increas-
ing till the temperature reaches 103°-104° F. The injection is, if
possible, made into the tumor itself, and repeated every two or three
days.' The remedy has been remarkably successful in some cases
of sarcoma, but less so in carcinoma.
^ Dr. ]M. D. Jones has reported a case in which a carcinomatous tumor of the size
of an orange in tlie pelvic floor was combined with a similar afiection of the ovaries.
.She removed all tlie diseased tissue, and made a microscopical examination that ia
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 tlie 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 Beconl, March 11, 1893, vol.
xliii. p. 292).
2 W. B. Colev of New York, Amer. Jour. Med. Sci., May, 1893, July, 1894, Sept.,
1896; Med. Record, Mav 18, 1895, p. 609, August 27, 1898.
DISEASES OF THE PELVIS. 715
CHAPTER IX.
Hydatids (Echixococci) of the Pelvis.
Hydatids are so rare that few physicians have had opportunity to
see a ease,^ 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.^
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, Ibrm has uever 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-
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 Tccnia echinococcus of the dog. As a rule, the entrance
takes place through the moutli, 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 througli the alimentary canal. The disease is endemic in
certain parts of the world, such as Australia, Iceland, Mecklenburg,
and Silesia.
Syiaptorns. — The disease may exist for years without impairing the
' Personally, I have only seen one case, and that was in the liver {PrncecilingK of
the Meilicdl Sorirty r,f Kinf/i', IJnioklyn, \. Y., IST'], vol. i. No."), p. 1'2I>). In the
ahove description I chiefly follow \V. .\. I'"reinid, who, livinjif for many years in an
echinococcus (iistrict, has had the rare opi)ortMnity of treating,' eif^hteen cases of
hydatid disease in the true and false pelvis, and who has descrihed thetn in his
Klinik (lir (rj/Kiikoln'/ir, vol. i. i)p. 29!*-!i'2(). Four of these he lias previously descrihed,
conjointiv with .J. K. Chadwick of IJoston (Aiiht. .lour. 01)4., Feb., 1875, vol. vii. pp.
668-079)".
* The Icelandic physician .Ion Finsen personally treated "2 15 cases of echinococcus
disease. Of these. 17'J, or more than 70 per cent., were in the female sex ( (^i/rshri/l
for Jy(rr/rr, '-'A series, 'A<\ vol. Nos. ')-8, ( 'opeidia^cn, 1S(J7). A French translation,
made hv mvself from the Danish original, is found in Archives gcnemks de Medecine,
Jan. and Feb., 1809, vol. i. pp. 23-40 and 191-210).
716 DISEASES OF WOMEN.
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-
fei-s, 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
echinococcus 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 echinococcus cysts in the con-
nective tissue. The last point is the basis of the diiferential 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, iuosite, 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 pathognomonic of a hydatid.^
If exploratory puncture is resorted to, it must, however, be made
with the strictest antiseptic precautions.
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 ])otassium iodide
and tincture of kamala (3J-§ss) has 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
^ Garrigues, Diagnosis of Ovarian Cysts, p. 74.
DISEASES OF THE PELVIS. 717
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. 507). 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 proi)er 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 section on Physiology (p. 123) that fecunda-
tion consists in the union of the male and the female generative
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
miscarriage, 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.^
Sterility in the Hale. — Infecundity in man may be due to imjwtence,
or inability to perform the sexual act ; to asjiermatism, absence of
ejaculation ; or to azoospermia (also called azoospermatism or azob-
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 ])roduce healthy semen in liis 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 gonorrheal discharge for years, and
^ Samuel AV. Gross, Impotence, Sterility, and Allied Disorders in the Male Sexual
Organs, Philadelphia, 1881, p. 88.
718
APPENDIX. 719
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/
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 Avomen 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 Avhen 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 witli 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. 594). By the development of
cysts and solid tumors of the ovaries the ovisacs may disap})ear,
but the sterility so common in these cases is often due to other causes
(p. 623).
2. Incapacity for Copulation. — Incapacity for copulation may be
mechanical or nervous.
(a) Mechanical incapacity may either be ((b-solutr, as in cases of the
absence of the vulva (p. 273), coalescence of labia (}). 27G), or atre-
sia of the hymen (p. 345) or vagina (p. 347) ; 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 ttimors of the vulva
(pp. 294-30G), kraurosis (p. 307), or cysts, fil)r()i(ls, mucous polypi,
or carcinoma of tlie vagina (pp. 378, 379, 381 ). A tear of the peri-
neum, allowing the semen to How out, may also be a cause of steril-
ity, but is of c<)m})arativcly small importance.
{h) Xeri-ous incapacity is connected with hyj)eresthesia of the vulva
(p. 294), painful urethral caruncle (p. 300), and, in its worst Ibrm,
witii vaginisnuis ([). 375).
3. Incapacity for conception may either be local or constitutional,
(a) Local incapacity may, again, constitute an absolutely insur-
' E. Noet^ijeratli was the first to call attciifion to latent ponorrliea in both sexes,
and its iiitlnenei' on fertility ( Tniiii<. Ainrr. (lyn. Soc, 187'), vol. i. p. 2GS, ct .sw/.).
' These retrojrrade l^rlK^'sses hi;ve In-en earefnlly studied and delineated by Mary
Dixon Jones {MaL Jtironl, Sept. I'J, 1891, vol. xl. p. 324; and Amcr. Jour, ('bst.,
1897, vol. xxxvi. pp. 17o-200j.
720 APPENDIX.
mountable obstacle to conception, as in cases of absence of the uterus
(p. 406), a rudimentary uterus (p. 407), atresia of the genital canal
(pp. 345, 347, 410, 440), or only a more or less serious hindrance.
Vaginal catarrh (p. 364) may cause sterility through the hyperacidity
of the discharge, which kills the spermatozoids. Women with urinary
fistulae rarely conceive, partly on account of mutual disinclination to
copulation, partly in consequence of concomitant diseased conditions.
Most of the maliformations 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. 411, 412), congen-
ital or acquired displacements of the uterus (pp. 413, 453-483),
elongation and hypertrophy of the cervix (pp. 400, 431), stenosis
of the cervical canal (pp. 413, 441), superinvolution of the uterus
(p. 451), chronic endometritis (p. 427), or a polypus obstructing the
cervix or the tube (p. 492). 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. 535) infecundity may be due to the consti-
tutional disturbance as well as to mechanical obstacles.
In regard to the Fallopian tubes congenital contortions (p. 553) or
acquired displacement (p. 578) may oppose an impediment to the free
movement of the ovum or the spermatozoids. They may be imper-
vious (553), or their inflammation (p. 557) or neoplasms (p. 578)
may prevent conception.
The surface of the ovaries may be so covered with inflammatory
products that the ovum cannot escape (p. 594).
The presence of hydatids in the pelvis (p. 715) 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. 320)
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. 721
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 leuconheal 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 i'ault
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 Milling to give the neces-
sary information, he should, first of all, be questioned in regard to
copulation, ejaculation, syphilis, and gonorrhea. The proper pcjsition
of" his meatus urinarins 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 tliis 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 be 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 tliis somewhat re})iigiiant
procedure.
In examining the woman, the physician will bear in mind all the
malformations and diseases just enumerated that may entail sterility.
TIk! vaginal secretion sjjould be tested witii litmus-paper. It is nor-
mally acid, bnt it may be so to such a degree that it kills the sperma-
tozoids. Ft should also be examined microscopical ly for ])Us-cor])Us-
cles, th(; presence! of which always shows inflammation. 1'Iie utero-
tubal nuicus is oi)tained by introducing a s|)eculnm and taking the
nuiciis directly out of the cervical canal. This is normally alknline,
and any acid fluid is deleterious to the spermatozoids.
Trcfdinnif. — In regard to the treatment of the man tiie reader is
refern'd to works on venereal diseases.
46
722 APPESDIX.
Often 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. iSIany months may even
ela])se before it occurs between perfectly healthy individuals. A little
patience is, thei'efore, always to be recommended. But, on the other
hand, accurate statistics have shown that three-fourths of married
women get a child in the coui*se 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 hrutonvm. 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 carnogen, 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, fiicus marina, phytolacca, 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.^
A too small uterus may sometimes be enlarged by the galvanic
current.
Many different operations maybe 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 bo kept up by the use of Outerbridge's ])ermaneut
dilator (p. 192); a polypus may have to be cut oft'; a spongy endo-
metrium may need curetting, etc. Sometimes the operation required
is not one of division, but of union, as when a torn perineum and
vagina are rej)aired or trachelorrhajihy is performed. A torn cer-
vix would seem to favor impregnation by offering freer entrance to
^ Such a diet should l)e 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 j^int of claret or
Moselle wine, a cup of lilack coflee, 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, Ijeer, jjotatoes, beets, puddings, pies, and other sweet dishes,
as well as bananas.
APPENDIX. 723
the interior of the womb ; but, on the other hand, the endometritis
following the tear is a bai'rier to conception ; and, as a matter of
fact, I may state that I have repeatedly removed sterility by this
operation.
Laparotomy or colpotomy 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. 562).
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 s})ermatozoid and an ovum (p. 123), 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 intercoui'se 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. 176), 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 ofi'
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 lx;d on her back, and if she
feels any pain an ice-l)ag should be a})plied to the hyj>ogastric 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 catameiiia (p. 125). It may, of course, be repeated
during several months, if the first attempt does not succeed.
11. LACK OF ORGASM.
A coxDiTrox for which we are not infVofpicntly consulted is lack
of the noi'inal feeling oi" the highest sexual excitement called orgasm
(p. 123), lioth the husband and the wife (lei)lore a defect which
deprives the marital relation of its highest ])hysical satisfaction, and
some knowing women, in order to retain their husbands' affection,
724 APPENDIX.
simulate a state wliich 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,tbut 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 iiave been brought together, the edge of the mesentery is
doubled up and stitched together, and tiie flap formed in this Avay is
itself fastened to the remainder of the mesentery with a few stitches.
B. Lateral Anastomosis} — 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
' Robert Abbe, Med. Record, April 2, 1892, vol. xli. p. 365.
APPENDIX.
725
divided sufficiently to draw tire ends of the severed gut past each
other, so as to make thera overlap for six inches (Fig. 364). 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 jwints. Next, another over-
hand suture is started at one end of the incision, uniting the two
edges nearest the previoiis 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
Fifi. 304.
Fig. 3r..->
Abbe's Intestinal Ana=;tomosis.
MnunseU's Intestinal Invufiination : n,
a. tenii)()rary suturos; 6, needle carry-
ing horsehair.
of the first two sutures are taken up one after tiie 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 opcratiou, but in order
to l)e |>erformed within a ren.^onable time it (leninnds a hand u.-^ed to
that kind of work.
Dr. Halsted of Baltimore says that the peritoneal coat of the in-
testine is so thin that it is impossible to suture it alone, and even
sutures comprising the ]M'ritoneum and the niuscularis tear out easily.
A thread of the strong fibrous subrnurosa should be included in the
stitch. This coat is recognized by the resistance it offers even to
th<' point of a fine needle. It is air- and water-tight, and is the skin
in which .suisag<.' meat is stuffed and of" which catgut is made.'
(.'. Kn(J-t()-r)ul Apjn'oximdtion hj/ Arfiflcid/ I inutt/iuitfitm.- — "^Pwo
teniporary sutures are placed, one at the nicsenterv and one just oppo-
' W. S. Halste.l. riilhi.l.'lphin Mnl. Jour.. IS'.tS, vol. i. No. 2. |>. ('.4.
'' H. Wideiihani Maiinsell, Amer. Jour. Mid. i'c/., Marcli, IS'.CJ, p. 245.
726
APPENDIX.
site, carrying tliem throusxli nil three coats of tlic two ends of the
severed intestine. Next, a lonijitndinal liole, one and a half inches
long, is cnt in the larger part of the intestine one inch from the end,
and the two tenipornrv sntnres are hanled out through this opening,
carrying the end of the intestine after them. Ten horsehair or silk-
worm-gnt sutures are now carried through both walls of intestine
(Fig. 365), picked up in the middle, and cut, thus forming twenty
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^ Button (Fig. 366). — 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 different
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-
nestrse, 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, ^yhen this pro-
cess is finished, the button is carried down
through the intestine and expelled through the anus, usually in the
^ John B. Murpliv of Chicago, 111., North American Practitioner, Nov. and Dec,
1892 ; New Yurk Med. Record, May and June, 1894.
Murphy's Int
ton ( enlarged
closed.
APPENDIX.
727
Fig
course of the second or third week. 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
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 o-oing in the reverse direction. This forms the
running thread, which when tightened draws the incised edge of the
gut within the cup of the button. A sim-
ilar 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 diameter of the button used. The lig-
atures are tightened round the central cyl-
inders, 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
tlie flange, and this should be grasped with
a forceps and held while the first half of the
knot is ijeini; made. When the jriit is drawn
dose 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 cver-
sion of the mucous membrane and insuring
the overlapping of the mesentery. This is
(jbtained by beginning at a opposite the ines-
ent(,'ry, using a top stitch along the incised
edge, taking a return over-stiteh (h) at the
mesent(!ry, and eoiitinuing the toj) stitch on
the opposite side, l)aek to the starting-point
(Fig. ••MM).
This method is tlu' simplest and most expeditious one of all
Mnnnoi- of Insortiii!,' Rnntiiiiff
siituro in Kiid of Intestine
(Mur|)liy) : <i, start i M),'-|ii lint ;
b, return oVLT-stitch ul mus-
entery.
728 APPENDIX.
E. Ecphyadcdomri, ftcolccectomj/, or removal of the appendix vcrnii-
formis. If in pcrforniino; laparotomy the appendix Aermiformis is
found diseased, it is projier to remove it. A continuous 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 is made. Next, the appendix is divided, leaving a
stump at least half an inch long. This stumj) is stretched by intro-
ducing a pair of fine forceps through it into the cecum 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.^
^ Dawbarn, International Journal of Surgery, 1895, vol. viii. No. 8.
INDEX.
Abbe, intestinal anastomosis, 725
Abdominal hysterectomy, 451, 517, 549
regions, 115
section, 641
wall, adherent to ovarian cyst, 653
Abortion, cause of disease, 135
Abortionist, 414
Abscess —
after ovariotomy, deep, 669
mural, 669
of vulvovaginal gland, 309
ovarian, 591
pelvic, 701
Accessory abdominal ostia of Fallopian
tube, 553
A. C. E. mixture, 222
Acid —
carbolic, 197, 211, 290, 312
hydrocyanic, 227, 287
sclerotinic, 506
Actinomyces, 558
Adenoma —
benign, 428, 492
malignant, 428, 492
uteri, 492
Adhesions
ovarian, 585, 597, 641
peritonitic, 704
severance of uterine, 476
tearing of, 473
Aftor-treatmer)t, 239
after ovariotomy, 651
complications during, 667
Air-pressure, 467
Ala vesjKTtilionis, 2(5. 67
Albugincii, 27, 71
Alcohol for disinfection. 209
Alcxunder's operation. 471
Alinicntation, rectal, 241
Allantois, 32
Alligator forceps, 648
Allongfincnt of polvpu.s, ">05
Aloes. •_'J2
Ameboid bodies. 612
Airienorrhca, 255
proiMT, 256
Aincncan method of hy.sterectomy, 519
Ampulla —
of Fallopian tube, 66
rectal, 87
AmputatiiMi —
of cervix, 438, 448, 449, 464
of inverted uterus, 490
supravaginal, of uterus. 517. (See
Hysterectomy. )
Anal region, 101
Anatomy, 35
Anesthesia, 218
causing nephritis, 220, 530
paralysis, numbness, or pain, 208
for examination, 162
in elevated-pelvis position, 221
Aneurysm of uterine artery, 679
Angioma —
of uterus, 493
of vulva, 300
Anodynes. 243
Anteflexicm, 413, 458
acquired, 459
cervical, 458
cervicocorporeal, 458
congenital, 459
corporeal, 458
deyelo})mental, 459
Garrigues' oj)eration for, 462
irreducibb;, 458
reducible, 458
salpingo-oophoi-ectoniv, 464
Sims's operation for. 463
Anteposition, 453
Anterior commissure. 36
Antevei'sion, 453
ojx'nilions for, -157
Aiiliblennori'liagic drugs, 368
Anlidysmenorrheal drugs, 263
Aiitiphlogistine. I'.to
Antipyretics, 245
Antisejisis, 209
Antiseptic —
fluids. 217
material, 209
Anns, preternatural, 400
Aperients, 241
Apostoli, electrode, 248, 249
729
730
INDEX.
Apostoli, method, 250
Applications, 175
Applicator, Garrigues', 175
Arhor vita^. 40
Arch, tendinous, !t(J
Aristol. 217
Arnold, sterilizer, 209
Arteries —
circular, (51
lielicine, 01
ligation of internal pudic, 189
of uterine, 188
of perineal region, 107
of uterus, 00
Artificial impregnation, 723
prolapse of uterus, 145
Ascites, 019, 028, 033, 065
Asepsis, 209
Ashton, speculum, 152
Aspermatism, 718
Aspiration, 101, 197
exploratory, 161, 629
through vaginal vault, 573, 629
Aspirator, 170
Dieulafoy's, 170
Emmet's, 170
Potain"s, 170
Assistants, 204
Asthenopia, 130, 429
Atresia —
acquired, of uterus, 440
of vagina, 348
ani vaginalis, 354
vestibularis, 354
case of, 350
hvmenalis, 345
of urethra, 392
of uterus, 410, 440
of vagina, 347
acquired. 348
combined with double vagina, 353
complete, 347, 353
congenital, 348
incomplete, 347
Atrophy of uterus —
acquired, 451
puerperal, 451
senile. 451
Atropine injected suhcutaneously before
anesthetizing, 222
Auscultation, 101
Aveling, repositor, 489
Azoospermatism, 718
Azoospermia, 718
Azoospermisui, 718
Balloon I x(;. 148
Bandl. operation for ureterovaginal fis-
tula, 393
Barnes, operation for inversion, 490
replacement of inverted uterus, 489
Bartholin's gland. (See Vulvovaginal
Gland. )
Barton, Khea, operation for rectolabial
fistula, 401
Base of bladder, 80
Baths, 195
general, 195
Russian, 195
sea-, 196
sheet-, 196
shower-, 196
sitz-, 196
sponge-, 196
steam-, 196
towel-, 196
Turkish, 196
Bath-speculum, 195
Battev's operation, 564
Bed, 202
Beef-juice, 240
Beef-tea, 240
Belladonna. 287, 433
Belt, abdominal, 199
Bernays, uterotractor, 547
Bichloride of mercury —
for pai'enchymatous injection, 545
internally, 242
standard solution, 217
Bicycling, 201
Bimanual examination, 144
replacement of uterus, 468
Bipolar electrodes, 247
Bismuth, 242
Bisulphide of carbon, 720
Bladder —
adherent to tumors, 525, 653
anatomy, 80
catheterization, 39, 162
distention. 036
fetal, in adult, 83, 523
function, 83
irrigator, 179
irritable, 429, 433
Blasius, operation for fistula, 389
Blind canals in vagina, 353
Blister, 190
Bloodletting, 194
Blood-pressure increased before menstru-
ation, 119
Bode, vaginal shortening of round liga-
ments, 476
Bodies, ameboid, 012
AVolffian, 20
Body, jierineal, 100
of womb. 48
Boldt, ]»lunt pelvic dilator, 001
table, 203
INDEX.
731
Boucies with iodoform, 426
Boves uretero-ureteral anastomosis,
655
Bozeman, button, 388
dilator, 374
operation for fistula, 388
scissors, 505
speculum, 388
table, 388
urinal, 398
Brandt, Thure, cure for prolapse, 480
cure for retroflexion, 473
Braun, syringe, 176
Breisky, pessary, 480
Brewer, speculum, 147
Broad ligament —
cysts of, 681
diseases of, 680
during pregnancy, 58
solid tumor of, 684
varicocele of, 680
Broca's pouch, 37
Bubo, 312
Bulb, vestibulovaginal, 39
Bureau, operation for fecal fistula, 403
Burning sensation in genitals and abdo-
men, 293
Burrage, speculum, 152
Button, Bozeman 's, 388
Murphy's, 726
Byrne, carcinoma uteri, 546, 547
Calcikkatiox —
of corpus lutcum, 595
of ovarian cyst, 620
of uterine fibroid, 500
Calcium carbid, 544
Calculus due to suture, 391
Camj)hor —
emulsion, 371
in collapse, 224
Canal —
anal, 87
cervical, 50
Gartners, 20, 378
of Xuck, 37,
hf'matoccle of. 281
Canals, blind, in vairina, 353
Cancer —
carried through lym|ib-vesscl>, 675
definition, 531
of Fallopian tube, 579
of jjoritoncum, 634
of vulva, .'!()2. (See ('iircin(fi)in and
S(i ri'(i])iti. )
Canfor-c(ll< in a>ritic tluid accompany-
ing malignant tumors, 542
Capsub' of tibroid tumors, 494
Carbon bisulphide, 720
Carcinoma —
in negro race, 537
not transmissible by coition, 538
of body of uterus, 536
of cervix, 536
of Fallopian tube, 579
of ovarian cyst, 610, 620
of ovary, 675
of pelvis, 714
of uterus, 536
of vagina, 381
of vaginal portion, 536
of vulva, 302
syncytiale. 537
Carnogen, 242
Carrier, 232, 420, 504
Caruncle, urethral, 300
Canuiculic myrtiformes, 47
Catamenia, 117
Cataphoresis, 250
Catarrh —
of uterus, 430
of vagina, 364
Catgut,'^212
buried, 329
chromicized, 214
sterilized with alcohol, 213
cumol, 214
dry heat, 214
formalin, 214
Catheter —
double-current, 178
self-retaining, Pctzer's, 513
Sims's, 387
Catheterization —
of bladder, 39, 162
of Fallopian tube, 562
of ureter, 165
Cauliflower excrescence, 536
Cauterization, 187
galvanochemical, 247, 248
gal va?iot hernial, 252
bemostatic, 186
of fistula, 385. 402
Cautery-ciamp, 648
Cavity —
of uterus, 49
liclvipcritoncal, 96
Celibacy —
in relation to disease, 131
to uterine fibroid, 500
'•(".•liofomv," 644
Cells, proliV.'rating, 612
Cellulitis, 6:;(i
anterior, 708
chronic atrophic, 710
])elvic, 705
posterior. 708
Cervical canal, 49
732
INDEX.
Cervical carcinoma, 530
gaiiEjliou, (i5
speculum, 152
stenosis, 441
Cervicitis, 423
Cervix, 48
amputation, 438, 448, 449. 404
cone-niantle-shaped excision, 439
concjenital cleft, 417
conical, 441
cyst^, 433, 492
development, 32
discission of posterior lip, 403
elongated, 414, 445
fuTinel-shaped excision, 447
high amputation, 448, 449
laceration, 415
single-dap excision, 439
stenosis, 441
supravaginal amputation, 448, 449
. ulcers, 444
wedge-shaped excision, 438
for retroflexion, 460
Chain-ligature, 602
Chancre^ 312
hard, 312, 444
mixed, 313
soft, 310
Chancroid, 310, 444
chronic, 296, 311
Change of life, 125
Charts, 101
Chian turpentine, 545
Childbirth, cause of disease, 132
Chloral hydrate, 288
Chloride of zinc, 174
for cauterizing carcinoma of uterus,
543
Chloroform, 222
embrocation, 243
-mask, 222
Cholesterin, 613
Cicatrices in vagina, 373
Circular artery, 61
Cirrh(jsis of ovary, 591
Clamji —
compared with ligature, 514
Ko'lierle's, 191
method for hysterectomy, 511
Cleanliness, 142
a cure fur fistula, 385, 401
Cleveland, ligature-carrier, 233
table, 203 '
Climacteric, 125
treatment, 127
Clitoridectomy, 319
Clitoris, abnormal, 274
absent, 274
amputation, 319
Clitoris, anatomy, 38
development, 34
enchondroma, 300
function, 39
horn, 300
Cloaca, 34
persistent, 354
Cloacal o))ening, 34
Closure of uterus, 440
Clover's crutch, 207
Clyster, 178
Coalescence of labia, 276
Cobbler's stitch, 649, 602
Cocaine, 223
bougies, 370
Coccygectomy, 343
Coccygodj'nia, 342
Coccyx —
anatomy, 342
extirpation, 343
Coe, improvement on Lefort's operation,
482 •
preventive excision of cervix, 542
Coffee against vomiting, 224
Coil, 195
Coition —
during menstruation, 132
modo brutorum, 722
Cold, 195 ■
Cole, administration of oxygen with
ether, 218
Cole}' mixture, 714
Colica scortorum, 558
Collapse, 223, 224, 529
Collector, 249
Colpeurynter, 489, 504
Colpitis, 303
Colpohyperplasia cystica, 369
Colpoperincorrhaphy, 327
Colporrhaphy —
anterior, 350
bilateral, 357
lateral, 357
median, 357
posterior, 300
Colpotomy, 5r)3
anterior, 475, 510, 513
posterior, 510, 513, 702
Columns —
of Morgagni, 90
of vagina, 43
Comparison between ligature and forceps
in vaginal hysterectomy, 515
between oj^erations for retroflexion, 470
between total extirpation and supra-
vaginal amj)utation of uterus,
525
between vaginal and abdominal section
for carcinoma of uterus, 549
INDEX.
733
Comparison between vaginal and abdom-
inal section for fibroid of
uterus, 529
for salpingo-oophorectomy, 569
Conception, incapacity for, 719
Condurango, 544
Condylomata acuminata, 296
Cone-mantle-shaped excision of cervix, I
439 I
Conium pills, 243
Connective tissue, pelvic, 95 i
Consent of patient necessary for opera- '
tions, 504 I
Conservative treatment of appendages, i
563, 596
Contents, 5
Copeland, method of arresting vomiting,
201
Copiopia, 205
Copulation, 123
incapacity for, 719
Corporia arenacea, 615
Corpus —
albicans, 77
cavernosum of clitoris, 38
luteum —
calcified, 595
changed into cyst, 595
into gyroma, 598
false, 77
of menstruation, 74
of pregnancy, 75, 599
ossified, 595
verum, 599
nigricans, 77
nigrum, 77
uteri, 48
Corpuscles —
lienneft's large, 611
small, 612
colloid, 611
iJrysdale's, 612
genital, 39
gorged, 611
Niiiiri's, 611
Corroding ulcer of cervix, 444
difl'erent from rodent ulcer, 540
Corset, i:!l
Cortical substance of ovary, 71
ottnii, styptic, ISO
otiiiter-irritalioii, 196
outlier-pressure liook, 235
our~cs, 1 17
otirty, inversion, 490
ramps, 124
reuliii, 177, 217
rn-hy, needle-liolder, 232
nis of clitoris, 3M
urettage, \X0
Curettage for uterine fibroids, 508
Curette, 156
Kecamier's, 182
Simon's, 156
Sims's, 156
Thomas's dull-wire, 156
Current —
constant, 249
interrupted, 249
Cusco, speculum, 152
Cyst—
of abdominal wall, 635
of broad ligament, 631, 634, 681
of cervix. 433, 492
of Fallopian tube, 578
of liver, 634
of mesentery, 635
of omentum, 634
of ovary, 606
of pancreas, 635
of spleen, 635
of uterus, 488
of vagina, 378
of vulva, 301
of vulvovaginal gland, 308
ovarian, 606
parovarian, 680
renal, 034
tubo-ovarian, 017
Cystocarcinoma of ovary, 675, 676
Cystocele, 356
Cystoma of ovary, 615
dermoid, 615
glandular, 606 .
mvxoid, 005
papillary, 000, 014
Cystopexia, 300
Cystosarcoma of uterus, 532
Cystoscope, KiO
Czerny, ventrofixation, 474
Czerny-Ijcmbert suture, 053
Daktos, woman's, 37
Davidson, svringe, 175
Death-
after hysterectomy, 529
after ovai-iotomy, 071
from chloroform, 220
Decidual sarcoma, 5:)4
Dcciduoma malignum, 534, 537
Decuhitus acutus, 538
Depressor —
durrii^ues', 151
Hunters, 149
Sim-s, 1 J!)
va-iiniil, 149
Dermoid cvsf -
of ovary, •>15
out>ide of ovary, 017
734
INDEX.
Descent —
of ovary, 23
of uterus, 478
Detrusor of rectum, 87
Development —
arrest of, of uterus, 400
excessive, of uterus, 406
irrejijular, of uterus, 413
of t^ie cervix, 82
of the female <j;enitals, 19
of the hymen, 33
of the ovaries, 22
of the uterus, 31
of the va<xina, 31
of the vulva. 31
Diaphragm, pelvic, 97
Diet-
after operations, 239
tiuid, 239
for reducing fat, 722
Dieulafoy, aspirator, 170
Digitalis for reviving, 223
Digital pressure for replacing uterus, 468
Dilatation —
of cervical canal, 156, 192
of urethra, 144, 165
of uterus, 158
of vagina, 348, 350
Dilator —
hlunt pelvic, 661
Garrigucs', 157
Goelet's, 158
Hanks's, 157, 158
olive-shaped, 159
Outerhridge's. 192
puncturing, 198
vaginal, 348, 350
Discus proligerus, 28, 73
Disease, gelatinous, of peritoneum, 621
Diseases —
exanthematous, 290
of broad ligament, 680
of Fallopian tube, 554
of ovary, 581
of pelvis, 679
of perineum, 320
of round ligament, 684
of sacro-uterine ligament, 684
of uterus, 406
of vagina, 345
of vulva, 273
of vulvovaginal gland, 308
venereal, 310
Disinfection, 200
by steam. 209
internal. 404
of catgut, 214
of instruments, 239
of laminaria tents, 157
Disinfection of silk, 213
with boiling soda solution, 210
Disj)lacement —
of Fallopian tube, 578
of ovary, 583
of uterus, 453
Distribution of organs between perineal
fascia;, 112
Douche-can, 175
Douglas's pouch, 94
prolapse of intestine into, 354
Dowd, sterilizer for catgut, 213
Drainage —
abdominal, 192, 194, 666
after (jvariotomv, 666
of uterus, 192, 193
-tube, 193
vaginal, 667, 670
with iodoform gauze, 192
with rubber tubes, 193
Dress, 130
Drink, 240
Dropsy of Graafian follicle, 601
Duct, 'Miillerian, 29
Wolffian, 19
Dysmenorrhea, 259
membranous, 259, 435
nervous, 259
obstructive, 441
Dyspareunia, 123
Dyspepsia, 241
EcHixococci, 715
Ecphvadectomy, 728
Ectropium, 416, 427
Edebohls, table, 203
Edema —
indurating, 304
of abdominal wall, 635
of lacerated perineum, 325
Education, 129
Ehrich, speculum, 151
Elastic ligature, how to tie, 518
pressure.
Electricity —
Apostoli's method, 250
bipolar electrode, 247
chemical, 247
galvanocauterization of the cervix,
251
different qualities of poles, 250
frictional, 246
high-tension coil, 247
inductional, 246
molecular ni(jvement. 250
Electrode —
aluminium. 248
.Apostoli-s, 247, 248
bipolar, 247
INDEX.
735
Electrode —
Engelmann's, 248
Fry's, 443
Garrigues', 249
gas-carl)on, 250, 251
Martin's, 248
platinum, 248
Electrolysis, 253
for stenosis of cervix, 443
inetaliic interstitial, 253
Elei)hantia.sis of vulva, 297
Elevation of uterus, 485
Elytritis, 303
Emmenagogues, 257
Emmet, Bache, trocar-forceps, 702
Emmet, T. A., aspirator, 171
button-hole operation, 31ti
counter-pressure hooi<, 235
operation for fecal tistula, 404
for inversion, 490
for lacerated cervix, 419
for uterine flbroid, 509
for vaginismus, 377
for vesico-uterine listula, 395
perineorrhaphy, 332, 339
pessary, 409
tenaculum, 227
trocar, 040
wire-twister, 235
Emphvsema, 669
Ems, 197
Emulsion of camphor, 371
Enchondroma —
of clitoris, 300
of uterus, 551
Encysted ])eritonitic exudation, 033
Endocervicitis, 423
Endometritis, 423
atrophic, 429
catarrhal, 427
chronic, 427
decidual, 429
exfoliating, 435
fungous, 427
hemorrhagic, 429
hyj)erj)lastic, 427
menstrual, 435
Endosaipingitis, 554
End<ithelii)ma (Ackermann) of ovarv,
599, (i74
f. Jones) of f)vary, 597, 599
Ein-ma, 178
tuitrient, 241, 007
Engflmann, electrode. 248
rt'trai'tor, 227
Enterocf'le, vaginal, -'{51
Emiclcation —
alxiominal, 525
from broad liirament, 520
Enucleation —
from pelvic floor, 527
from uterus, 528
Miner's method, 657
of uterine fibroids, 508, 525, 526
vaginal, 508
Enuresis, operations for, 359, 398
Epididymis, 22
Epispadias, 274
Epithelial coalescence of vulva, 276
Epithelioma of vulva, 302
Erection, 123
of internal genitals, 58
Ergot, hvpodermically for fibroids,
507
Ergotine, 507
Erosions, 433, 444, 507, 542
Erysipelas of vagina, 373
Esmarch's mask, 222
Esthi(^mcne, 303
Ether, 218
chloric, 223
Ethyl chloride, 223
Examination —
bimanual, 144
chemical, 101
combined, 144, 145
digital, 141
for sterility, 722
in general, 134
in regard to operations, 206
intestinal, 144
microscopical, 102
of abdomen, 100
of bladder, 102, 558
of i)elvis, 141
of uretei-s, l'i5
of urine, 101
of uterine aj)))endages, 558
of virgins, 159
physical, 137
rectal, 144
under ane-tliesia, 109
vairinal. 142
verbal. 134
ve-ical, 144
Exaiitlienuitous disea,ses, 290
P^xcitor —
bipohir, 247
uterine, 247
vaiiiiiai, 247
Kxcretions, 130
Kxercise, 129
Exploratory —
aspiratioii. 101. (;'J9
inci.-ion, lOl. 0:'.<l
iapanitomy. 573
)iun('tiire. 029
F^xtniets of meat. 241
736
INDEX.
Extraperitoneal shortening of the round
ligament, 471
Extra-uterine pregnancy, 631
Facies ovariana, 62")
Falling of the womb, 478
Fallopian tubes —
absence of, 553
accessory, 553
anatomy, 65
caTicer, 579
carcinoma, 579
catheterization, 562
cysts, 578
development, 30
diseases, 554
displacement, 578
examination, 558
fibroma, 578
function, 68
lipoma, 579
malformation, 553
neoplasms, 578
palpation, 558
papilloma, 579
relation to menstruation, 118, 120
sarcoma, 579
tuberculosis, 579
Faradism, 247
Faradization of diaphragm, 224
Fascia —
anal, 97, 103
deep perineal, 102
distribution of organs between peri-
neal fasciae, 111
levator, 103
obturator, 96
pelvic, 96
perineal, 102
pyriformis, 96
superficial perineal, 102
vesicorectal, 96
Fat—
-granules in ovarian cysts, 613
preperitoneal, 645
retropubic, 95
Faure, hysterectomy, 568
Fecal fistula after ovariotomy, 670
Feces, impacted. 636
Fecundation, 123
Fergusson, speculum, 146
Ferripyrine, 174, 186
Fertilization, 123
Fibrocyst of ovary, 567
of uterus, 607
diagnosis, 632
treatment, 530
Fibroid —
of uterus. 494, 631
Fibroid —
of uterus, calcification, 500
causes of death from operations, 529
complication with pregnancy, 527
diagnosis from ovarian cyst, 632
indications for operations, 530
loose, 498
migrant, 498
mortality after operations, 528
sloughing, 528
of vagina,379. (See Fibroma, Myoma. )
Fibroma —
molluscum, 300
of Fallopian tube, 578
of ovary, 672
of round ligament, 283
of uterus, 494
of vagina, 379
of vulva, 299
case of pedunculated, 300. (See Fi-
broid, Myoma.)
Fibromyoma —
of uterus, 484
of vagina, 379. (See Fibroid, Fi-
brom.a.)
Fibrosarcoma of ovary, 674
Fimbria ovarica, 66
Fimbriie —
anatomy, 66
development, 30
Fistula, 383
abdominal method, 391
Bandl's method, 393
Barton's method, 402
Blasius's method, 389
Bozeman's method, 388
Bureau's method, 403
combination of methods, 392
congenital rectovaginal, 354
denudation, 386
Emmet's method, 395
entero-vaginal, 399, 404
fecal, 399_, 670
flap-splitting methods, 389, 404
Follet's method, 395
Fritsch's method, 403
ileo-uterine, 399
ileovaginal, 399
Pozzi's method, 394
produced by coition, 283
rectolabial, "399
rectovaginal, 399, 402
rectovulvar, 399
Schede's method, 394
Simon's method, 388
Sims's method, 386
suprapubic method, 389
Taylor's method, 403
Trendelenburg's method, 389
INDEX.
737
Fistula, uretero-uterine, 390
ureterovaijinal, 391, 395
urt'terovesicovaginal, 390
urethrovaginal, 392
urinary, 383
uterovaginal, 41G
vesioo-uterine, 395
vesico-uterovagiiial, 396
vesicovaginal, 3S;5
Vignard s method, 403
Wsilcher's metliod, 890
Fistulous tract, (iTU, 704
Flap-operation for atresia, 350
Flap-sliding metliod for rectovaginal fis-
tula, 404
Flap-splitting perineorrhaphy, 327
Flatus vaginalis, 342
Fluid—
in cvsts of broad ligament, 082
in ovarian cysts, (;64, 610, 617, 629
in uterine til)rocysts, 499
Fluids, antiseptic. 217
Foerster, table, 203
F(etas in fa-tu, 622
Folds, genital, 33
FoUet. vesico-uterine fistula, 395
FoliicU's—
(Jraalian, 26
])riniarv, 28
Folsoni-Skene, speculum, 154
Fomentation, 195
Food, 180, 240
Forcfp. —
alligator, 647
artery-. 190
compared with ligatui-e, 515
cyst-. 646
dressing-, 152
hemo.-tatic, 190. 511
intra-utcrinf packing-, 185
pedicle-, 647
pressun;-, 190. 230, 511
tenaculum-, 228
tissue-, 228
tongur-. 223
tniction-. 228
trocar-, 702
Forcipressure. 190
used in hystfrcctomy, 511
ForcJLrn Ixxlji
in ovary, ."iH"J
in uterus. 422
in vagina, 362
Formalin cat;,'!!!, 214
Fornix of vai^ina, 42
Fossa—
ischiorectal. 1 03
navicularis. 10
Foiirchctte, 37
(7
Fowler, pessary, 470
Franklinism, 246
Franzensbad, 196
Frenulum of clitoris, 38
Freund, hysterectomy, 549
operation for prolapse of uterus, 482
Fritsch, enucleation, 526
hysterectomy for prolapse, 482
operation for fecal fistula, 403
Frost, vaginal syringe, 709
Fry, electrode, 443
Fundus—
of bladder, 80
of uterus, 48
Furrow, genital, 34
Fusion of ovarian cysts, 619
Gall-bladder torn in ovariotomy, 654
Galvanism, 247
Galvanocauterization —
chemical, 250, 251, 507
for carcinoma of uterus. 546
for extirpation of uterus, 548
thermal, 252
Galvanochemical cauterization for ute-
rine fibroid.s, 507
Galvanopunc-ture, 252
Ganglion, cervical, 65
Gangrene —
of uterus, 452
of va<;ina, 372
of vulva, 289
Gariel, air-jtessary, 480
Garrigues', appai'utus for transfusion
and infusion, 529
blunt ex))anding jierforator, 198
colpoperineorrhaphy, 327
diliitor. 157
headache jiowdcrs. 243
intra-uterine ap|)licatoi', 174
electrode. 249
packini^-forceps, curved, 185
strai-^djt, 185
tube. 177
j)erineal jiad. 324
scar! tier. I Hi
serretiiies. ■■'.22
trachelorrhaphy needles, 418
weiiflit s))eculuili, 22')
(lari-ulity ot" vnl\;i, 312
(Jarlner'^ canal. 20. ;!7S
(ias arliliciallv develojx'd in stomach,
161
(ois-ether anesthesia. 220
(iauze
ball-. 210
pads, I'lO
.-|inne;es. 211
(iehi'iiii'.;. |iessary, 455
738
INDEX.
Gelatinous disease of peritoneum, 021
Genital —
cord, ;^1
cori)Uscles, 30
folds, 33
furrow, 34
tubercle, 33
Genitals —
external, 35
internal, 35
Geode, 488
Genn-e]iitheliuni, 28
Germinal-
spot, 74
vesicle, 74
Gestiition, incapacity for, 720
(iiraldez, organ of, 22
Glands —
Bartholin's, 40
coccygeal, 105
Littre's, 79
manimarv, 116
pelvic, 62, 536
Skene's, 79
utricular, 51
vulvovaginal, 40, 308
GlanduliB vestibulares majores, 41
minores, 39
Glass plug for vagina, 354
Gloves for operating, 209
Glycerine tampon, 188
Glycerite of tannin, 188
Goelet, dilator, 158
ligation of uterine arteries for myoma,
509
Gold, 243
Goldan, inhaler, 221
Gonococcus, 364. 367
Gonorrhea, 133, 286, 287, 310, 366, 425,
558, 591, 695
danger of, 133
latent, 133, 718
Gordon, S. C, excision of cervix, 488
operation for chronic metritis, 438
Gossypii radicis cortex, 244
Graafian follicles —
anatomy, 71, 72
development, 26
dropsy, 601
Gram's method of finding gonococcus,
864
Granular os, 428, 444
Greenlial<rh, metnjtome, 443
(Jymnastics. 200
(ivnecological treatment, cause of dis-
ease, 133
Gyroma, 598
Hackdokn, needles, 280
Ilagedorn, needle-holder, 231
Hallucinations due to lacerated cervix,
416
Hanks, dilators, 157
Harris, M. L., separate collection of
urine from the two kidnevs,
168
Headache powders, 243
Heart —
artificial contraction, 220
examination in regard to operation,
205
Heat, 195
Heels, high, 130
Hegar, amytutation of cervical portion,
438
extra-abdominal treatment of pedicle
in hysterectomy, 519
funnel-shaped excision of cervix, 447
operation for chronic metritis, 438
for complete laceration of perineum,
336
for pelvic abscess, 703
sacral hysterectomy, 549
Helicine arteries, 61
Hematocele, 631, 696, 698
of the canal of Nuck, 281
Hematocolpos, 345
Hematoma —
of broad ligament, 631, 691
of ovary, 586
of round ligament, 282
of vagina, 361
of vulva, 295
pedendal, 283
Hematometra, 345, 408, 441
Hematosalpinx, 345, 554, 577
Hemorrhage —
at climacteric, 128
from torn hymen, 860
from wound in vulva, 41
in hysterectomy, 529
in ovarian cysts, 619, 627
in perineal region, 110
int(!rnal, after ovariotomy, 667
intraperitoneal, 667
pelvic, 696
Hemostasis. 186
after ovariotomy, 664
Hemostatic—
drutrs, 248
va«,Mnal ])lug. 183
Heredity, 129
Hermaphrodism, 276
Hermaphroditism, 276
Hernia —
ant<'rior labial, 278
crural, of ovary. 582
in the canal of Nuck. 279
INDEX.
739
Hernia —
inguinal, of ovary, 582
inguinolabial, 278
posterior labial, 279
umbilical, complicating ovarian cyst,
605
uteri, 418, 491
vaginal, 854
vaginolabial, 279
Herpes, progenitalis, 290
Hewitt, cradle pessary, 455
High-tension current, 247
Hilum, 08
Hodge, ])essary, 408
Hofineier, enucleation, 527
Horn of clitoris, 800
Horn-cells, (il2
Horns of uterus, 31
Horsehair, 210
Hottentot apron, 37
Hot water, 180
Hot-water l)ag, 195
Houston's valves, 90
Hunter, J. J3., needle, 514
Hvdatid—
of liver, 084
of Morgagni, 30, 554
of pelvis, 715
Hydramnion, diagnosis from ovarian
cyst, 082 "
Hvdrobroiiiate nf hvoscine, 243
Hydrocele, 2H0
of ovary, 017
interi'iiitteiit. 554, 018
Hvdrolciiic. 270
Hvdrometra, 127. 411. 441, 032
Hydronaphthol, 218
Hydroii('pliro>is, 084
Hvdroj)s —
■folliculi, 001
tub;i' profiufiis, 554, 018
IIydn»rrheu. 480
gravidarum. 4;!0
put-rpcral. 480
Hydrosalpinx. 554, '■■
Hydrotherapy. 190
Hygroma, 844
Hymen —
alinorma! opening
al)>ent, 845
anatomy. 40
atresia, 845
bifenestratus. 847
bif-.ris, 847
cribriformis, ;M7
(level. i|iiiient. -V-',
d..iit.le. :\\-
fleshy. :!47
hemorrhai'e fn>m torn, 8tiO
5, 031, 035
in, 347
Hymen —
malformations, 345
septus, 347
subseptus, 347
Hyperemia —
of ovaries, 580
of pelvis, 129
Hyperesthesia of vulva, 294
Hyperplasia of vulva, 294, 304
Hypertrophy of uterus, 445
infravaginal, 445
supravaginal, 440
Hypnotics, 243
Hypodermoclysis, 226
Hypospadias, 273
Hysteralgia, 452
Hysterectomy, 510
abdominal, 451, 517, 549
compared with vaginal method, 524
American method, 519
causes of death, 529
extra-abdominal treatment of pedicle,
519
Faure's method, 508
for carcinoma uteri, 547
for hemorrhagic endometritis, 440
for prolapse, 482
for supravaginal hj'pertrophy of cer-
vix. 451
for uterine libroid, 511
Freund's method, 549
Hegar's method, 549
intra-abdominal treatment of j)edi-
cle, 518
mortality, 528
Pean's method, 510
perineovaginal, 550
Pratt's method, 517
retroperitoneal treatment of pedicle,
518
sacral, 549
Schroeder's method, 513
Schuchardt's method, 550
S))ecial difficulties, 522
su})ravaginiil am])Utation comiiared
with total extirpation. 525
vaicinal, 451, 4H2, 511, 517. 710
C(im]iared witli abdominal, 524
vaLrino-abdomina], 517
with i^alvanocaiitery, 547
witii ligatures, 518, 547
with pressure-forceps. 511
witli therTnocauterv. 547
without ligature or foici'ps, 517
Hysteria, 20.')
Hy>terocele. 491
Hysterocleisis. 897
Hysterocvstocleisis. 897
Hystero-epilejisy, 205
740
INDEX.
Hystcr(>]>oxift, 473
al>cU>ininal, 474
vajjinal, 473
HYsterotrachelorrhaphy, 418
IcK-HAU, 19")
Ichtliyol-<:;lyt'crine, 182
-lanolin, 17")
Impotence, 718
Impregnation, artificial, 723
Incision —
exploratory, 170, 630
of vaginal vault, 562
Incontinence of urine, operation for,
3.39, 398
Incubation, 311
Indurating edema of syphilis, 304
Induration, absent, 312
Inflammation, perimetric, 693
Infusion of salt solution, 529
Inhaler —
Allis's, 222
Esmarch's, 222
Goldans, 221
Injections, 175
antiseptic, 176
astringent, 176
cleansing, 176
emollient, 176
hot-water. 187
hvpodermic, before operations, 206,
221
intestinal, for diagnosis, 161
intraperitoneal, 180
intra-uterine, 176
intravenous, 180, 220
iodine water, 702
rectal, 178
subcutaneous saline, 180, 529
vaginal, 175
vesical, 179
Injuries —
of ])ody of uterus, 414
of cervix, 415
of intestine, 653
of perineum. 320
of uterus, 414
of vagina, 361
of vulva, 284
Insanity. 265
Inspection —
of abdomen. 160
of trenitiils. 141
I]i.--trmiif'nt> —
common. 226
disinfection of. 210
how to clean. 239
needed in all operations, 228
in ovariotomv, 642
Instruments —
selection of, 239
Intermenstrual ])ain, 424
Intermittent hydrocele of ovary, 554,
618
Interpolar effect, 249
Intestinal —
obstruction, 530, 628, 668
surgery, 724
Intestine —
adherent to tvnnors, 517, 653
anastomosis, 724
button operation, 726
injury during ovariotomy, 653
invagination, 725
laid on abdominal wall, 565, 656, 665
resection, 724
Schroeder's method of repairing, 524
surgery, 724
Invagination theory, ()22
Inversion —
instrumental replacement, 490
manual replacement, 490
of uterus, 485
of vagina, 360
operations for, 490
partial, 485
total, 485
Iodoform, 217
bougies, 426
gauze, 184, 185, 666
solution with tannin, 432
suppositories, 243, 324, 427
Iron contraindicated in uterine hemor-
rhage, 245
pills, 242
Irrigation with hot antiseptic solution,
186, 239
Irrigator for bladder, 179
Irrital)le —
bladder, 429, 433
vascular excrescence of the urethi'a,
300
Ischuria paradoxa, 636
Isthmus —
of Fallopian tube, 65
of uterus. 49
Jacksion, speculum, 152
Jay, urinal, 398
Kaltkxbach, su])ravaginal amputation
of cervix, 449
Kangaroo tendon, 216
Kasper, cystoscope, 166
Keith, opinion about Apnstoli's method.
508
Kelly, catheterization of ureter, 165
rubber cushions, 203
INDEX.
741
Kelh', spud for hysterectomy, 518
suspensio uteri, 474
vcntrotixatiun, 474
Kelsey, speculum, 152
Kemp, rectal tube, 17tt
Keyes, irriijator, 179
Kidney —
extirpation, G55
floating, •;o4
separate collection of urine from, 106
Kleptomania, 2(J5
Knives, 22i»
uterine. 442
Knot, Staffordshire, 566
surgical, 233
Kocher, tissue-forceps, 228
Kieberle, artery clamp, 191
Kopnig, method of reviving, 220
Kraskc. hysterectomy, 549
Kraurosis vulvse, 307
Kreuznach, 196
Kucher)fneister, scissors, 442
Kiistner, Hajvoperalion for atresia. 3')0
operation for inversio uteri, 4'.»0
L.VHAKK.Mii'K, solution, 704
Labia majora —
abnormal, 270
anatomy, 30
function, 37
Labia minora —
anatomy, 37
function. 37
Labor, ovarian cyst during, 605
Laceration —
of cervix. 415
of perineum. 320
compl.-t.'. 321. 325, 335
inconipl.-t.-, 321, 322. 320. 330, 338
inti'i-ni'-iiiate operation, 320
primary o])('ration, 322
secondary operation. 320
of vaginal entrance, 325
Lack of orgasm. 72:5
Laminaria. di>inffction of, 150
Lamp, clrctric, 055
I..aparotoniy. 043
compared with vaginal section, 524,
549, 570
for st.-niitv, 723
Late li..ur-.'l31
Laterol|e\i.,n. 113. 47S
Latern|)o-ition. 113
Laterovi'r>ion, 4l:i. 47K
Lauenstejn. suture. 33H
Laxol, 311
I>ead and opium wa-h. 2h:!
Li'avens, -lUure-,. I'l 1
Leech, artiticial. 194
Leeches, 194
Lefort's operation for prolapse of uterus,
481
Leggings, 207
Leg-hoider, 208
Leopold, apparatus for elevation of pel-
vis. 141, 203
Leptothrix vaginalis, 309
Leucorrhea, 268
in jihthisis, 270
Ligaments —
i)road, 57, 680
infundibulopelvic, 25, 65
interureteric. 83
of bladder. ^2
anterior false, 82
true, 82, 97
lateral false, 82
true, 82, 97
posterior false, 82
superi(^r false, 82
suspensorv, 82
true, .^2
ve?ico-uterine, 56, 82
of ovary, anatomy, 66
development, 23
of rectum, 98
of uterus, 55
perineal. 102
])ubovesicai. 77. 97
round. 5'.t
sacro-uterine. 50
sul>i.ubic. 102
superior round. 58
suspensory, of clitoris, 38
tran.-vei-se. of pelvis, 102
triangular, of urethra, 102
vesico-utei-ine. 50. S2
Ligamentum susj)ensorium of bladder,
82
Ligation of ])edicle of ovarian cyst, 047,
002. (Si'c Ligature. )
Ligature —
-carrier. 233
chain-. 6i;2
<'oin])ared witli forceps, 515
ela>ti<'. 2:'.:!. 4'.iO. 51H
for fec.MJ ti>t>ila. 402
in ovariotomv. 004
ma.-s-, ISS
materi.'il. 233
method t'.ii- hvsterectomv, 513
of arteries. 1H7
of internal iliac artery, 5."><»
pudic artery, ]s'.\
of utci-ine artei-y. l^s
Lipoma — ■
of Kallo|)ian tube, 579
of vulva, 29'.)
742
INDEX.
Lip? of cervical portion, 48
Liquor —
ferri chloridi, 184
folliculi, 28, 74
Liver —
adliesions, 655
floating, 034
Lotion to be used witli tincture of iodine,
197
Lotions —
carbolic acid, 197, 290, 312
chloral hydrate, 288
hydrocyanic acid and lead, 288
Lubricant, 142
Lungs, examination in regard to opera-
tions, 221
Lupus of vulva, 303
Lyjnjthadenitis, pelvic, 711
Lymphangitis, pelvic, 711
Lymphatics —
of perineal region, 110
of uterus, 63
of vulva, 41
Lysol, 218
Malformations —
of Fallopian tubes, 553
of hymen, 345
of ovaries, 581
of pelvic peritoneum, 679
of uterus, 40()
of vatcina, 345, 347
of vulva, 273
Malignant tumor diagnosticated by can-
cer cells in ascitic fluid, 541
Malposition of uterus, 413
Mammary gland, nonnal development
simulating tumor, 116
for uterine fibroids, 507
of sheep in menorrhagia, 245
Manual replacement of inverted uterus,
490
Marcv. cobbler's stitch, 663
needle, 231
subcuticular suture, 650
^larienbad, 197
Marriage —
as a cure, 261
in relation to disease, 131
Marsupialization, 655, 660. 683
^lartin, A., enucleation, 526
hysterectomy, 541
Martin, Franklin, ligature of uterine
arteries for myoma uteri, 509
Massage. 199
for adhesions, 473
Masturbation, 316 '
Maunsell, artificial invagination of in-
testine, 725
Mayer, pessary, 480
3Iayhem, 564
McXaughton, apparatus for elevated-
pelvis position, 204
Meatus urinarius, 89
Medullary substance of ovary, 70
Membrana granulosa, 28, 72
Menopause, 125
treatment, 127
Menorrhagia, 263
Menses, 117
suppression of, 255
Menstrual —
disorders, 265
period, 117
Menstruation, 117
abnormal, 255
coition during, 132
influence of operation, 121, 570
neglect during, 131
operations during, 201
precocious, 262
scanty, 258
supplementary, 258
tardv, 263
theory of, 122
vicarious, 258
Mensuration, 161
Mental aberration after ovariotomy,
671
Mercury, bichloride, 214, 545
Mesentery, adhesions, 625
of Miiilerian duct, 30
Mesoarium, 23
Mesorchium, 23
Mesorectum, 87
Mesosalpinx, 25, 67
Metastasis —
from ovarian cysts, 620
from uterine cai'cinoma, 538, 540
Metbvl blue, 545
Metrftis, 423
acute, 423
chronic, 427
parenchymatous, 436
diphtheritic, 426
dissecting, 426
gonorrheal, 426
operations for, 438
parenchymatous, 423
Metrorrhagia, 265
Metrotome —
Green halgh's, 443
Simpson's, 443
Migration of tumors, 498, 619
Mikulicz, abdominal tamponade, 186,
526
Milliamperemeter, 249
Miner, enucleation, 657
INDEX.
743
Mirror, concave, for throwins; light into
abdominal cavity, 665
Mitchell, Hubbard, speculum, 149
Mitchell, S. "NV'eir, rest-cure, 241
Mixtures —
A. C. E., 219
condurango, 545
hydrocyanic acid, 227
pepsin, 241
putash and belladonna. 287. 433
Schleich's, 218
strychnine, 242
Molecules moved bv electric current, 250
Molimina. 135, 141
Mons Veneris —
anatomy, 35
function, 35
Monsel's solution —
in enucleation of fibroid, 527
in ovariotomy, 665
.Monthlv—
How, '117
sickness, 117
;Murcellation, 505. 516
^lorgagni, hydatid of, 30, 554
hicuna' of, 79
Morphine injected subcutaneously before
anestiietizing, 221
Miillerian duct, 29
Munth', speculum. 149
Murphv, button, 726
MuM'ics—
bulbocaverno.sus, 104
(•occyi;eu>. 99
com|)n'>sor urethnc. 10.5
constrictor urethne. 105
vagina', 106
deep transversus perinai, 106
dej)ressor urethra', 105
detrusor recti, 88
external sphincter uni, 88
(Jutliii.'s. 1(»6
intf-riial sphin<'ter ani, 88
iscliiocaverno.-us, 105
iscliiococcygeus, 99
Jarjavay s, 106
levator ani, 99
oliturat'icoccygeus, 99
jn-rinfal. 105
pubococcytci'ii-. 99
su]i('rti<'ial tr:iiisv<'r.-us perina-i, 106
tliini y^pliiiict<'r of n'ctum, 8K
transversus urethra-. 106
Myotibroiiui —
of utfTus. 494
of V!ii,'ina. 379. (See Fihroi'l, F'l-
lir"»ni. l'"ihr<ii)itiuina, Mi/ditm. )
MyoniH —
cavernous, of uterus, 494
Myoma —
complicating ovarian cyst, 665
lymphangiectodes, 494
of uterus, 494
of vagina, 379
of vulva, 300
teleangiectodes, 494. (See Fibroid,
Fibroma. )
Myomectomy, 527
Myosalpingitis productiva, 554
Myxoid cystoma, 605
Myxoma —
of uterus, 492
of vulva, 300
Myxosarcoma —
of ovary, 674
of uterus, 532
Nakoth, ovula of, 427, 430
Neck of womb, 47
Needles, 230
handled, 231
Hunter's, 514
Marcy's, 231
perineum, 437
Polk's, 519
Schroeder's, 519
Needle-holder —
Crosbv's, 232
Hagedorn's, 231
Neglect of skin, 129
Negro, carcinoma, 537
uterine libroid. 5(K)
Nelaton, artificial respiration, 220
cyst-forc<'ps, 646
Neoplasms —
of P^illopian tube, 578
of ovary, (iOl
of uterus, 492
of vagina, 378
of vulva, 29<)
Nephritis caused bv anostlietics. 220,
530
Nerves —
of perineal region, 110
of uterus. 65
Neuralgia —
hunbo-abdominal, 431
of ut<'rus. 452
Neuroma of vulva, 300
NitroLclyccrin, 223
Noe<j;;erath. iiucrsion. 4!K)
latent t;i>norrhea, 133
Nott, catlieter, 179
Nozzle witli stojK'ock. 209
Nubiiitv. 116
Nuck. canal of. :i7. 59. 281. 679
Nunn's i^orL;<'d coriuiscles. 611
Nussliaum, suj)rapuliic uretlira, 397
744
INDEX.
Nyniplia> —
anatomy, 87
progressive atrophy, 307
Obliquity of uterus, 414
Ooolusion dre.<siiii;. >V24
Okliuni albicans. 3t>U
Ointments —
chloral hydrate, '-'88
oonduraiii:;!). 044
Olshausen, ventrotixatioii, 474
Omentum adherent to tumors, 523,
655
Oophoralgia, G78
Oophorectomy —
results of, 5ti9
Oophoritis, 590
acute, 5'Jl
chronic, 593
follicular, 591
interfollicular, 591
transition to cyst, 594
Oozing tumor, 297
Opening, cloacal, 33
Operating-room, 202
Operating-table, 202
Boldfs, 203
Bozeman's 388
Cleveland's, 203
Foerster's, 203
Operations —
after-treatment, 341
Alexander's, 471
assistants, 204
diet after. 239
disinfection, 209
during hot season, 201
during lactation, 202
during menstruation, 201
during pregnancy. 201
for incontinence, 359, 398
in general, 201
instruments which are used in nearly
all. 227
preparation for. 202
of patient, 206
room, 202
rubber cushions, 203
spectators, 205
taljle for, 202
time of day for. 202
vessels needed in, 209
Opium —
pills. 2til
suppositorie-. 243
Organ of Giraldcs, 22
Organ. Kosenmiiller's, 22
Orgasm, 123
lack of, 723
Os—
externum, 49
graiuilar, 428, 444
internum, 49
pinhole, 441
tinca>, 49
uteri, 49
Osmosis, electrical, 250
Ossilication —
of corpus luteum, 595
of ovarian cysts, 620
Ostium —
abdominale of Fallopian tube, 66
accessorv abdominal, of Fallopian
tube, 553
uterinum of Fallopian tube, 66
Outerbridge, instrument for uterine dila-
tation and drainage, 192
perineorrhaphy, 334
Ova-
absence of, 719
anatomy, 74
development, 26
expulsion, 77, 119
formation, 26
primordial, 28
Ovarian —
abscess, 591
cyst —
adherent everywhere, 655
adhesions, 619. 653, 655
ascites, 628
blood corpuscles in fluid of. 610
calcification, 620
cancerous degeneration, 610. 620. 675
cholesterin in, 613
complicated with labor, 665
complications. 636, 665
congenital. (508
contents. 610, 617
cut oft' blood-supply from, 661
dermoid, 615
diagnostic value of examination of
" fluid. 629
difi'erential diagnosis, 630
epithelial cells in fluid of, 611
etiology, 622
explorative —
incision, 630
puncture. 629
extraperitoneal, 619
diagnosis, 636
fluid, 604, 610. 617. 629
fusion, 619
glandular, 606
hemorrhage. 619. 627
in mesentery, 658
inflammation, 627
intestinal obstruction caused bv, 628
INDEX.
745
Ovarian cyst —
intraligamentous, 619, 656
irremovable, with colloidcontents,659
metastasis, 620
mixed proliferating, G15
multilocular, 608
myxoid, 605
origin, 621
originating in chronic oophoritis, 594
in corpus luteum, 594
ossification, 620
papillary, 614
parvilocular, (SIO
part of, imbedded in pedicle, 657
pedicle, 618, 662
peritonitis caused by, 628
prognosis of, 637
proliferating, 605
pseudo-intniligainentous. 658
relation to carciiion.a, 610
retroperitoneal, 619
Rokitanski's. 604
rupture of, 620, 627
spindle-cells in fluid of, 618
suppuration of. 620, 627
symptoms of, 622
torsion of pedicle, 618, 627
treatment, 637
tubo-ovarian. 617
unilocular, 604
wall of, 604, 608, 616
with pregnancy, 637
tumor —
intraligamentous, 619, 656
oligocvstic, 603
solid, 631, 671
(See Ovarian Cyst.)
Ovaries —
abscess, 591
absence, 581
ad<;no>arcoma. 674
alttiriiatf swelling at menstruatinn, 122
anatomy, 70
carcinoma, 675
carciiiomatDUs cystoma, 675
cirrli<>.--is, 591
cvstocarcinoiiia, 675
cvsts, (;06
d"<sc<-tit, 23
di"v<'lopiiicnt, 22
di-.-a-.-' nf, 581
di>j(la<-fm<'tit, 5K2
enilotl)<'lioma (Ackermann). 674
(.l<.ii.'<), 599
excessive growtli, 5H1
tibromu, 672
fibrosarcoma, 674
fon-igri l>odies, 5H2
function, 77
Ovaries —
gyroma, 594
hematoma, 586
hernia, 582
hydrocele, 617
hyperemia, 586
inflammation, 590
intermittent hydrocele, 554, 618
ligament, 23, 70
malformations, 581
myxt)sarcoma, 674
neoplasms, 601
neuralgia, 678
palpation, 560
papilloma, 673
prola})se, 584
result of removal, 569
rudimentary, 581
sarcoma of, 674
carcinomatosum, 674
second ovary in ovariotomy, 649
supernumerary, 122, 581
transplantation, 571
tuberculosis, 677
with ))eduiiculated cysts, 605
Ovariotomy, 640
abdominal, 641
after-treatment, 651
causes <^f death after, 671
comjilications during after-treatment,
667
during oj)eration, 652, 665
contraindications, 640
difliculties. 652
drainage, 6f)5
hemostasis. 664
incomplete, 659
indications, 640
injury of gall-bladder, 654
of intestine, 653
of uterus, 65H
instruments. 642
opiates. 651
papilloma extending into other organs,
659
}>ar<)titis after, fi71
pre])aratory treatment. 641
j)rognosis, 648
second ovary. 619
shock. 667
temjyerature. 668
toili't of jieritoiieum. 664
vaginal. <p41
Oviducts, r.'.t
Ovi.sacs. 71
Ovula of Nabotb. 427. 430
Ovulation. 12(t
Ovum. (See Oni.)
Ox-gall, 178
■4G
INDEX.
Pachydermia of vulva, 298
Pachyperitonitis, hemorrhagic, 687
Pachvsalpiugitis, 534
Pack; hot, IOC.
Paokiiij::. vai^inal, 182
Pad, hypogastric. 200
perineal, 824
Pain, lotj
intermenstrual, 437
Palnne plieata>, 49
Palpation —
of abdomen, 160
of uretei-s, 166
Papilloma —
growing from ovarian cyst into other
organs, 659
in ovarian cyst, 614
of Fallopian tubes, 579
of ovary, 673
of uterus, 551
of vulva, 295
on outer surface of myxoid proliferat-
ing cystoma of ovar\', 609
on outer surface of ovary, 615,
673
Paquelin's thermocauter}-, 187
Parametric connective tissue, 57
Parametritis, 693
Parametrium, 57
Parenchvmatous zone of ovary, 72
Paring, 229
Parotid gland in oophoralgia, 678
Parotitis after ovariotomy, 671
Parovarian varicocele, 680
Parovarium —
anatomy, 77
development, 22
Partitioning the vagina, 481
Parturition —
pelvic floor during, 113
results in regard to pelvic floor, 113
Patch, mucous, 314
Patient, preparation of, for operations,
205
Pawlik, operation for incontinence, 398
Pean, artery-clamp, 191
retractor, 512
traction-forceps, 228
vaginal hysterectomy, 709
Pectiniform septum. 38
Pedicle of ovarian cyst —
com]iosition. 618
ligation, 647, 663
torsion, 618, 627
Pelvic —
abscess, 701
hysterectomy for. 709
opening — in two sittings, 703
carcinoma, 714
Pelvic diaphragm —
anatomy, 99
function, 99
floor —
anatomy, 96
during parturition, 113
entire displaceable portion, 112
entire flxed portion, 112
function, 112
projection, 107
pubic segment, 112
results from parturition, 114
sacral segment, 112
sarcoma, 714
structural anatomy, 112
hematoma, 691
hemorrhage, 685
lymphadenitis, 712
lymphangitis, 712
peritonitis, 681
phlebitis, 711
sarcoma, 714
Pelvis —
adhesions in, 654
diseases of, 679
hydatids, 715
malformations of, 679
three spaces of, 96
Penis captivus, 375
Pepsin, 241
Percussion, 160
Perimetric inflammation, 681
Perimetritis, 681
Perineal —
body, 106
cystic hygroma, 344
hvsterectomv, 550
pkd, 324
region, 101
Perineorrhaphy —
after-treatment, 341
Emmet's, 332
for retroflexion. 470
Garrigues', 328
intermediate, 326
Outerbridge's, 334
preparation for, 341
primary, 324
secondarv. 326
Tait's, 327
Perineum —
complete laceration, 324
development, 31
diseases, 320
incomplete laceration, 322
injuries, 320
needle, 233
old lacerations, 327
recent lacerations, 320
INDEX.
747
Perioophoritis, 591
Perisalpingitis, 554
Peritoneum —
function, 94
gelatinous disease, 621
pelvic, 92
pseudomyxoma, 621
taken for ovarian cyst-wall, 652
toilet, 664
Peritonitis —
diagnosis from ovarian cyst, 630
pelvic, 681
septic. 669
with ovarian cyst, 628
Pessary —
after ventrofixation, 469
Breisky's, 480
Emmet's, 469
Fowler's, 470
Gariels, 480
Geh rung's, 456
general remarks, 456
Hewitts cradle, 455
Hodge's, 469
Mayers, 480
retroflexion, 469
stem-, 461
Thomas's anteversion, 455
retroflexion, 586
vaginal, 455
Vienna, 455 ,
whalebone, 470
Petit s triangle. 7(»2
Petzer, catheter, 513
Phaijcdena, 311
I'liiintom tumor, 636
Phlebitis-
after ovariotomy, 671
pelvic, 711
Phvsiologv. 116
Physometra, 127, 411. 441, 632
Pilimiction, 616
Pills—
iilops and iron. 242
anti(ly.-iiif'ni)rrh(;ic, 261
C'bian turpi-ntiiM-, 544
coniuiii. 261
emmenagogue, J,-)i
'irihole os, 441
'inworms, 292
'latvsma, 58
'lf'(l'trct>. vaginal. 182
'liiM- palmatii-. 49
'iombi.'-ns. 196
'lug, vaginal, IH.-?. .'549
*oles, (|ualiti<'S <iC. "J.X)
'olvpus—
fibrinous. 493
fibroid uterine. 494
Polypus —
fibroid vaginal, 380
glandular. 492
hollow, 488, 491
intermittent, 499
mucous, of uterus, 427, 492
vaginal, 381
myxomatous, 492
Position, 138
breech-back, 139, 208, 388
dorsal, 138
elevated-pelvis, 140, 223
erect, 140
genupectoral, 140
high pelvic. (See Elcmfed pelvis.)
Simon's, 208, 388
Sims's, 139
ventral, 141
Posterior commissure, 36
Postural treatuient of retroflexion, 470
Potain, as])irator, 170
Potassa, 287, 433
Pouch —
Hrocas, 37
Douglas's, 93
oliturator, 93
para-uterine, 93
paravesical, 93
recto-abdominal, 93
recto-uterine, 93
utero-abdominal, 93
vesico-abdominal, 93
vesico-uterine, 93
Poultice, 195
Powders —
headache, 267
phenacetine compound, 267
Pozx.i —
injury to ureters, 655
operation for urethrovaginal fistula,
394
Pratt, hysterectomy, 517
Preoicity. 406
Pregnancy —
diagnosis from ovjirian cyst, 623
in relation to uterine fibn^ids, 527
o])('rations during, 201
with cancerous uterus, 548
with ovarian cyst, 637
Pregnant cancerous uterus removed by
vaginal hysterectomy, 548
Prenuce. 87
adherent, 275
Press) ire —
as hemostatic, 663
-fonej)s. 190. 230, 511
symptoms, ')<K)
Priessnit/'s cotnpn'ss, 195
Primary follicles, 2H
748
INDEX.
Primordial ova, 28
Probe, 155
Procidentia of uterus, 470
Proiiressive atrophy of nyinphap, 307
Prolapse —
acute, of uterus. 470
artificial, of uterus, 145
Brandt's nietiiod, 480
chronic, 471*
complete, 470
incomplete, 469
Lefort's operation, 481
of anterior wall of vagina, 356
of intestine into deep Douglas's pouch,
355
of ovaries, 584
of p()sterior wall of vagina, 359
of urethra, 315
of uterus, 470
of vagina, 360
operations, 481
Prolapsus of uterus, 470
Proliferating cyst, G05
Pruritus, 291
l*ryor, hysterectomy, 519
Pseudohermaphrodism, 277
Pseudo-intraligamentous tumors, 659
Pseudomvxoma of peritoneum, 621
Puberty, "116
dilferent from nubility, 116
Puncture, explorative, 629
Puncturer, expanding, 198
Pus, inspissation of, 574
Pvocolpos, 345
"lateral, 353
Pvometra, 345, 411, 441
Pyosalpinx, 554, 574, 631
saccata, 554
Pyromania, 265
Raphe —
ano-coccygeal, 99
perineal, I03
Pieceptaculum seminis, 67
Keftal—
alimentation, 241
ampulla, 87
speculum. 153
Pvect(jcele, 359
Emmet's operation, 332
Rectum —
anatomy, 86
functi<^n, 91
Reese, artitieial leech, 194
Regicjns —
abdominal, 115
anal, 101
perineal, 101
urogenital, 101
Relaxation of abdominal wall, 652
Repositor —
Aveling's, 489
Bvrne's, 490
White's, 490
for inversion, 489
for retroflexion, 469
Resolution, 243
Resolvents, 243
Respiration, artificial, 221
Rest-cure, 242
Retractor —
Engelmann's 227
Landauer's, 646
muscles of uterus, 56
Pean's, 512
Schroeder's, 227
vaginal, 227, 512
Retroflexed gravid uterus, 631
Retroflexion, 465
Retro-ovarian shelf, 93
Retroposition, 413
Retroversion, 464
Reverdin, apparatus for lifting large
tumors, 523
Reviving from anesthesia, 209. 223
Rheophores, 249
Rheostat, 249
Richardson's bellows, 221
Rima pudendi, 36, 43
Robb, leg-holder, 209
Rodent ulcer, 536
different from the corroding ulcer, 541
Rokitanski's tumor, 604
Roof of vagina, 42
Room, operating-, 202
Rose, H., separate collection of urine
from kidneys, 166
vesical speculum, 167
Rosenmuller's organ, 22
Round ligament —
anatomy, 59
diseases, 684
fibroma, 283
function, 51, 62
hematoma, 282
shortening, 471, 478
tumors connected with extrapelvic
portion, 280
Rubber — -
bag for injecting bladder, 180
cushions for o]ierations —
Kellv's, 203
Marcy's 203
ligatures, preservation of, 221
Rudimentary horn of uterus, 4(»H
Ruga; of vagina, 43
Rupture of ovarian cyst, 620, 627
Ruptures (hernite), 278
INDEX.
749
Sacral hysterectomy, 549
Sacro-uterine ligament, 56
diseases of, 684
Salpingitis, 554
acute catarrhal, 554
purulent, 554
chronic interstitial, 554
conservative treatment of, 563
cystic, 554, 572
infectious, 554
interstitial, 555
isthniica nodosa, 554
munil, 5->4
non-inffctious, 554
parenchymatous, 554
profluont, 554
Salpingo-iiopliorectomy, 563
abdominal, 564
for aiitetiexioii, 464
for hemorrhagic endometritis, 440
mortality, 568
results, 56!t
vaginal, 570
with ventroHxation, 478
Salt, solution of. 529
Sand-bodies, 615
Sarcoma —
carcinomatosum of ovary, 674
decidual, 5:^4
of Fallopian tube, 579
of ovarv. 674
of pelvis, 714
of uterus, 531
of vagina, 594
of vulva, 302
Scarification of vaginal [)ortion, 195
Scariticatur, Garrigues', 195
Scliede. operatioi> for un-terovaginal fis-
tula. .".'.(4
Scliimmi'Ibu.-th. sterilizatioii-box, 212
Scbl.-iclrs anc-tlictic. 218
Scliroedcr, ni'i-djc for hysterectomy, 519
operation for vaginal cyst, .'!79
repair of iiite.-tiric. 524
vaginal retiactor, 227
Scbuchardt, hy.-terectomy, 549
Scliult/.e. disinfection of lumiMaria tents,
15*;
nietliod of tearing adhesions of ovarv,
5h.'.
of uterus. 47:'
Scirrhus of vulva. :'02
Sciv-ors, 22'.»
Mozeiiian'> 505
Kucbeiuiiei'ter's. 442
.•-^i;! relief, ureteral, 165
.■^eciiiiii, \ airiiial. compan-d with abdomi-
nal. 524. 572
Sedativev 21:;
Segmental vesicles, 21
Segond, speculum, 511
vaginal hysterectomy, 510
Septicemia, 530, 669
Septum —
pectiniform, 38
retrohymenale, 347
transverse perineal, 103
Serrefines, 322
Shelf, retro-ovarian, 94
Shock, 528, 667
Shortening of round ligament —
extraperitoneal, 471
intraperitoneal, 471
vaginal, 476
Shouldering, 235
Silk, 212
Silkworm gut, 216
Silver wire, 216, 233
Simon, cone-mantle-shaped excision of
cervical portion, 439
curette, 155
operati()n for fistula, 388
position, 208, 388
Simpson, J. Y., metrotome, 442
Sims, Marion, catheter, 387
discission of posterior lip of cervix,
461
operation for anteversion, 457
for cystocele, 357
for rectovaginal fistula, 386
for urinary fistula, 386
speculum, 147
sponge-holder, 229
suture-shield, 234
uterine knife, 442
Sinus cojjularis. 30
urogenital, 20, 31
Sinuses of ^lorgagni, 90
Skene's glands, 80
Smith, cautery-clamp, 648
Snegiretf, vaporization, 186, 654
Sodium suljihate, 245
Solution —
horosalicylic, 218
ergotine, 507
Labarraquc's, 704
Monsel's, 527, 665
normal salt, 529
sclerotinic acid, 50*)
sodium carbomite, 210
tnnnin-iodoform, 432
Tliierscii's, 21 K
Villates, 70 J
Solutions, antiseptic. 217
Soullle, uterine. Ifil
Sound, uterine. 1 51
Space —
.-ui>cutan«-<ius, of jichis, 96
750
INDEX.
Space —
subperitoneal, of pelvis, 96
Spanish-fly blister, 197
Spectators, 205
Speculum —
Ashton's, 153
bath-. 195
bivalve, 147
bladder-, 165
Bozonian's, 388
Brewer's, 147
Burrage's, 152
cervical, 152
Cusco's, 152
Ehrich's, 151
Fergusson's, 146
Folsom-Skene's, 154
Garrigues', 226
Jackson's, 153
Kelly's, 165
Kelsev's, 153
Mitchell's, 150
Munde's, 150
plurivalve, 146
rectal, 153
Segond's, 511
self-holding, 150
Sims's, 147
tubuliform, 146
univalve, 147
urethral, 153
vaginal, 146
Sphincter —
ani, how to unite broken, 339
muscles of urethra, 79
of rectum, third, 88
Spina biflda, 635
Spiritus glonoini, 223
Spleen —
adhesions, 654
cyst, 635
tumor, 635
Sponge-holder, 228
Sponge taken for carcinoma, 538
S{)(jnges, 211
Sponging, 238
Spongiopiline, 196
Spontaneous opening of wound
ovariotomy, 669
Spoon, shai'j), 155
Spoon-saw, 505
Si)rings, mineral, 196
StatIV)rd.>hire knot, 566
Stt'airi as disinfectant, 209
as hemostatic, 654
Stearate of zinc. 667
Stem-pessary, 455
Stenosis —
of cervical canal, 259. 394. 421
after
Stenosis —
of cervical canal, acquired, 421
congenital, 421
of vagina, 347
Sterility, 718
after double ovariotomy, 671
in the female, 719
in the male, 718
primary, 719
secondary, 719
Sterilization —
of catgut, 212
of water, 216
Sterilizer, 209, 212
Arnold's, 211
Schimmelbusch's, 212
Stimulants, 223, 240
Stitch, cobblers', 649, 662
Stomach, dilatation of, 635
Stramonium pills, 260
Structureless membrane of Graafian fol-
licle, 69
Strychnine —
in collapse, 223
mixture, 243
pills, 257
Stupe, 195
Styptics, 186
Subinvolution of uterus, 436
menstrual, 263
Summit of bladder, 78
Superfetation, 410
Superinvolution of uterus, 451
Supporter —
abdominal. 199
uterine, 480
Suppositories —
with iodoform, 343, 407
with morphine, 343
with opium, 243
Suppuration of ovarian cyst, 620
Supravaginal amputation compared with
total extirpation of uterus, 525
Suspen.sio uteri, 474
Suture, 233
buried catgut, 329, 331
button-, 368
chain-, 238, 660
cobblers' stitch, 649, 662
continuous, 236
Czerny-Lembert's, 653
for fecal fistula, 402
for hemostasis, 191
for inversion, 490
for urinary fistula, 365
forming nucleus of stone, 391
glovers^'. 238
Halsted's, 650
horsehair, 214
INDEX.
751
Suture, how to remove, 238
interrupted, 236
kangaroo tendon, 216
Lauenstein's, 388
looped, 238
Marovs, 650
material, 210, 233, 322
mattress-, 191
quilled, 191, 236
removal of, 238
running, 236
secondary infection of, 233
-shield, 235
shouldering, 235
silk. 211, 233
silkworm gut, 216
silver wire, 216, 234
sterile, 210
subcuticular, 650
suhmucous, 338
tier-, 237
twisting, 236
Swedish movement cure, 200
Svlvester's artificial respiration, 221
Syphilis, 312
indurating edema, 304
initial lesion, 312
secondary, 314
tertiary, 315
Syringe —
Braun's, 176
bulb-and-valve, 175
Davidson's, 175
exploratorv vaginal, 169
for bladder, 179, 180
fountain, 175
Fritsch's, 288
Frost's, 709
uterine, 176
Tahlk—
Daggett's, 137
examining-, 137
'){)erating-. (See Operatinfj-tahle.)
Tait, llap-splitting operation for j)erineal
laceration, 327
operation for f<!cal fistula, 403, 404
for urinary fistula, 3H9
sujpini^o-oopborectomy, 564
sliort<iiing of round ligaments, 476
"Tail's operation," 564
Tampon —
abdominal. 186
vaginal. IK'J
Tamponade, I Hi
of Uterus, 1H5
Tannin —
U'lycerite, 1H2
solution with iodoform. 432
Tape-carrier, 504
Tapping, 197, 638
Tate, inversion, 502
Taylor, I. E., operation for rectolabial
fistula, 402
Temperature after ovariotomy, 668
Tenaculum, 228
Emmet's, 228
Tenaculum-forceps, 228
Tendinous arch, 96
Tent-carrier, 157
Tents, 156
Terraline, 270
Tetaims, 530, 671
Thermal galvanocauterization for cancer
of uterus, 546, 547
Thermocauterectomy of uterus, 547
Thermocautery, 187
Thiersch's solution, 218
Thirst, 239
Thomas, antevei-sion j)essary, 4')5
cla.ssitication of antetlexion, 458
curette, 155
enucleation of uterine fibroids, 508
invei-sion, 489, 490
operation for vaginismus, 377
retroflexion pessary, 586
spoon-saw, 505
stem-pessary, 461
Thompson, bladder-syringe, 180
Thrombosis, 530
Thrombus —
of vagina, 361
of vulva, 295
Thymol, 218
Thyroid, relation to uterus. 412
Tincture of iodine —
in ovariotomy, 665
in ])elvic abscess, 702
in the vagina. 175
on the skin, 196
Tissue-forceps, 229
Toilet of jH'i'itoneum, 664
Tongue-force})s, 222
Tonics. 242
Torsion of pedicle, 618, 627
Trachel()rrbai>hy, 41H
for retrollexion, 470
needles, 418
Traclielotomy. 442
Traction, for removing uterine (iliroids.
Transfusion. 529
Transpliintation of ovary. oTO
of vaLrinal l]aj)s, 353
Travelling, cure for sterility, 722
Trejilmeiit —
electri.-. 246
external. 174
752
INDEX.
Treatment —
in general, 172
internal, 240
preventive, 172
Trendelenburg, operation for fistula,
389
position. (See Elevated Pelvis. )
anesthesia in, 222
Trithiasis, 2!ll
Trichomonas vaginalis, 364
Trigone, Lieutaud"s, 81
Tripperfaden, uOO
Trocar —
Emmet's, (546
vaginal, 197
Warren's, 639
Tubercle, genital, 33
of vagina, 43
Tuberculosis —
of Fallopian tube, 579
of ovary, 677
of peritoneum, 633
of uterus, 551
of vagina, 382
of vulva, 306
Tubes—
double-current uterine, 178
drainage-, 193
Fallopmn, 66, 580
dilated, 177
rectal, 179
single-current uterine, 177
Tubo-ovarian cj'st, 617
Tumeur fluxionnaire, 437
Tumor —
fibroid, of uterus, 493
loose, 498, 619
migrant, 498, 619
of abdominal wall, 635
of broad ligament, 684
of round ligament, 280
of spleen, 635
of vulva, 294
(See Cancer, Carcinoma, Cyst, Fi-
broid, Sarcoma. )
oligocystic, 603
oozing, 297
painful, of urethra, 300
phantom, 636
Kokitanski's, 604
solid o\ariaii, (;71
vascular, of urethra, 300
Tunica —
fibrosa of Graafian follicle, 73
propria of Graafian follicle, 73
Turns, 117
Turpentine, Chian. 545
Tuttlf. fibroma moUuscum, 299
Tympanites, 178, 636, 667
Ulcer —
corroding, 444, 540
of cervix, 444
rodent, 53<)
simple, 444
tuberculous, 306, 382, 444
venereal, 310, 312
TJnguentum Crede, 175
Urachus, 31, 83
persistent, 517, 652
Ureter —
anastomosis, 655
anatomy, 84
at base of intraligamentous tumors, 659
catheterization, 165
course during pregnancy, 85
examination, 162
function, 86
implantation, 395
injury, 391. 393, 537, 655
ligation, 391, 530, 537
opening into vagina, 354
palpation, 166
Ureterocystostomy, 395
Urethra —
anatomy, 79
atresia, 392
caruncle, 300
dilatation of, 144
ducts, 80
inflammation of, 289
function, 81
irritable vascular excrescence, 300
painful tumor, 300
prolapse, 315
suprapubic, 397
vascular tumor, 300
Urethral —
ducts, 80
inflammation of, 289
speculum, 152
Urinals, 397
Bozeman's, 398
Jay's, 398
Urinary analysis, 161
Urine —
alkaline, 375
collected separately from kidneys, 168
examination with regard to opera-
tions, 205
suppression of, 668
Urogenital region, 99
sinus, 20, 31
persistent, 354
Uterine appendages of the other side —
in ovariotomy, 648
when one set is removed, 567
artery —
aiieurvsm, 679
INDEX.
763
Uterine artery —
during pregnancy, 62
ligature of, 188
cancer, 530
radical treatment, 545
carcinoma, 536
fibrocyst, 499
treatment, 530
fibroid —
aMominal enucleation, 521
apparatus for lifting, 523
cervical, 494
changes, 499
combined with pregnancy, 527
corporeal, 494
curetting, 508
galvanochemical cauterization, 507
hypodermic injection of ergot,
507
indications for operations, 531
in negro race, iyOO
interstitial, 496 •
intramural, 496
mortality of operations, 528
multiple, 498
pedunculated, 496
sessile, 496
single. 498
sloughing, 528
submucous, 496
subperitoneal, 496
supravaginal amputation, 523
traction method, 509
vaginal enucleation, 508. (See
I'fn-iis. )
Uterotract^tr, 547
terus —
absence, 406
acollis, 413
actjuircd atrophy, 451
adenoma, 492
anatomv, 4H
untcficxion, 413, 458
ariteposition, 413
antcvcrsion, 453
apoplexy, 127
arrest of devflopment, 406
artificial prolapse, 145
atresia, 410, 440
atropliy, 451
bicariiiTiitiis vctiilarum, 127
bicoriiis. 409
liiloculiiris, 409
bimanual rej)lacernent, 468
body, 48
cancer, 531
carcinDniH, 536
of body, 537
of cervix, 537
48
Uterus —
carcinoma of vaginal portion, 536
catarrh, 430
cavernous angioma, 494
cavity, 50
cervical carcinoma, 536
cervix, 48
closure, 440
congenitally atrophic, 412
corpus, 48
cystosarcoma, 532
cysts, 493
descent, 478
development, 31
excessive, 405
didelphys, 407
digital replacement, 469
dilatation, 158
diseases, 406
displacement, 453
duplex separatus, 407
elevation, 485
enchondroma, 551
erosions, 427, 433, 444, 542
excessive development, 406
extirpation, 510
fetal, 411
fibrocysts, 499, 632
fibroid, 494
tumor, 494
fibroma, 494
fibromyoma, 494
foreign bodies, 422
function, 65
fundus, 48
fangrene, 452
ernia, 413, 491
horns, 31
hypertrophy, 445
imperforate, 410
infantile, 411
inflammation, 423
injuries, 414
inversion, 485
irregular development, 413
isthmus, 50
lateroflexion, 413, 478
lateroposition, 413
lateroversion, 413, 478
ligaments, 56
lips, 49
male, 30
malformations, 406
maliiosition, 413
niucnus membrane, 51
myofibroma, 4!t4
myoma, 494
inyxoma, 492
myxosarcoma, 532
1 54
INDEX.
Uterus —
nec-k, 48
neoplasms, 492
neuralgia, 452
ohlicjuity, 414
pa})ill()nia, ool
parvicollis, 418
perforation, 181
jwlypus, 41»2
clandular, 492
hollow, 488, 491
mucous, 492
niyxoinat<jus, 492
position, o'2
procidentia, 478
prolapse, 478
prolapsus, 478
pubescent, 412
relation to thyroid, 412
repositors, 4(J9
retractor muscles, 56
retroflexion, 465
retroposition, 413
retroversion, 464
rudimentary, 407
horn, 408
sarcoma, 531
senile atrophj', 451
septus. 409
severance of adhesions, 475
shape and position, 52
subinvolution, 436
subse))tus, 409
superinvolution, 451
supravaginal amputation, 517. (See
Hystey^ectorny. )
suspension, 474
tamponade, 186
thermocauterectomv, 547
total extirpation, 510
compared with supravaginal am-
putation, 525
tuberculosis, 551
tumeur fluxionnaire, 437
unicornis, 408
vaginal portion, 48
vaginofixation, 472
ventrofixation, 474
wounded in ovariotomy, 655, 658
Vagin'a —
anatomv, 41
atresia, '348, 854
blind canals, 854
carcinoma, 881
cicatrices, 378
columns, anterior and posterior, 48
cysts, 378
development, 31
Vagina —
diseases, 845
double, 858
entrance, 43
erysipelas, 873
extirpation, partial or total, in carci-
noma of uterus, 547
faulty communications, 354
fibroid polypus, 379
tumor, 379
fibroma, 379
fibromyoma, 379
foreign bodies, 362
function, 46
gangrene, 872
glass plug, 349
hematoma, 362
how to keep open after atresia opera-
tion, 349, 350
incision, 472, 511, 514, 562, 702
injuries, 361
inversion, -360
laceration of entrance, 325
malformations, 345, 347
mucous polypus, 381
myofibroma, 379
narrowness, 348
neoplasms, 378
partitioning, 481
prolapse, 360
of anterior wall, 356
of posterior wall, 360
roof, 42
ruga?, 43
sarcoma, 381
stenosis, 847
tamponade, 184
thrombus, 361
tubercle, 43
tuberculosis, 382
Vaginal —
enterocele, 354
case of, 355
glass plug, 192
hernia, 854
hysterectomy, limits, 517
portion —
anatomy, 48
development, 32
subinvolution, 486
speculum, 146
Vaginismus, 347, 375
deep, 875
superficial, 375
Vaginitis, 868
acute, 363
adhesive, 364
catarrhal, 864
chronic, 863
INDEX.
755
Vaginitis, diagnosis between simple and
gonorrheal, 866
diphtheritic, 870
dissecting, 371
due to burrowing pus from pelvic ab-
scess, 872
dysenteric, 871
emphysematous, 869
epithelial, 368
exfoliative, 368
exudative, 850
follicular, 364
glandular, 364
gonorrheal, 366
gniTiular, 364
mycotic, 361*
phlegmonous, 371
primary, 363
secondary, 368
simple, 364
Vaginofixation of retroflexed uterus, 478
Valves —
Houston's, 90
of rectum, 90
Van Hook, ureteral anastomosis, 656
Vaporization, 511
Varicocele —
of broad ligament, 680
parovarian, 680
Vascular zone of ovary, 71
Vegetations of vulva, 296
Veins —
of ])erineal region, 110
uterine, 61
varicose, of vulva, 295
Venereal diseases, 310
Ventrofixation of uterus, 474
Becks metliod, 475
Kelly's, 474
Olshausen's, 474
Vesicles, segmental, 21
Vesicula prostatica, 30
Vessels needed for operations, 208
Vestibule —
anat<jmy, 39
development, 32
function, 4(»
A'estilmiovagiiiiil l)ulk, 39
Vignard, operation fur fecal fistula, 403
Villate, solution, 704
Viiieberg, vaginal fixation, 475
\'irgins, examination of, 159
^'itellin(! membrane, 74
Vitellus 74
Volseila. 22K
Vomiting, 201, 227, 242, 243, 667
Vuillet, method of dilatation, 159
Vulva —
absence, 273
Vulva —
anatomy, 36
angioma, 300
atrophic carcinoma, 302
cancer, 302
carcinoma, 302
chronic infiltration, 303
inflammation, 303
ulceration, 303
cysts, 301
development, 33
diseases, 273
elephantiasis, 298
epithelial coalescence, 276
epithelioma, 302
exanthematous diseases, 290
fibroma, 299
gangrene, 289
garrulity, 842
hematoma, 295
hvperesthesia, 294
hyperplasia, 294, 304
injuries, 283
kraurosis, 307
lipoma, 299
lupus, 803
malformations, 273
medullary carcinoma. 302
mclanosarcoma, 302
myoma, 299
myxoma, 299
ne()j)lasms, 29()
neuroma, 30:i
oozing tumor, 297
pachydermia, 298
pa))illoma. 296
pi-uritus, 291
sarcoma, ;!()2
scirrlius, ;)()2
thrombus, 295
tuberculosis. 30*1
tumors, 294
varicose veins. 295
vegetations, 2'.t'i
warts. 295
Vulvitis, 285
Vulvovaginal inland —
abscess. 3(t'.i
anatomv. 10
ciitarrh! :!(tx
cvsts, 30S
diseases, 30S
Vulvovai:initi> in eliildren. 372
Wai.ciikk. operation for listula, 3iK)
Walii<'h, cliaiM-snture, 662
Warren, tioi-ar, <i3'.i
\Vart> of vulva. 2'.t5
756
INDEX.
"Water —
hot, 18G
sterilized, 218
"Watkins, operation for cystocele, 358
Wells, pedicle-forceps, 647
White line —
at anus, 89
of labia minora, 37
Whites, 268
Wiley, Gill, shortening of round liga-
ments, 476
Wire-twister, 235
Wolffian—
body, 20
duct, 19
Woman's dartos, 37
Womb, falling of, 478
Xenomenia, 258
Zona pellucida, 74
CATALOGUE
OF THE
MEDICAL PUBLICATIONS
OF
W. B. SAUNDERS & CO.,
No. 925 WALNUT STREET, PHILADELPHIA.
Arranged Alphabetically and Classified under Subjects.
THE books advertised in this Catalogue as being sold by subscription are usually to be
obtained from travelling solicitors, but they will be sent direct from the office of pub-
lication (charges»of shipment prepaid) upon receipt of the prices given. All the other
books advertised are commonly for sale by booksellers in all parts of the United States; but
books will be sent to any address, carriage prepaid, on receipt of the published price.
Money may be sent at the risk of the publisher in either of the following ways : A post-
office money order, an express money order, a hank check, and in a regisiereil letter. Money
sent in any other way is at the risk of the sender.
See p<^es 32, 33 for a L'^t of Contents classified according to subjects*
LATEST PUBLICATIONS.
American Students* Medical Dictionary, See page 34.
American Text-Book of Physiology — Second (Revised) Ed. Page?.
Friedrich and Curtis on Nose, Throat, and Ear. See page 34.
Le Roy's Histology. See page 34.
Ogden on the Urine. See page 34.
Pyle's Personal Hygiene. See page 34.
Salinger and Kalteyer's Modern Medicine. See page 34.
Stoney's Surgical Technic for Nurses. See page 34.
Hyde and Montgomery's Syphilis and Venereal Diseases — Revised
and Enlarged Edition. See page 15.
International Text-Book of Surgery. See page 15.
Garrigues* Diseases of Women — Third (Revised) Edition. Page 13.
American Text-Book of Dis. of Eye, Ear, Nose, and Throat. Page 5.
Saunders' American Year-Book for 1 900. See page 8.
Levy and Klemperer's Clinical Bacteriology, iee i-age 17.
Scudder's Treatment of Fractures. See page 26.
Senn's Tumors — Second Edition. See page 27.
Beck on Fractures. See page 9.
Watson's Handbook for Nurses. See page 31.
Heisler's Embryology. See page 15.
Nancrede's Principles of Surgery. See page 20.
Jackson's Diseases of the Eye. See page J6.
Kyle on the Nose and Throat. See page 17.
Penrose's Diseases of Women — Third (Revised ' Edition. Page 20.
Warren's Surgical Pathology— Second ' Revised) Edition. Page 31.
Saunder's Medical Hand-Atlases. Sec pages 2, 3, 4.
American Pocket Medical Dictionary — Third (Revised) Ed. Page 12.
SAUNDERS'
MEDICAL HAND-ATLASES.
The series of books included under this title consists of authorized
translations into English of the world-famous Lehmann Medicinische
Handatlanten, which for scientific accuracy, pictorial beauty, com-
pactness, and cheapness surpass any similar volumes ever published.
Each volume contains from 50 to 100 colored plates, executed by the
most skilful German lithographers, besides numerous illustrations in the
text. There is a full and appropriate description of' each plate, and
each book contains a condensed but adequate outline of the subject to
which it is devoted.
One of the most valuable features of these atlases is that they offer a
ready and satisfactory substitute for clinical observation. To those
unable to attend important clinics these books will be absolutely indis-
pensable.
In planning this series of books arrangements were made with the rep-
resentative publishers in the chief medical centers of the world for the
publication of translations of the atlases into different languages, the litho-
grai)hic plates for all these editions being made in (Germany, where work of
this kind has been brought to the greatest perfection. The expense of
making the plates being shared by the various publishers, the cost to each
one was materially reduced. Thus by reason of their universal transla-
tion and reproduction, the publishers have been enabled to secure for these
atlases the best artistic and professional talent, to produce them in the
most elegant style, and yet to offer them at a price heretofore unap-
proached in cheapness. The success of the undertaking is demonstrated
by the fact that the volumes have already appeared in thirteen different
langnages— German, English, French, Italian, Russian, Spanish, Japanese,
Dutch, Danish, Swedish, Roumanian, Bohemian, and Hungarian.
In view of the striking success of these works, Mr. Saunders has con-
tracted with the ])ublisher of the original German edition for one hun-
dred thousand copies of the atlases. In consideration of this enormous
undertaking, the iniblisher has been enabled to prepare and furnish special
additional colored j^lates, making the series even handsomer and more
complete than was originally intended.
As an indication of the practical value of the atlases and of the favor
with which they have been received, it should be noted that the Medical
Department of the U.S. Army has adopted the "Atlas of Operative
Surgery" as its standard, and has ordered the book in large quantities for
distribution to the various regiments and army posts.
The same careful and competent editorial supervision has been
secured in the English edition as in the originals, the translations being
edited by the leading American specialists in the different subjects.
SAUNDERS^ MEDICAL HAND-ATLASES.
VOLUMES NOW READY.
Atlas and Epitome of Internal Medicine and Clinical Diagnosis.
By Dr. Chr. Jakob, of Erlangen. Edited by Augustus A. Eshner, M.D.,
Professor of Clinical Medicine, Philadelphia Polyclinic. With 68 colored
plates, 64 text-illustrations, and 259 pages of text. Cloth, $3.00 net.
" The charm of the book is its clearness, conciseness, and the accuracy and beauty of its
illustrations. It deals with facts. It vividly illustrates those facts. It is a scientific work
put together for ready reference." — Brooklyti Medical Journal.
Atlas of Legal Medicine. By Dr. E. R. von Hofm.anx, of Vienna. Edited
by Frederick. Peterson, M.D., Chief of Clinic, Nervous Dept., College
of Physicians and Surgeons, New York. With 120 colored figures on 56
plates, and 193 beautiful half-tone illustrations. Cloth, $3.50 net.
" Hofinann's 'Atlas of Legal Medicine ' is a unique work. This immense field finds in this
book a pictorial presentation that far excels anything with which we are familiar in any other
work." — Philadelphia Medical Journal.
Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald,
of Munich. Edited by Charles P. Gravson, M.I)., Physician-in-Charge,
Throat and Nose Department, Hospital of the University of Pennsylvania.
With 107 colored figures on 44 plates, 2^ text-illustrations, and 103 pages
of text. Cloth, $2.50 net.
"Aided as it is by magnificently executed illustrations in color, it cannot fail of being of
the greatest advantage to students, general practitioners, and expert laryngologists." — St.
Louis Aledical and Surgical Journal.
Atlas and Epitome of Operative Surgery. By Dr. O. Zuckerkandl,
of Vienna. Edited by J. Chalmers DaCosta, M. D., Professor of
Practice of Surgery and Clinical Surgery, Jefferson Medical College,
Philadelphia. With 24 colored plates, 217 text-illustrations, and 395
pages of text. Cloth, $3.00 net.
" We know of no other work that combines such a wealth of beautiful illustrations with
clearness and conciseness of language, that is so entirely abreast of the latest achievements,
and so useful both for the beginner and for one who wislies to increase his knowledge of
operative surgery." — Munchener mcdicinisclie Wochenschrift.
Atlas and Epitome of Syphilis and the Venereal Diseases. By Prof.
Dr. Franz Mracek, of Vienna. Edited by L. Bolion Ban<;s, M.D.,
Professor of Genito-Urinary Surgery, University and liellevue Hospital
Medical College, xN'ew York. \\'ith 71 colored plates, 16 black-and-
white illustrations, and 122 pages of text. Cloth, $3.50 net.
'• A glance through the book is almost like actual attentiance upon a famous clinic." —
Journal of the Amtrican Midical .-tssori.ttion.
Atlas and Epitome of External Diseases of the Eye. 15y Dr. O.
Haai!, of Zurich. Indited by G. E. dk S( mweini 1 /, .M.D., Professor of
(Ophthalmology, Jefferson .Medical College, Philadelpliia. With 76
colored illustrations on 40 plates, and 228 ])ages of text. Cloth, S3-oo net.
" It is always difficult to represent pathological appearances in coloicij plates, liut liiis
work Sfems to have overcome these difficulties, and the plate., with one or iwi^ exception.'-,
are aitsoiutelv satisfactory." — lio-<lon Medical anil Sit'xicil /ourual.
Atlas and Epitome of Skin Diseases. By 1'koi. Dr. I kan/ Mkacik,
of \'ienna. I'-dited by Hinkv W. SrKLWA<;o\, M.D., Clinical Professor
of Dermatology, Jefferson Medical College, I'hiladelphia. With 63 colored
plates, 39 half-tone illustrations, and 200 j)ages of text. ( "loth, 53.50 net.
"The imiH.rtance of personal inspection of c.nses in tiie study of rutaneuus discuses is
readily apprec iated, and next to the living subjects are ]iictiires which will show tiie ap|>ear-
ance of tiie disease under consideration. Altogether the work will be found of \cry great
value to the general practitionei ." — J«ui ual of the American .Medical A^uicialion.
SAUNDERS^ MEDICAL HAND-ATLASES,
VOLUMES JUST ISSUED.
Atlas and Epitome of Special Pathological Histology. By Dr. H.
DiJRCK, of Munich, luiited by Ludvig Hektoex, M. L)., Professor of
Pathology, Rush Medical College, Chicago. In Two Parts. Part I.
Just Ready, including the Circulatory, Respiratory, and Castro-
intestinal Tract, with 120 colored figures on 62 plates and 158 pages
of text. Price, $3.00 net. Parts sold separately.
Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed.
(ioLEBiKWSKi, of Berlin. Translated and edited with additions by
Pe.xrce B.viLEV, M. D., Attending Physician to the Department of Cor-
rections and to the Almshouse and Incurable Hospitals, New York.
^^'ith 40 colored plates, 143 text-illustrations, and 600 pages of te.xt.
Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidel-
berg. Hdited by Richard C. Norris, A. M., M. D., Cynecologist to
the Methodist I'-piscopal and the Philadelphia Hospitals; Surgeon-in-
Charge of Preston Retreat, Philadelphia. With 90 colored plates, 65
text-illustrations, and 308 pages of text.
IN PRESS FOR EARLY PUBLICATION.
Atlas and Epitome of Obstetrical Diagnosis and Treatment. By
Dr. O. Sch.\ffer, of Heidelberg. Edited by J. Clifton Edgar,
M. D., Professor of Obstretics and Clinical Midwifery, Cornell Univer-
sity Medical School. 72 colored plates, numerous text-illustrations,
and copious text.
Atlas and Epitome of the Nervous System and its Diseases. By
Prof. Dr. A. vox Strumpell, of Erlangen. Edited by Edward D.
Fisher, M. D., Professor of Diseases of the Nervous System, Univer-
sity and l)el!e\ue Hosjjital Medical College, New York. 83 plates and
a copious text.
Atlas and Epitome of General Pathological Histology. With an
Appendix on Pathohistological Technic. By Dr. H. Durck, of
Munich. Edited bv Ludvig Hektoex, M. D., Professor of Path-
ology, Rush Medical College, Chicago, ^^'ith So colored plates,
numerous text-illustrations, and copious text.
IN PREPARATION.
Atlas and Epitome of Orthopedic Surgery.
Atlas and Epitome of Operative Gynecology.
Atlas and Epitome of Diseases of the Ear.
Atlas and Epitome of General Surgery.
Atlas and Epitome of Psychiatry.
Atlas and Epitome of Normal Histology.
Alias and Epitome of Topographical Anatomy.
THE AMERICAN TEXT-BOOK SERIES.
AN AMERICAN TEXT-BOOK OF APPLIED THERAPEUTICS.
By 43 Distinguished Practitioners and Teachers. Edited by James C
Wilson, M.D., Professor of the Practice of Medicine and of Clinical
Medicine in the Jefferson Medical College, Philadelphia. One hand-
some imperial octavo volume of 1326 pages. Illustrated. Cloth,
$7.00 net ; Sheep or Half Morocco, $8.00 net. Sold by Subscription.
" As a work either for study or reference it will be of great value to the practitioner, 2a
it is virtually an exposition of such clinical therapeutics as experience has taught to be o;
the most value. Taking it all in ail, no recent publication on therapeutics can be compared
with this one in practical value to the working physician." — Chicai^o Clinical A'eTinv.
** The whole field of medicine has been well covered. The work is thoroughly prac-
tical, and while it is intended for practitioners and students, it is a l)etter book for the genera]
practitioner than for tlie student. The young practitioner esjiecially will find it extremely
suggestive and helpful." — T/te Indian Lancet.
AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHILDREN.
Second Edition, Revised.
By 65 Eminent ( "ontributors. Edited by I, oris Stakr, M. D.. ("on-
suiting I'ediatrist to the .Maternity Hospital, etc. ; a.s^isled by I'mo.mi'-
so.N .S. \\i..>rL()ri , M. IJ., .Attending Physician to the Dispensary
for Diseases of Children, Hospital of the Cniver^ity of I'eiinsyl-
vania. in one handsome imi)erial o<ta\o volume of 1244 pages,
profusely illustrated. Cloth, 57. 00 net; Sheep or Half Morocco,
$8.00 net. Sold l>y Subscription.
"This is far and away the I'cst text-book on children's diseases ever jiublislu'd in the
Knglish language, and is curtainly tlie one which is be^t adapted to .Ameriean readers.
^V'e congratulate the editor upon the lesuk of his work, and heartily commend it to the
mtention (^f every student and practitioner." — .XincriLan Journal of tin MrJical Siii-n<i-i.
AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR,
NOSE, AND THROAT.
By 58 Prominent Specialists. Ivliied by 0. E. DK Scmwiimtz, M.D .
Professor of 0|>hthalmology in the Jefferson Me(li(al College, Phila-
delphia; and B. Ai.kxandkr Randai.i,, M.D., Professor of Di.seases
of the Ear in the University of I*cnnsylvania. Imperial 0( tavo, 125 1
pages ; 766 illustrations, 59 of them in cohjrs. (loth, ^7. 00 net ; Sherp
or Half Morocco, SS.oo .oet. Sold bv Subscrif>tion.
Ukutrated Catalos:tie of the ** American Text-Booka" «ent free upon applicatiun.
6 Medical Publications of W. B. Saunders & Co.
\N AMERICAN TEXT-BOOK OF QENITO-URINARY AND SKIN
DISEASES.
By 47 Eminent Specialists and Teachers. Edited by L. Boltom
Bangs, M. D., Professor of Genito- Urinary Surgery, University and
Bellevue Hospital Medical College, New York ; and W. A. Hard-
AWAY, M. L)., Professor of Diseases of the Skin, Missouri Medical
College. Imperial octavo volume of 1229 pages, with 300 engravings
and 20 full-page colored plates. Cloth, $7.00 net; Sheep or Half
Morocco, ;^8.oo net. Sold by Subscription.
"This volume is one of the best yet issued of the publisher's series of ' American Text-
Books.' The list of contributors represents an extraordinary array of talent and extended
experience. The book will easily take the place in comprehensiveness and value of the
half dozen or more costly works on these subjects which have heretofore been necessary to
a well-equipped library." — New ]'orA Polyclinic.
AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND
SURGICAL. Second Edition, Revised.
By 10 of the Leading Gynecologists of America. Edited by J. M.
Baldv, M. D. , Professor of Gynecology in the Philadelphia Polyclinic,
etc. Handsome imperial octavo volume of 718 pages, with 341 illus-
trations in the text, and 38 colored and half-tone plates. Cloth, $6.00
net; Sheep or Half Morocco, $7.00 net. Sold by Subscription.
" It is practical from beginning to end. Its descriptions of conditions, its recommen-
dations for treatment, and above all the necessary technique of different operations, are
clearly and admirably presented. . . . It is well up to the most advanced views of the
day, and embodies all the essential points of advanced American gynecology. It is destined
to make and hold a place in gynecological literature which will be peculiarly its own."^
Medical Record, New York.
AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXI-
COLOGY.
Edited by Frederick Peterson, M.D., Clinical Professor of Mental
Diseases in the Woman's Medical College, New York; Chief of Clinic,
Nervous Department, College of Physicians and Surgeons, New York ;
and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy,
and Toxicology in Rush Medical College, Chicago. /// Preparation.
AN AMERICAN TEXT-BOOK OF OBSTETRICS.
By 15 Eminent American Obstetricians. Edited by Richard C. Nor-
Ris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome
imperial octavo volume of 1014 pages, with nearly 900 beautiful colored
and half-tone illustrations. Cloth, $7.00 net; Sheep or Half Morocco,
$8.00 net. Sold by Subscription.
*' 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." — Ali'.xander
J. C. SkeNk, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. V.
" This is the most sumptuously illustrated work on midwifery that has yet appeared. In
the number, the excellence, and the beauty of production of the illustrations it far surpasses
every other l)ook upon the suljject. This feature alone makes it a work which no medical
library should omit to purchase." — British Medical fonrnal.
" /Vfi an authority, as a book of reference, as a ' working book ' for the student or prac-
titioner, we commend it because we believe there is no better." — American Journal of tht
\f''dical Sciences.
Ultistrated Catalogue of the "American Text-Books " sent free upon application*
Medical Publications of W. B. Saunders & Co.
AN AMERICAN TEXT-BOOK OF PATHOLOGY.
Edited by Ludvig Hektoen, M. D.. Professor of General Pathology
and of Morbid Anatomy in the University of Pennsylvania ; and
David Riesman, M. D., Demonstrator of Pathological Histology in
the University of Pennsylvania. In preparation.
AN AMERICAN TEXT-BOOK OF PHYSIOLOGY.
By I o of the Leading Physiologists of America. Edited by William
H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop-
kins University, Baltimore, Md. Second edition, revised and enlarged,
in two volumes.
" We can commend it most heartily, not only to all students of physiology, but to ever}'
physician and pathologist, as a valuable and comprehensive work of reference, written by
men who are of eminent authority in their own special suljects. " — London Lancet.
" To the practitioner of medicine and to the advanced student this volume constitutes,
we believe, the best exposition of the present status of the science of physiology in the
English language." — American Journat of the Meduul Sciences.
AN AMERICAN TEXT-BOOK OF SURGERY. Third Edition.
By II Eminent Professors of Surgerv. Edited bv William W. Keen,
M.D., LL.D., and J. William White, M.D , Ph.D. Handsome im-
perial octavo volume of 1230 pages, with 496 woodcuts in the text,
and 37 colored and half-tone plates. Thoroughly revised and enlarged,
with a section devoted to " The Use of the Runtgen Rays in Surgery."
Cloth, $7-0(5 net; Sheep or Half Morocco, $8.00 net.
•' Personally, I should not mind it being called THE Ti:xT-Bof>K (instead of A Text-
Book), for I know of no sinj^le volume which contains so readable and complete an account
of the science and art of Surgery as this does." — IlDML'NI) Owi.N, I". K.C.S., Member of
the Board of Examiners of the Koyai College <f Surgeons, England.
•' If this text-book is a fair reflex of the present f)0>ition of American surgery, we must
admit it is of a very high onk-r 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.
AN AMERICAN TEXT-BOOK OF THE THEORY AND PRACTICE
OF MEDICINE.
By 12 Distinguished American Practitioners. Edited by William
Pepper, M.D., LL.D.. Professor of the Theory and Practice of Medi-
cine and of Clinical Medicine in the University of Pennsylvania. Two
handsome imperial octavo volumes of about 1000 pages each. Illus-
trated. Prices per volume : Cloth. $5.00 net ; Sheep or Half Morocco,
$6.00 net. Sold by Siibscriptio7t.
" I am quite sure it will commend itself both to practitioners and students of medicine,
and become one of our most popular t(Xt-l)Ooks.' — Al.KKKD EooMls, M.I)., LI,. I)., Lro-
fessor of Pathology and Practice (f Medicine, Lnirersitv oj the City of A no }o>/:.
" We reviewed the first volume of this work, an<l said : * It is undoubtedly one of the
l)est text-l>f)oks on the practice of medicine whieli we ])ossess.' A consideration <T the
second and last volume leads us to modify that verdict an<l to say that the comiilcted work
is in our o]iiiiion ///.' best <A its kind it has ever l»en our fortune to see." — A'eit> ^'orh Medicad
Journal.
Illostrated Catalogue of the "American Text-Books" sent free upon applkation.
8 Medical Publications of W. B. Saunders & Co.
AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY.
A Yearly Digest of Scientific Progress and Autlioritative Opinion in all
branches of Medicine and Surgery, drawn from journals, monograplis,
and text-books of the leading American and Foreign authors and
investigators. Arranged with critical editorial comments, by eminent
American specialists, under the general editorial charge of Geokcie M.
Gould, M.I). Volumes for 1896, '97, '98, and '99. One imperial
octavo volume of about 1200 pages. Cloth, $6.50 net ; Half Morocco,
$7.50 net. Yearl)Ook of 1900 in two volumes — Vol. I., including
General Medicine; \'ol. II., General Surgery. Prices per volume:
Cloth, $3.00 net; Half Morocco, $3.75 net. Sold by Siibscriptiofi.
" It is difficult to know which to admire most — the researcli and industry of the distin-
guished band of experts whom Dr. Gould has enlisted in the service of the Year- Book, or the
wealth and abundance of the contributions to every department of science that have been
deemed worthy of analysis. ... It is much more than a mere compilation of abstracts, for,
as each section is entrusted to experienced and able contributors, the reader has the advant-
age of certain critical commentaries and expositions . . . proceedini» from writers fully
qualified to perform these tasks. ... It is emphatically a book which should find a place in
everv medical library, and is in sever.il respects more useful than the famous 'Jahrbiicher'
of Germany." — London Lanwt.
ABBOTT ON TRANSMISSIBLE DISEASES.
The Hygiene of Transmissible Diseases ; their Causation,
Modes of Dissemination, and Methods of Prevention. By A.
C. Abbott, M.l)., Professor of Hygiene and Bacteriology, University
of Pennsylvania ; Director of the Laboratory of Hygiene. Octavo
volume of 311 pages, containing a number of charts and maps, and
numerous illustrations. Cloth, $2.00 net.
THE AMERICAN POCKET MEDICAL DICTIONARY.
[See D or I and' s Pocket Dictionaty, page 12.]
ANDERS' PRACTICE OF MEDICINE. Third Revised Edition.
A Text-Book of the Practice of Medicine. By James M. Anders,
M.D., Ph.D., LL.D. , Professor of the Practice of Medicine and of
Clinical Medicine, Medico Chirurgical College, Philadelphia. In one
handsome octavo volume of 1292 pages, fully illustrated. Cloth,
$5.50 net; Sheep or Half Morocco, $6.50 net.
" It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a
Credit to you ; but, more than that, it is a credit to the i)rofession of Philadelphia — to us."
1 \MES C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson
Medical College, Philadelphia.
ASHTON'S OBSTETRICS. Fourth Edition, Revised.
Essentials of Obstetrics. By W. Easterly Ash ton, M.D., Pro-
fessor of Gynecology in the Medico-Chirurgical College, Philadelphia.
Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00 net; inter-
leaved for notes, S1.25 net.
[See Saunders' Question- Conipends, page 23.]
" Emliodies the whole subject in a nut-shell. We cordially reconmiend it to our read
ers." — Chicago Aledical Tunes.
Medical Publications of W. B. Saunders & Co. 9
BALL'S BACTERIOLOGY. Third Edition, Revised.
Essentials of Bacteriology ; a Concise and Systematic Introduction
to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol-
ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218
pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00;
interleaved for notes, $1.25.
[See Saunders^ Question- Compends, page 23.]
" The student or practitioner can readily obtain a knowledp;e of the subject from a perusal
oi this book. The illustrations are clear and satisfactory." — Medical Record, New York.
BASTIN'S BOTANY.
Laboratory Exercises in Botany. Bv En^ox S. Bastin, M.A.,
late Prof, of Materia Medica and Botany, Philadelphia College of Phar-
macy. Octavo volume of 536 pages, with 87 plates. Cloth, S2.00 net.
"It is unquestionably the best text-book on the subject that has yet appeared. The
work is eminently a practical one. We re^^ard the issuance of this hook as an important
event in the history of pharmaceutical teaching in this country, .nnd predict for it an unquali-
fied success." — Alumni Report to the Philadelphia College of Phan/iacv.
BECK ON FRACTURES.
Fractures. By Carl Bh:ck, M.D., Surgeon to St. Mark's Hosi)ital
and the New York German Poliklinik, etc. 225 pages, 170 illustration^^.
Cloth, $3.50 net.
BECK'S SURGICAL ASEPSIS.
A Manual of Surgical Asepsis. By Carl Bfxk, M.D , Surgeon to
St. Mark's Hospital and the New York Cierman Poliklinik, etc. 306
pages; 65 text-illustrations, and 12 full-page plates. Cloth, $1.25 net.
" An excellent exposition of the ' %'ery latest ' in thi" treatment of wounds a.s practised
by leading L»ernian ami American surgeons." — Birimngluiiii (1-^ng. ) Medical Revie^u.
'• Tiiis little volume can be recommended tn any who are desirous ol Ic.iriiing the d(.iaii>
of asepsis in surgery, for it will serve as a iru.itworili}- guiile." — Loiuiou Ltiiuet.
BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND
OPERATIONS.
Obstetric Accidents, Emergencies, and Operations. I'y L. Ch.
PjOISLLN'Ik.re, M.D., late i^iiKTitiis J'rolcssor of Obstetrics, St. Louis
Medical College. 3S1 pages, handsomely illustrated. Cloth, <»2.oo net.
" .\ manual so useful to the stuilciit or the g<-neral practitioner has not been brought to
our notice in a long time. The field cmlirarcd in the tiile is covcn-d in a Icr^e, interesting
way. " — Yale' Medical Jouniiil.
BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised.
Essentials of Medical Physics. Il\ 1'ki i> |. P.kot KWA^, M.D.,
Assistant Demonstrator of Anatomy in the ('olleL:eof Physicians and
Surgeons, New"\'ork. (^"rown 0( lavo, 330 ])ag(s ; 155 fii;e illuslrations.
Cloth, 51.00 net ; interleaved for notes, ^1.25 net.
[S'.'c Sdii/idt-rs' Qucstion-Compciids, l)age 23. j
"We know of no manual that affords the mcdiral "-Inilftit a bcllcr or more concise
exposition of |)liy>ics, and the book may b" cnmmindcd a-, a mo>.t sati^lactory prociiLition
of lllo^e (ssmtial-. that are rc(iui->itL- in a cour-.<-' in medicino." — Xe;,' W'rk Medical J. uriial.
10 Medical Publications of W. B. Saunders & Co.
BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR-
MACOLOGY. Third Edition, Revised.
A Text-Book of Materia Medica, Therapeutics, and Pharma-
cology. By George F. Butler, Ph.G., M.D., Professor of Materia
Medica and of Clinical Medicine in the College of Physicians and
Surgeons, Chicago ; Professor of Materia Medica and Therapeutics,
Northwestern University, Woman's Medical School, etc. Octavo, 874
pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net.
*' Taken as a whole, the book may fairly be considered as one of the most satisfactory*
of any single-voUime works on materia medica in the market." — Journal of the American
Medical Association.
CERNA ON THE NEWER REMEDIES. Second Edition, Revised.
Notes on the Newer Remedies, their Therapeutic Applications
and Modes of Administration. By David Cerna, M.D., Ph.D.,
formerly Demonstrator of and Lecturer* on Experimental Therapeutics
in the University of Pennsylvania ; Demonstrator of Physiology in the
Medical Department of the University of Texas. Rewritten and
greatly enlarged. Post-octavo, 253 pages. Cloth, ^i. 00 net.
"The appearance of this new edition of Dr. Cerna's very valuable work .shows that it
is properly appreciated. The book ought to be in the po.ssession of every practising physi-
cian." — Attc York A/cdical Journal.
CHAPIN ON INSANITY.
A Compendium of Insanity. By John B. Chapin, M.D., LL.D.,
Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi-
cian-Superintendent of the Willard State Hospital, New York ; Hon-
orary Member of the Medico-Psychological Society of Great Britain,
of the Society of Mental Medicine of Belgium. i2mo, 234 pages,
illustrated. Cloth, $1.25 net.
" The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We
desire especially to call attention to the fact that on the subject of therapeutics of insanity
the work is exceedingly valual)le. It is not a made book, hut a genuine condensed thesis,
which has all the value of ripe opinion and all the charm of a vigorous and natural style." — •
Philadelphia Aledical Joui-?tal.
CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY.
Second Edition, Revised.
Medical Jurisprudence and Toxicology, By Henry C. Chapman,
M.D., Professor of Institutes of Medicine and Medical Jurisprudence
in the Jefferson Medical College of Philadelphia. 254 pages, with 55
illustrations and 3 full-page plates in colors. Cloth, $1.50 net.
"The best book of its class for the undergraduate that we know of." — New York
Medical Times.
CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES.
Second Edition.
Nervous and Mental Diseases. By Archibald Church, M. D.,
Professor of Clinical Neurology, Mental Diseases, and Medical Juris-
prudence in the Northwestern University Medical School, Chicago ;
and P'rederick: Pktkkson, M. D., Clinical Professor of Mental Dis-
eases, Woman's Medical College, N. Y. ; Chief of Clinic, Nervous
Dept., College of Physicians and Surgeons, N. Y. Handsome octavo
volume of 843 pages, profu.sely illustrated. Cloth, $5.00 net; Half
Morocco, $6,00 net.
Medical Publicntions of W. B. Saunders & Co. 11
CLARKSON'S HISTOLOGY.
A Text-Book of Histology, Descriptive and Practical. By
Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of
Physiology in the Owen's College, Manchester; late Demonstrator of
Physiology in Yorkshire College, Leeds. Large octavo, 554 images;
22 engravings in the text, and 174 beautifully colored original illustra-
tions. Cloth, strongly bound, 34.00 net.
" The work must be considered a valuable addition to the list of available text books,
and is to be highly recommended." — jVe7o York Medical Journal.
"This is one of the best works for students we have ever noticed. We predict that the
book will attain a well-deserved popularity among our students." — 6'/;?Vtf^'0 Mimical Recorder.
CLIMATOLOGY.
Transactions of the Eighth Annual Meeting of the American
Climatological Association, held in Washington, September 22-25,
1891. Forming a handsome octavo volume of 276 l)ages, uniform with
remainder of series. (A limited quantity only.) Cloth, §1.50.
COHEN AND ESHNER'S DIAGNOSIS. Second Edition, Revised.
Essentials of Diagnosis. By Solomon Solis-Cohkx, M.D., Pro-
fes.sor of Clinical Medicine and Applied Therapeutics in the Philadel-
phia Polyclinic ; and Augustus k. Eshner. M.D., Professor of Clinical
Medicine in the Philadelphia Polyclinic. Post-octavo, 417 pages; 55
illustrations. Cloth, gi.oo net.
[See Saunders Question- Compcnds, page 23.]
"We can lieartily commend the lif)ok to all those who contemplate ]iurchasing a ' com-
pend.' It is modern and complete, and will give more satisfaction than many otlier works
which are perhaps too prolix as well as behind the times." — Medical Ke^'irui, St. Louis.
CORWIN'S PHYSICAL DIAGNOSIS. Third Edition, Revised.
Essentials of Physical Diagnosis of the Thorax. By Akphur
AL CoKWiN, A.NL, M.l)., Demonstrator of Physical Diagnosis in Rush
Medical College, Chicago ; Attending Physician to Central Free Dis-
])ensary, Dejjartment of Rhinology, Laryngology, and Diseases of the
Chest, Chicago. 219 pages, illustrated. Cloth, Ik- .xiblc covers, ^1.25 net.
" It is excellent. The student who shall use it as his guide to tlie careful study of
physical exjiloration ujjon normal and abmiriual subi<Tt> (an scarcely fail to accjuirc a good
working knowledge ()f the subject." — I'hi'dJ' Ipliui J\>/\\/i>iic.
".\ most excellent little work. It biii;litctis the iiieinciry nf the ditt'erentiid di.ignostic
signs, and it .irranges orderly .-iiKl in -ciiiuncc tiie \arious objective phenomena to logic. il
solution of a careful diagnosis." — Joitrudl of .VerToiis and Menltil Diseases.
CRAQIN'S GYN/ECOLOGY. Fourth Edition, Revised.
Essentials of Gynaecology. I'.y 1j>\vin 1!. Ckacin. M. D.. Let turcr
in Obstetrics, Ctjllcgc of i'hy.sicians and Surgeons, .New NOrk. < lown
o(la\(). 200 jjagcs ; 62 illu>ti.iii()n>. (loth, ^l.oo net; intcrlca\ ed tor
noto, S' -25 net.
[See Sauni/rrs' Qu,stion-C<nnprnds, i)age 2,^.]
" .\ handy volume. aii<l a distinct inii'rovcm<-iit on .students' cmix-nds in g<nenil. No
author\vh o w Is imi hiin~elf a practical gynec..loL;i-.t cnuM have cnnMihed the Nludent'.s needs
so ihorougidy a.^ Dr. ( ra^jin has i.V,\\fi:' — Mcdnal Record, .\c\v \<.ik.
12 Meaical Publications of W. B. Saunders & Co.
CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised.
A Text-Book of Bacteriology. By Edgar M. Crookshank, M.B.,
Professor of Comparative Pathology and Bacteriology, King's College,
London. Octavo volume of 700 pages, with 273 engravings and 22
original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net.
" To the student who wishes to obtain ix pood rhuvii of what has been done in bacteri-
ology, or who wishes an accurate account of the various methods of research, the book may
be recommended with contiilence that he will Ihid there what he requires." — London Lancet.
Oa COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged.
Modern Surgery, General and Opentive. By John Chalmers
DaCosta, M. D., Professor of Practice of Surgery and Clinical Surgery,
Jefferson Medical College, Philadelphia ; Surgeon to the Philadelphia
Hospital, etc. Handsome octavo volume of 911 jxiges, profusely illus-
trated. Cloth, $4.00 net; Half Morocco, $5.00 net.
"We know of no small work on surgery in the English language which so well fulfils
the requirements of the modern student." — Mt'dico-C/iifw gical Journal, Bristol, England.
DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition,
Revised.
Diseases of the Eye. A Handbook of Ophthalmic Practice.
By G. E. DE ScHWEiNiTZ, M.D., Professor of Ophthalmology in the
Jefferson Medical College, Philadelphia, etc. Handsome royal octavo
volume of 696 pages, with 256 fine illustrations and 2 chromo-litho-
graphic plates. Cloth, ^4.00 net ; Sheep or Half Morocco, $5.00 net.
" A clenrly 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.
" A work that will meet the requirements not only of the specialist, but of the general
practitioner in a rare degree. I am satisfied that unusual success awaits it." — William
Pepper, M.D., Professor of the Theory aftd Practice of Medicine and Clinical Medicine.
University of Pennsylvania.
DORLAND'S DICTIONARY. Third Edition, Revised.
The American Pocket Medical Dictionary. Containing the Pro-
nunciation and Definition of all the principal words and phrases, and a
large ninnber of useful tables. P^dited by W. A. Newman Borland,
M. D., Assistant Demonstrator of Obstetrics, University of Pennsylvania;
Fellow of the American Academy of Medicine. 518 pages ; handsomely
bound in full leather, limp, with gilt edges and patent index. Price,
$1.00 net; with thumb index, $1.25 net.
DORLAND'S OBSTETRICS.
A Manual of Obstetrics. By W. A. Newman Borland, M.B.,
Assistant Denionstralor of Obstetrics, University of Pennsylvania ;
Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages;
163 illustrations in the text, and 6 full-page plates. Cloth, 32.50 net.
" By far the best book on this subject that has ever come to our notice." — American
Medical Review.
" It has rarely been our duty to review a book which has given us more pleasure in its
perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge,
a gold mine of practical, concise thoughts." — American Medico-Surgical Bulletin.
Medical Publications of W. B. Saunders & Co. 13
PROTHINQHAM'S GUIDE FOR THE BACTERIOLOGIST.
Laboratory Guide for the Bacteriologist. By Langdon Froth-
INGHAM, M.D.V., Assistant in 15acteriology and Veterinary Science,
Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts.
"It is a convenient and useful little work, and will more than repay the outlay neces-
sary for its purchase in the savint; of time whicii would otherwise be consumed in looking
up the various points of technique so clearly and concisely laid down in its pages." - Ameri-
can Meiiico- Surgical Bulletin.
GARRIGUES' DISEASES OF WOMEN. Third Edition, Revised.
Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro-
fessor of Gynecology in the New York School of Clinical Medicine;
Gynecologist to St. Mark's Hospital and to the German Dispensary,
New York City, etc. Handsome octavo volume of 7CS3 pages, illus-
trated by 367 engravings and colored plates. Cloth, $4.00 net;
Sheep or Half Morocco, $5.00 net.
'• One of the heat 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 tind expression in this book in a
most attractive and instructive form. Young practitioners to whom experienced consultants
may not be available will tind in this book invaluable counsel and hel|i." — Thad. A.
ReaMV, M.D., LL.D., Professor of Clinical gynecology. Medical College of Ohio.
GLEASON'S DISEASES OF THE EAR. Second Edition, Revised.
Essentials of Diseases of the Ear. ]\y K. I). (Jlkasox, S.B.,
M.D., Clinical Professor of Otology, Medicu-Chirurgical College,
Philadelphia ; Surgeon-in-Charpe of the Nose, Tliroat. and Ear Depart-
ment of the Northern Dispensary, Philadelphia. 20.S pages, with 114
illu-strations. Cloth, Si. 00 net; interleaved for notes, Si. 25 nei.
[See Saimders' Question- Compends, page 23.]
" It is just the book to put into the hands of a student, and cannot fail to give him a
useful intro<iuction to ear-affections ; while the style of cjuestion aiid answer which is adopted
throughout the hook is, we lielieve, the best method of impressing tacl> permanently on the
mind." — Liverpool .Medico- Chirurgical Jourtia I.
GOULD AND PYLE'S CURIOSITIES OF MEDICINE.
Anomalies and Curiosities of Medicine. Bv GioRCii; M. Gould,
M.D.,and Walter L. Pvle, M.D. An encyclopedic collection of
rare and extraordinary cases and of the most striking instances of
abnormality in all branches of Medicine and Surgery, derived from an
exhaustive research of medical literature from its origin to the present
day, abstracted, classified, annotatefl, and indexed. Handsome im-
I)erial octavo volmne of 968 pages, with 295 engravings in the text,
and \2 lull-page plates.
POPULAR EDITION: Cloth, $3.00 net. Half Morocco, $4.00 net.
"f)ne of the most valuable contribution^ cvrr made lo m<<li( al lit( lature I> i-. 'o far
a^ we know, absolutely unique, and every page is a."^ (ascmating a> a tiovd. .\(.| aKme for
the medical profession has this volume value: it will ^civi- a^ a IkkiK of rclerciMC lor ;ill who
are interested in general scientific, sociologic, or niediri> legal t<'pi(s." — /■>>,<< l-!\)i .Medical
I urnal.
"This is c<-rtainly a most remarkable and itiKi. Ming volume-. It sl.iiid- alone among
nw-Ueal literature, ati anomaly on anomalie-. in th.it there is nothing like it el.scwhere in
medical literature. It is a lMM)k full of revehiiion, fn.m its first to its last page, and euinot
but interest and sometimes almost horrify its iea<lers." — Americnt Medi. o-Surgual JUtlletin.
14 Medical Publications of W. B, Saunders & Co.
GRAFSTROM'S MECHANO-THERAPY.
A Text-Book of Mechano-Therapy (^Massage and Medical Gym-
nastics). By AxKL \'. Orafstrom, B. Sc, M. U., late Lieutenant in
the Royal Swedish Army ; late House Physician City Hospital, Black-
well's Island, New York. 1 2mo, 139 pages, illustrated. Cloth, ^i.oo net.
GRIFFITH ON THE BABY. Second Edition, Revised.
The Care of tfie- Baby. By J- P- Crozer Griffith, M.D., Clini-
cal Professor of Diseases of Children, University of Pennsylvania;
Physician to the Children's Hospital, Philadelphia, etc. i2mo, 404
pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50 net.
" The best book for the use of the young mother with which w-e are acquainted. . . .
There are very few general practitioners who could not read the book through with advan-
tage. ' ' — Archives of Pediatrics.
" The whole lx)ok 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 practitioners who have not had large opjx)rtunities for observing children." — Ameri-
can Journal of Obstetrics.
GRIFFITH'S WEIGHT CHART.
Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D. ,
Clinical Professor of Diseases of Children in the University of Penn-
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net.
GROSS, SAMUEL D., AUTOBIOGRAPHY OF.
Autobiography of Samuel D. Gross, M. D., F^meritus Professor of
Surgery in the Jefferson Medical College, Philadelphia, with Remi-
niscences of His Tiines and Contemporaries. Edited by his Sons,
Samuel W. Gross, M.D., LL.D., and A. Haller Gross, A.M. Pre-
ceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D.
Two handsome volumes, over 400 pages each, demy octavo, gilt tops,
with Frontispiece on steel. Price per volume, $2.50 net.
HAMPTON'S NURSING. Second Edition, Revised and Enlarged.
Nursing: Its Principles and Practice. By Isabel Adams Hamp
ton, Graduate of the New York Training School for Nurses attached
to Bellevue Hospital ; late Superintendent of Nurses and Principal of
the Training School for Nurses, Johns Hopkins Hospital, Baltitnore,
Md. 12 mo, 512 pages, illustrated. Cloth, $2.00 net.
" Seldom have we perused a book upon the subject that has given us so much pleasure
as the one before us. We would strongly urge upon the members of our own profession the
need of a book like this, for it will enable each of us to become a training school in him-
self." — Ontario Medical Jonrnal.
HARE'S PHYSIOLOGY. Fourth Edition, Revised.
Essentials of Physiology. By H. A. Hare, M.D., Professor of
Therapeutics and Materia Medica in the Jefferson Medical College of
Philadelphia. Crown octavo, 239 pages. Cloth, $1.00 net; inter-
leaved for notes, $1.25 net.
[See Sautiders' Question- Comfends, page 23.]
"The best condensation of physiological knowledge we have yet seen." — Medicai
Record, New York.
Medical Publications of W. B. Saunders & Co. 15
HART'S DIET IN SICKNESS AND IN HEALTH.
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. Cloth, $1.50 net.
" We recommend it cordially to the attention of all practitioners ; both to them and to
their patients it may be of the greatest service." — Xeiv York Medical Journal.
HAYNES' ANATOMY.
A Manual of Anatomy. By Irving S. Havnes, M.D., Adiunct
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart-
ment of the New York University, etc. 680 pages, illustrated with 42
diagrams in the text, and 134 full-page half-tone illustrations from
original photographs of the author's dissections. Cloth, $2.50 net.
" This book is the work of a practical instructor — one who knows by exjierience the
requirements of the average student, and is able to meet these requirements in a very satis-
factory way. The book is one that can be commended." — Medical Record, New York.
HEISLER'S EMBRYOLOGY.
A Text-Book of Embryology. By John C. Heisler, M.D., Pro-
lessor of Anatomy in the Medico-Chirurgical College, Philadelphia. Oc-
tavo volume of 405 pages, handsomely illustrated. Cloth, $2.50 net.
HIRST'S OBSTETRICS. Second Edition.
A Text-Book of Obstetrics. By Barton Cooke Hirst, M. D.,
I^rofessor of Obstetrics in the University of Pennsylvania. Handsome
octavo volume of 848 pages, with 618 illustrations, and 7 colored
plates. Cloth, $5.00 net; Sheep or Half Morocco, 56.00 net.
"The illustrations are numerous and are works of art, many of them ajipearing for the
first lime. The arranj^ement of the subject-matter, the foot-notes, and index arc l)eyond
criticism. As a true model of what a modern text-book on oi)stetrics should be, \\ c feel
justitieii in affirming that Dr. Hirst's book is without a rival." — A'cw York Medical Record.
HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL
DISEASES. Second Edition, Revised and Enlarged.
Syphilis and the Venereal Diseases. Bv [amis .\i\in> Hvdk,
M. 1)., Professor of Skin and \enereal Diseases, and I-kank \\. .Mon 1-
ooMKKV, M. D., Lecturer on Dermalolog) and Cenito-L'rinary Diseases
in Rush .Medical College. Chicago, 111. ()cta\o. nearly 600 pages, with
14 beautiful lithographic plates and numerous illustrations.
" We can commend this manual to the student as a help to him in his >tudy of veneica!
diseases." — Liverpool Medico-Chirurs^ical Journal.
"The l)est student's manual which has ap|)eared on the subject.'' — St. Louts. AUdiioJ
gnd .Surgical Journal.
INTERNATIONAL TEXT-BOOK OF SURGERY. In two volunus
i!v American and i'.ritish authors. Lditcd li\ j. Cmi.i ins ANakkin.
NLI).. LL.l)., Professor of Surgerv. Harvard Mcdicil Si hool. Iloston ;
and A. I'kakce C.on.i), .M.S.! K.R.C.S.. l,<(tiircr on I'r.i. ti.al Sur-
gerv and Teacher of Ojjcrative Snrgcrw Mid.ilcscx ilosiiital Mcdii.al
School. London. ICng. \'ol. I. C,V//./w/ .S'///;',-/! - 1 landsonic o( lavo,
947 !>;ig*^'>. \v'lli 4.v'"» beautitid illustrations rind <; lithographic jilalcs.
Vol.' II. Sprciiil or /vV;vc;;a// .SV//;;'rn . -1 Ian<lsome octavo. 107.' pages,
with 471 beautiful illustrations and S lithographic plates. Prices per
volume: ("loth, ^5.00 net; Hall .Morocco. ■$,(■>. 00 net. •
Ui Medical Publications of W. B. Saunders & Co.
JACKSON'S DISEASES OF THE EYE.
A Manual of Diseases of the Eye. By Edward Jackson, A.M.,
M.D., sometime Professor of Diseases of the Eye in the Philadelphia
Polyclinic and College for (Graduates in Medicine. i2mo volume of
535 I^ges, with 178 beautiful illustrations, mostly from drawings by the
author. Cloth, $2.^0 net.
JACKSON AND QLEASON'S DISEASES OF THE EYE, NOSE, AND
THROAT. Second Edition, Revised.
, Essentials of Refraction and Diseases of the Eye. By Edward
Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila-
delphia Polyclinic and College for Graduates in Medicine; and —
Essentials of Diseases of the Nose and Throat. By E. Bald-
win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and
Ear Department of the Northern Dispensary of Philadelphia. Two
volumes in one. Crown octavo, 290 pages ; 124 illustrations. Cloth,
$1.00 net; interleaved for notes, $1.25 net.
[See Saunders' Question- Compends, page 22.]
" Of great value to the beginner in these branches. The authors are both capable men,
and know what a student most needs." — Medical Record, New York.
KEATING'S DICTIONARY. Second Edition, Revised.
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, and Henry Hamilton ; with the collaboration of J. Chal-
mers DaCosta, M.D., and Frederick A. Packard, M.D. With an
Appendi.K containi g Tables of Bacilli, Micrococci, Leucomaines,
Ptomaines, etc. One volume of over 800 pages. Prices, with Ready-
Reference Index: Clrth, $5.00 net; Sheep or Half Morocco, $6.00
net. 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 recommend-
ing it to my classes." — Henry M. Lymax, M. D., Professor of the Pri)iciples and Practice
■>f Medicine, Pi./i Medical College, Chicago, III.
KEATING'S LIFE INSURANCE.
How to Examine for Life Insurance. By John M. Keating,
M.D., Fellow of the College of Physicians of Philadelphia; Vice-
President of the American Prediatric Society; Ex- President of the
Association of Life Insurance Medical Directors. Roval octavo, 211
pages ; with two large half-tone illustrations, and a plate prepared by
Dr. McClellan from special dissections ; also, numerous other illustra-
tions. Cloth, $2.00 net.
KEEN'S OPERATION BLANK. Second Edition, Revised Form.
An Oper-'tion Bl .ik, with Lists of Instruments, etc., Required
in Various Operations. Prepared by W. W. Keen, M.D., LL.D.,
Professor of the Principles of Surgery in Jefferson Medical College,
Philadelphia. Price per pad, blanks for fifty operations, 50 cents net.
Medical Publications of W. B. Saunders dt Co. 17
KEEN ON THE SURGERY OF TYPHOID FEVER.
The Surgical Complications and Sequels of Typhoid Fever,
By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur-
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia;
Corresponding Member of the Soci^te de Chirurgie, Paris ; Honorary
Member of the Society Beige de Chirurgie, etc. Octavo volume of
386 pages, illustrated. Cloth, ^3.00 net.
" This is probably the first and only work in the English language that gives the reader
a clear view of what typhoid fever really is, and what it does and can do to the human
organism. This book should i)e in the possession of every medical man in America." —
AmfHcan MeJico-Surgical Bulletin.
KYLE ON THE NOSE AND THROAT.
Diseases of the Nose and Throat. By D. Braden Kyle, M.D.,
Clinical Professor of Laryngology and Rhinology, Jefferson Medical
College, Philadelphia; Consulting Laryngologist, Rhinologist, and
Otologist, St. Agnes' Hospital. Handsome octavo volume of about
630 pages, with over 150 illustrations and 6 lithographic plates. Price,
Cloth, $4.00 net; Half Morocco, $5.00 net.
LAINE'S TEMPERATURE CHART.
Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x i^y^
inches. A conveniently arranged Chart for recording Temperature,
with columns for daily amounts of Urinary and Fecal Excretions,
Food, Remarks, etc. On the back of each chart is given in full the
method of Brand in the treatment of Typhoid Fever. Price, per pad
of 25 charts, 50 cents net.
"To the busy practitioner this chnrt will be found of great value in fever cases, and
especially for cases of typhoid." — Indiari Lancet, Calcutta.
LEVY AND KLEMPERER'S CLINICAL BACTERIOLOGY.
The Elements of Clinical Bacteriology. By Dr. IOrnst Lkvv, Profes-
sor in the I'niversity of Strassburg, and Fklix Ki.k.mpkrek, Privat docent
in the University of Strassbur-^. Translated and edited by .Augustus
A. lCs}iNKK, M.I)., Professor of (Clinical Medicine in the Philadelphia
Polyclinic. Octavo, 440 pages, fully illustrated. Cloth, $2.50 net.
LOCKWOOD'S PRACTICE OF MEDICINE.
A Manual of the Practice of Medicine. By George Roe Lock-
wood, M.D., Professor of Practice in the Woman's Medical C"ollei;e
of the New York Infirmary, etc. 935 pages, with 75 illiislnuions in
the text, and 22 full-page j^lates. Cloth, $2.50 net.
"Gives in a most concise manner the points cssoutial to treatment usually enumcrrtcc
in the most clalxirale works." — Massailiitsetts Mt\li((ii Journal.
LONG'S SYLLABUS OF GYNECOLOGY.
A Syllabus of Gynecology, arranged in Conformity with " An
American Text-Book of (iynecology." By J. \\. Long. M.D ,
Professor of Diseases of W'cjnicn and (hildreii, Medical College of
Virginia, etc. Cloth, interleaved, ;«;i.oo net.
" Tlie l>orjk is certainly an adniiralilc ;rf/^///r of what every ^ynocdlo^ical stuilriit nii''
practitioner should know, and will ])r<>ve of vahic not only to those who have tlit; ' -Ameruai
Text-Hook of ( iyiieeoloj^'V, l)Ul to olh'TS as well. " — Htool;lyu Mfiiiciil Jouina!.
2
18 Medical Publications of W. B. Saunders & Co.
MACDONALD'S SURGICAL DIAGNOSIS \ND TREATMENT.
Surgical Diagnosis and Treatment. By J- W. Macdonald, M.D.
Edin., F.R.C.S., Kdin., Professor of the Practice of Surgery and of
Clinical Surgery in Hamline University ; Visiting Surgeon to St.
Barnabas' Hospital. Minneapolis, etc. Handsome octavo volume of
800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco,
$6.00 net.
" A thorough and complete work on surgical diagnosis and treatment, free from pad-
ding, full of valuable material, and in accord with the surgical teaching of the day. " — 7Vif
Medical News, Ne'w York.
"The work is brimful of just the kind of Practical information that is useful alike to
students and practitioners. It is a pleasure to commend the bock because of its intrinsic
value to the medical practitioner." — Cincinnati Lancet- Clinic
MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE.
Pathological Technique. A Practical Manual for Laboratory Woik
in Pathology, Bacteriology, and Morbid Anatomy, wich chapters on
Post-Mortem Technique and the Performance of Autopsies. By Frank
B. Mallory, A.m., M.D., Assistant Professor of Pathology, Harvard
University Medical School, Boston; and James K. Wright, A.M.,
M.D., Instructor in Pathology, Harvard University Medif:al School,
Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth,
$2.50 net.
" I have been looking forward to the publication of this book, and I am gi.Td to say that
I find it to be a most useful laboratory and post-mortem guide, full of practical information,
and well up to date." — William H. Welch, Professor of Pathology, fohns Hopkins Uni-
versily, Baltitnore, Md.
MARTIN'S MINOR SURGERY, BANDAGING, AND VEiiNEREAL
DISEASES. Second Edition, Revised.
Essentials of Minor Surgery, Bandaging, and Venoreal
Diseases. By Edwvrd Marti.v, A.M., M.D., Clinical Professcrof
Genito-Urinary Diseases, Univ^ersity of Pennsylvania, etc. Crown
octavo, 166 pages, with 78 illustrations. Cloth, $1.00 net; interleaved
for notes, $1.25 net.
[See Saunders' Questioji-Compends, page 23.]
"A very practical and systematic study of the subjects, and shows the author's famil-
iarity with the needs of students." — Therapetitic Gazette.
MARTIN'S SURGERY. Seventh Edition, Revised.
Essentials of Surgery. Containing also \'enereal Diseases, Surgi-
cal Landmarks, Minor and Operative Surgery, and a complete de-
scription, with illustrations, of the Handkerchief and Roller Bandages.
By Edward Martin, A.M., M.D., Clinical Professor of Genito-
Urinary Diseases, L^niversity of Pennsylvania, etc. Crown octavo, 342
pages, illustrated AVith an Appendix on the preparation of the materials
used in Antisejjtic Surgery, etc., and a chapter on Appendicitis. Cloth,
$1.00 net ; interleaved for notes, 5! 1-25 net
\^tQ. Saunders'' Question- Compends, page 23.]
" Contains all necessary essentials of modern surgery in a comparativelv small space.
Its style is interesting, and its illustrations are admirable." — Afedical and Surgical Peforter.
Medical Publications of W. B. Saunders & Co, 19
McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re-
vised and Greatly Enlarged.
Text-Book upon the Pathogenic Bacteria. By Joseph McFar-
LAND, M. D., Professor of Pathology and Bacteriology in the Medico-
Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages,
finely illustrated. Cloth, $2.50 net.
" Dr. McF'arland has treated the subject in a systematic manner, and has succeeded in
presenting in a concise and readable form the essentials of bacteriology up to date. Alto-
gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the
students of Trinity College." — H. B. Anderson, M. D. , Professor of Pathology and Bac-
teriology, Trinity Medical College, Torottto.
MEIGS ON FEEDING IN INFANCY.
Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound
in limp cloth, flush edges, 25 cents net.
"This pamphlet is worth many times over its price to the physician. The author's
exfjeriments and conclusions are original, and have been the means of doing much good." —
Medical Bulletin.
MOORE'S ORTHOPEDIC SURGERY.
A Manual of Orthopedic Surgery. By James E. Moore, M.D.,
Professor of Orthopedics and Adjimct Professor of Clinical Surgery,
University of Minnesota, College of Medicine and Surgery. Octavo
volume of 356 pages, handsomely illustrated. Cloth, $2.50 net.
"A most attractive work. The illustrations and the care with which the book is adapted
to the wants of the general practitioner and the student are worthy of great praise." — Chicago
Medical Recorder.
"A very demonstrative work, every illustration of which conveys a lesson. The work is
a most excellent and cummendable one, which we can certainly entiorse with pleasure." —
St. Louis Medical and Surgical Journal.
MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth
Edition, Revised.
Essentials of Materia Medica, Therapeutics, and Prescription-
Writing. By Henry Mokkis, M.D., late Demonstrator of Thera-
peutics, Jefferson Medical College, Phila(lel{)hia , Fellow of the College
of Phvsicians. Philadcl|)hia, etc. Crown octavo, 28S jiages. Cloth,
gi.oo net; interleaved for notes, ,si.25 net.
[See Saun tiers' Question- Contpends, page 22.]
"This work, already excellent in the old edition, has ieen largely improved by revi-
sion." — American J'raclitioncr and A'eivs.
MORRIS, WOLFF. AND POWELL'S PRACTICE OF MEDICINE.
Third Edition, Revised.
Essentials of the Practice of Medicine. r)y Hfnkv >[()Kris, M.D.,
late Demonstrator of rherapeutics, Jefferson Meditai College, Phila-
delpiiia; with an .Appendix on the Clinical and Microscopic Ivxamina-
tion of Urine, by L/vwhknck Woi.i k. M.D. . Demonstrator of Chemistry,
Jefferson Medical College, IMiiladel|)hia. I'lnlarged hv some 300 es-sen-
tial formulru collected and arranged by Wii.i.iam M. J'owkll, M.D.
Post-octavo, .488 pages, ("loth. 51.50 net.
[See Saunders' Question- Compends, page 22.]
" Tlie teaching is sound, the prcscit itinn graphic ; in.UliT full as can be desired, •\arj
style attractive." — American Practiii^'iiir ,itid \c7iis.
20 Medical Publications of W. B. Saunders & Co.
MORTEN'S NURSE'S DICTIONARY.
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, Acci-
dents, Treatments, Operations, Foods, Appliances, etc. encountered
in the ward or in the sick-room. By Honnor Morten, author of
" How to Become a Nurse," etc. i6mo, 140 pages. Cloth, $1.00 net.
" \ handy, compact little volume, containing a large amount of general information, all
of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference.
It is certainly of value to those for whose use it is published." — Chicago Clinical Review.
NANCREDE'S ANATOMY. Sixth Edition, Thoroughly Revised.
Essentials of Anatomy, including the Anatomy of the Viscera.
By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and
of Clinical Surgery in the University of Michigan, Ann Arbor. Crown
octavo, 420 pages; 151 illustrations. Based upon Gray's Anatomy.
Cloth, Si-oo net; interleaved for notes, $1.25 net.
[See Saunders' Question- Compends, page 23.]
" For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at
school, it would not be easy to speak of it in terms too favorable." — American Practitioner.
NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition.
Essentials of Anatomy and Manual of Practical Dissection.
By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of
Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo ;
500 pages, with full-page lithographic plates in colors, and nearly 200
illustrations. Extra Cloth (or Oilcloth for dissection-room), ^2.00 net.
" It may in many respects be considered an epitome of Gray's popular work on general
anatomy, at the same time having some distinguishing characteristics ot its own to commend
u The plates are of more than ordinary excellence, and are of especial value to students
ill their work in the dissecting room." — Jotanat of the American Medical Association.
NANCREDE'S PRINCIPLES OF SURGERY.
Lectures on the Principles of Surgery. By Chas. B. Nancrede,
M.D , LL.D., Professor of Surgery and of Clinical Surgery, Univer-
sity of Michigan, Ann Arbor. Octavo volume of 398 pages, illustrated.
Cloth, $2. 50 net.
NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised.
Syllabus of Obstetrical Lectures in the Medical Department
of the University of Pennsylvania. By Richard C. Norkis,
A.M., M.D., Demonstrator of Obstetrics, University of Penns) b.ania.
_ Crown octavo, 222 i)ages. Cloth, interleaved for notes, $2.00 net.
PENROSE'S DISEASES OF WOMEN. Third Edition, Revised.
A Text=Book of Diseases of Women. By Charles B. Penrose,
M.D., Ph.D., Formerly Professor, of Gynecology in the LTniversity
of Pennsylvania; Surgeon to the (jvnecean Hospital, Philadeljjhia.
Octavo volume of 531 pages, handsomely illustrated. Cloth, $3.75 net.
"I .shall value very highly the copy of Penrose's • Di.seases of Women' received.
I have already recommended it to my class as THE BEST book." — Howard K. Kelly.
Prof ssor of Gynecology and Obstetrics, Johns Hopkins Unuiersity, Baltii/ioie, Aid.
Medical Publications of W. B. Saunders & Co. 21
POWELL'S DISEASES OF CHILDREN. Second Edition.
Essentials of Diseases of Children. By William M. Powell,
M.D., Attending Physician to the Mercer House for Invalid Women
at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of
Children in the Hospital of the University of Pennsylvania. Crown
octavo, 222 pages. Cloth, gi.oonet; interleaved for notes, $1.25 net.
[See Saunders' Question-Compends, page 21.]
"Contains the gist of all the best works in the department to which it relates."— ^
American Practitioner and A^e^us.
PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS.
Pictorial Atlas of Skin Diseases and Syphilitic Affections
(American Edition). Translation from the French. Edited by
J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex
Hospital, London. Photo-lithochromes from the famous models in
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-
cuts and text. In 12 Parts. Price per Part, S3. 00. Complete in
one volume. Half Morocco binding, §40.00 net.
" I strongly recommend this Atlas. The plates are exceedingly well executed, and
urill be of great value to all studying dermatology." — Stephen Mackenzie, M.D.
"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 venture to say, has been seen better in point of correctness, beauty, and general
merit." — New York Medical Journal.
PRYOR— PELVIC INFLAMMATIONS.
The Treatment of Pelvic Inflammations through the Vagina.
By VV. R. Pryor, M.D., Professor of (gynecology in New York Poly-
clinic. i2mo, 248 pages, handsomely illustrated. Cloth, $2.00 net.
"This subject, which has recently been so thoroughly canvassed in high gynecological
circles, is made availai)le in this volume to the general practitioner an<l student. Nothing is
too minute f(jr mention and nothing is taken for granted ; coiise(|uently the book is of the utmost
value. The illustrations and the techni(juearc beyond criticism." — C/'iicago Medical Recorder.
PYE'S BANDAGING.
Elementary Bandaging and Surgical Dressing. With Direc-
tions concerning the Immediate Treatment of Cases of Emergency.
For the use of Dressers and Nurses. By Wamer Pyf, F.R.C.S., late
Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80
illustrations. Cloth, flexible covers, 75 cents net.
" The directions are clear and the ilhislratioiis .ire good." — /.,'iidon Lancet.
" The .-lulhor writes well, tiie diagrams are cle^.r, mikI llie book itself is small and )X)rt-
able, although the paper and type are grxxl." — British Medical Journal.
RAYMOND'S PHYSIOLOGY.
A Manual of Physiology. P,y Joseph II. R.w.mond. .A.M., M.D.,
Professor of I'hysiology and Hygiene and Lecturer on (gynecology in
the Long Island College H()S|jital ; Director of Physiology in the
Hoagland Laboratory, etc. 3.S2 pages, with 102 illustrations in the
text, and 4 full-page cc^lored plates, ("loth, ;>i.25 net.
" F.xiremely well gotten up, and the il lust rat ion>< have been sclcctid with rate. The
text is fully abre.Tst with modern jihysiology." — /hiti<.h Medical /ournal.
(AUNDERS'
Question
Arranged in Question and
Answer Form.
npHE MOST COMPLETE AND BEST
^oi^TTTDrrivrr^c illustrated series of
Vi^L/lVJJrJlliNlJo coMPENDs ever issued.
Now the Standard Authorities in Medical Literature . . ♦ .
with Students and Prartitioncrs in every City of the United States and Canada.
^<*
^ OVER ^75,000 COPIES SOLD. ^
THE REASON WHY.
They are the advance guard of "Student's Helps" — that DO help. They are the
leaders in their special line, well and authoritatively written by able men, who, as teachers in
the large colleges, know exactly what is wanted by a student preparing for his examinations.
The judgment exercised in the selection of authors is fully demonstrated by their professional
standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of
them have become Professors and Lecturers in their respective colleges.
Each book is of convenient size (5x7 inches), containing on an average 250 pages,
profusely illustrated, and elegantly printed in clear, readable type, on fine paper.
The entire series, numbering twenty-three volumes, has been kept thoroughly revised
and enlarged when necessary, many of the books being in their fifth and sixth editions.
TO SUM UP.
Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of
them approach the " Blue Series of Question Compends;" and the claim is made for the
following points of excellence :
1. Professional distinction and reputation of yjthors.
2. Conciseness, clearness, and soundness of treatment.
3. Quality of illustrations, paper, printing, and binding.
Any cf these Compends Tvill be maikd on receipt of price (see next page for List).
Saunders^ Question-Gompend Series^
Price, Qoth, $J.OO net per copy, except when otherwise ordered.
" Where the work of preparing students' manuals is to end we cannot say, but the
Saunders Series, in our opinion, bears off the palm at present."— AVzt/ y'orJk Aledxcal Record.
1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition,
revised and enlarged.
2. ESSENTIALS OF SURGERY. By Edward Martin, M. D. Seventh edition,
revised, with an Appendix ami a chapter on Appendicitis.
3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Sixth
edition, thoroughly revised and enlarged.
4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC.
By Lawrence Wolff, M.D. Fifth edition, revised.
5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth
edition, revised and enlarged.
6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E.
Armand Semple, M.D.
7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE-
SCRIPTION-WRITING. By Henry Morrls, M.D. Fifth edition, revised.
8,9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris,
M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D.
Third edition, enlarged by some 300 Essential Formula;, selected from eminent
authorities, by \Vm. M. Powell, M.D. (Double number, $1.50 net.;
10. ESSENTIALS OF GYN/ECOLOGY. By Edwin B. Cragin, M.D. Fourth
edition, revised.
11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon,
M.D. Fourth edition, revised and enlargeii.
12. ESSENTIALS OF MINOR SURGERY, BANDAQiNO, AND VENEREAL
DISEASES. By Edward Martin, M.D. .Second ed., revised and enlarged.
13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.
By C. E. Armand Semple, M.D.
14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT.
By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised.
15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell,
M. D. Second edition.
16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff,
M.D. Colored "VoGKL Scale." (75 cents net.)
17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner,
M.D. Second ciiition, iliorouLjhly revised.
18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre.
Second edition, revised and enlarged.
20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition,
revised.
21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C.
Shaw, NLD. Tliird edition, revised.
22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D.
Second o<iiii(>n, revis(<l.
23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D.,
and I'.DWAKD S. LawkaN( K, NL I ).
24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D.
•Second edition, revised and greatly eidarged.
Famphkt containing specimen pages, etc. sent free upon application.
Saunders'
New Series
of Manuals
for Students
and
Practitioners.
* I ^riAT there exists a need for thoroughly reliable hand-books on the leading branches
of Medicine and Surgery is a fact amply demonstrated by the favor with which
the SAUNDERS NEV SERIES OF MANUALS have been received by medical
students and practitioners and by the Medical Press. These manuals are not merely
condensations from present literature, but are ably written by well-known authors
and practitioners, most of them being teachers in representative American colleges.
Each volume is concisely and authoritatively w^ritten and exhaustive in detail, w^ithout
being encumbered w^ith the introduction of "cases," which so largely expand the
ordinary text-book. These manuals will therefore form an admirable collection of
advanced lectures, useful alike to the medical student and the practitioner: to the
latter, too busy to search through page after page of elaborate treatises for w^hat he
wants to know, they will prove of inestimable value ; to the former they will afford
safe guides to the essential points of study.
The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior
to any similar books now on the market. No other manuals afford so much infor-
mation in such a concise and available form. A liberal expenditure has enabled the
publisher to render the mechanical portion of the w^orfc w^orthy of the high literary
standard attained by these books.
Any of these Manuals w^ill be mailed on receipt of price (see next page for List).
Saunders^ New Series of Manuals*
VOLUMES PUBLISHED.
PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology
and Hygiene and Lecturer on Gynecology in the Long Island College Hospital :
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1-25 neu
SURGERY, General and Operative.— By John Chalmers DaCosta, M. D., Pro-
fessor of Practice of Surgery and Clinical Surgery, Jefferson Medical College, Philadel-
phia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised
and greatly enlarged. Octavo, 91 1 pages, profusely illustrated. Cloth, ;S4.oo net;
Half Morocco, 35.00 net.
DOSE-BOOK AND MANUAL OF PRESCRIPTION/-WRITING. By E. Q.
Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila-
delphia. Illustrated. Cloth, $1.25 net.
SURGICAL ASEPSIS. By Cari, Beck, M.D., Surgeon to St. Mark's Hospital and
to the New York German Poliklinik, etc. Illustrated. 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 Phila-
delphia. Illustrated. Cloth. $1.50 net.
SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D.,
Professor of Skin and Venereal Diseases, and Frank H. MoNTOdMERY, M.D.,
Lecturer on Dcraiatology and Genito-Urin.nry Diseases in Rush Medical College,
Chicago. Second edition, thoroughly revised and greatly enlarged.
PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of
Practice in the Woman's Medical College of the New York Infirmary; Instructor in
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated.
Cloth, S2.50 net.
MANUAL OF ANATOMY. By Irvinc S. Haynks, M.D., Adjunct Professor of
Anatomy and DemoriStrator of Anatomy, Medical Department <jf the Ne'v Yorn
University, etc. Beautifully illustrated. Cloth, $2.50 net.
MANUAL OF OBSTETRICS. By W. A. Newman Dorlano, M.D., Assistant
Demonstrator of (Obstetrics, University of Pennsylvania; Chief of Gynecological Dis-
pensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, 52.50 net.
DISEASES OF WOMEN. By J. P.land Sutton, F. R. C. S., Assistant Surgeon to
.Middlesex Hospital and .Surgeon to Chelsea Hospital, London; and AkilHiK E.
Gii.es, M. D., B. Sc. Lund., }•'.!<. C.S. Liiiii., -Assistant Surgeon to Chelsea Hospital,
Lon<lon. Handsomely illustrated. Cloth, $2.50 net.
VOLUMES IN PREPARATION.
NERVOUS DISEASES. By Charles W. IUrk, M.D., Clinical Professor of Nervous
Diseases, Medico Chirurgical tollcge. Pliiladel]iliia ; Pathologist tu the Ortliopa'dic
Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph
Hospital, etc.
•»• There will be published in the same series, at short intervals, carefully-prepared workl-
on various subjects by prominent specialists.
Pamphlet containiug specimen pages, etc sent free upon application.
26 Medical Publications of W. B. Saunders & Co.
SAUNDBY'S RENAL AND URINARY DISEASES.
Lectures on Renal and Urinary Diseases. By Robert Saundby,
M.D. Edin., Fellow of the Royal College of Physicians, London, and
of the Royal Medico-Chirurgical Society ; Physician to the General
Hospital ; Consulting Physician to the Eye Hospital and to the Hos-
pital for Diseases of Women; Professor of Medicine in Mason College,
Birmingham, etc. Octavo volume of 434 pages, with numerous illus-
trations and 4 colored plates. Cloth, $2.50 net.
" The volume makes a favorable impression at once. The style is clear and succinct.
We cannot find any part of the subject in which the views expressed are not carefully thought
out and fortified by evidence drawn from the most recent sources. The book may be cordially
recommended.' ' — British Medical Journal.
5AUNDERS' MEDICAL HAND-ATLASES.
For full description of this series, with list of volumes and prices, see
page 2.
" Lehmann Medicinische Handatlanten belong to that class of books that are too good
to be appropriated by any one nation." — yournal of Eye, Ear, and Throat Diseases.
'• The appearance of these works marks a new era in illustrated English medical
works." — The Canadian Practitioner.
SAUNDERS' POCKET MEDICAL FORMULARY. Sixth Edition,
Revised.
By William M. Powell, M.D., Attending Physician to the Mercer
House for Invalid Women at Atlantic City, N. J. Containing 1800
formula selected from the best-known authorities. With an Appen-
dix containing Posological Table, Formulae and Doses for Hypo-
dermic Medication, Poisons and their Antidotes, Diameters of the
Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various
Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment
of Asphyxia from Drowning, Surgical Remembrancer, Tables of
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand-
somely bound in flexible morocco, with side index, wallet, and flap.
^1.75 net.
"This little book, that can be conveniently carried in the pocket, contains an immense
amount of material. It is very useful, and, as the name of the author of each prescription
is given, is unusually reliable." — Aledical J^ecord, New York.
SAYRE'S PHARMACY. Second Edition, Revised.
Essentials of tlie Practice of Pharmacy. By Lucius E. Sayre,
M.D., Professor of Pharmacy and Materia Medica in the University of
Kansas. Crown octavo, 200 pages. Cloth, $1.00 net; interleavec for
notes, S1.25 net.
[See Saunders^ Question- Co?npe?ids, page 21.]
" The topics are treated in a simple, practical manner, and the work forms a very useful
Student's manual." — Boston Aledical and Surgical Journal.
SCUDDER'S FRACTURES.
The Treatment of Fractures. By Chas. L. Scudder, M.D., As-
sistant in Clinical and Operative Surgery, Harvard Medical School.
Octavo, 433 pages, with nearly 600 original illustrations. Cloth, S4.50
net.
Medical Publications of W. B. Saunders & Co.
SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.
Essentials of Legal Medicine, Toxicology, and Hygiene. By
C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond.,
Physician to the Northeastern Hospital for Children, Hackney, etc.
Crown octavo, 212 pages; 130 ilhistrations. Cloth, $1.00 net; inter-
leaved for notes, $1.25 net.
[See Saunders' Quesiion-Co7npends, page 21.]
" No general practitioner or student can afford to l^e without this valuable work. The
subjects are dealt with by a masterly hand." — London Hospital Gazette.
SEMPLE'S PATHOLOGY AND MORBID ANATOMY.
Essentials of Pathology and Morbid Anatomy. By C. E.
Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to
the Northeastern Hos])ital for Children, Hackney, etc. Crown octavo, i 74
pages; illustrated. Cloth, $1.00 net; interleaved for notes, $1.25 n''t.
[See Saunders' Question- Compends, page 21.]
" Should take its place among the standard volumes on the bookshelf of both student
and practitioner." — London Hospital Gazette.
SENN'S GENITO-URINARY TUBERCULOSIS.
Tuberculosis of the Genito-Urinary Organs, Male and Female.
By NiCHOL.AS Senn, ^LD., Ph.D., LL.D., Professor of the Practice of
Surgery and of Clinical Surgery, Rush Medical College, Chicago.
Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net.
" An important book u|)on an important suliject, and written by a man of mature judg-
ment and wide experience. The author has given us an instructive book upon one of the
most im|X)rtarit subjects of the day." — Clinical Reporter.
" A work which adds another to the many obligations the profession owes the talented
author." — Chicago Medical Recorder.
SENN'S SYLLABUS OF SURGERY.
A Syllabus of Lectures on the Practice of Surgery, arranged
in conformity with " An American Text-Book of Surgery." By
Nicholas Skkx, M. I)., Ph.D., Professor of the Prat tice of Surgery and
of Clinical Surgery, Rush Medical College, Chicago. Cloth, $1.50 net.
"This syllabus will lie found of service by the teacher as well as the student, the work
being superbly flone. There is no praise too hii^h lor it. >i'<^ surgeon slioui<l be witbom
it." — Ne7v York Medical Times.
SENN'S TUMORS. Second Edition, Revised.
Pathology and Surgical Treatment of Tumors. Uy N. Sinn,
.\I.l), I'll.!)., LI,.D., I'rok-sx)!' of Surgery and of (iiiiical Surgery,
kti^ii Medical College: {'roli-s^or of Surger\, (hicago Polyclinic;
Attending .Surgeon to l'resl)\ terian llo.s|)itai: .Surgeon-in-( 'hief. St.
Joseph's Hospital, Chicago. Srroid h'.,/itioii, 7'/i(>r(>U[;/i/\ A'li'isrd. < )c-
tavo volume (jf 718 pages, with 478 ilhistrations. in< hiding i .; full-page
plates in colore. . I'ric e> : (loth, j;^.oo net : Half .Moicxco. >6.oo lui.
" 'i he mtjst exhaustive of any rccciU Ixnik in Mngii^h on this suliject. It is well illus-
trated, and will doubtless remain as the principal ni'iMO},'raph on tiie siii)ie(t in our language
♦^or some years The l.<><«k i> haiuisoniely illustrated and printed, and llie aiidior ha-, given .,
notable and lasting contribution to surgery." — Journal 0/ the .■Iniriiurn .Mr,li,<i! Association.
28 Medical Publications of W. B, Saunders & Co.
SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition,
Revised.
Essentials of Nervous Diseases and Insanity. By John C.
Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous
System, Long Island College Hospital Medical School ; Consulting
Neurologist to St. Catherine's Hospital and to the Long Island College
Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth,
$1.00 net ; interlea\ed for notes, Si. 2 5 net.
[See Saunders' Question- Competids, page 21.]
"Clearly ami intelligently written."' — Boston Medical and Surgical Journal.
"There is a mass of valuable material crowded into this small compasi.' — American
Medico- Surgical Bulletin.
STARR'S DIETS FOR INFANTS AND CHILDREN.
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), perforated
and neatly bound in flexible morocco. $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. P'ormulse for the preparation of diluents and foods are appended.
STELWAGON'S DISEASES OF THE SKIN. Fourth Ed., Revised.
Essentials of Diseases of the Skin. By Henry W. Stelwagon,
M.D., Clinical Professor of Dermatology in the Jefferson Medical
College, Philadelphia ; Dermatologist to the Philadelphia Hospital ;
Physician to the Skin Department of the Howard Hospital, etc.
Crown octavo, 276 pages; 88 illustrations. Cloth, $1.00 net; inter-
leaved for notes, $1.25 net.
[See Saunders' Question- Compends, page 21.]
" The best student's manual on skin diseases we have yet seen." — Times and Register.
STENGEL'S PATHOLOGY. Second Edition.
A Text-Book of Pathology. By Alfred Stengel, M.D., Professor
of Clinical Medicine in the University of Pennsylvania : Physician to
the Philadelphia Hospital ; Physician to the Children's Hospital, etc.
Handsome octavo volume of 848 pages, with nearly 400 illustrations,
many of them in colors. Cloth, §4.00 net; Half Morocco, $5.00
net.
STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second
Edition, Revised.
A Manual of Materia Medica and Therapeutics. By A. A.
Stevens, A.M., M.D., Lecturer on Terminology and Instructor in
Physical Diagnosis in the University of Pennsylvania ; Professor of
Pathology in the Woman's Medical College of' Pennsylvania. Post-
octavo, 445 pages. Flexible leather, $2.00 net.
" The author has faithfully presented modern therapeutics in a comprehensive work,
and, while intended particularly for the use of students, it will be found a reliable guide and
sufficiently comprehensive for the physician in practice." — University Medical Magazine.
Medical Publications of W. B. Saunders <& Co. 29
5TEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised.
A Manual of the Practice of Medicine. By A. A. Stevens, A. M.,
M. D., Lecturer on Terminology and Instructor in Physical Diagnosis
in the University of Pennsylvania; Professor of Pathology in the
Woman's Medical College of Pennsylvania. Specially intended for
students preparing for graduation and hospital examinations. Post-
octavo, 519 pages; illustrated. Flexible leather, $2.00 net.
" The frequency with which new editions of this manual are demanded bespeaks its
popularity. It is an excellent condensation of the essentials of medical practice for the
student, and may be found also an excellent reminder for the busy physician." — BuffaU
Medical Journal.
STEWART'S PHYSIOLOGY. Third Edition, Revised.
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 New Museums, Cambridge University ; Professor of Physiology
in the Western Reserve University, Cleveland, Ohio. Octavo volume
of 848 pages; 300 illustrations in the text, and 5 colored plates.
Cloth, $3.75 net.
" It will majce its way by sheer force of merit, and amply deserves to do so. It is one
of the very test English text-books on the subject." — London 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 ALedical Journal.
STEWART AND LAWRANCE'S MEDICAL ELECTRICITY.
Essentials of Medical Electricity. By D. D. Stewart, M.D.,
Demonstrator of Diseases of the Nervous System and Chief of the
Neurological Clinic in the Jefferson Medical College; and E. S.
Lawr.ance, M.D., Chief of the Electrical Clinic and Assistant Demon-
strator of Diseases of the Nervous System in the Jefferson Medical
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth,
$1.00 net; interleaved for notes, 51-25 net.
[See Saunders' Question- Compends, page 21.]
" Throughout the whole brief s])ace at their command the authors show a discriminating
knowledge of their subject." — Medical A'euis.
STONEY'S NURSING. Second Edition, Revised.
Practical Points in Nursing. For Nurses in Private Practice.
By l->Mii-V A. M. SioNKV, Oraduateof the Training-School for Nurses,
Lawrence, Ma.ss.; late Superintendent of the Training-School for
Nurses, Carney Hospital, Soutli Boston, Mass. 456 Images, illustrated
witli 73 engravings in the text, and 8 colored and half-tone plates.
Clotli, $1.75 net.
" Tlit^re are few books intended for noti-professional readers which can be so cordially
endorsed by a medical journal as can this one." — Tlnrapeutic Gazette.
" 'i'liis is a wcllwrilten, ciniiiciitly practical volume, which covers the entire range of
private nursing as distinguished f'oin hospital nursing, and instructs the nurse how best to
iniM-t tile various emergencies wliicli may arise, and how to jirepare everything ordinarily
needed in tiie illness of her patient.'' — .hnerican Journal of Obstetrics and Diseases of
lt\ii/ien and Children.
" It is a wcjrk that the plivsic Ian can pl.ice in the hands of his private nurses willi tlif
assr,ran<e of benelit." — Ohio Medical Journal.
30 Medical Publications of W. B. Saunders & Co.
STONEY'S MATERIA MEDICA FOR NURSES
Materia Medica for Nurses. By Emily A. M. Stoney, Graduate of
the Training-School for Nurses, Lawrence, Mass. ; late Superintendent
of the Training-School for Nurses, Carney Hospital, South Boston, Mass.
Handsome octavo volume of 306 pages. Cloth, $1.50 net.
The present book differs from other similar works in several features, all of which are
intended to render it more practical and generally useful. The general plan of the contents
tollows the lines laid down in training-schools for nurses, but the book contains much use-
ful matter not usually included in works of this character, such as Poison-emergencies,
Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms
used in Materia Medica, and describing all the latest drugs and remedies, which have been
generally neglected by other books of the kind.
SUTTON AND GILES' DISEASES OF WOMEN.
Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant
Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital,
London ; and Arthur E. Giles, M.D., B.Sc. Lond. , F.R.C.S. Edin.,
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand-
somely illustrated. Cloth, ;^2.5o net.
"The text has been carefully prepared. Nothing essential has been omitted, and its
teachings are those recommended by the leading authorities of the day." — Journal of the
American Medical Association.
THOMAS'S DIET LISTS. Second Edition, Revised.
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. Cloth, $1.25 net. Send for sample sheet.
THORNTON'S DOSE-BOOK AND PRESCRIPTION-WRITING.
Dose-Book and Manual of Prescription=Writing. By E. Q.
Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical
College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net.
"Full of practical suggestions; will take its place in the front rank of works of this
>ort. " — Medical Record, New York.
VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH.
Diseases of the Stomach. By William W. Van Valzah, M.D.,
Professor of General Medicine and Diseases of the Digestive System
and the Blood, New Vork Polyclinic; and J. Douglas Nisbet, M.D.,
Adjunct Professor of General Medicine and Diseases of the Digestive
System and the Blood, New York Polyclinic. Octavo volume of 674
pages, ilhistrated. Cloth, $3.50 net.
" Its chief claim lies in its clearness and general adaptability to the practical needs of
the general i>ractitioner or student. In these relations it is probably the best of the recent
sjjecial works on diseases of the stomach." — Chicago Clinical Review.
VECKI'S SEXUAL IMPOTENCE.
The Pathology and Treatment of Sexual Impoter.ce. By Victor
G. Vecki, MT). From the second German edition, revised and en-
larged. Demi-octavo, 291 pages, (^loth, $2.00 net.
The subject of impotence has seldom been treated in this country in the truly scientific
ST'.rit that it deserves. Dr. Vecki's work has long been favorably known, and the German
000k has received the highest consideration. This edition is more than a mere translation,
»or, although based on the German edition, it has been entirely rewritten in English.
Medical Publications of W. B. Saunders & Co.
VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised.
Medical Diagnosis. By Dr. Oswald Vierord r, Professor of Medi-
cine at the University of Heidelberg. Translated, with additions,
from the fifth enlarged German edition, with the author's permission,
by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume
of 603 pages; 194 fine wood-cuts in text, many of them in colors.
Cloth, ;^4.oo net ; Sheep or Half Morocco, $5.00 net.
" Rarely is a book published with which a reviewer can find so little fault as with the
volume before us. Each particular item in tlie 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. The reviewer would repeat that the book is
one of the best — probably //<«■ dest — which has fallen into his hands." — University Aledical
Magazine.
WATSON'S HANDBOOK FOR NURSES.
A Handbook for Nurses. By J. K. Watson, M.D., Edin. Ameri-
can Edition, under supervision of A. A. Stevens, A.M., M.D., Lecturer
on Physical Diagnosis, University of Pennsylvania. i2mo, 413 pages,
73 illustrations. Cloth, S^-So net.
WARREN'S SURGICAL PATHOLOGY. Second Edition.
Surgical Pathology and Therapeutics. By John Collins Warren,
M.D., LL.D., I'rofessor of Surgery, Harvard Medical School. Hand-
some octavo, 832 pages ; 136 relief and lithographic illustrations, t^Z iri
colors ; with an Appendix on Scientific Aids to Surgical Diagnosis, and
a series of articles on Regional Bacteriology. Cloth, $5.00 net; Half
Morocco, $6.00 net.
" 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.
WOLFF ON EXAMINATION OF URINE.
Essentials of Examination of Urine. By Lawrence Wolff, M.D.,
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia,
etc. Colored (Vogel) urine scale and numerous illustrations. Crown
octavo. Cloth, 75 cents net.
[See Saunders' Question- Compctuis, page 21.]
" A very gf>o(l work of its kind— very well suited to its i)urpose."' — Times and Register.
WOLFF'S MEDICAL CHEMISTRY. Fifth Edition, Revised.
Essentials of Medical Chemistry, Organic and Inorganic.
("ontaining also Questions on Medical Physics, Chemical I'hysiology,
Analytical I'rocesses, Urinalysis, and Toxicology. By Lawrence
Wolff, .\LD., Demonstrator of Chemistry; Jefferson Medical College,
Philadelphia, etc. C!rovvn octavo, 222 pages. Cloth, i^i.oo net; iiilcr-
leavcd for notes, ^1.25 net.
[See Saunders' Question- Comprnds, page 21.]
•'The scoi>e of this work is certainly equal to that of the l)C>.t course of lectures on
Medical Chemistry.'' — I'harmaceutidil Era.
CLASSIFIED LIST
OK THK
Medical Publications
OF
W. B. SAUNDERS & COMPANY,
925 "Walnut Street, Philadelphia.
ANATOMY, EMBRYOLOGY,
HISTOLOGY.
Clarkson — A Text-Book of Histology, 1 1
Kaynes — A Manual of Anatomy, ... 15
Heisler — A Text- Book of Embryology, 15
Nancrede — Essentials of Anatomy, . . 20
Nancrede — Essentials of Anatomy and
Manual of Practical Dissection, ... 20
Semple — Essentials of Pathology, . . 27
BACTERIOLOGY.
Ball — Essentials of Bacteriology, ... 8
Crookshank — A Text-Book of Bacteri-
ology, 12
Frothingham — Laboratory Guide, . . 13
Levy and Klemperer's Clinical Bacte-
riology, 17
Mallory and Wright — Pathological
Technique, 18
McFarland — Pathogenic Bacteria, . . ig
CHARTS, DIET-LISTS, ETC.
Griffith— Infant's Weight Chart, ... 14
Hart — Diet in Sickness and in Health, . 15
Keen — Operation Blank, 17
Laine — Temperature Chart. . . .17
Meigs — Feeding in Early Infancy, . . 19
Starr — Diets for Infants and Children, . 28
Thomas— Diet-Lists 3°
CHEMISTRY AND PHYSICS.
Brockway — Essentials of Medical Phys-
ics, 9
Wolff — Essentials of Medical Chemistry, 31
CHILDREN.
An American Text-Book of Diseases
of Children, . . 5
Griffith — Care of the Baby, 14
Griffith — Infant's Weight Chart, ... 14
Meigs — Feeding in Early Infancy, . . 19
Powell — Essentials of Dis. of Children, 21
Starr — Diets for Infants and Children, . 28
DIAGNOSIS.
Cohen and Eshner —Essentials of Di-
agno.-jis, II
Corwin — Physical Diagnosis, .... 11
Macdonald — Surgical Diagnosis and
Treatment, 18
Vierordt — Medical Diagnosis, .... 31
DICTIONARIES.
Borland — Pocket DicticMiary, .... 12
Keating — I 'renouncing Dictionary, . . 16
Morten — Nurse's Dictionary, .... 20
EYE, EAR, NOSE, AND THROAT.
An American Text- Book of Diseases
of the Eye, Ear, Nose, and Throat, . 5
De Schweinitz — Diseases of the Eye, . 12
Gleason — Essentials of Dis. of the Ear, 13
Jackson — Manual of Diseases of Eye, . 16
Jackson and Gleason — Essentials of
Diseases of the Eye, Nose, and Throat, 16
Kyle — Diseases of the Nose and Throat, 17
QENITO=URINARY.
An American Text-Book of Genito-
urinary and Skin Diseases, 6
Hyde and Montgomery — Syphilis and
the Venereal Diseases, 15
Martin — Essentials of Minor Surgery,
Bandaging, and Venereal Diseases, . iS
Saundby — Renal and Urinary Diseases, 26
Senn — Genito-Urinary Tuberculosis, . 27
Vecki — Sexual Impotence, 30
GYNECOLOGY.
American Text- Book of Gynecology, 6
Cragin — Essentials of Gynecology, . . Ii
Garrigues — Diseases of Women, ... 13
Long — Syllabus of Gynecology, ... 17
Penrose — Diseases of Women, .... 20
Pryor — Pelvic Inflammations, .... 34
Sutton and Giles — Diseases of Women, 30
MATERIA MEDICA, PHARMACOL-
OGY, AND THERAPEUTICS.
An American Text-Book of Applied
Therapeutics, .... 5
Butler — Text-Book of Materia Medica,
Therapeutics and Pharmacology, . . . 10
Cerna — Notes on the Newer Remedies, 10
Griffin — Materia Med. and Therapeutics, 14
Morris — Essentials of Materia Medica
and Therapeutics, . . 19
Saunders' Pocket Medical Formulary, 26
Sayre— Essentials of Pharmacy, ... 26
Stevens — E.ssentials of Materia Medica
and Therapeutics, 28
Stoney — Materia Medica for Nurses, . . 30
Thornton — Dose-Book and Manual of
Prescription-Writing, 30
MEDICAL JURISPRUDENCE AND
TOXICOLOGY.
Chapman — Medical Jurisprudence and
Toxic(jlogy, ... .... 10
Semple — Essentials of Legal Medicine,
Toxicology, and Hygiene, 27
Medical Publications of W. B. Saunders & Co. 33
NERVOUS AND MENTAL
DISEASES, ETC.
Burr — Nervous Diseases, 9
Cbapin — Compendium of Insanity, . . 10
Church and Peterson — Nervous and
Mental Diseases, 10
Shaw — Essentials of Nervous Diseases
and Insanity, 28
NURSING.
Griffith— The Care of the Baby, ... 14
Hampton — Nursing, 14
Hart — Diet in Sickness and in Health, 15
Meigs — deeding in Early Infancy, . . I9
Morten — Nurse's Dictionary, .... 20
Stoney — Materia Medica for Nurses, . . 30
Stoney — Practical Points in Nursing, . 29
Watson — Handbook for Nurses, ... xi
OBSTETRICS.
An American Text-Book of Obstetrics,
Ashton — E.ssentials of 01)stetrics, .
Boisliniere — (_)l>stetric Accidents, .
Dorland — Manual of Obstetrics, .
Hirst — Text-Book of Obstetrics, .
Norris — Syllabus of Obstetrics, . .
PATHOLOGY.
An American Text-Book of Pathology,
Mallory and Wright — Pathological
Technique,
Semple — Essentials of Pathology and
Morbid Anatomy,
Senn — Pathology and Surgical Treat-
ment of Tumors,
Stengel — Text- Book of Pathology, . .
Warren — Surgical Pathology and Thera-
peutics,
PHYSIOLOGY.
An American Text-Book of Physi-
ology,
Hare — Essentials of Physiology, . . .
Raymond — Manual of Physiologfy, . .
Stewart — Manual of Physiology, . . .
PRACTICE OF MEDICINE.
An American Text-Book of (he The-
ory and Practice of Medicine
An American Year-Book of Medicine
and Surgery,
Anders — Text-Book of the Practice of
Medicine, ,
Lockwood — Manual of the Practice of
Medicine,
Morris — Essentials of the Practice of
Medicine, .
Stevens — Manual of the Practice of
Medicine,
SKIN AND VENEREAL.
An American Text-Book (;f (ienito-
Urinaryand .Skin Diseases
Hyde and Montgomery — .Syphilis and
the \ encreal HistMses,
15
20
31
Martin — Essentials of Minor Surgery,
Bandaging, and Venereal Diseases, . 18
Pringle— Pictorial Atlas of Skin Dis-
eases and Syphilitic Affections, ... 21
Stelwagon — Essentials of Diseases of
the Skin, 28
SURGERY.
An American Text- Book of Surgery, 7
An American Year-Book of Medicine
and Surgery, 8
Beck — Fractures 9
Beck — Manual of Surgical .Asepsis, . . 9
DaCosta — Manual of Surgery, . ... 12
International Text-Book of Surgery, . 15
Keen— Operation Blank, 17
Keen — The Surgical Complications and
Sequels of Typhoid Fever, 17
Macdonald — Surgical Diagnosis and
Treatment, 18
Martin — Essentials of Minor Surgery,
Bandaging, and Venereal Diseases, . 18
Martin— Essentials of Surgery, .... 18
Moore — Orthopedic Surgery, 19
Nancrede' — Principles of Surgery, . . 20
Pye — Bandaging and .Surgical Dressing, 21
Scudder — Treatment of Fractures, . . 26
Senn — ( ienito-Urinary Tuberculosis, . 27
Senn — .Syllabus of Surgery, 27
Senn — Pathology and Surgical Treat-
ment of Tumors, 27
Warren — Surgical Pathology and Ther-
apeutics, 31
URINE AND URINARY DISEASES.
Saundby — Renal and Urinary Diseases, 26
Wolff — Essentials of Examination of
Urine, 31
MISCELLANEOUS.
Abbott — Hygiene of Transmissible Dis-
eases, 8
Bastin — Laboratory Exercises in Bot-
any, 9
Gould and Pyle — .Anomalies and Curi-
osities of Medicine 13
Grafstrom — Massage, ....... 14
Keating — How to Examine for Life
Iiisur;ince „ . . 16
Rowland and Hedley — .Archives of
the kocnIgiM Kay, 21
Saunders' Medical lland-.Atlases, .2, 3, 4
Saunders' New Series of Manuals, 24, 25
Saunders' I'ocket Medical lornnilary, 26
Saunders' ( hu-stion-Compends, . . 22, 23
Senn — Pathology and Surgical Treat-
ment of Tumors, 27
Stewart and Lawrance — Essentials of
Medical Electricity 29
Thornton — I)ose-l'ook and Manual of
Pns(ri])tion Writing, . 30
Van Valzah and Nisbet — Diseases of
the Stomach 3"
BOOKS JUST ISSUED.
THE AMERICAN ILLUSTRATED MEDICAL DICTIONARY.
For Students and Practitioners. A Complete Dictionary of the Terms used in Medi-
cine and the Allied Sciences, with a large number of Valuable Tables and Numerous
Handsome Illustrations. Edited by W. A. Newman Borland, M. D., Editor of the
American Pocket Medical Dictionary. Handsome large octavo, 800 pages, bound in
full limp leather, and printed on thin paper of the finest quality, forming a handy
volume, only i '4 inches thick.
This is an entirely new and unique work, intended to meet the need of practitioners and students for a
complete, up-to-date dictionary of moderate price. The book is designed to furnish a maximum amount of
matter in a minimum space and at the lowest possible cost. It contains double the material in the ordinary
students' dictionary, and yet, by the use of a clear, condensed type and thin paper of the finest quality, is only
1% inches in thickness. It is bound in full flexible leather, and is just the kind of a book that a man will want
to keep on his desk for constant reference. The book makes a special feature of the newer words, and
defines hundreds of important terms not to be found in any other dictionary. It is especially full in the
matter of tables, containing more than a hundred of great practical value. A new feature is the inclusion
of numerous handsome illustrations, many of them in colors, drawn and engraved specially for this book.
These have been chosen with great care and add infinitely to the value of the work. The book will appeal
to both practitioners and students, since, besides a complete vocabulary, it gives to the more important
subjects extended consideration of an encyclopedic character.
BOHM, DAVIDOFF, AND HUBER'S HISTOLOGY.
A Text=Book of Human Histology. Including Microscopic Technic. By Dr.
A. A. B;mM and Dr. M. vom Davidoff, of Munich, and G. C. Hubkr, M. D.,
Junior Professor of Anatomy and Histology, University of Michigan.
FRIEDRICH AND CURTIS ON THE NOSE, THROAT, AND EAR.
Rhinology, Laryngology, and Otology in their Relations to General
Medicine. By Dr. E. P. Friedrich, of the University of Leipsig. Edited by
H. Holbrook Curtis, M. D., Consulting Surgeon to the New York Nose and Throat
Hospital.
LEROY'S HISTOLOGY.
The Essentials of Histology. By I,oitis Eeroy, M.D., Professor of Histology
and Pathology, Vanderbilt University, Nashville, Tennessee.
OQDEN ON THE URINE.
Clinical Examination of the Urine. By J. Bergen Ogden, M. D., Assistant
in Cliemistry, Harvard Medical School. Handsome octavo volume of over 408 pages,
with 54 illustrations and I I full-page plates, many in colors.
PYLE'S PERSONAL HYGIENE.
A Manual of Personal Hygiene. Edited by Walter E. Pyle, M. D., Assist-
ant Surgeon to Wills Eye Hospital, Philadelphia. Octavo volume of 344 pages,
fully illustrated.
SALINGER AND KALTEYER'S MODERN MEDICINE.
Modern Medicine. By Tui.ius L. Salinger, M. D., Demonstrator of Clinical
Medicine, Jefferson Medical College, and E. J. Kalteyer, M. I )., Assistant Demon-
strator of C'linical Medicine, Jefferson Medical College. Handsome octavo volume of
over 800 ])ages, fully illustrated.
STONEY'S SURGICAL TECHNIC FOR NURSES.
Surgical Technic for Nurses. liy Emily A. M. Stoney, late Superintendent
of tile Trainiiig-School for Nurses, Carney Hospital, South Boston, Massachusetts.
THE AMERICAN POCKET
MEDICAL DICTIONARY. Edited
by W. A. Newman
Dorland, A.M., 2^D.,
Assistant Obstetrician
to the Hospital of the
University of Penn-
AMERICAN
POCKET
MEDICAL
DICTIONARY
sylvania; Fellow of the American
Academy of Medicine, etc. Over 500
pages. Full leather, limp, with gold
edges. Price, $ J. 00 net; with patent
thumb index, $J.25 net.
THIRD EDITION, REVISED.
This is the ideal pocket lexicon. — It is an
absolutely new^ book, and not a revision of
any old work. — It is complete, defining all
the terms of modern medicine, and forming
an unusually full vocabulary. — It gives the
pronunciation of all the terms. — It makes a
"One of the handiest lit le dictionaries for the
pocket that we have ever seen. Its definitions are
short, concise, and complete, so that it contains
within a small space as many words, satisfactorily
defined, as are found in some of the much larger
volumes." — American Medico-Swgicul Bulletin.
special feature of the new^er w^ords neglected
by other dictionaries. — It contains a wealth of
anatomical tables of special value to students
in preparing for examinations. — The new^ or
"reformed" spelling is employed. — A handy
volume indispensable to every medical man. J*
For sale by all Booksellers, or sent post-paid on
receipt of price.
W. B. SAUNDERS & CO., Publishers,
925 Walnut St., Philadelphia.
CLINICAL EXAMINATION OF
THE URINE AND URINARY
DIAGNOSIS. A
OGDEN ON Clinical Guide for the
THE URINE Use of Practitioners
and Students of Med-
icine and Surgery. By J. Berg^en
Ogfden^ M.D., Instructor in Chemistry,
Harvard University Medical School;
Assistant in Clinical Pathology, Boston
City Hospital. Handsome octavo,
425 pages, with 54 illustrations, and a
number of colored plates. Cloth, $3.00
net.
JUST ISSUED.
The design of this work is to present in as con-
cise a manner as possible the chemistry of the
urine and its relation to physiologic processes;
the most approved working methods, both quali-
tative and quantitative ; the diagnosis of diseases
and disturbances of the kidneys and urinary
passages. jIt jA ^ .^'t ^ jl jl jft j)t
In addition to chemic and microscopic methods,
w^hich have been described in detail, special
attention has been paid to diagnosis, including
our present knowledge of the character of the
urine, the diagnosis and differentiation of dis-
eases of the kidneys and urinary passages ; an
enumeration of the prominent clinical symptoms
of each disease; and, finally, the peculiarities of
the urine in certain general diseases of the body.
For sale by all Booksellers, or sent post-paid on
receipt of price.
W. B. SAUNDERS & CO., Publishers,
925 Walnut St., Philadelphia.
Kb
/ 01
IROO
THE LIBRARY
UNIVERSITY OF CALIFORNIA
Santa Barbara
THIS BOOK IS DUE ON THE LAST DATE
STAMPED BELOW.
Series 9482
i£SOm>jERNREGIONAL LIBRARY FACILITY
A A 000 146579
I