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, 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 ; hlo])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.
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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 bluden(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 , 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: ]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
founres and connective tissue, which are arrang(' 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. 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 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. .{■•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 tS.
' 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 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'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')) 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.vaminest 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. 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, 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 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)rainain.
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-
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)oy 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(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
prefy 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 un, 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 takes, 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-_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 ;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
provearts 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, /. /. ).
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-
hoon, 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-rcansion, 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 tiy 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 rrupted or continuous. Tiie
latter is begun at the uj>|)» r en 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 anught
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»- - ^
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 prepares. ])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.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('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 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 :uile 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 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-
var-
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 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.^/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 ;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 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»nening, 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. 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 <'i(;atricial plug from the angle. The cut
surfaces bleed freely, but there is, as a rule, no hemorrhage of
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()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 oy 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 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 itifrd, 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 feful.
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^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) anessary 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 sprears
runuintr fnxu the liif:im. 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 FaHfcnivning, 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 . 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. Ohfrt 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
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 referreoli//)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-
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. Lonn
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 increaseisl.^, 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']-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 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 aresent, 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. ()()). 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 ;
' 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 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-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 :ic9(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 tairimary or
.'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 ey 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. 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 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(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-
toun(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 :inl<'(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
extenn, 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 preventee(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 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, 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, (iipircoloil,(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)icifloration 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 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 reacherace 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, (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;/.
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<'uree 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(i5)
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
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.'. 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 (liminisjieeeuliar
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. 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, unites the two last condition, under the name of
circiimsrrllxfl or litiiitcd, hiinitnluii/r, opposed to tlie lirst, whieh lie ealLs frsil)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 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<'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'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. 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 ]"rcunsc (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). 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) : 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 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'"ihrnorrhea, 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.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"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. , 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 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«-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 fhy, 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 in eliildren. 372
Wai.ciikk. operation for listula, 3iK)
Walii<'h, cliaiM-snture, 662
Warren, tioi-ar, 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
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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.
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of text. Price, $3.00 net. Parts sold separately.
Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed.
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IN PRESS FOR EARLY PUBLICATION.
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Atlas and Epitome of the Nervous System and its Diseases. By
Prof. Dr. A. vox Strumpell, of Erlangen. Edited by Edward D.
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Atlas and Epitome of General Pathological Histology. With an
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Atlas and Epitome of Normal Histology.
Alias and Epitome of Topographical Anatomy.
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AN AMERICAN TEXT-BOOK OF APPLIED THERAPEUTICS.
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AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHILDREN.
Second Edition, Revised.
By 65 Eminent ( "ontributors. Edited by I, oris Stakr, M. D.. ("on-
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\N AMERICAN TEXT-BOOK OF QENITO-URINARY AND SKIN
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By 47 Eminent Specialists and Teachers. Edited by L. Boltom
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AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND
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By 10 of the Leading Gynecologists of America. Edited by J. M.
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AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXI-
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AN AMERICAN TEXT-BOOK OF SURGERY. Third Edition.
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AN AMERICAN TEXT-BOOK OF THE THEORY AND PRACTICE
OF MEDICINE.
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AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY.
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ABBOTT ON TRANSMISSIBLE DISEASES.
The Hygiene of Transmissible Diseases ; their Causation,
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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,
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ASHTON'S OBSTETRICS. Fourth Edition, Revised.
Essentials of Obstetrics. By W. Easterly Ash ton, M.D., Pro-
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Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00 net; inter-
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[See Saunders' Question- Conipends, page 23.]
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Medical Publications of W. B. Saunders & Co. 9
BALL'S BACTERIOLOGY. Third Edition, Revised.
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[See Saunders^ Question- Compends, page 23.]
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BASTIN'S BOTANY.
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BECK ON FRACTURES.
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BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND
OPERATIONS.
Obstetric Accidents, Emergencies, and Operations. I'y L. Ch.
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BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised.
Essentials of Medical Physics. Il\ 1'ki i> |. P.kot KWA^, M.D.,
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[S'.'c Sdii/idt-rs' Qucstion-Compciids, l)age 23. j
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10 Medical Publications of W. B. Saunders & Co.
BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR-
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A Text-Book of Materia Medica, Therapeutics, and Pharma-
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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.,
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CHAPIN ON INSANITY.
A Compendium of Insanity. By John B. Chapin, M.D., LL.D.,
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CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY.
Second Edition, Revised.
Medical Jurisprudence and Toxicology, By Henry C. Chapman,
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CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES.
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Nervous and Mental Diseases. By Archibald Church, M. D.,
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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
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CLIMATOLOGY.
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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.]
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CORWIN'S PHYSICAL DIAGNOSIS. Third Edition, Revised.
Essentials of Physical Diagnosis of the Thorax. By Akphur
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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
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[See Sauni/rrs' Qu,stion-C permanently on the
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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< 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 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,
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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.,
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535 I^ges, with 178 beautiful illustrations, mostly from drawings by the
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JACKSON AND QLEASON'S DISEASES OF THE EYE, NOSE, AND
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, Essentials of Refraction and Diseases of the Eye. By Edward
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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,
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KEATING'S DICTIONARY. Second Edition, Revised.
A New Pronouncing Dictionary of Medicine, with Phonetic
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Keating, M.D., LL.D., Fellow of the College of Physicians of Phila-
delphia, and Henry Hamilton ; with the collaboration of J. Chal-
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KEATING'S LIFE INSURANCE.
How to Examine for Life Insurance. By John M. Keating,
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KEEN'S OPERATION BLANK. Second Edition, Revised Form.
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Medical Publications of W. B. Saunders dt Co. 17
KEEN ON THE SURGERY OF TYPHOID FEVER.
The Surgical Complications and Sequels of Typhoid Fever,
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Diseases of the Nose and Throat. By D. Braden Kyle, M.D.,
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LEVY AND KLEMPERER'S CLINICAL BACTERIOLOGY.
The Elements of Clinical Bacteriology. By Dr. IOrnst Lkvv, Profes-
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LOCKWOOD'S PRACTICE OF MEDICINE.
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A Syllabus of Gynecology, arranged in Conformity with " An
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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.
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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
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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-
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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
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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.
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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
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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.
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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.]
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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.
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NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised.
Syllabus of Obstetrical Lectures in the Medical Department
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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.
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Medical Publications of W. B. Saunders & Co. 21
POWELL'S DISEASES OF CHILDREN. Second Edition.
Essentials of Diseases of Children. By William M. Powell,
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PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS.
Pictorial Atlas of Skin Diseases and Syphilitic Affections
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Hospital, London. Photo-lithochromes from the famous models in
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PRYOR— PELVIC INFLAMMATIONS.
The Treatment of Pelvic Inflammations through the Vagina.
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(AUNDERS'
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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.
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7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE-
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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
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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.
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22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D.
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♦^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,Mii-V A. M. SioNKV, Oraduateof the Training-School for Nurses,
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Clotli, $1.75 net.
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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,ranort. " — 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.,
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VECKI'S SEXUAL IMPOTENCE.
The Pathology and Treatment of Sexual Impoter.ce. By Victor
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000k has received the highest consideration. This edition is more than a mere translation,
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Medical Publications of W. B. Saunders & Co.
VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised.
Medical Diagnosis. By Dr. Oswald Vierord r, Professor of Medi-
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seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and
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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,
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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
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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,
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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
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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.
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