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A TEXT- BOOK

ON THE

PRACTICE OF GYNECOLOGY

FOR PRACTITIONERS AND STUDENTS

WILLIAM EASTERLY ASHTON, M.D., LL.D.

fttLl-OW OF T»E AHEPICAN (« VN ftCO LOG IC A L SOCLUTV;

PBOFHISOH «F CVHUCC*LO(;V |H THU M UDICO-CK I UtiBC IC A L COLLHGK.

4SO GVNELX>LOUIST TD THE M ED ICO-CK I R UKG IC A L HOSPITAJ., PHILADELPHIA;

FORHERLV LBCTLRKR ON CYXBCOLAOV l^t THB ]EFPE«E^S MBDlCAL COLLKGK, PK 1 LADE LFH 1 A {

Ona LiF THE KOL'NDRRS OF THK CaNGRHS INTERNATIONAL UK CVNl^COI-OCIB BT D'oBStAtRI QUI ;

MRU»R OF THE AMERICAN MEOICAL ASSOCIATION, ETC-

IVITH TEN HUNDRED AND FORTY-SIX
NEiy UNE DRAlVfNCS ILLUSTRATING THE TEXT

JOHN V. ALTENEDER

Scconft Edition

PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY
1906

Set up, dectrotypcd, printed and copyrighled, May, 1905. Revised, reprinted, and rec

righted, January, 1906.

PRESS OP

W. B. SAUNDERS COUPANY

PHILADELPHIA

THIS BOOK IS DEDICATED
TO MY WIFE

ALICE ASHTON

AS A TOKEN OF LOVE AND IN APPRECIAT10H OF HER

CONSTANT AND LOYAL COMPANIONSHIP DURING

THE YEARS THAT HAVE GONE BY

5150*3

PREFACE TO THE SECOND EDITION.

The generous reception given to this work by the profession and the medical
press has made it necessary to prepare a second edition in the brief period of
six months after publication. This very flattering result demonstrates that the
};eneral practitioner and the medical student appreciate a treatise on gynecology
which assumes that the reader is not an expert gynecologist and therefore de-
scribes in detail not only what should be done in everj' case but also precisely
haw to da it.

In making this revision of my practice of Gynecology within so short a time
the changes are necessarily few in number and chiefly limited to correcting a
fen- t}-pognLphic errors and altering several of the illustrations.

William Easterly Ashton.
30II \Val\ut Sthket,

January, igo6.

PREFACE.

TtiCR U, I lxli«ve, n place for a Practice or Oynecolo^ which siims to uke
iwibin); fi>r gnintrd in describing k;,' new logic iliseasi^, and wbidi nut unly viaies
wbll sh>>uld be done in every rase, but al<io givi-s cliicctions and illustrations so
rxpticit iKiit itiey may Iw inielli|!;enily ttrui easily followed. Althoujih 1 may lie
ttlun to (ask by some of my critics fur Icnvint; nnthing to the imaginaliun or
(OmiiKm seitse of my readers, yet I bclie\% the maas of the profession who lui^v
had neither the time nor the opixmuntiy t>i det'ute lliem(«]>v» lti x|)ecial!»m wiJJ
gladly acknowledge their limitations and appreciate a tmtisc on any subject in
medii-ine or >uri{ery which eiilcn fully into details and endeavxmi to meet the
n-miirrmcnis of prncticut men,

1 have considered fully both the medical and surgical aspects of f^necology,
swi have discu-wed each Kubjecl 50 far as |)OMihlc upon the basi.-i uf my fiwo
experience. If a muliiplicily n( methods or operations is given for the Ireaimcni
of a di«ca:te, tl>e restilL- "must be un.iatisfactoi^'. as such a description ts al l>cst
incom[itcte or fmgmcnt^irt* in characli-r .-iiid leaver the reader with an impcrfei-t
cunceptinn of the subject. I Kbv% therefore in each instance given that which
In my juilginetit is the lie>l plan of treatment, and afterward dr^ritwd such
nriatiuns as may be rr<|uirc<l in the management of at^iiioil rases. In follow-
ing tht» {>lan il hax \tcen netvk^fy to exclude certain operations and methods of
Imiment employed bj" other surgeons, and I <lo not wish lo lie mi.'sunderstdiid
as implyint; ihal \hey have no value, as I have been guided solely b)' the desire to
present a ln.-uti.se whiih shall >;i\-e a tlKirouKhly detailed aicount of the prarticeof
ajncodogj- (mm the ^iJiiutiHiinl of the general practitioner and the student of
Fncdif'inr.

The book is unusually Urge for a work on gynewlog)-. but it wa» impo9»llkle
lo k-ssen the number of pages and at the same time gi^'c the necessary tcchnic
details and ^pa(v far the Urge number of illustrations.

The ilhiMrations, which numlier ten hundred and forty-six cuts, are all new
line drawings which were made under my pergonal supervision from actual ap-
poratu*, living models, diM«ciiorw on the ciida\'er, and the operative technics of
other authors, I have endeavored so far as poisgible H> sh»>w each s^ep of the
rariuu* methods of iliugnosis and ircaimenl. as well as the dilTercnt opcnitrons,
by a Mfioratc drawing in onler to cbrify the text and enable the student to see
■I a gbnce (he 'frtails of the sexicral pnKcdurrs, All ihr in^lrumenLs. iKcdlcs,
mad "titure m:)ieriak useii in every iroportant operation are shown b>- a «paraie
drawing, which is placed licfore the operative tochnic, so that the surgeon may
readily wrlect what i* rcfpiired and be sure that nothing has lieen omitte<l. The
Mnw plan lias been followed in illust rating the instruments use<l in making the
various gynreolugic examinations, as it (va» thought to be an advantage for the
cumitwr to see at a gbncc precisely what was needed in a gi^vn case. The
drawing!! which ilhi.-trate the pathologic conditions met in g}'necnlo^c ptactkc
an- purely diagrammatic in character and m;ide lo repre*«nl tyi^csl lesions.
H.ilf tone* from plii>u>graphs of actual specimens were not usetl for il1u>tratiotb.,
a* Il wa> found iin)x»stbte lo reproduce details with any degree of ctcaraess, and

12 PREFACE.

the particular conditions which they were supposed to represent were so oft(
obscured by coexisting lesions that they were practically worthless.

The opening chapters, on Microscopic and Bacteriologic Examinations, tl
Blood in Relation to Surgery, the X-rays in Gynecology, Hydrotherapy, Coi
stipation, Diet, Indoor Exercises, and Saline Injections, have been written wil
the object of giving definite information which can be used at the bedside and i
the same lime serve as a working basis for the purely gj'necologic subjects whit
follow.

The chapter on Microscopic and Bacteriologic Examinations gi\-es tl
practitioner precise instructions how to obtain and preserve morbid secretioi
and tissues and deliver them in proper condition to the pathologist. The pra
titioner is thus placed in close touch with the laboratory and can take ad vantage I
scientific methods "of diagnosis. No mention is made of the technic by which t^
pathologist examines the specimens, as this subject should be studied in specL
treatises and not discussed superficially in a work devoted to practice.

The arrangement of the book on an anatomic basis permits a discussion of t^
methods of examining each organ before describing its diseases and rende:
unnecessary the usual chapter on physical examinations, which, on account of i
broad generalization, tends to confuse the student. This plan enables li
practitioner to study different methods of examination step by step, and i
familiarize himself with the subject in a practical manner.

I am under special indebledncss 10 my assistant. Dr. John A. McGlinn, fi
his faithful and zealous work in assisting me in the revision of the manuscript an
valuable suggestions too numerous to menlion. I also wish to thank my a
.sistants, Drs. Charles B. Reynolds and George E. Johnson, for their assistani
in the preparation of the index.

I am indebted to Miss Margaret P. Pridham, formerly Directress of t\
Training School for Nurses at the Medico-Chirurgical Hospital, and to it
"Handbook of Invalid Cooking," by Mary A. Boland, for much assistance i
the preparation of the chapter on Diet.

My thanks are due to Messrs. Charles Lentz & Sons, of Philadelphia, f(
the loan of instruments and apparatus which were used in drawing many of tl;
illustrations.

I lake this opportunity to express my appreciation of (he pioneer work i
Prof. Howard A. Kelly in the field of ureteral and vesical diseases, and to a<
knowledge my indebtedness to him for original investigations which have n
suited in a more intelligent understanding of these affections.

All the illustrations have been drawn by Mr. John V. Alteneder, head of tb
Art Department of Messrs. W. B. Saunders and Company, and I am especial!
glad to express my appreciation not only of his splendid work, but also his man
practical suggestions. His technic skill and untiring interest are shown in th
chantcter of the drawings, which are remarkable for their anatomic accurac
and clearness of detail.

Finally, I wish to thank the publishers, Messrs. W. B. Saunders and Con
pany, for their cordial and unselfish co-operation in assisting me lo complete m
laborious task.

WiiLiAM Easterly Ashton,

201 1 Walnut Street.

CONTENTS.

CHAPTER I.

FACE

General Technic of Gynecologic Exauinations 17

chapter ii.
Microscopic and Bacteriologic Examinations 37

CHAPTER 111.

The Blood in Relation to Surgery 50

chapter iv.

EXAIONATION OF THE AbDOUEN 57

chapter v.
Examination of the Rectuk 68

chapter vi.
The X-rays in Gynecology 75

J CHAPTER VU.

i Hydrotherapy 77

CHAPTER Vlll,
CoNSTIPATIOS lOJ

chapter IX.
Diet 106

chapter x.
Indoor Exercises 117

chapter XI.

Sauxe IxjEcnoKS 126

chapter xii.
The Causes of Diseases Peculiar to Wome.v 136

CHAPTER xm.
History Taking 144

chapter xiv,

The Vulva 151

'.I

14 contents.

chaftek xv. ,

The Vagina :

chapter xvi.

The Uterus.

CHAPTER XVI 1.

EXAUINATION O? THE FALLOPIAN TOBES, THE OVARIE.S, AND THE

Uterine Ligaments t

CHAPTER XVHl.

The Fallopian Tubes t

chapter XIX,

The Ovaries ;

chapter XX.
Diseases of the Broad Ligauents ;

chapter XXI.

■ Tumors of the Ovarian Ligaments ;

chapter xxn.
Tumors of the Round Ligaments ;

chapter XXIII.

Suppuration of the Pelvic Connective Tissue i

chapter XXIV.

EcHiNococcus Disease of the Pelvis <

chapter xxv.
Ectopic Gestation ;

chapter xxvi.
Hysterectomy for Diseased Appendages ;

chapter XXVII.

Effects of the Removal of the Uterine Appendages ;

chapter xxviii.
Conservative Operations om the Uterine Appendages <

chapter XXIX.

The Urethra S

chapter xxx.
Thk Bladder (.

CONTENTS. 15

CHAPTER XXXI. paoi

The Ureters 657

chapter xxxu.
Physiology 69a

chapter xxxiii.
Intestinal Disorders 698

chapter xxhv,
coccygodykia 73o

chapter xxxv.
Tuberculosis of the Genital Organs 738

chapter xxx\'i.
Genital Fistulas 750

chapter xxxvii.
Sterility- 775

chapter xxxviii.
The Pelmc Floor 781

chapter xxxix.
Antisepsis in Hospitals 807

chapter xl.
Technic of Minor Operations 830

chapter xi.i.
Technic of .Abdominal and Pelmc Operations 834

chapter xlii.
.VvTisEPSis IN Private House.s 944

CHAPTER XLIII.

Technic or Special Operations 955

chaptkr xliv.
.■\ppendk1tis 1013

chapter xh-.
Movable Kidney 1028

Index 1043

PRACTICE OF GYNECOLOGY.

CHAPTRR I.

GENERAL TECHNIC OF GYNECOLOGIC EXAMINATIONS.

Office Examining Table. — A [iro|>erly ron»truclcd cxnmining table b

il (nr the phy^icu^V (ilDcv, iind it should be so arranged as to cnabl? the

Icnminer lo place the patient in the diffcrcnl gynecologic postures. The A'khtiin

lablr i'' built witti siliuHiuble nuppan^ [<>r llic puticnt'n feet to rc^t on, and with

a inav-ible cxtctiMnn biurH iil the b.icle (<> lengthen the table when ihc patient is

fdscBd in the horizontal recumbent posture.

r--

tin 1 — .^nllOB(S Ormx EKumnwo Taru.
'mt Ibi mdjiaMi nrpcfU la IIk palaew'a Iri %ail Ihc nmvilile etlnniMi loud ind Kcp.

Hospital Examining: Table.^Boldi'K operating ublc is m:ii!r nf

octal and ctneTcd with white ciumel. It has a movable glass lop, which can be

Ldmlo) or towered as required, and adjustable leR-holdere and stirrups. The

[bUc u neatly L-(>n.%inicte(l and b e^|»eci:ltly well a<lapted (or giynecuhiKic

Fcamiiuilkin.'s and operaltom (Kik- i).

Rxamination at the Fatient'B Home.—li U imi)Anani when an
eumtoalion t* made at a priii'alc hou.-« th;it the piitient should he pl.icied in a
■ ocrrcl poMtioD, otherwise the results are unsalistacion' and mistakes are very-
|1kdf to be made in the diagnosis. By usinx ;lliju^lal^l(■ leji-holders ami Mirrups
■should lie nti diffiuiliy whatever in m.-ikinj! .1 Mti-^facion- exnminalion and
lining the condition of the pelvic organs without employing a specially
[tMkonicied (able (Fig. j).

The mnvaji or leaiher leg-holder' that arc commonly foM in the shops, and
•iiich arc fnsscd o\-er the shoulder of the patient to support the legs and (hifth.i,
l_irc utterly useless for an examination at a private house. .1.^ they do not Meadr
bndy and therefore it K difficult lo [lalpate the pelvis properly.
» 17

GENERAL TECHNIC OF GYNECOLOGIC EXAMINATIONS.

The patient may be examined in the following ways: (i) Lying lenj
wiseonabed; (a) lying crosswise on a bed ; and (3) lying on a kitchen tablt

Lying Lengthwise on a Bed. — This is an unsatisfactory position in wb
to make an examination, and should never be employed, except to palpate
inspect the abdomen, unless the patient is too ill to place crosswise on (he I
or to examine on a table. Vaginal or rectal touch and bimanual palpation
practically the only methods of examination that can be employ«l with a
tient in this position, as it is impMssible to use a speculum or any other insi
ment for diagnostic purposes under the circumstances.

The patient and the bed are arranged as follows: Lift the hips of the pati
a few inches above the bed and slip the leaf of a diningtablc or a small ironi
board under the sheet. This gives a firm support to the patient's hips and j

Fin. I.— Boldt'b Hospihl Kxahinino and OpmATiur. Table {page i ;).
SbawjDi an adjusiable nLirtup wiLh ftrnp and a htvJ Eiirrup.

vents them from sinking into the mattress. The head is then supported o
pillow, the knees drawn ui> and widely separated, and the feet placed near
buttocks. The examiner now kneels on one knee at the side of the bed, pa;
his hand under the upper sheet and over the leg of the patient, and introdu
the index-finger into the vagina or the rectum. The free hand is then pas
over the patient'.s thigh and placed on the atxiomen above the pubes ;
counter-pressure made downward in the direction of the internal finger.

Lying Crosswise on a Bed. — This is a ver>' satisfactor)- position in wh
to make an examination, as the patient is under thorough control and ihert
no difficulty whatever in using the speculum as well as other instruments
diagnostic purposes.

The patient and the bed are arranged as follows: Place the leaf of a dini

EXAIUNAIION AT THE PATIENT S BOUT..

«9

ubk- or I snull ironing-board Irngthwisc on the mattress and close to the &ide-
bMud of the bed under th« sheet. Nexi attadi Lentz'^ modified Edebohbt'it
ks-bulderi tu the udc-boanl of the bed and then place the jMtient crosswise

FkC. l-^ljsU't MuUfltAtlUH <^r bl.:tBI>IIll'> Ai.-II'VIMU Iji^MOIVtMt Itugr I?)

hLdnl of « hr«l

witb ber buitock> close to the edjte and her heeU resting in the stirrups. The
nsmioer now kncck on one knee in (rant of the v-ulva and makes the necessary
exuninatioDs (Fig- 5).

TW pErittaa tl Ifcc iraaini.boBd ud>1« iIie ibm u iiKhftint b) donrd hiiM.

If the pb)*«ician dor* not bavr the adjustable Icjr holders, (airly Rfxid sub-
flitutcs can be impTDviscd by pUcing two chairs ei};hteeti indies apart at the
aide of ibe bed for the patient to rest lier fe«t on (i^ijc- 6).

30 GENERAL TECHNIC OF GYNECOLOGIC EXAMIKAT10N5.

Lying on a Kitchen Table. — This is by far the best substitute for a spe-

Fio. J. — PoiTiTU or A Patient Ltwc Crosswise oh a Bed with the Heels ScprotTEO bv AniosTAaLE

SniKCPS (po^ jS).
The dolled lines iadiait (he poajdon of tbe iioruof- board under the ibeei-

cially constructed examining table, and as a matter of fact with the leg-holders
attached the latter oSers no marked advantages- A kitchen table can be ob-

Sta. 6. — FonuEB or a pATmn Lvihc Ciossitise on a Bed with the Feet Restiho oh Chaiis (pmc 19}.
The [naitioB of the itomns'boud it abowD by dolled lines.

KXAMINATION OF CWtS AI>n> UNUABRIED WOMEN.

uiDRl in every linuschold, ami the physician should always insist, at ka»t tor
the firit cxttinitiution, ujHin luivinK it timuRht tn the piitient'» room.

The patient ami the uhlc arc arranged as follnws: Co«r ihc toi» of the
ikMe with n liLinlcLt 3iuJ a Nhtet and attach the IcK-holden^. The {laiieni
» then placet! in the itor^l [losilidn with bcrleet fiuicDeil iu Hk stirrups and
bi*r head mling im a [liUow.

Fn. t.~Fa*tit»Mji Patiuit iTiiwaai iKnmui Tabu.
Tte ImI m M»p«ird hr a4iBt>bl> li«.|Hldfn uiuknl lu iht lap of lb) Ubl».

Examination of Girls and Unmarried Women.— An ancs-
Ihcttc should always be employed in the cxamtnatiun
tit icirli and unmarried H-nmcn, as the necessim- manipubtions
are naturally a ^Jux'k ti> iheir sense »( modcKiy, and they are usually in sudi a
ocrmuk and extilablcsutc under the circumsiances that it h practically im possi-
ble lo obtain !iutTi<'icnt relaxation of the muMies to palpate tlie oqtans ulb-
Udoril)-.

Unless there arc good reasons to the contrary, vag-
inal much should not be employed, efperiaily if the
bynrn is intact; but when the indkaltons demand an examination
by thai route, the {>))>-«ldan sliould not allow any false ideas upon the
wbject lo intrrfi-re wilh what i» l«»I (<* ihc [laticniV inicn?.t. In the mn-
jonly (if 13SCS. however, a thorough and complete examination ran W made by
nctal ur recto- abdominal pal[ialion. and consequently one or boih of these melh-
ads khould always be rmployeii before resoriintt to vaftinal touch, which can be
QHd Mibsequentiy if rwtuired.

Ancstnesia.^TJit" im|><irlanic of ilie routine use of an anesthetic in
Hywn'l-'gii rt.iminaiions is frequently overlooked, ami comequcntly many
avi.>B|.iMr nii^ukes are made in the tliagnosis of pelvic afleclionv. Ether,

cfai- i>t nittouK oxid gas should therefore be employed, as a rule, in

in" .1 pelvic dbeases, as it is often impossible without an anesthetic

(>>cr\."n>e the reiistance of the muscles or the sensitiveness ol the pari^.

aa GENERAL TECHNIC O? GYNECOLOGIC EXAMINATIONS.

I therefore strongly recommend the use of an anesthetic whenever the exam
has the slightest doubt of the condition of the pelvic organs. Under these
cumstances he should refuse to express an opinion until the examination has 1
properly made, as it is impossible even for an expert to ascertain the natui
an intrap>elvic lesion without an anesthetic in women who are fat or ner
or where the pelvis is tender and sensitive.

Nitrous oxid gas is a very convenient anesthetic for brief examinations
may be administered at the private office of the surgeon, the hospital, or
patient's house. The gas should be given combined with oxygen by mean
an apparatus devised by the S. S. White Dental Company of Philadelp
which is portable and easily managed. The apparatus consists of a ir
frame, two cyhnders of gas and one of oxygen and the necessary mixing va!
and the inhaler. The anesthetic is administered as follows: The nitrous ■
gas is administered alone until cyanosis and respiratory disturbances apf
and then a sufficient quantity of oxygen is mixed with the gas to give a hea
appearance to the patient's face. During the examination the mixture of
gases should be carefully regulated in order to obtain complete musculai
laxation, and at the same time prevent respiratory disturbances. When
examination is finished, the nitrous oxid gas is shut oB and pure oxygen
ministered for several moments. The patient returns to full consciousnes
two or three minutes and has no disagreeable after-symptoms.

Preparation for the Administratioa of Chloroform or Ether. — A
gative dose of citrate of magnesia should be given the night before, foUowe
the morning by an enema of soapsuds and water. The bladder shoult
emptied spontaneously just before the anesthetic is given. The exapiinatic
possible, should be made in the morning, about two or three hours after a br
fast of toast and a cup of tea or cofiee.

Antisepsis. — Gynecologic examinations must be conducted with dui
tenlion to the principles of antisepsis, and the examiner must not only gi
against becoming infected himself, but he must also prevent infection b
carried to his patient. The strictest precautions and the most careful wa
fulness are therefore required or accidents are bound to occur, and faealt
life may be the price paid for carelessness. The danger of infect
is always present. The patient may inoculate the examiner
syphilis or infect a slight cut or scratch on his finger which may resu
general sepsis. The examiner, on the other hand, may carry the infeaio
gonorrhea or syphilis from one patient to another on the instruments or
hands, or, again, he may infect the uterine cavity, the urethra, the bladde
the ureters with a dirty instrument.

Preparation of the Examiner's Hands.— The finger-nails should be
short and evenly filed (for method see p. 814) and the hands free from ro'
ness or abrasions. The unprotected hands should never be used to maki
internal examination if there is the slightest scratch upon them.

The hands are cleansed by thoroughly scrubbing them with liquid soap
warm water before and after making an examination. The brushes shoul
made of vegetable fiber (see p. 828) and sterilized each time they are i
They are very cheap and can be repeatedly sterilized. A good plan in pri
practice is to set aside the dirty brushes until after office hours, when they
be rinsed in clear water and boiled for five minutes in the office sterilizer coni
ing a I per cent, solution of carbonate of soda. The brushes are then tt
out of the solution and wrapped in a clean towel until ready for use a(
In hospital practice the brushes are sterilized with high-pressure steam
specially constructed apparatus (see p. 814).

ANTISEPSIS.

Pu. S.-'lhitiiii CiJivn.

I 9.ironf|il]r recomfnend the use of rubber gloves lo proierl the hands in

^auking grnecoto^c cxaminatiuns. Woiii-'^ ihcy arc. nftcr all. the Dniy certain

. m possess of prc\<rnttng infection. The risk that the examiner run^ in

tRUkim; daDy examinaiiona of a larfie number of women cannot \x o\'eresti-

' nnled, and he nhnuld Ihcre

ton span no expense or

muble in fcuatdinR hirotteU

spinet infection. The glo^xs

thouU never be used twice

whhoiii lesieriliEation, and it

» therefore iKcessar^- lo haw

iO'eral pairs. After making;

an exunination the gln\-ex

are msbed in warm water

I and liquid soap and rinseil in

pUtn water; thry are then removed from ihc hands and laid a:«ide for subne-
queiit Herilization. which is accomplj.'ihed by boiling them in a solution of soda
(1 per cent.) fur live minutes and linally wrappini; them in a clean towel.

TT»e u« of lingcT-a:>ts should be condemned, as Ihcy only partially pro-
tect the hands and arc therefore wonie tliaii useless.

Preparation of the Instruments.— The anlis«])iic jirecautioTi^ mti^t be
lkirau{[h and rw in^irumeni should lie used a second time without being re-
ttmliBed. The common habit of simply washing a speculum H'itb soap and
water and then tujn^ it again on the next patie:it i^ atnolutely wrotiK. 'i-'< ■> )»

not surgical cleanliness; and while
it lessens the danger of infection, it
\» not by any mean.i a |)i>^tli\-c prc-
\-ention. Practically there
is only one way to gu:ird
against accidents, and that
is nex-er to use an inslniment a
secont) time without thoroughly
cleaning it with liquid soap and
water and then boiling it in a solu-
tion of Rirbonate of -uKla (i p«r
cent.) for fiw minutes. This will
of course necessitate having a
double .-let of -.jieadum^ and other
instruments, but there should be no
hesitancy on that account when
we (xtnsider the great daii^r at
spreading infection.
The phni(,-)an »boukl have in his office a small white enameled sterilixcr with
handles and a perforated iray. 3 stand for the ^terilin^r. and an alcohol lamp,
or if gas is tised the stand sliould lie made whh a tubular liunsen burner nt-
tadMd (Ftg». 10. II, and 13).

One wt of insirumenu can then be placed in the steriliser while the other
M is beini! used, and in ihb way perfect asepsis can be carried out with but
wr>' llille irouMe.

Pnfwntion of the Patient.— The rectum .should lie thorouRhly emptied
widi an enema of suap^ud-^ .ind water and the bladder cx-ucuatCfJ simnuncously
jost before the examination. The bladder should never be evacuated with a
oibeter if it can be avoided, because the organ can be more thoroughly

GENERAL TECHNIC OF GYNECOLOGIC EXAMINATIONS.

emptied spontaneously than by catheterization, and hence we should not
necessarily expose the patient to the danger of septic infection. The cor
should be removed and all clothing that constricts the waist should be loosei
In some cases it is necessary to empty the lower bowel and clean out the
testines before the examination. To accomplish this, nothing is better t
giving the patient a purgative dose of citrate of magnesia the night bef
followed fay an enema of soapsuds and water the next morning.

When special instrumental examinations are made, the sterilization of
vagina, the vulva, and the surrounding parts must be thoroughly carried •
but when touch and direct inspection are alone employed, no antiseptic pn

Fio. 10. — STTJtiujEi Stand (page i^).

Ftc. 1 1 .— ALCOHOt Lamp (pace

ration whatever is indicated, as any form of douching or scrubbing will
move the discharges and thus obliterate in some cases the evidences of diseasi

The vulva and the external urinary meatus arc sterilized by scrubbing i
a gauze sponge saturated with Uquid soap and warm water and then doucl
the parts with a solution of corrosive sublimate (i to looo), which in tur
removed by sterile water.

The vagina cannot be thoroughly sterilized unless the patient is under
influence of an anesthetic, as the necessary mechanic scrubbing of the p
is quite severe and painful. (For Technic see p. 831.) Sterilization of
vagina, however, is seldom required in making a gynecologic examination
it is indicated only when the uterine sound is used or the uterine cavity is cun

Fic. II.— SmiuzEK Stand wna a Tubllav IttNSEH Burhei Attactied (page ij).

for diagnostic purposes or a piece of the cervix is excised for microscopic in
ligation.

Iftibricant. — A liquid soap contained in a bottle with a sprinkler to;
the best lubricant to use for the hands and instruments. VaseUn or other
substances are difficult to keep sterile and hard to remove, and conseque'
they are liable to harbor germs around the finger-nails or in the joints of
instruments.

.After cleaning the hands as described above and putting on a pair of stt
gloves, the examiner sprinkles several drops of liquid soap into the palm
the examining hand and lubricates the fingers with the thumb of the si
hand. After completing the digital examination he again sprinkles some s
on the palm of his hand and lubricates the blades of the speculum by dipp
them into it.

LITBRICANT.

As (leKiibAl elitcwhera, Ikiuid white \'aM;lin which has been previously

riltu^ liy U'ilina should l>c ij>«l to luliriciHi' inMnimrnts which arc used to

itiir Uk urrtlini, tlic ljU<lilcr, or the un-icr^. Thi» substance is unirri-

I !■- • . FIC. 14_

tut~ It. — iimiiuia tor lloTtU ('hhiauimi Liqi-ii> Siur. Fm. it — Utmnit of Srumum LiWiB

5m> ivmi th* r«w of III! Htm.

taiinff anil ttoM wi oral the mucuus mrmhrane or chan^ the appearance at
(he inns.

Glycerin is the liei.t luhriciint to \i.*c for thr ftnfSFm in mitkinf; nn enmina-
iMD in ouo »( cancer of ihc cmix, as it is easily n:-
miivod and no odor rrmain^ on ihc haivU.

The Cleuiiing And Lubricating Soap.— A
liquid Mup loiilaincd in a Ixntlc with a !i|irinkli'r
IM> ihtnikl iil«a>-4 be employtH] (or clennf^ing and
luiiticalint; jmrpo'te^ except, as stnied aboi-c, when
liquid white vaM^lIn is used as a lubricant un n-riain
ln<>trumenti>. 'Hie ndvantap.-^ »f a soap i)( ihii^ kind
KWttained in j Uillk- are sclf-evidcni. It never lie
xftnes (ontii minuted, a.s a ciike i>f kinl xup di>cs
tlui i> ik'Kil (iinslantly in cleanse the hands lielwcen
ciaininaiiuits, tiecuuse it ii- sjxinkled Irtim the Imtile
and there cin be ni> contact with wKal remains
unuwrl.

A icwkI liquid ituap cnn 1>e prepanol a* follon>:
Chif) eiinhi uuRcni nf Mwp inln small pici-cs and put
tbem int" an a^ate kettle t-onlainint; two quarts of lil-
Irred naicr. Place the kettle on a i^tove aixi as siun
at the wjler Itoiln ami the soap is thoroughly dis-
vitvtfl |ii)ur (he mixture into a cicun half-fEallon
bottle with a i:ri>uivl ttla-A sl<»i>|H;r. The liquid can
•hen be ixHired dirnlly into a snull bottle with a
kprinkler lop and usol when re<|uircd.

1 am in the ha)>it o( u^nig, the onlinArv tincture nf green suap Uinimfnlum
'<i*Mi'i mollit. V. S. f.) as a luliricani and for cleansing the hands, and con-
tiikr it B thorouKhly rptiatile pre] unit ion.

The Rtethod of Mcrilixing liquiJ Miap cimuined in small sprinkler top buitles
b'te«cHl>ciJ un paKcSU'

Fin. It,— K*UT'I SDWK4L

P4I1 ifiiat >C).

GENERAL TECHNIC OF GYNECOLOGIC EXAMINATIONS.

Irrlg^ating^ Pad. — Whenever it is necessary to sterilize the \-ulva or
vagina before an examination, an irrigating pad should be placed under the
patient's hips and the water allowed to flow into a bucket placed on the floor.

The Kelly pad is the best appliance for this purpose and should always be
used in preference to a metal douche pan (Fig. 15).

A piece of rubber sheeting and a bath towel may be used as a substitute for
the Kelly pad. The towel is folded into a roll and placed in a half-circle at
the end of the top of the table. The rubber sheeting is then thrown over the
towel and its free end dropped into a bucket on the floor.

Fig- 16, Fig. 17-

A-iHiON's SmarTVTE tob the Kelly Pad.
Sbowinc the method of folding Lbe badt tow«L (Fig. i6> abd ihc positioa of the rubber BhRIisg (Fif. 17).

The Bxamining Hands.— Internal Hand.— Usually only the index-
finger is used for palpation, as two fingers are apt to cause pain unless the
vagina is ver^' capacious. When the patient is under an anesthetic, however,
the examination should be made with two fingers, as more information can be
obtained at times with two than with one.

The fingers of the hand are held in two waysi First, the index-finger and
the thumb are extended and the other fingers placed in the palm of the hand;
if two fingers are used, the index and middle fingers are extended.

Second, all the fingers are extended with the thumb resting on the mons
veneris, the index and middle fingers inserted into the vagina or the rectum,
and the ring and little fingers tying in the gluteal cleft.

The tips of the fingers can always be carried higher up in the pelvis by mak-
ing strong pressure upward on the perineum with the knuckles of the examin-
ing hand (Fig. 20).

THE EXAMINING HANDS.

Fig. iS,— ^n»i or the Fimoeu ih Making ah Iktvual Examiitatioh bt tsi Fiut UrtaoD (m lad kX

Fig. tQ-^PcBEGr thk FiHOEirs ih Makjng as Internal Kxauihation it the Stxohd MttnOD (« kiidfr).

GENERAL TECHNIC OF GYNECOLOGIC EXAMINATIONS.

External Hand. — The fingers are used for palpation and the thumb to
steady the hand. When the pelvic organs are palpated through the abdominal
wall, the fingers should not be held straight and rigid, bul slightly flexed, so
that the parts can be easily and gently manipulated.

Assistants. — Every physician who is doing much gynecologic work should
have a female office assistant to arrange the patient on the examining table and
look after (he instruments, etc. She should be neat in her appearance, cheer-
ful in disposition, and thoroughly instructed in her work. It is not neces.sary
to have a graduated nurse, as any capable and wilting woman can be

Ftc. 3o. — Invagination 07 the Pctvic Ft^OB (page 16).
Diigrun b ahows tbe tip of Iht bnjicn curipd high up in Ifar pelvia by jbyaaui? on ihe pcriDcum with the
knucklq of thr uamioiDff hand. Diagram a ihows the potjiion of the lip of the fiog^r, whrn Ilie pelvic Aoor a
not invii^aaicd. N'olt tnr position of the tips of the lingers in tbe two diagrsms and also tbe alteru reUtionioE
tbe vagina, perineum, and rectum in b-

taught in a short time aU that she is required to know from a practical stand-
point.

Examinations in which an anesthetic is used always require extra assistants,
and the number depends upon what organs are to be investigated. A digital
examination requires only one assistant and the anesthetizer. When the bladder
and the ureters are to be examined, however, two assistants will be needed- to
support the patient if the knee-chest position is employed, whereas one is sufficient
when the dorsosacral elevated posture is used.

GYNECOLOGIC POSTUR£S.

Fir.. It.— PosiTTOH or the FiKCiMorTKE ExT»ii*t Hand in MAitHS jt BtiUMtiAL ExAinHAnoH.

GYNECOLOGIC POSTURES.

The indications for the various gj'necologic postures as well as their effect
upon the position of the pelvic organs are referred to in discussing the methods
of examining the different structures of the pelvis, and I shall therefore not
speak of them here, as a general summar)- under the circumstances would
necessarily at l>est be but incom|iletc.

The Patient's Clothing.— Il is im[K)rtant l>efore plating the patient
on the examining table to have her clothing so arranged that there shall Ire no
constriction over the abdomen or around Ihc waist, and, as a rule, the corsets
.'■hould t>e removed and the waistbands limsened. It is not necessarj', however.
10 remove the drawers unless they are closed. In making an exjiminalion in a
[irivate house or at a hospital Ihc patient sboukl wear ordinary stockings or long
cinton tlannel stockings which slip easily over Ihe legs and reach to the middle
• •f the thighs (Fig. 21).

Varieties. — The fotkiwing postures are employed in making gynecologic
examination-:

Dorsal position.

(a) Dorsal elevated.
Dorsosacral posiii<m.

(ri) Dorsosacral elevated.
Erect position.
Knee -chest position.

(a) Knee-chest clev'aled.
Lateral-prone piKiition (right and left).
Horizontal recumbent position.

3°

GENERAL TECHNIC OF GYNECOLOGIC EXAMINATIONS.

Dorsal Position.— Position of tiie Patient.— The patient is placed on

her back with the hips at the edge of the table,
the feet either resting on adjustable supporters
or fastened in stirrups and the head and
shoulders slightly rais«i on a pillow.

Arrangement of the Sheet and Clothing.
— The patient is protected from ejiposure by
throwing a sheet over the lower extremities
and the abdomen and arranging the clothing
beneath it. This is accompl^hed by pushing
the skirts above the hips behind and over the
knees in front. The lower edge of the sheet

FlO. 19. — Cahtok Flamhii. Stoci-

Fio. aj. — DaisAL PcmnaK.

is then parted between the
thighs so as to expose the
vulva.

(a) Dorsal Elevated
Position.— The patient is
placed in the ordinary dor-
sal position and after the
sheet and clothing are
properly arranged her
shoulders are elevated with
pillows.

Dorsosacral Posi-
tion.—Position of the
Patient. — The patient is
placed on her back with
the hips at the edge of the
table, the head and shoul-
ders resting on a pillow
and the thighs strongly
flexe<I on the abdomen
and the legs on the thighs. The lower exiremilies are hekl in this position by

FiQ. >4. — DoiuAL Position with the Sheet Dbafep to Expose the

GYNECOLOGIC POSTURES.

a sheet which is passed under the (op of the table and its ends carried over
the posterior suriace of the thighs just above the knees and tied or secured with
large safety-pins.

Another method consists in using a canvas leg-holder which is passed over the
sbouldei^and attached to the thighs immediately above the knees(Figs. 37 and 38).

Fig. ■). — t>ouAL Elevatid Posmoit.

Airangement of the Sheet and Clothing. — This position is generally used
when the examination is made at a private house or at a hospital, and conse-
quently the patient does not have on her street clothes. She is protected from
exposure by throwing a sheet over the abdomen and lower extremities before

}n. 36 — IVif^sAf-m PrjsiiioN WITH THE Thighs Srci'trn dv a SiitiT pAssfii i:npci the T^BtE.

pbcinK her in (xisilion. The hips are then brouphl down U> the edge of the
table an<i the lower extremities tle.xcd on ihe abdomen and secured as directed
above. The lower edge of the sheet is then separated at the vulva so as to expose
the parts (Fig. 29).

GENERAL TECHNIC OF CVMECOLOGIC EXAMINATIONS,

(a) Dorsosacral Elevated Position.— The patient is placed in the ordi-
nary dorsosacral position and the hips are then elevated twelve inches abo%-e
the surface of the table with pillows.

Pio. ly. — DoitwisArRAL Position with thf Thighs Secoved by
ROBB'S Lcc-uou>» <pa«r .<l|.

FlC, jS— R0«B'5 Lie -HOLD EH.

Tbe leR-hold« ia made of un-
hl«a(bcd canioq flaaOFl and can he
wubrd (page 3 1).

Erect Position.— Position of the Patient. — The patient stands erect
with the right foot on the round of a chair, the right hand resting on the back

Flo, 19. — DoitwucKAL Position with the Sheet Dufed to ExrosE the Volva (ptgt ]i>-

of the chair and the left hand placed on the left hip, or she may stand with her
back against the wall and (he feet separated about eighteen inches.

Arrangement of the Sheet and Clothing. — A sheet which reaches to the
floor is fastened around the patient's waist and secured with a safety-pin.

GVNECOLOCIC POSTURES.

The physician then kneels on one knee in front of the patient and passes his
h&Dd uodcr the sheet and clothing (Fig, 33).

Flo. 30. — DoiusAciii. Elev*ted ftwinoN.

FW. )l. — EaiTT FmiTTOH KITH THE RlGRT FoOT RuT-

1HC ow TUF Round or a Chaii.

Fig, 11. — FutrT Position with the
BicK «i;*ISST THt Wali akii thi
Feet Sefaiatt i).

GENERAL TECHNIC OF GYNECOLOGIC EXAMINATIONS.

Knee-chest Position.— Position of the Patient.— The patient she
kneel on a table with her knees slightly separated and the feet projec

Fig, 3}. — Erict PosmoH wim the Sbekt Dufto to Fkotect the Patiekt now Exkhdie omn

Examination (poac 3>).

over the edge. The side of the face is then placed on a soft pillow witl
upper chest flat on the table and both arms thrown back. The thi
must be perpendicular to the surface of the tabh

Fi(i. j4. — KNCE-rHFST Position r
The [highi mavt 1h perpendicular lo Iht Idbk 40 a« 10 obtain ihc- hii^hrst tlevation ol the pelvu.

order lo obtain the highest elevation of the pelvis,
the chest must be us close as pos.slble to the kne

GVNECOLOGtC POSTURES.

Arruigemeiit of the Sheet and Clothing. — The patient is protected from
exposure by throwing a sheet over the hips and back and separating it at the
gluteal cleft to bring the vulva into view. If the examination is made at the

FH. JS. — KHEt-(«llT PDUtlOH Wm TBI SHEET liM/LTED TO EXPOftt TSI VlTLVdL

l^ysician's office, the skirts are drawn up over the patient's hips after the sheet
has been thrown over her.

(a) Koce-chest Elevated Position. — The patient is placed in the ordinary

FlO. J6.— KuTl.rHEtt FHVATID POSITION ,

kn«;-che^l position and the pelvis is then niised higher by placing pillows under
I he knees.

lAteral-prone Position (right and left).— This position is also
known as Sim.s's or the semi-prone position.

36 GENERAL TECHNIC OF GYNECOLOGIC EXAMINATIONS.

Position of the Patient. — The patient is placed on her right side
edge of the table with her right arm behind her back and both knees dra
toward the chest, the left being higher than the right and resting on the

Fig. jt.— Right IjiraiAL-nONE Posittdh. Amunii Viiw.

Fic. j8. — Right Lateral-pelohe PositioNt Fo'iTEinfiii \'irw-

In this position the body of the patient is tilted toward the table and sup
by the chest and the abdomen.

Arrangement of the Sheet and Clothing.— The patient is protecte>
exposure by throwing a sheet over the lower extremities, the hips, and t

Vt^^- Jp, — RrOUT LATEPAt-PROKE PosTTION WTTR THE SHEET Deapeg lO Exn>SE THK VULl

domen, and arranging the clothing beneath it. This is accomplished by
ing the skirts up over the hips and separating the sheet at the gluteal i
expose the vulva.

CYKECOLOCtC POSTUKES.

Horixontal Rectimbcnt Position.— Position of the Patient.— The
patient lin flat upon her back with the head resting on a piUow and the anns

■O

I'M, «•.— IhmKiKTjiL KmnanrT Ponnoft.

at ihc side of the cbcst. The lower cxtmnitics are extended in a direct line
wHh the long axis of the body and the heeU placed in contact with each other.

-r5^

FK. 4t — HMiiDinu RMmaHT PonnMr vrm nut Stan DiAm ro Cimi Tm Aai>oiiDi,

Amngetneot of the Sbeeti nod Clothing.— A shed is thrown over the
chest and another pbccd over ihc abdomen and lower extremities. The cloth-
ing fai then lirnwn up to the tlie:it and the upper edjie of the lower »heel it fucked
WOaod the hipi to ai to leave the surface of the abdomen exposed to new.

CHAPTER n.
HICROSCOPIC AND BACTERIOLOGIC EXAHINATIONS.

(f i* nften impoMftrle for the mrgenn to make a positive diagnosis in cases
1! iMniT is suspected or to determine the variety of an infection or

'' : luture of a Kn>wth removetl by an operation without theco-op-

emtton oi ibr ratbolof(iU, In M;ekin(; his aid, however, the clinician must bear
in Riind that toe microscope and the culitire-iube are but ailiunct& to the diag-
rwxiu:ian's resources, and that they may not always be conctuKive in their evi-
dence.

38 mCKOSCOPIC AND BACTERIOLOGIC EXAUINATIONS.

The wide discrepancy, however, which occurs in many instances beti
the laboratory findings and the cUnical diagnosis is more often
fault of the surgeon than of the pathologist or
methods, and it not infrequently happens that erroneous repwrts fc
microscopic or bacteriologic examinations, because of the careless manne
which the material is collected and preserved.

It is not necessary nor expedient in a practical work on gynecolo|
attempt to give the technic by which the pathologist arrives at his coi
sions, as the subject can only be properly treated in special works
pathology and bacteriology, and any information given along these lines
book of this kind would not only be fragmentary in character but also
mifileading (0 the reader. Furthermore, no mention will be made of the 1
nic of a quick microscopic examination of tissue fragments by the frei
method, which is a valuable aid at times in determining the question of a 1
radical procedure during an operation in which malignancy is suspected;
finally, no description will be given of the necessary apparatus or the ttt
by which the presence or absence of a leukocytosis can be ascertained, bee
both of these examinations require special laboratory training and study 1
the part of the practitioner.

I shall therefore feel that my object has been
complished if I succeed in bringing the practitio
as far as the threshold of the laboratory, and leave
there to seek admission well supplied with specim
that are properly selected, carefully preserved, and
iclligently described.

The technic which will be given in this chapter for collecting and presei
material for examination is based upon the methods which are employi
the gynecologic service at the Medico-Chirurgical Hospital in Philadelpbi

mCROSCOPIC EXAHINATION OF TISSUES.

Specimens can be secured for examination by the following methods:
Curetment.

Excision of a fragment.
Removal of the entire growth.

CURETHENT.

Sqtllpment. — The necessary instruments and operati\-e parapher

arc given under curetment of the uterus (see p. 9SS)-

Technic. — The operative technic is also described under the same opera
Collecting the Curet Fio^ogs.~An assistant stands at the side ol
operator with a basin containing cold normal salt solution, and the tissue
ments and blood-clots are placed in it as the uterine cavity is cureted. 1
the operation is finished the solution is poured through two or three laye
gauze into another basin to remove the blood, and the tissue fragments w
are caught in the improvised filter are then emptied into a third basin contai
a fresh saline solution. The fragments of tissue, which can then be easily di
guished from the small masses of clotted blood, are picked out of the soh
and placed at once in the preserving fluid. It is ver\' important to secur
the curet findings, and this method of collecting them must be carefully
lowed, as the microscopic examination may be positivt
only a few of the many fragments examined.

MICROSCOPIC EXAMINATION OF TISSUES.

Preserving Fluid. — A lo per cent, aqueous solution of formalin (40 jwr
ceni. aqueous solution of formaldehyd gas) is employed. The ti^ues will
keep for any length of lime and are always suitable for examination. The
fragments should be placed in a relatively large bulk of the presening fluid
(e. g., two ounces 10 a tissue bulk the size of a walnut) and the bottle in
which the liquid is contained should be tightly corked and secured against
leakage.

Shipment, — The bottle is securely wrapped in cotton baiting, placed in a
box, and sent bv express to the laboratorj-.

Information for the Pathologist.—ll is importanl that the prucli-
tioner should send with the material for examination a statemeni that the frag-
menLv were removed from the uterine canity by cureiment, and also a few notes
of the clinical history of the case. Thus: Mrs. T., aged 43. white; the mother
of three children. She was well until one year ago, when a miscarriage
oci-urred which was fol]owe<l by excessi\e bleeding at the menstrual periods
and a profuse yellowish -white leukorrheal dLscharge. An examination of the
uterus and its ap|>endages gave negatii'e results.

EXCISION OF A FRAGHENT.

In the majority of instances when a piece of tissue is excised for examina-
tion it is taken from the cervix in cases of suspected malignancy, and the tech-
nic therefore of this particular operation will serve as a guide when an excision
for diagnostic purposes is made elsewhere.

Technic. — Preparation of the Patient. — No preliminarj- preparation is

op H«

I2E

Ft . 4J lNS7»rnfr*T*, Nufmf^, 4vn Srii'in M.*THHAr t'i>-i> in Rkhovim: i, Pir<T or Ti^^^i'r punii ihv

riirM\ Mpk Mil lll>s<orU K\AUI\A1EoK >IU|[|- 401.

re()uire<l, and the <ij*rjtion should lie jicrformcti in the morning, about twi>
iir three hours after a light breakfa-^t 'if toast ami a cuji of tea "r coffee.

Anesthesia.— .A general anesthetic should aKvay- be empli>ycd. as it is
imiio>-iblc otherwise to thoroughly sterili/e the vagina.

Position of the Patient,— Dorsal |)osiure.

Final Sterilization of the Patient. — See page 8,{i.

Hiimber of Assistants.— An anesthetizer. one assistant, and a general
nur* arc required.

laCROSCOPIC AND 8ACTERIOLOGIC EXAUINATIONS.

Dressinge, Sponges, Towels, etc. — See page 83a for the contents of the
conveyance boxes used in minor operations.

lostnunents. — (i) Simon's speculum (curved blade); (2) three bullet
forceps; (3) a scalpel; (4) two short hemostatic forceps; (5) a pair of scissors
curved on the flat; (6) tissue forceps; (7) dressing forceps; (8) Hagedom
needle-holder; (9) two small full-curved Hagedom needles; (10) No. 2 plain
catgut (Fig. 42).

Operatioo. — The speculum is introduced into the vagina and the cervix
exposed to view. The anterior and posterior lips are then caught with bullet
forceps and drawn down toward the vaginal outlet. .The portion of the

Ftc. 43r — Ejectseov or a Piece or Tissue nou tre Cervix.

Tbe cervii ifl ibowD pulled dorn into Ihe vuivu opFoing znd a wnlaF-shapFd parce of linue bdiu trdi d.

Ndic Iht flppCATUice of Ihe wound in ditcnm 6 iifler the nilura uve bccD introduced and two?

cervix to be removed is now seized with a third pair of bullet forceps and a
broad, wedge-shaped piece of tissue excised with a scalpel or scissors. The
edges of the wound are then united with one or two catgut sutures and the
uterus pushed back into the pelvic cavity.

The vagina is finally irrigated with a corrosive sublimate solution (i to
2000) followed by sterile water and dried with a gauze sponge. A gauze
sponge is then unfolded and loosely packed against the cervix and the vulva
protected with a gauze compress secured by a T-bandage.

Special I>irectioiis. — Judgment must be exercised in selecting the por-
tion of the cervix to be removed for microscopic examination. When the cervix

utcRosconc f:xauination op tisscek.

b ioHuniicd and by{«rtm|>li»e<), the piece of ti&sue mu^I be removed froin where
ihe puth<>li)K>(^ changes tire m<»i murk«l ; ami when a dUiinci nndule i^ present,
it imiM \x included in the excised portion. If the ccmx i^ ulcerated or eroded,
the we<tf:e-«ha()eil yttcc muM !>« tui diredly from it><«nier; and If ubimU out-
gToKih t* [>rr>«nt <in the ixTvix, it jJivuld be removed
l>y cMisinf; its base.

Tftriations in the Technic— Inadnubiful

cue il nuy be cxtolknt to ampiiliilc the entire
mvlx and subject the tissues to a microsropic exam
ination. I'wlcr the>e cirtiim*t;inces the openiiion
ot ninp<uiation of the cervix b performed as described
im ptiRc 459-

Aner-treatment.— Cftr« of the Wouod.
— The vidvar ('inr-jiress is tem|>orjrily removed
when the lH)<n'ct.> and bladder nre evaruaied. The
tampun is taken out at the end of twenty-fuur hours
and the vagina iiriRatcd daily with a solution of cur-
roMve sublimate ( i to looo) f»llovre<l hy Merilc water.

The Bladder. —The urine should be voided
naitnally-

The Bowels.— The IwweU »h«uld l>e moved
lily with a mild laxative.

The Diet,— iJurinc die first Iwcniy-four hours a
lk|ilkl diet (■•«■ |). :oft) should l>e pivcn jnd ihrn the
patient should l>c ptnced upon a cnnvalesceni diet
(»*e p. 114I-

Gettiog Out of Bed.— The patient should re
main in Ik*) fMtn five ila)'* tu one week.

Preserving Fltiia.- .\s soon as the piere of

cervical tissue is excbed it should be )>laced in a bottle containing a 10 per
it. atjucQus solution of formalin.

SUpmetlt.- The bottle i» {Mckcd in the same way as recommended for
eurrl finding;'; .inci sent bv expres- 10 ihc laboratory'.

Infonnation for t&e Pathologist. — The exHued jiiece of cervical
ttMur mu't be nctompaniitl by a brief rliuifj! hiMory and by a description of
the ap|)e4ranie if the icnix as well as a rough diagram showinn from wlial
pan of the cervix it was removed. Thu&: Suspciied ninccr of the cervix.
Mnt. <f.. afccd 40. while; the mother of five children. Alwa>'s well until seven
months aKo, when she began to have sli^t irregular hemorrhaKcs from Ihc
UtrriM, which have increat^ in severity and are a-v«rialed with a foul-smelling
leukfVTheal dischar)». The examination re%'ealed a rag)^ and indurated ulcer-
aliini with small papillary extTestrnces on Ihe riifht side of the (>osieTi(>r lip of
the cervix. From this iikeralt.il jxmiim a weiljte shaped piece of the cervical
waa exnscd as shown by the following diagrams (FTg. 44).

REHOVAL OF THE ENTIRE GROWTH.

:. — After the crowth has l>ccn removed it shnulil ^^e washed in
Mt »ntution and ptiiixil at onm in a bottle containing the pieMr«'in(t

Preserving Fluid. — A 10 (ler cent, aqueous solution of formalin b u»d.
Shipment. — The l>c>ttlc b [xtckeil in Ihe same way as recommended for
cum findings atid sent by express to the labomtory.

rrvijc

.eCi

iwc nif. l%>«iTirtK Awn RTLft^
nus*tut nn Ej*imi> Piecv
or Tm-nAt Ti»«-i

wbJLh iJi« fmiiiiiciil cj Eiuue o«v-

i> ro(lu«>' The d<«i> lajFiion ff);
(h^ edt* m rrbJinn triih tiie ■«-

MICROSCOPIC AND BACTtRIOLOGIC EXAMINATIONS.

Fir.. 4 5.^ Rough Skftoh Showing thf

ReLATIDNS op the I'UUOR VtTH THE

DlAgTAm a show* the urrrtis juid Ihe
rnsilioa which the LumoT occupud (i).
Uikfram b ahowe ihc lumoi (1) and ii>i
DniLDKl r«lm1ioEi» wiih Ehc uieniA as follows:
The buc ()>; Ihe surface of ihe grgwih Ij],

Information for the Patholo-

^st. — The gTHWth should be accompanied
by a statement informing the pathologist
from where it was removed and by a brief
clinical historj-. Thus, the tumor was re-
moved from the left labium majus. Mrs.
H., 28 years of age, white. She is in good
health at the present time. Two years ago
she noticed a small tumor on the vulva
which has been growing slowly.

When an entire organ is removed and
sent to the laborator\' it is alwaj's best to
stale «-hal organ il is, as it may be distorted by
disease and unrecognizable macroscopically.

When a tumor is removed from an organ,
it should be accompanied by a diagram, a^
recommended in cases where a piece of
tissue is excised from the cervix. For
example, if the growth was taken from the
fundus of the uterus, the diagrams in figure
45 will explain its relations.

HICROSCOPIC EXABUNAnON OF DISCHARGES.

Bqnipment and Instroments.— (i) One dozen glass slides; (a) a
small alcohol lamp; (3) a delicate steel or silver applicator; (4) Simon's
speculums (flat and curved blades); (5) two bullet forceps; (6) dressing for-
ceps; (7) urethral dilator, No. ^j, French scale.

Fig. 46. — EQUiriCENT and iNSTKt'URKTS L'sED IN SUF.ABINO DlSCBAtcrS ON GLASS SltDEB fOR MlCVDSfOnC

KXAWI NATION.

Each slide should be numbered by gluing a small piece of paper on one
end with the number written on it.

Absorbent Cotton. — Small pledgets of absorbent cotton should be at hand
to wTap around the end of the applicator.

taCIOSCOl-IC EXA3dlXATl(M OF DISCIUXCKS.

Pio *i— Vrii»i«n> Olui Sudc ■rni A Tim
TiuinrAiikT FiiK or Suacnsa Souin
0!i tH ii^mrut-

^K Technic. Prcparstion of the Patient.— There should be uo prelimi-
W tuT7 ctciinsint! *>[ douching of the {nns and the urine iJiould nnt be voided for
^^^ 3t (u^t ihrcr himn* prkir to the examiiulinn.
^H Position of the Putient.- Dor^i posture.
K Antisepsis. -The fjliiw slides sliould l>c wi|»c<l clean with a damp sicrilc

tcwrl ami llie iivi™nK'nt> ;inH cotton

ileritizcd by the UMiat mrlhoH^

AiT&ogement of the Equipment

and the InstnuneoU. —I'hc Rbf^s

jli<l<^ should l)c sprejid out on a iienle

towel in the onler of thfir ntimlwri. (i,

s. \, 4, e1i- )^ the iilt-ohol lump lighted

jDiI the I'olton Mvl iiiiirumeni.* pUit-ed

in their rc^witivr trays on ihi- tuhl::.
Hcthoo of Smearing the Slides.

— The end of the apjiliiuior i> ^tr;i|j)>ed with a thin film o( cnlton xnd dipped

into the iliuh-iTRe. which is then 5nic4rcd over the center of the slide for u

3iace of 4tx>ut t>nc square inch. Tlic slide is then put back on the table and
Irtwnl to dry. The smear nhiiuld he llitn and iran.ipareni. The slirle^ iihould
be Mnenred in ihe order nf their number^ and a record kept of where tlie dis-
chaffei ncre mllected. Tivo slides should be used for each locality from which

ihc itisrharttes ure Mcured, and the
record should read as follows: \os. i
and 3 from vuN'a ; Nos. 5 and 4 ffvm the
urethral; Ntw- 5 and fi from the gbnds
of Skene; Nos. 7 and 8 from the ori-
fices of the vuIviA-amiituI glands: Noa.
9 and 10 from the vagina ; and Nos. 1 ■
and 11 from the lervinil canal.

.Mtcr collecting the discharge from
one Jwality the end of ilic applicator
mu.M lie resterilixed befure using it
again in atw>ther situ.^linn I>y placing
it in the alcolwl llume and nrapping it
with a frt'-ih I'llm ■>( miinm.

Method of Collecting the Dis-
chai^ge. -Tlic distharges are ii'llmietl
from the dilTerent [lails uf the genito-
urinary' tract as follows.

Vulva .—The examiner separates
Ihe labtjt with the thumb and index-
finger of the left hand and passes the
applicator over the surface of the ^'ulvar
canal witerc the lecretioni' have ufl-
Iccted.

Urethra -—The di.>charge U ob
taincd by iniroilucing the imlex-tinger
into the vagina and pressing it against
Ihe urrihrn, at the Mme lime drawing tlie tip of the finger toward the
meatus. The diwhnrgr now Appears at the exlcmiil meatus and can l>e easily
tullev-trd !»)' dipping the end of tlie applicator into it. If the diKharge i^ s<i
*li]thl llkit It ninnot be forced out al the meatus, it can be collected by pa^aing
the appliraior into the urethral tjinal; care, however, being taken not to
rnirr the bladder on account of the 'langer of infection.

I n t^aMina irMiim tHi Cu>ili
WITH lai Ti* » rat tann m nt \ mma

MICROSCOPIC AND BACTEHIOLOGIC EXAISNATIONS.

Glands of Skene . — The openings of the two urethral ducts a
situated about one-eighth of an inch within the meatus on the floor of the urethi
They are readily seen in parous women, as the mucous membrane is alwa

somewhat everted, but in nullipara it is necc
sary to dilate the meatus and draw its lips aps
before they are exposed to view. The dischar
is first wiped away from the mouth of the ureth
with a pl^get of cotton and pressure is then nia>
from below upward upon the glands with t
tip of the index-finger placed within the vagi'
just above the meatus. The secretion is nc
collected by passing the end of the applical
over the floor of the urethra.

Vulvovaginal Glands . — The seci
tions are first wiped away from the orifices
the glands, which are located "just in front a
outside of the hymen on the inside of the lal
majora or labia minora, if these extend so I
back." The examiner then presses with his fin(
upon the glands and along the course of th<
ducts and collects the discharge upon the end
the applicator. If the ducts are patulous, whi
is sometimes the case, the applicator can
passed into them for a short distance.

Vagina . — The secretions are first wip
away from the vulvovaginal orifice and the speculums introduced into 1
vagina. Specimens of the discharge are then collected upon the applicai
from all suspicious patches of inflammation and from the posterior vaginal fom

FW. 40. — StTtJATWni OF TB« VuiVO-

vjuinuL Gl*ni>s.

Fia- so. — Method or CoLLEmNG the SEmETioHS jrok tbe Uteid*.

Uterus . — Simon's speculum is introduced into the vagina, the cer
exposed, and the anterior and posterior lips seized with bullet forceps. 1
discharges are then wiped away from the os uteri and the applicator passed

SACTEKIOLOGU' eXAUINATlOK Of UISCUABCES.

En the cervical oumI. Ttie spplkator should nol pa»s beyond the
internal os for fear of infecting the endometrium in case it has escaped
[nfcfiicn.

Shipment.— After the slides are
dr^' (hey arc placed one U{H>n annthcf
with niiHch-*lkk> l)eiwefH lliem !■>
I>rc\Tnt ihc vmran (mm nibbing: anil
secured with two rubl)cr bandii. They
are linally wrap|iei) in cotton tiattiiiji;.
placed in x box. and wnt by ex['rr^^
ti> the Ul>or4ti>n.

lafonnatlon for the Pathol-

C^lat.— A copy ol the record which

mu taken when the smeiir^ were

nude, Kt^ing 'he localities frum

which (be discharges were secured, should be sent to the pathologist in order

that he may inili<ate in hb Te{Kirt the micruMopic JindJiip. of each &tide by Its

number.

A>a^ linn nHit-iirf t wini Ur-iiiir» lUnci ikady
fD( Smmnrt to lira LAnoiAmit.

BACTERIOLOGIC EXAMINATION OF DISCHARGES.

Bqalpment and Instnunenta. -(0 ^>i sterile glass pipets; (a)
ntte (iHit of rubber lubinK with iiii exti-riul diiimeter of one-quarter of an inch
awl a haU-ouncc hnnJ-rublxT MTinp:; (3) Simon's ^jwculum* (flat and curved
blades): (4) two bullet forceps; (5) straight scissors: (6) dressing forceps; (7)
ft HBftU Alittbol lamp.

¥ ©I

n«. I*— tanrMUn Mb iHniDwnm V^wn w Cm-iumtn UmauMon tot Sviamiotocic tZAUniAncHi.

Absorbent Cotton.— Sierilc absorbent cotton should be on hand to wipe
•way secreiwins when required.

The Pipew.— The gln*s pipds arc not mnnufactureil for gHais dealers
U)d the jir-iriitiooiT must either make them himself, which i* rcmiily ilnne, or
«bc procure thrm from a |ialhiiloK>i' blwraiory. Thc^' are made as follows:

I. Take .t plete ol gla^ lubir;^ six inches litnK with an external diameter of
•me-quarter and an internal diameter of one-eighth of an inch. I1i<a tube
make* two ptpcU (Fig. Jj).

MICROSCOPIC AND BACTERIOLOOIC EXAWNATIONS.

3. Heat the tube at its center over a Biinsen burner and keep rotating it
until the glass is very soft.

Then remove it from the flame and gently draw it out until a small tube
about four inches long with a diameter of the lead in a pencil is made.

Fic. sj.— GiAM Trann

(piae 4S>'

Fto. i4. — Hkatihc Tax Glus Tiibe at m Cdttei ovtn a

F»>. sf. — Tri Glass Tr>E u SnowH Dbawh On at its Cntm.

3. The drawn-out portion is then placed in the flame and fused apart at its
center; we have now two pipets sealed at their points.

4. Each of these pipets is Anally made into a bulbous pipet by healii^
the thicic portion of the tube at its center in the flame and drawing it out to a
thin tube two and a half indies long.

Fio. s6.— Fdsihc afait nu Cemfm or the DuAWN-onr Poition or the Tu».

Fio- 5J. — Two PiPFTS Sealed at tbeir PoiirTS.

The practitioner should keep on hand one dozen sterilized pipets ready
for use. They are sterilized as follows:

I, Plug the thick end of the pipet with a pledget of cotton batting (Fig. 61).

BACTERIULOCIC EXAUINATION OF DISCHARGES.

a. Hold the thick end (d) in the fingers and pass the bulbous portion (b) and
the slender end (a) through the flame until it gets very hut, but not soft (Fig.

59)-

Now place the pipet on the table until it cools and then pass the thick

Fk. jS. — Ujuivc :I BCLaoCH Pirt sv Heatihg tni Tbick Foittoh ahu Duwiho It Out to a

Thin Tumi.

end {(/) and the slender part (c) through the flame until the plug of cotton becomes
sti^tly brown (Pig. 60).

The entire inner surface of the pipe! is now sterile and will remain so in-

FM. S9. — SraBIUBHC TBI

bnuioi or twe Bulkitb Fonrmii (t) «tiu nti SLMttin Em (a) or 1
PiraT.

FtC- Ad.— Srv-iti-iiiNC THi iKTERioIr or thf- Thk-r Fhit (d) anh the StfttnEH Pavt Er) or tre Pinr.

definitely unless the cotton plug is disturbed. In sterilizing the thick end of
the pipct care must be taken not to overheat it, as the cotton will be burned
and the oil containeil in its fibers will be condensed and run down the inside of

Fio. 6i.— Saowi THE Ni-HMi PASrm on trn Biuoi-s Poetiom ot the Pipei (lanc 4W.
N<itr ihr pJuc ol coiictt balling ID Ihr thick rod Id), A pmimly slrnliird fipty can 1>c kF|ri IndrAruEFlT. ^^

the tube. If this happens, the pluR becomes us>eless, and a fresh pledget of
H'tlon batting must therefore be inserted into the end of the pi]iel. It should
alwa\-s be borne in mind that as soon as the cotton becomes slightly brown
the sterilization of that portion of the lube is complete, and that any further

UICROSCOPtC AND BACTERIOLOGIC EXAMINATIONS.

application of heat will destroy the usefulness of the plug as a protection agair
the entrance of germs into the pipet. Each pipet ^ould finally be nui

Fia. ei.— Shiftihg on THE Fdscd Potkt or tbe Slihuci End (a) or the Pim with Scis90U

(page 40)'

FlC. 6i- — ROUFJEIIKG OFT THE RoUGH EdCES OF

THE Glass ih the Flame (pant m).

Fig. 64. — STFiiLirTNC the Oimn SurrAcr or '
Slehueb kHD (a) or the Pifet (page 4g).

bered by gluing a small piece of paper on the bulbous portion of the tube w
the number written on il (Fig. 61).

Technic. — Preparation of the Patient. —There should be no prelii

Fio. 65-— Method ot Sucimc the Ueethial Secefttohs into the Bui^bous Poftton or the FirBt

(paaf 4ol.

nary douching of the parts and the urine should not be voided for at least th
hours prior lo the examination.

Position of the Patient. — Dorsal posture.

HArreRIOtXHlIC EXAWKATION of DtSaiAXCEK.

Arrangement of the Equipment and Inatrumeots. — Tlie pipei> are
Rail «*il on ik IowpI in ihc "itJcr of ibcir numbcn {t. i. 5. 4. etc.). Ihc alcohol
Minp Hehicd. and the sterilized cotton and instruments placed on a tabic ulong
with ihc nibtwr tul>iti): imd the syringe.

_3'f wft*™- .

I* III! tliua ai a imu •.

Method of Collecting the Discharges.— The fused point nf the slcnder
ewi (<;) i)f No. i |ii|icl t snijipol oiT with scissors and the rough unettrn mur-
xitn ul tlw kIiim art* then niumlnl by j>lncin)c diem in the olge nl ihe lliime,
bciag can-fill, houcver. not ti> fu<< the glass nnd cIom- the i>[>cning. Unless
the slur]) ciIkc^ of die end of die jkipct are niundcil q8,
there i-> nlwayN lUnger of injuring the iLtKucA uml muking a
f:ilM|tM!«a|!C.

Tlie entire length of the slender end (a) i.i novr pasMd
Mverul times thraui^ the Hume lu stcriliw ii» outer surface.

Th<" |>ipct b now connected with the syringe by slip-
nhift die rul)l>er tu)>e over it.'« diiik end. The i^yrinne i.i
■del in die left liimd nnd ihc |>i;x'l in the right, .mil the
jlaadcr en<) b then pliiced in the diNchiir^e. whi<h i.i
■odnd ut> into the hullHiii." (loriion uf the tube by drawing
oot the pMon with the thumb.

The pf|)n i^ iheti remutx-d from the ruhber tulic and
it* tlcwMT end (o) dined by (using it in the Dame; the

fat. if- fcWMu nu RciMi-t riitiiiKt Of iiu PIKT Smuo ue Co»<
luaUKi i« SiiwtiMi.

^H ntber end t>( (he bulbous portion (t) a then tcoled by melt-
^H' bit the mix- in the Dune at pi>int c.

The itisduri^e is now hernvetically seuleil in the
bttttwu* tK>T>i<in »f the pi|)ct.

Tbi* Ik then Uiil n^ulv .-ind the next p]|)el useil in the
wine way xu lolWt tlic M.-treii'>iL^ from another liicuUly.
A trcnfd sbnuld l>e lce]>t indicEtliiig where the diiichargc is
frum in each pi|>rl.

If tJie secretions are [irufuMi, ihey ran lie colletleal
from (be urrthnt, the vulva, the ragina, and the cervical
canal u [iilli)«>:

Vulva . — The a!>«j.«t.ini v|inrale« the labia while the
ciatnJner pbre> the dit.liil eitd of the pi|>ei in the secretion and sudts it up
fnio the bullti>u^ |>>>Tti<>n nf lUv luW.

r r e t h r J . — Tlie nviiM^ini »e|uiraieft the labia and Ihe examiner intto-
dnm Ihe |ti|*el into the un-lhm, sucking up the secretion as it slowly pusses

Pic ««,— Tn llntom
IVirncn ot 1SI
■"ipm piAcii. n

A Tut It'BI uuil

jma lAiDCAtnair

50 THE BLOOD IN RELATION TO SUKGERV.

along the canal. The pipet must not be passed into the blad-
der on account of the danger of infection.

Vagina . — The secretions are wiped away from the vaginal orifice and the
speculums introduced into the vagina. The pipet is then passed into the pos-
terior culdesac and the discharge sucked up into the tube.

Uterus . — Simon's speculums are introduced into the vagina, the cervix
exposed, and the anterior and posterior lips seized with bullet forceps. The
discharges are then wiped away from the os uteri, the pipet introduced into
the cervical canal, and the secretions slowly drawn into the lube.

Other Localities . — If the orifices of the vulvovaginal or Skene's
glands are patulous, the discharges can readily be sucked into the pipet by
introducing its slender end into the ducts, and secretions can also be collected
from sinuses or false passages in any part of the genilo-urinaxy tract, as well
as from abscesses, cavities, and cysts opened at the time of an operation.

Shipment. — The hermetically sealed bulbous portion of the pipets can
be safely sent by express to the laboratory in an ordinary test-tube which is
packed in a box stuSed with cotton. The test-tube is first lightly packed with
cotton at the bottom, and after the pipets have been placed in it the end is
closed by a plug of the same material {Fig. 68).

Information for the Pathologist. — A copy of the record which was
taken when the discharges were collected should be sent to the p>atliologist in
order that he may indicate in his report the bacteriologic findings of each pipet
by its number.

CHAPTER III.
THE BLOOD IN RELATION TO SXHtGERY.

COMPOSmON OF THE BIXX)D.

The blood is composed of (i) the fluid portion and (a) the corpmctUar de-
ments.

The Plnid Portion.— The fluid portion of the blood is known a&

liquor sanguinis or plasma, and is undoubtedly closely connected with the
processes of elimination, metabolism, and nutrition, besides playing an important
part in protecting the system from the influence of morbid agents. It contains-
about lo per cent, of solid matter which includes the proteJds — fibrinogen, serum
albumen, and serum globulin, and, in addition, various salts, of which the
chlorid of sodium is the most abundant.

The CorptlSCOlar Elements.— This portion of the blood consists
of (a) red cells or erv-throcytes, (6) white cells or leukocytes, (c) blood -plaques,
and (rf) hemoconia or blood-dust.

Red Corpuscles. — The erythrocytes carry the oxygen from the lungs to
the tissues of the body and contain the hemoglobin. About 4,500,000 to 5,000,-
000 red corpuscles to a cubic millimeter of blood is taken as the normal standard.

White Corpuscles. — The leukocytes are supposed by their bactericidal
action to protect the system from (he invasion of morbid influences and to assist
in the elimination of products resulting from infection, irritation, or tissue meta-
morphosis. The number of white corpuscles to a cubic millimeter of blood
in a healthy individual ranges from 5,000 to 10,000, but if we take the data given
by a number of authorities, the normal average is found to be about 7,500.

GEKEKAL COMSTDEtATIONS. $1

fiix different variMicf' of leiikiK'vU's :itc- (ounit in normal lilixict, .tnd the num-
ber is in(T«i$«d in ceilain [wihologic cond ititms. .if, for example, ihc prcM-ncc of
myc!o«ytn in llie spleiiomiilulbry form of leukcmb ami of mononuclear neu-
tmphil« in ihi- grm-ral |Kin)K>is "( thr insane. The followinc Inlile. lakcn fnim
DaCiMa's work on Hemalolog}', gives the names of Ihc dilTcrcnl ^'llrielies of
nonmil tcukncyicK together with their reluiivc iKTcentages aiul nuinl>er w Ihc
cubic miiliRKier of blood.

S'inn» I'D
V*nm. PnTtar. Ctmc MiiuHtn,

SnuU lrnt|>hntytr* M-JO i.ooo-j.ooo

Large 1]rin|it>oc]rlpi and Iranuliuniil

formi 4-8 too- 800

PolTTiuiWr ncutmphflnl 6<»-TS 3.000-7,500

Eminofihilri , e.5-; 15- JM

[l4S0)ilutei 0.5 35

Blood Plaques. —These are small sphericul bodies which are supposed
til Iv derived cither from the cur]>tiscuUir <ir Ilui<] clemcnU uf tlie bluiid. Their
function i:^ hut tittle understood, allhouKh (hey are thought 1o piny a pnri in the
fotnutiort of a htiKxlcloi or a thrombus. The number of plaques to the tubic
niillinM;l<T of normal IiVk)iI U alHiui 300.000. but they may rarifie fniRi 180,000 to
500.000 :in'l still be within the limits «f hr;illh.

He mocoaia.— These arc small highly refractive bodies whith are con-
^tanili pn---rnl in iMith ruvrmal and almornial bUxHl. Variovi^ ihenricx have
ticen advanced as to their origin and function, but sit yet nothing delinite has been
(lixDvered and their presence in the blood is therefore without clinical Mgnifi-
raocr.

GENERAL CONSIDERATIONS.

Tile brilliant results that have been accomplished from the examination of the
bloiKl in iti relation to medical and suniical diseases have not only resulted in
marked xienlifii: advancement, but have iilwi placed in the hands of the phy^i-
tiun aitd surf;ei>n ■ melhiKj of investigation which is of ilecided practical value
tn the diagn'ni^ anil treatment of many affections that are otuaire and alwut
which hut little i« known. So far ms surgical conditionit are
concerned, the blood findings are not pathognomonic
In character and are too roniradictory and conflicting
(o br relied upon as the sole mean* »f making n |>o»i-
iIyc diagnosis. Taken in connection, however, with
ih« clinical nlclure <ir viewed «imply in the tight of
an additional mclhud at ourdispo»al to diagnose and
combat disease, the atudy i>f tite blood at once be-
cOmea of uimoKt importance, and it is therefore eitcn-
lisl to lake advantage of the knowledge which tamy
be derived from this source.

A Variable d<i.'m- of pathologic ch;inee may occur in the bloiHl o( perMn»
mflerlnn from ilifferent forms of disease of a surgical nature: yet these changes
may rott eiiend bejonil ihr ctlrenvc normal limil> fur >uch iniliviiluai> during
bollii. when uniter llie influence of conditions that exdle wide phv'siologic
duauutioRN in the char;icter f>f \mlh the red and white iclb. .^gain. envin>n-
^^ mcnl. diet, exercise, hoi and cold baths. <>tar\-alion, and the pr(?«nce of nindition^
^^B matcrJaJly influeitcing the general nutrition of tlte ))atient are capable of inducing
^^V Uooi).changi.-> that timuLttc clotely ami urv often indistinguishable from ihoec
■ dnckfping .u the mull of some surgical condition.

$3 THE BLOOD IN RELATION TO SURGERY.

Positive findings from a blood -examination have been demonstrated lo be
of great value in many instances, as shown by the leukocyte count in the surgical
comphcations of typhoid fever, suppurative conditions, general sepsis, and malig-
nant disease, as well as indicating whether a morbid process is diminishing or
increasing in severity. In bacteriologic examinations of the blood positive
results are conclusive evidence of the nature of the disease and the character
of the infection. A knowledge of the percentage of the hemoglobin or the
rapidity of coagulation of the blood is of great \-alue in determining upon the
question of an operation in cases in which there is a tendency toward hemor-
rhage, and under these circumstances a fatal result from shock or loss of blood
may be averted by a systematic course of treatment before resorting to surgical
interference.

Negative findings from a blood -examination are, as a rule, of but little value,
and should not be relied upon in the diagnosis of surgical conditions. Thus,
for eiampie, an encapsulated focus of pus is not attended with a leukocytosis,
and we do not always find an increase in the number of white cells in cases of
malignant disease.

In a general consideration of the subject of hematology it is fair to state that,
as a rule, all chronic sui^ical conditions induce a mild and at times a severe grade
of secondary anemia, affecting first the hemoglobin and later the red cells, with
or without marked changes in the leukocytes.

Acute inflammatory processes are capable of exciting an increase in the
number of Jeukocj'tes, and this increase usually involves the polynuclear ele-
ments. Yet numen)us exceptions are to be encountered, e. g., gonorrheal in-
fUimmation, when it extends to the deep male urethra and to the prostate region,
is accompanied by an increased number of eosinophiles. Appendiceal, tul^al,
ovarian, and pelvic inflammations and even abscesses are so commonly encysted
by firm fibrous adhesions that their existence is often not even suggested by the
blood -findings. The blood-changes are very slight in acute and chronic in-
flammations of the mucous membranes, but when the serous membranes are
involved a leukoci-tosis is excited, and if the disease is protracted a decided blood
dyscrasia results.

It is impossible to estimate the degree of blood-changes induced by fever, and
since the toxic products of many pathogenic bacteria have been shown to possess
the power of producing a vasoconstrictor action, it is fair to presume that the
polycythemia of certain surgical disorders may be due in part at least to this
specific action of bacterial toxins. Cyanosis is one of the commonest sources of
error in hematologic research and probably explains the confticling statements
commonly made regarding the blood-findings in all forms of disease. Again,
purging and hemorrhage cause a concentration of the blocd in direct correlation to
the degree of fluids extracted from the body. Ether anesthesia for similar
reasons, and possibly from its toxic effects upon the economy, as well as the
irritation it offers to the bronchial mucosa, excites a mixjerate and often a decided
leukocytosis. Ether also causes a decided reduction in the amount of hemo-
globin.

The injection of large quantities of normal salt solution either beneath the
skin or directly into a vein modifies the osmotic tension of the serum, and io
this way is accountable for many of the pathologic changes common to the blood
after hemorrhage. It is therefore of the utmost importance from a clinical point
of view that conditions capable of producing either concentration or dilution of
the blood be taken into account in conjunction with the blood-findings in all
surgical and medical affections.

LEDKOCYTOfitS.

LEUKOCYTOSIS.

Definition.— l^ulL0C)1mis i? an increase in the niim1>cr of Icukocylci
III the Mi""l In ihc nn>>.t frcijuent fonn of rhc iiiTcciior the polynuclenr iwu-
iroi>liilcrt lire iinn-iiM,i|. while iKcrc i* :i relative lessening in the proportion of (be
"ihrr ImkiM.yii'^, un>l in rare in-umes there may Iw ;i jw^ncral inmafte in all the
white (tIL- uitlMHit •llMurbtti^ the [>n>pi>rlioniilc number of tvich.

l.fukot y|ii>i< may l>e either Irmporttry or fonlinuom. acvonJii^ to tlic acute
nr I hroiiir nature uf the cause.

Clinical Varieties.— Clinicnllr two fumts of Imkocytoeis are nixi^-
aixgii: the phyiiologk and paihologk varietiri> of t!ie afFecuun.

Physiologic Leukocytosis.— Thi* i^ a icrm applied to an increase in the
numlKr ■>f Icukni-ytr^ iJuc to a physiologic rau!^;. Ss a rule, the leukocytusis is
lefflponr}' and of brief duration and the decree of iiK-re;i.se in the teukocyio I*
illw«y» imxlenue. It mav aflwt the [Hilynuclcnr nculn>philcs alone or there may
be a ^leneral increase in the number of all the leukocytes.

This it^ndilion ot-cur* in infants during the fimt two weck« after birth, in
prnpwnin* and (lantirilioii, durini; dipe^ii<m. evi)e<ially when the Ukx\ is rich in
nlliumtniiids. ^nd after active niii^cubr e\ercL«e, Hot and cold bath^, ma^iaftc,
anJ elertridty also produce lcuko<-yli>>i.i. and a miHlerute inavsiJie of white <«ll»
(rwmrnlly take* place 3 few hiturs before denth.

Pathologic leukocytosis.— Thi» b a term a[>|ili«l |u ait increaiie nj the
leukixyict ilue to a wiile vurictv of piiiho]i>];ic nindition*. The afTcdinn is
lempofary when the cause is acute, or permonrat when the exciting; factor is
incuTsblc. The nuniltcr of Icukotyte^ to the cubic niillimeler nf bloiMl in a mitd
i(f moderate ra*e •>( Ifiikmytosis i* lielow 16.000, whrxens in a marked ca*e the
count will lie l>clnerii 20.000 uiul J5.000, aitd 3Ih>vx- lli:it numticr (he lundttion
would \k con'i-lercil !«vi-rc. An incrwi»c to 10.000 would be of no itiniral
«ignllkntu.i: whale\rr, as the number of leukocytes often reaches tlial high in
beabh.

Causes.— In pkytiologit letikocylosif^ the actual number of white cells in
tile bliRi-l 1-- not ii>crcased and the high leukocyte iwinl U due to the concen-
mtionof ihcbUxN] in Ihe peripheral ve?M;U.-v« the result of a high .irtcri.iltm^ion.

In puihelogif leukocytosis, on (he <^hrr hand, (here is an .tctual inrrcdsc in
the white ciyrpuscles, which iirc i>fot>ably drawn into Ihe circutatinn throu;ch a
pmitit'e ihemi>l:u-lir influence exerliil by the chemic !>ul»lance« which arc prc;'-
ent in Ihe blood and producva
ol iihaKocyl'nit awl the tMtlvriiid.d utliim "f the 3ub4>1«nce» imKlucd by the
Irukiv \i('-

Sijjnifieance.— Leukocytosis i> a confltel between two
Dppoklnx forces — Infection and resistance, and if we con-
■ lantly bear this fact irt mind, (he blood -findinits will
often be of Incalculable value in lurgical af(eciion>.
The grade of a leukocncwb depends upon the virulcntT of (he infeciinn on «i>c
hand ami tt>c sirenKihof the resistance on the other. Thus a mild infection with
a T- ' ' 'niv rc\ult« in a moderate Ieuko<-yii>>,i«, and a Mrwre infiM'ti<m with a

"U- 111(4 I")*" produces a high leukocytosis. If. on ihe other hand, the

fe*i ' i-xT aivd the infection virulent, the orpiniim, liecominj; ^uildcnly

u»ri ^:■h n .-( byibe |>i>iMin.olTer> no resistance lo the inv.iding micro-otKani'.ms
an] tot '. there ts usually a decrease Ueukopmiit) instead of an increa^^

in thr '< iv Thoe (aclA htive an im|Niruim liearinjE at lime« U|>on lite

profiMnb of aurgiral affections, because the leukocyte count indicates ihe re-

54 THE BLOOD IN RELATION TO SURGEKY.

sisting power of the patient and determines the question of operative interferei
or the chances of ultimate recovery. For example, if leukopenia or a decre
in the white cells is present in a severe case of peritonitis, operative interfere)
is out of the question, as the chances of recovery under these circumstances
almost nil. If, on the other hand, there is a decided leukocytosis present,
prognosis is more or less favorable, because it shows that the conflict betwi
the two forces is still active and that the resisting powers of the system are
exhausted.

Another important fact to be borne in mind is that the white cells are
increased by a suppurative inflammation unless its products (plomains) g
entrance into the circulation in sufRcient quantities to eTiert a chemotai
influence upon the leukocytes, and for this reason the blood-findings
generally negative in cases of chronic pus cavities or purulent collections i
rounded by firm adhesions.

And, finally, we must also take into consideration the physiologic causes
leukocytosis in order to interpret the blood-findings and estimate their valu<
an individual case.

BACTERIElillA.

Definition. — Bacteriemia is the presence of schizomycetes or bacteria in
blood.

Canses.^The affection may develop during the course of a disease as
result of bacterial development upon or within the tissues of the body, i
ficient authentic information is now available to show conclusively that a If
number of bacteria have been isolated from the blood and that the recoi
of specific micro-organisms has not infrequently been of great diagnostic vi
in determining the nature of an obscure disease.

The following bacteria which have an important bearing on the diagni
prognosis, and treatment of surgical affections have been isolated from the bl<
Streptococcus pyogenes. Bacillus tetani.

Staphylococcus pyogenes. Bacillus anthracis.

Gonococcus. Bacillus mallei.

Pneumococcus. Bacillus tuberculosis.

Bacillus coli communis. Bacillus pyocyaneus.

Bacillus aCrogenes capsulatus.
Significance.— Positive results from a blood -examination are, of coi
conclusive evidence as to the nature of the infection, but unfortunately it is b;
means always possible to isolate the micro-organisms, and consequently nega
findings have but little or no clinical value. Von Eiselsberg found sp^
bacteria in the blood from 77 out of 156 cases which he examined.

HEMOGLOBIN PERCENTAGE.

Normal Percentage.— This will be found to be from 85 to 95 per (
in this climate, while among individuals living in the tropics a slightly hi
percentage is often noted, and according to Boston, in robust women a rea
of 100 or 110 is not uncommon.

Significance. — The precise value of the percentage of heraogi
in the blood from a surgical point of %'iew h as yet undecided, and s
authorities place but little or no reliance upon such information. Otl
again, take a different view of ihe subject and refuse to operate, except in t
demanding immediate surgical interference, when the hemoglobin is b

SPECIAL CONDITIONS.

SO per renl. Some Dpeniors, on the other hand, pbtce 40 or 50 per nnl. ai the
mrt 'it mMv, iirid conienil ihiii if iht-^ rule U in.iuivil upon Ihr niimlMT of deaths
(mm p»>l-<iM:nitivt; ^hork :ind hrmurrhagc will l>c diminished. The clinical
evidence. hoMcver, doc^ not bear out Ihts ciiremc view, and |>Tul)ai)>ly ihe wixcHt
cnuiMT 10 |tur<.uc would L>e tocunxider the percentage of hcmu-
glnbin in connection with the genera] condition of the
patient, and if ttoih ure \x\ow nonrtui deUy iiiirKicul interference ff poiMble
until n ikyxtemiitic courw u( trratmvnt 1ms txx-n given to correal the denciency.

RAPIDITY OF COAGULATION.

Normal Coag^ilation Time. — Hc;dihy hloo*! lewtetl by the glAss slide
roelhnil or liy \\'nKht'> cuii|[uli>mcter cogigulate:^ in tmm two to five minutes.

Sigrnificance. -In certain diseases which are uMociate*! with u tendency
to bemorrhiiKe or cupilbiy ooxinK a knotvletlKe of the cuaxulniion lime »f the
lik)od will prove oi vitlue i» delerminine ujion the question of opcrulive inter-
ference and the proper course of treatment lo pursue. This is esfwcially true
when an opemtion h amtcmpbled in a patient suflerintt from jaundice, hemo-
pbilia, or purpura, ami if under thcsv drcum^tanccs coamilation docs not take
pUce by the atiove tests within the normal time, but is delayeil for ten or fdieea
mtnutei, then nuTiiiail inlerfi-reiuc should i>e debyeil if po».>il)le until the de-
ficiency hs«. liecn tnrrcctcil by apprnptiale Irentment, otherwise there is danger
of dettth resutlinit from capillary oozing.

SPEOAL CONDITIONS.

Hetnorthage.— Numen>U!> obscrvali»n> have demonstrated that traumatic
anrl oilier form* of Iiemorrhajn! arc associated with a mcKlenite lcukocylo*i.i —
I j.ooolo jj.ooo — which comes on, as a rule, within from fivi: lo ten hours after
the .iccidenl, ahhough in ca»-s in which there is a lar^e amount of blood lost the
leubocytc i-oum mjiy show an increase within the first hour. As a rule, the
lruLiKytont)> thiclly in\iilves the polynuclear ni-uln>phitc.s but in rare cases a
lym|ihocytosi^ is present and Ihe diJTerential count shows that the percenlagei of
Ibe other leukocytes have l)een intreasetl.

There i» alM> a diminution in the numi ler of reri cells and in the perccniaRe of
benii>gb>t>jn L an imreafe in the bloodpbques; and the couRulation time h
mpffe ra)iid than normal, es|x-i'i:illy when the hemurrhaKc hn'^ Ifcrn ver%' w^-ere-

PetitonltlB.— .Ati in other infections, all forms of pcriionilis, except the
tttbcrvubr, may be a&wcialed with a leukocytosis unless the resistance of the
patirai h weak and tto reaction oci-urs, in which case leukopenia may be i>reient.
A wdalm rise in the leukocyte ci>unt during the coune of an attack of |»crilomtU
tnli<:alFs an extension of the inflammation. Anemia is no! infrei(ucnily ai^oci'
BtrtI with |H-niiiniti<. and there U often found to l>c a decrca>e in the number of
led '(■!!•> ir^'l in the iwru'ntJKc of hemoglobin.

Intestinal Obstruction.— .\s a rule, there is a rUe to at lea'^t 10,000
in the leukcn yte count in cat** of inlcvtiitiil ol>sir\iclion within the fir-t twelve or
Iwrniy-four hours after the accident occurs, .\ccording to some authorilie*,
cuet of slichl liowel distention due to post -operative intestinal paralysis and
aMOciated with KSHlric irritabihiy do not give a leukocyte count above 11,000 or
iSiOOO. and heme the diSerencc between the f^de of the leukocytoids in this
itiadltion and that of ohiirxiclion is a valuidile ]minl in making a difTervntial
diaKnmi^ in the ArM twenty-four or forty -eittht hours after an abdominal o|>eni-
tiuo. On the third or fourth day a low kukocylosis (below 10.000) indicates

56 THE BLOOD IN RELATION TO SURGERY.

gangrene at the seat of obstruction, whereas a high count (30,000 to 30,00
shows good resistance upon the part of the patient and a favorable prognoi
from an operative standpoint.

Septic Infection.— Hemoglobin and Erythrocytes.— Sooner or lal
an anemia develops and there is a decrease in the percentage of henu^lot
and the number of erythrocytes. This decrease depends upon the severity a'
the duration of the infection and is often found to be most marked in chroi
appendicular and other long-standing abscesses.

Bacteriemia. — The findings in ihe majority of cases are negative and t
specific micro-organisms are not isolated by the blood -examination. Positi
findings are of great value in assisting to determine the nature of an obsci
infection, but a sterile culture does not exclude the presence of sepsis nor
flucnce in any way the prognosis of the affection. According to some authoriti
the presence in the blood of the Staphylococcus pyogenes albus does not afii
the prognosis one way or the other, whereas the condition must always be a
sidered grave if the other pyogenic cocci are found.

Leukocytosis.- — An increase in the leukocyte count is a very iincert;
symptom in cases of septic infection, and it not infrequently happens that t
sign is absent altogether or the number of white cells is decreased below norm
The presence or absence of a leukocytosis depends, as stated elsewhere, upon 1
resistance of the patient, the severity of the infection, and the absorption of 1
poisons or toxins, and hence the leukocyte count in many instances is only
value from a diagnostic point of view when considered in connection with ot!
clinical symptoms. The degree of leukocytosis, as a rule, is not high in se]
cemia, and we may consider from 15,000 to 20,000 as an average count.
cases of simple catarrhal appendicitis there is no leukocytosis present except
rare cases when the leukocyte count may be moderately high. If, however,
appendicular inflammation is complicated by pus, gangrene, or peritonitis,
white cells increase rapidly in number and a high leukocytosis develops unl
the resisting powers of the patient are destroyed or the walls of the abst
prevent the toxins from being absorbed.

Diagnosis.— The presence of a localized abscess may be suspected if
leukocyte count is moderately high and there is an excess of fibrin in the bk
as well as a positive iodin reaction {the afiinity shown by the leukocytes
iodin). On the other hand, however, we cannot exclude pus if all the findi
are negative. Positive results from the blood -examination in cases of gen<
septicemia are a valuable assistance in making a diagnosis, but if the leukocyti
is absent the findings are of no value whatever unless specific micro-organii
are shown to be present. The iodin reaction is very constant in septic conditic
especially those of puerperal origin, and the early and rapid decrease in
percentage of hemoglobin and the number of erythrocytes is always sugges'
of this form of infection. In appendicular inilammations the value of a bio
examination is highly problematical, and but Utile or no positive information
be obtained, as the findings are identical with those of pus collections in
kidneys, the ovaries, the Fallopian tubes, etc, DaCosta holds in a general 1
that an "absence of or a shght leukocytosis suggests either (a) simple catan
appendicitis, (h) fulminant appendicitis, or (r) a localized pus focus from wl
no absorption occurs. Well-marked leukocytosis indicates either (a) a h
abscess from which absorption of toxins occur, (b) general peritonitis, or
gangrene."

Malignant Disease. — A leukocytosis may be associated with carcin<
and sarcoma, although these neoplasms are frequently present without any
crease occurring in the number of white cells. The cause of the high leukoi

SPECUL CONUITIO.NS.

ciHini in pnituilily due in most in^ances lo inn»inmaiory cunclitions nccumng in
iW nriglit>«fh(MMl ot the |*Towlh, yd i1 scorns not unlikely thai a posili^x chcmo-
tactic induencc nuty rc^^ult fnim ihc toxins of the tumor itself. The lcuki>«.yto»i9
ii uauktly Icm tlwn >o,ooo. iilthuufih it m;iy reach n> high at .to,ooo or 40,000
b ftrtafn cases, ami, .ts a rule, the count lis hig)icr in sarcoma than in cancer.

TaberculosiS. — The blood-dianges in tubercuta'^iii are varied awt nuKl
Uti^itisf.iitoT)- from II (liagruMlic »titm))>uinl. In rare cases of acute mil{«r\'
lubrrculo^i.i the Utdllus has been recovered fr'>m the blood, but in ihi- majority
<>f instance^ the bactcriolngic linclinjfs are neguii^^e. A> a rule, leukocytosis 18
abeeni in unttimplicaleil las** of tubercular infection, iind when tl doc? occur
during the vt>ur« of the di^ii-asc it is due tn a ^ecI)ndary infeclion ami not t" the
tuhcmilous process iiwlf. For this reason genitourinary- tubcrculM$.is is (rc-
t|uently os.wdiilo) with a hl^h ci>unt, ami it is not unaimmon to o1i>ervr a moder-
alc grade (vf leuknotosis in tubcrcubr conciitioiu of the utcru.s ihc uv-arics, the
Fal^MBO lubes, the bladder, and other organs.

CHAPTER I\'.
EXAMINATION OF THE ABDOMEN.

The frequency with which j>clvic tumi»rv nn-w iK-ynml ihe nivily of llie jielvK,
ami the necessity at limes to distinguish lielvreen (hem and abdominal enlarge-
ments, render it im|Ninant for the f() iietciloKUl to hu\e a thorough knoivled^e of
Ibe dilTereni melh'Nls of examining the alxlomen. The esamincr ^Imuh) abo
hjve u clear conception of ilie to|MiKraphic anatomy of Ihe abdominal carity. «o
titnt when he ha* succeeileil in tracing the origin "f a tumor he may knuw what
nrguis or p»rti<tTis of organs arc kicated in that position.

To facilitate itie MU'ty of the luatlion of the aUlominal orxani, the .lurface
of the nUhinx-n is divided into nine rcgi'>n* by four arhilmn,' linr*, two of which
arc horuonUl and ttvo vertical. The upper hi>ri»>ntal line extends across the
dUlnmen at the te^-et of the Uiwe-t'l {xiint on the inferior costal Inirder, and the
lovtrr line panes across the anterior superior spines of the ilia- 'Ihe terticul
lines eiicnd dire<tly upwani from the mid<lle of Poupart's ligament on either side.

The followiiiK, taken from Dcavcr's "Surgical Anatomy," >how> ilie orjcans
fotmd in e:ich region :

Hixhl H ypoiliendriM.— Liver (jwri of rijtht lobe). Gall-bladder (divided
!»■ the longituilinal line). Kldne)' (upper and outer |uin>). Colon (he[Kilic
fleiwre ami pan of asiendinn colon),

A*ij(jj/m.— U*-er (left M>e. quadrate, caudate, ami Spi)tclian lottes). Gall-
btidurr (divided by the longJiudiniil line). Stomach (pylorit and miildle iH-r-
liuiu with tlie c.inluc ami |iyloric orilirc*). 'Inlr-^line (li^^I, >ec(ind. and f^mrth
ptJTliom. and tlie Icrminalion of the third portion of the du'Mtenum and |wrt of
the tran*k-cr*e colon). PmcrcaA O'^id an<l Itody). Kidneys (up|)cr and inner
(Hiru. with sinus oix) pelv» of the ureterv). Suprarenal tmdies. Spleen (upfier
and inner part-v).

Lf}l If yfituhoMtlniif. — Liver (small ponion of left lol»e ocrasjonully). Spken.
Puucnra" (tail). Kirlney (upper and ouier |)ctrts), Stomncb (cardiac end).
Colon (".picnic flexure ai>d part of desi ending colon).

ttight I.timbar. —Kit\ney (lower and ouier partsV Intestine fastcndli^
folon, pan or all of the cecum, ami |xin or all of Ihc vermiform appen:ltx. Some
Miull tnte^ine, mostly ileum).

EXAMINATION OF THE ABDOMEN.

Umbilical. — Kidneys (lower and inner portion). Ureters. Intestines (low
part of third portion of duodenum; part of jejunum, ileum, and transve
colon; and, usually, part of the sigmoid flexure). Uterus in pregnancy.

Lejl Lumbar. — Kidney (lower and outer parts). Intestine (small intesti
mostly jejunum; descending colon and part of the sigmoid flexure).

Riglil Iliac. — Intestine (small intestine, mostly ileum; sometimes the
of the cecum and part or all of the vermiform appendix).

Hj'^ogosirif.— Intestine (jejunum and ileum of small intestine, and p
of the sigmoid flexure). Ureters. Bladder (in children and, when distend
in adults). Uterus in pregnancy.

Lejl Iliac. — Intestine (small intestine and part of the sigmoid flexure).

Fic. 6Qr — DrA<^BAU ^HOwiNr. the Nine Receoki; or tre Abdouinal Cavttt.
1, Rjflhl bypocbaadruic; a. Fpjgulric; 3, left hypochondriac; 4. liKhl lumbar; 5. unibilicai; b, left lutnbu
hflht ilLu; S. hypogutric: q, left iUac-

Hethods. — The abdomen can be examined by the following methods
Inspection. Percussion. Auscultation.

Palpation. Mensuration.

Preparation of the Patient.— A purgative dose of citrate of magn'
should l)e given the night Ijefore. followed in the morning by an enema of st
suds and warm water, and the blailder should be emptied spontaneou>ily
before the examination.

Arrangement of the Clothing and Sheets.— The clothing she

be so arranged that the entire abdomen is expiised to view and a sheet tho
over the chest and another over the hips and the lower extremities. If
patient is examined at a private house or a hospital, she should remove all
clothing e.xcepl the undershirt, night-dress, and stockings.

INSPECTION. S9

PosltiOtl of the Patient. — The position of the patient depends upon
ihe method of examination and will be discussed under separate headings.

Anesthesia. — The use of an anesthelic, as a nile, is not necessary except
in cases in which palpation is difficult or unsatisfactory on account of the resist-
ance of the abdominal muscles, overdistention, or tenderness.

mSPECnON.

Position of the Patient. — The patient is placed in the horizontal
rccumlient position.

Information. — We can elicit the following diagnostic points by means of
inspection :

The contour of the abdomen.
The movements of the abdominal walls.
The appearance of the skin.
Technic— Contour of the Abdomen.— Standing at the side of the
patient we note the shape, the size, and the symmetry of the abdomen as well
as any irregularities on the surface and the tension or laxity of the walls. We
also note whether the umbilicus is depressed or bulging and whether there b

Fn-.. TO— Siminsr. tHI Uisttmioh of thk Abwihen bftufi n riii: Pubfs »Nti U«»lticus CHAiAtrritisTic op

^ Lahge Pelvic Tuuor.

:iny evidence of hernia. In fat nr relaxed abdominal walls and in cases of
asiites the alxiomcn i> tlat and the flanks bulge, bul when a tumor is present
there Ls a distinct prominence and the ap])earance of distention is more or less
marked.

The surface of the alxiomen, as a rule, corresponds to the outlines of the
lumiir, and if il is lohulaled the abilnminal wall has an irregular or nodular
appearance. TTic point of greatest jirominence on ihe abdomen u.suallv indicates
the region from which the tumor has dcvcloi>cd, and if we find that the eniarRe-
mcnt is more marked Iwtwcen the pubcs anil the umliilicus than bclween the
umbilicus and the sternum, it is strong evidence in favor of the pelvic origin of
the growth.

Tlie examiner now stands at the feet of the jwitient and notes whether or not

6o EXAMINATION OF THE ABDOMEN.

the abdomen is equally enlai^ed on both sides. In tumors arising from the
ovar^' or the broad ligament there is always a want of symmetry, in thLs respect
more marked in small than in large tumors, and the distention is invariably
greater upon the affected side. In pregnancy and uterine tumors, on the other
hand, the abdomen is usually symmetrically enlarged and we do not notice more
bulging upon one side than the other.

If the patient is ill in bed we note the position in which she is lying before
disturbing her and observe whether she makes any voluntary movements or not.
Patients suffering with general or local peritonitis lie very quietly with the knees
drawn up to rela.x the abdominal muscles and relieve the pressure over the in-
flamed structures.

FlC. TEr — SVHHETHIC FOBH OF AbDOHEH AS BEEN FjG. JI- — AsVVULTRIC FoUl OF ABDOKEH AS

nOH IHE KEH CHAIlACTEIUSTiC OF PUO- SlIN FIOII tUt. FEET CHUACTEUSTIC Of

HAim AMD UlEUNE TUHOtS. OVAUAN AMD BlIOAD LlCAUEHT TDHOIS.

Movements of the Abdomiiutl Walls. — Standing at the side of the
patient the movements of the abdominal walls are carefully watched during
natural and forced respiration. If no adhesions exist between a tumor and the
parietes, the abdominal wall is seen to move smoothly up and down over the en-
lai^ement. This is especially noticeable when the surface of a tumor is nodular
and the irregularities are seen through the abdominal wall. The act of respira-
tion does not change the position of a tumor which arises from the pelvis.

In some cases we may be able to see the peristaltic wave of the intestine or
the pulsations of the abdominal aorta, and if the woman is pregnant to note the
situation and force of the fetal movements or the intermittent contractions of the
uterus.

Appearance of the Skin.— The surface of the abdomen should be care-
fully inspected and we should note the presence of skin disease, pigmenta-
tions, edema, linea albicantes, or dilated veins. When the abdominal walls are
excessively distended, the skin is white and glossy in appearance; and when they
are relaxed, they have a shriveled or puckered look.

PALPATION.

Position of the Patient.— The palient is placed on her back with the
head and shoulders slightly elevated and the knees drawn up to relax the
abdominal muscles and enable the examiner to make deep pressure over the
abdomen.

Information. — We can elicit the following diagnostic points by palpation :
The presence of a tumor.
The situation and origin of a tumor.

PALPATIOK.

fil

The shape and mobility of a tumor.
The consistency of a tumor.
Crepitation.

Local tenderness or peritonitis,
Technic.— The Presence of a Tumor.— The presence of a tumor is

Fic. 7j. — REGKmnNa TV E Presence or a Tuyom m\ Aidownal pAU4t10N.

readily ascertained by pressing the fingers of both hands gently and firmly over
the abdomen in all directions. The abdominal walls should move with the

Fig. 14— PALfAUso the Lohh Bo»i»:b iif • Tluch »«iiiNii t'on ihe A»imhiikal Cavhtt.
ScU Ihal Ehe Antfrrv can be pus«ldawn belwnn Ihc 1umi>r and the tympfayus pubis IpaKC baj.

fingers over the underlying organs and the hands should glide from one area to
another until the entire cavity has been palpated.

There is no difficulty, as a rule, in recognizing an abdominal gmwth if the
abdomen is thin and the muscles are relaxed, but sometimes the tumor cannot

EXAMINATION OF THE ABDOMEN.

be felt by palpation on account of the great amount of fat in the abdominal walls
or the small ?ize and the deep situation of the neoplasm.

The Situation and Origin of a Tumor.— Having ascenained the presence
of a tumor we must endeavor to trace its outlines and locate its boundaries.
The lateral margins and the upper border of a growth arising in the pelvis
are recognized without difiiculty, and we find that it is situated in (he middle of
the abdominal cavity, sUghlly more prominent, however, upon one side than the
oiher. The lower border cannot be felt, as the examining hand comes in con-
tact with the symphysis pubis before the inferior margin of the growth is reached,
which proves that the tumor is partly situated within the pelvic cavity. This
fact, taken in connection with a marked prominence between the umbilicus and
the pubes, is strong confirmatory evidence of the origin of the tumor. On the
other hand, a tumor occupying the same position In the abdominal cavity is not

Flo. ?s, — Maiiinc ihe t'ppEi BoiDM or a

TUUOI BY THE FaILDUE Ur RlSISTAHCI TO

TTiE (jLrfAB Edge or the Hjuid.

Note Ihal thf ulaat edge of the hud dipn
dnjdy imo Ihc tbdominal c■^ily ai thr upp«r
nurgm ot (he lunutf.

Fio. ;6 — Sbowiho thz Ulhu Edge or thi
Hand Passing Dihectlv mOH the Lowue
Mapcin or A Pelvic Tvaot onto tbe
SvuPMVsis Pubis.

Id the case oi a lumor uisnt lri>ni the ab-
dominal (avily the ulnar «lge of ^hr hand would
dip between its lower border and the ■ymphyu
puhii.

likely to be pelvic in origin if its lower border can be recognized at or near the
symphysis pubis or the tips of the fingers can be passed between it and the bom-
rim anteriorly (Fig. 74).

And, finally, a tumor situated in the central part of the abdominal cavity
probably arises from that location if its entire circumference can be clearly de-
fined and outlined by palpation.

The boundaries of an abdominal tumor are outlined by placing the palm of
the hand upon the most prominent portion of the enlargement with the thumb
and fingers slightly flexed and gradually moving the hand upward, downward,
and laterally, making strong pressure at (he ulnar edge of the hand, so that when
the margin of the tumor is reached it can be fell at once by the failure of resist-
ance. Thus, in the case of a pelvic tumor the ulnar edge of the hand will dip
deeply into the abdominal cavity at its upper and lateral borders, but when it is

PALPATION.

palpated from abo^v donnnatxi the rcsirtann; continue* nnd ih« hand psMwi
dimlly (mra the (umor unto th« symphj-sis pubis.

'Hi* situation and origin o( a tumor on .ilso Iw recognized by pal|ulin); the
abilocnim with Iwo hands by placini; them alongside of each other owr the most
prominent ixirtion •>( the growth with the (mg,tn and thumbs slightly tlexcd.
The hands arc then p^dually separated while the lip» of the fingers are prCMod
down U()'>n (he lum-ir in all directions, anil when the mar}:in»of the ^wth are
nacbcti the rcsiMiincc ceai^e« and the hnmts dtp deeply into the abdominal
aritv-

liie Shape and Hobiltty of a Ttunor. — Having located a tumor, its
ihane is reiidily ascertained by palpating uvcr its surface and by tr.icini: the
outiitw^ of its circwmfctcnie with the fitigers of 1»oth hands preued deejjiy into
the abdominal canty. Jiy this mcuni' we can determine whether the tumor
it tymnteiric in shape and whether its surface 1=^ smooth or nodulated.

The mobility of a tumor depends upon the abi>ence or presence of adhv!>ion«
and its sttttation. Inlestina) or omental adhesions even when extensive cannot
be recognExcd by palpation on account of the length of the mcscnter>-. whi<h
■UowB great latitude of movement. A brge tumor filling the atxluminul cavity

Km* ikM ikr itlmt Alaa ul kah iHBdi dip itiltf loM IlK alidaaUul t»nlr « the iMa ol iht iiuwt.

b iuunonble tvtn when it is not adherent to the abdominal wall or the tiscers.
Small tumor». as a rule, huiv more or leM. freedom of motion except when ihcy
tieciime incarcerated and lixcd within the pebic cavity. Intraperitoneal tumors
uiually nvnv up and down during the act of respiration: and the nKirer they are
thualc<) to the (ti.-i[>lingm. the greater will lie thtr« movements A tunmr which
aiim (rrim the [wlvis, however, diie^ not chiinge its position during inspiration ^itd
expiration. .\ p.-irictal tunt'T moves with the alMiominal wall and the tingcn of
Uilh handr> can lie |wivit>l uniirr it.

The mobility of a tumor cyn be ascertained by grasping it lietween the tingers
uf both hands and testing its range of mo\x'mcnt in various directions. This a
a man wtiKfaclon- incthod than changing the pn-ition of tfie jiallent. excei>t when
the kiwer portion n( the tumor b im)iiactrd in the peh-iK and can be freed by
pbcing the piktient in the ki>ee-che^i iMisition. The movenwnts of a tumor with
the all of respiration can \te cliiitcd by placing the hnmt on the fuiface of ihe
ab>li>men over the most prr>minent jxirtion of the growth and noting the changes
which take pbicr in il» ixKition during natural and forced breathing.

EXAMINATION OF THE ABDOMEN.

The Consistency of a Tumor. — It is imponant from the standpoint
diagnosis to determine whether a tumor is solid, fluid, or semisolid, to ascerta
its degree of hardness, and to recognize areas of softening. It is very easy
distinguish between a hard and soft tumor, but it is often difficult or impossib
to differentiate between a solid growth which is elastic or yielding and one that
cystic in character. The consistency of a tumor is ascertained by palpating it
all directions between the fingers of both hands and by tapping it to determi
the absence or presence of fluctuation. The left hand is placed firmly over t
abdomen on one side of the tumor and the fingers of the other hand strike
tap the abdominal wall on the opposite side; if fluid is present, a thrill or wa
is detected. The fluctuation wave, however, may be absent in multilocul
c>'sts and in tumors having thick, tense walls or viscid contents. The leng
and intensity of the thrill over different parts of an abdominal enlargeme
are of great diagnostic value in many instances. Thus, in ascites and uniloc
lar cysts there is no variation in the character of the wave, whereas in a mul

Fro. fS.^BlEAUNG THE FkT Wave in Obese Wouen bv an Assistant Placihg thk UUfAl Edqe

Hj« Hand ovei the Median Ijne on the Abpohlhal Wall,

locular tumor it differs as to length and intensity over different parts of t
growth. In obese women the fat contained in the belly walls causes a fa)
wave or thrill when the abdomen is tapped which may be mistaken at tim
for the presence of fluid. To eliminate this factor an assistant places t
ulnar edge of his hand firmly on the alxlominal wall in the median line wh
the examiner taps the abdomen in the usual manner.

.\n intermittent change in the consistency of an abdominal tumor indicat
pregnancy, as no enlargement alternately relaxes and contracts with any degr
of periodicity except the grdvi<l uterus.

Crepitation. — A grating sensation or crepitus may at times be felt 1
placing the hand over an abdominal tumor and having the patient take full dw
inspirations. This phenomenon mav be due to a localized area of perttonit;
to fresh adhesions, or to the di?pLicement of colloid matter within one of tl
caWtics of an ovarian cyst.

Local Tenderness or Peritonitis. — Ixical or general peritonitis and are
of tenderness are readily determined by palpating over and around the tumor

PEKODHIUN.

PERCUSSION.

Position of the Patient.— Tht {juitem h firei examined in the hort-
xonlnl rcntml>eni |Hrtiun.' iinil ilie (xisilion is AuliNC(|uently rhanKt^l if rheex'
smincr sii»|>ccl^ thi: prcsciti:c of .i^itc^. Thus, she may be placed Upon the
Hiiht or )r(t sHe and »lie muy sit up or staml erect.

Information. — U'e can elicit the dillowing diagnnstic p»intK by ]>crrw>-
fiiun:

The (>nr:'cijfe of a lumitr.
The situation antl orijpn uf a tumor.
The &hape of a lumor.
PrrcuKtion as n meant of diagnoi'is U not so vailuable as pal|vili<>n except t(>
ilrtrrt slight enUrgemcnts of the spleen or livxr, lo ascertain the presence <a ga«
in .1 lumi»r. to ctwcen awitos anil a cy*!.

^Ht^A',.

'"^flP^*^

tW- M.— AwmR Ami* or ttFium* mid
Tnniun in * Tiimn -w fiim Uiriia
Xatwim IHID >*■ AjumKHt ipif <«)'

Km* ibii dw JiJnm cnwhf Mw aoM

Flo. to —SMatnKo AiU or DuuiiH* ui>
TntrANV IK A Tram Aumn taao xir
AaiKiinH dMW U),

Knrr iliai iht inn ol duUnas ■• niiirdf
(umruivlr'l l-t trmiiaar inil d4a BOi umims
0010 UK puljt* u la U( uM al 1 pMric luiM*.

Technic— The Presence of a Tumor.— The prcwncc of a tumor is
revralr<l t>y ihr ]icriu>i'>i<iii ni>ir lic-io); ilul! or lltil where (ymjuinilic resonance
khiiufci normally W beard. It should always be borne in miivl that when a
tumor iroiilain.x ftas or it b covereil by a coil of Intestine tl»e {lercuK-^ion-note is
tym|nnilit', and untr<« the i>ro«n(x of the fcrowth hji» been previously ssctr-
Uimd by |>al|iali(>n it may be entirely overlooked.

1^ ralue of itnp and tuptr,iciai |>ert-u.4«lon muM tie constantly iKimc in mind
in eumininic the atxlomrn. olherwiH; the presence of a tumor may not tw de-
fcitrd Thus. If a (trowih U towreil by iniestine-'> it «iiuUi not be diM.-overed by
il [K-rtu'wior. J11 the i>"le winill lie tyiii|vinilic in character, whereas It
' '--uri: in made u|H>n it the gas would l>c dl§pLiccd and duUne^^ eiKite<l.
Amiu. a imall tumor or rnLir)ced omentum lyinj; over the inteuines can only

EXAMINATION OF THE ABDOMEN.

be detected by superficial percussion, as inteslinal tympany or a resonant note
would be brought out by deep percussion.

Hie Situation and Origin of a Tumor. — The situation and origin of a

Fio. 81.— Showing 1 Pelvic Ti'innt with * Long PnjtclJEAKB tbi Iktibtwee Ihtziposui betwiin 11 anp

THE Svifpuvsis Pubis,
Note ID the upper illnsUatiDD (hat there a a unlral jireA of duUrma eniirrSy tunwnded by H Ting of rrtoauue. u

la [he C4K of an abdomiiul lumor.

tumor are indicated by dullness on percussion. Directly over a tumor the dull-
ness is absolute, but it gradually shades off into resonance as its margins are
reached. A moderate size tumor which arises from the pelvis and occupies the

-^VMPANv^

Fir.. B).— Sbobihc A<ea or DULtNEsa «si>Tyi(p*NT m Asotib with the Patient ih ihi Hoiuohtu

Recliubent Position.
Note viuaiion of the Ascitic fluid and the posiliou of Ihe inleilinefl.

inferior and middle portion of the abdomen is surrounded by resonance except
over its lower part, and here the dullness, which is continuous downward to the
pubes, indicates its pelvic origin (Figs, 79 and 80).

UENSUkATION.

Soraetiines. however, a tumor with a long [>ediclc may rise so cnmplctclx out
nf the pelvic cavity ihut intcslinnl rcsonnntc is clidtnt immcdiatt^ly alMive llic
»yin]ihy%i£. In ihnc case there is a central area of llull^c^» which {> sunuunilcd
In- an uninienrupted atne or rinjt, of rcuintina; nml (omcqucnily a mislalcc in the
iltagnosh can easily be made as lo the origin of the tumor if the examiner slwuU
rely entirely upon the ^igm eliciteil hy jjervusikioR.

The Mtualion of the areas of dullne^ and resonance in tumors of [leK'ic
■•rigin 'n constant and i§ not affected by a chanite in the ]MMiiir>n of ilie julient.
In a>citr», (ui tlic other hand, tltene areas change with the posilion in which the
(Wlient is placed.

In the caw of a. brge tumor occupying llie whole abdominal cavity and

p^^^^

>c:

tu. t| — SamrDaa Aha or Duunru uin Tmrun ih Avrni wim Tin PmuT Lnita oh mw» 9ni(.
Caaviw ih< tkMttgn Ui tb* bTiuiva oI ibf ivtm riuid ^nA Ihr p<4iUon <af the iniminn mlta tbt fcvrieua

IIIUUKUUI

encmachin^ u[Kin the diaphragm Ihe surrounding area or aone of resonance is
nbnent and there n«iy be duUnes-i not only in the llunks but owr the entire ab-
ilnmcn. Sumi-timo .1 mixlentely l-irf;r tumor m.ay l*c aKoxJated with asidtes
and the 'lullnc^^^ may extend into the llanks. Under these cirrumslancrs if the
patient is placctl u|ion her side the ujitMisiie flank will ^ive a tym]Jdnitic note on
percwdon aixl thus demonstnle the presence of free fluid in the jwrin-ncal
□tvily

The Shape of s Tumor. — The outline <if Ilie area of dultnc^u corre!>|K>n<is
to the general shape »i the tumor. The outlines of a tumor are not altered b>'
pbcing the patient in different positions. In ascites. howe\'eT, the opposite con-
tlitkm prevaib, aiul tlic line at dullnes* changes with the poution of the jiatient.

5TENSURAT10N.

Position of the Patient. The patient H placed in the borisooul
rrcumliritt |u^ilion.

Xofortnatlon. — Mettsuration often gives us valuabk information as to
the origin an<l nature of an enlargement.

XeagtirenientS. — T1tei>e are taken with an onlitary lape-measurt aa fol-
bw*

I. Between the Eosiform Cartilage and Ihe Anterior Superior Spines
of the Ilia.— The* mcj-tiircmenK di-tii"n''ltntc the >ymn>cin "t j^ymmclry
of the abdomen when it b occupied by a pelvic tumor. The distance belwcrti

EXAUINATION OF THE RECTUM.

the cartilage and the ilium is greater on one side than the other in ovarian or
broad ligament tumors; it is the same on both sides in pregnancy, uterine

growths, and ascites.

3. Between the Ensiform Cartilage and
the Umbilicus and between the Umbilicus
and the Pubes.— These measuremenis de-
monstrate the origin of an abdominal enlarge-
ment. Thus, if the distance is greater between
the umbilicus and the pubes than between the
cartilage and the umbilicus, it shows that the
tumor has developed either from the lower
abdomen or the pelvic cavity.

3. The Greatest Circumference of the
Abdomen. — The greatest girth of the abdomen
is above the umbilicus in ascites and below it
in tumors of pelvic origin.

AUSCULTATION.

Position of the Patient. — The pa-
tient Ls placed in the horizontal recumbent
position.

Information. — By means of ausculta-
tion we can elicit the following physical
signs: The sounds of the fetal heart and the
placental circulation; the vascular murmurs in uterine tumors and aneurysms;
the friction sounds in peritonitis, and the movement of gas in the intestines.

Ftc. 84. — Measuieheftt^ or the Ab-

bOiaH. to [KOICATE THE Natube
jUID Oucih or AN Abdohihu.
EnAiomun.

CHAPTER V.

EXAHINATION OF THE RECTUM.

It is important for the gynecologist to have a practical knowledge of the
methods which are employed in making an examination of the rectum, as its
anatomic relationship with the vagina and the pelvic organs is so close and
intimate that they not only have many lesions in common but we often find the
symptoms of a rectal disease referred to the pelvic organs and vice versa.

Methods. — The rectum can be examined by the following methods:
Direct inspection. Vaginal touch. Indirect inspection.

Rectal touch. Probing.

Preparation of the Patient.— In order lo make a complete investiga-
tion the rectum must be thoroughly emptied and the bladder evacuated spon-
taneously just before the examination.

DIRECT INSPECTION.

I^imitations.— By this method of examination we can inspect the anus
and the lower portion of the anterior wall of the rectum for a distance of over an
inch. In cases of prolapse the bowel is rolled out when the patient strains or
bears down and we can make a direct ocular examination of the extruded por-
tion.

DIRECT INSPECTION.

FtC- is- — Exrwnao ttie Ahufi it Sefahatikq the Buttdcis (pm« ?o)<

Fie. M. — EXKMIHC THE InNEI Sv'HrAFE OT THE AhUS IT Stiitchinc ihi Anal Rinc wrm ime Tkdh

fjmgt to).

Fin. It- — Dtcttal Evnnon of the Ahteeioi Wall or the RErmi TStoucB rat Vaoiha (pi(e »).

EXAMINATION OF THE RECTUM.

Position of the Patient.— The patient is placed in the dorsal posture.

Anesthesia. ^No anesthetic is required.

Technic. — The examiner sits in front of the vulva, separates the buttocks,
and carefully inspects the anus.

The inner surface of the anal ring is then inspected by placing the thumbs on
each side of the orifice and drawing it apart, while at the same time the patient
increases the eversion of the raucous membrane by straining or bearing down;
under these circumstances if a prolapse of the rectum e.tisls the bowel rolls out
and is exposed to view.

Another method of inspecting the anal ring and the lower portion of the
anterior wall of the reclum is to introduce one or two lingers into the vagina with
their palmar surfaces directed downward and push the rectum out through the
opening of the anus.

RECTAL TOUCH.

I/imitations. — By rectal touch we can examine the anus, (he anal canal,
and the ampulla of the rectum. , The tip of the finger can be carried higher up in
the bowel by making strong pressure upward against the anus and the penneum
with the knuckles of the examining hand.

Fio. 88.~Reci*L ToDcu.
Diopam a shorn Iht tip ol Ihir finger camrd high up in Iht rtclum by prtMure on ihc prriocum with Ihc
knuckles of [he (.uttmiqing hand. Dugram * showi Ihe pojilicmof Ihe lipof the finger when Ihe peivK Booru d«
invaginaled.

Position of the Patient.— The patient is placed in the dorsal posture.

Anesthesia. — No anesthetic is required.

Technic. — The examiner sits in front of the vulva and palpates the
anal opening externally with the tip of the index-finger. The finger is then
introduced into the anus as the patient bears down upon it and the anal canal

VAt^NAL TOL'CH — PROBING.

carefully explored, after which the ampulla of the rectum should be thoroughly
palpated.

The size, shape, mobility, and sensitiveness of the rectum as well as the
contractility of the sphincter ani muscles can be readily ascertained. In making
an examination of the rectum the finger should first pass lightly over the mucous
membrane and then the rectal walls are pressed in all directions and rolled
between the tip of the finger and the sides of the pelvis.

VAGINAL TOUCH.

IfltnitatioiiS. — The entire course of the rectum can be palpated through
the vagina.

Position of the Patient.— The patient is placed in the dorsal posture.

Anesthesia.— No anesthetic is required.

Technic— The examiner sits in front of the vulva and introduces the

Fig. Rq- — ExAinHATin?f ot thr Recttth By Vacihac IVnTcn.

index-finger into the vagina up to the cervix. The palmar surface of the linger
b then turned downward and its tip pressed upward against the third sacral
vertebra, at which point the sigmoid flexure ends and the reaum begins (/>f<i:w).
The entire rectum is then palpated downward as far as the anus by pressing
upim the bowel in various directions and by rolling it from one side to the
other between the finger and the pelvic walU.

PROBING.

Litnitations.^This method of in\esligation is used to ascertain the
direction and situation of an ischiorectal or vaginorectal fistula.

Position of the Patient.— Dorsal posture.

InstnunentS.— (i) A long slender silver probe: (2) Simon's speculums
with flat and curved blades; {3) dressing forceps {Fig. 90).

Cotton Balls. — Small pieces of absorbent cotton should be at hand to re-
move the secretions from the vagina.

EXAUINATION OF THE RECTUU.

TectaniC. — The examiner sits in front of the vulva and introduces the
index-finger of the left hand into the rectum. A long silver probe is held in the
right hand and passed into the external opening of the ischiorectal fistula and

Fra. «o. — bnnmzRTS t>sm ih Pioiihc the Ricmi (piBc T)-

carefully pushed along the sinus until its tip enters the lumen of the rectum,
where it is at once rect^ized by the internal finger.

FlO. ai.—DlAGHOSlII OF AH IsrHIOIECTAL FlSTDLA BY MeaN9 ur * PVWE.

Kole Ihal the lip of The probe ia in conlact wilh [he finger in (he reclum.

In examining a vaginorectal fistula it will be necessary to expose the vaginal
opening of the sinus with a speculum if the false passage is situated high up in
the vagina.

INDIRECT INSPtCtlOX.

Fib. ^.--DiAQHout or 4 Va4^i!<oi(Utai. Ftifi^u »T MiAht M 4 Pnuti-
I iimt ikai Ibr ^iCibbI tfvninfl irf tb« 'uiuU w *it«A| b^r 'levAiing ihv uiirnAr miU of iha ?«ciDA with SlfuoTfe

^^B ipT<ulum,

^P INDIRECT mSPECnON.

^^ XimitatioiiS.^Thc wbote mucous wirlatt; of ihe rectum can be invest!-
Bl«d by irnliic*! in>|iAlton, ,ini) liy ihc u*c i»f ii lung tubular ttpecuUim ihc
idid iicjiurc can alK> be cs]w>wcl to view.

Preparation of the Patient.— The rectum and bla4lder muM be
aptini nml the cnneu rcmox-cd as well as all con^lridin^ bamlit about the

■ LM

PosltloD of the Patient.— The knee-chest pusiticm is employed.

A A

® 1

®\

fit q\ — tMnamnrn I'M!! w r» miwii ibh RtnvH *ir lutnun InncttrM.

The ihiKh* *h<>uU l>e |ien>^'x!>('uliir in the surface of the table and hence ihe
«Hg)U Mfuatting posiliHn umxJ in cy<.to»»py fnu:<t be avnidcd.

Anesthctia.— An iinefrlhetic l<> not required unleu the patieM is nerwut
or <«>■ »eaiili»-c to jiain.

In8trtmient8.~Thc foUowin); infiirument& are required: (i) A &phinc-
Itmcotf. (j) ^ |iri>ctoncu|ie eight inches lunK; CO <> silimoidosc^t'^ fourteen
fadbnlot^: {4) drcMing; forceps; (5) a head mirror.

EXAMINATION OF TBE RECTUM.

Each speculum as devised by Kelly consists of a cylindric metat tube hi
a funnel-shaped expansion at the proximal end, to which a handle is attai
and an obturator, which is used to facilitate the introduction of the instrui

An electric light or an ai^and burner gives the best illumination and a
dinary head mirror can be used to reflect the rays into the expanded re<
Direct illumination with skylight or an electric light will be all that is nece
when the sphincteroscope is used, as the tube is very short and the part
exposed almost directly to view

Cotton Balls.— Small balls of absorbent cotton should be at hand to rei
the secretions from the rectal mucous membrane when they obstruct the vie

Fig, Q4n — IwDiifECT Inspection of the REc-rm,
Diunjnd shows thr p«eaf the palienL add the poailionof Ihc cxiininer Uld the declric lifbt. Nc
ihc fhi^hi arc j>crpcDdicuur 10 Ibe table. Diagram b ihavi ihr cDrreci nay to hold th« jmctoKope da
act of jntrEHJuctinn-

Technlc. — In conducting the examination the sphincteroscope shou!
used first; then the proctoscope; and finally the sigmoidoscope when an exai
tion of the sigmoid flexure is required.

To facilitate the introduction of the speculum the obturator should be 1
cated with liquid white vaselin.

The assistant draws the buttocks apart and exposes the anus. The sphini
scope is then held in the right hand and the obturator pressed against the
ring; at the same time the patient is told to strain or bear down. The spec
is now firmly pushed into the bowel until its further progress is checked b
funnel-shaped expansion at the proximal end of the instrument. The obti
is then withdrawn and air at once rushes in and balloons out the rectum.

X-RAVS IN CANCER OF Tni: IfTEMfS.

inal e imw cxmninnl m fnlkws: Throw the light Into ihe speculum and
ihrti Krailuullv withdraw the insinimcnt from ihc ampullii until the upjuT edge
■)( Ihr anal (aniil i* rx|>iMr(l lo view. Alter cirvrully insfiei-iin^ lhi& iHtrtion of
the rtx'lum the instrument Ls now slowly and Mcadily withdniwn from th« txmel
and the npifiiramr of the mucoM careful!)' noted as the &phinctrr muscles dose
ottT ihi- di'iUl in»'nini; of ((»■ i{>railum.

Tlie jir- ' ■ r'iilnscojie arc passed into the rectum in the same

uner as i ■ i'' A> wwin ;is the in.itrumcnt enter* the ampulla,

which is from unc and j half lo twx> inches above the anus, the nlmirator I* with-
ilrawn and the iiir alloueil to ruMi in and expam! the rectum. The light is then
thmwn into ihc rcmim ami tlw ii[>e<uhim |>ii--Jie<l higher and higher up in the
bowel, KuidinR its distal end by sight around (he rectal valves and over the folds
ol the tnucttu» mcmhraive.

CHAPTER VI.

THE X-BIAYS IN GYNECOLOGY.

The tise ot the .r^niys as a ther.-i|>cutic remedy is still in an experimental «ta)ce,
■ml allhouich wme of the ^e^uIts iirr hr frttm !tjiti'ifac[<)rj' or aUnwt hi/, yet »o
much has lict'n aco>mptishcd in curing certain diseases of an intractable nature
thai the nitciit may now \te looked upon a^ an cs.tiit>li.4hed method of treatment.
In a Mork on gynei^iUi);}' it would be tnit of place lo discuss the technic of
tuloic the A-fuys or to present an analysis of a long series of cases, and I shall
tbcrcfnn bmil mywlf to n ccneral irvicw of ihe results which have been otnained
inlheg)mccob>^cdc])anmcnlof the Me<liiroChirurt;ic;il llospiul of Philadelphia
by Dr. O. K. Pfahler, director of the jc-ray bilHiralor^-, ami the ileiluciioat
drawn by Pu^ey .iml Caldwell in their excellent Irealise on the '" Kftnigen Rays."

Cftnccr of the Uterus.— A numlwr of ino(>end>Ie (jses of cancer of the
uUTii< lull- l«*en irc.iiol with varying; n-Nults. and in nearly every in>tance the
patient wu* made mure comfortable. In some of the cases the discharge was
lea«fvcil in qiianiiiy or entirely checke<l anil the odor l>e<ame le&i foul. The
^ny^ luve a dedded effect u[>on the pain which at limes i« such a distrcMilttg
•fmptom, and in many rases il was greatly relie\'ed or disappeared allogcUter.
la Miroe in^tanvM sloutchinjc wa.^ prevented, while in other* the ulcerati^v process
vu d>e«'ke<l aiMl the piUient saved from the miK-ry attendant upon a fistulous
ftptnitm in the later stages of ibc dfeease. .\nil, liiully. in some of the ^Tfv
I'i 'here was no noticeable effect, except iicrhajM a iUghi diminution

iii if the {uin.

Ill iH?*s Ihc AT-rnvs offer the only |K*ssililp lioi>e, and the earlier

ihe^ ai 'i the more ])ron<iun<'e<l will he the relief of \ymptomfs, llefore

ap{>lyini; ilic ray^ as much of the diseased lisi^ues asfmssible should he removed
Willi ihr • tiret and cuiiter)' lo guard af^inst the occurrence of toxemia or meU»-
t> 'I Mimrtimcft follows the destruction of a largjc cancerous ina» by the

The ra>-« ^oukl always l>c applied after a hy»tetenomy for malignant db-

< 'OsKible me.ins of presenting a recurrence, which takes pbce in about

' of nil lase? ofieruied ujxjn for isinccr of the cervix. But little work

■ yet along lbe^*e lino., .ind wc will jttnlKibly tmd a* ourex[>erience

k; Lyiliasva definite influence in pre %xn ting the recurrence of cases

(■{■eraiod u^iu early.

76 THE X-BAYS IN OYNECOLOCV,

Cancer of the Vnlva and the Vagina.— Judging from the br
results that have been reported by the .r-ray treatment of superficial cane
other parts of the bodj-, as well as the beneficial effects already obtain
cases of malignant disease of the external genitalia, it is only fair to pn
that this therapeutic method will prove of curative value in primary can
the vulva or vagina.

In treating an inoperable case the diseased area should first be thorc
cureled and cauterized and then exposed to the x-rays. It is always b
remove as much as possible of the diseased tissues before using the rays, as
been demonstrated by experience that the cure is more rapid and certain
this is done. The pain which is usually a prominent symptom of the dise
as a rule, promptly relieved, but the effect of the rays upon the diseased i
found to vary. In some cases they seem to melt away the cancerous tissi
increase the discharge for a time. In others the discharge lessens within
weeks, ihe pain disappears, the growth decreases in size, and the ragged ec
the ulcer become smooth and inverted as healing takes place. The p
toward recovery, however, is often very slow, and in some cases a mmplet
may take many months.

An operable le.sion must first be thoroughly removed by surgical mear
on the following day, if the conditions permit, the x-rays should be app
the seat of operation through the dressings. The treatment should be con
for at least six weeks, and in every instance the rays should subsequei
reapplied at intervals for several years. A radical operation must nc
delayed in order to test the effect of the rays, as valuable time may be k
the case become inoperable. If, however, the growth is first removed an
the original seat of disease exposed to the action of the arrays, the pal
given the benefits of the two best forms of treatment — complete extirpati
lite prophylactic effect of the rays.

The action of the a:-rays is especially airative in recurrent cases an
must be used at the first sign of recurrence. If taken early, the indi
usually disappears rapidly and a cure results.

The permanency of the cures in cases of superficial cancer by the
cannot as yet be determined, but there is every reason to believe that this )
will in time be a valuable addition to our resources in the treatment of carci:

Sarcoma.— There have been comparatively few cases of sarcoma
by the ar-rays, and their effect upon the disease is therefore not so well
as in cancer. Some remarkable results, however, ha\-e been reported, i
treatment should consequently be tried as a prophylactic remedy after tV
plete removal of a growth, and in inoperable cases, and also when rec
takes place.

Tnbercnlosis. — This disease may occur either in the form of
vulgaris or a tubercukr ulceration involving the vulva or the vagina o
The use of the ar-rays is now an established method of treatment in this i
especially in the former variety-, and the results leave no doubt whatever ■
efficiency in curing the lesions in many cases. The discharge from the uU
surfaces usually disappears quite promptly and the tubercles drop off,
a healthy granulating base. Improvement is usually observed at the e
few weeks' treatment, and in the course of several months the ulcers are
over.

The results obtained in the treatment of deep-seated tuberculosis i
parts of the IxxJy, such as the joints and the spinal column, justify us in
that the a:-rays will prove to be a curative agent in cases of genito-
sinuses caused bv tubercular disease.

ECZCUA— PBt'BJTlTS %T;LVa,

Bczema.— Roth arulc and chronic eczema have liccn ruml by means oF
ihr .r-niys. They arc csfiecially t-urativc, however, in Uie rlm>riii: liuluriiied
iy[ie ii( the ilLtea^*-. In Iwih ihc .irute and chnmic (i<nn.s Ihc pcrswlcnt itching
h- nrariy alwa)h rclic^isJ after a (c«- exposures; ihe ioduralion disappears later;
and the »kin finally ^tssume^ a he.ilthy appearance.

The xny treatment ain he iDmliinfl tvilh general and local mnlJcalidn.

Thr resiihs <i( the ireatmcnl seem to be pcrmanuiil in many iii^iance*. and
dfiCs h:nc l»c«n under oltowvaiiiin (or two year* wilhoiil any rccorrenic of Ihc
fli«ea'<

Acne.— The tr^iiimcny as to ihe cffcci of the .r-rav treaimeni In acne h
i •. unanimous, and pioi! results vhcniH ihcredire bceiqHTtui by apply inj;

I: .. iipil ii( trcalmi-nl tii the disease when ii atiack?i the xiiliTt. The ture of
Ihe nffei'iton in u<iuaUy permanent, and if tlic erupliim does recur tl it generally
tn n Rimliried form which re^idily yields li> ii few cx|Misures.

Prurigo. -'ITierc have I)een vm- few cascsof this disease treated with the
XTa\->, aii<l ibc results no far hav-e lieen un!iatl>facl»T\'.

MChen Planus. — Vinwy ha* rqH>rterI one ca»e nf lichen planus of ihc
:-nitum which he cwrcd by the .v-rays after two months uf trcalnient. Tin;
iihinjc 'K^of' iir^ rclie\^-d, then ihc jMtchen be^an to fade, and fnuilly all Inirc
fi (he di*ra*e di-cipix.-.irol.

Elephantiasis, The results Ml>t«ined by Mascat in the treatment
CA>); with the .Y-rays would lead ii> to cxfiect decided benefil in the
( ' 'f( cliiihantiasi.'t of the vulva,

FniritUS Vulvee.— The .v-ray.-. have Iwcn ulili/cd in the treatment
111 pruciiu'. vulva." awl a number of Micce*sful raiT* hai-c been re}Nirtcd, Tltcrc
y a dfvklcil effcd pn!<lucvd by the .v-ra)? in relieving itching, and they should
iberefnrr ahirav's be ^iven a trial in the treatment of |>ersUtent cuses of pru-
rrtu> vulviT.

niArniK vii,

HYDROTHERAPY.

The UMT of water as an auxiliary in llic treatment of Hb«a»ci of women
b too tre<|urnily lost si|{ht of or neglected .nlt<>Kether by the profcMion, ntxl,
»* & rule, even when hytlriatic mcth<id» arc employed but little or no beneSt
CTMilt*. This Slate of affairs is due to a general ignorsnte ujwn Ihe \nn nf
the prrifrsiion o( the subjeil of hydrotherapy ani! the atli»n of heat and coW
• hen applle-t l« the Mirface of ihc bixly ">r within ils ca\-ities. In order to
cmnlo) a temeily intelUiienlly we must have a ilcfinite kn«>wlc<!i;e of iu action
jryl i!'" ,1 (tear conceptiiin uf the re-Hults which may Ijc ex|>et'lcd to follow its
rwi,sc comph-te fiiiKirr or only partial success will be obtained. Il
ire, aliNohitcl) esM^'ntia! for the physiran not only to understand the
tavk of hydroihrr^py thon)U|thly, but to inMrurt hi-t patients carefully in the
Irrhnii. i-f the trcjlment.

The iL^ual method of employing a vaginal douche is a iciimI illustration of

tact that h)-drintic treatment h not, a< a t;meral rule, scientifically under-

The [Kiiient is simply told by her ph\>ician to inject a pint or i[uar1

i^cT into llie vagina omc or twite ilaily. ami a^ a result "f *uch iiuleft-

; -.•m'* Ihe woman n".Mime> a simipini; i«»ition over a ba^iin and douches

hctJtclf kt'illi a t|uiirt of water of an unccruin temperature. This technic

78 HYDROTHERAPY.

naturally -docs but little good, and may result in positive hann if the inJD
are used for a definite purpose. In discussing later on the action of hea
cold upon the tissues of the body it will become evident that the use of a vi
douche requires a definite technic based upon certain fundamental laws
that explicit directions must be given to the patient as to the ar
and temperature of the water as well as the position she must assume when
the injection.

Physiologic Action.— The effect produced by water at vj
temperatures when applied lo the surface of the body or within its ca
results in more or less permanent changes in the respiratory and circul
systems as well as in the rapidity and extent of tissue metamorphosis a
the character and quantity of the excretions and secretions of the body.

This action is due, first, to the mechanic contact of the fluid upo
tissues; and, second, to the direct impression produced by the tempei
of the water upon the blood-vessels and nerves.

To obtain the effects produced by mechanic contact the water
strike the surface of the skin or be injected into the cavities of the body
more or less force; consequently we employ for this purpose the jet-, sh<
or needle-bath, and the vaginal or rectal douche. The force of the
upon the peripheral vasomotor nerves produces immediate stimul
which is followed sooner or later by relaxation. These impressions are c
to the central nervous system and from there distributed to the respii
and circubtorj' centers, producing changes in the act of respiration and i
force of the blood-current which consequently influence tissue change:
modify the character of the excretions and secretions of the body.

The impressions produced by the temperature of the water depend
the degree of heat or cold and the duration of the application. The efl
a decided temperature is to stimulate the vasomotor nerves, which sooi
later relax again, and, as in the case of mechanic contact, the central nt
system receives the impressions and distributes them to the difiecent ce
Furthermore, stimulation of the vasomotor nerves causes contraction c
blood-vessels, which is followed in a variable length of time by relax
Hence while the vessels are contracted the blood leaves the part and thi
cular tension is increased, and, as a result, the activity of the oi^ans i
body is more or less modified. And, finally, when heat or cold is appl:
muscular fibers they undergo contraction, followed eventually by r
tion. Consequently, the narrowing of the blood-vessels which occurs :
only due to the vasomotor stimulation but also to the direct influence i
temperature reaction upon the muscular fibers in the walls of the arterie
the veins.

The degree of heat or cold determines the rapidity with which the \
contract, an<l the duration of the application governs the length of the ]
of stimulation. Thus, a temperature of iio° F. produces quicker i
than one of 90°, while an application lasting twenty minutes will result
longer period of stimulation than one of only half the time. Sooner or
however, stimulation is followed by relaxation, which is also spoken
reaction. During this period the blood-vessels dilate again, the extre
Income warm, the skin is more or less flushed, and the patient experiei
feeling of general comfort and vigor. It is evident, therefore, that «
always able to lengthen or shorten the period of stimulation by the tempw
and duration of the application, and upon this fact depends success or I
in the hvdriatic treatment of disease. Furthermore, as the activity t
internal organs is controlled by (he amount of blood they contain, and ;

CCNeXAL EPPECr OF COLD AND OP BEAT.

Kw'

rttuneous vessel!) are able to hold over 60 per cent, of the total quiinlil}' in ibe
WmIv, tt nniiirnlly fullowf' that ihc ilUtrihutiun i-f ttic blood ciin always be
morv <«■ Ics). lomrolU-il by the nppHcuiKm »i h«al or cold 10 lh« skin,

Moilcriilc ■lc>;icc*< uf hcAt or cold priM-lucc relaxation of the vat.omotnr
ner**> owf th<' muMviUr »vMcm, and conitniticntly the blood- vessels are
dilatrtl and the impressions conveyed to the central ncrvaux ty«lcm are Mill-
live ^ni nol ^limulniinc in chiirjicicr.

General Bffect of Cold.— We muke um of cold uDpliciitioiu nrin-
cipally lo hiin^ ^boui rrarlioH. and unless this occurs quickly and decidedly
de^iresftton resuhs and the vita) pow-cr» of the [uticnt arc lowered.

'f\ic ellcct o! cold u|i«>ii the rCRpiralion riiii^c a ilccjM-nins iif the respira-
tory act andagrcalcrsupply of airisconsc()Ueiitly i^ikcn into the lungs, thereby
I" ' ihe oxyicen in the blood, ami the climiiialiiin of carbonic acid. The

l- '.-t' stimubtetl and the va«-ul.ir tension i^ increased, .\s a result

•>( these conditions the tissue changes are augmented, more urea is excreted,
ibe urltic l« Increased in amount, and the piitieut's health and appetite lire
improvetl.

The dailr stimulation and relaxation of the peripheral vasomotor nerves
by the appUmlion of cold water cuum: contraction and sub»c<|uent dilaliitton
o( the cutaneous blood-vessels, harden the skin, slrengtheti the general system,
and Bccu^iom the surfai'e of the body to icmperaiure changes, and :ts a result
Ibe palient'it fmwer of Te''t^tinK morbtil intloenccs is greatly inrrenMfl.

In using cold as a therapeutic agent we must not confound the slimuLstiOB

the Vasomotor nerves with the stimulating effects produced upon the

icrat system by the reaction. While the former condition laM» the patient
is alwxys more or Ic^ shocked, and if reaction is delayed depression of the
vital power* en»ue». CoaMrqucntly stimulation of the vasomotor nerves
must give place to relaxation before the invigorating and stimulating effects
of the applic.tiion are experienced by the patient. Therefore in speaking of
tbr Mimubiing eflecl of cold upon the |>criphc-ral nenT-endings we do not
mean that the general system b necessarily invigorated, because, as we have
already »ccn, a continuous application is deprosing in its result*.

The pn)mplrM"is of reaction depcnris upon ihe degree "f cold, the duration
of the applii.iiii>n, the subsequent use of friction and exercise, and the natural
ability of the [Mtieni to reco\-er from the nliork. Reaction is always delayed
or is im[>erfcft in M)mc women even when graduated halhs are used to ac-
twtciin the suKare of the body lo a comp;tnilively I'ov tcm[>craiure. but, as
m rale, m»ft of thcM patients can be made to react promptly by careful attention
Uilbe technic of the treatment.

When cold is applied lo the surface the beat of the body » more or ICM
reduced, but al>ing with the Kubi>e<iuent reaction the heat-cvnler» are slimu-
htetl, «> that the final effect is to increase the tem|ierature. This faci is
«bown by the results of a cotd plunge in warm weather, which firs.1 c<>oU
Ihc bndy.bul later when reaction take* pbce the temperature is increase^l and
(nv perspiration occurs. If. however, the immersion is continued for ten to
fifteen minutes, the periiMl of vasomoiur stimulation i^ indefinitely prolonged
atul the ileprrvsion which results keeps the temperature reduced; the reaction
being imprrfeil or K'e:iily dehiyed. A prolonged immersion of the body in
cdM water i-> always injurious. .1« the patient becomes temporarily depressed
aad dcbilitateiJ and frequently suffers wtlh slight nausea and a feeling of
weight (upr the ei'igi''"''' rewion.

General Effect of Heat.— We make use of heat chiefly to produce a
wtUtivc niiion. \ hirt bath causes a feeling of general relaxation and a

8o BYDROTBERAPy.

tendency to sleep. Its excessive use is debilitating and relaxes the syst<
exposing the patient to the danger of catching cold if she subjects herself si
sequently to a sudden change of temperature.

The effect of heat upon the nervous and circulatory systems is sedati
it lessens reflex irritability; soothes the patient; and diminishes mer
activity. Its application is without shock and it produces a relaxing efl
upon the vasomotor nerves, which is followed by dilatation of the capill
blood-vessels of the skin and the withdrawal of the blood from the inter
organs to the surface of the body. The application of a very high temperati
however, is stimulating to the vasomotor nerves and the muscular coat of
arteries and the veins. The prolonged application of heat has the sa
result, so that practically the primary e/fecl of a high temperature is relaxi
and more blood is brought to the part, while the secondary action is stimulal
and drives the biood out of the tissues.

The prolonged application of heat is followed by free perspiration, wl-
eliminates the toxins in the biood and increases tissue changes.

Importance of the Technlc— No beneficial results can be
pected to follow the use of hydropathic agents if the treatment is applied i
haphazard or a careless manner. AH the details of the technJc must
clearly and thoroughly arranged and the patient given minute instruction
writing.

The following practical points should be noted;
The time of day the treatment is taken.
The method employed.
The position of the patient.
The temperature and quanlhy of the water.
The duration of the bath or the douche.

The special form of friction or exercise used to assist reaction.
The length of time subsequently devoted to rest.
The temperature of the bath-room.

The Time of Day the Treatment is Taien.— Sedative baths, as a i
should be taken at night before retiring or in the afternoon. Stimula
baths, on the other hand, are usually most beneflciat when taken in the mon
immediately after gettln;; out of bed. Vaginal douches, whether used
therapeutic purposes or tor reasons of cleanliness, are more convenie
taken the first thing in the morning or at bedtime than during any other
of the day. The time of day the treatment is taken, however, will often
pend upon the peculiarities of the patient, the state of her general health
strength, and also upon her environment. Every patient is therefore a
unlo herself, and a careful study of the indications must be made with the '
of selecting the best and must convenient time for treatment.

The Uietbod Employed.— The indications for treatment, the finar
ability of the patient to carry out the instructions, and any existing idio
crasy relative to the effect of mechanical contact upon the respiratory
circulatory centers must be carefully considered before selecting the met
Some women react quickly after a cold plunge, while others are only abl
stand the shock of a rapid sponging; or, again, a shower-bath will act
stimulant or a depressant according to the resisting powers of the pa
at the time. A little ingenuity upon the part of the attending physician
often enable him to substitute a cheap home-made apparatus for the r
elaborate needle- or shower-baths when the mechanic contact of wate
indicated in the treatment of a woman who is in moderate circumstances,
matter of fact, the adjustable jet- and shower-baths which are now comm

tUPORTAKCE or THE TECBNIC.

■nU in the shops are nearly as eflicadous as the more expensive pcnnanent
attni'hmrnit fouml in the hini'*<s of the weiilthy. (FIrs. 97. 98, and 99-)

The Position of the Pfltienl.— The posiiinn df ihc jititicnl dqwixls upiin
rile mrihod emphnetl and ujwin the ihcrjpeuiit indicaiions. Thus, strnic hrms
o( IrratRKnt require ibc erect «r >tiinilin); [xiNitinn, while in ntlicrs the patient
l«himiM lie flat upon her back. When a vngin.1l douche is uMecl (or pun">*e« >*f
cbnnlincM, the patient may sloop over a ba^in while Rinng herself the injection,
liul when it is employed lo relieve uicrine or [iclvic congestion or to treat
^diseases of the vagina &he must assume the dorsal pofiiion; otherwi'^ the irrignt-
fiuM vrill not {-ume tn contnrt with the atTected puns.
Tbc Temperature and Quantity of the water.—Thc
temticraiure of ihc w;iter i> one of ilie nioil imponani factors
[in the hydriiilic trentment of di-^nse, iind i'tinM:<iuvntly |[k> much
I can or Attention cannot be pvcn to this subject. Ignorance of the
■W» )cot«rnini: the phyiioloRiv ailion of heal or cold upon the
I livues o( the Iwxiy or neglecting to apply Ihem intelligently nilh
B view to meet the indications in individual cases is the great
caii-tc ol failure in tlic use of hydropathic' retneilies. We must
Je in e*-erTi' case whether n quick or n slow stimulntion i*
recpiired; whether relaxation is indicated; or whether a seda-
tive action L> c.illerl (or. We miL^t alio r«meml)cr that intense
, cold or heal produces rapid stimulation of the vasomotor nerves
I and contraction of the muscular fibers in the walls of the arteries
f%aA vrin«, anil that coit.-«<]uently when bent I* used to control a
oondition like postpartum hemorrhage the temperature of the
water must be high, as a quick or decided action is required. If,
however, a low temperiiture i» U5cd, the stimulation b corre-

rodlngly slow, and as a result valuable lime is lost in checking
hemorrhage. Decided degreeH of heat and cutrl arc stimulat-
ing, while nuideratc temperatures are sedative in thnr action
upon the peripheral nen'e-cndings and in their effect upon the
• Ctntnl nervouK ^yrtcm.

The temperature of the water must always be taken with a

ihermometcr, otherwise the action of the heat or cold cannot lie

rpMTCCtiy reflated .iml cim*e<iucntly no hcnelirini ti-suIin will

'IdBow. An ordinary bath ihcrmomclcT should be employed and

the patient instructed how to use it.

The quantity of water u*«d in a rectal or vagiiial douche is a

matler of great importance. A small quantity of water means

a thort application, and hence when the Injection* are used to

bovcroMDe congestion ihcy do harm rather than good, for the

^Ruon ihal reaction occurs quickly and the vessels liecome en-

I'forged with blood. If. however, a large quantity if employed,

Ihc period of stimubtion or contraction of the blood-vrsscls and

the muscular tissues U prolonged ami the sulMe^^uent relaxation or reaction is

lOOl so marked. 'Iticrefore a targe quantity of wnter l< alws>-s siimulatinK

Jed a considerable length of time is consun>cd in its application; but a smafi

tin the other band, b mure or less ledativc, a« the reaction a prompt

[ decided

The Duration of the Bath or the Douche. — The duration of the appli-
(mliun drIermincN the pcrioil of stimubtion and reaction. A brief applicaitoo
of coU io the form of a plunge, a jet- or shower-bath, or a quick sponging is
iilallniE in its action upon the general system, because the reaction is rapid
6

Fic. *i — U*r
Tn«*viHnn

8 3 HYDROTHERAPY.

and there is no subsequent shock. But a prolonged appUcation is depressin
as the reaction is delayed, and in the meantime the patient is chilled and h
vital powers are lowered. In the local application of heat or cold for the reli
of congestion or inflammation we take advantage of the fact that a prolongi
application produces a protracted period of stimulation followed by only a parti
relaxation or reaction. For this reason the vaginal douche should always be u&
continuously for fifteen to twenty minutes at a time, otherwise the congestion
increased. Again, the effect pnxluced by the long-continued application of
poultice or a fomentation is a good example of the permanent constriction th
occurs in the blood-vessels of the affected part under the circumstances.

The Special Form of Friction or Exercise Used to Assist Reaction.
Reaction must occur quickly after the application of cold water to the surface
the body or depression will result and the treatment must be discontinut
Vigorous friction of the skin followed by exercise will be found of great service
assisting reaction, and every patient should be carefully instructed by her phy
cian as to the proper methods to be employed. By neglecting these simple mea
of bringing about reaction many women are unable to take advantage of t
great benefit that is nearly always derived from the use of cold stimulating bai
Friction and exercise are also of service to women who do not need artlfic
means to bring about reaction, as they stimulate the lungs and heart and thus ;
as important auxiliaries in the treatment. Sedative baths and local applicatic
should not, as a rule, he followed by friction and exercise.

The Length of Time Subsequently Devoted to Rest. — Rest is an i
portant element in the treatment and its indications should be carefully stud
in every case. The health and strength of the patient should be consider
her idiosyncrasies noted, and the effect of the treatment upon her vitality watch
Some women require more rest than others, while those who are strong and rob
often feel better when they do not lie down at all after a bath or a douche. So
live baths should always be followed by a more or less prolonged period of n
and for this reason they are usually taken at bedtime, when the patient can h:
several hours of undisturbed sleep.

The Temperature of the Bath-room. — The temperature of the ha
room should be between 65° and 75° F. A lower temperature is likely to c
the patient after a warm bath, while over 75° is too enervating.

XemperatoreB. — In order that we may have a defmite idea of the differ
temperatures employed in the hydriatic treatment of gynecologic diseases I si
use the following classification when discussing the various methods:

Cold = from 50° to 75° F.
Tepid =- from 75° to 95° F.
Warm =from 95° to 104° F,
Hot "from 104° to 114° F.

Methods. — It is always more or less difficult to present the practical side ■
subject like hydrotherapy in a simple and concise form, but unless thi
accomphshed the details and methods arc so scattered that it is impossible to
a clear conception of the treatment, and consequently the general practitiom
left with his mind full of badly arranged facts that are utterly useless to '
when he attempts to apply his knowledge at the bedside. In order, thercforf
simplify the classification I shall discuss the teclinic of the different meth
under separate headings, as follows:

The full bath. The sprav bath.

The half bath. The sitz-bath.

The sponge bath The Turkish bath.

TIIK rULL BATU.

Thr Ru$.suin bath.
T\\e ihrtt hath.
The Nilt Uith.
Sea tjalhing.

'Vhf v:igin;il cJnurhe.

The inirauirtinc -tourljc.

Ut'-lxtK: Il"i-wi»ter Ikir; Comprttws.

Wutcr-ilrinkinx-

THE FULL BATH.

The full haih may l>r ukcn t^il. UpiJ. u.^rm. or Aof. The iMih-luh W tilted
with sulTiricnt water to immerse the paliem'^ Ixwly inmpleiely when <h(; li«
■liiMn in it

The Cold Bath. - The t.'ulii haih should l>e taken in ihe morning! on ^iting
out of li«l anil after excrcisinK (or five to ten minutes. Preliminan' exercises
»n vfn' im|Hirliint r.-icinrs. as they Mimulnie the rcspiriitori' and circulnlnry
cmttn and thus increaAC the t'JsruLir tension, Hcntc the patient's power of
miMame is tnirinit^d and she reacts more promptly and with greater viftur after
the pUinice. Many women who arc unable I0 Mand the slighie^I application of
(old under nrdiiur>' circumstantcs have no difficulty whaleiTr in reading after it
phinice in moderately cold water ((15° to 75" F.) provided ihey fint excrti*e foj a
minulvs. The exerctwi which I recMinmrnd nre the variouv movements
lsrril>e<l on page 119.
The temj)erjture of n cold lath xhould lie from 50' lo 75" K. The woman
(fuickly into the tub, immerses her body, and remains in the trater from
leo to fift«-n sccomls tmlesi she is ver>' vigorous, in which case the immersiun may
be (.'uniinued for une or two minute>. After KCllinK out of ihc liaih the skin it
tii-kly dric<l wiih a coarse lowtl, using strong friction, and the clothing promptly
moil. If the reaction iadebye<], a fewrminute» devoted to exercise will f[eDerullf
Irinji the bl'nnl (luickly to the surfucv of the l>o(iy.

tt'hcn the temperature of a bath U very cold (30* F. und below), tl should
■Iwan be uken as a quick plun)R. otherwise the shock will Iw too great.
The bath is tonic in its adi'in.

The Tepid Bath. — Ttds bath nbould he taken in the morning on getting

out ol lieil :in<l allir cxeriivincBit in lhcca*c of a cold plunge. The temperature

III the water should be between 75" and 95" F. The dunttion of the immersion

li lie fn>m two to five minutefland tliepulicntshoulil dry her iikin by friction

.1 <iutr>r towel.

The )uth i^ sliehtly tonic in its effects, but if its application is prolonged it

tri oron drprossini; in diameter.

The Warm Bath.— The warm l>ath should be Uken at bedtime and not
prctnJcit b) excrc isc ITie temperature of the water should lie l«lwecn 95" aivd
104* F. The duration of the immemion should lie from five lu fifteen minutes
or tunger act-ording to the effects desired.

The bath is srdatt^'v in its action: a prolonged applicntiun causes general
tdauUnn of the M'stem.

The Hot Bath. — 'Ilie bath should be taken at l>edlimc and not preceded

* The icm|>eratiire of the water ■•hotdd lie lietwcen 104" and 1 14" F.

I rjiiiin of the immersion should l>c (mm live lo fifteen minute* or k>nger
m the elTcds ilesired. The skut should be dricil without fridion by a

Tbebuth is very sedative in it> action: a pmlonged application causes general
tLixation and debility.

84 HYDROTHERAPY.

THE HALF BATH.

The balh should be taken in the afternoon, so that the patient may Have
opportunity to rest before dinner or supper as the case may be. Preiimina
exercises are not indicated. The tub is partly filled with water so that when t
patient lies down in it only half of the body is covered. The temperature
the bath should be between 65° and 80° F. After the patient lies down in I
tub she places a towel wrung out of cold water (45° F.) on her head and vigorou
rubs the exposed portion of her body, especially over the chest and abdomi

Fio. »6.— llALr Bath.

dipping her hands in the water from time to time. If the patient can afibrd
a nurse should do the rubbing. The bath should last from five to twenty minu
The patient then sits up in the tub and douches her shoulders and spine with <
water (50° F.), using for the purpose a sponge or an adjustable spray. '
douching, which should only last about half a minute, is followed by vigor
friction with a coarse towel, after which the patient should put on a woe
wrapper and lie down for half an hour before dressing.
The action of the bath is tonic.

THE SPONGE BATH.

The bath may be given as folbws:

Cold. Alternating.

Graduated. Sponging in bed.

Action. — Stimulating and tonic.

Cold. — The bath should be given in the morning on getting out of bed
after exercising. The patient stands in an empty tub and quickly sponges
body with water at 50" to 75° F. The sponging should not last longer tha
minute to a minute and a half and it must be followed by vigorous friction wi
coarse towel.

Graduated. — To gradually accustom the body to the shock of cold w.
Baruch advises "standing in 11 inches of water at 100° F., and resorting ■
rapid sponge bath of 80° F. This is reduced daily 2°, until a temperatur
reached below 50° F."

Alternating;. — The bath should be given in the morning on getting
of bed and should be preceded by exercise. Two large basins are placed
chairs alongside of the tub; one is filled with water at 50° to 75° F., and the o
at 104° to 114° F., and a good-sized sponge put in each. The patient now sti
in the tub and sponges her body, alternating with the cold and the hflt wf
until both of the basins are empty. She then dries her body by vigorous fric
with a coarse towel.

THE SPRAY BATH.

Sponging in Bed. — A mbber sheet is placed under the patient, her cloth-
ing is removed and a woolen blanket is thrown over her body. A basin containing
equal jwrts of alcohol and tepid water (75° to 95° F.) is then placed on a chair
or a table alongside of the bed. The nurse now rapidly sponges the anterior
and posterior surfaces of the body, including the face, the neck, and the upper
and lower extremities. The skin is then dried with a soft towel and the
ckiihing replaced.

The sponge should be dipped frequently in the basin and not squeezed too
dry, as it is necessary, in order to get the full benefil of the bath, to apply plenty
of water to the patient's skin. The patient must be well protected by the
blanket during the bath and only a small portion of the body should be exposed
at a time; otherwise there is danger of catching cold.

THE SPRAY BATH.

This form of bath requires an apparatus which throws the water in fine,
divided streams, either laterally or vertically against the body.

Permanent shower or needle baths are found in the houses of the wealthy
and in regular hydriatic establishments, but for people of moderate means who
cannot afford the luxury of expensive plumbing the adjustable connections which
are now commonly sold in the shops answer every purpose.

The adjustable spray may be attached to the nozzle of any bath-tub spigot;
if the plumbing b arranged with a mixer for the hot and cold water, the single

Fk ^>? — ApjvSTABrE Spiav wiitt Single

Fig. 0*.— AnjtsTABiE Spsay wrni

UOI'BIE AlTAOIMEKTr

Kfise i> employed, but if there are separate spigols the double attachment is
rK|uire<l in order to regulate the tempcralure.

The adjustable shower-bath with a rubber sheet attachment i^ an inexpensive
and a \ery efficient apparatus to use when an overhead douche or spntv is in-
dicated.

In houses which have no ninnint; water or bath-tubs a \erv serviceable ap-
paratus may be made by altachinj; a sprinkler to a larpe fountain svringe. .After
fiUinc the rubber bag with water at the proper temperature it U su^^iiended upon a
htiok (T nail and the patient then ■elands in an ordinar)- wooden wash-tub and
rfirects the spray against her body.

HYDKOTHERAPy.

In using the spray bath it is important that the force and temperature of t
water should be properly regulated. When running water is available, '
pressure is easily regulated by the faucets, and when a sprinkler is attached t
fountain s)Tinge it is readily adjusted by the height of the rubber bag from
floor. If a strong pressure of water is required, ihe [latient i^hould not allow
douche to strike her head.

The spray bath may lie given as follows:

Cold. Alternating.

Graduated. The Scotch douche.

Action. — Stimulating and tonic.

Cold.— The bath should be taken in the morning on getting out of !
after exercising. The water should be at jo" to 75° F. The temperatun

Fir. 99. — Adjustable Show et -bath
WITH A Rdbbki Shmt Attacmiient
(juge gj).

Fig. too. — NIethod of (Tsino a Foutttaih Si
and sprthu.eb a4 a substittte fob a

BaTII in the .\BSENr£ OT RUNNING 1
(togc Nsl.

regulated by the faucets and tested either hy holding the thermometer unde
shower or spray or by collecting some of the water in a basin. If a sprii
is attached to the nozzle of a fountain syringe, the water is mi.xed in a
pitcher before filling the rubber bag. After getting the water at a proper
perature the patient steps into the tub under the shower anil allows the wat
strikedifferent parts of the body; first the shoulders, and then the back, the c
the abdomen, and the upper and lower extremities arc exposed to the doi
If a needle bath i? used, the patient stands erect while the jets of water s
her body. When an adjustable spray is employed, the sprinkler is held ii

THE M-nC-BATH

«7

lit hatid and the stream of water HirecttKl fint over the shouklen and then over
back, ibe ch«>l. ihe aMnmen. and th« \ijt\>eT ami luwcr Mtrcmitie^.
1*hc 'turaliiMi ol the hiilh «h<nil(l ntit exceed, us a rule, more than frtni ten 1i>
iiny se«>nd*; wciMnnally, however, il may be conlin«e«l for (wo or three
™inuU-v. The liiilh mu>l Ik' (olUiweil by vijfiinms (rii'lion wilh a tiwric towel.
Graduated. 'I^ lei-hnk <>f the h.ilh if ihc sime a<^ when cold water is
Ml, rwejil thai tlie (c>iil>cr:iliire of the .«howt-r nr >|iray ^h(luld be 80" F. This
Il ndticed one '>r iwo <let!re(.-> ciuh murning unlil e^rnlually the douche i% given

Alternating.— The loth U Kiven in the morning immediately after Reitinic

lit of be<l and should be |>reicticd by cwrnse, A permanent needle or showrer-

ith or h<>t and «ild w jier spigots tu which iin adjustable «i'niy may be attached

Tei)Uired for du" alleniiilinjc douche. The water should fmX be hot (104° lo

m' K.) and Ihen abruptly (hanged lo cnld (jo^to 75°1''.). The hot douche

)h<<ulr| loulinue for one or two minuici and the cold not lunjter ihan I'dteen to

.Ihirty M-«iini|t. 'f'hc bath may aUo he j(iven by rapidly nhernating between hot

il colli for one or iwo minutes "^-ARain. the jwlient may resist the suddtn

of tetniHTaiure Ijeltcr by slandiiiK in ii fooi id water at 100" F. The

mu«t !«■ h)ll(iw<fl by viKiirou." friction wilh a coarse lowel.

The Scotch Donche. 'nu* douche U "a <.howcr-bath. in which the

jtempcr^iturc, :it the Iftginniiin, U about 86° F,,anil i> (gradually nii^ to iii" F..

hlch is about as hot uf^ can t>e b<ime; this is (ullnwctl immediately by a douche

■>ul aft void MS ice. The dutaiicm of the douche should l»e very brief (ten lu

aiy oecond*), and iihould l>e pre4-ede<J by uilive cxerci«e." (Dr. John V.

nietnaker.)

The liHth should be followed by %ir;orou<i friction wiih a cotirse towel. The

Pbnt lime bi take the douche i« in lite morning on getting up, or Ltc in the afler-

Mn.

THE SITZ-BATH.

, spriiiil form of tub whiih i> usually niade of zinc or tin i* re(|uirftl. The
' Khiiulil rva< h ju hiith as t))e umbilii*u» and Ihe p-tlient :th<>uld t>c i>futecte<l
from cold by having a ughl woolen bLinkd
Ihniwn anninil her.

Tl»e iKilh may be given as f(ill(fws:

Cold. Hot. Crjilualed.
Action.— -A (otd >)!/ I>alh In stimuUt-
IIm til the {■rK'ic ami atKiominnI organs; n
Ibiit )Hih ii. ^cdkitiiT.

Cold. — The iMth !th»uld n>H lie prt^rdol
by rxeni<c ami i^ Liken in ih<- aftrrmKni
unle«* there are sj>ciial thcr4|*mic reasons
^dw taking il .it Mime other time. IIm- water
uM be frf>m 50° to ■;$" p. and the duration
the luiih should I>e (mm ten lo thirty
itu(e«. The pHlit'nt fjMiuld he quickly
aften«-apd ami allowed lo rest for half
m hour l>cf'ire dre«Mng.

Hot. The balh should not l>cprecede<l by
eritM- ami is u«un!ly taken at Iwdtimc, TItc

»ler muM l»e from to.i" tn 114" 1'-. and llie duration of the bath shouU l>e from

■rnty to ihiriv minuirs. The patient is tiKn quickly dried and pbced in 1>e<l>

GfBdnated,— The twlh should mn \>r precole<l by eieni^e and is taken.

^rule, at InHliiiivc. Tlic iem|HTalurc of the water in the licginnini; mual be

fte. Ml.— !ii>i ■•'•I ^^'^• Maui mTM.

HYDROTHERAPY.

loo" F., and the patient then gradually adds water at 50" F. until she begins
feel chilly, which is usually in about ten or fifteen minutes, when she is quid
dried and placed in bed.

THE TURKISH BATH.

The hot-air or Turkish bath may be taken at a regular bathing establishm
or at home.

Action. — The bath eliminates waste products and toxic substances fr

the system and increases tissue changes.

Technlc. — The method of giving a Turkish bath at a regular bath
establishment need not be discussed here, as the attendants always carefi
instruct those visiting these places for the first time.

In order to take a Turkish bath at home a specialty constructed apparatus
cabinet is required. These cabinets are made of many different materials i
designs, but they are all essentially built upon the same principle. Some of
cabinets on the market are, however, more simple in their construction tl
others, and are consequently better adapted for general use. Figure 103 re|
sents a square cabinet which is very durable and serviceable. It is made c
steel frame with a double covering of rubber sheeting, and when not in usi
may be folded up and placed out of the way. An alcohol lamp which comes fl

the cabinet supplies the heat. '
lamp, however, is very incon\'eni
to use, and sometimes dangerc
and a small round gas stove, wh
can be bought in the shops
25 cents, should be used in pi
of it.

My method of arranging
interior of the cabinet is as folio
I. A wooden kitchen chair v
the back sawed off is placed
the flocr in the center of the a
net.

2. A round asbestos pad is pkiced on the floor immediately under the ch

3. The gas stove, which is connected by rubber tubing with a gas bumei
placed upon the pad, while another round asbestos pad rests upon the top of
stove.

4. A folded bath towel is placed on the chair and aUo on the floor for
feet to rest upon.

The amount of heat required can be readily regulated when a gas stove is u:
and there is also no danger of an accident from fire, which is not the case if
alcohol lamp is employed.

The bath should be taken in the afternoon about $ o'clock cr at bedti
It may or may not be preceded by exerci=e.

The technic is divided into the following steps: (i> Heat the cabinet
ten minutes before getting into it. (2) Before entering the cabinet drink om
two glasses of distilled water. (3) Remain in the cabinet, as a rule, for fift
or twenty minutes and place a lowel around the neck to prevent the escape of
air through the opening in the lop of the apparatus. (4) Immediately a
getting out lake a hut shower, needle, or spray bath (104° lo 114° F.) lasting
minute and then rapidly douche the body with cold water (50° to 75° F.).
Dry (he skin with a coarse towel; drink one or two glasses of distilled water; ;
either rest for half an hour rr go to bed for the night.

Fio. loj.— RouHn Gas Stove ro» FlEAitNo * TvmiiSH
Bath Cabinet,

THE RUSSIAN BATB — THE SHEET BATH.

Usually the body begins to perspire in about five minutes after entering the
cabinet; thcfacein ten minutes; and from that time on the perspiration becomes
fieneral and profuse. The duration of the bath varies in individual cases, as
some women require a longer lime than others to produce free perspiration.
When the vascular tension b increased sufficiently to cause a feeling of fullness

Fio. loj. — Tee AmoB's Mfmoo or Ahamoimq ihe lNre»io« o» a Tdmish Bahi CAmiNn.

or tiiTobbing in the head, the patient should get out of the cabinet at once; a
pulse-rate of 120 is an indication that the bath should be stopped. Sometimes
a cold compress placed on the head is not only grateful to the patient but it
makes her feel more comfortable while in the bath. The frequency of a Turkish
bath depends upon the strength of the patient ami the indications for its use.

THE RUSSIAN BATH.

The steam or Russian is the s;imc as the Turkish bath except that vapor is
fubMituied for hut air. The same cabinet i> used for both and their technic
i' alike in ever)' [larticular except that a tin or lojiper bi>wl containing one pint
ui water is pbced u]ion the asbcstiw pad on ihe gas stove to generate the steam.

THE SHEET BATH.

Action. ^Thc bulb is stimulaiini; and Ionic and is especially indicated in
neurasthenic cases and in women who become ]i!iysicallv and menlaliv exhausted
inm brain work or seilenlarj- habits.

Technic— The following articles are requirefl: A wash-tub half filled
with water and cracked ice, a muslin Ix-d-sheet, am! a towel. The sheet and
towel arc immersed in the ice-waler for five minutes. The patient removes
all her clothing and stands atong-^ide of the tub. The nurse now takes the
sheet out of the water, quickly wrings it liry, and wraps it completely around

HYDROTHERAPY.

the patient's body. She then wrings out the towel, and holding it in the ri
hand rapidly slaps the entire surface of the body. The strokes should be qi
and sharp and kept up for one or two minutes. The sheet is then removed,
skin quickly dried with a coarse towel, and the patient wrapped in a woe
blanket and allowed to rest for half an Imur.

Klc;, 104.— SutET Batm.

The nurse may use her open hands as a sulratitule for the towel to stroke
surface of the body; the movements should be short and rapid and sulfide
hard 10 produce stimulation. G»kx1 results are obtained, when the patient
afford the expense, from general massage given immediately after the bath
followed by a rest of half an hour.

SALT BATHS.

Action. — Artificial lalt water bathing produce." a powerful impression u

the skin and stimulates the cutnneous plands and nerves. The effect prodi
upon the vasomotor nerves is transmitted to the central nervous system,
from there its influence is felt by the respiratory and circulatory organs. J
result the act of rcsjjiralinn is stimulated and the blood -pressure is increa
causing corresponding changes in tissue metamorphosis and in the characte
the secretions and excretions iif the Ijodv.

The effects produced by salt baths also depend upon the temperature of
water. Thus, a cold bath is stimulating or tonic, while warm or hot salt w
baths produce a sedative action.

Technic. — Salt baths may l>e taken in the form of a lull, halj. or spi
bath. A full description of the technic of the=e methods will be found ui
their respective headings, the only difference being that 2 per cent, of sea
is added to the water.

SKA lUTIIINC— TBK VACIKAL UOUCtlE.

SEA BATHING.

Sen liathin): k a valuable adjunrt in the Ircatmcnl of g\-nccolngic diMaim.
The ^limuUtiitjc effect of ihe mid plunge, (he extrcist in jwiinming, and the
lonMant moli'm rc<(uir(il wliilp in llic txtri art as a tnnic to the iccneral uuiriliim
liy >limtibtini; t)i« lis^uc chaDgcs and promolin}! the climinulinn of wastr pro-
ihm^ ffm the ^yMcm. Th«c lienofu iiil resuli> ;irc *tiU further trnlinnced by the
itianjiic id sri-i»r, diet, nnd ;iir which the p:tticnT enjoys al iho seashore,

A sea I>ath niuM be followwl bv prompt rfuuion, otlierwiw thf results are
deprcwinK and injurtmi^. Ilic Kcneni) Inw already rrfcrrctl I", whiih Kiiverm
tb« cffet'l of a prclongcd application of totcl in ihc ^url.icc of the body must be
borne in mind ami the patient in^irutied u» to die leni^th of the Itath. The
tendency to remain ton long in the water «hould be Kuardcil .itpiinM and the [lalient
inti»l lie hdd to leave tlw bath to won as she fecb the slightest scDsatioD of chilli-
ntM,

The geneml condition of the patient &houtil be taken into consideration in

(Irierminin); ujion the frc(iucncy of the lMth>. Some women may bathe every

' "lit ■njitr»()ii> elTocln, while oihcrc ii^jin ■'liould not take a. Iiath idtrner

" ■ i>thcT day Of twite a week. The Icm^ierjiurc of the air and the water,

the stitc of Die weather, :^h<)ukl aUu be ciui&idered. as the reactinn i*

nipt and vigorous, ai) ihiniis l>einge4|U3l, on .1 clear uurm day than when

li^ <.ky i^ cloudy ami the air chilly. The {ciiicnt should keep in motion while

in the water, as the muscular exertion IcJoiens tlic dcprcssinn c(Tc(t% of the cW

itwl favuni reaction. Women who arc weak nr who naturally react badly after

•I raid plunfie •'houhl be prriwred for nea bathing by usini; graduated batlu for

Fcveral weeks liefore jcoinx t» the lea.^hore.

After the patient leave* the water 5he should ro at once to the Itath-hmuw and
B>A loiter about in wet dothinf;. Tlie >kin -^houlii tie quirkly drieil with 4 coarse
lunel, and if rr.mton i* delayed or the patient feels a sensation of chilliness
alter dressing she shoukl take a brUk short walk.

THE VAGINAL DOUCHE.

The Vftginal tb^urhe i> one of the mint valuable aRcms we posKss in the treat-
ment ol diMiises of the jwlvis ami the vagina, and >'et. tiotwithsumdinx the Ire
i|ixncY of its use, there is no remciiy that is so commonly misapplied. The
iUelUgrot u>e of (he ilouchc require? not only a knowledge of the physiologic
aition of hrat ujion the blood-vessels and nerves, but also a careful attention m
the details of the tcchntc of ii>t ad mint't ration.

Action. — The Im>1 ilouche acts as a vasomotor stimulant and causes
' 'n of the blo-id-ves-Hcls. The warm d<(uche prmluce^ relaxation of the

: nerves, ilible:i the bkxid- vessels, and increase* the congestion of the
^«itA. The douche i* .»l«> enip|o)-ed in a mwlicaiwi form in the ifeatment of
iKinal disease, nnd. I'lnally, it i.-i urfil for |>uri»o!*e> of ileanlincu.
Apparatus.— 'I'bv following; articles are required:
I. A rc^noir.
>. A dourhe-ftnn.
3. A receptacle for the owrflow.
I. The icscr\'nif, a, should hold al least one gallon of water and be suspended
( ... ( _. ;,(y,yip ,1,^ |«iiem. It i,i made of ;i(Bitewarr or steel ami tu* a spout near
in to which is altaclicil the Tuh)>eT itouching tube, .\ glass iioealc, b,
WU& u(icoinp El the cikI is attached to tlie tul>e.

HYDROTHERAPY.

3. The douche-pan, c, is made of metal with a small spout near the bottom
which is attached a rubber tube for the overflow.

3. An ordinary wooden or china bucket is placed on the floor lo receive t
overflow from the douche-pan.

When a patient lies lengthwise in bed or on a lounge the douche-pan is plac
ufK>n an ordinary ironing-board which i.s put crosswise on the bed under I
hips to prevent the springs from sagging and interfering with the overflow ii
the bucket on the floor.

Kelly's surgical pad is substituted for the douche-pan when the injection
given with the patient lying crosswise on the bed and her feet supported by t
chairs. In this position the douche may be given by the patient herself or b;
nurse. The reservoir and the receptacle are the same as described above. T
method is as follows:

An ironing-board is placed lengthwise on the bed under the sheet and I
surgical pad laid over it. The reservoir Is hung four feet above the bed and 1
bucket is placed on the floor under the apron of the pad. The patient now 1

Fic. 105. — Apparatus Used in Duuching the Vagina.
The rubber lubing ithich ii utschcd lo the roervolr and averSow ol Ihc doochciHa aocj the bucket *n

crosswise on the bed so that her hips rest upon the pad and her feet upon
chairs. She then introduces the nozule of the irrigating tube into the vagina :
allows the water to flow from the reservoir. To prevent catching cold a Ii
woolen blanket is thrown o\'er the abdomen and lower extremities.

If a surgical pad is not available a piece of rubber sheeting and a bath to
may be used as a substitute, as shown in figures 16 and 17 on page 26.

A surgical pad should always be used when a douche is given by the physic
in hi.'i office or when the patient is placed nn a table.

Technic.^The vaginal douche may be given as follows;
Hot. Medicated.

Warm. Cleansing.

The Hot Douche.— P osition of liie Patient . — The pat:
must assume the dorsal posture with the hips raised on a douche-pan. In
position ihc vaginal vauh will he below the oritice of the vagina and hence
water will be in direct contact with the pelvic organs during the administrai
of the douche. When the injection is givtn in a stooping position, the w;

TBF VACINAT. DODCOF^

cannnt reach (he upper part of llie vagina and <'onM^qucnlly the direct efTeci of
ihv hnt IK Umt.

Temprraturc of the Water .—The water rousi be between i lo'
orul iio'^F. Our object i» t<>«)>iainihcMin>ulailn)(effect.'iora hi)(h lemjierjilure
upon the ira.vminliir nertTS and ihc blixxl- vessels, and hence the use of tepid or
warm water is cnniraindicatcd unle» we desire to liring more Idood lo the peine
nrgani. The utiC «>f cold vaK>nal rloiiche^ is injurinui'.

Duration of the Douche.— The length of each douche must be
fn'tn fidcen m iweniy minutes. The ([uamity of water w therefore reflated by
the rapidity nf itn- ilciw , The ohjeil of a hut douche is to nbtain the steomtary
tS*'t of beat and the |)ermaneni stimulation which follows the prnlongcfl ap-
pl»(3lion of A hi];h deforce oi tem|)erutuns n>iiMr<iuently it i>> not necesKoin- li>
emplify a hiMvy Mre.im of water, an a small one will answer ever)- purpose and
obtiflie the necessity of hanng a large rcM^rrair. As a rule, from one tu two
plinitt of water will be nulTicient fur each iJouche.

7?,

HDvcn Tin ConciTT (a> wi< iHcvaact Ttmrtaii (t) AMvvnt at a Pkiucn n
nnumiin: ntt Vaoihji,
I Ik* nilfin in ik> ilniuJ nwtlnfi (formi) and Iht >ifiB> ^KauirA irilh irun. tHacraoi h
tbDn ikr ptiiMR la % um^n* luKun (UKHtni) u<l the »«■■>*) <nU' colUcrf.

Tine of the Application. — The douche b moHi conveniently
Mwn trnmedtately after getting up in the morning and just before retiring lor the
night.

Frcquenc y,— As a rule, the douche should be pven twice daily; but in
•ame cases it may be neces-s^ry to use il three or four tim» a day or even con-
ttaaously for ncveral hours.

Duration of the Treatment . — The character of the disease and
thr iherapcutit in<ticatiun!i govern the dunlinn of the treatment, which, a!< a rule,
wiver* a ci)n\iderab)c lenj^h of time- Many cases. howe«r. are benelited after
wtag thr douches fur several weelci or monihjt, while othen again must continue
^tem for two nr itin-e yearn before permanent rcsuUs aw obtained.
^H^ Tlic WArm Douche.— The icchnic is the ume as that of the hot douche.

HYDROTHERAPY.

The Medicated Douche. — This variety of douche contains various remed
agents which are used in the local treatment of diseases of the vagina. T
apparatus, the position of the patient, and the time of the application are t
same as when the hot douche is used.

The water should be warm (95° to 104° F.) ; the duration should be about t
minutes; the frequency is governed by the nature and acuteness of the disea
and the iength>of the treatment depends upon the results obtained. Before usi
a medicated douche the vagina must be irrigated with plain sterile water
saline solution to remove the discharges, and if a poisonous drug is employe
such as corrosive sublimate or carbolic acid, a final injection of sterile water
salt solution is given to wash out the chemical and prevent absorption.

The Cleansing Douche. — ThLt form of douche, as its name implies, is u!
simply for purposes of cleanliness. The apparatus consists of a fountain syrii
and a basin. The syringe is filled with warm water (95° to 104° F.) and suspenc
upon a hook four feet above the floor. The woman now stoops over the bat
inserts the nozzle into the vagina, and allows the water to flow from the syrin
The quantity of water used at each injection need not exceed two quarts. T
best time to use the douche is in the morning or at night. As a rule, one doU'
a day is sufficient unless the woman has a profuse leukorrhea, in which ca&
may be given more frequently.

If the injections are given by a nurse, the same apparatus is used as whe
hot douche is employed.

THE INTRAUTERINE DOUCHE.

Action. — The hoi douche acts as a stimulant to the I'asomotor nerves,
bloo<] -vessels, and the muscular fibers of the uterus. The medicated douch
employed in the treatment of septic conditions of the uterus and after intraute:

operations.

Apparatus.— The foil
ing articles are required ;

1. .\ reservoir and thenw'
eter.

2. A returnflow dila
catheter.

3. A surgical pad or a doui
pan.

4. A receptacle for the o
flow.

I. The best reservoir
general use is a fountain syr
holding three quarts of wj
In hospital practice a gradu
glass reservoir and a comt
tion thermometer is the
form of apparatus to emplo
3. The catheter showi
simple in construction, and tl
fore easily sterilized and
likely to get out of order.
return flow is readily regulated by a screw, which expands or contracts the
heavy wires that are placed parallel with the inflow tube. The catheter is
nected with the reservoir by the rubber irrigating tube.

Fic. iD^r— Fountain Svunce wfTH a Glass Irrec.ating
NuZELE Attach EP.
\\'hrn the ayrinflc u u^ far ^i-iag an inlraulFrior douche
a reium fluw caibrlcr (Tig- 109) is sulaliluTcd for Ihf glau

3- The fiUTKical p«t or the douche-pan is the tineas described under vagirul

4. The reecplAclc fnr the uvcrflow cx>nsi&ls of an ordinary mctnlllc or diiia
liUfkrt.

Tecbnic— If the lalient Li very n-eak »he inu»t not be diiilurbed, And
oMwcquenlly she should lie lengthwise in the bed with her hips rcstinc on •

t-fian »nd her knees dnvm up. The end of the overilow tube fe then
fkati ill iIht twikci on ihc lloor und ilie rocrvin U held by un u^isiant four
Irtl jUive the \k<\.

If the [uiM-ni is MronKenouKhloinove, the douche may be more oonvcnicnily
|)<Fn with ihe wnninn lyinu cro»Awise on the bed and her (eel supported by two
iJbif> or ndjuvluhli- Irg -holders. An ironing-boanl ii placed lcnglhwt» uKMig
1^ edge of the bed and a uir^cal pad laid upon it. The patient b now placed

no. •e*. — Rnnaii-rLow Ditanm C<THm>.

<Blhol her hip« rni utH>ii the pod and her feet on the chuirs or in the adjustable
trt-h<)liler». The butkcl n then placed tm the Door under iIm pad und an auist-
UR hukln the rrser«vir four feet above the bed.

'^i-n*K>n:tlly it may be very diHtcuh or e\-en impuraible to introduce the

iVirr with the patient lyin|t in bed, and ronjcqucntly ib*.- should be pbcedon

> aitchen table in the <li(r«al (loeition with brr hi[» rrfttinit u^ion n surgical pad.

HYDROTHERAPY.

If the patient is lifted carefully from the bed onto the table, no harm will res
even when she is very weak.

Having placed the patient in the proper posture, -the physician then inl
duces one or two fingers of the left hand into the vagina and locates the Os ut
Holding the catheter in the right hand, he now introduces the instrument into
vagina and, using the internal fingers as a guide, passes it directly into the utei
cavity up to the fundus.

Before introducing the catheter into the vagina,, however, the assistant id
allow the water to flow through the instrument; otherwise air may be carried i
the uterus. After the catheter enters the uterine cavity the physician withdn
his lingers from the vagina and the patient is protected from catching cold
throwing a light woolen blanket over her body and lower extremities. When
douche is finished, the external organs and the hips are quickly dried with a :
towel and the patient made comfortable in bed.

Fro. lie. — IimoDDCiKa * ^ai^hh* ntro m UTtum Cavttt.

The Hot Douche.— Temperature.— The water must be bet»
I lo" and 1 ao° F. Q u a n t i t y. — The amount of water required depends v
the promptness with which the e£Fects of the heat manifest themselves; u.<n
from one to two gallons are sufficient. Frequenc y. — The frequenc
governed by the subsequent indications.

The Medicated Douche. — The medicated douche must always be folio
by an in jection of warm sterile water {95° to 104° F,) or salt solution to wast
the chemic agent and prevent absorption. Temperature . — The w
must be between 95° and 104° F. Q u a n t i t y.— The usual amount of «

required is between one and two gallons.
controlled by the subsequent indications.

Frequenc y. — The frequeni

ICE-BAG I HOT-WATER BAG t COHPRESSES.

Action. — The use of an ice-bag or a hot-water bag enables us to ma
continuous local application of an extreme degree of heat or cold, and cc
quently its action is stimulating to the parts over which it is applied. Or
other hand, however, when a hoi or told compress is first applied to the sui
of the body its intense degree of temperature aas for a time as a stimulant,

ICE-BAC; ROT'WATRK UAO; CUUPRIISSES.

bteron a Mdaliveand rcbxint; adkm is produced bythi.- continuou.v .-ipplicntion

of a modcnlc iem[)emure nunbiitcd with the warm vapor (hat is gradually

^eneraied by the btat of the body

and the moiMure in the fotnentn-

ttOQ. In other w<mJ», a cnmprc^

ewtntttftl^ produces supcrificLil

h^-pemnb and BCti> a:* a poul-

ike.

Ice-bag.— The rubber ice-
iof shown !■■ the moj-l ronvenieiit
one to use. The bag b filled
vith cracked ice, which should
not be ton fine, ii* large ptete."

longer to melt. Ucfore screwing <»ti the cap ihv air is expelled from the

Fuj ICC —It I Hrti-'

/-^

(•) AND C"»«tei McntaD (*) o» Awmwe ts Imiaq,
It doMtvled with ur iiul Aoa mA adjttJt itvlE ta ihi RUif^tr al 1h* UtAy,
fa fi^lkd hrJcfTv Krfwinaon Lh# caiJ and Ihp t>aj( huiriEhr [nrtBfloirly.

lag by squeezing it in the left bund. If ihr< i% not done, the retained air inflates
the h^ and raalus it difficult to adjust and keep In place.

The Ita}; is plated directly on the >kin and allowed
to remain (or an hour or more, or it may be applied
several limes daily. Soniclimcs ibc application is con-
^^^^ tiniiwl without iniermissiun for several hourii al a lime.

V^V If the skin b M:n%ili\'c or the applicaiiim i» pmionged.

the tuiancous surface .should be protected by four layers
iif mu'lin |il.ii-{-il iM'iivrrn it anil the bujt.

Hot-water Bag. The hot-water bag shown fe
miule i>t nihlKT and >"!d in the drus-sliops.

The Ikik i^ tilled with iKiiling water or with water
coming directly from ihc hot spigot. The water mu.st
\)c vcr>' hot. otherwiM; the eftwi ftf a hiRh tenii)eniture 'n
not obtained. The surface of the bod)- must always be
protected by placing flannel around the bag; very scwrc
»kin bums hai-e l»een caused by neglecting ihi* precau-
tion.

An ordinar>' beer boitle or a hot .Mow plaie en-
Tct»|>ed in tlannt-1 i'' a ^hhI subMilule for a hoi-waicr
bag when the latter is not available.

Compresses. — Hot and cold compresses are ap-
pGed to the abdomen or die lutnlms-icral region. They conw*t of towels,
doth*, or surreal lint wmng out of water and covered with oiled silk or rubber

nt. 1 1 J. — HotnAn* be.

HVDROTHEEAPY.

sheeting to prevent evaporation and to retain the temperature. A compre
should consist of several layers of the material employed, otherwise it will n
be thick enough to hold the moisture or the temperature for any length
time.

A cold compress is soaked for one or two minutes in iced water and tlu
squeezed dry with the hands.

Fio. ir4- — McmoD ur WitiHaiNO out a Hot CoimEss witbout Scalddw tb> H'U(1>s.

A hot compress is dipped into water that has been brought to the boili
point and then wrung out ven.- dr\-. Unless the moisture is entirely remo
the skin will be scalded and a bad burn will rcsuh. A simple method of wring
I ui a hot compress is to pick it out of the water quickly and drop it into a toi
which is then twisted tightly upon itself.

The physician or the nurse should first test the temperature with his or
hands before applying the fomentation to the patient's body.

TATER-DEINKING.

The importance of water-drinking as an auxiliarj- in the treatment of disi
and its intelligent use as a part of the daily routine diet are frequently overlool
and patients are seldom instructed as lo the quality, quantity, or tempera'
of the water which they drink or the marked differences in its effects when dr
with the meals or upon an empty stomach.

Action.— Abundant water-drinking acts as a flush, so to speak, to the ei
system by increasing the quantity of the walen- and solid constituents of
urine, stimulating intestinal peristalsis, favoring perspiration, and enhancing
excretion of carbonic acid and the absorption of oxjgen. As the result, there!

WATrit-DRtNKINC.

of these iinpressioiis upon the organs of (hr hndy ihe prnduclK o( retrogressive
ritrinr cfaiuige are climinaied, and the wa^ie materials letained in ihe (issues, as
well as lime and other t»hf, are removnl. Tliesc r»ulu <te|>cnil not only unon
ibe quaniity and quality of the water, which are undoubtedly the prinapal
tacton, but akto upon il> teni]>eraturc when taken into the stomach. Ac-
<erduig to GUx. the local and general effects <>i heJil and cold arv similar whether
tbe application b made externally to the stin or the fluid is taken or injected
tiMo a cavity of the buily ; thus, wc ftntl that hot and (-old water when taken into
the stotnach differ in their effects in preciHrly the same manner as when a high
or Icnr temjierature U applied to the skin.

Quality of the Water.— It i* imixrativc Ihiit drinkine water should Iw
pore and that it should contain no pathogenic germs or mineral matter. The
DCcesMty for u^i^g water that is free from germ life U widely anpreiiatcd at the
present day. as the in^Tstigalion of the causes of typhtnd Cc^Tr, cholera, and other
rateric clborders Ua& fully demonstrated the imponani r6le which impure water
pb,«-s in tbe ountion of thex; anil kindred di.seases, V'n fortunately. li«we\-er. the
opinion prerails that if we use a water free from germ life or one that has been
made *tetile liv boiling there remains no necessity for consideriiiK fiirilier the
question of quality. Tliiv view, howe^fr, is only li.ilf nf the trutli, and it has been
Te«p>'n.-ible in the past for overlocikinR the injuiious effects produced by using
»-aler that contains mineral nudter but is otherwi.'ie pure. Furthermore, a
OOiraon idea preraiU that the mineral sahs of water »n required for the proper
■aimenance of health, and that if a water is used which docs not contain these
•aJts the initii'idual mast necessarily -.uffer physically. Nothinfj^, hnwevcr, can
be further from the truth, as the fiHKJ we eat supplies in abundance all the mineral
Mlt> rerpiired by the system. This statement is confirmed by the experience of
the AntiericaQ Navy, which has lieeii using rll.'tiilled ivater enclusively for
dfuduBg purposes for several years, with a marked improvement in the health
of the men attached to the service.

Water rK't only arts mechanically a.< a flush to the genenil system, but it al«>

niDOves the impurities and the earthy salts from the tissues by virtue of its

Bohmi prn|>crtiev It natiimlly follows, therefore, that the jnircr the water, the

grcaier its abwrbent jMiwer and the more thoroughly will it take up and remove

ibec ult5. The power of a))«or|>tion posses.sed by water is in diretl proportion

10 the smouM of miiKral matter it i-i>ntainj«, and ron.tequently it i^ a matter of

^^nt unportance for us to know the chemic properties of the water we drink.

^Hl'atef that » free from mineral matter possesses powerful ahsor1>e»t (|u;iliiies,

^Bnd when taken into the system it beaimes saturated with the impurities and the

^Kuthy sahs which are deposited in the tissues and carries them off through the

^eacwtory urRiio' of the Ixxly. .A hard water, on the other harul, i.i more i)r less

ntontnl with mineral s:dls. and ant^^^uenlly its absorbent fHjwer is greatly

EinElcd or attc^^ther destroyed. The absoibeni power of pure water may he

conipsred In a fre*h bloltinK-|>iul, which, as we all know, will lake up quickly a

larite qnaDtiiy of ink, whereas a blotter that has been in use is slow and limited

it> aciioD.

Il is almost impossible to ovcrntimate the ill effects of drinking water thai
mineral matter. The various salts of lime become deposited in all the
and e\-eittually calcareous clianges liike piice in the blo(Ml-\'es.sels and
•iUM of the body. The excretory and <ecrctor)' organs become sluggish and
a Rmg li*! of diseases results which are directly traceable to this cause.
UonoTier, in many in-itances old ^ge ap)>ears prematurely, as tbe general
ftitcfn beiromes so encrusted with these su Its so to »pcak, that it is unable lo
pafutm it^ functions properly.

loo

HYDXOTHERAPY.

Distilled water fullils all the requirements of an ideal drinking-water, an
should therefore be used as a daily part of the diet in preference to all otht
waters. It contains no bacteria and consequently cannot transmit the specif
germs of disease, and as it is free from earthy salts and solid matter its solvei
properties arc unsurpassed. When, however, this water is not obtainable »
should select as a substitute one which contains a minimum amount of sot
matter. There are a number of good natural waters on the market that are fn
from germ life and which contain but a small percentage of mineral salts as shov
by the analysis of their chemic properties.

The custom of using filtered water for drinking purposes cannot be too strong
condemned, as filtration does not remove the mineral .salts which are held
solution; consequently the water has poor solvent powers and does not re mo
the lime salts from the tissues. Furthermore, the domestic filter requires co
stant cleaning and sterilizing, otherwise the bacteria which accumulate in t
apparatus increase the likelihood of germ infection. Boiling filtered water wi
of course, destroy this danger, but it does not remove the earthy salts.

Fm. us. — EicTiMiAL View. Fio, 116,— Settiomai. Viiw.

The Pariaelee Sth.l.

Special Directions.— Distilled water may be bought from a re
or wholesale druggist or from a company that makes a business of distill
water for drinking purposes. Water from the latter source is preferal
as il is handled with antiseptic precautions, aerated, and put up in conveni
size bottles at a lower cost. While this water is uiuaily reliable and up to
standard of purity, yet the ideal plan is ti» have a distilhng apparatus in
house, as we are then not only absoluleh' certain of the quality and freshnes:
the water, but we can produce it cheaper.

The best apparatus for this purpose, in my judgment, is "the Parmi
Automatic Aerating Water Still and Sterilizer," which I have used in my <
home for several yeans and which has supplied all the drinking-water used
the household.

This still is simple in construction, automatic in action, and may be opeit
wilh either gas or oil; if the latter is used, a blue flame Primus or Khotal

WATSS-PltlNKIKC.

tot

BW khouli) ttf «fn[^yed. A*' Itir wiiU't issues fr«m iht still tt if coUccicd in a
Urgt glass biktilc, which is subspqucnlly i:i'rkc<l wilb n tllnt^ slitpprf :in ihat there miiy
almv^ I»c plenty nf water on hitml. 1"lie Ixnile* muM l»e Meriliw-sl \>y boiling
befiire ther are refilled.

II. u^ lus lieen already staled, dislilled water it. not alitainable, we may u«c
oi»c of the natural waters ct>ntAining a minimum amount of vanhy matter.
Th* rollo«-in)C waters which arc on the market have been analyicd to delermine
the numt)er of grains of M>]i(I material tn the gMllon (U. S.):

New York : Thr Colonial Sprinitt ul I-uhk l«liuidi .......... i.jo

Mainr: Tbr Pulnml Spring. J.76

TV IIJEhUnd Sprinip - 4>7t

UuHcfauaelU : The CoRHnocKt-jlih Mineral Spring t^S

Thr Mauawiil Spring. J4J

Ttie Nohseot Mountain Spring •.■3->i

Adtnislstratlon.— A i>crson in niirmal health »li()util drink fmm ime to
two iju^ns or m<tri- oj water <l;iil>'. It is a kiiikI nmiinc pradice to drink a slan
nf water immeiiiitlely ii|H>n grlting out <>f J>e<l iti the mornint; and just before
miring for the niRhi. 'ITic water taken in the morning ciciir' the muru^ from
the stomach, stimulates the ijcri.-taliic attion of the bowels, and improves the
aplidtic ai«l ((encral toiw of the system,
()ni> a small quantity of water should be
takrn at mraU. as a br^c amount dilutes
the diKf»li»« lluicls aivd cauM;s dysiwp^ia in
those who have weak stomachs; this Is
e»i>ecijilly true of ite-wator, a^t the action
o( <iikl uixler the tircum^ land's retards
di|Ce«tii'n. Ill addition, exi-euive drinking
II mrabi is often Ibe cause of obesity in
tJvise hams a natural tendency' to ac-
niinuLitc fatty tissue. It » im|K>nanl
tlul the largest t<an of the daily consump-
tion of water should be drunk when the
Honuich in empty, and at least one hour
ud a li4l( ybouiil elafisc after eating be-
hn drinking. Water may, howciTr, be
4rank a "Iwrt lime Wore meat, as it is
-orfwd. aivl hence does not mix
[.-.xl ■iuli^4.-<|uenily taken into the
Mum^ich.

In rei^ulatinR the use of water in an
bdividuul CSKC we muM l>c xui<ted by the
palholoeic c«)n(Iitions prr^nt and by the
pfTMinal imutiaritks of the patient. This
nuumlly a|>)ilie> tnore e^iwcially to the
■fiantity ami temperature of the water as
■ H ,s to the lime of iu administration.

I . , when hot w.iier is used as an aid to dif-cstion it must be drunk one hour
I'eioie eaiini; ami js hot as can l>e lH>rne.

The ({ue^lion of the purity of the i<ir which is used in cooling drinking-water
it an Imiwruni oik- not only when the water is cmplo>'ctl ihcrapeutioUy, but
kUai when it is drunk by the family. The ^'alue of dtsiillcfl water i» due la EU
freedom frum genn life and mineral matter, and if the ice cuntaitu these impuritits

5i'*toCHt4 Id cnii mil cuaa< iH IJI-
■UT Coittju:! win ivi lis <|iWf t*t}.

lOS CONSTIPATION,

the water becomes infected and its solvent properties impaired. It is important,
therefore, that the water should be cooled by keeping the bottles ic the ice-chest
or by using a special form of cooler that is sold in the shops and which is so con-
structed that the water surrounds the ice without coming in direct contact with it
(Fig. 117).

CHAPTER VIII.

CONSTIPATION.

The frequency of constipation in women and its evil effects upon the general
system, as well as its being the cause of many symptoms that are mistaken at times
for the manifestations of pelvic disease, make the subject one of great importance
to the gynecologist, and I shall therefore discuss it more or less fully.

Definition. — Constipation or costiveness may be broadly dehned as the
retention of feces from whatever cause.

Causes. — The condition may be produced by a number of causes either
of a general or a local character.

Among the general causes may be included sedentary habits, particularly in
women past the middle period of life; heredity; chronic diseases, especially of
the liver, stomach, or intestines; nervous disorders, such as hysteria or neu-
rasthenia; errors in diet, particularly that form of diet leaving too little residue;
and, lastly, drugs, such as opium or lead.

Of the local causes, there are: relaxation of the abdominal walls from over-
distention or obesity; atony of the bowel, which is most commonly produced
by repeatedly disregarding the desire for evacuation; contraction of the colon,
resulting from chronic diarrhea or dysentery; pressure from tumors, such as an
ovarian cyst or an enlarged or displaced uterus; and, finally, lacerations of the
pelvic floor which result in the formation of a rectocele.

Symptoms.— One bowel movement a day may be considered as normal,
but it is to be borne in mind that there are certain individuals who commonly
hai'e two or three movements daily, and, on the other hand, there are those who
go for days at a lime without suffering any inconvenience. As a rule, however,
constipation either of the temporary or habitual \-ariety usually presents certain
definite symptoms, as lassitude, headache, depression of spirits, loss of appetite,
a heavy or foul breath, and a coated tongue. In hysteric or neurasthenic
women palpitation of the heart, cold hands and feet, neuralgic pains, and a
sense of fuliness-in the pelvis during the menstrual periods are added to the
usual symptoms.

When constipation is prolonged more serious damage may result, as hemor-
rhoids, overdistention of the colon, the formation of ulcers, or perforation. As
a result of the accumulation of hardened masses of fecal matter (scybala) in the
sacculations of the gut, stercoral ulcers may develop from the constant irritation
of their presence. The formation of these ulcers may be suspected if the stools
contain slight amounts of blood or pus, or if in the case of an individual habitu-
ally constipated a diarrhea ensues. Another 'source of diarrhea in such cases is
the channeling or grooving of the impacted mass, and nausea and vomiting may
then accompany the other manifestations of the condition. Palpation of the
abdomen and rectal exploration will disclose the presence of the impacted feces.

Anemia of a slight degree is sometimes present in persistent constifwition.
In that form of anemia termed chlorosis, constipation of an obstinate type b
frequently encountered.

DIAGNOSIS— TBEATMEKT.

lOJ

IHsniosiS.— Tlw existence of conslipatioD, 05^ a rule, presents little dtffi-
ClHy. Ttir iini>i)rtuni \xnnx to be determined ii the exciting cause, for upon ibis
tkpciKl)^ its relief.

The nin»l common errof is to mbukc a ma» of fecat matter in the cecum,
or in (he hepatic or splenic Hextire of the rolon, for an alKluminul tumor. In
some iit^taoces aneurysm of the abdominal aorta has been dinimoc^ticated when
the puL-<iiion« o( a normal aorta were imfurted lo an impacted feral ma» in the
colon. PbcinR the ptiticnl in ihe Itm-c-chrM piwition, thus allowing the n>lon lo
tall away from the aorta, makes the diMinction itcur. Free purgation will cither
entirely remove the fecal mav-*^ wiih complcle di--^ipi»ca ranee of the tumor or
isake it evident ilut the cnn.<tipation was secondary lo pressure from a tunwr of
pennanent n.-iture.

Treatment.— In treating constipation the cKdtingcau«e should be remo^-ed
ifpossibte. ilaWn)! in mind that evacuation of ihe Imwels ii a normal and
OhiuU be a daily procedure, the ^imp!e^t metlncU of correclion >hiiu1d be

fnii-tised fir^t; recourse lo drugs should be the last resort.
n the I'lrii place, the patient should be instructed to po to the water-tlo^l erery
r' ficr b^rak(;^^l, as the bi>wcl fnMiucntly ac«niires the h;il)il of re^|K)ndiilg

1 lulus when this is persisted in. The sipping of a glass of hot w.-.ter at

bodlune him] aicain Iwfore breakfu^t in mber ca^es is often quite sufficient lo
bHnjiE .tbout the <lesired result. In ihosv, again, in whom (he tendency lo
nin>li[Kktion is slight the use of coarse-grained oatmeal, prunes, or figs is all
tlut to nece^'Viry to keej) the bowels open.

Diet.— An exclusive or nearly exclusive meat diet ts not an uncommon cause
erf con).ti[>aiion in that it kavcs bm Jiiilc residue. This may be counlcracied by the
nwof fooilit in which the residue after difcnt ion if( relatively lar|[c, .'tuch as t>ptnu(h,
rtlery, lettuce, com. tomatoes, and fruEis, as w«ll as the aiarsc- grained cereak.
Tbi:Te(nrc, in M:IeclinK a diet for the habitually conslipaleil ihtifc articles of food
poYnntng this property of leaving a large residue after digestion should always
DC dicMCn. Milk, in so many res|H;cis an ideal foo<t, is not a f:ood article of
diet fur the con*tii>nli-fl, a5 it i» open lo ihc great objection nf leaving but little
miilue, ami thus either directly causes or increases the tendency lo conslipation.

Ezerciae.^.\i .^erlentan' habits are amnn;; the most frequent cause* of con-
stlpatbn tt>ey shouM be corrected and the patient instructed to exercise in Ihc
open air by riding, walking, or cycling. Indoor exercises are also beneficial,
(tpectally those affecting the alxlominal miwcles (seep. 117), and they should J>e
taken for a few minutes ever}- night and morning. General massage also gives
liood retuU.-< jnd the pcriMJiUic action of the intestines should be siimulalcd by
deep knejdin)! of ihe altrlominal muscles.

Dross.— The great objection lo ihc ufc of drugs is the formation of a habit
or lotemiioQ. thus making the const i pa lion worse. To the large number of
psriptivT and l3Uli%'e dnigs this objection holtis good except when lcm|»)rar>'
evacuation is desired, as preparatory lo a surgical operation, or when temporary
unlootling of the bowel k indiratetl for other reasons. Thus, rhubarb and
castor oil if habitually used ultimately increase conslipation, and mcfcury dii-
onkr* the digestion and injures the teeth.

WTien constipation is due to atony as a rtJiill of deficienl Innervalfon of the
intrtiincs the u*c. for several weeks, of a pill containing nux vomica and belb-
donru will pro\T beneficial:

R. F.itncti nocii vntnkv ■ p. I

Kiinrti MLidnnnc •.>•>>>.••> i 0. fm

U FlptLor. l

SJg.— To Im Uk«a at hc<ltInK.

104 CONSnPATION.

To the above pill may be added aJoin gr. ^ if it should be desirable to increa:
intestinal peristalsis. This drug, however, should not be continued for too loi
a. period of time, as it has a tendency to produce atony of the bowel. Neithi
should it be employed by pregnant women nor by individuals suffering fro:
pelvic congestion, from hemorrhoids or other forms of recta! irrilation. When
is desired to increase the biliary flow and thus increase intestinal peristalsis, tl
pill of belladonna and nux vomica may be much increased in efficiency by tl
addition of podophyHin, gr. |.

Of all drugs for constipation, perhaps the most satisfactory is cascara sagrad
It is unattended with griping, does not increase the tendency to costiveness, ar
may be used for long periods at a time without producing toleration. It is be
given as the fluid extract in doses of from lo to 30 drops, or in pill form, in cor
bination, as in the following:

If. Extracti casrane sagradx, S''- 'J

Exirarti nucis vomica, S""- 1

Extracti belladonnie,

Aloini

vfl Reainff podophylli,

M. Ft. pil. no. i.

Sig. — To be taken at bedtime.

■IT*

Aperient Waters.— The best known are the Congress, Hathome, Saratog
Carlsbad, and Fried richsha 11 waters, any one of which may be given in doses
from six to eight ounces; /. e., an ordinary tumblerful. This dose, however, mi
be increased or diminished to suit the individual case.

The great field for the use of these waters is in that class of women who suff
from so-called hepatic torpor, or congestion. Such individuals are usually pa
the middle period of life, are high livers, take too little exercise, and are of tl
apoplectic type. As a result they usually suffer from constipation and a catarrh
inflammation of the gastro-inlestinal tract.

When it is desired to use an aperient water for any length of time the do
should be so regulated as to secure an easy and copious evacuation daily, lar;
watery movements being avoided, as they become exhausting. A half glassf
of Hunyadi Janos, for instance, diluted with tepid water and taken before brea
fast will usually secure the desired result. When the use of such waters is a
companied with griping pains, as sometimes happens, the addition of ten
fifteen drops of spirits of camphor or of chloroform will usually obviate the d
ficulty.

Individuals of the class just referred to often derive great benefit from a vi
to some one of the well-known mineral springs, such as the Saratoga Springs
New York or Carlsbad or Marienbad in Bohemia. The taking of these wate
with its attendant free purgation, the prescribed exercise, and strict dieta
regimen to which jratients are subjected, result in benefit often felt for mont
afterward.

Suppositories. — Suppositories should be resorted to only for the tempora
relief of constipation and should not be relied upon in the treatment of the hab

The official glycerin suppository is efficacious and may be employed to mt
certain indications; it must be borne in mind, however, that its too long-co
tinued use may produce irritation of the rectum. For the relief of very mi
constipation the so-called gluten suppository will at times be found useful.

Enemata. — .\ rectal enema will prove of service for affording tempora
relief under various conditions. When constipation is of mild degree, probab
the most effective enema consists of a quart of warm water, temperature 100° I
and castile soapsuds; this is the ordinary "house" or simple enema. Shou

ENEUATA. 105

constipation be attended with bleeding hemorrhoids, the daily injection of
half an ounce of the distilled extract of witch-hazel or a pint of cold water will
usually be of benefit. When a more stimulating enema is desired, the following,
sometimes called the "ox-gall" enema, will often give the wished-for result:

Powdered oi-gall or. zx

Glyrcrin, fjj

Water and soapsuds ( 105° F.), Oj

Rub up the ox-gall powder with the glycerin, adding the latter very gradually
Bntil a perfectly smooth paste is made, and then thoroughly mix it with the water
and soapsuds.

TTie mature at a temperature of 100° F. is then injected into the bowel
through a large-sized rubber catheter, or, better, through a flexible colon tube
passed as far in as possible, the patient lying upon the left side or in the knee-
chest position. In this way Uie injection is given high in the bowel, where it should
be allowed to remain for two or three hours before the bowels are moved.

For obstinate constip>ation good results may be obtained by the use of oil, as
follows :

Castor oil or olive oil, f^j

Castile soapsuds (too" F.) Oij

These should be mixed as thoroughly as possible and one drachm of spirits
of turpentine beaten up with the yolk of an egg added.

A plain enema of soapsuds is best made of brown soap and from one to two
quarts of hot water; its efficiency may be augmented by the addition of one
ounce of glycerin and a drachm of spirits of turpentine.

\ useful enema will be found in (he following;

Sulphate of Magnesia, 3 >i

Glyrerin, fjij

Spirits of Turpentine, f 5)

Hot water (100° F.) Oj

An ounce of glycerin injected into the rectum with a small hard-rubber
syringe is usually followed by prompt results ; it should be used in preference to
the suppositories, which are not so certain in iheir action.

The following enema is useful in obstinate constipation: Six ounces of olive
oil at a temperature of 100° F. The injeclion should be given through a rectal
tube high in the bowel with the patient in the left lateral-prone or knee-chest
position.

Should consti[»ation l)e associated with excessive tympanites, the injection of a
pint of milk of asiifctiila will Ik.' licneficinl.

I06 DIET.

CHAPTER IX.
DIET.

One of the most neglected subjects in the practice of medicine and surgei
is that of dietetics. Except in );eneral terms few, if any, of the text-books gi^
specific directions in the matter of diet. Proper attention to the subject wi
save not a few cases and avoid a protracted convalescence in othets. In surgic
cases the question of diet is most important, as a nourishing and suitable diet hi
not a little to do with the speedy healing of wounds.

In prescribing a diet for the individual case care should be taken, so far i
possible, to order articles of food that are acceptable to the patient. Milk, whi
acceptable to most, is sometimes distasteful, and simply because it is an ide
food its administration should not be insisted upon at the risk of a disorder!
digestion. Again, food should be given at a definite time, as an individu
anticipating its administration will often refuse it if offered before or after tl
time expected. The appetite is sometimes stimulated by making the service ■
food as attractive as possible; and of the utmost importance is the serving h
of food intended to be hot and the serving cold of food meant so to be; the i
termediate stage of lulcewannness is to be carefully avoided. The awakening
a patient for the administration of food is, as a general rule, to be deprecate
particularly during the night. If the patient is asleep at the time set for feedin
it is better, except in well-defined instances, to wait until she awakens for tl
giving of food. Overloading the stomach is to be as carefully avoided as und«
feeding, as it may cause the stomach to rebel and defeat the particular object f
which we are striving. Attention to the bowels, the renal secretions, and i
condition of the tongue, will usually show whether the food is being propel
assimilated or not.

It is important to have a large diet list to choose from in order to be able
tempt the patient's appetite and to select the most acceptable food in an individu
case. The physician should not only have a definite knowledge of the prop
articles of diet to use under various circumstances, but he should also know b(
they are prepared, so that he can give the nurse precise directions, if necessai
and make sure that the patient is receiving what was ordered.

UQUID DIET.

The following articles of food are the chief forms of liquid diet used for t
sick and in the prepiaratory and post -operative feeding of patients.

Milk. — Milk may be taken hot or cold. It may be flavored with sug;
salt, tea, coffee, or vanilla, and it may be diluted one-fourth with plain sot
or hme-watcr, or with seltzer, vichy, or apollinaris.

Milk-shake. — Take six ounces of fresh milk and add two teaspoonfuls
sugar and flavor with a teaspoonfu! of vanilla. Place all in a wide-mouth
bottle with some cracked ice; corksecurely and shake well for one or two minut

An entire egg or the albuminous portion only may be added previous to sha
ing; and wine may be substituted for the vanilla.

Peptonized Milk. — This is best prepared with Fairchild's peptc
izing-tubes, each of which contains 5 grains of extract of pancreatin and
grains of bicarbonate of soda.

The Cold Process.-— Place the contents of a tube in 3 clean quart bottle w
about four ounces (or a teacupful) of cold water and shake well. Then add c

LIQUID DIRT.

107

piM (or Iwo lumblerlub) of cold milk and s>hake again; afler whid) il shoukl bf
plactd on ire until ready far u.'>«. Il cniiy be «wcctencd with a little >ugar if
desired.

The Watm Process. — Mix the peptonizing powiler uiiii water am) milk ofi
in the coki pfoce^*, ami then place the bottle in w.tter at a ictnperaiurc "f 100° F.
(or waicf in which the h.ind an be comforiably placed) (or ten minutes. Then
pb<r <ti ii»' lo prevent any further (liRestive actinn.

Koumiss.— I >i.'iM)lve one- third of a cake of FieiechmAnn'syeasI in a small
quantity of warm water: add this to a quaii of insh milk warmwl to blood-heM
(99' F.) and sweeten with a tc:i^|K»>n(ul of txigixr. P"ur ihi.* mixture into clean
beer b»llk-s with adjui^-ible rubber cnrk§; «>hakc the boillcs for one mimile to
mix Uic inxrcflicnta thorouchly, and then plai-e them on en<) in a warm place
{80" F.) for at IcjiM twelve btnir^. TIk Uittln arc then pluccil on their side* in a
nfr^cnior until ready for use.

FUtettrized Milk.— *TI)ev process consists in raising! the iem|ieratiire of
the milk to if>j° F. .ind keeping it at that [Hiint for half an hour. Pusieurixation
b ai:i:i)inpU>hcd a.', follows:

Put the milk in Mertte lM>ttle^ .-ind sioi>peT with cDllon hiilting; which ha--> been
baked brown in the oven, Then pl.ice the bottles in a covered pail and pour in
water a<1uulty twilins *' the time until they are immerwd up to their neck*.
AUow the l>»ltk-> to remain in the pail fur thirty minuter and then phire them in a
trfrineralitr until nctdcd. The tech-
n>c may be variexl by first bringing
tbe water In a boil in the pail and then
irmovinR it from the ranf;e after put-
ling in tite liotllr^. This nie(h<Kl
nbcs the Icmpenlure of the milk to
167" F. aivi nuinL-iin> it at thai point
tnr half an hour while the water in the
[ail is cbolinc-

Puieuriurr^ are now for sale in
tbr shops which arc simple in con-

HructWin atMl nuke the procesii wry convenient. They consist of a tin or
copper inil with a lid and n wire mck to hold the bottleit.

A temperature of 167° F. destroys all bacteria that arc likclj- to be present and
docs nui alter iIk properties of the milk to the same extent as sterilization. The
Btitk is aho ca>ier to digest ^ml tnstco more like frrOi milk. Pastcurizcfl milk will
keep sweet (or twenty-four hours, but after that time il spoils, and should iwi be
awl (or food.

Sterilization of the Bottles. -After iiiing the milk the bnttlctare ihnmiiRhly
tinseil with Ikh siKijistid-- mid led standini; t'dleij with water which o.mtains i

INT irnt. o( sikU or tmnix. Heiore refdlinit the IhioIo with mJIk they are rare-
uUy rinwd arul Imilct for ten minute in plain water.

Cotton Batting Plugs.— In hospitals the cotton batlint; which i^ used to
ftnptief the n>outli>. uf the bottlcK i« Merilized in a high-jtrcwure >team sterilizer,
but in private bouses this melhod cannot be carrieil out and It will be neces^ry
to lukr the (-otton in a hot oven until it turns a linht brown. The importance
of Merilixint! the folton which h used lo stopper l>">th Pastcuriieti and sterilized
Btitk l"iii' ^1 always be borne in mind, as the degree of heat apidicd in

IhcM pr' in-oifririenl to de>trov the iKicterb In the cotton, alia con»e-

quetitlvih. II. lU "I II eventually become infected from thi' M>urre.

Sterilized Milk.— ThL-> process consists in niisins the temperature o( the
BQklo 310^ F.nnd keeping it at that |>utnt for thirty minutes. The sterilization

jpgpg

tin- I iS. - ArrALtnn m PAinrwcu* itnx.

loS

DIET.

may be accomplished as follows hy means of Arnold's milk sterilizer, which is a
inexpensive apparatus:

Put the milk in sterile bottles and stopper with cotton batting whidi has bee
baked brown tn an oven. The bottles are then put in the wire mck and pla<X
in the sterilizer. The lid is now put over the steriUzer, water for generating steai
poured into the bottom receptacle, and the apparatus placed on the rangi
When the water begins to boil, the steam ascends into the sterilizer and suirounc
the bottles, heating the milk to 210° F. (actual test made by the author). Tt
milk is subjected to this atmosphere of steam for thirty minutes, when the bottk
are removed from the sterilizer and placed in a refrigerator.

A simple method of sterilizing milk without using a specially constructe
apparatus is accomplished as follows: The bottles are filled with milk an
plugged with cotton baiting as described above and placed in a tin pail. Tl
pail is then filled with water up to the necks of the bottles and placed on tl
range. The water is now boiled slowly for thirty minutes, when the bottles ai
removed and placed in a refrigerator until needed. From tests made by tl
author with a self -registering thermometer it was found that this process raise
the temperature of the milk to aoS" F.

It is now generally admitted that the alteratk
which occurs in the properties of milk prepared t
sterilization is greater than by Pasteurization, ac
hence the latter method should always be employe
except when it is necessary to keep the mUk fi
several da>'s. Sterilized milk will keep in good cond
tion for a week or more, and can therefore be carrii

iliU'l IS ftll upon a voyage across the ocean. Its taste is chara
^ lj==2a^ teristic and is somewhat similar to that of boih
■UIlMft milk.
■ M Albuminized Milk.— Add the white of i

HI I I egg to half a tumblerful of milk and mix it by pas

ing the blade of a knife gently to and fro in U
tumbler. The mixture must not b
beaten, as violent agitation coagi
lates the albumen and destroys ii
digestibility.

Hilk Punch. — Take one cupful of milk, tv
tablespoonfuLs of whisky or brandy, one teaspmonf
of sugar, and a nutmeg. The milk is first sweetened with the sugar, tl
whisky or brandy added, and the whole thoroughly mixed by pouring from 01
glass to another. Then grate a little nutmeg over the top. If the ingredien
are shaken in two tin cups, one of which fits closely into the other, it mak
a better and more attractive punch.

Buttermilk.— Buttermilk should be fresh every day and kept in tl
refrigerator until ready for use.

Albtunin Water No. i.— Add Ihe white of an egg to a tumblerful of o
dinary lemonade and mix it hy passing the blade of a knife gently to and jro
the tumbler; the albumen coagulates if the mixture is beatei
Albumin Water No. 2. — Add the while of an egg to half a tumblerful
ice-water, mix as in No. i, and season with a little salt.

EffffS. — An egg may be taken raw and swallowed whole asan oyster by brea
ing it carefully into a wineglass and adding a little vinegar, salt, and peppc
Another method is to pour a tablespoonful of sherry or Madeira wine into a win
glass and break an egg over it.

FlO. 1 19. — AlNOLD'S ArFAUTOI

roR Stzhjuiihc Mile.

UQOID DIET.

109

8nr-nos.— Put the yn\k of an cgs in a tumbler and mix it well with a

Ittupiiunful iir-<u)r-ir' Th«n a<lil a (iilil<r<[KHinlul »f liramly, whisky, or tiherr}-

. winr and till ihr tumbler iilxiiil Inx'-third;^ full with ice-ciM milk. Then mix

ihunmichly by pourin;; fnim one ){tas.s to unutlivr orshukinf; in two tin (iips and

«tnin im<> 11 toll thin itUfts. Ileal the while ot the egg tn a Mill froth, a<h) n

tittle suear.and place it on the egg-nog. Then grate some nuimesoi''er thelop,

SSg Leniotiade. — Thoroughly lt»t line enjc with 11 liiblcipiMiiilul of su{Ear
and then mix with .1 uinrgliiT-vful ol water and the juice of a smiill Icnxm. POur
the whole Jntu a lumlilcr containing pounded ice Lind itir with a $[>oon.

Clam Broth.— Six Inr^ chiat in their :^IU nnr| b cup of water wUI be
Dcvde'l for this bri>th. Wash the shells thoroughly with a brush and pbce the
' eiua» with the w,iier in u kettle owr ilur lire. Tlie bruth i> Mmpiv the juice <if ihe
riam« and the water Imilii! for one minute. It docs not rr«)iiirc HM,«ining, as
the clnm juice itself i^ usually salt enough. When the shells open, the cUms are
taken out of the keille and the bmtb .itratnetl through a double layer of diecw-
cloth or a fine straitier. Tlic l)n>th may be screed hot or cold.

Oyster Broth No. z.— Select eight f re^ oysters, chop them fine ina chop-
plng-ltay, and lutn ihtm intoauuce[Mn with a cupof rold waier; «l the nure-
pan nn the lire and let ihe wairr come slowly to the boiling j>oint, then simmer
W five minulcs; strain the l\<\\iUi into a l>owl, flavor with half a sultspoonful of
talt. iirid M-nr ho|.

Oyster Broth No. a.-I'ut a dozen large omers with their liquor into a
»tew-|>ari jrwl M'^ ihein I" >iiiimer for five niinuies. Tlicn Jir.iin the liiiuor. leav-
ing out thr «\'Rier^, and add to it hull 11 cupful of milk or w:iler; set it luick on
the sto\e ami heat il just to the boillng-pi^int. Flavor with pcp|ier and sail.

Chicken Broth. — An old fowl will make a more nutritioiii and laMy
broth than a young chicken. After cleaning and removing all that is not clear
fle*h the fowl i« cut into Mnall pieces awl pbred in a Muceiian. h in then covered
with cold water, allowetl to simmer for tw»j hours, and nnally to boil slowly for
Iwi) hours Rtore. It is then strained and placed aaiilc to cool, when the fat is
tarelulh ^kinlml■d ulT. It i'i ^rverl hot and MraMineil with pepjicr and salt.

Xntton Broth. — 7'ake two [>ound« of mutton from the loin or the lean part
of the iwc'k. remove ihe skin and ihc fat. and cut it into small pieces aliout two
lochei Miunre. I'm the meat ami the lioncs ina saucepan or 0 krltlc, rnvvr wilhn
iiUinur«iUl water, and add a lablcpoonful of rice or pearl barle}-: then simmer
thrra gently for nvo hours, strain, and plac-e aside to cool, when tiie fat is carefully
tUmme<f t>tl It is Mr^-ed hot and .teaxmeil with pcp|Kr and Kill.

Beef Broth.— Allow one pound of meal, or meat and bone, to ever)- quan
of water. WasJi Ihe meat with a doth in cokJ water and cut it into small pieces.
Put the mrat am) the Ixine into a siuu'CiKin or a kettle with cold water and OMik it
It a k>w lem[>eralure for two hours. Tlien boil for two hours and strain ihrough

* (' I ■ i'lcr. Skifn a* much fat a.- imwible from ihc surface with a spoon
aw; 've tlte rrnuining ■'mall panicle* with 3 sheet of clean ua*i/«i fwtier
ilnun '-i-rr tlie surf:ice. Senson the broth with salt and [lepper and serve hot.
if the bnilh is not neede<l al oner, it >hi>ul<l Iw sd asiiie tu cuul. when the fat will
riie lo ihr i.-fi iin<l tan be easily rfmi)ved.

Beef-tea. Take u (Kiund of lean Ijcef. free from fat and fibrous tissuv.
ml it iniuMnallptccn. and plac-e them in a Inth -jar with a good cover. Add to it

• [Mnt nf cokl water ami stand in a moderately n-arm place for one hour: then
bt it limmcr gently for l«-o hours more, then strain and season with salt and
jiqjprr

Bottled Beef-juice.— Take half a. pound of juicy beef, remove e^-ery-
tUnjc cccepi the Icon, and cut it tntn small jnecea. Put the pieces ot neni in a

no DIET.

fnik-jar with a good cover and place it in a deep saucepan containing cold wate
Heat the water gradually for one hour, but do not allow the temperature to excet
160° F., and then strain out the juice and squeeze the meat in a meat-press or
lemon-squeezer. It is seasoned with salt and pepper, and served either hot 1
cold. Half a pound of meat will make about four teaspoonfuls of juice.

Broiled-beef Jnice. — Take half a pound of the round or any lei
portion of the beef and remove all the fat and the fibrous tissue. Put it into
wire broiler and broil over a hot fire long enough to heat it thoroughly throuf
(from six to eight minutes). Then cut it into small pieces and squeeze out ti
juice with a meat-press or a lemon-squeezer. It should be served hot or cokl ai
seasoned with pepper and salt.

Beef-juice wifl keep for eighteen hours in a refrigerator.

Botlillon.^First make a quart of beef broth according to the metbi
already described, and then add a pinch each of thyme, sage, sweet marjoiaj
and mint, and a teaspoonful each of chopped onions and carrots. Boil all 1
gether until the broth is reduced to one pint. Strain, season with salt and p>epp(
and serve either very hot or cold.

Oatmeal Gmel. — Take two tablespoonfuls of oatmeal, one saltspoonful
salt, one teaspoonful of sugar, one cupful of boiling water, and one cupful
milk. Mix the oatmeal, salt, and sugar together and pour on the boiling wati
Cook it in a saucepan for thirty minutes and then strain through a fine wi
strainer. Put it again on the stove, add the milk, and allow it to heat just to t
boiling-point. Serve it hot.

Cracker Gmel.— Take two tablespoonfuls of cracker crumbs, one sa
spoonful of salt, one teaspoonful of sugar, one cupful of boiling water, and o
cupful of milk. Mix the salt and sugar with the cracker crumbs, pour on t
boiling water, put in the milk, and simmer it for two minutes. Do not strain.

Klotir Gmel.— Take one tablespoonful of flour, one saltspoonful of sa
one teaspoonful of sugar, one cupful of boiling water, one cupful of milk, and 01
half of a square inch of cinnamon. Mi.t the flour, salt, and sugar into a pa:
with a little cold water and then add the cinnamon and the boiling water. Ni
boil slowly for twenty minutes, then put in the milk and bring it to the boilir
point again. Strain and serve very hot.

Indian Meal Gmel.— Take two tablespoonfuls of commeal, one tab
spoonful of flour, one teaspoonful of salt, one teaspoonful of sugar, one quart
boiling water, and one cupful of milk. Mix the commeal, flour, salt, and su(
into a thin paste with cold water and pour into it the boiling water. Cook it
a double boiler for at least three hours, as less time will not be long enough
prepare the gruel thoroughly, and then add the milk.

Oatmeal Water. — Put a cupful of oatmeal into two quarts of coo!
boiled water and place it aside in a warm place (80° F.) for an hour ant
half. Then strain it and put in a refrigerator.

Barley Water. — Put three tablespoonfuls of barley (the grain) ii
four cupfuls of cold water and place it aside fur twelve hours. Then boL
gently for an hour and a half and strain. Season it with salt, sugar, a
lemon-juice and serve hot.

Wine Whey.— -Warm one cupful of milk to a little more than blood-hi
(100° F.) and pour into it one-half of a cupful of sherry wine. The acid a
alcohol in the wine coagulate the albumen, which is then separated from 1
whey by straining. If it is necessary to make the whey quickly, heat the m
to the boiling-point before adding the wine.

Toast Water.— Toast three slices of bread until they, are very bro
and then break them into small pieces. Put them into a bowl with a pint

MPT MKT.

Ill

water and Ml ntide in soak for an hour. Then strain Ihrnugh a napkin
and »qUMzc oul the liquid, to which n added a little cream and sugar. It ia
scrveil rt>ld.

Rice Water. — Put two InhlcTipoonfulj^ of rice into a <auccpan with a

San ol boiling water and simmer ii for two hours, Then strain ihe liquid
rouich a &nc Mrainer. season with sah, and sc^^-e either hot or oild. If taken
rt^, the addition of two tablespoonfuls of sherry, port, or Madeira wine makes
A good Mimulatiii); drink when indicated.

Coffee ; Tea ; Cocoa. — These anicW uf diet are prepared and sc^^'ed
hi the ordinary way

Mannfacttired Poods.— The followini; ani^lc^o( fond which are inrluded
in the lijt of liquid diet an- .icrompanicil with instructiims giving the method ol
prcpdring them for use: (i) Valentine's meat juice, (i) Bovininc. (.0
Liquid pepioimds. (4) Unfermenied KRipe-juice. (;) Mellin'* food. (6)
Nellie's food. (7) Horlick's malted milk. (8) Somatosc.

SOFT DIET.

The time when a soft diet may be substituted for the liquid depend* entirely
upon the individual case: the temperature. piiLie. .inii condiiinn of the wound;
and the partkular kind of operation. In any event the change mu!^t be gradual,
fint one article then another being substituted until the soft diet ts fully «tab>
Efthed.

Soft diet should alwa)-s be supplemented by any of the articles inchided in
liqulil diet aixl tlie patient's ap]>etiie tempted by selecting such foods u arc
e«peci)lly nKreejble to her.

The follotting articles are ihc chief fonns of soft diet:

E((S: Poadiet] (plain or on toast); »ciambled: omelet; »nf|-boiled.

Oyilerv: Raw; stewed; panned; malted.

BrMd: Stale bread; Graham bread inaMed; croutons; sippets: milk-
bultercd water loast; cream l»a«t; dry toast; buttered dry toast; plain
kers.

Soups: Chicken; cieam-nf- celery; iTeam-of-rfce; chicken panada.

Poutoes: leaked; creamed.

Sw«e1bre«di; Creamed.

Miisb: Oatmeal; fariai; wheat geim; cracked wheat; hominy.

Fruit: Oriingcs; grapes; baked apples; slewed prunes; stewed apples.

Dtnens; Wine jelly; soft or baked cusiani ; junketorslip; crcam-of-rice
pudding; i^^-ach foam; corwiarrh fnMldin^; Ixiiled rice with cieam and sugar;
vanilb irr-iream; rice cream; orange jelly; chicken jelly; sponge-cake and
mam: liarle>' pudding.

Tile fnllowioK lire the reci|>e5 far the preFNtratkm of those articles uf diet in
the at>o^r liM which arc not in common use:

Graham Bread.— Take one pint <i{ milk, two tnbleapoonfuU of !i.ugar,
HOT tMvp"<'nlul h[ s;ilt, one-fifth of a cake of compressed j'cast, two cupfuls of
white f3our, and enough Graham flour t" make a dough. Scald some milk, and
bofD h mcasuire a pint; t» this add the nugitr and *alt. While it is n»ling
(ifl tume Graham flour, atxl when the milk has become lukewarm, put in the
ycaii. which has previously been dissolved in a little water. Then add tlie while
Hour Niftrfl) and enotiiih of the Gimhun flour to make a MiiT dough, but not sti£f
enough to nwild. Mix thoroughly and shupe it into a round mass in the dish.
.\ftrr this follow the same directions as for water bread, letting it rbe the same
tine unci kikln;; it In the tame manner.

112 DIET.

Croatons. — Cut a slice of bread one-third of an inch thick, butter it, an
divide it into small squares. Place them in a shallow dish and put the dish in
moderate oven for fifteen minutes. When done, they should be light golde
brown throughout, crisp and brittle.

Sippets. ^Sippets are oblong pieces of bread delicately toasted. They ai
made by cutting a thin slice of bread and dividing it into small pieces one inc
wide and four inches long. They may be served dry, buttered, or with panne
oysters.

Buttered Water Toast.— Toast four thin slices of bread. Put a pii
of hot water with half a teaspoonful of salt into a shallow pan and dip each slii
of toast quickly into the water. The toast is then buttered, put in a covert
dish, and served hot.

Cream Toast. — Take one pint of milk, one tablespoonful of flour, oi
tablespoonful of butter, one saltspoonful of salt, and several slices of breai
Make a white sauce with the milk, flour, and butter, according to the folloi
ing directions r Pour the milk into a saucepan and set it on the fire to heat. P'
the butter and the flour together in another saucepan; place it on the fire ar
stir gently until the butter melts; let them bubble together for two or thr>
minutes. Then pour in a little milk and stir until the two are mixed; add
little more milk and stir again until it bubbles, and so continue until all the mi
is in. Now add the salt and let it simmer slowly until the toast is prepare
Soak the slices of toast thoroughly in salted boiling milk, arrange them in
covered dish, and pour the cream over them.

Chicken Soup. — Thoroughly clean a good fowl. Separate it at its join
and cut into smalt pieces. Put the meat into a saucepan with three pints
water and stew it from two and a half to three hours. Then take out the mei
but let the liquor continue to boil and add to it one tablespoonful of rice, 01
tablespoonful of finely cut onions which have been fried with a bit of butt
until soft, but not brown, and three peppercorns. Cut the best portions of tl
meat into small pieces and put them into the liquor, letting all simmer un
the rice is very soft. Then take out the peppercorns and season with whi
pepi)er and ceiery-salt. Ser^'e hot with croutons.

Cream of Celery Soup. — Take one stalk of celery, one pint of watt
one pint of milk, one tablespoonful of butter, one tablespoonful of flour, on
half of a teaspoonful of salt, and one-half of a saltspoonful of white peppt
Wash and scrape the celery, cut it into half-inch pieces, put it into the pint
boiling water, and cook until it is very soft. Wlien done, mash it in the wat
in which it was boiled and add the salt and pepper. Cook an onion in the mi
and with it make a white sauce with the flour and butler; add this to the cele
and strain it through a soup strainer, pressing and mashing with the back of
spoon until all but a few lough fibers of the celery are squeezed through. Thi
put the soup in a double boiler and heat it until it steams, when it is ready
serve.

Cream of Rice Sotlp.— Take one-quarter of a cupful of rice, one pint
chicken broth, one pint of cream, one teaspoonful of chopped onions, one sta
of celery, three saltspoonfuls of saU, a hltle while pcpf)er, and one-half a sa
spoonful of curry powder. Put the rice and the chicken broth in a saucepan
cook and simmer it slowly until the rice is ver\- soft. This will require about ti
hours. . Half an hour before the rice is done put the cream into a saucepan wi
the onion, celery-, pepper, and curr\' and let them simmer slowly for twen
minutes. Then pour the mixture into the rice and broth and strain through
soup-strainer; add the salt and set it back on the stove to heat to the boihn
point.

son- DIET.

113

Chicken Panada. — Tnkc one cupful of chicken meat, nnc-lulf nf a cup-
ful of brrud <oakril in milk, one pjni of (;iiickcn broth. onehAlf of a Icaspoonful
of ult. ami one-quarter «( a Miltspoonful <if pcpix-T. Cut ihc chickrn meal up
very fine and pnrss ihc breaii ihruugh a coarec wire ^Iraincr. Place ihcm bnlh in a
uuccpui iind add ilic brolli, ihe »lt, and (he pcpfwr. Boil fur one minute und
itrw Iwt,

Creamed Potatoes.— Cul Ihe ix^umt^ into sm^ill «i|uaru>, pul them in an
omelet pan, scaMin them with miIe and pcpixrr. and jxiur in milk until ihcv are
almost on-ered. Then gimmer f;einly until all the milk is absorbed. To ewry
pint (if |iutaioes make a pint of white sauce (m% cream lua>l) and KOton il
with Mill anrj chopped parslc)'. After the ix>tai<)cs are done pour the sauce
over thero and ^crve hoi.

Creamed Sweetbreads.— Make n cream kiucc with a cupful of cream,
ft LiblrsptMnful of Hour, and h.ilf a tablespoonful of butler. Then cut a •;weet-
brciil into half-inch Mjuurc:^. sail ihem slightly, ami sprinkle .1 little white pep|ier
ovtr Uiwn. Mix c<iiiat ([uiiniitie< of ihp snTclbrcad and the creum saute mgcther
Bitd put ibcm into [wrcelain palty dishes. Then sprinkle ihc top with buttered
breiMl -crumbs and bsike in a hot oven for ten minuter.

Wine Jelly. — Put oiK-founh of a box of gelatin in a bowl with one-fourlh
u( II cupful of cold water and lei il soak for half an hour. Then |K>ur one and
onr-founh rupfuLs of boilinjn water, in whicJi a iimall piece of cinnamon and one
ckiw have been ^immerin^, over the <ioftened gelatin. Add half a cupful each of
■upir and shtrrr}' wine and tiiir until the gebitin and sugar are jierfecily di4M>lvnl.
Then >irain through a fine napkin into a mold and put it into the rcfrigcralor
III coiiL If preferred, one-quarter of a cupful of lemon juice and a lablcspoon-
ful of brandy may be substituted for the rinnumon and clove.

60ft Costard. — Take one pint of milk, the yolks of two crrs, two table*
spoonfub of suf^r, and one saltttpoonful of tcilt. Put the milk into a saucepan
and placr it on the smve to boil. Beat together (he yolks o( the eggs, Ihe salt,
ami the sugar, and when ihc milk jusi reaches the boiling-point jxiur it in slowly.
MirrinK until all is well mixed. Then pour the mixture into the nucqxin at
once anil a>ok for three minutes, meanwhile stirring it slowly. Then strain it
Into a cool dish and flavor it with a Icaspoonful of vanilb or sherr>' wine.

Baked Cap Custard.— Heat one egg thoroughly; add a tliit tea.-'poonful
of Hifpr. tN-iit dgain and |>i>ur the mixture into a breakfast colTcC'Cup. Then
ilir in suiriiient milk to fill the tv\> three-fourths full, place a leasjKHmful of
butter tin the top, ami cnile some nutmeg over the surface. Hake in a fairly
bit oi'cn for thirty minutes and then put the cup in a refrigerator to cool.

Jonket or Slip.— Put a pint of milk, a table].|HK>nful of sugar, and a
tcaipoDnful oi rcniK-i into a gkiss pudding-iJith and stir until the sugar is thor-
tragnly dissolved. Place a cover o\-er the dish and put it into a warm place
<abinit 9S° F.). .\s siNin u the junket » Mt or become* solid, pbce the dith in

refriicervior to cool, and then sene in snuitl saucers, grating some nutmeg

' the top, If preferred, brandy may lie added to the rennet before it b mixed
lb the milk

Cream of Rice Padding.— Take one quart of milk, one-half a cupful
I lable^jioonfuU of ^u^ar. and one »3lL-|>oontul of salt. Put the milk,
I , anil oil together in a pudding-di^h, ^lir until the sugar is dissolved,
tbcn pkiir the dish in a |ian of water and bake in a slow own for three hows,
cuitinti into the rruNt which fnrmti on the top once during lhi» time.

Peach Poam.— Peel and cut into small pieces three or four very ripe
jieachck; pul Uicm into a bowl with half u rupful of powdered sugar and (he
white of one egg. Tlicn beat with a fork for half an hour until it forms a

114 DIET.

thick, smooth, velvety cream, and serve in a small dish with or with'
cream.

Cornstarch Padding-.— Take one and a half tablespoonfuls of co
starch, one tablespoonful of sugar, one aattspoonful of salt, two tabtespoonfuk
cold water, and one pint of milk. Put the milk on the stove to heat. Mix i
saucepan the cornstarch, sugar, salt, and water, and when the milk begins to \
pour it in, slowly at first, stirring all the while. Then pour the mixture int
double boiler and cook for thirty minutes. At the end of that time beat one t
very light and stir it in, pouring slowly, so that it may be mixed all through
hot pudding and puff it up. Then cook for one minute, turn into individ
molds, and cool. Serve with cream.

Rice Cream. —Take two tablespoonfuls of rice, two cupfuls of milk, r
saltspoonful of salt, two tablespoonfuls of sugar, and two eggs. Cook the i
and the milk in a double boiler for about three hours; should the milk evapor
restore the lost amount. When the rice is perfectly soft, press it through a cm
soup-strainer into a saucepan and place it on the fire. While it is heating, t
the eggs, sugar, and salt together until very light, and when the rice boils pou
the egg slowly, stirring gently with a spoon for three or four minutes, or unt
coagulates and the whole is like a thick, soft pudding. Then remove from
fire and pour into a dish. By omitting the yolks and using only the whites of
eggs a delicate white cream is obtained.

Orange Jelly. — Take one-quarter of a box of gelatin, one-quarter i
cupful of cold water, one-half a cupful of boiling water, one-half a cupful of su
one cupful of orange-juice, and the juice of half a lemon. Soften the gelati
the cold water by soaking it for half an hour; then pour in the boiling wi
stirring until the gelatin is dissolved; add the sugar, orange juice, and lei
juice, in the order in which they are given, stir for a moment, and then strain
liquid through a napkin into molds and put them in a refrigerator.

Chicken Jelly.— Clean a small chicken, disjoint it, and cut the t
into small pieces; remove the fat, break or pound the bones, and put all into
water (a pint of water for every pound of chicken). Heat the water very sli
at first, and then simmer for three or four hours or until the meat is ter
Boil down to one-half the quantity of water, strain, and remove the fat. 1
clear it with an egg and season with salt, pepper, and lemon. Strain it thn
a fine napkin, pour into small cups, and cool.

Barley Padding.— Take two tablespoonfuls of barley flour, one t;
spoonful of sugar, one saltspoonful of salt, one cupful of boiling water, one
of a cupful of rich milk, and the whites of three eggs. Mix the flour, sugar,
salt in a saucepan with a little cold water. Wlien smooth and free from lu
pour in the boiling water, slowly stirring to keep it smooth, and then set it o
fire to simmer for ten minutes, continuing the stirring until it is thick. A
end of ten minutes put in the milk and strain all into a clean saucepan throi
coarse strainer, to make the consistency even. Beat the whites of the eggs
light but not stiff, and gently stir them into the pudding, making it thoroi
smooth before returning it to the fire. Cook for five minutes, stirring and fo
the pudding lightly until the egg is coagulated. Then put into a china pud
dish and serve cold with cream.

CONVALESCENT DIET.

Just as in substituting a soft for a liquid diet, the change from a soft diet I
adapted to convalescence should be gradual and lentati\'e.

The patient must not be allowed to eat pastry, heavy puddings, highl;

NUTRITIVE ENEUATA.

soned or fried food, crabs, lobsters, hot or fresh bread, overcooked meats, pork,
sausages, or veal.

A convalescent diet comprises the liquid and soft diets and, in addition, the
following nutritious and easily assimilated articles of food:

Meats. — Rare roast beef; rare broiled tenderloin steak; rare mutton;
broiled lamb or mutton chops; sweetbreads with peas.

Salisbury Heat Cake. — Cut a piece of tender nimp steak about half an inch
thick, place it on a clean board, and with a sharp knife scrape off all the soft
part until there b nothing left but the tough, stringy fibers. Season the soft
pulp with salt and pepper, make it into small flat cakes about half an inch thick,
aitd broil them over a brisk &re for two or three minutes. Serve on thin slices
of buttered toast.

Game.— Venison; partridges; pheasant; snipe; plover; reed birds; wood-
cock; ducks; grouse.

Fowl. — Broiled squab on toast; roasted or broiled chicken; turkey.

Fish. — Broiled fish of various kinds.

Vegetables. — Spinach; asparagus; young peas; celery; lettuce or water-
cress with French dressing; lima and string beans; mashed potatoes; mush-
rooms; onions.

Fruits.^ Grape fruit; blackberries; blueberries; raspberries; peaches;
pears; watermelon; cantaloupe.

NUTRITIVE ENEHATA.

Care of the Rectom.— The rectum must be kept clean by washing it
out every morning with a cleansing enema in order to preserve its retaining
capacity and to prevent inflammation occurring.

Fic. lao- — ArFA»ATi."5 vsfd in Giving, a Ni'TBirivt tlNEiiA Ipagf ii6).

The following enema is useful for this purpose:

Cleansing Enema. — Take a number of scraps of Castile or any other pure
ioap and boil them in water until a jelly is formed. Keep this jelly in stock

1 16 DIET.

in a sterile, covered fruit -jar. When required for use, put one or two tablespoon
fuls of the soap jelly into a sterile quart pitcher containing a pint of boilinj
water and mix it thoroughly. Then reduce the temperature with cold steril
water to 105° F. and inject the mixture into the rectum.

Apparatus. — The apparatus consists of a plain rectal tube of No. 3
French scale about ao inches in length, and a hard-rubber syringe with
capacity of four ounces.

Antisepsis. — The tube should be sterilized before using by boiling it in
I per cent, solution of carbonate of soda or pfain water, and after giving th
injection it should be thoroughly washed with warm water and soap. The syrin^
should be cleaned with warm water and soap before and after giving tt
enema. The rectal tube should be well oiled with sterile vaselin or olive o
to prevent setting up soreness of the anus.

Special Directions. — A nutritive enema must be given at a temperatui
of 100° F.; in quantities not exceeding four ounces; and at intervals varyii
from four to eight hours. In order to facilitate the formation of peptones an
the absorption of albuminoids a small quantity of pepsin or pancreatin must t
added to the enema; and to prevent it from being rejected when the redu
becomes more or less irritable, from 5 to 10 drops of tincture of opium are miw
with the nutritive injection. The enema should alwaj's be given high in order
facilitate its retention and bring it in contact with a large absorbing surfac
The patient should therefore be placed either in the right lateral-prone or ti
knee-chest position to facilitate the passage of the tube.

FoTmmas> — The following formulas for the preparation of nutriti
enemata will be found useful when it is necessary to employ rectal feeding:

No, I, The yolk of one raw egg, brandy or whisky fsvj, liquor pancrea'
iS'tj, and beef-tea fSiij-

Ho. 2, One raw egg, table salt gr. xv, brandy or whisky fjss, and peptoniz
milk fjiij.

No. 3. Beef -juice i^.j, brandy or whisky f^ss, cream fjss, and liquor pane
atis fsij.

No. 4. One whole raw egg, liquor pancreatis fgii, and beef-tea fjiij.

No. 5, Beef-juice f^iij, and liquor pancreatis f3ij.

Ho, 6, One raw egg, and peptonized milk fjiij.

No, 7, Table salt gr. xv, beef-juice fsj, and peptonized milk fsiij.

No, 8. Table salt gr. xv, one raw egg, beef-juice fjij, and peptonized m
flij-

INDOOR EXERCISES.

117

CHAPTER X.

INDOOR EXERaSES.

The importance of outdoor exercise in maintaining the general health and
developing the physique is being more and more appreciated at the present day,
and the interest which is now taken in gotf, tennis, riding, and other forms of
recreation is producing a type of women who have healthy bodies and vigorous
organs. The beneficial effect of indoor exercises either as a supplement to out-
door exercise or as a substitute for it in women of limited means is frequently
o\-erk)oked by the profession, and the benefit which may be derived from this

Fio. III. Fto. i)»,

tic. t>I SnOltS iMOlttCT Po-.H'H: USB RII.AKAIION Of TBE ABrwmHM, W«I.U; FlQ. Ill Srowi

C^OmtCT Pot^ll'HF. ATlt) CONTH^CTEU AbDOUINAL WaLLS (page 110}.

Nuie ihc iiifl*Tcncc in ihe shapp of Ihe KlKlruntii.

iherapeulic means is therefore not taken advantage of in many cases in which it is
dtiinctly indicated.

Indoor e.xerckes are a useful adjunct in the treatment of certain gynecologic
affeaions. and also in the technic of hydrotherapy, and I shall limit the dis-
tu?sion of the subject to the consideration of these indications.

The equihbrium of (he jielvic organs and the condition of the circulation
depend brgely upon the strength of ihe abdominal and thoracic muscles and the
aparily of the lungs. As long as the retentive power of the al>domen is normal
the uterus and its appendages maintain their position and there is no tendency
to peli-ic congestion. WTien, however, the abdominal walls become relaxed and

INDOOR EXERCISES.

the action of the diaphragm is restricted by shallow or inefficient breathing, th
pelvic oi^ans become displaced and passive congestion results. The effect (
indoor exercises counteracts this tendency by strengthening the abdominal an
chest muscles and increasing the breathing capacity of the lungs. The movi
ments which are used in these exercises produce decided results even in wome
who take outdoor exercise, because they are designed to have a special effect upo
certain muscles which control the act of respiration and preserve the integiil
of the retentive power of the abdomen. In early womanhood the abdomini
walls are tense and well developed and they hold the viscera well back in ptositioi
Later on in life, however, ihc muscles become relaxed and more or less atrophic
from disuse or want of exercise, and the abdomin
organs cause the abdomen to protrude, forming what
commonly called a "pot belly." Eventually fat aca
mutates in the parietes and the omentum and a wel
marked pendulous abdomen results which no long
supports the pelvic and abdominal organs. The bi
results which are caused by such an abdomen are a
due to the fat which it contains but to the relaxi
and atrophied condition of the muscles, and cons
quently we must direcl the treatment to the relief of tl
latter condition (Figs. 121 and 122).

A mistake is ofien made in treating obese womi
suffering with pelvic congestion or a uterine displac
ment by ignoring the atrophied state of the muscles ai
directing the treatment solely to the reduction of t'
fat. Under proper dietetic treatment these patier
naturally lose considerable weight and their wa
measurement is decidedly lessened, but they derive
local benefit whatever because the retentive power of 1
abdomen has not been increased in the slightest degn
Indoor exercises also play an important part
the technic of hydrotherapy, and ihey are often e:
ployed with decided advantage. For example, soi
women cannot take a cold hath in the morning befc
breakfast because it is not followed by reaction, a
consequently when this variety of bath is clearly in'
cated it cannot be employed under the circumstanc
The reason for this is that the circulation is slugg
immediately after getting up in the morning, a
unless a woman is naturally very strong and robust !
cannot stand the shock produced by the cold wa)
If, however, five or ten minutes are first devoted to active movements of ■
body the action of the heart and lungs is accelerated, the blood -pressure is
creased, the surface of the skin is covered with a gentle perspiration, am
cold plunge is now quickly followed by a rapid and healthy reaction.

liie following rules must be strictly adhered to in taking indoor exercises:
Rule I. — Have the windows down from the lop so (hat there will be pie
of fresh air in the room without causing a draft.

Rule 2.^E)ress in pajamas and stockings. There must be no constrict
about the waist, the hips, the chest, or the neck.

Rule 3.— The e.xercises should be taken in the morning before breakfast i
at night before retiring. The stomach should not contain food and the blad
should be emptied before beginning the exercises.

70V ExFHCfSFS — PAIA-

HAS AVD Stockings,

DEEP BREATHING.

119

Rule 4. — The time devoted to the exercises should be from ten to fifteen
minutes, or longer if indicated, and the number and diameter of the individual
movements should be regubted according to the general condition of the patient.

Rule 5. — Instruct the patient to perform the exercises regularly and never
to omit them because she feels tired or lazy. The patient should not become
discouraged too soon, as it may take a long time to attain the desired results.

Rule 6. — Concentrate the attention upon the exercise and the action of the
muscles involved, otherwise the best results cannot be attained.

Rule 7, — After each exercise there should be a brief period of absolute
muscular relaxation, and if the breathing or the heart's action becomes hurried
a rest must l>c taken until they calm down again. Never exercise too rapidly or

Fic. jaj. Fir., uf.

FxtirrsE No. 1. Dttp BrMLtbiog.

Shf>*Lnc ibc p«i:inQ t«fdv ■oJ duriDiE Iht evrrci»r Note Ihr eleviliafl ol ihc ghc>uUJnJ ami choI id

filfurr 135.

the correct |»osilion of the Ixxly and the pro|>er play of the muscles will be dis-
turbeii.

Rule 8. — Aflcr exercising in the morning take a cold sponge, spray, or
plunge liath, and dr)- ihc skin vigorously with a coarse lowt'l. .^fter exercising
at night take a full warm bath and get into bed at once.

The following exercises should l>e taken according lo ihc foregoing rules in the
firder given, and the numl>er and character of the movements should be regulated,
as stated above, by the strength of the patient.

Exercise l. Deep Breathing.— Stand erect with the hamls resting i>n
the hips and inhale slowly until the lungs and chest are fully e.xpanded. Now
hold the breath and contract the abdominal muscles for a few seconds and then

130

INDOOR EXEBaSES.

exhale gradually until the air is completely expelled. Breathe through the o
and repeat the exercise tour times in a minute.

Bzercise 2. Abdominal Contractitms. — Stand erect with the hai
resting on the hips (Fig. 124) and alternately contract and relax the abdomi
muscles.

SxeTCise 3. Tnmk Bending Backward.— Stand erect with the hai
resting on the hips (Fig. 124), and after taking a full breath and contracting
abdominal muscles bend the body slowly backward; then gradually straigh
up again and exhale the air from the lungs. Rest ten seconds and then rep
the movement.

Fio. 116,— Ex BSCiSB No. a.

Abdomiiul CmtractionB.

The dofled line show? I he mort-

menis of the abdominal wall.

Fir., iij. — EXEtcise Kq. 3. Tnmk Bmd-
ini Backwud.

Exercise 4. Trunk Bending Forward. —Stand erect with the ai
raised as high as possible above the head, the palms of the hands turned
ward and the thumbs loosely interlocked. Then take a full breath, conti

the abdominal muscles, and bend the body forward without bending the kr
until the tips of the fingers or the palms of the hands touch the tloor. Pi
return to the original posiiion, raise the heels from the floor, and exhale the
from the lungs as the arms are slowly lowered to the sides of the body, f
ten seconds and ihen rejjeat the movements.

In bending the body the arms and hands must be kept extended out in tt
and the back gradually bowed as the trunk falls forward. At first the pati

TSUNK BESnilNG — TKUKK TWISTING.

tai

ibic to touch the floor with the lips of the finRer», hut after usltig the
exrtdsc for mnic lime t)i« spinal column be^omcx llcxibte and it can be acoom-
litl'ihed without ilitht-ully.

Bxetciae 5, Trunk Bending Antero-laterally.— Tlie movementH are
be same as in No. 4. except that the lK«!y is ln-nt bit-rally in^ie^d of directly
forward and the lips of ihc fingers touch the tloor first on one side and then
on ibc "(her I'Fif;. i;o).

Exercise 6. Trunk Bending Sideways. — Stand erect with the hands
revting on the hips (Fig. 114)- Then take a full breath, contract the abdominal

Flo. iti HlG, iiv

Fjrewiin Ko- 4. Truak B*ii4liic Forwai*.

■nd bend the trunk alternately Acveral times tow-ard the right and
head should follow the movements of the body. Rest ten wcondA
■nd rrpeal the cwrci** (FiR. 1,11).

Exercise 7. Trunk Twitting.— Stand erect Vith the heels close logiether,
thrKntMUre«iini;i>nt))chip>iFi;^. iijl and the thighs and legs rigid. Then take*
'the alMlomituI miisiles, and twist ihc trunk several time? from
" r a« fur a^ povsihir; the head •'hiiubl follow the nin^vmcni&of
Ihc Uxly. Km ten Mocmds and then rejicat the exercise (Fig. 133).

123

INDOOR EXERCISES.

Bzercise 8. Squatting.— Stand erect with the hands resting on the hip

the heels separated about four inches. Ti
full breath, contract the abdominal muscles
slowly assume a sitting or crouching po:
with the buttocks close to the heels. '
straighten up again and exhale the air froi
lungs; rest ten seconds and repeat the r
ments.

Exercise 9. Trunk Raising.— Lie fi
the floor with the legs extended, the feet
together, and the hands resting on the
Take a full breath, contract the abdoi
muscles, and raise the trunk slowly until a s
position is attained. Then gradually retu
the original position and exhale the air
the lungs; rest ten seconds and repeat
movements.

Until the abdominal muscles become a
tomed to the exercise the patient should s
her tegs by placing the feet under a bureau
couch. During the movements the shot
should be thrown welt back so as to ex
the chest and keep the spine straight.

ExerciBe 10. Raising the Legs.— Lie flat on the floor, the feet

Fla. tja. — ExEioBE No. s- Trunk
Btnding Aauro-Utarall; (pige
III).

Fia. Tji. — ExEiosE No. 6. Trtiak BmmUhc

Sidcrar* (pa|c iii).

Fio. I3J.— EjmiciSENo. T. Tmok
Twiitint (pigc m).

SQUATTING — TRUNK RAISING.

IS*

Fio. Tj], Fmj. ij«.

ExEtcrac No. a, S^iMttliic.

Fio. 1]S.

ExEXcIlE N'o. g. Trunk Riiilof.

INDOOR EXERCISES.

together &nd the hands resting on the hips. Take a full breath, contract
abdominal muscles, and slowly raise the legs straight up to a right angle y
the trunk. Then gradually return to the original position and exhale the
from the lungs; rest ten seconds and repeat the movement.

If the patient is unable to raise both legs at the same time, they should

Flo. IJT.

Fio. uS.
ExuosE So, ID. Riiiini the Legi.

elevated alternately until the muscles become strong enough to accomplish
regular movement.

Bxercise li. The Dip Movement.— Lie on the stomach and chest,
palms of the hands flat on the floor close to the sides of the body, the toes somen
beat, and the feet close together. Take a full breath, contract the abdom:

ia6

BAUNE INJECTIONS,

Special Directions.— The beneficial results which should be derivec
from the exercises cannot be obtained unless the technic is thoroughly carriec
out and the rules strictly adhered to. It is especially important, except In exercisi
No. 2, to have the abdominal muscles firmly contracted and the lungs filled will
air while the various movements are being made, otherwise the muscular ton
of the abdomen will not be restored and the breathing capadty will not be in
creased.

The effects produced by the exercises are greatly increased if the patien
breathes deeply and keeps the abdominal muscles moderately contracted whei
walking. At first this is rather difficult to accomplish, but gradually as thi
muscles regain their tone the effort becomes less marked, and in time the abdom
inal walb contract naturally.

CHAPTER XI.

SALINE INJECTIONS.

Preparation of the Solution. — A normal salt solution is compose
of one drachm (0.78 per cent.) of sodium chlorid to a pint of distilled water.

It is prepared and kept ready for use as follows: Six glass flasks (each havin
a capacity of two quarts, about 2000 cc.) are filled with distilled water, and t
each is added four drachms of chemically pure sodium chlorid, which is nm
prepared by manufacturing chemists and sold in drug-shops.

Each flask is then plugged with cotton battin
and its rim protected with a layer of the sam
material, which in turn is covered with a piece c
gauze, and the whole secured by a string tie
around the neck of the bottle.

The flasks are then placed in the high-pre
sure steam sterilizer and their contents sterilize
as follows: The steam is turned into the heatin
coils and the outlet valve of the sterilizer left opei
As soon as a large volume of steam escapes ^i
the valve, which shows that all the air has bee
driven out, it is shut off and the pressure in th
sterilizer allowed to reach fifteen pounds. At tb
end of five minutes the steam going to the heatin
coils is shut off and the pressure allowed to grat
ualjy fall to zero by the simple process oj condei
salion or cooling, which occurs in about thirty-fi\
minutes. From le^^ts made by the author with
self -registering thermometer the saline solution
subjected to a temperature of 241° F. It is nece
sary to bear in mind when the steam is turned o
at the end of five minutes that if the exhaust \-ah
is opened the sudden release of the pressure wi
cause the solution in the flasks to immediately vai>orize and their conten
will be lost. On the other hand, if the pressure is allowed to gradually fall 1
zero by cooling, vaporization does not take place, and but little, if any, 1
the solution is lost during the process of sterilization.

When the pressure falls to zero, the flasks arc removed from the sterilizi
and placed in the storage case until ready for use.

F[C 111. — CUS! Ft ASK COMTAIH-
ING NORHAL S*i,I SOLlinON ANIJ

TT-rc^.EO WITH Cotton Bat-

TINO.

TKHFEtATltllE OP THE SOimON,

Preparations at the Time of Operation.— At the time ol an
ot«nilii>n or whenc^'cr a salinr injci tirni i* rei|uirrci tlie r«:t|uiMte number of Basks
are taken out of the ^^orage ra$« and half »f iticm [ilnced in the in»trumenl vterilizer
ami immened up lo dwtr necks in water. The steam b then turned into the
hruiing c»il» and the wiiti-r luiiled for ten minuici, which ruises the lemperaiure
u( ibe MiUnc »>lution in the llasks to ig6° F. (actual test made by the author).
We luvc now iw(> !>ei!^ of diiskti, one of whidi contains cold and the other hot
salt solution, which are rently to be mixcil in the injection rejcriroir when needed.
Vi'hen ex'enr'thing U prefwrcd to rIvc the injection, the string around tlie neck
of a but ami a cokl lliivk is rut with ^ci-uor^ nivl ihe |>rotectinf; cip ;ind plug of
ftaiuc and cotton balling removed. A quart trf the a>ld Milulion i> then jioured
directly from ihe tlisk into the );lass rescrx-oir and the hot wluiion added until the
ibermonwiCT registers lltc pn>|ier tcmfieralurc.

In removing the protecting caps from the flasks' care must be taken not to
aw the free edges of the gauxe and cotton l>altinf; lo come in contact with the
uuth of (be bottles, otherwise they will t>ecome conlaminainl and infect the
solution when it U poured out.

Tbenaometer.— It i.4 absolutely nct-es.'ary to uie a ihennomeler in order lo
determine wiih accuracy the icmijeraturc of the solution in the glas.* reservoir.
The instrumeni U sterilized by placing ii tor ten minutes in a 5 per cent, aqueom
>i>)utii>n of formalin ami riaMng it with ^l<!^ile WAter.

The combination thermometer is the l>e^l instrument I know of

for the fKirT»«e, and it is kept in the glass rcscr\"oir to register the temperature

oi the dilution while the injeclinn is l>einK given. Before sterilizing the thennORi.

both end? are proiecte^l with rubber tubing to keep it from knocking Against

be siller of thf reM;r*-oir and breaking (Figs. 144 and 145).

Temperature of the Solution.— The tcmj^rature will rary acconling
lo the ruuic by whioh the j^iluiion is thrown into the circulation, and it must be
^■Misluntly rcgi^teml l>y ihe ihcrmomeler in the re^rioir.
^M There is, iin an average, a lossof fmm live mien degrees of henl in the wlution
^■bcfcrc it rvat.he> tin? cannub, needle, or rectal lulie when the ordinary' apparatus
^■k useil for atlmini-^lering s.ilinc injcrtinns, Jind the icmiieralure in the reservoir
OWM iberefofe l>c regulated to offset this reduction and deliver ihe tluid jil the

tmper tempemturc into the Ixxly. With a properly c()nsirucle between one and
twoileffrret. acconling to the route by which the injection enters the rirculition.
Thv kiM nf heat U int1uen<«d by the temperature of the room, the length and
nijbrr nf ihe tulic, and the sixe of the onnula. needle, or rectal alLtchment.
Tbrrr i^ Itmi Iom of beat in a tube of brge caliWr than in a small one, and in a
tb)irt than in a long lube. It is a mi.it:ikc therefore to have the tulw over six feet
la Irttf^h, as the reservoir should never be elcvale<l higher than thai distance
ibove the |Kilicni anil any additional tubing Ls not only unnecessary but it makes
mffe dilTiruil to *U'lain the pro|»er temjiersture of the solution. There is
ny* i-onswlrrable loss of heat when a small ncerile i- UM-d, a* ihc solution flows
I ^)w)y ihrmigh ihc tube that the tcmjwrature of the room has mure ellcct upon
I than when the calitirr is Lirge.
(tne o( the most important factors In the lecbnic of giWng a nonnal salt
tiiin bto keep the Holutiun in the reservoir at Ihe proper
IB ta lure during ihe entire procedure. This ts easily accom-
Iby wilirfaing tlie tliermonwler in the reservoir and oddinga small tiuantity
1 tolution whi-n ll»e lemju-ralure liegins to drop. When the reservoir needs
MBBiqt the o|>rr.)ti>r must "top Ihc tlow by pimhing tlie lube nhilc the asstsunt
thv solution at llie rc(|uired temperature.

^^ter

128

SALINE INJECnONS.

General Indications.— injections of normal salt solution are indicated
in the treatment or prevention of shock, hemorrhage before, during, and after
operation, sepsis, uremia, and renal insufficiency. A saline injection must never
be given in cases of hemorrhage until the bleeding vessel is found and tied. It
should therefore not be employed in the treatment of a hemorrhage following an
abdominal operation or a ruptured ectopic gestation sac until the operator
actually starts to open the abdomen and search for the ruptured vessel.

Fta.

144.— ComiNATioH TauHOHcni

tpige

FlO. I4i.— RdBBW TUSIKQ PUCBB OH BOIB

Ends of the Thehouztik to pHmct 11
rBoii Imjuiv tpmsr u?)

Routes of Entrance into the Circulation.— A saline solution

may reach the general circulation through (i)a vein, {3} ihe subculantous tissues,
and (3) the lower bowel.

In giving injections by these roules the first is called an intravenous
injection, the second hypodermoclysis, and the third e n t e r o -
cly sis.

I30

SALINE INJECTIONS.

An ordinaiy fountain syringe may be used and the cannula attached to it if
graduated reservoir is not at hand.

Instruments.— (i) Scalpel; (a) tissue forceps; (3) dry dissector; (
straight scissors; (5) Hagedorn needle-holder; (6) two small full-curved Hag
dorn needles; {7) plain cumol catgut, No. a, three envelopes (Fig. 147).

Antisepsis. — The apparatus is sterilized in the high-pressure steam
instrument sterilizer. The hands of the operator are carefully prepared by mea
of mechanic sterilization (p. 8 14) and the bend of the patient's elbow is scrubb
with warm water and soap; then washed with a solution of corrosive sublinii
(i to 1000); and finally douched with plain sterile water,

Temperatnre. — The solution in the reservoir must be kept at a constj
temperature of 105° F., which gives an average of 103° F. or more at the moi
of the cannula.

Fio. 148.— SoramaAL Vfins or the Ann

AND FOKZAUI,

Step.
The urn constricttd by s budife uul the niitt
foTcann diilamed.

Rapidity.— The reservoir should be held from two to six feet abov»
patient. At six feet the solution flows into the vein at the rate of four ou
every minute, or about one quart in eight minutes. The speed of the flow sb
be regulated by the strength of the pulse, and if it is weak the reservoir shott
held closer to the patient so that the injection will not enter the vein too rap

Quantity.— The quantity of a single injection varies from one pint t
quarts, according to the indications in an individual case, and it may be repe
if necessary, in the vein of the other arm. Usually, however, an intrave
injection is followed later on by either enteroclysis or hypodermoclysis i
necessity for a rapid or profound impression does not continue.

tt*'— tnuvuKHn Stum titxmoK.

TW •ftatl Ut—wr IWd. Ibt iir<«|i> vHb-
tnm^ ukl • tap <M>qai cm m»ti taom Ik*

■U-— IiinitvuiotTi Sum iHiicncni. fM

Sup l|H«C I|II.

Shom iht itnrul* l>Mna untiMliM*d tBta OwvMBiUe
Ike uhubhi u hfM Op(» vM MMfs.

SwftiMl Step.— An incuion » made directly scrooa Ihe most prominent Tetn
: I ' ^-f-Kiit ur nvnrlhchcnrl of Ihe elU'wami ihr vcv*cl expotcd.

, 1 ' rt i-ijiosiRt; the vein ^houkl not be made junUkl to its bonier, u

the veod vli^n lu one i>i>lc and it Ls difficult to dissect OUl.

13a

SALINE INJECTIONS.

Tliird step. — The vein is carefully dissected out with the tissue forceps anc
dry dissector and one inch of its length exposed. The forceps are then passet
under the vein and two catgut ligatures placed beneath it (Fig. 151).

Fourth Step. — The dbtal portion of the vein b tied with the lower tigatun
and the tissue forceps withdrawn. The middle of the exposed portion of thi
vein is then seized with the tissue forceps and put on the stretch, and at the sam
time a deep oblique cut upward is made across the vessel with the scalpel, ex
posing its lumen {Fig. 152).

Fifth Step. — The operator allows some of the solution to flow through thi
cannula in order to expel the air and get rid of the fluid which has become cok
in the rubber tube. He then inserts the cannula through the opening in the veil

Put. I]4i — INTKAVIN0D9 SaUHI IhJECTTOH. Fifth

Step.

Tlir cumulu introduced into the vein and Kcured
10 postLoo by Ihr upprr lacalurr.

Ftc. 115. — IxniviHatn SAun Ihjictioii.

■ath Sup.
Tht cuiduIa withdrawn and the (vtuonial a
the vein liftaled.

while the solution is flowing through it, and secures both the cannula and ve
by tying the second ligature tightly around them (Figs. 153 and 154).

Sixth Step.— The compression above the eibow is removed and the solutii
allowed to flow directly into the circulation.

During the injection the assistant constantly watches the reservoir and not
the temperature and quantity of the solution.

Seventh Step. — When the required amount of solution has been used, t
second ligature is cut and the cannula withdrawn. A catgut ligature is th
placed under the vein and its proximal end securely tied.

The wound is then closed with two or three catgut sutures and dressed wi
sterile gauze which is held in position with a few turns of a roller bandage 01
strip of Z.O. plaster.

HYPODERHOCLYSIS.

Indications. — This is a comparatively slow method ofi
troducing a saline solution into the circulation and should be employed only a:
supplement to an intravenous injection or in cases in which time is not an impa
tant element. It is therefore indicated in cases of slight shock or hemorrhage
which a delay of twenty minutes to half an hour is not injurious to the patient,
is contra indicated in profound shock, excessive hemorrhage, uremia, and

HYPODEKMOCLVStS.

»33

marked renal in»uf&dency except ss an adjunct to ibe intravenous route. If
ihe heart's actuin '» vay rapid niul weak, tlK aljM>rpii(>n i* so »law at in ren>
er hypitiiTtnorlysE' i>raclic.illy inefEcctiw and more or less useless.
Apparatus.— This consists of a t^aduated (tlass reservoir, a thermorocter,
(cet •>( rutilMir tiibinfc (culil>er ^ of an inch), nnri ii litr^ it«pintinK ncedte.
If a graduated rr^wrwiir i« nnl at hand, the aspimting needle can be attached
I an ordiiuiry founuin syringe.
^stiscpsis.— The Mtnt antif«ptic preiiarutions are cairied out as for an

Fic

MVi roi GivmD HiMDumcinu.

ettous infection <sce p. 130). Stippiimtion shouUl not occur in ihc tissues
nlcM the icchnic of the openliim is imperfect, esccjrt, however, in cases of
in which it »on>ctimcs results despite every precaution that is taken to
ai^iiisl the ac<ident.

jmpcratnre.— The wiliilitm in the Tr»cr%'oir muM be kept nl a con^ianl
Icniper-iUirr ••In ;° !■'., which give* an average of 110" F. or more at the mouth of
the needle. A hi^h temperature causes quick stimulation and promotes rajiid

Pio. Ill— Actual Sis or nu KtmLa t'un n tlniipniiminn.

^B^ Rapidity. — TTic reservoir shouhl lie held six feet abnw th« patient. At
^Hk» heiKht ihc M>lulion pa^MS into the subcutaneous tissues at the rale uf about
^^nc jitni in from fifteen to twenty minuleti.

Qoantity. — The quantity of the wituiion injected into the tissues depends
Upoa the irulicalioDS in an individual case. Frequently re|ieatetl injections of
MwU amounts are more efTeclive. .is a rule, than a lincli- Lirgc injection, From
I fluncnt li> one pint are iiKU.-illy gi\Tn evrn- six houi^. and in some instances
,}' be necessary- to inject at frequent intervaU as much as three or four quart*
I Mihiilon within twvniv-four houn.

134

SAUN'E INJECTIONS.

I/OCal Anesthesia. — The skin should be anesthetized by a hypoi

mic injection of cocain, or by freezing i
ethyl chlorid or ice.

Situation. — The injection must be gi
where there is plenty of underlying loose ceUi
tissue, and under no circumstances should
fluid be injected into a muscle. The best sit
tions are (i) at the sides of the chest ab
three inches below the axilla, (2) under one
both breasts, and (3) between the crest of
ilium and the twelfth rib.

Operation.— The operator first all-
some of the solution to flow through
needle in order to exp>el the air-bubbles and
rid of the fluid which has become cold in
tube. He then thrusts the needle deeply 1
obliquely into the cellular tissue while the si
tion is flowing through it, and as the tissues
come distended gently strokes or rubs the e
to facilitate the absorption of the fluid. '
assistant constantly watches the reservoir ;
notes the temperature and quantity of the solut
When the required amount of solution hoi b
thrown into the (Issues, the aspirating needl
withdrawn and the operator places his flngerc
the site of the puncture to prevent the fluid b
escaping. The wound is then dressed wit
layer of sterile gauze covered with collodion.

Flo. ijS.— Situations in which Hy-

FODIBVOCLY&IS 15 (jlVEN-

Fio. 150. — GiviNR HvponmiiorLisi? I'Nueb ihk I.trc Br£«3T.
NcHf that the fluki conlainins hoi nnd crtid Afklin? ^Uitinn frar IrrrpinE the fluid in Ihe reKTvoir ai a comUDt
ivrnlure are placx^d ni'ar llii' pa[it'd[x

CKTUtOCLVStS.

I3S

If thr flow (if i)ic «aluliOH t* too slow or li noses altogdher, it cun l>c remedied
tiv T>in|i|iin|} ihe tulie with the lingers from :ilK>vr downward or by rotitin); the
lie or pushiriK ii in further uiul iben HiihdRiwing it a tittle or dunging tite
sitioa n( its point.

ENTEROCLYSIS.

Indications.— Thb melhtxj i^ frequently eropluytd as an adjuDd to
intrjv«n'<u.s injoclioius and hy|>oderm<H-U->in. It is mucb lesii effcrlive
than cither nf the other two methods and is never used alone
when A detitled and rapid action is reqiitret). It ti often Riven, however, as a
riiytine pnclicc aUt-r ;)lxlominal i>|H;niti<>nE before the palicnt leaves the operal-
iiij; i.ilik In order to lessen the desire for water during ihe first twenty-tour hourK.
Apparatus. — ThLi consists of a icniduaicd glass reser%'oir. a thermometer,
MX feet of rulibcr tubing (caliber J of an inch), and a rectal lube twenty inches
looR (No. 35 Frendi scale). If a Rraduale<l rr*erVoir is not at hand, llie rectal
tube nn Ke attached to a fountain syringe.

Antisepsis.— The apparatus Is sterilixed in the bigb-pmaure steam or
irument ^t(■^ili/c^.
Temperature. — The tolu-
in the reservoir must be kepi
'iCronsiani tempenturcuf iii°r.,
trh Kive» an .ivcrage of al>out
i" oi the nwmh of ihe rectal
tutie, ^i« there U less lo9.e hcM four feet slxit'c the
itieni.
Quantity.— This depends up-
itbe tndi«alwns in an Individual I'll /^ m

t'wally. lH>wever, from one
to one <|uan is injected every
tiit hour^.

'Situation. — llie injrdlon
be gi^en high up in the
cwelor it will l>c ex))elk>d. as the
ilum itnelf will not retain over r>o
[ lix •■.f et);ht ftun^.'es.

Position of the Patient.

— Tbf |iiuiii xhnuld l>cpbcrd on her side in the right lateTal'prone position
hi|is cirviitcd on a pillow. If, however, she cannot be movcrl from
t rerumlient [xf^ifinn. the Injediun can readily be gi\%n by ekvaling
■ hii"? .loi! 'Irawinj; up the knees.

Operation.- The opcraK'r first allows wmc of the solution to flow through

ret tal tulie in order to expel the air amt gel riil of the lluiil that liax betxime

, ill Ihe lulling. He then stops the llow by pinching the tubing, and after

itinj; the recint lutie with sterilized vahelin or oUw ull, introduces it slowly

I ihr rrtlum Ixyond the slemokl tlexure. The required amount of solution

(hen allowed to flow gr.iduully into the liowel, after which the retlal tube is

VriihilmwD aiwl the [tatirni place<l in her former |Hi*ili(in,

The ai^ixant coivitaniiy watches the reservoir and notes the temperature and
Tianljiy nf the solution.

nnat.

Otmu Einu»-

136 CAUSES OF DISEASES PECULIAB TO WOKEN.

CHAPTER XII.
THE CAUSES OF DISEASES PECULIAR TO WOOEN.

The causes of the diseases peculiar to women are classified as follows:

1. Anatomic Causes.

2. Hereditary and Congenital Causes.

3. Civilization.

4. Social Conditions.

5. Education.

6. Unhygienic Conditions.

7. Childbirth.

8. Sexual Relations.

9. Criminal Abortions,

10. Venereal Diseases.

11. Accidental Infections and Traumatisms.

12. The Different Periods of Life.

Anatotnic CatiseS. — The relations of the uterus and its appendages wi
the abdominal cavity and its contents, as well as the fact that in the female the
is a direct external communication with the peritoneum through the Fallopi
tubes, constitute important factors in the etiology of diseases peculiar to womc
Thus, in cases of general and local peritonitU having their origin in causes cot
mon to both sexes, as in appendicitis, intestinal obstruction, etc., the effe
are distinctly different upon the female pelvis. The inflammatory exudates i
only cause intestinal adhesions, but they may also result in distortions and fii
tions of the uterus and its appendages, producing many chronic subjective syn
toms and the destruction of the functional activity of the pelvic organs. Aga
the direct communication with the peritoneum, by means of which varic
septic and specilic infections gain access, results in the production of cert;
diseases which, so far as their origin is concerned, are peculiar to women. Th
for example, gonorrheal, tubercular, and other forms of infection may be '
posited upon the vulva, in the vagina, or in the uterus and pass directly through 1
Fallopian tubes into the general abdominal cavity. The anatomic relatic
existing between the genital and urinary organs render the latter espedally lia
to diseased conditions dependent upon infection and traumatism. The sh(
ness and dilatability of (he urethra and its comparative freedom from strict
lessen the chances of a vesical calculus forming and exempt the urethral ca
from many of the organic affections common to the male.

Hereditary and Congenital Causes.— The inherited tendency
tuberculosis and malignant affections is often a predisposing cause of disease, i
women of a strumous diathesis are found to be susceptible to certain functic
and organic disorders, such as dysmenorrhea, uterine displacements, and 1
korrhea! discharges. A morbid proliferation of embryonal cells is the caus<
dermoid and parovarian cystoma, and also of cysts of Gartner's duct, while .
interference with the vitality and development of these cells by the infection of
fetus with syphilis, smallpox, measles, or scarlet fever may cause an arrest in
normal ^owlh of the organs of generation without influencing in any way
general physique of the individual. Again, cont;enital influences which prod
various malformations and anomalies of the female genito-urinary organs
simply attempts on the part of nature to return to a former tyf)e in the pro-
of evolution. And, finally, a woman may be sexually weak as the resul
inherited defects in the vigor of her genital organs. "Such defective here

Cn'ILtXATION — RDUCATION.

'37

^^b probably not finterally iminc<li»ie, but is jn'jduul in iu tlrclrnNion, gencnlly
on tbf mmcmiil side, tcmlini; (>y 'nntinuims ik-grncntiim to induce in ihc pmRcny
'e«blc ^«T^u.^l [urmiiiion. frofiutnily in the uienis. 'Iliu* ihc (ini .sihkc tn:iy be
tunil in a vronun of (Icfiricnt sexuiil appetite, having a uirru.'' of mcxJenlc
i:vcUii>fni;nt, but contracted at itf^ o|>cninK. which may be lacerated in her first
mfinement so. |wrhai», as to |jrevem further convc|ition. The child, oolil-
nnrred, misymimlhelif, iin<l egoiMic. wiili :i (eebly detrlopcd uienu and
ist at marital rights, becomes pre);nanl only by chance — it may be. long
tfier marrlaice, or after suaessful o|>er.ilioii ; or, with a coniccnitnlly i-untmded
ihmtgb pCTTnrnbic upper vaginu, ctowil hymen, or a tendency to the infantile
Ivis «ilh absence of sexual api>ciiie. she becomes the mother of one child,
iho has a yet feebler unimprrKiuible uieru* utuI jilmphicil ovaric*. with dc-
cmtatnenbl discharKe ;ind a premature menopause; or more marked
.bmnnfclity may occur, and tlic woman be sterile" (Playfair).

CivlUxation.— Tile natuml muscubr Mrenglh ami power to resifl di*-

fc ti greater in women belonging to sa^'age tribes. In these races there b

t little, if any, difference between the endurance of lite male and ibe female.

1 af ni: aKCvml in the ^^Ic of iniclii^-ncc and dvilizatton. leaxing the natural

a more artificial life, the contrast becomes marked, and amon); highly civilized

Maple t)ie m.ile in. by far the most powerftd. AF:ain. ^tmnntE savage rai-c-- there K

ICH Inumatism during lalmr. as the children have small head» and consequenlly

many i>f (he immedLste as well as the remote conditioni dependent upon cod-

6nement are \c^ Irefi'Lienily seen.

Sodftl Condition, -'rhere is a PMrked difference between working-
women itnd women of the bijtber grades of society as to the frequency uf various
Heninvurimri' diKeaacg. The lower claw*? receive le-« skilful altentiun during
aivl after cunbnemcnt, twnwquenily septic infection is companiti^-cly frequent and
irxumati>mi (kcut more often and arc cither improjwrly rejiaired or nrglectet]
ahogctbcr. The higher classes, on the other hand, suffer more from neurasthenic
oonditions and various subJM-li\« >ymiit»nv- which are more or le.ss dependent
oxm their envinmmenl and habit* of life. Furthermore, women of the lower
CttMcs are atTeited loss by the dLteases from which they suffer, and it b not
unrommon to find ihem altendins to ibitir.'' anil Inliots which are ainsequeni
to bringing upa large family, while suffering from local conditions which would
mice an invaliil of a woman tn the higher walks of life. Finally, ceruin occupft-
ikiBn are hkely ti> rvT'ult in [wlvic <ti>«a*rs, and we find that women who work io
Urlorirs or stores where they are recjuired to stand continuously for hnun at a
tirae (retjuendy sudcr from uterine dUpliceraents. while those who use the sewing-
tnachine an a raeai>« of support arc very apt eventually i" de^lop [Mirtal and
|«lvic congestion. Occupations requiring heavy hfling cause retrod isplacemcnl
ami prolapse <rf the uienti, ftiixrtially in women who have iMirne children.

Sducatlon. —Our modem hystem of cJucation has a decidedly injurious
influente u[ion the general and sexual sirenf^h of women. Too little attention k
[Hid Io the drvelopmrni of (he physique and the general health in our elTons to
Ipve yiiung girh a polished education. There is no altem|>l upon the fiart n(
iHfents or oluial'irs to rrT,-ulaie the ^unount or character of mental work to suit
ihe hotllhaml (emju'rameniof the individual, and luxtmNiileralion U given to the
ntosftity for speiial care and attention at the time of puberty and during the
'""I'trual [icriods, when nature demands physical and mental rest. Vouog
;ire »enl to m hnol or to college atwl subjected daily to kmg hour> of study, in
Liuintwfl [Kl^il>»R^ ami In Indly ventilated class-rooms, regardless of their urc
or phyKical condition or the demamli- of their ?exual deM-lopmeni. "In
"nr tvaid, it ia to the present cramming and high-prcMure «y«tem uf cducaliuD,

138 CAUSES OF DISEASES PECULIAR TO WOMEN.

together with its environment, that I attribute much of the menstrual derange-
ments, the sterility, and the infecundity of our women, the absence of sexual
feeling, the aversion to maternity, the too often lingering convalescence from a
first tabor, which is frequently the only one, and the very common inability to
suckle their offspring. From this cause come most of my unmarried patients
with ner\e prostration, with their protean mimicry of uterine symptoms, — un-
married often because they are not well enough to wed. If woman is to be thus
stunted and deformed to meet the ambitious intellectual demands of the day, ii
her health must be sacrificed upon the altar of her education, the time may come
when, to renew the worn-out stock of this Republic, it will be needful lor our
young men to make matrimonial incursions into lands where educational theories
are unknown" (Goodell).

TJnhygienic Condltlons.—General and Local Cleanliness.— The
general health is often impaired by neglecting personal cleanliness, which re-
sults in blocking up the pores of the skin and interfering with the function ol
one of the most im|)ortant and necessary excretory organs of the body. While
want of cleanliness is common among the lower classes, yet women of thi
higher grades of society are often careless or have improper ideas as to the can
of the skin and the genital organs. The imponance of the vaginal douche i^
frcquenlly overlooked, and consequently many cases of pruritus vulva and othei
forms of vulvar irritation occur which are directly caused by irritating dischai^e;
from the vagina.

Care of the Bowels and the Bladder. — Constipation is an important factot
in the causation of many diseases and symptoms peculiar to women. An over
loaded bowel mechanically interferes with the pelvic circulation and tends t(
produce congestion of the uterus and its appendages. As a result misplacemenb
of the uterus occur, followed by functional and organic disorders, which givi
rise lo dysmenorrhea, menorrhagia, metrorrhagia, sterility, endometritis, etc
Slow toxemia frequently results from the absorption of the fecal matters by thi
blood in obstinate cases of constipation. The symptoms of this condition an
characterized by headache, neuralgic pains, anemia, general indisposition am
a slight basic heart murmur with deficient respirations and chest expansion
Irregularities in emptying the bladder, while not so injurious as constipation, havi
nevertheless a bad effect upon the pelvic organs. Habitual overdistention ma;
be the primary cause of a retrod isplaced uterus or of vesical irritation, am
neuralgic pains in different parts of the body not infrequently result.

Precautions During Menstruation. — The civilized woman, unlike he
savage sister, does not recognize the importance of physical and mental rest a
the time of the menstrual periods, and consequently many pelvic disorders ar
directly traceable to carelessness, neglect, and imprudence upon her part. Shi
exposes herself to the inclemencies of the weather, often wearing thin shoes o
insufficient clothing, and makes no changes whatever in her daily social and house
hold duties. If the continuance of the flow interferes with her plans, she oftet
checks it by using a cold vaginal douche or taking a cold bath. Young girls
especially those passing through the period of puberty, are not permitted to res
quietly at home during their periods, but arc sent as usual to school, where the;
are kept hard at work, ignoring absolutely the demands of nature. The suddei
checking of the menstrual flow either by design or accident may cause inflam
matorj' changes in the uterus, the ovaries, and the Fallopian tubes, which fre
quently result in endometritis, salpingitis, peritonitis, functional disorders, ani
sterility. Many of these women become invalids and are condemned to constan
suffering as the result of neglecting common-sense precautions at the time 0
their menstrual epochs.

UmVCtENlC CONDITIONS.

»39

£iercis«. — Daily exercise in the open air is essentia) lo he»l(h, bul unior-
tuiutely mnny vr<>inen ncfilKl thL% imjH>rtitnl tncaiiN uf kcvpinft (he muMruInr
^Kystcm and the orKanlf and niher fomis of outdoor sports have develojied the physique and
'wren^liencd the vexuiil n^)(iln^ of the younger women, but unfortuaitcly many of
the oilier vromcn luke but little or no exercise, and consequently suffer from
obesity, Unpaired digestion, trreRularities in the menstrual fundion, neuralj(ic
ptiu, bM of n[>|>eliir, and dirunic con^ltpittion. V^'hilc (he importance of
excTtise cannot be overestimated, yet we must War in mind thai it should be
ref^Ltrd to meet the re<iuiremenls of the iivlividual, anil that o\-erexeraw Is
ftbo apt Id be folbwed by evil rer'oll^. I'unhermore, exercise is contra indicated
ditritiK menstniaiion, and young girls and women should not dance or eiigaf^e in
outdoor %p(irLH at a time when nature demftnd^ Inxlily and mental n^t.

Food.— The health of the entire body depends upon the character of the food,
and hence errors in diet are amoni; the most frequent causes of disease. The
iK>rmaI a>ndilion of the Kcncrati^'c organs cannot be maint.iined by poor blood or
an cxhttusted nervous s)-stcm. and con^qiicnily women often suffer from various
qmploms i]r pelvic affections which are directly caused by the state of their Keneral
bckllh. Thu«, the uric arid diathesis often produce* d)'smenon'hea 3nd load
neuralgic pains; anemia is frequently rt^|>nnsible for amenorrhea, cxrlain forntt
at endometi^tLH, and various other «imiiii<iiis de|ieti<ii-iit u[>un impuverlihed
blood; and chronic dysjiep'ia or conMipatinn, tiM> often the re«uh of over-in.
dulgena in catinK and drinking, adds to the already long list of female coro-
ptainU. The drinkinK and overfeetlin;; of women in brite ritiert, opecially (n
fashionable fociely. have a marked causat i^v influence upon dii;cam;s of the female
pelvie. The formal dinners and late suppers where unliealthful and indigestible
NxxU anil drink), are taken are certainty not conducive to a strong body with
normal functions, and consequently women who thus indulge their appetites
cTOttUully sulTer from an undermined conMitution and rhnmir pelvic di>cai&
Dkm. — The chief fautis in the methods of dressing arc insutScicnt protection
I body from cold ai>d dampness, constriction of the w-aist, and traction upon
_ iloniinal muM:lesby thcclothtn|(.

If the entire iHxIy is not protected from cold, the blood is driven from the
irr .ind the inlernal organs become tooKesicd. Tlie (lelvic vi^kcera are very
uTptible to tlwNC inlluenccs. csjiccially rluring menstruation, when the parts
ire naturally enKorgcd with blood. Serious injuries arc therefore frequently
)iau«ed by wearing thin shoes, or undergarments made of unsuitable materiali,
»hich leave the iwrck. the chest, the arm*, the alwlomen. and the lower ciiremitics
Bn(iroie<-ied. \Von>cn who habitually near i/^fiV/rMorvTr^' light gowosoftcn suffer
imm fiiiittional or organic dborders of the fwlvLi through exposing them^K-es
E)i> >uildrn ihanfcn of tem;icramre, es|)cc-ia]ly when, after becoming o^nrrbcated
(ky (lancinc- ihry leave ihe ballroom and become chilled by silting in a draft.

The nwih.mic elTcfls of alalominal n-'»tridion wriously inlerfcrc with the
urmal conditions and the functions of ihc thoracic, abdominal, and peliie
Thus, respiration is modified by resiricling the pluy of the diaphragm,
the heart, and coinpre^aing th« lung« and the alxlomiuil muscles,
'ui^-and-down motions of the .ibdominal and pelvic organs, which arc de.
pemlcnl upon full inspiration and expiration, and which assist maleruilly in
urorinf; intestinal |Krixlatuii aixl e4)uatixing the circulation of the {iclvis, arc
injuriously restricted by crowding the diaphragm and the lungs. Tight lacing
liao ilUplaccs the alxiomliul viscem downward upon the jielvic orf^-l^.'i, weakens
■ad atfnphic* the aUlomiTuI walls, and impairs the function of all the organs.
The uterus b usually dbplaccd backward and downward, obstructing (he pelvic

I40

CACSES OP DISKASES PerULUR TO WOMEN.

circulation and causinf: chronic congeslion, which results et-entually in (unclinnal
and iirganir Hi«inl(rrs. The uterine ;i|ipenila^es an- Itkcvrii'c crowded out of their
normal position; the Fallopiun tubes arc bent and the relation existing between
their fimbriated cxircmilics and the ovaries is desiruyed. ConMricli(>n of the
abdomen during pregnant y m;iy iircxluce a)K)rli<m or prvmaturc labor, or it may
change the normal presentation and position of tiK fetus. It aha in<.rea>e3 ihe
natural congestion or hyperemia of pregnancy, and therefore predisposes ut
varicose cnndiliorwof the thighs and the vulva. These women usually haw weak
labor pains and convalescence is delayed by a slow involution of tlie |>elvic or^m.
The i>r):ans of the abilominal cavity also suffer seriously fnim the pressure
exerted upon them by light corsets. The caimcily of the stomach is lessened and
the food fiasscs into die duodenum before it is prepared for intestinal di^e^tiun
Thi> results in gastric and intestinal dysjieitsia, which is accumiNinied by dis-
tention of the iKiwels. The IrTiusvcP'e C"i<m and the kidneys are displaced
downward, the liver is compressed, and its duas may be obstructed. The ma-
stipiilion whidi usually reAults fnim tight lacing i& caused by the gastric and in-
testinal indigestion, the loss of peristalsis, and the constant pressure of ilte dis-
placed pelvic organs upon the rectum which in time lessens the recuil reflexes.
Apficndicilis has also been tr.itefl m the wearing o\ tight corsets. While the evil
etfecis of tight lacing upon the health cannot be dbputed, yet there is no valid
rciisim against wearing corsets which arc properly made and applied, except in
the case of women whose occupation rctjuirc* them to Ix-nil forward when in a
sitting position. Under these circumstances corsets exert an injurious pressure
ujHin the al>domen and crowd the vis<'era down U]Jon the i>clvic organs.

The habit of supjKirling heavy clothing from the wiiist has the effect, as in
tight lacing, of also pressing the contents of the lower abdomen downward upon
ihc |jelvic organs.

High-hecled shoes arc injurious l>ccause they cramp the feet ami preveni
acti^'e exercise. They are e-''pe<-ially harmful when worn by young girls liefore
the articulations of the body arc fully dcvcl"i>cd, n-^ ihcy alter the normal spinal
curvature and pchic obliquity. Garters worn around the thighs predbpose to
varicose veins of the legs.

Rest. — Women often destroy their health and exhaust their nervous encrg}-
by keeping late hours and by not devoting sufficient lime to sleep. This is
e?i])ecially true of young women in fashionable society, who night after night
attend late social functions and consequently suffer In lime from neurasthenia
and mcnslrual irregularities.

Childbirth.— Injuries Resulting from Labor.— Injuries resulting (mm
labor are a frequent cause of pelvic disease. The lower classes, owing to poor
environment, and unskilful or careless attention upon the part of the physician,
suffer more often from traumatisms and their results than women in ihe higher
grades of society. TTie immediate and remote results of these injuries depend
upon their situation and extent. Tears of the fierincuni destroy the intcgrily of
the pelvic Hotir and result eventually in rectocelc, cyMoreIc, hemorrhoids, and di»-
placenienis of the peiiic organs. If the tear involves the sphincter ani, incon-
tinence also results. Laceration.'; of the cenix relani or check involution of the
uterus and predispose to cndomctrilis, menorrhagia, displacements, eversii>n of
the cervical mucous membrane, cystic degeneration, and malignant disease.
Deep lareralions of the vaginal vault may ojien into the base of tlie broad liga-
ments, and in the majority of instances gcnito-urinarj- fistulas are caused by
traumatisnis of lalwr. All lacerations are immediately dangerous on account
of the increaM^l liability to sejisis, while the remote results are generally due to
interference with involution nr the pelvic circul;ition and to the destruction of the
normal supports of the pelvis.

CUILDBIKTH.

t4I

Bad Huiagement During Labor.— Women frequently \nfe their lives or arc
condemned to chmnic invalidism from unskilful, carek'». or f)c};lcctful attention
during: labor. The tmined nurse .ind the prarlinil leachinii ■>( (>tf>tetni> in ooir
mllcnes liaw undoubtedly done much to lessen the danger* of labor, yet we can-
Dot iRiKirc die fjii th;ii miiny women jrc still uscle*slyMnTifited from these cauM%.

BJul UnQagement After Labor.— Bad miinuEemcnt alter Udwr t. unfor-
luiulely a very comnton cause of [>elvic di«>ease. The obstetrician muM alwajTS
bear in mind that normal convaloteme dejicnds ii|xin a healili) involution at
the organs and that any atti«e or CDndilinn which interferes uiih this process
nmdures immedialc or remote results whiih arc more or less danf^erous to
ufe or In health. The mixil (rectueni and ;il the ume lime the mr»A prcveniuble
errors in the inanagemcnt of puerperal patients arc— the failure to recognize
and repair lacerations: an imi>erfect antiseptic lechnic; the custom of keeping
the patient upon her back lor several tlay-f or longer after delivery; the use of a
li^t bandage; and gelling up too early after conimcment.

A careful examination shoiiUl be made imme<Ii;itely after lalxir for the [>re»-
ence of bcerations involving the perineum nml the vagina, anil l>efiire the patient
i^ finally discharged the entire };cnilal tract should Ijc thoroughly investigated in
onler to make Mire that no iriiimiitism-'' h;ive l>een uverUH>kr(l. This routine
practice l-^ e^seniial to the future welfare of ihe patient, as neglected lacerations
will eventually result in conditions which are exccedini^ly diffit-ull to cure by lale
•econdary opcriilimw.

An imperfect anitwplic lechnic upon the pan of the obstetrician or nur»c
•houtd be strictly Kuanled againsi.as infection is oneof the most unfortunate and
dangerous accidents that can happen t<> b Inng-in woman.

The custom of keeping a puerperal pa.tient u[)on her back for an inilcfinilc
lime after lalxir is a ixrnicious and tinrcii^malile j»mclicc. In the dorsal recum-
bent jxisture the heaw uterus must of necessity fall backward and downward,
iu liftaments being put u|)On the stretch itnd the pelvic circulation more or leis
ubsiructtd. Furthermore the luchial discharge collects in the \-nginal culdcac,
torming a stagnant pool which interferes with free drainage and increases the
dangcn of se]ini.><. This i>nictice, therefore, checks involution. predisjKiscs to
puerTHrral seplicemb. and is a frequent cause of chronic retrod isplacements of
tbc uterus. The useof a ti^hi bandage after bbor, especially when a compress
nude of several towels is placed dircclly over ihe uterus, cannot l»c too
cantestly ct>ndemned. The practice is absolutely contrary to reason and is in-
joriuu* to the jutient. Tight compre.viiun of iheabttomen farc«s the inte^lines
down upon ibe {lelvic organs and pushes' the ulcr\is and its appendages back
ifainst the sacrum. .\s a conwquence the uterus may lie bent upon itself, its
ckcululion otMtrucled, ami the loihial disc^uirKr ke^X up beyond il.« normal
lirar. Tile i>i<>iiion of the uterus also predisposes to a permanent retrod isplace-
laent. and a biicraiion of the cervix, if it exists, is prevented from healing by
aowditifi; the neck of the uterus against the ^'agina and thus everting Ihe lorn .-.ur-
(aocs. And. finally, the Fallopian tubes may be bent aiM) their secretions escape
imo the peritoneal cavity, causing sufficient irritation to set up a slight exudu-
fin inflammation.

AUowing the |>alient to get up loo soon after confinement or aflcr an abor-
dnn will almost surely result in subinvolution an<l dispbiemenl of tlie uterttt.
Real ia eseenlini after lalKir. in nnter that involution may go on normally sikI
that the pans may be restored to their original condition. Assuming the erect
poaition loo early |nils an abnormal sirain u)M)n ihc uirrine hgiiments. which,
weuming Mrelchett. allow lite ulcrus to descend and the circulation of Ihe pelvis
la become obsiniclcd.

143 CAUSES OF DISEASES PECULIAR TO WOllEN.

Sepsis. — In the vast majority of instances, for the reasons previously dis-
cussed, septic infection is due to bad management on the part of the physician
or the nurse, during or after confinement. In some cases, however, puerperal
septicemia may result from a previously existing pelvic disease becoming sud-
denly active after labor, and thus, as the result of either an extension of specific
inflammation or the rupture of an old pus tube, septic infection of the peritoaeum
may occur.

Sexnal Relations. — Marriage. — The primary object of nature in the
creation of the sexes is the continuance of the race, and the fulfilment, therefore,
of a woman's destiny is completed by marriage. Nature is an exacting mistress
and resents any interference with her laws by causing atrophy in organs whidb
are neglectful of their functions. This rule not only applies to the organs of
generation, but to all parts of the body, and perfect health and symmetry of
action can only be obtained by all the bodily functions fulfilling their purpose.
Thus, if the muscular system is weakened and atrophied from want of exercise, the
general health of the individual suffers, and in like manner the condition of the
entire system depends upon the vigor of the genilal organs. While single wonteo
naturally escape the accidents dependent upon marriage, pregnancy, and labor,
yet they suffer, in many instances, from certain conditions resulting from celibacy.
They are, for example, more liable to develop uterine fibroids; the ovaries often
become painful and cirrhotic; the superficial fat disappears from the body and
they become thin; they are apt to be anemic and suffer from neurasthenia; and
the menstrual flow may become irregular as to its periodicity, quantity, and
duration.

Long engagements are a common cause of the break-down which happen:
to so many young women when, for financial or other reasons, their marriages an
indefinitely postponed. ttTiat Playfair describes as the "sexual engorgemeni
in love-making" is responsible for the backache, the fatigue, the hysteria, th«
nervous exhaustion, the anemia, the leukorrhea, the menstrual Irr^utarities
and the general debility which so often result in these cases.

The marriage of women suffering from pelvic disease is often followed b]
acute exacerbations due to the congestion and traumatism of sexual inter
course upon an otherwise quiescent lesion, and not infrequently serious domestii
unhappiness results when pain or a mechanic obstruction prevents coitus. It L
for this reason that complete hysterectomy is contra indicated as a routine opera
tion because of the shortening of the vagina, which seriously interferes with thi
sexual act. Furthermore, the question of sterility often arises when marriage L
contemplated, as an unfruitful union may be a source of great disappointmen
and consequently the cause of a slowly developing neurasthenia. And, finally, i
must always be borne in mind that certain conditions, such as menstrua
irregularities and functional disorders of the nervous system, are frequently
benefited by marriage.

Sexusl Intercourse. — Women often suffer both locally and in genera
health from unnatural interference with sexual intercourse. The most frequen
excuse for disturbing the normal relations is the prevention of pregnancy, >
practice which is unfortunately hut too common at the present day. Thesexua
act must be complete, and any interference with (he normal function of coitu
by "withdrawal," the use of condoms or injections, or other means to preven
conception causes congestion of the pelvic organs which eventually leads ti
functional and organic disease. Sexual excess exhausts the nervous system am
in time produces chronic aingeslion of the uterus and its appendages and result
in endometritis, menorrhagia, and other forms of pelvic disease. Violent inter
course during pregnancy may cause abortion or premature labor. Vaginismu

CMUINAL ABORIIOSS— VENEREAL DISEASES.

'■W

Is tifien ilie re&ull of brutal or incffcclual aiicnipi§ at ioiercour^, while iinpotency
upon tbc part of the male t>nMlui:eH (iiiiKOHliuii of i)ie female urgans and neu-
licnui. Coitus during mcn^irvuiion ha» been knnnn to caufe pcKic hcma-
Masturbation anil dll forms of ^xual pcntmon result in lo<:a] confiesllon
iiniMurment oi the health. A <li>pn>|ioniuii between the nule »nd female
organs majr cause various degrees of traumatiym. This is frequently observed in
ckMSof npe when the vittim buH not yet re-dihed tlie period uf pubeny. A |ienis
of cxctssi^'e length may injure the peine organs bydirecl cnnud durinje coitus.
CxiniiUll Abortions.— The chief danger of criminal abortions is
Kpu>> which may (juse immediate denth or result in Mcrility and dmmic in-
v^idism fr«m pcrmancni damage to the Fallopian tubes. .^Ksin. subinvolution
or dlspUcemenU of ilic uterus arc ver)' apt w folloiv. as patients do not remain
lung enough in bed for the or^antt to return tn their original slate. In ca.'>n of
BOORiptcte abortiua the ovum or the membranes may remain in the uterus for
cciMiderable lenftth of time and cause a continuous heniorrhaite. which often
luces A prof<>un<l anemia. 1'hc ignorance, a.^ a rule, of the pn>fc9.''i(>nal
ibt on all matters jjcriaining to antiscpsb and the subsequent managc-
'inent of the ciNe; the secrec}' demanded, which does not allow the patient to
rcccii'e the pro|>cr care and altcnlion; and the utter disTcgard of the serious
nature nod d;)ngcrs of the operation, contribute to make criminal abortions
etpectally fatal or liable to be (oIIowqI by chronic lulio-utenne disease. On the
otacrhand, wlukt adi^crrnt picture is presented when the gravid uterus is emptied
jot ll» wnicnts for tlicra|>eulic re^isons! There is no secrecy because tJiere is no
linaliiy, and the ojieration i* t>^rformeil practU.dly without ibnger to life
nause seixsis is prevented by a pn>pcr opeTati^v technic onrl the cn%-in>nmenl uf
operating room, while the remote consequences are guarded against by the
Dt»*«<]iM-nl f-.treand attention.

Venereal Diseases. — Gonorrhea and syphilis produce pathologic con-
Utiou wbich are jiechkir to women.

Gonorrhea is the most frequent cause ol those grave pelvic le«ons which
mull in loss of life, sterility, or dironit invalidism. ^\^leIl the infection attacks
the urrthni, the clleil> are ihe same as in the male; but when the vulva is the
e-ji of ditease, ihe specific tnllammation is liable to enter the duels of the vulvo-
aginal gbnds and cause an ali^^ss or a chronic form uf gonorrhea, or, again, the
*(M)dfic virus may extend to the uter\» and it» ap|>endngrs and the periloncul
cavity. The absence of glands in the vagirul mucous membrane is the probable
noaon why that organ is so seldom primarily infected. Latent gonorrhea Is
my frequent in both kxcs, and the diM.-n!« may remain in a dormant slate (or
years, but still retain ils power to infect another person. This is the cipbnution
of the fact tliat so many young wives arc infected by hu.->bands who have lM>t had

KiMirrheu for tnonlhs or years before marriage aitd who are unconscious of any
at trouble. The importance, therefore, of the absolute < ure of all gleciy dis-
tharKes before marriage cannot l*c ll^'e^u^tiInalcd. I.alcnl pmorrhea i* the cau.-t
: time* of (Hierpcnil sepsis and of recurrent attacks of [)erilonitis. The infcc
na of a wom:i» with gonorrhea does not. as a t\ilc. produt« acute symptoms.
C^ gradually cause* luluicuie [wrlvic manifcslniions accompaniol with im|iatred
-Whh and nlcriliiy. Gonorrhea occurring in childhood as the result of rape or
icddental infection may cikusc an arrest in the ilevelopmenl of the gcnitid organs.
The primur}' unil ^econdai^- nunifestations uf syphilis when they attack Ihe
LrulvB are more or less modified by the character of tlie eilcmal organs. Thus,
[the hnl aiwl m'>i)'lure of the pan.> as well a> the effect pmdured by Kpftosing
fwrfacca are apt lo ullcr the usual characteristics of chancre^. coi>dyk>mata, anil
nthcr IttkMis. CliancToids for the same reasons are often atypical in their courw.

144 HISTORY TAKING.

Accidental Infections and TranmatlBm8.—Fonner1y septic in-
fection following intrauterine medication and treatment was a most common
cause of disease. Fortunately, however, modern views have in a large measure
done away with thb source of danger by relegating to the past the routine office
use of the uterine sound, the employment of tents or stem pessaries, the direct
medication of the endometrium by injections or by cotton-tipped probes saturated
with an astringent or alterative remedy, and dilatation of the uterus without an
anesthetic. Bad results are likely to follow an imperfect antiseptic technic
in minor operations upon the uterus, urethra, or bladder. Atresia of the cervical
canal may result from an amputation of the cervix or a trachelorrhaphy, or from
the application of strong acids to the uterine cavity. Rough manipulations
during a pelvic examination of an adherent uterus or of diseased appendage;
may produce acute pelvic inflammation and even death. A badly adjusted oi
cared for pessary may cause serious injury from pressure or septic inflammation
Vaginal injections containing bichlorid of mercury or carbolic acid may causi
poisoning from absorption unless the vagina is subsequently irrigated with plaii
sterile water or normal salt solution.

The Different Periods of I^ife.— Women are susceptible or exposes
to certain diseases or accidents during the different periods of life, beginnin)
at infancy and ending with senility.

CHAPTER XIII.
HISTORY TAKING.

A clear and concise history of the subjective symptoms of every patient i
important. It not only serves as a guide in making the physical examination
but also brings out symptoms which may be overlooked.

In taking the history a regular order in asking questions must be observed
othenvLse important i>oints in the case are sure to be neglected. It is unneces
sary lo have a printed book for recording histories. They may be kept in :
large blank-book or on cards which are filed away alphabetically. It is raud
more satisfactory- to record a hisiorj' in this manner than to write down the symp
toms under printed headings and subdivisions; the latter method lacks continuit
and does not make a connected statement.

The following order must be observed in taking the history;

1. The patient's statement. 8. Discharges.

2. Name and address. 9. Pain.

3. Age. ro. The bowels and bladder.

4. Single; Married; Widow. 11. (General health.

5. Occupation; Habits. ra. Family record.

6. Menstruation. 13. Particular symptoms.

7. Child -bearing record. 14. Summary of symptoms.
The Patient's Statement.— It is not good practice to begin at once ask

ing questions; rather let the patient explain her condition in her own words, as i
enables the examiner to become better acquainted with her and gives him
clearer idea of the chief symptoms.

Name and Address. — Always keep a record of the name and address
the reasons are obvious.

Age. — The age of a patient is important because she is liable to certai:
diseases at particular periods in her life.

AGE,

'45

Durinfi injanty (h« organs of generation are without function, and conse-
ilucntly thi- rhild does not t-mUki fn)m (liscuute* jKCuliur lu hrr mx.

At puhcrly the ^irl is in a transition gtalc. She is neither u child nor yet a
ttiinun. \ivt Te[in>ilu(iive orKmts are undrritoinK ritpid (Icvclo]>mcnt ami the
afifirfinim e o( the nwnMrxial How imticitcs that ovuliition is being established
■tHl that ^he is passing into the child bearing period of her life. Irregular) I ic»
in the ftinclion^ <>( the or^atu of genenilion at \\w jicriod \\avq a fur dilTerent
signibiiincc titan di^turb.incrs later on when n woman has reached full maturity.
For rxxmple: as a rule, menstruation doe> not occur at regular |)criiHlii durin|{
bub«ny. 'Pie first nivnstrualiun may be (ollowed by a jicriotl of rc-il bsting
m>m xstti 111 three months, and frequently the flow docs n<it become regubr for a
Vnr or ntore. Again, the tlow itself may be irregular while the Mihjevti^'e dU-
lurbances of me n»l run lion may occur e%'ef>' Iweniy-eighl daj*!. I'urlhermorc,
tbeiT ifi n>orc distress and pain at the lime of menstruation during the period of
puberty than later un. when .-ill the functions have been fully r>tid)Ii.-<hed. The
Riinil jnd character of a j'oung girl during putx-rty are undergoing those changes
whith arccitntually to produce in her ibc lypidil characteristics of her sex, Thb
ficl, ihtrcfure. mu't l* n inside red in weighing ihe evidence be twc-en dtseai^ed con-
ditions jnd symploms which may In.- (lejK'ndent upon development. We must
H(i(, ho»-c>'ef , atiriliule e\cty symptom lo ithystolo«ic iihenoinena. This would
far it mistake, bec^niNe |uilhoh>^ic conditions are frrtjuenily met during putterty.
For tn^tanoc. in cases o( imiKTforaic hymen the subjecuve symptoms of menstrua-
tion oour rciculitrly, but there is no apiieammx- of the How. Mliile it may l>c
|cf1eiily normal during jnibeny to have (he subjective symptoms occur regularly
vhhouc the same regularity in the appearance of the Sow. yet ihc fact that tnen-
itrwilkin ha& newr been e^tabll^heil wouI<l indicate at once some abnormal
«ondKii>n.
1^ The ihitJ-hearinx Prriod i> the mcMt im[)Ortant time of a woman'-i life. She
Httytakchinl full itvitunly. and It is during this qioch that the vast majority ■■( the
^^I^HDgic i4<ndiii"ns |R-coliar to her sex occur. Irregularities at this time in
r ibc funrliim^ of the reproductible organs, ns well as nmny other >ymplonL>, are
I pathoViglc. and tlir cau^e or causes for them must be found; and while we may
uftrn avoure a young girl wlio is passiitg through puberty that nature will etTect a
cnrr, the <<ame <locs not hold k'mhI in a woman during the child liearing [leriod.

Ilir mmopaiue k a ))cri<xl in the life of a woman during which atrophic
changrH .ire taking place in the organs of generition. These changes occur
»fc>wly, covering a i^riod of two or dirce j-can^, and while lhi» i% a mticnl time in a
woman's life, she should pass through it, as a rule, without any special symptoms.
It i> a grave mi^tjkc to tell a patient who Is tillering from symptoms at ihiA
■imrthat nature will effect a cure, and di'mis> her wiihoul a i>li>>icalexaminali4m.
Many litrs are thus lost because the attending physician faiU lo realize that
Brnorrhngia >nd metrorrhagia occurring at the time of
the Ricnopatite are always pathologic, being caused in
itie majority of cases by malignant disease of the uterus.
Hr ■ --'r •■, in (he beginning lo make an examination, believing that the
" I life" is the cause of the symptoms, and it is loo laic lo perform a

f»anj o when the mtitake i* di.Movereii. The physician must lia*e a

ibonij. iiilge of the mbjecttve and objective tympionv.-'' which ate luiiural

i< i-e, so thai he may be able to retugnize tho<c manifeslntions

« idcnl u|>on disease. It is stifer lo make an apparently unnece»-

«-. rijiinn during Ihb period ilun to remain in doubt n> lo the meaning

»1 ■ ■■!; intn.

SaU/ityh the lul >ta|celnihelifeof aw-unnan. It b the period o( wma) rcsl

146 HISTOKY TAKING.

and functional inactivity. The atrophic changes of the menopause axe now
completed, the external organs of generation and the breasts are shrunken and
flabby, the vagina is shorter and more contracted, the vaginal portion of the
cer\'ix has disappeared, the cervical canal closed, and the uterus and its appen*
dages atrophied.

Single ; Married ; Widow. — The social state of a \^-oman has aa impor-
tant bearing on the diagnosis.

An unmarried woman has not passed through pregnancy and labor, which
are often directly the causes of many of the diseases complained of by women.
She has not run the risk of infection from a husband suffering with latent or acute
gonorrhea. On the other hand, she is more liable to painful menstruation, to
fibroid tumors of the uterus, and later on in life to cirrhotic changes in the ovaries.
We must always bear in mind the possibility of sexual intercourse occurring
in unmarried women.

In married -women and widcnvs who have borne children we must remember
the possible existence of lesions due to gonorrhea, sepsis, or traumatism following
labor, and pathologic conditions the result of interfering with conception.

Occupatloti ; Habits. — Many diseases peculiar to women are due either
directly or indirectly to their occupation and habits, and it is most important,
therefore, in every instance to obtain a thorough knowledge of these conditions.
By intelligently considering the occupation and habits of a patient and correcting
various irregularities and abuses we may frequently relieve existing symptoms
and bring back a condition of health.

A knowledge of the predisposing causes of gynecologic diseases is essential
in making a correct diagnosis and instituting a successful line of treatment. For
example, take a case of amenorrhea occurring in a hard-working woman,
who is underfed, has poor hygienic surroundings, and who possibly is
anemic and exhausted. What good, under these circumstances, would fol-
low the use of drugs to determine the flow of blood to the pelvic organs,
of medication to the vault of the vagina, or of any form of treatment
directed to the pelvis ? The cause of the amenorrhea is not pelvic in origin,
but is directly the result of the woman's mode of life and surroundings.
She does not menstruate because there is not the blood and the necessary nent
force to keep up the function, consequently the only successful plan of treatment
is to remove the causes and Improve her health, letting the pelvic organs severely
alone.

There is nothing relative to the habits and occupation of a patient but what i&
of importance from a diagnostic and therapeutic point of view, and we cannot
therefore be too thorough in our investigations. The arrangement and characteC
of the clothing worn by the patient; the care of the skin, the bladder, and the?
bowels; the diet and the regularity of taking food; the amount of exercise in the;
open air, as well as the time devoted to rest and sleep, should be carefully con-
sidered. It i.'* important also to inquire into the precautions taken during the?
menstrual periods. This is especially true in young girls, as their health fre-
quently suffers from too close attention to study and confinement in the class-
room during menstruation. Careless and injurious habits during the men-
strual periods are often the cause of uterine and pelvic disease. Women frequently-
expose themselves to the inclemencies of the weather, to overexercise, and, ia
some instances, they make use of cold water vaginal douches to cut short the
menstrual flow so that social engagements may not be interfered with. The
importance, therefore, of a woman's habits cannot be overestimated, as the
diagnosis, in many instances, is of no value unless the causes are recognized
and removed.

ilE-VSTBCATIOS,

'■»7

It must be rctncmbcTcd that Hctivc and passive congnlion of ihr pelvic
orpins nuty be <au»«<) by wxuat inicrcourse occurring! during ihc menstrual
pcrkid, or lo the mctluids which are employed to |>reveni roncqnion. such a& the
use of vaginal injections. cundom», etc. Thcr^r condition!' disturb the normal
rclstimui of (he sexiul act and arc oficn followed by inflammalory and organic
IcNons of the pelvic organs. Tart muM alwiij> be exi-rciscij in (lucylioning a
(lalicnl on maltcff [icrtaining lo (he seximl relaiion^, a<^ the subject \i a delicate
one and ihc natural nwilcsiy of women iihould l»c tc*f>ei:ted. Il U f!(">d practice
lij wail until the ph>"5icil e\;irtiin.-ilion ba> Iwen matic l>ef"rf nfemng I" the
»ukjc(1. an<t even then it h still belter to tnik with the hui^band unle^'' the jMlient
wiluhl.iriK mi'iiiioii.-. il.

Menstruation.— A carcfid investigation niu»t be made of the menslnul
hiwoiyof every iKiiieni. A know IcdKc of thenormalconditiont^isesseniiai, if the
value of abnormal symptoms i* tu be cwrrecily c^timaieil. It i.s also necei^ry to
remember that every woman is a l.iw unto herself, and thai the
frried. the duration, and the quaHlUy »/ iJic /low are controlled more by the pcr-
Mtnal equation lluin by hanl and fixed rule:>. There is, of course, a general aver-
afte Ko^eming the variims phenomena of menstruation and ovulation, but the
line of perfect health may W far removed in *omc instances while in a numlicr of
I'lher lase:' it may i)c only .ippniximate. To judge ci)rreitly "f the value "f the
iihcnomcna of men^irualion in a given case, the lyfif must tin^t be a^xrlaJned.
Tlibcanunly lie <h>nc by invent isaiinR the character is lit-s of the flow soon after
il bos been fully cftablishnj at j>u)>eny. During thi^ )>f riiHl a woman develniM
hfr lype^by i>'pe we mean the periodicity, ihe quantity, and the duration of tnc
taw, and if Liter on in life she continues to conform with it, her condition is a
Dornial one, no matter how far it miiy be removed fnim the general average.

The cliief subjects lo consider in the in\'esiigalion o( the menstrual history
■re, Ihedalearul reRli>f pul)eny,andlhe pcriodicily, the quanlily, and the dura-
tion of the flow, as well as any abnormal symptoms which may he pre*«nt.

Tile niie ai whith menstruation first ap|iearcd must lie iuscenained. This
(ad will i:iveu.«s»me idea aslo when lheincno[uu»e may becx[>ecte'l. An early
tnibrrlv nvtrans a laic menopause; on ihc other hand, if a girl reaches maturity
Ue in lifr. ii inilinilcv a Uc k of sexual vif-ur, and ihi- 1 limacleric is likely tu occur
before ihe usual time. The history of puberty revrols the type, which is necessary
to kiww in order to esiinute (alhologic variations correcily.

We A*k the iMtieni the length of time l>elween the menstrual periods and
cumparc her statement with ihe type already ascertained. Perfect heahh is
cfiDMsiciil with occasional deviations from the original periodiciiy of the (low.
There are so many factors, both menial and physiiiil, which affect the reguLirfty
of meiHtru.ttion without any ap|>arcnt injury lo the health that ne must he wry
uUe{ul noi to by too much stress upon occasioail deviation. -Again, we must
licar in minil th:il perm.iivcnt 'le^iations frttm the original ly[ie are not incoci'
«iktcnl ulth hralth. We frequently meet women, especially ihi>»« who have
Imene chililrcn. »h» meitsiniaie a day or two ahead of time witliout any apparent
eflcft uiMin ihrir health or the |>elvic organs.

The next question to consider is the quantity of the flow. The amount of the
Bow \$ lit more imiMirlnnce than its duration. There is alwaw a cause for
rxccMive bleeding at the time nf nwniitruation— i 1 is a symptom of a
pathologic condition — and its origin must Iw determine*! before con-
tUerinK the ipicMian of treatnicnt. A full ht>lory h. im|Kjnani. therefore, Lo
mD oue» of mcnofTbagb, as the lifcof a inalienl may de[>end ufmn a correcl
dhgyit.

The avemge dumilon »f the flow ii> IcM ronHtanl tlian other characterixttca

148 HISTORY TAKING.

of menstruation. The duration in a given case must always be compared with
the t}'pe. Health is not inconsistent with irregularities in the length of the
menstrual periods provided the quantity o£ the flow is not increased.

The subjective symptoms of menstruation are not marked, and women who
are normal only experience a sensation of weight and bearing-down in the pelvis
and in the lumbosacral region. Pain indicates a pathologic condition. There
are so many causes, both local and general, producing irregularities in the men-
strual function that an intimate knowledge of the subject is necessary to diagnose
and treat this class of cases successfully. The causes of the abnormalities of
menstruation are fully considered elsewhere and need not, therefore, be enlai^ed
upon here. We must, however, always bear in mind the ever-present possibility
of pregnancy and the necessity for a thorough investigation of the effect of habits,
social conditions, etc., upon the function of menstruation.

Child-bearing Record.— We ascenain the number, dates, and histories
of the labors at term, and also the cause of any miscarriages that may have
occurred. Rapidly succeeding pregnancies often lie at the root of certain
pathologic conditions. For example, the hypertrophy of the left ventricle which
normally takes place during pregnancy may become permanent, if the recurrence
is rapid, and result in an organic lesion of the heart. The character of the
labors often indicates what we may expect to find upon physical examination.
Thus, a rapid labor may cause injury to the soft parts or an instrumental de-
livery may result in extensive tears of the cervix, the vagina, and the perineum.

The history of a patient during convalescence after confinement gives us a
practical knowledge, in many instances, of the stale of the pelvic organs, so far
as conditions dependent upon sepsis are concerned. If there is a history of
puerperal septicemia, we may expect to find a pelvic lesion unless the patient has
subsequently borne a child, which fact would prove that the oviducts had not
been permanently damaged. Premature deliveries and miscarriages are a con-
stant source of septic infection, and a pelvic examination must always be insisted
upon in these cases. If a i>atient gives a history of having had an abortion, we
must ascertain at what period of gestation it occurred, and if possible the cause.
The general causes of abortion must be borne in mind, otherwise many points in
the diagnosis and treatment will be orerlonked. The paternal as well as the
maternal causes must be considered in cases of spontaneous abortion, as such
diseases as phthisis, syphilis, and alcoholism in the father may affect the fetus
and render a miscarriage inevitable. The maternal causes are of more impor-
tance, and too much care cannot be taken in their investigation. Criminal
abortions are especially liable to be followed by septic infection. This is due to
the want of technic knowledge and a lack of antiseptic precautions upon the
part of the professional abortionist.

If a woman is sterile, inquire if she employs any method to prevent conception.
If she does, it is unnecessary to look further for an explanation of her condition-
On the other hand, if she is naturally sterile we must endeavor to find the cause,
and not lose sight of the fact that the husband may be at fault.

Discharges. — We ask the patient if she has a discharge between the men-
strual periods. If she answers in the affirmative, we must inquire as to its history
and charactef.

The history and character of a discharge frequently explain the existence of
lesions found upon physical examinations. Thus, a discharge following puer-
peral septicemia or gonorrheal infection would explain the presence of a chronic
endometritis or pus tubes. Discharges which are associated with grave pelvic
lesions generally present a definite cause and are the result either of septic infec-
tion or gonorrhea. The discharge which comes on so gradually that the patient

PAIN.

'49

icuiwltle to fix the date of its ap|iear3nccis,as a rule, due to pa56i\<c omfcestion
■nd due* not result in ktihus jx-lvic (liM;ii>e.

A diM'harKc from (he i;cnual canal other than the nicnstruat flow is »]>oken of
an a Uukorrkea, or " Iht vhiUi." It m.iy inine fn>m ihi- mi1v», the urrlhni, the
\'aeinii. the tervix. the cavity <if the uieni'S, i>r (he oviducts. The nurm.nl secre-
tions from the different portions »f the K^nitai trail have their peculiar rhar-
a<:teri»li<%l Ihu.*, fnim the \-\i\v-,i and viigin:i the)' are whtli^h in oOor jnd nf n
oxamy (.-onsutcncy, from the ccr\-ix (hey are tenacious and clear, like the white uf
anrxK, nml (mm the uterine cuvity and nviducts they are thin and white.

The nomMl M^rotions an nheml by di^ea»e, and nt timo ll b impottsibte to
deicrminc ihcir source without the aid of the microscope. Severe inflamnuiions
anri infertionx due to );<>""''''''<■'■> '"" ^^j'^i^ produce j>us cclU, and the <lt^haricc
liecnmcs purulent. The presence of bWid also changes it* di^linguishinR |>ro|>cr-
lic*. and it liecomes ^nRuineous in character. An offensive odor indicates
putrrfnttion, and v- frequently ciiuswl by ntnccr or a vUniKhing poly]>.

Hypervcri-tion in not necessarily a sign of disease, as ii may be due 1o a
«l)|tlit c(>nf;esti«n from a tem|Kir3r>- cause and requires no »>]iivial atlcniinn.
Many •<in>en ntui huve a leuknirhr.il diM'hiirKe JUM before and after each
Rtcn^mul period, which b caused by the m<inihly congestion of the peine orfSins.

A.« a geiKral statement we may say that a discharge which occitrs
hefnre puberty lia» its origin from the vulva, and after that
period its source is, as a rule, ulerinc.

Fain. — Pain in the nwwt constant Kyiwculojiic iiyra|)tom, and El i» kitualed,
BS a rule, in the iumtwia^rai and iHguiitii/ regioHt.

LumlK>:^cral puin or backache is not characteristic of any special form o!
pelvic leiion, and it may l>e due to a variety of «iuse>, a*, for example, the |in»-
sure of a ulerinc or pelvic tumor, dragging upon the uterine Itfjamcnts, e.-.|wiially
ihc ulerosacnl, chri>nic const i) Kit ion, etc. Retn id i-. pin cements of iIh* uterus arc
u n>mninn cau.'^- of backache, and the sym3>tum is most marked when the ivomb
b bound ifown by adhesions.

Pain in the inKuinal rvgitmi UNually indicT■te^ disease of the uterine appen-
dai^ or ligaments, but its true cause can only be determined by a |ib)-skal
eumlnation,

i'ain may al»o be situated within the [iclvis, above the symphysis pubis, at or
near the coccyx, in the anus, the rcciun), the vulva, the ^"agina. or along the couf»
o( the urethr.i. or it may be asM>cble<l v'itb a function of one of ihe {lelvic
orpins. Pain due to a |)elvic le»ion may I>e referred m a distant pan nf the
U«iy ; thus, there may be iKumlgia of the anterior aural and enemal cuiane-
i<Uk nerves of the thigh, or it may lie (clt in the region of tlic heart, the altdomj-
Btl ntcrra, the head, the face, or the ntammary ghnds.

A^k the luticnt if site has pain, and if she answers in the afTinnative aMvnain
the (ollowbg details: Where it l* siluatcil; the jNiinl nf gFealc^t intensity;
•faethrr it is sjKmlaneous or evoked; its characteristics; the effect of exercise
upon it ami il.s jHissible connection with a function of one of the jwlvic organs.

The iiluutiun of [Niin at once dir«.'cti( nur attention lo the prtitublr seal of
tnnible. Thus, in a lesion of Die ooccjs the pain will be felt in the coccygeal
Trgi'tn. the ^Jln)c is tr\iei>f theanus, the nrctuni, ihcbkuldcr, the vagina, and of all
the privir i-ruan-! If the pain is felt wilhin the pelvic cariiy, its jxiint of greatest
ale in a general way the organ invobwl. Spontaneous |iain
'd !>}■ an acute comlition. while evokol |>ain indicates a more
'< kM chronii- dictate. The characteristics of a pain often show tlic nature of
the IcKMin. In retrodfepU cements of the uterus the pain l> felt as a dull ache, in
•cBic indammatiotui of llic uterine apifcndiigc* it is sliarp and brKinaling, in the

I50 HISTORY TAKING.

obstructive forms of dysmenorrhea it is paroxysmal, while in inflammatory
diseases of the external organs of generation it is burning or itching in character.
Exercise or exertion of any kind increases pain.

Pain may be associated with a function of one of the pelvic organs; thus,
painful menstruation (dysmenorrhea) or pain during coitus {dys pareunia), \inn&-
tion, or defecation may be mentioned as examples.

Pain in distant parts of the body should be carefully investigated and its pos-
sible connection with a pelvic lesion borne in mind. It must also be remembered
that pain may be referred to the opposite side to that in which the disease is
situated. This is not common, but we find it to be the case, for example, in
lateral displacements of the uterus which put the ligaments of the opposite side
upon the stretch.

The Bowels and Bladder.— We must question the patient as to the
condition of the bowels and bladder.

Constipation is the rule in a large proportion of women, and it is all-impor-
tant to determine its causes and results upon the pelvic organs. The causes
of constipation are due, first, to those conditions which are common to both
sexes; and, second, to those which are peculiar to women. One of the most
frequent causes from a gynecologic standpoint is a retrod Jsplaced uterus. The
constant pressure of the fundus upon the upper part of the rectum dulls the
rectal reflexes and consequently the presence of feces ceases to excite defecation.
The same condition results from the pressure of adhesions and pelvic tumors.
Lacerations of the pelvic floor interfere with the mechanism of defecation and
render it difficult for the patient to completely empty the bowel.

Constipation is not only responsible for a number of so-called gynecologic
symptoms, but is also the cause of many local and general diseases. A chronic-
ally overdistended rectum, for example, pushes the uterus forward in the pelvis
and stretches the uterosacral ligaments and eventually results in a permanent
backward displacement. Congestion of the pelvic organs and hemorrhoids are
also due to constipation. In obstinate cases the patient's general health suffers
from the absorption of fecal matters by the blood, which gives rise to a well-
known train of symptoms. Prolapse of the rectum and fissures of the anus result
from straining at stool.

We must always remember the necessity for a full investigation of the rectal
symptoms, and the importance of the gynecologic causes of constipation and its
effect upon the local organs and the general health. The relief of constipation
alone is often followed by the disappearance of many of the so-called gynecologic
symptoms.

Some women suffer from diarrhea at the time of menstruation.

Bladder symptoms are ver)' frequent in woman. The most common are,
pain, frequent urination, and retention or incontinence of urine. Some women
have more or less vesical irritability at the time of the menstrual periods; this is
not pathologic.

In investigating urinary symptoms we must first consider those causes which
are common to both sexes, and second those which are peculiar to women.
The gynecologic causes are due to the anatomic arrangement of the pelvic
organs, their functions and diseases. These facts must be borne in mind when
taking the history of a patient. Owing to the anaiomy of the female pelvis the
support of the l)ladder and the urethra is often destroyed by traumatisms oc-
curring during labor which produce various degrees of prolapse. The intimate
relation e.xisting between the bladder and other pelvic organs frequently causes
functional urinar}' disturbances as well as organic diseases which are due to the
extension of inflammation. The various functions of the oi^ans of generation,

CKNEHAL HRAI.TII— PARTICTLAB SVlirTOUS.

"S»

•achumenstniaruin.Mxuiilinten^irie, child bearing, and lalMr, expose women
!<■ TTwnv <ip«iscs :inil injuries which arc nftcn direttly nr indircclly ihp caiL-* nf
funi'tioniil IT (fr);anic uriivin,' disorders. Pres>urc uiwii ihe bliirJdtT by a iwUic
ttinwir or an enbrxnl or <lt>pbced uieriu may cau»e frequeni urinution ai the
result (>( iTTitAlinn or Ict^icncil c.ipjicily. If the prL-ssurc is tirtn and directed
j|Cain.Hr ibe base of the bhdder so as to shut o^ ilie urethra, retention of urine
ra»uli.v Thu cundiiiun k met in imiiactecl )x-h'ic luinors and in<'arcicralion& of
the pregnant uterus.

The female bladder is less liable than the male organ
to inf lamina tary attacks, and consequently severe form*
(if cyst it is arc comparatively rare. In many instances the urin-
ary «vmplom.i are )>urely reilex ami are <tii*! to ()is«l^e> in other orpins.

' ti^neral Health,— A careful lii-i<)r>-nf the Kcncrjl stale of the patient's
health is imtMtrtani, as functional disorders <'f tbc alimentary canal and the cir-
cublury am! rer\ii*i» M-mplonw arc often deiiendent u]H>n relVx irntation.s (ram
pelvic diseases. A^in, we may meet with patients who are suffering with pelvic
»ym|>iom!> which nre <Iet>endenI entirely u|M>n organic di»eascs in other oi^ns,
and in wb<»m iw> V>ral lulbologic condition i* found. The importance, therefore,
oi X careful, general histor)- must not be ov-crlooked, as it is a valuable guide in
nuking the physical examination ami a great help in mrrectly judging l>etween
aiuse ana] ellett. It enable us to locate the ^eat of disease and to place the
pfifier value ujmn rcllex symptoms in other organs or in mhcr jKins of the boily.
Amenitirhea may di.-|>cnd upon pulmonary phlhi-ii>; memirrhagia, upon a heart
Inkm: or various pelvic aches and [uiins upon nerx-ous prostration and
other general causes. On the other haiul. we must remcmWr that a pelvic
legion may lie the priman' cau^ of a nervous break-down, and thai no
imimtvement may be expected untU the local disease is relieved.

Redex »ym[Homs in other \niTlt, of the bcxly due to [lelvic diieaM are verj*
frequently met. Ciastro-intestinal disturbances are the mosl common pheno-
mena. t>>'4pcp«ia h frequent and is often iis«ociiie<l with nausea and vomiting.
ronMiiiiiiiim with ilaiulcmc may Iw a distre^King symptom, and in rare instantr*
jialients sutler from intestinal catarrh. Neurasthenia, next to ^asim-inlestinal
dbturbanccs, U a riom )mi>oriant manifestation. The symptoms are naturally
vuied anil there is nothing chnr.irt eristic in their Rniupinc (o indicate the cause.
The motor svmpioms, as a rule, are not marked, although patients may be
unable lo lake a(li\e exerciNe on ai-omnt of the I<>m •>( mtL-icular strength.
Tl»e seniwirj- phenomena arc more or less constant, but ihey «xy both ait to the
charaiier and severity of the symptoms. Most patients complain of a tired feel-
ing and an utter lack of di-sire to exeri t)iemsetve\. They nuy abio suffer from
headache, ^-ertigo, cold hands and feet, or from cardiac palpitation.

Family Record.— In tl»e study of discuse, whether it is local or general,

the family ht.slof)' t^ im|>i>na»l. The muther'.-> axe at pulteriy may at limes

siimini for the lite apiiearance o( merKtruation in the daughter; the simc i*

lis*. Mcnstnul i>e4'utiJinliesmay bea family trail and certain

M-ptibility to >uch lieralltaTj- dt^eajes as cnmier, neurosis, and

■ ubrri ulc-i-.

Particular Symptoms.— I'nder this heading are included symptoms
■ad jMihul.-xic cunililions m»t previouidy consjdercil. Thus, a |ialienl may
cwfnpUin vd a luntor or an enbrgemcnl in the abdomen or in some ]inrt o( the
genital tnirt; or. aKain, there nuy lie some special symptom connected with a
f - - "( one of the organs of genemiion. A ihomuKh hiMory' mu.it ilicrcfoee
of all tMini<-uUr symptoms, as Ihey haw an im|H>rUnt Ixaring u|ion

Via, ibi. Flo. lU.

nttEtHAt GntliLU,
Fif. >Ai, QaoUklb elcMd : a, Afi»ri« (ommlBun: «, [■Mniiv imnmiwurF, FIf. lAi, Gtolw

miniii (, mmui*. t. hfiiMai ^ nflsal nniiii; i, Intu nnnculnni: t, jntii'iior niRiBii«m.

Information. — Inspection is one nf the mnsl valunbic mclhivtK wc iK>f»C«
for rcco((nizin}! the various affeclions of tlie vulva and adjacent parts, as nearly
all ihc le»i»n» in ibcsc Mtiiatiuns ran be diugnci^td liy ihelr iipiiearunt-e alone.

MCTHODS OF EKAMINATION.

■S3

Preparation of the Patient.— No prcparaiion whatcvier is required.
If tlic mns are ilouchei) i>rior lo itve exuinination, the iittnuitnul tlbchur^cs are
i«vJ>c<I away anH hrmx nn ino'ircvl (li;ift:no'<4K is likely lo be mftde.

Position of the Patient.— The examinaiion is made in the doreal
poution

TechniC— Adcr jiUcing the patient in ihr proper position the examiner
tia or standi in from of the vulva and iiujjci u the parts widioui disturbing their
OKturaJ rebtioiu miih eacli otiKf. We note whvlhrr (he twd xidi.-> <>( ihe vulva
arc in apposition or whciher ihc vulv.ir canal is gaping. In (he latter c3m; the
«(>nun Ws probably borne sevx^ral (hildmi. and a mure extended examinatiim
wilt rcvMl the pnf^enrc of a brrraiinn accompanied by pndap^e of the anlerior
aim! pdMcrior walls of the i-agina {eyslwf/e and rtttoteit). If the vubar canal
11 cicMol, the labia Khoulil W M-)Mirjte<l and the vaicinal orifice ex)Ht>ed. Th«-
examiner then i><>tcs the :ibsence or presence of the hymen or its remains and any
p«thok>f^c ciinditiofls thai may be present.

The Mimralc orjjan.* atmpotinn the vulva as well as the external urinary
mealus are now examined, and finally the perineum and the inner f^urfaces <•{ the
dklKh* are inspected fur the pre^nce of eruptions ur the exien^ion of :in inO:im-
aatiaa such as fl vulvtlK. If thcrcisany cvidencof discnM-foundal the tirin.vry
nmtus. tlie urethra should be examined in the manner described elsewhere,

Any abnomul serrelinns which are (ib-*rved on the vulva or .idjacent fmrt*
during the rxamination :<hout<i be carefully Mudicd and their vnirce, if iHxtsilile,
tracnl. Usually ihc^e discharges come from the \-agina, but they may also Iw
cauMd by a vulrilLi, or, again, tliey may uri»e in llie uretlura ur in the Juda of the
vulvovtt^nal gbnds.

PALPATION.

llie Limila t io n5. Information, and the Preparalion

and I'o.itioti n( the Patient are the ■^mr a» in Inspection,

Technic— The examiner sits i>r stan<ts in front of the t'ulva. The in-
tegrity o( the |>rHneum is firM detcrmine'l hy inirixlucinR llic imlex finj-er into the
vagina for a >ii->lanc« of one inch ami placing the thumb externally w th;i1 hs
lip is al the cilite ol (he aniertor margin of the anus, liv now rslimatin;; the
amaunt of re*iitance awl the thicki>es> of the >(ructurcs lu-iween llie'e two oppos-
ing poinln the examiner can determine whether or not a median Uar \h present.
Tlic Ko-callefl skin iierincunu often ap|)car n«>rmal on inspection, hut when the
pona are imlfiated the hmall amount ol ti.'<«ue fouml lielnecn the finger in the
vagina and (he thumb externally will at once dcmunsiratc concluM\-cly llic pres-
ence o( ■ laceration.

Ailer campleiinjt the examin.iiion of the \'uln>^-aginal orifice, the examiner
itwn carefully pal^uies the pathologic lesions of itie vulva which were seen
upuD intpc^tion, in order to cunlirm or dUprove the diagiKuis.

MICROSCOPIC AND BACTERIOLtXilC EXAMINATIONS.

Umttatlons. llieM methods of investigation are limited to the examina-
tion ol the dL>charf-e^ which are found on the vulva or of those coming from the
duclN of tlie ml">vagin;d gbndi or the urethra.

Infonnation.- We can determine the chancier of ihe infection in cases of
vulvitis or in inllammatinn of the vulvo\-at;inid gland.<> or the urethral raiuL

Technic. -The methods of colWiting and prrseri-ing the dischaigcs for a
Mibacqurnt microocopic or haclerioloKii. examinaiiun arc fullv discUEScd in
Chapter II

154

THE VULVA.

HALFORlOAnONS OF THE VULVA.

In considering malformations of the vulva it is important to recall to mind
that the clitoris is derived from the gentUil eminence, which in the male becomes
the penis; that the genital jolds, which bound laterally the genital jurrovi on the
under surface of the eminence, become in the female the permanently separate
labia minora, while in the male their edges unite to enclose a canal, the penile
urethra; that the penile urethra thus becomes continuous with the now enclosed
urogenital sinus; which latter, in the female, remains open and constitutes the
vestibule of the vagina; and that the genital ridge, which encircles the genital
eminence as well as the site of the future anus, undergoes local thickening and

Fic. 16,1.

Fio. 164. FiQ. 165.

DrVttOFHEHT OF THE EXTEtNAt GCKITALIA.

Fio. 166.

I. Cliloris; 1. glini cUtoridis: j, uiiaogcnilil fixure', j. labii mnjaTa: s. torn; 6, oxcfgai tmintim; j. btu

miiwrm Imoftitied from Tounieuj)-

becomes in the female the bbLi majora, while in the male the laterally thickened
portions unite with each other to form the scrotum.

As ihc male type of external genitalia represents a more marked deviatbn
from the indifferent fetal condition than does the female type, over-devetopment
of one or more of the fetal structures in a female may easily produce a striking
resemblance to male organs, thus giving rise to some form of false hermaphrodi-
tism. Less pronounced variations produce the minor or more familiar malforma-
tions of ihc external genitalia, such as enlarged labia majora, united labia minora,
abnormally large clitoris, etc., the explanation of which is sufficiently indicated
by what has been said above.

THE VULVA AS A THOLE.

The following congenital anomalies have been observed:
Absence of the vulva.
Double vuU'a.
Infantile vulva.

Precocious de\'elopment of the vulva.

Absence of the Vulva. — This condition is occasionally observed ii

non-\'iable fetuses and is nearly always associated with other anomalies in de

velopment. The anus, as a rule, is also absent, and the parts are covered witl

an unbroken skin surface extending from the symphysis pubis to the coccygea

UALrURUATlONS. CUTOUS.

tS5

rrf'iDn In ra^^ in wlikh the anus is present the chikt may lit-c and void the
urine (hniiich tlK umtiiliai.'*.

I>OIlble Ttxlva.— 'ItiU is a sxry mre condition. It k usually a^sKialcd
wilJi Afi im|nTf<ir;iii- anus ai«l u partial alKtente of ihe redovaRiiuI >«ptum.

Infantile Vulva; — nii* ^innninly i* u^uiitly .-i<«Ki.i1c(t with an im-
|>rrfcii l"riii.iii'>i) •>< ihc uicru)' an>t it^ uppcnduftn am] 3 poorly dcvclopcil
jtcnrml pliyMi)ue. Tlic imiiviiluiil is apt lo lie thloriitic and >ii.'kly. Tlic
»Tjl*ar<-wml>lcf«lhui t<(a child prior l»i mdwrtviind rhi- brea".!* arc undct-rlopcd.

Prccodons Development of thc'Vulva.— This condition is otca-
Monally seen in vrry xoiinf; children >c^<:rMt year- l>cfi)ro the normal period »f
pubcfljr, and b murknl by the uf^ual phytit-^l and menial diangcs of adolcKMKe.

THE OJTORIS.

The folkmring consenilal anomalies have been oliscr^-ed:

Al>i«n<v of the ilitoris. Clennge of the clitorK

Atniphy of the diloris. Adhrrtni prcpuoc

Hvi)*nrH])hy of ilit iliiiifi-. Rfiiitrninni prcfujrc.

Absence of the Clitoris; Atrophy of the Clitoris.— In mre

in'tamrs ihc i litoriv li:iv 1>rrn found lo Iw absent, and in exteptional coses it may
he JiriiphinI or >m:illcr ihun normiil.

Hypertrophy of the Clitoris.— A ^tichi h>')wrtn>phy of ilte cliloriit
it by nil nte.ttb ^n uncommon tomliiion. and in exceptional instances the orgut
may be as brnc as a moaleniteHze )>eitis.

FM. <«}.— nm Siw. Pw. iM-^Mond Sup.

Flf. rtl. OlifaH**( lb( |atvv», Fif- iM,(BB>nl u( Uw nAiadiol pcrtioB Ip^a ■«»)

Cleavage of the Clitoris. -Cases have been observed in which the
ditorb wa« ^plit in Iwn Lik-rul |Hiriiiin>. A« a rule, ihi^ malfiirnuliim b. assori-
»tn) writh ppiT>pniliaK uidI e»ln>|)hy of the bladckr; but in nirr instances llicn.*
iwy t f:iilure of union Ix'iwcrn (he pulm bones and a separation nt

ibt ul ' I wall immrdialely :i1><ac t)ie symphj'^s.

^•atmmit.— 'Pie division of the rliioris tus no clinical significance. The
cotmphy of (lie bbddcr, the scfnration <>f ihc alMlominal wuU. and the cpi-
•fiodias err cured by the usual ojicralive prtxcdures.

>S6

THE VOLVA.

Adherent Prepuce. — Adhesions between the prepuce and the glans are
not infrequently met, and they are very apt to produce reflcji symptoms similar
to those in the male.

Treatment. — The treatment consists in breaking up the adhesions and
keeping the surfaces apart until healing takes place (see p. 205)-

Redtmdant Prepuce. — A large, flabby, redundant prepuce is occasionally
met in children. These individuals are apt to form the habit of masturbation on
account of the local irritation which is produced, and unless the deformity is
relieved by operative measures a serious neurotic condition may develop.

Fig. 169.— Third Stip. Fio. i je.— Fourth Step.

OrEitATiDK row Red^^kdattt Prepuce.
FLr. i6gf Suluns in places Fig. 17a, flutuna Iied-

Treatment. — The treatment consists in the excision of the redundant skii
and the approximation of the raw edges with sutures.

Operation. — A general anesthetic should be employed. The prepup
is seized on each side of the glans with forceps and divided with a pair of straigh
scissors along the dorsum of the clitoris (Fig. 167)- Each half of the divide*
prepuce is then removed with scissors and the raw surfaces covered over b;
uniting the edges with interrupted catgut sutures (Figs. 168, 169, and 170).

THE LABIA MINORA,

The following malformations have been met with:

Absence of the labia. Hypertrophy of the labia.

Rudimentarj- Uibia. Adherent labia.

Multiple labia.

Absence of the I^abia ; Rudimentary I^abla. — In rare instance
the nymphs have been found lo be absent, and in exceptional cases they ma
be rudimentary in character, consisting of slight elevations of skin along the side
of the vulvar cleft.

Hypertrophy of the Labia.— A slight enlargement of the labia minor
is not an uncommon defect and even a decided hypertrophy may be occasionall
observer!. Among the Hottentots the nympha; are normally very much hypei
Irophied and hang down between ihc thighs for a distance of seven or eigh
inches, forming the so-called " Holtenlol upron." An enlargement of the labi
minora is usually of no clinical importance unless it causes local irritation c
mechanically interferes with sexual intercourse.

IS* THE VULVA,

Treatment. — The redundant tissue is removed with scissors and the edge;
of the wound united with interrupted catgut sutures.

Adherent I<abia. — When epithelial coalescence occurs during fetal lift
between the labia, it gives rise to a deformity known as " apparent vulvar atresia,'
or atresia vulva super/icialis. In the vast majority of cases the union is incom
plete and there is a small opening left anteriorly through which the menstrua
blood and urine escape. If, however, the atresia is complete, the newborn chik
is unable to micturate and the deformity demands immediate relief, Thi
malformation necessarily interferes with sexual intercourse, although impregna
tiun is not rendered impossible, and the small size of the vulvovaginal orifice ma'
offer a serious obstruction to childbirth (Fig. 171).

Treatment. — \ grooved director is introduced through the opening and th<
tissues divided in the median line with a scal{)el. If the raw surfaces resultinj
from the division are extensive, the wound on each side is closed with a continuou
catgut suture; otherwise the parts are kept separated with a strip of gauze whici
should be renewed daily until the healing is completed (Figs, 172 and 173).

Multiple Labia. — Sometimes the nymphie are increased in number b
longitudinal divisions, occurring during fetal life, which result in the formatio
of several folds of skin in place of the development of a single labium.

THE LABIA HAJORA.

The following malformations Jiave been met with:

Absence of the labia. Hypertrophy of the labia.

Rudimentary labia. Multiple labia.

Abnormal situation of the labia.

Absence of the Labia ; Rudimentary Labia.— Cases have bee

observed in which the labia have been absent or rudimentarj' in character withoi
the vulva presenting any other evidences of an undeveloped state. These ii
stances are very rare, howe\'er, and, as a rule, the labial malformations are con
bined with a nidimentar)' condition of the vu]\'a as a whole.

HjTpertrophy of the Labia; Multiple Labia.— The labia majoi
may be enlarged or increased in number. Hypertrophy of the labia is not a
uncommon deformity, and occasionally cases are observed in which the orgai
arc increased in number by cleavage occurring during fetal life.

Abnormal Situation of the Labia. — Sometimes the kibia majoi
are abnormally situated and they e.xlend as far back as the anus. Under the
circumstances the nympha; may or may not be involved in the deformity.

THE HYHEN.

According to Tourneus and Legay, the hymen is developed from a sms
mass of epithelial cells which appear alxiut the end of the fourth fetal month t
the posterior wall of the urogenital sinus at the point where the now united due
"f Mulicr join the sinus. The vaginal pari of the united Miillerian ducts, tl
primilive vagina, is not pervious at this time, ils hning epithelial cells complete
filling it as a plug. In the succee<ling months ihe vagina acquires its lumen, ar
the lower part of its ventral wall, corresponding lo the site of the anlage of tl
hymen, breaks down, thus affording communication with the urogenital sinu
The urogenital sinus is now become the vestibule of adult anatomy, and tl
vagina, in common with the urethra, opens into the vestibule, and thus it resul
that the hymen, situated at and partly closing the vaginal orifice, is continuoi
by its outer surface with the vestibule and bj' its inner surface with the vagin
In fact, the deci>er of the two lamella of which the hymen is said to consist i

UALFURMATIONS. tlYMEX.

'59

accordinf; m Toumcux, ihe extreme lower part of the anterior vacioul vriM,
which (oldi aKuimt and adheres to the wall of the urogcnitul sinus during the
inur^c i4 the Utcnl c-nLirKcmcnl of the <'aiial in fetal life.
The foUovring anomalies of the hymen have been noted:
Abience of the hjnten.
RudunentaT^' hymen.
Abnonnal openings in the hymen.
Anumnliei in structure and ahape.
Imperfnralc hynicn,
Abeence of the Hymen.— The hymen is found lacking only in vct}- rare
instjnuir-.

Rndimentary Hymen. — Sometimes the dcveIo[tmcnl of the hymen may
be dciettiie ami ii> (>rc--«iKe merely marked by several small elevations or ridges
at the outlet i>f the vagina.

Abnonnal Openings In the Hymen.— 'Hic fiilkiwing abnonnal
opening h.ive ticcn "Itscrvcd:

Hrmfn bijorh or bijentslralus, in whith there are two o|ienin)js placed iide
by kieie with a bmid septum between them. Ilymm septus, in which there nre

.*,T.

rw. It*. Fin. fn- Fro. irt. Fta, ■•?.

ABMMMii. Ommia* i<t na Kvwnr.

FIb (M. BfWB Wotf. FiB. Its. bincaKmK Fit. i A tifiun >ulKiitu*; Tit,- iJT.tiyincncribrifetniii.

two opeiun|C& separated l>y a narrow septum. Hymen sulistpius. in which the
ofienini; t» pnrtiiilly filled by a sejilum that groit^ either fn>m the anterior or
posterinr surface of the hymen and i« thinner than the membrane itself. Hy-
PMM cfibhjimnis. in whiih the membrane ha.s several small o|>eiiin(i^

Anomalies in Structure and Shape.— in w>me in-ttance* the

hynsea may be so thick and resistant that it <:nnnril be ruptured in attempted
sexual intcrrrjurse, anil v^iitinismus may result from load irnliilion cauieii bylhc
ineticctual cITurts. In others the membrane m.iy be m> yieWing nr elaj-lic that it i»
wC ropiuroi duriiiR intercourse, and cases have also been noted in which it
rrnutncd unbroken after the btrth of a child at term.

The shape of the hymen is often changed, and In place of the usual crcsccnt-
Kfce form of ibe membrane its cdfies may lie serraied (dtnlUiilur hymen), pro-
jecting (m}undihiili{orm /rymen), fimbriatcil. or irregularly curved (srttlfrlured
iywm) fFigs, 178. i;9. 180, ai>d 181).

Treilment. — >{alf(>TTnittiun]^ in the shagw of the hymen are of no clinical
silpiificaiice whatever, but tbox involving its structure ustially demand operative

i6o

THE \XLVA.

measures for ihcir relief. These consist in removing the m<.-mt>ntne wilh *ciwors
:\n'\ iniitiny; ihc nnv nii^i-s wilh intemi|ited c-atRUl sutures.

Imperforate Hymen.— This malfurmniion, which cumpletely rJo<«9 the
vaginal orJAcCi i^ known as alrtsia liymenalis, aivl is due bt the persistence of that

^■y

-y

Fn, ill.

Pm. i)«. Fill iro- I'm. '»o.

Ajuoituiu IH nil Sia«rt or tmc IIimui yffttt i)ol<
Flit »(i. Cinorfli'iluivtl hrmn; I1|. itck dfniiculiir hrmrn: Flu. >Ko. iafuniJibuHlonii brmcai FI|. iBt, Kulp-

part (if (he jwstcrior wall of the urogenital sinus which normally bmk« down to
prudiHf the \^lKinlll outlet, as well a> [>erhaps to the overgrowth of ihe cells
referred to above as the aiilagu of the hymen.

Course.— Prior lo puberty the anomaly dues
not, at a rule, otuK any locnl or utenentl diniurb-
ancc, but in exceptional cases, howewr. there
may lie an exir.u>r<lin;iry amount of mucus
H.Tfelc<l, which, lictnii unable lo e>ca]N; (mm the
vagina, cvoniually causes distention and resuhs in
tlu.- <le\'t'Ic)pni(.'nl nf a fluituatiiiK iK;U'ie tumor.
This tumor bulges at Ihe vulvnvagin;il oririic. and
if it attains to a considerable size, may cause more
or less interference with defecation and micturi-
tion.

In Ihe \'a>I majority of rases the anomaly

tKTiiiii.* to cauiw trouble only at the time of puberty,

owing to the fact lliat the menstrual blood is then

obstructed by the atresia aiwi cannot esnif)e from

fi^ the vagin.i. In lime ihe vagina bcii)mc^ rlinlcndnl

(hrnwlorolpos). then the uterus [htmatomeira), and

finally the Fallopian tubes (kemalMalpinx).

'I Tlu- muscular ctirtf of the vagina, the uterus,

""^^ and the lulics also unilcrgo more or less hyper-

Fio ia».-Jii«utfiiiiAn! Unas. trophy, anil the hymen il.-elf Iiec^mes thickened.

The cerx'ix is usually dilated with menstrux)

blood before the IhkIv of the uterus is involved, and, as a rule, there fa no

communication lietween the tulatt «nd the uterine ca\-ily, the hcmalosalpMnx

being due to the blood which comes directly from the tubal mucous membrane.

The siKeof the tumor depends upon Ihe quantity of the rctuined bloMl.and

':ii'-:

UALrORUATIOMS. MpeXTOKATti UYUXS.

161

after the iiHllviilunI bus mcR^lruiitetl fur n cniiHdrnible length of time a brgc
fluctuitting; mat* muy be Celt filliRg up the pcUic canity and cxicnding into the
nlxkimcn. Under these circumstances the bladder and the reiiiiin arc enema ched
u|<<iii and their (umtinn more or \c*s interfered wilh. The retained hlotid in
lime ktft^ its fluid ch^rjctcr and Ijeoomcs thick, ven* tenacious, and tarn* in
mnotstency. .tnd nf a dark brown ut ulmu>i hLtck nilor. Somelimr^ ihe rrinineil
tbluod bvcotnrt inle<.te<l, and it assume:^ a purulent churncler which produc^-s a
pyonlMs, a pyomtlrn, or » pyosalpinx. ("nder these niiuHlitHis jteneriil ^c|Bi3
Is likely li> fiiliim- .ind the life "( llic )i.-itient is plnccti in immcii.Hc jci>p.irdy.
.\)piin,inTn!isicmii>n may cause rupture of the t"j|;iiui, the uterus, or ilic tubes,
ancl :i Keiier.d |><rrlt<iniMl int1umm;)ti>in muy develop.

Symptoms.— During chitdhixid, ax a rule, no <yinploms develop unless thr
rruiineil mucus is in sufficient quantity to cause trouble, in which mse the paiieiit
rompUins uf fuHnt^N^ and weight in the |)elv{s along with more or lc!4 vcsimt and
recul irrilaiion.

Pin. itj. — llnuKuvHiaM. Ilijui«»n«, ur> HuunHAinMi cuim kv u Ivfimaiun llnnw.

'n>e nulform.ition doc* not reisrd or interfere with the normal phy^ir-Tl and
\i' changes that t^kc place at pulicny. and. as a rule, amenorrhea i* the first
ri ihjt caiUattenii>>n to the ln(-;il iroulitc. The men^l^ual miiiimen occurs
'>ica{>]icanin^e<>(llie How. and j-^ the pent-up blooii increases in amount,
u>licky (Klin* recur wilh inircusing severity eaih month along with a sease of
(ullnc» in the iielvls. Tliere i> also more nr lew interfercnsx- wilh micturition
and ilcfei:nlion, and not infrccguently a t-icarious hemorrhage take*^ place rrom
ihe wx. the rectum, or tiic bladder. If the genitnl orpin.4 r\iplure or the re-
tained duid lien>nMii infecte*). symptoms of peritonitis or of :?epsis interwne and
, oWtire Ihe true ihanicter of the toc:il condition.

In rare itt^ldnic^ the (irexmcr of (he anomaly k not ntfpecleil until the jiatient
'1 fill* thai sexual interc">ur*c c.innol lie accomplished. The absence
mptoms In tltcse <ases «- prxilMbly due lo the fact that mamace ik-
diriy, "-r [lulxTty wii* 'teUycl it there h.v\ In-en a »ointy llnw: in any
I, the ainiiunt of retained blood was nut suthcient to cause marked kical di»-
turliancrv

l53 THE VULVA.

Diagnosis. — The history of the case is significant and the malformation
should be suspected when the physical and psychic changes of puberty occur
without the appearance of menstruation, esp>ecially when a well-marked men-
strual molimen is present. A positive diagnosis, however, is based upon a
physical examination, which should always be insisted upon when a young
woman passes the peritid of puberty and exhibits symptoms of genital obstruction.

Inspection reveals an elastic tumor occluding the entrance of the vagina, which
becomes very tense and projects considerably beyond the vulvar canal when Ihe
patient bears down or strains.

Recto-abdominal paipalion elicits the presence of a fluctuating mass occupying
the pelvic cavity and extending beyond the symphysis pubis in cases in which a
lai^e amount of menstrual blood has accumulated. The situation and size of the
tumor renders palpation of the tubes difficult or impossible, and their exact ad-
dition can therefore seldom be determined even when an anesthetic is employed.

Prognosis .^Without surgical interference the prognosis is bad and the
malformation may eventually cause rupture or septic infection. The distention
and hyptertrophy of the tubes which are associated with the condition may result
in a permanent destruction of their function, and sterility may continue after the
removal of the cause.

Treatment. — The treatment consists in removing the obstruction and
draining away the retained fluid.

Operation . — The patient is anesthetized and placed in the dorsal position.
A small opening is then made in the most prominent part of the bulging mem-
brane and the menstrual blood allowed to drain away slowly, without making
any pressure over the tumor, in order to guard against tubal rupture, which
might possibly occur if the contents of the vagina or the uterus were suddenly
evacuated. After a considerable quantity of the retained blood has drained
away and the tension is rcheved, the opening is enlarged by a crucial incision.
The vagina is then flushed with a warm solution of bicarbonate of soda (Sss to
the quart) in order to dissolve the tarry blood and complete the e\'acuation.
While the irrigation is going on, the index-finger of the left hand is introduced
into the vagina and an examination made of the uterus. If the latter organ is
found to be distended, the nozzle of the irrigating apparatus is directed into its
cavity and the retained blood flushed out. The uterine cavity and the vagina
are then douched with a warm solution of corrosive sublimate (i to aooo),
followed by a copious irrigation of normal salt solution, and the vaginal canal
loosely packed with a tampon of plain gauze. A gauze compress is then placed
over the vulva and secured by a T-bandage.

The tampon is removed in twenty-four hours and the uterine cavity and
vagina flushed once a day with a hot solution of corrosive sublimate (i to 2000J,
followed by a douche of normal salt solution. A clean gauze compress should be
kept constantly applied to the vulva and the patient should not be allowed to get
out of bed for at least two weeks.

Special Directions. — The strictest antiseptic precautions must be carried
out at the time of operation and during the after-treatment, as septic infection
is liable lo occur if the slightest error is made in the techntc.

The danger of tubal rupture occurring during the evacuation of the retained
fluid is, in my experience, greatlj' overestimated by most authorities, and con-
sequently I am opposed to the removal of the tubes and ovaries if a hemato-
salpinx is discovered before the ohstruclion is removed. It is better, under these
circumstances, lo drain the fluid away slowly and give the tubes a chance even-
tually to evacuate their contents into the uterus, than to unsex the patient at the
start by a mutilating operation.

UAtFORHATlONS.

•63

HERMAPHRODITISM.

The imn " kfrmafihrodilism," mninint: liirnlly the uniting of thetwowxes
in one ori^tnlitm. i^ udnt Mimcwltul loosely employed lo describe an indi^ndual
«ho«« i-xicmal genital organs [anake oi ihe nature of Iwiih ^^xes. The crudal
U^t t>( >cx t> nul to be lounil, however, in thi: coniiition nf ihe eMrrnal organs, hul
dependent uponihe nature of the es.senib I »extul gland or glands present in any
ftvm caK. If llieie ftUiKl.'^ are Icne^, (he sex !.-> male; ami il the>' are <ii-arie«,
live KX \* fcfnuk, hoiicvcr mut.-^ ihe extmi.Tl genitalia may simulate ihove of the
ii(4«Kitc sex. It fre(|uenlly hap|jens in rases presenting external orRans rescm-
btinK thine of both xxe*. that the internal orftanft or sexual glands will tie found
to beuni»cxunl. ThcMare, therefore, instances of fabeor pseudo- hermaphrodi-
tism. Thk hermaphroditisin, on the other hand, mcan» (he presence of both
onrt and teitii'le on oik* or both «ide», or of an ovary on one »idc and a testis
on l^e other, whatever may be the condition of the external organs. True
bcrniii|ihroditi'in is iguite rare. In denmlnRg the I'arietie.^ of hermup)iroditi>>m
tlic ela#iriration of KIrliv will be followed.

Tme Hermaphroditism or Androgynes. -As staled above, true
hermapl>ruilitt->m < <it>->i-'>i> in the jin-senti- ui Imih ovary and (citi-sor of Ixith
ut-arian and leslioibir tissue, in the t&mc individual, and may be theoretically of
three tyjies:

Zjiteral Hermaphroditism, in which there i» an o^'aryon one side and a

. te^tiLie on ibe other. An example of this variety in the t'tiivcrsity of Prague

|t»lle<-lion showii a testis epididymbi, vits, rudimentan- oviduct, and round

'URamcnl on the right side, and an ovary, o%-iducl, and ovarian ligament on the

' left side, besides uterus, wgina. and proslalc. To account for lliti anomaly

' ( a-sume the WoIlTian body and duel of one *ide In have undergone the

ijsrulincemlulioninlo testis. epitlidymis. and vas, the MUllcrian duct of

j ll>c sanx; >ide liaviiig only |>anially develo[>eil, while <>n the other side the MUl-

I Irrinn dint amt the iniiilTrrent ^xua! gland iicvcti)ped in the manner normal lo the

(emat.-, the Wol^ian duct cnrrer;]ondingly suffering arrvsi and partial obliteration.

Bilateral Hermaphroditism i> understood to mean an nrary and a teslis

or a coai|Mund organ containing both ovarian and lesticuLar tissue on both »deft

u( the body. There is believed to l>c no well-authenticateil human example.

Ucilataral Hermaphroditism means the presence of both ovary and te^i»
ua one 'idc. but only one kind ft orcun. tilhct ovan- or testis, on the other.

Palac or Pscndo-hermaphrod itism.— In faUe hermaphrodiilHrn
(he hi^vual mllnif^ttalio^^ iire conlincil (■> the genital pa<.sage» and to the ea-
lemal cenilaLs the sexu.tl RLirvls being alwa)'s uni^xual.

ltal« False Hermaphroditism.— Testes are always pre^nt.
Internal F -i 1 v e 1 ! e r m .1 p h r i> d i I i s m , —There is a rudimentary
jvaKina and sometimes aWo Fallopian tu)>csand a uterus. The external ofxana
ly or tnaynoi be well furme<). To produce tht» condition, the Miilterian duels
Ihave undcrgoiM: more or le^'S development to evolve those parts of the female
[•eiual aiiparatus which are present, in addition lo ihe normal evolution ol the
jindilTrtrnt tcxual ftland and the Wolffian IkkIv and dud into the Icstictc ami ita
|*yMrjn of exerelory passages

ExlL-rnul Faltte Hermaphroditism. — The bisextul mani-
' ' liniiteil to ihe external orgaiK which "imuUtc those of (he fenule.

1 exhibits general female characteristics. There arc no ovaries,

tutw^, utcniK, or vagina.

Kiternal and Internal or Complete False Hermaph-
rodfllsn. — The hbexual features may he presented by any parts of tbe

164 THE VULVA.

genital system except the glands, which are always of the male type. Vagina
utenis, and oviducts are sometimes fairly well developed, sometimes mdimentar}
the ducts of MUller having undergone, to a greater or less degree, the evolutio
peculiar to the female. The external genitals, owing to defective devclopmen
resemble female organs. The genital eminence developing imperfectly pnxlua
a small hypospadic penis which resembles a clitoris. The orifice of the urethi
is at the base of the defective penis and opens into the vestibule from the fact tlu
the genital folds hive failed to unite with each other, by which union the peni
urethra is normally formed. The persistent vestibule or apparent ori&ce of tl
urethra also leads into the vagina. In other cases the penis is nonnal in appea
ance hut contains two canals, the urethra and the genital passage.

Female False Hermaphroditism. — This is much less common than U
male variety. The ovaries are always present, indicating the true sex of U
individual.

Internal False Hermaphroditism . — The external organs a
of well-developed female type, the evidences of the apparently bisexual nature
the individual being internal. The Wolffian ducts, instead of producing vt
tigial structures in the manner normal to the female, undergo partial evolutii
into rudimentary testicular ducts, which are to be found in the broad ligamer
and in the uterine and vaginal walls and occasionally are prolonged to the clitor

External False Hermaphroditism. — Tlie hermaphroi
tism is confined to the external genitals. The cUtoris is apt to be so ovi
developed as to resemble a ]>enis, the labia majora may be large and partia
united, resembling a scrotum, and the vaginal orifice may be contracted.

External and Internal or Complete False He
maphroditism . — The external organs resemble those of the male,
one reported case there was a prostate; in another, a prostate pierced by 1
vagina, while an ejaculator>' duct and a sac resembling a seminal vesicle open
Into the vagina.

WOUTJDS OF THE VULVA.

Causes. — The situation of the \-ulva protects it in a measure from the mi
common forms of injury to which the rest of the body is exposed. Wounds
this region, however, are serious and liable to be followed by severe or ei
fatal hemorrhage or septic infection. This is accounted for by the great vaS'
larity of the parts and the relative situation of the vulva and the rami of the pu
and ischium, which cause extensive and dangerous wounds when the soft tissi
are suddenly forced against the bony structures by direct violence.

Labor. — This is the most frequent cause, and the tissues may be contused
lacerated during the deiiverj' of the child, the application of the forceps, orot
obstetric operations. The perineum is the most common seat of injury, i
next in point of frequency are the nymphs, which may be torn in a diago
or transverse direction; these tears, however, are seldom serious. The la
majora are more often contused than lacerated, although superficial tears
quite common, and in some cases there may be a severe injury involving
vuh'ovaginal glands. Dangerous or even fatal hemorrhage may result fr
tears of the vestibule near the clitoris.

Direct Violence. — As previously mentioned, wounds from direct viole
are particularly dangerous on account of the anatomic arrangement of
structures of the \Tilva, and a traumatism even with a blunt instrument r
cause an incised wound by forcing the soft tissues afjainst the narrow edge of
rami of the pubis and ischium. Injuries from direct violence may be duf
falling astride of an object, or to kicks or blows. Many cases have b

WOUNDS. svurroMS.

■6s

Te(»ncd from lime to limc of »evtn nnd even falnl injuria fnim ihctc causes.
Women huvc bllen xcnx^ the ba4:k of a chair, ihe edge of s tabic, or a fence

tiickei, and tbcy have aUo been thrown from the sa<l<lie of a, hicycle onto (he
iBixllebars or fnime. In tlic miijority of these oimts the wound c«rTcs|inn<led
with the [Hjiilion of the ranii of the pubi^ and Ischium, in%T))vin); the nyniiihs,
the (iiloti.^, iinil the veNlibiile, uml vnis ;iiu-ntlr(l niih exco.M^'e bleeding.
. \\'i>uiul> rebutting [n>m blows or kick« are usuully -Iluaied in the labia majora.
Chihlrcn huve been injured by >|i]iiitem of wikmI jK-iictr^ittoK the vutv;i while
IsUing down an incliiux) boani, or by l>eing violently thrown from a s^led
tafunal an object vrhile caastiiift. ^Mnckcl reported the ca^c of a woman who
linui uttacked by a bull and seriously Injured in the vulra and ]>cnncum by his

Coitus. — Injuric* of the vulva from mxuhI intereourte are rare. During
the Tir^l intercourv the hymen h ru[iturcd, but the bleeding \f \cry flight and of no
consequence. Occasionally, however, the licmorrhajie may require sur){>cal
t' ' ■ 'lit. In cai'es of ra(>e Mjxin younc k"^'' culenMi-e lacentiim^ nuy be
A chikl of about nine ye.trs of age, who came under my obMrA'alion,

Mi,

bolh

T"!

Flo. ■•«.— vriTiKT-iovieiHiu Stem.

I whom a rape had been commiite<) «'as badly lacerated in the perineum and
'on each silc I'f the vulvovaginal orifice; the tears extcndini; into the bbi.i.

The lairmlion* which are jircxIiKcd by M-xual inicrc"ur»c with young girls

are due to the disproportion in sixe Itctwcen ibe genital organs and to (he lender

rcoaditioo of die umlevel<>|ied 4tructttre> of ihe vulvu and v'ngina. Lacerations

' may occur durinK intercourse with old women on account of a want of ebnttcity

oi the parts due to senile atriiphy or to the tliangcs ocf urring in kraunwis vulvie.

6]rmptottl8.— Local Syrnptoms.— 'Hh^ are: (i) Pain; (3) hemorrhage;
(3) imjialred lundion; (4) retraction of the edges of the wound.

Pain, —At the lime of the injury the pain is acute and sharp; but il soon

tKeome* ilull or xmiirling in character, an«l .nfter a few bnup' it (ti.'v:ip}>cari en-

tinrly unles» infUmirulion occur; or tl>c parts are not kept at rest. In M»ne cases

' |Kiin i> nd felt .il the iTu>nicnt of retciving the injur,', owinK to excitement or

lu uUtet ricoIjI causen.

Hemorrhage .—In wouikIs of ilte vulva, especially those of the ^-esiibulc.
tbr Httitfit, or the nymtitue. ibe bemofrhagc is conilnuoui and excessive and may

I66 THE VULVA.

even rapidly become fatal. This is due to the great vascularity of the parts at
to the severe character of the traumatism, which is caused by the so
tissues of the vulva being drrven, at the moment of the injury, against the shai
edges of the rami of the pubis and ischium.

Impaired Function . — Wounds of the vulva, as in other parts of d
body, result in loss of function. The swelling, pain, and tenderness interfe
with locomotion and sexual intercourse, and in some cases the distention of d
parts acts as a mechanic obstruction and prevents urination or even defecatio

Retraction of the Edges of the Wound . — While there
always some gaping in wounds of the vulva, it is not so marked as in other pal
of the body on account of the character of the tissues and the lateral pressu
which is exerted upon the seat of injury by the surtounding structures.

Constitutional Sjrmptoms. — These are: (t) Shock; (a) fat embolism.

Shock . — Severe wounds of the vulva are apt to be attended by shoe
especially those which are caused by great violence, such as falling from a he^
astride upon an object. Women, as a rule, suffer less constitutionally frc
injuries than men, and young girls generally recover rapidly from shock wh
there has been no great loss of blood. Old people, who have no organic lesioi
bear injuries well so far as their effect upon the nervous system is concern*
The tendency to shock is always more or less influenced by the habits, the e
vironment, the temperament, the menial condition, and the health of the patiei

Fat Embolism . — The possible occurrence of fal embolism followi
wounds of the vulva should not be overlooked. The condition is due to t
entrance into the circulation of the fluid fat of the tissues and its deposition
the lungs, the brain, the spina) cord, the liver, or the kidneys. Fat embolism
liable to follow crushing injuries involving bone or adipose tissue. Should t
fat-globules contain septic micro-organisms, pyemia will likely result.

Complications. — The healing of a wound may be interfered with
suppuration, gangrene, erysipelas, or tetanus, and septicemia or pyemia m
resuh.

Treatment. — The treatment is considered under the following headin,
(i) Hemorrhage; (a) shock; {3} cleansing the wound; (4) coaptation of I
edgesof the wound; (5) drainage; (6) dressings; (7) rest; (8) general treat me

Hemorrliage. — Digital pressure or a compress held in position with a T-bi
dage will control the bleeding until more permanent means are applied. Wh
using the finger or a compress, care should Ije taken to crowd the wounded tissi
against the rami of the pubis or ischium, otherwise the bleeding will not
controlled. In slight wounds a compress is all (hat will be required to pern
nently check the hemorrhage. In some situations of a wound it is necessary
tampon the lower end of (he vagina in addition to placing a compress direc
over the seat of injury. Injuries of the vuIvo\'aginal orifice, including laceratic
of the hymen, are examples of wounds requiring a vaginal tampon. Free or p
slstent capillary oozing may often be controlled by the removal of the blo(
clots and exposure of the wound to the air for a few minutes, or by the use
compresses wrung out of hot water and pressed against the bleeding surfac
Capillary oozing is generally checked by the gauze which is used in packing <
wound when the dressings are applied. Cold should not be employed as a fie
ostatic agent, at it interferes with the processes of repair by its lowering eff
upon the nutrition of the parts, and styptic agents should not be applied, as tl
destroy the vitality of the tissues and increase the danger of infection. Bleed
from small vessels may be permanently controlled by hemostatic forceps if ■
compression is continued for a few minutes, or torsion may be tried if 1
bleeding persists after they are removed. Large vessels and all points wh

WOUNDS. T«l::AniEKT.

.67

continue to bleed shoulil be ligaled with catgat, which is prrfcniblc in ttik on
account of iL<^ utKWflinbility.

Shock. (Sci- Trcaiment «f Shock, p. 859.)

Cleansing the Wound.— .\U foreign substances, blood-clots, and devitalized
liwu« mu'') l>e romoxtNl with forceps, turei, ■'(-isMirt. or f^mxe SF>onf;es, »nd the
wound thoroufihly irrigated with hot sterile vrater. I'bc liair it (hen cut clow,
tltr »uiTotindii)K suru(«i washed with liquid Miap, and thcwQund irrigated with
» Niluticm "( lOCTtKivc ^ublintHle (i to 1000).

Coaptation of the Edges of the Wound.— The skin and underlying libsucs
are flowed with intemijUcd -^uture> ^^i silk. .silkwonnRut. or catKul. The latter
is preferable in flight ni-cnin<)» of the siiKu, but in the dce|)er one« or where (here
b m-^ee or less tension sitk worm-gut is the best suture lo employ.

Drainage, — The netv^tity (or drainage de|ictids u[Hin the character o( the
wouml niKl it*, freedom from scjrtic itifvilion. A clean-cut incited wound re-
r)uires nn dniinuKe. as hetiUnK iKCur> by [irimury union afttr the edges arc brou);hl
li>celher bv ^utu^e^. On lliv other h^ind, bvcrated and mntused wounds re4|uire
dnaiiuige. as (he wcrctions' arc too profuse to be absorbed and provision must aba
be made for the e:w3|>e of necrotic tissue.

The indicati'iiu for drainage mu^^t be carefully stwiied in each aue to obtain
the iftsi rcMilis. and in some instances the wound mu*I be cnbrRcd lo give free
vent to the iccrrtion*. Ajctin, counlet-opentn)!^ may be nei-es>^Ty, and finally
ibe wound may be left i>pcn at its moM dependent part tor drainage. In wounds
of the vulvii we nuy employ rubber tubing, gauze, and strands of sitkworm-gut
or honchnir for dminagc material. In lar^e. deep, and infected wounds rubber
tubing olTcrs (he bcsl means at our disposal for the free and continuous discharge
o( the >e<re(ii>ns, as it k nc\ib!c and readily iidapl.-> il>clf to changes in i>ns(tion.
Glau tubes should never be used in wounds of the vulva. CapilLiry drainage
tqrt»ean>of9tr,md> of .silkworm-gut or horsehair is indicated in wounds which nre
dcKerl by xuture< but where it is un^fc to trust the obsorjition of (he sccretioiu
ti' nature.

DfMSinp. — WoundK which are closevl with suture^ shoulil l>e pnxecterl with
a giui* compress and a T-bandage applied. Wounds which remain open and
bcal b)' granukititin should be [Kicked with gauxe over which is placed plain
Uenle fpuKC aiwi the whole held in pi^ilinn by a T-bnmbge.

The dressings shoukl l>e changcfl once or twice daily on account of the situa-
tdw of (he \-ulv:t amt ii-> ex{K>sijre 10 the contact of urine and feces. When the
diVMings are chanKc;! in cl<rte<l wounds, (he [wrt* should !>e djwchc"! with a
lolulion of corrosive sublimate (i to 1000) and thoroughly dried; open wounds
diould be ifrlgatcl with hydngen iieroxid followed by the Milu(ion of hichlorid
nf mrrcuri". The separation of sloughs is aided by cutting them awTiy with
Miwur^i aiiit cKubcmnt gntnuLitions are rentoved with the solid stick of nitrate of

Rwti— The surgical principle underlying rwi in the trcalment of wounds
muM not be k»4 >igh( of in injuries of ihe vulvn. Rest in l>ed wi(h the use of the
bcil [nn b of (ir>( im|i»nancc. as it lessens hemorrhage, serous efTti^ion, irritation,
and inin, uiul lustens the normal processes of heulint; and repair. The patient
WmuIiI Ijc (djiomt in the nxnt comfortahte (KKiition, wilb the tliighs slightly sepa-
ntevl a<id the knee^ elevated.

General Treatment.— Tlic [win and Kencr:il reslle»ncss arc relieiTd with
•rpium. the l->wi'l- .ire mo^T^I with 3 s;iline and then kq)t regubr with a mild
taatlvc or an encmii; the p^klienl i- given nourishing .ind easily digetle<l food;
uid the bedroom is ncU \rntilate<l. The general condiiion of the patient murt
ak> Recft'e altenlion and all |>alhotngic conditions which inteKere with the

l68 THE VULVA.

healing of the wound or add to the constitutional dangers of the injury must be
carefully treated.

Classification. — ^^'ounds of the \'ulva, as in other parts of the body, are
divided into:

1. Subcutaneous wounds or contusions.

2. Open wounds.

(u) Incised.
(b) Lacerated.
{(■) Punctured.

3. A,seplic and septic wounds.

SXJBCUTAPJEOUS WOUNDS.

Definition. — A subcutaneous wound is a bruise or contusion caused by a
blunt object in which the skin is apparently uninjured,but in which the underlying
tissues are more or less destroyed. When the bleeding from the ruptured blood-
vessels is diffuse, subcutaneous discolorations or ecchymoses are formed ; but when
the effused blood is circumscribed, it is known as a blood tumor or hemaloma.

Symptoms.^The parts become tender, painful, swollen, and discolored.
In superficial contusions the discoloration of ihe skin occurs at once, but it may
be delayed for several <lays when the deeper structures are involved. The
subcutaneous effusion of blood results in ecchyraosis or hematoma or both, and
the swelling an<l tenderness may interfere with coitus, locomotion, or urination.
A greater or lesser degree of shock may be present.

Treatment. — In slight contusions lead-water and laudanum should be
applied to the wound. The application of an ice-bag is useful when employed
soon after the injurj' is received; it is contra indicated, however, in severe con-
tusions or in old and debilitated women, as the continued application of cold
depresses the vitality of the parts and endangers their integrity. After the swell-
ing, pain, and inflammation have subsided, tincture of arnica or distilled extract
of witch-hazel may be substituted for the lead-water and laudanum or ice-bag.
The subcutaneous effusion of bloixl in superficia] contusions seldom goes beyond
ihe formation of a few spots of discoloration or ecchymosis, and requires no
special attention.

In severe contusions heat should be applied tothevulvabymeansof a hot-water
bag or a hot solution of lead-water and laudanum. These applications should
be discontinued after the acute symptoms have subsided and tincture of arnica
or distilled extract of witch-hazel substituted.

If suppuration occurs, a free incision must be made and the pus e^Ticuated.
The wound is then irrigated with hydrogen peroxid, followed by a solution of
corrosive sublimate (i to 1000), and jiacked with gauze. It is then covered
with a gauze compress, which is held in pisilion with a T-handage. The
wound should be dressed twice a day until it heals by granulation.

As a rule, hemorrhage Is not excessive in subcutaneous wounds, and is readily
controlled by a compress and T-banilage, but at times the bleeding may be so
persistent as to require surgical interference. Under these circumstances a free
incision must be made, the bleeding vessels ligated, and the wound irrigated,
packed, and dressed as described aljove in the treatment after the e\'acuation of
pus. Exuberant granulations are rem<ived with the solid stick of nitrate of silver.

raaSED WOUNDS.
Definition. — An incise<i wound is a clean cut inflicted by a sharp in-
strument, which heals, as a rule, by primary union.

LACERATED WOUNDS.

169

SytDptoms. — Tliccclgcsof thrwdtinil^pv.thcIicmorrhnKc is profuse, and
lh«i|ain, whith i*sliarj)and atiUcat lir^l, ^oon&ubsMeis intou smiininKwnMtion.

Treatment.— Hemorrhage. — BlM^ling is ciuily cunimllcct, when only
KRuill vcv*«U :irc di^icltyl, by the cipplicaibn of hot water uml cnmprci^ion, and
it t^ permanently checked wjicn the vi«unded surface!' arc hr»uf;ht into upjitnition
with ^utun^. Larp; vessels refj^iiirc lifiution. If a lurgc vessel is onli' panially
irul through, it h somrlimcs Hithcult lo place 11 ligature iiroumi it, and it maybe
twiTsiiiry to enlarge the wound Iwfore iht- ht-mnrrhaiit.' ran lie iheck«], StypLlc
■grnlt 'houW no! beiippliiil.UN tticy intcrfcnrwiih ret>air by destroying the vital-
ity of the tissues and increasing the danpeni of infection.

Cleansing the Wound.— The hair should be cut tUne and the surrounding
siirfacn wa^cd whh liijuirl uiap and the w-ound irriKaie<] with mitnul salt
wlution followc"! by a solution of it>rTosivc sul>limiile <i tn 1000).

Appoaition of' the Edges.— 11iv wounded »urfaccs i^hould be brought
into dircrt contact by deep inicmiptcd sutures. u.*ins c:ire not to leaw any
poekets or dend sjwoes fur the collection of bliKxl nr seiretionw.

Drainage.— If titc uxtund is ctean-nit and aMrptic. no drainage, as a rule, b
required, provided the suturing has been properly done; but it may tw ncrosin-,
however, in some cases t<> use dr;iiiuige (or the first twenty-four or forty -eight
bour». Nothing is l»elter for this purpose than capillary drainage by means of a
(rw stmnds of silkworm gut or horschjir, ivhich are pbred in the bottom of Ihe
wound iinti th<ir free enfis brought "Ul at each angle of ihe incision.

Dressings. -The wound should be covered with a gau/e cumprens held In
(■o>ki(ion with a T-tKindtige, atvi the dresMng removed every day and the ]ant-
wulied with a kolulion of currusivc sublimate (1 to loooj.

LACERATED WOUNDS.

Definition. — A larerjtcd wound i^ oni- in which the livur« >re lom
■mrt', when ihcy lire al-"i cnished. ihe wound is spoken of as being i-nntuscd.
Thr-e wi'und- -lough and heal by granulation.

Sjfmptoms. — The skin and underlying tivftues are 1on>, lacerated, and
crushed, and the eilge* of the w<mnil are irregular. Severe wounds of this nature
are usually assign iaie<l with pronoimoeil shock, while the primary hemorrfuge is
grner.illy slJKhl owinx to the weakened heart action and the lacerated Dindition
cj the blood vessels, which favors the formation of clot>. Excessive intermediate
henmrrhafie, however, may occur wlien miction from shock sei» in, or a M'conditry
hcRiorrhnice may rcuh when the vessels are reopened by the separation of the
■liHj)!^. The |iain is not acute, but the wound feets tender and there i> a sensa-
tion of sorciieu in the .''urmuiuting (virls. .^fter the nrcmlU* tis-<-iie uimI sloughs
are thrown off, the wnutwl heals by gr.inulnlion; septic infection is liabW to occur.

Treatment. Cleansing the Wound.— The liair should be cut ilo^e and
the (urnmi-litii; :>urfa>es w;i-.hc\l with liquid wup. All foreign material, dirt,
hUxHl-i liiiv. and devit.<lized tissue are then removed and the wound irTig;ited
with iwirnud salt solution fotlowx-d by a Hotulionof nimuivc sublimate (1 i<> 1000).

Bemorrbage.^The greatest care must be taken lo guard against inlcr-
mcdble and secondary hemorrhage. .\ll bcerated \esseb of any sin; must be
ligalei), whether ihcV are Meetling at the time or not. lo guard against hemorrhage
(wnirring during the jHTiod of reaction fn^m shock. The woumi should be care-
fully Wdirheil during the se)>aralion of sloughs, as faLil bk-edJng may occur at
^^L tiui liiw from ihr r<ii()cned vTMcb. The ciimpre*»ion cxerteil by the dressings
^H amtruli the Kozitig from the smaller vcsscb and to a certain extent prevents a

IT© THE VULVA.

Drainage. — The gauze packing used in dressing the wound, as a rule,
accomplishes all chat is required for purposes of drainage. In some cases, on
account of the situation or character of the injury, it is necessary to make counter-
openings and use rubber tubing for drainage. The surgeon must always be
guided by the indication in each case, making counter-opening either into the
vagina, the perineum, or in diSerent parts of the vulva as in his judgment may
seem best.

Dressings, — After the wound has been cleansed and sterilized and the
bleeding checked it should be packed with gauze, over which is placed a
gauze compress, and the whole held in place with a T-handage. The dressings
should be changed once or twice a day according to the indications and the
wound irrigated with hydrogen peroxid followed by a solution of corrosive
sublimate (i to looo). When the process of sloughing begins, it should be aided
by the application of antiseptic fomentations. The best method of applying
fomentations is to lay over the wound a compress of gauze saturated with a
hot solution of corrosive sublimate {i to looo), and then a piece of rubber-dam,
against which is placed a hot-water bag to keep up the warmth. Exuberant
granulations are removed with the solid slick of nitrate of silver.

PUNCTURED WOUNDS.

Definition. — A punctured wound is one in which the injury is produced

by a more or less pointed instrument penetrating the tissues. These wounds
heal promptly if the object causing the injur)' is sharp and aseptic, but if the
tissues are lacerated or infected by a blunt, irregular, or unclean instrument,
septic inflammation results and suppuration follows.

Sjanptoms. — The pain, as a rule, is sharp and acute. The hemorrhage
is generally slight in punctured wounds in many parts of the body, but those of
the vulva are liable to bleed profusely. Infection followed by suppuration is
likely lo occur.

Treatment. — Cleansing the Wound.~It is very difficult to clean and
sterilize the wound thoroughly. If, however, the injury has been inflicted by a
sharp, smooth, and comparatively clean object, the hair about the injury should
be cut close and the parts washed with liquid soap and douched with a solution
of corrosive sublimate (i to looo). When the tissues are lacerated and contused,
the wound must be enlarged by a free incision and treated as a lacerated wound.

Hemorrhage. — In small punctured wounds the hemorrhage may often be
controlled by a compress and T-bandage. When, however, it is unsafe to trust
to this method, the wound must be enlarged and the injured vessels ligated.

Drainage. — Small r!ean-cut punctures require no drainage. Lacerated
and contused punctures must be enlarged by a free incision, and in some cases
counter-openings must be made and drainage established by means of gauze
packing or rubber tubing or both.

Dressings. — A simple clean puncture should be covered with a gauze com-
press, which is held in position with a T-bandage. The dressing should be
changed twice daily and (he parts washed with a solution of corrosive sublimate
(i to looo). The dressings for a lacerated puncture are the same as those de-
scribed for lacerated wounds.

HEUATOUA.

171

DISEASES OF THE VULVA.
HEMATOMA.

]>efinltion.— A oircufnt-rriliol ^vvclling due la ihe cfTusinn of bkwd in the
conncitiM' iis>ttc.

CAttsee. — VnrUtiw vein.1 and pregnane}' are preditpoimg rousts.

The rxiitii); ctutf.i .ire: (i) Ijilmr: (3) lniuma(»m; (3) muscular effort.

Labor.— Th* atTcciion {re<)iieni!y octurs from the pressure of the rliiM's head
duritig U'lnr, oriiwruinddibLilionof the.Mjfl {iiirt> in |>r(;dpitntc delivery and In-
jun' Id iltcvcin< (luring Ihcapplicaiinn of the forceps or other obsictrkuperaiions..

Traunutism. — In ihc non-prei;nant ^utc a heniiitnmii has hecn cnu)wl hy
direct viiileme, »udi a» a kick, falling ii»lridc of an object, or an injur)- during
I i>[ierji)on.

Muscular Effort.— Si niininit al stool or heavy Ufiinji; ha» been tnllowed hy
"the rupture of a varicv^e vein and the subsequcni formation of a blood tumor.

Snbjectivc SsTnptoms.— As a rule, the lumor appear* >ud«)cnly,
aci-ompsnicil by m'lre or tcs^ inienM- pnin, fullowcil in a shnrt limc by a feeling
of fullm-s': in some ci^^cs there is rectal and vesical tenesmus, and bier on pru-
rttu». Mlien the tunxtr la very.tmall, thc|hiiieni in.iyn'iibcronM.-i»u^»f it^exiM-
cnix. Should the hem.iloma suppurate, "symptoms of vulvar abscess intervene.

Objective Symptoms.— The tumur is usually >iiuate<l in one of the labia
nmior.1, allhouKli it m.ty l>e found in any pari of the vulva. In the nonjireRnant
state lite tumor is i^niall. rarely becoming larger than a hen's eg^: but when it
ixrunt during chiklbirth, it may rKith the ^iw of a fcial hcatl and extend mto tlie
vagina and bcyonil the outer Uinter of the vulva. The tumor is globular in
•hapc, clastic in consist cney, purple in mior, and often tender to die touch.
In Mime ciivh Aoudl ecchymo-'p^ are obH«^v«^d in the surroundin); tissue,

BeioltB and Prognosis. -A hematoma may Ivealisorticd. encapsulated.
or umlcrpio suppuriti-m If ii Weomes encnpsulilcd, the >:ic (.'onLiin.-i either
blood or a clear tlui<l. The prognosis in the non-pregnant »latc is f3^'orablc, as
Ihc tumor is uswdly small and yiebU readily to treatment. During. latK>r, how-
ever, it i» a jtrave eompliciti'tn. as it may interfere mechanically with libor,
rmlancer the jMtient's life from hcmorrliage. or produce puerperal sepsis.

Treatment.— In tli« non-preftnani Mate the tumor should be o|)enn|, the
cliilis lumcl i>ut. and the cavity washwl with a solution of nintBive sublimate
(i to looot and closed with deep suture* or [lackctl with Rauw. If it has
brcfime enca|isuliierl. the s:ic >houl(t l*e cxiirpaled ;ind the wouml clo^ in
lh« Mroc manm-r. When Mippumiion occurs, the hemalonut should be treated
a* a vub-ar abscess (sec p, 180).

TI»e treatmeni during lalxir is to open the Himor. turn out the clou, and wash
the cavity uHth a hot solution of biclilnriil of mercury {i (0 1000), atid park it
with ftati^. \\1ille the hemorrhage i-" usually t<>nirolled by the packing, ii mny
be nctCMary in uimc cases to locate the bleeding point and piaa* forcqrt nr
li)plurc^ upon the injurctl vessels.

A bematomn of the vulva i^hould never be trusted to
nature, a< il is {>ecu)iarly liable to undergo supfwralion ttecausc of its
proximity to the vagina ami reitum ami the irrllalinn to which it it eX|H>sed dur-
iag vxual inter courM- and in w.ilking, Funhermorc, when it occurs during Iubi>r,
the tlsAuexof the vulva are brutscl niM] ihrir jiowers of resi>lance lessciwd; con-
vipurnlly ntworuiion it> not likely to take plac.

It i* not adviuble to close the cavity with sutures, after turning out the cloU,
of a hrmai'^nu occtirring iluring labor, for the reason that the bruised oondttion
of the tiwurs prcwnt<> primary union.

f}2 THE VULVA,

GANGRENE.

Definition. — Gangrene or mortification is death of a part of the vulva in
mass.

Causes. — Traumatism.— The affection may be caused by injury during
labor, especially when the vitality of the tissues is impaired by edema or extrava-
sation of blood. Chemic agents may also produce the same results, and cases of
gangrene have been reported following the use of vaginal tampons or vulvar
compresses containing strong corrosive remedies. Direct violence, such as a
kick or falling astride of an object, has resulted in serious injury followed by
mortification.

Infection. — Erj-sipelas, diphtheria, and puerperal septicemia are causes.

Overdistention of the Tissues. — The vitality of the tissues may be destroyed
by overdistention from edema, dependent upon heart or kidney disease, and from
subcutaneous extra ra sat ion of blood in cases of large hematomata of the vulva.

Eruptive Fevers. — Gangrene of the vulva may occur during the course of an
attack of typhus or scarlet fever, measles, or smallpox.

Diathesis and Environment. — Under the name of noma pudendi gangrene
of the \-ulva may occur in weak, strumous children living under bad hygienic
surroundings. The disease is due to an infection and is considered to be in-
fectious.

Symptoms.— The disease usually begins in one of the labia majora with
severe local pain and elevation of the temperature. A spot of infiltration soon
appears which is dark red or black in color, and vesicles or bullfe form upon the
surface of the affected part, which rupture and dischai^e a thin sanious fluid
and expose the gangrenous tissue beneath.

Prognosis. — The disease has a high mortality and death may result from
septicemia, embolism, or exhaustion. If the patient recovers, the parts are
healed in about four weeks, and the normal contour of the vulva is apt to be
more or less chanf!c<l by cicatricial contraction. Noma pudendi is generally fatal.

Treatment. — The treatment is divided into (i) the general and (2) the
local.

General Treatment.— The strength of the patient must be sustained by the
free use of alcohfJ in the form of brandy or whisky and by forced feeding with
concentrated liquid foods. Strj'chnin or digitalin should be administered as
indications arise.

Local Treatment, — The gangrenous sloughs should be removed by excision
with the knife and scissors and the wound thoroughly cauterized with the thermo-
cauterj' or an 8 per cent, solution of chlorid of zinc. Antiseptic fomentations
are then applied or the wound may be continuously irrigated with a solution of
bichlorid of mercurj' (i to 15,000) until healthy granulations appear. The
diseased area is then dressed with iodoform gauze and protected by a compress
which is held in position wilh a T-bandage. The dressings should be changed
twice daily and the wound irri|jated at the time with hydrogen peroxid followed
by a solution of corrosive sublimate (i to 1000). When it is not advisable to
excise the gangrenous tissues on account of the extent of the disease, the affected
parts may be completely destroyed hy the thermocautery and treated in the same
manner as after excision.

SIHPLE CATARRHAL VULVITIS.

Definition. — An inflammation of the \Tjlva characterized by a free dis-
charge.

Causes.— Traumatisms. — The affection may be due to masturbation.

SIUPLE CATABKUAL VULVITIS.

'73

ezccsKiTc or brutal coitun, nyie, irritulion o( the pitru in abe«e women, blows,
U. ami kicks.

Irritations. — Simple vulvitis b. often trau^ by want of cleanliness, especially
bcrt weather, penliculi i>uliiv, 5«iit-worms. wprngenic mirniljw rtrsuttifiR fn>m
etompmcd sccrctu>n« or urine, abnormal discharges from the uterus, vagina.
LiiMer. or urethra, fecal or uritury fi^tulaji, and malicnani disease.

Diathesis. — The strumous dimhesi^ i» a prcdiAjxiMng cau»c, etpecuUy in
iblrcn with unhypicnic surround in gs.
Varieties.— The dUe^w may l>e acute <ir cfaronic; the acute form is the
more itimm'm.

Subjective Symptoms.— In the acute variety the paiicni tnmptuins of

)oal imi:ii!"n m u-niUTtK-sv .iml {Kiin, or >ni;irling a\ the lime of uriiiatinn. (mm

le <-iinl.icl of the urim- with ihc intUmcx) surfaces. The discharge i^ usually

ir'>fu*« and mu(x)|>uru)ent in duiraitcr. und it may <:ause an irritation around (he

njil region and o\vt the inner stirfaceti of the thish^. The (win is chiLrai-terUtic

f tntlammalion in other parts of the body, and iu severity depends upon the

iolcnre of the iKithiildnic procesxeit.

In the chronic variety itching and a burning wnwition are piontinent

i|iMn«, The former may at times be so severe ihat the patient's Hfe is made

■lo" ami her Mrcnj;iti exhatistc<l by luss of slei-j). The illHiharge is thinner and

in quantity thjn in the acute form. The excoriations cau»e<) by scr.itthing

tlill further to ihe dis<x>m(ort of the i«3tiem, and in fat women the inner

iCtTS of the lhi)tl)s and the groins are apt tn lie inlLimcd and er<xk'i|. If the

nguiiul ifLinds are in\i'lvcd, the patient complains nf pain in Ijoth gniins.

Objective Symptoms.— in the acute fonn the parts arc inflamed and

rollcn. ami although dry at the beginning of the attack they »»on l>crome

tbetl vrilh a jifofuse secretion. The nymph^c may become edematous. The

charge is gcncr^illy profuse and mucupurulent in character und the inner

ees of ihe thighs and around the anal region show signs of irritation. The

rge often acnimulates lietween the labLi. .ind benimin): mixed with pud

smecma has a vcr)' offensive odor. 'Itic inlbmmatinn i" not so severe nor

it -tt bicely to invade the adjacent organi as the jn)norTheal ^-arieiy of vulvitis,

m'>c<pii-nlly the duct.'' of Ilanholin. the mucous gUnds of the meatus the urethra,

od the vjginj .ire seklom affectcil by an cKtension of the di^ase.

In the chronic form the inllammaiion is leu niarkol. Tliere is little or no

swelling of the |ianv, ami the discharge, while Mill mucopurulent, >« thinner and

in quantity. Excoriations and abrasions cau-sed by scratching arc observed,

n (at winnen the inner surfaces ol the thiKhs and the groins are a|>t to l>e inflamni

rul croiled. In severe cbjc* superficial iilcenitinns are M'en on different iwrts of

le v\iU~i and the pupilbe are enlarged and bleed readily. The lymphatics raay

oitne intbmed ami in)niinal a<lenitis result.

OiagnoSiS^—Tbe diagnosis, as a nilir. i' easily made, by the history of the

ou«e. ihc character of the inflammation and its tendency not to invaite adjacent

organ%, and the absence "f a ■specific micnvlie-

The dilTercmial dLignosis lietween the gonorrheal and catarrhal forms is of

the utmost im|H>nance, es|iei-blly if there is a medico-legal question to decide;

nA In this connection it mu'st be remembcrol that strumnuii children with bad

yirienlc environment may develop a very severe simple catarrhal vulWtis from

Want of <leanlinc>>. ai>cl that a moFi.1 careful and thorough eximinaiiua should

be made before deciding that the case is one of gonorrheal origin.

Progliosls. —The disease in its acute form is of short duration and re-
ifintKlK readily to treatment. The rnuw muM necessarily affect the prngncalt.
Slid if the vulvar irritation is due to maligitant discaw, little or mthing can be

174 THE VULVA.

done unless the disorder can be eradicated. In j'oung girls of a strumous di-
athesis the course of the disease is more or less protracted, and in the chronic
form a Ruarded opinion must be given as to the time required to eSect a cure.

Treatment. — The treatment is divided into (i) the removal of the cause,
and (3) the treatment of the disease.

Removal of the Cause. — T raumatisms . — The habit of masturbation
or excessive coitus must be corrected. Fat women who suffer from friction in
walking should be placed under medical treatment for the obesity and the vulva
protected with a pledget of lint. The external organs of generation and the
surrounding parts should be washed twice or thrice daily with warm water and
castile soap and then gently dried and dusted with a bland powder, such as
talcum, cornstarch, or lycopodium.

Irritations. — Want of cleanliness must be corrected, pediculi pubis
and seat-worms removed, disdiarges from the uterus, \'agina, urethra, or bladder
treated, and fecal or urinary fistulas operated upon.

Diathesis . — The strumous diathesis must be treated upon medical
principles and the environment of (he patient improved.

Treatment of the Disease.—The acute form is treated as follows:

Rest . — Absolute rest in bed is essential, even in mild cases, during the early
stages of the disease.

C 1 e a n ! i n e s s.— The vulva must be frequently douched with hot normal
sail solution to remove the secretions and prepare the parts for local medication.
The solution must be allowed (o flow from the nozzle of a fountain syringe upon
the vulva and care must be taken not to force any of the secretions into the vagina.
If the local inflammation is severe, a hot sitz-bath taken twice a day will keep
the parts clean and relieve the intense throbbing and burning.

Local Medication . — In mild cases the vuU-a is douched with a
warm solution of bichlorid of mercury (i to 2000 or 5000) and the labia separated
by a pledget of lint wet with the sublimate solution. The bichlorid douches are
use<i in everj' case as a routine plan of treatment, and if the inflammation is severe
it is followed by the application of lead-water and laudanum by means of lint
compresses placed over the \'uha and between the labia. A saturated solution
of boric acid may be substituted for the lead-water and laudanum after the acute
symptoms have subsided, and later on, when the disease has nearly run its course,
the free use of a bland powder dusted over the parts will hasten recovery, TTie
powder should be applied several times daily after cleansing the vulva with
warm sail solution and gently dn,-ing the parts. The following powders are use-
ful for this purpose: talcum, lycopodium, subnitrate of bismuth, oxid of zinc, and
calomel.

The B o w e 1 s. ^Salines should be freely used in the early stage of the
disease. Later on a simple laxative, with the occasional use of a saline, is all
that will l>e required.

The L' r i n c . — The urine should be rendered bland and non -irritating by
the free use of pure water. If it is over-acid, liquor polassic and tincture of
belladonna should be given; if it is alkaline, benzoate of sodium or ammonium
should be administered.

Diet . — During the acute stage of the diseases soft diet (see p. iii) must be
given, and later on it may be gradually changed to a convalescent diet (seep. 114).

In the chronic form of the disease the same care and attention must be given
to cleanliness, the care of the bowels, and the condition of the urine as in the acute
variety. While it is advisable for the patient to Iw as quiet as possible on account
of ihe irritation produced by friction in walking, it is not necessary for her to
remain in bed.

liONOIRBeAL VULVITW.

'75

The (oca) trtatinent <!oiuiHt!i in tiouchinR ihe vaU-a twice d.iily with n M>lution

of tiichlurid (if nwrcun- (i In joconr 4000) followed by n(innuls:ttM^>lui)<)n. The

puns lire then gcntty dried wkh ulisorbcnt couon and dueled froi-ly wiih lakum,

^uhniiralc of bi-smuih, lycnfxxliiim, nxid uf zinc, or adomcl. Thrtx tin>Cl K

jtreek the entire vulvjir jurfiuc i< painlcl with 11 dilution of nitrate of silver (gr.

" to f.^f). Il is Jilways dd^isilile lo ke«p the liilii.i sc|iiirjtt;d with it jileilset of

til. whidi ix rctaitini in iMisiii^ii l>y idciiin of 11 C"mi)ri-M ;ind T-bundagc.

Lint compresses 3 1 >pl)«d to the vulva soaked in an aqueous solution of iirgyrol

15 per ('Cfit.),iiceiatc of xinr (^r. j to fJj),Milj>luiie nf zinc (gr. ij \n f5J},iit sulphute

cmpI>«T (gr. ij to fS)) "ftcn give good rcMilt:^. l-^xcorintinns and citisions arc

tl«l with bciunatcfl oxid of zinc ointme-ni and the occasional application of

nitrate of .tilver solution.

TtH-irralmcnt o( the pruHlUbi^considvrtH] elsewhere (seep. i84),and intUm-
nulioris of the urethra, the ducts of the vulvovaginal Klandv, and the mucous
j|tAnd> of the mcslu^ are (liacuKM.-d under their rojtcclivc headings.

t GONORRHEAL VULVITIS.

I>efinition.— ■\i{>ccitic infUranMlion uf tltevulv.i caused by the gonococ-
15 of .NciMcr.
It is the mo.^l frcciurnt variei/of vulvar inflammation,
nd I he disease has a marked tendency not only to involve
the external genitaU but to spread to ncifthborin): or-
^■Kans. Thui>, ihc infcdion r;ipidly cxtemis to the duda and gliimU of Bar-
^Hiolin, the urethra, the mucous gi.inds of the meatus, the vagina, the uterus,
^pSie tul>es, and Ihe |>eriioneum. The urethra and vagina may t>c infected at tlie
HEiMme time a« the vulva, »r later by the spreaii of the di>ca>r. The inguinal
{•Unds may be involve<l through the lymphatics and undergo suppuration.
.\flrr all the aeulc symptoms have subsided the gonococci may remain in a latent
Uaie in the uleniK. the vagina, the duct^ of the ^-ulvclvagiIul glands, the mucous
[bndsof tlK meatus or Ihe urethra, and <au^ infection in Ihe niale. Gononheal
alritii nay occur as an epidemic among ehitdren living together in biwpitaL',
g-bouscjt. or Mhools, In children Ihe hymen lo a certain extent piiHccts
vacim from infection.

8aE*)ectlve Symptoms.— The symptoms are the same as in the c.-itarrhal

a, emepl thai diev ..re nv.ire violent. Acule urethritis develops early and there

ling .nnd smarting during urination. Later on il the vulvovaginal gUnds

ae iniiilvcd symptoms of an acule circumscriljed inllammalion arc [.recent.

If the Inguinal glands become in(e<ie<I, the patient complains of soreness and

teudemew In the groins. In j-oung children the tcmpcmlure may be elevaied.

Objective Symptoms.— The symptoms arc the same as in the calairhal

rirm, except thai ihcy atK more proi>uunee<l. The discharge U [rrofuse and

jlcnt awl pre^vurc on ihe uTclhra is followed by the ap|icarance of a drufiof

at the meatus. If the iTiK'ovaginal glands are involved, ail the signs of a

K.-ili/ol inH-immaiion arc present, with or witltout pus. The gbnds in the

"groin* may lie enbrged. lender to the touch, and inttamed.

Diagnosis.— The diagnosis is based upon the \iolencc of Ihe local in-

illy when it follows a .■^u>pidou> intrrcoune. Involvement

liaraclerislk. as a rule, of the specific nature of the vutvilii',

ialiammaiion of the inguinal arxl \'ul\'o\-a|pnal glaiuls h also suspicious.

he presence of gunococci in the «ccTetion» eonlirms the dbgr>i<»is.

FYOgHOSlS. - TI1C prognosis must always be guanlcd, as the tendency of

the infekiton to sjiread and involve the iKlvic organs renders the diseaiie one ul

lyfi THE VULVA.

the most dangerous that can attack a woman. The latent form of the
disease and its contagious nature must also be borne in
mind.

Treatment. — The primary object of the treatment is to destroy the specific
nature of the inflammation and prevent it5 extension. The vagina and vuiva are
douched two or three times daily with a gallon of corrosive sublimate solution
(i to sooo), followed by a quart of normal salt solution. An aqueous solution of
arg)T(>l (25 per cent.) is then applied to the vagina on a cotton-wool tampon and
over the vulva on a pledget of lint which is held in position by a compress and T-
bandage. In the course of a few days, after the acute symptoms have subsided,
the vagina and vulva are painted twice weekly with a solution of the nitrate of
silver {gr. XXX to f5j), and in the meantime the douches are continued twice or
thrice daily. Later on, the vulva should be dusted over with talcum, lyco-
podium, oxid of zinc, subnitratc of bismuth, or calomel, and the douches
gradually discontinued.

Attention must be given to the care of the bowels, the character of the diet,
and the state of the urine. These subjects have been fully considered under the
treatment of simple catarrhal ^Tilrilis.

If the infection in\-olveH the neighboring organs, the treatment is based upon
the principles laid down under the headings devoted to diseases of these structures.
The latent form of the infection must be borne in mind and the presence or ab-
sence of the gonococci determined by the microscope before pronouncing the
jwtient cured.

FOLLICULAR VULVITIS.

Definition.^ A localized inflammation of the follicles of the vulva.

The disease attacks the pilous, the sebaceous, the sudoriparous, and the
mucous glands, and the mucous membrane between the follicles is unaHected by
the inflammation. Tlie surfaces of the labia majora, the nymphip, andtheprepuct
are more or less covered wilh small red elevations from the size of a pin-head to
that of a small pea. These elevations are the follicles distended with their
normal secretions or an accumulation of mucopurulent matter. The removal
of a hair is usually followed by a drop of pus. As a rule, if the disease is limited
to the inner surfaces of the vulva, the follicles are not distended, although the
parts are constantly bathed wilh an offensive mucopurulent discharge.

Causes. ^ — The disease may be caused by want of cleanliitess, pregnancy,
or irritating vagina! discharges, and it may also occur as the result of an attack
of simple catarrhal or gonorrheal \Tjlvitis.

Subjective SjTnptoms. — The patient complains of pruritus, irritation,
and hvjiercsthesia of the vulva. The itching is most marked when the disease
involves the inner surfaces of the vulva. If the urethra becomes involved, there
is burning and pain on urination. The i-ulvar secretions are increased in amoiml
and ma)' become offensi^'c in odor or irritating lo the parts. The extreme sensi.
tiveness of the vulva may cause vaginismus and interfere with sexual intercourse.

Objective Symptoms. — The appearance of the vulva has already been
described.

Prognosis. — As a rule, the prognosis is favorable. If the disease is due
to vaginal tlischarges dependent upon malignant disease, little or nothing can be
done of a radical nature. The duration of the disease is influenced by treatment.
The follicles may &])ontaneously rupture and dri- up, but in the majority ol
instances the inflammatory condition eventually produces small, hard, nodulai
indurations. If the disease is allowed lo a)niinue unchecked, the urethra i;
likely lo become invob'ed. The discharges arc very irritating to the male urethra

FOLLICl'LAR VLtVITIS.

'II

uhI may nu!« a severe aimck of simple urelhriiU. If foUicubiT vulvitis h due
la prcK'unry, i( iiMully (livi|>|icarN utter bbnr; in exceptional iiuiances the
local irrilalioTi cnuM:s a mUcarriagc.

Treatment.— Tlw cuuive, if jwwible. must be removed. Absolute rest in
bed *!• niX rL<rnii:il, iiUhniigh the ixUicnt »houlrl keep ns quiet a» (HW^ibk l»
rctieiv tlw irriiuiion due lo friclioit in wnlking. The vagina and vulva should
be diiuclied srvrrti limes diiily with ni)rm;i) niH iulution to remnvc the secretions,
umj hoi sitx-lialh^ );ivcn lo Ic^M'n ihc irritali'm nnd pain. A mtton-ivool inmpon
should be imrwtocni into ihc vagina to tolkvi the discUargt^ and protect the
iiiKii. lliv txiux'U .''huul'l )>e ki-pl (rvr by the use "( a ■umplt hLinlivc or mi
imrmj and the occasional .idniini~ir.ilion of a saline. The patient should drink
(•Irnty "f pure w:iter, amt if iht- urine is over-afid liiiuor potasAa; and tindun- of
belU'liitin:i >h<>ulil be fdven: if it W alkaline, Ix-nziMlr of Mxliuni or ammonium
sJuiukl be administered. Tbc diet shouki be simple and easily difjcstcd.

Local Hedicalion. — The alTetrteil (laris shouki l>e ininted with a solution of
nhnilriif til»er()(r. x\-fSj)ever>tyrortr three day)! ;ind lint a>mi>rc?«* snaked in a
hoi sdluiion of bicarlwnaie of sodium (gr. xx-fSj) or potassium (gr. x-f5j) con-
dnuouhly applied l<ein-een the labia and o\-er the vuha. If lhi^ tre-^tment Is
HOC followed by relief in Ihc cviunc of a week, the (ullicle» muAt be punclutvd

«r- .,;:,.,V'> ^

■S'J.'W"

/"f

y-i

-isss

.v-.i-v;.^

f"^-^!

F>«. iSf. tic -66.

MiniM> a* llAKiau t Vuiikal TiiamL

with a Rlender liistnur)* and their conienl^ squrezeil out. The>- are then painted
with a sohiiion of nitriile of silver (i;r. \xx-f^j) unil llie followrinc ointnKtii
applied:

ft. Wiih.».>ti I3J

Acidl caibtitici, StI. R

GI)«rTiM fSj

UnipirMi^tfoUn. q, *. ad , , S)

M Sis -Usr kwilly.

If ttie infUmmation n vn^' se^tre, knd-vratrr and laudanum should lie
■|iplic<l (or a <l:iy or lieo licforc u.'^ing the it:hthyol oinlnictil.

Wltm lite <lt><^uc hn« ncnrly run iln mursc, licn/ualrd oxid of zinc ointment
WkiuIU tie >ul>stitulcd for the U:hlhyol preparation, and after all »gns of intUm-
mation have dis.i])|>eared ibe vulva sboukl lie dusted over vrith lalcum, lycopo*
dium, uvid ol xiiK, •■ulinilr^ile of Immuth. or calomel pomler.

Not mirtr lli.in a <t'>Mn folticlcs shoutl t<e punctured at one sittinK on account
u( the diinyrr iif >,iu iiiK i>>imu>h irritiition. In .■u>me casi^ it may lie necciaarjr
III ctoterue the lia^ of the follklcn with luiur caustic. Ualvanu-punclure hiu

IjS THE VULVA.

been used with good results as a substitute for puncturing the follicles with a
bisloury and applying nitrate of silver.

In very rare cases the tissues are so altered by the follinitar inflammation
that it is necessary to dissect oS the diseased skin and bring the denuded surfaces
together with sutures to effect a cure. (See Excision of the Vulva, p. 963.)

DIABEnC VULVITIS.

Definition. — An inflammation of the vulva caused by the decompositioi
of diabetic urine from the presence of the lorula stucharomyees.

Subjective SymptOmS-^Intense and constant itching is the mos
prominent symptom, and there is also local pain and tenderness with increase*
secretion. The patient complains of burning or smarting during urination
due to the contact of the urine with the irritated and inflamed tissues, and th<
general health suflers on account of the pruritus, which interferes with rest ant
sleep.

Objective Symptoms.— The entire ^^llva has a reddish-copper color an
the mucous membrane and skin are parchment-like, corrugated, and dry, with her
and there small spaces which are swollen and moist. The parts are more or les
excoriated from constant scratching and occasionally small boils develop, A
the disease progresses the same changes occur in the skin of the motis venerl
the gruins, the inside of the thighs, and over the anal region.

Diag^nosis. — The diagnosis is based upon the presence of sugar in the urir
and the appearance of the vulva, which is almost pathognomonic.

Prognosis. — The duration of the disease depends upon the course of tl
diabetes. The local symptoms, however, can be greatly benefited by trealmei
and the patient made comfortable.

Treatment.— The treatment is divided into (i) the treatment of the diabet
and (2) the treatment of the local lesions.

The Diabetes.^ — The treatment of the diabetes is based upon general medic
principles, and need not, therefore, be discussed here.

The Local Lesions. — The treatment of the local lesions is included under (
cleanhness and (b) local medication.

Cleanliness . — The vagina and ^^llva should be douched several tim
daily with hot normal sah solution and the parts carefully dried by gentle pre
sure with a soft towel.

Local Medication. — The vagina should be irrigated once a d
with a solution of corrosive sublimate (1 to aooo) or creolin (1 per cent.) ai
the following ointment applied to the diseased areas:

!(. .Wdi siilicylii-[ F' '

Ungucnli pclrnlati, 5j

M. Sig. — Use locally.

Dusting-powders are often beneficial in the treatment of diabetic vulvil
as they keep the labia apart and protect the skin and mucous membrane fn
contact with the urine. Equal parts of calomel and subnilrate of bismuth
oxid of zinc are especially useful under these circumstances and may be si
stituted for the ointment recommended above.

The excoriations and abrasions should be treated by painting them occasi<
ally with a solution of nitrate of silver (gr. xs-f,^j); and then applying be nzoal
oxid of zinc ointment containing 3 per cent, of carbolic acid, or an ointment
cosmolin containing 20 per cent, of oxid of zinc.

The treatment of the pruritus is considered elsewhere (see p. 184).

IKFLAUUATION OP THK V I' L.VO VAGINAL CLANDS.

<79

TNFLAHBIATION OF THE VULVOVAGINAL GLANDS.

Causes. — [mlimmiHion of the» glands may be <iiic to tlic fullouing ciuaes:
(JDnorrbca.
TraumatUm.

Extension of inflammalinn.
Suppuration of a cy^i of ihe gland.
Goooniiea. — In nearly all cii»e* the cnuf^c U gonorrheal in
) r i g i n . aiul the dii^casc starts as a specific ^iiUnti^. which extends to
lie duct!., anil ihrouKh th«m eventually to ilte Kland.i. In Mime cases the
ids are infccic") at the Nime lime a* the vuK-a. .\n abscess of one of ihc
. often occurs long after all the :')'mpto(nsof a gonorrheal mtvitis havedis-
cared and the paticni has liecn diM'hurRed as nired. Thi.-< is due to the fact
»ttl)egon<Ki>cci frequently remain durmanl in the ducts for an indefinite lenglh
' time, and later on become active again.

Traumatism.— The trauniatLiin may Iw due to a kick or fnllinjc ludridc of nn
!>ject. itiwl violent or excessive sexual intercourse has been kno»-n to produce
iflammalion of the slam). An abscess from this cause is most frequently ob-
"»crse<t in m-wly nurnetl women and in yotmn iini>tinite-*.

Di&chargcs. --Septic discharges from the o^-iducis. the uterus, the vagina,
III the uriiur>' tract may cause infe<-iton of the duiis by direct conuict. Ab-
ce?>c» <>f the vulvovaj;in.il gbindK arc met occa*ion:illy during the course of «
piientcral f<psis.

I Extensioa of Inflammation. — In exce[>ti<iiuil inwiancrs in the »im[de

! catarrhal forn» of vulvitis the intlanimalory process extends to the duet*, and
^_c%imtuully throu)(t> ihem to the glands.

^B Suppuration of a Cyst of the Gland. — \ simple cyst of one of the gland*
^Hvhich has remained quiescent for a long lime may suddenly take on inflammatory
^^■Ctlrm und suppurate. Tim may l>e (3U--«d by an acute or blent infection or
^Bomr f'Tm >>( Iraumatisra.

I Pre qticncy. —The disease is\'er)'rommon and only attacks one (tUnd.aa a

' rule, at a lime, usually the U-ft. .\I>m.t^<cs of ihe^c K^n(l^ arc com |iura lively

irare in the upper chs-^e* and ver\' frequent in prostitutes,
Snbjectivc S3nnptom8. — T)ie )>;iti«m sutlers from the usual symptoms
drpemlcnl u|R>ti iin a-uic inliimm^itiim. There is a M-ii*:ition of heat and burning
in the aSccted part, and the pain, which is constant, is sh^rp, lancinating, or
tliroblting in character. Tliere in also more or Icv" prurituii. All the symptoms
are aggmvalcd by M^imting, walking, or sitting, and the patient is comparatively
1 comfortable only in the recumbent poMure with the thighs slightly scjKiratcd,
In the majority of atMi there is a slight rbe in the tem{icniture and a fn'ling of
^Harnemt dixiimfort. The aRected pari is "v-ciy sensitive and tender and there
^^^ay be mention of urine.

^^ Objective Symptoms.— In thcbeginningof theatLnktheiisualMgnsof

an acute iiiiUmm.itinn .in- present and the overiving skin is immovable. The

vnvllllig and olema are marked, aivl as the inllammatory prociDiS increases in

^levtrity the cnLirgcmi-nl of the labium exteml-- to the anus. The mouth ot the

Mi of ibe gland is inflamed and surrounded by a red areola which resembles

Ika-ltitc^the so-c.ille<I gonorrhfal matHie. The evidence of the formation

put a first apparent on the iniicr side ol the Libium. and if Ihe abscess is

iimouhIv c\'in\wted its contents escape by several lisiulous openings below

lAcc of the duct. TIte pus, which is dUch.iryml in brge quantities, has a

ii<r and in many instancTs contains gomnoici. The sinuses mn-iin for a

af<L-r all utute symptoms have disajvpearcd and communicate either

l8o THE VULVA.

with small abscess cavities in the diSerent lobules of the gland, or with a common
cavity which results from a general suppuration in the gland structure. In rare
instances the sinuses open into the rectum or on the perineum, or they may
coalesce and form a large ulcerative surface.

After the acute inflammatory action has subsided the gland remains in a
state of h)-pertrophic induration and a purulent, milky, or greenish fluid is dis-
charged from its duct or the sinuses. This dischai^e, as a rule, contains gono-
cocci, and frequently infects the male during sexual intercourse; or it may
infecl the uterus and oviducts by being carried into the vagina by the penis.
Again, it may at any time set up an acute gonorrheal vulvitis or be the direct
cause of an attack of pueq^eral sepsis.

The inguinal glands may become involved during an attack of inflammation
of the vulvovaginal gland and undergo suppuration.

Pro^UOSiS. — The disease yields readily to surgical treatment. If the
abscess is not treated, it pursues a chronic course, and the gland and its duct
become dangerous foci for the distribution of gonorrheal infection.

Treatment. — If the abscess is seen in the acute stage, it should be opened
by a free incision on the inner side of ihe labium; care being taken not to wound
the vulvovaginal bulb, which lies just above the upper margin of the gland.
The diseased gland is then completely removed by a sharp curet; the cavitj
flushed with a solution of bichlorid of mercury (i to aooo), and pure carbolic acic
applied. The duct is now opened its entire length and treated in the sami
manner. The wound is then dried and packed with gauze which is held ii
posilion by a compress and T-bandage. If the abscess is seen soon after it ha'
been spontaneously evacuated, the opening should be enlarged and the cavit;
treated as above.

In chronic cases where the gland has undergone hypertrophic induration i
should be completely removed by dissection or curetment and the duct am
sinuses opened. They are then curcted and pure carbolic acid applied to th'
wound, which is finally packed with gauze. Immediate closure of the wouni
with sutures seldom results in primary union, and should therefore not b
attempted.

The treatment of inflammation of the gland before suppuration has take
place consists in the api)lica(ion of flaxseed poultices, rest in bed, the admin
istration of salines, and the use of morphin to relieve pain.

INFI-AMMATION OF THE DUCTS OF THE VULVOVAGINAL GLANDS.

Catises. — The etiology is the same as in inflammation of the gland itsel
The duels are frequently the seat of latent g()norrhea and often become infecte
without involving the glands.

Subjective Symptoms.— The s>'mptoms are obscured by the genen
vulvitiii unless there has been a direct infection, in which case the patient con
plains of localized soreness and pain.

Objective Symptoms. — The opening of the duct is inflanned and su
rounded wilh a red areola, which resembles a flea-bite; the so-called gonorrke
macu/c, which remains for a long lime after all acute symptoms of inflammatit
have subsided and is considered bv some authorities as an almost certain evideni
of a pre-existing gonorrheal infection. Pressure on the duct causes a drop ■
pus to appear at its orifice and the presence of gonococci in the secretions dete
mines the specific nature of the inflammation.

Prognosis.^A simple catarrhal inflammation of the duct, which is a ve
rare condition, generally rcsyhs favorably. Gonorrheal infection, on the oth
hand, is a very serious condition, and shows but little tendency toward self-cui

cvicnt or tur vulvovacikal clakhs.

iSi

It b impoSEiiblc liy any plan of traim«n1 to eradicate ihc disease and at the
unw lime pfe^rve tbc intficrity of tin- duel and itbnd. The cuntlaDt
danger nf anucutc inflamntalMin recurring and Ihc
likelihood of infecting the male during sexual in-
Irrcotirnr niu»t be Ixirne in mind.

Treatment. ^I'he Irratmcnl nrcessarily (Ic^troy^ the funclion nf the duct
arxl heme ihe ahnd ^htmkl he removed at tlie same linw. After cnueteatinK
the (Jbixl by diASL-didit the dmi i* split i<N cnlirc Irnglh aix) curelwl. The
wound ia then Ilu§heil n-ilh ;i >iiluiii>ni>fc<>Tri>^ivi' sublimate (i loiooo): swabbed
with carbolic miil. and )«ckcd with gtiuxe, Mhkh a held in [losilion by > com-
pKM and T-b»nd.ige.

CYSTS OF THE VXJLVOVAGINAL GLANDS.

TIkm cyi>1« are either superficially <>r deeply <j(unted; the ftirmer are due to
dbtentjon of the duct, while the bttcr arc located in the f>liind. Cy^ts of the duct
an alwiy» onilocuhir, nhik- th<»c <>f the gl:in<l are miini)|iK-utar when a single
lufaaler ii tnvi>lvrft (ir mulliti>iul;ir when ni'>rr than one i« af[ecl*.-d.

Causes*— {-'y^i A uf the vuU'ova);iiuil gland and il-^ duct arc due to rclcniion
of (hi- xl-indulai ^nn'tiiin, causal by oblileralion i>r rnnMricliDn d the dud,
the Mnuh of an intLimmation, which h u»^ually gonorrheal in urigin, A cv?t may
«|u> result from a change in Ihe <harai'ter of the secretions, which may become
lick ami unable ti> (lavi Ihriiugh the duct.
Sobjcctive Symptoms.— A small mi causes but little or no in«n-
lientr. A large tuntur. however, interferes with walking and coitus, and in
i>eDe eamr* icxual intcrcouDw it impovMble on account of mechanic obsiniction
Dd pain The natural Icndcnry of a cyst of the vulvovaginal gland is to remain
ocmt, but the friction to which the [Kirls are Mibjectcil in walking often
the luroor and causes inflammation which may eventually nrsuli in
ilion.
)bjcctive Symptoms.- Cyst of the Duct.— The tumor i» situated
under the miit>>ii> menibr.inc at ihc base of the nymph>r and project* some-
what into the ^-ajpna. The enlargement is Rlobubr or ox-oiilal tn shape, seldom
kiscr than a ha«lnut, »omelinie> iransiiarrnt, arul freely movable under the
uv^ylng tiifiucs. in some cases the mouih of the duct is patulous and a thick
Krrrtinn may be forced out by pressure.

Cy»t of the Gland.— llie tumor b. ^.ituaied in the|Ki«ieTior part of the labium
maju*. between the ragtnal inlet aiKl the ascending ramus of the ischium. Il is
uiroicLil in sha|)e. with a smooth surface, and freely movable under ihc overlying
Umucii. a* a r\ilc. the^* ry-t* <Io not grow Inrger than a hcn'< e^, but caf« arc
uccukinalh- met where they attain much larger proponions. They are seldom
tiantparvot and are «b~crveil nxM frc(|uently on the k-fl side of the vulva. The
' on prcwure i-> clastic, irreducible, wilhuul pain unless tnllamcd. and gives
;«'te on pcnu.ssion. The lonicnls of the <>-st may lie simply the normal
(cretion of the cL-ind. which is cokirlcss ai>t) hkc the while of an egg. or its char-
may lie changed to a yclkiwish or chocolate colored fluid c^ a thick and
(nu* coriT^tMcrMy.

Prognosis.— If the c}-»t iaempiicd by an lociition or !i)tonuneaui cracua-
li>n occtirs. II will refill. Tlw tendency to become inflamed and undergo sup-
puration tJmuld lie Ixitne in mind.

Treatment.— The gland and it.* duct should l>e cxiirfKiled and the wound
doacd with deep ami <u|>crf)rial ^^ulures. If the cytt is inllamcd or suppurating,
liie tcfhnic of the operation is th« same as in cases of abscess of the vulvovaginat

i8j the vdlva.

PRURITUS VULVAE.

Definition. — An irritable condition of the terminal sensory nerves,
which is characterized by intense itching of the vulva and surrounding parts.

Causes. — The affection is caused by so many different pathologic con-
ditions that no general classification is possible. The following causes have
been noted:

Diseases of the vulva. Habits.

Irritating discharges. Reflex irritation.

Parasites. Diathesis,

Congestion. The menopause and old age.

Traumatism. Nervous origin.

Diseases of the Vulva. — Diseases of the vulva are often accompanied by
pruritus, and the affection is therefore frequently associated with vulvitb, varicose
veins, edema, eruptive diseases, vegetations, and trichiasis.

Irritating Discharges. — The oviducts, the uterus, the vagina, the kidneys,
the bladder, or the urethra may be the source of a discharge which may irritate
the vulva and cause pruritus. An abnormal discharge from the rectum or anus
may cause itching of the vulva, and malignant diseases of the genital or^ns are
also particularly liable to produce pruritus. Incontinence of urine and fecal or
urinary fistulas are a source of constant irritation, and a severe pruritus often
results from fermentation of dbbetic urine.

Parasites. — The following parasites may cause pruritus: The ascarls
lumbricoides or round-worm ; the o Jyuris vermicularis or scat-worm ; the pedicu-
lus pubis or crab-louse; the pulex irritans or common flea; and the acarus
scabiei.

Congestion. — Pathologic conditions which result in congestion of the genital
organs, especially of the vulva, are frequent causes of pruritus. The most com-
mon of these conditions tire, misplacements of the uterus, cystocele, rectooele,
hemorrhoids, constipation, congestion of the fielvic organs, and diseases causing
obstruction of the porta! circulation. Sttme women suffer from pruritus at theii
monthly periods and others are troubled with itching of the vulva during preg-
nancy, especially at the beginning and end of gestation, when the congestion it
most marked.

Traumatism. — Mechanic irritations of the vulva result in congestion oi
inflammation, and later on pruritus develops. Thus very fat women suffer fnm
friction of the parts in walking and women who lead a sedentary life are apt tc
have vulvar irritation follow unaccustomed exercise of a violent character, sucl
as horseback -riding, skating, long walks, etc. The habit of masturbation event
uaily leads to congesti<m and pruritus. Excessive venery is also a frequen
cause, and is common among young prostitutes.

Habits. — Pruritus is often observed among the lower classes from want o
cleanliness, and in some cases a sedentary or indolent mode of life may be respon
sible for the symptom. High jiving, indigestible foods, or the use of immoderati
quantities of wine or spirits may produce general plethora and cause pruritus

Reflex IiritatioD.^ — In certain cises diseases of the genito-urinary organ
and the intestines may prn\'oke reflex irritation of the terminal sensory nerves o
the vulva and cause pruritus. Itching of the gjans penis in vesical stone is ;
familiar example of this form of reflex disturbance in the male.

Diathesis. — Pruritus is often due to uric acid, and some women suffer fron
the affection only during t!ie cold weather, while others are free from itchin;
except during the summer months.

The Menopause and Old Age. — Pruritus \Tjlva; may develop during th
menopause and be accompanied by an itching or burning sensation over othe

ittunnvs vuLv.£.

"83

puis of the body. The symptom, as a nilc. gmdually Hisappcnn with lh«
arcublor)- nnd nervous phcmimcna of ihe climaclcfic. The atrophic changes
which lake plate in ihe muci>us membrane of ihe vulva, ttie vagmii. iind tiie
utemt may result in senile inllanimalion^ which arc n^^ociatcd nilh excess-
IvHi irritattng tlUchiirpe* ihai irrimte ihe vulva and cause an intolerable
prurilus long after the menopause hat- been pa.'M.'cl. tn senile vulvitis the
miicDU> ^aaA» of the meatus are in«-olved in the inflantmator^' procca and
iDcna^c the wwrity of the local symptoms,

Hervous Origin. — In exceptional cft<<r< M>me authorities have regardcl the
tymptom hn purely ncr*y>us in origin, and pruriius from thb cause may be met
in iromcR late in life who haw a ncun>iic temiterament. It is vcn' rare, however,
in yuung wumen and in those having a normal nervous ^sicm.

Unutisficd Mxual desires may be a uiuse of pruritus, and thLi^ Conn of the
afTevtion b met in }'oung widows and wortKn whose liusliands huvt been ab»nt
f(tf a I'uii! lime.

Sabjectlve Symptoms.— The it<hing maylje constant or intemittcnt,
i»l it nuy otcur at niiht after gelling inlo tw<l <>r after exercl->inf;, cspedHlly in
irirm weather, Tlie ;Mrox)'sn»* are alM> bn)ughl on or aggravated by sexual
inteTo>ursc or masturbation, .ind u)me women suffer only at the menstrual

Ctioils or during pregnancy. The atlacks may be paroxysmal and there may be
tervab of r«veral hours or days between them.

The irritation in the beginning h not marked. a« a rule, but Krailually be-
aiRiR* Ml cKiilini; thai the patient b compelled to constantly rub and Kraich
the |i3rt> toul)iain relief. Tlic 9><:ratchinK.howe\-er. while it affords temiH>rary
allrvLilion, only make» the 0)n'lili<m worse by Incnaxing the cimgc^tion and
irritaiinR the ^kin ami »erv<-etii lings. In some cases the paticru rubs the parts so
vwilmlly ihit cxciirblions and abrasion^ occur ant) the hair b pullol out. In
ca>r» of pruritto due lo senile \Tilviiis, or in those occurring from a nervous
cau«e in women with a neurotic lent )<eni men t, the itching t> cunstanl. intense,
and intolerable.

The clitoris alone may be the seal of irriuiion', usually, however, the entire
vulv3 in involved, and the pruritux may spread lo the \iigina, the inner »urracc
i)( the thighs, and aikil region; in cases occurring during pregnancy the lower
abdomen may lie alTccteil.

The health of the (Miieni »ufTi-rs severely in agKravate<l ca»es and the lotf* of
sleep aiKJ apiietitc te.id to ^^ysical exhaustion. Urave nenous symptoms may
«]po develrtp and the i>atient nuy Iwcume melancholic or insane. The use of
opii ' 'irther ad(U to thedr^in u|H>n ihe sy^'lcm and eventually incTva>es the

Un.. The sexual desires arc greatly increased and the patient may

Mifirt irorii efi'tii M-ii-.iii"iis whidi e^vntually lead to masturbation.

Ol^ectlve Symptoms.— '11>c appeamnoeof the vulva depends upon Ihr
cau«r of the pr\iritus. The rubbing and seratching increase the inflammatory
cumlition» and there in more or le» edema of the clitoris, the vestibule, and the
nymphjc. The inris are vxconatol and envtci 3i>d »mall ulcers may be ob-
nenred. Later on, there may l»e fwrmanent thitkcninf; or hypertrophy of the
ttviie*. and •null cicutricni may l<e »cen whidi are due to the healing of 9,nudl
111- where the summnding jwrts are invoU-cil the irritation attd in-
liiscrvetl on the inivcr »urface uf the thiglis, tlvc anal region.

Thr
da"

\i at the juris in cases in which no local rau»e cxbts is more or
rt>tu'. TliF skin and mucou.^ membrane have V»l their normal
are lilca(he<i or anemic in ajtpearuncc and small whitish spots are

ubaervod whkh aiv paler than llie surrounding tissues.

l84 TRE VULVA.

Diagnosis. — Pruritus vulvie is a symptom which is due to a definite cause

and the diagnosis is based therefore entirely upon Its recognition.

Prognosis. ^The prognosis depends upon the cause producing the symp-
tom. Cases due to ner\ous causes, senile changes, or obscure conditions an
always unfavorable, and those occurring during pregnancy or at the time of dw
menopause usually disappear si>ontaneously.

Treatment.— The treatment is divided into (i) the treatment of the caust
and {2) the treatment of the pruritus.

Treatment of the Cause. — The treatment of the causes of pruritus is dis
cussed under their respective headings.

Treatment of the Pruritus.— The treatment of the pruritus is di^ndet
into (a) the general; (6) the local; (r) the use of the .r-rays; and (d) the opera
live.

General Treatment . — A highly nitrogenous diet must be forbidden
The food should he nourishing and easily digested and the free use of milk i
especially recommended when it agrees with the jratient. Alcoholic drinks mus
be avoided. The bowels should be regulated by the daily administration of
simple laxative and the occasional use of a saline. The urine should be mad
bland and non- irritating by the free use of pure water and over-acidity correct*
by ihc administration of liquor potassa; and tincture of belladonna. If the urin
is alkahne benzoale of sodium or ammonium should be given.

The duration and character of the exercise taken by the fMilient depend upo
the cause of the pruritus. \Vhile we must be careful not to weaken her by clos
confinement, yet we should abo remember that in many instances the local di
ease is frequently made worse by friction of the parts in walking. Under the
circumstances the patient should take a daily drive in an open carriage and enjo
the benefits of the fresh air and sunshine. A change of environment is especial!
beneficial when the disease occurs in women with a neurotic temperament, an
under these conditions a residence at the seashore and sea-bathing often eSe
a cure after all other means have failed.

A general tonic course of treatment is indicated in a large propwrtjon of tl
cases of pruritus, and the administration of mineral acids, quinin, arsenic, ar
iron is often followed by beneficial results.

Large doses of sodium or potassium bromid often relieve the general nervou
ness and local irritation, and equally good results are obtained at times by tl
administration of potassium io<iid or tincture of cannabis indica. The use ■
opium and other habit-forming drugs to promote sleep must t>e forbidden. Tl
following remedies are recommended as hypnotics: sulphonal, gr. x-xx; para
dehyd.gtl. xx-axx; or urethan,gr. xv-xx, given at bedtime and repeated in tv
hours; chloralamid. gr, xv-xl, given one and a half hours before bedtime; trion
and tctronal.

Local Treatment . — Cleanliness. — The vagina and vulva should 1
irrigated twice a day and kepi free from irritating discharges. The foUowii
douches are recommended : Normal saH solution ; bichiorid of mercury(i to 200c
a 2 per cent, solution of creoHn, acetate of lead, or carbolic acid; and a satural<
solution of boric acid.

The vaginal discharges should be kept within the vagina by a tampon
colton-wooi and not allowed to come in contact with the I'ulva. The tampi
shouki be saturated with horoglycerid, or one part of acetate of lead to seven
glycerin, or 25 per cent, of ichthyol in glycerin. .\ drv tampon may be used
some cases, and nothing is better for this purpose than dusting with Iwric acid
borax. .\ hot sitz-bath keeps the parts clean and allays irritation.

AppiUations. — Direct medication to the vulva is made in various ways and

PKVRITVS WVfM. |8S

an impnrtanl part of the ircaimcnt. The (ullowin); mcihod^ ami nrmeclics are
Kc'MnmciMlnl:

Lini «>m|)rcsscs arc an cxcdlcni means of applying remedial BKcnis. "Muny
raMsi AFC (CTcaiiy lioiM'fiied by a «aiurate<] •4>)ulion of poiii5^«ium biomitl. Good
rr^ult* arc ai>" i>liiaine(l wiih bi^-hlDrid of mcrcur)'. i U> ^ooo: .1 3 [>«■ ct-nt.
Kihiiion (if nirlfolic add; 3 )0 per ccni. soiuiinn of cocain: or Icad-ivulcr and
I' 1:1 C'loih.-v « nin); out ofhoi or cuhl niuer and applied to the vulva of len

V -imry rrlicf (oiliiwcil by a niKht's rvsl.

Sulur.ilin^ j pIcdgH <>i al>5orbcm coii'm held in the gmp of a pair of drr^ln];
(ort'irfn tvith a rtmclid a^rnt uiiil juiiiilinf! (he surface nf die vu\rii iv 3 very
eflitirnl medi"! »i .i|i|>tyinK tmai Irr.-itnicnt, 'ITw frequency nf ihc application
dc[>ends ii|>c>n ihediur.nicr and Mrcngih of the rcme^iy. The follow ins prepars-
ti(>^^ have l>ecii found of seriiie: A 10 [irr ecu). Mdiilinn of oirljolii' ucM or
t<M.uin: dilute hydmcyanicadd.f.^ij.acetatc of lcad.gr. xl, and glycerin, fAJ;lhree
(•r^iii^ of morpbin to one ounce of water; and one juirt of dijuie hyilnxyanic
dtiil to an ounce of jtlycerin. A cure ha,i Ixxn eflectci! in >ome ca>e* by )uinlin){
ihc [wirii^ with pure ichth)»l once or twice daily. The use of one i^in of curro-
ki\e sublimate to an oun<-e of the emulsion of almonds, applied twice a iluy, has.
boil w><in«lcrful ix-'uli> in relieving iHc conitil ion (Skene) ; "i^lcen drnp* of clik>it>-
fomi to an ounce of the same emulsion is alM> benetHial. (iood results arc
l«l>liiiiied l>y (he daily al>]ili(:ttio» of ei|ual parts of luirturc of i>»lin, atonile. and
lium niixcii with S (x-r ccni. of c;irlmlit ;i<-ii!.

lulitiinK ihe {kiiIs with a ]>cn€il of menthol often gi^'es lemimrary relief and
ri/.tnit (hem with a solid ^itick of nitrate of silver or |iure ciirlnilii acirl either
!t>r LornbiiK*! with equal parts of lint lure of iodin may be tried withho]>etof
becea wltcH less fe\crc remedies have failed.
A M>liiiii>n of iixloform in rlher »|irayed over the affected pan$ with an stom-
Icaves a fine deposit which soothes the irritation and Ki\'es relief.
T1te u*< of healing and siHiihing jKtwders du%le<l i>vrr the vulva is e^v^ntb]
ill tlie Ircaimeni of rcHain cases of pruritus. 'ITicsc (jowders pmtett the dbeased
faa» fn>m irritalinR discharges and lessen the friction in walking. Tite
pomJert lor tbi* jiuqxise are oxiil of xinc. Mdmitnite of bismuth, talcum,
(DHidium. and ralomcl.
OirUmctiis are beneficial in many cases. The folkiwinif are recommended:

ft. AtMl carbolkt f3M

Mrnibuli KT- 1:1

L'l^ucMli prtroUti. SJ.— M.

n Chhwjilk Si

L'ngurnti prituhli 3]- — U.

I'etnilrum ointment combim-tl with acriaie of le.id. chloroform, or camphor

fn-qtirntly employol with good rwults. liennuicd oxid I'f zinc ointment

'viih i |)cr cent, of cartiolii. acid is often used to protect .ind heal tbc

n* am) abrasion*. 'I'he f<>l[owinK formula makes a {[ood ointment to

«y the irritation:

II . Mrmli'ili p.r

Vnmii'nii iTKwott

Uugucnii campbotK.

t'l^gutnil bclUiloDnK,

Vngucui iwimJBtl. USIj-— U.

In (itmcure rases where no loral cause can be dbcov-ercd. excellent rrsulte
itc (ottowrtl the i>*e of the galvanic current applied lo the afTected |nns.
The I' f> e of x - r a y » .—'I'he jrray treatment of pruritut i* di^cui^cl on

I 86 THE VULVA.

Operative Treatment . — In chronic cases of pruritus vulvae which
do not respond to medical treatment operative interference must be thought of
and the question of partial or complete removal of the external organs considered.

In some cases the labia majora, the nymphcc, or the clitoris should be
removed, and in others a complete extirpation of the vulva may be necessary
to effect a cure (see Excision of the Vulva, p. 963).

KRAUROSIS VULVAE.

Definition. — A progressi\'e atrophy and contraction of the tissues of the

vulva.

Pathology. — The disease affects the labia majora, the nymphx, the
vestibule, the hymen, and the vulvar orifice. It begins by the appearance of
small brown spots, of irregular shape, on the surface of the vestibule and nym-
phiB. These spots are slightly depressed below the surface of the affected pari,
and either spread, or disappear entirely, to recur in another place. During the
later stages of the disorder the spots are altsent.

As the disease advances the tissues become tense and contracted and shining
white in appearance. I-atcr on, when the atrophic changes have become well
established, the vulva is shrunken, dry, hard and brittle, and its normal ap-
pearance altered. The vulvovaginal orifice also becomes contracted, and in
some cases the narrowing is so marked that it is impossible to introduce the
finger into the vagina without tearing the tissues. The hair on the vulva be-
comes dry and gradually falls out. In the advanced stages of the disease the
nympha; and clitoris have almost entirely disappeared and the vulva is scarred and
wrinkled.

In some cases the \'u!va may be bather! with a slight discharge which is
brown or yellow in color and extremely irritating.

Cause. — The cause is unknown. The disease may occur at any time after
puberty and affects both virgins and married women alike.

Subjective Symptoms.— In some cases the patient suffers little or no
inconvenience. In the majority of instances, however, there are severe par-
oxysms of pain, and a sensation of burning and pruritus in the diseased parts.
The vulva is especially sensitive during the early stages of the disease when the
small brown spots are present, and the contact of urine during micturition
causes severe smarting. In many cases coitus is imjwssible on account of the
extreme contraction of the vulvovaginal orifice and the severe pain occasioned
by the attempt to introduce the penis. .-\s a rule, the parts are dry, but in some
cases patients complain of a slight discharge which is often very irritating and
offensive.

Objective Symptoms. — The appearance of the vulva has already been
described.

DiagTiosls. — The diagnosis is based on the objective symptoms.

Prognosis. — The progress of the disease is very slow. Labor Ls usuallv
attended by extensive lacerations of the soft parts due to the contraction and want
of elasticity of the tissues. The disease has no tendency toward a spontaneous
cure and no relief can be looked for unless radical measures of treatment are
instituteil.

Treatment.— The treatment is divided into (i) the palliative, and (a) the
openitivc.

Palliative Treatment. — The palliative treatment is directed toward the
relief of the pain, the burning, and the pruritus. All local applications are more
or less unsatisfactory'. The most permanent relief is afforded by the application
of pure carbolic acid or the solid stick of nitrate of silver to the diseased tissues.

TUUUAStS.

1*7

b vcf)- ttmporan- in its action and in some cases its use increases the

of the >vm|>ti>iTU>. A lint i:i>m|iTcss >c>iiknl in ii ^iiliir.ited sntution (^f

Inle (if Ira'l uml bid over ihc purls often pvrs thr pulicnt iiimfnn. Vasclin,

>tn!iinol with i per cent, of yellow menuriL oxid and imcjrol over the piuls, U

cnrlii ijl in v^mc^ tut*^, iind lint ciimiirr-v>r< or cloilin wrung out uf hot water und

[jplicii lo the «ilva urc odcn vm- w«>lhing.

The cracks and fissures which occur from lime to time are Irctitcd hy toucliinK
Hem with a solution of nitrate <>f Mlvirr(gr. xx\ Id r3j)Hnd applying benxnuictl
till iif zinc ointment. Tlic vulvn must be protected from the urine durin;;
turiiiun, and mithtuK Is 1>eiter for this purpose than vii>clin conlainlnj; 3 |ier
Dl. of cnrbnlic acid.
Operative Treatment. — The following operations axe recommended;
I) FordhkdibLilvon of ihc vulvovaKinalorilke; (6) curdmeni: (<) cuulerixt-
>n; (rf> excision.
Fiircit)le Dilatation of the Vtilvovaftinal Orifice. —
The upcraiinn mu*.! Iw |M:rf"rmc<l under an aneMhetic with the patient in
the dorsal jxttture. The ttiliialion is accomplished by means of Simon's
•pcculumik, or the >i(ier,ilor'> lhuTnK>, which are imroduml into die ^-a^ina ami
ivn apart. In a case ocairrinK in my own practice the subjective symptoms

Kteally relieved by this operation.
Cu ret m cnl . — Tile rem(«-al o( the itfaeated skin or miicnun mem-
brane with a sharp rurct is followe<l in some cases by good sympmmaiic results.
ic o|icT:iti<>ti i* iiMticuleil only when (he disease k limiterl to :i ?imall area, and
»en tlien cxi ivion i* a twlter operative pnmilure im acmunt of the raw ^urface»
^ich are left after curctmcnt to heal by granulation.
C> U t cr iza I io n.— Ttie dise:isctl iis><ue> may he caulcrixeT) with a
iMery or ^lv.-inncautcry. 'Ilie o|><:Taiion has the same indications and
ilkms as cureiment.
Excision.— Ciimplelc removal of the dU^asetl surfaces, including the
LDnnerlivie tissue immediately beneath the skin, which, accordini; to Lon;;-
jrcar, it. »<'len>tic, is ihc o))erd(ion wtiiih proml'-rs the l>ust and mii^t [fcrmanent
rcautlk. The (echnic uf ihU procedure t» <lc»cri)>cd on page 963.

TRICHIASIS.

I>efiniHon. -When the hairs al>out an orifice become inverted and rtow
inwiiT't. ibc tondiiion h known a* trirhia.M^. T)ic di.-«a.-« L% nire. The hairs
he labL* nujori arc mixt rrr(|tient!y affccteil. although the condition may sbo
on the mons veneris and around the anus.

ibjective Symptoms. —There i» an inlen.->c prurilu* and a hurninj;

n in the afTcclc-rl p:irls. If the dtvasc is followed by inflammation of the

aiv». the vubjectivi- ^ympt'ims of simple catarrhal vulritis are al.^o present.

Otijectlve Symptoms. ~.A careful in^'pedion of the lartf re%'eaK the

invcnal hairs. .\t the ^ite of each ingrowing hair a small pustule is ob»cn.Td.

i m ami .ibr.n>iiin-> may lie present from MratchinK ami the siirfate may

1 with small scat)^ of ilricd pti«. If the vuK'a is intlumed, (he phyMCul

,11- -1 v;(Kiiii are pri-M-ni,

Diagnosis. - Thr dtiKm^i" i-t ha.«e<l on the presence of inverted ImIts.

Prognosis. The condition >-iclds rcii<lily lo treatment.

Trc-;itmcnt. — The p:ipilla->>f il»e invcne^i h.iirs should be destrtn-ed by

The applii^tion of the current to the follicle must he matle ))efore

:, remove<l, ns it ser^-cs as a i^idc for the inlroduction of the neeilte

(he papilla. The current should be applietl fur al>oul half a minute; it Is

lumcd oB and the hair Rra>ped with fine foriei» ""d Kenily remuve<l. If

l88 THE VULVA.

the hair does not come away easily, the current should be applied a second time.
Not more than twelve hairs should be removed at one silting, and in order to
prevent inflammaUiry reaction occurring they should be taken from dilTerent parts
of the vulva. During the first twehe hours after the operation hot compresses
are applied to the vulva and the parts then covered with benzoated oxid of zinc
ointment containing 3 per cent, of carbolic acid.

The routine treatment of trichiasis consists in the daily use of a vaginal
douche of hot normal salt solution and bathing the vulva with a warm solution
of bicarbonate of sodium (gr. xx to fjj) or potassium (gr. x to fSj) to remove the
scabs of dry pus.

ELEPHANTIASIS.

Definition. — Elephantiasis is a chronic hypertrophic disease of the skin
and subcutaneous connective tissue, characterized by an increase in size of
the affected part, accompanied by inflammation of the vessels and lymphatics,
swelling, edema, thickening, induction, more or less pigmentation, fissures, and
warty growths (John V. Shoemaker).

Causes. — The disease is endemic in tropical countries, especially in local-
ities where the drinking-water is taken from a subsoil contaminated with decaying
vegetable matter and other filth. The prevalence of the disease in the Barbadoes
Islands has given the sjnonym of " Harhadoes leg " for the affection when it
occurs in that region of the hod)'. Sporadic cases are seen in all parts of the
world. The disease usually be(fins between twenty-five and fifty years of age;
it is rare before sixteen, although cases atTccling the lower limbs have been re-
ported as early as two years of age.

The affection is probably due to the presence of a thread-like worm and its
ova — the filaria sanguinis hominis — which organisms are introduced by the bite
of the mosquito, .\ccording to some authorities, it may be caused by repeated
attacks of lymphangitis, traumatism, er^-sipelas, or any condition causing local
obstruction to the circulation.

Subjective Symptoms.— The local symptoms are chiefly due to the
mechanic inconveniences resulting from the hy[)ertrophied \Tilva, which cause a
sensation of weight and interfere more or less with walking, sexual intercourse,
urination, and defecation. In some cases patients complain of pruritus and
smarting, or there may lie a discharge and severe pain if the parts become irri-
tated or excoriated.

Amenorrhea and chyluria arc frequently observed, especially in the endemic
form of the disease.

In tropica! countries the disease begins as an acute lymphangitis, with marked
local and constitutional symploms, lasting for about two weeks, and gradually
subsides leaving the vulva slightly enlarged and edematous. Subsequent attacks
occur, with intervals between them '■ur\ing from several weeks to as many
years, which cause the vulva to become |)ermanenlly and enormously enlarged.

Objective Symptoms. — The labia majors are most frequently affected,
next the clitoris, and lastly the nymphie. In some cases the entire vulva, the
perineum, and the tissues surrounding the anus are involved. When the
growth is large, it is more pendulous than pedunculated, although its base is
elongated by traction and bemmes the narrowe'^t part. Some tumors are so
large that they reach to the knees or ankles and weigh forty or fifty pounds.
The surface of the tumor is hard and it may be smooth, rough, or warty. Fis-
sures and excoriations are observed, and at limes distinct patches of ulceration
are seen, which are caused Ijy friction and the urine getting into the depressions
on the surface and undergoing decomposition. In some cases the ulcerations

vARicuse vBrNs.

189

K Ar

|vutv« ihe lymphiiiic vc^.-Mrb ami ihe Irmpli k discharged upon the uirbcc ii(
r icn>n'(li, irjusinj! an oficnsiv-c odor,
ilir tiutuinal itUtnds arc frnjuenily enlflrRcd.
DlttfftlOSis.— 11h' tlia^tHih jx tui'scl nn ihc Mibjcctivc and cilijoclive
>m|it(>m$ and xhc mkrosiopic cxaminaiiim.
Prognosis. ^The dUf;i>e U lu'vcf rurcd S)itiiiliinc(>usly, bul pursuvs a slow
imntc «x>urf« imd dinr^ ii«>1 cmliinKi-r lift- unless |iyrmiu wr thnimbaMK super-
veOfS. It h, liowovcr. anvcnablc 10 suiEical ircalnienl.

Treatment.— The irtatmem is ilivided into (i) Ihc medical, (a) the *ur-
pital. and (31 ihc use I'f the -v-rays.

Medical Treatment.— ResulU can be oblainehaI^Ii^ .ihoukl In; Irvated on general prindple-i
and (he patient placed absolutely M rest in bed. the bowcU kept open with salines,
and clclns w-runf; uut uf hut or void water or suiuruted with a solution of lead-
water awl budnntitn applied to the vulva. AElcr the .iculr intltimmatory pmcets
has disappeared a generous diet ^ouUl be given and all alcoholic beverages for-
biililen.

An oinlmcnl conliiininE mercury or io<iin i* appHwl daily t» ihe vulra and
sure made u|>i>ri ibt- jwrii wilh a u>mprc^i ami T band;i.ne. Intcnully the
* patient should be gitt-n ir<>n, arsenic, qiiinin, or (Hita.uiuni or NHlium i«<lid.
^idaKagc and (he appliralinn o( the galvanic and famdic turrcnis combined with
^Hld'trotysb have pn>ved bcnct'uial in many cuaea. A change of climate adds
p^hrgely to tin; chance* "I ultimate rc<t>vcry.

Thomasz. "I Ceylon, uses the su1phi<l of calcium inicniatly combined wilh

^^bc t(>cul application of oinimcnl5 and comprei^'iion. He claims lo cure caws of

^^wt months' (lur.ilion in fmm one in two months and m benefit grcjilly othcn^ of

^^DUBer standing- He gi^'cs one grjtn of the rcmoiy twice a day, after eating,

(or a perind of one numlb. 1'lie (Idm: is then in<TraKfl lo one grain and a half

knd lalrf on lo t'vii ciains.

Surgical Treatment. — The hpnmdir travel wen in thi» country and the

dironir forms id the lii^-:!-* nwt in ihc ir»|)ics .irc ircalci! by removing the hyper-

trophied [arts wiib a knife. The icchnic of the operation de[>cnils upon the

peitili.iritimofrAch case, and no )[*^neral ride» can. therefore, be laid down which

^^ritl answer all indication*. The miiin •ibjpcts in the icchnic are to remove the

^^H§eaM«l tissues completely and lo bring the etiges of ihe wounil together m> as

^^B} rc^liifc as nearly as possible the normal contour of ihe vulva, "ihc antiMplic

^Hrrcaulk>n« muM he nbM>lulcly perfect, a« suppuration h particularly tiangerous

^^n acc<>unl "f the dilated 'ondilion of the Kmphatit vessels.

The Use of the .v-rays. — The *niy ircalmcnt of elephantiasis is fully
|»I on page 77.

VAfUCOSE VEINS.

Dcfinition.'A iwrnunenily dilated, eUmgaird, knotty, aixl tnrtuotn cod-
Btion I'l till ii'iii*.

Canaes. -llierauM^ are; (1) Pregnitnc^'; (i) coiMjiiionii interfering with
vrn>tu» I ircubilitm of the vulva.
Pregnancy.— 'ITw brgrsi number of caws arc seen during pfegttancy, as
' iy«><i|»t:ic congi^tion of Ihc [kitIs at lb:il tinie i^ not only .1 predisfmsing
I active cnuv, .iinl when the pregnant uterus i? reinali^placeil or grtlalion
xj wilh .1 snwll p<'b-ic tumor, the pressure u|»n tl»e return circublion

•[- '-nusrs tlir vi-ifi.- of ilic vulvn lo rnlnrKe.

Cr- ■-■ ■:=. Interfering with the Venous Circulation of the Vulva.—
irculnl»'>n of the vulvit is interfered with by |>e|vic exudates o*

19a THE VULVA.

The vein?- are then drawn out of the incision and a ligature of plain cumol cat-
gut carried nn an aneurysm needle passed under their distal and proximal ends.
These ligatures are now tied and the intervening bunch of dilated veins excised.
The stumps are then held in close apposition and the free ends of the distal and
proximal ligatures securely tied.

The wound is then closed by three silkworm-gut sutures and the vulva
covered with a gauze compress which is held in position with a T-bandage. The
sutures nre removed on the eighth day.

Varicose veins occurring in other parts of the vulva are exposed by an incision,
ligated and removed.

EDEMA.

Definition. — An effusion of serum into the connective tissues of the vulra.

Causes.— Venous Obstruction.— Edema of the vulva may be due to
pregnancy or to general anasarca, caused by certain diseases of the abdominal
or thoracic viscera, and it may also be associated with varicose veins.

Infection. — This cause is not infrequent, and is met in specific or septic in-
flammations of the vulva.

Traumatism. — Edema mav be caused by direct violence, such as a kick or
falling astride of an object, and it may also result from excessive or brutal inter-
course or from the traumatism of labor.

Angioneurosis. — Intermittent angioneurotic edema of the vulva is occasion-
ally obBer\ed.

Symptoms. — When the edema is due to general anasarca, the entire
vulva i'^ enormously swollen, the contour of the parts is lost, and the vitaJity of the
tissues impaired. In some cases the swelling is so great that the patient is
unable to bring her thighs together and there is also difficulty in urinating or
passing tile catheter. The edema resulting from other causes is not so pro-
nounced, the i)arts do not lose their characteristic shape, and the integrity of
the tissues is not destroyed. Traumatic edema is usually limited to one side
of the vulva, unless both labia majora are injured.

Inlermillenl angioneiirolic edema or acute circumscribed edema of the skin,
as its name signifies, is a recurring disease, and appears suddenly on any part of
the hiKly, but more especially on the face or the back of the hands or legs, and
cases have also been obseri-ed on the vulva. The edema is circumscribed and
soft, and pits on pressure; but occasionally liis hard. The surface of the affected
jKirl is raised and is either congesle<l or somewhat more jjale than the surround-
ing skin. The swelling varies in dimension? and occasionally attains the size of
an orange. The disease often begins for the first time during the night, and the
swelling, us a rule, develops and disappears within twenty-four hours, although
sometimes it may persist for several tiays. Relapses are more or less common and
the disease may recur at short intervals for nn indefinite length of time. TTie
patient complains only of tension in the affected parts, and, as a rule, itching and
pain arc absent.

Progtiosis.^ — The jjrognosis is favorable except when the edema Is due to
general anasarca, and even llicn it may be greatly benefited by appropriate
treatment. Inlermillenl aitj^ioneiirotic edema is a \'cry obstinate disease and a
permanent cure is always doubtful.

Treatment.^ When the edema is due lo infection, traumatism, or varicose
veins, the swelling is not marked and no s|iccial treatment is required except that
which is directed lo the cause. General anasarca calls for the diagnosis and
treatment of its cause and the management of the local edema. The woman
should be placed at rest in the recumlient posture, and lead-water and laudanum
apj>lieri frequently to the vuha hv means ctf compresses held in position with a

liYt»ROCFJ.E OF THF. LABIt*]] UAJTS.

193

T-bandagc. When ihc swelling bccnnic^ fo great that the vitality of (he tissues
b thrcatrncl. mullipk iiuUions ^houVi Iw nude lhruuj);h ihv ^kJii to let out the
■enim uiui rcliov ihv tensinn. Aller the ^wulling has sub»de<l i^ulTidenlly [»r the
patient to be out of bed, the |kans shout<] be kepi dusted with a hiand powder,
such a* ly(,'t>]MMtium. suhnitrale of bismuth, cxlumcl, or boric add. and tlie labia
»ciuiniie<l hy a plnlfcct of tint to pretx-nt fricli<>n in walking.

In iniermiUeni auK'otieurolie (Jema ihe Iwst nniulLi are oIiL-iincd by givin);
small iJ(<~r>of Milium Militvlaie internally, rc-jcuLiiiTig tttr Ixiwtrls with silinc^, and
tuJmini^lrring such l»nics :^s (|uinin and Mrychnin. The general condition of the
patient 3h<rukl reicivc attention and dintrder^ of diKe^tioii should lje corrected.

HYDROCELE OF THE LABIUM JUAJVS.

Definition.— A (olledion of st.'nni" lluicl in the peritoneal sac which
forme'l ihc canal of Nuck during fetal life. The rlisejse is very rare.

Pathology.— l>uring feial life the )>eritoncal cinerinK "f the round li|»nient
extends beynnd the internal ring and forms n pituch which is called the cunal of
Nude. This canal beconves olililerate*! after birth, uiid in the adult the peri-
tatMmtn Mops At the internal ring. Wlwn the ranal fails to tIom:, it constitutes
A patulous tract and t>enies ihe sac of a hydrocele. The fluid contained in the
Mtc b thin and straw (-otore<l. but viotenre may alter illiy aiUMnganextravasiition
ol blood, or intLimm.*ilion m.\v occur and cau^ it to bccumc purulent. .-Vs a rule,
ifaenc isshut off ftoni the peritoneal cavity by adheiiions Itctween its surfaces and
the fluid b> permanently encysted. l.a1>Lil hydrocele may occur on both xidM
of th<- vulva

Snl^cctivc S3rmptom8.— The tumor, as a rule, cauws litlh; or no In-
nmiTnirnte, unlevt it atl:iiri* to brge prt>iM>rtions, when il mechanically inter-
feres wiili walking, sexual intercourse, and labor. The enlargement is slow in
.de^'cloping and Marts a> an ohlong tumor in the inguinal canal and gradtuilly
'Ifpnn downward into the labium majus.

Objective Symptoms.— When seen early, the tumor is situaleil in the
mguiii.il rjn;il, but later on it de^ccnd:^ and ap[>e.;iT^ in the upper part of the
bbium majuv. 'I'hc swelling is clastic, fluctuating, and translucent, and there
it no [Min on pressure. It is dull on )>ercus>iLin and when not enc\>te<t disapjieaiy
ea ptcwurc or when the p:itient assumes the recumbent posture; it is increawd in
Sfar by bearingdown or coughing. The enlargement \'aric6 in siic and may be as
■null «s an almond or ns larj^e as a cncoanut.

IMagnosis. —The diagnosis is important l»eca«sc of the danger of mistaking
ih* di«<a*e for hernia. The following diagntiMic point* should be <-onsidcre<l in
makinft the di'iimtion In-tween th<r two a>tidiiions: The gradunl dc^-elopmeni
rtf the tumor without any V>calor general sympioms; the dullness on (wrcu-'wion ;
tf ' :' eniyi the cLisiirity and lluduation if (he tumor i» enc>'MC(l; and the

.1 I .til Mgn>ol intUmmation.

Ilic ilillrrcntial dbgnosis twtwecn a sirangubted bemia and an inllamed
hydnicrle is ier\' difFi<iilL but the ab.nencr of all symptoms of intestinal ob-
Mnjciion in the latter con<tilion should not be lost sight of.

Prognosis.— The disease pursues a chronic course aiKl tlierc U no tendency
iirwanl a *{»>nLineoits cure and life is ho( endangered unlr<s suppuralion occun.
The only symptoms likely to \x complained of by the patient arc (hose due to the
site tif the tumor, which may interfere with walkin)[ or coitiu and obstruct the
ptBagr I'f the ihikl's head during Libitr.

treatment.— The treatment is purely jHrgint/and cnnsuts m the removal
ot Ihe Mc.
I.I

194 ^'BE VULVA.

Operation. — An incision is made over the entire length of the inguinal canal
and the sac exposed. The sac is then dissected out, twisted, and ligated with a
silk ligature close to the internal ring. It is then cut o& about half an inch from
the ligature and the wound closed in the same manner as in the radical
operation for an inguinal hernia.

When suppuration occurs in a hydrocele, a free incision should be made and
the cavity cureted and thoroughly washed out with a solution of corrosive
sublimate (i to 2000) followed by normal salt solution. The wound is then packed
with gauze and allowed to heal by granulation. In cureting away the sac caie
must be taken not to open the abdominal cavity at the internal ring.

ANTERIOR OR INGUINOLABIAL HERNIA.

Definition. — This form of hernia corresponds to the scrotal variety in the
male. It descends through the inguinal canal, following the course of the round
ligament, and appears in the anterior part of the labium majus. It may be single
or double and the sac may contain the intestine, the omentum, the uterus and
its appendages, or even the pregnant womb.

CatlseB.— In a general way the causes are. the same as in the male. The
failure of the canal of Nuck to become obliterated at the end of gestation weakens
the canal and predisposes to hernia. While not infrequent, the condition is less
common than in the male, owing no doubt to the absence of the spermatic cord
and to the greater strength of the tissues forming the inguinal canal.

Symptoms. — The patient complains of more or less griping pain or dis-
comfort, especially on exertion, and of gastro -intestinal disturbances which show
themselves in the form of dyspepsia or constipation. The hernia appears in th(
l>eginning as a small round swelling in the neighborhood of the external rii^
and after it has descended into the labium it becomes elongated in shape anc
constricted at its upper end.

When the hernia! sac contains intestine (erUerocele), the swelling is smooth
regular, and elastic, and its size and tenseness are increased by coughing, stand
ing, lifting, or straining. It disappears or becomes smaller when the patient i
lying down and when pressure is made upon it with the fingers. When th>
hernia is reduced by taxis, a gurgling sound is heard as the gut sUps back inti
the abdominal cavity, and the swelling returns again when the patient cough
or assumes the erect posture unless the inguinal canal is temporarily obstructe
either bv direct pressure or by the finger placed in the ring. Percussion gives
tympanitic note and the characteristic impulse is felt by the examining haa
when the pjitient coughs.

When the sac contains omentum {epiplocele), the swelling is irregular i
shape and has a doughy or boggy feel. The percussion -note is fiat; the tumor i
less readily reduced and no gurgling sound is heard as the omentum slips bac
into the abdominal cai'ity; and there is but little impulse felt upon coughing.

In an erUero-epiploceU the character of the contents of the sac is more or le
uncertain and the physical signs varj- in different parts of the swelling, accordin
as they are occupied by intestine or omentum. Thus, the percussion -note ma
be dull over one part and tympanitic over another; a portion of the hernia ma
make a gurgling sound on being reduced, and the rest of the contents of the M
slip back without any characteristic sign; some parts may be smooth, tense, ar
regular, while others are irregular in shape and doughy or boggy to the toud
and, finally, the impulse on coughing is not so distinct.

The possibility of the uterus or its appendages occupying the hernial sac mu
be borne in mind. When the sac contains the uterus, the usual physical signs a
absent and the tumor is hard, irreducible, irregular in shape, and there is no ii

BKNIOK TUJIoas.

■9S

pubr upon couKhinK- A petvic examination reveals the absence of the uleru.1 or
the |irc«iuc 'inly of if Uiwcr ^cgmrni, [nillr<l toward the affectnl siilc awl lixc<l.
am) mmbiiicl touch r^tjbli^hcs the connection bciwecn the lumor and the inin-
vitpnal )H>ni>in i>( the cervix. Should the ulcru^ contain j fetus, the hernia
grows »|>idlxi tlu-re is m:vi-ic )<H*al i>ain: »nd the usu^l »igns of ptrgnanr^- are
pment. Hernia of ibe ovan, is ulnn-it always »>%sutiuled wiih the same- (ili|)L-tce-
m^nl of ihc oviduct, the inte-vlincor Ok- omentum, and it tKfcU3.''a ^m.-ilhilnwnd-
shupcil maj.5 ocx^upying the inguinal canal ur Uie upper part of the labium, which
ljv0a iwrulL-irMikeninft MnsatJun on pressure. A pelvic- examination nrveaUa
uteml displacement of the fundus of the uterus and cximbincd touch establnhcs a
connection betHiren it and the inguinal tumor. The usual signs of hernb are
mf>re or lc^« n)iKlitie<], de|)endinK uixm iKc amount of intc»tinc or omentum
present and the Mlujiion of the ovary,

Differential DiapnosiB.— tlie aiTei-ii<in must Iw ilisiiniiuished from
hntnxTle, rnl.tii:<'iiu-iii oi tiie \'uUii vagi mil ^land, and a lumor of the labium
ijus

Treatment.— The tr«itmeiitbi divided into (0 the palliative, and (a) the

itive Treatment. — This form of treatment contiisis in the use of a
tniw, and i* inilJcaled in a reducible hernia which cnn be controlled by mechanic
preRMirc.

The pntieni iJtould be rautiuned a]|[ainst heavv lifting, stniininji;, or any form
of violent miKcuUr efFurt, and the bowels should be kept regular.

Radical Treatment.— The object of a radical operation is to obliterate the
jinal canal aivl preivni the subsetjuent ileMcnt of the viscera. The radical
!<• indMTAtcd when the hemiit k irreducible or Mnngubled and when it
not be cnntroltcd by a trus.'t. An operation should not he recommended if a
in b over tiftv years or the hemiu Ik small and easily cuntrnllcd unless she
tu wearing a truss.
Operation .—The tec-hnic of the opersLiion is the *nme a* in the male, except
that thcubscncvof the spermatic cord diangcs the anatomic conditions somewhat
ui renders it unnecessary to construct 8 new inguinal canal.

BENIGN TUMORS.
While IxrniKn tuny)^ of the vulva are compnra lively rare ihey occur, howewr,
rntly often to make it necessary to refer to them and discuss briefly their
tili>nulolo)Q- and treatment from a gynecologic stand)K>int.
SjnsptOOU. — I'he physinil cluinicteristic» of benign tumors of the ruU-a are
Ibc same as when the neoplasms occupy other portions of the body and their
development and growth are in no way interferetj with by their %ilu»tion, except
that il etfNncs them to injury or to irritating discharges from the vagina, the
bUililrr. an'1 the rectum, unless the patient U vtry cleanly in her habits. In-
Ibmmitioti, iliereforv, frequently oirurt in large tumors, and in some com* the
«kin Iwcome* deeply ulcerated, causing >were and even fatal hemorrhage.
Vartou'. form- of degeneration also occur, ami in thl"* re>peci vulvar tumon do not
JifTcT from rvcopltism* Mtiuted rtsewherc- The symptom' caused by vulvar
ium'>r» an- ihtetly due to the mechanic interference which iheir presence has upon
■ m? of the parts. Tliu.'*, their >iKe and situation may interfere by
c pre^iure with locomotion and <cxu.tI intercourw. and in *i)me cases
'obainjct the bladder or reaum or direct the flow of urine alone an abnormal
innH-

Trcaunaot. —Tumors of the vulva should be extirpated nod the wtnind
with interrupted sutures of catgut or sillcworm-gul.

196 THE VULVA.

Fibroma; Myoma; Myxoma; Mixed Growths.— These tumors
are not common and the)' generally grow from the labia majora, but they have also
been observed in the nymphx, perineum, and vestibule. They usually increase
temporarily in size during menstruation and pregnancy, and they mar suddenly
become enlarged from the formation of a hematoma caused by direct %-iolence.

These tumors are either pedunculated and grow from a slender stalk, or they
are sessile and attached by a broad base.

Fibroids of the vulva occur at any age, but, as a rule, they do not develop
before puberty, and they may attain to the ^ize of a child's head or e\'en larger,
reaching in some cases down to the knees. Myxomatous tumors do not grow
to a large size.

Ifipoma. — These tumors are rare. They grow from the fatty tbsue of the
mons venerus, labia majnra, or nymphffi, and occasionally become very large.
They may imdergo a rapid increase in size during pregnancy, and if the surface o(
a tumor becomes ulcerated from any cause a severe or even fatal hemorrhage
may result.

Neuroma. — These tumors are verj' rare and are apt to cause vaginismus.
Simpson reported a case where a neuroma was situated near the meatus urinariu;
and was felt as a small tender nodule.

Angioma.— A vaacularor erectile tumor is verj' rarely met with on the vulva
It has but little clinical imi>ortance and usually causes no inconvenience to thi
patient.

CYSTS.

Vulvar cysts are comparatively rare and result from occlusion of sebaceoui
glands, dilated lymph -vessels, dermoid growths, serous collections in the sai
of an old hernia, or a patulous condition of Gartner's canal.

Sebaceous cysts, which are the most common variety, are superficial and occu
usually on the lower part of the labia majora as well as on the vestibule above th
meatus urinarius. They contain either a greenish -yellow fluid or a pultaceou
mass, and their size varies from a small bean to a hen's egg.

The other varieties of cyst are dcep-scatcd.

Blood tumors, hydroceles, and cysts oj the vulvovaginal glands are not in
eluded under this heading and are discussed elsewhere.

Symptoms.— \'ulvar cysts, as a rule, cause little or no inconvenience, unles
they become inllamed and suppurate. When the cyst is the size of a hen's eg
it may interfere with locomotion and cause painful or difficult coitus.

Treatment. — The sac should he extirpated and the wound closed with dee
interrupted sutures of catgut or silkworm-gut. If the entire cyst cannot b
remo\ed. the remaining portion of the sac should be destroyed by curetment c
the actual cautery and the wound packed with gauze and allowed to heal b
granulation.

CANCER.

Primary cancer of the mlva is ver\- rare. Epithelioma {squamous- or cylit
dric-ce/led) is the most frequent variety observed, and cncephaloid or scirrboi
cancer is very seldom met,

Sitaatlon, — The disease usually starts from the depression between tl
labium majus and the nympha. It may. however, develop from the prepuce 1
the clitoris, the orifice of the urethra, the nymphae, or the perineum, and in vei
rare instances from (he vulvovaginal glands.

Causes. — The majority of cases occur between forty and sixty years ■
age, and exceptionally the disease has been observed in very old women and youi
children. Psoriasis, traumatisms, chronic inflammations, and irritable war

CAKCKIt.

197

11 '"

I »vr

II '^

i^^

y be mcniioned amonft ilw firetlisimsing t.'nuses nf primary rancer, nnd the
■»■ m.i> ;iIm> occur a* n ,i(i^iin</a''_v grouifi fmm olhcr pun* of ihc Ixxly.

8yinptonia.~PruritU'5NiilvA- ban curly und niorcur IcMoonsianl prcotoni-
tonr sym|>(om of vulvar nincvr, e?{ieriiilly when ihr clituris i.4 the >ciil nf the
vffeclkMi, The itching u^iuilly occun in paroxysms of crcaicr or less intensity
atkd cfintinucs off and on ihrouRhoul the course of the disease. The afTeclion
befcins ;i> n >kinall, hAnI, elevaicil nocltiic situ:iii.ii in the tkin or mucoiK membrane
and (i>vrml by several layers of thickencxl cpilheliutn. Later on the nodule
ukentes iiul secretes a thin watery diMharwc haviii)- a foul or fetid odor. TTie
aecielfa>n* ev'enlually !^^^c their senni-i duinictrr anec<imc purulent, very
"rnww, aivl mixed with broken flown tissue. The ulceration hcsins early, as
rule, and s{>reaiL'L rapidly. Jntiilvini; the surroumlin^j |ian-s and in»t-u1alin|c the
opf""rtc >ide by direct nmlact with the healthy liv.Ties The []i»ca»c b nut likely
I'l eKlend into the vagina unless il l*c^ins in the x'eatibule.

Ttic margins and ba^e of tli« ulceralion are irreKular in i-hnpe and indurated

I Kiihrd in a MTnj>uruk-nt div^^hargc. The inlihTaiion extends into the sur-
undineparisas the ulceration spre-^ids, and when the vai^nal walls are involved
r urethra feeU Hke a h;iril tuti« (o tlie examining Imjcer. Pain i.* usually a Ulc

•vmplom, and may exceptionally be absent altogether in some case*. Hemor-
nui^ are not common. an<l when ihey ociur the hleedinf;. as a rule, is i»Ol
vtIous. I'lie lymjili.itit' KlarxK of the jcroin f)ccome inferird and swollen.

When Ihc disease develops on a wart, it starts as a sluRp'sh. irritable uK-er
which gradually i{>reads anJd eventually acijuires tlte usual <;haractCTi»lii> o(
itii;n,inl ulivraiion.

Diagnosis. —The disease must be distinguished in its early sUges fitini
Iapu» vulgaris, duim re. ihaiuroids, ordinary warls (itrriua vilgarh), condyio-
nulla Utrruca acuminata), and urethral caruncle.

Lapus. — The litslnr>' of the caw U imjxtrtant. Lupu9 usually begins tn
early life; il develops verj' slowly; the gcneml health is not, as a rule, affected;
anil pain is usually ab^nt or lery slight. C.in<^r, on the other luind, otcura
most often between forty and >ixty years of ajK, it develo;n more rapidly, the
ftcnrfal health is atTeaed. and pain is a more or less constant symptom.

The o!>t*tiht 'iw^niBi present certain features which should !« carefully
Mwlietl. The naalulis in luptis are multiple >inil wift. The ulceration is supcr-
(Uwl and nnered with "bright rwl granulation tissue": it is not drcumNtriVied,
but cMerxU in various di^cc1i<>n^ with healthy skin Ix-tween the lesions: and
tadunttiiin i» al»ent. Again, uWration and hypeqilasia exi^t side by side and
eii'atfices arc observed ai different points, indicating a tendency toward rcjuiir
which istltaracterLMicof thedi.-ieanc. Furthermore, the lymphatic glands are not
Aiilved, an a rule, awl the discharge fmm the ulceration is profuse, odorless, and
.riform in character. In earner there is usually but one nodule, which is hunl
■txf infiltrateil. The ulirration is deep and circumMTihct with indur.ilcd atld
uwlerminet) edges and the ba^ of the ulcer is covered uilh fungoiil granulations
■ad bruketi down li>-iies which are liaiheil nith a scanty, viacid, malodorouf
MCiTtion. The utn-faU»« pnicevi i- dunn-liTi/^l by nintinuous destruction
ot tl»e surroutxling tissues without any tendency toward (icatriratlon and the

iphatic glattds are in^^itved early in the rourse of the di!«asc.

II muni not be forgotten that can<:er and lupus may attack the vulva at the
me time and obscure the diagnosis.

Ctuuicrc. — Tlie apt^earance of a chancre in it» early stages resembles cancer

cliixcly. In the former disease there iv usually a hisitm- of infection followed

well'definnl perioil of inculxktion: the uker i^ nut ))ainful and ihuw> im>

to ftptead; ifae discharge b thin, tunious, and scanty; the lymphatic

198 THE VULVA.

glands are involved very early; and constitutional symptoms are developed,
as a rule, within a certain time.

Chancroids. — There is usually a history of infection followed by a. period of
incubation. The lesion is rapid in development, usually multiple, and seldom
involves more than one of the lymphatic glands at a time. The ulcers are highly
inflamed; they have abrupt, "punched-out," undermined margins; they are pain-
ful to the touch ; and their base, which is not indurated, is at first smooth, but
soon becomes granulated and secretes a profuse purulent and auto-inoculable
discharge.

Warts. — An irritated and inflamed wart can hardly be distinguished from
cancer, and as the tendency of all wart-like growths is to become malignant, no
time should be lost in removing it for a microscopic examination.

Condylomata. — Venereal warts may be mistaken for the papillary form of
cancer, and in case there is any doubt of the diagnosis they should be removed
at once and examined by the microscope. The history of the case, the duration of
the disease, and the absence or presence of pain and ulceration are important
aids in the diagnosis.

Urethral Canmcle.^A mistake in the diagnosis could hardly be made
unless the caruncle becomes ulcerated, and under these circumstances its im-
mediate removal, followed by a microscopic examination, is indicated.

Progliosis; Course. — Death usually occurs in from two to three years
after the first appearance of the local lesion. Pruritus may exist for a long time
before the nodule develops. After ulceration once begins, it spreads rapidly,
and death is due, as a rule, to marasmus, produced by chronic septic absorption,
loss of rest, and mental depression. Metastatic involvement may also occur
and hasten the end.

Treatment. — The treatment is divided into (1) the radical; (j) the use of
the 3;-rays; and (3) the palliative.

Radical Treatment.— The only hope of a cure depends upon the early
recognition of the disease and the removal of the cancerous structures.

All forms of papillary or nodular growths occurring on the vulva after forty
years of age, or even before, should be looked upon with suspicion and their
complete excision recommended at once.

The looseness of the vulvar tissues prevents traction on the sutures even when
there is an extensive removal of the structures, and consequently there need be no
hesitancy in making the incision large enough to eradicate the disease completely.

If the cancerous infiltration surrounds the urethra, it should be held out of the
way with a sound while the diseased tissues are excised ; and If the lower portion
of the urethral canal is also involved, it should be removed close up to the neck
of the bladder, leaving only enough of the canal to control the urine.

The technic of the operation of excision of the vulva is described on page 963.

The Use of the .\-rays, — The .r-ray treatment of cancer of the vulva is
fully described on page 76.

Palliative Treatment.— This form of treatment should be adopted when the
disease is well advanced and a radical operation is out of the question.

The ulcerated surfaces arc first cureled and then thoroughly cauterized with
the thermocauter)'. The wound is then douched with a solution n( corrosivt
sublimate (i to 2000) and dressed with gauze which is held in position by a com-
press and T-bandage.

As the ulcerative process spreads, the indications are to control the fetic
discharges, pnitect the surrounding parls from irritation, and relieve the pain
Lysol, I per cent,, carbolic acid, 3 to 5 per cent., creolin, fsij to the quart, corrosiii
sublimate, 1 to 2000, and permanganate of jjotassium, 1 to 3000, are useful ir

SARCOMA.

»99

the fcinn of tnticiiistol«k!«nihcquanlil>'iin(lnfT«m»'rcUnractef of thedlsdiarge.
PetToieum frefinc-l oil) U tikewi&e very b«nclicul and may br applied upon a Hnl
compreaa. Spraying die jKirbi with ImlroKcn p^ruxid before appljinft the
Wion is vrry useful in keeping them clean nnd correriiniK the odor of (he dis-
charges. The occasional use of the curet anil scissors to remntY pieces of
broken-down lisaue will often wn* a UM-ful i>uqMw« and lessen the dis-
chance. Till- ulccralire pn>ccss is frequently held in check or modii'ied hy the
ase»( n»ctliyienc IjIuc or -violet, aiid the dry jxiwder of either picpam lion muy be
duMed Dvrr the ulceraterl Mirfuceit w a i per rent, solution may be applied as a
btion.

The surrounding piiri> muM be ket>t denn with wap and vrntr and protected
with caHxibted v^iM-lin (3 |icr crni.). An :il><ofbcnt pad ^Imulil lir rnn-itantly
wont tnvt ihc vulva to alnorb the discharges and protect the adjacent skin vur-
(aues from cimtaminution. Pain ^buuld be contn>L]ed with opium and (he dose
grvdualty incrcuMd as the dbeii*c pntgresses.

SARCOMA.

Primary sarfonta b the rarest form of niuliKnant disease attacking the vulva.
It majr occur as a round-, spiiulle-. or rnlxeil- celled Mirconu or as a oidanolic
tumor; the Utter variety is (he mot^t frequent. Mixed tumors. «uch as fibro-
aarooma and mytoMrtoiai, have aUo teen observed ni>d operated u)>on-

CftnSCB* — ^Tbe di.->ea.<e '\% more common in yi>un|l than in olil women, and
il may aUo occur .-it .-inj- pcri^id of life either as a primary or n xffonJnry lr<Jun.
SyiBptoniS.— The objective symptoms depend upon the variet)- of the dis-
eau. In melanotic sarcomata the Ic^iorifi arc multiple and vtty painful.
They «tar1 in the skin of the ^oUva or from a pigmented tnole. wart, or nexus,
ami ap[jeiir a* hanl nnind nwlulcs which arc birown or black in color. The
nnJufes rapidly extend and tend to coalesce, but do not. as a rule, grow to a large
niu, and eveniu;«lly they become ulcerated. The sarcomatous nuieriab are
(UMeminated by tbcbloud-vie»elsand llic lymphatic gland* may become involved
throng these channels.

In other rarieties of sarcoma the legions are generally sin>;le and not patn-
Jul uolos the tumor liri-omes ulcented. They begin in the skin or on a mole.
or an old ciuiirix, and appear as small, hard iwxlulcs of a reddish-pink
Tile tum»r gTows npiilly anal may Iwcume icr)- large, and is attached to
' vul\it l>yn|>t:<Hr)eor3 broad bau. The lymphatic glands are rarely affected.
I^inckrl lias reported three cases of sarcoma which are Instructive on account of
ir Urjce tlie and long duration. Titc (ml ca^e wa« a round -cvlletl •hirc«>nui
! site of a man's lu-ad. which grew from the left labium by a jiedicle the thick-
. o( a child's arm. .md had extHte<l (nr eifiht year*. The seoind case was u
arcom^i situated nt-ar live orilire of the urethra which had latled (or 6(ieen
irxl wa« the sjxe of 3 child's head. The third ca^e was a fibromrcoma the
4 fiol, cri'tiing fr<>in the riglit bhium ^uju^.

a rule, vub^r vinomata show but little lemlency to ulcerate untCM the

I i> bnikrn by friction or some other cause, when a [Minful cxiorialion results.

is rupidly fdllnwed by the formation of a bleeiling, ^uupurating, iwcroilc,

' ] man. Their gmwth is usually rapid, but occasionally they may develop

, nr, tigain. tlKir progressive increaMt in stie may be temporarily checked

i» of quie-wenre, and Ihc activity of the tumor fceins 10 Ue dormant.

fn-ipirnlly lake pbce into the substance of the lunvor on account o(

I ihr wjIU ijf ihe b!^»»>^■ve^»eb and chamKls which ramify among

"■ or even fatal extern.il hemorrhnw* m.iy occur when the

Hatbu- 'Il iKcumes ulcenttcd. Rapidly growing tumors are vascular

300 THE VULVA.

and those which develop slowly are poorly supplied with blood-vessels. A
sarcoma may undergo fatty or myxomatous degeneration, or blood-cysts may
form in the substance of the tumor, and finally a large portion of the growth may
beconie necrotic.

Secondary growths, which are generally of the same structure as the primary
lesion from which they originate, may occur in any part of the body, but more
especially in the pelvic organs, the peritoneum, lungs, and liver. The sarco-
matous elements are almost always disseminated by the blood-vessels and the
disease often recurs locally after its removal, which is explained by the fact that
the surrounding tissues were infiltrated at the time of operation. The consti-
tutional symptoms are the same as when the disease affects other portions of the
body, and the size and situation of the tumor may interfere with locomotion or
with the functions of the genito-urinary organs.

Diagnosia. — The diagnosis is readily made by a careful study of the
physical characteristics of the tumor, the history of the case, and the microscopic
findings. A very small ulcerating sarcoma must be distinguished from lupus,
syphilis, and cancer.

Prognosis.— Death from sarcoma usually occurs within two years, and
only a very small'number of cases are recorded of a radical cure following th«
removal of a sarcomatous growth of the vulva. The disease, as a rule, recun
locally or death results in a few months from metastasis. The melanotic variet]
is the most malignant of the sarcomata, and in some of the other varieties, a,'
shown by cases already referred to, the tumor may exist for years without causing
death or secondary deposits.

Treatment. ^The treatment is the same as already described in cancer o
the vuh-a on page 198.

VENEREAL tILCERS.

Under this heading will be considered chancroids, chancre, and the syphil
ides, which will be discussed only from a purely gj'necologic standpoint by point
ing out the modifying influences exerted upon these lesions when they occur upoi

the female genitalia.

CHANCROIDS.

Situation. — \Vhile any part of the vulva may be the seat of primar
chancroids, the affection is most frequently situated on the fourchette, labi
majora, nymphas, vestibule, and the vulvovaginal orifice. It is very rare fo
chancroids to occur on the wall of the vagina. They have been observed, how
ever, with comparative frequency on the cervix, and also on the perineum, th
thighs, the anus, the lower abdomen, and in the urethra. Secondary inoculaiioi
from the original sores is much more common in females than in males, on ac
count of the two sides of the vulva being in close contact with each other and th
difSculty in keeping the parts clean. Multiple chancroids are therefore the ml
when the disease attacks the vulva.

Preqtiency. — Chancroids are observed more often among the lower tha
the higher class of prostitutes, for the reasons that the former are indifferent as t
whom they cohabit with, and they also neglect to examine the male organ befor
permitting sexual intercourse to take place. The higher class of prostitutes, o
the other hand, detect at once any open sore upon the penis and thus save then
selves from infection.

Course and Duration. — The course and duration are affected more c
less by the situation of the vulva and (he anatomic relations of its different part
and the prognosis is, therefore, in a general way less favorable in women than i

CMANOIOIDS.

nen. Ttius, the external organs are constantly exposed In contact with tcu-
prrhcil (ibchiirKcs, menstruiil 1>I(k>1. iind urine, and to friciion in walking, and
Js thercicre nftcn dil)irult to kwj) ihc sores clean or inv (mm mcihaniv irri-
Af^in, ittondary infections arc verj- common in vmmen. and new
n^idtt may cleveloti indd'miteK' unless careful attention n given to clejinlincss
the separation ol the apposing surfaces. And, finiilly, mrcs which are
Do»l healed may start lo ulcerate actively at;ain as the result of local imtatioD,
J plugcdenk ulcere, althuuith rare, are met frtim lime to lime in women who
rr delnlildlcxt from alcoholic excess or chronic diseases.
L Diagnosis.— The dtafi:nu~J.-> may at times be dUTicult and the diseaie

^^taistaken for chancre, hcTpc<. eczema, and cancer.

^H CkitHfToidi i-enecully appear within five or six days after sexual intercourse,

^HimI ne«r Ulcr ilum twelve days. They are mpid in development, usually

^^Bultiple. and seMom invulve more than one lymphatic gland at a lime. The

tnfecieil eland becomes intensely inilamed and tends to undergo «ui>puralion.

The ulcers are highly inflamed and painful In the touch. They have abrupt,

jiun died -out." undermined edges, and thin, non-indurated bases, which are

liroi smooth, but soon become granuLir and discharge a profuse purulent

Uloinmulable secretion.

Treatment.— The sores should be cauierii!e<) at once to con\-eTt ibem into

i;*|n-. iiii: ukcrs and thus prc»-ent auto- inoculation. They should first be

sthctiied by a sohition of cocain and ihcn cauterized by the thermocautery or

phufic acid. The va);ina and vulva are then thonnighly doucheil with a

jtinnof corn>si%-e sublimate (i lo sooo), followed by normnl salt solution, and

drying the parts with absorbent cotton a vaginal tampon is introduced to

lin the setretions. The chancroid.i are then dusted with ItMloform. unlcM

. odor is ub)ectionabk, in which case aristol, calomel, curuphcn, or subiodid of

iith may be substituted and the labia Mparated by a piece of lint which iw

in position by a compress nnd a T-bandsge.

The ulcers should be sprayed with hydrogen peroxid and fresh dressings

applied twice a dav.

As BOOB as healthy granulations begin lo form, the dusting- powder should be

dbcoDtinued and a stimubting ointment subsiiiuied. Benzoate<l oxid of zinc

ointineiit containing ^ (ler cent, of carbolic acid is a good preparation for this

ptirj)06e. I>a Costa recommends one part of the ointment of mercuric nitrate

•evm parts of vaselin. If the gramdations become unhealthy nr exa'ssivc,

ry shrndd tie cleaned with h>xln)gen ]M'n>xid and painted with a solution of

lie of silver (gr. xx to fij) or touched with the solid stick.

I'hai^tdfftit utterf must be cauterized wiih the actual cautery or nitric acid,

^the [Ktns douched and dressed as in cdscs of ordinary' chancroids. In some

' it may be advisable to apply a lotion of corrosive sublimate (i to aooo)

sly to the ulcer fur two or three da)>. The paticni's gencnil c»ndilion

iistainol and improved by nourishing food, alcoholic stimulants, careful

to hj-gienlc rules, and the ad mi ni-'it ration of ionics, e.^jiecially tincture

the chloriil of iron and quinin.

nie development of a bulK> demands rest in bc<l. painting the inllanted gland

rith iiidin, aimI np|)lying a small riim[>Te>s and sjiica hambge. In wme ca3es

\ ireatmenl will ctvfv the inflammation la end In resolution, but if suppuration

t, a free incision musi t>e made at once and the infedeil gtaivl curetcd

■y. The infiltniied "kin along the Hgcs of the inct<i<in i« then removetl with

I snd the wound flushed with a solution of corrosive sublimate (i to tooo).

ibaetM canity is ilieii |Ktcketl with gau» anr] the parts protected by a

which i* hetil in position by a epica bnivlagc.

a03 THE VULVA.

CEIANCRE.

The ioitiat tesion of syphilis may occur on the female genitalia and the
characteristic induration is more frequently absent in women than in men,
especially when the lesion is situated on the nymphse or fourchette.

Situation, — Chancres are less frequently found on the genital organs of
women than in other partsof the body, and the reverse of this is true in men, as
nearly all of the initial lesions occur upon the penis. The most common situatioD
of a vulvar chancre is on the labia majora, and the next most frequent locations
are the fourchette, the nympha;, ihe clitoris, the moos veneris, and the gioin, in
the order in which they are mentioned. Chancres have also been occasionally
observed on the cervix, but their occurrence on the vagina is extremely rare, and
is denied by most authorities, owing to the absence of glands and the thickness of
the pavement epithelium covering the vaginal mucous membrane preventing
inoculation.

Course and Duration. — As in chancroids, the course and duration of the
lesion are mure or less affected by the surroundings, and the ulceration, as a rule,
is superficial. Gangrene and phagedena seldom occur.

Diagnosis. — Owing to the conformation and relations existing between the
various parts of the vulva it is very easy to overlook the presence of a chancre,
and unless the examination is most carefully made an error in diagnosis will
result. Again, the frequent absence in the female of induration around the base
of (he sore makes an early diagnosis very difficult, and the surgeon should there-
fore be cautious in expressing a positive opinion until secondary lesions appear.
The disease may be mistaken for chancroids, herpes, and cancer.

Treatment.— The treatment of a chancre and its complications, phagedena
and buboes, is based upon the principles referred to in the section on chancroids,
with the exception, however, that the sore should not be cauterized unless it
becomes phagedenic.

SYPHILIDES.

The vulva may be the seat of any of the syphilides. Mucous patches, how-
ever, are the most frequent vulvar manifestation of secondary syphilis, and they
are usually situated on those parts which are in close contact and subjected to
the irritating influences of heat and moisture. The lesions may undergo super-
iicial ulceration and their secretions become profuse, purulent, and offensive, ot
the constant irritation may cause Ihem to hypertrophy and develop into venereal
warts or condylomata, ilucous patches are very rare on the vaginal wall and
on the cervix uteri.

The most common vulvar manifestation of tcrtiarj' sj'philis is the gumma.
which usually develops in the labium majus as a round tumor and tends to breali
down and ulcerate.

Treatment.— The ])arts should be kept clean and the labia separated
The vagina and vulva should be douched twice or thrice daily with a solution oi
corrosive sublimate (i to aooo), followed by normal salt solution, and a piece oi
absorbent lint placed between the labia to prevent friction and absorb the mois
tore. A vaginal tampon is also indicated when the patient suffers with a leu
korrheul discharge. Ointments should not be used because they increase th«
moisture of the parts and prevent healing of the lesions. Sedative and stimu
lating dusting-powders, on the other hand, serve the double purpose of medica
tion and absorption and arc therefore beneficial in these cases.

Mucous patches should be painted daily with a solution of nitrate of silve:
fgr. XXX to f5J), and dusted with iixloform or one of the dusting-powders recom
mended in the treatment of chancroids. It may be necessary, where there is :

VUlitt'C«.

903

tcndeacy to ukcrntivn or hypenntphy, lo spray ihc pntchcs with hyilrogen
peruxid and much them with the solid Blick of nitrate of silver onoc or twice a
week.

The ireatnwni of vrntriMl «*:iriv it, ducuncd under cDndylnmuU on page
304.

The local irejlRieni of n mippimtint: nuitima is bo-twl u|M)n the principles Infd
down in the maiugcmcnl of gangrene of the \idvu on page 173.

VERRUCAE.

The I'trrum tir waH h the moii frci|Utnt new-|rrowth appearing on the vulva,

MKiit is titel either as ft) the vcmica vul[::iri>.. or (3) the vcrruin aaiminuta.

Verruca Vnlgaria.— This %:irici>' is the ordinary wan, which M^ldom

uins to a br^ct ^izi' [luti frum -a pin's htm<l to a smaU bean, aiul usually a|>[>cars

la UToiifM, allliouKh ii i* n<» uncommon for it tn be iMiUicd. it may or may not

be (lodum-ublol : usually, however, it h attached by a broud or sessile t«»se, and

its color is Kenernlly the Mme as th;il of the NurroumlinK^kin or mucous meml>rane,

n It Iwcomo inttimed. In some cases it is soft in consistency; in others it b

I or evea homy; an<). as a rule, it is not sensitive unless it liecomej^ irriLiled.

e usual situation for lhe>e wuris to aplMKtr i* on the labia majnm, the nympha;,

«nd ihr mum veneris, and it if not uncommon aUo to find them on any part of

the vulva or around the anus.

Verruca Acuminata.— Thi^ variety k spoken of as vegetations, venereal

warts, txmdyiomala, moist warts, iig-vvarts, and caulidower excrescences. They

grow very rapidly and attain to die M/r of :i fi.->t or even larger. The uarti' are

sioitlr or mulliplr, iiedunnibiol or scv-^ile, and in snme cases they form large

of excrescences resembling tauliilotvcrs, coclu^combs, bunches of Kfa^ies,

mullierrteA. Their a)|or dcjicndN u|Hin the vascularity o( the growth and the

liiion of thio epidermis. If the epidermis is present and the surface is dn*,

ir color b the same as that of the Mirrtiundin^ skin or mucou* membrane;

if the wart> ore more va.scubr than normal and (he epidermis is removed by

or maceration, they arc of a deep re<l or puTi>le hue, and the secretions

purulent, ofFcibive, and liishly irritating. CondyloninUi are situated on any

>>f itie vulva, around lite antis, on the inner surface of the thighs, and also on

the ^'UKin-il wall.

I Causes. ^^Tlic ordinary uiirf in usually catiscd by want of cleanliness.

II (hrii'm, at ("leviurc, and in sonw cases it has been attributed to an impAired
I »uic of ihe sysicm.

I Vemtrtat ictim are dtte to irriiaiing discharges, gonorrhea, want of cleanli-

^^e^, and the congestion and Icukorrhea of pregnancy.

^H Symptoms. — Ontinaryicarls lau.ne n<i j-ubjeelii-e symptom* unlcw^ they be-
^^ttnie irriuiiril and inllamcd.

I'cutrrui Xi\iftt arc attended with an irritating and foul di&charge. They
BUr abo become irritated or infbmeii ami ruiiv^ |Mtn or tritdemotf in the part*.
L«rge irowlhs interfere with w.ilking ami scxuid intercourse, and in rare cases
whhunnalion. They alto produtvaienKalKmnfdragitinftorweight in the vulva
and marked local diKnmfi>n.

ZMagnOBis. — t'lVJK-a imlgarh is a characterislic lesion and cannot readily
be ni»uken for any other condition.

CondylimuUa, on the other hand, are fometimes more dillicull In dbgnufe

may l>c mUlaken for mucous patches. Tlie Ijiiler affection is associated.

a nilr, with"|hcr manifis>ta(ioii»>of »yphtli$: it devclofisf lowly; the lesion* are

rr in number; the vurrouiMling (issues arc not indurated ; and the papules are

304 TBE VULVA.

flat, vary in size, and are either depressed or raised above the surface of the
parts.

Results and Prognosis.— Orrfiwury warts are of no special importance,
causing but little or no inconvenience and yielding readily to treatment.

Venereal u-arts are a more or less serious condition and call for prompt and
energetic measures. When they develop during pregnancy they may atrophy
and finally disappear after labor. In old women they may undergo malignant
degeneration or become gangrenous and cause death. The discharge from
warts is very irritating and is apt to infect other parts of the body. Thus, it may
cause purulent ophthalmia, vulvitis, vaginitis, urethritis, or puerperal sepsis;
and, again, it may infect the eyes of the child during labor, or the urethra of the
male at the time of sexual intercourse. Condylomata are liable to return unless
they are carefully removed and all the diseased tissues destroj-ed. They may
grow to a very large size and obstruct the urethral or vaginal canal.

Treatment. — The treatment is divided into (i) the general, and (a) the
local.

General Treatment, — As some cases of verruca are dependent upon or
associated with an impaired condition of the general system, it is important in the
treatment of these patienls, e.^pecially in strumous or anemic children, to consider
the question of internal medication and 'to administer those remedies which have
a tonic effect upon nutrition and hematosis. The following drugs are recom-
mended; Arsenic, the mineral acids, cod-Uver oil, bitter tonics, and iron.

The following remedies are considered to be more or less specific in their
action upon warts: Tincture of thuja, in 5-minim doses, t. i. d.; tincture of
iodin, in lo-drop doses twice a day; and carbonate and sulphate of magnesia, in
S-grain doses each before meals twice daily.

Local Treatment. — The ordinary wart (V. vulgaris) is removed by ezdsion
or local applications; the former method is preferable. The wart is grasped with
tissue forceps and cut out with curved scissors and the wound cauterized or
brought together with a catgut suture.

Nitric acid is the best local application for removing these warts, and should be
applied by means of a glass pen — the kind used in marking with indelible ink —
directly lo the surface of the growth after first smearing the surrounding tissues
with vaselin. Deep cauterization should he avoided and several light applica-
tions of the acid made instead of using a large quantity at one time. The follow-
ing local applications also give good results: salicylic acid and flexible collodion
(3j "> fSi)'. bichlorid of mercury (gr. xx to f^j) and lactic or acetic add.

Venereal warts (V. acuminata) should be excised with curved scissors
and the raw surfaces cauterized with the thermocautery or the wound closed
with interrupted catgut sutures. As a rule, a general anesthetic is required, but
in some cases the operation may be performed under the influence of a solution
of cocain applied hypodermically.

Condylomata developing during pregnancy should be removed before labor
in order to guard against the possible occurrence of sepsis and the danger of
infecting the child's eyes.

If for any reason the removal of venereal vegetations is contraindicated, they
may be made lo disappear and sometimes permanently cured by applying equal
parts of calomel and salicylic acid or oxid of zinc and subnitrate of bismuth.
The parts should be kept clean by vaginal douches of corrosive sublimate
(i to 2000), followed by hot normal salt solution and the daily use of a hot silz-
bath. In case the vulvn becomes irritated and walking causes pain, the labia
should be separated with a piece of absorbent lint and the parts protected by
a compress held in position with a T-bandage.

ADHESIONS OF TITE CUTOIUS.

»S

ADHESIONS OF THE CLITORIS.

Causes. — The rrt;ilii>iiN cxi?>tm|{ IhIw-ct-h ihc supcriur (olds of the nympli.-c
xl the rcunded cxiicmiiy of the clitoris nflcn lead to adhesions between the
icliino uikI its [)fe)>U(-«; ii> (he result of irrltuiiiiK di.schutite.s. iiiflammniion, and
unc)»nlincs«. Adhesions ore quile tximmon in new-tmrn children. They iirc
\rr\- T.m in the [wrto race, and aecordiiiR lo Morris 80 per cent, of the Aryan
Annrioin women ittillfr more or 1cn> from 11 ftiL-.^ union of tin' ifl'ins.

Symptoms.— The kital and rcllcx disturljances depend upon the extent o(

the aiDip-ii'ii-v. and are most [mmounted when the entire jjlan> is Ixiund down hy

prepuce. In ■Hime case* sel«ceou^ mailer accumulatrs under the hood of ihe

litom and causes an irritation which results in local tenderness and jwiin.

hKain, adhnions may prrHluce serious rellex symptoms; they mjiy lea<l lo the

abil of mB&turbalioni and they may also be (he exciting cause of morbid

MMUal desires.

Acctinling to Hmx authorilicK, ndhe-
ft»on& are a common cause of ill health
ynint; women and an important factor
itic c.iUN'iiion of various ncunwes.
sympl'.inis. as a rule, are more
Qunreil liurinK thildtio<Kl than later
in life, and ihey an abo usually of a
norc serious character.

INa^rnOSlB.— A physical examina<
»n reveals ihc pre^ncc of the adhesions,
iome authorities advise thai all female
liildren should !)« cxaminwl when ihey
two or three months old and the
Ixriis hlieniled if found to l)e ndherent.
lile thi'i mjiy or may not be (»ii<xi prac-
te, there i-an (« no douht of ihe tietcssily
[ir sutli an rx.iminalion whenever local
irritation or rellcx symptoms manifest
them«cl«'e>. A neKleci of thi^ pre<aution
will often lead lo an error in diiignonis
Ami want of succrss in ircaiment.

Prognosis.— .Ailhesion* of the cli-
toris arc readily cured by |>n>]>cr treat-
■Dent. Adhesions reurd the <icvclopmen(

the cUlorb, iiTul unlMi they are broken up the organ ii apt lo be under-

Treatment. — Tlie irealmenl consists in the separation of the adhe»ii>n» AS
alliH-ri; 'Ilic piilient i' placnl in the dorsal jiosition .ind a 10 per cent, solution
cocatn applied on a pledget of cotton lo the clitoris and upper portion of the
iiphr. The clitorU is then t;rasped between the thumb and index-finger of the
lund aful the pre|Hice pulled back a« far as it will retract, while at the same
the glans is completely exposed by breakin); up the adhesions with ■ dry
or. Tlvc pan.i are then cleaned with a warm snhition of corrosive suhli-
itc fi (o 1000) and carboUted va^lin applied to the raw surfaces before allow-
inR the prepuce to slide back o\-er the p;lana. To f^uard a^.tinM the relonnation
iif lite adhe^i"n> the Rbns l> exposed and xiiMlin ap|)lic<l cwry day until (he parts
nluni to their normal stale.

Ft&- igr.-'-OTtuiioir ini Annunnm or ma
Shan ihe idhtiUiBi bilni !«4cb up anb * dit

206

THE VULVA-

HYPERTROPHY OF THE CLITORIS.

Causes. — Prior to puberty the clitoris is relatively large, owing to the
undeveloped condilion of the labia, and later on as the vulva increases in size it
becomes less prominent. True hypertrophy is comparatively rare in our climate
and is met, as a rule, in tropical countries. In hot climates the heat decomposes
the secretions of the parts, and if a woman is uncleanly in her habits the result-
ing irritation may in time cause hypertrophy. According to some observers,
the normal size of the clitoris is greater in the tropics than in temperate climates.
Winckel states that it "is also enlarged among the Abyssinians, Suzees, &Ian-
dingos, the androgynous and lascivious women, and to such an extent among
the first named races as to sanction the custom of removing it with the knife."
Notwithstanding the statements of some writers, it is unlikely that masturbation
is ever a cause of hypertrophy. Sj-philitic infection is occasionally a cause, and
for that reason hypertrophy of the clitoris is more frequently met in prostitutes.

Fic. i«9.— ItyFEanorHV or thu Clitoris.

ViG- iQi- — OpEkATioN rot HYraitmoPHiKD CLITOm-
Sfaows wrdcF-gbiped iDdiion ud nium in plue.

Symptoms. — The hypertrophy i^aries from a slight enlargement to the size
of a normal penis, and the clitoris niay possess the powerof erection. If adhesions
exist between the labia and the clitoris is greatly enlarged, the sex of the individual
may be concealed. Hypertrophy of the clitoris usually causes no inconvenience,
but in some cases it may interfere with sexual intercourse or deflect the stream
of urine from its normal course, and it may also become irritated and inflamed,
causing itching, burning, edema, and excoriations.

Treatment. — When the hypertrophy is moderate and causes no local
symptoms, treatment is not indicated. Inflammation is ^elie^■ed by rest, by local
applications of lead-water and laudanum, and by hot sitz-bath.s. Excoriations
should be fwiinied with a s()luiion of nitrate of silver (gr. xx to fjj) and covered
with carbolized oxid of zinc ointment. The itching should be treated in
the manner already described under pruritus vuIvk on page 184.

Excessive hypertrophy may require amputation. The hypertrophied portion
of the clitoris is removed by a wedge-shaped incision and the wound closed by
interrupted sutures of catgut.

AmiLstom or t»k lahia.

fOJ

TUHORS OF THE CLTTOIUS.

Tumor* o( iltc cliloris are vt-ry nire. Cystic Rn>wilis have been obwrverf
Kvcnl times, ami they generally contain 3 bkioJy tluid and may grow to the size
of a lien's cvR "r even larger. Horny ami encbonrlrumiitou^ (umors have been
met and v:tri<>u<^ fonns of nulignanl ami benign growthn hu^v l>cen reported (rooi
time t'> lime-
Treatment.— The treiiimeni i* hase<l upon Reneral furKical jn-inciples.
E%'Ai.'uat>on of the cnnicni& of a cystic tumor shoul<l \k tried iH-fore rvMirling to
reftrctiiin, a* these Kruwlhs have been known to di^ppear permanently after
ihcy have been tapped and their c»nient» withdrawn.

ADHESIONS OF THE LABIA.

Aclheiions of the labia occur more (requenily during infancy, childhood,
Matliiy, and in the unniarric*! «tate than in women who are t>earinK chiUln-n,
and, as a rule, they exist between the nymphx. but in mre catrs the hthin majoni
imy also betome united. In most instances the \TiK'ar orifice is not completely
ck>M<l and there is a ymall 0]>eniiiK left immedbtely Iteluw the urlnar)- meatus.

CattKS*— InAamnuilion. iiriialing di'<ch,irce'^. and unclc,inlincs.s arc the
most uinunon causes. The <irjp.(ns nuj' l>c simply glued or cemented together
bjr abnuemal set retiiin% and in ^ome c^.-ie-t llicrc ma^y be a firm organic union due
to the destruction of the protective epithel-
hua of the »kin. Sometimes labial adhe-
tiuRi are runKeniliil.

Symptoms. ^The patient majr com-
plain <>i i feeling of irritation nt discomfort;
the stream of urine may he directed upward;
and the menstrual flow may be retained in
(be t'ajntu Of dhchnr^ed with more or le«s
dificuliy. Sexual intercourse may be im-
pMsiblc. ditTicult, or iKiinful, or it may take
placr through the urethra, and should preg-
lunry occur the adhesions may form an
Dbttruclion to the ilelivcry of ihe ihilil.

Treatment.— If Ihe labia are simply
glued t>'K«her by seaetions, they are forcibly
tcfMTateil with lite thumlia and a v;iKitui]
douche of cnrrosi%'e sublimate (i to aooo)
jdno. The tabu are then separated with
a pfedgel of lint co^vred with ctcliolated
Tallin and the parts protected with a
d'Oipreas secured by a T-bandage. Fresh
drcwMOK* should Ik applied every day, or
ofteitcr, if necessary, for at least one week.

If the adhesions are firm and well or-
nnizcd, they mu<t be separated by a cutting o(>eratiun. A groove<l director
K (Biro(luce<l through the opening below the urethra and the labia divided with
a Wsl|>eJ aiong the line of false union.

WTicn no njiening is prcfent below the meatus, the urethral canal h held out
of the wny with a tound ami the parts put upon the stretch by lateral pressure
with the thumb and indei-fmger. .\ninci^ion is then maile between tlie adherent
labia with the Miiljiel and the index-ringer inlmduced into the ■•|>rning, which is
now exiendnl along ihc line of fal^; union (Fig.v 195, 196. and 197).

Fio. 104-— Aioiuioa* o* m Lasu.

Fu. <ot- Fn>. lift.

OnuTiDH rm Abhbiqh or iwr Laiia (lurr »:).
Flfl' lot dlowt (br «dhnicini hcinf fcmihlT H|urair4 with 1h« Ihumbt^ Fin. igAahotnth*

dlitM

Tbe dressings and the after-treatment of a cuttinK npcralion an; the »aRir

as in cases treated by fnrdble ^paration of
tlie 3<lhe)0Ti» with tlu- fingers.

HERPES.

Definition.— Hcr|>es b an acute In-

flu miiiii lory iilTcciion which iii Don-conts-
giousiiiidmarlccd by ihc formation of groups
of vesick-s siiuiiteil ui)on an inflamctl l»a>e.

Wlien the alTctliim -iiinck* the viiln. it
is known as herpes prof^enitaiia, and corre-
spond-^ with herpes prtputialh in tlic nuilcL
it i.* ailleil iirrpef grstnlionh when it occurs
during or immediately after pregnang*.

Causes.— The diwaxe wunlly Accun
during adull life nnd hns also been observed
in young t;irU. Il h frequently found in
conneilinn with mcnstntnlion. especially in
fill or neurotic women, and prostitutes often
suffer with heqie-i "» account of the con-
stant irriliilion to which the genital organs
are i^ubjeded. Conditions producing con-
([csticin nnd infliimmnlion in the genito-
urinary tract ami pelvic organs are often
causes of herjwv. Digestive disturbances,
atmospheric changes, cold, nervous depres-
sbn, and local irritations due lo a want of cleanhness or acrid discharges ore
frequently found lo be the exciting causes. Herpes may also ocnir in con-

Pra. i«T — OrtKATiOH mk Auunom or
ni> Ljuiu (lut* KT).
Sb«n ihr iMtllAd ol dlitdiaf ibt uUw
Am vbea >ui upHiMf ii pii lunl bdav ihc

BEXPES.

309

Brio

DMlion with prcgnann'. Usually, the affection is liable to attack womeD with
a driicntc or irritalilc skin iiru] ihm* who Mdn fmm an excta of uric acid.

SytnptomB* —The at!cclton h usiially preceded by local prcmonilory symp-
IMn* of lewleniess, pain, buming or itching, and in some cases there may be
hcsdactie, ffver, and a :>cn>:iti<>r of <*hi!linRic<t. Herjic^ may al.-ui nccur during
an Bltjtck of leva. When the di'^a:^ i:- caui^ed by inn^c^tion of the parts at
the time of mcitslruation, the eruption Keiierslly appears et'erii' month about two
days before the flow. Utrpti gatnlionis usually apiwars about the thin! or
h month of pregnancy, and it has .ilso been ob^rvcd as early as the third

fourth week, fn ^me case^ the eruption becomes RTeally nKRTJ^-aled a few
(Uye before labor and occasioiuilly it doe not make its af>pcarance until after
ronfinemcnt

The legion.-! of heri>es bcicin as small ^-e!>icle» about tlie »ixe of a pinhead
which are situated on an inflamed hn*^ and contain a clear serous or a seropuru-
km fluWl. They arc arranged in (.Toups and are usually few in number, In
other piirts of the tHxty the v«>i('lcji do not rupture, a* a rule, hut Kr:idually dry
up and form yellowish -brown scabs or inists which fall off in a week or ten daj-s
toivitiK a ili|chily reddeneil surtati-. \\1ien the eruption occurs on ihe vulva.
the beat, moiMurc, and friction of the piUts cau»c the vesiilo [o niplure »hori!y
after thejr appear, and small ulcers arc left which are slow in healing. These
euur{kiioi» generally coalesce ^nd the diMhiirfto may iH^time offensive in odor
and purulent in chamcler. 'I'he pruritu.i, which b a mon or 1cm conrtanl
«y»(>tora, may at times be veT>- sevvrc, and the rubbing and scratching may cause
a violent inflamm^itioii of the vulva accompanied by etlcma, Ihickeninjt of ihe
U>AUts.. and enlargement of the glands of the inguinal re^iinn.

HeT\it» Rcoerally attacks the inicrnal surfaces of ihc labia majora, the nym-
phs, the prepuce ot the clitori*, ami the %T<tibulc. e^iwdally in the ne!gM>orhood
uf the meatus urinarius, and the eruption may also he found on the mons ^vneris,
(he external surfacTi of the labia majora, and iJt rare Justatices on the vaxina or
the cenix ulcri.

XHfferentlal Dia^osls. —Herpes must be distinguished from eczema
uml \rncreal ukers.

Eczema.— In eczema the wsictes arc sm:illor and le^* rtatiencil, Ihe skin is
tniirr *w«>l)en, and there b a tendency of the disease to esiend. In herpes the
tv<trlrt ocrur in i.uc(««Mve crops urran)^l in grou|)S or clusters: the)- are >iluated
on an inflamed luisc and seldom dry up without nilKurinft when situate*) on the
iTilra, The course of an attack of herpes is short.

Vcnereil Dicers. — A differential diaxnoi^is between these ulcerationi and
bcrpes is easily made if the case i* seen l>eft>re the herpetic ^T^icles rupture, but
it becomes a more difficult problem to sohx during the ulceraii^x stage of the
latter ullcclinn, ei'(>ecially in aggravated cn^e^ which are acmmfKinied with
violent inHammalion. edema of the parts, and involvcmenl of the inguinal glands,
and under these circumstances it may be necessary at times to reser\-e our opinion
Bod await dcvetopmenis. The <ii,igr»ot«s dqwnds upon the htiiury of the case
a nirvful stitdy of the characteristic of the local lesions.

CkanfTttiJi give a hbtory of setua) intercourse and generally apjiear within
or *ix days, never later than ten or twelve daj-s, after exposure, 'I'hey are
In dcvciopmcnl, usually multiple, and seldom inroive more than one
it at a time. Tlic oUers are highly inflametl: lhc>' have abru[>i.
' undermined margins; lbe>' are tiainful to the Inuth: and their
., wbidi arc not induraied. are at first smooth, but soon become sranubied
aad dikchat^ a profu.-^, purulent, and autoinmulabtc *eeretk>n. In htrptx
there it a bi^lory of timllnr attacks. The ulcers arc super6nal: they »how no
'4

3IO TH£ VtJLVA.

tendency to spread or become excavated; and there is no characteristic involve-
ment of the inguinal lymphatics, as is the case in chancroids.

A chancre develops slowly; it is single; not painful to the touch, and has a
definite period of incubation. Its base is indurated and the niargin.<> of the ulcer
are sloping. The secretion is scanty, thin, and not auto-inocu table, and seveml
of the inguinal glands become enlarged, hut they are not tender and seldom
suppurate. In herpes the ulcerations disappear in the course of several da>-s
without any involvement of the inguinal lymphatics, and there is a history of pre-
vious similar attacks.

Prognosis. — Herpes usually lasts from one to two weeks and relapses are
less frequent in women than in men. In herpes gestationis relapses generally
occur in subsequent pregnancies. A severe systemic disease will sometimes
temporarily prevent the appearance of recurrent herpes and the aSection will
not return until the patient regains her usual health.

Repeated attacks of herpes may cause mental and phj-sical depression in
neurotic and nervous women.

The ulcerations occurring in herj)es are generally £up>erficial and seldom
cause scars.

Treatment.— The treatment is diWded into (i) the general, and (a) the
local.

General Treatment. — The predisposing causes of the affection must be
removed when possible, and the general health and hygienic conditions of the
patient carefully studied. The bowels, the kidneys, the digestion, the diet, and
the amount of bodily exercise must be considered and appropriate treatment
and directions given to meet the indications in each case.

During the acute stages of the disease walking or exercise of any kind must
be forbidden, as the excoriations and inflammation are aggravated unless the
parts are kept at rest. During the inter\'al between the relapses, however, both
indoor and outdoor exercises must be taken by the patient. The character
of the internal medication depends upon the indications, and is chiefly
directed toward regulating the \'arious funciions of the body and remoring
systemic cwndilions which may be the exciting causes of the disease. Amonj
the drugs, given internally, which are especially beneficial in the treatment oi
herpes for their general tonic and alterative effects are the mineral adds, cod
liver oil, arsenic, iron, and quinin.

Local Treatment. — The local treatment of herpes progenitalis is mon
important than when the affection attacks other parts of the body, as the emptioi
is often so altered and changed by the heat, moisture, ami friction of the part
that the disease becomes aggravated and difhcult to manage. It is necessary
therefore, to remember that the local treatment must be carefully directed, am
the indications clearly understood not only by the surgeon but by the patient a
well.

Careful attention to cleanliness and rest are necessary in the treatment o
herpes. The vagina and vulva should be douched twice daily with a solution o
corrosive sublimate (i to 2000 or 4000). followed by warm normal salt solulior
A hot sitz-bath exerts a beneficial etTect upon (he disease and is also very soothin
to the parts. A dr\' vaginal tampon of cotlon-wool should be employed to pre
tect the vulva from uterine or vaginal discharges which may be present, and th
labia should be separated by a pledget of lint which is held in position with
compress secured by a T-bandage. Absolute rest in bed is not necessary, unlet
the disease becomes severe and inflammation develops.

When the case is seen early, an attempt should be made to abort the vesicle
Salicylic acid (5 per cent.) is very useful for this purpose and frequently giv<

ECZEUA,

9tt

i;ood rvsult!^. It fJmukl be combined wiih vntelin and applied ar sn ointmnit
ur dKsnhTd in alcohol and painted nvci ibc aftccinl part. Ichthyol nt rcsordo
( lo lo )o \>et rent.) comUiuxt with Klycehn xImi exerts a good eftta, ukI should
be applied by mc-ans of n lint <'iin)]>Tes8.

Another m<th<xl which is successful in these cases is lo pUDClure the vtMcles

and louih them li^ihlly witli a )Kiini»l mkk of nitrate of Mh-er, nr the Mral of the

eruptinn maybe painled wHlh a lo per cent, sulution of the same drug. Alcohol

alone, applied by means of a compre^ held in position wiili a T bandage and

lefaaniced several times daily, is very elTirat iiius. One per cent. <if thymol or 3

Kr cent, of rc«>r< in or menthol may be combined advantageously with the alco-
1. anil if the jiart't :ire [minful. the addition of 3 per cent, of cocain or 5 per (cni,
of cxirad of cannabis indicu will reliexe the load dt»lrc>».

When the vesicles are fully formed or have ruptured, dusting- powders give
' mixM Mtiisfadory re^ultn. The^ |>owders are du.ited freely over the v«»icle4
the pans pmtccled by s contprR<« of al>sorbent cotton, which is held in
ponElion with a T-banHagc. Tlie following powiierj are recommended : Calomel,
nkmeor combined with bUmulh-, i^ilnim; lyt"t>iMliuni; Mibniiniie "f bismuth;
■ cnud of zinc; arislnl; (ircurophcn; and the addition of camphor, mnrphin. or
>ct>cain if there is pain. The u."* of du.iiing-puvrders hasten* the drying up of
the vokk"', pnitefis the excomtion.*, and a^siMi' in *eit!ing the quc!>lion of
diagoosis when chancre or chancroids are suspected, as ihey have no heabng
tnAuente u|x>n venereal sores. If the excoriated vesicles arc slow in healing,
the uw of dusling-i)o\vders should be discontinued and the parts covered with
l)cn/oated oxid of zinc ointment and paintcl even* few days with a solution of
niiraie ol silver (j^. x to fSj).

A t>c%'eTc inflammalion, accompanied with edema of Ihc vulva and inirolve-

ment of the inguinal glands, shoukl l>c treiiled by absolute rest in bed, the litily

ft»e of a hot ^ilx-balh. and the local application of lead-water and laudanum.

, After the acuie symptoms haw subsided active measures arc discontinued awl ibc

lk>ioa> treated in the manner d«scril>ed alx>ve.

ECZBSIA.

I>efiiiitioil. — " Fxixmsi is a non-a>nlagious. inflammatory aficction of the
skin, acute or chronic in character, appearing at its l>epinning tn the (orni of any
nf ihr elementary lesions, »uch as erythema, papules, vehicles, pustules, or a
rnmbinalion of them, accomiKinird with itching, more or \c^ inliltration. and
fntiuently attended with a discharge and the fonnation of scales and crusts"
l(John V. .'Shoemaker).

It ii>im|><>»ibleina work on g}'nccology to fully consider the subjea of ecxema,
as tbe disea.se appears in so many different forms ami varictie^, and tbepniciilioiier
|inu«t ihcrrforc refer 10 authorities cpecially de\^Icd to diiicasc* of ihe vkin tor
ihontugh study »( the affection. Eczema will consc(]iientl>' be treated from
|a inireb' fiynecologie stait<ipoint, and tittle or no reference will be m.vie to Its
■frncrnl cii-'logy <»r to the clinical picture uf the various eruptive phenomena.

Varieties.— The Milva may be the seat of any of the primary or sttomiary

HMRK III ct/ema. When the affeclion api*ean> on the organs of geneniion, il is

a» tczemti genUulium.

Causes. — Kciem.^ of the %iilva occurs ai all ages: it is more fret^ueni,

bowevrr. ilurinff the child-bearing [terifHl ni»l after the menopause. Ilie

1 'I'crlooked by l>cing mistaken for chafmg and other forms o(

I ; the iiarts are naturally c)ij">se>l. Tbe vulvj is ii.-inicuUrly

I i-c on account of the fniiueniy of local and j-eU-ir conditium

I ' '>r levt chronic iiriuiion xnd congestion. I'hus uncleanlittess,

aia THE VULVA.

friction of the apposing surfaces, nibbing of the clothing, and the natural moisture
and heat of the parts are often exciting causes. Again, eczema may occur
during pregnancy or at the menstrual periods, and it may also result from ^'utvar
and pelvic diseases as well as the local irritation produced by a vesicovaginal
fistula or diabetic urine.

Sj^mptoms. — Itching or pruritus vulva? is the most prominent symptom.
The patient also complains of pain and a burning sensation in certain varieties
of the disease and the health may be seriously affected by the exhaustion due to
local distress and loss of sleep.

The objective symptoms depend upon the character of the lesions present.
The disease may be mild or severe and acute or chronic; it is more commonly
met, however, in the chronic form. It may appear primarily on the vulva or
may be due to an extension of the disease from the surrounding parts. Eczema
usually occurs on the labia majora, and it may also extend to the mons veneris
and lower abdomen; the perineal and anal regions; the inner surface of the
thighs; the nvmpha: and vagina, and in very rare cases to the cervix uteri.

Differential Diagnosis. ^Eczema must be distinguished from lichen,
syphilis, pediculosis pubis, ring-worm, prurigo, herpes, paresthesia, and acne.

Prognosis. — Eczema occurring on the genital organs Is more obstinate
than when it appears on other [wrtions of the body, and the prognosis depends
upon its cause and variety as well as the duration of the eruption and the thor-
oughness with which the patient carries out the general and local treatment.

Treatment. — The trcalment is divided into (i) the general, and (a) the
local.

General Treatment.— While it is true that in many instances the cause of
eczema is purely local in origin, and therefore general treatment is apparently
not indicated in everj- instance, still experience shows that the disease is more
often cured when careful allention is given to the state of. the patient's health
and the nature of her environment.

The general treatment is based ujwn a careful study of the cause in each case
and the selection of the proper remedies to relieve the constitutional condition.
Thus, for example, if the eczema is due to an excess of uric acid no local treatment
will be successful in curing the eruption so long as the constitutional cause is
unrecognized and neglected.

It is important in the treatment of eczema to keep the bowels regular and the
kidneys active, and to select the diet with a view to the general indications in each
case. It should ab^o be borne in mind that certain articles of food, such as pork,
shellfish, cheese, alcohol, etc., have an injurious effect u|x>n the lesions of eczema
and should not be used by patients suffering from the disease.

The hygienic conditions of the patient must receive intelligent consideratior
and careful directions should be given as to the nymber of hours devoted to sleep
the character of the clothing, the amount and form of e.wrcise, the ventilation ol
the bedroom, the necessity tor plenty of fresh air and sunshine, and the propel
methods of bathing.

Local Treatment. — The local treatment is based upon a careful study o
the eruption in order to determine the nature and duration of the primary am
secondary lesions and to select the proper remedies in each case.

Local cleanhne.ss is of first importance in the treatment of eczema, and thi
scabs and scales should be thoroughly removed in order that the medication ma;
be applied directly to the diseased surface. The patient should be instructed
to .stoop over a basin containing warm water and soap and wash the parts genti;
with her hand instead of using a sponge or i)ath towel. The soap must be o
good quality, and nothing is better for the purpose than sapo viridis (U. S. P.

XiOtUIA.

ntMtllc Mnjip. It musi he Iwrne in mind that «onp it not always bcnrfidal
io ca«c$ nf rcirmn and that it Mimrlimcs causes irritation. Under these cir-
ctinv>tani'» the use of soap should be discontinued :ind a warm alkaline or
vmolhmii «iiz-luilh luMitukil. The alkaline liaih cinf^ists of one ounce of
bic^rlxiiutc (if wNlium nr pnt&ssium to live gallons of warm water and the emol*
liriii Uiih u[ half a pound of stardi, lin.ieed, bnin, or Keliitin to the !>ainr quantity
of dukl.

If the ecates or cnists arc difficult to remove by the methods mentioned xbove,
■ blnml oil. xuch »_■> ttn«ec(l, <-utlon-seied. or olivi- oil, ^hrxild be ^p^l:.-l(l freely over
ihe nffi'ttcd twrlR, and when the secontbrj- products arc softencil the \'ulva is
deantied with i;reen soap (U. S. P.) and warm water.

It i* ImjxHsibk; to describe a definite plan of luail ireiUmcnt in eczema of the

fttui organs, as K ccnain remedy may pro\Y bcnelicia] in one case and in-

arious in another, and besides much depends uj)on the variety and Ata^e of the

iption. In a {Ceneral way, therefore, the object of tlic Irealmenl i» to relicre the

'immaloT}- nditions and cure the disease by (o) cleanliness; (b) rest; <r)

itic dire<i appliialion of medical aRents; and (i/) the use of the XTayt.

Acute Eczema. — C I e a n 1 i n c .■> ^ . — .Acute c»-*c5. a* a rule, arc more or less
nivated by ihc use of warm water and soap, and donscquently alkaline or
illicnt -iu ImiIis should be employed. These baths not otdy keqi the lans
r:in, but they ;ire .i)M>KoolhinK in tltciraclion ami allay the inflammation, )>ain,
anil it( hing. The)' should be employed several times daily and the water should
be hot, a> a tep> not ^i^'e ffood results.

R e K t — Local rest i* verj' imiwrlant in the trealmeni of acute ecxema, and
unless it is enforced many cases arc aggravated and pass into the chronic stage
tkal could uthcmtse be eiisily cured. The external orKan.i may l>e put at rest
iJiy insrrtins fl small piece of lint between the labia and applying a T-bandaKC, or
phirinit the (Kiiicni in l>cd. If the symptoms are severe, the latter method
indicate'l: and in mild raw^ the former pLin fulfil.'' all the requircmcnlf^.
The Application of Medicinal .A gents .—The remedial
nerally employed are .utx-batli^, lotions, ointments, dusiinK-powder&,

Hot alkaline <W emollient sil7-baths are especially valuable, and should

Xiven tun or three time^ d.tily for five to ten minute.H according to the indi-

Itkos. 'I'hcy arc imUcatcd when the inflammation is <cvcrr and the subjective

itoms arc uigenl, and arc abo useful as a routine treatment in most teases.

ScdaliiT and aMrinj^nt lotions serve a licnefidal puriKne and are applietl by

means of lint compresses which arc held in position with a Jbandage. When

water b use<l as the vehicle, it should be sofl fdistilled). as a hard water irritates

1' ' dwl increa><'s the local intlammntiDn. Hot or cold fomentations of

iter are a simplcamlclTectivcplanof treatment to relieve inllammation

.a . < ' ihe p4tn and (xrurilus, l^ad-waler and bu<bnum are also useful for

'll.r ..iui. purpcmes. The following seilativc and nnlrinKcnt liiliiin% :irc rc<om-

mcnilni: Kiguiil parts of lime-water, glycerin, and di^lillcil water (especially

U>rful when the affeclci part i> irritable, hut, and dr^-): bJcarl>onate of xxlium

nr pota>uium. two drachms to one quart of di«tillc<l water (Ir'seivs serous oozing

j^*i»d relie^'cs the burning and pruritus); weak solutions of alum or tannic acid;

^hiil or hj-jioNulphiie of Milium, two drachms to one quart of water; a »fltu-

«olulion of lH>ric acid ; a weak solution of thymol or carbolic acid; bUck or

elk>w waiA; and diluted hydrogen peroxid.

Scriative or attrini;ent ointments are more suitable tn the nuijorlly of coseS

llun k>lk>ns, and may be applied directly to the pan or first spread upon a piece

of Uat which i* bckl apiinst the vulva by a. T-bafulage, Lanolin or one of the

214 THE VULVA.

simple cerates, or both combined, form the best base for ointments, and they
should ahvavR be employed, as preparations of petroleum have little or no ab-
sorptive qualities. Good results are obtained from the use of zinc, in the form of
either the carbonate or the oxid. The benzoated oxid of zinc ointment is also
useful, and good results are derived from one drachm of subnitrate of bismuth to
half an ounce each of lanolin and cold-cream. Goulard's cerate and the ointment
of carbonate of lead are both effective preparations. The addition of chloral,
morphin, camphor, or menthol to an ointment is indicated to relieve pruritus and
lessen pain. The oleates of lead, zinc, bismuth, and aluminium have been found
serviceable in the treatment of eczema, and should be used with equal parts of
lanolin or simple cerate.

Dust in R- powders protect the affected parts, exert a sedative, astringent, and
curative influence, and absorb the secretions when the eruption is accompanied by
serous oozing. The following are recommended for their soothing and protecting
qualities; Starch, boric acid, lycopodium, talcum, rice powder, and arrow-root.
Subnitrate of bismuth, salol, calomel, and oxid or oleate of zinc are stimulating
or astringent in their action and should be employed when a decided effect is
desired. The addition of camphor, chloral, or morphin to the powder lessens
the pruritus and relieves the pain.

Bland oils may be used alone or in combination with sedative or astringent
drugs in the treatment of acute eczema. The following oils have been employed
with good results: Cotton-seed, olive, fialm, linseed, and almond oil. The oil
should be gently rubbed over the affected skin and the parts protected with a lint
compress secured by a T-bandage.

The Use of the .v-rays . — The a;-ray treatment of eczema is fully
discussed on page 77.

Chronic Eczema. — C I e a n 1 i n e s s . — Warm water and soap are the best
means at our disposal for cleansing the part and removing the secondary lesions
and foreign material. Alkaline and emollient baths are also serviceable when
soap irritates the affected skin and cannot be employed. If the scales and crusts
are difficult to remove, a bland oil is spread over the parts, and when the secon-
dary- products are softened the vulva is cleaneiJ with soap and warm water.

Rest .—In chronic eczema rest is not so important as in the acute form of the
disease, and hence it is seldom necessary or advisable to place the patient in bed.
The parts, however, should be supported by inserting a piece of lint between the
labia and applying a T-bandage. Se.xua! rest is clearly indicated in all cases,
as coitus causes congeslion and increases the severity of the local symptoms.

The Application of Medicinal Agents .—The local reme-
dies employed in chronic eczema should be sedative, astringent, or stimulating in
character. In the chronic form of the disease the skin is inactive and the blood-
vcs,scls and lymphatics require stimulation, and hence many remedies are used
which would be contraindicated in the acule variety. The remedial agents
employed are sitz-baths, lotions, soaps, ointments, and dusting-powders.

Hot sitz-baths are of great service, and they should be alkaline, emollient, or
stimulating in character. Corrosive subHmate, 1 to jooo or 5000; carbolic acid,
t to 3 per cent.; and creolin, one drachm to every quart of water, are the best
drugs to use for a stimulating silz-bath.

Lotions are ver>' effective and should be sedative, astringent, or stimulating
in character. Hot or cold fomentations of distilled water, lead-water and
laudanum, and the various sedative and astringent lotions referred to in the treat-
ment of acule eczema are beneficial in the chronic form when used as indications
arise. Stimulating lotions, however, are more frequently indicated on account
of the sluggish action of the skin and the chronic condition of the eruption. A

TUttU^U.

ilutioti of kichliirid nf Dtcrcury, t (o 5 trains to th« ounce, will nfieii .\ltay the
iiitL-imtnatkin, itrliin;;, and pain. Car)H>lic iidil, i to ^ (trr <Tnl.; crcawtr:
IvMtl, 0.5 tn 1 )>cr(i:m.; thymol. 5(0 15 grains to ihcnuncc; orcrcolin, jdrurhms
III the qunrt. arc useful and cffcaU'c rcmcilics. HomKlytrid U a viilunblc
>]ipliaitjiifl, awt an aloihoUi- solution o[ menihol (jir. xx t« (aj) ha^ n d«*i(l«<l effcn
In rrlirvint! the puin iind itchintc. A 5 per cent, ^ulutinn uF i4in-<an>bin in liquor
V < ' ' > iiw (1 part of gutta-percha in 10 pans of chloraform} will nt limes art
i 'v and cff«t a curt.

Sup t» an imtxiriant aecnl in the treatment of ccwma. not only fnr its cleans-
InfC effect in renv>\'iiTf; forei^ii material iind M-comiary products. I.ut aht> im
count <■( its MiniubtinK ;mi<>n upim the di^ciMnl *kin. P«i.ii.h or wdl wap
3^ i-iriifis, U. S. P.) use! l»i> or ihrcc limes daily with n-arm water is an
r.\, client remeily and may pmduie Rood rcsuiLs. If a hard or ioda .vinp is em-
(il.'Mil, )1 muM l>e pure and neutral. Sonjt may lie adi-anijijteously nimhineil
with various drugs to increase its therapeutic effects, and may iherciorc be
itlicntfl with sulphur, naplithol, tar, bkhlorid of mercury, salicylic acid,
'■1. and carbolic or )>»ric acid.

The scdaiiw and astringent ointments which are rccommende<l in the trcal-
mrni of acute c<'zema m.iy titr tisrful under certain drcuni.>[ances in the chronic
I of the di>i-a>c, Stimitliiing prcparntior*. however, arc especially indicated,
III dia(hyl<^i ointment serves a u^ful purpose in these cases, (jood results
■re abo obtained from the use of salicylic acid. carlK>lic .ncid, rc.-«>rciii. crcasole,
k'hlhyol. thymol, mcnihot, artMol, cumphcn, chrisi robin, naphihol, bichlorki
"f mercury, oil of cade, sulphur, and camphor. The addition of morphin,
nral, mentlxd, or caniplior to the ointment lessens the pain and relieves the
iiritus.

DuMiniC'powdrTs are used in the same manner and for the »ame reusMK u
Hhc acute tariely.
The Use "f ihe ,v-rays . — The x-nr treaimeni of chronic eczema
ti fully dis<rut«ed on {fajie 77.

THRUSH.

imt*h of live ^-u^^ anti la^ina i» due to the surch^iromyxft alhUaiu, an
»m whifh U die cause of )>amMlic stomaliti*. The diK-a«e i* met
-1 olicn in nursing women and in ihofc who arc exhausted from diabdcs,
ttiRTuint disease, or tulierculosis.

The nflected jKirts are on-ercd with slightly eleratcd whitish spots or aphthie
lich have 3 tendency to coalesce and e«ntuaUy leaw small shallow ulcers, which
' not {uinful unlevi iIkv become irritated. Tlie color of the sfHils i.^ not constant
il may change lo a yelbu' or brown from slight extravasations t>f bloo<l.
The prc/:ioti§ is fatorable except in women who arc suffering from a
fraie <un>iiiiitii>nal chnmtc ■li.M;a>e.

Treatment.— The vagina and ^'ulva should be douched twice dally with
■ if corri>^ive suldimatc (i lo looo) followed by a quart of hot normal
•- . I in aiwl llie intriHluition of a V'aginal tam|H>n >nlurate<l with .1 35 jier

trni. Hdulioti of ichlbyol in glycerin. The \-ulva should then l>e dusted with a
|iu«-der co(n|>osed of equal parts of aristol, calomel, and subnilrate of bismuth
and the labia »e|Hini1ed with a piece of lint which i» secured by a comprem and
T-tundage.

When ihe ulcers arcslow in healing a solution of nitrate of silver (gr. xio fJJ)
M be ariplied. iinil if the diM-harge* lieci>mc offcmive frum fetid |«Tliclc5
rinv to the aphthous patches, the parts should be washed KiTral tiroes 3 day
%*lih ' iicroxid.

1': A medication depends upon the caiutitulioiul conditions com-

3l6 THE VULVA.

plicatin); the affection. Fractional doses of calomel or bichlorid of mercuiy
should be employed for its sp>ecific efTect upon the local lesions.

SIMPLE DERsurrris.

Synonyms. — Dermal vulvitis; Intertrigo; Chafing.

Definition.— A simple inflammation of the skin involving only the epi-
dermis and the supwrficial layer of the derma.

C&nscS. — The affection is most frequently observed in fat or fleshy women
and occurs primarily where the skin surfaces of the vulva and surrounding parts
are in apposition or thrown into grooves or folds. The constant chafing and
friction to which the parts are subjected in fat women is very apt to cause a
dermatitis, especially when the natural secretions and leukorrheal discharges are
allowed to collect in the cutaneous folds and undergo decomposition.

Symptoms. — The local condition varies between a simple erythema and a
severe inllammation. In aggravated cases the surface of the aSected part is
excoriated and covered with a serous discharge. The amount of physical dis-
comfort depends ujion the degree of inflammation, and in some cases the parts
are so painful that any form of motion is impossible, while in others the patient
only complains of tenderness and pruritus.

Prog;nosi8. — The condition is readily relieved by proper treatment and
attention to cleanliness. It must not be forgotten, however, that the predisposing
cause is always present in fat women, and that a relapse may occur at any time,
especially in hot weather, from friction of the apposing surfaces.

Treatment. — In simple cases of chafing the parts should be washed two oi
three times daily with warm water and soap and thoroughly dried. They are
then covered with a bland dusting-powder, such as equal parts of calomel, rice
powder, and subnilrate of bismuth, and pn>tected by a compress of lint. Lyco-
podium, talcum, oxid of zinc, and starch powder, alone or in combination, an
also valuable substitutes, and should be employed when the indications arise.

If the parts are excorialcd they should be cleansed as described above and a
stimulating ointment applied, which is covered with a piece of lint held in positior
by a T-handage. The following ointment is useful:

^. Bismuthi suhnitratis, 3iss

Acidi carlmlin £"■ "I

Laniilini ,lij

Ungucnti zinci oxiili, 5vj

M. Sig. — Apply liKnlly.

It may be necessary in some cases to stimulate the e-"ccorjated surfaces witl
a solution of nitrate of silver (^r. x to f^j) and after the acute symptoms havi
subsided to cover the parts wilh a flusting-powder.

Rest in bed for a few days even in milfl cases of dermatitis is a great help ii
the treatment, and should be resorted to whenever the patient can afford ihe time
If Ihe patient is around attendini; to her usual duties, the apposing surfaces shouk
he separated by :i iiiece of absortjent lint and a compress applied which is hell
in position with a T-bandage.

Careful attention tn cleanliness and the constant use of dusling-powders an
necessary to prevent relapses.

PRURIGO, LICHEN) ACNE.

For the description and treatment of these diseases the reader is referred ti
works on diseases of the skin.

The use of the .T-rays in the treatment of prurigo, lichen, and acne is full;
discussed in Chapter VI.

KKYSIPELAS.

ERYSIPELAS.

Definition. — An acute, spcciiif, conlagious inflammation of the sUn,
«ub(*uUnn>u> ii»uei', and muc<>ux mcmbninc:*.

Canaes.— Tlw specific caufc of cryupeles is the sirepioforem trystpttalU
t4 Fctilcben. The cocci f^ain ucoe.t> m the tl-uues throuKh an injun' of the skin
or muuni^ membrane, and arc con\Tyc<] to the »cjit of infection by the ntmos-
phere, dolhins. unclean hands and initrun>enis.

'Hie fulJuwini; predt^posinK duties are Important nnd will 1>e briefly mt-
siderrd,

Sex. — The disease is more prevalent in males than in females. Recurrent
itlackH are oc(3iion:illy oliM^rved in women at ihc lime of the menstrual iicrinil*.
Ery?il>elas is also a source of piicriK-ral infcclion.

Age. — The disease is most frequent between the nfjes of twenty and fifty

Sin. EryNipelait of tbc vulva has been ubservcil in infant* from a primary
rciion of ihe umbilical cord.

S^Aon of tbe Year. — Dr. ]. M. Andera has shown firim an exhaustive
aiwly of (he »ub)rci thai the diwa»- i<^ more prevalent rluring (he itpring and
ilUlumn than durini; other seasons of the year.

Former Attacks. — Kccurrt^nt .iitack.-'. which are occa>ionally nbser>-ed,
am aci'ninict dir ujiun ihc lho>r>' that the cocci remain dormant at the point ol
[ oripn.ll infection, and iMri-ome active again from some editing cause, such as ibe
perifxltc o>nf;<^tiiin of menstruation.

VuItat Diseases. ^Various diseases of the vulva, «uch as ccxema,
iieipcs, and inllanunalion, and certain ulcerative ctimlitions which are accom-
by excorin lions, crti»ion>, abntsion-t ami uk-emtions, are predispcising
causes.

Injuries. — Trauuialisms of the skin and muci)u?i membrane of (he vulvn,
^RSuIiiDK fr>im chjilinf!, sur^^cal operaiinns, labor, and ^xual intercourse and
LBV oiher similar lause?, offer iMiinis of entrance to ihe nicci.
Unbvgienic Condltion8.~.An unhe.dthy cnx-ironment and inMilTineni
(ood ami all cener.il inilucnces which have a (cmk-ncy to lower the state ui the
l^jWrm undoulit^lly jiredispow to the di>e:ise.

Varieties.— Kr>^ipeUi' nf the vidva, as in other part* of the body, may
Inccur in several varieties on account of certain conditions allerint; the typical
counc of the dbcase. Tlius the alTcction may extend lo dlntant ur neighboring
fp«rts (tryiiftiiii mifirant): suppuration may occur in the vehicles {rryfipetas
puUnloium); suhcuUmcous suppuration may take place {pMesmonoui try-
sifidut); or an inieRK.* int'ihration of the conneiiitT li^Mie may produce gangrene
{jfmifrfiutm frniptiat),

Symptonu. — T^ symptoms are divide«l into (i) the general, aiMl (i) the
'local.

Geaersl Symptoms.— The diwasc usually bepns with a cftill or sensal»oi«
of ihillincss. In chiklren conv-ulsions are apt lo occvr in place of the rigor.
Slight ttauMa t» an early symplum and may lie accr>mpanied with viimiting.
The icmijcriiture t'tia at once and ranges between ioi° and 104" F"- or even
higher, reaching tu highest [loint on the third day. It begins to decline rapidly
to normal on Ihe w^enih day, and may even become subnormal in severe case?,
on account of ihc general syslemio depression rause<l by the ilUease. Occasion-
.ally erm after the tcm|>eniture has declined to nonnal Ihrre may be a fre«h
eilrn^bitR of the inflammation without causing a febrile reaction, although, af a
rule, Ihe lever returns. Tlie pulse I* rapiil, van-ing from 100 10 iic f-r higher.
and uiuiliy ^'fi ami <if [:<mnI volume unU-» Ihc intlammatinn b of a severe ty|ie,
wbcD it thons a iciuleiKy to weakness. The tongue is heavily oiatcd wiih a

ai8 THE VULVA.

yellow ibh -white fur; the skin is feverish; the urine is high-coiored and scanty,
containing an excess of urates and in some cases a slight amount of albumen;
and the bowels are generally torpid, although diarrhea tnay occur as a late
symptom. If the disease assumes a malignant type, the symptoms become
grave and the typhoid state rapidly develops.

Local Symptoms. — The affected part first becomes swollen and has a
pr>lished appearance, and the patient complains of pain, heat, pruritus, and
tension. Usually within twenty-four hours the characteristic eruption develops
and a red spot appears on the skin which disappears temporarily on pressure.
The inflammation and swelling rapidly increase in severity and spread to the
surrounding tissues, and the affected parts become infiltrated. The margins of
the infliimed area are clearly defined, but Irregular, and small red spots and
streaks are seen extending into the healthy skin. Vesicles varying in size and
containing serum now appear and spread over the affected part (erysipdas
vesieulosum). The inflammation, as a rule, reaches its greatest intensity on the
third day, when it begins gradually to subside, and at the same time the swelling
disappears, the vesicles dry up, and the color of the skin changes from a red to a
red dish -ye I low hue. In from ten days to two weeks convalescence occurs and
desquamalion of the epidermis begins.

Diag^nosis. — The diagnosis is not difficuh after the disease is fully es-
tablished. It may, howe*'er, occasionally be mistaken for acute eczema and
erythema. In eczema the inflammation is scattered ; the surface is covered with
very small vesicles or scales; the swelling is very slight; the itching is intense;
and there are no constitutional symptoms. In erythema the inflammation is
superficial, diffused, and unattended with pain; the constitutional symptoms
are absent; and the affected parts are not swollen.

In the pltlegmonotis \aricty the iisual local symptoms of deep-seated suppura-
tion are present and the a>nstitutiiinal manifestations are accentuated. In the
gangrenous form of the disease the infkimmation is severe and masses of broken-
down or necrotic tissue are observed on the affected surfaces.

Prognosis. — The prognosis, as a rule, is favorable, although certain con-
ditions and complications may render the case verj' grave. Erj'sipelas of the
\-ulva occurring during the puerperal slate is usually fatal, and the gangrenous
variety generally ends in death. The phlegmonous form is very slow in its course
and has an increased mortality. The prognosis is unfavorable when the disease
occurs in old women or in alcohoHc subjects and when it is associated with an
acute or chronic disease which im])airs the vitality of the .system.

The hair on the vui\'a frequently falls out and shortly after desquamation it
begin* to grow in again gradually. Er\-sipelas may have a curative influence
upon lesions situated whhin the area of infection, and it has been known to cure
ulcerations due to lupus, cancer, and sarcoma, as well as to cause the disappear-
ance of chronic skin affections.

Treatment. — The treatment is divided into (i) the general, and (a) the
local.

General Treatment. — If the patient is young and strong, the bowels should
be opened early with calomel followed by a saline, but in asthenic cases violent
purgation docs harm by slill further depressing the vital powers, and a mild
laxative or an enema should therefore be employed. Absolute rest in bed with
the use of a bed-pan is important, and the patient should not be allowed to
move about under any circumstances on account of the inflamed condition of
the parts.

The strength of the patient should be guarded and sustaincl by ever>' means
at our disposal. While this is especially important in severe cases, it is also

ESrSIPFJ^S.

Dcres&an- in mild ones, and therefore careful aticniion must Iw frivcn m ilic dirt
3cwl to ihc ailmini>iratiim of silmuLints. Th« food shuuld Iw citsily digesiol and
tHiuruhing and ukvn at short intcrvidx, und nhtlc the fever 'i% hi)Ch it ^i>utd be

\$^vtn in a liquid form. As nausea and roniiiing arc frequent Eymptums in the
rariy iXafjc of the dix-nM, tlui Moitinch miLV not Ue able i« retain nourishment,
mimI it will \k nrte^Mrir' fur the titnc brin)( to rcNirt to rvcl^il feolinK. Alcuh«l
and mrtviinin are the ntost u^ful slimutinls to emjdoy; ihey should no* l»C
gitm. howc^iT, 111 II ri'kiline |irii('li<T. Iikil rt.-.-<«r\'vil until th« inrlit'iilioii for ibcir

, «>* ari^o. In ^^rrc cawis and in a^lhtnic cnndilioii'. whisky or bramly mm-

'liinwl with smihnin should he frt«ly administered, and if nausea or tx^miting:
is prcnrni a dr)* chamjiiigne Nlmuld \k K'vcn a^ a suh-viilule in small quantities
It J time. Delirium is not necessarily a cunir^indicalion to the um.- of alcoliolic

I uinubntM.

When the frm|>eT»ture become!^ high, it ashould be kept drm-n by the uk of nn
k'e-t.ap und si>ontci»)!- Anlip)Teitcs. except in the form of alcohol, arc contra*
indliratc«l, and Nhoutil not be cm[tlo)-e<l on account of their rleprcssing action
ufion ihe heart. Sleeplessness is controlled hy the use of bromide or morvhtn,
aionr or in aimbinalion.

The u>c of <lrugD internally U dL4;i|>|>ointinK in the nuijoriiy of <ases, und our
diief relijncc nni»i therefore W placed upon the diet and stimulation. In ^tronj;

'healthy -ubjeits the ine of h)ilrochloratc of pilocar]jin ha* been highly rccom-
mrnilrd duiing the early *laKe of the di^<'a>c to lower the jnilsc-rate and tempera-
ture ami lessen the intensity of the local inlbmnijlion. The druK ^huuUl lie
fivcn hyp«Klerniiially (gr. ft to }) evcr>' four hours until three dnM» arc ad-
miniMernI, l..3rKe dt»«.s of the tincture uf ferric chlorid and quimn arc also
bcnri'icial. aiwl Vr. J. M. Anders claims that small doses of bichlorid of mercury
modify the teveriiy of the konil and conMliutional symf>toms.

The adminbtration of nn antitoxin in cases of cr>'sipelus if still in the «x-

' perimenlal >ta|{e. diul its results are as yet uncertain.

Local Treatment.— The %-ulvn and vagina ^h»ubl lie douched witit a warm

[.*otut>on of corrosive sublimate (i to 4000). followed by normal silt wluiion,

Laixl the luirts Kently ilrie<l with sterile alKMirliem cotton. A vaginal cotton-wool

llanipon !-> then inir<»luced and an ointment of equal jkiiIs of ichthvol and
buMittn rubbcil well into the inllamed area. A piece of lint xmeanil H-ilh lite
ainuoctu ii now iiboed between tlie labia and over the vulva and tccurcd by a
T-lmulaf^.

The |urts shotdd l>c douched und dressed with the ointment twice a day, and
when the inflammation tieiciiL'* to siiliciide, l)enioate<l oxid of linc ointment
«hirukl lie sulisliluled und it'^ u<e continued until deM^uamation ceases. A bbnd

' »nlative dusttiis-|H>wiler sJtuuld then be emploji^l and the douche* continued

rfor two iw three wetrks.

When the (xiin and lociil irriialion are very severe. liili>m* of lead-water and
laudanum serve a u.seful purji-iM;. and hot fomentations of corrosive sublimate,
1 to 5000 or 10,000. or a 3 to :; jier <x:nt. v>luliiin of cartfolJc acid also f;i\e S""*!
results. I>r.JohnV. Shoemaker recommenils the olealc of tusmuth very highly a»a
•nlatiiT for the relief of ihc pain and burning whith accompany the atTection.

In addition to the irhthiitd ointment already referrcit to. various methods have
been advi^ for the purpose of timitin}* the spread of the inDammation. uikI one
lit the l>e>t means Is a lotion of corrosive sublimate, i to ijooo, or a 5 per eent.
Mtlutinn of (urtxilic arid applied conitnw>it»ly lu the part uf>on a lint c<>mpre>s.
!' I results lta^v .xlso been obtained from the use of an ointment of protargol

l<n (Kr. XX to St), which b smeared un a piece of lint and applie^l to the seal
i4 ditci-x. Annilver plan is to tightly scarify the healthy skin around the diMtt^

aao THE VULVA.

area and then apply the corrosive sublimate or carbolic add lotion. The scarifica-
tion must be very superficial and the lines should cross each other at right angles.
Finally, hypodermic injections of a few drops of a solution of corrosive sublimate,
I to 4000, or a 3 per cent, solution of carbolic acid into the skin immediately
around the eruptive patch has in some instances limited the extension of the
disease and checked the inflammation.

The use of a compress and T-bandage to support the vulva adds greatly to
the comfort of the patient and has a tendency alsij to prevent the infiammation
from spread inp.

When convalescence is fully established, reinfection should be guarded against
by careful disinfection of the entire body and a change of clothing and bedding.

DIPHTHERIA.

Definition. — Diphtheria of the \'ulva is an acute, infectious disease due
to the Klebs-Loffler bacillus and characterized by the formation of a 6brinous
exudate upon the vagina and inner surfaces of the external organs of generation.
In children the disease is generally secondary to an infection of the pharynx
and upper air -passages, although it has been known to attack the %'ulva akjne.
In adults the disease is usually a primary infection of the vulva occurring during
an epidemic or the puerperal state, and in some instances the bacilli have been
introduced during an examination of the vagina or an operation upon the or^ns
of generaiion. And, finally, the patient may infect her vulva through careless
attention to cleanliness while nursing a child suffering with diphtheria of the air-
pussages.

Symptoms.— The constitutional symptoms differ in no way from those
which arc present when the infection attacks other jwrtions of the body. Locally
the vulva is tender and swollen and its inner surfaces are covered with the char-
acteristic exudate.

Dlag;no8ls. — The diagnosis is based upon the history of the case; the
character of the constitutional symptoms; the appearance of the exudate; the
frequenl presence of albumen in the urine; and the bacteriologic examination.

Treatment. — The constitutional treatment is the same as when the disease
attacks the air-passages, and includes hygienic measures, nursing, stimulation,
and feeding, .\ntitoxin must be administered early.

The local treatment cimsists in spraying the \-ulva and vagina three or foui
times a day with hydrogen peroxid and douching the parts with a warm solution
of corrosive sublimate (i to 4000), followed by normal salt solution. A com-
press of lint saturated with hydrogen peroxid is then placed between the labia
and over the vulva and secured by a T-bandage. After the exudates havt
disappeared the lotions of peroxid are discontinued and dusting-powden
substituted.

Gangrene or noma piidendi is treated in the manner described on page 17a,

PSEUDO-DIPHTHERIA.

This variety of mlvar inflammation is characterized by the formation of a
pseudo- membrane, and Is not due to the Ktebs-L6ffieT bacillus but to othei
organisms, especially the streptococcus.

The affection occurs most frequently during an attack of puerperal sepsis an<i
the false membranes are found on the contusions and lacerations of the vulva
and vagina caused by labor. A pseudo- membrane is sometimes observed on the
vulva during the course of an attack of typhoid fever, scarlet fever, or small-
pox when the disease is grave and the patient has passed into the typhoid state.

VAOIKISUUS.

3>t

Symptoms. — There UnnihinKcbantcterUlic in (he appearance ol the vulra
m iFtcu'lo-diphlhrrin when il orrurs during the pucrpcml state except ihe pnt"
cnir of the fab« membrane, an (he snollen. contu^d, and lacerated condition of
ih« inns as w ell as ilic presence of the purulent discharge are the result of septic
intediim nnd (ntumatifm.

Diagnosis. —The diagnosis is based upon ihe hisior)'of the case and the
■acholotpc examination.

TrCtttinent.— When pM:ijdi>-<lii>htheria nccurs during the puerperal state
I special form of treaimeni is indicated and the general and local septic syntp-
are treated in the ii-vual manner witliout any reference whate\'er to the
iwrseme of the false membrane.

If the diseaw apiMriirs dtirin); the course of one of the eruptive (ewrs, the
mlviir Icion?^ shinikl Ih.- treated aclixetyand the Mime local measures carried out
as ia the case of true diphtheria of the tiilv^ (sec p. 330).

VAGINISMUS.

Definition. — A hrpercsthetic condition of the vulvo\-agina1 orifice chsr-
attcri/cl liv juinful ami spasmo<iic contractions of the muscles of the pelvic
t, Imt mi'Tc i-%i>ccially of those surrountlinK the vulva and lower iwri of the
iltitia. In some cases the spasm involves the levatorani muscle and the muscles
ol the lhip:l», anil there may also l>e genera! ionvulsivc mowmcnlsof the entire
b">dy. The a'lxiition i* comi»arati»-cly rare and is alwa>'» a *ymptom of a cau»e
which may or may not be discovered.

CaUKS. — Tliere is Kenerallya local cauw for the symptoms, and a brge
t'r»t>»ni«n of wwrnen who suffer with vnginismu,* are young, neurotic, and
lyiileric The nervous aymptoms, however, are often the result of the vaKints-
iuf and tuM the cause. Tlic fact of so many of Ihc^ patients lieinK minx ■*
rxplaiocd by the nujority of the local lesions occurring at the vulvovaginal
nrtfire, wl»ere the irritations and iraumati^ms i)( early marrie<l life are most likely
' ' f. in the form of an irrit.iblc condition of the torn hymen and smnll

■ ris Of fissures. These lesions arc constantly irritated by coitus, and
eveniually t)eiumc so leivler and painful (luit va;;inismUN re-iulls.

In •ome C4»es the origin of the lri>uble may be a urethral caruncle, a neuroma
of the fossa nuvicularis. varicose veins, or prolapse of the mucous membrane of
the urethra, anal in others a fi.>isure of tlie (ourcheite, the vuh-ovaginal orifice,
the neck of the bkulder, or the anus may be the cause. Vaginismus may also
dcpemlcnt upon an infhmmalion of the vulva, the vagina, the ccr\-ix, or other
. of the pelvis, and it may likewise be <jiie to a proUip>e of the ovaries, a
'tli^ilBcefiKnt of the uterus, or coccygod>'ni3. Lead -poisoning is also said to
be A canse, atvd masturbalorsarc espccbtly liable to the affection on account of
the tocal irritation and iteneral nervous <tcprex.^ion which the habit pmtluces.
Many la^es where no dislinctitY fc>cal lesion is present are due to in-
iluil Jtirwjtis at sexual intercourse, which in time produce great nerrous
iuhiliiy ami kxal tensili%YoeM, acc<>m|iiinied by the fear or dread ol pain
< coitus b attempted. These conditions gradually become aggravated, and
'iome of Ihe severest fonns of vaginismus result. Among (he causes which
bring altoul this condition of affairs arc a rigid or unyielding hymen, a dt<pro>
portion in the sixe of the penis and the vaginal inlet, and a toes of erectile power or
pccoMlUfe cjacubtion u|M>n the |>an of the nule. .\gain. in some women the
<nt)VB U pbced too far forward, and Ihe i>enit, insir;id of iienclraling the vagina,
ptilbt* the f<issa navicularb and the urethra against the symphysis. Coilus
andcr tboc circumnances is incomptete, and in Ihe course of time the parts

iaZ THE VULVA.

become eroded and inflamed and (he meatus may be sufficiently dilated to admit
the penis.

Symptoms. — The intensity of the symptoms varies. In some cases the
shghtest touch with a feather or the introduction of a urethral catheter catises
severe and painful spasms, and in others the phenomenon occurs only when sexual
intercourse is attempted or when an examination is made with the finger or
speculum. Generally when viiginismus is due to a distinct lesion, such as an
irritable or ulcerated hymen, the pain in the beginning is limited to the situation
of the local trouble, but gradually the sensitive area extends and the entire
surface of the vulva becomes hyperesthetic. In severe cases of vaginismus
sexual intercourse or an examination without an anesthetic is impossible.

The contractions are generally located at the vulvovaginal ori&ce or some-
what within the vagina, and in some instances there may be convulsive move-
ments of the antire body.

Vaginismus may occur suddenly or come on gradually according to the cause
and the nature of the lesion which produces it. Thus, it may come on im-
mediately afler a brutal intercourse, while it will be slow in developing when the
cause is a local lesion or the affection is due to ineffectual attempts at coitus.

Vaginismus is most frequently obsened in the newly married, but many cases
are also met in women who have borne children.

Women who suffer from vaginismus become nervous and hysteric, their
general health fails, and there is more or less mental depression. In a large
proportion of cases they suffer from neuralgic dysmenorrhea and the bladder
and rectum eventually become irritable.

Diagnosis. — The affection must be distinguished from dyspareunia or
painful intercourse. In vaginismus the pain is associated with spasmodic «>n-
traclioiis of the muscles of the pelvic floor, while in dyspareunia no contractions
occur and pain is the only symptom.

Prognosis.— The prognosis is good. It must be guarded, however, when
no appreciable local lesion exists and the patient is neurasthenic or hypochon-
driacal. The disorder may disappear during pregnancy and reappear after
labor; but, as a rule, delivery eff'ects a permanent cure. Cases are on record
in which the contractions due to vaginismus interfered with labor and delayed
the delivery of the child. Without treatment vaginismus becomes progressively
worse and the general health is eventually seriously impaired. Sterility is
common.

Treatment. — The treatment is divided into (i) the removal of the cause,
and (2) the trealment of ihe symptoms.

liie Removal of the Cause. — The local lesion which is usually the cause
of the spasmodic reftc.\cs must be sought for and removed. It is not always
possible, however, to find a local lesion, as it may have disappeared spontaneously
and left the parts in a permanently irritable condition. Again, cases dependent
upon brutal or ineffectual attempts a! sexual intercourse present no local lesions,
as the symptoms are due to nervous apprehension or fear and become progres-
sively worse as the patient's health fails.

After the removal of the cause the vaginismus, as a rule, remains and requires
special trealment. It is good practice, therefore, at the time of operating upon
the ca\ix to forcibly dilate the vaginal orifice and insert a glass plug, as described
under the Ireatment oj Ihe symploms.

The Treatment of the Symptoms. — In slight cases the hyperesthesia and
painful reflex contractions may be relieved by the local application of cocain.
A pledget of absorbent cotton is saturated wiih a 5 per cent, solution of cocain
and applied for a few minutes to the lower end of the vagina and over the vulvar

VACINISUVS.

surfaces before un allcmpi at Mxunl inlcrfourae is made. Tbb uBually relieves
ihc hy]wrc5ihcsia and pcrmils txtint* to lake plniT wiihoiii (win. anil should
prcgnaniy follow » permaoent relief from ihc symptoms mity be looked for after
bbor.

A hot 'itz-bath taken night and mnmtng is often bcnelirini in the»e cases, und

rxcrllcni ^p^uIli have followed ihe daily use of the galvanic current by applying

ihc pii^itive pole lo ihc vulvuv.nj-inal orifitc and surroundin): purU. The spas-

itiimIu- iirilabiliiy an lie (trc.illy li-7.>cnr<l hy piiinlinK the

I aflcilcil |uin> twice a week with a solution of nitrate o( silver {^. xx it f.ijj ; by

i|he use "fan ointment of stnipiii (jtr. ij to SJ); by retuil supi«i>itorics of opium

[ttttd bHbdonnj; and by vaginal iuppiwimric^ nf iodoform (gr. v m \). Good

|lV9uh<' often follow ihc use of Rraduaictl U>URics, which may l>c inserted into the

[ngtna by the palient herwlf when nhe ukes the niu-bath at night and in t)ie

mtirnini:.

The ficneral health and mental condition of ihe paiicni must l)c looked after

y« -

^'jji'r

TC iMthiid at MtUnt vllh ibE Ifcumta; ^tI iin iftoin dtluinoa Mof ((lOBtiitldiri •r»li Simun'i

and cueful attention given to ihc digestion, bowels, kidneys, and other orfpins.
Carefully resubted exercise is of tcreat importance and the |>aticnt muM l)e giwn
■ deftnite direction^ a.t lo it* character and Humtion.

tn wvcrc cases of vapnismus M*xual excitement must be forbidden und the
hufbam) and wife should ixcupy "eparHtc beds. The iteneral health and by-
gietilc KarTnunilini;> <if the luilicnl must he Wikol after and the amount of
physical exercise should rcceiw careful considers lion, as a cure is impassible un-
Itm the [Mlirni is pbced in the l>e^ pi>«sible rondilicm. Forcible diblaliun of
the wlvoriiftiiul orifice ii> indicated In the» ca<es. and is usually followetl by a
cure. The patient ts anesihetixed and pbced in the dorsal ])osition and the
njpoal entran<e ihorouxhly Mreldwd by rneaiK of the opcrator'& thumbs or the
Uaida of Simon'x !^(ieculum$.

A cbss plug is then in.'«rted into the vap'nn and retained in ponEiion for one
day while the |Mitient i» recovering from the effect* of the operation, after which
dme it t* wurn for two hours nighi and murning durini; a |ieriod of from two 10

224

THE VULVA.

three months. The size of the plug depends upon the dimensions of the vaginal
entrance, and it must always be sufficiently Urge to stretch the parts. If the
patient sufTers pain when she inserts the plug, it may be relieved by saturating a
pledget of absorbent cotton with a s per cent, solution of cocain and applying it
to the parts.

Gradual dilatation is recommended when the hyperesthesia is not pronounced
and when contraindications exist to the use of a general anesthetic. The opera-

Fio. aoOr Fic. TOl.

FoinBLE Dilatation or the VotvovAOniAi, OBinra.
Fig. JDO showa The s^ass plug m placf^ Fig. joi shows Sims's |1uB T^IV'

tion should be performed twice a week at the house of the patient and a local
anesthetic employed. The blades of a bivalve speculum are gradually intro-
duced into the vagina and slowly extended until the patient complains of pain.
The instrument is then withdrawn and the glass plug inserted for several hours.
During the interval between the dilatations the glass plug should be introduced
into the vagina night and morning and allowed to remain for two hours.

MCTHOra OP EXAMINATION OF THE VAGINA.

CHAPTER XV.

THE VAGINA.

METHODS OF EXAMINATION.

The vi^Tui cnn be cxitmiitcil t>y ihc fulluwiniic tnclhutlit:
Direct ins))ccUon.
VnKi'ul touch.
Inilirt-ct impcction.
Microscopic and Bacttriologic Examionlions.

DIRECT mspEcnoN.

]t Imitations. — The ^uhoiMj-iml orifuf. the lower portion of the ^iifcina,
in) ihe aiiieri')r .-iiriarc of the r^nat on \k fxnminiil l>y <Hr<;cl ins[>cctii>n.

Itlfomiation. — Direct inspection h one of the most valuable methods wc
poS5o> f<'r rcL-oKnldnx aiTcctioiii of the vuKJn;!. as the miijority »( ihe lesii)n« are
■iMiiinl in the lower |Nirti(>n nf ihc c«nul and cun he si-en wiihoul ihe u?c of in-
-trumeiii-i. Thus, we tan dtaRiiose a prolaps^e of ihe aiiierior and posterior wall
(fvitoftJe amt rrrlofelt) a> well ^s a lacenitinn anil other paihuloijic cunditioDs
U the vulvoviiginul orilice. Wc Gin also rccugnizc ncDphiMiis and fistulas

numn

fVs. tat.— 'DrvccT lvirtrni>^ cr iitv X'j^i'-tim fptfr itA).

which arc situated in llic lower purt of the vagina and detect the pretence of
atinomul dix hart;e>.

Preparation of the Patient.— No pnimration is requirc<l. If a
douche is Kiwn prior lo ihe exaniinalioit, the jecrctions are renwved, and hence
an imiTferl itiaKnoiti* may t>r made.

Position of the Patient. — The ilunal jiosture is employed in making
Uif rxamuulion.

Technlc.— After placing the palicni in ihe proper position the examiner
Mb in (n>nl of the vulva and carefully inspects iIm vaginal orifice, iMing the

936

THE VAGINA.

presence of a laceration and other pathologic conditions. He then instructs the
patient to strain or bear down, and if there is any tendency to prolapse of the
anterior or posterior wall, the vagina will bulge into the outlet; a cystocslc or
rectocele can be made more prominent in the same way.

The index-finger of the left hand is then introduced into the vagina with its
palmar surface directed downward and the perineum firmly retracted or pulkd

Fia. laj.— DimEn iKSPEC-nOH 01 THC V«oiHA.
Etpcsng the ptjsicnoT viginal wall b^ rcinciiai the pcnBCVm wiib ibc iaiti uid niiddlc Gnfm.

back, when the anterior vaginal wall will come into view and can be carefully
inspected (Fig. 202).

The lower portion of the posterior vaginal wail can also be exposed by in-
troducing the index and middle fingers just within the vagina with their palmar
surfaces directed downward and retracting the perineum.

VAGINAL TOUCH.

Wmltations.— The entire canal of the vagina, from the vulvovaginal
orifice to the fornices, can be examined by vaginal touch.

Information. — We can determine the condition of the perineum and the
vaginal outlet; the presence of a stricture, a neoplasm, or a prolapse of the
walls of the vagina; the position of the fornices; the location and extent of
sc;;r liwue, and the accumulation of feces in the rectum.

"^^^^

Fic- 7D4. — Feuale Bladdem 5oum>.

Instrument.— A female bladder sound.

Preparation of the Patient.— The rectum should be emptied with an
enema of soapsuds and water and the urine voided naturally just before the
examination. The cornets should be removed and alt clothing that constricts the
waist should be loosened.

umcOlM or EXAUIKATIOV.

»*7

Position of the Patient. — The exsminatioD should be mode in th«
donitl poeitloa.

Teclmlc. — The index-finger of the left hand is lubricated with soap and
umler the sheet toward the perineum. M soon as the lip of the finficr
h tile i<crincum it U cnrrict iipwiml into the vnitinat opening and the pnlmar
ri^i* lurocO downward. The vulvovaginal outlet is then palpated and the
puaed along the ponterior wall of ihi' vagina until tt reaches the vault.
c finger is (hen turned with the palmar t^utfnce upward and the imterior
vaginal wall examined as it is slowly wiihdrawn.

VnKiiuil touch should be ctimbiticil with rectal palpation and sounding the
bn and the bladder in certain lesion* of the povtcrii)r and .mlorior v.-iginal
lis. Thus, a rccioccle can be recognized by introducini; ihe index-finger into
the rectum and hooking it forwanl *tt tliat the tip enien the peculation, where it
an be felt by the vaginal linger and the diagnosis confirmed. Again, a
tnmor situated in (he posterior vaginal wall can be more salbfactorily examined
by ctimbining vaginal with rectal touch. A urethrocele or a cj'Stoeele cnn be
easily recognized by intrmlucirg a sound into the urethra or the bladder and
ling the tip oi the in.'^trument in the (tie with the «pinal finger. In the same
'Ay tumors of the anterior wall ul ihu vagina ciin be iJi>lingiii«heil by gnlpaling
between the vaginal finger and a sound, or by employing vagino-
li&ftl touch.

INDIRECT INSPECTION.

Definition.— ^This method of examination requires the use of special
iik>trumeni*, «hiih arc known as vpcculums, and which are introduced into the
vagina to expose the surface of the canal.

Ifimttatlons.— The entire vagina, from the i-ulvovaginal orifice to the
vault, I jn lie in_>|>eclcd with a sjicculum.

Inlbmiation. — The information ettftteipeciioTi i> in most
pan cnnfinrd to Ie>ionK of the mucous membrane, as the pn»iiii>n of the patient
and the support given lo the walls of the t'ugina by the blades of the speculum
often tempi'raHly replace all forms of saix-iilalion or proliipse. Thu», with the
patient in Sims's or the knee-chest posture the vagina balloons out and the vaginal
walla ticcooK more or less tcnw even In cases in which marked [jrolai>sc exists.
The Mtnc Lh true when tl>c patient is examined in (he dorNal [MiMticn with a
bivalve spcc^m. berauM- Ihe blades of the instrument are placed parallel with the
anicrtor and jHWierior vagiital walls, an<l consequently they obliterate all evidence
of a rettoivlc or cvvtocclc. However, astvill be }ecn blcr on tndiscus^inK the
trchnic, by u^ing a perineal retractor or a depressor for the anterior vaginal wall
by applying the bLides of a bivah^e speculum in various pooitions e^-en a
cculation or a pmb[>se of the v.-igina can be exposed to view.
We can recngnixe the following lesions of the vagina by indirect inspctlien:
nuiMtions, ttotulas, neot>liKm>, !iiricture», scnr tissue, a redocvle or a cyMocele,
the oriytn 'if abnormal discharges.

InstramentS.— Tlic folbwing instruments are recpiired: (i) GoodcU'a
bi\'alw »|ir<-ulum; (a) Sinw's thick-bill jpcculum; (3) Simon's specutums
^(curved and llat blades); (4) a vaginal depressor; (5) long straight dressing
'"tcep*: (6) long flexible »ilvcr probe (Fig. 305).

Description of the instruments. - Goodell's Speculum .—This

it the \<fM hiv.iU-e s[ieculum in u.-*. The bhdes must not be over three and

hot! inrlio king, .ind the handle muM be short and lighter in weight

,B the blades, otherwise the instrument will slip out of the vagina unless it is

nlly held in |lf>^iIlon. On the other hanil. if tlie proper proportiom [a

It eti-tt lietween the handles and the blades, ifae instrument is practically

22$

THE VAGINA.

self-retaining. A simple method of determining this fact when purcha»ng
the instnimeot consists in balancing the speculum at the proximal ends of the
blades on the index-finget. If the blades are the heaviest part of the instru-
ment, they will naturally dip downward, while the handles will rise. The
bivalve speculum is used with the p>atient in the dorsal position.

Fic. JOS, — Ihstruhknts fov Ikdiiect Inspection or the Vaoiha (pace aj).

Sims's Speculum . — This instrument consists of a handle with a
permanently attached duck-bill shaped blade at each end. It is used in the
knee-chest or the left lateral-prone position to pull back or retract the per-
ineum and expose the anterior vaginal wall.

Frc. 3o6r — Testing the Weight of the Handle or a Goodell's Sntruuru.

Simon's Speculum . — These instruments consist of two handles witt
adjustable blades of various sizes and shapes, and while one speculum i:
used to retract the perineum, the other, with a flat blade, can be introducec
if necessar)* to elevate the anterior vaginal wall, thus taking the place of t

HXraOOS OF EXAWKATION.

' rsftinat clqirciuor. Simon's speculums are used in the doisal, ted btenl-prtHM!.
ABti knei;*rh«!«l |>(V>ilii:in» (FiR. x6&).

Vaginal Depressor.— This initniment is u»e<l in connection with
eiih«r Siins's or Sinton'i speculum to clo^ate the anterior vaginal wall when
it t« rebxiil ami *nji^ down, ihu» ohMuring the pnrts above naA rendering
, tospeclion cliRicult or impowibic (Fig. aog).

^^ l^oaj^ Sttaiicht Dressin;; Forcep*. — Tim in.xirunient is uvd
^Bb bold »mall balls of ab^rbcnt cotton which arc Fomtiimc rc<|uiriil to remot-e
f Mentions which collect on the vaginal muc«us membrane.

LoDR Flexible Frobe.— This instrument iiu^eil to probe the vaginal
oitKKHa and explore sinuses or fiMuLis,
: Preparation of the Patient.— Same as for Vapnal Touch.

Position of the Patient.— Thr« pnHiion* are emi>lojC(l in making;
' examinations with tlte spciuluni: The dorsal, the left latenil-pmne, ami the
knee chest pcfciure*.

Dorsal Position.— For routine examinations this posture i:i vcrj- sili»f4Ctory

tnd is used more fre(|uenily than the others. In this position the vaginal canal

doc* nut expand or balloon out, and hence n rrlaxatiun ur ;i prolapse is readily

becuuM' it is not temporarily obliterated. Un the other hand, however, the

Fw. **T.— Cbm*! Snmoii.

oi the canal cannot be exposed kyII in women who are fat or who
vjgina) walls.
iJBft Lateral-pron« Position.— In llib posture when the speculum is intro-
duced .mil llie |>rrincum is retractetl air ruhhu Ln at once and balloons out the
jrina, and at the same time the intestines and uterus sink away, leaving the
lire \-af:inal canal exposed to view. Under these i.iriumst:inci.-s a prolapsed or
a relaxed condition of the vaginal wat!s is lemporanly obliicrntcd on account of
(be expansion of the canal and the traction cxcrie'I by the iielvic organt- upon it.
i Tbla poiilii'n is therefore particuLirly valuable wlu-n a careful inspection of the
^^uJBBl mucous membrane is required in ca^es of inflammation, fuitulus, or other
^^^^■loipc conditions situated in the upfier part of the cnnnl. It in also especially
^m^nlageou> in fat women and in tbo«c who have marked relaxation of llie walk
of the raitina.

Knee-chest PoBitlon.— The indic-iiions are the fame as for the left hleral-
pmnc poaition. In the knce-chcsi p<>siiinn. however, the vagina is more fully
espanded, and heme a li-tter view js oblutncil of the ranid. For this reason.
tbenfnre, it i* iIh: bc?>i [urtition in which to place the patient when a thorough
iwpn-iiiin at the wbulc ragina is requited.

330 THE VAGIKA,

Antisepsis. — Although the subject of antisepsis is discussed fully in the
chapter on " The General Technic of Gynecologic Examinations" (see p. aa),
I feel that an additional word of caution will not be out of place here, as the
examiner cannot be too careful in preventing infection being carried on the instni-
ments from one patient to another. Practically there is only one
way to guard against this accident or — if we wish to
speak frankly — crime, and that is never to use an in-
strument a second time without thoroughly cleaning it

with soap and water and then boiling it in a solution
of carbonate of soda (i per cent.) for five minutes.
This will, of course, necessitate having a double set of speculums and other in-
struments when a number of patients are seen close together, but when we take
into consideration the danger of transmitting the infection of syphilis or gonor-
rhea there certainly ought not to be any hesitancy on that account.

Techttlc. — Having placed the patient in the proper position, the speculum

Fia. 30(1.— Vaginal UEriESsot (page 119).

is warmed by dipping it into hot water and the blades are lubricated with liquid
soap. The examiner is now ready lo introduce the instrument.

Goodell's Bivalve Speculum. — The patient is placed in the dorsal position
and the vulvar canal separated by the thumb and the index-finger. The blades
of the speculum are closed tightly and then passed between the thumb and the
finger directly into the vagina parallel wilh the lateral walls.

The handles are then turned to the patient's left until the blades become
parallel wilh the anterior and posterior walls of the vagina, when they are spread

UCTllOrM OF IJCAUINATtOK.

»3»

ap&rt by pmsinit the handle lof^ther and fixing Ukri in thb po&ition by means
of tbc urcws.

no. IIS,— iMttm ImnJL-Tlun Di :iii • u.^lL^

MtPT tn^pccling the vaginn ihe scrtm arc lonscned and (he handles turned
hmdt, bringing tlic blades pamllcl with the laieni vaginal walb. Again spread-

mfnr- —

iag the bbde* apan, the ngina Is cxpufied lo view and the antcxior and posie-
n»r wmlfe an now be iborouglily insiwcted (Fig- an).

332

THE VAGINA.

Sims's Speculum. — The patient is placed in the left lateral-prone or the
knee-chest position and the vulvar canal exposed by separating the buttocks.

Fia. m.—lHDinCT iHSPECnOH of TDK Vacih* (pafciji).
EiposDC Ihc uHcrior and poUnior walli of ihc VBgina wiih GcxkIcII'i ipecuhmi.

Fio, jij. — luDUKCt IsspimoN OF iHi Vagina.
TntfoctucliaD of ^m^'^ ^{Kculum.

The handle of the speculum is grasped in the right hand and passed directly into
the vagina with the convexity of the blades toward the coccyx and the handle ot
the instrument over the perineum.

UXIllODH DC EXAUIMAIIOK.

»M

no. ti<-— Iniurr Imptninn >>i nii Vudiia l|act tMl-
k> mncwd (rilb Staa't •tatulum and lh« umw nil bI Ite iitfiw dmnd wiih ■ •■(Mai

Pie iiv~I*s<ttct tmru-noH o« n» Vkum I|a|* im'
CM^< •■< >■■ UmIs d Itaaa'a HnulaH loifBdiKvA >Ub iki imhm In At tnR-ihM

*i*

THE VAGINA.

The perineum is now retracted and the vaginal canal exposed to view. If the
\-a)nna does not expand well and the anterior vaginal wall sags and obstructs the
new. the depressor should be used to elevate the relaxed structures (Fig. 214).

Simon's Speculums.^The patient is placed in either the dorsal, the left lat-
eral-prone, or the knee-chest position. The instrument is introduced in the same
manner as Siras's duck-bill speculum. For routine examinations in the dorsal
position Simon's speculums are very useful, and a good exposure of the entire
\'aginal canal can usually be obtained by using the flat blade anteriorly to elevate
the \-aginal wall while the perineum is being retracted. The instrument may ako
be used with advantage in the left lateral-prone and the knee-chest positions in
place of Sims's speculum, and if the patient is correctly placed the whole vaginal
canal, including the vault, will be exposed. If there is any tendency to sagging in
the anterior vaginal wait, the flat blade can be used to elevate it or the parts can
be held out of the way by a vaginal depressor (Fig. 315).

mCROSOOPIC AND BACTERIOLOGIC EXAMINATIONS.

Ifitnitations.— These methods of investigation are limited to the examina-
tion of the dLscharges which are found present in the vagina.

Infonnatiou. — We can determine the character of the infection in cases
of vaginitis and other inflammatory' conditions.

Technlc. — The methods of collecting and preserving the discharges for a
subsequent microscopic or bacteriotogic examination are discussed in Chapter II.

HALFORHATIONS.

As in the case of malformations of the uterus, congenital deformities of the
vagina are dependent for the most part upon variations in the evolution of the
ducts of Miiller, and heme vaginal and uterine anomalies frequently coexist,
although it Ls by no means uncommon for one organ alone to be defective in its
development.

The following anomalies have been observed:

?er.=iifitent cloaca. Absence of the vagina.

IJciuble vagina. Stenosis of the vagina.

Blind |)ouches.

Persistent Cloaca.— This condition maj- be properly clas.sed with
defcdsofthc vagina, since the vagina presents an aperture leading into the rectum,
through which the feces are discharged, if. as frequently happens in such cases,
the anus is absent. The defect is the persistence to a greater or less degree of
that stage iif development when the gut and the genito-urinarj' passages open
into a common receptacle — the chaia. The urethra may be practically normal
or it may oi«-'n into the vagina at a higher level than usual. The septum which
noriTi^illy divides the cloaca into the rectum and the urogenital sinus is defective,
leaving the a]>erlure of communication between the rectum and the vagina
referred to above.

Treatment. — Buckmaster's modification of the ordinarj- operation (or
(Iri-ing the false passage by bringing di)wn the rectum and making a new anus
is tlie liesi procedure to follow in cases in which no anal opening is present.
He makes a new anus immediately in front of the fibers of the levator ani muscle
:irid briniis down the end of the rectum and stitches it in that position. At a
later jieriod a secondare- operation is performed which consists in splitting the
fibers of the muscle and making a sphincter.

Double Vagina. — This condition is also known as septate vagina and
results from the imperfect coalescence of the lower parts of the MUllerian ducts,

the septum between the two failinj; whollv or in part lo t>reak down and diaap-

pear. The septum occui)ic* the long

axis of ihc %'3gina at or near the

mcdUn |>lane. ami it may lie complete

or im^implete, nllhi>ugh it M:ldom

divides tht canal into equal halves.

If the seplum runs from lief ore

bukwani, the vagina b divided

btcraDy; but if it is Iransverse, the

««Kiniu lie one in front o( the other.

In very rare cases a double vagina is

AMOcialed with two uteri an<l two

dirtinci vulvar "[icniRgi, but usually,

however, the nulfonnatiun exists alone

or in cunncctiofi vrith a utenix duplex

uxl a hymen having cither one or tu-o

If a double vnRina is as«ocnt«d
with a uterus duplex, each v»0ta and
ulent» form a dUtind wxua) appoini-
Uift and impregnation can occur on
one *Kle independently of tite other,
if thi u(eru» b MnKle. the cervix opcnx
mu> line vapnn while ihc other ends
in a bliml iMuch, and Meriliiy i^ tilcely lu rcnull unless the canal connected

2^6

THE VAGINA.

with the uterus is used in sexual intercouise. In cases in which the uppv end
of the septum is incomplete the cervix communicates with both partitions of
the vagina, and impregnation Is therefore not interfered with even when sexual
intercouree is confined to one side alone. In some instances one or both sides
of the vagina are imperforate at their lower ends and the menstrual blood
accumulates after puberty, causing a hematocolpos, or the obstruction, if
it exists on both sides, renders coitus impossible.

Treatment. — A double vagina is of no clinical importance unless it prevents
the escape of uterine or vaginal dischai^es, interferes with coitus or impr^;natiDii,
or obstructs the passage of the child during tabor.

Atresia of the vulvar end of a double vagina is relieved by a crucial incision
and drainage, as in the case of an imperforate hymen. If the septum should
interfere with coitus or impregnation or obstruct childbirth, it must be divided
along its entire course with scissors and the vaginal canal kept constantly packed
with sterile gauze until healing takes place to prevent reunion.

FiCr a 10.

FlQ. 310.
MALrOBlfjtTlOHS OT THE VaGINA.

Fia. 111.

Fig. 319, CompLrte double vagiiu wiih a lioglc mrrui; Fi|E- 3Jo. iocomplete dnible VAfJaa; Fig. ■■■. douUe

vagina wilh two uleri.

Absence of the Vagina.— The vagina may be absent throughout its
entire length or only in part. The defect is due to lack of canalization of the
lower parts of the ducts of Miiller, these tubes remaining solid epithelial cords
instead of becoming hollowed out to form true canals. The malformallon
usually coexists with absence or ill development of the other internal sexual
organs — the tubes, the uterus, and the ovaries— or these organs may be nonnally
formed and functionally active. In rare instances the anomaly may be associated
wilh absence of the vulva and an uninterrupted skin surface may cover the entire
vulvar region.

Results. — Up to the period of puberty an imjjerforate vagina is withoul
clinical significance, but after menstruation becomes established the vaginal atre-
sia prevents the escape of the menstrual fluid and the uterus and the Fallopian
tubes become distended (hemaloinelra and hemalosiilpinx); if the vagina is only
partially lacking, there is also dilatation of the patulous portion of the cana.'
{hematocolpos). If the uterus and tubes arc not functionally active, the mal-
formation may not be discovered until the woman marries and finds that inter-
course cannot be accomplished.

KALIOKMAriONS— STENOSIS OF THK VACIINA,

»37

■Symptoms. — A* In the ca>e of )m[>crfoiutc hymen, the mnlfonnation nwy
discovered until puberty, when symptoois of ol»tniction manifest ihero-
Lf ihc uterus mvi tlie ovaries are not tiefective. I'he physical nnil pkychic
phcnomeiui of ad'ilcftvno; become c»tabli»hed and the absence of the men»trual
fltrw (.'Jills attention lo Oie pot^^ible presence of M)nie form of anomaly iilTecttn((
ihe genital or^an.*. An examin.^tion ihcn retcil.« the [irc*encc of an imperfunilc
vagitiB and a lluctuaiing lumor situated imcnediaiely above the sympbysb pubis
ftud ettcixlinx downward into ihe |ielvit divity. Tlili tumor, if carefully ob-
tcned, i< found lo incr«a«« in size at e.ich mcnMru^l cpuci) and to become

Ehully smaller again durinf; the inlermeii&irj^l jieriod^.
DUgnosls. — The (luKiuni^ is lnuwl u|i»n ihc hiMor)-, the *ymi>tom». and the
sital examination. 'ITic latter reveals the presence and extent of the atresix
tlte tumor cause<l by the reUiincd menstrual bWxl.
E^ogDMis. — In ca!>c« in which defective development of thcittcms and the
ries u |>rcKnt, as indicated by the abscn<« of a menstrual molimen, noihinf;
itcver <iMiukJ !» done to relieve the awdilitm except pcrhajiv the donblful
expedient of mnkinj; an artificial %'agina for the purpn^ of sexual intercourse.
If, boivewr. the uterus and il:^ adnexa are (unttionally actitv, there is danger
of tulial rupture or MrixiK occurring unless an itultet is mode fur the CMca|ie ul
the [icnt up menstrual blood.

tTreaUnen!.— The treatment conabu of the following i>roce«lure»:
Mjiking an aniftcial vagina.
Hyslerccloiny.
Making an Arlifi<Ti,il Vagina . — If the vagina and orariot are
nctionally adivc. the indication is clearly to make an anificial ragina of a
nmnll ofiening through which the menHtruul bloiNl can e»ca]>c; but if ihoe organs
ur abwnl or defective in development, it i^ best to let the malformation alone,
W th« lenrlenry lo contraction would eventually make iiucb an o|>emnK useless
I for (cxual inlemHir^e.

^^^OftralioH. -Tlw patient is placed in the dorsal jiosition and a sound intro-

^^^^Bl in the bU<ldcr, to act as a guide aionx »ilh the indexfrnger of the left

P^HVln the rectum. An incision i< then made transversely through the skin over

thai part of the vulvar canal which would nonnally be occupied by the outlet

ut the vagina, and using the lingers, a dr^' di«»cctor, or a blunt -|Hitnted pair of

sdaaan, the surgeon gradually works his way upward until the uterus or the

blood-sac is reached. The artificial opening is then enlarged with (he fingeri

or the bliule^ of a Iwavy jnir of forceps an<l the retained blotxl etitcuaieil by

irri^ion, as describe*! in cases of imperforate hymen. Skin-flaps arc then

taken frum the nyin|>h3- aiwl the jierineum lo cmer Ihe surfacei of the opening

and furni a new vagina. If this i<. impnicticable. a glass plug i< um<I In keep the

cartD »rparated during the healing process aiul subsequently to prevent the o{)en-

ing from clitsing by conlnction.

^^ II y >t e re c I om y ,— Removal of the uterus by the abdominal route

^^klbout tbe ovaries Is indicated in »l!^es in which an artificial va)[iiu cannot l>e

^^Kt;>i <<ulh< iently |>Htulou« to drain the menstrual blood completely utd prevent

^^fete f!ui<l from re.iit umuljling.

^^ Stenosis of the Vagina.— Abnormal narmwncsj of the vagina. c*pe-
cully i(ajiVHi,iteduitha iinii'trnale orasymmetricallydei'eloiicd biconute ulenis,
may l>c due to an arrr-idl development of the lower end of one Miillcrian duct,
I and under llie*e ririum»l:im"e» the canal is not only cnnlr.ictcd along its entire
len([th, but \* aUo genenlty situaieil to oim side of the median biie. Stenw>is of
the ngina may aho lie tauM^I by thepicMnceofoneor m»re perforated wplums
ur soliil membranes which are stretched acnses tlie canal and obstruct its lumen.

ajS

THE VAGINA.

The partitions are either due to incomplete canalization of the MUIlerian ducts
or to the coalescence of opposing surfaces during fetal life.

Treatment. — A generally contracted vagina is of no clinical importance

Fid. 111.

Fm. 114.

FlO. 113,

MALroiiunaNS or n» Vaoikji (pige 13;).

Pia.iii.ContnclkiBottlicTaciiu: Fii. iij. perioratrd tcpiuin of ihc tisiiu; Fi(. >i4.>ol>d mcmbnaeocdDd-

JDC the vjiginn.

unless it is small enough to interfere with sexual intercourse, in which case
forcible dilatation should be performed under an anesthetic and the canal suf-
ficiently stretched to permit easy penetration of the penis.

Membranous septums are treated by excision and stitching the raw edges
together with intemipled catgut sutures, or they are
freely divided by a crucial incision and the parts
kept separated with a gauze tampon until the
healing process is completed.

Bliad Pottches. ^Sometimes blind pouches
or canals, due probably to overdeveloped lacunz,
are found just within the vaginal entrance upon
the bteral walls of the vagina. These abnormal
pockets in the walls of the vagina may be consider-
ably over an inch long and three-quarters of an inch
in iliamcter. They cause no trouble whatever unless
they become the seat of an infection, in which case
the micro-organisms are difficult to destroy, and it is
therefore often necessarj' to split open the canak be-
fore the disease can be eradicated.

WOUNDS OF THE VAGINA.

Causes. -~The situation of the vagina protect!

it largely from external violence, but it is, however,

often the i^eat of traumatic lesions due to labor 01

sexuiil inlcramrse. Vaginal injuries vary in impor.

tance from a simple contusion to a large open woumi

involving the surrounding organs. Thus, a tear may extend through th(

vaginal vault into the peritoneum or up into the base of the broad ligaments; ii

may also injure the ureters or bladiler; and, finally, it may involve the rertum.

Ftc. m. — Malfopuation or

TJIK \'Ar.inA-

Sbo^'tnfl blind ptmchen in [h?

lovrer p^n of die vagina.

W0CKD8— SYUPTOUil. aJ9

Tbe muse nf ih»« injuries are con^'enienllr discussed under three hcadingSi
B> |i-lt<)W'\: (i) [^il)ur; (3) i-(iilu-'>: (,;) rxlerniil vinlenci-.

Labor. -Iliis h the most frcqucnl cau>«. Injuries during lubor are due to
tbe pAiMfte uf the child through the hinh-canal and to carete&s or improper lue
uf the haods or injitruR>ent» in jK-rfurming llic various utwtetric <>]wrii(kiR« or
DunipubtioDS. Lacerations are apt to occur in rapid deliveries, in old primi-
par:r. or in ca.-KS of otyttruiijon due to an impacted head. Under the latter
oondtiions the tissues become bruitdt as the result of pre^ure, and cveRlually
aloush, cau»inK ^^tulous openings between the vagina and the bladder or the
rectum. Kxicni'ii'c 1mm of the viiRinii m;>y lie rju.-*d by t>[>onianeous rupture
of tbe uterus, and in some cai^c^ the connective tissue of the ^".tginal walls may be
injtired \^itlH>ut tearing the muouus membrane and a thrombus or hematoma
rvulU, fts ia olhtr |i;ins of the IxmIv. The ob-.tetric ("ri-e|is olien causes Mrriout
infurics through tarclc^sness or ignorance upon the part of the operator, and
one of ilie blade» may tie |iu^i«d ihn>ugh the vagin.ii v'ault into the peritoneal
ai\ ity. (« other parts of the vagina may be badly cut nr lorn during the application
of the inMrumcnt or M-hen traction is made U|>on the head, especially during an
■llCBipt Id n>Lite the ncd|>ut anteriorly. The intnKlunion of the hand into the
vagiui lo turn the child by pndatic version aixl the extraction of the bones of (he
iMal bead after craniotomy have frequently caused more or lew extensive
kccmlD(M. When the \-agina '» the Mrat of cancerous inliliniiicin. it> diUlabUlty
It tmpaired and tears occur as ihe head is forced through the birth-canal.

Coitus. — Thi^t cause h < 11 m para lively rsire. Raiic ujion thildrcn or young
girls frc>iucntly produces cxien>ive Jnceralion on accnuni of the disproportion in
we l>clneen the genital organs and the tender or uiuJcvelojied condition of the
tiMUGS. Inlercourie witlvokl women i% another i.-au:ie, owing to the (act that the
parts haw lost their dilatability and have bccutnc more or less contracted. It
ftOfMttmc* hap()en.-' that lacerations nf the hymen ocnirring a1 the fir>t sexual
iDterrounc may extend into the vapna. A great disproponion in size between
lh« male and female organs may cause extensive tears, CKtiecially when brutal
riolente ii \tsr<i during the .net. Operations which result in shortening or narrow-
in|t of the vagina are a prcittsposJng cause, and, fin;dly, the same is true of aU
fomw of conoenital aivumalius, such as «tenosis, aire^a, double vagina, and
fafaaiOe cnndnions or lack of de^x'lopmcnt.

fixlemat Violeace. — Injuries from this cau-^c. as previously mentioneil,
an rare, ^l1e^^gi^a maybepcnctnitc<l by falling on a sltarp object, by splinters
o( wond while sh<ling down an inclined board, and by the horn of an animal.
71)e<« cau!«i f>fO(luce exiensite and danf^nius wounds. Injune* are alfo
■ ^r. rti by the inloiduction of foreign bodies into the ragina by the patient her-
11 vif , and the vaginal walk may be lacerated by the hand or an instrument during
I a gynccoto)^c operation, .^ml, linally, 11 brutal hut-luind may tntlici a dangen>us
I injury, as m a case reported by Mann, where there was .t "serious laceration of
Ithr left hjfic of ijie ragina, nude by the fist of the husliaml, wliich was fonibly
■Ktlrivluin! into it in a lit of {Kisvion."

^V Symptoms.- Naturally thecharaclerandscverityof thcsrmplonudepend

Up<'n the situation and extent of the injury. .A i^lighi (car in the mucous mem-

Imne Mill give ritiC lo no local or constitutional disturbance's, whereas an cx-

I'lt'itc wound or one involving adjacent orgsins will result in marked symptoms.

It mutt alM) be borne in mind iltai the symptoms of a \-nginnl injury- caused by

labor are always more or less modified or masked by the owrstretching of the

from the nnssage of the child through the hinh-canal and by tlu.- presence

niirmitl iliicrurges. Thus the ncr\-c-rndings are blunted and pain is

il, while a slight henwrrhage may be readily overlooked. In non-puerperal

24© THE VAGINA,

injuries, however, the symptoms are apparent and can only be attributed to the
traumatism.

Local Symptoms.— These are: (i) Pain; (a) hemorrhage; (3) impaired
function; (4) retraction of the edges of the wound.

Pain . — This symptom is more or less constant. If the injury occurs during
labor, it is impossible to distin^ish the pain produced by the traumatism from
that caused by dilatation of the parts during the second stage of labor. As a
rule, in non-puerperal injuries the pain is sharp and acute in the beginning,
and it soon disappears entirely unless complications arise in the wound.

Hemorrhage . — The bleeding, as a rule, is not severe unless the vaffia.
is the seat of varicose veins, or the injury involves the structures of the vulva.
The hemorrhage in puerperal injuries is generally masked by the normal dis-
charges.

Impaired Function . — As in other parts of the body, the functions
of the vagina are more or less modified. Thus a puerperal tear may extend into
the peritoneum and some of the lochial discharge may escape into the general
abdominal cavity instead of by the normal channel, and in a non-puerperal lacera-
tion sexual intercourse may be prevented by the tenderness of the parts.

Retraction of the Edgesof the Wound . — The situation of
the \-agina and the pressure which is normally exerted upon its walls prevent to a
greater or less extent the gaping which usually takes place in the edges of a n-ound
in other parts of the body. There is, therefore, but little or no separation of the
margins unless the wound is very extensive and irregular or the intestines ha«
descended through it into the vaginal canal. Transverse wounds are apt to
gape on account of the lateral pressure on the vaginal waits.

Constitutional Symptoms. — These are: (a) Shock (see Injuries of the
Vulva, p. 166); (ft) fat embolism (see Injuries of the Vulva, p. 166).

Results and Prognosis.— Injuries of the vagina are liable to result
in septic infection if the peritoneal cavity or the base of the broad ligaments is
involved and the tears are extensive or irregular. A wound communicating with
the peritoneum may result in a temporary prolapse of the intestines or a per-
manent hernia. Intestinal prolapse increases the danger of general f)eritonitis.
and if the accident is unrecognized a knuckle nt intestine may become adherent
to the wound and, subsequently becoming gangrenous, form an ileovaginat
fistula. Finally, the vaginal canal may be narrowed and distorted by cicatricial
tissue or permanent fistulous openings may form between it and the bladder or
rectum.

Treatment. — The treatment is considered under the following headings:
(i) Hemorrhage; (2) shock; (3) cleansing the vagina; (4) coaptation of the
edges of the wound ; (5) dressings; (6) rest; (7) general treatment.

It is important to examine the vagina carefully in all cases of injury, other-
wise fata! mistakes will be made as to the extent and character of the traumatism.
The entire canal may be readily explored and the subsequent treatment carried
out by placing the palient in the dorsal posture and introducing a perineal
retractor or some other form of speculum. In puerperal lacerations a gauze
tampon should be placed against the cervix to keep back the uterine discharges
while the examination is being made and when the dally dressings are
applied.

Hemorrhage. — .\I1 spurting vessels are tied with catgut and the oozing is
controlled when the edges of the wound are brought together or when the vagina
is dressed with gauze packing. Styptic agents should not be employed, as they
interfere with repair and increase the dangers of sepsis.

Shock.— (See Shock, p. 859.}

WOCINDS—TKEATUENT.

Cteanaun tb« Vagina.— Finn remove all foreign malerbl ant) blomi-clois
with dressing fnrcqit :ini| smiill gauxe sfxingcs- The injury Is ihtn carefully
exunined to determine its character and extent, a» it b imporiant (u know
wbetber the UtL-riiiion i^ UmittHl to the vafCJrul walls or whether it extends into
the periloncal cavity or inwiives adjacent organic. If the v-ngina alone is inwilvcd,
I > douche o( luit norniiil sail solution i* given and the pans dried with 4 \^\i>x
I (ponglC- f^e wiitinii is again itxamined and all irrej[ubr m.-iriiin^ and devi-
^^aBaed tissues removed with scit&»rs. 'I'hc vagina i^ irrigated niih a hnt solution
^Bf corrosive suhlimale (i to 1000), followed by the sail solution, and dried.
^V When the wound commuiiicalciL with liic peritoneum a
douche must not be given, because ihc fluid may gain
eBtraDcv into the genera I peritoneal cavity and csti>e
ftCptic infection. Under the»e drcum^lancrs, after mnnving the
trregubr nurgins of the wound and the devitalized tissues, the vajrina iscleaitsed
by sponging it lhoriiu)(hly with hut normal >alt solution; the «iililimatc Milution
must never I>c used f<*r tiii'^ jiurfioM'.

CoapiatioQ of the Edges of the Wound.^The management of the wound

depends ujion it* charmler .imi extent. Clenr-cut incised wounds invnUHng

the vagina alone or communicating with the bladder or rectum are carefully

doaed with intcrru(>te<l ijttKul or silkworm fiut sutures, while lacerated or

coaluud Injiiiie^ are allowed to heal by gnknulatinn. ^\1icn the wound com-

mutiicatcs with the peritoneum, it should be kept open, otherwise if infection

ko place there U no way to <lrain the jiclv-ic cnnly except by removing the

tures. furthermore, free drainage fmm Ihc start in these caM% lessens the

r of seprijs.

essings. — Sutured, liicx'rated, and conluscd wountl? arc dresMd with
icauze. The parking should be firm during the lirst twenty-four liours
to conuitl ilic txMing, and if necesnT}- 4 comprcx.s and T-bandage should be
applied. After this time the gauze should be loosely packed and the Tbandagc
will not be needed. TIte tampon is remo%-e<l d^tly and the vagina irrigated with a
wdntion of ci>m>^ive :<ublim.ile (1 to 7000), foltowctl by hot normal salt •'•lulion,
anl dried ; fresh dressings are ihcn reintroduced.

i( liw wound c-ommunicates witb the jientuneal c^viiy, it is packe<l with a
nrjp of gauze, which i^ allowed to remain undisturbed for three days ai>d then
(cently removed after exposing the parts wiib a speculum. The vagina is then
cleaned by sponging with hot salt M>lutit>n, atrefully dried, and the pricking
rtptaced. Fresh dressing are then applied every day until the wound closes
and at the end of the 6rst week a doudie of normal .sail solution may be wbiiii-
tnled for ^jmnxiitg-

RMt.'-In wounds involving the peritoneum, the bladder, and the rectum

rtU in beil with tlie use of the lie<! pin It eN.>enliid. The :iurgica1 |)rinciptc»

ilrrlying reM in the treatment of wounds must not be lust sight of in ihe care

ibt?r injuries. The patient should remain in bed for one week uficr the

.nre^ are removed in rectal or bLid<Ier wounds, and in thote communicating

■he peritcine-il casHty ^he should not be allowed to assume the erect posture

itil the injury b entirety healed. The len^fih of time the patient ^dlould remain

the reeunil>cni (loMure in wounds involving the vaginal walls alone depends

<n the extern and character of the injun*.

Oanaral Treatment. ^The genrnil treiitmcnl i5 cJirried out upon the same

on .ilrradv l.iid down under injuries of ihe vulva on page ibj. In

s. however, inwiving the bladder or rectum the treatment differ* samr-

whai, and in «imiLir t» the after-care of ojxnlions for the relief of vesicovaginal

and ledovagjnal fmlulas (see pp, 761 and 771).

ith

242

THE VAGINA.

DISEASES OF THE VAGmA.

ACQUIRED STENOSIS AND ATRESIA.

Acquired obstructions may occur at any part of the vagina or they may in-
volve the entire canal.

Causes. — Lacerations. — Lacerations are a frequent cause and are due to
traumatisms occurring in labor or injuries produced by foreign bodies. Under
these conditions cicatrices result and the vagina contracts or the canal may be
narrowed by direct union between apf>osing raw surfaces.

Ulcerations. — The vitality of the vaginal tissues may be destroyed and
ulceration result from a prolonged labor or the pressure of a foreign body, and
from caustic or acid applications. In some cases extensive sloughing may occi^
during the course of an attack of syphilis, diphtheria, smallpox, scarlet fever, or
typhus, and the lumen of the vaginal canal may be seriously contracted.

Inflammation. — Adhesions may occur as the result of an adhesive inflam-
mation and narrow the vaginal canal.

Fig. 32<i. Fig. ijj.

DiAG^c^i^ or ArQL^Ru^ Stknoais op Trie Vagina.
Fig- 336thain lip of fin^r in coniact wiih ihc ub«rruf linn; Fig- ja^ihowfl [he ubsmiciion srcD ihrouch SuDoo'i

Operations. — A faulty operative tcchnic may narrow the vagina and result
in a stricture.

Symptoms.^ The symptoms are due to mechanic interference with the

functions of the ^apina iind to various nervous reflexes. When stenosis or
partial obstruction exists, there is no interference with the escape of the vaginal
discharges or the mensiruiil blood ; but if there is atresia or complete occlusion,
retention results, giving rise m charncleristic symptoms. (See Imperforate
Hymen, p. i6i.) The effect of vaginal strictures upon the act of copulation
depends upon the silu;ilion and character of the cicatrices and adhesions. If
the obstruction is situated in the upper portion of the vagina and the tissues
are not tender, sexual intercourse may take place; but if the parts are painful
to the touch or the stenosis is located in the lower end of the canal, penetration by
the male organ is difficult or impossible.

Local and reflex pains are often present and are caused by compression of the
nen'c -endings in the scar tissue. In sume cases the reflexes are felt in adjacent

ACqCIlLBO STEKOS1& AND ATRESIA.

»43

</>-

while in others the patient co«)]>bios of paio under the left mammoiy
fiLintl ami in ihe e)>if;ii.-<iTi£ region.

IHagnoSlS. — il'hc palicnl » ptacccl in the dorsal posture and the vagina
ezainitu.-<l In- touch and sight. If the legions are hinh up, ihcy are readily felt
with the linKcr or seen ihmuKh the npci'ulum. When it v*- im|)n»it)le in intro-
duce a (-jirculum. on account of ihc oi:cIui-i<in being near the vaginal entrance,

c»umincr must relj' entirely ujnm the sense of touch.

It w>RW-timcx hap|H-m thiii inihcvions or cicatrice* situated low down in the
vaginal caiuil conceal others which are located hifiher up. and it L* therefore
lpo»(l>le to diMiiver them until the lower onei' are removed.

A> a rule, an iincMhetic should be administered before making the examiiui-

Differential Diagnosis.— Stcnn»i)t or atresia of the \-agina must be dis-
tinf^itf^hnl from congeniial inaliormations, adhesive vulvitis, and vaginismus.

FrOffSOSiS. — The pfo;;ni>sis dejiontts u|H)n the situation and diaracler of
the )c«)on. When il t^ Mtuntrd in the upper
part of the vagina, vxual intcrcour^ is not
•criouslr fnterferei! «iih. even if tVie i imiiice*
cannut be removed; but nhen the abnormjil
CHrulition occupies the Jowxr two third?, of
the canal, tlie pro|;ni»L-i t-< entirety chanKi'd,
and un<leT ihc^ drcum$tam.-es copubtion
impossible if tlw atlhesions are extensive
id luniract the vaginu, unlcv* the c.-in;ii
in be ^ulhciently enlarged to admit the
rni« witltout inusini! the woman luiin.
lie pr»)gni»ts nf alie^u 15 always favorable
far as the vsca|ie of v-aKitial <liM'har>K^
ad mrnMruid blood b CDnccmed, as it is an
tsy m4iier lo make a permanent opening
loxye en(>u|d> to druin the canal.

Tbc rflecl of pregnancy upon t-aginal

tiriecc u to M>ftcn them, so that when

ibor o<Tur» they arc diUiable and cause

little or ih> trouble unless Ihe constriction is

mjirkol and involves an extensive iirea.

Treatment.— The iwiiml i* Hnc».thc-

Xr<l and pLiceil in the dorsal position,

the 4>|>crHtitv tcchnic neccs-sarily itegiendft u|>on the character of the ob-

an in ejch caic. there are, however, certain rule» which liave a general

ition.

I. Guard aitainsi injurlnn .-id)acent orKani by iniroducinfi the indexfrnger

«u (Ite rectum ami a nmnd into the bladder before removing the obstruction.

3. In wpaniiing adhesions use a dry dissector or the fingers as much as pos-

3. Unite Ihe mar^ns of all raw surfaces whene^'er feasible.

4. Always use imcrruplc*] sutures and introilucc them in the Ions axis of
«B|[tna, an the caiul will !« conKliii-tetl if the woimd ti tmiughi together

nn^vefiely.

Kind- f'f ndhcHion are rut off dose to the vaginal wall and the crlgeai of the

'<: unites! uilh stilurvs. lml>e<ldrd scar tissue is dissected out and

■ -cd. When it ts tm|><>ssibk- lo remove uU the cicatricial tissue,

Jtiple (amtlcl indxions are made into and aruund it and the vagina slowl/

FM. ») — t>t<oiirau> or .Stgcius SrtMO-

ii> ur lm> VjtUKik.

SiMwInC ■» olaDuoli* la ihf hivM pan <4

Ibc vtcuu (oonaHnt • inaadx Wcku up.

244 THE VAGINA.

stretched with hard-rubber dilators until its caliber is normal. A glass plug
(see p. 224) is then inserted into the vagina and kept in position by a T-bandage
until the incisions are entirely healed. During this time the patient must re-
main in bed, and subsequently the plug should be worn for two or three horns
daily for an indefinite period to prevent the recurrence of the constrictions. In
simple cases a few weeks or months are all that are necessary, but when the
cicatrices have involved a large area it may be necessary to use the plug for years.

In ca.ses where the adhesions and cicatrices are very extensive it is not alwa\-s
advisable to complete the dilatation of the vagina at one operation, on account
of causing too much traumatism. Parallel incisions are made at each opera-
tion over a limited portion of the vagina and the canal packed with gauic.
The packing is renewed daily, and after the final operation is performed the
glass plug is employed as described above. The great advantage gained by
repeated operations in these cases, apart from guarding against serious trauma-
tism, is the softening effect of pressure upon the cicatrices and adhesions which
is exerted by the gauze packing.

The operative tcchnic for complete occlusion or stenosis of the vagina is the
same as in the congenital variety (see p. 237).

FOREIGN BODIES.

Causes. — Foreign bodies are frequently found in the vagina. They may
be placed there by the patient herself to prevent conception, to produce abortion,
for purposes of masturbation, and as a hiding-place for stolen or smuggled
articles. The original intention upon the part of the woman is to remove the
object, but as it is often forgotten or she is unable to withdraw it, its presence may
not be noticed until symptoms of irritation arise. When an object is used few
purposes of masturbation, il frequently slips into the vagina and passes beyond
the reach of the woman's fingers, and she is unable to remove it. Sometimes
foreign bi>dies ulcerate their way through from the rectum or bladder and are
found in the vagina. The close relationship exisling between the vuhxivaginal
orifice and the anus predis[H>ses to the entrance of intestinal worms into the gen-
ital canal. Various kinds of parasitic insects have also been found, especially in
women who are uncleanly in their habits. It sometimes happens that an object
used for a therapeutic or operative purpose is forgotten and becomes a foreign
body. This is particularly true nf no n -absorbable sutures, tampons, pessaries,
etc.. and cases have been recorded of instruments and sponges, left by mistake
in the abdominal cavity at the time of an operation, ulcerating their way into
the vagina. In rare instances women have fallen on a pointed object a piortion of
which has broken off after i>enetrating the vagina and remains as a foreign body.
Finally, an ecloj)ic gestation sac or a dermoid cyst may rupture spontaneously
and ita content;* lodge in the vagina! canal.

Sstnptoms. — The local conditions depend upon the size, shape, and char-
acter of the foreign body. If it does not produce pressure or become infected,
its presence may cause no Inconvenience and produce no local symptoms. Usu-
ally, however, the jiatient comjilains of a profuse, foul-smelling, serosanguineous
discharge, pelvic pains, and backache, and uterine hemorrhages due to septic
endometritis are not an uncommon symptom in cases of long standing. Sexual
intercourse is not only painful to the woman, but the foreign body may also
irritate the male organ. A non -absorbable suture, such as silver wire or silk-
worm-gut, which was overlooked when the stitches were removed after an
operation is often not noticed until the husband complains of irritation at the
time of sexual intercourse.

rotllCN BODIES.

BIB 3

Results. —The urethra tiuy become infected in time from the purulent
larjtcs .ind an acute urethrilis result. Tlit presnure cserteil u\>tin the tl»ue«
iL foreiKn body causes ulcerstion which forms false pa^^gcs bcitvcrn the vngina
mad adjacent org^iu iinil endui^rs the life of the [laiieni from peritonitb or a
pelvic ab<cc$s. Furthermore, vaginal adhesions anil «>ntraniun:t ;ire liiibic to
occw. aoH in some cases almost comptelcly close the canal. Sometimes a ioreign
body i» more or Ir^t cmmpleiely IniritNl or eni'a|Kul;ile<l in the vaginal wall by
ulcentling below the surface, and eventually bcciiming mvored over by granu-
blion tinsue.

The lenf^h of time u foreign body may rrniiiin in the I'ajzina without jiroduc-
ios symptoms depends upon its character and si«. Thus, a pessary- made of
il c>r hard-mblwr or an article composed of iK>Usbed kI^^^ or ivory will cause
tie nr no trouble for an tndclinite period, whereto a rough or an abMirbent
•ka quickly becomes infected by thcsccrctioni.. Large and irregularly shaped
objects almoKl immediately ^au^« ulceration from pre»ure. and in some ianiancvs
a foreign body may Iwciome covered with n calciiretnj!^ deposit which changes
it> shape aiKl causes irritation fn>m the ragged nature of its surface.

Diagnosis. — The <tiaKni>>is drpend.>i u|K>n the recognition of the fnreitcn
objet 1 liv l>>u( M and sight. The patient is placed in the dortal poniure and the
cxaminaiiiin made with the index-lint^r, or Simon's speculums are introduced
and the vagina explore*! by >ight. These melhod$ of expluraiinn arc pt>wlive
in their results only when the foreign object is not hidden by contractions, ad-
ions. Of granulatmn tissue. Under these conditions vaginal and rtflal louch
lUst be o^mhined if the ohje<i i* situated in tlic posterior wall of the vagina, and
It a in the anterior wall counter-pressure must be made by abdominal palpation
abote the hymphysi* imbU or with the sound introducetl into the bhuhlcr. When
the object is buried in ihc vault of the vagina, its presence is discovered by com-
bined ragiiini and aMominal toitth, and it may be necessuTy in some instances
tefMuale the adhrviiin< or to remove the ci»ntniction:t in the vaginal camil Iwfore
impossible to make the diagnosis.
Treatment. —Tlie indit^^^tion.* are [o remove the foreign boly and treat
ibc contlilionv cause«l by its presence.

The necessity for the administration of an anesthetic dejwnds upon the
racier of the c:ise. It shoulil always Ik employed to facilitate the o|*erutlon,
uvc the patient pain. bimI to leswn the danger of injuring (he tissues when there
ibe slightest diSicutty in removing the object. For example, a lar:Be body or
one with ^hurj) olges requires the Kreale.'.t amount of care in hi exirncliun lo
pnvrat the mucnti.< membrane of the vagina from being lacerated, and hence a
(cncnl anesthetic L« iiwlicami.

The [Hitient i> plated in the dorsal pasture .tnd the VTigin.-i irriKalerl with a

luttim of lorrosive sublimate (i ti> looo). Simon's speculum^ are then inirO'

iced arnl the liest method of pnxolure mnsidcreii.

Va((inal irrigaiitm through the sivt^^ulum ii* an efficient mean* to remove !>mull

s. intestinal worms, and parasitic insects. An ordinary' pair of dressing

i& all that will t>e needed to extract articles which are free anri not too

Small pieces of broken gliiv^ should be picked out separately with tiMue

md Urge objects should be reduced in size by crushing or cutting and

> proleited with Literal mniclors if their ctlges are sh.ir]i or uneven.

Cuniinc mini' aitd adhe^imK arc removct with a knife or scissors ai>d free in-

cisiiHu UK made into the vaginal wjII when the object is buried or encapsulated.

In (itnule ea--«n after the foreign Imdy ha.^ Iwvn removed the vaj-ina should lie

iR%atc<] daily (or one week with a solution of corrosive sublimate (i to aooo),

lotbwn) bv hot normal salt solution. If, however, serious lesions remain in the

in I
ab

ibi

24t

THE VAGINA.

vaginal canal or involve adjacent organs, they are treated upon the principles
laid down under Injuries of the Vagina (see p. 340), and sometimes an abdom-
inal section may be required for the relief of a coexisting peritonitis or a pelvic
abscess. And, finally, if the urethra or the endometrium has been infected by
the purulent discharges, the resulting inflammation will demand our attention
and should be treated in the manner described elsewhere (see pp. 594 and 436).

CYSTOCELE.

Synonyms. — Prolapse of the bladder; Prolapse of the anterior wall of the
vagina; Vesicovaginal hernia.

Definition. — A prolapse of the anterior wall of the vagina accompanied
by a downward dislocation of the posterior wall of the bladder.
Causes.— The causes are classified as follows:
Lacerations of the perineum and pelvic floor.

General relaxation of the structures of the pelvis from disease or fre-
quently repeated labors.
Subinvolution of the vagina following labor.
Tears of the anterior vaginal wall during deliverj-.
Prolapse of the uterus.

Fig. 32Q- — SErnosAL View or a Cy^tocele.

Fig, ijo. — FBOHTViewor aCv^tocelx.

Laceralions of the perineum and pelvic floor are the chief causes of the affection.
The supporting power of the tissues of the pelvic outlet being destroyed, the
vaginal walls eventually prolapse, and as the posterior wall of the bladder is
closely and firmly connected with the vagina, it also Ijecomes displaced downward.
Cystocele is also observed in women whose pelvic structures have been over-
stretched by the delivery of a large child or by frequently repeated labors. In

CVSTOCKLC.

347

' tan instances prolapse of the vacinal walb may occur in women who have
^'bome rhildrcn and in yinini; Ktrh as ihc rr-sull o{ a Hudden or violem musculur
Subinvolution of the viigina fulluwing bbor or mKcarriage mny also be the
cause of a ve&icov-aKinul hemu; anil, rinally. the afleciion may accompany a
genenl relaxed comiition in womc-n who havi- lust floh as ihc mult of a
chronic disease. It should be Lome in mind that o-siocelc always accomps-
nie» ii)mp)ele prutupM: ol ihe uierun.

Preqitency.— The affection is very frequent in working women. In the
hifiher cksses, however, it b less often observed, because thew women receive
belter obHcirlc attention, as u rule, and are able lo remain quid until the prorcsses
iif involution arc completed. As the %'ast majority of c>'stocele8 are caused by a
raptured perineum, it naturally follows titai lhe>' may l>e prevented by prompt
repair of the IntumAti^m; and hence when the onmlition occur* in a wcll-io-oo
woman, it shows, Renerally, that the attending obstetrician was either careless
and neglectful or the ignomnt of the subsequent re£ult:i of iIk- injur}-.

.vs'-f

1-^^

'I-.

Pk- ni.-'SarnDHM Vltw m * Cnm •

mt Ksneiiu. VuH (p>t* *«D'

Symptoms. —The symptoms de7>end upon the extent of the prtilapsc,

There is always n flight bulging of ibe anterior uall of (he vagina in women who

Ve borne children, but these i :l^e^ prcrrnl no symptoms whalcwr, .ind it is only

<m the dolocation becomes markal Ihat the patient is cua-'ciuus of any lucsil

trouble.

I'Yhn chief tympionw arc:
A sensation of distention at the vulvrtvaginal orilicc.
A sensation of weight and <lragginK in the pelvic cavity.
I.<N» of jMiwcr in urimilion,
ScoMtioo of Distention at ths Vulvoraginal Orifice.— The feeling of
dtMeDtion b due to the prolapM^I and Inilging vaginal wall and hLtdder. and is
bh only when the patient strains or asGumcs the erect poslure. I'nder \he*e cir-
cumstances the intra -jlMlominal pressure acts upon the pelvic organs and forces
die C]nton-le downwartl. The liim<>r it somrlimo mUlakcn f>>r a probpsed
Utcnis by (be [Mlienl, aitd in describing hei M-miUnms she Mates that " the womb
i* down "

Sensation of Weight and Dragging in the Pelvic Cavity.— It Is only in

lariK cyNooetes and those accompanied by more or less prolaptv of (he ulenii

,lhBt a teMalion o( weight or pressure b felt in tlw uelvic cavity. The symp-

b usually due more lo the general dblocation of the pelvic or|[aas than to

ihc egging of ihe anterior vmll nf the vagina alone, and h is naturally absent
wbeii the alKlominal prereure is rcnmvci! when ihc patient lies down.

Loss of Power in Urination.—
The- [Nilicnl nim|iliunN ut more or
le^ difficulty in urinaling und a
wimt of |>owcr to empty ihc bbdder
completely. The cxlrMnrliiutry
effort required to void ihc urine is
due to (he fuii that the abdominal
pressure cnnnot act directly uptin
ihc bbddcr on account of the dis-
loi-alion of the uriian, and the de-
ticienci- musl therefore be ovTcrcomc
by violent siraining. When ihe
i-)-.%l(>cele is InrKt. n jHiriion of the
bladder i' siluntcd below the ".xsico-
urethral junction, and oinsequeolly
(here U always a ci>nfki(lcrab1e
quaniiiy of urine remaining after
the atl of uriroiiion U .^u{>poMd to
be completed (Fj»t- »3i).

The presence of residual urine
may niuHe le.^iial irritation and
frequent urination, and the patient
soon learns to assist hcreclf in emp-
tying the bladder by pushing the
anteriorvaginal wallupwilh theAn-
fjeni or a^uminK the knee-chest (>os-
turc during ihp act of minurition.
DiagTiOSis.— The physical signs of a. cystoccle are characteristic and ihe
diagniisis is not difficult. When the patient liei u[>on her Iiaik, ihere isuAuall;

F^c. *.u — DH'iHoni or i Ctstociib.
SfClkiaal rt'*, •hnwinil fhi tylrictle 1rgli;inq dcyund iBc

CVSTOCELE.

>49

little evidcno! of a tumor; but when fiie strains, the pmla|«nl anterior
of the vagin.1 bulges .ind [ireseiiB iix«U at the urifice xi a round ela&tic
which disappears on pressure nr after ihc patient ccatcf (o bear dtm'n. If
the bhdder i& full of urine, ihe c)'stocclc is ^^cry tense and there is a dislincl
Gcnsarion of fluctuation im[iiiriv<l li> the exiimininfi; finger.

The posit>«% test in the diagnosis is to introduce a cur%-ed snund into the
bladder and turn iu |H>irit downward into ihc most promineni ]>an of the swelling,
wbere it may be readily (cit by the examining finger ihmugh the inl^;^^■t■ninK walla
o( the vaeina. ARain. if the tip of the sound is pushed firmly agninsi ihc wrall of
the bladder it will distend ihe vagina and a projection can be diMJuctly Been at
thai point (Figs. 13$ and 136).

Anuther method of {Ilif;nosb is to fill the bladder with Merilc water and then
withdraw it and note (he changes in (he chnmrter uf ihc enbirKcment. When
the bladder is distended, the swelling is tense, smooth, and ebstic, hut when il is
empty, the probpied vaginal wall is relaxed and flabby. \\'hen the cysiocele is
aseociatKl with compkle uterine anil vaginal prolapse, Ihe bladder hang» outride
ol the orifice of the vagina in front of the uterus, and the diagnosis is made by
Iheuimcmelbodsa* wlunihf atleitionis unromiiliciied (Figs. 137 and »j8).

Difrerential Diagnosis. ^The aflcrlion must be di^linguijihed from
an anterior %'aginal hernu and a tumor situated in the >-aginal wall. The phj'sicsl
*ip», however, of a oXorcle are «> characterl^^tic tli.it an error in diagnosis is
almrist imposs-ible when oidlnar)- care is used . The following arc the chief [taints
the iliScrcniial diagnosis:

cmucKU.

Situainl in tlvr anitrior wall of thr vn^ns.
lacTT»r* in SIC and Itiuion on cou^ng

or Mraininit.
DiMpfMar> on twvMuir.

Teav uid rIaMic wlwn tltr (ilailder ii full.
Only ihr •oifinal and liUiliIrr <ntl» bc-

twvaq Ihc tuminiofi Ungn and a sound

la Ihe Madder.

CVBTOCn.1.

'. Sttuaicd In tbr aBUtior va^nal walL
Iniiraaa la ilic and tcnuioo on coughing

or tinunini;.
DUwppaus on pmsurr.
TesM and ciuDc when the bladder in tuU.

ANTKBIOa VACINAL IIUMtA.

I. Sane.
i. Same.

3. CiMppeara on pmaure with a gurgUag
•ound.

4. A1way> tod and douKhy 10 the lourh.
$. The (Wlinm of thr jnlencninm ttrixturea

■1 jncrease<l by Ihe pmencc oS tbr in-
UMino.

VMUMAL TinOR,

I .S*mc.

1. No Inrreuc In ilie and teiuJon.

J. Do« not diuppear,
4. Condition of Uic bladder haa no effect
ufian ihr ititnnr.
Only th» t^nal aad Iflxhicr n-alb be- $■ Tlir IhicknrM of Ihr inlervening itnie-
tWMn Ihe wamning fingtr and a Mmnd lutes a incteaaed by (he preMore of Uie

ia ih* bladder. luoiot.

Its. — In small cysioteles ihe \'aginal wall is u^ual1y hypenrophied as

Il of Mibinu'lulifin, ami Ihc siw uf the pmUjrtol inirtion of the bladder

b aWTespondingly increased. Oradimlly, however, as the afleclion de^*cki]>s the

Icr Dulget more and more, and atrophy <>i'cur>. The vaginal wall then loses

foli|» or mgir i»d l>ecomes Mrcuhcd and thin and the mucous membnine bus

anemic or blanched appearance. When the condition is as-socbled with

[iletc probp»e «>f the uterus, ihe vaginal mun>u» mcmltrane may become

in character or even ulcemicd from friciion and exposure to the air.

b always more or less dilataiiun of the bladder in chronic ca->es of cyslocek

{n rxrr in%Lance« ihe ureters may liecume itlMended fmm constriction.

_ Upon gcitcral principles we would nalurally conclude that cystitis and urelhri-

tk mre vf frequent oirurrence owing 10 the irritation produced by alluiUnc

CYSTOCELE.

»5i

ddrompo&ition of the residual urine and the dislocation of ilw parts. On
the cuntrarj', however, ihcBc affctiions are not often
ine( a« cimpllc aliens of cy^toiele uoIcks the bladder
becomes infected from other causes.

Progll08is>~I*roU|Mc of ilic bladder has no lendeni^ inward spnniane-
nus cure. :tnd the condition UMutly goc» from bad to worse until the rnlire
bUtldcr Ix^comrs dulocated. I'hc opcraii\-e prognosis depends upon the general
Unlc ol the |>el%'ic orKiinN, the cnuM- of ilie prolapse, and the uite of tliv patient.
In )'»ungwon>cna complete curcu»uiill}'fo|[ow*]i therc|uiro[ the (lerineum and a

f», <f»— iKiTttTiiwn ^tlI^ w A"iii-«mi CiLnxiiiAntv (paar iti).

e"^

ACT UAL SIZE

luntiwing of the anlcrtor trail of the
jngiia. When, l»m«\'er, a woman is
ivaoce<l in yenn an<l has Icnl devh, or
brre is a general rcUxation of the pelvic
i[|ur», it b practically impossible to
the inrts t'ompk-lcly ■<> (heir
itmul condition, and the best thai can
htified for b to lessen the deRree of
iluoilioa and relieve the liLidder symp-
toms.

The nn>fin<»-.b b aln'avH tnfluenie>l hy
~ xlition "( the vaKin'il walls, and
iWy ore amiphicd, thin, and over-
' ~ i) b unfavorable: hut when
■n thick and ha^-c not bwt (heir
itnctilc powers, it b ffxtd. If the c>'sioccle is assocbtcd with complete
I'Upse o( (he u(crut>. it cannot be relieved unleM the uterine dbbcation is
trmanenlly (nrrectcd,
Treatnient.— The ireatmenl is divided into (i) the Tsdical,aod (a) the
.paflklivr

Radical TrMbDVnt.—The radiciil treatment is opcnli^T and consists in
the rrfMlr of (he {>crineum and the putttrijor vuf;inal wall {toifnptritieotrhcphy)
Aod lunowinft of the anterior wall of tl>c vapna {auitrior (otptittkapky). The

fu to,— SMUT roiiniuiia. N'notM. PU-

WD in AwrtuM Cduouaum (pac*

2sa

THE VAGINA.

perineal operation is generally indicated because the majority of cystoceles are
caused by a laceration of the perineum, and unless the integrity of the pelvic floor
is restored an anterior colporrhaphy alone will be followed by a recurrence of
the prolapse.

Colpoperineorrhaph y. — The technic of this operation is fully
described on fwge 802.

Anterior Colporrhaphy (Anterior Elytrorrhaphy).
— This operation consists in narrowing the anterior wall of the vagina by denud-
ing a portion of its surface and suturing the edges together. There are a large
number of operations advised for this purpose, diSering fronn each other only in
the shape of the denudations, and consequently the technic of all is practically
the same.

Technic 0} the Operation. — The Preparation of the Patient
and the Preparations for the Operation are described on pages
830 and 831.

Position of the Patient . — l>orsal position.
Number of Assistants .—An anesthetizer, two assistants, and a
general nurse are required.

Instruments. — (1) Simon's speculum (curved blade); (2) scalpel; {3)
right and left Emmet's slightly cur\'ed scissors; (4) four bullet forceps; (5) two
short hemostatic forceps; (6) tissue forceps; (7) dressing forceps; (8) needle-
holder; (9) shot compressor; (10) three slightly curved, round-pointed needles;
(11) perforated shot; (la) silkworm-gut — 15 strands (Figs. 239 and 240).

Opera t i o n . — First Step.— The siieculum is introduced into the vagina
and held by an as-i^istant. The anterior vaginal wall is then seized with bullet

forceps about half an inch above the external
urinary meatus and just below the junction of the
vagina! vault with the eerviic.

Second Step. — The speculum is withdrawn
and the ujiper part of the vaginal wall pulled
down into the orifice of the vagina. Traction is
then made in opposite directions with the two
pairs of forceps and the vaginal wallseized on each
side by additional bullet forceps midway between
the corvi.x and the external urinary meatus.

The distance between the two lateral forceps
depends upon the size of the cystocele, and the
correctness of their position can be tested by
bringing them together and noting the amount of
tension at that point. If the ten.sion is found to
lie too great, the instruments are placed nearer to
each other; if, on the other hand, the vaginal
wall does not become sufficiently taut, they
should be attached further apart.

Third STKP.^The assistants make traction
in opposite directions with the forceps and put
the intervening vaginal wall upon the stretch,
which f<irnis a flat diamond -shaped surface. A
straight incision is then made through the
mucous membrane between the four points on
the vaginnl wall grasped by the forceps.
This incision marks the boundar\'-]ine of the area to be denuded and gi\'es
a clean-cut margin for approximation.

Fig. 141. — AsmiOB Colpoihb*
puv — First Step.

'54

THE VAGINA.

the sutures the denuded area should be kept taut and care should be taken
not to injure the bladder.

Sixth Step. — After Ihe sutures are all in position the lateral bullet forceps are
removed and the edges of the wound approximated with perforated shot.

The free ends of the sutures are tied in a knot and pushed up into the vaginal
canal.

Seventh SxEP.^The vagina is irrigated with a solution of corrosive sub-
limate (t to 2000), followed by hot normal salt solution, and dried. A loose
tampon of gauze is then introduced and the \'ulva protected with a compress
secured by a T-bandage.

While the majority of operators tie the sutures, I prefer to secure them with
perforated shot, as the amount of tension can be accurately estimated when the
edges of the wound are brought together, and they are also more easily removed
from the tissues. Silkworm-gut is the best suture material to employ, except

Fig, J46,— Fifth Step.

Fic. 3JT'— Sixth Stafb

Ah IF mm CoiPOlKHAPHV,

when ihc o|)enition is combined wilh u |)erineorrhat)hy or a colpoperineorrhaphy,
in which case No. 3 cuniol catgul should always be used in order to avoid the
necessity of removinf; the sutures and thus endangering the integrity of the
jierincal wound.

Viiriiiliotis in the Technif. — The shaj)e of the denuded surface may be oval,
figure 248; or the VLi);in:i may lie narrowcl by <]enuding two or more surfaces and
folding ihcm ujwm each cither, as in Sims's ojjcration, figure 349; and, finally,
wme operators advise that the denudation tie made transversely, as in Reed's
i>jKrration, figure 250. The effect of the last method, however, is to shorten the
vagina and ]iull down its upi)er imrtion, and consequently there is no support
given to the prolapsed bladder.

If a lysloccie is ass<iciated with uterine prolapse, the latter condition must be
cured \>\ ojierutive measures and an anterior colporrhaphy performed at the
same lime.

CVSTOCELE.

355

Aftfr-trtalM€nt. — C are ol the Wound . — The Rautc packing is rc-
nx>VGd in f(irty-ct>^i hours and not rcintnxluccd, and the vikjtina irrinnied once a.
day with a dilution <•( mm't^ivc >ublimiilc (1 to 7000). followed by hoi normal
lah solution. Afltr the patient gets out of bed the anti.'eplic douche shcmld be
dJKontinued nml thv vujtliu irrigated with a, gallon of h«i Miline volution once a
day /or several weeks.

The itiithci lire removed on the eighth day.

The It I Add cr.— The urine muM be i-ridcd spontaneously or drawn by »
athrter even six hours (or the first two wceko. A* [i rule, the patient has no
trouble in jiavinK hvi urine, but if ne<■e^»«^^■ a miheter murt l>c usfl it the dfa-
tenlion will tausc an injurious traction upon the sutures in the I'aginal wall.

The Bowels. — The Imw-els arc moved in twenty-four hours with a
tnik] laxative, followed In' a ^im[>le enema, aivl then kept o[>en e\KTy day by the
umc means.

The Diet . — The diet is reftulateid as fulfows: DiiriiiK the fimt foriyeight

rirs liquid diet (kc p. loA); then »ifl dirt until the end of the week ([^eej>. iit);
I tinalh' ('<>n>'iik:M'cnt diet (sec p. 1 14).

VtutnoM a tut Trriiior >ir Aairain* CtaKaniAnnr.

RcBtlcssncss; Pain . — There is genenlh' no ocraslon (or the use
of drugs, btit somrtiitie>|Mticntsarcreslle9<«nrM)fTcr moreorle.v^lKiin. aiidumler
UlHc condilionii .in eighth to a quarter of a grain of morjihin b pi<rn hj-poder-
mkally and rcp«ilc<l if ncces.sarj-. After the first twenty four hours if the
(Mlknt ti rvstlcw at nii^it or doc not sleep, sulphonyl or trinnal ts admini*tered.

Gctlin|i;Oul of Bed.— The patient should remain in bed for two weeks
after an ojirraiiiin for n snutl cyMocclc. and in taMK in whiih the lr>ion is pro-
aouriLctl ihe time hIhiuIiI W cwciuied to Iwcniy-ooc da>i-. The paticnl should not
kavr ' (or at lejst one week after icettinf: Up and sexual rctalioRS should

nM U ! fur two months.

L c •> 1 <- 1> i n 1; the 1 n 1 r a - a b d o m i n .1 1 P r e s s u r e .— It is im-
ponant during ilte fir^i six mi>mh.» after the ci|iemtion for the intra-abdominal
pftmire to tic mlun^d to a minimum and to pianl the patient ai^irt^ any Miilden
wriiihl lieini* placeil u|N>n the [>eUi( orKiinsi oihcrwL->e the vaginal prola|>se may
m-ur ami the bbdder l>e(omc di^locatod seain. As a prcwntive measure, ihere-
tctr. r'- - -i -n must be instructed noiiolift heavy weif^ls. lake violent exercise,
or d-. that oilht for stninn mu*oilar effort, ami an aUlominal Mipporter

dmakl lic Hum fur nne year lo relieve the pressure of the intestines uptjn the

956

THE VAGINA.

pelvic organs. If the abdominal walls are flabby, the retentive power of the
abdomen must be sustained by wearing the supporter for an indefinite period
and the muscles strengthened by using indf>or exercises, as described in Chap-
ter X.

Palliative Treamtent. — It is important to have a clear idea of the trcatnient
of c,vstocele from a palliative standpoint, because we often meet cases wheie
radical measures are not indicated or where the prolapse has recurred afta an
anterior colporrhaphy has been performed. Thus, women who have passed
the menopause and are thin or who ha%'e a general relaxed and flabby condition
of the pelvic structures are poor subjects for a radical operation. Again, large
c>-stoceles associated with an atrophied state of the vaginal walls are seldom
cured, and women who have lost flesh and fat as the result of a chronic disease
are often not benefited by opemtive measures.

The palliative treatment only aims to lessen the severitj- of the bladder symp-
toms by controlling the degree of prolapse by the following means:

Repair of the perineum.

Lessening the intra-abdominal pressure.

Tampons, Injections, Suppositories.

Pessaries.
Repair of the Perineum . — All tears in the pelvic floor must be
repaired, as the tonicity of the perineum is necessary not only to support the

Ftc. isi. — Suhe's Pessaiv fob PnotAPSE or the Bladuek in PoimOH.

lUiiKraltDD a showithe coualruclion of th« penary.

organs of the pelvis, but also to sustain in position the mechanic appliances
employed to keep up the prolapsed bladder. The technic of perineorrhaphy is
described on fwge 802.

Lessening the Intra-abdominal Pressure - — TTie ma-
jority of these women ha*e relaxed and pendulous bellies which destroy almost
entirely (he retentive power of the abdomen. An abdominal supporter must
therefore t>e worn to relieve the pressure of the intestines upon the pehic organs,
and the strength of the abdominal muscles should be increased by appropriate
indoor exercises. (See Chapter X.) The patient should be warned against
violent forms of muscular effort, such as lifting heavy objects, etc., and she

wtcrociiir.

aS7

shuuM aisc be imtnirtcd not to wear clinhing (hut conauicts the waist. It is
aiso inporiaiit lu have the bowels kept regular und to empty (he bbddei eveiy
»ix ur cicht hi>ur>.

T&mpi>n»i Injections : Su|>j>"*ii«Tics . — In some cases
the daily introduction of a (ampon of coiton-woi>I saluraicd with a imluilon of
alum, unc. or tiinniii often seri-es a lucful ))ur|)05« and contracts ihc vagina by its
&aringent action. The tampon is hIm a mechanic mtpgrnrl to the probjijed
bladder, and if it h properly made the or^an is tcpl up sufficiently high in the
pcivb to reliew the diflicuhy <-\|>iTi<:nreiI durinn: urination. Sometimes Ik-Uct
ftsuhs arc obtaiivcd by u.«in); drj- tam[x>ns. which arc dusted over with t-mntn or
poirdcrcd alum anal then iniroduceil into ihe vagina.

Vaginal douches should be um:<I ni^ht .-inil morninn 05 a routine plan of
tRBtment as follows: A i^llon of hot normal s.ilt solution is injected into the
vagina and (be (KiftK then (lushed with a <{u;trt of hot water containing alum, cine,
or tannin.

X'afpnal suppositories containing zinc, tannin, or alum often scr^'c a useful
purpfiw and may )>e MiltKtilutei) at timet (or the astrinnenl injections.

Pcssa ries.— UtHxI results arc obtained (mm a symptomatic 5lanHpo!nt
by the uk u( a pesoary which supports the anterior wall of the vagina and pushes
up the prob{>4«'l btntder. Skene's pcsfary i* the only inMrumcnt of which I have
any knowledge that gives utisfaclor}- results. It b made in !rc\'crRl sizes and is
iiiiruduivl into the rapna in the s-ime manner as a retroversion pessary.

Uefofc employing a pcwary for the relief i>( a cyslocelc it is always advisable
Ki use aatrlngcnl tampons for a few weeks to harden and cootnict the
vagiaA.

RRECTOCELE.
aonymft. — Prolapse of the rectum; I'rolapfe of the posterior wall of the
Kcctuvaginal hernia.
Gnitlon.— A prolapse of the posterior wall of the \~agina accompanied
titrus)>>n of the anterior rectal wall into the pouch (Figs. 3$3 and ly).
Prulaptc of the poiiterior wall of the vagiiui Is not always, strictly sjieaking, a
f«*nTtt synonym for rectorctc, because in rare aiscs, owing to the lin»»e anatomic
c'>nr>eriii>n l>etween the two organs, a dislocation of the ^^ginul wall may occur
without any |>mtru--ion of the rertvim (Fig. 359).
CaoaeS.— The causes are cla^silied as follows:

hi. Fre«)uent causes,
(a) Larerutions of (he iierineum and pelvic floor,
(ft) Pmbpsc of the uterus.
9. Ocwiunal causes.
I (d) Sudtlcii muMrular effort resulting in scute uterine and vaginal

I prolapse.

I (A) Subintiilution of the vagina following blior.

I (f) Oner.il relaxation of the structures of the pelvis from disease or

I freftuenily repeated bljors.

n (be great majority of aincs a redoccle is cauted by a laceration of the peri-
neum .ind pelvic floor which results in a loss of support to the vagina and pelvic
urican awl inteTfi-n-s wtlh the normal mei.harii>m of ilcfctalion. Tbc tonicity
^o( the perineum l>ring es^niinl to ihr equilibrium of the organ<^ of the pelvis. i( fol-
^Hnn that when this is destroyed the structures lend to pn)b|K>e, and cnmequcntly
PKc pnaurrtor wall of the vagina IwgiRS to wkg. until evcniuallv it (arms a bulging

2S8

THE VACmA.

tumor 3t the vaginal entrance. The first step, therefore, in the formation of a
rectocele is a prolapse of the posterior vaginal wall, and for a ^ort period of time,
as a rule, the rectum remains in its normal position, but sooner or later it is
forced forward and downward into the vagina. In a normal woman durii^g the
act of defecation the vaginal canal is closed, the perineum elevated, and the anal
sphincter dilated by the contraction of the levator ani muscle. The effect of
this combined action, which is further assisted by the pelvic fascia, is to give a
firm support to the anterior wall of the rectum during the expulsion of the feces.
The opposing force of the perineum at the same time directs the fecal matter
through the sphincter, which being relaxed is dilated by the contraction of the
levator ani muscle.

When the pelvic floor and perineum are torn, the mechanism of defecation is
entirely changed, and the force of the intra-abdominal pressure against the fecal

Fig. jjj. — SEcmoHAt View of a Rectocele (page >;?>.

Fio. ajj. — FwjMT View o» a Rictoceu

mass is wasted and the woman is obliged to strain violently to overcome the
deficiency. As the feces descend along the rectum it meets with no guiding forces,
and. seeking the direction of least resistance, it pushes the posterior wall of the
va.rfina forward and downward. The fecal matter higher up in the rectum now
crowds against the mass below, which has been temporarily arrested by the
absence of counter- pressure from the perineum and levator ani muscle, until it
eventually reaches the sphincter, only to find it contracted. Still more violent
bearing-down efforts are now required to force the feces through the ana! opening,
which is normally dilated by the levator ani. The anterior rectal wall and the
posterior wall of the vagina receive the brunt of the strain, and as a result they
protrude more and more until finally a rectocele appears beyond the vuhar
opening.

Frequency. — Rectocele is a very frequent form of prolapse in the lower
classes, for the reasons already given in discussing the frequency of cysto-
cele.

RECIOCELE.

»S9

Symptoms.— The symptoms luilurally drpcnd upon the cxicnt of ihe pro-
la[)»r. «nd in sli^l rases the palicnl may not be aware of ita exiMen^i;.
Th.' chief ».ym[»loms are:

A sensation of distention at Uie xTjlTOvaginnl orilice.

A M-tiSiition of wrijiln anci clritgKinK in ih« jwh'ic cavity.

Diflficulty in drrt-olion.

Fm. «t4.— Tn« A*MH> iHiHcaln nu Dturneai TnKui BVTHFtCEi ximMi mm Act<v Noiiut,

AMD huni^U Att. SaC¥VL«T>D.

Scnutlon of DiitenttoD at the Vulvov8{ina1 Orific«.— The wnuiion
rf dJhU-ntii<n iil (he vulMivngiiuil urifuc iv i!ur to ihr i>r<.'M.'n(~c of the jirolnpscd
>-i|[ina 4II-I mium. itnil is only felt ubcn iIh- |>dlienl siraias or sMUmcfi the
ttnt [xiniurt. Titc wonuii ofii-n misUkci the |irotru&ion for a prolapse o( the
iiunn.

26o

THE VAGINA.

Sensation of Weight and Dragging in the Pelvic Cavity. — The peUic
symptoms are common to all forms of vaginal prolapse and are caused by the
dislocated orRans pulling upon the adjacent structures.

Difficulty in Defecation.— The interference of a rectocele with the normal
mechanism of defecation has been referred to above. The violent efforts which
are required to empty the bowel when the rectocele is pronounced are often \-en'
distressing lo the patient and she frequently assists herself by pushing up the
prolapse with her fingers. The rectum is not entirely emptied in marked cases
and there is always more or less rectal tenesmus or a sensation of incompleteness
following defecation.

Dlag;nosi8. — The physical signs are characteristic and the diagnosis easily
made. When the patient Ues upon her back and separates the knees, there is
but little evidence of a bulging tumor except in pronounced cases; but when she
strains or stands erect, the rectocele presents itself at or beyond the vuh'ar opening

Vi'-.. is6.— REi-rorn.R. Fic. 157.— DwomKis or * Rktoceix. Sec-

Showi oUileralinn uf (he cde with the imki-finger. hokal View.

Showing ihr rpclorple buLgina bcyoDd tbe v*tin^
oriiKC when Ihe palKnt slmuis.

as a soft globular mass which disappears on pressure. The swelling increases in
size and bcaimcs tense when .she bears down, but it rela.xes again and becomes
smaller when the intra-alxlominal pressure is reliei'ed.

The p()siti\e test in the diagnosis is made by introducing the index-finger into
the rectum and hooking it fonvard into the most dependent part of the prolapsed
pouch, when the nature of the alTectiun at once becomes apparent. If the case
is one (tf jirolajjse of the vaginal wall alone, the rectal examination with the
finger will reveal the fact thai the rectum is not displacwi.

When a rectocele is associated with comjilcte uterine and vaginal prolapse, the
anterior wall of ihe rectum hangs outside of ihc vagina behind the uterus, and the
diagnosis is made by the same mclhixi.

Results. — In slight rcclocclcs the vaginal wall is generally thickened as the
result of subinvolution. As the affection develops, however, the wall of the
vagina loses its folds or rug;e and becomes atrophied and stretched, and the

RECTOCELE. ^^^^^" t6l

mucous membrane has an ancmk or blanched appearance. When ibe condition

i^V*

■<\

Fia.()S.

Diiu.VM» nr • Itinwiit.

Fti\. ija-

Fi( It* ikiM* 4* JndH ioMT Id ihf m<uin puihiiu ihr rnvnlt btpod ilir •ipiwl ■tnAn^ Fli ho ihMn

to'

» UHOTUlod wiih ulcrinc procidentia, the vaginal muum^ membrane be«'omcs

huU or cutano>u<i in iharactrr and ulcrrii-

lions may occur from friction and ex-

poMire In the air. OliMinate (i>nMi{Kt-

lii'n h a frr<|ueni result of a large rcc-

lot-elr. as ihe bowreJ caiinol completely

NRply it»me

bluRteil. 'the accumulation of feces in

the rprium incrvjses the severity of the

knal (rouble ;ind the hkio<l liecwme* p«»i-

MintiJ l>y iIk abxirption of fecal material.

Chrunic inllammation ami ul«'mti'in of

Ihd rectal muntuK memliranr may occur,

■ad hemorrhoids. fLHiub.s, arul aiul fu>-

••ure* art ofirn Iracnl to the vimc ■^itin-c.

In rare innes, uhcre the rectum does not

prtiUpv nloiu; villi the Migina the culdc-

MC of I>oiikLls pushc< down l»rtw-e<'n the

vaipaal wnll and rectum and ihe iiiies-

ifnn dcMend arul (orm an enteroccle or

hrmia.

Ljuttt rcct»n'«lr» arr itenerally anso-
ciainl with Metiliiy on account of the
esrapc of semen ai tlw time of sexual
intrreoutv.

ProgUOfllB. - A rcclorele has oolenrl-
mi,7 luwanl optmlannius <'ure amt )c<^nrr-
tUy fte» from bail to wnr»e until the prolapse becomes marked and the vaginal

;

■^-■i

ami villi IVaiAfuCir TmUlMMMOi
Vuiiu

mt y^mt) cfiArc lnhind ibc atvlx.

36a

THE VAGINA.

wall atrophied and stretched. The operative prognosis depends upon the condi-
tion of the pelvic organs and the age of the patient. In young women a colpoper.
ineorrhaphy is generally successful, but if the patient is advanced in yeais or has
lost flesh, or there is general relaxation of the pelvic structures, the best that
can be hoped for is to lessen the degree of prolapse and relieve the rectal
symptoms. Again, when the vaginal wall is atrophied and thin the results
of operative interference are bad, and if the rectocele is associated with com-
plete prolapse of the uterus the prognosis depends upon the curableness of the
latter condition.

Treatment. — The treatment is divided into (i) the radical and (i) the
palliative.

Radical Treatment. — The radical treatment consists in the repair of the
perineum and the pelvic floor (col po perineorrhaphy). If the case is associated
with other forms of prolapse, they must also l>e operated upon at the same time,
olhenvise the equilibrium of all the jielvic organs is not restored and the rectocele
will recur.

Colpoperincorrhaphy . — The technic and after-treatment of this
operation are fully descril>ed on jiage 802.

Palliative Treatment.— The palliative treatment aims to correct the diffi-
culty in defecation by lessening the dcRrcc of prolapse, and is indicated In cases
in which a radinil operation is contra indicated or has beeti unsuccessful.

The treatment consists in:

Lessening the intra-abdominal pressure (see Cystocele, p. 256).

Tampons; Injections; Suppositories (see Cystocele, p. ag?)-

Care of the bowels.
Care of the Bowels . — It is important to keep the bowels regular and
avoid the injurious results of chronic constipation, which are especially marked in
cases of rectocele.

HERNIA.

Definition. — \ vaginal hernia starts either behind or in front of the broad
ligaments. In the former case it begins in the culdesac of Douglas and descends

Fig, j6i. — l\isU'h<>r ^a^iu] hernia. Fjc, ittz. — Anleriur vagLiuJ herajs.

VAbiNAL Hernia.

between the rectum and vagina. Ii then sepanites the fibers of the levator ani
muscle and appears al the posterior part of the labium majus, or in the perineum.
The second variety starts in the vesicouterine fold of peritoneum and, passing

UKRNIA.

»63

beblNCB tbe bladder and vs]|[ina, finaUjr i)iintnid(s at the postenor extremity of
tb» kbhun maju$.

Cftnses.— Lactralions of the |>crineum and rolaxation of ihc structures of
ihe pclvn due lu Lilx>r arc |iro<IU))uMi)): muM«. Some authorities aiiril>uie (tie
coodiiutn to a tnngcnilal mallonnalion »f ihe iMTitnnciim and pelvic orpins.
This (onn iil heruU h verj' rare, especially when it starts in front of the broad
liguDcnu.

^rmptoma.— tn the bcf^nning the liemui forms n tumor on the anterior or

Cnlmur vnU at tlie ^'nKina, Iml cvenlually it ap)>euTs at the posterior |iurt of the
bium majus or in the perineum m-ar (he Hnu» or the vulvovaginal oriAce aDd
prtvrni.-. ihe usual jihysital iigns of cnicrooele,

2>iffinential IMagnosiS.— If the hemia Isslill vHlhin the vaKina. it may
be aislaken for a redocclc, a cj-stoorlc, or a tumor; and aflcr it has appeared at
thr vuK-a, tl may lie ronfoundetl with a tysi of the vulvovuKin^l Klond, a tumt-r
of ihc bl)ium. or an inf^nial hernia thvt lias de^^'cndtxt into the labium
najus.

A hernia >.iiu.-iie<l on the anterior or posterior wall of the vagina h incrcAied
in air and brcnmes more tense
apon enuring or sirainini;; it
illsa[ipi-ar* on prcMiure with a
ptrittiii}; sound; tt b soft sixl
di>aid>y to the much; and the
thickness of Ihe inters en in^
uruclurcs is found to be in-
cnsucd wlien a reiti>v^i|;inal or a
veituTa gina I e^intin^ttion is
made.

A rectoceic is aliraysdlualed
on the fxMterior wall »f the
nKix*; It is iiicmscd in size
aiul Lcnimes Icoie upon couKh-
ing or utrainini;; it diMiFtfteani
im preMure wiihuut a gurgling
•ound aad only the rectal un<l
raglrvi) wall* intervene twlwcen
ihr tin|;rf in (he nrr(um and the
thumb tTi ihi- s-.i^i'ia-

A ' i ' alw.iy^silunted on thi- :interiorwallof (he vagina; i( i^ incrcaMd

in d*> me^ ten^<- upon couj;;hin}; or straining; il di$a)>pear^ nn prr^^sure;

it t> tnLir aivl cb'iii when the bbdder is full; and only the vatnnal and bladder
walk inicrtvnc between the finger in the vagina aiu) a M>und in (he
bbddrr.

A tumor may be nil ua ted in any {Kirt of the vagina; there is no increase in&iie
awl leminn uptm (<>ughing nr straining; it iloc» n»l di«a[>pear on preMUre; and
b feh io the vaginal wall a» a drcumseribed trasi over which the mucous mem-
bnae iboMi (rvely.

A trytt of the vulmvuKinal gUnfl or a tumor of the bbium is circumsditie*! ;
it* vurtace i> umioilh and lirm; it i^ freely movable under (be overlying struc-
tures; it docs not disapjwar on pressure; :ind it is not incrcafcd in Muand

«k>n upon coughing or >initniiig.

inguinal hrmia which has descended in(<> the labium can alwa)** lie
nl fmm a vsiginal emeroccle by watching the direction (hat the in-
< when ibc ru|fturo is reduced.

h'lr.. lA).— Vkum ilniiu (paff i*^
Sbcwint * bud nlAct riot ihhu)' uamdlkw <kc liwn

364

THE VACWA.

Prognosis.— There is but little danger of strangulation, on account of the

character of the false passage through which the intestine descends, unless the
gut becomes pinched during a protracted labor.

Treatment. — The reduction of the hernia is easily accomplisfaed, after
emptying the bladder and rectum, by placing the patient in the knee-chest positioii
and making steady pressure upon the tumor until the contents of the sac slip
back into the abdominal cavity. The hernia is then controlled by introducing

Fig. 164.— iHSiBUHEtm Uud in the Ohutiom n» VAGtHU HuHU.

,f- tn

^'^^

5 L^ -J

?i^C2

1- =; Lu

zWo!^

— z

FtC. J65. — N'tHDLtS, SiTTUlE MaIEIULS, ANn INTESTINAL INSTRUMENTS UsED IK THE OpKIATlDlf FOE

\'aoinal Her ma.

into (he \'af;ina a hard-rubber ring pessary large enough to distend the canal and
obliterate (he false passage (Fig. 263).

After Ihe reduction of a hernia, if the woman k in lakior, the pelvis should
be kept elevated until the child's head passes the superior strait, by placing a
pillow under the hijis.

The use of pessaries in the treatment of vaginal enlerocele is unsatisfactory,
because the benefit derived is only temporary, and in the end they increase the

IDJINIA.

J65

tniulilc by still tunher stmchin}; tl>e parts and IcfMninf! the Mrength nf the

tiMUC*.

Radical Cure,— The operation for the cure of a vaKuial hemin niiultu In
ojirniiiK (be alidumen fn>m abo\« anil ('l<>i.inK the fnl^e puMage with ^ilk ^»iurc».
It i^ nlMayd nctTvar}' in repair the pcrinrum if il i^ laccfnlrd :md |*crforni an
anirrior and [Husterior (x>lpf>rThaph)' if a cyslocfle i»r recioivle is (>ri-scni. If the
Ulenu U ^cl^Hlt^|l^(-ell <>r proUpNed, a v-entrnl .-tUAiienMon or Axation sboulil be
performed at the same time.

posterior H c r n ia.^/'wAmV «/ the Operafion.—The Prr^arolioH
»} tht I'alienl and ibe I'fffitirtiliom {or rtc Oftralioit are dcscril>ed on [lagcs
8.M owl »J7-

Potilion 0} Iht Pnlirnt. — Trendelenlmrs.

Numbtr of Atsinl-tHli. — An iincftbclixer. one a^Mstant. and a general nurse.

/lulruMnt/i.— {1) Scaliwl; (1) straif;ht scissors; (j) three short hcmosiniic
foft-ep*: (4) iRo |i>ng'blafle<l bemi'static forceps; (5) Ashdm's >cl(-reiiiimn);
abdominal reUacturs; (b) abdominal rrlrarton; (7) dressing forceps; (8) iwo
bulkl (orce)H; (0) ml t<H>Th tk'^uc force|>s; (10) needle- bolder; (11) two »mall
full mr^wl Hagetlom nc^-dic^: (i') Ihrec long, MmiKhl, trinnjiular-pointed
ncnllrs: (13) braided nlk. Nos. a, 7, and 11: (14) plain oiniol catKiil. N". 1,
four i-nvrlri)>e>; (15) Mlkwnrm-Rul— 1^ stninds; (iA> intestinal in.-<t rumen ts and
needles- -Mur|>hv's button; nnaslomosiK fiircejis; ilamps; two straight and Iwo
Rir«Til intestinal netxilcs.

Pw MA.— Onaatwni rva Vmou BuwA-nm Step.

'Ofitriiliint.—FitiST Step.— After ojwninc (he abdomen ihe fundus of the
utent« i' •K-ir.eti with Imllct (ora-]io and pulleil upwiinl into the uUlominal in-
d*i>in.

A cartful inMtettion b then mark of Dnufi^las'!) nildesac in determine (he
iwnence nf adhr-iionii and .i-uerl^iiii hi<n* [.ir lb<- |>eH|oneum t\i\n down lieiween the
vatcir-a awl reitum. II ihi- Inle^lincs .ire ndherent U> thi- »ac. ibt-y are carefully
separated and .dIoM-cd to drop Ixick into the |ieril<>T>rul i-a\iiy.

St<x>s't> STKf -'I*he sac U pulled out "I the lal.-e lanal. >cucd with
hmfibLulnl bemttftAtic f<iriT|)s, and tifihily iwisted u)>on itwif. The snr Lc then
lipiird wiib a ollk bgalure (No. 12} and ibe re<lundanl |ionton cut oS (Figs,
.-ft; and j(tS).

li ' rnnniit be jtulleil out of the false nnal cm account of adhesions,

the hi-utd be tkKol with intrrrupied ^Ik Kilurr» (No. 7) at the normal

level of Ltfuglas's culdesar (Fig. 2b^).

:>66

THE VAGINA.

Fid. i67.~8econd SWp. Fio, i6S,~-Sacond SUp.

Operation roi Vagisal HfitNiA (pAge i6s\

Fir. 160 — OpuAnoK fo> Vaginal Hmnia— SbcooiI Sup.
ShowA Lhi- ^uILird in jAact fur riming Ihr falv fr^KDat Cpatf« j6s).

.■\nterior Hernia.— The lechnic is the same as described in the

ojwralion for a pusterior hernia.

VAGINITIS.

Definition. — An inflammation nf ihe mucous membrane of the vaginal
canal.

Etiology. — The invesii^ations of Doiierlein and J. Whitridge Williams show

thai the normal secretions of the vagina rapidly destroy morbid bacteria and
that they must first become abnormal in character before they can act as a
cidture-medium. It natundly follows, therefore, that any local or general con-
dition which changes the nature nf these secretions is a predisfwsing cause of
vasiniti'i, and that the entrance of pathogenic germs alone or the action of irri-
tants is not sufficient to inflame the mucous membrane. Thus, when the uterine
discharges are increased in amount or altered in character by disease or during
pregnancy, child-bed, or menstruation, the vaginal secretions are at once modi-

SIUPLB VACINtnS.

96?

fied anrf form a good medium for the dcvxiopmcnl of baatria. AKain, th« same
a>n(!iti»n> occur whc» iIk uterine ;inil vaKiii4l $«:retion» aivumuUte in the
npn^i (n>m wsint of ckiinUncss after un >>))rnitiiin, or when a iin^san' is worn
or when a foreifrn bMl)*, such as a tampon, hus bvcn forKolten and left loo lung
in laMJtion. And, finultv, while (he hymen under tirdiiiar}' cimimM.mi'e* act»
U a KuanI nifaiiM the enlnina- of grrmis il mny at times predispose In vaginitis,
opn.'inll)' i( its o|)cninft b small, by rclaininj; the <l{schur^es. which etTnlually
beoimc infef:le<) (mm mast url 1.1 lion or handling (he parts. Acute ^-aginilis has
iiflcn l>«rn traced to this cause in vounK children. " Irritation" factonlinj; to
IV>zu> "it. niA, a> held liy tlie okk-r authors, a >ufBricnl C3u.%r. Burninj^ with the
m! h->1 ir»n and (he aclion of causti<~? will cause hut a local legion, an ulcer
without siirroundinR in tlj in mat ion. if injeclion^ l)c employed which prevent Ihe
art-umubliiin of .■^crelionit, while the sime k^ion, or ihe pri>eiitr of a forci^
boiJy otherwise a^ptic, such as a |>cssary, will dc^'elop an intense vaftinitis if
with nrKlert of cleanlinesis «rc have the coiiditioib which fa\'or the dev«lo]>i]Kni
ol the micmbcs."

The situation of ihc vagina rcmlcrs it liable to ailaclci of inflammation
tlirvuRh the entnin<« of |ialho|cenic microbe* fn^m the ulcru*. the vuha, .ind the
ttrtlhra, and the part the orjican plays in sexual iniercour?« and labor exposes
ll 111 specific aiKl septic infections. Tlie mtittu^iion anil hypersecretion of men-
«iniati(>n and prejtniino' arc alM> im]ior(ant pri.ili*[>osinK (•ic(or'. and. I'lnally,
traumatisms may ex;poM' ihe vagina to infection from outside inllucnces.

Vapnitis may lie a primary or xftoHdnry condition; the former occurs En-
frw|ucntly compared with tboM; infections which have their origin in neii^boring
cans.
Varieties. — The diiwase present itself under llic following form^:

Simple vaginitis;

Gonorrheal vnginilLi;

GninuUr vaginitis;

Senile vaginitis;

£mt)hy»emalout viiginilis.

Sl»C?LE X'AGINtTIS.

inition*— A nun-s{*i'dric inllammation of the vaginal mucous mcm-
'ili.ir.iui-rijted liy n freedi.-<char>,-e.

Tarleties. —I'he disease may l>c atnte or chronU and also primary or
ucondary. Ihe acute lygw is comjara lively r.ire, while the chronic form is
frequent. The affeciion may begin a^ un ncute amdition and gnidually panA
InKi the chronic stage, but generally, however, il slaris as a subacute inllammation
without nurkc<l locil symptoms and with no consiltutional reaction, The
prifnar>- variety is iu>t often met wilh, a" (he iliNcaM in motft c»M* it wcondac)'
to an infection l)ei!inning in u neighljoring orgjn.

CaoseB.— The Primary Variety may arite from any of the folktwiag

Foreign l>><lies, such as jKasaries, tam)mns, etc.

Ket.iine<l di.Mhareo' fmm a want of rleanlineM after an u{)eralion, the

presence of the hymcD, and vaginal tumors;
Rccto^-aginal ami vesicovaginal fiatulas;
Irritation fn>m excessive venci)-;
~ !(.liun from coitus or tnasturbatioo:
to e(>ld ;
'Congestion awl hj-peisecretion due to organic disease of the heart,
liter, or ki'tney>;alMlominal tumors: pregnaiKyandmenstrualiun;

368 THE VAGINA.

Labor and child-bed;

Seat- worms ;

Gaping of the i-ulvovaginal orifice;

Caustic applications;

General diseases, such as chlorosis, anemia, debility, tuberculoss,
constipation, and the exanthemata.
The Secondary Variety is due to the following pathologic conditions:

Uterine dischai^es (chief cause);

Inflammation of the vulva;

Infection of the kidneys, bladder, and urethra.
Subjective Symptoms.— Acute Variety.— The patient complains of i
feeling of heat and pain in the vagina, ful]nes.s in the pelvis, a throbbing seDsalion
in the perineum, an<l backache. All of these sj-mptoms are exaggerated by any
form of bodily exertion. There is usually a slight elevation of the temperature
accompanied by more or less gastric disturbance and nervous irritability. At
first the normal secretion of the vagina is lessened or suppressed, but in twenty-
four to forty-eight hours it makes its appearance again as a thin, white, mucoid
discharge, which soon becomes mucopurulent or purulent in character, and
has a yellow or greenish -yellow color and a thick cream-like consistency.
The discharge is usually profuse and offeniiive, and at times so irritating to the
external organs that it causes an intense vulvar pruritus, which still further adds
to the discomfort of the patient.

The severity of the local and general symptoms depends entirely upon the
intensity of the infkmmation. If menstruation occurs during an acute attack of
vaginitis, all the local symptoms become more pronounced for the time being.

In simple vaginitis, unlike the gonorrheal form of
the disease, the urethra is seldom involved, and con-
sequently there is no pain on urinating.

Chronic Variety. — The chronic type of the disease is characterized by >
vaginal discharge, more or loss tenderness of the vagina, a slight sensation of
fullness in the pelvis, and pruritus \Tilva;. The general health may be afiected
by the drain upon the system from the leukorrhea and the distress and loss of
sleep caused by the vulvar itching. In exaggerated forms of the affection neu-
rasthenia is apt to develop as the result of general debility and mental worry over
the local condition. The severity of the local and general symptoms depends
upon the extent of the inflammation and the quantity and character of the dis-
chai^e. In a large number of instances leukorrhea is the only symptom com-
plained of by the patient, and, as a rule, the general health is more or less
affected.

Objective Symptoms.— Acute Variety.— The mucous membrane is
red. swollen, and hoi, and more or less tender to the touch. The surface of the
vagina is sm(M)th and in the beginning of the attack the normaP secretion is
lessened or absent altogether, but in twenty-four to forty-eight hours a thin,
white, mucoid di.'icharge appears, «hich rapidly becomes mucopurulent and
finally purulent in character. The vaginal mucous membrane and the external
organs are bathed in the discharge, which becomes foul and very offensive unless
the parts are kept carefully cleansed. The entire surface of the vagina is not
involved, as a rule, and patches of inflammation separated from eac£ other by
healthy tissue ma>' be seen scattered over the vaginal mucosa. In some cases,
however, the inflammation is general and the entire surface is affected. This is
likely to occur when the disease is due to the exanthemata or is caused by a
cxirrosive injection. As the disease progresses the infection spreads to the ex-
ternal organs and symptoms of acute vulvitis present themselves.

SIllPLe VAGINITIS.

169

1n0hi

Qtrooic Variety. — All th« ^iRit.> of acute inflammation are absent. Tiie
pte i« no longer tcndiT to the touch and a t hitrough :n»{KCtion of the vagiiia
■uybe iKid« throuRti a speculum without causing any discomfort lo the i)uticm.
Ibanionis membnine b dark nH i>r blubh in cnlor; it h more or le»s ihick-
ti0l;and patches of erosion may be seen here and there in bad t.i-»c*. Tlw; dis-
ikHp if thinner utid te-v> purulent than in ihr acute stage, and as the disease
more aiwJ more chn)nir the inflammitlion gradually relreal.'s to the
I culdesac or t'aull. where it remains in a latent ^tnle for .in In'lefinite
I of lime, twcomiii};, howtwr, sontewhal active again during menstruation
ud {fepunc)-,

M^gOOSiS. ^Thc patient is placed in ihe knee-chest position and the
neu cxjHiscd with a Simon's n))CL'utuni. The enlire canal is then carefully Jn-
Sftatd anl the condition of ihc mucous membrane noted.

; a atires6Ary lo ckterminc whether the disease is a primary or seccfuiary

lion, becaux no treatment ivill \x succetisful nhich is applied lo the vagina

! incises in which ihc affection hns it< origin in a neiKhlHinng or^an .tnd

Am it a wnlinuU reinfection of the rajrinal mucous membrane taking place.

HUle the discharge is a i>n)minenl symptom of vagimlis, il must not 1>e

en that a profuse mucopurulenl or purulent lcuki>rrhe;i tn.iy escape from

pna without ihc mucous membrane licing inflamed, and that, under these

ORUiiBtancics, the >'3^in:il canal U simjUy a driiina^cetulw for the exit of pus

■UA any coux from a pcKic abscess that has ruptured into the v.igina or from

ihc uterine cavity.

DUSerentlal DlagnoelS.— The differentiation IwtM-ecn the primary »ni\
»Miarj varieties is usually not difficuJt. The former is comparatively rare.
Atlidnr^' of the ca)« and tlie ciiu.se are, a« a nile, clear and defnuie, and ihe
ioluninaiion bc^ns acutely. The latter variety, on ihc otlier hand, i:? more
hqixnt, the historv' is unsatlsf acton.', the dLaease usually begins as a sul>acutc
vtknmic nmiiilion, anil ihc «iu.->e is traceable to a septic dischar}^ from one
*f Ike Dci^hbnring organs.
Simple v.i^initi\ mu>l lie dliitinfiuLshed from:
Gonorrheal ("aginilis.

[>i-^thari;e' from the uterus or a pelvic abscess.
Gonorrheal VaginUb.— Tlie hislory of ihe «« is significant. The disease
b^u aoilely. ihcre may be a hislory of a suspicious intercourse, and the sub-
Jecdre and objeciiw sjroptoms are more intense than in the simple variety. The
iiftiminaliun i» violent, the discharge is pmfui^e and purulent, the urethrn is In-
volved, which b not the case in the non-specific form, and there is a marked
toAtaCf for the disease lo sprejid lo neighlmriiig orxan-'^. \'ulviii.s is a con.stani
omqiBation, aiul the %-uK'ovaginal glands are. as a rule, infected. The Jnl^am-
■ntiMi also spreads upuard and involves the uterus and Ihc oviducts, and
agrnploiitt of grax-e [lel^ic dtvase may manifest ihem.setvts. ir>|ihthalmia or
niinik developing in other members of the family is a strong point of e^i^lence
in la^iT of ihe gonorrheal origin of the infection. It must, however, be rcniem-
bend thai rase* "f simple «giniiis are amtaglous when the <lischarge is profuse
and purulent and proper precautions arc not taken to prevent infection. The
diflcrmtiaiion l>etween the simple atut specific forms of v-aginitls in joung
diildreii is iixr)- impnruini from a medico'legal i>oint of ww. The traumatic
evidence* of rape, if they are present, will indicate the possible existence of

fyJUWllMI.

The positive proof of the specific nature of the disease L* the presence of
pmococci, and the discharges from the uterus, vagina, urethra, aitd vulva sliould
dienrforr be examined mirm»copicaUy.

a 68 THE VAGINA.

Labor and child -bed;

Seat -worms ;

Gaping of the vulvovaginal orifice;

Caustic applications;

General diseases, such as chlorosis, anemia, debility, tuberculosis,
constipation, and the exanthemata.
The Secondary Variety is due to the following pathologic conditions:

Uterine discharges (chief cause) ;

Inflammation of the \nilva;

Infection of the kidneys, bladder, and urethra.
Subjective Symptoms. — Acute Variety. — The patient complains of a
feelint; of heat and pain in the vagina, fullness in the pelvis, a throbbing sensation
in the perineum, an<l backache. All of these symptoms are exaggerated by any
form of bodily exertion. There is usually a slight elevation of the temperature
accompanied by more or less gastric disturbance and nervous irritability. At
first the normal .secretion of the vagina is lessened or suppressed, but in twenty-
four to forty-eight hours it makes its appearance again as a thin, white, mucoid
discharge, which soon becomes mucopurulent or purulent in character, and
has a yellow or greenish -yellow color and a thick cream-like consistent}'.
The discharge is usually profuse and offensive, and at times so irritating to the
external organs that it causes an intense vulvar pruritus, which still further adds
to the discomfort of the patient.

The severity of the local and general symptoms depends entirely upon the
intensity of the inflammation. If menstruation occurs during an acute attack of
vaginitis, all the local symptoms become more pronounced for the time being.

In simple vaginitis, unlike the gonorrheal form of
the disease, the urethra is seldom involved, and con-
sequently there is no pain on urinating.

Chronic Variety. — The chronic tyjw of the disease is characterized by a
vaginal discharge, more or less tenderness of the vagina, a slight sensation of
fullness in the pehis, and pruritus vulva;. The general health may be affected
by the drain upon the system from the leukorrhea and the distress and loss of
sleep caused by ihc vulvar itching. In exaggerated forms of the affection neu-
rasthenia is apt to develop as the result of general debility and mental wony over
the local condition. The severity of the local and general symptoms depends
uiKin the extent of the inflammation and the quantity and character of the dis-
charge. In a large number of instances leukorrhea is the only symptom com-
plained of by the patient, and, as a rule, the general health is more or less
affected.

Objective Symptoms. — Acute Variety. — The mucous membrane is
red, swollen, and hot, and more or less lender to the touch. The surface of the
vagina is smooth and in the beginning of the attack the norma P secretion is
lessened or absent almgethcr, but in iwenty-four to forty-eight hours a thin,
white, mucoid discharge a[)pcars, which rapidly becomes mucopurulent and
linaily purulent in character. The \'aginal mucous membrane and the external
organs are bathed in the discharge, which becomes foul and very offensive unless
the pans arc kept carefully cleansed. The entire surface of the vagina is not
involved, as a rule, and yialches of inflammation separated from each other by
healthy tissue may be seen scattered over the vaginal mucosa. In some cases,
however, the inflammation is general and the entire surface is affected. This is
iikely to occur when the disease is due to the e.vanthemala or is caused by a
corrosive injection. As the disease progresses the infection spreads to the ex-
ternal organs and symptoms of acute \Tj|vilis present themselves.

SIUPLE VAUtNtTIS.

J69

Chronic Variety.— All the Ngns of acute inllammatinn arc absent. The
(nni are mi l<«igcr lender to ihc Much and a ihorouKh insiwciion of the vagina
may \k made thruuKl) u x|>eojlum without rau->ini: any dUcomfon 10 the pulieni.
Tilt mutxnis rm-mbninr h durk n-d «r hluUli in cnU^; it i» more or less thick-
rnni ; aini [wuhes of erosion may l>c *«■« here and there in bad toMs. The dU-
I hiiri^ i> thinner aixl let'* fmrulcnt than in the ai'ute Makit, and a.i ibe d»ea«e
ticii>me!> morv and more chronic the intla mmalion |!radujl)y rctrral« l« the
I'nKinal >.ukl<>:ii' or tault. where it remains in a latent ^tate fur an inilefmitc
Irngih (if lime, liecomin);. huwever, M>men*hat acti\v again during nwn»tniatiun
awl (irrKti.in;!'.

DlngnOBis. — The |iatient i> pbixil in tUi- Icnveclii-st tH>silM>n aivl ihc
\-a|!in:t i-\("'m-i| with a Sinmn's siwculiim. The entire canal is then carefully in-
^(letied and the condition of the niua'iK membrane noted.

It i» necemar}' to determine whether the di.<eiu>e is 11 primary or seeondary
CDoditidn, iKTcnUM; no ln.Mtmcnt M-ill \k successful which is up[>l)C(l to the va^ru
Bk>ne in ia?«es in which the affection has its origin in a neightiorini; nrfpn and
there t> a ccmtinual reinfection of tlie va|:ina1 mtKt>us mcmlirane taking place.

\V'bile the dischar^ is a |ir<iminent sym|ilom of t-a);initi», it must not be
fiiripilleti that 11 profuse mucopurukm or purulent leukorrbea may fsi-.i[»e fmm
ihr t'JKitu withiHil the mii(.iiu--> memtinine t)eiiie inlLimed. and that, under tliev.'
dreumslanies. the vaginal canal is simply a drainagC'tutie for the eiii of pus
whii h nMi' come fmm u jmMc aljMrehs thai lias ruptured into tlie vnitina tn fmm
the utcriue ciivhy.

Differential Diagnosis.— The differentiation between the primary »wl
tn'ondiiry varklicA i> ll^ually not dilVicult. Tlie former i^ cumfxinitiivly rare,
llie hLMiiry of the case unci (he cause are, .is a rule, clear ami definite, and the
inflamnution lieK''^'' acutely. The latter viinely, on the other hunri, i* more
trtrquent. the hiMor> is un^atisf actor)', the diseasi- usually beinns as u subacute
or dimnic utiMliiion, and the cuum fe traceable to a septic diKhufRC from one
111 (he nrijthlfoririK otgiinn.

Simple v.iginitis must be distinguished from:
Cfonorrhea) v-apnili^.
Uinli^irKr^ (rum the uterus or a peUHc abscess.

Gonorrheal Vaginitis. —The history of the case is sixniflcant. The disease
faciplM anitety. there may l>c a history of a su^pii-iou." intcn-mirM:. ami the stib-
|ecli>r and objective symptoms arc nwwe intense than in the simple variety. The
Intbinmntion is vtolcni, the discharj^e is profuse and purulent, the urethra b in-
«iilve<l, which is not tite rase in the n»n-«[>ei'iric form, and there is a marked
tendency' for the di<e3i>e to spread to ncighbcirint; organs. Vulvitis is a constant
compUoUion, and the vulNvtvai^inal Rbnds are, a« a rule, infected. The inliam-
nuttioo nbo >|>md<> upwarri and int'ohe^ the uleru< and the onducts, and
fTaiptoms of grave jielvic di.'ea^e may m.inifesi themselves. Ophthalmia or
nilnti* doTkiping in oilier memlter^ of the family i> a stmn); jioint of evirU-nce
In faiiir of the ipmorrhril origin of the infection. It must. howx\Tr, be remem-
bereil that cases of simple vaginitis are contagious when the disdiurge is profuse
wA purulent aiwl profxr precautions are ni>l taken to prevent infection. The
diflcrrntialiun bctMTcn the simple and specitic forms of vaginitis in young
ditliirrn » very imi>ortanl fmm a medico le^ral point of view. The tnumalic
vvidcsoe* o( rape, if they arc present, will indicate the poMible ext»ieiK« of

T'" ''I- jwixif of tlve siiecifo- nature of the rlisease 'v ihe presence of

tpmx the di^rtUlrgeA fmm the uterus, vagina, urethra, aitd \ulva dwuM

lltttvture be cxiimined mieroscopii'ally.

2-JO THE VAGINA.

Discharges from the Uterus or a Pelvic Abscess. — A speculum ezam-
ination reveals the origin of the discharge and an absence of the objcctin

symptoms of vaginitis.

ProgmosiS. — The acute variety responds readily to treatment and lasts
about two or three weeks; the chronic form is difficult to cure and often lasts for
an indefinite length of time without any other symptom than the discharge.
The disease does not, as a rule, spread to neighboring organs, and the general
health does not suffer except in chronic cases in which the discharge is profuse
and the constant drain upon the system causes debility and loss of nervous
eneigy. The possible infection of the uterine cavity and the subsequent extension
of the inflammation to the oviducts must always he home in mind in considering
the results and treatment of vaginitis. The prognosis of secondary vaginitis de-
pends upon the situation of the primary infection.

Treatment.— The treatment is diWded into (i) the removal of the cause
ami (3) the treatment of the disease.

Removal of the Cause. — \M)enever possible, the cause of the inflamnnation
must be removed (see etiology of primary and secondary vaginitis).

Treatment of the Disease. — In the acute form the disease is treated as
follows:

Rest. — Absolute rest in bed for one or two weeks is essential even in mild
cases.

^owe/j.^ Salines should be freely used in the early stages (the first three or
four daj-s), and later on a simple la."tative with an occasional dose of salts are all
that will be required.

Diel.^-The diet should be regulated as follows: During the fii^t week liquid
diet (see p. 106); then soft diet (see p. iti) until the patient gets out of bed;
and, finally, a convalescent diet (see p. 114), followed by the gradual return lo
ordinar>' articles of food.

Pain. — Opium should be administered whenever the pain is severe, and it
should be given hyj)odermicalh- rather than by suppositories, as the latter
method may spread the infection to the rectum.

Clenii/iness ami Local Meificalion. — The cure of the affection depends upon
prompt local treatment. As the inflammation is always due to infection, the ob-
ject of the trealmenl is to destroy and remove the pathogenic microbes which
are responsible for the disease. This is accomplished by the use of cleansing
and antiseptic douches, which are given three times a day (morning, noon, and
night). A gallon of corrosive sublimate solution (i to 2000) is injected into the
vagina and followed by a quart of normal salt solution. A cotton-wool tampon
is then saturated with an aqueous solution of argyrol (25 per cent.) and placed
in the vagina. After the patient gets out of bed the douches are given twice a
day (night and morning) and an argyrol tampon placed in the vagina at bedtime.
The treatment is discontinued when all signs of inflammation have disappeared
and a douche of at least a gallon of hot normal salt solution given night and
morning for several weeks.

Variations in the Treatment . — The use of hot alkaline or
emollient silz-baihs (sec p. 213) will be found very beneficial where pain and
pelvic distress are prominent symptoms. The baths are employed once or
twice a day according to the indications.

In rare instances an abscess may form in the vaginal wall {phiegmonous
vai;ini/is) during an acuie attack of inflammation. The treatment consists in
evacuating the pus by a free incision, irrigating the abscess cavity with a solution
of corrosive sublimate (i to 2000), and packing it with gauze.

COKOBSBEAl. VACtyms.

•71

Id the chronic form ihc Hiwose fe tTcated u follows:
Jttst.—The patient should n'>t be ronlincd (o thr hiiuc«, bui should be en-
reowngctl lo take plenty of exercise in t)ie u^xn air and sun»)iinc.

Btnttlt. — Any tci><lcT>cj' to (i>n»tiiKiti«n should l»e corrected by the u« of a
mild hxative and the occasional administration of a ^Unc.
Dia. — An easily (tinted and nourUhinx diet is indicated.
CUanJiness owrf LtKtil MtJirnlion. — The vagina is dnuchcd nij;ht and morning
whh a pillonof corrosiw sublimate solution {i to jooo). followed by a quart of
■line tohition, and a anginal tam)Hin siturated with ^n ^quc<)U« si>luli<in of
Ewgyiol (95 per cent.) is introduced at bedtime. The trcaimenl is continued for
[one week and then antriniteni injections arc su Instituted for the corrusiv'c .^ublimate
rsohition itnd the arg\'rol t.-im|K>nK. '['hn,' nrr gi^vn night ami morning immedi-
ately foltovfing a douche of n0rm.1l sail solution. The best aMrinRcnls to emjiloy
are boric »(iil (nalurstted Milution) and «.ul|>hate of n]ijKt (gx. iij to f^j). or rinc
{gl. iij to fSj). Ai the end of two or three weeks if the dif'chargc and intlamma-
lion still continue, the \'a^ina is exposed with a spet-ulum and painted u ith a
solution of nitrate of kUvct (gr. xxx to f^j). The pntient iw placed in the knec-
tfaefl posture and Simon's speculum introduced into the vagina, which is thor-
[oitichly cleansed by swabbing it out with pledgets of cotton s<iturate<l with hot
It i» then dried with absorbent n>iitin and the entire mucou!^ membraoe
led wiih the sohition of nitrate of silver. The vaj-ina ts then loosely
rpneked with iodoform gauze and a compma and T-lKinilage appli^l. 'llie
! tiivn i» reapplied even' four or fi\T days for three weck», and in the meantime
a Insh tampon is inM^rtcd e\'cry twcnly-fcur houK after irrigating the vagina
with a |pilk>n of belt wiiter. Tlie jKilient ^hould be placed in the dorul position
taad Simon's speculum introduced when the daily change of dressings is
[oHule. After ine ntlraie of silver anri tumpun ire«1ment has been carried out
{tor some time, the patient should uw an injection night and morning of a
quart of creoUn or tysol sotulion (i per cent.) for several months.

Variations in the Treatment. — Mtringcnt powders arc often
UMnl with good results in place o! the injections recommended in the routine
I treatment. The Ite^l pre{)uralions are boiit aiid, Mibmiratc «i bi>muth, oxid of
olomcl. or tiinnin, alone or in combin.itinn. The proper method of
ipptyfnx the powder is to place the patient in the dorsal posture and iniro-
rduee ^invon';! Njieculum. The vagina a then douched with a gallon of hot
normal mU solution, dried with pled^s nf cclton, and a half an ounce of the
powder [ibced in tlie vaginal vault. A cotton-w-oul tamfmn is then inuried into
ibc vagina and (HL-Jied well up into the cultlrsnc lo keep (he powder in position.
Tbls Ireatntent >s continued daily for two nr three weeks.

As patients often object to the odor of iodoform, it ts ne<eMary to employ
[iKxnc o«hw remedy to .ipply on ihc i»m)H<n which if uwd in the nitrate nf silver
' of the treatment, and under these circumstances boroglycerid or carbolated
Un <,i per cent.) n a gix^il ^utntituie and should tie u>ed on n CDllon<WOol
impoa. Enmions arc treated by occannnally touching them with the solid
tatkk of niuate of rilvcr or painting them with a sohilion of the salt (gr. xxx to fJJ),

GON'ODBIIEAL VAGINITIS.

Definition.—.^ t>pecific in&imniatkm of the vagina caused by the gono-
f-eocru*.

Tarictiee. — The tlt^ease may be acuir or thronU. and abo primary or

it€»nd<try. The ainite form is rare, while the chronic type i» more or fcss com-

Tbc dbcaee may begin as an acute condition and gradually pass into the

272 THE VAGINA,

chronic stage, but generally, however, it starts as a subacute inflammation without
marked local signs. The primary variety is rare in the adult owing to the resisting
power of the vaginal epithelium and to the " phagocytic action of the add-forming
bacillus of the vagina" (Doderlein). In children, however, the mucous mem
brane has not the same power of preventing the in%'asion of microbes, and con-
sequently the disease is comparatively Irequent. Gonorrhea of the
vagina is usually secondary to an infection beginning
elsewhere. It starts most frequently in the urethra, next in the cerivcal
canal, and lastly in the \-ulva, and from any one of these situations the disease
gradually sjireads to the vaginal mucous membrane.

Sulljective Symptoms.— Acute Variety. — The symptoms are the same
as in acute simple vaginitis except that they are more intense. It must also be
borne in mind diat other organs are usually involved along with the vagina, and
thai symptoms of urethritis, endometritis, and vulvitis are added to those de-
pendent upon the vaginitis.

Cbronic Variety. — The symptoms are the same as in chronic simple vaginitis
except that acute exacerbations are more likely to occur during menstruation,
pregnancy, and the puerperal state,

OlliJective Symptoms. — Acute Variety,— The symptoms are the same
as in acute simple vaginitis except that the local signs of urethritis, endometritis,
and vulvitis are added. As in the non-specific variety, the inflammation may
Involve the entire surface of the vagina or it may occur in patches separated
from each other by healthy mucous membrane. When the infection starts in
the urethra or vulva, the lower part of the vagina is usually affected; but when
the disease l>cgins in the cervical canal, the inflammation is generally limited
to the posterior vaginal culdesac.

Cbronic Variety. — The symptoms are the same as in chronic simple vagin-
itis except that the diseas^e has a stronger tendency to become latent.

Diagnosis.— Differential Dla^osis.— See simple vaginitis, page 269.

Prog:nosiS. — The prognosis must always be guarded on account of the ten-
denc)- (if the infection to spread and become latent. The course of the inflam-
mation is also influenced by the variety of the disease and the promptness with
which the treatment is instituted. An acute primary infection which is at once
place<l under treatment is usually cured in from two to three weeks without
in\olvinK any of the ncighljoring organs. But, unfortunately, in the chronic
form the uterus is usually infected before the patient seeks relief, as the vaginal
symptoms are, as a rule, so insignificant that they cause but little or no incon-
venience. The pRignosis in cases of secondarj- infection depends upon the
situation and extent of the primary involvement.

Treatment. — The treatment is the same as in simple vaginitis (see page

The patient should not be pronounced cured until the gonococd are shown
to be absent by repeated microscopic and hacteriologic examinations of the
discharge.

Granular Vaginitis.

Synonym. ^Papillar>' vaginitis.

Description.— This is the most frequent form of vaginitis. As the result
of inilammation or tongeslion the papillae of the vagina become infiltrated and
the mucous membrane assumes a granular appearance. The granulations are
hemispheric in shape, small in size, and are profusely scattered over the mucosa
of the vagina and cenix, and in rare instances they extend also to the raucous
membrane of the external organs of generation.

SKNILE VAtilKTTIS.

'73

CaueeB. — The alTeciion may result from simple or gonorrheal raginttb
ami fti'in the «)nf;cstion fi( [ircgnniK'y.

8ytnptoni&. — Itiv suhjefthe tymplomt nn ukwiII)' Mibncutc in ch«nic1rr.
"Tht: vagina is K-ndcr, ihi-ii- t» ;■ (i-rlin^ tif fullness in ihc pclvb and a muco-
punilrni di^cbarge- Prurilus \uUa- U a more or leis constant symptom ud the
estrmul »f]gai» arc (x-ni'.iiiiully tin- lurJil »! un cojcmalnuji eruption.

The •Aj«'(nr symfilorHs ;trc i"hanmcri«:<l by the prcMflCc of &Ria)I (^nulaliona
■cattcrcd <nrt tlic \%txina und Uiv (-erviic.

Diagnosis. -The inticnt should he phiced in the knee-chest position and
the t aK>na) canal cx|»i«d with Simon*^ specuium. The presence of the Ktsniib-
tiofK ci>iihrm> ttic {tiaicnui^is.

Prognosis. —The divasr f^neralty yields readily to trcatmrnl. and when
the afTri-ti»ii i^ due to prcKnjmy it often »pi>niunei>u-->ly di^p|>cars at the end of

Treatment.- Rest.— HlhcdiscaseoccursduringprepiaiKy.ii isadvi-Ahle
for the |Mtirnt to j.vume the renimlieni {Hit<turc two or three limc> daily, for ten
%» lifteeii minutes, to relieve ihe pnrssure of the pregnant uterus on the [>clvic
(•ncinK. Onlinarily, however. ihU is not necessary, and the patient should be out
every day tn the «\iKn air and sunshine.

6owels.— The bowete should be ke|>t regular with a mild laxative and the
i>ct-a*iunal u^^* •>( a >aline.

Ditt.- .\n eiisily digested and nourishing diet should be gi^vn.

Cleanliness and Local He<itcation.— The vagina b douched once a day
with a K--1II011 of hut norniid s^ih Miltilion fullowe<l by lw<> {iuart> of corrvMiie
Kibiimate 1 1 to 4000), and a tampon of cottonwool, sjilunitd with an aquetius
volution o( arnyrol {j; per cent.), IwroKlyrerid, or Rlyccritc of tannic add (10 per
irnt.i, i* then iiiiriBhue-i ami ,ilIowe<l t<' rtmuin for twenty-four hours.

Variations in the Treatment.— In .-ometaiies it is necessary in addi-
tiiMi to the ulHive treatment to {):Linl the gr.tnublionv wilh nitrate of Mlver (ftr.
XXX 10 f^JI. and jomclimes good results arc alsji obtained by substituting df)'
Ulrinitenl tampon^ for the glycerin combinations (t4x varblions in the treat-
ment of *implc v.iginitis, p, 371). And. rinally, thedirca applinitionof sulphate
"( copficr (gr. xx-xxx 10 fSj) often ha^^lciis the disap[>ea ranee of the granula-
t)i>n* aixl rure* the di!«ai«.

Sf.'JitK V'AciNrns,

Synonym. —Adhesive raginitin.

liefinition.^An intl^mmaiion of the v.igina occurring in women who
have pti-'vd the mi^iM>pauM; whiih i> t'har;icteri.ced by ihc formation of adhe7>ioR.\.

Canses* -'Hie di<ease is due to the ;»ir>)phic changes of old age which
rcMili in defeuiive nutrition and Vva of epithcliun). Eventually those portioDs of
the muOTu* membrine which have had their rcsL>ling ]>o«er thus weakened or
destniyeil l*c(ome infe4:lcd and the local conditions (>eculiar to thiji form of
v»l^nitis manifeni them.^ehes. The disease ts essetktbiUy one of old age. and t1
(Ki ur> «i frei|iM-nlly that most women after sixty imller more or lev-, from it.

Symptoms. - The i nhjfdhr syfnptfmn are not in any way characteristic
and all the julient usually complain* of is a thin. >erou>. leukorrtieal dischai^
whirh is not pnttusf or constant and which is at limes streaked with blowl.
Ir -^si there may lie a Imrning sensation in the vagina, .1 feeling of weight

111 I via. and a di^irevsing irritation of the ciiternal organic nf genL-nilion.

Scnul intrrcourT* is tiihet impossible or very {uinful.

The ahjttlh'* symfiiomi, on the other hand, arc marked. The mucous
nemtifane b fouiul to Ik smooth, aiiuphied, and covered with n scanty »eroiu
til

374 THE VAGINA.

secretion, while various sized spots of ecchymosis and superficial ulceration ait
observed scattered over its surface. Adhesions resulting from contact between
the ulcerated surfaces are common, and in some cases the vaginal vault as veil
as other parts of the canal may be obliterated or greatly distorted.

Diagnosis.— The examination should be made with the patient in the
dorsal posture, and care must be exercised not to injure the parts during the
necessary manipulations. The adhesions can readily be detected with the Einger,
and it may not always be necessary to introduce a speculum, as the characterise
lesions of ecchymosis and ulceration can often be seen in the lower part of the
vagina by sep)arating the labia.

Prognosis. — When the adhesions are recent, they may sometimes be
separated and the normal shape of the canal restored; but unfortunately this
is generally impossible, and radical measures are therefore out of the question.
As the disease h caused by changes which are incident to old age, a pennanent
cure cannot be looked for in the majority of cases.

Treatment. — When the aSeciion is not accompanied by annoying symp-
toms, there are no indications for treatment, and the interests of the patient are
best subserved by doing nothing. If, however, the subjective symptoms are
marked, the indications arc to cure the ulcerations, to prevent adhesions, and
to allay the subacute infiammaton- condition which is present.

The treatment is purely local, as follows: The vagina is douched every twenty-
four hours with a gallon of hot normal salt solution and two quarts of corrosive
sublimate (i to 6000). The antiseptic is then washed out with a quart of the
salt solution and a cotton-wool tampon saturated with boroglycerid is intro-
duced into the vagina. The spots of superficial ulceration are painted with a
solution of nitrate of silver (gr. xxx to fgj) twice a week.

Variations in the Treatment. — Ointments spread upon a tampon and
applied to the vagina often give marked relief. Thus, good results have followed
the use of cold-cream or vaselin, alone or combined with equal parts of lanolin,
and benzoated oxid of zinc cinlnient. The efficacy of these preparations mav be
increased b>' the addition of 3 per cent, of carbolic acid. Warm injections of
creolin or lysol (i per rent.) are often grateful to the patient and soothing to the
vagina, and should he remembered as valuable adjuncts in the treatment.

The question of the management of adhesions may at times present itself.
In my judgment, old adhesions should be let alone unless they prevent the exit
of discharges. Recent cases, ho\ve\'er, arc readily bmken up with the fingers and
kept separated with a medicated tam|x>n until the raw surfaces heal.

Emphysf.matous Vaginitis.

Synonym. — Coipohyjieqilasiii cystica.

Definition. — An inllammation of the vagina which occurs chiefly ir
pregnant women and is characierize<l by the formation of small cv'sts filled will
gas.

Causes. — The affection usually occurs in pregnancy and it has also beei
observed in the non-prcgnanl slate.

Symptoms. — The suhfrrlh-e symptoms are not characteristic. The patien
complains of a >light leukorrhca and tenderness of the vagina to touch.

The objective signs are re;i(iilv recognized. The lesion consists of a numbe
of small cysts situated on an inflamed and somewhat swollen base. These lilt!
vesicles arc fdled with gas and colhtjise at once when they are punctured. The
may break spontaneously and leave a small sujicrficial ulcer, or they may grade
ally disappear by a proces.s of desquamation. They are usually seen in group

cvsrs.

'75

the Wol:

tn the upper pan of itic \-ainna. bul ihey may also at limes extend over the entire
^urlarr ')f the canal, and in Mimo uimm ct'cn the cervix if invnlt-ed.

Prognosis. —When ihr (iUcaw occurs durin)* prcpnaocy. it disappears
»pcini.imi'u.-.h uithin two or three months aitcr LiUir. Tlic {irogncKLJs in non-
pngrunt wonwn U k^kI, ^i" ill* diH-iisc yields readily lo ircolincnt.

TKatment.- -No ircatiucm is indicated when the affcition otcnrs during
pregnancy. In other ch.m;^ fi^md n:>ult* are olit.-iinod \>y giving a daily injection
ot B faUon of hot normal salt solution and tn-o quarts of corrosi^T sublimulc
(I to 4000). The antiseptic is then washed out with u quart of the ult solution
and a oitton-w-ool tampon nturaied with glycerilc of tannic add (30 per cent.)
ioiroduoed into the vagiiu.

Vihca ^uperflcial uloeratiofiH occur, they should be painted twke a week with
aJUaic of silver (gr. xxx to fjj).

CYSTS.

Ijjin.'ln the majority of insunccs cj'sis of the vauina are prolubly
iinic in ohKin and are caUMil liy die dirumulatiun »f tluid in the remaiiiN of
the \Vol(Kan canal or in lite duels of Gartner or MUllcr. According to tome
attlhoriiics, they may be retention cysts of the v-aginat glands. Poiii, howewr,
belicvM that thoe Klaiuli do i>»t cxL-tt, tHJt that "lhe>' may Ik .oimuUted by
cmA or faicunc n-hich, by obliteration of their orilices, may play the same
paibolutdc r6le." In some cases, as the result of traumat»m, a hematoma
urtrrt in thr vaginal wall which may l)ca>mn cnca{>sulatc«l and give nV to .1 blood-
c)it, or, if the vrum is not absorbed, a hygroma conlainini; a clear, serous lluid
drvek)[n. Af^in, vaginal c)'Ats may be due to dilatation of the lymjihatic vcs*
*eb; jind, finally. b<»th hydatid and dermoid OM* have been met in the vugina.
Vaginal (y^ts u-hujIIv occur tn the adult, but no age is exempt, and tlw)' have
been 'ily-arcfl in the ncw-lxim child.

Description.— W'hUe vaginal cj-sts arc not common, ibc>' are. however,

Be m('^l Iriqui-iu form of neupLtsm met in (hat situalioR, and, as a rule,

bey are linind in the anterior or posterior wall, althou^ in exceptional ca^s

bey may grow from iiiiy [tan of the canal. Ac<'or(iing to some obscr^-cri^, they are

[lund mnvt frc<(ui'nlly in the upftcr p<trt of the vagina, while oihery again arc of

DJon that the majority of cysts occur in the tower portion. Cj-sis of the

i>ccur '■ingly, a* a rule, but in ver^* rare in^^tancr* several may be found

in a row or in grimps. This is especially characteristic of cyt*. dc-

from the Wolihan canal. The growth of v.iginat cysts is very slow and

may lake year* li> develop, but ihcre arc, however. cxcc|«ion* t" thi\ rule, a*

. are occasionally met where the dcvelopmcnl is rapid. About one-half of all

miinal ty'l.'> .ire the siw of a pigeon'* cRR; the remainder vvin', however, between

' e«ircme hmits of a small pea and a ne^t'-lK>m child's head.

A vaginal cyst is rounl and circumscril^ed. but it may become pear-shaped

have a more or lew. di^linci |>cdicle. If the mucouf membniiw of the vagita

ryvrmal, it moves freely over the surface of the tumor: but if it l)ccomc« atro-

fnim dixicnlton »r pre^'nirc, or the cjM l>ccome» inflamed, adhesions ocrur

the mobilily of the mucosa is (lexlniycd. The wait <>f a large ryU are

lUy thin and almiBt transiKirciil. The foMs ami ruga? of the \-agina are

dtfffoyed, and the surface i-: smooth and shining from atrojihy and dLMrniion.

Tbtconirni^^of thecystrarj-in chaniclrr. although usually the liuid is clear, thin,

Uan^p(lre^l, atui of a light yellowbh hue. or it may be thick aivi tenacious.

i'oiriiirws it is tlnrk chxcoble in color fmm the pretence of dimrganited

j, or, again, it may cvniuin granular epithelium, pus, or fat cells and oyttals

»!e^erin

S76

THE VAGINA.

Symptoms. — The character of the symptoms depends upon the size and
situation of the cyst. A very small tumor usually causes no trouble, but vihen
it has attained a considerable size certain phenomena arise which result from its
presence. Thus, it may interfere with voiding urine by pressing upon the
urethra ; it may cause frequent urination by lessening the capacity of die bladder;
or it may deflect the stream of urine into the vagina. The pressure upton the
rectum causes constipation and hemorrhoids, and there is a feeling of weight or
dragging in the pelvis due to traction upon the upper part of the vagina. The
pelvic symptoms are all increased in severity when the woman strains or stands
erect. Again, the mechanic obstruction offered to the entrance of (he penis
makes sexual intercourse difficult or impossible. And, finally, it may act as an
obstacle in labor; it may cause leukorrhea or a profuse fetid discharge by irritate
ing the vagina or pre\'enting the free escape of the normal discharges; or it may
interfere with walking and sitting, especially when the growth protrudes beyond
the vaginal entnmce.

Diagnosis. — The diagnosis, as a rule, is not difficult, and is based upon the
situation of the tumor and iLs physical characteristics.

Ftc, 170. Flc. »7r.

F^R- 27D flhows a cyT^ in 1 he posterior wall of Ibc vagitid', Vit- '7' KbuwBa cyti in the onrrrior ««U of Ibc vifnu.

An cfTort must first be made to prove that the tumor grows from the vaginal
wall. This i.'; accomplished by grasping the enlargement with the fingers and
making traction uiwn it in various directions, when the sense of touch will at
once demonslriite lis connections. If the cyst is on the posterior wall, we must
also use the combined rectal and vaginal touch ; but if it is on the anterior wall,
a sound should be passetl inK) the bladder and counter -pressure made through
the viigina with the inde.i-finger of ihe left hand.

If the cviit is situated in the upper part of the vagina near the cervix, the
e^iamination must be made under an anesthetic and the tumor carefully palpated
between the index-finger of the left hand in the vagina and the fingers of the
right hand making counter-pressure downwan! through the abdominal wall just
above the symphysis pubis {vagino-ahdominal touch).

CTSTS.

a77

TV lumor is ien»e, ebsiic, and u»mllr cimimscribci). Fluctuation is
grncrnlly present in a lary;c c^-st and may he dcmonMratcd by gruspin); the lumor
bctwv«D \bc thumb and tb« index an<I middle Aiifceni nr by rvctovuginal and
vaginn-aliddminal tinich. Tl»c ^aRinal mun*us membrane moves freely owr
the ntriacr of the cyst unlcM it is adhcrcni from overdistention or inflammiktion.
The VBf^nal mucosa U normal in »mall cysu, but in i.-irgi: <>nc!' it is smonth and
shinini;, without foldi^ or rugr.and of a darker color than the eurroundinf: ti&&ui;!i.
The size <>f the lumiT i* nol affected by bearinic-doun or the (lusiiion nf the
patient, .ind .1i.-tt':iiioi-, i.f liif dl.iilder doe* iwil inarase the tension "f the tissues.

Differential Dia^osis. -A vaginal cy^t must bedistinguiihcil from i
CTUocete. a reetoccle. a urethrocele, a ^"sginal herniii, a miuv in ihc pelvic cav-
i^, And a collcclion of mcnsiruat blood or pus in the culdesac of a double
ni:ua.

Acyi-locele is ahvayti situated in the anterior wall of the vagina; it isinrre^sed
ID fiiic and tension up<in coughing or straining; ii disappears on pressure; it is
tense and elastic when the blad-
iter U full; and only the vaginal
■ and bladder walls imer%-enc Ik-
ftwcen ihc finRer in the vagina
and a tuund in (he bladder.

A rectoccle is always situ-
ated in the tM>>terior wall of the
vagina. It l" iniTrvuMd in sikc
and tension upon coughing or
Mmltunx; it di^npiieani on ^rmt-
surt; •nti only the rectal and
tmipniil walU intervene between
tbe iiwlcx-linger in the rectum
and ll»c thumb in the vjgina,

A ure(hn<cele U alway> situ-
ated at a point in the vaginal
wall which n>rre>)>ond8 to ihe
miildle third of tbe urethra: ii
b not affected by 'training or
bearinx-down: it disappears on
pressure which causes a (cw iIto\» of urine to escape fr*im the mralu<'; and

ly the urethral and vaginal walls inierti-cne between the finger in Ihe i-agina
and tbe tip of a sound |ia.v>e<] into tlie sac through the urethra.

A vaginal hernb is a1way< situatr^l in the .-inlerior nr [KMterior wall of the
vngina: it t> inrreasc^l in size jnd tension upon coughing or straining; it dis-
appears on [irev'.iirc with a Kurxl'nK sound ; it is soft ami doughy to the touch;
and the thickness of the inlencning structures is found to be increased by the
inicMine when a rectovaginal or a vesico\-ai9nal examination is made.

A mass in the |H:lvi* aiu»e<l by a lesion of one of ihc |>eKit organs may be
miualcen for a <ysi of the raginal wall, especially when the tumor contains fluid.
Ili»iK>t dilhndi.him-ever, uiuler the influence of an anesthetic to demun-Miatetty
nclovttginji aitd vagi no-abdominal examinations that the wall of the vagina has

ccinncction with iIk efllargemcnt and that the mass b situated in the pelvic

_ CUM (4 double %agina where the cervix ts also bifurcated the auxiliary

flntan may end in a <-uldesac in which the menstrual blood accumubtes after
puberty and forms a cystic tumor. The diflerenii^il diagnosis between this
umdiiion -md a cysl of ihe vagina cannot be made until the paru are expotcd
tnalformaliont re^'eaM at tla- lime of operation.

Ftc »}».— DiAGMMiK m A Cnt lit nn VrMa Put or m
Vaoiih,

=78

THE VAGINA.

Results and Progrnosls. — A large cyst situated at the upper part of the

vagina is apt to drag the uterus down or push it forward, backward, or laterally.
Vaginitis is often caused from the irritation produced by the presence of the
growth; by the retention of the normal secretions; and by the deflection of the
stream of urine into the vagina. Inflammation followed by suppuration and
gangrene has also been observed as the result of traumatisms, especially those
occurring in labor. Rupture may occur spontaneously as the result of injury ag

Fir., i;;.— !\-<Tm.nESTs l!.i;:i is THi; (>pK«*TiriN ron ™f. PmnAL Rehoval of a V'agikal Cist (poseiTi)).

®G

suppuration, and unless the secreting portion of the

sac is destroyed the cyst refills.

Vaginal cysts, as a rule, grow slowly, or may even
cease to develop altogether and remain quiescent for
a long lime. They cause no danger to Ufe unless in-
fection occurs, and in many instances the woman is
unaware of their presence. Operative measures are
alwavs followed by a cure.

Treatment.— The treatment is operative and
consists in (i) pariial removal of the sac, and (2)
complete removal of the sac.

Other forms of treatment are dangerous and
useless. Thus, punclure followed by the injertion of
iiKlin or carbolic acid into the sac to bring about an
adhesive inflammation often fails to cure and at the
same lime endangers ihe life of the patient from
septic infection. .\ simple incision is never followed
by t;nod results anil should not Ik; einj>!iiyed as the s:ic always refilU.

Partial Removal of the Sac, — This operation is always indicated except
when the cyst is very small and situated near the vaginal entrance. There is
great danger from ci)mplete extirpation in woun<iing the bladder, the ureters,
the rectum, or the peritoneum, and. in addition, a serious hemorrhage may re-
sult from the e.vtensive dissection required.

Technic of the Operation .— ^The Preparation of the PatinU and
the Preparations jor the Operation are descril)ed on pages 830 and 831.

ACTUAL SIZE

Fifl, 374- — XF.ZriLJS ASD SUTl'ItE
MAT>:iri4ir TsVI* IN TirR

Oi-ppATiiiii roK Partial Re-
UOVAL nr A \'Ai".inAL Cv^t

CYSTS.

379

PotilioH 0} the Pa/jVw/.— Dorsal po^iiinn.
Xiimter 9} AssUianis. — An iLnesiheiizcr. two uebunts, and one general
nunc.

ttutrumenti. — (i) Si-

nKin'n ttieoitums (cunwl

utd Dm bbiln); (3) ri^ht

Mid Irft Emmets nliKhtly

cunvd »cUsorsi (3) sc:tl-

pri; (4) two short hemo-

ttaik [orct|»; (<;) twn

taUri forceps; (6) tissue

bmept: (7) drewsini; i»r-

ixft, |8) iu.f>llr-h»l'ler;

141 tv-o !inuU (ull-{'urH«d

iliffilflm needW; (10)

]iiki wmol cat^t— No.

i. im ctivclopes {Fira.

tiiunl i74».

(i>i»4tf HH». —First

Sn?— TTie *i>et-utuin U

m •lu'.fl inKi the v:igitu

|i«y ihc cys* cx|>o^«d to

'mr. Tli'e aiicx «>f the

<^ it then :^ei7»l uilh

Mri f(ircc[)9. Khkji are

pktd Hbmil bnlf an ini^

\ij»t. and an ofiening

ttadt niih a si-ult>cl into tlic sic Iwlween the instruments. The Index-finger
'ii An tvaacd inln the cyst and its connections ascrnaim-d.

yic, iti.—OnMXTKm roi lai 7uiiili KamAi. Of 1. Vaciwu.
Cwi— Hut Sm*l

fl-ffit

'•. i^' ■ Fio j;: Fill n*

■»- ■c- ^ ■ ■ '*■ lam-m IjinmilMcrt JmK iniln Lrwt irfih« v»i»l will: lii t)) dimii ihr n^irficMl
•"■■•"•fnl imiaini -Jl >rv iniW tictod >ill. I'lf. (rSAomiftt nipmtntl fonai* ol ik( (gni nootid
*■■■ kdiH <d Iki HI •ipiail

SlTOKD Step.— The openin); inlo die cyst is enlaiKed in opposite dircctioDS
viA N&aun down to the level of the vntc'naiw-gilland the two hal\-c» cut off clow

28o

THE VAGINA,

lo the vagina with the right and left curved scissors, leaving the bottom of the
sac in place.

In cutting away the anterior portion of the cyst traction should not be made
upon the tissues or too much of the vaginal mucous membrane will be remo^-ed
and an extensive raw surface left which may be a long time in healing and even-
tually cause a serious stricture.

TmRD Step. — The raw edges of the vaginal mucous membrane and
the wall of the cyst are approximated and united by interrupted catgut
sutures.

FouBTH Step.— The vagina is irrigated with a solution of corrosive sublimate
(i to 2000), followed by hot norma) salt solution, and dried with a gauze sponge.
The cavity of the cyst and the vagina are then packed with a strip of iodoform
gauze and the vulva protected with a compress secured by a T-bandage.

Variations in the Technic .-^Some operators do not consider
it necessary to unite the edges of the vaginal mucosa to the cyst wall with sutures.

but I beUeve, however, that it is always best
to do so, as there is more or less retraction
of the mucous membrane, which leaves a
raw surface and delays the healing of the
wound. Again, sutures control the bleed-
ing, which may be considerable at times,
and furthermore there is less danger of in-
fection when union occurs by first intention
than when the edges are allowed to heal by
granulatbn; in either case the cyst wall is
spontaneously exfoliated in a short time.

In suppurating cysts there are two points
of difference in the operative technic which
must be borne in mind. First, the mucosa
and the edges of the cyst wall should not be
united by sutures, because the parts are in-
fected, and unless the drainage is free there
is likely to be an extensive burrowing of pus
into the loose connective tissue; and, second,
after the anterior portion of the cyst wall is
cut away the undisturbed part of the sac is
cureted with a sharp curet and pure car-
bolic acid applied.

If an embryonic vaginal cyst communi-
cates with a cystic tumor of the parovarium,
the technic is the .'ame as in an ordinary cyst except that the prolongation
of the cystic cavity is packed with a narr<)w strip of iodoform gauze which is
removed and reintroduced daily until contraction and closure take place.

After-treatment . — Care oj the Wound. — The compress is temporarily
removed when the bowels and bladder are evacuated. The gauze packing is
taken out in forty-eight hours and reapplied daily until the wound is entirely
healed. Before packing the vagina it is irrigated with a pint of corrosive sub-
limate solution (1 to 2000), followed by a quart of hot normal salt solution, and
carefully dried with small gauze sponges. The irrigation is continued until the
wound is entirely healed, and then a daily douche of a gallon of hot normal salt
.solution is given for several weeks.

The Bladder.— The urine must be voided either spontaneously or with a
catheter every eight hours.

Fic. ijo- — 0»s«AHos loi TMK Pabtial Re-
moval or A \'aginal Cyst — Tbird Step.

CYSTS.

38l

7'ke A«iit/j.— The bowels should be moved in Iweniy-four hours and then
■iprned reuuLirly oiue a thy.

Tht Diet. — The tlici is rcgubml iis folIi>«-st During ihc firsi forty-eight
hmirn liquid diet (see p. 106)-, then soft diet (sec p. tii) until the end of ibe
wpck; iind, finally, convuleKent diet (see p. 114).

/taUmnctt; Pititi. — A» a rule, there is no occa»on for the use of ilru^s.
If necessan,', ■ hypodermic injection of morphin (pr. J) may 1* used durine lf>e
firs] iwenty-fouf hours, .tiul il ihe jialient i^ rrMlrst ul night or does not !-lcep,
rulphoniitor irional is administered.

Ottting Out 0/ Heti. — The patient should remiiin in bed until the wound is
entirely hejlr<l.

Complete Removal of the Sac— This operation is seldom indicated nnd
muM be (onfine<t to ver}' &ruiI1 cysts situated near the vulvovaginal orifice.

(!)

iMb.— tnttrwiiin Vvat m ivk OnuA-ncm to* rat Connin IUkdval or i VAmMi Cwt.

®Q

Technic of the Operation.— The /'«■
pcr^lioH aj tht PulifiU. the Prepuraliam )or ihr Opera-
liim, the Poiilion aj Ike I'aiifnt. and the Number oj
Aiiiilauli are the same as in the oftenttion of jiartial
removal of the mc

intltumtntt. — (t) Simon's spcculums (curved and
flat blades): (1) ripht and left Ivmmei's slightly
rurveil ncfMors; (y) Kcalpel; (*) six short hemostatic
( 'S> Iw bullet forceps; (6) liteue forceps;

!ui! ("rcc|w: (8) dry divse<lor; (9) needle-
h<>l>(r.i, (10) two ^mIlll full-nir\e«l Ha gedom needles;
III) plain cutnol LUlgut -N'o. i. four envelo|ies.

O^a/ioit.— FiKST STKr. — The si<eculum is in-
tr»ducrd into the vagina and the c)-st exposed to
view. The xyex of the cj-st is then sei)se<] with bullet
furrcpi. which are |>lnred about one inch opart, and

an incision made through Ihe mucous membrane down to but not through the
qrvt wall (Fig. 181),

SxcoNp Stkf. — The cp\ is enucleated t>y separating it from the surrounding
iK*ut-i with the finger and dry dissector, care being taken not to rupture the
«{ (Hit. aH.;)-

TiiiKti STfF. — The redundant portion of the vat^nal muoous membrane \i

ACTUAL 51 Z£

MutHUi. I'lUi m im
OFiiAnox roB nil Con-
run KuiDVAL or ' V*-
omu Cnt

382

THE VAGINA.

cut away with the right and left curved scissors and the wound closed with deep
interrupted catgut sutures.

Fourth St£p.— The vagina is irrigated with a solution of coirosive sublimate
(i to 30oo), followed by hot normal salt solution, and dried with a gauze sponge.

FiQ. )8i.— FLr»l Stap. Fio. jgj.— S«conil St«».

Opeuttom roK THF, CoifrLETE Rehovai- or A Vjuiihal Cyst (ptfe i&ty

Fio. iBj. Fig. »8s.

Operation roi tiif Couplete Reuovalop a Vacinal Cyst. — Third Step.
Fig. tS4 shows the redundant pnrtion of Ihr vAgjrul wall \rtiDg Tcmuved; Fig- fSs ihowi (be suturs in pUce-

It is then packed with a strip of plain gauze and the vulva protected with a
compress secured by a T-bandage.

Wiriations in the Technic .—If the cyst ruptures, it b very
difficult or even impossible in some cases to remove the sac completely. To

nBBOUATA.

'83

gaud agkinst this danger Poui recommends ihe (allowing method: "The cysi
B ftnt punctured with a trocar, wjishcd out with hoi wau-r. anil mol ett (laraffin
btrudtuwl at a tcnv ieni]>craiur<:. When the mviiy i» <Iiistentli-d, ice is applH-d
■nd at titecntlofa few minulcswc obtain a mass which is vcn- easily extirpated."

Artcrlreatment . — Care i>/ Ihe II 'oHHd. — The dumjiresii is tem|K>rarily
rrnMived when the lx>wet» jnd bkdHer ure evucuuieil. The gauic packing is
taken out in fony-ciRht Hours and not imnxluced again. The t-agina is then
irriga led daily with a inrrosiwaublimnte solution (1 to looo), rollowvd by a quart
o( nut ivimi^l ult solution. The (loucht^ nrx- (unlinucil until the pnlivnl gets out
o( beil. aitd a daily irrigation o( hot normal salt dilution is then gii'cn for several
weckv

The care oj tk* hcwets ami Itie bliJdfr. the rrgutittiett of Ike did, and the
iWJf/ »} ttttiasntsi and pain arc discussed under the after-treatment of partial
mnovml of the anc tm iiage aSo.

Cdting Out of fl<rf.— The patient slunikt rctnuin in betl (or ten day«.

FIBROMATA.

De»crlptioil.--Tbe connective ti&^uc and muscular tumors are the mi»t
infreiiucnt of ibe neupLi^mN of tlie vagina. T1ic>e ^rowihs Renendly oc^'ur as
myoiiWumnla or tit>nrn)y<)mnta; a tumor made up of tibmu't or muscular tissue
akine is cxcceilingiy rare. As a rule, these groivihs an- situated in tlw upfier
pan <>f tlie anterior vaginal wall, but they have aUo In-en ol»er\'e(l upon ihe
ptnienor and in very r<ire instances upon the bicr^il walls, A fibmus tumor
(fs occurs singly and is of slow growth, requiring several yean., as a rule, to
lalan^size. It i^seldom bigger thiin n man'> fist and ranjnvs in ^ize fmma
t bean to a child's head. Al lirst it is round, with a bitiad or scssik base, but
ll>r lumor increases in aixe and weight it drags upon the vagina and forms a
or lew distiiK't pnlicle (fibroid fiolyfi). Sometimes its &hape b changed
by the prcseiuv of the vaginal walb and the growth becomes oblong.

CanseS.^The cau»e i> unknown. The)' are mtn>i often met during the
]iU boring prrJiMi of a woman's life, but rtoage is exempt, and they have been
yximi in all ai;cs and as congeiiiLil tumors in young infants.

SjrtDptotns.— The clumler of the ^)-mptom.^ ilepcnd« U|K)n ihe siie and
"itunlatn '<( ihc lumor, A small growth causes no inconvenience 10 ihe patient and
It usually di**\Aer«l by accident. A large fibroid, on the other hand, maypreas
tipon the urvthra i<r libtlder and acl cither a.-s an oli^iruction to urination or cau£e
redcal tenesmus When the neoplasm is situated in ihe posterior raginal wall
and p(iitruil<:s Ijcyoii'l ihe oril'nc of the vagina, it may deflcci the stream of urine
13UM; great annoyance to the piilienl. 'ITie pressure which the tumor exerts
■m the rectum c»uh-s constipation and hemorrhoids, and the traction of the
. upon the v'jginu when thf {uiienl i« erect produces a feeling of weight or
itt llie |»elvi». Large Himont interfere with walking and Mlting: ihey
I ao obttrudion to coitus and labor; they catise leukorrhca. or a profuse
and, finalty. hemorrhages nuy occur if the surface of the tumor
• ulcenicd.
DUtfttOalS.— The diagnosis is based upon the situation and the physical
mctcristics of the tumor.

AnelTon mu»i f)r>t be nude to prove that the tumor grows from the vaginal
•ail*. This is accomplbhed by direct palpation and vesico^-aginal. rectovuginal,
ngino. abdominal i>iucli. {See Diagnosis of Vaginal Cysts, p. i;b.)
The tumor i» either hard or soft in con^i.'iiency and circumscribed. The
ot bardncss depends upon (he relative amount of fibrous or muscular

a84 THE VAGINA.

tissue forming the growth. The vaginal mucosa moves freely over the surface
of the neoplasm unless adhesions have formed from overdistention or in^m-
mation. The mucous membrane is normal in small growths, but in large ones
it becomes smooth and shining. The size of the tumor is not affected by stiain-
ing or the position of the patient, and a large amount of urine in the bladder docs
not increase the tension of the mucous membrane.

Differential Sla^OSiS.— Fibrous tumors must be distinguished from a
cystocele, a rectocele, a mass in the pelvic cavity, and a malignant growth.

A cystocele is always situated en the anterior wall of the vagina; it is increased
in size and tension upon coughing or straining; it disappears on pressure; it is
tense and elastic when the bladder is full; and only the bladder and vaginal walk
inter\'ene between the finger in the vagina and a sound in the bladder.

A rectocele is always situated on the posterior wall of the vagina ; it is increased
in size and tension upon coughing or straining; it disappears on pressure; and
only the rectal and vaginal walls intervene between the index-finger in the rectum
and the thumb in the vagina.

A mass in the pelvis caused by a lesion of one of the pelvic organs is differen-
tiated from a vaginal tumor by demonstrating that the wall of the vagina has no
connection with it. This is easily accomplished by making a rectovaginal and a
vagino-abdominal examination under the influence of an anesthetic.

The slow growth, the absence of infiltration, and the regular outlines of the
enlargement make iteasy to distinguish a fibroid tumor from malignant neoplasms.
WTien, however, a fibroma becomes inflamed, edematous, or ulcerated, the da%-
nosis is difficult and can only be made with certainty by the microscope.

Resnlts and Prognosis.— -A large tumor is apt to displace the vagina
and pelvic organs. Vaginitis may also result from the irritation of the growth,
the retention of normal secretions, and the deflection of urine into the vagina.
Inflammation, suppuration, and gangrene may occur and severe hemorrhages
take place from the sloughing mass, or the tumor may become separated from
the vagina and be expelled si>ontaneously. Calcareous and myxomatous de-
generations have been observed and malignant changes have taken place in these
tumors. A fibrous tumor may become edematous and be mistaken for a cystic
growth or an abscess on account of Its soft fluctuating character.

The prognosis is favorable unless infection occurs or the tumor acts as an
obstruction in tabor, Fibniid tumors do not return after being removed.

Treatment. — The treatment is operative and consists in the removal of the
tumor.

Sessile Tumors, — Tumors having a broad or sessile base are removed by
complete enucleation.

Technic of the Operation . — The Preparation of the Patient and
the Preparations jor the Operation are described on pages 830 and 831.

Por^ilion oj the Patient. — Dorsal position.

Number oj Assistants. — An anesthetizer, two assistants, and a general nurse.

Instruments. — (See complete removal of a vaginal cyst. Figs. a8o and 281.)
(1) Simon's speculums (curved and flat blades); (2) right and left Emmet's
slightly curved scissors; {3) scalpel; (4) si.x short hemostatic forceps; (5) two
bullet forceps; (6) tissue forceps; (7) dressing forceps; (8) dry dissector; (9)
needle-holder; (10) two small full-curved Hagedom needles; (11) plain cumol
catgut — No. 2, four envelopes.

Operation. — First Step, — (See complete removal of a vaginal cyst. Fig.
282,) The speculums are introduced into the vagina and the tumor exposed to
view. It is then seized with bullet forceps and a free incision made through the
vaginal mucous membrane.

nSROUAIA.

aSs

Second Step. — (Sec complete removal of a vaginal cyM. Fig. aS.}.) The
growth r, rnu(-leal*Kl by M-iNinuing; it from the surruuncling tbaues with ihe dry
disaecli>r and the lingcf^,

Thuu> Step.— <Scc complete removal of a vaginal n-sl. Figs, 384 and 285.)
TIk rFiIumliiDl |K>rtioii of ttie vj;;{iul mui-uus membr&nc h tvi u^viiy with t1»e
right ^nil left oin-cd sci^Adn anil the tvuund cliwcd with ilvqt interniplol ratgul
futures.

FooRm Step. — The vagina in irrlgaint with a wiluiion of cormsive !iul>limaie
(t U> 3000), fnlinwed 1^' hot normal salt Milulion, and dried with a gauze sponge-

©)

-®-

IM..

k-~twmjltt]im L^to ui TH OritATitM n*fl nil Miwjvai. or k Pm>(iiii iri4<ui rim

®G

ACTUAL Size

H then [KK ked with frauze and the vulra protected
ritb A (ompirtK Matured by a T-biiiuliiKe

Spifrial Directions. —The imiroale mn-

idon cxistinfi in some cases between the tumor
ant tlte blad<lcr, the rectum, or the ]>eriliini'iim makr^
it neiest^r) to use the jn^atest care during the enu-
dcaliiin of the fcrowih to prevent injuring either of
the»c orpiiu. Should ;urh an accident happen,
the false opening b united with buried catgut sutures
and the ml of the wound clo>«(l in the u.«ual way.

Ilrmorrhage i^ conlmlleil with hemnttatic forceps
durini! the operation, and before the wound is cl(>^
the tr-'^-L'i which cunlinue to bleed are lignied with
atgut.

Aftcr-irea t men I. —Caw of the H'tntml.—
The vaginjil tamfx^n i* removed in furlyeiKht

loun mid not ininxluced again. Tl»e \-agina i^ then irrigated daily with a
■luiioR uf ciirroctif'c sublimate (1 to 3000). followed by a qu^n of hoi salt
nluiinn. Tlie antisejuic d<iurhc< are continuwl until the [Miient gei» out of
bed ami a (bily injection of hot mIi solution k then giivn for several weekv

Thf BtaJJfr. —The urine should be vx>ided ipontaneousty or drawn with a
catheter every right huun>.

Tkf fliTwWi , — The t>i)wels should be moved at the end of twenty-tour hours
ami ihrn opened reiEularly r\-cr\' <lay.

The />»>/.— During the fiffil fony-eight hours a liquid diet (mc p. 106) Hbould

Pm. iSi— Nnnic* w» s^
mi MAnauL Vm> m
na Oniunoa m nil
Ruovu or Ik PiDVW.
(vuni> ToBOa nt nt

VjWIIII* <tMCt jM).

386

THE VAGINA.

be given; then a soft diet (see p. iii) until the end of the week; and, finally,
.he patient is placed upon a convalescent diet (see p. 114).

Restlessness and Fain. — If necessary, a hypodermic injection of moiphin
(gr. J) may be given during the first iwenty-four hours, and if the patient is restless
or does not sleep sulphonal or trional is administered.

Gelling Out 0} Bed. — The patient should remain in bed for ten days unless
one of the adjacent organs has been injured, in which case the time should be
extended to at least two weeks.

Pedunculated Tumors.— Tumors having a pedicle are removed by cutting
them away on a level with the wall of the vagina and uniting the raw surfaces
with sutures,

Technic of the Operation . — The Preparation of the Patient,
the Prefiaralions jor the Operation, the Position oj the Patient, and the Number
oj Assistants are the same as In operations upon sessile tutnois.

Fic, iftS— Pint Step. Fjo, iSfl. -Second Step.

Ofebation jciif inE Hmov*Lor a PEncNcuLATED TrMon op me \'4G1NA.

Instruments. ^(i) Simon's speculums (curved and flat blades); (a) right
and lefi Emmet's ?!ighlly curved scissors; {3) three short hemostatic forceps;
(4) pcLilpeJ; (5) two bullet forceps; (6) lii^suc forceps; (7) dressing forceps;
(8) long silver probe; (9) needle -holder; (10) two small full-curved Hagedom
nee<lles; (11) plain cumol catgut — No. 2, four envelopes.

Operation. — Fibkt Step. — The speculums are introduced into the vagina
and the parts exposed to view. The lumor is then seized with bullet forceps, and
while slight traction is being marie ihc j«tiicle is divided close to the vaginal
wall

SrcoNP Stkp. — The edges of the wound are brouRht together and united with
interrupted catgut sutures.

Third Stkp. — The vagina is douched with a solution of corrosive subUmate
(i to 3ooo) , followed by hot normal sah solution, and dried with a gauze sponge.

CANCUi.

38;

It i» then packed with gauze and the mlv» protected with a compress seaind
by a T-bandage.

Variations in tk.e Tct-hnic . — In br^e lumon with thick pedicles
I prolnn^tkin oJ the rectum or bUddrr is occasionally found in the constricted
portion of ihe neoplasm. This » pmbably due in an nbnormal connection
Dritcin.illy fonned with the ium>(>r. which later on became pedunculated and
dnggcd the arlhcrrnl bladder or reon) nail wllh it. In the^e ruses a aireful
gination mu>t \x made Iwforv rutting through the pcdictc by introducing

I'm. M0-— OruuiKW ro* tk> Kximvai u> a i .up Tvina or ni Vnaajt.

•HMO.

a long siK'cr probe into ilte blad<l«r or rectum and exploring the conDectio»
1)1 the tumur

Attcr-treatmen t. — "necare a} thewtwid.ihe kla^Ider.and lbe6ffit«/j,
the rrgulatwH of lk< di*l, ai>d the rdici «/ rfxllettnen or fain are •ltM'uv*«d under
the afief-irenlmml"f the operation for ihe removal of a ses^le tumor on pufie iSj.

OtUing i'W ej bt'i.—T\\« patient sltuulil remain in tied for uncweelc unless
ibc wdttJe is very thick, in which cam the time should be extended to al leaiU
jWjra.

CANCER.

CaiikS* — Cardnorru may alLick Ihe vagina as a primary or iteondary

lion. The iodner i» ^-cry teklom met and is ex-en rarer than primary

of the vulva, Secondary- involvement of the vupnu is common and

fr<tm rliretl exteni>iun of m«ta«ta»tK. WTiilc tin- most fi«iuent

of ilie disease is the cervix, il may ato IjCRin in the rectum, llw

he orellira. or tin- viilv^ and extend into ibc vafiinal walls. When

■Auc<> occurs from neiKhtmrini! or remote organ*, the »econdar)' growth

of the name nature a& the primary legion. Meta»tatic nodule» have been

a88 THE VAGINA.

observed in the vagina in cases of primary cancer of the ovary and body of the

uterus; in the latter the infection Ls usually due to an implantation of cancerous
tissue.

Nothing is known of the nature of the cause of primary cancer of the vagina.
The majority of cases occur in women between thirty and forty years of age,
but no period of life is free from liability, as the affection has been met
after the menop>ause and in young children and infants. T. Smith reported
a case of n^alignant disease in an infant fourteen months old; Gueisant in a
child of three and a half years; and Johannovsky met with a tumor thesize
of a hen's egg in a child nine years old.

Symptoms. — There are two varieties of cancer which primarily attack the
vagina — epUkelial and spheroidal celled. Tlie first variety is the most fre-
quently met and appears as a papillary tumor or excrescence with a broad
indurated base which is generally attached to the upper part of the [tosterior
raginal wall. The f«conrl variety may be either scirrhous or encephaloid in
character and occurs as a diffuse infiltration involving a large portion of the
^•agina. In some cases the growth completely surrounds the vagina and constricts
its caliber.

The disease spreads rapidly into the surrounding structures by infiltratioD
and through the lymphatics. The pelvic and inguinal glands soon become
invaded. Ulceration begins early and is rapid in its course, and false passages
are formed with the rectum or bladder, or both. As a rule, the ureters are not
involved until late in (he course of the disease, when symptoms of hydronephrosis
and uremia may present themselves.

The characteristic symptoms are hemorrhage and discharge. The hemor-
rhage, as a rule, is first noticed after sexual intercourse or defecation. In the
beginning it is slight, but as the disease progresses it becomes more and more
severe, until finally there is a continuous loss of blood and at times free hem-
orrhages. The discharge is watery in character at first and of an offensive
(xliir, and as the ulceration advances it becomes mixed with blood, pus,
fragments of broken-down tissue, sloughs, feces, and urine. The odor in the
later stages of the disease is fetid and putrid.

Pain is a more or less constant symptom which may be felt in the pelvis, the
rectum, the bladder, or along the sciatic nerves. As a rule, it is not present undl
the later stages of the disease, and in some cases it may be absent altogether.
Pruritus vulva; is a frequent manifestation of the affection and is caused by the
irritating discharge fr()m the vagina. The symptom is often very exacting and
weakens the patient from loss of sleep. When cancerous infiltrations are ex-
tensive, they interfere with the function of the bladder and rectum and prevent
sexual intercourse or act as an obstruction to labor.

The con^ililittional symptoms and the efjfcl upon the genera/ health are the
same as when the disease occupies other portions of the body.

Diagnosis. — The diagnosis is based upon the symptoms, physical char-
acteristics of the growth, and the microscopic examination.

The hemorrhage, the discharpe, the pain, and the pruritus vulvae are all
significant symptoms and point to the nature of the affection.

A malignant papilbrj' gr()wth has a broad indurated base and an ulcerated
surface. Even if an ulcer is not present the fixation of the tumor and the sur-
rounding infilirat ion are characteristic. When a cancerous excrescence occurs as a
cauliflower tumor, the induration of its base, the brittle nature of its structures,
and the tendency to hemorrhage are suggestive. In the scirrhous or encephaloid
variety involvement of the neighboring tissues and early ulceration point to the
character of the trouble.

CANCEK.

The cnlangcntcnt of the peUic and in^inal i^nds is an imporUnt factor tn
■<lu(;nii>i'' :inii must not lie kut >i>{ht of.

XNfferentlal Diagnosis. — Cancer of ihc vagina must be ilislin^ishcd
Inini ukcrjiLii fil)[»Mls, ii>iiiitniata. and Mrtoma. A fibroid rtows slowly,
there b nlncncc of tiitihralioii in ihc .■'Urroiiivlinfi liw>ur:i, .ind the ttimur is always
ciraiimcribrd. Wh«n. however, the ulocralion is extensive and the growth b
inflamc^l or edematous, thr dtiiii:ni»i.i<uin only l)e made with certainty by mennsof
rairroricupe. In simple i-ondylomata there is but little lendenc}* lo bleeding
jn luuch. the tbsue* are not (riatde. and there is absence of infiltration. The
iRtwriik iii -^m-nmn musi be «:llle<l by lh« mimi»to[)C nione.
PrognosiB.— The course of cancer of the vagina is generally vwy rapid,
and dcHih uikes [ilace. »»■ a rule, in about the same length of time as when the
dbwue be|iin> in ilvo uterus. The openttive pro^o^is is bad, a» the disease
invariably n-tunu even after complete removal of the growth. The fact thai

L"*^^

-^j

no. *vt.— fini Ut9. PlO. Ml.— SKOOd Step.

ittn^nm torn CwiFn or thi Vuioa Iiaar >v>).

SO lew cases ace operated upon early may have M'mething to da with the coo-
»uni recurrence of ibe rlincuMe. He that as it may, howewr, the only hope for

Kitieni c' an early recognition of the affection ant] it.s thorough extirpation.

Treatment.— The irealmcnl Udivi<lecl into (i) the radical; (a) tnetiseof

i-ray>.; atvl (,;) the {tallialivc.

Radical Tireat meat. —The radical irentmcnt s operative and aimti to eradi-
ic the disease by (a) the removul of the growth and (d) the total extirpation of
the v3Kina.

The Removal of (he Growl h— This operation is indicated
«ben the tunww i* locnllMd and its complete rrmoni is [mssible.

7'ftkmu nj Ihf OpiT.<rt««.— The Prep.iratfon oj iht I'lilirnl and the Prepara'

I Iff fhf if p^'tiiofi are <lescril)ed on paRci S.io and 831.

Poiillonof the i'atieni .— Dor»l position.

Number of Assistants. — An ancsihetizer, two assisunts, ami 11
SeaenI fluf«e are ctriuirefl.
in

i__*bei

290

THE VACIKA.

Instrument s. — (See p. 281, complete removal of a vaginal cyst.) (i)
Simon's speculums (curved and fiat blades; (3) right and left Emmet's sl^tty
curved scissors; (3) scalpel; (4) six short hemostatic forceps; (5) two buUet
forceps; (6) tissue forceps; (7) dressing forceps; (8) dry dissector; (9) needle-
holder; (10) two small full-cun'ed Hagedom needles; (11) plain cumol catgut-
No. 2, six envelopes (Figs. 380 and aSi).

Operation . — First Step. — The speculum is introduced into the vagina
and the parts exposed to view. The tumor is then seized with bullet forceps and
an incision made around it through the vaginal wall and well outside of the in-
filtrated area (Fig. 291).

Second Step. — The tumor is pulled forward by the bullet forceps and
separated from the underlying structures with a dry dissector or scalpel
(Fig. zga).

Third Step. — The edges of the wound are approximated and united by

deep interrupted catgut sutures.

Fourth Step. — The vagina is iirigated
with a solution of corrosive sublimate (1 to
2000), followed by hot normal salt solution,
and dried with a gauze sponge. It is then
packed with gauze and the vulva protected
with a compress secured by a T-bandage.

Variaiions in the Tecknic. — The walls
of the vagina are naturally very relaxed
and elastic, consequently a lai^ wound
may be made and primary union obtained.
This fact is important to remember, as it
is always necessary, in extirpating the
tumor, to make the incision well beyond
the infiltrated area.

When the tumor is situated in the an-
terior or posterior vaginal wall and the
underlying portion of the bladder or rectum
is involved and adherent, it should be re-
moved along with the growth by making
a deeper incision and cutting away the
entire mass with right and left curved
scissors. The wound is then closed with sutures. (See the technic of opera-
tions on vesicovaginal and rectovaginal fistulas, pp. 758 and 771.)

Tumors occupying the posterior \anh of the vagina, which are adherent to
ihc peritoneum, are removed by opening the culdesac of Douglas and excising
all the diseased structures. The peritoneum is then closed with catgut sutures
ami the edges of ihe vjiginal wound united in the usual way.

It is imjMirlunt to obtain primary union whenever possible, and In cases
requiring resection of a portion of the vagina! vault the raw surface miay often be
covered over by drawing up the lower edge of the wound and suturing it to the
ccrvi.x, which has previously been denuded.

When the inguinal glands are involved, they must be removed.
Ajter-lTeatmenl. — Care of the Wound. — The gauze packing is removed
in forty-eight hours and not reintroduced. The vagina is then irrigated daily
with a solution of corrosive sublimate (i to 2000) and the antiseptic washed out
with hot normal salt solution. The corrosive sublimate injections are continued
while the patient remains in bed. and a dail>' douche of hot normal salt solution
is then given once a day for several weeks.

I'll.. JVJ-"'-^PtHATII>N rUR CaNI-KA lit THE

VA1.IK*. -riiira Step.

CANCER.

391

Trc BLADDrK.— The urine »houUl be parsed sponUneouK^ordnwn wiih a
catbnef every ciRhi hours.

I'liK H(twF.i„s.— Thr. b»weU Oiould Ite moved on ihe wcond day and then
o|>ctK<l iiiKc even- iwmly four huurs.

TuE Diet.— DuriiiR die fiw (orly-eiRhi hours a liquid dici (sec p. 106)
fboalcl be pvcni then a .'^ifi diet (>ee p. 1 1 :) uniil Uie end of die week; and,
6fulK'. the [Kiticni is placrd upon a convnlesccnl diet (mi* \<- 1 14)-

Re-stlessxess and Pais. — Pain is (wnirolled by the use of recul supposi-
tories or bypo<le*inic injections of morphin, urul »ulphonal or irioruil i* iidminis-
tered if the patient becomes rcstlcsfi.

Geitik'C On or Bed.— The pnlient ^oul<) remain in t>ed for ten days
Dntc^ the rcclunt, bbdder. or jM-riioneum have been woundeil, in which case
the time should be c.flcndcd lo at least lis-o w-ecks,

TiHail Kxiirpiiiion of the Vasina. — This operation, in my
jt»dgment, should iKvcr be iwrformcil. Iwcjiu*? il Ihe di»c8» b exlcnsiw enou^
to require total extirpation of the vagina the case is absolutely hopeless, and
bcncc operative me;tMire> iiivutvint; immeiliule danfcer 10 life without olTering
llie dightCKl chance (if relief cannot honcsily beadvi%ed.

Tb« Use of tbc v-rays.— The array treaimeni uf cancer of the vagina ii
fully de>cril>«-d on {Kige 76.

PAilUtlve TreatiDcnt.— 'Hiis form of treatment is indicated when tt is found
10 be impossible lo eradicate (he disease by operative measures.

The iriMimeni in purely |>alliaiiv« in chufncier and directctl towoni the relief of
Be ft>lk>«in}; symptoms: (it) Wscharge and hemorrhages', (A) pain; (^ drib-
[of urine aiid escape of feces; and (if) exhaustion.

ii»chargc; Hcmorrhaiies , — Thfric symptoms. which accompany

later stages of ihe dbcase, arc cxieedingly annoying and dLMressing lo the

itieni, and lustcn tlH* end from cxluuslioii. The foul and olTrnsivc milure u(

ngimil secretions makes the patient rrpulsi\T lo herself and to throe with

I hhe mmes in twntact.
Th*"^ lyinplom* arc «"ntrollcd by the following ojier.iliiin:
CfftimrHl and CauUrisaliaH.- This operation is followed by good results and
hnuUI lie the first ste|) in the palliative treatment of vapnal cancer. It le^-vits
quaniity an<l corrcclc th*- odor of the discharp; and Mo|» for a time the con-
Duou?. blcrding which L« exhauslint; ihc patient. 'I'hc development of the
i». ihirefore. lew rapid and llie [aiient rendered more comfortable.
rr<.-||s»- or THi: On RATIOS.— I'he I'rtP'iralion of iht /'otienl and the
fttpa'-ilii'm for ihe OpfT^ilion arc descriltcd on pages 830 and 831,

Owini; lo ihc ultvrateil ami fri:ilile ti'mlilion of the lU-iue^. the u.-iual melbod

iiuing ihc vagina al the time of "(leration cannot lie followed in ihew cases,

■ious injurj' might resuh or a false {xi»?^gc be maile into one of the ncigh-

inK organn. It mnilil lie im|KKi.Hiliie. under the circTimslance>, to Merilixe

|nns e^vn if an attempt was made lo do so, and the cleansing should

itm ounsisi in irrigating the vagina vrilh a solution of corrosive sublimate

tu 1000), foUi>vre<l by the same ((uantiiy of hot normal Sith noluiion. The

trmal >trgam, perineum, anal region, and ihe inner surface of the thighs nre

thoroughly si rubbc<l with a gauze sponge saiuratol with warm water and

itid PCMp, ami tile jtart" linalty douched with plain "terilc water.

/'oiitiim itj tbr l'ilirHl.—ThirM\ ixisition.

.VwinVr ■>/ Aiiiilartii. — An anesthctixer. one a&ststant, and a geiwra) nurse are
mfuifc^l.

imilrumtutt. — (1) Simon's spccuhims (curt^ and Hal blades); (3) right antt
1 EjtUBn't) slightly curved scissors; li)^x ahon hemoviaiic (orrep«i; (4) dre»ing

393

THE VAGINA.

forceps; (s) tissue forceps; (6) sharp spoon curet; (7) Paquelin cautery; (8)
needle -holder; (9) two small full-curved Hagedom needles; (10) plain cumol
catgut — No. 2, four envelopes.

Operation. — The speculum is introduced into the vagina and the parts «-
posed to view. The canal is then dried with a gauze sponge and the situation

Fic. a94r — Instri-'uekts Used t» the Operation or Cueetuent and Cal'teuiattoh eoi Cahcu or THE

VACtHA.

r?\

and extent of the ulcerated tlisues carefully examined. The diseased and friable
structures are now cautiously scraped away with the curet until apparently
healthy lis.sue is reached, and the uneven and ragged edges of the wound are
removed with curved scissors. The blood and fragments of loose tissue are wiped
away with a sponge and the cureted surfaces cauterized
with Paquclin's cautery. The vagina is then irrigated
with a solution of corrosive sublimate (i to 3000), fol-
lowed by hot normal salt solution, and dried with gauze
sponges. It is then packed with gauze and the vulva
pn>tei:ted with a gauze compress held in position by
a T-I>andage.

Spkcial Dihkctions-— There is alwaj's more or less
danger in curctment of making a false passage into one
of the neighboring organs. This can only be avoided
by a wrj' careful manipulation of the curet, which is
guided by the eye of the operator and the sensations
conveyed lo his fingers through the handle of the
in;>trumenl.

In the l>eginning of the operation the hemorrhage
is u:sually severe, but it les.sens as the diseased tissues
are removed and ceases entirely when all the friable
structures have been scraped away. If. however, a
spurting vessel is seen, it should be caught at once
and ligatcd by passing a curved needle threaded with
catgut through the tissues immeiliately bencalh it.

\'ariatioxs i.v THE Tfchnic — Purc sulphuric or nitric add may be
substituted for the cautcrj'. Under these circumstances the surrounding mucous
membrane must first be protected by smearing it with vasclin, and the chemic
agent subsequently neutralized by applying small pledgets of absorbent cotton

®c=

ACTUAL SIZE

Fic- igs — NtEnirrs Asi*

SUTUKE MaTEHIAI. UstL>
IM Tttr. OPEBATIOS Of
CukE-mF-KT ANU CaD-
TthlEATinN FOB (.'AHCtB
or THE VAtllWA.

CAKCBR.

993

r« saturated wlulion o( sodium bicart>oiuitc directly to the dKca&ed
areas.

ArrM-TREATiMiNT.— Cure oj Ihe H'oKnrf.— TTic Rauzc packing is taken out
in twenty-ltnir hourii ami tint reintroduced. The vaKinii U then irrigated djiil)'
with a Mtluiion of corrosive sublimate (i to 3000), followed by a quart of hot
normal salt wlution.

Th* KhdJff.—Tbe urine should be {Kuacd *]K>ntanenusly or drawn with a
catheter evcri,' eight hours.

Tkt Bffo.'ds. — The bowels should be mowd on the day after operation and
then opened once every Ivremy-four hour».

Th* Diel.~A liquid diet ()«<.* p. 106) should be given during the first forty-
cifEhl hours and the fKitieiu tlien pLiced upon a (ronvaie>cent diet (see p. 1 14)-

fttititiinrn and I'ain. — The free u»c of opium i" indic.iled antl the drug
■JwHild be ffxta in the form of rectal suppositories or administered hypoder-
mioitly.

Gtttiitg Out of Bed. — The patient should remain in bed one week.

The SrBSEOUENTTREATME-VT.— After the patient gets out ol bed cwryeflfort
nuoi Ite mN<lc tu conind iht chanicter and cjuaniity of the (ii^ihurge^ and protect
ihc vulva from ihcir irrilaling influence. The lin.l of thc^c inditalions i> met by
the u>e of medicated vaginal douches, which should be used night and morning.
Crvolin, (sij to the qiuri; Iv.-miI, i jwr tent.; and i>ermanK^iiaic of potassium.
I III jooo, arc vcr)- u^^ful preparations, and are n"l irril^lint; to the vagiiLi.
me iMiient.i do well on carbolic acid. 3 to ; jxrr cent., or corrosive sublimate
1 1i> 7000). and when these remeilie> are emiilii)v<l the medicated douche should

followvtj by an injection of a quart of hot nxrmul %alt volulinn to preixnt local
irritalion or ]>oL'>oning from absoqilion. The daily use of hydrogen pcroxid b
of great ad\:anlage when the di^'chiirge bctiime^ ofTen^ive. and it should be
■pfiGed ever}' moniing or ewnins just bcfure the medicated douche is given.
The (uitirni -Ifmlil lie ujHin her back and iniecl two or three ounces of the remedy
into the vagin;i with a small hard -rubber syringe.

Tlw ulicntive j)ro(Css is often heW in thutk and more or less mcKlilied by the
me at methyk-neblue or violet. Tlie <try jitiwdt-r o( eidier prejiaration may l>e
^B^tttvd over iIk ulcerated surface through a speculum or a t per cent, solution
^Ssty be apjitied n^ a lotion upon a cotton-wY>ol tampon. Petroleum (refined oil)
ho» al"o jirovnl U-ncficid in thevp cases, and one ounce of the oil may I>e injected
djily into the vapina and kept from escaping by inserting a cotmn-wool tamixm.

Somrlimes tlw Meedinf; liecomes exceir^ive during the later stages of the
dncaae ami mdv require special tmitment. It can usually t)v controlled by
(tiphnu hot water vaginal injections and the introduction of a tampon of iodo-

1.1 r,

TTii.' Ire^itment shoukl lie {tiven regularly and tonlinued as long

-"line Lists. GoofI results arc also oblaine<l with a Lir^e coiiun-vrool

I in a saturated solution of alum and introduced into the vagina,

:t of the piilient i.'< greatly incnsi-^it by prv>tecting the exlerriBl

• n. M.nlail wilh the irrilaling v.iginal <H>cliar)io- "Hiis is accom-

V '.t.i-hirig the vulva night and morning with warm water and soap,

.irbolizc<) vuMlb (j( per cent.), and wearing a vuh-ar |iad to ab^trb the

Pain . — This symptom must Iw o>nlrollcd with opium and the dose grodti-
incnuiwil a^ tlic dis«-aM; progrcMes.

Dribbling of Urine; Escape of Feces.— The management
Inns t. fully disfus-««d under ll»e treatment of vesicoragiiul
ubs on pages 76J and 77 j.
La h>* u»tiun.~\\1iile nothing can be done lo benefit the patient pa-

394 THE VAGINA.

manently, yet much may be accomplished both mentally and physically by an
intelligent management of the constitutional effects of the disease and the ad-
ministration of tonic remedies. The surroundings of the patient should be made
as cheerful as possible and her mind must be kept from brooding over her troubles.
She should not be told the nature of her disease unless there are reasons for doing
so, and the word " fuwffr" should never be used in her presence.

The diet should be easily digested, appetizing, and nutritious. Alcoholic
stimulation is important and may be given in the form of a red wine or champagne
at lunch and dinner, or a millipunch containing about an ounce of whisky or
brand)- may be taken three times daily. The amount of alcohol of course de-
pends upon the indications in each case, and judgment must be used to preient
overstimulation. The patient should have plenty of fresh air and sunshine and
she should walk or drive ever}' day if her strength and opportunities permit.
Verj- few drugs are indicated internally. The use of opium to relieve pain has
been referred to. Sulphanal and trional are at times useful to promote sleep, and
str^-chnin is often indicated for its stimulating action. 1 have derived good
results from the following formula, which I am in the habii of giving for an in-
detinite period after the operation of curetment and cauterization:

I}. Hydrargyri chluridi corrosivi,

Acidi arstnosi &i gr. j

Extract! nucis vumkie gr, xjtv

FiTri !■! quinina.' dlralLs gr. cc.

M. il fl. pil, t.

Sig. — Onv ijill ihnt limts daily aflvr muals.

SARCOraA.

Causes. — Sarcoma of the \agina ma)' occur as a primary or secondary

disease. The former is u ven.' rare affecti<)n, and is met even less seldom
lliaii primary canter of the vajjinu. While the most frequent starting-point of a
secondary involvement is the cerAi.'t, it may also begin elsewhere, and eventually
attack the vapina by metastasis.

Nothing is known of the cause of the disease. While the majority of cases
occur in early life, yet ail ages are liable, as the affection has been obsen'ed in a
new-born infant, in vounK children, and in veri" old women. When sarcoma of
the vagina occurs in childhood, it generally manifests itself about the second or
third year of life.

Symptoms. — The disease occurs clinically as a round circumscribed tumor
and as a diffuse su])erficial infiltration. The first variety is the one most fre-
quently met in adults and is the usual form in children. It appears in the
beginning as a globular tumor with a broad base, which later becomes more or
less pedunculated and resembles a fibroid polypus. It is bright or dark red in
color and undergoes ulcerative change \crj' slowly, as shown in a case occurring
in a new-born infant which did not result fatally until the seventh year.

The second variety begins as a small nixlule or gn>wth in the vaginal wall
which gradually increases in si/e. anil at the same lime the mucous membrane
and surrounding tissues become infiltrated. Ulceration finally occurs and the
affection rapidly goes from bad to worse.

The disease spreads into the surrounding structures by means of the blood
and the walls of the blond -vessels. The lymphatic glands, as a rule, are not
invoh'ed except in Ihe melanotic form. The bladder and rectum eventually
become affected, and in time the ureters and kidneys are involved.

The usual situation of wircoma is in the lower part of the vagina. In the

VAC-ISAL PLATTS,

»9S

adult it attacks the anterior and posterior walls with equal frctiuciKry, but in
chil(li«n the anterior wall h the usual seal of the alTection.

The chief s^mploms .irc hemorrhage itn<l diuhargt. 'I*he bleeding, which is
caused by ulccratioi), is slight at first, but bicr it bcroiDcsmorr and more marked,
until there U a continuous loss of blood, which i« uctomtianieii at timei vriili
wverc Ucmorrhane!'. The ilLschargc in the beginning is w:itcr)' in churacler and
of a foul odor, but 4s the uU:crali»c process spreads and the tissues become
KanK'enou!! it u mixe<l with blood, fRiKinenu of broken -rlou-n ti.<«uc. pu», and
>li>(ighini; masMS. and il :iL<o conUins urine or feces if the bladder or rectal wall
i>deslR>>«l-

PiVM tU'n not, u!i a rule, ornir until ulceration iKpn*. and \s referred lo the
pdvL^ the recnini. or the Madder and almig the sciatic ncnes. Pniriliis t-iih-ff is
a freiiueiit symplom, and is due lo the irrilulion prodmcd by the vaginal di>'
chargo. And, riiulty, the sarcoma tous iiifiltnition inierfcrct uilh the functions
of the rectum or the bbdderiind presents scxualintercourse or acts as an obstacle
< Ubor,

Whwc the dbeasc occurs as a circumstriberl tumor, there is a sensation of
rcssurv and bearit^-down in the pelvis. This gmptom i^ manifested very early
I chililriMi on account of the small dimensions of the ^iiKina :ind Ixmy [leUv.
The tanflUulion^t t\mpl<iin\ and ihe flfr<i upon ihc gcurral hnillh arc Ihe
fame as when sarcom.i attacks other p^rts of the body.

IHa^osis. — The dia|!^o^i.■> is ba^^^t u|>on the >ymptom'i, the phy^{cal
chanii lerittio of the growth, .ind the micnivpopic examination.

Diflcrential Diagnoais. — Sarcoma uf the vagina roust be distinguished
\>m hliriima 4i«l iar>im>ma.

Prognosis. —'I'hc coun* of the disease is rapid when it occurs as a diffuse
j[icrliii;tl intiltration, and slow in the circumscribed form. The prognosis js bad
\en nfier cumplcle enliqMlion, The only hope for the patient is an early rceog-
Ution of the disease and its thorough removal.

Treatment.^-'nie treatment is the Nime :i> already descrit)ed in cancer of
vngina on pugc 289.

VAGINAL FLATUS.

Itefinition. — The acaimubtii^in and audible expulsion of air or gas from

i-agina. This affection b also known as garritlUy or in<ott;ine»<e of Ihe

<tva.

Canses.—I'he disease is not uncommon. It is most frequently caused by

ixallon aitd Raping of the vuh'ov-^ginal orifice due to traumalL->m ami 1ih» of

lipiMT timiie from ^enend cmncialifm. Uniler the^e conditions any change of

Mtiofl which results in the intestines falling temporarily away from the pelvis

rill c.tuse the air to be sucked into the vaKiiui atid subsequently expelled witli

KWK or less aa\»e when the intra-nlxlominnl pressure u|»on the (wbHc organs

lurns. Thus, air may be drawn into the vagina when the patient assumes the

lit |K»ture, hut miiro es|>c<'ially when slie quickly rolU ovvr u|K>n one side

other. I \v,\vt met sever.d cas« where the symptom occurred only

Id - -ual intercourse. The vaginal entrance was more or less relaxMt in all

fX: ■ <^'n.in<l theaflectton wasuniloulttedlydue to the piNtonlikc arliunnf the

pciua drawing in and e\|>ellingllic air. Gas may escape from the rectum into the

■Ciiu through a bstulous oiicning or it may also he produced b)- sloughing

lerina- or vagiital tumors aiul W ex[)elled when the alKlomina I pressure is exenc<).

J linally, the symptom may be artificblly cau.scd by pbcing a woman in the

M ]M»turr dod then swldenly changing to the recumbent (imition
ro^nosis. — 'I'he alTection can always be cured by renwving the cause.

396 THE UTEKUS.

Treatment. — The indication is to discover and remove the cause. In
some cases the affection is cured by repairing a torn perineum or narrowing
a relaxed vulvovaginal orifice, and in others it may be necessary to remove a
sloughing tumor or close a fistulous opening into the rectum.

CHAPTER XVI.
THE UTERUS.

METHODS OF EZAMINATICffl.

The uterus can be examined by the following methods:
Indirect inspection.
Vaginal touch.
Vagino-abdominal touch.
Recto-abdominal touch.
Rectovesical touch.
Artificial uterine prolapse.
Sounding,
Microscopic and bacleriologic examinations.

INDIRECT mSPECnON.

Ifimitations.— The intravaginal cervix is the only portion of the uterus
that can be seen by in-pection through a speculum. In cases of prolapse, how-
ever, it is often ex|>osed to view at or outside of the vulvovaginal outlet.

Information. — Hy inspection we can ascertain the size, shap>e, and general
appearance (if the cervix anil the os uteri, as well as the presence or absence of
inflammation, erosion, laceration, cystic degcncralion, cervical diseases, ulceration,
neoplasms, and other pathologic conditions.

Instruments. — The following instruments are required: (i) Goodell's
bivalve speculum; (2) Sims's duck-bill speculum; (3) Simon's speculums
(curved and flat blades); (4) vaginal depressor; (5) dressing forceps; (6) two
tenaculums.

Description of the Instruments. — The instruments, with the exception of
the tenaculums, are described under Inrlirect Inspection of the Vagina on ps^e
227.

Preparation of the Patient.— The rectum should be emptied with
an enema of soapsufis and warm water and the urine voided naturally Just before
the e.xam illation. The corsets should he removed and all clothing that con-
stricts the waist should be loosened.

Position of the Patient. — Three positions are employed for inspect-
ing the (.XTvix: The dorsal, the left lateral-jirone, and the knee-chest postures.

Dorsal Position.— For routine examinati(ms this position is very satisfactory
and is more frequently used than the (iihcrs. The disadvantage of this posture,
however, is that the cervix is exposed by forcibly separating the vaginal walls
with the blades of the speculum, and consequently its lips are apt to be more
everted or turned nut in cases of laceration than thev are in reality. And, again,
as the vagina does not twilloon out in thi* [jositinn the cervix is difficult to expose
in women who are fat or who have relaxed vaginal walls.

998

THE UTERUS.

Antisepsis. — See Indirect Inspection of the Vagina (p. 330) and the
chapter on The General TechnJcof Gynecolc^ic Examinations (p. 22).

Technic. — ^Having placed the patient in the proper position, the speculum
is warmed by dipping it into hot water and the blades are lubricated with liquid
soap. The examiner is now ready to introduce the speculum.

Goodell's Bivalve Speculum. — This instrument is used with the patient
in the dorsal position; the method of its introduction is described under
Indirect Ins()ection of the Vagina on page 230.

Sims's Speculum. — This instrument is used with the patient in the knee-
chest or left lateral-prone posture; the method of its introduction is described
under Indirect Insricction of the Vagina on (lage 232.

Fn:, 300. — IrJDikK-T [x^ri-.rTHiN' or tmk 1"t>.px."s.

SklltVb'S 111

i> m

Fii., ,100— Inihbeci iNsracnos or the Vtkh-*.

r ^.luina I'aMixjni'-t iml when rhi tiJiniinirioii Shctw* Ihp cmix bnnj{ dravq mlo Ihe lumni of
i!i(ta in (ht knrc-dn-sl T"«ili"n II^BI- Ml)- the spKulum with a Itnarulum.

Simon's Speculums. — These instruments are useil in the dorsal, left laleral-
pnme, nr the icnet'-chesi piisilion; the meihixis of ihcir Introduction are
described iiniler IncHrcct Ins|>cctiiJn of the Vagina on page 234,

Special Directions. — If the cervix only p;irtially engages in the lumen
of the lipLTulum after the iiistrunifnt is intniduceil into the vagina, it should be
hooked with a tenaculum and drawn into the proper position. Sometimes the
secrclions arc- so profuse and thick that the underlying surface of the cervix
cannot liL' >een. and under iht-se circumstances they should be removed with a
pledget of ab-orbenl cotton held in the grasp of dressing forceps.

VAGINAL TOUCH.

Ifimitatlons. — Ry vaginal touch we can fwlpate the intravaginal and
supravaginal cervix, Iho anterior surface of the biidv of the uterus when the organ
is in its normal |K>sition or the posterior surface when it is retrodisplaced, and
also the lateral uterine wulis.

uenioDG or exaiunatiun.

999

blfonnatlon.-^Wc an dcli-rminc the sizv and shape of the os uteri and the

j^fornt, and mnsblciK) oi ilie cervix, as well as aoy evidences of laccra-

"on. tvsii« ilcKentnition, diM)iari;if.%, ulnratiuii, nco|>lA»rTVt, etc. The

ttlnit of the [uikIus and the position and mobility of the uterus cnn ubo be

eruincKl.

Va|[inal touch L-> chielly uM>ful in diugnosinn legions nf the itiiruvaitinul cervLt,
ml In the hands of the cxpeit this method can also be employed with iidvantaicc
ia ncoKnising uterine displacements and fixations. But it should
never be relied upon alunc to diafinose the>e con-
ditions, because in the absence of counter-pressure
which ii U!ie<l in bimanual touch the uterus slips
«way from the finger anrl consequently the organ
C a n n 'I I I> c t h o r o u j: h I v or satisfactorily p .t I p a t e d -

Preparation of the Patient.— Sanw at. f.r Indirect Inspection.

■■■:i\

LuiiuitinH or nir t'mn ar V>
r«*t1 inMdHI. XM> (ht .IIIIrtcMf In Iht iliVie of .\

■ -\ ih> •umliuiisn hmt 1

Nirru* In Ihc I

Position of the Patient. — Two position* are employed in pnlpatinic
the uterus: Tlic dorsal aivl the creel postures.

Dorsal Position. — This posture i* use.l exclusively.
Erect Position.— This [xmilion is only empkn-c<l to ei.t<-enain the degree of
i-ni it) r.iM'S of {imlapse of the uterus and the \'afpnal walls.
Technic. — llaWns pLicnl the imient in the dnrsil jiosiiion the examiner
i:i (mnlof the v\t]y3L ami inirr-luccs the index-finder of the left hand
with the jnlmar surfatc ilirei.lc<l upward. TTie tip of the fuiRcr
: in <T>nt:ii-t with the tenix. which is gently )ml)iaicd, and any
■ iiiioos tarcfuUy noted (Fir. ,io_i)-
I'he liti^et is tlu'R JMSM^I in front, liehinil, and on each !<ide of the cervix In
rl Joe il>e liinly of ilie uicTus, which will dive the direction in which to look for
(he fundu*. Having locitted ami asfcnained the |msitton o[ tltc uterus atwl notetl
■'■•"■rmal altenitions in shape, siite. or ci>nsirtency, its mobility i.^ then o-
|i > pu^hi^c the organ in various dirvclions and abo by placing the lip

inr iioKitr (lirealy under the cervix and making itrosuic upward (Fig. 304).

Fin, JO* — ^;xA«nl•TlO[J or nic I'inn m VjLCi<iiLt Toim IfMr »•»).
Shorn Ibc ractjiUiy ol ihi uicfui ln'inii ininl by dotiiDji ilit urili vuh Ihi ikf ol Ibt Antn. TW 4nmI

VAGmO-ABDOmNAL TOUCH.

Limitations. — By this method of iin-estiKalian we can thoroughly poil-
fMe the ciiiirc- uteni9.

Information.— \Vc «in ascen-iin the si«r, shape, consisicno', position,
and the moinliiy <>( ihc uterus, .is well n* the presence of neoplaMns and we est)
abo dilTerenliatc between uteriiic eiilaritcmenU und peKic tumor?.

Prepatration of the Patient.— Same » for Indirect Inspection.

—

UETBnDS OF EXAkUN'AttQK.

301

Position of the Patient.— The exBtainatkm should be made with the
paiicot ill ihc dor-^l positiun.

Anesthesia. — An imcsthclic is scklofn required in thin women. Il
should, however, always be used whenever any doubi
exists as to ihe condition <>( the pelvic orjtans. be-
cause a mistake in the diagnosis is very likely to
occur unless there is perfect relaxation of the ab-
dominal muiclev. It is. therefore, necc^san' 10 employ an anes-
ihrtir in women who are muscular or fat or who are nervous, and also when
pelvic intUmnution is present and the jjnrU are tender or sensitive.

Technic— The object of a bimanual examination is to press the uterus
down against the vaginal Gni;er anil tu hold it in that position while the orxan in
pft]()aled. If the [xrlvic orjcan.* are found tt> lie mi.>rc or less immovable, the in-
Uniai atxl external pressure must be cautiously regulated, otherwise there Is
dangKT of breaking up adiiesions or rupturiti}; a pus sac.

*^/,

no j*s

E&umunoH or n» t'naii »i

VAjOIV? AAIKHfltMAI.

Ton™

n«.

I !!■■• na^od gl ptipitlaf tha funtui uul rBUmBiiiw iW Iciujh ajvS mubiUiv at (he uierv: Ftf. ja^
^ma aiclbal tl iiliillni llw bait et Ar uimui ukl ilu iluJiai— uul nulnliiy at ihr kiib.

After placing the patient in the |>rcif<cr jKMition the ex:iminer sits or stand*
in front of the vulva «tMl passes the index-hngcr into the vagina up against the
orrvii. The fingers of the free band arc tlien placed over tlie pubcs and pressure
i> made downward tlirough the abd0min.1l trail until the iniemal finiter ftx-U the
ruunterrcttlMance af^ia'ii the eervi.t. The vaginid finger is now placed in front
i»f the crrriji while the external hand forces the fundus awl Uwly of the uterus
dirwn upon it. Tlie internal finger then palpates the fundus and the anterior aiul
hicral Rurfaces of the uterus and ascvrtain* their slupe and cotuisiency as well
a* the wiilib of the or^n. By balancing the body nf the uterus between the in-
ICfnal and cxtenul Angcn we can estimate the ihicknew of the organ, and by
tixivini; it upward, backward, and to cither side il» mobility ran be verv'arcuralely
dcHrrmincil.

The length of the uterus can be determined by placing the internal finger

302 THE VTEKUS.

against the tip of the cervix while the external fingers press down the fuDdus, and
then estimating the distance between the two points of resistance.

If the fundus is posterior, the internal finger is plat^ back of the cervix and
the external lingers are pressed into the abdominal walls toward the prom-
ontoiy of the sacrum and the structures crowded downward against the anterior
surface of the uterus. The internal finger then outlines the shape of tiie uterus
and estimates its size, mobility, and consistency.

Frc, 307. — ExAUiNjKiio:^ or TKt Utepl's by VAGrNO-AiiDoinNAL Toaai,

Sbova ihc mtlhod ul ulimiiing ihp Ihickneas and mohiUfr of a mrodisiiaced ulena.

Whenever il is necessary to make very deep palpation with the internal finger
an udvance of from one to three inches can be gained by firm pressure with the
knuckles of the examining hand against (he perineum (Fig. 20). If the exami-
nation is made without an anesthetic and there is difficuhy in outlining the
uterus on account of muscular rigidity, the patient should take a full, deep
inspiration, followed by a rapid expiration, which causes a short period of re-
laxation, which can be taken advantage of by the examiner.

RECTO-ABDOMINAL TOUCH.

Limitations.— By this method of investigation we can palpate the entire
uterus. It is especially used to examine the jiosterior surface of the womb, which
is more accessible through the rectum than through the vagina. Again, recto-
abdominal touch is employed in children and unmarried women and in cases
where the vagina is abs:;nt or the scat of a painful affection.

Information. — W'c can recognize the shape, size, consistency, position,
and mobility of the uterus, as well as the presence of neoplasms. The re-
lations existing between the uterus and a retro-
uterine tumor can be more clearly outlined through
the rectum than through (he vagina, and in all cases
which are in any way doubtful the rectal examin-

lieTRODfi or CXAUI.VAT10N-.

303

■ tion tihould itlwitys supplement the vaginal 10 cod-
(trm or disprnvc the (iiagnosts.

Preparation of the Patient. —Same 11* (or Indirwi Inspection.

Position of the Patient. —The examination -thould l»e miide with the
(uiirnt m the itorsul poiiition.

Anesthesia. — In some cims an anesthetic is not rc(|uired, espedilty In
women who are thin; l>iii, as a rule, a thorough invcsiiEuriun cnnmil be made
nnlen the pnticnl a nncthvtized. It it therefore neceiisary
ti> employ 30 anesthetic in women who are fat or
aervnu!i, and alia when pelvic inflammation is
present and the parts are too tender to palpate.
Children and unmarried women should always he
examined under an anesthetic.

FK. jak^CKAMDunoK or nu I'tnr^ ai tttno-taDomniii, Tovoi.
SboH* Ibt ■wlknt <4 rmnBiw«i> ■ tmrmtfiai iiuMf.

:htlic. — After plai-in); the patient in the donul position the eiiiminer
-lan'l* in front of ihc loilva and [wsws ihe index-finfEer of the Icfl Kand into
Ihc rcitum with the jKilmar surface dircclcd upwjnl. The fingers of the free
ind now make prcwurc <l<)wnw;inl ihriiuRh the iilxlominiil wall in the direction
Ibi; pti'mnntory of the sacrum, if a retrodis}>lacenKDt b present, until llic in-
■I finder feeli the counter- resistance communicated to the uterus. The
■ctal &n^n is then passed over the posterior surfncr and the sides of the utenis,
^'linf: the shape, sixc. consistency, position, and the mobility of the organ, as
"ell as any adjacent [Mth'>lo)tie lesinns (FiR. 309).

U tlie mcrus is siitiafcd jnlrriorly, the fingrrs of the free hand press the fun-
diM barkwani m> a* tn Ixinj; the |><»>terior surlaie of the uieru-> within reach of the
ncul finjier (I'ig. 310)

Udurint; the examination the intestines arc found crou-ding the pelvic orK>ns,
the finiter i* withdrawn fmm the rccluro am) the [latient placed tem))orarily ia

Tin. JIB,— ExAUSUTioit OP mt t'nkui ui Ric lu •■nniUNu Tom.
Shorn a iKirmillr ni'ui'ri uihiu Iirinji piuhid bukmnl usuui ilir fiiigci in Use naua. TIk dMIid aiUiw

shon IM araUltUr dEplixvmrni

by keeping the hips constantly higher thuii the abdnmcn while she is being turned
upon iter back. The iniernul TinRcr can be passed higher up in the roctum by

UETBODfi OF EXAUINATIOK.

30s

nuking fam pressure with the knuckles of the naminme hand ngninM tltc anus
and the pnineum (FIk- ftS)' A icmpomn' rvLixaiiim of ihc nbdominal
muiclr^ ami a deeper (ouch can be obtuincd when ibc puiienl is tiol under an
■Dr^lhetii, liy hutini; bc-r Uke u Ion;; in->|itr^ti(in fullovrcd by a .short expiraiion,
and inljuling th« parts rapidly while tlte uir i» being expelled from the lungs.

RECTOVESICAL TOUCH.

Ifimitations. — Tbi'' melhoil of o.u mi nation is wry seldom employed,
atHt it i» only U)«d to drletmine the pre!«nce or ab^^ncc of the ulenis in cases tn
which the ^'agiaal cinal is coni;enitiilt)' deficient ur entirely obliterated.

Ill'

Buiiuu SncMO.

iKtiiiiiRKt Vm torn SitMiHUTun ta mi Dmn >v Kumwauui.

Preparation of the Patient.— The rectum should l>e emptied with
an enetaa of soapsuds and warm water ami the urine vended naiimlly ju.->t before
the examinattnn. The <,-or>cls should be remoi-ed and all clothing that restricts
the waint mu&t be loosened.

' \)-

'-^^^'

k,^^.

Pn 111 fK 111

KluiinaniHi Or nt Vntvt n Kmi/i nitM TOpt*.

Kg. in ikixn Ike inroiu •tnal; Vig. ]ij ihcnn ilw uichh invaL

The cilrrnul urfniin- me:ilUfi and ilie vulva ^uuld be tht>miiKhIy MerJIued
hv vTubbinx the (ttrt.* with a piu;cr sponge saturated with tincture of pecn
wdp jnd wtirm water, and then washing them with a solution of t-orrosivc subli-
fiutrt I i» 70001, which in turn U remi»'e<l by douching with normal ^alt solution.

pDgitlon of the Patient.— Dorsal' posture.

306 THE UTERUS.

Instruments.— The only instrument that is required is a small steel
bladder sound having a slightly curved tip (Fig. 311).

Antisepsis. — The sound is boiled in a soda solution for five minutes and
then placed in a tray until ready for use. The instrument should be lubricaied
with sterile liquid white vaselin to facilitate its introducdon into the bladder and
the examiner should wear rubber gloves to guard against infection.

Anesthesia.. — An anesthetic is always required.

Technic. — The examiner sits in front of the vulva and exposes the urinan-
meatus. The sound h then introduced into the urethra and passed directly into
the bladder. The index-finger is now introduced into the rectum with the pal-
mar surface directed upward and the tip slightly bent in an anterior direction.
The end of the sound is then turned toward the base of the bladder by rotatini
the handle and an effort made to feel it with the rectal finger. If the tip of ihe
sound is felt by the internal finger when it is moved up and down and laterally
in the pelvic cavity, there can be no solid body occupying the pcIWs, and hence
the uterus musl be absent.

AKTIFiaAL UTERINE PROLAPSE.

I^imitationS. — A more thorough and complete examination can be ob-
tained by this method than with bimanual [»alpation alone. The entire surface
of the organ can be distinctly felt and thoroughly palpated.

Information. — This method may be used in connection with vagino-
abdominal and recto-abdominal touch. The lesions which are usually ascertained
by these examinations are more clearly defined and more easily recognized
when the uterus is drawn down toward the vaginal outlet than when the organ
is examined in the usual way. Artificial uterine prolapse
should therefore be practised when the results of an
examination are unsatisfactory and the nature of
the lesions uncertain.

Preparation of the Patient. — Same as for Indirect Inspection.

Position of the Patient.— Dorsal posture.

Instruments. — The only instrument required is a pair of bullet forceps.

Km. inr — Jk'LLET l-'oicfrs.
Inslnjmrnl use-i m iiutinc ^n nniii^iai uleriar |iro]aj]H.

Anesthesia. — An aneslhelic should usually be employed.

Contraindications.— This method should never be jiractised when ad
hesion> or an intlammaiorv tubo-ovurian disease is present. The uterus shouW
be mobile, and if it cannot !«■ <lrawn down without using undue force the medioc
musi not be attempted.

Technic. — The examiner sits in from of the vuhn and introduces the inde.i
finger into the vagina up to the cervix. The bullel forceps is then passed alonj
tiie finner lo ihe cervix, which is seized by the anterior lip and slowly pulle*

UETaOUS OP EXAWKAnON.

J07

down dnee lo the wIvovBgiiul orifice. An assistant now talcu the iortxpt and
holds the crrvix in tbk poMiion while the examiner introduces the index-finger
o( the left hiind into the recttim iind pliice* the fingers yf the free hand on tht
abtJiimet) just ubcive the [lubes. The fiindii<^ and i>osterior Mirf^ce nf the uterug:ic condition* found. In nnler lt> pnlpale ihc anterior ^urfiice o( the
ulcrus thnnigh the nclum the ctaminer hooks the tip of the finger o^'cr the

Pn). 3IJ Flu. ]■«.

AantKMi t'tnnit rMurtt.

I da lii» fcii mm) poantni nil «f tin vuni lutai ibIpdIhIl Fif. i<a ihovt iIh n«tl hntn hWiHJ
•«« iht lanilii* iM iNt koiaK* hiU oI Iht uuwm \ir<nt |i>l|i>lnl.

fiiivluf and gnidtuUy pulls it downward toward the perineum. Ihuii producing an
rugi^iemled dcpree of retroflexion.

After-treatnient.— When the cxaminallon if compieietl. l)ie foreep* b
•!etache«l from the ci-rtix and ihc uterus restored ul once to its normal pinilion In
ihr j^Uii. This is acconiplishot by pushing the cervix up with ihe indcxfinKer
■ml •Imwinc tlie fundus fiirw-.ml t>y the alvlominiil hand.

The puiirnl sb<iuld renuin in bc<l for ut leAM twenty-four houts lo guard
apiiM any possible bad elTeci from the manipubiions.

SOUNDING.

Infonnation.— The uterine wnind t» wldom uwd 111 the present day.
Foimertr, however, tt vias constantly cmp1o)-e<j for diagnostic puipoMS. and
many cijks oI -^piic endometritis wfih »ul>^i|ueni tubal infiMion foilowvd its
otr, The n>mm"» (iraciice among some ith>'>inani' of tiiumling llie uterine
■ riiy u a routine melhiid of diasiKMt^ is dangerous both to the health aiwl the
' of their fialicntJ), aa K])iic infection followed by pelvic complication!! is likely

3o8

THE CTEKUS.

to result. The larger my experience grows, the more I am convinced that a safe
rule to follow is, never enter the uterine cavity nor the
cervical canal unless it is done under an anesthetic
and with strict operative antisepsis.

So far as the diagnosis of uterine lesions is concerned, nothing can be ac-
complished by the use of the sound which cannot be more satisfactorily and more
safely ascertained by other methods of examination, and hence the instrument

Ji;.— ISSIKUMENTS USED K>» SOCBOINC ™i UlBHTt.

should never be employed except in making a differential diagnosis between an
inversion of the uterus or a polypus or to probe a uterine fistula and to locate a
congenital or traumatic atresia of the canal.

Preparation of the Patient. — The urine should be voided naturally
just before the examination and the rectum should be emptied with an enema of
soapsuds and warm waier. The corsets should be removed and all clothing
restricting the waist must be loosened.

.bi

Fic, ji8,— I'tekine Sounp. Acrtm, Siif,.

After the patient is fully under the anesthetic the vagina and internal oi^ns
are thoroughly sterilized (see p. 831).

Position of the Patient. — Dorsal position.

Anesthesia. — An anesthetic must always be employed.

Instruments.— The following instruments are required: (i) Goodell's
speculum; (z) Simon's speculum (curved blade); (j) uterine sound ; (4) bullet
forceps; (s) dressing forceps.

MALFOKUAriONS.

309

The uierinc found a a long ^ur^cal probe made of copper and pUled with
nickel. To nurk the normal Icnglh of ih« uierint- c.ivity a knob i^i niiiilt nn the
in-'inimeiii si inrhc* (mm its lip, which serves as a guide lo iiHJicale how £ar the
koumi h;k^ cnivnxl ihc uterus.

'>.

VV;^;CL:

:!" _}

{sepsis. — Th« in^imments are stcrllixed hy lioilinf; ihcm in a Mxta

_ [>n (iir (ivf minulcN.

Technic— The examiner sil? in front nf the vulva, introduces the ajicculunt

ntu the va|(ina, and cxixme:* the cervix tn view. The .-interiur liji {>■ then *eixed

irith bultel forceps iiml held in <i fixed poeilion while the cervical and uterine

il is explored with the sound.

MICROSCOPIC AND BACTERIOLOGIC EXAHINAHON.

Ifimltfltlons. — lliev methiKlx of inve«ti)Kilion are limited to an examiiu-
lion 111 ili6ciiarg<«, udscd fragments, and curct fiodings frocn the cervical and
uterine ovitiri.

Isfortnatlon.— We can dclerminc the character of the infedion in cases of
rodumetritis; lite aleence or prescn<'c of ntaliKnani deRcnera lions; and the
nature «f "ihrr [Ktth«li)t[i<' (on<tilioibi.

Technic— The methods nf atlleciing and pfcseT^-ing the specimens for a
«ubaci|uciii miaxwenpic or hacirrioloKtc examination are fully dlicussett in
II.

RALPORMATIONS OF THE UTHRUS.

JJirrine anonutlles .ire readily understwM) bv rerallinf; the fact thai the uterus
\-axii>-i result from the (-(>:ilfS4'enc« ur fusion id the lower |Mirlions of the
. of Muiler and lluil the up|M.'T pgirts of these lubes, which do not unite,
Iwannc the oviducts or the Kaltopian tubes (Figs. 320, jit, 31a, and 32^).

3IO

THE UTERDS.

The following uterine malformations have been observed :
Double uterus. Rudimentary uterus.

Septate uterus. Fetal uterus.

Two-homed uteros. Infantile or pubescent uterus.

One-homed utems. Absence of the uterus.

Anomalies of the cen-ix.
Double TJtems (Ulems Duplex or Didelphys). — This anomaly results
from a failure of union between those portions of the Miillerian ducts which

fii;. .ijo. Fir.. .111. Fir. 111. Fig..(i3.

DeVF.IQPHFNT of THF. VAr.lNA. ITIE L'TEEirS) ANP THE ^AtUIFIAN TuBL-S ritOM UI'LLKA'd DuCTV {paflC jro),

normally coalesce and form a single uterus. If the lowest portions of these ducts
also fail to unite, a double vagina is formed and each cen'ix opens into a separate
vafiinal canal. While these two anomalies are usually associated, a number of
cases have been observed in which a double uterus was present and the vagina
found to 1)6 normally developed. A double uterus consists of two distinct organs
lyinp side by side bui not united, and each has but one oviduct, one o\'ari', one
n>und and one broad ligamenl. Menstruation, as a rule, is normal; pregnancy

Fni. ,iJJ — DOI'BLI I'TFIft-?^.

Flo. jas-— Septatt Ttfut:*.

mav occur in both uteri at the siime time; and childbirth generally occurs without
accident. If, however, one uterus is im|ierfiirate but functionally active, it
becomes distended with blood at the time of putjenyand a hemalometra is de-
veloped.

Septate TJterus {Ulems .S'e/'/i/jy— This anomaly results from persis-
tence, wholly or in part, of the coalesceil walls of the united Miillerian ducts,
the uterus being single, so far as its muscubture is concerned, although its in-
terior is (li\'idefl into two cavities by a septum or partition. This septum may be

UALPOKMAnnN'S.

CDiDpktc and riclriul from the fundus to the i^xicrniil os ulcri, or it may be hi-
amfikXe (uleru) iuhteplui) and divide off only a part of the ulerine cavity.
MrastTUi>lii<n, ai » rule, ocmni normally, iiiid prcKiuincy mity lake jtlxce in either
tuU ul file utcniii i>r in both at once. Childbirth usually occurs wiihout any cotn-
pliu(lion& UDle&A the placenta ia attached to the septum, in which case a serious
p(Ht-]Nuium bemcwrhagc may rc»uh. A Mptatc ulcnis may be auocisled with
cither n double or <inKl<* vaf;ina.

TwO'homed Uterus [Vlrriu BiVorwM).— This anomaly may be defined
iL£ duplinty to a greater or less degree of ihc body of the uierus. while the lower
pan of the tjody and the cervix are siniile. The dupliciiy may be slight,
beifiK indi*ate<l liy a wHfh on the ftindu!' (iitrrns forJijonnis), or it may
extend .ilnKKt to the os imernum. In ilie latter case there may be found a
»e|Xum junially or completely dividing the (.-crvital c^nal. Af^iin, the devetop-
meni lA the ivt-o horns may not be symmetric, bo that one may Iw liirger than the
other, and in some taws tliere vrill be found more or less divtiion of the vagina.

This unomalr retulls from failure of union between the Miillerian duels to an
extent «ormpim<)tng to ihe (kgree of duplicity in any individual case.

'-r

Pn.j>;.~5r.i^iul VWk.

Twa-uoai'iD VmrL

led Uterus ii'term t'M(i'«rF*fi).—Thb malformation differs from
i|; in thill ihi- Mullerian ductH have nut only failed lo unite throughout
area, but tlwit one duct has fniWI lo devclo|) uterine charaetemtics,
(ir.ir IMC >'(her has gone on lo the pnxluction of fleshy walls, uterine glands, etc.
Hence the F.iUoptun tul^; on the ni)n.4lev«lo|x'd $ide opens into the base of the
tiofit uterus hi>m, More commonly, howcvxr. there will l>c .i twlic only on the
(idc of ihe uterus lioni iiuo whii'h the lattirr genenilly merges ai its upper ex<
nUKi ' fine no (umluN ulrri. In tvises of uniiornaie uieru* both ovaries

tttty i ii. but the uterine liganKnt", the ureter, .ind the kidney of the

aSccinl uttr m;iy l>e idi>ent nr rudimentar>'. The anomaly h not at all tocoro-
(■lililr «ith n"rm:il men^imntiitn and prejtnitmy (Fiji- .ij8).

ftndlnieiltary Uterus. — The dewlopment of the uterus may have been
arR^irdat -ucti an early |irri<Hl of prvnatut life a» to have produced anorganwith-
"Ut any of the essential uterine chiiriclrrisiics,find therefore functionally u»elcsA.
Thrrr may be total b<k of mus4.'ulalure (rtttrui w/mfrnind.'mwi) and the ni-
dtcDMiiary organ may prewnt only a partial cavity or the cavity may l>e entirely
abteal. In tite bttcr en-« there has lieen a partial amst of development In tlw

3ia THE UTERUS.

first month of feul life, during the stage when the Miillerian ducts are still solid
cords of cells.

Such a. serious defect in development as a rudimentary uterus, as might be
expected, is usually accompanied by defective development of the vagina and the
oviducts. The ovaries may also be detective, while the external genitals are less
apt to show deviation from the normal condition.

Petal TTtenis. — The fetal type of uterus is due to the fact that develop-
ment has not progressed beyond the stage normally present at birth, at which

Fio, jiB. — OmnDiNED t'THii-5 {ptgt jii). Fw. jte-— FnAL L'i«»ii».

time the cervix is larger than the body of the organ, the fundus is absent, the
cavity is narrow from side to side, and there is no distinct intemal os. Poor,
or even absolutely defective development of ovaries, tubes, vagina, external
genitalia, or mammx is apt to be associated and produce corresponding functional
derangement.

Infiantile or Pubescent "Uterus.— This form of defective develop-
ment dil^ers from the last in more nearly approximating the normal virgin
uterus. The organ has the characteristics common to the uterus of childhood —
a relatively larger uterine body being one of the chief points of distinction.

FlO. 3 to. — iNJAKIILt UlE>U».

From an mfanl vat moalh uld (cntHlLtipi froni Surica).

In these cases menstruation is apt to be absent, or it may be scanty and as-
sociated with dysmenorrhea and vicarious bleeding. Sterility is the rule, although
in exceptional cases, as the resuh either of treatment or of a spontaneous growth of
the uterus, conception has occurred and pregnancy continued to term. Usually,
however, if impregnation docs lake place the product of conception dies and
abortion occurs. The sexual appetite in these patients is usually more or less
impaired, but, on the other hand, it may be perfectly normal.

INJVRIKS or TlIK BODY.

313

Absence of the Uterus. — Complete alweiice of the uleru^ is a very rare
ocaurrnce, and, as a rule, in ili(»« r:i>«s in which 5uch a duifcnons was made
^durinj; life an autopsy has rc%-eal(-d some slight w^ligc of the organ. The
aouty i* u^unlly u.->soi-iate[| mth ilefemive <levi-lo|>ment in other genital orgxm
IS well a^ a gencnilty ill-(lL-vel»t>c*] ph>vi<]uc, allhntigh tl may be found in women
who art well proponioned and othcr«-isc perfectly formed.

Anomalies of the Cervix.— Mnlfurmm ion of the cervii may exist alone
in connection with other genil^l defects, especially of the body and fundus of
the uterus.

The folhtwing cer»k.nl malformiUions have been noted: Atresia, stenosis,
Dnption or h^-pcnrophy. a conical shajic <if the ccmx associated with a pinhole
I, ab»ence or defective develupmenl, and a doulilc os uteri.

DISEASES OF THE UTERUS.

INJURIES OF THE BODY.

CanseS. — Owing lo the position of [h« nnn-sraxld uterus il is so well pro-
leclcd (hat evta when the vafjina in the >«al of a severe injury it usually e»cmpes
Itogeiher. When, howevrr. pregnancy occurs the conditions are changed, and,
a* an abdominal organ, it is expose*! lo various forms of trjumatism. I'lerine
injuries nry in im)H)rtance from a simple contusion to a brge wound com-
munkaling with the iN-riinncal caviiy.

The causes are conveniently divided as follows: (t) Parturition; (a) cx-
tcnui iriolenee; (3) internal violence.

Parturition. — The uterus may be ruptured during labor. (See treatise on
ofcAtetrics.)

External Violence. — Although injuries from this cause are companili^'ely
rare, still quite a number of cases haw been reported where tlie iruumatism had
muhed from .italilnng, ^liootinx, kicks, blows, anil the horns of an ^rninul,
A^in. the iire^nant uterus luis been mislnken for a cyst and a trocar plunged
tnio it at the time of performing an abdomiiud section.

Internal Violence. — niis is ihc most (requent cause, The« injuries may
occur iluring an iniriiuterine operation or result from an attempt to perform a
cTunituil abortion. Under ordinary' (Wuliiion-H the walU of the uterus are 10
tim and resistant that llicre is but Utile likclihnod nf causing an ojx-rative in-
jury, but when pregnancy exists or the organ is the seat of malignant degeneration
or Mptic infection the livMies become noft and friable and there U always danger of
prnctrating into the peritoneal cavity with a curct or a uterine sound. Gmve
and ultra fatal injuries have been inrtlclcd upon the utcnis in atlcmpling to pef-
fortn « criminal abortion with a tent, Mxtrvi, mtlieler, or iNiugie, an<) ver}- ex-
tetttivr trounds ha\-e also be«n caused by women themselves iniroducing various
.lorrign objects into the uterine caviiy for the pur()ose of ending ge>tation.

A very intert^ling case ilhiMnting the mrlhoils of profe^-ioreil aborttonists
irrvd in my service at the M«iico-Chirurgital Hospital in 1897- The
,]Mlieni upon whom the abortion had tteen performed was a single woman twenty
of age. The alM>niont*^l inserted u tu[>clo tent into the uterine caviiy aiul
ided her to take hold of the siring which was attached and remoxT il on the
inDowing day. This she endeavored lo do, but without success, as Ihc lent couki
out be diiloilgcd. I mw the case for Ihc (irsi lime tvro days after the criminal
ion, when her general condition was bad 1 the temperature was lo^** F. and

pulie t4A j>er minute and very weak. From the hurried history 1 received of
Ibc ca>e 1 believed bcr condition to be dcpejidcnt upon a septic cmlometrilia, and

THE UTERUS.

at once dedded to dilate and curet the uterine cavity. Upon introducing my
finger into the vagina a loop of siring was found hanging from the os uteri. This
was easily removed, and after dilating the uterus its cavity was found to be
empty, which led at once to the suspicion that the tent had been forced through
the uterine wall when it was originally inserted. I had no difficulty in discover-
ing the perioration with a uterine sound. The abdominal cavity was then opened
and the pelvis found shut off by recent adhesions which were easily separated.
The tent was discovered lying transversely in Douglas's culdesac. Supra-
vaginal hysterectomy was performed, followed by glass drainage. A glance at
Fig. 331 will explain why a hysterectomy was done instead of the more simple
method of closing the tear. In the lUustration the tent is placed in the false
passage lu indicate the direction and extent of the injury. The tent penetrated
the uterine wall at the internal os, passed obliquely upward, and was forced through
the serous coat posteriorly just beiow the left horn of the uterus. The oblique
passage thus formed could not be drained into the uterine or cervical canal, and
as the uterine walls were aheady infected hysterectomy was indicated. The
patient made a good recovery ("Medical Bulletin," Philadelphia, July, 189;).

Fio. jji.— liHus I'KinoiJAiEii BV * 1 iPtLo Tr.st- l»coun.Tir. ABnoHiKuL IliraiEt£cn»iT — REcovKai

(.Autsor'r CaskI.

Dia^OSiS. — In cases due to external \iolence when the woman is pregnant
a positive iliiignosis of ihc injury cannot he made until the uterus is examined
after opening the alxlomen, as ihe general and local symptoms are the same in
all severe injuries of the abdominal viscera. When the uterus is perforated during
an intrauterine operation, the resistan<.-e to the instrument suddenly ceases and
the Dpcraior rcali;!es that the luret or sound has jwneirated farther than the nor-
mal limits of the uterine cavity. I'^urlhermore, if the abdominal walls are thin
the end of the instrument can he readily felt through them.

Injuries caused by criminal altiirtion can only l)e sus]iected by the develop-
ment of sepsis, but as this sj'mptom is very often due to infertion without trau-
matism we cannot he certain of the diagnosis until t!ie uterine cavity is dilated
and exuminet] for t!ie presence of a wound.

Prog^nosis. — Pregnancy always increases the danger to life in injuries of
the uterus. Miscarriage follows, as a rule, and death often results from hemor-
rhage or septic infection. The extent, situation, and character of the wound
must always be considered, as these conditions determine the nature of the
operation and the post -operative complications. Thus, for example, some in-

FOftFJGK SQDIES.

5*5

arics only require sutunng the lorn ulcriiK- wall: others, again, give a positiM)
wliaiii'vit fur hy>trrcciomy, and, finally, cesarean section may be necessary to
ive thv life »{ the mother.

Pcrliiration o{ the uterine wall with a curcl or sound during an aseptic openi-
k*n is «ekli)in followed )>y bad reNults, l>ut iS tlic uif>e h scpttc or the anli:«ptic
jianiili>«s ha^Y been imperfect infection of the |>cril<ineum b> likely lo occur
I eniuc.

itznent.— The jiriiKiples underlying the ireaimenl of penetrating
]<i of ihe ahdomen tttiiM be applied to injuricK of the uteru« resulting
Itoin MabbiiiK, ^homin)!, or the horns of an animal. It is, thcieCore, impcralive
I caws to make an explotalfwy incision at once and aHceriaui tlw chanictcr
injur)' wilhoui any reference vrhatcvcr lo the probabilities in the c.i<e. il
lm|w>^>ibleiodetermineibenatureof the injury or the orRdns involved until the
kUli'mcn h ofiened, when a careful examination w-ill rc\'eal the true condilioiB
aniJ the indications for ireaimenl.

If the uterine wound has ivit resulted in an extensive loss of tissue, il should
■ closed vfith interrupted calgut or mIIc ^u^«^^^, <ilherwL»c a >upnivaginul hysler-
lomy sliould be performed. In wounds ihai arc treated by suturing ihc torn
the <iuR>tion of ceMirran section ni^turalty prescnti itaelf if the uieru& lias
Kit licen emptied sjiontnncouf.ly cither thmugh Ihe n.ilur.d piu>Nige»> or inio the
ilidomitui laviiy. If ihc liquor iimiiii has noi escaped, il h fair lo presume ihat
lie child tia^ ni>l )>een injure*], and, therefore, cesarean section in not Jiidiculetl.
lot if Ihc membranes have been ruptured, the contents of the Uterus mUM I>c
niiwsl ihrou;!h the ul*domeii Ijeforc the icjr in the uterine vr^U is closed. If
tie pn-gnunt uterus is minlakcn fiw a cynt and puncttirvl with a trocar and the
membranes nj|nurcd, cesarean <c:tion inu«<t be periormcd at once. Hut if they
ivc CM a|>C(J injur}-, the content-i of ihe uicrw should be left undisturbed and the
ind closed with inicrruplcd sutures.

i.« Mimctimes ditlicult to decide upon the |iroper course of ircntmcnl in in-

niUAvd by inlenial violence, and thv >\irgcon h therefore often cidled u|>on

more than ordinar}- judgment in dealing with \\\e^ rases. If (he

i hu l)«en pumiureil duriii); an operation, nolhinf; should be done except to

I Ihe |Kiiicnt ((uici in bed for u week :ind m«ive the Imwel." every r|ay with a

lUnc. Kecial enemas should noi he employed, as they distend the bowel and

fplace the pelvic orgaiv, and miMriiucnily inierfcre with healing of the uierine

jund. Intrauterine injccciiins are also positively

^umratndicaled. a^ the fluid mar be forced into the

leriloneal cnvity and »el up a septic inflaniniailon.

' pubc aiMi temperature must be carefully watched, and if there b the slightest

u of iep>Ls ilw alxtonien sliouId I>e opentti at once and supmvaipnal

my pcrformeil. When the interline or omentum ha* proliifMed inio

Si -4ii*i lilt: cavity, the abdomen shoukl be oitencd at once, the Imwcl rcpticetl and

oDuiihty wrasheil with hot nornui n;i1i -1uiion, and lite wound in the uienis

*rilh intemiploil sutures. If the case is septic, hy»lcreclomy >hould be

ami if tlie pil has become gariKrenous, it should be resected and

inited by an cnd-lo^nd or a lateral anastommLs.

FOREIGN BODIES.

Caniee. —Foreign IxNlica arc not often found in ihe uterus. They may.
be €>cciu>ioiulty placed there by desii^n or accident. Various objects
jby women l" induce abortion have l)een found in the Uterine cav(ty and
vfMntnti have forftotlen lo remow gauze umpons which were placed in the uterui

3i6

TBE UTEXUS.

at the time oi an operation. Sometimes an instrument or the nozzte of an
irrigator has broken ofi during an operation; a pie« of cotton or gauze has
been unintentionally left in the uterus; or the stem of an intrauterine pcssai?
has become separated from the rest of the apparatus and retained as a fordgn
body.

Symptoms. — The presence of a foreign body causes an acute endometritis
which is accompanied by a more or less foul-smelluig leukorrbeal discharge, and
in some cases painful uterine contractions occur as the result of local irritation.

The character of the discharge depends upon the nature of the fore^ object
An article which is bard and has a polished surface will simply, for a time at least,
increase the normal uterine secretion, while an absorbent object is generally in-
fected at once and the discharge becomes purulent.

IHagnosiS. — It is impossible to make a diagnosis before the uterine cavity
is dilated and the foreign object found, except where the history of the case gives a
definite clue.

Fic. 331, — iHSTinfENTf; K.'^ZD IV RruosHNC FoimaN Bodifs ranu the UmiA.

Results.— Septic infection is likely to result and extend to the oviducts. If
the foreign object is composed of hard material, it may eventually ulcerate through
the uterine walls into the bladder or pelvic cavity. In some cases the walls of the
uterus become infected and contain collections of pus.

Treatment. — The indications are to remove the foreign body and treat the
complications.

An anesthetic must always be employed except in cases where the foreign
body is seen at the os uteri and can easily be withdrawn with forceps without
invading the uterine cavity. Whenever it is necessary to di-
late and explore the cervical and uterine canals,
the strictest antiseptic precautions must be car-
ried out, and this cannot be done unless the
patient is under the influence of an anesthetic.

Technic of the Operation.— The Preparation of the Patient
and the Preparations for the Operation are described on pages
830 and 831.

fXlxniGN BODir3.

3*7

Position of ihe Patient .—Dorsal position.

Number n f Asslsiania. — An ancsiheiuer, one lusLnUint, and
I general nunc.

Instruments. — (i) Simon's speculum^ (currcd and flat bbdes); (a)
two bulkl forccpx; (3) Gtwckll's heavy uii^rinc dilaior; {4) uterine sound; (5)
mai^l scisson; (6) dressing forceps; (7) Sims's sJiurj) curet; (S) Martin's
aircl; (9) diblinK uterine douche.

O p c r a I i <) n . — 'ITir iilcrine cavity is dilated (iWe \i. 955) and the fomgn

budr located with the sound. It is then sciivd with dressing forceps and care-

(uUjr cjitraclcd. The uterine csiviiy is finiilly flujhfd with a iulution of nirroslvc

kte (I to 3000), followed l>v normal salt volulion, jind the vagina dried

^and loosely packed with a strip uf fiauze. The vulva is then proicaed wit)i a

oonipreas ood T-batxlage.

>-m^k>'i ii

he. iM. — Riaovimi « rinmiii Dom nnii na Vnao*.

Vaxiations in the Technic— If the foreign substances cnnsist of brokco
inccc of xb^< a careful cxi>U>raiion of the ulerine ca\ iiy must be made with the
lound li avoid the iHiviihihiy of overlooklnK »<>nie of the fragments and leaviitg
ihem in the ulenis.

lilj)ccti> which are iml>edded in the uterine tUsues may rc(|uire an extensive
m for Iheir removal. Thus, acoir^ling to Rct»), "Miltermaler found It
ale III rttnovc the frt^mcius of broken x^ss from the taviiy of the uterus,
111 ai.ctimplt-kh which he had to diviite ihc uieru> from ifte bbdder. draw tlte fun-
dut down into the vagina, and make an Incision into the uterine cnviiy. Having
rray>ve<t the glua. he vtitclied up the incision and relumed the womb to its
atimul position."

If Mptir endomctrilb has rcsuhe<) from the presence of the foreign body, the
Uttfinc cavity muM Ih- cureted (^ev lechnic, p. 955), and if (he walb of the utcnia
ksirr beciimc infected, supravaginal hysterectomy (sec technic, p. 9S4) h in-
t dialed.

3l8 THE DTERDS.

After-treatment. — The after-treatment is fully discussed under the opera-
tion of dilatation and curetment of the uterus on page 96a

DISPLACEMENTS.

GENERAL CONSIDERATIONS.

The Normal Position of the Uterus.— Normally the uIctus lies be-
tween the rectum and the bladder and below the abdominal cavity and above the
vagina. Its long axis forms a right angle with the long axis of the vagina, while
its fundus touches a point a Uttle above the plane of the superior strait. The
uterus is slightly anteflexed with the concavity of the curve fadng forward; the
anterior surface of the body rests upon the bladder; and the cervix points back-
ward toward the coccyx.

The uterus is not fixed in its position but moves normally within certain limits
as it is influenced by various conditions. Thus, the act of respiration imparts to
the uterus a continuous up-and-do-wn motion, ascending during expiration and
descending during inspiration. A full bladder pushes it backward, while an
overloaded rectum accentuates its forward position.

Ftc, JJ4. — Normal Position of the I'TTitDi.

.Again, ihe abdominal pressure evoked during defecation and urination
presses il lower in the pelvis, and, finally, its relalions are influenced by the posi-
tion of the woman, being more depressed and further forward in the erect than in
the dorsal recumbent poslure.

The SapportS of the Uterus.— It is impossible to clearly understand
the nature of the influences that are ut work by means of which the uterus is sus-
pended in the pelvic cavity unless they are studied as a whole and realizing that
no one factor is independent of another, but that the harmonious action of all
determines the result. The uterus is held in position by the following forces:

The pelvic flfwr.

The pelvic organs.

The retentive power of the abdominal cavitv.

The ligaments.

DISPLACtMIINTS.

3 '9

The Pelvic Floor. — \s the uicrub is tuspendnl in the pelvic between the
abdominal cavity and the |>clvk floor, it naiuraUv follows that the latter conirib*
utct U> il« ^uptK'^l. The jiclvic Boor, llivrcforc, by preservin)]; ilie [XMicion and
integrity »( ull ihc organs and ^nfi parts of the pcKis indtrcclly »u[>|K>rts the ulonis.
When the |»erineum in turn and the vagina » no lonRcr a clo^ canal, the ab-

^iif^'

TM. ut^— ClEUv rioin»i> Fomimd by am Oikb-

dominjil prcMUie arl-« directly u[H>n ihc uterus and (orres it downward; the
bUdder l(»c» the support of the interior vaginal w» II and lieconacs probjMed,
fiTminit a fvslacelf: and. finally, defecAtion liecomcs difficuh owing lo the fart
that, the prriiwal pressure being absent, the feces are not directed toward the anal

^■il

KntcT bi PiMtiOTt ITPOK nci Sin'«nuii ar nil L'naui.

ownlni; hut are forrol sguini^t the pnnericr wallof the vdiiinn. whidi eveniu-
ally becomes rebxed and forms a ttfio<tt€. 1'he uleniK under ihe^ mnditions
aiRnot mainmin it-t normal )M»Itii>n l>eeiiuie the support <il the other pelvic
•iri^iM hiUi been taken away and all (lie iip|>er ftmctiire^ of the [whi- draf3:ed
dmni by the jinilapsc of the rectum and bladder. Funhermore. the abdominal

3ao

THE UTERUS.

pressure is increased during Ihe acts of urination and defecation and the
retentive power of the abdominal cavity is impaired by the patulous state of
the vulvovaginal orifice.

The Pelvic Organs. — As we have already seen, all the organs of the pelvis act
as cushions upon which the uterus rests, and consequently any interference
with their normal position or condition results in uterine displacement.

The Retentive Power of the Abdominal Cavity. — The action of the
diaphragm influences the position of the uterus by causing it to ascend during
expiration and descend during inspiration. These movements stimu-
late the pelvic circulation and increase the strength
of the uterine ligaments, and consequently assist in
maintaining the uterus in its normal position.

The Ligaments.— The uterine ligaments are nonnally relaxed, as their
function is not to support the uterus in a certain fixed position, but like a tether
rope to confine the organ within certain limits. When the uterus, for any cause,
moves beyond these limits, the ligaments then become tense and stop further
movement. Thus, abnormal displacements backward are prevented by the
round ligaments; downward by the uterosacral ligaments; and laterally and
downward by the broad ligaments. While the uterine ligaments are not a con-

<^/)r.

FlU IJO- t''<'- .140. FlO. Ml.

DiAnSAHa S»io'*TNfi THF TEtH»:if-ROPf: Action op the Utuihe LicAicEHn.
Id Fif. J4I the LigaEnpais arc cloag^inl and atlow KhK fuodiiB lo lfd\ back of Lbe duigrr-pouu.

slant support to the uterus, their function as tether ropes is absolutely essential for
maintaining its normal position. If for any cause the uterus becomes misplaced
backward or downward for a year or more, the ligaments become so overstretched
and degenerated that it is !mpos,sibIc for them ever to regain their normal con-
tractility, length, or strength; consequently even if the cause of the displace-
ment is completely removed and the organ placed in its normal position again it
will not remain for any length ()f time. Ijecause the tether ropes are too long and
too weak to keep it within the danger- jKiint. Normally the abdominal viscera
lie against the posterior surface of the uterus, and pressure from above therefore
increases the anterior position of the organ by forcing the fundus nearer the
symphysis pubis. So long as the abdominal pressure is directed against the pos-
terior surface a backward displacement of the uterus cannot occur, but if the in-
testines get between the fundus and the bladder then the force from above is ap-
plied against the anterior face of the womb and the organ is driven backward.
When the ligaments are normal they do not permit the uterus to fall back far
enough for this to occur, but if they are elongated or relaxed the backward move-
ment is not controlled and the danger-point is soon reached if the intestines
slip between the fundus and the bladder.

MSPLACEUBXT5.

3*1

Classification.— TV uterus nuy be displaced as follows;
DLs|>Lii«menU as a whole.

A>^i-rnt: UcM^nti Anierinrly: PoMeriorly; Lnlcrall)'.
DtspUtvincnts in version and flexion.

Ptwierinr; Antenori Lateral.
Torsion.
Inversion.
DtipUcemenU u « Whole.— By ihcM forms of ditpUcemcnt we mean that
thr i-nlirr uterus changes its position in the pchic caiily. Thus, for example,
il we move a Uible which »ccu[iioN ()ie ctrnter of ii nit>m uvet urinal tlie wall, it
fe displaced as a whoici btii if wt till it up on two of iit, legs, only a portion is
reinoved from its original position.

KIWI

^nCr»f=-

-pwlenor

3^0 lua

TW. Ml.— DiACUOT Saennini nn Dnnjuxiaiin oi thi I'ni'^ u a Wxtu.
Dtecrafh J lAm iht IaictbI dUtiAActnf deb

DispUcements lo Version and Flexioa.— By versUm we mean thai the long
^Rxt* "f ihc uterus has duinxed ils po^itioi) jnd thai it nn InnKcr forms a ri^hi an^le
ith ihc long axi* of the vagina. 'rhu>, ihr fundus may poini [xtvirriorly, liiicr-
lly, lit iiio far anlcriorly (Fij;, Ji4j}. A ^tx'um is a bend in ihe uterus which
Mft^'V* tiw iKirmal furve of ihe utcriije lunul. Tliu.*, the Ijmly of ihc uteru% may
he brill »» that tlK fundus [>c>ints [KMiteriorly, laterally, or too far anlcrioriy (Fig.

1441

Torsion.— By torsion we mean ituit the uieniH » turned u|ion iti. lonf[ axB
to that one side is RM>fe anterior than the other.

Iover«ioD.—An inversion of the utcru.s is where the organ is turned inside
^cuiM that the fundus b pushed through the cervical opening into the x'agina (Fig.

While Ihr alore cla«Mfication includes all forms of di>pUT«n>enis. il does not
give U'' ^ pr.iilkal working bii'is \i\inn which to (iin<^idc-r the «uh)cc1 from the
«udpoiot (d iTmlntcnt. for ll>c reasoti that many of the malpositions art sccon-

332

THE UTERUS.

dary conditions dependent upon pathologic lesions, and as such they are of no
cUnical importance as deviations from the normal position of the uterus.
Thus, if a displacement is caused by a tumor push-
ing or adhesions pulling or it is associated with a
gross pelvic lesion, the position of the womb becomes
a matter of secondary consideration, and the case
from the standpoint of treatment is no longer one of

uin.

F^C. J4J. — DlAGIAlCS SHOWfNO THE DlSPLACEUKTfl Of THX CJtUDB V* VtJUIOH {jMgt A*')-

Diianm a ihoHi Ibe lauril vnwuu.

Fic. 344. — DiAGUw Showinc the Dist^^rEUF^ts or the I'ntDS in Fuxton (pifc 311}.

Diagram a aliuwB ihc Jalernl flrxioDS,

uterine displacement. In considering displacements of the uterus
from the standpoint of treatment I separate those which are of primary from those
which are of secondary importance and dependent upon a local lesion. Viewed,
therefore, in the light of this classification my conception of the consideration of
uterine displacements narrows itself down to the discussion of only those mal-
positions which are of primary importance. The fact that a pri-
mary retro-displacement becomes adherent to the pos-

DI SP1. ACEU CVTS.

i»3

terior prlric periloncum docft nut miikr it of »ccoii-
dnry importance, because the adhesions under ibese
circumstances are nut the cnuse but merely nne of
the results of the ma Iposil inn. When, on the other
hand, the uterus is dragged posteriorly by tubo-ova-
rian dii>ca^e and it become* adherent iilung wElh
the diseased uterine appendnges, then the displace-
ment in clearly a secon<]ary condition, and as such il
is of DO importance from the sliindpuint of treatment.
I classify dispbcerocnts of llic uterus from the standpoint of treatment as

Primary Importance.— (i) Di^placementsBisa whole (descent or prolapac);
(a) Anterior llexions: 0) Posterior veTMons and flcadons; (4) Inversions.

Secoodary Importance. — (■) I>i^plal-ements a& a whole (ascent, pos-
teriorly, anteriorly, laterjlly); (2) Anterior versions; (3) Lateral versions and
fiexiuni; (4) T"Rvion>.

The uterus may \k dUitLi<<cd n^ a whole in an anterior, a poMerior, or a.

■^•;^

i^-"

■-V>

^j^

FM. Ml-— l>*vm™i ■>' n> l'TTav> rim* m).

it direction. Again, there may be descent or ascent of the organ. All of
(lt^pla<;fments wiih the exception of descent or prolapse arc of seomdary
■piKlaniie. liciiiK due to itrxM* jielvic lr«ion)i or lo adhe^i<>n^. Tlie ui<.'ru> may
displaced by %<crMon or llcxioa in an anterior, posterior, or latenil <lirection.
''Tbeae displacements are all of primary imixirtanre exi-ej^t tlie bicral irmons
and flexions and antervM- vcmion*. which are. as a rule, caused by jx'lvic lc^ions.
TonJunftof the uterus are always secondary to a pelvic lesion, while inversions are
dasaified under those dltpbtcemenis which are of jirimary imjiunance frooi the
•londpoinl of treatment.

In cnnsidering this classification it should l>c borne in mind that the displace-

nmtft of prim.ir)* importance ma>' Ik serondan,' nt time* if ihcy are asso^ialed

[with a peU'ic Irsioci. Thus, for example, a posterior I'ersion or llexion may tie

[flur lo I utio -ovarian ditcaw or a )urtial inv-rriion may lie cau>eil by a uterine

1 palyp. Or) the mhet hand, liowe\'cr. di^plnccmenis of sect^ndary importance are

' prjmiuy beeauM they ate always due lo a patbotof^c lesion.

3>4

THE UIEXirS.

PROLAPSE.

Definition.— Prolapse of llie uicrua is sinking or falling of ibc orfpn
below iis nurni.ll level in ihc [wlvt". Tlte exicnl of a prolapae varies frwn a
slif^l falling of the womb to iis complete escape through the vulvi>v.i]cinal orifice.
So long as the uterus remains within the \-agina the displacement t »{H)ken atu
an itKompUIr frroliipye or Jetceiuus uJfri, hut whi-n the organ ha* craped ihrou^
ihc rapnaj ojx'ning il in kmiwn jls roinpleU or loUit ptoU>ps< and a,* prtKidm^A.

Pathology. — The pathologic changes which occur in casics of prolapse
<ic)>cnd ujnin the extent of the displacement, ttlicn the prolaf)*e is >light, ibe
uterus is below its normal level in ihe [>elvis and somewhat reiroilispbcttl and iw
bng nxi.i i^ nearly in a line with ihc long iixit of the vagina. In more pronounced
cases the uterus is still lower in the pelvic aivity anil ihc ccr\ix b cloiie to the
vulvo>-aginat orifice. There is al»> more or less bulging of the posierioc and
anterior vaginal ■vii\\\>—tmocde and rjfj/oce/<— and the uterine ligaments are
relaxed.

Complete prolapse or procidentia i^ accompanied with marked chaagcs ia att

PI*. j«6.— lomm pltir .

Piount ot tHi I'Tim,

Pib. i4;.~-^o'»f'n(.

the organs anil structures of tlie pelvis, \\1ien tlie patient i.i In the erert ixMiun
or when she brars down, the uterus c«apes through the vulvnraginnl '>rihce and
hangs behvccn the thighs sujiporicd by ihe vaginal walb and the uierine liga-
mcniA. In fome latieH it Incomes hyi^nrophied »* the mult of slow intUm-
malorj' changes and remains ivrm.incmly outside of the vagtno. or it may swl-
denly become enlarged from an acuie eilcmaious swelling. The uterine mucous
membrane frequently beiomes ihiikeneil, and in ca^vs of king standing it i« not
uncommon m lind that the utenis ha» bcronic atrophied. The cervix Ijccomes
elongated and hypertrophied and is often tin- seal of ulceration. The elongation
of the ccTvix, which i-t evidently due lo tnntion, often increa.'tes the length of the
Uterine canal several inches, which is, however, greatly lessened when the utenii
u replaced. In some instances the mucous membnine of the cervical canal a
everted. The vagina is turneil inside out and hang» supjK>nf«l by its ktwer ni-
tachmenis. The culdcsac of Douglas and the vcsico-uierine fold of periloiKUm
follow the vagina in its descent and |iiiNS oubi'Je of the vulvovaginal orifice al
with the uterus. There is also a prolapse of the anterior wall o( the rectum ;

PROUiPKC.

33S

'MX

!■>*.' 1

th<r MUMrtor wall of the bUcl<tcT, forming ;» rftiotdf and fxtit^de. The va^iul
«|>itnc)ium l)c«imcs dry, ihickciMvl, and homy by being exptieetl In ihc air and
Iriaion of the rk>ihinK iirul iliiKhA in wallciitK- In some instances the continued
Irritaiinn niu?n irre^larty t^hapcd ukcn lu appear at dJITfrem |HiintS on the
cxpciwil racttui walls. The prolapse of ihc anicrior vaginal wall dispbccs the
I urethra anil libdderand unruiion Wiumen more or leu difficult and inromplele.
Th*- uterine ligaments are vlt>nKalcfl. rcbmcd, and degenerate)), and act only as
attndimrnis lo Ihc proUpc^i uterus. If the broad liftaments become Iwistetl.
the urrtcrs may lie oli>irui-tr<l ami caate a icmponirj' hydroiiephroiix. or a
iiifieottJr may result (n>m inierfeiencc with the circulalinn. The pcnioneal
culdoacs in front of aw) tichind the prolapsed uterus usually contain a onI
of iotrKlinr atkl the uterine a[>]>cndaKi-'^.

Cansea.— The causes of prolapse and of posterior displacements of
the uierui are the f»mt, and to
I'Mra rcprlilion the reader Ik re-
fertwl III jMRe ii^ for a full dfa-
fuuiitn of the '•ubject.

Symptoms.— The »ymp-
(Qcni of )it<>L-i|Ke come on gradu-
ally anti dciK-ml u[>i>n I)m- extent
of the d)s|4ji>ement. In «li^ht
ouc* of uterine descent iIkv <Io
Dot differ matcriiUy fnim thu^
ciuscd by jM><.teriiir displace-
mmi>. but in complete {trohjisc
thr jiym{>i<miii are aogrjivalcd
•0(1 Ilic jiatient suSm great
I inctinveniente. Sonw wi>men,
him-e^er.gn about for years nith
a total probpse of the utcru-^
without any annoyam'c nhat-
cvcr excc]>l the mechanic incon-
irnienre df the womb hanging
|jet*ren the thigK<.

The symptoms are cotU'idcred under the following headings:

Backadie. McRsiruation.

Pelvic <i}-mpton». Conception; l*re||:nancy.

Kcaal symptoms. Headache.

Bbdder symptomn. Digestive duiturbances.

Lrukorrticn. Ncru>u* symptoms.

Specul symptoms.
B«ckache.^ThiA is a common ;<ympt<>m. Tlie iiain U u.->Uii1ly felt over Ihe
luml'i-ii rjl nttion as. a dull he.ivy arhe. which i» more or lev rclitvefl when the

Client lies down, but which b increased in severity by the erect poeturc, walking.
ivy woek. am) ewrcise.

PsWic Symptomt.— There is ^nerally a feeling of weight or prewure in the
pvlvb ubiili is Aggravated by the erect posture and riokrni exercise. 'I'he

Klirnt often denrritit^ her sem^ilion.i an beiuinf[-(town or dragging in character,
in frc^ijcntly ni'Iiates from the inguinal regions down (he ihighii.
Rectal Symptoms. — The rectal symptoms are caused by the rectoccle or
Ijc anierior wall of the rerlum which retull^ in difficult defecilion,
ig^uiiion. hemorrhoMls. and .1 tewlency (o inllammation of the tower
LwwtL lu slight cases of pit)ki{K« the pressure of the uterus upon the rectum

V ■- '

tv,. i^.—Omnm PiiotAra at nra 1.'T¥>n nr* t>c-

336 TH£ UTERUS.

causes constipation and a sensation of fullness in the bowel which is not relieved
"by defecation.

Bladder Symptoms.— It is rare for the bladder to be aSected in slight cases
of prolapse. When the displacement is associated, however, with a well-marked
cystocele or prolapse of the posterior wall of the bladder, symptoms of vesical
irritation may result from the residual urine, and it may also be difficult for the
patient to empty her bladder without great effort unless she first replaces the
prolapsed organ with the fingers or urinates while upon her hands and knees.

Leukorrhea.— Congestive endometritis is always present. The discharge
is non-irritating in character and its color varies from a white to a whitish -yellow
hue. Septic infection of the endometrium is very rare notmthstanding the ex-
posure of the cervical canal.

Henstruatioo. — There is usually a tendency to menorrhagia, which is caused
by the congestion of the uterus and hypertrophy of the endometrium. In some
cases, on the other hand, (here are no disturbances whatever in the menstrual
function. As a rule, the menopause is somewhat delayed.

Conceptioa; Pregnancy.— While prolapse of the uterus is frequently a
cause of sterility, yet it is only relatively so, as women often conceive and go to
full term without any bad symptoms even in cases of procidentia. The displace-
ment always recurs after confinement.

Headache. — Pain on the top of the head or over the occiput is a common
symptom. In the majority of cases it is more or less constant, while in others it
occurs only at the time of the monthly periods.

Digestive Symptoms. — In some cases the digestive symptoms are marked,
while in others they may be entirely wanting. They are usually characterized
by a loss of appetite, gastric and intestinal indigestion, nausea, and constipation.
The general health eventually suffers and the patient becomes thin and anemic as
the result of impaired nutrition.

Nervous Symptoms. — Neurasthenia is a frequent symptom of prolapse
of the uterus. The motor and ^nsory phenomena are \-aried in character. The
patient in unable to take activf exercise on account of loss of muscular strength
and an utter lack of desire to e.tert herself.

Special Symptoms. — In cases of complete prolapse walking and active
exercise are often [jrevenled b)' the uterus and vagina hanging between the thighs
and the pain resulting from the irritation of the ulcerations on the cer\Tx and
vaginal walls.

Causes and Symptoms of Acute Prolapse.— Sudden prolapse of the

uterus is a rare condition, li hiis been observed in the parous and in the nullip-
arous woman; in women (luring the puerperal stale; and in those suffering with
j>elvic tumors. It is caused by a sudden and extraordinary muscular effort,
such as heavy lifting, or a fall from a height. In all likelihood the uterosacral
ligaments are ruptured, whereas in chronic prolapse they gradually become
elongated.

The symptoms are characterized by shock and severe expulsive pelvic pains;
there is also a sensation of something having been violently torn within the pelvic
cavity. I'rinution ma\' be interfered with or complete retention may result.
The uterus ami vagina arc (lec))ly congested, and become edematous in a short
time if the displacement is niit corrected.

Diagnosis. — The exiimination should be made with the patient in the
erect posture, a.s gravity anil inlra-abdominal pressure force the displaced struc-
tures down and reveal the true jxisition of all the organs. In the dorsal position,
on the other hand, it is easy to overlook a slight descent of the uterus, a rectocele
or cystocele, or even a total pnilapse unless the patient displaces the organs by
bearing ilown.

3>«

THE VTKRCS.

il while Ihc fingers <>( Ihe right hand ]mliKi1e over ihr lower nlxloincl
the position of the fundus, which is found lo be retrod isplaccd &i
nnrmal in the |ieUis.

Complete prolapse nr procidentia i$ recognized by light and
uterus and vii^iiu art fuund protruding beyond the ^-uivovagtaal
hanging ticlwecn ihe itil^hs, am] external palpation rombined with i
demonstrates the marked descent of the ulcniK in the peUic cavity (I

Tlie apparent lenfrthening of the ccr\ ix whicli occurs in prolapiic a
due 111 the vaginal v.iuh Iw-ing |iulled clown cl(>M;lyaRain.-'t the supnivni
as. the uterus descends disappears at once when the patient i^ placed i
chol jKisition and n stfeculum is intnwiuced into tlie v-agina. Vndt
cumstances the uterus foils back in1i> the [itlvic un-iiy. the ten>ion U|
ginal vault is relieved, and the structures unfold themselves and restovi
III i|^ normal length.

Differential Diag:nosls. —Complete prolapse may be m

NV^

:**^.

>>. /*'

Wrr

FI6. JSt.

Fii-M.

ibrli

OlJkoinnia or l*Koi,iiFut or nra t'nin.

>|i^UTiii clniKiMniii ill till crrvu whni lt>e paiical li phiBl Ss ihi uvr-iticM pa

inversion of the uterus, cervical pol)!^^, and hypertrophic er
cervix.

In inversion oj Ihe uUtu.i the crrvtn forms a dtfilinct ring comp
the protruding mass, and at no point of the circumference of tlie li
sound pass Into the uterine cavity. Agnin. the ap|>canincc of tl
fundus in no way resemble* Ihe cervix, and finally recto-abdominal toi
sir&tes ihe absence of the fundus of ihe uterus and the presence of M
depression above the cer\-ix. f

In ren-scal pplypiis a sound will pass into the uterine cavity at all p
circumference of the collar formeil liy the cerxix except where the
attadied unles.s abnormal adhesions exist. Kect.il touch oimbinei
dominal palpation shows that the uterus is in its normal position.

In hypertrophic nxlargefHtnl oj ihe tervix the vault nf the va(
obliterated a« in prolapiw; the fundus of the ulcnjs is in its normal po
the length of the cervix is not decreased as in uterine descent «hcn ih
placed in the knee-cheat position.

PKOLAPSK.

339

Prognosis.— Prolap^ of ihe uterus usually dcsirors a woman's health and
ttimdin. [>tMth may ocinir in nn intitaiu^s frcim obttirucijon of die unrters or
ir"m gunKtvnr uf the pruluiK^ ur^n. Good n»ult» arc generally obtained
frim irc.iinjcnl.

Treatment.— A alight descent of the utenu Li alwn>-* asiuidaieil wtib a
poMcrior (1 is pLi cement, and hcncv the trcitntcni n-ill be considered undirr retro-
utioiii un pSKe 3i(>-

1'hr irv-jtment of ]ir(>n(>un<«d ca»cs of proUjae will be dl»cus»ed under the
: headings:
The |Hre|)araiory ueutment.
The removal o( ihc oium.
Permanent replacement of ilie uter\)s.
The Preparatory Treatment. — N»ihin)c whaten-r vhotdil he .ittempted in
way of u ra<iic.il plun <>l tre<iimcni until ibe jaticnt'^ genentl heulth and local
Kltiifiti:! are pUiiiI in ibe t>e«t possible state. Careful preparatory treatment
in reducini; tli« nixe of the uteru-^ and v.i);iniii decreaHCa tke length uf the

insated (Tr\'ix: cures the ulcerations cauwd by friction and irritating dis-
and relieves to a marked extent the passive conResiion of the parts. In
iher \i<trcK, the [lerineum, the vagina, ami tlie uterus mu&t be prepared for the
itirriiuent radical opcTattons.
'Iltc prepEir:>iory irraiment h divided as follows into:
RvpUrinK iIk- utcni*.
Temporary replacement of the Uterus,
VaRinal injection>.
Pchir mil SSI gc.

Treatment of ulceration and diseased conditions of ibe eenix.
General treatment ami hygiene.
Replacing the Tie r us. —There is usually no difficulty whatever
repladng the uterus in cases of oomplelc prolapse unless the organ ts cnbrgecrtri>phy <ir [t h swollen awl cilemntiio" a.s ibe
vult o( Dfule strangulation. In uncomplicated cai^es the patient is placed in the
'liiier-diBl (Msttloii, after th(»rougbty evacuating the rectum and bladder; and

33°

THE UTERUS.

the Uterus grasped by the fingers of the left hand and gently pushed in the direc-
tion of least resistance until the displaced structures glide back into the pelvic
cavity. The position of the patient materially aids in the replacement of the
uterus by relieving the intra-abdominal pressure and causing all the organs to
fall toward the upper part of the abdominal cavity (Fig. 353).

When the uterus is enlarged by chronic congestion or edema due to strangu-
lation, the patient is placed in the knee-chest posture for fifteen minutes to de-
crease the amount of blood in the pelvic organs. The uterus is then grasped with
the fingers of the left hand and compressed for ten or fifteen minutes longer and
pushed back into the pelvis. In some cases it may be necessary to administer an
anesthetic and use some force in replacing the organ. Again, cases of acute
edema often require compression for several hours with an elastic bandage, which
is applied directly around the uterus and vagina. In some cases the application
of hoi-waler fomentations or lead-water and laudanum are all that is required
to control the swelling and lessen the size of the uterus.

Fir., isj. — TmipoiiABY Rkpl*™iekt or * PuoLiPstri I'Tim-i av tmi Paheht Heisilt is TBI Knoi-carsi

i'OHlTlONr

Temporary Replacement of the Uterus . — This is a very
essential jiart of the prc]Darat(>ry treatment, as it relieves the congestion and
reduce^ the size of the uterus and vagina. There are two methods which are em-
]jloyt'd to keep the uterus in pnsilion — the tampon and the knee-ckest posture.

The liiiiipon is intrnduceil with the patient in the knee-chest posture and
consists iif a strip of plain K^mze sufficiently long to pack the vagina snugly and
keep the uterus in position. It is secured, if necessarj-, by a vulvar compress and
T-bandaKc. and reapplied daily.

While the kiicc-clie.-:! posture is not, of course, like ihe tampon, a direct support
to (he ulcriis, yet it serves a most useful purpose in (he treatment by relieving the
engorgcmcnl of the pelvic vessels and temporarily replacing the oi^ns. The
patient should, therefore, he instructed to assume this posture for ten minutes
three limes a day and shown how to sejiaratc the margins of the vaginal orifice

■•ROLAI-SE.

«•

wtUt the imlcx anrl mujdic Angcis in order Iq admit the sir and balloon oul the

X'nicinnl InjcciionH .— VaRinal douche* o( hoi nurmal -wiH tolu-
tt<>n shiiubl be gisvn (tiiJIy hy Ihe )Ay»idun or nui^c nhcn ihc iamt>i>n is reapplied
or thcv ^h*>ukl Ix.- rmploycl iiii;ht and mtirnint; bv the fxilicnt licrself in tiiMM
vhrrr lumtM'ii:i<linu i>( ihe vu);inii h mil rmplujefl.

P c I V 1 1 M :i !i h II ); c , — Mu^^agc of the pelvic of)^Rii in indicakil in thn«
ca*e* |i> relieve (he enKiTi-cmcm of the hluul-veMeL'' and should Iw pwn unly
by a nur^ who ihomiiKhly iinik-:M:iiid> the lethnic.

Trcaiincnt nf I'lceration* and Diseased Condition*
ti( llic Cervix .^Ultvnilioiis of the cervix and \apnii which t.ccur fmm
(rii-tii>n 4Im1 irritilin^ di^chargc^ aa- u^unil)' relieved by keeping the utem« in
(vpviijon an>l cmpiuyinfi Lampoas and douches of hoi norm;il suit solution. If,
Ixiwcvcr. they arc >iu(aii'*h or slow in heatlinit, n MimulutinK ointment nhmild be
ap|)ltcd, such us ■.dfi>i>laled benzoated oxid of zinc ointment (j percent.)! or
•n»e >i>ni:tinint; iiNloforro, and ih« ttr>>"ulaiiiiK surfaces (nintcd twice ii «-eek
with -i «ilmi<in ii( nilnitc of silver (gr. xxx to is])-

The tn-jliiient uf cystic deftenctation of the cervix and e^vfsion of ihc cervical
muiini> ntenihr.inr is diMUSned on \>nne 454.

(i I- 11 c r 4 I T r e :i t m e n I .1 n d Hygiene. — Cirelul iillenlion musi
l>e pjivcn III oui'l'Hir and indoor exercises, rest, diet, and trjtiiinf;: the l«i>wel>
inu«i t>v kq>i nrfiiibr; the bbddcr must nut be iillowcil lo Iwcume (|L->.ienile<);
Ihe ilothing mtiM not <-on»lrit-l the |Kilk-iit*s wuist: and a pni|ierly adjusted
nUtomituI Itandaf^ must be worn lo increase the retentive pouer of the
utialiimen (t'tK. K50). 'Hie generid health uf the jKilienl ^lioiikt .lUn Iw n>n-
*idemJ awl the otntilutional treatment rcgidalcl In meet the indications in eiach

The RemoTti of the Cnuse. Afier the preparatory treatment has l>een
camril "Ul for mx or eight weeks areJ tin- jiclvic ^iiU(ture.-> lunt been pliurd in u
good eiindiliiin, ihr siirjtiail cnusct of the dt-^jila cement ■ihould be cnnsidereil and
approftri^ite o|ier.ilivc measures insliuiled. Thus, it nuy be necessary to repair
M UccT.nii-n i)f ihc perineum or wrvi.v; j)crform an anterior or [loilcrior colpor-
rha|^> ; .impui.ile ibe neck of ihc uirnj>; or curtt the endomclrium,

Pennancnt Replacement of the Utenis.~In considering the best meaii» to
pcmunenlly rc^'Uce Ihe uteruii after carryini; out ibe pre^xinilury tnaimenl aitd
rcnwini: a* far »* [>ossible the causes of the < t is pb cement, we must bear in mind
thai it is not only the womb which i.- prolapseil but also the ^'aKilla, tltc rectum,
the bladder, ami other ^l^ucture^ of ihc |(elvi>, an) that the normal atlacJimenls of
'the»e orKumi have liren desln>ycil. It naturally follows, there-
lore, that any form of supj^ort which will keep the
uteru* and the other pelvic organic in a relatively
normal position must act from above by fixation or
(roni below by clevatiun. The methods by which the
womb i« held in po»ilion arc therefore either opera-
tive or mechanic.

Operative M el hod »,— Thcware:
Ventral lixat>'>n of the uterus.

Supmnicinal hystemtomv folktwol by fixation of ihe cervical Mump
to the iilxlomiiuil wall.
Vmtr-il Fir>7iu>n oj llie ('feM*.*.— The object of thistnierstion blomakea firm
< liriwcen the anterior iilxliiminal wiill and the fumlus of the

I which ihc womb, ihe v.iknn.i. the nrclum. anil the bladilcr are

pulled up anil ke]>i In a rclali\-cly normnl |M»iiii>n. In other M-ord7>, the utcrxiK is

332

THE UTEHUS.

hung upon a hook sufficiently high to take the slack or prolapse out of the pelvic
structures which are attached to it.

This is the best operation in my opinion for the permanent relief of cases of
prolapse which are not complicated by a uterine tumor. It must be rememb^ed
that the resulting union between the abdominal wall and the uterus is very firm,
and if pregnancy subsequently occurs there is great likelihood of abortion or
premature labor occurring, or, if the patient goes to full term, of dangerous
obstacles presenting themselves to the delivery of the child. I therefore make it

FlO. 3S5— ^ENTRAl Fl\*T10N OP TlIF, LlMtS— Pint SUp.

a rule never to perform the operation, except in women who have passed the
menopause, without first rendering the patient sterile by ligating each Fallopian
lube in two places in order (o insure permanent occlusion of both o\-iducts, and
consequently I frequently resort to mechanic means for holding up the uterus in
women who desire children.

Technic of the Operation. — The Prtparation o} Ike Patient and the
Preparalions for the Operation are described on pages 834 and 837.

Position oj the Patient. — ^Trendelenburg.

FiCr 3i6.^^VFNTifAL Fixation or trf, I'TEifus — Second Step.
'ihe lorccp^ soizinK ihe K:k]WipJan luba art Deri bIidwd.

Number oj Assistants. — .\n anesthetizer, one a.ssistant, and a general nurse.

Instruments.— Tht list of instruments is the same as in the operation of
salpingo-oophorcctomy, which is described on page 973.

Operation. — First Step. — The uterine appendages are delirered as in
the operation of salpingo -oophorectomy (see p. 974) and both Fallopian tubes
ligated as shown in the illustration. (The ovaries are not removed if they arc
heahhy.)

raoLArar..

V the pAticnt has p(tM«d the menoimixe, tlie mcoiuI Me|> of the operation be-
comes iltc ttrxi. jinil wc |in>rte<l lit once to denude the fundus <>( (he uten» with-
uut lifpitiag the lubes.

SrroNO Stki>. — 1'he Paltoptun w\x» are fcmtl with InnfE-hhtlcd hemo-
•Utic forceps ami the uterW' drawn inm the abdominal inci>{ion. A stMice nnt inch
loQg ami half an imh wide is then marked out on the fundus by auiwrfidul in*

Pui- >!!■— Vivnui- F)3unaN <n ntt Utodk— IMrd Sup.

with the •icalpcl and the inicrvcninf! peritoneum dissected ofT, leaving n
ITr|>roximutK>n >urface..

riimii Sttp. — Two <ilkwi>rm-g;ut suture* .tit pjis.'ed fmm one ji«lc of the
fundus to llie other under the denudeil arvu; the forceps rcmo\'cd fmm the
t,, and the uieru< is iemiK>runly allowed to fall ImcIc into the jwlvir cuvity.

r<t>.>t*.-rMftiiBMK

n(.ua<

Ita. DO — 'ourUi St>p.
Vmnu FrUTKM ar TM f'Tvaui.
■(kUI ilinudMliol) Ml cadi Mt it iIh ■Momiiul UKuiaa. Tit. U« *M> IW
Onusb lilt abdunloii ••II. Thr rinllMI lUa IndisM* lli« nau 4 puiM

The ^ulurrN are introduced with a ainvH llngedont needle and buried about
r-qaartrr of nn inch deep in the uterine ti^^ue. They enter close to the ed|!c
I the divided peritoneum anul piivt c<>mj>letely unilcr tlw denuded area to emerge
~t the v»n>c point on the oppi-sitc vide.

Fotmrn Sn:!".— A urip of pnrictal [iefit«)neum half the sij* of the raw sur-
hcv on iHc funilu> i* rvmovcil with sdnont on each »ide of the afxlominal (nctiion

334

THE TJTERUS.

near its lower angle and the free ends of the fixation sutures passed completely
through the walls of the abdomen, so that when they are tied the denuded uterine
and abdominal areas will be in contact (Figs. 358 and 359).

Fifth Step. — The abdominal wound is sutured and closed in the usual
manner (see p. 904).

The operator then makes traction upon the free ends of the fixation sutures
and brings the fundus of the uterus in close contact with the denuded area on the
under surface of the abdominal wall. The sutures are now tied and the wound
dressed in the usual manner (see p. 905).

After-treatment. — The fixation and abdominal wound sutures are removed
on the eighth day.

Supravaginal Hysterectomy jollowed by Fixation 0} the Cenncal Slump lo the
Abdominal Wall (Baldy's Operation). — This operation was devised by Baldy,

Fir.. 360.— Ventral Fixation or IHE UiFRUS— Fifth StBp.
Thcbwcrfixdiii'n.^uiur^ IS shown li^aniliractJnnaibeiriBinuL? upon (h? upper niture.

who says it " is lo be chosen when a verj' large amount of relaxation exists and
the viijjinal v;iult would not olhenvise be lifted up sufficiently high to giv-e ihe
requi;^ite suj)[H)rt.'' I cannot agree wilh this indication for the operation, be-
cause a ventral fixation can easily be made high enough on the abdominal wail
lo take up any amount of slack or projajjse of the pelvic organs, and also for the
reason that a hysterectomy is too serious an operation to perform for the relief
of a uterine displacement. The only indication, therefore, in my opinion for
the operation is when the prolapse is associated with a fibroid tumor of the uterus,
and undci these circumstances I consider Oaldy's method a distinct advantage.

The technic of the oj>eralion is as follows: "After the uterus has been re-
moved by amputation at or below the internal os the cervical slump is fixed to the
abdominal wall at the lower angle of the alxlominal incision by means of two silk-
worm-gut sutures (wisscd through the full width of the cervix from side to side.

I>H0I.AI-SE,

33S

tlie (tee end!) brouKht through the peritoneum, muBcIes, nnd deep fiurfia of the
■bdominal wnlt. where the)' are securely lictl together, oil oti »hori, and the knots
buried when the incision is cloecd. ITic open broad ligaments should be closed
b\' a rontinuous catgut suture on each side, preferably before the cervix i^ an*
rhtire<l by its fixntion sulua-s. The abdominal uxninrl i« then closed in the usual
manner." ("An .\nKrican Text-Book of GynecwIoKj-," page 319, Ki'ond
itton.)

In employing this Icchnic I do nol bury the fixation sutures, but past them

mpk^ely ihrou;:!) the abdominal wall, as in the openiiion of ventral fixation,

ii i* gilho Itrtlrr, in my judgment, to denude the under »ur(iicc nl (he ab-

inal wall where it come.' in oniitiil with ihc cervical stump; otherwise the

n may l»e wciikeneil by the (leriioneum Mripping.

echanic Methods .— I'hcsc are: (a) Pessaries: (b) colpcur}'nlen;
<c) tampons.

Mechanic supftorts arc rew>ne»l to when o|>cr:iiive measures arc contniln*
ted on account of the advanced age of the patient nr the state of her health,
and they should alao be empIo)-ed when a woman desires to havu children or she
b unwilling to submit to radical methods.

^Bca!

Fh>. Mi.— Or oi Rum I<) tnutt wirB IHtiuial Scrran.

Patarie.^. — A cup or ring pessary with an external sujiport is tlie only in-
■trument which will i'lev«ie the uicru> .inci hold it in jHiutiun. An ordinary
III iinij fehoukl never be used, as it cannot support the organs and is eventually
laroBd oui of the vagina .

The pewiry should l>e removnl at bnltimc and whenever the [miient as-
SU0»s ibc recumbent posture for any Icn^h of time, ll should be carefully
cfeniHcd with soup and water ami iborouKbly dri«-<l. A vuf'inal douche of hot
nnrmalialt solution should boused Highland morning and once a week the vafpna
sbrjuld l>r imt^led wKh warm water and »>ap.

Cotfeurynltri. — Braun's colpcuiynler is a wry effeclive instniraenl fof re-
taining the uterus in position and may l>e used when a pessary cannot be worn on
account of causing pain or fails to holil the (>rgan< in po«iti<in. The cotpeurymer
sbmld be rrmoNcd when the patient goes in bed at night and Ihe ragina irri-
Otcd twice a diiy with nnrnuil Nilt v>hiiion. The iaMrumcni jhouU be
_CBnfully clcanMnl and the rubber bag covered with zinc ointmcnl each time it is
Juced into ibevugiiu to pre%'eni (he |ians from becoming abraded (Fig. jbi).

33^ THE UTERUS.

Tampons. — A cotton-wool tampon is an excellent means to keep the peine
organs elevated and is especially indicated in the treatment of prolapse b vnj
old women. The tampon should be large enough to give the necessary amount
of support and it should be dusled over with tannin, alum, subnitrate of bismuth,
or boric acid alone or in combination. It should be removed at bedtime and the
vagina irrigated with normal salt solution night and morning.

Treatment of Actite Frolapse.—The patient is placed at once in bed,
the uterus restored to its normal position by the means already described on page
329, and the vagina loosely packed with iodoform or sterile gauze. The urine
must be voided spontaneously or drawn with a catheter every eight hours and the

Tia. 36a, — BrAUH's COLPEUIYNTEK (pAgC JJSl-

bowels freely moved with a saline. If the pain is severe, a hypodermic injection of
morphin should be given. The patient must remain constantly in bed for at least
three weeks and she should not be allowed to lie much of the time upon her back.
A fresh tampon should be introduced once a day and the vagina irrigated night
and morning with hot normal salt solution.

The tampon and douches are continued for two or three months after the
I»atient gets out of bed, and heavy lifting or violent exercise of any kind should be
avoidwi.

II the displacement persists after several months' treatment, it should be con-
sidered as a chronic condition and treated accordingly.

ANTEFLEXION.

Description. — During fetal life and in early childhood there is a sharp
angle between the cervix and the body of the uterus, and the lower uterine segment
is relativeh' larger than the upper. This condition of anterior flexion is, in a
lesser (iepree, normal during adult life, and the anteversion which also exists places
the ulerus at a right angle with the long axis of the vagina. The fixation of the
cervix by the ulerosacral ligaments and the constant pressure of the abdominal
\isrera u|K)n the posterior surface of the uterus are important factors in produc-
ing the normal position of the organ, .\nterior flexions are never
pathologic except they cause dysmenorrhea, endome-
tritis, or sterility, or they are associated with a pelvic
lesion and become of secondary importance. An an-
terior displacement, therefore, is not a true deviation
but an exaggeration of the normal position of the womb,

Fre que ncy.^.\nte flex ion of the uterus is a ver>' common form of displace-
ment and is met most frequently in women who have never borne children.

ANTlirLKXIUK.

337

CansCB. — Dui I'ltie k known o( the inic nulure of ihr Ciiusc<> of antcflcxioD
u( tbr utmis in tromcn who luivc ni>( l>i>rtH' «-hil<lrcn. ['nitmlily the cundition is
a amtiiiuution of th« shaqi anterior tlcxion which normully exists during iniiu-
utcrim- UK- aivl thilcihiMMi. Bui why ihi^ arrest uf ckt-elo{unen( tIiouIcI occur in
wow w-umcn and not in othc-n wc ilo nol know, a< sharp tlcxionii hit often
obMnvil in wunvcn hating tvell-tlevclioijcd physirjuea anil oihcrwi-st luwmal
g. . ; , nrpin*. In imnthcr vU'ss of ia*«--», hovrp^icr, (he .inirHexiim i* ac-
t ' ; with an infantile utcnii and other cndcnccs of an undeveloped con-

diUMtt't the ijceiiital iiT>^it>.

Anli-lleAions are rare in women who have borne children, and when the)' do
occur the)' art puerjwRiI in origin. Thu^, the uterus may tn- tiltcvl nhnornully
fnrwani by coniractinn ■>( the ulcrixsicrul ligamrnu and ilf wall.s !^ftci>cd by
•u bin volution. Under ihe*c condiiioaH the pressure of the iitxlominal viscera

^^^0y rjsilv henil the funilus forwanl and [trivlutv a well-in.irkr<l llexion.

^H Ssnnptoms.— The chief s)'nipioms uf anieHexion of the utenis are: (a)

^^ijnuDcnorrlH-a; (fr) sterility; and (r) leuknrrheu.

1 10, ]fij. — AMTiruaMsi or ■■■ CnaM.

DjrGtDenorrbea. — The menstnial pain is due to an cbsiruclion of the ctrvfcal
Otn;t1 whlih t> (uusrd by the flexion and live '•wollcn >ir hy|)erirophie<l londilion
Ihv cnilomnrium. '^hi^ f»rm of dysnienorrhea h known as the utntruciive
krirly and isdesiribed on pa)>i- 721.

Slerillty. — An telle lion iloc» not ulway^ cau^e Alerilily ami women often

CiuRH- pm;iuni jfler i^ulTerinf; for years with severe ob»iruclivc dysmenorrhea.

the iMxlrniy b, hnm-vtr, lor ihi-se W'^mcn not to bemme )>rei!njnl, on ac-

anl o( ihi- >tn)<iMral ilwnjtes in the endomelrium priRlmwl by ihc chnmic

eiid<iRu-triii>' which acoimiuinies and U eauMil by an anicllexion of inng standing.

Leukorrbea.^TlH' bending of the utenis u|Hin itself methnnicalty interferes

with the rlr<-uijiti'>n, niwl in lime a pastive i-on^iion occurs which eveniuulty

•■ '• -i 1 '(fonic (i>nKesli»'e emiomelrtlis. The jeuliorrheal discbarf;c which

'liindtsciLsc i«i niinirritatirii; in fhnructCT, whiti>h in mlor, and more

' Icvi (jniiu^-. npct-Mlly Ju5[ tiefon; and immediately after the menstrual t1»w.

338

THE UTERUS.

Diagnosis. — The jtalient Ls placed in the dorsal position and tht diagnosis

made by vaginoabdominal touch.

The index-finger of the left hand is introduced into the vagina and the cervii
palpated lo determine its position, which is usually found to be normal, althou^
in some instances it may be strongly flexed and point directly forward. Thf
finger is then pushed up into the anterior culdesac of the vagina and counter-
pressure made with the fingers of the external hand immediately above the
symphysis pubis. The fundus is easily felt between the opposing fingers and at
once recognized by its shape and consistency.

The examination so far has demonstrated that the uterus is in an anterior
or normal position, and the next step is to discover the flexion. This is readily
done by keeping up the external counter-pressure from above while the tip of the
internal finger is slowly passed over the anterior face of the uterus from the
fundus lo the cer\'i.\ and the shape of the line between the two points noted.

Fir. 361.— I>i*r,\osi! OF .\KiiiiLKXir.N ^ir the l'n;>i;s by Variso abixhhhai. Todcb.
Shiiii'JDK p'k.^tiiin of fundus and poinl oi Hciion.

Knowing what the norma! curve of the uterus should be, it is an easy matter to
determint- whether a flexion exists and lo recognize the sharpness and situation
of the angle.

Prognosis.^Anleflcxion associaleii with an infantile uterus is incurable.
When the displacement, however, occurs in a uterus of normal size, the prognosis
if \ery finorabie if the jiro^jer surgical treatment — dilatation and curdmenl of Ihe
uterine cavity — i^ carried out. This operation cures about 80 per cent, of the
cases of obstructive dysmenorrhea and benefits the remainder; it restores the
endometrium to its normal condition; und pregnancy frequently follows even in
flexions of lone standing.

The beneficial results following dilatation and curelment of the uterus are
generallv noi apparent at ihc first menstrual flow after the operation, and pain is

POSTEHIOR VEB5IOKS AN'D PLIilXlONS.

339

Uy felt al that prriod. The subsequent menstnul qwch!), however, are
ICrnnally characlcrind by imjirovcment in the nymploms. and the pain Anilly
cltNtiiiivitrv

Womcfi suffering with nnteDcxion oficn become prvRnunt Sioiincr iw Uier after

RnrriBKe if the endometrium hu.i ti»t unilerKime chronic ^tnjcluml rhangcs and
^laliuti px^ l(> full term ilx.- uicrinc Ic^on h iienniincnily t-ured.
TKatment. -The irraimcm is ojicraiive and ain>i.->L% in dilniiitinn »nd
irclmcnl i>f ihe uteriiie taviiy. The lechnic and ihc iiflrr-ircuttncnt oi the
..,>cr;ilt>in arc ilcscfilxil '>ii IMgt-* 055 ami g6o.
^^ Special Directions.— Thcoi*raiii(ii ^hauld be iierformer) alxnit one week
^Hltcr th« menMniul tlow >io|n.

^V After ihc uterine ravity has been cureted and flushed it should be lighllr
I raclcc«l with a «trip of gauxe, which U allowed ir> renuin fur two (Uys in order to
^^icep up thcdibtatioit and ]>rcvcnt ihr Aexion (mm recurring-
^H The ]iii[ien1 should remain in bed for one week after operation and at the end
^^! fngriecn dayi .the may Iw allowed to le;tvc her room.

When the <itieraliim is jHTformcfl for jicrility, coitus should take place a day
^BT two l)efore and immcvliaicly atlcr menstrua lion for >c«Tal succisslve mootha.
^^ If ihv operation U not followeil by the relief «f symplomt, it should be repeated
■ once or twice before ip^'ing an unfa^^imble )>ni)^usb.

^fe POSTERIOR VERSIONS AND FLEXIONS.

^^HA>efinitioil.— Ity reiroicnioH we mean that the utcru> lurnn upon it^ tran»-
PH^^ .ixt> Jiwi tills tlw funitu.1 luckwan) and the cervix forwani. The normal
curve o( the utcriiK canal is nol chan^^ and its concavity olways faces anteriorly,
but ilie k>iiR axis of the uterus no longer forms a right angle with the vagina. \
rctr>'ver!iion frequently exists alone, although it is not uncommon to Bnd it as-
^•xiAXt^S with a rcimflcxion. A posterior version is always auodated wiih Mime
prola[>-e, 3.1 ific ulcTo>air;iI lij{ament.> muM twome morr or \tf* elongated before
Ihc ccn'w ran br dlspbccd and carried forward (Fig, ?.('$)■

A rtStn^txion of the utcrxis U 3 liendinK of ihc orRan luckwanl uimn itself W

al ihe fundus points [nixleriorly while the ct-rvix, theoretically, remains in its

irnul jHiiiiion. The curve *>l the uterine canal is altered and its nincavity

wayt Utv [loslcTiorly. .\s a matter of fact, it U imiHiv>ible for a rvfrotlexion to

cur M'iiboul wme degree of \Tr^on, ami cunMqucnily marked examples of

lib forms of posterior dispbcements often coexist in the same case (Kig. 566).

Fre<iaency< — Posterior displacements are much more frei)ueni than any

hrr form of uterine dislocation. The)- arc more common in parous than in

i^r, women, and in the latter versions occur more often dian llexions.

! rrl rod is placements o( the iiierus arc vcr\' rare. The alfophiol ulcnis

r Uit menopause is usually displaced backward.

CanSCB.^'nie nornuil situation of tlic utenu dqwncK upon the integrity of
ippo[l>. and it natunlty follows that any condition ivhich impairs or destroys
forces is a cause of displacement. The conditjoas are, therefore, classiiinl
a«fcil)oM>:

ThoM w^ich destroy the supporting power of the pelvic floor.
lliose which im|uiir the »u>taininK action of the pelvic urgam.
Those whi<*h weaken the ri-1cnlive power of ihc abdomen.
'rh<«sc which interfere whh the strcnsth of the uterine ligaments,
the condition.'! Liflrclint; the various stipjMirli of the uterus usually involve
than one at the umc lime, it is evidently im))ossible to consider tbem sepa-
icly, and c»n»e4)ucntly they wilt be discussed aia whole. I shall, more-

iV>

THE UTERUS.

over, consider the subject only from ihe standpoint nl
pTimary <Iis|ilaccmenl^, ignoring cniirclv the etiology

if eases whith are xccohtlurv in pelvic Io^io^^. on il con-
ic quenily no mention will be made of pelvic lumort,

idhesions, tubo-ovarian diseases, and other gross con-
ditions which inriden til My pu»h or puil the wotnb ua;
o( its normal situation. If, for example, a Urge pelvic
tumor crowds Ihe uterus against the sacrum, the dis-
placement is a mere incident, and of nn importance
from the standpoint of treatment. Ii is the tumor, not Iht
mal]Ki>itiiin of the uterus which ccmccrnh ihc surKt'iin nnd hiv jutient, and the
diagnosis, proiiiiosh. and /ri-u/wi-M/ are hiiscil solely u|nm theprrvnceof thcncw-
growlh. Ilsliould also be bomc in mind thai in certain iiascs the deitmclioo
of i>ne of (he uterine su|>|Mirl> so inlerfero with ihe e((uihlirium i>f all the lorcei
that they, in turn, arc aRccled and Ihe causes of the displacement become general

PostXMOi VnuoH ANs FuxKM 0* nn VnnB Iiua* tnh

For example, a laceration of the perineum not only impairs the i>ow*r of the
pelvic HfHir, but secombrily the |M-lvii- orKans lose their «u»iainit>}: action aivl the
force of ihe retentive ]Mtv,-fT of ihealxlomcn and the uterine ligament-- i* wrakennt.
On Ihe other hand, however. i>ne o( the supjionA may l>e alTected without in any
way iov'dlvinK ihe re^t. and thus a heavy Miliinvciliiinl uterus mav cause a dlspbcr-
ment by ^trcidiin^ and urakening llic uterine ligamenia without afTe<-ting all the
other sustainin)! forces.

Tlie fiiliiiwinn causes pnxluce Ihe conditions which an- responsible (or retro-
dijplaremcni'i "f thculenisr

Laceration or Relaxation of the Tissues of the Pelvic Floor Due to
Ltbor or Accident .—'Ihe lr;ium;ilisms of labor are ihc most frequent cause of
posterior d is place men Is. When the perineum is rupturetl. defecation is rendered
difficult and extra force U reouired to empir the rectum, 1'his is due to the fact
Ihal normally the levator am asnisi* in dilating the sphincter and directing the
feces toward the anal opening. When, therefore, the [wlvic floiit is lorn, ihe

POSTERtOR VERSIONS ASD FLEXIONS.

' of ihe lc«ti>r iini U iiWnl ami the fecal mailer is driven by Uie
niiul jirrssure u);"i"^l '^i* posterior wall of the vagina l>efnre jia»5ing ilimugh
: niul ii|ii-ninf;. Tliis trvenlu;iliy r^ulls in the fumiiiUan ft u reclocrlf. and
I pu^ierinr tkiiiinul wull ihvn |iu)l« ujum i)iv ctrvix iind dmgs down th« uienis
ihc MrucWres iu llic upper pan of ihc poU-is. The tendency lo [-i)nMi|iiit»on
ruhn, due in liluntini; of llie reitiil reflc.wji by tlic ti>n»lani presence ol
I mailer in ihe Unvel, h an additional cau»e «f dbpbccmrnl, and, ajtatn, the
ittg iif ihc [Hwicriiir vuf^na) wall destroys the support of ilic anicrii)r wall.
1 intiinc4lM>)ic<'<>ine.v pnilanswl. I1tus lh«t>]add«r, the >-agina. the recluiD.
Ii« upper ».iruciurcs of the i>clvi6 no longer assist in supponinK (he uienj>. and
it f> hrltl in [tusiiion for a time by its lif^mentv. tlKy. however, gmduully
lime more ami miiri- eloniiaicvl an'l Mrrtchcd, until finally Ihc womb is db-
linl biii'kivard and downnar'!. The ulcrot^ciul lif^ments, on atcount of
tcreiklet tesi.-iin): {mwcc, are the la^l to yyvc way and lit-i-umc <-l'in^icd.
njvcr. ihc c<(ul|»oi<c of the ulerus within the jwlvic cariiy being destroyed,
the rdciiii^c iK>wcr of ibc alxlomcn H impaired and the up 'inJ-doun moiiunt
of the '•Te}in either icase aUot;cther or are greaily dimini.ihcil.
^P Kit{>i<llt succeeding p[c}:nanctes arc %-en':ipt to lausr a rrbxed condition of all
WKf peUic siruciures, intludinR the uterine ti^mcnls. and are therefore an im-
pMttunl (iidiir in iIh- eliolii;;^' uf kukwanl and downward di^pbrt-ments.

Aboomully Roomy PelvU.— When the peine canty is abmirmally caps-
ttous, the pclvif orjjans do not lie in clow apportion, and conseoueinly ihrre in a
: of muEu.-il suptmrt which rcMiltx in mon^ or leu Kiuting and )(».'' ol suKlaiiung
rcr (11 the mcTXi:', The lipanH'nls under the**- cirnimslances bcoome elon-

I, .ind in iifiie the utcni.^ -iiil;> (lermanently lower in the |>elvic caviiy.
Overdisteut ion of the Bladder and Rectum.— When ihc bladder i^ dis-
^1. the fundus of ilic uterus is pushed back towar<l the sacrum, and the
kI awl iilenwacnil tipimmU liwoinc taul. In women who arc careless in
Myinic the Ijljidder the liganH'nis gradually become more and more clonKalcd
pi finally the fundus psi^^^r? the danger-line and the intestines uvnvd down u|»c>n
I anterior fa<eof the uleru.s awl a |)crmani;nl i>c»ierior dt»i)laciemcni resuhs.
llhiriDX defecalitjn ihc crnix is alna)-s icmpor^trily pushed forward and
rnward, and an o\'eTl(Kided bowel due lo «rhmnic conMi)Kktion prrMlucc ihe
(he difference. honT<'\rr, t)eing thai the cer»is rcNumes its
>n imn>e<:liaiely after defecation, urhereas an accumulation of fe<-e9,
rtnni mrchanic i>n->sure. kee|is tlte utrrusacr:il li)tan>eni^ taul until the
»vi i' rJH)clJci|. which in Htmc cases twcur^ only once or twice a week, and
eoRSMluently the I'onsl.mt tension jiemianently donates or weakens the Itgnmente
1 oiUK^ a (l■v^le^l•r ili'-placcnM'nt «( i)ie uterus.

iDCreued Weight of the Uterus,— The- uterine lifCHmcnts fail to act as

' ^r'rl)|tc^ wlieti ihe uterus ii abnormally heavy, liet'ause nature has endowed

triih vuditient strength to resist only a certain fixetl amount of traction, and

I this is exceeded, forany considerable length of lintc.lhey become elongainl.

an<l utKlcr)c» (kf^'iierjiive dianges. TIm- temporar>' streichins to

V ' ms are normally sub_iec1e<l durinR the [ih.'i'jjotoijir actions of the

in lH.-du_-c the tension Ls ijuitkly relieved and they regain at once

' nimn.il loiiicily ; but uhrn ihc overvln'li hint; is indefiiiiiely prulotif^ed, they

their elasticity ami remain permanently relaxed. Subinvolution

the uieruH following labor or miscarriage is thcre-

Kommon cauitc of posterior displacement i. In
the increased slm* of the uterus the subinvolutcl conrlilion of the
iierine IticanientA whidi is usually present in Ihcsc cases must abo he
!» B tauulive (actor. L'lulcr these circumstances the n\ffj» h

343 THE UTESUS.

weakened and its waib are apt to become prolapsed and the elongated and
hypertrophied ligaments allow too much freedom of motion to the utenis.

Improper Maimer of Dressing. — Tight corsets constrict the abdominil
cavity and act injuriously upon the organs of the thorax, the abdomen, and the
pelvis (see page 139;. Respiration is interfered with and consequently the
retentive power of the abdominal cavity is impaired, and the uterine ligaments
and the pelvic circulation are no longer strengthened by the up-and-doutt motions
of the womb which normally accompany expiration and inspiration. Moreover,
the compressed abdominal visceru force the pelvic organs and uterus downward
and thus permanently stretch the uterine ligaments. Hea\-y clothing worn
suspended from the waist has the same effect upon the pelvic organs as tight
corsets {see page 139).

Lying upon the Back too Long after Confinement. — One of the most
frequent causes of posterior uterine displacements is the common habit among
obstetricians of keeping their paticnis in the dorsal recumbent posture after con-
finement. The heavy uterus, with its hypertrophied and elongated ligaments,
and the relaxed condition of tJie tissues of the pelvic floor, must of necessity
fall backward of its own weight under the circumstances, and consequently when
convalescence is established the woman leaves her bed with a permanently
retrod isp laced and prolapsed uterus (see page 141).

The Use of a Tight Abdominal Bandage after Labor. — ^Tbe custom of
applying a tight bandage after confinement is a common cause of posterior dis-
placements, us it forces the enlarged and heavy uterus back against the sacrum
and permanently stretches the uterine ligaments. A tight bandage is, of course,
indicated in cases of [x>stpartum hemorrhage, but it should not be worn longer
than twenty-four hours.

Muscular Effort, — When the bladder and rectum are overdistended, a
sudden muscular ctlort, such as lifting a heavy weight, jumping from a height, or
violent straining, may prixlucc a sudden descent of the pelvic organs and cause
a retro<iLsplaccmenl of the uterus.

Occupation. — Posterior displacements of ihe uterus are often obsen-ed in
women whose work requires ihem to remain standing continuously for hours al a
time, and who are more ur ie^s careless in emptying the bladder and rectum.
Again, women who work sitting at a bench or a table with the body bent forward
arc likely to suffer c\enlually from displacements, as this position crowds the
abiiomiiial viscera against the jielvic organs and forces the utenis backward (see

P- '37)-

Posture. — An incorrect posture in standing, walking, or sitting may in time
cause a posterior displacement of the uterus. If a woman stands erect in the
proper [Kisition, the line uf [gravity falls at the symphysis pubis; but when she
stoops somewhat, it strikes hImiuI the center of the plane of the pelvic inlet, and
consequently the full weight of the abdominal contents presses against the organs
of the pelvis (see pageii").

General State of the Health .^Downward and backward displacements of
the uterus are frequently met in women suffering from general debility due
to habits, occupation, old age. and disease. Under these conditions the peKis
loses some of its fatl)' and cellular tissue and there is a want of tone and elasticity
in the uterine ligaments, and the genera! muscular weakness which results
causes a decided lessening of the retentive power of the abdomen. In cases of
chronic lung disease the intra-abdominal pres,surc is increased by the persistent
coughing, and consequently the ligaments of the uterus, which have already lost
some of their resisting (lower on account of the general state of the system, arc
unable to stand the additional strain put upon them.

POSILXIOH VESSIONS AND FLEXIOtfS.

s*s

SytuptOtUi. — The Inml and genemlKymptocns of posterior displacTments of
Ih* ulcnif' arc due to mechjnic pressure, rcAcx paii», and iiilcrference whli the
privic <rimilalion. Ii sbuuld ulwnyii lie borne in mirvl th.it a trctl-nurked
pciMeri(>r dc>'i)bcei»cni miiy Iw ]>rr^m in Mime cases without giving rise to any
■ut»)eclik4- sympioRiG whatcv^er.

^Tbc ^)'Inptotn» «e <.-onveiueiilly diMU&icd under the following hesdines:
Saduche. Mensim^lion.

Pelvtc symptoms. C(>iKei>iion-, Pregiuncy.

I Reil.il Nymjimms. Iltvidachc.

liiaiJdcf vvmjdoms. Digc^tiw du.lurbnnce».

Leukuirhni. Nenous s>-ni|)H>nK.

Baekacbe. — Thb is one of the most common symptoms. The pain b gener-
ally fell ottr the lumbosacral region, and while it v^its. in intensity, it is uuinlly
dumicmcil liy a dull Iwavy ache which i» inrrcn>ed in severity by ihc erei:!
puMure but h more or less relieved while ibe patient is lying down.

Pelvic Symptoms, ^The pt^lvii- Mmpiomn are very cunsiant. The pnlient

U*ualt)'iimi|>liiri>c.f :i fe<-liii)i"f weight or a dragging sensation in the pelvis; ilierc

ub(> acute juin when the ulcrine appendage; are [>riilap^«d along with the dit-

iktI litem?; and not inlri-iiuenlly pain.-' tatliate frum the inguinal rrgi«nsdown

c iinirri'ir jmrl "f ihe thigh^.

Rectal Symptoms.— The pressure of the fundus of the uterus upon the rcc-

bltiiiii< the rectal reltexes and gi\e> rLie to a>r)5ti|);ition and hemorrhoidB.

re i.1 also a «>iu^ant scnskiion of fullnc&s in the bowel, which k not entirely

lie^ed by defecation. All of the symptoms arc aggru^'ate^l if the uieruit becomes

hereni.

Bladder Symptoms.— It b rare for the bladder to be affected in posterior

llis{ilaceiDenLs of the uterus. In extrerm' rn>cs, hovrc^vr, nf reirovvrsirin it is

jblc I'lr ^ri-irnl irritation to result from the long-continued pressure of the

rvix. ami there ntay aL^ be more or lr» iiK-uniincnce of urine due to the dmg-

nff <i( the din|>iii(.'eil itfg^in u|>on the urethra and bladder.

I.«iikorrhea. - A k-ukorrhejil discharge due to congestive endomctritii is
>Try fici|ueni sympH'in. It h profuse, as a rule, and often rau^ra an erosion of
rrrvix. IIk diMharge is seliiom irrilaling to the extenul organs and tls
>r ^ariifi from a white to a whitish-yellow.

II eostruatioo.— Excessive men-itrualion or menuirhagiu i:t often ubrtervcd,

I i% due !•> uterine <.-ungC7ition anrl hy)>crtri>phy of the endometrium. Dys-

niirtlMra is seldom a symptom uf ret nxlLspl;! cement of the uterus. at>d in cases in

^hich It i> (irr-^eiil the |uin is ionKeriii\i: r,ith<'r than cjl»tnictiiT in character,

Cooceptioa; Pregnancy. -While posterior displaccmenLs are frequently a

"■•terility, yet they arc only rclativvly m>, as women frequently conceive

to full term wiiht>ut any Ikk) M'lriptoms, llie uterus .tpontaneousty be-

iffiini; replitceil during the e'aily months of pregnancy. If the uterus b firmly

Iwrrnt, lioncver, KCMaliun is intcrruplcil and uburtion or inciirccnttion o^cun*.

Uy the trrvix occupies the [Mwtcrior culdesac of the vagina, and it is bjlhrd

I the Mrminal fluid after sexual intercourse, and citnsoquenily when it assumes an

Bterinr piMiiion in ri-trovcnion it i* more or Its* difficult for the upcrmalnioa lo

the ofi uteri. I'hb b uiuloubtetlly an imporiam factor in the causation of

in these C3se«. as concept Wiik Irwjuenily occurs shortly after the uteru* 1ms

ai*l held in ivysili-in by an operation or a pessary-.

e.— t^iin on the loji of the head or owr the occiput i* a ven- common

Icm. It varic-i in intenNilyaitd duration, arul in the majority of ctscs is more

' lew constaDt, while in others it occurs only at the lime of mcnstruatioD or is

aitgrsvaled by the mimihly periods.

344

THE UTERUS.

Digestive Symptoms. — In some cases the digestive disturbances are marked
by loss of appetite, gastric and intestinal indigestion, nausea, and constipation.
The general health of the individual suffers and she eventually becomes thin and
anemic as the rei^uit of impaired nutrition.

Nervous Symptoms. ^Neurasthenia is a most important and constant mani-
festation of posterior displacements of the uterus. The symptoms are natural^
varied and there is nothing characteristic in their grouping to indicate the cause.
The motor symptoms, as a rule, are marked, and some patients are unable to take
active exercise on account of muscular weaknes.'i, and the lumbosacral and pelvic
pains. The scnsorj' phenomena are constant, but vary both as to the character
and severity of the symptoms. Most patients complain of a tired feeling and an
utter lack of desire to exert themselves. Less frequently they complain of a
dull aching pain in the back and thighs, or they may suSer from headache,
vertigo, and numbness of the lower extremities. An increase in the frequency of

Fic. .ifty. FlC, ]68.

Dl.ll^Mlsl>^ m I'li.Ti BICIH \'nislON-s or the I'lEKIr^ SV V»r.l\0.*B110U!N*L ToucH.

Fic. 3^7 ^hcws ;LlAcncc i.if lun.his anirriorl^; Fj^. .sCrb shows prmMict of body po£(ffiarIr.

the heart-beat is a more or less constant symptom, but attacks of cardiac palpi-
tation, however, ari; rare.

Diagnosis. — The (tiHient is ])laccd in the dorsal position and the diagnosis
made l>v ztiiiiuii/ and I'lii^ino-a'it/omiiui! louch.

Posterior Version. — Introducing the indcx-fingcr of the left iiand into the
vagina, the cervix is f<iund to be lower than normal in the pelvis and pointing
forward, instead of backward towanl the coct>x. As the normal position of the
fundus is interior, it should be sought for first in that position by pushing the
index-finger up inlu the anterior rulilcsac of the vagina while counter -pressure is
made with the fingers of the external band ibrouKh the abdominal wail im-
mediately above the symphysis pubis. If the fundus is in its normal position, it
will be readily felt between the opjiosing fingers and at once recognized by its
shape and consi>lency. Not finding the uterus anteriorly, it is then sought for
posteriorly by carrying the internal finger up into the posterior culdesac of the

POSmUOR \-EBS10NS AND FLEXIONS.

34S

vaxiiu whilr countcr-prricsurc is made from above through the abdomiiul wall
by puling Uw siruciurcs down slong the curve of ihc iacnim with the tingers of
die extrrnul hiifid. Tlic fumhiK !:( thus aiu^hl between the opptjriinK fincera and
eaitihr recof^iizec). Still keeping U]> counter-pressure from abo^-c, the tip of the
interiul fini^r h slowly (uis^eii over ihe »>i»teTior surfuce of the uterus from
ibe fuiiflii* to the rer%ix. nmi the shape of the line between the two iwintt noted.
U ihi^ line is convex, the uicru.^ h displaced in version, because the normal curve
of the uterine iiinal h not cluini^eil. us its conruviiy ^till fuce^ anteriorly.

PMterior Flexion. -The same methods are used in (he examination as in
lases of wr^ion. The >Jiape of ihe line lielwceii the fundus and the cervix on the
poMCTlcir face of the uteruN It cononve, becauM the cun*e of the uterine canal is
Altrred and its conciivity idways faces poAieriorly in retroflexions. While theo-
relicttlly the cervix retains its normal position, ytt as a matter of fact posterior
llrxion* are alwaj-< asKociaied with mure <>r le^s version, and consequently the
Deck trf Ihc uterus points somewhat forward.

^- " >V^-T.

?>>•

^\-

■K^\

■Nv-^SV^

Tm- jB». — DiMwocno* ■■csiKim fumaH o* mv l*Tnr« av Vuauo-tmvowaui. Tiii<ca.
lihiMi Ike tacci ID \ic iotir «t tatto tnottinily.

Differential Diagnosis. —A retrodisplacemeni must be disiingiuiEbcd
from a libniu! uoduk on ilie jxi^tcrior w^l) of the uterus, an uii-uraulation of feces
in tbc rectum, ;ut rxlr.iuti-rine ^r:'l3tion x\c, a gmv^ lubu-ovarian le^inn. and u
Mtbwriloneal fTowih.

Tl)CdiA|in(*^'H'^'^u|^'' lotntinK the (unduMif the uterus, which is always
pufihrd DXTc cr Ir^s furwaid by tlu; retrouterine nu'ks and is reco^inized by its
•lupc and ti>iL-<t-->trn* y as well as i)ie unmistakable cuniinuity of structure existing
brtwrrn it and tlw lenix. Kerlal awl nrioaldlominiil touch >hould nUo be em-
plD>vd in muklni; the examination, as these methods of palpation usually dehne
or outline the |KKii-uicHnc enlargement and .issisi maieriall)' in clearing up the
tjiiBBo«is ( Fin. .170).

PronoalB.— Primary posterior displacemcnu of the uterus are only in-
dfrtdjjr tungcnnis to life by their debilitating eSecl upon ibe (tencral health and

346

THE UTEEUS.

nervous system, rendering the patient less able to resist intercurrent diseases. A
large number of so-called cases of nervous prostration or neurasthenia whidi
cause chmnic invalidism and general debility are due to posterior displacements of
the uterus.

Treatment.— From the standpoint of treatment I divide all priman' pos-
terior dispL-icements of the uterus into—
Recent oises.
Chronic cases.
Recent Cases.— By recent cases we mean those which have been displaced
less than one j'ear. The practical necessity for this division lies in the fact that
after the uterus has been displaced for over one year the tissues and ligaments ha«
become so oveAtretched, separated, and degenerated that it is impossible for
them ever to regain their normal contractility and sustaining powers, and con-
sequently all forms of local,
mechanic, or general treatment,
which at times cure a recent
case, are absolutely useless
after these changes have taken
place. It is. therefore, appa-
rent, if success is to result
from the treatment of posterior
displacements of the uterus, that
the length of time the lesion has
existed be taken into considera-
tion.

The treatment of a
recent case should be
continued for at least
twelve months, and if
ut the end of thif
period the ligaments
have not regained

their normal sustain-
ing powers, the dis-
placement must be re-
garded as a clironic
one and treated ac-
cordingly.
The treatment is considered under the following headings:
Removal of the cause.
Rc])iacemcnt of the uterus.
Keeping the uterus replaced.

Reduction of the size of the uterus and stimulation of its ligaments.
General ircatmcnl and liyt;iene.
Removal of the Cause , — Tears in the perineum, pelvic floor, and
cervix must l)e rc[xiiretl; cervical lesions treated; and if an endometritis is
])resent, the uterine cavity must l)e cureted.

Replacement of the Clerus . — .\fter the causes of the displace-
ment un<j the injuries to [he soft parts of the pelvis have been removed the next
step is lo replace the organ in its normal position. Two methods are emplo>'ed
for this pur[»ose, the bimanual method, and replacemenl oj the uterus in the knee-
chest posilioH.

Bimanual Method. — It is difRcult to replace the uterus by this method in
very fat or muscular women.

Fig, 3J0r— DlAiJNOilS ut PoFiTrPIOk JIlSPTrAITrHF.NTS np THI
(TEH'S (pJKP J4').

Slmn-in^ A fil)r'>id noclulcin Ihr postrrinruicrinc wallsimulaitim
oflc ■

rcTroflfzucm.

rOSTRRlOS VRRMONS AND FLEXION'S.

The lechnic is as follows: The bladclcrand rectum arc CRi|>liod; the dothing
looscnccl: .itiil the iNttient ))b<'<.-(l in (he dorsal po^iiion.

FikST SiiiP.-'I'hc index und mitldle fingers of tlw left hand ore introduced

fin. in —Pint Stop. in.. t^,—tinl i*tp.

IIIIUNII4I KmATtaan M », tmoDiirLMSlt ITntM.

Into the raciiu and the dltplnced fundus pushed up to the promoniory of the
tciUfn.
Skcokd Step. — A» itoon m the fundiu in on a level with the promontory the

Pir., )ii. -SMAfllSlsp.
Kmuwu. Kmw-utm nt * kanotwrui'is t'naii*.

iW riniit haml rmw^l ihe iiUlomiTuI w;ill liehind the uiery*. which li
ritt in |»■^iti•>n. while ihc inleinal liriKcr^ urc placed agiiitut the untcriur lip
' cervix and (m^h it upward tind iMckward.

348

THE UTESUS

Third Step.— The pressure upward and backward on the cervix is con-
tinued and the uterus is pulled fonvard into position with the extenial fingers.

Fig. 3J4, — Third Stap.

Fir.. i;s,— Kl rl.AI IIMtNT (ir A IViSTEVTOI iTEBlKf DlSPLiirjIlST m THT. KhEE-CHKST POSITIOS.

POOTKXIOK VKXSION!^ AND FLEXION'S.

i49

ftrplaffmettl it* the Knee-fheU PofUwn. — Thw is Ihc best method tn emplo/
in the tnajiirity of C4>«;s, as ihe futulu§ o( ihc ulcms frequently gravitates un-
I atiJcd into an iinterior posllion, when Air niilies in and litilloon.s uut the

^H The tcriinir r>afl (oUoi«'«: The l>lad<ler and rectum are emptied; the clothing
^^BOscocd: und the patient placed in the Icncc-che^l |)i>Mtion.
^^ Simon's sftcculum (curbed Made) is introduced into the vagina and Ihe peri-
' neum well retracted. If the uicru» d»» n<>l (all furwanl at cmcc of it» own
I wciuln. ll»e anterior lip of the cerxix is seized with bullet forceps and drawn fof-

wanl in onlrr to .ilbu- the fu^du^ l» swing clear of ihe sacral promontory.

Should the fundus still remain fixed, a ball of abMirbent rniton held in the

gr&jip of dressing (orcejia bi in-esiie<i sRainsl the posterior wall of the uterus

and the crr\>ix drawn towanl the vaginal outlet. This maneuver usually putbes
^^>c uterus clear of the »acmm and allows it to fall forward into position.
^H In caiiC5 in which there is <lilfirulty in replacing the uterus in the knee-chest
^^osture it may often be overcome by placing the ixilicnt in ihc knecchesi rJnaitd
r ptMitlon, which increases the force of gravity and aids malerially in helping the

furxlus to swing pa«t Ihc «acral promontory.

tin. ijt^-acm'HaooK Poun.

Flu. JH'—Tn""** PiafMA-%.

Keeping the Uterus in Position .—The uterus ^lould be kepi

poaltiun by a Smilhllodice ora Thomas hanl- rubber jjesMiry.

The /*«!«»■¥. — iNTinintffriON'.— The [uticni is placed in the dorsal position

Ute blita viKirjted with ihe thumb and index-finger of the left hand. The

I' in held by ihc anterior kir t)clwecn the thumb and index'hngcr of the right

%oA the pMsieniir bar iRM-ned in the transverse diameter of the vagjiu (Fig.

i» then pu4ir'l downw.ird ami iMckw.in'l .ilnng the nirve <>( ihe jictvi.% until
pivrteriiT Iwr lies transversely in tlie vagina and clo>« against the anierior
lipirf the icrvix iFIk. .170).

The itwlcx-linger of the left hand Is nou' introduced into ihc vagina under the
uilrriot liur uf lite |iessiiry and its tip pressed against tlie posterior bar, directing
il ili-wnward and tnckward bchinil the cervix (Figs, jto und j8i ),

In *ocne instanf-cs it may be advisable to introduce the pessary with the patient
in the knee (hrst ftowilion. TItU x* ea.'ily nccomplidirrl by !>iuhl after the peri-
neum it n-ir.icled by inserting ihe inMninvent Inlo Ihe viigina artd pbcing the
|(intcri»cbar)M-hiiul the cervix (Fig. jSa).

POSIEUUR VEKStOKS AND FLEXIONli.

3SI

the nccnfiary ahcralinns in shape. I'hc shape may easily be altered by coaling
that ]unio(i of xlm [wssiiry to l>e chu»RC<l with vascUn ;iiid huldin); i( nver the
dune nt an aU'iihol tamp until the nil>ber is Nuficnwl. Tlie required altcralions
•re then made aiid the insirumcnl ptun)^ biio cold water.

The pniicni ;>iw>ul>l iiluuys Ite examined in the erect |)o<iitlon after the pessary
has been tniroduccd. in urder to <lcterminc whether or nut it fits properly. A
vrcII-adjtHcd ]>e:AaT}* ^liuukl hold the uterus in pbcc and cause no inconwnicnce
or pain. In the erect posture ihc ewmlner's finger shnidd pii»-> lietwcen the
pcMar>' aiul t)ie Vii;;inu at nil jmints: the posterior cutde^c should be lauti the
nrvtx should be in front of the jKxiierior turaml [loint in ;i Itiickwsrd dlretiion:
anil thr up-and dovn movements of the uterus >hould he fell during' respiration.

If the |je»iry hold.', die uterus abow or below its normal level, the circulation
» ol&tructed ami the (>elvic itrjtin^ l>e<iime conftestwl. The heifcht of the uterus
be reKulaied by cluiiigmg the length and angle of the posterior curve of the

r/, i-

Fm- ill'— lifnooiiciMH o* a ttm*n ■■ im Hint man poanoti <*■«( im}.

; a long, «Jiarp curve hoUU the organ up htfther than one which li short
• acute.

A pCMDry is supported in front by the pubic rami, and if the pre^ure falb loo
wmA upon the neck of the bladder or the urelhru it b mdily relieved by changing
the anterior iMixe.

Id the majority of posterior displacement a Smith llfdpe pessary fulfils all
Jfae indications, hut in certain cums of sHarj) flexiiin .1 l'h(ima> )>eNNir^' will give
iter rrmhs on account of its broad posterior bar.
A properly adjusted pessar}- should not obstruct the vagina and interfen inaoy
way whh tcxv»\ intercocrte.

CAW.—The patient should be under obsermtioo during the entire litne she

wearing the jiesMir}', She shoulit lie examined the day following its inlro-

Tion; then once a week for a month; and finally cvcrj- wn week*. The pes-

>h()u|i| lie removeil every four months in order to ascertain its condition ai»d

taObaUtVlea ikw instrument if the old one hiL* become sliglitly eroded.

352

THE UTERUS.

Vaginal injections of hot water should be used night and morning, and once a
week the vagina should be douched with warm water and soapsuds. Salt solu-
tions should never be introduced into the vagina while a pessary is being worn,
as ihey cause incrustations to form on the rubber and eventually inflame the parts.

The patient should be instructed to have the pessar}- examined whenever ii
causes pain, or to remove it herself if necessarj- by hooking the index-finger o^-er
the anterior liar and making traction in the direction of the vul\-ar outlet. It
sometimes happens, even after a pessarj' has been in place for a long time, that it
suddenly becomes displaced during a bowel movement or during some unusual
muscular effort. Again, the utenis may become misplaced and cause pain while
the pessar>' itself remains in fairly good position. And, finally, if the [Mitient
becomes pregnant, she should be examined once a week and the pessary re-
moved at the beginning of the fourth month.

Indications and Contraindications. — A pessary should only be used in
primary posterior displacements, which are free from adhesions. It is contra-
indicated in secondare' displacements and in cases associated with lacerations of
the pelvic floor and the cervix.

Fig. 3S^i. — Show^ Methop by wnirH a Patit-st Heksflf Rehoves the Peuakv.
Norc Ihfil The indci.fiii|[«r is hoalE?<] avct the anifdur bir ol Ihc iDKrumoiI.

Dangers.— If the pessary is too large, it may interfere with the bladder or
rectum and aiuse iin excoriatiim in the vagina. There is, however, but Utile
likelihood iif either of these conditions occurring if the simple fact is borne in
mind that a pro|ierly fitting pessary causes no pain or inconveriience to the paticni,
and that an examinaliim is indicated whenever ihe woman is conscious that she
is ivciiring a i>ui)|)ort. On the other hand, neglect may cause deep excoriations,
ami death may result in some cases from the pressure of a pes,sary upon a gross
pelvic lesion which was unrecogni^d by the surgeon.

.■\cTiuN. — A ]H'ssar\" holds the uterus in position by elevating the posterior
culde^ac i)f the vagina and drawini; the cervix upward and backwanJ. The
fundus is thus thrown fonviird and the abdominal pressure is directed against the
posterior face of the uterus. The j)essar\' is ke]>t in position by the supjwrtinj;
action (if the jielvic floor and the retentive jMiwcr of the abdominal cavitv.

Reduction in the Size of the Uterus and Stimula-
tion of its Ligaments . — The following routine methods of treatment

l>0«rKltIOK VERSIONS AN'I> PLKXIONS.

353

u¥ rvcnmmcnded lo cure the &ubinvoluted cundilion of ihe pelvic organs and
uimtiUic ihi? tiu-rinc Itfcamentu: (i) Vuginal douches of tux water; (i)ichthyo)
tamiMins; niul (3) pcK-u: nut^^saije.

The ]lhy^i»lclf;ic action ami tet-hnk of ihc ^-aginal dituchcs are desaibed on
r>u|Ec g I .

An U-hthynl tampon should bt introduced into ihc v-apna three times a wedt
rcmiivfl ofl the folIowiitK morning. It ^h(•ull] lie miuk- o( cotton-wool and
lttirate<l with a »iihit>i>n of ichlhyol and glycerin (35 per tent.).

IVlvic nusu^c ii iiiOicalc<l and should be cnnpl<»yed provided a properly
qualifieil nur>c iMi^uilalile.

fieneral I'rcattncnt nnd Hygiene. —Careful attention should
be pivcn t« the general condition and environment of the patient.

The h"«web shmild U^kept regular with a milif bxativc and the orcasional use o(
aahne; gastric dislurbancrsshould bccorrcctrd; and the patient placed upon a
tonic niurw of tre-jlment. Tlie patient's ctoihinf; should t>e arranKed so a& not lo
i-iintirkt or dng ujicin Ihc ;ilwtomin;il viwera and crowil ihc uterus backward,
and the abdomen should be suppmlcd by a bandage to increase ils retentive
power. TI1V iKitltinii shoulil l>e rcKubted and at leiist eight hours deified to
'lerp Tlw itnt'wir c.x»Tri«c» drKTilidi im (Higc 117 arc especially indiralcd and
!:I be cniploycil on account of their stimuhting action upon the retentive
I r <>( the alxlomen.

Chronic Cttes.-The trcalmenl of chronic [x>sicrii>r displaremcnl<- uf the
uterus is iij)ei,itivc. The causes and results of the ksion must be removed before
a radical oiiefation i% |>crformc«e Re«-ent Ciiws), and consequently if the
cervix » Inm il must l>e nstorctl tu ils normal condition; tears in the perineum
or the pelvic lloor must be re|>aired; ami the uterus cureted if endometritis is
pre«ent. By rcikiiriRg the lacerations and curding the uterus immediately be-
(ure ihc alulomen is ojwncd to corrc* t ihc displacement the entire scries of
tiiiM mn \k (lerfumicil at one time and the necessity ol placing the

(•rnl iipain utKkr an .-inc^lhclicobviatctl.

The uic of a pe:>sary may in some cases effect a
»ymplomutie cure, but the displacement n-ill recur as
5oon us the instrument is discarded, and it should
therefore only be employed when the patient refuses
operative measureft. .Adhesions and pelvic lenderncsft
are absolute contraindications to the use of a pes-
*»Tr.

the o|teralion<, in my judgment, which should be cmplo}-ed for the radical
curt of jHisicrior 1 lisp la cements of ilie uterus arc:
Venlral Mivpcnxion of live utrni.-i.
Intr.-i|icrii<>iic3l sltortcning of the round ligamenls.

Ventral Suspension of the fterus (Kelly** opcralion). —
TtikMii el Ihf (}fitT.itiini.—TUe I'rrpunilion n/ the Palitnl aivl the PrepttraUoiu
/#» /Ac ( ifmtimi are ilestril»«i on pages 834 and 837.

Pmiilitm i>f Ike /•<)/(>«(.— Trendelenburg ptMluit.

SumStr tj Ajsitlanls.-~Ka ancnthctixer. ofw usiiUnt, and a general
nimr

tmilmmfHli. — (t) Scalpel; (3) blunt-pointed scissors; (3) three short
benKMjilic (orre|i«; (4) dressing forccp«: (5) two »mall. delicate, full-cuned
nenllM: 16) ihree long, straight, trbngubr- pointed needles; (71 No, 3 braided
«&: ■ I rumol catgut No. a. three envelopes; {9) silkworm-gut — ao

^4).
cumpUcateil by other pelvic lesjons the full list of instruments use<) tn

^n>era

3S4

THE UTERUS.

the operation of salpingo-ofiphorectomy should be sterilized and ready for any
emergency which may arise. (See p. 973.)

Operation. — FiBST Step- — An incision is made through the abdominal wall
in the median line just above the symphysis pubis and extending upward for a
distance of two inches.

ACTUAL SIZE

FlC 3S4. — iN^TItrilENTS^ N»^t:llLLJ>, ANU SUTTIE MaT»1AL^ UsED 1H TRE OPEBAnOH Of V'

or THE Utebus <paj[c iSii-

DfTUhL SUVI^AOM

Second Step. — The index and middle fingers of the left hand are passed into
the peritoneal cavity and gently inserted between the uterus and the rectum.
The adhesions are then carefully separated and the fundus of the uterus lifted
forward into its normal position.

Third Step. — The peritoneum at the lower angle of the wound is seized witii
hemostatic forceps and drawn into the incision and the first suspension suture

Kii;. .iSs. Kiii, ,186. Km. jS?.

\'f r^TPAi. Si'-iPEKSioN of THE UTTRrs — Third Step.
Vig- jSf shtn*s ihc iir*l sii^pensinMi Huiurc btina inTrrtlureil lhrou«h Ihr peritoneum: Fig. jft6 ahmn the
samr sucuri- bt-inE pas.vx] jnlf> chi: tundu<^ of ihr u[(.-ru&; Fiftr jS? ahown iJitr viniv Hulun bring paiacd throuch ^
pcriwncam on Ihc oppusiEf sidi-.

introduced close to its divided edge on ihe left side. The index and middle
fingers of the left hand are then passed into the abdominal cavity and the uterus
securely held while the suture is passed through the fundus.

The suture is now introduceci into the fundus directly on a line dividing the
uterus transversely into two equal halves and buried one-quarter of an inch deep
in the uterine tissue with a distance of about half an inch between the points of

POSTERIOR VEBSlOm AND FLEXIONS.

3S5

vnfniiice and rxii. The uterus is then released by the fingrrs of the left hand and
tin- vuture |>;i-*.?i*<l tluouKh tlie peritoneum opposite to iu point of eniranie-

Tbc Kcnni! suture is mm- [kism^I through the i>rritoncum nn the left side one-
qtiuler of an inch above (he first suture. It is then pas^rd through the fundus

'fundus

I !

rift iM

rw.jM. FU-^O-

VunvM. So*RM>eM i» THi I'mii— Third Sttp.

1^ tiit 111 uab •apMBias Hiiura li, i, b»I I, i>.

■bilut onc-tiuarin- of an inch behind (he fir^i suture, and fitmlly throu);h the
[wriKmeum o|^><ite to its point of entntncc.

It li ai» aixti&uy in hold the fundus between the fingers while the second
Miiurc i* inimitu<.-ed, ux the uterus can f»e eainily coniioUed by miikinn tniiiioD
upon ihc free ends of the first suture. After bolh sutures have been introduced

Pib.

^adiftet.

FlO. MB

TId. )ft>.

MM* nakUig tnifn (lialiir tnkui In muvJuiiBi ihr •uium •! itH luaci ancle of Oa a1iiDnifBir«MD4.

ibeir free ends arc KHxed wKh forceps and pbvcd on eadi Mt of the abdomiul
iadMiin.

Kut-imi Stti*.— The ihrnu)th and throuch sutures closing the •bdomtDol
iacbion are Intftiduceil and the %us|>ciiMi)n sutures tic).

3S6

THE UTERUS.

The first three sutures closing the incision at the lower angle of the wound
must be introduced so as to pass completely- under the peritoneum at its points of
attachment with the fundus, otherwise the weight of the uterus will cause strip-
ping and a large dead space will result which will eventually become filled with
serum or blood and suppurate (Fig. 392).

After all of the incision sutures are introduced the suspension sutures are
drawn taut so as to take out the slack and bring the fundus of the uterus up
against the peritoneum. The sutures are then tied and their free ends cut off
dose to the knots (Fig. 391)-

Fifth Step. — The abdomen Is closed and the wound dressed in the usual
manner (see p. 905).

The fascia is first united with a continuous suture of catgut and the wound
then closed by tying the through -and -through sutures. The sutures in the lower
angle of the wound are tied first, and especial care must be taken to remove the
slack and bring the peritoneum, at its points of attachment with the fundus,
snugly against the abdominal wall.

General Remarks. — The operation of ventral suspension of the uterus was
devised by Kelly and its results are most satisfactory. The procedure Is prac-
tically without danger to life, and
when properly performed no bad
effects are observed during subse-
quent pregnancies or labors.

The technic of the operation
as described above is practically
the same as given by Kelly, with
the exception that the suspension
sutures are introduced through the
peritoneum in a different manner,
and special attention is also called
to the necessity of guarding against
leaving a dead space between the
peritoneum and the abdominal
wall. If suppuration occurs at the
point of attachment between the
peritoneum and the abdominal
wall, a firmly fixed union occurs and the object of the operation is defeated.

Figure 394 shows the correct and incorrect methods of introducing the sutures
into the fundus of the uterus. The small needle in the illustration gives the
correct method, which aims to secure a narrow and delicate attachment between
the fundus and the peritoneum. As the result of this technic there is developed
in the course of a few weeks a small band or ligament, about two to two and a half
inches long, half an inch wide, and one-eighth of an inch thick, between the uterus
and the abdominal wall. The ligament holds the uterus in an anterior position
and acts as a tether rope by preventing the fundus from tilting backward. The
uterus is not held closely against the abdominal wall in a fixed or immovable
position, but has a wide range of movement, and there is no interference with
its development during pregnancy or with the normal presentation of the fetus
during labor.

The bad results which have been reported from lime to time following the
operation of ventral suspension of the uterus are due to the fact that the majority
of operators use an incorrect technic and introduce the sutures with a large,
curved needle, entering the fundus near the oviduct and coming out on the op-
posite side in the same position. The sutures also include the aponeurotic fascia,

Fig. iw. — Ventral Si"speksion of the L'teius.

Sbowi KcUy's p>rIhod of inirodudog Ihe uupfluioD

suiurcs-

POSTERIOK VtKSIONS AND FUXJONS,

357

the imiitrl«», nnci the pcritonrain, and are wcurcd by tying iheir free ends over ibe
ftpow*m>5i» before the alxlominal incision in dosed. Naturally, this technic
mtut rirsull in 4 firm :ind tnatini; union )ieti\'«en the uterus and the belly wall, and
CPiuequcntly evil rr^ultK arc almo^'i certain to follow durine pregnancy or labor.
As the result of a large experience in the operation uf ventral suspension of the

fto- M«' ho. JO).

VKNnAL SrimuniaH or ras Vnaut-

Vlg, iM(km«A*cant(tiBdiiK«nmnirtli»l>nl inifodunnt ilx talyfaii I'lf, wt •he** Ili( fSipKmy llguMil

fnulUOf froir rbc opmlko.

Uterus I have no he^ jtalion in Baying that it is the best treatment for the radical
cure of dironic posterior dispL-i cements, an'l, funhermore. I twlieve thai when
lliis npcTalionisproperly appreciated by the prnfc^ion many of (he cases of id-
cjiiifd nenvM prostraluMi will be pcnnanenily rclieiiTd and a large number of
women restored to health.

Uterus
fiI.ADDER

Pl». >»*— Vtunu ScuMoaoo or nii I'liiri-VarMllOB in TKhnlc
AvtiM( WyWi mxbad at thcnnunf Ihr ntiiul TitimrB'i

VnnaJiaM in Ike TuknU.— la sonw of my operations of ventral niiipeiuioa
I nhonen the round ligaments by Wytk'* method before tying tlie su^pen^ion
Hiiurc^, in <'rd«r 10 strenKtlien Ihc position of the utcnu atid guard against
a nrurrcncc of the dUplacement.

-4^

3S8

THE DTEBUS.

The procedure is very simple and consists in seizing the middle ol the ligament
with forceps and pulling it into the abdominal incision. A silk ligature is then
thrown around the ligament and tied so as to make it taut, and the loop which
remains is finally obliterated by one or two additional ligatures (Fig. 396)-

I n t r a - per i t o nea 1 Shortening of the Round Liga-
ments (Mann's Operation ). — Tedtnic 0} the Op€ralion. — The
Preparation of the Patient; the Preparations for the Opekation; the

ACTUAL SIZE.

Fia. 3^f. — INSJTKUUENTS, XlLPLES. ANIl SuTUkK MATERIALS I'SRD ]K SilOETENlNO THE ftoUND LlCUONn.

Position of the Patient; and the Nl'mber of Assistants are the same as in
the operation of Ventral Siis|>ensii>n of the Uterus.

Instruments. — (i) Scali>el; (2} blunt-pointed scissors; (3) three short
hemostatic forcei)s; (4) dressing forceps; (5) Hagedorn needle-holder; (6) two
small full-cur\-ed Hagedorn needles; (7) three long, straight, triangular- pointed
needles; (8) No. 7 braided silk; (9) pbin cumol catgul, No. 2 — ^three envelopes;
(10) silkworm-gut — 20 slrand^.

Fin. joS— SiiottENiNC TiiF. Rt)iM> LitAUfNTS— SeconiJ Step (Mahm"! Ofeiatioh).

In cases complicated by other pch'ic lesions (he full list of instruments used
in the uperxition <if siiljHngo-oiiphorectomy (see p. 973) should be sterilized and
ready for any emergency which mav arise.

Opera tiox.^FirstStkp.^TKc index and middle fingers of the left hand are
passed into ihe abdominal cavity and the uterus brought forward, after separating
any adhesions which may be present.

[h'\'ERSIOK'.

359

Secokd Stkp.— The round ligament on each side of the uterus is folded upon
itself twice so as to form three equal pans, which Are held io(;ether and per-
lauienlly tiniied by >ilk lii^ilurcs.

The ligatures arc introduced as follows: The first li^iurc (d) is passed
clip« to ilti- menu un<l throu^ the (olds of the liflxment; the »ecflnd (fr) is
pav«d thmuEh the inrietal end of the ligamenl: unil the inlerwning xpact is
united by additional ligatures (f, c, i", () (Fig. 39S).

The opcralittn ii la(-ilitiilc<l hy tyinK each future ns il k iaiened.

IndUmimts jor Iht OpfftUioH.— 'Vhr indicjiliont are the imme a* in I he opera-
tion of veniral suspension of the utcms. In scoondary dkplacerocnts associated
wjlh thitkcninK of the Utse of (he liruiLcl tiKainenU ihe operation gives especUljr
good roultt and »huuld L>c iwrformcd instead of \vn(nil suspension.

INVERSION.

Definition.— An inversion of the uicnis U where ihc ornan is more or less
oompletrl) luriieil in.'.ideout. Itie diT.placemenl niay lie ^r/iii/or fffM^rff; in
the formei' the fundus is dq>rr<.''«-(i, .md in ihv laller (hr uienis b pushed through
the crrvical opening. An inversion may also be described as aaUt or chronic,
accKTtline (o tjie length of lime it Ilis exlMed.

Causes.— The cAndilion is ven' rare. It occur: most frequently during
cbildliinli, but it has also been observed in (he non-gravid uterus ami in vir^ns.

Helen it U tMn^ihlv for un inv<rf>ion to ociur there must be a reUxation of a
portion of the uterine untl which is sumiundcd by normal muscular activity.
Thi* i)oint of rrbxa(ion in cliildLiinh is the silc of the placenta, and in ihe non-
pavtd ulcnvi it i^ iJienrnlly the .-liliution of u new-growth. Any form ol traction

Pk>, jm.— Pui >I Fib. <Ml— C«apM«.

dtvuuMt at rnt lintui.

1*4 helovr or pnssure from above will therefore >tiin an inversion b>- depressing
** (tbxeil (ii>nion of the uterus, which is a( once ncletl »iHin by ihe ^urnninrling
^'■ciB, whiMC ctmtntctions gradually impcasc the displacement until il becomes
^^ *t IcM wmplcte. In mher wonh, (lie de|Mes.s«d portion acts as a foreign
^"^y in the uterine caviiy anil the uterus in attemptint; M vKiiel it n.ilurully (urm
~^'f iniide i«il. SometinwLH tl»e cniire uterine wall may be relaxed .ind an in-
^*^<")o nuy ix'uir (nvni <<>nlinur'l (niclion or [Mrcs.ture.
the PtJerpeni CauMS are:
A Jxin i'>nl.

Early imtiion uiwn die cord.
Fumtal alluchment of the placenta.

360 THE UTERITS.

Adherent placenta

Deliver>' in the erect posture.

A rapid labor.

Injudicious pressure or palpation over the fundus of the uterus.

Violent intra-abdominal pres-sure.
The Hon-puerp«ral Causes are :

Interstitial uterine tumors.

Uterine polj'pi.

Unknown condiiions causing spontaneous inversion.
Pathologic Anatomy.— The condition of the uterus and its appendage
depends upon the degree of inversion and the duration of the affection. In some
cases there is only a cup-shaped depression present; in others the indentatioii of
the uterine wall is so deep that the inverted portion reaches as far as the external
OS; and, finally, the fundus may be pushed through the cervical rim into the
vagina or the organ may hang between the thighs if the case is complicated with
descent of all the pelvic structures.

A complete inversion of the uterus is very rare; in fact, the possibility of the
condition occurring is denied by some observers. In acute cases the internal
funnel formed by the inverted fundus contains the uterine appendages, the round
ligaments, and, in some instances, also a knuckle of gut or a portion of the
omentum. In chronic ca.ses, however, this funnel becomes more or less obliter-
ated by contraction or by adhesions occurring between the peritoneal surfaces,
and consequently it usually contains only the oviducts and round ligaments. In
acute cases the inverted uterus forms a large pear-shaped tumor occupynng the
vagina or hanging between the thighs and constricted at its upper or narrowest
portion by the cervix. The mass is soft and vascular and the opening of the ori-
ducts may be seen if a careful search is made. If the placenta is not attached, its
site is easily recognized. In chronic inversion, on the other hand, the appearance
and characteristics of the tumor are entirely different. The mass is not so soft; it
has lost much of its \'ascularity; an<i resembles somewhat a pear-shaped polj-pus.
The endometrium is also altered ; it has fewer glands than normal; and looks like
the surrounding vaginal mua)u5 membrane. If the surface of the tumor be-
comes irritated, ulcerations may occur; and, again, in some cases the mass may
become gangrenous from constriction. Ulcerative changes are more apt to occur
when the case is complicated with prolajjse of the vagina and the inverted uterus
hangs outside Iwtwcen the thighs. In this jiosition the surface of the inverted
womb liocomes more or less hardened and cutaneous in character.

Symptoms. — The character of the symptoms depends upon the rapidity
with which the displacement occur>. A puerperal inversion occurs suddenly and
is an acute condition, but in a non-gravid uleriis the displacement develops slowly
and pursues a more nr less chronic course.
The symptoms of acute inversion arc:

Severe pelvic jmin.

Profuse hemorrhage.

Shock.
The hemorrhage may not be severe if the placenta is still attached to the
uterus, and in very e.xcepiional instances dangerous symptoms may be absent
altogether; this is probably the rule in cases of partial inversion.
The symptoms of chronic inversion are:

Hemorrhage.

I^ukorrhea.

LumlHisacrai pain.

Sensation of bearing-down, dragging, or weight in the pelvis.

INVEHSIOM.

361

PrctMiTC upon the rct'lum iinrl hlacMrr.
Anemia.
N«ura>theniu.
As a Tuir, the hi-mnrrhjigc is onlinutms, anil Ihr tliiily loss of a small quantity
likxxl cvcniuiilly produces marked anemia an<l general debillly. In ulhw
the bleetliiiK » intermittent nr viulcni hcmorrhnRe.s may occur at the
I »( the mcntilruiii |>criofls, l-eukorrtici h a vm- constant symptom. The
UifRf often llaomc^ purulent and vex) offcnMve. having all ihc iharucteriit-
h'* cf m.iliin'-""'^'-

Dia^osis. Acute Inversion.— The diagnosis, as a rule, is easily made

from t)ie hi^t(lf>' of (he case and the phy-iicul eicaminutinn. After the delivery of

^4he chiltl the (Kitienl Muldcnly complains n( <«^-ere pelvic pain, which is quickly

follownl by profuw hemorrhage and shock. A vaginal Fxamination reveals the

ce in the ^-a>:ina of a soft. pcaT'.'iha|>e<) tumor, which is constricted ntxtve at

I namwesi |">rli"n by a rim or collar— the cervix uteri, lievond which the linger

or a sound cannot be made to pass (Fig. 401 ). The surface of the mass U wku-

tax UkI ibe upeiiing? of the uvidut U may l>e Men. The placenta may or may not

'•^'^;

-DutDMin* or Ikvooosi At nil t.'n*n ottii ni Idhu <n mi vmms Somo iir
Cimrjit. Col ua.

attached: in the latter case its ute is easily reeognifed. Rectal touch

altined wiOi prewnre from above through the .-itHlomin.-tl Mall (rrtVir-

iominat palpation) demonstrates the absence of the body and fundus of the

and the presence of a funnel- or cup-shaped depression at or above the

Knition {>f the cervix (Ftgs. 40> am) 403). In fat women the abience of the

iirru'- m^y be drtcnnin«-d by rental touch combined with a H>und in the bladder.

Chronic InverstOD.— There i.t nothinK ch.irjcieristic in tlie symptoms or

U*ti>n>- of the case, and (he diagnosis consniuenily depends entirely upon the

liyiical examination. Vaginal touch re%'caL'i the presence of a pcar-sha{'ccl

Qor tP-*mblinK a uterine |«ilyp. Tin- Mirfaci- of the mass looks like the sur-

litig muctius membrane, arid it mny Ix' the »eal in Hime rjn*.» of s[Kit> of

I or e%'en gangrene. If the displacement is complicated with proUpse

' ttic vapna, ihc endometrium heroines hardened and cutaneous in character.

36>

THE UTERUS.

A cervical collar surrounds the upper or narrowest portion of the mass and ■
sound or the finger cannot be passed up for any distance between it and the in-
verted |iart of the uterus. The absence of the fundus of the uterus and (he
presence of a funnel- or cup-shaped depression are determined by the same
roethixis as those used in cases of acule inversian.

Differential Diagnosis. — A chronic inversion of the uterus may be
mistaken for a uterine polypus.

Fio 4C1. Fic. 40J.

t)lAi:N"OSIFl 07 TWER^ON OT THE TTEBrS (page .I'll).

Fin- tai ^hnw& ihe absence oi tht body o! the uienis imm Ihc pelvic cany: Fin, 40J shawa the pmcnoc d( ■ viy-

shaped drpmson aliox'e Ihe cenix.

ISVF.RTEU L'TEKUS.

I. Always pyrifiirm .iml symmi-lric in

shape.
I. Dwp ri'iJ in ciiliir and of » siifl consi...-

ttnry.

3. Blfu'ils cisily,

4. Orificoa cif oviilucls arr u^M:illy sctn.

S- Abs<'ntf of body an<] fun<]u^ abo^-e cer-
vix.

6 Cviji-^hapi-i! depression Jibi>vi- cervix.

7 I'ri'senic of cervical collar iir rim,

R. AKsrnce iif ccri'ical and ulerini' canal-i.

9. Uterine sounil will not pnss iniii cavily
of uttrui.

Uterine Polypus.
1, Ofien irregular in shape.

=. I.ightor in color and nol so soft.

3. l">i>es not bicfd easily.

4. Abicnl.

5. Body and fundus of uteni': in nnrmal

p^isilion,

6. .\bsem.

7. Same.

8. Uterine and cervical cannU not obliter-

ated.
Q. Sound will paf-s into uterine cavity ex-
cept where il is obslnicu-d by the at-
lachmeol of the polypus.

The exustence of a parlial ini'crsion of the uterus is often overlooked when it is
associated with a uterine lumor or polyp. The diagnosis depends upon the
length of Ihe uterine canal and the presence of a cui)-sha]Ted depression at the
point of inversion. .\ neoplasm always increases the size of the uterine cavity;
therefore, if ihc canal measures less than normal, two and a half inches, it is fair
to presume ihat the decrease is due to a parlial inversion, and if the examination
reveals a cup-shaped dejiression al the fundus, the diagnosis is established.

im'EKS ION.

363

Prognosis. —Acute Inversioa.— The prognrntis U very grii>-c,a»i1 death
may occur Crnm bcmitrrhage, »h<Kk> »r »eii«i». If the di^placemenl is reduced

Via- 404. Fro. ^%.

nimuvruL Dusvxn wrwrrK Ivrtxinv nr nt I'nti-i t>^ k I'timct PoLTm.
Fit- 40* aboa* Uic puaacE i4 ■ imiuI obKnitii-I l-r thi inmiE-l uiciv. Tin r>< ilunni ■ BMinil is Ihc iBaiiu
cnif V BAiI iiImi dot fitvlfutml 4] the |K«nl of iiuchmoK id Ihi ^iTpua-

at once, the )ir<ij!nosiA is more favora)>le llian when several hc)ur> nr days are
allowed to ebpM: before making an attempt to replace Ihc organ. Spontaneous

no. 4ea.— DnrnunML Dmunxii or i TAaiUL IsnauioH ^aM>a«m> mm A Vrtxim Tuhoi.
Shoo* ibc «■» ihtgiJ ilnrwiriii al Ihc poiM ol in^cnKa uid Ihc iboitcaiat of the dutUk umr tatot dr-

DiinurKal by a uioiEM »und.

reduction is very nrc. The lendency of a piutial mTcrsion is to gnidualtf in-
crcuc uDtil it becomes more or less complete. Prc];nAiKy may tA^ place after

364

THE UTERUS.

the reduction of an inverted uterus provided the oviducts have not been in-
jured by septic infection.

Chronic iDversion, — A patient suffering with chronic inversion of the utenis
eventually dies, as a rule, from exhaustion due to heoioirhage and pain, or she
may fait a victim to some trifling intercurrent disease. Spontaneous reductini
is a rare phenomenon, and amputation of the inverted body and fundus bu
been known to occur as the result of gangrene.

A partial inversion of the uterus associated with a uterine tumor is usually
permanently cured by the removal of the neoplasm.

Treatment. — Acute Inversion. — An attempt should be nude to reduce
the inversion immediately after the accident, as delay increases the chances of fail-
ure and death.

The patient should be anesthetized, placed in the dorsal posture, and the
reduction of the displaced fundus made by the hands, as instnunentai taxis is sot
indicated in acute cases.

FiC. 407.— RETLATtHtNT OF AN AruiE Ihvehsioh DT THE L'TEIUS Bt THt FiNCEU FOUSD URO It COHI.

The technic of the procedure is as follows: If the placenta is attached, it should
be removed immediately. The fingers of the left hand are then formed into a
cone, introduced into the vagina, and pressed against the inverted fundus, while
the fingers of the other hand make counter -pressure from above through the
abdominal wall upon the ccn-ical rim or collar.

As the result of these manipulations the fundus slowly passes back throu^
the cervical rim and the uterus is eventually replaced.

After the reduction is fully accomplished the hand should remain in the
uterine cavity while a douche of at least two gallons of hot salt solution is thrown
into the uterus to relieve the relaxation and stimulate the muscular contractions.
The case is now treated upon general and obstetric principles as one of simple
uterine inertia.

In some cases it will be found impossible to reduce the uterus by the method

INVEUtON.

365

de»CTfbe(l nnH a more |i;n(lu»l fonn of reduction musi be empla)-ed- The
»t pmcTflurr under these ciTcuntKtDnces U to push up only a small portion ol (he
^verted uicrm at 4 tin»c m iih the linger near the c'en'ical rim, continuing the
ini)mLilu)n until tlie entire ma.-ui i« repUce^l,
'Hie palieni should be placed under the iniluence of chlornfortn during the
mluclinn uf the di^pUcenienl and all manipulativt; cIToria should CKXie when the
intcnniltdit nmlni. limi.i oi the uterus occur.

Cbronic Inversion. - -The treatment is divided into:
Prqiarab>r>' ireaunent.
Keplaccment u( the uterus.
Vaginal hj-siciectomy.
Preparalory Trea i me n t .— Be(i>re atlcmpling the replacement
the pialtcnt should lie placnl up»n a prepantlon,- course of treatment for a period
of twoMeek^iolcMen thccongestiiinnf thcpelvicoTKansandlhe&izcof thcutcnu.
The treatment idtould con.iiit of leM in Iwil; a va);inal duuche of two gallons of

■/i

nJ-

K...

He. wft — KmAmam nf «■ Atiti tmimiiw or tm ['Tni>i at I'vunac vr a Snaii. rDtnov M nc

]ir\1RfU> OiGAV «■ '^ Tiiri

Jut normal salt solution, morning, noon, and night; the regulation of the Iwwels
the tue of u mild laxative or an enema and the occa&ional administration of a
ilinr. and a simple and cilmIv i|iKr>ted diet.

Repl4Lcmenl of the I'lerus .—After the prqianitofj- trralmcnt

t\ lirrn ijinird out in the manner jus! <le>i.'ril>ed an alicmpi should be made to

ftbce the utenu.. The gradual method of rettlncemcni u. in my judgment not

Jy the ma<t successful, but at the same time the safest plan to adopt, as (he

rtural cbanKe.* in the uterine vralla and the adhesion:* and contractions which

likely to eiict in cases of chn>nic inversion rrwlcr an attempt at forcibtc re-

w'liun extremely dangerous to the life of the patient. I shall therefore only

trllie ai»l tecommi-nd i^ndual re|)bccment of the uieruii in chroni<r caM^, and

' the kamr linw cinwlcmn all m/inunl or instrumental means and cullint; nj>crji-

'TfefM. becau-^ I Iwlievc ihai if rcdutlion o^nnot be accompli^hctl by the slower
: lufrr plan the lase is h»|ielev% and the organ should tie removed by va|paal
rtamy.

366

THE UTERUS.

Gradual Replacement. — The length of time required to effect the replacement
varies with each case on account of the structural and other conditions which may
be present in or around the uterus. The method, however, should be a>ntuiued
for at least five or six weeks, although, as a rule, the reposition of the organ takes
place sooner. During the entire period the patient must be kept in bed; the
bowels regulated as recommended in the preparatory treatment; and the cathets
employed if urination is interfered with by the necessary distention of the vagina.

Gradual reduction may be accomplished by lampimading the vagina or by
the use of Braun's cotpeurynier. The latter method of replacement acts by
direct pressure upon the uterus, and consequently it not only lessens the size of the
inverted portion of the organ and removes the adhesions about the cervix, but it
also constantly tends to push the fundus up through the cervical rim or collar.

The Method of Tauponading the Vagina is as Follows: The patient
is placed crosswise on the bed and arranged in the dorsal position. The vagina
is then irrigated with a solution of corrosive sublimate (i to aooo), followed by

FiC. dCg.—REPUCEllEKT OF A CHtONIt INVEBSIUN OF IHt I'TEBUS BY TaUPONADIHII TBI VaCDU.

•

normal siilt solution, and thoroughly dried. Simon's speculum is now intro-
duced and the vagina ]>.icked with strips of iodoform gauze three inches wide.
The larapim must be carefully and firmly packed in the culdesacs and also
around and below the inverted uterus until the vagina is completely filled with
^auze. The packing is held in position with a compress and T-bandage which
is temporarily removed when the bladder and bowels are emptied. The
vagina should be thoroughly irrigated and a fresh tampon applied every second
day.

Tiij: Mkthodok Employing the Coipeurynter is as Follows r The posi-
tion of the patient and the preparation of the vagina are the same as when the
tampon is used. The rubber bag is smcare<l with zinc ointment to prevent
abrasions and then introduced into the vagina. Warm air or water is now
injected into the instrument until the patient complains of the distention. The
coipeurynter should be remo\-ed for several hours each day and reintroduced

TTEMNE WSnACKUENTS OF SECOKDA«Y IMPORTANCE. 367

with the sunt precautions. The amount of air or water injected into the bag b
Uraduall)' increaMd ax the (Kiticnt become* accustomed tu ili« pressure. Son>e-
l)me» the bag ubMnKls the urethral c.niuil and it may be neccssarr to tempo-
rarily let out some oi ihc air or water when the [laticnt desire* to urinate.

A colpcur>'nier i& OM>re cBeciivc in its results and easier to adjust in ibe
vajiiii.i than a utm[xin, and <-onse<|Ucntly it .Oiould alwuvi be preferred. More-
o\tt, it rc«|uires considerable skill »nd experience to pra|ierly p.ick the vagina in

fw. 4M. — RmjumiirT or a QmwK Ihvcuhih or nn Umn vna BaAtni'i CowvnTinn.

tof Uterine in version, and many insUnronf unMirrt-uful ^tiemplv at rcduc-
tioa by thi» mrja% arc directly due to an improper methtxi of introducing the gxuie.

\' J g i n a 1 H y s I e r e c t o m v.— The (ompleic removal o( il»c uterus by
the vaitinni route is indicated when gradual reduction (ail* to restore the organ to
its normal pnrMtion. The tcchnic of the oprraiion is described on page 999.

Ampulalioo of the inverted portion ol the uterus
abould be condemned ao an un^urgtcal and danger-
out operation.

UTERINE DISPLACEMENTS OF SECONDARY IMPORTANCE.

As the-* displacements are swondari 10 or caiued by certain Krc>» jwlvjc
te*toni>. it tuitundly (dIIowk that the sym/Xomt, diagnoiis, prognotit. and Irral-
(•en/ ■)( these f.ws are ba»cd upon the pathologic conditions present and not
Upon the maI|Misitlon of tlie uieruei-tive rhaptrrt and need not. therefore, be discussed here. It shouM, how-
ever, always be rememliered that after the lesion has been removed by surgical
lalerferenc* the di'placement often remains because ihe ligament." of the utertrt
hare been overMretched and permanenOy weakened by tlie abnormal pniiiiion <if
the ufpin. Under the»e circumstances, therefore, the
uteru* should be restored I0 its normal positiim by
either the operation of ventral suspension or intra-
peritoneal tboftcnfng of the round ligaments.

368

THE UTEKUS.

FIBROnATA.

Causes. — Nothing is known of the cause of these tumors. Thejr de^-riq),
as a rule, during the menstrual period of a woman's life. The largest number of
cases is obseired between thirty and forty-five years of age, but cases have been
reported in young girls before puberty and in women after the menopause. These
tumors arc not only the most frequent neoplasm of the uterus, but they are also d
very common occurrence. They are more frequently observed in single and
sterile women than in those who have borne children, and the colored race
in this country is found to l>c more susceptible to the disease than the white.

Description. — Fibroid tumors are found in all parts of the uterus, but
they occur, however, most frequently above the internal as. They are developed
from the muscular or middle coat of the organ and are composed of the same
tissues — unstriped muscular fibers and fibrous connective tissue. They ate
classified hisloingically into fhroma, myoma, fibromyoma, and myofibroma. The
muscular tumor, or myoma, is less common than the other varieties. Fibroids

Fic. 4" — V«iii^is OF Fibroid Ti'moisof tiib Uterus.

may be sinple. but in the majority of cases they are multiple, and exist in groups
or ure found scattered o\'er different portions of the uterus. They range in size
from a small pea to a tumor weighing one hundred and eighty [xiunds or more,
and dilTcr in consistency from a hard fibroma to a myoma which is sometimes so
soft Ihat a sensation of durlULilion is imparted to the e.famining fingers. These
luniors arc while or jiinkish in color and they show upon section concentric layers
of fibrous connective (issue arranged around various central points which project
somewhat bc><ind the cut surface. Usually the tumor is surrounded by a capsule
of loose conneclii'c tissue, from which it is readily shelled out or enucleated unless
adhesions have occurred as the result of inflammation. Fibroids are benign
tumors, bul they may, however, be associated with malignant disease. They
grow slowlj', as a rule, and arc often many years in attaining to the size of a
child's head. In the case of multiple tumors they do not all grow with equal
rapidity, and it is the rule to find growths of various sizes in the same uterus.

PIBROUATA.

St»9

Somrtimo a fibroid will cease (o grow alingcthcr am) remain quieKcnl for ui
iiiitv t'*'"'xl' oril mny <li;vi>lii)i mi iUynly llial the (tatienl tv liunlly aware of
-J.. iiM.-mbc in its sixc. When a fibroid lumor suddenly bt-
KiD« to Rrow rapidly, it is usually due to pregnancy
■ if <y»lii r|e|[vncrat ion.

Varieties. - l-ibroid tumors, as has already been said, de\'elop from the
muMubt "r miiidk- nml al the uterus, an<l from Ihis situation xhey rtow cither
Ittnrurd ihej^riti'ticum. inl.i ihc utcrim- cavity, or ln-twecn the layers u( the jwlric
liwuisi. Tncy arc, thcicforc. known a inlerililiul or inlramural fibroids wbcn
titcy arc hiluatol wli<iU>' itilhin ihe niUMular wall; a.i iubpttitoiKnl or subterom
fUin>iili when ihcy bul|j!c outwanlly lioiealh the i>eriiiincum ; as subntutont fi-
t>raiil!> uhcn they pu^ innardly into the uterine cavity; and as inlruligiimtnt0iu
Utt^M* when ihi-y [>rujn-t from the sides of the uterus or fnxn any |>art oj the
»oi»r»xi»uinal cenix t)ei«een the Uyers oJ Ihe pelvic liiwues.

laterstitial Fibroids.— These tumors are ncnerally associated with libfoid
by^iertrophy «( liie niuMular coal. The uterus is symmctn<^ally increased in »ize
and itn Mirfoce is jimxiih. The gem-riil c-nlargcment of the uicru» h fomrtinKS so

Plo, 4.,-
niiii

< >tni Si*-
ur nu

treat that it form^ a tuntor occupying the cntiiT abdominal cavity. U|»in scclion
;i numlirr ol tumors are observed of varyinK mc scattered lhmuf;hout the uterine
walls. Thej- are Ui-tialty haril, circum«:ribf<). and enclosed in capsules, frt^m
wht<:h ihrv arv reiulily shelled out unless adhesions have furmetl a^ the result of
It: ' " <n. Ill oilii-r c'AM», however, tlie tumors are more or lets »ofl and

» . . i-»lini( 'he.itliv

Sobpcritoneal Fibroids.— These tumors, as a role, arc multiple, although
i> 1 I 'ti.i [K ^1 -iiit^Ir iiivliilc i> «een uj>i>n the ^^urface of the uterus. The milules
diT- ,. ..Hi ri>lo\rr i)i« uterus ami var\- in sixe from a small [lea to a mass weighing
(■iriy [«^^ut>ds«irmore. These tumors alw.iys beRin ai sriMle Rrowlbs. Uil as ihey
drvrlo|t and push the jieritiineum forwani d>cir attachment or connection with
the uteru* Imotnes morr and nvtre constricted, until eventually distinct pedicles
Jiic ftmncd which var>' in len^ih and ihicknc^. Sometimes the jtedide becomes
twirf<vt ~ ' ~'~i' fibroid i* cumpteiely sefkinitcil frt>m the uterus, when it either
taao* with and derives a nen- l)loo<l -supply from one of the nei);hl»or-

■XC uncarL-., ui It tunains unattached in the abdominal cavity and b ktum-n as a
n

370

THE UTESCS.

\\\

minraling tumor. U a large lumor is iiltached l» the fundus, it h likdy to pull
the utenif) upward as it grows and cause the lourr utrrinc segment to become so
KTeatly slrttcheil a> lo give it the appearance of a narrow or tonstrictwl [ledictc.
The range of movement in a jieihincii ialctl tumor (lefwndt ii|*<)n the Icnj^h of its
pcilicle and the siUiation of the ncihesioiis, when they are present. If the growth
is attached to ihe intestines or omentum, its mobitiiy is not restricted; bui if it

has become adherent to some fixexi point
in the pelvis or abdomen, it must neces-
sarily remain permanently in ih.il pt>st-
lion. SiibiK-rilnm-al tumors cause more
or less irritation lo the peritoneum and
arc therefore likely tn fcirm iitt:ichments
with neighboring (■rgans as the result of
localized adhesive inflammation.

Submucous Fibroids.— These tumors
are usually single, although the>' may
occa-yonally be multiple. The tumor be-
gins, as in the .suliperiloneiil v.iriety, as a
sessile growth, but as it develops and
pushcn further and further iiitn llie uterine
cavity it graduidly iR-romcs more and
more pedunculated until finally it has a
di.itinil pedicle which i-ariiti- in length
and thickness. These pedunculated
submucous fibroids arc known as fibroid
polypi, and are frei|uenlly met in women
during mcn.slrual life, A fibroid polypus generally starts from the body of
the uterus, hut in rare ciises it may originate in the cervix. It is a vascular
tumor, usually somewhat soft, and vuries greatly in *ize from a small mass to one
a.s lat^e as a man's fist or even larger. It maj' become edematous and slough as
the result of torsion or constriction of its pedicle, or the mucou.s membrane cover-

Fia. 4i4.'-Suaiil'coi-( Pidioiii Tuuo* of iui

A«

n^k

Fto. *■}.— Aoleiloi.

Fta. 4i«.~Po>tariiu.

Fin. ii;.— Idlainl,

ing it may become idceniled from overstretching, A polypus is apt to excite
uterine contractions which frequently result in its spontaneous expulsion liirough
the cerx-ical canal, and in rare instances, when the pedicle is short or attached to
tlie fundus the uterus may liecome ini'erled.

Intraligamentous Fibroids.— These tumors on account of their situation

nmtOUATA.

J7»

Ititiinfiil ami wrimiA |>rr»»iir« >ym|)l<>in» and nre also ihe most diflicult to

Jc trcim a surgical ^Uindpoinl. I'lic) may <Icvclop from the anicfior or

postvriif )><>riii>n »( (he supravaginal tervJx and from the kteral aspect o( the
bwlv "1 llic ulenisur tbt icnix.

An Mtirrior lum«r gmws fiTWLicd and upward and canics with it the peri-
itm and bladder, which are oftcr) found dattencil out u)ion the nnteriur lur-
' of Ihe groviih, A finslerior Itimor gro«-» backward and upward, pushes up
■ culde^ac of D<iUK)a>>, and becomes rclropcriloiieal. A hlerat lumor sefiaraies
Ibc byeo nf ihc bniad lt|{ament, di.-^pbi^es ihe jielvit structures, cau»c$ serious
prr^ture aympfims, himI may c^Ynluatly extend into the abdomen and cany with
it jII Ihe ovcrlyinR OTfjuns.

Changes intheTJtems.— Fibnml tumors cnuvu jjenvnd hyiKTlr-iphy of
the miiw-MUr wall of the ulenis. The degree and cslent uf the cnl;tri;cmcnt dc-
; ' 1 the varicly ninl xiluaiion of the iji^iwlh. The hy|>ertniphy i> more

I I ihr iriteritiliid aiul MilimucouN tumnrs than in the sub]>crilone]l and

It ■ ij Mcnt'ios Allhi>uj;h. as a rule, the ulerine wall is always more orless
rti. ir// i 111 all varietkrs, yet it is not uncommnn tn I'md ime or mom small »ub-
(•eriionnl noilulei> witl»nit any increase ir ihc ^ize o( the ulcnis. As has slmtdy
Leeiv menltuncd. ihc general hyperirnphy of the uterus is sometimes so Rrcal that
ii (ortHK u lumor filling ibe alulominul cavity. The uterine ranal usually in-
rrrsse* in size |>r"p<>n innately with the (ticneril cnbrKcment of ihe organ, but
in itie case of submucous tumors il somclimcs becomes cnorm<)usly dilated and
: 'I h Iteil when the gmwlh l^eaime* more "r Iws jHilunculated. The intTcii»ed
tit of the uterus causes it lo Iwcome u-irtyiitplaceil and prola|MM.-d unle?» the
tumof .-iltiiins a brjje siw? anil iHi-upies the aUlominal caviiy.

The enilometrium is often the scat of an interstitial or a gbndubr hyper*
trophy, «i»d in submucous tumors it may become edematous and ewniually
ukvniie ns the result '^f pr<-ssurc.

Bffect upon Neighboring and Distant Organs.— The oviducts
Ate often di-'placcd and bound <Iotvn by ailhcsiuns. They may also become oc-
1 luilnl anil contain serum, bloixl, or pu« {hytironttpiitx. fiemaiosaJpinx. or p)0-
Miipinx). As a rule, the ovurii's are enbtged; their capitulcs are hypcrtrojihicd,
ihey bcciime adherent and displaced, and often tbitenetl by ihc pressure of the
tunor- In >ome i^>e> ihe uterine appembfces are so completely buried by ad-
Iwriani lliat it i« dilTuult or impo^.'^ible to fmd them until after the growth i&
rcmoiTcL The bloud-supply of the uterus ts greatly increased in amount and
ihr artrries and veins are immeiL^ely cidarKe<l. The uterine littamenls also be-
camK bvperlrophicd and slrcUhed and the veins, especially of ihe bnuid Itn-
nwnt*, are vani(»cd and excessively distended. Adhesions arc apt to occur be-
tween Ihe tumor nnd the )>eritoneum a.i the result of friction which jmiduces a
Im-aJuetl adhesive inflamtuiilion. In tutnc ci1m:» the^- :ulhcs)ons are very rit-
leruivc and the growth is found lo be firmly united with many of the abdominal
: ~.A ;<elvic vUcera. Si>metimes tlie peritonilis may be due to the extension of an
-iimatinn (rnm the tumor ilwlf , and when this is »q)tic in rhnrscler death may
■•'''■ fi' tti a general infection of Ihe peritoneum. .\nd. finally, a large and mov-
' i<r may irritiite the peritoneum and eaute a»dtet. Serious ami annoying
■ •tm are «imrlimes rause<l by pressure of the tumor upon the bladder,
or ihr urethra. These eondiiioru are e»|iecially likely lo occur when
il^e jielvic or^m and when it i<^ inlnili£amentiius in {Hisiiion.
ii.sLinces urination is interfered with and ve>ical irritability
lib. or ittere i* retention of urine fnim pressure upon the urethra. Ilemor-
mid* and ci'niiti|ialion are al^o of frequent occurrence when the growth prcaw.s
the reetum, and iIm general health of the palicnl may suffer from the ab-

$T2 THE UTERPS.

sorption of fecal miiteriiils by the blood. Grave lesions are sometimes caused by
pressure upon the ureters, which may become dilated and undergo organic
chanpes. Under these ron<iitions hydronephrosis may occur or the kidney and
its pelvis may become inflamed and suppurative pyelitis may result.

Large abdominal fibroids may cause structural changes in the heart and liver.
The left side of the heart becomes hypertrophied and dilated and its muscle
undergoes fatty degeneration or brown atrophy. The liver may also be the seat
of a fatty degeneration.

Secondary Changes in the Ttunor.— The following degenerati«
change.s may occur in uterine fibroids:

Atrophy. Necrobiosis.

* Calcification. Amyloid Degeneration.

Fatty Degeneration. Colloid and Myxomatous Dcgenenition.

Infection. Cystic Degeneration.

EdemiL. Sarcoma.

Carcinoma.

Atrophy. — Sometimes a fibroid tumor undergoes senile changes and atrophy
along with the uterus after the menopause. It then becomes reduced in sire and
harder in consistency, and may cither disappear altogether or remain for an
indefinite length of time. Fibroid tumors have also been known to disappear
after pregnancy by undergoing involution along with the organs of genera-
tion.

Calcification. — This change occurs as the result of a deposit of lime salts
(carbonate and phosphate of time) and usually takes place in titmors after the
menopause. It is not an uncommon degeneration and is more often obser^'edin
subperitoneal tumors than in other varieties. The lime salts are deposited
either in the tumor or in il.s capsule. In the former case small particles of lime
may be found scattered throughout the tumor or the entire growth may be affected.
forming «hat is known as a uomh-.tlone. Upon section these stones show
the concentric arranj^ement of the l)undles of fibrous tissue which originally com-
poseii the tumor. When Ihe lime siills are deposited in the capsule, they form
a hani shell which more or less completely surrounds the tumor.

Fatty Degeneration. — This .secondary change may involve only a portion of
the tumor and form cyclic spaces in the growth, or the entire neoplasm maybe
affcdcd and the muscular li>~ue completely destroyed. It is a very rare condition
and is most frefjucntly observed in tumors after the menopause and in those cases
in which the growth spontaneously disiippears after pregnancy.

Infection. — Inllummalion of a fibroid tumor is not an uncommon occurrence
and it i,s likely to l>c followed hy .supjmralion and gangrene. It is usually caused
by infection from a liirly sound or an instrument which is introduced into the
uterine cavity, or it may result from a surgical operation upon a submucous
tumor or a polypus. In rare cases infection has occurred from the intestines and
rectum when ihcy have become adherent to the tumor. A fibroid polypus is
more liable to infection than other varieties on account of the frequency of ulcera-
tion occurring in the mucous membrane which covers it, and also because of the
likclihoixl of its circulation being interfered with as the result of pressure or con-
slrirtion.

Edema. — This condition may he due to inflammation or it may result
from a temjMirary interference with the circulation of the uterus, and it has also
been ob.served durini; pregnancy and at the menstrual periods, especially in
young v.'omen. When a tumor becomes edematous, it rapidly enlarges, under-
goes softening, and is filled with serum, which may enormously dilate the
lymph-sjiaccs in some ca.scs and pnxluce a pseudo-cystic degeneration.

PIBROUATA.

313

Necrobiosis. — Tliis fe a frequent ^condan' change in uterine fibroids, as
uwn liy Cultin)^i>rlh, wh4> rr<-eiitly re|K>rte(l fifteen in.itiiiire.% of necroftiii with-
It infection in :i scries of one hundred cofcs. The nccrobiolic degeneration
tnually involves only a part of the neu|>Iu^ni and occurs in patches, but in other
~l*e» It may »fl«-l the entire growth. It atlarks must fre<)uently the interstitiiil
cly and the subperitoneal tumors with u sessile bFise. According to the above
iliktir*. the viiuniteM woman was only twenty -?«vcn ywri of age and the oldest
Kty-two \-eHr*; «he had i«iv«*H ibc mcnoiwuM! at fifty. There i,s always danger
of ^(itic infct tion •» i tirrin>; in 3 tumor the scat of this form of degeneration.

Amyloid Degeaeralion.— ThL-v i.-i 3 v-ery- rurc condition. Only one cue tbtis
bu h*' liocn i.b«T\«l.

Colloid and MyxomatouH Degenerations.— These conditions arc rare and
they may re>ult in lyslic < han)(e> in the tumor.

CyMic Dc^eneratioD. The causes of cystic d^enenition occurring in
fibvufd tumors arc considered as follows:

I. Lymplungiet'taiic lumnrt, in which the I)'mph-;tpace)( are vnormouiily
dtUted And loim large cavities which arc lined with endothelial cells and which
an; filled with u clear fiuid that cou);ulatc» upon exposure to the air. Tbb
variety h the moti fre<iuent form of tyslic Hegenention.

I. Colloid and myxomatous dcKcncralions mny he followed by the de\'elop-
meiii of a fibnxyMic tumor. The mutui<l .substance under these circum.stnnces
iy cT>ili>»e<l in sfuiccs within the iiKfuai of the jtmwih which are not lined with
mduthrlial cells, as in lymphangiectatic tumors.

,(. Cavities may tie formed in a tumor fn>m any \-ar>ety of degeneration which
undergoes softening .ii>d sutxvqueni deliiiucscencc us the result of im|»iircd
nutrition. These cases arc examples of necrobiosis or necrosis without infection,
.ind they may occur when fatty or s.trcx)maiou.« chiinfte« are present in a fibroid
gniwtb. The material contained in these cysts is ihici; and opaque, and blood
may sl<vi be present a.^ the result of an imnicvMic bemorrhaf^.

4 The cavernous tibroid is due to dilatation of the blfiod -vessels in the
1 xsm llelJN^U/titih). In some cases small venous cavities are found filled
. . i1uidi>rcl<>tlet| MiMXI.
Sarcoma. -There is now no doubt that mwifibromala of the uIctms may
;ii ^a^conMt(>us degeneration. This fact lias Ijeen demonstrated by
rchow, (iilli-n, and other inventigatort who have oliscned this form of matig-
iRl change in these tumors.
Carciooma.^W'hile carcinonva should not pmpcrl.v be included among the
raiite changes in fit>roid tumon<. for the rea.-4>n that it i.s impoiisible (or the
tih itself to undergo canceroii.^ (ransformalion. vet as the two conditions
caaidnall) coexlM it vas thought pro{>er to refer to the subject under the
<tvr rLiwilicalion.
Symptoms. - The symptoms arc classified under the following headings:
llem< <rrhj|;e. Pain in the surrounding patls.

Ixukoirhni. Urin.ir)- organs.

Pain in the tumor. Rectum.

Oenerti i.ym|it<>ras,
H am orrhage.— Hemorrhage is the most constant and the most significant
iptiini. It usually increase:^ the amount and duration of the menstrual flow
BtturrrlKHuA, aiwl in M>me ca.MSt It e\'cnttially occurs also between the peTiiid.s.
Jtrr Itting severe (or a long lime the bleeding may cense atlogdher aiM return
in several months, or it may lonlinue indefinitely. As a rule, mu.sculur
on. actual inlcn nurse, and emotional intlucnce-v increase the ([Uantity of the
ige. If the tumor undergoes atrophy at the time of the menopause.

374 THE UTERUS.

the bleeding gradually lessens and finally Ktops entirely. Sometimes a wgman
who has had no hemorrhage (or .leverai years after the change of life will suddenly
begin to bleed, and an examination will reveal an ulcerated fibroid polypus. The
blood is usually in a liquid state, but in some cases when the patient is in the re-
cumbent position for several hours large vaginal clots are formed which aie
expelled as soon as she assumes the erect posture. When the clots are
retained in the vagina for a long time, they are apt to become decomposed and
ill -smelling.

The severity and duration of the hemorrhage depend upon the situation and
character of the tumor. A fibroid polypus is generally accompanied with con-
stant bleeding and also an increase in the quantity of the menstrual flow; sub-
mucous and interstitial growths, as a rule, cause menorrhagia alone; subperi-
toneal fibroids, especially the pedunculated variety, have but little, if any, efiect
upon menstruation; and the intraligamentous tumors arc often the cause of
excessive hemorrhage during the periods. A true myoma and an edematous
fibroid cause profuse bleeding during menstruation, and at times also a metror-
rhagia.

The bleeding in uterine fibroids is due to a hemorrhagic endometritis which is
caused by the presence of the tumor, and in some cases it may come direcUy
from the capsule of the neoplasm when it has been exposed by atrophy or ulcera-
tion of the endometrium.

In exceptional cases, even in large tumors, hemorrhage {menorrhagia and
melrorrlmgia) is absent as a symptom.

Leukorrhea, — This is a more or less constant symptom and is due to an
excessive secretion of the uterine glands {hydrorrlua). The discharge Ls gener-
ally serous in character and ver^' profuse. Sometimes it may be mixed with blood
or it may become purulent, espcdally in cases of sloughing polypi.

Pain in the Tumor. — Pain occurring in the tumor itself is a very significant
symptom of some secondary change taking place. Under these circumstances the
pain is not only sixinlaneous, but it is also evoked by pressure. Pain may also be
caused by a rapidly growing interstitial tumor stretching the walls of the uterus,
or there m;iy be expulsi\e pains, which are intermittent in character, that are due
to the presence of a submucous growth or a jxilypus.

Pain in the Surrounding Parts.— Pain is a more or less constant symptom
of uterine iibroids; it is more marked when the tumor is situated in the pelvic
cavity, especially the intraligamentous variety, and it always increa.ses in severity
during the menstrual ]>eri(«ls. The causes of pain are various. It may be due
to pressure or traction upon adjacent organs ; to disease of the uterine appenda^
or neighboring parts; and lo local peritonitis or adhesions. There is usuaUj' a
sensation of fullness and weight in the pelvis and localized pain in the lumbo-
sacral region. Pressure upon the ])elvic ner\'es results in neuralgic pains which
may Ije referred to \'urious parts of the body, as the [>elvis, the abdomen, the head,
and the lower extremities.

Urinary Organs. — As has alrcad)' been mentioned hydronephrosis may
occur from pressure upon the ureters, or the kidney and the renal pelvis may
become inflamed and suppurative pyelitis result. Vesical symptoms are very fre-
quent, especially when the tumor occupies the ])elvic cavity or it is intraligamen-
tous, or grows from the anterior surface of the uterus. Under these circumstances
the capacity of the bladder may Ijc lessened and a constant desire to urinate
re.sull, or there may be an obstruction to the flow of urine, which is so marked in
some cases that it is almost impossible to introduce a catheter.

Rectum. — Constijiation and hemorrhoids are a frequent result of tumors
that press upon the lower bowel.

nSKOUATA.

375

G^oeral Symptoms.— The hcallli of the jiatieni Mfitn frotn the continuous
ti'ifrhugc. the leukurrheii, the piiiii. ihc vftrrt upon neiglilxirmK and {li>tanl
Itani (rum (he prc^-inc of the tumur, and from the sccondan- changrs vrhich
takr [iLii* in ihc jiixmih iisclf. Profimnd anemia i-s tht rule in bad cases and Ihe
charoilcr of the liluod i.i ^till further impnircd t>y the coprvcniii which results from
chronir ron^liiuilinn. Patient^ as a nilc, become exhausted and lose weight,
e\. e]>( in uncumpli^'aied caM^, when it is iK>t unusual for them to k"')^ ^^ '"^
Ihti "me (lit- In some <ii>«n then; m:iy l>c mitwle disease of the heiirl (/jMv df
xrufniliim in hrtmn altopkx), or. again, the left side of the organ may become
ti.vprrir<i|ihicd and dilated. The liver mny iil ume-s- \tv ilie seat of fatty chiinfcs
tuxJ the [jrevvure ii( ihe tumor may cause an enlargement of the vein,* of the ab-
domen or ascilii^. Sometimes edema of the legs is marked and temporary
pamly^i.'- may iKcur in the lower extremities from preoure.

Pro^OSiS. -1~he earlier views in rci^rd lo the prognosis of uterine
^hnimyomata have not stood the test of time. ;ind. a* the result of a more extended
and [ifurii<:al eji]MTiencc, these ne<>|itiism.t arc now conMdcred to he rl.in^rous ti>
lite and (re^iticnlly the c<iu% of chronic invalidism. While it is true (hat et~en s
Uxf^c Abrok) may cause no marked >ymptom.s during mcn.itrual life, that these
Dct^iUiniK may atrophy an<l di-vippear .n1 ibc menopause or afltr pregnane^', and
thai a submucous tumor may etcntuall}' be spontaneously citpcUcd as a nbroid
p<iK-pu$. it U also e<iually true ttwl the.-* results are the exicj>tion and not the
fule, and that death may occur while the palienl vainly wnit> for a (avonible
emling to her coiKlition, According lo tbc investigations of Noble, death results
in ,1) per cent, and chronic inv'ali<)i»m in 15 [ler cent, of all cu.ses not operated
upon.

ITie reiisoRs (or ihc dungeriJUS outlook in coses of uterine flbromyomata are
nt* dift'u ult to (ii;^covc^ when we wnsider the efTecI of Ihe lumor upon neightiur-
mg and distant organs, the secondary degenerative changes in the growth itself,
ami tbc cKhau-^ting nature of the iiymptom.-i which arc dq>cn(knt upon the pre>-
ence of the ne\'(>lasm. The danger lo life l>efort' or after operative interference
friirn organic lesions of t)w heart and kJdney.s bus been frequently demonstrated.
IVriliitHnil intlaminalioas ami adhe-vions have priNluceil grave conditions, as
>hirwn in a ca*r re|«)rti-(l by Cullinptworlh, "of a ?loui;hing interstitial libromyoma
tTi ivhich ihc slough had ulceratc<] thn>ugh the uterine wall into the peritoneal
and iiad tliere infected the wall <A ihe tranNverie colon, to which it wan

< rrnl. with the rt«u[t of causing sevcnd intestinal pcrforalinns." And,
tinally, thetbngcr of the oviducts becoming infected must also be considered.

I>CKa)erative ^lla^ge^ in Ihe lumor il^-If are Ixith fm)uenl and dangerous lo
life, anl in view of our present knowledge upon the subject the prognosis of uter-
ine hbroids must be guardetl. In a series of 100 cases CuUingworth found that
"in no (ewer than ;i ca^es, or rather more than one half of the whole :>eries, the
!■! undergone «Hne form of sccondarA' (degencralive) change." The
.ind falty fornvx of ilcKcneration are tl»c least dangerous of the sccoo-
'.•f^. Infection i< likdv lo be followoi by suppuration and gangrene.
I'u.iHv associated with rapid cniargcmeni of the lumor and severe
,h- ' id atwl myxomatou.'i changes may l>c followed by the for-

m i< ihe lumor, A letangiectaticllbroid may cau^e *wlden death

ftiim emiioli.sm and a librocyslic tuntor may endanger the patient's liic from ex-
faaui4lim i>r it may rupture s])onianeously into the peritoneal cavity. Sarcoma-
iDU* degeneratiun h n danger always to be considered, and Ihe fart Ihai
MK« may .-iitack the cervix or endometrium should not be loM sight of.

The pruf'Mind aiM.-mt;i that arcom|«nie> cilm-s of fibr^iid tumors of the uterus
are chamctcrixed by continuous or rtr|H-ated hemovrfaagcs b oiM ol the

376 THE UTERUS,

most dangerous symptoms resulting from the disease. These patients have m
reserve power whatever, and they often succumb to a trifling intercurrenl af-
fection that under ordinary circumstances would not have a. fatal issue. The
health is further undermined by leukorrhea and pain in the suTTonnding parts,
which is usually the result of pressure; and, finally, chronic constipation, bv
causing copremia, destroys the quality of the blood and impairs the vitality of the
genera) system.

From what has been said the causes of death and chronic invalidism in
uterine fibromyoma are easily understood. While sudden death from hem-
orrhage is unusual, the effect produced by the constant loss of blood is apparent
in the anemic state of the patient. Fibroids of the uterus, as a rule, delay the
menopause for several years. There is always a relative sterility, and if con-
ception occurs there is danger of abortion or premature labor resulting. If the
pregnancy goes on to full tenn the delivery of the child through the natural
passages may be extremely difhcult or even impossible on account of the mechanic
obstruction caused by the tumor.

The effect of the menopause upon the growth of uterine fibroids is very un-
certain. In my experience I have seldom seen the retrograde changes spoken of
by the older writers take place, and the tumors have either ceased to grow and
remained stationary for an indefinite length of time or they have become active
again several years after the menopause.

Diagnosis. — The diagnosis of uterine fibromyomata is not, as a rule.
difficult, and is ma<le by the history of the case, the general subjective symptoms.
and a physical examination of the tumor. The history and subjective symptoms
have already been discussed, and it is therefore unnecessary to refer to them
again, except to call attention to the fact that they are often important as an aid
in the diagnosis of these neoplasms. The physical examination reteals the origin.
the situation, and the characteristics of the tumor. From a diagnostic standpoint
each variety of uterine fibroid must be considered separately, as follows:
I. Interstitial fibromata.

(a) Pelvic in situation ; (6) Abdominal in situation.

3. Subperitoneal fibromata.

(a) Pelvic in situation ; (i) Abdominal in situation.
3- Submucous fibromata.

4. Uterine jKiIypi.

5. Intraligamentous fibromata.

(u) Between the folds of the broad ligamcnLs; (6) Posterior tumors;
{() Anterior tumors.

Anesthesia.— General anesthesia should always be employed in doubtful
cases. It is im])ortant to have the abdominal muscles thoroughly relaxed when
making the examination, otherwise it is impossible to determine the origin, the
situation, and the characteristics of the tumor. An anesthetic is.
therefore, indicated in small tumors, especially when
they are associated vvilh a lesion of an adjacent or-
gan, in nervous and unmarried women and in pa-
tients who have a fat or muscular abdomen.

Methods of Diagnosis.— I n s p e c l i o n .—The patient is placed in the
horizontal recumbent position. The examination reveals the symmetry or asvm-
melry of the abdomen, the probable origin of the tumor, the smoothness or un-
e\enncss of the surface of the abdominal walls, and the dilated or normal con-
dition of its veins.

Abdominal Palpation . — The jiatient is placed upon her back with
the knees drawn up and the shoulders slightly raised with a pillow. The exami-

FIBROMATA.

377

* S

nation shows ihv origin aDd boundaTics u( Ibc lumur und its consiKtcnc}', shape,
mnd surface <.i>iMJitiuns.

Percussion . — The guiieni \* plaitil in (he horizonial ru-umbent [m»i-
iii>n, 'Wix cxaminBlion demonstralcs the origin und boundaries of the tumor ant)
the aliMiit-e ur presence of lluclualion.

M c n h u rn t iu D . — lliv |>4tient ik |>liiced in the horizonuil recumbent
jMBJiton. The examination dctcrmioes the symmelr)' or asymmetry of the
abdomen.

A use u lla t ion .— The patient iv phced in th<- honxonlal recumbent
|M»ilion. The Mclhoscope rc\'eal» the uterine souffle when it i.- present.

Vaginoabdominal P a I pit t i o n .^Thc p.itienl U plucud in the
iliifsal iK>sili<>n, llic examination reveals the size, the silujilion, the con^i<-lency,
ll>e mobility, aii<t the >urface conditions of the tumor. It slso shows the relatione
ol the tumor with the Iomxt
part »f the rectum and the
tiUd<ler; tUe condition and
the ourpiumlings of the intrd-
vii|;inul »tiA supnivagiiial jior-
tiiMi ii( the tervix, and Uie
Gt4te of the \'aginal vault.

R e c I o - a b d o m i n a I
r a I p 1 1 i o n .—The patient
t*. pUccil in the dorsal jxAi-
liim. The examination re-
xrAl» the surface conditions
of ihc posterior aspect of the
lumor .mil iu retrouterine re-
Li t inns.

V e*ico- ■ bdom ina I
r a I p a I i o n .—The [ulicnt
i- phu'ol in (Itc doricd jxp-i-
liiin Anil a utiinil iv inlriNlkKe<J
into the bladder. This me-
thial is u'«d to demonMrute
the rcbiionv rxttting between
the bladder aiiil the tumor.

laterstitlal Fibromata.
— P e 1 V i c in S i I it d ■
t i o n . — rujcriK) - oMomittdl
PatpitlioH.~\\'hen the tumor

ib accom|Kime(l with };cncral libroid h<,-})crtrophy (he uleni» is found to be en-
Lrfied, Imnl and .symmetric in -haiic. and lis external surface smooth. If the
ulMu^ i% not uniformly hypcrlruphiri), the iir^ii^tn i> arvvmmetric in >lia)M.' and
mItrKCil on the side of the tumor. In lh<.' case of a true myoma the uterus is
latt in ( on.iL>ten<ry und a >ensiti<)ii of lluctuatiun is im|Mrtc<l to tlte cunutiiiiK
finger*.

k<fla-(M»miwt PalpalioM. — Somelinws it is nccc^saty to make a more
thooHDch exjiminnlion by seizing the cervix with bullet- forceps and pullinR the
ulmi« dinrn. while at the same time the posterior surface of the neofilasm is
eiplorefl by rcctoalMlominal touch (urtituial uterine pn>la)>se. p. .io6).

Abdominal in Situation.- l»^pt(lion.—'\'h<: alMJomcn Uenbrccl
and fivminetric in sha|)e exce^it when ihe (jeneral fibroid h)*[>ertri>phy is not uni-
furni. in which caw lite aymmetry ia. destroyed and there b a distinct buljpnfi utwn

."^^

Fia. 4>8.— niMiMaiH Of lirtoniiiu. Ftn«is «« (■» Umu
ar Aannrw I'nsixc pMtjiru Couautur irini Rtno-

378

THE UTERUS.

the siile on which the tumor is situated. The surface of the abdomen is smooth
ami regular and its lower is more prominent than its upper portion owing to the
pelvic origin of the growth. The superficial veins in the abdominal wall are
found to be dilated when the tumor obstructs the circulation.

Abdominal Palpation. — The pelvic origin and the boundaries of the tumor are
first ascertained, and then its shape, consistency, and surface conditions are
determined. Its shape may be symmetric or asymmetric, depending upon the
character of the general fibroid hypertrophy. If the enlargement is uniform, it is
Rlobular or ovoidat in shape, but if otherwise a prominence will be felt through
the abdominal wall upon the side of the uterus on which the tutnor is situated.
The consistency of the neoplasm is hard, non-elastic, and unyielding except in the
case of a myoma, when it is soft and apparently fluctuating. The external
surface is smooth and regular except where one of the tumors shows a ten-
dency to become subperitoneal, in which case a slight bulging will be felt at thai
point.

ym. ^Tg, — Diagnosis or Isthistitial Fibioeds uy thk I'terus by \'AGiNO-AB[K>inNAL Touch.
Shtrwint- ihv luDDi-ction bclHccn Ihe umor anJ Lhc ulcrus.

I'ertussiou. — This method of examination determines the pelvic origin and
boundaries of lhc tumor and the absence of fluctuation.

Mensuration. — The symmetry or asymmetry of the abdomen is determined
by comijarinR the measurements between the ensiform cartilage and the anterior
superior spinous processes of the ilium.

AiisculliUion. — The uterine snuffle is frequently heard in these tumors.

Vagiiw-abdomiivil I'alpalioii. — A mass is felt e.xtending from the pelvis into
the abdomen which may be symmelric or not according to the uniformity of the
general fibroid entarf,'cment. The lumor is hard and unyielding except in the
case of a mvoma. when it is soft and fluctuating. The external surface is smooth
urn! rcfjiiiar cxcejit u'here there is a tendency toward the formation of a subperi-
toneal [growth. The abdominal portion of the enlargement is shown to be a part
of thf uterus by pres.-ing down upon the mass through lhc abdominal wall and at
the same time placing the vaginal finger against the cervix. The force from

riBKOMATA.

379

is thuN ntit only communicated to the cervix, but the lowrcr scgmcnl nf the
u(rru« niKl ibc lumof lUii lie |)U!shed u[>war(l by the vaginal fiDtter or |ire»6ed
<l4>wnwanl by the abdomiitui h^iiu).

Rtito ithdomiiMl PiJpiiihn.-i\ combined examination through the ree-
lum i-nj)>!cv \iw Kur^cuft i<> explore the {xisterior surface o( the tumor and co«-
linn the ffsulls already obtained.

Subperitoneal Fibromata. — As aubserou^ fibruid)^ are, in nearly all cartes

Iassoci;iled with initr-iiiwl tumors, and also with more or le« ^neral fibroid
b> f>^r<ri>i)hy nf the mu^cubr walls of the meruit, it naturally follows that the
^init al i n»ni(-ieriMM n of tht^ latter \-3rie1y are found to l>e {ircscnl upon cvamina-
Ibin. Tbercforc in diMUssing (he diagnosis of ftubiwriinneal tumor* no refcrenre
bUI be made to live interstitial variety, as it would otherwise be a repetition of
phat ha.< already licen «iirf upon the .subject.
Pelvic in S il ua t ion .— ragmo-rtMomi'iw/ Palpation. — Nodules of
^-ariotu *ixe are felt upon the Nurface o( the ulcrua. some of which are scssik
and others tx^hinndaleil. The sessile tumors arc closely connected with the
ulcni3 and cannot be moved

tn any ilirediim widKnit dis-
placing the entire organ.
The ]>nlunculalc<l growths
are di-timily felt by the
examining fmger to be x\t-
amiefl from the uterus and
they c»n lie movol alxiut
within certain limits without
aftrcititg the |>o^iti(l^ nf the
i)rj;an. A large prduncubie'l
fibniid may ItUxIc up the
pdvic c;ivil]r and crowd
Bxafost the uterus, in which
i~x-x it t* im[K>t>Mblc to dis.
,lJngui&b it (n>m a >r«ile
vlh. Sub|>€f^toncal li
nitU atwav-« displace t)>c
trnjs unlnv^ Dury arc iimall.
which cjise they do not
uiferiatly alTe<1 iu [Kisitinn.
ti nut umommon t" fiml

Fin. «tB.— DiMMHi «* 1 riDitwrunn SuarcHTQacu fl-

nr itr more small fibroid nodules up<in the external uterine surface that cause
xubjeciivc ^ymIHl^m.^ whatever. Sub«;roii* I'lbroi^b are haril atid unyield-
to the touch, anil thry nuy Ih* munil, oblong, ax uvoiil in ilui]>c.
h'ftiiKiMopiimil i'tiipalion.— This method of examination confirms the
jIi^ already obtained.

Abdominal i n .S i lua t ion.— fntptf lion. — The abdomen is enlarged

id ■tymmelrM*. Its .luKacc \» irregubr and nodules may be seen RMving tutder

t>clly wait during the act of rcHpiralion. The symmetry of the Alxlnmen ni>d

irance of its surface depend uiK>n the size of the tumors and the general

'Hi of the uterus. In the ca--^ ol a large subpcritoiicrd tumor growing

[lie lumlus of tlic ulenis the middle jMirlion of the abdomen m-iy tic more

lincnl than its lower (urt and thus obscure the pelvic origin of the neoplasm.

4MamiH<il J''ilfi>iliim.^-'thv sub|HTili>neal noduk-s are easily reco|jni«d by

ating (hr idxlonicn over tlie enbrKcment in various directions. They are

aiwf unyielding and of various shapes and sixes. The senile tumors are

38o

THE UTERUS.

closely united with the uterus and are distinctly felt projecting from its surface.
The pedunculated growths are separated from the uterus and are always more or
less movable unless adhesions have formed with a fixed point in the abdomen.
Mensuration. — The abdomen is asymmetric in large tumois.
Vagino-abdominal Palpation. — The enlat^ed uterus is felt extending from the
pelvis into the abdominal cavity and the sessile nodules are easily recognized as
they project from its surface. A pedunculated growth may be moved about
within certain limits by pressure through the abdominal walls, but so soon as its
pedicle is put upon the stretch the utems is displaced and the movement is
transmitted through the cenix to the vaginal finger.

Recto-ahdominal Palpation.— This method of examination confirms the results
already obtained.

SubmucouB Fibromata. ^Vaginoabdominal Palpation
shows the uterus to be enlarged and more or less globular in shape. As a rule,

the tumor is associated with the
interstitial and subperitoneal
varieties, which give thrir own
peculiar clinical characteristics to
the enlarged uterus. It is im-
possible to diagnose a submu-
cous tumor without exploring
the uterine cavity. It is, how-
ever, of no practical importance
to know for certain that a sub-
mucous growth exists in a case
in which there are interstitial or
subperitoneal fibroids, but when
the uterus shows no evidence of
general involvement the uterine
cavity must be explored to de-
termine the cause of the hemor-
rhage. Under these circum-
stances the cervix should be
forcibly dilated and the uterine
cavity exaniined with the index-
finger and the uterine sound.
The canal of the utems will be
found greatly lengthened and
enlarged and often more or less
distorted; and the finger will
feel the tumor projecting into the uterine cavity.

Uterine Polypi,— The s;ime indications exist for the necessity of a [xwitive
diagno^i.'i in fibn>id jiolyjii us in the case of a submucous tumor. There is, how-
ever, less likelihood o( gcnerui involvement of the uterus in the former variety,
and consequently an examin.-ition of the uterine cavity is more frequently re-
quired. The examination should be mude with the index-finger and the uterine
sound after forcible dilatiition of the cen-ix. The uterine canal will be found
lengthencfJ and enlarged und the tumor attached by a pedicle and not by a broad
base as in the submucous VLiriclv. Sometimes a polyp may be found in the cen"i-
cal canal, or again it may have been expelled from the uterus into the vagina,
where it is seen hanging from a pedicle attached to the endometrium. It some-
limes happens that a polypus is temporarily forced into the cervical canal (in-
termittent polypus) by the expulsive pains that occur during menstruation which

Fig. ^aT.^DiAciNnsi? or a Si'bhitoi'j: Fibpoii> Ti'wob
or THF Ctf.iu'm iiv Abihiminai. ■['i>i'f-u CouHrvicb with

IHE iNlll.KHNiiH IN THl, I'tEHTNE CaVIIV.

nSKOUATA.

38t

are excilnt by tlie presence of ihe tumor. aii<] Uius a pcdunculatol Krovrlb which

lis cii.«ily d«'«>vrre<l l>y sighl and touch iil lhr« iicrimls i> al olber limes l<» high

up tn the uterine cjivity to be recognixctl cKxpt after forcible dilatation of the

Inirtligameatous Fibromata.— B ctwern the Folds of the
Droad Ligaments .^This fonn uf intra liga men lou§ liunur i.t readily
nrognix«d by ra^ino ahdominal and rfxiaabiiominal loiirfa. The neoplnsm
IITVWs from one or both side^ uf (he uieriKt and fri>m the mpravaginal portion of
ihe cenit and pnijn t> lietween the UAtU uf the broad ligamenU. It i> hard and
unyieMing in omsistcncy. scsMie in (har.icliT, and imwlty iKCU|>ic9n bwposi-
Itun in the pelvis, tjeing situated ju^l above the lateral (uldesais of the vagina,
which are t>flcn more or lc».< dei>r«^'«te<I or llaltenetl out. Sometime.'-, how-
evrr. the^e grou-lhs occupy one or both of the iliac fossaii. anri are intimately
ronnertcd with the utenu. When the tumor h^ unilateral, the uterus is dis-
' pLunl lowani the o|i)M»iie side: but whun it is bilateral, the |>elvic cavity be-
smes blocked and the structures firmly wedged.
pDtlerior Tumor> .—The evamtnatjon is made by vaginotiMomiHai
, mlo-aU&mimal paip<ilio*\. The tumor gnws fnim the ponierior surface of
_^ 'supravaginal portion of the eervin and develops backward and upward,
pmhinR up the luIdcrNii i>f DougbK and be[i>ming retmpenluneal. It eventually
taitrs the uterus nut of Ihe |>el\i->Hnd becomes llrmly attnchcd to the [wivic floor.
The uterus aiul the tumor thus form a wlid. imniovahle mas.s which is apparently
rcln>)H;Tiloneal in origin. The vaginal vau It i> flatteneil out nr depre>.->cd ami the
atnvaginal portion of the cenix may be entirely taken up by the neoplasm, leav-
^ing nothing but the external os uteri to mark its original po<^iiion in the vagina,
' Hani fibrfju.t iMxIules arc felt ]Huteriorloiheoauteri which arc firmly attached to
\ Ibc cervix.

Anlerior Tumor» .^I'he examination i.-> made by '.■aj^inoabdominai
\ v«tk»-4iMomi»iil palpation. The tumor g^ow^ fmm Ihe anlerior surfarc of
EsitpraVBginal (mrtion of the ccrvi.t and i!e\clops upward and forward, carry-
ing tnlh it the reflettion of {irriloneum .-ind the bladder, whith are often li>iind
ftnllened out upon the anlerior faic of the neoplasm sevcnd inches above the
; >ymphyMk pubk. \'aKin» abduminal tiniih determines tht^ position of the growth.
I the (ibliteration of the vaginal culdesac. and the altNenie of the intmvaginal
fimrtion of the cervix if it has been taken up by ihe tumor. By introducing a
[•(MiDd into the bLulder and at the Mime iinie making prvs-iure through the ab-
kjminal wall above the symphysis pubi« we are able in mme rascM. if the ab<lo-
b not too fat, to demonstrate the elevated pivsilion of the organ upon the
tumor. The direction oj the >ouml ami feeling ib^ tip through the betly wall
ibv guides in ihi- niclliiid 'if exaniinatii>n,

INagnoBis of Secondary Chatigfcs in the Tumor. — Secondary

hange* occurring in the lumuT itself are, a^ a rule,

Pnni even suspected until a section is made of the

I r o p 1 ■ « m after its removal. The reason for this is that it is pmc-

Ni. jiti Impinisible to diagno^e these chanf^CA prior to ojieration, ns there arc no

'.e or objective symptoms, in the majority of instances, which have any

,..^,t.--',ii value whatever. This ntatement a)>)>lie4 more es(>cctdlly In riUoa-

uu>. fall}. neir<>)>iolic, amyloid, colloid, ami mytonutous degeneration*.

*Jn tlie other hand, however, such chanses as infection, edema, cystic degcnera-

an. urrnma. and carcinoma prr.<«nl certain symptoms which may in »omc

<ble IIS to make a positive dingnosis, aiK) in other cases to have nt

II ' susfiicion of the probable coixlition,

Paia.—Pain «curring in the tuntor itMlf Ik a \tty ^gnificanl (frnptom of wme

383 THE UTERUS.

secondary change taking place unless it is due to a rapidly growing interstitial
fibroid stretching the walls of the uterus or to a submucous growth or a poU-pu&
irritating the uterine cavity. Again, it must be remembered that pain in the
surrounding parts may be due to {tathologic conditions in structures and organs
so close to or intimately connected with the uterus that it is sometimes difficult or
impossible to locate the symptom in the tumor Itself. There is nothing distinctive
in the character of the pain that is due to a secondary' change which would lead us
to suspect the presence of a degeneration unless we are able to exclude all other
causes for the symptom and it occurs in a tumor that has been quiescent for a long
time and then more or less suddenly becomes tender and painful.

lafectioD. — Inflammation is not an uncommon occurrence and it is likely
to be followed by suppuration and gangrene. It begins, like all septic infection:;,
with an elevated temperature and pulse, which may be preceded by a chill. The
tumor rapidly enlarges in size and is the seat of severe pain and extreme tender-
ness upon pressure. The history of the case is often an important aid in the
diagnosis, as it may point to the cause of the infection. Thus, for example, the
above symjitoms may follow the introduction of a uterine sound or an opera-
tion upon a submucous tumor or a polypus. The danger of infection from the
intestines or the rectum where adhesions exist must also be remembered.

Sloughing and gangrene are likely to occur in a fibroid pol}-pus, and also
occasionally in a submucous tumor. If the process is confined to the pol\p, the
condition will manifest itself by a profuse, purulent, fetid, and sanious discharge:
but if the uterus becomes infected, symptoms of general septicemia are also
present. A positive diagnosis must be made in these cases by exploring the
uterine cavity after forcil)le dilatation of the cervix and submitting some of the
diseased tissue to a microscopic examination. If a polj'pus becomes gangrenous
after being expelled from the uterus, the diiignosis is readily made by direct in-
spection through a speculum, Kven un<icr these circumstances, however, the
microscope should be empioye<l to guard against error.

Edema. — This change often occurs in fibroid tumors in women l)efore the
age of thirty years. It m;iy be a.ssoriated with inflammation of the tumor or it
may be entirely indejwndent of it. The fibroid suddenly increases in size and
becomes very soft in consistency. It gi\es a sensation of fluctuation to the
examining fingers and closely resembles an ovarian cyst in many of its physical
characteristics. It is u.sually accompanied by severe uterine hemorrhage.
While the diiignosis is frequcnilv impossible, yet a strong probability as to the
nature of the disease may be arrived at by a careful study of the sjinptoms and
the history of the case, together with a thorough examination of the tumor and
its relations with the uterus.

Cystic Degeneration.' — Cystic degeneration of uterine fibroids is com-
paratively frecjuent, but it is rareiy met in women under thirty-five years of
age. When this degeneration attacks a tumor, it increases in size with greater
rapidity than is the case in normal uterine fibromata. Palpation demonstrates
the existence of one or more cy.sts situated nt different parts of the tumor and re-
veals the fact that lhe\' are surrounded or separated from each other by hard
fibrous tis.sue. This is characteristic of these cysts, as ihev do not involve the
entire tumor but only portions of it. By vagino-abdominal palpation we find
that the cystic tumor is a part of the uterus, and it is not uncommon to feel hard
fibroid nodules below the cyst in the lower segment of the uterus.

A continuous buzzing murmur and thrill are often heard in telangiectatic
tumors.

Sarcoma; Carcinoma. — The diagnosis of malignant diseases of the uterus
is discussed in their res[>ective chapters.

nnitouATA.

.1«3

Differential Diagnosis. — Uterine fibromata must )« diminguuheil
from ilic following conditiMai:

PiTgiwncy. Cyslk tumors of ihe ovary.

DiiplacemenL'' of ibe ulcruH. S«>li(t tumorxtf throviiry.
Im'cr^inn nf the ulcnib. limud ligament tumors.

Pregnancy.— As a rule, the differential dijgnosjs between a uterine fibroid
And prrfin^ncy is i»>t difticull unlcM the tumor i> a true mynmii. in nhich f»x
a mi^Likc m^y rt-;i<lily be madi; unless great care i^ taken in nuking the cxjmina-
tiiin and in eliciting; ihc hi^ton' (rf Dte case. In doubtful case» time
muAt be relied upon to clear U]) the question by de-
veloping positive ^igns of pregnancy, tn all case* the
«ul>jn'tive and objective mkh.'* of pregiuncy and of fibroid tumors must
be carefully studied before tomitig to a conclujion us to the nature of ihc
cnbn;cment. When, however, the fetal heart-sounds arc reeogiiized by auscul-
^Inlion or the ditTereril )Mir1> of the fetui. are felt by abiluniiiinl pat[>ation, the diog*
Inoists ts cerlain. The intermittent contractions of the uterus which occur during
r|>rr5nanfy cannot be relied uj>on, as tbey also take plate in sivft fdin>ids. Felal
I movements are an im(Kirtant nign of pre^iaruy, but it niunt not be fi>rgollcn that
llhe^- are ab<<eni when there is nn excess of liquor amnii and when the child is
|«rcak or ilead. Funhernnire, these movement, m^y be niL>Liken furcuninutions
[of the musiles of the alxlciminal wall or the [wristidlic .irtion of the inictines.
[The breast changes are generally absent in fibroid tumors, but the line of
Lpiipneniation on the aUlomiiMl wmH between the umbilicus :ind the pube>. and
ga»lric dUlurbame^ which are hi often mnnifesKxl <luring the earlier months
»f pecgnani-y. arc frequently present. In fibroid tumors Ihe uter\t> I- generally
[uytmnrtric and h.ir<l in con.iiNlcncy exc-ept in the ca>c of a mTOmu, when it is, as
a rule. s>-mmetric and soft, A fibroid tumor develops much mere slowly than a
pretrnnnt uleruv it mu»l also lie twrne in mind thai occasionally menstruation
[may persi'l during pregnancy and that a tibmid may not be accompanied with
tithcT iricnorrhagia or metrorrhagia. The uterine souffle is not always present
littromata and the umbiliai.'' docs not present the chi^nge^ <>f ]>rcgnun<'y. The
^jIc or violet ilisoiluratinn of the vulvov-aginfll orifice and the throbbing of the
ies of ihe vagina are valuable signs of pregnancy. Softening nf the i*r\ ix is
I an imp>>ttanl aid in the diagnosis of )>regnan[y. t>ut mUl^kcs arc apt to be
mjite if irx> much reliance h placed U]x>n this s)-mptom. I have ob-
,)ervcd softening of the uterine neck in several cases
>r true myoma, and in all of these patients the dif-
ferential diagnosis was extremely difficult.

The jxissible owxisleiicc of pregnancy and fibroma must always be remem-
i, a» it i» not an unusual atmpliialion in uterine fibmids. In a wonun who
kcxpiieal to piegnancy the sudden and rapid enlargement of a tumor |)fe\iimsly
' more or lew quiet and station. irv is wry AiMnificani.

iDtoplacements of the Uterui.— A snull subperitoneal tumor '.iiuntcd on
the anterior or |n>sterior surf;icc or on the side of the ulcnis mav be mi-ijkcn for
a fomrd, backw»nl. or bieral uterine (lU|>la cement. T)ie dilTefenti.il diagm'sU
iriiicfa b made by xagiw ibdominai and retioii>niomin-tl palpation will reveal
ibe cbarsaeristics of ibe tumor and tbe true position of the fundus of the
tllCfUt.
lavtnioD of the Utcnts.— A large fihmid polypus that has been expelled
from tlic uterus into tlie vagina may lie mistaken for a uterine inversion. In the
naecrf a polyjiun rerto alxlominal and vagino-alKlnminal |nl[Mtion will demon-
Klnie Ihe prceme of the fundus in its normal positixm and Ibe .-it>sence of a cup-
■faaped de(iression above tbe ceT%'ix. If tlw caie U one of inversion of tbe uterus.

384 THE UTERUS.

the fundus is found to be absent; there is a cup-shaped depression above the
cer\ix and the sound will not pass beyond the cervical collar or rim.

Cystic Tumors of the Ovary.— There should be no difficulty in distinguish-
ing between a cyst of the ovary and a uterine fibroma after a careful study of the
histor>- of the case and a thorough examination of the tumor. The diagnosis,
however, is often impossible in cases of fibrocystic or edematous uterine tumors
and where the ovarian neoplasm is adherent to the uterus. Fibrocystic tumors
do not involve the entire growth but only portions of it, and abdominal palpation
reveals areas of hard fibrous tissue between the cysts. By vagino-abdominal
palpation the tumor is shown to be a part of the uterus, and it is not uncommon
to feel hard nodules in the lower uterine segment. The fluctuation in an edema-
tous fibroid is limited and does not involve the entire tumor, as is the case in an
ovarian c)St. Unless the body of the uterus can be recognized by vaginal ot
rectal palpation in cases where an ovarian cyst is adherent to it a diagnosis is im-
possible.

Solid Tumors of the Ovary.— These neoplasms may readily be mistaken for
a pedunculated subperitoneal fibroma, especially when the pedicle is long and
slender. A pedunculated fibroid is usually associated with subjective and ob-
jective signs of general uterine involvement, and if both ovaries are recognized by
vagino -abdominal or recto-abdominal palpation the diagnosis is certain. If,
however, the ovaries cannot l>e felt, a diagnosis of pedunculated fibroma is justi-
fied on account of the general uterine involvement. If the case is one of an ova-
rian tumor, the uterus will be normal in size and consistency, although it may
be displaced, and all the subjective and objective signs of fibroma will be want-
ing. Sometimes a solid tumor of the ovar)' becomes adherent to the uterus and
it is impossible to make a differentia! diagnosis.

Broad Ligament Tumors. — Solid or cv'stic tumors of the broad ligament
may be mistaken for intraligamentous fibroids that project between the folds of
the hroiid ligament. A positive diagnosis is usually imixissible. If the uterus is
enlarged and nodular and the tumor in the broad ligament is intimately connected
with it. a diagnosis of intraligamentous fibroid is justifiable, especially if the
neopla.'im is bilateral. But if the uterus is not enlarged or nodular and there is a
deprcs^ion between it and the lumor, the diagnosis should be in favor of a broad
ligament growth. It must be Iwrnc in mind that these fibromata may undergo
cystic degeneration and simulate cysts of the ligament.

Treatment. — I am strongly of the opinion that the
vast majority of uterine fibromata demand removal.
The prognosis of the disease and its history, viewed in the light of our
jirescnl knowledge, can admit of no other opinion as regards the treatment of
these tumors, .■\gain, the low mortality following operations upon uterine
fibroids is an additional reason why it is safer to remove them at once rather
than alluw the [lalienl to cx])ose herself to complications which are not only
dangerous to life but are also destructive to health and usefulness. On the
other hand, however, we occasionally meet cases where the indications are in
fa^or of palliative treatment and in which it would be wrong to urge an immediate
operalinn. The selection of these cases depends upon the size and situation of the
tumor, the moliiUly of the uterus, and the absence of pressure symptoms or
serious hemorrhage. A small tumor, not occupying the lower uterine segment,
with the uterus freely mo\ablc and the surrounding parts not subjected to pres-
sure, does not demand immediate operation, especially if the woman is nearing
the menopause or the |Julient is young and desires children. But a growth
situated in the lower segment of the utenis {in'.raligomenlous), even if it is small
in size, should always be removed, as it produces serious pressure upon the

FIBROUATA.

surrouraltnK parts, and if the woman becomes pnrgiumt it is likely to act as as
obHTtK'tion to the ilelivcfv of the child during laboir.

The Irralmrnt of hliniid tumors uf the uicnu b diridcd into:
The sympiomalii: ircaimcnl.
TKiiimrnl g>nr|>:irator}' lo operation.
The suigk.il Irr.itmcnl.
The Symptomatic Treatment.— In addition to the indi('iiiion» nlready
given (or liu- |'.illi:iliK; triMtmciit, we iire at time* ionctl to resort to lentalii'c
mcuAurc^ liccau^ palicfitii refuse to submit to surreal relief.

The symptoR» which demand our atlentiun :irc (u) ln-morrhage, (A) pain, and
ii } the re^uil.'^ (■( mcthimtc pressure.

Hemorrhage. -This symptom is controlled by rest, vaginal injections,
vapnnl tampons, cureiment of ihc uterus, and dnifp.

fitJt.—Kefl in bed white the hemorrhage continues will aid materially in con-
irulUni; the ej;ces8ivT bleeding in cat«s of menurrhaRia and roetrorrha)tia.

I'agiHoI iHJtctiotu. — Vaginal injedion^ of hot niirm.~il Kill solution (i30^ P.)
should be used twice a day for an indc^nltc length of time. .\\ least two gallons
must be used at each injection, and the douches should not be discontinued
durint; the mcwtnwl jieriiKls.

Vaginal Tampons. -\ vaginal tampon is a valuable aid in checking, (or a
_U(ne. at leant, a continuous hemorrhage. Again, it i> the most certain mediod we
to control either an cxces-'ive hemorrhage or a prolonged or profuse
iitrual Sow. 1 ha^M; seen se^-ere hemorrhages controlled for months by its use.
Tbe iam|i»n a made o( absorbent gauxe, cut into a striii >ijc inches wide and suf-
6uently long to contain enough muierlal to Ihorougnly pack the vagina. A
i:mn[xess over the v\iWa and a T-bamlage complete its application. It should be
rriootnl in twenty-four hours and reapplied if necesitiiry.

Curftmtnt aj ihr (/(eriu,— Cureiment of the uterine cavity may be resorted
lo wbcn tbe hcnvorrhagc fe continuous or severe and does not yield to ordinary
Ifcatnent. A >iuqt curet stxiulii \k liviil and the mucous membrane thontughly
nmovtrl. This treatment is followed at once by marked improvement in the
Biajotity of cii.-«N. and is one of the \<ery bol mcan.i at our command to i.-ontnl
the symptom under consideration.

Mmj.— The most useful drugs to control hemorrhage are ergot, hydtastis

CsnaHrtMis, and cnnnaliis inilicu. Crgot i.s cither administered by the mouth or

V"T"iHermu.-aIIy'. preferably by the former method, as the injections arc not only

il. t>ui they are Ibble to cause abscesses. Er^in in doses of > to 3 grains

turn- iime« a <lay i* the l>«>t form in which (o use (he ilrug. On account of its

dcl>r^-^*ing cfieci Upon the heart, strychnin should be given at the same time (gr.

1 <!.). Tile tluKt exir.tri of h)'driu-.tis i.-inadensis and the tincture of can-

in>li(a may lie cmplnyeil where no re^ulls arc derii-ed from the use of ergot.

■ .1 i n .—The r<iutinc treatment for pain which 1 have found most useful

I L>t\ in vaginal iojeclions of liot normid salt Mtlulion (t^o' F.) twice a d-ny

and the intnxluction into the vagina of cotton -wool tampons s^turtled with a 15

per frill, s'llution of ichthyol in glycerin. A tampon should be introdut-ed two

ftr three timcn a week aivl removed on the followmg mi>minK. Tlie tincture of

unnabis imlica combined with sodium bromid shoukl be administered intenully.

Hlicre |>ain is caused by pressure the knee-chest position gives great relief.

iwi khouVl l)e used akmg with the n>utine treatment described abm-e. The

polienl should ansume the position for ten or fifteen minutes three times a day —

in ihr 'linjtoui of )>ed, at noon, and u|Kin retiring fortheni^t.

>hould be given to Ibe pulieni b to lie as much as po»-

wtkcn rccumlH^Bt, upon the abdomen or side, so as to remove the weight of

386 THE UTERUS.

the tumor from the points pressed upon when in the erect or sitting position. The
use of posture in the treatment of pain due to pressure has, in my hands, accom-
plished more than any other method of treatment.

When the pain is due to localized chronic peritonitis, saUnes should be em-
ployed in addition to the routine treatment, giving a sufficient quantity of the
remedy to produce one watery movement daily for several days and then using the
salt once a week for an indefinite length of time.

The Results of Mechanic Pressure . — In the treatment of the
results of pressure upon the rectum, the bladder, the ureters, and other organs but
little can be done beyond having the patient assume the knee-chest position in the
manner already described. In some cases the results of this treatment are ex-
cellent, while in others there is but little difference, if any, in the severity of the
symptoms. Of course, much will depend upon the size of the tumor, its situation,
and also its mobility. Good results are seldom obtained in these cases from the
use of tampons or supporters.

Treatment Preparatory to Operation. — The profound anemia and grave
kidney complications which often exist in cases of uterine fibroids render it im-
perative that a thorough general examination should be made and the patient
placed upon the proper treatment before subjecting her to an operation. Neglect
of this precaution endangers the patient's life, as she may not only take the anes-
thetic l^dly, but death may also occur after the operation from a want of sufficient
reserve force to stand the surgical shock. A careful examination
must therefore be made, especially of the blood, the
heart, and the urine, and the patient treated upon
general medical principles when the occasion re-
quires it.

The Stirgical Treatment. — The operative procedures advised at the present
time for the cure of uterine fibroids are:
Abdominal Hysterectomy.
Abdominal Myomectomy.

Abdominal Hysterectom y. — This operation is the one of selec-
tion in all forms of fibroma except in cases of ulerine polypi or where the neo-
plasm is limited to the vaginal portion of the cervix; the treatment of these cases
will be considered later on.

A hysterectomy may be either complete or incomphle; the former is known
as panhysterectomy, or the removal of ihe entire uterus; and the latter as
supravaginal hysterectomy, or amputation of the organ at its junction with the
cervix.

The selection of these operations depends upon the indicalions in a given case-
Panhysterectomy is indicated in sloughing fibroids with general infection or when
malignant disease is associated with the tumor. On theother hand, supravaginal
hysterectomy is always the preferable operation when these conditions are absent.
The advantages of supravaginal hysterectomy over total removal of the uterus are
as follows : The mortality is lower; the operation is
more quickly performed; the hemorrhage is less and
more easily controlled; the dangers of sepsis arc
minimized, as the vaginal canal is not opened; the
capacity of the vagina remains the same and conse-
quently there is no shortening to interfere with
sexual intercourse; and, finally, a vagina! hernia
cannot result.

The technic of both operations is described on pages 984 and 996.

Abdominal Myomectom y. — The object of this operation is to

nBROMATA.

3«7

ntnii\« the tumor wiihoul sacrifidnf; the uterus. The lixKcftlioiK for myumcc-
tiioiv nn nm fully iJrlcTmincil ujxin :il the present timr. It is undoubt-
edly a more dangerous operation than hysterectomy,
a» secondary hemorrhage and se|>«is are imst- oper-
ative cumplicatinRK which are always to be feared,
v»(iceiaily in cases where large inicr<<titial tumors
are enucleated. Ilie n[>erfition >hould ht- rr>lncli.il to prduncubtcd
oubperituneal tumors where the uteruii i» n<it invnhed. Another class ol lases in
which enucleation may be resorted to is where the uterus U mit enlar)i;e<l and
inull t«>.>ile •■ubMrouit nodule* |in>ji;(-l u^Hin i\^ surface. And. linally, a small
intrrytiiial tumor or H'^'cral ginwths localized In a circumscribed area in the
uimnc vrall may be removed without taking away the uterus.

t'nfonunatcly, howewr. myomc<-l»m)- ijt seldom indicated, as the Uterus is
wually the scat of general fibroid hypertrophy and multiple inler^lilial ii sub-
mucuus ifrowlhs. Under thc:>e circumstances hysterectomy must be the ojiera-

Fm>. Ml,— Imnvaum I'-uv is nu Oru^non n» ma RufWAC o* a thtnat t>>iTmt (pa|» tW'

tiMl nf ^ele^tiMn, a.< n'kihing U accompllshcfl by fi-movinK only a [toriion of the
dJMaacd tissues. Ue>idrs, it must always be remembered, even when the opera-
tion b rewnol to in an u|i|Kirently favorable i:ase, thai a secondary operation
{hyaltttetomy) may eventually be requiml l>eciiu!« of the raptil dcvetopmenl of
■mail inierylilial nnidulos which were not noticed at the lime the origin^il tumor
•fa« remnveil. Whenever myomettomy is decided upon tlio piiticnt must there-
fiifr lie informcfl of the incrca^*! dangerc of the (^x-ration and the jiowibiUty
eA the occurrence of a secondary growth <!einanding surgica] interfcFcnce.

'riic technic of the r>;)erat)i>n U iIcm rilicd on page 9&1.

Treatment of Fibroid PolTpl.— IV treatment of pe<luiKulair<l
Bbnnnaia gn'wing from the uterine cavity or the cervical canal is surgical and
(■•niiM« in their removal by the vaginal route.

_Tecbnic of the Operatioo.— The Preparation uf the PuticDt
Prcparaitons for the OpemiJon are described on pages
83..

Pofilion of the Patient . — Dora) position.

388 THE UTERUS.

Number of Assistants . — An anesthetizer, one assistant, and a
general nurse.

Instruments . — (i) Simon's speculum (curved blade); {2) two bullet for-
ceps; (3) vulsella forceps; (4) scalpel; (5) right and left Emmet's slightly cur\'ed
scisstirs; (6) uterine sound; (7) hea\y uterine dilator; (8) Sims's sharp curel;
(9) Martin's curet; (10) dressing forceps; (11) dilating uterine douche (Fig. 431).

Operation . — The ojwration is divided into two steps, as follows: First,
the removal of the polvpus, and, second, curetment of the uterine cavity in order
to cure the coexisting endometritis and promote the involution of the uterus.

Simon's speculum is introduced into the vagina and the anterior and posterior
lips of the cen'ix seized with bullet forceps to control and steady the parts.

If the polypus hangs in the ^'agina or appears at the external 05 uteri, it is
seized with volsella forceps and severed from its pedicle with curved scissors.
When the growth is situated above the internal os, the cervix must either be dilated
with the heavy dilators or a bilateral incision made with a scalpel up to the
vaginal junction. Usually the upper part of the cervical canal is found to be e&-

Fia. 4IJ,— ^PEItATlow jna the Removal nr a pEDUNfULATKii Fibhoid PolyTCS Of THE rttirt

Han<.lnc in the \'Ar.isA,

larged, but if this is not the case, it must be dilated with the heavy dilators be-
fore the tumor can be reached. As soon as the polypus is exposed to view it is
seized with the volsella forceiis and its pedicle severed with curved scissors. If
iht jicdicJe rannot be seen when tniclion is made u[K>n the tumor, it should be
located !))■ introducing the index-finger into the uterine canal and the scissors
guided by the sense of touch.

If a Jiirge jiolypus completely blocks the vaginal canal and it is impossible to
locate the j>ediclc, the tumor should be seized with volselb forceps and reduced in
size by cuuin;; awuy small pieces wilh curved scissors. The index-finger is then
intrcN lined into the vagina ;nni ihc petiicle located and diWdcd close to the poly-
jius. The ])ei]ic]e is then exnniined, and if neccssarj- the redundant ]x>rtion cut
away with scissor>.

After die jiolyiius has l)cen removed the uterine cavity is cureted (see p. 955)
and the vagina and uterus irrigated with a solution of corrosive sublimate (i to
2000), followed by hot normal salt solution. The parts are then dried wth

HBItOllATA.

389

ages and ihe uterine cavity and ccn-ix packed witli a Mrip of liMU-ifotm (tnuze.
K \Tih-a is ihen protected with a giiuze wimprtv- and T-liunilaec,

v.-;

^^e^

Fm. 4)4. PK, 4M

,Oraunmi n>( fht Kiii»**i or * Ljtkoi nMoio Poino or nt l'n*i-i Iiiiim^ nn Vuu.vt
ftc. 4)4 •boinlhi IMifBr boiac oaculUifdi fl(. 41} ilianllw rnttdi Mof oil awtf.

mind iluit a uterine
ciinscijuentljr before

Special Directions. ^It muM nlwiiyT> be l>omc in
lypu* may niusc An ini-cr^ion of the utcms, and
severing the pciliclc a careful vagino ubdominul ex-
ituit^n must be made to exclude thi* cnndi-
n (Fir 4»<>)-

The hemnrrlmgc h seldom profuse after the re-
moval of a pcityiius, a* it-* lilmxi -supply is p.-ncrally
limhed and llie lilcnling points arc dicckcd by the
ntnet»<iri of ili« ttuues at the hcm of opemion. If,
bowevcr, the bleeilinii i« excessive, it i» readily c"n-
iroUed b>' the intrauterine irrigationB and the iodo-
form itaiue paclctn); which are emploj-etl in the
opetmtive tecbnic.

A n)icnisco(>4c examination of the polypus and
tbr curei Krapinj^ from the uterine ca\'ity tJiould
thirty* be Rudc: oiticruHsc a nulit>nani degeneration
may be overlooked and the opportunity of perform-
iitf an early hysterectomy k>st.
bH After-treatment. ~^V« of tkt Waufi4.—'V\iK
P^Hofurm )!,A\i/M ]iackinK b taken out in twenty-
f Inar hour* ami nut reimnxlurwl and ihr vagina
' iiti^ed daily with a vilutinn of corrosive sublimate
(I to looc), fi>llov>tMl by hot normal Kdt xilution
r ini|tatintt« are krjit u]i until the {taticnt gct^ out
and then a dally douche of a g^ilkm of hot
1 Ntli Miluiion is itiven for fes-eral weeks.
"Yht eart t) Iht bluddrr and hovtls ; the rtgulation 0/ the ditt ; and the relie}

T\& 4ja — <lril4t1<r^ n>t TO

RtsmnLoi iFi»iiii>roL«-

tV% 09 Tilt I'Ttfert

5hinniif ikc aiAtii <l
wuniliiit Iht uiiria ithis • far-
lUI (O-vnioB ocTun Iran amnio*
■vca Ihr niRw-

39° THE UTERUS.

ol restlessness and pain are discussed under the after-treatment of dilatation and
curetmeni of the uterus on page 960.

Getting Out 0} Bed.— The patient should remain in bed one week.

Treatment of Fibroid Bnlargement of the rntraTaginal
Cervix. — The indication in these cases is amputation of the cervix, and the
techric of the oiwration is described on page 459.

Treatment of Fibroid Tumors Complicating Pregnancy.—
One of the most difficult problems with which we have to deal is the question of
treatment in cases of uterine fibroid complicated by pregnancy. It is naturallr
impossible to formulate fixed rules under these circumstances, and all that can be
done i^ to point out the dangers and accidents that are liable to result, leading the
management of the individual case to the experience and skill of the sui^eon.

Abortion is not only a frequent accident, but it is also a grave complication,
as hemorrhage or sepsis is likely to occur. These dangers are greatly increased
after the end of the third month, as the abortion is often incomplete, and, owing
to the changed condition in the shape and direction of the uterine canal, it may be
impossible to remove the retained placenta and membranes. Pelvic incarcera-
tion of the uterus may occur during the early months of gestation when the
neoplasm occupies the lower uterine segment or when the growth is situated
higher up, but becomes caught and fixed below the promontory of the sacrum.
An interstitial tumor may become edematous, undergo softening, and give rise to
painful and serious pressure symptoms. Tumors occupying the lower uterine
segment, and particularly those which arise from the supravaginal cervix, cause
severe pain from pressure, which increases in severity as the uterus develops in
size. Finally, fibroid tumors may act as a mechanic obstruction to the passage
of the child or they may so interfere with the natural processes that labor is greatly
prolonged and the patient's life endangered from exhaustion, sepsis, or hem-
orrhage.

The expectant plan of treatment should never be ad\Tsed except in exception^
cases. Thus, for examjilc, we may hope for the continuance of pregnane}' and
the successful delivery of the child In a case in which there is a pedunculated
suh]>erit(ineal tumor or small subserous nodules without general fibroid invoh'e-
mcnt of the uterine walls. Again, a fibroid tumor involving only the intravaginil
portion of the cervix may lie removed by amjjutaling (he neck of the uterus with-
out disturbing gestation, and a polypus which is attached to the lower part of the
uterine canity or the cervical canal may be removed during pregnancy or at the
time of labor if it is not discovercit until then. With these exceptions delay in
resorting (u surgical interference is not justifiable, as the life of the mother is not
only in constant danger during gestation, but it is also in great jeopardy during
and after parturition. General fibroid involvement of the uterus, and tumors
occupying the lower uterine segment, which include those arising from the supra-
vagin.il cervix, demand hvstereclomy at once. Myomectomy should
never be ])crformed upon a gravid uterus, as the dan-
gers of operative hemorrhage and sepsis are enor-
mously increased. The induction of abortion or premature labor is
never justifiable, for the reasons given above, and the latter operation should
therefore not be considered in the interest of the cliild. whose chances of life arc
greatly increased !iy cesarean section. When a patient comes under obsen-aiion
for the first time at or near the period of fetal viability and no serious symptoms
arc present, the case should l)e carefully watche<l, and cesarean section, fol-
lowed immediately by a supravaginal h>-sterectomy, performed about the middle
of the eighth month.

CANCEK or TBE BODY.

CANCER OF THE BODY OF THE UTERITS.

39»

CaasCS.— 'ni« (lUe)tj« U far krsa fTCt^uciil ih^ri t^iKrt of the cervix, It is,
howrvrr, l>y no mcun; nuc. and rcccnl invc^liniitiunsh-nxiihownit tn occur more
ollcn than was f(>nncrlysuppi>Kd. It occurs Uicf in life than cancer of the cervix
knd the nuijoritr of ca^es »te >«cn lielween fifty 4n<l Mxty years of age. Allhuu^
fbe di«Uie i( one of niliancing )Ynr<, yet it hii% )icen "ccs^ioniilly obscr\Td early
in Hfe. Cullcn has reported tlirec cjscs occurring in women ihiny years old. anrj
in rnr own )>riictice alMluminal hy>terettoniy wii-. iierfurmed u|Hin .1 ynung un-
marricl woman of twenty fi^r ndcnocuTciniima of ih« Ixidy of ihe ulcrus. The
inirm«oi|>ic liiulin)^ in this caw left no room for doubt a» to the nature of the
nei>]ilanm- The dt^Cii^e iiitaclcs vn>n)en who hiive borne children and those who
uir sterile with about equal frequency. L'nlikc cancer of the ccnix, therefore.
tT3uRviit!Jtns of labor are not |irc(li^i>osin^ cau.sei of the di.->eiise. The true cause
o4 I amx-r of (he body of the uterus U unknon-n. but the imintion of the endome-
trium (irxl the lo^ of its power of resistance caused by chronic endomctritb and
libioi'l tumors nre !iU|i|>nsed to act iis preili^|H>-.infi facliirs. The question of race
^U»e^ w^i ^rvm lo enter into the etiology of the aRection, as it occurs with equal
Hvniucn47 Anxxi^ white Jivd colored women.

Pathology.— Can<fr of the \>oily of the uteruH prcscnij itself in the fimn
ot .in lulenocarcinoma. The diM-aM may <.>ccur as a circumscribed oulgroM-lh
fn>m any jMn of i)ie uterine ctivity <>r it nuy in\«lve the entire en>lometrium
(nim the tian. In cither ca.'«c Ihe <>utgn)wth consists at &i>l of ^mall delicate
[u|>illiis i;niwic^ from the mucous membrane which gradually increaw in sixe
and eventually become fungniil in character, having a larxe or a small btu«; in
ibe LttCT case the mass has the shai>c of a polypus. These fungoid masses,
continuing to grow, hiully occupy the whole of the uterine cavity, when they
rwntunlly brealc down or slouch, leaviii;: a foul, uhrmiing surface which cats
away tl>e uterine it'nlU and forms a crater-like canty. The cancerous oul-
ICRiwihs an w>fi and friable and bleed readily upon the >]ightr^l touch. In cer-
tain aiscK, however, on-ing to "an excess of connectiiT tissue." they are hard and
du not have tlte |>)t\si(al characteri.Mics of malignancy. .\--> the disease advances
ll»c uterine wall-- l>cci)tne infdtnited and nodules .-ipiiraT under llic peritoneum,
wliich arc %'wllowtT.h -white in color and soft in consistency.

.\» « rule, the pn>gTe<s of Ihe dUea>e is mu(h slower than cancer of the cervix
and • (Dtigcr lime elapses before the affcainn Iwcnmes inoi>crab)e from a radical
standpoint. Tlie o<TtirTctKe of secondary carcinoma of the body by melastasis
» rair. It occurs more frequently, however, by nmtinuity. when the dis-
om: starts in one of the adjacent organs and adhesions form with the uterus.

Bxtension.— Tlie <lbease may extend by continuity lo adjacent organs or
by meU'UsU t'l more remote Kiructures.

Mrustasis is more frcqucnl than when the HLsea^ begins in the cervix, and

the invi>lvement of distant ••nMU-^ i.4 not uncommon. c-s{>ecially in the later SlajtCl

■ if the disease, when the lymphiitic gbnds Iwcnmc invnb-ed. Mcla^tatic nodules

vr been ol»servcd in the pleura, the lungs, the liwr. the peritoneum, the

ntum. and in ihe lymphatic gbnda of the neck. Secaiulary infection by

is tc frequent in the vagitu and aLwi in the ovaries and oviduct*.

Irmienl of the lymphatic glamls is a very late manifestation of the disease,

n it has taken place the ca.%e h l)e>'ond niilical operative relief. E n -

rmcnl uf ihc glands from an increase in their

nnective-iissue elements is. however, frequently

served, and must not he mistaken for a malignant
tnliliration. This has been demonstrated by Blood-

39^ THE UTERUS.

good and Cone from their studyof enlarged axillary
glands in cancer of the breast, and the importance,
therefore, of this fact cannot be overestimated from
an operative standpoint, as it is impossible to de-
termine the true nature of the glandular hypertro-
phy without the aid of the microscope.

The disease may extend by continuity to adjacent organs, especially when thej-
become adherent to the uterus. Thus, the intestines, the peritoneum, the omen-
tum, the bladder, the rectum, and other structures may become in\'olved, and
subsequently a perforation may take place and a false passage result.

Symptoms. ^The symptoms may be classified under the following
headings:

Hemorrhage. Pain.

Discharge. General symptoms.

Hemorrhage. — This is the first suspicious symptom noticed by the patient.
It usually manifests itself in the beginning as a show of blood following coitus,
straining at stool, walking, or some form of active exercise, such as lifting heaiT
objects, etc. Sometimes the vaginal secretions may be streaked with blood or the
linen may Ix; slightly stained. As the disease progresses the menstrual flow be
comes profuse and irregubr hemorrhages occur between the periods. These
increase in amount and duration, until Anally in the later stages of the disease
the bleeding is more or less continuous. If the patient has passed the meno-
pause, the hemorrhages often occur with enough regularity for them to be
mistaken for a return of menstruation.

In some cases the only evidence of hemorrhage is an increase in the duration
and quantity of the menstrual flow, and the presence of the malignant disease is
not even suspected until the cause of the menorrhagia is investigated.

Discharge. — Leukon-hea is an early symptom, occurring usually before the
appearance of hemorrhage, although, as a rule, it is not noticed by the patient
until later, as a slight increase in the amount of a pre-existing vaginal discharge
would not be apparent.

In the beginning the discharge may manifest itself as a simple leukorrhea
streaked with blood without any other abnormal characteristics, or it may be thin,
watery, and jirofuse from the start, having a disagreeable odor and causing more
or less irritation of the external genital organs. As the disease progresses it be-
comes j)rofuse and purulent in character. The odor becomes foul and disgust-
ing; the color changes to a dirty brown, from the presence of broken-down
blood; and the secretions are mixed with shreds of decomposing cancerous
tissue. Sometimes the discharge continues to be serous in character and without
odor during the entire course of the disease.

Pain.— In the early stages of the disease pain is usually not a marked symp-
tom, and in some cases it may he absent even when the cancerous degeneration b
well advanced. In the beginning the pain is not, as a rule, acute, but later on,
as the disease progresses and neighboring structures become involved, it fre-
quently causes intense sulTering. It is fc!t in the lumlwsacral region, in the lower
abdomen and jielvis, in the legs and thighs, and sometimes along the crest of the
ilium. It may be cimstant or intermittent, and is described as shooting, burning,
or colicky in character, or it may manifest itself as a dull hea^y ache in the lumbo-
sacral region and jielvic cavity. Se\'ere paroxysms of uterine colic are frequent
during the later stages of the disease. They are caused by the local irritation
of the cancerous outgrowths and the distention of the uterine cavity with loose
necrotic tissue and retained secretions. Pyomcira is not nearly so common in
cancer of the body of the uterus as when the disease begins In the cervi.x, and

CANCER or THE BODY.

iienti)' h jiermnnmi inirulcnl arcumukiion scMnm occurs, al(hou);h lliere
in*y b* ii trm)>onir)- blocking up of the CMvical canal wiih a fniitmcni of iDncer>
lite li^ue. Sometimes the parux)>m^ of ixiin art iluc lo nvurilts, which is a
fmiueni roin]>lic!iliiin iintl (3uk» intcnM: :^unrring. Wh«-n ihr disease rxienda to
ilic |icriioncum and to the adjacent siruclurcs, the pain l>ecx>ine& more Jtfvcrc and
nvraiituniMif luuilized jwriioniii.s may develop.

Geoeral Syaptonu.— The general sympmms arc diecu&wd under oincer of
Ihe (ervin on page 399.

IMagDOSis.^A n«3rl}'<liaKniiNismu»t he made ufran-
ler o( iht body nf ihe uterus if permanent results
ire in be c x |> e c out of place to
Min insiM u)M>n the uritent need fi>r a thorouKh investipiion of the ciiu»e of all
irreguUr hemonhageK from Ihe u(eru». The situation of the dis-
se, the similarity of its clinical manifejitaiinns
ith other pathologic condition!* of ihc uterus, and
ic Innidiou!' nature of its early symptoms combine
_|o mask the true character of the affection unlet.* ■
clone and properly c o n d 11 c t c tl study is made o f e v c r y
case by ihe attending physician ur a specialist.
The diJgIu>^i^ is made as follows:
The histiirj-: >
The symptoms.
The i»hy*ical ^gns.
TI1C mimiMopic examination.
Th« HiatOTj,- There i* \-erj' little in tlie history of the patient thai points lo
the nature of the di>e:ise l>eyiind u kiiowledfce of her age. A.* ha,« nlreudv been
itcd, i^ncrr of iIk' Ixidy of the uteru<^ is a diseaw of advancing years, and with
I* exceptions it occurs at or after the menopause, fnlike cancer of the cervix
tltnili> nulli)i.iri<- and midtip.irx- with ctiu^l freqiienry. and conscqucnily ibc
ir.iunuli'^ms of Libor cannot l>c con.'.idcred as prcili; polling muses.

The Sytnptomfl.^The <hararieri!.lii* ^ympti<m> arc hrmorrUagf, di^chnri^t,
vi fi>}in Lnforlunatcly, however, they do not become marked until late in the
jr«c of the disease, and consequently cannot t>e depended upon in making an
riv (liagnofU. Hemorrhage b the earliest nym|ilom that directs our .iiicniion
the uterus, and it may manifest ils<clf as a menorrhagia or a metrorrhagia, or it
ly appear js a siiow of hlood upon the linen or in the ^-aginal dLM^harges. The
[rukorrhcal dinhargr i* «ldom of su»icicnt imjjonnncc to claim the patient's
ltentii>n and passes unnoticed until its charjiiler changes or it becomes irritating
})c exierail organti. A pn>fuse. thin, witlery diM-harge should always lie in-
rfigatod e*f n if it is without ihIof and tines not cause irrilaiinn.
ni* Physical Sign*.— The physical signs arc siudie<l by (o) touch. (A) sight,
unrll.

Touch . — The patient is placed in the dorsal position and the examination

vaginal loud) combined with recto-abdominal and ragino-abdominnl pal-

The cervix and vagina are {ml «x.imined ami then the Inxly of the uterus,

m1 finally the |ielvic orpins are carefully pa Iptiled by the combined melhoils.

The tcfvix is softened and its canal is patulous or easily dilated by the eumifl'

: Anger. The Uteru* in »ymmclrirally cnLirjtnl in the e.irly «tagc», Ihii later

t "urface becomes irregular or nodulate«l from cancerous deposits

cath the |icrit(iiieum. The IkhJv of the utenis U softer than t»r-

n«i du«l often Mimcwhal lender upon prewure. The utenu nt fint b movable,

394 THE UTERDS.

but as the disease extends adhesions take place with neighboru^ structures and
it eventually becomes fixed in the pelvis. The existence of an old inflammatory
lesion must not be lost sight of as a possible cause of fixation; this condition is
fully discussed under cancer of the cervix (see p. 405}. If the vagina is the seat
of melastulic nfxlules, they can easily be detected by the examining finger. It b
impossible to recognize a secondary invoK'ement of the ovaries and oviducts with
any degree of certainty, as the organs may be enlarged from other causes.

Sight . — The speculum gives but little or no information unless the vaginal
surface of the cervix or the walls of the vagina are involved.

Smell . — A.=* a rule, the discharges are without odor in the early stages of the
disease, but later on the fetid, foul, and disgusting character of the secretions is
more tir less pathognomonic.

The Hicroscopic Examination. — The diagnosis must always
depend upon the microscopic findings. This is absolutely
true in [he early stages of the disease and practically so at all times, as the
degenerative changes take place within the cavity of the uterus, and are there-
fore hidden from observation. Furthermore, the characteristic symptoms of
cancer of the body of (he uterus are in no sense pathognomonic, as other uterine
lesions produce similar subjective and objective signs.

Whenever irregular hcmo rrhagcs occur or the men-
strual flow is increased in quantity or duration the
cause must be determined without delay, and unless
an absolutely satisfactorj- explanation for the symp-
toms can be found outside of the uterus its caviiv
must be cureted and the scrapings examined by the
microscope (see p. 38). If the examination gives negative results, the
patient must be kept under close and intelligent observation until all danger of
malignancy is past. If the suspicious symptoms recur, the uterine cavity ^ould
again be cureted and the scrapings examined.

Special Directions . — -It is not always necessary to use the dilators,
as the cervical canal is often sufficiently dilated in cancer of (he body to use the
curet without first stretching the parts. It must always be borne in
mind that the lesion is frequently limited to 3 cir-
cumscribed area in the beginning, and that unless
the entire endometrium is removed by the curet the
diseased portion may not be included in the findings,
and consequently the scrapings submitted for exam-
ination may consist only of normal mucous membrane.

Whenever the cervix is soft and dilatable, the index-fmger should be intro-
duced inio the uterus before the endometrium is cureted and its cavitv carefullv
explored by touch. If the dilatation is not sufficiently great to admit the finger,
a uterine sound should be substituted. These methods of examination often
resuli ill obtaining valuable information from a diagnostic standpoint by locatii^
the causes of menorrhagla in cases that are not due to malignancy but to such
lesions as uterine polypi and submucous fibroid tumors.

Diflferential Diagnosis.— Cancer of the body of the uterus may be
mistaken for the following lesions:
Uterine polypi;

Submucous and olhcr varieties of uterine fibromata;
Retained placenta;
Chronic endometritis;
Sarcoma.

(.'ANCEK OF THE BODY.

39S

All o( iht^ |utliuU>fcic noiuiiiton.^ |>m«nl ii parlbl nr cnmplrtc cliniotl picturr
of taiiccT (•( live uicrus, and conscqueiiily a ditTcrcntial ili;iKno-U ihai is huftii
upnn ihc hiMcn' uml Ui« avmploms alont u-nulil ofttn lend m hi a*irdy iind in
nuny ai<«s ti-Mili iti ;i muligiunt 'Jegcnmttiim i>cing oiTrlookcd. I i^all. ihcrr-
(<>rr. ix>i <lbius* the variaiioiis in ihc hi.iiory .iiid synifilonL* l>etw«en Uic-m; con-
liili'iti'- -ind uleriiic ramtT, as it wmilil Ik miMcailing, for the rcaMin that wc
»*>iul<t l>c dealing in unncrcKiarj* prnbabililirs when wc posse&s a pasilive tnelhod
of nviikiiij; ihi? ilitTcrciiiiAl dbgnofli^.

Ilrmnrrhagc nr u <li«chargc is ihe symptom which
cal1» our attention to the uterus, and the caustc must
at onc« be <tctcrmin«<l by dilutinf! the cervical canal,
expl»rini; Ihe uterine cavity, and submitting the
finilinfis to a microscopic cxaminaiinn. There U no other
niirtnut in<'th<Hl of prill edure in the^e o»c», **■ the Icinn is hidden from view

1 within the uieiine ravitv und its physical charai:tcrL<itii:s cannot be seen and

Mludk*!.

^K Recognition of the Involvement of the Periuterine Tissues.

^^t-Thr psltcnl K anc«lhrlized and placcij in ihe dorul poMtiDn. The tervix b

Haen Hcixed nilh bullet forceps atut Irjaion made in the dimlinn of the vuhiir
iirifiie l'> leNt the miilnlity of the lUeni*. which is an important guide in delcnnin-
ing the question of pelvic in'i^lvemciH. If the uterus is freely mov.ible, there is
inalll^ruiMhililyiioe.tleioionuf thcdi.seasc; but if it U fiixd and dinnut lie )>u11ed

L^inrn. wr i>h»uld a^Kume that the canccmus infillraiinn has invaded the peri-

^Blefinr li&sucs unless the adhesions are uiused by an old inrlammatory

^^P^Tbe mubility of ihc uterus shnuld also be tested by recto-abdominal and
^VRUJno.tbdominul pa!]iation, and the same fonns of touch >huuld also be em-
ployed I" exjiminc :i!l ihc |»elvic Mnicturc:» fur (he presence of no<lular mawes and
I areas of infiltration.

I II is often difEcult to distinguish t>etween an inflammatorj- Iwion o( the up-

pettduKe^ ami canwrous iiiKth-cmeni of the periuterine tissues, as they are i>oth
Mttutcd high in the pelvis. Later on, however, as the malignant fltj>ease od-
' vanco ihe lower portion of the broad ligamrnis become* invadcil and feeU like
parchment slrclcbcd across the pelvis. Furthermore, the cnlargcmeni and
I thickening due l<> an inllammatory lesion lack the liartl and nodular feel that U
cbonorristic of nulignancy.

Pn>^08i8.~l>eath invariably results unless the disease is cured by a
ndksl operation. The jirogrcsti of the di.->ni.se U mudi slower than in cnncer of
ihrcerx'iT. ami it may exiM for Ncvend months or even one or t«-o years l>ef»re ihe
mjlign.inl ilcgcnemliim reaches an adv.-mced stage. Ahhough the uverage dura-
ti-in "i ihf disease is not known, it is, howc^-er, very mtich loiif^er than cancer of
ibe cervix,

IV operative prognmis is very good when the dbcasc is limited ia the utcnis.
ilyttereeiomy, under these condition*, results in
from 60 to 7s per cent, of permanent cures, which
it in marked cnnlrast to the prognosis in cancer of
the I e r ; i \

Causes of Death. — The cnww of death are dtscusw) under cancer of
the vet\i\ .in [mu'c 400.

Treatment. — Tlic treatment of cancer of tltc body of the utenu i» divided
Into:

The radical treatment.
The pnlltativr trealmctii.

396 THE UTERUS.

Radical Treatment.— Complete alxloniinal hysterectomy (see p. 696) is
the nperniiun uf selection, and tlie general indications for the procedure are the
same as those gi\en for the radical cure of cancer of the cervix on page 407.
Vaginal hysterectomy is contraindicaled.

Palliative Treatment.^Thc palliative treatment is discussed under cancer
of the wrvix on page 408.

CANCER OF THE CERVIX.

Causes.— Cancer of the cervix is a ver^- frequent affection and nearly one-
third of all cases of primarjcarcinomata occur in the uterus. The disease attacks
almost exclusively women who have borne several children; it has been obsen'cd,
however, occasionall;' in nullipara^. Traumatisms of labor are probably the
most important prcdisjHisin^ influences in the production of the disease. This
is shown by the frequency of childbirth in women who suffer from cervical cancer,
and also by the fact that in the cases met in the nulliparous several gave a histoii'
of operative dilatation of the ccnix or an injur)' from the spontaneous expulsion
of a uterine fibroid polypus.

Cervical cancer is mo.st frequently observed between thirty and sixty years of
age; the largest number of cases occurring immediately before, during, or after
the menopause. The disease is seldom met early in hfe, although cases have been
observed before twenty years of age. Cancer of the cen-ix is uncommon In
women o\er s^cnty years of age. The di.seasc is more frequent in the lower
classes than in the higher walks o( life. Cullen has shown that cervical cancer is
as frequent in colored women as in while, and the old theory, therefore, that the
African race enjoys a comparative immunity is erroneous.

Pathology.— Cancer of the cer\ix occurs in two varieties:
Squamous -ceil carcimimii.
Adentxarcinoma.

Squamous-cell Carcinoma.— This i? the most frequent variety and the
disease starts jirimarily from the squamou.s epithelium covering the mucou.'t
membrane of the vaginal portion of the tervi.x. In the beginning the cervix is
somewhat hype rtro]) hied, hard and n(xlu!ar in character. The mucosa is paler
than normal, but its surface shows no ^igns of erosion. Later on several groups
of small (k'licatc |>api!las are ob-erveil springing from the surface of the cervix
which are very friable and bleed ujiiin the slightest touch. These papillary or
caulillowcr growths may remain fur some time as small warl-hke vegetations or
they mai' grow rapidly and c\cntu:illy occup)' the entire vaginal vault, completely
hiding the ccnix. After the caulillowcr mass has attained a large size it begins
to break do\in ^ir slough, and fmalh' it (lis;ipf)ears altogether, leaving a deep
irregular ulcer on the cervix. Ur-ually at this stage of the disease the ce^^^cal
tissues arc more or le>s ileslroyed b)' the malignant ulceration and it is not un-
common to find that (nic or both of the lips of the cervix have entirely disappeared.
.■\b the disease a<i\"iiices the cervi.v i,s completely destroyed and the dome of the
vagina is occupied by a ilcci> crater-like cavity. The edges of this excavation are
irregular and indurated and its sides are covered with shreds or small masses of
gangrenous tis^uc. The cancerous tis.".ues are verj' friable and a severe hem
orrhage fre(|uen(ly follows even a careful examination of the parts. Gradually
or rajiidly the vagina becomes invaded and the disea.se finally extends to more
distant structures. Sometimes the cancerous infiltration occludes the cervical
canal anrl the uterine cavity iR'comes distended and filled with pus (pyoineira).

Adenocarcinoma.- This variety siiiris primarily in the cen-ical canal. It
develo]is citiicr fmni the cvlindric epithelium covering the mucosa of the canal or
from the glands of the cenix.

CAJiCEH or THE CKIIVIX.

^0?

The ilwmsc f-mns in^kliously when the crmcal mucnus mcmWanr is not
X|Knnl !«■ a dccji InbUTuI laceration i»f ihc cervix, and ihirc may tic an exlcn-
vr inviilvrnirni ljc(x)ri- any jKUhnliigit chango a|i[)car al ihi- L-Aicrnal »>y. This
I r^iwciAlly ihc aim: wtien csrcinoma br|;ins in ihc u|)|kt part of the canal, and
1 b Dol unaimmiin l«» have the cerviral lissun ciiminiidy >lii;lled out lukirc the
mcmtirune of the vaginal surface of Iho ccnix i> destroyed. When,
nwiner, llw di'*ii.»c starU in ihe lower pan of the ccrvjiral lanal tht extenial
■pn1 of ihc ceni.v immcdijtelv surrounding Ihc i-xtemal os b quicklv in-

Adenoaircinnmn o( ihc cervix <lc\-elop* slowly and the nodular ma»cs of in-

Xrattoa do not U'liulty tirtak down and ulcTrate until bte in the munte of tltc

In some ca^es the entire <XTvix may l>o conkpleiely involvetl and the di»-

fcM" cxtciidiil Literally Ix'fore there i< the slightct evidence of any jic>tructi»'e

btutgr takint; |>L'tce. Be/ore ulremtion ixcurs the cervix is hypertrophieil.

&nl, Jind niHlular, and the mueous memhranc i^ paler than normal: Imt after the

ptuiM tffnik down tlte Kcneral characlerL'iiii's of the ulceration ^rc the Name u>

>i\uamintS'<vl\ rjirrilicMnii. In rire in>lanci^ n (iinrerou:^ Kninth spnnKini;

ttm tlte lervical canal may present itself as a caulidowcr-likc inas» protrutlinK

•ttm the external tw.

Pyomrtr.i may occur in caMS ot adcniK'ar<'ir>oina and is due to (he Mime
ku.-<<3 as when the com plica lion {s asboclaied wilh a Miuumou-t-cell cancer of the
ervix.

When the cyltndric epithelium of (he cerv-ini car.al extends abnomuiDy down
ryond the external wc. a» it somciimes d<»cs as a congenital condition, an ndeno-
miniiniji nuy develop upon llic vaiciiul surface of the cer%'ix.
£x tens ion.— The disease may extend by infiltr.ition into the adjacent
uciufes or hy metsMasU to more disLint juariiof the body. As a rule,
tnnccr of the cervix remains as a local condition
jnd doe» not extend to distant organs by mcla-
»lasis, In nre instimces. Iiowever. meu^tatic invx>lvement ha^ been ob-
trneil during the Usi Stages of the disease in the lungs, the Uvcr, the »iomach,
■lul iilher or|cxii\.

Body of the Uterus. -The body of th« uterus always becomes invaded as
^^bc dticsue profTesses. The invob'cmcnt occurs earlier in adenocarcinoma than
^Ki the iHiiMm'tu^'Cell s-nrieiy- Acconltng to mc3ut auihoriitcs, there is an inler<
^^■itial or gUntluLir endometritis fnvscnl in the enrty M:ixe< of cerHcal circinoma.
^^^ulJpn, however, liolils tlial diere jre no abnormal changes in the endometrium
^Tnlew the cervical canal be(x>ine» ociluded hy extensive infdtrjlion. Under
ihew circumsunccs the uterine secretion* are retatncil and eventually pyamftra
fhytomelrii dct'elo)yi. In the Ire^innini; ihe mobility of the uleru« is n>A m-
lirmi, tnil rt.t the di>cnse extend^ and alt:itk> the |>eriuleriitc structures it
iKines hxed and immovable along with mher |«elvic »iruclurcv
VailOB.—The vngina is usu.ilty tnvotved sooner or later in the course of the
11h- exlcniion occurs e^irlii-r in M|uam>ius-{«il cardiu>ma ih.in when
growth develops in the cervical canal, t'sually the cantrrouit infiltration is
timiied to the up|>cr part of the vagina, but in sonic cases the disease may involve
entire canal.

Bladder.— In vol veciKn I of (be bladder is a frequent complicalion and It

early when the disea.ic >t;irt> in the anterior portion of the cervix. The

I is more often invaded in Mjuamouvcell carcinoma ihiin in adenocurciiioRia,

the latter v.iricty 6stulous openin^rs into the vagina do not. a; a rule, occur

ale in itie crnirsc of the di>ea?«. Owint; to the anatomic relations existing

rren tlte liladdcr and the uterus il in not uncommon to find the external coat

398 THE UTERUS.

of the former organ involved early in the disease and to obsen-e cancerous nodules
near (he trigonum vcsics. These foci of carcinomatous degeneration eventually
ulcerate and form false passages between the bladder and the %-agina. The
unaffected portions of the mucous membrane become inSamed and give rise to
symptoms of cystitis. The capacity of the bladder also becomes lessened, until
finally the orgun is almost obliterated by the contraction and infiltration of the
lissllet^. in advanced cases after fistulous openings are formed the interior of the
bladder anil the sides of the fistulas are covered with pus, gangrenous material,
and foul discharges.

Rectum. — Owing to the position of the rectum it is less often involved than
the bladder, and when the invasion does occur it usually takes place late in the
disease. In the majority of instances the patient dies before the ulceiati\T
changes have progressed far enough to form fistulous openings into the rectum.
and for this reason the.se false passages are comparatively rare. When they are
present, however, they differ in no way from the fistulous openings into the bladder.
The rectum b usually not involved directly by an extea'iion of the disease from
the uterus, but indirectly fnim the vagina, except where the pelvic organs haw
liemmc adherent as the result of a jire-existing inflammation. A tight stricture
<if the rectum seldom results from secondary involvement from the uterus or
vagina, and in this resjject the disease <liffers from primary cancer of the bowel
During the final .stages of the disease inflammation of the colon is a frequent
(.■omi)li cation.

Kidneys; Ureters, — Suppuration of the kidneys may result from infection
of the ureters either as the result of direct extension from a septic bladder or from
cancerous involvement followed by ulceration. Again, hydronephrosis and
chninic inflammation of the kiitneys may be produced by obstruction of the
ureters. This usualh' occurs from direct pressure when the cancerous infiltration
is siluate<l in the broad ligaments or from the invasion of the ureters themselves
by the disease. Sometimes the i)rifices of the ureters may become obliterated
^shcn the cancerous process affects the walls of the bladder or the canal may be
so distortee followed by the fomtation
of a uretcro vaginal fistula, which is, however, a comparatively rare complica-
tion.

Urethra. ^Involvement of the urelhra is very rare.

Pelvic Connective Tissues. — The pelvic connective tissues become in-
volved by extension of the disease from the body of the uterus, the cervix, or the
vaginal cuklcsac. \\'hen this occurs, the broad ligaments become thickened
and lose their elasticity; the uterus becomes immovable; and the pelvic struc-
tures are firmly united and fi.xcd. The infiltration eventually compresses the
pelvic hloo<l- vessels and nerves, which causes the edema and pain that are
commim symptoms laic in the course of the disease.

Lymphatic Glands. — The ]ielvic, rctroj>eritoneal, and inguinal glands
usually become involved after the periuterine tissues have been invaded, and
conse([uently the case has then progressed so far that a radical operation is out
of the question.

Pelvic Bones. — The jjelvic bones are only involved in ver>' rare instances, as
death generally lakes place bcffirc sufficient time has elapsed for secondary
extension In occur.

Peritoneum.— .\ direct opening into the peritoneal cavity from an extension
of the ulceration is a vcn,- rare complication. This is due to the fact that the peri-
toneum resists the ulcerative i>rocess bj' causing adhesions to form around the
infiltration as the disease advances.

II IIU

HKtn
piUier

PC-

CANCEX OF THE CSSVIX. 399

Symptoms. —The <.yinptomi>maybrcbssi&ccl undcrUtc following headinfp:
Hcinurrhaf^. Pain.

Piichiirgc- General ^x-mptoms.

[emorrhage.— As s rul«, the fim symplom is a sli(d>t Jiow of blood. Thb
IK (olUuvs .lotne form of i>)i)-:jjtal exertion, lucli as coiiu*. »tmining ii( slool,
m walking. The bleeding it usually vny ^rnall in Binouni and dimply suiiie the
't-'-t^ or Kirealu tbe vagiital discharj^^ wiili blood. SomettmL-? the hemonha^
. i iuclf 4* n menorrhagLi or there itwy be a \o» of blooil between the periods.
\k:.iiri. mcfisinjation may become more frequent or more proftise at the linie of ilie
mrii<)]uii>«. or a more or lest periniilir t1iin* may occur several monllu or yran
aficf the change of life. Tlie bleeding in tbe bq^nning <>f the di^e.3<e is not due
ii> ulterjiion, txil h caused by the chronic uterine lonj^-^tiun aitd endunKtritu
which are |>roduccd by the neopU-^m, ;in'l to Ihe rupiurr of the\'c«aelscoiiiaiDed
in tlw snwll papillas which grow from the surface of the ccrvis,

A* ihc dit^ase ad\'anceiri ami ihe ulccr.itive process Wgin? the hemorrtuige
bccomeK more and m«>re constant -tnil profu<e. until eventually there is a ron-
tirtuous liMS of blood along with the Icukorrhed dUchargc. Sonieiimcs the walk
ot t»n nrterj' may be ulceraie'l through iirwl a ^u(hlen ant! wvcrc hemorrfuge
results that may place the life of the patient in danger. As a nile, howeter,
(Iciih it seldom ciusc<l by » sudden hemorrhage.

Diachkrge.— I^ukorrhca ix an early Mmptom of the disease. It usually
licgins At the same time as the fir>t appearnnce of the bleeding, but in some cases
it nuy precede or folbw it. Itie iliM-harge i> at fir>l >erou> or n-alery in char-
without odor, frctiuently $.treaked with blond, and often ver>- profuse.
icr ulceration begins it liccomcs mucopurulent and mixed with blood and
fragments o( necTulic tii-Hue which impart an oclor of decom[H»ilion that i^ vQiy
felid atnl disgusting. As the disease progresses and the ulceration extends the
dbchargCT be(X>me more and more profuM and irritnting, and finally cause
tiuns on the inner surfaces of the thighs and s distressing pruritus Milva;.
Pain. — Pain is not |krescnt. as a rule, in the bcfiinmnR of the disease, and »
U the ctncenus growth, is limited to llic intr^^^ginnl ccr\-ix but tittle or ik>
.miienoe is experienced by the |>atient. But when ihc gromh invades
the uterus and the peK-ic cxmncdive tis-iuen. the nerves are either prcs«<.-d u|wn
ttr their vlructurc aftccti-d by the disease, and pain become^ a marked M-mptom
i.it gradtbilty wears the patient out from toss of sleep and Jcute sufieritig. Pain
thrrrfore, usually a bte symiXom. and doe» not mnnifeAl itiidf, a» a rule,
until the aw v* well .idvanced; somelimtes it may be al)i<ent during the entire
of the disease. Pain is generally felt in the lunibo_s>rral region, in the
■Ivlc ca*'ily, in the lower ^iMjomen. or it may radiate down the scijilic ncr\e*, and
the difease extends it may be referred to the perineum, the rectum, the bladder,
ureters, titc ludneys, or tlic |>entoneum. It nuy lie l,'oa^tant or occur only at
U, and ■• dcsailjed as bndnating, gnawing, burning, or shooting in char-
In some rases the puin U not acuit* ;inct the fulieni ^uRcrs from a dull
lant ache in the lumlHuacral region. Sometime^ the cervical canal t> con-
;cd by Ihe cancerous growth ai>d uterine colic result* from tlie effort ■>( the
Menu to expel the retained ^cretions: hcmatomelra, p>'ometra, and henuio-
Ipliu may iKCur in I'ery exce|>ti»nal cates in this way.
Gaucril Symptoms.— The general health usually remains good durini; the
i> -t i^m of the disease, but later on the nutrition U im]i:iired and the [KUieni
mcheclic and rapidly k>M-< fledi and wtrrngth. I-I^'entualty uremU
^ Irom obstnjclwn of the urelers or kidney complications, and the patient
more and more apat)M-tic a* to her condition and vurToun<ltng>.
0Utro-lnicsltnal dinturbdinces are characterised by lose of appetite, nin-

itirr.

400 THE UTERUS.

stipation, nausea, and vomiting. While obstinate constipation is the nile,
diarrhea may be present in some cases, and it is not at all uncommon to ha^-e the
two conditions alternating with each other. Toward the end of the disease there
is often difficult and painful defecation and not infrequently the patient passes
large quantities of mucus from the inflamed and irritated colon. The nausea and
vomiting are partly due tu the uremic state and to the foul odor of the discharges
which, along with the loss of appetite and constant thirst, tend to keep the stomach
more or less unsettled and irritated. When the bladder becomes invoivwi, there
may 1>c vesical irritability and painful urination due to the inflamed and allered
condition of the mucous membrane, and not infrequently blood is present in the
urine. Retention of urine is a rare complication. Urinar)' fistulas communicat-
ing with the uterus or the vagina are often caused by ulcerations which occur in
the later sluges of the disease. Symptoms of hydronephrosis and uremia maoi-
fest themselves when the ureters become obstructed and in some cases suppura-
tive nc|)hritis may develop. Peritonitis is a rare complication, as the peritoneum
protects itself by forming adhesions as the ulcerative processes advance. Fistu-
lous openings may occur in the ureters or in the rectum toward the end of the
disease. Edema of the lower extremities is a late symptom and in some cases a
plilegmasiit alba dolens may develop. Ascites is frequently present and the
superficial veins in the abdominal walls arc often enlarged.

Causes of Death. — The majority of cases die from uremia and exhaustion.
In rare instances death may be due to sudden hemorrhage, to pulmonary em-
boiism, septicemia, or peritonitis. Cancerous patients frequently succumb to a
trifling intercurrent disease.

Diagnosis. — The importance of an early diagnosis
in cancer of the cervix cannot be overcstirnated.
as every hope from a radical operation is based
upon it. Unfortunately a large proportion of the cases seek the advice of the
specialist loo late for any hope of permanent operative relief, and all that can be
done i;^ to ameliorate the most distressing symptoms without the slightest chance
()f siivinj; the patient's life. The failure in making an early diagnosis is due to the
insidious nature of the onset of the disease and to the erroneous views heU \sv
the Kt-'ncral practitioner and the patient upon the importance of investigating
at once the cause of all irregular hemorrhages and bloody discharges coming from
the vagina. Cancer of the cervix often occurs so insidiously that the disease b
well advanced and the surrounding structures invaded before the fatal nature
of the trouble is susjiected and a physical examination is made. The ten-
dency of women to belittle menstrual excesses and
irregular hemorrhuges from the uterus and their
ignorance of these subjects are almost universal,
anil \vc cannot hope to combat the ravages of uter-
ine cancer liy a radical operation until they are
tauplit to recognize the absolute necessity for seek-
ing advice when there is the slightest show of
blond at an irregular time or an excess at the nor-
m ;i I periods. There is also a habh among some practitioners of attribut-
ing tlicsc irrcf^ularitics to the chnnge of life or to some acute condition such as
cnngc-^lion. and to tell (he patient that "ever\-thing will come right in time."
The examination is lhcrefi)rc put off or delayed while the patient gradually be-
comes worse, umil eventually the urgency of the symptoms demands a ph>^ical
invc:.ligation, when a crater-like cavity is diso'vered in the vaginal vault and
the |ialient is brought pcist-ha>tc to the specialist, only to be told that the time
tor jiermanent surjiiea! relief has passed.

he <lia)!n<>«i^ i' »ud« as follows:
The hiiioR'.

*Thc sympnims,
Tlie [ilij-skal sifnis,
'['111- riiii'r"»M>>|iif «xnrniiution.
The History.— While ihc (liagn«<.is cannoi be based upon the history of the
ealictii, yet it vritl often lead us at kasl to susjx^t the possibility of miilieiiaiicy.
11 is. thcrefi'rc, im|>ortjint to know the afK of the {Mtient, the number "I chJMrrn
Ae tuts had, her mcial condition, and i^uch other particulars as may have a bt^t-
|ag uiMin llic jirrcli^iiosinj^ muses of rancer

|p Tdc Symptoms, —'ITvc rhariKtcri«i<* »ympl»iiu( of cancer of the cenix
»rr he'n0frliai;r. diifharge, and p<,jin. Hut these manifestations Itelong to the
tiAfX of the disea^ when ulcenuive ibani^e^ Ua\-e taken plaiT, ami when the
■KP>"^'^ 'f^ ej^ily nunle liy the phvsinil Miins, Thecjirly diagnn^i^ depends upon
Hlhopiugh physical and mitroswpic examination to determine the cause of all
mvnsim.nl excrvst^c and bloody disi'harjtes n<> matter hf>w ^littht they may be in
UBOunl. Nature sounds the warning in thclcukorrheal
dlkcharge streaked with blood, or in the few drops

tlch apfieur after »e.\ual intercourxe or straining
stool, and if she is not heetled the patient is
n m e i] . Siimetimcs in early cases the examination docs not ^wc jKisitiw
result*, and il may lie n«^e>viry, therefore, to keep the jiatient under conitanl

E;rv.itit>n until all danger of malignancy !:> |ust.
IIcnti)rrluiEe. either in the form of menorrhuKiit of ■ slij[bt show o( btood al
Itular [fcrnxK U the earliest and m<»l imjiorlant symptom "f cancer of the
rix. Il usually begins long bcf>>re ulceration has taken place, and is due, Ii5
hiu \\tm K.iid. l>> the t-nil<>mt^triti.-> tvhii h i> u.iuatly a.i,siit*i:ile<l with the dtte-n^e or

•rupture »t the vc>*cls in the |iapillas which grow fft>m the tenix. In those
its which niie n-i history of early lileeding tlie probabilities are that the ft}'mp-
i) had lieirn for|t<>lten by the [Kitient or lh:it the ammint "f bloofi lost was so
flight and the occurrence of the hemorrhage so infrequent in the beginning of ll>e
" px*c tlut [I was entirely owrlookeii. While leukorrhea unually occur» wry
fly in the course of the dneaM, it* importance from a diagnomic pinnt of view
NML'tii'.ilIy worih nothing, as all women sulTer more or less from s<»me teu-
Thriil >1iM')iiirge nivl a i^light inirease in it^ amount would jiau unnoticed.
■ijI lax-* a |(n)(uK' tt".itcr>' discharge has l>cen known to precede the
it of cancer of the ceriix. It is usually more or less irritating: to the
eUcmai oncaib> "f t;<-''ieraiion and fieiH-rally caUM'> a severe i>runtu> t-uh-x-. The
Btipeantncr. ilM-refun-, of a di.<'dur;gc of this character demands an immediate
examination of the uterus.

»Tht Physical Slens.— Th« phi-slcal signs of oincer of the cervix ore studied
fa) tnudi, (6) signt. (r) smcfl.
Touch. —The patient is pbccd in the dorsal pa^itinn. This method of
cnminaiiim pvcs tlM! lies) oinceptinn of the chancier arul extent of the |atho-
lofpc dunf{n. The manipulnlionv shotikl Ite carefully made, as a severe hem-
may rp^iili Idim roughness ujion the [urt of the examiner. The in-
rmpt>yinj{ i.'^tginal touih. aiwl jfler the rtrvix and \aeina
i-xaminiHl recto-alxlomin^aland vagi no -abdominal [lalpijtioQ
be employed to determine the comlition of the boily of ihe uterus, the
cc or ali>cnte o( uterine distention (pwmetni), the slate o( the [)eriulerir>e
■. arul the mobitlly of the {tclvic struilures and organs.
'S l)Ch I.— I'he piitienl is pUced in the donal position. Intpectinn of the
cenrLt ihrouKh a *|ieculum b seldum LiMlii.^te(l except in the eark stages u( the

403 THE UTESUS.

disease to observe the changes in the color of the mucous membrane, the appear-
ance of small erosions, the characteristics of delicate papillary growths, and the
condition of the external i>:^ in adcnocarcinuma. In the later stages the use of the
speculum is not only \'en- painful to the patient and liable to start a severe hem-
orrhage, but it is entirely useless, as it does not add to the information obtained b;
touch.

Smell .■ — In the early stages the vaginal discharges are usually without odor,
but after ulceration has begun their foul, fetid, di^usting, and nauseating char-
acter is so significant that a diagnosis by smell alone is possible in the rast
majority of instances.

In the early stages the two varieties of cervical
cancer differ in their physical characteristics, but
after the breaking-down process begins there is no
difference in the picture that they present. I shall
therefore divide the physical signs into those which are present early in the dis-
ease and lluise which present themselves after ulceration begins.

F.a rly Signs. — Squamoiis-rfll Carcinoma. — In the beginning a careful
cxaminalii)n will show that the cervix is slightly enlarged, and that the tissues are
harder than normal and somewhat nodular in character. By looking throu^ a
speculum the mucous membrane of the cen'ix is found to be somewhat pale and
its surface lias a glaze<l appearance. The secretions may or may not be increased
in amount and they are without odor, but they may l>e watery and thin in diar-
acter. In this stage the physical signs are so slight and apparently so unimportant
that the condition of the ccrWx woukl not arouse suspicion were it not for the
symjrtoin of irregular hemorrhages or blo(xiy discharges. We must therefore relj
upon the microsaipe in making the diagnosis, and it is at this period especially
that such an examination means so much for the patient's chances of life aftera
radical operation. In a short lime a more charaaeristic state of affairs inten'enes
and small delicate papillas are observed on the surface of the cervical mucous
membrane which are very friable and bleed readily upon touch. These ex-
crescences may grow sKiwly or rapidly, but in either case the vaginal' vault is
finally occupietl by a large cauliflower mass. It is not long after this mass has
attained some size that it begins to break down and undergo disintegration,
leaving a deep irregular ulcer on the cervix. The further progress of the dbease
is now similar to that of adenocarcinoma after it has reached the nlceraii^'e
stage.

Aiieno(drcinoma. — In the Ijeginning the cervix is hypertrophied, hard, and
nodular, and ihc mucous membrane is \>a\ex than normal and has a glazed look.
The physical i-igns at this period are, therefore, the same as in the squamous-cell
variety :ind the diagnosis must likewise be made with the microscope. The
rliseasc is \ery insidious, it develops slowly, early bleeding is often atisent, and
c.\lcnsi\(! invubement is trcfjuently jiresent, not only in the cer\'ical tissues but
also in the surroiniding jiarts, before there is any tendency to disintegration in the
canccrniis nodules, .\gain, when the disease begins in the upper part of the
cervical cavity il is very late in manifesting itself at the external os, and the
entire canal may be destroyed before the physical signs indicate the dangerous
extent of the involvement. When the disease starts, however, near the external
cs il soon ajjpears on the vaginal surface of the cervix. It should not be forgotten
thill in rare instances a cancerous cauliflower-like mass may grow fn»m the ceni-
cal ranal :inil protrude from thecxlernal os early in the disease. In rare cases the
cvlindric epithelium may extend abnormally downward beyond ihe external os
and :in adenocarcinoma may start from ihc vaginal surface t)f the cervix. When
an adenocarcinoma iif the cervix begins to break down its further progress is

CANCCI or IIIE cutvtx.

405

klentical wiih that of ihe squamow-cell %'ar(el/ afier the btier teaches the ukcn-

UlcvTalivc Stage . — As ha> been Mated, the pbysinl agns src simi-
lar in iKtth varii-tii-H uf m-x-iciil cimnr during ihc ulccratit'c MMfce. The chunf^
'hidi ocniT in ihc |)olvic firmans and the muM of the (.-xttrnsiim of the rliM.ise to
)ttcent stnitiurcs arc fully (lesi:ril>cd uivIlt iht [wilmloiy of squamous-ccll
mrrinom.i, iind need iv>l ihrrcfiirc he nirniinnitl ii){i>>n.

The h>ral coniJition^i finiiiiJ upcin vaginal touch arc so characteristic that the
nature i>f (he disca>c cunnot 1>c mistaken by any one v.\w hu.i tmd ewn .1 entail
experience in tht?e ai^r^. The craler-likc cavity or the inickcrc<l and indurutcd
dcfirts&ion in the vault of the vngini. Ihe character of the ulceration, the advnnc-
tii|: rid|;e« of cun<x-rou^ inlihration, the friiihlc nature uf the lisnuo, the tendency
III lilcr<l U|>(m the t^lightct^l touch, the masses of gnngrenuu^ muteriul, and the
fi-ul dUihjr};c. mixed with 1>1ckk1. pun, and necrotic debri^ point luunistukably
til ttir nuli)!n;int nature iif the ;ilTci'tion.

The Microscopic Examination.- When malignancy is suf^pccted, a wedgc-
%hape«t (lii-cc <•{ lii-vic should U- rcmovci from ilie cervix and *cm to u palhulogist
for examinution (see |>. 39}.

The success of 3 radical operation depends upon
tta early rccocniilon of the disease, and the micro-
• rnpe should therefore be employed in every cu»e
where there is the slighiesl suspicion of cervical
c n n c e r . If the mi* rosmpic findings are nef;ati\'e. the patient must t>e kepi
under cutHiant obBcniition and the cenix cx.iniincii by sight or touch eivry
ni'>nlh IT ^ix weeks, noting carefully uny increx-c in the induration or the
.kji;>c.irun<e o( outgrowths U]>iin (he miKoiiK membrane. If the local condi-
tioiw »h"n* llie slightest unfavorable chanpe. a piece of the cervical tissue
imial lie exciseil :init the mit ruM-Djie aguin em|)l(>ye(l. It nut infre^iuently
h»p|ient> that the t^iind ex.imin.it inn Ei\"es [>"siti\-e results, and unless this fad is
lAirae in miml ibc ne?Jlive findings of the first examination may create a fube
*rnx ■)( !4!i;uriiy in the mind «f tli« Mirgeon which mny lie fatal to the [mtient.*
A nejcative miinntcitipic re|>'>rt d*)C5 not by any means prove the absence of
caitccr, and in some instances it is justifiable to perform a radical ojieraiion upon
the evilencc iiresenieil by tlie cliniml »ymplomi. alone.

To guaH iigiiinsl an tnor I'lt diitgHosh and le discmtr malignaney in (Oses
Oftnttd ufon jor fireiUtnMy inm<f(ttl (i>ndilicui il shoulil he a routine ptiUlUe
lo matea m\ero.ut>pi( txiimitMtioH oj Iheliaufj rfmmfd in pcrjorming a IraikflQr-
r ■ 'in iim^utalion of Ihe rr«i.v, m siW/ as ali icfapingi jrom ihe uUrine and

inah and gtwiht extirpated }ram Ihe iarjofe cr the inleriorof Ihe iilrrus.
Diirerentlal Diagnosis. -The mitn>sco[>e must tx- reliiil upon in jII
1 ■ii'.iibi tascs, as h ii i-iiLii Liii|Hissihle to make the differential diagnosis from
tile cUniial bi>iiory ami the physical i'ign>.

The following legions may Itc mistaken for cancer of Ihe cervix;

Eversion of the iniracervical mucous membrane.

Cysiic degeneraiion.

Simple erinkioat or ul«'ralion&

Specific ulcerations (thanen, ehancroidi, and tahtrettlnii).

Scar ttwue.

ll>T«Ttrophy.

Ci>t)dvl<>ma.

S^rtoma.

Uterine and cervical polypL

Submucout uterine fibroma.

404 THE UTEKUS.

Eversion of the Intracervtcal Hucous Membrane. — This is a compara-
tively r;ire condition except in aises of laceration of the cervix. Everston mar
occur in nullipara; from ulher causes, and it may also result from a congenital
defect in which the cervical mucous membrane extends beyond the external os.
An cvcrsidn of the mucous membrane of the cervical canal is red in color; it feels
granubr m the touch; it does not bleed readily; it is not friable; it is without
induration or hardness; and it is clearly de&ned from the mucosa of the raginal
surface of the cernx. A slight ardinar\- leulworrhea is the only subjective symp-
tom complainetl of by the patient.

Cystic Degeneration. — The cysts arc easily seen, they have a bluish or pearl-
like coliir, and the;- contain a clear, whitish, tenacious fluid, which is the normal
sccreiion of the cervical glands. They are readily evacuated with a bistuur}':
there is no tendency to bleed, and the tissues are not friable. When a laijc
number of cjsts are present, there may be some hardening and thickening of the
cervix, but the characteristics of cancer are absent.

Simple Erosions or Ulcerations.— -The ulceration is irregular in outlioe
with shar])iy defined margins and (here is an absence of the elevated and indurated
condition of the edges observed in cancer. There is no destruction of tissue; the
surrounding )>arts are not inliltratcd; the ulceration does not bleed readily upon
touch; and the granuliitions are not friable. The surface of the ulcer is coi-ered
with tjiiical granulatitms, over which may be spread a small quantity of pus and
brnken-<iown tissue. The general appearance of the ulcer denotes a slu^sh
condition anti Uicks the active inHammatory characteristics of cancer.

Specific Ulcerations. — (Chancre. Chancroids, and Tubercuhsis.)—
Chancre .^The initial lesion of syphilis is rarely found on the cer\TX. In
women who liuve borne children and the intrace^^■ical mucous membrane is
exposed by a i)ilateral laceration the parts are more susceptible to infection and a
chancre is more likely to occur. A chancre occurs as a single ulcer and presents
the usuid ckinicl eristic physical signs. The diagnosis is Ixised upon the histcR
of the ciisc. the aj>pcarance of ihc seaindar)- lesions, and the dLsappearance of the
ulccnition under appropriate treatment. Chancroids .—This is also a rare
lesion on the ccrvi.K. The diagnosis is Ixised upon the presence of several dis-
tinct ulcerations; the hir-lon' of the case; and the disap]>earance of the lesions
un<lcr Lijipropriate local treatment. Tuberculosi s. — The affection is
usuidly associated with tuliercular deposits in other parts of the body, especially
the lungs, and it may also Ik; secondan.- to an infection in another part of the
genitourinary tract. The ulceration is situated, as a rule, near the external os
uteri, or it may comjilelcly encircle it, and the surface of the ulcer is eroded and
coveretl with a purulent caseous secretion. The margins of the ulceration are
clearly defined, soft to the touch, and not surrounded by induration, as in cancer.
Miliar}- tubercles may \x seen scattered over the adjacent surfaces and a micni-
scr)pic or Ijacteriologic examination may reveal the presence of the tubercle
Iwcillus.

Scar Tissue.^A plug of cicatricial lissi'e situated in the angle of laceration in
tears itf the cervi\ is not an uncommon occurrence and may be mistaken for the
iniluraiion of cancer. Its ii;ilure. however, is readily determined by the evidence
of a lacenlifm; the situation of the scar lis>ue which is surrounded by normal
mucous membrane; and the absence of induration in the adjacent structures.
In doubtful cases the scar tis^>ue should be excised and examined by the micro-
scoi^.

Hypertrophy. — This condition may lie ilue to subinvolution or fibroid
changes and may be mistaken for the indurated stage in adenocarcinoma. In
hy[>ertrophy, however, the tissues are not so hard and there is an absence of

CASTCIt OF THE CES\1X.

40S

uliir fanna lions. The rnUr^mcnt of ihr ccrtijc, at a rule. i» nn-.tlcr sixl the
mtt>u* mcmhr.iivc in !>moi>th niv\ mirmul in ajjix-'araiitc. There i» no t«>dcnc>-
hired upon cuminalkm, after ^■lnlu^ or Mniining iil >Iihi1, l>ut the mensirual
w may lie .Mimi-whal excessive, especially when ihe uterus is ubn invuKxd.
ULM ii( doubt the ix-rvkiil caniil sliuuld l<c diluted and it^ mui-ous lining «-
:ti£il by sight and touch and a piece of tiKsui- excised tor miawcopic cxnmina-
n.

Coodylonu. — Thi;^ is a xxr^* rare alTcctton. u?'Uiitly ncrurrliig durini; preg-

ncy, iirulKcneniUy assodatetl with condylomata of the vulva. As a rule,

II vc)!Cliition» ^[>Tin)(tnj; frum the cervix are ma-

iKOBnl in character, and a wctlgeshu))ed [>ieie of li<LMi<- sliuuld

wav-o be remuvol fn)ni the base of the gn)wth and examined by ilie miiroscope.

-(|U,inw*us-cell carcimimn the h.i>e of ihe jwpilliiry oulnfiwth in-h h.ird am!

luf.iieil to tite touch, but in the ^mple form of cinclyloma the>e characteristics

if mali):n.-in<-y are al>Nenl.

Sarconu.— The affection is less fr«K|Ucni than carcinoma and vct^' little is
ijwn a( ihe clinical jilciure that the disea.ie prc«nu in iu early stages. The
liotiscope must lie cmjiloyerl in all c.nses m decide the diagnosis.

UterLae and C«rvical Polypi.— .\ jxilj-pus growin}; from the uterine or the
niijl oniil may t-iigjieM dncer <il ihc CKr\ix or the ulcnis on accnunl of the
<compnnyin>: hemoirhage and discharge. Again, the suspicion of malignancy
)'■ Kreairr when i)ie |>i)]y)ius becomes icanurenuns and sIuughN. <-:lu^inK a foul,
urulenl iliscbarge. which, together with the constant hemorrhaRe. rapidly ex-
.-ta>t^ the inlient and pfoduccs anemia and cachexia. The mctlnKl of making
ic dbgnnois in ihci« au^s l-> to (tilale the cen-ical and uterine cavities, find the
Jj'inis, tem')ve it. and send the tumor to an expert pathologist for examination,
he dla);n(i»i» should alwuy> depend upon the mi-
roscupjc findings and not upon the physical ohar>
(I*ri>(ies of the jfrowlh, because ii may present
II ihr appearances of being innocent and yet be
align ant in character.

In ti «»e i>f fibroid ("ilyjni* the cervix is noTTnal, no induration <w nodules are
ll.and the external OS is uimewhat dilated. The uterus is enlarKe<l, but itswalU
re not thickened or inliltniietl. If the tumor is Um down in the crniuil canal it
y lie (rlt by the ex.imining linger or "cen ihmugh the s|>eculum at the mouth
if tlie ■ffvix. S<imetimes ibe polypus Ls cupelled from the uieru.% and h^ngs in
ihr vagliu xuxpriiileit by tl^ {ledji le.

Submucous Fibroma.-Thts variety of Bbroma is rare in the cer\*ix. hut It
more <* less frequent in the b«ly of the uterus. The *)-mptnms of hemorrhage
ml leukc>rThe.i <<UKK*^^t the )>on>tbility o( c.inccr. If the cervical mmiius mem-
Iminc toieriiH! the neoplasm Iwiomes atteiiuaie<l ami slough>. the fmil "tfenji»«
di»tl* ■ the ^.UNpinon of mnlign-mry. The dLignofiis dejjends u[K>n

the ii ' 'ing'. The ccnix shouhi tic dilate>l and the grt.KiK rrnif^eit

^iii t" a futhotoKisl. It may stimetimrs t>e nect^sar^- to split the cenix
reach tlie iunii>r. When thiv is dune, the edfies of the wound should lie
luiibi t"i;"-iher with (;ili;ut sulure-.

Rccogrnition of the Involvement of the Perititcrinc Tlssaes.—

i\ i* imjMTtiinl from an operative standj^oim lie<4u>e if there is decvlc^l in-

Krmenl no form of ra<lical operatii>n will cffed a |<erm;ineni cure. The iialient

ulil lie nnej>lhetixe<l and placed in the dorsal position. The cervix it then

with bullet Itutcps and iDcllon nwidr in the dire< linn of the ^iihrar orifitc

the mobility of the ulerus. which is a valuable Kui<lc in dctermininf; llic

4o6 THE UTERUS.

question of pelvic involvement. Free mobility justifies the opinion that there is
little or no invasion of the periuterine structures, whereas if the uterus cannot be
pullea<i ligaments and other peh-ic structures.

It must not l»c for^tten, however, that the uterus may have become adherent
from un old i^lvic inflammatory lesion and that the fixation of the organ may be
due to this cause and not to cancerous infiltration. In a case of this kind we
must consider the variety of the carcinoma and the stage of the disease. A
squamous-cell carcinoma of the cervix does not, as a rule, involve the periuterine
tissues until the disease is well advanced, whereas an adenocarcinoma may be
associated with extL'nsi\e lateral involvement before the cervical infiltration shows
any tendency to break down. Consequently fixation of the uterus in a case of
squamous-celi carcinoma that has not advanced sufficiently to eat away the entire
cervix, leaving a craler-like canity in the vaginal vault, is probably due to an old
inflammatory lesion. On the other hand, if the case is one of adenocarcinoma in
which the cervix is generally infiltrated but not broken down or ulcerating, the
immobility of the uterus is more than likcl)' due to an extension of the disease
laterally into the broad ligaments.

The mobilit;' of the uterus should be tested still further by recto-abdominal
and vagino -abdominal palpation, and the same methods of touch should also be
employed to examine all the pelvic structures for the presence of nodular masses
and areas of infiltration. When the tissues are generally involved, the uterus
and adjacent peUic structures are firmly matted together and the broad liga-
ments feel like parchment stretched across the pelvis.

Again, the situation of an >-M inflummatorj- lesion is significant. The thicken-
ing is felt high in the pelvis and corresptmds with the position of the tubes and
()varics, which are often found to be enlarged. A cancerous induration, on the
other hand, is situated liiw down and is felt through the vaginal vault extending
directly from the <li.scased cervix into the base of the broad ligaments. And.
finally, the enlai^emeni and thickening due to a simple lesion lack the hard,
nodular, stony feel thnt is characteristic of malignancy.

Complicating Pregnancy.— Pregnancy occurring as a complication in
cancer of the cervix, while not frequent, i:; still far from uncommon. The changes
in the endometrium and the foul discharges are conditions which are unfa\-onible
to concejition. The ordinarj- symptoms of the disease are not, as a rule, affected
by the complication, except that the hemorrhages are more profuse, owing to the
greater vascularity of the uterus. The progress of the disease also becomes more
rapid and the cancerous involvement shows a marked increase during the period
of gestation and for several weeks after lalxir. The results, so far as pregnancy
and lalmr are concerned, are very dangerous to Ixith the m(rther and the child,
("jenerally these patients alxirt liefore the placenta is fu|ly formed, but if they go
I)eyond this period, the child is usually carried tci the end of gestation. According
to Cullen, "the patient may pass term without deliver}-, as was demonstrated by
^^cn;^ic's jiatient. who dicil seventeen months after conception; at autopsy the
liquor aninii had dis;tpfieare<l, hut (he child, although somewhat compressed,
showed no signs of maceration."

.An abortion is esjiccially dangerous and death is likely to result from sepji-
cemiu or hemorrhage. If the case goc^ lo full term, labor is seldom normal and
ihc child is generally slUI-boni. F.Mcnsivc lacerations may occur invoh-ing the
rectum and bladder iir the diseased cervix mav lie completely torn from the lower
segment of the uterus. When the infiltration i- extensive and the cerrix does m t
undergo dilatation, the uterus i-i likely to rupture and its contents escape into the
aixiominal cavity units'^ operative measures are instituted at once. Delivery of

CAN«:II lit THr ttRVIX.

the chiUl throuftli the iinlur:il ijiij.^i^ i.< u.4ually (ollowrcd \vy fatal hcmtxThu)^ or
acjitii'rmLi .

Prognosis.— ^^^^«n tiw course of Ihc rfbease is nut inter/crcd with by
ofjeraiivcur |i.i!lE.iiivc liVHtmcnt, Hcjith m««riobly rc^ull:^ in fr»m oni- to i no war*,
vvl In ll)c miijnriiy of LUics the fatal cnilinj; b rcacliMi in al>oui L'it;hl«'n mimtlEi.
The |jalli:itivc in-:iimriit. hy <t>nin>llini; the hutnorrluKe iind the ilt^h^irgc. [>ni-
loni^ life fur ?i-\cn»l m-mihs < r cvi-n l>>nj:cr. At Iht pmtui lime ftyttertitomy
vgftt but i/iji;A/ hafe oj a laUmn aire. The ^■ast majority o( the tJises u[)eniud
uprtn hjuT II liKi»l recummce "f the <li^jsc, and irnt nvnv than j to to prr ccDt.
arc |)cr?nanenily cumt. Tnibahly cwn this is too lari^o a proportion of iv-
oiXTricA ami we would be nearer the truth in e^limatinf; it at 5 (>cr cent.

TItc operative pr'ifcnoniK in the future depcmls
upon the early recognition of the disease, unci the
Krorral practitioner, therefore, should consult a
specialist so soon as there 19 the slightest suspicion
of cnnceT and not wait until the time has passed for
railtnil ■•|ierativc relief.

Treatment. —The tredtntcnt of cancer of the cenix is divided into;
The |if<>|>hylactk. The palliative.

The r-idiail. The use of the ,v-ray*.

Com pill a ting prc^ancy.

The ProphjrUctic Treatment.— While noihinK i^ known of the cause of
antcr , iret it is u clinind fact tluil ihe disease occur' »lmii:>t exclusively in women
who have Ixime several children, and. consequent ly, so far us our

r recent knowledf^e serves us, it is important that
acerations of the cervix should be viewed in the
li|[hl of a dangerous predisposing cuuse. As a pro-
liylartic mcsf^urr. tl)eref»n-, all Mich tniumatisms should tw repaired.

This is cs|Nn-blly true I'f liiccrati«n= which are assocbtetl with evcrsion of ibe
Encrolinine of t)i« cervical canal. c>i>tic deicencnition. ertHion, and
of the tissues of the cervix. The obstetrician before
iftcharRinK a ]>ntient after confinement should ex-
mine the cervix, and if a laceration is found to be
ire*rni, it should be repaired within three or four
liinthk. It should also be the duty of the general
irftctilioncT to examine the cervix of all women
'ho consult him for pelvic symptoms and urge a
^epalr nprration if a laceration i« found. And,
iinally, I ntiuld urge, us a routine practice, Ihc
'lamination of every woman over forty years of
^Ke who has borne children and the immediate re-
pair of all lacerations of the cervix that may be
diftcorrred .

The jMtipliyladic trentmunl of cancer of the cervix, in mr judgment. «* mort
im|>urtAnt, and I am convinced that the frequcncv' of the disease oiuld be malcri-
ally Ir-Mrnctl if tin- Keneral (inirtitioner would educate his patients to apprcdaie
the nccewly (nr rciuiirinK cmical tears.

The Radical Treatment.— The only permanent cure for cancer of the
irrxix i* ih<- ii>m]ilcl<! <'\iir]iatiiin of the uterus ami the remot-jl of a |Kirtiiin of
the surrounding Itcalthy tissue. Il is only in the early stages
when the disease i.i limited to the uterus that hys-
terectomy l« indicated, and if the vagina, the
clum. the blad<Ier, the broad ligaments, or ihs

4oS THE UTEXUS.

cellular tissue of the pelvis is involved, a radical
operation is useless.

If the disease has advanced beyond the uterine structures, it develops moic
rapidly, as a rule, after a hysterectomy than when palliative treatment is em-
ployed, and consequently the radical operation under these circumstances hastens
the death of the patient.

The indications for a radical operation should be carefully studied in ead)
case. In the last stages of the disease little or no difficulty should be experienced,
as the extension of infiltration and the ulcerative changes in adjacent structurts
are clearly evident. Early in the course of the affection, however, it is ofien
difficult to determine whether or not the periuterine tissues are involved, and a
careful e.vamination under an anesthetic should therefore be made in the manner
described above. As has already been stated, the bladder may betx>me in-
filtrated early, and consequently a c>'stoscopic examinatioii should be made when
symptoms of vesical irritation are present.

Complete abdominal hysterectomy (see p. 996) is the operation of selection
in all cases of cancer of the cervix demanding a radical method of treatment.
Vaginal hyslereclomy is a less radical operation, as the extirpation cannot alwa>'s
be carried far enough into the surrounding tissues to completely eradicate the
disease, and consequently a permanent cure will not be so likely to result.

The Palliative Treatment. — The palliative treatment is purely sympto-
matic and lessens the hemorrhages and foul discharges; temporarily checks the
projjress of the disease; prolongs the patient's life; and renders her condition
more endurable. It is indicated when the disease has extended beyond the
uterine structures.

The chief symptoms which present themselves for treatment are:
Discharge; Hemorrhage.
Pain.

Constipation.
Exhaustion.
Dribhlinn of urine; Escape of feces.

Discharge; Hkmorbhage. — These symptoms are controlled by the opera-
tion of Curflniciil •iitd Caiilerhalion, which should be the first step in the
palliative treatment.

It may be nccess;\ry to rcjieat the operation se\'cral times during the course of
the disease on account of an increase in the amount of the dischai^e and hem-
orrhage. Under these circumstances an exominalion demonstrates the presence
of masses of friable tissue which have developed since the previous curetment and
which must be removed and the surface cauterized before the symptoms are
relieved ag^in.

Tochnic of the Operation. — The Preparalion oj Ike Patient and
the PrepaTations jor lite Operation are described on pages 830 and 831.

The usual method of sterilizing the vagina at the time of operation (see p. 83 il
cannot lie cmplovc<i if the ulceration is extensive, as a false passage might readily
be made into the bladder or rectum and add to the complications of the case.
The |"iarts sh<juld therefore be sterilized as follows: Douche the vagina and vulva
with a solution of corrosive sublimate {i to aooo), followed by hot normal salt
stilution, and scrub the eMernal organs, the perineum, the anal region, and inner
surface of the thighs with a gauze sponge saturated with warm water and tincture
of ^reen soap. The parts are then irrigated with a solution of corrosive subli-
mate.

Position oj Ike Patient. — Dorsal position.

Xiimber oj Assistants. — .An anestbetizer, one assistant, and a general nurse.

CANCEX OF THE fKBVIX.

*>9

Ame3lktsM,—T\te uw <)( a general ancsihriic h roniratiut it'll ler] i( the ptittrnt
is pmfoumll)' i'iiih«i'tic or a btavc ki<inc>' legion i-^ jurx'til. nnd under ihesc
rir<-um«Lin(ts ii 4 jier ccni. Milulum iif nicain should be applied to Uie vaj;iiut iind
vulv3 on a piece o( utenrbcni cnilon.

/a3trumentt.—(t) Simon's t^pcnilumN (curv«<J uiul flal blades) ; (2)ri|;^tand
Wt F.mniet'^ ^IikIiiIv (.urvwl »n!»(>r«: (3) three long heroo^tatic force|i»: (4) two
-h<>n hcmustatii: (ori'eps; (5) two bullet forceps; (6) dressing forceps; (7) sharp
n(iiK>n mnn; (8) ncedlehoiiler; {9) two mtuiII (ull-cun-ctl Magedom neciilw;
(10) plnin tiimnl olgui N<». i —three envelopes; (11) tlieimocautety.

Opcrtttion. — Simon's s|)cculums are ininMluccd into Ihc vugina and ihc field
■<( ojirntiixi exiMiMxl to view. Ilic vagina i^ ihcn dried with gauze sponijes and
A (.^irrful examination mack uf the di^MMSed area.

©■ ©-

® (^

h'l. 4Jt'— tiBHi^wirt L'tui in iMx r*j>iLiAti*( «irui>ira« n* Cawk "i inr Cum

\ ACTUAL SIZE \

r»i> n rai I'uiutn* ■.mxiiiiH torn Cahu

The Mahit vtruciurcs are now
cautiously Mzrapei! away with the
turn until apparvnlly lieallhy ti>sue
» rmihr«l. 4iiil ihe uneven and
! isl^iM <if ilie wound are cut
ih I urveil .M'Us<ir». The bkxnl
anil (tajidM-nt^ of li^ue arc re-
m"n-<l In'intlic vagina with a fiauze

i'>;i- ami tlie t-ureteil ^u^(.^t-e^
>^t.i(-iiHil with the thermocauter)*,
llir v^iicitiii is then irriifaled with a
■nluttiin of tdrrrwive AuliUnuile (i to
)aoot. fMllimed t>y hot niirmai mU »)luiinn, and thoroughly dried, ll H then
)' ith intlotorm Kauxe and the \'ulva protected with a compress held In
I a T-lmnda^.

>pri iai Directions and Variations in the Tcchnic—

The bliNfll ami fragment.'' of ranocrou.s ti»ue which culled in the vagina during

the (iTDiievi of currtmeni should be removes) fn>m time to time by a gauxe tpingc

-n.t the field of o]>eraiW>n kept well exposed. Thb is an imponani part of the

ic, as It i« i>cce*siry to »ec exanly what tissues arc lieing rem"ve<l by the

and avtiid the dangier of tnalung * fake ojxning inlu u neighborinn;

it Ihe bladder or reclum is involved, a careful examination must be made by

4IO THE UTESnS.

touch before beginning the operation. A sound should be introduced into the
bladder and the anterior wall of the vagina palpated to deteimine the thickness
of the intervening tissues. The rectovaginal septum should also be examined
for the same purpose. There is always more or less danger of making a false
passage, and it can only be prevented by a very cautious manipulation of the curet,
guiding it nut only by the eye but also by the sensations conveyed to the fingen
through the handle of the instrument. If the bladder or rectum is opened, noth-
ing can be done to repair the injury and a permanent fistula results. If an
o[>ening is made through the \'aginal vault into the peritoneal cavity, it should be
closed at once with a tampon of gauze, which is removed after the operation is
completed and reapplied when the vagina is finally packed with gauze. Should
this accident occur, the vagina must not be cleans«l by irrigation after the opera-
tion, as some of the fluid may gain access into the peritoneal cavity and cause
infection or corrosive sublimate poisoning. Under these conditions the deansii^
should be cione with a gauze sponge saturated with normal salt solution, and after
the vagina is dried, it should be packed, as usual, with iodoform gauze.

In the beginning of the operation the hemorrhage is usually severe, but it
ceases almost entirely when the friable tissues have been scraped away. If a
vessel spurts, it should be controlled by touching it with the cautery, by passng
a curved needle threaded with calgut immedbtely beneath it, or by seizing it
with a hemostatic forceps, which should not be removed for forty-eight hours.
Sometimes the circular or uterine artery may be wounded and require ligation.
The general oozing which occurs after the operation is controlled by the packing
of ioiloform gauze.

The cautery should be kept at a dull red heat. The actual cautery may be
substituted for the thermocautery- when the latter apparatus is not at hand.
Good results are also obtained with the galvanocautery. The cauterj- is prefer-
able lu the application of pure sulphuric or nitric acid, as the heat penetrates
more deeply and destroys the infection in the underlying tissues. If, howes-er.
an acid is employed as a substitute, the healthy mucius membrane should first
be protected by smearing it with vaselin, and subsequently the chemic agent
shiiulil be neutralized by applying small pledgets of absorbent cotton soaked in a
saturated solulinn of sodium bicarbonate to the parts.

Sometimes it is best to cut away portions of the cervix with scissors before using
the curet, and under these circumstances the bullet forceps is a very useful in-
strument til seize and steady the parts. The forcejjs can also be used in the
same way in trimming off the ragged and irregular margins of the cureted sur-
faces.

After-treatment. — Cure o} the Wound. — The gauze packing is
removed from the vagina in twenty-four hours and not reintroduced. The
vjigina is then irrigated once a day with a solution of corrosive sublimate (i to
2000). followed by hot normal s;ih solution, and a gauze compress placed over the
vulva.

If tlie peritoneal c^ivity was o];>ened at the time of the operation, the gauze
paikint; should not be disturljed for forty-eight hours. The patient is then
pl;ued intherlnrsal posture and the vaginal tampon removed. Simon's speculum
is ihen introduced and the vagina cleansed with a gauze spionge saturated with
hot normal sail solution. .After dri'ing the parts the gauze packing is carefully
withdrawn from the opening into the peritoneal cavity and a fresh tampon in-
troduced. The vagina is then packed with iodoform gauze as in uncomplicated
cases. Fresh dressings should be applied daily while the patient remains in bed.

The IHiiddfr.— The urine should be voided spontaneously or drawn with a
catheter every eight hours.

CAKCCR OF TIIK CXXVIX.

411

Tht Btnttij. — The boweU should be mot'ed on the second day by a talld
tine, fKlliiwx-d by un enema (if sonpsudit and warm walcr, nnd then kcjA

(Uily by the wmc means.
TIk /'!«(.— [>urinKt)i« fiist tvrenty-f»ur houniii liquid diet (seep. io6) should
be KJ^'en and ihcn the [Kilicnt should be pbccd upon a convalescent diet (wc p.

i>4).

Kf-it/ninfM and Pain. — The free use of opium is inrliiiiied.

Ortiiitg Otil «l ffn/.—The [ntirni should remain in bcil for one week or ten
dan.

The Subsequent Treatment . — After the patient gel* out of
bed cwry effori must be made to control the character and quantity of the
<li>c)uir|:r attd pn>te[t t)i« vulva from iis irriL-iting inRucnces.

The (iFft of ihRw imlications i% met by the um; of me<licaled vaginal douches,
which should Iw used nif^t and morning, or oftencr. if the case require* it. The
fnlliming druKS arc benetitial and mm irrilatiii); to tlic \iany. crculin, f^ij to the
quart; ly»ol. t per cent. »>lul^>n; i><>(usMum jwrmanganale, i to 3000; nirbulic
acid, 3 to 5 percent.; and corrosiw sublimate. I to aooo. When the« agents are
' " I'led, the (IiiiK-he shmiM lie follnneti hy an injection of hot nornuil salt
. :i>>n to [ifrvcnl k>t:i] irriLilion or pois>ining from al>H)rplion,

The daily v* of hvilro^cn pcro.iid is of peui adxanlage when the discharRe
become?^ oflrnsivc. It xhoid'l l>e UM;d in the morninn jtiM before the me^licaled
douche is givTn and the patient should lie »n her back and inject two or three
auncci> of the remetly into the vagina with a hard rublicr syringe.

The ulcerative jiRKie** is frequently helii in check ami mure or less modified
bj- the «?*• of ntclhylenc-blue or -violet. ITie dry powder of either preparation
nuy be duMeit over the ulcemted surface through a speculum, or a 1 |)er rent,
whition may be applied with a tampon as a lotion. Petroleum (reliiwd oil)
hu alK> gi^cn i^hmI reNul(> in tliewe ca^er-. An ounce of the oil is injected every
day inlii the vagina and kept from escaping by in^ening a cottcm-wfiol (am[>on.

If the lil«e<ling l>eo>mes excessive during the later stages of the disease, it is
ci>ntrollrrl by the daily ii*< of aipioii* hotw-jter vagimil inje<-lion> (3 RallcinN) and
a tampon of iodoform gauze. This treatment should be continued so long as the
bleeding Ustit. Good resulu are also obtained by the use of a Urge cotton-wool
tani|<on wet with a salunilcd solution of alum.

The |Kttient is made nwre comfortable by protecting the external organs from
ointacl wttli the irritating vaginal di.^chargcs by washing (])e |KlrL^ night and
morning with warm water and wmp; applying carlioliicd %aftchn (3 per cent.);
ami wearinga vulvar pod to absorb the secretions.

pAi.>< — Tfai* Kymptom mtL->t lie controlleil with opium, and the dote xradu-
1^ as the disease advances. It should be given in the form of a
;v tt admiiiisicml hypodermittiUy.

C*i«Bni*ATlON-.— 'Pie teivlVncy tii ron<-ii|Mt[on Ls relie\Yd by regulating (he
(fee p. 103) and administrring a mild laxative or a rectal enema (see p.
104). The uirasi'inal u.ie of a .■>;iIioe 'n> of ad\'aniage and often relieves the dis-
UvMin); redal symptoms which are frequently associa(r<l with omslipalion.

ExnAi'STlus.—Thc surroundings of Ihr patient must be made as cheerful
k» powiltle and Iwr niitKi kepi (rocn brooding o^«r her Imubles. Slie should
MX be lokl of the nature of her disease unlcM« there arc itawns for doing so,
■nrl at any nir the word "ftinrrr" must never be used in her presence.

The dirt should be easily <tige>ted. apt>eti/ing. and mitrilious- Alcnhoftc
«ilmubt)»n is im|H>rtant ami may Im- given in the form of a real wine or cham-
paHtw at luni h atul diiuiiv, or a milk-puncli containing aliout one ounce of whisky
say be taken three times a day. Tlw anviunt of alcohol dq>ends upon (be

fe.'

41* THE UTERUS.

indicatinns, aiui judgment muBi be used to prevent over-stimutation. The
necessity of regukting the diet so as to prevent constipation has already been
referred lo.

The patient should have plenty of fresh air and sunshine and she should iralk
or drive ever>- day it her strength and opportunities permit.

Vcr>' few drugs iire indicated internally. The use of opium to relieve pain has
been referred to. Sulphonal and trional are at times useful to promote sleep, and
strychnin is often indicated for its istimulatiog action. I have derived good re-
sults from the following formula, which should be given for an indefinite period
after the operation of curetment and cauterization;

If. Hydrargyri chlorMi rorroslvi,

Ad<li arsi-nosi ftftgr. j

Exli^cli nucis vomirir gr. xxv

Ferri et <)iunms citralis, gr. cc

M. ct fl. pi], r,

Sig. — One pill three limes daily after meals.

When the kidneys are afTected and symptoms of uremia occur, the medicinal
and dietetic treatment is based upon general medical principles.

Dribbling of Urine; Escapk of Fkp^s. — The management of these
conditions is fully discussed under the treatment of \'esicovaginal aitd recto-
vaginal fistulas.

The Use of the .v-rays. — The ,v-ray treatment of cancer of the cenix is
discussed on page 75.

Complicating Pregnancy.— The treatment of carcinoma of the cervix oc-
curring during pregnancy nhould be considered under two headings:

1. Those cases in which the disease is limited lo the uterine tis.<tues.

2. Those cases in which the carcinomatous degeneration has in\'ol>'ed the
surrfjunding structures.

Disease Limited to the Uterine Tissues . — The Hit 0} Iht
mother alone should he ronsidered u-lien lite disease is limited lo the uterine
/issues. No time, therefore, should be lost before resorting to abdominal hys-
terectomy, which is the operation of selection. If the child is viable, cesarean
section should precede the hysterectomy. The radical operation should ne\-er be
delaycii , even for a few weeks, in order to allow the fetus to reach viability, as the
disease de\elops ^'ery rapidly during pregnancy and the life of the mother may
Ik; sacrificed. Furthermore, a living child under these circumstances is the ex-
ception and not the rule. The iniluction of abortion or premature labor is
alwins likely to be followeil by hemorrhage and sepsis, and hence neither of these
ojjerations sliould ever precetie the removal of the uterus.

Disease Involving the Surrounding Structures.—
In thesf cases the radical <iperation is not indicated, as there is no hope of eradi-
cating the disease, ami consequently the lije oj the child should he considered, as
the death oj the mother is ri'entiial/v (ertnin.

If the general health of the jiatienl is fairly good and she is not rapidly losing
tlesh or becoming cachectic, the pregnancy should be allowed to continue until
the child is viable. When thi'^ period is reached, the fetus should be deli«red
by cesarean section anri the uterus immediately amputated above the cer^u
(siif>riiva/;inii! Iiysleredomy). C'esarean section alone is a more dangerous pro-
cedure in these cases, and while septic infection is alwav-s to be dreaded, yet there
is less likelih(Hid of its occurrence when the uterus is removed above tlie cervi-X.
I)eli\'ery by the natural passiigcs i> very dangerous both lo the mother and to the
child. The rigidity »i the cerviY. ihe great danger of a laceration occurring and
extending inio important slruciures, risks of hemorrhage and sepsis, and the

CANCEK OP THE TERVIX.

413

cHhood nf a nipiurwl uleni* arc conditions ihal combine tn make thi* rrorlhod
<•( <lrlitrr)- far mon- fnlal than wWn ihc chilit i> ilftitvrcvl by ibc abdominal
nmlc.

if (lurinfl the c<>ur» ii( ffesUtion iJie palicni btf^ns la lose flesh rapidly nnd
ni> [•fffnimtly aiwmic or cachcdir, ihr |irfj!nari<-y should ni>l be allowed to

. iiuc, as ihc vinlily of iht- fctu* b ncti-ssarily impaired tiiid ttie pnisjiect* o(
ikli\Tri]i4i It livinK diitd when llic iieriiHl of viability is reached are vti}-
p>H>r, and cnnwqiM-nily the mxthtr should nm \k jiermiticil to suffer the
additional drain uj»n Iwrr system. Under these circumsunces cesarean wclion
.f»lk>wrd liy KupravaKituil hynlvrectnmy ^lould he performed at once, and if the
Kcstaiton is not far advanced it is tmnei-cssar}' to remove the conlcnl* of the uterus
tiriofe amjiutatinK it uln^v the cervix.

If lite frtu> dio i'm uUrtt. the i>[)crati<in uf suj)ra vaginal hysterectomy should
\x pcrformcif al once.

A» ha> ainvuly Wen staled, delitxrry by the v'sginal mule is especially danger-
(lUfc wlwn the cmix i* the w.il ii( ran«'r. and n>nie<)uenily the induction of
alairiiiin or premature labor Ls co nt mind ica ted. In all case^ the alxlominal
rouie i» by far the sifc^t, ;ind the fetus should he remoif^l. either with the uterus
or by <-e^irean section, befwrc am[n]tating it above the cervix, if the preRnaney
'» far uilvamcd.

The |Ntllbtive treutment nhouM be emjtioyed in hopeless cases, both in ihc
inlcre^ of the mother and <)f the child, and the symptom* of ilischarKe, hem-
■irrliace, ixiin, coiwiijwtion, exhaustion, and the escape of feces or urine must
Ik relievrtl by the nK-lhitN whirh are rccommendeil in ciincer of the cervix un-
■ iTiplirated by pregnancy. The operation of cureimcnt and cauleriration is.
i;i. r.-f'irc, m»t contra imlicatet I when the discharRe and hemonhage can be cbeckc<l
or luntnilled by removing the triable tissues <d the ceni\, ^\'h(■n, howcifr, the
(rlu* i* within three or fi>ur weeks of viability, the operation should Iw deliiyol
untit after the ihild i> ik'titrrrd by the alHlominal mute, on account of the danger
of i.-iu.-iin(;al>'>nion. If. however, (^station is not so faradviinced. the ojicrfltlon
>h<>uli] lie pcrformeit at once, as there are more risks to the fetus from delay, on
aiifiunl of the drain ujton the mothcrS system imjuairinfc it* vitality and tlius
Irvkcnini; its chances of reaching ^iabilily. than of an ab'>nion occurring.

Recurrence after a Radical Operation.— The dbease returns

"l^^ in\-ariably -it the seat of removal in the ^^ginal vault. A recurrence

• >m l.ike> place in the gbnds or in the structures beyond ivithout a locil

^M>benu-nt liol manift-vtinK il-«,-l(; melaslii->i> after hysterectomy is. therefore,

lilom met The liH:al return of the disease t' due in mo*t casc^ to a nrntinunnce

the catwenms itrowth, while in other instances it is accounted for by the

Htciilalion irr implantation of cancer cells ;ii the time of the operation.

The symptoms of recurrence arc the s-ime as those already dewriljcd in

2' aincrr of the c«rvix. The ikalient*s attention is usually first attracted
1 hemorrhage:' ami a liiMharge. In rare instances, however, there is a
of Miength and weight t>cfore the local symptom<^ manife^t tliem>ehvs. A
mtiiial rxaminatiim reveaU the indurated and nodular condition of the %^ull o(
tt»c vaginj, and bier i)n the char.Kl eristic ulceratiw changes of malignancy
drvckip 'Pie pnigress of the disease is the same as in ca»es that have t«>l Iwen
uprraldl uiH>n by hysieredomy Mvi tlie physical signs and the local and general
rmplom* rio not dilTer.

TIm- imitment is the same as in inoperable cases of prinur>' cancer of the
vix. 3ImI coiuLits of |NillLitive measures (see p. 40S) and the use of the x-nys

414 i^£ UTEXnS.

SAKCOMA.

Causes. — Sarcoma may attack the uterus as a primary fx a secondary con-
dition. The latter is very seldom met, and when it occurs, the disease usually
starts in one of the ovaries and exientis to the uterus by continuity. Priman-
sarcoma is a comparatively rare disease, although it occurs more frequently than
was formerly supposed, as it has been shown thai sarcomatous degeneration is not
an uncommon occurrence in a uterine fibroid. The disease usually starts in the
body of the uterus, but occasionally the cenix is the primar)' seat of the affection.

NfUhing is known of the cause of sarcoma. While the majority of cases occur
lietwecn forty and fifty years of age, yet all ages are liable, and the affection has
Ijcen observed in young children and in very old women. Pregnane!- or the
traumatisms of labor have no prcdL-«)x>sing effect upon the disease, as it attacks
nullipara: more frequently than women who have borae children. The cocxki-
ence of sarcoma of the body o( the uterus and cancer of the cervix has been
occasionally observed.

Pathology.— Sarcomata of ihc uterus may be classified into:

1. Those primarily affecting the parenchyma.

2. Those primarily affecting the endometrium.

Disease Primarily Affecting the Parenchyma. — This variety is known as
fibrosarcoma, sarcoma of the uterine parenchyma, circumscribed fibrosarcoma,
;in'l recurrent fibroid. The disease Ijegins in the uterine parenchyma, or probably
miire fre<)uently in the connective tissue of a fibroid tiunor of the uterus, and
grows toward the ulerinc caWty or toward the peritoneal surface of the organ,
and is, therefore, either interstitial, submucous, or subserous in situation. The
malignant growth apfiears in the form of multiple nodules of ^-arious size, which
are not surniunded by a cajHiule hul which gradually involve the neighboring
tissues and eventually break down and slough. A submucous nodule may be-
come pt'dunciilaied and form a polypus which may cause inversion bv dragging
upon ihe fundus of the uterus. Sometimes one of these polypi may act as a ball-
valve at the inlcrnal os and cause a leminirary retention of the uterine secretins.

Disease Primarily Affecting the Endometrium. — This variety is known
as diffuse sarcoma, and starts in the endometrium, usually at or near the fundus.
It appenrs as soft jiapillary or lobulated growths which, as a rule, project from
a cirtiimscribcil area, allliouph they may occ;ision;illy involve the whole surface
of the mucosa. Sometimes the iiutgrowth c<msisls of a single tumor which is
round or oval in shajR' and ^oft in c-onr-islency, or it may resemble o hydatid mole.
when it sprini;s from the cervix and apfjears as a bunch of transparent cysts con-
taininj; a thick, viscid fluid. Occasi<mally the sarcomatous mass forms a poh-p-
iikc lumnr which may Ije mistaken for a rienign growth when it protrudes from
the external os.

Diffuse sarnima develops rapidly, infiltrates the uterine walls, and forms
nfKlutar niLissesun ihc i>criiimeal surface of the uterus, which becomes adherent to
adjacent organs. Ulreration ^ind sloughing »)ccur early in the course of the dis-
ease, dt'-^iriiying liie parenchyma and forming a large crater-like cavity.

Extension. — The disease may extend by continuity or by metastasis. If
it advances by ihe former method, the adjacent organs eventually Ijecome in-
vulvcd and the disease spreads to the vagina, (he bladder, the rectum, and the
alj<lom!n;il anrl )«lvic cavilics, and jiniduces the same ulcerative lesions that are
nbM^rvfd in the laler siages of cam.-er of the cervix. Metastatic involvement may
occur in the jieriloneum, tiie cumeclive tissue of the |>clvis. the vagina, the lungs,
the pleura, llie liver, the vertebras, the skin, and in other organs.

3AKCOWA.

Symptoms.— Tlie sympioms nf diSuH; sarcoma ilifler so materially from
tb(>^ III (ilifiixiri'ornii ihiit il will Im: nc4:essary to a>n»ifkr llicm se)Mraiely.

Difluce Sarcoma.—- '11k symptoms n^cmblc fo cUistly ttitisc of cancer of
ihr IkmIv ui the uterus (hat clinically il is impo^iUle to |>uint nut any charac-
icriAlk (liffermcvs l>etu-ccn llKm, nnd ii» llic hrm<>rrh»gr, the dtschurgc. (he
pain, and the general symptnros arc the same, il would, therefore, be a useless
rcf>rtiti<>it to refer to them aj^iiiu. (Se« aymptoms of cincer of the body of the
uterus, |i 39}.)

Fibrosarcoma. — This form of sarcoma almost inrarijbly occurs as a
dciterM-riiiivi- i'iiaii);i- in uterine I'lbromata, and the M'mfilunu in the beKinning arc,
th«n-forr. ch.ir.icicriMic of the Iwnign tumor and not uf the malignant gntwih.
(Sec syiti|iti)ms "f uterine fibroids, p. 37,)-)

So uncertain are the symptoms and the phy»ical
signs of sarcomatous dcKcneralion occurring in.
these tumors that thc<liseaseia not evvn suspected,
in the vast miijorily of instances, before ihegrnn-lh
ti examined microscopic allv after iis removal. In
• pncnil vr.ty iImt sudden occurrence of jiain atvi r.t|>iil itr*>H'lh in a fibroid
tumur ["Mnl let luimc form of H-ainflnr^- dcgcrcralion taking place; but these
symptoms d" not indicate the nature of the lesion, and consequently the diagnt^sts
i> f.ir Imm tettainot snisfaitory. (SecdbRnosLiof secomliiiy duiniw-s. p- 381.)

y.wn in ihc later slaf^ of the disease the lucal cardinal *igns »f mjilitmancy—
prtijuse hfuiorrhiii^es and ojjemhe Jisfkarga — do not manifest themsehes unless
the growth !.■' submucouj, or attack.-' a fibroid (ulypus and inv'iili-r.-> the endome-
trium in the ulccrali^T changes which take place. A deeply seated interstitial
tumor or one ltu>l b situatctl l>cneAth the peritoneum rarely in\x)bTs the uterine
muctwi, and consequently the symptoms do not dilTer clinically fr(Mn lho«c caused
by fibroid tumors.

Diagnosis. — An early diagnosLi mu>l In- m:ide of Mircoma of the uteruk if a
pcrmaiwnl turc i> to \x h<)|jcd (or fn>ni a r.idical i>i>cnnion.

'Iliis subject is fully discussed under cancer of llie cervix and the body of the
L uicrui,

^K The diagivnis if made as follows:
^H The hktory.

^H I'he ^ymfitflnis.

^V 'Ilie physical signs,

^H Thi.- miirosiDpic examination.

^™ The HUtory.^Therc is very little kmiwIcdRe to be gained from the history of

the pntieni. although her age has some licaring upon the nature of the lesim, as

ibr majority of eases occur liciwreen forty and fifty; >«t il mu>l not be forgixten

that the i!i>ea>c m^y attack vrrj- old women .md j-oung children, .\nolher fact

importance is that sarcoma is more frc<{ueni in nulli;>ai3- than in women

_ ve borne chililren, and con.seiiuentiy the lr:iunuitL->m.- of lalH>r do not act

predbno«jng cauM-s.

tba symptoou.— D iffuse Sarcoma .—The symptoms of this variety

<ILs(usse<l under cancer nf the body of ihc uterus on {Mge 393.

Pibrosarcoma .— Unless ulcerative changes ha i-e occurred in thcendo-

trium the symptoms do not differ from ihfl»e caused by uterine fibroids,
ter the** change* haw taken place, however, the profus* ai>d constant hem-
orrhage and the fotil, disgusting nature of tbe discharges indicate disintegration
and pa>vible nuHtinaiKy.

lite Physical Slgai.— The physical signs ait studied by (o) touch, (b) sight,

»adL

4l6 THE UTERUS.

Touch . — The patient k placed in the dorsal position and the examinatioii
ma<lc by vaginal touch and reclo-abdominal and vagino-abdomiHot palpation.
The vagina and cer\ix are first examined, and then the body of the uterus, and
finally the pelvic structures are carefully palpated by the combined methods.

Difjuse Sarcoma. — If the disease is situated in the body of tbe uterus, the
organ will be found to be somewhat enlarged; tender upon pressure; and more
or less softened. The enlargement is usually uniform except when nodules are
formed beneath the p>eriloneum which give the uterus an asymmetric or irregular
shape. The organ is morable in the beginning, but it eventually becomes fixed
in the pelvis by adhesions or by extension of the disease to neighboring structures.
The existence of an old inflammatory lesion as a possible cause of fixation must
be bi)rne in mind. (See cancer of the cervix, p. 405.) The cervical canal is
usually patulous or easily dilated and the examining filler may sometimes be
passed into the uterine cavity. Poljp-likc masses arc readily felt when they
project into the cervical canal and ihe friable nature of the tissues indicates their
malignant character. Secondary involvement of the vagina is easily detected by
the ex:imining finger, but it is im|X)Ssiblc to recognize sarcomatous involvement
of the ovaries and oviducts with any degree of certainty, as the organs may be
enlarged from other causes.

\\hen the disease begins in the cervix the characteristic outgrowths may be
felt by the examining finger if they project from the external os. The cervix
itself is enlarged and somewhat softer than normal and its canal is usually widely
dilated.

Fibrosarcoma, — In the Ijeginning the ph>'sical signs are the same as tho.se
found in uterine fibroids. Uui as the disease progresses and the nodular mas.<ies
begin t<i soften the change in their consistency may be detected by bimanual
jKilpatiiin if they are situated on the surface of the uterus. When a submucous
nixlule becomes pedunculated, it may project into the cervical canal and be feh
by the examining finger.

Sight . — The speculum gives but little information unless the sarcomatous
mass projects into or beyond the external os uteri.

Smell . — In the disuse variety of sarcoma the discharges may be without
odor during the early stages of the di>ease, but later on they become foul and
disgusting, as in cancer of the Ixxiy of the uterus. In fibrosarcoma the dis-
charges are not purulent and fetid in character unless the endometrium is invoh^ed
and disintegration occurs.

The Microscopic Examination. — The diagnosis is based upon the micro-
scopic finilings. The subject is fully discussed under cancer of the body and neck
of tlic uterus on pages 394 and 403.

Prognosis. — Death invariably results unless the disease is cured by a
ra<lical (>j)er;ition. The average duration of life in a case unintemipted by
ireatmcnt is about llirce years; death may occur, however, as early as four
m(mths or as late as ten years. The duration of life is longer and the operative
[irognosi-. is muth more favorable in fibrosarcoma than in the diffuse variety.

Differential Diagnosis ; Recognition of the Involvement of
the Periuterine Tissues ; Causes of Death; Treatment. —These
subjects are fully considered under cancer of the cervix and the body of the uterus.

INFLAHMATION.

Inflammation of the uterus will be considered under two headings:
Fndcmctriiis, or innammation of the coq)oreal mucosa.
Endoccr\icitis, or inflammation of the cervical mucosa.

■OONCESTtve ENDOMKTIimS.

The <<tflr[i»K-|M)ini of infhmmatoTy affections of ihc uterus is generally the
vnli)nw1num, im<l t)i« dtx-iix: may vvciiiuiiUy extend to the muMtilitr walla o( the
ut«u^ nnd even to the peritoneum. Metritis, or inflammniion of the uterine
pa/cnLhyniii,b>, iherefore, notd<lUtinaoras«paratc<ii«ea^, buia condition that
i> wcundary to an infection of the enclomrlrium. Sumclimr> the i)erlloneal coal
r>f the uterus is primarily affected ami Ihe disease subsequently involves the pu-
cfKbyma o( the or^an and Gniilly ihe eiulomeiriuni. These cafe<^ are, howc^vr.
OMnpkratiwIy rare, and .treduc to septic intlimm^itinn in one of ihe [lelvic organs
i3iu«inK »n ailbesion between il and Ihe uterus. Again, a laceration of ihe lou-rr
•cf-ount of the uterus may be follow-ed l>y septic infection which maj' extend into
the pnrcnchynu before inwlving the endometrium.

In Ihe liRht of modern pathology inflammalioa
af ibe uterine mucosa bceontes a subject of vital
importance, as il is the starting-point of nearly all
the inflammatory lesions of the pelvic organs.

EndometrilL" or cndocervidlit may exi-^t nione, Imt, a> a rule, the tnflumma-
lion is i»oi limited to either the uterine or cervical canal, but in^'oK'cs the whole
uterine raucous membrane.

ENDOMETRITIS.

InAammation of the corporeal endometrium is divided into fire varieties:
Congcsii\'e cndomeiriiis.
CimoiiiutiMul endomilritis.
Gonorrheal cndomctriib.
Sei>t)i endometritis.
Senile endomel rills.
The first two varieties are usually s{>olcen of under lite term "limfie en-
4om4trUu," In cunlnulblinction to the ginvvr formti of the dUca»e.

COHCBSnVB EMDOMSTKn-tS.

Definition. — \ non-sfietilic inlLimniaiion ui the corporeal endometrium
whidi is always subacute or chnmic in character and which is characterized by
hyi«rrsecrciion of the uiricuiar glands.

Pathology.— 'ITie disease presents itself in two varieties— ;/iiiKfif/iTr and
mttntitiai tndamrUitis. In Ihe former the utricular glands arc h.vpGrirophicd
and ineressed in number, and in Ihe latter there is a cunneciive-tMite orerfimwtb
ln-lHcen the uterine follicte».

.\s a rule, c(>n)^)^iive endometritis is characterized by general hypertrophy of
the mucma, but in some cases, howeviT, it dots not involve the enltre endo-
nHriuin and i^ limited to circum>crit>ed areas. \Mten Ihe hy|)ertruphy b
cxccMivc, the name of "juhkoU tniomtirUii" is gi»-en loihedisejisc. Occasion-
Ally in the gbndular variety polypoid oul|zruwth>> develop upon the mucoM
and form (Itc Ni-callctl mii<om poiyfii. In some cases at each meittlrual period
tbe rrhUmictrium is exfoliated in shreds or thrown off as a cisl of the uterine
catiiv. Ulien thik phenomenon ocnirs. iIk name of " exfalMiht tniiomfirilu"
i- -^:. (See Membranous Dy«n*etiorrhea, p. 719.)

I enilonteiritis are frc<)iiently foun>l in the same uterus, af-

i' '(■ p>irtHin% of tlw miici>ii> membninc nr exUling -.ide bv ».ide.

, . - may otcur in old chronic cases of endomclritii and entirety

re|(tece the mutoiu and its glandubr elements b\' a connective- tLvsue membrane.

4l8 THE UTEKUS.

Causes. — This variety of endometritis is due to congestion and is caiued by
any patholo^pc condition that produces stasis in the circulation of the uterus oi
the pelvis.

The followinp arc the chief causes:

Uterine displacements, especially flexions.

Uterine tumors and polyjii.

Su bin volution of the uterus.

Lacerations of the ccrvi.x, especially when they are associated with eversion

of the intra cenica! mucosji.
Pelvic tumors and adhesions.
Tubal disease.
Suppression of menstruation from exposure to cold and from cold doudi-

ing (luring the menstrual flow.
Acquired stenosis ()f the ccr\'ical canal.
Chronic constipation.
Sexual excesses.
Exanthemata.

Tm]>rnpcr method of wearing the clothing.
Symptoms. — The disease develoi)s slowly and is subacute from the begin-
ning. Its unset, as a rule, is so insidious that pa-
tienis cannot remember the exact lime when the
leuk<irrheal discharge first appeared.

Many of the symptoms complained of by the patient are not due to the
pathologic changes in the endometrium but to the causative lesions and as-
sociated complications. Thus, there may be present a group of symptoms that
are caused by a lacerated cer\ix, a displaced uterus, or pelvic adhesions which
may change the local and general manifestations dependent upon the endo-
metritis itself.

The following arc the chief symptoms of the dl-iease:
IjCukorrhea.

Hemorrhage; Menstrual disturbances.
Pain.

Sterility and a Ik) rt Ion.
General symptoms.
Leukorrhea. — Ilypersecrcfion of the utricular glands is one of the dtief
symptoms. The tlischarge is usually thin and serous in character, but it may
at times, however. bec:ome mucopurulent or even purulent. In some cases it may
have a milky apjieamni'e, and in others it may be mixed with a small quantity
of bloiMl. It is usually without odor and is non -irritating, but when the patient
is uncleanly in her habits decomposilion may occur and the discharge, beaiminp
verv offensive, mav l>c mistaken for malignant disease of the uterus. .\s a rale,
the intra cervical mucosa is also inflamed and the secretions from the cenix mis
with those from ihc uterine cavity and give a thick and viscid consistency to the
discharge. The vaginal secTctions also become mixed with it, and by the time
the discharge reaches the vulvar orifice it contains the secretions from the utenis,
the cervix, and the vagina.

The character and the quanlity of the leukorrhea often depend upon the
variety of the iliseasc and the condition of the endometrium. The discharge k
profuse when the mucosa is hyperirnphied. but it Incomes ver\- slight in amount
after alro]ihic changes have occurred. It is usually very profuse in the glandular
variety and is frc(nienliv purulent in ihe fungoid form of the disease or when the
endometrium is the scat of mucous poij'pi. The general pelvic congestion that

CONCESrrVE kndometritis.

419

occurs at each monthly period increases the discharge, and it is Iherefore wry
prufu^ (or iwo or three <lii>s bcfon- ;itni after men>iruauon.

Hemorrhage; Menstnial Disltirbances.— UnlcsMhc muciiKi is decidedly
hypcrirophicd menstrua lion b gcncriillv unaffected, and in a large jiroponion of
the aise>, therefore, no nien-itru;)! 1 lint urban ten or heniorrhiigen uciiir. Men-
orrhagia or mclrurrlufiiii iir lioth fre<iuer«tly aca>mpany the interstitial variety,
and arc marked and persisicni symjjioms when the endonieiriuni lake* on u
lungoiil ur |H)ly]x>id tJinnge. In the btter inAtance ihe nii-[U'rrlia]i:i;i is Mt free
and the intermcnjiruai hcmiirrhngcs so severe thai they arc out of all proportion
10 the character of the local lesions, and the prescntre of a ^ubinucouH fihroma
may he >uK|>erte<J. Menstruation i> M>nK;tiines ucrc>mp:i nicil hy pain, e»]wdally
in die interstitial variety, and symptoms of the congesti\'e form of dysmenorrhea
are not an uniommon occurrence when lliere is marked hypertrophy of ilie
endometrium.

When the uterine mucosa is atrophi<d the menstrual flow is lessened in
amount and more or le» watery in cliaracler, and is accompanieil by an in-
lermittent hyixigaMric pain whiih begins s«'veral linurs l>cfnrc the bltxding occurs.

Pain. — As a rule, nhcn jiain is present it is caused by the causative lesion and
not by the endometrJli--, Sometimes, however, variuti.s local and reflex jmins may
be directly due ti> ihc inHametl mucosa, and there may be vertical or occipital
headache, pain in the lumbosacral, the inguinal, or the h>'pogastric region, and
orca->ion.iIly also a burning sensation imme<li:itcly Itchind the syinj>hrsL-> pubis.

Sterility and Abortion.— Sterility and abortion are ven' common results of
eridu metritis, as the muci»a becomes so altered hy the dtr«ase thai it is no longer
suitable for the aitai-limenl of the o^um or the fiirm.iiton of the deciilua, and
furthermore the changed uterine secretions arc destructive to the life or the
activity of the spermtitoww. There is. however, ord)' a rtlatiw sterility in Uicse
cases, and should conception occur abortion is more than likely to eventually
result, as the ilLseiiseil muious membrane cannot, ui m;iwy instan(;cs, umler^ the
physiologic changes of pregnancy.

When atrophic changes occur in the endometrium, conception rarely takes
place, Sit the legion destroys, more or leis completely, the .structure of tlie mucous
lining of the uterine cavity.

General Symptoms.— Neurasthenic symptoms are not uncommon. The
paiient Lt often nervous and hysteric and, at time», there is more or lo-s depression
of spirits and a lack of desire for any form of mental or physical exertion, (iett-
cral debility, loss of appetite, and anemia are fre()uenily met, and are due (o the
menstrual irregutanlirts the local symptoms, ami the jci.-'iro-intc^liniil distur-
bances which accompany the disease. Dv'spepsia and intestinal flatulence arc
often associatol with these cjises. and there is aUo a marked Icndencj to con-
slipuiion, which still further contributes to the ill heahh of the indinilual.

The general symptoms are not alwaj-s well nuirked in endometritis, and in
cases in which the looil lesions nre slight ihene mjiy lie no sj-stemic disturbances
whatcvrr. Again, the local and general eflects of the caiisaiiw lesions and other
complications must not l>c Inst sight of. as they arc often responsible for symp-
tom.^ ituil arc "Timgly allrihnted to llie infl.imcd uleruis.

Diagnosis.- The diagnosis is made as follows:
The history.
The symptoms.
The ph,vsical signs.
The microscopic examination.

The History. — The historv' of the patient may aid at times in making the
diagnosis. L'n married women are not, as a rule, liable

430 THE OXER US.

to the septic or Ihe specific varieties of the dis-
ease. Married wnmen, on the other hand, Ire-
quently suffer from the graver forms of endometritis,
as they are more or less exposed to septic and
specific infections. The insidious onset of the attack and a lack of
knowted^e ujwn the part of the patient as lo when the discharge first appeared
are signiticunt and point to a simple variety of the affection. Grave infections
come on suddenly and are usually, except in the case of gonorrhea, acute in the
beginning and iiccompanied by well-marked symptoms.

The history of a previous o|>eration upon the uterus or of intrauterine treat-
ment may suggest some form of septic infection, as the endometrium often be-
comes infected, under these circumstances, from want of care in the antiseptic
precautions. This is esjieciiilly true where local applications are made to the
uterine mucosji by the physician at his office. And, finally, a careful inquit)'
should be made of all facts in the previous history of the case that might be a
possible cause of septic infection, as, for example, puerperal septicemia and
like conditions. A thorough knowledge, therefore, of the patient's history will
often enable us to exclude the graver forms of the disease and to conclude, with
reasonable certainty, that the endometritis is congestive in type, unless the phj-s-
ical examination reveals some other cause.

The Symptoms. — The only subjective symptom that ia at all characteristic
is the leukorrheal discharge. But the presence of a leukorrhea means \-erj- little
from a diagnostic standpoint until its origin is ascertained by a physical examina-
tion, as we cannot tell from its appearance whether it comes from the uterine
cavity, the cer\ix, the vagina, the Fallopian tubes, or from a ruptured pchic
abscess. Furthcrmt)re, the secretion from the utricular glands alwaj^ becomes
more or less mixed with the cervical and vaginal discharges before it reaches the
vulva, and consequently its appearance and character are so altered and changed
that Ihe source of the trouble is vur>' uncertain. On the other hand,
hoivever, we must bear in mind that in a very large
pro]n)rtion of cases a leukorrheal discharge is
uterine infirigin, and consequently we may assume,
when this symjitoni is present, that the endometrium
is the ;>cat of the disease.

The Physical Signs. — The physiail signs are studied by (.;} touch and (ft)
sight.

T o u c h . — The |):ilicnt is pljiced in the dorsal position and the examination
made hv \'aginal touch combined with reclo-abdomiiujl and vagino-abdomitul
palpation.

We first endeavor lo discover a cause for the disease. This may be found b a
lacerated cervi.\, in a re trod isp laced, subinvoluted uterus, or in one of the various
gross pc-hic lesions referre<l to under etiology. Having found the probable cause
of the uterine congestion, we next examine the uterus itself for any change in its
size, sha|>e, or consi-^tcnty lliat may result directly from the dise;isc. As a rule.
there art no changes in the uterus that can be detected by julpation except
those which are caused by the causative lesion. If, however, the mucosa is
greatly hypertrophied or there are fungoid or |)olypoid outgrowths present, the
sha|ic of the uterus is rounder than normal, the cervical canal is somewhat
patulous, and the lonsi.siency of the corjuircal and cervical jtarenchyma is more
or less softened, and Mimelimes tlie fundus may be tender on pressure; but
these local conditions are exceptional, unless they are <Iue to periuterine
disease.

Sight .—The s[>ecuhim reveals ihe origin of the discharge which is seen

OONaKSTTVE ENDOMETKinS.

escaping from ihc mouth nf Ihc w<>ml>. A* ha^ nlrculy liwn iii.itett. the MMTCtion
ol Uic utrimbr Klitnds is usually mixed wiih the disclurgc frum the cervix, and
OMMCqucnily it i'' nci vxNiir)' to 4:leaiis« the cen'ical canul u ith ii ^IihIrcI of cotton
bcfotr the unmixixl curiKirval mucus can be »ecn. This can unly be accomplished
when th« cerviJt is lacerated and the iniraccrvita] mucosa is everted.

't\\e Hpc<:uluin alw Nhuws the nin; and »ha[)c of the cervix and the proence or
atncnce o[ a paihokfgic lesion.

Tbe Microscopic ExaminatioB.— .\s the o{>cr3tion of dilatation and curei-
mmt tif thfuicnis.ilwiiynnicrs into the routine lrr;itmfiit of i:un^e:|iliveendome-
tritts it is unnctessan' to icn'n i<> this <i|)cralivc pniccdurc for the sole purpose of
dlaglxitU, and hIuIc in Uie ni;ijiifiiy uf iti>ljnces there is no ditCtuhy in determin-
ing tlic nature of the disease without the aid of the micnucope, yet the currt
xruplnits should always l>c ?cnt to a pathologist for examination as a precaution
^;;iin-'i tivccliHiktn;; :i lieyiiiiiinx maliKnaiit (ieKeneraiion.

Differential I>lag:nOSl8.— Congnlivc endumctrilit nuiy be mistaken
lor the follow iiij; lesions:

MjiLi)inanl di»e:ise of the body of the uicrus.
Incomplete alxmion.

DiMJtarKea tunnnf; from the Fallojilan tubes, the vagina, or a ruptured
pelvic al>^ce^!'.

Tlie dilTcrentbl diagnosis of congestive endometritis l« usually not difhcult
fitri't where ^ purulent di«harKe or hcmorriiagc-MKiur from the uterus, as is the
la^c wlien the cndomelritim i> the veil of funKoIil or ftiily|)<)id outgrowth*.
I'^ujlty there is not the slightest evidence either in the history of the case or in
the |it)v<<iail Aij^ns lu cause even a suspicion of the presence of malignum tlisease.
In the fungoid or ihe polypoid variety, however. Ihc blood and the discharge*,
which arc often reiaine<l and become uffensi^v, render the diagnosis uncertain
without ttK aid of the micnHco|K'.

Sixnctlmes a vaginal discharge may come from the Fallopian tubes, the vagina,
or a rupiureal jielvic abscess, and lie mi.Htaken fur cndumetritU. The differential
dugm-ii" in these cuiie* U made by the hislorj- of the ki»c and bj' the |ihy»ical
vjotntnalion.

Ak ■ role, when the discharge comes from the Fallojiian tuties it Is more or les
intermittent and (re<|uenlly accompanied by pain. The discharge. v.-hich is
punjknt and very profuse, cea«LS as soon as the tube empties itself, hui reappears
■gsin alone with jKiinful i-ontniclinn» when it refdls. Ttie--wc patii-nts have oho
a hfewiry of «omc form of infection followed by a chronic inl1ammalnr>- lesion of
the pdi'is which is revealed by a physical examination {rtdoahdominal jnd
VogimoilbilaiiiNat p<tlpalun(). llie jielvic miu-^s iIecTca.'>es in size while the
discharge continurs. but enbrges again when the tube begins to refill.

If ibe disdurge luis its origin in the xagina, the history will point to some
brm of vaginitis, and an inN;ie«'ii<>n of the \kxt\> ihmugh a :^[>eculum will rc^-cal the
pmcncaof a vaginal inflammation

A ndvi*; abscess b more likely to ru[fture into the rectum or into the s^gina than
[au> lAc uterine canal. 'Pie diagnosis i> made by lindinK the fisluh>Ui' o{>ening.
The patient is placed in the dorsal position and the vagina thoroughly irrigated
with warm water. .\ sfteculum is then inlriKluceil and the can.-il dried with gauxe
jningrs. 71>e vagina IS now carefully inspected, beginning with the v-aull atHl cim-
tiDutng tile rxamituiinn until the entire surface has been thoroughly scrutinized.
U 3 i>inu* iv iIli^iivctciI, pus will lie seen cKcaping from it. ami the diagnosis may
br lonlirme'l by passing a probe into (he false opening. Sometimes no evidence
wfaalevcr of a fistulous tract is oliJerve<l until pressure is made upon the pcKic
oonbcnta citltcr through the rcclum or thnxigh the abdominal wall above the pubo.

433 THE CTTEHUS.

when puR may be seen escaping into the vagina. In cases where doubt exists u to
the source of the discharge a cottonwool tampon placed against the external
OS uicri fur several houn< will collect the secretions if they come from the utenu
and settle the question of diagnosis.

Prognosis. — This variety of endometritis seldom causes grave pelvic com-
plications. The practice of making intrauterine applications, the use of the
uterine sound, or a careless anti^ieplic operative technic m:ay cause a seriou.<: in-
fection and convert a simple endometritis into one that may destroy the life or
the future health of the jMilient.

The etitilogy of the disease and the character of the causative lesions must
always be considered. .\n endometritis due to a lacerated cervix is a simple
affair compareii with a case where the affection is due to a pelvic lesion or to a
tumor of the uterus. Consequently not only must we consider the curability of
the causative lesion, but also the diingers to life involved in its treatment and cure.
Furthermore, unless the cause is recognized and removed the endometritis will
recur after it has ap[)arently been cured. And, finally, unless the treatment of
the disease Is intelligently and prcperly carried out no results may be expected.

The ]K>ssibility of fungoid or of jwlypoid endometritis being a predisposing
cause of cancer of the corfKireal mucosa should always be borne in mind.

Treatment.— The treatment Ls divided into:
The j)rnphyla.\is.
The removal of the cause.
The cure of the disease.

The Prophylaxis. — A knowledge of the causes of congesti\-e endometritis
and their jircvcntion arc the essential factors in the prophybctic treatment
of the disease. Although many of the causes cannot be controlled, j-et in a
fair pn)[H)rtion of cases ihcy can tie entirely prevented, as the affection is
frequcnliy due to traumatisms of lalxir, impro[>er treatment during the puerperal
state, ;iri<i injurious haljits, which are all causative conditions that can usually be
guarded against.

The Removal of the Cause.— There is alwaj-s a defmite cause which we
may or ma)- nut be able to discover, and unless it is removed any attempt to
cure the disease is useless, as it is certain to recur within a short time after trtai-
mciit. Fur e.\am]ik', if the uterine congestion is due to a retrod isplaced uterus,
a lacerated cervix, or a [>c]vic tumor, the indication is to remove the pathologic
lesion and at the same time or subsequently to treat the diseased endometrium.
.\t;ain, if the disease is the resuU of injurious habits they must first be corrected
before the local c(mdili"n is remedied.

Whenever it is possible to do so, the diseased mucosa should be treated at the
same time llie caui-e is rcmovcl. This can readily be done when the cause k a
lacerated cervix or a displaced uterus, by first dilating and cureting the uterine
cavity and immediately afterward repairing the cervix or performing a ventral
suspension of the uterus, as llie case may Ijc. In some instances, however, the
treatment of the endometrium should l)e postjwned for a future occasion, as the
causative leMons may have resulted in fixation of the uterus, and consequently an
attem[)t to dilate and curet its cavity may result in severe or even dangerous
traumatism.

When the disease is not caused by a pelvic Icsitm, but is due to sexual excesses,
constipation, improper methods of wearing the clothing, imprudences during the
monthly periods, clc, in addhion to the correction of these injurious influences
and the subsequent curclment of ijie uterine cavity a special plan of general and
local treiilment is demanilcd for the relief of the pelvic congestion. In these
cases the food shoulfl l)c nourisliing and easily digested; red meats should be

COXCESTIVB EXDOMETWTIS.

4»3

trn; and pure water should Iw freely taken lieiwecn mnb, The

lufTaln Liihia. Pnbrxl, and dUtillcd watcn are benefimi under iho« circum-

stances, as they otnuin but a f^mM amouni of solid ingrcdicnu and ih<^n>u^l]r

fbtfb ihc »ysiem. 'Pic ItoweU should tie openeit claily. Any temlciKv to

-,— •||„ili,)n iiKTea<es (he peine congestion and adds to the liKiil tmuble. Tile

ux o( a mild laxuliv'c and the weekly administration of a valine pun^ will

ilv In* suflident t" kwp the IjowHt (rw. Srttines are esjjccially bcnertcial,

i.y IcsK'n the ainpr^tinn; thcv lihould ihcrefore always be employed, either

ju .1 wwl.tv punitive, or used "Ijiily in plate o£ a simple la.uilive. Good results

fuljiiw iln- UNe of Hunyndi J.iiwis .intt stiinc mineral spring wnler», e^|lcnally

iImisc mntatnini; sfxlium cl)l<>iid. The patient should exercise daily in (he open

air [HiibiK, riiliiix, ami u-alkiiiK are l>enericial. but Uie u5< of the bincic shoukt

be avriiij<?d, lnd«)>ir excrciMS should be employed to Mrenirthcn the jielvic orf^iu

and the muscles of the abdomen and to stimulate the circulation of the pelns («e

p. 117). ((rncnil maMsafce i> al>o indicated In these <ases and siiould be fiwa

diiily or M lea*t three times a week. A pri>-

(icfly (twde alidomiiul binder (see p. 850)

•JiouM be worn w)i«n the lielly-wslj is re-

bxed or [witdulous, as it acts as a supjMrt

!■< ihe pelviror^Mns aiKl imrevses the reten-

ti'.r |"iwrT of the aUlominal cavity. The

! ill); should be supimrtcd from the

i.uiers and not from the w.iist, as any

huTO of n»it<lriclinn iin>und the lower ab-

'i-m'-n exerts an injurioits pressure and

•XA the cunj^esiion of the peKie

. f(;..lis.

The kical treatment is an un|x>rl3nl
lictor in kr^wening the ct>n)ce>li')n. A
vasinal douche of one or two gallons of hot
1 alt solution sJi'>ukl lie used night
moniinf;. T>v»ce a week the vault o(
the YMK>na aivd the vaj;inal surface of (he
rrr^it thouM Iw painicrl with timlurc of
bidin anil a eolton-wtx)! tampon siluraied
witit itbthyol ami Kjyccrin (15 per cent.)
Bp|>linl aiKt left in (Misition until the fol-
ktwiii^ imimin^, when il Ls rcm^ivcd t>y the
IMtirat licfore usiiij; the douche. Depleting

the (xnix by punt lit rinji; it with 11 bi^ti>un>' is often followed by Rood results and
shoakj he emplovcd in suitable case? once or twice a week when the lodin a
ptic<l.

The ledinic of this little of>eritton i» %er>' simple. The palteni is placed in
donal (Ntsilion and the ccr\'t\ exposed by a »pec>ilum. The pniterior lip i>f the
is then c.iuKht «ith ImiIIcI for<efts and drawn toward the vulva. Multiple
ncturc^ are now ma<le avtr the cervix u-ith a narrow >ir3t);ht-|>otnted bisioury
the (kj)th of from J to J of an inch and the bUde of the instrument withdrawn
b]r a fdi^l mtari' motion in onler (o increase llic size of the puncture. From
not tu iwii ounces of hkxMl shoukl be taken, arul if the biccrlinit i» slufwish a
ptndteei Iff cotton •atiir.iloJ with uunn water should be pbccd agajnsl the cervix.
■-■| I ■ i t!,. ;' ci>nlinue after a "iifiiiient amount of blood has lieen taken.

: ped by applyin); a plcd^t of cotton saluruteil with hM water
L ajmI |4acinK ^ K-^"''^ Umpon axainsi tl>e cervix.

Fia. 4i«.— DcrtxTHK) Titt Dunx win >
Umovii.

434 THE DTEKUS.

The Cure of the Disease. — This is accomplished by the removal of ibe
diseased endometrium with a sharp curet. The operation is known as DiltUa-
tion and CuretmetU of the uterine cavity and its technic and after-tieatment are
fully discussed on page 955-

Special Directions . — The best time to perform the opoation is
during the intermenstrual period, when the monthly congestion of the pelvic
organs is absent.

The uterine cavity should not be packed with gauze after the operation, as it
interferes with free drainage and retains the discharges. There is never any
danger of a severe primar>' or secondary hemorrhage occurring and the sli^t
amount of bleeding which is present generally ceases within a few hours, although
sometimes the hemorrhage may be rather profuse during the operation.

The patient should remain in bed for two weeks after the operation. While
this is a longer period of time than Is required after most cases of curetment, it is,
however, necessarj-, as the congestion of the pelvic organs is greatly beitefited
by a prolonged rest in bed. In addition to the antiseptic douches that are em-
ployed in the after-treatment of curetment, vaginal injections should be gi\'en
morning, noon, and night, consisting of two gallons of hot normal salt solutioD.
These douches should be continued while the patient remains in bed, and sub-
sequently they should be used every night and morning for three or four months.

Injurious Treatment . — The common practice of treating en-
dometritis by making frequent caustic or alterative applications to the interior
of the uterus is dangerous both to the health and the life of the patient, as septic
inflammation is likely to result and produce grave tubal lesions. And, further-
more, such applications are utterly useless, as the disease involves the deep
structures of the endometrium and can only be cured by removing the infected
tissues with the curet.

Recurrence . — Sometimes the disease recurs after the operation of
curetment and the patient is annoyed by a return of the leukorrhea and other
symptoms. It may, therefore, be necessary to repeat the operation once or
oflener as the case may be.

CONSTITUTIONAl, ENDOMETRITIS.

Definition. — A non-specific inflammation of the corporeal endometrium

that is iilways subacute or chronic in character and which is primarily due to
constitutional causes.

Pathology. — The disease presents itself in two varieties — glandtUar and in-
lentilidl endometritis. The endometrium seldom becomes bjpertrophied and
the fungoid or polypoid outgrowths which are a frequent complication in the
congestive variety rarely occur in (he constitutional form of the disease.

Causes. — The disease is due lo constitutional conditions which cause a
hypersecretion iif llie glands of the uterine cavity.
The chief causes arc:

Tuberculosis. Rheumatism.

.Anemia. Chloremia.

Scrofula. Lithemia,

Gout. Chlorosis.

Symptoms. — The disease is subacute from the beginning; its onset is ven-
gradual; and patients cannot remember the exact time of the appearance of the
leukorrhea.

The symptoms of the disease are caused by the pathologic changes in the
endometrium, and, unlike the congestive form, there are no local lesions or

coNsnnrnoNAL endouciutis.

4as

npltcaljons pmducint; a Mparatc group of [Klvic s)'mploins which cither mask
' churiKc the uttrine si^nn of tibeasc.
The (ulldwing »n the diicf kymjitumx:
Ltrukonhni.

Hcny^nhxge; MenNtniiil tlLsturliances.
Pain.

Sterility and abortion,
(icncral *>in|(tomfi.
Leukorrhea.— Letikorrhca is the only constant smptom. The discharRe
if thin .itmI M-niu.-i in tharactor ami in yome iil^e:^ it is vtry |ir<i(iise. It i> wilhuul
odor ami non- irritating. At lung<iid and |Ki|yiH>id oiilgmnih^ iirr rarely piT>enl
lhL^ variety of cmlometritis. the <lischargc is wtdom purulent in charattcr or
IJxcd with ItliKxI. When the patient in uncleanly in her hat)il» and the leu-
nrrhca is profuse, the di»^-irgc may become decompnwd and haw an olTcnsive
rlL As n rule, ihe cerrical mucoMi is also in^xilved and the sccnrtions from the
of ihr (crvix a» well m i\wm: from the tiigina Iwrome mixed with the
il disch^rjEe. The Irukorrliea is increased in amount for two or three
cfore nwi after the mea-tnivil tlow. arnl it U usually profuse in the glandu-
pcty of en<iomi'trilis iir when the endometrium i^ liyjicrlriiphicii.

rbage; Henstrual Disturbances. --These symptoms are rare,
tjon may Xx' ,i< lomgianicd liy juin wUvii the endomelritis is cauned by
pml or rheumatism.

Pain.— This symptom b Kldom present, ^\^lcn, however, the pathologic
chtngdi in the endometrium are m.irkeil th<!re may be occipital or vertical heiul-
r, and |»in may be fell in ihc hypogastric, the inguinal, ur the lumlxi»ttcr»l
«>n.

Stcrilhy and Abortion.' -.\s the structural changes in the endometrium are

to profiount-ed a.* in the conRcsiive vMricty. there is, consequently, less icn-

' to Meriltty and .-ilKirtiim. On tlie other haml, however, conieption may Ite

Bled by the ciin^titulional conditions cauMng the cmlnmetritTs. and shoulil

iDcy occtir it may be iiilerrupied by the depraved stale of the patient's

eoeral health.

G«oera] Symptoms. — The character and the se^trity of the general symp-

ami de]iend usually u|>o« the nature of the cunsiiiulional disorder. If ihe

irge is wry j>rt)f«,»c. which i^ nol ihc rule, it may .nlfl tu ihc alrcjidy cxtMing

rain upon the patient's &>-steai, and thus iaacasc the ill effects of the general

Diagnosis.— The diagnoefe is made as follows:
Till- history.
The symptoms.

The local and general ph)-sical signs.
Till- microscopic examiiuilion.
The History.— The hiMorj- of ihc patient t>oini» lo n comtituiional di»ea*e
ilch is a recognised cause of this variety of cndomelrili". The age of the
lient, the fact of bcr being married or single, and bcr child-bearing history
no Ixaring u|w)n the <liagno»i», except w fur a> these condition-t; may enter
the etiology of the ainstitutional affection.
Tbe Symptoms. — Leukorrhea is tiw only constant symptom. It is usually
or »cTou* in character ond may at limp* Iw thick or vL-wcirl, although il b
lure purulent or mixed with bk>od. Hemorrhages, mcnsirual disturbances,
n arc usually absent, .ind the general >ymploms are clearly traceable to i
:utintuil cause. The local )»ehic symplom* which are diK lo the cjiuutive
and cemplicalions in congestive endometritis are entirely wanting.

ite

Itn

43b THE DTERUS.

The Local and General Physical Signs. — L o c a 1 . — The patient is eiam-
ined in the dorsal position. Vaginal touch and recto-abdominal and vagino-
abdominal palpation show no appreciable change in the uterus unless the en-
dometrium is the seat of polypoid or fungoid outgrowths, in which case the shape
of the organ is rounder than normal, the cervix somewhat patulous, and the
corporeal and cervical parenchyma more or less softened. These patholc^c
changes in the mucosa are very rare in the constitutional variety and can hardly
be considered of any diagnostic value. The pebic examination should be
thomuRh so as to exclude all the lesions that may cause the congestive form of the
disease. It should also be borne in mind that an en-
dometritis may be both congestive and constitu-
tional in origin and that a local lesion may be
associiited with a systemic disorder. This fact has
an important bearing upon the treatment of these
cases, and a cure cannot be accomplished until all
the causes of the uterine inflammation are removed.

After completing the examination by touch a speculum is introduced into
the vagina and ihe discharge is .seen escaping from the external os uteri. The
character of the dischat^c and the changes in its appearance caused by mixii^
with the secretions from the cervical canal and the vagina have already been
referred to under congestive endometritis (p. 410).

General.— The local examination excludes the causes of congestire
endometritis, and a aireful investigation of all the organs of the body will usually
reveal the nature of the constitutional origin of the uterine inflammation.

The Microscopic Ezamination.—lf the uterine ca\-ity is cureted to
cure the disease the scrapings should be collected and sent to a pathologist for
examination (see p. 38),

Prognosis. — The disease rarely causes pelvic complications unless im-
proper local treatment is employed. (See congestive endometritis, p. 41!.}
The prognosis depends u|)on the curablencss of the causative constitutional
disease and the character of the uterine treatment.

Treatment. — The treatment is divided into:
The removal of the cause.
The cure of the disease.

The Removal of the Cause.— In the constitutional \-ariety of the disease
we must not lose sight of the fact that the general condition of the patient is
jjrimarily responsible for the pathologic changes in the endometrium, and hence
our first effort must be directed toward correcting those vices of constitution to
which we ha\e referred in discussing the etiologj- of the disease, as it would be
useless to attempt a cure by means of lc^cal treatment until this is accomplished.
If, however, after the patient's general health has been restored the discharge still
continues, it is an indication that the changes in the endometrium have become
])t'rm:incnt ;inH that the removal of the uterine mucosa by means of the curet is
ret|iiired to effect a cure.

The Cure of the Disease. — This is accomplished by the operation of Dila-
liilioii and Cnrelmcnl of the uterine cavity.

Recurrence.— Sometimes the disease recurs after the curetment and it
ma>- be necessary to re])eat the operation.

coKuxRiitAL KKutuieruns.

437

GONORRHKAl. ENDOMBTRtTIS.

Definition.— A ^jwcifK ioilammalion of ihc riir|>ureal endometrium
aiu->r<! \i\ ilir K'lncMiHfu^ of NeiK'cr.

CaUKS. 'ITw disease ainaj-s br^n§ in ihc ccnix, cither as a primary or b
iiioniiiiry infet'lion. The fonner mcihMl of in\':asion L-> more frc(iui-ni tluin ihe
biUf. anil n lauMxl by Ihr direct infcdinn (>f the inlnrcrvital mutusa by ilte
jirnU tumin); in c»nLi« with the external <» uteri. The allctiion, however,
m^iy lie >ci'<)ra]ary ai limts tu » tcoiwrrheal inihrnmation in ximc other part of
the p^^iull tract, and a& the v^K'no i» Ibe least likely vituaiion for u ^imific
infnrion oMiitK "> 'he resistant (>owcr *if the I'lpiud ejiithelium iijtnlnM tlw in-
i:ini-<n t>f )Kitb(>)ienii* mii'ro orKiiniNiiL-', il n;ttumlty fi>[li>H> ih,-il the rcrA*i(al ranal
mj) fifiucnily cscnpe when ihc ureihr.i and the iiiKii arc primarily itiuilved.
I In itic iithrr haml. however, the vai!i'u niuy !»■ primafily i)r M't^iidiirilr in-
volved, awl. if it fw;ii[>e* ;iliciKcihcr, the infe^'iioh may lie carricrf from the
external <'r)pinfi to the (>s uteri cither by the peni^ or the |in(;er% of the imtieni.

>\1)ilr 1 (ulty lielieve In the tlicory of a latent K^tonhea in the male at limes
cauMRK a s|>c(ili<: emlometritiH year- after the 0rigin.1l attack, vt-l I lunnot i\i\i-
srrilM; 10 the assertions made by Noefigerath and Tail a* to tlie fre«)ucnrj- <>( lhif>
taUK i>f infntton, [<ir the reaM)n that tlwy are not l)orac out b)* llie fact!^. The
mi«» whkh arc l^ruught fonmnl to uphold thhi the«>r>- ^ow, in many instances,
^that post inieri>eral infettii'n and not gonorrhea was the tause of the (lelvic
n. It iv aWi fre()Uent1y im|KiMible in chronic tutul diMMse to <ktemiine the
nature "( ihc inledifin. as jttinorrJieal endomelriti- i^ usually iiubncutc or chronic

i)uini(li-r from the lieitiniiinj!. and often attacks a uomiin and apjiarenlly
■MiKtri away without the patient beinc nw^re of any kkcal trouble. Furthermore
Jn many case> of Konorriieal salpin^iiti-' the i^nococxJ are not foutid nhen the
jRlentn of the tulien are examined; and, finiilly, how nre we to e:i|>lain the fact
•t such a viLst immltcr of m-tiriagc); arc followed by conception? Surely, if
flfacac uuthoritie% are correct in their vievrs sterility should Iw the rule and

, (be exceirtion, us gunorrhcii is. to »ky the laul, a v^iy rommun disease in

J>toni8. — ^Thc ili^eahT may henrrtreorf/rrtfitfV. As a rule, however, it
Blc or ihronic from the licginnin);. but in exceptional rases it starts
iriilrly wiili w'll markwl local an<! He"<^'""l symplonis. As the dw-u?* results
Ifrom the e\irn>»i>n of an intlammaiion in the intraieivii-:)! mu(.lI^;l, the *ymp-
||om« of jfulc or (hMnic endoccrvicitis are alwavs ussncbtc^l with it.

In the rhronit jorm tlie onset of the disease is fienerally so insidious that the

palirnl is not even aware of its pa-x-ncv. anil the >ymj)tom^ are idenlinil with

[thinkr rauscil by the simple forms of enilonvetrilis (fi?»ijteiir:r and cointitulionai)

rucpt that eventually (he infection extends lu the ovtilucts and signs nf tubal

Itwatc promt tbemM-iven.

When llie disease Itcxins aeuleiy, il Is ushered in by a chill firllowed by an
clcvatnl tcm|wmiurc ami n rapiil put>*. Tlie inttent complains of severe |>clvi<
*n; ruitsea ami vomitin);; iliarrhea; aral rectal or vcngiI tenesmus, ami in
rDwrseof fl few hours a mui-ous dis<'lvurf;e ajijicars which rapidly lietomc*
ent in character Jiivl OK^sionaily mi^ol with blood. The temjiemturc i*
derate and the ihilt is not severe. allhouRh il may Iw re|x'atcl 'cvcr.il
Tif Ihe <li)>cii»e evieixls to the oviducts symptom.> of acute >ulpiii;!iii> and
local {>rntonili)> intervene, otherwise the actile manifestations trradualb lictome
ficM prtHnnimvd, anil in the counie of a tcvi days tlic aficctjon piis^e into the
ibnctite or rhnmlc Pta)cc.

4j8 the uterus.

Diagnosis.— The diagnosis is made as follows:
The history-.
The symptoms.
The physical signs.
The microscopic examination.

The History. — The historj- of the patient may at times aid in making the
diafi^o^^is. The woman may possibly admit having had a suspicious intercoune
which was followed by a mui-upunilent discharge from the vagina or by an in-
crease in the amount or a change in the character of a leukorrhea that bad existed
previously. The history of an acute urethritis k stror^ presumptive evidence of
gonorrhea, and the same is true of an acute endometritis not caused by scp^
and of an acute attack of vulvitis when one or both of the vulvovaginal glands are
involved. Sometimes it is possible to trace a gonorrheal infection occurring in a
man to an apparently innocent discharge in a woman, and thus establish the
nature of the leukorrhea. Unfortunately, however, as has been already stated,
the onset of the disease is generally so insidious and its symptoms so chronic in
character from the beginning that little or nothing can be elicited from the bistoij'
of the [wticnt pointing to the prob;i.ble nature of the affection.

The Symptoms. — In the subacute or chronic form the symptoms are of do
importance from a diagnostic standjioinl, as they are identical with those caused
by the simple forms of endometritis, unless the infection has extended to the
oviducts and the subjective signs of salpingitis and localized pelvic pieritonitis
are present. Under these conditions we may suspect gonorrhea in a woman who
has not borne children and who gives no history of a possible septic infection of
the uterine caWty as the result of intrauterine treatment, the introduction of the
uterine sound, or an operation upon the uterus. In the acute form of the dis-
ease, however, the local and general symptoms are sudden in their unset and
always well ma rke<], and unless some cause for septic infection is discovered by the
histnrv to account for the irouljle, it is safe to assume the existence of a gonor*
rhe;il inflammation.

The Physical Signs. — These arc studied by («) touch and (b) sight. It is
imjjortant to instruct the patient not to use a vaginal injection or to empty the
bladder Iteforc presenting herself for examination, otherwise the discharges from
the various parts of the pen i to -urinary tract will have been removed and a
sul)sequent appf)intmcnl made neces.saT^'.

Touch . — The patient is ])iaced in the dorsal position and the examination
made by vaginal touch combined with recto -abdominal and vagino-abdominal
palpation.

In the acute form the uterus is found to be enlarged, somewhat softened, and
very lender In ijic touch. The cervix is swollen, and its canal is more or less
patulous and a <ir(umscril>cd area of erosion is often felt surrounding the external
oi- uteri. If the infection has extended to the oviducts, bimanual palpation
will evoke severe p;nn and j)ossibly also reveal some enlargement in their size.

In the chronic form of the disease there are usually no appreciable changes in
the uterus unless the endometrium has become greatly hypertrophied or it b the
scat of funj;oi(i or [xilvpoid outgrowths. Under these conditions the uterus is
rounder than normal, the corporeal and cervical parenchyma is somewhat soft-
ened, and the canal of the cervix is more or less dilated. All of the pebic organs
should be carefully jKilpated si) as to e.xclude or confirm the existence of tubal
disease resulting; from the extension of the infection in the endometrium. The
presence of tubal involvemerit jKiinls to gonorrhea as the origin of the endome-
tritis only in cases in which ii occurs in women who have not borne children and
who give no history of septic infection.

CONOBUHEAL EKDOUKtlUTrS.

439

S i K h I . — 'rtie cxicrnol and inlemal rirgsns arc examined l>y djrcd and
lirett in>pecrion. The cxiimiiiaiion must he iv^icmalkaHy cuwliiclcil and
«»p>UKh. «ihenvi-« mitny im|K>n;inl ^rniiloms arc likely to Iw overt wkcH.
'Pirrc i:^ niHlting ihaniclerihiic in the appearance ot the dii^chai^e Ihal will
ililc us lu di^tin^uiah it [rum a leukurrhca <;au.4eil tn' eunditinns nther t)un
DDiirrhca. On the other hand, hon-ever, the rocxiMence of inHummniion in
irtii of the fccnito-urinan- Iracl that arc seldom involvol except by ^jKrific
■fcctioi) would ^iron^ly |>oini to a ttonorrbeal origin of the uicrine diM'hargc.
"he [iri-ycnie. ihereforc. of >i)Cii.->of inllammalionin theurclhr.i: in Skene'<^ )!li»K^
ur tiretlinil ducti^: or in the ^iiluivagin^d gl;ind^ is -ttiong prcsumjiliw evidence
' IConorrhea.
Aller the wtenul organ* han" been in*)wctcd a speculum b introduced and
VQgiM carefully cKimined for signs of chronic inllammalion. In cases ol
nl endcMnetriiiA it U ni>t uncimmon lo find circum>cribcd areas of in^
immation on the [Histertor vaginal vault which are clue to secondary infer-
frum the uterus and arc iinponanl evidence of tlie nature of the uterine
ts«.

In the (Jirmiic form ihc cervix is usually normal in appcaranoe and a mucous

a mu(ii[Mirulcnt di:^harse is seen escaping from the n» uteri. Jn the aailc

riety, Imnreirf, the vcrrix is swollt-n and <;ring(Tstcd and the <>* is surrounded

a (iroimstrilxil area of erosion. The discharpc is generally profuse and

nilent in ihiir.nier.

The Uicroscopic Examination.— The only positive endcnce of the disease

(he presence of gonocucci in the tissues o( the infected endometrium or in tlw

iiirgcs. If, itow^wr, the niii7iiM'0|tic examination yields a ncgatiw result.

nnnot Niy that the iliscast- i> non st>eci()c, and, consequently, we must, if the

c b a susj>icious one. rel}' ujKin the clini<:al liUlon' and (he jihysii'al >ii(iu In

tcrminc the n:iiure of the iinc<li»n. Hut ev^n then it is often impossible to

111 a prohaUe conclusion, as the insidious onset iii the disease and (he

if si^ns of infection in the urethra and in other suspicious parts of Ihc

,ct may render any opinion utterly worthless. Tlie gonoiocd may

from U»c dischaifws and rcm^iin indefinitely in the tissues of the en-

, or they nuiy vitni''h entiri^ly and ihuv rcmoiT all pitive ciidence ol

ture of tile <li»eu^e, 'ITiis fad i^^ ncll illusiraied tt) ihc sicrile diarader

the |ius in law.-* of p<,-ns:dpitix of uivloutili^I K""""lieal ortKin, Aipiin. we

loulij mncmber that ihc Kononnti U-iome more niimcniu> and active during

icri'-tntJition, and alu> just l>cfi>re ami immediately after the period, than al any

:hcr time, arwl for tliU rea.son the itisdiargei tthuuhl l>c examined »oon after ihe

mihly (tow <m«(S.

.\s dilatation and airctmctit of the uterine cavity arc ihc irealmem of f^nor-

lleal endoniriritU, and shoulrl lie iterformcd al oniv whenever iconococci are

mil in the 'liMliarKcs or there i* a >uspicion of the inllamm^tion l>eing specific,

is. th.Trfnre, unneiessar^' to cure! the uicru^ tor ihe sole pur)Hise of dta);no»ls,

II I>e Mivecl ul the time of the u[>eration anl »ent to a patbol-

.■iti,

IHffcrcntiai Diagnosis.—The acute form of the disease may tie

■Oakro (<>r .I'rifc "-fli/ fndamfirilit In the Litter affection, hnwrwr, ihe

n»litutionjl aint locnl "vmirtoms arc usually more se»'ere: the hislor>' show* a

a*v fur the scpsU which may he po»ipuer|wrsl in origin, <>r it may follow

ulrrinc trcittment nr an ojicnition: the urethra, the glands of Skene, and the

.gtrui gUitds are not involved; anit, rin;tlly, gonococciareabtcnt from the

In acute gonorrheal cndotni-trittt, on the other hand, there i» no

ol M-pllc hifettion, hut there may be of a suspieious sexual intercounc;

43© THE UTESCS.

ihere is usually coexUtinR inllammation in other parts of the genito-urinai}' iratt;

iiiwl K"n"i<><-ii mu\' t>e present in the discharges.

The chronic variety uf ihe disejise may ht mistaken for:
Congestive endometritis.
Chronk- septic endometritis.

The lesioas discussed in the differential diagnosis of congestive en-
dometritis on puge 4^1.

It is impossible at times to distinguish between the various forms of chronic
endometritis with any degree of certainty. The gonorrheal origin of the disease
mav l>e suspected from tlic liistorv of the case and from the coexistence of chronic
inflammation in other jjarts of the genito-urinar)- tract. The presence of tubal
disease excludes in all jirobabiiity the congestive \-aricly but not the septic, and
if gonococci are found in the discharges or in the tissues of the endometrium the
diagnosis is ]x»sitivc, but their absence is of little or no importance from a diag-
nostic standpoint.

In the congestive variety the onset of the disease is nearly always insidious
and there is no history of septic or s|)ecific infection. The uterine appendages, as
a rule, show no signs of disease, there are no coexisting foci of inflammation in
other fjaris of the geni to -urinary- tract, and the physical examination generally
reveals a cause for the congestion.

Septic endometritis presents a history of post -puerperal infection or of in-
flammation following intrauierine treatment or operation. Tubal disca-se b
frequently present, but tliere is no involvement of the urethra, the glands uf
Skene, or tlie vulvovaginal glands.

Prognosis. — The disease is actively dangerous to life and health on
account of the frequency with which it invoh'es the oviducts and the peritoneum.
The prognosis is influenced by the promptness and thoroughness of the Itwal
treatment, and the e.Ment lo wiiich the j>eriuterine structures are involved [ozi-
diicti anil peritoneum). The disease may cause death in a short time or it may
prixluce chronic tubal legions and necessitate the removal of the uterine ap-
pendages to restore ihe |iaiienl lo health. Gonorrhea! endometritis is one
of the most frequent causes of slcriliiy in newly married women, and ihe
disease often results from a latent gonorrhea in the husband which attacks the
wife SCI insidiously that ihe only ajiprecialile symptoms arc sterility and a
slight leukorrhea.

The uterine paa'nchynia is never tlie seat of absccs-ses or sloughing in this
variety of endometritis.

Treatment. —The disease liegins as a local condition and the treatment
mu<t Ik' directed to the endometrium. Grave pelvic complications can only be
jirevcnted hy prompt and efl'cctive action, which reduces to a minimum the
chances of the infection exteniling to the oviducts.

Tills is arcum|)lislied by Dihilalioii and Ciirelment of the cervical canal and
the uterine cavity. The tecbnic and after-treatment of the ojjeration are fully
discussed on page Q55. The o])cratiiin removes the diseased and infected mu-
cous membrane and at the same lime destroys the specific micro-organisms and
prevenI^ the further spread of the inflammation,

Curetnient must lie ]H.Tformcd at once if (he endometrium Ijecomes infected
during llic cniirse !if an acute attack of gonorrhea, and no time should lie lost,
under ihe^' circumstances, in lem])ori/.ing or employing so-called conser\-alive
jihins cif treatment. The same indications for treatment are present in subacute
or cbninir cases in whicli the disease has existeil for ^Jime time Ijcfore the patient
seeks ndvice. When the oviducts are involve<l. either in acute or chronic cises.
the Irealmcnt is neccs.sarily somewhat m<nlified or altered to meet existing com-

SEPTIC ENOOUETRJTIS.

43*

IB. If the chanicter of the lutnl loiom miuires ihc remowl of the

ttterinc npiiciwljii^t^, ilw uterus should be turcietl imravdbicly before pcTfurming

Lhf .lUJoittiTuI H.-!, lion, unlcvi ihc mubiliiy >•! lti<- |>clvii, urK-m^ U »<■ rriirutcil by

hcsii>n^ lh;it ihc operation cannot be done, in which rare ihe curclmciU iJioukI

|H»t(ii>nc(l until after the ;)atiL-nt recovers {n>m Ihe y;n\Tr operation.

^ecUl Directioas.— TIr- \iv^ time to perform rurctmcnt in the Hibncuie

chrunii. cusc» i^ during; the ititcrniensimal perio<t.

After tJic ulcniK in €urel»l aiv! flushed wi|]t ii Mihilion u( rorrosive sublimate
le uterine c3\ity is thonmghly ^^wablicd with pure carbolic acid to cumplciely
iit-iir«>y the mii rc> orKanism> and |>fie«nt reinfection.

The piilient should remain in l>cd (i)r one wx'ek iiftcr the ojwriiiion.
Recorrence.— Sometimes the operation is followed by a recurrence n( the
dMra^, iind it will then^fore iie nectrwiiry t*i rejicul the luretmcnt. When this
^hitppcns. the curct I'indings and the diKihurge should aifflin W vxuniineil micm-
|Bb]|)ically.

^H SBPTIC ENDOMBTRmS.

^B IDcfinition. — An inlbmmation uf the endometrium due to septic micro-
^Br^nL>'m>. c<p«ciully the staph vhfKran .ind the streffotorcus ; llie btlcr b
^Tieldimi |ire>eni t\tq>i in puer^ieral cases.

Cfttises.— The diNoaNC is due to the in%'a»ionnf the corporeal endometrium

py sieplii miiro-orsanisms, and, as the niwmid uterine Cii\iiy i-ont.iinH mi iK-rnt-, il

tUiu'H thjl H'hen infection oicurs the |uih<>li'):ic Itaiieria are intn)duccil into the

erut. In the v;tM majurily of ca^e^ the diMM>e is prevenuble. and is eitlier

ic u> ignorance or iwgleci ugton the part of the vitcnding phy.-viuan or iIm ro

lit o( a criminal abortion.

The (olldwing arc tlte chief cauBc»:

Infection following blxff or aljortion.
Intrauterine office treatment.
The use of the uterine sound.
Dirty ojjeralioicv.
SJouphinj; uterine tumor*.
InfKtton following Labor or Abortion.— Post -puerperal infection is i)i«
frcquenl liiu^e il the ■Iimmm'. n•>t\vi1ll^tand[n]c the brillbnt results achieved
modem midwifcrj*. In well tonduclc^i matemiCy hl>^pitllU and amonit the
cluses the obsletriiiin ohl.iins a icry low percentage of infeclinn-. but in
working cla»«« o|)[Hi!<ile miulitions prevail, and il !& often impossible even
h the greatest care to avoid pi>st-pucr|>eTnl ?«(»?»».

Frc(|urni vaKind exuminiitions during lalxir. the unnecessary use of the

rce^Rt, methJleMtme mani)>ulaliorLH liurtng llie second stafie, the introdudioii of

han») into the uterus to detach the placentn, and the routine u»c vf vagiiuil

ihe* arc i>flen the cuu.-u; of sepiif endometritis, and should therefore be

iitiilnl. Infeititin may aW> rcfiull from inimeili;ile operations for the rejiair of

rntnl i-iT\i)c and from canning pathogenic miciv-organujns from tlie

Iting lidili- til ihe Kit of n woman in labor.

Septic cniionw-trilis following simniniwou* and criminal aUmions is so

uent ilut ev*ry pnutitioner has had more or less experience with thi» class

ciM». The gnat 'bnger in a s[x>niane>iu.4 aliortiun is tlut it mav not lie cnm-

artcl that the retained membranes may infect the uterine cavity. This is

a «>mm<)n ^implication in cases of induced 3bi>rtion. bimI there i* aUo the

jldanceriif infrclioii (XTurringat the lime the operation is performed.

Intmuterine Office Treatment. —The )>racticie anM)ng M>me pht-^irians

nuking local applications to tlte endometrium at thctr offices or at the palient't

432 THE UTERUS.

home h dnngernus both to health and life, and septic infection is eventually
certain to rciiult. Not only are alterative and sedative applications injurious,
but thcj- are also utterly useless as therapeutic measures, ajid should thenfore
never be employed.

The Use of the Uterine Sotmd. — The uterine sound should never be em-
ployed unless the patient is under the influence of an anesthetic and the vagina
thoroughly sterilize* 1 (see p. 307).

The instrument has been responsible in the past for the death of a large number
of women when it was generally empbved in the diagnosis of uterine diseases
and used by the gvnecologist ut his office without proper antiseptic precautions.

Dirty Operations.— Septic endometritis often results from the use of dirty
■[nstnimcnts in performing operations upon the cervix or within the uterine
cavity, and also from a general want of care in the antiseptic management of the
after-treatment. The danger of pelvic complications following infection of the
uterine mucosa musi, therefore, always be borne in mind, otherwise the operator
may look upon minor o[>eralions as being of but little importance surgically,
and infect his patient.

Sloughing Uterine Tumors. — Sometimes sloughing may occur in a uterine
polypus or in the inverted portion of the uterus in cases of inversion, and unles
prompt o]>enUive measures are adopted a grave form of septic endometritis is
likely to resuh which may be quickly followed by tubal involvement.

Symptoms. — The disease may be either aciile or chronic in character.
Usually, however, it begins acutely and subsequently passes into the chronic
sla^e.

From a clinical siand)x)int seplUcmia Ls dirided into two forms: (a) Septic
intoxication, sapremia or jiutrid intoxication, which is catised by the absorption
intii the blcMwl of piomains tliai are the alLiloidal products of putrefaction or the
toxins of the bitctcria that are present; and (&) septic infection or true septi-
cemia, whicli is caused by the absorption of bacteria into the blood, where they
mtilliplv Ri])itllv and priKiuce constitutional symptoms; tosins are also present.
The dilTiTCTKt', therefore. iKtwcen sapremia and septicemia is that in the former
the blood only contains loxins, while in the latter both bacteria and toxins are
prc-cni.

Acute Variety. ^S eptic Intoxication .^Thc gravity of the symp-
tomr; di'(>cnds u|)i>n the dose of the (loi^in absorbed into the blood. The toxins
do not increase in quantitv after they enter the blood, and consequently the
amount ab>orlied from time to time depends u|x>n the condition of the putrefy-
ing areas, which is alwa>s more or less modified by loud treatment.

The symptoms usually manifest themselves within
twenty -four or forty -eight hours after labor or
after an intrauterine operation. They are ushered in by a
severe chill, which is followcii by a high tcmi>erature and a rapid pulse. In
:i tew hmirs the lochia] discharge is diminished in quantity or temporarily sup-
pressed; but it returns again in a short time and is very dark in color, purulent
in character, and lias a very offensive, putrid odor. The patient suffers almost
frnni the beginning with intermittent utcruic pains which soon becxime con-
tinuous and vtTv acute. .\s ihc di.'^casc advani-cs all the symptoms become
exagizeraled. The chiils recur irregularly, the temperature is very high, often
reaching 104^ to 105" ¥., the pulse is weak and rapid, the urine is suppressed or
diminished in quant itv, diarrhea sets in, and if the case passes from bad to worse
^ymptllm^ of the typlmid stale develop and the jiatient gradually grows weaker
until death finally ensues.

The chills are \cry irregular in their recurrence; they may occur several

SEPnC ENDOMF-TRmS.

times in the course of twenty-four bnun, or they may be entirety absent after the
initial rifjor; or. again, they may recur two or three liine.^ during ihe progreKt
of ttic diwasc. The tcm|icr:iUirL- Iwiomc-i. vltv hiKh imiTi<xltiilt-ly after each
chill, and it may cither remain elcratcr] with slighl remission.', or it may drop
several dcRrees in the course of a few hours. There i* nothing charjiicrisiic
in the (ei-er curve cxcejit il> irregular n;mi«ion» and it.* tendency to remain
dcvated. As a rule, the temperature reaches a very high cle\-aiiQD immediately
before (leath takes place.

Septic Infection . — The gravity of the diiwasc and Ihe wrerily of the
symptoms depend upon (he extent and the rapidity with which llie bacteria
increase in the l)loo<l.

The wympiom^ usually manifest themselves in
from four days to one week after labor or after an
intrauterine operation. The discuse K-Kins. as n rule, with fever
and a rapid pulse. Sometime* the on<<et i* marked by a chill, but usually
it is absent or il may occur later in the coujrsc of the infection. The puise is not
rapid in the l)e;{inninf;. l)Ul as tlie disease pronres-NCs it ifradiiallj' increases in
frequency and c\-entiJ.illy become* wry compnc^siblc am! weak. .\s a rule, the
elevation of the temperature is not marked at fir^t. but if the disease continues
unchecked it may iinally become very high. It often Jiows an evening exacer-
bation and u moniing remiK<.ion, but generally the (ever curve is irregular and
uncertain. As the disease advances gasiro- intestinal disturbances present tliem-
selves and (he patient suiters with vomiting and di^irrhea. Profound exhaustion
cbaractemcs the alTcrtiim. If ihe source "f the infection is not destR>ycd or the
poison is not eliminated from the blood, the case gradually goes from l>ad to worse,
until I'lnally >ym|Ufims of the ty]ilioid Male dtvelup an<l death lakes place.

Chronic Variety.— When the acute forni* do not end in death, the symptoms
gnidually subside and the disease eventually Incomes dironic in <hara(-lcr. The
sympti>mK do not differ vcrj- materially from ihoitc caused by the chrcinit: funnsof
simple endomeiritis^riMi£f!rn« and tonstUulumal.

The following are the diief fiymptoma:
Lcukorrhea.

Hemorrhage; Menstrual dbturbances.
Pain.

Sterility and abortion.
General symptoms.

Leukorrhea .^Tht^ >)-miitom is constant. The disch.irge L* more or
less profuse and always purulent in charaacr. indicating the presence of p)-ogenic
cocci in the uterus. Occasionally the discharge is mixed with blood which is due
to fungoid and |ioly|N>id outgniwttis which develop from the muoosii in chronic
forms of endometritis. The ^vcretion is usually odorless unless the patient is
uncleanly in her habits, when il becomes offensive from reiention and decom-
paction in tlie vagina. The inlra<'ervical mucnttii Ls, u.« a rule, uLho affected, and
the secretions fn)m the glands of the ccr\-ix as well as from the vagina become
mixed with the uterine discharge. The leukorrhea is more profuse just before
and immediately after menstruation.

Hemorrhage: Menstrual Dis'turba nccs. — Uterine hem-
orrhages are rare unless the uterus has not l>ecn entirely emptied of the products
of conception. Men.*trualion. however, in freijuently profu.^e in amount and
longer in duration than normal, owing to the pathologic alterations in the en-
dometrium.

Pain . — There is teldom any puin in the uterus itself, but the iLssociated
tubal and periuterine inflammation which so frequently results from the septic

434 THE TTTERUS.

forms of endometritis causes more or less pelvic tenderness and distress. Tbat
symptoms may be constant or they may be noticeable only when the patieiU
exerts herself. In some cases the in^mmation of the mucosa may produce reflu
vertical or occipital headache, or, again, there may be pain in the lumbosaoal,
inguinal, or hypogastric region, and in some instances the patient may com-
plain of a burning sensation behind the symphysis pubis.

Sterility and Abortion . — Sterility is very likely to result from the
septic infection in the uterus extending to the oviducts and causing a destructive
lesion that permanently obliterates them. Even if the tubes are not involved con-
ception is not likely to occur, as the pathologic changes in the endometrium are
usually of such a character that it no longer offers a suitable attachment for the
ovum. Furthermore if conception does take place abortion is likely to follow, as
the diseased mucous membrane may not be able to undergo the necessary changes
of pregnancy, and, finally, the altered character of the uterine secretions is more
or less destructive to the activity of the spermatozoa.

General Symptoms . — The general symptoms are seldom well
marked, and in some cases there is no systemic disturbance whatever, unless the
discharge becomes very profuse and exhausts the patient. Unfortunately,
however, the associated pelvic lesions frequently impair the general health and
cause debility and nervous exhaustion. These patients suffer with gastro-in-
testinal disturbances, loss of appetite, and local discomfort, and are unable, as t
rule, to perform the ordinary duties of life.

Diagnosis. — The diagnosis is made as follows:
The history.
The symptoms.
The physical signs.
The microscopic examination.

The History. — In the arule variety the history points directly to infection,
and hence the diagnosis should not l>e difficult. In the ckronte form, however, the
statements of the puticnt cannot always be relied upon and the original cause may
therefore be difficult or im|X)Ssible to determine. On the other hand, when a
patient who is suffering from a purulent discharge from the uterus gives a hision-
of pot-t-puerjieral or some other form of septic infection, it is fair to assume that
the case is one of endometritis caused by pyngenic cocci.

The Symptoms. — In the aciile variety the general and local symptoms af^
pear suddenly and ;irc associated with an ele\;Ued temperature and a high pulse-
rate. The systemic disturbances are well marked and indicate a more or less
profound gcnenil infection.

In the ilironic jorm the purulent discharge from the uterus Is the only
significant sj-miitom that is cimstanily present. Menstrual irregularities and
uterine hemorrhiijies are present in other pathologic conditions and are
therefore of no juirticular aid in making the diagnosis; the same is true of the
rctk'x p:iins and ihi' general symptoms. Local peKic pain caused by tubal or
periutc-rine lesions indicates either a sejrtic or gonorrhcul origin of the disease.

The Physical Signs. — These arc studied by {a) touch and (6) sight.

T o u r h , —The examination is made by vaginal touch combined with
abilimiinal palpation.

In the anilc variety followinfi labor at or near term the uterus and cer\*U
arc found lu he relaxed, si'fl, and llabby; the normal contraction of the organ is
absent and invulution is retarded or checked; the temperature of the parts i*
elevated; llie vajzina is moist and filled with the lochial discharge and purulent
secretions; the os uteri is patulous and there may be evidences of a recent
traumatism ; and the biKly and fundus of the uterus are enlarged and tender to

SEPTIC KNDOurruns.

43S

(oucfa on account of the septic metritiE whidi is often present. If the

bAamiTidtion hi* enlcnded to tti« oviducts, bimanual palpation will eljdl
[uin .ind iios-tjl^y fttmc mlargcmcnt. In non-purrptrai c.-i»« the uterus is
V enlnrgCTl. Mtfier than normal, and lender to the touch. The os uteri Is
i_:«>uua; the ccnU m swollen and ioh; the lemperuture of llie jiarts '» raised;
«Dd the vugina fe moist and bathed with a profuse purulent discharge. A
temnual cKamiiutiun rcveak the presence or absence of tubal in\'olveinent.

In the (hronU jorm the jthyjitcal Mgns do not dilTer from thow that are
pKicni in other varielkf^ of cndomelritis. The uterus i« slighllv enlarged', its
Dud]r is sumcwhul rounded; ibt t.un.sbtenc>' of the entire or^un l" >oficr ilun
namiBli amj the vhuim is moistened with a purulent discharjic. Elimnnual
palpaiMin does not chctt pain, as a rule, unless the uterine appendages are in-
wjl»*d.

fc^ i g h t . — In poit- puerperal cases Ibc external organs, the x'agina, and the
ut are bathed with a pumlent discharge mixed with the lochia. The os
I i» {Nitulou.^ attd the <-hnni<-terLitic !>ecreti(>n '» tten eMUping from the mouth of
tbc crrviml cannl, Oiphthcric deposits or gangrenous areas may sometimes be
teen upon the external orpins, the vagina, and the cervix. In nonpuerpernl ra^es
the cbaracteri-'tic di-idLiryc is *«en eM'aping from the to uteri and luilhing the
put* beliow. Sometimes the ceim is crndot and presents a very angry and in-
fluaed ait|)eamti'c from the constant irritatiuii produced by the alicrol secretions.
In the chromit jarm the disdurgi- is tlw imly diasmMic sign. If the leu-
korrhea is profuse ami irriialin);, the cernx may be eroded and somewhat in-
tlameil.

The HicroKOpic EzamiSBtton. — In pmt-pucrpenil septic endometritis
ihcdiAgnosisi'-an usually be made without resorting toa microscopic examination
of (be dMharpTK. But if for any reason it is desirable to know the exact nature
of the infection, such an examination should tie made; the same is true in
oon-tnwTperal uni\ chronic cases.

Dtfferentlal Diagnosis.— The amtt jorm of the disease may be mb-
•■■ goni'irrheiil indomelritis. In the latter aSeclion there b no
,1 infetlion, but (here may be of a Mis|Hciau» »exual intercoUTM;
dMn bi us-iully cncxnline inflammation in other parts of the genitourinari- tract,
nd gnnucurci may l>e fouivl in the discharges. In acute septic endometritis.
uB tbr olbrr hand, the ainstilulii-niil and looil <ymplonvs are more set-ere; the
hbtnn' shows a cause; the urethra, the glatids of Skene, and the %^vovagiilal
gbnd' are not intvlvetl, and, fiiully, sUphylococci or sireptococci or both are
fouml in the diM*hargcs.

The iktimif variay of the <lbease may be mistaken for the following lesions:
The tiimple frirm* of endometntts.
("hn>nic ^onorrheiil endometritis.

The iifie'lioiis discussed in the differential diagnosis of congestive en-

d»nieiriii< on Jiage 431.

*rhe timple forms of cndomelritis arc insidious in their origin and there is no

]tht»r> o( a remote ^iepiic infedion. 11ie uterine appendages, as a rule, are not

aflrcted and tlic truLorrhnd ilischiirge is non-|iurulent in character, whereas it is

ai««r* iwrulent in the <e|)4ic variety.

'fbr Konorrhol form of end(imelriti« can only be disiinguinhed from the septic
bv a mtfTTvirnpir examination,

Prog:no8i0.- TIh- ilisease isaclivrly dangerous to life and health on account
ol (hr lri-i|urmy with which live intlammation spreads to the oviducts and the
{■rrit'iorum, 'fht (liircncliyma of the uieruis may abo be invohed, producing
• *c|jtic metritis which b often complicated by sloughing and multiple absceaeca,

436 THE UTEECS.

and which may involve the serous coat of the organ and cause a fatal peritO'
nil is.

The prognosis depends upon the promptness and thoroughness of the local
treatment; the extent to which the inflammation has spread; and the cause
and nature of the infection. In the beginning of the attack prompt and
radical measures often succeed in limiting the disease to the endometrium and
presenting its extension to adjacent stnictures. But after the parenchyma of
the uterus or the oviducts has become involved the outlook is exceedingly grii-e.
and the life or future health of the patient is in imminent danger. Infection oc-
curring in the parturient woman is always more serious than when it occurs in the
non-puerperal state, and sterility is a common sequence of the disease.

Treatment. — The disease begins as a local condition and the treatment
must be directed to the endometrium.

The treatment of the affection is discussed under the following headii^:
Acute puerperal cases.
Acute non-puerperal cases.
Chronic cases.
Complicated cases.

Acute Puerperal Cases. — In septic cases following premature labor the
uterine cavity is irrigated three times during the first twenty-four hours with
a solution of corrosive sublimate (i to aooo), followed by hot normal salt
solution. If at the end of that time the symptoms have abated, the irrigj-
tion is continued twice a day for several days. Should, however, the symptonu
at the end of the first twenty-four hours show no marked signs of impron-
ment, the uterus must be cureted. It is often necessary to resort to curat-
ment at the start and not wait for possible results from the use of intrauteriir
douches in cases in which the constitutional symptoms are severe and indicatt
a large local area of infection or when the physician suspects that the uterine
cavity is occupied by retained material. As a general rule, possibly it is safer
to curet at once and then use the uterine douches, as there is danger of the in-
fection spreading when less radical means are employed during the first twenty-
four hours. The judgment of the attending physician
and the special symptoms which are present must
naturally determine the course to pursue in an in-
dis'idual case, and it is therefore impossible to
recommend a j>ositive rule of action.

Technic of Puerperal Curetment . — Positum of Ike Pa-
lienl. — The patient is placed cros.«wise on the bed or on a kitchen table and
her hips supjjorted on a surgical pad.

Anesllicsia. — A general anesthetic is indicated, and should always be em-
ployed except when the jwlient is weak or exhausted.

Slcrilizalion oj the Patient. — The vagina and vulva are douched with a
solution of corrosive sublimate (i to 2000), followed by hot normal salt solution,
and ihe parts dried with a gauze sjKinge.

Dreisings ixtid Sponges. — Three dozen gauze s]X)nges; a vulvar compress;
a gauiK lampon; and a T-b:indage.

Irrigaliii); Appiiniliis and Solutions. — The irrigating apparatus is des-
cribed and shown on i>age 94. The solutions consist of corrosive sublimate
{i to 2000) and normal s;ilt solution.

Instrumetitf. — (i) Simon's speculum (curved blade); (a) two bullet for-
<*ps; (3) dressing forceps; (4) large curet; (5) curet forceps; (6) scissors.

Operntian.—'the uterus is irrigated with a solution of corrosive sublimate
(i (o 2000) and its ca\'ity e3ii>lored with the index and middle fingers of the left

of mattii-il art' carefully Mrparatcd and removed with ihc finj^cn froin the ulcrine
Est-ity, Sinrnn'" *|>iMi!uni b
DOW ininxluccd iniu ihc va-
ginu diKi ibe anterior and
pcMlcfior lips of the ccr-
Wx ivuol i>y Inillrt forcciw.
Thr isiviiy t>( thr uterus is
aicain irri)CalHl nnd then ru-
rctc<l <vith thv Urge nirct und
Ihc oinri (ortcjis. Il b ihcn
llui>h«d. ibc »|ictuUim uiih-
■Iriwn, and ihc uterus agnin
n|)l>ircd with the rincert lu
dctmnine whrlbcr or nut its
raviir Ims beta rntircly
ilr;incd. U it '» (<>und tluit
any U>rr^ nuirrial rrmains,
the i-urrltnt; iiisirunM'ni.'i are
axai'i rini>lnyc(l. and the
irtpru> fiiudly irriisiied with
It tulutiun "f i<im)>ive
r innate (I lo looo). !■>)-
loti^ by a tjiiart of Ikii
nomial mII Mtluiinn. 'Pu-
vagina n then dried wilb
Xauac rponices and the \'ul^'ft
|MuUclol uilli a Kiiuzc turn-
]■■'■ ' '' in |MM.itinn l>y a
T

Adcr-trealmenl .— A» the uterine otrliy fct not packed with giiue

Fin, «i).--Cn*imniri ea xm I'lmt po* Acvn Simr tm-

v<mtntm.
SbuiMic lit iiiml •( nuiatd (jumtl limm lAk Ac IttJn-

43S THE tJTERtrS.

after the curetment the drainage is free and unobstructed, consequently fuithtr
attention to the utenis is unnecessary' unless the subsequent symptoms indicate
a continuation or return of the septic process. The vagina is irrigated twice a day
with a solution of corrosive sublimate (i to aooo), followed by hot normal sah
solution ; the irrigation is continued for one vretk and then stopped if the ooDdi-
tion of the patient is normal.

If the temperature or pulse keep up after the operation, the uterine caiitT
should be irrigated once or twice a day, and in some cases it may be neccssaiy
to repeat the curetment a second or third time.

Septic endometritis following an abortion during the first half of pregDancy
is treated by dilatation and curetment of the uterus, as described on page 955.

Acute Non-puerperal Cases. — These cases are treated by dilatation ud
curetment of the uterus {seep. 955)-

Chronic Cases. — The treatment is dilatation and curetment of the uteras
(see p. 95 s).

Complicated Cases. — These cases include those in which the infection has
extended beyond the endometrium and involves the uterine parenchyma, the
periuterine tissues, or the oviducts.

I have never met an uncomplicated case of suppurative mfiammation of
the uterine parenchyma following labor, cither upon the operating table or at
a postmortem examination, and those which I have seen were associated with pus
accumulations in the uterine appendages or in the connective tissues of the pelvis.
The reason for this is probably due to the fact that the septic infection exteixh
to the periuterine structures before the necessity for operative interference is ap-
preciated or death takes place. It is impossible to determint
positively in an individual case whether or not the
parenchyma is the seat of infection, and our only
guide is the result of local treatment. Thus, if a case goes
from bad to worse after repealed curetments and flushings, we are justified in
believing that the parenchyma is invol\-ed unless a gross lesion of the ap-
pendages or the periuterine tissues is discovered. I admit, as a matter of course,
the extreme uncertainty of the e.xistcnce of an uncomplicated septic infection of
the parenchyma of the uterus; yet we must all recognize the fact that whoi the
endometrium is the seat of an acute disease the tissues beneath the mucosa
must sixjner or liilcr become involved unless the morbid process is arrested.
When the jiarenchyma L"; the seat of septic infection or of multiple ab-
scesses, abdominal hysterectomy is indicated. We must, however, be
fully juslificd in our opinion that the infection has involved the mus-
cular wall of the uterus before resorting to the operation, as a mistake
in the diagnosis will not only result in the unnecessarj' removal of an
imiwrlunt organ, but it will also lessen the chances of recowry. It often
requires, therefore, the greatest diagnostic skill and judgment on the part of a
surgeon to know precisely what to advise. Again, it is often best to post-
pone the operalion until the jiatient's condition improves and warrants the resort
to operative interference. If the |> a 1 1 e n t is in a condition of
profound septic prostration, with a high tempera-
ture and a feeble and rapid pulse, she has a much
better chance of ultimate recovery by deferring the
operation until she is able to stand the shock of a
grave procedure like a hysterectomy. This is espe-
cially irue if the disease has lasted for several
days, because it shows that the absorption of septic
material into the system is slow and that nature is

SENILE EM>OUR'UTIS.

439

endeavoring lo shut off the urea o( infection, and
any ialerference involving tbe slightest shock might
weigh the balance in favor of death and rob the pa-
tient of her only chance of recovery. When the broad
ligMnentA .ire in\'ol\'c<l and abscess formations occur, the pus should be c>'acu-
Ucd thmtigh the ^ault of the vagiiui. Tliis i^ a much tafer route than
tbe abdominal, under tlte drcunutanoes. as the patient is not usually in a
oottdition during the pueqwrium to stand the shock of a radical operation, which
may be jicrformed later if required.

It i» c»lremely dilBcuh, if not impossible, to recognize septic changes in the
oviducts before ihc disease has developed Miffideotly to cuu»e an cnlurgemcnt, nnd
uoder the>e circum-viiincet, therefore, the indications for their removal are not
dear. When a gross lesion develops in one or both of the Fallopian tubes during
tbe puerperium. a careful examination should be made of the [ntient's general
cDDilition and the »amc principles applied which govern the treatment of an
infrnion involving the uterine parenchjina.

SitNILB BNDOMBTRJXa.

Definition. — An atrophic form of cmlomctriiis nccurrinf; in old women
that u churactcnied by a thin [>iirutcnt iHschnrge which b often stained with
bbxHl .in'i h cxrt-eiiini;!\ irril;iling to the pans.

Pathologic Changes.— The emiumetrium and flK gUiulubr elements
twcome airo[)liic<l and arc more or less completely replaced by a connective- tissue
monbrane. llicre is often an atresia or a stenosis of the uterine ca%ity from its
wmlb powing together, vrlileh u more amimun at the iniemal n than at any
other tan of the ainat. and when the 'xclusion is complete the retained <ecrctions
distend the uterus, forming a cyst-lite tumor, which is known as a seuiJe pyo-
mrtra or liydnimetra.

Caases.- 'I'he disease occurs after the menopause and is known as "posl-
f citdi'fnrtrilh." It is tiMially the tv^ult of an o1i] or .1 new infection on

tl iving munist which has !e^s resistance than normal on account of the

mrogniiii; changes which arc taking pbce, and consequently it is more susceptible
to nintbicl inllueni'e^.

Symptoms.— 1'hc disease de\Tlops more or less gradually after the metio-
pause. Lcukorrhca is the must constant and dtaFBCteristlc symptom. It b
uMully pn)fu>e, oflen^ivc, and purulent, ami in M>nie case? stnineil with blood.
As a rule, it U ^vry iiritAling in character and frequently causes an intense pru-
ritus vuhie, and there may lie a montlily increase in the quantityuf the discharge
a9(ie»|><>nding in tin»e tn ihe fitrm<r iH-riinN »if mrn^irualion. Slight hrmor-
fkUM may occur in rare cases from the ruplure uf small sewcls in ulcerated areas.
Tbeae patients, as a rule, arc not welt nourished, bul there are usually no
f|ieciat reflex or general Mtnploms pre<eni unless the secretions become retained
within the uterine carity from atre>ia of th« internal us. L'mler thcte cifcwm-
auoiis the patient cumpbtiLi of a dull juin in the lumbosacral region and lower
•bdotnen, lou of apfictilc and strength, and a feeling of mental depression. If
Ihe retained secretions l>ecume infected, symptomo of a mild form of slow »e]»is
devel<>i) which are marknl l>y a slight riw in the temperature and pube, occa^nal
*waU,and great physical prostration.

DakKBOSis.— i'hc diagnosLt is made as follows:

The hiitiiry.

The symptoms.

The phwical sigtts.

The microscopic examination.

440 THE CTEKCS.

The History.— The age of the patient and the fact that she has passed tht
menopause are in favor of senile endometritis. This opinion is still furtha
strengthened if there is no history- of a leukorrheal dischai^e until after the climac-
teric. We must, however, bear in mind the fact that the affection may be caused
by an old infection, and that an endometritis existing prior to the change of lift
may afterward become atrophic in character.

The Symptoms. — The leukorrheal discharge is the only symptom that is
at all significant. If it is stained with blood or is associated with a slight hemor-
rhage, the indications are in favor of the presence of malignant disease, and tht
microscope must be used to settle the diagnosis. When the secretions are retaiiied
and become infected, the symptoms are of no value without a physical examina-
tion, as they simply point to general sepsis.

The Physical Signs. — The physical signs are studied by (a) touch and (i)
sight.

Touch . — The patient is placed in the dorsal position and the examinatkin
made by vagina/ touch combined with vagitioaidotninaJ palpation.

The usual atrophic changes are present. The fundus and body of the utenu
are undersized and the ccnix is more or less atrophied. If atresia of the uterine
canal exists and the secretions are retained, the signs of distention are present
and readily determined by combined touch.

Sight . — The speculum reveals the origin and character of the dischaije
which is seen escaping from the mouth of the uterus. If the patient is suffering
from pruritus vulva;, the local manifestations of the affection will be seen upon
the external organs.

The UicroBcopic Examination. — The diagnosis is based upon the results
of (he microscopic examination of the curet findings which are secured when the
uterine cavity is curcled to cure the disease.

Differential Diagnosis. —The disease may be mistaken lor cancer
of the uterus. The differential diagnosis depends upon the results of a micro-
scopic examination.

Prognosis. — -A spontaneous cure may occur if ulcerati^v adhesions take
place and the cavity of the uterus becomes obliterated. This result, howerer,
is rare and the suppurative discharge, as a rule, continues indefinitely, unlew
cured by appropriate treatment.

The disease Ls readily cured by operation.

Treatment. — The irealment consists in dilating the uterus and remo\ing
the entire endometrium with a sharp curet. (See Dilatation and Curetmem of
the Uterus p. gS5')

Special Directions. — .After the uterine cavity has been cureted and flushed,
the (Icnuckd surface is cauterized with pure nitric or carbolic acid, care being
taken 10 protect the vagina by packing gauze around the cen'ix. The uterus is
then irrigated with an alkaline solution and the operation completed in the usu^l
manner.

ENDOCERViaTIS.

SjTlonyms. — Cervical catarrh; Cervical endometritis.

Definition. ~-.\n intlammation of the intracervical mucous membrane.

Causes. -Inflammation of the intracer\*ical mucous membrane may occur
cither as a primitry or secondary infection. The former is due to direct in^■asicln
of the mucosa by sejtlic or specific germs. Gonorrhea frequently attacks the
cervical canal as a primarj- infection without involving other parts in the liegin-
ning, and the same is true of .^eptic inflammation resulting from the use of dirty

EXDOfMlVHTnS,

441

instruments, etc. SecoiKJury infection resuiu from exlension upward from the
tugina and downward frum the uterine cavity; the latter sourve, hciwe^'er, is
very rare.

The reblicms existing Iw-Iwwn llic cervix iind vagiiw fs|ifniiHy cxpuve the
cervical canal to various forms of infeclion. Again, as the cana\ is usually occu-
pied by Kerms, the lightest alteration in the normal condition of the fiarLs, ^uch
as congCKlion or Ir.iumiili^m, cau»cN ihe buleriu to multiply rapidly and bc«-ome
pathogenic. Furthermore, when infcclion occurs it is wry difficult to dislod);c,
M the fteni» occupy the glaiulular cT>-|its and remain there in a more or leui
active or a bteni i-omlition. And, timilly. the internal os uteri may act as a
barrier to the spread of the inilammaiion into ilic uterine cavity, and hence a
chronic infection of the tervix at lime« remains loolizrtl unle--^' the ili.-va>e is
curried into the uterus by a sound or some other mechanic means.

The cxciliiiK causes of cndocer\'icitis are the same iis those of endometritis,
and I shall, therefore, rhiMtify ihemaK follows:

t'ongcstive causes (sec Congestive Endometritis, p. 418).
Consliimioiial causes (see Constitutional Eiidomeiritis, p. 4:14).
Gonorrheal infection (nee Gonorrheal Endometritis, ji. 437).
Septie infection (see Septic Endometritis, p. 43 1).

Il is unnecessary to repeal again what has already Ixrcn fully discussed under
the eauses of the different varieties tit endometritis, _\'et it will, however, not be
improper or useless to refer bricily to the fn-iiuency with which ihc traumatisms
of lalwr act as causative lesions. M staled elsewhere, one of the piiiholoi-jc
changt:> which rrsullsfrom a deep hibteral hiceralinn t> an eversi<in of the lijiK
of the cervin which occurs sooner or later in the majority of instances. When
the lips are thus everted, the Jmraicnical muious membrane is natuniUy ex
posed and is subjected not only to infection, but also to irritation from contact
with the ('aginal walls. M a result, inflammatory changes develop, the tenix
bee<»nes eruded and hjiierlniphiisl, and c)?.tic de){cner:itioTi occurs.

Symptoms. l>rukorrhea Is the only distinctive symptom of endocer vie ills.
The distharge is clear, thick, and tenacious, like the white of egg. and at time*
vicry profuse. VMien ihe inHammuiion is ^ui)pumlivc in character, the secretion
beoonics opaque in color and creamy in consistency from the presence of ]>uscelU.
Other symptoms which may lie pre--eni at limes are not due to the local disease,
but to its causniive le>i(in* ur lo an exicn.*ion of the inthmmalinn to adjacent
structures, such as the endometrium of tlie uterine cavity and the oviducts or
periloueum.

IMagnosis. - 'llie diagnosis is made us follows:
Thchistox)'.
The symjitoms.
The ph>-sical signs.
The microscopic examination.

The History.^.A careful imiuir}' .-ihould l>e miidc a.i to the cause of the dis-
charge, which may be traced lo 3 gonorrheal or septic infection in some cases,
and in others the hisiojy may show a congestive or consiiiutioiia! ori^n.

The Symptoms-— I^'ukorrhca l» the only constant sym[itom, and if the
discharpc is not mised with pus its origin is readily determined by the character
ollhc^./eii'Hi. whiiii.asstateilabove, is clear and lenaiiou.'., like the white of egg.

The Physical Sigos.— Tlic phj>ical signs arc *tu<lied by (uj touch and (b)
sight.

T o u e h . — The [Kitieni h plHce<) in the dontal position and the examina-
lion made by vaginal and lugino abdominal palpation.

In UiKomplicaled cases of endoccrvicitis Ihe iniravagiital portion of the cenlx

44a THE UTEKUS.

is slightly swollen and soft to the touch. The os is more or less patulous and a
circumscribed area of erosion is often felt surrounding it. In multiparous
women the disease is usually associated with a laceration of the cervix, and hence
the characteristic physical signs are wanting and the pathologic changes depen-
dent upon the traumatism are easily recognized by the examiner's finger.

A thorough examination should be made of the position of the uterus and
the condition of the uterine appendages in order to complete the investigatim
and confirm the diagnosis.

Sight . — The speculum reveals the origin and character of the discharge,
whicli Is seen escaping from the external os; the area of erosion; the patulous
condition of the os uteri; and the congested appearance of the cervix. If the
cervix is lacerated, the characteristic pathologic changes are observ-ed and the
extent of the tear ascertained.

The Hicroscopic Examination. — The diagnosis is based upon the results
of the microscopic examination of curet findings or glass slide smears.

Differential Diagnosis.— The differential diagnosis depends upon
determining the source of the discharge. This is rarely possible, as endometritis
is usually associated with cndocer^icitis ; and besides it is of no practical value
tu distinguish between the two conditions, as the treatment is the same for both.

A discharge from the Fallopian tubes may be mistaken for endocervicitis when
the distinctive character of the cer\ical secretion is altered by pus cells. (See
Congestive Endometritis, p. 421.)

Prognosis. — Endocervicitis of gonorrheal or septic origin is acti^'ely dan-
gerous to life on account of the tendency of the infection to spread to the corporeal
en<i<)metrium and the oviducts. Gonorrheal endocervicitis is often very chronic
in its course and may remain localized in a latent state for an indefinite period,
causing infection in ihe male or acule sejrtic symptoms during the puerperium.

Endoterviciiis arising from congestion or constitutional causes seldom re-
sults in lulial disease, and hence the prognosis is always favorable to life,

.■Ml fiirms of endocervicitis are vcr\- chronic in their course and show little
or no tcndenc)- toward a spontaneous cure.

Treatment. — It is im(N)st;ible from the standpoint of treatment to separate
endocervicitis and endometritis. The two conditions are usuaUy assodated and
the same principles of treatment apply to both. I-ocal applications to the intra-
cervical mucos;i nlimc are liangerous lieciiusc the infection may be carried to
the i"r|Kireal eniionictrium, and ihey are useless l)ecause the disease lurks in the
fllanilular iri-pis and is unaffected by the medication.

The treatment, which is Uisod upon the cause, and which is the same as for
endometritis, is carried out as follows:

Congestive in origin (see Congestive Endometritis, p. 432).
Constitutional in (irigin (see Constitutional Endometritis, p, 426).
Gouorrht'iil in origin (see Gonorrheal Endometritis, p. 430).
Septic in origin (sec Chronic Septic Endometritis, p. 436)-

\\'henc\er curetmenl is indiciitcd, the procedure should include the caviti- of
the utems, ulherwise the operative results are unsatisfactory and the cure uncer-
tain, as the inllammation has usuallv extended bcvond the internal os uteri.

SUBINVOLUTION OF THE UTERUS.

Definition. — .An arrest of the physiologic process of involution which
takes place in the uterus after labor or alwrtion and by means of which the organ

returns to its normal bize and weight.

SDBINVOLV-nOK.

443

Pathologic Changes.— When involution b anesicd, fatty dcRencnition
and ubsorpdon of the muscular and connective lissues of the uieru.t do itul take
pbcc, and (he or):;sn remain!. Iijpertroiihiwi for an indebniie Icnglh of time.

The li)-|)mn)|>liy may he limited (o the body of the utcni& or the cenix, txjl,
MS K rule, the entire organ is involved, and it is symmetriciUy enLirgwJ iind heavy.
The uterine walls are lliick ami wift ; the cavity i* often incrcdsnl in length to
four inrtirs or more; attd (he endometrium is congested and swollen. The
uterine lif;amcni& are also subin\i)lule<l ami remain nhnormnlly thickened and
daogBtcd. The hlood-ve»sclK remain increased in number and size and the
pelvic organs arc in a state of passi\'e congestion. The heavy utenu, un^upporled
by its ligaments, gntdually Mnk\ lower and lower in (he [lelvic cavity, and Us
furuluH ei'cntunlly l>coomcs reirodisplaced.

Canses.— The causes arc always puerperal in origin tnd cla.t.ti&ed as fol-
Jows:

Septic or specific infection.
Laceration of the cervix.
Uterine displacements.
Septic or Specific Infection,— Infection of the utem* during the puerperal
Male arrests invojulion .nl oiiie, and if the di«ieji>e Is nm checked the organ be-
come* ^uliinvoltilcd. This is a vrry common priman' cause of the affection, and
as the result of the increased size and weight of die uterus a ret nH I iipki cement
ui.u.4ll)'i>ccurs when the pL-iiient get.<oulof 1imI.

Laceration of the Cervix.— .\ ccn-ical tear interferes with the retrograde
changes that are necessary to restore the uteru.-> to its normal >ixe, and hence it i»
a prim.-tn' cauM; of subinvolution, which eventually results in some form of uterine
dispute mrnl.

Uterine Diiplacements,— A prolapM or a retmdtspbccment of the uienis
is a prinuiy rau^ i>( subimvluiion. So long as the uterus remains a( its normal
level in the |>elv)i- uiivily the ^vnous flow of blixKl i» unimfieiled in its counc and
in^Mlutiim progrcs.*c normally, but when the organ sinks Ik-Iow this point the
waaeh bcoome etrctdwd and kinked, the circulation is obstructed, and the
Knillimt COOgestlon inlerlercs with the al(M>ri>iion of the pnKlurU of fatly de-
Erneration.

A uterine displacement may de^vtop during the pucrpcrium from the follow-
inc cauie*:

Septic or specific infection.
Laceration of the cervix,
laceration of the perineum.
Getting out of bed loo soon after delivery.

Lying ixmstandy upon the back and the ute of a tight bandage after
bbar.

The first two of these causes have already been discussed.
A lareration of llie |>erini-um InierferH witit the balance of power in the
tnerhanL*ni of uterine support and may become a cause of uterine displacement
(*rr p. .;iq).

Orttinc out of bed too soon after a labor or an almrtion abo remits in pro-
bp«c or retrod ispla cement because (he uterus at that time is too heavy for its
lifCOflWnU, ami hence they beoome overstretched and allow (he organ to fall
hackward and downward.

L>-lnS(on4innllyu|Min the bock and the use of a tight bandage after labor are
■ I miin rau»«s of uterine displaiement. and tannui, therefore, he too earnestly
• mi»rd. I'niter thc-r condiiions the heavy, enlarged, and softened uterus is
acted upon by specific gravity and gradually fa'lk backward because its ligaments

444 ^^^ UTEKUS.

for some time after labor nre so elongated that their function as tether-tope b
temporarily lost.

Symptoms. — The symptoms are divided into:
Local symptoms.
General symptoms.
Symptoms caused by coexisting pathologic conditions.

Local Symptoms. — The local symptoms are lumbosacral pain and a bear-
ing-down sensation or weight in the pelvis. The menstrual flow is inatased
in amount and there is a more or less profuse leukorrheal discharge.

General Symptoms.— There is usually some gastro-intestinal disturbance,
which is manifested by loss of appetite and constipation, and, as a nile, the
patient suffers from \-ertiGil or occipital headache. The general health is
frequently impaired; the blood becomes anemic; there is loss of strengtbaod
weight; and cveniuatly symptoms of neurasthenia are developed.

Symptoms Caused by Coexisting Pathologic Conditions. — Hieie
symptoms are due to uterine displacements and lacerations of the cervii or
perineum, and are fully discussed under their respective headings.

Diagnosis. — The diagnosis is made as fallows:
The history-.
The symptoms.
The phj'sical signs.

The History .^Valuable information is often obtained from the statements
of the patient. She may give a hislorj- of good health up to her last confinement,
which may have been instrumental and followed by a slow and unsatis&ctoi)'
convalescence with subsequent symptoms pointing to subinvolution. ,4gain.
there may have been a septic infection or a displacement may have resulted from
lying upon the back too longafter labor, or from getting up too soon after confine-
ment; and while these statements do not lead to a conclusi« opinion, }'et tlie>-
;issist materially in forming a correct diagnosis when considered in conncaion
with the symptoms and physical signs.

The Symptoms. ^ — Taken alone, the symptoms are not characteristic; but
when studied in connection with the patient's history and the physical signs, they
become imjxirtant as an additional link in the chain of evidence. Thus, if the
local and general symptoms of subinvolution are present and the siaiemenls of
the patient point to a cause, vc are justified, all things being equal, in attrib-
uting the enlarged and .soflened uterus to an arrest of involution.

Hie Physical Signs. — The patient is pbced in the dorsal position and
exiimineti by (<;) touch and (ft) sight.

T ouch . — The e.xamination is made by vaginal loiirh and by vai^ir.o-
abdomimit palpation,

Tiic uterus is equally enhirgcd in all directions; it is not tender to the touch:
its Willis are suftcr than normal; and if a sound is introduced the length of the
lavily i> found to lie increased. The cervix, as a rule, is not much in\-olved,
and may iherefiire \x only slightly hy[)erirophied. The uterus may be found
dis)»lac(.'d and the ccrvi.v and perineum torn. \ careful palpation should be
made of the uterine appendages to exclude the existence of a tubo-ovarian lesion.

Sight . — The perineum and lower part "f the ragina are carefully itLsj)ecte(l
to dclermine the absence or presence of lacerations. The condition of the txn\%.
and the origin of ihe leukorrheal discharge are revealed by a speculum e.xamina-
tion. Tlie cervix may or may not he lacerated and (he uterine secretions are
often seen escajiing through the ns uteri.

ProgtiDSls. — The re>ults of treatment dejwnd upon the changes which
have taken place in the uterine structures, and if the affection has not become

St'lllKVOLltTIOK.

chn>ntc a cure can usually lie expected ; but if the mucous memhrane has under-
gi>nr iicnnAncni ihickeninit; nnd hyiwiidima i>f the cunnrciivc tb^uv has tuken
pUi'r in ihc muscular ^inictUKs, the cliseaw Hill nui be materially farnefited by
any (»fin <if trcniment.

Treatment. —'I'hc cnhrged uterus and the coeKKtinj; endometritis are
ooi»tAnt lesjon^ of suliintolutioi}, and hence they alwu)-^ m|uirc treatment in-
<lri«ndcnily of the ciiust- cir the iiwidntifl |ui ibolii^K ciiiKlilii>n>.

In it citsc nf (^ubinxi.ilution in uhicli no cnuf^e rcniuin^ or in which no associalM)
tuitht>lnf;i< (ondilion cxi'ts the trvatinenl i^ directed -olcly to die cure of the en-
urgoi ule^u^ jml ihe cnilomctriiis. Hut when the <ii»c.i.'sc i> as.-ujdiili'd with a
fCtn)di»iilacrd uterus or a lacerated ccnix or perineum, no cwamx" result will
IbUow toe treatment unless thoe lu^i<>n^, which are eit)i«r the |>riniun' cau^e nf the
•ffcdiun ur Kav-e lieciime secondary cauM%, are cured alon^ with the structural
dutiRDS in ihe organ. For eumplc, in a case of subinvolution of the uterus
iMndjiied with ret riHlispla cement we muKt fir¥( dibie and curet the uterine cav-ity
kod at ihc isame time restore the organ to its narmal po^tinn and keep ii there
with a pessary or hy |>crftirmin|; the o|»cration of ventral sus[iension. lAlwn the
I' ' -. rei-ixtred from th*- iilxfominnl ojirmliim, ur iil once in a recent case

il : . ha* l)Cfn in-^ncd into the vagina, she S'hoiild lie treated locally and (jcn-

ir^lU i<if ihe cnLirjp^nwnt of the uterus, which, ticiw that the i.au»e (rftniJit plate-
mail) ha* Iwen removrd :ini| the endnmetrilis tiirc<l. can usually In: accumplished.
The indications therefore in the irviLimeni of subinvolution are;
To litre the cocxtitinK endumetriti.i.
To reduce the fixe o( the uterus.
T" rcmow the cauv and associated pathologic lesions.
To Cure the Endometritis. — Thb i» aoMmplishcd by the operation of
tlilatatMin and >iiretmcnt of the utcni*. which is fully described on page 955.
To Reduce the Size of the Uterus.— This is accomplished as follows by:
Local treatment,
(tenenl trtatmeni.
Local Treatment . — The luiiient should dnurhc ihe vagina night and
mnrniniE, while in Ihc dnrtjil position, with a ^llon or more of hot normal salt
M>luii»n, and before f^int; to t>cd insert into the vapnal canal a^ainM the cer-
vix a cottonwool tampon saiijrutcti with glycerin which should be rtmo^td on
Ihc (ollowing morning.

Twice a week Ihe attending physician shotiUI remove from one.lialf to an
imncc or more of bkwM] fnim the ccnix with n sharf) bistourj' (sec endometritis,
P- 4^3): iKiinI the cervix and vaginal vault with tincture of iodin; and introduce
lot" ihc vagina a «-ot ion wool uini|K>n of ichthyul and jilycerin (j; per cent.),
which is remo^-cil on the foliiiwinR morning by ihp (niienl herself.

The IcKa) treatment must ))c du^continuccl during the menstrual periods.
General Treatment . — Rel'errinK to the general <yn)|)tiims cauted
lij' the di'ura^r we find that the paiienl's health is grrally impaired and that many
of the funiii'insof the bndy arc weakened or perverted. It is therefore important
Ihal ihr gc-ncra) irealntcnl should he (ran^futly .^elected and carried out in order
to ha<Jai the cure o( the Uterine affcciion. which will be delayed or ewn pre-
^MaOni uiilcHi ihc iihysical cunditioD of ihe patient returns to the normal ilandanl
^■rbaolth.

^^^ Tttc diet should Im* nourishing and easily digested; pure water should be
drunk freely 1 and ihe ItoweU ii|)ene>l <lnily. n> any temlcnn' to conslipiition
tncreaxa the \ic\\\i ii>n)!c-^lion and adds lo the local trouble. The daily
uw irl a mild laxiititr an<l tlic weekly ;id ministration of a saline will UMially lie
Hiftbrat III kcc|i the bowels free. Satinet an very bcncTicial, as they lesAcn the

44*^ THE UTESUS.

pelvic congestion, and good results therefore often follow the use of dtrate of
magnesia, Hunyadi Janes, and the saline minenil spring waters, especially thow
containing sodium chlorid.

The patient must exercise daily in the open air and sunshine. Driving,
riding, and walking are beneficial, but the bicycle should be avoided. Indoor
exercises should be employed to strengthen the pelvic organs and the mUKles d
the abdomen, as well as to stimulate the circulation of the pelvb (see p. 117).
General massage is also indicated and should be given every day, or at least thm
limes a week. A properly made abdominal binder (see p. 850) should be vom
when the belly is relaxed and the retentive power of the abdomen impaired. TTie
clothing should be supported from the shoulders and not from the wabt, as con-
striction around the lower abdomen exerts an injurious pressure and increase
the congestion of the pelric org-.ins.

Hydrotherapy. — Good results are obtained by the use of stimulating and tonic
liaths. The following baths are especially recommended; The cold plunge,
the alternating spray, and the sheet bath. In nen-ous cases sedative baths are
indicated, and their use is frequently followed by decided improvement in tbe
neurasthenic symptoms. The following sedative baths give good results. The
full hot bath, the Turkish or Russian bath, and the hot sitz-bath.

To Remove the Cause and Associated Pathologic Conditions.— Hie
treatment of these lesions is given under their respecti\>e headings as follows:
Rctnxlisplacements of the Uterus (p. 346); Prolapse of the Uterus (p. 339);
Lacerations of the Ctrvi.x (p. 452), and Laceration of the Perineum (p. 8oj).

Variations in Treatment. — Amputation of the cervix is recommended
as a routine procedure in cases that do not yield to ordinary treatment. Tie
diminution in the size of the uterus after this operation is sometimes very rapid
anti the results are often most satisfactory'. Curetment of the uterine ciriiy
must alivajs !« performed and should immediately precede the operation.

SUPERINVOLUTION OF THE UTERIK.

Synonyms. — Puerperal alro])hy; Acquired atrophy.
Definition, — A continuation beyond the normal limits of the phj-siolcpc
process of invuluiion that takes place in the uterus after labor or abortion.

Patholo^C Changes.— Tlie iji>dy of the uterus and the cervi.x are smalk r
than normal iind the measurement of the uterine cavity may be reduced to 1 or li
Liulics. Ill some cases the atropliic changes also involve the uterine appendages.
Causes.— Su peri n volution is a very rare disease and its cause is obscure.
It })ri.ljalily occurs more often after abortion than after labor at term.
'I'he fiilliiwingare the -snpiMif^d causes:
.Severe |Hist-iwrlum hemorrhage.
Se|)tic infection.
Protracted kiclaliim.

Kxh;iusting diseases occurring during or shortly after the puerperiuro.
Symptoms.— The diief symptoms are:
.\mcu'^rrhea.
^icrilily.
XciirLislhenia.
Tile ameiiorrtiea and sterility are caused by the atrophic changes in the uteras
and its appendiiiics. I'lider these circumstances the monthly cungestion is
aliment, the necessiry nervims f<'rcc is wanting, and hence the function of men-
stniutinn is suppressed.

The neurasthenic symptoms are accounted fur by the general state of the

SirPEKINVOLimON.

447

palienl's health and are nol due to the ioail changes tn the uierus. These
wttmcn tin: often hystL-ric and ncn-uus; tbey compUin of pJiin in the luinba-
Mt-Ril region "nd Iw-ad; (hey sleep baclty and are freoucntly depressed in spirils;
and ihcy »utTer toon nr leu from gaMro-inlc»tinal dbturbant-es and general
iJcbiliiy.

I>uCllD8i8.— Tlie diagnosis is made a& follow!>:
Tlic hinlorj*.
The symplonis,
The pliy>iciil sign».

The Hiitory.— llie statement of the patient may show that she was in gord
hcaltti up to her last conrinemcni and that (be puerperium was c'omplicated by
one of tlie suppoMd oiusati^'e affections.

Th« Symptoms.— An amcnorrlica follo^tiiiK a fonfinemcnt. that is nol due to
lartiitidn, ptr>;n;in(y. or Minu.- conMtUilicnjl caun*^ which ai~l> an a drain upon the
rc^lcm. iri'tii ilri. at least, the po^ibility of supcrinvolulion being present.

The Physical Signs. — The patient is placed in the dor^l position and
cmmincd t>v {a) touch and (b) ^ight.

To u th.— The examination is niadc hy vaginal taueh and vasiHo-ahdcmiHol

The uterus and ecrvix arc found (o be smaller than normal, and if a (ouiid it
introdui.'ol the lentnh of the cavity is shown lo be decreased.

Sight .—A :i)wnilum examination rcveaU ll-c atrophied cervix, and in some
cases il may be so reduced in size that nothing remains to murk its presence
etccpt B small knol> in the dome I'i (he vaf^inal vault.

IMIferential Diagnosis.— I'he affection must be distinguished from
ibc foUowti^ forms of atmphy :
Post-opctativc atrophy.
Senile .iin>]ihy.
Congenilal atrophy.
5KfuIeain>iihy only <KCur» after the climacleric, and the congenilal form i*at
once excluded il the woman has borne a child. In post -operative atrophy there is
always a history of an operation either u|)on (he cer\'ix or for the rentnx-al of the
iubi> and o\-!irie»,

ProsnoslS* — Superin^'ohition may K>nietimcs only be icmporsn' and the
titenu may return to itii ni>rm.il sixe und<rr appropriate treatment when (he
pBlient** health p restored. If. howe^vr, the atrophy is marked and the uterine
ra*ttv tncii'LTcs less than (wo inches, (here Ls liu( liiilc hope of cffc< ling a cure,
'freatment.— The treatment of the affeclion l> diuilcd into: (i) The
cr^iiM", (jl ihc l<M-:il, and f j) the jientraK

The Operative Treatount.— Diliiiaiion and ruretmcnt of the uterus should
be perffirmeil ;i» a ntutine pnicedure in cases of su|M-rin volution, as the operation
incrcaMi ihe blo™)-Mipply an<l stimulates the Rtowlh of the uterus.

The Local Treatment.^Tlic object of local treatment U to draw more blood
bithc iJclvit: organs and not lo diminish the amount. The use, there-
fore, uf hut vagina) douches; applications of iodin
to the cervix and the vault of the vagina; or the
u»e of ichihyol and glycerin tampons are ab»o-
luicl)' cnntrain<licated, as they all tend (o drive
ihe blood from the pelvis and thus lc»ftcn congest ion.
The following Iixal remedies arc indicated:
W.irm vaginal doucbes,
I'uruturing the cervix.
Pelvic massage.

448 1^£ UTERUS.

Warm Vaginal Douches . — The patient should douche her ragina
night and morning, white in the recumbent position, with a gallon of vara
normal salt solution (95° to 104° F.).

Puncturing the Cervix . — Twice a week the attending pht'sidan
should remove from one-half to an ounce of blood from the cervix by puncturing
it with a sharp bistoury (see Endometritis, p. 423),

Pelvic Massage . — Pelvic massage should be given three times a wetfc
by a nurse who thoroughly understands the manipulative technic of the procedun.

The General Treatment. — ^The general treatment should be directed b>-
ward improving the patient's health, increasing the activity of the pelvic circu-
lation, and curing all coexisting chronic affections.

The diet should be nourishing and easily digested; pure water should be
drunk freely; and the bowels opened daily with a mild laxative if any tendeon'
to constipation exists. Aloes, on account of its eSect upon the pehic circubiion.
Ls especially indicated in these cases, and it may be advantageously combinni
with podophyllotoxin. It Is important for the patient to have sufficient skep,
and when possible she should lake a nap in the afternoon. Sexual intercouise
produces congestion of the pelvic organs, and is therefore beneficial except when
the [uttient is ph>'sically exhausted.

The patient should exercise daily in the open air and sunshine and indoor
exercises should be employed to strengthen the abdominal muscles and stimulate
the pelvic circulation {see p. 1 17). General massage and electricity are also in-
dicated, and should be given three times a week, or more frequently if rcquimi.

Drugs . — The following drugs have a special action in determining the btaod
to the pelvic organs and increasing the congestion of the parts, and one of ihem
should always be employed as a routine method of treatment in cases of superin-
volution of the uterus: Uinoxid of manganese (gr. j to v, I. i. d.); apiol (niiij
to vj, t. i. d.); and permanganate of potassium (gr. ss to j, t. i. d,).

It is clearly impossible to discuss the general use of drugs in the treatment
of this disease, because the indications for internal medication differ in each caie.
anti consequently they must be carefully studie<l upon general medical principles.

Hydrotherapy . — The hydriatic methods employed in the treatment ot
the disease de))end ujKin the general condition of the patient and upon the in-
dications in each case. As a rule, however, hot sitz-baths are especially benefi-
cial on account of their relaxing and sedative action upon the pehic circulation.
In ca.ses associated with general debility the sheet bath gives excellent rcsulti.
es[>ecially when it is followed by general massage. The stimulating and tonic
action of the cold plunge or the alternating spray bath is often indicated, ami
in nervous jwitienis who sleep badly great benefit is deriv-ed from -a Turkish
or Russian bath or a full hot bath taken before retiring for the night.

LACERATIONS OF THE CERVIX.
Definition, — A laceration of the cervix may be defined as a rent or tear in

the lower segment of the uterus which is usually due to the traumatism of labor.
Causes.— L;u era t ions of the cervix are ver\' common. The cervical
rim is more or less lorn in the majority of women dur-
ing their first confinement, but a large proportion of
these tears are insignificant and heal spontaneously
without causing any trouble. The chief cause of cervical tears
is meddlesome obstetrics; for example, want of care or judgment in the use of
forceps, premature rupture of the biit; of waters, the injudicious use of ergot,
mechanic dilatation of the cervix, and roughness in performing podalic version.

LACK)IATION« OP THn CEIMX.

449

Ttacw caufwfi arc a^'oidjihlc, lu n ni\t, nnH ithould Ihererore be bome in mind in
OTtl«r to iT^tucc lo a minimum rhc frequency of cemoil laa;raiion^

In |u>m«cn«<»b^e^ulton^1^keI>Ial:eu:^ th« result ofan unyielding condilion of
ibr cervix. The presenting pnn j>rrv-inKiijion iheos, under lh(s>«.'tiriiimManrt*,
CaiU to iltbic it, am) u> a teMili thi- li.'.^ucs arc fjm. A rigid omdition uf the
ccrt-ix bcnusol by miilignant itiriliniiionMiml hyiwqilasia, and is abm likely lobe
present in vromcn who arc dcli^^red of ihetr first child l.ilc in life. Agiiin, [irema-
mre ljil>or nr alM>ni<>n may re.xull in a lom ccr\lx. owing lo the fact that the
tiiBiunt are noi preixirctl to unttcrgn (tibt^ilioii ; and. liiully. a tear may Ik cau.ied
by ihe sfNinianeous expuhion of u tibroid polypus urun instrumental dilatation
of a fvnn-gmvlil uterus.

A prenpilatr labor is often the cause of an extensive tniumniiiim, and tbe
Mtne c<H>dition is likely to result when a disproportion in size enisls between the
child iind the liirlhitanid. Somclime^ ihe prcilongct) preisure of the child'a head
ufMMi llie irrvix during a tedious labor may l>e follcivred by necTosi:tand«ulK^-
quent loss of ibsue.

Pia^M.

S'uirrrr* or OnvtCAL T«an.
Ha. 4J<. BlUtmli n«. tii. iwtiwrwl; Uf. 414. auliipk or udbM.

Varteties.— Lacerations of the lervix may occur at any part of its clr-
cumlerence. Tliey m;iy Iw fc»/<i/f/rt/,or on Iwih »i<le»; Nni/o/r/'a/. nron one side;
and muiliple or stclbte.

Bilattrai leurs are most frequenlly obsen'ed. xikI the (numatliim b. j^eniHy
more e«lea*ive on the left Me ihnn on the right, owing, no doubt, to ihc greater
pre«V>minjkncc of left occipiio-nnterior positions. For the same reason when
A birnition is unibicral it usually on-urs on (he left f'ide. Tian>%Trtc ieai>.
^itiding the cervis into an anterior and a p«»terioT lip. are more common than
aaiero-poeterior lacerations. 'Ihe pmbablc reason for thi.-* fan »* that the latter
heal, as a rule, at once on accouni of the pre^^iirr exerted by ihe bleral wall» of
■be tagina, which kre(>s the lom surfaces in u|>iKtsiiii>n. ^^'hen a laceration b
•cry exiciHlve, it ni.iy exlcnd into adjacent |>ans ami invr>l\v the (.Iructures
pMlKrior III ihe utcnl^ the bladder, or Ihe Ini^c of the broad ligaments.

A laceration nf the ccrvuc nuy be eompleJe or imom^tlt; tl>c former splits
•9

4SO

THE UTEKUS.

all ihe tissues of the cer^ncal rim at the point of injury, while the latter does not
extend through the mucous membrane which covers its vaginal portion.

Symptoms. — The symptoms are not pathognomonic
and are due to the lesions which are caused by the
laceration. The most constant of these secondary conditions are sub-
involution of the uterus, endometritis, and uterine displacements, and the symp-
toms which are usually described as being due tolacerationsof tfaecemzanin
reality caused by one or all of these complications.

The following are the most frequent of these symptoms:
Lumbosacral pain or backache.
A feeling of weight or bearing-down in the pelvis.
Vertical headache.
Leukorrhea.

Menorrhagia; Metrorrhagia.
. Sterility; Abortion.
In the course of time the general and nervous systems are affected and the pa-
tient loses weight, her appetite becomes fickle, she is insufBciently nourished, diges-
tion is impaired, chronic constipation eventually lauses
autointoxication, there are neuralgic pains in various
parts of the body, and finally neurasthenia dewlaps
with its various sensory and motor phenomena.

In addition to the above symptoms, there are certain
local and general manifestations which develop and ait
directly due to pathologic changes in the cenTx itself.
The cicatricial tissue resulting from an attempt upon
the part of nature to repair the laceration often products
reflex irritations which are not only annoying but ei-
haubling to the patient, and it is a matter of ever)-(lay
experience how (juickly these symptoms cease when the
scar tissue is removed. The plug of cicatricial tissue
is not the only cause for the reflex irritations, and v,t
find that otb.er pathologic changes in the cen-is— scle-
rosis and cystic degeneration — are often responsible for
many of the symptoms.

In extensive tears involving the base of the hmad
ligaments piiin is feU during defecation and sexual inter-
course, ami also when (he jtiiticnl walks or takes any active form of exercise.
A digiliil examination in these cases causes suffering, especially if the pehic
structures nre ]iut uijon the stretch by pushing the cer\*ix upward with the
tip of the finger. If ihc cervix is deeply eroded or has undergone c>"stic de-
penenition, it is not uncommon to observe a show of blood after sexual inter-
course.

A hiccnition of (he cervix presents no symptoms at the time of its occurrence
unless the circular anery is (urn and a free ar(erial hemorrhage occurs.

Pathologic Changes in the Cervix.— A b o u t one-half of
nil I a c c r a [ i o n s heal spontaneously and cause no
local or (;ener;il symptoms. When, however, this does imH
occur, the cervix undergces certain pathologic changes which are alwa;?
mure or less modified by (he extent and situation of the tear, and art
e'ipecially marked in bikiteral bcerations which extend up to the vaginal
junction. .As the result of a liiccralion normal involution ceases and the cervix
Ijci-omcs congested iind inflamed. The cervical tissues eventually become
h}j)ertrophied and the cervix feels hard and indurated. Gradually the torn

Km. ^^^• — Is'fOMi'iiTF I.ac.

EUAriON OF Till- Ct.flVJX.

UCKHATIONS or niK CKtVIX.

45<

Kuriacot b««n»e oeparatol ■ixl ihe cervix prwmu a rhib-sliapod nM».-irancc.
The Tulllng out ai ih« lip» oi the cvrvix vxpoK^ (he cirnicjil cunal and inc mucous
mcmbrunc soon becomes inOamcU and swollen. 'Hie ^'untls lake on intresiMd
•ctiwty (ftn-ieal talarrk), urul, fm:illy.a« ihe rcMill of loHRcontmucil iniUition
awJ exposure. ermion< snd cj^ik dcgcncralKin make their 3p[>canincc. Nature
in her elTori to repair Uk injun' i\\h the angle of hverutton in ith a j>lug lA sair
lixuie whitb %i\v>- :i rooimJe*! uppcanncc to llic Iwiium uf (he wuund and csuscs
ihc reflex symjitocns referred to above,

Results.— 11>e results of a bcenilion ure eitltcf immtdiaU or remott. Of
the fiifmer. the morl frequently oWned arc. hcmoTrhogc. sepsis, and VTjico-
\-:;ifCinuI tKtuU. The septic infection may extend from the wound to the uterine
cavil) an>\ ibe ov)duei», or it may l>ei;in in lh« cellubr tiwues of the [>elvtv when
ihey arc cxpo!«d or opctKd by an cxtcnsivt; laceration. The principal remote
rr«ult» Are subin^'olulton of tlie uterus; chronic endometritis: uterine displace-
ments, due to vubinvotution or to contraction of nculricinl iImuc in the cellular
^iniiiurrf, iM-tiiwl the uterus; chronic tubal and ovarian disease; and cancer.

DiacTiosis.^The diagnosis is mjde by («) louth and (b) siRht.

Touch. — Hie crnix i\ fnund to l« en]ntp.-cl. hiinicneil, .ind indurated: il
i* no Itmitcr rounded at its extrcmiiy lilce a cone, but is bnud und club-shaped;
uxJ the everted or rollcd-oui ed^es of iu torn lipti are easily n-cof;iiized as the

riiM-.iKnat nr t'rancju Tub*.
tbnv* a MkHn) lumiii*. Kk- «>; ikoiai ihc 'I1tM(4 1I|ib oI Ibe onw in* tnmBhi lain >MCMitoa

tnnlnini; linger passes upward into the vagimil v^ult. The angle of laceration
b newlily felt ami ihe pluK ol itcar tivsue :tt the bottom of the wound is easily
pclpaied itnd pn^^rure on il causes locnl and radiating [Kiin». l*he ct'crtcd
tnuonis membrane of the icr%1cal canal and the erosions have a swollen and
wlvrty feel atwl iIh- enLii)^ nii.-i-mt>NC ^liind.-i (cyntic Jexeneralion) gjiw the
wn'aii"'! of smnll shot under the lip of the linger.

Sishl.— The(>aiient i^piKed in theknee ihestor Simp's position and Simon's
HMrcuTum inlriHlunnl into the vagina, .^s the (-er\'i<c cumo into view the bccra-
Itoti ami gmthologic changes arc readily observed. .\ linal ter^l a» (<■ the nature
'f the U^Mn ii> made liy hookinK a tenaculum into each Up of the cenix and
•Imwing Iheni together after cn»s,*ing the instrumrnt*. Ha lacenition is jircsent.
ih«: irr>-ix is thus Icmpor-irily restored to its r>ormaI <hape and the e^vrtion of the
- H-rmbrane of the ter>'icii] cimal and the eroiions will disappear as the'
- are brought into apfxisition. Thi;^ mani|>ulation i* alwajn »U€C*ssful
■.I hrn the bceralion is assiocialed with a large amount of infdtration which
dh ami hiir>len« the tiwues and femfcts ihc li|B of the torn cervix immovable.
vi-i <>( an innimpitle te.ir is made by [M^-^ing a M>und into the
I iid niilirig its increased calilxr, and at the same lime feeling the lip
of tbr itwuuincnt through the uninfurcil mui-ous membrane (Fig.s. 438 and 439}.

4Sa THE UTERUS.

A tubular nrhivah-e speculum should never be employed in malungtbe diag-
nosis of a laceritted ceri-i.x, as the lumen of the former instrument is not large
enough lo expose the entire surface of the torn neck, while the latter increases
the rolling-out of the lips and the eversion of the mucous membrane of the
cervical canal and consequently gives a wrong idea of the pathologic changes.

Z>l&'eTential Diagnosis.— The aifection must be distinguished from:
(a) Carcinoma; (ft) eversion of the mucous membrane of the cervical canal
without laccralion; and (c) erosion of the cervix without laceration.

Carcinoma. — Carcinoma may be mistaken for a laceration of the cervix
which is associated with extensive erosions and cystic degeneration. In cancer
true ulceration is present; the tis.sues are brittle and bleed freely; the leukoirbcal
discharge has the characteristic malignant odor and appearance ; and the disease
is rapid in its couise. In case of doubt an examination of a piece of the tissues
must be made with the microsi-ope.

Eversioo of the Hucous Hembrane of the Cenricsl Canal. — Eveision of
the intracervical mucous membrane is rare except when the cervix is lacerated,
but the fact that it may exist alone must alwa}^! be remembered. I ha« oi)-
served a number of these cases in young women who were engaged to be manied

Kin. IjS. Kll-.. 4JO.

Di*i;vD=is i>[ «v I\c uiipLLTK l.*rm«TroM or ike Ctsvix »riH a L'tuihe Soithd (ptge 451).
Fig. 43U ahcm-s Ihv iacnam-i ralilx-r til ihr rrrvii-al i-jinaL : Fis- 430 shows the lip of the louwl bofli Ml
ihrijuiEh ihc uninjured niucous mrnilinnc.

and in whom the iwWic orpiiins were congested from the " sexual engorgement in
love-making."

Erosion of the Cervix without a Laceration. — This condition is- not un-
common in women who arc broken down in health and suffer with an irritating
discharge from the vagina or the endometrium. The diagnosis Ls based upon
the physical signs and the absence of all local symptoms of laceration.

Prognosis.- -The jiriignosis of lacerations of the cervix depends upon the
results of ihu traumatism, which, as stated above, are cither immediate or re-
mote, and u[Minthe L'-vlcni and situation<)f the tear. The laceration itself is easilv
curei! by operative measures, but some of its consequences are serious and a
guarded prognosis must Ik given. I'Nir example, little if anything can be done
for a uterine di>plarcmenl caused by cicatricial contraction of the cellular tissues
behind the uterus, and chronic tubal disease caused originally by a lacerated
cervix nect'ssitales an abdominal section to effect a cure.

Treatment.— In considering the treatment of lacerations of the cenlt it
must be Ijorne in mind that 50 per cent, of these tears are physiologic and should
W let aiiine. as ihev are followed bv no evil results. On the other hand, however,

LACPJunoNS or thk ruvix.

4S2

it must also be remembered ihal cemcal lacerations are oixca re>ponikiblr for
certain li>cal and general cnndilions which not only dMtmy ihc hr.ilili of (he
|«tirnl Inil iirc e\-cn dangvnms to tife. The Mkclihoud of can err
developing at the site of a laccralion must not be
foFKOtlen, and I believe we will ulway* be on the
cafe side in operating upon selected cases solely
with the object in view of prevcniitig the
p(i»iilbilitr of malignant dine it »c occurring.

"Vhe ireutmcnl k alwiivh i>[>erativc in chanicter, us it is impossible for the edttes
cif the wound to be reunited and (he intraccr^ical mucou» membrane te^lored to
it> norm:tl position by any other meuns.

lodicatioos for Operation. — As a large number of lacenttions require no
tnatmeni whatever, ii is impor(ani lo have a clear and det'iiiite idea iut to wha(
rlssa wl tasn require o[>crali\-e interfercnie.

The foUowini; rules ha^'c been formulated for (his purjiose:
I. Opcnite uiKin alt laceralion.i which are cumpltiatt-d with induration and
hypertrophy of (he ccr\Hc«l tiv^un; cvereion «>f the iniracrrviml mucous mem-
brane: cys(ic degeneration; and erosion,

3. Ofieraie u|H>n all lacerations which are roponsiblc for ^ubinvohJlion of
the uteniy. endomelrilis. and ulcnne displacements.

$. Oiieraio upon all lacerations which are associatnl with a sensitive plug of
*car tiMue in the ant:le of the umiml.

Contraiodications for Op«ration.— Grave pdvic disease is a cootraindica-
linn (or operative interference in i-ascs of laceration of the cervix, Thi* doe* not
inchidc all forms nf i^bic loiim^, nuch as simple congestion or inflammation of
the uterine apiwndages, but only those condilions in whic^ pus exists or lirm
'' ■ -w>ns are prcwni. Tlwre U al»-jy* consiiierable driiKfiinK upiMi the ulerus
\)i an operation upon the ceT\'ix, and (he^e manipulaliims may cause a fa(al
pcnionitt* by l>reaking up old adhesions.

Preparatory Treatmeat.— The object of the pre|Kirator>- treatment is to
rein')ve so far as jinsstble the p.tlholo|pc changes in the cervix and (o place the
F»iieni in a pKtd general condition for ofteration. If the i>atient is operated on
within three or four months after confinement tvfore the remote results and
[utholngtc clian)tcs referred to have occurred, there is no need, as a nile. for any
prqMTatiiry treatment. But if the caie is neglecteil for many month* or years,
as iiften ha[>pens, the cervix liecomes indurate<l, hv)ierirophied, and emdcd, and
(he intmcerm-al mucr)us membrane everted and the seat of extensive cystic
drKcner.iiion. Under these circumi^ancen an immciliate ojicralion would fail
net 'mly in restoring the parts to their normal condition, but also in curing the
trffex and olher symptoms. The importance, therefore, of
making a careful examination before discharging
■ patient alter confinement should always be borne
In mind, a* a laceration of the cervix may be
ditcovered and an early operation performed lo
prevent subsequent complications occurring.

Another rcuNon, which i» often overlooked, (or the necessity of a preparatory
cnurwof irealmeni is its modifying effect upon the renical le:sinns and the sub-
-e*iurni -elciliiin of a lesc radical operation. For example. .1 bceration lom-
ptkxted with a hanl. indurated, hvjjenrophieil cervix usually ilemands an am-
pilUtn>n f'^r if cure, whereas if the ojicratiim is delayed for a few weeks the
pTChi; ' of treatment may soften (he cervical tissues and the less

ndh'i , ( trachelorrhaphy nuiy brsubt'lituted.

Tbe «amc is inie of all the local changes resulting from bcerations of the

4S4 THE UTERITS.

cervix and, as will be referred {o later on, their presence or absence detennincs
the question of operative lechnic.

The length of time required for the preparatory treatment depends upon tbe
character of the cervical lesions. If the cervix is slightly affected, two or thrtt
weeks are sufficient ; in other ca.ies a much longer period will be found necessai}'
to modify the lesions and place the parts in the best possible condition for (^ra-
tion. As a general rule, nothing further can be
accomplished after three months of systematic treat-
ment, and at the end of that time the operation o[
selection should be determined upon.

The preparatory- treatment is local and general in character and may be dis-
cussed as follows:

Local Treatment . — Under this heading are considered (i) the rou-
tine treatment and (2) the trcatmctii of special conditions.

Routine Treatment.— Th^ routine treatment consists in the tise of \uA
vaginal injections and the local application of ichthyol and glycerin.

The patient should douche her vagina every night and morning with a gallon of
hot normal salt solution, and before f[oing to bed introduce a cotton-wool tampon
saturated with ichthyol and glycerin {25 pc cent.) again.st the cer\ix, and remow
it on the following morning. This treatment is continuously carried out inde-
pendently of the local applications which are made b>'
the attending ph>'sician from time to time for the cure
of special conditions.

Treatment of Sperial Conditions. — The special con-
ditions which require treatment are subin\'olu[ion of
the cervis, erosion, and cj-stic degeneration. In addi-
tion to the routine methcxls just described, local de-
pletion is of great benefit when the cervical tissues
are subinvoluted and indurated. From a half to one
Fio. 4JO.- st-.vkiinATios or ounce or mure of blood is removed from the cen'ix
c:i. 1"^ * 'uT. L twice a week by puncturing it with a sharp bistouT^■.

ShoHing thtmnhoii of making ,, , . i ' , ",^, . '. , ,-

ihe suprtficiai imisions. (Scc cndomctnlis, p. 423.) The entire cervi.t and the

vaginal vault are then painted with tincture of iodinand
a tampon of ichthyol and glycerin (15 per cent.) is placed in the vagina. If the
cervix is eroded, it is scarified once or twice a week and an ointment of iodoform
(V. S. P.) applied. The ointment is spread over the tampon of ichthyol and
glvcerin and placed against the cervix. The scarification should extend slightly
beyond the eroded surface and should consist of a number of superficial parallel
incisions which :irc crossc<i by others at right angles. In cases of cj'Stic de-
generation each cy.st is punctured with a sharp bistour), its contents e%'acuated.
and the iiKloform ointment apiilic<l to the cenix. If there is a large number of
cy.sts only six or eight should be jiunclurcd at one sitting, othenvise the parts may
become irritated and lause a severe inflammatory reaction. In case the cysts
refill jfter they have iiecii punctured, their walls should be destroyed by appl}'ing
pure ciirliolic acid directly to each ,sac.

The local treatment must be discontinued during the men.strual periods.

General Treatment . — The treatment .should be directed toward
pliieing the health of the patient in the best possible condition. Thedaily useof a
siiline is imports nl on account of its dejdeting effect upon the pelvic circulation, and
the i>atient should therefore haie one water\- bowel movement everv twentv-four
hour<. The digestion should be looked after and any gastro- intestinal trouble
corrected. The food should be easily digested and nourishing, and if tonics are
indicated such remedies as strychnin, quinin, and iron may be administered.

LACrjtAnONS OF THK C«l\1X.

4SS

The paticol ^ouM be out sc>'eral hours e^cry day hi the open air and suiuhiiie:
!)d c^-cry iiJKbt ;iiiil muntmg sli« should devote a few minuie> to indoor uercisc

• mltr to sirrnglhcn Ihratxlominal walls and pelvit contents (sec p. iij). The

" k sluiuld be tcpi in a health) condition l>y cnrefu] attention tn i^nernl and local
l)llncs>, ami in M>me vaavt a systeniiilic course nI stimulating baths i&

licAicd.

Treatment of CompUcations.— It is itnpurbint to benr in mind that sub-
ini'i>)utiiiti n( the uterus, cndometrilU, and ulvrine displacements are usually as-
saxjiated with chronic laccralians of the cenix. and arc, as a rule, the direct
mults o( the iraumalisms. Tlierefore if a retrod ispla cement of the uterus exists,
rhc Liceration of the tcnix is tin-t Tci)uir«l iind then the abdomen is immediately
opt-nol and the fund us attached to the anterior abdominal wall (veittrai sutpmsivn
e; iHe Mlttus, see p. 35^). A)i;ain, if emlomcirilis i> proent dilalJilion and cum-
merit ol the uterine cavity must prcceilc the operations for the repair of the torn
trrvix and the replacement of the uterus. And. finally, if subinvniutinn of the
uienii i» asMKialcd urilh the endometritis iind uterine displacemcni. (he special
opcntions (or their relief will at the stme lime tend to cure the hypertrophy.
The mere restoration of a cervical tear will not rurc
ibc complications, and if thi« fact is not borne in
mind failure will often result after operative
measures have been carried out.

Selection of the Operation.— A torn cervix may t>e rrstoied ellhcr by a
tmrkriorrliaphy or an ampultition, aitd it is im|Kirtant to know which of these
opcntions to select in a given case, oiherwiie t)ic results will he uiuatisfactoiy or
bad.

rntfAWorrAd^Ar should be performed in cases in which there is only si iRhi low
of tiMtue, and an abiteiK'e of induration, cy.ttic < lege nenit ion, or extensive erosion.

Am/tulatitm. on the other hand, is indicated in stellate lacerations; in tears
which urc a.-oociateil with f^real loss of tisnuc; and in e«--<es complicated with
cervical induration, cystic degeneration, and extensive ero«ton.

Tlie selection of the operation In many instances depends u|>an good ]u(l|;ment
and ciHnmon ?«n.'«c, and the neci^ty for a coune of prctMnitor>' treatment, as
mentioneil above, must not be forRotlen, It is obviously bad surger)- to restore
a cenicul canal which U the seat of cystic dciceneration by ]icrforminK a tracliet-
orrhaphy, bccauM' it docTi not cute the disca^^d inlrarrrvical mucous membrane,
which although hidden from view by the operation still remains a focus of local
trrilalion, keeping up many of the relVx s\~inploms and chronii- rhannes In the
uterus. A)^iin, a cenix which has become indurated and sclerotic and remains
»*i alter a careful preliminary axirse of trcuimciit is clearly un.^ui[ed f^r a
rrparaiive openiion. and e%*m if X\w <Ienuded c«lg» of tJie laceration unite, the
local irritation due to tlte sclerosis will continue.

Trachelorrlisphy.— T e c h n I c of the Operation. — The Pfr/ura-
liim it Ihe PalirnI atnl the Prepof^liont Jorlbr Operation are described on pages 850
andSjii.

Pmilion 0} tht Patimt. — Dortiil )>««.ture.

Sumbtr ol Aiuflinli. ~.\n anesthvlixcr. two assistants, and 1 general nurw,

/(Mffimwrn/j.— (i) Simon*3 ^jceulum (curbed blade); (i) two bullet forceps;
^3) MaljH-l; (4) sltaiKhl scixtors; (5) tiwue forcq>s; (6) dre-wnf: lor<eT>j;
J) neeflle hohler; (8) shot compressor: (g) two small fullcuneil Hage-
nceillra; (io> |>erfora(ed shot; (11) silkwoRD-f:ut''t5 strands (Fig. 44r).

Tlic li*t of instrumenh required in the operation of Hthtalion and ciireimmt

the uterus, which should always precede a trachelorrhaphy, will be found on
955-

4S6

THE UTEEUS.

Operation. — First Step. — The speculum is introduced into the vagina and
the anterior and posterior lips of the cervix seized in the median line with bullet
forceps.

Second Step. — The area of denudation is marked out with the scalpel on

®G

ACTUAL size

Fig, 411. — IssiBVMENTS, Nkkiiles. StTi'nE MAimrAL. *sti I'EHKHiTED Shot I'sed im thi: Ore>*iit» w

TltACHELUIlPllAniY (pAflft t5i)-

the torn margins of the cenix in such a manner that the incisions pass beyond
the angles of laceration externally and leave a strip of mucous membrane \ of
an inch wide in the middle of each everted lip for the reconstruction of the cervical
canal. The object of the preliminarj- incisions is to prevent the removal of an
unneccssar}' amount of tissue and to obtain clean-cut approximation surfaces.

t'lti. 447r — First Step.

Ftc. +«.— Second Step.

TuAIIIKLniTBHAPHV.

Third Stkp.— The edge of the area to be denuded is seized with forceps *f
the free end of the cervi,\ and the superficial tissues removed with a .scalps
down to ihy an^Io of laceration. The opposite lip is then denuded in the saiU^
manner and direction and a wedge-s!iape<i jjiece excised from the angle of lacera"

tACEBATIONS OF THE CERVIX.

457

tion. The opposite side of the ctnix is th«n denuded, if the tear is bilateral, and
the niw edge* brought together with crossed bullet fori-eps to test the decree of
tension wlien the purts arc linally approximutnl. If the edges u! the Inm lip»

Pio. M4.~Thitd sup. Flo. ui,— Tbird Stoft

TlACHROn H MM Y.

do not come together withoiii undue strain, the redundAni tis-fue should be
rnnovn) with scissor! and the lest again made with the bullet forceps.

KovRTH Step. — The sutures are introduced as follow*: The firet ^utu^c
cnlcrt tlw n;r\'ix near the outer cd}«e of the denudation ai the angle of lacerati^in,
passes completely under the denuded surface, and cmcr);cs in the eervical canal

no. ut.—TtHun Slip.

TucHiuMtuiAntr.

Fio. m;.— FauTtti sup.

at the margin of the strip of miicoti.'i membrane. It is then {iass4^ ihRniuh the
edge of tlie inl^lcT^^■ical mucous membrane of the opposite lip of ihc cenix and
brought out just behind the extenuil line of denudation. The remaining i-uttires
are imroduced in the ^ame manner and secured with iterforatcd shot.

4S8

THE UTERUS.

Fin. 44S.— TiiArHELO«»H*p»v— FUth Step.
'res[inK ibe inlir^ty o[ Ihc ccrvii.-il canal.

Fifth Step. — The straight dressing forceps is passed into the uterine cavity
to test the integrity of the new cen-ical canal and the vagina irrigated with coiro-
sive sublimate solution (i to aooo) followed by normal salt solution. The puts

are then dried, a loose gauze tampon
placed against the cervix, and the nin
protected with a compress secured bj
a T-bandage.

Special Directions . — If the
uterus is more or less immovable, cm
must be taken not to make too mudi
traction upon it when the cervix is
pulled don-n with bullet forceps at the
beginning of the operation, otherwise
old adhesions may be torn and the
patient's life placed in jeopardy. It l«
important to remove all of the scar plug
at the angle of the wound, and also
any Induration which may remain in ibe
lip>s after the parts have been denuded.
The sclerotic tUsues are easily recognized
by touch and removed by lifting them up
with tissue forceps and cutting them
away with scissors. The bleedii^ is
usually very slight and is controlled
when the sutures are tied. If the circular artery is cut, the suture at the an^
of laceration should be introduced at once and lied. In cases of bilateral
kceralion the sutures on both sides of the cervix should be introduced before
any of them are tied, as it Ls difficuh other-
wise to pass them [»rojx:r!y and secure an
accurate xipproximalion. Without excep-
tion, the sutures must paw aimpleicly under
the (Icnutlcd surfaces, and unless this rule is
observed onlv a |>arlial union takes place
and a condition resembling an incomplete
tear rc'i-ults.

\'ariations in the Tcchnit.
— .\n incom]ilete laceration of the cervix is
first made complete by cutting through the
vaginal mucous memliranc and then denud-
ing the edges of the torn lips as in an orvli-
n;\Ty laceration. The subsequent steps of
the operation nre the same as in bibteral
and vinilalcral tears.

If a ci'lpo])crineorThapliy is jierfomied at
(he >iimc time ;i^ a trachelorrhaphy, chromi-
cixed Ciilgut should tie sutislituted for silk-
w<irm-gt.it in the cervix, otherwise the freshly
united jierincum may be torn when (he
un^ilisiirhahle cervical sutures nre removed.
.\n ami)utation of the cervix is indicated
in stellate or multiple tears, and the practice of cutting out lobes between
fissures an<l uniting (he raw olges should be condemned except in very rare
cases in which only a small single IoIjc exists. Another practice which is not

Fir.. 440. — OprRATins rnr IvnmnEnt
IjirkRATION or THi: Cei\i\.

b>' cuirins ihrDuqh ihc vagiiul
i>ranu uf Ihc ccnii.

IDUCDUS md

LACEKATIOKS OF THE CERVIX.

459

suiklnl (i[H>n picxl surgicul principles is cxrision of Ihc mucous membrane of
the wTviaii tuiul, when ii has iindcrf^ow cystic ilcgcneruiion. ami ihc repair
(if thr ciTvk-ul liuenttioH by the: o|teriitiMn or trichelurrltii|ihy. I'ndcr ihoe
r>in>lilii>tiv ampuUtKiti is ibc o)>cnilk>n of ivlrctiun and not Iracbclorrtiaphy,
which should atvtt be performed if the mucous membrane is extensively

dL-1C-Jt<'<l.

A ( I c r - I rea 1 m en t .— t'lirc o/ the Wound. — The vulvar cacnpress is
lempiinirily ^emo^«ll when the ImwcU ami biatldcr ure evaluated. The f;iiuze
mckinK i^ tukeii nui in Iwenly-four hiiur> itnd nut rrinlnHlucrd, and the vagina
K thru iirinnte'l d.-dly with a solution nf cnrmsi^x sublimate (l to looo), followed
Uy h>» mirmal Mh solution. Tlie vaginal irriRalbiL-> are ke(>i up until ihe iKiticnl
m(» (Hit i>f lied, and thvn a daily douche of n fcnllon of hot norma) salt solution is
givrn fur several weeks. The sutuns arc removed on the ei|;hih day.

Tlic Oirr oj the UaJJtr and lio-j-fh. tlie Tt^uhlion oj the did. and ihe rfiie}
of r«t(/enit(Ki •mil puin are diM*usscd under the Aftcr-irvalmcul i>f I>ilat^lit>n ami
Curctmeiit of the I'tcru* on page q()0.

Ortling i>Hl of Hfd. — The )i.i(ieiu shouht n;nuin in Le<J for (en days and tic
uiloHcl ii> >;•! I'll! .It ihp end <<{ ihr i^owd week.

Amputatioa of the Cervix. — T cchnit of the Operation. —
Tl»e f'r^/ninUioH oj lite PalirnI : the Prepariilu'ni jot Iht Operilion ; ihe i'oiilion
oj Ihr I'alieitt: am) the Number 0} Anistanls arc the same as in the opcfation
nf irachclofThaphy <lcscnt)ed on page 455.

QPa

-©-

aoQo

(i>-A

Q){

®G

ACTUAL SIZE

4tB.—tmneitwnK XtinuA Suri'it Miiini*). ut> ■■tanMttti Shot I'od pi n» OKutmii or
\tirt tAikn 'ir nti i:tttn,

^" ItuirumnUf. — (i) Simon's speculum ^curved Idadc); {>) livo bullet foicops;
[ (j) «cnlpel: (4) rij;lit ami Mt ^li;{hlly cur^-ed M-Lvxns; (5) lis&ue forceps; (6)
n\rr^ .i.iini; liullci (oTceps; (7) drcssinc forrepc; (fl) need led wkkr;
u;i Imt Mitiiprtiiiir: (10) two small (till 4-ur\e<l H3RC<k>ni needles; (ii) silk-
worm gtul-jo «tramK; l\7\ perforated shot.

The Itst of instruments reciuiml in tlte nperjtion of PUaMioH and Curtimfnt
(he tilenw which MhoukI always precede an amiwiaiion of the cervix will Ix
iwl on |MRc .JSJ.
O^ii/iiirt, — FlKST Stpp.— Tlw speculum U introduced into the vagina ami
' aiHerior ami jKiMerior llp^ of the cervix wzed wiih t>ullet forceps and drawn
^twn t'twunl the vulvar orifice. 'I'he dn^ng forcejis is then intmduccd into

46o

THE UTERUS.

the bltuldcr tn determine the relation existing Iwtwcen it and the cervix in onkr
to prevent wounding the or|j;im when the iinterinr imicnl lip U amputated.

Skconr Step.— a circul;ir incision is made with the scalpel ihrouKh itie mu-

cdus membrane i-ompleiely anmrxl the (trvii
be>'(ind the di»ea»ed and Licemtcd area and the
anterior and posterior lips umputaicO «iih the
i:urvc<l ^tissur^ an<t knife.

TiiiKD Stu*,— 'ITic rewrMT-acting htilkt
forceps is iniroiluci'd into the tvrvical aitwl and
ilx lilikdcs x'paraliil in unler to nintrol the
stump of ihe cervix and pull it dou-n while the
sutures arc inircKlucwI. Tlic instrument -ihi
mu^k^ the [xnition of ihc ainnt and is a giMt
when the sutures arc passed.

FuURTH Step. — The t'a^inal tnuntiu meiD-
hriinc is drawn over the «er\-ical slump and
secured with shotted silkwurm-Kut suture*.
The first ^uture. which t> intiiMluoed at tlic left
liilcral etijie <>l the slump, enters the ngirut
mucous niembmnc anteriorly alxmi oncei^ili
of an inch from il> divideil e<I|!e. |Kts<es thioti^
the trrricaj tissue, and emerges at the cmicr of
Ihc raw surface. Il is then reinirotlucetl intn
Ihc cervit.il tiwue and bmuf^hl out |><>slerii>rl}-
through the vaginal mucous membrane u|>-
posite the fMiint <>( entranw. Ilie remainingc
mlures on the left side of the cemcal canal, usually two in number, are in-
troduced in a similar manner, and the stump on the ri^hi >ide U tlien MilumI in
the same way.

L #4]

■^^.■■■"^-

FM- 4ii.-^-Auti:TATioK or nit: CrivLX

—tint Sttfi.

Sbowini Ihe dicultw (umiB inUuluud

idiuiIh Lilwlder,

Pra. 4)1.— Sscoad Stm

AxriTATioM or mc Cuvix.

fw. 4fj.— SM0n4 Sm*.

A space of ai lea>t one-thinj of an inch must be left between Ihc two middle
fttiture^ to prevent atresia and form an opening for the ccrx'ical canal.

LACERATIONS OF THK CERVIX.

461

Ulim alt the »ulurc« are in (xMition, the wnuntl i- cl'>Mcl by securing thco)
with |>t-rfi>rjtc<J shoi nml nn insmimcni i^ then pa»«<l into the uicrine cavity la
tr4 ihc init'K'iiy '»( ihc ccrvitul canal.

Fimt Step.— Thr \-iigiiu is irriKulvd with a »i)luiiQn "( comnsi^TC sublinuie
(1 Ii> >00o). folli>we"i Ity normal salt solution, and the opcniiiR into ihc lerviral
i:;inal (ui kwl H'iih ii lurmvr Mrip uf piuw. The \-j|j^nit L> filially dried and the
«*uU^ |)rt>tc<*lc<l with it (t>mjirc»« K-i*UTcit by n T-bandagc.

\' n t i a t i ■> n s in the T c c h n i c . — When a intlpoperineorrhaphy it
pcrformcil at tbi- Nimc time as :iii am|>ul<tlion, rlinimicixcd catgut should be
Milx'tiliil«-il for ^ilkw<>nn-pnlt in closing the cvmc^il stump.

After- Ircatmen t.— Tlic niripof i;auu Jioul<l rcmiiiii in the ccrvicaJ
uinal fur two days to [ire^'cnt adhesion.'^ incurring Iwlwccii the raw edges of the
wound,

llie rest of tlw after- treat ment ik the «ame a» that following the c^rtitioi) of
tnu'helt>n-)u|(hy (see p. 459).

PW. 415. — Fautlh sup,

AiBVt*naii n tm CnvDC

tn *iU.-Ttttb Sup.

liatc Operations.— Lacerations of the cri-vit should not be
ihc limr ol their oi • iirrvncv, 4.1 it L^ u^vually impuuiblc, on ai count of
^c cnmlilion o( the cervical tit^sues after labor, to rccognixe the extent or chnr-
[ler uf the traiimaliMn and a|>i>rt)ximalc Ihc lorn structures. And, furthcrniore.
danttirr uf K'jilie infetlion rexultinjc from an immedbte ofwnilion is m>
IKireni thai thts plan of trcMtnu-ni is unsurgical and should be earnestly
idcmned.
II the rinular arten' t> turn, however, it ^Iinuld be controlled by a deep
iture of rhn>m)(i/c(t calKut iinil the laceration rcjKiircd al the same time.
Intermediate Operations. —The ^^callcd iniermediate aiicratian
L<i-r.iii-i[i- •>( thciTr\ix i.>ri^i-l> in Tcp.iirinR the injur>- after the fifth day
thu )nirr|>crium liv rcmuiint; the ^granulations and suturing the edges of the
riral tear, NolwilhHtiindiii); th.it thi.i |>r<iiwlurc is advixuited by .«*rtne of the
romi priimincnl iKiichersof oI>*tetri<N. it is not ItaMiJ u|mn muml .surxical prin-
,;..!.-. ,,.,) should lie i-orwlemne»l lictauv of the danger of causing infection at a
1 I nn a.MTplic (Mirturicnt tmct is of the utmost importance to the safety

ii>r ) Ml tent.

4f>2

THE UTEKVS.

HYPERTROPHY OF THE CERVIX.

Hypertrophy of the neck of the uterus will be divided Into three varieties, as
follows:

Supravaginal hypertrophy.
Infra vaginal hypertrophy.
Apparent hypertrophy.

SUPRAVAGINAI. HYPERTROPHY.
Definition. — A true hypertrophy of the cervical tissues above the junc-
tion of the cenix with the vagina.

Canses. — The hypertrophy is probably due to an abnormal development
of the supravaginal cen-ix at the lime of puberty. It is very rarely met in women
who have borne children, jjeing almost exclusively limited to virgins and those
who are literile.

Pathologic Changes.— The increased weight of the uterus stretches the
ligaments and the organ descends, pulling with it the upper part of the vagina.
The pRitapsc gradually becomes more and more marked, until finally the cervix
appears at the vulvovaginal orifice or beyond it, and the vagina is turned inside
out as in the ordinary form of uterine descent. The exposed mucous membrane

of the vagina undergoes the same
changes that have already been de-
scribed under prolapse of the
uterus.

Symptoms.— As descent of
the uterus is the essential pathologic
change in supravaginal hj'pertrophy
of the cer\ix, the symptoms are.
therefore, the same as those of
uterine pTOlai>se (see p. 325).

Diagnosis.- This is the only
form of uterine prolapse met in
virgins and sterile women, except
the verj- rare cases of acute de-
scent that are caused by violence.
The patient is placed in the
dorsal position and examined by (a)
sight and (b) touch.

Sight. — If the prolapse is com-
plete, the cervix will be seen protruding from the vulvovaginal orifice, which li
always more or less dilated; the vagina is turned inside out; and there is no
evidence of a laceration in iht pehic door or in the cervix, which would be the
case in true descent of the uterus. Again, when the patient bears down or
strains, the jirotrusion of the uterus is not greatly increased, as in prolapse, and it
does not tend to recede within the vagina when the woman assumes the recum-
bent posture.

When the cer\-ix is still within the vagina, the perineum is intact; the \Tih-o-
vaginal orifice is not dilated; and there is no evidence of rectocele or c\-slocele or
relaxation of the lower third of the vaginal wall. In true prolapse, howei-er,
the vulva is gaping, the perineum torn, and the ti>wer third of the \-agina ls re-
laxed. This is due to the fact that in supravaginal hypertrophy of the cervix

Fir.. 4S7- — SrpBAVAr.INAL HVPEPTROHIV OF THT CeSMX,

N'olt ihc IPTiK^li uflht reriif W-rwwntln' ^»i;jna] ^aL]][ inj
ibeaDlfhorand I'oKcriorrtflci.'Tionsof ihe in-Hluneum.

SCPRAVAOINAL IIYPtlKTROPllV OF TRS CERVIX.

4«J

upper pan of ibe valuta sa^^s first, while in proUpsc ihe bulging ol ihc an-
rior nnd posterior lower third of the Citnal taiti place bejore (he descent of
^tht- uicnis.

Touch. — IntroilucinK the in<lex-ringer of the left hand into the vagina, ibc
tBfnvaginnl cervix is found tu Ik nortnid in uxt und .ihape, l>ut utcupyind a lou-er
poaitioD in the pcUis. Viigino-alxlominal palpation reveals the po<^ition of the
tamlus of the uterui', whiih i» luf^ii-f than i» con^^lcul with the dc(;rcc of ccnical
descml, indicating, therefore, not only prnUipsc, but elonmtJon of tame part of
ih<^ "nc^n, whkh can often be demonstrate, by palpation, to be situated in
the -lu I >rik vaginal cemx.

When descent of the uterus is marked in hx'pcrtrophy of the cervix, there it a

|0>

'©

(i)

h 00*

odfM

<j>

F*a. aia— Imiacucifn I'up in nn 'irntnoH m Htr.n Aiiri.i4iu» or ibk Cnrn <|imk HW-

^®

Sm->» Mtitiuu.
I'rr-ll \umiMKn M nti

rided want of mubilily In the orjcan and
is nmreor k-«s<lilTnult inrq>Uce, Tim ..
due to tlw itdaiged utcnis encroaching n @ Vi f^

■[Min the i.ipaiity (^ the )iclv)C cavity, and ' il "^

nnl met in cafvs of tnie prolapse,
rhcre the mluction of the nrgan U easily
arcomplii'lirtl.

Prbgnosis. ~A cure c«n only lie
leilctl by surKidil nie:i:^ure& and iio form ACTUAL SIZE

pulluitive Ire.-ilmeni i> of any benefit. f,^

Treatment.— The following o(>eri- ;

arc emi>l<>>-e.

Hifth amputation of tlie cervix.
Anterior am) posterior colporrhaphy.
HyHterorrhaphy.
Hifh Amputation of the Cervil. — High .imputation of the cervix i.> the
Jy operatiiin n-ijuired when hypertrophy of the cervix is .iwotialcd with a i>ltght
Irgrre of decent, hut if theuienne proliipt« i:> marked ai>d the raginal walls are
iixetl, il must be fiillowed blcr on by coliwrrhaphy or hytierorrlinphy or iHrth.
Up-* <>|Mrralion9 should not lie performed too soon after the amputation. cxirc(>4
I fiireme ciit««. hn the ^uWtiuent derre.i>e in the «iac and weifclit of the uterus,
a* well Its the incrcui« in the tonicity of the ^-aginal walls, may render further
•ur|[ioil Interfrrcncc unneccssaTy.

464

THE UTERUS.

Technic of the Operation .—The Preparation 0} the Patient and
the Preparations for Ihe Operation are described on pages 830 and 831.
Position of Ihe Patient. — Dorsal position.

Number 0} Assistants. — An anesthetizer, one assistant, and a general nurse.

Instruments. — ( i) Simon's speculums
(cun-ed and flat blades); {2) two lateral
vaginal retractors; (3) two bullet forceps;
(4) reverse-acting buUet forceps; (5) scalpel;
(6) straight scissors; (7) four short hemo-
static forceps; (8) two long hemostatic for-
ceps; (9) dressing forceps; (lo) bladder
sound; (11) shot compressor; (la) needle-
holder; (ij) two small full-cur\'ed Hagedom
needles; (14) plain cumol catgut No. 3, six
envelopes; (15) silkworm-gut — 15 strands;
{16) perforated shot (Figs. 458 and 459).

Operation. — First Step. — Simon's specu-
lums and lateral vaginal retractors are
introduced into the vagina and the anterior
and posterior lips of the cervix seized vith
bullet forceps and pulled down toward the
vulvovaginal orifice. A circular incision i=
then made just above the vaginocenical
junction through the wul! of the vagina down to the tissues of the cervix.

If there is much hemorrhage from the divided vaginal arteries, they should
be seized with hemostatic forceps and ligated with catgut.

Seconii Step. — Strong iraction is made upon the cervix with the bullet for-

FlO, 460.— Hir.H Allri'I»THl!< or THE Cl».
vix— Fint Step.

Ftc. 461 .—Second Step.

Feo. 461. — Svcond Stop.

]Lii;ii .^upUTATtoN or the Ckbvix.

ceps anil the cervical tissues .'^cjwraled with the fingcrK in front and behind from
the surrounding structures as far a.s the level of the uierine blood-vessels.
The arteries are ihcn ligated on each side close to the cervix with catgut liga-
tures.

Third Stf.p. — The cervix is di\-ided on each side as far as the uterine blood-
wssels and a silkworm-gut suture carried on a cur\'ed Hagedom needle passed

L Fimt Strp- — Two or three addittonul silkwnnn-gut »ulure» arc puaed

■ ihrou)^ the vnitiaal wait, the Icmmc connective tissue, and the cervix on each Mt

466 THE UTESUS.

of the original sutures in order to cover the stump, as in the operation of simfrfc
amputation (see p. 461).

Sixth Step. — The sutures are shotted, and the vagina ini^ted with a solu-
tion uf corrosive sublimate (i to aooo), followed by normal salt solution. The
pans arc then dried; a narrow strip of gauze packed in the ccr\-ical opening; a
loose tampon placed against the cervix; and the vulva protected with a ccmpnss
secured by a Tbandage (Fig. 466).

After-treatment .—The strip of gauze in the cer\-ical canal and the
vaginal tamjxjn arc removed in forty-eight hours and not introduced again, and
the vagina is then irrigated daily with a solution of corrosive sublimate (1 10
3000), followed by normal salt solution. The douches are continued until the
piilient gets out of bed, and then a daily irrigation of hot normal salt solution is
gi\en for several weeks.

The sutures are removed on the eighth day.

The care of the bladder and bowels; the regulation of the diet; and the relief
of restlessness and pain aredescribedunderthc After-treatment of Dilatation and
Curelment of the Uterus on jwge g6o.

Gelling Qui 0} Bed. — The patient should remain in bed for ten days and be
alloweii to go out at the end of the second week.

Anterior and Posterior Colporrhaphy.— The technic of these operations
is described on pages 251 and S02,

The 0|>eratii>ns, as stated above, are indicated when the relaxation of the
vagina! w-.ills is marked or is not benefited by the decreased weight of the uterus
after the cervix has been amputated. The operations should not be performed
for at least one month after the amputation, and, if necessary, a h}'steron'hapbr
should be done at the same time.

Hysterorrhaphy. — The technic of the operation is described under the
treatment of uterine prolapse on page 331.

The ()[}crution is only indifuted in cases in which the relaxation of the parts
is so great that the uterus cannot l>e supixirted by an anterior and posterior
colporrhaphy alone.

INFRAVAGINAI. HYPERTOOPHY.

Synonym. — Hyijcrlrophic elongation of the vaginal cervix.

Definition. — A true hypertrophy of the cervical tissues below the junctiMi
of the cervix with the vagina.

Causes. — The hypertrophy U always congenital and is met only in virgins
and slerjic women. It is a \'cry rare condition, and even when present the
enlargement is seldom sufficient to cause symptoms.

Pathologic Chang^es. — As stated above, the elongation is due to a
true !iy]>ertn)[ihy of the normal cervical tissue, which may be ver>- slight in some
cases anil in others the rucrgrowih may be so great that the cervix protrude'
from the vidvovaginat orifice. The h\'pertroi>hy results more in a lengthtninfj
of the vaginal cervi.x than in an increase in thickness, and in most cases its
diameter is but little, if any, greater than normal.

Symptoms.— Moderate degrees of hypertrophy cause no symptoms. The
accompanyinit stenosis of the cervical canal and the change in the position of the
cervix may interfere with impregnation and thus tend to cause sterility.

In well-markcfl cases, on the other hand, sterilitv nearlv o!wa>"s exists, aitd
sexual intercourse is seriously interfererl with by the presence of the enlarpeii
cervix. When the organ protrudes from the \iilvo vagina I orifice, locomotion i>
more or less difficult and the exposed cervix is likely to become inflamed from the
constant irritation ;ind friction to which it is exposed.

INreAVAOJNAL HYPKXTXOPHY Of THE CEBVIX.

IHasnosis.— The patient is examined in the dor»al and knec-dKfit positions

{ii) -ifiin .iivl (A) |i>ti<-h.

Sight. -With ihc iKilirni in tlic <lon.nl poeilion nmhing if ol><vrvc<l rxirmally
unlrsa the icrviJi i)RHru(lc9 frmn the vuhar oriinv. Inirddudn); a spcntlum
into thf vnjcina -n"! rriractinK ihc |HTiii«im, the itrvU t« s«n m Uc cnUrRWI und
ctinkal in shaiw. PUcing ihc woman in the knrr-chc^t {wslure and rcinlro-
durifif: lh« Hp«iuhim, lh« cervix in afr-iin »)i»r>e(l to view imd fnuntl to \k llie Mine
Irnglh BP nhvn ihr rxatninatton was made in the dorul position. Thii^ is a most
■mpofUiiit |xrinl in the exu mi nation, as (he cerxix l)e(-om(rs much tJioncr in pn>-
bp*c iif the uterus when i«rn with the txiiienl in the knce-chwt poMlinn, The
mu4)n hir this is ihdt in prolapse as the uterus descends the vault of the \-agina b

Iw ibf. tin. 4f>i.

tanAvmiiiAi. HimtiDFiiT o* na Cnm.

r polled down rk^ely afpiinst the Miprnvaginal cemx, Riving the appearance of
rlimKition to (he infravaginal jxinion, which doe* not exUt in reality. Upoa
^ the patient in the knee d)«t )KKiiii»n and intrmliicing a ?iperuhini air
,..-1..^ into the vagina; the uterus falls back: the tension upon the vaginal
vsult a relietTd; and the apparent elongation u( the renix dtMp(>ean.

ToBch.— The examination i> m;idc with the patient in Ihc dorsal [HK.iiion.
Vaicinal titucfa reivalfl an el«n^tc<l and conical ccnix. Ttie (tome of the vagina
ft not otililrrated or rlrann down, a& in probfwe, and the funduii cil the uteni.t ts
fffuniJ «i lie in its n')rmal ignition.

DifTerential DiagHOSte.— Hypertrophy of the cetvix maM I>e distin-
Cui«l>e<J Ir'.ni {>[>-l.i|.<se of the utenis. Tlie (liagnoM* b n»de OS billows ^l-'i)p.
460. 470. 47'. """' 47'):

Hyrunmnry or tnx Cnvix.
I f>ceun bi viii^M smI in t1«rilr wooitn.

J. No TtiArnu ol Irsunutum In Ibe trtvit

at peiumim.
p Crrwt •loaiatiH] and cooJral.

1 Karr<ltnt tv«4iI<ki ilor* not Intru ibe

( I>amr n( i.> nnmul.

'-■■■ ■ : ii .rimi m rnr vagina) walll.

I Ihr tUmw la naniMl podiion.

PaouvM or the Cnxcn.

I. Omirt in wnmca who have bomr chil-

dnrn.
J. CtTVti anil prrioram inttiUy lacFrnln].

J. CcTvU appatinllr clongatrd bwl not con-
ical.
4. KnFp-chnt pMilinn faiaa Ibr apparrnt
tloagation to iliiitppr<r.
DoBir o( Ibr vigiiw (s obUtrralnL
R«ctac«tr aarf mMcclt.
Fimdut lower tboa mnwal.

Fm. 471-— Ilypcriioii)!)'' rie. 4I»— PlApe-

nimnxTiAi. l)iWHCi>i« UTYIU1I' lititAVAaniu. HmamnivoriniCuTiiASD P»ii.*nr<W m tiiit*

>>|. 4!i iluiiii rtul tKc LH*-(t>KI Imiltlnn ilnn lurl Inan Ihr Imfihaf iht (trrii; fit i;> rik>*«ihM Itel
djM pioliiun (iiua tlu ipptrmi tlungiiina ol ihr onli in driapiavf

Treatment. — The trraimcnt consists in th* remonl ui ihc elongated tmi«
b}' aiii)>u[aiiun ah di^trribe'l un \K%)iv 459.

APPARENT HYPERTROPHY.

In tilts (orm of liyperlrophy there U an ap|iarent but not an acitul elongBiwo
o( the vaginal cprvix. The cnmlitinn is cnuMil I>v the allcrwl rehtion" that ciisl
between the uterus and the vault of the vaf^ina in case* <>f uterine pn>h{M
Under these circumstances, a» Mated elscwliere. the vnginal vault i* pulled dnwn
by the descending uterus and lies cU>se against the supravai^nal cervix.
ducing the effect of elongation in the infravaginal ponion.

CEHVICAl. l-OLVPl.

469

Apparent hypcruophy i>f ihc cervix h merely one <i( ih« phy>k*.il »igns of
|)roUp»« o{ ihe ulcm.-i, ami the reader is referred to that affection for a detailed
discussion n( the subjetl (Figs. 351 and .jja).

CERVICAL POLYPI.

Varieties.— The fnllowing arc the must common (ftrms <if cervicnl polypi:
Mutous Polypi.
Fibroid I'olyjii.
Warty or Papillary Growth*.

Mucous Poljfpi are the most frequent of all the \-arielics. They develop
from the gland.-i of the intmcervical mun>sji and are the result n( inllammalion.
The mouths of the ducts bccwmc obliterated; distention occurs; the <mall en-
liirgemeiiin l«ecome constricted; and the jwlypoid masses project from the sur^
fioc <i( the mucDUK membrane. Siimeiime-s nuicouK [K>lypi grow lu a large nxe
and protrude in a mass from the external os uteri,

Fibroid Polypi are not nc;irly so loinmon as the mucous variety. They
occur singly, as a rule, and begin lis a smiiU inleiMitiiil filirtius m.i^< in the cervix,
which fiRidu-ally projecL-. into the ccr\ical canal ami eventually becomes peduncu-
lated. The ))rdii*le is usually long ami slender and the [xilypu.i often oscii^WK
from the cervic.il cmal and hangs susi>cnde«i in the v;igina by its stalk.

Warty or Papillary Growths are not common, but they arc occasionally
found in the lower jiart of the cervicid ctinal nuir the external u> uteri and present
the usual appearance of such grviwihs elsewhere.

Symptoms. ^The symptoms are not distinctive. The most important are:
I.rukoiThe3.

Menstrual disturltance^.
I'lerinc hemorrhage.

Letihorrhea is a more or less constant symptom and is due to an inflam-
malion of the jnlraccr^iuil mucous ineinbmne whi<U usually accompanies
polypoid growths. Tlie cliaracler of the ilischnrge is the same .is in iinmm-
plicated cases of cndoccrvicilis. unless the canal becomes infected or the jjolypusi
protrudes Into the vagina, in whidi case it becomes very profuse, purulent, and
oScnsiiT.

Menstrual Disturbances arc common, ami manifest themselves in the form
of mcnorrhagia or dysmenorrhea. The i>resente <if the growth cau.-tes irritation
which Tcsulls in uterine congestion, and hence the menstrual llow is often pro-
longed in duration and increased in amount- I'or the same reasons the monthly
ningrstjon of men.->lruation i.i accentuated and dysmenorrhea is a cummon
symptom.

Uterine Hemorrhages are a more or less constant symptom. Sometimes
the bleeding is flight ami m.-iy follow .-iclivc exertion, siniining .it st<Hil, or >exu<il
intercourse, and in other cases it may be so [>rofusc and persistent that acute
anemia results and the patient's skin becomes jiale and waxy in appearance.

Diagnosis. ~11ie pulient is placed in the dorsal p<Jsit ion and examined by
(a) sight and (b) touch.

S^ht. — If the |>olypus protrudes from the external c« uteri or hangs suspended
in the vaginn it can readily lie seen thmugh a speniUim, but when it cKcupics the
upper or middle third of the cervical canal its presence cannot be detected until
the cervix is diLited in order to determine the <aus<- of tlu; symptoms. The
external os uteri and the cervical canal, however, are found to be dilated, and
there b frequently an area of erosion onihc Lcr\ix which is due to the irritation of
ihc Icukorrncal discharge.

470 THE UTERUS.

Touch. — The polypus is easily detected by the examining &nger when it
protrudes from the cenis or hangs in the vagina, but if it is situated hi^ up
in the cervical canal and cannot be palpated the characteristic gaping o! the ex-
ternal OS is the only physical sipn present.

Differential Diagnosis.— Cervical polypi, unlike uterine tumors of
the same nature, do not, as a rule, attain a large size, and hence they are seldom
mistaken for other conditions, as their relations with the surrounding parts an
not obscured by their large bulk. Sometimes, however, a ceriical poh-pus
may continue to grow until it filU the vagina, and it then becomes necessur
to distinguish it from an Inversion oj lite Uterus (see p. 362).

The question of malignancy must alwa\-s be borne in mint] in cases of cemcal
polypi, especially when the growth occupies a high position in the corneal canal
and cannot be detected by sight or touch. Under these circumstances an tx-
ploralorj- dilatation and curetment of the uterus must be performed in order to
discover the origin <if the symjjtoms and exclude the possibility of cancer of the
cervix.

Another routine rule of practice which must al-
ways be observed is to examine microscopically
every polypus that is removed, otherwise the malig-
nant character of some of the.se growths may be
overioiiked and the opportunity for an early hyster-
ectomy Inst.

Prognosis. — There is always clanger of malignant degeneration occurring
in a cervical jjoljpus, and hence it should be excised at once. If the tumor l<
benign in character, the prognosis is good, and it docs not return after remoi'al.
A sjiontancous cure may take place at times as the result of the pedicle becoming
constricted and the tumor sloughing off.

Treatment. — The treatment in everj- case is surgical and consists in the
removal of the growths. (See Treatment of Uterine Piil>-|ji. p. 387.)

EVERSION OF THE INTRACERVICAL MUCOSA.

Causes.^Ectro])iun of the intraccrvical mucous membrane may arise from
the following causes:
Traumatism.

Congestion and inllamniation.
Congenilal defect of the external os uteri.

Traumatism. — This is the most frequent cause of evcrsion and is due to
e.vposurc of the intracervical mua)sa by a laceration of the cer\ix. This variety
is fully discussed under laccriUions of the cervix on page 451.

Congestion and Inflammation. — .\ large number of cases of evcrsion are
due to long-continued congestion or inflammation which causes the mucos.i to
licconie swiiilcn and gradually dilate the cervical canal. In time the external oe
becomes |i;[tul"us and the thickened endometrium, not fmding sufficient room
within the iLimil, bulges toward the jxiint of least resistance and protrudes lieyond
the cerviial lanal.

Fndoicrvicitis is a more or less frequent cause of this variety of ectropion,
which is especially liable to occur when ihc cervical inflammation is associated
with a pelvic tumor that interferes by pressure with the return circulation in the
pelvis. Agaiii, I have also observed a numl>er of these cases in young women
who were engaged to 1h' married anil in whom the j)elvic organs were congested
from ''the sexual engorgement in love-making." And, finally, certain vinous
habits, such as checking the menstrual How with cold-water douches and the use

EVERSION OF THK INTItACKkVICAL UUCOftA.

47*

nE conrlomK in mxuuI inteioxirse, an well a» other umibr |>ractkei', are \'ery apt
lu fsiux (ongc^lton (i( ihc uterus, which may o-enlunlly be followed b}' eirruon of
ih* rrrvUat nmcosa.

CongenittI Defect of the Eitemal Os Uteri. — In this viirieiy of et-en.ioii
the tn<r4i:crvitj| mucous membrane, which nomully Mope at the external as
tUrri, '» ciiniinued and spreads otcr the outer a>pcct of the terrix. Th» ah-
tuirmal cxlvn^jun of the glund^ unci the epithelium lining the cn-vical oivity
nckults from an cmbi^onic defect in the development of the miucular fibers
uf the lower sckiii^x' ^' ''■<! wrvU. wliiiji (nil to contracl and cdcIom the entire
etna I.

Symptoms.— The symptoms depend upon the cause and extent of ihe
evcTMon

The local and Kenetnl miinifcT^tations of traumatic ectropion are diKusscd oa
ptgfe 451 and need not be refeired to here.

The displiicemeni i.< usually vcn' limited in c3>c$ <4 congenital nod in-
tUmmalon' e\'ersioRs, and hence it f^ve^ ree to no chamctrrii^tic eymptoms.
When, houever. the everfton is markei], the exposure of the mucous mcml>nine
tit the adil t«cretion« of the vagina nnd Ici friction nfcainM the vagin4l walU
prrxluces an inHammation of the ^'^ndular structures which results in hyper-
Mxrrtion. These ra-K^. therefore, have more or les> leukorrhcul discharge and
thr ivrnptimu are <imibr to those causod by a deep bilateral luLCration of the
icr»i\.

lyiagnosle.— The diagiwiMs is made a* follovrv:
■•"he hislorv'.
The symptoms.
The physical signs.
The microGcot)ic examination.

The traumatic variety of ectropion will not be
considered. •

Tlie Histonr. — There Is usually no histor)' of a previous bbor. A careful
innuir)- shnulil be mu<lc as to the cxisteiurc «f any C4u*e* i>f peine cnnge»lion or
inflamnutliun and a note made of those which arc likely to result in lenical
e»tro(iii>ri.

Sycnptomk.— The symptoms are not distinctive and in Mme cases they may
be jbscnt iilliqiether.

Physical Signs.— 1'hc |>aiient if (ilnceid in tlie dorsal [Kisition and examined
by (it) sight aiMl (ti) touch.

Si K hi. — In -nlifiht ever^on the shajwof the cenix i» nonnalaitda fcranubr
arcft b Men sumtunding the ok uieri. When the everted mucnus membnne
cttrrrs a lar|;e surface, as is sometimes the case in the congenital variety, the
CfTvix beconici club-shafied at it.s extremity and its upjjcr |uirt is constricted,
givlitic it the apfx-annce of a )>edicle.

The cvertnl mucous membr.inc has a granular or eroded a[^>cannce which
i» not readily iliilinKuiNhed from a true enmion unlevi cystic dcKCneration '»
present in Mime of (he glands which nould (Kisitirely pro\-e the existence of
cvcrxion. In grinuiar tundilioib of the cervix the presence of an evcrsion of
the iniraicrvi<:id muios.i should alway* be su^iieiteil when there Li no hiMory
of 3 previous prptfnancy or when the parts show no evidence of traumatism.
Cervical ero^ion^ due to congenital evcniion have been found in a brge number
of new born infant-).

Tout h,-By vaginal touch we are able to recognize the soft, vdvel-IQce
afca of emersion i^urroundin^ the external at; the presence of Xabothian c>'Sls;
ibethajicnf the cervix; and the absence of any evidence of laceration.

472 THE UTEKDS.

The Microscopic Examination. — If it is necessary to confirm the diagnosis,
a wedge-shaped piece should be excised from the cervix and sent to a pathol-
ogist for a microscopic examination.

Differential Biag^nosis. — Eversion of the cervical mucosa onist be dis-
tinguished from the following conditions:

Ectropion with laceration of ihe cervix.
Malignant disease of the cenix.

Ectropion with Laceration. — This variety of eversion occurs in women wba
have borne children. The physical signs of laceration are present; the cervix is
enlarged and indumted; its extremity is club-shaped; the angles of laceration an
recognized by sight and touch; and the hard plug of cicatricial tissue at the
bottom of ihe tear is readily felt by the examining fijiger. The cervical canal is
distinctly traced on Ihe anterior and posterior lips as a clearly defined strip of
mucous membrane which disappears from view when the ^lape of the cervix is re-
stored by bringing the everted parts together with crossed tenaculums (Fig. 437).

Malignant Disease of the Cervix. — The microscope must be relinl upon
to distinguish between the early stage of cancer or sarcoma of the cervix and the
so-called erosions that are caused by eversion of the cervical mucosa. In the
later stages of malignant disease the physical signs are characteristic and a
mistake could hardly be made. An early diagnosis is imperative from the stand-
point of r.-idical treatment, and it Is therefore necessary to view aU cervical
erosions with suspicion.

Prognosis. ^The affection is readily cured, as a rule, by appropriate
trcalmonl.

Treatment. — The treatment is based upon the following causes:
Traumatism.

Congestion and inflammation.
Congenital defect of the external os uteri.

Traumatism. — The treatment of this variety is discussed under Lacerations
of the Cervix on page 452.

Congestion and Inflammation. — The eversion in these cases is always
secondary- to a local or general condition, hence we must first discover the pri-
mary cause and then remove it, and at the same time apply treatment directly to
the everted mucous membrane itself, .^s stated elsewhere, the affection is
primarilv caused bv an endocenicilis and the swollen mucosa is eventually forctd
through the os ulcri. The cause of the inflammatory condition must be souf;bt
for and treated ujion ihe principles laid down in the management of that disease.
\\*e mu?l also bear in mind Ihe rOle played by vicious habits and long engage-
ments in the etining)' of cervical congestion and ectropion, otherwise no ben^
ficial results will folKnv the treatment.

.\s the endoccrvicitis or congestion is relieved the mucous membrane dimin-
ishes in thickness and the everted portion gradually retracts within the cen'ical
canal. This result is materially hastened and assisted by the following local [dan
of treatment:

1. .\ douche of one gallon of hot normal salt solution (110° F.) is used every
night and morning with the patient in the recumbent position. Before going
Id befl a fotlcm-wool tam|>on siiturated with ichthyol and glycerin (35 per cent.)
is introduced iiitu the vagina and remove<i on the following morning.

2. From one. half to an ounce or more of blood is removed from the cenii
twice a week with a sharp bistourj- (see Endometritis, p. 423), and at the same
lime the cverteil jiorlion of the mucous membrane Is scarified by a number of
.superficial parallel incisions which are crossed by others at a right angle. (See
Lacerations of the Cervix, p. 454.) The entire ceri'ix and the vaginal vault ate

ACOniKO ATIE«A OF THE CFJEVIX.

473

iben painted with tincture of iodin and a tampon of irhihyol and fclycmn (95
per cent.) intrinltiiHl into the vagina.

All local irr.ilmcnt mutt be discontinued during the mcnslrual periods.

Th« retno%'al of the cauw combined wlih ihc local trtainwiit uf^ually rvsults in
a complete cure of th« evenion. But If it atill peraLsU and is limited in extent,
the mucous membrane with ii« icl'~tnduliir dements must be destroyed by the
aciunl cautery. When, however, ihe eversion is marked, radical measures must
lie instituted and the lower third i)( the cer\-ix am|iulated.

(!) p r r a t i o n of C u 11 1 c r i z a 1 i o d . — No preliminary prcparaliun b
required and an anesthetic tK unnecessary.

The |>alient is placed in the dorsnl poiiliim and the cervix exposed with a
»l)cculuin The anterior and postcrl<)r lips are then seized with bullet forceps
arxl drawn ilunn lowitrd tl>c vulv;ir ojwnini;. The ct-ciicd mucous membntne
fturroundinft the 05 uteri i.-; now deeply seared n-ith Ihe platinum point of a
Pat]uclin cauten' or a pointed piece of steel heated to a red-heat and the wound
dressed by plannfC a 4vttl<>n-woul lampun coveretl with iudoform ointment (U. S.
P.) aK»insi the cervix. The tampon is removed esTry iwcnty-four hours and
mipplir*! after the vagina has Iteen irriKaied with a hot normal salt wlutiun ( 1 le"
F.), The wound ([enersilly heatv in abtml 4>nc week, and in (he meantime ihc
paiirtu i^ allowed In allow! U< hct uf^uA dulies.

Congenital Defect of the External Os Uteri.— The evenion in lhii> variety
bcinc due in an embryonic <tclicicncy in ihe lower portinn of the cer\ical canal, it
nnUinilly follows thai treatment uill not cause ihe displacement to retract, and
Itenie ii mu»i lie deMrujed by the (auier>' or removed by amputation of the tower
of the cervix.

AOQUIR£D ATRESIA OF THE CERVIX
Definition. — A complete closure of the cervical canal due to acquired

ttbologlc Changes. —An atresia of the cervix prevents the escape of the
islrual blood and uterine setretioan, which pudually accumulate within the
ivity o( the uterw aixl proiluce the (ollnwing conditions; titmi.Uanitlr<t, or a
CoUection of blood within the uterus; hydnintlrn. or a colleclion of mucus;
pyetnetn, or a colleclion uf pu^; ami pkyiomeira, or a colleclion of Ra-ses.

The Uteru^L mrely attains a Uigcr sixe ihan that of .in orange and ils walls
Iher liecome disiended and thinner than Dormal or they lake on h)'pertrophy
ini'reai« in thicknox, as in prrxnanc)-.

If lite distention of the uterine cavity is mariced, the Fallopian tubes also be-
»me involved and a kemalofaJ^nx, a hydroioifinx, or a pjmalpinx U devclu[ied.
CaubcS. — Atresia of the cervical canal may be caused by ulcerative ad-
bciiona or pressure incases of cai>rcr of the cervix; a faulty lechnic in n|)erationa
m the cervix: and ctcalriccn and adhe^ioat from sloughs occurring; during bbor
from the apfilii^ition of add« or the actual cauter)'. An ill-filting [ici^iry may
inflammation and subsequent closure of the cervix. Ulcerative chungcft
ay also occur during an attack of diphtheria. Miirlel fever, or >null|i>ix, aixl
daw the extenul o» uteri. And, ttnally, adhesive inHammaiion may occur in
wumen who have |u5sed the menopause and ol>literate ihe cer\ical canal.

HtmaJemdra occurs, as a nile, in women tteforr llie men(i|ait»e, and is due
Ki damning-up of the mcnstrunl blood. itydT^mtira is most frequently met
in oM Women who ha^v passed the climacteric, and pyomara is comparatively
coounon In cancer of the cervix, but is rare in casei in which the midicnant
diaemM » »ituate<l in tlw body of the ulceus. PhyivmfJfa occurs most ofirn in
iiinnectiaa with ityometia, and is due to the de^-eloprocnt of gasps in Ihe pus.

474 THE UTERUS.

Symptoms.— The symptoms of atresia depend upon the age of the patient
and the character of the contents of the disttended uterus.

After the cHmaaeric the affection does not give rise to symptoms because the
uterine Rbnds are inactive and the menstrual flow is absent, and hence there aie
no fluids to be dammed up and distend the cavity of the uterus. Id young
women, however, atresia of the cervical canal gives rise to amenorrhea and other
well-marked local and general symptoms that are caused by the retention of the
menstrual blood within the uterine cavity.

In cases of hydrometra the symptoms are entirely local and the patient com-
plains of a sensation of weight and fullness in the pelvis which is accompanied
by more or less backache. The intensity of the symptoms naturally depends
upon the amount of uterine distention, and in some cases it may be so great as to
cause marked local distress.

In pyomelra the contents of the uterine cavity are infected and, in addition to
the local symptoms caused by the presence of the enlarged uterus, the patient
develops a more or less active type of .septicemia.

Physomeira is associated with pyometra and the symptoms are similar.

Diagnosis. — The diagnosis is made as follows :
The history.
The symptoms.
The ph>'sical signs.

The History. — The statements of the patient may point to one of the causa
of acquired atresia, und she may have had an operation upon the cervix or some
form of intrauterine treatment, or there may be a history of a vaginal inflam-
mation occurring with an attack of diphtheria, scarlet fever, or smallpox. The
age of the paiient is also important, as hematometra usually occurs prior to the
menopause and hydromeira is generally an affeclion of old age.

The Symptoms. — Amenorrhea accompanied by a menstrual molimen if
significant of ihe prcscntx' of atresia. The local symptoms produced by the
pressure of the distentitid uterus upon the pelvic organs are of no diagno:lic
value, iis they accompany all forms of uterine enlargement. General septic in-
fection piiinls to Ibc purulent character of the uterine accumulation when the
atresia and rlisteniion have been recognized.

The Physical SigDS.^The jiatient is placed in the dorsal position and exam-
ined by (if) touch and (ft) sight.

Touch .^The examination Is made by vaginal touch, -Mgino-abdomiHtsI
palpation, and the uterine sound.

Vaginal touch and vagino-abdominal palpation reveal a round, symmetric.
elastic lumiir, and if the uterine walls arc distended and thinner than normal.
fluctuation may be elicited; bui if the muscular coat of the uterus has become
hvperlroj)hied, it is difficult t() recognize the cystic nature of the enlargement.

If there is an obstruction at the internal and also one at the external os, the
cervical and uterine cavitie? arc ilii^tcnded separately and the tumor becomes con-
striclcil at or near its i.-entcr.

In cases of marked uterine distention a round elastic tumor may be felt
through the abdominal wall above the symphysis, and if the uterus contains gas
(phy.-omflni) u tympanitic note will be elicited upon percussion over the en-
largement.

The examination with the uterine sound should be made by sight under the
influence of an anesthetic and with strict antiseptic precautions. A speculum
is intrfMluccd into the vagina and the anterior and posterior lips of the cen-ii
seized with bullet forceps. A careful examination is then made of the cervical
canal with the sound and the situation of the obstruction located.

ACOtn»Et> ATKESIA OP THE CFJIVIX.

475

Sight .—An examination ihrough a spf<-ulum rcvcate nothing unless ibe
•}b5iruciit>n is situated at the external oh uteri, in which cue the closure o( the
, ofiemnit may be >ecn am) the fliiijcnnfis confinncd,

I Differential DiagliOSls. —Atresia of the cervix resuliinK in distention of

^^be uterine cavity must Itc ili^Uiifcuishcd fmrn pregnancy und tibrnnu of the utenu.
^H In pregttancy the uiual subjective and objective signs are present and there
^fci DO hi^ory, as a rule, of amenorrhea prior to );e:^iation.

! A pbroid tumor it uMially accomp;iniwl by menorrh.igia or metrorrhagia or

both, nnd the enlarged uleru.s is hard, nodtibr. and inelastic. An examination
with the iiicritic >ound rcveaU a paiulou.i teniciil canal.

Prognosis.— .^ a rule, the nffntion runs a chronic course, Pyomctra,
jwever, nwlangers life from septic infection, and the pro|;nosis liccomc.^ very
ive if the oviduct:! are involved. Oicasionally in physumeira the confined
I break ihrouffh the <>l>struclion and a spontaneous cure results.

-®- .

, 4Tt— Inneiicin* I'lm ■■ nn OnaiTiov ma me Ruovu or ui Aiqi'iam ti»Tioi~ni>ii ■■ \

UntVXL t'AHU.

The mults following operative meaKurc« arc usually good and the imlienl
nerall>' reiotrrs unless she i.s M>ptic at the time of operation {pyometn^.
Treatment. —The indicaiti>n.-> for Irealinenl are as follows:
To remove Ihc obsinjction.
To keep the lanal patulous.
Til rclri-vt' the romplii atiotu.
To Remove the Obatructioo.— This is the c»cntial (actor in the treatment
b ancomuliihed by the o]>eTation of tUxutiion and lidsioH.
Tcrhnic of the Opera i ion .—The /Vi*^r<i/f4mtf/iA*/*it/ifii/antI
tp<]f<jtit>nt jof Ike Oprration arc describe<l on pages 8jo ami K31.
Potitia* tff the Patieitl. — Dot^al jKi^ilion.

l^umbtr 0) Anhlatiit. — An anc^thetixer, one asusUnl. and a general nunte.
Inilrumrnlt.—li) Simon's sjiciuKim (currcd blade); (j) two bullet forceps;
j) ftniiitlii narrow bkttouryi (4I liKht uterine dilator; (5) heavy uterine dilator;
b) Mraighl Kbsors; (;) uterine sound; (S> dressing forceps.

476 THE UTERUS.

Operalion.~~Thc speculum is introduced into the vagina and the anterior
and posterior lips of the cervix seized with bullet forceps and pulled down toward
the vulvar orifice.

If the olistruction can be seen at the external os, it is incised with the straight
bistour)' and the cer\ical canal stretched with the heavy dilator to the extent of
from one to one ami a half inches. When the occlusion is higher up in the ceni-
tal canal and cannot be seen, the obstruction may usually be overcome by divul-
sion alone. Under these circumstances the tight or heavy dilator is passed up
into the ccr\ical canal until the tip of the blades meets the obstruction. The
cenical cavit)' is then forcibly dilated ljy squeezing the handles of the instrument
together \\ith the right hand and the cervix steadied by the lower bullet forcqis.
which is held in (he left hand. The i>ressure upon the handles is then relased
and the blades allowed to come together again, when an attempt is made to pas*
the instrument higher up into the canal. Each successive dihitalion tears ajtarl
some ()f the tissues at the ]H)inl of occlusion, until iinaUy the obstruction is com-
j)leteh- overcome and the instrument jiasses into the uterine cavity. The cenix
is then .stretched with ihe heavy dil'.itor to the extent of from one to one and a
half inches and the instnimcnl withdrawn.

The uterine cavity is now irriKatCfl with a solulion of corrosive sublunate
(i to aooo), followed by h()t normal salt solution, and the vagina dried. The
uterine cavity and the cervical canal are then packed with a narrow strip of game
and the vuh'a jirotccted with a compress secured by a T-handage.

Variations in T e c h n i c . — In cases of pyometra the uterine mucosa
is infected and the uterus should be cureted after the pus is evacuated. (For
the list <i( instruments see Dilatation and Curctment of the Uterus, p. 955.)

When a high i)bstructii)n cannot be overcome by divulsion alone, it should be
puncture*! by a sharji bistoury anil then stretched with the heavy dilator. Care
must bo t^iken to keep the blade of the bistoury in the line of the canal, otherwise
it m^iy penetrate the walls of the lervix and injure the adjacent structures,

.■\ f I e r - I r e a t m e n t .—Cure oj liie Cer.-ical Canal. — At the end of forty-
eifiht hours the patient is )ilace(l in the <lorsal position either on the edge of the
bed or u])on a tabic and the gauze packing carefully remove<l from the uterup.
The vaginal canal is then irrigated with a solution of corrosive sublimate (i to
2000), followed by hut normal s;dt solution, the speculum introduced, and the
\agina dried with gauxc sponges. The anterior and ]x>sterior lips of the cen'ix
are then seized wilh bullet forceps and the cervical canal packed tightly with a
strip of gauze. The dressing is renewed in the same manner ever\' second day
while the patient remains in bed.

In cases of pyometra it mav be necessarv to remote the gauze packing from
the ccrv'ix every twenty-four hours and llush the uterine cavity with corriKiive
sublimate and normal salt solution before reintroducing it. The indications in
each case, however, must be our guide, and if the jialient has no elevation of the
tem])eralure or |)uUc and there is no foul discharge coming from the uteru,-!, the
uterine llu.-^h should not be cmployeil.

The cure oj Ihe h/.iildfr unil ho-iivls. the rcf;iihlion oj Ihe die/, and the reiiej
oj rcsllexiticis and piiin are discussed under the After- treatment of DilaLition and
Curelment uf the Uterus, on jiagc q(io.

Celtinfz Oil! oj lied. —The patient shimid remain in bed one week.

The S u 1) s c (| u e n t Treatment .—When the patient gets out of
ijcd. she should use a vaginal douche of hut normal .salt solution (two gallons)
night and morning for several weeks.

.\n examination of the cervical canal should be made every four weeks for a
period of several months, and if the atresia recurs the cervix must again be dilated.

To Keep the Cervical Canal Patulous.— This indication has been con>
sidrrvol un<kT .idi-r trr;ilmi'iii.

To Relieve the Complications,— The tubal rompUcations nuy. at timet,
rcquirr irxMinH'iii. iiml if tlw ovkluib remain clistendeil .irier the uterine cuvity
IS l>n-n cmiitini. it muy Ih' n<vesA;in' cvcntunlly lo consider the question of
Jcir tcniinul. (Sec Disejtses of the Falloiiian Tubes.)

ACQUIRED STENOSIS OF THE CERVCC.

Definition.— A niimming or Mmture of the cemcal canal due to
rquirt'ii i;iusc>.

Pathologic Changes.— Tlic constriction imerfcres with free drainsfte

>m ihe uterine tiiviiv ami ceniciil <-»niil ami ihc secretions ami menstrual

JcMxI arc temporarily dammed up. Kndocemritis and endumeiritis arc frc-

"quenily cauMil hy stemwi^ and ihe hyperlrwphicd and swullen intniccn-ical

mu«'»6:i aKKravaln^ the troulile liy incrcasinR ihe lighlncsks of the stricture.

Canses.— ThcalTcitioiimay l»cdue to uterine displacements and also to sny
nf ihe (.kUM-v th.ll pnHlurc al^e-^ia. .Antel1e\iiin i> the mii-it common cauM of
Crrvind ileno*is, .ind as it is u>ually ;is.*iicia(ed with cmldcenicitis, the swollen
^'Diiilitioii of ilw mu<-i>us membrane imrciisci the conslriclion at llic point of
rxi<in :trid proiliices a ven' lighl siritlure.
Symptoms.— The follo«ing arc the cliief symptoms:
Ix'iikorrhea.
['ainful meret'lrunlion.
Paroxysmal lwaring-<iown pain&.
Sieriti'ty.
Leukorrbea. -Conficslivc endometritis and cndocenidiis are usually a*-
iH iated with ^te^ll^is uml t)ie <li.-Kliar({e ha> the diMimtive iharai-teristic:! of the
»terine ami lenical M-ctelioiis. As a rule, the leiiknrrhi-a is slight in amount and
-inirrilatiti^;, and util<--> the uterine lavity Itecomesinfeclcd. il is free from pus.
Painful Menstrualion.^Tlie olwirutlion in the (ervii^l lanal prevents
the free escape of the mcnsliual hloiKJ, which is lem|i')rarily 'lammc<f np within
jihc uterine canity and paroxysmally cx|>cllcd by (uinful cnnirncilon* of the uterus^
lit oinililioi) ix km>wn as obstritclHt dyimtnorrhta and b fully ditcusscd on

Parozsyinal Bearing-down Pains. — ThU is a very rare symptom, and is

fue III the expulsion nf the mucus which ha.« accumulated above the |>oini
f strfliure in cases in which the stenosis is near the external ns uteri and Ihc
CTviuil r.ivily aUive i> di^tendeil l>y the retainc*! sciretions.
Sterility. ^Sterilitv t< common in hlm's of mLirke^l anteflexion and o>ncep-
i'ln ut'Uaily promptly (kcuts after ihc deformity has been rcmo\T(i. The in-
bilitv ii|Hin the |iart of tin- uterun to heiome imprtcnaled is not due so mudi to
ihc ol^tniclinn prcventinR the cntnince ii( sjiermntoitDa lus it U to tlte Mnictural
jtlwinse^ that jre j»rc«nl in the corporeal cDdomctrium which render it unfit to
ri*T .inil nuturc the o^-um.
Diagnosis. —The dtagnosk is mule a» folkws:
Tlie history.
'ITic symptnmB.
The pliysical sipis.
The History.— Ttw ^(ateOM-nts of the paltrnl may point to one of the causes
iffatemisi^. TlirjRCof ihi- palienl is im|>orlanl l»ctau>c narrowin); of the cervical
liul, as a rule, has no .nyroplomatic slgniticancv after the meni>[iuu»c, and a

^_lhci
■fTht

478 THE DTEROS.

previous pregnancy would practically exclude anteflexion, as this displacement
is most often met in sterile women.

The Symptoms. — I'uinful menstruation associated with sterility and leukor-
rhea would probably indicate the presence of some fomn of mechanic obstruction
in the cerviciii canal.

The PhyEical Signs. — The |>atient is placed in the dotsal position and
examined by (n) touch and (ft) sight.

The diagnosis of anteflexion is discussed on page 338.

Touch. — The examination is made by vaginal touch, ragifia-abdomiiial
palpation, and the uterine sound.

When the obstruction is situated at the external os, the examining finger may
recognize that the opening is contracted, and if the cerWcal canal has become
sulhcicntly dilated to change the shape of the cen'ix, it will be more or less globu-
lar in form and the tissues will be soft and elastic.

The examination with the uterine iwimd should be made by sight under the
influence of an anesthetic and with strict antiseptic precautions. A speculum
is introduced into the vagina and the anterior and posterior lips of the cenii
seized with bullet forceps. The uterine sound is then passed into the cervical
canal and the shuation of the obstruction located. If the canal Ls dilated from
the presence of retained secretions, the tip of the sound moir-es freely in all
directions after it passes the external os and emerges beyond the stricture.

Sight . — An examination through a speculum will reveal the small size of
the IB uteri and the globular shaj)e of the cervix in cases of distention.

Prognosis.— The affection yields readily to treatment, The progncisb
of obstructive dysmentirrhca is discussed on page 732.

Treatment.— The indications for treatment are as follows:
To diliite the stricture.
To cure the endometritis and endoccrvicitls.

Both of these indications -are met by the operation of dilatation and cureiment
of the uterus, which ij^ described on p;igc 955.

CHANCRE OF THE CERVIX.

Description. — The j>rimary lesion of syphilis is rarely found on the cervix.

and occurs in that situation with about the s;imc frequency as on the vagina.
The sore occupies cither the anterior or posterior lip; it is usually single, but may
be multiple; ilsap]jearance does not dilTer in any way from that of a chancre on
other parts of the g'.'nilal trad ; and in some cases the ulceration may extend into
the cervical canal. The inguinal glands are not affected, but those wiiHin the
I>clvis arc fr<.'i|iicnily involved :ind give ri.-e to a lymphangitis or a lymphadenitis.

Diagnosis.— The diagnosis is liascd ujxjn a phj-sical ex;iminalion; the his-
tory of a Misp'cious inti'rcour>c ; and the appearance of constitutional symptoms.
The sore jircsciits thi: usual characteristics of a chancre and pressure upon the
vaginal vault may reveal the lender and swollen lymjjhatic vcs.sels and enLirged
glands. A positive o j) i n i o n . however, should not be
given until the sjiecific nature tif the sore is deter-
mined beyoml doubt by the appearance of the
secondary eruption, otherwise a mistake may easily
be made a 11 il the patient ji 1 a ce il upon a long cour.'e
of t re aim en 1 for the cure of a disease from which
she is n<i( suffering.

Treatment. —The jiaticnl should no| l)c placed upon anti-syphilitic treat-
ment until a [Kisilive diagnosis is made. In the meantime, however, the sore

BERNIA OF THE ITTCSDE.

479

■faould \x treated uk IoIIuwa: Irrigate tlw vsfijna with a wluiion of corrosive
rubtimmc (i to >ooo), follun-cd by normal salt solution, and cituierin; the wre
wiib purr nitric ackl, Then dust tlw ulcer with iodotorm poH-dcr and [wtk the
\-iijtina with iodoform gauxe. Frcflh drex'-ingt >hould be applied diiily until the
ton hcaift.

HERNIA OF THE UTERXJS.

Synonym. —HyMen>t«lc .

I>CScription. —The presence of the ulcrux in the tac of a Ivernin is. a very
lure ciituliiion. Cflse* haw bccii rcjiortcd, howc\«r, in which the uterus was found
in the uir of a crural anil .tit inguinal hernia, and in two instances impregnation
MTurrcl iiii'I ^cstJlioT) :idvaDoeid up to the fourth month.

Diagnosis.— The f)h>'^cal cxaminalicin denrionsi rates the ilwence of the
UUna from the pelvic aivily and the pr»?-*ncc in the hrrni;il ^-ic of a firm body
bftvinx (he Keneiul outline of the organ and moving slightly when smmg pressure
fe made Ufin (he \-^)Kinal %'aull.

Treatment. -If the utcms is unimpregnatcd. a radicnl operation for the
cure of the hernia should be ]>erformcd and the displaced organ returned lo ibe
pelvic cavity. Sometimes the local chanKe^ thai occur in an<) about the mc of
an old hernia prevent the replacement of the uterus, and it may lie necessary,
iherrftnf , to remo^■e it. If the uterus is impregnated, hysiereaomy should be
fnUiTtnetl and the hemb relieved bj- a radical ojieration.

CHAFTER XVII.

[NATION OF THE FALLOPIAN TUBES, THE OVARIES,
AND THE UTERINE LIGABJENTS,

These organs can be examined by the foltowiiig melhod&:
Vagino-abdomiikal touch.
Recto-abdominal touch.
Anilirial uteriite prt)!a|>M:.
Ifimltations, — TIk Falloptiin tubes, the ovaries, and the uterine ligaments
kit be more or ks6 tborou^ly palpated. In thin women there is no difiinilty
ttevCr tn recngniKinK and outlini»g ibc difTerent urfoa", Iml in women who
'■re muM-ubri'r (at aiul in p<ilirni< who have gross inl1ammali>r>- |«lvir lesions
where ihc organs .ire matted lugether and Ixnind down by lympli ii L- often
icuU or iin)MiK>>Ilile lo fcpamie one organ from artolher. In these ciiM-*. there-
in:, the di.)gnnfitt depends u[>on the experience of the examiner and hi* ability
cbtlnuie tlK pathologic >igmfiaince of ihc k-.Mon» which are rei-oKnizdl b^
yutit. Again, even an expert gynecologist must ai
irs be contented tu simply find x pelvic mats
iboui being able m acquire any positive infor-
tlon as to its origin or character.

lation,— By these melluxlh of examination we ran palpate the

aumial organ* and aUu recoj^irc the various diseases with which they may be

let-Jnl

Preparation of the Patient.— The rectum should be emptied by an

tif KKiptudfe and warm water and the uiinc voided naturally jusl before

imi

48o

KXAUINATIOK OF THE tTIERINE ADNEXA AND LIGAMENTS.

the examination. The corset should be removed and all clothing that Tcstricts
the waist should be loosened.

Position of the Patient.— The dorsal is the best position in idiidi to
place the patient in making the diPFerent examinations. An examination cannot
be siitisfattorily made in the lateral-prone position, as it is awkward for the
exiimincr, und besides the organs sink back beyond the reach of the fingeis.

Anesthesia. — In very thin women it may be passible to make a satis-
factory examination without the use of an anesthetic, but, as a rule,
it should always be employed, otherwise mistakes
are likely to be made in the diagnosis which may subse-
quentlj- be corrected by another examiner who is more thorough in his methods.
An anesthetic should usually be employed when the uterus is puUed donn
toward the vaginal outlet (artificial ulerint prolapse) to facilitate the examination
of the organs.

VAGINO-ABDOHINAL TOUCH.

Indications. — This method of examination is particularly useful in
palpating the tubes and the ovaries when the uterus is in its normal position. It
can also lie employed to examine the round, broad, and uterosacral ligaments and
the space lietween the uterus and the bladder. When the uterus and its ap-
pendages are retrodisplaced, valuable information can often be obtained by this
method, but it should always be supplemented, however, by recto-abdominal
touch, which gives a more accurate knowledge of the pathologic lesions under

these conditions.

Technic— The ex-
aminer sits or stands ii>
front of the \'ulva and in-
troduces the index -finger
up to the cervix. The tip
of the finger is then pressed
upward again.it the cerxlt
to test the mobiiitv of the
uterus and to ascertain the
presence or absence of
tenderness in the utero-
sacral ligaments and the
pelvic cavity (Fig. 304).

The finger is now
passed gently but firmly
around the cervix to de-
termine whether the va-
ginal vault is normal or
obliterated, or whether
there is an enlargement at
the base of the broad liga-
ments, and to note any
contrnction of the tissues at the sides of the pelvis.

Next llie finder is jiresscd posterior to the cer\-ix and the culdesac of Douglas
carefully |):ilpated. Sometimes a prolapsed and enlarged ovary or tube can be
fdt in this situation, which may lie dearly outlined against the pelvic wall by
gentl}' stroking it. .\ proUipscil normal ovari- may sometimes be felt f)osterior
to the uterus, and is rcrognizerl as a round, movable, little mass which constantly
slips away from the tip of the finger as it is palpated against the pelvic wall.

Fio. 474- — T'AJT■AT^^^c Ar.AiNST tmt Pflvit Wall an Ovapy wurcfl

I?. .^ITfAIUP IN TJlt ClFLtlESAO 0^ DOVCLAS.

VACINO-ABDOMISAL TOCCU.

Having compkled ihe cxnminittion with one finger alone, lh« examiner now
pkcc» the free liani] un the abdomen jtut atxivc (he ]>u\x.- und |)at|taie!. the tube&,
the ovanvN and lh« broail .tnil munil ligumcnts by the bimanunl mrthotl. I'hc
ri^ht intlcx-fin^cr should be used in Ibc vagina to paijuilc the right side of the
Itelvi.-, »nti ihc led iiuli-s-finttcr ihe Icfi side.

If (li<- utmiv is in its norm.il jxiMtion, the internal finger is pressed lightly- tipon
Ihc lufulus "hilc the external fiJiKcn dip downwiinl through the abdominal wall
frii(n jlH>ve. Hatitix the fuiidii-s now uikIct nintrol. the lingeri of both handv,
Still in conLtrl. arc slippctl over the side of ihe uterus and the inlerv'ening stnic-
lum (.arefuUy palpated in the dim^tiun of the lateral wall dl the pelvis.

The niirmal Fall()pian Xu\x. which (eels like a long, smooth, soft, rounded
MfiJiture, ranmU bv rccognixed, as a rule, with cerlainty; but when il is disGU£od
tir enloriced, il forma a club-shaped maxs which l)i|iers tovrani the utcru».

The noRHiil (ivar>' can usually be felt unJ is recoignizcd as a little body, somc-

* ' ■ ' "fa small olive, which i* freely movable in all directions

HI y from the lingers.

iwtnellI^c^ ilie ovary and ih* tulic are prolap.-*d and i-ann<>l lie fell when the
&i4{Kr« >Ji<le "if fn>m ihc %i<le i)f llw uterus, t'ndcr these rircumslances ibc
inlenut finger is placed at ihc side of (he ceriU and the e.Mernal finjteri pre.'«ed
diiwn u|>on it. Krepinp; the fingers in conturl so that none of the inier^'ening
•truciuro can t>lip by wiilv>ut being rctngrtized. thry are gradually moved up-
ward ag^in t<) the side of the fundus of the uterus and out toward the pelvic wall.
Thii mAnipuUtion U-^ualty enables ihc examiner to (-atch the apjiendages be-
Twoen the mirrrul and exiernal lingers, ant! if the maneuver faib, it should be
rviMnlc<l unlil ihcy are linjlly rerognUcd.

1"he TiHind ligaments arc (ell anterior to the (uixlii* hv plaring the internal
finiter in front and to the ^ide of the ulcru; and forcing the structures downwaril
upon It with the abdominal fingers. The normal ligament is very difficult to
J"

482 EXAUiNATION OF THE UTEBINE ADNEXA AND LIGAUENTS.

palpate, as it is a relaxed cord-like structure which blends with the surround-
ing tissues and escapes recognition.

The anterior uterine space can be palpated by placing the internal finger
back of the bladder and crowding the fundus of the uterus posteriori}- vith the
external fingers. The lingers of both hands are then brought into close contact
with each other, when any inter\ening growth can be easily caught and care-
fully examined.

Lesions of the broad ligament are easily recognized by placing the internal
finger at the side of the cer\ix and making counter -pressure with the external
hand. The examiner then slowly palpates the structures upward to the fundus
of the uterus and laterally to the side of the pelvic cavity.

The uterosacral ligaments can usually be felt by making slight pressure up-
ward back of the cenix, and at the same lime pressing the fundus of the uterus
toward the vaginal outlet with the abdominal fingers. The ligaments are then
recognized as len-se cords extending from the cervix to the sacrum.

When the uterine appendages are matted together by adhesions and inflam-

KlG. 47^ — FXAUINATION rir TK>: AsTFKIOk l>V.JtlNE SpACE BY VACEND-ABtlOVIHjiL ToiTCH-

matory exudates, they lose ihcir characlerislic outlines and form a mass which is
more or less firmly fixed in the peh'ic cavity and which assumes a ^■a^iet)■ 01
different sha|K's.

If the uterus is relrn<]isplacefi (he appendages cannot be palpated as well by
vaRino-iibdiiminal as by recto-abdiiminul touch. However, bv pressing the in-
ternal finser somewhai posierior and lo ihc left of the cervix and making counier-
pressurc- tlirou}<h the abdominal wail, wc can often distinctly feel and outline a
tulial or an ovarian enlargement.

When il is necessary tij make deep paljKilicm with the internal finger, an
advance iif from one to three inches can be gained
by firm jiressure of the knuckles of the examining
hand a j; a i n s t the perineum (Fig, 20). If the cxiimination is
mailc without an anolhetic and [here is difficulty in outlining the organs on
account of muscular rigidity, the palient should take a deep inspiration, fol-
lowed by a rapid expiration, which causes a short period of relaxation that
c^iu be taken advantage of by ihc e.\aminer.

K£CTO>ABDOMIMAL TOUCH.

4S3

RECrO-ABDOHWAL TOUCH.

Indicatioas. — This mt:lh<Mi of I- xii mi lull ton U jiarticiilarly ii.seful in palpat-
inj[ the tubes and the ovaries when the uterus or its appcnclugcs i>r bmh ;ire
rcim<liNp!nteti. Reinititerinc tumors and other lesions occupyinR Douglas's
culdesac can be distinaly (cit through the reclum iind ihdr physical ch;inicieri:<-
lics uscenained.

TechnlC. — The examiner sits or stands in from of the vulva and iniro-
ducvs the indcx-fingcr of the left hand into ihe rectum with ihc |i;ilm:ir Mjrfare
(lifecied upwani. The finder is then carried high up in the recium, and if the
intcsliDes arc found cn>wding ihe pelvic orfsins it is withdrawn and the patient
placed temporarily in the knec-cheft |K>siti»n and uir udmiitc<l into the vagina.
The fKHiiion of the patient is then slowly changed again to the dorsal posture and
the intestines kejn <iut of the jjelvis liy keeping the hipt constantly higher than ihe
abdomen while she is bring turned on her back.

After again inirodudng the index-finger into the rectum the fingers of the
free hand are placcil over tht ntxlomcn alww the symphy^iN ami <!ownward
pressure is made in the direction of the proo]ontor>' of the sacrum. The internal
and extcrnitl lingefN are then brought in contact behind the uterus and the lulde-
Lsac of Douglas carefully palpated, noting the absence or prcwncc of di^ejised
organs or intlanrunalory exudates. The rectal finger can be car-
ried higher up in the pelvic cavity by making firm
pressure with the knuckles of the examining hand
against the anus and perineum (Fig. 88). The internal and
external lingers are ihc^n jiusNcd on eiith \'hIc of ihc fundus uteri an't a thorough
examination made of the structures. The uterus is then caught between the
.exnmining fingers aiul the exislcnc'e of inflammiilory a< I hesion.'? ascertained by the
nount of mobility present.

AKTIFICIAL UTERINE PROLAPSE.

This method of investigation is fully described in discussing the examination
of the uierux by artificial uterine prolapse on [jage 306.

CHAPTER XVIII.
THE FALLOPIAN TUBES.

MALFORnATIONS.

The following .inoni»lie5 have been observed :

Absence of the lubes. Supernumerary and a«esM»ry iuIks.

RiKlimenliiry lulw^. A(-<t=wtiry tistia.

Annmiilii-s in viw ;ind >hapc, Dbpbccments.
Absence of the Tabes.— Absence of one or both Pallnpjan 1ut>e» is a
very rare (Kcurrence and is usually associated with »omc anomaly of the uterus.
If both lubc^arcalK^ent. the ulcru*' i« generally wanting: but if only one lube is
lacliing. the orary is absent and the uterus is unioomate or one-hnmed.

Rudimentary Tubes.— One or Ixilh tubc» may be defective or nidi-
mentarr in dei-clopment and the corresponding o«ries ili-formed or absent
altogether. Sometimes the rudimentary condition of the lubes n found to be

484

THE FALLOPIAN TUBES.

due to failure of canalization in the Mttllerian ducts, which remain as solid
cordfi either completely or partially obliterating the lumen of the oviducts ant
destroying their function.

Anomalies of Size and Shape.— The oviducts are sometimes greailr
increased in size and length and occasionaiiy one tube is found to be larger tfau
the other. In other instances they may be contorted by a number of spiral coit-
voluiions which obliterate their caliber and cause sterility.

Fig. 417.— Accesso«v TuBts.

Fir.. 4rS. — .XrcFS-wav Osiu.

Supernumerary and Accessory Tubes.— Supemumeran,- tubes m

very rare and are usualiy associated with supemumerarj- oraries. Accessoir
oviducts, on the other hand, are more or less commonly met, and are found at-
tiichwl either to the broad ligament or to the tube itself.

Accessory Ostla. --Accessory ostia are not uncommon and are genmlh'
liiciitcd in the neigh tjorhoixl uf the abdominal openings of the oviducts.

Displacements. —A Falloi»iun tube maybe displaced downward, back-
ward, or upward, and cases have been noted in which it occupied the ac of
a hernia.

DISEASES OF THE FALLOPIAN TUBES.
SALPINGITIS.

"nypTiiUf^n.— An infliimmation of the Fallopian tubes.

Causes. -Salpinnilis is not only a commondisease, but it i.s also, with \ti 3
few ?W?J?TOfis, the oidy alTcction of the oviducts that interests the surge*in fro«n
a practical stanii|K>int.

The ilir-wsc is nrarly always secondan.- to an Infection of the uterus ortt:»-
jiori til Ileum, ami the inflammalion either spreads bv continuity and contiguii
of strurlure^ directly to the lubes or the palhop?nic organisms are carried by tl'
lym|ihalic vessels or the lilnod. In the vast majority of case>—
h o w e \- (■ r , the disease begins as an e n d o m e t r i t i s a n '
the t 11 I) e s become s e c o n d a r i 1 v involved b v <1 1 r ect tc:
tension of i h e inflammation from the uterine c a v i I v^
Scii'niiary infeciiim from (Ke peritoneum is comiiaralively infrequent, hut ras^^
are oci^isimiallv met in which a s;ilpingilis has had its origin from an tnllam^*-
vermiiorm ap|icndix or from a disease! area in some part of the intestinal tra, <"■
til which the oviduct had become adherent and subsequently infected, .^jtain-
a luI)cn\ilous inliamnialion of the tubes may l>e secondar>- to tuberculosis of th*"
]icrilonciim or it may be a part of a general infection, and in some cases It may bf
jiresenl as a primary lesion.

CATARKRAL tiAl-PlNCniK.

4«S

In the further ron^^idcmtion of ihe eiiolo)!_v of Siilpingiii.i vr shall only dis-
nifts ih« uterine causo ui iht <li*eiL*e. a* chIi«t jouriTs of infection arc vcrj- rare,
and the »]>ccial forms ^uch as tuberculosis of the tube^, urc j^iven e].-«wh^rc.

It is unnccessarv to refer afiuin to the cuums of cndoniclrili;', as the)- arc given
in detail under its diiTen-nt variciW. but it will. howc^Tr. render the *uhjeil
ciriirer for us to beur in mind that inflammation* of the endometrium are (iue li>
congestive, lonsiiiuiionnl, ipmorrhwil, ,iiid sqnic «um», and that the sources of
these [)ath(il(>);i(- <t>ni)iti<>ns arc manv and various.

Vai-i^H^« ^Thr disease occurs in two furmn: (i) Catarrhnl salpin^tJK
and (a) purulent :uilpin[!iii>. —

Catarrhal Sal.pingitis.

Causes.— The disease is niilKM b^ The ^fflgBWI^'c and constitutional forms
of ctiilnmcmtis and i.* not nearly so common as (he purulent variety.

Pathology.— Calarrhnl sidiMngitis aKuallv runs a mild course and is not
fnlUmeil, .!> .1 rule, by grave ijclvic lesions. Tnc disease maj' be cilhcr aeule or
chrntic.

Acutt.^ln this form the inflammation i« confined to ihc mucous lining of the
lulic, but in sonic cases the niusoilar and peritoneal coals may Iw somewhat
ciinxcstcil and ^liKhIIy ihirkeneil. Tlie mucous memliranc i> swollen, erlema-
tiius, and inllaniK-d, and ihc tubal secretion is greatly increased in amount. The
disease may either run a nipid totirsc or it mj»y continue and puss e^'emually into
the rhronic stage. As a rule, mild cases terminate without
causing any damage to the fimbriated extremities of
the oviducts, and hence the atiilominal and uterine
openings of the lubes remain patulous. Somelimcs the
tUDCs become a'lhercnl to the adjacent »tru«ures durinjt the arutc stage of the dis
e;ise, .imi dicse adhesions remain |»crmanently afUr ilie inflammiiiiim has entirely
$iit>sidci|

Chronic. — The inflammation, a* in the ticute variety, is chiefly limited to the
inu((iu> lining of the tube, but in some cases the muscular and peritoneal coats
may be slightly invulve<l and the oviduct increased somewhat in size. The
mucx>u> membrane i.^ hypcrlrophinl .mil ci>nB<'*lei! and the tubal «(-n'tii)n i*
incTcascd in amount. The- abdominal and uterine openings of the tube may
either remain patulous or liecome occluded. In die former case the secretion*
are dnnned into ihe uterine or pelvic cavilie*, and in die latter they are dammed up
and the tube becomes distended, forming a cj'stic cnlar^mcnt knon-n as a hydro-
utipinx. In rare insL-intes the intlammulion may Ite hemnrrhagic in chancier
and hlood is mixed with ihe x-cretions. and if the tubal o|)enings arc occluded a
ktmaiosal pittx develops. The function of the o\iducts i* often interfered wilh
ly the <levtrucl)i)n of their ciliated q>ilhelitim, which rcmleri the patient sterile
or ejtposes her to the danger of ectopic gestation. Adhesions between ihc
lubes and adjacent structures are not uncommon, esjwcially when the lubes are
ccludc! and form cj'vticenUrgcmcnls.

^ymctog^— The local legions in cases of atitU ratonktii salpingitis arc «o
sligfItinarTni^4ymptom-i. are nearly always til»cur«l by those due to the cocnist-
ing cndouw-trilis. and hence ihc ttib.il disease often runs its course and terminates
In recovery or ffasscs into the chronic .'itagc without the patient being aware
of any additional Innible within the pelvis.

In Ihe (hronir stagfs the symptom.^ arc even less markc<l than in the acute, am)
the presence of the dUen^ iv n.Mialty entirely overlooked unless hydrosalpin.v or
ltemalns:ilpin\dcvcki[)s. in which case there may be a feeling of wei^tht and drag-
ging in Ihc (>eb-ic cavity if the cystic lube is Urge enough to produce pressure.

486 THE FALLOPIAN TUBES.

The symptoms, therefore, of catarrhal salpingitis are the same as those caused
by the congestive and constitutii>nal forms of endometritis, which have alrtadv
been given un<ler the following headings: Leukorrhea; uterine hemonhage;
menstrual disturbances; pain; sterility; abortion' and the general sympttHis
(see p. 418). The effect U[H>n these symptoms of an extension of the distast
from the endometrium to the mucous lining of the oviducts is to slightly
accentuate them, but not to change their character, and as the localand general
manifestations of endometritis often vary in their severity and nature without
the coexistence of catarrhal salpingitis, it naturally follows that there ia
nothing characteristic or even suspicious in this fact. In the early stages oi
severe acute utuicks of catarrhal salpingitis the pulse and temperature are
pn)bal>ly somewhat affected, and the patient may suffer from headache or back-
ache; but these symptoms arc, after all, so slight that they are hardly noticed,
and there is no doubt of the f;ict that these cases are more common than !>
generally sup]x>.-ied.
./ ^^ ^i^S&ttSJ^' — '^ '-'' impossible to make a positive diagnosis of acute catarriul
^-" sulpmgilis, us the symptom.s are indefinite and the local lesion produces no
changes in the o\ifluct that can l>e detected by palpation, except in chronic cases,
where hydrosalpinx or hematosalpinx develops. But even under these cirnin-
stiinces we can only infer from a general study of the symptoms that the original
inflammation was catarrhal and not purulent in character, and hence our con-
clusions arc of but little value, or at best they are extremely doubtful.

The diagnosis is based upon a consideration of the following subjects:
The history.
The symptoms.
The physical signs.

The History. — .^s catarrhal salpingitis is caused by the congestive or c«i-
stitutional form of end<)metritis, the non-purulent nature of the tubal disease mar
be inferred if the history of the patient points to one of these varieties of uierint
inflammation. This subject is fully discus.scd in the diagnosis of congestivt
and conslilulional endometritis on pages 419 and 425.

The Symptoms. — .^s alread\' stated, the symptoms are so indefinite that Ihw
arc entirely obscured in most instances b\' ihase dependent upon the coexi-*ung
endometritis, and even in acute cases accomjianied by a slight elevation of the tem-
perature and an increase in tlie puUc-rale no definite opinion can be formed, is
the physical c.vamination yields negative results.

The Physical Signs.— In acute cases bimanual palpation does not reveal
any change from the normal in the size or the consistency of the oviducts. There
may Ije in some cases, however, a slight jjain felt upon pressure over the tubes.
The physical signs arc entirely wanting in chronic cases except when a hydro-
sal])inx or a hematosalpinx is present.

Prognosis. — The majority of acute cases terminate in a spontaneous
cure without doing any damage to the tube. Chronic ca.ses, on the other
hand, are slow and persistent in their course and liable to cause occlusion of the
tubal openings i)r a destruction of the ciliated epithelium. Both of these
pathologic conditions cause sterility, while the latter is one of the most frequent
causes of eitopii- gestation.

The cure of (he coexisting endometritis is followed in many instances by the
restoration of t!ie tulw to its normal condition, even in cases where the ciliated
epithelium is involved ; if, however, the tubal openings are occluded, no curative
results will ensue.

Treatment. — In considering the treatment of catarrhal salpingitis we
must bear in mind that it is inseparably connected with that of the congestive

l-UtULKVI SAU-INOJ-nS.

4»7

and cotLoliiulionitl formt of endomeirititi. iind that (he lesions within ihc utrrine
(aviu AK tlic s-imc :is iImsc within the oviducts. Furtbrnnorc, we mvM appre-
lialc liic fiKl ihut lh« rcltcf of the tubal )iitlainn)uik>n !» cntirdy dependcDi UfMO
ifac cure of the i-iKt<>in«!ri(i», aiul hencr the tmlnu.-nt of catarrhal salpingitb
bci;tns atul ends with that of the uterine disease. The i>nt indication, ibere-
fdTc, in the treultneiil of salpingilU h to diagnooe the variety of the coexisting
emiomelriiiii (sec pp. 419 imd 4>5!'. Mriond, to cure the uterine inHammation
(see pp. 4IJ and 4a6); and, third, to relieve those condilioiui thjit arc (tccullar
to the lubid alTettiun, »udi a.i (•}) the >Ji);hl fc%'er and pclviv pain which net ur at
tiiao in tile nciitc variety; (b) the hydrosalpinx or the hcmalosalpinx whldl
may de^dop in ihe Lhronic fnmi: and (r) the adiicsions which may t>e pfcsent
bctnei-ti the oviihitt.i :iikI the ^u^^>un■ling structures.

Fever and I* el vie fain . — Should pchic pain and fever ocfur dur-
inK an acute attaik, lite patient must )>c ke]>t aW^lutcly at re>t uml the I>cd-nan
Mnpliiyed when ilie l)Ui(Uler or bowels are e%-acuated. The vagin* shouhl be
dotKlied three limes every Iwcnty-four hours with two gallooi of hot (1 10° to
im" F.) m^mul salt solution, hot coRipres.<>eit are placed over the tower abih^men
(we p. 07). and the l>owels are freely mo\'ed with a saline purgative. The diet
abould be liquid (see p. 106) for the bnt two or three days, and after that it >h>iuld
be tolt in duridcr (see p. tii) until the [>:ili<mt gets out of l)rd. The 1h>wcIs
arc tivintiJ regiil.itiy once in every twenty-four hours with a Kdine. followed, it
ne^'CMin'. by a simple enema. Small diisc^ of moq>hin ahould be i;iven hypo-
(lernilialiy if the (Kitieiit t> reNtless or suffers much pain.

'rtie >ym|>t<>m:< uswilly yield readily to treatment and the patient is generally
out of bed in from ten days to two weeks.

Hydrosalpinx and Hematosalpinx .— Tl>e treatment of hy-
drosalpinx or hematosalpinx should be opcrati\-e, and consists in the prtial or
complete remot-al of ilie disJendetl lulie. A poMiitv diagnosis of the nature of
Mcfa an cnlarKenH-ni iv imi>»s»il)lc prior to operation, and we are not justified
in mssuming llial it will n<>t endanficr the ptilicnl's life at some future period.

Ad hesions . — .Vlhe^iuns are either rmt present in the V3»t majority o(
caM^ or they are too slight to cause sympinrns. Occasionally, h<jwc\Tr, the ovi-
ducts may be firmly adherent to the surroundin); uigim.-> and severe jielvic |iain
and dr*trei.i result. Under these circunwiancc* an utNfominal wciion should be
{■rrfurmed and (he 3<lhe<ions broken up, without, hon'cver, removing the ovi*
duels unless thej' are found to lie Irreparably <lam.-ige<l.

Variation In Treatment.— After the coexisting endometritis has been
cured it is often necessary to institute a pbn of treatment to hasten the restoration
ol the tulies to ihetr normal condition. Thi> is accomplished by employing
the local and general treatment recommimded in subinvolution of the uterus
(m:c p. 447).

PuRui.i!r«T Salpingitis.

Causes.— The TJivii"' ** ■-'■■■•^i by thr vcptic and g^nnofThcai variftig 9*

■gj^BM^^^^I'he inl1:immation of the uterine mucosa extends ctlreelly lo ine
WBrtB^pCMUces in them Ihe same form of infeiiion. Puruletil Stl-
pingitlx i% a very common disease, and is, with very
few exceptions, the cause of the various inflamma-
tory lesions met in the pelvis. The vaH majority of caws
that are due to Miwt^ are puerperal in origin, and they even exceed in number
ihoar tlwt are due to ftonorrhca. In nearly uU instances where tlte eivlomelrium
I> the *oil ol a gonorrheal or septic infection the lubes become invoh-ed; on the

488 THE FALLOPIAN TUBES.

oiher hand, however, we undoubtedly meet cases in which the disease remiins
ainfined to the uterine cavity and the oviducts escape entirely.

Pathology. — Purulent salpingitis may be either acule cr rhronir in char-
actti. Tlie ttptic variety, as a rule, begins acutely
with frank, well-defined symptoms, but occasion-
ally in mild cases the disease is subacute and
follows a chronic course from the start. Gonorrheil
salpingitis, on the other hand, is nearly always
subacute or chronic from the beginning, and in
the e xccp t io na 1 c ascs in which the affection begins
acutely the inflammation is in all probability due
(o a mixed infection. Sometimes in acute cases only one tube is
involved at first, but as the disease progresses the second oviduct is also in-
fected and the inHammation becomes bilateral. So long as the cndomctiiuai
remaias diseased the second tulie is always apt to become infected in time, but
if the uterine inflammation is cured the infection may remain limited to one side.
As a rule, therefore, salpingitis is bilateral in chronic cases.

Acute. — The inflammation begins in the mucous lining of the tube and al-
most immediately extends to the muscular and peritoneal coats. The disease ii
very rapid in its course, and in a few days the oviduct may become as Urge as
the thumb, or it may be enormously dbtended with pus. The fimbriated tx-
Iremity usually becomes occluded as the re.=;ult of the inflammator)' process and
the purulent secretion csca]>es through the uterine opening of the tube, which, as
a rule, remains patulous in the early stages of the disease. Sometimes, hon-eiti,
the abdominal ojKning is not sealed up at once and the pus may escape into the
peritoneal cavity. The tube is often distorted or displaced, and, as a nilc, it be-
comes soft and friable in consistency.

The inflammatory lesions may either undergo resolution and the tubes return
to their normal stale, or the inflammation may subside and lea\'e them moreor
less permanently damaged. Ag^iin, the case may terminate fatally from ptti-
tonilis or general sepsis, and fin;illy the disease may pass into the chronic fom.
There is no doubt that many of the milder cases of purulent salpingitis an
entirely cured and the oviducts either restored to their normal condition or eL=t
<lamage(i to a greater or lesser degree. In the vast majority of cases, howevtr,
except those which end fatally at once, the inflammation finally becomes chronic
or sulMtcutc in character and .structural changes occur in the tubes which destroy
their function forever and either conlinually endanger the patient's life or make
her a hojwicss invalid.

ChrtJP''^ — In the chronic stage the lesions are more marked but less acule in
character, and there is no tendency toward resolution. The fimbriated extremity
<if the tube is usually closed, but the uterine opening may remain patulous and
the purulent secretions escape into the uterus. So long as the uterine openini!
remains per\ious the secretion escapes and the tube dries not become dis-
tended. Under these circumstances the disease is known as chronic adhemi
or hilerililiiil s(ilpiiit;ilis. and it represents the advanced stage of an acute attack-
The oviduct is greativ increased in length and thickness; it is u.sually moreor les*
tortuous; anil its avails arc either soft and friable or hard and nodular in
consistency. In most cases the uterine end of the tube is only slightly in-
filtrated anil hyper(rophic<l, while the rest of the organ is greatly increased in
si;5e. gi^'ing it a club shaped appearance. Sometimes, however, the entire tube"
is involveii and the uterine end i)e((imes so soft and brittle that it is readily cuc^
through by a ligature. .\s ihc tul)e increases in size it gradually separates thts^
layers of the mesusulpinx, and in many instances it comes into direct amtaci witt»-

PUBULENI SALPINGITIS.

489

(he ovary. The lumen of the tube is often ainstriclcd at one or more points,
which pws a beaded appearance to the oviduct, and forms ^(;p;traIe sin^ in
which pus accumul.Hes. The entire lutw may Ijenimc atmphiod in old chronic
aises and nothing remain of the oviducl but a cord-like siruciure.

When both Ihe alxlominu! and uterine n|)cninf^ of the tube are closed, the
Kcrctton is dammed up nnd cy»tic distention titk» place. This distention is
called a pyosalpinx when the tube contains pus; a hydrosalpinx when it contains
lenun, and a kemaloiulpinx wbeii it contains t>li>o<l. These r;'.sli<- tumons of the
m-iducts will be considered in detail Utcr on.

The closure of the uterine opening may be due to edema and hyJ^e^troIlhy
of the mucouK memlirane; to ulcentive changes which may result rithrr in ad-
hesions between opposing surfaces or cicatricial contractions; or to the lumen of
the tutic being constricted by a sharp Scxion or an external band of inilamniatory
rxudate.

The fimbriated extremity of the tube becomes dosed in salpingitis by two
methods, acconling to Bland Sutton: Firtl, the " inflammalurj' m::tten
effu»«I among and in the tissues of the fimbria: cause them to swell, and adhere
together, and often to the ovai>\ The efiuscd material organizes and binds the
aftglutinated fimbriic to adjacent Ntniclures. such as the ovary, brmtd ligaments,
pelvic periloneum, uterus, or rectum, and mechuiically seals the ostium."

Fio. 110 fta, «>*k

Citnnti o> III! AauitiiiiAL OttMrnO Ct not FaUOvUH TVat.

(MiuiimD ruM SuTw*.}

Hi. A> <nn«f thr iiim^ir diir (n l^ngihriungof iIh muAcutD nmt of tbr ev1« mh^ pmnaH ini-rruun ot w
Hknr^ FtK tS< thmx ihr lonplMt ia>cni«i ofibrtabflv: BM« thai ihe lintna att capwd hy cuiiiat
• Hdlw Irun tbr »tU <il ihc tulir.

Sftottti. "the Fallopian fimbriae may be regarded as luxuriant protrusions of ihe
mucoid membrane, lieyond the ostium. When inflamed, they enlarge greaUy,
As Ihe inflammation extends into the muscular coat of the tube, it becomes
lenfithened, and gradually bulges over ihe fimbrix, until the ostium presents a
rounrled onfice, instead of its u»ual fringed a])[>eanince. Eventually these
rounded margins contraci, narrow Ihe orilicc, and cohere, giving it a smotrth,
rounded end not unlike a sea-anemone with its tentacles retracted. On slitting
up swh a tube the I'lmbrTar will nci^.tionitlly {>e found neatly folded up within
it," fw "a few of them may be nipped by the contracting ostium and W It-fl
projecting,"

A cysiic tumor of the oviduct is usuatly shajwd like a iiear. a.* the uterine
portion of the tube i.' generally but slightly enlarged while the fimbriated end is
greatly diUteil. In other cases Ihe whole tulx is distended and the tumor as-
sumes the shape of a sausage. 'ITie inferior portion of the tube In held ilown by
ihe mesosalpinx, and as die oviduct becomes distended and elongated the su-
[tcrior portion dilates more rapidly and the tumor become^ shaped like a retort; in
many cases the tube become* tortuous and is fold«-d more or less U[»on itself. A
•peculated condition of ihe tube is not uncommon in cases of pyosatpinx. and in
rare instances a serous, (lurvlent, or Uoody fluid may be found in wparaie pouches

49° 1'HE FALLOPIAll TUBES.

in the same oviduct. It is not uncommon to find one tube filled with pusaod the
other with serum or blood.

PynMlyjuy. — When the Fallopian tube is distended with pus, the conditiMi
is caOea a pyosalpinx. The size of these cysts varies from a finger or a thumb to
that of a felal head, but, as a rule, they do not attain to vtry great praportioiii.
In the beKinnin^ the pus is always septic and coa-
tains pathogenic germs. But later on the micro-
organisms may disappear entirely, and the pus is
found to be sterile in over 50 per cent, of old cases
of pyosalpinx. Sometimes a chronic pyosalpinx becomes converted into
a h\-drosalpinx by a clarification of the pus. Under these circumstances the solid
constituents become deposited upon the walb of the cyst and a clear serum is sub-
stituted for the purulent material. Again, a hemorrhage may occur Into an gld
pyosalpinx and fill it with htood {hematosalpinx) . This is due to the rupture of a
blood-vessel in the wall of the c)'st, and may be caused either by direct violence ot
by torsion occurring in some portion of the tube. In recent cases the walls of the
cj'st are hypertrophied and much thicker than normal; but as the distention in-
creases the tissues become thinned and a rupture may occur, followed by ibt
escape of the tubal contents into the ])eritoneal cavity or into one of the hollow
viscera. A pyosalpinx is usually firmly adherent to the surrounding structurej,
and it is sometimes difficult to enucleate the cyst without rupturing it. In other
cases, however, the adhesions are soft and are easily separated without causii^
any injury to the walls of the tube. In most instances the cyst is adherent to the
culdesac of Douglas and the posterior aspect of the lower portion of the broad
ligament. When a pyosalpinx becomes adherent to the rectum, the character
of the pus is altered and it has a foul fetid odor. In rare cases of pyosalpinx
there may be an intermittent escape of pus into the uterus. This is due to the
uterine end of the oviduct being sufficiently patulous to allow the tubal contents to
escape whenever the tube becomes distended enough to overcome the obstructioa.
An old pyosalpinx that has remained dormant for a long time may become freshly
infected and cause an acute attack of purulent salpingitis; the infection in tfae»
cases comes from the rectum, the intestine, the bladder, or the uterine cavity.

Hydrosalpiiiz. — When a tube is distended with serum the condition is called
ahydrosaTpmx. It may result from catarrhal salpingitis when both tubal
openings are closed, or it may occur in an old pyosalpinx from the conversion ot
the pus into scrum. The fluid ^-arics in color and character. Usually it is com-
posed of clear scrum, but in some cases it may contain a little blood or pus. As
a rule, it is free from germs, and if rupture or leakage occurs it is rapidly absorbed
without causing any irrilalion of the peritoneum. The size of these cysts varies
from a slight distention of the tube to that of a felal head; but, as a rule, they do
not grow larger than a small pear. The tubal walls are thin and transparent:
the mucous membrane is atrophied and entirely destroyed; and if the c>-st
ruptures it may siirivel up and nothing remains of the tube but a fibrinous-like
cord, Occasionatlv, as In pyosalpinx, the uterine o|>ening of the oviduct may be
slightly patulous and there may be an intermittent discharge of serum into the
uterine cavity.

Hematosalninx. — When the tube is distended with blood, the condition k
called a hematosalpinx. This condition is ven,- rare and only includes those
cases in which a hemorrhage occurs into a cystic tube. Extrauterine pregnancy
and .in efTusinn of blood into an oviduct during menstruation are examples of
spuriiius hematosalpinx, and should therefore not l>e considered here, A pyo-
salpinx or a hydrosalpinx may be cimverted Into a hematosalpinx from a hem-
orrhage occurring inio the cyst as the result of direct violence or of torsion oc-

PVXtrLENT 3ALPtN4:inS.

49 1

^^Bimng in Mime |v>ninn of (he mhr, Thr blond in these cases may rvmain fluid.

^ or )l may cnuKulaic nnH («m an organizcrf iloi, or it may thliLen and (>ea>tne
lany in i.i>n>t-'l<!nty. The cluiracier of ihe u'iiIIf of tlir cy«t ilcpcixli^ upon iIk
naiurv nf the tuWl •lisli-nlion ()rw>r to the intrao-^iic hemorrh^Rc; it may. therc-
(>>rr. rr^cmblc u pyo&iilpinx nr a h>ilri»alpinJi. :ia ihe aL\e muy lie. Should a
>\rriutn:<al|)in\ become (rohly infedeil, il will Iwoime rcroin'cned into a pyo-
>>al[>iiu. «iid symptoms of acute purulcni salpingitis will rapidly imcrwnc.
Bxtcnaibn of the Tabal Infection.— There are »cvenil way» by

Mhicn Ki Iffl^-RM lU'P'Riidp^Jrom the luVe m Ihc adj;iccni slrucmrcs:

I . Thr punilent s»:reiion may escape ihrough ihe abdominal opcninit of the

tube.

a. The infection may be carried by the lymphatic channeb through tbc walls

of the lulic.

,V The pathogenic orfanismfc may i)encinilr Ihc mesosalpinx and infect tbc

cellubr tissue nf the brtuid ligament.

4. A m'otudpinx miiv rupture and lU contents escnpe into (he pcMc mvity.

5, Adhesions may form between the tuW aitcl the surrounding structures and
iieron theinEc<-iion may pass through (hem 10 the adherent orjwo-

Through the Abdo'"|'^^ 9iWflh?f P* ^* Tube.— The abdominal opening

' <■ Ecnerally l>conncs closed early in the course of an attack of purulent

aiul. as a rule, only a smalt qiumity of the tubal ^«<.-rvtion eM^ijies.

1 Iw k-iLi^e UMully 'Hnir* v).Ty i:ni>lually and i> -unall in amount, and results in

the f^■^l1ultion of adhc^tuns l>rtwcen the tube and the ovar}' and the sub>e<)uent

i)<r>ufe of the abdominal o|)enin|: liefore the iufeciion hx-> luid time to e.xteiwl to

the peritoocal cavity. The pn)ccM is therefore an effort upon the pan of nature

to keal up the infection and prewnt the occurrence of gcner.il perilonilis. Some-

tima. howet-cr, a lure<e quantity of the purulent Kcrrtion escapes before the tubal

openjitg is clo>e<i and ;i rapidly fatal peritonitis cruue».

Through the Lymphatic Channel*.— An extension of (he infection (hmugh
the woJis of ihe lul>e is n rommoo occurrence, and. as a rule, it only results in tlie
foniMikm of adheMotu. In some caseH, bovre\Yr. it may cause a ^erioti« pen-
tonitts, or A tulM.awiun abscess may develop if the lulic becomes adherent to (he
ovary. This method of extension is more common when the tubal opening* are
doiwd and tlve tube is di.-'iendeil n-iih pus dun when the uterine end of ibe
<rridurl i^ [mIu1<«i> ;in<l ihc secretion escapes into ihe uterus.

Through the Mesosalpiiut. — TTic im-olvement of the connectiw tiuue of the
bfmd Uaameni b>'TW! Illll'niWirTBSSinB; ihrtmith the mesosalpinx is a compara-
ttvebrlnlrequent coitdiiion, and is more apt to occur in cases of pjxisatpinx where
ibe /oki* of the ligaiment are separated by the enlarged tube. This method of
infection, however, may al-io ocair in the non-cj'slic forms of the dise&se, and
results in a cellulili'' or a broad hgament abscess.

Through a RuptUf^^- One of the <-onMant (bn|{er« in case* of pv-o<;i|pinx b
the ruptiitc «{ tTeTuncand the esc.ipe of its aintenis into the peritoneal cavity.
The rupture m:iy I>c caused by some unusual form of exercise. 4uch a^^ lifting a
bavy objm. violent struininK at Mool, and brutal oiitu>. Sometimes it may
neauk (ron a full, a Mow, ot a kick, and it may also occur from a vagitui cxami-
iMtloii or an oiwration u|>on the cervix or the uterine i-uviiy.

Through AdhetjODS,— In not u few cams the infection passes from the tube
tn an iid^cciimiSnniirough adhesions which ha« formed between them, and
ihr intesiinn. the ovar\-, the bladder, tlw rectum, the vermiform a|>pcn<Hx, and
oihrr mructures m.is Uc<>m<- in^-olved by (his route.

Itg^ra-ttihfil Pfaiilm.— TKr results of chronic purulent Mlpiogiti* ut

lird ufKler I

atudira

' (he followini; hcadingN:

49^ THE FALLOPIAN TUBES.

Adhesions.

Local and general perilonilis.

General sepsis.

Walled-off alwcesses.

Cellulitis and abscesses of the broad ligament.

Tubo-ovarian abscesses and lubo-oi-arian cysts.

Fistulous openings.

Appendicitis.
M^fff^i""' — The most frequent result of purulent salpingitis is the fbnnauon
of adhesions which may van' in extent from a simple agglutination between th*
fimbriated extremity of the tulx; and the ovary to cases in which all the pelvic
organs, the intestines, and the omentum are firmly malted together. Rtfent
a<lhesions are soft and readily separated, while o/d adhesions are firm, tough, and
organized. In the fibrinous variety of peritonitis the formation of lymph, as a
rule, precedes the infection and limiLi its destructive action. The adhe^ns are
usually firm and they glue the peritoneal surfaces quickly together. In time the
lymph berames organized, and the adherent structures cannot be separated
without causing more or less laceration of the parts. The serous and suppuradvt
forms of peritonitis, on the other hand, are attended with soft adhesions which an
readily broken up, and which offer but little obstruction to the dissemination of
the infection. In these ca-ses the pelvic organs and intestines are covered with
flakes of lymph, and in the serous variety the pelvic cavity contains several ounces
of serosa nguineous fluid.

In some cases the adhesions existing between coils of the intestine or between
the gut and one of the pelvic organs may kink the bowel sufficiently to cause
obstruction and jeopardize the patient's life. Sometimes the intestine may be crai-
stricted by a fibrous hand drawn tightly across it, and the same condition result-;.
In other cases the lumen of one of the ureters may be encroached upon and
hydronephrosis may de^'clop.

Local and General Peritonitis. — The local forms of peritonitis are more
common than tlie genera flnTlmjn lc purulent salpingitis, for the reason that the
aMominai end of the lulje is sealed up and the infection must spread along one
of the slower routes to reiich the jwritoneal cavity. Under these circumstaDces
before the infection can Ijecome general it is walled off by the lymph that is
thrown out, and the inflammation remains k>ca!ized. Sometimes, however, a
virulent and ra])idly fatal general ijeritonitis may be caused by the rupture of a
pyopalpinx or an abscess of the broad ligament and ovar>'. Again, an oW tubal
disease that has remained liormant for a long time may suddenly become actire
again from a fresh infection and cause a general jieritonitis. Furthermore, the
breakinR-u]! of old [>elvic adhesions by a rough vaginal examination or by pelvic
mas.sagc may injure the walls of the intestine or the rectum sufficiently to allow
the contents to escajie into the alMiominal cavity and cause a general infection.
.Ami, finallv, a walled. off abscess or a small focus of pus may rupture at any time
and )iro<hice a suppurative peritonitis.

General Sepsis. -The absorption of septic material by the s\-5tem is not
ne;il1\' si>lrei'|iJerif as in the acute form, as the inflammation is not acti^'e and the
diseased area i< shut olT by organized adhesions. Besides, old collections of pus
arc apt to lie sterile and cannot cause systemic reaction. Sometimes, however, a
fresh infection may occur in ihesc cases and general sepsis may rapidly develop.
In other cii^cs a >low absorption goes on continually and the [latient presents all
the phv>iial '■ii;!!-- and ^vmpioms <if chronic infection.

Walled~off Abscesses.- When the infection extends from the tube and at-
tack?!Thc |)olvic j'crLloneum, local >upj)uration may occur; and l>efore the septic

PtlKUI-ENT SALPINCmS.

4«

immnlHin has had tintc in spread tci iIk* gmcral cnt'ily, ih? pu!i is walled off by
adbr-ijiins. Ill »uch caaes cither tiw.' cntift- pelvis m^y l>c Glled wiih pu» or small
lu4'i of jiuniUrnt matter nay he found ^altered thniuKhoui a tn^i?.-! nt a(ili«rvni
inicMincs. In the (nrnwr o.'t ihc mc of llii- abscess K fnrmed by the adherent
(.oiU o[ intmine and the omcnium, which completely cncluw the pits ant! pretvni
ihr oiturrcntYiif general fieri i< mil I''.

CellttlitJB and Abxcttei of the Rmad Ligament.— .V stated abow. the

uIntU bv ihc iiifectiiiii

(If.

...nnenlW IISHIUUI Ulc NfUUI ll}!.. < n.< .IK iuv

■i)" (iin>ueb ihe mc^<'KnlpiIl\ alirr l-^^J|llIl^; Itimi llir IuIk?. In tlieM" niM^.in

I jnlliimmnlion of ibe crlltdar li>.sue follows and e^'eniually suppuralinn may

('•ilk-itiorv" of p«s Iwtwrcii ihc folcU of the broad liftameni ^inelime*

■■V. :i liir(>r >iw aiw) may muNe a fatal emlint; by >u(ldenly rujilurinjic into the

prniiinml civity.

Tubo-oraf iim AbscesMS and TtibctoyAriaaCvsts.— If the orar>' become*
a'lherrni t<> ihr idIh- iin<l iRfivlion lcdlow». tin- iiiHT\-cning li^'^ut^ arc desirm-ed
kiwi a t'^rnuiictit oix-ning i>c(u» between them which results ii) a tul>o-o\'arian
ali^nv. Tlte ovary is infet-ie«l in these cases either dire«*ily through its outer eoai
itT ihfouKh a menlly ni|iltiml GrnaAnn ^'cside. The adveniiiious o|>eninK h
u-<ujlly situ.ilcil at the p<>int of adhesion, and may therefore Iw at tlie tim
lirijilcil extremity or in the >idc of the tube. A> a rule, the idKlominal njirningof
thr fivi'liKl be<oiiic* ;nlhcirnt lo the fivarj-. biit in >iime cases the adhesion may
<• ul its »i(te, either from simi'le <oiitait Ijttwcen iIk- inonrjpiitoior from
t r iiion of lite laye^^ of the mr>o%iilpin.t by an enlarged tube. Tubo-

ariai) abt^cev^c^ m.iy attain to a large size, and are usually so generally and
tnly aillierrnl to llic surroundiiii; siructurc^ that they are enucleated with the
|freate»t diflti tdly.

U An ov~arian n'st bcttHtie adherent to the oviduct or ir> a hj-drosalpinx anil
ihr fnteneninp wall of Mjiaration l>ca>[ne» abwrbeil. a tubo-ovarian tTSt
r■^iutt^. These cv'St» are usually follicular in origin, although cases have Ix-en
ob>«rvpl in which an advcl1lit)ou^ oi>eniti>: wa- |ire>cnt belwern ihr tul>e and a
lurite pniliferou* cyst ry>l> of fo]Ii<-ubr origin may Iw either unilateral or bi-
lateral. They vary- in size and arc rarely larger than a man'.- fi*t. They tuitally
<oniAin a flenr senim, which m;«y, howev*r, Iwcinic bmwn in a>lor frum the pres'
ence of divirgani/e>i hWxl, In M>rm- cases ihe uterine end of ihe IuIk- rcmatas
luiulous and the tliiiil esca|*s into the uterus (fnn^uenl tnarian hyJrops), (hm
jireventing the ilisieniion of the siic aivj the gnmth of the tumor.

Fiitulotis Open ingj.— When a |m;i8al|>inx adhem^ m imc of the hollow

viscera, tticn- 1- always a chance that the wall of sefKiration may Iwfimc infecteil

urxl rvpiiiujiUy break down ami fnrm a liMulnui' communication l>ctween the lube

lit (hr bladder, lite vagin.i, the intestines, the rcclum. or the alMtomirud wall.

: I r ofienings seldom heal s|ionl;ineou.<ly ;ini) u>uatly continue to iIiM:harge for

liie [wriiHl. SoHK-times iii<-y lictumc infected w ith tubercle tuacilli. or the

, i.iv gra'tually iH-comc exh.iusled from the long lontinueil suppurative

'li.iio ii|-Ti her system. And. linally. the inllamntaliim whi<h result." fn>m the

punilriii 'liM harKe llwi rtows into Ihe bladder, the rcclum. or other orgarvs may

i.iuM' ni«"t di-ircs>ing ■'vrnplomv and even endanger the |ulicnt's life.

ApHjuUutU^-lntlamination of t)ie vermiform appendix lomctime^ occurs

I ■umleni ^.dpiniiiiU fr»>m the orKan adhering to ihe dise:>^ oviducts. Tills

' ' ipin-ixliiitis is not a rare occurrence, and although the apfiendiruUr

i>>n Ruy not be re<ognixe«l .-it (he lime, ret the ot>in|»nttive fre<)uency

i:i ^1 in< li tiM a|>]>cndix ill fmind adherent to an old pyosalpinx or lo the uieni*

nvro that the Icslun is more cunimun than is gen

ally » up posed .

494

THE FALLOMAN TTBES.

SyttOtMnji^The diseai* may be eilher atule or rhnmic.

XcuTeT^rn^icutc form "f purulent ^^ilpingiii-- nc;irly ulwayn results from a
sepTli" (tIf?u!oii of the cndomciriuni fiilloniiig an alxiriion i>r a labor. The
symiHonv of \\\<: lulial ilfc*e;i>f eiiiiiuJl !>e sqiaratetl from ihoic depemleni upon
(he acute septic cndomctriii* and tlit Itjciil or general jwriioniliA whicli may a<r-
comixiny the aSection. In other words, there arc no syinp*
tomit which j)o.%)iively point lo un extension of the
infection to the tubes during an acute attack of sep-
tic puerperal endometritis. \Vc may, of a>ursc. infer that ^udi
Es the <<i](c from the grivily of the .'iymptomK, fmm Mgns of jierilunilis. (rum un
increase of the pain in one or both iliac iossas, and fmm the pl)\-^ical examination,
but. after all. our opinion is only a prolwblc one, whiih i> based upon inferent^
alone, and iluTefiirc m.iy noi lie (iirrect. run.Mrtjucnlty from a praclical ^tand•
point we must recognize the fatt that the symptoms of acute purulent salpingitis
are so ohsiurei! by those clue to the puerperal septicemia that in describinn the
latter we say jtW there i» U> be ^aid about the former. (Sec symptoms of acute
septic endometritis, p. Ai3.)

^Chr^ic.— The chronic form o( the <lisease is either Hue lo a jtonorrheal in-
(caSnwBWi is nearly nlwaj"s subacute in character fmm the beginning, or to
septic cases that have survived the acute slaRcs. In addition lo the symptom*
that are causcl by the- liibril leiion. wo mu»l also take into con side rat iim those
which are dependent uixm the chmnic inflammation cnexi»iting in the uterine
cavity, and which are always associated with cases of chronic purulent salpin-
gitis. These >Tmptom.'i do nut. as in the acute form nf jiunilent salpingitis,
obscure the manifeslalions of the lubdl disease, because the uterine alTection is
chronii' and does not cau^c any ipccia! local di.sturbanie.

The symptoms of chronic gonorrheal and st:|)tic cndomelrilb arc gives on
pages 4^7 and 433.

TJniyaf^^itomimf rhrt^ii; jji^f iili-iil :<;i!pirg!ti« nre itmwirreil under the follow-
ingj '

[jvKmf™||y|itgi. (..nn-.il ■.jiiiinnms,

Menorrhagia. KiiMrnnr . no attacks.

Ameti'Trijici^ _ Fit li Jnfii Uuw:..

Pain.- Till 1, the most constant nn<l tl;, nn.-i vinnificant symptom of in-
terMilial -.il[iipiL;.\i-. ;ind of cystic distention m" ilir.- n'. idiicls. The pain i» not due
so much lo ihc- palhologii' chan;;fs in the lube it>el{ as to the extra-tubal con-
ditions and complications. The mechanic pressure produced by a pyosalpinx or
one of the i>thcr forms of cv'Stic di.'itcntion is accountable for most of ttie )>ain and
tliscomfort cvt>ericncerl by these patients, and the di^pl.-icenient of the uterus and
its appendages which usually accompanies the disease is also an important
causative factor. Much of the di-^lrcRi in these ca.HC.H i> undoubiedly due lo
traction u[«in adhesions thai h.ivc fi)rmeii between the tube iind the adjacent
structures and which inlcrferc more or less with the natural movements of the
intestines, the rectum, ami the ]h;lvic o^g■a^^. Ami, I'lnally, ii.nin may be caused
by a local or gcneml peritonitis which remits fmm a slow leakage or a rupture of
the tube.

The character ami severity of the jwiin. su* a rule, varj- acconting tti the cause;
but the\- do not. however, always corres|>ond to the serious nature of the lesion,
and hence some patients may suffer only 3 slight amount of fliseomfort from a
tubal cyM that i.s almost reaily to nJpture, while others, again, may have marked
local symptoms from a non-cystic oiiduct. The pain may be dull anil heav>* in
character or it may be acute and agonising, and in some ciise.\ the [Kilient may

PDRtn.ENI SALPINGITIS.

49S

\iB\t only a sensation of wrighl and flragging in the jtelvis. OoauioiUilly wnmcn
complain of a buminR senMtion in ihc region o( the oviducts, and others, again,
KufiTcr in<m n^ieaiai atU(k.> uf jielvic colic. The (luin iii cuxck uf dironic puru-
lent salpingitifi k usuuUy contlnnt, although it may be more or less modified by
itie poaitiofl of tlic palient and by conditions that arc dependent upon the func-
tions of thf pdvic oTgiiiis or u|>on external cauites. As a rule, the recumbent
position relieves the acuteness of the s>-mptoin, and patients generally feel
much more (omfiirtible early in the mominK than after they ha\'e been out of bed
and on their feet for some time. The p:iin is increased by ihc erect piHttirei
by walking or other forms of exercise: by the evacuation of the bladder and the
lK>wrel»: by the pre^^sure of the dolhing about Ihc wai^t: and by sexual inter-
course. CongtipatioD also increases the leitrity of the symplom, and women in
whom the bowel movements arc irregular suffer more than those who have a
daily evacuation. Tlie jielvic dlscumfort, pain, and .-•orenes.s are aggriivated at
each menstrusl period owing to the congestion and swelling that take place in the
intemal organs of generation. Usually as the disease becomes more and more
chronic Ihc pain jcradually lcs!«n» in severity, and in some case* it may entirely
disappear after the menopause.

The pain U ^ituated in one or both itiac regions and it may extend to the
lumbosacnl region or radiate down the thighs. If the pelvic organs arc generally
adherent, the patient complaiiis of tenderness o\'er the lower abdomen and of
)»rene>s iti the pelvis whenever she w;ilk.i or takes any form of enerd.-*.

Dysmeoorrbea. —Painful menslroation Is a more or less constant and char-
acteristic symptom, and its severity does not seem to be influenced by the c.tteni
or seriouxneMS of the tubal lesion. The pain l>vginK about one week More the
flow and does not rea<« until se\-eTal days after it has stopped. It radiates from
one or both of the iliac regions into the pelvic cavitj' and down the thighs.

Henorrhtigia. — The disca.se is usually accompanied by a shortening of the
intermenstrual periods and a lengthening of the dumtion of the How, which may
last in some cases from a week In ten day^ or e\'en longer.

Amenorrhea. -In \'ery exceptional cases the menstrual flow is scanty in
amouni and il may even be absent altogether.

Sterility.— Wtimen ^utTe^ing with chronic purulent salpingitis seldom con-
ceive. The sterility in these cases is due to thickening of the cMernal ciiat of the
civan-, which prevents the rupture of llie Oniat'ian follicles an(l the subsct|uent
escape of the o^-ult^; to the cliBure of the fimbriated extremity of the tube; and
to the loss of the ciliated epithelium, which prevents the ovum being carried
through the oviduct into the uterus.

General Symptoms. — The hc;illh of the patient is always more or less af-
fected by the local pain and general discomfort, as well as the slow absorption
of septic matter which may accompany lb*- iltsease. ficneral debilitv, loss of
weif^t, ner*-ous cxhriu*tIon, and ga s I ro- intestinal distu^bance^ are common,
and hence these palienis frequently suffer with dys|^cp^^a, want of .-ippclitv, and
COnstijutinn.

Recurrent Acute Attacks. -It is not uncommon for acute atticks of local
l>enti>nitU to occur in the early stages of chronic purulent >alpingiiU, and thei,- arc
by no means rare in olil chronic cases. During the intervals between the at-
tacks the patient may either enjoy comparatively good health and suffer but little
local discomfort, or she mav be a semi-invalid and incapadt^tcsl from attending
to the duties of life- In old cases of p)'n<alpinx and interstitial salpingitis the
»dh«iun.s are so firm and the closure of the fimbriated extremity of the tuK' sn
secure that there is but tittle danger of the purulent material escaping into the
peritoneal carity, but in the early stages of the disease the opposite conditions

49t> THE FALLOPIAN TUBES.

exist, and the peritoneum is therefore more or less frequently the seat of a. local
inflammation that for the lime being converts a chronic case into an acute one.
These attacks may be indirectly caused by roughness in making a x-aginal exami-
nation; by ojieratinns within the uterine cavity or upon the cenix; by senil
intercourse; by a blow or kick upon the abdomen; and by other forms of vidcnce.

The attack is markc<i by an increase in the pelvic pain and tenderness. 1^
temperature rises lo loo" or loi" F. or higher; the pulse is rapid, but seldom goes
beyond too or i lo unless the inflammation becomes general; and the lower ab-
domen is distended and tender lo the touch. If general peritonitis de^-elops, all
of ihe symptoms arc increased in severity, the entire abdomen becomes swoUtn.
and the condition of the ]>alienl is profoundly septic.

Fresh Infections.— As stated above, over 50 per cent, of the cases of pvo-
salpinx contain sterile pus. But occasionally a fresh infection may occur, and all
the symptoms of acute purulent salpingitis are developed in an old pus-tube that
has remained dormant for a long lime. The reinfection under these drcuin-
stances is si>melimcs verj' active and comes from the uterus or ihrou^ an ad-
hesion beiwecn the oviduct and one of the hollow viscera.

IDig£J)f||S^. — In discussing the diagnosis of purulent salpingitis n-e mud
dr.i"" sharp line between the dciile and rhronic forms of the disease, because in
the former the symptoms and the jihysical signs are so completely obscured by the
ciiexisting endometritis that it is often impossible to decide the question of tubal
inviilvement; in the latter instance, however, the opposite conditions exist, be-
cause the uterine di.-iease is in a quiescent stale, while the lesions of the oviducts
cause certain characteristic symptoms and are more or less readilv recognized by
paipaiion. We must aljui bear in mind that while the gross lesions in the chronic
form of the disease are. in a seneral way, easily determined by a bimanual exami-
iiali(in, yet it is often difficult or impossible to know with any degree of exactness
the jirccise nature of these lesions or to differentiate between them. For example.
it is not within the ranpe of our ability to distinguish between an interstitial
sal[)iiiKilis and a bcninning pyosiiljiinN. because the tu!>e in both cases is about
equally enlarpeil. The d i f f c re n t i a ! diagnosis between a
]jvo^.alpin\, a hvilriisalpin.i;, and a hematosalpinx
is usually a matter of inference, and, finally. I h t
e.xtcnt of the pelvic adhesions or the presence of
foci of pus in the pelvis can only be determined at
the lime of operation.

The iliaitno>is is based u]Kin a consideration of the following subjects:
The history. ThfejjluaitaLaMais.

The Symptoms. Themicrosrogjyyjjyjjijjiyion,

The History. Thehistory of the patient is ol t lie utmost jiractical impwrtann
in both llie iinilr :\n(\ 1 lironii- {'{irms of the disease, as it enables us to trace the
tubal atTcclion back ti> a -^cyitir or Konorrheai infection and ihus cstablbh tk
diii^niisi-..

.\ c u t e Form. The bi,-t"r>' of an infection in these cases is more readily
olitaineil than in the chronic variety, becau.se the patient is suffering with an acute
ilisca-c the canst- of which is fresh in her mind. These cases nearlv alwavsocc^i''
shiirtiv after a labor or an aliciriion, and there is therefore no difficullv whateitr
in recnpni^^inK tile rau-e. In exceptional cases the infection may be due V'
Riwrrhea. ami a careful inve-tigation will usually elicit the fact ihat the n-omon
had a >uspiiiou> intercourse shortly before she was taken ill, and although afulf
purulenl sal(iinffitis i- rare under l!ie<e circumstances, its possibility most alwaT'
ijcbnrncin mind. When cases arc nicl which do not jjjve a history of either cftlif
above means of infection, wc must naUirally que=;tion ihe italienl and endeawrio

PDKQUNT SAL.riN(iITI8.

497

dbcover ont of the oiher causes of septic endometritis. (See Cattses of Septic
EDdomelritis, [>. Ai*-)

Chronic t'orm .—The age and social position of the patient are im-
{}onant. Pelvic iiiHammation occurrin); in younf; girls and In virf!in!i U i^neratly
due lo a dermoid cyst or lo iid)erculost.i. In miirried women and prostitutes, on
the other hand, gonorrhea and sepsis are the great causes.

When a lutjal disease has l>een caused by a septic infection following a labor or
a miscarriage, a careful investigation will neuirly always reveal its origin even in
(hose cases in which the infection was slight and had oCLnirrcd many years before.
In these ca^ts the jKitient remeiiilHrr^ iliat ^he was kept in bed longer (h:tii usual
and that she suffered with mtire or Icvs |>nin In thr lower aUlomcn. She also
retails the fact that she had "chills and fever" forsevtraldays. and that when she
got about again there was a constant pain in one or iKith iliac regiitns, whirl) hiu
conliltued up to the present lime. Occasionally there is a history of recurrenl
acute altadu of [lelvic inflammation which «erc associated with tenderness in
the bwcr alKlomcn and fever, and which [Kiinl lo the presence of chnmic puruicnt
salpingitis. The history of a labor at term following .id nliack of puerperal
Kpnb is strong presumptive evidence that the dliicase had left no tuhil damagr,
aiid thai, consequently, a more recent cait*e mu.il l»e found for the exiMing [»clvic
inflammation.

Il ix ^nerally more or less difficult to trace the origin of a tulial inflamnuition
to a gonorrheal infection, because, with the cxcei>tion of pmstitulrs, there is
always a natural inclination upon the part of a woman to deny having had illicit
sexual interanir^. and liek:iu.-<e in many in-stamvs where wives have l>een in-
fected by iheir husbands they arc absolutely ignorant i>( the nature of thediscase or
the p056ibilily of its occurrence. Besides, it U never advisable, for obrious
TOUons, to ask an unnuirricd woman if she has had scxiuil intercourse nor a wife
if she suspects her husband of hav-ing infected her. As stated elsewhere, x
gonorrheal infection i\ nearly always subacute or chronic from the Wjcinning, and
the symptoms are not sufficiently marked, as a rule, to attract the patient's at-
tention until bteron. when the gross lulial lesions are developeii. This is directly
contrar)- to the hisiori- of a septic ca-w, which nearly alwa>> U-gins as an acute,
frank attack, and presents a clear record of a cause. In the case of proslhuiesor
of invnien who do not h«>itale to acknowU^lKe their habits the history of a gon-
orrheal infection can usually be elicited by a careful investigation of the facts, but
when the opposite conditions exist the interrogation of the patient must be con-
ducted with tact so lu-k not to arouse Mii^picicin. It is not uncommon to meet tra^tn
of gonoTThea) salpingitis in women who havt been recently married. These
women axe usually sterile, or they may hav-e harl one child or an abortion, and
the hbtoT}' of infection, which is generally very nbficure, can only be obtained
by a careful investigation of every trivial genito-
urinary symptom thai has orciirrert since marriage.
Thc<e [Mtients usually give a history of good health and normal pelvic organs prior
to marriage, but shoni)' afterward they began to complain of slight smarting
during uriniktion, of more nr tcv% Irukorrhen, and of some irritation of the vulva.
'ITiese symptoms gradually disappeared and were soon forgotten, but Liter on
painandieiideinc-vsdcveloj)eil in one or Iwth ili.ic regions and their general health
began losulTcr.

Tb« Symptoms.— .\ cute Form .—The symptoms caused by the salpin-
^lis cannot \>t >e|i;irjted from those that are due to acute septic inflammation of
the endometrium, which obscure and overshadow them so ompletely that they
arc of but little value in determining whether or not the disease has extended from
the utenis to the tubes.
J*

498 THE FALLOPIAN TUBES.

Chronic Form . — Pain and dysmenorrhea are the duel symptoms tbat
direct our attention to the presence of a chronic form of inflammatory trouble
in the pelvis. Sterility is also an important symptom, as it points to the possible
existence of a tubal lesion, and, finally, the run-down condition of the iraman's
health is significant of the chronic nature of the pelvic disease. The coezisting
endometritis should also be taken into account, as it explains the origin of the
suspected pelvic lesion and confirms the diagnostic value of the other symprtoms.

lite Physical Signs. — A cute Form . — The examination is made by
recto-abdominal and vagino-abdominal paJp>ation with the patient lying in the
dorsal position cither on the bed or upon a table.

In the vast majority of cases following labor at term the ph^ical signs of
tubal involvement cannot be determined with any degree of certainty or satis-
faction owing to the large size of the uterus, the tender condition of the pelvis, and
the small amount of hypertrophy that is present in the oviducts during the early
stages of the dLsease. Under these circumstances all that can be elicited by
palpation is a sensation of fullness on both sides of the uterus, and the diagncsis
must therefore depend more upon the history and symptoms than upon any
definite information derived from the physical signs. In very thin women, how-
ever, we may be able to recognize the tubes if they are sufficiently swollen, but
these cases are the exception rather than the rule, and we must therefore generally
be content to base the diagnosis upon inference and not upon facts. In septic
cases following an abortion in the early months of pregnancy the local conditions
are not the same, and we are, therefore, better able to determine the condition of
the tubes by palpation. In these cases the uterus is only slightly enlarged, and
consequently there Ls sufficient room in the pelvic cavity to map out the oviducts,
which can often be done if they are enlarged and the woman is not too fat.

WTien pelvic peritonitis exists and the organs have become bound together by
adhesions, the uterus is found to be immovable and the vault of the vagina feels
hard and unyielding. The presence of cellulitis may be suspected when the base
of the broad ligaments feels swollen and tense, and if suppuration has occurred a
soft, doughy sensation is imparteti to the examining finger, or fluctuation may be
recognized if there is a large collection of pus.

The physical signs dependent upon the coexisting endometritis are given on
page 434-

Chronic Form. — The examination is made by reclo-abdomimU and
vagino-abdominai palpation with the patient lying in the dorsal position on a
table. An anesthetic should be used in all cases in which the examination is
unsatisfactorj-, other\vise a tubal lesion may be overlooked and errors made in
the diagnosis. A slight enlargement of a tube is often very difficult or even
impossible to recognize by touch, especially in women who are muscular or stout,
and a c)'stic oviduct may be so completely surrounded by adherent structures
that its physical characteristics cannot be determined by palpation.

The physical signs due to the following lesions are considered separately:
Chronic interstitial salpingitis.
Cystic enlargement of the oviducts.
.Adhesions.
Waited -off abscesses.
Tubo-ovarian abscesses and cvsts.
Fistulous openings.

Chronic Interstitial Salpingitis .—In some cases the tube
is soft and so slightly enlarged that it cannot be recognized by palpation. In other
instances it may be felt as a round, elongated, often irregular mass that is con-
nected with one of the uterine horns by a hard, cord-like structure, which is the

WTRULEWT SALPINClnS.

499

infiltruted pmximal end of ihe oviduct. Thi» infiltrated condition of the tu1>e may
Rtwrally bcdci«l«l by careful |iiil|iiiti<in, aiid its it is ii$u;i]ly prpseni in chronic
intentitial »)pingiti$. it should be considered a vcrj- valuable siuii of tubal
di»n!W. In M>me ca^ei iiintead of the inlilLration lieinfc uniform iintl reiiular in
character it occun in Ihe form of one or more hard nodules situated in the lube
near the uterus, between which and the pelvic mass no distinct conneciion can be
traced. The diseu.ied oviduct i:^ UNually displaceil ami a<lherent in the cukiesac
of Douglas; it may also be found Ijeside the uteru*^, or immovably fixed by ad-
htMims til the ]Jitotcrior aspect of the broad ligdmeiii; and in rare in»tances it may
be situated in fnml of the womb. When the tube and nvar^' arc bound together
by atlhesions. the)' form a tumor which is more or less round in shape and some*
what hart] in <-(>n>i!ileni'y. Ax a rule, the size of the ma-NS i» Kreatly increased
by the lymph which Mirmunds it and by the adhesions which it forms with ad-
jacent or([ana, and under these circumstances a tuboova-
rian enlargement ix often ftiund to be much »miiller
when it is enucleated at the time of operation than
when first outlined by palpation. If the ovary U not densdy
adherent to the lube, it may nften lie felt as a hard, ovoidal mass, somewhat en-
iarged. lender to the touch, and more or le^ immovable. In cases in which the
{■elvic organs are univendlly adherent the tulie caruioi be outlined, and we are
therefore only able to deled an irregular, Itxed mass which lillN the jiclviN and is
cMinecled with the uterus.

Cyytic I', niargcmeni i>f the Oviducts . — Deep pal|iati<>n
repeals a cystic mass situated in the pelvic cavity which can be traced to the
uterine hnm. and consequently recoRniKed as a distended widuct. The tumor
frequently form.s a torluou*, sauKige-jJiaiictl mav, or it may have the outlines of
a relon, and in some instances the ovary may be felt closely atuched to it. As
a rule, the mas* is lender and iMiinful when pressiti ufK>n by ihc examining
finger, and if adhesions are present it is more or less immovable. .\s staled else-
where, the Rreate^t amount of di.stention is in the outer two thinis of the tube, and
hence a sulcus or dciirevvion c;in often lie felt by ihe fmger l>clween it and the
womb. The mobility of the uterus depends U|>on ihc presence or absence of
ailhesi(>n>; a.* a rule, however, the organ i» more or lew llxeii in ihe pelvic cavity.
The prewnce of Huclualion in Ihc tubal mass dcftends upon Ihe amount of fluid
it contains, the thickness of the walls of the oviduct, and the extent of the sur-
rounding ailhevions. fn a brge isirtfwalpinx we arc UMialty able to lietecl
fluctuation, and even in cases of moderate distention it may readily be recognijicd
i( the walls of the tube are thin and the adhesions are not extensive. As a rule, a
pyonlpinx and a hemalonidpinx impart a doughy senitatinn to the examining
finger, while the fluid in a hydrosalpinx can usually be detected if the tumor is of
moderate mm and not generally adherent. .\* in the case of interslilial salpin-
gitis, a saciosalpinx may In- found adherent to any part of the (wlvic cavity. It
is impossible to dLstinguish lielwecn the three varieties of tubal distention with
any degree of certainty by the |ihys.ical sitcn^. and hence the diagnosis mu.-it ix
based u]>on the history' and the symptoms of the patient.

Adhesion* . — The presence iir the absence of adhesions as well as their
extent can be uppmximatcly determined by the latitude of motion in Ihe uterus
and its appendages. When all of the pelvic organs arc found to be fixeionK are general; but when the
utems, the tubes, or the ovaries possess more or less mobility, it is vcr>' dilTieult
to recognize the precise extent of the 4dventitiou% union. This is especially true
when we endeavor to delect adhesions between the tube and the inlc:<tine. I>e-
cau&e the normal range ol mobility possessed by the bowel is not likely to be

498 THE FALLOPIAN TUBES.

Chronic Form . — Pain and dysmenorrhea are the chief symptoms thit
direa our attention to the presence of a chronic form of inflammatory trouble
in the pelvLs. Sterility is also an important symptom, as it points to the posublc
exii-tcnce of a tubal lesion, and, finally, the run-down condition of the woman's
health is significant of the chronic nature of the pelvic disease. The coexisting
endometritis should also be taken into account, as it explains the origin of Iht
suspected ))elvic lesion and confirms the diat^ostic value of the other sj-mpttms.
The Physical Signs. — A cute Form . — The examination is made bt
reclo-iibdominal and vagitw-alidominal palpation with the patient lying in the
dorsal poshion either on the bed or upon a table.

In the vast majority of cases following bbor at term the physical signs of
tubiil involvement cannot be determined with any degree of certainty or satis-
faction owing to the large size of the uterus, the tender condition of the pelvis, and
the small amount of hypertrophy that is present in the oviducts during the early
stages of the disease. Under these circumstances all that can be eUcited ht
palpation is a sensation of fullness on both sides of the uterus, and the diagntsis
must therefore de|Krnd more upon the history and symptoms than upon any
definite information derived from the physical signs. In very thin women, how-
ever, we may be able to recognize the tubes if they are sufficiently swollen, but
these cases are the exception rather than the rule, and we must therefore geonslly
he content to base (he diagnosis upon inference and not upon facts. In septic
cases following an aljiirtion in the early months of pregnancy the local conditions
are niit the same, and we are, therefore, better able to determine the condition of
the tubes by palpation. In these cases the uterus is only slightly enlarged, and
rcm.'iefiuently there is suificient room in the pelvic cavity to map out the onducLi.
which can often be done if they arc enlarged and the woman is not too fat.

When pelvic peritonitis exists and the organs have become bound together bv
adhesions, the uterus is found ti) be imm<ivable and the vault of the vagina feels
hard an<l unyielding. The presence of cellulitis may be suspected when the base
of the broad ligaments feels swollen and tense, and if suppuration has occurred a
soft, doughy sensation is imjjarted to the examining finger, or fluctuation may be
recognized if there is a iurge collection of pus.

The physical signs dejKindent upon ihe coexisting endometritis are given on
page 4,u.

( hronic Form. — The esamtnaiiim is made by recto-abdominal ar^
-.■iigiito-abdominal palpation with the paticnl lying in the dorsal position on i
table. ;\n ane.slhetic should be used hi all cases in which the examination i*
unsiitisfuctorv, otherwise a tubal lesion may be overlooked and errors madt in
the diagnosis. .K slight enlargement of a tube is often very difficult or eiw
impossible to recognize by touch, es])ecially in women who are muscular or siwl.
and a cystic oviduct may be sii completely .surrounded by adherent strunurfr»
that its physical characteristics cannot be determined by palpation.

The jihysicai signs due to the folhnving lesions are considered separalelj:

Chronic inlerstiiial salpingitis.

("vstic enhirgcment of the oviducts.

.Adhesions.

Walled-otT abscesses.

Tubo-o\'arian aliscesses and cysts.

Fistulous ojicnings.
rhronic Interstitial Salpingitis . — In some cases the lub^
is soft and so^lighllvenlargeil th:il it cannot be recognized by palpation. InoinC
instances il mav be fell as a round, elongated, often irregular mass that is con-
nected wilh one of the uterine horns by a hard, cord-like structure, which is ti"

PUKtaKNT SALKNCinfl.

499

Ihc:

tnl [iroximui end n( ihc ovuluci. Thi?i tnhllnilcd cowlilion u( ibe lube may
lly be drtiM-ieil by t'»r«(u] }Kil|>atian. unci su it i< uniolly present in chronic
itial Ml{iiR^tis, it should be considcretl a vcn' valuable fifiji ol tubal
In fi-ttx ca!«cs instead of (he infiltration l>cin); uniform and rrgubr in
Icr it iKcur> in the form iif oik nr more hard nodules situated in the tube
fncaf tilt utrms belwtcn which and the i>clvic mato no dtMind nmnectiun can be
The di>ea-->e<l mulurt tt u.iuully di^phiinl iiiul adherent in the cukle^c
,;b»: it nwy ;il»o In; found beside the tilcms, or immovably fixed by ad-
lo ihc j'oslciioraspctl of ihc broad tij^anicni; and in nire in.«tan(V> it nuy
. inl in friinl <'f tlic numb. When the tu)>e nnd oviiry ire bound together
tit j(ltir->i>i[iN, the)' form a tumor i^ hich h more or less round in shape :ind somc-
vrhal hjtil in cunsislenry, A» a rule, the i>i2C of the ma.w it greally inrreaticd
'by the lymph whi^h ^umitinds it and by the ndhesions which it forms with ad-
vent orgaiiu. and under these circum^lancefl a lubo-ova-
rian cnlnrKement i« often found In be much smaller
whrn it i« enucleate t) at the time of operation than
w b c n iirtii outlined by palpation. If the av-ar>- » not dciLtely
ii to the tube, it may often lie felt as a hani, nvoidal mass, iwmewhat en-
irtHlrr lo the touch, ami more or less imniHivable. In cases in u-hiih tltc
I -- are univcrs.-illy adherent the lulic lannut l>e ouilineil, anrl we are
hly able to delert .nn irre^lar, r>\v<l mass which lills Ihe jiclvifi and in
uintiei tei) uiih the uleruh.

Cy»tif ICnlarfiemcnt o( the Oviducts ,— Deep palfmtion
nrveib a cynic miuf Mlualnl in the pelvic cavity which can be traced to the
Bicrine bom. aiv) con^xiucndy rccognixed aji a distended oviduct. Tlie tumor
fnquenlly (orm.^ a torttioti^. ^.-lusiige shaped m;i».s, or it may have the outlines of
a nrlort, and in some instances the ovar>- tnay be fell closely attached to it. As
ryle, the miuu. is tcmler and (uiinfut when prcs'ioii ujwn by the examining
T, and if adhesions are prt- sent it is more or less immo% able. \i stated elw-
'. (he ftreatest amount »f distention i.>> in the outer two thinU of the lube, and
a 1l^lcu^ or dcpi«xsion <t;in olten be fell by the finger licf.vcen it and the
Wixnb. The mobility n( the uterus dejwnds upon the presence or ab^enie of
~" Kiitt: oji a rule, however, the organ ia more or lew fixed in ihc pelvic canty.
ptBcnre of fluituation in the tubal mass <te[>cnds upon ihe amount of fluid
Ins, the thickness of the walls of the oviduct, and the extent of the our-
■rlbevionn. In a brge NidtMiilpinx we arc usually able to detect
iiutiun. and r\xn in ca.^^ of moderate distention it may readily be recopiiud
• wallk uf the lube arc thin and the adhesions are not exteasi\-e. \s a rule, a
ami a hcnutovitpinx im]Mn a doughy lens^ilion lo the examining
'. vfaile the lliiid in a hydrnulpinx can usually lie delected if the tumor U of
ley/e .ind not Knier.illy mlhcrent. A* in the case o( inlerMitial rtalpin-
aadMalpinx may t>e fouml iidherent to any part of the privic cavity. It
"lie to divliuguish lielween the three varieties of tulwl di^lention with
of leMainiy by the physical Mgnv, ;inil hence the diagno»is munt be
einn the hi>tor>- and the symptoms of the patient.

<1 ■ 1 1 i o n s .—The |)re>ci« e or tlw aliMence »rf adhesiom a.i vrell a^ their

H nn lie approximately determined by the latitude of motion in the uteni»

elvi<- oncan.i are found to be fixed and

iiie, it ik clearly eviflrnt that the adhesioiu are general; but when the

I llic tubes, or Ihe ovaries possess more or less mobility, il is vcta- difficult

•"itnixe the pretiw extent of the arlvenlilioui union. Thi-> i> e--t)etially true

"e eiidrnvor lo detect adhcsionv livtwem the tulic and the tnle>iine. tic-

the normal range o( ntobility jxis^iesscd by ihr bawd is not likely to be

500 THE FALLOPIAN TUBES.

reached when the pelvic nrf^ans arc pushed in various directions by the exanuning
fingers. When the tul>e is adherent to the side of the uterus, the ovan-, tli
Iiopierior surface of the broad ligament, or to the culdesac of Douglas, dttp
palpaliim will usually reveal its jusition and the character or extent of the
adhesions.

Walled -off .\bscesses .^A physical examination wiD not revtal
the presence of small foci ()f pus scattered throughout a mass of adherent intestiiKS
or in adhesions between adjacent organs. When, however, the pelvic cavity is
the seat of a large abscess, the vaginal vault is greatly depressed or obliteratol bv
the pressure of the purulent collection upon it. and fluctuation can usually be
elicited by careful bimanual palpation. The uterus can seldom be outlined by
the examining finger, as it is genendly crowded out of position and surrounded
h_\' dense adhesions. The tubes and the ovaries cannot be palpated, as ihei- are
also hurieil in a matted mass of adherent organs which form a part of the n-all thai
.■'huts otT ihe abscess from the peritoneal cavity and limits the spread of the
infeclion.

Tu bo-ovarian .\bsceBses and Cysts . — A positive diagnteis
is out of the question, as the physical signs <lo not differ from those elicited in
cases of sactosalpinx. When, however, a tulx)-ovarian absces.s or cyst is smail. it
may occiision ally lie jiossiljle in vcrv' thin women to outline the ovoidal shape of
the iivary and truce its connections witli the di.*tcnded tube; but if it has at-
tained a large si/e, tiiis cannot be c!i)nc. as the organs are crowded together, and
hence tlic lesion is not knoivn or even susjiected in the va.st majority of instances
until the patient is operate{l upon.

K i s lu lou s Open i n gs. — Bimanual palpation re\"eals the presenceola
pelvic mass that is adjaccnl to and closely connected with the hollow viscus from
which the purulent matter escajjes.

If the discharge comes from the rectum, the jialient is placed in the knee-
chest |)Osiii"n and a rect;il speculum intro<luced. The opening into the bowel i^
then lcn:[ted bv sight and the index-finger of the left hand inserted into the vagina.
Pressure is now made u()on the |ielvic mass with the vaginal finger and the
puriilenl matter escajics into the rectum if the fistulous opening is tubal in origin.
When the discharge comes from the bladder, the patient is placed in the dfffso-
siicnd elevated posilion and a cysloscope inlnxlucei.l. A careful inspection of ihf
intcriiir of the bladiler will reveal the situation of the fistulous o[>emng, and it*
connection with the tul>e may l>e determined by presiiure in the same way as in
cases ill which the rupture has occurre<i into the rectum. If the discharge comfs
from the vapina. the patient is placcit in the dorsal position and a vaginal spem-
lum intrixliued. .Vflcr I<H'ating the opening by sight deep pressure is made
through the abdominal wall immediately above the symphysis pubis upon the
lielvic mass, and if (he fi.'-tulous tract communicates with it. pus is seen escapinf
into the vagina. The i>resence of ;t false passage between the tube and the in-
icsline mLi\' lie inferred when ]>us escapes fn)m the anus and no fistulous opfnins
can be di.-.covereil in the rectum.

'I'he connection between a sinus In the alxlominal wall and the tul>e is de-
termined cither bv pressing upon the pelvic mass with the inde.\-finger in thf
vagina anil >ecini! the ]uis esca]ie externallv or bv passing a long probe into (he
fistulous (raci and feeling the li]i of Ihe instrument in the pel\"ic cavity.

The Microscopic Examination. — In those cases in which the history of the
jiatienl is iiuletinite and unsatisfactorv the cause of the chronic tubal lesion maj'
s(imetimes lie ilcterniinefl and the diagnosis made by discovering gonococri inUif
secreiitms I if the uterus, the vagina, the urethra, the glands of Skene, or the ml''*-
vaginal glands.

SF.OPI.A!UtS. 503

cvacualed by a vaginal indsion and an abdominal section performed al a later
date tP Tcmuve the di»ea.<ed lube.'..

Sa(lesaJpinx.—'iaip}ni!p-<>o\ihonxUtmy {ahdomituU route) is indicated in all
<r:i*C9 of jivuAalpin.t, bcmalosalpinx. and nydrosalpinx.

TiAO'(n'iiriiin AiMCisfi and fyjd.— These cases require salpingo-oopliorec-
lomy (abiitmiinai route).

FittuIoM Openings. — An abdominal section is indicated in these cases. The
adherent and di»c;i;«<t iiil>e i» firti removed and then the ojiening into the hollow
viscus is closed if possible by sutures; but if this nnnoi be done, it is shut off
frofn the K^neral peritoneal ca%ity by glass drainage and gauze packing.

Apptndidlh. — The atxlominal raiitv mu.Nl l»e o))enLtl by a median inciiuon
and appendectomy followed by salpinpo-wphorcctomy performed at onc«.

NEOPLASMS.

Tumors of the oviducts arc companitivciy rare, usually of small size, and of
but little cjinical interest.

The stibjectr.f and ohjectiir. symptoms differ in no vray from ihme caused by
other pelvic growths, and a physical examination demonstrates only the presence
of .-I tulMl tumor without revealing iu chaiucier.

Thc«e tumors shoult) l>e remin'cd by ihr alxlomina) mute.

Pibromyoma. Fibroid tumors of the oviducts arc very rarely met. Th«y
dcvcloji in the musi iibr aiat and are seldom large enough to cau.4C loc^l symp-
toms. In a case reported by Simpson, however, the tumor attained the size of a
child's head.

Papilloma.— This Ik a nire form of tubal di.->e:i.'4;. The papiltomalnus
mass may dilate ihc tube and protrude from its abdomiiul opening, or it may
even rupture the oviduct and partially eM'a)>e into tlie peritone:d cavity.

Lipoma. —Small fatty tumors of the oviducts ha^-c been described.

Cancer.— Cancer of the oriducts is usually secondary to cancer of the cor-
poreal endometrium or tile ovan*. The di.'^'ue seldom results from cancer of the
cer» IK unless the body of the uterus is tir*t involved Primarj- cancer of the tubes
v. :i veiT fJte fiirm uf the disease.

Sarcoma. -The diNCiw* is exceedingly mre and is nwirly always secondaij'
to >afcoma of the body of the uterus or Ihc ovary. The tumor docs not, as a rule,
re:ii'h a hir^e Aix.

Gummata. — These tumors are occasionally found in women suffering
Willi icniar^' syphilis.

Cysts.— Small cysLs that have no practical significance are fre<iuei)tly found
in the oviducts. They gencmlly have thin transparent walls and contain a dear
serous Suid which is non- irritating to the peritoneum. These cysts may devriop
from the mucoui, rou.scubr. or serous cout of tin- tube. In the majority of cases,
however, they are embryonic in origin .in<l are dcvclopol from the remains of the
Wolffian body or the duet of Muller. Sometimes a hemorrhage octurs in the
walls of the tutwand forms a blood-tumor whith nuy eventually undergo changes
and be converted into a serous cyst.

The most common varict>' of tubal cvst is the so-called hyiiitid oj Morgagni.
which originates Imm the upper ctid of the canal of Mtlller ami is usually att.ichcd
by a slender pedicle to the timbrialcd end of the oviduct. These cysts vary in size
from a pea to that of a walnut and contain a dear, non- irritating, serous fluid.

502 THE FALLOPIAN TUBES.

through the vajipna, and later on a celiotomy should be perfonned and the

diseased organs removed.

As a rule, abdominal section is contra indicated in cases of aoite punikot
salpingitis, excqjt when general peritonitis develops, because these patients arc
usually profoundly septic and unable to stand operative interference. Pus col-
lections in the pelvis, however, can be evacuated by the vagina without ad-
ministering an anesthetic or causing shock, and this route should therefore alwan
be selected during the acute stages of the disease. Later on, when the patient
has recovered and is no longer septic, celiotomy should be perfonned and the
infected organs removed.

Chronic Cases. — W ithout Gross Lesions . — The expectant plan
of treatment may be tried in cases of chronic salpingitis in which no gross lesions
exist, but unfortunately the results are seldom permanent, as pain and othfr
symptoms usually recur when the treatment is stopped. This form of treatment
Ls conlraindicated in cases of sactosalpinx, and also where the uterus and its
appendages are displaced and adherent.

The palliative treatment consists in first curing the coexisting endometiitis
{see pp. 430 and 438) and then relieving the tubal inflammation by emploving
the local and general measures recommended in subinvolution of the
uterus (see p, 445)- If the patient is not benefited after se\-eral months of
treatment, alxiominal section should be performed and such operative measures
adopted as the existing pathologic conditions demand.

With (i r o s ^ !.«««« n s . — The following lesiims are considered from
the standpoint of'treatraent:
Adhesions.

WaDed-off abscesses.
Abscesses of the broad ligaments.
Sactosalpinx.

Tubo-oy ari^, ^^st^^iK^ and cysts.
Fistulous openings.
Ajjpendicilis.

Adhesions. — .Abdominal section is indicated when the adhesions are suffi-
ciently extensive to cause local pain or per\ersion of function, and the condiuon
of the [iclvic organs must determine the extent and nature of ihe surgical measure*
t(i In- cLirriuci (lilt in each case. If the uterus is retrodisp laced and adherent alon|
with thv uiffinc ap(iendagi!s, the adhesions should be broken up and the fundus
attacliud U> tho aluinminal wall. (See Ventral Suspension of the Uterus, p. .t^,;-'
The uterine appeiKiajics should always he carefully examined to determine the
qui'-^tion of tbt'ir removal, and if the alulominal openings of the oviduct j aft
jKtluloii- the urgari-i >h<uilil not be removcfl. but when they are closed salpingo-
(ii)])hcir('iiomv is (jcncraliv indicated unless the patient is desirous of having
children, in which ca.-c a conservative operation .should be performed and thetubf
and iiv:in nf unc side s;ivcd. (Sec Conscnative Operations, p. 572.)

\V,i//f'l-o/] . l/i.vrc.vjcv.— A lollciiinn of pus in the pelvic cavity that is walWoff
liv omental and intestinal adhesions mii>t lie evacuated and the sac diaiwd-
The vaginal route should be selected in the>e cases for the reason that whenlbe"
iipcraticin is performed ihroiijjh an abdominal opening it is necessarv- to separai^
the adhesions, and heme the general pcriloneai cavity is liable to become inieclfi-
Hy evacuating the pus through a vaginal incision, however, the adherent slruclute^
arc not dii-tvirbcd and ihe abscess cavity can be drained with but little or no ri>.1
to the j>atienl. I.^ilcr r.n. when the sac iif the abscess has contracted, abiloniiii^i^^
section should be perfiirmed and the discasal tubes removed.

Ab.itfSfes oj ihe hroad l.igameHls. — A broad ligament abscess should

KP^PLU1U.<;.

503

actutcd by a \-agina) incision and an ubdominal section pvrfonned at a Uler
ale to remove the diseaiol (u1>c4.

Saetctiilpinx. — Siilpinjiik 4>(>|>liorec1o«nv (abdmninai route) is indicated in all
Gxses of pvusalpinx. hematosalpinx, and nydrosulitin.x.

Tuhfi-ffiaridn AbiftJiei and Cyji.t.— The* cawj. require salpingooOphorcc-
lomy (uMomituii roHle).

FiMttioui OpeHingi.—\n alMlominal section is indicated in the*e caws. The
adherrni and discit^^tl lulw U fimt rcmfn^ed and then the opening into the hollow
vbcus is dosed if poasibk by suture)^; but if this cannot be done, it i!> shut oS
from iIk Keneral peritoneal cavity by glass drainage and k:iu/« {jacking,

A PfftuiidH^.— The iil>ilo[nin:il taviiy mu»i I»e 0(>enej by a median incision
an«l *pi>cndeclomy followed by sa)[iingo-otiphorcclonny perfonned at once.

NEOPLASMS.

Tumors of the oviducts arc compan-ilivcl)- mrc, usually of snail size, and of
but little clinical inierc%l.

The sutijeciite aiKl ohftdhr lymfiomi differ in no w»y from those caused br-
other pch ic growths, and a ph>-sical examination demonstralei only the presence
cif a IhImI tumor withoul rc*calinR its character.

Thee tumor' ^)iou)'t Ix- removed by the abdominal route.
Plbroiliyonia. - l-'ibroid tumor* of the o\'iducu are ven,' rarely met. They
dr\Hi>{> in llic mu-^ular loat and arc seldnnj larjie etiough to cause local symp-
inti- In a case rctKiTtocI by SimpMHi. l)ou-e\-er. the tumor atUincd thetuzeof a
. (: I I's head.

Papilloma.— ThL> in a rare form of tubal dise.-iw, The papillomatous
ouas mjy iJibic the lube and protrude from its abdominal opening, or it may
wen rupture tlie ovi<lutcal endometrium or the ovary. Thedi.^cnw Kidom results from cancer of the
> \x unle» the bod>' of the uterus is tirst inwhcd. Primary cancer uf the tube*
) a >en' rare form of the disease.

Sarcoma.— The (li.%e-.i.'«c u. exce«dingly rare and is nearly always secondarv'
> Mp»Knu of the body of the uterus or the ovzzy. The tumor doe* not, a» a nile,
%A a Inrtie size.
GtUBtnata.— Thr«e tumors are occasionally found in women suffering
lilli tertiary' syphilis.

CjrstS. — Small cysts that have no pmcticnl <igniltcance are frequently found

*= ihe (fviduclA. They generally have thin I ransparent walls and contain a clear

f'-.n fluid which is non-irritatiitg to (he [teriinneum. The*e cysts may develop

' 1 ibc miKoua. rous>,njlar, or ivorou-^ coat (*f the lube, In the majority of cases,

i\rT. thevareembrionic in origin and are dc^cjoiwd from die remain* of the

' '(ir. , t_.l, or tlie duct of Miiller. Sonu-lime* a hcmiirrhjiBe ncrurs in the

' * l-eanrl |i>nnsa blood -tumor which nuy eventually undergo chanxei

'"*** ■•I inti>a sernuscyst.

'i <rnm4in varicii' of IuImI c)-*1 i* the Jocallcd h-nUttiJ «} .itari;asnl.

***icii nnipnaic^ (r>>m the ujijiereiidof thecanal of MHIler.md is usually alUched
yr a. Ucoilcr pedicle to the fimbriated end of itie oviduct. The?* cyu var\- in size
IroKb a |)a to that of a walnut and contain a dear, non-irntating. serous ^uid.

S04

THE OVARIES.

DISPLACEMENTS.

The oviducI» may be dLt|>Ltre<l in ;tny <lire<riion within the pdvic cavity or
drawn upw.ml into the abdomen by tumors, and ihcy may also be found in the sac
of «n inguinal or crural hernia a^ well as in ibe cup-:>hapcd dcpre»ioi] formed
bv an iitverted uterus.

CHAPTER XIX.

THE OVARIES.

Thf fnllnwing nr|;i|ti>rm.Tlj('ps li;^vy lirrn iiii-.iTvr;it:

Ahspmc of ihf ovaries^ SuiH.nuimerary and accessory ovarJeg.

. _^'5"<'''"e"'-trv "v^Hev '""jf'T"'"'*"! '

Absence of tne OVaneS.— Absence of both ovanes is a vcr\' rare anomaly
and is usually associated with a njdimcniar)' condition or absence of other geintal
or^ns. Abseni"* of one o^'ar^', however, i.* more frtri)uently met, and is .Haid to be
due to a constricting off nf the oviitmh aiiiage during the process of development,
the separated organ consequently undergoing atrophy and complete oblJtenitiuTi.
The ronihtion i» u.^uuUy awocintcd wiili <lcf«'ti\T development of the corrrspond-
ing duel of Muller, and it is therefore not uncommon to find the anomaly associ-
ated with a unilateral \-agina. a one-horned uterus, and an absent Fallopian lube,

Rudimetltary Ovaries. -While an ill-dcvc!opcd or rudimentar)- condi-
tion of llic ovaries is not a very frequent octurrencc. it is. ho«evcr. more com-
monly met tiwn aliM-nce of these organs. Tlie Oriiiihan ftillirles and the
ovules are pciicr:illy defective in their development or absent ollogcther, and if
iKith ovaries are involve>l menstruation is either seamy or amenorrhea is present
and the jiutient i.i aliM>liile1y sterile. This variety of ovarian deformity is often
associated willi imperfect development of other genital organs, especially the
lulies and ihe uterus, and in rare instances the large blood-vesscU of the body
and ihe nen-ous sy^lem ;iri- found (o lie defective.

Supemtunerary and Accessory Ovaries.— A supemumcrary ovary
is an exceedingly ran- ociurrenie and uniy one auihenlic cjisehas Ijeen recorded
(Winclcel). 'liu- |Misvibilily of the exislence of a third ovar)', howcvx-r, must be
borne in mind in accounting for Ihe continuance of menstruation or the occtir-
reiue of pregnanc-y after the removal of Iwith <>\'aries. .Accessory ovaries, on the
niher hand, arc not uncommon, and arc due to a constricting off of a part of the
developing nar>'. the separated portion retaining more or less of its identity.

DisplacementS.^Congenitaldisplacemenl-iof the ovaries are more or less
ciirnmon, and the organs have been found occupying various abnormal positions
in the pelvic and abdomiiuil cavities, as well as forming a part of the contents of a
heniial sac.

DISEASES OF THE OVARIES.

OVARITIS.

j. —Inflammation of the ovary: Oophoritis,
ieties.— Tlir disease may be mute or tiiroitk.

ACVTE OVARmS.

SOS

Canses.-

^^_^_ -ITic disca*c h nn'-i frcijinDtly caused by purulent salpingitis
{ftpiK or xonorrhtal). allhough in *ume taics the infection may 1» tarried
dirccll) (nim tlie ulenis lu the ov.irii;* hy tlic lym|)hi)tic %t>^cI» before the tuljc* arc
Involved. The disease is comparaiixcly rare csccpt in connection with puerperal
»cp«'i», iilthnugh oises ore met from time lu time whidi ure due to other ("uu^es, iind
the affection has been iib»cr\w! in iKiiwning with nrscnic or pho.tphorus; in
the exanthemata: in cholera; in acute suppression of ihc mcn!««: and in acute
rlicurnali^m. Tliein'ar>' may \)C injected ti_\' the tiilon liatilhi^ when it U adherent
lo the rectum or intestine and by the |ineumococcus during an attack of pneu-
monia.

Pat hol O gy . — The civiiry l>eri>mts swollen, eiJeinntouK, and intiltraled with
seruni, flhd if^"urfacc is covered with lymph which forms adhesions with adjacent
organit. If the inflammaiory process continues, small f<ui of pit* are suitered
throughout the owrian Mroma. and r\'enltiully a large abscess is developed which
completely destroys the ori^n. In the miltlcr forms of the di»ca<« the inflam-
mation mar gniilually sulislde and end in resolution Itefore Kuppuration occurs.
These cases, however, usually become chronic, and the ovar>' either remains
permanenily enlarged or the connedive tissue umlergoeM retraction and cirrlKRi.t
results. The changes that ocnir in ihe ovary from thickening nf its capsule and
ihe hypertrophy or cirrhosis which is present are discu.'.sed under the Pathology
of Chninic Ovaritis, and need not ibcrefore \k clestTiljed here.

An ovarian alwcess may increase in siw and linally rupture, causing general
peritonitis. As a rule, howewr, the lymph ami adhesioni which surround the
ovary pre^'enl this acriileiil, and the condition {usscs into a chronic stale, the
pus cither c\Tniually becoming sterile or con^iTnefi into a cheesy mass. .\n old
alincc» which han remaineil dormant for a long lime may Iwcome suddenly active
again from ■ fresii inlcctitm, n» in the cose of a pyosalpinx, and present all of the
ftymptoms of the orij^inal attack.

Alien an acute ovaritis i.i due to gonorrheal infection, (he lr<nnn^ are chiefly
limited to the surface of ilic ovar)-, and exiensivr adhesions are usually formed
with ^iiljiuiiii .-'irmtures.

Symptoms. — The symptoms of acute ovarilL* must be studied in connection
with tnc causi-s of the di!«afr and also with reference to ihc character of the
ovarian legions.

When the infection Mans in the uterus and the oMiries Ijccome secondarily
involved, either through |hc tubes or by way of the lymphatic vesscU, the symp-
tom* of the ovaritis are so obscured by those due (u the puerjieral seplicemia
(septic endomeirUh) th.it in ficscribing the latter we say all there is to be said
about the former. (See Acute Septic Endomeiriiis, p. 432.) In other words,
the ".ymplonis of the ovarian (Iisea>e cannot be separaleil fr«im ihosc de-
pendent u[K>n the uterine infl-immalion and the local or t;enerjl periionilU
which may accompany the affection.

In cases of acute ovaritis, howe^Tr, in which the disease is not due lo uterine
infection the ovarian inHammation stands, as it were, alone, and is therefore not
overshadowed by another lesion whose sympttims are predominant. Con-
sequently when an acute orarilii' i* cau*ed by arsenic or phovphonis poisoning,
the cxonthcmaia. cholera, acute rheumatism, sudden suppression of the menses.
or b>' the colon liatillus or ihe pneumoooccus, the local symptom." are clearly
defined and point with more or less certainty to the orary as the seal of
trouble. The patient complains of pain and tenderness in the ilbc regions which
are asiionated with elevaieil lem[)eniture anil rapid (HiLse. The pain lh sometimes

S06 THK OVAKIES.

very acute; U is burning or lancinating in character and radiates to the thighs,
the lumbosacral region, the bladder, the rectum, and occasionally to the breasts.
In many cases there is more or less nausea and vomiting; the patient lies with bet
knees drawn up; and. as in orchitis, the parotid gland may become swollen.

THh fp^fjaia.— The diagnosis is based upon a consideration of the following
subjects:

The histon-.

The pnySl^a'nsigns.

The Hislory .— l nese cases nearly always occur shortly after a labor or an
abortion and are associated with acute septic endometritis. When the uterine
infection is absent, a atrcful investigation will reveal one of the less common
causes of the disease.

The Sjrmptoms. — When the infection starts in the uterus, the symptoms arr
overshadowed by those dependent upon the coexisting septic endometritis, and
consequently they are of but little, if any, practical value from the standpoint of
diagnosis. In the less common forms of the affection the sudden development of
ovarian pain and tenderness, associated with elerated temperature and rapid
pulse, points to acute ovaritis.

The Physical Signs. — The examination is made by recto-aMominal and
vagino-aiidominal palpation with the patient lying in the dorsal position either on
the bed or a table.

In acute o\-aritis the o\-an,- is found to be enlarged and tender on pressure.
It may or may not be mobile, according to the absence or presence of adhesions;
u^iually. however, the organ is found to be prolapsed and adherent. An ovarian
abscess is round or globular in shape and fluctuation may be elicited if the patient
is thin and the purulent collection is large.

In puerperal cases following labor at term the associated endometritis and
peritonitis as well as the large size of the uterus render it difficult or impos.siUe
lo jiiilpjiie the ovnn.' unless it is very much enlarged or the seat of an abscess, .t;
a rule, however, ihe only physical sij;n:i that can lje elicited by bimanual palpation
are tenderness and fullness over the repon of the ovaries; but as these symptoms
are also ])rcsenl in salpinsilis ani] in lucul peritonitis, the diagnosis cannot be
baseil upon th^m. In sei)iir cases following an abortion early in pregnano" a
bimanual examin;ilion will often reveal the enlarged and lender ovary, which an
|je clearly outlined between the lingers if the woman is thin.

In non-puerperal la-vs the nvary may usually Iw palpateiJ and the phvsicj!
sifins of ovaritis determined.

Differential Diagnogis. —The importance of distinguishing beniMH
acute*iTVm-pufq>cr?n"ovanlis Lind ajipendicilis must be constantly borne in mind,
as Ijuih jifTcclions o>mc on suddenly and are churnctcrized by pain, tcnilemw.
olcvatfd iemp(T:iiure. and rapid jiulse. The history, the symptoms, and iht
physical >\'s.\.\~ of both diseases must be carefully studied, and If any doubt remain*
as lo die n;iliire of the case an explonttory incision must Ik? performed at once.a>
it i- lii'UtT In he oi;c:i^ion:[llv mistaken in the diagnosis than to run the rii-t I'l
siibicdin^ the [)aiieni tu tlie rUinirers of an unrecognized attack of appendiciii-.

PrognflaiS'" The non |iucT[icr;il forms of acute ovaritis are seldom danger-
ous to life and the acute symptom-; usually subside in about one week. Tk
oviirv. however, u^uallv rem:iins enlarged or undergoes cirrhotic changes ihit
de^trov iis fuiuniiin ^imi reniler the woman .sierile. In some of the cases of ar-
rested developnieni of the sexual organs met in young women the maliormalion-
hiive undouliiedlv originated from an acute oophoritis occurring in childhow:
whidi WHS caused bv one of the exanthemata.

CHRONIC OVARITIS.

SO7

Th« puerperal fonns of the <li»«aM are alway^^ rinngrrou* to life, noi only on
ftcirouni »i ihe character of (h« ovarian inflammalinn. but abo from the cocsiMing
«i<lumctnii» and general Aci»is. If ih« o^'arian inflaminaiton subviilcs lieforc
supfmraiion occurs, resolution may take place, but even in lhe»c cuftcx th« otary
» uvualiy irrepiirably danuKed and the disease becomes chronic In some cases
4n aty^tc^s dcvclo{Kt in the ovary which may rupiure into the )i;eneral peritonea]
aivii) . rau-'inf! a fatal peritonitis, or it may burst into one of ihe hollow ri»cen
an>l form a {icrmaneni I'utulous openinK.

Treatment.— The treatment of acute ovnritift b classified as follows into:

—The treatment is the same as in acute purulent uIpingitH

Puerpef
(•eep. 501 ).

Ron-puerperal Cases. ^Tlie [xttient must be kept absolutely at rest in the
rccurabetit position and the bed-pan wol when the bladder and the boweb are
evacuated. The \-aKina is douched three times every iweniy-four hours with two
gallons of hot normal salt "olulion (iio^ to tio^ F.) and an ice-bag (see p. 97)
or hoi compresses (see p. 97) arc pUccd over the alTect«<l pariA. Tl»c lioweb
should Ix- tvell llushe^l ai once with a saline purgative and then kept open daily
with half ti bottle of the diratc of magnesia, followol, if neccasaiy, by a simplie
enema. The diet shouM l»c liquid (see p. 106) for the lirtt tn-o ur three day», awl
after that it shoiiM In: 7,0(1 incluMCter (ieep. i it) until the patient gctsouiof bed.
Small lii'ics of inoq>hiii should lie giivn if the juiieni i.i re^tles^^ and she suffers
much pain: these iymptoms, however, rapidly disapiwar after the bowek are
fm-ly mo«d. 'Hie jKitienl >hoitl(l l>e sponged regularly ever}' day to keep her
cumforlnhlc and aL»o when the Icmperature reaches to,}" F. The symptoms
usually yield readily to treaiment and the palicnt is generally out of bed in from
ten days lo two wTek».

If suppuration occurs in the ovart', abdominal seaion must be performed at
once ami the ilisea.->ed organ removed.

1^ CHRONIC Ovaritis,

^B CaoaeH. — Chrfvnic ovjirit iriHh^iMi^nTra^'arieljy of (au*e». Il i» far mote
^^nnmoo Dlan ibe acute form ■•[ mc •liJnsi! .IHI U mosf frequently mei during the
^^ntkl'bearinx |ieri<>d of a wom:!!!" life Tlie allcciion often results from an in-
Ltmipleie Pfjolution occurring in awo of .icuic inilammaiion of the ovary: it
may alto he isu^ by gonorrheal endomciriiis: in rare instances it may be scplic
in oeiKiii aitd subacute from the start : and it may ako develop during an attack
of >v]ihiU^. In a large pr<>|>(>rli<m of ihe CA.«et of chronic ovaritis ihe dLtca-se b
u>nf:r>t>«e tn origin, and develops \-ery slowly as the result of pathologic conditions
tli.it inlerlerc with ihe pelvic dr('ulali<<n. The moM common of these catiscs are,
ili-Iili.cfinrnts of the uleru!^ and lis .i;>|>«-iiil;iin^: ma->turlK>liun: cxccMit'c *enul
< -^Tual desiiv: the immiHler.ile use of alcohol: pelvic

i le liliroids: and ste-rility or iTliliacy. Hyperemia

I the ovaries is also commonly met in yuung girl* at
ubcriy wht> are kept closely applied 10 their studies
nd who are given hut little time 10 devote 10 ihe
rvetopmeni of their phyilque.
PatholOigy. —'lite di?eiisc ti usually h^laienl and ihe ovaries may or may
BeaHIwffm.

In tome ca^«s the ovary b ver>' much increawd in >ixe and the leat of cyule
neniioa. The cysts are caused by ibe h/penrophied onrian capsule

5o8 THE OVARIES.

preventing ihe nipture of the Graafian follicles, and hence a small cyst is formed
each time one of them ripens. Thus, eventually the ovary becomes studded with
small cysts which may finally cnalei^ce and form one large sac filled with a dear
watery fluid which may at times contain blood or have the consistency and ap-
pearance of the white of egg. A cystic ovary is generally free or only sli^uly
adherent.

In other cases the ova.Ty becomes the seat of chronic interstitial inflanmiatiaD,
which finally produces cirrhosLs, and the organ becomes a small, hard, shriveled
mass, firmly imbedded in dense adhesions.

Symptoms. — The ovarian disease may be associated with endometritb,
salpingitis, piivic tumors, and adhesions, and it is therefore important to bear in
min<l the symptoms of the coexisting lesions.

The symptoms of chronic ovaritis are considered under the following head-
ings:

Pain. . Sifiiilil^»,

Menstrual disturbances. General symptoms^

Pain.— Pain is me most constant and the most signmcant symptom of duonic
ovaritis. It is situated in one or both iliac regions and is usually most intense iipoa
the left side. It may radiate to the lumbosacral region, the thighs, the bladder,
or the rectum, and in some aisus severe reflex pains may be felt in or under one or
both breasts. The intensity of the pain is usually increased at the menstrual
periods, and also when the uterus and the ovaries are displaced and adherent.
If the menstrual flow is profuse, the pain is lessened in severity, but if it is soniy,
the pain becomes more marked. The pain is intensified by the erect position, by
walking or other forms of exercise, by defecation or urination, by the pressure of
clothing about the waist, and by sexual intercourse. As a rule, the recumbent
position relieves the acuttness of the symptom and patients generally feel much
more comfortable early in the morning than after they have been out of bed and
on their feet fur some time.

Menstrual Disturbances.— Menorrhagia and metrorrhagia are frequendy
assncialed with large cyslic ovaries; in cirrhotic cases, on the other hand, the
"pjio^itc- conditions exist and amenorrhea is likely to result.

Sterility.— Women suffering with chronic ovaritis seldom conceive, as the
ovaries are cilhcr entirely destroyed or the thickened capsule prevents the ova
from escaping.

General Symptoms. — General debility, loss of weight, nervous exhaustion.
and pastro-inte>linal disturbances are common, and hence these women fre-
quently stifTcr from dyspepsia, want of apjietite, constipation, mental depression^
hy.steria, hysUTo-epilcjisv, and migraine.

Dia gn OSiS. —The diagnosis is based upon a consideration of the foUowiaS

The historj'.

TRe "symptoms.

The physical, signs.
The History.— The |>aiient should be carefully interrogated to discover, i»
possible, a cause for the disease. The history may reveal the fact that the woma. "
had had an acule ovaritis man>' years before or she had suffered from acute ibeii -
maiism. .Again, the |ialien! may be .syphilitic or she may have had a gononhei*'
or sejuic infection. The congestive causes of the disease should be thoroughly
studied, esjiecially those which aa- due to irregularities in the sexual life of tli^
fjaticnt. And, finally, we must not lose sight of the possibility of the exanthemaUi
of childhoiw] lieing resjxmMble at times for chronic inflammatory changes in the
ovaries occurring in women after puberty.

CHRONIC OVARITIS.

509

The Symptoms,— The situation, character, and constancy of the local pain
direii our attenlion to ihc presence of a pcMc lesion. The reflex pains in the
brcusl-'. ihe sieriUty, anil the acute sutTcrini? liefore each mensinial [•eriixl nuf^test
ibc [wssibilitv ijf chronic orarian inHammntion.

The Physical Signs.— The examination is made by retto-abdeminal and
vagiiw-ahdominiil |ial|iali(>n with the jiatieni lying in the dorMil |xw>itinn <>n a
table.

An enbrged or cystic ovary may usually be recogniaeii by palpation. The
organ is oral or gIdliuUr in !.ha|«:, lender Ui the loudi, and nitualed cither on one
side of the utcms or in the culde^ac of Douglas.

A rirrhoiic ovar>, on ihe other hand, cannot be felt by the exumtninR fmfccr,
as il is atrophied and usually burin! in a mass ciirLiiNling of the mlw .ind toils
of iiuc-'Unf malted together by a<!hesions.

Progn OSiS.— Chronic ovariti> rarely cause* death unles-i suppuration oc>
cui^^BcrTPTfflowcd by [wriloniiis, ITic di^-asc, hoii-ewr. \s seldom cured
spuntaueuu.'Uy. and trcatniciil, as a rule, only results in lemporary relief. The
\vmplofn« ichtrar no tendency to les-sen in sewrity until after the mcnupaiLte, when
they gradually become less marked or disappear entirely. Sterility b common.

Tr^Ltmgat. — The treatmcm of chronic ovaritis is classified as follows:

i-aimnnie tnaltpent.^
myg^L treatment.

•iTic ra

The PalliativeTTSSfHTPHTr^Tliii. form of treatment may l«e tried in women
who have in(lc|>cnik-nl iiie;in» ^ntl are willing^ to submit l» (be nrces.'-an* incon-
Unforiunaietjv however, the results are seldom permanent, as ibc
usually recur when the in.-jinient is Moppcil. The best

venienc«s.

p»in and other symptor

remits are nbtained, lul^ver, in women who are appniachitiK the mrnopauM;, as

ihcj- may often be kapt comparatively comfon.ablc until menstruation ceases and

nature relievc>lli^fKilhiiI<i}[ic conditions. Women who are dependent fur a living

upon their own dions should not empltw the pallbtiw treatment, as the results

are loo uncerl^ to conipcnsalc them for the loos of time and money.

The pulli:jfvc irralmenl is noi a|)])licit>Ie to e\-erj- case of chronic orariti* and
a careful siufly of the pelvis must be made before deciding to adopt it. The
treatment n^y Iw tried. f>ruvided the ovaritis is not lumplicaleil nvilb salpingitis,
and alst> w^cn the ovaries are but slightly enlarged, free from adhesions, and not
prolapsed^ It is contra indicated, on the other hand, when the hypertrophy is
marked, At the organ.-> are div|iL)ci^t anil immovable. The name is true when
the ovadcs arc cirrhotic, as tio form of local or general litratment can restore
the disoLsed and altered condition of ihe siruclurca of ihe organs.

Thd mlliative tre:ilmenl mav be diMWaed under the following headings:

j:*'' ■ ■ ■ ■

rr^^^l^gdEeneraltreat meni .
The K c m o v^joT^TTe" Cause - — It is impns.«blc In derive any
benefit from treatment without first removing the cause of Ihc ovarian infiam*
nation, and if this i-annoi lie dune juilliallve measures should not t>e instituteid.
When, therefore, the affedion is due to such conditions as sal])ingitis, [wlvic
tumors, uterine adhesions, stcrilii)'. or celibacy, it is useless to irj- local and general
methods of treatment. On the other hand, there are many causative lesions that
can readily be remov^ed. as, for example, endometritis, laceration of the cenil
or perineum, and a recently displaced uterus without adhesioas. In these cu!«es
the endometritis should l>e curei] by curetment, (he iaccrntiun should be repaired,
and the uterus should be held in position by a pessary. A careful consideration
should be given to the habits of the patient, and those whic^i have Iwen the citise
of the disease or are likely to aggravate it must be corrected. The immoderate

510 THE OVARIES.

use of alcohol and the habit of masturbation or excessive coitus must be foibiddm,
or if the affection arises from unsatisfied sexual desires, the mind of the «'oinan
must be directed toward more healthful subjects and conditions.

The Local and General Treatment .—Rest is an impomni
adjunct in the treatment, and whenever it can be carried out the woman should be
put to bed for the first six or eight weeks- During the menstrual periods the
patient must be kept absolutely quiet in the recumbent position and the bed-pan
used when required. (^'lood results are also derived from taking a short nap evert
afternoon and retiring early for the night. Coitus must be forbidden and the
husband and the wife should occupy separate beds to avoid the possibility ul
sexual excitement.

The vagina should be douched every night and morning with a gallon «i
more of htil normal Kilt solution, and before going to bed the patient should insert
into the vagina a ctilton-wool tampon saturated with glycerin, and remove il on
the following morning.

The entire cervix and vaginal vault should be painted twice a week with
linclure of iodin and a tampon of ichthyol and glycerin (15 per cent.) introduced
into tile vagina and allowed to remain until the following morning.

The diet should be nourishing and easily digested; plenty of pure water
should be drunk; and the bowels should be opened daily, as any tendenq- In
conslipati<in increases the pchic congestion and adds to the local trouble. The
daily use of a mild la.xative and the administration twice a week of a saline are
usually all that will be needed in the way of purgation. Good results often follov
the use of citrate of magnesia, Hunyadi Janos. and the saline mineral spring
waters, especially ihoi^e containing sodium chlorid. General massage is in-
dicated in these cases, and should be given every day or at least three times a
week.

The administration of internal remedies is important in the treatment of
chronic ovaritis. As a routine [)rocedure 1 place these patients upon the iodid of
potassium and the bichlorid of merrurj' (gr. t^b)- I begin with five minims of
a siiturated .solulion of the ioiliil of potassium three times daily immediately
after eating, and every day increase each dose one minim until fifteen or twHity
minims arc taken; the remedy is ihen continued indefinitely. The chlorid
of gold and sodium {gr. -^ to ■^) may be substituted for the mercuric chlorid.
as it seems to have a beneficial effect upon the ovarian inflammation and 1
tendency to reduce the size of the organ.

If the jiaticnt is restless and ncn-ous, bromid of sodium should be given two
or ihrtT time-* daily in doses of ten to thirty grains. Cannabis indica in the form
of ibc linclure {HLx to xx) is also of value in these cases, as it relieves the ovarian
pain and quiets the nervous s\stem ; it may be taken alone or in combination with
bromid of sodium.

Tho following bitter ionics are often indicated and employed with advantage:
Tincture of mix vomica; compound tincture of cinchona; strychnin; ami
ijuinin.

The .severe ovarian pains that are felt for a few days before menstruation arc
usually rclie\'eil by administering tincture of cannabis indica, antip>Trin, tincture
of puls;itilla, or the brf>mids. A hot-water bag apjjlied to the tower abdomen is
also of .licrvice in these cases.

Exercise in the ojien air and sunshine is ver>' beneficial in cases of chronic
ovaritis. Indmir exercises are also emploved to strengthen the pelvic organs and
the muscles of the abdomen, as well as lo stimulate the circulation of the pelvis
(,«ee |>. 117), and a properly m.ide abdominal binder (see p. 650) should be worn
viheii the belly is relaxed. The clothing should be supported from the shoulders

PROLAPSE.

And not front the wuut, as cnn.«(ni;tinn araund the lower abdomen exerts tin in-
jurious prrssurc iind increases the congestion of th( pelvic organs.

Hvlroiherafy. — Tht following solalive batlis kIvc itood rcsults:The full hot
hnth (|>. SO ; the TurkL-.li or KuvM.tn bath (p. X9J ; ami the hot »itz -hath (p, S7).

The RadicAl Trentment.— Chronic ovaritis, af, a rule, cvcnluiiUy demands
M>mc form of surgicul inlerieremc. not only on account of the ii.vwciiiieil [lelvic
loinrt^, l>ut al«i In-rauK their i* seldom any [wrmanenl lienefil derived from the
(Alltalive treatment. The alxlomina! route should al«ay» be M;lecte<l and such
open live me;l-Ml^e^ adojileil iis the cxi>t;nK ^uthologic coTidilinns recjuirC-

Sal{>iniu;o-o>i|>hi>rectimiy is imlic:itnl in cases in which the ovar;- is cirrhotic
or the tube is irrq^iarahly damaRtd. When the ovary is enbrfted or cystic and the
oviduct \n lalulous t)ie <)ue.Nli<tn of a con^ervnlivc ojieration (see \i. 571) must be
cnnsiilercil if the putient b devious of having children. When (he uterus It
n:imcli!.])bced and adherent along vrith the appendaxe^ the adhc-tion.-. should be
Imiken up anrl the fundus «t(uche«) (n the abdocnmal wall (see Ventral Sufi-
|>enston ni the Tterus, p. m) ; ihc condition of the tubes and ovaries deciding
nltcihcr salpinKO-ojipbDrectomy or ^omc form of conser^'ati^e u[>eniiion should be
performetl.

^''"ISSBr -■'*"' cauMs of pn>la[Ke of ihe ovai}' ore due dlber to iHSSdStl.

I"hc awplacemcni i.s %e<mdary when the organ is pulled downward by n relro-
placni ulcnis or a diseased tube. It may also occur from the contraction of
hcsicins that have formed upon the ovarj' during an attack of peritonitis, or
(he orj^n ttiav be dislocjited by the pressure of a ])eh'ic tumor. These variellet
nf pr^pse will not bccon^dcred here, as thcf are simply complications occurring
with other a»d gr^ivcr legions.

\ prim-jry pr<)b)>><^ is one in winch the <li*i>lacemeiil of the oviiry occurs in-
dependently of other )>clvic lesions and withnut any accompanying dislocation of
the uleruN or the ovidiKt. The chief cause uf primani' pn>latise !% an increvi^c in
the weight of the ovary, and wc lind that subinvolution is one of the most frequent
CBtnalive factors. The ovaries. a> well as tl>e other peKic organs and liitunients.
hecon>e hypcrln>phie«l during prepiancy, and if in^nlution is interfered with after
blxir pn>lapsc is likely to occur, as they arc abnormally heavy and thdr support-
inK liganicnLs arc elonftated and rela.xcd. \ ihronic ovaritis resulting in an en-
UrjEcd or c>'^tic ovary is often the cause i4 prtiUi><«, and cast« are occasionally
met in which theincreasedweightof the organ is due to a small tumor. An acute
probpoe may be cau-«d by an injur)* or a suilden strain, but il is very doubtful
mhethrr the displacement becomes iiermanent uidess the ovary Is enlarged and
hew icr ilun normal. Prolapse of the ovaries is sometimes found in patients who
are ■•ufTrnog from n chronic <ii:Kase tliat i-t acromjKinied by loss of weight and
getieml debility. The disjilacement in the^ cases is due to the lack df pelvii.
£11 and the rdaacd stale of the uterine and ovarian lifpments.

-^t..- i^ti, ..^.r^. ;^ p..,^ r r c u u c n 1 1 v d i » p la c e d than
LjL^^2^JbL» The reasons for inis difference are, fint, the left ovarian
vein has rut valve and opens into the renal at a right angle, and hence the onry
i*I"rrdi*i"»>ed to pikA!<ivc congcstw>n: s«ond, the rectum lies to the left of the
mnlUn line, ami Lon-sequently the ovary on that side b affected first by the
oH-ih-inii' intcrfemKC that ihc urs in i-a>e< nf clininJc constipation; and, Ihir4.
ibi- Uii ^.■llln licdime' more h>-i)ertrophie(l during prepnanri' than the right.
jful 11 IS thrrefiire heavier and more readily displaced if involution is .irrestcd
after bi bur

S'i

TH£ OVAURS.

a. — The f'ymptoms due to prDbpw of the avuy ut
comHinctfwitli tfiuM: cuiiscil by chnmic iwurilin or hy mliinvolmiim "f the oli

Pain Ulhcchicfi^ymptum of prolapse, which Uusiullvab^nt wliilrthc|Kil:
b in (he rrcumbtiii |h u-.it in ii ; l)Ut when ^he stands ertci or ii.v<uinc> ihr - i :;
posturt, there is aln-iijs more or lew suflering. The pnin is incrtaKti ■'■ 'in;
cnttti". urinatioD, and defctiation, and h also agRravated by walkini; ur >>. irr
form iiJcxcrdse. as well a.t by light Lidngor Guii.iifiction.H uround the wnin. lU
prolapsed ovary b sometimes so tender thai milus b impossible, and ihe \am
fcill(>win(( defecation often continues for an hour or more. The |iain ii iit_ -.M
in the iliac regiim or deep down in tlie |telvis near tltc NuTum, nnd it mav r. i '
to the hips, the lumbosacral repioti, ihe recltim. or down the lliicli-
pain is (refluent ly fell tn the brea.ii ih.ii airrespumis with ihe [mil.
The pain raries in chiiraiier fmm a dull. he,i%T ache to a vharp, ngimi^iii); miu-
lioii which is often aciompanied by fAinini-ss and nausea.

Mrnstruiilion is apt to be more or tesA affected. Tlvc flow r*, »^ a n!f, i^
creased in amount; ilysmenorrhea i» often i>re!«ni; aiwt th<- monihl)- cnnqtEtlkt
causes the prolapsed ovarj' to iK-come more swollen and lei>der.

iVuKJcu and vomiltHg are atrnmon .■.ynipii)m>. Tlve patient may nlv- •-*<
from gasiro-inicstinal indigestion, hj-slerU, and hitadache. Xeiiratth/v:
a rare condition, and it is often actomiwnied by menial 'lejircsiiun, jnhj-^'im n
liau>lion, and groal irritubiliiy of lempenmwnt.

" " — The examination is made by feft4f<ihd«minai and v^^t-

dfic/offlfflS^^I^ion u-iih the patiem lying on a tible in the dor^il posture.

Tlie tliiif.'n'isis is baM^I ujion fnwlinK lliv ovary in a prolajiseii p<nili">n..

The di»pl,ic'ed organ i* reaigni/cl by ilsirh.ijic and connection wriih llveboraol
ihe uterus, ll mjy or may not be movable, and pressure u|«m it cuu.-ve^ pain »»l
a peculiar nauseating seiisition. In some ca»n the ovary may be only tJiitliUy
displaced: in others it may be completely prolapsed snd found lyinfC behind the
ccr^-ix in the eulde>ac of IJougliis.

Dlflferential IMagnQsi8.~The ;iS'eclion must be dtstinguiiJwd <it
limeTTFWHrWnSrnspSccBnilerus or a small |>eduncuLited uterine fdiroitL

A pr)lap.M.il ovary lying iH-himI the I'crvix in the culite*ac of Douglis miy h^
mistaken for the fundus of the uterus. Under these lirf umsiaiKCj the fUDdti&
will Ijt fuund in its normal i^i.iition. white the piiM-utcrit>e cnbrgcment will \iC
lender u|Kin prfN>ure anil freely movnble unles* .adhesions are pre»cni.

A sm;.ill jwduncuUiled libroid is not sensitive and is harder in ci'ibLiieiKy tktf>
the ovary.

Prognosis. — The prtignosis de|>ends u^ion the catt«e of the dbplaccflienc -
When ineaTiecilon is due to chronic orarilis or to a small ovarian tumor. little or
noihin){ tail lie done by local and Kenenil medication; but when it i« caufcd by
subinvolution or by a debilitating disease, the outlook b more encouratpni;, an<l
the nvar\- may occa.sionally l>c fwrmiinently restored to iu normal {Kmlion.

Trefltmciltfc— The ireatmctil of |irola[)>e of the ovary i» dinded into:

vr "■"""'■"■

The Pallian?* Treatment.— Tliis f<irm of treatment should be irwd wfc»
the proLip-.c- !■> caused by ^tibinvnlutioTi or by debililJtini; dteuscs; it is, how-
ever, contra indicated if the ovary i> di>ea>ed. greatly enbrscl. or adhemi.

Rc.1 is an imjmrt.int adjunct in the treatment, and iluring the mciMrul
periods the patient must be kept alisoKitcly at rest and the bed-|>an u*ed »^«i
requii%d. Benelicial results are alst) rkrivvd from taking a sliorl nap et«ry ilM
not>n and retiring early for the night. Coitus must be abwiutcty prohibited ii»i
the husband and wife should occupy separate tteds.

513

^wice a day with a gallon or more of hot
. to bed the jalient shmilit itiNcrl a viigirul
tmnvc it nn ihc following morning,
aid be painted wkv a week with tincture o(
[glycerin (35 [ler cenl.) inlroduccd into the
ite following; morning.

Jwe-chesi jKKition for icn or fifteen minutes

lbi> ]iusitii>n :t]l ihc pelvic orgnns full

^.Trying ihc ovan- out of the pelvis and

The i^ilient should ui^o sleep at iiiKhl

•lievK the juvstuir uj»>n the pmbp^d ovTiry

l.proUpsed ovnry cannot be recommended,
V the imiiblc by exerting pressure upon the
iced in the posterior vapnal culdesac is,
il of >upp(>rlin); •! pniLi|>«<;il ovar>' and
y the tampon becomes dii^placcd almost
: little, if any, use.

id racily digested; plenty of ])urc water
\)c opened daily. In addition to the daily
en fulluiv the nd ministration of citrate of
■ mincml spring w.iters, especially ihow;
il massage is indicated and should be given

.vk.

■ cxerdscs should be employed to strengthen the peine organs and the
mmcles of the abdomen, as well as to stimulate the rircuhilion of the [)elvi5 (see
p, 1 17). Hcnty of exercise in the "iwn air and sunshine is indicated and should
be insisted upon by the attending physidaD. If the abdonurul walls arc relaxed,
a properly made liiniler should \x worn and the flolhing :ihoul<l Iw supported
from the shoulders so as to rclic\'c the constriction about the waist.

Hyd rot her apy ,*-The folloning tome baths give good results: The
cold full baih (p. Kj); the cold sponge biilh (p. 84)1 the Snitch douche (p-&7)i
and the cold sitz-bath (p. S7).

The Radical Treatment.— Thisi form of treittment, which is esseiiti^ly
Mirgic.-il, is indicntcd when pnlli^iive measures fail to restore the ovnr)- to its
normal position or relieve the s)'mpIoms. and should also be recommended when
the orgun is dise;ised. greatly enlargeil, i>r adherent.

The abdominid route should always be selected and such operative measures
adopted as the eusiing pathologic condilions require.

Salpingn-<>(>ph(>re<'t(>my i.i indicate!) when the ovan.' i.s disea.<«<l, greatly en-
larged, or the scat of a tumor. If no gross Icsionof the ovary is present, the organ
should not be sacrificed, as the displacement can he [lermanently corrected by
suturing the infundibulopelvic lijpimenl abtnc the brim of the pelvis (see p. 580).

A conservative operation upon the ovary should always \x considered even
when it is more or less ilisea&ed, and resection followed by suspension of the
infundibult^lvic ligament practised if the patient is anxious to have children
and willing to run the ri^ of the necessity for a secondary abdominal section.

t HERNIA.

Description. — Hernia of the ovary is a comp,iratt\-ely rare condition. It
may be utquirtd or eongenilai: the latter form. howc%'cr, is so seldom met that most
authorities question the possibility of its occurrence. In some instances the her-

514 THE OTAMES.

nial sac may only contain the ovary, but, as a rule, the onduct and the omentum
or the intestine also accompany it. In these cases the ovaiy becomes adfaereot
lo the omentum or intestine and is pulled into the hernial sac. The displaced
ovar>' may become inflamed and undergo cystic degeneration or it may become
adherent to the sac. Suppuration has also occurred and in rare instances the
organ has become cancerous. Unless the organ is diseased ovulation contiiiues,
and cases are on record where conception has taken place.

Varieties. — The ovar>- has been found in an inguinal, a femoral, an
obturator, a ventral, and an umbilical hernia; it has also passed through the
greater sacrosciatic foramen.

Symptoms. — Insomecasesnosymptomsarepresent except those caused by
the hernia itself. Generally, however, the hernial mass becomes swollen and
tender during menstruation and the patient complains of severe pain. If the
ovar>' becomes inflamed or cystic, pain and tenderness are constant s)-niptom5,
and when suppuration occurs the signs of a localized abscess are rapidly
developed. •

DJAgnosis. — The diagnosis is based upon the presence of a herrual sac
which contains a hard mass corresponding in shape and size to that of an ovarv;
the nauseating seiksatJon felt upon pressure: the prosimit}- of the uterus to the
hernial canaU the absence of the ovar>- on that side: the traction that is felt
upon the hernia when the uterus is pressed upon by the examining finger; and
the swelling and tenderness that occur during menstruation.

Treatment.— The treatment i.* divided into: (i) the palliative and (a) the
radical.

The Palliative Treatment.— This form of treatment, which consists in
reducing the hernia by taxis and a]>plying a truss, is contra indicated if the ovary
is diseased or adherent.

The Radical Treatment.^Hemiotomy is indicated when the o\'ary' is
diseased or adherent, and also when ihe patient prefers a radical cure to wearing
a truss. The ovarA- should ne\er be extirpated unless il is sufficiently diseased to
destroy its function.

HEHORRHAGE.

Causes. —H emorrha ge of the o\anes may be caused by any condition that
inteneres with the venou:> circulation of the pehis. Thus, it may depend upon
sexual excesses, coitus during menstruation, onanism, masturbation, peh-ic and
abdominal tumors, adhesions, uterine dispbcemenis, diseases cf the heart, lungs,
liver, and kidneys, and upon sedentar>- habits. .\ predisposing cause is also found
in the h\*(>eremia of the ov:trics that is commonh' met at puberty in young girls
who are kept closeb- apphed lo their studies and who are given but little time to
devote to the development of their phy-ique. .\train. an o\arian hemorriiage may
occur during the courseof an.icutefcver.or it may be due to phosphorus poisoning,
anemij. .-cunv. and puerperal sepsis; and. finnlly. it may result from an extensive
bum or from tr,iumati~m,

^^^jjJggjj^The hemorrhage may occur cither into the Graafian follicles
or mto tne .-troma of the ovar)'; the former is kni>v.n as ;oilictilar hemorrhage and
the latter as oi'itrtiin iirop/exy. «

The oHiculiir itiricly is the most frequent form of the atJecticn. and the ovary
itself is only slightly enlarccd. but the follide becomes di-iendwi fn>m the size of a
pin's head to that of :'.n iinin^c. In sonieca.-^cs imlvone follicle is involved; but
when the hemorrhacc occur> into sevcr.ii icsides. the surface of the ovarj" i>
studded with .small, liixk. rounded elevations which either remain separated or
coalesce and form a simple large bkxxl-cysi. .\s a rule, the e.^tiavasated

UVDSOCELK.

S'S

biMXl is at»orbcil unci llic t>vizy restored lu lis normal condition. [(, however,
abfiorviian do<^ not lake (tUiu. ihc blood eiihrr bctumcs Lirr>' in ronsL-ttnty and
ctwccMiitc in cvlur ot ibe M>liil iun.ilituciib are >c]Mirated [rt>m the lluid portion
and a tentus cj'Kt remains. Sometimes suppurslion occurs in the sue ^nd an
ovarian abscess is (orm«d, or the hem;iU>ma may rujxure uuu tlie peritoiiwd luvily
and either form an intraiwritoneul licmatocck or cause u i:<-ner.il [icritonitis.

An omruin jfitiplrxy may vary in amount from miin)scu]fic exlnvasjili(iu> o(
bluod M^altered thnniKhiiui the stroma of the i^vary to that of ^ hcm^ilom:i the si«
of an "tiingi- ur even larger. .\^ a rule, however, small hcmorrhagii -jjob are
seen » ith the naked eye on the cut surface of the or^an. and in e.\i-q)tii>nid taAe>
the entire stroma may be infiltnied with IiUhhI. An ovurbn apopli-xy may be
wtundar)' lo a f<41icuUr hemorrhage. ;tnd it may aUo occur as a primary tun-
dilJon. It may terminate by absor]>lion; undcrjEo (he same chanftes a» in ibe
aUK of folliiubr liemorrha)i;di ot if the a|>»|ilexy i* vei)- large, the ovan' may
rujiturr and the blood e^^ajx either between the layers of (he broad liKaroent or
mtn the Jilidnminal cavity.

*^ynir*'"""ti~'""' -■^■'"""' 't*p"--' upon the extern and results of the
)>emt>rr'i;ige, and ismall extra vasation$ may occur without f;iving rise to any local
manife^t.llions. .\ hcroonhafce br^e cnouKli l" <au-ie di^Iet1Ij»]) will be acmm-
MOied Willi more or le^s pain in the ovarian regiim, :inil il rupture occurs and (he
Heeding is excessive symptoms of shock may de\cli>]>. If suppuration takes
(tlacc in an inurian hematoma, the local and KGneral sym|)tomn of a pelvic
alMceu are pre>enl.

Diagnosis. -The dia^osis of ovarian hemorrhuKe ii seldom midc at the
bcilMiJe. .1? Hie symptumii are not cburacteriBtic and merely jM.int to the pelvis
u the teat of trouble. The phystcid examinution is likevrise uns:itisf3clory, and
octy reveals an ovarian tumor without RivinR any indication of its lulure. The
Kidilni development of >ymptom» pointing lu internal hemorrhage does not in-
(Uiale thai the ovar)' has ruptured, as lhL'> condition is mure fr«i(UvnlJv (he rendt
ol other leu(>n.n. If. however, no ovarian (umor can lic fett in a jMtient who was
Vanwn to have hod a Urge nvar^', we would be justified in presuming tluil the
hnnonhage was due to rupture of the organ.

, — .\ >ni4ll fiiI]i(-uUr hemiirrluge and flight exlnvas^itions of

licTlroma of the ovan.' arc ne^cr recognized at the tM-dside. The

I WK is true when the ova r>' is di.itended with Uocm], oa thephvMcal ex;imination

iloiply feveaU the |)re*en»e«fan ovarian (uin«ir. A» the Ircitment in all cases of

■ oniun tumor is extirpation. Ihe qur^ion of (he nature of the lesion U of no

Kcal tini>(>Tlan<'e. The development of symptomtt pointing in an internal
rthiKe miuires that an alxlnminul i^ection should be performed at once and
l^tii|ii«rcd ovary removed along with its (ubc.

HYDROCELE.
^ Owrim hydroceles, aci-onlins to Itland SuKon, "ariic In a (unic ol [icri>
'™*Wthat occarionnlly inve:<lii ihc ovary much in the same way that the tunica
'■Otulit clothes the leslis."

Sutton summuri/e^ lite rharaeteriMic!> of these cy»t» ns followfi: (i) lite
'""ptn lul>e o(icns by its aUtnminnI ostium into a sac on the posterior aspect of
•".'"nad Itjrimeni. (3) The tube is elon^ted. dDated, aini ii>Ttuou>. aiwl a«
"Rftih jjrtly cxpreNte* it. the general outline of ihe part* resemble* a retort with
i^'WtJiiittj <Ielis-rn' tulw. (i) As a rule, there b i»o cridence of inHammutioii.
I^tyii mny aiippumte should ihc tube l>e(:ome affeiied with sidpingitix. (4)
Id uiqI) c<nu the ovary will be found projecting on the floor of the ac. In

Sl6 THE OVABIES.

larf^er specimens it will be incorporated with the wall of the sac, and in very large
specimens it is unrecognizable.

An ovarian hydrocele varies in size from a very small cyst tg that of a chQd'i
head. The sac contains a clear, straw-colored fluid, which may, however, be-
come punilenl in character if the Fallopian tube becomes infected. In very rare
inslalK'C^ :in ovarian hydrocele may be intermitting in character and disdiarge
its fluid contents through the lube into the uterus.

Hydrocele of the ovary must be distin-

^^„,,„^^ guLshed from a tubo-ovarian cyst. In the

^'^^ ^^Si_p— 1,^ j^^ former the tube communicates with the CTst

f ?Wtjt|,L[|i4^ riMTiii''^^ by its abdominal opening, which is rrcognized

/. -^MkP^S'S^Jj in '^f* instances by the presence of the fim-

!^^^^^^fe*S^Sw^J briie; the ovary is usually found in the wall

^E' j!<^^a|SteB!^*^^t '^^ *he cyst or protrudes into its cavity; and

^F^^sS^^J'lx?^ the oviduct is elongated and tortuous, but

^^g5||B|W^v/{. '^ ^ not distended unless salpingitis is present

ffl^H^K^^wiy ^^y Mk ^^ ^ complication. In the latter variety of

*)|^^^^W''''^^^J!)|^ cyst, on the other hand, the tube communi-

V^i. ' t^^P^f f cates with the sac by an adventitious open-

N^^^ ' ''~'}^^^ ing; the fimbriae arc not present; the ovaij

%i^^^^~* — "i^^^ '^ usually destroyed and replaced by the

^*«. 'i**** (.yst- jtn(j tjjg tyjjg ig distended, as the falst

no. ,»,^v«uK HvMocEL.. ^„i„„ ^x^^^ri the two organs is always the

result of inflammation.
Sjtnptoms. — The symptoms are not characteristic and theydiSer in no «»y
from those caused by other varieties of tubo-ovarian tumors.

Diagnosis.— The nature of the pelvic enlargement cannot be determined at
the bedside, as the physical examination only reveals the presence of a cystic
tumor of the ovary.

Treatment.— The tube and ovary should be removed by the abdomiiul
route.

SOLID TUMORS.

^. . .w 1. ->V-'

Solid tumors of the ovary are comparatively rare, constituting not more than
5 per cent, of all ovarian neoplasms met after puberty; prior to that period, how-
ever, they represent about 26 |)er cent, of the total number of cases.

"DingTins^H.^^The differential diagnosis between the different varieties of
solid tumors ot the ovarj- is usually impossible at the bedside, and a posidw
opinion cannot bcfiivenas to thenatureof one of these neoplasms without the aid
of the microscope.

The rliagnosLs is based upon a physical examination which reveals a tumor
that is usually movable, not connected with the uterus, and having the general
outlines of the ovarj'. The presence or absence of ascites should be deierminfti.
as tree fluid in the peritoneal cavity usually points to malignancy, although it may
sometimes be associated with a benign growth. It is also important to ascertain
the size of the tumor and the rapidity of its growth, as a malignant neoplasm
generally attains a larj^e size and develops very quickly.

Treatgjfint.^A solid tumor of the ovary should be removed by the ab-
dominii] route as soon as discovered. The possibility of malignancy must always
be borne in mind and immediate operative interference advised on account of the
uncertainty as to the nature of the growth.

niWOUA— UYOUA— SAECOMA.

S'7

FIBR05IA.

Description.— Fibroids of ihc ovar>- are of rare occmrcnce and the)'
Bclckin) grrm hiTj^er thiin a lentoti, Init exccjitionitl cu^es have bc«n re]H>rt«<l of
tunwirs atuining the size of n mun's hcnd. The ovar)* is usunll) «)inincln<:all}r
vnUmeil, ret;>ins iu normal &ha{>c, and the tube does noi bcomie attached to the
gnnrili unlcKs the tumor ffWt* downward between the byerN «f the bruad liga-
ment and becomes inltallgamentous. Ovarian hbroids arc hard in conystency;
tbey ate UMUxlIy uniliiieml. hut may involve both ovarict^; ihey arc ^Iway^ pedun-
ruUtcd except when the growth becomes intndiKamenlnux; and they are liiible
lo the same secondary changes as uterine tibromaia. Their presence in the peri-
UMMsl cavity frequently causes asdics which prevents adhesions occurring with
atijacenl structures.

CaiiSCS.-'I''ihroid& of the ovary may ocfur at any age of life. They are
met miTc frti]ut(itly, howewr, In j-ouny women, but tlie affeciion has aiwt been
(.l.^ricj in (lie *-er)' voiing (five yenr>) and in thc.ige<l (*ixiy-Mx years).

Sj'tnptotns.— The symptoms arc not characteristic and differ in no way
I- I i,nuM.i! Ity other varieiies of ovanitn tumiir>. M('^.^l^uat disorders are

i'-icnl and the pjlictit may suffer with dyfrncnorrhcanr with an irregubr
it jifituic flow. The tumor is OOI painful, a* a rule, unless it attains a large si«
' bectHi)c» weilged in the pelvit. The paiient usually nimplain^ of more or le^
io one or 1»lh iliac regions, which is n.-lievrd by the recumbcnl |>o»>iurc and
mted when she stands creel or lakes exercise. The symptoms in this respecl
trr the luime an thoM of ovariin prohijise and are cause*] by the dispbcement of
the iivary. The tumor grows slowly, and as it seldom attains a large size (he
[uitirnt may not be aware of its presence.

Diagnosis. — Bimanual examination rcveak a peduncvbted tumor llinl is
hard ill consistency, symmcmc in shape, freely niovable. and not connected with
th4r utmit. M\ tA these |>hysiciit !>iK:i>, howetvr, are pre>eni in ■ pedunculated
uiefinc fibroid, and hence a positive diagnosis is imp<K.^ihlc unlc»> both ovarie*
can be palpated; a probable opinion in favor of the uterine origin of the growth
may Itc given if lite uterus bi enbrited and nodular.

If an ovarian fibroid gn>ws between the byers of the broad ligament its re-
bdoiu with the uterus are the same as an inltaligamentous uterine tumor, and
hence a dilTrrrntial diagnoniv l>etween them cannot be made at the bedside.

Treatnient. — The tumor :>houlil be remove! by ibe aiNlominal route as
una as it is discovered; delay in these cases is dangerous, for we can nei-cr be
that the growth is not malignant.

MYOSIA.

A myoma or a fihrnmyomii is not h> rare as a true fibroid.

An ovarian myoma H>mctimes attains a brge size; it is soft in consistenc>' :
mA. like a fibroma, it may be pedunculated or grow between the layers of the
tmarf ligament

Treatment. —The tun>or should be removed by abdominal section as soon
*» ii ia disorvered.

SARCOMA.

Description.— Sarcomata are the most frequent variety of solid tumon of

QTuy, The aQection i» not nearly w rare a» wtw genenilly suppn^ed, and,

— Mdlng Io Stilton, the majority of the tumors that were furmerly cbssilted as

BnoMta, myomata, or fibromyomata were in reality sarcomnlous in character.

5l8 THE OVARIES.

An ovarian sarcoma varies in size from a small lemon to that of an adult's bead,
and in some cases it may develop into a large abdominal tumor. The growth is
smooth and symmetric and the general shape of the ovary is retained. The
tumor may be hard or soft in consistency ; it is always pedunculated, except wbeo
it extends downward between the folds of the broad ligament; and it is accom-
panied with ascites.

Orarian sarcomata have the following peculiar points of interest: (i) Both
ovaries are involved primarily in about 30 per cent, of the cases. "Diis is con-
trary to the history of sarcomatous growths in other parts of the body. (3) An
ovarian sarcoma, as a rule, develops very rapidly, and it may assume enormous
proportions in a few months. (3) In rare cases metastatic nodules may deralop
simultaneously in remote organs. (4) The stimulating eSect of pregnane)' causes
an ovarian sarcoma to increase very rapidly in size.

Causes. — Sarcomata of the ovary may occur at any period of life. Thev
are met more frequently, however, in young women and children, and cases haw
been observed not only in the new-born but also in the aged.

Symptoms. ^The symptoms are the same as those of ovarian fibronu.
The tumor, however, grows more rapidly, attains a larger size, and is assodainl
with cachexia, which appears early in the course of the affection. Then i^
gradual loss of strength and weight.

Diagnosis. — The physical signs are similar to those of ovarian fibroma.
Thetumor, however, is usually not so hard, and ascites is always present, whidi is
not the case in benign tumors.

A positive diagnosis cannot be made without the aid of the microscope.

Treatment, — The tumor should be removed by the abdominal route a
soon as discovered. It is less likely to return after removal than carcinoma.

CARCINOMA.

Description. ^Cancer of the ovarj' may present itself as a sdrrhenf.
medullary, or (olloid groullt, which begins either as a priman,- disease or is a
secondnn- infection from another organ, especially the uterus, although it has also
l>een observed in cases "f mammary carcinoma. In the majority of instances the
iliscape alTccts txilli ovaries. In rare cases primary carcinoma may attack a
normal o\'ary, but the affection is more likely to occur in a cystic or a solid
ovarian tumor.

When cancerous degeneration begins in a normal ovar}-, the organ is win-
metrically enlarged and a distinct pedicle is present; but later on, as the dl=eaM
advances, the lumor becomes round or irreRular in shape and its pedicle a
destroycil by the infiltration thai takes place into the surrounding tissues. Tlie
tumor V!irics in size from a small lemon to that of a man's head, or even brgcr.

When the <lisease Iwgins in a solid or a iysiic ovarian tumor, the phi-siral
characteristics of the original growth arc more or less preserved.

Cancer of the ovary may extend to the jieriloneum. the uterus, the lymphatic
vessels and elands, and to the connective tissue of the [lelvls. or metastases may
occur in distant orgiins. .^s in cancer of other peKic organs, the disease niai'
involve the ureters or the rectum and cause uremic symptoms or stricture of the
bowel.

Causes. — Ovarian carcinoma is more frequently observed between the ages
of thirty and sixty years than at any other time of life. The di.sease, however,
may occur i>efore puberty, and cases have also been met In very old women.
Primarj' cancer, which is rarer than (he secondary form of the disease, develops
more frequently in an ovarian neoplasm than in a normal ovary.

BEKIGN PAPILLOUATA.

S>9

Symptoms. —Id the beginning the synipiom& ar« th« same as Ibose of be-
ncopbsma of the ov«rv. Laler on, however, the following sympliim* arc

rBi:ien3lic of llic m;iligniint nature "f llir lumnr: Rapiil growth, ui<iiei,
clirotik perilonilt!. nlcnu o( the feci and lower limbri, cichcxU, and itraiJual las&
of strength and «'ei};lii.

CuKCTOus lunuirs of the ovnrv' grow more mpidly than benign neoplmms and
ihey are assocUicd early in tbc cour^ of the diM;a^ wiilt ondiR and chmnic
(irriionitb. The ;isdiif A\M i- iLMially mixed with bkniil and it frequently caiues

'ked alxlomitui di^cniion. The pcritonitb b subacute in chamcler and

more di-itren than actual pain, which is not, as a rule, acute in ovarian

Edema of (he feet and legs ocxnirs early and is a distinctive sym|nt>m of

disease. The gradual progressira loss of strength and weight ■> characteristic
maliptanc)', aikI oicfiexi.'k is ;t comparatively c^rty !^'m[>tom.

L>e.ith ut^ually rc^^ults from cxhau^^tion or uremia.

Pbjrslcal Stains-— A binunua) CKiminatinn reveab the presence of a
tumiic which tii;iy or may not have the iJiapc of the ovary and which is not con*
oecied with the ulerus. The growth may be pcduncubted or il may I>e nt-
Mched by a broad indurated ba^. Il may be hard or *oh in consistency and lis
nurfaoe may be smixnh or irregular to thv touch. If the disease is wrll ad-
vanced and the neighboring structures have beoinie involved, ruMlular masses
are felt in the pelvi> (particubrly in the culdewc of Douglas) and in the lower
abdotnen. The ascites is mdily detected by tombinetl palpation, and If
the ascjtic accumulaiton is marke<l the alxiomvn will l>e dt>tendcd.

PrOgfnoeis.^The dUeaw i.i very malignant: it de\flops rapidly and in-
volve* adjacent and dtstani orgms; and operatiw iiilerference offer> but little
hope u( a permanent cure. According to Penrci^<', "in more than 7; per (vnt.

I of (he case» Ojieratvd upon the disease has returned and temiinated in death
ii!iin tlw firei year."
Treatment. — A cancer of the ovaT>' should be removed along with the tube
by ibc ialiilomin.ll route, prmided the di<«ai« ha» not invotvetl the i^tnneum or
ad)icent slnicture^. If the affection ha< extended beyond the o\-ar}', the re-
m '-Hi of the growth would only ha^en the cluih of the pialicnt.

r\ tccondar)- ovarbn cinccr is inoperable unle^ the dbea»c began in the
119 sik! had not cxtemled be}\>iMl the ovary.
BENIGN PAPILLOMATA.
Description. — Soliil warty outgrowths springing from the surface of the
twary .ire a rare occurrence and must not be confounded with pa[>il|omata that
hu«riepcrf<»rate<l the waHs of a {xtnWi|>)ioritic cy«.

The wart.* may lie [icduncubted or ha^* a broad base, and Ihey vary in stxe
fmni a very small outgrowth to lliat of a ma.t^ at. hrsc n.i an orange- The rliseosc
usttstly involves both ovarie* and often spreads to the peritoneum and the brand
Ugamrnt" The affection h gener.iily a^-onnpanied by nsclteA.

DlagnoelS.— A positive diagmni^ c»nnot be made at the bedside. A
bbumuil cxamimtixn Mmjily rcwals the presence of an ovarian enbrgemeni.
PrognoBls.— The outgrowths have n lendency to undergo nulignant
»ncr*

Treatment. —The enlarged ovarj- and its lube should be removed by ihe
abdominal route as soon as discuwred.

THE OVARIES.

CYSTIC TUMORS.

C}'&llc lumors maydcveloptron^tlicr the outer or the inner pAn of tbeowy.
Thft outey Of cff .htaring fmrtian of theon-nn h callftd ihe laphiiraiL. uiA tbe biKr

Fra. •>).— Snowau rmi Cv>tk Rtonw or nt Ovu«.
or nirdull.nn- ZDnr. which nrvrr contains Graafian veaclcs or ova. k ailed tk

flvariiin osLs are (herefoiv cb-tsilift], acrording tn the pan ni (he o\-aiy tren
which ihcy dc^Tloj), inti): Oiiphoritic and Paroophoritic c>'sts.

' tviln

OOPHORITIC CYSTS.

DermSIcTCT^ts-

Syiionyms-^Dropsteal Graafian folBdes; Hydrop* (ollicularfe-

Caiises. I'filliculur cysts of the orarj- nrc due lo the failure lo rupltirt tad
the ^ii^sctgucnt <lisien[inn of a Granlian follicle. This condition m^y be breu^
about by \\\K <leei) Hiiuaiion of the ve.iicle. by chmnic uvurilii^ aiu>in^ a lbklumD|t
of the surface of the ovary or a hyperplasia of its stroma, and by an acult in-
Qamniaiion of the organ, producing dcpoiii* of lymph upon it.

The diseii.M; may occur a\ any time lieliveen pul>eny and ihc tnerrapaUM.
^gfttholjjjjjj^Jhcse q-sis van- in size from a hemp^rd lo thai of a iB«D
lemon, and in exceptional cases they may hetow as lafRC a^ a Rian'» head, Tbt
ovnry may l>e cn-nipied by n peat number of small cyMs. or Ihrre may Ije cat
lar^e c>'Et as^nciated with several small oncr.. or the distended foUictes may coakwi
and form a single larRe cv-si cavity. The conienu of ihe ry»t v. cnmiinsed c^»
clear, nlluLline, semui* fluid. h3\nnR a, sjwcific grai.-ity of i.ooj lo 1,010. ««'
docs not coagulflle u[>nn cxiKwure lo the air or by heat. Sometimes ihc fluid n»'
be a chocolate color from the pre^ietice (if hlixKi, or it mny be purulent in chanocr
if the c>'Kt Iwoimes infected, .^n omm is "ttcn found in small r>sis. 3r»d in e»-
ceptional cases cwn in larfie sacs. The cyst wall, as a rule, is thin and trani-
parcni. but in vme <.i^es it i% hygiertrophied and denacly n[>a()ue.

The disease is usually bilateral.

CVSTS OF THE CORRP* LltTKOU.

Sai

Syrnptojnfl^sThc symptoms depend upon ihcsizc of ihecysticenlaiRcmeni,
the piisitiim t>\ ihc (n;iry, fliid the ahsente or presence of :idhcsit>n:', So long n»
the ovjry k- bul slightly enUrged iind n-miiin;^ in ils norma! posilion, the symp-
tom* are similar to those of chronic ovaritis: but when the or}^n becomes rfi&-
pbctd and falls down into the ruldesiu of Dougbs, the loiiil and genera! mani-
festations of otTuian prolapse beaimc apiiarcnt.

Pain is the most prominent symptom of folUailar distention of the oviiry, iind
it is decidedly more miirketl when llie cj-st is prulapsed or adherent. This
symptom ts always more severe in i^tnall ov-arian lumors than in large ii^wths
extentting into the ntidoroinal cavity, owing to ihc fact iliat the former eniw-d the
pelvic organs and cause painful pressure symptoms. The (iinttiim nf menstrua-
tion is apt to be disturbed in cases of follicular cyst, and menorrhagia or metror-
rhagia i!^ fre()iiently llt)sef^'ed.

Diagnosis. -.-\ positive diagnosis of ihe nature of the ovurian enlargement
canflHTTf Wn? .M the bedside.

The dlagll<>^i^ i^ biisetl upon the physical examiiutimi and the histoty of the
patient.

The bimanual examination re>«ab an enlarged ovary at the side of the uterus
or in the culdcsac of Dougb*. If the cyst li»s.iiLiinerl the siw of an egg, we ntiy
be able to elicit fluctuation or elasticity, otherwise the altered consistence- of the
o\TirT.' cnnnut lie detected. The disease is u.tualiy bibter.ii and the enlarged
ovaries are frcquenily fixed by adhesions.

The symptoms show |^e chronic nature and slow development of the cnlarge-
mcnt.

ftggnosJs^The disease does not endanger the patient's life unlets the
qrsi beromeSmecied and an ovarian abscess develops. The general health and
usefulncM of the woman are, howet-er, seriously impalrcii by the menstrual
disturbances ai>d the constant pain and distress in the pclvU.

^l^tlUenJi^^The treatment of follicular r)-st)( of the nv.iry is opnatit'e. as
ito locIRI^Mien^alKative measures are curative in the slightest dcgive. The
indication for surgical interference is usually determined by the Ne\-eriiy of the
local sympliims; but the mere presence of the nvarijin tumor should be sufRcient
reason for the medical attendant to advise an abdominal section, owing to the
ini|xiuibility of knowing the e.\act nature of ihe growth and the danger of its Iwlng
imlignunt.

At the time of operation the surgeon must be guided by Ihe character and
extent of the ovarian lesions in deciding between a .tsdpingo oophorectomy and
a conscr^-ativc surpcal measure. This is not so imi>ortant when only one ovary
h involved as it is when the disease is bilateral and the woman is anxious for
children.

If the disease is unilateral, satpingo-odphorcctomy, as a rule, is indicated.
If, however, lioth ovaries are affected and the patient desires children, a con-
servative operation should lie performed and a.s much of the ovary as positible
should be saved. L'ndcr these circumstances the small cysts should be punctured
with a bistotin,' ami their conlenU ;dIo«cd to escape. A large cyst should also
tie incised, its wall renvivetl. and the e<lges of the wound brought logclher with
a continuous suture of 6nc catgut or silk to contrt^ the bleeding and close the
Incision.

rare in ir<

iFTHE CORPUS LI

i-ohicn.

onmihon in such

These cjBls are rare in h't^ncn, twit the**^
domestic animals a.s the cow, marc, sow, and ewe. They occur not only in women
who have borne children, bul also in nullipara:, and bence they do not develop

522 THE OVAKIES.

from the corpus luteum of pregnancy alone. As a rale, the cysts ara not laige
than a cherry or u walnut, but cases have, however, been met in which the lumoi
attained larger proportions and reached the dimensions of a man's head. The
i yst wall is thick and of a bright yellow color and the sac is filled with an albumiD-
ous fluid.

AT AumiTTAP rygyf^

9yllOIly^5^8•^P'^litc^ous glandular cj-sts; Ovarian adenomata; Multi-
locular ovarian cysts; Myxoid cystomata.

Causes-— These cysts arc probably congenital in origin and are developed
from embryonic structures in the ovary known as the lubes of PfiUger, wludi
normally become converted into the Graafian follicles, but which may sometimes
persist after intrauterine life and eventually undergo cystic degeneration.

This variely of cystoma is by far the most common form of ovarian neoplasm
—cystic or solid ; and while it may occur at any period of life, the greatest numIxT
of cases are observed between twenty and fifty years of age.

Pf y Tjjt^ii^r I — * glandular cyst of the ovary may grow to enormoiu
proportions and fill Ihe abdominal ca\ity so completely that the thoracic visceia
are encroached upon. The shape of the tumor is spheric or ovoidal, but its
general outlines are i>ftcn changed when the cyst becomes crowded against the
abdomin;il or pelvic vi.scera.

The surface of the cyst, as a rule, is smooth and has a pearly white, glistening
appearance. Sometimes, however, the contents of the cyst may give it a dif-
ferent color, or it may be roughened by inflammatory exudates and adhesioiu.
Sometime^ the outline of the tumor may be altered and its surface become more or
les:^ nodular from the prei-cnce of follicular and mucous cysts in its walls. .V
a rule, ihe normal ovarian tis.sue is destroyed when the tumor reaches the size of a
man's head, but in rare in*-t;iTiccs this docs not take place and a corpus luteuni
may be seen on the surface <vf a large cyst.

A glandubr cvst in nearlv every in.stance grows into the peritoneal carityand
not liciueen the folds of the bniad lij;;iment. It is, therefore, an intraperitoneal
growth except in those rare iii^lances where the lumor is extraperitoneal End
develops between the layers of the broad ligament; in these exceptional cases iht
cause miiv have been due to an abnormal position of the ovary itself.

Ciliuulular cysts are always multilocuiar. that is, they consist of a large
number of cyst cavities varying in si/e and in the character of their conient^.
Iii the beginning the number of daughter ty-ts is very great, but as the tumor
(ifdws the walls of sepanitinn are fre(|ucnlly absorbed, and eventually a cyst cn3>
beciime unilocular in iharnctcr from a surgical stand]:oint, aUhough even in these
ci.-^es a careful examination will i^encrally reveal a few secondary cavities or the
partial remains of septa.

Ovarian adenomata arc unilateral in the vast majority of cnses, but occasion-
al!v the disease mav be bilateral and, as a rule, the cysts are unequally developed,
although cases have been obsen'ed in which large cystic ovaries were adherent
and formed a single tumor having twii pedicles.

This wirieiv of cvst is attached by a ]icdicle which consists of the oviduct
and the broad and ovarian ligaments, and which becomes hy|iertrophied
an<l elongated as the tumor develops.

The contents of (ibndular cysts var\' greatly in color and consistency, and it is
no unusual experience to find different fluids in the daughter cysts of the same
tumor. .\s a rule, however, the fluid is more or less viscid, of a clear straw color
an<l alkaline reaction. It has a .specific gravity of from i.oio to i.o6j, and L'
coagulated by heal, but rarely by exposure to the air. In some instances the

IiKXUdlD CYffTS. 513

ovarian fluid mny be Ihin and tim]>id, or. aKxin, it inay be at thick and tenadoiu
Kft riil or synip. or it may even havr the rnnxl.^ieni:}' o( jelly ; ft may l^e tntnElucnit
or opaques and. finally, it may have a gray, ydlow, brown, or blaclc color.

DERHOIO CYSTS.
CftMCfc— The origin o( dcrmnid cysU is not known, and many more or le*fl
inj;i.nioiJS fncones h.i\-c l>CTn advawcl (rom time to time to account for iheir
presence in the ovaries and in other jmUs of ihe body.

IVrnKiidfyttsof tlieowiryocturat all jge^L i>o period of life is exempt; and
tliey huve cren been known to ikwlop during intniuterine life. They arc (he
tathi common variety of o\'arian lumor |)rii.>r to puberty, and after that period
they cnitstiliile alKiut 4 |ier cent, of the ca^es.

~ " " -Thc*c tumnt^ Mldom attain lo a siac brgcr than a man'K

head cJtcqit wWrnRey are associated with a proligcrous cyst or where they be-
come tnft-dcit :ind tlwir fluid contents increase in quantity. The outer surface
n( tlie c}-st i:s generally of a dull ^^y hue, and not infrequently it nuy present a
bfowiiiiib yellow <'o|or. aiid the inner .aspect b covered lo a greater or lesser extent
with a membrane roembhnK skin in apix-annrc and structure. Ovarian
dermoids, like proliferous c}-Ms, are iseitcriilly inir:i|>eriii)nr.il lumon, but they
may, however, grow between tite layers of the broad ligament and become intra-
mi-nU'UK or extra|ierilone:d in >ituiiiion. Dwnioi<l cj->Ls are umlocubr, but
Mime cases they may Iw a|i{Kirunlly mLitlilocuLir in character when they are as-
te«l with a pfoligerous c>'si or there are.lwo or more dermoids springing from
tame ovaiy,

In tour-liftbs nf Ihecaw* the affection i^ unilatcnil. Sometimes the ovary may
the H'at ol onl}' one cyst, or it may contain i>cvenil dermoids which may finally
Icsce and form a singtc large cavity or cbc communiaitc with each other by
itwnu openings. In some instances a woman may have a dermoid cyst in
wary and a proligcrou.-> tumor in the other, or, again, whe may have bo4h
rtrtetip^ in one organ — mixed lumur. Like proligrnms cysts, "i-arian dermoids
■ re attached by a pedicle which b competed of the _-jme sinictures,— the oviduct
aod the bnwd and ovarian ligiiments.— «im1 which likewise become* thickened
ml elongxttd as the lunwir develops.

Dermoid cysts usually develop ver>' slowlyor they may remain quiescent fort
imr without causing any inionvcnience. When, bowe^vr, they become In-
roed or are assocwted with a glandular tumor, they develop very rapMly and
utediMreMingsymplonu. These cysts are frequently adherent totlteiureound-
structures, arid ihey may eventually either ru[)lurc into one of Ihe hollow
or form adhesions with the abdominal wall and discharge Ihdr contents
a sinus. The nmtenis of the ry«t are extremely irritating to the (leri-
and their esrajw into the j)fritiHM;al cavity may lie follcnvc«l by [wri-
Sometimes under these drcunisunces the epithelial elerr»enis contained
uid contents of the c)'st mny beiimie implanlnl u|H>n the jicriioncum .ind
1 inio secondary growths. Cystic degentr;il>i>n ocosionaliy occurs in the
luitrous and sudorific glands of the tumor and secundarr cysts are formal which
ve the walU a lulwbled appearance.
The following structures have been found in dermoid cysts of the ovary:
ccout gbnds, sudorilk glands, mucou» membrane, liair. teeth, hora, cartj-
gc, tione, mitmnury gland, un:<tri[ied muscle f>l>cr», brain-like ti».sue, nervca,
irachej, a heart, and an tyr.
The M-luceinis are more numerous than the sudorific glands and the latter
tt»U&Uy occur in buncbc*. 'H'c mumus membrane found in thc« cyvU rescinbW

514 ^I^^ OVARIES.

that of the stomach and intestines. The hair may be present in great abundanoe
or the cyst may contain only a very ?mall quantity. Sometimes it forms a siritdi
or tuft iieveral inches or feet long rolled up into a ball which is held together bf
sebaceous matter; and, again, a number of small balls of hair and sebaceous
matter may be found lying in the cavity of the cyst. As a rule, the hair is only
several inches in length, but in a case reported by Mund^ the tuft was fully five
feet long. The color varies and does not usually correspond with that on dw
patient's head. In old women the hair is apt to turn gray or white in color, and
often tails out, leaving bald spots on the inner surface of the cyst.

Teeth arc found in the majority of o^'arian dermoids. They are usually
imbedded in loo^ l>one or cartilage; in some cases they are situated in the wall of
the cyst or are found scattered throughout the tumor when they are present in very
great number, and in others they are unattached and free in the cavity of the
neoplasm. .\ dermoid c>Bt rarely contains more than ten or fifteen teeth, but
occasionally a large number are found, and as many a.s three or four hundred haw
been removed from a single tumor. Dermoid teeth, as a rule, have only a single
root and resemble canines and incisors in shape and construction. They an
frequently well developed, or they may be malformed and show evidence of decay
or erosiun. Some writers claim that they may be shed like the temporary teeth in
the moulh, and cases have been reported in which a decayed tooth was found
directly over a sound one imbedded in a piece of bone; the pulps of dermoid
teeth are usually supplied with nerves. Bones are frequently found in dermoid
cysts. They are usually imbedded in the wall and are irregular or flat in shape.
Rudimentary or perfectly developed mammary glands and nipples are more ijt
less Lomm(mIy met.

The fluid conlenis of an ovarian dermoid may consist of a pultaceous mass
of seliaceous matter mixed with hair or an oily fat of a brownish -yellow color.
The consistenc)- varies from an oily fluid to that of a semi-solid material, and
sometimes the cyst cavity is filled with hard balls of fat more or less mixed with
short hairs. The contents of a dermoid solidifies when exposed to the air.

PAROOPHORITIC CYS]^^^ ^
These cysts are known^as:

Causes. — .^ paroophoritic cyst springs from the paroophoron or the hiium
ot the ovarj', and is prof>ably congenital in origin, being developed from the re-
mains of the Wolffian body. These cysts are not often met early in life and the
greatest number of cases are observed between thirty and fifty years of age.
They occur less frequently than the glandular variety and constitute about lo
per cent, of the total number of the cases of large ovarian cysts.

D^9<?zipti0n< — Papillary cysts rarely reach a size larger than a man's head
antTdevelop much .slower, as a rule, than the glandular variety. They may grow
either as intra jjeritoneal tumors or, on account of springing from the hilumof the
ovary or tlie paroophoron, they may Ijecome extraperitoneal and grow betwetn
the layers ot the broad ligament. The latter direction of development probably
occurs more frequently than the former, although many of these cj-sts haw a
distinct pedicle composed of the oviduct and the broad and ovarian liga-
mentn. An intraligamentous papillar>- cyst may force its way against the side
of the uterus, and in that [wsition it will present all of the physical signs of a
uterine growth extending laterally between the folds of the broad ligament.

SYUPTUkU or CrVARIAN CYSTS.

SaS

According to Penrose, " piipillomaicius c^rsts an more often bilateral tluin any
other c>'slic tumor of the ovary. They affect both (iviiricv in imm 50 to 75 per
cent. «f the caw^. " Papillary cysts of the ovai^' arc generally unilocuiar.

The occurrence of [Kifiillomata or wait.-i upon the inner surface of tlic c) '^t wall
is a distinctive feature of piiroophoritic cysts. 1'hc uulgruwths arc soft and
friable; they bleed readily when handled; they may be pedunculated or are
attached to the c)-*! wall by a hnwd ba*e; and they are either pale or reddish in
color acconling to lite richness of the vascular supply. They vary in sim from a
small wart to that of a Urge, cauliflower -lilce mais the d/e of a child's head. The
imallcr warts may be distributed generally over the cyst wall or they may be
arranged in ^lUfMi or dusters. Sometiroeit cakareuus defeneration urcMnt, and
under these circumstances it is not uncimmon to find small solid txxlies resem-
bling grain.1 of sMtd scattered throu);hout a large ;)api!lomuious outf;rowih.

The papillary growths in the^c lumore show a mnrknl tendency to jicrforate
the cyst wall and escape into the peritoneal cavity. The rupture of the eyal
under thcNCcircunuiances id due either lo the direct pres.4ure exerted by the
excrescences i>r to fatty degeneration or atrophy of (he cjst wall itself. The
cases in which perforation occurs should not be mistaken for benign paptUomaU
^[>ringing from the surface of a healthy ovary.

The wart.s and fluid o>nlcnts of these cms infect the tissues with which ther
oome in contact and secondary papilloma tou.i outgrowths result. \\'hen a cyst
ruptures either npuntanenu.ily or at the lime of njieration, secondary warty
formations develop upon the peritoneum. These new outgrowths are often
found --.cattered throughout the peritoneal cavity, but thej- are, however, always
more numerous in the cul'lesiic of Douglas and on the mcsenter}' and ihe omen-
tum. Sometimes the abdominal opening may become infected during the re-
moval of a papillonialoii.s tumor and a secondare' iirowih may develop in the tine
of incisjon. An adherent C)'st may rupture into a hollow viscus. and hence
warty mas.ses may be expelled from the cavity of the uterus, the rectum, or the
bladder. Ascites usually develops when the peritoneum becomes infected with
papillary outgrowths, and consequently the presence of free tluid in the abdominal
cavity in connection with an ovarian cyst points to th« possibility of the tumor
being papillomatous.

Tlie fiuid contained in a papillary cyst is watery in consistency; of « clear,
lighi yellow color, which may change to a reddUh-brown from the occurrence of an
inuu^tic hemorrhage; and has a specific gravity of 1.005 "^ >-040-

GENEJtAt CONSIDERATION OF OVARIAN CYSTS.
■"'gVMPTOiaS.
The symptoms of an ovjirun ivii u>md!y develop very gradually and the
tumor may often extend into the ,il"l' m. n r.ifure they are sufBcienily well
marked to call the patient's attention Ik iln ; :ii.<i< >;ic condition whhin the pelvLt.
None of the symptoms arc pathof^nomonic. and they do not differ from those
caused by other pcMc neopl.-tsms which produce the same degree of prcsstire and
the same amount of congestion in the organs of Ihe pelvis.

The ivrnptore* may l>e ronveniently Studted under the foUowinK heading : _

aisordm.

536 THE OVARIES.

FreSBnre Symptoms. — The pressure symptoms caused by ovamn cysb
are seldom observed at the present day, as these growths are usually removed be-
fore they attain to a large size. If the tumor is intraperitoneal in dcvdopmeu
and is not bound down by adhesions, it usually ascends easily into the abdomen
without causing much disturbance in the pelvis. But if the growth develops be-
tween the layers of the broad ligament or becomes adherent, serious symptons
arise due to direct pressure upon the adjacent organs. After the cysi ascends,
into the abdomen it crowds and displaces the abdominal organs and eventu-
ally encroaches upon the thoracic viscera.

The chief pressure symptoms are:

Constipation and hemorrhoids.
Irritable bladder.
Urinary disorders.
Digestive disturbances.
Respirator^' and cardiac disorders.
Ascites; Edema.
Pelvic and reflex pains.

Constipation and Hemorrhoids. — The rectum may be encroached upon
and chronic constipation, hemorrhoids, or partial obstruction result.

Irritable Bladder. — Pressure upon the bladder lessens its holding capadtr
and causes frequent urination. A large cyst may pull the bladder and uiethn
upward and produce vesical irritability or retention.

Urinary Disorders. — Encroachment upon one or both of the ureters me-
chanically interferes with the flow of urine and causes hydronephrosis if the
obstruction is complete. Pressure on the renal vessels may result in albuminuria.

Digestive Disturbances. — A brge cyst that extends well into the abdomen
crowds the abdominal organs and causes various gust ro- intestinal disturbances.
Nausea and vomiting are common symptoms; the appetite and digestion are
usually impaired; catarrhal jaundice may develop when the liver and the bile-
ducts are pressed up>on by the cyst; and intestinal obstruction may result if a
knuckle of gut becomes kinked.

Respiratory and Cardiac Disorders. — When the cyst fills the entire ab-
domen and encroaches upon the thorax, the symptoms become marked and
distressing. Tlie patient suffers from dyspnea and irregular heart-action. The
lower ptiriion of the lungs k often found to be in a state of partial collapse and tht
presence of a pbural effusion is not an infrequent complication. If the pressure
e.xetled by the cvst is very great, tlie lower ribs become spread apart and the
intercostal spaces are increased in width.

Ascites and Edema. — .-Wites is not an uncommon occurrence when the
cyst encroaches upon the vena cava and pressure upon the iliac veins causes
edema of the legs, the vulva, and the vagina. The abdominal wall may be over-
stretched and very thin or it may be edematous; and linea albicantes, dilated
veins, and pigmentation are frequently ol>servcd upon the surface of the ab-
domen.

Pelvic and Reflex Paios. — Pelvic pain i'^ a more or less constant symplor*^
in small cy.sts. Il is bearing-down or dragging in character and situated in tl»-*
iliac region, and may radiate into the hi])s, the back, the rectum, or down tt*-*
thiphs. A reflex pain is often felt in one of the breasts and in the head.

Menstrttal Disorders. — Menstruid disturbances are not so common ^.
would be supposed when we consider the character of the lesion. Menorrha^»J
is observed in small adherent cysts and in intraligamentous growths. It al^W
occurs in ivomen who have passed the menopause, from congestion caused 132
the cyst in the uterus and adjacent organs. Ob.stinate menorrhagia or nm^rt

rOMPUCATIONS OF UVARIAK CVSIS.

S>9

presence of a gravid uterus or (he (icxurrencc of a cystic enlargement in both
ovaries; anil suilden or unusual movements upon the part of the patient.

Ti'rsinn <>( llie |ieiiiile t-.innoi dtiur if tlie liimur is aiihcrrni nr i> imjKuieil in
the pelvis. The accident i»morc likely tn occur in (^mall th;in in >cry laiiee tumors
ami in ejsta in which ihc pedicle is long and slender. Dcrmoi<l cisis are more
likely lo undergo a.xial roiiilion than olhcr ovarian tumore, and hcncr iwirtinjt
of the pedicle is comparalii'cly frequent in this raricty of cystic Rrowth.

Pathology. — Twisting of the pedicle nuiy (unir iu a stow or rapid proft.is.

In cases of slow torsi o n the luthologic changes are gni<iual1y brought
about and are seldom grave in character. The blood-vessels in ihe pedicle slowly
become a>ii*lrit-leil and passive nmRPsiiim occurs in the t;"st, which m:iy finally
result in a slight inlrjcwic hcmorrhaEe. Under ihe^ circumstances the c)-si
contents become dark brown or chociilate in c-olor ami small exinivas-ilion^ of
blotKl are fuund iu llie cyst wall. If the prnccs* of torsion coniinurs, adhesions
usually form Iwlivcen the c)>t and the surroundinj! siructures. These adhesions
eventually become oscular and nourish ihe tumor in case the i>eilicle becomes
severed or the circulaticm cnmpletely obstructed. This form of Iran^pbntalion
by adhesions i* more frequently obser\'cd in dermoid cysts than in other rarietics
of ovarian growlhs. In rare iniitances lonion luu ettecteil a !>{>unianeous cure
by diminishing the bluotl -supply and causing atrophy or fatty degeneration to
take plate in the c>m. S")mc-
limes the pedidc may Iw grad-
ually severcil without adhesion.^
occurring between the cj'st and
the adjacent parts snd occa-
sionally tumort haw l»een
found in the abdominal caWty
without any attachments what-
ever. Slow lorsion occurs more
frequently in comparatively
large tumors than in >niall
growths. When adhc^ons ensi
Ijtrlwccn the cyst and the inies
tines axial rotation of the tumor

may c:tu>e obsimciion of the bowels. 'ITic numl)er i)f twists in the pclicic varies
in dilTcrcnl casts. In some instances only a [urtial lorsion lakes place, and
in others the pedicle may lie completely twisted u|M>n itself ten or twelve times.
The direction of the a.vial rotation of the cyst al;^) varies, and it has Iwen found
to occur from right to left and from left to right with about equal frequency.

Rapid torsion of the pe<licle l>iHngs alioul (juick and fjinive patholo^c
dmngesin the cyst. The l>lood-ves$cU in the pedicle are suddenly obstructed and
the tumor rapidly l)erumes edematous and engorged with blood. If the sirangu-
blion continues, suppuration and gangrene foljowcil by perilomtts may result and
end tlie palicni's life. Extra ^'asations of blood, as a rule, take place in the cyst
wall, and »iimctime» the larger veins may rupfurc, causing a [>r*ifu'^ ininicystic
hemorrhage which may endanger life frf»m acute anemia. In some cases the
bleeding ti Ml Tevere that the lacliecomesqiiiikty distended and may ei-en rupture
and discharge its contents into the abdominal cavity. Rapid lontion of (he jiediclc
occurs more frequently in small cjsis than in large tumors.

Symptoms. ^The sym|itoms depend ufKin the nipidity with which torsion
takes place and also upon the extent to which the vessels of tlie |>cdicle arc con-
•trided.

Slow Torsion . — ^The symptoms are not characuriittic and a positive

Fib. 4it-— Tramn or im htpiru a* tx Ovuiur Cm.

53© THE OVARIES.

diagnosis cannot be made. " Dull constant abdominal pains in a patient who
keeps in good health and bears a cystic tumor that increases but little or not at aU
in the course of several months or years is a suspicious symptom" (Doran).

Rapid Torsion .—The symptoms are marked and often so distinctive
that the diagnosis is easily made. They are: Sudden enlargement of the tumor;
severe abdominal pains accompanied with nausea and vomiting; and in some
cases signs of internal hemorrhage or of beginning peritonitis.

The symptoms of rapid torsion of the pedicle must be distinguished from those
caused by a ruptured tubal pregnane)-.

Prognosis. — Slav; torsion seldom causes grave symptoms or endangers life.
Rapid torsion may cause death from hemorrhage, sepsis, or peritonitis. Im-
m»iiate ovariotomy is usually followed by good results.

Treatment.— Ovariotomy is indicated in both .slow and rapid torsion.

Rnpture. — Causes, — The rupture of an ovarian cyst is not an uncommon
occurrence.

The accident may be due to:

Overdistention of the cyst wall.
Hegeneration of the cyst wall.
Perforation of the cyst wall.
Traumatism.

Overdistention . — The general increase of the fluid contents of the
cyst which naturally takes place as the tumor develops causes the walls to become
so thin and overstretched that they may give way at any time, and occasionally
a profuse intracystic hemorrhage due to rapid torsion of the pedicle may result in
rupture from sudden overdistention of the sac.

Degeneration .^The cyst wall is often weakened by degenerative
changes and a rupture may occur from atrophy due to continuous intracystic
pressure, or from fatty degeneration, inflammation, suppuration, and gangrene.

Perforation . — Rupture due to perforation is a frequent occurrence in
papillary cysts. This accident is fully discussed under paroSphoritic cysts.

Traumatism . — \'arious forms of traumatism may result in rupture, and
the cyst wall may be torn by blows, falls, sudden jars, unusual movements upon
the part of the patient, rough manipulations during a bimanual examination,
contraction of the abdominal muscles in labor, or straining at stool and perforat-
ing wounds of the abdomen.

Results.— When a multilocular cyst ruptures the fluid contained in the
secondary cysts does not escape, and hence the cyst is only partially emptied of its
contents. The rupture of a unilocular cyst, on the other hand, is usually followed
by the escape of all its fluid contents, and hence in these cases a spontaneous cure
may be effected, A multilocular cyst, however, is never cured by tapping or
by spontaneous rupture.

The rupture of an ovarian cysl is generally attended with hemorrhage, which
is, however, seldom profuse, because the ruptured portion of the cyst wall is thin
and not supplied with large blood- vessels. A severe and suddenly fatal hem-
orrhage is nearly always caused by rapid torsion of the pedicle and not by con-
ditions that are gradual in their development and results.

The effect upon the peritoneum from the rupture of an ovarian cystoma de-
pends entirely upon the character of the tumor, and if the fluid is unirdtating it is
easily absorbed and eliminated by the kidneys e\en when the quantity is large.
If the contents are mucoid or colloid in character, they irritate the peritoneum and
either cause a severe inflammation or they produce secondary peritoneal growths
of a tough gelatinous nature, varying in color from gray to yellow and scattered
in masses throughout the abdominal and pelvic cavities. When a papillary.

COlUiUCATlONS or OVARIAN CYStS.

S3'

I
I

DaHgnftnt, or dumoii) cyst ruptures, its contents are scattered throughout the
pentnncnl cavity and ^imibr sccondnry growths are engrailed upon tW peri-
toneum. The nipturc of a septic ovarian cyst is followed by a fatal peri-
tonitb.

An ovarian c)-st ruptures mmt frequently into the peritoneal cavity, the rectum,
the bbdder, or the vagina, and in rare instances into the intef>iine», the oviduct,
the MtuRuch. ihc uleruK, or the alxlominul wall. The adventitious opening
seldom closes permanently and the contents of the sac are more or less continu-
ously discharged through the hollow viacus into which the ru|)ttire iirigin»lly
occurred. Somelime). when the c>"st communicates with the rectum or the
inicsiuies, ihc g<ises pass into the sac and givv a tympanitic note upon percussion
over the tumor.

S^mBUlB^ The chnracter of the symptoms dqicnds upon the nature of the
cyn and the (|Uiimit> of the escaped fluid.

c...i^-» "'-' — miiL '"

Rcan3iiBMBio^>f fluid in the jnrst.

A b d o m ii^^^^^F^^Utf d WSTSBo mi h al pain is a ron«iant symptom
in all r:iM» of rupture. It vuries, however, in inlen.'tity, iind in some cases the
patient experiences a sharp acute pain, not very se^rre in character, which gives
her a sensation of something having snapped or given way in ihc alHlomen; tn
othcn the symptom is »u agontxing and inien»« thai the woman is thrown into a
suic of profound collapse.

I>i u re* i.N .^Diuresis is a »ymi>tom thai ;i])])e.irs soon after the actual
rupture of the cyst. If the quantity of the escaped fluid is small, there is no ap-
preciable increase in the amount of urine, but if a large monocytic tumor lias
ni|>ture(l, the kidney> liecome veri- .iclive and the patient may puM several
gallons of water within the firit twcKT or twenty-four hours.

Disappearance or A Iter :i lion in the Shape of a
Tumor. —The ^c of a monocystic growth collapses when rupture occurs, and
hence the tumor disappears completely and the abdomen becomes flat and flabby.
But in the m>e nt .i multitoiular growth the i>rctencc tit secondary- cysts prevents
the entire disappearance of the tumor, and con^-quently, while it may be much
smaller in siae or altered in shape after the accident, it is still easily recognized by
palpation.

Free Fluid in the Abdominal Cavity . — The presence of
free fluid in the abdominal cavity, considered in connection wiih the other symp-
(on», Lt strong crmfirmatory evidence in favor of rupture ha\'ing occurred,
especially in those cases in which there had hccn no previous signs of ascites.

Per it o n it i.^ .—Inflammation of the peritoneum occurs only in those
cases in which the c*ca|Hi| fluid is septic or of u nature to auiM- irritation; the
symptoms of |>eritonitis do not appear, as a rule, until several hours after rupture
ha-toccurrol.

Rcaccu mutation of Fluid in the Cyst .—The resccumula-
tlon of the fluid in the cyst occurs too bie to be of any value in delermining the
question of rui>ture at the time of the accident. If. however, the patient give« a
history of the sudden disappearance of a tumor and its subsequent recurrence,
the probable indications are that such a complication had taken place at some
previous period.

S3* THE OVARIES,

Prognosis. — The prognosis depends upon the character of the escaped

fluid and the promptness with which surgical interference U instituted.

Treatment. — Immediate ovariotomy is indicated in all cases.

Adhesions. — Ovarian tumors are frequently complicated by adhesions
which are caused either by inflammation or by the columnar epithelium being
rubbed off by friction against the surrounding structures. They vary in extent
from one or more slight fibrous bands binding the cyst to a knuckle of intestine
or to some other organ, to a firm and intimate union between the tumor and all of
the surrounding structures. A cyst that is universally adherent presents a
shaggy appearance after its removal. Pelvic adhesions are especially dangerous
on account of the liability of wounding a ureter or one of the targe blood-vessels
when the cyst is enucleated. Sometimes a kink may occur and intestinal obstruc-
tion result, or a fibrous band may surround the gut and completely occlude its
lumen. Oid adhesions are often veri- vascular, especially when they are con-
nected with the omentum or the intestines, and in cases where the pedicle has been
severed by torsion the tumor may be nourished by the blood-vessels which they
contain.

It is very difficult or even impossible to determine the character and extent of
abdominal adhesions at the bedside, and tbeir true nature therefore cannot be
recognized until the time of operation. This is due to the fact that the intestines
have a wide range of mobility, and even if the tumor is extensively adherent to
them it can usually be pushed freely about in various directions. Pelvic ad-
hesions, on the other hand, are more readily palpated, and we are generally able
to determine their character by estimating the mobility of the tumor and its
connections with the adjacent organs.

The diagnosis of an uncomplicated ovarian cyst is seldom diflicult at the bed-
side; but it is often impos.<iible to distinguish between the different varieties and
to recognize existing complications prior to the lime of operation. Such a dis-
tinction, however, is of no practical value, as all ovarian tumors demand the same
treatmen t — o va nolo my .

The history and the symptoms of the patient are of but little diagnostic im-
portance, as they neither prove nor disjirove the presence of an ovarian cyst, and
a positive diagnosis must, therefore, dei>end upon the physical signs which are
elicited by the examination.

For purposes of diagnosis we distinguish the following stages in the growth
of an ovarian cyst:

Pflvir ''t-igg, _

Atxlominal stage.
Pelvic Stttgy-^nur'ng this period in the development of an ovarian

cyst it is entirely within the jielvic cavity and the diagnosis is based upon its
recognition by bimanual palpation.

The bowels and bladder are emptied: the patient placed in the dorsa! posi-
tion on an examining table; and the examination made by j'agiwo-airfotnina/ and
reclo-ahdoniinal palpation.

Thef^owini^flhYsiml .^ifcoLiiiS-^alfli-

The posilK[lLjUtJh*-*yfit.

The moKilily^pf-tb^.cJst.

The reIa_tiQp5^ef jllf, cyst.

The"sRape .^thr '"1"^' .

The "tofisTsiency of the^cyst.

DIACKOKIS OP OVAMAN CYSTS.

The Position of tli« Cyst.— The incmsetJ neiKhi nf ihe nvary au5e» ft
li|l>btr<l. ■tiv.l licncc we u»uull)' feci i)k tjsi Inw ilimn in ihr jwlris. A&l

j^iaddet^

Fm. di. Fin. at.

l^winoH ar tn Of kttur ird BaiMn Liouiihi Cm
•■OHfliaina In ibt (uhlnw 'if lk<uelu nunbliw >tir iirfrui (uriranl; Fw. tM tbewt i bnwd

*tc, in irilni)M!riloi)Ful nsl occupies the culdesic of Douglas, liul in <Mime cases
' be tu uoe tide uf or behintl ihc uterus. A tmud liftament cyaioma, how

t*t

r---SHa*iiM Till UniMb or Tignisn im M<<aiim or ui Ov^kBiUi <**n (pi«f ih)-

I t)il I* fwknl U|miu<l ht Ikt iBMHl (npn and luOid Ivwwd Iqp Ihr ri*ctn M ikr nlaviut

[(ity« I'lw dimn in rhf |>rlvis :in(l r|i»^ tu the «i([c of ihc uterus, and as it
W wfiml) i& fiuiJuHl 4f!3inst the Imcrjl vmW d1 the pelvic r.inty.

534

THE OVAUES.

The Mobility of the Cyst.— An intraperitoneal cyst that is not adhen
be moved about freely in ttie pelvis and even pushed up into the abdom
pedicle is sufficiently long. An intraligamentous cyst, on the other hand,
and cannot be displaced by the examining fingers (Fig. 487).

Tlie Relations of the Cyst. — The relations of tiie cyst reveal iu orij
it is therefore necessary to determine the connections existing between it
uterus. An intraperitoneal tumor may be moved about independently
uterus unless it is adherent, but an intraligamentous c>'st, however, is so
connected with the womb, on account of its position between the layer
broad ligament, that such an independent movement is impossible. The 1
tion of a pedicle still further confirms the ovarian origin of the tumor, i
Ls accomplished by recto-abdominal touch while an assistant pulls down th
with bullet forceps. Under these circumstances the pedicle is put u]
stretch, and it may usually be felt by the examining dnger as a more or k
cord-like structure. The origin of the neoplasm is also shown by a gr

Fir. 4gS Fig, 489.

MkTKIIEIS of DFTCRUIMFjr THE RELATIOFfFi OF A Cv^T.

Fj;. 48S ihowa (iic pcdjrjc nf an ovAri.in cyul Vinir paLiblrd by r^clo-abdomina] touch comtuBcd wil
ulrriiie pTDlapAc; Fij{. 4H4 shows Iht oeparuUon nr groove thai eiJBiB brlm«n the utcnu nd 1

furrow which exists between it and the uterus; this sign is present in botl
peritoneal and broad ligament cysts.

The Shape of the Cyst. — The shajw of the tumor is round or ovoid
surface is smooth and regular in outline. A medium-sized multilocuL
however, may have an irrcguUtr shape and its surface may be nodular fi
presence of secon'iarj' cysts, and in rare instances a papillomatous tumor
recognized by feeling the piipillar>' outgrowths through the vaginal vault.

liie Consistency of the Cyst. — The consistency of the tumor t
upon the nature of its contents, and a dermoid cyst usually conveys a hj
doughy sensation to the touch. The other varieties, however, feel elj
tense, aUhough, as a rule, the intrac>',stic pressure is marked and ftuc
cannot be recognized.

Abdominal Stage.— During this period in the development of thi
occupies the abdomen and may be readily recognized by inspection and pal

DIAGNOSIS (jr OV'AKIAN CVSTS.

$S5

The physical sign* arc elicited by ibt following mean»;
Vaginoabdominal uml TCcto-iibdominal palpation.
Inspection.
Palpation.
Pcrcu-tsioii.
Men sural ion.
Auscultaiion.
Explonitory incision.
Before beginning tlie l-x;i mi nation the bladder and the bnwcls should I»c
emptied and the clothing arranged mi llial the entire abdomen may be e.\po*ed.
The posilian of (he patleni changes with the different melhods U!<etl to elicit Ihc
ph>-*i{al signs.

Vagino-ftbdOTniiul and Recto-abdominal Palpation. — The patient h
pbced in the dimnl jHMilion.

The nnt step ti>war<l making the diagnosis is to examine the pelvic cavity

£2^

tut. 40*. — UiTBOO or SKTAUTim: thi I'nii-i •■on > i v>r n Vinmn-iaiioiaKAi Touch.
K«tE Qaa Um cyu it aomitd tuckavl ttid ibc oNnu cmpnl b) tbt Aii«m g| iht rumiDint lundi.

and determine whether i>r not the tumor ariwr^ from one "f the organs of the
pelvis. Any abdominal cj^^tic tumor of pelvic origin which does not spring from
the utenis is with but few exceinions an c>\-nrinn or a parovarian <'\-storaa, and the
examination mui^i therefore be directed toward excluding uterine neoplasms.
If we are able to recognise the uterus by palpation and determine that it is not
enlarged or connected with the tumor, we .ire justified in ctmcluding that the cyW
b ovarian in origin.

TTie position of the uterus varies in r;ise« of ox-ariin c>'SL^, and It may He In
front of or behind the tumor, or be drawn up almost out of the pelvU by traction,
in which case the vagina is elongated and the intra vaginal portion of the cervix is
more or less ohiilenled bj- the tension exerted upt)n the vagina] \'aull. Under
these circumsiannrs wr may be unable to palpate the uterus, and hence the
diagnosis must be based upon other physical signs. The lower portion of the
cyst b usually felt in the upper pan of the pelvic cavity, and when the uterus can

vfi

Tax ovASin.

be flpBlcrt «c iboM endofw to pron that Utty uc not amiwcwd with eadi
Mfca. TVs c*s aKa% be »nwnilwhfd imlew the oums uid the tnniGr an
doseljr Mftefem or an crowfcj togahn in bkji s war that tbdr mattotaic oot-
SnoanVM. The otariaa oripB of the growth my be pccwwwd if a hzrttmor
pooTc ■epuuiE the RinMT bva the alcra»; if a pedicle on be felt nher potliny
ihe cxfTu down wiih bullet ionxpe; oc if the lunwr on be oonsl indepeixlentiT
at the Btens. Tbe »faafe at the tmaae can ea>ilr be THO^nucd by pLi<rioi! the
bud open the abdomen and pttmiae in the diiectkiD of ibe peh-iv while the
fingm nf the ocfaes hand an in OMKaci with the vapna) portkia ot the cyn . Bt
HKUK at thtt iMpipuhriPw we any ft«l nudolar incguluities or papO^ir
naases opoo the peine miioe oi tbe ttuaor, and at the same time determine the
CT'itic natvn uf the (towih by clkitiiii; fluctuatkio.

-Tbe patwBl h pbced in the bocimMaJ Rombeat |>"wiTifn>

^ i"T*^ -6 rir' ■*" '■''^iir ffiiii

Ihe

TEe-af

The STTl JIP I'^-rtn^Wmniten .—Slanding at ihewJeofifar patient,
we obeene the uniKual pnxninence of the abdomen ovtr the ^tuatiiia of thr rysi.
wfakh can often be indi>tincth' uallined thrmi)^ the abdominal waU. \V> also
note that the etdargemeol b dkkv nurtnl txTtwrm the pubc and the umbiliou
than between the unbiScus and tbe sternum. This difference b> at om^ ;njg.
gcMJTC of the pelvic oei^ of the tnmur, xnl tbetefore unponant from a lilan-
aoedc sowtpotel. We next ofascn* the surface of ihe abdomen, whirh i^ u^uaflr
Mnooih and ccerespoads to the outHncs of the <:yn. lu thote c^-er-. honx\W.
in which Mcnodary ct:^.-' are proenl ibc tobublcd cimdhiiin of the f^unticc nf the
tHBor pns tbe abdomen an irregular. aoduUicd appearance. The cxantiDct
MOW flutds at the kri of the pntieni and nolo- whether or not the abdomen i»
mually enhrged upon both £ide&. In cajcsofox-arianc}-^ there is always a team
of qrmmettT in llut re*|wct. more mariced in small than in iarj^e tumors, and the
detention if inTariably greater upon the side of the afFccted oxtry.

The Movements of the Abdomen . — Siandinf; at the side of the
paiicni, tbe motcmcnls of the abdominal wuU arc c^rrfully watched duriii)(
natural and forced rr>~piration. If no adhcsinns cxift between the cni and the
pariete*, the alMJuminal wall is $een to mot-e fmooihly ui> and down over the
tttmor. This. i> ojietially noiicciib^ when tbe Mirface of cne cy»i is noduLir and
the imgaiaiilics are seen throng the abdominal wall. Tbe act of r»pif«tioa
doa not fhanice the position of a tuirwr which arises from tbe privis, ajid am-
feqoently the cj-rt it»elf remains bxed.

The Appearance of the Skin . — tinea albicanles an ustudlr
pnsenl in taxes of br](e c^^^tic tunwes, and they an Miuaied, as a rule, on cacfa
EJdc of and below the umbilicu". Tbe>' haiT r>o diagnostic %-aluc whatever, atxl
an due to the rupture of the skin of ihe abdomen from ovenlistentiim. Pig-
mentition. diLticil \cin*. e^ijedatly near the iliac fooaui, and in rare insiancts
edema of the abd>^minal wall are also «lj««r%-ed.

P||g^ig^^Tbe paiicm is placed in ihe boriionial rFcumtient )M>>ii>nii t^ith
the KjeeTdrawn up «> .1.1 to rebx the a1i>)umin:il muM-lo and (.-nahlc ihe examiner
to make deep presure over the abdomen.

Bv B|>»n^ of »ylp.tin« w«. ^l^il ihy followmo ^^..nw^tr »»;»t..

Th.. ^^j„-.,>.,r. f r(i nrgi- «* 'J— ■■■— ^

TEeT

I
I

DIAGNOSIS OF OVARIAN CVSTS.

sj;

Th« Situation and OriKin of the Tumor.— By palpatini^
Atibdnmcn in v;)ri<n» (lir»:li<in»HTurr iiMc to iev\ (lie outlines of the cyst and
ddtmiiK its situaitoii and ori^n. The blcral marKina and the upper border of
tir ffomh ;ue re4.'<>K"i'%il witWut difTn-ulty, and we find that the (uimtr is pnc-
Ikilly situated in the miildlc nf the abdominid cdviiy, slighily more prominent,
boiixver. upon one side than tlie other. The lower border of the cyu ctiinoi be
>l((iinl, an the exiiminin); huTul ci>mej> directly in itintucl with the "^ymphpLs
obii tfcfnrc ihc infciior portion of the growth is rcuchcd, which proves that ihe
^fci (>elvit in ori;{in ami that it is situated partly within the pelvis. This
■ken in connection with llie previous rccoKnilion of ilii; lower pan of ihu
f tapno-alxJominnl palpation and the marki-^l pfimincnre of the abdomen
iweti the umbiliiMS and the pulies. U strong confirmatory cviilence ot the
dfitpii u( (lie tumor. By means of jiuljialion we arc abui able to recogni/.c the
nioiiiiili of ihe cy^^t, which c^n be moved about in varicnjs dircctioris accurdiiiK
t*' the leiij'th of its ftedide and Ihe character i>f the adhesions. A very larffc cyrf
ii [ffiiiicuUy immov-iible, on account of it.-^ size, but a mcitium (um»r i» always
nK«r<T IcM movable even when it is adherent in the intestines and to the ah'
iliittinil parieies.

The Shape o[ ihe Tumor. — A small cii's( is usually well defined,
TOud in shjpc. and ils surface smooth and regular. A large cy^^, on the oOier
tuil, b a\A lu tie irtCKi.il'ir in outline from the pre^'iice of >ecund;iry cy»t--« in its
Vllb, wfaidi give the tumor .a lobulalerl ^hapc thai U re^idily rccogniurd by palpa-
IWi la ca>es of pjpillonutous cj-st the outgrowths may sometime--, lie felt ujion
ihtwrlKYofllM.- lumorif the aliiliiminal wall is thin and relaxed. .Sometimes the
(Ml|[nnrlhs arc fell upon ibc omentum or upon some neighboring structure as
rvrll u u|ion ibc surface cif the cysi, an<l, as a rule, in these cases udtes i'< {ux'seni
■Uttumplitation.

The Consistency of the Tumor.— The connistency of an

•"Mfan cj-si depends upon its size and character. A small cj'st is tense. eluMic,

JAlrrsiiianl, as tiw in tracyMic pressure is too Rreal to allow a wave uf |]uclu.-ilion

■"le (rll, and hence all thai can be dcmon^tmied in an overdist ended sac is the

P«fc»Ue nresencc of fluid. Even this sign is absent in many cases of dermoid

■iH lajiilUry cyst*, as well as in glaniluLir lumnrs ih.it have thick w^ills anil n

I '"gf nuRtbn of loculi. A sm:ili dermoid cyst feels either hard or doughy to

I Iht txaittioing frnKers, and, unlike a Kl'indubr tumor, it lacks the tenseness and

[tliMidiy (bat imticatc the presence of fluid oml'mcd under pressure. After a

I Cjn hti attained to a cunsvlcruhle site anJ it emends beyond Ihe umbilicus

■ixtnikin i» readily (elt if its content!' are not too thick. In other words, lis the

^ detekips (be tenseness and resistance of ihe sac gradually disappear and

•"Wluilly ttudualiiin may Iw eiusily demon.ttnileil. Tlie mnient.'i of dermoid

•uiWfi are serai solid and c^inscqucntly tluctualion is absent. The wave of

ftlUtion is more distinct and l'>nger in duration in unilocular than in multi-
btcpts. This U due to Ihe fact that the partition walls of the loculi in the
TunnoMs inlcrnipl the llucluaiion thrill and lessen ils length and intensity. An-
ft^jKiim of diagnustic value which U characteristic of multilocular cysts is the
•"JUB-m in the length and intensity of the waw of HurtualitMi over different
i PWU ul the (un>i>r. In the case of a unilocular cyH Ihc fluid is contained in a
[jpltartiy, and lienit ilic wave m\M alnaj's tnvcl ihe sjime dUtance to readi
["♦■^wxuiie side of the c>"Si wall, and therefore this variation is ftol present. In
MRulitliinibiiumor.on the other hand, the (i>mlitiunsarvnot the same, and there
\^U^ ■> markrd difference in the wave, which is accountctl for by ibc (act thnt
ISu.'"" "' '''* '***^"'' *'''f''^ '" dilTcrent portions of (he c)-si, and that when we
\™a HaatutiuR over a large locuhin the thrill is longer and l«>> >harp than over s

539 THE OVAUCS.

entail fiat, because the \ibratoT>- wa\t im a greater distance to navel and be-
cause the intracjMic prer='Jre fc not so ^reat.

Crepitation . — It the hand? ate placed upon the abdomen and the
patient i: ini-truae'l vj take deep in?piTatii>n?. a gialing sensitioa mav be ieh as
tbc a)jdr>minal irali glide: up and dowit over the cya. In these casc^ the oepmis
may be due to indammatkjn ot the surface of the cvii. or to the dispIacenKiu of
c'lUoi'l nutter within one 'ii it^ ca\-itie^. and in mnte instances it may be caused
by fricri'in between the abdominal wall and papillan' outgrowths.

Local Peril oniti? . — The presence of local peritonitis mar be
inferre<l when [jalpation reveals area? of tenderness oi-er the cy-5t-
_ Percussion.— The patient i^ placed in the horizontal recumbent poshioa.
^B^neSj^oT percujiion we elicit the iollowTng diapiostic poims:
I he prKWlfd /iT IBc"runi'jr.
The sltuail'in 'SM Tingin of the tumor.
The shape of the Junior.

The Presence of the Tumor . — The presence of the erst is
rcvealcJ by the percussion- note being dull or flat where tympanitic resonance
ib'iul'l normally be heard. This b due to the fact that the cyst is situated in
the anteriijr {lart ot the ab<lomen in close contact with the abdominal wall, and
that the intestine:? are crowdeiJ behind, above, and to the sides of the tumor.
It should alway> be b<ime in mind that when an o^'arian cyst contains gas the
liercusrrion-n'ite i^ tymjunitic and the tumor might possibly be overlooked on
that account. .\ mL^take of this kind, howei'er. is unlikely, as palpation would
reveal the presence of the ium<ir and reaify the error. In sotne instances a
■ oil (if intestine may sli[i in between the cyst and the abdominal parietes and
' hange the tumor duUne-s to tymiwniiic resonance.

The Situation and the Origin of the Tumor . — Tie
presence of the cyst as well a.- its situation and origin are indicated by dullness
on percuTrsi'in. Direcily o^-er the tumor the dullness is absolute, but it graduallv
shades olT into resor«nce when the bteral and upper margins of the growth aie
reached. Beginnina; at the upjwr part of the tumor, the note is absolutely dull
down to the symphysis pubis. .\ moderately large cyst or one that occupies
the lower and middle fKirtion of the abdomen is alwavs surrounded bv reso-
nance except at its lower \mn. and here the dullness which is continuous down
to the symphysis pubi> indicates the pelvic origin of the growth. Sometimes,
however, a cyst with a verv- long |>eiiicle may rise so o'mpletely out of the pel-
vic cavity into the alxlomen that iniesiinul resi-nanie is elicited imraediatelv
alyjve the pubes. In ihe-e cases there is a central area of dullness surrounded
by an uninterrupted ame or ring of resonance, and a mistake in the diagnosis
may easily be made as to ihe ririi;in of the tumor if the examiner should relv
entirely ujxm the signs eliiiterl by jjercussion. The situation of the areas of
dullness and resonance in ovarian cjsis is constant and is not affected bv
a change in the jxisition of the patient.

In the t"dse of a \cry large cyst occupying the whole abdominal cavitv and
cn'.roaching u[ion the diaphragm the surrounding area or zone of resonance i-;
ab.icni. ami there m:iy Iw dullness not only in the flanks but even over the en-
tire aVxiomen. I'e^cus^ion in these cases is of hut little diagnostic value, and
our chief reliance must therefore lie placed upon ihc results obtained bv the
vagino-atxlominat examination. Sometimes a miKleraiely large tumor may be
associatetl with ascites and the dullness may extend into both flanks. Under
ihcMc circumstances if the jKiiient is placed u[Hin her side the opposite flank
will give a tymjtanitic note ujxm jicrcussion and thus demonstrate the presence
of free fluid within the alnlominal cavitv.

IHFrCReNTtAL t>IACNOSJS tiV OVARIAN CVSIS.

539

banc
i>nd» ((■ inc general ^hnpc of ihc cysi.

Buration.^Tlic |i»lienl U placed in the horiznnlal recumbent position.

The iliiinme In-tw-wn the nwiform t-.-irtilain; or the umbllini-' Jind the an-

- - -ior spine ii( the ilium is gre^lcr upon the side of the allected ovan-.

■ iit-e nn (inly indicates the ovary invoh'wJ, but also the asymnietry

■j -Wiirm-n which i* thiiracl eristic uf ovarian cyM*.

Tbe distance between the cnsiform canibgc and the umbilicus is relatively

l^&^IncTfa^-*! Iiv [he tumor th:in Ixitween the umbilicus and the pubes. In other

^pK>nt^. the pniminencc i)( llie Inner jWomcn if a diMinctivc (e.ilun; in lumon

of peUi, iTi^;in.

AuKuItatioo.— The patient i^ pb(-e<l in the horizontal rei-umbent (xMilion
Willi the knees drawn up aiMt the shoulders slightly elevated.

Cre|>iiaiion or (riciii>n sounds may be heard in some cases, but Ibe sign is
no value in lite itiai:n<»iN of ovarbn cy>tv Auscultation, however, » im-
lani in making a difTerential diagnosis between an ovarian cnt and prcg-
acy nf where both comiiiions Jire iissntiated.

E Exploralorjr Incilioo.— The Ireilment nl all nvariati liirnur* i^ nvarifHomy.

:ch should nevi-r Ik delayc<l bec-ju^e cf any uncertainly exi^tinje as to the

oi the growth. And coiLocquently an cxplnratorj' incision is always indi-

DIFFERENTIAL

li miy be necessary at limes to distinguish an ovariun c)^* [mm onr <>( the
IwllovrinK Ctinililipn-: ^■™^^^~^"

' I'lTgl^hc^'. *

PhaiufUUu&QOCL

Fat JnfK^intimliwii wall.

Enc .

Cysj(||^ugig^^hc kidney.
Pa TV v^mauyMw
Fibrocjj^jy^jll^itenis.

Pregnancy . —It U aiwnys an unfortunate blunder to make a mistake in

iHr dUgniiiis between an o\-arian tumor and pregnane). In other conditions

•uch ,111 error i»ol but little imjMTlance. as many of these lesion.s demand laparot-

irniy fur ilielr relief, ami if an ina>rrcc1 tiiagnfisi-i Iwn twtn marie it ran easily

^ tMiJieil at the time of operation with no in«»nvenience to the patient and

vUiunly u tiliuJ)t feeling of chagrin u|H}n the part of the surgeon himself. 1 o

lltrcase of prcgna n cy. h ■> we vc r, the situation is en-

I'ftly (litfcreni,and an error in judgment may sub-

I'ttn pregnant woman to the unnece.ssary danf>prs

'fino|icratinn, or it may wrongly accuse an unmar-

'Itil wom.in of prcisl i t u I io n when she is suffering

Ifoin an ovarian cyst.

Time is the most imporidnl factor in the diagnosis of pregnanc>% and the

""■""■■' ■*"iuld never be in a hurry to express a jjoftitiw opinion when there

(St doubt as tn (he nature nf the cnse. If ihe objective i^igru- of get-

iJii jliscnt. they will become ap)uircni in a short time, and no harm will

[EniD the dclny tnvn if the gim; turns out to be an ovarian cyst.

Br ilillcreniial diagnosis is l»sed upon a careful stuity of the fubjeclive

|nriiib(Ktive ^vraptoms of pregnancy and tltc variations and similarilica which

''•I bttwecD tbcm and the signs of an orarian cym.

S40 THE OVARIES.

The subjective signs of pregnancy should be brought out by taking a
thorough hision- of the patient. Nausea, vomiting, and loss of appetite are
common in both conditions, but in pregnancy they are early symptoms and
are not associated with bad health and loss of weight, whereas in ovarian
tysts ihey develop late and the woman is usually more or less emaciated.
Amenorrhea is the rule in pregnana' and the exception in cases of ovarian cyst.
But we must remember that some women menstruate regularly during preg-
nanci', and that in the later stages of an ovarian cjst amenorrhea may be caused
by exhaustion, cachexia, intraci'stic hemorrhage, and disease of both ovaries.
The abdomen, as a rule, enlarges more rapidly in pregnancy than in ovarian
cysts, but the distention is not so great. Sometimes, however, in cases of hy-
dramnios the abdomen rapidly becomes enormously distended and the enlai^ed
uterus encroaches upon the diaphragm.

The differential diagnosis, after all, must be based upon the objective signs or
symptoms which are elicited bj' the physical examination, and which are always
present and can be demonstrated unless they are overlooked through careless-
ness. The most important signs are the recognition of the fetal heart -sounds,
palpating the fetus, and feeling the fetal movements. If pregnancy is sufficiently
advanced, the heart -sounds are usually heard and ail question of doubt is at once
eliminated. In some ca.ses, however, they arc absent, on account of the death or
feebleness of the fetus or an excess of amniotic fluid. The recognition of the
fetus ami ihe fetal movements are valuable factors in the diagnosis, but un-
fortunately they are not positive signs of prcgniincy, as the examiner may be mis-
taken in what he feels, and besides they are absent if the fetus is dead or feeble or
hydramnios is present. Fluctuati<in is absent in pregnancy and usually present
in an ovarian cyst. It must be borne in mind, however, that if the contents of the
cyst arc semi-fluid, there can lie no wave of fluctuation produced by percussing
the tumor. In cases of hydramnios the uterus is distended and fluctuation is dis-
tinctly felt over the upper [rari of the al)domen. whereas in ovarian cysts it is more
general and not limited to anyone portion of the tumor. Softening of the cervix,
ballottement, and Braxton Hicks 's sign are very valuable symptoms of pregnancy,
and they should always be sought for in making a differential diagnosis. We
should alsfi beiir in min<l the fact that the characteristic changes in the breasts
which occur in pregnancy may occasionally be caused by an ovarian tumor.

The coexistence of an ovarian cyst and pregnancy is occasionally observed
and the diagnosis may be extremely dilBcult after the uterus and the cyst occupy
the abdominal cavity. Prior to that pcrifxi, however, there should be but little
difficulty in recognizing the tumor and the uterus by recto- abdominal palpation.
When, however, they are both abdominal in situation, the abdomen may be so
greatly distended that the recognition iif two distinct tumors may be imjJossibLe.
Under these conditions the existence of pregnancy must first be demonstrated
by a careful consideration of the objective and subjective symptoms, and then we
must endeavor to recognize the cyst as a distinct tumor by means of a vaginal, a
rectal, and an abdominal cxamimuion.

PhantoraTutnor.— There should liemnlilbculiy in distinguishing between
a phantom tumor and an ovarian cyst. \'iiginal and alxlominal palpation fail to
demonstrate the presence of a lumor and a tympanitic note is elicited by percus-
sion over the entire alxlomcn. The administration of an anesthetic or firm
pressure with the hands on the ulKiomen dis|>hiccs the gas in the intestines,
relieves the contraction of the abrlominal muscles, and causes the disappearance
of the apparent growth.

Fat in the Abdominal Wal],— The administration of an anesthetic is
indicated in these cases, as the thickness of the abdominal wall may prevent a

DIFFKRENTtAL UIA(:\*l>SI8 OF OVARIAN CYSTS.

54 <

frnin tirinjc rettigniu^l. Resonanoc h elicited bv i)crcu»ion over

■ alxlnmi-n. iiml ihc abst-nrc of ii Himor is ilcmuiiMraK^ by vngirul aiul

j| |>iil|iaiii>n. Tlvc chUtkccI and {wndulou^ condiiion of rhc abdomrn

' be aioiiinled (or by rcim^nizinc the reliixcd state of the belly wiill iind the

; of »ubi:utancous (at, the amount of whidi can lie eslimutcd by gnuping

i^ntrii the haitds.

Encysted Ascites.— Vii|iin.-il i-wiljicilinn gl\'e* a turRiitiw result. The

lib ntiil its a|i])eiKia)tes arc found in ihcir norm.il fmsilion, and the lower

liif ill* tumor cinniit be (ell in the u|i[itT ftan of the pelvic aiviiy. a* would

tat in an ovarian f>>t, Al)(lomiii;il )i:il)i:iliMn reveal* a riroimNcribcd

'' tlDltr tuvinji: indi.'tinci uuilincs and more or Ic^s llabhy walls. It lacks the mo-
fun ovarian ttimur.iml noseoindary c>-M--arefell on its surface. Fluctua-
ikdi'lincl an<l general, but (here arc no Mirialions in the length and intensity
llhtlhhll. Ttie (>ercu-6 ion note is dull if Ihc abdomen forms the antetior wall
I )h( (aviiy, but if the uscilic flui<t is <-urnnin(Ie<] by intesiincs resonam-c will l»e
HoIrI mvt the entire tumor. The pcrcu'^s ion nine h ui^ually rcAonanl between
fc lower iiur||;in of the tumor and the symphysis pubis.

fM. MI — ni*RINKI< or Tt,T IN THI AB»0IIIII41 VfHtL n BMAIIUU. PU#*tlOM.

Cystic Tumor of the Kidney.— Thr growth of a cystic tumor of the
rtnej is usu-iUy slower than ;io ovariiiti cj-st nnd il develops fmm aliove dowm-
' i' Va|tii>"l I'Hii'h fi;iv» n negative result. Inspection shows that the abdo-
imctrically enlarged and that ihe Hunk bulges u|Hin ihe affected side,
r prominence of the lower aUli'mcn which is i'haraeteri.<tic of an
"-'u; t)»l i-- «l"eni. and the Grcilesl dislcnlion is hiijhcr up upon ihe affected
I'.iljiition reveals the (aci that the tumor L- dt-ejily and t'irmly lo(ale<l in the
M and that it mmplelely fills the lumbar hollow. The lower border
- 1 II is usually felt jusi alxjve ihc pubcs and in some caiws the colon may
nenued mwn the surface of the tumi)r. The area* of dullness and rc«i>-
iiUffcr from iht>se of an ovarian cyst. L'fwn the affected side the flank is
^eiely dull, but ov^cr the o[>|)osiie Hank the |>eTCUNiion-note Is resonant.
^Tanj^ is also elicited Wtworn ihe lower mar^pn of the tumor and the pulm
1 Ao ai itn uptirr ln>rdcr. In other words, the area of dullness is surrounded
^brkiw, and on <inc siile only by a /one of tympany. .An ovarian tumor, oti
rliatid. is Mirrouihte'l alxiw an<l on lK>lb sides by resonance, but ihc dull-
' ihc c)'iil U aboolute down to the pubes. The cokm, which lies on the

S4»

THE OVABIES.

surface of the tumor, may be occasionally outlined by percussion, and sometimes
when the small intestines crowd in front of ihc kidney the area of dullness is
absent and resonance is elicited over the greater portion of the growtb.

ParOTarian Cyst. — It is usually impossible to distinguish between an
ovarian and a paroi'arian cj'st prior to the time of operation. A parovarian cyst
prows ven- slowly and may exist for a long time without affecting the patient's
health. It is usually unilateral and seldom grows larger than a man's head- It
is globular in shape; it has a smooth surface ; its walls are \'ery thin; and fluctua-
tion is distina over the entire tumor. The c>'st dips down low into the pelvis
and is situated close to the side of the uterus, and, unlike an ovarian tumor, it is
fixed and immovable.

Fibrocyst of the Utems.— The diagnosis is based upon a careful study
of the subjective and objective symptoms. In the case of an o\'arian cyst the
uterus can usually be palpated and its outlines definitely traced, showing that
the oigan is not enlarged nor the seat of nodular deposits. In the case of a fibro-
cystic utems, however, the womb cannot be separated from the tumor, as they
are intimately connected and form one mass; the cenix is usually found to be
somewhat enlarged, and palpation reveals hard nodules in other parts of the
organ.

Ascites. — This condition should never be mistaken for an ovarian cyst or
vice ver^, except in cases in which the distention is so great that the physical
signs of ascites are absent or difficult to demonstrate. This is also true in
those instances in which an ovarian cyst coexists with ascites, as the presence
of the tumor may escape detection on account of the large amount of free fluid
in the abdominal cavity.

The chief points of differentiation have been arranged as follows:

Ascites. Ovahian Cyst.

CiinKol History.

Previous history of disease of heart, liver, or No such history.
kidneys.

General health is impaired before the en- General health is not afiectcd tintil the en-
largement is noticed. largemenl becomes pronounced.

Enlargement of the abdomen is symmetric The cnlargemcnl in the beginning is aum
from the first. upon one side than the other.

Vaginal Examination.

Vault of the vagina bulging.
L'terus freelv movable.

\'a^na not lengthened.
No change in the cervii.

Pehic cavity free.

Vault of the vagina nonna) or accentuated.
Uterus usually immovable and displaced bv

the cysl.'
Vagina may be elongated.
Cenii may be obliterated by traction of the

cyst upon the utems.
The tuu'cr part of the cvst may be felt in

upper |>art of the pelvic cavity.

Ins peel ion.

Enlargement is symmetric in the dorsal or
erect posili'in and sitting up.

In dorsal position abdomen flat with bulg-
ing in the loins; not prominent l>elow
umbilicus.

In erect and sitlinR positions the lower ab-
domon is prominent.

The navel is often bulging and thin.

With the patient upon her side the abdo-
men ^s asymmetric.

Enlargement is asymmetric in these positions
except in the case of a very large cvst.

In dorsal po^^ilion abdomen rounded and
prominent wiih no bulging in (he loinsi
markeil enlargement below umbilictis.

No change in fhupe of abdomen in these
positions.

The navfl never bulges.

Very little change in shape of abdomen in
this ]H)iition.

DF.ScIXEJtATION or OVUtlAS CYSTS.

545

Falpalia n .

Enlargrmcnt oAcn do mUtiincc when pm-

tuK t* made upnn ihc^ abdomen unleu

(he dislc-nlinn it irry (jreat.
No tumoi U fell in abdomrn.
The thspc of ihe abdomen can be chnngcd

by prrMOrr.
Fluctuaiion i) ecneral in ihi: abdomen and

in Ihe llants-
FlucEuaihin lit ven' di&iinn ind ihe len|{ih

anil intensity of Ihr Ihrfll is coMtanl.

Aim of itiutunlion rhnngcs wilh ihe pn»I-

lion of thi- i.Hiiirnt.
Aflltk pululion abgcnl.

Diiiinci mbunfe U tell when the vfH b
palp«led.

Tumot U diilind-lr fell and outlined.
No iorh rhanHe jioMlble.

Fluctuation limited to the cy*'-

Fturiuation leu ili»tini-i ittiA the lenMU and
intemilv of the thrill vaiy over difierent
pan* ol the tY»t,

fiTtA of flunuatlun ia, cunMiuil.

Aortic pulvilion maj- be prenenl.

Ptrttttiitm.

The oreu of dutlnna and resonance change
ivlth the poiiiton of Ihe juiticni.

In donal (unltlon ihrrr i& a crnlral area iif
crwnanfr Mirroundnl on Ixilh tides and
below by dullness. Bolh flanks are
dull.

Id erei'l pmition the upfirr line »l dullnr'A i»
concave and not vt hi)(li in (he abdunicQ
OA in the dorial position (Fig. ii)i).

Lying upon the <aAe ibc o|fpuidic flank i«

rCKRVUII.

Mo diaagc in ilic areas of dullnen and m>

ononcc.
In doTMl [KitEtion tbere i^ » crntrsl nrra nl

dullnna surrounded above and on both

sides liy resonance, Boih flanks nmet-

onanl.
In iTCcl ^Kialtion the ujiper tine uf dultnrm

corrnpondi to the outline of the cyii;

it is {onTci and m the uimc lc^'l-l nt in

the dorMl {Hnilfon (Kij;, 4(}j),
The flank is munani in every position.

.I/em uriiT Jan.

The gnMctt drcumfefmcc of the abdomen
U at the umbllinu.

The greainl drcumferencie U below the

navel.

va:

Fn. «n.~Aidln. Fn, wi-— Owiu Cn*.

DiMsoat acTWTiH Avtk* akiiaii Ovuki Cm it fiamjiinii nni the riTraKTiii ma Enrr f^oanoH.
\de thai iaaa()im)ieup|vTUnr'4<1ullnf«« I4 cnm-At? ariC In wn4n lyii ftia««i*

DEGENERATIONS.

An ovarian cyst may undergo calcareous, fait}-, mysomatoufl. and mali^nani
(IcKeneraiiont.

;44 ^HE OVAKIES.

Malignant degeneration is not an uncommon occurrence and it may develop
n anv \'arieiy of ovarian cyst. It is more likelv, howe\'er, to occur in papiliaiy
Tsls than in dermoid and glandular tumors.

PROGNOSIS.

The course and duration oi an ovaTrtffWST^cp^id upon its character and
he occurrence of complications or the lieielopmcnt of malignant degeneration.

A g/aiidii/ar cv.il grows more rapidly than the other varieties; it may attain
1 large size within six or eight months; it develoi>s continuously; there is no
imit lo its dimensions; and it generally ends falally, unless removed, within a
>eriod of about three years or within two years after the woman's health begins
o decline.

A dermoid cyst may exist for an indefiniie length of time without causing
iny inconvenience or interfering with the general heahh of the individual. It
^ows vcr\- slowh'; seldom attains a large size; and is particularly prone to
ittacka of inflammation.

A papillary cyst develops less rapidly than a glandular tumor, especially
vhen it is situated between (he layers of the broad ligament, in which case it
^ws verT,- slowly and may take years to altain the size of an infant's head. The
juration of life is longer than in o'sts of the gbndular variety.

A spontaneous cure may excejitionally occur fn)m a rupture followed bv
he disappearance of the tumor, or from slow torsion of the pedicle causing
itrophy, calcification, or fatty degeneration to take place.

The most common causes of death are progressive wasting and emaciation,
peritoneal infection, and pulmonary embolism. Many women die from exhaus-
.inn which is due to loss of sleep, malnutrition, and dyspnea, which are the
lirect results of pressure ujnin the aMominal and thoracic viscera. Kidney
x>mplications, obstruction of the lioweLs. inflammation and suppuration of the
:vst, torsion of the [>cdicle, rupture and hemorrhage, and other accidents con-
;ribute their share toward bringing about a fatal ending.

The peritoneum may be infected by the rupture of a papillar\- cyst, a glan-
dular tumor containing colloid maierial, or by a dermoid growth. The contents
)f these cysts are not only liable to cause pcritonhis, bul they also produce
secondary outgrowths which ma\- \x scattered throughout the peritoneal cavitv.

The occurrence of malipnant degeneration mav be suspected bv a sudden
ind r.ipid enlargement of the tumor, profound e.xhaustion. marked emaciation
ind cachexia, extensive edema of the legs and alxlominal wall, and by indura-
;ion with fixation of (he |K.'!vic organs.

.\ vcr>' guardetl prognosis should lie jti^en in papillan,- cj'sts, and the fre-
quent occurrence of ?econdar>' infection must not l»e overlooked, notwithstand-
ing the fact thill in many cases o(>cratinn has l>een f<i!lowed by a cure. The
|)rc,-iencc <if ascites is always unfavorable, and hence the prognosis should be
Eyarded, although the condition docs not neccs.sarilv denote a fatal endine,

-iRFUwriiyT.i

The treatment of an ovarian cyst is ovariotomy by the alxfominal route.
The tumor should be removed at once, as there is less danger in operating uix>n
a small pelvic tumor than a large alxlominai growth which has undermined the
general heahh and formefi adhesions with adjacent organs. The coexistence of
pregnancy- does not amtra indicate i)variotomy. as it is safer for the woman to
have the cyst removed than to run the risk of complications occurring during
gestation and labor. (Operative Technic. p. 978.)

PAXQV'AHIAN CYSTS.

545

CHAPTER XX.
DISEASES OF THE BROAD UGAHENTS.

PAROVARIAN CYSTS.

TTiw cTMs Herelop from I lie parovarium, wliich is tTic remains of the WoK-
\My and ^iiiuiri] wiihin ihr hyers of tlic hniad li)Ciimcni bc(w«en the
rfail of thr iiv:ir\- And ihe r:d!iit>iiin lube.

Tfc pororamim coaiUi* ot a nundicr of tubules which are divided into
pam, as f<i)lowK: (il 'the outer tuhultv. which are iiruittacherl nl ihrir
tel nlnmiiies and known as the tubes of Kobclt; (i) the middle or rerlical
, whitJi convcrfp; and «Her the Inner part or luiroitjihoron of the ovan*
I tlu*il c«reinitic*; {3) ihc inner iubutc«, which are obliicraicil and form
; *iii! (Oftl'i; and (4) a iramvTr^c tube, known as Ganner'-v duct, into which
iW uiUT iind ferlii::il tubules I'jii'ti and which may (icc.iMonallv be traced to
ttiueni.' iiiui thence through the vrall of the vaginii to the urethra.

Tht luoivariiim U h<>m<'l<>ji<>iL* with ihe epididymi> ;ind the rasa effercnlia
llknuk, and (hv iluii o( (iarlncr nim:.»]it'tids to the vas deferens.
Jhr pum-arium is n ithout function and is often the seat of cystic changes,
hroorian cyxt.* nrc dividcti jnio tli">e which devclup from (i) Kobelt's
riadcstixl {3) ihii verticil iind transverse tubules.

'«r

Pm. tM'—OlMuM SmrniRi thc pKtavAtniL

CYSTS OF KOBELT'S TUBOUBS.

^?^ "^ 'I'e twl»e« of KoIh-Ii miiy umlerK" r\->tic » lege nerat ion, become dis-
™"'.aiul (iirm u pedunculated ly.'it ihc size of a pea. 'I"hc*e iyM-> have no
^WHjU^tigni^ia ii<e. as they cause no inconvenience or symptoms, iind it i> im-
"J* '<* ftiwpeci i(K-ir prewnce prior lo opening the alxlomcn for sonic other
""■■ Tliey ure fre<|Uently nlwcned. however, at the lime of operation.
W ifr t.fifn mk!laken tor a hydatid of \torijagni.

"■* "f tlwse r>'sis is met at ihe lime i>f an oiieration. il shouH Ik emptied
rpunctojt ,« rnnovnl .tfivr pbiing a li)i;^ture around its |nilidc.

9jgTS OF THE VERnCAL AHD TRANSVERSE- TUBULES.
r.^slt Hrc huMi\idv<l inio (1) pedunculaicd and (a) iCMile C)"»U.

54^ DISEASES OP THE RROAD UCAUENT&

Pedunculat f.ij Cysts of the Parovarium.

WTicn one ofTTi' ^WtWlI lUlUUi WniPPgW* <^>>uc'nc^cilB«Iioii. it bwooc
di.itended, and occasionally it may betxirac AOparaierl from its coruir<i)Ca> t:^
(orm a snijill ptdiinculatfd rjst. Those cysts have verj- thin wajb ind rvrJtt
ally rupture inio the peritoneal cavity. The sac under Ihoc dnruifaUtir-
becomes obliieraied and a friiiKt-like tuft romikln^ 1<> miirk the Mtuitioa of lir
c\f\. 'Hiese cysis h;ive no ctinicat significiincc and they cause no incoamiicxr
or symptoms,

if one of the«e c>'st.s is di^covrrcd al the line of an operation, it thinUb^
punctured or lipied and removed.

SB&S11.B Cysts op thh Pahqvariiim.

Synoii}-:!!. They are l!*llSlly sf^ikTlTTi^cT-irfre e>-st4 o( tbepuoninib

Cnil^c-^. lie (Vsi.'' iU-Vf]>ip friiiu ;i >iriKle tvriicil tubule or bonA*-
triTi li r 1 I !ii I ihc parorarium known as (Jtlrtner'>^ duct. Thry occur dv^
int! ilii: liiild ijiMiiiii; period of a woman's life, and arc seldom, if erer-Kl
befuri: ptil>eny. Tlii-y .ire rare compiircd with the frequency' of udf^onikud
pariiojihi^riiii i \ -t-

Pathology. -The cyst is inlnli^rimenious or extraperitoneal in do^p-
mcnl ;m(l K(WW. lUHwcfn the byer* nf ihe lin«td lig'-iment. As it de*clo|»> —
size it lies in close ctmiact with the uurus. the raliopian lube, ami liatomf—
RtwK Mtualfd in the broixl lij^aniL'tit il has ti<> pe<lii:le extqit in tirrr rtffiD-
Manccs in which tlic ligament is clt>ng:ite]>H»ite side of the pclvi,« by ihe tumur and the FalhipJun tube b stteidtA
over its surface. In large cysis the tube may be enormously eloogattii w*
meji*ure froni fifteen to iwenty incht^ in leiiKih- The ovaiy i> uiiullv wniaB-
in sh<ii>c nnti structure, is attached to ihc side of the c>-st. and in >wj' \up^
tumors it may be so greatly fljitened out by pressure that it is difficult in w —
ognize at the time of oiHrr.itiun.

Parovarian cy^i^ Rrow very slowly and may be years in .-iitaininK tnx^
mwiium sixe. .\s a rule, they are seldom larRcr ilian an infant's head, hut —
casionatly they may Iwcme cniirmous and diMend the abdomen. 'Hit* ir*
almost without cxi:ei>ti(>n unilocular in character, altiiough a few cascs bn\t t<m
oh^e^ved in whidi several di.^tinrt loriili were found. Paro\-arian cysu wriy
form adhcsitms, owing lo the fail that they arc completely cowre<l bv periooKW
ant) because they arc not liable to the complications which cause infunmul*'''''*
ovarian Jiimors.

The wall of the cj'st is vcjy thin, transparem, and of a greenish hue. and i^
delicate blood vcnscU of the peritoneum arc seen ujwn its surface. TbesKd*
large cy« may lose il» tr.insluccnvy. becoming more or less opaque and «( ■
pearly lighl blue color. The [>critoneum is easily separated from the wallof ih^
cj'M unle>% iuibmmntor\' adhesions have occurred, in which case the ci»iekali<*
bccumcs verj- difficult ur even impossible. A parovarian c\-sl is always EtUr t<>
rupture on account of the thinness of its sac, but the tluid U not irritating M"*'*
peritoneum and is rtyidily absorbed. The cj'st refills ^try slowly under it^
drcumstances. and in some cases it bemmes obliterated. The contents iJ tb«
cyal consist of a clear, colorless fluid, which is non-irritnling in cJmrartctandb**
a sjiecifir gravity between i.ooi and i.ooR.

In .some instances a jjarovarian cy»t may become papillonulouit, awl *•»*
Inner surface of the sac is then covered with papillary outgrowths or warB. »**

PAROX'AUAK CWIS.

547

AjtiaLniUtion.

Kuptur;-,

walls are thicker and more opaque than in th« non-papillary vari«i)' and the fluid
content loses iis clear, watery diameter, becoming cloudy and xt lime* mixed wilU
h\iHMi nhidi ooKcs from the warty oulgrowrths. Tlicsc c>-sts arc clinically similar
to cysts n[ the iMrobphuron, and the juptlbry outgrovrths may jwrforatc tbe sac
and inXcd the peritoneal cavity in llie s)ine way,
CooiPlicationa. — The chief complicalions yc :

Indammatii n ^cl'lnm occurs in parovarUn c>'Stx, and ihey rarely sii[i|>urate<]
in former days whtn tapping was resorted to for the purpose of effecting a cure.
Ilcmorrluge U a mre aciJdeDi, except in papillary cysts, on account of the nature
of the tumor and the extreme thinncw of its wall, Axiiil rotation due to prcg'
nancy luis l>e«n observed by Sutton. Rupture is a frequent occurrence and the
escaped ttuid is readily abt>orl>efl by the peritoneum and eliiniiutcd b)' the kidneyn.
The sac usually refills slowly, and in M>me instance* it may Ijccome nblitemtcd.
Often in iiapUbry lysis the first symptom of the disease is perforation and subse-
quent infection of (lie iKrilimeum. Adhe-jons are rarely formed between the
tumor and adjacent parts, except in papilbr)' cj>ls, on account of the (;ici that the
cj-»t i^ luvirtd with peritoneum and that it is not liable to inflammation.

^jUBtdAIB^^i^U; ?ym]ilom> of a jiarovarbn C}'nt are lumibr in many
ways to those of an o^-arian c>'Btoma which develops between the folds of the
liToad li^ment.

'ITie symptoms may l« amvcnicntly studied under the followinji; headtngit:

sure svmDtoD

' HiKiWtlBJTiPTil

ers.

Cnmc

Pressure Sgmntflms.— Symptoms due to pelvic pr«ssure occur early in the
COun^>riii^I^^r^^mPTliiTii.ir i> fixed in it? i«»ition and cannot move about
or aceommndjii- it-cli. Un the i>ther band. howc«T. ^)'oipioms dtic t«.-.

Tbci

kt-i'irji
.\srilcs ,

inces.

ardiac disorden.

The cffea uponTn^SIvK^iructures may be marked and the patient may
suffer with constipation, heroonfaoids, irritability of the Madder, hydroneph-
rosis, or albuminurb. The dtgc^tivc, rcspir.-ttory, and cardLtc diMurbtinccs
whidi are so common in large orariao cj-stomata arc rare in paivrarian cysts.
Asdles » a frequent occurrence in the {napitlary variety and pressure upon the
iliac veins may result in edema of the legs, (lie Niilm, ami tlie vagina. The
prcMrnce of the tumor niuses a liearingdown or diaxging sensation in the pcMi
and pain may radiate inm the hip, the Iwck. the rectum, or down the thiKli^. A
reflex fi.iiii iiuiy also be fell in one or both t>reasis and in the head.

Menstrual Disorderg.— MenoTrhanta, mctmrrhngia, and dysmenorrhea are
carly-SIBmBfWWSpBipRlins in parovarian ttunois. Amenorrhea, however.

548

DISEASES OF THE BROAD UCAUEKTS.

which is present in the laicr stages of an ox-arian Q-^t, is not observed in ihcsc
dfteii, aK i)i« general health of the woman b not profoundly aS««.lcd by ibe
disease.

Sterility.— Si criliiy is the rule in tumors of the paro\:ariuro on account of ibc
diMurteil ^n<l min)tliice<l ainilition nf (he iitenix iinrl it» apftcndiiges.

Gcocn^ygftgips. The general hralth, as a rule, is not impiuirMl and the
anemi^BSroSaiaiexia common to ovarian cysts are not obser^'ed in these oises.
The pnlicnt may Itcaimc ncuraKllicnic anil lose flesh ami vrcighl fmni the .le^-eriiy
of the pressure symptoms, bul otherwise she Is not scriouslj- alTcatfl unless the
c}'M b> iwpillomatoiis. Enkirxement of tliemammarvfclaniL', pigmentation of the
areob. and sccietlon n( tolosimm are occAsionally associated with these tumors.

Compltc^^BUf^— Tlic complications are the same as those occurring in
ovanan^y.-' and are iIJacil-umkI on jiajte 517.

^IftgnoaJ^SI-Thc history anti the symptoms of the patient are often of
dia^HWc^ffilucTand the nature of the tumor may o(:ciL-.ionalIy l»e inferred by it»
extwnely »low growth and the aincnoe of caciiexi.1, which is so common in
ovsrian cviXs.

For purposes of diaKno^s we disiinf^ish the follow-ing stages in the growih
of « parovarium cyi :
Ppi\-ir ■^'"m,
Abdominal H^ge .

Pelvic Stage.— Ifi^Mwcirand bUdder are emptied, the patient placed in the
dorsal piisiiion upon a tabic, and the examination made by xaginoabdominat
and refto-.ihilominal palpation.

The fiillmving phv^ir.il -i^nsarcclidj

'I'hc P'

The ni"l, , ilic ..-ysl.

The f ;, I'lMi- .'I l;:i (VSt.

Thi- -^ i|>. ■■; 1,

The '■'JHSL^

The Posiii'iii .•} ine^nS^t. — The tumor Ik diMinclly fell low down
in the I^elvi^ and always to one side of the uterus, which il cnm-ds in the op|>oisite
direction.

The Mobility of the Cy »t .—Tlie <7»t Is fixed and cannot be dt*-
placeil by the examining lingers.

The Kelalinns of the Cyst . — The cyst is situated t>etwern the
layers of the braad lipimeni and in ilose rnnlaci with ihc uterus. Uelwcen the
tumor and the uterus, a gmnvc or furrow can be felt, but the connection lietw«en
them is so intimate that neither the womb nor the cyst can Ix- mov«( inde-
pendently of each other, a.i woulil be the case with an ovarian giowth. The low
Htuiitinn of the cv-M In the jielns it characteristic, and it often bulges the lateral
culdcsac of the vagina. The tendency cf an orarian cyst as it lievrlinxs is to
ascend into the alxliinifn, anil licncc when il becomes abdomiiLal only its inferior
border can be fch in the upper pan of the pelvis. .\ pirovarian tumor, how-
ever, completely (ni-iii)ie* the |)elvic iTivily ex-en after it nas atlaincl a large siie
and encriMches upon the ahdnmina! organs. If we are able lo feci a dUtincl
pedicle or to palpate the lube and ovary, the origin of the tumor i.*, of course,
positively determineil.

The Shape of the Cyst. —The tumor U round or ovoid in ^pe and
its surface is smooth and regular in outline. If the cyst Is {Mpillnmatous. we
may be able tu feel ihe jiapillary outgrowths upon the tumor. Ascites is usually
present in these cases.

The Consistency of the Cy s t .— Thetumorisdbtincllycyttlcin

VARlrOCELE.

S49

diaracier. no solid or irreguJar ma^fies arc felt, and SuctuatioQ is readily elicited
thnmiirh itic vaK>niil vault.

Abdominal Stage. — The physical signs arc elicited by the (olton-ing means
(see ovarian cysts, p. 534): (a) Vaginoabdominal and recto-abdominal palpa-
tion: W ins|ic:(ti»n; (f) palpiition; (J) percussiun; (c) menKumtion; (/)
auscuttaiinn; (j) cx|>lcirai<>r}' incision.

Unlike a cyst of the ovary, the tumor always lies to one side of the uteruK, the
vagina i» not i-Inngiiteci, and ihe Inlravajti mil |K)riion ot the cervix is not obliler
ated. The lower part of the tumor compk-icly occupies the pelvic t^vhy and
bulfce* Ihe laieml culdesac of the vagina. Pressure downwarti u|x>n the tumor
through the nbdominiil w-all move* the utcnj* ;i* well as the growth, showing the
intimate and close connection between them. A groove or furrow tan usuall>- be
(ch JKtween the lumor and the ult^rus. No jiedicle (3n lie (iiilline<l. Bimanual
examination reveals a smooth regular surface and duciualion can be dietinctly
clidte<l by vaginoabdominal palpation.

Fluctuation is vm- distinct over the enlirc area of the abdomen occupied by
the tumor, and, unlike sn ovarian cyst, the length and intensity of the wave do
not wiry over ditTereni [Kiri.-. of the cyst.

Differential Diagnosis.— See ovarian c>>ls, page 539-

Prognosis. Rupture U sometimes followed by a spontaneous am. A
partTWrtrTTTTfTr'^w^ vi-ry slowly and miiy exUt for years without ciiUhinn; any
inconvenience or endangering the patient's life. Hapillomnlous degeneration
ift dangerous to life by perforation and subsequent infection of the peritoneum.

TtCtttUiftllt. — Tl'c cy*t >hould lie removeil by the atHloniiiial route a.* soon
jOTrtPBBWWW^Thc cnesislence of pregnancy docs not contra indicate surgical
interference. (Oi>eradve Technic, p. 983.)

VARICOCELE.

Synonym. — Parovaria n varicocele.

Caases.— The disease is due to the following causes: Subinvohition and
dispUceriifiil-i of the uterus; <«nnlipation; and exhausting chronic dixe-ascs which
produce 3 reUxed condition of all the tissues of the IkkK'. The affection is much
less frequent ih^n vario^cele in the male, of which it t' the homologuc. Thb b
due 1(1 the fact thai in nun the veim of the testicles are placed i)er|K;n«Hculacly,
whereas the ovarian wins follow a hori-
zontal luurse.

Description.— The mass formcil
by the varicosed wins varies in size from
a walnut to that of a lien '> r^y. The dis
case occurs more often upon the left side
than upon the right, as the left ovarian
rein H without a \^We and open* at right
inglc^ int'i ihc- renal vein,

Sjtnptoms. — In the majority o(
ca^e* the wuman suffers no jni'oni'enience
wfaatcwr, as the veins are but slightly di
lated and cause but little, if any, local dis-
turbance. When, however, the varico*e«l veins form a distinct tumor in the
broad ligament, they become the source of constant irritation, and the patient
consequently suffer' with more or Less severe [tain. Tlw pain is dull, burning or
dragging in rhamcier, and situatcl in one nr both of the iliac regions, whence
it radiates upward into the neighborhood of the kidneys. It is affected by the

no. 4M.— VMKOaU OT Tm Hmu LWUODrt.

SSo

mSBASEG OF THE BKOAD UCAUENTS.

poEition of the patknt and by exercise. It is relieved or tliiuppcars abogtUir
when the patient is in the recumbent posmrc, but wlicn 5hc sits up or uudt i
rcturnK. il» severity h :ii»(i increai>ed by Wiiltini;, ndinf;, and .ilJ fumi» r4 tm
CISC, and in »)mc cases the su^ering mny be mi great when the poiicnt is ootiaili
reciiml>ent jiu^iti'on ibal site becomes u dironic invalid and is cunfinnl to her btt

IKagnoSiS. — A positive (Jiagnosis is practiailly impOf-'^iblc prior 1e Hi
time ot operation. Recto-abdominal palpation may reveal a douf;by mass la di
broad li^ment which !.« smaller when the ]aiirni lies down than when ihc
in the creel position.

The disea.ne must be distinguished from an cnlarRement of the Faltopii
tubcfj rr tlie oviiriwi and (nim Himors of the broad liRaments.

Prognosis.— The disease is not benefited by any form of local or rcoh
trralmcni, itnd it ran only be (nircil by resorting to Miripcal mea^urei. ThAi
alwayy danifrr of the enlarged xTin;- rupturingaml causing a dangerous liiiiiinil^
either into the pelvic cavity or bet ween the folds of tl)e broad lif^ment^ i

Treatment.— .\s a rule, the di-eas* Is mil even su%pec1cd until ihr abdoa
is opened for some other pelvic Ic-iion. ^KTicn, however, a parovarian i-ariom
is found lo lie present, it should always be extirpated, whether it cutis i
associated with tubo-ovarian disease.

y".

^^^

tia, M*. Fib. «*t.

Rud'i onution tern Vlococuz or (■« Baoui Liaitmrr.
fit- 400 rhamt an Jntc-rruitTpd Ngilurr tnnc ibifudutErl under the t^ks^ of wai. tH 4tfJ tkf^t IfeffM
in (ifkULiiin ikEi'l the iriu iiuwd bilii— i

If salpingo-oaphorcclomy is performed, the «ricocclc i? DCceswarily
in (he ligature that is passed through the broad ligament before cutting awarlfc"
tube and ovary, and hence the diluted vein.i are removed ai the same time.

If. hiiwever. ihe varicocele exists atone, it ain be readily remti>«J widXtti
sacrifuinR the tui>e and ovary by Reed's operation, which consbis in tig>tfai(l^
{»un]>inifurm {ilcxu.s in M;ction.t .ind incisitiK die veiits between ibe ligSttlRi.

SOLID TUinORS.

The following tumors have been found in the brond Ugunenls:
lipoma, carcinoma, and sarcoma.

Fibromata nri'sc in the unMriped muscle tissue between the folds e( iM
broad ligament and develop cither downward, encnxiching upon the vacini. »'
Upward, carryinR the anterior .Nurfatc of the broad ligament into the aboow»-
cavity. These tumi>rs v;iry in jixc. and, ns a rule, ihey sel<Iom griiu' very brp
Cases have been occasionatly obscn'cd, however, in which the tumor atuintc
brge ]>roporlions. and either extended upward as high as the umliilkus ccilc
vctoped downward displacing the vagina and appearing at Ihe vulvar orifice

Llpomata are very rarely seen in the broad ligament.

Carcinoma ^nd Sarcoma of the bmud Ligament are secDodary lo nuligBBn
disease in the uterus, Ibe ovary, or the peritonetiin.

TuuoKS or ruE ovauan and ROU^a} ugahexts. 551

The nature of a Ktlid lumur of tlie Inanti ligament cannot be determined prior
to opening the abdomen. As soon, therefore, as such a growth is diM:over«d,
la{)aiotoiny should be perfonned and lite tumor eztirpated.

CHAnEK XXI.
TUHORS OF THE OVARIAN UGAHENTS.

The following tumors have been found in the ovarian ligamenis: Fibroma,
carcinom:!, and sarcum;!.

fibromata .ire very rare and setdom attain a size brgcr than a hen's egg.

Tumors of tlic ovarian ligament cannut be dislingui'Jictl from neoplasms of
the ovarv pri»r to opening (he alxlomen.

The treatmeot is abdominal section followed by the removal of the tumor.

CHAPTER XXn.

TOHORS OF THE ROUND LIGAHENTS.

The foUowing ttimora have been foun<l in the round Uf^menU: Pibrnnt.'i,
carcinoma, and urcoma.

FibroniQta. — The$e tumont arc more common in women who have Imme
children ihan in nullipdnc. and they arc more frequent in the right than in the left
munil ligament. Thc>' may present Uiem«elves nthcr as a fibronu, a fibromyoroa,
a myxofibroma, <i fibms-iraima, or a IjTnphangiecl.ilic fihrom;i. They may be
exlruperilotual in development and occupy the inguinal cjinal or the labium
maju», and ihey may also !« intra ptriloru-al and ari.sc from the pelvic portion
of (he round ligament which lies between the ulcrus and the internal iiUjominal
ring. While the^e neopbsms, as a rule, de^'elop slowly, they arc often stimu-
Lttrd umier the inllueivce of pregnancy and rapidly increase in size, and in very
e.tceptiona) cases Ihcy become brgcr at each men.<tni.-il {>cri<Kl. A fibroma of the
round ligament is usually hard in consistency, generally pedunculated, although
ocoLttonally it may he »ed.-<ne, and \\i surface is smooth or only slightly Irregular.
It varies in size and is not tender upon pressure.

Symptoms.— The symptoms depend upon the size of the tumor, and a
small growth may cau>c no inconvenience whatever, but a Urge one will neces-
sarily produce painful pressure symptoms.

Diagnosis. -The. presence of an inlra periloHMl fibroma b determined by
ragino iMoniin.il {Kilpalion. The tumor is fell high up in ihc anterior part of
the ;>clvis in the ^ghborhood of the internal abd0min.1l ring or between it and
the hon) of the uterus. The diagnosi.i is hated upon tlie hiMory of the r-ii.se, the
situation of the tumor, and the absence of all [wivic symptoms except those
due to pressure.

Extra prriloittal libromati of the round ligament must be ilUliitgui-ilied from
the following lesions: Omental or ovarian hernia, a cyst of the gland of llartholin,
and enlarged inguinal lymphatic glands. When the tumor occupies the inguinal
canal or Uie labium roajux, we find that tliete n no inapulsc upon coughing or

$$3 SUPPORATION OF THE PELVIC CONNECTIVE TI5SOE.

Straining and the enlargement cannot be reduced by taxis except it is voy small
or is situated high up in the canal.

Treatment.— ^T he treatment is extirpation as soon as the tunrar b di;-
covered.

An intraperitoneal growth must be removed by the abdominal route. If the
tumor is pedunculated, it is readily excised after tying a silk ligature around ib
pedicle. A sessile tumor should be removed by resecting the round ligament and
suturing the cut ends together in order to restore its function. If the gbroma is
situated near the internal Inguinal ring, it should be removed by resection and tht
uterine portion of the ligament sutured close to the opening of the inguinal canal

A fibroma situated in the labium majus should be extirpated and the wound
closed with deep sutures. If the tumor occupies the inguinal canal, it should like-
wise be removed ; and if the wound is small, it may be closed with deep sutures,
but if, on account of the length of the incision, there is any danger of a rupture
occurring, the radical operation for hernia should be performed at oDce.

CHAPTER XXIII.

SUPPURATION OF THE PELVIC CONNECTIVE TISSUE.

Causes. — In discussing suppurative conditions of the peh-ic conntdive
tissue I shall consider only those purulent accumulations that are the result d
primar>- cellulitis and exclude secondary infections which result from disease of
the Fallopian tubes and ovaries.

Primarj- cellulitis is an extremely rare occurrence, and although in fonner timei
nearly all pelvic inflammatory conditions were attributed to that cause, yet «
now know that such is not the case, and that with but few exceptions the disffl*
is secondari- to a tubal or an ovarian infection.

Exclusi\T (if tuho-ovarian disease, pelvic cellulitis is usually puerperal in
origin and is clue to vnrious injuries that subsequently become infected. Thus,
the cellular tissue of the ])clvis may become involved in cases of laceration of ll*
perineum or ihc cer\'i\ ; in tears of the lateral culdesac of the vagina which eiltinl
into or open uj> the base of the broad jipaments; and in septic endometritis when
the infection is carried by the Ivmjihalic vessels and veins or when it pase
directly through the wait of the uterus.

In non-puer])cral cases the disease may result from a suppurating hemaloM
of ihc broad ligament or a pelvic hematocele; from infection following a vagiiul,
a uterine, or an intrapelvic operation, from an ulceration caused by an ili-filti'¥
pessiiry; and also from the passage of pathogenic germs from the bladder, tlw
rectum, the intestines, or the vermiform appendi.\.

Pathology. — Pelvic cellulitis may end in resolution; become chronic; "r
result in ihe formaticm of pus. Purulenl collections mav be situated in any
portion of the cellular tissue of (he pelvis, and while (hev are more common in 'I**
broad liRnmcnts than in other structures, yet ihey are occasionally found inlhe
connective tissue in front of or behind the uterus. The pus u.suallv burrows a!oi»!!
the route of least resi.stance and finally escapes through an adventitious opewap
into the bladder, the vagina, the rectum, the intestine, or the peritoneum. I"
some ciises il may burrow between the vagina and the rectufn and appear in if"^
lower part of the labium majus or the perineum; in others il may pass throup"
the saphenous, sacrosciatic, or obturator opening; and, finally, it may escap*

SVUnOMS— DIACNOSJS— PROfi^OSIS— TREATVENT,

553

al ih« umbilkus iw lhn>ueh ihc »kin above, but »l(lom below. Poupari's liKunKnt.

a rule, in iht** cases the iibscc^s breaks into the ^'aginu, whereas [niniknl

uinulnlion» in rhe cmncdive Uswte ihut are f«i:Dn(Uin- lo tubal or ovarian

dincasc rupture into the inlL-slinc ta the bladder. Peritoniiu -icldoro occurs,

as the nbMrnw rarely brejiLs into the periiuneal cavity.

If oat ot (hvt« ab^^cewcM nj|ilure<, the »ac usually becomes obliterated, if
draifuffe i> (^hxI, and a »pi>ni4nciius cure results.

Symptoms. —The *ymi>t<)HL^ are in nti way chamcteri^lii; of the dioaw
and are prni'iically the same a^ llimx nf tubal or ovarian suppuration.

Tlie iMlieni tumplains "( severe iMin in the lower ■■«lj(l<imen and in ihc pclvi*.
rhiih <'ften nidi:ilcs <lt>wn the tliiKhsi ihere is a rise in tcmiM-niiurc; the pube
Tapi<l diid wejk; and there is loss of apiwtiic. preat pro>iration. and often
lol I'hilU. The rectum and the bladiler may Ixxome iTrilable and ou*e
Inful uriiMlion and defccilion. The abdomen is not du^tendcd as in peri-
tonitis .md there Ls no tendency to nausejt or vomiting.

Diagnosis. — It i--! pr,t<ii<^lly ira]Ni.v>t)blc to diMinguidi between a ci^ nr
«up[mniive cellulitis due to tubo-ovarian disease and one that is due to other
tau^e^. The [iliy>iail si^nj of pelvic sup|>uniti<)n arc determine*] by rcelt-
iihdatninai aiuI -itgitt^ liltiomittal palfialion.

A.* a rule, the patient complains of [lelvic pain and tenderness during ihe
\ examination- Ttw m;i» (ormeil by the purulent acriimuLition i^ irreKubr in
■Hiape. ntore or less difTu^e*!, .ind immovably fixed in the pelvis. It nuy be
^Boft And l«>f;Ky to the lou<h • r it may be so completely surrounded by inllam-
r Dulor)- cxudato th.tt it n-nwy^ a hard rcsi-linj; >enKilion to ihc eKaniining
I finder. As a rule, fluctuaiicn c.->nniii be clictied; but in brgc abscesses this
"I 1'^ easily dcttrmiiwl and the examiner ha!> but tittle, if any, difficulty in
^.■>ttnizinK tlw prtM-mc of pus.

I'he aliocew riMV be situated in the bniad liK^iment or behind or in front of
ihe uterus. If tile aumeciiw ibmue of the bmnd li)ciment i# involvei). the lumor
piabn the uterus low.itd the opposite side of the pelvis and bulges into the
nrnr-piindinii! lateral nildecic of the v.-t>-ina. An at»tv« Whind or in front
"I Ihc menis ilistends tlie pifsterior or anierior v.iRin-il fornix.

Prognosis.— The pmunosis in cases of purult-nl cellulitis not due to tubo-
1 "nriin iIimmm-, while iiecesKirily (traw, <le[>en'l.% to ;i Lirxe extent ujHin the
I awe of llie infection and tl>c promplncTis i>f vi]ri:ic:d interference,
k^ II an iibtces.'i ruptures into the abdomitiat cavity the peritoneum Incomes
^Hbtvlly inlLimrd. und a fatal re>ult u-iually follow:!. On the nlher hand, how-
^^ttn, if lite pus escapes through the skin or into one of the hollow viscera, the
I Mr usually becomes oblileraletl nnil a ^[Ml^tat1eou!t cure results. Death in
I Mtar cases may be rausol by geiM-ral m;i>sk.

I Treatment,— The trraimem of suppurative pelvic cellulitis is based uiion

' ' ' principle whiih teache:^ Uf- to evacuate an absccv without
. I free draina};c, In these cases, howe'iX'r, the question at
i".i ii-i-li AS to the mute that >huulil U* sch-cled to re.nh ihe pus. Shall
i thnitiRh the v;iEina or should Liiwmiomy Ik- iterfiTmcil f If we are
!. tul>o ovari.iii disease as the cause of the abscess, the i)iieslion
I i- -iy ai»wereil and the v~a|i:innl mute selected a> Iwing safer and of-
' ':' lirlier advantages for irri)£ation and drainage than abdominal section.
-' nunately, as stated alK>ve, it is practically impossible to determine
' 'if the case prior to optming the iilHlomen: and ns |>rimary cellulitis
'• ^T:) rare ciindition. the chances are all in favor of an intraperitoneal source
which wuuld not Im; lienefited by a vaKiiul section, as there i> no

554 Ecmjfococcus disease of the pelvis.

possible way of draining ihe numerous pockets of pus that exist and whidian
so characteristic, in cases of purulent infiammation of the tubes and o^'aiie;.

In view, therefore, of the absolute uncertainty of the diagnosis, laparotoni;'
should first be performed, and if the uterine appendages are found to be nor-
mal, the abdomen is closed at once and the abscess opened and drained ihrou^
the vagina.

CHAPTER XXIV.

ECHINOCOCCUS DISEASE OF THE PELVIS.

Canses. — Hydatid di^icasc ii more frequent in the female than in the malt i
Jon Finsen, of Iceland, who personally observed 245 cases, found that oitr
70 per cent, occurred in women. The primary source of the disease is deri^td
from dogs who are affected with tenia echinococcus. The eggs or lar\-a otihe
tapeworm enter the human botly throug'i the mouth or, in the case of a wonun.
also by way of the vaRina. If t!ie larvas enter the mouth of an individual, they
pass directly into the intestine, and evenlually either burrow through its waM
or gain access to the portal vein; they arc then distributed to various parts of
the body and finally form echinococcus or hydatid cysts. The disease k en-
demic in Iceland, where men. women, and dogs live together in closely con&oed
quarters. It is also common in Australia, Mecklenburg, Silesia, and in olhtr
parts uf the world. The affection is rare in America and comparatively iiifn>
quent in A'iia and Africa,

Description. — I lydatid cysts of the pelvis are most frequently situated io
the connective tissue near the rccium, but they may also be met in the aniertof
p irt "t the pelvic cavity, and occasiunaliy they have been obsorved in the utene
or lis appendages, in the broad lii;amenl,'^, and in the bones. Thev may develop
upward and form an abdominal lumor. or lliey may gradually burrow doira-
w.ird and pass ilirough one of the pelvic foramina or follow the connecrin
li-sue between the rectum and the vafj;ina.

The hydatid fluid contains about q8 \iot cent, of water; it is limpid awl
clorlc'ss; and has a neutral reaciinn and a s])ccilic gravity between 1.005 and
I.OI2. The echinorocci may die from want of nourishment, from the pres^urc
of surrounding siruciurcs upon the cyst, and from suppuration occurring in llw
tumor. If ilie cv>l becomes infected, the lluid content bea>mes purulenl in
character and thick or pulty-like in consistency. In some cases the c>'5t imy
cnntain a bloody fluid and in others us contents may become calcified. Oc-
casionally the cyst may liecomc infected on account of its close conneclioo with
tie rectum or intestine, and the resuhing suppuration converts it into a ptinc
absccs-;. Sometimes the cyst may rupture and discharge its contents into the
rictum. the bladder, or the vagina, and in rare instances into the pielvic avi'>"
or the uterus.

SymptOtns. — Echinococcus cysts may e.\ist for a long time in the pri>is
without interfering with the patient's general health or causing any local sitnp-
toms. .'Vftcrthe cysts have attained a large size, however, they encroach upon th'
pelvic structures and interfere with the function of the bladder, the kidneys. aO"
the rectum, and cause edema of the tower extremities as well as neuralgia"*
the sciatic nerve. The general health also begins to suffer and there is graduw
progressive loss of strength and weight.

DIACKOSIS — PKVSICAl SIGNS — PK0CN08IS.

5SS

FcvcT is srltkim prcsi-iil during tlie mane of the disease unl«ss ihe cysl be-
comes infctled. in which ca-sc th<- usual symptoms of jtclvic i^ujipuriUion nunifcst
thciDMlves aiul the palient su6cn with rigors, fever, sweating, and rapid Ia&>
of llesh.

Diagnosis.— The diai^osis is difficult and otKa impossible, and can only
be miiilr by rx('lu.''i(ifi (ir <lelectinft certain <-haracteri&uc phy^cal sit;ns, which are
more marked if the tumor extendi; into (he abdominaj canity than when it is
confined to the pcIvU. The prevalence of the discaiic in certain countries and
localilioi ."hould lie liome !n mind as well Ji^ the absence, as a rule, «f fever and
pain. The fact that the general hcijlli is not impaired and that ihc [wticnt h not
emaciated are in favor of the discaw bcin); hydatid. If the cyst ruptures into one
of the hollow visceni ,inil the characle^i^til' hooklch arc diMOvcred in the dis-
charged contents, the di.af;no»is becomes positive.

The coexistence of a hydatid lyat in the liicr or some other abdominal organ
has an important tie^mngu|>nn the diagnosis of .1 pelvic tumor having some of the
subjective and objective characteristics of e^chinocoocus disease.

Physical Signs.— The physical sij?ns of k hydatid cysl are more or len
charactetislic, but unforlun.-ilely they arc not to distinctive when the disease is
confined lo the pelris.

If the di>ea$e is limited to the pelvic cavity, recto-abdominal anil vaf;ina-
abdominal [lalpation reveals one or more cystic tumors, situaltd usually in the
posterior part of the jiclvis. behind the een-ix and near the rectum. The
tuinur> are ntund anA elastii'; their walU are smooth and let^.te; they arc
;K>mevii-hat mo^'able: and they arc not tender ti)>on pressure unless inflamed.
Carciui palpation reveals the fact that the uiems and its 3ppenda);es arc not
connecieil with the tumor arul the cervix in more or icKV cn\-cred over by the
bulging and cUslic vaginal forntces. The hydatid ihritl or jremitus cannot be
detected when the di.-«)se is eonfined to (lie [>ctvic aivitv.

When the disease extends into the abdomen and forms a palpable tumor
above the n>'miA>-sis. certain physical stgni arc obiatnablc. in addition to iho.ie
juti descrilH'd. which are ch.inrteristic ^ind of great importance in making the
dtagnosis. The situation and the origin of the growth, as in the case of an
marian cj-st. arc <lctemiincd by rci-to-al>dorninal and vagi no- abdominal touch, by
al>dnmin3l palpation, and by pemission. The bimanual examination reveals
conditions within the pelvis similar to those described above in discussing tile
physical .Mgns of a jidvic hydatid cyst, aflii in adilition we are aMe to detmt the
eonnertion ttelwecn the ab<lomin.-il (umorand the mas.ses)n thepcHs. i-'luctua-
lion is very distinct in cchinococcus cysts, and we may at times l>c able to feel the
hytlatid thrill or (remituii whkh when present is a jialhugnomnnic sign. The
latter phenomenon is elicited hy pressing the palm of the hand lirmly against the
tumor and making light percussion upon the opposite «dc; under these cimim-
ytaiKes a tn-mblini; iiTipu]>e or thrill i-i felt over the c)>t. .Acconling tn some
luthnrities, auscultation gives "a short, sharp booming sound when the tumor
is percussed, that may be likened to one produced by striking a membrane
stretched over a mcLtllic frame."

Prognosis. —The prognosis is always grave. Spontaneous cures have been
observer! ffKini lime to time which were due to calcification of the sac, tu the death
of the cchinococcus, and to rupture of the cy-sl. The disease may exist forsci-erai
years without causing local or general symptoms. Suppuration is a serious com-
plication and one that U liable to occur In hy<lalid iltteaxe of (he i>elvis on account
of the clow relation exi:'ting between the cyst and the intestinal tract. Death
may occur in some instances from the coexistence of a hydatid cysl in the liver tir
some other organ.

5S6 ECTOPIC GESTATION.

Treatment. — The treatment of hydatid disease is surgical.

If the tumor extends into the abdomen, laparotomy should be performed and
the cvst enucleated; or if this is impossible, the sac should be stitched to the
abdominal incision and packed with iodoform gauze after removing its contents.

If the cyst is situated in the pelvic cavity, an exploraton- abdominal incision is
indicated to make the diagnosis. Should the tumor prove to be a hydatid cyst,
the abdomen must be closed at once, and an incision is then made through the
vaginal fornix into the growth. The contents of the cyst are then removed and
the sac packed with iodoform gauze.

CHAPTER XXV.
ECTOPIC GESTATION.

Definition. ^By the lenn " eflopie" qt" exiraulerine" gestation is meant
a pregnancy that develops outside of the uterus. The ovum may be fertilized in
the Fallopian tube, but unless it is arrested in thai situation it eventually passes
into the uterine cavity and a normal pregnancy results. It is therefore obviously
incorrect to speak of an ectopic pregnancy as originating outside of the uterus
unless it is understood that the o\Tim is permanentiv arrested in that situation.

Varieties.— .An ectopic gestation may be Primary or Secondary. The
former is the seat of the original implantation of the fertilized OMim and the latter
is the new situation which is assumed bj' the embrjo or fetus when it is disturbed
by the process of development or rupture.

A primary' ectopic gestation is subdi\'ided into a Tubal Pregnancy when the
fertilized ovum is implanted in the tube, and into an Ovarian Pregnancy when
it develops within the ovar\'.

From a practical standpoint we ma)-, however, re-
gard all cases of ectopic Rest u lion as tubal in origin,
and therefore this ^■a^iety alone will be referred to
in the subsequent consideration of ihe subject.

An ovarian pregnancy is an e.\tremely rare occurrence, and the possibility of
the ovum being fertilized within the Graafian follicle has been for a long time
denied. The views of the ])rofes.sion, however, upon lhi> subject have changed
within a comparatively recent period, and the (>ccurrence of an ovarian pregnancy
is now admitted.

It is impossible for an abdominal pregnancy lo occur primarily, even ad-
mitting that the ovum may become ferlili/ed in ihe peritoneal cavity, for the
reason that the product of conception would at iince be destroved and absorbed
by the [leritoneum.

TUBAL GESTATION.
Causes. ^ — Tubal pregnancy is n comp;ir;i lively common occurrence, as
shown by Formad, who found 35 ectopic gesiaiiims in ,^500 general autopsies.
The affection is apt "o occur after a long j>eriod of -icriliiy, or it may sometimes
happen within a few weeks or months Lifter confinement, and, finally, it may
occasionally coexist with a normal pregnancy. The accident may occur not
only in muhiparous but in nuilipurous women as well, and no peri<id in a woman's
child-bearing life is exempt . A number of instances of a repeated tubal pregnancy

Tl'BAI. OESTATION — CAt»ES.

557

bten obsnvnl, ind we »tu>ul(] therefore alwavs bear in mind (he passibiliiy
\htr niii<!fnl <«rcurrinf; in ilie other lube at mme future period.

, '£*ii>jii( ni'>latii>ti IN |>roUibly due to M>mc mechanic aiusc which obslrucis

IIIf lumen ■>( the lube nnd prevrnts (he fcriili2«d ovum reachint; the uicnne

^B~hc ciuxet may be divided into:
^^ The inuatubnl causes.

The extr.itubiil causes.

^Tbe latratubcl C«u$».-ThcsG aiusas are subdivided into:
^P Chmnic salpiiiKilii. Ctu^enllal malformitiion.''.

NeopbMn.i, Displn cements.

Chronic Sa Ipi n gi t is .— The k-sions due to chronic infl^tmmation
)i t>« tuljcs are the mnsi frequent mate of eclif|iic gelation. The h>-pcrtrnphy
dI t\v tube which in ii«iully nwocialed with chnnic salpinRiiis interferes with
lis ruiurdl pcriMaltic movements and constricis iii lumen, ami hence the fcr
uttsed ovum is likely to lie jiermancntly arrc*tc«l lieliirc rrjching the uterine
avity. In M>me ra»cs Ihc ovum may be arrested by an inflammatory stricture,
and in others, accordint; to Tail, the destruction of the ciliiiied epithelium with
Ihe cDnMquent absem-e of the norm.il lubjil currcnl toward the uterus prevenls
the pmduct of conception from pa.'^sing through the tube. The 1 a 1 1 e r
thcoiy is now denied by must authorities, and Kelly
ha» <lcmonKlralcd that a ''careful cx.itninalion of
indimed tubes shows thai the cilia arc rarely de-
« t r o f e d , even in well-marked c :i •• c « of p y o » n 1 p i n x .
; indare perfectly preserved in cases of catarrhal

*a Iplnc 1 1 is. "
^—^ TVe onim from the ovary of one side may pass across Ihc pclvb and enter
^Bk i;|>posite tulre. This is known us Ir-imminration of the avum, and it explain*
^Pk>ccue!« of luluil pregnane)' which occur on the oppoHte side to the o\'aty
^■Mbiiiing a recent corpus luicum. According to Kelly, -Dr. Williams has
^Wilibic to demonstrate it in five out of thirty iii^es, of which he had accurate
pihnkfic reci>nU. In all of ihrm the fimbmied cMrcmiiy of one tube wus
™plclely occlude<l by old inllammalory processes, or ihe lube wa§ converted
Wia h>'<]n>!i;ili>inv. while die oilier tube was the scat i>f the pregnancy, and
ff^tBleil a patent limbri.ilerl extremity. In each case the ovnr)' on the prcg-
^^lai *ide presented no eviden<'c of a toqms luieum, while Ihe ovar>' correspond-
^H^ ki the occluded lulw container]>us luieum of preRnancy."
^H^Mtopla fi ms . —Tubal neoplasms are an infrequent cause of ectopic
^BMuinit. They cause an oii^truction in the lumen of the iul>e and peTmnnently
^vtuthe pansiifce of the fertilized ovum at that [mini.

^H Cnngeniial Malformations .—The following malformations
^^^wihe iKTurrence of tuliiil prranancy: IMwrtindumv. anesvorj' o.Mb, and
"«' Wniiience <if a (ela! t)*(>e which results in a long, -lender, lonuous lulx-.
_ Ditplacement.s . — A diipUcemeiil of the tulic cannot t:au.te an eclo-
W prtgnanry unlcx* il proilucev lorvion ■)r kinking, in which rn*e the himen
*■ "iii-irn ii-d or ulil it (Tiled jnd the oiTim cannot pass through into the Ulcnjs.
The Extratubal Causes.— These cau.->es are >ulHlividetl into:
Ailhoions.
Tumors.
\il h e s i o n a . — Pelvic adhe^ionx are not an uncommon cau>e of ecio]ilc
i*tioo. The)* in:iy bind down the tube in such a position thai its pcri^lallic
Yemenis are impeded or they may cauNC torsion and kinking, and in some
the lumen b cotvlricted by a to^h band of inllaninutort- lymph.

SS8

ECTOPIC GESTATION*.

Tumors . — The lumen nf ihc tube may be disioned and coDfireud
from the pressure exerted ufion it by n ni;(ipliu->m ol the uvart', tbc |>ir'
or the uterus, and Ihe fertilized nvum prcvi-nicj [mm reachint.' the uicritn

Classification. —(^eit tat ion may take place in any part of ibc tu
ihc t'imbriatfd e.Mrcmily to ihc ulcni». Tubal pregnancies an: ckf^i <
cording to the original &cai of implantation of the iiDprcgiuicd ovum as foUon:
Ampullar preitnuncy.
bthmic pregnLincj'.
InitTiiiiul preftnanc)'.

Ampullar Pregnancy. —litis is the most frequent Form of tubal pregiuiK;
and the ovum h attached to the ampullar or ouier punion of the tube. A ni*
ovarian prcgnana'. nhich is a subdivision of ihe ampullar, occurs wheo <ht
flmbmtc^ exiremily 'n. glued down to the ovary and tbc latter organ fotnti
part of the Refutation sac,

Isthmlc Pregnancy.— ThU variety is not nearly w common as unfmUs
pregnaiiCT. The (milia.-'l o\"um is nttadiol to the free |H>rtion of thenbeit
any point lietwccn ihc ampulla and the uteruF.

Interstitial Prefpiancy. — Thi^ is itie niresi form of tubal pregnancy. Tht
ovum h lodged in thai pnri ■■( [hr lulw which [>cnetiatc» the waU of the uterv.

[nffraltrU

"^^^

Fid- AoK^^^LA^incATrmi nr Ectouc GBvrAmjw.
Sbdhinj ihr titt* of imiiTimuluii cf thf vyud.

CotlTSe of the Gestation.— In the beginning the tube becomes biT»
irophicd, swMllcn. and lurgid. and it* vascularity i* gre.illy inovawil. 1^
al«liiminal opening Rraduaiiy bcoimea timiracied. until finally by the «(^
»Yxk it is cnlirriy closnl in n m^inm-r similar to that already described ind^-
cursing the closure of the ostium in cases ■>( salpingitis (p. 4S9). A» the I'tiH"
dei-clopK ilie tulie tjecomes thin and distended and its vfalls are wealtrirf
by the pcnciratinn of ihe chiirinnir villi.

The pregnancy may end in one of ihc following ways:

Tubal abortion.

Rupture of the lube.

Death cif the product of conception before tubal rupture.

Development of the fc-lus 10 lull term without tuUnI rupture.
Tubal Abortion. ^By tubal abortion wc mean ihr iMrtiul or ttimj-ltW e*
pulsion of ihcpfi'duct oi romeplitm through the abdominal end of the lubf in*
the peritoneal cavity. UTicn this accideni occur*, it mu>l r»e(«r*%arily lake pb"^
before the eighth wreeV. Iiecause after that time the abdominal mlium [•■ <">
pletely clfl»d and ihc ovum canmt escape from the tube exct:\a by a ruf^v*
in iw walls. An abortion is most liable to occur in the ampullar fonn of t*"

TUBAL CESTATION^^TOUBSK.

559

prcgnaiwy; it very rarely takes place in the bthmk; and never happens in the
{nter>titUI t-;ir»ety.

The r\|iul«»»n of th« ovum is usu;iily accompanied by hemorrhage. In
•i>inc cu-ses it may be so profuse that the patient rapidly pcrifLhcsi in others the
ammint o( lilixxl tent i.i mH ^ufl)lienl to cuii>e marked dUiurluincei; and, fin-
ally, ihe pnxlurt of conception may be expelled into the peritoneal cavity with-
out any blecdinjt whatever. If the ovum i^ only purtiulty expelled [n>m the
tube it is aj)t to axine repeated and profuse hemorrhages, and under these cod-
dityjns the paiieni may quifkly bleed to death. Aa a rule, in addition to the
ntlr^lMTiloiH'al hemnrrlwge, bliKxl also iicrumubies in the lube, und if the
fimbriated extremiiy bcrome^ occluded a hematosalpinx is likely to result.

The fetus alwjy.i die:t after :i luhal abortion, and the results, to far »» ihe
miither is ronremed. vary in individual cases. Sometimes the bleeding strps
atui the embryo and blood are absorbed, and recovery takes pkre without
any unfavorable symptoms; in othere the p,itieni may rapidly i>eri»h from shock
simI hraioTrhage; and, linally, the peine hematocele may become infected and a
fatal pcritoniii-1 result. Oi oisioTially the hematocele i* walled ufi l>y adtiesiuiu,
and if it sul^wjuently becomes infected .1 pelvic abscess result* which mny rupture
and discharge its contents into the rectum, the intestine, the bladder, or the
rtgini.

'%.

^%S^

'-^y^

FW. M».— AHn'iua I'iiusaKcv.

fto. jeo.— TiTBii AKimnoH.

Tubal abortions are more common than were formerly supposed, and we
an know that many of tHe cases of peK'ic hematocele which were thought to be
■luf lo ^ hemorrhage from a non-imprefrnalc^ tube were in reality caused by the
"pulsion of a fertilised ovum through the aWominal n](eiiing of the oviduct.

Rupture of the Tube.— This is the mo<!t common termination of the preg-
■»ni-y, and il is direttly due to overdislcolion of the tube by the growing ot'um
'"d lu weakening of the tubal waIN by the penetration of the villi. The
'K^tcmal causes of rupture, which are purely traumatic, are vaginnl examinations,
'' rntsslcp, straining at stool, violent exercise, lifting heavy objects, and sexual
"»trf\Tiun#.

The rupture may take place in one of three directions (Fig. 501):
Into Ihe abdominal cavity,
(teiween the folds of the broad ligament.
Into the uterus. *

Into the .Midominal Cavity . — Rupture into the abdominal
eaviiv may occur in all three varieties of tubal pregnancy. — amfiuHur, isihmic. and
"ffrintiiiii — anil it is usually followed b)' death within a few hours unless the
"'e^Jinj; veiivlh arc controlled by an immeiliate bparotomy. The hemorrhage.

S<to

ECTOPIC CESTAnOK.

as a rule, is more severe and more rapidly fatal in an inleretitial pr^iuacy thu
in the other \'arietips on account of the greater thickness snd vascu^ritj- of the
uterine end of the lube.

The rupture may t^tkc- pliice suddenly iind a large rent niay be nude is Ike
tube through which the ovum and iu membranes are expdted and the blooil

Abdominal

i,ri.ff.

%tptMI

ytiiry

FlQ. wi —KinTttii or * Tm*L PinuuHcr IpM* (w>-
Shemtnc tbr ihret dinofoiu In which > rupttn iBtji ukc flKt.

npidly escapes. Sometimes, however, the tubal walls give way groduallj, ul

the bleiilinK i.v cmitinuous hut mil profu.ic. <>r it may be checked altOgtUitt br

the ovum blockitiK up Ihc opening.

As stAied alti>\c, the [taiient. as a rule, dies within a few hours after tujcue

unlesi ail immediate laparotomy is |>eTformcd; but ihiftdoes not always btfftt.

as she may rally after the te
hemorrhage and ultimately ftntt
from a sulwcqueni altark; « lie
bleeding may stop pcrmanentlv isl
a sfiontjineou.i recover}' take piMC
after the blood and the ovum bn
been abf^rbed by the peritoMW
Sometimes the hematocele becooti
inferlcd and death results fno
periloiiilis.or if it is «alkdef I?
adhesions it may rupture into Ml
of the holloiv viscera.

The fetu^ as a rule, dies at the
lime of the lirsl hemorrhn^ lo
ven' nire cases, howocr, aftv At
(etuithMe«ca|>ed into the peritcMil
cavity it may continue to ievtkif
provided its membranes are wt
torn and its (^acenial attacfamfrt
to the lube is not dcsirojTd Thr
old theon that the fetus could ai
tach it»lf to the peritoneum Uii

continue lo grow is no longer taught, and we now know that the fetus iwBl

[lerish at once if its original attachment is destroyed.

Hctween the Folds of ilie Broad Ligament.— Rupture d

Ihc tube downwurd between the layers of the liroad ligament nvay occur in bihraic

or in ampullar pregnancy, but it is not so likely to luppen in the jnlerMitial varictjr.

?t°S|i.rt;

^i^>

TUBAL CESTATION — COURSE.

561

hemorrhage, a£ a nile, is not profiuc. as the blood is pourl^d out into a cnti-
AdmI KiMce and the l)leedin>- Lca.-tes when ti\h i» litled. The biuud hgament
Wm:i|i)inu which is ihu^ funni.-il nuy be absorbed in time along with ihe embryoi
>'r 11 nur tiecumc ink-tied and produce a (wJvic ubsceu.

The frius, ns a rule, (Iks when the rupture occurs hut in some instances it may
tinue l» develu]! and ^u tu term. If tlie •.'mbr^o lives, llie intra ligu men luus
ce Crjdti.tllv enlarges to .-iccnmmodulc the growing ovum and the pdv-jc

Kiitr i\is\A:i<'t.fi (>r jiU-Oied a.-ide. In .-tonie iit-^tance^ the broad li^'itmcnt is
lo stand the strain put upon il by ihe incre.i^ing distention, and a M-condary
I oetiirt iind tlie (etus is expelled into the peritoneal cavity. I'nder these
tonniiwns the pregnane)' may continue iind go to term provided the e.tpulsion of
the fctu.t is f>rddual, the amount of hemorrhage slight, and Ihc placenta retains
its utLirhmrnt«. .Ajia ruk, " luJl-term erlopU jetuin are txtraptTilontuS."

Into the Uterus, —'[lie gradual expulsion of Ihe o\-um into the
!il«M-iae rnvity may occur in inlcrtilitial pregnancy, and if the placental attachment
sf Dvr fetus i-s nut dt^Inned the gestation may continue to term and the child be
delivrmj liy the natural pasKigcs.

PniiiD r>F KfFTtJRi:. — In cases of tubal pregnancy the rupture may take
at any time.

KirniiD Tnu PttoKunii.

In itthmif and ampuihr gesUtions it may occur between the fourth and the
'^dfth week; in the majority of case*, however, the tube ruplum jiiuul the end
^rf thekoooml munth.

In inUtfliliil ge3talion<i it may occur Iwtween tlie fourth and the iwenlicih
*«k; uiuallv, htuvevcr. at the end of ihr (mirlh month

Death o^ the Product of Conception before Tubal Rupture.— Il may

^Kuionally happen thai the felu:t dies early in the counc of pregnancy from a

■nuTfaage into its membranes, and the gestation sac and its contents arc Ihea

wowtted into an organized maw which is called a luhal mole from its rcscro-

.•nw to a «iffli)ar uterine condition. The size of the mole de|>ends upon the

i|Mnent of the fetus at the time of its death and the amount of intratubal

Jg A tutxil mole that does not become infected nuy lie retained in the

^Iw n Iiing time without causing any other symptoms than those dependent

" pre*enfc of a ma,*s in the pelvi.i. The most common cause of hcmaiCK

t the death of Ihe embr>'o from intralubnl hemorrhage prior to rupttire.

tTclopment of the Fetus to Full Term without Tubal Rupture.— In

'"J ntt innanrcv the fetu.* may dexelup within the tube and die after the gcsts-

^ bt reached full term.

563 ECTOPIC GESTATION.

HiBtory of the Ovtmi. — The changes which occur in the onim in aaa

of tubal pregnancy depend upon various conditions and circumstances.

The early death of the fetus, occurring before the tube ruptures, results ink
tubal mole or in suppuration. After tubal rupture, if the ovum is expelled into
the peritoneal cavity, the fetus usually dies at once, and it may either be absoifocd
or undergo suppurative changes ; in rare instances it may continue to devdop and
even go to term, if the rupture occurs between the folds of the broad ligament,
the fetus, as a rule, dies; but the absorption is apt to be very slow, and hence ■
mole may be fonned. Again, suppuration may take place or the pr^nancy may
continue and go to term, or, finally, a secondary rupture may occur into the
peritoneal cavity, when the embryo generally dies, but in rare cases it may con-
tinue to develop.

The late death of the fetus results in certain changes which are peculiar and
interesting. These changes take place either before or after full tenn and when
the fetus occupies either the tube, the peritoneal cavity, or the broad ligament

Thus, the fetus may become calci&ed and form a lithopedion; it may be
changed into adipocere; it may become mummified; or, finally, nothing mij
remain but the skeleton. After undergoing one of these changes the fetus usu>%
becomes encapsulated and remains quiescent in the mother's body for jeais, or
the gestation sac may rupture into one of the hollow viscera and its contents but
escape into the intestine, the rectum, the bladder, the vagina, or the peribwol
cavity.

Sometimes suppuration takes place after the death of the fetus and a pdvic
abscess forms which may break into a hollow viscus or into the abdominal cavtif.

The ^Hiysical Development of the Fetus.— In the majority of
cases the fetus is poorly nourished, ill developed, undersized, and often de-
formed, although at times it may be physically perfect and apparently healthr.
Hydrocephalus, spina bifida, club-foot, and visceral displacements are comnum.

If the pregnancy goes to term, the child usually dies at the lime of i[s re-
moval, and even if it survives the operation, death usually occurs within a frw
daj-s or weeks.

Changes in the TJtertlS. — During the development of a tubal gestatit n
the uterus is hypertrophied, the cervix is softened, the os becomes patulous,
and the decidua vera is formed, as in the case of a normal pregnane}'. Tht
shape of the uterus is not so round or ovoidal as it is in a uterine pregmncy,
because the greatest increase takes place in the length of the organ. The uims
ceases to eniarfje when the ovum dies, but if the pregnancy goes to term, ii ton-
tinues to develop, and may eventually reach the size of the fourth monlbofj
normal gestation.

Sutton, quoting Pam-, says: "The decidua is rarely retained until the toni-
pletion of gestation, and thrown off during false labor. More frequfnlly. '*
the patient goes lo term, it is discharged during the early periods of pregnanO'
in small fragments, and without producing (>ain; or else it is expelled en w*"'
with symptoms of miscarriage."

Symptoms, — The symptoms of tubal pregnancy are classified into tlii«
which are present:

Before primary rupture or abortion;
At the time nf rupture or abortion;
During the latter half of gestation.

Before Primary Rupture or Abortion. — In the rast majority of o-'* *
tubal gestation terminates by rupture within the first three months, and hrti'
from a practical standpoint this period is of more interest to the genenl P"^''
litioner than the latter half of pregnancy, which is only of importance in tf"**

TUBAL GESTATION — SVyPTOUS.

56s

\tTy rare casct of ecto|nc gcsUtion that continue to develop and nuj- in ex<cp-
lional iftstaocrs reach full term.
The sympiofTLi are divided into:
The subjective vympinms.
The objeciivc symptoms.
The Subjective Symptoms . — These are classified as follows:
I. Symptoms of curly pregnitncy.
(<t) Morning sickness.
(b) SeniutioaH of fullness of the breasts.
(e) Amenorrhea.
9. Expul^on of the deddua x-era.

3. Hypogastric and inguinal pains.

4. History of previous sterility.

5. Colostrum in the breast.s.

Symptoms 0} Early Pregnancy.^ln ihc majority of cases the early symptoms
of a normal gestation arc present and the patient bclic^■cs herself pregnant.
But in ?ome in»tancei ihef« symptoms may be entirely .ibsent ami the first in-
dication of her condition may l>c a Mxldcn and w-vcrc internal hemorrhage from
a ruptured tube. As in cases of normal pregnancy, the paiicni compbins of
morning idckncss an<l a senution of futlne^a of the bteast.i. Men^iniaiion, as
a rule, ceases when the pre^anc%' occuni; but in some cases it may not be
interrupted, and, again, it may not slop until the lime of the second or third
monthly pcriixl, or there may be a ce».>uiiion of the inen>«.'' lor one or two n>onlhs,
and after that lime the flow may a^me on again. In cases in which the menses
are uninterrupted a careful inveUigation of the patient's history will often
elicit the fact that the flow Ii.tj le^Mned in amount and shortened in dura-
tion.

Expuitian 0} the Dendua Vtra. — Tile decirlua vera is frectuently thrown off
by (he uterus in the form of small pieces or shreds, or as a complete cast of the
k uterine cavity. The ejqiubion of the deddua is accompanietl by metTorrhaKi^i
and in some en;** the hcmnrrhaire is mi *evcrc that the patient Wlie^-cs she has
miscarried. In other instances, however, the hemorrhage may be slight in
amount, irregular in occurrence, often of a dirty brown color, and mixed with
shreds of dcddu.1l membrane.

Hypogastric and Inguinal Paim—T^c patient often complains of colicky
paini in ilie hy]K)Rastrium and in one of the injiiuinul n-^ion*. These pains
ttsually come on toward the end of the second month, recur from tinu to time
SI irregular periods, and arc probably caused by uterine and tubal coniracUons.

Sterilily. — Tlie paiteril often gives a history of previous sterility.

CoSoUrum in /Ac firoiiii.— After the third month colostrum appears in the
breasts.

The Objective Symptoms. — These are claMifienI as follows:
t. Symptoms of early pregnancy.

Changes in the enern.tl organs, the vagina, and the breasts; soft-
ening of the cervix; and enlai^cmcnt of the uterus.
i. Presence of a distended tube.

3. Coniradions of the wall of the gefttalion sac.

4. Microscopic examination of the cnM or shreds thrown gS by the
uterus.

Symfifoms a} Early Pregnancy. — The chnnjtes which occur in the %-ulm and

vagina in a normal prefn^ancy are not noticeable until about the end of the

~ month, and cr)nse<)uently tbe>' are usually absent in cases of tubal get>ta-

'lion before that period. If an ect<^c geslaiion docs not terminate early, there

564 ECTOPIC GESTATION.

are more or less leukorrheal discharge, pigmentation of the vulva, and a violel
or blue discoloration of the vagina. The vaginal aneries are enlarged and the
pulsations may be felt by the examining finger. The breasts usually begin to
enlarge after the first month and the superficial veins become more distinct.
The areola becomes pigmented and swollen and the tubercles of Montgomeiy
arc hypertrophied. The cervix is softened and the os is patulous in cases <rf
tubal pregnancy; softening of the uterine neck is an early sign and begins with
impregnation. The uterus is always enlarged, but its size does not correspond
with the supposed period of gestation, and hence this variation from -the
normal points to a tubal rather than to a uterine pregnancy.

Enlarged Faliopian Tube. — The enlarged tube is recognized by vagino-
abdominal palpation and found to be situated either on one side of or posterior
to the uterus. In very rare instances it may be in front of the uterus, and cases
have been observed in which the tube was adherent to the fundus. The tubal
mass is usually elongated or ovoidat In shape; it has a soft, boggy feel; and is
generally tender or painful upon pressure. The examination must be very gently
made, as rough manipulations are likely to rupture the tube and cause a fatal
hemorrhage.

Contractions of tiie Gestation Sac. — Contraaions of the wall of the gestation
sac have been olaerved in a number of instances.

Microscopic Examinations. — The decidual character of the shreds of tissue
which are mixed with the bloody discharge may be determined by a nnicro5CD|MC
examination.

At the Time of Rupture or Abortion. — The symptoms are divided into:
(i) the subjective and (3) the objective.

The Subjective Symptoms . — The symptoms of tubal rupture
come on suddenly, as a rule, without any premonitory warning. In some cases,
however, the patient may complain for a few days previously of colicky pains
and slight pelvic pressure symptoms. The rupture may occur when the patient
is in bed or when she Ls around attending to her daily duties, and in some cases
it may follow an unusual or severe form of esertion. In extremely rare cases
a rupture or an abortion may occur without producing marked symptoms and
the patient may not be aware of her serious condition.

The patient is suddenly seized with severe pain which is quickly followed by
collapse. The pain is felt over the lower abdomen and in the affected side of the
pelvis. It is acute, agonizing, and excruciating in character, and at times so
severe that the patient becomes unconscious at once. Symptoms of shock and
collapse rapidly follow the occurrence of pain, and the pulse becomes weak
and very rapid, or absent altogether; the temperature is subnormal ; the respira-
tions are sighing and shallow; the .skin is anemic and has a deadly pallor; the
eyes are glassy and the pupils dilated; the extremities are cold; the surface of
the body is bathed with a clammy perspiration; the face has an anxious, pinched
expression; and there is twitching of the facial muscles. Nausea and vomiting
are common symptoms, and it is not unusual for delirium and convulsions to
occur. If the patient is not unconscious, she may complain of impaired vision
and of a singing sound in the ears.

The chanicter and severity of the symptoms depend upon the situation of the
rupture and the size of the hemorrhage. The symptoms of a tubal abortion
resemble those of a tubal rupture, but usually they are less marked and the hem-
orrhage is not so severe. When the tube ruptures into the peritoneal cavity, the
hemorrhage is usually profuse and continuous and the patient generally dies
within a few hours unless she is saved by surgical interference. Occasionally,
however, the bleeding stops spontaneously, reaction sets in, and the patient either

TVIIAL (JKSTAnoN— DIAGNOSIS.

S6S

'ntttmt or dies tatcr on from a fresh hcmorrii^igp. Wlicn the tube ruptures
bt<«mi ili« (iikis of the broad ligament, death seldom results from hcmorrham', sis
lb( IiI"n) U |M>ured out into n oo:ifine<l sfiace, :in<J hence the hk'Cilinic i.* cjuickly
nxintJlci]. The tearing apart of the stniclures of the broad ligament bv the
hleai cauMS intense nufferinf;, and if tlic <listentiun is sufficiently (treat severe
pnottfc symptoms dcvelof>.

The Objective Symptoms. — These arc discussed under Iwo
bcMlinf^, u rolktws:

Inintprn'tarvral rupture and tubal abortion.
Ruplurt- btiwetn ilic folds of the broad liRamcnt.
tMnptr\lon<n{ Ruplurt and TiibaJ /I fcorfiuM.— Himnniul examination reveals
a [ulinc<s in th^- culdesac of Douglas and the presence of an enlarged lube on one
ndr ur tlit ntbcr of the uterus. The distention behind the uterus is ill-defined in
ship* tml imparls the *en!«iti<m o( free fiuid it> the examining linger. Later on,
«Atn Ihc blood cosguUtes and (he hematocele is enclosed by intestinal adhesions,
■ mm ctf lexi distinct tumor of a doughy conwisiency i_-. fell, which bulges some-
•tal intu the vagina and extends upward into the abdomen, where ii may be
Ml bt lUtomiiul touch. Under these condition!^ the uterus is pushed forward
fit Ihe ^Ivic structures are crowded out of jtiKition.

}!iifliirt ti^iii'fen tkf l-dds of the liroait Ligament. -.\ broad ligament
HfTwi.imj foniis a cinuniMTil>ed. tense, elastic tumor, which is situated on one
' ' f [he oilier ■>( th<- uterus, and which bulges downwanl into the %'ugina and
il'^jnj jbu^e Poupart's ligament. It encroaches upon all of the pcK-ic orgatis
uil pmhes the uterus lowanl the opposite side. The mass may also extend
'Am! the cervix and ."urround the rectum, forming a nm^triction about the
' ''I nhich is easily felt by rectal touch. We are <eldom able to palpate the
utoinr ipiiend.ige!- or to rec<>);ni«; tlie enbiged tube on account of the siic aiul
■hr a'ttuiion of the blood-tumor.

Dining the Latter Half of Gestation,— With the exception of certain varia-
•i^tbesubjci live ;»n(l i)lijfMi\c syiiij>ltiiTis of gcstniion are alike in ectopic and
MRul pregnancies. 1 shall, therefore. ?imply poinl out these differences and
Mutempl to dix'U.vi the signs of pregnaiKv in detail.

Amenorrhea is not a constant symptom. Menstruation may or may not be
nt. aiul in some cases irregular hemorrliaRcs accompanied with the dischar^
'ndeiidUHl debris may occur throughout the entire |>erj<iil of pregnancy.

The fetal heart -sou nrls, the fuesence ;ind the movements of the fetus, and
'khtleinent are rwogniKwl earlier and are more distinct becau.se the gestation
wifonin'r the alHlomituI Mirf.ice ih.m in a normal pregnancy.

Tbe ihu[>e of the alulomcn is asymmetric. This want of symmetry, which
*> « diaracteri'tii of an cclopit pregnamy. is less marked after the seventh
•*tli, "lien the atHlomcn becomes well di-lended.

Tile |»hcTU>mcna of spurious or false labor occur at or near full term and the
«tf die*. The |)atn$. which resemble th<ne ul normal bb»r, vary in duration
*td intensity, and are accompanied by a blocxiy discharge conlitining shreds of
■Ittiluil membrane.

11ic uterus continues tn enlarge during the course of gMtalion, and at or near
'•ilterm it measures from four to eight inches in length.

Diag;iiosi8>— The diagnosis of ectoj>ic pregnancy is discussed under the
Wbsiog heailing<^;

Before primary rupture or abortion.
-At ihc lime of nipiure or aiiorti^m.
Ourinf; llie btliT half of gestation.
Before Primary Rupture or Abortion.— The diagixwis is seldom made

566 ECTOPIC GESTAnON.

prior to the time of tubal rupture or abortion. The majority of patients believe
themselves to be pregnant, and as there are no symptoms indicatii^ an abnomul
condition, the necessity of a physical examination is not appareot, ajxl hence
rupture or abortion often occurs before there is the slightest su^idon of an ex-
trauterine gestation being present. This is especially true in those cases in which
the rupture or abortion occurs very soon after impregnation; but when tbe
gestation continues beyond the third month the subjective ^-mptoins of preg-
nancy may show such marked irregularities that the patient is forced to seel
advice, and a bimanual examination may reveal the presence of a soft mass
at the side of or behind the uterus.

Tbe symptoms upon which a diagnosis is based are classified as follows:
1. The subjective symptoms:

(o) Symptoms of early pregnancy, such as morning sickness,

sensation of fullness of the breasts, and amenorrh^
(6) Expulsion of decidual membrane or shreds.
(c) Hypogastric and inguinal pains,
(rf) History of a previous sterility,
a. The objective symptoms:

(a) Symptoms of early pregnancy, such as changes in the cxtmul
organs, the vagina, and the breasts; softening of the cen-ii
and enlargement of the uterus.

(b) Presence of a distended tube.

(d) Microscopic findings in the membrane or shreds throws oS
by the uterus.

At the Time of Rupture or Abortion. — The symptoms upon whid a.
diagnosis is based are classified as follows:
I. The subjective symptoms:

(a) A careful study of the previous history.

(6) Sudden, acute, agonizing, excruciating pains over the lover
abdomen and in the affected side of the pelvis which are fol-
lowed by shock and collapse with symptoms of internal hc^n-
orrhage.
3. The objective symptoms:

(a) The presence of an enlarged tube.
(h) Hypertrojihy of the uterus and softening of the cen'ii.
(f) The presence of free blood in the pelvis or a broad ligamr^**
hematoma.
During the Latter Half of Gestation. — The diagnosis is based upon ^
careful study of the subjective and objective symptoms as described on page 5& 5*'
Treatment.— T he treatment of ectopic gestation « *
operative under all circumstances and conditior» ^
and our sole object in view must always be the safeC ?
of the mother, as the child has no claims w hate vert ^
be considered even in those very rare cases in whic ■*
ge, station continues until viability is reached. Tt**
dangers, under these conditions, through which the patient must necessarily p» ^^
overwhelm absolutely any argument that may be advanced in favor of the lift *^*
thcfclus, which, as stated ahove, is worth but little on account of its low ritali*^_
and defective development, as well as the practical certainty of its death ea*"'?
in infancy.

The rule which guides my practice in cases of ectopic gestation is to opers» **
by the abdominal route at once whenever the condition is recognized or s*-**"

JVtM, GESTATION — TREATMKNT.

5*7

pcctcd, irrespective of the period of pregnane)' or (he presence or absence of
the placental bruit.

For lechnic rciuwinj the Ireiitmeni should be coiLsidered uixlcr the following
conditions r

Before primary rupture or aIx>rtion.
At the time of rupture or abonion.
Subsequent to r\jpturc or abortion.
Durinji the latter half of gestation.

Before Primary Rupture or Aborttoo. — The indication is io remove tite
inijjreKnaled tube at once. Lnfortunaicly. however, cases of tutial gatation
arc .>el<lum recogniu^t prior to rupture, aixl in the mnjority of p.-itienl» npemird
upon before that time the true condition was not suspected, as the operations
were [terforincil for supposed tubo-ovarian disease. As Penrose Siiv.*: "The
ca.-^?* show the value of the general rule to operate without fielay for all gross
diseases of the tubes."

Operation . — ^The technic is verv simple and the impregnated lube
may be nisily removed, as in thecuse «'a hyrlmsalpinx, Mithoul rupture, and
hence the c&se is not complicated by the escape of the contents of the gestation
sat,- into the iwriloneal cavity.

If the ovary is heidthy, the lube alone should be removed (salpiHgedamy,
p. 57"); hut if it is di.'«ascd or badly adherent, both orijans shouW lie e.xiir-
paleil [tcitpinp) oiiplwredamy, p. 97;).

At the Time of Rupture or Abortion. — The indication is to operate in
txery ta.se vrithuui unneces.-tary delay, whether the tulie has ruplurc<l inin the
peritoneal cavity or lietween the folds of ihe bro<id ligament. We must not
wait for reaction from collapse or shock to set in before operating, as the patient
may perish in the meantime from lo^^ of blotid. 1 am ivell aware nf the ad-
vantages to be gained by not operating during collapse if it can be avoided,
but we mu.tl rememlier that the case is one of internal hemorrhage, and hence
ihe dangers of delay olTsd all other considerations; U-sidcs. it is \inwisc to stim-
ulate the patient by saline injections and other means until everything is ready
to ojwn the alxlomen, for the rca.%fin that under thtvie circumstances the hemor-
rhage is likely to start again with rvncwrd vigor and force.

Operation .— ,\s nipturc gcncrallj' occurs between the fourth and the
twelfth week, the entin^ tu)>e, whidi of course contains the scat of implantation
of the fcniliecd oium, is easily removed by salpingectomy: the ovary should
not be estirpateil unless it is diseased or extensively adherent. Tlie details of
the Iwhnic of sil[nngccH>my and salpingo oiiphoretiiimy arc fully discuwed in
another chapter (see p. 577 and p. 973) and need not therefore be described here.
When, howeiCT, either of these operations is jwrformed for tubal rupture,
there are certain i-ariation.s in the lerhntc which mu.it l»e clearly understood ami
appreciated by the surgeon.

These variition.- are summarized as follows:

t. In slerihr.ing the aWomen rough manipulations must be avoided, a»
llwy are likely to disturb the .'cat of rupture and start a fresh hemorrhage.

3. Iteforc ani-sihc-lir.ing the (natient all the pre{Kiratii>ns for the operation
must be completed in order that the duration of the nncslhusia may not be
unneces.sarily increased t>y sub5e<juen[ delays.

y Stimulation by mcan.s of an intravenous injection of normal Mit xolution
is b^^n sosooo as tiie surgeon starts to open the abdomen and continued through-
out the operation. If the loss of blood has t>een great, it may be necessary to
administer the saline after the operation is finished ami inject »e\-«ra) quarts
of the solution before the cannula is finally withdrawn from the vcio.

568 ECTOPIC GESTATION.

This method of employing normal salt solution in cases of mptuicd tutnl
pregnancy has undoubtedly saved many lives that would otherwise have been lost,
and should therefore be used as a routine practice.

4. The patient should be placed in the Trendelenburg posture during the
operation to keep the blood in the head and upper part of the body,

5. As soon as the abdomen is opened the operator must at once search fn
the impregnated tube and bring it into the abdominal wound. If the vesxk
are bleeding at the time he immediately applies hemostatic forceps to dx
uterine and pelvic ends of the broad ligament which control the hemonbage
from the proximal and distal portions of the ovarian artery. Ligatures are no*
subaiiiuted for the clamps and the tube is then removed,

6. After extiqating the tube the blood-clots and debris, which include the
embryo when it can be found, are removed by the hand, and if necessary tbt
abdominal and pelvic cavities are flushed with normal salt solution. If there
is much shock or collapse, it is often advisable to leave some of the salt soludoa
in the abdomen, as it rapidly becomes absorbed and acts as a general stimuluL

The question of drainage depends upon the nature of the case.

7. When the rupture has taken place between the folds of the broad liga-
ment, the operative technic is the same as above, with the exception, howei-cr,
that the opening into the ligament must be closed subsequently with buried
catgut sutures.

Subsequent to Rupture or Abortion. — There is a class of cases in vind
the patient is not seen until she has recovered completely from the effects of
the primary rupture, and under these conditions the question of operative in-
terference at once arises. The danger of secondary' hemorrhage or infectioa
occurring in these cases far overbalances the possible advantage to be gained
by waitinR for the spontaneous removal of the blood and debris by absorptioo,
and consequently immediate laparotomy is always indicated.

During the Latter Half of Gestation.— The indication in these caiws is
to remove the fetus by lapiirolomy. The operative technic depends upon the
period of (;cstittion Miii also whclher the fetus is living or dead.

Prior to thj; End of tht Fourth \Io\ib the entire sac may
usual) \' be extir|>atcd without causing uncontrol-
lable hemorrhaRe, and consequently the placental
circulation, in cases in which the fetus is living.
does not materially complicate the operation. Tlit
complete removal of the gestation sac which includes the embryo and
the placenta is comparatively simple in cases of unruptured tubal preg-
nancy, and the bleeding is easily controlled by iigating the pelvic and uterine
ends of the ovarian artery before removini; the impregnated tube and its ron —
tents. When, however, the sac is situated between the folds of the broad liga —
ment, the ojieration is necessarily more difficult, but in the hands o^
an e\j>erl operator the hemorrhage is readily controlled and the entire ma--S-
removed. This is accomplished by ligaling the ovarian and uterine arteries^'
before removing the affected tube and enucleating the gestation sac aW^
its contents. After the e-\traulerine mass has been extiqiated the cavity in th^sr
broad ligament is closed with buried catgut sutures. If the case is one of prl -^
mary tubal rupture or abortion with continuation of fetal life, the hemorrhap^^
may usually be controlled by ligatinK both ends of the ovarian artery as weL ^
as any large vessels that may be seen pas,sing to the sac. It is also advisable^
as a guard against hemorrhage, to pass deep ligatures through the tissues a *
the seat of attachment and then to cut the sac away at this point with a knif^*
or scissors.

Bt-STERECTOUV FOR DISKASFJ) APfKNUACES.

569

After the Fouktu Month of gestation ihe opcralive tedinic depend*
upon whether ihe felus h livini; or dead. While the (eius is alive
iti>almo>t impossible lo remove the placenta with-
out causing an uncontrollable hemorrhage. This is
due in many cases 10 ibe widespread attaclimenl of the placenta over
the [>elvic organs, the intestines, iind ihc large blood -vcs^rls, and henoe
it is impoB^ible to stop ihc cxtcisive bleeding wbiih occurs by ligaiing the
ovarian and uterine anefie>. When, however, the fcius dies,
the placental circulation gradually becomes ob-
literated by the formation of thrombi, and at the
end of one or two weelc> the vessels arc completely
obliterated and the bruit can no longer be heard.
In three or four weeki from this time the thrombi l»e<-ome tluimuRlily orgnnixed,
and n>nsequently there is but little, if any, danger of hemorrhage when ibe
placenta is separated from its atlachmenis at the lime of operation.
The ireaimeni of these case* may be .-iumnuiriud as follows:
Fetus Living .—Laparotomy should be performed as soon as the con-
dition is rcdJRnized. The many dangers incident to the coniinuatjon of an ab-
normal ge>lati<>n in.ikc it inadvis.'dile 10 wail until the fetus dies -it term and the
placental circulation becomes obliieraied.

The operation is performed as follows: After opening the abdomen the sac is
incised anil the feui* rcmo^-ed. The cord is then ligatrd as close as possible to the
placenta and cut away. The sac is now stitched to the lower edges of the ab-
dominal wound, cleaned with gause 9k[>ungex, and parked with a wide strip of
plain sterile gauxr. I'he gauze packing is removed in fony-cight hours and a
glass drainage lube substituted which is kept in position until the sac l^ecomes
obliterated. At the end of one or two wcek$ the placental circulation ceases and
the placenta gradually l>egins to come away piecemeal, until finally it is all re-
moved and the sac closes.

It the plaieiita is accidentally separated or injured during the operation an
attempt must Ix- made In snvi- the j<:itient's life by instantly compressing tlte aorta
and ligaiing the ovarian and uterine arienes n* well as any vesMls thai may be
disc"»Trcil iMiwing to ihe seat of impUniation.

The post -operative dangers to be feared are Kcondarj- hemorrhage and sqitic
infeciiim.

Fetus Den d .— T^pnrntomy should be performed at once and the
placenta removed at the time of operation-
Treatment of an Interstitial Pre^ancy.— In ca»« of intraperito-
neal rupture the iiienij should lie .lyned if |tos^ible by removing the lulic and
suturing the openini; in the uterine comu; if this cannot be done, supravaginal
liy»lcreciomy Is indicated.

CHAPTER XXVI.

HYSTERECTOHY FOR DISEASED APPENDAGES.

The question often pnsenis itself at the time of an operation in which double
wljiingO'Oflphorcctonty has been performed as to whether or not the uteru.^ should
afco be reinove«l- The unvatisf.irlory results met at tinjcs after the removal of
Ihe uterine appendages foe well-marked Insions havr led to an inquiry as to the

;70 EFFECTS or SEUOVAL Of UTEUKE APPENDAGES.

'eason why these patients should continue to suffer with pelvic pains, leukoiriiea,
ind bloody discharges as well as many reflex and general disturbances. There
an be no doubt whatever that in some of these cases the bad results are due
o an incomplete removal of the tubes and that the remaining poitions act as foci
)f irritation and infection which prevent the usual atrophic changes from taking
ilace in the uterus. But this cause does not by any means explain the bad
>ymptomatic results which sometimes follow double salpingo-oophorectomy ia the
lands of skilful operators, and we have been forced therefore to look for another
explanation, which has been found to be a coexisting diseased condition of the
Items. In other words, these patients have not been benefited by the removal
if the uterine appendages because the entire focus of disease was not eradicated.

Indications.— The indications for hysterectomy should be clearly under-
stood, not only because of the necessity for the removal of the uterus in these cases,
but also because the operation should not be heedlessly performed and the patient
sxposed to additional risks.

The chief indications are as follows:

I. When the uterus is decidedly enlarged or subinvoluted.

3. When chronic purulent endometritis and metritis exist.

3. When the tube is friable and the ligature cuts through the pedicle.

4. When the uterus becomes torn or badly mutilated during the separation
if adhesions.

5. W^en the uterus and the appendages are matted together and form an
infected mass.

Technic. — The uterus should be removed by incomplete or supravaginal
lysterectomy (see p. 984). Complete hysterectomy is never indicated in these
:ases, unless some special reason exists; first, because the entire removal of the
litems adds decidedly to the dangers of the operation, and, second, because if
ihe cervix is left in place it acts as a support to the vaginal vault and prevents
shortening of the vagina.

CHAPTER XXVII.
EFFECTS OF THE REMOVAL OF THE UTERINE APPENDAGES.

The results following double salpingooSphorectomy may be conveniently
classified into;

The symptomatic results.

The symptoms of the artificial menopause.

The effect upon the sexual appetite.

The effect upon the mind.

The general effects.
The Symptomatic ResnltS.— In the majority of cases a slight hem-
orrhage takes place from the iileras within twenty-four lo forty-eight hours
after the operation which usually lasts for several days, but which has no
pathologic significance. It is probably due to the acute uterine congestion
which is caused by the sudden change in the pel\ic circulation when the tubes
and ovaries are ligated and removed.

Atrophy of the ulems takes place, as a mle, after the removal of the appen-
dages, and menstmation permanently disappears when the bleeding which
jsually occurs immediately after the operation has stopped. In some cases
Ihe flow may recur for one or more periods; in others nothing may be seen for

SYMPTOUS or THE ARTinaAL UENOPAUSE.

S7>

several moRtln after the operation, and cben it may return and appear several
times before it enlirelv cea^so; anH. tiniilly, it may continue indctinitely. Cnscs
of continued periodic hcmonhage from the uterus arc ai times difficult to tx-
phin, becau.'ie vce kciDw lh.it if the tubesand ovaries have l>een completely removeit
strophy of the uicru!^. as a rule, promi^tly talu» place and the function of the organ
is destroyed. We must therefore conclude, when rcf^lar or irregular hemorrhages
occur, thai there had tieen wime fault in the operative lechnic, and that a por-
tion of the lube was left or all of the orary had not been removed, which
t> likely to occur when exieni^ive and firm adhesions attach it to the broad liga>
ment or the {wivic nail. .Again, the hemorrhages may be caused by an irri-
lalion in and around the stump iihich causes congestion of the parts, or they
may result from iiillamnKition or a ne<>plasm of tlie utenin.

As a rule, if the patient suffers with endometritis prior to the removal of
the appendages the subsequent atrophy whidi lakes pkce in the utcrat cures
the in^ammalion of the endcimctriiim and the Icukorrheal di<cli:irgc gradually
disappears. Sometimes, however, thLs is not ihe case, and the discharge, like
the hemorrlianes, may fominue indefinitely when the utenm is enlarf^ed or »uh.
inrolutcd or the scat cif a dec[v»eatcil and Intraciublc chronic purulent endo-
metritis.

Pain is the most prominent symptom of tulw-ovarian disease, and it h very
important, therefore, that the patient should Iw given sitmc idea of the results
which may be cxpecte<l to follow removal of the appendages. In some case*
the relief from jiaiii iit marke<] and immerliate; in others it m.iy not disappev
entirely until the general beolth of the paiicni is Improved and the pelvic organs
have bad time in which lo readjust themselves to the new conditions caused by
the formation of fresh adha^ions at the site of operation; and. fmally, more or
less pelvic diseomfon and di.siress may remain indefinitely. The continuance
of pelvic pain after double «ilpingo-<iiiphorccl"my re«ull:« most frequently from
fresh adhesions occurring between the pedicles or denuded surfaces in the pelvis
and the omentum, the intestine, the bladder, or the rectum. Someiimck it is
caused by the pressure of a ligature upon the nerve- li laments in tlie stump of the
pellicle, and it may also be due to patholof^c conditions of the uterus.

The general liealtb of the )iatient gradually imjiro^-es, a» a nde, after the
removal of the diseased apjx-ndages. 'fhc reason for this is readily understood
when we recall that the ofieraiion relieves the intense suffering, the uterine dis-
charges, and the gastni-inle-slin:il disorders whirli have been for years exhaust-
ing the strength and impairing the nutrition of the patient. We must not, how-
ex^r, look for a complete return to the normal condition in all cases, liecause
the damage done by the disease in the pelvis b often v> extensive and tlic gcnetsi
cnndition of ihe patient so weakened and impaired that she can never hope to
enjoy perfect lie:ilth again. But we may in nearly all cases hope to relieve the
state of bed-ridden invalidism and restore her to comparatiw health and use-
fulness.

The Symptoms of the Artificial Henopatise.— Double s:i1pingo-

oOpborectomy iireaies an ariificial menopause » ii)i [ktvmus and gastro- intestinal
.tympioms .similar lo thi»e following the natural climacteric except that they are
often more marked and apt to last lunger. W'c cimnot, (hcrefore. ex|wct to <i(>-
lain the full beneficial results of the operation until these phenomena haw sub-
wideil. which in many aise* may not lie (or one or t«-o years or ewn longer.
The nerx-ous symptoms which do not. as a rule, appear for se^'eral weeks atterihc
operation generally manifest themselves in the form of vasomotor disturbances,
and the patient a>mpUin« of flushes of heat followeil by perspiration and a
feeling of chilliness, to some cases the patient may complain of headaches,

57a CONSERVATIVE OPERATIONS ON UTESINE APPENDAGES.

disturbances of vision and hearing, vertigo, sleeplessness, somnolence, bleeding
from the nose, faintness, depression of spirits, and a feeling of numbness, csjic-
dally in the lower extremities. The gastro-intestinal disturbances, as a rule,
are not marked, although many of these patients are constipated and suffer
more or less from dyspepsia and flatulence.

The Effect upon the Sexttal Appetite.— Generally speaking, the
effect upon the sexual appetite differs but little, if any, from that of the natunl
menopause. In the majority of cases the sexual desire is increased because
the woman is restored to health by the operation and she no longer suffers
from pelvic tenderness and painful coitus. In rare cases, however, it may be
diminished and at times even destroyed by the removal of the uterine ap-
pendages.

The Effect Upon the Mind.— It seems unlikely that the removal of the
uterine appendages is ever directly the cause of insanity, and so far as myowD
experience goes I have never met such a case. Women have undoubtedly be-
come insane after double salpingo-oophorectomy and at the lime of the natural
menopause, but I believe a careful analysis of these cases would show thai
an inherited predisposition to insanity existed and that the usual nervous
disturbances accompanying the change of life, whether artificial or natural, were
the exciting causes of the menial breakdown.

Neurasthenic women belong to a class in which the nervous phenomena of
the artificial menopause are most marked, and they consequently exhibit mcnul
symptoms which may last for an indefinite length of time. The loss of the uterine
appendages may eventually cause despondency or even melancholia in young
women who become anxious later on to have children, but who have lost forevff
the power to conceive. In these cases the mental condition is often distress-
ing, and, as nothing can be done to remove the cause, we must wait until the
lapse of lime has lessened the desire for children and given the patient the;
courage to bear her burden.

The General Effects.— The popular impression that double salpingo—
oophorectom)' causes a woman to lose her feminine attractions is an error. Tben^
is never any tendency whatever toward the development of the masculine tvpc- _
and there is no growth of hair upon the face, no change in the voice, or alteratii>x7»
in the figure. In some cases the j)atient may become fat and matronly lookinfa; ;
in others, again, she may not show any tendency toward obesity; and, finally,
the relief experienced from suffering causes the majority of women to becoir*^
more attractive in their personal ap|>cyrance.

If the (iperation is performed prior to puberty, the sexual development of il^^
giri is arrested.

CHAPTER XXVIII.
CONSERVATIVE OPERATIONS ON THE UTERINE APPENDAGE^

Definition. — A conservative operation on the uterine appendages is oc^'
in which the operator endeavors lo preserve iheir functions by not removing
healthy tube or ovary and by saving any portion of either organ that is sound,

Wliik such operations are still in the experimental stage, yet enough has ce:^*
tainly liecn accomplished to warrant the belief that, as our experience grows a»- '
we become better able to select the cases in which conservatism is indicateC^^

AUVAKTAGES AND DUiAD\'ANTAOES OP COSSEEVATtSil.

S73

many of the nt<jtriil proceclurp* that arc now advised will ^adually Iwawnc more
and mf>rc rc-^lrictci! in ihcir apiilicalNin,

Advantages of Conservatism. — The a4iv.intiiKeA derived from cun-
K-rraiive ii|>eratiiJns mi ilit iu!>c» and ovaries cxinsi'l in the conservation of the
funaions of these orgins and the prcwntion of the mcnia) and ph,vsical dia-
turbitnces ivhicl) so often follow the :inifK*ial imJucliun af the mt-n(i;»ii>e.

Ovulation, in all pnibabiUiy. is not the sole function of the ovan,'. and there
are reasons for believing that iiaUohasan internal secretion which plays an ira-
portitnl rtle in tlie i>h>-siial coimimy. Howard A. Kelly «iy*: "Therris.T growing
conviction that the ovary belong to ihc same group of organs as the ihmiid,
thymus, and pineal glands, ;ind that, in addition to it.'^ luiittion of ovulaiitm, ii
secTdcs a Milu-tJinte which is alwirlied and <\mMimci| in the animal economy, and
which is necessary to it in relaining its physiologic balance." If lhi» view is
CDfrect. (he loss of this substunre ni;iy be the irause of many of the phcnumoia
which occur at the time of the natural menopause or after the removal of (he
uterine appendages, and is consequenil)' an argumeni in (avor of conser%'a[i*m.

We have practically nu kiiowletlKe of the excretor\' and metabolic inHuencrj^ of
mensitruation upon the physicjil economy, but we know from clinical experience,
however, thai the natural as well as ihc artificial menopause is accompanied by
nervous and gaMro intestinal di>tur)Mnc(». Perha^K the moM serious results
which occur at limes after double salpingo-obphorectomyarc due toihe effect of the
cessation of menstruation u[>on the mind of the patient, csjiecially if she is young
and aniiou.'c to ha»t children. The knowledge under ihe>e circumManccs that
she is sterile and forever incapable of omceplion may give rise to grave psychic
fUsturliances and even luni'irmed mc^bncholb. ai>d for this reason alone it may be
advisable lo leave a small portion of ovarian livue tu maintain m-ulation and
menstruation even when the chances of a future pregnancy are most problematic.

Disadvantages of Conservatism.— While conscrvnlism. as wc haw
just seen, has certain ucll-dctined reasons in its tavoT we must noi lose sight of ihe
(act that there are ^-alid arguments aftain.-<t resecting diseased lubes and uvarie».
I'he principal objections that have been urged against conscrvntism are:

I. The unlikclihtxid of restoring function.

3. The return of the di.<c»sc in the ^c■^«^cted organ.

3. The occurrence of the disease in the opposite side after a unilateral opera-
tion.

4. The failure to effect a symptomatic cure.

5. The risks of an ectopic gestation.

6. The (Linger of infection following rewclion.

7. The unneccssan," lisk to life from a secondary operation.

The Dniikclihood of Restoring Ftutction.— Ov-ulation. as a rule, is not
|jiicrru|>ted by disease of tlie ovaries, and we find from ex(>erience that llie function
continues if a small piece of the ovary is preser^■^d at the lime of ofwration. The
function of the Fallopian tube, on the other hand, is usualh' pcnnanenily damaged
by infl;imm.-)l(>ry conditions which are liable to obliterate tin lumen and destroy
its usefulness as a channel through which the o*-um reaches the uterus. There
is no duuht. however, that a ba<IIy damaged lul>e may occasionally undergo
a spontaneous restoration to norma) conditions and jtrcgnancy lake place .ifter
a long period of acquired sterility. If this is true, there is no reason, in well
scleclnl ca.tes. why the same re.tulu should not follow a conservative operation,
and in point of fact recent clinical ejtpcrience justifies this opinion.

Tbe Return of the Disease in the Resected Organ.~Thc probatnliiy of
the reium of the diseiu^e mu.M, of piurse, )>c .admitted by all o|>erators who are
exponents of cun»cr%'alism, but when we consider the possible advantages to be

574 CONSERVATIVE OPERATIONS ON UTERINE APPENDAGES.

gained by conservative operations in pmperly selected cases this objection does
not hold good, especially when the patient is willing to take these chances rather
than submit to complete mutilation. Again, we must bear in mind that there are
certain pathologic conditions of the tubes and ovaries that will be referred to in
discussing the indications for conservatism, in which there is but little liability of
the disease attacking the healthy structures left behind.

The Occurrence of the Disease on the Opposite Side after a UnUateral
Operation.— There is no doubt whatever that the opposite tube is liable to
become affected after a unilateral operation for inflammatory disease. Tias
is due to the fact that the uterine endometrium is the source of infection, and
that unless the disease is eradicated in the uterus it will sooner or later spread
to the sound tube. We are usually able to prevent this by cureting and apply-
ing pure carbolic acid to the endometrium immediately after the diseased tube
has been removed. The risks of the disease occurring on the sound opposite
side vary according to the nature of the infection, and as this subject will be
considered fully in discussing the indications for conservatism, it will sufBce
to state here that cases of purulent salpingitis and pyosalpinx are more likely
to cause trouble after a unilateral operation than simple catarrhal forms c^
inflammation and hydrosalpinx.

The Failure to Efiect a Symptomatic Cure. — \\'hile it is true that a symp-
tomatic cure may not always be effected by a conservative operation, yet it is
equally a fact that the complete removal, of the tubes and ovaries is often dis-
appointing from the same standpoint. It is obviously unjust, therefore, to
attribute to conser\'atism the post-operative pain which sometimes persists,
unless it can be shown that the disease has recurred in the structures left be-
hind, because the same symptom not infrequenily continues after radical pro-
cedures in which both appendages were completely removed. This is readily
explained when we remember that post -operative pains are often due to fresh
adhesions occurring between surfaces within (he ]>elvis that were denuded and
torn during the enucleation of adherent organs, and that these inlrapelvic con-
ditions have nothing whatever to do with the con-^^en-ative or radical nature of
ihe operation. If conser\-atism is taken lo mean the partial or incomplete re-
moval of grossly diseased siruclures, then, as a matter of course, we cannot
expect any relief from the pain or ihe other subjecti\'e svmptoms which are so
con.stanlly as-wciated with tubo-ovarian <ii.sea.se. But if a consen-ative opera-
lion removes all the diseased portion of an organ, (here is no reason why the
remaining part which is healthy .should lie responsible for the failure to effect
a symptomatic cure unle.ss, as stated almve, the disease recurs.

The Risks of an Ectopic Gestation. — The fact that salpingitis, which is
usually bilateral, is the great cause of ectopic gestation, on account of the sup-
piised desquamation of the ciliated epithelium which often takes place as the
resuh of the inflammation, would lend us to believe that conservatism would fre-
quently be responsible for an extrauterine pregnancy in cases of unilateral opera-
tions or in resections of the tubes. Our clinical experience, however, does not
bear out this view, and accordinjj to Kellv, " Nn case has ever vet been reported
where a consenative operation has been fallowed by an ectopic pregnancy."

The Danger of Infection Following Resection,— This objection to' con-
servative operations on the tubes and the ovaries is an unanswerable one in
case.s where jius is present, as the danger of infc-ctidn under these conditions
is extremely great and cannot usually be j!uar(lt'<l ii<;ain>t. U u 1 in cases
that are non- purulent in character there is no such
risk and a resection should not increase the opera-
tive mortality in the sligiitest.

RESCLTB OP COKSEXVAT1SU UPON STEB!UT\-.

575

Tht Uimecessary Risk to Life from a Secondary Opera tioo.~Tli«
possible benefits which may Iw deri^'ed from (ronwrvaii-MH oulKoixh in many
instances Ihc chances of the nccc.<-«ily for and the dangers of a secondary opera-
tion. W'heihcr or not this statement is a correct view of the case the fact re-
mains thai the paticnl whould always be Riven an opptirtunily lo decide for her-
self the amount of risk she is willing to tiike in order to prevent the loss of oritans
thatpUy such an important rflle in the physical economy.

The Restilts of Conservatism apon Sterility.— In a general work

on (t>'nccokjRy ii is obviously impossible to dciote suf&cicnt space to an analytic
consideniiitn of this subject, and I shall therefore diM^us» it ven- briefly. Re-
markable instances of pregnancy following conservative work on the uterine
appenila^es have been obser^-cd by diSerent operators, and hence no doubt ca.n
exist as to the cnralive influence of ci:in:>ervaltun upon sterility in properly se-
lected cases. These observati'ins have shown that conception has followed con-
servative operations upon almost cvcr>' known pathologic condition iif the appen-
dages. Thus, adherent tubes, ovaries, and uteri have been liberated and restored
to their normal functions. The tube has been made patulous by breaking up a<i.
hcsions about the .abdominal o|tening ancj by ampulalin)t its diotjd portion in
cases of chronic salpingitis with occlusion and in cystic distentions caused by
the acTumulation of pus, blood, or scrum. Pregnancj' has also ociurretl after
puncturing cj-stsof the Gnuilian ve.iicles iind corjius lutcum; after resecting the
ovATV and leaving a small piece of ovarian tissue : and after excision of a hematoma.

The twncrta! of the uterine appcndage-s on one side does nut make a woman
sterile provided the functitm," of the lube nnd o\-ar>- on ihc opposite side are pre-
.•served. Clinical experience has demonstrated that ovulation continues if a
small piece <>f ovarian tii^ue i.^i left, and under thcNe tin-umstanccs pregnancy
is possible if the tube is patulous even when it has been resected and nolhinp;
but a short Mump remain.*, Kelly has reported the occurrence of pregnancy
"after leaving one tube and the opposite ox-ar)','' which proves the possibility
of conception taking place with the only Temainini; tube aiut ovar)- situated on
opposite sides of the uterus.

Atrophy of the ovary docs not necessarily interfere with os-ulation, and such
an organ ^hould not be sarrifice<l if the opposite ^de i.i removed, as pregnancy
has been known to follow a conjeniitive operation which left only a single
atroohic ovary.

General Contraindications.— Comervative operations upon the
uterine appendages should not be undertaken without having a clear concep-
tion of the contraindications to this form of surgery, oiherwi.-ie s«riou-i or un-
satisfactory results are certain to follow, and consrri-atism will therefore be held
responsible for failures which should justly be placed upon the inexperience or
Ignorance of the oi>erator.

The fnllon-ing are the chief contra indications lo conservative operations:
The presence of pus.
Tlie age 'if the fiatient.
Maliiniani disesM;.

The Presence of Pits.— P us is a positive rontralndicaiitm
to coti^erv.ntism, and no altcm])l should be made to
save a portion or the whole of an organ that is the
teal of a purulent inflammation. I am well aware in making
this statement thai it it ojiposed lo ihc riews of many of the active exponents of
con^e^^'ati^'e surger)- on the uterine appendages, yet when we take into {ron.udera-
lion the rtiki. of infection as well as the great pn>liability of tailing lo nmorc
function, the few nicccMful cases that have b(«n reported do not in my judgment

S76 CONSERVATIVE OPERATIONS ON UTERINE APPENDAGES.

o&er an argument of the slightest value in favor of conservatism uuder these

conditions.

The Age of the Patient. — The age of the patient must always be considered
in deciding the question of conservatism, as the necessity for preserving the
functions of the uterine appendages in a young woman is far more important
fn^m every point of view than in a woman who is approaching or who has passed
the menopause. In the latter case the desire as well as the ability to concnve
is usually lost, and hence the function of ovulation need not be considered
Under these conditions, therefore, there is no necessity to preser\'e the uleiine
appendages, and consequently conser\'atism is contra indicated. The possibilitT
of serious nervous disturbances as well as the eSect upon the system from the
loss of the internal ovarian secretion, after an artificial menopause in a wonun
who is nearing the natural climacteric, is not of sufficient importance, in view of
our present knowledge, to offer a practical reason in favor of conservatism in these
cases.

Malignant Disease. — As a matter of course, conservatism is contraindicated
in malifjnant disease, and the ovary or the tube should never be resected under
these conditions.

The opposite ovarj- should always be removed, as the disease is bilateral in
the majority of cases; and even if it is apparently healthy at the time of (he
operation, it is liable sooner or later to become involved. The only exceplioii I
make to this rule is in the case of a young woman, provided she is willing to as-
sume all the risks of recurrence and to place herself under observation for an
indefinite period of time.

Malignant disease of the tubes is nearly always secondary, and it therefore
demands a mutilating operation which involves also the removal of the uterus.

Indications for Conservative Operations on the Palloplaii

Tnbes. — If the uterus or both ovaries are removed, there is no reason for pre-
serving the tubes, as their ui'e is merely that of a channel through which the ovun
passes to the uterus, and under these conditions allowing them to remain wonkl
be to run the unnecessary risks of a subsequent tubal infection.

If onl)' one tube is diseased, its fellow on the opposite side should not beI^
moved, notwithstanding its liability of becoming infected later on. The danger
of the occurrence of the disease in the sound tube after a unilateral operatiMi
should be thoroughly explained to the patient and she should be advised to take
the chances of a secondari' operation becoming necessary rather than suteul
to a mutilation that would result in permanent sterility.

The following tubal lesions are amenable to conservative methods:

Adhesions.

Occluded tubes.

Benign tumors.
Adhesions. ^The tube may be adherent to the uterus, the broad ligament-
the ovan.-, the floor of the pelvis, or to the intestine, and its function destroyed by
the twisting and kinking which the adhesions cause. In these cases the interiof
of the tube is not inv()Ivi'<i and the separation of the adhesions is followed bvllf
re.storation of function. Adhesions of this character generally represent an o"
inflammation ll\c activitv of which has long since passed, leaving the tube bound
down and distorted without causing any organic changes in its walls.

Occluded Tubes. — Conservative ojieralions may be performed upon a closw
tube provided its uterine end is not diseased and pus is absent. The distal end of
the tube may be amputated in the following lesions:

Hydrosalpinx and hematosalpinx.

Chronic catarrhal salpingitis.

INMCATIONA to* CONSHtVATlVe OPEXAnttNK OK THC OVAUES.

577

ir llie tKcluMon i.t cuuiietl by adh&doiu al>out the fimbriatty] cxtmnity, they
nn utunlly be brokm up and Ihc function of the lube rcilored n-ithoui resortinic
\o res«:tion.

Benign Tumors. ^The entire tube should noi l»e ?mrrificcd whcD it Sb oc'
CU[>iol by a neoplasm unlciis ihc grnwih involves the whole or^an. If the tumor
is siiuated in the distal portion, an amputation should l»e performeil and ihc
uterine eiwl of the tube led tn c.irT)' on the function of thf orgiin.

Indications for Conservative Operations on the Ovaries.
— The imporLance of the ovaries to the animal economy hus already been dis-
cuMeii. and from wh.it ha»b««n *.iid it i»evicient that the)- should only be rcniov«l
for p^.iss disease an<l not fimply because the uterus or the tubes are cx(irpate<l.
Fi.>r the same reasoas if tK>s.tible an effiirl shoukl alwavs be made to save both
thr iu)>c ^ind ovar>' in the c.ise of a parovarian cyst whicii can often be enucleated
wit^iout sacrilicin;^ these organs.

The followinii; <)\-ari:in te«ioiu are amenable !■) conservative methods:
Adhesions.

Cy&ts of the Graafian vesicles and corpus luleum.
Hematoma.

Glandular and dermoid cyMs.
Benign tumors.
ProU|>se-
.\ trophy.
Adhesions.— The ovarie*. like ihe tube*, may be adherent to any of the i>elvic
structures. The adhesions van' grtatly in chataclcr, and in some cases they may
be so dense and extensive tliat the ova are unable lo escape: in oiher> they may
.«■ alter the norm.it rebtioivv eiiisling between the lube and the ovary that con-
ception is practically impossible for mechanic reasons. The se^iaralion ol these
adhr:sti)n<> is ui^inlly followeii b>' the normal e.scajw of the ova and the or;gan ts
pbced in proper relations with the fimbriated extremity of the tube,

Cysts <rf the Graafian Vesicles and Corpus Luteum.—Oraalian cysts are
neklom Miffirienily Litki' '>r numer[iu> iu> luieum. wliirh,
as a rule, do nnt grtnv larger ihan a cherry or a walnut, and are not iniim;ilely
omivcte^ with the tis-uc of rhe oi'ari".

Hematoma.— If the hematoma t> >nial], the ovary should not lie sncrifioed;
but if the hemorrhage has been excessive and the whole organ is ini'olvedr il
shoul>l be removed.

Glandular and Dermoid Cysts.— The whole ovary should be removed if
^tbe dbcase i^ unilateral, but when both ovaries are the M-at of a cyst wc should
endeavor lo preserve some of the ovarian lissue if ii can be found.

Benign Tumors.— A rmall lumor should be excised and a ptmion of the

saved.
Prolapse. ^Ute di-pla<ement of an ovari- is not in itself an indication for
oophorectomy, and the orjcan vhould never l)e Kirriliced un<ter these condition*
unless it is the seat of a gross lesion.

Atrophy.— If the di^«ea.ie is bilateral, the least damaged of Ihe two ovaries
sliould be saved. Alri>phie<l ovaries are u.Multy found cm)>edde<l in ilenie
adhesions and the subjecti^'e symptoms arc gcDemlly relieved when the organs
are releasni.

Technlc of Conservative Operations on the Fallopian Tttbes.
—Unilateral Disease.— If the ovary is healthy, the tube alone should be re-
moved.
3?

Flo, f«6. Fla. )D-

ConuvnTivi DpiEiJinoiM on thi Puiorah Tcmx-
Iboataf lb* noBvil nl uUmtotu hrivna th( lubr uiil ihr uktui Novibi iLi»»nnf—*r rf a* Ut >**
ovMiKi ifiM iht ndhafiHu lux bttn c^i {Vn, soii-

mcnt are then brought together and the opcnini; dosed with a cono'iiwW™'
hand suture of cjlgul or fine silk.

After the abdominal opcrotion is finished the patient i« placed in iheil*™
position and the uterine cavity oireted and swabbed with pure cariwiit u>l
(see p. 955). '

Adhesions. — No definite nile» can be i^ven go\'CTTiing the breaking-up/'
adhesions to free the tube, and each case must therefore be mansKed acwnW

TCCUMC or CONSEKVA'n%'E OPEBATIONS ON THE OVARIES.

579

I the okmIIiEoiu present. The operator inu»t be carrrul not tn injure the tube,

if (lie a'lhc^>n» cannol be ra^ly Mparaicd with thr fingers the parti should

rfae eii]>ui^ and cut with blunt jioimcd sc[s»or». 11 tlie tube cnnnot )>e (ell or

*een, the cornu o( the uterus .•■hoult] Iw bnciughi into view in order lo trace the

Libf fnim ii:E uterine end to where ii lies colored by adhesions. ;\f<er the lube

been relrasnt from it^ abnormal atUichment^ it should be carefuiiy exAmined

Ici *4x II it t" tu-isiLHl or kinked upon Itself and the 3dhe»ions which arc present

cut with sTRsnrs and the "rsan restored to its normal shape.

Resection. — Reaction of the ovidurt is performed n» follows: The opcr-
ftlor Kiwptlhedistaljioriion with hi^lingen. and while making slight traOionthe
lube is .impiitated with scissors beyond the area of dbease. After (-ontrolling
tlK bleitliii;; with ItitalureM the {>eriti>iieal anri mucuus conts ■>( the tube arc
unilc<) by intcmipied catgut or line silk suiuro in order lo establish a permanent
openine. If the abdominal openinj; is ver>' small, it may tje enlarued by flitting
Itbc luVte for a distance of half an iiKh, if the length of the lube ix i'ufficieol to
Ipcrmil it, and uniting the peritoneal and mucous coats.

^^3T.j

Fk). lot. Flo, }e«.

0«in»v«nvE n*uttnHOM mt Pauamn Tnai^
[ihi iiMiilim iif > Itinaml lulit. Sou Ihc rradi r**vit Ihrouih ihr tube inln ihc uuru aul lltt mMM
ftf tutufiog Ihr Hump in luparr too-

Before compleiing the o]>eration a fine protic is passed into the uterus to
Vest ilie condition of the uterine oiwning «( tlie lube.

Technic of ConscrvatiTC Operations on the Ovaries.—

Re»ectioD.— Tlie ojimitiiiti uf re.-*erliori, vvhiili i- emplove<l, as already staled,
sions which invoUne only a part of the o^-arj-. cm^iM^ in excising the
<mI [loriion with a knife or sdssors and uniting the edges of the wound by
ntiniii'U' f.iigul or fine silk sutures, (Fi(;s. 510 anil 511)-
Adhesions, -.'Vlhrsions of the ovary are treatnl un the Hime principles u
lnise "( the Fallopian tube tFi^;^. pj afid ^i.^i.

Cjrsti of tbe Graafian Vesicles and Corpus Luteum.— Small cyxts should
punctureil and their contents allowed to escape. A large cyst should be
nci»e>l. its walls removei!, and the edges of the wound brought together with a
>nlinu<nL( Hiiure of c.itgul or fine silk (Figs. J14, 515, and 516).
Hematoma.— If a hematoma docs not involve the whole ovnr, the
AfTetieil (fonion is excised and the wound closed with a continuous catgut or
Ksc kilk »uiurc (Figs. 517 und 518).

tie, ti> nc fij.

Sbowiof th« rfinat^ of iblh#uao« bfl(w«*n tbff dwx tai ibr latffWh

Benign Tumors. — If ihe tumur does nol invnlvT rhc cniirc ovan-, the op
lion of rcsrciiim U performed and the wound dosed u-iih a runtinuous ol;
or fttie silk suture.

Prolapse.— .\s nlrrady staled, prolapse is nol in itself a reason for saoifian.-
the ovary, and unless ilic cruan is ihe seat of a cross lesion it iJ>ouM be resio
to its normal position by 0]>eriiiive means. This is accompUsbed by r*" — "

OMMiivinvii OTnATtomoK n« OvAim ip&t( (tai.
> Mdnd nliiuniluniv (mtU c^i nl iht GraiAut mitis: tic. jif liuitn ■ lu|t CM el ibt
tWUMi: fit' iidiliti^ lilt *ppMnui«ul ihtcnui' dia ibcmnuvilvf ilie(>M,

fKi )■?. Fio. Jlt,

CiHniivtTivt OniiDDn HK ma OvAmi (VW* t^v'.
I ifcowi k bfSE hunawnM el Ihe u>uir; Flu 1>S •tuJ'H Ibe ipfiMnuia uf ihc •**r> tba ihc KmoHl at

Ibc huoilom*.

IfM^^r CtmiKVAfivR OmAnoHi oar riir OtAVu

*4 tbi iiuiijM.

jga THE URETHKA.

thf infundibulopelvic ligament as follows: A silk ligature {braided N
threaded on a small full-curved Hagedom needle is passed twice throuf
infundibulopelvic ligament at the outer edge of the ovaiy and then c
through the peritoneum and underlying structures above the pelvic br

COHSEIVATIVE OpEIATlOHS OH TBE OvAIIES.

Showing the opcralion for pnJapie of Ibe ovuirir

front of the external iliac artery. The ligated portion of the ligament ii
brought in contact with the lateral pelvic wall and the free ends of the li|
tied. The ovary is thus raised out of the pelvic cavity and held penna
at its normal level in the pelns.

CHAPTER XXIX.
THE URETHRA.

HETHODS OF EXAHINATION.

The urethra can be examined by the following methods:
Direct inspection.
PalpaliDn,

Urethroscopy or Indirect inspection.
Sounding.
Microscopic and BaclcriolojTjc examinations.

DIRECT mSPECriON.

Limitations. — By flimi in-peciion without the aid of instru
examine the external meriiu:-, the lower portion of the urethral ca
course umlcr the .Tnterfnr vai^iniil w;ill. ami the ojienings of the glan

Informatioii.— Tlic fullnwini; cnndhinn? can be recognized

External Meatus. — Intlamni:iiiiin, evcrston of the muco
benign and malignanl tumors, liisiliarpe^s from the canal, and i
glands of Skene.

Anterior Vaginal Wall.— Tumors, cysts, dilatations, or s
"11 buret hral abscesses.

uirraoDis up exauination.

S83

Preparation of the Patient.— The [Kiiieni ftMjuires no pivparation
whatever, and as a maltcrof facntic pans should nm be cleansed nor douched nor
lite urine »>ided prior to the examination, because tJie iiiM:har]re9 about the meatus

^^.

no. 5>(. Pio. t)4.

Dinn iMKCtioii or tm Umuu.
Pil. aj ihov* lh( ownul urinuT nmnii. Mb( npcanl a^ih Ibtihumh tml InAnHnEtr, tit )M ibowi
(xova^KBUItauiof ihtumhnbir rnaun i^Uiui ibt uiul mih iJic <tp u( ihe tncrt tn ihi ia«liu

would thu» have been washed away and a correct idea of the conditions in some
cases [uuld not l>e obtained.

Position of the Patient.— The examination should be made in the
dorsal pa^iure.

Tec hnic. —After pLtcin); the [lalicnt in the dor«al position the cutniner

>:^.^

Pta. jif. Pia. iio.

I)i»cT iMSRcnoH or TBI Vunu Iptt oii)-

PIc. j>t*^*m<konA«*(tbttaMutniHni>briaEimiidiCTlepni»ithit»<liiiintit: fir ;>> iliiwi ibt pdMMlw

w»l»>l **]1 btint RCnclH atlb Ibc Uida->nta » u ii> itt«r the ttet^ win «I <tis ntfM.

sits or Stands in front of the vulva and expo^ies the external urinary meatus by
separating the nymphx with the thumb .inri index-finger.

He then in<pcas the urethral opening and notes the presence or absence of
abiwrnul conditions or discharfge^ To make sure that a purulent urethritis

S84

THE URETHRA.

does not exist the canal is milked toward the meatus by pressure thnugh tht
vagina again&t the symphysis, from above downward, along the whole \engdb
of the urethra. The secretions in the middle and upper portion of the uRthn
are thus forced into view and can be carefully inspected.

Having thoroughly examined the meatus, he then exposes the lower end of the
urethra and the orifices of the glands of Skene, which are situated posteriorh
just inside of (he urethral opening, by stretching the mouth of the urethra with
the index-fingers or the thumbs. And, finally, the index-finger is passed intotbe
vagina and its posterior wall pulled back so as toexpose the portion of the antervu
wall under which the urethra lies. The entire length of the canal can thus
be inspected and abnormal conditions noted (Figs. 525 and 526).

PALPATION.

Ifimitations. — We can palpate the external meatus, the lower ponion of
the urethral canal, and its entire course under the anterior vaginal wall.

Infonnation. — ^The following conditions can be recognized by palpation:

External Ueatus. — Inflammation and urethral caruncles, cancerous in-
filtrations about the meatus, and neoplasms or other pathologic affections can t«
thoroughly palpated and their consistency, sensitiveness, and general characteris-
tics noted.

Anterior Vaginal Wall.~The outline, consistency, mobility, and sensi-
tiveness of the whole urethral canal can be examined and pathologic dunges

Fid. ji). Fia. 51S.

Palpation of thi I'ltTBIA.
FJE 537 hHdws ■ urFThral tumor K-inK paliPACrd bciiteen ihe Ihirmb uid iDdev-fintd; Fif. t^ — *— - ^
uTerh»r cuiil bciDg [4lpaici1 rhroujrli iSr laRJjia by iht indci bhgrr. The illmtnlifln ddB^uraicv '*'
Virr9?DiF of A uriMhral Lumor by vaginal palpaiion.

recognized. We may thus determine the presence of urethritis, benign *"■'
malignant neoplasms, cysts, dilatations of the canal, and periurethral inflamma-
tion or abscesses.

Preparation of the Patient.— Same as for Inspection.

Position of the Patient.— Dorsal posture.

Tec hnic— After placing the patient in the dorsal p>osition the exanunff w'tJ
or stands in front of the vulva and exposes the meatus. He then palpatts rh'
urethral opening and the lower end of the canal with the tip of the indexiif^
by pressing upward against the symphysis and notes any abnormal changes th»'

UKTIIOrtS ni- EXAMINATION.

sss

ly be prneni. I( a neoplasin is locaiet] at the urethral opening, it should be
illMifl U-iwcen the thumb snc) ihi- index-linger and its constMcncy and sensi-
tiveness noicd,

(L-iviiiK ihofoui;hly examined the meatus the index-fin^-r i.'^ ilicn inMrrted into

iv v.igina ami the whole length of the urcthnt pttlp.itcd bv gently stroking the

il And rolling ii about in various directions while making prcMuie upwani

lin^l the sym(>hysis. By thus manipulstiiig the anterior wall of the viigtna the

tminer nin n-aigiiizc the phvMcal characteristics of pathologic condiiioa*.

Itat may be present and elicit v-aJuable information as to their nature.

^M URETHROSCOPY OR INDIKECT INSPECTION.

^V Limitations. — The interior of the ureihrul canal can be inspected from
^Bir vesici) timhr.il juncture to the external meatus by means of a urethroscopjc

examiiutii^n.
I Information.- By this method of examination we are able to determine

with acniracy the presence of inflammation, tumors, and other pathologic con-
ditions situated within tlie urethral <:anal. The o|)ening through which ,i sub-
urethral ahscr*.* diMrhargrs its pus into the urethra can be seen, and we can also
delinitely locale ihe lesion in r;i«^ of vcsico urethral fissure.

Preparation of the Patient.— The urine must be voideil natwrally
D>t tieforr ih<- [vnieni is cx;iminc<l.
When the piaiicnt'i^ pUied on the table, the meatus and the vulva mu.^ be
nmughly Meriliited ii> prevent infection l*eing carried into ihc bladder. This is

s ^^

®1

FM' MO-'— t)At«tTiii]vn roB I'fetTmnvf'OFv oi ItcnimcrT IiKFirtToii or tn ITtttwVA.

'^^Dmplia'hml by >rru)>bing the parti' wilh a gauze >ponge Miturated with tincture
J!' fciop and warm walcr. and w^ashinj; ihcm wilh a solution of corn>sivc sub-
^•^^le f 1 to loool, which in turn h removed by douching with sterile water or

Position of the Patient.— Dorsal posture.

InstrnmcntS.— (t) The Ashton Gun* urethroscopes (three sixes — Nos.
• ,10. jivl ;(t l-"rmch scale): (3) Kelly's cone-shaped urethral dilator; (3)
^K ■teliralc alligator Jaw forceps.
The Urethroscope.— Thi» apparatus consist)! of a cylindric metal iut>e three
"""he- bng with a rouiwl flat flange at its proirimal end. to which is attached a
Fw-|aisi for seturing the elertrir light attiirhment and an obturator which is
to laiililale llic inlnxluction of the insirumenl. The cleclric-light carrier
I o* a delicate coW lamp ffrom iwo to four volts) ai the end of a slender

586

THE URETHRA.

tube which is connecled with a handle having a push-button to turn on the cunniL
The lamp lies free and exposed in the lumen of the urethroscope and takes up no
space and interferes in no way with the manipulations through the instrument.
The battery consists of four diy cells which are enclosed in a box and connected
by a rheostat.

The urethroscope is a modification which Dr. S. Leon Gans and I made
of Valentine's original male endoscope, and was manufactured for us by Charles
Lentz 8; Sons of Philadelphia. The instrument is superior in even' way to any
other urethroscope I know of, and is simple in construction, easily sterilized,
affords a wide range of vision, and the necessarj- manipulations can be made
through it with the greatest ease and certainly. I employ the instruineni
not only as a urethroscope, but also as a cj'Stoscope, in all cases requiru^

FiCr 5io. — ^TirK A^iiiTON-t^AV* L'hethhosivpe,
Tllu^lr.itiitn o ?Uiot4 thr olituraior wjihia thi' cylinilric mbc^ iilLi.:ir.iiioD b fhaws (h? rlrctric-lighl canirf il^^^

1(1 tKi- lull..-.

an e\aniniation or trt'alment of the bladder and the ureters. The aclTaii-
tapes of an electric lamp at the distal end of itf
urelhrii^copc are self-evident and are in strong con-
trast willi the unsatisfactiiry nature of an examin'"
tion when a reflected light is used to illumine"
thcurcthra or bladder.

The Urethral Dilator.— Kelly's cnne-shai>ed urethral dilator is a metallic
instrument with a round [xnnt which graduallv increases in size unli! it beconie
i6 millimeters at its base. The instrument is graduated so that the eitainiW
can determine when the required degree of dilatation is reached. The ti-
terna! urinary meatus i^ the only part of tl"
urethral canal that requires dilatation, as ll"

UKTBODS OP tlXA HIKATIOM.

rest of the canal is very dilatable
stretched by the urethroscope.

and

.^^_J=_

The Alligator- jaw Forceps.— This inalmment is used lo bold smull ball*
of aljMirlx'iit niitcn wlndi xtv em[ilii)'ed to «-)[)« the secrelionK Irum the uretbra
and expose the mucous membrane.

Fin. vt».- AiuoATOniA* FiU!in

Hia hjmillim which an ikir khoamftre Ijcal uaaknicln vs MacA luobtcraaiht ifit«<FM|- ffo).

Sterilization of the Instniments.^The ttrtihrotroprt, ihe urethral dilator,
anil (he aiiigalor-jaie joreeps arc boiled for fi\-c minutrf in er («nl. solution of carli'ilic acid. The handle
of the light-carrier is wrapped in sterile pauze.
as it ciinnot be plarnl in an antiseptic Koliilion
without injurine its connection.

Abflorhcnt Cotton and Ifiqnid White

Vaselin. — Small iik-dgel* itf al.'Mirlirni o>lton
m\i<t be on hand to removie dischaiRcs from the
urethral canal and one ounce of Uouid white vaselin
for lubricating the dihtnr ami urethroscopes.
Liquid white vaselin does not
coat nor change Ihe appearance
of the mucous membrane, and is
therefore preferable to other lubricalinfi mate-
rials for ureihroM-o[ii<- and ni>.tii>copir eTamina-
tinm. It b Mrritiicd in the ume manner as
Hquid 'oap (see p. 814).

Robber Gloves.— Tlic examiner »houH
wear rubber gloves to guard against the possi-
bilit}- of contaminating Ihe inslrumenis and car-
T>-injt infection into the bladder.

Anesthesia.— A general anesthetic is not
required unlev> the patient is nervous or very
seiiMtivc to pain, and the examination can there-
fofe usually be made under the local effect of
cocain. A pledget of cotton is saturated with a 10 per cent, solution of cocatn
and placed in the lower urethra for five minutes before the examination.

Technic— After dihiing the meatus 10 the required extent the obturator
b placed in the urcihro^smpe and the iimiruntent passed directly into the
bladder {Fig_^. 554 and 535).

Fn). 13) — UrmuD >.-r SnuuiDN

mi LllilllCAItlllr AMU t-AJM

Aa <4>Iintn (1» 'umMrr pu-
Mtf bllcl MLh Oie taUM|r<k nhuMl
ii iHil. Soli Uh turik taut
wnpnil trtmut On h^dfc si Urn

58ft ^^^^^^f TKK rXCTRSA.

The obtunior is then withcirawn, the lii^l-orrier attached to the amlit»>

l^'- )M- FiC in

tTBKTttB'mTtPv ^Jt Ihihivli-i Itnnmrw 41 Tin ViiriiiA 'i^f* t^lt

fk-U*dia"*lbenHtha4i><mii»JuriniiiIiT uTFihr4l dilnicr. fig, ttiibwHikmnibiiliJ

f 'li^pe, and the haiuilc- conncdcd with the battery. The currcni is then ftnri
on D>' prcfi''ing th« button in the h.imile ;iml (he rx/imincr looks ihmiglilW

urcthro^ailw iiita the bladder. The tmtnuM
i» then Knidually witbdrauii nm] ilie 'f-an
ur«(hnil jtincture i-»n-fully exutninrd ahte t
comes into new. CimlinuinK 10 *fc'»iy ■**■
draw (he urelhroflcojie. the euminet iilerr*
the apprimncc nf ilw- mucous itiemlinMi*^
cloKs over the distal end of ihe in^lniiotoi t*
notes the jiuthologic chiinget present.

SOUNDING.

Limitations.— Tlte meuiu* atk) thrn
length <>( till- riinid nn be ciplund «ii>
soitnd.

Information. ^By MmwHRm: the uir^
we Clin ilUiinguish between 3 growth lUiuH'i
at the meatus and an evcrijon of the nn*'"''
membrane, loruie ob>(runt<>n>- due lo ttnctm'
ncopla<m¥, it impnncl c.ilcuh, am) aUi t»"<
nize saMulaiions and dilataiion> nf the rawl

Preparation of the Patient.-s*-'
as (nr uri-ilin>-<vi|iy.
Position ottht Patient.— I>i)rsal p<tf.iurc.
Instruments. — (1 J A >liglii!y tuned bbdder wund; (j) a »« o( •w'

FlCn JLtft.— If 11*111 l'"*"'OI'V o» Iwpi-

urr Ixii-ii-iinH •» lilt 1 itmKA.

4A iht «fr[hn»«Dlw kkk Ei

■duwly

•OVKDINa.

s8g

Antisepsis. — Thr iiu-trnmenu ore l>oiIe<J Utr live minutes in a soluiion
Kulitier t;ktve« xhouUI l>c tvnrn and liquid while va»elio used as a

Anesthesia.— An nnc:>(>i«lK- 1< mH required,

Technic. Alter placini; ihe [laticni in ihc dorea! position ihc e^miner

■o

Fh* tf* -UlTttyiMi hit S>l^1l1>l«li> 111k I'kl lit* A

ni of ihc vulvn and exi)r)»c?i tlie me.ilu«t. The urethra in then explored

cun'cd liljuldrr mkiikI l>y ^uidini; iIh lip in the normiil direciii'n of

iht aniiL If the sound enters the bludiler iviihuut ntecting with resiMance,

■con cirlude the prc^nre »f u striiiure. a neMjiUfin. or a alcubs; if. how-

I tw. an obbiruction t^ met. its nulure

and an
\mf» il

ii-fiilly >|tiilittl
ikl Im- made i»
atlii d ><iulli;r iii>^ Inline lit.

With n liouKiv h boule
*t can drlcrminc the
PTosimii I us well us the
4lilal end of the oh-
^ttuctinn and thus csti-
■i»I« its extent (Figs. $iq
•»«! j*o). An impacied timnc can !«
■fiiicnincil by hearing and touch when
Ip I'l^ iound strikes upin^

It iJii wmnd is snusl)" Kraspft hy
'*' -rr-hfa whik il b* ItftiiR ililnf-
>cfr can \x rMxIiktalion of
il: but if the iiiMrumcnt
nlxwl freejy a* In o ciiviiy
ilun ils own diameter, the
of ilic cifKan i& abnornully
I. In cuwK of urethrocele
>^<t4tlnx tile lip of Ihe sound
*'»ii«»r(| into iIh- utxublion the
f»3" M 111* inMninicDt tan be t«cn

iaio ih* unnrv-

and fcU through the amtrior vsgiiul

S90

THE URETHRA.

Fio. ;jo. FfC 540.

Figr S3D c^vi K Unigie & bouLr obslruclcd \tj ihr jiroiiiiial end of a fltncluTE ^ Fig. 544 ibowi tbt viUiAiHl
oj (he iaairmnenT obsirucled by the dislal end ol ihc coDSQictioD.

mCROSCOPIC AND BACTERIOIOGIC EXAHENATIOWS.
If Imitations. — These methods of investigations are limited to the emu-
ination of urethral discharges.

Information. — We can determine the character of the infection in ojcs

nf inflammation of the urethra.

Technic. — The melliods of obtaining and preserving urethral dL'^im
for a subsequent micrtjscoiiic or bacleriologic examination are fully described in
Chapter II-

HALFORHATIONS OF THE URETHRA.

The following anomalies of ihe urethra have been noted:

Complete or partial absence of ihe urethra.

Atresia of the urethra.

Hypospadias.

Epispadias.
Complete or Partial Absence of the VTQtiaa..—Compleie otiW
'if the urethra is an exceedingly rare condition and usually occurs in ihat f"""
of persistent cloaca in which the bladder, the vagina, and the gut open into"'*
common receptacle. In some cases, however, the rectum terminates nunW
al the anus and the bladder opens direclly into the vagina bv a transveiscsW
through which the urine amslantly dribbles unless the opening is suffidtnUJ
closed I" ;dliHv a certain amount of accumulation to take place before inco"'
linenre occurs. .

Piirlial absence of the urethra may involve either the proximal or di-'*
cm! of the canal; if the former is absent, the bladder opens directly inw tw
vagina and incontinence results; but if the latter part only is wanting, the pal'''!
has perfect c<'ntrol over the contents of ihe bladder and the stream of uriK ^
diverted inio the vagina.

UALFOHMATIOKS— ATBr-SlA.

»»

Treatment.- Absence of the lower portion of the urethra require:^ no treat-
menl, as the patient has perfect control of the bbdder. If, however, ihere U
complete absence or the upper portion of ilie urethra ii invoU ed, an e&oit ahoutd
be made to form a new urethral canal by means of a flap operation and ihe vesico-

\'y^

FlO. J4I.

Oiimrr* Amwicx or imt tfanwu.

Frc. M5,

Fir M< fhom III ibiflKir •! Ill* uinhn vtihoui mit Mkir miUimuonn: Re i*> •>!<"•« >A ihanm (ri
Ihc nmtin BaseiiHWd «i1h « cU4<«: thr mtufn Mn4 bliidJrf cm^^rini^ iflto thr vullu; rkf $4J fhowi «■ ftt«rot4

vaginal opening Kubtteiiiiently cloanl in the same manner as dcurribed dwwhere
in casM of acquired fi^^tuhs.

Atresia of the Urethra.— In some caws the entire urethral canal may
be imperforate; in others only a poitioD may be involved; and, finuliy, the

'^^■-

F»t iu.

PactijU. AaaDMT or Tin l^BmnA,

no, us.

Fi*. tM *h»*< •> ■loroct lit Ae {"■Aiml *od nt tlw untbn uil ifec Mat'ln onMytiia i&M Ac ndM: fit'
.1 ihowi ui ilaina ol tkc lUad md of ihc imOin ui<l Uw apninc throuah ■hidi iht tOcaa at luinr n
ii-nud jnia ibf Ticiiu u 1^ tint ef luinitfoa.

ohMruttion may be due to a thin membranous septum, which b tisually stretched
acro:v<i the urethra near the neck of the bladder (Fir. 546).

Atresia renulu in retention of urine, and the bladder, the ureters, and the

S9»

THE t-KeriUA.

V .-

kidneys nuy become »(> dislended ihal pnrncCTitc$i« musi be perfntmed htkn
ilw (ctui tan be delivered. In some cases, however, ihc urine i* dLtciurficd at
the umbilicus thniugh ii paiulouit umchus an<l diitiention of the uhoaiy otpM
doca not lake place.

Treatment.— Complcic atreua., as a rule, results fatally in the child daitaf
intnulcrinc life, but if, however, it should hiipprii lu be bom alii-c, an ortifiail
veiif in .ininat tistula must be made al once to pvt esil to the urine. In casci iJ
alre;^!:! involving thr dlMal end of the urethra an unifH'^^l un-thixiviiginal l)>tal)
should be miide jufil beyond ihc o1i--lrurli<>n, bul if the pn>xim^l {mrtion is »f
fetietl. an opeiiinc inuM lie made bctwti-n ihc bladder and the vaKina, which may
be closed later on if it l* poviible to form a new urethra by meanv of n llap open
ti->n. A membranous scplum should be puniiurcd with a small trocar ■»!
kept dibited until tlie raw edge^ have completely healed.

Hypospadias.— Thb i^ t

deficient J-. laryinn tn de|;rcc.d
the l)iK>r of the umJmi, the
effecl being tlut the caiial upcai
at a hifchci tcvd ilun rairiiuL
It i» due to deferiiv* c]r*elt^
ment of the wall of '' luj

sinu-N. If lite dci'i' ite

tliuir of the urethra ini-ut>i7ll»
vcsicovaj-iiial junctutT, inmedi
neine results i but if h >«tr
affects Ihc disl.il iMirtion of iW
caiiid, the |iattcnt lu^cnitiriut
irxil of her bUddcr and iheooli
iiKuitiYnience u thai uhpth a
due In the abnomul dimiim
pven to the >treain of unativ
inj; nitilurition.

Treatment. -If the atde'
die bladder is ttiwilvnl anil ibcit
is im-onlinence. an effort tio»H
be made to restore the lIo«t(
the urethra by denudinp; thrvl
jacent mu(ou<; membrane ^
unitini; the raw surfaces *^
sutures. If. bownei', the [4timl
ha» complete ronlnj nf herunK.
there is but little t-r no atro

venience. and nothing need therefore be done to remedy the defe«lttv cro

dition.

Epispadias. This is an anomal)' by defeci in the \-entr3l wall w rw< ■J

the ureihra. There may be an aecomjianyinE cleft condition nf the cbt«ii.="'

may be astorinted >vith cxtilrophr of the bladder. Inconiittcnce of urine luy c

may not be present.

Treatment,— If the defect of the urethra cannot he remrdiod by a jdi**

operation in ca«e< in which the pntirnt has no control of the bladder, noibnfta'

be done bcrand wcarin); an ambulatory urinal and kecj^ng the parts taaffito^

dan.

ir:^^:

Fic- ttit—Anui* or tun L'*»ni» [p*cr mi).

Showtni a Itiin (nrmliiaiKiui »|Hiini ttti (be taliddn.

rRETHRITES.

593

DISEASES OF THE URETHRA.

URETHRITIS.

Causes. — Thedbeast is not ncirly so common in n-omcn as in men. In a
very large miijnrily of the n.ies the aftei tiun j.-i >{ )edfi<- in origin and !.■> Kiuited by a
gonorrheal infection which is ako usually {tn^cnl in the vulva and in other parts
of the f^nital canal.

The tion gonorrheal (()rm« of iheiliMaic are due to the following cauiics:
Inflammation of the bladder.
The tubercle bacillus, syphilis, and ensipelas.
Tr.'iumnli<.m, u^pemlly in childbirth; puKsageof a calculus; and rough

instrumentation.
Irritating vaginal discharges.
I'rrthral ne(ipl.-ism».

Symptoms.— In the gofwrrhfol jortn of urethritU the disease begins with a
M-nsnlion of itching in the urethra which lust> for une or two daj-n and i.i followed
by burning and puin upon urinution. A» Ihc inlliimmalion progrcsMS the symp-
toms become more intense and the desire lo void urine is usually increased in
frequency. ^Mien the intlammation beKin.>i to >ubside. Die Kvmplom.s gradiuilly
lessen in intensity, and e\entually thej' disappear entirely if a cure is established.
If, Iiiiwevet. Ibe iIiNea.-* passe.-, inio a subacute or chronic state, the symptoms are
not completely rclirv<'ij and the jiatient may complain of .some siirene$» in the
urethra and sjlght frequency in voiding urine. Chronic infection of the glands
of Skene doe* not, at a rule, give rise to local di.scomfort. and there is no pain
during urination.

In the noH-fonorrheal formx of urethritis the symptoms are less severe and the
disease runs a shorter course.

Physical Signs.— Alter the disease becomes established the e.ttemal
mca(u.« \* inllamecl and «v>-ollen and the urethral mucous membrane is somewhat
prolapsed. A purulent discharge is seen at the mouth of ihe urethra and the
openings of Skene's glands appear as small, ovoid, yellowish spots surrounded
by a xone of dee^t congeritinn. If no pus is found at the
meatus it may be expressed from the canni by
pressure with the finger upon the urethra through
the vaginal wall. In (he .tame way pus may be
pressed out of the ducts of Skene's glands and
the presence of Ihe disease demonstrated in these
structures.

The urethra is found to be lender upoo pressure and the canal feds indunted
and cord-like to the examining linger.

The local signs of inflammation entirely disappear if the disease is cured; but
if the affection becomes subacute or chronic, there is a slight purulent discharge,
some pouting of the urethral mucuMi, and sli^il soreness upon pressure over the
urethra.

In aeiile casfi the urethroscope reveals a reddened and swollen condition of the
entire urethral mucosa, but in the (hronU jornn of the ilt.ieiu« there is little or no
swelling and small ulcers or granular patches arc often seen scattered over the
mucous membrane.

The microscope will drmnnitniie the presence or absence of gonococci in the
pus which i- taken from the urethra or the glands of Skene.

'Prognosis.— GonorrhaiJ urethritis Is a ver}' difficult condition to cure on
account of the frequency with which the gonococci permanently intrench ihem-
3»

S94 THE DRETHSA.

seh'es in the glands of Skene. The prognosis of the non-gomorrkeai jorms of the

disease depends upon their cause.

Treattnent. — The treatment of the disease depends upon the stage of the
inflammalion and may be divided into: (i) Acute cases and (3) chronic cases.

Acute Cases.— The treatment is divided into (i) the general and (3) the kxal.

General Treatment. — Under this heading are included rest, diet, drink,
internal medication, and general and local baths.

Rest.—Rest is one of the most important factors in the treatment of the
disease, and if the circumstances of the patient will permit, she should be kept in
the recumbent position, preferably in bed. If this cannot be accomplished, fht
should be given careful instructions to avoid all unnecessary forms of esercise,
such as waliiing, standing, or lifting, and lo lie down on a lounge for ten or
fifteen minutes at a time whenever it is convenient to do so.

Diet. — The diet must be carefully regulated. In the treatment of anit*
urethritis it is impossible lo emphasize too strongly the importance of selecting
those articles of food that have the effect of rendering the urine bland and un-
irritating to the inflamed urethral mucous membrane. For this purpose no
article j>osses.ics the advantages of skimmed milk, and if possible the patieni
should be restricted to its use during the early stages of the disease while the in-
flammation is acute and the pain upon urination is severe. Unfortuiutelr
many patients object to an absolute milk diet, and we are therefore obliged to
allow them other articles of food, which must be, however, of a nnn-stimubting
and easily digested character. The following articles must be avoided; ALhighh
seasoned foods; meals of ail kinds; greasy or fried foods; coffee or tea; salt,
pepper, or vinegar; acid fruits or vegetables; and asparagus.

Drink. — The drink of the patient must be carefully selected and alcohol in all
forms prohibited. The kidneys should be kept active and the urine diluted by
drinking two or three quarts of distilled water daily; if, however, this water
cannot lie obtained, we should use a natural spring-water containing a minimuD)
amount of earthy matter (see p. 101). .Apollinaris, soda, and sehzer water; art
also useful and beneficial in these cases.

hilenial Meiiiralion. — Internal medication is important in cases of urethriii>
to relieve the local inflammation and render the urine innocuous. The buntls
should be ke]it regularly anfl freely flushed with salines; rectal enemata arr
contra indicated on account of (he ilanger of infecting the rectum. If the urine i>
acid, beneficial resulls are obtained from drinking alkaline mineral waters and ihf
internal administration of the sails of fxitassium; if it is alkaline, ammi-'nium
ben»>ule. salol, and lx>ric acid arc indicated alone or combine<l with the infiti'ii
of liuchu or uva ursi. Culjebs, oojKiiba, an<l the oil of sandalwood ]XK-e-.'
marked curative properties in cases of urethral inlbmmation. and they shouW
iherefore lie given as a routine practice alcme or in combination.

iUiieral mnt l.nrd/ liulhs. — General and local baths have a sedative anJ
curative effect upon the disease. The pain upon urinating, the tendemesr. and
the intcnsily nf the inflammaiion are decidedly relieved by the application nfJ>°i
water. Under these circumstances the ]i;itient should be instructed lo take a full
liol lialii |>ee ]i. Ai,) at l>e<itime. and also a hot sitz-bath (see p. 87) once orl»i'f
durin;! ihe day. .A medicated vagina! douche containing bichlorid of mtrcun'
(1 lo 3000], followed by an injection of normal sail solution or plain water. shf^uH
lic ;;iven licfore the full h<Jt bath at bedtime and also in the moming an"'
geitini; up.

Local Trkatm^nt. — The specific nature of the vast majority of the ca*
of acute urc(liri(i.-i must not be lost sight of, and hence the indication is todft'"'?
the iionococci at unce bv direct medication to the urethral canal.

(

UKETUKITIS.

S95

The fallowing arliclCK ore required: (i) Kelly's surgial
rubber pad; (i) Skene's rcthix urethral CEiihetcr; (3) founlnin syringe; (4)
skeni-'it bivuKv urethra) »]>eculuni; (5) applicator; (6) abMrbeni cutlun; (7) a
•'ihiiioii of argyrol (jo per cent.); (8) a solution of cocain (10 [wr rent.).

/'o-AihV.— TIm: local treaiment is carried oul as followr?:

I. The ]i.tiieni L-> plaied in ilic dorsal )M)^iiion and ihc surgical pad arranged
indrr her h'\\K.

3. The vagina is then douched with a solution of corrosive sublimate <t to
7000) Mkweil by normal Mill M>luiio».

3. The solution of cocain is now applied 10 the urethra on an applialor
wound with nXton and atlowexl to remain for tive minutes.

4. The rcllux calheicr I'' then introduced into the urethra and ibe caiul
llu^hcl with II )ki»i of hot normal ult xotuiion.

5. I1>c s{ircultim is now intriNluced a» far «<■ the internal meatus and the
ii[>p)ii-atof, which is wound with cotmn and satuniied with the argyrol solution,
|u»etl inio the tanal. The s|>cculum U then rcmovnl and the applicator slowly
withdrawn from i)h- urethra.

The nbo^« ircalineni nhould W Ki^en d^aily nnd continued until the disease is
tureii or il Jiow^ j tendency to In-ci'me chronii-.

The rcdux lathctcr should not be [tassed beyond the intenwl meatus, other
wi*e there is (Linger of carrjing the infection into the bluddcr, and, besides, the
iinliumrni in Ihut jxisiiion will not llush the urethra,

Wlwn tlie purulent character of the dischurge le^->ens or disappears, it Is ofien
•dibble to di»ci>n(inije The use of argjTol uml i^uhstitute one of the following

Pio. (4(.— SeiuwV HivjiETt I'Btmiiu Srtntiim

ats, a pint Kolution of which shuulil he injected daily into the urethra with
■ tflux cJllK'tcr: Tannic acid. gr. x to f.?j : siil|ih:ite o( rinc. gr. j or ij to (Jj ;
»'nalci>l)!iii(,gr. xtof^j; acctateoftead.gr. ij to f.jj; or 3 50 per cent, solution
*< Inilnigen (M-mxid.

Chronic Cams. -The ircatmeni may be conwnicntly divictcd inio: (i) the
eiwilaml (a) the local.

I CiNKftAl. TitiAnii-NT.— Tlic general trraimenl of chronic specific urethritis
|aiWi(tiDdar>' consiileraiion. and ihcrc is but little to suggest iic)ond keeping
*t<itiflc bl.itid and unirriiaiinK by the means already described and looking
'''(TlliciligirMii^n and ihc nutrition i>f the p.ilicnt.

Ij1<'AI TRiATUtXT.— The loc.nl irealnifni. on ihe other hand, b nll-
' li^Ttam. us the inll;imnuti«n may continue indefniitely and subsequently infect
*'*t]iulsof tlic genito-urinary traa or transmit (he dtwase to the male urethra.

596 THE UKETHSA.

As Stated above, the lesions in chronic urethritis manifest themselves as small
ulcers or granular patches scattered over the urethral mucous membrane, or as a
purulent discharge from the glands of Skene. These conditions often enst
together, but it is not uncommon, however, to find that a small drop of pus mav
be expressed from the ducts of Skene's glands after the urethral mucosa has been
restored to a normal state, showing that the infection may be intrenched in these
structures without giving rise to any subjective symptoms.

Chronic cases of urethritis where no lesions areob-
served beyond a general subacute inflammation of
the urethral mucosa are treated as follows: (i) Cocainize
the urethra in the manner described abo\'e. (2) Paint the entire canal with 1
solution of nitrate of silver (gr. ij-f.^j), using the urethral speculum and the ap-
plicator wound with cotton as recommended in applying arg)Tol.

The above treatment should be given once or twice a week and continued
until the discharge entirely disappears.

Granular patches and small ulcers are treated a
follows: (1) Cocoainize the urethra. (2) Introduce a urethroscope up to the
internal meatus. (3) Take an applicator wound with cotton, dip it into a st^utioa
of nitrate of silver (gr. xxx tofSj),and touch each patch or ulcer. This appliatton
should be repeated once a week until the lesions disappear.

Chronic inflammation in Skene's glands is treated
as follows: (i) Dilate the external meatus. (3) Introduce a probe ind
slit each duct open on the urethral surface. (3} Cauterize the raw surfaces wi4
a Paquelin cauterj-, pure carbolic acid, or the solid stick of silver nitrate.

STRICTURE.

Causes.— -Stricture of the urethra is a rare occurrence and il 1; tioi
nearly so common in women as in men. The condition
may be due to a cicatricial contraction of the tissues of the urethra resulMS
from a previous ulceration or it may be caused by narrowing of the lumoi of
the canal by a neoplasm or a periurethral infiltration.
The following are the chief causes:

Gonorrheal urethritis; chancre; chancroid; and tuberculosis.

Traumatism resulting from childbirth or from operations on the urellu*-

Caustic applications to the urethra.

M:ilignani disease of the urethra.

Urethral tumors.

Adjacent malignant disease causing periurethral infiltration,
Description. — A stricture due to cicatricial contraction is usuallv hciiixf"
and involves the entire circumference of the canal. It may be situated at anvpar*
of the urethra from the internal to the external meatus, and in rare cases the wliol'
canal may be narrowed. The largest number of these strictures are situated al ^^
near the external meatus.

Strictures due to urethral tumors, to malignant disease, and to periurethr*'
infiltrations ore. as a rule, very extensive and affect the entire length of the on*''
Symptoms. —The most common sjmptom is frequent and difficult mi'^'
turilion, which increa.ses in severity as the constriction in the urethra K"
comes mure marked. In rare instances the patient complains of incontinenC
of urine, and in others the stricture may so completely occlude the canal as to
cause retention. We should always bear in mind that the incontintntt ff/
retention which is cibserved in the male may also occur in cases of utethtai
stricture in the female.

STRICTORB.

591

■ vl

Physical Signs.— The presence of ihe Mriclurc is revealed by (i) palpa-
tion. (3> the u»c of (he sound, and (3) Ihc urethroscope.

The induration alxiut (he ^iie of the .stricture may usually be felt by [ia)palinf[
(hniugh the vngina along the amrsc of the urethrid amid. 'Hie Jtridure may also
be located by the resistance or obstruction offered to the passage of a sound, and.
finally, the lower portion of the con.«Irii-lion may be ■«en thmugh an endoKope.
If the stricture is located at or near the external meatus, it cnn generally be seen
by direct inspection.

Prognosis. — ^The prognosis dqieriU upon the c.iuse. The removrtl of a
Uiethrai nttiplaj^m is usually followed by a permanent cure, while malignant
disease and periurethral inJiltraliim are of course incurable. Stricture.-i due to
cicatricial con(Taction arc very liable (o recur after fnrcible dilatation iiiile-s'< the
sound issubsequendy pas.'^ed at rcj^jlar inlcr^'als, as in the male. A tight stricture
at or near llie meatu.i i.-> likely (i> cau.NC dibtation of the urethra from [he back-
ward pressure of the urine during the act
of micturition, and cystitis, with subse-
qiienl infection of the ureters and kidneys,
often rc*ulli^ frum the same cause.

Treatment.— The treatment of ure-
thral neoplasms ;ind malignant dticaM b
discussed cbewhere.

In l•ase^ <if ci<atriciji coniraction ihe
treatment h conveniently dii-ided into the
following methods:

Forcible dilaLation.
Gradual dilatation.
Intem.-d urethrotomy.
Making an artificial urethrovag-
inal fi-tu1a.

Forcible Dilatation.— This proccd>
ure is applicable in the majority of cases
and is «jniraindica(ed only when the
cicatricial tissue i» mi dense and eMen-
sive that dilatation canno( be performed
without cauMn^ 1(ki much traumatism.

The dilatation should be done at one
sitlinitr under an anesthetic, with the pa-
lienl in (he <lona) {xMition, by me:ins
of Hegar's uterine dilator)', beginning

with a small instrument and increasing the s!i:e until the urethra is dilated to
half an inch. An excev-^ive or a too nipid dilatation muM lie titrefully
a^wided.aslhe urethra may be lorn and incontinence result (Figs. 550 and 551).

A dibtor should be passed every three <Jays for two weeks after the operation
to kec]) the canal [i:i[tduus. The urcthn shoulrl Ik- aKainiz<fl before using the
jnsirument if the i>3t)eni complains of much pain. Should the stricture subse-
quently show 3 tendcmy to (ontrac(. (he palien( should lie (augh( to use ilie MHini]
herself and given instrudJons (o jiass ihe instnimcnt in(o (he urethra once ever)'
month or six weeks for an indefinite length of (ime.

Gradual Dilstaticm.— This me(hod is indica(ed when the piKieni refuses t»
take a general anesthetic or when (he stricture is wry limited in ex(en( and
situated near (be external meatus.

Tlie dilatalion is accomplished by means of Hegar a uterine dilators, begin-
ning with u small ins(rumenl and increasing the size e^vry third day until the

iiLii.

Kic M9'— Sn«^'*K of Tn> ttRtnn*.
Sboanc t luiantn o< ihc umhnl lasil nur ik

598

THE URETHRA.

urethra is stretched to the desired extent, which should not be beyond one-half
of an inch. The urethra should be cocainized before passing the sound, as
the instrumentation is nearly always accompanied with pain.

Fio. jso. Frr.. s^i,

FonriBI.I DlI,*T*Tll>N ni" • I'HRTMHAI, Sl«trIllKt (mjf luS).

^'ifi- SSO' Hcgar'^ dilitori Fir. 5Si show^ [hr meth'xl ol i^Udiin^ a urerhral arrklur^.

Fig. 5^1.— Dnr*L Em> or Otis'* ST>ATr,Ht Dinii-jo l'iiF.™»oroiiE.
lUuiiratinn 0 showi Ehc inslrunK.'nt Jospd; iUusEriiinti h shows ihe dilaling punictn full) vipinded And ihtb:*.'^

The subsequent treatment is similar to that of forcible dilatation.

Internal Urethrotomy,^ Dense fibrous strictures should be treated b*'
(livisiiin with a knife or with a urethrotome such as is used in similar conditions ii*
the male. A general anesthetic must be employed and the patient placed in the

VEStCO'CKO'lUiAL FISSVRE.

S»

dontal position. A^ier culling the stricture the urethra should be thoroughly
stretched with Hcgar's uterine dilators.

The >uLse(|tiem treuimeni i.s >imilLir to thut of furi-ible dilatation.

Making an ArtificiAl Dretbrovaginsl Fistula.— If ilie stricture U situated
in the distal end of the urethral canal and cannot be ilibied nor cut, a new route

'/'^\\

Pin. 5«i— limaw" ('•mtunmtv .
Aom Ok attliaS of (viUuc t itiiavrr ulih ■ 'tii'i dUsilOf uRthmoiM.

should be made for the urine between the urethra and the vajpna. The urethral
canal should be o|)eneil juM t>ehin(I the niricture, care heinx taken not to injure the
bladder, and the mumsn of the urethra and the vjigina united by interrupted
catgut sutures to insure the permanenc}- of the opening.

VESI0I5-URETHRAL RSSURE.

Definition. A crack or fissure in the urrthml mucous membraiM whkb
is sJtuiiicd near the internal meatus and eflends into the bladder.

Causes. — The affeclion i» clue t<> an inflammutlon nhich eventuall)- results
in an iirilablc ulcer at the vcsico-ureihrnl juncture.
Tlie chief causes are:

Gonorrheal urethritis.
Displace me nis of the bladder.
Injuries dunn^ (onl'inement.
Unskilful tn.'itni mentation in the urrlhra.
Passage of vesical calculi.
Description.— .Alwut one-third of the lissure is sttujte<l in the Madder;
the remaining lu-o-thirtls run lenglhwi» in the urethra at the bottom of one of
the depressions formed by the longitudinal folds of mucous membrane ( Fig. 554).
The enrk or ulcer m;i_v in^ulvc any jart of the rirtumfcrence of the urethra)
caiul and it re^cmhlrs wmewKat an irritable fissure of the anus in it:' general
ai>pearance. It has a yellowbh-gray base; indurated, abrupt, and inSuncd

6oo

TnR I'RKTIIXA.

trtlKC^; and wben put upon (he strcldi by a uTelhros<-n))e it kwilu. lilte a boh
blcc'linj; tc.ir in ihe mmx>U-i. membrane.

Symptoms. 'I'hc svmpntTns of ihc affection arc due w ihc <iituauon of ibe
Icjiiiti, If the iK-ure was lotal«i wholly wilhin the urethral canal, it ivnukl a«*
only a shgln liiirninii M;iiMHiiin <lurin)|; urination, lull a* il al»4i inti>K-ej the tas*
of the bladder, it is cunstanlly irriioied by the pressure a iid (iresenre of urine and
by the musnilur nmindioiis whkh tucur ul the xc^ico-umhral junnure duhnf
the act of micturition as well as the tenesmus which h such a prominent (actor in
the»« aiief..

A %-e»icn-ur<:thnt) feisurc is accompanied bj* a con^^unt desire (o raid utinr.
severe tenesmus, a constant burning sensation ai the neck of the bhulder, and u
acme [tain ilunnK iind im mediately following urinatinn. The |xiin is most ia-
lensc after urination, and in many cases it becomes «p>ni7Jng in charader Aodit
a.i.suciuicd with a severe and distrcs^^in); tenesmus. In ^ short lime alter uniuiag

Itnlfmi Onfif«:

Vntu^lOr^ut.

Flo. HI.— ^*»iri " '» Tiiot Finvn (paar («•).

the pain ^ubRides, ahhough it never entirely disappears, and ti retunw tpi""
soon a^ ilir urine t"llccls in the bladder.

Physical Signs.— Pres-sure over the neck of the Madder ihtnugh Ai
\':ipna reveaK a -imii of circumMrilieil icnderncs* and causes a shnrji. »!«<«■<
pain The hssure is readily seen through the urethroscope and Uic cxtcMo'l^
legion deierinined.

Differential DlagliOSis. — It is important that the di<«i*e shwMle
dislin(!uislud from iireiliriiis and i-jMitis. as there i> a stronK re>enibbnrenilt<
symiJinmatoloKy of all three affections, and while vcsico urethral tis»urei%*i'''''
paratively r.irc omilition, no excuse can l>e olTeretl (or ovcrlookinn the k^"
There is no doubt whatever that m.iny cases of uf
I li r i I i 5 and cystitis are treated unsuccessful!'
because the presence of a coexisting veiico-urethr*'
fissure has been overlooked.

Treatment. -The ireaimenl of the affection is surpcal and crtri*
in the following proce<iures;

Divulsion of the veftico-urelhrul juncture-
Making an anilidal vesicovaginal fistula.

PROLAPSE.

60I

DivulsioD of the Vesico-uretbral Juncture.— Forcible cHlaiaiion of the
urethra results in .1 |)rrmiinrni turc in the uiHprily of cases, and should always
be the mclh"d of ireatmcni first adopted.

The preparation of the patient is !m)iurt;tnt. as tt is neceKuiry for the success at
ifae Ojicralion that ihe urine '■hould be bland and inniicimus. so ihul it will not be
a source of irritation while ilic fissure is hraling. The patient should th<Tcfort be
placed upon a re.-nricled dii-l for a few day^ before the ii|ienili«n, anil nothinj! is
better under these circumstances than skimmed milk, along with other articles
of food of a non-stimulaiinii and ea-ily i-lijwiifd iharacier. Alcohol in all forms
is prohibiteil and the |iaiienl should ilrink two or ihm* quariv nf distilled water
daily. The natural spring-waters (see p. 101 j containing a niinimum amount of
eanhy matter. an<l s"i<ia, a]K)lliiiaris, or *ell/et water ;ire al.vi benel'icial. The
bowels should Ih- kqtt regular with alines, and if the urine is acid the salts of
potassium should be administered, but if it is alkaline, ammonium beiuuate,
salol, or boric acid is indicated alone or in combinHtiun,

The operation is performed under an anesthetic with the patient in the dorsal
position by means of Hcgar's uterine dilators, lieRinning with a small instrument
and iiicre;isinK the >'ne until (he nrethm is ililatcd to (he extent of half an inch.

The patient sliould remain in bed for tme week; there is no necessity (or a
subsc'iucnl dilat.iti'iii.

HakinganAnilicial Vesicovaginal Fistula (Vugittal Cyftolomy, ]>aiK 970).
— Should dimlsion of the urethra fail to effctt a lure. an artificial vcsicovafiinai
fistula should be made ininieili;»ldy after |ii'if<irniiiiit a »e<ondari' (orrfble dila-
tation. The \-aginal and vesical mucosa are not united by soilurcs and the false
opening usually closes spontaneously by ihc lime the fissure is healed.

The bl.idder should be washed out dail}' with -,x i|uan of Ixtric acid .Mitulion
Ifj. x\- to fSj) by passing the nozile of the irrigating apparatus through the
fistulous opening and allowing the flui<l to drain away by the same chaimel.

PROLAPSE.

Defioition.— By prolapse of the urethra we mean an eversion or luniing
out of the urethral mucous membrane through the opening of ihc external meatus.

Canscs.— The normal urelhnd muco.x;i i-annot l)e<omc everted, but if ii
becomes relaxnt or hr|ieTtmphied or its attachments herome loo>eneil, prolapse is
likely to result and the membrane protrudes tlirough the external urinar}- opening.

We commonly find more or less e%-en>ion or iiouling of the mucosa in «-omen
who have borne sc\cml children, which has no pathologic significance whatever;
but il is a rare occurrence m meet a prolaijse which forms a wcil-marked pro-
trusion Wyond the external meatus.

The a^ection is usually se«n in old and debilitated uximen: in Ntning chililrcn
of a strumous diathe^tis: and in girls who arc (MMirly nourishaland chlorolic.

Prolapse may result from a dilhcull laljor in which the urethra is torn and
»eparaled from its atuithmcnls; from a severe urethritis associated with marked
swelling of the murou'' membrane: fromovenlilabitionuf the urethral canal : and
from traction exerted by a tumor or a polypus. Sometimes the le^on may be
(au.<>e(l by vesical tene>mus and is assoriate^l with i-ystilis, vcsico-urcthral fissure,
stone, or a bladder tumor. .Again.se^ereattacksofci>uKhing may be the exciting
cause, and. finally, the c^erJon may be due lo the acute rectal tenesmu.'* which
results fn>m an anal fisMire or hemnrrh<mh.

Description. -The siw and extent of the eversion vary gre;it!y. Some-
lime* oiiiv iniv piiriii-in of the urethra is involved and in other cases Ihe whole cir-
cumference of the canal is tm])licate<l. In women, a» a rule, only the lower por-

602

rax irsbTniEA.

lion of the urethral mucous mcmhnine h .tffecled, bul [n children ih* ujipCTpuii
the canal U invoUxd as well, and conscquciillv the tumnr h usually brget.

I{ the entire i-ircumference of the canal is prolapsed, the mucous mernhnx
protrude? from the external meatufi a* a dark cong^-'ied nu.'W. in Ihc ccnlw i4
which in the opening into the urethra ; when, howeief , the eversion b limiMd to
one pi)riii>n. it present ii>elf ai> a small tumor which U apiKirenily attached la ih«
m.tr|;;in of the urinnn- opening and which resemble a caruncle in a:
If tlie meatu> does not cause constriction, the miioous suifaie of the everttd
b but little changeil :tl tir>l; but Inter (in it become--! T,ui>]len. indam<tl. «&}
edematous from local irritation, ami in lime the tumor bivumci jciwitivr. II^
surface i* excoriated, and it bleeds readily upon touch. .\s the eilema inira«
the tumor beciimes more and m()re constricted by the meatu.'^. and in >cime caw>
strangulation may occur and the entire muss may be thrown ofT ns a ^jou^

Symptoms,— The symjjtonvft closely resemble those of an jfritable grrrt
at Ihc external meatus, nuch as a ciiruncic or an intlameil (Mtlypuii. The [olitli
therefore complains of frctiucnt and pa intul urination . The f rcquenc}' of mictm

^Sl'.ii

*xa

PmiiAHi III nif ratTii>» Munii't MiBtiitH
Pl£- 1(1 linwn (niUpKOl Ihc Imxi half •■! Ihi- ui-iWi -, hia. t(A ibiwi < pnttem tl lit

lion is due (o cystitis which often accompanies the affeclkm. and tbepUa>
accounted for by the presence of urethritis and the •«n:>iltw cnoditionoftU;'''
l:ipsed muoisa. The local pain and tendemcw arc sometimes t«i marknl iW
they m;iy interfere with walking and also render coitus imiM>»ible

Diagnosis. The diat;nusis l« based uixin ttie physical iippearanir »^
the situation of ihi- tumor

When the prolapse involves the -whole circumference of tht cjinal. ihc pr****
of the o|>cning of the urethra in its ceziier e^tiibliihc- tbe diagnusi*. If onU "<*
portion K implicated, the lesion may be miKtaken for a small iNilyinis or a ufriin-
caruncle. A prolapse always has a broad base and may be incrca>«d in vir b*
pulling il downward or rwluced by .teixinK the urethnd mucnn with a pur ^
delicate forccp* above the lumor and pu:«hing it upward in the riireclion of ^
bladder, A polypus or a caruncle, on the other hand, i.s usually [xolunniblrf
and cannot be reduced unleu Ihc tumor U pu«lie<l directly up into the ureArJ
canal.

Prog^nosiB.— '1'hc discaw is rarely cured by means of loc&i apptiatiDU

noi jiPHT..

603

ami in cases in which the prolapfie is apparently restored it is almost certain to
return after the treatmcnl i* >toi)pcil. 1'hc i)jnTiili%*c results, hiiwcvcr, are
generally satisfactory, and the urethra is permanently restored to its normal con-
dilion.

Cystitis, with sulurqiient infection of ihe kidneys, may rc8utt at time« from a
severe case of prolapse thai is associated with purulent inflammation of the ure-
thra.

Treatment. The fmt indic-ition is to discover and remove, if possible,
the cdu_-e of ihc le^ion. Wlien the case is recent and die mucnuM memhrane u
hy|ieTtn)phicd. relaxed, or overNlrelchwl, permanent results may follow a' non-
operative plan of treatment-, bill when Ihe changes are of a chronic nature and the
ti-vHues arc atioplticd or the urcihrj torn fr^m its normal attachments, nothlnff

I riiort of iin o|)eriitiun will accomplish any

■ good.

The Ireatmeiil may therefore be di
vjded into:

General and local treatmenl.
SurKii"ui measures.
General and Local Treatment.—

jThej* means may be tried in children of

strumou« (ti:ithesi« and in jvrls who arc

■iy nourished or thiorotic. In these

Fcase» tliere i> 110 appretialile chiinjie in
the character of Ihe urethral mucosa
lieyond that of rela.\alion, which is a
local manifest;ition of .1 general condi-
tion, and when the patient is fjiven ap-
pr<>]>riate internal tn-jilmciil and placed
under (food hypcnic surmundings the
pn)Up^c iiradualty ()etomes reduced a.*
Ihe general hcillh imprxne*. Owes of
pn>Upse de|)cndent ujion roclal or vesical
tenesmus arc likewise often rotoretl when
the cause of the local irrit-ilinn i.s removed.
and, finally, an cversion which kdue to a
swollen condition of the urethral mucous
membrane in cases of acute urethritis en-
tirely diiappeant when the intlammalion :cubfiides.

Soon after beginning Ihe appropriate medical treatment and removing the
cause the prolapse itself demands our aiieiilion, as its permanent reduction can
usually \ie hAMeneil by mean.', of non operative methixU. It is imporUnt tl1.1t
the p.itieni should remain in l>ed three or four weeks, and that she should sub-
wiiucntly avoid any form of active e.Terci>c. The Intwels are kept loose with a

tmild la^alt^f .tnd thi? urine is rendered bland ,in<) innocuouv A hot sltz-balh
should be given d.iily for ils effect upon the inflammation ."ind as a stimulant to
the relaxeil mucou> membrane.

When the swelling and edema have subsided, an effort should be made to re-
duc« the prolapse, and after this is accomplished astringent injections or ap'
plication) are made directly to the urethral canal by means of a reflux catheter
or an applicator wound with cotton. A pint solution of alum (gr. x to fjtj) or
tannic acid (gr. v-x to fj^j) should Iw injetled with a retlux catheter into the
urethra once n day; and twice a week the urcthriil mucosa is |uiinted with a
solution of Diiratc of silver (gr. ij to fjj).

Fio. }};.~Di«ciconi or F^oum or (MN

[kmwiiatruuif th* iwnca at Av nppnUtt of
Ihc urtdio in ikr nour at da tnUpm inHi

6o4

THE URETHRA.

Urethral suppositories containing alum (gr. ij-iv), tannic acid (gr. ij-iij),
acetate of lead (gr. iv), or acetate of zinc (gr. ij-iv) are also beneficial, and
may be substituted for the injections.

The above treatment should not be continued indefinitely, and we must resort
to surgical methods if the local conditions are not cured or materially benefited
after two or three months' trial.

Stirgical Measures. — Surgical treatment is indicated when non-operative
procedures fail to effect a cure in the class of cases referred to in the preceding
paragraph, and it must be resorted to at once when the prolapse cxrcurs in old
and debilitated women, or when it is due to a difficult labor, overdilatation of
the urethra, or traction exerted by a urethral tumor. In these cases the struc-
tural alterations are so marked and of such a permanent character that it is
utterly useless to waste time in trying the effect of a non-operative plan of treat-
ment, and hence an operation should be immediately advised.

The operation which gives the best results is Excision of the
Prolapsed Mucous Membrane; performed as follows:

Technic of the Operation . — The Preparation of the PatiaU
and the Preparations jor the Operation are described on pages 830 and 831.

Position 0} the Patient.~T)orsa] |x>sition.

Number oi Assistants. — An anesthetizcr, one assistant, and a general nur^.

ACTUAL SIZE.

FlO- 558. — iNSTBUMtNtfl. NftniTS, ASli SfTUBF ^^ATRJtlAL-S rSFI> IfJ THE OrEItAtlU:^ TOH PholAFSE OF
Tilt: .Mi:i.'OU^ MtUBKA^t IIV Tilt Ubethra.

Instruments. — (i) Tissue forceps; (2) right and left Emmet's slightly cur\-ed
scissors; {3) two short hemoslutic forceps; (4) neetllc-holder; (5) two slightly
curved round-jxunfed needles; (6) No. 7 braided silk; (7) plain cumol catgut
No. 2, two envelopes.

Operation. — First Step. — The prolapsed mucous membrane is seized with
tissue forceps and drawn laut. A silk ligature is then passed through the upper
edge of the external meatus, directlj' across the canal, and made to emerge at the
lower margin of the urethral opening.

Second SiKP.^The redundant mucous membrane is cut away in front of
the ligature with scissors and the transfi.xion suture pulled partly out of the
urethral canal with forceps.

Third Stkp. — The loop thus formed i.« cul. leaving two sutures, which are
then tied to control the edges of the wound .iX opjKisite ]Kiints and prevent
retraction of the urethrtil mucosa.

Fourth Step. — A series of intcmipted catgut sutures are then introduced
about one-eighth of an inch apart completely around the circumference of the

6o6

THE URETHRA.

The Bladder.— T)\e lirine must be voided either spontaneously or with a
catiieter every eight hours.

The Bowels. — The bowels are moved in twenty-four hours and then regularly
once a day.

The Diet. — The patient is given a liquid diet (see p. io6) for the first twenti-
four hours, and from that time on until she gets out of bed a convalescent did
(see p. 114) is indicated.

Getting Out oj Bed. — The patient should remain in bed ten days.

DILATATION OF THE THOLE URETHRA.

Causes. — The affection is not so common as dilatation of a portion of llit
urethra.

It may be caused by the spontaneous expulsion or the instrumental extraction
of a vesical calculus or tumor, and it may also result from forcible dibtationidtbe
urethra for diagnostic or therapeutic purposes. Coitus per urelhram in wotDen
suffering with atresia of the vagina and the introduction of candles or other foreipi
bodies into the urethral canal for purjioses of masturbation have been the
causes of extreme cases of dilatation. A tumor or stricture situated near the
external meatus may obstruct the flow of urine and the backward pressure may

cause the urethra to gradually dilate
above that point.

" The hyperemia of the urethra whidi
occurs in pregnancy, and which tends to
produce ovcrdistention of the vein.s,fai-on
dilatation of the whole urethra. It is
not uncommon to find an apparent ia-
creasc of tissue in the walls of the urellua
during ulerogestation, and the dilati
bility of (he canal is al«o often incrwitd
This condition of the part* disappears
during the involution which takes phn
after deliven,' : but when from any raiw
the pnxess of involution is intemipltd.
the enlarged vessels and the relaxed am
dition of the urethral walls remain awl
somciiraes increase. When to this ftaie
of the parts a catarrh of the muow-^
membrane is added, the enlargement oi
tht membrane by swelling still further in '
creases the caliber of the canal" (Skene) -
Symptoms.— Inctntintnce i> tf»«:
most characteristic s>-mplom of dilatation, and the urine may escape continuiiU--*>'
or only when the patient makes a misstep or during the act of coughing, snee*'
infj, ur liflinj; a heavy object. The continual dribbling of urine causes the su *"
rounding |i;irts to become irritated, and unless the patient is very careful >^
keeping herself clean a severe vulvitis is likely to result. If the dilaUtion •
accomp.mied l)y urethritis or prolapse, the urethral canal becomes senfiti^'*
and the patient complains of painful micturition.

In cases of miwlerate dilatation there is no incontinence of urine, but only
slight loss of control of the bladder and a frci|uenl desire to urinate.

Physical SigfllS. — The canal never presents the appearance of an 01^
tube, as its wall? are always in apposition, and hence when the urethra is examine

P'iG. 5fJl. — Dll ^rATTUN *IF THi: WllOLE I' If *:T1 IH A -

DILATATION OP THR WROI.F. rSEIJIKA.

607

either with the finger or an inetniment wc simply detect an extreme Aegne o(
diUubility.

The physical signs arc elicited by (i) inspection, (a) touch, and (3) the use of
the xiuml-

Ingpection. — Inspcriion revealj<> nn enlarged or |>outing meatus and a dis-
tinct bidging in the vaginal wall corresponding to the course of the urethral
canal.

Touch. — The enbrged urelhni is fell ihnuigh ilic vaginnl wall as a more or
less elastic and compressible elevation extending from the imernal to the external
meatus. The degree of dilatation i» reailily (IcinnnMriiled by introducing the
index -finger into Ihe urethra and passing it into the bladder.

Sound. — The .'m>u[k1 is a valuable aid in the diagnusi.-. in cases of dilatation of
the urethra. Not only arc we able to judge of the degm- of dibialion by
noting Uie latitude of movement at the lip of llie instrument, but we arc also
able to del<s;t the thirkne^-iof the urethrovaginal >eptum by pre^ting the li.viuest
with the Miund against the index-linger in the vagina.

Prognosis.— The prognosis depends upon the cause. In the majority of
cas«si ditaUlitm i>f ihc iirrlhni is due to traumatism, and ihc wall.i of ihe canal are
torn and hopelessly overstretched, llcncc nothing short of an operalion will be
of the .tliglitest Itenefit, and when the dilatation is extreme e\'en this method of
tTcatmenI wldom effects a very salisfaciorj' cure. If, hnwcvei, the lesion i$
caused by subinvolution following labor or an obstruction at Ihc external meatus,
n(m-ii|ieTiilive me.t-Mirt> are imlimled and usually effect a cure.

Treatment. The first indication in the trcatmeni is tn restore the urethral
mucuM tti its normal condition and then to rletcrmine the degree of dilatation and
Ihc probable cau.-^ of the le.>ion. f>iLil.nti(in is frec|uenlly ;icciimpaniei) by in-
flammation and prolapse of ihc urethral mucous membrane, and these lesions
mtiM fin>t lie relieveil Itefore ilirecting ntir attention to the cure of ihe abnormal
uze of the canal. The irealmenl of these diseases is fully described elsewhere,
and nothing further nee<l tliereforc be said here.

When dilnLition i^ due tn :<ubin\-i)Iution following labor or to a constriction a1
the rvlcmal meatus, ihe structural changes in ihe wall of the urethra are seldom

CMilTieienlly well marlied to preclude ihe piissibility of effetting a trure by non-
opcralive proct-durw; but when the loicn i* cjiu.»c-i1 by ir.-iumati>m. ihe lorn
>nd overstretched tissues can never be restored to their normal condition by any
fonn «l local treatment, and hence we must n»ort lu an operation to IcsiMii the
lumen nf the canal.
The treatment may be divided into;
Generid and Iwal treatment.
Surgical measures.
General and Local Treatment.— These methods of treatment siiould be
tried, as .vlaled alxivc, when dibialion is due In subinvoluli'in of the uretlira or
to an obstruction at the external meatus. In the former case the tre;itmenl may
l>e)pn at mice; but in the Utier in.->Iance we inu.st fir»t dilate the stricture or re-
move the growth causing the obstruction.

The patient should avoid all forms of active exercise, such as walking, lifting
he:ivy object.'', ami straining at stiiol. The biiwel.s are kcjit regubr with a mild
laxative and the urine is rendered non-irrilaling. .\ hot silz-bith should be
gi»en daily for its soothing effect upon the urethral mucous membrane and as
a slimubling tonic In the tissucs-

The local apphcaiions and injections that are made to the urethrtil canal are
the same as those which are recommended in the treatment of prolapse of the
urethra (sec p. Oo}).

6o&

THE UHKTHRA.

A pessary' sn conMructed as ui prens iigiiinst nnd lift up ibc urrthra ifaonU be
wtirn by the patienl. Such an instrument often controls the incontinCDCC bf the
mwhanic pre^ure which it cxcrls, and ut the same time it hjiAtint^ the oire b;
suppirling Ihr rtbxcii iirrlhml wnll. Skene's jtejAar}* (or proUpse of the bladder
and the urcilira is the in*trunicnc best adapied for use in these cases. It h lalX'
duced ill the >ame way u.-. a HodRcorii Smilh-Hod^epeAMirj. uml tiiHiconstnicid
that the urelhnl ciinul is wdl »upftnrted nnd lesM-ncd in size. (Sec CyUocA,
page IS*^') The pessary will not remain in place and
hold up the urethra if the pelvic floor or perincBo
is lacerated.

Surgical Heastires.— Tlic operation which |i<^''^ >he best re^uh-t is rtridia
of 11 jiortiofi itf the antfriiir w;itl of the vagin:i and the po^lcrior wall of Ihe uirtls.
The amount of tissue removed depends upon the decree of dtlatatiioa. The
wound is closed by transverse sulurca of silkworm-Rut which [mws through lit
walU of ihe vagina and the urc^thra, but which do nol include the urethral PUXOB.
The lechnic and the aflcr-treatmenl of the operation arc tlie same as ihiuefwdx
r.idiial cure uf a uTCthruvat;iu>-il Ustul.~i (.^ee p. 768). .^fter ibe >lilchct in
removed the urethra should be siipporled by Skene's pessary.

Another method of operating, which has iK-en suci-cssfully performed to a»
of marked dilatation, i^ lo dLviecl ihe urethr:i free up to the nrrk of Ihe bbdds
and then to make a partial or complete roljition of the canal upon its udiidI
stitch it in this twisted condition tt> its original attachments.

URETHROCELE.
Synonym.— Sacculated urethra.

Definition. I'rethroccle is a dilatation or a sacculation of the midiU'
third of the posterior wall uf the urethra. The anterior wall remains in ill

normal position, and the shape of ih
urethra is chan){eil fn>m a sligliUy <wii
canal to that of a more or leu wcU-<kfiMd
triangular space.

Catiaes.— I'reihrocele is nwrt bt-
'^'- / ^flB^ll/T^H. qucotly oKiened than dilatation o( th* |

whole urethra, and the muMi comnwD
cause of the affection i^ liaunutis^
occurring during a difficult labor. A^ i
the child's head advanib it pushes h^' |
fore it the anterior wall a\ the tapi»*
il/K'.sllLi ■^-^'SISe 111 ill /I and ihe jiosterior wall of the urethra, »i»^

the tiMuc* of the urethral canal are mrf '"
stretched, torn, and bruised. The urethi^*
sails at it» middle portion and the dilit*-''
tion is subsequently increased by the p«*j
sure iif Ihe urine during micturition, ••'^
rvenlually « distinct pouch or saccuUtio^
is dc«loped. .\nother cause that is or -^
casion.'illy met tt. a stricture or a tuiaa^
Pn. )«4 — Vktiir'm I . > nt Ihe lower portion of the urrthi^^

which acts as an obstrurtton U the ""•^
mil flow of urine and thus indirectly favori dilatation of the canal.

Symptoms.— The chief symptoms ore frequent. [Minful, or difikuli nir -
lurition and {lartiat incontinence of urine. A frequent clesire to uriiute i.^

fc.

l'B£Tltlt(X'et.E.

^■09

>re»«nt in tli« vii»l majority <>f the »»£». The juiin during micturilion is due
'.!• .1 toexhlin^ urrthritU ivhich is :i frciiucnt complication of urethrocele and
iiilirct-tK i4U.-<vl liy ilic Ic>iiin. The urine ihul is arrested and

Ktalnrd in the ])(>uch nf the urcthrncele undergoes
comfi'Silion, becomes ^tlk^line, and by its irrilii-
lliin ^el•1 u i> a suli.ii'ute urcllirili^. The Mraming elTofU
rvhtch Bome patients nuke uliilr voiding iirinr arc due to tlie obstruction
:?U!4;<] by lli« iwctulatcd condition of the urrtlira and lu the vfsical tenesmus
■vliii'h is ()C4':u^ion.i)ly ejH'iied by the Ie»ion.

r^rtid) incontinence of urine is a constant and chsradcristic symptom of
dilatation of Uic miildlc lUirtl of the urethra. The urine <loes not escape con-
tintiousty, hut itt trreguhr intervals, in jet* or s|iurt» during the act of coughing,
snevKinv. bu^hin!;, or lifting a hvavy object, sind when the patient makes a mia-
1W1> The incontinence is not due to a want of control

fir., tAf ^'■■'■'■''(■L*,
(^■wWCthfuMuvhlrlili mmbpI In Ihr amhfaRlc *t the i!iiir of uiiiuliim.

ihe bladder, but to the urine being ejected from
'^ r )ti>ui:h of the urethrocele, where ft wnn arrested
>^i| r<-t.)ineil ul the lime of urination.

Physical Signs.-— TlKse are dictted by <0 inspeclion. (a) touch, and (3)
'*ru!cw( lh*;.M)Und.

Inipection. In^iet tion rcvcaU a distinct liuliiing in the anterior vaginal n-ati
*»n'^ixjii(IiiiK lo (he p«isiiion of Ihe middle ihirri of iht urethra.
IL Toticb. -The urethrocele a felt thnni^h (he vaginal wjU as an elastic .ind
J»o;fi-i.ihle Ium4>r <<ccuj>yint> the po>iti<iTi <<f the mrddle thin] of the urethral

W Sound. - TheuseofthesoundUa vulunble meansof determining the prcMiwe
•^ .^ urrthrocek', If the in'lnimrnt is inlriKluced into the urethra «iih its poiol
^ii'rint,|owiiM-ar>lugainst the posterior wall of the canal, it will sli|i into Ihe sac -
I and ('Jin be easily fell by the examining finger through the intenening
•-III the wginj. Again, if the tip of the sound in nun- pressed firmly against
w

6io

THE URETHRA.

the most dependent portion of the urethrocele, the exaggerated distentionirhid
results at that point in the vaginal wall is readily seen.

Flo. jM. — Touch. Fig. 56). — Saaul.

PavstCiU. SiCHB OF UiKTRiocrti (pace $00).
Fif. j66, fHlios ft UTFIhrDcde Ihioufh the vi^iiu wiLh the tip oi iIh LDd«i.flwcT; Fif. ^7, dsHAnnaig ik
prncEicc of a urethrocele by mutai of % ttmiia-

Differential Diasnosis.— Urethrocele must be distingui^ed bom i

suburethral ubscess and a tumor of the vaginal wall.

trHKTHHOCELE.

I Indistinct bulging.

3. Situated in the anterior vaginal nail.

3. Disappears on pressure.

4. Tumor elastic and cotnprcsstble.
S- No tenrierness.

6. No pain on walking or coitus.

7, Only the vaginal and urethral walls be-

tween the examining finger and a sound
in (he urethra.

Vsethbocele.

1. Situ.ited in the anterior vaginal wall.

2. Indistinct bulging.

3. Disappc.irs on pressure.

4. Tumur elastic and ronipre=siblc.

5. Only the vaginni and urethral walls be-

tween the examining finger and a sound
in the urethra.

Spbdrethbai. Absou.

1. Prominent tumor.
a. Same.

J. Only partially disappears when iobk of
the pus is squeezed out into URthn,

4. Fluctuating and prominent.

5. Very painful on pressure.

6. \'ery painful.

7. The thickness of the intemiu[i| nn'-

tures is increased by the presence of
the abscess.

Vaginal Tuhos.

t. Same.

2. Prominent tumor.

3. Does not disappem.

4. Tumor firm.

5. The thickness of the intervening W*"

tures is increased by the tumor.

Prog:il08is. — There is no tendency toward a spontaneous tnire, and if not''-
ing is done, the dilatation gradually increases. Treatment is followed by good
results in the majority of the cases.

ITitETHIIOCF.Le.

6tt

Treatment.— Tbc treatment of urethrocele is divided into;
Non-op«nt(ive procedures.
SurgiiTil meihixls.

NoD-operative Procedures.— This form of treatment is indicated in caKs in
which the uCfectiun is due lu an ulMiruciion at the exiemal meatus. 411H should be
iii»lituir(l .-iflcr removing the lumor or dilaiing the »incluic as the case may be.
As the affection is usually associated with urethritis, the next !>te|> in the treat-
ment u ti> cure this coiiditioii by the local and ji^enenil mcantt nirriidv described
in discuiising that disease (sec \). 594). Aftrr the urethritis has been relieved
local applications and injections arc made to the urethnt lo siimulate and con-
irarl theti-v<ues. These applicttionn are the same us those recommended in the
treatment of prolapse of toe urethra (see p. bo^).

Skene's jie.ssary (Fig. 356) should l>e worn from the licpnning of the treatment
10 support Uie urethral canal and hasten the cure of the lesion. The use of the
pcKsary ma terklly agists in the cure of the urethritis, as tt obtileratex the niccu-
lation and presents the accumulation of urine which would otherwiKe be retained,
become alkaline, and keep up the inflammation.

Stirg^cal Methods.— 0]>eni live iirocedurex are indicated at once when the
urethrocele is caused by the traumatism of labor, as we cannot hoi>c to restore the
torn and overstretchctf structures Ki ihcir normal condition by any form of local
treatment. They should 11I50 be insiitute<l when the non ojierative pbn of trcal-
DKnt has failed to effect a cure in the class of cases referred to above.

The maimgcment of these ca^e* iit carried out as follows:

1. NIake an artificial urethrovaginal fistula.

2. Treat the urethritis

3. CloM the fiKtuht.

4. Introduce Skene's pessary.
Make an Artificial Urethrovaginal Fistula . — If an

obstinate urethritis is pre^nt. an opening should be made at the most dependent
pan of the urethrocele and the mucous membrane of the vagina and the urethra
united by interrupted catgut tnitures to injure ihe jiermanency of the artificial
6slula.

The object of the (>|>eration i» to drain ihe urine ihroufih the false o|>cninK
and prevent its accumulation and subsequent decompo.*ition. The cauf* of the
urethritis is thus removed and its cure rendered possible.

Treat the Urcthriti ». — The urcthriti:* in now treate<l by the local
and general methods described on page 504, and after Ihe mucous membrane of
the urethral canal ha5l>cen restored toitsiwrmal condition the artificial fistula is
closed.

Close the Fistula. — The redundant tissues which form the urethro-
cele are cut away to reduce the \ixe of the ciiuil at the point of sacculation and the
fistulous o|Kming dosed as described in the operation for urethrovaginal fistula
onp«Ke768.

Introduce Skene's Pessary . — .After the stitches have been re-
moved and the patient gets out of bed. Skene's pessar>- should be introduced and
worn for several months to act as a support to the urethral canal and lo guard
against a return of the dilatation.

Vakiatio.v in Tkchmc— In cases of urethrocele which are not compli-
cated by urethritis the sacculation should be remove<l at once by operative
measures. This is accomplished by making an opening thn>ugh the vaginal wall
into the urethra and cutting away the redundant tissues which form the urethro-
cele. The wound is then sutured anil clo^eil as described in the operation for
ttrethrovnginal fistula on page 76S. TATicn the patient is ready to get out of bed,
Skene's pessary is introduced and worn continuously for several months.

6l2

TiU: URETHRA.

SUBURETHRAL ABSCESS.

Description. ^The abscess occupies the urethrox'aginal septum; itvaric?
in size from a cherry to a small lemon; and communicates with the urethra by
means uf a small oijening.

Causes. — This aSection is not common. It is supposed to be due in the
majority of cases to inflammation and occlusion of Skene's ducts, which are sut
sequently followed by an ulcerative perforation of the wall of the uiethra. It lus
also been obsen'ccl associated with a urethrocele caused by the traumatism rf
labor. In these cases the wall of the urethra is torn, and the inflammation, iilb
the subsequent formation of pus in the tissues beneath the urethral canal, is
supposed to be due to the presence of the retained and decomposed urine.

Symptoms-— As in abscesses of other parts of the body, pain is the mca
prominent and characteristic symptom, and its severity depends upon the enm

Fig. so8 — Si-ih-ki"tiihal Abstisb.

of the purulent inflammalinn. The patient complains of severe sufferinK dun'ii;
defecation am! urinntinn; sexual intercourse is impos-siblc; and in nun* ii
statues uMlking is jjrevented by the exquisite Iik.iI tenderness.

Physical Signs.— The patient i.'; anesthetized and phiced in ihf *if™
position. The physical signs are elicited by (i) ins]Jection, (i) touch, airf (]'
the urethroscope.

Inspection. — On separating the labia a well-defined ovoid tumor isot«nN
on the anterior vaginal wall. ci)rre.=ipondinK in a general way to the situation ol u"
urethral canal.

Touch. The tumor is tluctuating in character and decreases in siK nil""
pressure, the pus being forced out of the sac into the urethral canal and esapiDf
through the meatus.

Urethroscope.— An openinR is seen in the posterior wall of the ui»*t*
through which a fine probe may be passed into the sac and felt by the eiairumiH

SARCOUA — CYSTS— POLYPI.

615

affection miy be either primary or stf.ondary; but in most insLinces the ruin or
th« vagina is primiirily involved. Cancer of the bladder seldom extends to the
urethra

Symptoms. ^Thcsyroptomsor strandary cancer oi the urethra, in addition
to those caused by the primary aSeciion. are due to the obstruction of the canal
by the new-growth. There is idway? more or less diffuullv in |>aK>Jns urine from
the beginninfc but later on. when tlic canal becomes compiclcly clo£«d, symptoms
of retention manife-«t them.selves.

Primary (atuw of the urethra is usually ;issoci;iied with ;in irritating acrid dis-
charge which produces pruritus nilvx and intense itching about the meatus. The
urethra soon becomes inflamed and the patient compluiiii of painful urination.

D ia?nOSiB.— Srfonifury ratuer is easily recognized as an extension of the
dise.isc mim tlie %ulva or ilie vagina, and when the aScction is primary, the
character of the tumor is revuded by palp:tlion through the vaginal wall and by^
the u»e of the urelhroscope.

Treatment. ^Nothing can be done in cisesof jecwH/iiry cancer of the ure-
thra beviJiid keeping the urethral canal patulous. If this cannot be accomplished,
the bladder vhould be drained either through an arttlidal vesicovaginal fi&tuta or
a suprapubic ojiening.

Removal of the urethra is indicated in cases of primary eamtt in which the
dLse:i»e is limited to the canal. The removal of the distal end of the urethni does
not inicrferr with the patient's control of (he urine. If it is neccssar)' to remove
the whole canal, the bladder should be sutured and drained by a suprapubic
opening. Advanced cattes are treated in (he same way as secondary involve*
menis of the urethra.

SARCORA.

The Symptoms. Diagnosis, and Treatment of sarconia
of the urethra are the kame as tlioiie of carcinoma.

CYST&

Causes. — Small retention cysts of the urethral glands are occasionally
observed. They may occur at any age and arc not limited to any particular
portion of the urethra.

Symptotns. — These cysts dn not cause urethritis, and hence they result in
no inconvenience unless their presence conauicU the lumen of the canal and in-
terferes with the flow of urine.

Diagnosis.— Their presence is re%-ealed by palpation through the vaginal
wall and by the use of the urethroscope.

Treatment. — The cy^l^ are ex]>o^ed with a speculum and the superficial
portion of their tAc^ snipped off with scissors^ the base of each cyst is then
touched with pure carbolic acid.

POLYPL

Description. — Mucous or fibroid polypi are rardy obwrved in the
tirclhm. Thc-y may be ^ngle or multiple, and are sometimes found hanging
from the meatus by a slender stalk. The>' may occur at any age, and cases have
been obaer^'ed in ver>' youn); children.

SjTDiptoms. —They cauw no inconvenience whatever unless tticy become
inflamed or obstruct the lumen of the urethral canal.

Diagnosis. —.'^ urethral polypus is easily recognized by inspection when it

6l4 THE URETHRA.

bleed readily when irritated ; they may be pale or bright red in color, resanUing
more or less a raspberry in appearance; and in some cases they are erectile lod
become swollen at the time of menstruation. Urethral caruncles aie occasioaillf
met that are not sensitive and have but little tendency to bleed. These cases uc
the exception, however, as the vast majority of caruncles are exquisitely sensi-
tive and very friable. The painful condition is probably due to the incieastd
nerve-supply and also to the fact that the epithelium often becomes macerated
and destroyed, exposing the sensitive nerve-endings in the growth.

Symptoms.— The most characteristic symptom is pain during urinatioD.
The greatest suffering occurs while the urine is being passed, and after the act the
pain lessens in severity until in the course of ten or fifteen minutes only a slight
smarting remains. The character of the pain varies in individual cases: som^
times it is so agonizing in character that the patient is physically prostrated after
each act of urination ; and in others it may be so slight as to cause but little in-
convenience. In some cases pain is also caused by walking or by ftictioe of
the clothing, and occasionally sexual intercourse is rendered impossible on
account of Uie severe suffering and the vaginismus which are frequently associated
with these neoplasms.

I'he bleeding from a urethral caruncle never amoimts to more than • di^
oozing.

The effect upon the general health in aggravated cases is marked ; the pitial
becomes physically weakened and emaciated from the long-continued sufietiog,
the loss of sleep and exercise, and the lack of desire for food; and eventually she
presents all the appearances of a woman dying from an incurable organic diseiK-

A non-sensitive caruncle may cause no symptoms whatever.

Diagnosis. — The diagnosis is based upon the subjective symptoms and the
physical appearance of the tumor.

A small, red, raspberry -tike growth attached to the margin of the eitenul
meatus, which is sensitive upon touch and associated with painful urinatiiHi, is,
in nearly every instance, a urethral caruncle.

Prognosis. — ^A urethral caruncle is likely to recur unless it ts completel.r
extirpated. A non-sensitive tumor is usually discovered by accident during u
examination for other conditions, and unless it causes symptoms it should not be
removed, as a painful caruncle may spring up in its place.

Treatment.— The treatment is operative; local applications have no cun-
tive effect whatever.

A general anesthetic should be employed, as a rule, as the growth annoi
usually be satisfactorily removed under the local influence of cocain.

A pedunculated caruncle should be seized by tissue forceps and its V"^
severed close to the urethral mucous membrane with scissors. If the pedides
thick, the raw surfaces should be brought together with one or two intemipted
catgut sutures.

A sessile tumor should be seized with tissue forceps, lifted out of its bed, oA
excised welt below its base with curved scissors; the wound is then closed wilt
interrupted catgut sutures.

When the caruncle is situated high up in the urethra, the canal should be u-
lated and the tumor exposed with a speculum. It is then removed in the siB*
way as a pedunculated or sessile growth situated at the margin of the tSttnil
meatus.

CARCINOnA.

Cancer of the urethra is a very rare condition, and in the majority <rf c***
that have been observed it occurred at or near the menopause or even later. The

SARCOMA— CYSTS— POLYPI .

«»s

aSMtion may be cither primary or tfeondary: but in most iaslanccs the ^-ulva or
the vagina. ^ primarily involved. Cancer of the bUid<lt-r scUinm extendi^ to llic
urethra

Symptoms. — The symploms of sttondary tancer oi the urethra, in addition
to i\\afie- i-iiused by the primary' afieciion. are due to the obetructioti o( the onAl
by the new-growth. Tliere is always more or less difficulty in paa&ing urine from
the bepnning, but later on, when the ciiniil becomes completely closed, symptoms
of retention manifest tliem»elves.

Primary ianctr ol theureilira i» usually associated with an irriiatin); acrid dis-
charge wliich producer pruritus vulvx and intense itching about tlic meatus. The
urethra soon becomes inflamed and the patient complains of painful urinatioo.

Di&gnosifl. —Secondcry tancer \s easily recognized as an exten.tion of ihe
diseii.'tc frimi the vulva or the vagina, and when the aScctlon is primary, the
diarjctrr of the lumnr w revealed by palpation through the vaginal wall and by
(he u.^e of the urethroscope,

Treatment. ^Nothing can be done in cases of see&ndary cancer of the ure-
thra beyond keeping the urethral c.tnal [wtulous. If thi» cannot be accomplished,
the bladder ^ould be drained cither through an anilidai vesicovaginal fistula or
a suprapubic o|>ening.

Removal of the urethra is indioilcd in case« of primary ranee* in which the
disease is limited to the canal. The removal of the distal end of (he urethra does
not inicrfcre with the [uiiient's control uf the urine. If It Is necessary to remove
Ihe whole canal, the bladder should be sutured and drained by a suprapubic
oiteninii. Advanced cases are treated in the same way as secondary involve-
ments of the urethra.

SAROOSIA.

The Symptoms, Diagnosis, and Treatment of sarcoma
of the urethra are the same as those of carcinoma.

CYSTS.

Causes. —Small retention cysts of the urethral glands an occasionally
obsencd. They may occur at any age and are not limited to aoy particular
portion of Ihe urethra.

Symptoms. — These cysts do not cause urethritis, and hence they result in
no inconvenience unless their presence constricts the lumen of Ihe csnal and in*
lerfetes with the flow of urine.

Diagnosis. ^Their presence ts revealed by palpation through the vaginal
wall and by the um of the urethroscope.

Treatment.— The cysts are exposed with a speculum and Ihc superficial
portion of iheir »ac> snijipeH off with scissors; the base of each cyst is then
touched with pure carbolic add.

POLYPL

Description.— Mucous or fibroid polypi are rarely obsen-ed in the
urethra. They may I* single or multiple, and are tonteliioee found hanging
from the meatus bya blender stalk. They may occur at any age, and ca£cs have
been obsen-ed in very youiiR ihij<jren.

Symptoms.— They cause no inconvenience whatever unless Ibcv- become
inflamed nr obstruct the lumen of the urethral canal.

Diagnosis. ^A urethral polypus a easily recognized by inspection when it

6l6 THE BLADDER.

protrudes from the meatus, and when it is situated high up in the canal it may tx
seen through a urethroscope.

Treatment. — The growth may be easily removed by twisting its pedklt ur
by snipping it oS with scissors; when it is situated high up in the canal, it nuft
first be exposed to view with a speculum.

CONDYLOHATA.

Causes. — Papillomatous or warty excrescences in the urethra are genenlly
associated with similar vegetations of the vulva. They are usually causal by
gonorrheal discharges or the oozing from mucous patches on the extcmal genitab;
they have also been observed during pregnancy and as the result of an irritatiitg
non-specific leukorrhea.

Symptoms. -^Large condylomata may obstruct the urethral canal and ia-
terfere with the flow of urine. The disease is usually accompanied by an acrid,
fetid discharge, which often causes a severe urethritis and painful excotiatiDn!
of the vulva.

Diag;nOSlS. — The diagnosis is based upon the presence of papillonutoiu
growths on the vulva and the exposure of the excrescences in the urethra wild
a urethroscope.

Treatment.— The papilloma is seized with tissue forceps, lifted oulofiB
bed, and excised with curved scissors close In the healthy tissue. The raw sur-
face is then cauterized with Paquelin's cautery or touched with pure oriwlic
acid, ^\^len the growths are situated high up in the urethral canal, they tma
first be exposed with a speculum.

CHAPTER XXX.
THE BLADDER.

METHODS OF EXAHINATION.
The bladder can be c.vamined by the fdllowing methods:
Direct inspeclion.
I'alpaiion.
l'ercu;,sion.
Soundinc-

!lydro?talir dilalalion.
Cystoscopy or Indirect inspection.
Chemic, Microscopic, and KLicieriolopic examinations of the urir»^'

DIRECT INSPECTION.

I^imitations. -While no ywrtion of the bladder can be examined by di*',)
inspectinn, u pr<itru>Lon of the organ into ihe vagina or a distention above
svmi'hv^is )iubis can rcadilv be 'ven.

Information. — The fullowinfj conditions can be recognized:

Lower Abdomen. — .\ rounded tumor or prominence above the symph^
can he riccn when the bladder is disteniied viith urine.

Anterior Vaginal Wall.— A biilRinsr of the anterior wall of the vzpn^
observed when the bladder is filled with urine. A cvstocele also forms a dist *

M»:rilOI>S OK i:XAWINATION,

617

tumor in the same utuulion, which t*, how-ever, arcomjiiiniefl by mure or iew
prolapse of the bladder waU anti the vagina. A vesicovaginal fistula can be
readily recognized when the anterior wall of U«r i-apna is expooed lo vie*-.

Preparation of the Patient.— Tlie urine .shtmld t>e voided naturally
jtul lieforc the examination .ind the corsci lomovrd as well as all ctothinf; that
conMrictv the \t:i'iM or inierferei with intijictnion of (lie lower alKlomen.

Position of the Patient.- Abdominal Inspection. -The i>aii«nt
should lie pl:i(.<^l in the hori/^ini;ii rvcunilicnt |x>^ition with the li>wcr exireniitici
extended anil nn the >ame plane a& the re^t of the bcMly. This jKuilion thor-
ouKhlycxpo^^ the hypogastric region and incrca$c$ the size of the swelling caUMx)
bj' the distended bladder.

Vaginal Inspection.— The dorsal position kIiouM always be employed.

Technic. Abdominal Inspection. The c\.imlner stands at the side of
the patient and tarefuUy inspects the hy{K>ga-'>tric rej^on, noliiiji; uiy <'hange in iIk
size or sha|K:.

Vaginal Inspection.— The examiner now sits or sunds in front of the vulva
and intmdurir^ ihe iivlex-fin^r of the left luind into the vaciiui with the jialtn di-
rected downward. The perineum and the posterior vaginal wall arc now re-
lra<-leil with the ftujiier until the
anterior sMrfacc of the vagina
cornea into riew (l-'ig. k>i).

PALPATION.

Limitations. The entire
bladder can be thoroughly pal-
p>ated by means of (i) vaginal,
(i) abdominal, and (3) vagino-
alxlDmiiiiil Iimrh

Information. IIh- follow-
ing condilii>ns can be recognised
by (lalpiition:

Vaginal Touch. The base
of the bladder can be examined
and pathologic changes reirogntzed.
We may thus determine the pro
encc of a distended bladder, cystty
tele, foreign IhhIIcs. calculi, neo-
plasms, and intlammation.

Abdominal Touch.— If the
bladder is (li.ileniled. a round,
tense, elastic tumor can be (dl
abo\-e ihe .-iymphy^is.

Vagino-aMominal Touch. -
Btltianual |uIpation gi^cn the
mo«l Mti.<facti>rY results, as the

bladder can be ihorouf^l.v explored with the index-finger in the vagina and
the fingers of the other Iwrxi making counter -pressure downward through the
alxloniinal wnlls above the synlphy»i^. The organ can thus be rolled in all
direcltons between the opposing fingers, and the thickness, mobility, .tml >ensi-
tivenCiw of its walls, as well as other |>athologir cmnditions, clearly determined.
We can thus recognize the presence of 3 distended bladder, neoplasms, calculi,
foreign bodies, tul>ercular involvetncnl, and localized areas of Infiammalion.

jUiHimHU Tubtn
Sham (bt mHhsl el noiciililnf fMMoctc nadiiba* cil
Urn libiUii l/f |i>)(uii.<i

6l8 THE BLADDER.

Preparation of the Patient. — Same as for Inspection.

Position of the I^tient.—The dorsal posture is usually emplond
in palpating the bladder ; the Itnee-chest position, however, can also be used wbtn
the organ is examined bimanuallv.

Anesthesia. — In order to make a satisfactory examination an anestlKtic
should be employed in women who have fat belly walls or rigid abdcnniiul
muscles.

Technic. — The examiner sits or stands in front of the vulva and paipats
the abdominal wall above the symphysis {abdominal touch), noting any chai^
in its size, shape, or resistance; he then introduces the index-finger of the left
hand into the vagina (vaginal touch) and notes the absence or presence of bti^uig
in the anterior vaginal wall and any abnormal condition at the base of the bladder;
and, finally, the fingers of the free hand are again placed over the symphysis and
pressure is made downward through the abdominal wall until the tip of the
vaginal hnger is felt (vagino-abdominal touch), when the whole organ is cattfuUr
examined by rolling it in all directions between the two points of reststance.

PERCUSSION.

This method of examination is employed to recognize a distended bladder.

Normally the percussion- note over the h>'pogastric region is tympanitic, wd
so long as this is not altered t h e bladder cannot be distended
with urine. When, however, a round, more or less tense, and fluctuatiif
tumor is present between the symphysis and umbilicus and percussion gives i
flat note over the entire swelling, we may be almost certain that the bladder is
full of urine. We should, however, under these circum-
stances verify the diagnosis by ca t he ter izi ng tbt
bladder,

SOUNDING.

I/imitations.— The entire cavity of the bladder can be explored with the
sound.

Information. — By sounding the bladder we can determine the presence oi
a foreign body or a calculus, and if combined with vaginal insfjection or touch **■
can estimate also the thickness, the mobility, and the sensitiveness of the wali*
of the organ as well as diagnose a cystocele.

Preparation of the Patient. — The urine must be voided natural*'
just before the patient is examined.

When the patient is placed on the table, the meatus and the vulva must t'

FlO. S71.— StEtl BL»tlIll« SODHD.

Tnuruniral uanl [or Hjundin^ The Uadder,

thoroughly sterilized to prevent infection being carried into the bladder. This
accomplished by scrubbing the parts with a gauze sponge saturated with tii»-'
lure of green .soap and warm water, and then washing them with a solution ^
corrosive sublimate (j to 2000), which in turn is removed by douching wm."*
sterile water or normal salt solution.

Position of the Patient.— Dorsal posture.

Instmments.— A short slecl female bladder sound with a slightly cur*"**
end is the only instrument required.

UtniOUS OF »:XAUl!f ATIUN.

619

tisepsis. — 11k sound is boilod in a soda solution for five minutes
n placed in a ttuy unlil n:ady for use. Rubber gloves should be worn to
inst contnmiiiutiiitt the iiisirumeiit ami utrn'injt infection into the
Liquid white vnsclin which hits been previously sterilized is used to
the tound and facililiitc iLs intruduclion into the bladder.
.e8i&> -No aiKs.lhelic is rvipiireil.
lie— ^Tiie examiner siis in front of the vulva and ex|M:n«s the external
leaius. 'Hie wnind is llit-n iiitnxiuc<^ into ihc urcthr.i and passed
lly into the bladder. The instrument is then moved about in various
tiong, tiiking cure ni>t to injure the muooMi by rouKh manipuUlinns, and
reseno! of any pathtdogic conditions notod. In cnscs nf cyslocele by rotat-
le tip cif the sound downward into the sacculation the point of the instmment
«e !«cn and felt thnKigh t)ic anterior vaginal wall. Again, if the lip of the
i in directed downward and at (he same time (he indcx-finger is introduced
l)ie vagiiu. yee are able lo estimate the mobility, tlie thickness, and the sensi-
icss of the base of the bladder.

■V,

■>.\<s-

^ _ , . ^_- £,

HYDROSTATIC DICTATION.

bformation. — H>-dTos(atic dilatation of Ihc cavity of the bbdder is (he
important method of examination we have at our command to e s 1 1 m a I e
capacity of the organ and diagnose cases of con-

c t i o n which arc often the cause of frequent micturition. It is also useful

imonMniitig the presence of a cysioceie by incrcaiing the intravesiail |>ro-
which form^ under the circumiianccs a round. Ien>c, elastic tumor in the
(Or vaginal wall. When the rcsenoir is lowered and the intr;ivcsical pre*-
b reUes-ed, the tumor diNappcars and the vaginal wall becomes wrinkled

Klutod.

bjo

TUE BLADDER.

fic- s74r — AsHTD}«'s ArpAkAiis von Hydrostatic DiUTAitOMor ruE BLAMm.

Shorn Ihc mflhoil i.t irnxJoyina luilrnfl^ilir dil.ilaiinn Tlir iliftFTHitc l«I««n Ihc oripi"! I™
Jrri-^un^ k'vrl c»f Ihc duid in Ihi^ ri'<^TVipir i< Ihi- cu]Eiiilv tA the blaUdcfr

HI:TI1UUK OF t,3iMStiiATlOS.

bit

Preparation of the Patient.— Sam* as for Sounding.

Position of the Patient. -Dorsal jHWiurc.

Apparatus. -Tho ;i|i[ur:itu> i-iiii>i.>ts <if :i gbs* cutheter, (our feci of nibber
tuhini;. -i i,'r.idu--il<^l glass rcscnoir, itnd a ihcrmotuctcr.

Antisepsis. Tbc apparatus b steriliixtl by boilin;: it in pbin water for
fivr mitmli-..

Anesthesia. -Xci anesthetic is required,

Teclinic.— After plaiinjj; the jKitienl in the |iro)irr|>nMlion with the hips
resting nn a surgical jind, the glass reservoir is filled with ivarm normal s;dl
solution (too" 1'.) and aMn.il] r|u:intily of the tlutd altmved li> es(-a|ie throuj;)! the
i*alhei«r tu [»rei-ent air jjcetling into the bladder. The examiner now ci]«>ses the
meatus and passes the catheter direetly into the blailder. The reservoir is then
held 4)x)ut four fi%t alNJW the surfnix nf ibc lahie and the lluid allowed to How
into the bladder until the patient complains of distention. The level of
the fluid in the reservoir Is now trom pared with the
original level and [he difference in ihe quantity be-
tween the tn-o will indicate the holding capacity of
Ihe bladder.

To demoa'itrritc ihc presence of a cystocele the same apparatus is employed,
and after tlic talheler is ininxluced into the bladder ihe anterior taslnal wall be-
comes alternatelv distended and rela.xed as the Te>ervoir is rni^wJ and (uwered.

CYSTOSCOPY OR INDtKECT INSPECnON.

IrimitatlonS. - The whole surface of ilic mucous lining of the bladder can
l>e c-\|io«'() lo vk'iv by a cvfitoMopic ejiiamtnation.

Information. -By means of a c^'stosco|>e all of the pathol(>gic condittonti
met in liiL- l>jjil.k-r tan be thoroughly examined by indirect insiwction and au
accurate diagnn^is made in nearly ever}' instance. The value of a
cystoscopic examination in cases of cystitis can-
not be overestimated, be<*ausc tlte character of the
treatment fre'|uenlly dc]>ends u]>on the situation
and nature of the inflammatory lesions.

Preparation of the Patient.— Tlie colon mu^t lie thoroughly evacu-
ated by inking tlu- patient a bollle of citrate of magnesia, followed by a large
rectal enema of >oapsiid^ and warm water. Xo food should lie taken for several
hours Itefore the examination and the urine miuM be voided nalundly immedialriy
before the ptilient is examined.

When the patient i- place«l on the examining 1al>le, the external urinar>-
meatus and ibc %-ulv.i mu-t be ihiiniughb* slcrilixnl. (See .Saumiitt); Ihr BiiiJJrr.)

Position of the Patient. -Two positions are employe"! in nKiking a
cy*toMnpii examination. Tbc dofMiNacra! elevated and the knee chest postures.

Dorsosacral Elevated Position. - The hip?^ miisl be elevaiwl from twelve
to fourteen inches abo\-e the surface of the table so as to raise the pehns and
allow the bbulder lo IkiIIixhi out when the <-yN|oseo|ic i^ introduced.

This is the best position for making a cy!>to*copic
csaini nation and should be employed in all cases
except in women who are very fat.

Knee-chest Position.— The patient is placeil in the knee-fhest p<isition with
the knee^ .scjuralod aUm! twelve inches and the buttocks on a line
with the middle of ihe calves nf the legs. II ti>e patient
is examineil under a general anesthetic, she can be held securely in this position
by supporting the hipa and thigh.'* with I.cntz's moditied Edebohls's leg-holders.

633

THE BLADDER.

Very fat women should always be placed in the
knee-chest posture for a cystoscopic examination,
as the bladder does not balloon well in the dorso-
sacral elevated position and consequently a thorough
inspection of its cavity cannot be made.

liiStrtunettts. — (i) The Ashton-Gans cystoscopes (three sizes, Nos.14, 3^
and 36, French scale); (2) Kelly's cone-shaped urethral dilator; (5) k>ng,dcli-

Tia. 57a. — iHtnimum rai Cnroecopv 01 Imnuct ImncnoM at rmz Buddd.

cale, alligator-jaw forceps; (4) Ashton's modified Snell's residual urine mc-
uator; (5} Kelly's ureteral searcher.

The cystoscopes and the urethral dilator are described under Urtihiv-
scopy on page 585.

The Residual Urine Evacuator. — This apparatus is used to remove tbt
residual urine and keep the bladder dry during the examination. It consistsof i

3zr)

Kic. syy-' — Ashton's MODincATioN or SvELr's Rt£n>rrAt UntNt Evju-nAia.

rubber exhaust bulb and a long delicale metal tube which is perforated at te
distal end by several small openings.

The Alligator-jaw Forceps.— This instrument is used to hold small ballstf
absorbent cotton which are employed to absorb the residual urine, keep the «s-
ical end of the cystoscope clean, and remove secretions from the mucous mw
brane of the bladder when thev obscure the parts.

The Dreteral Searcher.— This instrument is a long delicate sound whidii*
used to probe the vesical mucous membrane and locate the ureteral orifices.

UETUOIIS OF eXAUIN'ATlON.

693

Sterilization of the Instnunenta.— The cY!iioNcop», the uretbnil diUlor,
the urioe craniator, the alligator-jaw forceps, and the searcher arc boili^ for
five minutM in a soda .solution, ^nd ihc light -carrier, wbich includes the lamp and
slender connecting tube, is imtnersetl for len minutes in :i 3 per cent, solution of
earttolic acid. The handle of ihc lighi-carricr is wrapped in sterile k^^uix

(p- ;«-)•

Absorbent Cotton and Boric Acid Solution. —Small balls of ab

sorbent cotton and a saturaied solution of borjc acid must be on hand to
absorb the residual urine, keep the cystoscope clean, remove the secretions
from the mucous membrane, and steriliie the vesical trigone if it is necessary lu
u»e the ureteral se.irrher.

Liquid White Vaselin.— This material is used lo lubricate the instry-
ment» and is sterili/eil in the ^me manner as liquid soap (see p. 814).

FW. tin— CmoMon o* iHnuTT Imfwtiiw or mi ttiAram witm nn Ftnixi ai tki DoaMi Eimnn

Rnbbcr Glovca.— The examiner should wear rubber gloves to guard
a^nin-si rcmtjmiii.iTinx (he instrument.-' and <*.irr)*in); :nfr< tion into the bladder.

Anestliesia. A general anesthetic is requirtxl. as n rule, for the firM
examinatii>n. and if a local lesion is discovered it nuy lie trcateil subsequently
UT>der the intluence of a 10 per cent, solution of cucain applied to the urethra on a
pled Ret of coitoti.

Technic. — The examination ^ould be made in a darkened room, and b
divided into three steps as follows:

634

THE BLADDER.

Dilatation of the external urinarj' meatus.

Introduction of the cystoscope.

Inspection of the bladder.
Dilatation of the External Meatus. — The dilator is introductd into ik
urethra with a rotary movement until the meatus is stretched to about i: miiji
meters. A greater dilatation than i6 to i8 millimdeti
should never be practised on account of the danger
of rupturing the urethral fibers and causingapirr
manent incontinence of urine (see Fig. 534).

Introduction of the Cystoscope.— The obturator is pkced in the crstosoir*
and the instrument passed directly into the bladder by following llie mtunl

Kic- 5*0. — Cystosiupv oh 1nihkf<-t iNsnriroN o^ the HLinnvB with niK PAnnrr ih rui K«(**^

I'liSITIilS,

dimtitin of the urethriil can:i] (sec FiR. 555). The obturator is tht-n mtbdn^
the I L^'ht- carrier attached to the cystoscope, and the handle connected wift"*
hatk-rv.

Inspection of the Bladder. — The current is turned on by pressing the bull*
in the handle ari<] the exiiminer looks ihrough the cvstoscope into the blaW''
(rii;. 57<)l- If the bliidder does not balKion out well, the fault is generally oy
to the piitient being |ihiced in an incorrect posture, and the difficulty is ttwi!
ovLTiome by increanng the elevation nf the hips, if the dorsosacriil f/fi'J'"
p!)-!!ii<'i i~ used. Somftime-^ the ;iir fails to enter the vagina when the ^""^
r!:r-l fto^liirr is cmplovid. :ind if the bladder does not expand thoroughly a snu"
sjjeculum should be introduced beyond tlie vulvovaginal orifice.

fta. fXt. — Mcmnn oi tUwnTKA Ta( Rmmiu [Tunc Ounxc s CnfOHimr lUuDiMjinait.

CHEEQC niCROSCOPIC AFO) BACTERIOLOGIC EXAHI»ATIONS OF THE

UKINE.

Irlmltationg,— These methods of investigation are limiled to the exami-
nation of ihe urine

Information.— We can determine the presence of a cystitis and the chamc*
tcr of an infcttion,

Technic. — The urine .ibnuld l<e nbtain«l hy <-;ithctcri7^ilion. nthcrnif* it
becomes mi\H with the secretion? from the vagina and mlva. This method o(
kobtaining the urine U especially necessary if a specimen is required when the
rpolienl is menstni.itiiig.

After introducinK (he catheter a small quantity of urine is first allowed to
escape into a urinal; il is (hen collected directly into a boKle, which l* corked
with a cork stopper nnd .1 thick layer of cotton batting spread over the neck and
iccurel)' tied. The bottle and the cork must have been previously sterilized by
Ixiilins lliem in plain water for five minuter, and (he cot(on liatting must alio
hive been rendered sterile.

The boille of uiine U carefully pacJced and sent to a labotaiory for exatnioa-

tiuR-

«36

THE BIAUUER.

HALFOBHATIONS OF THE BLADDER.

Anoraalioof the liludikr :irc {'nidiijUy the s:ime in Unti iexes.Biid
usually a&sociHlnl with murkrd mnlfonniUinn'' in oiIht ^iiiio unouy
The [oUowing nia)fonnalion» have been noicd:
Ab-^ciue of ihc l)!;n!der.
DividcxI bladder.
F-x^lriijihy n( the bl;>dder.
Absence of the Bladder. —This is an exceedingly rare anonuly.
ea«-5 th:it hive been rctordcJ ilie ureters were either implanted in Ibc u:
or in llie n-cttim. Tlie child i^ seldom bom aliv« or j>erUhc» shortly alter lnVm

Divided Bladder. — In rare instances the bladdiT ha.<. I>een diiiiU
Ltteratly into twn [larK by 3 mcnibrjnuus squum mnninfi anicro-poslmw)'
In these c:i»» each half of the bUdder has one ureteral ori6c«. ihe urcthn vfot

•^^^

(

Fu. iSj. — Ili.vDni3i DJVit>Et> iirra Two PutB nv * MEaniinDn Smm.

into one of the compartments, ^nd ihc urine from (he other escapes 4nMP'
Rtnnll opeiiiTiK ill Ihe septum.

Exstrophy of the Bladder.— Extroversion of the bladiler is ("**•]
more frequently met in rijIcs ihnn in females. In thi< romliiton the*bd«i»''
wnlK and K\\v- >ymi)hy>i.-' pubis are separated and the anterior wall of the l*"*"
is absent. The mucous membrane o( the ]>n»terior vesical wall occupiesibt^
formed by the iieparuted structures, and the ureteral orifiecs, wlitrh ni* enWA
can be readily seen. The bladder mucusa is fjenerally more of less inilampl 'r*
exposure an(l covered with phosphnlic deposits and si>ots of ulrmticD.

The genital orKan* may or may not be involv«l. Usually. ho<«Trr, *•
clitoris is split in two lalcml hidvcs; the va|[iiui may lie more iw less rwlint*'*"
in character: but the uterus, the tubes, and Ihc ovaries are, as a rule, nrtiM"'
developed.

The treatment is the same in both sexes and it described in Uwii*^ -•
gen end surgery-.

CYSTITJS.

6s)

DISEASES OF THE BLADDER.

CYSTITIS.

Definition. — Cystitis is an intlumiiution of the bladder due tn the in-
va»on of patbogcnic organisms which Itxlge and dcvfliifi either upon or within
the nulls of (he orRan.

Causes.— The causes of the affection are divided into:
The predisposing causes.
The excitin); causes.

Tba Predisposing Causes.— The presence of pathogenic oTganisms in the
urine, with but few exceptions, is not in iiself sufficient to cause a
cystitis in a healthy bla<ider, ;tnd it is therefore ne<:esMin>', hefore an intlarnmiitiun
can be set Up, that thcorgan should undergo certain path-
ologic changes in order to destroy or lessen its re-
sisting power and render it a proper soil for microbe* to lodge and
develop in.

The predufposing causes may l>e summarized as follows:

I. Congestion .—This is one of the mosl common causes, and is due to
a number of conditions, such as diseases of the Uterus, the ovaries, and the tubes;
pelvic iind alMlomin;d tumurs olMlrurtin); the cirrulution; peritonitis; ihe normal
coniieation of menstruation, pregnancy, and the pucr})eral state; and exposure
to cold.

a. Retention of Urine . — The retention m:iy be (ovuplele or iwom-
pUte; in the former instance the damage to the bladder wall is due to acute
overd intent ion, while in the latter case the residual urine underjioet ammoniacal
decompoajtion and irritates the vesical mucous membrane. The foUowint; are
the chief cause* of retention: Strictures and neof>bsms of tlie urethni; extra-
vesical growths; cystocele; and dist>Ucrmcnts of the uleni».

3. Abnormal Urine .—The character of the urine may be abnormal
and caii«e irrit;iti<m nf the \-e*ical mucous membrane, Thi* may ix*nir from the
climinalion of turpentine, caniharidcs. or the oil of sabine when taken into the
system and the ingestion of certain foods or alcoholic drinks. The changes which
take place in the urine in ca^>«' of rheumatism and in those KuRering with uric add
diatbiesis are also a predisposing cause of cjsiilis.

4. Foreign Bodies .^-Vesical rakuli, pencils, hair|)in», and other
foreign objects irritate or wound the bladder mucosa and thus pre'dE'pose the
ti^ues to the influence of pathogenic orKanisms.

5. Traumatism .—The bladder may be injured during the intro-
duction of a catheter, a sound, or a c>'sto6cope, or by an instrument
at the time of an ojicraiion upon the organ, and it may also be contu.->ed or bniixed
by the pressure of the child's head during labor or by a kick or blow on Ihe lower

' abdomen.

6. Neoplasms . — Tumont of the bladder ate asodated, as a rule, with
tystilH.

The Exciting Causes.— The pathogenic organisms which are muM fne*
qucntly found to be the exciting causes of cystitis are:

Colon badllus. Proteus \-uIgaria.

Conococnis. Tulierrle bacillus.

Streptococcus pyogenes. Typhoid bacillus.

Staphylococcus pjogenes. Mined infection.

As stitrtl ;dMive. pathogenic germs may !«.■ present in the urine without in-
fecting the bladder provided the organ is healthy; but when, from some cause at

638 TOE BLADDER.

Other, its resistance is destroyed, the bacteria become active and cystitis lesulti
This is true of all the bacteria with the exception
of the gonococcus and the tubercle bacillus, which
may, as is now generally conceded, infect a perfeclly
healthy bladder; in other words, these organisms
require no predisposing cause to prepare the walls
of the bladder for their lodgment and de velopmeni.

Channels of Infection.— The various channels through which patho-
genic organisms gain entrance to the bladder may be classified as follows:
The urethra. Adjacent organs.

The ureters. The blood.

The Urethra. — This is the most frequent channel of entrance into the bladder
for pathogenic organisms. The direct relations of the urethra with the vultu,
and indirectly with the vagina, the uterus, and the anal region, as well as tht
shortness and dilatability of its canal, render it especially liable to become
secondarily involved when the surrounding parts are the seat of an infection. Ob
the other hand, the bacteria do not always gain a permanent foothold is the
urethra, for the reasons that the canal is very short and it it
being constantly flushed with an acid urine that exerts u
Inhibitory action upon a large majority of the patht^enic germs. If, howeva, the
bacteria become permanently lodged in the urethral canal, they may gain en-
trance into the bladder either by continuity or on a sterilized instrument to whici
they adhere as it passes through the urethra. Again, germs may be carried
through the urethra into the bladder on a septic catheter or some other instra-
ment or on a foreign object introduced by the patient herself; and, fiiuUj, i
sterilized instniment may become septic before entering the urethra by onlad
with infected surfaces about the external meatus.

The Ureters. — The ureters not infrequently convey bacteria from the kidnnt
into the bladder. This method of infection is observed in pyonepbritis, in fhuI
tuberculosis, and in acute infectious diseases in which the germs are elimiitatol
by the kidneys without becoming involved themselves and carried bvtheuriiK
into the bladder.

Adjacent Organs. — Cystitis may be caused by the bladder becoming in-
herent to a neighboring organ which is (he seat of a septic inflammation. Thus,
in suppurative lesions of the pelvic or abdominal cavity bacteria may passthimigli
the adhesions and attack the bladder or a purulent collection may rupture iiW
the organ and cause infection. And, finally, the colon bacillus may pass (tot
the rectum, the inte.stine, or the vermiform appendix if any one of these otpns
becomes adherent to the bladder.

The Blood,— The infection may be carried by the blood-current into tie
bladder waits and deposited in the form of small septic emboli or as free genus-
This method of infection is demonstrated by the presence of smalt multiple
abscesses in the bladder wall and by the occurrence of primary vesical tubetcu-
losis.

Reaction of the Urine.— The reaction of the urine in cystitis depeods
upon the variety of the pathogenic organism causing the infection. Some O'
these biicteria have the power of decomposing u rf a ■
and the urine therefore becomes alkaline; othefS'
again, have no such action, and consequently lli'
urine remains acid.

The reaction of the urine is acid and not alkaline in the majoritv of ca.**!
cvstilis.

The effect of the various bacteria on urea and the reaction of the urine are sum-
marized as follows:

10 action on Urea:

Culon bacillus.

Gunucoccus.

Streptococcus pyogenes.

Tubercle bactUus,

Typhoid bacilltiv.
Decompose Urea: Urise alkaltiie.

Pmteu.'. vulfyirU.

SlaphyWotciis pyogenos,
TTrioe Acid or AUiaime.

Mix<^l infer lions.

Pathologic Changes. Marked siructuml chanf;es In
ty^liti^ are the tx^eptiun rather ihnn the rule in
■v u m c n . Thit is due to the ^hortne^ and dilatabih'ty of the urethra, which
aikiw free and lunstani liraiiu^e of the bladder, iind (-on.tequenily thrrc k less
Jenry of the intbmm.-ilicin liettimini; vinilftil in the fcm;tlc than in the male.
Tin (he mild jorms of cvMilis the intlammaiion is usually limited lo (he vesical
truuipl« iir to a ^htnall ar«ui iimund one uf the ure(era] ojienin^f'; in (he inrrr
vutittirs the leiii>ns are srallcred gencnilly over the mucou ; and in (he virttitnl
lyPtt iif the afleclion the whole mucous lining i>f ihe bladder i.s involved.

Acute Stages.— In (he wiH jormj of (he <lit«i*c ihe ve«ciil triangle is hy-
pfrreinic jnd (he surface is coverr^I with a slight mucous secretion.

, Jn the stvtn lurielies the mucous membrane of the bbdder i* swollen, edcma-
E, and hyperemic. an<l hler, n^ Ihe inllammation develops, the swelling in-
■X'^ and Ihe surface i.* covered with a profuse muropurulem diacharf-e. The
Ithrliuin i> exfoliated in jilnio and imall denuded ;ireas. which have a (en-
ncy to bleed, arc scuiicfed o\er (he whole inner surface of the bbdder.
In (he virulent l^pei "f tlic disease the inflammation is intense from (he
|itining And rapi<lly becomes diffuse, involving nol only the mucous membrane
Ihe deeper .itrudures as well. The InAamnKilion in Ihesc cases often be-
tf\ purulent in chamcler (fuppnralix-t cyttilit) and abscesses form in the
dtler wall which may either rupture into the cavity of the or^ian anri Icjiv« deep,
il uliers, or they may cau.-* a perlonitiori and disc^tinrge (heir ronleiils into
_tAlxlominal c.ivity. In other instances a whilish-gray or yellow membrane
I fcrtBB over (he infliimcd areas {exuJaliMf, iHplithcri/. memhrnnous. pMnous, or
^'Uh^mi (yjlilh) which i.i caused by necrotic changes in ihe bladder mucosa
^*n«l which in very w-vere cases involves the muscular and peridineal coat> as well.
' "leexudjlc i> apt lo br«vik down and either leave a deep irregubr ulcer or cause
' [lerfonitiiin of (he bbdder wall. In f-ilid c<ises the whole bladder may become
* foul slouKhini; mass. And. tinalt)*. the inllummatorj' reaction may result in a
Dci i-i .1 „r rumptete e.xfolintion or (letachmenl of the mutxius membrane of the
{fxloli'ithf ryjiilii ) which is discharged with ihc urine in small pieces or
^^'idiii9 urilhin Ihe cavity of ihe organ as a foreign Uxly. In very grave forms of
^ft<U»eawa [wriionnf the muscular coal may be detached with the mucosa.

The ailjacenl organs are apt to be infected by the direct extension of the
'Ittri'c in virulent tyjies of cyvlili.s, and ihcy ctinwquently soon liccome firmly
"i 1 ■ ' logetherby inliammatory adhesions.

i 111- kidiK)'s arc especially liable to lieconie involved by direct exteuJon of
*hpin(«iion along Ihe ureters in severe and virulent forms of cystitis, and il is not
unceoimon lo meet (ascs of pvonephritis from this cause.

OiTOnic Stages.— The lesion.* which are pre.'^ent in the mucous membnine
ddriin the chronic siJiges of cystitis are either scaKrred over (he whole surf.n-e or
"xtlinni lo ■ par(»<-u)ar area ; in Ihc l.t(ter case Ihey are generally limited to the

630 THE BLADDER.

vesical triangle. The ruga; are elevated and assume a polypoid appearance;
the mucosa is grayish-white in color and bathed with a more or less pn^use muco-
purulent secretion; ecchymotic spots occur in various places which latn on
change to a yellowish hue as the blood is absorbed; and in some cases supeifidal
or deep areas of ulceration are present. If the ulceratioD is deep, the muscukr
coat is usually involved and the ulcers are irregular in outline; in rare instaoces
the only gross lesion present ma)' be a single well-defined ai«a of uIceralioD— the
so-called "simple" ulcer of the bladder. Sometimes in cases of chronic cystitis
small granular or eroded areas of inflammation, surrounded by healthy mucoiu
membrane, are obseried scattered over the whole mucosa or else confined to the
base of the bladder. These patches vary in size and bleed readily when irritated.

The muscular coat of the bladder is hypertrophied, its walls are thickeiied
and contracted, and its capacity is consequently more or less diminished.

The ureters and the ladneys are apt to become involved in chronic cystitis.
This may result in some cases from an extension of the infection to the ureien and
thence to the kidneys. In other cases, however, the vesical openings of the
ureters may be more or less constricted by the thickened and hypertropbicd
bladder wall, and the flow of urine is therefore impeded. Under these conditioos
the ureters may become dilated or hydronephrosis may develop if the occliuian
is complete.

Tubercular Cystitis. — In the beginning the disease is usuaUy circumscribtd
and located about the ureteral orifices and the trigone, but later on it involves tbc
posterior wall of the bladder, and in some cases the entire organ is aSectcd. \t
first the mucous membrane is swollen and hyperemic, and small grat'ish-whiie
tubercles appear upon its surface. As the disease progresses the tubercles softta
and break down, leaving small irregular ulcers which are covered with a puniltnt
discharge. The walls of the bladder are thickened, hypertrophied, and con-
tracted and the capacity nf the organ is diminished.

Sytnptotns.— The character and severity of the symptoms of cystitis vaiy
so greatly thai it is necessary to study them under the following conditions:

1. Acute Singes:

(d) Mild type.
(!>) Severe tyjie.
(r) \'irulenl type.

2. Chronic Stages.

Acute Stages. ^During the early stages of the disease the symptoms depewi
largely upon the severity of the infection, and while there is a general similafiir,
yel there are distinct and marked differences which must be considered.

Mild T y p e,— The symptoms are essentially local and there is usualhi"
absence of fever.

The disease manifests itself b>- jrcqitenl mklurition, vesical lenesmiis, pain.i^
urinary changes.

There is always a frequent desire to urinate, and the patient usually sufle*
grciit annoyance from this symptom. The irritability of the bbdder is notacuK-
and while the tenesmus is generally distressing, there is an absence of the int««
sufferint: which is so characteristic of severer types of the disease. The palieni
com[>l:iins more or less of a burning or smarting sensation along the urethra ai"
111 the ha.se of the lihuider during and immediately after the act of micturitiM
This feeling, however, soon subsides and does not return until the bladdo i*
emptied ;igain. There is :dso a constant feeling of soreness or tenderness at I**
neck nf the bladder, which is more acute when the patient is in the erect posilt"''
than when she is lying down. The urinary changes are not marked; theurin*

ClfSnTIB.

fi3<

b usually high colored or slightly opaque: its specific gravity varies from 1.005 ^
I -030, mix) it ihmn'ft down a small deposit on standiiiK-

Scvcrc Type.— In this form «f the di)«iue (l»c symptoms are bolli
ttKui and gttieral in tharaclcr.

'Ilic locji )iyin|)tomK ntanifest themselves by jttqueal tnieiurUion, vttiait
ttunmui, pain, htmaluria, an^ uriHary ^-itangti.

Tlie desire to urinate h almost constant day and tdght, and the patient be-
luroes wt»m out by lite (rciiuen<y of the «ilb to u*« the urinnl. '[he vesical
lene^nus is acute and agonizing, and at limes the muscular spasms of the bladder
ore Mt cntutjnl and uritenl that (he iialieni is com|>elleri to remain for hours upon
the urin;ii. sutTrring the most severe p;iin nnd distress. The tenesmus is not
al»'jy> relieved after uriiuiing. and there is often a sensation of a few drops of
unnr rrmaming in tliv bladder, which cauKes the |iiiticni to make vinlent bciring-
ijdwii efforts to expel. Constant and severe pain or soreness in the suprapubic
region i» a prominent and pcrslAtent symptom of the affection. It may radiate
at times to (be jierineum and the siicral region, or along the urelhra. down the
thifths and into the groins. It b increased in severity when the bladder contains
urine and when the lutient ax.''umes the erect po.'iition. The »1i}(lite%t prev'<,ure
over the aJMlomen aggravates the pitin, and the patient usually lies in bed with
the letc* drawn up to lessen the tension of the abdominal muscles. The presence
of hl<H>i] in the urine, or hematuri:i, is a common ^ymjiiom of (he disease, and i(
iblully manifests itself by 3 few drops escaping after urination. In some cases,
hoiTCier, A small quantity of blood may be ejeclcd with the urine, an<l in other
I i-.ire.* a more or Icsji n>piouH hemorrhage ocnirs during micturition. The
.1!:l iry changes arc marked. The urine is lurbid or opaque in appearance or it
may be reddi.->h in ci>lor from the pretence of blood. It contains pus,, mucus, and
T^)ithelial cells: also numerous bacteria (see txtUing causes 0} cystisis): and if
m reaction i« alkaline, amoq>bous pbosphateii, ammonium urate, and triple
phosphates are also usually present. On standing, a sediment forms in the
bollom of the vessel which is dirty white or red in color and cun.sisLs of the ab-
Mrmnl ton^tituenU of Uie urine. If the reaction ts alluline, the urine has m
luul or fclid odor.

The gfiural symptoms manifest themselves by fn'tr, rigor, and incrtantd
fktieratf.

The elevation of temperature is not marked in this form of cystitis, and the
dlv.\«e may or may not lie u-nheroi tn by a chill. If an initi.d Hgor occurs, it is
x'i'livn rq>ca(ed during the subjequent coun«e of the affection. The fe\er and
tbc increa.'»cd pul»c-ratc persist during Ihc active stages of the inflammation.

Virulent Type .—In ihl» form o( the diwaiie the symptoms are both

'n !,' .iiut grtirral in character and prcsen( the usual manifestations of profound

■ iiemij. Virulent types of cystitis are very seldom obwrved escept in puer-

I n<-n, and tbcy are uHUully associated with infection in some i>ortion of

' 1 tract.

1 111- /flij/ -.vrnptiim* manifest them*el\'e-* by frfquntt t»icturili<m. vaimi
irK-iniui. fiiUH. hrnt'Uuria, and urimtry (haitges.

these symptimis are more severe and uculc than in the foregoing (>'^ie of

t^>'iitiv The Kuprnpubic and pelvic pains are intense, and general peritonitis

nu\ in(cr»-ene when the inflammation I>efomes suppurative or diphtheric in

ihuiacter and the blad<)cr wall i.t perforated. [lematurin i* a prominent symp-

(•Bi.annl not infrequently profuse hemorrhages occur from the bladder, especially

'heti the disease a.isumes an exfoliative or diphtheric type. The urinary charges

*n iBirkrd In addition to Iluite described as occurring in the foregoing type

"^ (TUitis, we find that (he urine is overloaded with pus, broken-down decompos-

63a THE BLADDER.

ing tissue, and shreds or small pieces of detached mucous membrsne. Rctntioa
of urine may occur in the exfoliative form of the disease from the urethral opening
being blocked by a piece of the detached mucous membrane, and in some casts
the bladder may become enormously distended before the condition is discoveied.
It is well to bear in mind, in attempting to empty the bladder in these cases with 1
catheter, that small pieces of tissue may occlude the instrument and picveol the
escape of urine.

The general symptoms manifest themselves by rigors, jeitr, rapid pidit, and
the typhoid slate.

The general manifestations of profound septic infection are present from tht
beginning, and the affection usually lends toward a fatal ending.

The disease usually begins with an initial chill, which is repeated at ^■sn'in);
intervals during the attack; the temperature ranges from 101° to 105° F.; and
the pulse gradually increases in frequency as the symptoms become grave. If
the condition of the patient goes from bad to worse, the urine lessens in quanlily
and may be suppressed ; uremic symptoms manifest themselves; and the ptatirnl
gradually sinks into the typhoid state, which is characterized by a dry, bronn
tongue; mild delirium; ner\ous and muscular twitching; headache; gastric
disturbances; and coma.

Chronic Stages.— In this form of the disease the symptoms are both /traf
and general in character.

The local symptoms manifest themselves by jrequenl micturition, vtsutl
tenesmus, pain, and urinary changes.

Frequent urination is the most common symptom in the majority of the casK
of chronic cystitis, and the patient is compelled to empty her bladder at short
intervals during the day and night. The act of micturition is followed by lene-
mus, which is sometimes verj- severe, but, as a rule, it does not cause the zgoiat-
ing suffering experienced in the acute stages. The patient complains of supra-
puitic pain and tenderness, which is aggravated when she assumes the ttra
(losition or strain.s at stool. The pitin, however, is not verj' .severe except in thiw
cases in which the vesical lesions arc ulcerative in character, when the bbddtr
naturally becomes extremely sensitive and tender. The urinary' changes air
marked. The urine is highly irritant in character and has a vcr^- offensive, fetid
iidor; it is turbid or opaque in apjieurance and may be colored red f rom tb*
presence of blood in the ulcerative forms of the disease; it throws down adiitf
while dc])osit on standing for several hours, and the specific gravity ranges tc
Iween 1.015 and 1.020. The sediment contains pus, mucus, epithelial ceil*,
shreds of connective tissue, and numerous bacteria; and if the reaction nf iht
urine is alkaline, amorjihous phosphates, ammonium urate, and triple phospluin
arc also usually present.

The ncncrat symptoms manifest themselves by neuraslhenia, malniilrili^-
and loss oj -.icighl and sircnglh.

These conditions are due to the long- continued suffering, the loss of itS.^i^
the consl;uH aiinoyarue to which the patient is subjected.

Physical Signs.— The physical signs in cystitis are elicited by (a) Wi"*'
('') //)(■ eyslosfope: iinil |f) a ckemic and nticroscopic examination of the urine.

Touch. — The location of the pain depends upon the situation of the Itsioii*-

Iti the ociile mild type of c\'.-titis pres,sure over the base of the bladder throup"
(he vagina causes pain; in ihc .sr.'cre type the whole bladder is more or If^'
tender upon touch land in the ;7>i(/fn/ /y/ic the entire organ is so sensitive thai il*
impossible to palpate it without using an anesthetic.

In the rhrviiic stages of the disease the location of the pain likewise dept'*''
upon the situation of the lesions. If (he trigone alone is involved, pressure oi'T

CV8TITIS.

«33

III

the base of the bliuliler c^iuxe* piiin; and if the lesions arc scadered, the whole
bladder is more or less lender ujitwi })ul[)iition. The pain, as a rule, is not severe,
and in nuhit instances the bladder feels sore only when pressure is made upon it by
the examining fin^m; in the ulceratitc forms of chronic cjsiitis. however, the
orc^n is so sensitive that an examination cannot be made without an anesthetic.

The Cystoscope.— Inspection of the bladder tbroutib the cystoscope re^'eals
the patholopc chanses wliith ;ire t h.irai Icrivtic of llie various lyjies of the dL-tease.

Chemic and Microscopic Examiaations. The character of the abnormal
consliiuenu of the urine i> determined by a chemic analy»s and a microscopic
examination.

Differential DiafrnoHi^^Q'^^li^ lou^l be distinguished from the
following afTcclidii-:

Infection of the ureters and kidneys.
NeuroMs of the bbdder.
Contraction of the bladder.
Vcsico -urethral fissure.
Stone or (ivreign liodie*.

The symptoms c.iu^enl by these pathologic conditions (pus in the urinr,
frtqutMl anii po'mjtil mUlurttim. ami trntsttitis) are wholly or partiidly similar
to thfvte of (-vMitis and a mist;ike in the diagnosis may readily Ijc made if the
examination is carelessly or ignor.inlly conducted. I shall not refer in any way
to (he subjectiic symptoms in considerinp these affections, as the differentbl
diagnosis is bunted entirely u|>nn the j)hyNic;il signs.

It is important to bear in mind that frequent urination is often caused by a
dLsplaceil uterus pulling upon the neclc of the bbdder or by the pre:^«urc of an
extravcsical tumor. In the^ ca^cs the bladder ualU ;ire normal and there is no
c\idenre whatever of di-*ase. the frc(|uency of urination bcinR due simply to
lessened capacity from the uterus drawing upon the orgim or the tumor crowd-
? it.

Infection of the Ureters and Kidneys. — A cysloscopic examination reveals
ft normal bladder wall, and pus may be seen oozing fmm one or both of the ure-
teral oriiiccs.

Neurosis of the Bladder.— .\ cyKtottcnpic examination reveals a normal
bladder wall, and the urine is found to contain no abnonnal constituents, as in
the case of cystitis.

Contraction of the Bladder.— .\ cysloseopir examination reveob no i<Kal
lesions of cystitis: the urine is normal: and the capacity of the bladder is found
to l)e decideilly diiiiini'^heii by mea.^uri^R the quantity of i1uid that it will contain.

Vesico-urelhral Fissure.— The chanirierisiic Irsion of thi.i affeciion i." found
at the \'csico urethral juncture and the urine and the bladder walls arc normal
unlev cy>titi.* is present.

Stone or Foreign Bodies. Bimanual palpation and a cystoscopic exxmina-
lion will repeal the pre-ence o( the foreign b«»dy: there Is nearly always a cocxist-
igcy^iiii'*.

Prognosis.— In the acute mild type of cystitis the proftnosis is good and
the di.tease usually disap]>e3rs in from one to three weeks under appropriate
treatment; there is but little dait^r of the ureters becoming infected.

In the acate severe type the prognosis must be )!uarded on account of the
danger of the ureters and the kidneys Incoming involved.

In the acute virulent type the prognosis is always very grave. The patient
may die within a few days from septicemia or at a later period from involvement
of the kidnevs. .Suppression of urine i« a common symptom and many deallis
result from this cause. Perforation of the bladder may occur in some cases and

634 I'll^ BLADDER.

a rapidly fatal peritonitis ensue. Exfoliative cystitis is the most virulent torn

of the disease and almost invariably has a fatal ending.

The chronic forms of cystitis are often difficult to .cure and the disease may
last indefinitely despite everything that may be done for its relief. The uretcn
and the kidneys are apt to become involved by the direct extension of the infcctioo
or by occlusion of the ureteral orifices from the hypertrophied and thickened
condition of the bladder walls.

Treatment. —The treatment of cystitis is based upon the stage of the
disease, the severity of the infection, and the character of the lesions, and cod-
sequendy no two cases are managed precisely alike.

The treatment as a whole is conveniently divided into: (i) the general, (2)
the local, and {3) the operative.

General Treatment. — Under this heading we include:

Rest in bed.

The diet and drink.

The care of the bowels.

The condition of the urine.

General and local baths.

Compresses.

Special remedies.
Rest in Bed . — Rest is one of the most important factors in the treaUnml,
and the patient should he put to bed at once and kept in the recumbent posffirr
so long as she suffers from local pain and vesical tenesmus. Under these con-
ditions the bladder is not crowded by the weight of the intestines, nor by tt*
tension of the abdominal muscles, and hence the inflamed organ is free from this
source of irritation.

The Diet and Drink .—These subjects are fully discussed undo
the treatment of acute urethritis on page 594.

The Care of the Bowels . — The bowels should be kept in a semi-
fluid state by the daily administration of a sahne, and nothing is better for tliii
purpose than F.psom or Rochclle salts or a solution of the citrate uf magneaum.
The Condition of thel'rine . — In addition to rendering the uriw
bland and innocuous by carefully rcRulaling the patient's diet and drink, «
must correct any abnormality in its reaction, and thus lessen its irritating prop«-
ties. If the urine is strongly acid, the patient should drink alkaline miwral
waters and take internallv potassium cilnite. carbonate, or acetate, or the jolulion
of potassii; but if it is alkahnc. she should be given boric acid, salol. benojif
acid, or ammonium benzonte. Good results are obtained by combining one or
more of these remedies with the infusion of buchu or uva ursi. .After the in-
flammalion begins to subside cubebs, copaiba, and the oil of sandalwood shuuM
be j^iven for their curative and sedative action upon the diseased mucous rnem-
brane.

General and Local Baths . — The painful and frequent urinami''
the \ esical tenesmus, the pelvic and suprapubic tenderness, and the severity n(
the inflammation are decidedly relieved by a full hot bath (sec p. 83) at W'
time and a hot sitz-bath {see p, S7) once or twice during the day. Bene6ciJi
results are also obtained by hot vaginal douches, which may be given twoorthr"
limes daily. The pain and muscular spasm during micturition are giwll!'
relieved by having the patient sit in a hoi sitz-bath while the bladder is btiK^
emptied.

Com p r e s ses ,^Hot compresses (see p, 97) continuously applied ijT
several hours to the vulva and the lower abdomen give the patient marked reliti
from pain and lessen the frequency of urination and the scveritv of the tenesmus.

ViR. (k.i— Inu TiMiviKi ot Cnntn (ix* "!*)•
SkamiW RKthiMlof imiiiiiiii iticbUdila.

e Local Treatment.— L'ndw this hMding »« include.

IrriKaimn of tht hUddiT.

Dircrl ii|t|ili(-.iijon( to Ihc interior of the bladder,
r i g 3 I i CI n u f t li c It I a d d e r . — Tlir A[)|>;iralu!i consists ol a k''^
, four feet '>[ rubl>«r luhing. a ^radualtd glas$ rtiicn'oir, and 4 thennome-

574).

636

THF. BLAJ>[>EK.

Tbe nnti^eptlf solutions which are most useful for purposes of iiriptioa i
CorroEivr sublimiile, 1:30,000 to 1:5000: jirnnnnieiinate of poUssium. ■ 104
per cenl.; and hydrogen pcroxid. ao lo 50 per cent.

The follow iii>; rraiedieii in solution have a curative and toothini; HIect vp»
the inflamed mumus mcmlinine: Nilraic of mIvct. i lo 3 fwr cent.: boric ind.
a »turiitetl solution; crcolin, 0.5 lo 1 percent.; and l;-sol, 0.5 lo i iierieoL

Tffhnir. — 'Pic- jiaiient isplarcd in the<li>r.'a]]Hi^jtion with lhehip« miingcci
surKicalpadandlheejtlernsl piiirls thnniughly sterilized. The urinr i> then dn«ii
with a gla.-o (utheler and the [escr\'oir filled wiili normal »]t wlution (iio*F )
The physician now ex|M»-es the meatij.> and |ia.s>e» ihe cathclcr dirrctlv into ihr
bladder. The reservoir is ihenheld about four leet abovx the l^blc and tbeMd«-
tion allowed to flow into Ihe bladder until the patient cunipbin.i of o\tidBti>-
tion. The resen-nir h now lowcrenl below the level of the bladder And iheMd
allowed to flow into a bucket on tfac door. The reser\'oir is then lefiUed, tni

-.u-'-:'^

,■.■■•

.'V'

Fig, [8(.— Loc« T»ni"rsrt ..r Cnnm.
Sum the ambol of nnlunt i illrrfi ip[>]>tii>uD la Ac imcitar d Ac \ittio-

the process repented several times until the solution comes amy clear. Ib<<l
in this way ihoroughly washed out Ihe bladder, the rescTMiir is DQtd "il*"
medicated fluid and the irrixalion itmtinueil in the tumt manner. Aftcrdoud>>'
the bladder three or four limes it is finally irrigated once or twice uilh hrt i**'
mal salt solution to prevent the daiiKer of jioisoning !>>■ absoqiiion (Fip. (SU

When a -miIu tion of nitniie of silver or jjermanRannte of potassium is enii'tol<^
the bladder is first washed out with plain sterile water, and after Ox mtdia^
douche is fi'^'^n it is immediately irrif^ated with normal salt toKition.

.ArgjTol h.is lately come into prominence in the treatment of cystiitt, tiio
rvllent results have followed ilsusc. It should be employed daily us follows: Wud
the bladder out Ihoroughly with warm sterile w.iter u- dew rilH-d sUivc and ll**
inject one drachm of a jo |»er cenl. aqueous solution of argjrol with a long UM"
hard rublwr syrinpe. The solution is allowed lo remain In the bladder ud it
eventually expelled when die patient urinates.

Direct Applications to the Interior of Ihc Blad^tf-

cvsnxis.

637

— Dirwt applications are jtcnerally employed in conjunction with irriitalionof the
bladder and nn initicHted when the lesioiM are l[>calieed. The medicament is
applied dirtNTtly to the disea»^ arras through a cystoecope. Nitrate of ^Iver is
the most u>eful remedy to employ and may be applied cither in the form o( a
solution (1 to to [ler cent.) ui^in an ajiplicator wound with cxillon or the solid
stick held in the gtasp of alligator jaw forceps.

liefore a]>plying the ulver the diseased areas should be wiped clean with a
pledget of absorbent cotton held in the gnts)> of the nlligntor-jaw forceps, and
after the application the bladder should be irrigated with hot normal salt solution,
llic applications should l« made e;'ery five or six. day.i until the legions disupjiear
and the mucosa returns to its normal condition.

■Rie Operative Treatment.— The only practical operation for the relief of
cystitis is fagimil ryshtonty, which cxiti-sisbi in ni.tkinji an artilicial \~esicovaglnal
fistula. The operative technic is fully described on page 970. and as it may be
nece»aTy to keep the t'lsiulous o;>eninK patulous for an indetinile Icninth of time,
the mucous membrane of the bladder should he united to the mucous membrane
of the vagina by iiuemiptcd sutures of catgut. When the patient gets out of bed.
(he urine may l>e allowed lo (rolleit on an absorbent vulvar pad, or she may wear
a specially constructed urinal for the purjxise (sec Kig. 764)- It is important for
the patient to keep herself scrupulously clean: otherwise the parts are likely to
become intkimeil and excoriated.

The operation is indicated in aaite rases of cystitis when penrral and local
treatment fails to effect a cure; in all chronic cases which resist ordinary measures
for their relief; and in the virulent f»rm-« of ihe disease when druiiiage or the
removal of detached and sloughing tissue is imj>erativcly demanded,

TTie fistulou.s opening which results from the operation of vaginal cystotomy
aJIords immedialc relief to the patient by giving the bladder complete rest; it
also establishes free drainage and facilitates carr^'ing out the local treatment.
The bladder is douched hy jKiurinK tlte solution from a large ])ilcher into the
irrigating reservoir and allowing the lluid lo escape through the fistulous o[>ening
into the vagina.

After the local lesions have disappcarefl, in the course of several weeks or
months, the vesicovaginal opening is permanently closed by operative means.
(For technic see p. 758.)

Treatment of the Different Types. -Acute Mild of Type of Cyrt-
itis. — The infection in ihii form 01 the disease is so mild in cliaracter and the dan-
ger of the ureters or the kidne^'Hliecominginvolveil.'Xislighl that there is seldom, if
c^er. any necessity to resort to local measures, and hence the patient is placed upon
Ihc general treatment described above, which asually effects a cure in from erne to
three week-

Acute Severe Tjrpe of Cystitis.— In this form of the disease the treatment
i> )>olh i^trural and leitnl in iharacier.

Ucoeral Treatment .—This is the same as de^ribcd abow.

Local Treatment . — The infection in these cases is of a severe type
and tliere is imminent danger of ihc ureters or the kidney.s becuming im'olved.
No time should ihen-forc be Inst in destroying the pathogenic orgarusms causing
the inflammation and thus prc^enting an entcnsion of the infection.

Thi.s ii at compli-thed by trrigalii]^ die bladder once or twice a day with an
antiseptic solution for a period of about one week and then using nitrate of silver
or one of the curative and soothing remedies already referred to. In the majority
of the ra.ses it is well tri l>eKin with ciwrostve sublimate, and after 3 few days to
employ a weak solution nf nitrate of silver, which may later on be discontinued
and CTColin or lysol substituted.

63S THE BLADDER.

Argyrol used as described above is very efficacious in these cases.

If the disease is not cured by the treatment and it passes into the chronic st^e,
it may be necessary to make direct applications to the interior of the bladda or
to put the organ at rest and secure free drainage by performing a vagina] cystot-
omy- In the latter case the bladder should be irrigated once or twice a day with
creolin.lysol, or sulphate of copper, and the localized lesions painted with a strong
solution of nitrate of silver. Later on, when the symptoms disappear and ibc
mucosa returns to its normal condition, the fistulous opening should be per-
manently closed and the bladder restored to its original state.

Acute Virulent Type of Cystitis. — In this form of the disease the treatmmt
is both general and local in character.

General Treatment . — The most important factor to consider is tbt
profound sepsis from which the patient is suffering, and consequently the genenl
treatment which is recommended in other types of the disease is contraindicaud
in these cases. In other words, the grave condition of the patient demands tlut
the treatment be supportive in character irrespective of its efTect upon the con-
dition of the urine and the local inflammation of the bladder.

The patient is therefore placed upon a highly concentrated liquid diet and
alcohol and strychnin administered according to the indications. The boirds
should be well flushed in the beginning with a saline laxative or calomel and kept
open by the daily use of a rectal enema. The occasional administration of a
saline, such as a solution of the citrate of magnesium, assists materially in fl»
elimination of the infection from the system and lessens the danger of a bul
ending. The local pain and tenesmus are relieved by hot fomentations plactd
over the vulva and lower abdomen and by hot vaginal douches. The inienal
administration of tincture of cannabis indica and the use of ichthyol sup-
positories arc also serviceable for the same purposes.

This plan of treatment should be continued until the general manifestatioDSof
the liisease disappear and the pulse and the temperature become normal. TV
case may then be considered as a sex-ere type of cystitis and treated accordingly.

Local Treatment . — The two cardinal principles upon which ihe
treatment is based are drainage and sterilizati(m. The first is accomplished by
performing a vaginal cystotomy and the second by employing antiseptic douches.
The artificial opening between the bladder and the vagina must be sufficientlr
large to allow free drainage and the removal of sloughing tissue. The bladder
should be irrigated twice a day with corrnsive sublimate followed bynormai salt
,'M>lution. L:ifcr i)n. when the disease is under control and the pulse and the tem-
perature have become normal, the case mav be treated as a severe typeol cystitii.

Chronic Cystitis. — In this form of the disease the treatment is both geftt^
and heal in character.

General Treatment ,— This is the same as described above, ewept
that it is not absolutely necessary for the patient to remain in bed, althoufiif
she can afford to do so the symptoms would be less se\'ere and the cure maleriaU''
hastened.

Local Treatment. — Thh is based entirely upon the eysloseepic
findings, lint! hence -i thorough examination oj the vesical mucous memhi^
should he made at once in eTcry case. In some instances the local lesions wy
be cured by irrigation of the bladder and direct applications to the diseased areas:
in others, again, the cystoscnpic examination will demonstrate that no benefit will
follow the employment of these procedures unless a vaginal cystotomy is also per-
formed and the bladder imt at rest and free drainage established.

In some of the cases, therefore, it will be necessary to make an artifiri*!
vesico\';ipinal fistula and then to wash out the bladder with medicated solutio'''

IRRITABtUTV.

«39

and apply nitrate of siKxr directly to the localized lesions. The solutions which
] hiive found most ut^lui in lhe>e vases are trorroMve sublimate, nitrate of silver,
pcrmangunatc of potassium. cRMlin, and ly»ol.

ArftjTol is indicated in cases of chronic cystitis, and nood results have followed
its use. Tlie bhulder should l»e irrittaietl with vrarm M^rilc water and one
drachm of 3 10 per cent, aqueous solution injected as described above.

.\fter the di.sease is cured the fistulous o[)enin|! between the bladder and the
vagina should be permanently cliwed in the usual way (sec p. 75S).

and t

IRSITABnJTy OF THE BLADDER.

De fin itlon.— Under this term arc included all cases of vesical hyper«s>
thesb in nliii !i no organic le.>tion of the 1)lail<Ier i> |ire>enl.

Ffttbology.— A cAstoscopic e:t.imination of the bladder may reveal in some
aaia a slight hyperemia of the triune or the mucous membrane surrounding the
orifircK of the ureters, but in the majority nl in»tances thix condition is not present
and the mucosa is found to be absolutely normal.

Causes.— The alTection is vcr>' common in women and in the majority of
no cause whatevtrr c.tn \te diwovctiKl.

TTiC chief causes are:

Xcura.tthenia. Lit hernia.

Hysteria. Sextiid jrref!:ul.irities.

Malaria. Diseases of ncii{hbi)rint; or^jans.

TIte di.sea.-* is mo>t frei|uently uli.ierved in women in whom the neurotic and
hysteric tcmiieraincnts a'c well marked .ind who become neurasthenic from over-
work, bad hygiene, dyspepsia, mental anxiety, and other causes. These women
of ten suffer from neurulgicpainsinvarioux parts of the body; from backache and
headache; they arc badly nourished and suffer from menstrual irreRularitics; they
are ily.«peittic, peeviiJi, and irniaUe; and ihey sometimei develop Rymptumn of
mclanch(di3.

An irritable condition of the bladder is occawonally observed in cases of
malarial intoxication, and the \'e»ical (h'.itre»K U usually mmi Mvere during the
Bflcmoon and evening.

Tlie bbilder is often irribiied by a highly rtmtentrated slate of the urine In
lithemia, and the patient suffers fmm a constant desire to urinaie.

E.veasive seiual intercourse or masturbation produces congestion and irri-
Lability of all the pelvic organs, and the [xiticnt niters from enlrcme ment;tl and
physical weakness. The bladder under these circumstances becomes enfeebled
and h>peresthelic and there is a constant sense of vesical fullness which produces
an inces-sant desire to urinate.

An irritable condition of the bladder is frequently observed in women suffering
from di.'^ascs of neighboring organs. Sometimes a pelvic or abdominal tumor
may press upon the bladder and diminish its hotdinj; capacity; in other ca.sex
a general pelvic inllammalion may be associated with vesical irritability; and,
finally, the relics disturbances which often accompany hemorrhoids, vaginismus,
and other like disorders, may produce hyperesthesia and a frec|uenl denie to
urinaie.

Syrnptoms.— In the largest proportion of i-a.ses of irrit.il>ilily of tlte bbd-
der the only s;-mptom present is a frequent desire to urinate, which is often ex-
tremely annoying to (he jialieiit and interferes with her rest at night.

In some instances, however, there is al.tn a feeling of welglit or pressure and a
bearing-down sensation in the region of the bladder, which are aggravated when
the patient assumes tlte erect position ; in oltiers the act of urination may be pain-

640 THE BLADDER.

ful and accompanied by more or less tenesmusi again, the pain may be more
severe immediately after than during micturition; and, finally, the bladder my
be so irritable that it will not tolerate the presence of even a small amount of
urine.

The loss of sleep and the annoyance caused by the frequent act of urination,
as well as the local distress and the original vicious condition of the system,
gradually undermine the general health, and eventually the patient becomes pro-
foundly neurasthenic.

The urine may be normal in character, or it may be highly concentrated «
diluted; but it does not show the peculiar alterations met in cystitis.

IHagnosiS. — The symptoms are not ])athognomonic and the diagiKisis
must therefore be based upon a microscopic and chemic analysis of the urine,
a cystoscopic examination of the interior of the bladder, and a thorough con-
sideration of the causes of the affection.

As stated above, the urine may be concentrated or diluted, but it never pos-
sesses the peculiar physical and chemic properties met in cystitis.

The vesical mucous membrane is normal and the bladder does not contain x
foreign body or a calculus.

As the irritability of the bladder is simply a local manifestation of a general
condition, it is most important to determine the cause in each case, and we should
therefore bear in mind that the trouble is often associated with neurasthenia,
hysteria, malaria, and lithemia, and that it may also result from sexual inegu-
larities or from diseases of adjacent organs.

Prognosis. — ^It the cause can be discovered and removed, the prognosis is
good; otherwise the ultimate curfr of the patient is extremely doubtful. The
length of time the affection has lasted, as well as the condition of the patient's
nervous system, has a decided influence upon the prognosis. Unfortunately
many of these patients suffer from profound neurasthenia, which is con-
tinually aggravated by the local condition, and if the vesical irritability cannot be
removed there is danger of melancholia developing.

Treatment. — This is divided into:
The treatment of the cause.
The symptomatic treatment.
The ojierative and local treatment.

The Treatment of the Cause. — We should always endeavor to discover and,
if possible, remove the cause. In the majority of instances the treatment will be
based upon the general medical principles, which are fully discussed in treatises
on the practice of medicine, and which need not, therefore, be referred to here.
Under this heading we naturally include the treatment of such conditions as
neurasthenia, hysteria, malaria, and lithemia, when they are present as causes of
irritable bladder.

Se.xual irregularities must be corrected. I%>:ressive coitus or masturbation, as
we have already seen, causes congestion and irritation of all the peUic organs, and
the vesical irritability cannot be cured so long a^ either of these habits continues.
The diet in these cases should Ije nourishing but not stimulating; the bowels
regulated by a mild laxative; a cold plunge, sijray, or sponge bath taken every
morning, and a cold sitz-bath given ai night before retiring; and a course
of outdoor and indoor excrcir-es prescribed. The reading of erotic literature
[ir seeing sensational plays must be forbidden and the patient should refrain
from the use of alcohol in any form. Onod results are obtained from the sedative
iction of bromid of sodium or potassium, which should be given in full doses three
limes a day and at bedtime.

If the vesical irritability is found to be dependent upon some pathologic con-

OOKTRACriON OF TUB LUUK».

641

dition in one of the adjacent organs or structures, we must rcmot-c the cause by
trealinK the leHioii u|ion the principles laid down in discussing pelvic diseases.

The Symptonrutic Treatment.— It is often necesKin- in treating ai.*es of
irritable bladiicr to use certain remedies for the purpose of lessening the frequency
of urination without aii\ rt-iereiice whatever 10 their curative action unon the
disease. A solution (oni^iinint; from 10 to 15 grains of chloral hydnilc injected
into the rcclum al bedtime often controls Ihe vesical irrit.ibiliiy and gives the
patient wier.il hour> of unJJMurbed sleq). Bromid of sodium (Rr. xxx) in abuo
an efficient sedative .md ;i<ts ver\- Imieticiitlly in some caws. Good results arc
also obtained from rectal suppositories containing belladonna. hyoscyaJUUs,
ichth)-»l, ur iodoform; opium should ne^'er be em[)loycd on account of die danger
of the patient forming the drug habit.

Small dose^ of strychnin and the internal administration of valerian, asafetida,
or belNidonnA u^u^illy le.iAeti the irritabilit}' and tone up the bladder.

The urine should be kept well diluted by drinking plenty of distilled water and
b\- admiiii>ierin^: the infasion of parcira brava or tjuchu. I( the reaction of the
urine is .ihTiorm.il. it should he coTrected by the remeilie* that are recommended
in the ire.iinieni of e\ -litis (^ec ]>. f>;4)-

The Operative and Local Treatment. — Forcible diLiiation of the urethra
should be performed at once in every case as a routine,
empiric plan of treatment irrespective of the cause
of the affection. This npcnition nione often resutt.'t in a complete cure
of the vesical imtabiUty and the disappeamncc of the frequent desire (o urinate.

Tlie direct ap|ilication of a solution of the nitrate of siKcr (1 to 10 per cent.)
to the base of the bladder and the ve^co-urethiid juncture i.s Mimettme» followed
b)' most gratifying results when divulsion of the urethra fails to relieve the symp
toms.

OOPTTRACTION OF THE LUMEN OF THE BLADDER.

I>efillition. -Hy this term is mcinl a condition of the bUdder in which
its caliber is lessened and its holding capacity is diminished.

CaUBCS.— Thi.i affection i.t Ciiused by ihickeninK, hypertrophy, contraction,
or atrophy of the walls of the bUdder. it may therefore result fn>m a previous
attack of cystitis in which the caliber of the bladder is diminished by the thick-
ened, hy pert niph led. or contracted ronclition of the walls of the organ. In these
cases the bladder has al'o lost its elasticity, and conseijuently ns the urine ac-
cumulate', its walU do not di.itend and increase the capacity of the organ. Atro-
phy always follow> disuse, and contraction thenrfore often result.* from the fre-
quent act of urination which accompanies cases of chronic cystitis, irritiibility of
the bhdder, and the enuresis of childhood when it continues after puberty. In
these cases the blad'ler becomes weakened and the mu.'^rular tone of its walls is
lost to a greater or lesser extent because the urine cannot accumulate in mU
fidenl quantity to distend and eserrise tlie orfian. a.*) in health.

ConUaclinn of the bladder is frequently caused by calculi or neoplasms, and
il may also result from an operation upon the orfcan in which a portion of its wall
is resected or cicatricial li.viue .•wbsequenlly form^.

Symptoms.— Frequent urination is the only manifestation of (he affecilnn.
The loiiitiiiit desire to urinate is not due to vesical irritability but to the dimin-
isheiJ capacity of the bladder, which becomes filled and requires emptying when
Otjy a few ounces of urine have accumulated. The frequency of the desire lo
urinate (lepemls, therefore, upon the amount of urine the bladder mill accom-
modate, and in some cases tlie quantity is so slight that the patient is constantly
u<jng the urinal. The ad of urinatioo is not attended by pain or tenesmus and

643

THE BLADDES.

the suprapubic and pelvic soreness which are constant symptoms of cystitis uc
entirely absent.

IMilg^noSlS. — A cystoscopic examination reveals no local lesions; the uiiic
is normal; and the capacity of the bladder is found to be decidedly le^ened.

The capacity is determined by having the patient void her urine natartDf
and measuring the quantity of normal salt solution the bladda willamtiiiL
To accomplish this the irrigating apparatus used in the treatment of cystitis («
p. 635) is employed and the reservoir held about four feet above tbe bed or taUc
while the solution is allowed to flow into the bladder until the patient complainiof
distention. The level of the fluid in the reservoir is now compared with die
original level and the difference in the quantity between the two will indicate At
holding capacity of the bladder.

Prognosis. — The prognosis, as a rule, is good, and in the majority trf

Fio. 585. Flo. fBt.

TlTEATUEKTOr CoNTllArnT>MOTniC LUMZHOTTHEfiuhUDtl^

Fig. jSs ihomihE bladder diunuicil iriib fluid: Fig. iMnhnw) ihc mtrroir towcnd beln* I>k Ind d ibt Hiti

aod lb? bLaddpt empty.

cases the bladder is practically restored to its normal condition after a fe* *«^
or months of tre;!lment.

Treatment. — The object of the treatment is to increase the capadtvci
the bladder by alternately distending and relaxing the walls of the o^i?
hydrostatic pressure.

The patient is placed in the dorsal position on a table or a bed; the™!**
sterilized; and the urine drawn off with a catheter. The reser\oir of the ini-
gating apparatus is then filled with normal s:ilt solution (100° F.) and a |rfaS
catheter introduced into the bladder. The ieser\-oir is then raised about fW
feet above the bed and the solution allowed to flow into the bladder, and wl*
the patient complains of distention it is lowered below the level of the urethn-
The reser\oir is repeatedly raised and lowered in this way for five or ten minutft
after which time the catheter is disconnected and the salt solution allowed »
escipe from the bladder.

CALCVLVS.

643

The treatment shauld be given c^'cry day for Mveral months, or until the
capacity of the bladder is sufficiently increased to relieve the abnormal fiequenc}-
of unn^liuii.

The c.iparity u( the bl;ulder should be measured at the beginning of the treat-
ment and a daily record kepi to note the improvement in the case.

VESICAL CALCULUS.

Causes.— The causes of vcsic.il c.ilculi are usually the same in both sexes,
but owing to the aniitomic relatione and conslruttiun of Ihe fenmic bluddcr uod
urethra it is necessary to point out certain causative factors that are peculiar to
women.

Vesical calculi are rarely met in women owing In the shortness and dilatabiiity
of their urethral canal. A secondari.- calculus is an extremely infrequent occur-
rence, l>ecauic if a »maU renal ^loiic should happen to come from llie kidney it is
usually cq>c!led at imrc from the bliidder and docs not remain as a nucleus
around which the urinary salts may be deposited. Vesical calculi in women are
therefore primary formations, as a rule, and in llie majority of the ca.-ic^, jiccord-
ing to Emmet, they occur after the repair of vesical fistulas. He attributes their

«V

Fie. fdT.—S'nirmm o* * Vibcju. CUfVLin (tiii> &4t].
SbomEbtagMrqiiDppiaiciIiticiunaiol luiiw br • iBUll WMM MBptafflr UdcUdc itw uTMliral ocoiu of I^r

HiHitTf dnflDf mifT^iffclfrfti

occurrence under theae circumstances to ibe fact thai the sutures have been im-
properly introduced to clo$e the tistukiu* opoiiiiiKS. and that instead of passinK
ihcin only up to the mucous membrane of the bladder tliey included it. and con-
sequently, being cjuposod 10 the urine, the salts arc deposited upon them. A
ryslocele may Ite a preili.^po^ing cause of a calndu.s owing to the residual urine,
which occupies the prolapsed portion of th« bladder, undergoing ammoniacsl
decom[Hmtiiiri and lontaining e]>ilh«lial celbi. mucus, and urinar>' cn,'stals. which
may form a nucleus for the rievelopmrni of a stone. An<l. linally, the urinary-
salts composing a calculus have been found deposited about a foreij^i body nhicn
had been inirtxluced by Ihe patient herself or overlooked by the physician at the
lime of an operation, or had ulcerated through into the bladder from an adjuceni
pan

Sjmptoms. — The symptoms are not cfaaracteristic and they usually reMiia>

644

TOE BLADDZft.

ble those of c)'»titiR. FrequenI urinathn, pain, veitcai tenesmus, and JhfiMft»iim
ihp most cnmmon miinifctalions of the iiffcclion. Som«imcs the tutitfllODa
plains of stoppaRC of the sirram of urine when the stone is &null ana lemponrili
obslrucb the ve.-aco'Urtrthralofieninicdurjng the art of uriniiiion (Fi^- 5IS7) 1(
the stone ip lurge ;inil the iucom jinny ing cj-siilis is scrcrc, the frctjuenfr of uiai'
tion and the vcsiciil tenesmus are marked and disiri'sainR, esjx-iiuljy during it*
diiy. IfemulMriii is not an iiifreijuent ay m[iti>m and the [Mlicnt u$uall) fqucon
n few drops of blood out of the urethra nfler the net of micturition. lo MOt
cases blo«Jd may t>c fouml in the urine, and in others there may be more ot \t»4
a free hemorrhii|;e ixrurring whtn the bladder i* emplioJ. Iksidcf ihe kal
nnd referred pain, which is caused by the accompanying c>-slitis. Ibc pRscotctf
the stone il^elf produces a uinMiint dull uclie in the supni|mbic rcK*"D «bict
often ntdiatu into Ihe external organs of generation and down the thi^is- la

-. .^-i

)

^i#

.'■.i.*^^

tm.ftt.

Diumut or * VmrAi Ouvbn.

FW »•♦

n<. jM tliQin the mrlhal nt •Itinting n •innr wiili ilig K-iiin'l: Fit A ihai Ibr wibBl M

joung girls sulTcring from stone the pain and soreness may be fdi ainxHl r^-
sively in the vulva, and the common habit ol thcM iiatients of caiuiml'
scratching tlie pari* should lc:id the physician lo $u$pcc1 tne presence o( a w«J
calculus. If the stone is irrcf^lar or roiit;b in »hai>e, the bUdder Ikoio"
acutely sensitive, and a ^har]), bncinatin^t puin i» fdt immniuttely ajtcf unu
tion which is otien referred tn the vulva.

IM a gnosis. —The symptoms are not pathoginomonic, and the ifap""
must llicrciore be based upon a physical examination of the bladder. TV'''
accom)ili-hi--<l by (,() ihe sound, (ft) palpation, and (c) the cj-stoscone.

The Sound. This is one of the best methcKl> of exploring the bUiMw**
stone. Ulien ihe sound comes in contact with the calculus, a neculurtbl:'
heard, and a grating scnsntion is i mpartcd lo the finders as the tip of thr ai^
menl scrapes o\-cr it. We must bear in mind ihui il i» not alwn\i poeabkt'

^ISICAL CALCULUS.

64S

■vcognue ihe presence of a sione with the wund, becniiM it may have caused
ulcf ration and bccomccno'^trdor it may be imbedded in a clot of blood or a mSES
of lymph; or, uff''"- ■' (^"y ^>^ attached to tlie anterior wull <if the hbtider and
etude the instrumcMit.

Incrustations of the mucous membrane of the bladder which are due to the
deposit of urinary salts in caw* >if chronic cjslili* are rejidily recngniKwl by the
Hiund and produce a grating noise HRd sensation as the instrument passes over
them,

Palpation.— Owing m the anatomic rrlations of the fcmnic bl-idilcr, the
presence of a foreign body may readily be detected by bimanual palpalion. In-
IroducinK two I'mfiers into the vaxina and makint: -suprapubic pressuttf with t!ie
finger* of the- free hand, the bbddtT is easily pal)iiilcd between them, and if a
Stone is present it can easily be felt.

The Cystoscope. — .\ lyAiuacopic examinaliun should always tie made, not
only for Ihp purpose of eliciting or
confirminfi the diagnceis, but also
III determine the cmidilion of the
vesical mucous membrane, as c>'s-
titis is always associated with a
foreign Ittxly in the bladder, and it
is necessary from the standpoint
of ta'jiment to have a definite
idea of the ih.-irarlcr of the lesions.
Prognosis.— -As a rule, the
I>ro«ni.c <if a Nesic^ Cidculus
caus<« such marked local distur-
bances that it is detected and re-
moved before Mmclural changes
have occurred in the bladder or
the kiiineys have hectime invol^'sd,
and consequently the prognosis
under these circumstances is good.
If, however, Ihe ki<lney« have
become damaged the prognosis is
IkhI. as the patient may either die
from llic renid com plica I ion ^^horlly
after an operation for the removal
of Ihe .tttme or at a later period
from the nalund progrrs^ of the

disease. The cystitis which always accompanies vesical calculi generally dis-
a[i(>eart under a|iprt>priate treatment Mxm after the stone is rcmovwl unless
structural changes ha\e occurred in the bladder or its walls ha\-e l>ec(>me con-
tracted. Even under these conditions, however, a cure is usually effected by
Irratini; ihc rhronic tyslitis and the contraction of the bladder.

Treatment.- The treatment of vesical calcului is always operative and
may he considered under the following headings:
^_ Removal through the urethra.

^^H Lithobpaxi,'.

^^" Vaf^nal ryslotomy.

I Suprapubic c>-stotomy.

I Removal through the Uretbra.—OK-Ing to the shortness and dilatabiUty

I of the female urethra a small stone may be remtived from the bladder through
I the urethral canal. As a matter of fact. howcA-er. we seldom meet cases in which

Show* lb< toMbod nl rvmciiinf « >mt]! iiuDt thrvuxb Ihfl

646

THE BLADDER.

this method is advisable, on account of the frequency with which contraindications
to the operation are present. Thus, a stone measuring over one-half of an inch in
diameter or with a circumference of over one and a half inches should aeva be
removed through the urethra, as it is Uable to rupture the sphincter and oust
incontinence; a rough, uneven, sharp calculus is likely to tear the vedco-uretfanl
opening and damage the mucous membrane of the urethra ; a coexistijig cysdiis
or a vesical neoplasm is always a contraindication; and, finally, the operadoo
should never be periormed in girls prior to puberty, as the UFcthrn is too nanmr
and the tissues too tender to permit of instrumentation.

Operative Technic .—There are two methods by which a sum
may be removed from the bladder through the urethra: (i) with forceps and (i)
by palpation.

The preliminary steps in both of these methods are the same: Plaa die
patient in the dorsal or dorsosacral elevated position; sterilize the parts; washout

FlO. 50lr — TllCATIIETfT OF A \'f*ilfAL CaLCTTLUS.

Shorn the method of Tcrnovine a fmall fhtne ihrouah ihr urethra hy mmiA of binuniuL -palpatiDO. Thr JBCin
lineal show ihe pr<rgrcu ot thr alone ihrouah ihe urelhn] cuuj.

the bladder with a warm saturated solution of boric acid; dilate the urelhra; ^^
inject three ounces of warm normal salt solution into the bladder.

With Forreps. — The stone may be iocated by bimanual palpation or 'W
the cystoscoj)e.

In the former case after the position of (he stone is recognized the forceps »k
inlroducfd into the bladder, and, guided by the vaginal finger, the calculus"
grasped by the inslrument and slowly withdrawn through the urethra (Fig- 59"'-

In the latter case, iiftcr introducing the cystoscope and allowing the »ll
solution to escape from the bladder, the stone Is located by indirect inspetUn^
seized with the forceps, and slowly withdrawn through the instrument.

By Palpalioii. — The bladder is examined by bimanual palpation and ll«
slone loc.iled. By means of the vaginal finf;ers and by counter-pressure wilh the
fingers of the free h;ind above the symphysis pubis the calculus is now cmmo
into the vesicourethral opening and into the ureihra. The vaginal fingeis Iben
push it along the urelhral canal and out through the external meatus.

FOREICN BODIES.

647

Litbolapftzy. — This opt^nlion consists in crushing the stone v.-ith a lilholritr
and washing away ihc (rasments.

It i.s inilicatdl if ihe stime is not over an« siul a half to two indies in diameier
snd soft enough to crush. Un the other hand, the operation is contniindicatcd if
the stone is hard and large or ii is ency.sicd ; if the bladder does not hold at least
four ouncrs nS lluid ; if c*y»titi,s or a vesical ii«>pla.*>in is jiresenl 1 and if the [uliciil
has not reached the age of puberty.

Operative Technic . — The patient is aneslhcliJied and placed in the
dorsal jiosition. The ])arU are then »[eritiM.-(l, the bladder wai'hed out with a hoi
raturaird solution of boric acid, the urcihra dilated, and from six to eight ounces
of normal salt solution injected into the bbdder.

The liihotrite is now lubricated with sterilized oil and introduced into the
bladder. The operator then locates the stone with one or two tingcrs iu the
vagina, and while the bbdcs of the Itlhutrite are opened l>y an assistant he seizes
the calculus and crushes it. After all the targe fragmenl^ have been broken up a
CfStoscDpe is introduced and the debris thorouKhly washed out by means of a glass
ciitheter which is alt^chetl to an irrigating apparatus containing a warm saturated
solution of boric acid.

Vaginal Cystotomy.— Thi.i operation consists in removing the stone through
an opening made U'twcen the bladder and the vagina, li is the »per<t-
tion of selection in the largest proportion of the cases
because of the fact that cystitis is almost invariably
present and subsequent drainage of the bladder is there-
fore indicated. The only positive contraindication to vaginal cj-stotomy
is when a stone occuri in a girl l>efore the age of puberty; under tliese circum-
stances the genital tract is too small and the tissues loo lender to permit of the
necessary instrumentation and manipulation nithoul causing serious injur)' to
the parts.

Operative Tech nic— The operative technic and tbeaftcr-trcatmeiit
are fully described on page 970.

If cystitis is present, the opening should be made petmanent by stitching the
mucous membrane of the bladder to the mucous membrane of the vagina with
interrupteil catgut >ulures, and later on, when the inflammation ha$ been re-
lieved by appropriate treatment, the fistula is dosed in the usual manner.

Suprapubic Cystotomy. — This operation is intticafed in girls who have
not reached the age of jjuberly and in women when the stone is too large to re-
move by the vaginal route.

T\ie technic uf the operation h described on page 965.

FOREIGN BODIES.
Classification. — Foreign UMlie> in the blad<ler may be classified ac-
cording to their origin as follows:

Those that enter through the urethral canal.
Those that enter by perforation of the bladder.
Those that enter through the ureters.
Those that originate in ihf hbildet iUelf.
ThoK that Eater through the Urethral Canal.— Foreign hodiei may ac<
cidenlalb slip into the bladder dminjt an operation or during some internal
munipul.-ilion u|K)n the organ, anil it is abio not an unconunon occurrence for
hysteric women, as well as mastuthators. to pass all sorts of articles through
the urethra.

Those that Enter by Perforation of the Bladder. — Foreign subsiaaca

TH£ BLADDER.

r "":;V

may enter (he bladder either by flirctl pcrforuiion or by ulccralion oi iis *ili.
Thus sruiill pieces of bone und fragments of clothing have been diixat lUo
the bladder b}' gunnhoi wound» and severe pelvk' injuries. ]'c»sirin have Wn
ktirmn to ulienite llieir w.iy thrt)Ugh from (he \^gin3 into the bluddcr, iDd
non-ab^orbflble ligatures or suiurcs used in iielvit o|>eralions hair eveMUali
penetrated the widls <i( tlic orjtaii. A (i->lultius nxnmuniotlion m:iy exist bttmca
the bladder and the intestine und feta! mutter as well as various inteitintl ftn
sites mav !!.iin iicce^' to the cavity of tbc ur}[;in. Ecfainococn hsvr bren ioon
to penctr.ite the vesical walls, nnd in some instances the conitrnts of an erUfK
gest.ilion Mr. ii dermoid cy^t. or a [lelvic jihsress have ruj>ture(] ijjln (be bUfa
Those that Enter through the Ureters.— Kenj) ratculi, various puaatts,
»uch as the eihinococci and the littiria simpjinis hominis. pus, and bbodotf
descend from ihc kidnn's and crier ihc lihdder from Uie ureter*.

Those that Originate in the Bladder Itself. -Under (his heading «e

indudetl the %'arious kiiKb id esi-
mli.

Sjrmptoms.— The ^rmfiUB
■'^'' '" — r=;==^^-^ — Jin- iht Nimt: ii> then* of loiol
Diiculus and cystitis. Theirrhir
alter and severity, h<>»evcr,d(i«rf
liirgely u|>on the lutuxe cf ibr
foreign body, and beixc a <inou(h
objei't is IcAS irritadng llun onr
h;iving sh^r^t uneven ed|^ Soe-
times a foreign sutetoiu-e nut
remain in the bladder iniMiiitd^
without causing any locsl mem
\ertieni'e, but, .k.s a rule, lynptBrni
of intbmnuilion rapidtr occur, and
the jiaticnl suiTer^ from FmiiKsl
urination, ]>iiin. icnenmUi. ud
hematuria. A foreign bcjr h»r
ing a cuttinrtedf^e or a ihiiv
point may {H-neir^tc the tnlt «
the bladder and cause i bnl
peritonitix, or an ukeratioo mj
occur and perforation lake jibft
either into the peritoneal «"i> ti
the vagina.
Diagnosis.— The symptoms are not pathognomonic, and the diifiM
mu5t iherefiire be tvv.sed upon (lemimstnitint; the presence of the foreign Mb
Stance. This is accomplishol by fu) the sound, (h) palpation, and U) ihecrrt*
scope. Tlie technic of these methods of examination b fully described u"*'
the diagnosis of vesical calculus, and need not therefore be referred to here.

Prognosis.— If the foreign body is removed at once, no harm rtmlti: fc*
if it 15 overlooked and alloweil to remain, structural riiani;e» occur in thrtW
dec; the kidneys may become involved, and urinary salt* are gradually dff"*^
around it and a vesical calculus is formed. The cystitis gcrterally diapp**"
under appropriate treatment after the foreign object ha* ()een removed, t"! ■
the kidneys have become infected the prognosis is very Rrave, and the pW*'
evi-iitu.illy dies from the renal complication. .\ foreign ImmIv nur pCTfao"
the walls of the bl.idder and c.iuse a fatal jK-ritonitis or escape into the n^-
or, •again, it may be expelled spontaneously through the urethral canal.

'v; 'iBt

Flo, fti.—tnAnun or Fouicm Bomd m nn

tlUUUU-

4Iki*i llir tnfihiHl or rrmniimE Ihp hr<tkrn md of i ^iuM
(nthrlri rhrrniKh ihr uivihral ftlul allh InrnlM

VBortAsia.

649

Treatmeot.— ForeijcD bodkii in ibe bi&ddtr BXt removed:
Through the urrihni.
By vaginal cysitnomy.
tfy siijiMjiuliii ( _\ itotiimy.

Through the Urethra.— liy fiir Ihc brgtsi number nf foreign bodies found
in th«r bbddcT enter ihc cavity of the or[;dn throuRh the urethral canal, nod
hence ihey an usually be extra<'ietl by the simic route unlcM Iheir itijte hii» been
increased by the deposit of urinary Hdt$, in whicli cnse they should be remo^'ed
through an artificial vesicovaginal opening {vaginal cysloiomy). Again, a co-
existing cystitis is always a contrjiniliciition (o this method of extracting a
foreign object, and. finally, the urcthriil mute should not be selected in girls
who have noi reached tlie age of puberty.

The opt-ni livf lei linic 'm di-.M:ril»cd under vesical c.-ilnjius <tn pag(' (145.

Vaginal Cystotomy.- This is the operation of selection when a foreign
IhhIv i.'« a-viotiaied with marked inllammalftri' changes in the mucous memhmne
of the bladder and when it is incrra^cd in mm: by the dq>ostt of urinary s-ills,
and also in the case of a ruptured dermoid cyst or an ectopic gestation sac.
The oiienitioii should not lie performed on >^rls prior to the age of puberty.

The operative technic is described on page 970.

Stiprapubic Cystotomy. — This operation is indioilcd in women when th*
foreign body is too large to remove by the vaginal route and in girls who have
not reached the age of puberty.

The technic of the operation is described on page 965.

NEOPLASRS.

Vesical neo))IiLsm» are diher primary or stcpnditry; the former originale in
the bladder itself, while the latter begin in an adjacent organ and extend br
contiguity or by mcLi>tii>is. Sttondary grarj.'IkK are com i>ani lively frequent,
and it is not an uncommon occurrence for carcinoma of the cervix Uteri to
involve the anterior wall of the vagina and the bladder. Primary lumors. on
the other hand, are exceedingly rare, and they arc from three to five limes less
frequent in women than in men. They may occur at any period in a woman's
life from infancy to e.itreme old age. although they are most common lietwecn
toitv and niMv ;ind cnmiwnitively rare before the ape of thirty,

varieties.— The following growths of the bladder have been described:
Fibroma; myoma: li])oma: ent'hondroma ; papilloma; adenoma; carcinoma;
and sarcoma.

Fibroma; Myoma.— These tumors are very rare. They develop from
the muscular mat nf the bladder an<t are either pedunculated or ari.sc from a
broad base. I'hev' are usually single, although the\- may be multiple, and in
some cases the tumor may grow toward the peritoneum and form a sulwerou.i
enlargement upon the external surface of the Madder. These tumors may
undergo myxomatous degeneration.

Lipoma. - Small fatty tumors of the bladder have been describett; Ihej- are
exceeilitixb' rjte.

En chondroma .—This variety of tumor has been observed.

Papilloma.— Papillomatous or villous growths are the most common variety
of ve^iul tlc1lpb.^ms. The>c tumors may be cither brnign or nialigiunU in
character, and although the macroscopic appearance of the two varieties is, as
a rule, ver>- different, it is impossible to muke a positive diagnosis of the nature
of the growth without the aid of the microscope. A benign papilhma may
remain indefinitely without causing ulceration; it is usually attached by a narrow

650

TRK BLADDER.

pedicle; it does nni return sfter removal, and the bladder walls do nol becaat
infiltrated. .\ mulignatil papilloma, however. \ai a brcuid h.-uc; the bfaiUa
walls are indurated: ulcerative changes and metastases occur; and the t&ost
return* aflcr rcmuval.

Adenoma. —This variety i>( vesical lumor has been occanonally otu^nrtd
Carcinoma.— Cancer is the most frequent variety of mali);naot f;n>*lb an
in the bladder.

Sarcoma.— ^1'h is is a very rare form of vxsical tumor. The discate is n-
cecdin^ly rapid in its course and the growth is either pedunculated or uixi
(n>m a briiad ha>e.

Symptoms. — There nre no subjective symptoms present, as a rule.dnrini;
the early siaRCi in the devel(>]>meni of u vesical tumor, but later on in iti hiUDii
the (ollowitig |)hrni>mcn:i manifest tlicmKeb'es:
[Icmjiuria.

Sudden .stopi>age In the stream of urine.
Cystitis.
Pain.

Fragments of the ffrowth in die urine.
Frequent micturition.
t)cneral symptoms.
Hematuria.— Blood in the urine h one of the most constant and clurMia'

istic symptom.-. <»1 a ve^-ai mv
pUi>in. It usually nrrurv Mil
denly wilhoui any obvious lawt
and recurs intermitienUr f^ »»
iiulefinitc Icngih of litr.
appears allo^lher in ib''
of a lew d*ys or week*. Is
henigH ttimars, as a mie ■■"">' '
few dn>p!i of bliKul air
:it the end of miiiurii> ■
occasionally in th«' mom: .' '
urine may t>e dvund i" tir in-
colored from the precox >' »
small ijuanlily nf blmxl la
ikj/ijIUjih/ i^iouihs.fv- ''< <*'*'
hnnd. the heinorr':
follows !ume form < 1
ci»e, and in np<t to be '
in nmounl, producins .'
more or lew phj-Mcul cxKj .j :i '
Ilematuri:) in Ixdh Uu^f
and malignant tumors is nol acconnpanicd by pain or vesical tenesmus.

Sudden Stoppage of the Stream of Urine.—A vesical ncofdiMi scUw
obstruct:! the llnw -if urine, but somciimcs a fraRment of a tumor or a prdunn
bled Kf'"^th "^y ^ drawn againsi or into llie urethral upeninR and a^
sudden .-ttop^^ige during micturition, which is Kcncriilly aicompdnltd "^
bearing-down efforts upon the part of the patient and by more or less tcu'
tenesmus.

Cystitis. - fnferlioTi of the mucous membrane of the bhdder ocnm ■«■*
or later and s>'mptoms of cystitis manifest themselves. TIii» compile* I iw. ■
a rule, occurs earlier in maliKiutnt thun in beiii^tn tumon. and is usually ""*
severe in the former rariely. Sometimes a benign growth may be presm' *

'^'■

. ^IV

■y

I-;;

-^^.....

'idi

Shniri ihr fciirfdrn ^tavptKr of ili« «trcBm erf urinr iiy ■
■■All pf<limcub(Al jitriMfh blockiotf ihe ucuhraJ dpeninjl oi th*
Ubddn duriiu mjrturiiicin

NEOPLASMS.

651

the bladder for yean without infection occurring, and in these cases the patient
may complain of no sulijci:ti\e *ym[)toms whatever. With ihc onset of cystitis
the Kf"<^ral l'e:illh iif thi; patient r:ipidly Ijctumes impairwl and >e(iindaf)- in-
fection of the ureters and kidneys is apt lo occur.

P«ii.— Loial or referred |Kiin, ext-epi when it i» due to cysliltK, i» » very
inaiii^t:iiit symptom of a vcsicsd nropksm. In ftmi: vaset, howwer, the presence
of the tumor itself may cauMr pain in the rcRion of the bladder, which may be
referred lo the ve«.tlbule, the |>erineum, and the rectum. Tumors occupying
the base of the bhidder are apt lo be accompfinicd by jiain and vesical irritabitity
as well as an increase in the frequency of urination. Malignant tumore, as «
rule, are asiMX'Jated with jiain, which iip[i«iirt early and Jncrea^iet in severity
as Ihc disease adrances and involves the walls of the bladder.

Fragments of the Growth in the tTrine.— .\ \'cr>' siKnificant .symptom
which i> tHia^ioniilly IJrt^^<■nl i.v ihc diMliiitge of fni)j;mi'nt.< of iJic tumor with
the urine. Under these circumstances a careful microscopic examination should
always lic made of the e^)ielle<l tissues, notwiths-tajidinf; the fact th^I it is usually
imjMi^Mlile to make a positive diagnosis by this means.

Frequent Micturition.— As a rule, the frequency of micturition is not
increased except when the mucou* membrane beromeii infected and cystitis
dciclofK. If, liowever, a benign or mahgnani growth occupies the base of Ibe
bladder, the patient is apt to complain of icsicul irritability and frequent urina-
tion. A):»in, ihe ^i^' of the l>ladder may be diminivhed by ihe iiresence of
the gn>wlh, ;ind consequently lis capacity is lessened and the imlicnt is com-
pclleil lo urinate frei|ucnlly. And. finwlly, the same result may depend upon
Ihe inrillnilitm which lakes place in the walls of ihe bladder in malignant
tumors.

General Symptoms.— In benign tumon the general health <4 Ihe patieflt
is seldom affecled unless cystitis develops or the kidneys become involvc>d. In
Ihe malignant forms of the dise:ise. luiwever, t^aihexia, emaciation, and exhaus-
tion are cnnM:inl and well-marked s>-mptoms in the late stages of the afFeclion.

Dlai^osis.— The diagnosis is ba^ upon the phj'sical signs, which are
delcrmiiini by mKiii.< of fiinutitiuil patpatttm and ibe rystosfope.

An intermiltent hematuria occurring without any apparent cause, and which
is not accompanicil with pain or symptums of lysiitis, .'Jiould always tie looked
u[ii)n lis lieing po.wibly due In ihc prevnce of a v*:*ic:il tuiiM>r. The disch;irge
of fragments of the tumor with the urine' is an important and characteristic
symptom, but we mu.it always lieir in micxl that broken-down lis&ue and debri.i
may ;d«) be expelled from ihe bladder in certain forms of cystitis.

Bimanual Palpation.— .\ digital examination of the walls of the bladder
by meuri.-> of a tinker in the vagina and the fingers of the free hand making
counler-prrssure behind the symphysis pubb is of value only when the tumor
b sufficiently hard to be rerognized by ioin~h and when the or^an is the seat of
a gentnd malignant tnAllralion. In Ihe Intter case the thickened, hard, and
indurated condition of the walls of the bladder is readily made out and the
probable malignani nature of the disease determined (Fig. 594)-

Tde Cystoscope.— The only positive meihod of determining the condition
of the interior of the bladder !■> by means of ihe cystoscope, which enables us
to recognize the situation and nature of the growth, .ix well as the Mate of the
vesical mucous membrane,

Profftiosls.- A benign tumor may exist for years without causing any
local dislurtKtncc- .\ miilignanl growth, however, ends fatally, in fn>m one lo
two years. In both varieties cystitis and renal complications arc apt to intervene
and hasten the course of the di.sea»e.

653

THE BLADDES.

Treatment.— The irealmcnt of vesica} tumors may be divided st I
into: (i) ihr niilital ;tii(! (;) ihc ptilli:i6vc.

Th« Radical Treattnenl.— A lumur i>( the bladder should be roiioradbf
surKJc.-il mtMn» as mxjii as it is discovered, {irovidcd thai the health of the yxOM,
the charHcicr and extent of the tumor, and the londiiion of the kidney's do ml
ccinlniindiaiie the em)>loj'mciii of radical methods. In oid women and in jwim
children the grouih is generaUy malignant in nature, and hencr u opcniim
is seldom advisable.

The (-haracler nf the n)ieratIon <lepcnd^ entirely upon the naturt. atBili^
and i-xirnt o( the ne<iplasm, ;inii it may therefore ro^^l■>t in -imi'ly mnoriqi
small pedunculated tumor or it may require the {ladial or cumpleic rxcison (4

^/f

-cy-

Fic. KM ~ltituHiii9 cr A KronAtw or nit tti-ODti [|HCf aiit.
ShoM (hf mrlhoil dl mocoiilBii a Traul lunrx br UniBdtl |«lflfa«,

a portion of the wall of the bladder, or, again, in cases of nuliKnani iDvah^
men! cysieclomy may be indicated.

Having decided upon an operation, there are ihref routes by which ifctlawt
may be removed: (o) By the uretlira; (b) by vaginal cyMotony; uidlc)!?
*u]>r.ipiibic CAstotomy.

By the Urethra .— Tlie urethral route should only be employed o
e:L'>e^ of peduncubted tumors, ii* it is uns.-ife to dilate the urethra with aii in*"
ment that is larger than one-half an inch in diameter or with a circomltRi^''
of over one and a half inches, an<l hence there i> not sufficient *nace in w*''^
to properly manipulate the instruments in removing a sessile growth.

OpfTiUive JfVWiwiV.— HavinR dilated the urethra in the usual minnCT. 6*
tumor is located I>y direct inspection through a cvsioscope, and a galvaooou'
lery loop or a wire cnare is then placed around its pedicle in such a wjv '•"'-
portion of the vesical mucous membrane is includes! in it. Cnle* tbf
b completely removed in thi.t manner the growth may rcium e«n when » •■

NC01>LASHS.

(►S3

bcnii^ in chantcUr. The excised ncoplitsm must be txainined by a palbol-
iigiu, and if it t^ dtMroi-crw) to be malignant a su|jru|iubi<' cystommy ahuuld be
)icrfiinn«d n1 cnte iind the bu.^e of the ^ruwth removed along with n ]K>rtiun of
the henllhy bbHdcrwall.

.KjUr-trfiilmcnl. -The |taiieiH shouUi remain in bed one week, and during
till' |>rriotl ihe bhddcr .-.houlil \k impileil otKv a day with a sttuiulrd M)lulion
u( iNrrii' acid or m^rmal ^ili ^(ituiion. For this puqxi:^ a rcium-flow catheter
■ItjiLlMxl 1(1 a fuiirilain Mriii^e <ir a resen«ir with ruhtier tubing should be em-
ployed :«> a.- nol III distend the bladder and irritate the wound. While the
patient temainr in bed she should be given a liquid diet (see \t. io6] and the
urine rcndcreit bland and innocuous hy the free use of di^lilled water or a natumi
»l>rinR water t-ontatning a minimum amount of solid mailer. The bowels should
lie moved daily by an enema or a mild bxati^'e. am! if the urine is not (lassed
iialumlly it >l»(>ut<l be wiliidrawn with a cathtrier t\«n eight houn.

It y \' a g i n a 1 Cystotomy. — ThJK nmle is only applicable to cases
of t>'duncutaled tumors and small .-e^le uronths nf a 1>cni|!n nature. The
limiied 3paee atTnnh-d by the Mtgin:d opening prevcni.-' the ihnrough removal
off) larKe tumor or one th.it \s mali^.inl in rharscler. and consequently requiring
the tiimpkie cx< Uion of a portion of the bladder wall.
K iiprrnlKf 'ltiliuir.—'Y\\v veMKivajiinal opcninj; \> made in the usual manner
■Bee p. O'o). and. )i;uided by the index-fingcr passed through ihe iniision into
Uic bladder, the tumor is sciznl with volsella forcqis and pulled out into the

JVgiim-

B If the growth is pedunculated, the vesical mucosa isseiwd with bullet forceps

V (i[>]fo^itc |K>inls a »hon dii^^tjime from llie bu.->c of the |H-iliclc. which i:^ then

wvereil with siiKMtrs so as to include a portion of the surrounding mucous

mcmlir.mc. Ilie niw edffes arc then unite*! ^vilh interruplc<l catgut sutures and

Uic artilii iai opening! clo-cil in Hie usual manner.

If the groulh ha.s a broad flat lja.-<c, the vesical mucosa i.v caught by bullet
forceps at op|HiMte jHiints a shorl distance from the b>isr of Ihe tumor, so as to
cmtrol the seat of operation while the neoplasm is l>eing removed and the suture*
intrfxluced. Having secured llie bladder ami the tumnr in this way, ihc i:niwth
ix tlien ditiseiied out with srissori and a knife and the raw edges united with in-
temjptcd catgul sutures. The artificial opening i& finally closed in the usual
manner.

,I/*rr-/rcii(wini|/.— The patient should remain in bed ten days and the stitches
in the vaginal wall arc removed on tlie eiKbth day. The bladder should be
catheieriJ!e<l every four Imurs <luring the tir>t three days tn prevent tension
upcin the levicovaginjil wound, and then e\-en- eight hours unless the urine is
I sponLincously. While the patient remains in bed a vaginal douche of
. .. ive Mililim^te, i to sooo, shuul't Ih' given daily, followed by normal salt
Hilutioii or pl.iin vierile waler, The irrigation of the bladder, the diet, the
drink, and the care of the bowels arc the same as when the tumor is removeil by
the urethral route.

By Suprapubic Cystotomy . — This is by far the best and the most
satisfaitory route through which to remi»« llic majorily of vesiciil tumors, as
il ihoniughly ex(>i)res the sesit of operation and facilitates the necessary niani|>u-
blions during the extirpation of a large tumor or the excision of a portion or tlw
whole of the l>laddcr.

OffrtUht Ttthnif. — The tcchnic and after-treatment of suprapubic cystotomy
ifully discussed on page 965, and 1 shall therefore only refer tnceruin jxiints in
' ojferalion which are important tu l>car in mind when it is performed for the
vai of a tumor of the bladder.

654 '^^^ BLADDEX.

T. After the bladder has been opened the edges of the indsioD are tempo-
rarily stitched to the abdominal opening to steady the bladder and to facOitUe Ibe
removal of the tumor.

2. The cavity of the bladder is then carefully explored by sight and toucfato
determine the situation and character of the growth.

3. Hemorrhage may be controlled by catgut sutures, the theimocauleiy, and
tamponing the bladder and the vagina. If the tampon is left in the bladder aflo
the operation, it is removed through the abdominal opening at the end of tven^-
four hours and another one inserted if the bleeding continues; the vaginal tam-
pon is also removed at the same time and reintroduced if necessary.

4. The removal of the tumor is greatly facilitated by having an assistant [dace
two fingers in the vagina to push forward or steady the bladder as directed hj ibe
operator.

The nature of the operation depends upon the char-
acter and extent of the growth.

A pedunculated tumor is removed by dividing its pedicle close to the bladder
wall with scissors and suturing the edges of the wound with interrupted catgut
sutures. The incision into the bladder is then united with interrupted catgut
sutures, which should not include the vesical mucous membrane, and the ab-
dominal incision closed in the usual manner. The after-treatment is the suoe
as when the growth is removed through the urethral canal.

A benign tumor having a broad base and involving only the muams mm-
brane oj Ihe bladder is removed by incising the mucosa around the limits d
the growth and dissecting the entire mass from the muscular structures bdow.
The raw surface is then covered by uniting the edges of the wound with in-
terrupted catgut sutures. Sometimes, however, the dissection is so eitensive
that the edges of the wound cannot be completely approximated, and it Is iw-
cessary to leave the rest of the denuded surface to heal by the formation of on
mucous membrane. ".Almost the whole of the vesical mucosa maybe taien
away and yet it will regenerate, but whenever little islets or strips of sound
mucosa can be left this should be done, as the new mucous membrane starts to
grow from these centers" (Kelly). The opening into the bladder and the ab-
dominal incision are finally closed in the usual manner. The after-treatment ii
the same as when a growth is removed by the urethral canal, except in cases b
which there has been an extensive resection of the mucosa and the edges of the
wound cannot be completely united. Under these conditions a penMiKUl
catheter must be kept in the bladder one week or more and the palitW
should remain in bed three weeks. The bladder should be irrigated daih' •it''
boric acid or normal salt solution as in uncomplicated cases.

.■\ benign tumor involving Hie muscular coal or a malignant griniih should be
removed by completely resecting the portion of the bladder wall occupied by lb*
neoplasm. In the case of u malignant tumor a sufficient amount of healthy
tissue should be removed to insure the complete e.vtirpation of the growth, Ili-'
often astonishing what a large portion of the bladder may be resected withoul
materially interfering with the function of the organ, especially if, later on,
hydrostatic jjressure is employed systematically for several weeks to increase its
holding capacity.

If the neoplasm involves the free or unattached portion of the bladder, lie
operation is comparatively simple. The peritoneal cavitj' is opened by enlaij-
ing the abdominal incision and the tumor and the bladder wall are then resected-
This results in an opening which is easily closed with interrupted catgut suluns
that are passed from without inward, including all the structures except lie
mucous membrane, and tied on the outside or the peritoneal surface of the blad-

NRUPLAKM.

fiss

r»uprapubic opening; in the bbdder and the abdominal incision arc
fiiuQy closed in th« uniitl manner. The ajUrUtalmenl a (he sum« xit when a
Rfowih is mnovcd through the urethrul canal, except thnt a permanent catheter
%h(>uli| he !tei)i hi liie 1il»<li!er about one week and tlic patient must remain
ill bed tuvo weeks. The bbdder .fhould be irrigated daily with boric add <>r
nomul nit solution.

Wwn ii>e tumnr occupies the ba>e or an attached poninn of the bladder, the
dilTinittics and dangers of the opcr.ilion are grt-Jitly tinrea>ed. 'I hi.« 'a- r>penally
true when the new-growth involves the stmttures in the neighborhood of the
urctcr>, and the greatest >kiU and care muHt be employed to pfe>x-nt injuring
ihetn. In lhe» cases the ureters ^ould fir^l be dlv«ecl<.-d out and then Irans-
plartted liiglier up in the posterior wall of ilie bladder or even in the fundus. The
bbdder wall imd the tumor are then di.tMcted from the vagina and the adjacent
structures with a knife, a blunt di»«ctor. and the fingers, being extremely careful
ind cautious not to wnund the aurrounding piirla. Tlie «eat of o]>cnilion >h(iiild
be kqil rnn^lanlly dry by ligtitin^ all bleeding vessels with r.ntpit ."uturc. The
vtiund is then closed by uniting its edges with intcrru{)ied catgut suturr^, which
*re [MM^I from within outward, imludinK nU (he coaf of the bla<lder, and tied
irithin ihr canty of the organ. Sometimes it i» imi>ns.-ibir, on account of the
lire of the wound, to appmximatc its edgei completely, and it is necessary to
leave a rjw surface whith eventually hcrils by gninulalion. If the edges of the
■round can be accurately united, the suprapubic opening in the bladder and the
abdominal iiKision should be closetl at once in the usual manner, olberwise they
mukt Ik left open and dniinage eAlal>li.-<hed with gau/e nliove and a permxnenl
catheter Ih-1ow in the urethra. The ajlff-lrralmftil is the same when the supra-
(mhic opening i» closed as when a tumor is removed through the urethral canal,
except ihiit a permanent catheter must be kq)t in the bl.-iddcr seven days and
the patient should remain in bctl three weeks. The usual boric acid or normal
sail »ohiii«n ^Jiould be used daily as ii douche. If. however, a gauze drain is
used above the pubes, it should he remove cx'cry iwenty-fimr hours arid another
one insiTted into the bbdder; ihi.s dressing should be reapplied daily until
the wound becomes contracted, when it should be discontinued and the opening
aUowed to heal by granulation. The pernvment t^iheter should remain in
ponilion two weeks except when it is temiximrily removed each day to irrigate the
btaddrr. The patient should not get out of bed under three weeks.

/h (ittei of exltmiit maligtinul dhtase it may excq)tionally be deemed proper
to remove the entire blad<ler (fyslulamy). Thi* has been succes.''ful!y accom-
plished by I^wlik, who first dissected out the ureters and turned them into the
vagina. ai>d three weeks later completely e\tiq).il<-<l the bhulder by a tombined
Hiprniiuhic and viiginal incihion, preserving the urethr.il can.il, nhii h he sutured
into Inc vjgina. lie (hen closed the vulvovagiiial orifice (.omi>leiely, converting
the vagina into a reservoir for l)ie urine, which wat voided through the ltan»-
^Ultcd urethni.

KSpecial .-Vftcr-treatment .— Frenuently after the successful re-
Voral of a vesical tumor the patient is not restored to a normal condition because
of the pTe%eitce of chronic cystitis or contraction of the walls cf the bladder which
lessens the holding capacity of (he organ. I'mler these conditions the (Kitient
iiappa/ently but klightty Itenefiicd by the extir|i(ition of Ihe tumor, and conse-
ijlMntly a careful examination should ^ilwaj's be made and the existing lesions
wfinitety determined in onler lo institute the proper treatment.

Cvsnns,— .Vi we have already seen, intlammatioo of the bl.tdder isa common
jwn plica I ion of vesical tumors, and while a benign fnrowth may exist indclinitely
ttuut this affection occurring, yet it ik only a question of time before Ihe vesical

656 THE BLADDER.

mucosa becomes infected in aU cases. The disease is usually subacute or chronit
from the start and the lesions are generally permanent in character, and cod-
sequentl)' the removal of the tumor which is the predisposing cause of the infenion
does not always cure the cystitis. Therefore when a tumor of the bladder has
been removed and (he symptoms of cystitis persist after the patient gels oul oi
bed, a careful cystoscopic examination should be made to determine the naturr
of the lesions and the character of treatment to be instituted.

Contraction of the Lumen of the Bladder. — It is not uncommon m
meet cases in which painless frequent urination persists after the removal of j
vesical tumor and in which a thorough cystoscopic examination fails to revKil
any abnormal condition of the mucous membrane of the bladder. Under tlwie
circumstances the capacity of the bladder should be tested, and if it is found 10
be decreased, hydrostatic pressure should be employed to restore the organ If^
its normal size.

In these cases the lumen of the bladder is lessened by the hypertrophy and
contraction of its walls which accompany the presence of a \'esica! tumor orwhich
result from a coexisting cystitis. In other instances it may be due to the da-
tricial contractions which take place after the removal of a vesical growth,
especially when the edges of the wound are not accurately united, and, finallt,
it may result from resection of a portion of the bladder wall.

The Palliative TreatiDent. — In non-operative cases of vesical tumors «
are frequently called upon to treat the local symptoms, which arc not only dis-
tressing and annoying to the patient, but which also, on account of th«r severin'.
endanger life or hasten the fatal ending. In these cases the principal symptoiis
to combat are frequent urination. ve.=iical tenesmus, pain, and hemorrhage. In
some instances as the tumor increases in size and encroaches upon the itsioi-
urethral opening retention of urine occurs, which may be partial or complete lod
often the cause of great distress.

The formation of an artificial vesicovaginal fistula (see vaginal (ysWomy.
p. 970) is imiicittK) in non-operable cases, as it ]iuts the bladder at rest, and af-
fords constint drainage and hence relieves the symptoms which are dependMi
upon the cystitis and the presence of the tumor. Good results are also oblainri
by irrig.iiing the bladder daily through the urethra and allowing the fluid w
escape inio the vagina. For this puqmse nothing is better than the antifeptic
and .''oodiing solutions recommended in the treatment of cystitis (see p. fti?).
which may be emjjloyed by means of the Irrigating apparatus already descrihtd

(Fig- 574)'

The control of hemorrhage fnim the seat of disease is sometimes not nnly
difiicult but even imjiossible, and in malignant cases the constant loss of bkwd
quickly exsiingui nates the fiatienl and hastens her death.

In some instances the bleeding may be conlrolled by irrigating the bladdfl
with hot sterile water or normal salt solution, by injections of alum or tannic add-
and by ap|ilying an ice-bag over the hypogastric region. Good results ate shim-
times obtained by packing the vagina with gauze and allowing it to remain for
six or eight hours, and, finally, the use of a solution of adrenalin chloiid (i w
1000) directly applied to the mucous membrane through a cystoscope will ofiw
check the bleeding.

The pain which usually accompanies non-operable tumors of the btaddn
should be controlled by the free use of opium, which mav be administotd
hypodermically or in the form of a suppository combined with belladonna.

I ■ iham ibe vtun [ualN ihrauih ihi 1iu> d ilie IikhiJ Uguncon U ibc blwUct, ntUth i> dnm
lowud thv rinhi,

VAGINAL PALPATION.

litations.— The uMCTs can be palpated throushthc raRinafrom the
9t thr 1.ii>.iii li|;ame»t> In tlieir entrance into tlie bluclder (FIk- JqA).
formation.— By vaginal i>nlpnlinn we arc able to recognize (he ait,
t, mobility, aixj sensitiveness of (he ureter*. In cases of ureteritis tKe raiul
and tender tn (he tinnh, and in *ome instanc** fined in it^ ptisition by
Irral inflammation. In tubercular ureteritis the outline of the canal is
tr and ui>evcn, nwinc lo the presence of nodules in its wall*.
hrepnration of the Patient.— The rectum should be thoroughly
with an enema andthe urine should be voided natur-
Aft the blfldder la more thoroughly evacuated
lU way than by the use o( a catheter.
' ti

Sbawkit Ibc rifhi umn Uia« pKlpaictl ihwuili ilu vnfUu by ihi Ml iBAA^iff

The index-finf^r is introclucfrf Into the unurolaleral vmult of ikf '"f^
which is made Icnse by an upward and latent pressure with ihe tipotlWy
The stniclures are now rirraly hut Kenlly jialpalcd in various dirtcticiP •'^
limited space until lh« ureter is fell and reroKnixMl a« a tlal. mnlUkc b '
one-eighlh of an inch in diameter which i§ reAdtly diipUccd in iU bnJ - -

UETBODS OP EXAUINATION.

»S9

cellular tissue. By moving the I'liiKer either toward the broad ligament or toward
the bladder all that portion of the urricr which can be reached Ihnyugh the
\-agiiia is imdily jmlpaleil and examined.

Variations in Techaic— Tli<r ureter may also be patjiuted by vagino-
abdominal touch. The index-finger is introduced into (he anterobtenil vault

..V

■■-^-i^y.

Fu. ]a8.— KuuKAnDH or nii t'linBi m Vaniin>-«aDOHDUi ToccM.
Showiac Ibc tigit ukUt haeg taliiunl Mmco Ae inimu] liff *ixl ■)>' Hnfn si ibc nirtB*l hnd.

of the viigina and cuunler-pre^ure made dunnwani through the alxiomjnal wall
above the symphysis inibib. The ureter cjin thus be entity pail|>ated and recug-
nued by the internal finger.

Towanl the end of x^tatton the ureter can lie palpated by pressing the
vaginal vault against the fetal head after it has sunk into the pcNic cavitf.

SECTAL PALPATION.

I, imitations. — The ureter can be palpated ihrou):h the rectum from the
base of ihi- hrncid ligament arul aionj; the |>ostericir wall of the jielvis to the ui-
perior -trail fFi^. 599).

Information.— The same a* in vaginal palpation.

Preparation.— The xime as for vaginal fnalpalion.

Position of the Patient.- TTie same as for vaginal palpation.

Technic. — Tlie left index-Anger h used to palpate tlie left ureter uid lh«
right finger the right ureter.

The finger is introduced into the rectum and passed upward and backward
to where ihe common iliac artery rli\'ide^. The intemiij iliac artery- is then
located and traced downward by the tip of the finger. Palpating somewhat
behind and at Ihe side of the artery, the ureter can be fcJlowed along {t» course
until it passes under the ba.se of the liroad ligament (Figs. 599 and 600).

66o

THE URETERS.

Fig. ^v>- — Examination of tbe L'lETFkS vv Rectal PdUf ation Cpwe 6sa>-
Sbowi thenlAlion oE Ihc left ur«n vnlb the pelvic CA^ily uid brim md tlw cDDuWBUiduKeTUlibvim^

Flfi. 6ciO- — F-XAVINATION Or THE l"yKTEKS BV ReCTAI. PaLFATION (p«CC *S5^'

Showing [he Icil uicln bcinj pilpiicd ihroueh ihe ncium b|> the tcfi inda-Giiia*

UKTBODs or EXAIimAnON.

66i

abdoshnal palpation.

Ifitnitatlons.— The nonnal ureier can seldom be f«h by abdAminul pal-
paliuii. When it is inftiimcd, however, piiiii » eliriled at the brim of ihe pelvis
about tine lo one and a quarter inches on either side oi the promonton- of the
sacrum and over the u|>per t« renal purtion Ijy dceji i>alp;ili(>n. An enltirf;ed
ureter c-.in often be felt as it crosses the brim of (he pelvis, iind in patient> who
ha« exceedingly thin lielly walls tlie nurinal organ may also l)c onrasionally
palpated at thr same point.

Information.— Inflammation and enlarj^ment of the ureteral canal can
often he demimslnited by deep alKlomin^l pulfnlion.

Preparation of the Patient. The bladder ^luiuld be cmj>ti«4l
KponlaneDUsly and the inlesljnes (hurcuHhly c^■acuaIcd so that the colO'nwitI be

IK\

?>:

;nw-

fta-tM. — f— — f— — or mi t'MUfim n As-

wammu. PufAnoK.

Stmn die pMldeai of ibe ontcn ■■ ibi» pv« nm

Ibc brin of the pritii.

1-ib, Cm — ExAWHAtion or nn I'unM >t Aibon-

1)1*1. PurAIKM.

Shuw Ihc pMiw* ul ihr urormnnory t4 ih* ivniih nd
At tivtihd of Spuing ihr If 'i urMf'

oollariactl at the time of the examination. Thb is (xrst aco>m]>li>lie<l by Kiiinn: (he
p:itient .1 bottle of dlriile of magnesia and following it with a large rectal cnpma
of soapsuds and warm water.

Position of the ^tlent.— The patient M placnl in the horizontal
recumbent posture with the lower limbs flexod and the shoulders elevated upon
a pillow.

Technic. — The examiner first loc3it«s the promontov^' of the sacrum by
pressure downward and backward through (he abdominal wall. He then
moves his finger fn>m c>iie l» one and a <iu:irter inches on either >.id« of the pr»m-
onlcffi-, where the ureter can be palpated as it passes over the brim of the |)elviR.
If the upper portion of the ureter U intlamed, the course of ihc canal can be
followed by the pain which is elicited on prcsmre.

INSPECTION.

Usiltations. - Tlie \-rsicaI orifice is the only portion of Ihe ureier that can
be seen by ins;>c<:lJon through the cystoscope.

Information.—Tliis method of exjiminaiion often f,ives very valuable

663

THE URETERS.

points in the diagnosis of a case. Thus, the appearance of the tqieniiig ma;
indicate ureteral inflammation or eversion of the mucosa; a calculus or > pohp
may be seen partly projecting into the bladder; a complete obstruction of &c
ureter may be suspected when urine is seen escaping from only one of the orifices;
and, finally, if blood or pus is observed coming from one or both of the uiMcnl
openings, we have decided evidence of a tubercular or purulent inflammatjoa
being present. If clear urine is seen spurting from both of the orifices, we mar
exclude pyoureter and pyonephrosis.

Preparation of the Patient. — The colon must be thorou^ily evacu-
ated by giving the patient a bottle of citrate of magnesia, followed by a latge
rectal enema of soapsuds and water. No fcxxl should be taken for several bouR
prior to the examination, and the urine must be voided naturally just before tht
patient is examined.

When the patient is placed on the examining table, the external urethnJ open-
ing, the vestibule, and the entire vulva must be thoroughly sterilized to prevent
infection being carried by the cystoscope into the bladder. This is accompbshed

Fic. 6o3.~lN6riniuiNis l^ED rot Exahiniko the UmETEis BY iNBncnoii.

by scrubbing the parts with a gauze sponge saturated with tincture of green swp
and warm water and washing them with a solution of corrosive sublimate (i <"
icjoo), which in turn is removed by douching with sterile water.

Position of the Patient.— The patient is always ex-
amined in the dorsosacral elevated position. The iip*
must be elevated from twelve to fourteen inches above the surface of the tibk
so as lo raise the pelvis and allow the bladder to balloon out when the c)-slos<T<
is introduced.

T have never found any necessity for placing a p^'
tient in the knee-chest position to inspect or sou'"'
the ureters, and even in very fat women there is'''
ways enough dilatation of the base of the bladder to
readily locate the ureteral orifices.

Instruments.— { I ) The Ashton-Gans cystoscopcs (three sizes— N«- '<•
30, and 36, French scale); (2) Kelly's cone-shaped urethral dilator; (3) ^■
delicate alligator-jaw forceps; (4) Ashton's modified Snell's residual u""
evacuator; (5) Kelly's ureteral searcher.

Description of the Instruments.— The instruments are described iub"
cystoscopy on page 622.

ur.Tuoi>s or bxaminatiom.

663

SterilitatioD of the lostniments.— 11te method of steriUeiDf; the uutru-
menu is givm undiT cysloscopy i>n p;igc 6^4.

Absorbent Cotton and Boric Acid Solution.— Small pledgets
of abnurbeiit cistloii and n siitumlol dilution of burit' acid mutit be on hand to
clean thr trigone of the bladder if it is found nectsfaiy to use the searcher in
locating the ureteral orifices.

Ifiqaid White Vaselin.— This material is UM?d a.« a lubricant for the
instrument.^ and i:^ slrrili/cd in the same manner as liquid foap (see p- ^14).

Hubber Gloves.— The examiner ^ould wear rubber nlove* 10 guard
again'-t r<!ni.'imiii:>iing the instnimenl^ and i*arn-ing inferlion into the bladder.

Anesthesia. —A general anesthetic is required, as
a rule, for the fitAi examination; and if a subsequent inspection
is ncccssar)', it may be accomplished under the influence of a 10 per tent, .wlution
of cocain applied on a pledget of cotton to the urethra.

Tcctanic. — After (liblinK the exlerrml meatus of the urcllira. introducing
the cy>lwsco|}C, and removing the residual urine in the manner alresidy iltM ribefl
under the tcchnic of cystoscopy on page 635 (Figs, 534. 5^55, 581}. the examiner
llien locatcj. the ureteral (>|ieTiing.> (or insiieclion as follows:

Gnidually witbdnuv the cystoscope from the bladder until the interna! open-
ing of the urethra begins to close over it, then advance the instrument about one-
liiini of an inch and raise the handle to expose the vesical trigone. Now turn the
cystoscope cither to the right or left about ihtrly degrees and one of the ureteral
orifices will appear in the field of lision.

The vesical opening of the ureter varies in apjiearance e\-en in health, and
oence it may be occasionally difficult to locate. I'sually, howe^-er, its position
b marked by a small pinlush prominence, or i( may look like a delicate slit or a pit
or dimple in the mucous membrane at the extremity of the inlerureteric ligament,
from which a little stream of urine is seen to spurt at regular inter\'als. Some-
times, hnwiTcT, no distinctive m.irk is apfiarenl, and the orifirecan only be located
by observing the position on the surface of the mucous membrane from which
small jets of urine are ejectei] or by exploring the 1>ase of (he trigone with the
sejirchcr.

Unless the examiner sees the urine actually spurting from the orifices of the
ureters, he cannot be certain by inspeclion iiione that he has located them. This
fact b important lo bear in mind: otherwise, ha^-ing incorrectly located what is
supposed to be a ureteral opening, and after watching it for a few minutes without
seeing any urine C9ca]>e. the examiner may conclude that a t-ompleie obstruction
exists somewhere in the canal; whereas if the sup|>osrd opening is probed w-tth a
searcher l>efore ooming to such a conclusion, a mistake of this character would be
avoided,

CATHETERIZATION AND SOUNDING.

Limitations.— The entire length of the ureteral canal and the pdvis of
the kidney can lie explored by these me(ho(j».

Information.— By the use of catheters and sounds we are able to reeogni«
the presence of siriciuies and calculi: the existence of a hydrouretcr and a
hyiln)nephnwis or a pyoureter and a pyonephrosis; lo collect the urine separately
from each kidney u neon tamina ted by the bladder; and, finally, to diagnosticate
a toraion in the ureleni canal by the peculiar rotary motion whidi the catheter
takes as it is withdrawn from the ureter.

Preparation of the Patient.- Same as for inspection (sec p. 66a).

Position of the Patient. -S^me as in inspection (.see p. 66j).

Ingtrtiments.— (1) The Ashton-Gans rystaeco[>es (three sizes-— No*. 94.

664

THE URETERS.

30, and 36, French scale) ; (2) Kelly's cone-shaped urethral dilator; (3) alUptor-
jaw forceps; (4) Ashton's modified Snell's residual urine cvacuator; (5) KcUjr's

? •^•#>

(?)

Flu. 604.— INSIBI- BUNTS IsEO I0« C»IlltirHII-il. *MI SOISOINIi IHI L'lETUl.

Fir. (wc; — li.mmn Sii.K liiiiiB.i, ('AriiF-Tni. Am JH St/t

ureteral stMrcher; (fi) flexible silk catheters; (7) Kelly's metallie cathetw; f**
Kelly's flexible hard-rubber sounds; (9) Ashlon's conducting forceps for fenw
catheters.

METHODS or KXAUINATION.

66s

Flexible Silk Catheters.— These instruments are so inches long and 3
mittimelcn in tliumeter, ami. bdiig very flexible, readily pass thiough the urethra]
caDal. The French catheters arc superior to those tuadc in other couiiiries, as
they ace more delicately shaped and slronRer in conAiruciion.

With flexible catheicrsi we can collect the urine separately from each ureter;
diajjnoiie the presence of calculi and strictures; and asi-criain wheth<T the ureteral
can-il or ihi- peU !■- ()f the kidriej i> distended with puN or urine,

Hetal Catheter. — This instrument is 12 inches long and 3.5 minimeters in

a C

■^

Fla. Set.— Kcik'* UkijiUic I^iznaAi. Cjlisetel

diameter, and is utetl to pa»» a stricture or a Inist in the vesical end of the ureter
which oli^truct? the inir<xIuction of a ficxiblc catheter.

Flexible Hard-rubber Sotiiids.^The MiundA are made of hard-rubber and
vary in size. They arc so indies long and rounded vE at their points into an
u]itT-sha)>c<l cone (I'rum 1 ui 5 miUimeters in diameter) Mhiih i> thicker than the
handle or ^haft of the inMnjrnenl.

Conducting Forceps.— This instrument is made upon the simc principle
as the atlig:ilor-j;tu' (urce^ts-, exce|it that tt> blade Is grooved and u|)ens at right
an^es 10 the shaft. It is used to seize the veucal end of the catheter and conduct

Fio- M7— Knir'< Itim ii:iii>ib Fi.ixmct I icnsti. Soi'Hn. Ai-tital Mti or ttiiru. Kvn.

it into the ureteiBl canal, doing away with the neccwily for a stylet to stiffen the
instrumcnt-

Sterilization of the Inalniments.— Tlie metallic catheter, the flexible
rubber ^t-undi. and the conductinR forceps are sterilized by boiling in a loda
solution for l:\eniinuies before UMng. The method of steriliarinp the instruments
which arc also used for tnnpetting the ureteral orificei. is giicn under Cystoscopy
on page 613.

The silk ealhMer* are made atteptie as follows: Before using, each catheter
is rinsed and flushed out with a cold solution of corroMve sublimate (1 to 1000),

I'lo. toS. — .\iirT«n('< CcHtiiiTmc T<oerra. AriKtt, Sia or Dnut, Em.

followed by sterile water, and laid on a fterile towel until required. After use
the catheters arc :i)!ain rinsed and flushed with the corrosive sublimate solution
and ^te^iIc w;iler and laid out ulraight on a rferile Inwe! lo (\r\. They are then
wrapped sjcparalely in a towel and placed in the storage ca^' until needed.
In septic ca.^fti after nich catheter !.» rinsed and flu.thed tt i.i sterilized by higb-
prcssure steam or by hoilinK in plain water for two minutes; it is then laid on a
towel to dr\' and put away in the storaRe ca.se. Before sterilising the catheters
they Rittst be wrapped separately in gauze in order to keep the surface* apart
and prexent them from becoming glued logelhcr.

A flexible silk catheter should not lie sterilizMl hy steam <^t boiling water

666

THE UHETERS,

immediately before use, as it loses its stiffness and is more difficult to introduce
into the ureter. For the purpose of flushing or cleaning a catheter nothing is
better than an ordinary hj-podermic ajTinge. After filling the syringe the necdk

Feo. 6og. — Ttf of a Hahh-iuiibeb Flexible Sound Coatxo with Wax.
Aclupl uzc oi distal end of Ihe sooodr

is passed into the proximal end of the catheter and the solution forced througfa
its lumen.

Rubber Gloves; Absorbent Cotton; Boric Add Solutioa;
Iflquid White Vaselin.— The various purposes for which these articles
are used are given under Inspection of the Ureters on page 663.

Anesthesia. — A general anesthetic is usually required.

Wax-tipped Sounds. — In cases in which a calculus is suspected iidij

Fir.. 610. — Cathetfiikation and Sol-nt>ino op the I'veteh,
shout Ihr starchcr liring iDKodutcd into ibc oriB« ol [hi righi uiMct.

coats the tip of a hard-rubber flexible sound with melted wax and il!o«i','''
harden. When the tip of the instrument comes in contact mth the sttint '"
rough edges scratch the surface of the wax, and these marks can be seen l»J' t"
naked eye or a lens of low power after the sound is withdrawn.

MRTHOnS OF F-XA«1N"ATI0N'.

667

Technic. — After dilaliiiK the external mealu.t of (he urethra, introducing
the cystoscopc, and removing (he residual urine as described under the technic
«( ryittisnipy on page 6ij (Figs. 534. 535, and 581), the examiner locates (be
ureteral orifice* by inspection and in^kcK mitc of their [lonition, if there be any un-
certainty, by passing the searcher into the canals for a sherl distance. Before
intniducing (he Ncarcher, howeier, (he opening of (he ureter and the Mirround-
ing mucosa musi be thoroughly deanjc^l wilh boric acid wluCton.

Tlie end of the ca(hc(cr or sound is now dipped into liquid white voMelin,
passed through ilie cjino.scope into (he ureter, and introduced tery slowly up the
canal

When a flexible silk catheter is used, care must be taken to prevent it be-

Fic. Aii.'CA'nnminii'i txi) SnimniKii nii Pitna*
Sbewi 1 ttahU lilk cailiea' bant intnduwl Uuo Oh rtghi mwr bf muH irf AihUia't oaduciiai (oktm-
Kotf ibtnrlo aliKli i)i( mmiBCT hukU the fnzcihlelltK ulbrUt in hii Irfl tuul. DhumiioB' (>aii>l>ur)
i timn At itail rnd at iIh tan*|a hnldlnt thr aittaa.

coming infected while Iieing in(n.>duced, and to guard against (hiii accident (he
instrument should be held by the operator close (o the cystoscopc (Fig. fin).

The catheter is grasped by the conducting forcepa about an inch from its
TCsical end and pa.i-sed Ihrimgh the cy^ltwtopc into the tirelcral <'aiiid. The
blades of (he forceps are then loosened and slipped along the catheter for about
one inch, when they are ^igain tijthlened aiid the catheter pu.slied further up the
tireieral canal. This procedure is repciiteH until the catheter reaches the jielvis
of the kidnev or meets an obstruction. The introduction of a flexible catheter

£68

THK VKtiraiA,

is greatly facililated by the use nf the conduciinf; forceps, as the opcralor is lUt
tn direct the {nittniincnl with [)n-d.->ion iind prr^rnt it from doobUtf noi
it^K.

Method of Obtaining Separate Urine.— To nbtain apanit um
from the- iir(-Irt> n lkxil>le nilhcit-r ■» piuv-^d inin both of the unlcnl amli lo^
tii« urine allowed lo escape into Ic&t-tubcs or sterile bottler. After the nibma
have hfc-n iulnxtucefl the nMosroiie Ik withdrawn and the [Mtirnl plncnJ ia At
ilorstisiirml position by removing the pillows from under tlic Imtiiiri*.

Il is important in obtaining scpariilc urine to mark the cathetpr> » « fc-
know iiilo which ureter each i>f them i^ jtu^sed. Thib i:^ icadUy aa.uni)ii^h

fir, fju.— .MillfOI- O' t'yt*rMV- Sr'AUIt r#Tvf

Noll ihai ihr wiiml is Id Ihr diKHBaniLl iniiiun Inm dcvainl) lAd ihii ■ lUiiii it unli

IIUt^H'*

lying n nieicof strinR around one of the caibeteis and noting inlowhidiunwii
is iniriHliiifd before with<lr;iwinK the n'stoscnpe.

Method of locating the Situation of an ObstrnctiOB.!"
cases of ureteral obslrin lion it Is often im|ioria»t to know bow Ur iht callflB
or sound has pas-wtl into the urcler in nnltr to locate the situation "I tlit b**
and determine upon ihc proper plan of treatment. Tliis fc rcudily it)i« I*
graspinf; the ratbeter or tfiund cbwe to the ureteral orifice widi di«a>odwa«
forceps and measuring the distance to its lip after the iiuirumenl hft*b«6**"
drawn from the ureter.

SEGREGATION OF THE UKINE.

Limitations.— The scgregjilor can collect the urine sepontelj' fw ^
kidneys, but ii rannnt deliver the urine free from bladder roni.imin.ilJMi

Information.— OwinR to the limiijitians in the use of the nTPqt***' *
cannot lie employed to <liviin|{ui.ih between rtstJtis and ureierjl or kidtin Ic****
because the urine is contaminated by the bladder, and ronviiuendy il c> in(<^
slble lo know the source of any abnormal constituents ih.it may be present* i*
urinary cucretion!*. In these cases, therefore, ne must resort to catbewiB""
Hnd obtain the urine directly from the ureters.

UETRODS OP KVAMIXATION-.

e69

On (h« other ham), however, seRreKaiion ha» distinct advanta^s over calhelcr-
ization, and [Kwilivc tnformiitian of a valuable charactcJ' can oflrn be dvlcrmincd
by obtaining >cparalc urines with the scgrcg.itor. The advantages of the inslru-
mrnl are that there i* no danger of infeLling the uretere with septif or tiil)er(-iil:ir
material from the bliiddcr, and it is inlnitlucetl v.Hlh but Ittllc, if any, discomfort
or [Klin to the patient.

With the segre^utor n*e arc able to determine the {>resent-e of two kidn<-y« and
their relative functional activity in caw* in Vihich a nephrectomy is contem-
plalec]: in the case of a unilateral renal lesion we can locate the diseased kidney
by analyzing the >ciiafntc urines; the presence nf a complete iibstniction in one
of the ureters can abo be demonstrated, although its ciiusc can only be elicited
with the catheter or the Kiund; and, finally, segregation should always be em-
ployed when the <iuc»tion arise* of having accidentidly cbmjwd or ligated a ureter
during a pcliic operation.

Preparation of the Patient.— The rertuni should be thoroughly
emptied wuh an enema ;ind the urine vuidtid naturally immediately before the

tiD- Atj. — Run*'* SiaiieiTO* roa Sioise*nMi nii Unm.

examinatioD. WhcD the patient is placed on the table, the meatus and the vulv,i
khuuh) be thormighly sterilized (see Inspection) and the bladder irrigated with a
warm Kiluratcd uiliition of boric acid, allowing enough of the lluid to remain to
slightly diMcnd the cavity of the organ.

Position of the Patient.— The dorsal position is employed.

Instruments. —The only instrument requireil is Harris* urine NCgregator,
which fi)rm> a watershed by raising the base of the bladder between the orifices
of the urcin>.

Antisepsis. — Sterilization of the lastnimeot. The Mgrcxalor, tHe
glass vials, and the exhaust bulb are boiled for five minutes in plain water and
placed in a tray until ready for use.

Rubber Gloves. - The examiner should wear rubber gloves to guard againxt
infecting the segreRator and thus carrying septic material into the bladder.

Anesthesia. ~ -An an«thetic is seldom miuiml exce|>t in nen-nus or vety
sensitive women.

Technic— The seRregator without its altachmenls and its flat dLsul ends
In contact so as to form a single continuous shaft i.« inlrcKlucrd into tlie bladder.

670

THE VKCTCXS.

EacIi f.-ilhetcr l« ihn mtntcd on il» long nxi? by directing each proucul md on
ward and downward, llic vesical ends of the scgrrf^tor are ihut vptnicd lad I
lie done Ki the ureteral orifi<fes.

The vaginal kver is now introduced into the va^iu and coniwctn] wA 6( |

, i^-

Fill. (114

'■IT I'nrn.

Slunn Hanii'i artnci'it inimlucnl iDto ilw bbdda •• • doftt riniliiiiiin M

cathctent by mranK of a fork .itinrhment nnd its distal end held betnaA*
vesic-il ends of ihc scgregator by a spiral spring, thus fonninf; a watcrshd*!*'
base ol the bliidder which separ.ite.i the ureteral f>riftce». The niblxr taiiK
connecting (he proximal ends of the scgregator is now rcmowd and the i

-^1

Kli'. 6it.— Smiiuutioiv «• Tlir t'llKl.
Stunn thf miul Mib o\ ihr vKR«*lnt Hpanini uul l|in< ikar in tke MfMnld**

fluid allowed lo ewapc from the bladder. The vials are then Btt«Wf ,_
c^illieters by the rubber tubing, and by means of the exh.-iuyi bulb ik* ""'^
sucked into the catheient as fast its it escapes from the ureters and te"*^'^
receptacles.

Special Directions.—" Aspiration with the bulb tliould noc be f^P"^

METHOnS OP EXAMIXATION. 67I

or it will draw iht mucosa into the opcningB of ihc tathcier. Very sJighl aspini-
linn is all lUal is iier«NS.tn-. A.% ii few <iT<}\>* of lluiil art apt lo remain ii) the
bladder even after ihe u.*c of the catheter, the first few drops that come over
-<hiiiild he 'liscirdod. Thi- instnimrnl should W opened cartfiillv when in the
bladder so as not to excite hemorrhage bv injuring the mucosa. The distal ciir\-<'
should be just within the bladder, whidi is determined by noting the length of

_ /A

(V.

Fio. «iA.— SioiDMncn' or nn (.'uki.
Show* Ik* vciiTitAior ;liiiI ju «IIAdiincnu in poidfwa mad Ihr opfnlw cpmpr«w4iig ihc vihuul bulh-

the urethra on Ihe Krale. Pom the iiwtrument into tlie bladder and open il
before introducing the lever into the vagina. The ends of the catheters arc easily
felt through the vagina and the lever should 1>e dJrcctlv in the mi<ldle, midway
between the two ends and |)res.sed Kntigly into the angle. The pressure should
not be sufficient to cause pain, as the watershed is vcty easily formed. The urine
tloei not drop continually into the vial&, but intermiliingly, juftt as it escapes
from Ihc ureters" (Harris).

CHEMIC. SnCROSCOPIC. AND BACTERIOLOGIC EXAMINATIONS.

Limitations.— These methods of investigation arc limited lo the cuamira-
tion of ureteral disiharges.

Information.— We ran determine the character of the infection in rena!
and ureteral i nil .animation.

Teclmic. —The urine and the ureteral di.vliargei are ol>tained by calheteriz-
iDg the urelcrs and collecting ihem directly in sterile bottles which are sent U> a
pathologist for examination.

THE X-RAYS.

This method of investigation is used to determine the presence of a ureteral
calculus. The tcchnic of the ex.tminalton v,Hll l»e found in j-jiedal works on
ihc x-rays, and need not therefore be discussed here.

672

THE URETERS.

lilALR>RMATIONS OF THE URETERS.

Anomalies or malformations of the ureters are very seldom met except at
autopsies or on the dissecting table. This is due not only to the fact that they air
extremely uncommon, but also because they rarely give rise to symptoms w tun
any pathologic importance.

The following anomalies have been described:
Duplication.

Abnormal implantation of the orifices.
Occlusion.

DUPUCATION.

A duplicated or double ureter is the most frequent malformation met, and it
may be either complete or partial. In the former case each ureter arises from u
individual pelvis and enters the bladder without fusing with its fellow. UsuiUf.
however, the orifice of one of the ureters is occluded and a partial hydron^jhiosis
is present.

In a partial duplication, on the other hand, the ureters may arise from in-
dividual pelves, but. fusing lower down, they enter the bladder as a single tube, at

Fiii. fir;.

Fir., tuo.

Fro.. 6iS. KiG, 6iij.

MAIrFOkUAriflSli OF TMF THtTFIIS^

FiR. fii7 shi.ws 1 complcie double urcipr; l"igs 61.1. Oio, jnJ 610 show diflcnnt forms of a puiiiliw*

the division may occur below the kidney and the ureters either continue as sep*-
rate duels or they may unite again before penetrating the vesical wall.

Symptoms.— These malformations cause no subjective or objective .«™p-
toms, unless a partial hvdronephrosi-i occurs as the result of occlusion of ll"
vcsic.il orilice of one of the ureters. This subject will be fully discussed in cM"
sidcring the malformaliotin due to occlusion.

Treatment. — Notrealmcnl is indicated except in cases of partial hjtin*!'*
phrosis from occlusion.

IUIJORUATII>!t.1.

673

ABNORMAL IHPLANTATION OF THE ORIFICES.

The nrificL- ii( mic of the urcUTs triiiy open ^iltnortniilly jn ihc urelhra, the
vagina, or ufioii the surface of the x'ulva near the external urinary meatus.

Symptoms.— The jiiiiii-nt givu a histur) a{ conMani invoh]ni;ir>' dribbling
of urine fr«m binh. The urine also accumutalcs in the bladder, and although
it is voided at regular periods the total amount passed in twenly-four hours ia leaa
than the uvert)>t^.

Diagnosis.— If ihe incontinence or dribbling of urine has existed from
binli. il is due to a trongenilal mulformation, and the next question to deride is
the origin of the involuntary dischurge. Imontinencc of urine occurring pri-
marily in an adult is always acquired, ^nd wc must ihcrefore look for other than
congenital cauNSs. Having decideil from the history of the patient and the
absence of any ac^uire<l cause that the condition is congenital, we must then care-
fully examine the patient to determine whether the abnormal implantation of the
orifice of the ureter i* in the ureihr:i. the wigina, or upon the surface of the vesti-
bule, and whether any communication cxdsis between it and the bladder.

The patient i^ placed in the dorsal pasilion and the vagina and the external
partx douched with w.-irm sterile water. A jwrinenl retractor i* then interled
into the vagina, which is thoroughly wiped drj- with a gauze sponge. The
reiratior is then withdrawn and the surget^n carefulh- insjiecis the external uri-
nary me:ilus and the vestibule for several minutes- If llie ureter opens in the
urethra, urine will be seen dribbling from the external meatus, and a urcthro-
icopic examination will show ihc i»»ilion of the abnonnal urifire; bill if the
adventitious opening is implanted in the vestibule, the urine wilt be seen escaping
intermittently from a small orifice in that siiuiition. If. however, the external
part^ remain dri'. wc rcinlroducc the perineal retniilor; and if urine is found
in the vaginal culdesac, the situation of the ureteral orifice must be in the vagina.
An inspcclion should now t>e made of the entire vaginal canal to locate the pou-
(ion of the ureteral opening, which is rc%caled by an inteimittent jet of urine
escaping from a small orifice.

Having liH-ateil the situation of the suppa'«d ureteral opening, we must then
determine whether there is any communication between it and the cavity o( the
bladder. This is accomplisheil by calheterizing the patient and injecting into the
bladder a suluticm of creotin fo.5 pre rent.) or sterile milk and noting the color
of the urine as it escapes from theabnormnl opening. If no change takes place,
the diagnosis of an abnonnal implantation of the ureter is rendered certain; but
if lliL- color changes In white, the vesical source of the urinary discharge will be
established.

Treatment.— The malformation can only be corrected bya surgical opera-
tion which will dit-erl ihe llow of urine and direct il into the bladder. From the
standpoint of treatment it is unnecessary lo determine whether a complete or
partial duplication of the ureter eJcisLs or whether the abnormally implanted
orificeis t he only one dniining the kidnei', because if there is a dupliiaticm and the
supernumerary ureter is ligaied instead of being turned into the bladder, partial
h)'dnmp[jhmsii due to onlu^iim would neccriiiarily result.

Implantation of the Ureter. — This is accomplisheil by incising the vagina
and dissecting ihe ureter free as far Imck as the base of Ihe bladder. A small
o](ening is then made into the bladder thnuigh which the end of the ureter is
inserted after rcmoWng the redundant portion and splitting the orifice. The
ureter is then permanently fise<l in its new position by stitching it to the wall of
the bl-^dder with catgut sutures, and the vaginal wound is finally closed with
interrupted silkwonn<gut sutures.

674 THE URETERS.

Formation of a Fistulous Opening between the Ureter and the Bliddn.
—The bladder is first opened by a suprapubic incision (see suprapubic cystotomy,
p. 965) and the ureter located. An opening is then made throu^ the t»seo(the
bladder exposing the ureter, which is split open and the edges of the indsoa
stitched to the bladder wall with interrupted catgut sutures. The ureter is den
ligated beyond the false opening and the suprapubic incision closed witbout
drainage.

OCCLUSION.

A congenital occlusion of the ureter is a very rare malfonnation. In stnv
Gases the atresia is due to a flexion in the canal, and in others it is caused by 6x
distal extremity of the ureter ending in a blind pouch or sac. The tattn d^
formity is usually associated with a complete or partial duplication of the ureter,
and the abnormal canal either ends in the bladder n-ithout dilatation or it fonns
a sacculated lumor which encroaches upon the cavity of the organ. Insomeose
the distal end of the ureter has no attachment whatever, and if it becomes dilated
forms an ovoid cystic tumor which may be readily palpated throu^ thevagiaii
vault.

The effect upon the kidney of an occlusion of the ureter varies, and we find
in some cases a portion or the whole of the organ atrophied, while in othas 1
partial or a well-marked hydronephrosis may be present.

INJinUES OF THE URETERS.

Causes. — The ureters may be injured by any form of external »Tolence,sudi
as a severe crush or a squeeze of the lower abdomen and the pelvis, and byi
bullet or a stab wound. The most frequent injuries, howe\'er, occur during 1
pelvic operation, and it is not a rare occurrence for the ureters to be wounded oc
ligated or clamped when a tumor or the uterus or both are removed by ddMt
the abdominal or the vaginal route. Serious injuries are likewise apt to occur,
in the hands of an inexperienced surgeon, during operations upon the anteria
wall of the vagina, and it is not an uncommon occurrence under these cinnim-
stances for ihe ureters to be accidentally cut or ligated.

Varieties. — Wounds of the ureter may be either (a) incised, (6) contused,
or (f) lacerated.

An incised wound may completely divide the ureter or it may only partially
cut through it in a transverse or longitudinal direction. This varictj' of wound
may be caused by an accident during an operation or in rare instances by a stab.

A contused wound i.s caused by unintentionally ligating or clamping the
urcier and by external violence.

A lacerated wound may occur during the enucleation of a pelric massor
from the penetration of a bullet.

Symptoms and Diagnosis.— The symptoms depend upon thechaiactff
and extent of the traumatism. Injuries caused by external \-ioIence, ev«i riim
the ureter is ruptured, cannot be diagnosed in the beginning because the s]mp-
Icms arc marked by those dependent upon wounds in adjacent organs. U-suillT'
however, (he patient complains of pain and tenderness in the lumbosacral regiw;
micturition is frequent and painful; the amount of urine is diminished: ^
hematuria is generally absent unless the kidney is also involved. In the coukoi
a few days or weeky, if the patient sur\'ivc,s her injuries, an indistinct, bogF
tumor may be fell at some point along the course of the ureter, which is occasion*
by the e.Mrava.-ialeci urine around the .';eat of rupture. In the case of a ff'^^
or slab wound involving the ureter the nature of the injurj' may be suspeciw

IKIinUES.

«7S

fromlhcsituationof the wound, the diminished amount of urine, and the absence
of hematuria. In M>nic iitvlumcA thtr xinttK nuiy vMrupc from the entrance ot Ibc
wuuiul and ihu-" continn the diagnosis.

\\'ounds occasioned by a faulty ojicralive technJr are luwitly less difficult to
recoiiniKie liecau>e uf the ncutcness of ihc symptoms and the hi«lon' of the case.
If the ureter k wounded during an operation on the anterior wall of ihe vagitu. a
ureicro vagina I liitula re>ulu aixl there it a con.^l;lnt dribbling of urine. The
>amc conililion mat' likewise follow an injury during a \ivWk o[>cration by (he
raginal route if the urine succeed.^ in lindin); an outlet lltn>ugh the vagina. Usu-
ally, however, when the ureter i.'' wounded during a jwlvic operation, espetblly
by the abdominal route, a fistulous communication with the vagina ix vei^- seldom
formed, and lonsequently extravasation of urine occurs into the surrounding
livsues whirh may be felt by bimanual palpation as an indistinct. b<>i;Ky tumor
or mass.

The arcideiitid ligation or clamping of one ureter during an operation may
bo followed by acute hydronephrosis, which mariifesU itself by a seven-, sharp
pain extendinK from tlte region of the kidno' to the Iklsc of the bladder, and is
accompanied by chills, elevation of temperature, rapid pulse, vomiting, and eX'
ireme restles.snes.-i. On the other hanil. however, there may l)e an entire absence
of all symptoms and the patient makes an uninterrupted retowry. L'nder these
circumstances the kidney gradually becomes atrophied without t^auMnR consti-
lutionaldi.>(turliiincev.and nothing rem^iins but a slightly diluted pelvis and ureter.
Again, the symptoms of ureteral occlusion may be fn completely masked by lliote
de]xrndent u|iun other |Mi>t o)i«ritive uimpliialions that the accident to the ureter
may not l>c e%cn sus|>ecled, and there is n o d o u b t whatever that
in many instances in which death has been attributed
to sepsis or shock the true cuuse has been an injury
to one or both ureters. The amount of urine voided by the bladder
is always diminished in cases in which oneuretiT has l)een litc;itei| or clam|ied.
The dia^oBi.i depends upon the nature of the operation and Ihe jiossibility
of injuring a ureter; the s)'mptoms of acute hydntnephro.-us when they are pres-
ent; and the diminished amount of urine. If the latter s\-mplnm is due lo
ureteral occlurvion. Harris's se^gator will demoiiMrile the fact that urine only
collects in one side of the bladder.

When lK>th ureters are ligated or clamped acute hjxlronephrosis may develop.
OT the only sinnptom in many ciU'-es f<»r the first iia>' or two will I»e suppre*sion of
urine, which i.s shortly followed by urrmia and tlfjth. The iliagnosis de|>ends
upon ihf nature of the ogieraiion and the |M>vsibility of injurinc the ureters; the
symptoms of acute hydro nc|>hrosis when the)- are present; the suppression of
urine; and ihe uremic phenomena.

Treatment-— The treatment of wmmd.* of the ureter, whether due lo vio-
lence or lo un accidnil at the time of an operation, is purely »ur^ical in character
and has for its object the restoration of ihe function of the cana!. 'I'o accomplish
this purpose, several operations have been <Ic%-isc<l to meet the indications, which
nalurally dqiend u|H:jn the character and silualion of the wound, 1 shall, there-
fore, describe these operations separately, and at ihe tsime time point out the
indication.' for their selection. Before doing so. however, il shouhl be clearly
undersliiod ih.it the n--s|[>ralion of the function of the ureter must be undertaken
surgically as soon as the diagnosis of an injurj* is made, and thai the principles
underlyinx Ihe treatment arc the same whether the injury is ilue directly to a
wound or whether it is caused by the accidental application of a ligature or a
cbmp.

678

THE UKETEKS.

the vagina or rectum or upon Ihe skin i^urfuce In the neigh IjorhtHid n( ibt liltcr.
U is indic.-itet) whfn the wound of the ureter i» m> extensile llut a Breirt^
ureterostomy or a urcterocystoitomy cannot be jjcrformed. am) wfcm iIk
pulient is unal>lc In stand the >li(ick of a nephm urci erect nmy. Whm lit
condition of (he patiiMil has imi^roved. however, (he rmio^-nl ot the kvltin
and the ureter should he undertaken, and in (he tncaiitirne ihc urine i* albncd
to e»ca])e dirough the TinIuIou^ npeninx- I'he fliiiiger n( an a»ren(lii]( ioitiim
mtist always be borne in mind when the implantation of (he ureter is midtiug
Ihe rectum.

Tccbnic— The oj)eratIve icchnic 1* vewv simple and the finpUntJti<(
should usually be made upon the skin surface of the loin. Aft- ' tlicbim

eodof theureterwiihsilk, the upper jiortionisdisacclcd free. L . liitniM

made from within ouiwanl in ib
loin. A narrow forceps is n-iu' pintd
ihrou^h this incition frutn wtttiwii ui

Jtf tf ^^^^^Biw / '''''' *^^"'' "' '^^ ureter seized and |idtni

Mbt ^.^^^ISk^ through the opening- The vnta »

WHhflV^^fc^ "'^^ ^''''''^ ^^ ^^ ^*" *''^ '■"^'"

Ap^^K' \.'A wB? ^^^^ and the abdomiiu] incisiun closed

BWT IV'^WtB^ Ls^*^ Wephro-ureterectomy.-T
^KI \ ' v'^^W \'^-^ enticin tonNiiils in remmingiri' 1
^HA ti-^^ril ■,"r\Tfc ". and a whole or a part of Ibc aiw

It is indicated when the iiijurv !» 'l"
urelcr i» «>e)[lcn^vp (hdt it i ■
^\^ ^ ijf| \ siblctoresloreilsfunitiiin Tli^' ;■

tion should lie |>erfomic<l at omeiiltii
condition of the piitient Is ffxtl.aihii
wise it should l>e |Kis(|Hin<'l oodatnn
ponir)- urelcral ttslula made

T c c h n i c . —The operation ^'

\ 1 no it>'necoloRic pecultaritMS and ut

^\ \ reaiicr h (hercforc referred (d "wl-

on );cnito- urinary suri;cr>' for a i^

criplion of ihe ojwrativr leihnic

Accidental Ligation of tit
Ureters. -If I'nc or lioih ri tW
urelept arc lixated or cbunped innot
an operation and the accident i^ '('<""
ercd at the time, the liRaturr 1:
should be imineilLi(c4y rrmt»"l - ■
the patient cloiscly waicbeil for ton^l
days for si^ns of urinarv- leak^jt
Ulien ilie accident occurs upon the anieriar wall of (he v.-igina, no immoUH'
harm results it a urinan- SsluU docs occur, und there is conse<|uemly nxihirfk
be done beyond watchinR the patient and upcratinR later if nerev%ai^'

If. hiiwcvcT, the \)reteT is ortlii<Ie<l durinft; a jielvic ai]>cnk(iun, a glass dfiiM?
tube should be inserted into the pelvis through the abdocninal incMlan. or, d<^
vaginal route is employed, a drain ufgaujte.thoulil l>e inserted (hrou^anopnix
in the vault of the vagina to ^inrd against urinary- infiltration and enabk ^
surgeon to immedialcly recognize a rupture if it occur* in (he umeral will.

Tlie effect of a ligaiure on a ureter, if it is removed ut (he end of the o^ietati*-
cannot always be determined. In most cases ii will do no harm whitcttC' ^
others a urinary fistula results; or, again, it may cause a stenoMft or an itmn

|Pc-"-

Vin. bif.— L'triniMroii)

IXJUUBS.

677

suture is ihen passed trom within outward in the same way ihmufth the wall
of the lower end of the ureter .iImiuI h:iU iin inch l>elow the angle of the Incision
nearest ihc bladder. The upper end of the ureter h now );radua]]y passed
through the inciNion in the lower |iiinion and the suture drawn tiiut and tied on
the outside. The anastomosis h then mudv secure by stitching the Upper end of
ilie ureter to (he edges of the incision in the lower portion with inlemipted c.a[gut
KUturcs and by protecting the seat of D[)eriition with a covering of peritoneum.

-»"»--•

IlhiiUicSaii a ihowB Uic mrtbod nl iiitmluttcijt ihf uiiurc ihruuuh Ihc HijiCaI ind imnnul md* ol lb* imevn;
iUuilncion b ^owi Ihr ■najiiDiiinsi annplclfd

Ureterocystostotny. — ^This ojwralion <'(ln^ist:s in making an anastomosis
between the upfwr end of the divided ureter and the bladder. It is indicated
when the ureter is completely divided and the division is .Hiiuale<l il<we to the
bladder, otherwise uretero-uretentstomy slioulil be jterformed, as the traction
would be too great at the scat of operation.

T e c h n i c .—The lower end of the divided ureter is ligaled with silk and an
opening made in the bladder large enough to receive the upper end of the canal.

Pra. ««j. no. «H.

I'lituocntotTom ■) Vjm Hon** UnROO,
Fl|- te] ibon th* raaOifKl of iotruducioc Uie amurrft mv> thm vw avd Uidte; Hft. M4 thoin iht ut^tiaiaodt

The opening in the bladder should be made in «uch a position that there will be
a minimum amount of traction upon the implanted ureter. The introduction of
the .tutures, the implantation of ihe upper e:ul of the ureter, ant] the additional
sutures employed to s«'urc the anastomosis are the same as in uretcro-ureleros-
tomv. and are shown in Fig. 612.

Urate rostomy.^This operation cotuists in making an artificial ureteral
fistida by ligating the hrwer and implanting the upper end of the lorn ureter into

6i&

TaK URETESS.

thr viiginu or recttun nr upon the skin »urface In the nrifchlxirlifiad i4 tbt k*^
It 15 indic.ntcd when the wountl of the ureter is t-o c^iciimvc thai 3 tiniv
urelernsiomy or a urcicrocystoNtomy cannot be pcrfornie*!. ami *hto 1;*
patient is uiiatile to sliinri (he :?iha('k of 11 nejihro un-lrrri lomy. Whtn Ut
condition of the pulicnl has improved, however, the removal of Ihc kidnn
ami the ureter Utould be undertaken, and in the meantime the urine » aUkmri
to escapu thrviugh the fixiulous u|>cning. 'I'bv danger <>f an nsceiulinf; iointMi
must always be twmc in mind when the implantation of the ureter is madt ub.
the rectum.

Techn ic.--The operative technic is very simple and the impluuiitt
should usually be made upon the skin surface of the Iwn. After lifraiioi; tbr k^rr
cad of the ureter with »ilk, the up^ier |Kiflt»» t.^ di.t.sccicd fre« anil a »mjl! iai)->-

made from within outwanj in lir
loin. A narrow fortqa i> no" [u.v*j
through thiii incision from without *>d
the end of the ureter *ci«d and prfni
throu)^ the opening. The urtia u
ttipn .^liiched to the skin with lairji
and the abdorninal iiicistim rl'Mol

nepbro-ureterectoiDy.— Tilt* i>
eration omsist* in remo% ing iSr bino
and a whole or a (Mri ol the irtwr
It i* indi<.-aie(l when the injurv t" ihr
ureter is so extensive that it i- ■■
sn)le to restore i Li fmiiii' 10- Ttu
lion shdulil be |)erf»nneil at owe ^ ibr
condition of the patient is Kood.oiiff
wise it >huul(l lie |>o«l{H>ne>l and ■ un
porar}' ureteral fistula m;tde.

Technic . — The ofieratioa kn
no KjneioloKic peculiarities anrt at
reader is therefore refcntd to "iiH'
on Kwiit*- urinary ?.urjtery lor 1 df*
rriplion of the operatii-e lerbnic-

Acddental LlgaHon of Uie

Ureters. -If mic or Uiih « f^

ureters are ligated or damped dutiaf

an operation and the accident is*«o«

crcd ;il the time, llie lignturc or cbsf'

should he immedialHr rnnond u)

the patient closely watched for stitnJ

day.i fur sij^i at urinary* Icakajcc-

When the accident occurs upon the anterior wall of the vagina, no irtunafav

harm results if a urinaT>' fistula doc* occur, and there U consefjuently i^itliiC*

be done beyond winching the julient and oiicraliiiK later if netevar?*

H. however, the ureter isoctluHcfl during a peb-ic operation, a glas.* diw«u(r
lube should be inserted into the pelvis throuFih the abdomiiul incttioii. i».3*"
vaginal route is emplnyed. a drain of gauze shouki be? inscrtnl throui^UOpsi'l
in the vault of the vagina to guanl agninst urinar>' infiltration ai>il catlfc^
surgeon lo immediately recognize a rupture if it i>ccuri> in the urttenil nU

The effect of a tignlureon a ureter, if it is removed at thcendof ihcof-^^'*
cannot always be determined. In roost cases it will do no harm whU' '
others a urinary fistula re.->ulia; or, again, il may caujie a Mcnoois or ai> '^—

FM. Alt — Uamiomiii

STBlCnilE.

679

of ihe ureteral caoal. A cUmp, oo ihe other hand, causes more Ifaumattxin, ami
tlie t'onse((ueiit cruxhitiK uf the liv^uc> i.i apt to be followci] by a fiittula or n more
or lc?s complete occlusion of the iircter,

Drainage in Ureteral Operations.— If the operative lechnie ha»
been tareluliy tarried nut. ilrainagc will scklom be required In operations on ibc
utdrrs; M>nict]nics. however, owin;; to the local conditions in a particular caae,
it may be found neteti-ar)' lo use a ghia tut>e or pmix 10 guard sigiiin.st urinary
inriltr»lii>n should lerikaEC occur.

Method of Determining which Ureter is Injured.— The im.
port.iriK- of ilfttrmiriing wlmh utcler !•■ iiijunii hefnre »>]icning the iilnlomcn Is
frr<|UeiillyovcTlookcdbyoperators, andasB result valuable lime is lost in locating
Ihe ^ile of the iraumatisra. To obviate this difficulty, Harris's seRregalor i). in-
Inxluceil iiilii the bladder («ee p. ^69) ami the xiile from which nourineiscoltectci)
vriil be found to correspond with that of the injured ureter.

DISEASES OF THE URETERS.

STKICTURE.

CflUSeS. — *llrictiire» "f the urclcr result from cicatricial conlnctions follow
ing :in .illatk of ureicriiis or ihe passage of a rmal calculus, nnd from external
tiulcm«orIhe leinfiorary crushing caused by a ligature of a clamp during a pelvic
operiilion.

Description.— A stricture may cause complete or partial occlusion of the
ureter and ii may Ite Ioi-atc<l in any iiart of the canal, although it is muat fre-
quently found in the neighborhood of the bladder or the |H-lvis o( the kidney.
In some cases there may be only one stricture present, while in others the ureteral
canal may be occluded in «veral places.

Symptoms. —The symptoms depend upon the character of the obstruc-
tion ;iiiil llip pri'.Nence or absence of JnfiMion. In an aseptic case where tlie oc-
clusion is nol complete no sym]>loms whatever may be pn-x-nt, bul if the stricture
p^e^'cnts the escape of urine the symptoms of h)droncphrosis e^entuall)' manifest
lhem>elv(3 nnci the amOuni of urine voideil by the bladder is diminished. If,
however, infection takes place and a pyourctcr and a pyx>nephro.<.is flevcJop, pain
b fell along the course of the ureter, a swelling is formed in the region of the
kidnc}- which i.i tender and [lainful to the lnuch. and iJie purulent accumulation
gives ris« to general septic symptoms -ra/>id puUe. jeifr. and rxfiUHMion.

Diagnosis. —The diagnosis is based upon the physical signs, which arc
elicited by (it) touch: (£) the use of Harri^'it g^gregator: (c) toumling the ureter;
and (d) abdominal palpation.

Touch. — If the ureter L-t found U]>on palpation through the rectum or vagina
to be enlarged and Ihickcncd, the probability of the cxUtencc o( an inflammatory
atrictuic should be ccinsidered

Harris's Segregator.— Thi.t in.->trument is iiiinxlured into the Madder, and
if no urine is collected from one side a stricture probably exists in the correspond-
ing ureter

Sounding the Ureter.— A metal catheter may be men! for sounding the
t'csical end of the ureter: but for its upper or renal portion a long flexible catheter
is required.

The calhcicT should be introduced slowly until it meet9 with an obitlruclion;
it is then gradually pushed beyond this point, and if urine suddenly
escapes in a steady stream the diagnosis of s stricture
is confirmed. The amount of urine esca[Hng through the catheter being

68o THE URETERS.

greater than that which is Donnaily encreted by the kidney io the same leogb of
time proves the presence of a hydroureter and a hydronephrosis.

Abdominal Palpation. — In infected cases associated with conmletc oc-
clusion palpation over the region of the pelvis of the kidney and along the course
of the ureter will reveal the presence of a tender and painful enlargement. Id
aseptic cases the tumor is usually neither painful nor tender to the touch.

Prognosis. — Occlusion of the ureter results in hydroureter and hydrow-
phrosis, and eventually atrophy of a portion or the whole of the kidney may bk(
place which lessens or completely suppresses the excretion of urine. If infedioit
occurs, a pyoureter and a pyonephrosis develop.

Treatment. — The treatment of stricture of the ureter depends upon dx
situation, the character, and the results of the obstruction, as well as upon the
absence or presence of infection.

The following methods of treatment have been successfully adopted in ap-
propriate cases:

Dilatation.
Division.
Resection.

Local medication of the ureter.
Nephrectomy.
Expectant treatment.
Dilatation. — A dilatable stricture situated near the vesical end of the ureter
may be dilated with a metal catheter ; if, however, the obstruction is in the middlt

<?. -'Stg^g^^^— o a\b

Hlmytumaii. l„.iii 1^.. -:i:i--^ii. "■■!•'» .ilBliii'.i-ii'n' .■■■■- _ T ^^)lii,T.-'"-a^.

I'm. O36. Fic- f>a;,

Fknch's Mfrmiii of DivtoiNO * Ihetisal STiiiTrie.
FIr. 6jA <ttcvjn a lonKitiidina] indvion IhrmitfK ihe urpier^l val] and ihr nnctun ; Fifl- 63; ibort Ibr ^"^
of .^ulurinH Iht mci^on so ds Iv iDtrcJisc ihe taliixT ol ih* endure-; note thai tlfct ^D^ki ol the nwad J iad 1
■n: unilcd.

or upper portion of the canal, a long flexible catheter must be used. The inslni-
ment should be pas.'>ed once a day, beginning with a No. 2 catheter (i millimders
in diameter) and gradually increasing the size up to No. 5 or 6.

The result of gradual dilatation in suitable cases is ver>- satisfactory in many
instances, the patient experiencing decided relief from pain, and the obstniction
to the flow of urine is greatly diminished. It should, howe\-er, be bom*
in mind that a stricture which has been fully dilated may still obstruct the flow of
urine if (he ureteral walls remain relaxed and flabby.

Division. — A tight stricture which cannot be dilated by a metal or flcdblt
catheter should be divided according to Fengrr's method. This consbts in mak-
ing a longitudinal incision through the ureteral wall and the stricture and suturing
the angles and sides of the wound together so as to increase the lumen of the ui^f
at that point.

Resection. — Resection of the ureter at the seat of obstruction f ollowd b}'
urclero-ureteroslomy (\'an Hook's method) is indicated in cases in which 4(
stricture is not dilatable or where Fenger's method is not applicable on actwini
of the extent and character of the occlusion.

Local Medication of the Ureter. — Gradual dilatation foUowed by Vxu

STHICTURE.

681

medication of the urdnal canal is indicatMl in cjim« in u-hich the stricture b
associated with infection and where there U either a discharge of pus from the
ureter into the bladder or where a [)youreter or a {wonephrtijis in itreiient. We
arc indebted to the brilliant investigations of Kelly in (he domain of urcteiul
surgcrj- for this method of treatment, which he has ingeniously devLipd and suc-
cessfully carried out with the result of greatly imj)r<»ving and in «)me inMameH
in (urinji the (lathologic conditions.

kelly brKt gniiln.illy dilates the ureter until it allows the introduction of a
No. (1 catheter (0 millimeters in diameter), and then liegini* ■'system;ilitally to
wiish out the ureter and kidney with a bichtorid of mercurj- solution (1:150.000),
constantly increa.Mng the .ttrenglh until t: 16,000 i^. used, and occasionally sub-
stiluiing for the bichlorid a i per cent, nitrate of nlver lolution and a weak
iodin M^luiiun."

In describing the method of giving the ureteral injections in one of biti earlier
<:a»s Kelly says: " After drawing off all the fluid, a piece of tine rubber tubing

■■?'

MttiKiu u> CnnKi Ixitt-nom vm tir PntH or nil Kuan. (Ucuimn mbuh Kuiv.)
f\f . Alt ibowi tht thai ruonjcu iaiA lb« |v4fV <tt thf ktAatj-, Vm- A*v Aawt tbt rrfara flow aufivJ br Iwnfipg

thri - -

nilh 3 funnel at the end was connected with the catheter, and a nturaied boric-
acid solution, equal to two thirds of the quantity of Duid taken out, w.-i$ nm into
the ureter by gra\ iiy b) simpl\ elevating the funnel filled with the iluid from jo to
(« cenlimi-ters almvc ihc level i)f the b!ad<ler. Care was L'tken to have the tubes
full of tluid. so as not to inject air. The patient, during ail thr^ manijitdations,
was in the knce-btcasl position. She took no anesthdti , as the treatment was not
painful. .\f(er the cilheler was in the ureter she raised her>elf vn )ier bands and
knees to dispose the fluid to run out faster. When the injection was given, she
again lei her chest down to tlie lable, and rone again when it was to Sow ouL I
found that 1 could wash the urtnari- tract repeatedly with the same fluid, if I
desired it, by holding the funnel higti for the fluid to run in, and by holding it an
equal distance beiow the letel of the table foe it to run out again, often bringing
witii it a conviderable amount of shreddy white debris from the ureter."
I Nephrectomy.— i->lirpat ion of the kidney is indicated in cases of stric-

1 ture imly when the ureter becomes 10 diseased and dtiorganixed that its
I function i* entirely lo»t.

68! THE URETERS,

Expectant Treatment. — In cases of stricture of the ureter in which ttu
kidney has become completely atrophied no form of treatment is indicated anle»
the ureteral canal and thepelvisof the kidney are distended with pusoi the patiai
guSers pain. Under these circumstances the fluid should be evacuated tlin«^
an incision in the loin, and if necessary the kidney should be removed.

Special Treatment. — In treating strictures of the ureter the condilkinoi
the mucous membrane of the bladder must be carefully determined, and if cystitis
is present it should be treated at the same time.

CALCULI.

Causes. — Calculi are not so commonly met in the ureter as in the pdvisof
the kidney or in the bladder. In the majority of cases they come from the pelvic
of the kidney and arc arrested somewhere in the course of the ureteral caoaliluiiDf
their passage toward the bladder. In rare instances, however, the stone but
form in the ureter itself , and cases have been observed in which urinary salts wtit
deposited around a silk ligature used in making a ureteral anastomosis.

Sitnation, — A ureteral calculus may become impacted in any part of dit
canal, but it is most frequently arrested either immediately below the pelvis o(
the kidney, at the pelvic brim, or close to the bladder.

Description. ^Ureteral calculi are elongated in shape; thej- usiiallv
have a ragged irregular outline; and in some instances there is a shallow longitu-
dinal indentation on the side made by the urine in flowing past the obstnirtion.
After a calculus has been arrested in the ureter for some time, it becomes wiy
much lengthened out from the deposit of urinary salts at its ends and from thekc^'
of substance by friction at the sides.

Results. — The effect of a calculus on the ureter and the kidney drpeod-
Lirgely on its shape, character, and size. In some cases the obstruction is not
sufficient to interfere with the flow of urine, while in others the urine is more or
less dammed back, causing a dilatation of the ureter and the pelvis of the kidnr
(hydroureler and hydronephrosis) ; and if infection subsequently takes place, the
collection of fluid bec()mes purulent in character {pyotireler and fiyonephresiA
tn cases of complete obstruction the usual atrophic changes eventually occur in the
kidney, and its excretory function is impaired or destroyed altogether, accordim;
to whether these changes invohe the whole or onl)' a portion of the orpri. .A
large, rough, irregular .stone may cause un ulceration of the ureteral walk and
result in the formation of a fistula.

S3'inptoms. — The s\-mptoms of ureteral calculi may manifest thenwh*-
eithcr in an <iciile or a chronic jorm. The acute symptoms are caused by lif
passage of the calculus through the ureter, and they disappear suddenly wbtn
the stone reaches the bUddcr; but if it becomes impacted, they become chronii'
in charncter, although subsequent attacks may occur should the fore^ b«iy
be dislodged and again descend along the ureter.

The acute, symptoms are those of ureteral colic, namelv — -agonizing pu"
along the course of the ureter from the pelvis of the kidney to the bladder, tapii
pulse, nau.sea, vomiting, and often collapse. In some cases these phenoiwna
are accompanied b>- chills and moderate fever. As the attack subside tlw
pain lessens in severity, and if the stone has become impacted theunKL*
diminishetl in amount or temporarily suppressed, and a fluctuating mass may
at limes be felt in the region of the kidney. During an attack of ureteral rolit
the patient is often able to describe the course of the calculus as it desrtW-*
along the canal by the position of the pain. Hematuria is often present in acutt
renal colic.

cAvcatj.

683

Tbe (kronie iymptomt are rhiiriu'tnixcd by u dull ache or pain alont; the
((Mirnc i>( ihc ureter, which is (xinicuUrly severe at or near the locution of the
inc. If the i)liMru< lion i[iI<;rfiTe> with the llow uf urine, symptoms of h)-dro-
Bter and hydronephrosis arise: .ind .should infection occur under these cir-
iViluiKeii, the local and constitutional nunifeAtiilions of dammed-up pus thovr
tmsclvc* Sometimes the *Ume i* more ur leu movable itnd acts a6 a ball-
live which causes what is known as an intermiUeHt hydronepkniit or (he al-
trnialc relenlion and escajw of urine.

Diagnosis.— The diagnosis of an a(i<te all>ick of ureteral colic due 10 the
sage of a calculus is usually not dit^cult, in. tlie tLymptiim.-^ dcMrribcd above
suffiiienlly rhiinirterislic and cx»n>lant to rnat>le the siiff^n lo suspect the
^turc of the affection. In 3 thronk (me, however, the symjitoms arc not defi-
le, anil a.^ the)' are often prencni in other petvie le.sion.>t. lhc>' us.sist ver<' little
H-unl m:ikin|! the diagnoni's unlc:^s the patient gives a clear history of a prc-
Bus attack or attacks of acute ureteral cotic. A positive diaKn(>>i.'i in both
acuie and chronic cancit i.s therefore [wssible only when the stone can b«
^finitely loc.nlcd by me:ms of a dJrcrl examination.
The presence of a ureteral calculus may be determined by the following
lliods:

Vapnal touch.
Rectal touch.

The use of a ureteral catheter or sound.
The use of the rvMoscopc.
An explurator)' inri.ston.
The .v-r.iys.
Vaginal Touch. -A stone tliat i« impacle*! in the ureter in front of the
ii.irl lii;;inient can UMialty Ik* palpated and rrcofntiied throut;h the vagina.

Rectal Touch.— A calculus located in the ureter poMerior to the broad

jumeiit c.in l>e fell thrMic'i tht rciliira a.s (ar up as the brim of ihe pelvis.

The Um of a Catheter or Sound. -A stone occupying the lower |>orlion

itic ureter c.in he Itnalcti by a metal latheter. which i^ arre.>le<l when the

I 111 the inslmmeiil re.nhes the ob*!ructiiin, ;ind the contact can be both felt

he;irfl by the surRc>>n.
A caltulu^ iMinipying the upper or renal jiortion of the ureter can only be
*led by ,\ llcxibk- h-inl rubber sound the lip of which Kelly covers with a
^n b>er of dental wa?(, so that when it eonics in contact with tlie rou;^
jtci of the .itone, scratch markti are made that can be wen n-hen the instru-
em i" withdrawn (Fig, 609).
The Use of the Cyetoscope.— .\ calculus located at the ureteral orifice and
I^BitniitinK into the bhiddrr may readily be seen through the cystoscope; it is
HB[>i)rtani, therefore, lo examine the openings of the ureters as a routine prac-
TCe in .-il! ..i.sts where Ihe presence of a stone is suspected,

Ao Exploratory locisioa. -The presence and location of a calculus may

detcrminwl. if neces'-iry. by an exploniion,' incision, either tlifouKh the ah

(Hiiial wi-ill or ihrouKh ihc loin over the rrftion of the kidney. In the latter

incc, after exposint; the kidney and opcriing Its pelvis and drawing o^ the

lined fluid, a long. Ik.vible, wav-tip|>e(l .-nund is passed into the ureter until

rli> the obitrunion. It is then wilhdniu-n and the coating of wax examincl

' the presence of the characteristic marks which are nude by ilie rough surface

of tlic >lone (Fig. 5w).

When an exploratort' openini: >s made through the abdominal wall, the
location of the sioite is determined by palpating the entire course uf the ureter
throuicb the indoion in the abdomen.

684 TB£ URETERS.

Tbe x-rajs. — The technic of the examination will be found in spcdsl wo^
on the a:-rays.

Treatment. — Operative treatment is not indicated in every case of ureteral
calculus, because the stone may pass into the bladder and give rise to no further
trouble. Or, again, a patient may have several acute attacks without the stone
finding permanent lodgment in the ureter and thus interfering with the flow of
urine. Therefore unless the clinical history of the patient and the direct exam-
ination show that the stone has become permanently arrested, nothing should
be done in a radical way. When, however, an acute attack is followed by a
persistent dull heavy pain somewhere along the course of the ureter, or the urin-
ary excretion is diminished in amount and Harris's segregator collects the urine
from only one side of the bladder, or a tumor is discovered in the region of the
kidney, we must at once relieve the obstruction by surgical means.

The treatment of ureteral calculus should therefore be divided into:
The treatment of acute ureteral colic.
The treatment between the attacks.
The removal of the stone by operation.

The Treatment of Acute Ureteral Colic— The patient should be given
a full hot bath, hot fomentations or a hot-water bag should be applied over the
kidney and the course of the ureter, and full hj-podermic doses of morphin and

FiC. 6jo, — UlAONO'ilS IIT A l'RtT>:ffAL (.'ALrt'Ll'5 (pAge ^83).

Showi thf LidDFy drtivrftrd Ihrough an iudsiun in Eh^ l'>in. the vcU-h opcard» and a long, flexible, wui-tipped bjund

paucd JDIu Ihe UfLfler.

atropin should be administered. Decided relief is also obtained by drinking
hot water or hot lemonade in larpe quantities, and if the pain becomes unbear-
able, inhalations of chloroform must be resorted to.

The pain is sometimes greatly benefited and the paroxysm shortened by a
hot sitz-bath, which should be continued for at least thirty minutes and the
patient protected with a lifiht woolen blanket.

The Treatment between the Attacks.— The hygienic, dietetic, and
medicinal treatments are very important and should he thoroughly carried out
in every case, as much may be accomiJlished by these means in preventing the
occurrence of subsequent attacks.

The patient should exercise regularly in the open air by systematically walk-
ing every day and increasing the distance gradually as her strength improves.
Horseback -riding and cycling are also beneficial forms of exercise, and may
be indulged in with moderation. Indoor exercises (see p. 117) are especially
indicated, and are of great value in lessening the tendency to the formation of
a calculus, particularly when they are followed at nipht by a Turkish (see p.
88) or a full hot bath (see p. 83). The benefit derived from the systematic use

CALCUU.

of Turkish baths cannot be ovcftslimaltd, if they are given properiy and care-
fully reKulaieil accordmi; lo the indications in each case.

The diet uf the patient must be carefully consideml and all articles of food
having a tendency to the formation of uric acid should be forbidden; crwun and
butter are the only forms erf fat allowed. Overeating should be likewise inter-
dicted, and the Mxot iilcohol, especially the red wines and champagnes, diould iwt
be permitted. A good Scotch or rye whi.iky is the least harmful form of alcohol
in the^c caM», and may be used in iniHler;ition.

Thr patient should drink a l.irge amount of pure water every day (from six to
ten glasses), and for thii purpose distilled water is probably the best, on account of
its iibWutc purity and freedom from eiirthy >n\t», althotigh good mull» arc aL'<n
obtained from the use of Bedford, I'oUnd, and Saratoga watcn>, as well as Buffalo
and l»ndonclerrj' lithia waters. The CarUlad and Vichy waters are especially
beneficial on account of their allialinity, which c«>rrects the acidity of the urine
and renders it non- irritating.

While there i« nu evidence for believing (hat a stone
once formed in the pelvis of the kidney can be dis-
solved by means of drugs, yet there Is no doubt
whatever thai certain remedies are prophylactic in
their action and lessen the tendency to the forma-
tion of calculi. Phosphate of sodium is the miMi valuable of these
remedial ugcnt«, and it i^ b«t administered in the form of an cflencsccnt salt be
fore retiring for the night and immediately on getting up in the morning. Carli-
ImuI Sprudel Salt in doACS uf one lo two i(r:ichm.« well dilutnt anci i.ikrn before
breakfast is often followed by good results and should be employed in prt^rly
selected cases. And, finally, hydrochloric acid alone or combined with tincture
of nux vomica may be use<l as a routine meth«l of Ircntment,

The Removal of the Stooe by Operative Measures.— A calculus may be
removed from the ureter by one of the four following routes:

A lumbar incision.

An inira|>eriionea] incision.

A vaginal incision.

Through the ureteral orifice.
Lumbar I n c i s i o n . — Tlii.» mute shoidd be selected when the *tone
is located above the superior strait and when the ureteral canal is infected.
As the peritoneal caviii' is not opened, there is little or no danger of peritonitis
following the ofieralion. and
in case of a fistula developing
the urine can escape through
the incision in the Inin.

7"«A(i(V.— To expose the
ureter an incisinn is made
beginning immediately below
the last rib at the edge of the
quadralus muM'le. and. ex*
lending obliquely donnward
lo the cre^l of the ilium, it
is carried forward as far an
the anterior superior spine.

When the fatty li.-u>ue nverlnng tite peritoneum is expotvd, the cdgn n( the
wound are firm!)' retracted while the operator separates the structures with
hb fingers and lays bare the ureter. If there b any difficulty in finding the
ureter, it should be made taut by traction upward upon ibe pelvis of the kidney

iwt fjlrr Kboikv nun L'*an>.

686 THE URETERS.

and tracing it from above downward. After locating the stone by direct palpttioD
a longitudinal opening is made in the ureter just above or beyozid the stmt,
which is removed and the incision immediately closed with interrupted catgui
sutures (ufflerorrkaphy). which should not include the mucous membrane. Tlu
incision in the loin is then closed in the usual manner and drained for forty-
eight hours with a few strands of silkworm-gut placed at the bottom of the
wound and brought out at each end of the opening in the skin.

Intraperitoneal Incision . — This route is indicated when iht
stone is located between the superior strait and the broad ligament. Thedu^
of peritonitis occurring if the ureteral canal is infected, and the possible escape of
urine ipto the peritoneal cavity should leakage take place, must not be lost sghi
of in operating by this route.

Tecknic. — The abdomen is opened either in the median line or abng tbc
outside edge of the rectus muscle on the same side as the affected ureter. After
locating the stone it is removed, as described above in the exttaperiloneal opoi
tion, by a longitudinal incision, and the p>eritoneum drawn over the ureter and
secured with a continuous silk suture (Fig. 621). If the ureter b infected or
there is danger of leakage, a glass drain should be placed behind the utentsud
not removed for at least forty-eight hours.

Vaginal Incision . — This route is indicated when the stone is
located beneath the broad ligament or between it and the bladder.

Technic. — The f>atieni is placed in the dorsosacral position, the bladder is
emptied, the position of the stone accurately located by palpation, and a periiKil
retractor introduced into the vagina. An incision is then made through iIk
vaginal wall, directly over the position of the stone, sufbciently long to expose the
ureter above and below the calculus. The ureter is then controlled by passing
two ligatures beneath it, one above and the other below the stone, which are tied
at each end, making two loops about six inches long. These arc held taut br thr
assistant while the oi)erator makes a longitudinal incision in the canal and n-
movcs the stone. He then closes the opening as described above in the extra-
peritoneal operation. If the ureteral canal is not infected, the vaginal wiwnd is
sutured at once; otherwise it should be left ojjen to guard against suppuralioti-
After extracting the stone a ureteral catheter should be passed up the canal \»
determine the presence or absence of additional calculi.

Through the Ureteral Orifice .^This route is indicated wh«
the stone partially projects beyond the ureteral orifice into the bladder.

Technic. — The end of the stone is first exposed to view with the cystoscope and
then seized with forceps and drawn into the bladder, at the same time asasting
the extraction by pressure upon the ureter through the vagina. If this is succes-
ful, the stone is then removed from the bladder with forceps by pulling it through
the cystoscope ; but if the calculi cannot be extracted from the orifice of the uiewr.
it must be removed by the vaginal route, as described above.

NEOPLASMS.

Tumors of the ureter may he either primary or secondary in origin.

Primary neoplasms are exceedingly rare; small cysts, poUpoid gn)"tlii,
cancer, sarcoma, and gumma have been described.

Secondary neoplasms are not infrequently met and are usually due 10 ihf
extension of a malignant growth of the bladder, the pelvis, or the kidney.

Symptoms. — Small cysls and polvpoid growths cause no sj-mptoms w!"!-
ever except in rare instances, when they are complicated by hematuria. Sm"-
times, however, symptoms of ureteral obstruction manifest themselves, when ihe
growth blocks up the canal and interferes with the flow of urine. This is(^'

UCCtVSIOK rauU exTLRNAt lltESSliRK.

«7

cblly apt to happen in cases of primary or secondary tumors of a malignanl
niilurc iinil in hirjif hctii^n smwlh^

Treatment.— The ircaimeot of urrlcniJ neoplasms is based upon general
principle.4- t'.iually their presence is not suspecinl, but if obalruclion occuts
and the}- arc discovcnid at the lime of an exploratory opcniiion, (hey may cither
be removed through a longitudinal incision in the ureteral wall or resection of the
ureter may be jierformed at the >ite of the lumor and (be cjinul resiured by a
urelero- ureterostomy (Van Hook's mclhod).

Primary malignuni growths are usually loo far advan<«d when they are dis-
covered to permit a radical operation being pcrform*'d. and surgical interfer-
ence is Hkeuise ion Ira indicated in secondary tumors on account of the sur-
rounding di»eii»e.

FOREIGN SUBSTANCES.

In addition to calculi, which have tieen already described, the uretenil canal
may be obstructed by blood-dots, an echinoooccus cyst, or pus originating in
the kidney.

The symptoms, diagnosis, and treatment are (he same as in ca«esaf
ureteral calculus.

OCCXUSION FROM EXTERNAL PRESSURE.

CansCB.— The chief causes of iliis variety of ureteral obstruction are:
I'ehic tumors.
Inilammator)- exudates.
Malign.inl infiltrations.
Indammaior)* adhesions.
Tumors of the bladder.

Chronic cystitis associated with a thickened and ntntractcd bladder

wall.

Description.^ The obstruction umalty involves hcith ureleni, ak the

most common causes act bilaterally — for example, malignant infiltrations and

fibroid tumors of the uterus. Sometimes, however, lite cause is unilateral, and

therefore does not oRcct the opimsiie urcti-r.

The ureteral occlusion is situated in nearly all cases between llie superior
iitniit and the hbidder, for the reaMin tliat the causative faclor> are generally
located in the pelvis.

Symptoms.— The symptoms, as a rxite, are indefinite, as the)' are usually
more or le»j completely obiu-ured by thow dependent upon the causative leiaon.
This is e^cially true in cases of obstruction due to cancerous infiltrations and
fibroid tumor* of the uterus. When, however. Imth ureters becume iHcluded,
symptoms of uremia inlcr^xne which point to the nature of the com plic.i lion,
and in some cases the diagnosis may be suggested or confirmed by the appear-
anrr of ;i mmur in the region of the kidney.

Treatment.- The treatment consists in the removal of the cause. If,
therefore, the cau.t;iiive factor is amenable to treatment, the obstruction can
be relieved, but otherwise the case is hopeless.

Pelvic tumors, inflammatory exudates or adhesions, and neoplasms of the
bladder can be removcxl by surgical mcanit and the lumen of the ureter restored
to its normal size.

When Iwth ureteral orifices are otxluileil by a thJc^ned or contracted blad-
der and life is threatened from uremia, the ureter should be ex[xised by an in-
ciskm through the vaginal wall, opened longitudinally, and the edges of the

688 THE UKETESS.

wound stitched to the vagina so that the flow of urine may be uncAistnictcd.
The vesical lesions are then treated (see cyslilis and contractum oj tkt Uadder],
and if recover}' takes place, the fistula should be closed and the stream of urine
turned back into its normal channel.

Ureteral obstructions caused by malignant infiltration are hopdess, ud
therefore no form of surgical interference should be undertaken.

URETERITIS-

Causes. — The most frequent forms of ureteritis are caused by an initc-
tion which is due either to the staphylococcus pyogenes, the streptococcus pyo-
genes, the gonococcus, or the tubercle bacillus. The infection may start in ibt
bladder and extend upward, or in the kidney and pass don-nward into the un-
teral canal, and it may begin in the ureter itself when the canal is occupied bt
a foreign body.

In the majority of cases the inflammation starts in the bladder as an tattt
or chronic cystitis, and eventually the infection extends to the ureter- As i
rule, therefore, the ascending varieties of the aSection are caused by the gono-
coccus, the streptococcus, or the staphylococcus, and a tubercular inflammatioii
of the ureters, which is comparatively rare, generally originates in the ktdim

Patliology.— The disease presents itself in an aciile and chronic jem.
The acute variety is characterized by hypertrophy of the walls of the urettr,
and with swelling and congestion of the mucosa. The chronic variety may result
either in dilatation or in contraction of the ureteral canal. In the former the pus
or urine is dammed up and the ureter above the obstruction becomes ek>o|Med
and tortuous and its walls thin and translucent. In cases in which contiactioii
lakes place the walls of the ureter lose their elasticity and become tbickened
and hypertrophied. The caliber of the canal is diminished In size by hyper-
plasia of the connective tissue and the presence of strictures, and the ureter is
usually firmly bound down Ijy periureteral intlammation.

Symptoms. — The symptoms are not characteristic and are usually more
or less obscured by those depending upon the original source of infection—
Ike bladder or the kidneys.

This is especially true in cases of acute ureteritis occurring during an attack
of active cystitis, and apart from the pain which is felt along the couree of the
ureter, the symptoms are the .same as those caused by the inflammation of the
bi;t(lder — frequent and painjiU urination, vesical tenesmus, pus in At wi«.
and hematuria.

In chronic cases, which are also characterized by frequent and painful urini-
tion and tenesmus and pus or blood in the urine, the symptoms are the sime
as (hose of cystitis, except that, as in the acute infections, pain is felt along ilw
ureteral canal. When, however, contraction or dilatation of the canal ocnus.
the symptoms become more marked and evidences of the accumulation of pis
or urine above the seat of ob.struclion eventually manifest themselves (see smp-
toms of stricture of the ureter, p. 679).

Diagnosis.— The diagnosis cannot be made by the subjective smptwns;
but if pain develops along the course of the ureter during an acute or ci'**"
attack of cystitis, the extension of the infection to the ureteral canal should bt
suspected.

The diagnosis must therefore be based upon the physical signs, which it
elicited by (a) vaginal touch; (fc) rectal touch; (r) abdominal palpation; *""
(rf) sounding the ureter.

Vaginal Touch- — The ureter in front of the broad ligament is found up"*

TrmsKTitMei^

K>be

dot a
Bach.— TW

ft liwftkni

As ft mk tk* twirtwJ «Mi^ u <*< luiMlvtl

■ sn&cc at thr bnad Kgawiw a» hi u)i *> lh< Imm «| > sVtA

the pi^'J'yi- thMBfj» IB tbe dul cKitnl »> tMM:nli>\l 4U>\f (t-tK a^'I

AfetallBal Ai^tioa.— The |aiwnl cMtupUiits i«l m^imt (Mim nhMt t^i***-
XUR b made dtrDU]d> dw abdootiiul wall aikI the tintn i« i iviwil.-
brim <4 the pclris; in ittt iUb uronwn ii iiwy hr (Hi IviksmIi i:
finfCen <Fig- boi). The further «\tMis»vMi \4 liw ititLimiiMlitMt hii\ U 'Ivtivm
stnted by the piin nhkh i» (ell altxt); the urelcr »* il is |Ml|><tml ii|>w»iil in ih*
peltb' oi the kiiiiwy.

Sounding the Dnier.— Thi» method »l «lifiRi>«M*. m Ith h li ilt<M rlltml Uliitor
ureteral striclurrs <wc p. 679). sitnuki only Ik- itn|iKninl In ilin<»h iumw ht
demofuinif the presence of a diliitiitiun t>r ait olwiruilitwi In lh« uinui

Prognosis.— The prnjcninb ilqirnih lunrdv ti)""' l'^^' t'i*i*<> nf ll>t> llitm
bon. A gonmTl\cikl iiillamm.iiion tJ> always likely l« intill In n ulililuh' An
■cute alLirk uf ureleritU nviy simelime* run iln t-ouFM) ntllhiitil trrlotml) iliiltliiii
ing ihc function nf the urclcr and cauwnji nliy lm)><>tliii)l ■Iniilntol iIiaIiki'h In
it^ niill.i. Ndihin}; c^n lie done for a uri-tf-rilin wlilrli urlHtlxili'" lli>tn iin linni
able disease uf the hbdder iir kidney*, us lln* mmifii- «( l)ii< IiiIm Itxn ntiMml Iw
removed. The effect u|K>n \he fuiuiion nl ihr kidney* n'ld llii' iiirti'io iini*l Iw
bomc in mind when giving 11 |irii{cnt»iM in dimnlc L-ttMM iiimk:I«IinI Willi illlilhllliMI
or stritiure.

Treatment.— The iremment i» divi<l«l mi (nllttwk tiilid
The removal of ihc cauw,
The ireiilment ci( the urelrral inflammnliun.

The Removal of the CauH. Noihinx <-an Im* ni'r>im|>IUIiiu| nnh-M III*
origin;il ><>urce of ihe infeition i!> removcil, tiiul heme wlirn (lir iinicrillii lo|lii«i'i
a n-stitis we mu^t trr^l (he vc^icul ir>>-i)>lr lut \i f'H). '" " ihi' I»IIhIi<Mi4||(iii
has i'taned in the kidneys, our Jiicniion khinild Ixt dim Inl hiwiiid tvlin Inn lli#
renal com ji ligation .

Tb« Treatment of th« Ureteral InAuiimNllon. In <i<u/# mt** lutUmn
of local treatment U poteibfe. an molidiul uMillcnllon* ninwrf U miulw Ifi lliv
orcleral canal urdew a itrjcture hut develofMl iiml |Ih> urMff Immwim dll»lai|.
We muK, therefore, rely tijxra the rs|>e<tiini (liin of r>faini«tit hiuI »iHl»«kiir In
wmorc the tounv of infcclion. In the ma^ifflx of rmtr '' : iiiirtlnl In llw

bladder, and the general awl Vxal iratBwfria whlrlt an 1 Im !!■ r*(laf

hare at the ante lime a curative effect u|inri the dJ«eaMj ufiUf («w Irfmmmf

Tbe trcauneM of thrmU CMtt Jtpwdi HBO* ibf ciwfMtar mU MIMN t4
dK palhefepc chaaeca in the ureter: Ati w(^ b fulytniMMw^fcuihWMi'
iBH MfKtui^ ("e p- 000/'

TUBCVCI/LOHI*
u— TiAoaiu iad^maltM (i die itniMn le MMtf ■f««f* 4«« Iv
1 fran te tMwy.aM>iin)> lo rwe liJaotw M Mn "'«f

■■ iM «ali wttifc pwfKf iWf ir Vf^MB A* M<ria«« m4 mmt*mtM

ttm WW«WaJ MMriae iA-

690 THE CRETERS.

bladder becomes involved and tubercles are found scattered over tbe trigone
and around the ureteral openings. As the disease progresses tbe tubercles break
down and the entire cavity of the bladder hnally becomes affected.

Tbe disease may be iinilaterai or bilateral; in chronic cases, as a rule, only
one ureter is involved. Occasionally tbe tubercular inflammation may be
limited and only a portion of the ureter affected, but in the majority of instances
tbe disease invades the whole organ and tubercles are found everywhere in the
canal from the pelvis of the kidney to the bladder.

Symptoms. — The following-are the chief symptoms: (a) Pain; (ft) fre-
quent and painful urination; (c) pyuria; (d) hematuria; and (e) fever.

Pain. — ^In tubercular inflammation the ureter is exceedingly sensitive, and
constant pain along the course of the canal is complained of by tbe patient.

Frequent and Painful Urination.—These symptoms are always well-
marked and are more or less characteristic of tubercular ureteritis. The de-
sire to urinate is often so frequent that the patient is compelled to empty her
bladder every few minutes during the day and night, and the act is usually ac-
companied by severe pain and tenesmus.

Pyuria. — There is always more or less pus present in the urine, and in some
cases large quantities of purulent matter may be suddenly discharged at different
times (intermittent pyuria) when pyonephrosis exists and the pelvis of the kid-
ney empties its contents into the bladder.

Hematuria. — As a rule, no blood is found in the urine during the early
stages of the disease; but later on, when ulceration takes place in the ureter
and the bladder, it is present in varying amounts, and it is not uncommon for
a free hemorrhage to occur.

Fever. — In cases in which pyonephrosis is present and there is an obstruc-
tion in the ureter preventing the escape of the pus, a general septic condition
intervenes which is accompanied by an intermittent temperature.

Diagnosis. — The diagnosis is based upon the physical signs, which are
elicited by (a) vaginal touch; (b) rectal touch; (c) abdominal touch; and (rf)
the use of the cystoscope.

Vaginal Touch. — The ureter anterior to the broad ligament is found to
be enlarged, nodular, and exceedingly .'Sensitive.

Rectal Touch. — The ureter between the posterior surface of the broad
ligament and the brim of ihe pelvis also presents the changes described above.

Abdominal Touch. ^The ureter is found to be very painful and sensitive
when pressure is made through the abdominal wall and it is crowded against
the brim of the pelvis; in very thin women the enlarged canal may be distinctly
palpated at this point. The course of the ureter above the superior strait may
be readily traced by the pain that is elicited from pressure upward over the
inflamed organ.

The Use of the Cystoscope.— The characteristic tubercular lesions at the
base of the bladder may be readily seen through the cystoscope.

Prognosis. — Unless the diseased ureter and kidney are extirpated early in
the course of the affection the patient eventually dies from extension of the
disease to the bladder or adjacent and remote organs. When both ureters are
involved, death may occur at any time from uremia if the flow of urine is ob-
structed.

Treatment.— No form of general or local treatment is of any avail, and
when the disease is unilateral, the kidney and ureter must be removed at once
{nepliro-uretereclomy); when both sides are involved, nothing can be done.

ruBom.

691

CHAPTER XXXn.
PHYSIOLOGY.

PUBERTY.

Definition. — Pubei^ is that period of human life duritq; which a fpt\
de%Tli>ps inlo :i wnmim.

Age. — In this country puberty usually occur bclwcen the thirteenth and
hfteenth years, awl in northi-rn climate* the averai^ aj^ is sixteen to seveiileen,
while in hot counlricv girls Itcjtin to menstruate about ihe ninth ywir. Ilrtrdily
is also a determining factor, and experience demonstrates that girls of Latin
extraction develoi) into womanhuot] earlier than those uf .-\n)(l»-Saxon descent.
And. finally, env-ironmcni and hygienic surroundings play an imporUnt rAle in
delerminins the age of puberty, and for these reasons it o<:cur5 earlier in Ihe rich
than in ihc umir, ;ind in city girls thiin in those who arc rjdsed in the country-.

I>aratlon.— The physical changes that lead up to puberty are gradtjal in
their development and are not fully completed until tJie age of twenty, which i»
called the period of nubility, because nt thut lime the individual is fit to conceive
and bear children. At the bepnning of puberty the girl is capable of reproduc-
tion, but she should not lie allowetl Id marry until the full jihysic.il <levelopmcnt
of womanhood is reached and the pelvis and its organs arc matured. Early
m.ilernily noi only in< reases the dangers of fieslalion and labor, but it also has an
injurious etTcct upon the chilli, which is apt to be poorly developed and often
dies soon after birth as the result of marasmus. Mothers should therefore not
only be ttught that puWrty does not mean lilncss for reprodu<-li«n, but iher
should also be reminded of the law of Plato, which says, '" A woman may bear
children to the SLtie at twenty j-ear? «( age."

Changes. — Aspubcrty approaches the general contour of the body becomes
fuller anil mi)re gracefully molded; the voice dianges; the hips enlarRc; the
brciisls not.ibly Jncrciise in size; the external and internal generative organs
develop; hair grows upon the mons veneris and the labi;i majors; menstruation
•ippcirs; and the sexual [>e[*uliarilies are diflerentiated.

The psychic ch<ingcs, which arc also well marked, have been eloquently
dc-wriljci] by Parvin, who says: "The girl [jaiuiing inlo womanhood puts away
childish things! turning from frivolous nmuKcments. from the toys and pUys,
or from rude sports in which she has found pleasure, she enters a new life, has
new thoughts, ilesires, an<I emotions. Hitherto she has been living .solely in and
for the present: but now the future with its lights and shadows, its hopes and
feant, makes a lartje part of her life. She is more sensitive and reserved, and
manife^s a mMest dignity, giving and expecting resjiect; her imlividualily
becomes more m;inifest, her sense of duty stronger, and her ambitions greater."

Management.— Pul>erty is a <-nt)ail ejKich in the life of a woman, and her
future health and usefulness depend hirgcly upon her mode of liWng during
this period. The future burdens of maternity require a sound and vigorous
constitution, which ainnot be ohlaincd without strict attention to the care of
the body. The diet should therefore be simple and wholesome, the character
and amount of exercise carefully n^Iated, and o\'crstudy should be strictly
forbidden, especially during the menstrual periods.

692 PHYSIOLOGY.

SIENSTRUATION.

Synonyms. — Courses, periods, unwell, menses, menstrual flow, mcmthlT
sickness, turns, and monthly flow.

Definition. — Menstruation is an intermittent function which is chir-
acterized by a bloody discharge from the uterus. It begins with puberty and
ceases with the menopause. It is absent diuing pregnancy and laclatkm, al-
though numerous cases have been observed in which periodic hemorthages hare
octTirred during the entire course of gestation.

Symptoms. — The symptoms are both general and local in character. Most
healthy women are affected more or less by some of the phenomena of menslnu-
tion, although the general and local symptoms may be so slight tliat the flov
comes and goes without causing any inconvenience whatever. In othen, agsin,
the symptoms arc so accentuated that they cannot be considered normal, and a
cause for the pathologic manifestations must be sought for.

The general symptoms manifest themselves by nervous irritability, which
is often hysteric in type, neuralgia, flushes of heat and chilliness, drowsiness and
indisposition to active exercise, impaired appetite and digestion, and disnbca
or irritability of the bladder. The breasts are often swollen and painful, the
thyroid gland is increased in size, and dark circles appear under the eyes. Some
women also suffer with frontal and vertical headache, and not infrequently lax
appears upon the skin of the face, neck, or shoulders.

The local symptoms often precede the flow, and are characterized by back-
ache and a feeling of weight or fullness in the pwlvis.

Chans:e8 in the Organs of Generation.— The external organs b^
come congested, swollen, and sensitive and bathed with a more or less profiK
discharge. The internal organs also become enlarged and engorged with blood.
The vagina is intensely congested and assumes a violet color; the cervii is
swollen and softer than normal ; the uterus is enlarged and its mucous membrant
thrown into folds, and the activity of the cervical and uterine glands is increasfti.
Eventually the superficial epithelial lining of the uterine cavity becomes desqua-
mated, ihe capillaries rupture, and the menstrual flow appears, which relieves the
congestion and causes the local and general symptoms to lessen in sweriti- «
disai>pear altogether. The menstrual discharge comes from the carity d thf
uterus and not from the cervical canal, and in some instances a small quantit)'
of blood may also escape from the Fallopian tubes.

Character of the Flow.— At the beginning of menstmation the Sc*
is composed of mucus streaked with blood, but when it becomes well estabtiifJ'
it con.sisis of pure blood mixed with mucus and epithelial cells from the uieriw
cavity and the vagina. As the (low begins to subside the blood lessens in qiW'
tity, and eventually the discharge becomes mucus in character again.

The flow is dark in color, hkc venous blood; it is alkaline in reaction and doe
not coagulate, owing to the presence of mucus, unless the discharge become-
excessive in amount. The color of the menstrual flow is altered in disease, aw
in chlorntic women it becomes almost watery in consistency and very ligit i"
color.

Recurrence, Duration, and Quantity of the Plow.— Eierv
woman is a law unto herself, and consequently while there is 1
general average bv which we estimate the characteristics of the menslniai func-
tion, vet it must be borne in mind that there can be wide differences wilhou.'^*
pathologic condition being present. The true test, after all, is the health ot «*
individual, and it makes no difference whatever how near to or how far *■ '*'■

UeXSTKUATIOK.

«93

from the general average a woman's menslrual record may be, provided she
remains perfectly well,

The mtMiKiruul tlniv recurs, on an averapic, every twenty-eight duy», or thirteen
limes each year. The frctnienty, however, may be short-
ened or lengthened and ycl pcrfcit health be main-
tained. Thus, Slime wifiiim menstniale every iwi) wwks, and olhcrs, .tgatn,
only two or three times a year. Cases arc on record of women mcnslroatinK
only in wiirm weather, and It is not a rare <)ccurreni-e to meet iH^rfeilly hwillhy
women who are exirrmely irrrgiiliir, often f.mn^ for months wilhoui the slightest
show, ft i.% al.Mi not unLommon for women who arc in the habit of nienvtrualing
every twenty-eight days to have the llinv (KTur e^"ery ihnN; weeks fur an indebnite
period and then retwrn to their normal time. In fact, it is the exception rather
than the rule fur an individual to menstruate regularly, and if a woman will keep
a careful record for u j-rar or more die will \x very likely li> find a difference
ill the dates of the recurrence of ihc flow.

During the lir>t year of mcn>lrual life the recurrence of the llnw is often
very irregular, and it is not uncommon for it to l>e absent for several months
after ib. fimi apfiearance or to recur three or four times at varying intervals be-
fore it becomes fully c.-'talili.ihed.

The menstrual flow usually lasts from three to si.i days In some cases,
however, the duration may tie less, and in nther^ it may be lengthened without
the woman suffering any inconvenience. As a rule, the flow continues longer
in plethoric women than in individuals who arc not robust, nnd it is not uncom-
mon for the former to menstruate right or len days each month without feeling
any bad efTrrL*.

The quantity of blood lost at each period vanes, on an average, from (our
In six or eight ountxs, although ihe amount may )>e le^t or even more in womcD
who are perfectiv well.

I^ength of^ Menstrual Life. —The average length of men.4trua) life 1.4
from ihirly lu ihiny-live years. It,* duration is intluenctrti, however, by phy-
siologic and pathologic causes, .\ woman who menstruates early,
as a rule, continues to du mi lunger than one who reaches
puberty later in life. Various forms of [ictvic dirwasv, such as uterine tumors
and lubo-ovarian inHammaiion. prolong ihc duration of menstrual life and
d«b)' the apjieanincc of the menopause.

Uanagetnent of Menstruating Women.- -The care of women dur-
ing the mcnstniLil period is based upon comnion-^en.se principles and the general
bw» of hygiene. During the frr»t twenty four h^^u^^ of the llow the |>elvic orKanx
arc intensely congesie<l, and it i.s therefore advisable for a woman li> remain in
ber room in l>ed or lying on a sofa. Her duties subse(|uently should be as
light JL* iKis>ibIe, anil while the flow la.M.s all forms of active exenine, such a.s
hmg walks, ri<]ing, or cycling, should l>e forbidden. Cold bathing in any form
should be avoided, as it tends to check the flow and bring about chronic con-
gestive conditiunK of the ficlvic on;an.v For the same reason ex|iosure lo the
inclemencies of the weather and sitting in drafts should be carefully guarded
against. The laws of cleanliness should be strictly en-
forced and the body kepi clean and the xkin aetiie by
a general sponge bath of tepid water and soap. I'be
external organs should also be cleaned twice or thrice
daily with icj>i(l water and soap, as the discharges
are apt lo become rancid and offensive, especially in
warm weather. The napkins should be changed frequently and not
allowed to become o\'er- saturated and foul. Vaginid injections tJiould not

694 PHYSIOLOGY.

be employed while the flow continues unless ordered by a physician for thera-
peutic reasons. Sexual intercourse should also be avoided, as the congestiMi
of the pelvic organs is increased by the act of copulation and it may result is
chronic inflammation or the formation of a pelvic hematocele. The dirt during
menstruation should be simple and easily digested, and all varieties of ^iod
or highly seasoned foods should be interdicted. Alcoholic stimulants an also
injurious, as they tend to prolong the flow and increase the pelvic congestioo.

OVULATION.

Ovulation may be defined as the maturing and rupturing of a Gtaa£ui
follicle with the subsequent escape of an ovum.

But little is practically known of the relation existing between o^-utation and
menstruation, and as to whether ovulation is iwriodic in its occurrence or whether
it is a continuous process; and, finally, if it does occur periodicaUy, wheliHr
it is synchronous with the menstrual flow. The final solution of these que-
tions has not been accomplished up to the present time, and as it woukf be a
useless task to discuss the various theories and views held by the profemioii,
I shall simply give the following facts, which have been recorded from time lo
time and which prove that ovulation may occur indejiendent of menstniaticn.

1. Conception has occurred during lactation and even after the change of
life.

3. Young girls have been known to conceive before the appearance trf tbt
menses.

3- In rare instances women menstruate only during pregnancy.

4- While just before and immediately after menstruation are the most litdf
periods for sexual intercourse to be followed by impregnation, yet it is a wdl-
known fact that it may take place at any time during the month.

HENOPAUSK

Definition. — The menopause is that epoch in the life of the himun
female when she ceases to menstruate and bear children.

Synonyms. — The menopause is sometimes called the change of lit*, itt
dodging point, the critical period, and the climacteric.

Time of Appearance. — In the majority of insUnces the menopause
occurs between forty-five and fifty years of age. Cases have been recorded,
ho\sever, in which menstruati<tn ceased as early as the twenty-second jtar, and
also when it continued until over eighty years of age.

As a rule, early puberty is followed by a latemeno-
pause, and late pubert>' b>' an earl_v cessationofll"
menstrual flow. The appearance of (he menopause is also influenced
by hereditary conditions, and the daughter is aj)t to reach the change of life at iw
same age as her mother. The climacteric occurs earlier in cold clitnates to
in tropical or temperate zones, and in poor women than in the rich and inddfl"
classes. It also appears earlier in fat and weak women than in indiWduit
who are lean and strong, and in nullipara; than in women who have bonw c'li''
dren. Early maternity and rapidly succeeding pregnancies, as a rule, shorten
the period of se.vual life and bring about an early appearance of the meni^u*-
The change of life is often indefinitely delayed by tubo-ovarian inflammattt'^
conditions and uterine or pelvic neoplasms, and it is not uncommon under lt^«=*
circumstances for the flow to continue long after the normal period of the din*^^"

UF.N'OPACSe.

«95

teric. And, finally, the menopause may occur abruptly al an earlv age from
a sever*' uciack of typhoid lever, tliokra. or mabrw, and also as tnc result of
psychic inHucn CCS. such as grief, sudden fear, or nicUnchoUa.

DuratiOD.^The climacteric, like puli«;riy. lomcs un gratlu.illy, .ind con-
tinues, as a rule, from two and a half to three years or c^'cn longer. In rare
caaM, however, it may be brief aod sudden, meiistru3lioa continuing regular!)'
up to a certain d:iie, wheti it i.tc>|is and never returns.

Phjrgical Changes.— During the menopause senile chauf^s take place
which are atrophic in character and eventually result in a complete altera-
tion in the physical appe;ir;incc ol the sexual organs. The vulva becomes
lliiitened and shriveled from the los.s of subcutaneous fat, and the huir on the
labia anti moii'* veneris Ijecnmes ihiti .iim1 c^'entually turns gray. The vagina
atrophies and its walls become thin, less muscular, and llnhby. and the ilimen-
sion:^ of the canal arc lessened. The uteru.s al»o uiHlerniK-'s general atrophy
and becomes smaller in sixc. and the glands arc diminished in number. Tbe
iniravaf^iaiil cervix gradually become::! ab.-'Otbed, and in time iKithing remains
but a small, kTioh-like Ixvly. The change which take pbce in the Fallo-
pian tubes and the ovaries arc also well marked, and these organs e\'cntualty
become mi .shriveled and contracted that they may di.'uppear altogether. Tlw
breasts gtAdu;illy become flattened and Ihibby unless a local deposition of fat
occurs, anti thick, shori hairs uoi infrequently appear on the up|>er lip and the
chin. The general mnlour of the iKNiy changes and the individual becomes
stout and matronly looking, or she may lose &^il and become thinner tlun l;e-
fore the c«^\iation of the men.sirual tlow. And, finally, the alxiomen may be-
come enlarged and pendulou.'* fnim the accumubtion of fat in the bdly walls,
llie omentum, and the mcscntcrj'.

Symptoms. ^T he normal menojiause is attended with
few local and general disturbances, and, apart frnm the
gradual or ahru|it ce.s.salicm of the men.ttRial flow and occa.sioniil flushes of
heat and chilliness, with perhaps some psychic phenomena, there are no symp-
tom.i to mark the changes that arc taking place in the sexual life of the woman.
Linforlunalely, Imwcver, a large numlter of vromcn sutTer more or less severely
during the mcno{>ausc with a variety of symptoms which are referred to the
cinulatory, nervous, and digestive systems, as well as. ti> the [ichic organ.i tliem-
sdves, and it i:- nece'.siiry. therefore, that a description of these phenomena —
which are not. generally s[>eaking, pathologic in character— be given in order that
the)- may be recognized and their iiigniruance appreciated.

Ceuatioa of Heostruatton.— T he first symptom of the
change of life is the gradual or abrupt cessation of
ihc men.ttrual flow. In most cases the process is g;radual, and instead
of menstruation occurring at the regular time, it will be delayed for a few days or
months, and then recur as usual, to be followed by cnntinued irregularities in
re^nl to i»eri«licity and quantity, until Sn.illy it ccn«C£ permanently. The
advent of the menopause is seldom marked by the abrupt cessation of the men-
siniat (low, and it is a rare occurrence to meet cases in which women hitherto
perfectly regular h;ive suddenly ceased m menstruate.

Circulatory Disturboncci.— The most frequent symptom of the menopatiae
is the vatiumotor disturtances, which manifest ihem-'<«lves by s^udden sensitions
of heat over the face, the neck, or the entire body, followed by more or less pro-
fuse sweating and a feeling of chilliness. These symptoms occur at varying
intervals, and in aome i';i>e.v they are extremely jinnaying and very frequent.
Among other circulatory symptoms which arc less constant may be mentioned a
sensation of fullness in the bead, indistinct vision, headache, ^eeplessiie»s, rer-

696 PHYSIOLOGY.

tigo, faintness, cold hands and feet, buzzing noise in the ears, epistaxis, bletd-
ing from hemorrhoids, vicarious hemoirhages, ^nd palpitation of the heart

Nervous DiBturbaiices.^These are irritable temper, hysteria, neuralgia in
various parts of the body, general and local pruritus, burning sensations, fcdisg
of numbness and tingling in the lower extremities, nervous depression, fesr and
anxiety, loss of memory, melanchoUa, and even insanity. The sexual appetiie
is often increased at the time of the menopause, and, cunou^y eDou^ souk
women hitherto without marked desire suddenly develop a passionate nature.

Digestive Disturbances.— The digestive functions are frequently dcnngd,
and some of the most annoying symptoms that present themselves during die
climacteric are due to disorders of the alimentary canal. Dyspepsia is conmm
during the change of life, as well as some torpidity of the liver, and intestinal flatus
is not infrequently a disturbing element in these cases. Constipation or diairlm
is often present, and many of these women are annoyed by the appearance of icne
upon the skin of the face and chest.

Local Disturbances. — The local disturbances are due to pelvic congtsdoa
which occurs from time to time, and which is not relieved, as usual, by the peri-
odic discharge of blood. These phenomena are chiefly manifested by batiadM,
slight pain in the inguinal regions, irritable bladder, and a sensation of wdgbtor
fullness in the pelvis.

Abnormal Symptoms.— M enorrhagia and metrorrhagia
are never caused by the menopause, and when profuse
menstruation or irregular hemorrhages occur, thev
must not be attributed to the change of life. The
same is true of irregular bleedings which take place
after the climacteric has been established, and of
hemorrhages which sometimes occur long aftermtii-
struation has ceased. These p h e n o m e n a a i w ay s de-
note some pathologic condition, and a physical ex-
amination must be insisted upon, which will usuallr
reveal the presence of cancer, a uterine neoplasm,
inversion of the uterus, or a benign fungoid growih
of the endometrium.

As a rule, all benign lesions disappear during the period of the menopau*,
and therefore uterine discharges that are dependent upon chronic endometrilis
gradually lessen in amount or spontaneously cease altogether. If, howeiw, i
previously existing leukorrhea increases in amount, or a vaginal discharge ap-
pears for the first time during the menopause, a physical examination
is imperatively demanded, as it may be the forerun-
ner of a malignant disease.

The mental state of the patient .should be carefully watched during the cli-
macteric, as melancholia and other forms of insanity may develop at this pen™
in women with a. hereditary taint or in individuals of a pronounced neurotic
temperament.

Diag^nosis. — The diagnosis of the menopause when it occurs at the uiiwl
time offers no difficulties whatever, but cKcasionally when it appears premalum)'
it is often a question as to whether the cessation of menstruation indicates ik
change of life or whether it is a temporary condition dependent upon a pailiolo^
cause. The solution of the problem must be based upon a careful and ihon'upi
fieneriil examination, as well as a study of the patient's histon,-, in order, ilp"^'
mIiIo, to determine a cause for the amenorrhea. This examination must con.^e'
of a systematic investigation of each organ in the body, as well as the blood- ""
urine, and, if indicated, the sputum, because only in this way can those orp""

M£XOPAUSB.

697

be excluded which have an inhibitor)- in6uencc upon the function of
menstruation. If after such an examination no cau.te ix found fur the dis-
u[>jie:irancc of the m(mslru;tl How, and ihc clinical hislofi- of the putiml presents
no c\-ident« 10 the conirarj'. wc may nriiKinably conclude that a premature meno-
pau.ic ha& occurred. On the other baud, however, if the exam in.-it inn of the blond
show» an anemia, or if the lungs arr lulxrrcuiar. or if the patient b syphilitic,
the amenorrhea is evidently pathologic in character and due to a definite muite,
whicJi may or may nol be amenable tn treaimenl.

PropnOsiB.— The prognosis of the normal menopause b always Rood.
Benign dise;ise:i ul the pelvic organs show a tendency to undergo sjioiitaneou.v cure
during this period; on ihe olli(,-r hand, howwer, malignant diseases
often manifest themselves for the first time at the
menopause, and women in whom a hereditar>' taint uf insanity is jire^ent
may become insane.

Treatment.— The management of the change of life may be conveniently
dlsoissetj under (.1) the routine and {h) the K))ecial treatment.

Routine Treatment.— This consists in kcqiing the patient's health in the
best (Missible cuiidition by careful attention to the laws of hygiene, and in-
vestigating al once any unfavorable symptoms which
may develop.

The bowels :^hould be opened daily and any tendency to conntiiiation should
be corrected by a mild laxative. The occJisioniil use of a saline b especially
beneficial, as il lessens the pelvic congestion, which b the cause of many of the
hKal symptom." of the menopause. The action of the kidne>'» should be
carefully watched and the urine examined from time to time. The patient
should keep the kidneys well flushed by drinking three or four pint, of water
daily, and nny tendency to lithemia >l)ou!il l>e rt^iicied by the admini.slration
of lithia, citrate of potassium, and other anti-uric acid rcmc<iie>.

The diet should t>e simple and nuirtiiou!^. and all .init ed and highly seasoned
foods should be forbidden. Tea and coffee shoulfi be used sparingly and
alaiholic ftlimulants should be avoided altogether unless Ihey are esi>et^ially
indicated.

Exercise in the open air is especially beneficial during the climacteric, as it
lessens the pelvii longcstion and equaUzes the general < ircTilatton. The same is
true of indoor escrci.sc (see |i. 117), which \houl<l l»c l.ikcn every morning im-
mediately after getting out of bed, and also for a few minutes before retiring at
night. .\ cold .%|K)nge, spray, or plunge Iwtli .thould tie taken every morning
before breakfast, and twice a week the patient should be given a full hot bath or a
Turkish balh just before retiring at night. The action of the i-old tialhs U
slimuialing to the vasomotor ccnieri and rclieve.s ihe [lu.<)ies which are at times
ut annoying. The sedative action of ihe hol-waler or hot-air bath is also marked
and a.vsUu materially in lcs.«cning the nervous tension and mental irritability.

A thorough local examination should be made at
the beginning of the menopause, and if a laceration
of the perineum or the cervix exists, it should be
repaired at once to guard against the development
of a senile prolapse of the pelvic organs or the pos-
sibility 11 f rervical cancer.

Special Treatment. — The special indications in the treatment of tlic meno-
pause are frequently dependent upon londitions which are not conneitMl with
the pelvic organs, but which involve ihe circulaton". nervous, atid digestive
n-xlems. and hence they must be treated upon general medical principle*. On
the other hand, howe\*cr, there are certain phenomena which arc distinctly due to

69& UENSTRITAL DISORDERS.

the climacteric, and therefore their management and treatment requiic a biid
special consideration.

The vasomotor disturbances, which are at times very marked and annoyitig,
are usually relieved by cold bathing and the administration of sodium bromid in
ao-grain doses three or four times daily. Picrotoxin (gr. ji^ to ^, three timKi
day) is also a useful remedy, and frequently controls the flushes which attend (be
menopause. If the flushes are associated with headache, good results axe ob-
tained with fluid extract of gelsemium in 2- or 3-drop doses ever>' three houij
and the administration of a drachm of phosphate of sodium every morning bdoit
breaUast. The diet and exercise should be carefully regulated and the ixmA
opened daily, as any tendency to constipation increases the pelvic congestion and
adds to the discomfort of the patient. The occasional use of salts in the tre»!-
ment of the menopause should always be borne in mind, as nothing will relim
the local congestion and the vasomotor symptoms more quickly and thcHougtilF
than Rochelle or Carlsbad salts, Hunyadi Janos water, phosphate of sodium,
or a bottle of the citrate of magnesia.

The nervous symptoms are usually controlled by the administration of saliuo
bromid, valerian, or asafetida, and a full hot bath or a Turkish bath takeo trice
a week just before retiring for the night also has a beneficial eSect. The cold
sheet bath (p. 8g), followed by general massage, is very useful in reliei-ing the
nervous depression and physical exhaustion which are sometimes present in these
cases.

The local symptoms which are dependent upon congestion of the petric
organs are controlled by hot-water vaginal douches, glycerin tampons, scarifia-
tion of the cervix, and the occasional use of a saline purge.

CHAPTER XXXIII.

MENSTRUAL DISORDERS.
PREcnaous henstruation.

Definition. — When menstruation occurs in a child prior to the SJT of
puberty {thirteen years), it is called precocious.

Kreqnency. — While precocious menstruation is a rare occunenct, jtt
examples are not uncommon in which it has appeared very early in childhood,
and cases have also been obser\'ed of periodic hemorrhages from the ^Ul
orf^ans e\'cn in infancy.

Causes. — The causes, as a rule, are difficult to determine, although it ^
been traced in some cases to hereditary influences, and in others it has b«n
found to be associated with a pathologic lesion, such as an adherent prepuct.i
neoplasm, or an irritable condition of the vulva from uncleantiness, parasites, «
masturbation. Again, vicious companions, reading lewd literature, and un-
healthy forms of mental excitement are occasionally found to be the predfr
posinij causes in some instances.

Results. — The appearance of precocious menstruation is usually attendw
by other evidences of puberty, and the genitalia develop, the breasts enlarge, »»
the sexual appetite sometimes becomes manifest. The occurrence of ge^"*"
in some of these individuals proves their capability for reproduction »'"' *

KKTARnrjt OR DELAYED MEKSTHrAnoN.

699

tablishcs the fact that the changes which take place in the organs of generation
»rr simihtr tn those which occur durin;; a normal puberty.

Diagnosis. —The dbgnosis h biLsci) upon the occuTTcnce of a periodic
dl>k:hargc of blood from the genital canal, which is usually associated with other
o'idcnccs of |iul»erty a* desiTibed uIhu'C.

Precocious menstruation must be curefully distinguished from other hem-
orrhageA or bleedings which are in no way connecled with the funciion of the
menstrual How. and which are not unc-ommoiUy obscneil in young children and
infants. Sometimes the di.ipcr of a new-born child may be stained with bluod
which i* (1l»* hurgixl from the rectum (melena nconuloncnt); or there may be
slighl irregular blcdling;. from gr.iniibr patches on the vulva or about the exicmal
urinary meatus; and, finally, hemorrhages may lake place from a sarcomaluux
gr»sv-t)i. [ t i.-t alM> not unt^onimon In nbNer\*c a Mngle discharge of a few drops of
blood from the genital organs of infants and young children without any obvious
cause whatever, and the red stains which are so often seen on the clothing xns
foun<] in mo»t instances to l>e a <Jeposil of red urates.

Treatment.— The treatment is based upon the removal of the cause and
tliv hygienic management of the patient.

The external organs should be thoroughly examined and all sources of local
irritation removed by appropriate ircalmenl. If the moral character of die child
b at fault, she should tie guarded again.^l all injurious influences and carefully
watched to prevent masturbation.

The character of ilic diet, the amount of exercise, and the hours devoted to
sleep .ind .%ludy should be carefully regulated. The use of cold baths is often
beneficial in these cases, and they may be giv«n id the form of a sponge, a spray,
or a plunge (see hydrotherapy, p. 77).

RETARDED OR DELAYED MENSTRUATION.

Definition, if iw meitstrual finw doe.>i not a|)pe:ar liefore the individual
i» liftet^ii vivir^ ui ..^i-, ii i^ cunsidiTcd to be retarded or dclnyed.

It is not uncommon for healthy girls to begin their mcnsCnial life later ttun
the average time of pulierly. and iui>es h.ive lieen recunled in which the flow
appeared for the tir<t time -it tliirty-one years of age.

Caosea. — Retarded menstruation may be due to hereditary influences or it
may result from a congeiiiLil cause or lardy <lcvelopmenl of the internal organ.t of
generation. The uterus or the ovaries or both may be absent or only partially
developed, and in some cases there may be ati atresia of die genital canal, which
b lu-ually found to l>c an imjierforate hymen. Sometimes the appearanc-e of the
menstnial flow may be delayed on account of bad hygienic conditions, such as
hard work, oversiudy. i«Hir or impro[ier diet, ami tainted air, or. again, it may
bcdue to chlorosis, phthisis, congenitid svphilis, and other constitutional dixKue*.

Symptoms. ^Absence of die flow is die only manifestation observed in
the majority of i-a.^es and the general health is u.'^ually no| imjiaired. The
other c%'idencc* of puberty are generally present and the girl gradually de-
velops (he physical and mental attributes of her sex. If the absence of men-
struation is due to an atresia of the genital canal which prevents the enc-ipe of
the flow, symptoms of the mmslrual mfiliuun occur each DWDth, and conse-
quently the cau.se may be .tuKpecied.

Diagnosis.— The diagnosis depends upon the recognition of the cause, A
congenital detect or an atresia can generally be recognized by a phy>ic4l examina-
tion; hereditary influences are oMrerUinoi by a careful inquiry into the men-

7CX) MENSTRUAL DISORDEKS.

stnul history of the family; and the presence of bad hygienic cxmditinis and
constitutional diseases is usually self-evident.

Prognosis. — The prognosis depends upon the cause. An atresia of tbe
genital canal can usually be relieved by an operation; defects in the devdofttDcoi
of the uterus or the ovaries are generally permanent and cannot be remedied by
treatment; bad hygienic conditions can be corrected in most cases; and cwsti-
tutional diseases can often be benefited or cured.

Treatment. — The treatment is based upon the c&use, and is fully dis-
cussed under Amenorrhea.

HENORRHAGIA AND HETRORRHAGIA.

Description. — Menorrhagia is excessive loss of blood at the mautnul
periods, and metrorrhagia is hemorrhage from the uterus independeDl of mcD-
struation. The line separating these conditions is more theoretic than real, ud
as they are practically the same, they will be considered together. lo some
women the intermenstrual period is shortened, and consequently the anount
of blood lost during the year is excessive.
CaaseS. — The causes are divided into:
I. The local causes.
Uterine in origin.
Ovarian and tubal in origin.
Pathologic conditions in the surrounding pelvis,
a. The general causes.

Acute and chronic diseases.
Reflex conditions.
Special causes.
3, Unusual causes.

Foreign substances in the uterine cavity.
Local Causes. — U terine in Origin. ^These are: (i) DisplacHntnti
of the uterus; (2) pregnancy; {3) malignant diseases; {4) chronic uterine in-
flammations; (5) tumors; (6) diseases of the cervix; and (7) inversion ol the
uterus.

Displacements oj the Uterus. — Uterine displacements by dragging upon the
blood-vessels cause pelvic congestion which eventually results in endometriiis-
The congestion which normally takes place at the menstrual periods is coB'
sequently greatly increased and nature relieves herself by an excessive flow.

Pregnancy. — Certain conditions dependent upon pregnancy cause uieiiue
hemorrhage, such as placenta previa, separation of the placenta, and hjdatidi-
form degeneration of the chorion. Incomplete abortions are also a (requefll
cause, on account of the irritation produced by the retained membranes or fewf.
In rare instances pregnant women have a periodic flow of blood from the uttnis
at a time corresponding to the normal periods and menstruation continue
regularly throughout gestation. These patients, as a rule, continue to full lenn.
.Malignant Dife<ises. — Cancer, sarcoma, and chorio- epithelioma caffie mtn-
iirrhapa by bringing more blood to the uterus for their nourishment, by offl-
geslinn resulting from irritation, and, finally, by rupture of the blood-vfsstb
from the ulceration which ultimately tikes place. The hemorrhage is vtn^ pn
sistent. and at times it may be severe, causing rapid anemia. Tubmul^
ulcerations also cause metrorrhagia.

Chronif Uterine Infiammalions. — ^Subinvolution of the uteru,<; and ew^
metritis are a cause of menorrhagia. In the former disease the uttnis ■*
increased in size and is more vascular, while in the latter the changes in ibe"'

UKNOSRilAdlA AND llETKOBKUAGIA.

JOI

_;domelHura set aa an irritant and increase the p>clvic congestion, This occurs

SIT i.-»[>o.'iiill,v in thiiiw forms of dironic cndomcintia which an characterised

' swelling and ihicki-ning of th« mucous memlirvuK.- — the sO'CaJled kyptrpUutie

iomtlrHii.

Tumors. — Uterine (umon catise menorrhaKia by obamicling the venous

Illation, bv irritalion, by incrcji«ing the dennand for blood, and b}' hemoirhnges

the Rniwth iliclf. The situation and histologic chaiactcr of a uterine

Abroid ilctemiine the .imouiit of hemon-ha^, and the bleedin]; is nio«I severe in

A subtnucous f^owth. There is l»s hemorrlingc from the inlerstitial variety,

and » nu)i|ieritiineal tumur has little or no dTcct upon the menstrual How unless

it is fitujtcd )xiTlly within the ;i:iTeiK'hyniii of the ulerux or i.t large enough to

^obstnict the venous circulation by prrssurc, Some of the mo^l persistent riem-

^brtuf^^ nit' cau^wil by muo>us and fibroid |>oIypi. and a uterine myoma is

P^^nerally associulcd with cxces^^ive bleeding.

Oht/^^e% a/ Ike Cen-ix. — Lacer.itions and cj'stic degenerations of Ihc ccrv-ix
iuv frei(uently the cause of an increase in the amount of the menstrual l3nw, and
tbe vaginal discharges may be stained at limes by bleeding from a granular or
I traded surface. This is espcdally liable to occur from contact with the penis
during sexual intercourse and friction aKa:n.-.l the vagina in walking. Hy|>er-
trophy and tumors of Ihe cervix an also a oiuse of mcnorrhagiu. Malignant
, diseanea have alrcid) been referred to.

■B InvmioH of Ihe Vlfrm. — The chninic forra.s of invenJon of the uteruit cauw
P^Vsbtent 3aA, at times, seicre hemorrhage.

Ova/ian and Tubal in O r if; t n .—Intlammaiory diseases and
;>Usms of the uterine apjwndiigrs give ri>e to mennrrhngia by causing con-
■lion. In some cases nn ovarian tumor which liecomcs incarccmtcd in the
ivb will obntrucl the circulation and inrn-.-isc the nnrmnl menstrual Qow.
Pathologic Conditions in the Surrounding Pelvis."
Tecal im)>aclion. tumon of the pelvtik, the rectum, or tlie bladder, and diseases
I the brihid ligaments, »uch as variciKele, hematoma, solid tumors, and cysts.
^Suse ntcnorrhagia by increasing the blood-supply and obstructing the return
circulation.

General Causes.— A cuiv and Chronic Diseases. -There is a
clas of diseases which cause mcnorrhagia chiefly on account of the changes which
they proilui-e in the blood. These aSection.t are: hemuphitiu, >airvy, purpura,
my forms, of anemia, malaria, syphilis, incipient phthisis, acute infectious
Ifcrs. septic infections, chlorosis, and general debility. Some of these diseases.
Ch a.1 anemia, chloronia, debility, etc., a.s u rule, cause amenorrhea, but not
frequently we find them associated with mcnorrhagia. In another class of
mcnorrhagia may be due to atTections which cause an obstruction to the
return of venous bltKKi; and thus, for examjile, it is not uncunimon fur exce.^-

BnM-n.i.truiiti<>n to \ic ^is.-'iH'i^ited with cardiac diseases, especially mitral in-
icicncy and steiio.sis, enij>hyscma, diseaMS of the liver, kidneys, or spleen, and
omJna] tumors.
Reflex Conditions .— Mcnorrhapa may be dependent upon psychic
, cnndittom, am) uiwler these circumstances it is reflex and not due tn iwlvic
1 dbease- 'Ilu: chief causes arc: hysteria; various emotions, as fright, sorrow,
or fear; mentjj impressions produced by the first sexual intercourse; and the
BxeR incident to puberty, the menopause, and bctaiton.
Special Causes .—The habits of a woman may be the cause of men-
~ igia. A scdcntar)- mode of life, as a rule, predis|)oses to amenorrhea, but
ionally it results in excessive mcnstTuniion. High living, especially the
! of alcoboUc stimulants and rich foods, may be a cause. A change of residence

70a UENSTRDAL DtSOKDESS.

from a low to a high altitude or from a temperate to a tropiol caonli; but
afiect the menstrual function and temporatily cause menoniiagia. Cotiin
chemic poisons, such as lead and phosphorus, increase the menstnial flow.

Unusual Causes. — Foreign Substances in the UteriDt
C a V i t y .^Foreign substances may be left in the uterine cavity at tbetiiiKof
an operation and eventually, if they are not expelled, become the cause (rf mn-
orrhagia. Gauze and tents are the articles most likely to be found under these
circumstances, and neglected pessaries have been known to work their way inio
the cavity of the uterus, producing an offensive discbarge and bemonfaage.

Symptoms. — Uterine hemorrhage and the excessive loss of blood at Ihe
menstrual periods are the characteristic symptoms of metroiriiagia and mn-
orrhagia. The bleeding may be only sli^t in amount but persistent, and in
some cases a severe hemorrhage may come on suddenly. The duration of the
menstrual flow may be increased or the amount may be excessive, and xnx-
times the intermenstrual period may be shortened.

The constitutional symptoms of menorrhagia depend upon the cause and &
amount of blood lost; some patients become profoundly anemic.

Diagnosis. — A bnormal bleeding from the uterus isi
symptom, not a disease, and the diagnosis is the rec-
ognition of its cause. Hemorrhage during the intermenstnial poiod
is always pathologic, but it is sometimes a question as to whether or not the
menstrual flow is in excess. To determine what is excess, the original type must
be ascertained and compared with existing conditions. In other words, How
does the present periodicity, duration, and quantity of the flow compare with Ihe
same menstrual characteristics after the function of menstruation had been h%
established at puberty ? We must, however, bear in mind that there may be
differences existing between the original type and present conditions without inr
apparent effect upon the health. This fact, therefore, must be considered when
the question of excess arises.

During puberty while the menstrual function is being established irregularities
in the phenomena of menstruation frequently occur. Excessive menstnialioD
under these circumstances has a significance far different from the same sjinplom
later on in life; the former, as a rule, is not pathologic, while the latter is neailv
always so.

The imporiance of a correct diagnosis of the origin of uterine hemotrhaps
cannot be o\'erestimaled, and this is especially true of menorrhagia or metiM-
rhagia occurring during or near the menopause. The mistake is too
frequently made of ascribing these symptoms to the
''change of life,'' and valuable time is lost beforta
physical examination reveals the true condition.
E\ery woman should be most carefully watched dur-
ing Ihe menopause and the cause found for every
symptom which mav occur. The same is true of uterine hemoirbap
occurring at other periods in a woman's life, as malignant disease may apptar
early, and unless recognized at once, it may pass beyond the reach of surgery.

In unmarried girls after puberty and up to the age of twenty-five years «-
cessive menstruation is usually due to general causes; in unmarried women up w
forty, to fibroid tumors of the uterus; in married women who have borne children,
to such local causes as uterine displacements, chronic inflammations of the uterus,
fibroids, and polypi; and in women at or near the menopause, to cancer of iw
cervix.

Hemorrhage from other parts of the genital tract must not be mistaken Iw
menorrhagia or metrorrhagia. For example, a hemorrhage may be due lo fUfi"

UENORRaXGIA AND UETRORKHAGU.

703

ture of varicose veins of the vulva, to specific ulcerations o( the external organs
of gienenilton or vaginii, and tu various injurieii. Hemorrhage may also occur
from rupture of ttic hymen during the first t«xual iQicrcour»;, and blood in the
urine from iicmaturia or hemoglobinuria ha& been mistaken for uterine bleeding.

It in impossible in some cuset of menorrhagia and metrorrhagia to discover
Ibe cause. This does not mean, howc\'cr. that ihey arc idiopathic, but simply
ihal ihe cntise rannoi Ite localed and tts nature dctermineic!.

Progrnosis. The prognosis iiq>ends upon the nature of the cause. In
some cases it is easily found and removed; in other instances it i.* uncertain or
obscure; and, finally, the cause itself may tend toward a fatal ending.

Menorrh:)gia and metrorrhagia arc seldom directly fatal. The constant loss
of blood, however, results in anemia, destroys (he patient's health, and render*
her liable tu death from a trifling intercurrenl di.wasc.

Treatment. —The tTcatmcot of mciiorrhagia and metrorrhagia isconsidered
under two headings:

The treatment or removal of the cause.

The treatment of the hemorrhage independent of the caute.

The Treatment or Removal of the Cause.— .\fteT the cause has beca
determined our attention is at once directed toward its trc.iimcni or rwnoval.

The Local Causes .—The treatment of the various local causes o(
uterine hemorrhage is discussed in their resi>ectivc chaplerN and need not there-
fore be referred to here.

The General Causes . — It is obviously impossible to discuss the
(realmrnt of many of the general causes in a treatise upon gynecology, and if,
for example, the uterine hemorrhage is dependent upon a disease of the liver, the
kidneys, the heart, or the >j>leen, the management of the case must be baserl upon
the principles laid down in works on the practice of medicine.

The management of uterine hemorrhage dependent upon juychic conditions
requires special mention. If the cause is due to Uclalion, the child must be
weaned; or if the hemorrhage occurs in a newly married woman, sexual inter-
course taunt Ik forhiilden and the husband and wife should occuiiy .lepar.ile lieds.
Menorrhagia due to various emotions, as frighl. sorrow, or fear, seldom con-
tinues (or any greii length of time, and is treated by the use of .sedative drugs.
Hysteric women are usually neur.tslhenic, and if th<- ca-^ is a pronounced one, the
"rest-cure" is usually followed by good results, Reliex irregularities occurring
during Ihe menopause and pulwrty are treated with sedatives.

The treatment of the special causes is simply the correction of those habits cr
conditions upon which the menorrhagia depends. Thus, if a sedentary mode of
Kfe is the cause, the patient must be instructed to take systematic exercise, high
Uvingmust be corrected, and thcuscof alcoholic drinks and rich (ntxis forbidden.

Menstrual irregularities due to a change of residence arc seldom pennancnt
and yield rculily to sedatives.

The Unusual Causes . — The Ireatmenl of the unusual causes ot
uterine Uemorrhane (insists in the removal of the foreign substance from the
cavity of the uterus and curctment of the endometrium, which is generally in-
fected in these tases.

Tbe Treatment of the Hemorrhage Independent of the Cause. — In all
cases of menorrhagia and metrorrhagia s routine plan of treatment must be in>
stituted whether Ihe cause is determined or not.

The routine triMlment is considered under the following headings: (1) Rest;
(1) diet: (3) care of the bowels; (4) local treatment: (;) drugs.

Rest . — The patient is place<l in the recumbent position and the foot of the
bed raised about ten inches. The bed-pan mtiM be used and the patient npt

704 MENSTRUAL DISOKDERS.

allowed to get out of bed for any purpose. Mental rest is also important and qd
unnecessary excitement should be permitted. Visitors must be excluded from
the sick-room and the patient should not be allowed to be worried about her housr
hold duties.

In cases of excessive menstruation the rest treatment must be carried out dat-
ing each menstrual period and the patient not allowed to get out of bed for at
least twenty-four hours after the flow has ceased. If the menorrhagia is slight
it is not necessary for the patient to have absolute rest, but she must keep ia her
room during the period and lie down frequently. In cases of uterine bemorrliage
occurring during the intermenstrual period absolute rest is indicated, and it mast
be continued so long as the flow lasts.

Sexual rest is imperative, and not only must coitus be forbidden, but the
husband and wife must occupy separate beds.

Diet . — The diet must be carefully regulated. The food should be smpk,
easily digested, and not stimulating, and red meats and vegetables which pit-
dispose to a uric acid diathesis avoided. Alcoholic stimulants and coffee in
not allowed and the patient should be instructed to drink plenty of pure water.

The Care of the Bowels .:— It is important to keep the bowds
regular, as constipation causes pelvic congestion and increases the amount of
bleeding. The intestinal canal should be flushed with a bottle of dtrale of
magnesia and the bowels kept regular with a laxative pill and rectal enemas.
The occasional use of a saline purgative is followed by good results, and it sbouU
be employed once or twice a week as a routine measure.

The Local Treatment .^The local treatment depends upon Ax
nature of the case, and is considered as follows: (i) Hot water nginal
douches; (2) vaginal tampons; (3) applications of cold; (4) saline injcctioiu;
(5) dilatation and curetment of the uterus; and (6) uterine tampons.

Hoi Water Vaginal Douches. — Vaginal injections of hot water or nonnal alt
solution are one of the best means we possess for controlling uterine hemotihap
and excessive menstruation.

The injections must be given three times a day, and the quantity of water
required in each douche depends upon the severity of the bleeding. In niDd
cases from a gallon to a gallon and a half arc sufficient, and when the bleediniis
excessive at least double this quantity should be employed. The injections ait
continued during the intermenstrual period and stopped when menstnialioD
begins. No harm will result in using them during menstruation if the flow iJ
excessive or prolonged, and under these circumstances they should be empkijtd
to control the bleeding and lessen the loss of blood.

Va^ituil Tampons. — A vaginal tampim i.s the most certain means we posses
lo control hemorrhage from the non-gravid uterus, and it should be employed
between (he periods to check the bleeding while an efl'ort is being made lo remove
the ciiu.se of the local condition. It is also a valuable remedv in cases of ulfriw
hemorrhage in which no cause can be determined, and its use under these cir-
cumslancos often slops the bleeding for an indefinite length of time.

In cases of excessive menstruation in which a long time is required for At
irL'atmcnt or the cau.'ic cannot be discovered and (he loss of blood is injurious '1*
the palioiil's genera! health, nothing gives such good results as a vaginal lampw-
It should be used for several months at each menstrual period, either when the
flow begins or after it has continued for two or three davs. If the flow is»-
rc-^sive from (he st;irt, the tampon must be intrwluced at once; but if the i*^
<'f liloixi is due to the duration of the period being prolonged, it is belter to ivu«
for two or three days before packing the vagina. The use of a vaginal tampt*

UeN'OKRRAGIA AND UKTRORKHACIA.

70s

■

under these drcunisianccs stops the excessive loss of blood, improves the general
health, .itid the {lalicnt nr->.[ii>ni]s he(t«r lo treatment.

AppHcalioni oj Cold. —Cold is applied by means of ice-bags, which are placed
over the lower abdomen and the lumbosacral region. The application of cold h
not, however, often iidvi:>ible in tlic Ireiitmtnl of uterine hemorrhage and exces-
sive mcnstruiition, because patients who are suffering from loss of blood require
Ihe stimulating effect of heal, which aLno produces a quicker and more permanenl
contraction of the blood-vessels.

Sdlitte jMJections.^'thc injection of oormal salt solution into a vein (I'n-
Inntiutus), into ihe «il)cutimeou7^ tissues {Jiypodrrnuicly.fh), or into ihc rcclum
(erUfrodviii) is a valuable adjunct in ihc trcaiment of severe or sudden uterine
hemorrhaKe ami exhuu.->lii>n de|>endenl upuri tlie continuous lotis of blood.

DilaUUion and Curtliwnt oj ihr Uterint Cavity. — Dibution and curctmenl
of the uterus are indicated as a routine treatment, especially when the cause is
locid in origin .md change^ have Liken place in the endometrium. Thew <'hanges
often keep up a hemorrhage e\-en after the original cause has been removed, and
if the symptom is due to a uterine jntlyp or a gruss pelvic lesJon, dilatation and
curetment of the uterine aivity mu*t follow the primary' o[>cralion. Again, as an
empiric plan of ircatnicnt in cases in which no cause can be discovered, curetmcnt
of the uterus and the a |)pli cation uf pure carbolic acid to the uterine cavity have
been follonxd by permanent results.

Vlerine Tampon. — The uterine tamjion ctintrols bleeding and is indicated in
the trc.itmenl of monorrhagia and mctmrrhngin after the removal of large uterine
polj-pi. submucous tumors, incomplete abortions, and after an operation which
kaveN the walls of the uleni> relaxeil or it* ciivily enlargeil. I'nder these circum-
stances the tam|wn checks blccrling and stimulates uterine contractions. It
mu.st he removcil in twenty-four hours and not reintroduced unless the indication
is imperative. The rcintro<iuction of n ulvrinc tamjxm must be attended with
the strictest antiseptic precautions, and iu use therefore cannot be recommended
as an empiric plan of trcaiment for extvsfxw biw of bloml in ra,^e^ of mcnorr^iagta
.and mcirorrfaagia. (or the reason that a vagina) tampon meets all the indications
without the danger of <'au.ving .^epIic infection.

Drugs —The following remedies arc recommended in the treatment o(
uterine hemorrhage:

Ergot. — This tirug 1* indicatcsl when mcnorrhaicia or metrorrhagia is uterine
in ori^n. It is therefore especially useful in subinvolution, interstitial fibroids,
and many forms of active and paie>ive conRcslion. If the cause of the bleeding
is extiauterine, it has but little cHect, and practically no renulu follow its
use in pathologic conditions which are limited (o the endometrium. Ergot
may be given alone or in combination with other drugs, and, on account of its de-
pressing cITcct upon the hi;;irt, especially when given for an imtefinite length of
time, it should always be combined with sulphate of strichnin. The fluid extract
o( ergot and erjiotin are the best preparations to employ, anil thc>' should be
administered by the mouth nnd not by h>iM>flermic injections.

//jrf/OJ^i 5.— Hydrastis, through its effect on the vasomotor ncn'CS, stimulates
uterine action, and is therefore a valuable remcily in ciLses of monorrhagia and
metrorrhagia due to subinvolution, interstitial hbroids, and chronic uterine
congestion. It is esperially u.sefiil in rases ()f hemorrhagic endometritis, and is
aU» inilicatvd in uterine bleeding occurring during pregnancy, on aatiuni of
not intcifering with the normal course of gestation. Hydraslinin and the Huid
extract are Ihe best pre|)amtions to employ, and they coml)ine well with ergot.
Hvdnislis is usually given during the intermenstrual periods, and in ca»e.s in
which the flow is excessive it may be continued during menstruation.
45

job U£NSTRDAB DISOBDEXS.

The following is an excellent combination for the administration of hydiuds:

IJ, Hydraatininat hydrochlotalis gr. x

Ergotini gr, il

Strychninffi sulphatis gr. ts

M. et fl. pil. no. zx.

Sig. — One pill three times a day.

If the duid extract of hydrastis is employed, it should be given in fuU doses and
combined with the fluid extract of ergot.

Viburnum prunijolium. — This remedy is indicated in menoirfaa^ aid
metrorrhagia due to reflex conditions incident to puberty, the mem^use, and
lactation, and is also of great service when the cause is due to acute and chrnuc
diseases. For example, il has been employed with good results in ezosan
menstruation occurring during the course of acute infectious fevers, and in osts
of anemia, malaria, and chlorosis the remedy has proved of value in controOiiig
menorrhagia. It is also useful in menorrhagia associated with dysmenonfaea,
and is invaluable in the treatment of uterine hemorrhages occumng duiiog
pregnancy.

The fluid extract of viburnum b the best preparation to employ, and it sboold
always be given in full doses.

Hamamelis. — Witch-hazel is indicated in passive uterine congestion whentbe
hemorrhage is small in amount and persistent and the blood dark in color. It is
therefore a valuable remedy in menorrhagia due to retrodisplacements ct tbc
uterus, subinvolution, and hyperplastic endometritis, and has also been uied «iA
success in uterine hemorrhage caused by purpura and allied conditioiis. TIk
fluid extract is the best preparation to employ, and it may be givoi alont or il
combination with the fluid extract of ergot.

Iron. — The indications for the use of iron in the treatment of mcnonlugia
and metrorrhagia must be carefully considered, as its indiscriminate adniims-
tration will often result in increasing rather than diminishing the excessiw do*
or hemorrhage. The preparations of iron are chiefly employed for thrir efftti
upon hematosis, and are therefore especially valuable in the treatment o! mtt-
orrhagia and metrorrhagia due to acute and chronic diseases which product
changes in the blood. Thus, they are indicated in hydremia, anemia, chlorost
hemophilia, and allied diseases, and in cases of debilitj' arising from eicesait
lactation, indigestion, general exhaustion, etc., the remedy is invaluable. Iron
should be given only during the intermenstrual period and discontinued wbentbt
flow appears. On the other hand, however, there may be exceptions to this mlt-
and it will be found advisable not to discontinue its use during the flow.

Less Imporlanl Dnigs. — Other remedies which are of value as uterine ban-
ostatics are the mineral acids, especially dilute sulphuric; alum; gallic add:
cotton root, and chlorid and carbonate of calcium. Digitalis is valuable in iht
treatment of uterine hemorrhage occurring during pregnancy, and the brotnids-
opium, and cannabis indica, on account of their sedative action, areof sffridin
cases due to reflex causes.

AMENORRHEA.
Description, — Amenorrhea is the absence of menstruation. Under ill's
definition arc included acute suppression of the menses from cold, scanty inrt-
struation. and the concealed form due to atresia.

Catises. — The causes of amenorrhea are classified as follows into:
Physiologic causes.
Congenital causes.
Acquired causes.

AUl^NORKUEA.

Pbytiolt^ic CauMS.— Amenorrhea in Dortnal when il (itrui^ during <:ertain
pCTiods and conditions of a woman's lift-. Thus, mcnsiruation is absent before
jmlterly and during ^enilily; iI ia IrreKular in its peritxlicitj' during [tuberly and
the menopause; iiiid, us ii rule, it i* »bsenl during pregnancy and UcUitUm.

Congenital Causes. — These are subdivided into (i) congenital obslruclions,
and (i) im|M-r[ri I i!evd(i|imcnt, or .ib>cme of ihc organs of jfeneniliim.

Congenital Obstructions .—Congenital atresia may be a cause
of amenorrhe:), anil although mcnairuation Iakv^ [ilaie regularly in these caties
the (Jow is concealed and unable lo pas" beyond the obstruction. The menslnial
blood accumulates and the amount is imreascil at each monthly jjeriod. The
nt^na eventually liecomes iitleil with menNlnial IiIixkI (liema Into! pot); then the
Uterus {hematomfira); and finally the oviducts (hrmalosiilpinx). The airvsix
may be situated in the cerviutl eanal, the vagina, or the vulvovaginal orifice;
the latter situation is the mo!^t common, and the obstruction is usually due (a an
impwrforalc hymen.

Imperfect Development or Absence of the Organ*
of Generation . — Nothing is known of the cause of these abnormiil con-
ditions, and men.struation does not occur )>ec'auNe nature hay. lail«d to provide the
necessary orpins for Ihc purpose. lmi«:rfcct <levclopmcnt or absence (i( the
sexual organs U a rare condition. Cases have been met in which no sexual
change.% iH'Curred at the time of puberty :in(l the hrui.vl.'' were not enlarged, hair
did not apl^ear on the mons veneris, and the external organs, the %-agina, the
uterus, and the ovaries retained their infantile chararieri>tit:s. Again, amenor-
rhea is present in another class of women, known as the "maxculine lype" in
which the organs of generation arc apparently well developed and yet faD to
perform llicir funrtion.i. These women ;ire u.^ually trained fmm early child-
hood lo be professional athletes, and ihcir muscular system has been overde-
veloped at the ex|iense of their sexual ajiparatus.

Acquired Causes.— These arc subdivided into (i) the local and (i) the gen-
eral.

The vast majority of case* of amenorrhea are due to acyniiri-d conditions, and
<jt these the genera) causes are the roost important.

Local Cau.>ies . — Vagina. — Amenorrhea may lie due lo atreKia of llie
vagina caused by traumatism, labor, inflammation, ulceration, or Oi]>crative
procedures, and under these circumstances the men.itrual llow U («nccalcd, as in
the ningenital fi)rms of obstruction.

Uterus. — Amenorrhea may be caused by atresia resulting from operations
ufKin the cervix ami the apptioition of the ncttial cautery or acids to the cervical
canal. It may also be due to the sclerotic stage of chronic hyperplasia, and to
atrophy or .^ui^erin volution of the uterus, dejiendent U{H>n frequently succeeding
pregnancies or prolonged lactation.

Uterine Appendages. — It is extremely rare for any form of acute or chronic
disease of the uterine appendages to cause amenorrhea. I'hc tendency in these
' cases is to cause menorrhagia rather than a lessening of (he menstrual flow, and
although a large ovarian cyst may cause amenorrhea, the condition is not due to
the tumor itself, but to the <iebility and exhaustion which accompany it. In nire
instances acquired atrophy of the ovaries may cause amenorrhea, and the ccSEft-
tion of men.ttruation ma>' therefore follow a,* a sequela such acute febrile diseases
as measles, smallpox, scarlet and tvphoid fevers.

Operative. Kemm-il oj the Uterus ami its Appendngei. — Amenorrhea results
from the removal of the uteruic or its appendages. .Afler iheovarie* and oviducLi
have been removed menstruation ceases, although exceptions to this nile are met
from time (o time, and women have continued to menstruate re^larly for an in-

708 UENSTRUAL DISOKDESS.

definite period. These exceptions may be due to a supplemental; maij; to
an incomplete removal of ovarian tissues or the oviducts at the tiise of die
operation; to a diseased condition of the uterus or endometrium acting ui
local irritant; and, finally, to the law of habit. After a hysterect(»ny ina>-
struation ceases, unless the appendages have not been removed, in which ast
the flow may return and be discharged by the vagina, or it may become vicarious.
Later on, however, the ovaries usually atrophy and the function beamK
extinct.

The phenomenon of menstruation continuing after the removal of the pdrk
organs is illustrated by the following case, which occurred in my practict.
Both ovaries and tubes were removed in 1895 by a Philadelphia gynec^ogist, and
after the operation menstruation became more frequent, occurring nery two
weeks. In 1896, one year later, I performed a supravaginal hysterectMUf, and
found the ovaries and tubes absent and the stumps close to the uterus. Men-
struation ceased for two months after the hysterectomy, when it returned,
and then appeared regularly every four or five weeks up to September, i&)9,
nearly three and a half years after iht body of the uterus had been removed, wHb
I tost sight of the patient.

General Causes. — Exhausted Stale of the System. — This is the most
frequent and important cause of amenorrhea. The absence of men-
struation is due to the fact that nature cannot afford
to e:tpend the necessary amount of blood and Dcrre
force required to carry on the function, and ameo-
orrhea results, not from any local pelvic disorder,
but because the woman's system is unequal to ihe
demands made upon it.

Acute Diseases. — Acute diseases are the cause of a temporaiy absence of
menstruation on account of the debility which accompanies them, and thus
amenorrhea may occur as a sequela to typhoid fever, diphtheria, scarlet ioe,
pneumonia, rheumatic fever, and allied disorders. Menstruation is absHit in
these cases, as a rule, for several months, and returns again when the patjeni
ha.i been fully restored to health. In exceptional instances, however, atrophy of
the uterus or its adnexa results as a sequela and the amenorrhea is penninent

Chronic Diseases. — Chronic affections which debilitate and exhaust Ihesys-
tern often cause amenorrhea, and hence the affection may result from tube-
culosis, especially pulmonar>'; chlorosis; anemia; malaria; neurasthenia;
sypfiilis; my.xetlema; exophlhalmic goiter; organic diseases of the abdominal
and thoracic viscera; malignant diseases; etc. Amenorrhea due to chnjiuc
diseases may or may not be permanent, according to the nature and curaWMw
of the affection which causes it. If the disease is curable or there is e»tn »
temporar\' impro\-emeni in .the patient's condition, menstruation returns as in
evidence of increasing strength.

Bad Hygienic Conditions and Surroundings.— Thc^ conditions are respon-
sible for the largest number of cases of amenorrhea, and indolent habit' aw
want of exercise in the open air frequently result in scanty or absent niea=troi-
lion. The excessive use of alcoholic stimulants affects the function of mw-
Rtruation, and althouf;h, as a rule, alcohol increases the flow, yet wentuail}'
or.canic diseases may result which will debilitate the system and cause ameoor-
rhe:i. The drug-hahit continued for an indefinite period sooner or law
interferes with menstruation, and amenorrhea is often obsen-ed as one of dw
most frequent symptoms present in morphinism. Workers in certain chemif^'j'
such as lead, mercury, etc., frequently suffer from chronic poisoninj: v^^"'
results in cachexia and interference with the normal menstrual flow; tbesani*

AUENDRHBEA.

709

lie wheo these chemicals arc taken internally, by design or as the result of
an acrirlent. Brain work, especJatiy if cxcrci&e is neglected, interferes with the
functions of nutrition and reproduction, and literary' women and those whose
duties require them lo live a sedcnlury life arc likely to suffer from amenorrhea.
Young girts who oventudy and arc confined for a long time each day in the
daas-room arc seldom normal, and the How is scant>' or absent. The most
frequent cauites of amenorrhea in the poorer classes arc overwork, insufficienl
food, bad genenil hygiene, and impure air.

Acute Suondary Awmia. — Anemia may cause a temporary absence of the
RKa'Slrual flow, and amenorrhea frequently follows a hemorrhafie in typhoid
fever, pulmonary lubcrculosia, ulcer of the stomach, and openitivc procedures.

Obesity. — Women who arc obese and who rapidly accumulaie tal arc apt to
have amenorrhea, .-Mninty men.itrualion, and lenKihcnin;; of [he intermenstrual
periods, and it is not uncommon for obesity to be associated with sterility.
The menstrual irregularities in these cases arc due to the accomi>anying anemia
aiM] the wviikened condition of the nervous and circulatory energy of ihe pdvtc
organs.

Afute Supfirenion oj Ihe .I/«hw-i.— Menstruation is frequently suppressed
from exposure to t)i(: inclemencies of tlie weiither, and the flow may iil»o be in-
tentionally cut ^hort by the um: of a cold-walrr vaginal douche or a cold bath.

Payehic Conditxom. — The inllaencc of various emotions upon the function of
mensirualion has been fully dcmonstraled and .imcninrliea from these causes is
not iiifrctiuenl. Thus, menstruation may be temporarily suppressed by grief,
anger, fc:>r, fright, anxiety, sudden joy, and otiier emutions, and among prisoners
and the insane amenorrhea is a fretiucnt occurrence. Married women who are
Merile and anxious to become pregnant may have amenorrhea associated with
lympaniles. The fear of pregnancy following illicit intercourse frequently
Cftusei a temporary suppression, and a change of residence or associations often
causes amenorrhea. Thus, it 1* cnmmon among emi|;rants :in(l women who have
taken a long sea voyage, and young girls who arc sent to bo;trding-school often
hare a teni)>OTary nuppre^oJon of menstruation. Men-'tirual irregularities are
frequently obseT>-cil in hysteric women, and mrgical opcnitiims iire frequently
foDnwod by temjiorar)' amenorrhea or menstrual irregularities due, no doubt,
to menial f^ock; ibis t.t e^iM^riatly true of operative pr<K'edure» ui^on the pelvic
organs.

Symptoms and Diagrnosis.— The absence of menstruation b the chief
symptom. In some casi-s sympliims of the mcn.Mnial moHmen show themselves
and the p.ilienl suffers from itushcs of heal, headache, bearing-down sensations in
the pclviK, buckairhe. diiturbcil ^liJ,•e^^tion, i»ervousncss, and hysteric eptlejiKy.
Again, patients may suffer from hv^>eThidrosis and various formis of skin eruption,
«ich iLs heri>ei. ec«;mi, urticaria, and acne. The constitutional and general
iymp|[im.'« depend upin the cauue of the amenorrhea.

The diagnosis of amenorrhea is the recognition of
the cause, which must he <leter mined in every case.
The subjective tymptom* must first be elicited and then n thorough physical
txamination made, not only of ibe pebic orgaos, but of all the viscera of the body,
as well a!< the IiIoikI, t)ie urine, and the various excretions iimJ secretiomt. An
ancslhelic must be cmployeil if necessary In making the pelvic examination.
Scanty menstruation is a rclatiix term, and the normal type must first be deter- '
_nuned Iwfore ronrltiding Hint the -symptom is pathologic.

Physiologic Causes, -.\bfence of menstruation is the only symptom in cases
UmniOTrhtM dqirmluiii upon physiologic coiuliiions, and the diagnosis is b«s(d

710 UENSTSUAL DISORDERS.

upon the recognition of the cause. Mistakes in diagnosis arc only likely to occur
early in pregnancy and in cases of ectopic gestation.

Coogeoital Causes. — O bstructions . — In these cases menstniatiai
has never been established, and while the menstrual molimen occurs reguluiy, tht
flow is concealed by the obstruction. After the uterus has become distended widi
menstrual blood the patient may notice a swelling above the pubcs, and ^ may
suffer severe pain in the pelvis at each molimen on account of the incnafd
distention at that time. In the course of a few days, however, the organs gradu-
ally accommodate themselves to the increased quantity of retained blood, and the
acute pain ceases, leaving a sensation of weight or fullness in the pelvis.

The subjective symptoms in these cases are characteristic, and the diagnosis
is confirmed when the physical examination reveals the obstructi(»i. Id ibe
majority of cases the atresia is situated at the vulvovaginal orifice and is due to
an imperforate hymen.

Imperfect Development or Absence of the Orgaos
of Generation . — In cases of amenorrhea due to imperfect develG^ment
of the organs of generation menstruation is either never established and there is
no molimen, or there is a slight periodic eSort upon the part of nature, wbidi
results in pelvic symptoms and a leukorrheal discharge streaked with blood. Id
the "masculine type" of women and in those in whom no sexual changes ban
taken place at puberty the subjective symptoms are absent and the Sow does doi
appear. If the organs of generation are absent, menstruation is never csUb-
lished and the amenorrhea is permanent.

The diagnosis depends upon the physical examination, which revols ihe
cause and determines the condition of the genital organs. The infantile con-
dition of the external and internal organs of generation as well as the breasts io a
girl who has passed the usual period of puberty without menstruating shows Ihat
no sexual changes have occurred, but in professional athletes of the "nuicii'nK
lype" thediagnosisdependsentirely upon the history of the patient, as theo^iB-^
of generation are apparently well developed.

Acquired Causes. — L o c a I .—Atresia of the vagina and uterus giits risf
to the concealed form of amenorrhea. The menstrual molimen is present, and
in time the blood accumulates in the vagina, the uterus, and the tubes, pnns
rise to pelvic pain and distress, and later on a tumor is felt in the lower abdwntn
The diagnosis is based upon the history and physical examination.

Atrophy of the uterus from chronic metritis or superin volution presents no
characteristic symptom other than the absence of menstruation, and the diag-
nosis is based on the history and physical examination.

Atrophy of the ovaries as a cause of amenorrhea is very rare. In some in-
stances there may be a menstrual molimen and the patient suffers with senit
pain over the ovarian, lumbosacral, and hyjiogastric regions. The diagnosis i^
difficult and is based upon the subjective and objective symptoms as well as ihf
history of the patient.

In cases of amenorrhea resulting from the removal of the uterus or its ap-
pendages the menopause is suddenly and prematurely established aod »«■>;
motor disturbances occur which are common to the normal " changt ej lijf-
The patient may suffer for an indefinite length of time from flushes of '"''
and chilliness; vertigo; faintness; numbness and heaviness in the exircniil'*^'
sleeplessness; and an irritable condition of the ner\'ous system. The diajnost
is based upon the history of the operation and the absence of the organs.

General . — In cases of amenorrhea dependent upon an exhausled staM
of the system the general symptoms are characteristic of the disease causing i«

AMBKHtRiieA,

711

absence of incr»truati»n, and the dia(;noHU Ls therefore ba.sed upon Ibe recogni-
tion of tbc cause

A cute suppTfiiion of the menses from exposure or Ihe use of cold-water vagina)
douches or a cold bath mayor may iiiit be attended with mti^lilulioiial ^ym|ll(>m.v
In some cases j-encral disturbances are nol present and the How returns on Ihc
following month. OiheR, again, arc marked by profound constitutional symp-
toms, and mcnstrwilion is not re-cttAblinhcd for scvend months. Sometimes
grave |jelvic t^jm plications may arise, such as inflammation of the uterus, the
tubes, or the [icriloneum, ami ibe org,'ins lN:a)nie permanenily damaged. When
constitutional symptoms arc present, they arc usually ushered in by a chill, fol-
lowed by an elevation of tem|>eralurc, rapid pul>e, hc.idachc. and pain in tJie
pelvic and lumbosacral reijion^- If the congestion of ihe jielvic organ.^i in marked,
there is a sen.salion of weight in the pelvis and the bladder becomes irritable.
The diagnosis ix hn-seil upon ihe ^ymplom^ .tn<l ihe hiMnry itf the |>atieiil.

The symptoms of the psyrhic causes of amenorrhea differ somewhat according
lo the nature of the emotion producing the menstrual irregularity. Sudden
emotions, as n rule, afTcrl menslruulion only when the fiow h.is actually begun,
and it usually reappears at the ne\t perio<I. Grief and sorrow, on the other
hand, .ire more {>er)nanent in iheir resulU, and the Niime is (rue of case.>( of amen-
orrhea due lo the mental depression .itTecting prisoners and the insane, .\mcn-
orrhea due to ihc fear of pregnancy following iUitil intercourse usually lasts one
or two monlh.-', and in ca^ev "f pMriidi>cye*i> the llow may Ik; absent (or an in-
definile length of lime, .^menorrhe;! due lo a change of residence is not attended
by any constitutional symptoms and the flow is reestabli.^hei! in a few months.
It is not uncommon after o|icTalic>n» ujion the [lelvic organ> for tlie |iatient to ml.ts
her nc:ct menstrual period, and in occasional instances menstruation may be
absent or irregular for scleral months.

Prognosis.— The prognosis of amenorrhea depends entirely upon the
cause. The late a|tpcarincc of pubert)' in young giri.i need cause no sgiecbl
anxiety unless the symptnms indinite a local iir general chujc for the delay. U,
however, menstruation is not established before the nineteenth year, a physical
examinaiion should be made under an ancstlieti* and tlie cauae of the trouble
determim-il.

Treatment. — The treatment of amcnorrhe.i depends upon ihe cauuc.
The ab.tencc of men.-vtruation En .■'imply the manifes-
tation of a local or general pathologic condition,
and a careful study of the entire system must be ma<lc
before resorting to therapeuli i: or hygienic measures.
It should also )k bomt- in mind that amenorrhea is nol necessarily inconsistent
with health e\cci>i in cases in which the cause affects the general constitution of
the individu.-il.

The treatment is classified a» follows into;
Gcnerjl trcaimeni and hygiene.
Em m en.-i gogues.
Treatment of the cause.

General Treatment and Hygiene.— In a large pm|>ortion of c.-i«* of amen-
orrhea ihc cimdiilmi <4 llu- lilofid. nervous system, and nutrition is at fault, atld
the treatment must, therefore, be directed toward placing the general syslen
and health of the patient in a normal state.

This is accompli-'thwl by the following meuns: (i) Rest; (») excrdse; (3)
diet; (4) care of the bonels; ($) bathing: (6) massage; (7) elcctridty; and
(8) the "reM cure."

Rest . — Many cases of amenorrhea are due to a broken-down condition of

713 MENSTRUAL DISORDEXS.

the health and nervous system from loss of rest, and it is therefore important thit
at least eight hours a day be devoted to sleep. Mental rest is also essential, and
all causes of worry and excitement must if possible be removed. Sexual inter-
course is contraindicated in exhausted conditions, as it is an additional drain upoa
the system; but in cases In which the uterus and the ovaries require stimuUlioa
it is beneficial on account of the temporary congestion which it produces.

Exercise . — Systematic exercise in the open air and sunshine must be
insisted upon, as well as the use of indoor exercises, which strengthen the »b-
domen and stimulate the pelvic circulation (see p. 117). Before deciding upcG
the character and amount of exercise to be taken the general condition d tht
patient must be considered and a thorough examination made of her heart, blood-
vessels, and lungs.

Diet . — The diet must be carefully considered and articles of food selected
to meet the indications in the management of each case.

Care of the Bowels . — The tendency to constipation should be
corrected by exercise and a proper diet and the bowels opened once a day with
a mild laxative. Aloes is especially indicated in cases of amenoniiea on account
of its stimulating effect upon the pelvic circulation, and may be ad^'a^tageous[y
combined with cascara sagrada and podophyltin. Salines are also useful, and
decided benefit is often obtained by giving the patient a bottle of citrate of mag-
nesia once a week.

Bathing .—The care of the skin is important and the body must be
bathed once a day. The method of bathing depends upon the indications Id
each case, and as amenorrhea is due to so many different causes, great care should
be taken in selecting the character of the bath and the length of lime devoted to
bathing. Thus thermal baths are indicated in cases of obesity and contniD-
dicated if the amenorrhea is associated with a lesion of the heart or blood-itssek;
somepatientsarebenefitedby cold ami others by hot water bathing; and.finalhr,
in extreme cases of exhaustion it may be nccessar>' to bathe the patient in bed.

Massage , — Pelvic and general muss;ige are employed with advantage in
many ca.ses of amenorrhea; the former is more or less limited in its application,
while the latter is valuable as a routine procedure in nearly all cases on account irf
its effect upon the general nutrition. Pelvic massage is indicated when amm-
orrhca is due to an undeveloped condition of the genital organs, and also after
an acquired cause has l)een remoi*ed and the function of menstruation is slow in
being rc-est;iblishcd. (Jcncraj massage improves the nutrition, strengthens lit
heart and circulation, and increast's muscular activity. It has therefore a wide
range in the treatment of the causes of amenorrhea, and may be used adi^an-
tageou.sly in nearly all cases.

Electricity , — The static, faradic. am! galvanic currents may be em-
p]oyec one cleclrmle is plarefl on the alKtomco immediatelv over the s)in-
]ihysis pubiri and the other either over the luml>os;icral region or in the vapia;
under no circumstances should the current be ap-
plied directly to the uterine cavity.

Tlic Rest Cure .- — OikhI results are obtnineil bv a properlv conductw
rest cure in selected cases, and this plan of treatment is therefore employed wiw
Hdviintiice ulien nmcnorrhea is associate<l with neurasthenia and allied con-
dilicms.

Emmenagogues. — These remedies excite the functional activity cf **
jielvic organs hv stimulating the uterus and iivarics: Increasing the [lehic c* J^
kition; an<] improving the general nutrition and the quahty of the blood, ^j**

AIieNORIIREA.

713

phv&iolo)ric action of the various emmen.igugucs mii.'tt he borne in mind and the
indiciiiions fur Ihcir use carefully considered in even- case. Thus, in cases
of arocnorrliea due lo an exhaustcil state of the sys-
tem no results will be obtained by the use of remedies
thai stimulate the uicrus and ovaries, as ih« indica-
tions are to Improve the nutrition and correct the
quality of the blood.

M a n g a 11 e ti e .—This remedy is useful whenever an cmmcnagogue is
indicated, and it is specially lienefidal in acute su|)pressian when the flow fails
t(i return on the following month and In cases of scanty or irregular mcnstnulion
dependent upon uterine or ovarian inertia. Manganese is used id the form of
btnoxid of manganese (gr. j lo ij, 1. i. d.) or perman^nate of poiatsium (gr. ^s
to j, t. i. d.), and may be administered alone or combined with other remedies.
It shoulit Ite giveti three or four times a day after eating atul continued for
' several weeks. Its special physiologic action is to increase tliv flow of blood
going to the pelvic organs.

The follnwing formula Ua u.seful comhinaiion :

hit- Polauti pemi«n|tanalb .........,,,. ........((r. xi
Acidi oxalid .......;....,... gr. v
Frrri rt quiniiue cilrati* gr. d
M. d fi. i<il. no. XK.
Sig,— Om- pill three limfg a day after tncala
A p i o I . — Thi* dnig-i'au»et congestion tif the (>elvic organs and is useful as
an cmmcnagogue when u direct action is required. It is. therefore, employed to
reestikbli.ih menstruation after suppression from exposure to cold, emotions, etc. :
I in cases recovering from acute and chmnic dise:n«*; and in congenita) and
acquired forms of amenorrhea when the molimcii is present. Apiol is admin-
istcrwl in capwile* In doses of th«* lo wx minims three lime* 3 day after meals,
and should be given scleral days before the flow is expected,

.Aloes .—This remedy is also a direct cmmenagogue, causjnic congestion
of the ficlvic organs, and the inclic.ilions for its iiw are ihc same as those for npiol
and other stimulating cmmeoagogues. It may be gi\%n alone or combined with
other drugs and administered for several days before the ex|>C( teil flow. The best
preparjitinns arc purified nl"cs (gr. j to xx) and nioin fgr. ^ to ij).

Oxalic Acid (gr. J-ss). — This drug is a verj- effective emmeiiagogue,
and is es])edally useful when amenorrhea is due l» .'■.^ich [isychic causes as a change
of residence, associations, etc. The gcncr<il indications for its use are the same
as those for other direct emmcnagogues. Oxalic acid should l)e given alone or
combined with other remetlies in pitl fi>rm nr <:aji?;ules and continued without
interruption for Ihrt-e or four months.

Santonin (gr. j-iv). — This drug is itidirated tn amenorrliea due to
chlorosi.i or anemia, and also to relieve the {>elvic symptoms and bring on the flow
in cases of acute suppression from exposure to cold.

(^ u a i a c u m . — This remedy is u.tefiil in amenorrhea anodaieid with
ihcumalism. The ammoniated tincture of guaiac (>*IX lo f^j) is the best
preparation to employ.

Iron .^Preparation.v of iron are employed in (he treatment of amenorrtica
for their effect upon hematosis, and are, therefore, useful in esses of primary and
secondary anemia, chlorosis, hysteria, aiul allied tli.'wnlers. The vasomotor
disturbance* following the removal of the uterus or its appendages are greatly
relieved aitd often cured by the administration of tiitcture of the chlorid of iron.

Strychnin .—This drug is useful as an emmen.igogiie on account of Its
influence u|H)n ll>e uterine ti-oues, the vasomotor centers, and hcmatosis, and b

714 MENSTRUAL DISORDERS.

given in the form of sulphate of stTychnin or nux vomica — alone or in rombina-
tion with other dmgs.

Oil of Rue (ni,ij to v). — This remedy is indicated in aaienonfaea due to
ovarian inertia and in cases of hysteria associated with anemia.

Oil of Ta n sy (mij to x). — This preparation is recommended in sup-
pression of the menses from exposure to cold, and is given in pill form or capsules
or it may be dropped on a lump of sugar.

Oil of Hedeoma ("lij to x). — This remedy is beneficial in acute si^
pression from exposure to cold and in cases of amenorrhea due to emotiomf
causes.

S a V i n e .^This drug causes congestion of the pelvic organs and is em-
ployed when a direct emmenagogue is indicated. The oil of savine(tiiijioiv)
is employed.

Salicylic Acid . — -This remedy is a useful emmenagogue on account of
its stimulating effect upon the pelvic circulation and its a nti rheumatic acttoD.

C i m i c i f u g a . — This drug is especially indicated in amenoirfaea due lo
mental depression and ca.ses dependent upon allied psychic conditions. The
fluid extract in half-drachm doses is employed.

Gold . — Gold and sodium chlorid (gr, ^ to ■^) has been successfully used
in cases of amenorrhea due to neurasthenia and exhausted states of thesi-slem.

Hoang-nan . — This drug is recommended in amenorrhea as a gcoeal
tonic and is indicated in cases of malnutrition and anemia. The fluid eitracl
(i%v to xsx) is employed.

Other Remedies .^Among other drugs used as emmenagogues mir
be mentioned leonurus, or motherwort, fluid extract, fjj-ij; tincture of mjiA.
fSss-ij; polygonum or water pepper, fluid extract, "Lx-f.^j, for several daj"sbff«e
the expected flow; sanguinaria, gr. ij-xx, or its tincture, "ix-fgi; senep.
fluid extract, n^x to xx; and serpentaria, fluid extract, "ix-xxx.

Treatmeot of the Cause. — Congenital C a u s e s .— Amenonbei
due to congenital atresia is a surgical affection and is treated upon the princijiles
laid down elsewhere.

If the symptom is due lo the absence of the organ*
of generation, the condition is permanent and noth-
ing can be rlone.

In cases dej>en dent upon imperfect development of the organs little or iwlhins
can he accomjilL.shed, and the question of treatment depends upon the absence or
presence of the mnlimen. If the molimen is absent, all forms of treatment are
useless ; but if it '\R present, good results will be obtained at times by dilatation and
curctment of the uterus, followed by attention to the general hygienic condiliow:
the employment of massage and cleclririly; and the ndministration of en-
menagogues If the treatment fails to establish menstruation and the hralli
of the individual suffers on account of the molimen and the nervous symplooi.=,
it may be necess;m- in some instances to remove the uterine appendapes.

In the " masfuline type" of women and in cases of amenorrhea due to llw
absence of sexual changes at the time of pul>ertv (he molimen is not presenl a™
no form (if treatment is of any use.

The (|uestinn as to the advisability of the marriage of a woman who has in
imperfectly developed uterus or ovaries is a serious one. and she. as well as hw
prospective husbanil, mu.sl t>e informed of the practical certainlv of sienliiy
even if there i^ mure or less molimen ;md the treatment has resulted in estaWi-*'
ing a slight flow at the monthly periods. In all cases of congenital amenoiAw
a [ihysical examination must be made before considering the question of maniip'

AUENOKRHEA.

715

AS the physical defecU in the or{caii» of gciieniium may be nbitructive in rhar-
aricT and render sexual intercourw impossible.

Acquired t a u sc & .— /.ofd/. — Amenorrhea due to atresia of the
vagina or cer\-iciil c.in;d i» ob»tnictive in chankcter and ix treated upon the prin-
ciple» described elsewhere.

In cases of .>U|>erins-olution or atrophy of the uienis treatment may be fol-
lowed by favorable results if the cuvily of the organ dues not measure less than
two inches and a molimen is present. The trcatnienl, which is directed toward
the stimulation of ihc uterus ami tbc impnivcmenl of the general health, is the
same as in the congenital forms, and is described elsewhere. Scarification of the
cerv-ix is of Ijc-nefit in these ta.ws and increases the flow of blood to the pelvic
organs. It should Ik performed iwHce a week for an indefinite length of time
and also when Ihc molimen is jircscnl.

If the ;imcn<>rrheii i.i due lo e.xhau.«tion <lei>endent ujion a large ovarian tumor
menstruation is usually re-established along with the impro^-emcnt in the gencntl
health of the patient after the removal of the growth.

The removal nf llie uterus nr it.i apjiendages is followed by a {icrmanent cewtit'
tion of menstruation, and the symptoms of the artificial menopause which result
arc treated iijHm the principles laid down on pajte 697.

(Jentrai. — Ameiitirrheit due to an eichiiusletl .state of the jij'slem <U'prndcnl
upon acute and chronic diseases is treated upon general medical principles, and
there are no .s|)ecial indtcationn to meet from a ^lelvic >tandj)oinI, as menstrua-
tion returns when the patient is rcistored to health.

The largest number of cases of amenorrhea are due to IkkI hyt^enic habits and
surroundings, and the (refitment is based ujKiri the correclion of the injurious
conditions and attention lo the patient's general licallh. Indolent and sedentary,'
habits must l»e lorrertcd and ihc p.it)cnt in.'^tniitcd tti exercise evcr>' day in Ihc
open air and sunshine. Women whose occupation or means will not permit
ihem lo take outdoor cxcreisc should walk lo and from their pbce of business
and employ indiHir exercises for a few minute> cirrj' night anti morning,

Young girls who overstudy and are confined too closely in the class-room
must t>e given shorter hours and less brain work, and if ne<-es»ry taken away
from school for an indefmile length of time.

The treatment of amenorrhea due to the alcoholic or drug habit is based upon
the correction of the abuse; meeting s]>e<'ial indicalioas as they arise, aivd at-
tention to gencnl hygiene.

Women who suiter from amenorrhea Ihe result i>f overwork, insuflicieni food,
bad general hygiene, and imjiurc air should be treated upon general medical
principles and a change made, if possible, in tbeir occupation. These patients
are also benefited by the admini.slralion of iron and tonics and careful attention
lo the regulation of the Ixiwels. The " Mixture of the Kour Chlorides" (Gnudell)
b often indicated, and may be given in the following lumbination ;

R. llTrfrargyri chloridi corrosivi rt. j

L4<|uan'.i ftncnki chloridi fit. ilftif

TincluTi (crri ( lilnriili.

Addi bydiTjchlorici diluli..............^... U fctio

Syrupi xintphcm ....q. *, m1 i\t]

M. SiK- — One dcMCiUpoonftil !n mm' nfici nuli mral.

Amenorrhea due to acute anemia is usually temporary and requires no special
gjTiccologic treatment.

The treatment of amenorrhea due to obesity is based upon general medical
principles, and includes diet, exercise, thcrmaHjalhs, dnigs.and general h)-gicnc.
The indications in each case must be carefully studied and a thorough eMmiia-

7l6 MENSTRUAL DISOKDERS.

tion made of all the organs of the body in order to determine the character of the
treatment. Local medication and the administration of emmenagogues are DM
indicated until the excess of fat has been reduced and the general h^th impiovcd.
The uterine cavity is then dilated and cureted and stimulating enunenagyKS

administered.

The treatment of suppression of the menses from exposure to cold after (be
flow has begun depends upon the absence or presence of local and constitutiaul
symptoms. In some cases they are entirely absent and no special treatmeU is
indicated, as the flow returns naturally on the following month, although it is
advisable, however, to keep the patient indoors for a few days as a piecautioDUT
measure. If symptoms accompany the suppression, the patient must be put at
once to bed ; mustard applied over the hypogastrium and lower extremities; lod
a saline purge administered, preferably a bottle of citrate of magnesia. Dit-
phoresis should be excited by broken doses of Dover's powder, and hot-wain
bags applied to the body, and if the pelvic pains are se\-cre full doses of opium an
given by the bowel. A hot sitz-bath sometimes gives great relief and may tc
employed in cases in which there is acute distress in the peK'is. If menstiuatioii
does not return on the following month, systemic and local treatment must be
instituted and every effort made to restore the menstrual flow. The patient
should be given a pill consisting of quinin, iron, and strychnin, and pennanganaie
of potassium should be administered (gr. ij, t. i, d.) for its eromenagogic effwt
The local treatment consists of warm water vaginal douches ni^t and moraing
and the introduction of a cotton-wool tampon saturated with glycerin and id^
thyol (25 per cent.) into the vagina twice a week.

If the amenorrhea stiil persists and there is no indication of a return rf 4e
menses, dilatation and curetment of the uterine cavity should be perfonned in
order to stimulate the uterus and increase the flow of blood to the pelric oipns.

-Amenorrhea dependent upon psychic causes is difficult to cure and often
tjixcH the resources of the attending physician. Sudden emotions, such as anpr,
fright, and joy. usually cause only a terap<)rar>' cessation of the menstrual func-
tion, and (he administration of se<latives is all that will be required to re-eslabMsh
the flow unles-s ronslilutional and local symptoms intervene, in which case ilw
IKiticnt should be treated upon the principles laid down in discussing IhemaIlag^
ment of acute suppression from exposure to cold.

The causes of such emotions as grief , fear, and anxiety are always more ot fas
permanent in character, and conwquently when amenorrhea results it pnsisij
until the mentLiI state is relieved. There is no special treatment indicated in llw*
cases and emmenafioRues and local medication do but little good. The caiw
must hv removed if |)ossil)le and the piittenl encouraged to take a more sensibk
view (if her troubles and look ujHin the bright side of life. The moral inflwnff
and ixTsonality of the physician are of great assistance in the treatment of lite*
c.^,•ie^, as m:iny of the patients are neurasthenic and require the "rest cure." i»i
(ilhcrs, af,':un, who arc le.ss profoundly affected may be treated upon ^nenl
medical principles. The most difficult patients to treat are women of educaliw
and refinement who have limited means anil cannot afford the necessaf>' c^"*
of a ihorouixh course of treatment.

-Amenorrhea clue to fear of ]ircgnancy following illicit intercourse, ^ft^y
cveHs. and mental depression occurring in prisoners and the insane is psyiiucin
origin ond requires no special form of treatment. Suppression of men=inuli«i
folluwin<; u change of residence is tem[)orar\\ as a rule, and should be ireafw w
stimulating emmenagogues and genera! tonics, .Amenorrhea following furpa'
operations is unimjiortant from the standpoint of treatment and requires im
."^peci^l altenticn.

VICARIODS UCNSTRUATION.

717

VICARIOUS MENSTRUATION.

Definition, — A periodic bleeding nccurring from any part of the bmly,
pxcfpi the uU-nis 3i ihc time of the norma! nwaitruiil flow is known at vicariout
mttMruiilion. U lite ectopic bleeiliiiK i> a>»uci3twJ with the uterine Row, it is then
>|>oken (it as sufplemenlary menftrtnition.

In vicarious mcnsuualion there h no bleeding from the uteru», and in the
^upi'Ieinentury variety the uterine flow,»n mlc, is scanty. In treses of vicarious
tncn^lruiition other diMrharges may take the place of the ecttmic blec<ling, and
there tnay be a monthly ^jecrctiun of colo»mmi, a profuv irukorrhca, or a
iJiarrhea.

Frequency.— Ectopic bleeding is a tare menstrual irrcRularity. and is most
often Rict in vaxa of unde\'eloped ^eniL-d organs, atresia, and pi^muture meno-

Situation. —The no§e is the most frequent site, although the bleedinji; may
occur fnwn any (wrt o( the body, and lake i)lace from the respiral(>r}- tract, the
noM. the brjnx, the bronchial tiil^cs, the luni^. the alimentary canal, the gums,
tbc buccal cavity, the stomach, the interlines, tlie rectum, and the anu%. Vicari-
ous bice^ling nuy also occur at the iiite of an old scur or wound; from & raw sur-
face or ulceration; and from the e<ir, the conjunctiva, the kidneys, and the
bladder. !n some cases a monthly secretion of cohtstruni or bleeding may take
place from the nipples; while in others the hemorrhngc is subcutaneous and
pelcchiid spol^ or ecchymo^e^ arc obsen-ed.

Symptoms.— The characteristic symptom »> the ectopic ble«<ling. The
pelvii niiihik-^lations of the mnlimen are present, and at the situation of the
vicarious brmorrhni^ the parls become painful, congested, and swollen. Women
who suffer from lliis form of menstrual irregularity, as a rule, are neurasthenic-

Progrnosis.— The seriousness of the symptom depends upon the situation of
ectopic bleeding and the general condition of the patient. Hcmorrhageit from
the rc^)iratoryoralimenur\' tract are serious, and Ihc prognosis must be guarded.
Again, the dangers of cerebral apoplexy must be taken into coniideration. and
cases arc on rtconl in which the Midden st«|iping of Ihc vicarioii.i bleeding has
been followeil by a hemorrhage of the brain.

I>ia|^OSiB<— The diagnosis is based on the periodicity of the ectopic
UeedinK; its coincidence with tlie pelvic molimcn; .ind ihe characteristic pain,
oOflfceMton. and swelling in Ihe tissues at the site of (he hemorrhage. A careful
differentiation must be made between an organic lesion and vicarious bleeding
where the hemorrhage comes from the re-s-|)irat<ir>" or alimrnlJiry tract.

Treatment.— As vicarious menstruation is closely associated with amen-
orrhea and the su|>plementary form with a scanty menstrual How, the treatment
b neceuarily direcied toward establishing the normal functions of the uterus and
bappcndages. llic hrst consider,:ition is the recognition of the causes and (heir
nbaequcnt removal, and a.^ lliese subjects haw been di.ii-ussed under amen-
onliea awl sc;inty men»tnuii"n, they need rnit, therefore, be regtealcd here. It
must be rcmemlwrcd. however, (hat the condition is most often met in cases of
undevelo] xxl genital organ.s, atirMa, and premature menopause, and that lltew
MMnen are. as a nile. more or loss neurasthenic. In esses of atresia the re-
moval of the obstruction is indicated, and in women with undneloped genital
ormna the <|u«Mion of the exiijpalion of the ovaries must lie considered if the
tmllLaltve treatment fails to effect a cure.

In a larRe proportion of cases of vicarinutc menstruation the condition of the
blood, the ner\-ous system, and the nutrition is below par, and careful alientmn

Jli UENSTXUAL DISORDERS.

inust therefore be given to the general treatment, which is discussed under uata-
orrheaon page 711.

The use of emmenagogues, especially those which are direct in tbdr adion,
is indicated, andnospecialloca! treatment is needed at the site of ectopic binding
unless it becomes excessive, in which case it should be controQed by proper
surgical and medical means.

DYSSIENORItHEA.

Definition. — Dysmenorrhea is painful menstruation. The majori^ of
women suSer more or less general and local discomfort at the time of the im-
strual period, but the symptoms are not marked, and in no way intnfcie witk
their habitual mode of life; in comparatively rare instances menstniitioa is
unattended with any subjective symptoms. ,

Causes. ^Dysmenorrhea may result from:

Neuralgia.

Diathesis.

Pelvic congestion and inflammation.

Malformed or undeveloped genital organs.

Obstruction.
Neuralgia. — In dysmenorrhea due to neuralgia the pelvis may or mif Dot
be the seat of disease, and in some cases no evidence of any pathologic leston cm
be discovered, while in others there may be some slight abnormal condition vludi
would not of itself cause pain at the menstrual period unless the puicol
was also neuralgic. Dysmenorrhea due to neuralgia is associated witb > <l^
praved state of the blood, nervous system, and genera] nutrition, and under thts
circumstances the nerves are over-sensitive and the congestion incident to mo-
struation causes pain. This foim of painful menstruation is met voy fI^
quently, and is due to constitutional diseases, habits, and environment. Amoog
the causative diseases may be mentioned hysteria, malaria, syphilis, chlonas,
anemia, plethora, and inherited neurosis. The habits of a patient are also olia
the cause of an exhausted slate of the system, and the affection may result frecii
high living, a sedentary mode of life, or mental and physical overwork. Odu-
ism, masturbation, and excessive sexual indulgence may result in neurasthenii,
and the menstrual irregularities met in young women are but too frequently iht
result of our false modem methods of education, which require long hounof
hard and exhausting study during the period of puberty. Painful menstruatiaii
is also due to bad hygienic surroundings, and obstinate constipation may result in
neuralgia from the absorption of fecal matter by the blood.

Diathesis. — Gout and rheumatism may produce pelvic disturbances »«1
cause painful menstruation.

Pelvic Congestion and Inflammation. — These conditions are frequently
the cause of dysmenorrhea, and women who are married and have borne chiWreii
are naturally more or less liable to this form of the aSection for the reason that »
large proportion of the causes of congestion and inflammation are directly due 10
sexual intercourse and child-bearing. The normal local congestion of mensnu
tion i.s unattended by pain, but when a pelvic lesion is present which interfew
with the circulation venous stasis results and dysmenorrhea follows as a natuni
sequence.

Among the causes producing congestion and inflammation of the pel**
organs arc, acute suppression of the menses from exposure to cold, overeKrtiW'
intestinal disorders, uterine tumors, polypi and displacements, subinrolutio'i-
chronic hj-perplastic endometritis, and varicocele and tumors of the broad \\P"
ments. Pelvic adhesions, chronic pelvic peritonitis, acute and chronic discs*

the tubes and ovaries, prolapse of the uterine appendages, tumors of the
ovary, and l(ir[>idity of the portal circulation oho cause ;>elvic coni^eHtion and
result in dysmenorrhea.

HaUofmed or Undeveloped Genital Organs.— Dj-Mnenorrhea caused by
congenitiil m:ilf<irm;iti(ins may be produced in t>o ways; Fir%t, by an ineRectual
molimen provoking uterine colic, and, second, by a stenosis or atresia of the
genital tract causing an obstruction to or a retention of the flow.

Obstruction. — In dysmenorrhea due to ac«{uire(l obslruditm the men^tnial
(unction is normal up to the point of the flow licginning to escape from the genital
canal, and at this stage the discharge meets with a stenosis or an atresia, either
in the ceri-ix, the vagina, or at the vulvovaginal orifice. If a stenosis h present,
diflicult and painful menstruation results: but if the obstruction is due to atresia,
the menstrual blood ^^ retained. In eases of stenosis the lenirwraiy retention
of the flow excites uterine ton tract ion.<, which liecome more ana more severe as
the blood continues to accumulate, and fin.illy by a violent effort the uterus forcea
the discharge and clots jiast the obstruction and the pain ceases until the over-
distention occurs again, when the snme phenomena arc repealed. In cases of
atresia there is a periodic increase in the amount of retained blood, and the moli-
men is attenrled with painfiU contractions due to uvenli3.tention of the vagina,
the uterus, and the tubes.

The chief causes of acquired obstruction of the genital canal are: flexions of
the uterus; small jM>lypi situated at or near the internal os; cervical stenosis and
atresia; chronic endometritis; vaginal stenosis and atresia; and ejifoliative
endometritis.

Uterine flexions are a common cau»e of dymncnnn'he.a ; the l>end in the
uterine canal forms an angle which obstructs the flow of blood, and the coexisting
endometritis causes a thickening of the murou? membrane which materially in-
creases the stenosis. Finally, the congestion incident to menstruation swells
the inflamed endometrium and still further increases the obstruction. .Anterior
flexions are a more freipient cause of dysmenorrhea than jJoMerior displacements,
and are more common in unmarried and stcrDc women than in those nho havt
borne children. Small polypi are >ometimes situated at or near the internal os
and act as a ball-valve in kequng bock the menstrual flow. Cer^•ical stenosis
and atresia may be caused by caustic applications, the u^ of the actual cautery,
inflammation of the mucous membrane, malignant di.sea.se, and an improper
lechnic in operations ufwn the cervix, and obstructions of the vagina may be
due to ulcerations following the traumatism of tabor or as a sequela of typhus
kvn, tul)erculi>sis, ili|ihtheria, and syphilis.

Exjolialivf atiloniftriih. while not a common affection, may occur at anjr
period of menstrual life, from puberty to the menopau.se. and is found to be more
frequent in unmarried and sterile women than in those who have given birth to
children. The uterine colic which occurs at the time of menstruation is caused
by the expulsion of a membrane (JBcmftmnom dysmeftorrhfo) which consists of the
hyjjertrophieil menstrual decidua, and isexpel!e<i .is a complete cast of the uterine
cavity or is thrown off in shreds. Membranous dysmenorrhea is inflammatorr
in origin and is laused by interstitial endometrites.

Symptoms. —Pain associated with the menstrual function is the character-
istic symptom of dysmenorrhea. The situation of the pain, its character, and its
relation with the appearance aru] duration of the flon- diflfer widely in many in-
stances and depend l.irgely upon the cause of the affection.

The situation of the pain is not con.stant and varies even in cases in which
the etiology of the dysmenorrhea is the same. Tt is most fretjuenlly hicated, how-
ever, in the hypognstrium, and may also be sititatcd in the pelvic cavity, behind

730 U£NSTSCAL DISORDERS.

the symphysis pubis, in the loins, and over the lumbosacral or inguinal re^n. la
severe attacks of dysmenorrhea the pain may radiate down the thighs, into iht
abdomen, thorax, or more remote parts of the body, and in exceptional cases the
breasts become painful and tender.

The character of the pain also varies, and is described as constant, inter-
mittent, remittent, &xed, shooting, expulsive, labor-like, sharp, dull, bcaiii^-
down, heavy, and dragging.

There is no constant relation existing between the pain and the appcatuxx or
duration of the flow, although in some cases such a relatioasfaip don exist ud
may indicate the origin of the dysmenorrhea.

In severe cases of dysmenorrhea the general health suffers, sod nenou
symptoms are likely to manifest themselves. Some patients became neuiastbenic,
while others, in rare instances, may develop hysteric epilepsy. An acute attack
of dysmenorrhea leaves the patient weak and exhausted and unable to attend
to her duties for several days. Nausea and vomiting are frequently assodited
with the attack and gastro-intestinal disturbances may continue after the ccsatioD
of the flow.

ITeuralgia. — The pain, as a rule, begins before the flow and ceases witii its
appearance. In some cases it may continue intermittently or remittently duiiig
the entire flow, and in others it may not cease for some time after the poicd. Tk
pain varies in severity, and in some cases it may be slight, while in otben the
agony becomes so acute that the patient becomes wildly hysteric or faints. Il ii
not fixed in one location, as a rule, and shoots from the pelvis down the thi^or
into the abdomen and thorax. The general health of the patient is bad, owing to
the constitutional cause of the dysmenorrhea and the exhaustion which follon
the monthly suffering.

Diathesis. — The attacks of dysmenorrhea are irregular and the patient nay
be entirely free from pain for several periods. As a rule, they occur simulttw-
ously with manifestations of gout or rheumatism in other parts of the body. The
pain usually begins a short time before the flow and continues renaittently through-
out the entire period, or it may gradual!)' cease as the flow is established. It^
situaled in (he pelvis and hypogastric region, and may be felt as a dull ache or it
may be sharp and agonizing.

Pelvic Congestion and Inflammation,— This form of dysmenorrhea being
due lo 3 local peh'ic disease, the pain is generally an exaggeration of that which L-
felt ciurinR the intermenstrual period, and is referred chiefly to the organs intolitd.
It is therefore situated moslly within the pelvis, in the back and the hypogastnc
and inguinal regions, and at time.s it may shoot down the thighs. The characttr
of the pain may be dull, heavy, bearing-down, or dragging, and it is seWoni ^
sharp and acule as in the neuralgic form of dysmenorrhea. The pain usually
precedes the flow and gradually ceases after it is fully estabhshed. Then
are many exceptions, however, to this rule, and the pain may have various f-
lations with the flow.

The local and constitutional symptoms of acute congestion from e.vposuie W
cold have been described under amenorrhea, where the>' properly belonp: i<^
whiie suppression of ihe menses from this cause is usually associated with iool
pain, the chief symptom is the suppression of the menses, which need not «
discussed here.

Malformed or Undeveloped Genital Organs.— The symptoms dej*^
upon the character of the congenital condition. If the organs are undeitlop'O'
the molimen is veri- painful and there is little or no discharge of blood. K
stenosis exists, men.struation is difficult and the pain is paroxysmal and e^ul^ve
in character. It the cause is due to atresia, the flow is permanently reoi"™

ItYKillCNOkRIIBA.

7>I

beyond the point of obstruction, and the pain which occurs along with the sub-
jeclive ^yn1|)tom^ of men«tru:ition is due to distention of the organt by the fresh
accumulation of mcnstnui blood.

ObstrucIion.^Thc symptoms of acquired obairuclion are the same as in the
congeniUil v.iricty, und th« pain begins before the flow makes its appearimce. Ii
is paroxysmal and expulsive in character and continues, as a rule, during the
entire period. The temporary damming-back of the menstrual blood excites
uterine contractions luleritK colic), which become more and more M>'ere as the
distention increases, and finally, by a violent effort, the uterus forces the discharge
and cl(>L^ beu)tiil the point of ob«tniction. The pain then c«3»es until the blood
begins In rcaccumubk- in the ulcrine cavity, when the obstructive paroxysms
bcf;in a^Ma and the :^me phenomena are repeated.

If the «l»tr»icti(>n is due to tx}oli'ili:'f rnJomflriirs, the violence ant! duration
of (he pain depend upon whether the membrane is expelled ,is a cast of the uterine
cavity or is tlirown off in slircds. The pain bevtins with menstruation and con-
tinues to grow more and more s<'verc. becoming labor- like or expulsive in character,
until finally the uterus empties itself and the membrane is expelled. Lhiring
this procetci the tervioil canal becomes dibted, and after tlie expulsion of tlie
membrane the pain ceases and does not recur unless a portion of the caM still
remains in the uterine cavity. The expulsion of the membrane is usually fol-
lou-ed for a few hours by excejsii'e bleeding, ami during the intermenstrual period
there is a purulent or sanguineo- purulent Icukorrhea.

If the dy^imenonhea is due to atresia, llie menstrual blood is permanently
retiiw! nntt the symptoms are the same aj in the rnnftenil;d form.

Diagnosis. — The diagnosis of dysmenorrhea is the recognition of the cause,
which is <letermined by a careful consideration of the local and general symptoms
and a thorough examination not only of the pelvic organs but of the entire sAstem.
Tlie character of the pain and iu. relation to the flon- are too uncertain and variable
lo be of much value from a diagnostic standpoint. .\n exception, however, to
this stalenkcnt is met in dysmenorrhea due to congenital or acquired stenosis,
and In this class of cases the expuUive and Uibor-like character of the pain is
almost pathognomonic.

Weuralgia.— The character of the pain and its relation to the appearance and
duration of the flow inu-it l>e carefully considere<l. The physical examination of
Ibe pelvis gives negative results, and the diagnosis is finally based upon the
tecoenition of a systemic cause for the neuralgia.

Diathesis.— Tlie diagnosis is biiscd ufion the symptomatology and the
presence of gout or rheumatism The pht-sical examination is negative.

Pelvic Congestion and laflammation.— The pain in this form of dysmen-
orrhea is [lecull-ir in that it is generally an exaggeration of the suffering ex|>er-
ienced during the intermenstrual (>criod and is referred chiefly lo the organs in-
volved. TIte character of the pain and its relation to the How have already been
iltscusMd. I'he diagnosis is based upon a physical examination and the recogni-
tion of a gross pelvic legion.

Malformed and Undeveloped Genital Organs.— The diagno»Ls depends
upon the symptomatology' and physical e.x.iminaiion. In cases of undeveloped
organs the painful and ineffectual molimcn is pathognomonic. Atre^a results in
the retention of the flow, whllr stenosis produces difhcult menstruation, char-
acterized bv expulsive and labor-tike pains followed by the discharge of blood and
dou

Obstructloti. —Atresia causes retention of the flow and stenosis produces
difBciUt and painful meT\struBtion. The diagnosis is based upon a physical
etaminaiion and tlie recognition of the character of the obstruction.

•}22 MENSTRUAL DISOEDESS.

In cases of dysmenorrhea due to exjoliative endomelriiis the disduiie of
a cast of the uterine cavity or shieds of menstrual deddua with the flow is
pathognomonic. The discharged membrane may be mistaken iix an euh
abortion, and a microscopic examination should be made to confitin the diag-
nosis.

FT0£^08is>— The prognosis depends upon the nature and duration of tht
cause and the general condition of the patient. There is always a cause fee
dysmenorrhea, although it may be obscure in some cases, and faHuic in tie
treatment frequently results from a hasty and careless diagnosis. It is
necessary, therefore, in every case to make a thorough study of the sv-mptoms
and a careful examination not only of the pelvis but of all the important otpia
of the body.

Neuralgia. — The prognosis, as a rule, is favorable. The nature of the cuat
and the abihty of the patient to carry out the treatment must always be cat-
sidered.

Diathesis. — This form of dysmenorrhea is dependent upon a gouty cr
rheumatic diathesis, and the prognosis defwnds upon the relief or cure of the
cause.

Pelvic Congestion and Inflammation. — The prognosis must be guarded ii
this form of dysmenorrhea, as the symptom of painful menstruation in the ml
majority of cases is of secondary importance from the standpoint of treatmcsL
The local lesion which causes the dysmenorrhea claims our attention and Ac
prognosis depends up>on its relief or cure. Many of these lesions require die
removal of the uterus or its appendages or both, and inddentally the dygna-
orrhea is relieved by the artificial menopause which follows the operation.

The prognosis is favorable in cases of acute congestion from exposure to cold,
overexertion, etc.; uterine tumors and f>o!ypi removable without mutiUtiDo:
uterine displacements and subinvolution; chronic hyperplastic endometiilis:
intestinal disorders and torpidity of the portal circulation due to benignant causes;
prolapse and unilateral disease of the uterine appendages, and also opo^
diseases of the broud ligaments.

Malformed or Undeveloped Genital Organs.— In cases of undevtfapKl
genital organs the prognosis is bad. and little or no good will result from treatoieot
Young girls who are late in reaching puberty owing to want of nerve force ind
defective nutrition arc usually benefited by treatment, and menstiuatkm is
eventuallv established. The prognosis in cases of stenosis or atresia of the
genital canal depends upon the nature and situation of the obstruction. An im-
perforate hymen is readily relieved by surgical means, and in cases in which the
vagina is absent and the uterus and ovaries are normal the prognosis is favoraWe
provided a permanent outlet can be made for the menstrual flow.

Obstruction. — The prognosis is generally favorable. Atresia of the cenicsl
canal or vagina is readily relieved bv an operation, and in cases of stenosis due to
flexions of the uterus, small polypi, chronic endometritis, etc., the operstin
results are good.

About So per cent, of the cases of dysmenorrhea due to acute antefiexioii «f
the uteru.s arc cured by dilatation and curetment of the uterus, and ao per tent
are more nr less benefited. ExjoUalhe eiulomttritis is an obstinate disease k
cure anti the prognosis must be guarded.

Treatment.— The successful treatment of the affection depends upon
the recognition and removal of the cause. The administration of alcohdl and
opium in the treatment of dysmenorrhea should be condemned as a mutiK
practice, as they are not curative and the patient may Ijecome addicted 1" ■'*''
use.

The ireatmcnl i!^ clasMfied as follows:
General treatment and hygiene.
Drugs.
Treatment of the cause.

General Treatment and Hygiene. — These subjects are roiuidcred under
the following hvudings: (i) Rut; (i) exercise; (3) diet; (4) care of the
IxiweU; (5) bathing: (6) clothing; (7) counter-irritation; (8) vaginal douches
and tAm]>ons; (9) change uf residence; (.10) mu.tsa^; 0 0 electricity; (i») iind
the "rest cure."

Rest .^Physical rest is important, and the patient should remain in her
room during the Havt or at least while the pain Irist^ Sexual interrourte .«h<>uld be
forbidden in cases of dysmenorrhea due to exhausted states of the sj-stcm or gross
pelvic lesions, and the husband and wife should occupy separate liciU.

Exercise .— Rxenisc in the o\Kn air and sunshine and the use of indoor
exercises are important factors in the treatment and should be insisted upon by
the attending physician in properly selecte<l ca!<cs. The nature of the >^tise of
the dysmenorrheii, however, must be considered, and jiaticnts who are suffering
from gross pelvic lesions or organic diseases of important organs should not b*
alkivred to take violent form.* of exerci.-ie.

Diet . — The diet should be carefully regulated and the sx-stcmic condi&iu
consiilered in selecting articles of food. The ki<lneys must l>e kept active and the
patient encouriiged to drink plenty nf pure vmivr in order to llu.-'h the system and
eliminate the waste products which arc factors in the causation of many cases of
dysmenorrhea.

Care of the Bowels . — ^The bowels must i)e caicfutly regulated in
order to correct the tendency to constipation and prevent the absorption of fccai
mattem by the blood. .As a rule, a Aimplc laxative, such ,-!.■< the lluid extract of
casoira sagrada. alone or combineletc the i>eUHc circulation
and lessen the congestion.

Bathing .—The sktn must be kept active b>' a daily ball) of the entire
body. The metho<i of bathing dqicnds upon the indications in each case.
Turkish or Russian baths are vct\' beneficial, especially in cases due to neuralgia
or the uric aciil diuthesi.s, and also in other fomis of dysmenorrhea on account of
the general relaxation of the system which follows ihcir use. Hot sitz-baths fre-
quently give a great amount of comfort to the patient, relieve the severity of the
juun, and are >perially tndicateil in cases of anile (*ongcstii>n, neuralgia, uric
acid diathesis, and ineffectual molimen due to imperfectly developed genital
organs. A full hot bath continued for fifteen to twenty minutes is often followed
by goo<l rcsulLi ami frerjuently les.sens Ibe acuteness of an attack or even aborts it.
Sea bathing is also curative in certain cases, und is cspcdally indicated when a
general tonic action is required.

Clothing .— Woi>1 should W worn next In the skin cxce[>t in hf>l weather,
to protect the body from sudden changes of temperature and equalize the pelvic
circulation. This precaution is an iinj»ortant part in the nunaji^ement of dysmen-
orrhea, and is esj>erial!y indicated in cases due to neuiulgia, uric acifl diathesi.s
inelTectual molimen. congestion and inflammation of the uterus, and lesions of
the uterine appendages. .A ilannel bandage should tie worn over tltc abdoroen
and the clothing should not constrict the waist and crowd the viscera down upon
the pelvic organs.

Counter irritation . — Tincture of iodin applied on the skin of the
abdomen directly over the position of the ovaries and to tnc vault of the vagiiu is

734 MENSTRUAL DISORDERS.

beneficial in the treatment of dysmenorrhea, and is especially indicated in the
neuralgic fonn of the affection. The applications should be made three timcsa
week to the vaginal vault and once a day on the skin of the abdomen. Dij cups
applied to the abdomen are also of benefit, and may be employed in casesdueto
neuralgia and pelvic congestion.

Vaginal Douches and Tampons . — Hot-water \-aginal doucha
are of the utmost importance in the treatment, and should be cmplo>-ed in asa
of dysmenorrhea due to neuralgia, diathesis, pelvic congestion, or inflanunatiDti
and stenosis of the genital tract due to uterine flexions. They are useful not onh
during the intermenstrual period, but also at the time of an attack, as the)- ksan
the severity of the pain and relieve the uterine spasm.

Vaginal tampons of cotton-wool saturated with a solution of glycerin and
ichthyol (a; per cent,) often ser\e a useful purpose in the treatment of dv-smen-
orrhea and are indicated in cases due to neuralgia and pelvic congettinn. A
tampon should be introduced into the vagina every night before going to bed and
removed on the following morning; its use should be discontinued during tht
menstrual flow.

Change of Residence . — A change of residence is often folkwd
by curative results, and is especially indicated in cases of dysmenoniiea dut lo
neuralgia, diathesis, and an ineffectual molimen in girls in whom the chan^
of puberty are delayed.

The climate must be carefully selected to meet the indications, and patients
who suffer from neuralgia or uric acid diathesis should be advised to live sovtb
during the winter and early spring months, as these seasons are particiilirfr
injurious under the circumstances in the northern sections of this countrj'. Tht
sea air seems to have a beneficial effect in some cases, and I have met a numberci
patients having severe and obstinate dysmenorrhea, without any apparent koloc
general cause to account for the symptoms, who never suffered the .■dightesi pain
during the menstrual jwriods while residing at the seashore or taking a sea w'agt

Massage .—Pelvic and gener.il massage arc of distinct advantage. lOil
should be employed in the treatment of certain cases of dysmenorrhea. GnKra!
ma.ssage has a wide range of u.sefulne.ss, and may be employed as a rouiiw
practice on account of its effect upon the heart, nutrition, and muscular si-sira-
Pelvic mas.-iage, however, has a more or less restricted application, and isconin-
indicated in cases due to inl^ammatory lesions of the uterine appendage; and
peritoneum. Good results follow its use in cases de)>endent upon ncuralgii.
uric acid diathesis, undeveloped organs, and chronic uterine congestion caused
by a ret rod ispla cement or subinvolution.

E 1 e c t r i c i I y. — Electricity is useful on account of its general Ionic *Ski
in the treatment of dysmenorrhea, and it mav !«? cmploved in the fomi irf thf
static, faradic. or galvanic current. The local application of the current L'io-
riicaled in oases due to neuralgia, diathesis, undeveloped genital organ.', and
chronic uterine congestion. One electrode should be placed over the liif*
gastrium and the other over the lumbosacral region or in the vagina: undfr
no circumstances should the current be applied A''
rectly In the uterine cavitv.

The Rest Cure .^This form of treatment has a limited application aw
!■- iii(iiciite<i in cases of dysmenorrhea associated with neurasthenia or nent
exhiiustinn.

Drugs. — The following remedies are recommended in the trcatmfni "f
dysmenorrhea :

.\ p iol .—Thi-i drug is administered in capsules and is given inda'*s"f'""''
three to five minims, three times a dav after eating, for one week befurr ■'"

DYSUENOBKUEA.

7>S

pcTuxI. and if nnxssan* during the tlow. It i» very rffectirc in thr ncunilgic tona
of ^ly^meno^■h<a, and good results halt followed it* use in cases of uieriiM- colk
dependent up'in ?^tencK>i». As a routine remedy it muy lie tried in iUl cases of
dysmcn irrhe-J and for the relief of pain during un acute iiltack.

Phenaietin .—This remedy is given in doses of from two to ten grains
three or four lirncs a il.-iy. The \>e»l results are obtained, however, by givti^; five
grains every half-hour and discontinuing its use after six doses are taken. The
remedy i.* u^ful in all forms of dysmenorrhea, and is cs{)Ctiall)- indicated when
the symptoms are Associiiled with neuralgia or uterine spiuMn.

A n t i p y r i n . — This preparation is given in doses of from two to ten
grains. The indicjtiun.i (or its use and the method u( udmini.itr.ition arc the
same as phenacctin. The depressing action of antipyrin u|Hin the heart nituuld
be borne in mind, and guarded against by the use of strychnin.

Pulsatilla .^This drug ii given in (he form of the tincture in doses of
five drops three times daily for one n-c«k before the flou-. It has a decideil seda-
tive action and h especially useful in cases of neuralgia.

The llromid:' . — The hromiil nf ammonium, fx>ta.t.'(ium, or sodium
i- administered in doses of from twenty to thirty grains, -three or four lime» a
ilay. Brornid uf ^txlium U preferable to the other siilt> and is less irritating to the
stomach. The hn)mid< are given for one week Wforr t)ie ))crioil and continued,
if necessary, during the flow. They lessen fjelvic congestion and arc sedative
and .'tnli^()a!imo(lic in their action. While useful in cases avioiialwl with con-
gestion and uterine n>lic, they are csp<K*inUy valuable in the neuralgic funny aixl
in dysmenorrhea due to ovarian irriution. The action of the bromids is in-
rrett.«ed by combining ihem with i-alerian, gelnemium, and atuifetida.

Tincture of Cannabis I nd ica .^Dose, "L x~xk.) This
remedy i-i efiicaciou-t in many forms of dy.-vnenorrhea to relieve tlie acute suffering,
and must be given freely in twenty-drop doses ciery three hours. «> .1,1 to gel
its full physiologic action. Cannabis indica Is analgesic arul antispasmodic in its
action, and tlierefore a goo<I routine remedy, e^^jiecially in lu.nes aaAOCtated with
uterine colic and neuralgia.

Camphor. -This drug is often effective in the treatment of dysmenorrhea
on account of iLt anti.s{>a.^mcx1il' :in<l annlyne action. It i.i not a.'i prompt in its
action, however, as $ome of the other remedies, and is. therefore, not employed,
as a rule, in severe cases. In the milder formn of neuralgic and obstructive dys-
menonbea its u.->e i* followed by good results, and it nuy be given in a two-grjun
pill cvfTy two. three, or four hours during the attack. Monobromated camphor
is probably preferable to camphor iuelf, and Ia given in four- to five-grain doses
every three or four hours while the pain b.<t.s.

Viburnum Prunifolium.or black haw, Piscidia Ery-
t b r i R a , or Jamaica dogwood, and Hydraxtis Canadensis, or
goldenseal, arc useful remedies in the treatment of dysmenorriica, and may be
given in a combinmion known as " Liquor Sedans" (Parke, Davis & Co.), which
is a very effective and agreeable |ire(Mration. Rvery f1ui<lotinre contains te grains
eitch of goldenseal and black haw and 30 grains of Jamaica dogwood ; the dose
is from one to two fluid drachms. These remedies arc niore or less slow in their
action, and are, therefore, of but litlle value if used only at the lime of an attack.
They should be given for two or three months during the intermenstrual periods
and continued when the flow ap|*ear>. They are especially beneficial in cases of
dysmenorrhea a.'uocialed with mennrrhagia nr neuralgia, and in the membranous
form excellent results have followed the administration of 10 drops each of the
fluid extract of black haw and golden.seal given twice a day, begin'ti^g eight or
K nine day^ before menstruation and continued during the flow.

736 UESSTRUAL DISORDERS.

A m y 1 Nitrite and Nitroglycerin . — These remedies art vahuble
in the treatment of an acute attack of neuralgic dysmenorrhea. The fon&er b
given by inhalations in doses of 3 to 5 minims, and the tatter is administend
hypodermically in a dose of -j^ of a grain.

Salicylate of Sodium (gr. X-3J) and Ammooiated Tinc-
ture of Guaiac(nt x-fsj) . — Either of these remedies is very t&adoas ia
the treatment of dysmenorrhea due to uric acid diathesis, and if given fw one
week before the menstrual period will frequently prevent an attack.

Alcohol; Opium; and Chloral Hydrate . — These dnigs
must be used with great caution in the treatment of dysmenorrhea on account of
the danger of the patient becoming addicted to their use. If opium is employed,
it should be administered either hypodermically or by the rectum.

General Anesthesia may at times be required in the treilmat
of an acute attack of dysmenorrhea when the pain is very severe or the patioU
becomes hysteric, and under these circumstances chloroform sboukl beiucdio
preference to ether.

Other Remedies . — Among other drugs used in dysmenorriui in
oxalate of cerium, gr. j-x; acetanilid, gr. v-xv; exalgin, gr. j-yj, or from sii
to twelve grains in twenty-four hours; cimicifuga in congestive dysmcniMTfaei;
fluid extract of coUinsonia, f^ss-j, for one week preceding and during the 8m:
aconite in the congestive form, and belladonna, stramonium, or hj'oscyuDiis ii
the spasmodic varieties.

Treatment of the Cause. — N e u r a I g i a . — The treatment of the neunlgic
form of dysmenorrhea is considered under the following headings:
Treatment of the s>'stemic condition causing the neura^ia.
General treatment and hygiene.
Drugs.
Removal of the ovaries.

Treatment oj the Systemic Condition Causing Ike Neuralgia. — The trratniaii
is based upon general medical principles and includes the cure of the systemic «id-
dition which is responsible for the depraved state of the blood, ne^^■ous systtn.
and nutrition, as well as the correction of injurious habits and a change of n-
vironment.

General Treatment and Hygiene. — Physical, mental, and sexual rest ire im-
portant in the management of this form of dysmenorrhea, and the patient sbcuH
be instructed to take a short nap every afternoon. Systematic exercise in tl"
open air and sunshine must be insisted upon, and a few minutes night and bkW'
ing devoted to the indoor exercises described on page 117. The bowels mustbt
kept regular and the diet selected to meet the indications in each case. The fiK
use of pure drinking-water is essential in the treatment in order to incroM to
activity of the kidneys and flush the system. The skin must be kept active ud'
daily bath given, the character of which should be selected according to U*
strength of the patient and the general indications. Turkish and Russian baihs'i*
x-ery beneficial, and good results are also obtained from hot sitz and full bath-'
Sea bathing is especially indicated in some cases and should be used in modenDon.

Wool should be worn next to the skin and the clothing should not consntC
the waist. An abdominal bandage made of flannel adds to the comfort of to
patient and protects the viscera from sudden changes of temperature.

Hot-water vaginal douches are beneficial as a routine method of treatmea'.^'"'
should he used not only during the intermenstrual period but also at thetioj
of an attack. Vaginal tampons of cotton-wool saturated with glyrerin »«
ichthyol (25 per cent.) or plain glycerin are useful in the treatment of tiik foU"*
dysmenorrhea, and should be employed during the intermenstrual periods.

DVHUKKOSRIIEA.

/»7

A change uf rciidence i.i oficn ol Iwnefii, ami piuti«nb( should live temporarily,
'tf possible, in a rlimatc lliiil is Miitn) In ihctr condiiiun. The winter ai>d early
vprinK months in the north are C!>pe>:ially unhealtbful fur iheu.- (KttienH, ^iml they
silnulil he fldvuttt) li> re:iMie in the wutli. |>rer<rrahly iil ont- nt the seaside resorts of
Ktnnda. Ihinng the littc spring und summer some patients do hetier lu the
mountains, and others, ajtain, arc (lecide<ll>' impro^-ed by living ;ii ihc ^civhorc
or Uiking 3 sea vnyjgc.

Electricity and massage arc indkated in the neuralgic form of dy:imenorThea,
anil in neuriu-liicnii- jiatieiiu it'xxt results are often ublained by :i " re*t cure."

I>n4gs-^.\]»ul is very 1-^01:11%^ in nrundgic dystncnorrhea and is given in
capsules of j to ; minims, three times daily alter meals fur one week liefore and
during t)i« iierirKJ. Fhcnacetin or atuipyriti in 5-gniin (loses every half-hour
until 30 grains arc taken is a good remedy lo employ at the lime of an attack,
and the admiiutration of tincture of Pulsatilla in 5-drop <lo»e.N thrve timet daily
for one week before the fit>w ustially gives gixxl results. The bromids, cspcdalty
the sodium salt, arc very beneiicial, and should be given three limei daily for one
vreA before the perifid, and if necessary cuntinueil iluriiig the How. 'I'he action
of Ihc bmniids I* imreasecl hy combining ihem wilh other drugs, and for ibis
purpose' valerian, gclsemium, or asafctida is often em|iloycd. Tinciure of eanns'
bis indica is etTe<:tive tn many casesi, and >hoiild Ik given in jodrop doses every
three hour> during the attiick. Camphor is only useful in mild cases, and may
be given in a i-grain pill every two. three, or four hours during the attack;
monubrumated camphor in 4- to 5-grain dunes is the most citicient preparation,
black h.iw, Jamaica dogn-ood. and goldenseal in a combination know-i] as " Liquor
Sedans" (Parke, DavisJt Co.) are very effective, and are es))ecialty indicated if
the dysmenorrhea U as.sociate(l with menorrhugia. I'his preparation must be
given continuously for two or three months, and administered in drachm dosc«
three times daily between meals, Amyl nitrite by inhalation in doses of 1 to 5
minims, or nitroglycerin iidminislcred hypodermic ally (Rf. jiz)- "*"t* ^"'^T
promptly and should be given during the attack. Alcohol, opium, and chloral
byclrale are dangerous remedies and are employed only as a last resort. General
anttthesU may be employed if the pain is very swcre or the jiatient becomes
hyateric, and under these drcumslances chlorufnrm is preferable to ether. If a
qiauxtodic condition of tlie uterine muscle is associated with the neuralgia, the
use of helliidonna, stramonium, or hyoscyannus, alone or in combination with
other remedies, is often followed by good rcsulu, and should be given at the
time of the attack.

Remffi^t of Ike Ovitria. — The operation of oophorectomy has been adv1»d
for the relief of pain in i-ases of obMinatc neuralgic dysmenorrhea after other
methods of trentraenl have failctl. The removal of the ovaries under these cir-
cumstances is a very serious (juesiion and should not be lightly considered or
thoughtlessly umlertakcn. The-« patients, as a rule, arc anemic and debilitateil,
and If the uterine ap|>en(L-iges are removed, the slumps are very likely lo become
irritable and increase the fullering instead of <liminishing it. .Again, the arlihcial
meno|uusc may pnxhite .1 profound impn-ssion upon the patient's mind and
re*»dt in serious pwchic and physical symptoms.

Diathesis .—The treatment of thi» form of dyHnenorrhea is considered
under the following heailing;<:

Treatment of the cause.
General treatment aiul hygiene.
Divg*.

TrtalmfM of the Couit. — The treatment of the uric acid dialliesis. manifnting

ilf in the form of gout or rheumatism, is necessarily baM>d upon general medical

728 MENSTRUAL DISORDERS.

principles, and need not therefore be considered here. It is important, hown-er,
in these cases to insist upon the patient drinking plenty of pure water in ordo to
flush the kidneys and carry off the waste products.

General Treatment and H ygiene.— Success in the management of these cues
depends more upon the general treatment and hygiene than upon the use erf drugs.
These subjects have been fully discussed in a general way on page 723 and wili
only be referred to again in calling attention to certain essential fact<»s in tbt
treatment.

The bowels must be carefully regulated and the tendency to constqiatioii
corrected by exercise and attention to the diet. The occasional use of a saline
purge is beneficial, and a bottle of citrate of magnesia taken just before ibe
appearance of menstruation may prevent an attack, or if administered after [be
flow begins, may lessen the acuteness of the pain. Turkish or Rusdan batk
are especially useful and may be taken two or three times a week. Hot-waltr
vaginal douches given twice daily during the intermenstrual period and at the
time of the attack give good results, and a change of residence during the trioter
and early spring months to a mild climate where outdoor exercise can be taken
is essential. Massage and electricity are very useful, and should be empkntd
for their tonic action and influence upon the pelvic circulation.

Drugs. — Salicylate of sodium (gr. x-sxx) or ammoniated tincture of piaiu:
("ix-fsj) given for one week before the menstrual period will often modifr the
.symptoms and prevent the occurrence of the paroxysm.

The following remedies are effective at the time of the attack: apiol, pboi-
acelin, antipyrin, tincture of cannabis indica, amyl nitrite, and nitroglycerin.

Alcohol, chloral hydrate, and opium are dangerous remedies and must be
cautiously employed on account of the liability of the patient becoming addicted
to their use. Morphin may be administered hypoderraically combined *ilb
atropin, or the extract of opium may be given with belladonna, stramwium, w
hyoscyamus bv the rectum in the form of a supposilorj'. A general anestbelit
is indicated in ca,';es of severe suffering, and under these circumstances chloro-
form is preferable to ether.

Pelvic C'ongestion and Inflammation . — The treatmenl
of dysmenorrhea due to these causes is considered under the following headinp:
Treatment of the cause.
Treatment of the attack independent of ihe cause.

Treatment oj Ihe Cause. — This form of dysmenorrhea is due to local lesioos,
and their Ircatmcnt is discussed in ihc chapters devoted to pelvic diseases. T!it
management of congestive dysmenorrhea therefore depends, first, upon a correct
diagnosis of the cause; and, second, upon our ability to remove it. In manyii
these cases the removal of the cause necessitates the extirpation of the uterus orte
appendages or both, and under these circumstances Ihe dysmenorrhea is rami
because menstruation ceu.ses. tJlher rases, however, are curable wilhoul ll**
necessity of a mutilating operation and causing an artificial meno|)ause.

TrealmenI oj Ihe .Allack Independent oj Ihe Cause. — The pain at the tinwi''
menstruLiiion is usnallv an exaggeration <if that which is felt during (he inl'f-
mcnstrual periixl, and the object of trealment is to lessen as much as possible ine
conf-cstioii caused by the local lesion. Sexual and physical rest must be insislfJ
upon and the bowels kept regular. The occasional use of salines mattriall?
lessens the pelvic congestion and relieves the local pain. The clothing mu-'l no'
constricl the abdomen and flannel should be worn next to Ihe skin. Hot-«aW
vagin.-il douches and cotlon-wool tampons saturated with a mixture of glyrtnn
and ichlhyol (25 per rent.) use<l during the intermenstrual period will lessientbf
local pain and relieve the paroxy.sm at the time of menstruation. Hoi-"'*'''

OVSUE-VORKIIKA.

7»9

irrigations nf the vngina at the time of the attack ate abo Indicated, and i^uld
1>c innpldycd when the pain i& scx'ctc.

The f(>lti>wii)t; remedies are eifeclive during the attack; Apiol, phenacetin,
:intipyriii, timiurc t>f liiniuhi^ indica, amyl niiriie, and nitn>gl)^-crin.

'Hic bfomids, r^pccially the Mxiium salt, arc indicated in the treatment, and
are u-»c<l during the in(emien»tru:il iierind with decided lienefit.

Then; is seldom any wccssiiy rtiiring the iKtvck lo ri-sorl In the use of alcnhol,
L-hloral, or opium, and ihe jNiJn U never severe cnoufjh to require the administra-
tiiin ui a iteiieral anesthetic.

Malformed and Undeveloped Genital Organs.— The
treatment of dysmenorrhea due lo congenital conditions is ba!>ed ujx>n the recog-
nition of the cauKe.

Slenofiis of (he vagina or ccn'ical canal is relieved b\' forcible dilatation or
divL-iion of the slriiture, and ca>e> of atresia due tu an imperronile hymen are
m-eicome by incising the membrane. Complete €>cclui>4ons require n careful
dis§ection in order to make the canal patulous and provide an outlet for the
meitMfual (liMharRe.

If the vaRin^i H absent, and the subjective j^ymptomsof menstruation occur
or sixrti of retention §how themselves, a permanent ojjcning must be made con-
ne<-ttnt; the vulva with the cervical catud, and the dimmed-up meR.'>.trual bloixl
allowed lo escape.

In ca.ses of imperfect development of the uterus or ovaries tittle or nothing can
be acccmptUheil by treatment except ulmi the organ.s arc late in maturing on
account of general debility and want of nene force. Under these conditions
dilatation and curelmcnl of the uterus .'.hould be jierformed in order to stimulate
the pelvic organs and imroii!* the flow of hlood to the parts. Coexisting con-
ailutionaldi.4casesmustl>e treated U|)nn medical principles, and careful attention
pven to general Irutment and hygiene, which includes rest, excTcine, diet, tare of
Ibe bowels, bathing, clothing, change of residence, massage, and the use of
elwiririty.

The <mp!oyment i*f drug« in the Ire.ilmcnt of dysmenorrhea due to atresia
is con tr.;iin<liL .tied, as the pain is tausnl by retention of the menstruul bl<Htd, and
cannot therefore be relieved until llu- obstruction is removed. In lhe->e casi-s,
howeviT, llie MufTering may lie mudilied and the aculencss of the p.iroxysm
l«:^4encd by the hypodermic ad mi nisi rat ion of morphin and atropin.

The foIk>witig rcmedie.s are useful in casr« of stenovis and painful molimen

<luc lo undeveloped genitit organs: I'henacctin. aniipyrin. the bromids during

the Intermenstrual period, timture of c:i[inubis indii^i. mmphcir, monobromated

enmphor, amyl nitrite, nilroKlycerin. bcllnlonna, stramonium, and hyoscj-iimuv

In rare instances alctjhol. opium, or gener.il anesthesia rnay be indicated.

The removal of ihc uterine apjiendages i» indicated if the ircjimeni fails lo
relieve the. ■•utiering ami the hv:iUh of ihe patient is being ile-lroycrJ,

Obstruction. The treatment of obstnictive dysmenorrhea is con-
xklcrcd under the following he-jding«:
Krmrtval of ihe cause.
Treatment of the attack.

Remov<il oj Ihr Catur. — In cases of anterior flexion Ihe treatment is surgical
«nd consists in diUtalion and curetment of the uterus (.see p. 955). The dilata-
tion must be done slowly, so that Ihe musi ular \\\wt< of (he coni* iirc thoroughly
«trel< hill and a laceration prevnitcl- The objVcI of the curetment is to remove
the inflamtfl and swollen eiulomeirium which increases (he stenoMS at the angle
<4 Region and forms (Mrt of the obstruction. Belon; com])lelinK the ojieraliun
the uterine rarity is parked lightly with a narrow strip of plain gauxc, which is

730 COCCYGODYNIA.

allowed to remain for forty-eight hours in order to keep up the dilatatkm and
prevent the flexion from recurring. The best time to perform the operatioii is
during the week following menstruation. In some cases the cure is not comjdtU
and a second dilatation and curetment may be required. If pr^nancy occurs, tbe
cure is permanent. The rehef of the symptoms does not occur imincdiaidj
after operation, and, as a rule, the menstrual pain does not disappear UDtii iIk
second or third period.

A stenosis caused by a small uterine polyp is cured by the removal of the
growth, and constrictions of the cervical canal and vagina are relieved by forcibit
dilatation or a cutting operation. If an obstruction in the vagina has hta
caused by a syphilitic ulceration, constitutional treatment must first be eniplo)td,
and later on the caliber of the canal restored by multiple incisions and divulsion.

Exfoliative endometritis or membranous dysmenorrhea is treated by dilatation
and curetment of the uterus.

Atresia of the cervix or vagina is treated by a cutting operation and divulsioD,

The technic of the various operations is fully described in their respectivt
chapters.

Treatment oj the AUatk. — In cases of atresia the use of drugs is contraiodicaiRl
except the administration of morphin combined with atropin to rdiCT"e IheaaiW
suffering of retention. In cases of stenosis the following remedies are empkn'cd
during the attack: Phenacetin, antipyrin, tincture of cannabis indica, amyl niHile,
nitroglycerin, stramonium, belladonna, and hyoscyamus. Opium, cfalont.
alcohol, or general anesthesia may be imperatively demanded in some cases,
Apiol, the bromids, black haw, goldenseal, and Jamaica dogwood are also used
during the intermenstrual periods, and continued if necessary while tbe flov
lasts.

In the membranous form of dysmenorrhea excellent results ha^-e foUowtd lix
administration of 30 drops each of the fluid extract of black haw and goldmsal,
given twice daily beginning eight days before menstruation and continued durinj
the flow.

The occasional use of salines lessens the pelvic congestion and decreases ti*
severity of the attacks.

CHAPTER XXXIV.

COCCYGODYNIA.

Definition. — A painful aifection of the coccyx and the surrounding siw-
tures, which is characterized by more or less intense pain upon motion or pnsaiit.

Causes. — The disease is rare in children and in nulliparous women.

The causes may be divided into: (i) the local and (z) the general.

The Local Causes. — The local causes, as a rule, are due to tniuiiialia»s>
and chief among these are the injuries occasioned by childbirth. As tht ft^
of a tedious, difficult, or instrumental labor the coccyx is dislocated orlraclif"
and the bone becomes fixed in an abnormal position, usually at a right ai^lt "J
the sacrum. Again, the muscles or the ligaments may be strained or torn aw
a severe and intractable form of the disease result. Sometimes osteitisornW""-'
develops and the bono becomes exquisitely tender and painful. An oH primiiW
in whom the coccygeal articulations are rigid and ankylosed is more liabkw*"
injury of the bone during labor than a younger woman in whom all the jo"""
are freely movable.

iynia may also be cauxrf by viiritius (orm» of e^ctcmal violence, such
as a kick or a blow or falling astride on a narrow objccl. and, finally, (he aSection
hA» lieen nn-asioned by muKh continuous horseback riding.

The General Causes. — While a coccygndynJa due lo general causes is
ip3raii\xly unctiminon. yet «c not infrcqucnlly meet liLsea in which no
ireciuble Wal lesion U |ireweiil, and where ihe .tflecli'm result" from theu-

B. tii.—Kotuu PonnoH a* m« CMCtx. PM. Sss.— DitkoutiiM or nu Comrx Foiwiaa.

, or neuralgia of the muacJes or lif^ments surroiinding the bone. These
patients, as a nile, have a rheumatic or gouty history, and the loail |i.-tin usually
follnWN e.YjKMUre to < iiUI or indiscretion in eating or drinking. In rare instances
pain in ihe coccyx is one of the sensorj' man ifeslat ions of neurasthenia.

83rtnptoms.^Paininlhcv^>cfyxan<l in the adjacent muscles and tendons b

the cardinal sym|itom of coccygodynia. It varies in severity from a dull heavy

ache lo an inlea-x? .tKimizinfc

pain which is relieved when the

patient is at rc*i and hccumes

acute again when shi- mukes any

form of muscular exertion. The

l>ain is caused by |>rcs.sure di-

rwrily on the coccyx or by the

cnntniction of the coci^gcal

mu^Ies. It oci:urs, therefore,

when the i^itient sits on n chair,

during defecation, coitus, or any

^ylden movement or jolt, and in

Hpie cnscs the bone is so lender

Tfial she is forced to sit ujjon one

Inillock. The [lain i^ often very

I acute, as ihe p.iticni sits down

! on or fich> uj' from a chair, and

she is frc'iucnlly unable lo rise

without help.

Diagnosis.— The dinRno-
ii» is biisni ujwin the recognition of the cause. If the physical examination re-
vnils no local lesion, we .-ihould search for one nf ihc genenl causes.

EiaminatJon.— The palient Is placed in the left laleral-prone position and
iSe indcx-finpcr of ihc right hand introduced into llie rcclum. The anterior and
Uleral surf;icirs •>( the iroccyx are then {Miljuiltil with the lip of the finger anil any
, slioormul change in its shApe, si/x. or sensitiveness noted.

The thumb is now i>laced externally over the coccyx and the bone grasped

PW. i>4

PAUttrnil an ntl ClHIVX Ottll III! IhpcX-

!>ht>«rfD)E ' itawtiii lUtlouEk* ol (ht hair-

73a

COCCYGODYNIA,

between it and the internal finger. The coccyx is then moved badwaid ind
forward to test its mobility and to ascertain the presence of tenderness as weD u
to elicit any evidence of a fracture or dislocation.

Necrosis of the coccyx is recognized by probing the sinus which bctnnedtd
with the diseased bone.

Dlflerentlal Diagnosis.— The affection must be distinguished htm
vaginismus, hemorrhoids, and anal fissure by a physical examination.

Prognosis.— The prognosis depends upon the cause. When the disease is
due to a local lesion, it can be quickly and permanently relieved by appropriaw
treatment; but when it results from general causes, the prognosis should be
guarded, as it is often difficult to remove the rheumatic or gouty tendency or lo
cure a well-marked case of neurasthenia.

Trea-tment. — The treatment of coccygodynia is based upon the cause, wi
it is therefore important to ascertain in every case whether the affection is due toi
local lesion or to general causes. The treatment of theforineris
always su rgica 1 , w h i!e t he latter is m a n aged accord-
ing to general medical principles. No form of treaUnMl

KlC. 6]S.— pAUiJTON Of THE CoCCVX WITH THE iHDEX-nNCtB IN THE ReCTCII *HD IBt TSClil Em»-

ALIV.

should be instituted until a thorough physical examination of the cocc>'x has bten
made, otherwise the symptoms may he attributed In a general cause when thejsi'
local in origin, f have removed the coccyx several times in neurasthenic vomra
in whom no examination had been made, as Ihc local symptoms were attrbulro
to the general condition <)f the system, and the treatment carried out accordingly
for several years without results. In all of these cases the coccyx had bwn
fractured during confinement and union had taken place with the bone m ^
distiirted position.

The treatment of the affectifm is classified as follows:
The surgical treatment of the local causes.
The medical treatment of the general causes.

The Surgical Treatment of the Local Causes.— Coccygectomy. w i«
removal of (he coccyx, is the operation indicated in the.se cases, and it sbouK w
resorted to without delay when the affection is due to a local lesion.

Technic of the Operation .—Preparalion o} Ihe Palient.~\^i^
of citrate of magnesia should be given the night before the operation, folk"™

TREATURNT.

733

rexl morning by an enema of soapsuds and warm water, and the bladder should
be cmi)lieil «|i<mtane(>u>ly ju>t jiriiir In the iiclminislri-ilion nl the aiie>lhctii'.
On the morning of the operation the putient should be given n full warm bath
and thorouRhly scrubbed with soap. After Kctiing out o( the bath Ihe vagina and
vulva should b« irrigatal witli ;t Mjlution iif corrosivr Miblimatc (i to aooo),
followed by Mcrile water, and the gluteal cleft, the perineum, the anal region,
and the huliiicks carefully sterilized as follows; Scrub Ihem with a gauze sponge
saturated in liquid soiip :ind water ;ind iheii douche with a solulitm of corrosi^-c
sublimate (i lo looo). which in turn is removed with sterile water. The parts are

then dried with a towel and a brge gauze
compress secureil with a T Ititmlage is
placed briween the buttocks and the legs
and thighs protected with canton flannel
stockings. Tlit hips and lower eitrcmitics
arc fin.-dlywnipjicd in n sterile sheet which
is secured on the right >ide by saletypins.

Position oj Ike P<itifnl.— \xi\ lateral-
prone iwtilion.

Finai Sterilization vj the P<trti.—.\UvT
the p.-ilient U ihomughly under the influence
of the aneMhctic she is placed in the proper
position, and the nurse then unfiUNlens the
Kifetrpins .tnd throws the sheet off Ircim
the hips and lower extremities. Thegauxe
compre.ss ^nd Tlninilage are nnw removed
and ihe oper.itor wrubs the gluteal cleft
with liquid soap and warm waler and
douches llte parl.-v with a solution nf corrcsivc sublimate (i lo lOOo), whicA
in turn U removed with sterile water. The parts are then dried aiul tuwelN
arc placed alxive, below, and at the >ides of the field of o|fcrittion and secured
with safety-pins.

\'umhfr oj Assistants. — An anesthetizer, one assistant, and a general nunc
are required.

OTesiinn^; Spnngn; Tmeets; c/c— Sec page Sjj.

tnilrHmfnls.—(i) A pair of straight blunl-poinied M-i««ur«: (a) scalpel: (3)
u pair of bone-holding forceps; {4) three short hemostatic forceps: (5) dressing

Fw. Oil-— Xmius um Svmx Uanmu

734

COCCYGODYNIA,

forceps; (6) two retractors; (7) needle-holder; (8) two full-curved Hagetkn
needles; (9) silkworm-gut— ao strands.

Operation. — First Step.— A free incision is made down to the coccyx and the
entire length of the bone exposed.

Second Step.— The tip of the coccyx is freed by severing its attachments with

Fio. 638.— FInl sup.

CoCCyCICTOHT.

FiQ. 6)0— SfCdad SMf.

the scalpel. It is then grasped by the bone-holding forcq)S and pulled fonrani
and the lateral structures which are thus put upon the stretch divided up to the
sacrococcygeal articulation.

Third Step.— The anterior attachments are severed with scissors and llw
sacrococcygeal articulation divided with the scalpel.

Fii;. nto —Third Step.

COCCVCECTOMir.

Fio. 641. — Third SUp.

It is alway.s best to disarticulate the joint and not to cut the coccyx away ^^
bom- forceps, as the end of the sacrum may be injured and necrosis result.

Fourth Step.— The wound is closed with deep interrupted silkwonn-P''
sutures and drained with m. few strands of the same suture material.

A full-curved Ilagcdorn needle should be used for introducing the sul""*-

TREATMEKT.

which are jjiiwe*! throunb ihc skin almut onc-quaricr nf an inch from the edge
of (he incision »nd anr ilieii t^anio] complelcly burled under the bottom of the
wound, emerging through the skin on the opposite side.

The iiilroduclion of the sutures is greatly facilitated by having the asisisLint
place his index linger in the rectum and pu»li U]> the bottom of the wound,
which is always very deep and di<hcult to
close unless it i." made ^hallow in thi.s way.

The strands of silkworm-gut which iire
u>ed (or drainage arc placed along the bot-
lom of the wouml and their free ends carried
out at the upper and lower nnglcs of the in-
cision.

I^PTH Step.— After tying the suture^ a
compress of gauze is placed over ihe ioci-
nion and held securely in position with a T-
bandagc.

Variations tn the Tcchnic.
—Some operators leave the wound open and
allow it to heal by granul.ilion. This h not

a good method, as the healing process is exceedingly slow and tmublemme,
owing to the gre:it depth of the wound and the fre<]tient <KCuneni'e of infcctJOD
taking place from the rectum. Others, again, close the wound without drain-
age. This is also, in my judj(ment. a bad methtxl, as the Iwtlom of the woimd
is ver\- likely to become infcctwl on account of its close proximity to the rectum
if a small acctunulation of scrum occurs in a pocket resulting from an imperfeci

Pio. iVjj.— C« Foonh SMp.

MHhod of iiiikpIuliilu Lhr KtUfT* in

fOTTifi fornplrit'ly unftrf iht t-jtiixD <A (be
vuuod.

Flc. a«t-~CnrvmsnaiiT— DcrsfAum nn Otmi or nu Woonu KCKm Ivtmiiidciib m Sptii>»~

Psurth Stap.
t)li«>uD • ikonllK tisiiam if ihr — miirl iwihnl up by ibt baiM Inih* tmun: duona tahootibt oiiwtl

approximation of its edges. Under these circumstences aJI the stitches must be
removed and the w*uunii packed with gause and allowed to heiil by gninubtion.
On the other hand, draining the wound for forty-eight hours remo%'cs this
danger and primary union usually results.

Aflcr-lrcatment . — Care oj the HVirKif. — TThc wuuiKJ should be

736

COCCVGODYNIA.

washed daih' with a solution of corrosive subHmate (i to looo) and a deaii com-
press and T-bandage applied. If any evidence of infiammation or suppmlion
occurs, the stitches should be removed at once and the wound packed with
gauze.

The silkwonn-gul drain should be removed in forty-eight hours if die dress-
ings are dry and there are no indications for keeping up the drainage. Id re-
moving the silkworm-gut care must be taken not to infect the bottom of the
wound. To prevent this, the strands at the upper angle of the incision are pulled
out about a quarter of an inch and then cut off close to the surface of the skis.
The lower strands are now grasped by the fingers and the entire drain pulled out
of the wound. The sutures are removed on the eighth day.

The Bladder. — For the first three or four days the bladder should be emptied
every eight hours with a catheter in order to keep the wound clean and premu
infection.

The Bowels. — For the same reasons the bowels should not be mov-ed UDtH dtc
fourth day.

Tin- 6*4. — SliowFi THE Points ov TMr.tiiv.urTr or thf. Five PosTEirOB Sacial Neivu.

The Diet. — During the first iwenty-four hours liquid diet (see p. 106) should
be given and then the patient should be placed upon convalescent diet (seep. imI-

Resllessnesi and Pain. — As a rule, there is no occasion for the use of dnip-
A hypodermic injection of morphin (gr. J) may be used during the first tirtBiy-
four hours if there is much pain, or restlessness and sleeplessness mat be
controlleil with bromid of sodium, sulphonal, or trional.

Cerirng Out oj Bed. — The patient should remain in bed for ten daj'S'
There is no necessity for her to remain in bed longer than this period.tito
if suppuration takes place and the wound is packed with gauze, as the diBS""?*
are readily held in position by strips of zinc oxid plaster.

Persislenrc oj the Local Pain. — Sometimes the pain in the coccygeal repon
persists with mure or less severity after the coccyx has been removed and dit
patient has reco\ered from the effects of the opieration. Under these cat^'
stances a complete cure can !>e effected by cauterizing the posterior sacral nen'"
as they emerge from the j>osterior sacral foramina (Fig. 644). To accomplisl ^"^
a narrow strip is burnt deeply over the skin with a Faquelln cautery or a brt "*

from ibc base of the coccyx on each side upward along the course of Uie sacral
foramina: the eschar i.t then treate<l a> an unlinary granulaiinK wound.

The Medical Treatment of the Gcoeral Causes.— The medical treatment
U divided iiUu:

The systemic Irealmenl.
The local treatment.

The Systemic Treatment . — This consists in tre.itins 'he rheu-
matic or gouty nindition or t}ie ncunulhcnia acconling lo general mcilical |>rin-
ciplcs.

The Local Treatment . — This form of treatment is not intended in
any way to lake the place of the systemic management of the disease, but is simply
employed as a means to controt or le&»en the coccygeal pain while the general
cause or causes are l>eing removed.

The following local remedies arc recommended: (i) Aquapuncture. (i) sup-
positories. (3) ointments. (4) electricity, (j) blisters, and (6) cauteiixalion.

Aquapuntturr. — This method consists in injecting sterile water unrler the skin
with a hypodermic needle over the seal of pain in the coccyx and the adjacent
parU. The local tension, which is followed by the absorption of the water, seems
to le&seii the acuteiic-ss of the [>ain by in some way modifying the hmd chemic
action.

Supposiioriet. — Sup|XMitorie* of belladonna (gr. J) or iodoform (gr. v-x)
have sjmetimes been used with go<Ki results.

Oinlmenls. — An ointment rubbed into the skin over the coccygeal region may
sometimes stop the (tain or lessen its severity and give the patient more or less
permanent relief. Vcratrine ointment (f. S. P.) is ver\' useful for this purpose
and should be reduced in alrcngth by adding an equal quantity of lanolin.
.As veralrine is very irritating to mucous membranes, care should be taken not to
smear any of the ointment over the anus, .'\conitc also acts benelicially in these
cases in the form of an ointment either alone or combined with belladonn^.

The following formula will be found very cfficadous:

B. Tinctura acxmiti f3M

UriKUrnii liellii(tann(e 3j

M. el fi- iingui-nium.

FAtctrUity. — The galvanic or faradic current may be applied directly over the
coccygeal region as an adjunct to other methods of local treatment : it has been
found of advantage in .some cascs.

Htisltrs.—.K tly blister is one of the Ijcst remedies we have at our commjind to
control the coccygeal pain, and it should always be employed when the milder
methocUfail to give relief. .\ blister half an inch wide should be placnl directly
over the posterior sacral foramina from the ba.se of the coccys on each side lo
above the first sacral foramen. In this position the blisters act directly on the
posterior siirriil ner\es as they emerge from the foramina (Fig. 644).

Caulrrizalum. — The actual cautcii' is by far the most certain remedy we
possess to control (lie coccygeal pain, and it should be tried when other methods
fail. In neurasthenic cases and in rheumatic or gouty
women I know of no local treatment that can compare
with cauterisation in its results; in my hand.t il ba.t
often i>crmancntly cured the pain and assisted mate-
rially in restoring the health of these patients.

The cautery should be applied directly over the jKWtcrior sacnd nen'e* as they
emerge from Ihe sacral foramina. To accomplish this, a narrow strip is tmrnl
dcepiv over the skin from the base of the coccyx on each side upward along the

738 TUBEHCULOSIS OF THE GENITAL OKCAN&.

course of the sacral foramina (Fig. 644). A Paquclin cautery or a hot iron with
a narrow point may be used to cauterize the skin, and the eschar b treitcd as
an ordinary granulating wound.

CHAPTER XXXV.
TUBERCULOSIS OF THE GENHAL ORGANS.

CaUBCS. — Tuberculosis of the female organs of generation is a cranpantiTdT
frequent disease which may occur either as a primary or as a secondary infcctkn.
While the lai^est number of cases are secondary to a tuberculous area in mok
other part of the body, yet we not infrequently meet a primary localizatioDaftiie
disease in the genital organs.

Secosduy involvement of the genital tract may take place as foUom:'

(A) By direct extension from adjacent structures.

(B) From remote organs through the blood and lymphatic vcs«k

(D) From tuberculous excretions and discharges carried to thegminl
organs by the hands of the patient herself.

(A) Direct extension of the disease may occur from areas of inffctin in
adjacent structures. Thus, the ovaries, the tubes, or the uterus may iwone
secondarily involved in tuberculous peritonitis, which is a very common ongii tS
genital tuberculosis. Again, adhesions may occur between a tuberculotB in-
testine and the pelvic organs, and later when ulceration takes place the badlligui
access at the point of contact. And, finally, extension of the disease from ibt
urinar}' lo the genital organs has also been observed in a number of cases.

(B) It is probable that the blood and lymphatic vessels may be the chinixk
through which ihe bacilli sometimes fin<! their way from distant areas of infotioii
to the pelvic structures. That this is possible is shown by the fact thai bbhv
women who die of pulmonary phthisis have also genital tuberculosis without iny
evidence, upon p<)Stmortem examination, of the contents of the abdomen bfiof!
involved.

(C) According to Williams, the " tubercle bacilli from the surf ace of inMstiml
ulcers or from oilier tuberculous abdominal organs may find their way into IK
peritoneal cavity, and fall to its lowest part, the pelvic cavity, without gi^Tngra*
to tuberculous peritonitis; and from there they may be wafted into thetub«
by (he currents produced by the action of their cilia, and, if they meet with suitiUt
conditions, may lead to their infection."

(D) Women who have pulmonary phthisis or tuberculosis of the inteiiw*
and urinarv apparatus may infect the genital organs with their hands ii ""T
become soiled by Ihc expectoration from the lungs or by the discharges (roni ihf
rectum and bladder.

Primary tuberculosis of the genital organs mav result from causes eflWl
to the patient's body. Thus, the bacilli may be conveyed to the organs of gW^'
tion of a perfectly healthy woman during i^exual intercourse with a man who "^
tuberculosis of the nenito-urinarv or intestinal tract. In the same way inooio-
lion may occur from the use of infected instruments and from douching ifi' ''^P?^
with a .wrinpe belonging to a tuberculou.s woman. The disease may li^}"
transmitted from onf patient to another bv the examining finger of thealtrw'^
physician if he is careless In his methtxls of personal sterilization. .And, ata^-

t contact of inCcclcd clothing with the %^li'3 may r««ult in ilirect inoculation of
ibf }>4irL^.

Tuberc\ilosis nf ihc gfiiiial DrRUTix may ociur iJurinK any \>ctUMl of life, and
rjM^ hsxve bccii obscrvwi in vrry joung infiints anil in very old women; the
largest mimber oi infections, however, arc mci between twenty and forty years of

trubcnulonts (iitva not attack all [jortinns of the genital tract with equal
iienqi'. for the leason. |>robably, thai some of the orKanii are more exposed
than nlhcrs, and we therefore find fnim cx[)ericncc tliat the uviiluits arc infwted
in the litritesl number uf ca^^. The uterus i» next in^xilvcd in order of fre-
quency, and then the iiv.irieA, the vagina, and the cer\'ix. and, fmally, (he vuU'a,
firh i>, liiiMistr. vcn' rarely the sent of tuliercul«u> iniHulation.
Prognosis.— Til l»criulo9ia of the genilid organs is alwaj-s a pave affection,
the lesion is primarv, the dan)|;er of other urgann be^uiniiig iTifected is lon-
ilantly |ir«-Nent; and if it is secondan,', the {i.-ilirnl'v life is slitl further jeopiinti/.ed
l»y the exlcn>ii>n of the disease.

A complete recover)* often result* (mm extirpation of a luciilized area of in-
fection, and although spontaneous cures are extremely uncommon, yet they bat-e
been known lo ixcur in tulienulo.sLt of the genitalia. The .v-ra>'s have a de-
cidedly curative cfiTcct upon the disease when it i\ limited to the vulva or vagina.
When llie afTe4:tion occurs during the puerperal state, it runs a rapid course anrl
Usuidly enils fiitidly in u short time.

tTHE VULVA.
Synonyms. -Lupus i-ulgaris; Tubercular vulvitis.

SymptOtna. — On the skin portion* tif the vulva the "disease commence*
JKJlh the appearance of many small discrete or grouped, reddish, brownish, or
^■k>wi»h-red spots, from the siiie of a pin's hend to that of a )>eu or a liean, ilceply
HKleil in the tnie skin. These well-dclined spots, siluatcil Ijcneath the epider-
mis, through which their color i.* observable, give to the skin a punctated ap-
|>earance. Iji the early sM^ of the di*ea>e lliey are nut hen.iil>le to the touch,
which merely causes them lo a£sume a lighter color. In the course of some
months they Juwly increa^ in si«. anil gradually approach llic surface of the
sitln, until linally thc>* beiome evident as papules and tulierrle.s, in ap|tear-
ancc and by palpation, Tliey usuallv present themselves in large numbers
•ful of sizes within the ranfte already indicated. Their color is brow ni.-ih- red,
^Blh iiurfjite*, either nuigh or smooth, sometimes more or less covered with shiny,
Vnltisli epidermis. The pafwles and lulwriles may lie either .soft or firm to the
touch anil are iM>t (uinful. The le>i»ns may, nt this stage, remain discrete, or
utiite and form llat or prominent infiltrations of greater or lesser extent, usually
of a circuUr or ser[»entine form. Having reached this stage of development, the
leiion.x. sooner or later, uivlergo either absorption, leaving behind a dr^qunmitting
ami more or less atrophied ^kin. or cl.su di.sintegration and ulceration o( the in-
toraieil skin <KCur. The lupoid ulcerations, which .ire painless m.iy be xuper-
lifinl or deep, and in appearance arc usually flat, rounded or irregular, with
h, soft, but well definetl marnin.t. Tlaerc may be a moilcrate purulent
' !i<Fn. witli crusting, .ttid lirhen the base of an ulcer iscx{>oscd it is red, smooth,
■n lovered with gmnuialions and easily bleeds. During the course of the ulcera-
'ion, or as healing Irtftiiui, jMipillary outgn>wth$ may ocnir. followed by more or
Ws warty, cicatricial tissoie. • • • • • The affection, however. fi«-
luentty prrwnls at the same lime several kinds of IcsionWihat is to say, the
Wrne region may present various pha.ses of evolution and ins'olution ot the

740 TUBERCULOSIS OF THE GENITAL ORGANS.

malady. The disease, under such circumstances, presents a most striking ud
characteristic appearance, there being often, at one point, the small pHmaiy spots,
at another papules and tubercles unchanged or else undergoing the process of
absorption or ulceration, with here and there scales, crusts, exuberant granuU-
tions, cicatricially atrophied spots, commingled with areas of una&ccted skin."
(John V. Shoemaker.)

On the mucous membrane portions of the vulva lupus " is not very appuent
in the early stage of the disease, as there is no evidence of its presence in tht
peculiar eruptive spots, as in the case of the skin. The mucous membrane first
attracts attention through the fact of its being reddened with spots about the sk
of a pin's head, somewhat prominent, and closely packed together. The spM
may be &rm to the touch, excoriated, easily bleeding, and appear at difftnnt
points, of a silvery-gray color. Later the patch may become more inegukr mi
the color more gray or opaque. The thickened epithelium desquamating, then
is left an inflamed superficial or else a deep-fissured or an ulcerated surficc.
Gradually these conditions disappear, and there remain simply scars that nu;
have a shining and silvery-gray appearance. On the other hand, the pilcli
may be depressed, from being bound down to the underlying tissue, or seconduT
inflammatory infiltration may develop, leading to suppuration, abscesses, ud
ulceration of the part, attend«J with cicatrization. The destructive acti<xiaitiK
disease, therefore, occasions unsightly scars and considerable defonnlty." 0<ihi
V. Shoemaker.)

In some cases the ulcerative processes in this disease are very destractiTe, ud
fistulous openings are formed into the rectum and vagina or even into the ui«lin.
The subsequent cicatrization which takes place in these ulcerated areas aD»
more or less contraction of the tissues and the development later on of aoDOTii^
strictures.

The disease develops slowly and is exceedingly chronic in its course. TT*
general health, as a rule, is not affected even in cases where the trouble l»s
existed for a long time.

I>ia.gnoSl8. — The diagnosis is made as follows:
The history.
The symploms.
The microscopic examination.
Animal inoculations.

The History.— The chronic course of the disease and the fact tint 'i*
general health of the individual is good notwithstanding the long and persiSeot
presence of the lesions are strongly in favor of the condition being hjpus-
The history shows a very slow development of the malady and but littlt. "
any, pain is complained of by the patient.

The Symptoms. — The character and grouping of the lesions are very agm^
cant. Thus, we may observe " at one point, the small primary spots, at aW*lw
papules and tubercles unchanged, or else undergoing the process of ahsorpliM*
ulceration, with here and there scales, crusts, exuberant granulations, dotii-
cially atrophied spots, commingled with areas of unaffected skin." Witbthb
group of lesions there should be but lillle difficulty in making the diagnosis,
especially when the vulva is deformed and contorted by unsightly cicatrices. Tl*
disease is not usually as.sociated with tuberculous infection of other gW"
organs.

The Microscopic Examination. — A positive diagnosis can only bemuc
by means of the microscope,

T e c h n i c .—No preparator\' treatment is necessary. The patient is PJJ
under the influence of an anesthetic and placed in the dorsal position. 1"

vulva is now genttr washed with warm water and K>a|i and a dtniche of hot
normiil sail ioluliun is givtii (n <.'tc;m»c the parts.

'VUc suspwlwl area is Ihcn sci/xd with tissue forceps and a 5ru1I ])i«cc cxci.ted
with a scal[wl or scissont. The spedraen is at uncv placed in a lo percent.

titiun of (urnulin uiid H-nt to a pathologist for examination.
The raw surfaces arc broUf;hl together wJtll one or two «it|^t sutures and the
itid dreswd with iodoform gfi\ux.

Animal InocuUtions.—'I'hc secretions should be collected (see p. 45) and
sent to a pathulo^isi, who should examine then) for the presence of tubenle
bacilli anri make minimal iniN'ulationii.

Differential IHagmosls.— The disease must be dislinKui^thed from

tihili.s and Lariiiioma of ihe vulva.
In ^yphiIi^ the injiuin.^l gland's ;ifc involvrd. there is a single urea of ulceration,
i six-cific irealmenl gives positive results. In lulieix uIoms, on tlie otticr hand,
the inguinal glands are .seldom involved, the ulceration is multiple, and the
ills of spccitic treatment are negative.

null I

Carcimoiu.
Not an (low.
Sln^r Dodulc.
Unially Amp.
EvciIhI and undetinlned.
M«rl[cl iiifiltrnlHin.
SurfacT lungiiid in ap[iranuice.

Nil lorinalion of ciuuricn.
CachiM:!.!.

TvKanrOLoaa.

Very »!■>« in drwlopmcnt.

Sevcml ncHlulr*.

Uke'itiiin Bupt-iticiiil.

Matgini ul ulcct nni evened.

Maripni of ulcci tllRhtlr InAltnlrd.

Suifncr covcrril tntli Iirighl nd granula-
^K \iiiaa.

^Bfecleacy to rriMiit rndiHK with dcjil(i««.
^Krly oiSni* Renml health.

^■Prognosia.— The course of the disease is vct>' chronic, often cKlendin((
nver a jteritHl of many years without afTectin)i; the prtlient'i^ hc-tlth; in Mime cases,'
however, it ends faLiUy from assoiiated pulmun:ir>' phthisic.

The lesions arc ilifiicult to cure and yield very slowly lo trealmml. Relapses
are common and often or<'ur after the ajiparent re-slonitiun ni the tiyvues to ■
oomud condition. The disease is apt to cause unsightly deforntitics from cica-
t coiilrAi lion.t.
Treatment.— Tlie iimlmcnt is divtdefl into: (i) iHc operative; (a) the
(() the piTicnl: snd (4) the use of the .v-rays.

Operative Treatment.— The operative mellioda are: (a) Total exd-
(6) curetment; and (f) rauterizjiion.
Total B.^cision .—The looseness of die vidvar sInicttiTes permits an
«tten>ive removal of the tissues without MuKtetiuent ten»ion ujwn llie »uturei
when the wound is closed, and hence (here need be no hcsit.-incy in making Ihe
incision Urge enough to complelely eradicate the diseased area,

Whenever (he di.sense is limited to the vulva, the radical o|ieration of exeinoD
is absolutely indicated, fn cases where the lesion only involves a small area it
■boukl Iw exri.icd, alonjt with enoujih nf the surroundinj; healthy tissue to insure
tomptete enidicalion of the disesisc, am\ the wound closed with ca(gu( *utiire* and
dressed with a t;auKe compress. Should the vulva, however, be eictensively in-
:ted, )( -'-hould \x entirely removed. The tecbnic of Excliuon of the \'ulva

rilicl on page 963.
C u r e t m e n I .— ttTien the disease not only in^-olves the vulva, but also
*lcin nf the NurroundinK partK. the «j>eration of curetment iihould be performed,
re|iealeit as often as the lesions reappear.

The infected s^Mts should be thortnichly scTU[ied with a sharp niret utd
icbed with a solution of comisive »d>limate (t lo Moo) and drcased with

742 TUBERCULOSIS OF THE GENITAL ORGANS.

UKloform gauze held in position with a T-bandage. The vulva should bedouched
with a solution of corrosive sublimate and fresh dressings applied once a day.

Cauterization . — This operation has the same indications and Lmi-
tations as curetment. It consists in the application of the actual cautetv or
nitric acid to the infected spots,, which is followed by a douche of roirosivc
sublimate (i to 2000) and a dressing of iodoform gauze held in position by a T
bandage. Sometimes it may be advisable to scrape the diseased surfaces viA
a sharp curet before using the cautery, in order to remove the surface of the lesions.

The Local Treatment. — The local remedies which seem to have a cuiatit'c
effect upon the lesions of lupus are iodoform, tincture of lodin, and lactic acid.
If iodoform is employed, the vulva should be dusted with the powder t«o or thrtt
times daily and a lint compress worn ; or tincture of iodin or lactic acid may be
painted over the diseased areas twice a week.

The General Treatment. — This is conducted upon the same general medi-
cal principles as the treatment of tuberculosis in other parts of the body.

The Use of the a:-rays. — The ar-rays should always be employed, eitbtr
alone or in connection with operative or local medicinal measures, in eitn
case of tuberculosis of the vulva.

This subject is considered on page 76.

THE VAGINA-

Frequency. — Tuberculosis of the vagina is a comparatirely rare Useut
on account of the resistance that the vaginal epithelium offers to the bvasionrf
pathogenic germs. When, however, the mucous membrane becomes ^rsfWc*
eroded as the result of injury or of maceration from retained secretions, thtsf
organisms find little or no dilhculty in attacking the vagina and causinf!
inoculation.

Methods of Infection.— The disease is usually secondary to tubercu-
Ifisis of (he uterus or oviducts, and is due to the inoculation of the vapna by lit
infected secretions from (liese organs. In .some cases, however, tubemilir
ab.-^esses occurring in the rectum, the intestines, or the bladder may rupture inli'
the viigina and cause infection. The disease has also been obsened as a sKon-
<hirv ni:inLfi';.lation of lulierculor^is in cases of jiulmonary phthisis. And, fimllv.
while primary involvement of the vagina is very rare, cases have occasionally
been met where it wa.s impossible to discover any other area of infection in ihc
body.

Symptoms.— The lesions are usually situated in the po.Merior wall of the
vagina, and involve, as a rule, only the upper third of the canal and iheculdeai
behind the cervix. This is the mo.sl dependent portion of the vagina. aiKJ lift*
the infected tubal and uterine sccrclions collect there, macerate the epithelium,
and cau.se indrulation. In cases of |)rimary tuberculosis, if the tubenli' 1«-
rilli are introduced from outside sources, the lower third of the vagina and tl"'
vulvovaginal orifice arc involved, while the upper jiortion of the i-ana I general!}
remains free from infection.

The <liscase first appears in the form of miliary tubercles, which evenlualh
become converted into velloivish-grav masses of cheesv matter that break ao»j
and dcvcio]) into ulcers. The ulcers ;tre irregular in shape and shalloi', i""
iheir margins are clearly defined. The floor of each ulcer is covered with pariu^
lations, which are more or less hidden from view by a layer of cheesy mailer,*™
surrounding the ulcerated s])ot is a hyperemic area that is studded wilfi ""''^
tubercles.

In some cases the ulceration mav become extensive and involve the d*^'"'

me nERcs,

745

Whrn the di«casr iKginf upon tbr r.-tgina) a$pecl o( the rervis the nature oC
the lemons m^y be dctcnnincd by a speculun) eiuuninalion.

The Microscopic ExamiiutioQ. — A jiositive <]u^tmis)s depends ti]>on a
mKitfficopk examtruition of ihc uterine discharges and jin excised pie<cc of the
cenix (see pp. 3S. 41, and 45)-

Animal Inoculations.^Some of the )«crcl)on» shotitd he u'wd by the
pathologist lo m;ikr anin1.1l inocubtions in order to confirm the dtagnotds.

INnerential Diagnosis.— The dL>ease n)u>t be di>iii)gul$heil (rom
cancer of the »-cr\ix. The >imiUrity in the apiKanince of the lesion* in the tvfo
affections is sometimes so marked that it is necessary to base the diaj^ctsis
entirely ufKin the micn»»-oj>ic findinc&.

Treatment.— If the di(«.-u« is prinury and limited lo the cervix, aa
amputation should be performed (for tcchnic. see p. 459). But where it abo
involve* the body of ttie uteru^ a complete hysterrcloniy with the rcmnvnl iif the
lubes and ovaries is. indicated.

Id cases which are secondary to an infeiteii focu» in a renmic iirxan. or wliere
the lix'al di.iease in mi exten.iive thai ei;liq>;Lli(>n is nut of (he ijur^ion, ihe treat'
roenl should cimwjm t.f curetment. cauterization, local medicinal measures, and
the u^ 01 the A-rays as recommended in tuberculosis of ihc vagina and vulva.

THE UTERUS.

Description. — The di.Kea.se may occur either as a primary or stfondary
condition. The former is very rare, and is caused by direct infection from out-
side sources. Secondary' lubcrculows of the uterus, however, is not an infreqtwnl
disease, and is most oflcn met in connection wnth luljetrular infection of the ovi-
ducts. It is also found in women sufFerinu with pulm<)nar>' phthiMS, and it may
occasionally occur as a manifest:) tion of general liiberriilosis. I'hc <iiveAw is
usunlly Mmitetl to the body of the utems and shows no tendency lo c.ttend be>'ond
the internal os uteri. The mul•ou^ membrane alone is infected tn the beginning
oJ the di.sCiue. ami it is not until the later stage.'' of the affection that the muscular
font of the uterus becomes involved.

Varieties. —Tuberculosis of the body of the uterus occurs in three forma
a& follows:

Miliary luberculosis.
Chronic difiu^e tuberculosis.
Chronic fd)n>i(l tuberculosis

Miliary Tuberculosis.- This form of the disease h seldom met except at
fcutopNie.*; it i^ uMialty a^>s(>('i:ileil with genend miliary tiibemilosit, and is 3,\so,
in all probability, the prim.ir>' lesion in the other varieties of Ihe affccliim. The
tubercles which are deposited in the mucous membrane esentuatly undergo
caj«0U9^ degeneration, break driwn, and form irregularly .ihapnl ulcers which arc
similar to those observed in tuberculosis of the cerii.v and the vagina.

Chronic Diffuse Tuberculosis.— This, is the most common f<«m of the
di-'icase. and i.s gener.iUy known a^ caseous endometritis. The affection begins
in the form of miliary tubercles deposited in Ihc endometrium, which filially
break down into irref^arly shaped ulcers covered with ca-ieoui material.
SiKmer or later the entire mucous lining becomes invoIvTd and the uterine
cavity is (ilied with cheesy matter. The disease docs not c.Ttend iritii the cer-
vic-il canal, but in someeaaes the iniem.1l us hecomes vUrxA and the cnndilion
known as pyoinetra results. In time the musndar coat of the uterus becomes
affected and the orf;an increases in size. .\s the disease processes the uterine
walls be(x>me degenerated and softened and a rupture is likely lo occur.

744 TUBERCULOSIS OF THE GENITAL OSGANS.

Treatment. — The treatment is divided into: (i) The operative; {»)the
local; (3) the general; and (4) the use of the Jr-rays.

liie Operative Treatment. — The operative methods are: (a) Total a-
cision; (£) curetment; and (c) cauterization.

Total Excision . — This method of treatment is only indicated in asa
of primary infection of the vagina where no other oi^ns are affected. Vihat
the uterus, the oviducts, or other organs are involved, no radical plan of treatmest
should be instituted.

In suitable cases the diseased area should be excised, the vround dosed nth
catgut sutures, and the vagina packed with iodoform gauze. The posl-opentive
treatment is the same as in other plastic operations upon the vagina.

Curetment . — This procedure is indicated in cases of secondary tubcrni-
losis of the vagina.

The diseased area is thoroughly cureted with a sharp curet and the n^
douched with a solution of corrosive sublimate (i to aooo) and dried. A (ampGn
of iodoform gauze is then introduced and reapplied daily, using at the same ttnie
the vaginal douche of corrosive sublimate to sterilize the parts.

Cauterization . — See cauterization in the treatment of tuhemilosb d
the vulva on page 742,

The Local Treatment. — See tuberculosis of the vulva (p. 742).

The General Treatment. — This is based upon general medical priodpla.

The Use of the x-rays.— See tuberculosis of the vulva (p. 74a).

THE CERVIX.

Frequency. — The affection is a very rare one and is usually associated «iA
tuberculosis of the vagina. In exceptional cases the body of the uterus miTbe
involved, but, as a rule, the disease is limited to the cer^'ix and does not extend
beyond the internal os. Cases of primarj' tuberculosis of the cen-ix haitbci
obsen-ed in which no area of infection could be discovered elsewhere, andibt
di.'iease has also been met as the only manifestation of secondary extensioo in
pulmonar>- phthisis.

Symptoms.— The disease begins either upon the vaginal portion of ibt
cervix or within the cen'ical canal and appears in the form of mitian' tubente
which eventually break down and develop into tuberculous ulcers.

Beginning in the cervical canal, the disease manifests itself al firs! as u
endocer\iciiis which is accompanied bj' the usual discharge from the ctnw-
Later on, as the tubercles develop and break down, the cen'ix increases in S"
and the secretion becomes purulent. Uterine hemorrhage may occasionall;'
occur, and, finally, if the disease extends beyond the external os uteri, the fh^-
aclerislic tuberculous ulceration appears upon the vaginal portion of thecwit

If the disease begins upon the vaginal aspect of the cervix, the lesions ire
similar to (hose of tuberculosis of the vagina.

Diagnosis.— The diagnosis is made as follows:
The histor\'.
The symptoms.
The microscopic examination.
.■\nimal inoculations.

The History. — The chronic nature of the disease and the ciistenct "f *
tuberculijus infection elsewhere in the body point to tuberculosis of the ct"^

The Symptoms. — The cervical discharge, the uterine hemorrhages, and tK
increased size of the cenix are of no diagnostic value unless the disease hi'O-
tended beyond the external os and the characteristic ulceration is exposed to ^'^-

THK PALLOPIAX TUBES.

747

tcrcclomy with removal of the uterine appentlage* should be iierffirmed in even-
case, providwl ihe K*^neral londilion of tlic paiicnt is good.

ttTien Ihc tubal aftcclion iis .«*icind;irv lo a lubert-uUr area in iJie lungs, ihe
que:<tion of hysicrcclomy depends upon Ihe ^lage of rhe pulinonar>- disease and
the henllh of the woman. Generall) speaking, it is always
advisable to remove the pelvic fntus of infertioo
whenever the patient is strong enough to stand the
shock of the operation.

In cases in which the vagina as well as the uteru.* is involved o]>er«tivc in-
lerfercme h coniraindicaled. "

In ;ill nnn operiilive r».M;> the treatment -■>hould be palliative and consist in
curelnicnt of the uterine cavity, followed by the application of tincture of iodin.
which nhouUI he reapplied Iwit^e a week for an indefinite length of time; good
results are al>n obtained in Mime c.tM» by introducing an iotloform sup]>u>ilory
{gr. x) into the uterus two or three times a week.

THE FALLOPIAN TUBES.

Description.— Tuhereulotiis of the lubes is a more fretiueni di»ea.ie ihjui
is generjily suppo>ed. and. according lo Penrose, who ha* made a scries of
valuable o!>scr*'ations on the subject, " tuberculosis is present in from 8 lo i8 per
cent, of all ta.ie^ of inlUmmaiory diseaie.i of (he uterine appemia^i." The
disease manifests il»elf either a> a primary nr a-fondtiry infection. While pri-
mary lulicrculosis of the oviducts is not an infrequent afTeclion. yet the vast
m.ijiirity of caM'> are secondary to a Kenerul infection or to a tubercular condi-
tion of the iH-riloncum, the intestines, or the uterus.

Both oviducts are. ai. a rule, alTcfied, and tlic disease eveniuallir spreiuU lo the
uterus, the ovaries, and the peritoneum.

Varieties. - Tuberculosis of the tubes occurs in three forms as follows;
Miliar) lulierrulosix.
Chronic diffuse tuberculosis.
Chmnic fibroid tuberculosis.

HilUry Tuberculosis.— This form <tf the di.«esise is not infitqucotiy met.
and i; usu<tlly a'-'oriitied with general miliory tuberculosis, although it may
occur as .1 primary condition. It is always the initial lesion in the other varieties
of the afTe<-tiiin. and, like miliary tuluMculosis of the mucous membranes else-
where. i!ie tubercle- are dc[)osited beneath the epithelium.

Chronic Diffuse Tuberculosis.— The ias«ou.i <>r cheesy pu.-i tubes whkh are
met fnim time to time are due to thi» form of tubeTruk>>4s. Like tubercular ilt-
fcction of the uterus, the disease begins in the form of miliary tubercles de|Hi«i(e<)
in Ihe mucosa, which finaUy break down intit rafiK'-'d uli-en coverwl with cheesy
matter. Kventually the entire mucous rrwmbrane becomes involved and the lube
is distended with typical yellowish cheesy material, which may be fluid or semi-
fluid in con;4slency. In some case^ the cxmtenis of the lulie liecomc m<«e or less
calcilied or in.»pi.«.;ileil and form a hanl. dry mass. Sometimes the caseous
material is replaced by a collection of pus which forms in laine sacs and often
rau-HC* eno^nlou^ <lis|cntion of the lube. The iiiNe;i>« is confined, as a rule, to
the mucous membrane, hut in advanced cases the muscular coal may become
affected. Usually, however, the fimbriated cxiremil)' of ihe lube is <-l<Me(l and
iu walls arc more or le.ss thickened. Sometimes the cheesy maieria) may be
seen ooxing from the mouth of the lube and soiling the adjacent peritoneal sur-
faces, When the affection is associated wiili tubeRuIar peritonitis, the iut>e b
»iudded exlemally ivilh miliary tubercles and c>ficn covered with a cheesy deposit.

746 TUBERCULOSIS OF THE GENITAL ORGANS.

Chronic Fibroid Tuberculosis. — This is the rarest form of uterine tubrrcu-
losis and it has only heen observed at autopsies.

Symptoms. — The disease is very chronic in its course and is usuallj' as-
sociated with symptoms of tubercular infection in adjacent or remote organs irf
the body. Endometritis is the most prominent and constant local conditioo. bul
unfortunately there is nothing during the early stages of the affection in the
character of the discharge to distinguish it from a leukorrhea due to one of iIk
simple forms of inflammation which are so constantly met. Later on, howotr,
after the disease has become well advanced our attention may be directed lu the
nature of the trouble by the cheesy matter that is often found mixed wiih iht
uterine discharge.

Diagnosis. — The diagnosis is made as follows:
The history.
The symptoms.
The microscopic examination.
Animal inoculations.

The History. — The chronic course of (he disease and the evidence of i
general or local infection are strongly in favor of the affection being tuberaiUi.
Afjain, In cases of primary tuberculosis of the uterus the nature of the disease nav
be suspected if the husband is found to be suffering from any form of tuberculK
infection.

The Symptoms. — The symptoms are of no diagnostic value unless ihr
uterine discharge contains cheesy material or the physical examination denwn-
slrates the presence of tuberculosis in remote or adjacent organs. Thegras
changes in the uterus itself are not characteristic of tuberculosis, and art ibfl*-
fore of no diagnostic value when considered alone; but where thej^ exist in
connection with infected areas in adjacent or remote structures of the body, iff
with a leukorrheal discharge containing cheesv matter, or Oiev develop in J
woman with a tubercular husband, they then become im])ortan( links in tht chain
of evidence.

In the advanced stages of ihe disease the uterus is enlarged and the hjIIs
softer than normal. When atresia develops at the internal os and the secreiiiffl'
cannot escape from the uferine cavity, the orfjan becomes distended and (om-'i
tluctuiiting tumor (fiyomclm) which i.s readily felt by the examining fingers.

The Microscopic Examination.— The diagnosis should always be ron-
firmed by cureling the uterine cavity and examining the scrapings and secreiwn-
with Ihc microscoyie.

Animal Inoculations.— The pathologist .should make animal inoculatiiin-
with some of the secretions sent to him by the surgeon.

Differential Diagnosis.— The disease must be distinguished (r»ni
non -tubercular endometritis and carcinoma.

Non- tubercular Endometritis.— Tuberculosis of the uterus in h w'l?
stages canniit be distinguished from ordinary forms of endometritis exiepl t*)
means of the miin),-;co| le, .As il is always important from the stand iwinl of
treatment tn riT<igni;ie a tul>urcular lesion early, the uterine cavity should be
curcted in every suspicious ca.sc and the scrapings and discharge examined Wf'''
.scopically.

Carcinoma. — .\ jrasitive diagnosis cannot be muile between cancer u( il"
Iwidy of the uterus anil tuberculo.sis without ihe use of the micn>sa>j)e, i™"
shoulfl be resorted to at once on account of the necessity in both dlsea?es ferean;
surgical interference.

Treatment.— If the disease is limited to the uterus or is associalrtl "'i"
infciiiim of the lubes, the ovaries, or the peritoneum, complete abdominal ")''

THE OVASieS.

749

fluctuiillnK massti in the pelvis. As a rule, the uterine appcndai^ are dis-
placed cinH tirmly Jidlierenl tn ihe xurrmincliiig slrutlurtt. When llie |>eriluneum
is involved wc may ocrasionully feci ihc miliarj- tiibcrcJes scattered over the
surface tif ihc lulics or upon the posterior (ace of the broad ligamenls and the
uterus.

The Microscopic Examination. — TKc microscope should be employed to
examint- ihe v;i}tiii.il ili.Htharge." fur the jireseiice of tuliercle bacilli, which may
occasiotiallv Ih* found, anil thii:' dni'k the tiu<=>tii>n i)f iliattnnsi.v

Prognosis. The prognosis of the disease is always grave. If the af-
{ectiiiri is M-i<iniliir\' lii tul)LT< iilosis in another pari of (he IkmIv, it ad* ijnd w^condar)- luhol infections have
a slronR tendency to spread lo the fK-ritoneum. the uterus, and the ovaries, or to
ciiUM: :i genbnd lulicrculosi.i. Some(ime.-( tubal >uppurati(tn may <]eveliip arwl
the patient may die of exhaustion and ^-psis, or the abscess may rupture iotemally
and cause a fatal peritonitis.

A ^[xinLmeini.v cure may orcur in \'er^' nre instnnceit by the lesion undergo-
ing calcareous or libroid changes.

If the disea.-* is limited to the tubes, the uterus, and the ovaries a complete
cure follows their removal in many in^t:lnl'c^. Tul>ercular peritonitis i.'s also
occasionally relieved by (he operation of salpingo oophorectomy.

Treatment. — Tlie <)uestion of operative interference depends u|»on the
situation of the \'iirious areas of infertiitn and the gent-nd condition of ihc patient.

If the disease is limited to the tubes, &alpingo*oOphorectomy should be per-
formed; but when the ovaries and the uterus are aUo involved, <'om]>leie ab-
dominal hyjitcrectomy with removal of the a])penduge^ is indicated. Incom-
plete hysterectomy is always contra indicated under these circumstances, a& it is
imiKvwible in know whether or not the inlraoervicul mucosa is the sent o( in-
fection.

TulJenular ijeritonitis is never a contraindication for opentlive measures,
unless the disease is well advanced ami the |iatii-nt'x general condition is bad, as
abdominal section followed by drainage has a curative influence U[joR the dis-
ease.

In cases of early phthisis sidpingii-oii]>hnrectomy should he performed to
remove the pelvic focus of infection and prevent the subsequent de^'eUipnienl of
dunxenius local or geicral conditions. When, huwevcr, tlie disease is well ad-
vanced or the gener^il contlition of the patient is not good, all fijrms of operative
procedures are contra indicated.

THE OVARIES.

Description. — According to Williams, 'no one has rles(Ti1>e<l a case of
primiiry Itilicniilii^is of the oi*an'." SffomUiry infection, on the other hand, is
not an infrequent disease, and is generally associated with tuberculosis of the
peritiineum or the oviducts, and in some cases it may be <lue to a genenil infec-
tion. In rare instances the ovary is the only genital or^an aflcrtcd in cases of
phthisis or of tubercular peritonitis.

Pathology-— The disease occurs in the form of miliar}- tuljcTcles. cheesy
masses, or tufwrcular aKtce^^e^. The tubercles may only be found Upon the
surface of the ovar\-, or. again, they may also c»ccupy the deeper stniclures of the
orjcan. In Mime ca.ses the iibnd contiins cheesy de^Misits, while in others small
pockets of tubercular pus are formed which may increase in size and eventually
rupture into the peritoneal cavity. .Adhesions do not occur, as a rule, between
the ovar^' and the surrounding sinictures unle.ss the tube is also involved or
caseous mosses and exudates form upon the surface of the organ.

748 TUBERCULOSIS OF THE GENITAL ORGANS.

As the disease progresses, dense and general adhesions frequently fonn betwceo
the uterine appendages and adjacent organs.

Chronic Fibroid Tuberculosis. — According to Williams, this ionn "diflm
from the other varieties in the excessive formation of fibrous tissue in and towcn
the tubercles. In this form of tubal tuberculosis the lumen of the tube is distortal
and may or may not be the seat of the ordinary inflammatory affections. That
is but slight tendency to caseation in these cases, and their most marked fcatun
appears to be their chronicity; and no doubt in some instances it may indioUe
the spontaneous healing of the affection, just as occurs in other organs."

Sytaptoms. — The symptoms of tuberculosis of the oviducts diSa in no
way from those of a non- tubercular salpingitis, and as a matter of fact the pres-
ence of the disease is seldom suspected before its nature is revealed on the
o[>erating table or at an autopsy. When the disease is associated with infec-
tion of the uterus, the vagina, or the abdominal cavity, the local manifesta-
tions of these lesions modify the ordinary symptoms of salpingitis and obsniic
more or less their significance.

Diagnosis. — So long as the tubercular infection is limited to the oviduCB
it is impossible to recognize the nature of the lesion, and in cases where the disease
coexists with tuberculosis in adjacent or distant organs the diagnosis is bucd
solely upon inference, and our conclusions are therefore extremely doubtful
For while we may be justified in suspecting that a tubal mass is tubemilu in
origin when the disease exists elsewhere, yet we cannot say with any degree rf
certainty that such is the case.

The diagnosis is based upon a consideration of the following subjects:
The history.
The symptoms.
The physical signs.
The microscopic examination.

The History. — The family history of the patient should be ascertaintd in
order, if possible, to prove the existence of a tubercular tendencj-. The pitseote
of a tuberculous lesion in Ihe husband is always suspicious, and should sugp^ia
possible connection between it and a tubal enlargement in the wife. The clinical
histor\- of an existing salpingitis should be carefully investigated to ascertain, if
jiossible, iLs origin, which can be traced, in the vast majority of cases, loap^
\'ious attack of .sepsis or gonorrhea; but if the disease has developed » sJowh'
that the patient is hardly aware of its presence and she can give no de6nitt in-
formation as lo a possible cause, the tubercular character of the tubal massshouU
Hi least be suspected. '.And, finally, the personal history of the patient is im-
portant if it shows a previous illness of a tuWrcular nature which has rtmain«i
inactive and apparently cured for a number of years.

The Symptoms. — There is nothing characteristic in the sv-mptont' ilia'
eiuble us to dislinguish a tubercular from a non-tubercular salpingitis, and «
can therefore only assume orsusjiect that the former condition exists whereal'il'sl
mass is associated with tuberculous infection in some other part of the body.

The Physical Signs.— The local lesion.s are revealed by vagine-abdm*'i!
and recto-atidominat palpation, and when considered alone they are of do diag-
nostic value, as they are similar lo those occurring in cases of pyosalpini; ^
where ihcy are associated with luberculous areas of infection in other parts of thf
body, or the vaginal discharges contain cheesy material, we mav a.ssume ibal tM
disease is tubercular in origin.

The char.KiLT of the local lesions depends upon the duration and e.tlei" '^
the disease. Sometimes the tubes arc slightly enlarged, hard, and nodular. <»■
again, iht-y may be enormously distended with tubercular pus and [onn sof"-

THE 0VAXIS3.

749

flueluaitnn masses in the pelvis. As a rule, the uterine appendages are dis-
uU( cil .iml fimili, iiilltcrcnl t" ihc ^urroundinK >irmtu «■-■>. When ihc |icriloncum
U involved we may uccasiimiilly feel ihc miliar)' tubercles scatlerwl over the
surface uf tlK tubes or upon the poslcrior face of the broad Ugamcnis and the
ulerus.

The Microscopic Exsminmion.— 'rho microscope should be employed to
examine ihe vaj-rnaJ disiluirsea for the presence of tuliertlc bacilli, which may
occasiiin.iUy Itc (mind, and lhu^ decide ihe i^uestion of ilia|i;nnsi;i.

Prognosis.- The prognosis of the diseiise is always grave. If the af-
fection t> >ti<iii<lar\' lo lul>ert'uli>-\i:i in another pari of the IhhIv, it aild^ lo the
pre^'iaii'.ly existing dangers, lioth primnr)- ;iml wi-ond;in- tubal infeccions have
a strong tendency lo spread lo the peritoneuni, the uterus, and the uvarie.<^, or lo
caute 11 general tuliereulosU. Sometimes tubal Mjppuration may develop iind
the patient may rlic of exhaiislion and »ep$is, or the abscess may rupture internally
and cause * fatal peritonitis.

A *j>onian«iu* cure may oaur in very rare InMances by the lenion undergo-
ing cnl^Areous or tibroid changes.

If ll>e disease i.* limited lo the lulws, the uterus, and the ovaries a complete
cure fnJl>ou> their removal in m.'iny in>lanccs. Tubercular peritonitis ii^ abo
occaaionally relieved by the operation of salpingootiii>horectomy.

Treatineiit. — The question of o]»eraiive interference depend* upon Ihe
liiuolion of the various areas of infc<'tion an<t the genenil condition of the patient.

If ihc disease h limited to the tubes, sidpingo-oiiphoreclomy should be jwr-
formeal: tmi when the ovarii and the uierii> aic also involved, comjileie al>-
domiiul hy>ter«tomy with lemova! of the apjieiidages is imlicnted. Incom-
plete hysterectomy is always con Ira indies led under these circumstances, as it is
impossible to Iciiow whether or not the intr^tcervical mucu»i is ihe seat of in-
fection.

Tuberrular peritonitis is never a contraindication for operative men.iureii,

unles-t the di.seaM; i.s well adiunceil and the patient's gcncr-il condition is bad, aa

Bbdominal section followed by drainage has a curative influence upon the dis-

In ciLsCK of early phthisi.s Kidpingo-niiphorcctomy should be performed to
remove (he pelvic focu* of infection and prevent the subM^quent devclopmeni of
(Luif^CTOun local or fcencral londilioni. \Vhc», however, the di.sca.se is well ad-
vanced or the gener:d condition o( the patient is not good, all forms of operative
procedures are contra indicated.

■ THE OVAKIES.

^ Description.— AceordinR to Williams, " no one has described a case of
primary tut)erculri.-.is of the oiTiry." Seiondary infection, on the other hiind, is
not an infrvc|uenl disease, and is generally associated with tuberculosis of the
peritoneum or the oviducts, and in some cases it may be due to a genenil infec-
tion. In rare inskinces the oN-ary a. the only genitid organ adeclnl in cases of
|jhthi!^s or of tubercular periionicis.

Pathology.— The dise.ise occurs in the form of miliary- lulicrrlcs. cheesy
mB»e», or tuliercubr abscessw. The tulKrcles may only be found upon the
surface of the ovary, or. again, they may also occupy the deeper structures of the
nrf;un. In some rases the Kland contains cheoy de|Misits, while in others small
pocket» tA tuberrubr ]>us are formed which may increase in size and eventually
rupture into the jwriloncal caiity. .\<!hesior»s do not wcur, a* a rule, between
the ovary and llw surr'ninding stru<'ture> unless the tul>c is also involved or
COMOUM nuMcs and exudates form upon the surface of the organ.

750 GENITAL nSTULAS.

SytnptotnS. — The symptoms are not characteristic and they differ in no
way from those caused by a. non- tubercular inflamnsation of the ovaiy.

Diagnosis. — It is impossible to make a positive diagnosis, and in the via
majority of cases the disease is not even suspected until the patient is opcnud
upon or an autopsy is made.

A probable diagnosis of tuberculosis is based upon the principles discuswd
under the diagnosis of tubal infection (see p. 748).

PrognosiB.— The prognosis is always grave. If the disease is Umited to
the ovaries, tubes, and uterus, a permanent cure may follow tb«r remm-iL
Where the ovarian infection is secondary to a tubercular peritonitis, conifdHe
recovery may result from the operation of salpingo-oophorectomy.

Treattnent. — The question of operative interference depends, as in tbr
case of tubal tuberculosis, upon the situation of the various areas of primai; ia-
fection and upon the state of the patient's health.

If the disease is as.sociated with tuberculosis of the tubes or the uterus salpir^
oophorectomy or complete abdominal hysterectomy with removal of the uterine
appendages is indicated.

Where the affection is secondary to a tubercular peritonitis, the operation of
salpingo-oophorectomy, followed by drainage, should be performed unless ibe
general condition of the patient is bad.

In cases of phthisis the uterine appendages should be removed unless die
disease is well advanced and active.

CHAPTER XXXVI.

GENITAL FIS TU LAS.

Definition.^A genital fistula is an abnormal opening which connects
the uTerus, ffie'vagina, or the perineum with the urinar\- tract or the inlestines.
Classlficatioii. — Genilai fistulas are divided into two primary variecies:
1.' Unnary__fi5tulas.
2. Fecal fistulas.

1. ^inary Fistulas.^TheseJistulas .are, subdivided, ijjtj):

Vesicovaginal. Urelhrovagiiial.

Ve.sico- u terine . U rctcro vagi n a 1 .

\'esico- u tero vaginal . U rete ro- u teripfi.

2. Fecal Fistulas.— These fistulas are subdivided, into;

Rectovaginal. Kectolabial.

Recloperineat. En tero vaginal.

VESICOVAGINAL FISTULA.

Definition. ^In this variety of fistula the abnonnal opening occup m
the Vesicovaginal septum, and there is consequently a direct communica'iW "
ivvccn the bladder and the vagina. ,

Description.- -These fistulas van,' in size from a minute opening »™^
scarcely admits a fine probe to that of a large hole in the septum involving '«
enlire base "f the bladder, and through which the vesical mucous membrantpf"-
Iruilc-; inli) the vafiina. The opening may be situated in any part of the yejn^
vaginal sC|>tum, and it is usually oval or irregular in shape. In the beginning""

VeSICtn'AGINAL nSTVLA.

75'

n|)cninR » alway» irrcKubr in outline and its margins arc thick and ulcerated.
Later >m, however, it )t;ra(luiii1}' ri<nlr3[l> iintl it> edjtes beromc ihiu and h:ird.
The tendency uf a Tislula i» lu iIom- cither bv gmnulntiun or dcatrizalion, and
n'en if (be closure is not com)>lele the opening is always greatly reduced in siie
tn iIk <'ounc of a few weeks. In the ca$e uf a btrj^c lixlulii cicatnciitl tiandt are
generally obM>rved radtating from it over Ihe vaginal wbIIjs and in some in-
inccs the lislulou.t ojieninx >■' firmh' Uiund down afpiinst the jnibic Iwne.
Causes.— A vcsico^-<igin:ii li.--itil;i is the must common form of lislulous
connected with the genital Irjit, It Uiiuully rtMillA (ntm a prdtrsutetl

in which the advancing head bctumcs impaclcd and crowds the bladder

nKBin»l tlw symphysis puhis. l'n<ler these circumstances the vesicovaginal
septum i^ injured and a ^Jough occurs whicli become^ ^epanited within a lew
days from the ^^urroundini; tissues, leaving an artificini opening between the
blad<ler and the vagina. The obstetric forceps iLicIf U pnibably never the cause
of ihcse injuries, .ind when they occur the delay in using the instrument is alone
tesponuble for the traumatism. A vesicovaginal fistula is also oiu^^cd by the
tkiughing which occurs in malignant dis-
tase nl the vagina or the bladder; the
|>r»surc ol an ill-fitting pessar)'; the
idtenition which Mimetime^ reMjIU from
Ihc presence nf » Ini^ vesical cakuhis;

^U by the bumiuing of a jwlvic abscess.

^M .A^in, the septum may be injured in
pef<<»nning a vaginal hyslerectomy; a
fistulous tract may remain after a faulty
rrpcration on the anierior wall of the
vagiita; and an artificial opening may
be puqwwiy made tn secure tcm[K>rary
drainage of the bladder in the treaimcnt
of cyslitU. In rare instances a syphilitic
ulceration is re^^iionsilitc tor a fistula, :ind
in some cases it may be due to a hcma-
looM of the Linlerior x^t^inal wall which
becomes infected and break* down,

H Symptoms.— The alTetiion is .liar-

4rtenxe<l by more or lew constant drib-
liUng of urine from the vagina. If the

fimula is cauMHl by a [iroiracted lal)t>r, the incontinence does not generally
mnnifcsl itself before a week or ten days after the confinement, and in the
Interval there is usually an elevation of the lemperalurc. frequent and tiainlul
mk'turition, and possibly a >mal1 qu^inlitv of blood mixed nilh the urine.

The deprcc of incontinence depends upon the situation of the fistulous open'
inp and the position of the patient. If ihe fistula i» in the upi>er part of the
tViiicov.i|;inal ^-^plum and the p;ilienl assumes ihe creit position, the involuntary
discharge may cease entirely uiUil the urine accumubting in the- bl:id<ler reJichca
!he level of the "[leriiiij; i Fig. ^4(1). K«r (he same reason there is .ilso tem)M)rary

-JMitinenie whc:i die lisIuU is situated low down and the patient is in the rccum-

Iknl imsluic (Fig. 447).

^k Sometime!! when the i>atienl is lying down the urine accumulates in the

^kinul nildcKic and escajres in 3 gush when she tiJ,sumrs the ercci position.

Tlic ron.stanl pre.sen<e of the urine produces intensr irnlaliun. and the \~ulva,
tlie tagma, and the inner surfaces of i)ie thighs t>ecomc inQametl. clem.ituus.
excoriateil. L'rinar)' sails »]m accumulate un the parts over which the

Pre. (l*j,-Voiim*iiiK*i. Fisici*.

7S»

(iENITAL FISTULAS.

urine dribbles, and Ihe v^^iAlf^ix vulvn, and ihv mucous mcfntinoe ei At
bladder become encrusted with an offensive |ihosphatit dqwsii.

The ;ifr«cti<>n is usually cnmpliiulLiI by chn>nu- cy>litU. opecUlly ia cub
in which llie <irt)iici»l upening is Ijirgc, and i( h not uncommon uodet tec
eondilions fur Ihc kidneys lo become discawd as ibc result q( an xsccDifiiis in-
fection. The bladder and ibc urclhni evenHially become coniracied frocn dana
and the vesical walJs thickened and infillrateid.

The fienenil hwdih, tin a rule, »til1[ers, and the patient often becoiDCi nucuial
and anemic.

Diagnosia. — The diagnosis of a vesicovaginal fistula is based upM (t)
lh(; |]iMi?i''and (i) l'^£ll!iXsi(^lLj9Bfi^£&tiBP-

History. — The patient usualtypresmc a histofvof dthera pnXracied lain
or a vaginal (i|ieratii>n which was f»l!<jwcd shortly aficrwartl by a constant drifaUa|
of urine fnjm the vagina. As u rule, the urine is not p.-t.-v>cd a( regukr inlcnalli

BLADDER

Unm

Pis. 646. • fw. •«.

SVMrnnM or a VRimvuniHiii. Furri* Ivf ;t')
Fin. (.46 ilim whT Ih* laMtUBIift <tiwhstiF nl Fit- At; •>>o*t "Mt Iht a^oM*'

nriiw iraiK B miiuMitiiigJ AmuIi In lu Upprr jawf ul Iht tbtrgt nt urinr tmn « ««ia<a(IHl !■»»

MpiuRi irun winpnrlly vbta Ibe ptlirni iiMina ihc ihc Ioott IhIi of ihc aritan nam HBia^

vtwD [he euUoi uwiiiB IW lUMMf*
lion.

grtcl pnulinn.

and there is never any attem|>t upon the part of the patient to empty the titH"
nalundly. If in addition to the normal act of urlai*
tion there is dribbling of urine from llie vagiai-
llie rase is probably one of ureteral fistula.

Physical Esamin^tifiO- — I" .•>ome ca.ses the parts arc so tendet and f^eeio
that n 13 aecesMry lo employ a geneml itncslhelic in order to make a lh«W
exxminAtion.

The physical signs arE.cUdted by ia}. louctj. and ffi) inMUftipn.

Touch . — Tlie patient is placed in the donal poHiitm and the Iiidei-alRi<
introduced into the vagina. If the fi.-viula is large, it can readily be dcUcXd,^
Ihe vesical mucous membrane felt proiruiHnR through it. In M<me instaDrt**'
lip of the finger can be pawed into the bladder and Ihe vesico-urethnl i^'^J
palpated. By passing the finger over the vaginal wall in the neighborlKod«
the fistula the' character and extent of the cicatricial l>and> nui be a«wl«ii»l tM

VESICOVAOINAI. FISTVLA. 755

fH. ArWI bf nucrifi 3ii
Addih..ri.i , Sllj
Aqu« cinnainiioU. fS^U-
M. Sig. — Tib!ci|ioonftil in w»Im (ourliniti daily.

After the urine has been rendered acid the dose should be carefully regubted
in or<ler to m^iintiiin the mirmiil uddily without derungiiig the diue^tion. The
patient -ihould also drink thirc or four pini.v of disiillnl, E'olimcl, or Bedford
Wilier daily Ic ililuie the urine and keep it bbnd and innocuous.

In cases of sm.ill ri.viitla> ihc aliuve treatment may re:«iilt in a s[Kinlnneoue ^really diminished and the parts plac-ed in the l>ext |K»sihle
condition for an operation.

Chronic Casea,— The management of chronic h.siulas is divided into (a) the
prepaid tor?' ir^imenl. (b) tJie operative Ireatnieiil, and (c) the treiilmcnt i)(
inoperable cases.

Preparatory Treatment . — A preparaltMy course of treatment is
usually "iWJll fin) III ni«es of rhrunic fL-itulnn in onlcr, firtt, In remove Ihc |iha-
phalic deposits; %econd, lo heal ihe e.\ cor iat ions; third, lo promote the absorption
iif the induration around the lisiuU; jourtit. co cure the cocxi.iling cy.itilts; ;!///(,
to relieve the tension <-au.%eil by cicatriiiul baniU and adhesions; ii.nA, iixUi, to
improve the general condition of the patient's health.

DimrioN OF the PsKPAR-vroRV Treatmem. — No definite lenjtth of time
can be slated, as the chararlcr of ihe Iwal conditions varies greatly in individual
cases. In some instances but little, if any, jireparalory trealnienl Ls nc'cdc<l; in
others, again, il may l^e from one month tu six weeks In plate the (KirLs in a
proper condition for ogxration; and. finally, the lesions may be of such a char-
acter ihal seier.-U months must elapse before any allenipl c^n be made Id dose
the fistulous oiwning.

PhosphiUk Deposifs.—The deposits of urinary sails are removed Inmi the
vagina and tlie surruunding part> with a ])ledget of alK>orlH'nl mllon held in ihe
Krasp of dressing forceps, and the T3tc surfaces remaining are painted twice a
wecif with a .dilution of nitrate of silver fgr. x-f.sj) until tliey are he;ilei[. The
rcaccumulation of the Milt.i i.% jirevenleil by irrigating ihr viigitiii thrcx* time.t a
day with a gallon of hot boric acid solution (,'ij lo the quart) and rendering the
urine acid with Emmet's mixture or Sfcmin do.nes, lhn« timc^ daily, uf the l>en-
loate of sodium or ammonium. In addition, the patient should drink three or
four pints of distilled, Poland, or Bedford water daily to dilute the uritic and
ren<ter it inntx^uous.

ijrrtffij/iOTW.—The exoonalions which occur on the vulva and Ihe inner
aspect; of the thighs should be painted twice a week with ihe .solution of nitrate of
silver mentioned alM)ve and the .turfacex protected from the dribbling urine by
smearing them lightly night and mornini; with carbobted oxid of zinc ointment
(3 jier cent) after washing the parts thoroughly nilh warm water and laiap. A
hot !.iu balh at lieiltimc is often very iK-neficial in these cases, and not only
assists materially in relieving (he local irritation but also promotes the licaliiig
proceu.

/ nduraliont . — The hypertrophied and indurated condition of (he margins of
the fasluia is relieved by the vaginal injection of hot Imric acid solution, the
remcivid nf incru.ilalion.-^ the apfilicatiun <>f the silver snluiion to the raw edges,
and the use of a hoi sitx-bath at bedtime. The improvcmeni in the appearance of
the fistula after seieral « eeks of treatment is most marke<), and ihe hard nodular
margins become soft aiul normal in ctHi.'^^tency.

C>'»(flM.— The ppTM^nce of cystitis is always a contraindtcalion to the closure

7S4

GENITAL FISTULAS.

In fistulas of traumatic origin the tendency is toward spontaneous dosuit by
granulation or cicatrization, and in some instances primary union may even take
place. Although this tendency toward a spontaneous cure exists in all fistulas,
yet as a matter of fact the vast majority of these artificial openings are penaanciit
unless they are closed by surgical means, and it is not uncommon tot a vny
minute sinus to remain patulous for an indefinite length of time.

Operations for the relief of vesicovaginal fistulas are, as a rule, successful
although in some instances more than one operation may be required befon ihc
opening Is finally closed. The operative prognosis, however, is not good in oits
in which there is great loss of tissue, or where the opening and the septum are
firmly adherent to the pubic bone, or where the bladder and the urethra are con-
tracted. A thorough examination must therefore always be made befon ex-
pressing an opinion, and the examiner should carefully note the size of the fistuli,
the condition of the vaginal walls, the facility of approximating the edges of tlic
opening, the presence or absence of adhesions and cicatricial bands, and (be
capacity of the bladder and the urethra.

¥ic- 6so.■^^I.^^.NOSIS or a \'tsirovA<"LiNAi I-'istvi-a by JifSFtc-nos (pa^ JSj).
Thr patimT is ^uwn io ihc kn^r-cluM piKiun. ihr jirrini-Liiii mr^icird. and 4 wun>i puvil IrmiW imMrt

through Ihc ^lub muj Iht vagim-

Treatment.— The trcalmenl of vesicovaginal fistulas is divided into i1k
manigemenl of (i) reient_j;33es and (2) chronic cases-

Recent Cases. — As stated elsewhere, "iTie sloughcloes not separate nnf '''^
urine begin lo <iribble from the vagina for several days after the occunmeot
the injury which is the c;iuse of the fistula, and in the meaniime the obstelridan
usually does nc)t even suspect the imture of the complication. .V soon as IM
character of ihc accident is recognize*!, however, an effort should be madeW
bring about a spontaneous closure of the fistula by means of local cleanliness JM
attention In ibc character of the urinary excretions.

The vagina should be irrigatgl llite?"'' ^"^^ times dailv with a quart of n""
boric add solution {^1] to t\'c quart) and the urineT^ni^ft^slig^fly acid top'^
vent' the formation of ])hosphatic deposits, which occurs onlv when the reafHW"-'
alkaline. For this imrpose nothing is better than the following formula W""'
mended bv Emmet:

Fi6. «5i.^TauwmT ur

VUICOVMUKU r»>
tLL-U-

iMmniDJnff iht ui^uunr of

Ibr fdNn if ■ 4mixxh to-
jlcthrr

the dorsal or led bleral-prone position and exposing the fisttila with a Sims or
SiiDon speculum. Thv clgr^ of the fi.tltib are then caught with icnarulumt U
Opposite points and drawn together lo cstimntc the amount of traction. In mak-
ing thi:( lest n*e should always endeavor lo bring the margins together lalrraily in
a line with the long axis of the vagina. a» a tranKver>e union of (he opening nuy
result in a serious shortening of the vagina and inter'
fere mure or less with its functions.

If the cicatricial bands are slight and su|)er6nal and
the edges can be brought together with a moderate
amount of tension, no pre|)aralMry ireaiment of the
adhesions is required, as they can readily Ijc ilivideil at
the time of operation when the fistula is finally closed.
In somi- ca:^c<, however, the cicatricial bands are so ex
tensive that the mar^ns of the opening ikrc Axed and
cannot be approximated in any direction, or in oijters the
scar tlwue may obliterate more or le»s the lumen of the
vagina and interfere with an operation, Under these
circumntancey. therefore, a preparatory course of ircat-
mem must be instituted to relieve the ten.sion and
enlarge the vaginal canal.

There are Iwii method.t by which theie objects are
accomplished, and their selection in individual aiscf
must depend upon the personal eipericncc of the sur-
geon. They are: (A) Divi.->ion with subsequcnl dilata-
tion; (B) division with immediate ^^tuiing.

Divtsios AND Dii.\TVTios.— The patient is aucs-
ihetizM ana placed' iii ciilier the dor<al or left lateral-
prone position. The perineum is then retracted with Sims's s[>eculum and
the Kitualion anil character of the cicatricial bands axertained by sight and
touch. They are then divided with blunt scissors or a bistoury* in various
directions until the tension on the fisluLa is relieved and its edges can be >p-
proximaiefl.

The vagina is then irrigated with a hot solution of boric acid (i^ij to the

quarl) and dried with a g-juze ^|)«nge. A
Sim.>^*s glavt vaginal plug (sec Tig. soo, p.
m) is now introduced into the vaj|[tna
and held in posiliufi with a gauze com-
pma and a TlMindagc.

The plug should be worn constantly
for three week* anti removeil tem|>oraiily
once or twice a day for the purpose of
cleaiting the vagina « ith a solution of boric
acid. If the urine accumulates in the
bladder on account of the closure of the
Sstula by iIk plug, it .should lie drawn
with a catheter even- eight hours, other-
wise all that will be requires) is to
change the compress and T-bandage (re
quently. At the end of a week or ten days the gutient nhould be allowed to get
out of bed and go around with the vaginal plug in (he vagiiu. At the end oS
three weeks the incisions are usually healed, and an examination should
then t>e made to determine the condition of the giarts. If the tension on the
55lula has been relieved and it> edges can readily be approximated, the open'

\,\^^

Flo- bu — TlUTKurr o« • Vwrwmiiiai
fmnA tn I^rviuo* jlwi DiuMiAtnin or
THi Cicimnu Hum.
1. 1. lUrfmaii Ibt aoniruinl iru liiiur; a. *.
iadicaici ibc lUivuiua ol rbc Uaa id iariwa.

■

756

GENITAL FISTULAS.

of a fistula, and we must therefore cure the inflamniation of the Madder bdixc
repairing the injury in the septum.

The treatment of the cystitis consists in keeping the urine diluted and digbtlj
acid by the means described above, the use of a hot sitz-bath at bedtime, ud
vesical douches of a gallon of hot boric acid solution (sij to the quart) time timts
daily. The patient is placed in the dorsal position with her hips resting oo i
douche pan and a glass catheter, which is attached to an ordinaty fbunliin
syringe, introduced through the urethra into the bladder. The fluid from 4t
syringe first flushes the bladder and then flows through the fistula into the vagiu
and over the vulva. When these douches are employed, it is unnecessary to pw
the usual vaginal injections of boric acid solution, as the vagina and surroundic^
parts are sufficiently irrigated by the fluid which flows through the fistulnn
opening.

Wlien a fistula is small, the residual urine which collects is often the cause of
the cystitis, and unless we secure free drainage of the bladder the inflamnutotr
condition cannot be cured. Under these circumstances the fistula itsdf is dtber

Fig. 6si — TurATiiiifit or a VtsiioviciKii Kisit-u.
Ftuahing the bladder and ■■ ibr same lime irri^alinii Ihc viMpna Lhmufh Ibe blula.

enlarged or a .second opening made in the most dependent part of the septum a
urder to prevent the accumulation of urine and thus remove the sourttoflK
vesical infection.

In some cases the kidneys are so badly diseased that all forms of optnvt
procedure arc contra indicated, and nothing can be done excqit to k«p ■'"
parts scrupulously clean with hot boric acid injections and have the pa'"''''
wear an ambulatory urinal (Fig. 764).

The bladder should always be examined for stone as a routine practirt W*"*
beginning ihc preparatory treatment or closing the fistula, and if a calculus'*
found it should be removed at once through the opening in the septum.

Tension. — After the vagina and the surrounding parts have been restowi ">
as healthy a condition as possible, a careful visual examination should be WJ*
of the fistula and the adjacent vaginal walU in order to determine accuratoV"*
amount of scar tissue present and the facility with which the edges of thf^'
ing can be approximated, as the slightest traction upon the sutures will wu*^''''
operation to be a failure. This is accomplished by placing the patient in «™

VESICOVAGIKAL HSTtUA.

mg has become more or less diminished in siz«. llie tissues »re therefore not
only in ihe bcM |(o«Mblc condition lo ojierute U|ii)n. Ijui the fixlub has Uetn p\m
an iipjjortunitv tii clow; ^jjonlancou^iy, whicli tl snmclimes dots if llic opening is
»mal].

In (hronU fatts (lie lietl lime to operate Lt when the part^ have been restored
m a healthy condition bv the prcparalor)- Ircatment. In some instances, when
the listula is small and not attended with tysiitis iir other local lesions, very tittle,
if any, time U Teiiuire<I for ] ire) ki rat ion before fnially closinc the upcning.

Kit. b)j. — iNfm^Kfcn t'kai> m im Oi-UAn-jH ion the Kii'mit ^'t * \^iAi<.u^'.tri(>«]. FtttVL4-

-©■

-#-

In ca^tew in which a jwcoml operation is required on
account of partial or complete failure it shoidd not be
performed until mx weeks have clap!*cd since the first at-
tempt u-a.t made In cloie the fistiit:i.

Preparation of thr Ptiticnt.^'The patient is prepared
in the .tame manner as for an ordinary pla.itic oiieraiion
(see p. S30), cxcciil that a boric acid Htlution (31) to the
quart) is substituted for the corrosive sublimate injcc-
liim^ that ate Um.i! In cleanse the vagina, ;is the ex[»ii--.ure
of the vesical mucous membrane contra indicates the
employment of the latter antiseptic.

Final SUriliiali^i' jj Qft /Vtftfiftf — After placing the
patient on trie operating table tbe vagin» and vulva arc
ihonmfthly .scrubbed with liquid soap and warm water
(tec p. 8ji)~, the bladder t1u.'<>heil ihmugh the tirethrit
with hot boric acid solution, and ifae vaginal canal is
wiped dry with a t;au/e i[Hiiige.

/'(Ill/ ri; ,. ihr I'.ilirnI I prefer to opeTntc. a)* a rule, with the patient tn tHc
dorsal |"'-i in In Minic lascs. however, a better exposure of the field of opera-
lion can be ohlained and the iiperative manipulations facilitated b)' placing her
in the left lateral-prone position.

.Virm/)fr oj Asiiitanh. — An anesihetizer. two assistants, and a general nurse
arc required.

rrtisings. tU. — For the contents of the conveyance boxes sec page 833,

tnslruuunls. — (1) Simon's speculum (curved blade); {2) Iwo lateral vaginal

ACTUAL Sl2L

Pic 6tS.~Nuetn.Siints
Matvviaia. Axif Pifero-

■AIII> Slll'l I'tt-B IK
Till ^IPE*,t1X<V' TO* nir

IJWIIIU FUTVLt.

7S8

CEMtAL FISTULAS.

lion for closing the opening :4i«ul(l be performetl withmil hutbcr dcfar; brt
if there is still some trsction remaining, the division and diktatioa of Ac 6a-
tricial bands should be repeated.

The gliiRS |ilug which is used must be suffiricntly I«rge to stretch the ngiB
and control the bleeding; Crom ihe divided lis&ucs without causint; enoufili prenm
to produce iJouftliiiiK. 1'he changes which occur in the |KiTt> alter wcaiag the
plug lor several weeks are sometimes suqirisinK, .ind it is nol uncomoooa laini
that the vagina has been greatly increased in siw and the ciralricixl Uisue mxttt
lesft c(implelel)' absorbed.

Division and Strrt'KiNC. — The putienl is prepared and amti|;cd tot &t
operation as in the prc\'ious method (dhhion ami diitUalion), and after ihepiRs
areexpoNed the ricalriciat band>are divideil in v.irinus directions until ihcininM
on the fistula is removed and the edpes can be readily approximated. TV
resulting wounds .ire then drawn npan with lenaculunu nru) ctot«l by appraii-
mating their anKle% with catgut sutures.

The ajltr Ircdtmritt consists in irrigating ilic vagina twice a day irith tair
acid solution and keeping the bowels regular mi n» lo avoid traction i^xa iW
sutures. The patient should be allowed to get out of bed in one week. amJaltkr
end of a month (he final operation for closing the fistub may be perioiMi

I'lc, Af4 — TijuTWEMT or A Vjuii-aV4»EfiAL Fniiiui n DivinoH ^md Soma^
On ihi Idl of ibf fittult in indiion it iliiiwn ihm<i(h iht laitnviKnl lint* wfitih khum AiB,^
oa llw riKbi Lbe <i||in uT Ihr inculon U- i^ uc drawn apeti *1lh Lm*(tilvni* obJ ihr a«aW« cf tkcvwiu'

provided the lenMon has been relieved. If, however, the traction ^on ik
opening has nol been completely removed, the operation should eith0btl^
peated m^ described above or the division and the suturing aa be done ■111'
time of the closure of the fistula if the extent of the adhesions doo notnow
indicate such a procedure.

General Condition of the Palitnl. — Advantage should be taken ol tbc Vt
consumed in the prcparalorv- treatment of the local lesions to impnn'c tkegW*
health of the patient and place her in the best possible condition fof teeirt*
This natundly includes atiention to the digestion and the bowels. aixlAr>l'
ministration of such remetiies as may be required from lime to lime lo d»«I l**
special indications in the case.

Operative T r i- xi t m e n I .— Thi* comiatt jp d<y»)dii^ ^t ti^ **
the hstp^ mul ttppn ' irii iiirig thi-m with sulujuftk

T%e Proper Tinu lo <.>ftrjlt.— In rettnt cjjej the best ttaieloopenltfcfi'*
six weeks to two months after confinement, or even longer if the fisiubib*"''
tendency lo close spontaneously under treatment. \t this iwrkd the w*^
involution of ihe paru which occurs after pregnancy hat tnkei) plan', '/f '^
hesioDS. and the contractions which form later are absent, and the utukat'V'

XTStCOVAClNAI. MSTlfU.

759

has become more oc less diminished in size. The Ussues are therefore Dot
ily ill (he \tv^t |>i»Mli!r conilition to ciprmtA it|ii>n. t>u( ihr fi^tulii has hetn given
I ti|>jK>rtunitv li> iIoK- sponiancously, which it sumctimrs docs if the opening iii

ilp rlirmir rtufs iht be«l lime to oi>crntc is when the parts have been restored
a hcallhy condition bv the preparatory ireafmcnt. In some instances, when
t (inula i.H •^mutt jnd not uiienileii with cvstitiA or other Itxiil le^ion.H, very llttk.

dDob

Pm- Ai^.— Imttiiyitiiih Umbei ih jiii ii]-taAri'>i t^-u iHf KirAu ut « VuKftw^inti, fttiiri,*.

■@-

-(^■

In cn«« in which a second operation i* rcquin-d on
act'ouiit o( (tarttal or complete failure il should not Iw
■merforninl until six weeks have da)Kte<l >ince ihe fir»t at-
|ftfnp( wiu made la close the li^tula.

Pftpataiion oj the FutUnl. — The piiticnt is prqiarcd
in the <jmc mann<'r as for ,-in onlinary pla.vlic (iixmitiiin
(see p. 830). cxi:q>t that a boric acid solution (.lij to the
aiuirty is Mil>slitute>l (or the cornwive sulilimatf injec
lions that ure used In r!e;>n*c llic v^i^ina. ;is ihc ex|">Miri'
of the vesical mucous membrane contra indicates the
employment of the Utter anii.ie;iiic.

Fitiil SlrrHhiiioi gj /Ac J'alienf.—MteT placing the

Jienf on tiio operaiiiiK table Ihc vagina and t-ulva are

Drtnighty M.Tubbc<| with li(|u>d soup and warm water

p. 9.11I: the bLddcr flushed through the urethra

jllh h4>l tH>ri(' :i(:id xiluiion. and the vaginal canal is

\Kti dr>- with a g-tuzv vjn.iige.

f'aiilien oj Ihr IKitirnl. —I prefer to operate, as a rule, with the |Kitienl in the

uj |>(»tiife. ■ In ^)me (a.«e*. however, a better exposure of the field of opem-

can \^ •>blaincd and the operative muni pub I inns facilitated by placing her

. the left U tern I -prone jMnition.

Xumber 0/ .iiihlanh.—An anc<lhcti«;r, two a.tsjitanU, and a general nurse

' required.

frtiungt, eit. — For the conlcnis <rf the conveyance boxes see page &y3.
/Hjlrufwenfj.— (1) Simon's s[)«culum (curved btadc); (s) two bteral ragjnal

Pm AfA. — \vmT.i[4- SvTTriu

■AT1I> SllOt t'(*I* IH

till opn.iiiuv III* nil
KiTvk u> A Vmca-

760

G£iaTAL nSTULAS.

retractors; (3) right and left slightly curved Emmet's scissors; (4) saH^; (5)
four bullet forceps; (6) needle-holder; (7) tissue forceps; (8) dressing fonqe;
(9) shot compressor; (10) two straight and two slightly curved round-poiiiied
needles; (11) silkworm-gut — ao strands; (13) plain cumol catgut No. >, four
envelopes; (13) perforated shot (Figs. 655 and 656),

0£«'jl(jaii"r-FtKST Step. — The field of operation is exposed to view by
retracting the perineum with Simon's speculum, and, if necessaif, sttetdiiiig
the lateral walls of the vagina apart with retractors.

Second Step.— The anterior vaginal wall is seized with bullet forceps at foni
points opposite to each other and about one-half of an inch beyond the margins
of the fistula. Traction is then made in opposite directions and the inteivaiiiig
tissues drawn taut.

Third Step. — A superticiai incision is made with the scalpel around ibc
fistula to mark the limits of the denudation and prevent the removal of an un-
necessary amount of tissue. The incision should extend about one-fourth of u

Kic, 657. — OprBinnN K>« mr. Rpp«(« op a VEsirov*RiK»i. Fistrat— Fi«t. Svcnid. Tliirit •o* r»«tb

SUpe.
a. IndiculFs fbr tuiir-r^iial ind^itn mjrkinH ihr limiis of ihf denudaiion; b, Ihc drnudpH tfinr of il^ hvi^
r, Ihf- mucous mrmhrinr of Ihe bl^dcFr Sale Ihar ihr left .side of Iht biula is bruif dcaudnl.

inch or more beyond the edpc of the fistula in order to insure a broad appron-
mation surface when the denudation is completed.

Fourth Step. — The vaginal mucoi>a is seized with tissue forceps at any pfij"'
along the line of the inci.^ion and the mucous membrane cut away in strips ffitii
scissors down lo but not including the mucous membrane of the bladder.

Fifth Step. — The edges of the fistula are approximated in the line of i^'
long axis of the vagina by crossing the bullet forceps that are attached v>lii'
sides of the opening, and they are then brought together transversely nilh 'f*
upper iincl lower forceps in order to ascertain in what direction ihe mntpnscan
be united with the least possible tension u|ion the sutures.

Sixth Step.— The wound is sulurcd by intrixiucing the needle abiuiinf-
eighth of an inch from the denuded edge of the vaginal mucosa, and pa-^-W "
beneath the raw surface of (he septum to emerge at the edge of the vesical "'"'^
membrane. It is ihcn rcintrotiuced on the opposite side of the fi<ituia JM

according to the principles laid (town od page 675, and the edges of itic GstiUa
again unilcd.

GETTixr, OtiT OF Bed. — The pnlicnt should rcmnin in bed for Iwo weeks
and th<'n be kept in her room for xwn days more before being nllowcd to go oul-
of-door*.

CoNTRACWOS or TOE BwoDiyi.— If the size of the bladder is only
moderately diminished, it usually regains its normal capacity in the course of
one month nr six week.-k iifler the rlcutirt; of the tixlviLt. and under ihesr condi-
tions no special treatment is therefore required. Hut when the contraction is.
marked and the patient continues l<> suffer from fret|ueni urination after this
period ha5 el;i]>ved. the lil.'idtlrr must I)l- Irrattil by hydrostatic dilatation (see
p. 047) until it is siiflicienlly dilated to enable the w-oman to hold her urine
fur six or eiKlit hours at a time.

CciN"TKA<TioN OK THK L'kkthra. — This Complication can usually be cured
by dilating the urethra twice a week with a metal sound until a No. 52 (French
Kale) instniment (las-ies freeb' into the bladder.

I'liri'ilion^ in llrr Oprralht Tfrhnir. — The following operative procedum
have been succe.vifullj' adopted in large vesicovaginal fistulas in which the lost of
li^»uc in the vaginal septum is ^o fijKut and the .-urar listue in the vagin^x to cxtcn*
five that the edges of the opening c;innot be approximated in the usual way.

I. Howard \. Kelly dissecU the bbdder entirely away from the uteru» and
sulure< it to the dcnudeil vaginal w;<l1 anlcrinrly. He begin^i by making a cres-
centic incision around the posterior two-thirds of the listula and separating by
blunt dissection the bladder wall fmm the vagina and the cervix up to the re-
flection of the perilnneum. The rdges of the anterior third of the fistulous open-
ing arc then denuded down to but not including the vesical mucou.s membrane.
The posterior wall of the bladder is then pulled forward and sutured to the
denuded anterior third of the fistula with inlerrupled silkworm-gul Kutures-
The >uture» are pius^ed through the under surfaK of Uie iHitHerior bbdder wall
so as to invert il» ctlges and prevent the urcthnd orilice fn>m being comprcsse<i
when the opening b closed. The vaginal wound is allowed to heal by granula-
tion.

a. Mackenmdl makes an Jnci.tion completely around the edge of the fistula
and separates the bladder from the vagina by a blunt di.'iscction. He then
denudes the margin.i n( the bladder wall and suture* the vesical opening inde-
pendently uHth silkworm-gut. Icanng the vaginal wound to heal by granulation.

The following operations should never he per*
formed tor the relief of large or inoperable fistulas:

C'LOSfBK or Till: Vacina {Col/>orlfisis).—Tht object of this operation is to
rloM! the vagina and utili7« il as a common receptacle for the uterine discharges
and the urine. Stagnation and infection eventually occur in every case, and the
condition of the patient becomes so serious that free drainage must be secured by
reopening the vagina.

Clos(tkf. op thf. Fisn'iji with thf Ckrvix Utkri.— In this operation the
neck of the uterus is utilized to close the fistula by turning it into the bladder and
securing it with sutures to the mar^ns of the opening. .\s in the case of the
previous operation, stagnation of the uterine discharges and the urine is certain
to result, and the infection may extend to the Fallopian tubes and the (writiineuro
or to the ureters and the kidneys. I'rinary* ^Its are also depocsited in the bbdder
and the juiiient sulTeni intensely from cystitis.

Treatment nf Inoperable Ca^es . — Thi-t consists in removing
and pretrenling the fomution of phosphatic deposits, hcahng the excoriations,
curing the coexisting cjtlilis, and improving the general health of the patient.

j62 ' GENITAL FISTULAS.

Ajter-treatmenl. — Care OF the Wound. — The vaginal tampon i> iHDOTOi
at the end of twenty-four hours and not introduced again. The vagina is tbtn
douched once a day with a Miiution of hot corrosive sublimate (i to looo), fol-
lowed by normal salt solution.

Bladdeh. — During the first two days the urine is drawn with a catheter emr
tw<rh6urs~nd then every four hours until the sixth day, when the patient is »(■
lowed to empty her bladder naturally every six or eight hours. Under no cir-
cumstances should a self- retaining or permanent catheter be employed. In
cases in which the fistula is small it is unnecessary to empty the bladder irilh a
catheter, and the patient should, if possible, void the urine herself evei}- four or
five hours for the first three or four days.

Bowels. — The bowels should be moved on the second day by a puijatiit
dose oT citrate of magnesia and then kept open daily with a mild laxative and
the occasional use of a simple enema of soapsuds and warm water.

Urine. — Careful attention must be given to the renal excretions during con-
valescence,'and the urine should be kept slightly acid and diluted by the admiaii-
tration of Emmet's mixture (see p. 755) or 5-grain doses of benzoate of sodium
or ammonium and the ingestion of three or four pints of distilled, Bedfiod. or
Poland water daily. Unless the reaction of the urine is kept normal by tbest
means, urinary salts are likely to form on the vesical surface of the line of uniu
and imperil the results of the operation.

FlC. 6se.— DOUBLE-CI-'IIIIENI FflliLt rAinF.TIlt,

Diet, ^During the first three days a liquid diet (p. 106) is given, and ihoia
soft diet {p. in) unlil the patient gets out of bed, after which she is placrfuni
convalescent diet (p. 114).

Position of the Patiknt.— It is not necessari- lo keep the patient in ow
position for any length of time, and she may therefore from the first lie on ber
back with a pillow under the knees, or upon her side.

Removal ok the Sutures.— The sutures are removed on the eighth day
In renTOX'iiig them the ti-aclion should be toward the line of union and amnter-
pressure .should be made against the tissues with a tenaculum, othen\-ise thm i->
danger of tearing the freshly united edges of the wound apart and destrojing lif
results of the operation.

I.NTRAVEsicAL HE,\ioHRHAr,K. — Should blood or clots accumulate In the blad-
der, it should be irrigated with a hot solution of boric acid, using for the put-
pose a double-current female catheter attached to a fountain syringe. Tb(
double -current catheter flushe> out the bladder without distending it, and iht
force of the flow can be rcgulaled bv the height of the riibber bag SbouH
this method fail to control (he hemorrhage or wash out the clots, the fistub nu-"
be reo]iene<i, the hlcwling point found and ligate<l with a catgut ligatuft. die
bladder irrigated through the urethra whh hot boric acid solution, and "l"
sutures reintroduced.

OccLt-siON OF THE Ureters.— If symptoms of occlusion of one or bo**
of (lie ureters occur, the sutures must be removed, the ureteral injuries trol"'

VESlCO-rTEJUNE FtSTOLA.

jes

History .^The patient presents a hbtory of a protruded labor, followed in s
short time by a constant dribbling of urine from tnc vapna. As a rule, there is
no attempt upon the pan of the patient to empty the bladder naturally, as «,-ould
be the case if tlie incontinence was due to a ureteral fistula.

Fio. Wi— Vesko vnaiHr i uivLk

Physical Ezamioatioo.— The physical signs are elicited by (a) inspection
and lb) touch.

Fra. *6i —DiAejKBit or * 1 :
Tba lip ot > mod u ihan puad trom ili* l<i.

In»perlion. —The patient is placed in the dor>i>l jxisition and the cervix
exposed with a speculum. The vaftina ami ihe os uieri are ihen wipeil drj- with
a gmuxc sponge and Ihe examiner watche» to detect tlie urine escaping from the

' -jh ilut fivoU wd n mauM Mib ■BOIbn' hnwI ta
the uiiiul mial.

764

GENITAL FISTULAS.

These subjects arc fully discussed under the preparatory treatment for opcnlioD
(see p. 755), and need not, therefore, be r^nred to again.

FlC. 6«0, — AuBI'tATDty UuKAL.

A properly fitting ambulatory urin:il should be worn to collect the urineasil
escapes from the vagina and prevent the external parts from becoming iiiflaiiif<l
or excoriuted.

VESI(X)-UTERINE FISTULA.

Definition. — In this variety of fistula there is an abnormal opra]"?
between the bladder and the cervical canal.

Causes. --Those fistulas arc traumatic in origin and are caused by a if*'
during labor extending through the anterior lip of (he cervix into the Wadoff-
The lower jxirlion of the laceration usuallv heals and leaves a fistulous iract
above, through which the urine esca])es tnl<i the cervical canal.

Symptoms. --The affection is characterized by more or les.s fis"^"'
dribbling of urine from the vagina and llie u.-^ual dejHipit of urinan- .-alls. T"
exlerncil ])arts become inflamed and excoriated and the general health of '''*
patient, as a rule, suffers.

Diagnosis.- The diagnosis is based ujion (1) the history and (1) "*
physical examination.

n s p F c t i n II .— Tlic patient h placrd in the (tiirsil posilion and the cervii
M(Mx«() wilh u speculum. The vtij-ina .ind the os ulcri are ihcn wi|iwl cir>- wilh
h puux s|Minxc Ami the examiner watclies lo delect tbc urine escaping from the

766

GENITAL FISTULAS.

cervix. In order to make sure that the fistulous opening is not connected wilh t
ureter the bladder is distended with sterilized milk, and if the fluid is seen floiring
from the os uteri the vesical origin of the urine is positively determined.

Touch . — In some cases it may be possible to introduce a metallic sound
into the bladder and then pass it through the fistulous openini; into the cervical
canal, where its presence may be detected by striking it with another swnd
inserted into the cervix (Fig. 662).

Progfnosis. — Vesicouterine fistulas, as a rule, tend to heal spontaiieoaslT
by contraction and granulation, and at least sbt weeks or two months should he
allowed to elapse after the injury before resorting to surgical means to effect a
cure.

Treatment. — These fistulas may be closed by either of the two follow-
ing methods:

First Method. — The original injury is reproduced by dividii^ the anleiiw

Fir, 66,i. FiG 66j.

OpEflATIOM TOB THt KEFAIH OF A VESTCO-irTERlHE KiSTtLA. {MoDlFrLD FBnif KfclLT-)

Shdwinfl ihc iccond melhodn ur The f>pcraljnn liy 1h? iiupniubic rouu.

lip of ihe cervix down to the sinus Iracl, which is then denuded and the wiiw
wound closed with interrupted silkworm-gut sutures. The sutures are remoiwi
on the eighth day.

This is (he operation of selection in all ease.'i e.tcept where there is a I;"?*
amount of cicatricial tissue in the vagina and the contraction of the carml pre-
vents the neces-sary exposure of the parts.

Second Hethod. — In this operation the sinus is reached through an incisiun
in the abdominal wall immediately above the symphysis pubis. After openine
the abdomen the uterus (•; pulled into (he incision and the bladder carffu%
separated by dissection down to the fi.stulnus track. The sinus is then divi^"'
and the opening in the bladder closed by interrupted catgut sulurcj. T^*"'
margins of the uterine end of the fistula are then denuded and appHwimalwi lo]
intcrru]itcd catgut sutures. The peritoneum is then drxiwn over the hfW "•
{iperation and sutured to the uterus; the abdomen is closed in the usual nunner

VESICO-UTEROVAGINAL FISTULA.

Definition.— In this variety of fistula there is an abnormal opening t"-
Iween the bladder and the vagina through the anterior lip of the cervii.

KEd'OVACINAL nSTL'LA.

;09

URETERO-XJTERINE FISTULA.

DefinltiOtl. — In this v;iriely of fislulfi ihcre is an abnormal rommunica-
lion lii-twecii one of the ureters and the ccn'kal canal.

1'he causes, symptoms, diagnosis, prognosis, and treatment are dis-
cussed under Maifurmalions and Injuries i>f the Ureters on pages (yji and 674.

RECTOVAGINAl. HSTULA.

Definition. — In lliis variety of tisiula there is an almormal communira-
tion between ihe rectum and the vagina which may lie situalcil al any part of the
posterior vaginal wall.

Description.— These fistulas vary in fixe from a ver\- nninute opening to
that of one brge enough to admit a finger, and in some coses almost (he entire
ie«ova.i;in:il septum is destroyed.

Causes.— The ulcention which tiike-.« place in c.inc«r of the cervix is fre-
quently Ihe cause of a fistulous opening between the upper part of the vagina nnd
the recium. and a fi.vtula in the lower part of the canal is not uncommonly due to
an imperfect union following an o|*er:ili()n for the rejuiir of a laceration through
(he sphincter ani muscle and the rectovaginal septum. In some cases a fistu-
lous opening may t>e due to a 5yphi]itic
or tul^erculous lesion, and in othen it
may be caawd by the burrowing of pus
in a prereclal or jielvic ab*ce*.i. In-
stances ha\c also been obsen-ei] in
which the fi.itul.-i wa* caused by the
long- con tinned prrf^urc of a jwwiirj- or
some other foreign body in the vagina,
and case* have likewise been met in
which the abnormal o|Mrning was doc to
a |>cneiraiing wound the result of cster-
nal violence.

Symptoms.- Thcchief symptoms
of the affeition are the escape of feces
and flatus into the vagina and the mh-
sequenl development of vaginitis and
vulvitis from the irritation produced by
the constant prcvnce of fecal matter.
The local condition of the patient is
often di?4[U9.ting ; »he broo<U over her
condition, secludes her*<lf from soriely,
and in some instances she may even be-
come melancholic.

The severity of the ^mptoms dqwnds upon the sixe of the fistula. A targe
opening allows the feces and the flatus to escape freely into the vagina and Ihe
rulva is c«n,«ci)uently co\'ere<i with eKcrementilial matter. On the other hand,
solid feces will not pass through a small fistula, and hence the patient can usually
keep the part^ in a clean condition tmless she b suffering; with diarrhea. There is,
howexer, ab^loiely no control over the gas, which escapes from time lo lime
with an jiuiible sound and prevents the patient from enjoying social intercourse.

Diagnosis.— The di:tgiu>si.i of a rettovagfnal ti»tula k baie<l ujiun (1) llie
history and (2) the physical examinatton.

■>i

^r;

!^VK

Pio. M«.~IElctDf iiui Fittvu.

770 GENITAL FISTULAS.

History. — The patient gives a history of inability to control liquid feces and
flatus, and sfae complains of the constant presence of more or less excrementitial
matter on the vulva.

Physical Ezamioation. — The physical signs are elicited by (o) touch and
(6) inspection.

Touch . — The patient is placed in the dorsal position and the index-finger
introduced into the vagina. If the fistula is lai^, its vaginal opening can readily
be felt and the tip of the finger passed into the rectum. A small fistula, on the
other hand, feels like a shallow pit or depression, and its connection with the
bowels can be demonstrated by passing a probe through the opening into the
rectum, where it can be recognized by rectal touch (Fig. 92). The rectal end of
a fistula always forms a characteristic funnel-shaped depression, which can be
located by palpating the anterior wall of (he rectum, and then, by pushing it
forward with the tip of the finger, the vaginal opening becomes dilated and can
readily be seen.

Inspection . — The patient is placed in the dorsal posUion and the posterior
wall of the vagina exposed by elevating the anterior wall with a Simon speculum.
The entire surface of the vaginal wall is then carefully inspected, and if any
abnormal pits or depressions are noted they are sounded with a fine probe, which
passes at once into the rectum if a fistulous opening exists. Large fistulas are
readily seen by simple inspection, but small ones are very apt to escape detection,
and require a special method of examination to ascertain their position. This
is easily accomplished by injecting milk into the rectum and observing the point
on the vaginal wall at which it escapes into the vagina. The best apparatus for
the purpose consists of a fountain syringe with the rectal nozzle attached; the
bag is filled with milk and held about three feet above the patient while the fluid
is allowed to flow into the rectum.

Prognosis.— A fistula caused by cancerous ulceration is incurable, and the
prognosis should always be guarded when the abnormal opening is due to syph-
ilis. In the latter case the operation for closure is almost certain to fail unless
the patient is first subjected to a long course of and-syphilitic treatment and
placed in a good general condition.

Fecal fistulas of traumatic origin, as a rule, show a decided tendency to heal
spontaneously, especially if the parts aje kept clean and the sphincter ani muscle
is stretched.

The operative prognosis should be guarded in all cases, as infection from
the rectum and the mechanic disturbances of the wound which are caused by
the accumulation of feces or gas in the rectum, as well as the act of defecation,
may jeopardize the most skilfully performed operation and cause it to be a
failure.

Treatment.— The treatment of fecal fistulas is divided into the manage-
ment of (1) recent cases and (a) chronic cases.

Recent Cases. — An effort should always be made to bring about a spon-
taneous closure of the fistula by means of local cleanliness and the proper care of
Ihe bowels. The vagina should be irrigated three or four times daily with a
quart of hot boric acid solution (sij to the quart) and the bowels regulated by
an occasional purgative dose of citrate of magnesia and the daily administration
of a simple laxative followed by a rectal enema of soapsuds and warm water.
As the sinus lessens in size it should be stimulated once a week with the solid
stick of nitrate of silver or pure nitric acid.

The above treatment is often successful in healing a small traumatic fistula,
and it should be continued for two or three months, or even longer if the opening
shows a tendency to close.

URETERO-UTERINE PISTUIA.

iltion. — In thU variety of li^tiitu there if- an abnormal cnrnmunica-
vi-iii .int o( the ureler* ami Ihc ccnical tanal.

causes, syinptouis, disgnosis, prognosis, aiul treatment .ire lOa-
cd under ilallonnauoiib and Injuries of the Lrctcn> on pages O73 and 674.

RECTOVAGINAL FISTULA.

Definition, — In this varicly of fislui;i llu-ri; i.% nn nltnormal communu-n-
itxii Ik'Iwccii ihc rectum and Ilie vagina which may he situated at any pait of the
(HMterior vaji'nal wall.

Description.— These fistulas vary in siie from a very minute npening to
Uiat of une Ini^c enoui;h to admit 3 finger, and in some cases almost the entire

r<iv;i);inal wrjitum L-i destroyed.
Causes.- The ulceration which takes place in cancer of the cervix h tit-
XcniJy tlie cau.^e of a fijlulous- ojicninR between the upper pan of the vagina and
* rccttim, and a Itslula in the lower piirt of ihr <'auai i.'^ nul uncummonly due to

an imperfect union following an operation for the repair uf a IsccFalion through

l)ie sphini ter ani mu.icle and (he rectovaginal septum. In some ca^cs a tistu-

louB oiwning may l>c due to a syphilitic

or lubcrtulous IcUon. and in others it

ttuy be c'au>«d by the burrowing of pus

in a prerectal or pelvic abscesv In-

stance.4 liavc aUo been observed in

which the li.'^lula was cuuseil by the

long- continued pressure of a pcssat>' or

some olbtT foreign tioily in the vagina,

and cases have tikenisc been met in

which (he abnormal opening was due to
^penetrating wound the result uf exter-
^■U vtuk-nce,
^■SjanptomB.— The chief symptoms

of the alTcction are the escape of feres

<l ttatus into the mgina and the sub-
uen( (leveliipnient of vaginitis and
vitis from the irrit^tiim pniduced by
, the constant j)rescncc of fecal matter.

P- local condition of the patient is
n disgusting; she broods over her
(lilion, secludes herself from society,
in some inMances she may even be-
te melancholic.
The severity of the symptoms depends upon the size of (he fistula. A large
I Opening uUnws the lcrr< itnd the llaltis to esi:n|ie freely into the vagina and the
vulva is consequently covered with c\crcmentitial matter. On the other hand.
M^lid feres will not [>a.'<.4 through a small fl^tula. ami hence the iiatienl can usually
keep the parts in a clean condition unless she is suffering with diarrhea. There is.
however, ab.solulely no control o\'er the gas, which escapes from lime to lime
uiih tin ;iiiijible MHmd and p^evcIll-^ the |vilient fmm enjoying .Hmial inlercnurse.
DiagnoSiSi— The diagnosis of a rrclovuginal listula is based ujton (>) 'he

tt ami (i) the phvsical examination.
t

Pl& M^<^H(C7<>VA>II>I»I tlUVUI.

770 GENITAL FISTULAS.

History.— The patient gives a history of inability to control liquid fccts and
flatus, and she complains of the constant presence of more or less excrementitial
matter on the vulva.

Physical Ezamination. — The physical signs are elicited by (a) toucb and
(6) inspection.

Touch . — The patient is placed in the dorsal position and the iDdeX'fi£f[n'
introduced into the vagina. If the fistula is large, its vaginal opening can readEr
be felt and the tip of the finger passed into the rectum. A small fistula, on the
other hand, feels hke a shallow pit or depression, and its connection with the
bowels can be demonstrated by passing a probe through the opening into the
rectum, where it can be recognized by rectal touch {Fig. 92). The rectal md of
a fistula always forms a characteristic funnel-shaped depression, which can be
located by palpating the anterior wall of the rectum, and then, by pushing it
forward with the tip of the finger, the vaginal opening becomes dilated and can
readily be seen.

Inspection . — The patient is placed in the dersai position and the posterior
wall of the vagina exposed by elevating the anterior wall with a Simon speculum.
The entire surface of the vaginal wall is then carefully inspected, and if any
abnormal pits or depressions are noted they are sounded with a fine probe, which
passes at once into the rectum if a fistulous opening exists. Large fistulas are
readily seen by simple inspection, but small ones are very apt to escape dcleclioii.
and require a special method of examination to ascertain their position. This
is easily accomplished by injecting milk into the rectum and obser\-ing the poini
on the vaginal wall at which it escapes into the vagina. The best apparatus for
the purpose consists of a fountain syringe with the rectal nozzle attached; lit
bag is filled with milk and held about three feet above the patient while the Aiiif
is allowed to flow into the rectum.

Prognosis. — A fistula caused by cancerous ulceration is incurable, and tbe
prognosis should always be guarded when the abnormal opening is due to syph-
ilis. In the latter case the operation for closure is almost certain to fail unlBS
the patient is first subjected to a long course of a nti- syphilitic treatment and
placed in a good general condition.

Fecal fistulas of traumatic origin, as a rule, show a decided tendency to beaJ
spontaneously, especially if the parts are kept clean and the sphincter ani miiidf
is stretched.

The operative prognosis should be guarded in all cases, as infection from
the rectum and the mechanic disturbances of the wound which are caused bj-
the accumulation of feces or gas in the rectum, us well as the act of defealwi.
may jeopardize the most skilfully performed operation and cause ii to be J
failure.

Treatment.— The treatment of fecal fistulas is divided into the amn^
ment of (i) recent cases and (2) chronic cases.

Recent Cases. — An effort should always be made to bring about a spon-
taneous closure of the fistula by means of local cleanliness and the proper careM
the bowels. The vagina should be irrigated three or four times daily wiun
quart of hot boric acid solution (sij to the quart) and the bowels regulaieo by
an occasional jiurgative dose of citrate of magnesia and the daily adminisimW
of a simple laxative followed by a rectal enema of soapsuds and warm b's'^.
As the sinus les'^ens in size it should be stimulated once a week with iht SMid
ftick of nitrate of silver or pure nitric acid.

The above treatment is often successful in healing a small traumatic fistuh.
and it should be continued for two or three months, or even longer if the opcing
shows a tendency to close.

■ECTOVAniN'AI. PlfTTULA.

771

Chronic Cases. ^The nuinuKcmi-iit of dimiiir ftKtuIiu is divided into (u) the
oper.ilivc Irciimcni and (ft) th<: Ircaltncni of inopcrnblc cases.

0 (1 e r ;» t i V i- T r c a I m c n 1 .—This mniiftts in denuding llic edges (if
llir fi^luln and approximaling ihcm willi sutures iii the same way as in ciuung
u v«.-si<x)Vdgin.'il b:>tula.

Frefrnralioti oj Ike Patient. — The patient t> ymytartA in the jame manner as
for an ordinary plastir (»]>er»tton (scr {>. 850), rxrepl ihnt ji boric iicid M>liilinn
(31) 1(1 th« quart) h substituted for the corrosive sublimate solution to cleanse
tlu: v;if;iiui and the l>onelt>.

Three days before ihc operation the bowels are Hushed out with a purgative
do(*e of citrate of mii^iic^ia followed !>)■ u hir^c rectal enema of >oiip><uds and
warm water, and then ojiened daily with a mild Ux^itive. On the evening
Wore the day of operation the patient is given .t bottle of citrate of maf^ncsia,
a»d on die folloninK niornini; a rectal enema (ioapauili and uiirm Kutrr) Is
admin istiTcd, The diet during the three days of preparation should lie litpiiij in
character in order to leave as little residual matter in the intestines as possible
bikI thibileiui-n the datifier of cxorementitial material accumulatiiiK In the retium.

I'osilioH ol /Ac I'alifHt. — The palienl Is placed in the dorsal position.

'I'hc nuinbrr oj asusliiHls, iht dressings, and the/tVf 0/ intlrumtnts are the same
ts in the (>per;ilion for the clo-iure of a venico^'a^inul li^ltda (>«e p. 754).

Ofieralian. -Tlie first step in ihe oiiernllon is to pnraly« the sphiiii ler ani
Btuscle by stretching the anus in oitlcr to prevent the collection of j;as and fetes
durinii; the pniu'eu of healing. The va)!iii:i nnil the rectum are then douched
with l>oric acid si'lution and thoroughly dried with a gauze sponge held in ihe
^sp of the drcMing forceps. The rectum above the fistula is then packed with
* strip of Btcrile gauw lo keep back the fecal mutter and prevent it from infect-
Inf; the fiekt of operation.

The edges of the fi.slulouji opening are denuded and sutured in i>rerixcly the
Same way as in closing a vesicovaginal fistula; the rectal liimpnn removed; the
vagina irrigated wiilt a solution of rorro%ive sublimate [i lu jooo) and wiped
dry; and ^ Imne i:au/e tampon inserteil into the vagin.il c.-inal.

Sfiffiiil Pirrdiitns. The same precautions must be taken in making the
denudation and in introducing the sutures as are mentioned in the operation for
re|>airing a veMcovaginnl li.stuht.

AjtfT-lreatmtnt.—ilAKV, uk ^nv. Wou.sn. — The vaginal tampon is removed at
the endoflM-enty-four hours and mil re-introduced. The vagina is then iaig-jted
«Hicc a day with a quart of corroMvc sublimate solution (t to 3000], followed
immediately by a pint of hot sterile water,

BLADtiER. — Tlic u.se of a catheter is unneecajkaiy, and the palJent ihould be
«ncouTagcd to void her urine naturally.

B<>wi;ls. — The bowels should be moved every day after the first forty-eight
Itoun with half a bottle of titrate of magiienia or a mild bxative pill. Kcctal
«nemata -ire contra indicated, as ihey distend the bowel and mcrhanically inter-
fere with ihc wound. If the sphincter ani muscle has been thoroughly paralyzed,
there is no ten<lent y toward the collection of Hiitu'. ami it piLv*^ freely out of the
anus without causing distention. If. however, the muscle has not been properly
stncrhed aiul gas ac(umulatcs in Ihe rectum, a tube should lie pas.scd into the
1*™*! juiil beyoml tlie inienud sphincter three or four limcf a day, or m often as
may Ik ttecesviry.

Diet. — During the first week a Ii<(ui<l diet (p. ie6) is given, aiuf (hen a soft
dart fp. lit) until th« [wtienl gets out of bed. after which time «hr is placed on a
convalescenldiet (p. 114).

PostnoN OF THE Patient. — It is unneccMary to keep the patient in one

77a

GENITAL FISTULAS.

position for any length of time, and she may therefore lie either upra ber
back or upon her side.

Removal of the Sutures. — The sutures are removed on the eighth day aui
care taken to avoid traction upon the line of union in withdrawing them ifm
the tissues (see vesicovaginal fistula, p. 762),

Getting Out of Bed. — The patient should remain in bed for two weeksuid
then be kept in her room for seven days before going out-of-doors.

Treatment of Inoperable Cases . — The vagina should be
irrigated two or three times daily with boric acid solution (31] to the quart); the
diet regulated so as to leave the smallest amount of residual matter in the inlts-
tines; the bowels evacuated thoroughly once a day to avoid the constant presoice
of feces in the rectum ; and a hot sitz-bath should be taken at bedtime to pmmt
local irritation occurring about the vulva.

RECTOPERINEAL FISTULA.

Definition, — In this variety of fistula the sinus begins in the rectum and
opens anywhere on the perineum from the vulvovaginal orifice to the anus.

Treatment. — These fistulas are difficult or imp>ossibIe to denude, and
hence they must first be converted into a median tear involving the sphincter id
muscle before an attempt can be made to close them. This is accomplished br

FlO. 610.— RRCIO^KRlNKiL FlSIUlA.

Fir.r 671. — OpEPATioN roil ttie Rlfuk ot i R**^

PEWNEAt FtSH'U.

introducing a Rrnovcd director along the fistula into the rectum and hmp<4 ^
tip outside of ihe anal opening. The inter\'ening structures, which incMf '"
sphincter muscle, are then divided with a bistour>' and ihe exposed sinus l^f
denuded along its entire tnurse down to, but not including, the recta! muf*^'
The wound is ihen united with sutures in a similar manner to that eraplo)t<''°

774

GENITAL FISTULAS.

is accomplished by first intrcxlucing a stiff silver probe, threaded with a loi%
narrow, elastic, rubber ligature, a short distance beyond the labial opening aod
directing its tip downward against the perineum just beyond the external edge of
the sphincter ani muscle. An incision is then made through the tissues ovtrthc
probe, which is liberated and withdrawn along with one end of the Ugatuic
(Fig. 673).

A flexible probe is now threaded with the other end of the ligature and passed
through the labial opening into the rectum, where its tip is bent forward and
directed out through the anus. One end of the ligature now protrudes throuj!ii
the anus and the other through the incision in the perineum, thus leading tk

Fic. 6j<. Fio. 6ts.

OPEBATION FOB THE ReVAIII OF A ReCTOLABIAL FtSTDXA.

T'li. 674 shows the LgAlurr Bllachrd tn The ftiff probt diawa ihrou^h Ihe ap«ain« id the pcnsnin '''^
the olhpr end of Ihe ligaiurp bnng carri«l 00 a dcnbfe pmhe ihrough the fistula iaio the rtttum aviiff fl *
anus (61 ^ Figr tfjs showa one ena of the lifatuir [iratrudLiiK Irom the anus abd the other end IroD llv ikVA
in Ihr ptrineum.

labial end of the sinus tract entirely free and changing the abnormal comniuni-
cation to a simjile fislitla in ano. Both ends of the ligature are now dravn la"!
and tied, and the labial end of (he original sinus left to itself.

After-treatment, ^It is unnecessary to confine the patient to bed, ajihwe
is but little pain or discomfort following the operation. As a rule, the lipture
cuts ils way through in from six to eight days, and if the pressure become! rf-
laxed before the process is completed the remaining tissues are readily dii'i'lM
with sci.ssors.

The labial opening usually closes in from one to two weeks.

ENTEROVAGINAL HSTULA.

Definition. — In this variety of fistula there is an abnormal communio'i""
between the intestine and the vagina. .

Treatment.— If the fistula is small and the lower part of the bo**" ■*
patulous, an effort should be made to close the opening by denudation and Minir-
ing in a manner similar to that already described in the treatment of a t"^

STEW UTV—OKPINITION— CAUSES.

77S

rsgioal fisiulii. A large fistula or on« that is associated with occlusion of the
lower end o( the intestine should be Ircnlcd by opening the abdomen, separating

/ . ^-

fi^.

ai-t

CHAPTER XXXVII.
STERILITY.

(be bowel from the rsgina, and re])aihng the lesions according to the indication*
pteenl.

^P Definition. — By stcriliiy w-e mean an inability upon the part of a woman
i^io prtMlucc a living child. This dcfiniiion therefore indudes luH unly women who
catinol iiontcivc, (>ui also (h<jse who become |>ri'gnaiil .md habitUAlIy abort
briorc ihe [Wriixl i>( i*i:itiilily.

Sicrilil)- ma)- be cither primary or iteondary. It is allied primarj- when a
woman hai never conceivci]. and nerondar^' when she has bitrne one child.

Causes.— It i» esiimafcd ihat about one marriase out of nxn- eighl or ten

[i-hildlcss, and until moden) limes it was fuenerally bdievetl that the rau5C was

" Host entirely lo ihc wife. Recent invcs ligation, howcier, has determined

lhat the husband is oficn cither dircill)' or indirectly at fault, and it Is

?V>rr nwe-iMry lo amwrler the possibilily of ihe miile being Merile in all cases

in which marriage i*. nol follon'cd by offspring.

Sterility in the Hale. —The most frcqucni rauNe^ of ^.terility 111 the male are
<<i) a Ijck of erciiilc [wiwcr of the penis {(wi^n/cwcy); (ft) an abi^enie of jiwr-
inatozoa in the semen (jroiij^/iirw); (e) a deficient secretion of seminal fluid
{tuprrmia). In aildiliim to these direct causes of (.icrilc marriages, the male
may infect Ihe female nith gonorrhea, and thus indirectly be responsible for the
bnrTetine<d which results from .■■peciti<- difteases of the uieru.s and its adntxa.

We arc prolwhly not far from Ihc trwlh in slating that one out of every «x
childless marriages is due to the absence of &pcrmalo/.oa in the semen or inability
OD the part of the m^tlc tii properly perform the ad of copulation ; and if we also
include those women who become sterile frum gonorrheal infection, the propor-

Jj6 STERIUTY.

tion will be about one to four in which the husband is responsible for the Id-

fecundity.

Sterility in the Female. — The essential factors in procreation, so far u the
female is concerned, are (a) the presence of an ovum, {b) the capadly fear
copulation, (r) normal secretions, and [d) a healthy endometrium upon irhidi
the product of conception can lodge and develop. Sterility is physiologic prior
to the period of puberty, during lactation, and subsequent to the menopause,
and it is not uncommon for women to cease bearing children several years bt-
fore the change of life actually occurs.

The causes of sterility may be either (ongenilal or acquired, and they out
involve any oi^an of generation or portion of the genital tract from the vulva to
the fimbriated extremities of the Fallopian tubes. In addition to the local caoscs
of sterility, the general condition of the patient is at times responsible for the
absence of conception, and it is not uncommon for women who are suffering from
some constitutional affection to remain barren for an indefinite period.

The Vulva . — Congenital Causes. — Absence of the itilva acts as tat-
chanic obstacle to copulation, and therefore prevents insemination.

Acquired Causes.— TumoTS, of the vulva and elephantiasis prevent into-
course from taking place, and in cases of urethral caruncle, kraurosis, inflam-
mation, or other painful local conditions it is rendered impossible on account
of the pain which results.

The Vagina . — Congenital CdHJK.— Sterility may result from abseDcetr
atresia of the vagina and from a transverse septum which is sometimes found in dK
upper part of the canal. The vagina may also be abnormally short and unible
to retain the semen. In some cases the hymen is at fault, and it is found to be
imperforate or so thick and elastic that coitus takes place without nipturii^it-

Acquired Causes. — Atresia or occlusion of the vagina resulting from a serwe
inflammation or a faulty operative technic is sometimes a cause of sterility, TIk
hyperacid discharge caused by a vaginitis is likely to destroy the spennaloi'"*.
and thus j^revent conception from occurring. The toxins which are produced by
the urine that accumulates in the vagina in cases of genito-urinaiy fistulas afl
in the same way. Inflammatory conditions and vaginismus render intercourst
impossible on account of the pain or spasm which they cause, and vaginal tumors
acl as an obstruction to the entrance of the penis.

The Uterus . — Cotigenilal Causes. — The following congenital malfon"*'
tions result in sterility: Displacements, absence of the uterus, atresia, a caixM
cervi.x, and an infantile or a rudimentary uterus.

Acquired Causes. — Sterility is frequently of uterine origin, and the bh*'
common causes of barrenm'ss, next lo diseased conditions occurring in the Fil-
lopian tubes and ovaries, are found in the uterus.

Endometritis is often a cause of sterility on account of the discharges wm
accompany the disease and the altered character of the uterine mucous iW"
brane. Under these circumstances the spermatozoa are usually destros^ed by w*
discharges and conception does not occur; or if pregnancy does take [Ja*
abortion follows, as a rule, as the fertilized ovum cannot become securely ''"
tached lo the uterine mucosa, which has undergone pathologic structural change^'
In cases of cndocervicilis the mucous membrane of the body of the uienis e
usually also inllamed, and sterility not only follows as the result of this condition-
but the ccr\'ical canal may become plugged with thick mucus and prevent''"
entrance of spermatozoa into the uterine cavity. Subinvolution itself does ""'
usually cause .sterility, but the coe.xisdng endometritis and the frequent pre5«|*^
of lubo-ovarian inflammation are often responsible for the infecundiiy ^'^
accompanies the affection.

CAUSES.

777

Wen-marked flexions of (he uierol are often aisocinled with «lerility. In
lhe»e case*, liowever, the lack <i( fwuniiity i* nt>l due in the l1e\cil condition of ihc
uterus but to the accomjii/inying crnkkmctiitU. which is associated with u profu!«
diMJiarge and sn altered condition of the mucous membrane. U'e often meet
youi% women in wl»"m ihc iiieni.< is sharply beni anteriorly, and who suffer from
a severe form of obsiructiic dysmenorrhea, becoming pregnant soon after mar-
TU|te. These ca.te.t dcmonitrale tlie fact tliui a Hexinn iL-«lf It not cnjinble of
preventing concq>li<>n, and that sterility doc* not nccvir until the mucous mem-
brane becomes pathologically altered by (he lung-conlinued presence of the dis-
tortion.

Uncomplicated cases of retroversion of the uterus very seldom, if e^er, result
in .tlerility, and when infecuntUly docs occur, ilie cause is usually tourid to be due
to lulhi-sions, lubnt disease, or .1 riM:>:t,viin); cndnmctrilis. Kilin:>id tumors in
some instances may mechanically prevent (he entrance of s|>cniialoxoa into ihe
uterirve (mvity, but, as a rule, the infecundily is due to ihe accumpunyin); endo-
metritis and not lo the presence of the neoplasm. If conception occurs in these
cases, the fertilized ovum usually becomes dislodged and abortion follows.

Hypertro))h)C elonxation of the cervix, .itetuWis of the cervioil ranni, nnd
Lccrulions of the cervix are not infri-(|ucnlly accompanied by sterility, and, as a
rule, the infecundii)' is due lo ihc coexisting cndomctrilis, and not to the presence
of the lesion. Atrf-Mii of the cervit^il canal resulting from a faulty oi>era(ive
tcchnic or the application of strong iicidti is, of course, a positive obstacle to Ihe
iRgresa of spermalozo^.

Uy|>erin volution of the uterus usually ciiuses .'tterilily, and if the uterine- cavity
measures less than two inches the cise is hopeless. Malignant disease of the
body of tlie uterus U seldom associated iviih pregnancy ; involvement of the cervix,
on the other hand, is not. as a rule, a barrier to conce{)tion in the early stages of
the disease, and if gestation occurs it may continue to full term.

The Fallujiian T u h e s .—CotijchwiVo/ Cuiwa.— In tome cases
sterility is due lo the tubes Wing absent, and in others their development is
rtidimentary or defective. S'>melinies the oviducts have an abnormal number of
convohtiions, or they are e.vc<ssive in length, whii h interferes with the passage
of the nvum and the ingress of the spermatozoa.

Adjuirtii Cauiei.—'Vhe oviducts play a very im]KirtanI rflle in the processes
of concquion, as they arc the channels through which the ova arc conveyed to ihc
uterus, and even ihe most lrivi<il interference with this function often results
in pcrmaiienl sterility. We therefore f i n il that pathologic
conditions u( the Fallopian lubes are the most
common causes of infecundity, and that women u-ho
norm.al fail to conceive on uccnunl
tubal affection which can only be
the abdomen is opened at the lime
of an nperalion.

Salpingitis or inflammation of the oviducts is responsible in the majority of
instaiKes for tlie .>trui:iurdl thanges which lake place in the organs and destroy
their function. Thrje changes ;ire usually <lue to either gonorrheal or sqitic
infection ; the former being a frequent cause of cases of primary sterility occur-
ring in ytmng married women who have becunie infectd by their hu^lKind." MJth
a latent form of the disease. The changes which result in sterility may afle<c(
either (he serous, the muscular, or the mucous coat of (he oviducts, and the;' vaty
from Mlight or unimportant conditions to extensive degenerations which cause
complete dcslniclion of all Ihe tissues.

AiihestoDs iDvolving the serous coat are veiy common, and they are probably

■ re apparently
of some slight
detected after

778 STERILITY.

a frequent cause of sterility They may pass across ttie tube and occlude its
caliber or bind it down in a tortuous or kinked position; again, tliey may cause
fixation and prevent the abdominal end of the oviduct from coming in contact
with the ovary; and, finally, they may obliterate the tubal opening by agglutinat-
ing its fimbriated extremity.

Inflammation of the muscular coat interferes with the peristaltic action of
the oviduct and tends to prevent the ovum from passing into the uterus.

The pathologic changes occurring in the mucous lining of the tubes are the
most frequent causes of sterility, and they are very apt to be present in both the
acute and chronic forms of salpingitis. Acute catarrhal salpingitis may result
in temporary sterility on account of the swollen condition of the mucous mem-
brane, and if resolution takes place the function of the tube is restored as the
swelling subsides. Chronic salpingitis is very liable to produce desquamation of
the ciliated epithelium and cause sterility. This is due to the fact that the
function of the cilia is to carry the tubal contents toward the uterus, and if they
are destroyed the passage of the ovum through the oviduct is prevented. Under
these circumstances the ovum either dies and sterility results, or it becomes
fertilized and an ectopic or tubal pregnancy follows. Inflammation of the
mucous membrane of the oviduct may produce a permanent closure of its ab-
dominal or uterine opening or both, and thus cause an insurmountable barrier
to conception. These changes are often associated with a collection of serum or
pus {hydrosalpinx and pyasalpinx), and the tubal structures are usually so com-
pletely degenerated that the function of the oviduct is forever destroyed. And,
finally, salpingitis may be accompanied by an acrid tubal secretion which is
hostile to the spermatozoa and ova and causes their destruction.

In rare instances the presence of a tubal neoplasm obstructs the lumen of the
oviduct and causes sterility.

The Ovaries . — Congenital Causes. — Sterility may result from an ab-
sence or a rudimentary condition of the o\'aries.

Acquired Causes. — The ovaries may be bound down by adhesions in such a
position that the fimbriated extremities of the oviducts cannot come in contact
with them, or thej' may be so imbedded in inflammatory exudates that the ova
cannot escape from the ruptured follicles. Sometimes the ovaries may be
simplv displaced without adhesions being present, and sterility results from this
cause alone. Inflammation of the ovary may produce atrophy and the organ
become sterile or incapable of maturing ova. It may also result in thickening
of the surface of the ovary and prevent the Graafian follicles from rupturing.
And, finally, cystic or solid tumors of the ovary are usually attended with ster-
ility.

General Causes . — Constitutional disturbances are not an infrequent
cause of sterility, and it is more or less common to meet barren women in whom
the pelvic org;ins are apparently normal. In estimating the effect of the general
causes upon sterility we must always bear in mind, however, the possibility of
some undetected or trivial tubal lesion being responsible for the condition;
otherwise we may place too much importance upon the former and arrive at an
incorrect diagnosis. Great obesity is one of the most frequent causes of infec-
undity, and women who rapidly accumulate fat soon after marriage seldom have
more than one or two children. Sterility may be caused by anemia, especially
when it is attended with adiposis, and it may also be associated with lithemia,
chlorosis, diabetes, and chronic renal inflammation. Women suffering from
chronic alcoholism, tuterculosis, and cancer are not liable tn conceive, and abor-
tions are very apt to occur when the constitution is affected with s}'philis.
Women who masturbate are usually sterile.

tHAGNOSlS— PROttXOeiS.

779

ubjec

cilhfrs

Curious instances have been obscncd in which a divorrc has follow-cd atier

wvcr.-il years (if Iwrrcn M-eillut k, ^n<l the hu^)>and m&mc^ a setund wik- ant] the

,wifc a s«f>n<l hiir^hand, ;ind Imili m-trriagcs are followed by offspring. The

use of the sicrilily in ihei* cxiraordinary cases is not IcnoM-n, and ii can only

attribute*) to an indefinable se.vuitl inci>nn)>atibilit}' briweai the huxband and

■ife.

Diajrnosia.— The diasnoits is bai«d upon the rccoRnition of the cjiusc.

In cases of pnmnry sterility the i n vi-n I i gallon mirst include both the husband

ikI [he u ife, as (he former may be at fault or the bller may have an ai'(|uire<l or

weenil.At condiliiin which will explain llic in fecundity. In cases of strondary

erilily. however, the inve>ti(;."ili<in iv llmiiral (n the .iniuired cniise* in the wife,

IS tite fait of her having l)ome a child would nece^'uirily exclude the husbanil or

the ciini;cnilal i uu^-t^ fr«>m tieinj; respi)iv.vihle for the slerihly.

Tlie Husband.— The phy:^ici;iii slioujd not have any false modesly nboul
lionini; the husband concerning the sexua) act. us it is unfair to the wife lo
cl her to nn examination ;ind tnr^itment unlesn it is cerLiin that 5he is
nHble for the lack of otTspring. We should, therefore, question the husband
Irtlhe erectile power o/ his penis am! his ability l<i properly |ierfi)rm the sexual
t. In some ca*ei com|»lelc imjiotemy exists and pcnelr:Uion i» impossible; in
the ejaculation may occur before the penis is introduced into the vagina;
, linally. the orit^n m.iy become flnccid wiihoul ejainibtinn Mion after |iene-
tion. We should nlso a»cert-Tin whether the husband ha* ever contracted
iliilis or gonorrhea; and if he has had the Liller disease, whether there was a
hiirge present at the lime of hi,> marriage, I'mler theie circum^lances
:>ic examination should be made of the urethral secretions in order lo
iver. if iKissiblc. the presence of gonocM:ci. The penis siiould I* examine)]
the position of ihe external meatus determined, us case» of sterility have been
icI which were due to a hypospadias. And. finally, a microscopic exami-
must he maile of die seminal tluid In nMertain tlte preM'nce or ahsence of
sperm.itoxon. The semen is collected as follows: 'I'hc husband h;is connection
with hi." wife with a condom, which is immediately i>lace(i in a brittle and -leni
lo hi.< phy.virian, who eA.imine* the strmen at once, if no spermalo^.on are found
in ihe semin.il fluid by the microscope, the sterility is due to a«M>spennia. and it
U therefore unnei es.sary to subject the wife in an examinutiun or treatment.
The Wife.— A ihorough examination must l>c made of ihc genital tr.ict from
vulva to the ovaries to ascertain the presence or absence i>f an>' of the ac-
iiet) or eongenila) causes of sterility, i'he general eau.«e^ mu^t aha be con-

I and .t nreful investigation shoidd l>c made of Ihe entire system.
Il is imponani in all cases, as a routine practice, to determine the reaction
of the Vaginal and uterine diM'harges. as they nre not infrvipientty m> altered in
chararirr th.il they destroy the spermiiloiZOA and cau.!* sterility. These secre-
ts .ire collected on a probe wound with .iliMirbent i-olton and then tesle<] with
ilinu^ [laper. The vaginal disch;irges an* .-^liglillv acid in health, but if hyper
"Hdily exists they arc huslilc to the spermatozoa. The uterine discharges (uteto-
tA>)/), on the other hand, are alkaline, and an acid reaction L> therefore .ibnormal.
Prognosis.— The prognosis in c^ses of both primary and acquired sterility
very uncertain and unsatisfactory'. In a general way il depends upon the
use, although we cannot prnmLse. even if it is removed, ih.-it pregnancy will
Itow. Congenital causes involving an absence or a rudimentary' condition of
r«])n>duc tit's organs arc hopelewt, and the prognosis is equally liad in many
the acquired raascs, I'niess the uterus or it,< adne.xa have been removeil by a
rgicn) operation pregnancy may occur even in cases in which it seems im-
ihle, attd the most extraordinary In^tunccrk are met from time to time in which

Jtion

ySo STERILITY.

women have conceived after years of barrenness. This is true not only of secoD-
dary sterility, but also of the primary form, and it demonstrates the fact that it is
possible for pregnancy to occur even in apparently hopeless cases. The phy-
sician should therefore be very cautious in expressing an opinion, and under do
circumstances should he be led into giving a positive prognosis one way or the
other.

In cases of primary sterility the probability of having children is not good if
three years have elapsed without conception occurring, although it must be ImnK
in mind that conception not uncommonly takes place after that period. .^-
cording to carefully compiled statistics, about three-fourths of the women men-
struate but once after marriage, and are delivered of a child in the course of the
first year- Sometimes, however, perfectly healthy men and women many uid
several months elapse before conception occurs.

Treatment. — The treatment is based upon the removal of any local or
general cause which may be present.

If the secretions of the vagina are hyperacid, a vaginal injection composed oS
two drachms of bicarbonate of soda to a quart of warm water (rio° F.) should be
given immediately before intercourse to counteract the acidity and prevail the
destruction of the spermatozoa before they enter the uterine cavity. The in-
jection should be given with the patient in the dorsal position, so that the solutioa
will thoroughly flush out the vaginal culdesac and neutralize the discbaij^es.
She then assumes the erect posture and allows the excess of fluid to escape from
the vagina. These injections should be employed for an indefinite length of tinif
or until pregnancy results if the treatment Is successful.

The entrance of spermatozoa into the cer%'ical canal is undoubtedly faciiitaled
by elevating the hips upon a pillow during the act of copulation, and this postural
treatment may therefore t>e employed as a routine practice in cases of sterilitr.

Curetment of the uterine cavity should be employed as an empiric phn of
treatment in all cases of sterility in which no cause can be discover«l lo account
for the condition. Under these circumstances pregnancy has frequently folloiifd
this operation, and as it is devoid of all danger, the patient should be given ibt
benefit of any good results which may ensue.

As stated elsewhere, the most frequent causes of sterility are tubal in origin,
and they are often of so trivial a nature that they cannot be detected without per-
forming an exploratory abdominal incision. The question therefore iLiturall.'
arisesasto whether we are justified in advising such an operation in cases in whicb

no cause for the infecundiiy can be discovered. Personally I amnf
the opinion that this question must be decided by
the patient herself, and if she is willing to runl^if
slight risk to her life that the operation necessaril)'
involves with the hope of having offspring, the fUf
geon need have no hesitancy whatever in exploring
the uterine adnexa through an abdominal opening-
The technic of this operation is fully described in the chapter on Conset"-
tive Operations uj>on the Uterine Adnexa on page 572, and therefore nf™
not be discussed here.

THE PELVIC FtOOB— ANATOUV.

CHAITFR XXXVin.
THE PELVIC FLOOR.

ANATOHY.

Synonjrms.— Perineum: pelvic diaphragm; and inferior waU of the
pelvis.

Definition.— By the pelvic llm>r is meant the soli pari* which AH up the
bonv Diiilei nf the pcliis.

Description.— The flM>r of the pelvis is componed of skin, superiicial
and deep fa»uas, and muscles, and is perfonited in the female by the rectum, the

PM- «|T>— U«MLM 04 tm% PELTK RMB.

vagina, and (he urethra. The rectum slone is clo<<d by a true sphincter, whUe
the anterior and posterior walls of the vagina and the urethra are kept in close
aplMx-iitiun principally by the anlion of the levator ani muvle, which lifti up the
lower end of the rectum and fbtieiu out the structure!^ between it and (he jnibic
arch. The action o( this muscle is somewltat increased by the contraction of the
tnmvcpie perineal and hultxK-Avemosi muscles, which are situated on each side
of and below ihc vafsina.

Mnscles. — The muscle? of the pelvic tluor are eight in number, as follows;

782 THE PKLVIC FLOOR.

Two isrhiocavernosi.
Two bulbocavcrnosi.
Two transverse perineal.
The levator ani.
The sphincter ani.

The Ischiocaveraosi Muscles. — These muscles arise on each side from
the tuberosity of the ischium and the ischiopubic ramus, und are inserted into
the sides and under surface of the crus clitoridis.

Action . — They constrict the crus clitoridis, and by retarding the reluni
of the venous blood assist in maintaining the erection of the organ.

The Bulbocavemosi Muscles. — The^e muscles arise in the perineum a»l
pass forward, one im each side of the vagina, to he inserted into and around thf
ci>rpora ca\-ernosa of the clitoris.

Action . — They assist to keep the vulvovaninal orifice closed and also to
maintain the clitoris in erection by compressing the dorsal vein.

The Transverse Perineal Muscles.— These muscles arise on each side from
the ramus and tuberosity of the ischium and are inserted into the ))erineum, where
they blend with the muscle of the op])oBitc side, the external sphincter ani, the
bulbocaverno.si, and the Icv.-itor ani muscles.

Action .—They assist in keeping the vulvo\'aginal orifice closed.

The Levator Ani Muscle. — ll arises on each side from the posterior surfact
of the body and ramus of the pubes, the spine of the ischium, and the white line
of the pelvic fascia, and pas.ses downward and backward to be inserted into tht
sides and posterior wall of the vagina and into the rectum, where it blends with
the muscle of the opposite side, and is finally attached to the tip of the coccj-i ami
the raphe extending from the coccy.x to the rectum.

Action . — It supports and compresses the jJelvic and abdominal viscera.
dilates the anus during the act of defecation, and draws the rectum, the perincuni.
and the vagina upward under the pubic arch.

The Sphincter Ani Huscle.- It arises from the tip of the coccyx, surrounds
the lower enii of the rectum, and blends anteriorlv in the perineum with fibers tif
the transverse perineal, bulbocavemosi. and levator ani muscles.

Action . — It closes the lower end of the rectum and assists in the aclion nf
the pelvic diaphragm as a whole.

HECHANISH.

The pelvic floor supports and compres.ses the pelvic vi.scera and maintains
their normal relationship and e<juihbrium. It al.so .surrounds and holds i"
position the lower portions of the rectum, the vagina, and the urethra, and «■
aljles them to properly perform the functions of defecation, coitus, child -beariii|i
and mil lurition.

All the muscles of the pelvic floor blend with each other and form a comjJeie
muscular diaphragm, which fills the bonv outlet of the pelvis. These muscles
are still further strengthened by layers of strong pelvic fascia which bind them
together and increase their power. The muscular elements which enter into ll*
construction of the floor are its chief source of strength, and the levator ani isliif
most important of all the muscles, as the support which is afforded to the pt\<v:
viscera depends entirely upon its integrity.

The |)clvic floor docs not support the superimposed structures in the soof
of being under them and holding them up, as the foundations do the upper slotif^
of a building, but it fijrms a sling composed of closely interwoven muscles and
fascius which is allathcd to the body and rami of the pubes, and which encircle

t^sOira

I UKthra. the vneinn. and the mtum. This slinR therefore iicts in the tAtae
way ns the lopcs ol n snin));, which .ire attschni In n beam and support a teal
which is llirown across the loop near the ground. The pubic bone represenU the
beam: the ureihni, the va|;jna, ur the rectum the seui; and the levator ani

«sclc Ihr rope.
As we luve already seen, llie levator ani muscle, on account of its si/e and tlw
irhmrnl of it;' fihers aniuiid the >ides .lud ponterlor w;ill uf the urelhni, ihe
vapna, and ihe rcclum, form* the chii-f strcnj*lh of this sling, in which the ter-
minal p(lflion^ of lhe>e nrftans arc swung. Tlicrefore vi lonjt a.-, the intcKrity of
this muscle is miiinuincd the pelvic floor will Mipport the mpcrimposcd structures
and lllc equilibrium of the pelvic organs will remain normal. The momcnl,
however, the muscle is lorn Ilic sliiiR i-n <lestriiye<i, and tlie pclvir orearw will Mg
downward and backward, just a-N a child would drop to the ground if the ropes of

^^winf; were cut.

^BMow let u.< Mudy for a motneni the effect thai this sling-like action of the

^Rstnr ani muscle has upon the
jielvtc %iMera and the lower ends
of the rex'tum, the v;iptia, and
the urethra. If we place a nutlip-
annis woman in the dorsal
position, we will note the f<ill"wing
conditions: The anus and vulvo-
vaginal imilet arc drawn wl-11 u;>
under the pubic arch. Ihe unal
micning is more or less retracted,
■ind the Mi-callcd perineum is
t-imeivhat convex, Separating
the labia, wc noli<-e that the an
tcrior and posterior walls of the
vdfiina are in dose contact, and
that when itie woman bears down
they are firmly forced against each
other wiihi>ut. however, showing
any lendency to roll out of the v.i-
ginal ouilct. At the same time the
{>erineum becomes niure prominent
or convex and the distance be-
iwecn ihc anus and the fourchette
i- im'nM>e<l. If the wnman is now
lold to draw in or contract the

muM-lcs of ihc pelvic floor, the Icwtor ani lifts the anus further up under the
pubic arch iban normal, irowtiinK the anterior and [losterinr walls of the
vacina acainst each other and decreasing the length of the perineum.

If (he index linger i>pa.ssetl into the vagina, we ran true a broad elastic Imim)

tiuscular tissue from the Ixxly and nimi of ihc pubi'S downward on ejch side of
below llie vagina, which becomes tense and rigid when the woman contracts
mu^clei of the floor. The anatomic cionneclion of thi.« musrular sling with
■be rectum can also be demonstrated by making pressure with one index-linger in
tither vjjonal .sulcus and the other in the anal canal while the woman contracts
and relaxO'" the muscles. Under these drciimvtanccs the muscular band be-
mmen allemalely rigid and relaxed, and we can realize by the sense of (ouch
Uiat the re<'(um and the vagina arc actually puUed up toward ihe pelvic arch,
1 u if a flat cord w«» placed under them and its free ends <lniwn up.

Fm. «jK.— Uimumii or mt I'uvic riooi-

ShiA* ihr il^nM-b'kf kiii« ui Ub filial ul ibf \r*tfor
ani miivtc whuh cndrrlc iht uwhn. tte nfus, uid Ihr

0* nil nLVIl* fMO*.

R esii 1 (s. —These tears are of no praclic&l imp*'-
tancc, as the inlcKrity of the levator uni inu»clct)
not daraugcd ii u r dr^lrnycd, und hence the aupp""'
ing jKiwer nf ihe pel»'ic flour rcrauin* unimpai'"'
Somrlimcs, howcier, the cic^lrix which w furmml miiy become inilahlc (■■'i
cause ItK-al lendernew iind reflex disturbances.

Diagnosis . — A rrcent Icar tan be reudily recognized by Mpcinnw '''*
Ubia and inspectin;; the parts. The presence of the UccralioD c«ii thi» ^ ^
ceriained and its situ.iiion and extent detcmiincil.

.All did Uar is recognized by the low of li.wiic Iwtween ibe \-uln>n^ntl e""'"
ami the anus, the spUt in the fourchclte. and ihc presence n( Mar !!»•»''''
perineum. Tlie iosm i>f perineal tissue can be estinuited by ininxJnm)! ''l'
Index.finger into the vagina and piadng the ihumb cxtcmallir ortrllit p«»-

PtTEXn'.RAL tNJDUES.

78s

neum with iLt tip on x level with the anterior Burpn of the anus and com*
pre&sinK the structures between ihcm. In this way a m-called ikin prnnrum
can be readily discovered and ihe true nature of the tear delermin«d ( V\^. 680).

Median Tears loTolviag the Sphincter Ani.— This variety tA Iflreralion
extends bnckward in the meiliaii tine from t)ie ft>ur<'hel(c through the sphincter
ani muscle, and in some cases it may continue up the rectovaginal septum for a
disiant-c nl an inch or more. Sometimes all the fibers of tl)e sphincter are not
completely divided anil the appcnnincc oi the tr^ir may be decq>tive.

Results . — These tears permanently destroy the function of the sphincter
muscle and uiuse im-ontinencc of feces and t^.t. if the liben of the s|)hincter
are not completely divided, Ihe piitieni may hA\K control over solid feces, but she
cannot prevent the involuntary escape of Datus or liquid material. A chronic
diarrhea often accoinjiunies a laceration involving tlie rectovaginal »eptURi.

The levator nni muscle is
not torn, and hence the sup-
porting power of the ])elvtc
floor remains unimpaired

Diagnosis .—A recent tear is readily
recognised by impeclion and loueh. If
the labia arc separated and the parts in-
spected, a laceration will be .teen beginning
at the vulvovaginal orifice and extending
through the perineum into the rectum. The
anul ring wQl l>e absent and there will be an
eversion of the recUil mucous membrane.
In case of doubt the index-finger should be
introduced into the anal cnnni, and if the
muscle is lom there will be a complete ab-
sence of a sphincter action at the terminal
end of the rectum.

An old tear is al.so recognized by i«-
sprclion and touth. The anid ring is
absent and the torn ends of the muscle arc
retracted and only encircle the posterior
margin of ihc anus. The rectal mucon is
e^'ertcd, and if the tear has extended up the
rectovaginal sejnum the rectum and vagina
open into a common outlet. Nn tesLitanre
is offered when the index-finger is introduced
into tlie anal canal, and the sphincter action
is also absent.

Lateral Tears Involving the Vaginal Sulci.— This variety of laceration
exteiid.-i fnini the fourvhclte up into one i>r Ixitli of the saginal sulci and is usually
accompanied by a superficial median tear toward the anu».

Ai a rule, the laceration is bilateral, the left sulcus being more deeply torn
than the right, and in rare cases the injuri' may occur on only one «dc of the
i-agina: it is the exception for the sphincter ani muscle to be involved. These
\ea,T% extend on each -iide of ttie vagina toward the i.schioreclal fossa, dividing the
fibers of the levator ani muscle and Licernling the fascias and .unall muscles
opiiosile the Literal margins of the vaginal outlet.

R c Ml 1 1 > .—The function of the levator ani muscle is destroyed, and the
pelvic organs, as well as the irrminal enils of the urethra, the \agtna, and the
rectum, are no longer supported or ntainlaincd by Ihc pelvic floor. The lorn
so

5iai«t*''

PiO. «Si.— Uoii*!s Tr.u Of nn P»i.rip
Ftoo* [svaiTUia tnE SnuvcrrB Ajii

Noi* tS( urn mJi ot Ihc felUmts »ni mv*.
(k •0(1 tlM tSaana el Ou tuti linf .

7S6

TllF. PBLV1C rLOOR.

muscles gnirluullv retriic'[ ami evtniuaUy umlngo strophy from disuir, lodif ih
repair of ihc bccration is indefinitely <lc]ay<.-d, the)' never regain iheir full font
or sirenijlh. As a rule, iiivolulion of ihc uleriu and ihe V3g;tna U
evcntuiilly the uierine ligameiils ;i» well aj. the [lelvic connective tiMtie I
elongated and stretched, remlling in prolapse of ,tll the organs of At pdia~
ThcM' changes become |iermaneiit in time, iind even if the injury ii fimUv ce
paired, the uterus will not remain in its normal position unless a fixation opentka
is performed to forreci the prolajis*. When the tear only ins-olve* one ofl
vagin.il sulci, there is les,* llahility of the jK'lvic organs becoming pfoIa;r-e(I«|
the muscle on the uninjured side partially sustains the superim|KMed »truc

Diagnosis nf a Recent Tear .^A recent loir is rcadilr dM«id
by scpamling Ihe labia and inspecting Ihe posterior vaginal trail with ■ fMi
light. Under these circumstances the examiner will obserw a deep nfpl

DuoMMH tn InnmoK or L«iiiii,i. Tcjiai <>t mi Filiic Kum tmnviiK m Vmoiu Mo
Rf. Ut tbofn * nulUpwoui vul'i; Fi|. «Si khom iIif ([irimuiic al > miia imaiui Iraa lomlu'*

^olviofi ike ^'^uaS ulci-

laceratJon occupying one or both of the vaginal Butci. which conveip •' *
posterior margin of Ihc vaginal outlet and continue backward « » ^
tear in the median line toward the anus.

rj i a K " " * i ii •' ' " " Oil! Tear . — The diagnosis ts based np* I"
physical signs, which may be elicited by (a) inspection and (h) fuljation.

/)i<jhri-j;tfi».— Plai:ing the jiatienl in the rfw/u/ pesUioti we Dole ttol ■
vulvn is relaxed, the labia separnled. Ihc \-nginal orifice patulous, and iheiS"'*
and posterior walb. of ihc vagina arc not in apposition. The perineua i*^
and usu^iUy longer than normal, :md it is not uncommon in tbc<e ntM* V ^
that the fourchcttc is intact. The anal ring is promirwnl and the recUl w"*
is frequently found to bo everted. The rectum is displaced tftward lb( («'T*
and the anus is more or less relaxed. If the w««utn is now Olftde to OMO"'"

lOtESPIUtAL IN'/VRIES.

7»7

(he pelvic floor, the anus and the vsginal opGiung are not drawn up

toward the pubic aich and the anicrJor and poiierior walk of the vagina arc

at (Tovnled against «ach other. Wiivn she hcan down, however, ihe vagina

ilU out iind cxpweii the lower portion of tbc canal.

Palpation. — When the index-finK«r a intntdurcd into the vagina, the slini;

of tnuM-uliLr tis,%ue is found tii l>c abMinl, and ihc structures around Ihe vaginal

sulci remain soft and yicldinR e*-en when ilie mu>rl« an: cnnlr.nctcd. showing

that the supporlinK band has been destroyed. By careful palpation we may be

able to feel the relaxed ^nd tnrn mu:^:le-'i han^iiii; parallel tu the Literal wnlU of

the vafciiu, and if llic injurj' is unttnteral the nblinue ilin-clion of the uninjured

muscle is in marked conimst to that of the opposite i^ide.

Treatment.^Injuriesof the (lelvk- lluor demand aurgicnl irentmeni, and
the opentive Irihnic in each ciise i« ba!«d
tipon (he duration and the character of Ibe

t sh.ill iherrforr consider the subject
under the tolli»wing headings:

I Primary operations,
(a) SupcrCuial m<-<lian tears.
lb) Median teais involving the
>|>him'ler ani.
{c) Lateral tears involving the va-
ginal sulci.
Intermediate operations.
Secondary operations.
{a) Superfidal median Xfun.
\b) McdUn tears involving Ihe
sphincter ani.
(c) Lateral tears involving the va-
ginal *idci-
Primary Operations.— A pWmarj-
an immnli.ilc uperiUi'iii is perfurmed
"itliin the first twenty-four hours after
lalmr.

Indications .~A primary opera-
tion It always iniliciieil, as the loni struc-
tures can be more accunitrly approximated
immediately after labor than at a later per-
iod. The danger of infeLtion xn aL<(> re-
JHHlo^'ed and the [Mticnt is s;t\ed from the
^fertous re«ult& which often follow in neslcried eoMs.. And, finally, if Ihe
^operation is imlHinitcly deUycd, the musck-s reinicl and undergo atrophy and
never regain their normal Mrcngth even after the tear i* rqiaired.

Contraindications. — T\\v. conclilion of ihe ji.itient from loss of
lood or other causes may render it inadvisable lo disturb her immediately after
Kir. anil consequently the primarj- ojiCTation shmild not be performed.
A nes t he sia .— The parts are so benumbed immediately after labor
at an anesthetic, as a rule, is not Te(iu!re<l unless the patient is nervous or un<
ilrothbte. \ jtmerni or local anesthetic, however, should always be cmplcn'ed
[the operator linds that he cannot properly perform the operation wilhoul it. or
en ihe laceration is extensive and involves imi>omnt siruclurcs.
_ Preparation of the Patient . — No i)reliminary preparation b
"nquirerl.

VOLYlHu tut V*r.lH*l M'ld,
^Tunrt the \\\^ uf tIk imlrn fiDV i^lmiln^ \hm

788

THE PELVIC FLOOR.

Position of the Patient . — The patient should be placed in ihe
dorsal position, either crosswise on the bed (see p. 20) or on a kitchen tabic
(see p. 21), with a surgical pad under her hips. The latter position is ahran
preferable if the patient is strong enough to be moved, especially when t^xiatiiig
upon lacerations involving the sphincter ani muscle or the vaginal suld.

Superficial Median Tears.—The repair of these lacerations is outducttd
as follows:

Sponges; Dressings; Solutions; etc . — Two doEcn guue
sponges, four large gauze pads, a gauze compress, a X-bandage, a solution of
corrosive sublimate (i to aooo), and hot and cold sterile water or nwnut salt
solution.

Instruments . — (i) Right and left Emmet slightly curved scissors; (i)
tissue forceps; (3) dressing forceps; (4) needle -holder; (5) two short hemostatic
forceps; (6) shot compressor; (7) two small full-curved Hagedom needles; (8)
tvtfo perineal needles (Emmet's) ; (9) silkworm -gut — 30 strands; (10) perforated
shot.

Assistants . — An anesthetizer (if necessary) and two assistants.

®o ®

\ ACTUAL SIZE {J

Fio. AS). — Ikstruuents, Neehlcb, Stitupe Matehial, and PEiroRATEn Shot L'sed in rHE Vta^a

DpEIAtlON ro» IMt KtPAlB 0» * SDPEHriCIAL MEDIAN TEA" Of IHE PzLVlC FU10».

T e c h n i c . — After placing the patient in the proper position the assisBnl;
separate the labia and expose the posterior wall of the vagina, the \iilvarcanil,
and the perineum.

The operator then dips a sponge into the solution of corrosive subliraatt sm
squeezes the fluid over the parts. After drying them he unfolds
a gauze pad and tampons the upper part of'^t
vagina to temporarily keep back the discharg*^
that would necessarily flow over the seat of opeti-
tion and obscure the view. The tear is then carefully inspK'"'
and if its edges are ragged or uneven, ihey should be trimmed smoolh 1'"
scissors, otherwise union by first intention may be prevented.

If the tear extends up in the vagina as well as backward toward the anuSi ■"
sutures should be introduced as follows: The first suture should be passed nw
the upper or vaginal angle of the wound by introducing the needle aboul «'■
fourth of an inch from the edge of the tear. It should then be carried out**™
so as to include a thick wedge of tissue and made to emerge at the bottom «
the wound. It is then reintroduced near the point of exit and brought ow

ihixvuiih the miicoHS mcinl)ranc on the oppocitc siilc of the tear. Similar smturcs
art ilit-ti placed about onc-founh of an inch upari down to the lower or perineal
xn^le of ibe wound.

The Kill of ojienitioR is now douched with the corrosive sublimate solution
followed bv sterile water; thcsuturcsshotlcd.beginninRat the up[>er angle of the
loir; and the tuimion removed from ilie viiRinii, The free end* of ihe e;(lcmal
Hilures are cut oH about one-half of an inch bc\'ond the shot and the interna)
NUturea are tied together and pushed up into the vagina out of ihc way. A fniuix
compress secured by a T-bundage \i finally placed over the vulva and the patient
put back in bed.

After-treatment . — Cart of the II-'o«'irf. — The vulvar canal should be
duuclicd twice a day with a Nulullon of corro!iive sublimate (i to looo), followed

^-*'^: "-•■'

Pin. MA. Fin tt].

Ptiiuii OmitiDK n» ntii Xnui or * SifvancnL Umuw Tiai or n» Pn.nc Fuxit.
tit. tW Ac** Iht HituiH lavadiinili Ftc- Ml •!»«■ Iha wtum JiaUal.

by Sterile water or normal salt solution, and the gause comprca changed as often
as required. The siitchtTv should lie removed on the eighth d.ny. It is un-
necessary- to keep the knees tied after the patient recovers from the aneathetM;,
and she may be allowed to lie on her 'ide or nnove from one position to another.

BffuWj.— The bowels should he moved daily by a mild lnX4tive.

HIaddtr.—'thc use of a catheter should be avoided if possible on account of
ibe danger of cauMng cysliti.'*.

iietlipg Oul o} Htd.—^T\u: patirnl diould remain in bed two weeks,

HedUia Tears lavolving the Sphincter Ani.— The repair of these lacers-
lion<< is conducted as folluws.

Sponges; Dressings; Solutions; etc .—The same as an
^, ti»d for the repair of a superficial median tear.

79©

Tlll^ PELVIC ytXtOR.

Inslrumenls .—The same as an used for the repair of a

A S S i 5 I a n ( s . —An ane»lhrluer (if nrccssan-) and two assKtaaU.

T r c h n i c .—After iilatii)^ (he jmlit-til in Uic |iro[KT jKisitiun an astutiM
st:in<l> on each side and KCf)(iriitft« ihe lahiji ami ex)H»e- ihe Ucmition.

Tlic operaior niw douches ihf [i«t1* with sterile nutcr or normal sah sohitics
and pueks llir upper pari oj the I'lt^fnii with ii RttuK pad to beep l>aet ihe iliuia/ta.
The bt't^riiliiin i.v tiicn ciirefully in:^|>ei led iind all uneven nr niggrd nlge» tiimiud
away with scissors.

The next .ste|j in the ojierutlan i* to close the superlidal median tear ami (bem-
toviL)(inalNeptumw*i(htntcrni|)tcd silkworm-gut Kuluics. The first septal <^iiirt»
inlTDthicrd through Ihe vaginal mucous membrane at ihe upper angle of the u-ouad
about one-fourth of :in inch from the cdjte of the tear and made to emcrite nt the

T .

-r^

ilu bU

Fm ■«•

Pmhaiv DntAimn to> nil R(p>ii or 4 Mtnuo I'tu or ini {"nvtr Itoea tviwoH •■

SPi'Jhctiit Am,
Hi «M itnitii Iht nilum Inirnriutxl ikiIok Ihe miuiaiiliul KfUioi: Fi|. tAotbau Uw tMMia(W< ■^
•UlUHi (hotldt muA ihr luium iniroduwd in oniit tht urn nuli oT ihc HMniMr MMfc

reclid margin oi llie torn septum wiilunit [wnet rating the mucous lining of ih'^^
The suture is then rcinlrtxluccd in the same position on the other side of the ^<^
and brought out thrwugh the vagina opjKwitc lo the point of original cni''^'
Similar sutures one-fourth of an inch a]Kirl. are tJtenpuvied downward lo*'-'^
ono-ihinlofaninchof theanal opening. 'I'hc sulurcH are now shotlnl. btjito'K
at the upper angle (idhe tear, and the operator then proceeds to appnwinultw
torn edges of the sphincter ani muM'le a.i folliiw%i

The first suture is introduced tinder the inner man^n of the lorn cml J ••
sphiniier am' muM-lc and carried throunh the tissues at the edge of the W"
mucous mcmbr.ine, emerging at the angle i>f the Ltcenition ju*t Iwlo* ifc* Ij*
BUture closing the seplum. It is then reintroduced and brought out up)0*f
op^Kuite »ide under the inner margin of the other end of tiK sfiUncttf '"

WtnPtKkL INJt'RIKS.

muscle. The second suture is inlr(xlu(<c() under the outer margin nf the muKle
itiul|Hi&scdiu a liimilar manner to emerge upon ihc opposite side i Hg. 6S9I. The
uiture:< arc (hen shdiied, :in(l if neccs.N.tr>' one or iwu ^u]lc^fi4i^l Ntilche* may

ill (roduccd to approximate the skin above the unileiJ >{>hincter muscle
i«. hoo).

[n inlrwIucinK t)ie iiulurL-s tliiil i\>ntnil ihc lorn entU i>f lh« xgihintter mu-vie
(he operator mu^l be i:aiciiil to pass the nei-iMc very tio!* to the edge of the wound
in order lo prevent iiiver^iun of ihe !Jcin, which would m:ceiisurtly interfere with
i>T prevent union from tiikiii^ plate.

The operation is completed by douching the parts with a solution of corrosive
lultlimnle (i to 1000). follower] by nonn;il sidl ^iolution or Merile water, and re-
mtivini: ihr vagin.il tampon ^flcr cutting otT ilie fnc ends of the Mitur<.-> about
half an inch beyond the shot (Fig. 690I. .\ gauJic
comprew in t'liuily plarol over the vuWa and tlie
pdlirnt put back in bed.

Variations in the Technic . — If
the tear d<>c> not involve Ihe rei'tovaj^inal <>«ptum
llie superficial median tear in the perineum is lirst
doMi) a& already deMTibed. aiid then the lorn
of the sphincter muscle are united. The
itures are introduced in the same manner us
IhcKl in the refiair of a Uceration involviiifc

rectovaginal si-;)(um.

A median tear that orUy involves the outer
fil>ers of tlie sphincter ani mii^Je must lie ntre
fully sutuml, othervrise partial incoiilinence will
result and the patient will have no control over
li'iuid fetes or tislus. The lorn tibcrs of the
muscles iire ca-ily brought together when the
Miturct arc ininHlured to appro.\iinale (lie lower
angle ol the woimd by passing the needle well
under the jiartially lacerated ends of the sphincta*
on ench >>idc.

Atter-treatmenl .— C<ir« oj Ihr Wound.
— It b uimecesMry to keep the (uilietU't- knees
tied, and >he >hr)ulii Iw allowetl to lie on her side
or move about as after a normal confmemenl.
The }>arts shouM \ye dou<'hcd twice a <lay with it
iin of ciwrosivc sublimate (i to aooc). fol-

iil by sterile water or normal salt dilution,
and ihe )t^u/e o>mpre->> i hanged .is often as
nece>*ary, 'Hie stitches should be remoi'cd on
the eighth lo tlic tenth day.

Bontti.—T^t t>i>wch must not be permitted lo become r»n!>ti)>ated and
siniining nl st'X>l must be avoided. 1 am in tJie )iabi1 of moving them on the
second day by itivinit a mild l.ixative followed by an injection of an oum-e of
glycerin into the rectum, using for the puri>ose a >m.ill hardrubber synnge wiih
4 narrow noiJile al>out Iwo inches lonR, Tlie Ixiwelsarr then kcj)! openrfl daily
by using llic Lixmive either al4>ne or in conn<rclion with the Jnjtrclion of gljcerin,

Blaiidtr. — The use of n c.ilhcler. as a rule, is not reijuirtil.

Gelting Ouloj Hrd. -Tlir patient should remain in U-d two weeks, and after
netting up she should avoid all forms of Itvuvy exercise and sexual intercoune
for at lrj»t Iwo m^inlhs.

tni KtrAih i<) A Mii.i4n
Ttj,« or Till 1^i>it^ fitt^
lnviii-viMi III! SriiiMitt Am

Shmm Ihr »itum ualiuif Ihr
tm tttli ■•( Ihr inuwin ititinal nd

ihf OlKTItlUlB (B«>|llH«l

("lo. (01- FW tni-

pHiuiv OHKinoH »■ n» RcMW or Litbial Tiau or m ravtc Tuna IxTotTnK t

Svia.

Fit- 6v> thimi Ihr antcnor mjiiiul nil itcvftMd vitb Slnao'i lUn-uluiD uul iht nan ni«id , t>t *u *^
Ibe mum iaiioducal-. noli Oiat EmmcCi l-thivni luiuna m uad Id (laH ih> hM^

Snonnes; Dressings; Solutions; etc . — The siine » »**
used for till; repair of .1 su|)erficlal median lent.

I nstruracn ts.— (i) Righi imd left Rmmci's slighlly oirveH •a***■
(>) lisHue forceps; (3) dressing forceps; (4) nccdJc-holdcr; (s)iwoJMftb*'

nTERI'CRAL INjUues.

79J

< f.

latic forcqis; (<>) short comprt.-»uT: (7) Simon's speculum (flat blad«); (ft)
two small full-curved HagciloiTi needles; (9) two iwrineal needles (EmmetV);
;o) iilkwomigui— TO-itiJind^; (11) )teHordted «ho( (Fij;, 691).
Assistants .—An ancsthclizcr (jf necessan) and two aasUianU.
T e c li n i c . — After placing the jialicnt in the jinificr position the ii$»ist3nt&
M|inrate the Ut>iii and vx|)o»c the [Hi^teruT wall o( the va^ai, Ihe vuli'ar canal,
and ihc perineum.

The (>|>emtor now doucliot ilie jMirls with a rorrosive sublimate solution
( I to K»o) and pufkf /Ac ufprr fxirl of Ihe vagina wUh a goux pad lo keep back
the disfharges. The anterior vaKinal waU i.s then ele%'ate(l hy SimtinS speculum
and all raKKt<I or uneven edgci trimmed awnv (mm the margin of the wound
with scissors (Fig. 6qj].

The bcerations in the sulci ure now closed sep-

1 arately hy a series of interrupted sutures beginning

I at the upper angle of each wound and continued

d<»wnward until the edp;e of Ihe nui>erti(.-ial te:ir at

llie pwiterior margin of the vaginal outlet is

reached. The iuiiires are first introduced in the

left Mil(-us and iIkvi in the right, and after both

I series ha^e been passed they arc shotted and the

sutures introduced into the perineal ivound

The suture% cio«in^ the Wt ^uU*u^ are intro-
duced through the vaginal mucous membrane
about one-eiRhth of an inch fnini the outer margin
of the wound and then ntrried oulwanl and down-
ward, emerging «t the bottom of the tear below
the le\'el of the point of entrance in order to en-
circle and pull up the retracted muscular fibers.
I The needle is then reintroduced near the fioint of
exit lit the Imttom of the wound i.n(l brought out
again on (he vaginal surface opposite to the ori-
ginal point of entrance. The sutures closing the
I right suluH are pas^e^t in a simihr manner, t-i^cept
that the point of cnlrnnce is ai the inner margin
I ttt Ihe wound and Uic exit :ii the outer ctlgt dn.'.e
I to the latend vaginal null (I'ig. 693).

The c.ilemal wound in the perineum is closed
in the same manner a-s flocrihed in the repiiir of a
sujxrrficial median tear.

The operation is finally completed l>y re-
moving iJie vaginal tampim and douching the
parts with a solution of corrosive sublimate followed by sterile water or
, normal salt solution. A gauze itimpres.'i .secureil by a T-bandage is placed
■Kfct the vulva and the patient put back in bed.

^V Afler-lrcalmcnt .— Care oj Ihe Wound. — The parts should be
douched daily with a solution of corrosive .sublimate (1 to 1000), followed by
Sterile water or normal) salt solution, and the gauze compress changed as often
as requLTtd. Ii is unnecessary- to lie the knees, and the patient should be
allowwl to lie on her side .i.-i after a normal ronlinemcnt. The extenuil sutures
arc removed on the eighth day and the vaginal stitches are allowed to remain
two wciAs.

flmeth. — The care of the IwweU is the sune as in cases of median tears
involving the sphincter nni muKlc.

:l^

FlQ, 604--^PBIUAfeV Or«BArir>H Pftt
THK K>-rut iir 1>-4ii* nr tkk

ibr u|ar«fjirn cuinploinl \olr ihal
Aft pltnd up in Iht Ti^nfe,

794

THE PELVIC FLOOR.

Bladder. — The use of the catheter is not required, as a rule, and the patient
should be encouraged to void urine naturally.

Gelling Oul oj Bed. — The patient should remain in bed two weeks, and after
getting up she should avoid all heavy forms of exercise and sexual intercoune
for at least two months.

Intermediate Operations. — An intermediate operation is performed
at any time from twenty-four hours to two weeks after labor.

Indications . — The operation is indicated when the condition of the
patient renders a primary repair unjustifiable or when the obstetrician has failed
to recognize the lesion or has neglected to restore the parts immediately after
labor.

FiC. 6g5. — InSIKCHLKT^ LSED in the InTKVHEDIATF OpFBAnOTJ rOK THE Refaii of Laceiatiois of m

ACTUALSIZE

Fin. i'lb — -Vf EDLE3, SuniBE Matkbiau, asu PEifOBArfD Shot 1*!e» rn tmb Ikteiuediaii Omin"

mv I.ACERATIUSa or THE I'ELVIC FlOUV-

Results . — The operation is not always successful, although good twulis
frc(]uent!y follow if the lechnic is thoroughly carried out.

Anesthesia . — While it is usuallj' best to administer a general anesllif if-
the oi)eration tan be readily performed under (he Incal effect of cocain bv injtrt-
inf! ;i few drops of a 4 ])cr cent, solution around the edge of the wound and as*
applying it directly to the lacerated surface on a pledget of absorbent coiloii'
If the coiain is occasionally applied to the raw surfaces during the open don.
thc|i;iin will be still further controlled and the patient rendered more comforUi'lt-

rre|iaratiiin of the Patient .— .\ bottle of citrate of nugnesa
should be given the nij;ht l)efore, followed in the morning by an enema of soap-

PUKXPtXAL tS'JVKlCS.

19S

iid& and vann water, and ihc bladder sbuuld be emptied sfionbiDCotuly jiut
•Son ilir i>|icralii>it.

Position of the Pulicnt .—The patient should be placed on ii
Utchm Lible in tiic dorsal position with a 6uif^Ka\ pud under her lii|i!. (see p. lo).

Sjmngcv; Drcsiiufjs; Solutions; etc .—The same as are

■d ill a primjirj- oixMalioo (or the repair oi the three diffcrciil varieties of teart..

] nk t ru men !>.— (i) Simon's siic-iulum (Hat bbde); (i) sh^rp .<.[>oon
irct; (3) !<:al|>cl; (4) riglil ami left Kmmct's slightly curved s(iisor>; (5)
itwtK fortrtw; (d) dressing fortq)*; {7) twu short hemol^itic dineps; (8)
Dc«dlc Itolder; {9) shot compressor-; (10) two small full-runed tiagcdurn
needles; (ii)two perineal nee«tles (Emmet's); (ii) sillcworm-gut— lo iUund»;
(ij) |Kf(orated shut.

A h » i » t a n t s —The same number ts arc used in a primary operation for
I re^utir o( the three different varieties of tears.

T e c h n i t .—After placing the patient on the operating table the assistants
sepurale the bbi.i .tml expose the <^eat of injure'. The operator then douches the
)Kin.>i M'ilh a l.1)^rti^ive sublimate wlulinn (1 to aooo) and lomfioni Ike upper
agiitii loteepbitrA IheJiifitiirget.

The granulating surfaces are then carefully insj>ec1cd and the situation and
Chamcter of the tear axeruineil. The gninidatiim ti'^Mie i.n now temped nway
vith u curel or the knife and the nigged or unei-en edges trimmed with scisMirs.

The Mrtwnd is now comeried into a rctent injury, and llicrcfore the intn>-
duction nf the witures and the Mib^-qui.'nl twhnie. as well as the after- treatment,

the same as described in the primar)- o{M:rations for juprrficial mttlian Itan,

I^M" "•'" i»\vlving the tphimfer tttti, or luleral Ifiirs imohnng the vitginaJ mid,

lie riiM." may l»e,
iiPCCOIldaiy Operations.— A >ei-iin<l;iry operation is performed at any
"fifiirihe woumflLi'^ hc^ilci: it is gcKwl practice, however, to wait forat least
1 weeks after lalx»r in order to allow involution to Like place.
, n e s t h c A i a . — ^.A general ane>thclii; should alway* lie employed.

Preparation of the I'alient . — A hottlc of citrate of magnesia
Ji')uld l>c git en the night liefnre. fullovied in ihc moniing by an enema of soap-
suds and warm water, ;in<l the bladder should be emptied 5|>ontaneously just
]iriikr to the administration of the anesthetic.

On the morning of tlie ujieratinn tlie patient should lie given a full wnrm
balh. thoroughly scrublicd with soap, and the hair on the lower part of the
vidva dipped. j\fter getting out of the Uith the vagina and t)ie vulva >hould
be irrigated with a wjlulion of comivive suWim.Tte (1 to ;ooo). followed by
slerile water or normal salt solution, and the glulcat deft, the anal region, the
|ii-rineum, the external organs, and the inner surface^ of the thighs r^irefully
sterilized as follows: Scrub the jiarls with a gauite sjwnge dipi^xl in liquid soap
and water and then douche with the cornwive oublimate Miluliun, which in turn
i' rrnv>ve<) with sterile water or normal s^ilt solution. A large gauze comprc&s
secured l\v a T-bandage is ihen pbccd over the \'ulva, and the legs and thi^ts
l>Tuleeted with Canton flannel stocking*. The hips ami lower exlremitie» ate
liiully wrapped in a sterile iiheel, which i- secured in front by safety-pins.

In tears involving ihe sphincter ani muscle merluinic sierili^iition sJiuutd Ih;
relied on exchuivcly, as there is more or Ics^i d.inger of serious i>oisoning otcur-
ring from absoqiiion by the 1m>wcI when a thennc agent is used.

Preparations for I h e f ) p e r a t i n n . — See page S_i i .

I nsl r u men 1 s .— (1) Emmet's right and left full and slightly curved
KivHlr^; (1) four bullet forfetis; (3) tis.'.tic (orcqi^.; i.\) dre.vjng forceps; (5)
two (.Hurt hemustutic (orcq»: (6) nccdle-hnldcr; (7) shot coRi|>rcs5or; (8) two

THE PELVIC FLOOR,

small full-cuned Hagedorn needles; (9) two perineal needles (Emmet's); (10)
silkworm-gut — 20 strands; (11) perforated shot.

Number of Assistants . — An anesthetizer, two assistants, aod a
general nurse.

Position of the Patient , — Dorsal posture.

Final Sterilization of the Patient . — After the patient is
thoroughly under (he influence of the anesthetic she is placed on the operating
table and the nurse then removes the sheet and the vulvar compress. The c^w-
ator now pours two drachms of liquid soap into the vagina, and with a gauze
s[>onge saturated with warm water and held in the grasp of dressing forceps

Flli. 6g7.— lNaikllll*:ST5 I'SED IN Sm'ONUAHV Mph-mTION'i JOU THE RlFAI» Or [-ACtlnAUOKS W IW

®_

®G

®Q

ACTUAL SIZE

Fin. 608.— N'lHlLES, SDtUIE M«IE«I»L. ASI> 1'E11F1pB«T£I) SlHlT t-IO IH SrroNDAM Ofeiaitosj IMI"
KRPAH or IJCEBATIONS OF THt I'lLVlC FlOOI.

mechanically sterili;ies the vaginal canal by vigorous scrubbing. The vagina is
then douched with a solution of corrosii'C sublimate (i to aooo). followed by
sterile water or normal salt solution, and the vulvar canal, the perineum, and in*
anus thoroughly scrubbed with u gauze sponge dipped in liquid soap and waW.
after which the parts are again douched with the sublimate solution and sterile
water or normal salt solution.

In tears involving the sphincter ani muscle chemic sterilization should w'
be emploved, for the reason previously mentioned.

Denudation . — The object in denuding the site of the old lacemlioii a

PirCtlPKRAI. tNJUURS. 797

to remove (he ricnlririal tisMic an<l cx(Ki:«e (he torn and Kporatcd underlying
stniiriure^ «> that thcj- tan be united again »r>l the integrity of the parts rcilnrcd-
W« must, lliereftire, aim lo rc|irodu<« as clowly as. pONii'lile the outline* nf the
orijiinul tear. wi(ho\ii, however. entriMiching iijmn or ^imricing normal tissue,
bcirinc in niin<i. however, that more or less contraction ha* occurred and thai the
denuil<'iti<vn must tun-wijiiciitly lie greaier than the area nf the »c;ir »iirfiicc.
To accomplish this, a cin-fii! inj^pcclion must lirsl be made of the situnlion and
extent o( ihe scar tissue, ami then before siariiuK 'he dtnLKluiion leriuin |iiiiiiU
on the oiillinev of the old le:ir .-in- nuiKhl with Inilk-t fiin-epK and held tiiut so thJil
Ihc iiiteneniiig spates tan lie e;isily denuded wiih the scissors. The l<H-alion of
thcM- |M>inL\ will t>e noted later on in di.-unjsiiing ihc ofxruttve Icchnic uf (he
dilk-n-nt varietivK of pcrincol (cars.

Sutures .—I use silkworm-Rut sutures exclu?jvcly in my practice In the
repair of all injuries <ti the la'lvie lloiir, and :«ecurc them H-tth pcrfontc<) fthnl.
'liie necessary amount of iraclion to make ufKin the suiunrs in bringing the edges
of llic Hotiiwl tngcilier retiuircs i >in.si<lerubte experience, and I believe there i.-. W-v
danger of vJiu^ing ti>o much or tmi little tension by fastening ihcm with shot than
by tying a sufgical knot.

After t l(»ing the wound (he free end.i of the extcmat sutureH are rul off almut
onc-lulf of an inch l>e)'ond the shot, and the internal sutures are gathered to-
gether and tied in a bunth; the short ends projecting btjund the knot are then
cut i»tT. The internal su[ur(:s are Anally puvhcil up in the ^i;iginii nut of the way,
where lh«y remain until s\ibsequently removed. The removal of the vaginal
sutures is Rresitly facilitated by leaving iheir cndi. long aii<l tying them together,
as the shot i-nn be ea<ily eievateil ;ind ihe scissors passed beneath them by milking
slight traction upon the knot. In operations involving the vaginal sulci the
ituirs in each sulcu'i are Iinl tngcdier sriiii rately.

in intriKJucing the sutures die needle should not be passed too far away from
die edge of the wound, a-s in^crNion of the ikin or mucous membnine i^ liable In
occur when they are shotUii and interfere wilh the union. .Again, the needle
ihould not be passed parallel with the raw surface of the wound, but should be
earned well outward so as to include a thick wedge of ti.-»ue and then made to
emerge at the bottom of the te»r, whence it is reintroducetl and pussed out od
jlie o])p(Kiitc side in a simibr manner.

Final S I c p a of the Operation . — The operation i« rinally com-
iletcd by douching the \-3gina and the external organs wilh a corrosive sublimate
solution {1 to zooo>, followed by .ticrile water, and then ilmng Ihc vaginal canal
tt-ilb a gau/.e sfMinge hd<I by dressing forccjw^ The ends of the internal sutures
are then pushed up in Ihe vagina and a compre&s secured by a T-bancUge is
placed over (1m- vuha.

After- treatment , — Can */ Ihe Wound. — The vagina and the exter-
nal organs shouUI Ik- douihed daily wi(h a solution of corrosive sublimate (i 10
300o), followed by normal s.-ilt solution or %terile water, niul the vuhar (i>mprcvs
change*! am often as rciguired. I( is unnecessar)- (o (ic (he knees together, and
the putti-n( should be allowed (u move ali(iu( in bed and change her pasition after
the Art day,

Hrmai'iil 0} the Suttirrs. —The sutures are remowd in superficial median tears
<in the eighth ilay; in lacerations involving the sphinclerani muvle. on the eighth

the Irnth day: *nd in injuries involving the vagin.il sulci the external stitches

removed on ihe eiuhlh ilay and the intenial suluri-s at the end of (wo weeks.

Hvti-rli — Th<' b'lweU fiiould lie movetl <laily after operations for (he repair
«( £U|)(Tlicial medi.:in tears.
~ In aue& in^-oiving the »]ihin<'teTaiiirouscleor the vaginal sulci a mild laxadve,

<in '

798

tHK PKLVIC FLOOC.

rulluwcd by a rectal injection of an ounce of glytarin, is givm on the momk) Ait,
Tliv liiiwi-ls arc llicn krpt opcnnl d^ily, an<l any tcndtrncy hi i-i>0!>ti|Miwn »
avoided by usin^ 3 bxutivc cither alone or in connecttun with Uk glttcm
injection.

IHadilfr.— The use of a cnlheicr is not required, as a rule, and It b aJaifs
advi^nblc, if jioiwlile, lo ha>-c (he piitieni vui<l her urine luilunilly.

Pitt. - [>tiring the Wrsi two dnys liquid dici (see p. io6f should tie p\ta mmI
then the jialicnt ihnutd be plaieil on a convale«em diet (m^c i>. 114).

KtslltHNf-tx and i'liin.^A hy|m<icrmic injwlinn of m[>rphin (gr. \) nur be
given during the tirst twenty-four hour-, if ihcre is much \y.i\n tit reslleunrio, lal
slce[>Iexsne.NS may be rummlleil v<'ah bromid uf MNlium. >ul)ihunal, nr IiWuiaI

OettiHg Out 0/ lied. — The patii^it >li»>uld remain in bed two weeks

r-«':Vi

^T^:

-,.^*i 1

Vk. Am.

Flo. Mb

Sr^ovnAiT <)F>t»nav roi tiii Bimii o» * SpKinrt*!. Mmnv Tiu at nu twitr ft**

Fi^ 6i» ahtrnk ihc thm- lurttpit In jKAixJ^in ^^ a. A, nml ■- inH iUt nnxmiuu iVijawn fin
V'tt, 'M thfivt the mu(DU< mrmlinnr t«int ilrnnM Iron < to ■

after gelt inR up she should avoiditll forms of heavy work or actireeiercurli'*'
least two months.

SexiMl Intercourse. — The sexual relalion.tm.iy iMTemmed in Iwomowhii*'
ihc opcriitiim.

Superficial Median Tears.— A -.econdar^' ojierattMn ts usually Mt nft'"^
in these tears inile^i' an irril.ible siar has f<irme*r in '■'
vagina, as no important structures arc involved and the integrity of ihrpf''*
floor is unimpaired.

Operation .--Two points on opposile sides of the lower nwrnip'rf*'
vaginal openint; just in (nml of the >iriti<e.* nf ihc vulvoraKinil ' "' '

are cau;{hl with bullet forceps and the inlenening tissues pu; ' ' ''

Stretch. The |>uslcrior wall of the vugina is Ihen caught hy liullcl l<>cir[i^ <>' '^

Pl'KKPICRAt. INjrSIES.

799

median Uiic. about half an iiuh above the vaKinxil orilice (fr): three fo[ce|is are
now In f>iK>i lion —one on each m<)c of the ta^inal i)rifii.-r iiiul one on the [xKtcnor
valt of the v.i^n.-i. Ky mnkinje ;>lii:ht Iridion u|>un ihnir forceps in apposing
brections a Iriangubr spate is formed {I'lg. bgg, ti, b, t), which i-oircspundN in
\he lif>l area to be denuded.

Thi- cipcrator now sci^x-s the mucous membrane at angle c with tissue forceps

nd denudes a strip of mucous membrane with siissors up to annle h. A MmiUir

i.s then denuded from anjile ii lo (>. un<[ rin;illy fmm :ingle c li> ii. A »mall

ip of mucous membrane now rcTnuiiis in the center of the triangle, urhi«'h

liicn removed and the upper denudation compleleil.

The tower or )ierine;il end of the tear i» then nught with bullet forceps at

jnd the three points, a. r, and J, nude taut, thus formin); an e.xicmal tmii}!uUr

pace which b denu<led in a sinttlar manner lu the internal or vaginal iri»n)(lc.

/■

ii'

Pw. Wl. I'll., y.-i

SUDHiMnv OrumoTi io( nrt RtrAii ■» * iivri-ificui. U«oi*n T«i« ot tut P»i.vir Fiam.
|. T4I *bui>f (b( u|>pu KB ttiriDi) iriuiKto (4. \ r\ cotnpJrivIv rTrjiiirlcvl , V\t- ?Q3 itiowt Ibr rrmoinjiic KVIf
mufoua msnthnnc bNoc RtiwiMl Ifom Itv \owtt tt prnnnl nuo^lc la. t, i).

The wound is then closed as follows: The lirsi suture should lie piLsscd near

be upper or vaginal anfile of the wound by inlnHhn ihk the needle .iboul one-

[[hlh of an inch from the edge of the deiiud.ilion; it should then Iw tarried

vard so as to include a thick wedge of tisisue and made to emerge at the Ixittom

he wound. It U then reintroduced ne:ir the ]*oint of exit and brouithl out

DUgh the mucous membrane opposite to (he original point of entmncc.

nilar sutures arc then placed about one-fourth of an inch apart down to the
or i>criiWMl anjjle of ihe wound (Fin. 7o,!>.

The MiHirrs arc not shollcd uiilil they have all been introduced (Fig. 704).

HedJAn Tears Involving the Sphincter Ani.— The repair of the^e Lac«n-
liins i» (<imlu<led a.t follows:

Opcralion .—The posterior vaginal wall just above the apex of the tear

8oo

Tun PELVIC fLOOK.

and iwtj poinl<. on the op[)i>Mte sicie of ihe ruptured septum immcdiaidy kbon
the separated ends of ihc sphinclcr ani muscle (a. a) are caught wrjlh Mlet (n-
ce\rn (Fi^. ;o5) and ^ight traction made in opposing directif)n>. Thr aptnUt
now seizes the ^kil1 with tissue forceps and denuHcs with the sciswtn a braid
surface on the edge of the left septal tear. The denudation miut be mdc
enough to ^ive a ^ikkI appruximalion surface, and it ^hiiuld extend down In, he
nol lieyond. the rectal miicims memlirane. The edge of the tear on the uppoftt

_^e of the septum is then denuded in a samilar manner and tlic «uiuret inirixlund

" , folbw--.:

The first tiqital suture is pa^'^ed through the vajijinal mucous membraocatdt
apex of the tear about one-eighth of a n inchfrom the edjie of the vround and nidcb
emerge at the rectal margin of the curn »ct>tum without penetrating the hmkhb
lining of the 1>owel. The suture is iheu reintroduced at the sime pMilkm on th

"^'

Vk,

tm. TO). Piu. Tat.

Sn«HM» OnunoM km thi RKnia or A SomnouC IB^^ Tmi ornii I'nvK puot I*
nc-ns AwMIhe dtaudMlon amphud ml ilMtaHmtMNOHdi Fis. 704 tfeanibi^ua»*i

the opontbn ounplttsd.

4t^

Other side of the septum and Iimughi nut through the vagina oppo^te to ibr
ori(;inal point of entrance. Simitar sutures are then pA5«d downward to wiltni
one-third of an inch of the anal opening (P'ig. 706). The sutures are lo*
shotted, beginning at the ui)|ier angle of the tt^ir, and the operator tbea (A-
cccds to denude ihc cicatricial tissue around the unul opening and the t^
covering the ends of the torn muscle i Kig. 707),

A point on the outer side of the position of each sphincter dqiresslm fa cmh
with bullcl forceps (Kig. 707) and the free end of the last <«pui sulure it
grasped with a hemostai. The lhre«? forceps are then held by the asiistantt. wb*
make slight traction upon them ami put the inter\-enin(; liwue* upon the Nirrtil"
I'he operator now picks up the skin overlying the left end of (he sphincter < '
tiMSue forceps and cuts it away with full -curved scissors so as to coaipktdy txfoai

PUERPEKAL IK/l'KlES.

«0I

the torn fibcn of tht^ muscle ( Ftg. 707). He then denudes the cicttlricial ttuuefrttm
the left .ijde of the anal opiciiinf;. making a wiilc approximalioit surface dawn lo,
bu( not irtrlucltne. llic rtrtal mu(iH4. The (knudnlion nver the riKht end of ihe
muscle and ihe right margin nf the nnal opening is ihrn nwdt in a MmiUr manner.
The fir^t .luture is inlri>diiced under the inner mar);in of the lorn eiid of ihc
sphincter and airried ihrnujih Ihc tis,iue> ;il tht- eiigt" ii( the ret tal muami mem-
brane (o emerge ju.M below the last suture closing the scplum. Il is ihcn rein-
tmdueed and I trough I imt on the opposite side under the inner margin of the other
end of the sphincter. Tlie second MUtun- it intnxlticnl under tiie oiiler margin
of the sphincter and passed in a umibr manner, to emerge ujxiii the opjxwitc
side (Fin!. 708).

Flo. toi- t'K. )a*-

SmtaDtn Oruunim roR wk Hkfah nr j. ytania TCa* ot mr Fniw luni liiiKiLTiitn im

SpttiMi-iKt An Mv4(ir

y\g TdfklMw* Ihc Ifft !>']« «t ihr rrf i<h«(iiul j^«rn ilniuda] kbI iJk ^rtiuJi^ion '>riQN ^^f?"i *"* ^
n(St ulr, n(. TCA ibim the luium wtrulwrd >b ilar Ibt nuuitaiiul •riivn. 4. a. lo b<ch illinle>EiaiB
matk Ihc iiGMriuD uf Ihc ifihiivtrr d<pcv*'4CH

The sutures are then dwiiterl. and if nrcciaaT)' one nr two sufxrlicial slilcht^
mav be intrmhiced lo approximate the skin above the reunited ?.[ihintler mu-^le
(Fig. 690).

In introducinft the mluret that cont ml ihc torn ends of the muscle Ihc operator
must be careful to pass Ihc needle '.tp.- close to the edge of the wound iii order l<»
prevent inversion of ihe .Jtin. which would ne\«.vs»ril_v interfere with or iireveiit
union from taking pl.ice. It ivagood plan loMur the end of the muscle and pull
it out while the sutures arc being passed, as it is usually ver>' much rdraded and
may escape being picked up by Uie needle { Fig, 700).

V'ariaticin.s in the Terhnic, —If the tear does not involve (h«
rectovaginal septum, the superficial median (ear U fir^t opcraled ujhwi as alreadv
described, and then the torn endi uf the ^ihincter muvle an<l Ihe anterior margin
S»

803

THE PEtVlC FLOOR.

of ihir anal{>|>cniiicarcdrmide<l and »ulurec] in Ihcamcmaniwrisimhei
of a lat«ralion involving ihc scplum.

When only the outer fibers of ihenphiniter an! are ni|>(ur«l in a mrdiiakif,
the dcnudmiuii iit the Inwer end of the injury must be made so a to ihimuijili
e.xjHisc the partially separated muscle, and the sutures introduced wdl undolfair
lorn fillers un e^rli s.i(le. jiiM ii» In n romplcte laieration.

Lateral Tears IsTOlviog the Vaginal Sulci.—Thcsc laccniiotu ait n-
paircfl by Hmmcc's operation as folloxvs:

O p era t i ii n .^The fimt step i>f the upeminn is In srixe the cre«.i li iht
rcctuceic with build (or(X-p» at a pitint ii«;irt»l the ^'ulvoi-agin^l orifice mbMhoa

.^^

'M'

FlO. NT- r>6 ytlk

SsmmiAnr OnaAnon ma rut Rtrut u» a Miduw Tua ot nit Pnnc fuoa lamn^i'*
Sriiihcnt Awi Mrwtt <pBtfn loo «ad (tot).
fii IDT tbun [he tuium lUalnc ihe riitu'inmal uiiinin •hcitvl huI ibt ilnndiiM toapbMl •• tt' ■#
«Ur -A Till" arut n^minf . on thr rirlii ^(Lr iKr Oeih ctPrirlyinK if'^' fn ipninciir h |a<lad ^*it '"^'^
Iwiiut lui oiiy xiih uiuim, Y\g. >i« ihom ih' rlrniuU'i-'n torn|dc*rd oa hMh wkx^ ike IM) •fM«a'
lb( mum iDirnliKnl uuiilni Ihc itm radi o[ iht iphintiu uil niiiMlc.

be ilniwn up without undue traction close to the exicmal urinary mntaitf bfef
ally to the orifices of the vulvovaginal Klaiidii (Fii{. 710),

Twu jMiinis are then ciiught with forceps on o[>pnsile sides of tSc nciB*
orifice which correspond to the position of the lowest canintle nt irmaini iJ i^*
hymen. If wenowbriiifi the ihrM- forceps toK^her and approunulethnif'*'
the rectnrcle and the two points on the vaginal orifice, it will <hH« e«clK to*
the parts will be united and whal the size of the ncv.- outlet will be «Ik» **
sutures are introduced (Fiks. 711 nnd 711).

The neJil step is to ascertain how far the lorn Ir\-ator ani muwJe »ii<l *•
fascia on each side of the vagina have retraclcd toward the pebic wail*, t**

FVERPERAL IHjriUEK.

803

is accomplishwi by making traction in oppa'^ite (iirecliona upon llie two latenil
foreejiu. ami drawing 'lie rresl of the rvclocolf' wfll forwiiol and toward the right
side. When this has been done, a deep, gutter- shai>cd. triangular spate will
api^ear, running up the vagina fur a di>tani-e of one or two inihes at ihe sidi- of
the rtTlocclc Inwant the ccnu, which marks the limits of ihe retraction of the
lom struiturc* and indicates tlie area of the vaKinal surface to be denuded (Fig,
71^). The reclocele t* then dritvn toward the left side of the vaginal outlet and
the opposite sulcus exposed (l-'ig. 714),

The two lower forceps attached to b and c an now pulled >n opfioitlle direc-
tion*, the crest of the rectoccic (a) drawn forward unii tow:ird the right side,
and bullet forceps attached to the apex of the left triangle (d). The mucosa at e

fro. TOO.— SfmwiMLVT OniAfKUt Mim TUT ItS'

r«» 01 s MrtnAR Tiu at nte INtvir
FimR iNVaLcim tm Sniim-rak An

Sbmiiu ^^ nidhori vf fWaliEV Ihr toi of
Ike inhir'i-^ niuulii nUti tbi wium jn Uina
PimbI honaih ■.

Plo. ;io.— Emcrr't nna*tnm nia tux Sao
omMiy RiriB r.r I^hiai. Ttu* at ibk

Scio.

Shnfnnjt Lbv rnrthiil at driTmrninc Ibr utrnDuo
tj the rrrK nf tta* rtKlnttU-

U then sei/ed wIlli tiKtue forceps ami a strip of mui'riu.t membrane removed in »
straight line as far as </. A similar strip is then removed between -i and J and
then a curved denudation with the concavity directeii upwanl is made between
( and ft (Fig. 7 15). The rectiMek- i» then dniwn over towani the left side, bul-
let forceps attached to the apex of the right triangle (c) and the denudation con-
tinued lint fmm b In r and then fnim a to e. The line* of deniMlation which are
thus formed connect with each other and murk the area of iIk- original Ucera-
lion. The mucous membrane between these lines is then removed by cultin);
away contipious Atri]u vritli !tci»»or» until finally the entire area Is denuded as
shown in Fig. 716.

8o6

THE PELVIC FUX>R,

The .lulures are Tii^l iiiiniduced into th« lelt sulcus and then inta the n^
snd after b<>lli scries have hct-n pasM»J the)' iire .■^huttetl anr] rhe vutruendrf
the denudation is united last (i-'igs, 717 ami 718).

Th«leii.-'ulcuNisd(i»edasf(>llow»: The first suture la introduced ailW^fftr
angle of the wound ('/} by passing t)ie needle throuf(li the vagin.tl iniKnu> nxm-
brane aliout one^eighih of an inch from (he outer marRin of the dcnudBtiun ui
then cnrrytng i( ouiw.-ird and d'lwnwvinl. emerKin;; at ttic iMittiim of ibrCnrhr
low the level of its poini n( cnlr.imx. Tliy necdlt- i> then rviiitruduced wuihi
point of exit at the li<ini>ni of ihc wound and brought out again on the nfiiiil
surface o(>]j««lc lo the original jn-inl ot cnlrancc (Fig. 71*). This toaMinin
Kmmct's V-shapcd suture, which is an imi><>ri:ini fitctor in the ((cliDic. tsi
encircles and putU up (he retracted mus^ulur libers and tuxi^ when the Milnuii

Krr,. Hi), rio m

Exni'i OruATtaH 101 the Riru* or Lmtuu. Timu or rut I'ti.nc Flom lavaiiTw ni (■■■

8BW1-
f l(, jip thon ihc (ufuna intraduid In (tr.pit ihi nltit tul il tht doiu'l.i'Hn: ikr vgna •■■» b oW *
■■ crown itllch"; r)(. )» ihmia ibc wluiathutcd ud Ihc oiKriiltin itfnpbial

closed. Additional V-shapcd suluresubnut one-fourth of an tndi spirt in t^
introduced down to the x-uli-ar end of the deDU<latIan.

The sutures dosing the ri^ht .lulru.t .tre Ihcn passed in a simitar nunnrr,!*
ginning nt the up]>eT angle of the denudation («}, except that the piiiBii''^
trance of the needle is at the inner margin of the wound and the ftnl eiim I**
bui(;redge(:)ci->elt) the bterjl vaginal wull (Fig. 717).

.After the sutures in both sulci have been shotted the sup|H>riing pmrtf •"''
pelvic fluor is restored, and nothing now renKiin> but ihe suturing ol ihtnJiru
end of the denudjilioii. Tins is accomplished as follows: The first suIW!.""'
is called the crou-n sUlch. is intruduicd by po^^ing the needle thniugtl lbrtUi<*
the perineum cJuse to the wound ut tlie l.iienil edge of the dcnudaiiiui tod i^

yETHnDS OF STKtlLU:-*TIOX,

807

camint; it outward and upwani to cnwrfie u-itliin the denuded surface close to
the edxe o{ (he murou> inemhranr immc^ll.iti'lv tiHoiv the last suture in (Jw
kus. It 1!. then cjrrieil across the upijcr niarsin of the vulvar deiiuilatiun and
triMjuced under the mucous mciulinine (x>vcrinii; the rrcsi nf the rcctocclc (a),
iMite it emeTX<:^ "" the ojiposile side. "Il is then carried across the vulvar
denudatitm on the right side, introduced unclcr the lateral edjte u( the denuded
ace, and brought out opimsite In the uri^iiuil point of entrance. A second
ure is now inir<)ilur4-<i l)How tile iTiiwn stitch to complete the cK'.urc of the
cutancuus surface und the opcrnlion completed by sbollit^ both Miturcn.

deni

rcuta

CHAPTER XXXIX.

ANTISEPSIS IN HOSPnALS,

Il t* my puq»o*e lo ilrMribe in this ihapliT the .intiseptic lechnir which
I employ ill my own pr^iclicc. as I believe that the gludcnt will gain a clearer
roiKeption of th<; tiubjec t by first studyinK the- melhod^ of un individual npemtiir
Ihaii be would by reiiewing those of a numtwr of surgeon^s-

Asepsis, -By this lenn is meant the absence of licptic orp;anisms.

Antisepsis,— By this term ta meant th« methodt which are employed to
touow, inliihii, or (testroy septic organiun*.

METHODS OF STERIUZATION.

iRlliowing anii-^fpiic methods are eaipbycd to produce asepsis:
I. High pressure attain,
a, Boilini: aqueous solution of carbonate of soda.

3. Mechani*- sterilisation.

4. Chcmic sleri lint lion.

HIGH-PRESSURE STEAM.

Value. — Steam under hifih pressure is a certain an;u>lutely ilestn)y nil hacleria with their spores.
Time Required for Sterilixation.— From le>t> made by ilie author
with a self- rejci sic rinj; ihcrmomcler it was found that perfect >terili»ilinn
is <J>taincil in twenty miniilt-N under a nm.stant pressure of 1$ pounds of steam,
which irises a uniform IcmjKTatufe of 350'' F.

Apparatus.— Tmu.iimli/er-^ arc required— one for drc3sing;t,elc.,and the
other for water; they are hcilwl by g;is or liy Meam <iireclly from the power plant
ti( the hospital, ft is impossible lo understand the met ban ism of these sierilizcra
without a pnclicat denii)n.itrati<Hi of the action of the different ralve-'< and con-
nections, and consetiuenlly il would he usel^rv* In altempi such a description.
A pra<ii<al knowledne. however, is very quickly acquiml, and ev-en a pupil nurse
^^Htld have no dillinilty wlialever in taking charge of the sterilizers.
^B Sterilizer for Dressings. —The apparatus cimsisti of a large cylinder in
PHiich the articles iti lie sleriliard are placed, and is sup]>Iied with the necesaary
utlachmenis aiMi valves lo evolve the >Ieam aiu) keep It under a constant definite
life (Fig. 7ai>.

So8

ANTISKrstS IN llOSPITALS-

The sterilizer is rurnixhed wiili wire tiagas und convcvuncc boxes, io i
Ihc arlicle« Io be sterilized are pUccd. Tlie mustmciion nf ihc wire agiu
clearly shown by the illuittralioD, and therdure newlN no further deschptioo.

The boxes arc manuficiBml bf
Richard Kny & Cum|nny, of Krt
^'»^k, und are knuun a> Aifcun't
reciangular Iclcsoifiir bum. Tbn
are lo iiithcs Muure by 6 indiedvp,
imd coniiisl ui a hnivv (tmw ar
linis.O' nickd'phteil bnit and am.
The bullum of the &idts d Itit hu
iH perforated by a numlier of xiiil
hoW ihmugh which thr stam an
lilies, and is surrouDded hy a flugc
one-half of an inch deqi and (a^
fourth of an inch wldctlut fdcnbi
■Aiil into which the lid fitt. .Vw
fiilinii (he ttux with the nutnabht
Mcrilix-ition a strip of cotton Uuat;
h l(Hl^cly packitl in the tloi and At
lid sliil (Innn over ihc box a* bia
the small |>crforatjon>. when ■! u
held b)' pin.t on two vdc* "Wi ft
into hnlcs made for the pvpat
The Ixix is then placed in thedffil
izer. and after the tteriliulin d
completed, the pins are nitbfciM
;ind the lid allowed lo Hnk laloAr
cotton batting which fills Ik ^
The contents nf the box an Iks
])n'tec(ed from (i.inlamiiulionMka(
as the cotton batting is nM distHM
and the lid tvnMiii> in pbct. IV
advantage of these boxes is that the dressing?, etc., can be sIcTiliitd in \hmhi
Huccessive operations and kept free from any possible chance of eoatwiiMM

'^^'^^^

'^^^^

fl* T»l'

■Hif.M nrwOK Sham Snniuns

PM. !».— WiK C4Ct roB Hmniwi A«nn.ai mraiK StvniUAiMM.

until they are used, which is not the case when ordinary open xtttfMdnj^
employed. And, furthermore, these boxes can be conveyed any dtoiurt •*

8io

AtJTISEPSIS IN HOSPITALS.

Water Sterilizers. — This apparatus consists of two c>'lindric resenoin or
tanks — one for cold and the other for hot water — and is supplied with the nercy
sar)' mechanism to boil the water under high pressure. One of the tanks cmi-
tains a secondarj' coil of pipe, through which cold water is allowed to cimjlatt
after sterilixation in both reservoirs is completed, and thus in a short time ihe
operating room can be supplied with both cold and hot water (Fig. 724).

BOILING AQUEOUS SOLUTION OF CARBONATE OF SODA.

Value. — A 1 per cent, solution of carbonate of soda is emploved wIwd
boiling water is used as an antiseptic. The addition of the soda increases the
germicidal action of boiling water and prevents metallic instruments from rusting.

Time Required for Sterilizatiotl.— Sterilization is completed in
five minutes from the time the solution begins to boil.

Apparatus. — The apparatus which is shown is known as an mslrumtta

sterilizer; it is heated either by gas or .steam, and set upon a table or permanCTlly
atlaihed lo a si^cial .stand.

The sterilizer is supplied with perforated mclal Iravs in which thcarlide'J'*
placed and then immersed in the soda solution, and witha rectangular while >i™
porii'la in- lined trav in which warm sterile water is placed to cover the insini-
ment.s after thev are sterilized.

HECHANIC STERILIZATION.
Definition. — This method consi.sts in removing septic organism; •>;■
vificirous and continuous mechanic friction.

THE APrUCATION Of AKHSEPSIS.

Sit

Value.— Il i> ihc \teM mdlincj we plls<c6^ at the- pre«enl time for ftrriluing
thf hiinils :inii rorcnrms us wt-II -is the ticlcl of operulion.

Time Required for Sterilization.~The acrubhing should be am-
tiuudi (it rWli-i^ii iTimkiU'>.

Appliances.— Sterile brushes w^lcr, and map are required.

CHEHIC ST£RIUZATION.

Value. — The unt of I'hfmir sK^nt^ i» the lerhnic- nf .intiKepKi-t hitf Iwen
aUntvii cnlircly »wpcr!*<lfd by mnro crilain and s;»fcr milh^Hlii, nnd ul the present
time they jrc only cmijli^jfJ in a very rcsiri<te(l way or in conjunction with other

tli)th-prc(«ureslcam3ndaboilinf;sodaM>lution arc rapid and tcTlatii methods
of SterlUialion, and they arc employed cxclu>i*ciy. with positive reaults, to sleril-
(k nlnWHl c^ery article or ajiplLinre which i- m*tl at .-in ii|>eriition. It is, there-
fore, not only usclei^s but unmixctl nonsense 1o consider the relatiie value of
variou.i chemie aKentn aa compared with steam and boiling water. On the other
hand, however, there are a (ew arti<ies or applbnce* which are injuretl by ?lcam
or iMiling water, and under these circumstances the use of chemic agents is
iDdtcated.

The value of chemic .intiscptic.< in Elcriiixini; the hand« and Ihr field of npcru-
lii>n i^ a <)ctMilable question, and has not as yet been definitely settled. There is
nodiMibt. however, of the fart llial chemic <)i>in feet ion alunc U pr.utically value-
less, jind thai it mu:^t be preceded by thorough meih^nic Mrri)i/,4ili()n to accom-
|>li>h any nsMlls. I have not used chemic agents for sev-
eral year» in the preparation of my hands or fore-
arms because they injure the skin and cause it lo
become cracked and irritaieil. Allien the hands are
in this condition, il is impossible to sterilize them
mechanically, and consequently chemic agents often
in the end do more harm than good. When chemic antt*eptici
lire employed in sterilizing the field of opel'alion, we do not necl In consiilcr iheir
injiiritni' elTeil upim Ihc ^kin, as in the cvi-* i>f the hands, and I have therefore
always Utkcn ailvaniagc of any |>o;isihlc inhibitory i)r dolruttive pr<ij»eriy which
the>' may jmbacx*, ami have used them in conjunction with mechanic Mcriliaition
I in preiiaring the luirL-' fur iijHrr.ulon.

Indications. —Chemic agents arc used in conjundion with mechanic
strrilization in pre|>aring the tleld of operaliun. and they are also employed lo
sterilize such articles, as lianl-nibbcr sj-ringes, catgut, itiecial iruitrumcnti, etc.,
Ihiit are injured by steam or boiling water

Agents.— I employ the following chemicals: Bichlorid of merctin,-, forma-
' lin, fornvildehyd gas. oil of juniper, alcohol, and cumol. The various u^es of
h these agents are given in discu&sing the application of anli^isis.

^^^r THE APPLICATION OF ANTISEPSIS.

Instruments. -The instruments are placed in a fteHofatcd Irur and
liuitcd for five minute* in the whIji «)lution. The iniy is then n-moveil from Ihc
MeriluEcr and pljct^l in a reccpl.icle containing a ^fiitienl quantity of w^arm
sicrile water to cover the in.-tnimenls,

.\fter an operation the iliRercnt |>arts of the instruments arc seiwnited and
pbced lot five minutes in a iray containing <x>ld water to dissolve the dric<l blood

8l9

ANTISEPSIS IN HOSPITAtS.

vrhirh fidheres tn iheiti. Hot watrr (should not he used for thU |>urpnir. uil
coaguliilc^ the ulhunieii nnd makes ii difficult to remove the blood. Thti»
strumcnts arc then scniW>«J with warm w.iier and s*Mp, antl if ihej' ntwl poU
in|t, a K'*'*'' sand-soap should be used. After they hnve Ix^n smilibfd titi
arc rinsed in clear water ami then Imiled for one minute in ihe -iirta wloiiic
They arc then taken out o( ihi- stcrili/cr; rii[ndly drieil; and, after the tepioinl
parts are joined to);cthcr. pbcetl attain in the instrument »<«. L'nim ihtin
(itruments are first lioiled and then dried while ilicy arc very hot it i^tabncntn'
passible to dry ihem thuniiighly. as the towel ainnol reach the MUll joJMiMd
locks in which ihc moisture collects.

A ru])i(l and very ellicient method of dT>-in|! instruments after tliey hivrbcfB
boiled in ihc soda Kohilion is to immerse them tor a minute in 95 jier cent Miatxl
and then spread them out on a towel. The alcohol quickly evajmraics and )eti»
the instruments absolutely dry. 1 use this method e.uluMvely for tuiinsnob
having delicate mechanisms and for those having a canal which must be ktgit
free, as, for example, the cannula used in intrai'enous injections and tW Mtdr
emi>loye<l in hi'mxlerniocly.iis. After the idcuhol luis c^-jpor.iicil the»e iutn
meni-^ :irc iihn eil in n glas-* triiy iind immersed in coji-oit.

Needles. -The needles are passed through scveml layers of a ^utt yai
and put in a small wire ca^te (Fig- 716). They are then placed in a perfcnki)

Fid. ]M. — Shiihv Sii i l.ii.An'tD W<ii«ii> <xw Giau Suou. a Wiu C*ni, 4Wi Viiiiita Pww !■■■

tray with the insmimcnis and boiled in the soda soltition. They tit ll»
taken out of Ihe sterilizer and placed witli tlic in^rumcntfi in » recrfiCKk n*
tuinintt warm sterile water.

.After an iit)('r,ili'in tliey are rlcanc-d in ihe same manner a* ihe inntranKW*
Silk and SUkworin-g^ut.— Tlic *j!k ligatures arc wound <ii ttU«uli*»
(Fig. 716) and pLiiced inavinall wirecigcwith the needles, and ihe MlkBtwaffl
sutures arc wnippcd in a lowcl and scruroti with safely-pinv. The cigcu»l<^
towel arc then placeil in a perforated Iray. put in the slerilivser, and liciW''
the MHia solution, .\fier the -iierilixjiiion is completed the tray u mnattil**'
placed in a rerq>taclc containing warm sterile water.

Catgut,— The folluwinic method of prc[)arin); catgut h. cmpluveJ ** '^
Gynetean HuspiUil of Philadelphia; Take the raw calKUt mid loak ll ix*) ''
juniijcrfwoodi for one week and then in el her for forty -eiKht hour*, Xnlpi^''
in alcohol (95 per cent.) for forty-eight hour« and then boil it in an alcnhtil W^
for two houm. The nttgut is then wound on glass sjxiiilt and kepi in tfc**^'*''
in which it was boiled. Before an ojicratiun two or three *jm»Js jte uken ■■""'
the supply bollle and put in a sm;dl jar contiiininf; alcohol anrj U.ikd fi» **
minuie>. The glass top should not \k fastened down and the iiet-k J ^ P'
should be high enough out of the water to prevent it from lioilin); iiver iWo**

THE APPUCATION OF ANTISEPSIS.

81.1

alcohol. If ihU happtns. Ihc alcohol become diluted with llie »-aier and iht
MrciiKili tA ih^ Kut (> <lestruyed.

In iransfcrring ihi- giil fmm ime Nnlulion to another during the process of
jircparation and in winding it on glass sponU the hands must be MitKically a-<eplic
ant] a pair «( sterile rul)l)er glovo worn. Wheii ihc catgut i> taken out of llie
Mil>ply jar. atid also when it Iviv twrn bnilnl for an 0]>eration, a pair of forceps
muji be used to prevent infecting it.

The ak'olml is boiled by pLidnjt ihe gl:iw jan in the instrument sterilizer and
keeping the water boiling quietly,

1 list :i catgut pre(Kire^ by JohnMn & Johnsion, which is. Mcrilixnl by the
cumni method anrf put up in germprnof cnvelopej, (see p, 835), The process of
sterilization is com]:ilirated and not readily accomplished by ihc general practi-
lioiuT.

Rubber Gloves. — The gln^-es are slerilijml by high-pressure steam.
They are then platc^l in a basin containing warm sterile urttcr and lovcrcd with
a tiiwel. After an ugieration Ihey should be thoroughly cicanseil in.^ide and out

flc J(7.— Shci*» * Stkhili J'owil
I'lAnc ovm mr T'lr ■>■ a pii-
aim Jmo SicUMn hiib a Sutnr-

Via. ;>■.— SfMNSUB IDT BoriLr ptoncno
■V CAr •» Cau>i (vw Sial-

Ttie lUiuimvA nn ihr nchi thow^ ibr pntei'
dodi ID itw MP ol iIk hmtr.

with warm water and Miap and boiled for one minute in the -mkI;! solution. Thej-
arc then dried, wrapfied in a towel, and j)Ut away until needed. W'ilh nnli-
nan* tare a jtair of Ki<"'e> slmuld serve for M-\'eral o|»eTaiioris.

hypodermic Syringe and Needle.- These anirles are steriliml by
Ijoiling them in the soda wluiion. After an operation they arc again boiled in
the solution for one minute, then placed in alcohol, and fiiuilly immersed in coal-
oil until rradv for uw,

Abdominal »nd General Irrigators. — 'Dtese articles are sterilized
by liiAilini: ihcrr. :!i (he ■■■xI.h vitulion,

Pitchers; Basins; Sorf^cal Pad. -These articles are finit cleansed
with MMp and «,irni water and then sliTilixeil Ity high(>res.4ure steam. After
an ojieralinn ihcy are hgain cleansed with soap and water, carefully drietl, and
put away until nciyloi

Ganze Sponges, Pads, Compresses, and Tampons; Ban-
dages; Towels; Sheets; Operating Gown8;Cotton Batting;

8l4 ANTISEPSIS IN HOSPITALS.

Absorbent Cotton ; Safety-pins ; Brushes.— These articles are steril-
ized by high-pressure steam. The brushes are cleansed in soap and waim waUr
after being used and exposed to the air to dry before placing them again iniht
storage case.

Apparatus for Intravenous Saline Injections, Hypodermo-
clySlS, and Bnteroclysis. — These articles are sterilized by boiling than
for ten minutes in plain water or by high-pressure steam.

Abdominal Dressing; Rubber and Glass Drainage-tnbes;
Glass Catheters. — These articles are sterilized by high-pressure steam.

Hot and Cold Water.— The water is drawn directly from the hoi and
cold Verilizing tanks into pitchers and protected from subsequent contaminalian
by sterilized towels which are secured to the handles with safety-pins (Fig. 7)71.

Ifiquid Soap. — The soap is poured from the storage jar into the requisite
number of sprinkler-top bottles, which are protected by a cap of gauze and
sterilized by high-presfeure steam as follows; The steam is turned into the bealii^
coils of the sterilizer and the outlet valve left open until the contained air is m-
pelled. When a large volume of steam escapes, the val\"e is shut off and ihe
pressure allowed to reach fifteen pounds. At the end of five minutes the steam
is turned off and the pressure allowed to gradually fall to zero by cooling (sm
sterilization of normal salt solution, p. 126). From tests made by the author, the
pressure falls to zero in thirty-five minutes by the steam condensing, and iht
liquid soap is subjected to a temperature of 230' F. (Fig. 723).

Hard Soap. — The soap is taken out of the storage jar and rinsed in slerile
water before using.

Drainage Syringe.— The syringe is sterilized with a 5 per cent, aqueous
solution of formalin (40 per cent, aqueous solution of formaldehyd gas), TTk
formalin is drawn into the barrel of the syringe and the entire instrument im-
mersed in the .solution for five minutes. The syringe is then thoroughly rinitd
and placed in a pitcher containing sterile water.

PREPARATION OF THE OPERATOR AND HIS ASSISTANTS.

Personal Cleanliness.— 'Fhc operator and hi.s assistants must b*
scrupulouslv clean in their personal habits. They should take a general Iwifa
ever>' day and wear clean underclothing and linen. The hair should be tepi
short and free from dandruff and the nails carefully manicured. Too lil'le
attention, as u rule, is paid to the care of the hands, and it is not an un-
common otiurrenie (o meet surgeons who have long, irregularlv irimmftl. and
dirty finger-nails. The nails are the mo.st difhcult parts of the hands to sleriliw.
and unless they are [iropcrly cared for, no amount of .scrubbing will make ihem
clean. Thc^' .'.houkl be manicured iwiie a week as follows: First, file them vtn
short wiih a ihin. flexible file; scionti, .soak the hands in warm water and wup
for five minutes to s<iften the hard skin which urows under and around the nail*;
and, lliinf, trim this skin carefully away with a sharp knife and smooth of! the
irrcgulariiics with the file.

The operator and his as.sistants should not make postmortem e.taminatini^
allcnil infectious dist^ases, handle ])alhologic specimens, or unneces.sarily comein
direct contact with ;iny form of .septic material.

Immediate Preparations. — The immediate personal prepanlion>
for an operation are made in the following order:

1. Remove all the clothing exce])t the underclothes and the stockings.

3. I'ut on white canvas shoes with rubber soles, an operating suit, andata|'-

3. Sterilize the hinds and forearms.

4. I'ut on rubber gloves and an operating gown.

P-KKPAKATION OF OrtRATOK AND ASSISTANTS.

815

Shoes, Suit, and Gauze-turban.— Thv canvas xhtxs arc the same as ihow
used in piiij ing gi)li or bwn icnni^ und c;in bebouglil in any .shtiii. Thcy^huuld
be kcpl tlciiii wiih Mwii ami walcr ami whitened wilh pipeclay.

The Dpcraling *uil consists of a while comm shin wjih shun sleeves reach-
ing luily half way down the arms and a |Niir of cotton <iuck or linen trousers.
The suit can be boupht at any shop wlierc men's cloihinn; is wild.

The (urban is m.ide by takinjj; a van! of ^uze and folding il on itself
like a child'% diaper. It is then placed on the surigeon's head and .secured by
lying the free ends.

The suit is luutiderc<l in the orrlinary manner. The objcrt of wearing
ihc suit is to have dean and liglil clothing under (he o|)eniiing gown,
which is sterile, and the cap jircvcnts particles of dust
or perspiration from falling from the head into (he
wound. The suit necessarily becomes
more or less contaminated in putting
it on and during the preparation
of the hands and forearms, and it
must not therefore be depended
upon as an aseptic covering for
the body.

The dresses worn by the operating room nurse*
miiM be made of 3 material that can be washed, and
they should be put on cle.in before (he operation. The
sleeves should be short and reiich tmly halfway down
the arms.

Sterilization of the Hands and Forearms.—

ThU is accompli si led by means nf mn-hanic sleril-
imtion wilh brushes, hoi water, and soap. The pn>-
ce>s is divided into two stages:

I. The preliminarv' cleansing to remove Ihc ordin-
ary contaminations which a<eumulate on the hands.

1. The fnial s(erilix.-)lion, which removes the sejitic
bacteria from the cutaneous surface and the linger-
nails.

After the sierilizalion is com-
pleted the operator and his assist-
ants shoul<l touch nothing but what
is absolutely sterile, otherwise the
bands will become reinfected and
require another scrubbing.

I'KKLiumARY Ci-tiAssisc. — The preliminary
cleansing is made over the permanent wash-basin wilh running water from a
spigot which is controlled, as descrilred elsewhere, by foot tajts on the llnt>r.
The nails hands, and forearms, as well as the elbows, arc thoroughly scrubbed
wilh a bmsli, hot water, and soap for five minutes. The soap is then washed
oil under the spigot and the second or final stage nf (he sterilization t»^un,

FtSAL STKKm?ATio.N. — The final sterilizalion is made in a portable
basin, with a f^e^h bni*h, vKip, anil water. Tlie situbbing should be continued
vigorously for ten minu(es. changing the water twice during lluil (ime, and the
soap should then be «'ashe<l off by having the nurse pour cold sterile water from a
pitcher U[K>n the hand^ and forearms.

Separate brushes must be used for the preliminary
and final s ter ilina t ion, and under do ci rcu tns ta n ces

("10. Tn>'— OniAiina Sorr,

8i6

ANTISEPSIS IN HOSPITALS.

should a brush be used a second time withoui it

sterilizing it.

Putting on the Rubber
Gloves.— ThLs is fadiitaled by
partially filling each glove with
cold sterile water from a piifbcr
before it is slipped on ihe hand.

Putting on the Operating
Gown.— After putting on llw
gloves the surgeon takes his op
crating gown out of the box in
which it was sterilized anii 4\j->
his hands and arms through the
sleeves. The general nurse then
ties the tapes at the neck anl
the waist and thus securer the
gown in position. The ci[«r^iiir
now takes the assistanlV gown
out of the bo\ and holds ii f»r
hJm while he slips his hand.> and
arms through the sleeves: tht
general nurse then securo ihc
tapes.

The gowns are made uf whitf
muslin and cover the body from
the neck to the feel. ThesleeK^
are short and reach only half-way
down the am";.

Fii, j.io.— Methoi) of PurflNr. ok Riiiiikb Glovu.
Note ihdi ihc glovr is difipndod with water.

Fio. 731.— Shuwinc the OpFHiiou PirriNr. on ihe Assistast'b Gnws.
Note lh|. hanil4 of Ihv nuf^i; rr:ifly In si-quri' Ihr l>pr>.

OPERATIKC ACCOHUODATIONS.

«»»

Fn. TV-'ftaW yi"'

OpaAiTHC Com.

Pio. »].— BMk Vi»w.

OPERATING ACOOSIMODATIONS.

The sur^kal afmmmiMhitmn^t nf a moilrrn hiihpiUil should pTxn'Me separate
nxims (iir ofieraling, strritizing, :vafhing, and storugf. The ncccssitv for ihis
is self O'idcnt when we consider the eomptex iharaiHci of che technic of anti-
^psis anil ihe im|>eniive need «I hiivin;: rvcn'thinj; il^ nwirly ^^e[ltif^^:alIy airrwl
as posMt)tc ihat lias any connection whatever with an oi>cratinn. If. for example,
the same room is used for operating, sterilicinK. woshinK. ami >l<)raKe, U certainly
cannot l>e conMilered an ideal place in which to perform an ii)>rruli<>n, ht^rause
thr •^terilixer^ will vitiate and overheat the air, ihc drains connected with the
washstands may infeet the atm(H|)here. anii the presence of the instrument and
dreNAirift ca.4es makes it practically impossible to properly mop ami dean the walU
and floor.

In con.iiderinK the operating accomroodalionx that are required for carrying
out the itchnic of antisepsis I shall confine myself to a description of the r«f>m»
which arc devoted to the pynccologic scrijce at the Mcdico-Chirurgical Hospital
of Philaitelphia, aivl which form a \>*rt of tlie general tUiiii^ amphitheater
l>uiUIing (Fig. 734).

OPERATTNG ROOM.

Description. — The room is about iwenly feet square, wainscotted to the
ceiling with Italian marble, and the ll(»)r mviTed with larR* .Jahn of (-rayKnox-
ville marlile. Thcnr is a sloping sfcvlight ;ind a side-litEhc o|K-ning lo the itorlli,
which gives a wcll-diHused illumination for i>oth ahdaminjl and vaginal opera-
tions. The eleitrii lishtiriK i-* hy single li^liU lucateil in the ceiling, and there are
also plug outlets situated in the wall to which bunch and single purlahlr lights
with rejectors are attached. The room is heated and vcntUalcd by blowers

8iS

AK-TISFJ'SIS IN ROSriTAIS.

which Mijiply tfm|ieTC(l, warm, or cool air, and an exhau5t system whidi bite
awiiy Ihc viliatcd air, The bupply of air is broughl from above Uic roof o( III
main building througli a large shaft in which arc placed perforated pipe> <
uf which line jet^ of water are ihrxiwn tu wa.ih the air as it (leMreods mio ike i
chamber below. From this chamt)cr the air h drawn ihmugh a 6ae ctfipcr*
wire screen over which water is constantly flowing lo moisten Ihc air tad wjh
it a M'cond time. The .'lir now piu>.-WA nvtr heated sieam ruib and tbeixcniU
the blowers, from which It is driven into the operating room. To pm-cirilhr
condensation and the consequent dripping or clouding of the skylights b aU
weather coils of pipe through which steam lirculato are pbce<l under the ribt(4
ihc framework diiiding the glass. These coils are attached close lo the inmt-
work M) as not lu he conspicuous, and the steam is controlled by a separate nhc—

Wash
Room

Operating
Room

' I

Area

S tenlizdii
Room. '

0
©

5 tora^e
Room

Pio. 114— I'lJ'" or nri tiiMi :'!'» I' • i:t}, i.T'.L. i<.i.nis At im MmiM-ClnmBM'u nettttai^m*^-
SiTrltiitiv iwim' li> iniirummi KrnliKi: in iti nlinr Irr irmlnri- U) nufMrdtlb. t& 4l M<*''^
nixt iicriliKt Wwhruom. Ij. ;1 LuJun: ((>) kiuIi Imia *iul muble ifaib; ( i> Nrtflji Mlh Miii ■*
<(r) &bnK0 <BH-. (v) wanh'bobiQ and nurljti^ ^Uli-

Thc room is without permanent 6xturc5, such as wash«und5. dnfat.*]
tablcv, iitiil heme it ciiii he made practically sterile whene%'er required.

Squlpraent.— The room is equip|Kd with {a) an operating utile; (M''*j
stools; (c) An instrument tabic; (</} two wa^stands; (e> a supply table; wd0 |
two Imrkels.

Operating Table.—Iloldt's operating tabic (Ftg. 3), which is u»cd. ti n*
of white enameled metal with a gla^'^ top which can l>e raided lo the TVenW*
bur>! iHivition .uul has acljusUble leg hotdccMind Mirrups. The gliss Kf>i>*
arranged that drainage is accomplished in abdominal operations wiihotit itoo*
of a sur^icid pad. and the construction of the tabic is m simple ihji ihoro**
diflicully wli;itcver in kcejiiiif: all ihe parts cleiin. Tbt table can !« tmplojW*
all alKlominal and vaginal opcriiiions and also in making the tsriws £■*""
logic examinations.

Sao

ANTISEPSIS IN HOSPITALS.

WashstandB. — The wasbstands are made of white enameled metal and luve
adjustable basins. The stand used by the operator has two basins (Fig. 737)
aiKl that used by the assbtant has one.

Fio. 7jS. — WaiTE Enaheled Mktal Wasbstahd vttb Ohi Basih.

Supply Table.— The table is forty inches long by twenty inches wide, iDd
is made of white enameled metal with a glass top and two shelves.

Fin. J30. — White EN«Hri.En Met*! Sitfpiv Table intii a Glass Tnr ahd Tm) Sanvii.

Buckets. — The buckets are made of white enameled steel and have a ap*'
city of four gallons each. They arc used lo collect the drainage from theperindl

OPEBATINC AOCOUMORATimJS.

831

Pic. ;«Oi— U'mi Rxjiukud SisM.
Uimn.

|>sd during; 3 vaginal opcrolioD and to hold soiled sponges and pads during an ab-
dominal M-vtion.

Sterilization. — When we qwak (i( ^icrilixing ilic Operating room and iU
e<{ui|>ment, il must t>e disiinttly undrriiiixMl ihut
we do not u»c the word in the sime sca>c us uhirn
a|k|tlicd to ihc »terili2Ati<Jn <i( iiistninienLs dre»-
in((.*. rtc, Iwcauae il is practically impossible to
nuke the former axptic; and uiile» ihi.i (att is
fully aitpreciaied. errors in Icchtiit an.- bound to
txcur which will be (ollowcd by scjitic liifcclioti.
For example, we would n<>I ihirik inr u miimcnt
oj {HtttiriK the handii, after llicy have been sicril-
Lux), ngjinst the walls of tlie mii>i <-;irefully pre
pared room, nor would wc touch nny ut (he
niuipmcnt, becauM; they arc not and cannot be
made sterile.

Practiuilly there is no need for the room and
the e<|uipment to Ik- sterile In a laboratory sense,
because the hands of the ojicnilorandnf his assisl-
wtLs, as well as the t'leld of operation, do not come

in direct contact with them. On the other hand, however, il is ver)' necessary
for them to be carefully w.ishcd and clcnned, not only after an operation, to
remove the blood ami the di^ hurKes that have aixumulated. bul also before nn
opCTHtion, to get rid of Ihc dusl and parlidw of sqtlii matter which ordinarily

settle everywhere in a room and iiifcti the air when

dinturhed or .'iet In motion.

The o|)cr:iting room und its equipment are cleaned in

tlic fiitlowing manncir: Before an operation the ceiling,

^^\ \\ the wnlK Ihe windows and iheir (nimes and the fl(x>r

y\ 0 ~i~J W !"^ thoroughly mopped or wijicd with a wet cloth.

\i 1 U The equipment, conMMing oJ the o|icratinK table, the

W Wji \ stools, the instrument table, the wn>hstan<k, the gen

M Jtol I cral tabic, and the buckets, is scrubbed with warm

K^a^l I water and NHip and ibcn rinsetl with plain water and

wiped dry.

After :m n|KTntion the equipment Is again cleaned in
the same manner and ihe floor of the room thoroughly
scrubt>ed with hot wsler and soap.

Several times each month the entire room should be
scrubtM-d wiih hot water and soap and occaKJonalty it
should be disinfcrleil with (ormaldehyd gas. This
method of disinfection should be emjiloyeii ii> a routine
prineduri- after a septic operation. One of the bewt
|>ortubte formaldehyrl pis di«.infeitors on the market is
made by Charles Lent/. &: Sons, of rhlladclphiu; it is
•limiite in convlrui tiim and very readily man.igcd,

Temperattire. —The tcmiwrature of the operat-
ing room is kept about 75° F. A low temperature
hcSr DooKlSlii!'"*" intisl be «voide<J, a.s it i* apt to cause shock from loss
of heal, especially when ihe intestines are exposed
Uring .in nbdominal section. On Ihe other hand, a very high temperature
i: also injurious, as it produces excessive jHsrsjiiiatiua and exhausts Ihe patient
u well as the operator.

-Ijotrrt PDM-

h». »4i' -

aau FoaiiutiriiYK
Gib Dbbmikim-

833

ANTISEPSIS IN HOSPITALS.

STERILIZmC ROOM.

I>escriptlotl. — The room is about ten feet square, finished in maTble, and
lighted by a skylight and electricity. It adjoins the operating room and is
sei>arated from it by an opaque glass door.

Equipment. — The room is equipped with (a) an instrument sterilizff;
{b} a high-pressure steam sterilizer; (c) a hot and cold water sterilizer; and (Jj a
marble shelf.

The sterilizers arc described under Methods of Sterilization on page 807.

Marble Shelf. — The shelf is made of a slab of white marble 30 by 36 inches;
it is placed 30 inches above the floor and is permanently fixed to the walk in a
comer of the room. It is used to hold the trays and boxes before sterilizaiiMi
and for other similar puqxises.

Care of the Room, — The walls, ceiling, and skylight are thorou^T
mopped or wiped with a wet cloth every day, and once a week they are scniWwi
with hot water and soap. The sterilizers are kept ]>olished and free from the
accumulation of dust and dirt.

WASH ROOM.

Description. — The wash room is ten feet square, finished in maiilc, and

lighted by a side window, skylight, and electricity. It adjoins the opendn);

room, but does not communicate with it directly, and it is heated and ventilatHi bj

the same system as the rest of the building.

Bqtllpment. — The room is equi^wi
with (a) a washstand; (b) two kickers;
and (c) a supply table.

Washstand.— The washsUnd occupies
the whole length of one side of the ronm
and consists of a long marble stab 18 inches
wide by 10 feet long, in which are in.-ene>i
two basins that are connected with drain
pipes and hot and cold water miiinc
spigots. Foot taps are placed in the fluT
to control the flow and temperature of ibe
water and to retain it in or release it from
the basins. The unoccupied portion of ilw
slab is used to hold portable basia<t and Iioi
and cold water pitchers.

Lockers.— The lockers are used bv ihf
surgeon and his assistants for their oidiiwri'
clothes when they prepare for an o|)eration-
and also to store the operating suits, cJp*-
and shoes.

Supply Table.— The table is ifietn
inches wide and nineteen inches long, a""

is made of white enameled metal with a glass top and two glass shelves.

Care of the Room,— The interior of the room, including the kictch,

is thoroushly mopped or wiped with a wet cloth even' day and scrubbed on«*

week with hot water and soap.

STORAGE ROOM.

Description.— The room is ten feet square, wainscotted tour and a ^"
feet from the flo<ir with Italian marble, and the walls and ceiling are rovwed

Kir„ 74>.— SuppLV Tabu ro* t«e Wash
Koou,

OPEHATINC PARAPH ESNAUA.

8»3

with ft hard while eniimcl paint whkh is sprcLilly prc[i>ar«t to resist the aclion
of w>ap uixi u':itcf.

Bqnipment.— The room in c<qui{>)ied with (a] n storage cAse nnd {b) a

Storage Casc.^Thc one is miule of hurcl wood and f!,l»sA antl is constructed
ijtii shelve-^ ;tm\ lockers in which iirc stored the entire operative pATUphctnalia.

WHSbst«iid.--'I'he washstand occupies the whole IcDgib of the side of Ibc
ronm 31m) (-on.>>i3.t9 of a. slah of marble i8 indie'' wide by lo feet loii){, in one end at
which is in?;erted a liiisin that is connected with a dniin-pipe and u cold and hot
water mixing spiRot which is controlled bv foot taps. The other end of the
>Lib i> iL-*<l ;is ;i ulile

Care of the Room. — The interior of the room is thoroughly mopped or
wiped with a wei cluih unce or twi<e a week, and every month ii is thoruuKhly
KfUbl>er and wiLNhs(an<i are cciiisUinlly
cleaned with soap and water and the interior of the ciisc »nd its contents ure kept

! from all gra^a forms of contamination.

OPERATING PARAPHERNALIA-

The operative paraphernidia is kept in Ihe stonige room and protected from
groKK fofm.s lit conmmination, auch as dtist and particles of dirt.

The following list comprises the paruphcmaliu which h needed for minor and
Nli>minal oiicralioiv^;

Instruments. — The instruments are classified and umngnJ un a xhcif
i the stomge ca:^e.

Fia. J41. — AuiTOM't AaiHHiiKAL bnoATna Afrtuiu.

idles.— The needles arc inserted in a mw along ihe middle of a strip of
lohith h folded and placed in a metal box.
Abdominal IrriKator;— This apparatus con<JEts of n graduated glass
enoir. four fctl ■>( nililxT tiihing, a thvrnu>meter, and a metal tube.
General Irrigating Apparatus.— This consists of a graduated glau
voir, four feet of rubber tubing, a Utermomctcr, and glass lube (Fig. 744).

834

ANTISEPSIS IN HOSPITALS.

Rubber Drainage-tubes. — Rubber drainage tubing of different diuw-
ters and cut in lengths of ten inches is kept in a glass jar.

FjC. 744- — AsHTOH's GCNimAI. TllTaATTHG A^AIATns (PM' ^l)-

Glass Drainage-tnbes. — Tubes of different diameters and kogllis
arc kept in a gbss jar. The best variety of tube is shown in Fig. 744, Ithasa
flange at the proximal end, and the distal end, which is open, is perforated with 1

Fic- J45.— Glass DKAiNAfJF ti-be.

number of small holes. The tubes should vary in length from 4 to 8 inchc ind
in external diameter from | lo 4 of an inch.

Drainage SjTlnge.— 'I'he syringe is made of hard rubber with acapadt*

INO

Fli:. 7jA. — HAhD-RrBntJi Dkunaof SntivaF,

of half an ounce and has a long narrow nozzle which will reach down to ihf
hiillom of a glass drainage-tube. A number of these syringes are kept on hand
wrapped in a clean towel and put away in the case.

No 2

•) G

NO 7

E) Q

MO \Z

ACTUAL SIZE
Fic. ji;.— JlirrFBEHT Smcs or Bminrn Siin Lic;*Tt-«E5 asii Sryrnts.

Silk I/igatures and Sutures. -The silk is wound on glass spooU J»i
kep( in a jar. I use braided silk excluiiively, and employ three sizes: Xos-'-i'
an<l 12.

OPERATING PAKAPBEKNAUA.

toS

Braided is preferable ta twisted silk, as it is more readily muoipulated (lian

lie htter, which haji a (iciiilrd tendency to kink iind interfere with rapidity in

crating. Figs. 74S and 749 shuw (he difference in the pliability of the two

It b economy to buy one or two ounces u.t a lime oF each sixe of the silk.

^Flo, )4».-Twl«(d slk. Fin ;w -BMiiW lUk.

Snows ml KiniKa CnujkiTEB or Twimm Siti «iin Tiii PuiJiiuiv ot Biaidui Som.
SUkv

I ■

Silkworm -gut. —This material is bought in bundles of 100 strands each
and kqit in 11 glii.vt jar. The strand'' .vhoulii be from 13 to 15 inches long and
of three difTercni sizes— /fur, mtdium, and coarsi.

Catgut. — I have Iwen u»-

N=i Ml-

D G

No»

ACTUAL SIZE

D G

N&4

iag with satisfactory r»uh< the
"Red Cross" catgut prepared
by Johnson and Julinson. It ii
^crilizcd by the cumot method
and iKit up in germ-priNif en-
velo|>es. It comes in dilft-rent
dia and is either plain or
chromicEzetl. f employ four siww of each kind— Nn«. i. a. 3, and 4. If the
printed directions arc tarefiilly followed, there is no danger whatever of infect-
the gut when it is removed from the envelope at the time of an operation.

Frn. ISO.— Drill lEsi Siit; or Pum aud CnioucinD
Ctiuui.

Til.— SuMiBH Wmt« trnvrntxtv Sim
tntaiu.

Fn). III. — SiAiniii Wbitt EHAmuu SlUL

lUUK

If lUe Kurgcon desires to prepare his own catgut, the melh<xl that is des<-ribed
on page Si3 may be employed.

Pitchers and Basins.— The pitchers and basins are seamier and
nude of trhitc enameled steel. Spv'cn pitchers and four basins, exclusive of ibose

836

ANTISEPSIS IM HOSPITALS.

belonging to the washstands in the operating room, are required for abdomiiial
and minor operations.

Gaoze Sponges. ^The sponges are made by taidng a piece of gauze ij
by 15 inches and tucking in its edges toward the center until a. more or Ics^
rounded ball is formed. Eighteen dozen of these sponges are kept in a g^assjar
Gauze Pads.— My article on " Pads of Absorbent Gauze as a Substitute
for Flat Sponges in Abdominal Surgery" appeared in the "Medical News," on
February- 20, 1893, and since that period marine spOnges have practically bem
discarded by surgeons.

I employ two sizes: A large pad 9 inches square,
and a small one 4i inches square. Each pad is com-
posed of sixteen layers of gauze folded tc^ther in such
a manner that the edges cannot fray. The large pad
is made as follows: A single layer of gauze a yard
square is folded at each end upon itself so that ihc
folds meet in the middle. This makes two layers of
gauze which are oblong in shape: the other ends aw
now folded over in the same manner. There are
then four layers and the shape of the pad is square. It is again folded upon
itself, making an oblong pad having eight layers. Folding it once mote, the
pad is then composed of sixteen layers and measures 9 inches square. To
keep the pad in shape and the layers from becoming separated, the edges duv
be stitched together with ordinary white sewing cotton. The smaU pads are
made in a similar manner by using a piece of gauze iS inches square.
Three dozen large and small pads are kept in glass jars.
Gattze Compresses. — The compresses are made by taking a pica of

Fig. 7.^,1, — Gaitze Sfohqf.

J J If

^^ 1

'"1

Fio. js*.— Edgn slilchod. Flo. 7SS— Edges free.

Asii ton's Gauze Paus.

gauze 24 inches wide and 36 inches long and folding it so as to make two layffi
12 by j6 inches, ft is then folded three times in its long direction, makinpi
compress of sixteen layers of gauze 12 by 4^ inches. One dozen compres-ses are
kept in a f;l:iss jar.

Gauze Tampons. — F.ach tampon consists of one yard of gauze folded j*
as U> make a small lno.se roll which can be unfolded at the time of an operalion
and lut in any desired length or width. Two dozen tampons are kept in 1
^h>^ jar.

OPP.KATirC<l I>AIUrtlt:RNAI.IA.

817

Bandages.— The bandasc» .ire mmlo nf unblrartml mu.xlin iind arc used

lc«r|i ilr».sing> in |ikce. The T Wmlayc which Ls cm)Jor«J lo s«.ure a

Iv.nr ri>m|ircss is made by sewing a sirip <*( muslin 4 iiicbcs wiile liv .la inches

(on); to the renter of a similar stri|> 5 itK-lics wide l>y 40 inches Iodk. One

n of lltcsc bnndiigcs are Mured in :i glass jjir

Abdominal Dressings. The ci^e^sinKs umxI for the alxlominal wound

'onsL-oi iif iwii large ^auvie jukIb with 11 ihiik layer of nli«orlicnl cotton hclween

them. Kiich M;t nf dressings is u-nppcd in a clean towel and secured with

on.ii

I, A dmea sett of dre^iings arc kcjit in a gliuw jar, fmm which th^
\hen ncfdcij
sivc Plaster.— Several rolls of zinc oxid adhesive jttaster a)
tncne* w«ic ire kqn in slonige.

Rubber Gloves. Sc^crnl pairs of gloves are kept on hitnd wnii>|>e(l in a
clean louel jnd ;>n>iected from llic light, which has an injurious effect upon the
juhbcr {I-iR. S).
~ Rubber glo^-es have become an important factor in the tcchnic of modem

Pta. TjS'— Ci«iTtE Conns

FM. IJS , — T llAKBAOl!

__ ry. and there in no doubt whatever of the fait ilui openitivc results have

pptnved since they have come into general use. Thej' du not dull the ^nsc of

ch to any great extent nor interfere %eri(Hisly with rapidity in operating after

the Mirgeon has l>ecomc aci-ustomcd lo their use. and it is only when deni^' pelvic

Hi ■ii.a'i arc prev-ni that tliev imjiedc yim»-whal the operation. Under these

r L..^lstanccs the lips of the fmi^Ti of the Rioves slip and wrinkle badly when

tlic u<lhesions arc being separated, and it is sometimes im|>as$ible to cnuclestc a

Sa»

ANTISEPSIS IN HOSPITALS.

mass that is firmty adherent. I have been obliged to remove my gloves in that
cases a number of times and proceed with ihe operation without them. As a
matter of fact, however, this necessity occurs less frequently at the present time
than formerly, and I beheve that eventually a surgeon can become so expert in
the use of rubber gloves that they will very rarely interfere in any kind of operative
work. One of the objections which has been made to the use of gloves is thai
operators are liable to become careless in the sterilization of their hands, and as

the gloves may be cut or torn during an opera-
tion, infection may result. While this may
possibly be true of a few surgeons who do not
possess what Keen describes as '"an asepuc
conscience," I do not believe that such an ob^
jection should be seriously considered, as it
cannot apply to the vast majority of operators.
Towels, Sheets, Operating Gowns,
Cotton Batting, Absorbent Cotton,
and Safety-pins.— These articles are itpt
stored and properly protected from dust by wrapping them tn clean sheets or
towels.

BmsheS'^ — A supply of hand-brushes is kept in a glass jar. I use laip
hand-brushes which have solid wooden backs and bristles made of vegetable fibw.
They can be sterilized several times without injury; they are cheap; and ihc
bristles are flexible and yet stiS enough for all practical purposes. The

Fio- ;;o- — Hamd-b»dsh hade or V»>

ETULE FlBtl.

4e$4

Fio. j6b. — HvpORrRHic Syringe Have Entirelv of Mht*l *si> Contumho No P*cdib.

brushes which are used in a septic operation should
be thrown away.

Ifiqilid and Hard Soap.— These articles are kept in storage. I pni"
a liquid soap (linimcntum saponis mollis, U. S, P.), although a pure hard soap
which has not been milled in the process of manufacturing answers all ihe ^^
quiremcnls of an antiseptic (ethnic, provided that it is well rinsed in sterile mW
before using. The hard soap is kept in a glass jar and the liquid soap is presenol

Fic. r5i. — Glass Femtt CATirEITI.

in 3 large glas.a bottle, from which it is poured into sprinkler-top boltlef «'""'
needed at the time of an openition. The method of making liquid soap i= !!''"'
on page 25.

Surgical Pads.— I use the Kelly surgical pad, which is made i>( l""*

rubber having a rim which is inflated to direct the water or drainage on W^"
apron which falls into a receptacle on the floor. The pad measures 14 inchejin
width and the apron is 12 inches long (see Fig. 15, p. 3$).

OPKBAIINC I'ARAPllKRNAUA.

8>9

Apparatas for Intravenous Saline Injections, Hypodenno-
clysis, and Entcroclysis ; Nonnal Salt Solation.— A dc^ripiion
lliu>e arlklt:^ i^ k'^'i-'ii un'lf^i' .-Kiliivc iiijiMlittn», uii yagc lib.

pat

Fro. ]Ai.— PAQiTcuia'a Cuiniwv.
Nair ihu ihe Virnoiv i> nnunnnl in Ih* tunitls nl ihf apianlai.

ypodermic Syringe.— The hypodermic smngc should he made
Miiirelv o( KK'i.i! ,ir»i i<iii>irvicictl lu slant! thennal melhods of sierilizalion.
TIkiv :irv .1 immlicr of .such syringc;< now Mild in ihe ^hi)]i», und any one of thcin
will amwcr all the indications, provided (here is no
packing anywhere ill the construction of Ihe tnstni*
icni.

Cardiac and Respiratory Stimulants.—
ij-podermic tiil>lc^l.s or Milutinti.i of ihe folldwiriK drUF^s
kept on hund: Sulphate of slnchtiin. .itmimi. and
niiroRlyccrin 0.\yf!cn gas is kept in c>'liiidcrs.

Local Reinedle8.^Thc»c include cartxiltc »c!d
and liiKiurc of iodin. which arc kq>t in Ijottlcs wiih
(thiss >lop|icrs and jMiurol into small medicine glasses
when usisi »t tin- time of an upenitinn.

Glass Catheters.— The calhetcrs are kept in a
glass jar,

Paquelln'B Cautery.— Thi* nppanitus mu^l be
kq>t in good working order and tested fjcforc every ^*- t4i-— Ai™«» l-"";
lion.
Alcohol LamP'—A hmall aJcotii>l lamp roiide uf gbiis h kept ready for

830 TECHNIC OF MINOR OPERATIONS.

CHAPTER XL.
TECHNIC OF HINOR OPERATIONS.

PREPARATION OF THE PATXEFTT.

Examination of the General System. — A careful routine exainina-
tion is made of the heart, the lungs, and the kidneys, and, if necessan-, (Mother
organs of the body, in order to determine the general condition of the patimL
A serious organic lesion is a contraindication to any form of minor operation,
especiallv when the disease is in an advanced stage and the general condition d
the patient is bad. Sometimes, on the other hand, when the lesion is not serious,
a few weeks' treatment will put the patient in a good condition and tcidovc tht
operative dangers. It is most important to determine the state of the k)dDe>fi.
as they are the chief excretory organs of the body, and they are called upon, as i
rule, to perform extra work after an operation. An exact knowledge of thecon-
dition of these organs will not only indicate the proper preparatory and post-
operative treatment to pursue, but it will also determine the selection of the
anesthetic, and thus lessen the danger of subsequent uremic symptoms. Ether
is contraindicated as an anesthetic when a renal lesion exists, and chlortrfonn
should therefore be administered. The lungs should also be carefully examirKd,
especially for the presence of slight forms of bronchitis, which often devek^ into
a pneumonia when ether is used as the anesthetic. If there is the slightest
bronchial irritation discovered, chloroform should always be administered. A
cardiac lesion is not, as a rule, a contraindication to an operation, but when the
heart is diseased chloroform Ls a dangerous anesthetic and ether should aivayi
be employed.

I,eng:th of Preparation. — The patient is prepared in twenty-four houp
unless the condition of the kidneys or some other organ makes a longer [irepan-
tory course of treatment necessary-

Confinement in Bed.— The patient is kept in bed for twenty-four houfs
prior to the operation. If a longer course of treatment is required, she shouH
not be confined to bed until the day before the date fixed for the operation.

Regulation of the Diet.— A soft diet (see p. 1 1 1 ) should be given the
day before the operation, and on the following morning a breakfast consistingofa
cup of coffee, cocoa, or tea and a roll, or their equivalent in bread and milk.shouU
be taken not less than three hours before the anesthetic is given. This will in.>urt
an empt>' stomach at tlie time of operation and ob\-iate the danger of inhaling
particles of food should vomiting occur.

The Bowels. — A bottle of citrate of magnesia is given the night bffort
the operation, followed next morning by an enema of soapsuds and water. Voe
magnt-siasiiouldbetakcnonancmpty stomach, and therefore at least three houfs
should have elapsed after taking food before it is administered.

The Bladder. — The urine should be voided naturally immediately betoie
the patient is prepared for operation.

Sterilization of the Patient.— On the evening before the openti»n
the patient is given a full warm bath and thoroughly scrubbed with soap. ^
the morning of the operation the hair on, the mens veneris and the labia knit
close with scissors, the vulva and vagina irrigated with a solution of corroii''^
sublimate (1 to zooo), followed by sterile water, and the gluteal deft, w^
jHTineum, the e.vternal organs, the anal region, and the inner sides of liif
thiglis arc sterilized as follows: Scrub the parts with a large gauze sponRt
dipped in liquid ,soa|> and warm water, and then douche them with a sol""

rKKI'ARATIUN'S FOR TIIK OPKRATIOK.

8ii

Dti at corrosive sublimale (i to sooo), which in turn h removed with sterile
rater. The purt> urc itivn ilnni, a brge compress M-curcd with u X'I'^'k'bI^
i placed over ihc \-ulva. and the legs protected with sterile Canlon flannel
Jockin}^ which reach abtive the mialdle of the iliiKh.". Tlie hips and lower
exirrmiiicK »re then wrapped in a sterile »hcet, which is secured in front with
safety 'pine.

Anesthesia. — The patient ia anesilicti/td in hi-r lietlroiim or in a special
>i>m dcv.jlvcl ii> the puriK>scand placed on the operating table when she is un-
Jou&. 1 never nllon' the anesthetic to be given in the uperaiin^ roum, lu^ Jt
feres with the prepanition.i which are l>6in)( made and unncce>»<irily woiries
and excites the jKitient.

Immediately before administering the anesthetic the ptttienl is pvcn a hjiio*
dermic injection of i of a Rraiii of moriihin and j\, of n grain of strychnin lo i>rc-
pent i>osIo[>cr.iiive shock iind lessen tnc tendency lo vomiting.

Final Sterilization of the Patient.'— When ilie jiaiteni tit broufiht
Otn the (^lenitin;; nHmi. the resident physician and the etherizing nun:e
place her on the table and arr.inge her feel in the stirrups. The general nurse
then renvoves the sheet and the \-ulvar compre-v. The ojieralor now jiour> two
draihiiL-v of liquid soap into the vaKina. nnd with a gauxc siwnRe saturated with
hoi waler and held in the grasp of dressing forceps mechanically sttriUjtes the
vaginal canal by vigorous scrubbing. Tlic xa^ina i,v then doucher! niih a solu-
tioti o( corrcMsive sublimate (i to aooo). followed by sterile water, and the \-ulvar
canal, the perineum, and the anus are thoroughly scrubbed with a gauze sixmge
saturated with li<|uid soap and water, after which the ]iurt« arc again irrigated
jli-ith the ^lll)litnat« solution and sterile water.

Protecting the Field of Operation.— A sterillwd sheet is thrown
er the knees and alxlomen and il» lower edge tucked up so as to expose the
parts to view (see Fig. 19. p. 3a).

PREPARATIONS FOR THE OPERATION.

Operating Room.— The operating room and its equipment are cleaned
I the nianncr dc^criijcd on page 81 1, and sterile towels placed over the tops and
belve« of the instrument and wpply tables
The following articles are then arranged on the
supply table: Three pitchers, one each for cold, hot. and mixed water;
thrtv haxins for general u.^e; li<]iiid soiip; tincture of io<lin and carbolic acid;
the general irrigating apparatus: hy|x>dcrmic syringe; cardiac and respiratory
stimulants — >trychnin, atropin. and nitmnlycerin; a solution of corrosive subli-
malc ft lo ;ooo): and normal »idt in^lution. A cylinder of oxygen giis is placed
I a comer of the room ready for use.
The leg-holders are attached to the opera ting table, and a surgical pad placed
in position with its apron falling into a bucket on the Hoor.

The instrument table is arranged as folio we: On
the shelf of (he tnble is pbced conveyance box No. i an<I the iruy containing
lie inMniments, ligatures, etc; and on the top. conveyance box No. i.

Wash Room. — The wash room and its equipment ore cleaned in the
inner (li-scril>e<l on page 831 an<I the following nrtide^ arranged on the table:
Three pitchers, one each for cold, hot. and mixed water; a \w^n full of sterile
water for the rubber gloves; and conveyance box No. y

On the marble- sJab of the wajJtsiaiul are placed tlirec Itoninit ai>d the saoap for
dcaning the hands and forearms.

83J

TECHNIC OF MINOR OPERAnONS.

Contents of the Conveyance Boxes.— Three boxes arc required for
each operation. As stated elsewhere (p. 809}, it is important to remember that
steam will not circulate freely in the boxes if they are packed too tightly, and
consequently the articles must be arranged as loosely as possible. The boxes
are packed as follows and placed in the high-pressure steam sterilizer. The
articles are placed in each box in the order in which they are given:

Box No. I. — A X-f^^ndage; a gauze compress; two gauze tampons; thite
dozen sponges; and a loosely rolled layer of ab^rbent cotton, 4 by 11 inches.
Box No. 2.— Eight towels; a glass catheter wrapped in gauze; and one shML
Box No. 3. — Three operating gowns, four pairs of rubber gloves, and six hand-
brushes. The brushes and gloves are wrapped separately in a layer of gaua

and secured with safety-pins so that they can be
readily lifted out of the box.

Instrtuuents; Needles; Sntnrea.— The

method of arranging these articles before placing
them in the sterilizer is described under the Ai^ca-
tion of Antisepsis on pages 811 and 813. The ori-
ginal boxes containing the "Red Cross" catgut are
placed on the supply table in the operating room.

Number of Assistants. — The number of
assistants varies, and is given under the technic rf
the diETerent operations. As a rule, the following
assistants are required: An anesthetizer, one assistant,
and a general nurse. In operations upon the pdvic
floor and in other regions of the genital tract in which
it is necessary to use several retractors and fwctps,
an additional assistant is required.

The anesthetizer gives his undivided attention b>
the anesthetic; the general nurse changes the water
in the basins and brings whatever is needed during
the operation from the supply table; and the assist-
ants act solely as extra hands for the operator in
holding retractors, forceps, etc. A nurse is not
needed at the instrument table, as the operator takes
what is required during the operation from the boi«
and trays and threads the needles himself.

General Summary of the Preparatoij
Management.^The chief clinic nurse pacLi the
conveyance boxes and sterilizes their contents; pre-
pares and arranges the operating and wash roonu;
and places the different articles on the supply table.
When the operator arrives at the hospital, ht
selects the instruments, needles, and sutures that ait
required for the operation and hands them to the nurse for sterilization. The
operator (hen enters the sterilizing room and the nurse opens the high-pres.'ure
steam sterilizer. He then takes out conveyance box No. 3, containing the
operalinj; gowns, the brushes, and the rubber gloves, and carries them 10 the
wash mom. He now takes off his ordinary- clothes and dresses for the opera-
tion (see 1). 814). The operator and his assistant then .sterilize their hands and
forearm'^ and put on the rubl>cr gloves and the operating gowns. The assistant
now enters the (i[)cratinEC room and stands with her back to the wall, as shown
in Fif;. 7(14, until the ojieralion begins. The operator now takes the convey-
anie bo.xes (Nos. 1 and 2) out of the sterilizer and places them on the instrument

Fic, 76J, — Pose or the Assist-
KST W'uiLt. WArriKo Fua

A.S Ul-t.^ATmS TO UEI.IWr

XoU' ihai ihc ('Hows arp rest-
ing en Uu- hip^ LLHil the honda hrld
gill inin\ [he \miij.

PXepAKAnOKS FOK TUB OPCSATIOK. Sj3

The general nunc, undfr tht eyt «/ tiu operate, then lifU the perforated

"Tab I.

Ory5.n. Q

Bucket O

3itpply
TahU

OperaZar \

Operatiita
Tabte

■Anesllietizfr

l^lssistoiit

Fn. Ttf.— AMuvcoMuit tm ni> Oraunun Rami ro* a Mixat Orruiicrw.

trays out of ihc sterilizer, pours cold water over them, and places
the rereptiicle on the inntniment labU-.

Whrn the pniietit is brought into the opcraling
room, Ihc residcni physician ami the anesihelii: nuf^
place her im (he Litjlc .im! arrange hi-r feel in the
slirryji*. The general nurse then removes the sheet
anil the vulvar unniiret* ami the 0]ierati)r stiTili/e*
the i^gina and vulva and arranges the sheet nmund
the *cat o( o]>eration. He then puts on a clean pair
of ndjlter glovrs, places the u.<.'<isl:inUs in the pro|)er
imsitioiH, awl begins the o])cralion.

Plan of Operation,— Fift. 765 Rive* a clear
ideu of the ;irrangemcnt of the openXing room and
the positions of the operator, the assistant, and the
fieneral nunie.

Itie oi>en(tor sits on a stool facing the vulva with
the instnimem table jilaced upon the left and the
wash-tiinin.i I'llleit with sterile water U|inn the right.
The uwi^tant stands al the patient's hips and the

leral nurse remains clooc to the supply talile.

Visitors.— Visitors are not iillo'wnl in the

rating room until all the preparations arc com-
pleted ;iiid the 4>]>er;ition t> shout to liegin. Thcr
"houkl not stand too close to the operator nor the
field of oiientiion and they sliould he cautioned not
to liiucli anything in the nmm.

All B|>cct3lors are required to wear linen dusters
a> n precaution uKiiinni the piyv<iliiliiy of caiiyiiig
infectNin with their ordinary' clothing- The da>ten>
arc laundried in the usual manner and kept in a

veiiient pUce.

them in

uirnn tvoui ai

mr IxHDi

834 lECHNIC OF ABDOUINAL AND PELVIC OPERATIONS.

CHAPTER XLI.
TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

PREPARATION OF THE PATIENT.

Examination of the General System.— The importaoce of a

routine examination of the different organs of the body is discussed under the
Preparation of the Patient for a >Dnor Operation, and need not, therefore, b«
repeated here (see p. 830). It is often necessarj, however, to periormanimmediaii-
abdominal section to save life, and hence, unlike minor operations, we must choo.-*
the lesser of two evils and operate at times when the general condition of tlw
patient is unfavorable. In a large proportion of jwlvic and abdominal as**
operative interference is not urgent, and there is usually sufficient time at our
disposal to regulate the functions of the body when they are acting abnormally.
The extra strain upon the kidneys must always be considered, and the urint
should therefore be carefully examined to determine the presence of renal distaa
or insufficiency as well as the selection of tlie anesthetic. The condition of the
lungs and the heart must also be ascerlaine<i, as the danger of post-operative
pneumonia and cardiac failure must be guarded against not only in the selection
of the anesthetic, but in the preparatory and subsequent treatment of the patienL
We must, however, bear in mind that there is a class of cases in which the general
condition of the patient will not impro^'c until the cause is removed, and undo
these circumstances we cannot do more than temporarily stimulate the actiM d
the heart and the kidneys. There is still another class of cases in which the
condition of the patient can be greatly improved and the chances of opeiativt
success increased by treating the local cause as well as the general sv^stem. I
refer to cases of bleeding uterine fibroids in which the patient has become es-
sanguinaied and her power of resistance almost completely destroyed. If-
under these circumstances, the uterine hemorrhages are controlled by appropriiK
treulment (see p. 385) and the Rcneral system is improved by internal medicaliuo
and careful regulation of tiic diet, the bowels, and exercise, the patient will ofin
be able in the course of a few weeks or months to stand the shock of an openiutn
which would othenvise have been fatal.

The im{>orlancc of making a blood examination prior to an operatioo i^
di.scussed in Cha])terIII.

I,ength of Preparation.— In all cases, except when operative inttt-
ferencc is immediately demanded, the patient is placed under careful and *?;«■
matic ircalmcnt for si.\ davs prior to the operation. Sometimes, however, iinu)'
be expedient to ]jrolong tile ]jeriod of preparation on account of the condition"!
the patient, and in nervous women it may be advisable to shorten the time a™
operate within a day or two after the operation has been decided upon.

Confinement in Bed. — The patient is confine<l to bed durins '1"^
entire period of preparation, except when she is given her daily bath; itl-inj-
portant lo use the bed-pan in order to train her to empty the bladder and bowet
iii ihc ri'cumbent position.

Regulation of the Diet. — During the first five days of the period •''
pre|);Lrution the patient is given a liquid and soft diet (pp. 106 and in), anil m
twcnlv-fiiur hours preceding the o}ierallon the diet must be entirely liquw i"
character (p. lofi); on the morning of the operation, three hours belure li"*
ancjthclic is administered, a light breakfast is given, consisting of a c"!' "'
coffee, lea, or cocoa and a roil.

jMculiolic stimulants are not given unless there exists a special indication iw

PREPARATION OF THE PATIENT.

83s

and under these circumstances I atlnn* thp patient two or three milk*
(tuncheri or ejot-iioK^ Jaily or prescribe Ihc use of sherry, puit. madeira, or claret
with the meal*.

The object of placing the patient under a carefully rcfrulatcd diet is to im-
jirtive her Kcncral londitjun ami to eliminate .'Ul artiilci of food that lend to pro-
duce llatulent distention or cause di^Mive dUturtumrc^.

The Bowels. The bowels are freely o|>ened ;it the beginning of the pre-
[laiatory [reult»cn[ jiid Kubsequenily kept regular. I be^in by givinit 1 crains of
olomel, and follow it with { of a grain every half-hour until eight dofta an
taken. In two hours after Ihc last dose is taken an ox-gall enema (p. 105). or
one cun.sisting of a pint of warm .%oa(>-water (loe^ P.), a tablespoonful of sulphite
mi magnesia, and a tea«poonful of tur)'*-''*' '"*-'' '^ injected into the rectum. The
^BK'cIs urc then kept opened daily iviih the following pill:

n. Evtnrtl nucane iBipndK. gt. [

krdimc ptKlogihylU ..-.

(unncii t>cllsilonnK, .••■• .•.......>

M. Kl It. fii. no. j.

Sig.— To be uhcR M Ijcddmr.

sr.ii

?:1

Sulphate of str^'clinin (gr. ^) h given l>y the mouth Ihrw times daily during
the six days of preparatory Irealmcnt. It not only Mimulutes the he.irt and Ihc
nen-ous syslem, ihus lessening the danger of operative lihock. bul il also keeps the
inleslines well ci>ntracled, nhii h i^ an im|H>rtanl fiiclor. as lymjiany i.i one of the
most senous complicalions that can mnir cilhrr before or alter an operation.
If tynunny continues notwiihsianding the free evacuation and >ul)scqucnt
regulation of the bowels, the following capsule h given for three day» prior
,lhe operation ;

B. Snloll gr.lj

Bitinuthi tubnltrnili, , ff. v.

M. cl fl. (.iiKiulii nu, j.

Sig, — Ta be ukcti ihrw (iniMilaily between mavis.

On the evening preceding the operation a bottle of citrate of magneAi.i is
m upon an em|)ty stum^th (three hour.-k iiftcr ktking food), and on the fol-
'ing morning the lower bowel is thoroughly evacuated bv a large enema com-
posed of a quart of warm water (joo' F.) and Cas.tile .wap.sud.s.

Where there is decided pain or ten<lerne-,->A in the jielvis or over ihc lower
abdomen, the u»c of a saline for two or three* days in place of the laxative pill
unloads the engorged blood-vessels and i^ often followed b>' the disappeitrance of
the sympiiims.

Salines should hv given when Ihc stomach is empty, either at bedtime nr In
the miirnini; before bnukfasl. and the dose should lie sulUiient tu move ihe
boweln freely. I usually employ Kiwim or RochcDe salt and also occasionally
phosphate wf sodium. The most palatable way of administering them is in an
eAerxe^cent form, although the ordinary i»lLs can be readily taken by moM
patients. div-ii.Ived in hiilf .1 tumblerful of water,

The Kidneys. -'T\k ini[)orlinie of kiiowing the exact condition of the
kKlm.'}'s priiir li) ihc upcniiiun, as well a» the necesvity of .ippropriate irealmenl
where lhe>- are lound to be disc.ised. has alrciady been referred to, The treatment
■ rally based upon gentral medical principle>, and need nol. thtTefi>rc, be
t'd here. Apart from ihe tpiestion of s]iceial forms ol irealmenl. however,
I kcvp Ihe kidneys well (lushed during the entire period of preparation by having
the (laticDt drink Ihree or four pints of pure water daily as a routine practire.
The kidne)-s are thtu. preitared for the extra work which they will be called u{fon

836 TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

to perform, the urine is diluted, and the waste products are tlioroughly and
rapidly eliminated. The variety of water which is used and the method of its
administration arc discussed on page 98.

The Bladder. — The urine should be voided spontaneously or the bladder
catheterized by the nurse immediately before the patient is prepared for operation.

Sterilisation of the Patient.— The sterilization begins with the
preparatory treatment, and consists in a daily full warm bath and local cleansing.
The baths should be given preferably late in the afternoon, and the patient
should remain immersed in the water for about ten minutes to soften the surface
epithelium. She should then be washed from head to foot with soap and water
and the abdomen and the mons veneris scrubbed with a sterile hand-brush. The
surface of the body is then douched with clean water and thoroughly dried, after
which the patient is placed back in bed. When the condition of the patient does
not permit the bath being given in a tub, the mattress of the bed is protected
with rubber sheeting and the entire surface of the body thoroughly sponged
(p. 85), after which the abdomen and mons veneris are scrubbed with warm
water and soap.

The last bath is given on the evening preceding the operation, and on the fol-
lowing morning the hair on the mons veneris and the labia is cut close with
scissors (not shaved) and the vagina irrigated with a solution of corrosive subli-
mate (1 to 2000), followed by sterile water. A rubber sheet is then placed under
the patient to protect the bed-clothing, and the abdomen and mons veneris are
scrubbed for ten minutes with liquid soap and warm water. The soap is then
removed by washing the surface with wet gauze sponges, a towel is thrown over
the abdomen, and Canton flannel stockings are placed over the lower extremi-
ties. The nurse now sterilizes her own hands (by mechanic slerilizaiion) and
then thoroughly sponges the abdomen of the patient with alcohol and finally
with a solution of corrosive sublimate (i to jooo). A thick pad of sterile
gauze is now placed over the abdomen and secured by a muslin bandage. A
sterilized sheet is then wrapped around the patient, extending from the chest
to the feet, and fastened in front with safety-pins. This dressing remains in
position until the patient is placed on the operating table.

I do not have the mons veneris shaved because
the skin retracts around the ends of the hairs,
forming small pits which are more difficult to
sterilize than the short hairs themselves.

Anesthesia. — The patient is anesthetized in her bed-room or in a special
room devoted to the purpose, and immediately before administering the anesthetic
she is given a hypodermic injection of ^ of a grain of morphin and ^^ of a grain
of sulphate of strychnin to lessen the tendency to vomit and prevent post-
operative shock.

Final Sterilization of the Patient.— When the patient is brought
into the operating room, the resident physician and the anesthetic nurse place
her on the table and strap her legs to the Trendelenburg frame. The general
nurse then unfastens the sheet which is wrapped around the patient and arranges
its edges neatly so that they hang smoothly over the sides of the table. The
gauze pad covering the abdomen is removed by lifting it up at its center, and
the hands of the patient are secured by flexing the forearms on the arms and fas-
tening the wrist-bands of the night-gown to the shoulders with safety-pins.

The operator now vigorously scrubs the field of operation with a hand-brush,
soap, and warm water, and then sponges it with sterile water.

If the operation is one in which the vagina is to be subsequently opened, —
as, for example, a complete hysterectomy, — it must be thoroughly sterilized in

838 TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

The following articles are arranged on the supply
table: Three pitchers, one each for cold, hot, and mixed water; three basins
for general use; hquid soap; abdominal irrigator; hypodermic syringe; car-
diac and respiratory stimulants — strychnin, atropin, and nitroglycerin; (be
transfusion apparatus and normal salt solution; an alcohol lamp; and adbesivt
plaster.

A cylinder of oxygen gas is placed in a comer of the room ready for use.

The instrument table is arranged as follows: On
the top of the table is placed conveyance hot No. i and the tray containing the
instruments, ligatures, etc., and on the shelf conve)'ance box No. z.

Wash Room. — The wash room and its equipment are cleaned in the man-
ner described on page 821 and the following articles arranged on the table: Tbitt
pitchers, one each for cold, hot, and mixed water; a basin containing sterile
water for the rubber gloves; and conveyance box No. 3.

On the marble slab of the washstand are placed three basins and the soap
for cleansing the hands and forearms.

Contetits of the Conveyance Boxes.— Three boxes are requimi
for each operation. They are packed as follows and placed in the high-pressure
steam sterilizer. The articles are placed in each box in the order in which thev
are given.

Box Nu. I. Abdominal dressings (p. S27): two gauze tampons; glass and
rubber drainage-tubes of different sizes wrapped in gauze; eight small and four
large gauze pads; four dozen gauze sponges; and eight safety-pins folded in
gauze.

Box No. 2. Ten towels; one sheet; and one hand-brush.

Bo.\ No. 3. Three operating gowns; four pairs of rubber gloves; andsii
hand-brushes. The brushes and gloves are wrapped separately in a layer d
gauze and secured with safety-pins so that they can be readily lifted out of the
box.

Instruments; Needles; Sutures.— The method of arranging ths
articles before placing them in the sterilizer is described on pages 811 and Si.'.
The original boxes containing the "Red Cross" catgut are placed on ihe suRiiy
table in ihe operating room.

Ktimber of Assistants.— An anesthetizer, one assistant, and a genenl
nurse arc required.

The ane.'.thctizcr gives his undivided attention to the administration of lt«
anesthetic, and ihe general nurse changes the water in the basins and bringsBlui'
ever is needed from the supply table. The a.ssistant acts solely as a pairof eiua
hands for the operator, and under no circumstances is she allowed tolateanv
pari in the operation except when told .'ii>ecificallv what to do from time to line-
General Summary of the Preparatory Management— Befm
the surgeon arrives at the hospital the chief clinic nurse packs the convcyancf
l)o\cs and sicrili/.es iheir contents, but dues not open the door of the steriliw-
She also |ireparcs the operating and wash rooms and arranges the requ'^'^f
paraphernali;i for the o])cration in their proper places. .\s soon as the sutp*""
rcathcs the hospit;il he selects ihe instruments, needles, and sutures ihat an''"
quired iinti hands them ii> the nurse for steriliz-ition. He then goes to thesierl-
izing room nnd the nur.'ie opens the high-pressure steam sterilizer, from "■™''
he takes convevajicc box No. 3 and carries it into the wash room. He no*!*"^
otT liis clothing and puis on the o|ierating suit. He and his as.sistant then pieprt
their hands and ]hiI on the gloves and gowns. The as.sistant then goes m'"
the o))cr:iiinj; room and slimds with her back to the wall, as shown in Fig- '"*•
until the operation begins. The operator now removes the conveyance bouts

PREPARATIONS rOX TIIR OPERATION.

»S9

(S<». I and i) from the slcrilu«r and places them on the instrument inble. The
^nrral niinc, uuii^f Ihe eye oj the siirgetm, ihcn lifts the trnj' "Ut of the sterilizer
Aiv] i>Urcs i( in the rcccplade on the instruntenl table conlninin); warm atrrilc
wtittT, The iMtient ii now broujjhl into thcr operating room and pUcetl cm th«
table by the resident physkian and the anesthetic nur». The general nurse
then unfastens the sheet which is around the patient's body and pins the wri&t-
bondit of the niuhigown 1o the shouldcrv The uperalor then mtuIm the abdo-
men, anaoKes the towels around the »cat of operation, and puts on a fresh pair
of cloves. He then pUccs the assistant on the opposite side of the operating
table and b^ins Ihc ouenition.

PlAn of OperatlOn.-Fin. ;6q Rives a clear idea of the aTTanRCmenl ot
the ofieralinK room and the jkusitinn of the oj>erai<>r, the as^isiaiit, and the gen-
eral nunie.

The operator stands on one side of the patient and the assistant on the other,
and the general nurse is placed do>e to the supply L-ible. The insirumenl (able,
wbicfa contains evcr)'thuig that 'u directly used during the operation, is within

Assistant^

Ox^yn Q

Genera t |X|
BuehelO

AnuIhrfiuHfl

BuekttO Opemtariff

Insfrumviit
Tabl»

Fn. }«•.— AiiAmuiiHT or mi (ipriATjij Boox Ml «■ Abdcoidui. a* Pnne OrvunoH.

sy reach of the suritciin, and next to it is placed the washstand with T>asins eon-
nintt sterile water for wa^hi^g the liundi. There is nothing on the o^istant's
(>( the oi>eTating tnble except a w.'l'^hst.nnd with a basin containing Sterile
water, which she uses to keep her hands ckan.

Visitors. — Visitors Ate ncii admitleil lu the ojientling riMm until all the
eparali'ins .irc ci>mi)let«l and the o)icrali<3n is about to begin. They are re-
ired to wear linen du>ier> (-ee Fig. ;661, which arc bundricd in the ordinary
inner after they .irr us<i| .imi then put in a convenient place until needed.
Precautions Against Infection.— The old saying that ••the strength
of a chain is its weaki-^i link" inny aLxi be applied to the iccUnic of anti-
iwplic Mirger>', ami unless ibis Inith is groundnl in Ihe inner consciousness
i>f an operator, crrnrs are sure to occur which may at times <()&t a life. No de-
tail <)( anltsejtsis is therefore too small and twi precaution too insignil'iitinl for a
■urgeon Ui t»egltct, an the tmwt careful pTefuration will go for naught if infection

840 TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

gains an entrance through some unguarded channel. The operator is
responsible for the success of an operation, and
should a preventable infection occur, he must plact
the blame where it belongs — upon himself.

In addition to the ordinary details of antisepsis, I have adopted thefoUowii^
methods to guard against infection:

I. A personal supervision of ever>' article that is sterilized.

3. Personally overseeing the preparations of the assistants.

3. A minimum number of assistants at an opieratlon.

The first of these methods entails additional work upon the operator vitb-
out, however, encroaching upon his time, as the sterilization is completHJ in
the high-pressure steam sterilizers before he arrives at the hospital and the liga-
tures and instruments are boiled while personal preparations are being made
for the operation. I have been frequently impressed with the careless handling
by the nurses or assistants of the various articles after they have been taken from
the sterilizers, and there is no doubt in my mind but that infection is often due
to this cause.

The second of these methods is important, as it is a constant reminder to tbc
assistant of the necessity of a thorough antiseptic technic and it also prei'coB
the possibility of errors occurring in the details of the preparation. Again, if
the assistant is required to stand in a fixed position after she is completely prr
pared for an operation, there is no danger of rubbing against infected objerts
or becoming contaminated in other ways.

The number of assistants is a matter of vital importance in the conduct of
a modern operation, and every surgeon should endeavor to depend upon himstlf
for many of the details that are frequently relegated to others. A large corps of
assistants must necessarily add to the chances of infection and the daD|eis of
an operation, because the possible sources of contamination are incrtakd in
proportion to the number of individuals that come in contact with the field nS
operation. The truth of this statement is self-evident, and yet it is not uncwn-
mon for a surgeon to have, in addition to his first assistant and general nurse, 1
nurse to hand the instruments, another to pass the sponges, and still another 10
thread the needles, all of which he should do himself. In my abdominal opera-
tions I ha\'e only one assistant who comes in contact with the field of opemtBo.
and she is only employed to hold the handles of such instruments as relraclofS
and forceps, so that practically her hands never touch the wound. The anftll>^
tizer naturally cannot affect the aseptic conditions one way or the other, and ite
general nurse is therefore the only remaining individual connected with theopef-
ation who could ixissihiy cause infection. While her hands are clean, theyW
not and cannot be sterile, for the simple reason that she must turn the spijpt*
of the water sterilizers in filling the pitchers; handle in.struments, such as »
Paquehn cautery, etc., which cannot be sterilized; and perform varioiL* other
duties which would necessarily cause contamination from a surgical standpoin'-
If the operator fully appreciates the fact that the hands of the general nuwaff
not sterile, and educates her, therefore, never to touch anything that roinei in
contact with the wound, she is at once eliminated as a possible source of in-
fection, and cannot be considered as being connected with the field of opef*-
tion. The general nurse in handling a basin always holds it bem«ii ^'^
hands, so as not to touch the inside; and in mixing water she judges flf '["
temperature by placing her hand on the outside of the pitcher or rwennu-
leaving it to the operator to finally decide whether it is too hot or toocoM. 0"
the other hand, however, nurses who pass the instruments or the spon?f=^
or who thread the needles are in communication with the field of operation, l*-

AFT FJt -TKEAtMENT.

841

CBUW these articled which finally come In contact with ihc wound hfl\-c been
hatKikfl liy them.

By placing thv table which hn\d» the inKlrument^, )i^nlure». sponges, dress*
inf^, Ktc, within easy reach I am able to dispense with the services uf an extra
nurw ami rely entirely upon myself for hundlinf; the>e artidci. After a surgeon
has (rained himself there i* no apprccinlile toss of lime involved by this lechnic,
and the eliminalion of a possible source of infection is distinctly in favor of the
patient. There is no operation in the whole niniic of abdominal surgery ivhich
cannot be performed by a surgcf>n of ordinan,- dexterity with one iiNiinLint and
a iteneral nurse. One of tlic reasons why some operators depend so largely upon
a*:'is[nnls U that ihej- do not study Mmptiiity in tcrhnii- and devise melhwls by
which operative details can be rapidly accomplishcil. Thus, for example, there
is nothinj; more annoying aiwl which takes up more time than threading a needle
with »ilk during an o|>eration, unlcM it is done in the projier manner, :is the sur-
gcim'g hands arc sticky, the silk is wet and limp, .ind it is only niter repeated
Uials that the thread is finally coaxed through ihc eye of the needle. If, how-
ever, the end of the ligature i< pasNCfl through the l1ame of an alcohol bmp and
ilfi tip charred, there is no difficulty whatever in threading the needle and pro-
ceeding with the ojieration without delay (the method is described on p. 907).

AFTER-TREATMENT.

Preparation of the Bed and the Room.— So »xio as the patient is
taken to the operating room prqmrations are made by the nurse to receive her
lifter the ojieration is finished. The beil is prefMired a> follows: The mattre»
is covered with a clean muslin sheet; next a. rubber sheet is thrown across the
bed. and. finiilly, a draw-sheet is placed over it and securely fastened with sitfety-
pins. A single blanket and n ^heci are ncutly folded and placed on the back
of a chair ready to throw over the patient when she is put to bed. Hot-water
bligft or bottles are prefKired and xvrap|»ed in fbtnnel rc.-uly to place next to the
patient if needed, The room i* darkcnetl und the temperature kept Iwtwecn
70" and 75" ^- -^ cylinder of oxygen gas and a bowl of ordinary- vinejjar are
pbeeil in \he room n.'acty to u^f whtni the jiatient returns from the operation.

Recovery from the Anesthetic— The patient is placed in bed upon
her tMck, with the head low. and a blanket thrown over her. So wxin as she
hu been i>roperly arranged in 1x^1 the nurNC administers oxygen pas by holding
the noEzlc of the apparatus alM>ut two inches imta ihc nostrils and moving it with
the face as the patient rolls her head from side to side. Oxygen can also be ad-
ministered with a soft-rubber mask which fits over the nose and mouth and is
connected with the tubing attached to the cylinder. This is an cxcellem method
of admini.stering the gas when the patient Ls unconscious and a c|uick, decided
action is dcsiretl (Figs. 770 and 771).

When consciousness begins to return, the oxygen is dtscontinueil, as it gener-
ally annoys the patient, and vinegar is subMiiukil. It is poured on a soft piece
of muslin, lotdecl in several layers, which is held over the luitient's face so that
the can inhale the fumes until full consciousnes--v return*. The uiw of oxygen
after an aUlominal operation decre.-i*e!' the icmlenry to shock, shortens the period
oi unconsciousness, and in most cases prcvenLs the occurrence of nausc:i and

uting or lessens their severity. The inhalation of the fumes of Wnegjir is

; of the verj' be->l remedies to prevent naiiscs and vomiting, and if the oxygen
avaibhte. it may be used as a substitute so soon as the [>atieni is removed
from the operating table.

When consciouitneM has fully returned and reaction has taken place, the

Position of the Patient.— During the first twcnty-fiwr honri Ik
pnlient ii; kept upon her back ^^'ilh her head low, and if she ccimpUins d Buck
pain or ditttress it is generally relievnl by carefully rnisJnf; the kneo and pitfiog

a soft pillow under them.

After the firM day tbt ftM*
heud i.^ raised (U) a pilUiu- and hirbn
drawn up or oclcndtd as ^e atfit
sire. My rule ii lu change thr prf-
tiun of the jHiiient from her ban M
her side iiltcr the first (wtt-o^
hours, eicept in casea in whkh ita*
ii|;e is emplo}-«1. The aunt »«
(he shoulder and hip .-ind mil jA**'
nrearrani^xl under ihc palienlw*''
her btxly rcftl* on the o|ipo6iu "j^
After she wearie* ol thU jwdili* •■
pillows are xently reoiovtd tod ^l"™
unrlcr the opjioeite shoulder* ml V?"
the patient is allowed to re»l vyta^
back aitjiu.

Care of the Bed. -Th* ui»J«

sheet should nol be changtd fa"*

vreeic, after which time the patient is Kcnil)' raised from the b«d while il i) '^

moved nod a cleiin one put in it* place. The dniw-sheel and jiillnw osoi*

changed ever>' day or oftcner if they become soiled. The nurse skwU ^

Flo- T"' A^lirr^v't VifT Kl'IIJif.t MA.^^ TOM \l>-

iiliiii>il.i.i><L. I'lvor.v liufe&ti)'
Hiv ma^ IH uhfl hf Lhnui iitfclaUlti far inliiUiiut

bed -cloth ing smoolh nnr) ncil and the pillow well jJiaken and properly
Rccii under ihc (wticnt's head (ViR. 7;^),

Special Nursing^.— The palieni must not be left alone for a moment
ftcr the opcralion until ^hv regiiin-t rnmpleie cniisciou,Mic.-w. This rule admits
] no «X(:cplion>. and unless it is KTUpulousI/ obeyed serious accidents arc l>ound
> (Kcur. In thi^ case of a ward patient, if all jtoes well the special nurM; is taken
soon after the effects of the •nneslhctic ha^c passed away and vomitfnK ha»
^ U the luilienl h very nervous and the slomacJi i.i irritable, the nurse

remains on s|>crul duty until tlie following murninK- A nurse l'« alwa>'> kepi on
duty- with a private room patient (or the lirst twenty four hours, and after that
lime she re\eive> ^enend nursinR. It h always, heller, houcvcr. to have a .special
nurse in attendance for the I'lrst week, .vnd even durinj; the entire convak-iceiite,
'"■ ihc patient can afford the extra expend.

'.A-.

B- nt- — Metiumi nr XcmiHi « PATtonitnut ItrnSiDriv fijtciini a Pnu)* mmra nni Onoan Simri ■

p«i Mm Itir.

Post -oper.t live complications demand special attention, and it may be ne«g-
firy in some ca-f.'. to have a day and a night nurvc in attendance.

Pain and Restlessness.— More or less pain h usually fcit during the
twenty four hours after operation, anil in wme ca.sc» it becomes so severe
I ret|uire treatment. A1»r]>hin is not administered, if it can be avi>ide<l, on
lint of i\» tendency to unfile the stomach, decrease the peristaltic action
of ihc bowels, increase tlie thirM, and diminish the c]uantity of urine cucrctefl,
ncverUieleu wlten the |«iiin is >c%*cre a hypodermic injection of morphin (gr. i
in J) in given, and rqieated if necessarj-. Under these circumstances tlie slijtbt
theoretic harm nsultini; fr<im iinall doses of the druj: U more than overtuilanced
by the K'Hul olitaiiiei] in prcvcniin),! the exhaustion and depression which follow
nexere mi fieri ni".

As a rule, the jwin which occurs during the firtt twenty-four or forty-eigbl

844

TECHNIC OF ABDOMINAL AND PELVIC 0FEBAT1ONS.

hours is traumatic in origin, and therefore the use of morphin is indicated, ^hich
is not the case, however, when the symptom begins or continues after that time.
It is then usually due to inflammation, and the administration of morphin is
contraindicated, as every effort must be made to freely evacuate the intestines.

The restlessness which sometimes occurs during the first twenty-four or fort}-
eight hours is usually accompanied by pain, and is relieved by the morphin vhicb
is administered for the latter symptom. The use of sedatives is contraindicated
for the relief of restlessness, as they unsettle the stomach and interfere with di-
gestion. A sponge bath (see p. 85) under these circumstances often quiets the
patient and she falls into a natural sleep. A change in position is also beneficial,
and a patient who has been previously restless and fretful becomes calm and con-
tented when the knees are drawn up or she is rolled over upon her side. The
backache which is often experienced after an operation, and which causes more
or less restlessness and severe distress, is generally relieved by placing a soft pil-
low or a hoi-water bag under the small of the back. WTien this fails to give relief.

KiG. yj.i. — Mktiiod op Chanoimc thf DitAW-SHErr ay RnujKr. the Patifmi itmts H£i She asd ms
Back to ihh Dossal HtrtHBUNi Position (pagt 8<j>,

the pain u.iually disappears at once after the po.silion of the patient ii chanH
and she i,s placed u|ion her side with the hip and shoulder supported with piUni'f.
.And, finally, a gentle ma.ssage of the upper and lower extremities is often foilo»td
Ijy a fiiiieling effect and relieves the restless condition.

Nausea and Vomiting. — The stomach is usually more or less iniuWf
for ihc first twenty. four hours until the effect of the anesthetic has paswd <^-
and il is not uncummun for it to continue in that condition for fortv-eighl houtJ.
and in rare instances even so lon^ as one week. As a rule, however, when luu*"
and vomilinf; continue beyond forty-eight hours it is a serious symptom, aM
may indicalc a beRinninf; peritonitis.

The ireaimeni uf ether vomiting is ver>' simple and consists principal!)' in
putting the stomach at rest. 1 never allow anything to be taken by the '"*'"''
.so long as the nausea and vomiting continue, and if the gastric irritability 1* PJ"*"
longed beyond twenty-four hour.s, the stomach is thoroughly washed out "ith

APTEE-TSEATIfENT.

84s

, albu

' fori-'
the
and

iTRi normal sull solution. An ounce of Epsom salt dissolved in water is then
Injected ihroush the tube before it is withdrawn, and a nutrient enema given cv«iy
four hours until the gastric ilisturhaTitc disajj[iears. Small ijuaniilics of egg-
albumen or Valentine's mr.il-juice are then cautiously administered by mouth,

if necessar)' a drj' champagne may also be u_seil.
_ An ice-bag or a mufitiint le;i( aiijilieil iivrr the cjiiuiBistrium is often very com-
forting t" the patient, and not infrciiuenijy relieves the nausea. In some cnxi
the vomiting dinappean almost at on<:c when the {joMiion of the patient i» changed
and she is plated upon hersideandNUppone«iviilh pillows. And, finally, inhala-
ons of the fumeA o( vinegar or oxygen gas often give felict and quiet itic stomach.
Thirst and Drink.— Exces.sive thirst is prevented in a large pmportion
cnies by drinliing large quantities of water during the preparatory course of
treatment (see i>. A.iO an<l by giving a high rectal injection of a quart of hot
normal salt solution before the patient Icive* the operating tidiie.

No fluid i.i al)o\tcd by the niouili during the first twenty-four hours, and after
that lime if the jialient's stomai h i^ i|uicl a teii>|HKmful of hoi water i* nivcn rt'cn"

(fifteen or twenty minutes, grinlually increasing the amount if the fluid is not re-
fected. Hot water under these cireum!*tanct< i" better ilian colli, a* tlie biter
k apt to cause \-omiting by arciimubting in the stomach, and besides it does
Dot allay thirst so well, Allowing the patient to eat tracked ice is objectionable
K>r the same reasoas and shoulil not be |iermitied. After the )>oweU liave been
thoroughly opened the patient is gradually allowed to increase the quantity of
water until sne is taking a normal amount. The patient is always encouraged
to drink water freely during u)n\Tilescence. 11$ it flushes the kidneys and dilutes
the urine. Distilled. Poland. Bedford, or Buffalo lithia water is agreeable and
beiKlidat to moM iMiticnls, and for tlvise wlm prefer a .-vjjarklinj! water ! use .A|Hilli-
iris or a siphon of soda. Vichy, or Seltzer water.
If the patient compbin.-i of thirst iluring the first twenty-four hours after ojwr-
ktion she is given a low enema of vix ounces of hot normal salt solution e^*eJ}■
Bfee hours and her lips and tongue arc moistened with a piece of soft muslin
apped aniutvi a small bit of ice nr dipped in ice-water.

l^e Bladder.— 'I'he bladder is cathelrrizcd in eight hours after the opera-
and then three times in e\'erj' twenty-four hours until tlie urine is voided
ntumlly. As a ndr, the function of micturition i.s not re.More<l for at leiutt one
Of t«o days after the operation, and it is therefore necessary to use the calhelef
during this period, but occasi^mally the urinv is passed .Npontaneously soon after
Ihcpaticnl reco^'cn from the anesthetic.

The Kidneys. - There is always a diminished amount of urine eicrelcd
for the first three or four da>-!t after an operation, and not infreiiuently there
is more or less vesical irritability caused by its highly concenlrated condition,
A careful record is kept of the amount of urine excreted every iwenty-f<iur hours,
as well 3.< iU .specific gravity and genenil analysis. If the amount of urine ex-
creted in twenty.four hours falls below 30 or 14 ounces during the first few days,
the Udne)'s arc stimubted by a recia) injection e^-ciy twelve hours of a pint oS
L^prmal salt solution {118° F.) and the ingestion by the stomach of two or three
^Bass4-s of pure water daily.

^H The Bowels.^Mv experience h.i.t leil me to 1>elieve in the adiant.nges of

PHn early catharsis, and I therefore begin the administration of calomel Iwenly-

^four hours after the operation. Two grains of the drug arc given at ofice and

followetl by i of a grain c%'eTj' half-hour until eight linsts are l.nken. In three

hour; after the List dose is administered an enema consisting of one pint of warm

soap-water (100° F.>, one ounce of glycerin, and a t:dik-^]HHinful of .vulphate of

nuftncnia is injecterl into the rectum. If thi* is not followed by a movement

Itin two hours, an ounce of pure glycerin is injected into the bowel; and at the

846 TECBSIC OF ABDOMINAL AND PELVIC OPERATIONS.

end of another hour if no result i.s produced, an ox-gall enema (see p. 105) is
given.

After the bowels have been freely moved they are kept opened daily by the
administration of the following pill:

I). Kxiracli cascara: sugrads gr. ij

Kxlracti coloirynthidis compueiue, gr. iiss

Extracli bellacliinnee, S''- Vfi

M, ct fl. pil. no. j.

Sig. — To be taken at bedtime.

If the bowels are not moved spontaneou.sly next morning, a simple enema
consistingof a pint of warm soap-water (100° F.) and an ounce of glycerin is given
toward the middle of the day.

The occasional use of a saline is often beneficial during convalescence, and
is given as a substitute for the laxative pill. The salts are given either at bed
time or in the morning before breakfast, and they are usually administered inaa
effervescent form, although the ordinary preparations are readily taken in half a
tumblerful of water. The best results are obtained from Epsom or Rodielle
salt and phosphate of sodium.

The routine practice of obtaining an early movement of the bowels after an
operation is contraindicated in cases in which the patient is in a very weakened
condition, and under these circumstances it is better to wait for two or three days
before attempting to produce catharsis. It should then be accomplished bj
mild means, so as not to cause free purgation, which is likely to exhaust tbc
patient and increase her asthenic condition. In these cases the laxative pill
referred to above should be substituted for the calomel and given eveij' otha
day, followed in the morning by a simple enema of soapsuds and warm wattr
if the bowels are not opened sr>onlaneously. The administration of sah'nes is
also contraindicated until the condition of the patient improves, and they sbouM
then be given only in mild laxative doses.

Tjtnpany. — ICarly catharsis, as a rule, prevents the occurrence of ij-mpanr.
and what lilllc gas docs accumulate from time In time in the intestines isexpelH
!))■ the daily b.\ali\e or enema. Sometimes, however, patient.s are considembly
annoyed by the relentiim of llalus in the rectum, which they are unable lo expri.
probably on account of the fear of injuring the wound by straining, and aUooa
account of the piiin which the effort causes. Under these circumstantes ibe
rectal lube is passed into the rectum several times a day or left in it for an bouror
two at a time; usually this gives the jiatient complete relief. If the flatus is higbff
up in the bowel, a change in the position of the patient or the introduction of if*
rectal tube into the sigmoid is generally followed by the expulsion of thegassixi
the disappearance of the symptom.

Diet.— Nothing i> given by the mouth until the bowels are moved (wli"i
is usually in almul thirty-two hours), after which time if the stomach is quiet lif
|iatienl is allowed egg-albumen alternating with liquid peptonoids, Valentines
meat-juiic, or beef-tea. These articles are given in small quantities ever}' n"
iir three hour.';, and continued, if they agree with the stomach, until the nextdJ!-
when the patient is allowed lo select from ihe full list of liquid diet. The Kqu"
ilicl i^ continued for one week, and if all is doing well, the patient is then pli*™
upon a soft diet, which is changed to a convalescent diet on the fifteenth day-

If the patient is feeble or e.vhausted after an operation, she should be p^'i^
food at once by (he rectum, and sometimes it is also advisable to admini^f
.'mall quantities of concentrated nourishment by the mouth so soon as she r^in*
consrioii?iness from the anesthetic. For this purpose nothing is better than ^^l-
eniine's meal-juice or IJovinine given in very small quantities and repeated e>W)'
half-hour.

AFTES-TSEATMENT.

S47

Alcoholk stimulants are used when indicated, and they arc usually given
in llic form uf whUky. brandy, or a dr>- cbampaKne.

A (ull l»l of liquid, Mft, and c^nvale-srvnt dict.<^ and nutrient enemntn, as
' n-ell aft Ibeir prcpanition, h given in Chapter IX. jtage 100.

Milk U not f.Wtn during tlie tint tvn> week.% after an atKlominal operation,
unless it is i>cploni/.i.-d, as it ne-.irly iiluiiys eauKCS inlcslinal tintus and increases
the ien<leiii'V to ii.iu&ea and vomilitig.

Temperature, Palsc, Respirations.— The lemperature, the pulse,
and the respirations arr reoirdrii t-vcn s.ix hours for the first ihrec days, and
I then, if all (pies well, they are only taken in the morning, at noon, and in tlie
eiening.

I prefer the lemperature taken in the rectum, as it b more accurate than the
mouth and mistakes are less likely to be made. The tem)}erature in a normal
case rarely goc?* beyond 101° or 101' F., and in mo»l insitances i( docs not reach
hifihcr than 100^ F. It attains its highest point, as a rule, on the second day.
and after tl>e bowels are moved in the eveninf; it generally itni[» to aboiil oq' F..
' or normal. If, howewr, the tennJcralLirc rrmjtiri'- elevated after free catharsis
I and gnidually risef*. it is probably <luc lo infcilion of the |ieritiincum nr ^imc
other senou.i complication, A sudden cJevation in lempenlurc ormrrin)|! <luring
the second week is generally caused by beginning suppuration in the abdominal
^^rovnd or a circumscribed infection in the pcriiiHieal laviiy.
^H The )>uL^, an a rule, does not go much bcutnd 100 l>ciit> rluring Ihe first iwo
^^r three days, even after a severe o|>cratioo. and it usually drops, after free ca-
tharN», oD the e^'ening of the second day. A pulse beyon<l 100 besiLs after the
second day in always a {-ause for un«i.siness unless the opcmtion was unusually
severe and it had not taken a previous drop. A rising pulse after the ImiwcIs
have Iwen e\'aruate<l indicates inferlion, especially if il i' assoriatcd with tym-
pany and a moderately high temperature. If the pulse gradually rises lo 110
j beaLi or more after the second da)', Ibe case is .-.erious. and the patient, as a rule,
is in danger. A gnidually rising pulse asmcialcd with abdominal distention and
clevjied temperature and a tlushcd and anxious countenance indicates a fatal
^^dins.

^B Tne TlBe of Sulphate of Strychnin.— One-tM-cmieih of a grain of
^Bd[>liate of strychnin is given three times a day during the first two weeks for
^^p tunic effect upon the hesirt and nervous syittcm and to stimulate the pen»lahic
^^cllon of Ihc intestines. It is adminislered h>'])odcrmically during the first Iwo
I or three days and then by the mouth if the stomach ha> lictome thoroughl) settled.
i Toilet of the I^tient.— The patient is kept clean and romfortable

Irom ihc beginning, and on ihc evening tif the second day she is given a general
iRgebatl). The bath Urejiealeil even' dayduringcnnvalc-^ence. and soup anil
tpT are used to keq> the hands and other parts of the IxHly ilnin. rntil (he
psticnt can be rolled over on her side Ihc liack cannoi be siHinjjed. and the nurse
should not attcmpl lo w-a.>Ji this piart of the body without authority from the sur-
geon. I-«cal cleanlincM is very imporiant. and the anal and vulvar regions
idlouM be regularly vrashcd with soap and warm water after the palienl is able
lo Ik- placed on a bed-jian. .After ihc first week, if all goes well, a vaginal douche
oC two quarts of hot normal salt solution is j-iven every day to kce|» the vagina
clenn and iiKrease the comfort of the patient. The leelh and mouth are uadieil
sevrml times daily wilh a soft piece of muslin dipped in cold water lo which has
been a<ldcid a small quantitj' of listcrine or an aronuitic tooth wash. Alter the
patient is convalescent she should scrub her trrlb nifcht and nioniiiig wilh 4 tooth-
wa&h and rinse mil her nwuih se\'etal times a day with water and lislerine- The
nurse sltoutd comb and braid the [uitient's hair even- day.

848

TECHNIC OF ABDOMINAL AND PELVIC OPEKATIDNS.

The night-dress and undershirt of the patient, which should be made to apea
in the back, are changed once a day, or at other -times, should they become scHlcd.

Visitors. — Absolute quiet and rest are essential after an abdominal opera-
tion, and the patient must not be disturbed during the first week by ^isitOIS.
After this time, if no complications have occurred, she is allowed to see one or two
persons a day for a few minutes, and during the third and fourth weeks the
number of visitors is gradually increased.

Sometimes it may be necessary to allow the husband or a close relative to
see the patient soon after the operation, and under these circumstances the
visits must be made with the surgeon or his assistant.

Care of the Wotmd. — The dressings are not disturbed until the stitche
are removed unless the patient complains of pain in the incision or the tempoaturc
becomes elevated. Under these circumstances the wound is inspected at onn
to exclude the possible presence of an abscess in the abdominal incision.

Fig. J7J. — Aen.Ytrtc, Fbesh DutS'iiwnfl ro a Wort(&.
The adhnivc airaps arr EHring lui ai Ihr cdjip at the dreswiei.

On the eighth day the stitches are removed and fresh dressings applied. U
all goes well, the wound is dressed twice a week; and when the paiieni lea>f*
the hospital, the incision is protected by a piece of soft muslin which is held m
posilion by (he abdominal bandage.

The wound is dressed as follows: Cut the adhesive straps at the edgf f^
the dressings on each side of the abdomen (Fig. 774) and remove the compres
(Fig. 775). The wound is then washed with hvdrogen pero.tid, followed by a
solution of corro.'iive sublimate (i to 1000) ; a large gauze pad saturated nilh ilif
sublimate solution is now laid over the incision, and fresh section <ire>.'iniJ-j
uppliwl which arc secured hy placing strips of adhesive plaster over tkt "I"
ones attached to Ihc sides of the abdomen (Fig. 776).

\\'hen the stitches are removed, the wound may become infected hydn?pnf
septic material or dried serum through the suture tracts. To prevent this 11^''
dcnl (Kcurrinp, the following method is emploved: Bathe the wound freely "|"'
hydrogen peroxid, and after it is thoroughly cleaned place directly over the m-

FM. n«.— Arvtinini FiBO D««aaMa w m WiMn*.

850

TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

cision a piece of absorbent cotton saturated with a solution of corrosive sublimate
(1 to 1000) which is allowed to remain for five minutes. Each suture is then
seized with dressing forceps at its point of entrance, withdrawn about -) of an
inch, and cut close to the skin below the serum line. Traction is then made
and the suture slowly withdrawn from the wound.

Getting Out of Bed.— I allow my patients to get out of bed on the Iwentr-
first day and to return home at the end of the fourth week. A long rest in btd
under the circumstances is not only beneficial, as many of these patients are neu-
rasthenic and exha,usted from long suffering, but it also guards against
ventral hernia, which is likely to occur from getting
up too soon after an abdominal operation.

Bandage. — An abdominal bandage is worn for one year from the tine the
patient gets out of bed. It should be ordered and made by the twenty-first daj.

so that it will be on band when needed.
If, however, the bandage is not a\'ailable
at that time, a piece of canton daniiel
large enough to encircle the abdomen
and extend from the hips to the ^tiiig
ribs will answer very well as a tempo-
rary substitute.

The bandage which I employ is nade
of muslin and cut to fit the figure closelv.
being held securely in position by straps
which pass between the thighs. II taa
be readily washed, and by ha^ii^ two
bandages one is always clean. The bu-
dage is removed when the patient haiis
and when she goes to bed at night. Tbt
elastic bandages which are generallv used
lo support the abdominal walls after an
operation are not only useless, as ihf
rubber soon becomes overstretched and rotten, but they also absorb the perspin-
tion and become filthy in a short time.

A bandajje cannot o r <1 i n a r i I y support the incision
and pre\ent the formation of a ventral hernia, bm
I believe it to be of service when any extraordi-
nary strain is put upon the abdominal wall.':, and,
be, sides, its presence is a constant reminder to il"
patio lit of the tender condition of the wound.

Sxercise. — For a year after ihe patient leaves the hospital she musi avoid
all forms of wi)rk or c,\ercisc which pul an e\traordinarTi- strain upon the abdom-
inal walls. During the first si.v: months the patient must limit herself toiiri'i'?
and short walks, and after that time the game of solf, played in modcntion. i^
ihe most utlraclivc as well as the most beneficial form of exercise she can late.

Fig, jj).— Ashton's MfsuM A»D01dh*l Ban-
dace,
Thp bandA^r may ht made to lace al iht back.
OS shown in Ihr JEJuslration, ur id bucklt ai ihc back
nr ar Ixiih sideA^ ihe laiicr melhod n Ihe moat iaiis-
faciQry.

Post-operative Complications,
persistent nausea and vomiting.

If vomiting continues after an abdominal section beyond forty -eight hour?,
it i^ u^uallv a >crious svmplom, and may indicate a beginning peritonitis w^
renal insnfiiciein v. In nervous women, however, vomiting may continue I"'
several (lays, and unless it is relieved a fatal ending may result from exhaujiinn.

POST-OPERATIVK COUPUCATION8. Sjt

lin. the vomiting may cease wHthin a (ew kours after openiiion and return on
the second or third day, Under these circumstances it if often the fir<l symp-
tom cf u >ept)c iiifeclion, and is usually a&socuilcd vrith dUlres&ing retching
and c|>igJt^trii: distctilion.

Treatment. — .\ii in the case of »mple ether vomitinf;. all forms of food
mmx ht wiihhcl<l fn>m the stumach, gastric Iinan*^ employed (see p. S44), aod
the strength sustained by nutrient enemata iind hy|MK(ermic injcrlicms of strych-
nin {gr. 5V c*cry four hours), It is imporUint to move the bowels freely, and if
the Epsom sjilt which is injetted into the sioniaih after the lax-aRC does not empty
the intestines. ,'0 of a griiin of cfdomelcomhineit wiUi 3or3grainM>f bicarlHinate
of siMla t.- pven ever)' half-hour until ten doses are taken. One hour after ihc
bst powiler i> givtn uii enema (iin>isiing of wutpsuds. turpcnline, and warm
water is injected into the rectum. Somrlime* it may be necessary to use a more
stimulating injection, such as an ox-gall enema (see p. 105), or, again, good
results miiy follow the administration of a Scidlilx powder.
^H In some cases relief is obtuinerl by i)lacing a iur[)cnline Mupe, a hot-water
^Bag, a mustard plaster, a small fly-blislcr. or an ice-bag over the epigastrium;
^^1 other> marked benefit may be derived and the iierviiu.-v irritability of
the stomach lessened by giving ao grains each of bromid of md.i .md chloriil by
the r«'tum in three ounces of warm water or milk. The enema may be repealed
ci'ery three or four hours acconling tu ihc imiiralions and the eflecLi produced.
The .idminisiration of remedies by the mouth are genenilly of but little use, al-
thougli in some cases marked results may be obtained and thi- gastric symptoms
greatly benefited or relieved altogctlier. Tlic following formula may have M.

ratjvc effect upon the stomach and relieve the nausea:
[). Arrtani!ii)i gr. iitt
Cctii<-x;il.uU gt. V
CuciJn.-F hf^ilrwhloralit, ....gr. }
M. rt ft. tachcl do. j.
Si)i- — Oix oil het cvrry lira or thrcv hciuri iU Inclkattrf.
It the jNitient h' unable to swallow a cachet, the remedies may be administered
III the form of a powder which is placed dry upon the tongue and taken with x
little hot water.

Cucsin may be administeretl alone, either in pill form (gr. J nm- two or
^^rtc hours) or in solution (gr, Vij c\w>' hour), with decided benefit, and some-
^Hbnes small doi,e:s of tincture of nux vomica (1 dropevcry half-hour inn toaspoon-
^^ilof liot water), or iJb "' a grain of nitroglycerin, repented in four hours, may
stop ihc nausea and vomiting. In cases in which there is no evidence of septic
^Meritonitis morphin mav be given hyi>(xlernii(.idly tu pmducc sIiTp and relieve
^Hie genei^il nervnus irrTlubility. Tnder these circumstances the administration
^Bf the drug is often followed by the prompt dis;ippciiranieof the gastric sympiom.*,
Hwk) in the course of twelve or twenty four hours the Momach l-k able to retain
^imalt quunlitir^ of food.

In cases in which the \-omiting continues despite the above plan of treatment

it may be necessary to repe^il the giislric Utvnge and wash out the stomach every

ec »>r f<wir hourt with warm saline solution. In most cases, however, the fir*t

jivagc is followed by pennanent relief, and the stomach is able to reuin small

antilies of food.

It a patient suffering with persistent vomiting expresses a desire for some
cial article of diet, it is u.sually best to all<iw her lo try it, .-ls nausea has
^tcn been relieved in this way and the alomach settled when other means
Lve com^rictely failed to give results.

853 TECBNIC OF ABDOUINAL AND PELVIC OPERATIONS.

DELAYED BOWEL HOVEMENT.

In the majority of cases the bowels are opened as the result of routine medi-
cation on the evening of the second day after operation, but occasioQally the
movement may be delayed for several days, even where no serious complicatiim,
such as peritonitis or mechanic obstruction of the intestines, is present.

These cases are due to paralysis or spasm of the intestines, and usually follow
operations in which there has been more or less traumatism, exposure d the
abdominal viscera, or sudden relief from tension after the removal of a lac;^
tumor of the pelvis or abdomen.

During the first twenty-four hours after an abdominal section, if the case is
doing well, there is an absence of peristaltic action (aperislaJsis) and the inirs-
tines are at rest. There are several factors concerned in bringing about this na-
dition. In the first place, the preparatory evacuation of the bowels by cathaias,
and the use of a liquid diet and the absence of food immediately after sectioiL
remove the intestinal contents as a factor in stimulating peristaltic movements.
And, again, the rest in bed before operation and the enforced quiet aftera-ard tend
to keep the intestines inactive and prevent peristalsis. This condition is sol
only obsened after an abdominal section, but also after parturition, and, in fad,
in all cases in which the patient is required to lie quietly in bed for some limt.
The well-known fad that changing the position of a patient in bed reliwes tm-
pany in some cases and favors the downward movement of gas shows the cfiect
of exercise upon intestinal activity. If, therefore, any cause for paralysis w
spasm of the intestine is present at the time of operation, the peristaltic acDon
of the bowel is interfered with, and several days may elapse before the DorauJ
conditions are restored and a movement takes place.

Diagnosis. — The condition must be distinguished from septic peritonitis
and mechanic obstruction of the intestine.

In cases of delayed bowel movement the pulse is but slightlv affeclcd and
seldom rises aljove 90 beats ])er minute. There is generally a slight fever and
the temperature ranges from 99° to 101° F. Tympany is usually absent oronlv
slight in amount, the general condition of the patient is good, and ihe siomadi
is quiet, as a rule, although in some cases there may be a little nausea.

A high temperature and a weak, rapid pulse, associated with marked Ijin-
pany and vomiting, indicate septic peritonitis or intestinal obstruction.

Prognosis. — The jjrognosis depends upon the general condition of tlw
patient and the presence or absence of complications. The condition need cause
no alarm, provided serious symptoms do not inten-ene, if the bowels art not
moved for live or six days after ojjcration.

Treatment.— If the bowels are not moved on the evening of the secomi
day (see p. 845, After- treatment) nothing further is attempted until thef*^"*'
ing morniiiH, when a second ox-gall enema is given high in the bowel and i
grains of jiurified oxgall Qel boiis pimficalinn) is administered internally m
pill form cvm' hour until eight doses are taken. In the meantime the positw
of ih'j patient is changed and an ice-bag placed over the epigastrium. If "o
results follow in the course of eight or ten hours, a high rectal enenu composed
of the following ingredients is given:

IJ, Olive .,il f Sv;

Glyrerin f Si]

Spirits i)f 111 r| If mini' f ^j

Sui|jh:iic of ma^nt'sia ,..,..,.,.,,..,., Xij

.SiMipsudi unit water { [05° F,J, q.s. ad Oi]

If tHc bow«U Have not moved l>y the next mnrnlng, the patJent h given a
full boltlc of citrate of miifunniii in broken dnses (4 ownces cvcrj- hour), followed
]»y an ox-pall enema. If no results arc obtainetl bv the following day, croton oil
nay be iiilininiHtered a» fnllowx:

R, CtKtnnoil Blj

GIfccrin (Sj.

M. S)||. — One to two tcupooniuU evoy forty miaulis.

Thi* i> ;i very acceptable metborl of Kivin^ croton oil, and the howela are usu-
Jy moved afler tlic second iir ihirrl rlose.

The manaKemcol of these cases naturally varies at times, and other remedies

nay be trie<l when those recommended above fnil to accomplish results (tiee

bapter on consti|>ution). The caidlnal jirinciple, however, in the treatment

I not to crowd the use of remedies, a; it not infrequently happens that an cvacu-

ktion occunt spontaneously .'«veral hours after the last atlcmpi lia> been made to

cure X movement.

TYDPAKY.

Excessive tympany following an alHlominal or pelvic operation may be due
1 simple causes, such as intestinal paraly^ or constipation, and to serious com-
^licatiiins KucU as »eptic peritonitis or obstructioR of the Imwels. When
tympany is due to a serious cumpliciition, it k associated with a marked eWn-
^^lon of the temperature, rapid pulse, and vomiting, while in cases due to a simple
^Knusc the distention of tlie intestines is the chief and m<Ki prominent manifes-
^Baiion of the condition. Tympunites associated with septic peritonitis or intes-
^Hnal olI^t^ULlion will be considered later on and its treatment discussed in con-
^Kdering ihe^e compltnttion.s.

^1 The (xissibility of the occurrence of post- opera tixe tympany us greatly lessened
or prevented altuKClher by a careful course of preparative lre;ilmenl and the
proper management of the patient .ifler operations. In some cisc*. however. eJt-
^Kvssive tympanites develops deapile every precaution thai is taken, and allhuugh
^Ht i« sclilum in it-^elf a ciiuse of de.ith, yet it may priKlure greiil distre*$ nnd inter-
fere with the chances of recovery. In exceptional cases in which the abdominal
^—tlisiention i-. enormous, the pressure e.xerted uiKin the tliauhraj^m and the heart
^■nity reMill in grave interference with their functions antl c:ium; n fntnl ending.
^^ Treatment. — The chief indication in the treatment is tocause a free evacu-
ation of the i)owrfs. This am usually lie accomplished by changing the t>(i.sition
the ]);ilienl .tnd administering a purgative do.'^ of citrate of majpicsia, followed
I three hours by an ox-gall enema.

The introduction of a tube into the rectum nr the sigmoid llexurt- is often fol-
nwni liy ;\ free escape of gas and a decrease in the amount of tympany. GnM
X>mforl is often experienced by the patient if tlie tube ts allowed to remain in
die rectum, as it |>ern)ils the gas in conlinnnusly es<'ape nml thereby preveutt
listen I ion.

Gixid results arc fret|ucntly derived from the ndministrnlion of 3 i^ins of
^urifieii oxx>ll ■" pi'l form every hour until eight doM^ art^ given and the subtc-
juent injct'ltnn of a pint of milk of a.'afetida hijfh in the rectum.

Apj'licAtions to tlie surface of the abdomen alioNe the situation of the incision
^■pfien relieve the condition and assist maleri^illy in permancntty curing the lym-
^^nany. An ice-bag or a lurf>enline stu|)e h one of the best local applications for
^Bhii puiiK>>e. If the Utter means is empl»ye<l. it should l>e prof>erly applied,
^Itllherwi'C llie tur^M-ntine will )>e uneveni) distribuleil and act as a vesicant. A
turpentine tilU]>c ishould be given as follows: 'l1>oroughly mix six ounces of olive oil

$54 TECHNIC OF ABDOUIN'AL AND PEL\1C OPEHATIONS.

and two drachms of spirits of turpentine by shaking them together in an eight-
ounce bottle. Spread the mixture gently over the abdomen with the hand and
place a flannel compress wrung out of hot water over the parts. The compress
should be renewed everj' ten or fifteen minutes and the mixture reapplied cvmt
hour.

SECONDARY HEMORSHAGE.

Symptoms. — The sj-mptoms of secondary hemorrhage, as a rule, come on
gradually and become progressively worse unless the bleeding is checked or
death eventually ends the scene. The patient, as a rule, recovers from the anti-
thetic with a slow, full [)ulse, a normal temperature, and a good general condiiioii.
but in the course of a few hours a change takes place and symptoms of inlcniai
hemorrhage occur.

The pulse is quickened in frequency and diminished in volume and fom;
the respirations are shallow, irregular, sighing, and labored; the temperature
is subnormal; the face is extremely pale and has an anxious pinched expression;
the lips and (he finger-nails are hvid; the mucous membranes blanched; tbe
skin is cold and clammy ; the eyes are fixed and glassy and the pupils are sriddy
dilated; the extremities are cold; the patient is usually restless and move her
head from side to side or her arms in various directions, although in some rases
she may be listless or apathetic without any evidence of irregular muscular activii)-
or tremor; nausea and vomiting are occasionally present; and the patient may
complain of black specks floating before her eyes and a ringing or singing sound
in her ears. Finally, all the symptoms gradually increase in severity; theraiml
becomes clouded; muttering delirum develops; con\'ulsions occasionally occur;
and death slowly interv-enes.

Diagnosis. — Secondary hemorrhage is liable to be mistaken for shock,
and the differential diagnosis must be promptly made, otherwise death almost
invariably results from excessive loss of blood.

This subject will be fully considered under the Differential Diagnosis of Sbocli
(.eep. 858). _

Prognosis. — The prognosis depends upon the amount of blood lost m
the previous condition of the patient. If the hemorrhage comes from a fairly
good-sized vessel and it is not promptly checked, death usually takes pbcf '"
from ten to twenty hours. The secondarj' anemia which usually folloBS a se\'«t
hemorrhage may be \'er>- profound in character and last for se^'eral monlhi.

Prom])t operative interference combined with active treatment will a" ^
large projMjrtion of cases of secondarj' hemorrhage, provided the antiseptic pr^
cautions lire carefully carried out and the operation is quickly i>erformed.

Treatment. — The treatment consists in reopening the abdomen, ijingthe
bleeding vessel, and using appropriate remedies to stimulate the acliun of the
heart and replace the volume of blood lost.

Preparation of the Patient.— No prepanitor)- treatment is required "cepi
to catbeteri/.e the biaclder, ami the patient is placed on the operating table i-
soon as possible. It is unnecessar\' to resterilize the alxiomen, as it is protected
by iho dressings which were placctl over the wound at the time of operatiMi- ana
hence the jiarts are sterile. Cardiac stimulants and injection*
of normal salt solution must not be a d m i n i>tt'red
until everything is in readiness to proceed ati^i^'^
with the operation, as they tend to increajt '''*
hemorrhage and thus lessen the patient's chances 0'
recovery.

PflST-OPEHATIVE COUI-UCATKINS.

SS5

■tstheflia.— A minimum amount o( the an»tliolic should ItcixlminUtcrvd.
Th« wKikened aivl ajKitlu'lk <>>ivlit)'in nt the |ulicnl rcmler' it iinncci.'N.sun'
to push llic ancslhrtic. ami itic oiKT.ition should he ^t^itccl before complete tin-
BiUMziiiuMiCMS. tuing as lillle ti( iIm- (iru); >» po»sihlc and •.lopping its ad minis tra-
:il 0\v fiiTlicH ]M»Mt)te mom«ni.
Instruments.- (i) Swlpd; (a) scissors; (}) tw*o short hemostalic forceps:
(4) tnn long hemostatic forceiis; (5) two longbladeil henioststic [urc;et>i; (b)
"-' bullet forceps; (7) drtMSing (urcq»; (8) pedicle needle; (q) abduminal

/?^

-®-

ri;!

op J QPQjDI

® _o

Pm. tt^ — iNtnomim Van m Om«tiiio mii SironpAn IfrtraaiNMiR,

®_

ACTUAL SIZE

^i^iH.iors; (10) A»hton'« self-retaining abdominal retniclore; (ii) needle-
, hoMer; {la) two .imall full-curved Hagcdom needk-s; (13} three si night triun-
1 gulur iwinted Deedtea; (14) Nos. i, 7, and 11 braided silk; (15) .■itlkw-onn-
Rul— »o strundh.

Dreuings. — The contents of the conveyance boies arc the same as given
r abdominal operations on page Sji}.

856 TECHNIC OF ABDOHINAL AND PELVIC OPEEATIONS.

Cardiac Stimulaiits. — The following remedies should be at hand: Stiydi-
nin, nitroglycerin, atropin, and whisky.

Saline Iiijections.— The nurse should have three gallons of nonnal salt seda-
tion prepared (see p. 1 26) and the necessary apparatus for ginng an intiavenom
injection (see p. 119) and enteroclysis (see p. 135. ) sterilized and ready fornse.

Assistants. — An anesthetizer, one assistant, and two general nurses an
required.

Operation. — So soon as the patient is placed on the operating table the dress-
ings are removed and the operator proceeds without delay to reopen the wound
and search for the bleeding vessel. At the same time a hypodermic of strj-chmD
(gr. ^), nitroglycerin (gr. yiTr), and atropin (gr. -j-^) is administered, and tht
administration of an intravenous injection of normal salt solution is b^unBUI
continued during the operation until from one to six quarts of fluid are injedtd
into the vein.

The operator begins by removing three sutures at the lower angle of the ib-
dominal incision and separating the freshly united structures with his fingav
the handle of a scalpel. If blood is found in the pelvic cavity, the reinainnig
sutures are at once removed and the bleeding point located. The method i
procedure after reopening the wound depends upon the nature of the origiBiJ
operation, and valuable time will be saved if the operator at once directs his aUcn-
tion to the most likely situation of the bleeding vessel.

If the operation has been a salpingo-oophorectomy, one or two fingers sbould
be passed directly down to the fundus of the uterus, which is then seized iridi
bullet forceps and pulled up into the incision. The pedicles are then eiaiiiii«t,
and if the source of the hemorrhage is not discovered they are ligated again and
dropped back into the pelvic cavity. If one of the ligatures has slippeti, ttc
inner and outer extremities of the broad ligament are seized with lang-bladcd
hemostatic forceps to control the bleeding until the free blood is remo\-ed aod tfie
field of operation exposed to view. The vessels are then ligated and the stmp
dropped back into the pelvis.

\Vhen a secondan- hemorrhage follows a hysterectomy, the method of kw-
ing the bleeding point is somewhat different, as it is impossible to bring the uW-
ine stump into view without first removing some of the free blood and pladiif
the patient in a marked Trendelenburg position. The stump of the \iims b
then seized with bullet forceps and lifted as far as possible out of the pehic caoK-
If the bleeding point is discovered, it should be ligated at once; but if tbeKiuKt
of the hemorrhage is not apparent, an additional ligature should be applitd i*
each side of the uterine stump to reinforce the original ligatures and secure 'Iw
open vessel or vessels.

When a hemorrhage follows an operation in which there were eiten>i« a""
he.sions, a careful examination must be made of the entire pelvic cavil;'; aw
if the capillary oozing is profuse, it must be controlled by packing .-strips ofgai"'
around a giu.ss drainage-tube (see p, 902) after making sure that no bigcvfijtls
require Jigating.

.\ft(T controlling the hemorrhage the abdominal and pelvic cavities are iin-
galcil with normal Siilt solution until the biiwKi-clots are removed and iheM
comes out comparittSvclv clear. A large amount of the solution i.^ allo«™ '"
remain in the peritoneal cavity, and only so much is removed as can be squw™
out by gently compressing the walls of the abdomen with the hands.

The wiiund is closed and dressed in the usuid manner.

Before the patient leaves the operating table she is given a high rectal ini«-
tion of a ()uart of normal salt solution (ejitoof/yjiV, seep. i35)containinglwoo''mfs
of whisky.

POSI-OPERATIVK COUVUCATlOSi.

857

After*tTeatmeilt.— So soon a» the patient b removn! fmm the operatin)t
table she is immediately put to bed and wrapped in a warm blanket. Mot-wiitCT
bagt 01 lx)ltles iire then placed abttut her body and lower extremities, the fooi nf the
bed raised about twelve inchr* (n>m the floor, and a hypiKicrmic oi ^af 11 gnin
o4 Ntrychniii jtiven. The further ireatmefH n( the case depends upon the prompt-
ness and degree of re;icti<>ii, and no hard and fast mies can thcxcfotc be formu-
lated to meet the requirements in every cise. Usually, however, if the patient
in thiing fairly well and the reaction is good, ^^ of a grain of strychnin should
be given hj-podermiciilly ever}- hour until the indications point to a leMening of
the dow or mu^cuIa^ iwiichinf^ show that the |)hy»inlugic limits of the drug have
been mchcd. The dox 1> then reduced to ^ of a grain c^cr>■ three hours and
eventually increased or decreased acciinling to circunt.st;ince^. Six hours after
the o]ieriilion a hypKHlermic of atropin (rt. ji,-^) and nitroglyccfin (gr. yij) is
given and repeated every eight houn until three (hxNei. tiave lieen tiiken.

The frequency and quantity of the saline injections depend eniircly Upon
the in(licalii)n.i, ami the omditiim of the puUe muat always be t;iken into con-
sideration in deciding the queslion. By the time the patient b- put !<■ bed she has
received two or more quarts of nomul sail solution, — one quart or more by
the intiu%-enous mute and one <iuart by tlie rectum, — and unleM the bleeding
has been excessive no more wrill be required, as a rule, until six hours have
elapseil since the operation. From one pint to one riu.irl of the .solution h then
given by cnteroctj-sis or by hyptxlermoclyM." and rtiH-iHeil e^■eTy six hours so long
as indic;itcd. In addition, the strength of the patient should be supported
atKl the thirst rclieieil by giving a nutrient enema every three hour*, consirt-
iog of the yolk "f one egg, mx drachms of whisky, two drachms of liquor
paocreatis, and three ounces of beef tea.

So soon .1* reaction occurs and the ,ab«irbing power of the stomach is restored
stnall quantities of highly concxrntrated nourishment should be given \n- the mouth
to sustain the ])atienl and liasten coii^'alescence. Noihing is letter /or this pur-
pose than Valentine's meat-juice. Ivivinine, or liquid peptonoids, and in some
cases the use of a dr)- champagne or a fine brandy will al.-io pntve nf grcnt value.

Special Directions. ^\Mieii hyiMXIermic injections arc employed in
ses of scci>ndar)' htmorrliagc, they must be given in the subcutaneous tissues
of the che^t or abdomen, and not in the extremities, where the ctrculntion is
very wc:ik and the remedy will not Ix; absorbed.

In cases of severe hemorrhage Ihc upper and lower e.xtremitiet >Jiould be
firmlv bandagetl to force out the hlotjd ami ke<.-[i it in the head and body.

Tlie iimount of >timiilation and the frequency and quantity of the saline in-
jections, as well as the bcit route to empk>y in inlrorlucing them into the circu-
lation, de|teiid eniircly U(>on the indicitions and the ability of the surgeon to
inteqirct them o)rrectiy. Thus it may be Tound that larger and more fre<iuent
doses of strychnin. nilroRlycerin, or atropin are required to combat heart failure
and 5UNt:iin the inking forces. And. finally, it may lie necessary to rcficat the
intntvemms injection of normal wit solution tn the other arm or ndminisicr the
solution more frequently by tlie subcutiineoi» or rectal route.

SHOCK.

Symptoms. —The .symptoms of shock come on suddenly, as a rule,
shortly after an operation, and are chamcteriscd by profound depression of all
the vital centeni.

The patient docs not umally recover from the nneubciic in a Mitbfactory
tndilinn, the puUe U .nli^htly accelcnited and somewhat weaker than it should

8s8 TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

be, and her general condition indicates that she is not doing well. The actual
onset of the attack h sudden and the symptoms manifest themselves quickh.
The pulse is very rapid, weak, and easily compressed; the respirations are hur-
ried and irregular or they may be so shallow as to be hardly discernible: tlw
temperature is lowered one or two degrees; the face is pallid and pinched and
the features may be gready distorted; the tips and finger-nails are of a bluish
hue; the hands and fingers have a shriveled appearance; the mucous surfaces
are pale; the skin is blanched and covered with a profuse, cold, clammy perspira-
tion; the s])hincter muscles are sometimes relaxed; the extremities are cold and
the patient lies upon her back in a listless semiconscious state with haU-ck>sed
eyelids. V'omiting may occur in some cases, and in others delirium may inter-
vene, assuming either a mild low type or becoming maniacxit in character.

If the attack tends toward a fatal issue, all the symptoms become more maiktd
and the patient gradually passes into a state of stupor ending in death. If, how-
ever, reaction takes place, a slow improvement is noted and the vital forces finilh
begin to assert themselves, as shown by the condition of the circulation, Ac
respiration, the temperature, and the mental attitude of the patient.

Diagnosis. — It is always necessary to distinguish shock from secondur
hemorrhage, as the symptoms of the two affections are very similar, and a mis-
take in the diagnosis would naturally have a most unfavorable result.

The following points of difference must be taken into consideration in nuk-
ing the diagnosis:

Shock. HEUOKiaAcK.

I. Generally follows a prolonged operation i. May follow either a severe or a sa^
or one in which the abdominal viscera operation; (he Eeneral cmditioQ o(Ac

have been exposed to the air or more or patient does not lofluence its occuntscc

less roughly handled; it is also likely

to occur in women who are weak and

exhausted physically.
1. The patient is listless and apathetic and 2. The patient is restless and her miad

there is seldom any tendency to toss apprehensive and anxious.

about in the hcd.
J. Seldom recurrent attacks of syncope. 3. Recurrent attacks of syncope fTeqml.

4. Pulse anii ^neral condition not salis- 4. The patient reeoven from the >nesilutli

farlury immedialely after operation and in a good condition, but later od the

the symptoms of collapse come on sud- pulse gradually becomes accelwittiiT

dcniy, the temperature falls below i>otiiul. lad

collapse finally intervenes.

5. General stimulating treatment tends to 5. The pulse progressively gtows kkv

improve Iho pulse. despite all that is done to stimulate tbr

heart and secure reaction.

6. The blood findings are negative. 6, There is a moderate leukocytosis f ij,ooo

to 1S'°°°)'- '''= number of red cells urf
the percentage of hemorlobiQ >n
diminished (Martin and Hare): tbc
blood-plaques are increased in num-
ber; and the coagulation time of the
blood is more rapid .

Prognosis. — The time when reaction .sets in depends upon the se\eritT
of the symjitoms and the condition of the patient prior to operation. In favor-
able cases reaction ui^ually occurs within a few hours; if it is delayed from twelve
tn twcnty-fnur hours, the progn<>;>is is bad. Delirium is a verj- grave omen, and
if vomiting circur.s jfler the patient has been in shock for several hours the chance?
of recovcrv are not good. A continuous subnormal temperature for several
hinirs. as wdj as a ler)- rapid pulse, is an unfavorable sign; and \t delirious shock
ititorvcnes, accompanied by a high fever (102° to 103.5° F-) the condition o( ibe
patient is exceedingly grave.

MOSt-OPKItATIVi: COHI'UCATtONS.

859

Treatment.— The pulieni ts wrappoil in u-nnn blankets, hot-water bogs
are plutoil around her body and lower extrciniiie6, and a musUrd leaf is upfiltcd
wcr the re([iin) iif ihe lieart. The (™>l «( the bed U raUeil twi-he inches from the
floor and ihc pAlicnl'* head is (diieed directly upon the mailrcs^. :ihc is then
given a hypodermic of strychnin (gr. .V), niirnslycciin (gr. yJl^), and utnipin
(gr. TW)f ""<' imrnctliiilely ufieiwarrl nonnul silt »>liilion is, injcclLil inio ime
of the veins of the forearm (f-i-c Intravenous Injections, p. 129).

One-lwentieth •>( a gniin of strychnin Ls then giicn cwry half-hour until Ihe
^mptoms improve or mu.Tular iwilciiinKs occur, when the frwpiency and strength
of the dose arc reduced to meet the indications. The nitroglycerin and atropin
ut rq>eaie<l every tn-o or three hours if required, and a stimulating rectal enema
is adminKlered every three nr four hours colwi^l^ng of a pint of hot colTcv or beef-
tea, to which t. added two or three ounces of whiaky.

No food is given hy the mouih until reaction »el» in and l]ie aKtorhtng power
of the stomach is restored, when highly concentmtcd nourishment and brandy
are caulii>u>ly admint'tcrcd in .•■null ilo^'s (see Trc^itnicnt of Ilcmorrhase, p. 85").
Hypodermics mii of (he
chest ^ni! Ihe abdomen, and nol in the .irms or the legs, .is the circulation in the
exireniiliis U alnum entirely su.^|K;lHk'lI. .\s in ihc case of >econdafy hemor-
rhage, the amount of stimuhlion :ind the frequency and quiiniiiy of the saline
inject iota depend upon the indications and the ability of the surgeon to read them
correctly. It may be necei^iry to reiieut the .-alinet every six or eight hount or
oftener, and the)* should be given either by the intnivcnous or subcutaneous
route.

Crlle'S Observations upon Shoclc.— The following conclusions
of Crile arc quoted ftuni "An American Tcsl-Book of Surgery";

■ "SurgkitJ shoik is :i sUU- "f low blo<wl-pa-s'ure due to funclinn.1l impairment
oc exhaustion of the vasomdior center. 'I'his imp;iirment or e.thaustion i.% due
U> traumatism (operation or injury) of sen?>.itive ti.vNuc.

"Collapit i* a etate of low blood-prw*urc due to a suspension of the function
o( the heart or of the vasomotor center, or to hemorrhage. Amonc the causes
of c<>ll.t]ise nuiy be mentioned Injur}- of the heart; inhibition of the heart, rellexly
through the superior lan-ngeid or directly through injury of the vagus or vagus
center; injury of Ihc vasomotor center, etc.

" Tht diStrenlial rfi.i.t'wod'j Iietween shock and collapse is very largely dq)cn-
denl upon the hi*tor>- of the case. The symptoms in both are practically identi-
cal- Even in the cases of colbpse due to hemorrhage tlie difTereniiat dbjtni'sia
without the lti»tor)' and without the direct evidence of hemorrhage is almost im-
possible-

"The iymphmti of shock and collapse are incident to a low bio. hI- pressure,
and indicate'! by a feeble pulse, muscubr relaxation, mental impairment, pallor,
ckmmy skin, etc.

" The IrttJtmenl of shock fall.t under the following henrU: (a) Secure physio-
logical rest. This demands both mental and physical repose. If there is ex-
osaive pain, morphine should be given. The wound should lie kept as free as

rsihle from irritation. (/>) Meanwhile the blood -pressure of the brain ^hould
supported by elevating the foot of the bed. by pressure upon the extremities,
b)' bandaging, or by applying a pneumatic rubber ■>uit. by which a uniform pnss-
ure may l>e applied ujMin the eJilremiiics and the alulomen. The bU>od>pre8Sure
by IliU means may be raisei:! 25 lo (15 mm. of mcriiiry.

" Normal saline infu.->ion lui:> a certain range of u.M;fulnevi, especially when
there has been hemorrhage. I'hc vasomotor center being exhausted, v;L-u)motur
sticnulanl^, such as strychnin, are contraindicated, since this would ' lash the

86o TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

tired horse.' In severe cases adrenalin chloride (i : 25,000 of normal salt soh-
tion) in moderate dosage — i.e., a to 5 c.c, per minute — may be given.

" In collapse the indication is for tiding the ciitulation over a ciisis. TTiis
may bo done by stimubnts, such as strychnine, digitalis, etc.; by mecfaanial
support, as in shock; by saline infusion; by adrenalin chloride; by divubiif
the sphincter ani in certain cases."

ASEPTIC OR FERMENTATION FEVER.

Definition. — This is a form of fever which occurs after an aseptic apta-
tion, and is due to absorption of tibrin-ferment derived from the tissues at tie
seat of operation or in the abdominal wound. The elevation of tempentuR
in this common variety of surgical fever is spoken of as the " post-operative riu."

Symptoms. — Fever is the chief symptom. It usually appears withmaicr
eight hours after operation and continues from one to two or three days. Tbt
temperature ranges between 99.5° and 102° F., and generally reaches its hi^KSl
elevation about thirty-six hours after operation.

The pulse is but slightly, if at all, affected; the general condition and eipie-
sion of the patient are good; and there is an absence of any subjective or obJKtin
symptoms that would give rise to anxiety.

Diagnosis. — The diagnosis is based upon the early appearance and sud-
erate degree of fever; the character of the pulse; the general condition abd a-
pression of the patient; the absence of grave symptoms; and the aseptic naluit
of the operation. If, however, the patient was septic at the time of operatioiii, or
the peritoneum was contaminated by the contents of an infected sac, it wewJd
be very difficult for the first twenty-four hours to distinguish between sq*!-
cemia and aseptic fever, unless the pulse becomes decidedly accelerated and Ibe
general condition indicates the onset of a grave complication.

Prognosis. — The prognosis is good, and recovery invariably takes plaa
unless septic infection subse<iuently develops.

Trea.tment. — There are no indications for treatment.

TRAUMATIC PERITONITIS.

Description. — This form of peritonitis, which is also spoken of as pUslic-
is a purely reReneralive process, produced by aseptic causes, and therefore not 10
be classctl with iruc inftammations of the peritoneum. The febrile reaction ■hidi
is associated with thi.'i form of peritonitis is due to the absorption of fibrin-f«-
menl and the products of metabolic ti.ssue- changes into the circulation, and iw
to the iircscncc of infcclion. The plastic lymph which Ls thrown out amund
the area of irril^tlion soon becomes organized and ndhcsions occur between OROJ-
inn surfaces which may lead to serious kinking of the intestines. The adhtsJoM
mav beriimc permanent or they may eventually be absorbed and leave no tract
of their ijrcvioiis existence. The extent and severity of the peritoniti.* depfw
upon the nature of tlic operalion and the amount of exposure or rough handlins
to which the intestines were .subjected.

Symptoms. -The svmplums usually appear within si.\ or eight houisaflff
operation, ;in(l their sevcritv depends upon ihe cxieni of the peritonitis.

In moilrmir t^isrs the |nilse is but slightly accelerated and the temp«at'|f^
doe> iiiii go beyond 100.5" ^- There is localized pain, tenderness, and rigidi'y
of the abihimen. and the stomach may be somewhat unsettled. Tympany, is
a rule, is absent or but slight in amount, and the general condition of the pa"™'

ISMT-OPEIATIVE COMPLICATIONS.

86l

is good. Th« iiympKifns bcf^n to disappear aftn the second or third day and
convatcsceixc is ra;t>illy esLiljli^lioi.

In tnt/f tajes the symptoms an more marked, and in some respects they
cloMrly re^ralile llnwe caused by septic infection of ihc pcrittmeuni. The pulxe.
as a rule, is but slightly iiccclemtecl, aiid ib vulume i» full nnd simng; the Irm-
peraturc ranges between 99' and loa' [■",; lympnmtes i.s more or less marked,
and in some cases the distention of the interlines miij' Iw v> (peat 3> to jfriou.tly
interfere with respiration ; the stomach is un.-ii-ttle<I and there is nausea and vom-
ilinj[; llie patient c<)mplains of severe and agonizinR inlcrmilteni colic-like pains
in the lower alxlomen; the alxlominal uall i.i lemlcr ;ind rigid; .tn<l the liowcLt
are usually constipated. The general condition :ind expression of the |>aticnt
are fairiy good and bear no rcbiion to ihc severity of the symptoms- If. how-
ever, the symptonts are aggravated and cotilinue fur several days, the patient
UHUiJly Incomes exhausted and her general condition bad. The general and
local symptoms bc^n to improve in the aiuritc of lltree or four da}'», idlhough
they m.iy continue for a longer period and give rise to great anxiety before con-
VAlesence i> fully esublisb«i.

Diagnosis.— The affection must l>e di^tinguUhed from genend seplic
peritoniii.^. In mild cases the diagnosis is based uimn the aseptic character of
the otM-ratinn; the slow and full pulse; the general condition and appearance
of the pitient; and the absence of grave symptoms.

In aggravated cases it is often difficult or im-
possible to make a differential dtagno.^is until
the final outcome of the cnsr has been reached and
convalescence is established or death occurs. Thisl.^
cs|>ccially true when the »ymj)tomK are verj' severe and long-conlinuol and the
patient bccora« exhausted. Under these circumstances the pulse becomes
rapid and weak tttid the facial expressii>n of ihc patient .i.ssumcs the jiinched or
Uxious appearance so characteristic of septic infection. These are the
<B»es in which a mistaken diagnoAis is made, and
if death does not take pliicc they arc reported
as recoveries from general sfpiic peritonitis.

The differential diagnosis lielween an aggrai-ated form of traumatic peri-
tonitis and septic infection of the [icritoneum is based upon the aseptic nature of
the operation; the character of the pulse compared with the severity of the local
and general symptoms; the absence, a» u rule, of the pinched or anxious facial
expression of sc^jsis; and the strength of the patient- Nausea and ^■omiting
are not usually se<.-ere in caM» of traumatic [len'tunitis and tiie tlistressing retell-
ing which accompanies sepsis is not often present.

Prognosis.— Recovery usually tikes place even in aggravated forms of
the affe^'tion except when seriou,* com; >lic:it ions intervene. In some cases the
exudcl senim may b^-corae infected and sepsis develop; obstruction of the bowels
inny occur from adhesi>>:i-> kinking the inte>iiiie or a Ivmd of inllammalory lymph
occluding its lumen; and, finally, serious or grave sj-mptoms may result from
an excessive ivnipanitcs interfering with respiration.

Traumatic peritonitis, as a rule, remains limttitl to the irritited or injured
areas, and it shows but little or no tendency to become general.

Ifreatment. — The indications arc to restore peristalsis, ami induce free
purgation.

In mild cases in which the stomach b quiet a (urpenlinc stupe (p. 854) is ap-
plied lo llic alxlomen and the [latient given a full bottle of citrate of magnesia
in bnikcn doses (4 ounces e\try hour), followed by an ox-gall enema (p. 105).
This treatment, as a rule, not only causes free purgation and the disappeaniiice

862 TECHNIC OF ABDOMINAL AND PELVIC OPEKATIONS.

of the tympanites, but it also promptly removes the serous fluid that has hteo
exuded into the peritoneal cavity. No food is given by the mouth until the bovds
have moved, and if the condition of the patient in the meantime requires stimu-
lation or nourishment, it should be administered by the rectum. The food which
is subsequently given by the stomach should be highly concentrated, adnnnii-
tered in small amounts, and frequently repeated (from i to 4 teaspoonfuU ntiy
thirty minutes or every one or two hours). Album en -water, beef-juice, liquid
pcptonoids, Valentine's meat-juice, and other forms of liquid diet described on
page 106 are nutritious and easily assimilated by the stomach, and should be
selected in these cases.

In aggravated jorms of the affection it is often difficult to relieve the symploms,
as the stomach is irritable and unable to retain anything; the t^'mpa^ites is u-
cessive ; and the patient is weakened and exhausted by her suffering. A tuiptn-
tine stupe, a hot-water bag, or an ice-bag is first appUed to the abdomen, and t
rectal enema given consisting of olive oil, fsvj; glycerin, fsij ; spirits of tuipentiDe,
fsj; sulphate of magnesia, lij; and warm soapsuds and water, q. s. ad Oij. The
injection is repeated every two hours until the bowels are evacuated and tbcps
is expelled. If, however, no results follow after the third enema has been given,
and the nausea and vomiting continue to be severe or are accompanied bj the
regurgitation of a dark, foul-smelling fluid, we must resort at once to lavage li
the stomach. After thoroughly washing out the stomach with normal sah sota-
tion an ounce of Epsom salt, combined with half an ounce of whisky and thitt
ounces of beef-tea, is introduced and the tube withdrawn. Two hours ifttr
the lavage an ox-gall enema is given to assist the salt in inducing free puiptiai
and expel the flatus. If the vomiting returns, the stomach should be irubcd
out everj- three or four hours until it ceases, and each time lavage is enpdo^
beef-tea and whisky should be introduced through the tube before it is with-
drawn. As soon as the bowels are freely moved the patient is given a drr
champasnc or a fine brandy and placed upon a highly concentrated liquid
diet. If the nausea still continues, feeding by the mouth must be slopped iwi
nutrient enemata given ever;- four to si.x hours. The heart and nervous syslefli
should be sustained by administering strychnin hypodermically in dosesof jV
to Tj'u of a grain e\cr}* one or two hours.

The foregoing treatment will usually be followed by recover)-, but if the sjTBp-
toms are ciused by septic peritonitis, no relief can be expected, and the patient
eventually succumbs to the disease.

GENERAL SEPHC PEEITONITIS.

Symptoms.— The symptoms of septic peritonitis manifest themselves, ss 1
rule, in from twcntv-four to forty-eight hours after operation, and in the mtafr
time the general conilition of the patient is fairly good, although in sumeo-'s
reco\ery from the anesthetic may not be entirely satisfactory or normal. Tne
first indications that the patient is not doing well are shown by an increase in iK
rate and volume of the pulse and a slight elevation of the temperature. Tht
stomach then becomes unsettled or the ether vomiting may be prolonged untO
the gastric irrilability due to the infection manifests itself, and the palienl «""■
plains of r.har[> intermittent pains in the lower abdomen. In the couneofafe'
hours intestiiKil panilvsis intervenes and tympanites develops. The symplpos
gradualK'. :ilmost imperceptibly, grow worse and worse, and death from collapse
usually takes place at liie end of the fourth or fifth day after operation, althnup
il may be del;i>ed for u week or even longer if the patient's power of resistance
is strong and the virulence of the infection is moderate.

posT-opCKAnvf; coupucAngNs.

863

_ The puhe in th« bo^nning riingn bdwetn 8; and 100 bniu (n the minule,
and Liter on Kru<iu^lly rises to 110, 140, ifo, urmorc. ]| i' i^mull. Icnsc, and wii}'
at tim. arwi l;ick> the Mi(t. full volume whkh is tharactcriilk oi a.ie|ilic (ttcr or
traumatic |>crUonilb. As the <lu<«iie advances, howevTr, it becomes wcuker,
then threudv, and I'liully almost imperceptible.

Vomiting in nut i>cr>istifnt at firs-t, and usuuUy bcf^nj* by llie ntomach ejecting
its contents. It then bc<:ome6 bilious in character, and tinnlly :i dark, foul-smell-
ing Duid tt ^-omited which )>ccomcs fccul U refcfscd peristaUJs lakeH |>Ltce. As
Ihe diM-aM prugrcstes the iiHniiins Ix-come^ very [re<)ucnt and the [Ktlicnt sufTers
from coTL^tanl retching, which causes intense suRcring. especially in the lower
alxhunen.

The temperature in the beginning is usually not high and ranges between
100° and 101* or loi' F., but a^ the infection advances it becomes more elevated
and may reach 105 ' F ; and in some cases it may rUc In 106" or 107'* F. imme-
dbldy before death. In occaMonal instances the onset of the disease may be
mai^eil by a dUtlnct chill (ollon-ed by a sharp rise in the lem]>eralurc (105' to
105' v.), although, as a rule, there is ni> rigor and the patient only compbins of
a chilly sensation. The rise in lemi>craHirc is not a constant factor in septic
peritonitis, and in »ame ca^es it is insignilicunl compared with Ibe gnivity of the
case, while in others a normal or e\en a subniirmnl temperature may be present.

The .^hAI\^ intermittent abdominal pains which bc>;in early in the course of
the <liscii5e gr.idii;illy becume more frequent and severe, and are aggravated by
the violent abdominal contnictions' which accompany the excessive vomiting
and retchiivg. The tympanites i^intdualh' increases, and finulh' the abdomen
becomes greatly diMcmlcil and the rcspimtinn* are im|ieiled on account of
pressure upon the dbphragm. 'Fhc boncls are obstinately constipated and do
not respond to treatment. The patient becomes rc^tlejA and tusses about in
bed. Her expression becomes anxious, drswn, and pinched, the mind becomes
clouded, mutlerini; delirium is fre(|uciit, and the cj'cs are sunken. The skin
assumes an aslien hue and the surface of the IhkIv i« cmereil with a col<l.
dammy sweat.

There is> another form of septic (writonitis which i^ fulminant in character
and destroys life within twenty-four or forty-eight hmir^ after operation. In
these cases the [uticnt U o\er%v helmed by the virulcncy of the infection and the
local symptom.* are (jeneriilly absent. The <lisease usually liexin:^ within a few
hours after the operation ami is ch,-in»cteri/cii by great dq>rc5sion or collapse.
The puLsc suddenly becomes rapid (lio lo Kjo or more), then irregular and
weak, and finidly dis;ipiie;ini altogether. The temperature, as a rule, ranges
between 09. 5^ and 101° F., or it may reach as high as 105°. and in some cases it
mny l>e subnormal. The expression of the |<atient is anxious and )>inched;
the mirwl i* Usually clouded; and the surface of the bcMly U covcnnl with a cold
per^iration. Tympanites and other local symptoms of peritonitis may or may
not develop, acconlinx >» t)ie virulency of the infection and the niptilily with
which df-ilh occurs,

Diagnosis. —The character of the operation and the ihorouRhnes.i of the
anti))e|>tic precautions are often important jHiints tu coa'^iiler in ilending the
question of diagnosis. It is practically impossible at the outset of the disease
tii make n dtai^nosU and to say with any degree of certainty whether or not the
ease is one of sq>tic peritonitis, In iheeourse of twenty-four to forty eight hours
however, the disease can usually be rccocniied, although it must be remembered
thai aggravatet] funns of traumatic peritonitis mil}' so closely resemble the seotic
variety as to render such a diagnotas out of the <|ucstinn. liencndly speakmg,
when a patient l>egins lo do badly on or about the second day and has a gradually

864 TECHNIC OF ABDOMINAL AND PELVIC ' OPERATIONS.

rising pulse, associated with fever, vomiting, colicky pains in the abdomen, aui
tympanites, the indications are strongly in favor of septic peritonitis, and dus
suspicion becomes almost a certainty as the symptoms increase in se\'erit)- utd
the face assumes the characteristic expression of the disease.

Fulminant forms of septic peritonitis must be distinguished at times baa
shock and internal hemorrhage.

A consideration of the blood -findings in cases of peritonitis and septic inftc-
tion will be found in Chapter III.

PrOgtlOSis. — D eath invariably results in general sep-
tic peritonitis, and the reported instances of sup-
posed recovery from the disease are in realitycasei
of mistaken diagnosis in which the symptoms were
due to a localized infection or an aggravated form
of traumatic peritonitis. Owing, therefore, to the imposal^i)'
of making a positive diagnosis in many instances, and the fact that patients soot-
times recover after all hope is practically abandoned, we should give the patient
the benefit of the doubt and treat the case as if it was not necessarily fatal

Treatment. — From the standpoint of treatment the disease should be
looked upon at the beginning as a case of traumatic peritonitis, and mamged
accordingly (see Treatment of Traumatic Peritonitis, p. 86i), Vllien a fatal
issue is no longer in doubt, active measures should be discontinued and mor-
phin given hypodermically in sufficient quantities to relieve the patient's
suffering.

Operative interference is seldom, if ever, indicated. In the early stages d
the disease the diagnosis is too uncertain to warrant the risks of a secondar}- opaa-
tion, even granting, for the sake of ailment, that it would do good at tliat tinie;
and later on, when the symptoms have become characteristic, nottiii^ wiU be
accomplished by surgical interference except to hasten the patient's death.

Saline injections are indicated as a routine practice in cases of septic peii-
tonitis, especially when the pulse begins to fail and the kidneys become ^lug^
In addition to stimulating these organs, the injections do good by diluting iht
poison circulating in the blood and acting as a tonic to the nervous system-

LOCALIZED INFECTION.

General sepsis may be due at times to the introduction into the circulatiMi
of septic micro-organisms or their products from a localized or circuniscr3»l
area of infection.

The disease may arise from an infected pedicle or ligature; from a singlt «
multiple abscesses within the pelvic or abdominal cavity; and from suppuralitw
in the wound.

Symptoms. — The symptoms do not manifest themselves, as a rule, for thrte
or four days or longer after operation, and in the meantime the patient's general
condition is fairly good. The onset of the disease is marked by a gradual rue
in the jiulsf-rate, which ranges between loo and 120 beats to the minute, and
chilly sensations associated with dull muscular pains. The temperature ni^
As a rule, it is not high, and seldom goes beyond roj° or 103° F. it is u-'mH.'
lower in the morning than in the evening, and it may even occasionally dnip "'
normal for several hours at a time during the course of the disease. The put*
does not become weak and lose its volume, as in septic peritonitis, and it doesw'
often go beyond 120, except in verj- grave cases of infection. The patient's m''*'
usually becomes more or less clouded; the appetite is poor; the stomach issoiK-
what unsetded; slight tympanites associated with localized abdominal or prfiic

POST-OPEKATIVE COUPUCATIONS.

86s

U usually present; and (lie skin is covered vrilh a clammy sweat. The
iK'dg, as a rule, arc difficull lo keep rcguUr, liul in some c;i?.ea the opposite con-
'' dition exists, and diurrli>cu may dewlop am] aiJd lu the i>alieiit']. iliscomfort.

'I'hc disease usually runs a slow course and there is little or no tendency to a
fudden cxrllapse. If recover)' is likely to take place, llie symptoms gradually
subside and the juiticnl becomen cunvilesicent. On the other hand, if the symp-
toms become grave an exhausting diarrhtu Mrts in; rqtcaied rigors occur; and
the temj)cra(UTe becomes higli. The puUc loses its volume and becomes rapid
and weak; the t<m>:ue i> dn* and cnicked; the >lomach is very irriLdfle; and
the kidneys are slug^sh. The jMitient complains of great exhaustion, and
death Ls u-ihcrcd in by delirium and stupor fuUoivcd by coma.

Pyemia may develop during the onine i.( the dUcase,

Diagnosis.— The disease must be distinguished from traumatic snd gcn-
entl septic {>eriloiii(l't.

In ciscs of general sepsis due to a locdi^^d focus of infection the symptoms
do not usually appear for several da)-s after operation; lite pulse, as a rule,
h not very rapid nor weak; the temperature is generally lour; the condition of
the patient is fairly good and there arc no inJinitions of a sudden collapse; the
face is not pinched or drawn, as in septic peritonitis; and the course of the dii-
casc is hlow.

An examination may reveal a localized swelling in the pelvis or in the line

Pthe abdominal inciMon.
A con-.irJvnilion of ilie blixnl -findings will Ijc found in Chapter HI,

Prognosis.— The disease, as a rule, is amenahle to treatment unless the
infection i.'. very virulent or it U imptis^ible to remove the >ourec of »e|itic con-
tamination. In some cases the area of infection may become surrounded by a
thick wall of inllammatoni' exudate and the absorption of septic material into
the circulation is arrested; the patient then usually recovers from the acute
condition with a chronic abscess remaining in the pelvis.

Treatment.— The treatment I'onsisU in (a) removing the focus of infec-
tion; (b) sui^t:iinin^' the strength of the patient; and (c) assisting the system to
eliminate the p"i.-4i,iL.

Removinf; the Focus of Infection.— So soon as the symptoms manifest
Ihcm-H-lves and the surgeon suspects that the patient is septic, he should at once
endeavor to locate the fucus of infection. The alnlominal w<fund i.i first exam-
ine<l to determine whether it has become infected and is the scat of an abscess
or a beginning suppuration. If there is no evidence of intlammation upon
inspection, and palpation fails lo reveiil any hardened area« in the neighbor-
hood of the incision, it may be taken for granted that the point of contamina-
tion is situated eLscwhere. Tlie pelvic cavity is then carcfull)' examineid by
vaginal, recta), ami vagi no -abdominal palr>ation in order to thoroughly inve»ti-
gatc nil |>arts of the pelvis. If no suspicious enlargement or swelling is found,
nothing can be done beyond waichiiif: Die intlent carefully and repealing the
examination from time to time with the expectation that a localiied ana of

Kectiim may eventually be discovered.
In Ihe meantime, however, if the symptoms l>erome abrming and the patient
evi<lu)tly going front bad to worse, the abdomen should be reopened and a
careful search made for the |>oini of infection. If an al)scess cavity is found,
LJ^hould be thoroughly clenn>«<l (nol irrigatfJ) with a gniixc sponge .•dluriited
^Bh normal salt sobitioH and drained with a glass tube. In some cases it may
^w necessary to pack a strip of gauxe around the draiiugelube in order to pro-
I lecl (lie general cavity and prevent the infection from ^^jrcading.

If a localixed area of infcclion is felt in the pelvis, it should be reached through
SS

866

TECBNIC OF ABDOHINAL AND PELVIC OPERAnONS.

the vagina, thoroughly irrigated with normal salt solution, and a nibber T-dnio
inserted. The abscess cavity is then irrigated once or twice daily throu^ Ac
drainage-tube with hydrogen peroxid and normal salt solution until it is moa
or less completely obUterated by granulation tissue. The most frequent situa-
tion in which a purulent collection forms after an abdominal section is in tbe
culdesac of Douglas behind the uterus, and this locality should therefcoe altnys
be most thoroughly palpated in all cases where pus is suspected in the pehis.
In rare cases the uterine stump may become infected after an incomplete hn-
terectomy and pus may accumulate beneath the peritoneal flap. This coDdi-
tion can usually be detected by vagi no-abdominal palpation and free diainigt
established by forcibly dilating the cervical canal. The infected carity should
then be irrigated once or twice a day with hydrogen peroxid, and if ntctsaij
packed with a strip of iodoform gauze.

If symptoms of septicemia develop in a case in which gauze drainage liis
been employed, either through a vaginal or an abdominal incision, the fackiog

Fto. 780. Fic. Til.

ReUOVIMC * COLLECTTON 0? PUS HOH THE CUUIISAC Of DoUCUS.

Kig. fSo sJuvsaD iDd&iao bting mad? throuzh Ihc vagina jnio ih« cuIdP4Mc of Dduc1*s- f^- 7^' Anwitai^

Kr ^-dram in poaition.

should be removed at once, as the probabilities are that the secretions haW b^
come blocked and cannot escitpe. A rubber drainage-tube is then insattd
into the cavity which was occupied by the gauze and the parts irrigated daUr
with normal salt solution.

Sustaining the Strength of the Patient. — Highly concentrated fonosrf
liquid food ;ire indicated, and should he given frequently in small amounL'.
Strychnin should be administered h\-podermically in doses of 5^5 to -^ of apai"
every three hours, and a sufficient quantitv of whiskv given e\en' twenty-four
hour'; to sustain the iiction iif the heart. If the stomach is irritable and dcB
not retain food, stimulating nutrient enemala must be resorted to.

Assisting the System to Eliminate the Poison. — This is accompiy>«i
by kecjjinf! the bowels freely opened and employing saline injections.

A liursative dose of citrate of magnesia followed by a simple la.tative entmi
should be given every two or three days, and in the meantime the bowels are

POBT-OPKFATIVE COHPU CATIONS.

867

I On

opened by u cteily enema conskting of sulphate of magnesk, Sij; glycerin,
tSij; j-piril* "( iur|)enlmc, f3j; and hot ivalcr (110° F.), Oj.

Salinr injrction^ should he given ;i* n routine procedure, but the quantity
id frequency should dr[>end upon the stimgth of the puLie and the amount of
irine excreted. They should be given by tbe in ini venous, subcutaneous, or
KCtal route.

INTESTINAL OBSTRUCTION.

Causes.— The causes of posl-ope:rativc intestinal obstruction arc classified

follows:

I. Adhesions between the intestine and raw surfaces.

(a) To an omenlal stump

(b) To denu<U lions of the pelvic and parietal peritoncuni.

(rf) To u lierlide.

(e) To surfaces on the intestinal wall,
s. Paralysidi of the intestine.

3. Local spasm of the intestine.

4. Impacted feces.

5. Bandt of inflammatory lymph.

6. .Adhesions between coih of intestine or between the gut and neighboring
irLi, due to tiuunuitic i>critonitis.

7. Kinking or twisting of the inlesitDe <lue to a faulty operative tcchnic.

8. Including the inmiine within the loop of a suture or between the edges
of the incision when closing the abdominal wound.

L 9. Slipping (if .T coil of itilrstinr thnmnh .i >lil nr an npcrlurc.
f Adhesions between the Intestine and Raw Surfaces. -By far the greater
numt>cr of Ixiwd I>ll^tcurtio1l.>; are due to ihi.s cau.ie. A knuckle "f gut becomes
attached by adhesive inllummalion to a denuded surface. 3 kink results, and
ubMruclion of the l>owcl (oIKiws. Naturally the question will be 3>ke<l: How
do we explain the fact lh;H cm |iani lively few one* of oll^l^ucli<)n occur from
thb cause when iherc are so many severe operations requiring the separulioii
of cxtenMve adhe>ion.t? The an.4wer is that kinking does not necewarily fnl<
low the fixation of a knuckle of intestine, unless the gut .idheres in an abnormal
position: and, furthermore, I believe that many of the cases that end fatally
after an abdominal or pelvic o|>eraii»n, in which death li ascribed to peritoniil*.
in rMliiyihie to hoivct olnlniclion.

Paralysis and Local Spasm of the Intestine and Impacted Feces. —

^ ihe {Ltlhology of all these cauNC^ of obM rue lion Is ihc same, I shall discuss

them under one hciding. The correct explanation of ob'lruclions due to local

I tpasm or [uresis of the bowel will, moM probably, be found in a stuily of the

■H^uence of Viirious stimuli ujfon the nerve-i controlling intestinal perii^tidsis.

^Hbe inte>tin:il wall contains an automatic motor apparatus— Me plexitt of A ufr-

^HbcA — which inlluence!> tlie |>ensL-iltii' action of the liowel. "If this center is

not affected by a stimulus the movements "f the intestines cease — compamble

to (])e cowlition of the mcdulb oblongAta in apnea. The same is true just as

in the cav of respiration during intrauterine life, in con.->ei)uence of the fetal

blood t>ring well supplied with (). This condition may In- terme<i aprti^tahis.

It al*o ociTirs during >lcep, jicrhaps on account of the greater amount of O in

bkxil (lurinfi thai state. All stimuli applietl to the myenteric plexus in-

asc the pcrisLahis, which may become so violent as to cause evacuation of

tlie large gut, and may even pmducc sjiasmodic contntction of the muscubture

aftei

868 TECHNic or abdouinal and pelvic operations.

of the intestine. ThLs condition may be termed dysperislaJsis — coircspanding
to dyspnea. The condition of the btood flowing through the intestinal \-cssels
has a most important effect upon {leristaltic movements. The continued ap-
plication of strong stimuli causes dysperistalsis to give place to rest, owing lo
overstimulation, which may be called intestinal paresis or exhaustion."

During the first twenty-four or forty-eight hours after an abdonninal sec-
tion, if the case is doing well, the intestines are in a condition of dysperistalsis.
There are several factors concerned in bringing about this state. In the fint
place, the preparatory treatment of the bowels with salines, the liquid diet, md
the absence of food after operation leave the intestines comparatively emptr,
thus removing the intestinal contents as a factor in stimulating peristalsis. Again,
the rest in bed for several days before operation and the enforced quiet aftcrwani
add largely to the absence of intestinal activity. The causes of operatiw stimu-
lation of the intestines are exposure to the air, lowering of the temperaCun,
operative procedures, irritating fluids, septic matter, and neglect to thoroufidj
empty the bowels prior to operation. \Vc have found that dysperistilas
and paresis depend upon the same cause, namely, an irritation of thenwlM
center of the intestine; but that the intensity and duration of the abnonnal
stimulation alone determine the difference between the two conditions. For
example, simple intestinal congestion would most probably, even if long con-
tinued, result in a condition of dysperistalsis, while a severe inflammation, oo
the other hand, would cause paresis.

Bands of Inflammatory Ljnnph.— As the result of intraperitoneal Inflam-
mation following abdominal and pelvic opwrations, lymph is poured out upM
the intestine, and coils of gut become more or less adherent to each other. As
a rule, no bad results ensue, but if the adhesions destroy the normal rdatioo
existing between the coils or a knuckle of gut is constricted by a band othmpli.
then kinking or strangulation follows.

Adhesions between Coils of Intestine or between the Gut and Bei^
boring Parts due to Traumatic Inflammation. — These adhesions result from
an irrilalion of the serous membrane which is caused by exposure of the in-
testine to the air, to lowering of the temperature, to handling or manipulatiiMs.
and to operative procedures. Adhesions of this class are, in my experienct, *
necessary sequence of all intraperitoneal operations. Fortunately, traunuK
adhesions are, as a rule, not followed by fatal results, as they do not nectssanly
cause kinking or twisting of the gut. They not infrequently, however, aui<
more or less remote trouble by giving rise to colicky pains and a tendenci' B
constipation.

Kinking or Twisting of the Intestine Due to a Faulty OperatiTe Tech-
nic. — These obstructions are not the result of adhesions, but occur after anas-
tomotic operations upon the alimentiiry canal or after the rejiair of bowel leJu"*-
For ejiample, a coil of intestine may be kinked or twi.sted by suturinp il in ^
incorrect ])osition when an anastomosis is made, or, again, the bowel may M
torn trans\'ersely while separating adhesions and a fatal obstruction from tint-
ing may result from closing the ojiening. I..ongitudinal tears, even if exteny**'
may tic safelv closed with sutures, but a large transverse wound is very utd)'
to cause a kink if it is repaired in the usual manner.

Including the Intestine within the Loop of a Suture or between tto
Edges of the Incision when Closing the Abdominal Wound.— .At first sis«
these causes of bowel obstruction may appear to the surgeon as bems ""
tremcly unlikely, or at least very rare; yet cases have been reported in "'"J'^
the accident has occurred and death resulted from obstruction, as shown by
autopsies.

POBT-OPFKAnve OOSOiUCATIONS.

869

8IOL .

Slipping of a Coil of Inlestine tlmnigb a Slit or an Aperture. — ^This

cntknl mil}' <Krctir fruni the followiiift caiucs:

j\!> thi' mult of adhesions. Tor vxiimplc. » band of inflammaton' lymph
Oikv }x s<> uitichnl that an apcrlurc U formed; or. a^n, a cuil of i)i« intestine
^ thr mesentery mil}* adhere iind form a tcxif) through which a knuckle of gut
may slip.

2. From dcfe<■l^ in the mcihix) of <le:ilin;i with U'lir* or ind>i"n^ through
Qc mrscntcp,-. Thus, if thv mc^entcr)- is l<jrn during the Kparation of ndhc-

sioru and the tear is not clo?H:d. or the mcscnicric Haps are not .ouiurcd after a
icin uf the Urael, a coil of intestine i^- liable tu .sli|] into the ojMMiing and
nc ni|>;>ed.

3. Slippini; of a coil of intestine through the vaginal wound after complete
remoral uf ihe uterus.

4. A knuckle of i^t [mshing it* waj: (hrough the intestinal loop formed in
, otablishinK a lateral anastomosis, without resection.

^K 5. From fixation of the gaLI-bladder to the abdominal incision.

^H 6, From openings mude through the tmns\-rrsc mesocolon and the great

^Binentum to facilitate the attachment of the bowel to (he .niomach in performing

H^E t ro- en tennlo my .

Symptoms.— In the majority of c;iscs the symptoms begin to manifest
Ihem^cji ts between the second day and (lie end of the rjr>t week, although
the)- may Kp|*cttr earlier or Ix- dchiyed tor several weeks or months or even years.
This variation in the date of the onset of the symptoms is readily understood
when we Like into con.tideratinn the caiue.i uf po»t operative obstruction*.
Thuf. for example, u sh4r[> kink or twist in the intestine m:iy occur suddenly
and the symptoms of obstruction will naturally manifest tliemselvcs almost
from the st;ut. On the other hantl. however, the constriction of the bowel may
\x very slight at first and the obstruction slow in forminR. An olislruction
auMd by a l>and of inllammatnry lym|>h is bte in developing, as a rule, for the

! reason that the bowel is not seriously coni^lricted until the exudate begins to
organize and contract. It is evident, therefore, that the raj'idity with which
an obstruction occura de]ieiul« entirely upon the cause and chumclvr of the con-
striction.

The mosl prominent symptoms of intestinal obstruction are: (t) \-omlting,
fa) tympainy, (3) jMiin, (4) elevation of the (cmpeniturc, (5) rapid pulse, (6)

Knslipation, and (;) a discharge of mucus fmm the rectum.
I'omiliHi! i.t not only a constant and early siKii of obstruction, but it is also,
a rule, (wrNstmi, <ind in about one-lhin) nf the cases it becomes fecal in char-
ter. TympaniUi is almost always present to a greater or lewcr extent, and
II nuiy ap[ie.ir in some ciises before vomiting occurif: or, ag;iin, it may show
^itScU as n later symjitom. Like vomiting, tympany is usually tontinuous, be-
^^■Mning more and moro marked a.s the c;i--c develops. The extent of the ab-
^Hondiul dii^lention dciienctly InHucnced by the state of Ihe alimcn-
^^try canal at Ihe moment of oi>eraiion. In >j(ime cases Ihe distendetl coil* of
intestine can be s«cn through (hi- belly wall. It is interesting to note that
L^)rmpany may be absent in cases of obstruction on account of extensive adhesions
^^Ectween the intestines and the aUlominal walls. Kxcessive pain and Ifnilrnua
^Kwy not Ik- markr<l in post -opera live obstruction, although, as a rule, the |»ticDt
^^uBcrB acutely from .se^'ere [mmxi'sm.s of colic.

The Umpftaiure at the ^la^l is slightly eleinteil, and ranges helwcen q^.J*
and 100° or lor^'F. As the disease progresses, however, and collajrsr intervenes
It tiecoroes subnormal and the facial e.tpreiuion of the jMiticnl becomes Hi|>po>

870 TECHNIC OF ABDOIONAL AND PELVIC OPERATIONS.

cratic. A rapid pulse is one of the earliest and most constant symptoms ot post-
operative obstruction. It ranges between ic» and 140 beats to the miDute and
is very weak and feeble. Constipation is a prominent svinptam, ahhough it
times it may be more or less misleading as a manifestation of obstniction. The
passing of scybalous masses per rectum must not mislead the surgeon into tbt
belief that the bowels have acted, and, again, there may be several free more-
nients before symptoms of obstruction intervene. Finally, there may be ob-
stinate constipation at the start, which is followed in a few days by several loose
movements before the obstruction becomes permanent. The various degree
of kinking and constriction of the intestine account for this want of unifoimity
in the action of the bowels. A discliarge of mucus by the rectum is a nluabte
sign in certain cases of obstruction. I have observed this symptom in thice
cases, and in alt of them the obstruction was complete and appeared late (tweffth,
twentieth, and twenty-third days). The mucus discharged by these patients wu
perfectly clear, and resembled closely the white of an egg. The discbarge ms
always preceded by severe pain and bearing-down efforts. The quantiti' of
mucus varied from one drachm to one ounce each time it was expelled.

If the obstruction is not relieved, the symptoms become more and dwk
marked, the patient gradually becomes exhausted, and finally dies in a state of
collapse.

IHa£;tl08is. — Postoperative intestinal obstruction should be distinguisbed
from traumatic and septic peritonitis. It is impossible, in my j'udgmeat, to
make a differential diagnosis with any degree of certainty if the obstnictiMi
occurs within the first week after operation, except in verj- rare instances, aad
even in these exceptional cases any opinion expressed as to the probable lesion
would be pure conjecture. Furthermore, traumatic peritonitis may be present
from the start or develop within a few hours after operation, and in the coune
of two or three days an obstruction may gradually occur from a kink ortrol
which would present symptoms that could not be distinguished clinically from
those dependent upon an aggravated condition of the original peritoniti.s. .^gaia.
the clinicil pictures presented by septic peritonitis and obstruction are so siniilii
that a diagnosis is out of the question, and, besides, the former affection nur
often coexist with the latter, which would necessarily .still further obscure tbt
nature nf the lesions. It is therefore evident, if a patient does badly withio ^
first week after operation and presents symptoms of aggra^'ated traumatic pen-
toniti.s, septic inllammation, or obstruction, that the question of operative ioier-
fercnce must be most carefully considered before final action is taken; otbff-
wise the patient may lose her life as the result of an incorrect diagnosis. The
extreme difficulty of distinguishing between these
lesions is so great and the result of an analysis 0'
the sym])toms so problematic that I believe laoit
lives would be saved by not interfering surgically
than would be the case if the abdomen was frequ*"!'
ly reopened and an occasional obstruction acci-
dentally found.

On the other hand, a patient who does well up to the end of the 6r^t««t'
and then rlevebps bad symptoms, is probably suffering from intestinal oltinif-
tion and not from septic i^ritonitis. I should not hesitate, therefore, torwp^
the abd<imen and search for an obstruction if constipation, vomiting, wpw
pulse, intermittent abdominal pains, and tympany began to develop on or sub-
sequent to the seventh day after operation.

In determining the jircsence or absence of obstruction it is important W
the surgeon to bear in mind the various causes of intestinal blocking, a™ "'

PO&T-OPEftATIVK COUl>UCATION&.

87.

lake into considcratioD the lilcelihood of lh« operotion being follovrcd by such
a complication.

A consideriition of the Ulwxl- findings in (zsa of tnieitina] ob»tnjction wOI
be found in Chapter III.

' Prognosis.— Obstructions occuirinn within the first week after opcra-

. tion, as a rule, end fatally on account of the uncerLiinty of the <lLij^iitM(i,\ .-tiul the

; neceiuary delay or failure to reopen the abdomen. The prognosis, however,
b good in ca.tes in wiiich Ihc obstruction does nut occur until after the seventh
day, as the diagnosis cun be made early and prompt surgical interference in-

' stiluted. I have operated three times for post-operative intestinal obstruction
occurring after the tirxt week, and every ca&e made a good recovery.

^m Treatment. — If the general condition of the |iii(>cnl [» foirly good and

^Bmmediaie operation a not tndicatetl, we should begin the treatment by en-

^oeavoring to secure a movement of the bovrcb by mcun> of purgative medicines,
high enemuta, local applications to the abdomen, and change of position.
I begin at once with the administration of cruton oil as follows: K. Croton

I oil. 'n. j". glycerin, faj. M- Sig.—*^ne to tvro teasiKXinfuIs C\'ery forty minutes.
After Ki^ii'K 'he second dose of oil a high enema is injected into the bowel,
consisting of olive oil, f.Vj. K'ywrin, f.jij; spirits of iur|)cnline. fsj; sulphute of
tnagncsia, ,^ij: soapsuds imd water (10 j^ I"'')-'!- ^' ■*"' ^''j- ^ turpentine »1upc

' (we p. 854) ia at once appbed to the abdotnen and the position of the patient
frequently changed.

^m The enema should be repeated e^'cry hour or two and Ihc patient's

^Btrength supported with small quantities of liquid diet and the administration

^^of strj'chnin in doses of ^ of a gtain every three or (our hour*. If the treat-
ment fails in the COur« of twelve or twenty-four hours to relieve the obstruc-
tion, opemtivi- ititerfi-rcru e should be inMituted ;ind the idxlomen n-nj>ened.

Preparation of the Patient. — No preparation is required, except to catb-
etrri/* the bluiider iiid administer a hy|»od«rmic of -^^ of a gniin of strjchniii,
until the piiticnt i- plnced on the operating table, when she is covered with a
woolen blanket and surrounded with hot-water bags to guani against the occur-
rence of shock. If the original aUlominal drct«ing» have not been rcmmed,
it is unnrces»r)- to sterili:te the abdomen, but if they have been changed the skin
should be quickly prqiared by mechanic means (scrubbing with snap and warm
water) and the ap]iliQition of a itolution of corrosive sublimate (i to 1000), fol-

! lowed by sterile water.

^ Anesthesia.— The anesthetic should not be ndmini»lered until the patient

■B» pbced on the bible, and only a minimum amount of the dnic should be em-

P^loycd. It is. therefore, imperative to ha\c c»-erythinR in readiness to begin the
Operation Wforc the anesthetic i.t .iLirted. Chloroform, on account of it* mjiid
assimihtion. i.< prefcnible to ether.

' Dressiags. — The contents of the conveyance boxes arethe same as given

^^or alxlomirul operations on page 838.

^P Instrumentl. — (i) Scalpel: {2) scissors; (3) six short hemostatic forceps;

^*if4) dressing forceps; (5) tissue forceps: (6) alxlominal relractont; (;) Ashton's
self- retaining alidomin:d retractors; (8) needle- holder; {9) three straight tri-

; angular pointed nevdlcs; (lol Nos. 2 and 7 braided silk; (11) .si Ik worm gut—
10 stntnds: (la) inioslinal instruments and necilles— ^ttlr]>hyV button; ana^-
tomot^s force|>s: damps; two straight and two curved intestinal needles (Figs.
;8a and 783K

Operation .—The .sutures are first renunxd from the incision and the ab-
domen reopened by separating the freshly uiuted structures with the finger or the
handle of a scalpel. li tlie situation of llie obstruction is not discovered at once,

872

TECHNIC OF ABDOMINAL AND PELVIC OPESAHONS.

two fingers should be introduced into the abdominal cavity and a loop of ikum
close to the cecum hooked up into the wound. If it is found to be collapsed, tbc
bowel should be rapidly examined by pulling out loop after loop, while the
assistant at the same time keeps pushing the intestine back into the abdominal
cavity, until the obstruction is reached. If, however, the ileum is found to be dis-
tended at the ileocecal valve, the obstruction must be situated beyond that point,
and, as a rule, the block will be discovered in the sigmoid flexure or the rectum.
The operative treatment of the obstruction depends up>on the nature of the
lesion and the character of the comphcations. Thus, it may only be necessan'
to separate a few adhesions; to cut a constricting band of inflammatory' lymph;
or to withdraw a knuckle of gut from a false aperture or slit. Again, if die boiret
is torn during the manipulations, it must be sutured, and if gangrene has takei
place at the seat of obstruction, the intestine must be resected. And, finiDr,

Fic. )8i. — iKSTjEiwDm Used ib Opeiatiko tor IimtriNAi. Obst»dctio(i Ifttc 8ii).
® ®

INTESTINAL

INSTRUMENTS

& NEEDLES

D@0

D G

ACTUALSIZE

Fia, ?Sj.— NEEDLESt SUTUic Materials, and iNTEriTiNAi. In^tbuuknk and N'^chles Used in Onun^*'
Fim Intestinal <.>B5TiiticnoN {pane 871),

if the patient is extremely weak and unable to stand the shock of a prolonH
operation, it may be necessar>' to make a lemporar)' artificial anus and rtpiir
the deformity at a later date.

After-treatment. — ^The management of the patient is the same asiflfr
an ordinarv- abdominal section, and she should be carefully watched 10 di«1
any indicatinns whith may arise. The bowels, as a rule, arc moved spontaneoujl)'
wiihin a few hours, and il is therefore unnecessary to administer dmgs, as iw
means which were employed to brinf; about an evacuation prior to ihr opera-
tion now have an opportunity 10 act.

The patient should he given liquid food by the mouth after the bon'ek u*
opened, iind slrythnin should be admini.stered hypodermicallv so Inn^ a? ''"
necessity for stimulation exists. If resection or extensive suturing of the il"!"'
has been done at the lime of the operation, nutrient enemata should be admn-

FOST-OPERATnX COUPUCATIOKS.

873

btcrad for the first three or (our days, and only a vm* small quantity of highly
concentrated liquid food sJiould be pvrn by ihc stomach in case of necessity.
If cither »f these iirocedures are perfonnetl im the lower end of the ulimentar)'

I canal, fcttnl cncmatit arc contiuJndicited, iind the patient should be nourished
etclu>ively by the mouth.
I SUPPRESSION OF URINE.

Cfl11Se8.^Sup(iresMon of urine after an ojicnilicn may be due lo acute
Dt chronic ncpliritis and occlusion of one or both ureters vrilh a. ligature or a
cbrnji. The latter cause ia fully considered under Injuries of the t'rclcrs, and
will not be referred lo here.

Suppression of urine due to nephritis is less commonly met ai the present
lime than formerly, owin;; lo the careful preparatory treatment of the patient;
the TBpi<lily of w|)enition.<; the u« of a minimum amnunt "f ether; and ihc
routine pmctkc of injectinR normal salt solution into the rectum before the pa-
tient is removed from ilic operating Uthlc.

Symptoms. ^' lb e c'lmrilicalioii is cSi.inicteriwnl by gniilu.nl Himinution
in the (juantity of uiinc and the .ippcarancc eventually of uremic symptoms.

It muM l>e borne in mind ih^l llic urine i--^ K<vi>ll>' diminisbeil in amount
during the first day or two after opcr.ition, and that it may be reduced to 15 or
even 10 ounces in twenty-four hours without causing anrieij-, provided symptoms
of uremia do nut develop, After the finU forty-eight hours the ({uantity slowly
increases, and if all goes well the kidneys become normally active again about
lie twelfth day.

Treatment.— If the amount o( urine continue* lo diminish after the second
djiy, }, of a grain of spancin is given hypi «icrmitally ever}' four hour* and the
bowels are ciacualed with a purgjiive dose ui ritnitc of magnesia. The pittient
is encouraged to drink freely of water, preferably distilled, and a high injec-
tiun of Dumul ia\i solution is given by the return every five hour.v. Should
the treatment not ]>rove successful within tnenly-four hours and the urine con-
tinue to decrease in amount, an intravenous injection of normal salt solution
is given and repeat)^ in six hourtt in llie vein of the other foretirm. In the mean-
time the hypodermics of spartcin and the free use of water are continued, and
^ of a grain of cocain in solution administered every hour by the mouth. Six
hours after (he second intravenous injection hj-podermoc lysis is practised under
the left breasi, and repeated, if necessary, under the opposite breast in the course
of eight hours.

As a rule, ihc above trcalment increases the renal activity and lessens ihe
loxic elTects of the urine. Sometimes, however, the .lymjuoms l)en)mc more
marked and manifestations of uremia gradually develop. I'nder these cir-
rumstanics a hypodermic of ) of a grain of pilocarj)!!! is administereil c\'er>'
two or three hours; intravenous injeciions arc again reMirtdl to; and one ounce
of sulphate of magnesium given by ihc mouth. If the bean becomes rapid
and wenk, nitroglycL-rin uiid digitalin arc ar I ministered hypiKlermically. Should
ranvulsions occur and not yield li; diaphoreM» and catharsis, venesection should
be resorted to and a pint or more of blood withdrawn from the circulation.

EHPHYSEBflA OF THE ABDOMINAL WALL

This condition may be Ciiuwd by nir being fi)rced from Ihc abdominal cavity
inl') the subcutaneous tissues surrounding the wound, or it may be tlic rcsuh
of infection from the baciliut aerognts captulalia, or gu bacillus. If (he em-

874 TECHNIC OF ABDOMINAL AND PELVIC OPEKATIONS.

physema is due to the gas bacillus, the prognosis is very grave; but if it is tbe
result of air being forced into the tissues, the swelling disappeais in from two
to four weeks without causing any serious complications.

The emphysematous area, as a rule, is limited to the tissues id the immediate
neighborhood of the wound, although in some cases it may extend well ova the
abdomen or even involve the chest as well.

I have had three cases of emphysema of the abdominal wall occurring in
my practice. Two of the cases occurred after abdominal sections for pelric
lesions, and the complication was not suspected in either instance until tht
sutures were removed, when a small emphysematous swelling was found a-
lending on both sides of the incision for a distance of about 2 inches. Tbt
wounds were not infiamed and union was complete; both patients recovoal
in about three weeks without any local treatment. The third case occumd
in a woman who was sent to my clinic suffering from a lai^ abscess of tbe left
ovary. An emphysematous swelling was found, when the patient was admitud
to the hospital, which involved the lower half of the left side of the abdominal
wall and was unattended by any signs of inflammation. The diseased ovair
was subsequently removed, and when the sutures in the abdominal wound wm
removed on the eighth day, the emphysema had entirely disappeared.

Treatment. — Emphysema caused by the forcible entrance of air into tbe
tissues and unaccompanied by any evidence of infection in the wound nquires
no local treatment whatever, as the swelling usually disappears spontannwlr
by the time the patient is ready to leave the hospital. If, howe\-er, there is evi-
dence of infection in the wound, an incision is made into the emph^'semalous
swelling at once, and smear slide preparations obtained or cultures taken. Sbwild
the gas bacillus prove to be present, multiple incisions are made into thedisasol
area and the wounds irrigated with a solution of corrosive sublimate (i to 1000)
and packed with iodoform gauze,

THKOHBOSIS OF THE FEMORAL VEIN.

Synonym.— Phlegmasia alba dolens.

Cause. — The eiiology of the complication is not thoroughly understood,
although in all probabihty it is due to a mild infection in the neighborhood «
the vein which causes a phlebitis and the subsequent formation of a dot.

Symptoms.— The attack usually begins between the fourteenth and
twenty-first da.y after operation; it may, however, occur earlier or be ddiyd
longer. Up to the time of the appearance of the affection convalescence ij
perfectly normal, and there are no premonitorj' symptoms whatever to indicaK
anything bcinp wrong in the condition of the patient.

Pain and swelling are the most characteristic symptoms of the aftertici'
and arc usually accompanied by a slight fe\er and an increased pulse-nit-
Tlie pain, as a rule, is first fell in the hip, and then rapidly extends doirn tli'
thigh into the leg. In a short time afterward the thigh and leg begin to 5«nl'
and often within a few hour.s the entire limb is involved. The tissues becon"
edematous and the skin while and tense. The vein is swollen and may bene*'
nized upon palpation as a solid, irregular, cord-hke structure. After the kcow
day no s|>nntaneous pain is felt, as a rule, and the patient complains only «
slight discomfort in the affected limb.

In the majority of cases only one leg is affected, usually the lejl, but ocoaon-
ally the opjxisite one may subsequently become involved.

The symptoms gradually subside as the circulation is re-established, an<i ^
the course of two or three weeks or longer the swelling entirely disappeais. T'K

bnwe%'eT, may not recover tts full })ower at once, and it may tie weeiu or
even months before the bmencss is entirely cured.

^m Prog^nosis.— The affection U never fatal unless a portion of the dot

^Bcomes detacKeil and is swq>t into the circuliition, cauMng an cmboliim at

^fe pulmon3r>- aiten'.

^r Treatment.— The patient Is kept at ab^lute rest in bed and the affected
omb Miiiporteil iin n wU pillow. The \eg nnd thif;h are tlien WTn|)ped in i
thick l.-Lvcr of cotton b»tting and slight pressure made with n HanncI roller ban-
dage. Li(|ui<l and soft diets ^JiouUi be cmpluytd, all alcoholic stimulants with-
dntMn. anil the bowels opene<l every tUiy with .1 mild laxative or a simple enema.
After the swelling has entirely disappeared the patient is allowed to get out
of bed, but .the muM not be permitted to walk until a week bier, and in the
meantime she should rest on a lounge or sil in an easy chair vrith the limb sup-

fried on a lc\'cl with the hips. When the patient is ready to walk, the cotton
tting h removed and the limb wrapped in a ilannci baiKtage, which .-ihoiild
worn continuously for so'cral weeks, after which time an cbsllc stocking
should be substituted.

When ihe p:iin i.« very severe at the beginning of the attack, lead-water and
laudanum should be applied to the leg and the parts c>>vcred mih oil silk. This
dressing "Jiould be con.<tianlty applied for a day or two and the leg then wrapjied

t:»llon bntting as directed above.
STITCH-HOLE ABSCESS.
Causes. — A stitch-hole abscess may be caused by drawing the sutures
tijthi and .Mran^btinK the tissues. In some cases it may be directly due
tn infected suture; or. again, the germs may be carried from the skin to the
underlylag tissues when the sutures are introduced to c I ise the abdominal wound.
Finally, the suture tncls may become infected by dragging seplic material through
them when the sutures are removed (see p. S48).

Symptoms. — The symptoms usually appear toward the end of the first
week. The local reaction and general disturbance caused by a stitch-hole
abscess are so slight that its presence is often not even suspected until Ihe sutures
removed on the eighth clay after the ojierntion, when a small <)u.'kntity of pus
[found on the dressings and a drop of punitent matter is seen oozing from
■ or more of the openings of the suture tracts.

The p.ilient seldom complains of p.iiii or diiicomfnrt in the incision and the
liuro and Ihe pulse are but slightly nffcclcd, The fe>*cr rarely goes higher
_ ' F-, and the pulsc-raic ia only imrcasL-d a few beats to llic minute.
"DltignoeiS. — The slightcrvt elevation of the lemi»eraturc occurring after
the " fV't-opemlh'e ri.^f" has subsided should be investigated at once and the
, dressings removed .so that Ihe wound can be examiiicfJ. If a .stiidi-hole ab-
cccs^ is present, a drop of pus is seen wising at the point of entrance or exit o(
one of the suture^ and palpation reveals a small area of induration.
^_ Prognosis. — .\ Milchhole abc^cess is a very trivial compticnii'vn provided
^b infection is limited to the sinus occupietl by the suture, but when the sup-
^Mrativc process extends and involves the tissues on one or both sides of the
uycEiion, ft usually resulLs in the formation of a large |*ocket of ])us which dea-
H^s more or le>.s ihc union between the edges of the wound,
^fi An uncomplicated stitch-hole abscess is ea»ly cured by approprUte Ircat-
wient in four <ir five dayt or a week.
_Treatment. — So soon as the complication is discovered the infected sutures
be removed and Ihc sinus tracts syringed once a day with liydrogen

876 TECHNIC OF ABDOUINAL AND PELVIC OPERATIONS,

peroxid, followed by liquefied carbolated oxid of zinc ointment (3 per cxoL). A
thick compress of gauze which has been saturated with a solution of corrosive sub-
limate (1 to 1000) is then laid over the wound and the usual dressings applied.

SUPPURATION IN THE ABDOHINAL TOUHD.

Causes. — Suppuration in the abdominal wound may be due to a stitdi-
hole abscess, to infection of the tissues at the time of operation, and to careless
hemostasis. Patients who are exhausted by disease and who are anemic are
liable to suppuration on account of the loss of resistance in the tissues to infec-
tion. Sometimes an abscess may occur if the edges of the wouad are uneven
and ragged pieces of tissue are included within the line of union. - Under ^ese
circumstances small areas of necrosis develop which subsequently become in-
fected and form abscesses.

Dead spaces left between the lips of the wound in closing the indsion are 1
common cause of post-operative suppuration, as blood or serum collects in the
pouches and becomes Infected. Suturing the wound in layers Is therefore liable
to be fallowed by this accident unless the greatest care Is taken not to lean 1
pocket in which blood can accumulate. Again, the dead space which Is alwjjs
left immediately beneath the skin when the subcuticular suture is used is a
strong reason against employing such a method in closing the abdomina] in-
cision. Occasionally the edges of the wound are bruised during the open-
tion by rough manipulations or the pressure of instruments, such as heoxistaB
or retractors, and the vitality of the tissues so impaired that an abscess may
subsequently develop. Finally, suppuration is always liable to occur in iromei
with fat belly walls, as the fatty tissues have a low vitality and poor resisting
power.

Sittiation. — In the vast majority of cases the abscess forms in the sub-
cutaneous layer of fat and points upward toward the surface without inTOhiaj
the muscular or aponeurotic structures. In comparatively rare instances, on
the olhcr hand, the suppurative process begins in the muscular layer, and al-
though the abscess usually points toward the skin, it may, however, buiio»
downward and discharge into the peritoneal cavity.

Symptoms. — The symptoms develop, as a rule, during the second vtA
after operation, although they may manifest themselves earlier or be delaitd
longer. Up lo the appearance of the symptoms the patient's condition b per-
fectly normal and her recovery uneventful. At that time, however, tbe imb-
pcralure becomes slightly elevated and the pulse increased in frequency. Theit
is also more or less discomfort experienced in the wound, and as the suppuradw
process becomes intensified acute pain is feh in the line of the indsion. S"
soon as the pus is evacualed, cither .spontaneously or artificiallv, the temperalure
and pulse fall and the local pain ceases.

In rare instances the symptoms may be ushered in by a chill and the ifo*
perature may rise suddenly to io2°-io4° F. Usually, however, the fe^er i* 1^
high, and ranges between 99.5° and 101° F. The pulse is only slightly iiKra-'"
in fre(|ucncy; its volume and force are unaffected; and its character ffft^ ""
indication whatever of any serious complication occurring. The general wn-
dilion of the patient remains good; the appetite is not impaired; there is m
tendency to constipation; and the expression of the face is unchanged.

W'hen the su])[jurativc process begins in the muscular layer, marked sjinp-
tums of septicemia may develop and progressively continue until freedrainap
is established. If the abscess discharges into the peritonea! cavity, septic [<"-
tonitis rapidly intervenes and the patient eventually passes Into collapse.

POSI-OPERATIV'E fOUPU CATIONS.

877

IDC

Diagnosis.— Tlie <]bgi>n6i.4 is based upon the disco\'en' of the foctis of
infcc(ii>n. which will pre^«nl itself ii.« ;i ('ir4'umM:ri)itii am nf induntlion if |>us
ha& nu( formed; if. however, suppuration has ocoimnl, Huctualion will be (dt,
and if lite ntMcetii has dischurKcd its contents purulent mutter will be found on
ihc dressings and oo/.iiig fnim ,iii ujicning in the abdominul wall.

Prognosis.— The jtrognosjs is alway^reN« opens and dLtcharjuet into the ]>eriioncal cuvity. Suppura-
tion may weaken ihe alxluminid woun<l and favor the occurrence of post -opera-
tive venlral hernia on account of interfering with firm union lietwcen the edfces
of the incisi<m, .AtH^es^es invulviiin the jtuliculanenus f.-ilty tissues hnve no
elTett u|K>n the Jntcjiriiy of the wound, whereas those situated in the muscular
layer are freiiuenlly followed by hernia. .\|{i>in, the renuiti of an aliM-css upon
the strength of the incision depend upon its size nnd the extent to which the

ues have been undermined by burrowing.

The flliK'ess cavity e>-eiilually eli^e^ by vranubtion and cicatrization, and

length of time required in he.-iling varies from a few days to several trecks,
acronlin); to the size of the orif^iul [Kx'ket of pus and Ihc &iaic of Ihe patient's
system.

An abfccss occurrinK in a wound that is closed in layers with non-absorbable
sutun- material has more serious ion.'.c<|uenccs than one associated with a ihniugh-
and-through suture, as it is always nccessjiry in the former case to remove the
turcs l)ciurc healing can lake place.

Treatment. — if the [ocuk of infection it di-MOvercil Irefore fluctuation is
pre«cnl, and it is impossible to determine where the abscess will point, the in-
durated area mui't lie carefully watched, and opened at the earliest possible
moment. There is seldom any neiewiiy for making local ap]>lication5 to Ihc
wound, but if the pain becomes severe a hot -water bag may be placed over the
dressinpi with derideil lienefit and comfort to the p.ilient. Under no cimim-
stances, however, should a poultice be applied to the incision, as it is liable lu
favor Ihe exce»uve formation of ])us and cause the elites of the wound to sepa-
rate or break down.

So soon as pus manifests itself the abscess should be freely opened to prevent
burrowinx and to limit the area of destruction. A pn>be is then introduced
through the opening and the limits nf the abscess ca\-ity determined (Kig, 784),
U the line of incision is found to be undermined above or below the opening
the skin edge* of the wound should be separated with the finger or the handle
of a scalpel, so as to convert the cavity into an open wound and expose all
the blind jiouches or culdesacs (Fig. 785). To acxomplish thi.s. it may be
neces*arj' in some cji*e,s to sejiarate the skin union of the incision along its
entire length, otherwise the wound cannot be dressml properly aiHl healing will be
grently ddayed. A fteneral anesthetic is retjuireil only in very excei>li<>nal ca^es.

After the su])purating cavity has lieen completely c.T(Mised ine wound is
irrigated with hydrogen perosid. followed by a solution of corrosive sublimate
(r to tooo). and packed with c.irlK)liiteti oxid of r.iiK ointment (j per cent.);
the usual dressings are then applied. The wound should be dressed once or
twice a iby until it contrails and cventuuUy doses. When the tcmnubiiion
tissue reaches the level of the skin, it often Iwcomcs excessive (proud jitsh) and
requires an occasional application of the soUd stick of nitrate of silver.

So soon as ihc suppurative proce^ reascs. which is usually w-ithin two or
three days after dr.iimige has been eslablishcil. and granulation tissue begins
Iri form, the edges of the wound should he partially approximated after each
<lres»ing with narrow strips of zinc oxid jilaster. ;\ aimpress of gauite and
absofbcnt cotton is then applied over all and secured in the usual manner.

878

TECHNIC OF ABDOMINAL AND PELVIC OPEBATIONS.

If non-absorbable buried sutures were used to dose the original indsion
in the abdominal wall, they must be removed so soon as the abscess cavi^ is
opened and the wound then dressed as described above.

Getting Out of Bed.— If the abscess is limited to the subcutaneous fittr
tissue, the strength of the indsion is not weakened, and hence the padad is

Fic. )84, Fic. j8s.

TltEATUENT or SuFPUBAnON IN THE AbDOWNAL WoDMD (paftC S??)-

Figs 784, delcTmining tht limils of ihc flbscraa caviiy by probiajz: Fig. 7H5, conv^rtiDg the aiitj inM *b ops

wuund by bcitatatiot ibe skair

allowed to get out of bed, as usual, on the twenty-first day. An abscess, how-
ever, occurring in the muscular layer impairs the union to a greater or iessff
extent, and it is necessar)', therefore, for the patient to remain in bed until the
wound is nearly healed and the granulation tissue reaches the level of the skin.

SINUS TRACTS IN THE ABDOISHNAL WALL.

CatiSes. — Sinus tracts in the abdominal wall following intraperitoiw'
operations arc more or less frequently met. and usually occur in cases in vW
drainage is employed. Under these circumstances, if the seal of operalion i'
septic the sutures and ligatures remaining within the pelvis or the abdoiw *
come contaminated and cause a permanent sinus to form after the drainapi'
removed. In some cases, however, the drainage tract ilself becomes inftrtW
as the result of rnrelcssness in cleaning the tuhc, and the sutures within the pn'T-"
bcci'me septic. In other cases, again, the infection may be due ti' deby "^
removing the fjauze packing, which is likely to cause suppuration if left lixit*?
within the peritoneal cavity and thus infect the suture material.

.\ permanent sitius tract Is esjieciallv liable to develop in cases in which Ue
abd'iminal wall is sutured in layers with a non- absorbable material, as ii nuy
eventually irritate the tissues and cause suppuration. In rare instances tie

POST-OrKRATlVE C01II>UCAT10N&.

8J9

silk sutures which are enipU>yed in ihr opemlton of ventral suspension of tht
uterus may cvcntualiy act as an irriiant far«itni body and cause a sinus. A
|>mnantrni sinus tract is a rare [xi^t-upcrative cumjrli cation when al>M>rliablc
suture material h v-vti. and it is a<lvi»blc. therefore, to employ calgut in rases
in which the seal of operation is septic or drainage is indicated.

Prognosis. ^A itinus trad ccunmonicaling with the

r civic or abdominal cavity will not close until the
ofected suture is cither spontaneously discharged
or removed by the surgeon. As a rule, the ligature Is spon-
taneously expelled through the opening on the skin surface, but in lare instances
it may ulcerate through into the bowel or the bladder and escape unnixired-
The spontaneous discharge »( the ligature docs not occur, as a rule, for several
months after operation, and in some cases a year or even more may ebpsc be-
fore nature get.>> rid of the foreign materiiil. 0]ierative interference should be
delayed as long ss |>os^ble, a.* there i» always some danger of a post-operative
x-entral hernia or death occurring when the abdomen is reopened to remove the
infeclol -vuture.

A sinus tract caused by the presence nf no n -absorbable sutures in the abdom-
inal wall or following an operation for ventral suspension of the uterus never
heats sponlaneou.-'ly, as the foreign material i^ jiermanenliy fixed in the tUsues
and cannot be dislodged except by artificial means.

lure

Tin- TAC.^SllAfl rOB RjKCrVmU Atl luiTTTED RvTtTII nOH A Sl"irB T*ACT.

Sham ibt iinndi ol itiliininn-tut tiiadK^ lo ■ rouaddl |W« vl nond.

Treatment, — A sinus communicating with the peritoneal cavity should
not be Pjicrai«i upon until repeated cfTorls have been made to extract the liga-
ture with a Mi.-irc ami MilTicieni lime has elapted to render it pn>babte thai the

ign material will not be si>ontancously discharged.

I am indcbtct! to Dr. A. E. Spohn, of Coqius ('hrisli, Texas, for the sugges-
<rf a ver)- Mmple mcihiMl of extracting an infected »iilure which I have em-
ployed (or several years with good results. The inslrument which is used for
the purpose is »mp!e in its con.iiruction and eit-Mly made. It consist.%of a rounded

Slece of wood, n <|Uar1er of an inch in diameter and four inches long, tu which
ve strands of silkworm-gut are attached by their free ends with strong thread
in such a manner a« to form a number of loups uf cijual length (Fig. 7K6).

The l<M>j)s arc then prc^.'icl tngelher hclween the thumb and the index-
finger in order to make the strands lie close to each other and thus facilitate
their inlnHlunion into ihe Ainu^ (Figs. 7S7 and -SS).

Before attaching the siranrls of silkworm «ul to the piece of wood the sinus
should bccApIorcd with a flexible probe to determine its length, so as lo know how
long III make the loops. If the>' are tiKi sh'irt and do mil reach l» the l>ollom of
ilie sinus, tlie hgature will not be ensnared ; if, un the other hand, they are loo long,
the instrument is difficult lo nuinipulaie, as there should not be more than one
inch of free Mlkwurm-gut between the ojiening of the sinus and Ihe end of the
wooden handle after the snare is iRscned. Again, the preliminary use of a

88o

TECHNIC OF ABDOMIKAL AND PEL\1C OPEKATIONS.

flexible probe indicates the direction o[ the sinus, which is a valuable guide and
materially aids in the introduction of the loops.

The instrument is used as follows: The loops are held betneen the thumb
and the index-finger and gradually pushed into the sinus until its bottom is
reached (Fig. 789). The handle is then steadily rolled between the thumb and
the finger. The rotarj' movement is communicated to the loops of siUnnHm-
gut, and the strands becoming twisted entangle the infected ligature. The

Fic. j8j. — Sn*be ros Heuovihc am iKrcrmo Simi»E fbom a SiKUi T»act ([■(( Ih).
Shorn the knpa tKiag pressed logcthcT-

Fic. 188.— Skari to« Rehovino an luracreD Stm'«E nou A SiNC9 T»act (puc Ini).
Shows the shape of the siure aflcr thr loops have btto pvennJ toflellwF.

handle is now held firmly so as to prevent untwisting and the loops slowly vilh-
drawn from the sinus along with the ensnared ligature. If, however, the manip-
ulation has been unsuccessful, the loops are again introduced into the sinus and
the process repeated.

The sensation conveyed to the fingers when the infected ligature is ensnared
is characteristic and easily recognized after a little practice. W^en the loops
have been twisted, a slight pull will lie sufficient to inform the surgeon whwhtr
the ligature has been caught or not. If it has become entangled, a decided xax

Fig- 780-— Snahe rnn Rehovenc an Intecteu Si'TritE fvoh a Sirtvs Tr*cf-
Shows thti mclhod of holding the snore while ii ii being puHd lalo the siniu-

of resistance is felt upon attempting to withdraw the snare. If this resisiaiw
is not felt, the loops are allowed to untwist themselves, and again twiiied. by
rotating the handle of the instrument, after being pushed to the bottom of tif
sinus.

The .';ilkworm-gut being fle^ibIe and at the same time somewhat iliff. i' *''''
follow even a tortuous sinus with the greatest ease provided care and skill if*
used in manipulating the snare.

If the surgeon does not succeed in extracting the suture, an eicpectani pla"

itmcnl should be carricvl nut until the RCce}«ty (or opnalive interference
becime^ apparent, and in ihc meantime an occasional effort should be made lo
snare the foreiKit materia). It nut infre[|uently happen^ tlmi the itranutation
tissue at the opening of lh« sinus grows together and iib^tructs the drain-
age. When iliti lakes place, the proud flesh shuiild be cut away with scissors
fmrn time tn time and Inuched wit)i the ruiliil Mick of nitnite of silver in order
til i"ivc free vent to the dis<harj;e.

Operative Interferesce.— The infcclnl ligature can be readied by either

»txlr>ipfrilotU'il or an inlntperilonful aper^tlioH.
Extraperitoneal Operaiion.--A flexible probe is passed to
tlic bottom of the sinu.t and an incision made throiiifli the cic<ilri\ of the orisinat
abdominal wound above and be-low the lisluloiis opening down to the perito-
neum. The lower jwrt of the sinus which is located by the probe is now dilated
with the blades of o. pair of Ktriii^ht drcK.tin{c forc«ps and the ligature ievuA
and extracted with long tissue forceps or a blunt-pointed tenaculum.

Intraperitoneal Ofieratlon . — ThU operation should not be
performed until an effort has l>cen m.ide to extract the foreign mnlerial by the
extrajwritoneul metliod desiiibcd alio^e. If this fails, the inci^on above the
«nus is exteiidc"! into the iieritoneal c;ivity without removing the flexible probe,
which is kept in jxisilion to jitcatc the situation and extent of the fistulou)^ trait.
Alter opening the ulxlominjl cavity one or two fingers are introduced through
the wound and the end o( the probe locatctl by touch. The adherent coils of
intestine arc then carefully separated along the probe down to the bottom of the
sinus and the infected ligature exposed. It U then scizecl with tissue (orccps
and rcmovciJ. The abdominal wound is then sutured and the dressings applied
in liie usual manner. The i)Uestion of drainage dqiends upon the indications,
nlltioiigh, aisa rule, it is.-uifer to employ a gUi.-u IuIh; i^umiundeil by a >tripof gause
(or the tirst forty eight hours in order to isolate the sinus tract and protect th«
periti'iii-al iiniiv.

Infected Sutures in the Abdominal Wall.— A.S slated ekewhere, n
sinus resulting from the |ircsence of non-absorbable sutures in the abdominal
wall i> never .■i[HUiLineou5ly cured, and hence it should be relieved at once by
OjK'rative means,

The operation is ver)' simple and does not involve opening ilie abdominal
cavity. A short tWxilde pnibe i.i pu.vsed to the liottom of the sinus and an in-
cision is then made through ihc cicatrix of the abdominal wound alwvc and be-
low the Hsiulous opening. This incision is cautiously extended downward unlit
the bottom <if the !unu.> is reached and the infe<teil ligature exjMwed to view. After
removing the suture the wound is drcs,*eil in the manner described under the
tiratment of Suppuration in the Abdominal Wound.

0 VETn'RAL HERNIA.

Causes.— There are sex'eral cauitea of (mmi -operative ventral hernia, am!
alt result in a Mfunition of the edges of the f.iscia in front of the recti musclet.
The strength of the abdominal wall in this situation depends upon the integrity
of the aponeurotic layer, and if its margin.'i are not brought in accurate contact
when the wouml ii. wuiured, a hernia is likely to result. The use of drainage is
wkn a cause of the complication. The edges of the aponeurosis where tlie lube
[Mhe gau;cc passes ihn>uKh the belly wall cannot he approxtmatetl. and hence
TSe slightest exciting cause may result in the protrusion of the intestine at thai
■int. .\bsccsses in the abdominal incision interfere with the union of the
ami predispose to the development of a hernia, .\gain, in certain condi-
S6

88l TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

tiuns of malnutrition union is either delayed or so interfered with that hernia re-
sults. Separation of the fascia may also be due to getting up loo soon after
operation, heavy work or lifting of any kind, straining at stool or vomilii^
and carelessness in the use of the abdominal bandage.

Severe attacks of vomiting occurring after the stitches are removed are Kkdy
to cause a rupture, and for this reason the patient should not take a sea vojage
for at least one year after operation. Heavy work and lifting must be avwded,
but if this is impossible owing to the circumstances of the patient, care must be
taken to keep the abdominal bandage tirmly applied.

Symptoms. — The subjective syntptonis caused by a ventral hernia are dm
constant and vary in different individuals. Pain may be felt at the site of nip^
ture and there may be frequent attacks of colic, due to slight kinking of the in-
testine from adhesions in the neighborhood of the hernial opening. The bowds
are apt to be more or less constipated and the digestion is frequently distuitwi.
Again, adhesions in the lower abdomen may cause vesical disturbances, and.
finally, nen'ous symptoms may gradually manifest themselves.

The objectht symptoms are the same as in other forms of hernia.

Prognosis. — There is but little danger, as a rule, to be apprehended ffon
a ventral hernia, yet cases have been met in which spontaneous rupture of tbt
sac has taken place and strangulation has occurred. In some instances the pro-
trusion of the intestines forms such an enormous tumor that the patient is ue-
able to attend to her duties and she becomes a hopeless invalid.

A post-operative ventral hernia is never cured except by a radical operalioq
which is usually successful if the separation of the abdominal wall is not toou-
tensive and the surrounding structures have not become atrophied. A propob
applied abdominal bandage and truss will effectually support the hernial pto-
Irusion and make the patient comparatively comfortable. The tendeiuy of
a hernia is to gradually grow larger, and although the use of a support nilloftoi
]>re\ent this occurring, yet the only rational plan of treatment is to perforai the
radical operation.

Treatment.— The treatment may be pallialive. or the use of a support,
and radical, or the closure of the hcrnint ojiening by an operation.

The.-,c plan,'; of treatment have no gynecologic significance, and the readw
is therefore referred to special works on hernia for the technic details.

FECAL FISTULAS.

Causes.— .A fecal fistula following an abdominal or pelvic operaliOD miy
be due to the following causes;

Injury to the coats of the intestine in separating adhesions.
Necrosis of the intestine from contact with an inflammati>ry mass.
Leakage after suturing an injurj- of the inie.stine or making an

. an;istomi)sis.
Pressure necrosis from a ghss drainage-tube.
Prognosis.- --.\ fecal fistula seldom causes dangerous symptoms, and-i'
a rule, heils sjJont:[ne(>usly in from a few days to one year. In e.'sceptional ca**
an aljsccss miiy form in the ni ighborhood of the fistulous tract or an obstnirtu'"
may gradually develop and threaten the patient's life. If a fistula doesix'lhral
within twi-lve months after it appears, the chances are that spontaneous ctoiJi*
will never like place, and hence operative interference is indicated.

Treatment. —So soim as a fecal fistula makes its appearance, uhiifi is
usually abnut Ihrce da>s after an operation, the margins of the fistulous ot*iiinp
and the surroiiniiing skin should be kept clean with soap and warm wawtand

GENEKAI. OPEXATIVK TECBHIC.

protected from irritation with r.irI»olat«I oxtd (if tine dntmerH (3 per cent.).
The drcuinKH should he changed sevorjil limes a day or mi often iu they become
(oiled.

Uurini; the lirst week after the ft.-tulii develops nothing fhould be done to
ii.-uu»I nature in dosinf; it, as the atihi-sions which iMil;ite or *hut nff the ^iml^ tract
from Ihc periluneal cavity are not ^ufficienliy strong to pemiit of local a|>jilita lions
bcinit made. At the end of thai [leriiMJ. fnmc\'er. tlic sinu.s should \k washed
iiul daily with a hot normal salt »>hilion, (olldwed by an injerlion «f hydnigcn
pcroxid. In washinR oul the fistula a fountain syringe wilh a small glass no/zle
should be employed and the ^;ili scilution allowed Hi ilow directly into the bowel;
the hyilriijjen pcroxid should be injected with a sm;ill glas» syringe. Untlcr (his
treatment the sinus, as. a rule. j;niduiilly wniracts, and finally closes in the course
of a few days or weeks. If, however, it refuses to heal, the cause will usually
lie found lo be an inlccled lii^atunc or suture, which must be I(ic4ile«l ;ind removed
by 3 snare (see Simjile Sinus Tracts, p. 87^) before llic fistula can close.

Operative Interference.— The radical ojieratlon!! for (he cure of a fecal
fistula have no miictologtc significance, etnd the reader is therefore referred lu
special works u[K)n the surgery ol the intestines for technic details.

GENERAL OPERATIVE TECHNIC.

MEDIAN ABDOMINAL INCISION.

Position. —The incisinn is made in the mcdi:in line through any part of
the abdominal wall between the center of the niiiphysis pubis and the end of
the sternum. In ihe majority of gynecologic o])eralion.-> tiie abdomen is openeil
between the pubes and the umbilicus, but occasionally it may be necesoary lo
extend the incision upward to the ensiform
cartilage.

Iriimitatlona.— .^n incision below the
umbiliiu.o i.i employcfl lo exiKy»e the inter-
nal organs of geneniiiim, the bladder, and
Ihc pelvic portions of the ureters, and one
extending above to deliver ;i brfte solid
tumor or deal with complications in\'olving
the viscera in the upper half of the abdotn-
inal cavity.

I/Cngth.— The abdomen should never
be ojiciicil by an incision of more than 1}
inches in length, which is Icmg enough to
enable the operator lo introduce one or two
fingers and explore the peritoneal cavity.
The length of the incision can then be easily
increased if necessary and smple room oIn
lainerl. The incision shuuld a!way> lie ax
small as is consistent with the operative indi-
cations, as an unnecessarily long Mound
add.i lo the danger of |«osl-o|ierative hernia,

favors the escape of ihe ininiiines. and exposes the peritoneum to undue irritation.
On the other hand, if the incision is too small, (he edges of (he wound are likely to
l>e hnii.-ved during the operative manipubtiuaH, the movemenldt of the .surgeon
arc hampered, and ihe field of operation cannot he exposed to view when it
Iwcomcs necessary to combine sight and touch in dealing wilh complications.

nos or iiu Mumaii AjeownAi. In.
•moil.

884

TECHNIC OF ABDOUINAL AND PELVIC OPERATIONS.

Method of Making the lucisloti.— First Step.— Place the indu
finger on one side of the median line and the thumb od the other and nuke ttu
intervening skin tense.

Fig. 701. — Median Abdomihal Incibton — Pint
Step.

Fio. 191.— Minus .AenoKRAL Ikibibc-
S«and Stop,
a, Skia; b, nipcrtidi] fudi; c. ApoAnmcc hA

Second Step. — Map out with the eye the situation and extent of the indaon.
and with one or two sweeps of the scalpel cut through the skin down to the apo-
neurotic fascia in front of the recti muscles.

»r

Fin. to) — MrniAN Abhouinai. l.-icisioN— Third
Step.
ShoTiDK thr apnncum»9 iK'inE divided; a.
Skin. ^. ^prrlicidl fa.4cia; c. ajmueunAic lastit,',
d. ^hres of rcfli munclc^.

tia. JM.— MiDIAM A»I10111>UL Iwi"""

Foiirtli SUp.
Showing Ihr fibcra of ihe rrctvi """^J^
scpirawd; o. Skio; *, suprrSdtl (a™: ',^'!^

r.KN-r.RAI. OPCRATIVe TECHKIC.

8S5

Third Step.— The wnund is then held apsn with ihc thumb and ih« indci-
dn^ct of ihr left humt .inil ih« a)>oneur(Kiii> dividol with the ?ral[)cl. It is
uniiet'C^sarv to follow the lines alb^.

Fourth Step.— The fibers of the rectus muscle are now separated with ihc
handle of ihe ^ailjH-l and the iransvprsnli* fiiMria rx)Mued by relrading the
«ljj«-t of ihf wound with the ihiimb mui ihc index finKer.

Fifth Step, - The fuscin ntong with tht- •.uliptritimcid f.ntty tU-ue i,< then
pit ked ii|< by two hemoslalic forceps and divided with the scalpel down lo the
periioncum.

Sixth Step.— The peritoneum k then lifted up in the snme way and rolled
between the tJtumb and llie indcx-bnger lo ascertain whether or not a knuckle
gui in adherent.

hs- m — MiDikK Abiuiuh^i InoaaM—

Flllb SUk

IfcaiwlM iSf itftn^iiTulii I wit tnd th*

p>piiiiup«J Unj iiwLir Iniut lUitdMl g, Skla^

t, uptifcul Uuu: 1. uuiuuTilUc furU; V. tn-

■H aiiBClc: I. tnumxlii (una, J. irriinKun.

JW. mCl — UinuK AxixwiHtL lucutoai— SUtb
Step.

nrrm thn thumli ^nd in'lri-fiiiBrt d. ^In^ i,

Seventh Step. — A small nick is then made in the penir>neum and the index-
finder intnxluciil through the oiwning. The incision is ihcn enlarged to the
full length of the skin wound with btunt-poinied scissors guided by the fintcen
in the alHltmiinal cavity. So ^mn a* the ]>erituneum is opened air rushes in
■nd slij'htly distends the abdominal wall, and (he visceni recede from the wound
unlc>.s they an- adherent.

Hemorrhage. —The slight amount of capillary no;ting which ordinarily
M> iir> in the wound is of no |>ractin»l impi:>rtani-c. as i1 always ceases sponta-
ni>iiis]y by die time the prritoncmn is opcne*!. When extensive intraperitonCid
adhesions exist, however, the ve^icls in the atnlominal wall .ttc more or less di.
bmi, iitid it is therefore mil uniommon to meet free iKizinn or spurting anerics.
Under these circumstanti-s the lijwilini; mii't be checked before the peritoneum
if) oi»cncl. other»vii« the blood will obscure the field of operation iind gain co-
tiunce into the {wriloneal cavity (sec Oi>eralive Complications, p. 90S).

886

TECHNIC O? ABDOMINAL AND PELVIC OPEBATIONS.

Enlarging the Incision. — When it is necessary to enlarge the
incision, the index and middle fingers of the left hand are introduced into
the abdominal cavity and placed with their palmar surfaces in contact with
the parietal peritoneum. The under blade of a pair of blunt-pointed sdssors
is then inserted between the peritoneum and the fingers and the incision enlaigni
by slowly cutting through all the structures of the abdominal wall.

If it is necessary to extend the wound beyond the umbilicus, the incision should
encircle it to the left in order to escape wounding the EUspensor>' ligament of ibe
liver.

Fia. 79T^ — Median Abuokinal iNnaiON.
Showiog the mclbod of ealar^ns ihp indsioa.

Fig. 7oS- — Median Abdomikiu. Iscism.
ShuwiUE xht method oi making ihr bfiB^flU
fat »-07nfD- -V«e the Irajph ot tht ia(i»"
Ihroujeh the ikia and lu^xrulaorftus lilEfU-W^ '
Skin; i, iulicuunniuslilIT liwur. r, nHm™-
tuda; d. tecua mUKlr; r, prfiioDcuBi.

The Incision In Fat Women.— In cases in which there isavciilhicl:
deposit of subcutaneous fatly tissue in the abdominal wall it is impussiblt i'*
operate with any degree of freedom through a small incision if the wound is ^
equal length from the skin surface to the peritoneum. Under these circuin-
stances ndditional room is gained without increasing the length of the indiioo
through the aponeurosis, and the movements of the operator are facilitatol tiy
making a long opening through the skin and superficial fascia down tn the ap"-
neurotic layer in front of the recti muscles and a short one beyond that point-

EXPLORATION OF THE PERITONEAL CAVITY.

Touch. — So soon as the peritoneal cavity is opened and the length"'"'^
in<i*:ion in the peritoneum extended to the limits of the skin wound, theoperali"
introduces the index and middle fmgers in order to verify the diagnosis, 3*^"^
the nature of any complications that may be present, and determine Mof
the ca.sc is o]ierable or not. If the lesions ;ire limited to the pelvis, the ina*"
is then enlarged to meet the operative indications; but if it is found li> be nt«*-
sary to e\p!"rc the general abdominal cavity, the opening should first f*"^
long cnouiih lo admit the hand for purposes of investigation and then s"''*
quently extended above the umbilicus should the conditions demand it.

RENKIAL OPKRA-nVE TECIINIC.

S87

The eitamination by (ouch b fadlilated by having itie patient's pelvb devated
in ihr TmuicIciilHirn )to4ilion.

Inspection. Be-fore proceeding with the operation or dcdding how to
deal with the e.\i>linf; coinpluatinns it is ncce&san' in Mtmc ('.i:(» to place the
patient in a pfisiiionof miirkcrl pelvic elevation (45 degrees) and retract the edges
o{ (he wound in nrder ihnt the jwlm may be thomuKhly cxjio.xed to view and the
nature oi the lusi<)ii> carefully in.ipeited. The incision should nut \>e cnhrKed
Jn order In make this i-v;imin:i(i<in unless the o|>cralor find:- that it is loo small
' ad that additional room is required.

Fio. MO— EKnotuTioii or tnt I'mtoHiAL C*iTn si InracnnH.
Ebon At latirrLr in ibc TrrDdrlm^uri (uurion m-i ibr r-ljt^ nl the tbdornliul UKiuoa helil tgatt bf Aibinn't

Retractors.— The cd^ of the wound may l>e held apart hy ordinary
bilomiii.il retractors (FiK- 801); by Ashton's sclf-reiaininit bivalve leimctore;
nd by using the indcjt and middle finjters of iKHh hands (Fijr- 802).
Ashinn's retnutors have the advantage i>f lieing sclirei;iininR. and therefore
> ii)wi(i.-i ill's hands do not obscure or interfere with the field of vision. Further-
nrc, they can be adjusted so as to make a minimum amount of pressure upon
^e cdge« »f the wound, which i.« imixirliint l>ec:iuse the iirrlinury retractors are
J)t to bniise the tissues and destroy their vitality. The instrument is made
with cither fixed or adjualahle blades: in the latter cue the blades are of three

888

TECHNIC OF ABDOMIVAL AND PELVIC OPERATIONS.

sizes and move upon a pivot which permits a more even contact with the uai-
gins of the incision.

Trendelenburg Position.— Apparatus.— In my service at the Medico-
Chirui^cal Hospital I employ Botdt's operating table { Fig. 3}, which has a cod-
veniently arranged and simply constructed Trendelenburg attachment, and
in private practice I use Lentz's modified McKelway frame (Fig. 908), which
also answers everj- indication.

Advantages. — 1. When the pelvis is raised, the intestines fall toward liic
diaphragm and the pelvic cavity is exposed to view. This is accomplished !»■

Fra, Soo. — Ashtoh's Selt-kitaihiho Abdouihal Retiactois.

gravity, and hence the intestines are not bruised or irritated, as would Ix ^
case if they were constantly handled to keep them away from the field of i^'
lion.

2. The enucleation of extensively adherent lesions and the removal of if*
uterus or other organs may be more satisfactorily and rapidly performed, as tbt
various step'i of the operative lechnic are carried out under direct inspectwn.

3. The source of a hemorrhage can be quickly located and prompt nnaK
taken to control the bleeding.

Fiu. 801,— As Abdomih*! Rrthactoh Cfogc SSj).

4. The tendency to shock is reduced to a minimum, and operations ot™'
wise hazardous can be performed with comparative safety.

Precautions.— ^There are certain dangers connected with the u.-^of theTrtn-
delcnburg position which must be home in mind and guarded against.

t. The weight of the interlines upon the diaphragm may be ,eo preat »W
the pelvis is raised to an angle of 45 degrees or more that rcspinition i? imp'"'''
and dangerous symptoms are likely to inter\'ene. especially in stout voraeti- l'-
therefore, the patient develops sonorous breathing and becomes cyanosWi ™
pelvis should be lowered at once in order to remove the pressure from tht Dia-
phragm and re-establish normal respirations.

GENERAL OPERATIVE TECHNIC.

889

3. In cases i>f pus colleclions in the pelvis the purulcni miiteriiii wiJl gravitate
into the general peritoneal cavity and cause
septic infection utiles the accidcni is (tuarded
n gainst during the cnuclciilion i>f ih*; sac.
Before attempting its removal ihe field of
0(>er3lion should he isolated iviih litrRC and
small gviiixc |><id!« and the pelvis lovreri-d to an
angle of 10 to 15 degrees. In this way the force
oi fcravit)' is le.-ucnt-d, and if llie sac TUj>Iurcs,
its contents arc caught in the meshes of Ihe
gauze packing.

X. The Trenilelenlnirg ]>osil!on may lempo-
rarily check bleeding from vessels which have
been severed <luring Ihe operation and a serious
or fatal hemorrhage may take place after the
patient is lowered to the horiamtal rcciimhcnl
position. This accident ma>' be prevented by
luisely packing gaiiu; altout the field of (ipen-
tion and lowering The pelvis to an angle of 5
degree* before introducing the through-and-
through sutures into the aMominal incision.
After the sutures are all in place the lips of the
wound are retracted and the gauze removed.
If there has been bleeding from a vessel which
was overlooked, the gauze will be more or less

Siiturated with bI(io<l and the Kiurce of the hemorrhage can be located before
SUturini; the aponeurotic layer with catgut and closing the abdominal incision.

Degree of Elevation. — There arc no adtanl^^ci to be gained by elevating

Sbovi Ihe piIliDI In Ihe 1'Roililto<
burt pvoflJuD Ami l>ic nlin uf IIh kb.

iluRiiiia] inoiicin bcld kjAr by Ihe iatlex

890

TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

the patient higher than the indications require, and she should not be kept at a
marked angle longer than necessan-. I use an elevation of 25 degrees while
the abdominal incision is being made and then raise the body to a higher angit

..' ttf 'r "*

Fid. Ho4r— The I'lENDCLRNBric Positioh.
Tbe hcivy black haniontil line indiotn Ihe Ici-el of the lop of Ihc opcnliiic Iibk and llw liglii liia Rpi«
the eicvaiLcm oi the TrFddelciibuTi frame from s drftna lo go drgfrea.

if necessary. In most cases an elevation of 25 degrees will be sufficient tor ill
practical purposes, but occasionally it may be found necessary to useanin^lt
of 45 degrees or even more.

FlC. flos.— ElFtoajTiriN or THE Pr.BHO-irM. C«MTY BY IsSPtlTHM.
ShlT^ thr patient m the 'rmufeleabur^ poHtian atitl the pelvic caiicy illumiiuied by a ptinable eketnc t«lt

Illumination of the Pelvic Cavity.— The field of operadnn i-
a rule, is sufficiently illuminated by the iifiht that is obtained through iheW'
dou- in the ceiling and the side wall of the operating rrvom without resortini! '''
artificial means. In some cases, however, it mav be necessar\- to use a puruW

r.R\r,iiAi. npr.RATivr. -nxastc. 891

ric bulb with » refl«)or .-111(1 ihmw tli« lighr directly inlo the pelvis. The
ght is held b>- nn a^i^anl and h*. »%*$ directed to ditTcrcni parts of the pdvis
Mrditi^ til the instructions jpven by the operator.

COVERING RAW SURFACES WITH PERITONEUM.

Raw Mjrfacch ahimld mn tic kit expHMal in itie fsehk or iibdcirninal ca\Hty,
MS tiwy may be the i>(iurce cf serious (x xtngt:r Toci of septic infcctiun. Afiain,
a knuckle of gut may become adherent to the denuded area aiid a fatal ubslnic-
tion result from ktnlcinf!'

Whenever possible, the cdees nf tlic surroundin;; peritoneum should be drawn
Wer the niw .lurfune and ap]iroxi mated by a cunlinunu^ Milutc «! Mik or cilfnil.
I rule applies to dcnude<l .ircas on the surface of all the abdominal and pelvic
cera and also to the raw ends of the stump of a pedicle.
The terhnic of an i>|ieniti(in shniikl. if pus^iblc. provide for a flap of
eriloneum uhich can be used to cover a rau surface that is likely to be made
the lime. Tlius, for example, in performing a .\U|iniN-n^inal hysterectomy
peritoneal llap is stripped fmm the anterirr surface of itic uterus and used
10 cover the cervical stump after the orftan has been amputated.

TOILET OF THE PERITONEUM.

ifore the sutures are introduced into the alidoniinal incision the field of
ilion and the .lurroundinil parts are ciircfuUy inspected and all Huids or
tip! material rcmt.vwJ by (u) dr)- spon);ing-. (ft) local wasbinit; and (f) geo-
~ flushing of the abdominal cavity.

. *.^

\\-

^f^

•^•

^y -

— - Pi« led— Toon er mi PuiToauiTH liiMe>«*t.

Sbxn itt tftutJHS id ik* (uldnx of Dnuflu tiy dirrci iiupKtian of ihr lalnc «Wit.

Fluids and di.'KiharKes gravii.-iie, as a rule, into the mltlnae oj Dougia', llie
•itii(D-uttrint i/xirr, and the kidMV Iwliows, and each of these pouches mu»t
therefore be ins;>ccled.

892

TECH^fIC OF ABDOMINAL AND PELVIC OPERATIONS.

Dry Spon^tlg. — This is the most convenient and efficient method of
cleaning and drj-ing the parts and the one most frequently employed. The
modem technic of isolating the field of operation by means of the Trendelenburg
position and the use of gauze pads conlines the fluids or discharges to restricted
areas and enables the surgeon to quickly remove all traces of contaminaticn
with dry gauze sponges. This method causes little or no irritation to the
peritoneum and does not spread the infection to the general peritoneal carit;-.

The cleaning is accomplished with a small dry gauze sponge which is held
in the grasp of straight dressing forceps and passed through the abdominal m-
cision down to the f>ouches within the pelvis and abdomen. The patient's body
should be elevated to an angle of from 25 to 40 degrees, and if the indsion Uorer
two inches long, its edges should be iiept apart by Ashton's self-retaining retrac-
tors ; otherwise the sponge should be guided by the index and middle fingers d
the left hand in the abdomen. The sponging should be continued until all the
foreign material is removed and the parts made perfectly dry. A loose gaiue
paci(ing is then placed in the culdesac of Douglas and the vesico-uterine spaa

and allowed to remain until the abdominal in-
cision is abinit to be closed (Fig. 806).

I^ocal Washing. — This method is indi-
cated when the field of operation is septic and
the infection does not extend to the general peri-
toneal cavity. The patient is pbced in the
Trendelenburg position (from 25 to 40 degnes)
and the edges of the wound held apart by seU-
retaining retractors. The intestines are itm
covered with tno or three large gauze padswMdi
are carefully placed and their lower (dps
brought to a level with the brim of the pehis. A
gauze sponge held by dressing forceps is llm
dipped in normal salt solurion {110° F.) and iIk
seat of operation gently swabbed while the finpn
of the left hand hold the gauze pads in plaa-
The process is repeated several times until ibe
se])tic material has been removed, when thepara
are wiped dr>' and a temporar)- packing of piw
placed in the culdesac of I>ouglas and iht
vesico-uterine space.
General Flushing. — The routine practice of some operators of fliislinB
the Rencral peritoneal cavity with a normal solution of salt or plain sterile wjIb
after every abdominal section should be condemned as being unscientific sixl 3'
times dangerous tu the life of the patient. General flushing is indicated on!y«b«i
blond, septic discharges, and material from the cavity of a cyst have been scaltemi
through the alKlominal cavity either before or during the operation. I'nif
these circumstances irrigation is the best mean''"
remove the foreign matter, and it should alway-'l"
empliiyed notwithstanding the fact that it i." i"""
po^^iblc to render the peritoneal cavity perfefl'!'
clean. When the discharges are aseptic, this fact is of but little imporu™.^'
;is the ])enIoneum rapidly absorbs what remains; if, however, they are sepii''
death is practically certain to result from peritonitis, as the flushing canno' fl*^
lod);e the infccled material which is firmly adherent to the peritoneal suria«i»
the intcslines. General irrigation should never be employed to remoi"e lowli'™
ci)IIeciionst)f debris or discharges, as it always spreads the infection and ending"'

F1C.S07 — TfirLETornrt PEiriTONTrir.
Showa dry spiinaing nf ihe pcrifO'
neum uilh Ihe furcF^ Kutdi'd by ihv in-
dH ADil middle lingers of iht Icfl hand.

CENCRAL OPERATIV'E TKUINIC.

life »f thr pnticni. In nn ascplic case in which shock is threalenerl a quart
Br mon- of normal sallwlution (tio" F.) may bcptiurcd into th« abdnminjl cav-
'tly and alkiwed la retnnin with advnnlnKC as a ^tinmluni; tiul u|mr( fmm Ihi^
it seme* iwmsrful puqinsc, as |mi>I operative thirM i.vti-'iMlly runlnUlcd by giving
ciilcrwlyais before the [wttient leaves the opcrallnf; table.

I General abdominal irrijtation is fiivcn as follows: The

^^oliilion 15 mixoi in the RmiiiKiK^l re>eninr .il the pr<>|>cr limper.iturc (iio'F.)

^H)' i>'>uring hot and cold norniiil wit solution directly into il from the lla^kft, or,

^Bf sterile w.iler i* ii!«i), fn>m |iit(hei> contiiininK tuit and cidil water. When

PBir thermometer in the reservoir registers i lo" V.. some of the lluid is allowed

to run out into a bucket in order to get rid of the cold solution in the rubber

tubintiand hevil the irriga linn nor.dc. The j)alient islhen pbced lit an angle of

lodcsrcef and the lips of the wound held apart with self-retaining retractors or

with the fingeri of the left hand. The reservoir is now held almul three feet

above tW patient ami the operttor directs the flow of the Mitulkm to all purl*

of the alHlominal cavity by means of the irrigating nozzle which he holds in his

right hand.

After ihc abdomen becomes fdlcd with the fluid it overflows through the In-
cjsion and is drained into a receptacle under the opcralinR table. When tlic
ovity ha* l>cen sutVicicntly llushed, the patient i.^ lowered In the hori/imtal posi-
linn and the fluid forrcl out by compressing the alHlominzil nails wilh the hands.
The pcriioneuni 1= then ihoroughly dried with ^auze sponges and ttie fluid re-
movc<l from t)ie culdcuc of Douglas, the vesico-ulerine space, nnd the kidney
hollows.

H ABDOMINAL AND PELVIC DRAINAGE.

^f Indications.— The indic.itions for dminngc depend largely upon the

' Icchnic skill of the operator and the thoroughness of his antiseptic methods.

r>tirin}( tlie early days when alxlominal anil pelvic .lurxery were in an ei'olii.

tiiinuf)' stage drainage was verj' commonly practised, but later on the pendulum

" professional opinion svrung to the opposite extrcmc. an<i it was very selilom,

at all, employeil by the majority of the t>ej>t operalopk. .\t the [iresent rjay.

Bwever, the tendency among some of the leading surgeons is to lake a middle

irse of action and to employ drainage when in their judfimeni or experience

' nl)i!orl)ent powers of the peritoneum shouM not lie solely relieil u[Hm to carry

off the fluids which may accumulate in the peritoneal cavity.

The operator b naturally not respoii.'ible ftjr the pathologic fiiidinRS within
ibc nlKiomen or the [wivis, and when dniinajie in hi* judgment is mjuired to
meet certain TCell-defined conditions, it is not an admission upon his part of lack
of skill, nor should llie u>e of drainage under these circum.stance--' lie denounced
OS not iH-ing i<!eal surgery, as its object is to save life. and. after all. that is the

Kijly standard by which an operation can be judged. When an opcr-
tor is confronted with conditions which demand the
hotce of evils, he must select the one least harmful
D his patient, and while the immediate or remote
angers of drainage must be admitted 4nd carefully
considered, yei he should employ it whenever indi-
rutcd to save life, even if the so-called ideals of sur-
;cry arc overthrown and ilcstroyed.
The foUitwiiig are the chief indications for drainage:
To guar<l KgsinM Mptic infet^'tion.
To watch for secondar)- hemorrha(^.

894 TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

To Guard Against Septic Infection. — The danger of septic infection fol-
lowing an abdominal or pelvic operalidn is the mosl imjxirtant indication for
drainage, and the frequency with which ii is employed for this purpose depends
upon the judgment and skill of the operator.

In order to understand the question of drainage as a safeguard against in-
fection we must first have a clear conception of the various ways the accident
may occur after an abdominal operation, and also bear in mind that the absoq>-
tive power of the peritoneum, which is normally very active, may become greatly
diminished on account of the exposure or injury to which the peritoneal surfaces
are necessarily exposed during the operative manipulations.

Infection may occur from the following causes: (i) From septic pus or o'st
contents coming in contact with the peritoneum; (2) from sterile discharges
becoming subsequently infected; (3) from the presence of infected tissues which
cannot be entirely removed at the time of operation; (4) from injuries of tht
intestine, the bladder, or the ureters when leakage occurs and the disdiai^
escapes into the peritoneal cavity.

From Septic Pus or Cyst Contents. — In cases in whici
a non-localized suppurative process is present drainage is Indicated, but whm
the purulent collection is contained in a sac which can be removed without rap-
ture, there is little or no danger of infection occurring, and hence drainajt
is unnecessary. In cases of localized collections of pus, such as a tubal a
<>\'arian abscess, drainage is seldom required even when the sac ruptures and
its contents escape over the peritoneum, for the reason that the purulent matlCT
is sterile in aixiut 50 per cent, of the cases. It is important, therefore, in sudi
cases, to have an immediate bacteriologic examination tnade of the pus, and if
it is found to be sterile, the abdomen is closed; otherwise drainage should be
employed. If, however, the surrounding parts are well protected with gaua
pads and the septic pus does not come in contact with the peritoneum when Ihe
sac ru]itures, there is no necessity for drainage, especially if the operator thor-
oughly cleans the scat of operation with a gauze sponge and normal salt soluliofi-

From Discharges Becoming Subsequently Infecied-
— The possibility of sterile discharges becoming subsequently septic and
causing infection is often a .serious question in certiiin cases, and while tht pffi-
toneum does undoubtedly lake up a large quantity of fluid, and thus obiiiiK
the necessilv for drainage in many instances, yet we must not forget thai iisal>-
sorptive ))<)wer ma\' be greatly diminished by injuries or that the amount of fluid
may be so great that it becomes infected before absorption occurs. To guard
against the likelihood of these discharges becoming .septic requires not only jjct-
fctt antiseptic methods, but also thorough hemostasis in order to prevent dw
subsequent accumulation of an excessive amount of blood or serum. Theseil
of operation should, therefore, be made as drv us possible before closing the ab-
domen by ligating all bleeding vessels and controlling the oozing which olie"
takes jilace fn)m more or less extensive areas of denudation as well as hy Oi*-
fully sponging away all fluids that have settled in the pelvic pouchf?-
The amount of blood or serum which may be trusted to the absotp"'''
power of the peritoneum cannot be determined with accuraci-, and the pmbleni
therefore must be settled in each case by the individual experience of the op«aint
and bis knowledge of the probable effects of the traumatic conditions pte«i"-
Large areas of denudation, even when entirely dr>- at the lime of closing theS""
domen, may subsctjucntly be the scat of free capillar)' oozing, and a large amount
of blood and serum be poured out. Again, if the intestines are ex]Hiscd or r"upj'
handkfl. serous oozing is likely (o occur and add to the quantity of fluid dischaij™
int<j tile iifivic tavitv. Furthermore, we must take into consideration iha' ^

GES-EKAL OPeRAnV£ TECHNIC.

89S

■here are brKc denuded areas in lh« pclvi^ the fluids which gravitate into the
cukl<-<vic n{ liouRLi-v are ven- slowly abiiorheTl, und .ire therefun- litdy to 1>eci>tne
infccicil from close contact with the rectum, the w^lls uf which may nr may not
he injured. And, Anally, injuries of the intestinal walls, while they may not
be severe enough to cause iMluige, may, hnwevLT. jierniit nucri^-nrgani.-'m!' to
escape from the bo«-cl and infect the retained fluids. It is, Ihcrefure, evident
thai the itecexiity for drainage is minimized if the surgeon is eareful to repair
all intestinal injuries and to oivci, fii far as jHis^ible, all denucled surface* with
perituneuni. ll is obvious, from what has been s^iid, (hat drainage is indic:iled
in thesie cases when a brRC amount of opillarj- o<wiii(; U likely liiufcurand when
the pchi< is extensively ricnudei] iir the intestinal widls injurH if there is danger
■if the retainetl fluids t>ei.oming infected by the passage of septic orRanisms, The
use of drilna|i;c uniler these conditioI1^ not nnly ;L%>i-its the iicritoncum in carry-
ing i>fl the discharges, hut il also lessens the oozing by keeping the scat of opna-
tion dry and stimulating the capillaries to contract.

F r o m I n f e c t e d T i s s 11 e » W h i c h Cannot be Removed, —
Drainage is always indicated whenever it is impossible to remove all the infected
nietures at the time of opcr.ition. Thus, in cases nf circumscritted jjclvic ab-
csses in which the pus i* encl"se<l by the walls o( the pelvis nnil ihe intestines
it is obviously inipossiblc to get rid of Ihc dismsed structures and leave an aseptic
field. Tlie .vime tondiiiuns are alsii present when the inlc.^^ine is adherent to a
tubal or ovarian abscess and when the purulent a'llectiun is vitu.ited iHtwcen
the folds oi the broad ligament, .'Vn incomplete ojicration is a comparatively
rare KiiirreTKe among the best operators at the present day, and. as a mlc, ulcer-
ated or necrotic conditions i)f the intestinal w.dls cjn be thuniughly removed
by excision, thus doing away witli the necessity for drainage in this class of cases.

From Injuries o ( the H » 1 1 o w Viscera. —Drainage is oc-
casionally required in injuries of the intestine, the bladder, or the ureters as a
preciiutu>nnr\' measure in case of leakage. The modem lechnic in the manage-
n»enl of the»e trauma I isms, however, is fti nearly perfect that the danger of the
escape of the visceral contents is reduced to a minimum, and hence dr^nagc
U sektum imticaleil.

To Wttch for Secondiry Hemorrhage.— This indication for the use of

inaRe is verj' seldom met at the present day, alltiough in former limes, when
ihc operative lerhnic of abdominal and |iel\ic opemlions had not been [ler-
lected and the occurrence of secondary hemorrhages was not uncommon, a glass
lube was often inserted into the pelvic cavity for twenty four or thirty-six hour*

enable the surgeon to remgniire the onset of bleetling.

Different Forms of Drainage.— The abdominal and pelvic cavities
n l>e drained by the foltowiiig means: ( i) Glass tubes; (3) gau/e; (j) rubber
, tulxM.

^B Glass Tu&ss.

^B Indications. — A gLtss tube is prefcnibic In other forms nf drainage when

^Ble oj»iTjtiuri is ])crformcd through the abdomen, js diere is Ic.-w <langcr of in-

fcrtiiin by this route and the tul>e c;in be rarefl fi>r mure convenicnilv than when

it passes from ihc culiicsac of (louglas into Ihc vagina, tn the majority uf ca.ses

I gLtss drainage is empkiyed alone, but in some instiince.'v. owing to persistent oozing

I or to the ncceMity (or walling off the general peritoneal cavity from a fonts of in

fection, il is combined with niirmw strips of gauze, which ane tiacked around Ihc

tul>e and their free ends carried out through the alxlominal incision (Fig. 813).

Objections.— N«tttitbsianding the wbjectionii ih.it have been made In

Ihc use of the glass druinagc-lubc by some openilur^ the fact rcmain.s that It is

~ih-

89^

TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

the best form of drainage we have at our command to meet the indications in
the majority of cases where the operation is performed through the abdomeo.
As wiU be more fuliy explained later on, the capillary action of gauze cannot ac-
complish the same results as tubular drainage, and comparing the disadvantages
of the two methods, it will be found that the latter is the preferable means to
employ. In order, however, that glass tubes or other forms of drainage may
not be unnecessarily employed, and that the operator may have a clear concep-
tion of the dangers which confront him when the abdominal wound is not
completely closed at the time of operation, as well as being able to appreciate
the necessity for the most thorough and painstaking antiseptic care of iht
open wound, it would seem important that I should briefly refer to the dangers
of tubular drainage.

The most important of these objections may be summarized as follows: (a)
The entrance of infection through the tube; (b) the increased chances of post-
operative ventral hernia; (c) the possibility of the formation of a permanoil

Fig, 80S, — Tkthoductton or x Glass Dbatnag^-tttbe iwTO the Pelvtc Cavity.
Shows tit lube bring guided by \bt indei ud middle fiDgcra into ihe tuliiMM oi Uoiuflii.

fistula; (d) the development of a fecal .sinus from pressure of the tube upon tbf
rectum ; (e) the occurrence of intestinal obstruction from adhesions (onwng
around the lube and kinking the bowel.

Introduction of the Tube. — The tube must be long enough to tradi
the most dependent part of the pouch to be drained. In most instances the w
is placed in the culdesac of Douglas and the posterior wall of the uterus rtstsup*"
it. In others, however, the enucleation of a mass may result in the foniuiion
of a deeper pouch on either side of the median line, and the end of the tubenu^
be placed in it to secure complete drainage. AVTien through-and-lhw^F
sutures are used to close the wound, the drainage-tube is not inserted untiHn^
are introduced and ready lo tie. The tube is usually placed in the lower an?"
of the wound between the second and third sutures, but it may be necessan"i
some cases to insert it higher up on account of the position of the pouch 10 1*
drained and the situation of inflammatory exudates. In introducing the tu"
its end should be guided by the index and middle fingers in order that it mJ'''

GEMKJUL OPEHATIVK TECBNIC.

897

pkccd in the proper position nnd ml in the most <lei>cmtent portion of the [)»uch.
Af(i:r the tu1>e h placed in pot^itlon the fiinci.i above nnd below is united with a
continuous cutgut suture before the through -and -through sutures are tied.

^^j*^

Flo, (00— limonL'nii* or a ltH.n D>4Jiuoi'Tiin twro ntir Fnvtc Civrrv.
ShDvilbt CDrloflhvrubr in IhciuMf^ tit DoHictw. Note Ibc oo* Jma ol thr iqlnliod Aiwmd tllf tubt^

I>re8Slng the Wotind.— .\f(er the sutures &n tied the u-ound and the
surroundins ikin ntc t Wnscd in the usual manner and Ihe dminaKC-tube sucked
liiy with a lung niblwr syringe (^ee p. 89S, Vi^. 81 1). A compK^.^ of gaune net

LLi

Pio. <>».— Dkbom *k AaDMBHAL WovxD vwtu Guilt DtAiMWK n EHn»no>

Shorn Iht lubt jnitolBi UuDdih ihc Jraiirni anil Mnnrd miiti miino tiuiiiw. TIk 1u< itilp s( adtnic

fliflir i> baiw inC«4 in ik« <idt of ib* ■bdonm-

with a solution of comyuve niblimate (i to 1000) fe then. placed over the wound
and the usual H-ction dressings 3{>phed (see p. 8}7), which are held in poiUtion
by strips of adhesin; plaster. The tube is again sucked dry am] tu mouth
$7

B98

TECHNIC OF ABDOMINAL AND PELVIC OPEBATIONS.

plugged with cotton batting. A large gauze compress is then placed over the
tube and the dressings and a sterile towel laid over all. In lifting the piatieiit
from the operating table to the stretcher, and again onto the bed, care roust be
exercised not to disturb the position of the tube, otherwise its end may become
dislodged and thorough drainage be prevented. This is guarded against by
keeping the patient's body perfectly straight when she is being lifted and by tlw
nurse placing her fingers over the dressings to steady and support the tube.

Cleaning the Tube.— The dangers of general or local infection should
always be borne in mind when cleaning a drainage-tube, and every precaution
must be taken to prevent such an accident occurring. General peritonitis is
likely to develop if septic organisms gain entrance during the first twenty-four

Fin, Bll, — ClEANINO A DmiNAlie-HlBE.

Sboivs the unrctioru bnn>; 4uck«l qui of the lube wilh a long &yriiL|{e. Not<! the ponlion of tbf hmjidi Aod
arrui^Fmeiil nf thr bcdclolhn arid Ihe arpa arouod rhe dr^amgi.

hours, but after that time there is but little danger of it occurring, and if infec-
tion does take place it is usually limited to the tube tract itself or the ligatures
in its immediate vicinity.

The antiseptic precautions in cleaning the tube consist in (a) the care of the
syringe; (6) the steriUzalion of the hands; (e) the arrangement of the bed-
clothes and the area around the tube; (d) the act of withdrawing the fiuid from
the tube; (e) the application of fresh dressings.

Care of the Syringe. — The syringe is kept immersed in a 5 p>er cent, solution
of formahn contained in a tray which should be covered with a sterile towel.
When it is required for use, it is taken out of the tray and the formahn solution
forced out of the barrel. The syringe is then rinsed in hot sterile water contained

CCNESAL OPEKATIVK TECHNIC.

8»

in an mamvlcd pitcher and its barrel cleaned by suckini; up and rjcctinR ihc
water several limes. The syringe is then ready for use, and after the draiiisRe-
I tube ha» been tleiined it is again tlmniUKhly vra.ihed in 1ii>t >tcrilo water and placed

in the tray after filling; its barrel with the fnrnulin Mlulion.
i Sterilization of the Hands. — The hame care must be cxercLsed in preparing

ihc hands liefore cleanMng the tube as (or an "[itnition, and hence they munt be
bHKchxnically sterilized (see p. S14) ever)* time the drainage is withdriiuri.
^H Arrangemeat of the Bedclothes and the Area Around the Dres^nga. —
^H special nurse or an asasbint should arrange the l>tflcliilhes and the area
^piTTDurding the drcssinRs. The sheet and blanket arc neatly folded over acro*s
ihc thighs juNt Ix'Iiiw the putMrs anil th(^ nightKown i* drawn iiji lui as to rumpletely
expose the dressings, Sterile towels arc then placc^l over the chest and the upper
pari "if the abdomen ami also nver ilie IjcJtIoihcs belovr (Fig, 8ti).

Withdrawing the Fluid from the Tube.—The colttm plug is removed from
Ihc tube and its rim and lumen for a distance of half an inch arc wiped with a
pledget of abaorbenlcottun net with a sohiiion of corrosive sublimate {t to 1000];
care must be taken not to allow any of thechemicnl lodrip into the pcbiecaWty.
The nozzle of the syringe is then passed to the bottom of the lube and the fluid
nith<lr;ivMi. Thi> ^lould l>c rejieated until the tu1>e !.■> jierfectly dry and no
more lluid can be sucked into the barrel of the s>Tinge.

IZjUiM

i'|tt*8i.E

Tt*

'TASli

II*

I Flo. ti>.~liiMii*H xuowiini 1MK UKinoD or CmxKmm ini 1}(iihki ih U>i<inin DiAnn.
Sbum boil KvUiy lUc wrcrao i«a oUdmH ibr ubmioI tad cfaaruui ul ilic ilninanr.

Each time the tube is cleaned the drainage should be collected in a graduated
meciicine gbss and a record kept of Ihe anrnunl nf lluid withdrawn and of the
hour that the tulw was emptied. The glasses are set aside until the surgeon
I makes his visit, when they are cleaned and used again in l!ie same way.
I By Mi ineihod the stirxerm i.i able to >ee al a glance the inrreitw or decrease
in the amount of drainage, nnd al the same lime estimate Ihe changes which
take place in its rharactcr.

In introducing the nox/.lc^ of ihe sj-ringe inlii the tut>e care should f>c taken not
touch the (bnge or the inside "f the lube, otherwise septic genns may be car-
ried down into the pebis. When Ihe no£;:le touches the iKiltum of tlie tulw. it
should Ije withdrawn alK>ul one-eighth of nn inch Iwforc suction is applini in
tirdcr to preii-ent the tissues being drawn into Ihc syringe and injured. Some-
times thick tenacious material or bltHid-cloI^ arc suckett into the noule of the
syringe and Ihe discharge prcxcnlcd from being drawn up. When Ihis occurs,
the syringe should be w ithdrawn an<i Ihe tenacious matter forced out of the noule
by pU-'diing the (lislon down inio the Imrrel,

A syringe with a short no/;tIe to which a piece of rub-
ber lubing is altaihcd should never be employed for the
purpoxe of cleaning a gla^s drainage-tube, as such an
apparatus increases ihe dangers of infection by striking
he rim and sides of the tube when it is introduced.

900 TECHNIC OF ABDOUINAL AND PELVIC OPERATIONS.

Application of Fresh Dressings. — So soon as the tube is perfectly drv its
mouth is plugged with sterile cotton batting and a fresh gauze compress and
towel are placed over the dressings. In cases in which the patient is nenous
or restless and there is danger of the compress and towel being displaced I usually
make them secure with two or three strips of adhesive plaster.

When to Clean the Tube.— The frequency with which the tube
should be cleaned depends upon the nature of the case and the rapidity with
which the fluid accumulates. In cases in which there is considerable oozing
the tube should be emptied every fifteen minutes or half-hour in the beginning,
and as the discharge lessens In quantity the inten'als are gradually length«id
until from three to six hours or even twelve hours intervene between earfi tiw
the fluid is withdrawn. The tube should never be allowed to overflow, and henct
it should be cleaned before it becomes filled with the discharge. In cases of Aw
capillary bleeding if the tube is frequently cleaned and kept dry the hemonlugc
is more quickly arrested than when the blood is allowed to accumulate, and hnwe
under these conditions the tube should be emptied at short intervals.

When to Withdraw the Tube.— The time of the withdrawal of the tube
depends upon the character and quantity of the dischai^e and upon the dangtr
of leakage occurring in cases of injury to the intestine, the ureters, or the bladdw.
In ordinary cases the tube should be removed when the discharge becomes serous
in character and not more than one drachm accumulates in four or five boun.
In cases in which fecal or urinary leakage is feared the tube should not be laten
oul for at least three or four days, even when the discharge becomes serous in
character and slight in amount. In suppurative cases drainage should be con-
tinued for at least one week, or until the quantity of pus is decidedly lessened
and the adhesions around the tube are well organized.

In cases of simple oozing the tube is usually niili-
drawn during the first twenty-four or thirty-six hour*
after the operation.

Method of Withdrawing the Ttibe.— The tube is first cleaned awl
emptied in the manner described above and its rim then grasped Ixtween iht
thumb and the index-linger. \ rotatory motion is now given to the tube while
gentle traction is e.xerted and it is gradually withdrawn through the abdorainal
opening.

Care of the Sinus Tract.— The dressings are removed after tjtin:
out the tube and the abdominal wound cleaned with hydrogen pero.\ide, (oDoned
by a solution of corrosive sublimate (i to looo). Fresh dressings are then ap-
plied, and subsequently renewed every day until the sinus closes, which bpn-
erajlv within one or two weeks in simple non-infecled cases. When. hoflWr,
the drainajTc is purulent in character the sinus tract should be irrigated wic
daily with hydrogen pcroxid and the dressings renewed as often as necessar*.
Su|)puraiive conditions of the .sinus tract are apt to become chronic and result
in the formation of a permanent fistula (see p. 878).

The sinus tract .should always be allowed to contract spontaneouily aw
under no circumstances should rubber tubing be inserted after the glass tube b
withdrawn. Tliir^ i.* done by s<ime operators under the mistaken idea ihailM
sinus tract cannot take care of itself and that the subsequent drainage viU *"
esciipe. The arihesiims which form around the glass tube before it is mtlidra«
are sullicientlv strong to safeguard the peritoneal cavity without the aid of rub-
ber tubing, and its use is therefore not only unnecessary, but likely 10 cause in-
fection of a ])rcviously sterile sinus. ■

fE lECHSIC,

901

Gauzb.

Indications.— The chief indii-aliDnx fnr the tisc nf gauze in ibe abdominal
or pclric taviiv tirt to wall off septic fuci fmm the general peritoneum and to con-
trol excessive oounf; or bleedin);. The so-called cajiilliiry actiun
of ^ikuze i» very misleading, and it must be remem-
bered that the mat i' rial itstif is practically worih-
lesK fur the purpose of drain a k^- '''■■» '""f 'h"' during (he
Krst tiii- Itours 11 a-rtiiiii amount ci( thin Ilui<l or serum is drained away, hut in
a very short lime the meshes of the gauic become cli)g>;pii with nmeuLitol blood
iind (hick lenadous serum, whirb chM-k all ciii)iltiiry action .ind obsiruci the es-
cape i)f (he disohnrgrs. In other words, a gauze packing soon acts af an ob-
struclion and Ihc discharges arc pent up until it is removed. Thi.* naturally
faw>r» the burruwing of pus and tlie .tliMir^itJon of Mptic material by the blood.
It is therefore wident (hat when gauze is employed to shut off a septic fncus or
to control bleeding, it should lie combined nith tubular drainage, cither in the
form of gbu or rubber. The hitter shoulil be used with gauze packing when

■^

%?J

an operation is performed through the viigina. but when the abdomen is opened,
a f;liiS5 tulic is preferable except in ccrt.iin tases in nhich The Hexiliiliiy of the rub-
l}er is an advantage.

Objections.— The difficulty of remoWng a gauze packing is one of the
fH>ini<> r^tised .igain^t its Mfe in the abdominal or pelvic cavity, and a number of
ck-viccs have l>ccn employed to overciinie ihi- iibjcclii>n. .Among these may be
mcnli<"ne<! the <lrain "f Mikulicz, which consists of a gauze bag in which strips
«tf ftauzc arc packcul and the rubber ti.ssuc <y)vcrii>g cnipIoye<] by Pcnmsc. Both
tht-He dcviie*, howe\er, are of but little prvclic^l v.dur, as they prevent the gauz«
from lieing jacked nt the sCctt of operation in a ^^■ay to meet the indications, and,
l>e!tidcs, they are intended to be used without combining tubuLir ilminagi-, which,
4& we have seen al>ove, is an impr(>|>CT method to employ. I'hcrc is no difficulty
"Whatever in removing a gauze packing from the peritoneal canty if it has been
pTo|M-rty applied and sufficient time Is allowed to eLipse beforr making the at-
t«nipt- (tauTe acts as an irritiml (<■ the sumtunding peritoneum, and within a

903

TECHNIC OF ABDOUINAL AND PELVIC OPERATIONS.

few hours the field of operation is shut off from the general cax-ity by a w»II of
inflammatory lymph, in the beginning the union between the l^Tnph and the
gauze is very intimate and strong and the packing is firmly adherent. In the
course of two or three days, however, a slight suppurative process lakes plact
and this union is weakened, rendering the removal of the gauze a vtry simple
matter,

Introductiotl. — The gauze should not be inserted until the abdomioil
sutures are introduced and the drainage-tube is in position. A long stiip ot
gauze 6 or 8 inches wide is then passed through the abdominal opening and cr-
ried to the bottom of the pelvis. It is then packed in layers around the d^tinag^
tube until the septic fod or the bleeding cavities are thoroughly filled and On
general peritoneal cavity shut ofl. The end of the strip is then brought out of
the abdominal opening either above or below the tube and the wound closed in
the usual manner (Fig. 813).

In cases of vaginal section in which drainage is made through the vault of
the vagina a rubber tube is first introduced into the cavity to be shut off from the
general peritoneum and a strip of gauze 6 or 8 inches wide packed around iL

Flfi. An. — Inttoductioh op Gai'ek ahd Rubber Ohainai:!: into thi Pelvic Cavitt t^hikm a V*o™

iKdSIO.I.

Dressing the Wotind.— After the abdominal sutures are lied and tht
wound cleaned in the usual manner the same dressings are applied as •Iw'
glass lube is u.^cd alone.

When rublHT tubing is combined with gauze packing after an abdomiiu'^"
tion ii liirge compress, consisting of gauze and absorbent cotton, i* [^
directly over the abdomen to absorb the discharges and serve as a drtssinf w
the wound.

In cases in which gauze packing and rubber tubing are employed afl*r 3 vif
inal section the vagina is packed with a gauze tampon and the \'ulva pnil««"
with a ciimprcss secured with a T-bandage.

Subsequent Care of the Wound.— If glass drainage is uwd witb P'^
jKickinR ihc tube is cleaned in the same manner as when it is employed aiow^
the usual dressings applied. The gauze and the tube should be remo^wi in ■**
or three days ara! the abdominal wound cleaned with hydrogen peroxid. (oU^™
b)- a s<)lution of corn)sive sublimate {i to 1000). A rubber tube b ihtn phtw

CENERAL OPERATIVE TECHKJC.

903

I the bottom of the vraund and kept from slipping into the opening by attaching
. safety pin to its proximal end. Fresh dressini^, conHi-itinf; of guuu anil iib-
Dtfaeni cottiin, nie then applied directly over the wound itntl secured by sirijis of
line oxid planter. The dressings are removed o'erj- day and the cavity irrigated
thnniicli the tube with hydmi^en peroxid, usinj; a sbort-noKzIcd ^bss or rubber
syringe fur the purpose. The lulw should be wiihdrawn in the course ii( three
or four days when the cavity begins to contract, and the opening allowed to heal
5pont4inenusIy. ft, however, the drainaf^ Li punilcnt in chanider, the .iiuu»
ftbould be JTrigstcd twice a dity with liydrogen pen>xid .ind ihc drc^ings re-
ewed as often as required.
When rubber tubing and gauae pucking are used after an utxlominal ^section

FlO. II! ha, Bi«. no. Sit- Fia. tO.
UmKUi or Mu;mii ttatt't Ruvma T DuAitAnk-Tuaift.

nt- lif ibowi « rtcn nl nibbtr oMnt cut arti «i In tnd 4111I tpUi IM 1 iliHuKr ol u iadi uvl m half idlo
pii ■ anO hob la CHI oa Mch dOr ul Ox lulc (jitov ihc hue ol euh IU|i. Fli.kib ibuiHaine <jl ibr
Otft Mai ilnvn Uumich lie hule M ii> bur; Fiji, ti; ibun ihe furnuiwii □[ > T dniiuiKc-iulit. Fi|. iit
Ao>* Ilw nnbod oI inlnduanii the lubt idIo a cintt-

icy arc usually withdrawn in two or three days, and in the meantime nothing

h mjuired but a frequent change o( dressings.

1 In aiM9 in which a rubl»cr tube and gauze arc employed after a vaginal sec-

I Hon Ihty arc generally witlidrawn on the set-und or third <lay ami the cavity cither

loosely packed with irtr-h gauze or a rubber J-drain i)^ inserted and held

in piisilion by a vaginal tampon. If gauze is employed, the packini; >hould lie

removed daily; the wound irrigated with warm >lcrile waterora dilution of boric

add; and the vulva |iriileclt<l by a compress. The irrigation and the packing

are continued until the sinus contracts and the wound heals. If a rubber T-

drain is used, it should remain in place until the cavity i« well contracted, and

in the mcanlime the wound should be irrigatcxl every day with warm sterile water

^^r boric acid solution,

^H Rubber Tubbs.

^" Rublier dniiiLtge may be used alone or combined with gaua;. If the seat
of operation is walled off from the general peritoneal cavity, a T dniinagc-lubc
may be used alone, and it is especially indicated under these circumstances to
dntfn an abaceto cavity through the vaginal vault or an abdominal inci.Mon.
Combined with gauze packing it is fre*)uently employed in cn»e> of appendicitis,
vaginal section, un<I after an ablominal operation when the patient cannot be
conlrolkil and there is danger of a glass lube breaking.

904

TECHNIC OF ABIWMINAL AND PELVIC OPERAnoNS.

CLOSING THE ABDOMINAL TOUND.

In suturing the incision the layers of the abdominal wall, especially the fasda
anterior to the recti muscles, must be accurately approximated and no dead Sfaas
left. Imperfect union between the edges of the wound is a common cause of
post-operative ventral hernia, and suppuration is frequently due to the accumu-
lation of blood in dead spaces.

Method.— ^The wound is closed by introducing a series of tbrough-aod-
through silkworm-gut sutures and uniting the edges of the fascia with a continuous
suture of catgut.

Needles and Sutures. — ^The through-and-through sutures are intro-
duced with a straight triangular pointed needle, af inches long, which is held in
the fingers and passed through all the layers of the abdominal wall, including
the skin and the peritoneum. The silkworm-gut should be of medium thickcess
and the strands from 13 to 15 inches long.

The continuous suture uniting tbt
fascia is introduced with a smail M-
cun'ed Hagedom needle. Plain cumol
catgut No. 2 is used for this sutuic.

TedmiC— The patient is phcd
at an angle of 20 degrees in order 10
cause the intestines to fall backward
toward the diaphragm and a gauiepad
is spread out in the abdominal aiiff
immediately beneath the indsioa to
protect the viscera and collect mv
blood that may ooze from the suiure
tracts. The through -and -through su-
tures are then introduced. Beginning
at the lower angle of the wound tbey
are placed about i to i of an inrfi
apart and include all the la^-ers of
the abdominal wall. In introducing
these sutures the operator holds the
wall of the abdomen between ibf
thumb and the index-finger of the fcft
hand and passes the needle through the
skin about J of an inch from the (dp
of the wound. As the needle pij*
through the abdominal wall it is made
to take an outward course until its point reaches the subperitoneal (ally tissje.
when it is directed inward and finally pierces the peritoneum about J nf an
inch from the edge of the incision. The opposite side of the wound L' ihen
grasjicd by the thumb and the finger and the needle passed in reverse ordet,
emerging on the skin close to the edge of the incision. After all the sutures have
been irilrodutcd the free ends on each side are grasped with a pair of hemoslatic
force])s and placed llat on ihe abdomen out of the way (Fi|^. 819 and Sio)-

The gauze pad and the temporary packing in the pelvic pouches (niUeac
of Douglas and vesico- uterine space) arc then removed and the omentum dn"u
down under the incision. Upward traction is then made with the free ends of in*
sutures (o apj)niximate the lips of the wound and bring the peritoneal surfaces
together.

t-'ic- Mio — CTrOsivG THE AnnninxAL Woitnd.

Shoi'k'iiiK lti£ nicihoil ril jDiTulurinK ihc ihrciiigb^aDd-

Ihroueh futurts-

CENEBAL OPEBATIVE TECRNIC.

905

A continuous suture of cslgul u now inlnKluced and the edges of the apo-
Reurolic [a»cia united.

The wound is ttnally clooed by tying the through-and-through sutuns. Be-
fore esicli suture is lied tradion should be matie upward uilh iLt free ends to take
out the *b(k and bring the peritoneal surfaces in close apposition.

Fat Belly Wall.— Suimumtion i.i e»peciiilly liable to occur in a fat belly
wall I'H acciiunt of the low ritalily of the subcviUincous fatty lis^ut nnit (he danger
Qt Icaviiij; <li:ad s^iai^cs in which blood may accumulate and sub^quenlly become

PlO. H».— CtraiHO III! AllMlHlHU. WumD.

Sboot Ibr <ociilf>ut>ui (Uiurt nl ((i(ui IKX14 iniroduinl u> uoiir thr Msanrutaie latti^

tnfrcted. To guard against this accident the wound above the aponeurotic fascia
which i* cliwed by a (umliiiuous suture of catgut is drained with a few strands of
silkworm-gut ihisl are placed tiver the (asria and ihdr free ends brought out at
the upper and lower angles of the incision. The through -and- through sutures
are then tie<l and die wound dre^-sed in ihe usual manner. At the end of forty-
eight hours the silkworm-gut drain is removed and fresh drcMings applied lo
the wound.

DRESSING THE TOUND.

The through and -through sutures arc lied and their free ends cut off within
tmc inch of the surface of the abdomen. The wnund and the adjacent skin are
then ^ranged with sterile w-alcr and thoroughly dried. A large gauze pad wel
wJlti a solution of corrntiive sublimate (i to looo) is now laid over the wound and
Ihe abdomin;il dre»djn^ applied. These consist uf two Urge gauze pads
and a thick layer of absorbent coilon. which are made into a compress and
placed o%'er the wound. The dressings are secured with four strips of adhesive
(Z. O.) pLi.'tter and a sterile towel hid over all.

The adhesive strips should be jj inches wide and long enough lo give a firm
lUpifOTl to the ab<li>minal wall." tvhen they arc applied over the drev^inio.

I have employed this methml <>f dressing the wiund with uniformly good
results lor several years, and cons-idcr it a decided improvement o\cr tlie old-
faahioned flannel or many taileil luindagcs m cucnmonly employed. It tt per-

9o6

TECBNIC OP ABDOMINAL AND PELVIC 0PEKAT10KS.

manent, does not become soiled or loose, and leaves the patient's back and but-
tocks perfectly free. Again, the wound can be readily inspected without iiritat-
ing the skin by cutting the strips on one side and lifting up the dressings. Fnsh
strips can then be fastened over the old ones and the dressings made secure

FlO. Sll.— D»ra8IN0 THK A»I>011IN*L WOUHD.

SbowB the dmaiDft in poutiou uid 1h« fourth mid of adhrsi^-e p\mMB bang mtlvhed to (be lidt frf ih

(bdoiDco.

again. The ordinary bandage is a cumbersome contrivance and notadapteii
to keep the dressings in the best condition. It soon becomes loose and slips up
the patient's back, and always becomes soiled when the bowels are mottd or
a rectal enema is given.

EPITEROCLYSIS.
Before removing the patient from the operating table a quart of wrml
salt solution (iio° F.) is injected high in the rectum for its stimulating effKi
and to lessen post-operative thirst.

THREADING NEEDLES.

Being accustomed to operate without an assistant to thread needles, aw' "■''
using a suture-carrier in my technic on account of it making a larger hole liu"
necessary, I have employed a different method than usual in order not to n^
time and delay the operation. A silk ligature is always wet and limp mo '^
end more or less unraveled, making it extremely difficult (o pass throu(;li u*
eye of a needle. Even when the end is cut at an angle the fibers do not adlif*
closely, and become frayed so soon as an attempt is made to thread the nefv^-
To overcome this difficulty, I have a small alcohol lamp burning on the irtinJ"
ment table, and when it is necessary to thread a needle the end of the lipl"''
for a distance of one inch is passed slowly through the flame. The heat quK*^
dries this portion of the ligature and makes it quite stiff. The extreme end «
the ligature is then held in the flame until it chars black, when it is withdn*""

OPERAnVE COMMJCA710N8.

907

md the ch<ir slripjicd oR with the linfters, leaving a hard, sharp, symDMlricall/
[K>inte<J tip which c^n be easily passed through ihc needle.

Having prepared the end of the ligature in this way, the ihrcadinR is accnm-
iishcd afi (oliows: I'hc ncedh; b held rirnily between the >Mi>iid and third

AnrroH'i tlmioo or TBiBAnicc S'izdlh

H, Hit ■bom A limp wcl nik Ucilurt: Fif, %ti tho<fi% lb* aamc [JinTurc tStrt ir bu liccfi 1

iHKd Ibroocb u

ifedrad.

joirils of the ring-finRcr and the htlJc finRcr of the left hand and the ligature
pa.'i.^e(l thruugh tlw- eye a.t usual hy tlie liiigep- <>( the right hand. The thumb
till the index-finger of the left hand. Iwing free, grasp the end of ihe ligature
I soon HA il penGtrates llie eye and draw It coniplclcly throuiih. The a<h'antaf^
by this iilllc maneuver is that the end of the hgature a itecured no notm

Fio. »t4.--A*xm^ UmKoo or TMii»*oiiro Nnnr.n
I tht ettitc btid Iat«*n ibr rini tod Hide ftonn Mtiilr ihr lifaiurr i> baet pwml thrquth u> tyt ud

■KWM lf)r Uk UOOb Uki IDclei'fillJKI,

8S it penetrates the eye of the needle and prevented from slipping b.irk. In
^reading a nctxllc in the t)nlinary way the ligature verj- often slips out of the
" by its own weight when the fingers that hold it arc removed to secure its

OPERATIVE COHPUCATIONS.

The complicatinn.H which may arise during an abdominal or pelvic opera-
km cannot always be determined beforehand, and tlie surgeon muM therefore

9o8 TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

be prepared to meet them. It may be that a vessel is torn low down in the pd-
vis, or the intestine or the bladder is injured ; or, again, the diagnosb may have
been wide of the mark and the lesion found to be situated in an organ that was
not suspected of being the seat of disease. It is a matter of but little importaoce
what complications arise, provided the surgeon has a practical and diorougfa
knowledge of abdominal and pelvic surgery; but if, for instance, he simp^
knows how to remove a small mass from the pelvis and is ignorant of the opera-
tive technic for repairing an injury to a neighboring organ, he will eventually
add to an already long list of so-called "unavoidable deaths."

The compUcations met in operations upon the pelvic organs may be classifitd
as follows:

1. Accidents in opening the abdomen.

(a) Hemorrhage.

(b) Peeling off the parietal peritoneum.

(d) Wounding the intestine or an underlying growth.

2. Vomiting and contraction of the abdominal avails.

3- Escape of the viscera through the abdominal incision.

4. Adhesions.

5. Hemorrhage.

6. Wounds of the bladder.

7. Wounds of the uretera.

8. Injuries of the intestines.

ACCIDENTS IN OPENING THE ABDOKIEN.

Hemorrhage. ^There is rarely sufficient bleeding in opening the abdomn
to necessiLite the use of hemostatic forceps or ligatures. Under crdinaii or-
cumstances, therefore, the abdomen is opened without delay. If, however, [bt
bleeding is free, the vessels should be caught with hemostatic forceps, wilhmil
including the surrounding tissues in their grasp, and if necessary liga led with
catgut.

Peeling Off the Parietal Peritoneimi.— This accident may oour in
the earlier work of an operator when the union between the peritoneum and
the abdominal wall is very loose and is easily separated, under the imptesaon
that adhesions are being dealt with. Again, the same accident may occur "hen
a large abdominal tumor is a<iherenl to the anterior parietal peritoneum and its
enucleation attempted before the abdomen is actually opened.

If a small strip of perit<ineum is peeled oR in the neighborhood of theindaon
il need cause no concern whatever, as it is readily held in place bv ibe
sutures which close the abdominal wound. An extensive separation of the
peritoneum, however, requires special suturing, otherwise a dead space vui
be left in which blood is likely to accumulate and become infected. The peri-
tnneum under these circumstances should be reattached to the overljing sHiJ'"
tures of the abdominal wall by a series of c(mtinuous catgut sutures whidi 11*
applic'd in the same manner as when one piece of cloth is basted upon anoihct.

Injuries of the Bladder.— The bladder in an adult, when eiupir
or not displaced by a subperitoneal growth, is entirely a pcMc organ. ^^
in a child, prior to puberty, it lies partly within the abdominal cariiy. The
lower angle of the alxlominal incision should therefore be higher in a child tbu
in an adult, or the bladder may be injured when the abdomen is opened.

In large anterior inlrahgamentous tumors the bladder may be drawn up ^
high as the umbilicus or even higher, and unless the abdomen is cartfidl?

OPEKATIVE COMPI.HATIONS.

909

opened iin injury I0 the organ U certain to result. In nil cas» when in doubt
as to the po^itiunof thf bladder ihcinnoductionofasound will at once setlle the
qu<»ti(in (Fin, <)'f>)-
~ Wounding the Intestine or an Underlying Growth. There is

ways ilanger of this iiiiJdcn.t 01 turhtif; irniisc? in wliiih iIil' jiarii-u! pvritiiucuni
has become ailln-ruiu in Iht alKlumiiul nmti-nL*. Whik- muking the incision
throu^ the lielly n.ill muci) may be Ic.nrnc-d as to the pn>bablc presence of these
abnormal fixations. Tlius, an injected appearance o( the i-ucineclivr tissue and
the *,ubperiti>neal fat indicates adhesions or a thickened prriloncum. and free
blcedinj; from the wound al«i points to the same condition

I ) I

Shun iht fl>«tluil id Inmdodiw At wium lo miueli ibt prritincuiB.

In cases in which the abdominal wall is sreatly distended the jicritoneum
vt usually tliinner than normal, and un1cs> the ^uritenn i> very cautious in mak-
ing the incision the Jntmpcritonenl contents may be injured.

Adherent gut along the line of incision is always to be exitected in .secondarj'
operations, and the opening thn>u)th the alxlomcn should therefore be above
or below the original wound.
1 Injuries to ihe intmpcriloncal contents often occur from rccklessncsi or igno-

runce ujn>n the part of a >urKet>n who conceives the fal-< idea iliat rutting into
the abdominal cavil)- with one sweep of hiK knife is good surgery and cntiiici
him to tie daxsed as a brilliant <>]>eralor.

^M VOMITING AND CONTRACTION OF THE ABDOSONAL TALIS.

^1 These accidents, which are caused by the unskilful administration of the
r anctiihetic. not indy resuit in a ^eriou.^ iox*. of time durint! the operation, but
[ Ihc^' also increase the siib«i]urnt diinger by fnrcing the intestines out of the

alidumen and ex|">sinfi them to unnecessary irritation. It i» important.

there! ore. thai the a ne>lbetiKer should be qualified

and have special experience in sdmi nis t eri Dg an

anesthetic in abdominal operations.

910

TECBNIC OF ABDOMINAL AND PELVIC OPERATIONS.

ESCAPE OF THE VISCERA THROUGH THE JUdSiati.

Protnision of the intestines or the omentum through the abdominal opening
may occur during an operation, and is usually caused by vomiting or contrac-
tion of the abdominal muscles. Should the accident occur, the viscera must bt
replaced at once and prevented from escaping again by holding a large pad otct
the incision until the cause of the excessive intra-abdominal pressure has been
removed. It is often difficult or impossible to return the intestines en muse.
as ihey escape as fast as they are replaced or they block up the abdominal
opening. No difficulty, however, will be experienced if the coil of intestine

Fic. Pift. -S>io»5 mp Mt-rnnn of PntvEHTisn ihe Escapk of ime Istesiinis VBtx lat Pitinsi*'

Caviti ts Flushed.
Sole ihf pooilioD of Ihc finetn and Ibt noule of Ihe imgaling appwiui.

which escaped last is pushed back first with the fingers of one hand vm
the fingers of the other hand replace the succeeding segment.

The intestines are always more or less likely to escajw when the periton«i
cavity is flushed, and unless precautions are taken at that time, sevtral wi"
of bowel may be suddenly f<trced out of the abdominal cavity. The acridwi
can be j)revented by passing the index and middle fingers of the left band ini"
the abdominal cavity and inserting the nozzle of the irrigating appaialus "
tween them.

ADHESIONS.

The presence nr absence of adhesions determines the ease and safet}' *i"'
which an al)domin;il or a pelvic operation can be performed.

For practical purjioses adhesions may be classified into those which art ""**
and ihuM' which are flironic.

OPERAnVE COUPUCATIONS.

911

_ Recent Adhesions.— 'Ilicsc sdhc^oru arc soft, (riablc, and easily broken
"up, and an usually mei in early ojieralions for acute lemons associated with
eeneial or localised prrituniti^.

W».M.-

vu MroiDD or Kiuovik Amiuiom iwhi m Sjit tt im Ovtaum Cm wm *
OAVrt SHw^

- ■(-*'*■-;

U.*'.

?^*,.

VCi?l' fv.'^Ii

:vr«.3Li'

W- y}

&■>-

Recent adhesions can be sieparaled by the fingers or ft sponge without any
daogcr (»f injury to underlying or mljaccnt structures atid without the ntd ol
s^l. It is therefore unnctcssun,- to etilar^e ihc abdominal incision in order
to inspect the field of u)ieniti(}n. a--, a
mass can be enuclcutrcl :ind delivered
through a small opening provided the
adhesions arc fri.nble. A peine muss
niay be enucleated by inserting the
ti)u «r the index and middle fingerK
between it and the adjacent structures
and gradually working them in the
direction u( leust rmistiince until the
tumor i» entirely free. Omental and
intestinal adhesions arc ejisily rubl»cd
off with a. ^auxe s|Kin^c fnim the sur-
(oct of It brgc solid tumor, and they
are also readily remo\'ed in the same
Runner fnim the sac of an nvanan
c>-si as il is delivered through the
abdominal opening,

Chronic Adhesions. —ThcM
adhesions are firm and well organiwd
and si:imctimcs great skill h rcciuired in
dealing with tliem. They are tiMially
luund in cases of old or neglected
peltic disease and are often re>p(in>!tile
for Mime of the most difhcult o)>era-
tions in pelvic surgery. Again, we
meet them in ovarian cysts lliat have
ticrn (ap]>erl, in uterine fibroids pre-
liously treated by electricity, and also in solid pelvic tumors which have attained
, large sitt.

titoS Okr olherti^r n»iw>rk ^-( 'lie omrmruin S^e
tttti Wly ft M1U |iiR of (bt f*i>tnrij"i it tlherrfll,

If iKc omentum is aTlnchcd lo a tumor, a liRaturc is applied and (t i$al
away, leaving the adherent jwrlion upon the growlh (Fig. 828). The umtnWBi

is exceedingly ^-ascular, and t «ricw
hemnrrhugc may n^ult unks a lipiurc
is u^ lo control the bleeding- Vihm
the umentum U extcnut'ely odliOBi ■)
should lit- ligated in ^cclions and doIIM
eii mosse. L'nlcs^ ihi^ b done (hcTOMli
miiy not be sufliiicntly i-oni|in«snl U
prci-cnt hemorrhage and the otntUm
itself will no! lie evenly over the itfOBW
on arcnlint uf it* puckcreil (.-onditkn.
An adhesion existing belwKll
morbid growth and one of ilie abttwun'
i-isttn may he w> broad and firm lh»i il
Bill he ncccssar}- lo leave n pon»n <*
ihe tumor udhercnl rather tlae ran iW
ri)(k iif causing a seriim* injury a"! "■
creasing the dangers of the oprnlMi'

Old ndhe^ion3 »hnuhl lie bntrt - are ftfta^
witli die fingci*! or cut with sriwr* 1'
U often pus-dWc i" siret<'h the iJhtaUt
between adjacent surfuces and cut throu^ them with a knife or «d»**
Thus, for example, when the uterus is adherent 10 the rectum, if ihc hmd*"

FU- S)(.— Tin )ili.TUoi> tii SiaiTrtiiKi \i>iii
uom MUD Ci'insii tiiiu wiiii Sciumti.

tad Ihf uinut ur pui upon (he urcich Uj drtai-
bu£ the ludidu lorvird ,

OPERATIVE OOUrUCAtlOKS.

913

puUcd forward th« adhesions are drawn taut and can readily be cut without any
danger of injuring the b»wd.

HEMORRHAGE.

An intraperitoneal hemorrhage may (ncur (rtim ihe sq)iir;iiion of adhesions
during the enutlvalion of a tumor, from tearing the broad ligamcnt.i, and abo
from an injur)' to a gmwili twfure iu [xKiitlv L-. Ii)i;ale<).

^\1)en the accident occurs, the |mCicnl's Imdy must he raised at once to an
angle of 45 degrees, the hlccdinK point located, and the hemorrhage controlled
by gauze packing or ligatures or both.

Blceiting resulting from adhesions is usually slight and ceases quickly. If,
however, the ndlic^iions are extensive und free oo/ing follows their aejHiration,
the bleeding surface should be hrmly pitckcd with gauze, which can usually
l>c remi)v«i when Ihe operation is finished. Should the oozing still keep up,
the I'leld of operation is packed witli a strip of gauze and its free eiul leftout-
side of the abdomen; the packing is generally removed in from twenty- four to
fofiy-eij^t lM>ur>.

fte- JI3J.— Tlf4 iSfsvm 1*1 Cnimni.i.iw^ 4 KtuinmiiAnt nou nt* liiu'uo IjcvufUfT (pace f m).
thovlnt ■ UgAturr TttaKrJ multr Ihr ulerlnc tnd prhtc nvti -A tht oimruD *ntrr-

flemorrhage occurring from a tumor during its enuclcjition and deliver)'
need lause no concern, as it ceases so soon as ihc pedicle is ligalcd. Sometimes,
hi>we»*cr, il may be necv.*.»ar\' lo apply hemo.Htntic fIl^^ep^ to the lorn vessels on
the surface of Ihc tumor in order lo control the loi^s of b]oo<I and keep Ihc field
of Oi|)eTation clear.

Shelling out an adherent mass low down in the pelvic may result in serious
Irsumaiism, and cases have been reported in which one of the iliac arteries was
turn.

One of ihe most common causes of hcmorrhape i« rupturing Ihe vascular arch
forme*! by the aniislimioM.i of the ii\-;iniin and uterine arteries. These vessels
are li>m in brciking up arlhesions. by milking undue tension iipnti Ihe pedicle,
in removing the uterine apiieixlages, and by the ligature cuttinK inin the broad
UgumenL Sliould this accident occur, the stump of the pedicle should be brought
S8

914

TECUNIC OF ABDOMINAL AND PELVIC OPERATIONS.

at once into view and the upper border of the ligament inspected. The bleeding
point is then caught with hemostatic forceps and a second ligature applied. It ii
important to remember that hemorrhage from any portion of the broad ligameni
can always be controlled by ligating both its uterine and pelvic ends {Fig. 831).
Sometimes the pedicle may be insecurely tied and a serious hemorrhage re-
sult from the ligature slipping. Under these circumstances the upper border
of the broad ligament should be seized with hemostatic forceps and fresh liga-
tures applied to the bleeding vessels.

WOUNDS OF THE BLADDER.

The bladder may be injured in opening the abdomen and in breaking up ad-
hesions.

The wound should be sutured (cyslorrltaphy) at once and the urine which hu
escaped into the peritoneal cavity removed with a gauze sponge. Normal urine

Fic. 83].— Tbe Mzthod or Rkp*iiii«o « Woumd or tbk Bi*»de« Ikvoh-jku Omly its Orm OUB 'i
Means or a CownNuors Leubeit SutuieCpo^ oi5)-
The flUIUTE ia shown fd) drawn uul. lb) lying kxMctr in Uic tiisufs. uid (c) betof umrMiTrd.

causes no irritation of the peritoneum, but if cystitis is present the urinarj' secrr
tions arc likely to produce infection and endanger the life of the patienl.

If the wound has been properlj' sutured, there is no danger of subtquMi
leakage, and drainage is therefore not indicated. It may be necessarj' i[thel&'
is large to catheterize the patient every three or four hours for the first rfav alter

T'lc, Sm- — The MtTHOuor R^pairint. a WnuNO ov thi: Bladiier Involving all of 115 Coats nME*>-'
'i'wii I.AvtH\ OF Sl'ti'he'* (jki«c pis),
'l^hi: firsi l^vrr jr. a mniiniiou^ auiure inrluilinj( all ihi' coalj; M Ihi- hbddtT r'CcrJ Ihc mumu* ^f^'**'jf^.
is lihi^wn (ul Jr-iwn tiiut, (M lyinn I'li^'ly m Iht lii-sm's, and (r) L)citi;i inlrfHtLiipd. Thewi'inul Iijtt 1^ J '"'■"'
cUb [A'mlM-'n suture hurj-ina in the liiM ucr and is i^hou-JI <tO chaiftn laul anil U) K-in* inlrcMJua>i

operation, and then every six hours for the next two days in oriler lo av"ia ''■'''
lention and undue strain upnn the sutures. A permanent catheter >h('uM ""
be rmploved, as it is seldom indicated and may cause cystitis.

Operation. — .\ \esirai tear involving only the outer coals of the ^'^°r!
.'^hould be closed by a continuous Lembert suture of No. 3 braided >ilk. "'"'

OPEUTIVK atUPUCATIONS.

9tS

is nmecl ugxin a cuned inlesliiial needle (sec Fig. S43, p. 919) and posMd deep

, enoufih lo inchidc ihc t«ni sinii Iu^v^.

A deqj (car involving ali the toqIs and upuning the cavity of the bladder should
be closed b}' tun iJerMir layers iif»utur»a:^ fullowik: The riislliiyerappnixiniAles
the et\f^» of the wnuml and tliir second tier reinfon'c< iind buries (hc£« sutures,
thii?' guanllng a|i;ain»t the possibitily of leakage. The approximation layer con-
sists of a continuoii-v suture of cumol ca(|<ut [No. 1), which i* carried upon a
curbed intestinal needle {sec Fig. 843, p.9i9)and passed through all thecunt$of
the bl.tildcT except the mucous membrane. The reinforcinj; Her eoiui.sle of a
continuous Lemtjert suture of No. 2 briiided Mlk ivhidi i- also carried ufjon a
nirveil iiMdIe and passed through the peritoneum and the sujicTficial |ionion of

i|hc muscular coat of the Ula<idcr.

H WOUNDS OP THE URETERS.

^P The ureters have been lorn in lircaking \i|i adhesions, and the)' have also been
tied with a ligature or piertcd hy a nc*itle in lif^.tiinf: a lilcedini; ve**tl low down
on the pelvic ftixtr. In tying off Ihe l)a.>e of ihi- broad ligumenls. there is alwtiys
danger of including one or both of Ihe ureters, and the same accident may hap-
pen with a clamp in {lerforming a vaginal h)-9.tcrectumy.

The treatment of ureteral injuries is discussed on page 675.

V INJURIES OF THE INTESTINES.

H Classification and Treatment.— An intestinal injur}- may vary from
a superfkiol wound to a complete destruction of an entire segment of the bowel.

*«^vfli^$.^.:;,s';^

BjJ— TiiK MttH-ii) nr HrrjkiaitK T»rtm nr tin Sm-"-.; itu Mi irtjiAi Coin .« ™« l»i««a«»»T
MlAN^nr CirsKIHG'f Kitiiir 4.v;(.tn Sl'Tliu 4p«^ vi^J.
"nt lUlUR U ttuSB (d) dllHIl UUl. <() lylM luitely in llw liwuM. ttid (i> lxill| iDMDjiccd.

The following lesions may be met as operative compllcationit of an abdominal
section:

^^ t. Tears of the scrtnis and muscular coats.

^^L^ 3. Tean into tlie lumen of the interline.

^^^^^ (a) Longitudinal tears.

^^^^^^^ (A) Transverse tears.

^^^^^^k (r) Irregular

^^^^^^F (d) Tears invoK'ing loss of tissue.

^^V 3. .Ncnvitic areas.

^V 4. Wounds of the metienlery.

^H ;. Injuries of the rectum,

^^ Tears of the Serous and Huscttlar Coats.— .All suiwrficial team should be
Sutured in I'nier !'> guard agaimi tbi- 'langrr of leakage and to cover over Ihe raw
Surfaces which would otherwise form adhesions with ad}accnt structures.

9i6

TECHNIC OF ABDOMINAL AND PELVIC OPEKATIONS.

These tears should be closed by a continuous Lembert or Cushing's r^t-
angled suture, which should penetrate to the depth of the tear in the muscular
coat and bring the serous surfaces in close contact (Fig. 835).

Tears into the Lumen of the Intestine. — L ongitudinal Tears —
A short longitudinal tear should be closed by interrupted Lembert sutuns or
Cushing's right-angled suture (Fig. 836).

FlO, gjt. — ThI MeTBOD OT RlTAtltHC SHOIT LOHCITVDIHAI, TzAIS IHTO TBE LlTim Of TMI Ixmnan

Meahi Of Iinw»unTD Lehbeiit Snitmis.
The Bulura jm shown (a) lied. (£) lying loc«ety in the tinuea. aad (c) bcblc uUfodood.

A long tear, however, should be repwiired by a series of interrupted Lembot
sutures, followed by a continuous Lembert or Cushing's right-angled soturt,
which buries the first row and guards against the danger of leakage (Fig. 837).

Transverse Tears .—Transverse tears should be sutured in the SUK

Fro. iiT- — TiiF Method or REPdunihi^ Lane Lonoitudinal Tv*t^ iKio the LfMis or rrti iTcnsTjrtf
Means or Two La\i:ps or Si"Ti'r>s,
Thi' Ejrst layiTcnnsi^l^ol inlcmipled I.Finbcrt luturc^ iod n shown [a) lied, ib) IviDC looadf in 1^ "^^
and li> lu^inii inrrvduci-d. 'l^he second lavrr u a conlinuoud Lcmben suture burying in ihc fan Ikr ih»
thgwn {lit drawn uui and if) being inuoducn).

manner as longitudinal wounds, A tear which nearly or compleleK i\'ivti
the intcslinc transverselv will require an end-lo-cnd anastomosi.s.

Irregular Tears , — An irregular tear is one in which a longiiudi™
and a transverse wound are associated and form an injury which opens the luiW
of the bowel in two or more directions, as shown in Fig. S38.

When the transverse and diagonal tears are not loo long enterorrhaphv is in-

OPBtA'nvc COUPUCATtOtn.

917

llcated, but if they nearly divide the bowel across, an end-to-cod anastomosis
should be [icrformcd.

In suturing these tears the edges of the transverse wounds should be approid-
mated with interrupted Lemben futures; the lonKJludinal wnund U then cloned
in a similar munncr; iind, iinnlly, if imy iloulilexistsas tn thcrflicicna,' of the
closure, the sulurinf; should be reinforced by a continuous Lcmbcrt or Cuihing
right-angled suture {Fi^. 8^9).

v-^..

rm 8j».
Tut Uttiiou o> RErudRO luioiruu Tuu <ip

■bow* ibf TTitih'-l <-it (uiiinni tij nMOi ol Im larrn o' miuni

Kir. ajo.

'iiiiilinjil wminil: Plf-^o

Tcars Involving Loss of Tissue, — Wnunds of the intestine
jre often a5.wctaicd with more or less loss of tissue, and it is sometimes difficult
to di-cide how thej' should be rejiuircd, I'nder Ihrw cimimstances wc must
consider the effect of enlerorrhaphy upon the caliber of the 1m>wc1 and avoid re-
ducing it tn the extent of causing a decideil kink ur >tricture. F.nieriirrliu|>hy
is contra indicated if the lumen of the bowel is diminished mi>rc than i>n<--hulf by
ttituring, and rcwclion followed by aDastomosi» should therefore be performed.

'■'^'

FiO- Ma. I'Hi. an

Tumi hi m Ihthtiiii tmnmitr. Lsu at Tiuot-
. Bm •bawl * Uu inwivlaa u xiouin lovol lime: Fi(.»«i thmn ilx rOta upon ii<' i .iMtt '.I ihc
r uitiiia^ iIh Kilt* viih Hitiira ((BMnailuiiliiih N'Mt llix irhrn Ihr nlci* ■■ t iM ft ue i[>tinulniaMd
t twmimtoo naulu,

There is no necCf»ily of trimming the ragged cdgc» of a lacerated (ear before
ring, as ihey are inverted into the lumen of the gut when the u-ound is closed

I do no harm IFIrs. S40 and Hii).

necrotic Areas.— When .> knuckle of inli-iJiine become adherent to a pus
sat, its walls usuiiily become infcitol at die [H>inl of contact and a necrotic or
skMighiog area, varying in size. ii> iil»M>rvcd when the adhesions are serrated.

9i8

TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

The treatment of this lesion depends upon its extent and the condition of the
surrounding intestinal walls, which are often infiltrated and so brittle that the;-
will not hold a suture. A small superficial or deep area of necrosis surrounded
by healthy tissues should be lightly cureted with a scalpel and turned into the
lumen of the gut by interrupted mattress or Lembert sutures, which may, if
necessary, be reinforced by Cushing's right-angled suture. If, howei-er, the
slough is extensive or the tissues surrounding it are brittle, any form of suturing
is contra indicated, and resection followed by anastomosis should be perfonntd.
The principle in the management of these cases is the same as in tears i^^'ohing
loss of tissue, and the danger of a post-operative obstruction must alwaj's be bonK
in mind.

Wounds of the Mesentery. — A tear in the mesentery forms a slit throu^
which a coil of intestine may work its way and subsequently endanger the iffe
of the patient from a mechanic obstruction of the bowel. To guard against this
accident the edges of the wound are brought together and permanently united
by a continuous overhand silk suture (braided No. a) (Fig. 84a).

Injuries of the Rectum.— The position and anatomic relations of the m-
tum render it difficult to suture when torn during a pelvic enucleation, espedaOr

where the floor of the pelvis is
indurated and infiltrated nith in-
flammatory products.

Before repairing an injur}' of
the rectum the patient shouU be
placed in the TrenddeDbutt:
position (45 degrees), the pehis
isolated with large gauze pads,
and the field of operation an-
fully cleansed with gauzespongs.
A thorough examination is then
made by inspection and tht
method of repairing the injufj
decided upon.

Longitudinal. Iran sveree, and
irregular tears without loss of
tissue are repaired in a similar
manner to those occurring in the small intestine, and a double layer of .'■ulure
should be used to guard against leakage if there is any doubt as to the efficiency
of the sutures.

A braided silk suture (No. 2) should be employed and passed with a small
curved intestinal needle; a straight needle cannot be used, as there is not suffi-
cient room in which to manipulate it.

If the bowel is torn completely across, the upf>er and lower segments stinuld
be disserted loose in order to free (he ends and ai>proximate them nilli"'''
undue traction ujwn the sutures. The torn .surfaces are then brought tf^tllier
and an end-to-end anastomosis made.

Tears involving great loss of tissue are difficult to repair on account of 'I"
dancer of constricting the lumen of the bowel and causing a serious stricnw
Under the.'^e circumstances Kelly has succeeded in closing the opening by su""'
ing the uterus, in retro])osition, to the bowel on each side with a conlinuou-' J"'
turc.

Drainage is .nlways indicated in injuries involving all the rectal coat.-, f"^'
pcrhiips in verv small tears which can be tightly sutured and therefore arCJf*
likely to leak. It is always best to drain through the vagina in these casft''-''

F[G- fi4}.^TuE MF.THUit or RT.PAmrHC Wounds or tite

ontAnvR courucATioKs.

919

liar

ling Ihe posterior viiginal ctildesac, inlrotlucinfi a Tshai>ed nibb«r drain,
and racking a Ktrip of plain g»uzc around the scat l>[ injur>'.

TiK after- treatment is \he mme a» for ati abdominal section, cxcqit thnt ihc
bowels should not lit movriir (b)> after
Dperalion. Rwlal encmala are contra indicated, as tlic>' _ j

cause distention ;ind Ntniin the line of ^uIu^i^f(- Tlic
bowels should be moved by a tn'M Iiix;ilivc jiill or li.-ilf u
bottte of titrate of maKncsLa, und if the rectum conuins
hardened f«.*al matter, it nhoulil lie xiftencd by ^n injcilion

half an otincc each of castur oil ;ind plyccrin.

General Operative Tcchnic. Antisepsis.— So

nasan injure' iri disn>v<:reil tliL- liiiWL'l -Nliould be brought
out^de of the abdominal cavity and laid on a large gauxc
|Md. 11i« vrouiul >hould then be examined and Ihc ncccs-
6ar>' measures tiiken to Tqiitir it. In »(imc ouo, however.
It is ini]N)i^'itblc to lift the intestine out of the abdomen on
account of iidhesions or its aniilomic rebition.-i. :ind under
Ihcac circumstance^^ the ^seal <if injur}' should be isolated
from theKeneral peritoneum wilh gauze puds.

After repairing an injury the inicMtne should be thor-
oughly douched with nornuil salt solution (no" F.) .ind
replaced within the alKlomen. If, hnwe^'er, the IniwcI ha-s
not been biuught outside of the incision, the site of the
rci>aired injur}- should be cleansefl by local washing (see p.
K9]) before the gauze pads are removed and the surgeon
(.'ontinue;^ the operation.

In rase the abdominal cavity has been soiled by the escape of the contents
of the bowel, it should be cleansed by knal wiL'-hing anri not liy jwncral flush-
ing, which <c.ntlcrs the fcciil matier ihmugh the abilomcn and increases the
danger of infection. Sometimes, however, in cases in which an exten.sivc injury
has oci'urred the fecal matter may be su generally diMributed among the in-
testines that' local washing will not be Eufhdent to remove the contamination,
and irrigation must therefore be resorted to.

Fig. Mi — ImUtWAi

Siuc.

(OSLrmUhtOfnlle: (t)
•null (ull-cufwd nndW,
{I) nilucei ctlyi cvnl
cod at ihv cur**d anal*.

t tt», — Tmk Uiwmi or Fitvtymn Fbcal U*tm noM Ekaidr nnovea t Wnum> or im IimiiiiiT
•riijiz iMi SuTUm AH ■nira tanaont'cut i|oar«i«).
NdU UwI ihi iniiiiinr bu b«CB (Iijpprd m Ih itinlrnii )i«c)i Ihc ilunpt

Needles.— The n«e<lleK used for intestinal suturing should be slender awl
,J!Oundcd point in order that they may paM through the walls of (he
^'■ltfloalt cuttinK the tissues (Fig. 84.0.
I t»e • toDg Mrvight necdlv and a unitll one with a full curve. The straigjit

990

TECHNIC OF ABDOUNAt AND PELVIC OPESATIONS.

needle is used for domestic purposes and can be purchased in any shc^. It is
known as a No. 5 darning needle. The curved needle may have an ordinarr
eye or it may be calyx -eyed and is purchased in shops selling surgical supplies.

Suture Material. — Fine, white, braided silk, No. a, is the best suture to an-
ploy for intestinal operations, as it is very strong and yet sufficiently delicate for
all practical purposes. When catgut is indicated, I use No. i plain cumol gal

Special Directions in Suturmg. — Before the sutures are introduced Kw
intestine should be stripped between the thumb and the index-finger on eadi side
of the injury and clamps applied to prevent the escape of its contents (Fig. 844}.

U L

Fig. $4s. — MinpHT*a IvnsTiNjU. Clahts.

Fig. SjO, — DiAOBAU o^ the Coats or the Intestine.
(a) SrrDuif, (ft) muscular, (cj submucous or ^rbrous. and (rf) muojUL

Tntestinal sutures should penetrate all the coats of the bowel e.icepl iht iiiu-
cous, which should never be Included unless a reinforcing tier of suturing i><'''-
ploved on account of the danger of leakage occurring from capilian' aclion, Tw
stnmgcst and toughest portion of the intestinal wall is the submucous or fibrms
coat (Habted), and the sutures should therefore always include, if pos.=ibk. soD>(
of its fibers (Fig. 8j6).

In suturing ;in intestinal wound the peritoneal coat should be approxinuw
by a comparatively broad surface and the traction upon the sutures fhom "
sufficiently strong to prevent leakage without strangulating the tissues.

OPKRAIIVE COUPLICATIOKS.

991

Varieties of Intestinal Suture.— The follovrirg varieties arc em-
I in r«|>»irin]( (ears and making unahiomotic communications between diSer-
il segments of the inle&linal canul:
Interrupted Lembert suture.
Continuous Ixmbert Milure.
Cushing's right-angled suture.
Halsted's maUrci>a suture.
CoDtinuoux through -and -through suture.

!3'i:a ,iWi/!li

FM, l4i~tMTUiiitmii l,un»i Sutoul
Tlw ncum in (boaa (a) iM. (t) lylai loiwlir in ilw lunin. lad (() Ihuc Hwrodaod.

Interropted Lembert Suture.— The suture is introduced sx right angles
to the wound and penetrates all the coats of the intestine except the mucous.
he needle fii>t piiks up a fold of the intestittc. jiboul I'j of an inch in width and
_f of an inch from the margin of the tear, and U then passed across the wound to
the opposite Mde, where .1 similar (old of ihe tnle%linat wtiII j.s ■^cuieil in the »me
manner. When the suture is tied, the two peritoneal surfaces are brought into
conLicI and the margins of the tear are inverted into the lumen of the bowel
Fig. 847]-

Fid. AtK. 'lnttiovFTii' I.mibi.iii Siitii-
BwM a tgoi innnj |»rtUll]r ilnsnl b) isn tutuin brIiHi mlradudni ■>« Lfmbtn wrura.

The number of sutures depends upon the length of the le:ir, and. as n rule,
y should be pbced aliout \ of an inch ajiart. The sutures should not be lied
ntil all of them ha^c been introduceil eweiH in the ca.«e of a verj' limg wound,
which should be partially closed at tirsT bv two or more sutures in order to render
approximation more accurate (Fig. tt48).

Tw<i temponir)' traction sutures placed at cnch end of the wound anil clamped

with hemoiUlic forceps, as shown in Fig. 849. arc often of service in suturing, ftS

ic>' raitc a f<ild on mch side of the woutirl through which the approximation

Iturcs Cfin be more easily and accurately [iUK«d than by picking up Ihe intcsli-

932

TECBNIC OF ABDOUtNAL AND PELVIC OPEKATIONS.

nal wall with the needle. Each of these sutures penetrates all the walls of the
intestine except the mucous, and the forceps are held by an assistant, who make^

traction in the direction of the line of the wound.

Fto. B4!>.— Tehpohmv Tbichoh Sdtums Used io Fiioutate the Closdme oi a Teae ih lei Imtnn.
Nole Ihe ridge on e»eh aik of Ihe wound »nd tlw cue wiih which Ihe nwdle a iotnidiKoi.

Continuous I^mbert Suture. — The method of passing the suture and tht
approximation obtained are the same as in the interrupted Lembert suturts,
except that it is continuously applied (Fig. 850).

Fn;, aso-^Co«nmjoifs Leubeett SunrbE.
The imure is shown (a) taui, (A) lying liHisely in the lissutfi. and (r) bring inlroduced

Cushing's Right-angled Suture. — The suture is continuous and passe
throuKh all the coats of the intestine, except the mucous, on each side of and
parallel with the edges of the tear. It approximates the serous surfaces and

-ji^i^iiiSii

Fir.. K5U — Ti'smKii'.i Rii;HT'ASr,LFi> SvTL'nE.
Tlu; wturv i^ nhown (a) liul. fb) lying luoicLy in the tisiUL's and [c} tvinB LDlmdwrd.

UI'EKAnvi: O>MMJCAn0.V9.

923

inverts lh» margins of the wound into the lumen of the bon-el. Th« method of
intriMhu'ini; (his Miture is <l<^ir]y »h4>vm in Fig. tt;i.

I. Halsted's MAttress Suture.—Thr suture is intemiplFd and pasM« ihroURh
ul t)it- (Chills i>f Ihc intestine, except the mucous. It priictically C(>n.-'i.iL« of twn
ptcrmptcd Ix-mbcrl MiiurvN joined by ii looj) on one side of (he wound, and apart
pi'iii thi> difference it* method of introduction is ihe Mmc, The a)>i>roximation
obtained and the inxersion nf (he edges of the wound intn the lumen nf the ful
are also similar. 'i'cm|K>r,iry tniction i^ulurc^ may often be Uicd with advaatago
introducing! this suture (Fig. &$)).

ir n

W n

Continuous Tbrough-and-tlirougfa Suture. — The •.ulurc pa^es (hrough
III tile couls of the iniesline indiuUng llir murottf, and h employed us a prelim-
inan' means nf approximating the ed({c> of tlie wouiui. The approximation is
finally completed by a second tier of either Lcmbcrl or maltrcss .lutures, which
are ininvlueed and tied in the usual manner (!■'!(; 855).

Finecalgut (.\'o. 1, plain) is llie lie>l muierial to use for a continuous ihrouRh-
J-throuRh suture, as it is rapidly absorbed and there is no danger of an in-
ligature Ijecuminfi; imbedded in the intestinal walls.

Fid. til —Cfom'tvott TiiKoitnH-jtinvimocui Srrvu.
Tbr luiurr ii tbomi fa) tiul. [() lyint IwhIf in <>>< ibwM. and ('I brim inlrodMid. Kou IkM ibc wiiui* U
puwj ihinugb [he mufoua mcmcmnr

Intestinal Anastomosis. —Anastomotic communications are mode

iMCfii diftVreni segments of the intestinal ninal iw follows,'
I . Simple suturing without the aid of mechanic devices.

(u) Enil-ut-end an;tstomosi!t by means of Halstcfl's maltrtss sutures.
(A) Latenil (inii.«lt>mosis by means of HalstedS miiltrem mtures.

Pio. 8)5.— EsD-To-inD AxuTKitHU ay UUM* or Oustaft llJiTntsa Sttno—SMvailH* >■*

nm rRon KnutrnJ
Nim llul ibi ivn ■' iXKfunii'* niiumm iln oppodlp uilr of iht hamal o^M Iv <•■>■ AW ikMaa*
iht (uiuns wllh hliXHl'Tmf k cnnilBf inm (Ik i

Second Sti'.p.— Place five "presecdon" matlrp«« sulurt?^ aniunl "<
distal .inH prtixim.-il ends of the tmwel about ( of an inrli bnood the liw^ ihn"^
which the intestine i^ to be resected. These sutures are |>liiceil us folln«s: ^'~

936

TECHNIC OF ABDOMINAL AND PELVIC OPESATIONS.

sutures," and after they are all placed each suture is securely tied. In puang
these sutures care must be taken not to include any of the blood-vesseU near tbe
base of the bowel, otherwise its nutrition will be cut off and gangrene may result
(Fig. 858). If there isanydoubtas to the efficiency of the approxiiBaiion, a ctm-
tinuous Lembert suture should be placed completely around the bowd, bun'inj
the mattress sutures and guarding against leakage (Fig. 859).

Fio. 8j8,— Kfth Step. Fio. Si«.— Kfth Smp.

ErnvTO-EHD Anastouoss vy Means of Halstzd's Mattvess SimiKES,

Sixth Step. — The edges of the mesentery are brought together and iraiwi
by a continuous silk suture, care being taken not to include any of the Mood-
vessels going to the intestine (Fig. 860).

Fig, ifto. — F,s'D-Tn-t?Jif A.sastomosis iiy Means or Halsteii's MAmtrijs Srirstf — SirthStt^

Lateral Anastomosis by Means of Halsted's Hattress Sutures.-Fis-'T

Stei',— Strip the SL-gment of intestine to be resccte<l between the thumb and in-
(ic.x-fiiiser and apply Ihc clamps (Fig. 854). There should be 5 inches of inte'_-
line hcvorel each clamp aflcr the resected portion h removed, in order loha«s|'-
ficient lenglh of bowel for the invagination of the free ends and the ana>lonwa'-

938

TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

on a curved line in order to form an ellipse and broaden the site of the approii-
mation (Fig. 864}.

Sixth Step. — The anterior sutures are separated in the center and a longi-
tudinal incision is made in each bowel between the anterior and posterior rows
of sutures (Fig. 865)-

Tio. 863^^Lateial Ahastowkis by Means ot Haihteo's Mattme-<s StftviES.

STED,)— Pattlth Stap (page gi;).

(UoDims noB Hu-

Seventh Step. — The anterior sutures are tied and the edges of the meen
tery whipped together with a continuous silk suture (Fig. 866).

End-to-end Anastomosis by Means of the Laplace Forceps.— Laplact's
forceps is separable into two halves which are firmly held together by a clamp
and form two rings at its extremity. These rings are passed into the intestine il

Fic, 864. — I.ATEHAi. ANA5rnMosi5 BY Mkans Of HiuiTEii's M*mtE5s Sdtu»is. (MoDinED not Hu--

sTEc.)— Fifth St«p,

the seat of anastomosis and hold the parts in close apposition while ihe sulur^
are being introduced. After all the anastomotic sutures are tied the clamp is
remo\'ed and each half of the forceps withdrawn separately from ihe ^™
through the i^mail opening which remains unsutured. This opening is »en
closed with two sutures, and the operation completed by suturing the mKW-
tery In the usual manner.

93°

TECHNIC OF ABDOMINAL AND PELVIC OPEKATIONS.

Second Step. — Ligate the vessels in the mesentery within the area of ex-
cision with silk ligatures and resect the intestine with straight scissors, carryii^
the incision into the mesentery and removing a wedge-sliaped piece (see p. 917,
Fig. 861).

Third Step. — The divided edges of the intestine are united by four pniimi-
nary fixation sutures of plain cumol catgut (No. a) which hold the parts togetber

FiO. SfiS. — Etm-TO-Eini Amamxosn ai Miams or thi Laplace Foicin ij»tt«at!).
Showina ihe Icccia dunpcd tad opeocd u iwo ricici.

and secure an even approximation when the forceps is applied. These sutures
pass through all the coats of the intestine and are introduced as follows: TIk
first suture passes through the mesenteric borders and invaginates both iamiae
of the mesentery; the second unites the antimesenteric margins; and the thiid
and fourth sutures are placed one on each side so as to approximate the liunl
edges of the divided gut (Figs. 869 and 870).

FouKTH Step. — The forceps is introduced closed into the lumen of the

MdStjmn^i^

Fic. 86g.— Third Step. Fin. Sw — TliiiJ Sw^

EsD-TQ-Tsn ANA^TOiinsis by Mean^ nt mr. [.aplack Fohcefs.
Fig. Jf6g %hows Ihc inrcslinu rcs(^c<l and ihc liiaTioD smuri^ in po^lion ; Fig- !^70 &hoi^ ihe fair>n taiaia

pul between one of the lateral and the antimeiientcric fixation suture (Fif!. ^;0
and then opened slighdy so that one ring passes a short distance into the A\itM
and the other inln the proximal end of the divided bowel. The free edges I'l
the intestine are now inverted or pushed in between the two rinfp, whirfiafe
then closed and the handles of each half of the forceps locked.

Before locking the forceps the scat of approximation must be carefully a-

932

TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

preliminary fixation points between the rings and increase the area of approii-

mation (Figs. 872 and 873)- The handles of the forceps are then locked and the

thread withdrawn.

Fifth Step. — The divided ends of the intestine are united by a series of

closely applied mattress sutures which are passed completely around the approxi-
mated margins and include the serous,
muscular, and part of the submucous coats
just beyond the position of the rings of the
forceps. The sutures should be introduced
close to the handles of the forceps and car-
ried around the bowel, passing between the
divided edges of the mesentery up to tbe
point where the forceps emerges from tbt
intestine. The sutures are not tied undl
they are all introduced {Fig. 874).

Sixth Step. — The forceps is undamped
and the handles unlocked. The two halve
of the forceps are then withdrawn separaldr
from the intestine by a semicircular rowe-
ment (Fig. 875).

Seventh Step. — The small opening
which remains between the edges of ihe
intestine after the forceps has been tcmottd
is closed by two mattress sutures, and if

there is any doubt as to the ef&dency of the approximation a continuous Lero-

bert suture is carried around the bowel (Fig. 876).

Eighth Step. — The edges of the mesentery are brought together and unitei

by a continuous silk suture, care being taken not to include any of the blood-res-

sels which nourish the bowel (see p. 926, Fig. 860).

Fic. S7b. — End- TO- END Ana^stoumu iv
MEAua or im L*pl*ce Fdicbps—
ScTcnth Step.

Fic. 877. — Ehd-to.enp AN.ASTOHOSEic by Means of the O^Hara Foicets.
Showing the fyHara forceps.

End-to-end Anastomosis by Means of the O'Hara Forceps.— The aw^'
tomosis forceps is clearly shown in Fig. 877, and therefore no descripiw" ls
necessary.

934

TECHNIC OF ABDOMINAL AND PELVIC OPERATIONS.

accomplished by examining the blood-supply from the mesentery and ptadng
the forceps just beyond one of the mesenteric vessels.

Second Step. — The mesenteric vessels within the area of excision are
ligated separately with fine silk (No. 2, braided) and the bowel resected with
straight scissors as close as possible to both forceps, carrying the incision into
the mesentery and removing a wedge-shaped piece (Fig. 879).

Third Step.— The divided ends of the bowel are brought in contact with
each other and held in position by applying the serre-fine damp to the forceps
(Fig. 880).

Fourth Step. — ^The distal and proximal ends of the intestine are unild
by a series of closely applied mattress sutures which are passed completely anmiid
the approximated margins and include the serous, muscular, and part of the sub-
mucous coats just beyond the blades of the forceps (Figs. 8$i and 883).

The suturing should be started at the antimesenteric aspect of the bowd,
close to the blades of the forceps, and carried to the tips of the instruments. Tht

Fio. 880, — Ehij-to-ekd AMAsroMosis BV Means o» the O'Haui Foici«— Thirt Slip,

sutures are (hen tied and the opposite side of the di\'ided bowel exposed toviw
by reversing the piisition of the handles of the forceps. The sutures are ^"^
passed in the same manner from the mesenteric edge of the bowel and seoird;'
tied, when the last suture is introduced close to the blades of the forceps.

Fifth Step, — The serre-fine clamp is removed and one pair of forceps u"'
locked and withdrawn in a straight line from the bowel. The other foro^ "-'
then unlocked and passed above and below the line of anastomosL=; within <lit
lumen of the gut before it is removed, in order to make sure that the sutures ha"
not penetrated the intestinal mucosa and picked up the opposite w-all of the bo«d
(FiR. 883).

SixTn STEP.^The small opening which is left, after the forceps hasoMn
removed, in the antimesenteric aspect of the seat of anastomosis is dos«i D)'
two maltrcss sutures, and if there is any doubt as to the efficiency of the appw^'
mation, a continuous Lembert suture is carried around the bowel (Fig. W)-

936

TECHNIC OF ABDOMINAL AND PELVIC OPERATtOKS.

Second Step. — Ligate the mesenteric vessels within the area of eidsioD
with silk ligatures and resect the intestine with straight scissors, carrying the in-
cision into the mesentery and removing a wedge-shaped piece (see p. 927, Fig.
861).

Fic. Ms. — Ein>-K>-xini Ahastohosu by Means o» the Mubfbt Bdtton — Third SMp.

Third Step, — A silk overhand purse-string suture (No. 7, braided silt) is
placed around the divided ends of the intestine, before the two halves of the but-
ton are inserted into the upper and lower segments of bowel, in order to pucker
up their edges and draw in the mesentery within the bite of the button. Tbe

Fifi. SS6-^END-rO-END A.^A^T01|{>SIS BY MfANS OT Trt£ MltBWV Bl'TTON — FouTtb Step.

suture begins at the ami mesenteric surface, passes through all the ciats i« tW
intestine, crossing and recro.ssing at the edge of the mesentery, and finally emerp'^

aboul J of an inch from its point of entrance (Fig. 885).

FouKTH Step.— The female button is held by its stem with a pair of narto"

938

TECHNIC OF ABDOUINAL AND PELVIC OPERATIONS.

Sixth Step. — The anastomosis is reinforced by passing a continuous Lon-
bert suture around the margins of the approximation, and the edges of the mes-
entery are finally whipped together by a continuous siilt suture (Fig, 888).

Remarks. — The Murphy button, which is manufactured in se^'crat azti,
is an ingenious mechanic device for making an intestinal anastomosis, and is
especially valuable when the condition of the patient demands a rapid method
of operating.

Fio. SSg. — The Muiphy Buttdh.
The butlca ii ihawn opened and cloed-

The constant pressure exerted upon the intestinal walls with the bite of dM
two halves of the button results in necrosis, and the instrument is finally dis-
lodged and dischai^ed by the rectum.

Lateral AnastomoBiB by Means of the Laplace Forceps.— The Fiesi,
Second, and Third Steps of the operation are the same as in a lateral anastp-
mosis by means of Halsted's mattress sutures (see p. 936).

FiGr BQOr — Lateral \nASTOuosti by Meass Of TUE Laplace Fobceps — Fourth SEtp.

Fourth Step. — Each end of the bowel is held in turn by an assisunim
such a manner as to .'separate its walls while the operator makes a longituilii'^
opening along ihe a nti mesenteric surface about the length of the diamti« "i
the rings of the anastomotic forceps (Fig. 890).

Fifth Step. — The two halves of the forceps are clamped together and tiw
opened so as to form two rings. One ring is now passed through the lonpfii-

TECHmC OF ABDOMINAL AND PELVIC OPERATIONS.

'he sutures should be introduced close to the handles of the forceps and tar-
ed around the bowel up to the point where the forceps emerges from the
itestine. The sutures are not tied until they are all introduced (Fig. 893).

Seventh Step. — The forceps is undamped and the handles unlocked. The
vo halves of the forceps are then withdrawn separately from the intestine hy
semicircular movement (see p. 931, Fig. 875),

Fic. S04.— Lateial Ahastouosis by Means or tbe Laplace Potcm — figlith Sta|L

Eighth Step, — The small opening which remains between the edges of
le longitudinal incisions after the forceps has been removed is closed by two
lattress sutures, and if there is any doubt as to the efficiency of the approxi-
lation, a continuous Lembert suture is carried around the bowel (Fig. 894).

Ninth Step. — The mesentery is brought together and united by a con-
nuous silk suture (see p. gaS, Fig. 860),

FiO- Sg5r — Latebal Anastouosts by Means or the O'Haha FoifCEPs— Fourth Stop.

Lateral Anastomosis by Means of the O'Hara Forceps.— The First.

ECOND, and Third Steps of the operation are the same as in a lateral anas-
imosis by means of Halsted's mattress sutures (see p. 926).
Fourth Step. — The antimesenteric surface of the upper piece of bowel
picked up with rat-toothed forceps and grasped between the blades of one of

OPERATIVE UMlPLICATtUNS.

941

the anastomosis forceps whJdi is placed parallel lu (he long axis of the gut. The
lip of titc forceps must be placed un an exa.ct level willi the etdgf of the bowel,
and the length of tlK bite depends ujion the kuec of Ihe desired anaKtumolIc
opening. 'ITie antimcscDteric surface of the lower segment of bowel is then

Fts iq«.— rum SMf, Kir. »U7 — niih SMp.

l.AT»u AiiuniUDiii BT Mlun nr nu O'Mii • i'l'm m

picked up and grasped in a similar manner bv the bUdcv "f the other forceps,
making the hitc of the iii.'irument of tlie same lenRlh as that on the upper end of
Ihe gut by obficniDg (he graduated lines nn the blades uf the fnrce|» {Fig. 895).

' Pm. S«fi.— Latt**) Avumuoiu >■ tXum or ike CVIUu Fau:Br»-41itb )Wp (p«ce 04>) -

FiPTH Step.— The portion of the intestine lliat projects bc>'ond ilie bile
of each forceps i* cui away a^ dose as possible with straight ■uri'^Miry and the nw
edges of tlie anastomotic openinjp brought in riinl3<'t with each other and held
in position bv applying Ihe serre-fine ctamt^s to the handles of the instrument
(Figs. 896 aiid 897).

943

TECHNIC OF ABDOUINAL AND PELVIC OPEHATIONS.

Sixth Step. — A series of closely applied mattress sutures are passed com-
pletely around the area of approximation just beyond the blades of the forceps.
The sutures are first passed from the lock to the tips of the forceps; they arc tlitn

Fic. SM'— LjtTEiAi. Ahastohosib by Mkani or thi Muiray BcmiH— Fourtli Sta^

tied and the opposite side of the bowel exposed to view by reversing the poatka
of the handles of the instrument. Sutures are then placed in the same nasaa
on this aspect of the bowel and securely tied when the last suture is introducoj
close to the base of the blades of the forceps (Fig. 898).

Fig. goo. — LAttKAi. ANASTOUoiis Bv Means of the Mi'RPifY BrrroN— Filth Step.

SFVENTn Step. — The technic of this step of the operation is similar to the
fifth step (if an end-to-end anastomosis with O'Hara's forceps (see p. <)iA)-

944 ANTISEPSIS IN PRIVATE BOCSES.

Fourth Step. — Purse-string sutures (No. 7, braided silk) carried by a small
full-curved intestinal needle are placed on the antimesenteric surface of the ends
of the intestine around the site chosen for the insertion of the two halves of the
button. These sutures pass through all the coats of the bowel and are used lo
draw the edges of the anastomotic openings around the stems of the buttoo
(Fig. 899).

Fifth Step. — Each end of the bowel is held in turn by an assistant in sudi
a manner as to separate its walls while the operator makes an opening with 1
scalpel, slightly shorter than the diameter of the button, into the lumen of the
gut, parallel with its long axis and between the hnes of the purse-string suturt
(Fig. 900).

Sixth Step. — The male half of the button is inserted into the proximal
end of the gut and the purse-string suture tied. The female half is then pas.<«d
into the distal end of the bowel and secured in the same manner (Fig. 901). (S«
End-to-end Anastomosis with Murphy's Button, Fourth Step, p. 936.)

Seventh Step. — The male is slowly pushed into the female stem until the
two halves of the button come together and compress the intervening intestiaal
walls. (See End-to-end Anastomosis with Murphy's Button, Fifth St^ p.

937-)

Eighth Step. — A continuous Lembert suture is passed around the mar-
gins of the approrimation and the edges of the mesenteiy arc united by a con-
tinuous overhand suture (Fig. 902).

CHAPTER XLII.

ANTISEPSIS IN PRIVATE HOUSES.

GENERAL CONSIDERATIONS.

Selection of the Operating Room.— The room should be sefccied
by ihe surgeon or the attending physician. It should be close to the room to be
occupied by the patient after the operation; well lighted, when possible, bra
northern exposure; and so constructed as to be readily cleaned.

Axrival of the Norse. ^For mitwr operations the nurse should be sent
to the house on the morning preceding the day of operation and given detaifcd
instructions in writing as to (he preparation of the patient (see Minor Open-
tions, p. 830) and the necessary arrangements to be made. For ahdominal opiri-
tions she should Ix; sent lo the patient's house six days before optcration. n'hich
is the length of time usually devoted to the preparator>- treatment (see Abdomi-
nal Operations, p. 834).

As in hospital practice the preparatory treatment of the patient may be short-
ened or lengthened according lo circumstances, and in cases of emergenoii
mav be necessary to operate at once.

Preparation of the Operating Room.— On the day before iheopen-
tiim the furniture, curtains, pictures, carpets, and rugs should be removed ftnm
the nxim; the IliMir scrubbed with soap and water; and the woodwork, the ceil-
ing, and the walls wiped with a wet cloth. The operating and supply table ii*i
the wash.'.tand and chairs are then scrubbed with soap and water and Hiped "ith
a damp clnih.

On the mi>rnin.n of the operation the woodwork and al! the articles in ih'
room should be wiped with a wet cloth and everything properly arranged be-
fore the surgeon arrives.

ASDOUIKAL 0PEKAT10NS.

945

ABDOHINAL OPERATIONS.

The nufM must personally attend to the followini! prquiralions fnr the
operation :

Articles Reqtiired.— I. An ortlinar>- wooden kitchen table to be used
(or ii)>eniting u)>on.

3. Two utiles, ciuh about (our fi-ci l<jng nnil twenty inchcswide (one to be
uacd for the inslrumcnts, etc., and the other for ^up[jlies).

3. A wushxiiind or Uible I0 hold two liii>iii.i for sterilization of the hanils.

4. A wooden kitchen chair for the anesthclizcr.

5. Two china or wooden buckets.

6. Five chin:i or cnameksl pitchers (for cold, hot, and mixed sterile water
and for cold and hot normal »lt solution).

;. Four china or enarocled basins (two for tlie sterillxulion of iJie bandit of
ibe (>{)Crator and the assistant and two for utc during the oiHTatlon),

8. Three dean sheets (for the operating, instrument, and supply tables).

9. Six clean soft lowcls.

10. Two wtMik-n blankets (one for the operating table and the other to throw
over the patient).

It. Two targe tin wush-lMilent.

13. A tin pint ladle with a loi^g handle to use for dipping out and mciLsur-
Ing the sicrile water.

13. Six galliins each of hot and cold sterile water.

14. Three quarts each of hot and oold nornnal salt solution,

15. HyjKKlermic syrinRC.

16. A china dlth fur fiirmnlin solution.

Sterilization of the Water.— Tlie evening prece<iing the d(iy of
oprr^liun six gallons <.f water .ire Imik-d for half an hour in one of the wash-
boiJers (after it has been Ihorovighly scrubbed and rinsed) and set aside in the
operating room to cool ovcrniKhl. The tovcr sliould be kept on the lioilcr.
olhcrwiM Ihc water will t>c iinprotccti-d and may become contaminated. On
ibe mominR of the operation six additional f;allons of water are boiled for half
an hour in tlie other wash boiler und placed in the opemting room; the tin ladle
is stcrili/ci bv placing it in the wash-lxiilcr while the writer i' boiling.

Sterilization of the Pitchers, Basins, Fountain Syringe,
and China Dish. — On the day of ihcojier.-itiiin the pitchers, hasins.and china
dish arc ihoroiiphiy scrubbed and rinsed and then tailed for five minutes in the
wash-boiler which is used later for sleriliKing the hot-water supply. The water
is then carefully [wiured out of the lw)iUT, which is taken in the operating room,
and the pitchers and basins removed and placed on the supply table without
touching tlie iaside of any of the vessels.

The fnunt4iin sj-ringc is wrapped in a towrl which is secured with nfcty-pins
and boiled with the pitchers and basins. It is uken out of the wash-boiler and
placed on llie suF)p!v l;dilc still wni|ipe(l in the Inwel.

Preparation of the Normal Salt Solution.— Shortly beforv the

t^ralion tlic normal salt loilutiim shimid he jirciJurtd as follows; Take twelve
tea^fMionfuls of chemically pure stHlium chWid and place them in a small agate
cup holding s pint of water. lioil the siilulion for ten minutes and pour half
into one of the china pitchers and the nlher half into another pitcher. Then
I>oiir with the ladle three quarts of hot sterile water from the wash-boiler into
one of the pitchers and three quarts of cold sterile water into the other. The
pitchers are then Net a.Mde on ihe su|>]>ty table and the Mtutionit mixed at the
proper tentpcralurc when required.
60

946

ANTISEPSIS IN PRIVATE HOUSES.

Articles Sent by the Snrgeoii from the I>niggi8t.— These

articles should be delivered at the house of the patient the day before the opera-
tion:

1. Four ounces of chemically pure sodium chlorid.

2. A cylinder of oxygen gas and the inhaling apparatus.

3. Twelve hypodermic tablets each of sulphate of strychnin (gr. ^), sulpbate
of atropin (gr, t\z), nitroglycerin (gr. f^), and sulphate of moipbin (gr. J).

4. Eight ounces of tincture of green soap.

5. Fountain syringe (three quarts).

6. Two hot-water bags.

7. One roll of Z.O. adhesive plaster 2 inches wide.

8. Twenty-four corrosive sublimate tablets (i to a pint = i to 1000).

9. One pint of alcohol.

10. Three half-pound cans of ether and four ounces of chloroform.

11. Two hand-brushes made of vegetable fiber.
13. Bed-pan. Small alcohol lamp.

13. One pint of a 5 per cent, aqueous solution of formalin.

14. One yard of rubber sheeting.

15. Two female glass catheters.

window

AntitMjitr'a

ToHt for
liuTniwib

Siifply
Table

-9.

eutkfti

(Wr-
ing

__ffi_

sMuh
Staul

I » '

Door

Fifi, 003. — DiAOHui Shoivino the Aubanceuent of a Kooif Pbepaib> pok an Abzwunal Owmfw-

Arrangement of the Operating; Room, — Before the arrival of ^'
surgeon the nurse must have everything ready and properly arranged a? foll««'>:

1. The operating table is placed in front of a window with a chair for tl"
ane^lhclizer at its head and a bucket on the lloor alongside of the positinn of Jif
operator. Two blankels and a sheet are folded separately and laid on thetiblf
ready lo phicf in position when the adjustable operating frame is altachfd ^inl
the patifiii is under the anesthetic.

2. The instrument table is covered with a sheet and placed on the right-'iilf
of the optTLUinj; l.nhic within a convenient distance of where the o[>eralnr slaW'-
The twn basins which conUiin the sterile water used by the surgeon for hishaw-
during the operation are placed on the end of the table.

3. The .sujiply table is co\'ered with a sheet and placed out of the way nn ""
opposite side of the rnum. The following articles should be placed onit'i*'

ABOOHtNAL OPERATIONS.

94?

Two pitchers contnining htit aiul roM nonnal sill dilution, two filled with hot
and cold slcrile water, andonrrmpty pitcher for mixing'. (&) the fountain syringe
wnppnl in the lowd in uhich it was Merili»Hl; (c) a hytHxIcrmic >yrinKC and
the cardinc ami resjiinton Mimulanls: .str>Thnin, atitijiin, nilniglyi:crin, and
norphin; (d) mc oxid adhesive planter and the alcohol lamp; (e) ether and
chloroform; (/) a china dish filled with fortnalin Mflution.

4. The two wa-<h Ijuilt-rs mnt;iining hi>l iind cold sterile water, the cylinder
of oxygen RaB. and the second bucket are plated on the floor at the side of the
supply table.

$. The washstand or table used for hand sleriliitalion h placed on the oppo-
site side of the room from the supply table, and tincture of soap, two basins, and
six sod towels are arninnfl i^n it-

Articles Carried by the Surgeon or His Assistants.— The fol-
I lowing articles are brought to the patient's lii>use bv the surgeon ur bis as.iistafll

Pill. VII-— Auitoh'i Ij11u.( Ctn(Vt1*Hi:t Bttt.
Ngu <Ih Baagi nr innir rial et (t« Ud of iJw tea.

Operating pamphernalin,

A portable Trendelenburg
frame.

Thcmwmcter, rubber drain-
age syringe, and laij^ui.

Operating Paraphernalia.
—The method of sterilizing the
articles and the manner in
which they are conveyed to
the house of the patient de-
pend upon whether the surgeon
has access to a high-pressure
steam sterilizer or noi. If be
ha», the article^ arc steri!ize<l
by high-pressure steam on Ihc
day of the operation, otherwi.se
ihty are packed in a portable
sterilizer which is heated on the
range or by an alcohol lamp
at the patient's houi^.

High-pressure Steam Sterilizer. —For operations at pri-
vate houses 1 have devised a large convej-ance box which is made of heavy cop-
per or tin and divided into two comjiartmenl*. The box 1% ao inches lung, to
inches wide, and 7 inches deep, and the lid is made with an outer and inner rim.
The former is 3 inches and the latter } of an inch deep, and they arc se|>araled
from each other by a tq)ace »( { of an inch. This siiarc. which form* a narrow
slot into which the upper edges of the box fit. is loosely packed with cotton l>al-
tlng in order to t>r<)iect the contents of the Im>x after they have Ivi-cn sterilized
(Fig. 904). Witn Ihe upper edges of the box thus imbc-dded in cotton batting
the contents are absolutely protected from contamination and can be kept in an
aseptic condition indefinitely. I ha\'c a ciinva» cover fur the Imix which rirj[j«
tightly over it and keeps the lid firmly pressed down.

I keep two of these boxes at ihe hI•^|]iUil, each packed for an alxlominal sec-
lion, arwt when a call comes for an outxidc opemlion a li.st of the neies,s;iT>' in-
slrumcnls, ligatures, sutures, and needles is sent to the clinic nurse, who places
ihem in one of the boxes, which is then sterilized and -^-nt lo my ctlke. Tlw
Jiox in relumed to ihc hospitnl after the operation and at nme rquickcd.
~ The following illustrations show how the box is pbccd in the steriiuscr and

948

AN'mSKIS Di PatVATE BOOSES.

the method of [niltinf; on the lid after sterOixatioo without infectiof h»
surfaces (TiK^. 905 anil i)of>).

The contents of the box nrc packed in a special order so that tfaoM ;
whidi ure u.>>crl fim will 1>e on lop and can be taken out without tlisturlMng I
rest.

The foUowini; articles arc placed in the box in the coder in which they .
gii-en:

I, The abflomtnal drewings (sec p. Ssj).

a. Two ^auzc tampons (see p. 83;).

3. GlanA and rubber draina||[e-tul)es of dffTerenl ftizes: a long metallic 1
for the fountain syringe; a n<-e(ile for h>-podcnnocl)-^s; a canouhi (or ji
venous saline injections; and a rcclal tube for enteRKilynU,

Thetie arlide> are wmppetl in gauze and care should be taken to pfvtnll
the gUi^ drainage-tubes from being broken. The nocdlc, cannula, and ini|:it'
ing nozzle arc wrapped scparaicly in a .small towel with a teaspoonful ol' ai-
bonale of mmLi {to prevent rusting) and secured with safely-ptns.

4. Light small and four large gauze pads.

5. Four dozen ^auze &])onges.

6. Eight safei/pins wrapped in gauR.

Fin. oat. Fic «M.

MntinD lit STniiisNa wini Amroir'* Uuoi CoaviiuKm Bm
Fll'«ejihom live toi in iticUcrilUn >nil lIxiTlUin naHiaBar iuUd; Fik. noft i>B»i iW iiifltlil *•■
Ihc Ud on* tile Im bcton il u nmavnl Irora Ac HcnbH.

7. Eight loweli.

8. One shixl.

q. Instruments: needles; silk ligatures and sulurcs; and Mlkwonn-|
The in:itrume[it\ and ni-edlcs are wrai>]>eil in a towel with an otincT nt Ot-

bonatc of soda (to prevent rusting) and secured with safety-pins. DurinfAt
sierili^atioD the soda is dcfHisited as a fine powder on the in.->tnimeDt9 and iKeJi_
and ru.^ting la prevented, which in^':innbly ixvurs unlc;^ thiv precsiuliuii i>
The cutting inslniments are prulcctcd by wrapping absorbent cotton j
their blades and the needles kept together by pasising them ihrau^ ■ ut*"
gauze pud, which is then folded over u[«m itsdl and seeurcd with a «lf»r-l*
The silk su(urr» and ligatures are wound on glass slides and «n|ia *
gauze. The slrand-s of silkworm-gut are wrapped at full length in a loiMMl
secured with siifcly-pin.s.

10. Two glass female catheters wrapped in gauze.

11, Four pairs of rubber glcjves wrupjied in gauze.

I J. Three ojieniting gowns— for the surgeon, the assistant, and tJw n«*

13. Five hjnd-brushes, Four of these br\i>hcs arc wrapped togflfco*

gauze and are used fur the i'lerilization of (he hands. The fifth brush b •nff'

ABD0UINA1. OPERAnONS.

949

irately and is used to srrub the abdomen of ih« patient when (he parb are
rinally steriliKetl.

Portable Steam Sterilize r.— The Rochester combination sterilizer
is one of the best I know of, and can »afely be recommended to surfceoos who do
not have access to a high-|irc;Lsurc titr-im appamtus. It mu»t be targe enough
to hold the opcratiriR paraphernalia, and 1 have found from eipericnte that the
vteriti/er known xh No. toS, which is iS inches lon|{. 'i in('he> wide, and X inches
deep. cxclusiH'e of its lower part or ba»r, is inifficicntly spacious for all practical
iniruoses. The construction of the sterilizer is very aimj>le, ronsi^linf; of a
douWe-walled Ijox with a cover which sets nn n removable hume containing the
water for generating steam (Fig. 907). The two wire Iniys which come with the
a[»]hanitus are of no pnutical use and *houl(i lie disi-iirdcij. A canvas cover with
a leather handle should be made for the sterilizer in order to protect it from gross
forms of contamination and facilitate its transportation.

The surgeon should keep the sterilizer m his home with (he double -walled
box packed and ready to take to an operation.

The foIlDwing arliclea are placed in this part of the apparatus in the order
in which they arc given:

£EAtvi'

Fie. (b;.— Die Rnnmnci CouuHAiicm Siuilmu iNo. lel).

I. The abdominal dressings.

7. Two gauze tampons.

$. Glass and rubber draina)re-tubes of differenl sizes, a metallic irTigating
nozzle for the foinitain syringe, a needle f«>r hypt«|erraocly*i*, a cannula for
intravenous saline injections, and a rectal tube for enlcroelysis.

4. Eight small and four large pads.

5. l-'our dozen gauxe sponges,
^^ 6. Eight safety-pins.

^H 7. Eight towt^is.
^B 8. One sheet.

^H 9. Two glass catheters wrapped in gauze.
^H 10- Four [Klin of rubber gloves.
^H If. 'I'hree operating gowns.
^H 13. Five hand brushes.

^H The method of i'.icking these ;trticle« and protecting them from injur)' is
^T»e fame as described under hiph -pressure steam slcrilizalion.
I The in^tnimeiiL-. needk-s, silk ligatures and sutures, and the silkwnrm-gut

krc placed in the ba«: uf the ap[>aTnttis when a call comes (or an opcmtion and

95°

ANTISEPSIS IN PRIVATE HOUSES.

sterilized by the boiling water which generates steam for the double-walled box.
The methnd of packing and protecting the articles from injury is the same a^
described under high-pressure steam sterilization, with the exception that car-
bonate of soda is not wrapped up with the instruments and needles.

Portable Trendelenburg Frame.— Dr. G. i. McKelway's portable Tren-
delenburg frame, which has been modified by Charles Lentz & Sons, Philadd-
phia, is the best operating table that is made at the present time, as it is very
simple in construction and light in weight. The frame is made througfaoid
of tubular steel and the top is covered with thin metal sheeting. It can be
readily attached lo any kitchen table and made secure by clamps (Fig. goS). 1
have had a canvas cover made which facilitates the transportation of the taMe
and protects it from gross forms of contamination. The surgeon sbould keep
the table at his home.

Thermometer, Rubber Drainage Syringe, and Catgat. — A combioatioii
thermometer for testing solutions, a rubber drainage syringe, and selected sizes
of plain and chromicized cumol catgut are carried to the patient's house in a
small surgical bag which is packed by the hospital nurse and sent with tbt

FiG- ^oi- — Lemz's ^fODI^cAT1□H or McKelway's Pobtable TRENnKLENBiric Fkame.

conveyance box to the operator; if the surgeon uses a portable steriLzCT, ht
must keep these articles on hand at his home.

Arrival of the Surgeon. ^When the surgeon arrives at the house of
the [>atient, he should proceed as follows:

1. Inspection of the Operating Room. — The position of the tables ittfi
the arrangement of the various articles in the operating room should be cart
fully ins|)ectcd and any mistake or oversight made by the nurse corrected a'
once. It is u goo<l plan to have a written scheme of the arrangemeni nf ^
operating r(H>m as given on page 946 and check off the preparations niadf ^)'
the nurse in a systematic manner.

2. Attachment of the Trendelenburg Frame. — The surgeon direct the
nurse how to attach the Trendelenburg frame to the kitchen table and satkfifs
himself that it is securely clamped and the blanket and sheet properly sprrau
over it,

3. Thermometer, Rubber Drainage Syringe, and Catgut.— The ihtr-
mometcr and rubber drainage syringe arc put in the solution of formalin and
the boxes containing the catgut are placed on the supply table.

HINOR OPERA TIUNS.

«»

4, Sterilization of the Hands. — The nunc lakes ifac conveyance box out
o[ ils ntSL- ^ind |tl.icc« it on ihe instrument l^blc. Tlic lid i> then reiunvcd and
plated out of ihc way.

The surKei'n and hi* utuisUiiit remove their coals, vesis, colliirs, and cufTs,
nd roll up iheir shin -sice vvs well Iwyoinl the elbows, 'I'hc tu nil -brushes axe
then taken out of the conveyance box wilhout touching any other article and
tlie surgeon and his aM-i^tani (irucecd to sterilize their hands by Ihe method des-
cribed on |wigc 815.

5. Operating Gowns and Rubber Gloves.— The method of putting on
be liiownK and gloves i^ de>tTil>L'<l on iiiiiii; 81(1,

6. Arranging the Instruments, nMdles, and Sutures.- The lowd con-
lainin]^ the iiu-iirumciu.- and ncc<lle^ h ••)jciied an<l bid on the <lre^int;s at one
end of the box. The silk ligaliin--> ;md lh<: Mlkworm-gul are alvo unwrappol
and placed alongside of the instruments.

7, Final Arrangements.— The patient is cirrinl into the operating mom
by the ancslheli/rf nml the nurse, .ind if jihc ix wry heavy one of the servants
should be ordered to assist. She is then placed on the tabic and her legs fas-
tened to the Treiidclciiburi; frame. Tlie nur»c then .secures the patienl'> hand.s,
unfastens the sheet which is wrapped around bcr, and removes the abdominal
comi>ress (Fi);. 767). The o|>erat»r then scrubs ihc abdomen n-ith soup and
water and douches it with plain sterile water. He then [lut.^ on a fmh pair of
Itloves and protects the field of operation in the manner described on page 837,

JuAt before pnii-eerJing witli the operation the nurse put> on a pair of rubber
gloves and a sterile gown, which are taken out of the conveyance box and
banded to her by the operator.

Sterilization with a Portable Sterilizer.— So soon as the wrgeon
or his assistant arrives at the house of the paiicni the slcritizatiun of the operating
parapherniilia should l>e started. The base of the sterilizer is fdled with a i per
cent, solution of carbonate of soda; the apparatus placed on the range or
over an alcohol lamp or gas-bumcr, and the water boiled for one hour. The
steriltxer is then |>bced on the in.strumenl table and the doublc-widletl box lifted
from the base. The base of the app.Tratus is used as a tray for the instruments,
needles. an<l ligatures, and the upper box as a recei>tai:lc for ihe dreaitlngs, etc.

While die o|>erating paraj>hemalia i^ being sterilised the surgeon should
ins])ect the arrangement in the operating room, attach the Trendelenburg frame,
place the thermometer, drainage syringe, and catgut on the supply table.

KINOR OPERATIONS.

The nurse must personally attend to the following preparation.s for the
Ition:
_ tides Required.—!. An ordinary kitchen table to be used for

"opera tin K ujion.

a. Twi> i;ihles each about (our feet long and twenty inches wide (one to be
used for the Instruments, etc., and the other for supplies}.

3. A tva>b.-<ia!i(l or tiible to hol<] iw>i basln.t for .■'lerilization of the hands.

4. Two wooden kitchen chairs (one for the uperator and the other for the
sthetizer).

5. Two china or woixjen buckets.

6. Three china or enameled pitchers (for hot. cold, and mixed sterile water)
four china or enameled basins (two for the sterilization of the hands of the
ilor and hb iixsiKtant, and two for u.-ie during the operation). If two

953 ANTISEPSIS m PRIVATE HOUSES.

assistants are required, as, for example.in operations upon the perineum, an eitn
basin is needed for sterilisation of the hands.

7. Three clean sheets (for the operating, instrument, and supply tables).

8. Six dean soft towels.

9. Two woolen blankets (one for the operating table and one to throw ova
the patient).

ro. Two large tin wash-boilers.

II. A tin pint ladle, with a long handle, to use for dipping out the sterile
water from the wash-boilers.

13. Six gallons each of hot and cold sterile water.

13. A hypodermic syringe.

Sterilization of the Water.— The same method is employed that is
described under Abdominal Operations on page 945.

Sterilization of the Pitchers^ Basins, and Ponntain Syringe.
— The same method is employed that is described under abdominal opera-
tions on page 945.

Articles Sent by the Surgeon from the Drng-sist. — These
articles should be delivered at the house of the patient the day before the operation.
I. A cylinder of oxygen gas and the inhaling apparatus.
a. Twelve hypodermic tablets each of sulphate of strychnin (gr. ^), sulphate
of atropin (gr. ylr), nitroglycerin (gr. j^), and sulphate of morphin (gr. i).

3. Twenty-four corrosive sublimate tablets (i to a pint = i to locxj).

4. One ounce of tincture of iodin.

5. One ounce of pure carbolic acid.

6. One pint of alcohol.

7. Eight ounces of tincture of green soap.

8. Fountain syringe (3 quarts).

9. Two hot-water bags.

10. Three half-pound cans of ether and four ounces of chloroform.

11. Bed-pan.

la. One yard of rubber sheeting.

13. Two hand-brushes made of vegetable fiber.

14. Two glass female catheters.

15. Four ounces of chemically pure sodium chlorid (to wash specimens).

16. One pint of a 5 per cent, aqueous solution of formalin (to preserve
specimens).

Arrangement of the Operating Room.— Before the arrival of the
surgeon the nurse must have everything ready and properly arranged as follows:

I. The operating table is placed in front of a window with a chair at its
head and foot for the anesthetizer and the operator. A blanket and sheet are
smoothly laid over the top of the table and a bucket is placed on the floor for
drainage.

a. The instrument table is covered with a sheet and placed on the left at
the foot of the table within a convenient distance of where the operator sits.
Two basins for sterile water are placed on the end of the table.

3. The supply table is covered with a sheet and placed out of the way on
the opposite side of the room. The following articles are placed on it: (a)
Two pitchers with hot and cold sterile water and one empty pitcher for mixing;
(i) the fountain syringe wrapped in the towel in which it was sterilized; (c)
a hypodermic syringe and the cardiac and respiratory stimulants — strychnin,
atropin, morphin, and nitroglycerin; (rf) ether and chloroform; (e) corrosive
sublimate tablets, (incture of iodin, carbolic acid, and one pint of alcohol.

4. The two wash-boilers containing hot and cold sterile water, the cylinder

MINOR UPEKATIONS.

9Si

of oxygen, and the wcond buckd arc placed on the Hiwr al the »ide of the supply
table.

5. Th« washsUnd used for sterilisation of (lie hands is pUtnd on the oppo*
site side of the room frnm the supply table, and n bottle of tincture of green
»p. two biisins, and Mx si>fl towels arc arraiiRcd on it.

Articles Carried by the Snr£:eon or His Assistant.— The foi-

yviag, Aftidci are brought to the patient's house by the surgeon or his assistant
00 the day of the ofteration :

Operating paraphernulU.
Adjustable le.i;-hol<k'rs,
CfltRUt and Kelly's surgical pads (Fig. 15).
Operating Paraphernalia.— The opcratini; paraphernalia arc sicniizcd by
hi^-prcssure steiini at the hospital or in a jxirtable Merilixcr at the patient's
house.

High-pressure Steam Sterilizer . — I use the same kind of
conveyance box as described under Abdominal Opentions on page 947, and

window

OpcroItM Chair

Tabl« For

Initrufflffili

Orfisin9s

til t SOJIM

Anotiutii) rK CKalr

1 BoiUr)

Poor

Fw- oeo^— 'DiAf^iAM SiiowiHO iiu AnJ^L^vtifuhiti or a titnu VtiLrktU} roi a Mimii OmunciV.

Iwoof ihcrn are alw.-iy> kept packed at the hospital for a minor operation. When
comes for an outside opemiion. the necessary instrument*. Ii^j^iitures,
B, and needles are placed in the bo\, which is then sterilized and s*nl to
my <>flice.

I'he following articles arc placed in the box in the order in which ihey an
given:

I. A T-bandagc.
I a. A guuJie compress.
' 3. Two gauze tampons.

4. A loosely rolled layer of absorbent cotton 4X13 inches.
S- Tlirec dozen sponges.

6. Eight towels.

7. Two glass female catheters wrapped in gauxc.

8. One sheet.

9. Instruments; needles; silkworm-gut; and perforated shot.

9S4 ANTISEPSIS IN PRIVATE HOUSES.

The instruments, needles, and silkworm-gut are wrapped in the same man-
ner as described under abdominal operation on page 94S, and the peiforaled
shot is placed on a small gauze pad the edges of which are gathered up and tied
with a piece of string.

10. Three operating gowns (for the surgeon, the assistant, and the nurse;
an extra gown should be provided if two assistants are needed).
' II. Pour pairs of rubber gloves (an extra pair of gloves should be pnnided
if two assistants are needed).

12. Four hand-brushes (two extra brushes should be provided if two assist-
ants are needed).

Portable Steam Sterilizer , — The Rochester combination steril-
izer, which is described under abdominal operations on page 949, is spadoui
enough for all practical purposes, and should be used by a surgeon who does
not have access to a high-pressure steam apparatus.

The sterilizer should be kept at the sut^eon's home with the double-walled
box neatly packed and ready to take to an operation. The following aitidcs
are placed in this part of the apparatus in the order in which they are given:

1. A T-bandage.

2. A gauze compress.

3. Two gauze tampons.

4. A loosely rolled layer of absorbent cotton, 4X12 inches,

5. Three dozen sponges.

6. Eight towels.

7. Two glass female catheters wrapped in gauze.

8. One sheet.

9. Perforated shot.

10. Three or four operating gowns.

11. Four or five pairs of gloves.

1 2. Four or six hand-brushes.

When a cull comes for an operation, the instruments, needles, and silkKom-
gut are placed in the base of the sterilizer and sterilized at the patient's houie
\>y the boiling soda solution which generates the steam for the double-walH
box.

Adjustable Leg-holders. — Lentz's modified Edebohls's leg-hoUets ire
the best adjustable apparatus I know of (see p. 19, Fig. 3). as they are W
light in weight and can be attached to any table (see p. 21, Fig. 7).

I have had a canvas cover made which faciiiLttes the transportation of lie
leg-holders and protects them from contamination. The apparatus should be
kept at the surgeon's home.

Catgut; Surgical Pad. — The chnic nurse places selected sizes of nirool
catgut and Kelly's perineal pad in a small bag and sends them to the suigem
with the box containing the operating paraphernalia.

If the surgeon uses a portable sterilizer, he must keep all of the>e anidfi
on hand at his home.

Arrival of the Stirgeon.— When the surgeon arrives at the hoa-t
of the patient, he should proceed as described under abdominal openitionicn
page 950; the method of using a portable sterilizer is given on page 951.

95*

TECHNIC OF SPECIAL OPEHATIONS.

Operation.— First Stq>.— Ascertain the position of the uterus aod the
direction of its canal by the use of a uterine sound and vagiDO-abdominal pal-
pation.

Flo. eii.— DiLAiiuoii AND CmEiHiHT OF THK Uix«tn — S*Mnd St»J.

Fjc. oiji. — Dilatation ano Cvbetuent i>r the ViERua— Third Step,
Sh<m-A ihc handles of lioih liuJIcI lorccps hooked over Ihe ifr^ilualeti bar of ihe dilalor.

Second Step.— Simon's speculum is introduced into the vagina and '*>'
anierinr and posterior lips of the cervix seized with bullet forceps and dra*"
down toward the \'ulva (Fig. 912).

958

TECHNIC OF SPECIAL OPEBATIONS.

The handle of the set screw is now slowly turned and the blades of the dilator
expanded until the degree of dilatation registers an inch or more on the graduated
bar. The instrument is then kept in this position for two or three minutes in
order to paralyze the muscular fibers of the cervix and insure full dilatation.

Fourth Step. — The dilator is withdrawn and the upper pair of bullet for-
ceps handed to the assistant. The operator then steadies the cervix with the
lower pair of forceps and thoroughly scrapes the entire uterine surface with
Sims's sharp curet. Martin's curet is finally passed into the uterine cavity and
the narrow strips of endometrium remaining across the fundus are careful^
scraped away (Fig. 914}.

Fifth Step. — The uterine cavity is irrigated with a hot solution of corrosive
sublimate (1 to 2000) and temporarily packed with a narrow strip of gauze,
which is pushed into the uterus with the dressing forceps (Fig. 915).

Sixth Step. — A small gathered-up piece of gauze is held in the grasp of
the dressing forceps and dipped into pure carbolic acid. The temporary pack-

FiC. ^It- — DjLATATlON ASD CuKETUENT OF THE 1"tE»US — Siltb Stfl^

Showfl The ulcTTDc cAvir^ being swabbed om wiih pure caibalic Mad.

ing is then quickly removed and the uterine cavity swabbed out with the acid,
care being taken not to burn the vagina {Fig. 916).

Seventh Step. — The vagina is thoroughly cleansed with a sponge, the bul-
let forceps removed, and a gauze tampon loosely packed against the cer%'ix.
A gauze compress is then placed over the vulva and secured by a T-bandage.

Variation in the Technic— When dilatation and curetment of the
uterus are employed in the treatment of obstructi\-e dysmenorrhea due to a
sharp fle."don, the uterine cavity should be tightly packed with a narrow strip
of plain gauze after it has been swabbed out with carbolic acid (Fig. 917), The
object of this procedure is to keep the uterine canal j)erfectly straight and pre-
vent contraction of the muscular fibers of the uterus for a few hours after the
operation. The packing is removed at ihe end of twenty-four hours and the
same treatment subsequently carried out as recommended in cases in which no
uterine tampon is employed.

DILATATIOK AND OIRKTMEST Of TIIK IH-EKUS.

959

Special DirectionB.— Force fh(m\d never be esennl in tnlroditcing
l)f uterine dilatoi^, as iherr is <!an(!cT of making x false passage and scriou&ly
Tnjurinf; llic uteru>. Tlicre h lui ditTiculty, as a nile, in paHHing the heavy dila-
tors inio the tiii-ru!i it the light in^tniment i» used fir^l and the cnnal partially
diUitcd. Usually the h«vj' instnimcnt can be midily introduced by inserting
it a» br an {Ktwihle in the (anul an<l llieri oxpimdinx the blades by s<|ueezing
the handles tugelhcr. I'his maneuver, rcixtitcd Krveral times grndiially
straightens out the canal and dilates it sufficiently to allow the blades o( the
diUlor tn finally Nlip tnlo the uterine cavity.

IMUtalion of the uterus must be accomplished ven- t^adually. otherwise
the muscular fibcra of the cervix will not have time to stretch and a serious
tear may occur. The amount of rtwistunce t>fler«l to the cxpanwon n( the blades
is a valuable guide as to the rapidity with which dilatation can be etiected without
iraumatism, and when it becomes marked the ojicrabir should stop for one or
two minutes in order tn guard A^nst an accident.

Mi'

na. ai;.~Dii.«TtTioii uin C\-artiiun ni rni ITiuin. VariaHon In th* Ttcbnic
Shoin ■ ortniaatnl imfkiat nl muw httot inlnxlunil Inin iht utcdnr o»oit.

The crank which I have devised as a substitute for the small button or set
screw on the graduated liar of the heavy dilators is a distinct advantage, as
iJie levenige is entirdy under the conlrnl rif the oiieralor. ami the rajiidity of
the dilatation can therefore be accurately rri^dated. A small button, on the
other hand, is difficult to manipulate, and the pressure required to turn it so
Kreal that the lips of the lingers and thumb of the ojicrator are a]it to be bruised

Tig. 018).
The use of bullet forcepa^ to gmxp the («i^'ix and hold it in a lixed positmn

luring diUUiiion and curctmeni is better than employing tenaculums, as the
latter instruments haw an inscinirc hold and are very likely to tear the tissues.
A|^in, when the handles of the (orcq>s are h(H)lce<) over the graduated bar of
ibe dilators, the traction upon the cervix i^ steady and firm and there is no
chance of the blades sUpping out of the uterine cavity.

A curclment «lM>uI<t ahviij-^ be done with a .iharp iattrumenl. as a dull curct
only scrapes off the superiicial la>Tr of the mucous membrane ami does more

960

TECHNIC OF SPECIAL OPESATIONS.

harm than good, as it leaves the diseased endometrium in a bruised and torn
condition.

Excessive bleeding rarely occurs during curetment of the uterus, and, ts
a rule, the subsequent discharges soon become serosanguineous in cbaiactei.

If the uterus is perforated during curetment, the accident need not cause
any special worry unless the uterine cavity is the seat of a virulent infection,
in which case septic peritonitis is likely to develop and destroy the patient.
When the uterus is punctured, the curetment must be stopped and no applica-
tions made to the uterine cavity. The local use of carbolic acid or fiushing
out the uterine cavity under these circumstances is especially dangerous, as
the fluids may escape into the general peritoneum and set up an inflammation.

The uterine cavity should never be packed with gauze after curetment unless
a special indication is present, such as a hemorrhage in cases of abortion or
where it is necessary to keep the canal straightened out for several hours in
cases of obstructive dj*smenorrhea due to flexion. A dilated uterine canal and a
patulous internal and external os are conditions which favor free drain^;e,

Fio. V18 — Tne Hakdle of Coodell's Heivv Uteuhe DittiOR (psie oso)-
Showiog Ashlon's naok u 1 subtiiiuic for ihe buiinn on the graduated bu. The buiKa ii mhown br doUcil

and the use of packing therefore is a delusion, as it obstructs the escape of
dischai^es.

After-treatment. — The vaginal tampon is removed in twenty-four hours
and the vagina subsequently irrigated once a day with a quart of hot corrosive
sublimate solution (i to 2000), followed by a gallon of hot sterile water. At the
end of the first week the con-osive sublimate irrigations are stopped and the
douches of plain sterile water continued for two months.

The patient, as a rule, voids her urine spontaneously, although in some cases
she may be unable to empty the bladder and a catheter must be employed for
a day or two.

The bowels should be moved on the second day by a purgative dose of
citrate of magnesia or half an ounce of Rochelle salt in a tumblerful of water,
and then kept open daily with a mild laxative pill followed by a simple rectal
enema. The occasional use of a saline purgative during convalescence is of
decided advantage, as it depletes the pelvic blood-vessels and lessens the con-
gestion which is usually present.

During the first two days a liquid diet (see p, io6) should be given, and then

CUTORIDECTOMY.

961

the {atient »hould be |>bced upon a mixed soft and omvaJescent dl«U (kc pp.
Ill and tt4)-

The patient should remain in bed. as a nilr, for one week after curetmenl,
allhniigh il m.-ty be luivisiilile in M>mv cases, on account of the presence u( an
eiilarKcd or subinvoluted utcni5, (i> cxlcnil ihc time and kecji her ut rest in the
recuDibent position for two or three wcck&.

CLTTORIDECrOMy.

Definition.— Thi* M^ieniion pjiuiitt.t in the excision or rcmoral of (he
clitoris.

Position. ^The pnlient Is placed in the dorsal [Ki.sition with her feet
held by l->icbi>hls's Icg-holdcrt and slirrupti,

Ntimber of Assistants. ^An ancsthcti^cr, one assistant, and a general
nurse.

-©-

-©■

©I

©G

ACTUAL SIZE
Pm, «(o.— Ixmuicutn. NnaiuL iun> Survti Mimuu Uied ix tin Oruutnon or CumtiDn-idMr.

Instruments.— (i) Sral|»el; (2) iharp-poinied scissors curved on the
iUt; (3) .six short hemostatic forceps; (4) dr>- dissector; (5) rat-tooth tix»ue

'or

Pm. «>»— FInt SUfL Fin. «•' — SM«Dd Stav.

CunvBitcTotn <pwe *^y

forceps; (6) needle-holder; (7) twu small fuU-cun-cd tlagcdom neollcs; (&)
plain cumol catgut (No. 1, six envelo(xs); (9) sakworm-gut (so strands).
61

963

TECHNIC OF SPECUt OPERATIONS.

Operation. — First Step. — An incision is made con^letely around dte
gians and carried upward along the dorsum of the clitoris dose to the symfdiyss.

Second Step. — The tissues surrounding the clitoris are dissected awa; ud
the organ exposed (Fig. 931).

Fio. o>9' — CmoKUBnoiiT — TUrd SUf.
IBiiHntian a ihawi (be Buutna nitura which control Ihe blerdiiic in the nccnlu u«.

Third Step. — The body of the clitoris is divided close to the crura and die
organ excised from above downward. The divided end of the body is gra<p(d
by tissue forceps and the clitoris carefully dissected from its atUchmentf bj
means of the dry dissector, the scalpel, and scissors (Fig. 922),

Fig. Q13- — Faurth Step. Fir-- 924- — Fourth Step.

CuTontDErrovY,
Fig. n3i %hnws ihe mcthal of iniroduriruc i^t suikirn^ Dole Ihc ihm mailre&i sulum ciiDtnjIlukc htacf^Jfi'^
IbF vaAcuLiT area; Via- 9^4 shou^ che suiurcs tini.

ISlceding is controlled by means of hemostatic forceps and catgut HptuTC'
E.xcessivc hcmorrhane from the vascular area at the bottom of the wouml of*'
occurs and is readily checked by two or three mattress sutures of catgut.

KXci&ioN or Tue vulva.

963

Fourth Step.—The wouod Is doned by iipproximattng ils edges with deep
fiilkworm-gui sutures which pass coin|>lctdy under ihc denuded area and in-
clude ihc bleeding vessels that have not been ligalcd (Figs, 913 and 014).

Fifth Step.—The parts are douched wilh mrniMvc »uhliinutc solution (t to
3000) and a gauw mmprcss secured by a T-bandagc placed over the tvciund.

After- treatment. — Tbc dres^nfp are changed (>nce a dny ot oftener
if Ihcy become !«>ileil and the wound dourhevl with a solution of corrasive sub-
limate (1 to 3O0O), followed by sterile water.

The .-ititcJies are removed on the ci;;hih day «nd tlie patient allowed to get
it of bed on the tenth day if uU goes weU.

EXCISION OF THE VULVA.

SefiBlUon. — ^The operation consists in the removal nf a part or the
whole of the vtilva.

Position. — The patient Li placed !n the doraid position with her feel held
by £tl«buhlit'» leg-holders and stirrups.

Ofiapqi

Fmi (aj.— imnrHiim Vuo in mc OraMtlOH 0 Encnioii o> tiu VmvA.

^®

ACTUAL SIZE

Namber of Assistants.— An anestheti^er, two aMtj-lant"*, and a general
nur*.

Instruments.— (i) Scalpel; (2) right and Ml Emmet'.* slichily curved
uivMirs; (3) fix hemi>sialic forceps; (<) ral-tooih tissue forcqw; (;) needle-
l»older: (6) Iwti small iind tw-o very small full-cuned Hagedom nevdtes; {7)
pbiii cumol catgut (No. i, &ix enrdopes); (8) silkwomi-gut {yt stnmdii).

9*4

TSCUKIC Of SPECIAL OPERATIONS.

Operation (CompUle KxcisitMi.—Vint Step.— An incision is madccoa-j
plctclv urnund the vulva which converges at the anterior and poMerior cent- J
missuic^ and passes (hniugh the skin am) underlying mnnrcli^T lismt. .11
circubr inclsiun is then miiiii- iiniiiniJ tin- urinary meatus in order to ptotKT |
the urethral opening and prevent the subsequent (onnalion uf a inutiuiic ,
rtridure (Fig. qij).

Second Step. — The structures w-ilhin the lines of the inciiiun are ditMOH
from tliL- umkrlying [issues and mt away at the margin ot the ori&cc of (be
vngina (1-iK- <)i8), 1

Third Step.— The lower end of the vagina is dissected up for • distKiKecfl
.-in inch or more in imler tu looxen it» allachinent» and pull it downas > ftiptal
fissist in covering the denuded surfaces when the wound is sutured (Fi^ gjgL

SS"i

Fii.. nn- Fii^l Stfp. flu. oiH.-SMoalflH

FmuDH or nu Vnv*.

Ftf. O'T ibowi Uw prcUnihiikbrf iiuis^ua iMulv ■nmOd Ibc v1lti« 4ftiJ ll« ntnul labuf i
thutn ih( tiv IUII4I.O left ■([« lb* *iiln hu t«s cuwL

ihai

Hemorrhage occurring during Ihe ojienttion i» controlled by mrans nj I
static forceps and catgut ligatures. Excessive bleeding from rascnti
in the wound ia^ apt to occur and b readily checked by two ur ihm :
sutures of catgut.

Fourth Step.— The wound h dosed by deep sUhwonn-gut suturei "ii*
pa.*.-! under ihe <lcnu(led surfaces ami iniluile the bleeding veK^1> (hal hii*
not been ligatcd. The ed^es of the wdund should be vppmxinuted h>i**>
produce the minimum amount nf ira;:tion upon the sutures diid puniaf '•■•
fmm aitting. Fig. 930 show« how the edges of the wound uc brou^t taptltf
and uniictl Ijy silkworm jtu I.

Fifth Step.— The field o( operation in douched with a Mihilion o* mnoi^
mblimale (i to 1000} and a gauze compress secured by a T-bandage pbccd oA)
the wound.

SOPRAPfBlC CVSTOTOJtV.

9*5

After-treatment.— The dresjings are changed each (ime ihe bladder
is cmptii-d und the wound dourhed with .1 s'llutlon of omniivc sublimate (1 to
3). The urine should be drawn with a catheter €\^- etfibt hours dur-

ff~

K *)o -Third St»p.

Fid. qio.— Foutth Stip.

Exnneii or ni» Vrr.i*

_)bCi Ibc ouURW wlum Id the ruculu un ml the linii* rml nl tbt vtfini bdng illiMatd tram U* >Ua^

mcnl* (Fit Q>pJ-

inf( th<f tii>i ihree dars in onk-r t<i jirotect the field of operation and prevent the
uhnc from coming in contact with the wound.

The stilclic3 are removed on the rinhih day, and if all rocs well the patient
, allowed U> get out of be<l at the end <i( tlie second week.

SUPRAPUBIC CYSTOTOHY.

iflnltlon,— This ii)>er»tion consiM» in making an opening into the
M ;iUi\c ihc *ym|>hvsii pubis.
Preparation of the Patient.— The hair r>n ihc pubw and mons
enwi* is cul shorl and the Unwt jbiJumen. vulva, and ailjacL-nl parts thoroughly
stcrilize<! in the manner described under Minor and Abdominal Operations
p|>. 8.io iiiid 836).
A botllc of dtmtc of magnesia Is given the e^'cning before Ihc operation, and
the following morning the rectum is Bushed vrilh a copious enema of soap-
Kin aivl water.

The interior of Ihc bUdder rcqiiircs no sjiecial prqiaralion unless it is in-
kaled bj' tlte iialure of the vesi<al lesion, in whiih au< an irriKaliun of mirnul
fait or boric acid wluiion is given e%-eT7- day for one week before the operation

966

TECHNIC OF SPEaAL OPERATIONS.

(see p. 63s for the method of irrigating the bladder). The urine should be
rendered bland and non-irritating by the administration of appropriate remedies
and drinking large quantities of pure water.

Position. — The patient is placed in the Trendelenburg positioD ai m
angle of 25 degrees.

Number of Assistants. — An anesthetizer, one assistant, and a genenl
nurse.

Fio. 9JI.— ImsHDiienis Lsic ih the Opuatiom of Suwafdhc Cvstotokt.

ACTUAL SIZE

F11. oji — N'eedies *nd Suture M*teiii*ls I'bed ik thi OraBAnoH oj SonAFUBic CiiTOToin-

Instnitnents.~(i) Scalpel; (2) scissors; (,5) four short hemo^biic
forcept^; (4) alxlominal retractors; (5) Ashton's self-retaining abdominal re-
tractors; (6) two bullet forceps; (7) dressing forceps; (8) tissue forcqi*: ifll
needle-holdt'r; fio) two small full-cur\'ed Hagedorn needles; (11) two Urif
cuncd Hiigedorn needles; (12) two small cun-ed intestinal needles; (i.il N"- "
braided silk; (14) Nos. i and 2 plain cumol catgut, each four envelopes: (ij)
silkworm-gut — 20 slmnds.

$66

TECRNIi: OF SPItaAL OPKBATIONS.

Second Step.— A median inchion b made, aUiut i^ inches nr man b Icn^
immaliiitcly :i)>i>ve (he pube«, through tlie .skin. supeHtdul fasda, musrlo. ud
rransvcruti^ fiisciii. down In the
loiisc areolar (issue covering the
prevesical s(>ace. The peritoneal
fold h then Idcnled ncjir ihc sym-
physi.'' puliis and pushed upward
with [he finRcrs off the bladder
wall. The bladder is readily re-
cogniM"! by palpation as Ihe
hydrostatic pressure distends Ihe
organ, and it is felt as a round,
lense, dnslic tumor at ihc bottom ol
the wound.

The j)revc'iical ii.vsue i.-* n<iw
picked up with two hemostatic
fortejjs in the median line and Ihc
tnlen'ening .'*tnicture» lareluUy <li-
vided until the bladder is exposed
to view. The wound is then re-
Imcled and the bleeding points
conlnilicfl (Fir. 9j4)-

Third Step.— .\ bullet forcejis
is inlnxluccd acr<)ss tlic median line

through till! muscular coat at the Fw. wj— Scmnmic OtumtMt ■'

upper and Inwer limil.'. of the cx-
poi^ed bladder and handed to the assistant. The surgeon then pscks a Orip
of gnuzc in the iircvdical Kpace to protect the areobr tissue and opciu At
bladder between the forceps with a sharp scalpel.

-V

'-A

FM. «]e.-4(vaAri:*ii: CniDTOUT— F«ank 3M».
Sbfrtdoji Ih* hUilcltr iKnind bdn^ hvld opm bf Ibi IncUna nilui^

.Vs the fluid ocitpes the assistant makes tracliim up<m the bullet [ontpctf' :
pulls tliL- bladder well up into the abdominal wound (Fig. 9^5}.

al'PRAPUBIC Cli-STOTOUV.

969

Fourth Step. — The irrigaiini; reservoir U lowcrei l>t?low ihc \evc\ of lh« lop
of the laNc ai»t ilir tliiid <lriiiiie<l fn>m tin- liliuiilt-r. A N». 7 tiniulnl .mUc Milurc
is then pu&M^ through all ihc conls <i{ Ihc bludiltT iil Ihc tniddlc nt each ccIkc
of tilt- iipeninK and ihcir free ends tied. The bullet forceps are now removed
ami the :i»fisUnt hiilds the Uhidder wiiund <i\it:n l>y thi.* iraction KUlurc The
surgeon ihcn explores Ihc bl.idder with his index-finger and increases the length
nf liie opening if the nature of the ve>i(-al lesiioD requires more space for the
operative manipulations (Fig. 936).

In wome cas<> it may be necessary for (he nurse to intrmluce twi> fingers
into the v.igin^ and lift the bbdder upward and forvriird in order lo bring the
field of (ijieration into view.

Fifth Step.^Afler the special indications for the ojieration have been carrieil
out the wound in the bladder is cloMf I and the alHlnminal incisiun .•.uiured.

If the bladder is not infcdcd or the upcnilinn unattended by severe trauma-

FiO- Mi.^FUUi Stop.

Tm. Mt-— Filth si«p.
Svnjtmmc Cwfrnnin.

tit. 0)1 ibo» iht mrctiud of InmdDdqi IbcMo lijtnul •uium lu iliar tlx liUddit: Fin an Aon ibc
\UiMa woiiiul doKil, Ibe iuiur* ialraduDdUunmh Ike «d|n ol Uk ibjainiiul induaiL ami i lew imnila ol
lOk^DTbHtuI idAced cvr iJk tokal Hnsvnd-

tism, the ve-Mtiil opening is cIomhI nt once hy two layers of plain cumni catgut
(No. 1). 'ITic (inJt layer consists of a series of interrupted sutures which pass
through all the coat* of the bladder except thf munius and the second of a
conlinuiius I^embcrt suUirc which is introduced in ihe same manner as when
applied to an intestinal wound. A scries of ihrviugh- and -through sutures of
sUkworrn-gut are now pus.>ted through the ctlgn <>f the alxlominal incisiMn. and
a few strands of the same suture malcrial are placed over the vesical wound to
drain the prevesical space and guarri against leulcage. The free ends of the
&ilk«rorm-gut drain are then brought nut »t thr up)icr and lower angk^s of the
indriion and the abdominal wall sutures tied. The abdominal dressings are
applie<l in the usual manner (FigH. <ny and gjS).

Variations In the TeclmiC.— If the bladder is infected, (he wound
nbould l>c Icfi ojwn an<l its edges sutured to ihe parieles with plain catgut. The
cavity of Ihe bladder is fluiJied two or three liine> a day with one of the iwlutiond

970

TKCmnC OF iiPKCIAL OPERATIONS.

recommended in the local treatment of cystitb (.see i>. 635). The irrigation an
be accomplished rillier through the urethra and ttic overflow allowed i<> pus
out of the vesical opening, or it may be (tirected from above hy means of a wll'
mblfcr tulie ultai-hed tu an irriKatiiiK reservoir.

If a sc\-cre vt^iad hcmorrhngc occurs during the operation, it should ie
controlled by catgut suture^ the i'aquelin cautery, or gauze p.-irking. The latta
melhiKl should )>e einployeil when ihe bleeding iit jirofuM; and time it un elesicM
of cnn>.ideration. Under ihe^e drnim:<'t.inccs a strip of gauze .should be packed
in the bbdder and the vagina, and removed at the end of twenty-four liour^
The [ixclcing shoulil not be reintrtxluced unless the bleeding continues, in whidt

ca» the bladder a lid nsm
xhould l»e irri|;alcifl with hut
normal salt or l>«)r]c acid solO'
tioii and fresh strips of ^ua
a[iplied. In ca.se.t in which the
bladder is lamfM>ncd tlie end of
the strip of gauze i.s bnn^
out of the vcsitral and abdomin&l
wound and (he latter Li parti;
closed above nnd IjcIow with
thniu>!h-iind -through sutures of
Mikworm-gul. The edges of the
opening into the hbidder are
prciously united to the bottom
of the abdominal incUion with a!
series of mlerrupteil catgut su-
tures in order to shut oiT the'
jirevewcal space and prevent
retraction occurring. After the
tampon is K-nK>ved the n'ound
is (Kicked with iodoform gauxe
and allowed to heal by granula-
tion.

After-treatment. — If

the abdomiiiat incision is closed
at the time i>f the operation, ilie
stitches are removed on the
dghth day and the wound dressed in the usual manner (see p. R48). lo cajies
in which the wound is allowed to heal by granulation it should l»r dressed onceii
day by washing it with hydrogen pcroxid and appK-ing fresh gauze piicking.

The urine ^houlIl \>c drawn with a catheter c^■c^y three hours f(»r the first two
days and then every eight hours unless it is voided s[Hintaneiousiy, A self-
retaining catheter should not be employed as a routine practice, as it irritates
the blailder and is likely lo carry infection.

If it is necessary lo irrigate the bladder in ciLses in which the vciical wound
is dosed, a double-current catheter should be employed (see p. 763), as the usi
method of llu.shing may cau»e overdi:? lent ion and tear out the stitches.

Pui- o^Q, — SuPMAK^Bif: CvTrtDniHT, VartKtio&a i& TKhaic
pan pdfkd '
[ IicHHinbaiic.

Shows itw liluLls Uil vafioii puki^l wiib |(uh to CDQtni'

VAGINAL CYSTOTOHV.

isuat^

Dcfitiltioti.— This operation consists in making an opening into the
bladder through the vesicovaginut septum.

.SOP8APUBIC CYSIOTOHY.

97*

Preparation.— The preparation of the patirnt and the prcpaialione
for ihe operation are the same as ^ven uoder Minor Operations on pages 830
aod 8ji I .

Position.— Thi: paii«m is pUccd in the dorsal position.

Number of Assistants.— ■'^n aiicstbelizcr, one assistant, and a
jeneral nurse.

Instmments.~-(i) Simon's speculum (oin-cd blade) ; (a) mnic lithot-
nystiill; (3) ncalpd; (4) scixwrs; (5} two short hcmoalatic furccpa; (6) tissue

® d

obooaD

®^

forceps; (7) drcwinR forreps; (8) two bullet forceps; -

(9) ocpd If -holder; (10) shot compressor: (ji) perfor- /

ated shoi; (:j) two straiRhi and twfo slifihtly curved
mundpointed needle*; (13) .■iilkwcirm- gui— twenty
strands; (14] pUiin cumol catgut — No. 2, four cnvr-
lopes-

Operation.— Flrat Step.— The perineum i* re-
tractfxl Vi'ilh the speculum and the staff introduced into
the bladder. The anterior wall of the vapna is then de-
pressed with the staff directly in the mccji;in line and an r:
incision made along its groove through llie %'esicovaginal ^
septum into the bladder with the «al])el (Fijj. 04i)-

Second Step.— The Mnfl is withdrawn, the index-
fmRCf |i;iij(-il into the bladder, and the incision enlarged
i( netcs.i;iry with srissors, using the finger a» .1 guiilc.
The incision mii.it alwa)-s be made directly in the
me<)ian line in order to keep clear of the ureters and
guard against injuring them (Fig. Q43}.

Thii^ Step. —After the indications for the operation have been carried out.
le wound is cither closed at once or left o|)en if lemjKinirj- drainage is required.

Tlie lechnic o( closing ihe incision is very simple and is the same a* the o[)era-
sJon of B vesicovaginal tistub after the edges of the opening have hem denuded
(see p. 760).

If the incision is Ht i>[H'n (c)r temjiorar)- drainage, the raw edges mui^t be
covered over with mucous nwmbranc. otheniis* thej' will unite and iIom- ihe
artificial fii>tula. This is aocom]ilished by dr:iwing the vesical inuco«a out thiuugh

~1^

ACTUAL SIZE
fio. oti-—SuttM%. Sa-

ruiani' SinrT tcfD n Tax
c irtunvm or Vmihal Cn-

PM- Ml.— ViDiiML CraTOTOirir—FirM SI*p (f*<r «*')■
lUuitntlciii b ihon Ihc pckIlIoi) dI the iDduon ihroujh ihc ■nlcriac n(ia4) amll IdMMl Bm} <

of the c4i6oct ol tbc un:«m Cd» *),

Fid. «41-— Vmitiu. CntniraT— SKoad SUp (PHt V>i)-

After-treatment.— The nfHT-ireaimrnl is the aimc as m Gwrf
vesicovaginiit lislubs, in which the opening is cither cluicd bv an iipttlW*
Iril open on account of spccia] reasons.

Ce/vix

Fu. m«'~Vau)iai. OnTonmr— Thivd Slip.

SALPINGO-OOPHORECTOHY.

De6nition.— This operation comsjaU in removing the Fallopian lubes
ad thcoviiric*.
Position.— Thr patient is pUccd in the TreniJelenburg {wsition at an

Fia. (i<(-~t<i«'r>t-ii»(n I'ms tw iiti: OvuAnon o* SAinxotHiAnutucroHT Itaat 974),

■\-atIon of 15 (le^TWS anri Hul»j«juenily rai>«d ta n higher angle during the
fniti'-ti if ncCf'.Mry.
Kumber of Assistants.— An aocsUietiECT, one assbUnt, aind a gencnl

974

TECHNIC OF SPECIAL OPERATIONS.

InstnunetitS.— (i) Scalpel; (3) blunt-pointed sdssors; (3) six short
hemostatic forceps; (4) two long-bladed hemostatic forceps; (5) a pair of ab-
dominal retractors; (6) Ashton'sself-retainiDg abdominal retractors; (7) pedick
needle; (8) dressing forceps; {9) rat-tooth tissue forceps; (10) needle-holdeT;
(11) two small full-curved Hagcdom needles; (la) three long, straight, triangulat-
pointed needles; (13) braided silk— Nos. 2, 7, and 12; (14) plain cumol catgut-
No, a, four envelopes; (15) silkworm-gut — 2$ strands; (16) intestinal instru-
ments and needles — Murphy's button; anastomosis forceps; clamps; two
straight and two curved intestinal needles (Figs. 945 and 946).

<3>

D-h)

INTESTINAL®

INSTRUMENTS
& NEEDLES

Fro. 9i6. — Needles, Sdtcie Matkiiai^ ahd Intestinal iHaTiDKENTs and Nkxcles Used ih tbi Oida-

nOH or SALRNOO-oOMnnECTOMI.

Opcratloil.— First Step.— The index and middle fingers are passed
into the pelvic cavity and the fundus of the uterus located by touch. The tips
of the fingers are then carried laterally over the comu of the uterus and along

Ftc, 04?. — SalwncO'OOpiiohectohy — Pint Step.

the posterior surface of the broad ligament until the tube and ovary are found.
The superior margin of the broad ligament near the pelvic brim is now slipped
between the fingers, and the ovary and tube hooked up into the incision (Fig. 947).
Second Step. — The pelvic end of the ovarian vessels is ligated by passing a
pedicle needle threaded with No. la braided silk through the clear space in the

Fro. »5o. — SAiKwxmepnomKTToiiY— Fmirth Sti^

saupiniiooAphorectouv.

977

Variations in Technic. -The lechnk of salpinRo-ouphorectomy U
somcnhnt liitliTnil (nnn what lids bct'n (le-Mrrilicil ill L't-^CA of pyosiilpinx, in
which the lube is \CTy fmiliU- iind likely tu l>r <Ii^-ided nhcn ihe lipilurc ul
the uterine eml of tlie broad Ii(;amcnl i^ lied. In these <:a*.e.^ the liKJiure a1 the
pelvic britn U first inlroduiol ar.il licil, bimI ii semnd tift.iturc (wscd nt ihc
Uterine end of the brond li^iiment, ivhich includes only the ovariun ligament
and the DvaHan vessels. This ligature U then tied, the structures beyond il cut
away, and the tuljc rcsvclwl by m^ikinK n wc<l|ie i-li:i|»e<i tiici^ion inli) ihc comu
of the uteru--. The edges of ihc uterine n-imnd arc tinully brnushl tn](ei)ier
and Mit;ired with c.itKut (Fit;- !)S')-

Whcn the bnmd lignmenl is lense or thickenwl by inflnmniator^' deposiU, il
is <i(leii rlifTKull nr imiHissiltte to bring Ihc ovary and lube into the incision and
at the s;ime lime inlnKiui*e lji>th ligutures. V'ndcr lhi'>e circumstances the
ligature at the pelvic brim is firel introducod and lied. The uterine end oj the
Ugamcflt in then damped with forc«pa and the struelurea beyond the ligature

Fn.. vs>-' SHPtiK«yif,THnannuii\ . Vwlatiow In Iks Tichalc

illiuinUrMi ft pvn ihr ilfiiua ol rh* Ilitiuir.

at the pelvic brim cut away with scissors, carrying the incision alonK the uppef
margin of the bnwd liniment v^ell bdciw the hihim uf the ovar\'. The lube
niMl iivan-. l>einK ihii* freed from .itl their attachments exceiil tfiose ncnr ihr
Uterus, are easily lifted into the alKlominat wound and li);aied in the usual manner.
The removiil uf the iivary anil IiiIk" by an inlerlmkinii ur link >uture, which
puckers up the bnnad lienmrnt into a single thick pe<litle includini: alt the slnic-
lurcs to be excised. Jii>ul<i ii<il be priutived, a- the methixl i?. ^^^Rical!y wrong
and has no adv.intiyies whcilrver "vrr ih<' technic described above. The »ulure
cnnjstrictf an unnecessary amount of tissue and may cause a fatal hemorrhage,
or a hematoma may form beiwcen iKe layers of the broiid ligament fnHn Ihe
retraction of a bIfKKl-vcvsel. It als" produces undue tension of the bmad lign-
menl, and may Iw resi>onsible at limes for the jwrhic pain> uhich some women
aimplatn of aflcr ihe Ivilies and ovariev have been removed. In case* in which
the broad Itgnmcni is thickened or unWelding il is impossible to completely
remove the o^'arics and tubes with this ligature, as tbcre Is not suf&ctcnt room

978

TECHJJIC OF SPECIAL OPEBATIONS.

to make a pedicle and some of the ovarian tissue is certain to be included b the
stump.

Special Directions.— Before the ligatures are introduced al the pd(ic
and uterine ends of the broad ligament the surgeon should make a cartful
insfjection of the clear space in order to be certain that all the large blood -^-es«U
lie above the point selected for the passage of the pedicle needle, otber«ise i
post -operative hemorrhage may occur and the patient lose her life.

Although, as a rule, there is no bleeding from the upper edge of the ligament
after the ovan- and tube are removed, yet it is always best to suture the edgis
of the peritoneum in order to close the intraligamentous space and guard againa
the possibility of subsequent oozing.

REMOVAL OF A CYSTIC TUMOR OF THE OVARY.

Position. — The patient is placed in the Trendelenburg posture al in
angle of 25 degrees, and subsequently raised to a higher elevation during <ht
operation if necessary.

F)0. <JSS- — [K^lKt-'UE-ST^ I'SEU IN THE OpEBATION TOR THE REUOVAL Of A CvMIC TuUOI UI FHI <J^-iH-

INTESTINAL
NEEDLES &
INSTRUMENTS

ACTUAL S!Zt:

Fn. (154. — Nfhnirs, Sl'TUSF MaTKSHI.^. and 1NTESTIN4L IsSTVITUEhTS AND Nr»:pl ES l"SEO IN nlT i"'PTII
Ili.S filK TlIF KeMCIVHI. of A Cv^illC TtMOB OF TSE OVABV.

Number of Assistants. — An aneslhelizer, one ass]>tanl, and a ff^-
ernl niir-i.-.

REMOVAL or ACVSnC TUUOR OP TBE OVAKY.

979

ients.^{0 Scalpel; (a) blunl-poinicd scissors; (3) six short
Iicmostatic forctps; (4) Iwo Ii>n)(-tl«ci«d hem»i>iaUc fortc])*; (5) :i pair of ab-
iliiminiil relractur^: (6) Ashtmi's sclf-rctiiining nbdominul trtraclors; (7) jiwliclc
nwdli:; (8) drw.'ving (urcens; {9) a trocar wiih rubber tubing; (loj ral-toolh
li^uc forceps; (11) ncedlc-lioldcr; (la) twosmnll fufl-curved Hagedurn lUMxlIei;
(ij() three lonR, straight, iriangular-p«iintcd needle; (14) braided silk— Nos. a,
7. and 11: (15) pliiin tunwil caiRUl — No. i, four envelopes; (16} sUku-orm-Rut —
15 .-vtrands; (17) intestinal in^Irumenls iind newUo — Mur|>hy'» bullnn; annslo-
m(wt> foTcqw; damps; two straight and tn-o curved inieritinal needles (Figs- 95}
and 9S4)-

Operation. First Step.— S<> «ion as the abdominul inriMim is made
th*" index ami middle liiigcr> are passed through the opening in oider to ex:imine
Ihe surface of th<- c>':st for the presence of adh«xion&, and if posAible confirm the
di^iKnosts (Fii;. 955).

Second Step. — Wliilc the assistant makes latenil pressure over the alidomcn
■ i.perjtcr selects a i«>int on the wall of ihf cj->I that i^ free from blond -vxsseU

■n

€ '^

..!)i

.<^

U):

Fts. atf.— OnuLtno" k» mk RixovAt or w nvAiiMi Om — PImSMp.
Shorn ihc li(a nl tW liium p*lp*llii( Ibt pnllcli 4wl dturniliiuiK ihe ihuwia ul ilit lumor.

IwJ plunf[e* the iroc.'ir into its cavity. The fluid contents then csca{>e thmuf;h
the trocar and rubber tubing into a bucket on ihe ilimr and the wall of the
ij>t gradually becomes flaciid. The waW of the ry-it is now caught on e:ich
vide of the imciir with long liladwi tiemostatic forccivs. and as the Muid escaiics
the c\'?l is gradually drawn out through the abdominal iudsion with the fingers
or the hemustatit forceps. IJurinj; the delivcn- of the nu" the as^isUnt kec|H
up prcMun.' over the ^ilidomcn in order to facilitate the escape of the fluid through
le trocar and force the cj-st up toward the alMlominal opening (Fig, 95(1).

Third Step. — When the sic i» entirely deli^Tred. the abdominal (i[>entng is
rotecled with 11 gauze pad. the pedicle cUmpcd with a tong-blodcd hemofitatic
forccjus. and the cyst cut away (Fig. 957).

Fourth Step. — The ]>cdicle i» tranvfixod near the cornu of the uterus with
s pe<Jicie needle threaded with 3 double ligature of No. ii bniided .^'Ik, wrliich
is first lied a? an interlocking suture, and then oinried around w us lo include
the entire stump (Fig. 958).

98o

TECHNIC OF SPECIAL OPERATIOKS.

Fifth Step. — The forceps are removed and the pedicle trimmed down to
within half an inch of the ligatures. The peritoneal edges of the stun^ uc

Fic. 9S6. — Ore»*TiOH TO« Tin Removal or an Ovahah Cvst — Second SUp (paic o)b)-

Fu;. o^T- — • >?EPAri"N fi>h the R>:u'>val of an Ovahian Cvst— Third Stflp (jvigr y-tf>-

thcn invcrtt'd ivith tissue forceps and united with a continuous LemlHTl suture
of No. ahniideil silk (Fi;;. P5q)-

Sixth Step.— Tlic ojipusiic ovary is examined and the field of o[>erjtion
carefullj' inspcclt'd before closing the abdomen.

REUUVAl OF A (-V5>nC TUUUR OF THE OVARY.

9fti

Variations in Technlc.~A suppurating or dermoid cvst ^outd not
be L-i|it>c<l, .IS its i-imliTil.v may tsrapc into the alxJominal laviiy nncl infwt
Ihc pcrif'twum. Thtsc cj^ls should, therefore, lie flelivered iniuit by enlarging
the alHk^mlmil ind^ion iind gently f'TniiiK them thmugh the Dpeiiiiig.

Itihst

PM. fijR.-^ruAnat( ran riir RiuoVAt or la Ovahah Cm — Fourth Slap (pm* «»)•

lUwtntlion 4 Uinw* Lliv meihtri of mpfilyitur ill' iorerUHkioK tuturr-

A mullilonibr cysl is more difiiciilt to empty than one with a single sae,
Bnd it sometimes retguires ciinsiclenilile juil^ment :in(l .■<k[ll u|miu the ])iirt u( the
o^tcrator to deliver it through a small incisiiin. The cvsis which arc contained
within the nmin --ac i un umiuIIv I>c pumturctl one after the other with Uie trocar
and their inntenls dr:iine<l away in the u>u.-il manner. Tlie hand, luiwever,
>h<>ulr] be |ia!««d into the abdominal cavity to direct the trocar and prevent it

/P,

.Vj:

"-TJtrru^

V^5

■ 0)9.— OniATiiMi n» rat X(m*AL at *» < ivamiah Cm— Mill 9l*p (pmotol.

from puiKlurinK llie main sar. In some instances the cysts can he broken u|i
Ity i>as.sin); ihe index ami middle lingers into the tac and rupturing their walls
lA' direct prcs-'Ure.

A M-mtMilid cvHt ur one that in difRcttlt tn empty should be delivered by in-
casing the length of the incision, us the manipulations uften ik* harm, and

983

TECHNIC OF SPECIAL OPERATIONS.

should not be continued simply to avoid making a larger opening in the ab-
dominal wall.

A broad fleshy pedicle should not be ligated en masse with an interlocking
ligature, as there is always more or less danger of the ligature slipping and a
fatal hemorrhage occurring. Under these circumstances a ligature shoukl be
passed at each end of the broad ligament and lied in the manner described
under salpingo-ofiphorectomy (see p. 977) and the raw edges in the up;>er aspect
of the ligament which are left after the pedicle is cut away sutured with a con-
tinuous Lembert suture of No. 2 braided silk.

Special Directions.— Before tapping the cyst the surgeon should pass
one or two fingers into the abdomen and explore the anterior surface of the
tumor as far as possible. Unless this is done, anterior adhesions are likely lo
be overlooked and the delivery of the cyst complicated.

It is also important not to use force in deUvering the cyst, as adhesions may be
present between it and adjacent organs and a serious injury may result from
rough manipulations. The surface of the sac shoukl therefore be constantly
inspected by sight and touch during its delivery, and if adhesions present them-
selves traction upon the cyst should be stopped at once until they have been
separated and broken up in the manner described on page 910.

RHTOVAL OF AN INTRALIGAMENTOUS CYST.

The Position 0} the Paiienl, the Number 0} Assi'siants, and the List of Instru-
ments are the same as for the removal of a cystic tumor of the ovary (see p. 978),

Operation. — First Step. — The ovarian vessels are first ligated at the
pelvic and uterine ends of the broad ligament and the surface of the cyst exposed
by incising the peritoneum (Fig. 960).

The preliminary ligation of the ovarian vessels controls the circulation and

FlO- 96a. — Operation roB th£ Reuoval ftr as fNnALioAUR.STnvs Cvst — Fint Stop.

enables the ojjerator to enucleate the c\'st with but little, if any, bleeding. The
incision through the peritoneum over the tumor should be made at a point in
which there are (he fewest number of blood-vessels, and care should be taken
not to cut into the wall of the cyst.

Second Step. — The cyst is shelled out of the broad ligament by means of
dry dissection, using for the purpose the handle of a scalpel, the tips of the

REUOVAL OF AN' INIHALrCAUEKTODS CV5T.

983

fingers, and a gau^c sponge, filecdint; vessels arc secured wilh hemtistalic
forceps and ^uliNeiiueiitly liKutetl willi calg^ut aher the enucleation nf ihc c^'mI
ix onmplcietl (Fig. 961).

iS^r

J.:-

.-^^■>•

Fto. oCu-^eteand Sup. t'lo. «6i.— StcMid Stap.

OMBaxiun »i» YHi Rtwiv.ir. n» an IxnAUiuw-vrni'i Tikf .

F1g.«ai >ho>i l]ic nuriMlloa of ui uanpiuf*il <:><i; Fu- ««> ilmn ihc couclnuogol ttjn ilui kutn*

uppnt

During ihe shcIIinK-oul of ihe cyst ihe opierator should keep cbse lo il* wall*
in order ti> prevrnt (earing the hnuid ligament or injuring the underlying ^truc-
turci^. When the cj"st is Iarj;c and crowds the pelvii- cavity, it should be tapped
with a trocar and the fiuid evacuated licfure beginning the enucleatiou (Fif(. 961).

) I I

V.^

fio. ^i/-^>rtaAnov rot ni Rumvun* m lnn^in^junxtDi't Cnr— TMM Slap.
Sbmn thf aynlot ai tbt up gl lb* bAwJ Utaaifvi (laand Mil tht Kpannri kf*n of ilx tijpnRit bdni

In some cases It Li even necessary to perform a preliminary tapping before the
ovuriin vessels can be ligatcd, a» the pelvis is so cmw<te<l thiii it U impossible
ti> find Ihcm until the contents of the sac have been removed.

984

TECHXIC OF SPECIAL OPERATIONS.

Third step. — The bleeding vessels are ligated and the hemostatic forctps
removed. The byers of Ihc broad li^ment which were separated by thenst
are then united by continuous catgut sutures and the edges of the pentonniin
at the top of the ligament closed in the same manner {Fig. 963).

In some cases the oozing from the raw surfaces between the folds of the bwHd
ligament cannot be entirely checked and a hematoma is likely to form if ihe
wound is closed. Under these conditions the broad ligarnent is attached lo the
lower angle of the abdominal incision by interrupted catgut sutures which include
the edges of the ojiening in the ligament and pass through the peritoneum, musclt.
and aponeurotic fascia of Ihe abdominal wall. The cavity in the broad ligament
is then packed with a .strip of gauze and its end left outside of the abdominal
wound.

Special Directions. — So soon as the abdomen is opened the surgeon
should introduce his fingers into the abdominal cavity and thoroughly examiae
the relations of the c\st with adjacent structures.

In some cases it may be impmssible to remove the base of the cvst when it
is situated deeply in the pelvis, and under these circumstances the shelled-oul
portion should be cut away and the rest of the sac allowed to remain. The edges
of the ofwning in the broad ligament are ihen sutured to the abdominal indsion
and the space between the folds of the ligament packed with a strip cf gauze.

INCOHPLETE ABDOMINAL HYSTERECTOBrV.

Definition.— This operation is performed by the abdominal route, and
consists in the amputation of the uterus at the juncture of the body and the cer*-ii

Synonyms. — Supravaginal amputation of the uterus; Partial h\-sterec-
ttimv.

Fig. fl*4- — IhaTHVUENTS I'SEn ?N THF OpFBATI'IN "F [ \ I "-Jrt PI. HT>: ABDdUJ^At HVSTEHECIOMV.

Position.— The patient is placed in [he Trendelenburg position with
her l)o(ly at an angle of 25 degrees, and after the abdomen is opened the pelvis
is rai.scd to 45 degrees.

Number of Assistants. — An anesthetizcr, one assistant, and a

general. nurse.

IXCOUPLETE ABUOHINAL UVSTBRELTOUY.

98s

InstnunentS.— (1) Scalpel; (1) blunl-pointed sdsairs; (3) six short
h«innNtiitic ftirceps; (4) two long-bladcd hemostatic forceps; (5) a pair of ab-
dominal retractors; (6) Ashlon's seU-relainii^ abdomiiiul retractors; (;) two

ri«

INTESTINAL

NEEDLES &

INSTRUMENTS

ACTUAL SiZt

n9-4«)'

-N'tikOLn. SnniM MAtuiKut. tKu iKovnuM iHiTBciie.Kn a»[> Knnalt Vmd la IMK Omkji-
TIOH or iMntnxTr Axmumu kisniEtromr.

heavy hyslcrcrtomy traction forceps; (8) pedicle needle; (fl) drcwjngforcqw;
(to) rat-tixith tissue forccDs: (k) nceillc- holder; (ii) two small {iill-cunedHagc-
dom needles; (13} three l»n]i;,.-<iniighl. tn;inguliir-|Hiintei) ncvdlen; (14) braided
silk — No9, a, 7, and 13; (15) plain cumol calgul— No. a, four cnvel^^^le^; {i6>

Fie. vM,— IiKDHtwt AMOomnxi HmtKtxmmx-ietoni Sttp If^ «an.

Hlkwomi-gut — 40 strands; {17) intestinal instmmtnls and needles -Murphy's
bullun; anastomosis forcejis; clamps; two slnight and two curved inlcnttnul
needles (Pig>- 964 and 96$},

983

TECHNIC OF SPECIAL OPERATIONS,

should not be continued simply to avoid making a larger opening in the ab-
dominal wall.

A broad ilcshy pedicle should not be ligated en masse with an interlocking
ligature, as there is always more or less danger of the ligature slipping and i
fatal hemorrhage occurring. Under these circum^itances a ligature should be
passed at each end of the broad ligament and tied in the manner de:<cribed
under salpingo -oophorectomy (see p. 977) and the raw edges in the upper aspect
of the ligament which are left after the pedicle is cut away sutured with a tun-
tinuous Lembert suture of No. 2 braided silk.

Special Directions.— Before tapping the cyst the surgeon ^ould pas-
one or two fingers into the abdomen and explore the anterior surface of ibr
tumor as far as possible. Unless this is done, anterior adhesions are likely 10
be overlooked and the delivery of the cyst complicated.

It is also important not to use force in delivering the cyst, as adhesions maybe
present between it and adjacent organs and a serious injury may result from
rough manipulations. The surface of the sac should thereifore be consiantly
inspected by sight and touch during its delivery, and if adhesions present them-
selves traction upon the cyst should be stopped at once until they have been
separated and broken up in the manner described on page 9 10.

REHOVAL OF AN INTRALIGAMENTOUS CYST.

The Position oj the Patient, the Number oj Assistants, and the List 0} Inslnr
ments are the same as for the removal of a cystic tumor of the ovary (sec p. (i;8|.

Operation.— First Step. — The ovarian vessels are first ligated at the
pelvic and uterine ends of the broad ligament and the surface of the cyst eiposdi
by incising the peritoneum (Fig. 960).

The preliminary ligation of the ovarian vessels controls the circulation and

rill. 0^- — Opebation roB the Rkmoval r>w ak In-tbalicavkpttol's C*vst — ^RJlt Step.

enaliles the operator In enucleate the cyst with hut little, if any, bleeding. The
incision through ihe ]ieritoneum over the tumor should be made at a point in
which there nro the fewest number of blood-vessels, and care should be ukcn
not to rut into (he wall of (he cyst.

Second Step.— Tho cyst is shelled out of the broad ligament by mean- "i
dry dissection, using for the purpose the handle of a scalpel, the tips of tit

REUOVAl OF AN INTRALICAUEJtlOUS CYST.

983

Angers, and a saun; simnf^r. BltciliiiK vc^'^ln nre »«out<(1 with liemuslntlr
forcepM nn<l Mili-;e(|iK-ntty ligiitctl v.-il!i c.nlgut nflcr the cnuclnliim of ihc cyat
is atmpUrlnt (Kig. 961).

v>.

I /

Fu. «Ai.— Sacond Sup. Fin. gAi. Second Stop.

• majinoii rm nn Riwoviii. or ah IxriAi n-Aiiixnii'i I'wr.

During ihe .i.1icliinf;-(>ut of the cyst the upeniTor .thnukl kwp cl<i-'w la il$ wall5
in onlcr ti» present Icnrint; the brnad ligamrnt or injuring the underlying 5truc-
turtv When Ihe < ysi U larj;c and cmwd.* the pclvjf aiviiy. ii should be lup|>c<l
vilha tmcaraiid the lluid cvacuiitcci before t>efciiiiiing the vnuclcat inn (Pig. 963).

fte. •&!. — OreunoH roi mi Rtimvu. or ur t.vtaAinuMmnit Cnr— Tbud 9i*p>
I iht opiajiit ai tbt (uo ul ibc btMd UMmnii ikanl i*l iht acpanMl Urn* u' <li' li(*ni>ai Mb(

In M>m« caxcs it b ev^n necessary tn perform u preliminur>' lu|>piiiK bef'>r« Ihi-
uvarian vcssel.i can be liffaicl, as Ihc |>eK'i3 i>> s» crowded that it u impoMJbtc
In find them uniil the content" of the Mtc hiue been removed.

984

TECHNIC OF SPECIAL OPEKATIONS.

Third Step.^The bleeding vessels are li'gated and the hemostatic foictps
removed. The layers of the broad ligament which were separated by thenst
are then united by continuous catgut sutures and the edges of the peritoneuiB
at the top of the ligament closed in the same manner (Fig. 963).

In some cases the oozing from the raw surfaces between the folds of the broad
ligament cannot be entirely checked and a hematoma is likely to form if (bt
wound is closed. Under these conditions the broad ligament is attached in lie
lower angle of the abdominal incision by interrupted catgut sutures which include
the edges of the opening in the ligament and pass through the peritoneum, musfk.
and ajjoneurolic fascia of the abdominal wall. The cavity in the broad ligaronit
is then packed with a strip of gauze and its end left outside of the abdomim;
wound.

Special Directions. — So soon as the abdomen is opened the surgecn
should introduce his fingers into the abdominal cavity and thoroughly examine
the relations of the cyst with adjacent structures.

In some cases it may be impossible to remove the base of the cyst when it
is situated deeply in the pelvis, and under these circumstances the shelled-oui
portion should be cut away and the rest of the sac allowed to remain. The edges
of the opening in the broad ligament are then sutured to the abdominal incL^oii
and the space between the folds of the ligament packed with a strip cf gauze.

mCOHPLETE ABDOMINAL HYSTERECTOBIY.

Definition, — This operation is performed by the abdominal route, and

consists in the amputation of the uterus at the juncture of the body and the cenii

Synonyms. — Supravaginal amputation of the uterus; Partial hj-sleret-

tomv.

Fm, 064 — Is^THUME.^ri I'^irn i^j the "prH*rio« -jf Ki>iHpLETF. Aan^mTVAL Hv^THftxu'Wi

Position. — The patient is jilaced in the Trendelenburg positiin »iili
hi-r IjikIv at an unRte of 25 decrees, and after the abdomen is iij)cned ihc pel'i^
is niLscd to 45 degrees.

Number of Assistants. — An anesthetizer, one assistant, and 3
general nur.-e.

986

TRCBKIC or SPEaAL OPKSATIOXS.

Operation.— Pint Step.— So suon as ih? abdomen isnpcncii thctunpoa
iiHrcnrur<;> hi^ humis iniu the laviiy and ascertains ihc nature of the luiur.
the thickness of the sii|>rnvaginiil cervix; ihe pretence or ntuence ftf lulheiMi;
and ihc rclalicn of the neoplasm with adjacent organs. The iiUkiniiiid ■•
dsion i» ihrii <!ntar|j;«l suDkiently to allow the tumor to be dclivcrrd «illiad
U»nK undue force.

Seconal Step.— The tumor is delivered through the atM)omin.il inciiiMbT
seizing il nith :i pair nf heavy hyKteri-<. lumy f»rrep.-k and mitkiaf; ira<jl>ua tUHa
it. At the same time the assistant mnk<% Jatcnil pressure u)Min the abctoouiAl
wall.v and the sui>;eon guiden the (las^ge of the tumor with one or two fingn
intmdiKcd into the uppcrangic of the incision (Fif[. q66).

Third Step.— The assistant pulls the tumor toward thcsymphystcpulmud
the operatiir placfo tivo large fcauiu; pad> over the intestines immediatdy had

tit

t-;*^/^

V-

;-?

•-■".,

".o^^-

PiO. «Ai.— tKmitPMT* AnnoHiKM. HntEurton— Tlilid Stop,

of the supravaginal 1-cTvfx to shut off the field of opciatioD and protect the pntnl
peritoneal cavity (Fig. gb?).'

Fourth Step.— A tongbbded hemostatic forceiM i* pbced ckise to the ronm
of the uterus, and the uvjirian ligament, ihe Fallopian tube, ihe ntund lic-iimul,
and the uterine end of the ovarian \ei.'(el--i securely clumped. .\ sincle ilKsturt
(if braided .lilk, No. i3. i.i jiiiKvcd through the bnmd ligament under the oi.ihia
vessels and the round li);ament and carried over the upper border of the infutvfl-
bulopclvic ligament and tieil near ihc fimbriatol extremity of the iul)e- TV
bnxid ligament is then divided in an oblique direction cluwnward brloren |hr
limbrialcd cUremity of the tube and the ligature, toward the juncture ul tJu
body of the uterus ana the cervix, clotie to the uterine artery and veins.

988

TECHNIC OF SPECIAL OPERATIONS,

curved direction to each side of the uterus, where it becomes continuous srilh
the lateral divisions in the broad ligaments (Fig. 970).

Seventh Step. — The bladder is stripped from the uterus by pushing it with the
fingers or the handle (if a scalpel until it iscompletely separated down to the vu|i-
nal junction and the level of the lateral divisions of the broad ligaments (Fig. 971).

Kill. 073.— InLUIULEIE ASUUUINAL HlSTEBELTCIHY— Siith Sup [pucc «87).

ViG- lyl' — iNiTNVFirFrE Adihuitnal I [ vtte b FrTTiii y— Se venth Slep.

Eighth Step. -The niienlur draws ihe tiimiT upward and :impulalc> (he
uicrii- ill ilu' vaginal junction <m a level with ihe ligatures conlmllinn the uiiru.t
vi->:.el^ (Fii;. q7j|.

Ninth Step,— A ligature of No. 12 braided silk is passed rinse U< llic icnii
un'!(T the ]iodictf which includes the uterine vessels, carrieil through the liriuJ

TCCHNIC OF SPECIAL OPERAnoNS.

Fourth Step.^A lignlur? is pasMx] Uirouph iho broad liKiiinrnt, mxladi
mutid ligamrnt. and lird "vcr th*- u]>]>ct m;ir^in of the infuiKJiffUlopcU'k lin
mmt iwar the Fallopian tube. Th« broad ligament b now divided duwn li>^

Ftr. vKe- — OrKUROH mi tnr Skvdvii ot a.v bmAUctiliinaDi Ctduvk FtaaotD om Ohs

Fourth Slap.
Shorn thi niihl UtduI llganirni ligtinl uxl t*">> diviiM.

fir., oHi —Orautncm tn% nn Rxhotu. or ih l^ni Minima row I'nuxx Fibkud ox Bom o,b-

Flrrt 8t«.

va^iiiiil jum liim, the uterus removed, and ih« clamp on the uirrine nrtcrv n~\
plHcrd by a liijaHirc (Kig. 080). ' f

The MicreedinK steps arc the same ji^ lhi>>c described in the lyiiicjil oprraiton. |
An Intraligamentons TTterine Fibroid on Both' Sides.— First
Step.— The nxariiin vessels nnd the nnind ligiimein iirc lig.itcd M^jKirately

IKfXlMPLKIK Allt'OMINAf. HVItTKRKtTOllY.

w»

^ lire and ihe GmbHikictl exiremity o( the tube. 1o ihe ^'U);inal junction. The
J>rwcdurc i« then lepeato] on the npiMwic -vide imd the Mureiihng !-lcp* of ihe

|ti)w rill ion carried out in the same nwiincr a». already described (Fig. 9*S)-

Wheii Ihe tumor involve^ tlie ^u|l^:l^iIKi^aI cervix, or it is firmly fixed in the

'pelvis, it is sometimi-s diftiailt cir imjiov»iblc tn lift it tiut of the olxlomen :in(l
»e<UTe Ihe bloo<J -vessels In the usual manner. Under these rlrx-umstu tires the

p£l>domm3l inmion i* eillari;e<l in onler tii (rcely ex]M)>e the field of n|>eration.
in<l tlte ovarian vessels controlled by placing a lonff-bladed hemastalic furceps

'cliK'te to the cornu of the uterus and a tiKnturc at the pclvU' end of the bmad
lit^amcnt. The broiid ligament is then divided lu usual and the pnArdure
repealed un the opposite side, The tumor, being now freed from its lateral

*^^

\^*-

:e*-«

ri.

I i«t Maninii or RteMHUiMi an L*rWA*D DiutAitHtm u* (■( Buludu m * t»ac
Piwom TVua* iir nis Uiuut.

LBliachnMnls. can readily be delivered through the id>dominal incision and the
F-Miccccdii))!; steps of the operation tarried out as described above.

In a n'oman who is under lorly-rivc years oi age llic iivarics should not lie
removed if ihey are hc.iithy, for the rcasrn that if they are .■illowed to rcm.iin
in the i>elvis the nervous >ympioms of the artificial climacteric arc jirevcntcd
and thi- genend ouiditinn rf the patient l^ more sali<faclnry.

Special Directions.— In brse tumors the danger of wounding the
^bladder when tin' ;i)><innK'ii is opened mu.st alwavs be Uirne in mJntl. and the
ncibi«m sHouI the
aplasm may have lifted the organ out of the pcbis. The position of the blaiWcr
an be tleiermined prior to openition by inlroducinft a \ound and loi'ating it,
' feeling the tip u( the inEtrument through the abdominul walls (Fif^. 976).

ho. Ma^OrcMTToa ton n» Kmn'tt. or am tKnAii'-.jiitEinoD* Vtkum Piuoid osi Okc tev— ThM

SHp.

There it nil (lifSniliy. !i«a nilc in loaning ihcincrincartcn-. as it !«. enMrally
expcwcd to view beneath ihc intraligamentous growth fo soon a> tht bsi fibers
of ihc cervix :irv divkktl.

Third Step.~Thi- ba» n{ ihc brnad ligament H stretched ipan with Ihc
fingen; and the tumor cnucltated from its bed (Fig. 079)-

FiO. gSo. — UTDMnOH ron the Rchdvai oi o IvimijciuiiictOIis t'nmiSK FmuiD OH 0«

Fouitb Step.
Shawl tbt rlihi brnil lijamnii liRimt uhI fmnlyiinii^.

Flo. oil. — OnEUTIHH ttlK THK RunvAL »! Ut lltnAIM'.AUrXTO}3t VnMita Fkmiid cim

Fbit SMu,

The Position of the ^tient, ihc Nnmber of Asslstan

CUUPLETK ABDOUINAL HYSTE&eCTOHY. 997

ligalion n( ihc ul«rin« artcrits, as well as the separation of the bladder from
lite uienis. sre accomplislicd in the same miinncr iis desiiibnl in ilie typical
u{tcraii«n at Incomplete AlHlomitiul Hj-slcrcctomy.

The Kuccccdinc steps of the operation are car-
ried out a.% follows:

3pDl

P16. old, — Coiin.m A*iioaiiif«t HnnstrroHV— nitd 9tip.

First Step. — Traction upward Is madt; u|i<)n the uIltu.-> mid (he vaginal junc-
tion put ii|Jon the stretch. The bladder is then drawn forward wnlh the tip of the
index-finger and the anterior vaginal nildcsar opened with a scalpel (Fig. 9S4).

Second Step. —The indux-finger is introduced through the opening into the

SJ-

tn. «Sl.— CowruTi AiuonvAt Hniuxcniiy— FoiUIli Slac <WCe m'l).
' ftlki itdc the licalnR !• IM and Iht nv iluinpi uniMdi on Ih( Ml it iliinin Iht nMhod ol puuni ilw

Igina and the incision rarriwl romptdelv arouncl the cen'ix with itdiwort,

qiaralin^ it fn>m its vagin.il attachments (Fig. 9S5).
Third Step.— The hleedinR ve-v*el.i in Ihc ectces of (he inclMon arc Iigate<J
with catgut and the <;i)ening in the vagiiuil vault closed with catgut sutures
which pass to, but do nol penetrate, the mucous mcmbrancof the vagina (Fig. 9A6).

998

TECHNIC OF SPECIAL OPERATIONS.

Fourth Step. — An additional ligature is parsed under the uterine artery,
carried through the broad ligament above the upper pedicle, and securely tied.
The procedure is repeated on the opposite side. The union of the two pedicle
stumps on each side of the pelvis puts the broad ligaments upon the stretch and
supports the vault of the vagina (Fig. 987).

Fifth Step. — The field of operation is covered with the anterior peritoneal
flap and the united stumps on each side are turned under the peritoneum and
permanently buried beneath it b_y a continuous catgut suture (Fig, 98S).

Variations in Technic.^ln cases of malignant involvement of the
uterus the ligatures controlling the uterine arteries should be placed as far as
possible from the cervix in order to get well beyond the area of disease and lessen
the danger of recurrence. The likelihood of injuring the ureters is greatly in-
creased in operations for the complete removal of the uterus, and Kelly recom-
mends the introduction of solid bougies as a preliminary step in order to enable
the operator to recognize their situation when the uterine arteries are ligated
and the cervix cut away from its lateral attachments.

In some cases the uterine arteries are not ligated until after the vagina has
been opened and the structures divided in front of and behind the cer\-ix. The

FlO. 98S.— COHPtEIE ABDOlONAt HVSTMECTOUI — Fifth Step.

N<ilc rhal all Ihe raw surfHcea aic covered uilh periloiuum and Lhc slumra oE the pcdides buried.

two strips of tissue on each side of the cervix are then ligated en masse with
silk ligatures and the uterus removed by dividing the structures beyond them.

The question of drainage depends upon the completeness of hemostasis, and
if the field of operation is perfectly dr\-, the vagina should be closed as already
described. If, however, the oozing cannot be checked, drainage should be
employed through the abdominal incision by means of a glass tube and a strip
of gauze which is packed in the pelvis and its free end brought out of the wound.
Some operators, on the other hand, prefer to drain through the vagina with a
strip of gauze which is passed through the opening in the vaginal vault, and
then packed over an<l around the field of operation. The vulva is then protected
with a gauze compress which is secured with a T-bandage and changed as often
as necessary. The gauze packing is removed from the vagina and peh-ic cavity
at the end of the third day, and a fresh strip reintroduced everj' day or two
until the vaginal wound closes. Each time the dressings are applied the vagina
should be carefully irrigated with a saturated solution of boric acid and dried
with a gauze sponge.

VAGINAL m-STEKCCTOUY WITH TLAUPS.

999

When a. complete h^'stcreciomy h performed for maligoanl disease, Uicoprnt-
litin should be immcdialcly preceded by Uie removal u( the (^nccmua uttsue in
the cenix and ihe closure of U>e cenind raiwl widi n c^Jntin^lou^ silk suture.
Before the canal is closed, however, the diseased area should be tfaorougbly
cauterijted wiUi ihe lhermocautcr>' in order lo char Ihc [larU and preieni ilic
InuupUntalion of mncer-ircIU into hc-ilthy siniciure* during the operation.
When the disease is well advanced and the cervix is extensively involved, tlie

" d.-injier of the tninspbniation of cancer-cells Is KreaUy increased, and under these
rircumjl;inre> a* much us possible of llie cancerous tissue should be removed
with a sharp curct and the diseased area thonaughly charred with the thcrnio-

f cautery.

VAGINAL HYSTERECTOMY WITH CLAMPS.
Definition. —Thiii operation is performed by llie vaf^inal route, and

0»

©^

Fu. «■«,— ImnciiEiin Uim w no. Uraution of Vuiihju. Kmiiunoiff vin CUm*.

^COnsisU in the removal of the entire uterus by
means of clamps, whicfi control the uterine and
Ovarutn vevsds on both sides of the peU-is,
Position.— Tlie i»alienl is placed in the
dorsal positi<in with her feet held by KdelM>h]*"s
I-hnlders and slirm)j^

Ntunber of Assistants.— An nnesiliei
[Izcr. two a^^i^t;lnts, and ii Rcncra! nurse,
j XnStrtunentS. — (i) Simon's specutums
kcurvcd and fUlbludex); (3) In-o Ulenil va-
|giiul retmclors: (3) scalpel; (4) blunt-pointed
cissnrs; (5) six short hemostatic forceps: (6)
ft-o lonit hemostatic forceps; (7) four h)*terer-

f7\

® ®

ACTUAI 5IZE1

tiu L'lmmnn i'mtnan or V*-
eaAL HTfuiicToiiv mni CuuctK

^tomy clamps: (8) two heavy hi'stercctomy

faction force|>s; (9)dreiisinK forcqis; (10) rat' tooth tissue forcC|ts; (11) needle-

lOCO

TtCaXIC OF SPECIAL 0PF.SAT10N3.

holder; (la) two small full-curt-«l (lagcdtKm ncvdlcs; (tj) braided silk — No
13; {14) plain mmot calfcui — Xo. 3, &ix CDvdopes.

fm. wi. — VAOiKUiUynMicniiiviinTHCijuiFt—PirM St*p.

Vxa. wK.--V4Ci»iAt Hymuxmiit wit* Ctjutn — f ounli Sttpi.

VAOIN-AL IIV^rKXECTOUV WtTII L'LAUPS.

lOOI

Operation.— First Step.— ^The (trvix is cxpnMtl with Simon's »i>i-culuin
aixl all cADccnHi^ lissiic curirlc-iJ or cut away. The urcrinc carily is then plupgcd
wilh :i narrow sirip of gauze" llic oireiod arm »-haiT«l wilh llie (hernio(-»u(en>,
and the <;er\'ic.il i-jnai <-l<Ktcil with a continuous suture of silk (No. la. liraified)
(FiK. <)gi).

Second Step.— The speculum is withdnivrn and the vagina McrJIi^ in the
same m;iriricr as df>i*ribrrl on page 851.

Third Step. —Simon's spcculums arc intniduccd and the ceirix seized wilh
hca»y h> >ltrci ii>my forceps and druggol downward toward tlie vulva.

Fourth Step.— The lateral rclractors arc introduced into the vagina and
3 circular incision made around (he cenix in a line with the cervicovajtinal
junction (Fig, 991).

Fifth Step. — The vagina snd loose cellular tissue around the ccnix aro

'^^

I V

I^- nj.—VunuL llmt«K<.i<.>iiv niiM CiAim—Rltb Slav.

Mripfwd hack u-ith the h'-in<t)e of the scalpel or the fingers or if necessary they
axcdisscctcdoff by means of scissors and tissue forceps (Fig. 9<)j).

Bk-i-di»X ve».Hel!i are ligaleil with catjiut.

Sixth Step.— A small incision is nude in the culdesac of Douglas and the
'>)>cninK enlarged on citlier side ah far a^ ihc ba.sc of the broad lijiamenU by
tearing the tissues with ilic index-fingers. A digital ex3min.ition is then made
of the [)elvic cavity, and if adhesions are found to be present, they are broken
up More the rlamp.s are ajiplinl to the bnmd ligamenLv A j^uxe pud wilh a
hcnvy Filk lit;.-ilure attached is finally placed in the nildesac «i Douglas to protect
the intestines and absorb the l>l(MNi (Figs. qQ4 and 995).

Seventh Step.— Tlie n-Tyix is drawn barkw-sn! toward the [lerineum and
the bladder separated from llic uterus by pushing bark the tissues wilh the

I002

TECHXIC OF SPECIAL OPERATION'S.

finger i>r diiietling ihcm off with scissons and Ibsuc forceps. An uirLtion
then m^ulr ihnnigli ihe uieioveMail fiild of ;ieril(>iieum und enlarged l^itmlti
up to the broad ligamcnU with the; index -lingers (Fig. 996).

Fm. OT<-8imi3l*p. Pio. Mt-— Strth Sttp.

VttiKU tlriTiiiUTmit wrni Cluim (rant ieoi).
Fl^. 004 *hei» tbc vpcaioit bdojt nuJr laio the c^Mbbc uf Dciuj|U«; Fij|, qo) sbawv the opteiu

tfobrtcd with the indcft-fiQffrB.

no. «oA,— Vauimi. llTirKimiTi^uT wmi Claht*— Stvoilb SMP (mat IMI>.
jhan ibe uifH« lodilon Into Ibc pdilc cmvitv bsiiii coUrfid.

VAOiNAt. frysTetiEcn>iiv with clamp-s.

ia>S

T«nth Step. -The anlcrior vaginal wall and the bladder are suii|)orted with
Simon's llai-hladed .ipeailum ami the bmail liji-nnient >euiil hryond the uierin«
adnexn I>etw«n the thumb and index- ringer. ;\ hysicreciomy clamp is ihcn
pUi-cd on ihc liKamcnt fmm above downward a* far as the tip of the cbmp
(-itntii>lttnK the uterine artery. The li^c^ment is nciw divided licyoni! ihe cbmp
ami thi- iiterii.-i (trli^-ered. The ripptii^itc broad ligiimcnt b then clamped and
divided in die virac manner (Fis^. 999 and 1000).

Eleventh Step.— The vpeailum> and Inleral r<-lraclors are reintroduced and
the gauze pad rcm<ned fmm Ihe culdcsac of Douglas, .\ hTgp gauze pad is
then pas.sed into the pelvic iiivity and Ihe intestines pu^he() up out of the way.
The o]>er:ilor now rarefully iri?i[KTls ihe petlicles ami m.Tke* sure that the vessels
are securely clamped. .\ heavy silk thread is then lishtly wound around the
Itandles of each puir of fori:e])> .niid .securely li«l in order to guard againM the
|>os.iibi]iiy <if the links clipping (l-'ig. looi).

Twelfth Step. -The tiauzc pad is removed fmm ihe pelviM, and a ^l^ip of
Kauze |Nicked in tlie <-uIde«ic of Dougliisi up lo the level of the lips of Ihe
forceps controlling Ihe uterine arteries. A !^mall gauze pad i^ then placed
ketwevn Ihe forcqjs and the vaginal wall on each
Mile lo prevent pres-Nure and ttie vagina loOMly
])acked with a f^trip of gauze which is secured
by a vulvar compress and a T-hanilaRe.

Variations in Technic— Some opera-
tors ii^c ,1 cuulcry knife li> make the circular
incision around llic cervix and to open the
posterior vagin;d culdevwc in onier to char the
edges of the wound and prevent bleeding.

Another variation in the lechnic it. tn unltr
Ihe peritoneum to ihe cdge» of the vaginal wound
by a continuous catpil suture after the iulde>ac
<4 Dougla.* hiLs Iwcn opened ami the Iiludder
separate*! fr<>m the Uterus. The approximation
of Ihe jieritonrum to the edges of the vaginal in-
cisi<in prevents it from stripping and conirxils the
(Muing which usually occurs.

In some cases it may Ije eiusicr lo ttlnivert the
Uterus ami deliver the fundus pusleriorly than to
anlcverl the organ ;ind bring it forward un<Icr the

)>ln«)der. If tlic former methml is employol. the index and middle fingers are
[nssvd into ihc pelvic cavity and hooked over the fundus of tlic uterus, which
is then <!r^gge<l downward and forward thn>ugh the posterior opening in Ihe
raginal v.iult. It is then Mri/i-d with heavy- traction forceps and pulled low^ird
the vulva. The succeeding steps of the operation by which the o\-ari.Tn vessels
are eUmjied iiml the uteruv removeil are the same as already described when
the fundus is deliveo-d in antcversion.

Hemiscclion is sometimes employed when Ihe uterus is enlarged to facilitate
ill <le!ivery 3nd secure the ovari.in vessels with cbmps. The procedure, however,
is absolutely coniraindicuted in cases of c;iiicer of the utcnis on account of the
danger of septic infection and the transplanUlion of cancer-cclLs into healthy
Mructures.

After-treatment.— The urine is drawn with a catheter ever>- two
Imurs for the first iby, atirl then ever>' four hours until the forcei>s arc removed,
when Ihe patient is usually able lo empty the bladder s|Hmtuneously.

At the end of forly-eight hours the palient is placed on 3 (able in the dorul
potiiiion Aiid the forceps reniovcd.

Flc. imi.--V*ii|]LU. Hyin-Ufw-iiT
Hitii CuiHn El<*salh Slap.

Show (ho mrTh.Ht cif rfirtf ihr JuDillc
ol Iht loncpi

ioo6

TECHNIC OF SPEaAL OPERATIONS.

The bowels are opened by a mild laxative on the third day, and in the mean-
time any accumulation of flatus is reheved by the rectal tube. The use of a
purgative enema is contraindicated, as the injection distends the bowel and dis-
places the contents of the pelvis.

The gauze packings in the vagina and pelvis arc not disturbed for seven days.
At the end of that period the patient is placed on a table and the dressings
carefully withdrawn from the vagina and the field of operation. The vagina
is then gently irrigated with boric acid solution and a fresh gauze packing in-
troduced.

The suppuration which occurs after a clamp operation causes a mild septic
infection, and the parts should therefore be kept as sweet and clean as possible.
Under these circumstances the vagina should be douched with a solution a(
corrosive sublimate (i to aooo), followed by sterile water, instead of the boric
acid solution after the middle of the second week, and the vulvar compress should
be frequently changed.

The patient is allowed to sit up in bed on the tenth day and to lie on a lounge
or recline on an easy chair at the end of the second week.

VAGmAL HYSTERECTOHY WITH LIGATURES.

Definition.— The of>eration is performed by the vaginal route and
consists in the removal of the entire uterus by means of ligatures which control
the uterine and ovarian vessels on both sides of the pelvis.

The Position of the Patient and the Number of Assistants

are the same as for the clamp operation.

FlC. looi. — [^^^KU^IKHIS UsF.n in the OpFHAtlclK op VjSIVAI HlSTtBV.CTOlH WITR I.ll^AH Il>

Instruments.— (i) Simon's speculums (curved and flat blades); (;) mo
lateral vajjinLi! retractors; (t,) scalpel; (4) bluni-pointed .icissnrs; (5) <i\ shi^n
hemostatic fiirce|>s; (6) two lon^ hemostatic forceps; (7) two heavv hvsiem-
tomy IriL tirm forceps ; (8) Iwo long-bladed hemostatic forceps ; (9) pe<lii'lc

VARINAL m'STKHKCTilUV WtTU UUATURES.

1007

® @

\ ACTUAL SIZE g

ncttlk; (10) dres&iiigj; fiircepw; (11) raMwith tissue (i>rcq>R: (la) necdlc-hoUler;
(1;) two smiill full-curved Hagnlorn needles; (14) bruided sUk — No. 12; (15)
plain cumol lal^ul -No. 2, six crivelujies.

Operation.— The first seven steps of ihc opcrulion arc the same as de-
strilnni M\4 illu>lr>ili'd in llic li-chnit dl' vjfji-
ml hvslcre( loiny with damps (see p. 1001).

Eighth Step.— The tissue:^ are |)iishct]
away from each side of the cervix with the
finger' inward tlie \teivK u-aJLi and the liroad
ligamenls grasped Ix-twccn the thumb and
index-finifer white a bnalure uf No. 13
braidcii ^ilk, c-irried in a jxxiidc needle, is
posscd nlwvc the uterine .irtcrj'. The liga-
ture is then tied and the li^aled portion nf
the bniiid ligament dividi-d close to the
uterus. Tile procedure is now rc|ic;ited on
the ojipoKite side. The free ends of each
Iif;a(ure are left long (I-'igs. 1004 and 100;).

ninth Step. — The speculums and the retractors are removed anil the cervix
rclcawd (mm the grasp "f the traction forcejis, The index .ind middle lingers
i>f the left hand are then introduced into the pelvic cavity and tht' fundus of the
Uterus pushed forwani under the bladder into the vaginn, where it i.t seized

It.

Fio. inat'Sinmwi. «>m Sum* Miit-
■uu I'lCD ta nil OrKtinus or V*-

ru, isoi,— Klahth SMp. Kio. wot-— Elabth Sttp.

Vuiivu llvmKtCTMn ■itii Lic^ntau.
lOej ib«v4 ibt tiit4iure ItdOK ip^J'cd ta ihr Imm part of rhr ruhi htimA Tijcunmi; Hf . io*t thotrt Aa
liniiliim tlnl tnd iIic Umkii-oi fliVlilnl.

iflh Inuiion forceps and pulled toward Ihc vulva. The tubes and ovatics ftre
likewise ddivcrcd. and if necessaix- secured by forceps (see p. 1004).

Tenth Step,— The anterior vaginal waH and the bladder arc supported with
^imnnV tiAl-bbdrd speculum, the unligsler) [Kirtioo of the broad lii;-ii"ent i«
drawn forward v, ith the index -Kngcr, and the uterine apjwnditge* are lUlcd out

of the way, A lignlurc of No. i3 hniidui silk airriwl in a pcnlicle needle 3
then passed under the broad ligament and lied.. The ligament is now dividrf"

Fu), nM. — Vjuikal KnnBicTiim with LiatTlms*— TuUi Sup ((■•< lasi).
Sbnn tht utcni* drtin-rtd «ad Ih* upfvr jmn of the rlfbl bc««d ligWMoC bmitf llrjt*rf

Firi, IQOJ. — V*<-|lVrtl. l*TiIT»lirrTrtWV WITH I JCATt-|l>»^Ttn(h Stt9.

Shnm Ion hRud UvamMii ttnl uid bcinn •UsvlH. LlgxntlMi o i)iijn» thr t.inr Usiiumin f» natal

close to the ulcnis and the organ delivered. The opposite broad ligament is '
Ihcn ligatcd and divided in the same manner. The free ends of mch liKuturr |
are left long (Fig^ 1006 and 1007).

COUBINCO VAGINAL AND ABDOMINAL H\'5TEKKCTOUY.

1009

Eleventh Step. — The «]>cculuins and retractors are rdnlnNluretl inlii the

vapna and the gauze pad removed from the culdcsac of Douglas. A large

gnuxe pad w then pushed into (he pehic c.ivity und the inte^line.% crowded up-

liward. A careful inspection i:^ then made of the field of operation and all bleeding

poitits llffated with catgut.

Twelfth Step, — "file gauxe pad » withdrawn from the pelvis and ihe tirnad
tmeni stumps drawn by the free ends of the ligatures into the vaginni wound,
[which is then closed by interruptt^l ottKUt .-vuturei. The .sutures are passed

^f^m-

1'. ■ I

WK. iMl-— Vmoiu llniEiirrom «-tni Lietr

-TnKlh Stop.

to transrix each i^lump, and include the peritoneal and vaginal edges of
the wound. The vngina is I'lniilly loo'^ely packed with a >lri[> of gauxe and the
vulva protected "ith a compress secured by a T-bandagc (I'"ig. 1008).

Aller-treatment. — The gaune pacldng U removed at Ihe end of
twenty-four hours ami not ininxluasi ;igiiin, nnd the vagina irrigated with a
solution of corrosive sublimate ( i to looo). followed by sterile w^ter.

The douches ^ould then be given once a day until the wound heals and
the patient is discharged.

COMBINED VAGINAL AND ABDOMINAL HYSTERECTOMY,

Definition. The »perjtion consi^s in i'tr>i ligating ihc uterine arteries
nd .leiiariling the cervix from itx atla('hmeni> through a vaccinal innMon. and
Ihen i>j>ciiinK the aMomen und completing the removal of ihe uterus fnjm above.
Position. -The jwlicnt is placed for the vaginal section in the dor»l
position with lii-r feet held by EdebohU's leg-holder; and stirrups, and then put
m the Trendelenburg posture to complete the operation through the alxtominal
iDcision.

Nomber of Assistants.— An anesthetiwr, two amUUnU, and a
neral nurse are required for the vaginal section. When the abdomen is opened,
ty one as<^stani is needed besides the anc^thelizcr and general nurse.
Znstniments.— Fc»T the ragin.-tl iicction cither the instrumenu uied in a
0*

lOtO

TECHNIC OF SPECIAL OPERATIONS.

vaginal hysterectomy with clamps (see p. 999) or with ligatures (see p. 1006) are
required. In completing the operation through the abdominal incision the same
instruments are used as for an incomplete abdominal hysterectomy (see p. 984).

Operation, — The vaginal section ends with clamping or ligating the
uterine arteries (see vaginal hysterectomy with clamps or with ligatures, pp. 999
and 1006).

The patient is then placed in the Trendelenburg posture, the forceps applied
to the sides of the uterus, the ovarian vessels and the round ligaments ligated,
and the broad ligaments divided in the same manner as in the operation of
Incomplete Abdominal Hysterectomy (see p. 984). And, finally, the vaginal
opening is closed and the raw surfaces covered with oeritoneum, as in the opera-
tion of Complete Abdominal Hysterectomy (see p. 996).

ABDOmNAL MYOIilECrOIilY.

Definition. — The operation is performed by the abdominal route, and
consists in the enucleation of a uterine tumor without sacrificing the uterus.

The Position of the Patient, the Nttmber of Assistants, and the
InstrtunentS are the same as described in the operation of Incomplete Ab-
dominal Hysterectomy.

Operation. — After the abdomen is opened the uterus is delivered through
the alxlominal incision and grotected by gauze pads.

If the tumor is pedunculated, a wedge-shaped incision is made into the
uterus at the base of its f)edicle and the growth removed. The uterine wound
is then closed with deep interrupted catgut sutures.

Fio, lOOfjr Flc. 1010.

Abdominal Mvoveotohy-
Flg. 1000 shows a pcdunoiUlcd suhperilonea] uienn:' fibmiij: the doTinl line sho»i thf dircctioD at the
incision; Fig. iDio shows ihc lumor ^mov'td ;tbd iHf wound bting Aulured.

A sessile growth is removed by making a free incision over its surface and
shelling it out with the fingers or the handle of the scalpel. In some cases the
tumor may be adherenf and it will be necessary to use the scalpel or scissors
in completing the enucleation. The bed of the tumor is obliterated and the
wound closed by deep interrupted catgut sutures.

Temporan' hemostasis may be accomplished during the enucleation of the
tumor by placing an elastic ligature around the cervix and securing it with

APTEHDlCnK.

1013

thp calhdcr in not used s^in nn the same dn Y,.il shauld be placed in the sterilizer
awi rd">ilc<l before iniivxlucinj; il ini<i Ihc blnddtr.

Tbc iiniiNei}!!^ iirccuulluiu inuM he ihrtrouRhly i-arrie*] out in e%-ery iletiiil
and the nurse must prepare her handit by mcchiinic !^lrrilixalion. The patient
b plaeed lcnglhwt.se in bed in the dorul position and a sheet 1ucke<l around
her knee» iitid thighs «i as ti) expi'se the vulva lc then scrubs
the external urinarj- meatus and itdjacent \-mn^ v.Hlh n ^uze spmn^ie saturated
nilh tincture u[ green soap and warm water and doucho them with a aoluliun
of ctfrrosive sublimate (i to 2000), which is followed by sterile water or normal
sallwlution.

The nymphx are now separalefl with the thumb and index- fmiKcr and the
caihclcr. held in the gtnsp of the other himd, is parsed through the urethra
into the bladder. After the urine ceases to flow the catheter is grasped between
the thumb and middle Itnjit^r and >lowly withdrawn from thr urrlhra, while at
the same time the lip of the index-finger is pressed over the opening at ihc
proximal end. Unless the openins is shut off in this way the urine remaining
in the catheter will nin out alter it i> withdrawn and ?uil the patient's clothing.

CHAPTER XLIV.

APPENDians.

Catises.— The causes of appendicitis may be divided into (i) those that
are i>ermanent or constantly present, and (3) those that arc temporary' or ex-
citing.

Pemiuient Causes. — .Amon;: tlie permanent facton prerlts] losing to the
disease are (o) the constant presence of bacteria; (6) the antilomic position of
the appendix; and (c) the relrograde chan;:cs taking place inlheor^^n.

The bacillus coli communis is conMnntly present in the intestinal canal, and
consequently in the appendi.v. I-'inding its normal habitat there, il retains its
nan -pathogenic characteristics so Ions as the structure of the appendix i.v un-
altered. If. however, the lumen of the organ is interfered with by fecal accu-
mulation, or by a stricture, or by a disturbance of the circulation from whatever
cause, the bacillus penetrates the walls n1 the appendii:, where it does not
naturally belong, and then becomes pathogenic in character. Among the bac-
teria of ctiologic im)Hirtance in appendiciti.s are the •itreptociMcus pyogenes,
staphylococcus pyogenes aureus, and bacillus pyocyaneus. while among Ihoee
more rarely found may be mentioned the t(it>ercle bacillus. Probably the most
^■irulent infection resull.-t from the »tre|itococcus pyogenes.

Of the constant predisposing causes of appendicitis, the anatomic position
of ihc appendix must be omsiderml an important factor. lu niluatiun in intimate
relation with the ileum and hc;id of ihe c<)li>n renders it peculiarly liable to
become twisted or kinked whene\Tr these organs arc distended with gas or feces,
.\gain, posse.ssiiig, a.-i it iloe* in most in.stan<.'e.^. a very ^hort mesenleri" and re-
ceiving its bloixl-supiily through a single ves.*el. its nutrition is reiidily disturlicd
by interference with the circulation, which in dim stimulates bacterial activity.

.As it cxisLi in man. (he appendix is simply Ihe rudiment of the lengthened
cecum found in all mammalia, and as il is no longer of any use. demonslnilion
has shown that i( is constantly undergoing retrograde changes. The fact that
these dianges arc taking place predisgxtses the appendix to intlammaior)' con-

I0I4 APPENDianS,

ditions, as the resisting power and vitality of an unused and retrograding organ
are below the normal.

Temporary Causes.— The most frequent exciting causes of appendicitis are
to be found in the many acute and chronic conditions affecting the ileum and
large bowel. Indiscretions in diet followed by digestive disturbances, fecal or
gaseous accumulations at or near the head of the colon, and acute or chronic
inflammatory states of the intestinal canal arc all liable, at any time, to interfere
sufficiently with the naturally low vitality of the appendix to cause pathologic
changes in its walls or blood-vessels and thus favor bacterial escape into the
tissues.

Foreign bodies and fecal concretions may, by their mechanic pressure or
irritation, cause inflammation or ulceration of the appendix. That such are not
found at the time of operation nor upon post-mortem examination may be ei-
plained, in some instances at least, by the fact that the contractile power of the
appendix has caused their expulsion early in the course of the attack, although iheir
presence has been sufficiently prolongai to induce the circulatory changes ne-
cessarj' lo inflammation and bacterial activity.

It is generally considered that appendicitis is of greater frcqueno' in
men than in women. This statement, however, must be given careful con-
sideration, since it should be borne in mind that peritonitis, from any cause, in
the neighborhood of the head of the colon may result in appendicitis by dis-
torting the appendix or by direct extension of the inflammation. As women are
so liable to inflammatory diseases of the pelvic organs, it would seem that, in
addition to other predisposing causes, to which they are at least as prone as men,
they possess in their susceptibility to these diseases a peculiar liability to ap|!en-
dicitis.

The disease may occur at any age, and while it is not infrequently mel in
the very young, it is most often seen in early adult life. Heaiy lifting and
occupations involving long- continued standing appear to have some causal re-
lation to the disea.se. Direct traumatism is also a factor, as attacks occasion-
ally follow an injury or fall.

Among the less frequent of the exciting causes tuberculous and l}-[>hoid
ulceration may be mentioned, and the possibility that certain of the infections—
in particular, influenza — may cause appendicitis should be remembered.

Symptoms. — .Although apjiendicitis may be classified pathologically aj
being ratarrlia/, ulcerative, or gangrenous, from the clinical point of view iherf
distinctions are of little value, as the severest forms at first may present ihf
mildest ;.vm]itoms. so that it is impossible at the bedside to determine the degrte
of pathologic change taking place.

In acute appendicitis a chill at the onset is rare, the attack being usually
ushered in by sudden pain. This in the beginning may be located at any point
in the aljilomen, or it may be sharply defined or diffuse and colicky in charac-
ter; within a few hours, however, it u.sually becomes localized in the right
iliac fossa. Pain in this situation, which is its location in most cases (mm
the beginning of 'the attack, constitutes one of the cardinal symptoms of the
affection. Tenderness on pressure soon becomes apparent, and is most marked
al the so-called McBurney's point, which is situated at the intersection of a line
drawn from the umbilicus to the right anterior suiierior iliac spine, and a line
jjerpendicuiar to it and corresponding to the outer edge of the right rectus muscle.
At this fioint palpation frequently reveals a tumor mass or the eWdences of a
Ihickenwl appendix. A symptom of much value is rigidity of the right rectus
mu.'icle, a condition best determined by a comparison with the state of the same
muscle upon the left side.

PBYSICAI. SICSS.

lots

temperature o( appcndidtis is no* characterisik, but (ever (too* to
103° V.) a».tii)ciuto) with pain, tencicrneu, ami rigidity in the right iUuc fvusA

'usually means inllanimatiDn »t the ap)ieiM3ix. It must \k remembered, htiw-
c^'er, thjl the presence of fever is not invariable, and often ihc most virulent
c^ise^ preaeni a nurmal «r Mibnormal tfm|)cnitur«. Scverlhelevi fever i& a
symptum of great \'aliie in Ihc early sUigeof appendicitis, and in tlmsc instances
in which it i* absent other symptoms Renemlly arc present whith indiiate not
only the nature of the malady but aL^i.thi- uravity of the ni'.e. The puUe aecel-
eration is Ufiually in prnportion tn the tempcmlun; deration, but 3 rapid pul>e
a!>sodai«t with a normal or subnormal temperature U not infretiucntly €-n-

I countered; this incr«iJ«l frequency i* na important evidence of ine cx[»ling
icifection.

Al Ibc onset vomitinit h frequent; it c«ase» within twenty-four to thirty-six
irs and rarely becomes sierciirateous. It commiinly rctiims if perforation
occurs and Ujwn the development of general periicnitis. The tongue is coated
and moist, thouKh later in sev-crc cases it becomes dr\\ The bnwcl> are usually
conslipa^^^i. though at the onset diitrrhca may be present. The urine is scanty,
hiKb-ciiloreil.andofiencontainsa trace of albumin; occasionally vt^ical irritation

1 bi proenl al the tiexinmug of llie atUck, and its pre.vence. toother with the dt^-
ilion of the pmin, results at times in cases being mistaken for nephritic

Examination of the bloinl is of undoubted value in determining the pre«ncc
'^of pus. In simple catarrhal inllammation it is only of negative value, the leuko-
cyte count reniaininf;. a^ a rule, normal; occasionally, however, there b a sltf^t
increusC in their number In nj>pendicula r ab«ess itangrcne of the appendix,
and general peritonitis a high leukoc>>le count (10.000 to 3$xicx>) is often present.
It is to be borne in mind that the blixMl-i^xaminatiim must not be relieil ujxm
loo strongly, but is to be considered in connection with other clinical m.inifesta-
k.tions. Ovcnihclminft infeclitms and abscesses with non-absorpiion of toxins do
not show leukocytosis. Proli>n;^l cases of appendicitis with se])tic a))soq(tion
show a decided secondary anemia.

Simple catarrh.-J ai>|)endiciils if left to itself usually runs a course of from

a week t" ten day*; although slight fewr an<l some tenderness may persist longer.

It might be well to emphasize at this point the usclcssness of pathologic clas^-

fications in actual clinical work; simple catarrhal appendicitis undoubieilly

tenil« to reanerj-, while stippunitini; forms nnd gangrene of the .■i[>iien<lix present

X high mortality. Unfortunately the symptoms often bear so little relation to

.the (jnivily of the lesion that (mes arc not infrequently met in which the miiil

f*\'mplom.s are found .1( o|KT;ilii>n to Ik- associated with a gangrenous appcndiic

' Ufwn the point of rupturing. It must also be remembered that fever may be

[Slu^nt in rases of the most virvleni infection an<l when the a])pendix is

[gangrenous

Pfajrsical Signs.— The results of inspection early in the course of the
disense are neK^live, although later .^ume distention may be noticed, particularly
in the right iliac fossa. In many instances the attitude of the patient is pecu-
lliar, in that she lies upon her back with tlie right leg dcxed in an endeavor in
»elax the abdominal muscles. Palp-ilion rewids marked rigirlity of the right
rectus muscle. 4nd in some cases the presence of an indurated mass in the ap-
(lendicubr region nhidi yiekU somewhat to i-<mtinued pre».iurc. This sweUini{
may be ill-dctined. but more commonly is well ciraimscribed and easily detected.
tPain and tenderness are elicited on pressure at McBume\-'s point. Prrtutsitm
yields duUncAS unless a portion of the iritestiite overlies the indurated area, in
which case a tym[>anitic note results.

IOl6 APPENDICITIS.

Appendicular Abscess. — An abscess formation about the appendix is usually
preceded by the ordinary symptoms of appendicitis for about four or five dan;
then all the symptoms become aggravated, and there can be readily detected m
the right iliac fossa a tumor, which gradually increases in size and is exceedinglv
tender to the touch ; percussion over this mass gives a dull note. Fever is usually,
but not invariably, present, and the puise frequency is increased, even thou^
there be no elevation of temperature. Examinadon of the blood mav show a
high leukocyte count, but if the abscess is surrounded bv a well-defined non-
absorptive wall, the number of leukocytes will be unaltered. A well-marked
chill with sweating is rare. When an abscess forms gradually, the general
peritoneal cavity becomes protected by the formation of a strong barrier of
adhesions; but in cases in which this does not happen the peritoneum becomes
invaded before delimiting adhesions can be formed. Such cases are fulminanl
and present intensified symptoms from the onset.

General Peritonitis. — Inflammadon of the peritoneum results from fulmi-
nant infections, a ruptured abscess, or perforation of the appendix by gangrene;
evidences of peritonitis may be present from the beginning, but, as a rule, the
invasion occurs late. The onset is sudden with diffuse pain; the pulse is lapid;
there is moderate fever, which later may disappear, and the temperature become
normal or subnormal; the tongue is dr>'; the urine is scanty; the abdominal
muscles are rigid and hard, and should the condition occur early in the disease.
the nausea and vomiting of the onset may persist. Within forty-eight hours or
more the symploms become greatly aggravated, with distention of the abdomen,
diffuse abdominal tenderness, and abdominal respiratory immobility ; the patient
lies upon her back with the legs drawn up and the expression of the face b
anxious. Signs of collapse soon supervene and the pulse becomes rapid and
running in character; the features become pinched and the skin pallid, cold,
and clammy.

Relapsing Appendicitis. — A form of appendicitis in which a second attack
occurs before the sym])toms of the primary attack entirely di.sappear. These
subsequent attacks present no difference in the general character of their symp-
toms, except that the local manifestations are likely to be more marked, and
such interval a.s there is. 1^ usually attended by some local discomfort.

Recurrent Appendicitis.— With complete recover>' from the p ri ma r>' attack
at varj'ing intervals, from several weeks to a year or more, the patient suffers
from repeated attacks; and, should the intervals be short, her condition be-
comes one of chronic invalidism. The recurrences may be mild or severe in
character, and present no variations from the symptomatology of the primarv
attack.

Diagnosis.— In typical cases the diagnosis of appendicitis is rarely
attended with difficulty. It is ba.sed upon the sudden onset of severe pain and
tenderness localized in the region of the right iliac fossa; aMominal rigidity
more decided in the same neighborhood; and fever usually associated with
nausea, vomiting, and constipation. These symptoms occurring in an individual
enjoying ))revious good health admit of but one conclusion as to their cause.
Many instances of departure from the typical will be obsen'ed, however, and
abnormal positions of the appendix by adhesions or other causes may produce
some diagnostic confusion. Thus, pain may be referretl to a region remote fmm
the right iliac fossa, and, when the appendix is adherent in the pelvis, it is noi
uncommonly complained of in the left iliac fossa. These cases call for a vaginal
and rectal examination by which the inflamed appendix and the surroumlin;;
induration can often be delected. Subsidence of pain and disap-
pearance of fever are frequently concurrent with the

UIFPERENnAL DIACNO&IS.

1017

development of ^ungrcne, and no fBlt»e »ecarity should
be cnlcrtaincd by ihis apparently favorable occurrence.

In mild osts wbich arc uxn at Ihe onset or the attack it may be impossible
at limcx to ditTerentiute between a bej^innin^ nppendicilix and inte^limd Dilic,
and under tlicsc circumstances it will be ticccssaiy lu delay expressing an opinion
until the buneli' have been flushed with a saline pur^e. If ihc paiu and fccnenil
Bymptoms continue after the intenlinul canal ha» been emptied, we are justified
in looking iip'>n the case as one nf appcndicilis and treating it accordingly.

Differential Dia^osis. -Typhoid Fever.— The grciiter severity
of ihf pain, its localiM-il liianiittr ;itlrniit(l nilli indiirulion and rigidity, the
absence of a peculiar eruption, the Lick of a characteristic temperature curve and
nervMtis symptoms, constipation rather than diiirrhea wriili jieculiar and chamc-
Icristic .'tHiols, and the absence ot Wiihlf, and the diazo- reactions, together with
Ihc lack of any notable splenic cnlarRemenl. arc the principal negative features
»er\*ing 10 di.itintiulih appendicitis from i) phoid fever. Of poMtive imjHirlance is
ihc Icukocjic count, which in append iciti." is mirmal or increased, while in typhoid
fever it is diminishe<l. unless perforation should occur, when it shows a prc>-
grc^.-'ive rise. Appendicitis, also, i.« freijuently attcniled with niiuitea and vomiting
while typhoid fever rarely develop* these symptoms.

Intestinal Obstruction. — The pain is not apt to be localised in ihe righi
iliac UtK^t; nm.vtijj.ilion is absolute. jwriMalsi.t l)cing ao completely arrested
that even flatus fails to be expelled : fcA-er, at least early, is absent and the vomiting
may becomes stcrconi(«ous in character.

Impaction of the Cecum. — Constipation it- positive, the pain is dull in
character, and the Icndemcss is not so localized as in appendicitis. Furthermore,
a physic.tl examination reveals a larKe maiM of the contour of the liowcl and of
doughy consistence, which upon j>crcussion yields a dull note and upon ihe ad-
ministration of a bri.-<k purge disapt>ears.

Inlussusception.~~A mniliiion most frwiuently encountered in young chil-
dren: '.'f sudden onset and attended by tenesmus and the expulsion of bloody
mucus.

Cancer of the Cecum. — In thi.t condition the tumor is hard and irregular
in outline: there are eiidenl loss of weight and strength associatet) willi ihe de-
vdopment of cachexia, and the history of a chronic adment.

Renal Colic— The pain is in the lumbar region and is reflected along the

Eroiii and inner side of the thigh of the affected side. There is an alisence of
)cnlleetl tendeniess and induration, and although the [«in and tenderness of
appendicitis may have the distribution occurring; in renal colic, the bloodv urine
following the latter is absent. Finally, the pa.'^sage of a ralculu^ will at once
clear u|i the iHaKnosis.

ATumoror Abscess of the Kidney and Suppuration about the Kidney. —
The siiuaiion "f tlicsc pathologic conditions i.t difTeniii fmm that "( the indura-
tion attending apjicndicitis; it is higher, being .11 or ncjr the normal site of
the kidney, and the pain and tenderness are not likely to be obscr\ed at the same
point 4.S u) ap|)endicular inllammalion. Examination nf the urine usually reveals
Ihc presence of blood, j>us, or an excess of urates or phosphates, and is of service
rndcmonstmtini; the seat of the trouble to be in the kidne>'.

Acute Infective Cholecystitis.— Thi.^ condition rannot at all times be db-
tinguishcd from appendicitis. In tv]>ical cases the onset is mdden with parox-
ysms of pain in the region of tlie gall-bladder passing through 10 the back in
the neighlmrhood of the right shoulder-blade; this i* frequrnlly jillenilcl by
nausea, vomiting, some febrile disturbance and acceleration of the pulscrafe,
BtMJ marked prostration. Rigidity and localised leiulernesa occur in the region

IOl8 APPENDiaTIS.

of the gall-bladder, and at times the tumor resulting from its distention can tx
detected. Unfortunately the pain is not infrequently referred to the region of
the appendix, and under such circumstances an error in diagnosis is Ulteiy to
result. Symptoms of value as indicating inflammation of the gall-bladder ralber
than appendicitis are a recent attack of typhoid fever or pneumonia, the histon-
of a former cholecystitis or of cholelithiasis, in many cases jaundice, and in somt
instances the evidences of an enlarged gall-bladder.

Gall-stone Colic. — The pain associated with this condition is agonizing io
character and usually requires the use of morphin for its relief; it is referred to
the right hypochondrium and is reflected to the epigastrium and to the r^D of
the right shoulder-blade posteriorly. Jaundice is a common attendant of these at-
tacks and an examination of the stools may result in the disco^'er^- of a gall-stone.
Constipation occurs and the feces show a diminution in, or an absence of. Me;
the urine is dark in color and shows the presence of biliary pigments. If ihe
gall-bladder contains a number of stones a gall-stone crepitus may be elicited.
Although these cases are frequently attended by a febrile movement and nausea
and vomiting, they can usually be differentiated from appendicitis by theabsenct
of pain, tenderness, rigidity, and induration in the right iliac fossa.

Actlte Pancreatitis. — In this affection the pain, which is sudden in onset
and colicky in character, is in the upper abdominal zone and is associated with
nausea and vomiting followed by collapse. Within twenty-four hours the local
tenderness in the epigastrium is usually succeeded by ■a circumscribed swelling,
which may be either dull or tympanitic upon percussion; the abdomen bswoilen
and tense and the bowels are constipated. At first the temperature is nonnal
or subnormal, although later there is fever. Young, healthy adults are roost
frequently affected, and the condition not uncommonly follows attacks of indi-
gestion. The situation of Ihe pain and tenderness and the location of the swelling.
as well as the rapidly supen^ening coUapse, are the chief points in the differen-
tial diagnosis.

Hemorrhage into the Pancreas.— It is sudden in its onset and also occur
in individuals apparently in perfetl health. In addition to cpiga.stric pain,
nau.seu, vomiting, and collapse, there is extreme restlessness. The temperatutt
remains normal or subnormal.

Ectopic Pregnancy. — Rupture of n Fallopian tube resulting from an ectopic
pregnancy is characterized from the onset by severe pain in the lower part of
the abdomen, followed bv symptoms of hemorrhage, viz.. shock, rapid pulse,
normal or subnormal temperature, nausea, and vomiting. Vaginal examination
reveals an enlarged uterus with enlargement and tenderness of the involved tube
as well as tenderness behind and at the side of the uterus. The abdomen b
tender, distended, and (ympanilic. Women in whom this accident occurs usually
give a history indicative of a previous salpingitis, or have not borne children
for several years. Irregularity of the menstrual function usuallv precedes the
rupture.

Salpingitis.— Inflammatory conditions of the tubes are usually secondar>
to uterine inflammation, particularly gonorrheal or puerperal infections. Pain
in (he lower part of the abdomen associated with abdominal tenderness may
charaelcrize this condition, as well as backache and derangement of the men
strual function. During the exacerbations of pain the leukorrheal discharge,
if present, is apt to increase. Vaginal examination reveals the enlarged and
tender lube.

Inflammation of the Ovaries.— The attendant pain is commonlv won*
before the men;,trual period, the occurrence of which usually affords relief. Thi-
symptom is more apt Io be reflected to the region of the bladder and rectum

tnATMENT.

lOIl}

in to be definitdy localiEet!, as it is in appendicitis; it Is also agfi^nivated by
Valking. V'aginiil cxiinitnulion ahavis the onn- lo l>e extremely tender to the
ducb.

Dietl's Crises. — Thue are associated with movuble kidne>', and as ihcy

'arc characterized by intense pain, load swelling, and indur.ition in the neighbor-

luMxl (it the rijjbi iliac fofea, errors in diagnosis may occur. With the ccsMilion

of (he ])uin. however, tliere i.s usually a dL-ui)>]ieiimnLe »r (he sweJlii^, und A

careful examination will rcve;d the kidney in lis dispbci-d i">siti»n.

Acute Peritonitis of Tuberculous Origin.— The prtscnie of fever, ab-
dominal pain, and li-iidi-rncv-i i'>risiitulv ihv >)mpttim> likely (■) give ri:<c to the
IliafEnosl? of appendicitis. The absence of signs referred to the appendicular
^m, however, and t]ie more firadual development of tuberculous peritonitis,
ind the concurrent development of lutierculcnis pniccsscs in the lungs, serve
» establi-^h a correct diagnosis.

Perforating Gastric Ulcer.~In ilii.4 condition die on.tel i.« abrupt, and the
ain, which is intense, in addition to Wing referred lo the epigastrium, is very
tnequcntly reflected to the rij;hi iliac fossa. Such of these cases as present no
antectxicnt history of )i;i>.trii' disea.ic are almu^t .nlway^ mi.itaken for .igipendicilis.
The historj", ihercfore, of such pre-exisiing s.ymploms as would point to gastric
ulcer becomes an important factor in csiablii^hinR a correct diagnusi.s.

Tieatment.— The irr^tlment of :i primar>' -iltack "( appendicitis, ev-

isling alone or in connection with a tubo-ovarian lesion, should be operative, and

,lo soon as the diagnosis b made the appendix should be remo%-ed. I I i $

iwl within the power of a surgeon to determine

:hc pathologic conditions present at the seat of dis-

:k»c nor to know how the attack will terminate,

'mid delay simply means playing a game of chance

with the odds in favor of death. My perMmal exjiericnce in

the treatment of appendicitis compels me lu acknowledge a profound ignorance

iit to ihe prognosis of a mild attack, and I lannoi be far wide of die mark in .-ital-

|ing th.it this i|;nor;incc is nioally shared by the prnfcssion -il brge. Can the

'physician or surgeon at the bedside of a paliciU icll whether bacteria have jiene-

tmled the ds.iues of the appendix? And, if they have, can he suy whether ornot

they will pass through its walls and infect tlie peritoneal cavity ? Is it possible to

base Ihe prognosis of a mild catarrhal appendicitis upon the presence or absence

■ of an ap[«.'mliculiir stricture? Have we iiny wgn.t that point to the presence of

la foreign body within the appendix as the cause nf the intlammation, or is it

Kissiblc to know, when pus is forming, whether i)r nut it will become ciraim-

IccnlKd or escafic into the gener.d peritoneal cavity ? Surely no surgeon would

have Ihe temerity to answer these questions in the afBrmativc; and yet unles.'t

we are able to determine theie (.-undilicms, how can we allow a case nf .ippendi-

^dlis to be treated medically and give the juiticnt a false hope of security at a

[lime when dangers wc know not of may intervene and <'auM; a fatal ending?

The ifuestton of operation in cases of recurrent attacks of appendicitis is
F'not a difbciilt one to decide, as a seenndar>- <iutbreak of inflammation meaas that
the original lau.se U still present and likely at any time to jeopardize the life of
the patient. Again, as in the case <if a primar>- attack, we have no means of
knowing what the oiurse ci( the inflammalon,- process will be, nor can we deter-
mine the [lathologic conditions present at the seat of disease, and therefore an
appendectomy should be performwl w> «H>n as Ihr cliaeix^M^ is miiitc.

In cases of ret^irrent appendi(ili> :ippendcttomy should nc\-cr be postjionetl
I order to (iperale during the inIcr^al between attacks If, however, tlie jiaticnt

I020

APPENDiaTIS.

is seen for the first time during one of the intervals, advantage should be taken
of the quiescent state of the inflammatory process and the appendix removed.

Tecimic of Appendectomy, — The Preparation of the Patient
and the Preparations for the Operation are described on pages
834 and 837.

Position of the Patient , — The patient is placed in the Trendden-
burg position at an angle of about ao degrees.

Number of Assistants . — An anesthetizer, one assistant, and a
general nurse.

o ®g

o ®

ACTUAL SIZE

Fig. T018, — Needles and Sutuie Matevials I'sed is the <kPEBATioN of Appendectout-

I ns t ru me n t s .— (1) Scalpel; (a) scissors; (3) six short hemostatic
forceps; (4) dressing forceps; (5} Ashton's self- retaining abdominal retrac-
tors; (6) abdominal retraclois; (7) tissue forceps; (8) needle -holder; (9) two
straight and two curved round-pointed intestinal needles; (10) three straight
triangular-pointed needles; (11) two small full-curved Hagedom needles; (12)
braided silk— Nos. z and 7; (13) silkworm-gut — 20 slrands; (14) plain cumol
catgut — Ko. a, [our envelopes.

TKEATUKKT.

loai

0[>cralion. — First Step.— The abdomen is ojioiwd by an incixinn
nm li tci I incbcH of m>>rc in It^ngtli) whith ^K■^:ill^ about one inch above Ihe
Bnierior iliac spine and |K«.i«ji obliquely downwiinl ihr^iugh McBumey's [wint
in ih« direction of the fibers of tlteexlcTiul oblique muscle (Fig. 1019).

Pic, i«ia.— ApnKbEmMV— Rnt Sltp.
The Uaf Inma M h tho** ibc uiudiuii il lite uxiBOo (••(> UiBvBq'ft

Fis. >Dw — AfvcunKTiMr— nnl St*p (gut' ■«•).
ibi tmt tl lb( ndoB •iiUn Ibc ilaJamlMl ■fniml (oil ih! nimitpiviidii Ii^iitiI mil wnwJ. Tht
count lifuurc Ulird uvued tbs lfp(f (hei{i|KaiUi tad heM Uul bf OHmmttuai,

Th« appendix w then ImaiKt by (h* foUowing method. wMdi was orifilnally
BUf(KC»te() by J. Chiilmers PiiOwUi (" Me<lii-nl News," June 9, 1894): In«*rl
the index and middle fingers into the wound and follow Ihe parietal peritoneum

I034

APPENDICITIS.

Fifth Step.— A circular incision is made througb the serous coat of the
appendix about half an inch above its base {Fig. 1024).

Sixth Step. — The peritoneum is then stripped back beyond the base of
the appendix with the scalpel (Fig. 1025).

P10. loss.— AwBNIiIcnniv — Sixth Step.
Shorn thf serous crui alrippcd hock bcyoDi] Ihc Kueoflhe appendix.

Flo. loifi,— ApfttniicTOiiir— SeTBolh Slap.
Sbowa liic apppndii hriag ampulalvd bryond Lu butf.

Seventh Step, — The appendix is amputated below its base with scissore (Fig-
io?6).

Eighth Step. — The opening in the bowel is now closed bv in\ertinE its
edges with forceps as the purse-string suture is tied and subsequently introducing
two mattress sutures lo guard against leakage (Figs. 1027 and 1028).

•nEATiitxr.

I<M5

Ninth Step.— The surseon douches ih« scat of operation with warm normal
salt solution atul dries ihe [laris with a fnaze »iiongc. The gfiuxe pockins
arouiid the head of the colon b then rem»v<.-d; Ihe i-unln>l ligniuTt^ ml unu
withtlniwn from the bowel: and the colon allowed to sink back into the ab-
dominal cavity. The ubdomtnai incision is tinall}* closnl and drc»sed in the
usual Rianner.

Fiii 1911,— Arrrvnu-TAHv— Etfblli SMp.
Stout the funrnrlnt mIui* lirmt Anwa uui *bt\t At r-ltn ^4 ihi •niubl irr iniwinl *riih (omts.

Special Directions.— 1*110 control ligatures which pass through the walls
ol ihc lolon on lithcr side of the base o( the appendii >huuld pcneiratc only
the submucous nr tibnms timl, Ih'C3U.«c i( ihct}' enter the lumen iil the gut. infec-
tion may result from capillar)- attraction.

From the time ihe appcndjic is aminit^ted until the opening in the colon a
sutured and the field of operation douched and dried, the assistant mus.t keep

PMt Mri.— Ammumitr— Uchtli Sup,

Sbrwt Ibe eeat WMiDd (tovd by Ibr nin»«tiiiu •utun. The iwo nii»v onum ithldi irialvnr lb* i^

pmAniiioo tl ibr mund an Mic Wiairn.

the control liKalures taut In prevent the bowel from becoming displaced and
infei'linK the surrounding intestines.

The serous coat of the appendix must be stripped off well helow its 1mi«
so that when it is amputated a portion of the wall of ilic colon U also removed.
This not only thomuRhly eradiraius all Ihe disca'ii! sinntun^, but it alsii [ca\-e^
no redunilani li.viue to interfere with the close approximation of ihc edges of
Ihe wound. As a matter of fact, under these circuniglunce.'i. (he serous cost
65

I036

AppENDiaris.

usually retracts and partially closes the opening before the purse-string suture
is drawn taut. The antiseptic precautions employed during the operation must
be thoroughly carried out, as we are necessarily deahng with an open Wound
of the intestine. Therefore all instruments which corns in contact with thecal
of operation must be thrown aside at once, and not used again. Thus the knife
which is employed to make the circular incision through the serous coat, and
the scissors used to amputate the appendix, naturally become infected, and must
be discarded at once. A serious mistake is often made from an antiseptic stand-
point in operations of this character by using the same sptonge several tiinK
on the seat of operation. This technic undoubtedly spreads infection, and often
causes post -operative complications which can easily be avoided. A sponge
which has been pressed once against the tissues should be discarded ami not
used again. If this is not done, the pathogenic germs which adhere to the
sponge will be scattered over the uninfected' areas surrounding the field of opera-
tion. In an aseptic field this precaution is, of course, unnecessary, but when,
as in an appendectomy, the sponge comes in contact with the contents erf Iht
intestinal canal, it is obviously a dangerous practice, and one which must result
in jeopardy to the life of the patient.

Fic. lojo.^AppkHDEcroKV, V«iiatiofi ia the Technic.

Show« Cushrng'^ r^iiiurt: U^inji inrrodurpd. The aasisuQt is makinK imciion on ih? hf^ad of ihc coIoq vbitt tbf

aurRcon flie.idi(s the field of optralion wilh Ihc upper contntf liAalute.

Variation in the Technic. — If for any reason a purse-string suture cannot
be used to close the opening in the colon, a Lemhert or a Gushing suture may
be substituted (Fig, 1029). The lirst six steps of the operation are the same as
described al>ove, and after amputating the appendix, the surgeon gra.'ps
the upper control ligature about an inch from ihe bowel with the fingers of his
left hand lo steady the field of operation while the wound is being closed. The
sutures are introduced with a small, full-curv'cd intestinal needle, which mu?i
be held in the grasp of a needle-holder or a hemostatic forceps.

Remarks. — In performing an appendectomy there is always danger oi
infecting (he parts surrounding the seat of operation when the appcndi.x is ampu-
tated and the opening in the gul is sutured. The reason for this Is evident, and
is due to ihc opcrator'.s finders and the instruments coming in contact wilh the
exposed intcslinal mucous membrane at the seat of amputation.

M,nny of the unexpected deaths which follow operative interference in un-
complicated rases of appendicitis, as well as the chronic sinuses and the delayed
recoveries which result, are undoubtedly due tn an infection from this cau>*.
It could hardly be otherwise when we consider the usual methods employed
in the lechnic of ihc operation, as there is constant danger of touching the septic
mucous membrane with the fingers or the instruments when the head 01 the

TKZATUtST.

t037

colon b held lictwocn the lliuml) and lh« index-lin^ of the left band during
the imroduclion of the ^utur«;s to clwe the a|icmng in ihe Iwwcl. Aguin, the
hea<l i>f the colon may slip from the grasp uf tlie ojieraior's lingers during the
process of suiuring, iind l>clore it ran lie hnm^hl intu ^Hisiliun iijiiain, the sur-
niunding intestines may (omc in cuntact wilh ihc opening in llic bowd and
bet«inw infottetj.

The pratiiial importance of an opcriHive t cclinic which rwiiitc* 1o ii minimum
Ihe danger of dirett infcttion during ihc ncci's^an' maiiiiiuluiions of an appen-
dectomy ainiK>l be overir^timaltd, urid niih thin olijcci in view 1 huve dcvi>ed
the operation described above. Thf mciliwl gives the surgeon complete me-
chanic control of the ii>Ion and [irevenls hi^ finger.i or ihc inieHtincs from becoming
mfccted. as the appendix can be aniputale'l .iiid the opening in the bowel NUturod
without the operator louching the seal of operation.

Technic in Suppurative Appendicitis. — In all an*), in which the mrrouml-
ing intestines have been conlLinilnnied with pus or feail mntter, local washing
(»ee p. 8gi) or general flushing (sec p. Sqj) with normal salt solution should be
employed and the *eal of o|)criition drained with glass or rublwr tubing and
gsuxe. If only the adjacent coils of intestines arc soiled, they should be cleansed
by local washing; but if tlie septic maierial is scallered throughout the ab-
dominal CAvity, gcnend flushing should be enij)lnvcrl. The rtiital end of the
drainage-tube should be ]>laccd in Ihe most dependent part of the held of opera-
tion ntlid RHuiEe packed around it to protect the iitiestines. The free end u(
Ihc gaux« ts brought out of the incision and the abdominal wound closed above
and below the exit of the drain, The gauze should be removed on Ihe fourth
or fifth day and the gUss or rubber lubinj; allowed to remain a few days longer
according to ihc chaniclcr and quantity of the discharge.

After opening a eirrumscribed appendicular al(sce$« its cavltir should be
gently e.xplori-d with (he index-linger, and if the appendix cannot be readily
found a persUlenl search should not be made for it. as there is imminent dutiger
of nipturing the liarrier of lymjih and infecting the peritoneum. I'nder these
circumstances the appendix should not be disturbed, and the abscess cavity
should be treated by evacuating the pus, irrigating witli normal .sidt solution,
an<l driiiiiing with nibber tubing and a strip of gaurx: the wound is closed
above and Iwlow Ihc exit of the drain. The gauze should be removed on the
fourth day and the tubing allowed \« rcrmain until the mic contract.". After the
removal of the gaune the cavity shoidd be flushed once a day with normal salt
eotutiun. and at the end of the first week with hydrogen peroxid and a solution
of corrosive sublimate (i to looo), followed by <terile water.

When the base of the 3ppcn<lix has sloughed ofl and the colon is adherent
and ulcerated, it is ofien im;i>issible to intnxluce .-vuture* and rloi^e the ojiening.
In these iitte* the head of the colon should be isolated from the surrounding
intestines by gauze packing and the field of operation drained with rubber
tubing. In the course of four or five days a wall of lymph is formed and the
fpt\xT.c may be removed. The rubber tube should be allowed to remain until
the process of rq>air is well advanced and ontruction of the aivity ukes pbce.
In many of tliese cases a fecal fistula results and the contents of the bovrel
escape through the abdominal wound and the rubber tui>ing. The fistulous
opening, however, closes in the course of two or tliree u'eck>, and the fecal
matter passes out by the natural channel.

lOaS UOVAfiLE KIDNEY.

CHAPTER XLV.
MOVABLE KIDNEY.

Definition. — Movable kidney is a term broadly applied to any kidnty
which departs from its normal position, and is a condition of extreme importance
in its relation to diseases of the female sexual organs. The mobility of ibe
organ in question may be so slight that it is palpated with difficulty, or it may
be so freely movable that its abnormal position can be readily detected: again.
the departure from its normal position may be so great that the condition recei^'e
the designation of fioaitng or uundering kidney, and it may occupy almost any
part of the abdominal cavity, even to the opposite side of the median line.

Causes. — Rapid loss of weight with wasting of the perirenal fat normallv
surrounding the kidney is in many instances the causal factor of movable kidney.
and by some is regarded as the most important. Therefore, the condition ii
to be found associated with all wasting diseases, whether acute or chronic, and
it follows that it is encountered more frequently in those who are thin than
in the obese.

The rela.tation of the abdominal walls incident to repeated pregnancies has
been held accountable for the occurrence of movable kidney, although the con-
dition is quite as frequent in those who have never borne children as in ihose
who have borne many. Tight lacing, by forcing down the contents of the abdo-
men, is regarded by some as of etiologic importance, while others consider that a
tightly fitting corset affords the best means of retaining the kidney in its nonnal
position. Traumatisms, a jarring fall, heavy lifting, and e.xcessive vomiting may
cause a movable kidney, especially if predisposition to the condition exisii by
the previous absorption of the perirenal fat.

Nephroptosis, or mo\-abie kidney, may exist in association with enUrop'iO<ii.
liT displaoemenl downwanl of all the abdominal viscera: this fact i-houid nol
be overlooked in any given case.

Usually but one kidney, the right, is displaced; occasionally both, or only
the left. The probable explanation of the relative frequency of mobility on
the right side is that the right viscus, from its situation, is .subjected to pre;>ure
by the li\'er as it descends with each inspiration. It is of much greater frequency
in women than in men. doubtless because of the predisposing factors already
mentioned. It is claimed by some that in many cases ihe condition is induced
by congenital relaxation of the peritoneal attachmenls of the kidnev. a h\-pothe-
sis that may be reasonably applied to floating kidney, as arising from a con-
genital mcsoncphron, but appears to bear no relation to a movable kidni-y.
Between these two conditions il is well to make a distinction, the one. mov-
able kidney, being so much more frequent, and usually attended with more de-
cided symptoms than the other, or floating kidney.

.\ nwi'iihle kidney is one in which the range of m()bility is limited to the en-
larged area nf its fatty capsule, A fioaling kidney, on the other hand, has a
normal fatly capsule and its mobility depends upon a mesonephron.

The body form is an important etiologic factor of movable kidney, and not
only explains the greater frequency in women than in men, but also the reason
why the right organ is more often displaced than the left.

In (he normal subject there is a fixed relation bewcen the length and cir-
cumference of ihe Iwdy cavity. The body cavity consists of the thorax, abdo-
men, and false pelvis, and may be divided into three zones bv two iransver*
planes passing through the following fixed points: The first plane passes through

CAUSES.

toag

lie thoracic cnvHly at the tower cHkc <>f ibc Mcmiim prtifwr, and the ittond
ihrouffh Ific nbdamcn on a Iwd with the lower border of the tenth rib.

'I'he iipjuT aitie of the hixiy faviiy i.i imlurfed between ihe iuimuternat
notch and the lirsl i>bne. and contains th« thomrk lisceni. The middle jmhic
is iiiiludtd between the tirst and second planes, and contains the stomach,
spleen, iiancr«-ii-<, liver, and (he miijur intrlion of each kidney. The lower aone
ii included between the second plane and ihr Mi|M;riiir slntit of the jicMs and
ninlnin.^ the minor portion uf each kidney ami ibe intestines (Fig. 1030).

In women (he middle »>ne is liable to be contraelcil in all direrlion?;. and
consequently there is a tendency toward dis|>l.i cement downward of all the
organs occupyinR thL* region. The liver, bein^ compressed from before iKiek-
war<i. pushes the superior pole of the riEht kidney forward and displucvs the
entire organ downward.

SuproSlrmol
' Notth-

Zonc \i-

.Lower
Zona.

D- t«j^ — Smnmio im Tmxx Zoott or nit llonv Ctmv (Vr*n. Uiddl*. um Lown). *m nia
PniTioiH or Tu Two TaAtHVEui Plud.

From a systematic study of the body form. Becker and Lcnhoff were able
to predict in a Ei\en ix-e whether or not the kidneys would lie found di.iplaicd;
Ihe rel;tti<^n liclwcen the lenKlh nnd rirciimfrrcncc n( the body cavity beinj;
(pressed in an index the formula of which is denoted thus:

_,- , — -/r— . , , ■ ' • ' .— ,r- X 100— body Index.

The^ meji sure men ts are taken with die patient lyint; in the horizonlal
rvnimbeni |)osition at Ihe end of expiration during a normal resinnitory art.
The tmumfcrcncc of the body at the lower border of the tenth rib is first (akcn,
and then the distance lietween the Mipnu>lernitl notch and the symphy.sis (juxuU-
symfihyih meauiremtnl) Is ascertained (Fi|j!. 1031). llius. for esample. if the
jttgulo- symphysis measiiremcnt is found to be lo inches nnd Ihe circumfcrenec

I030

UOVABLE KIDNEY.

of the body at the lower border of the tenth rib 26 inches, the formula i>
expressed as follows:

luitulo-svinnhvsis measurement ao inches,, , ...

i,-^ ■/ -'-' , -., — i .~r X 100 — 76.0, which represenls the bodv ind«i.

Circumference at tenth fib 26 inches

It has been found from observation that the greater the contraction of the
middle zone of the body cavity, the higher will be the body index, and \ia
versa. Becker and Lenhoff came to the conclusion that when the body indn
was below 75, the kidneys were never found displaced; and when the indn
was above 77, the organs were nearly always situated lower than normal.

Symptoms. — A movable kidne)- may exist without producing any sjinp-
toms whatever, and the condition is often discovered accidentally. This is

Supro- Strngjl
Nofth

^/j/jMy".'

Fin. loit.'

.— SHOVflm! THK SlIl.'ATtOH5 OF THE Me*»I-RK1IENTS TfHT MIC TAEIN TO llETeilllSl IMr Hnt

I.^-DEX.

especially true when the mobility is slight, although even when the orcan i-
freely movable there may be no subjective symptoms.

Subjective Symptoms. — The subjective symptoms are considered umler
the following headings:

Digestive disturbances.

Neurasthenia.

AlMiominal symptoms.

Urinarj' symptoms.

Uterine and pelvic symptoms.

Dietl's crises.
Digestive Disturbances . — G astro-intestinal disturbances itt
of frequent, almost constant, occurrence. Loss of appetite and dyspeptic mani-
festations, often associated with nausea and vomiting, are frequent. Epiira^lrif

SVUPTOUS.

103 1

pain, occuning indqwndcnlly nf the sUgc of iligcMinn, but little influenced by
rcsnure, anil constant in iu location to tlic kit of the cnsiform cariiU^, H a
^miXom a>mm(inlv tximpbined of. Emciuiions of fpit, utTeiiMve breath, and
[constipation with lialulencc are frer[uenlly di»trc^ng »>'m|>li>in». As a rcMilt
of (ircssure upon the duo<lcnum dibliiion o( the stomach maj' sufwrvenc, and
abo UK 11 {>rcs-(tirr->ym|)t>im j;iunili<'0 m;iy be present.

Neurasthenia. — Neurasthenia is a constant and mn'i Im^runt mani-
(ettaiion of iruivable kidiie)', alihouKh there h nnthini; peculiar in the grouping
of the $yraplom« to indicate their cnii-'^e. Mint patients oinij'lain of a tired
feclinji und an ulter lack of deurc to e\cri thcm«clvc§. and of dull .iching pains
hi the back ami thiKh.N. Headache, vcrliKo, and numbness of the lower exlrvmi-
lics are symptoms less frtqucnlly met. Incneaseil treiiuency of the henrt-lHMt
a more or less constant symptom, and cardiac palpitation may be most per-
jsient and annoyinfc.

Abdominal Symptoms . — Abdominal manifest 11 1 ion« are almo»t
*«)■!( prctcnt. Not infrequently patients complain of distress when l>inR upon
the side (>])pnsile to that of the di^ph^ement. Of Mill more frei|uenl oieurrence
is a drajJKini* sensation felt in the loin!i iind the nbdominal cavity when the
patient i.i in the erect posture and after takinR a long walk or active exercise.
If the dUjiiac^'il kidtw'y is freely movable, it may be re<-">Rniw;rl by the patient
«S a swelling in ihc abdomen. This is es|>ecially true if the kidney is sensitive
and presMjrc not infrequently produces pain of a sickening character.

Urinary Symptom* .—The a-s.'<ociation of urinary iiym]itoms with
movable kidney is rare. These symptoms, when present, arc caused by the
twixting of the politic, producing acute hydronephrosis, which ts u.sually inler-
liltrnt in chanicter, and at times accom|>anied by severe and alarming local
rind coiulitutional manifestations. U.sually these symptoms are mild, the inter-
mittent hydninephro^is being followeil by m<x]etate polj-uria and frequent)' at
\ micturition.

I'terineandPelvicSymptoms , — The uterine and pelvic syrap-
I toms dependent upon moi-able kidney are nire. Tliesc may f)e manifcstc*! in
I the furm "if dysmenorrhea, menorrtiapa, miscarriage, and vesica] irritability.
During pregnancj' and menslruation the nymploms of a movable kidney are
' agRravated. In the latcr'period of pregnancy, however, the symplnms usually
\ entirely disappear, the enlarged uterus alTording adetjuate support to the kidne>'
I, and keeping it in its normal {K>sition ; upon the termination of jpMation the symp-
toms reappear.

Dictl's Cri«e» , — In some cases, usually those characteiijied by

marked mobility, there occur extremely arule attacks con.ti.iting of neveit ab-

I dotniiuU pain followed by nausea, vomiting;, chills, fe^'cr, and signs of collapse.

I The»e atUickit were first described by Diell, and are supjKJsed to be due to the

twisting ol the kidney upon its |M.iliclc. The uriiK, as a rule, i:t greatly dimin-

^^ished in quantity and CI inuins an excess of uric acid.

^H Objective Symptoms.— The ]ihysi<-^l .ilftns of movable ki<lne>' are, aa a
^Hrule, easily recognized, The c\<imincr must have an cxiict knowledge of the
' normal situation of the kidneys and the manipulative dexterity to prupcrly
palpate the alxtomen. Nfi.-oakes in diagnotii.-i are frequently marie atul mo\-alile
kidnc}'s unrecognized because of the examination t)eing roughly and improperly
miucled. Alxiominal palpation must be made with a light touch or a displaced
idncy may slip back into its normal iiusilion and iu exi.-<teiicc be unrecognized.
The physical sign^ are elicited by the fotlowing methods:
Palpation. Inspection.

Percussion. Mensuration.

1033 UOVABLE KIDNEY.

Palpation . — To examine the position of the kidnej's the patient shoukl
be placed in one of the following positions: (i) The horizontal recumbent posi-
tion; (2) the Sims's or the lateral-prone position; (3} the erect position; (4)
the sitting position.

Horizontal Reciimhenl Position. — In the recumbent position the patient lies
upon her back with the legs drawn up and the thighs flexed. The abdonunal
muscles are thus relaxed and deep palpation made possible. The surgnu
stands at the side of the patient with one hand placed under the lumbar region
while the fingers of the other hand palpate the front and side of the
abdomen below the costal margin. By using pressure above and counter-
pressure below, the mobility of the kidney may be recognized. Although this
position is the one most generally used, as it is convenient both to the patient
and surgeon, the diagnosis cannot be made with the same degree of certainty
as when an examination in the erect position is resorted to. Therefore if a na-
tive result follows an examination in the horizontal recumbent posture, the
erect position should be employed.

Sims's Position. — When the examination is made in the lateral-ptone or
Sims's position the patient is placed upon the side opposite to that of the
kidney to be examined. The surgeon stands in front of the patient with one
hand over the lumbar region, and with the fingers of the other hand makts
counter-pressure anteriorly below the costal margin. The position of the
patient causes the kidney, if movable, to fall forward, so that it is easily
recognized by the examining fingers.

The Erect Position. — The patient stands about one foot and a half from
the side of a table with the body inclined forward and the hands resting
upon the top. The lower extremities must be kept at a right angle with the
floor upon which the patient stands and the body inclined forward from the hip-
joints and not by bending the spine. The surgeon stands back of the patient, the
examination being made with one hand bv placing the thumb over the lumbar
region, the fingers being i)rcssed anteriorly below the costal margin. If two
hands are used in making the examination, the surgeon stands at the side of
the patient.

The erect position must be correctly taken or the space beween the costal
margin and the crest of the ilium is greatly lessened and the results of the e.t-
amination rendered uncertain. This position is by far the most useful of ail
in which lo examine Ihe situation of the kidney.=i. It is impossible for a movable
kidncv to escape detection, as It must fall forward and downward when the
patient stands in (he manner destribed. Mistakes are frequently made by relyinR
upon the horizontal recumbent position, for the reason that the kidney may
not be forced into an abnormal jHisilion during palpation. This, however, cannol
occur with the patient in the erect posture, as the kidney must of necessity leave
its normal ponitinn if movable.

The .Silliii/; PosiTwn. — In the sitting position the patient sits upon ihf
edge of a chair with (he body bent fonvard and the hands resting upon the
knees. The surneon sits on a chair at the side of the patient and the examination
is made as in the erect position when two hands are used. This posture is a
modification of the erect position, but has no advantages over it. On the olher
hand, the abdomen is not so well relaxed and the space between the costal margin
and the ilium is apt to be lessened unless the patient is very careful not to bend
the .spine.

P e r c u s s i o n ,— Percussion over the lumbar region is of no practical
value as a phy-^icnl sign of movable kidney.

Inspection .—This method of investigation is of value only when the

DIAGNOSIS— TREATMENT,

1033

lomin.ll walls are thin and the kidney tnely rnnvnblc. Under ilieKC circum-
stances ibc millines of llic kidney may be seen ihniu^ ihe abd<imin;i) «mlls
when the structures arc inmileil forward by slronR prewurc over Ihc lumbar
repon. A depression in the lumbjir region is never veen lis tbe result of a. (ii>-
placed kidney.

Mcnsuralion .—If the body iwlcx in above 77, Ihe kidneys are nearly
alwAVK dUplaced (^ec causes, p. 1018).

I^iagllOSiS. — The diaRnoM'v is made t>y tindioK a tumor possej^ing various
deip^rcs of mobiUly and having the ointmir. siw, and rtmsjsiency of the kidney,
^with or without the associated symptoms already described,

.Allhotigh the differential diaKm>si», as u rule, doc:i not present many difH-
Itics, the affection must be distinguished at times from the following lesions:

Ovarian Tumors,— Tumors of the o*Br>' are occasionally mistaken for

'Vublc kidney, but they may lie recognixetl by their fixed po&iiion and b>' tbe

Its of a \'3f!inal examination.

Floatini; Spleen.— .\ displaced spleen may rarely be confounded with a
lovabk' kidncv. The si>leen. however, is larger and of difiereiil ^ha|a•, the
anterior border is shaq) and presents one or more notches. Furthermore, a
movable kidney ujnin the left sifle iv relatively infrequent.

Ualignant Tumors.— .^ m.-diRn;inl neitplusm involving an ;itxlriminal viscus
is recfifiniird by its more or less lixed position and by not possessing the shape
and ci>nMsteni.-y of the kidney. The cf>iL>titutional di.sturliances in malignant
disease are characteristic: loss of weight .-ind strength, ciiche-xiu, and a iWcond.iry
anetnia with leukocytosis making a clinical picture not met in movable kidney.

Dlttention of the Gall-bladder.- Thi> le»ion m,ty be diSerentbted from
movable kidney by carefully studying its shape and contour, .is well as ihe extent
ami dirwtion of its mobility; an enlarged gall-bladder also U observed kt descend
with inspiration.

When the enlargement of the fcall- bladder is dtie to malignant disease. Ihe
lumoristirm. irregular in outline, and tender u|>on pressure: jaundice is mmmon
I and iachc\i:i develops sooner or later.

1 Treatment.— The treatment of a movable kidney depends ujion the

Incut and consIitiili<mal symptoms prxxluced by the lesion, and lience each cx$e
must be carefully studied before resorting to radical measures. The degree of
dislocation does not always c<>rres{)i>n<l to tbe seventy of the .tymploms, and il
is not uncommon to meet cases in which there is considcriible mobility without
general or lotal manifestations being presenl. It is important to bear this fad
in mind, a-v these patients require ni) special fnrm of irealment and their mind*
should not be allowed lo dwell upon ihe mobility of ihe kidney. Il is oflen very
<tiflicult to decide what is be>t to do in an individual case, and unless the symp-
toms can be Inicrd by a process of exclusion directly In the renal le-vinn. we should
not advise radical measures. If, however, this can be done and no olher lesions

I are discovered to account for ibe sympiom-s we are justified in altril>uiing ihcm
to the mobility of the kidne>- and directing Ihe ircatmeni lowani its relief.
L The treatment of ihc affection is considered under the following headings:
I The palliative treatment.

I The operative Ircitment,

I The Palliative Treatment.- An allcmpl may be made to restore and
mainLiin in its normal pUNition the displaced kidney- by means of a properly
adjusted abdominal b.indagc with a i>ad or compress so placed ihat it brings
^^toressure lo bear dirctlly u|M>n Ihe lower pole of the kidney when replaced in
^Bls pn'jKT [wiMlion. The |>atient should be instnirteil in Ihe melhiMl of re|tlacin|;
' the organ and llic adjustment of the support before rising in Ihe morning. Tbe

I034

IfOVABLE KIDNEY.

bandage should be made of m&sHn (see description of an abdominal bandage on
p. 850), as an elastic support does not produce sufficient pressure upon the
compress and cannot be kept clean. A well-fitting corset rather tightly laced
constitutes an excellent device for the suppmrt of a displaced kidney; it fulfils
one of the strongest indications for its use in movable kidney in that it afiordi
support to all the abdominal viscera; it should be put on before rising and
fastened from below upward. Supporting the kidney by means of a bandage
or a corset not only affords great comfort to the patient, but also relieves the
reflex symptoms and lessens the danger of the occurrence of Dietl's crises.

The rest cure offers the best means at our command to increase the weight
and fat of the body, and at the same time relieve the nervous and gas tro -intestinal
symptoms which usually accompany the affection. The forced feeding, massage,
and electricity, as well as the prolonged rest in bed, often modify the results
of the lesions, and in some cases bring about a symptomatic cure.

In some instances measures looking to the restoration of the musde-tonc
may be indicated, and good results have followed the use of cold sponging.
massage, and indoor exercises (seep. 117), together with absolute rest in bed
for several hours each afternoon.

Drugs, aside from those tending to improve the appetite and relieve consti-
pation, are useless, although any tendency to an excess of uric acid or caldum

Ftc. loji — N"e?"»ob«m»™v.
ShoA-s the posilioa of ihe paiLt^m sad EAchohWi kiilcKV cuabian.

oxalates in the urine must be combated by proper dietarj' regulations and the
exhibition of .such remedies and measures as will facilitate their eUmination.

A movable kidney can never become permanently
anchored again by palliative treatment, and no hope
of a radical cure should be held out to the patient
under the circumstances, as the relief or the modi-
fication of the symptoms is all that can be accom-
plished unless operative measures are resorted to.

The Operative Treatment. — The operation of nephrorrhaphy should be
performed in all cases in which a radical cure is indicated. The technic devised
by Edebohls is far superior to any other I know of, and I therefore have no
hesitancy in recommending it as the operation of selection.

Technic of Nephrorrhaphy .—The Preparation oj the Palinl
and the PrepuriUiens for the Operation arc described on pages 834 and 837.

An extra sel of dressings must be prepared to place over the opposite lumbar
region in order to equalize the pressure when the patient lies upon her tucL
after the operation.

Position oj the Patient. — The patient lies prone upon Edebohls's kidney air-
cushion which presses against the abdomen and crowds the kidney into the
lumlwr wound (Fig, 1032).

10^6

UOVAULE KIDKKY.

Secoho Step. — The fibent nf ibe latiMimus tk>ni are »epaniied wilfa the
handle of a scalpel just over iht- outer Ixinlcr i>f lh« erector spinu: without oj>caiti]t
ihc sheath of the blier muscJc {Fig. 1035).

Third Step. — The lumbar iind transveRUll)^ fa»ciai> arc divided and At
perirenul fatty tissue cxjmseil. The ilin hypogastric ncn-e, tvhiih ties beneaih
all the layers of the lumUir fiisciu ami testa upon the tmnA\er5atis luda, it

PliV 1035. — \Lnni(i*bri4i-iiy— Second Step.
Sbcwinc ihc ■cwratkn of thr Rtirn nl ifac biiuiinui 'imi uiuilIf aiih itac hundlt «l ■ i

drawn to one side out of the way of injury; if this cannot be done, it should be
divided and the severcil etvl.i retmilKl after anchoring the kidrvc}- {F\r. iojA)

FotiKTH Stkp,— The sheath of the quadratus tumborum is opened from ib»
rib to the ilium along the anterior aspect of its lateral border. The retnittitia
(>l the ait etlge^ of the xhealli expo.-iCK ti lar)i;e arui of niw muscle.

Fifth Srt.p, — The kidney is freed so far as necessary by blunt dissedioii
with the fingers and an occa^onal cli)> of the >ci5tic>rs.

MrecUr^

p'/

.^■'

Tra/tspefsaiis Mtts^e

Fic, ioj6, — \ipiii(onii]iAriiii^Thtr4 Stop
BhOviM ihc pniUon of I hi ni(ih<iii>«auii( txnc an.1 ilic nOiiiiHi of ihr uuianlc tiramot* iBiolml kflli

Sixth Stf.p.— The kidni-y is delivered thniugh the wound by traction upoo
its fatty Ctipsule and by rolling the patient upward and downward on the ait-
cushion (Fiji- 1037).

The upper pole of the kidni^ usually rmcrs:es fini and the rcM of the organ
follows. If the opening through the walls of the abdnmen pro^'es lix> smo
it should be enbr^ed by nickinK the outer fibeni nf tlie i)Uiu]nitu& near Its 7'
insertion before delivering the kidney.

TBHATUENT.

"37

Sevekth Stkp. — 'Ybv whole of ibu fnlty cap^ilr b dU^«ctcd off and oil

awjiy nnd (he fil>n>us cap&uk ex|iOMxJ throughoul lis entire len^lh (Fir. 1038).

The kitlney. iU pclris. nnd th«- upjjt-r end nf llic ureli-r jirr then e.^iibred, .ind

I if a calculus is foutnl, il should be removed before |)riHe«!int! with llic <>))er3lic>fi.

EiOHTU Stki-.— A >tnaU nick is made ihruugh the fil^rouf^ caj'sule 3I the

/ /

/'^.

Pk> iojj. — \'ep» ■!» MM *niv— Sixth Slap.
Sbfom the UdBEr Mw dcUnftd by Iruiuui u|»a Ui luty tafnle.

mia<IIe of the convex border of the kidn«v and the grooved director [xisMid
bcnejith it (Pij;. 1039). The capsule is Uien divided U|M>n the director a ion^
the entire Icnftlli of the conceit Ixinler of the lii<lnc\' lo half-svay artmnd Ixith
the upper ami inwer |w>l«s o( the orKan (Fix, toiq). The capsule is now care-
fully separated from the kidnc)- with Ihc handle of the saditel or ihe gnioi-ed
director on both sides of tlie incision {Vig. lOjo) and folded back over the un-

Pic. la^.— XEmaoiinArnv— ScTanlb Step.
Shmruit ihe luij aftuk Mni cui jaiy aod Uir fitn-ia uihuIc niianl iip in (he pditi at iha kidncr.

detachod portion like the lajiel of a cnat so a« tn leave one-half of the surface of
Ihe orffin denuded {Fig. lo^r). The suptrfluoiis )K)rii<m of the reHectcd cai|)-
^sulc uliouUl be held with lis&ue forceps and irimined off with scissors.

NlSTli Step.— Two tiUKiiension or lix;ttii>n sutures of forty.il.iy catgut are
on each side of the kidney thruugli both the rellccled and undetached

I038

110 V ABLE KIDNEY.

portion of the capsule close to their line of union. The first suture is placed
at the middle of the upper and the second at the middle of the lower half of
the anterior surface of the kidney, and the other set of sutures at corresponding
points on the posterior face of the organ. Each suture is introduced through
the reflected portion of the capsule close to the line of attachment, and b then
passed immediately beneath the undetached portion parallel to the long axis
of the kidney for a distance of two or three centimeters. It then emerges from

Fio. lo^.— £i|bth sup.

Fig- 1040. — Eighth Step.

Flc. loji. — Eig:falh Step. (Modified fpoh Kdebohl*!.!

NIIPHHOOHAPHV (page 10J7)
Fin- "OJQ shnwp (he capsule tiiv-ldpd over the upper |jo1e aoil the gron^T'l dilTCTor pa^wil hrDpalh tht fap-
Eulc ipMT ihr lou'iT piile ^-hile 11 14 licin^ divided y-iih a viLpel ' filf. 1040 ^how* The lepdraunn of the
tapsule frum the kidney wiih Ihf h^indlc of Ihc scalpel: the dolled lints ifidicAte rilcDl of K-paratkni : tia 104:
Fhou5 Ihe di'UcheU ponjon of ihe capsule folded Ijnek like the lapel of a cut.

beneath the capsule, and is finally passed through the reflected portion at that
jioint. A straight Hagedorn needle should be used to introduce the sutures, and
its broad surface should be placed flatwise beneath the capsule in order to prevent
injuring the surface of the kidney (Fig. 1042).

Tf.nth Stfp. — The kidney is gently pushed ihmugh the wound back into
the body and the eight free ends of the fixation sutures are pas.sed through (he
abdominal parictes from within outward, four to the inner and four to the outer
side of ihe incisinn, each suture piercing the tissues at a. distance from its fellow

from Mch other by disunccs which corrrspoDcl to the point ut which the;
attached to ihc captiutc; the highest suture being Ntuaioil immiMliiitely t:
the twHfih rih.

1'he free ends nf the sutures arc secured by heny>»tatic Torceps and zr
tied until il>e rauicles und tntcia are nitured (Fig. i04j). ~

IREADJENT,

1041

kidney Into dnw cxvntaci vrilli the raw surface of the quadr.itus muscle. The
two rmis of each of the four >UK|>eii.vi(in ^uture> are then tieil tu c.irh other nnd
ihc incision through the skin closeil with Ihr intracuticubr suture (Fig. 1045).

Thirteenth Step.— The dressings arc applied smuothly and evenly acrosii
ihe entire width of the hitok in order that the pulicnt's body will be equally sup-
[torted oil both sides of the spine.

V ^1 r i ii 1 i » n s in the T e e h n i c .—If the kidney L< nol reikdily de-
livered, the upper p<)lc should be seized with Ashloti*s kidney forceps and
^nlly drawn ihrouKh the incision (Fig. 1046).

I di!^'unl the inlniaittculAT .-uture in cloMng (he parietal wound and use a
through -and through suture which includes the skin as well u.s all the deeper
klructurcs and ubviatcH the danger of leaving; a dead space.

Before lyinn: the Mi.*i>en*i"n suturcx and closing (he incision I pass a few
strands of silkworm-gut under the parietal wound sutures and brinn their
free ends out at the upper and lower anRle of the lumbar opening. The «lk-
worm-gut acts as a capillary drain and remove* .my excess of serum which
may b« poured out during the (mt forty-cigh( hours after operation.

1^0- t^4A. — SVtiiHoviiijit-irv — VArUtion in T*chDtc.
EIuwi ihc Idilmy Ltinc tttUvrri'l «hh Ai)>I'<d'i lulmy l-scrps.

The parietal wound sutures are introduced with A.-sh(on'-s abdominal needle.

After-treatment .—Cere 0} the Wound.— The silkworm-gut drain
is removed at the end of forly-ci(tht hours and (resh dre»ings applied. The
stitches in the lumbar wound are removed on the eighth day and the incision
drcsse<l two or three limes a week while the jialieni remains in the hospital.

(Jtllhtg Out 0} Btxt. — The [Hitient should remain U[Hin her back in bed for
three weeks in order to allow the adhesions between the kidney and the surround-
ing parts to become lirm and strong. She should be kept in her room for one
week longer and then allowed t" go out-ofdimn.

Subsequent Care. —Heavy work should be prohibited for several
monlh.1 or a year and the patient should nvaiil >lniininK at .itnol.

Tlie bi»wcls should be kept regular .ind the patient's general condition im-
proved by appropriate merlical treatmcnt.

The jMtienl should wear an alnlominal bandage (see p. 850, Fig. 777) tor
six months, and after that lime a close-6tting conet should be worn.

INDEX.

Abdouzn, auscultation, 68

diagnostic value of appesrance, 6o
exaniination, J7
inspection, 59
mensuration, 67

niovements of abdominal walls, 60
palpation, 60
percussion, 65
regions, 57

sliape of, in ascites, sq
in fal abdominal walls, 59
in pelvic enlaigements, 59
in lumois, 59
slcin of, in disease, 60
Abdominal adhesions, 910
and pelvic drainage, 893
glass lubes, S95
gauze, go I
indications, S93
rubber lubes, 90J
varieties, 8gs
bandage, 850
dressings, 837
hysterectomy, complete, 996

incomplete, 984
irrigator, S33
myomectomy, 1010
definition, loio
number of assistants, loio
operation, 10 10
position of patient, toio
operations, after-treatment of, 843

in private houses, 945
wound, dressing, 905
closing, 904
Abnormal implantation of orifices of

ters, 6jj
Abscess in abdominal wound, 876
Absence of bladder, 6a 6
of clitoris , iss
of Fallopian tubes, 4S3
of hymen, 159
of labia majora, 158

Absence of labia minora, 156
of ovaries, 504
of urethra, 590
of uterus, 313
of va^a, 136
of vulva, 154
Accessory Fallopian lubes, 484

ovaries, 504
Accidental ligation of ureters, 678
Accidents in opening abdomen, 90B
hemorrhage, 908
injuries of bladder, 908
peeling off parietal peritoneum, 908
wounding intestines or underlying
growth, 909
Acne of vulva, 116

»-rays in, 77
Acquired atresia of cervix, 473
causes, 473
definition, 473
diagnosis, 474
differential diagnosis, 475
pathologic changes, 473
proitnosis, 475
symptoms, 474
treatment, 475
atrophy of uterus, 446
stenosis and atresia of vagina, 141
causes, 343
diaj^osis, 343
prognosis, 143
symptoms, 14 a
treatment, 143
of cervii, 477
causes, 477
definition, 477
diagnosis, 477
pathologic changes, 477
prognosis, 4 78
treatment. 478
Acute ovaritis, 505
causes, 505
diagnosis, 506
i«43

I044

INDEX.

Acute ovaritis, differeotial diagnosis, 5116
pathology, 503
prognosis, 506
symptoms, 505
treatment, 507
prolapse of uterus, 326
causes, 316
symptoms, 316
treatment, 326
suppression of menses, causes, 709
symptoms, 701
treatment, 716
Adenoma of bladder, 650
Adherent prepuce, 156

labia minora. 15S
Adhesions, abdominal, gio
recent, qi i
chronic, 911
of clitoris, los
causes, 103
diagnosis, 203
prognosis, Z05
symptoms, 205
treatment, 203
of labia, 107
causes, 107
symptoms, 207
Ireatmenl, 207
Adhesive plaster. 837

vaginitis, 273
Adjustable log-holiiers (Edebohls's), 19
After! real mt-nt of an abdominal upcration,
843
band<i);e, S30
bladder, H45
boweh, 845
care of wound, 848
did, H46
drink, 845
cscrcise. 830
getting out of bed, 850
kidneys, 845
nausea, 844
pain, 843

position of patient, 842
prep^r:itinn of bt'd and room, 841
pulw, K47

recovery from anesthetic, S41
res|ii rations, 847
restlessness, 843
special nursing. 843
temperature, 847
thirst. 843

After-lreatment of an abdominal operaiiam
toilet of patient. 847

tympany, 846
use of strychnin, S47
visitors, 848
vomiting, 844
Alcohol lamp, 829
Alkaline sitz-bath, 213
Ambulatory urinal, 764
Amenorrhea, 706
causes, 706
description, 706
diagnosis, 709
prognosis, 711
symptoms, 709
treatment, 711
Ampullar pregnancy, 338
Amputation of cervix, 459
Amyloid degeneration of uterine fibniids, 37J
Anastomosis, end-to^nd, Halsled's mittroJ
suture, 924
Laplace's forceps, 918
O'Hara's forceps, 932
Murphy button, 933
intestinal, 923

lateral, Halsted's mattress suture, 92(1
Laplace's forceps, 938
O'Hara's forceps, 940
Murphy button, 943
Anatomic causes of diseases pecubar to

women, 1^16
Anatomy of jielvir floor, 781
definition, 781
description, 781
muscles, 781
synonyms, 781
Androg>'nf!i, 163

Anesthesia in gynecologic examination.^ 11
chloroform. 21
ether, 21

nitrous oxid gas. ;i
preparation for administration of

chloroform and ether, 2-
routinc use, 21
Anesthetics in abdominal examinations, 5')
Anomalies of bladder, 626
of Fallopian lubes, 4S3
of ovaries, 504
of ureters. 872
of urethra. 390
of uterus, 309
of vagina, 234
of vulva. 154

INDEX.

104S

Anteflexion o[ uterus, 336
causes, 337
description, 336
dia.gnosi5, 338
frequency, 336
prognosis, 338
symptoms, 337
treatment, 33g
Anterior colporrhaphy, 251
elytroirhaphy, 151
hernia of vulva, 194
causes, 194
definition, 194
diagnosis, 195
symptoms, 194
treatment, 195
Antisepsis, definition, 807
in gynecologic examinations, u
finger-cots, 13
hand- brushes, 31
importance, 32
office sterilizer, 13

preparation of hands and instru-
ments, 31
rubber gloves, 23
in hospitals, 807

antisepsis, definition, 807

application, 811

asepsis, definition, 807

boiling aqueous solution of carbonate

of soda, 8[o
chemic, 81 1

high -pressure steam, 807
mechanic, 810
methods of sterilization, S07
operating accommodations, 817
operating room, 81;
operating paraphernalia, S33
preparation ol operator and assistants,

814
sterilizing room, 83a
storage room, Siz
wash room, 81 J
in private houses, 944

abdominal operations, 945
arrival of nurse. 944
general considerations, 944
minor operations, 951
preparation of operating room, 944
selection of operating room, 944
Aperient waters in constipation, 104
Apparent hypertrophy of cervix, 46S
Appendectomy, 1020

Appendicitis, 1013
causes, 1013
diagnosis, 1016
differential diagnosis, 1017
physical signs, 1015
remarks, 1036
special directions, 1025
symptoms, 1014
treatment, 1019

value of blood examination in, 56
variation in technic, 1026
Application of antisepsis, 811
Ascites, change of percussion-note, 67
character of fluctuation wave, 67
mensuration in, 68
shape of abdomen. 59
Asepsis, definition, 807
Aseptic or fermentation fever, 660

definition, S60

diagnosis, S60

prognosis, S60

symptoms, 8(io

treatment, S60
Ashton's abdominal needle, 1035

irrigator, 823
apparatus for enlcrociysis, 135

for hydrostatic dilatation of bladder, 620

tor hypodcrmoc lysis, 133

for intravenous saline injections, 129

for uterine douche, 95
case of perforation of uterus by a lupelo

tent, 314
conducting forceps for flexible ureteral

catheters, 667
conveyance boxes, 808
crank as substitute for button on Goodcil's

dilators, 960
gauze pads, 827
general irrigator, 824
kidney traction forceps, 1035
large conveyance boxes for operations in

private houses, 947
method of arranging interior of Turkish
bath cabinet, 88

of administering oxygen gas. S42

of performing appendectomy, loji

of threading needles, 906
muslin abdominal bandage, 830
office examining table, 17
rubber mask tor administering oxygen, 843
self-retaining abdominal retractors, 887
substitute for the Kelly pad, 26
Ashton-Gans cystoscope, 632

1046

INDEX.

Aihlon-Gaos urethroscope, 5S5
Ashton-SneU residual urine evacualor, 6>3

Aapcrmia, 775

Assistants required in gynecologic examina-
■ lions, j8

numljer when an anesthetic is employed,
18
Atresia of cervin, acquired, 473
congenital, J13
hymenaiis, 160
of urethra, 591
of vagina (acquired), 141
Atrophy of clitoris, 155
of uterine fibroids, J71
of uterus (puerperal), 446
Auscultatioii of abdomen, 68
position of patient, 68
information, 6S
Azoospermia, 775

Bacterieuia, 54

causes, 54
definition, 54
in septic infection, 56
in tuberculosis, S7
isolation of bacteria, 54
significance, 54
Baclcrioldgic examinations, 37
general considerations, ,57
of discharges, 45
equipment and inslrumrnts, 45
infonnation for the pathologist, 50
method of collecting discharges, 49
other localities, 50
urethra, 49
uterus, 50
vagina, 50
vulva, 4g
shifimenl to laboratory, 50
technic, 4S
Baldy's operation for jirolujise of uterus,

334
Bandage, abdominal, 850
Bandages, S;7
Biisins, S35
Balh, full, S.i

half, H4

Russian, Si)

salt, !)o

sea. til

sheet, St I

Balh, sitz-, 87

sponge, 84
spray, 85
thermometer, 81
Turkish, 88
Benign papiUomata of ovaries, 510
tumors of vulva, J95
symptoms, 195
treatment, 195
Bimanual replacement of relrodisplacoDnl

of uterus, 346
Bladder, 616
absence of, 626
adenoma of, 650
and bowels, care of, in relation to dii^

ease, 138
anomalies of, 676
catheterization, loii
diseases, 627

in imperforate hymen, 161
injuries during an abdominal operatvin,

914
malformations, 626
methods of examination, 616
preparation of, for a gynecologic cumi-

nation, 13
prolapse, 146
Blind pouches of vagina, 23S
Blood in relation to surgen.-, 50

acute inflammatorj' proccssei. ;i
thmnic surgical conditions, 53
composition of the blood. 50
cyanosis, 52

effect of normal salt solution on, 5;
ether, 52
fever, 52

general coniiderations. 51
value of blo-Ml -findings. 51
value of negative findings. $1
value of positive findings. ^;
Boiling aqueous solution of carbonate jf
soda sterilization, Sio
apjKiralus, 810
time required, 810
value, 810
Boldl's table, 17
Braun's coI|«-urynler. 335
Broad ligaments. 545
diseases, 541;
hematoma, 56]
Brushes. 82S
Bubo, treatment. 201
Bullxicavernosi muscles, 7S1

INDEX.

1047

Calcification in uterine fibroids, 37a
Calculi of ureters, 681
causes, 681
description, 6&2
diagnosis, 6S3
results, 6S1
situation, 681
symptoms, 68 a
treatment, 6S4
Canal of Nuck, 193

in anterior hernia of vulva, 194
in hydrocele, 193
in inguino-labial hernia, 194
Cancer of body of uterus, 39t

causes, 391

causes of death, 395

diagnosis, 393

differential diagnosis. 394

einension, 391

pathology, 391

prognosis, 395

recognition of involvement of peri-
uterine tissues, 395

symptoms, 39?

treatment, 395

;ir-rays in, 75
of cervix, 396
causes, 396
causes of death, 400
complicating pregnancy, 406
diagnosis, 400
differential diagnosis, 403
extension, 397
pathology, 396
prognosis, 407

recognition of involvement of peri-
uterine tissues, 405
recurrence after operation, 413
symptoms, 399
Irealment. 407
*-rays in, 75
of Fallopian lubes, 503
of uterus, ar-rays in, 75
of vagina, 187
causes, 187
diagnosis, 2SS
differential diagnosis, 3S9
prognosis, 189
symptoms. 188
treatment, iSg
ar-rays in, 76
of vulva, 106
catises, 196

Cancer of vulva, course, 198

diagnosis. 197
prognosis, 196
situation, 196
symptoms. 197
treatment, 19S
varieties, 196
x-rays in, 76
Carcinoma of bladder, G50
of broad ligaments, 550
in connection with uterine fibroids, 373
of ovaries, 5 18
of urethra, 614
Caruncle of urethra, 613
description, 613
diagnosb, 614
pathologic anatomy, 613
prognosis, 614
symptoms, 614
synonyms, 613
Ircatmenl, 614
Catarrhal salpingitis, 485
causes, 485
diagnosb, 486
pathology, 48 j
prognosis, 4S6
symptoms, 485
treatment, 486
Catgut, 8as

Catheter, double -current, 762
glass female, 8:8
reflux, 59;
Catheterization of bladder. loii

of ureters, 663
Cauliflower excrescences of vulva. 103
Causes of diseases peculiar lo women. 136

accidental infections and trauma*

tisms, 144
anatomic, 136
childbirth, 140
civilization, 137
criminal abortions, 143
different periods of life, 144
education, 137

hereditary and congenital influ-
ences, 136
sexual relations, [42
social condition. 137
unhygienic conditiotB, 138
venereal diseases, 143
Cautery, Paquelin. S19
Cervical cancer, 396
catarrh, 440

I048

INDEX.

Cervical endometrilU, 440

polypi, 469
diagnosis, 469
differential diagnosis, 470
prognosis, 470
symptoms, 469
treatment, 470
varieties, 469
Cerviit, atresia, acquited, 473
congenital, 313
cancer, 396
chancre, 478
hypertrophy, 463
lacerations, 44S
malformations, 313
scarification, 454
stenosis (acquired), 477
tuberculosis, 744
Chafing of vulva, 116
Chancre of cervix, 478
description, 478
diagnosis, 47S
treatmenl, 478
of vulva, 102
course. 203
diagnosis, 102
duration, zoi
situation, lo)
treatment, 10 1
Chantroids of vulva, 100
course, 200
diagnosis, 20 r
duration, 200
frequency, 200
situalLun, 200
trcalmont, 20[
Change of life, 694
Chemic sterilization, 811
agents, 811
Inilicalions, 3i 1
value, 8r i
Childlx'aring jwriod in relation to hislory-

takinK, M5
ChildUirlh as a cause of disease, 140
Chloniform in gi'necologic examinations, 21
Chorin-cpiihfiioma, 700
Chninii ovuriti'^, 507
1 auses, ^07
liiagnosLs, 508
jialhokigy, 507
])ro(<nosii, 500
svmpt<tmn, ^o8
treatment, 509

Civilization as a cause of disease, 137
Classification of uterine displacements, 311
Cleansing and lubricating soap, 24

vaginaj douche, 94
Cleavage of clitoris, 155
Climacteric, 694
Cliloridcctomy, 961

after-treatment, 963

definition, 961

instruments, 961

number of assistants, 961

operation, 963

position of patient, 961
Clitoris, absence of, 155

adherent prepuce, 156

adhesions, 205

atrophy, 155

cleavage, 155

clitoridedomy, 961

development, 154

hypertrophy (congenital), 155

hypertrophy (acquired), 206

redundant prepticc, 156

tumors, 207
Cloaca, 234

Closing abdominal wound, 904
fat belly wall, 905
method, 904
needles, 904
sutures, 904
Coagulalion of blood. 55
normal time, 55
rapidity, 55
significance, 55
surgical value, 55
Coccygcxlynia, 730

causes, 730

definition, 730

diagnosis, 731

<lijferential diagnosis, 732

]>rognosis, 731

symptoms, 731

trtalmenl, 732
Coitus in relation to disease, 142
Colloid degeneration in uicrine fibroids, 373
Colonial spring of Long Island, loi
Col|jturi*nter, use of, in chronic uterine in-
version, 366
in uterine prolapse, 335
Colpocleisis, 763
Culjiohyperplasia cystica, 274
Col[«)rrhaphy, anterior, 251
C-ombined hvilerectomv, 1009

INDEX.

1049

Combined vaginal and abdominal hystcr-
eclomy, 1009
dc&nition, 1009
instruments, 1009
number of assistants, 1009
operation. lOio
position of patient, 1009
Commonwealth mineral spring, 101
Complete abdominal hysterectomy, 996
definition, 996
number of assistants, 996
operation, 996
position of patient, 996
synonym, 996
variations in technic, 998
Complications after abdominal operations,
850
aseptic fever, 860
delayed bowel movement, 85a
emphysema of abdominal wall. 873
fecal Qstula. 88}
fermentation fever, 860
general septic peritonitis, S6t
intestinal obstruction, 867
localized infection, S64
persistent nausea and vomiting, Sjo
secondary hemorrhage, 854
shock, 85 7

sinus tracts in abdominal wall, 878
stitch -hole abscess, 875
suppression of urine, S73
suppuration in abdominal wound, S76
thrombosis of femoral vein, 874
traumatic peritonitis, 860
tympany, 853
ventral hernia, 881
Compresses (surgical), 816

hot and cold water, 97
Condylomata of urethra, 6 1 6

of vulva, 103
Congestive endometritis, 417
causes. 418
definition, 417
diagnosis, 419
differential diagnosis, 431
pathology, 417
prognosis, 411
recurrence, 414
symptoms. 41S
treatment, 412
Conical cervix, 313

Consen'aiive operations on uterine append-
ages. 573

Conservative operations on uterine append-
ages, advantages, 573
contraindications, 575
definition. 571
disadvantages. 573
Fallopian lubes, 577
ovaries, 579

results upon stctility, 575
Constipation, toi
aperient waters, 104
causes, 102
diagnosis, 103
definition, loi
diet, 103
enemala, 104
exercise, 103

frequency of, in women, loi
general directions, to.l
suppositories, 104
symptoms, 102
treatment, 103
Constitutional endometritis, 444
causes, 434
definition, 424
diagnosis, 415
pathologj-, 414
pri^nosis, 426
recurrence, 426
symptoms, 424
treatment, 436
Continuous ihroufth-and-lh rough intestinal

suture, 923
Contraction of bladder, 641
causes, 641
definition, 641
diagnosis, 64 3
prognosis, 643
symptoms, 641
treatment, 642
of muscles of abdomen during an ab-
dominal operation, 909
Contused wounds of ureters, 674
Convalescent diet, 114
Covering raw surfaces with peritoneum, 891
Crile's observations upon shock, 859
Criminal abortions as a cause of disease, 143
Crises, Diell's, 1031
Croupous cystitis, 629

Curetment for microscopic examinations, 38
Cushing's right-angled suture, 922
Cyanosis, effect of, upon blood -changes, 53
Cystic degeneration in uterine fibroids, 373
tumors of ovaries, 530

1 050

INDEX.

Cystic tumors of ovaries, classificalion, 530
complications, 517
cysts of corpus luieum, 511
degenerations, 543
dennoid cysts, 523
diagnosis, S3»
difFerential diagnosb, 539
follicular cysts, 520
glandular cysts, 522
oophoritir cysts, 320
papillary cysls. 534
paroophoritic cysts, 534
prognosis, 544
symptoms, 525
treatment, 544
Cystitis, 627
causes, 627

channels of infection, 61S
definition, 627
diSerential diagnosis, 633
pathologic changes, 629
physical signs, 632
prognosis, 633
reaction of the urine, 628
symptoms, 630
treatment, 634
Cysloccle, 246
causes, 246
definition, 246
diagnosis, 248
differential diagnosb, 245
frequency, 247
prognosis, 251
results, 2 49
symptoms, 247
synonyms, 246
treatment, 251
Cystoscopy, 63i
Cystotomy, suprapubic, 965

vagina], 970
Cysis of corpus luteum, 521
of Fallopian tubes, 503
of K obeli's tubules, 545
of urethra, (115
of vagina, 275
description, 275
diagnosis, 276
differential diagnosis, 277
origin, jjs
prognosis, 278
results, 278
symptom Si 276
treatment. 27S

Cysts of vertical and transverse tubuks ol
parovarium, 545
of vulva, 196
symptoms, 196
treatment, 196
varielies. 196
of vulvovaginal glands, 181
causes, 181
prognosis, 181
symptoms, 181
treatment, 181

DaCosta's method of locating the appen-
dix, 102 1
Defective development of cc^^^x, 313
Delayed bowel movement (poat-operalivt>,

diagnosis, 852
prognosis, 852
treatment, 853
menstruation, 699
causes, 699
definition, 699
diagnosis, 699
prc^noais, 700
symptoms, 699
treatment, 700
Depleting the cervix, technic, 423
Dermal vulvitb, 216
Dermatitis of vulva, 216
Dermoid cysts of ovaries, 523
causes, 513
description, 523
Determining which ureter is injured, 670
Diabetic \-ulvjtis, 178
delinilion, 178
diagnosb, 178
prognosis, 17S
symptoms, 178
treatment, 178
Diet, 106
convalescent, 114
general considerations, 106
liquid, 1 06

nutritive enemata, 115
soft, 1 1 I
Diell's crises, 1031

Dilatation and curelment of uterus, 955
after-treatment, 960
definition, 95;
Instruments, 955
number of assistants, 955

INDEX.

1051

Dtlat&lion and curetment of uterus, opera-
tion, gs6
position of patient, 955
special directions, 959
variations in (cchnic, 958
of whole urethra, 606
causes, 606
physical signs, 606
prognosis, 607
symptoms, 606
IrealmenI, 607
Diphtheria of vulva, aio
defitiilion, 210
diagnosis, no
symptoms, 120
treatment, 120
Diphtheric cystitis, 629
Direct inspection of rectum, 68
anesthesia, 70
eversion of anterior wall, through

vagina, 70
limitations, 68
position of patient, 70
technic, 70
of vagina. 31^
Diseases of bladder, 617
calculus, 643
contraction. 641
cystitis, 627
foreign tradies, 647
irritability, 639
neoplasms, 649
of broad ligaments, 545

cysts of Kobeit's tubules, 545
cysts of vertical and transvetse tu-
bules, 545
parovarian cysts, 545
solid tumors, 550
varicocele, 549
ot Fallopian lubes, 484

catarrhal salpingitis, 485
displacements, 504
neoplasms, 503
purulent salpingitis, 487
salpingitis, 4S4
of ovaries, 504
acute ovaritis. 505
benign papilloroata, 519
carcinoma, 518
chronic ovaritis, 507
cystic tumors, 520
cysts ot corpus lutcum, 511
dermoid cysts, 523

Diseases of ovaries, fibroma, 517

follicular cysts, 520

glandular cysts, 522

hemorrhage, 514

hemia, 513

hydrocele. 515

inflammation, 504

myoma, 517

oopboritic cysts, 530

ofiphoritis. 504

ovaritis, 504

papillary cysts, 514

paroophoritic cysts, 524

prolapse, sri

sarcoma, 517

solid tumors, 516
of urethra, 593

carcinoma, 614

caruncle, 613

condylomala. 616 •

cysts, 615

dilatation of whole urethra, tio6

polypi, 61S

prolapse, 601

sarcoma, 615

stricture, 596

suburethral abscess, 6i»

urethritis, 593

urethrocele, 608

vesico-urelhral fissure, 599
of uterus, 313

acquired atresia ot cervii. 473

acquired stenosis of cervix, 477

anteflexion, 336

apparent hypertrophy of cervix, 468

cancer of body, 391

cancer ot cervix, 396

cervical polypi, 469

chancre of cervix, 47S

congestive endometritis, 417

constitutional endometritis, 424

displacements, 318

displacements as a whole, 321

endocervicitis, 440

endometritis, 417

eversion of intracervical mucosa, 470

fibromata, 368

foreign bodies, 315

gonorrheal endometritis, 427

hernia, 479

hy[)ertrophy of cervix, 46*

inflammation. 416

infravaginal hypertrophy of cervix, 466

1053

INDEX.

Diseases of uterus, injuries of body, 313
invcraion, 359
lacerations ol cervix, 448
posterior versions and flexions, 339
prolapse. 314
sarcoma, 414
senile endometritis, 439
septic endometritis, 43 1
subinvolution, 441
superinvolution, 446
supravaginal h)rpertrophy of cervix, 461
loision, 331
of vagina, 141
acquired atresia, 341
acquired stenosis, 142
adhesive vaginitis, 373
cancer, 287
cystocele, 146
cysts, 375

emphysematous vaginitis, 374
fibromata, 163
foreign bodies, 344
gonorrheal vaginitis, 171
granular vaginitis, 371
hernia, j6i

papillary vaginitis, 173
prolapse anterior wall, 146
prolapse posterior nail, 357
rectocele, 357
sarcoma, 3^4
senile vaginilis, 173
simple vaginitis, 367
vaginal Qatus, 395
vaginitis, 366
vesicovaginal hernia, 346
of vuiva, 171
acne, 3 16

adhesions of clitoris, 305
adhesions of labia, 307
angioma, 196
anterior hernia, 194
benign tumors, 195
cancer, ig6
chaRng, 3 [6
chancre, 301
chancroids, 300
cysts, 196

cyEtts of vulvovaginal glands, 181
dermal vulvitis, 3[6
diabetic vulvitis, 17S
diphtheria, 330
eczema, 311
edema, 193

Diseases of vulva, elephantiasis, tSS

erysipelas, 317

fibroma, 196

follicular vulvitis, 176

gangrene, 173

gonorrheal vulvitis, 175

hematoma, 171

herpes, 30S

hydrocele of labium majus, 193

hypertrophy of clitoris, ao6

inflammation of ducts of vulvovaginal
glands, I So

inflammation of vulvovaginal glands,
179

ingui no -labial hernia, 194

intertrigo, 316

kraurosis vuIvk, 186

lichen, ii5

lipoma, 196

mixed growths. 196

myoma. 196

myxoma, 196

neuroma. 196

prurigo, 316

pruritus vulvff, 183

pseudo-diphtheria, 330

sarcoma. 199

simple catarrhal vulvitis, 17a

simple dermatitis, »i6

syphilides. 303

thrush, 315

trichiasis, 187

tumors of clitoris, 307

vaginismus, 331

varicose veins, 189

venereal ulcere, 300

verrucffi, 20 j
Displacements of Fallopian tubes, 504
acquired, 504
congenital, 484
of ovaries, congenital, 504
of uterus, 31S

anteflexion, 336

as a whole, 321

classification, 331

inversion, 359

normal position of uterus, 318

of primary importance. 333

of secondary importance, 333, 367

posterior flexions, 339

posterior versions, 339

prolapse, 334

supports of uterus. 318

INDEX.

1053

DisplacemeniB of uterus, tonion, 3JI
DistiHed water. 100

slill for making, loo
use, 100
Divided bladder, 636
Dorsal elevated position, jo
position, 30
arrangcmcitt of sheet and clothing, 30
position of patient, 30
t>orsosacral elevated position. 33
position, JO

arrangement of sheet and clothing, ji
position of patient, 30
Double -current female catheter, 76J
OS uteri. 313
uterus, 310
vagina, 334
vulva. 155
Douche, intrauterine, 94

vaginal, 91
Drainage, abdominal and pelvic, 893
gauze, 901
glass, 895

in ureteral operations, 679
rubber tubes, 903
syringe, 824
Dress in relation to disease. 139
Dressing abdominal wound, 905
Dressings, abdominal, 817
Dropsical Graafian follicles, 530
Duplication of ureters, 673
Dysmenorrhea, 718
causes, 718
definition, 718
diagnosis. 711
membranous, 719
prognosis, Jii
symptoms, 719
treaUnenI, jm

Ecmdococajs disease at pelvis, 554

causes, 554

description, 554

diagnosis. 555

physical signs, 555

prognosis, sss

symptoms, 554

treatment, 556
Ectopic gestation, 556
definition, 556
ovarian, 556

Ectopic gestation, primary, 556

secondar)', 556

tubal, 556

varieties, 556
Eczema of vulva, zii

causes, an

definition. 2it

diagnosis. 211

prognosis, 2rz

symptoms, ju

treatment, 212

varieties, 211

a:-rays in, 77
Edcbohls's method of performing nephror-

rhaphy, 1034
Edema in uterine fibroids, 371
of lulva, 192

causes, 192

definition, 192

prognosis. 192

symptoms, 192

treatment, 192
Education as a cause of disease, 137
Effects of the removal of uterine append-
ages, 57"
general, 573
mind, 572
sexual appetite, J72
symptomatic results, 570
symptoms, artificial menopause, 571
Elephantiasis of vulva, rSS

causes. 1S8

definition, 188

diagnosis, 1S9

prognosis, 189

symptoms, 188

treatment, 189

a-rays in. 77
Elongation of cervix (congenital), 313
Emmet's operation for tears of pelvic floor,

Soi
Emollient sitz-bath, 213
Emphysema of abdominal vi'all, 873

treatment, 874
Emphysematous vaginitis, 274

causes, 274

definition, 174

prognosis, 275

symptoms, 274

S)Tlonym, 274 ^

treatment. 275
Enchondroma of bladder, 649
Endocervicitis, 440

10S4

INDEX.

Endocervicjtis, causes, 440

definition, 440
diagnosb, 441
differential diagnosii, 44s
prc^osis, 44a
sympioms, 441
synonyms, 440
treatment, 441
Endometnlis, 417
I'ongestive. 417
constitutional, 414
exfoliative, 417, 719
fungoid, 417
glandular, 417
gonoirheal, 417
hyperplastic, 701
interstitial, 417
senile, 439

septic. 431
varieties, 417
EnemalB, cleansing, 115
la;ialive, 104
nutritive, 115
use, in constipation, 104
Enleroclysis, 13;

after abdominal operations, 906
antisepsis, 135
apparatus, 13s
indications, 135
operation, 135 .
position of patient, 135
quantity of salt solution, 135
rapidity, 135

situation for administration, 135
temperature of solution, 135
Enterovaginal 6s[ula, 774
definition, 774
treatment, 774
Epigaslrit region, contents, 57
Epispadias, 592
Erect position, 31
Erysipelas of \'ulva, 117
causes, 217
definition, 317
diagnosis, 3 iS
prognosLK, 218
s}*mptonis, 117
ircatmcnl, ji8
v.irielies, 218
Escape of viscera during an abdominal

operation, oco
Ether, effect of, upon blood -changes, 52
in gjnccoliigic examinations, ii

EversioD of inlracervica] mucosa, 470
causes, 470
diagnosis, 471
differential diagnosis, 47a
prognosis, 472
symptoms, 471
ireatmcnt, 47a
Examination of abdomeo, J7

anesthesia, 59

arTBQgement of clothing and sheets, 5!

auscultation, 68

inspection, 59

mensuration, 67

methods, 58

palpation, 60

percussion, 65

position of patient, 59

preparation of patient, 5S

regions of abdomen, 57
bacteriologic, 37
of bladder, C16

bacteriologic, 635

chemic, 635

cystoscopy, 6*1

direct inspection, 6t6

hydrostatic dilatadon, 619

indirect inspection, 631

microscopic, 635

palpation, 617

percussion. 618

sounding, 618
of girls and unmarried women, 11
of Fallopian lubes, 479
microscopic, 37
of ovaries, 479
at patient's house, 17
of rectum, 58

anesthesia, 70

indirect inspection, 73

inspection, 68

instruments, 71

limitations, 71

methods, 68

position of patient, 71

preparation of patient, 68

probing, 71

rectal touch, 70

lechnic, 71

vaginal touch, 71
of ureter, 657

abdominal palpation, 661

bacteriologic. 671

catheterization, 663

DfDEX.

1055

Exaimnation of ureter, inspecUon, 661
locating an obstruction, 668
microscopic, 671
obtaining separate urines, 663
rectal palpation, 65Q
segregation of urine, 668
sounding, 663
vaginal palpation, 657
T-rays, 67 1
of urethra, 583
bacteriologic, 590
direct inspection, 5S3
indirect inspection, 585
microscopic, 390
palpation, 5 84
sounding, 5SS
urethroscopy, 583
of uterine ligaments, 479
adnexa and ligaments, 479

anesthesia, 48a

artificial uterine prolapse, 483

information, 479

limitations, 479

methods, 479

position of patient, 480

preparation of patient, 479

rectovaginal touch, 483

vagi no-abdominal touch, 480
of uterus, »9ft

artificial uterine prolapse, 306
bacteriologic, J09
indiicct inspection, 196
microscopic, 309
recto-abdominat touch, 303
rectovesical touch, 305
sounding, 307
vaginal touch, 29S
vagi no-abdominal touch, 300
of vagina, 115
bacteriologic, a 34
direct inspection, 335
indirect inspection, 337
microscopic, 234
vaginal touch, 336
of vulva, 1^1
bacteriologic, 153
inspection, 15*
palpation, 153
microscopic, 153
Examining hand, pose of, in pelvic examin-
ations, 16
external, 18
internal, >6

Excision of vulva, 963
after-treatment, 965
definition, 963
instruments, 963
number of assistants, 963
operation, 964
position of patient, 963
Exercise, effect of, upon constipation, 103
indoor, 117

in relation to disease, 139
outdoor, 117
Exfoliative cystitis, 639
endometritis, 417, 719
Exploration of peritoneal cavity. 886
illumination, 890
inspection, 887
retractors, 887
touch, 8S6

Trendelenburg position, 888
Exstrophy of bladder, 626
Extrauterine gestation, 556
Exudative cystitis, 639

Fallopian tubes, 483

diseases, 4 84

examination, 479

in imperforate hymen, r6o

malformations, 4S3

rupture of, in imperforate hymen, 163

tuberculosis, 747
False hermaphroditism, female, 164

mate, 163
Fat embolism in wounds of vulva, t66
Fatty degeneration in uterine fibroids. 373
Fecal fistula, 88a

causes, 883

prognosis, 883

treatment, 883
Female false hermaphroditism, 164
Fenger's method of dividing a ureteral

stricture, 680
Fermentation fever, 860
Fetal uterus, 311

Fever, effect of, upon blood -changes, $3
Fibrinous cystitis, 629
Fibroid enlargement of intravaginal cervix,

treatment, 39a
polypi, treatment, 387
tumors complicating pregnancy, diag-
nosis, 383

treatment. 39a
Fibromata of bladder, 649

I056

INDEX.

Fibromata of broad ligaments, 550
of ovaries, 517
of round ligamenti, 551
of ulcnis, 368
causes, 368
changes in uterus, 371
description, 368
diagno^, 376

diagnosis of secondaiy changes, j8i
differential diagnosis, 383
effect upon neighboring and distant

organs, 371
prognosis, 375
secondary changes, 371
symptoms, 373
treatment, 384
varieties, 369
of vagina. 183
causes, J83
description, 283
diagnosis, 283
ditferential diagnosis, 184
prognosis, 284
results, 2S4
symptoms, 383
treatment, 284
Fibromyoma of Fallopian tubes, 503
Fig warts of vulva, 203
Filtered drinking-water, 100
Finger-cots, use of, in gj'nccologic examina-
tions, 2.1
Fislula*, fecal, 882

gi-niial, 750
Flcxilile silk ureteral calheter, 665
Floating kidney, ioj8
Follicular cysts of ovaries, 520
causes, 520
diagnosis, 521
palholog^', 520
prognosis, 521
symptoms, 521
svnijnj'ms, 530
Ircatmenl, 521
vulvitis, 176
causes, [76
rlufinition, j-jfi
prognosis, 176
symptom!!. 176
Ireatmcnl, 177
Foo<l in relation to disease, 139
Forceps, l-uplace, 921)

O'Hara, 932
Foreign bodies in bladder, 647

Foreign bodies in bladder, classification, 64;
diagnosis, 648

prognosis, 648

symptoms, 648

trealmenl, 649
in ureters, 687
in uterus, 31;

causes, 315

diagnosis, 316

results, 316

symptoms, 316

treatment, 316
in vagina, 244

causes, 244

diagnosis, 245

results, 345

symptoms, 144

treatment, 245
Full bath. 83
action, 83
cold, 83
hot, 83
lechnic, 83
lepid, 83
varieties, 83
warm, 83
Fungoid endometritis, 417

GASGBES'Eof vulva, 172
causes, 172
definition, 172
prognosis, 172
symptoms, 172
trealmem, 173
Garrulity of vulva, jqj
Gauze compresses, 826
drainage, ooi

care of wound, goi
dressing wound, p02
indications, 901
introduction, 902
objections, 901
pads, 826
sponges, 826
tampons, 826
General and local cleanliness in relation to
disease, 138
irrigating apparatus, 813
operative tcchnic. 883

closing abdominal ivound, 904
covering raw surfaces, 891
drainage, 893

INDEX.

10S7

General operative technic, dressing abdom-
inal wound, 905
cnleroclysis, 906
median abdominal incision, 883
threading needles, go6
toilet of peritoneum, S91
septic peritonitis, S6z
diagnosis, 863
prognosis, 864
symptoms, 86a
treatment, S64
Genital eminence, 154
fistulas, 750
classification, 750
definition, 750
entero vaginal, 774
fecal, 750
rectolabial, 773
recloperineal, 771
tec to vagina I, 769
uretero-uterine. 769
urethrovaginal, 768
urinary, 750
vesico-ulerine, 764
vesico-nterovaginal, 766
vesicovaginal, 750
folds, 154
furrow, 154

organs, tuberculosb, 738
ridge, 154
Genito-urinary sinuses, x-rays in treatment,

76
Glands of Skene, collecting discharges, 44
Glandular cysts of ovaries, 53Z
causes, 511
description, 531
synonyms, 511
endometritis, 417
Glass catheters. Sag
drainage. Sg;
care of sinus tract, 900
care of syringe, 8g8
cleaning tube, 808
dressing wound, 897
indications, Sgj
introduction, 896
method of withdrawing tube, qoo
objections, 895
when to clean tube, 900
when lo withdraw tube, 900
drainage-tubes, 834
Glycerin as a lubricant, 15
Gonorrhea as a cause of disease, 143
67

Gonorrheal endometritis, 417

causes, 417

definition, 417

diagnosis, 41S

differential diagnosis, 439

prognosis, 430

recurrence, 431

symptoms, 417

treatment, 430
macule, 179
vaginitis, 271

definition, 271

diagnosis, 271

prognosis, 271

symptoms, 172

treatment, 272

varieties, 271
vulvitis, r75

definition, 175

diagnosb, 175

prognosis, 175

symptoms, t75

treatment, 1 76
Granular vaginitis, 272

causes, 273

description, 172

diagnosis, 273

prognosis, 273

symptoms, 273

synonym, 273

treatment, 273
Gumma of Fallopian tubes, 503

of vulva, 202
Gynecologic postures, 29

arrangement of patient's clothing, 29

canton -flannel stockings, 29

varieties, 29

HAI.F-BATH, 84

action, 84

technic, 84
Halsled's mattress suture, 923
Hand -brushes, 818

use of, in gynecologic examinations, 22
Hard soap, sterilization, 814
Harris's segregator, 671
Hegar's uterine dilator, 598
Hematocele, pelvic, 560
Hemalocolpos in double vagina, 236

in imperforate hymen, 160

in partial absence of vagina, 236
Hematoma of broad ligaments, 561

1058

INDEX.

\'-

Hematoma of vulva, 171

causes, 171

definition, 171

prognosis, 171

results, 171

symptoms, 171

ireatmeni, 171
Hemalometra in absence of vagina, 336

in imperforate hymen, 160
Hematosalpinx, 490

in absence of vapna, 136
in imperforate hymen, 160
Hemoglobin percentage, 54

in septic infection, 56

normal percentage, 54

significance, 54

surgical value, 54
Hemon-hage, blood -changes in, 55
during an abdominal operation, 913
ovaries, 514

causes, 514

diagnosis, 515

pathology, 514

symptoms, 515

Ireatmeni, 515
secondary, 854
Hereditary and congenital causes of diseases

peculiar to women, 136
Hermaphroditism, 163
androgynes, 163
bilateral, 163
false, 163
female, false, 164
lateral. 163
male, false, 163
pseudo-, i6j
true, 163
unilateral, 163
Hernia, anterior, of vulva, 194
inguinolabta), 194
of ovaries, 513

description, 513

diagnosis, 514

symptoms, 514

treatment, ; 14

varieties, 514
of uterus, 479

description, 479

diagnosis, 479

synonym, 479

(realm cm, 479
of vagina, 262

causes, 363

Hernia of vagina, deGnition, 163
differential diagnosis, 263

prognosis, 764
symptoms, 163
treatment, 164
ventral, 881
vesicovaginal, 346
rectovaginal, 357
Her7>es gestationis, loS
progenilalia, loS
of vulva, aoS
causes, 208
definition, 30S
diagnosis, 309
prognosis, 2 to
symptoms, 109
treatment, 310
High amputation of cervix, 463
Highland Springs water, 101
analysis, loi
use, lor
High-pressure steam sterilization, S07
apparatus, 807
lime required, 807
value, S07
History taking, 144
age of patient, 145
bowels and bladder, 150
child-bearing record, 148
discharges. 148
family record, 151
general health, 151
importance, 144
menstruation, 147
name and address, 144
occupation, habits, 146
pain, 149

particular symptoms, 151
patient's statement, 144
single, married, widow, 146
summary of s>Tnptoms, 153
Horizontal recumbent position. 37

arrangement of sheets and clothing,
position of patient, 37
Hospital examining table, 17
Hot vaginal douche, 93
Hot -water bag, 97
action, 96
tcchnic, 97
Hydatid cyst of pelvis, 554
fremitus. 555
thrill, 5SS
Hydrocele of labium tnajus, 193

INDEX.

10S9

Hydrocele of labium majus, deGnition, 193
diagnosis, 193
paihology, 193
prognosis, 193
symptoms, 193
Ircalmenl, 193
of ovaries, 5 1 5

description, 515
diagnosis, 516
symptoms, 516
treatmen), 516
Hydrops follicularis, 510
Hydrosalpinx, 490

Hydrostatic dilatation o[ bladder, 619
Hydrotherapy, 77
cause of failure in use, 77
compresses, 96

duration of bath or douche. Si
effect of mechanic contact of water, 78
effect of temperature of water, 78
friction or exercise to assist reaction, 83
fuU bath, 83
general effect of cold, 79
upon the heart, 79
upon the respiration, 79
upon the temperature of the body,

upon the vasomotor nerves, 79
general effect of heal, 79

elimination of todns, 80
primary effect, 80
secondary effect, 80
upon circulatory system, 80
upon nervous system, 80
upon vasomotor nerves, 80
half-bath, 84
hot-water bag, 96
ice-bag, 96
importance, 77
importance of technic, So
intrauterine douche, 94
methods, S3
physiologic action, 78

changes in circulatory system. 78
changes in excretions, 78
changes in respiratory system, 78
changes in secretions, 78
position of patient, 81
reaction, 78
Russian bath, 89
salt bath, 90
sea bathing, 91
sheet bath, 89

Hydrotherapy, sponge bath, 84

spray bath, 85

temperature of bath-room, 82

temperature of water used in, S3

time devoted to rest, 81

time of day treatment is taken, 80

Turkish bath, 88

vaginal douche, 91
Hymen, 158

abnormal openings, 159

absence, 159

anomalies in structure and shape, 1 59

bifenestratus, 1S9

biforis, 159

crescent -shaped, 159

ciibriformis, 159

denticular, 159

development, 158

fimbriated, 159

imperforate, 160

infundibuliform. 159

irregularly curved, 159

malformations, 159

projecting, 159

rudimentary, 159

septus, 159

serrated, 159

subseptus, 159
Hyperemia of ovaries, 507
Hyperplastic endometritis, 701
Hypertrophic elongation of vaginal cervix,

466
Hypertrophy of cervix, 461
apparent, 468
congenital, 313
inftavaginal, 466
supravaginal, 462

of clitoris (acquired), 106
causes, J06
symptoms, jo6
treatment, lofi

of clitoris (congenital), 155

of labia majora, 158

of labia minora, 156
Hypodermic syringe, 819
Hypodcrmociysis, 131

antisepsis, 133

apparatia, 133

indications, 131

local anesthesia, 134

operation, 134

quantity of solution, 133

rapidity, 133

'in

iiiifM

1060

INDEX.

Hypodcnnoclysis, siluaUon for adminislra-
lion, 134
temperature of solution, 133
Hypogastric region, contents, 38
Hypospadias, 592

Hysterectomy, combined vaginal and ab-
dominal, 1009
complete abdominal, 996
for diseased appendages, 569
incomplete abdominal, 9S4
vaginal with clamps, 999
with ligatures, 1006
Hysterocele. 479
Hysterrorhaptiy, 331

Ice, 10 1
impurity as source of disease, 101
special ice-cooler, 102
Ice-bag, 97
action, 96
technic, 97
Iminediate operations for lacerations of

cervis, 461
Imperforale hymen, 160
causes, 160
course, 160
diagnosis, 163
prognosis, 162
symptoms, i6t
treatment, 162
Iropotency, male, 775
Incised wounds of vulva, i63
de&nitian, 16S
symptoms, 169
treatment, 169
of ureters, 674
Incision, median, abdominal, S83
Incomplete abdominal hysterectomy, 984
definition, 984
instruments. 9S5
number of assistants, 9S4
operation. 986
position of patient, 984
special directions, 991
synonyms, 984
variations in technic. 990
Incontinence of vulva, 19s
Indirect inspection of bladder, 62t
of rectum, 73
of urethra, 585
of uterus, 29ft
of vagina. 227

Indoor eicrcises, :

contraction i

walking, 12

effect on abdi

on chest m

on respirati

on retentivi

importance ol

indications, i

in technic of I

rules, 118

in treatment 1

use in gyncco

varieties, 1 19

Infancy in relation

Infantile uterus, 3

vulva, ijs
Infection, localtzec
uterine fibroids.
Infections and t

disease, 144
Inferior wall of pe
Inflammation of
glands,
causes, i
prognosi:
symptom
treatmen
of ovaty, 504
of uterus, 416
of vulvovaginal
causes, 179
frequency,
prognosis, i
symptoms,
treatment, 1
InCravaginal hypei
causes, 466
definition, ^
diagnosis, 4
differential
pathologic
prognosis, ^
symptoms,
treatment, 1
Inguinolabial hem
Injections, enteroc
hy podermoc lysi;
intrauterine, 94
intravenous salir
normal salt solu
saline. 126
vaginal, 91

INDEX.

I061

Injuries during an abdominal operatioa, of
bladder, 914
of intestines, 915
anlisepsis, gig
classification, 915
continuous Lembert suture, 911
continuous througti-and-througb

sulure, 973
Gushing' s right-angled sutuie,

9J1
end-lo-end anastomoses, Halsted
mattress suture, 924
Laplace's forceps, 928
O'Hara's forceps, 931
Muiphy button, 935
general operative technic, 919
Halsted's mattress sulure, 933
interrupted Lembert suture, 911
intestinal anastomosis, 973
involving loss of tissue, 917
involving lumen, 916
involving serous and muscular

coals. 9t5
irregular tear^, 916
lateral anastomosis, Halsted's
mattress suture, 936
Laplace's forceps, 93S
O'Hara's forceps, 940
Murphy button, 943
longitudinal tears, 916
necrotic areas, 917
needles. 919
suture material, 910
suturing, 930
treatment, 9 1 5

varieties of intestinal sutures, 911
of mesentery, 918
of rectum, 91S
of ureters, 915
of body of uterus, 313
causes, 313
diagnosis, 314
prognosis, 314
treatment, 315
o( ureters, 674
causes, 674
diagnosis, 674
symptoms, 674
treatment, 675
varieties, 674
Inspection of abdomen, 59

of vulva, 151
Instrument steriliser, Sto

Interlocking or link suture, 977
Intermediate operations for lacerations of
cervix, 461
for tears of pelvic floor, 794
Intermittent angioneurotic edema of vulva,

191
Interstitial endometritis, 417
pregnancy, 558
uterine fibroids, 369
Intertrigo of vulva, 116
Intestinal anastomosis, 913
clamps, 930
needles, 919

obstruction (post-operative), 867
blood-changes, 55
causes, 86 7
diagnosis, 870
prognosis, 871
symptoms, 869
treatment, 871
suture material, 910
sutures, 911
suturing, 9 10
Intestines, injuries during an abdominal
operation, 915
preparation of, for a gynecologic examina-
tion, 24
Intrab'gamenlous cyst, removal, 9S3
uterine fibrcnds, 370
removal, 991, 994
Intrauterine douche, 94
Intravenous saline injections, itg
antisepsis, ijo
apparatus, 119
indications, 119
instruments, 130
local anesihesi&, 131
operation, 131
quantity of solution, 130
rapidity, 130

temperature of solution, 130
Invagination of pelvic floor in pelvic eX'

aminations, 16
Inversion of uterus, 359
causes. 359
definition, 35a
diagnosis, 361
differential diagnosis, 363
pathologic anatomy, 360
prognosis, 363
symptoms, jfio
treatment, 364
lodtn blood-reaction in septic infection, 56

1063

INDEX.

i
1

Ini^ting pad, 36
Irrigator, abdotiilnal, 813

general, S73
Irritabiliiy of bladder, 639

causes, 639

deGnition, 639

diagnosis, 64a

pathology, 639

prognosis, 640

symptoms, 639

treatment, 640
Imtable vascular excrescence of urethra, 613
Ischiocavemosi musdes, 781
Ischiorectal fistula, diagnosis, 71
Isthmic pregnancy, 558

JUGULO-SVUPHysiS measurement, 1030

Kellv's irrigating or surgical pad, j6
metalijc ureteral catheter, 665
method of imgaling pelvis of kidney, 6S1
operation for retrod isplacement of uterus,

353
for vesicovaginal fistula, 760
proctoscope, 73
sigmoidoscope, 73
sphincleroscope, 73
ureteral searcher, 621
urethral dilator, 586
wax-tipped ureteral sound, 666
Kidney, floating, 1038
movable, 1028
nephrorrhaphy, 1034
Knee-chest position, 34

arrangement of sheet and clothing, 35
elevated, 35
position of patient, 34
Kobett's tubules, 545
Kraurosis vulvic, 186
cause. 186
definition, 186
diagnosis, 186
pathology, 186
prognosis, 1S6
sjTnptoms, 186
treatment, i36

Labia majora, abnormal situatioti, 158
absence, 158
development, 154

Labia majora, hyc
hypertrophy,
malformation!
multiple, 158
rudimentary,
minora, absence
adherent, 158
development,
hypertrophy,
malformation!
multiple, 158
rudimentary,
Ijibor, bad manaj
ease, :4i
injuries resulting
Lacerated wounds
of vulva, 169
. definition, i
symptoms,
treatment, i
Lacerations of cer
causes, 448
definition, 44S
diagnosis, 451
differential di
iimnediale^ op
intermediate <
pathologic chl
prognosis, 4S^
results, 451
selection of oj
symptoms, 4S<
treatment, 453
varieties, 449
of pelvic floor, \
of perineum, 78,
Lamp, alcohol, 821
Laplace's forceps, 1
Latent gonorrhea,
Left hypochondria
iliac region, con
lateral -prone po
arrangemen
position of ]
lumbar region, t
Lembert suture, ct
interrupted, 9i
Leukocytosis, 53
causes, 53
clinical varieties,
cold-baths, effec
definition, 53
effect of dissolut

INDEX.

1063

Leukocytosis, electricily, effect upon, 53

hot bnths, effect upon, 53
in infants, S3
in malignant disease, s&
in septic infection, s^
in tuberculosis, 57
massage, effect upon, 53
number of leukocytes in, S3
significance, 53
Leukopenia, significance, 53
Levator ani muscle, 783
Licben of vulva, 216

x-rays in, 77
Linen duster for visitors, 833
Lipoma of bladder, 649
of broad ligaments, 550
of Fallopian lubes, 503
of vulva, 196
Liquid diet, 106

soap as a lubricant, 24

sterilization, S14
white vaselin as a lubricant, 15
Litholapaxy, 647
Lithopcdion, 562

Localized abdominal and pelvic infection,
864
diagnosis, 865
prognosis, 865
symptoms, S64
Irealmenl, 865
Locating a ureteral obstruction, 668
Lubricants used in gynecologic examinations,

glycerin, use in cancer, 25
liquid soap, 14
liquid 'while vaselin, 25
advantages, 25
method of applying, 14
method of preparing, 25
tincture of green soap, 25
vaselin and oily substances, 34
Lumbar incision to e»pose ureter, 68;
Lupus vulgaris, 739
3c-rays in, 76

Mackenrodt's operation for vesicovaginal

fistula, 763
Male false hermaphroditism, 163
Malformations of bladder, 626

absence. 616

divided, 626

exstropliy, 626

Malformations of cervix, 313
absence, 313
atresia, 313
conical shape, 313
defective development, 313
double OS uteri, 3(3
elongation, 313
hypertrophy, 313
pinhole 05, 313
stenosis, 313
of clitoris, 155
absence, r55
adherent prepuce, 156
atrophy, 155
cleavage, 155
hypertrophy, 155
redundant prepuce, 156
of Fallopian tubes, 4S3
absence, 483
accessory, 484
accessory ostia, 484
anomalies in size and shape, 483
displacements, 484
rudimentary, 483
supernumerary, 4S4
of hymen, 159
abnormal openings, 159
absence, 159

anomalies in structure and shape, 159
imperforate, 160
rudimentary, 159
of labia majora, 158

abnormal situation, 158
absence, 158
hypertrophy, 158
multiple, 158
rudimentaty, 158
of labia minora, 156
absence, 156
adherent labia, 158
hypertrophy, 156
multiple, 158
rudimentary, 156
of ovaries, 504
absence, 504
accessory, 504
displacements, 504
rudimentary, 504
supernumerary', 504
of ureters, 673

abnormal implantation of orifices, 673
duplication, 672
occlusion, 674

io64

INDEX.

Malfonnalions of urethra, 590

atresia, 5gi

complete or partial absence, 590

epispadias, 592

hypospadias, 591
of uterus, J09

absence, 31]

anomalies of cervix, 313

bicomis, 3 1 1

didelphys, 310

double, 310

duplex, 310

fetal, 31a

infantile, 312

m :mbranaceous, 311

one-homed, 311

pubescent, 312

rudimentary, 311

septate, 310

septus, 310

subscptus, 311

two-horned, 311

unicornis, 311
of vagina, 234

absence, 336

blind pouches, 238

double vagina, 234

persisleni cloaca, 234

stenosis, 237
of vulva, 154

abstntc, i!;4

double, 155

infantile, 155

precocious development, 155
Malignant disease, hluod-changes in, 56
Mann's method of shortening round liga-
ments, 358
Marriage in relation to disease, 142
Mask (Ashton's) for administering oxygen,

84.
Massasoit spring, [oi

analrai.s, 101

use, 100
McKelway's [)ortable Trendelenburg frame,

'>S°
Mechanic sterilization, 81*
apiiliances, Sit
definition, 8to
lime rci|uirfd, 81 1
VLilue, 811
Mechanism ol pelvic floor, 782
Median abdominal incision, 883
enlarging, 886

Median abdominal incisioD, hemorrhage, SBj
in fat women, 886
length, 883
limitations, 883
method, 884
position, S83
Medicated vaginal douche, 94
Melena neonatorum, 699
Membranous cystitis, 629

dysmenorrhea, 719
Menopause, 694
definition, 694
diagnosis, 6g6
duration. 695

in relation to history taking, 145
physical changes, 695
prc^osis, 697
symptoms, 695
synonyms, 694
lime, 694
treatment, 697
Menorrhagia and metrorrhagia, 700
causes, 700
description, 700
diagnosis, 703
pathologic significance, 145
prognrsis, 703
symptoms, 703
treatment, 703
Menstrual disorders, 69S
amenorrhea, 706
delaved menstruation, 699
dysmenorrhea, 718
menorrhagia, 700
metrorrhagia, 700
precocious menstruation, 698
retarded menstruation, 699
supplementary menstruation, 717
vicarious menstruation, 717
Menstruation, 692
acute suppression, 711
changes in organs of generation, 691
character of flow, 692
definition, 692
delayed, 699
duration of flow, 693
length of menstrual life, 693
management, 693
painful, 718
precautions during, in relation to disease,

158
precocious, 698
c]uantity of flow, 691

INDEX.

1065

Menstruation, rccumna of Qow, 691
lelardeii, 699
scanty, 706
supplementary, 717
synonyms, 693
vicarious, 717
Mensuration ot abdomen, 67

&xed points of measurement, 67
informalion, 67
measurements, 67
position of patient, 67
Method o( determining which ureter is
injured, 679
of locating a ureteral obstruction, 668
of obtaining separate urines by catheteri-
zation, 668
Methods of sterilization, 807

boiling aqueous solution of carbonate

of soda, 810
chemic, Si i

high-pressure steam, 807
mechanic, 810
Metrorrhagia, 700

pathologic significance. 14J
Microscopic ejtaminations, 37
general considerations, 37
discharges, 43
antisepsis, 43

equipment and instruments, 41
glands of Skene, 44
information for patholt^t, 45
method of collecting discharges, 43
method of smearing glass slides, 43
position of patient, 43
preparation of patient, 43
shipment to laboratory, 45
technic, 43
urethra, 43
uterus, 44
vagina, 44
vulva, 43

vulvovaginal glands, 44
tissues, 38
curetment, 38

collecting curet scrapings, 38
equipment, 38

information for pathologist, 39
preserving fluid, 39
shipment to laboratory, 39
techniCi 38
fiagment, 39
after-treatment, 41
anesthesia, 39

Microscopic examinations, tissues, fragment,
final sterilization, 39
information for pathologist, 41
instruments, 40
number of assistants, 39
operation, 40
position of patient, 39
preparation of patient, 39
preserving fluid, 4!
shipment to laboratory, 41
special directions, 40
technic, 39

variations in technic, 41
growth, 41

information for pathologist, 4a
preserving fluid, 41
shipment to laboratory, 4 1
technic, 41
Minor operations in private hotises, 951
Moist warts of vulva,. 203
Movable kidney, 1038
after-treatment, 1041
body form, io»8
body indei, 1039
causes, 1038
diagnosis, 1033
symptoms, T030
treatment, 1033
variations in technic, 1041
Mucous patches of vulva, 301
Mullilocular ovarian cysts, 533
Multiple labia majora, ijS

minora, 158
Murphy's button, 93S

intestinal clamps, 910
Muscles of pelvic floor, 781
buiboravemosi, 78*
ischiocavemoai, 783
levator ani, 7S1
sphincter ani, 783
transverse perineal, 78a
Myoma of bladder, 649

of ovaries, 517
Myomectomy, abdominal, loio
Myxoid cystomata, 533
Myxomatous degeneration in uterine fibroids,
373

Nausea and vomiting (post -operative), 850

treatment, 851
Necrobiosis in uterine fibroids, 373
Needles, intestinal, 919

io66

INDEX.

Neoplasms of bladder, 649
diagnosis, 651
prognosis, 651
symptoms, 650
treaimcnt, 652
varieties, 64^
of Fallopian tubes, 503
of ureters, 686
symptoms, 686
treatment, 687
Nephroptosis, 10 28
Nephrorrhaphy, 1034
Nephro-uretcceclomy, 678
Nitrous uxid gas in gynecologic examina-
tions, 21
Nobscol Mountain spring-water, 101
analysis, 101
use, 100
Noma pudcndi, 171
Normal position of uterus, 31S
sail solution, 116

effect of, upon blood-changes, 53
Nubility, 601
Nutritive enemata, 115
administration, ti6
antbcpsis, 116
apparatus, ti6
catE of rectum, 115
formula?, it6
quanlitv, 1 16
temperature, 1 16

Obtainini; scparalt urines by catheteriza-
tion, 6fiS
Occlusion nf ureters (congenital), 674
by external pressure, 687
causes, 687
descriptions, 687
symptoms, 687
treatment, 687
Office examining table (Ashton's), 17

sterilizer, 33
O'Hara's forceps, 031
Ono-horned uterus. 31 r
Oophoritis, 504

0|>eralinK accommodations, 817
operating ri)om, 817
sterilizing room, 8ii
storage room, S2I
wash rixjm, 821
cap, 8[4
gown, 817
paraphernalia, 823

Operating room, S17
buckets, 820
description, 817
equipment, S18
instrument table, 819
operating table, 818
sterilization, S21
stools, 819
supply table, Sio
. temperature, 821
washstands, S30
shoes, 814
suit, 814
Operations in private houses, 944
Operative complications, 907

accidents in opening abdomen, 908

adhesions, 910

classification, 908

escape of viscera, gta

bemorrhage, 913

injuries of intestines, 915

vomiting and contraction of abdomiDal

nails, 909
wounds of bladder, 914
of ureters, 915
Otis's dilating urethrotome, 398
Ovarian adenomata, 522
cysts, 510

absence of fluctuation, 64
character of Ductualion, 64
crepitation, 64
mensuration, 68
ectopic gestation, 556
ligaments, 551
tumors. 53 r
Ovaries, 504
diseases, 504
examinalion, 479
malformations, 504
tuberculosis. 74c)
Ovariotomy, 978
Ovaritis, 504
synonyms, 504
^'arictics. 504
Oviducts. 483
diseases, 484
examination, 479
malformalions, 4S3
tuberculosis, 747
Ovulation, 694

Fads (gauze), 826

Pain as a symptom of disease, 149

INDEX.

lOO;

Pain as a symptom of disease, situations, 149
Painful tumors of urethra, 6ij
Palpation of abdomen, 60
infonnation, 60

consistence of a tumor, 64
crepitation, 64

local tenderness or peritonitis, 64
presence of a tumor, 61
shape and mobility of a tumor, 6]
situation and origin oF a tumor, 6a
position of patient, 6a
tcchnic, 61
of vulva, 153
Panhystereclomy, 996
Papillary cysts, 514
causes, 524
description, 514
vaginitis, 171
PapillomH of bladder, 649
of Fallopian tubes, 503
Paquelin's cautery, 829
Parmelee water still, 100
Parodphorilic cysts, 524
Parovarian cysts, 545

varicocele, s*9
Parovarium, 545
Partial hysterectomy, 9S4
Pasteurized milic, 107

compared with sterilized, 107, 108
cotton batting plugs, 107
preparation, 107
sterilization of bottles, 107
Pelvic connective tissue, SS'
suppuration, 552
diaphragm, 781
Boor, 781
anatomy, 781
mechanism, 782
puerperal injuries, 784
hematocele, 560
Percussion of abdomen, 65
information, 65

presence of a tumor, 65
shape of a tumor, 67
situation and origin of a tumor, 66
position of patient, 65
technic, 65
Perineum, 781

lacerations, 784
Periods of life as a cause of disease, 144
Peritoneum, toilet, 891
Peritonitis, auscultation, 68
crepitation, 64

' Peritonitis, general septic, S61
position of patient, 60
septic, 86:
traumatic, 860
Pessary, action, 352
adjustment, 350
care, 35 1
cup pessary, 335
external support, 335
introduction, 349
Skene's, 25 7
Smith -Hodge, 349
Thomas, 349
Phagedenic ulcers of vulva, 201
Phlegmasia alba dolens, S74
Pin-hole as uteri, 313
Pitchers, 825

Poland Springs water, loi
analysis, loi
use, roi
Polypi of urethra, 615

of uterus, 370
Position of uterus, 318
Positions, gynecologic (yiiie postures), 29
Post-climacteric endometritis, 439
Posterior versions and flejiions of uterus, 331
causes, 339
definition, 339
diagnosis, 344
differential diagnosis, 345
frequency, 339
prognosis, 345
symptoms. 343
treatment, 346
Postures, gynecologic, 29
dorsal, 30

elevated, 30
dorsosacral, 30
elevated, 32
erect, 32

horizontal recumbent, 37
knee-chest, 34
elevated, 35
lateral -prone, 35
semi -prone, 35
Sims's, 35
Precocious development of vuiva, 155
menstruation, 698
causes, 698
definition, 698
diagnosis. 699
frequency, 6g8
results, 698

io63

INDEX.

Precocious menstruation, treatment, 6^
Pregnancy, auscultation, 68

mensuration, 68
Preparations, abdominal operations, 834, S37

anesthesia, Sj6

assistants, 838

bladder, 836

bowels, 833

confinement in bed, 834

conlcnis of conveyance boxes, 838

diet, 834

examination of general system, 834

final slenlization of patient, 836

general summary, 838

instruments, 838

kidneys, 835

length of preparation, 834

needles, 838

operating room, 837

plan of operation, 839

precautions against infection, 839

protecting field of operation, 837

slerilizalion of patient, 836

sutures, 838

visitors, 839

wash room, 838
gynecologic examioalions, 13

bladder, 23

clothing, 24

intestines, 14

rectum, 23

vagina. 24

vulva, 24
minor operations, 830, 831

anesthesia, 831

bladder, 830

bowels, 830

confinemenl in bed. 830

contents of conveyance boxes, 832

diet, 330

examination of general system, 830

final sterilization of patient, 830

genera] summary, 831

instruments, 832

lingth (if preparation, 830

needles, 832

numlwr of assistants, 832

Ojieraling room, R31

plan of operation, 833

pnilecting field of operation, 831

slerilizalion of patient, 830

sum res, 832

visitors, 833

pTeparaikins, minor operations, wash toon,

operator and assistants for opcrstica, St4
personal cleanliness, 814
immediate preparations, 814
Prepuce, adherent, 156

redundant, 156
Piimaiy ectopic gestation, 556

operations for tears of pelvic floor, 7S7
Prolapse of anterior wall of vagina, 246
of bladder, 146
of ovaries, 511
causes, 511
diagnosis, 511
differential diagnosis, 511
operation, 580
prognosis, 512
symptoms, 512
trealmenl, 512
of posterior wall of vagina, 257
of urethral mucous membrane, 601
causes, 601
definition, 601
description, 601
diagnosis, 602
prognosis, 602
symptoms, 602
treatment, 603
of uterus, 324
causes, 325
definition, 324
diagnosis, 326
differential diagnosis, 328
patholog}', 334
prognosis, 319
symptoms, 325
treatment, 329
Proliferous glandular cysts of ovaries, 521
Prurigo of vulva, 216

i-rays in, 77
Pruritus vulva;, 18a
causes, 181
definition, 182
diagnosis, 184
prognosis, 184
symptoms, 183
irealmeni, 184
3r-rays in, 77
Pseudo -diphtheria of vulva, 120
causes, 220
diagnosis, 231
symptoms. 221
treatmenl, 221

INDEX.

1069

pMudo-hennaphroditism, 163
Puberty, 6q:
age, 691
changes, 691
definition, 6gi
duration, 691

in relation (o history taking, 145
management, 691
Pubescent uterus, 311
Puerperal atrophy of uterus, 446
injuries, pelvic floor, 7S4
classification, 784
intermediate operations, 794
lateral tears involving vaginal sulci,

785
median tears involving the sphincter

ani, 785
primar\' operations, 7S7
secondary operations, 795
superficial tnedian tears, 7S4
treatment, 787
Punctured wounds of vulva, 170
definition, 170
symptoms, 170
treatment. 170
Purulent salpingitis, 487
causes, 487
diagnosis, 496
extension of infection, 491
extra-tubal results, 491
hematosalpinx, 490
hydrosalpinx, 490
pathology, 48S
prognosis, 501
pyosatpinx, 490
symptoms, 494
treatment, 501
Putrid intoidcation, 431
Putting on operating gown, S16

on rubber gloves, 816
Pyocolpos in imperforate hymen, 161
Pyomelra in imperforate hymen, 161
Pyosalpinx, 490
in imperforate hymen 161

Rectal touch, 70

anesthesia, 70
information, 71
invagination of perineum, 70
limitations, 70
position of patient, 70
technic, 70

Rectocele, 257

causes, 157
definition, 257
diagnosis, 260
frequency, 258
prognosis, 261
results, 160
symptoms, 259
synonyms, 257
treatment, 162
Rectolabiat fistula, 773

definition, 773

treatment, 773
Rectoperincal fistula, 773

definition, 772

treatment, 772
Rectovaginal fistula, 769

causes, 769

definition, 769

description, 769

diagnosis, 769

prognosis, 770

symptoms, 769

treatment, 770
Rectum, direct inspection, 68
examination, 68
indirect inspection, 73
in imperforate hymen, 161
preparation of, for gynecologic elamina-

tion, 23
probing, 7r
rectal touch, 70
vaginal touch, 71
Redundant prepuce, r56
Reed's operation for varicocele of broad

ligament, 550
rubber T-drainage tubes, 903
Removal of intraligamentous uterine fibroid,

991.994
cyst, 982

operation, 981

special directions, 984
of ovarian cyst, 978

instruments, 979

number of assistants, 978

operation, 979

position of patient, 978

special directions. 982

variations in technic, 981
of uterus for diseased appendages, 569
Replacement of inverted uterus (acute),
36 J (chronic), 365
of retrodisplaccd uterus, 346

loyo

INDEX.

Replacement of retrodisplaced uterus, bi-
manual, 346
knee-chest position, 349
Resection of Fallopian tubes, 579

of ovaries, 579
Rest in relation lo disease, 140
Retarded menstruation, 699
Retentive power of abdominal cavity, 116,

3J0
Right hypochondriac region, contents, 57
iliac region, contents, 58
lumbar region, contents, 57
Robb's leg-holder, 31

use of, in dorsosacral position, 3a
Rochester sterilizer, 949
Round ligaments, 551

Mann's method of shortening, 358
tumore, SSI

Wylie's method of shortening, 357
Rubber drainage, 903
tubes, 814
gloves, 837

in gynecologic examinations, 33
Rudimentanr clitoris, 155
Fallopian tubes, 483
hymen, ijg
labia majora, 158
labia minora, 156
□varies, 504
uterus, 311

Sa<xui.ated urethra, 608
Saline injections, 116
enlcroctysis, 135
general indications, 08
hypodermoclysis, 131
intravenous, 139
preparation at time of operation, 117

of solution, 126
routes of entrance into circulation, 138
temperature of solution, 1J7
Ihcrroometer, r27
Salpingitis, 484
causes, 4S4
definition, 484
varieties, 48s
Salpingo-oOphorectomy, 973
definition, 973
instruments, 974
number of assistants, 973
position of patient, 973
operation, 974
special directions, 978

Salpingo-odphorec ti

977
Salt bath, 90
action, 90
technic, 90
Sapremia, 43a
Sarcoma of bladder
of hroad ligamer
of Fallopian lubi
of ovaries, 517
of urethra, 615
of uterus, 414
causes, 414
causes of dcatl:
diagnosis, 415
differential dia{
extension, 414
pathology, 414
prognosis, 416
recognition ol
uterine tissui
symptoms, 415
treatment, 416
of vagina, 394
causes, 194
diagnosis. 195
differential dia|
prognosis, 295
symptoms, 194
treatment, 395
of vulva, 199
causes, 199
diagnosis, 100
prognosis, 300
symptoms, 199
treatment, 300
varieties, 199
jt-rays in, 76
Sarcomatous degeni

373
Scarification of ceri
Sea-bathing, 91
technic, 91
value, 9 1
Secondary changes
ectopic gestation,
hemorrhage, 854
diagnosis, 854
prognosis, 854
symptoms, 834
treatment, 854
operations for te^
Segregation of urin

l^k

INDEX.

1071

bemi'proiie position, 35
ScQile eadometriiis, 439
causes, 439
definilion, 439
diagnosis, 439
differenlial diagnosis, 440
pathologic changes, 439
prognosis, 440
symptoms, 439
treatmtni, 440
hydromcLra, 439
pyomeira, 439
vaginitis, 173
causes, 173
definition, 273
diagnosis, 374
prognosis, 374
symptoms, 173
synonyms, a 73
treatment, 474
Sepsis after labor a cause of disease, 142
Septate ulenis, 310
Septie endometritis, 431
causes, 431
definition, 431
diagnosis. 434
difFerential diagnosb, 435
prognosis. 435
symptoms, 432
treatment, 436
infection, 431

blood •changes, 56
inloxieation, 432
Se:(uai intercourse as a cause of disease, 142
Sheet bath, 89
aaion, 89
technic, 69
Shober's cannula for intravenous injections,

129
Shock, 857

Crile's observations, 859
diagnosis. 858
prognosis, S58
symptoms, 857
treatment, 859
wounds of vulva, 166
Silk ligatures and sutures, 824
Silli worm -gut, S25
Simple catarrhal vulvitis, 17a
causes, 172
definition, 172
diagnosis, 173
prognosis, 173

! Simple catarrhal vulvitis, symptoms, 173
treatment, 173
varieties, 173
dermatitis ot vulva, 116
causes, aj6
definition, 216
prognosis, 116
symptoms, 116
synonyms, iiS
treatment, 116
endometritis, 417
ulcer of bladder, 630
vaginitis, 367
causes, 267
definition, 267
diagnosis, 169
diScrential diagnosis, 169
prognosis, 17a
symptoms, 26S
treatment, 270
varieties, 267
Sims's glass vaginal plug, 1x4

position, 35
Sinus tracts in abdominal wall, 87S
causes, 8 78
prognosis, 879
treatment, 8 79
Siti-batli, 87
action, 87
alkaline, 213
apparatus, 87
cold, 87
emollient, 213
graduated, 87
hot, 87

stimulating, 214
varieties, 87
Skene's bivalve urethral speculum, 595
pessary, 257

rcflun urethral catheter, 395
Soap, sterilization, 814
Social condition as a cause of disease, 137
Soft diet. III

Solid tumors of ovaries, 316
Sounding bladder, 6t8
ureters, 663
urethra, ;88
Special operations. 955

abdominal myomectomy, loio
catheterization of bladder, ion
clitorideclomy, 961

combined vaginal and abdominal hyster-
ectomy, 1009

1072

INDEX.

Special operalions. complele abdominal hys-
terectomy, 99G
dilatation and curetment of uterus. 955
encbion of vulva, 963
incomplete abdominal hysterectomy, 984
removal of cystic tumor of ovary, 978

of intraligamentous cyst, 983
salpingo-oOphoreclomy, 973
suprapubic cystotomy, 965
vaginal cyslolomy, 970
vaginal hysterectomy with clamps, 999
with ligatures, 1006
Sphincter ant muscle, 781
Spohn's infected ligature snare, S79
Sponge bath, 84
action, 84
alternating, S4
cold, 84
graduated, 84
sponging in bed, 85
varieties, 84
Sponges (gauze), S26
Spray balh, 85
action, 86
adjustable shower bath, 85

spray, 85
alternating, 87
apparatus, 85
cold, 86

fountain syringe, 85
graduated, 87
permanent plumbing, 85
Scotch douche, 87
variclLts. 86
SprinkliT-tup biiltle, Sii
Stenosis of ccrviit (congenital). ,li.l

of vagina (acquired) 242, (congenital) 237
Sterility, 775
causes, 775
definition, 775
diagnosis, 770

in relation to htston' taking, 146
prognosis, 779
treatment, 78a
Sterili-^ation:
abdominal dressings, 8t4
irrigator, 811

operations in private houses, 94^
absorbent cotton, S14
apparatus for enleroclysis, 1,15

for hydrostatic dilatation of bladder, 619

for hi'|ioderniorlvais, 132

for iTilravenous injections, 129

Sterilization: apparatus for nutrient «>»■

mata, 116
basins, 813
bandages, 813
boiling aqueous solution of crarbonate of

soda, Sio
bnjshes, S14
catgut, 811
catheters, S14
chemic, 811
cold water, S14
cotton batting, 813
cystoscope, 623
examiner's hands, 12
gauze compresses, 813

pads, 813

sponges, 813

tampans, 813
general irrigator, 813
glass catheters. 814

drainage-tubes, 814

slides for microscopic examinations, 4]
hands and forearms of operator and

assistants, 815
hard soap, 814
Harris's segregator, 669
bigh-prcssure steam, 807
hoi water, 814

hypodermic syringe and needle, 813
instruments for catheterization of ureters.
6fi5

for cystoscopy, 633

tor general uses, 811

for sounding bladder, 619

for sounding ureters, 665

for sounding urethra, 588

for sounding uterus, 309

for urethroscopy, 5S7
liquid soap. 814
mechanic, 810
methods, 807
milk, 107

minor o(>erations in private houses 051
needles. 812

normal salt solution. t26
office hand-brushes, 22

instruments, 23

rubber gloves, 23
o|)crating gowns, 813

room and equipment, 821
patient, abilominal operation. 836

minor operations. 830
pipcts (or bacteriologic e^camina lions. 46

INDEX.

1073

Sterilization: pitchers, Si 3
rubber drainage syringe, S14

drainage-tubes, Si 4

gloves, 813
safety-pins, S14
sheets, 813
silk ligatures and sutures, 813

ureteral catheters, 66j
silkwoim-gut, 811
sterilising room, Sti
storage room, S22
surgical rubber pad, S13
thermometer for saline injections, 137
towels, 813
urethroscope, 587
wash room, 811
Sterilized milk, 107

compared with Pasteurized, 108

preparation. 107
Sterilizer for dressinp, high- pressure steam,

807
Sterilizing room, Si 3

care, 822

description, 82 3

equipment, 8:i

high-pressure steam sterilizer, 821

instrument sterilizer, 822

water sterilizer, 82 1
Stimulants, cardiac and respiratory, 819
Stimulating sitZ'bath, 114
Stitch-hole abscess, S7J

causes, 875

diagnosis, 875

prognosis, 87;

symptoms, 875

treatment, 875
Storage room. 8]i

care, 813

description, S21

equipment, 833

storage case, 833

washsland, S13
Stricture of ureters, 679

causes, 679

description, 679

diagnosis, 679

symptoms, 679

treatment, 680
of urethra, 596

causes, 596

description, 596

physical signs, 597

prognosis, 597
68

Stricture of urethra, symptoms, 596

treatment, 597
Subcutaneous wounds of vulva, 168
definition, 168
symptoms, 168
trealmenl, 16S
Subinvolution of uterus, 441
causes, 443
definition, 443
diagnosis, 444
pathologic changes, 443
symptoms, 444
treatment, 445
Submucous uterine fibroids, 370
Subperitoneal uterine fibroids, 369
Substitute for Kelly's pad (Ashlon's), 36
Suburethral abscess, 613
causes, 611
description, 611
physical signs, 613
symptoms, 613
treatment, 613
Superinvolution of uterus, 446
causes, 446
definition, 446
diagnosis, 447
differential diagnosis, 447
pathologic changes, 446
prognosis, 447
symptoms, 447
synonyms, 446
treatment, 447
Supernumerary Fallopian tubes, 484

ovaries, 504
Supplementary menstruation, 717
Supports of uterus, 31S
Suppositories in constipation, 104
Suppression of urine (post-operative), 873
causes, 873
symptoms, 873
treatment, 873
Suppuration of abdominal wound, 876
causes, 876
diagnosis, 877
prognosis, 877
situation, S76
symptoms, 876
treatment, 877
of pelvic connective tissue, 553
causes, 552
diagnosis, 553
pathology, 551
prognosis, 553

1074

DTOEX.

Suppuradon of pelvic connective tissue,

symptoms, SS3
treatment, 553
Suppurative appendicitis, operative tecbnic,
1027
cystitis, 619
Suprapubic cystotomy, 965
after-treatment, 970
definition, 965
instruments, 966
number of aasittanta, 966
operation, 967
position of patient, 966
preparation of patient, 965
variations in technie, 969
Supravaginal amputation of uterus, 9A4
tyrpertrophy of cervix, 46s
causes, 463
defimtioD, 461
diagnosis, 463
pathologic changes, 461
prognosis, 463
symptoms. 461
treatment, 463
Sutures, intestinal, gii
Syphilides of vulva, xoa
treatment, 301
varieties, 10 »
Syphilis as a cause of disease, 143

Tampons, 826
T-bandage, 837
Tears of peivic floor, 784
Technie of abdominal and pelvic operatioiis,
834
after-treatment, 841
general operative technie, 883
operative complications, 907
post-opetative complications, 850
preparations for operation, S37
preparation of patient, 834
of minor operations, S30

preparation of patient, S30
preparations for operations, 831
of special operations, 955

abdominal myomectomy, loio
calhelerizalion of bladder, lOit
ditoridectomy, 961
combined vaginal and abdominal

hysterectomy, 1009
complete abdominal hysterectomy,
996

Technie of specia

eiu^tmer
cxeisioo of
incomplete

984
removal of

of intrali
salpingo-oO
suprapubic
vaginal cys
vaginal li}

999

with li

Tenia echinococci

Thermometer, bat

for testing satim
Threading needlet
Thrombosis of fer

cause, S74
prognosis, 1
sympiomSj
synonyms,
treatment,

Thrwsh of vulva,
cause, 115
prognosis, 11;
treatment, 31

Tincture of green

Toilet of peritonei
dry sponging,
geacrai ttushi
local vnashing

Trachelorrhaphy,

Transverse perine

Traumatic peritoti
description, R
diagnosis, 861
prognosis, &61
symptoms, 86
treatment, 86

Trendelenburg po
advantages, 8
degree of elei
precautions, f

Trichiasis of vulvi
definition, 18^
diagnosis, iS;
prognosis, 18;
symptoms, i!
treatment, 18

True hermaphrod
septicemia, 431

Tubal abortion, 5

INDBX.

I07S

Tubal geitatioD, 556

ampullar, 55S

causes, 556

changes in uterus, 561

classification, 558

courae, 558

diagnosis, 565

history of ovum, 561

interstitial, 558

isthmic, 558

physical developmeat of fetus. 561

symptoms, 563

treatment, 5M
Tuberculosis of genital organs, 7j8
Uood-changes in, 57
causes, 7j8
of cervix, 744
diagnosis, 744
dlfierential diagnosis, 745
frequency, 744
symptoms, 744
treatment, 745
of Fallopian tubes, 747

description, 747

diagnosis, 748

prognosis, 749

qrmptoms, 748

treatment, 749

vatieties, 747
of ovaries, 749
description, 749
diagnosis, 750
pathology, 749
symptoms, 750
treatmetil, 750
prognosis, 750
of ureters, 689
causes, 689
diagnosis. 69a
pathology. 689
prognosis, 690
symptoms, 690
treatment, 690
of uterus, 745
description, 745
diagnosis, 746
differential diagnosis, 746
s^ptoms, 746
treatment, 746
*arieties, 745
of vagina, 741

differential diagnosis, 743
frequency, 743

Tuberculosis of vagina, method of ialectloia,
74a
prognosis, 743
symptoms, 74*
treatment, 744
of vulva, 739
diagnosis 740
differential diagnosis, 741
prognosis, 741
symptoms, 739
synonyms, 739
treatment, 741
x-myt in, 76
Tumors of clitoris, aoj
treatment, 107
varieties, 107
of ovarian ligaments, 551
of round ligaments, sji
of vulva, 195
angioma. 196
benign, 195
fibroma, 196
lipoma, 196
mixed growths, 196
myoma, 196
myxoma, 196
neuroma, 196
Turkish bath, 88
action, 88

apparatus for use at home. 88
Ashton's method of airanging interior

of bath cabinet, 88
technic, 88
Turpentine stupe, 854
Two-horned ute^u^ 311
Tympany (post-operative), 853
treatment, 853

UuBiUCAt region, contents, 58

Unhygienic conditions as causes of diseases

peculiar to women, t38
Ureteral calculus, 683

stricture, 679

tuberculosis. 689
Ureteritis, 688

causes, 688

diagnosis. 6S8

pathology, 688

prognosis, 6B9

symptoms, 688

treatment. 6S9
Ureterocystotomy, 677

1076

INDEX.

I I

.'1

Ureteron-haphy, 676

Ureterostomy, 677
Uretero-ureteroslomy, 676
Uretero-ulerine fistula, 769
Urcterova^nal fistula, 768
Ureters, 657

accidental ligation, 678
diseases, 679
injuries, 674

during an abdominal operation, 915
malformations, 671
methods of examination, 657
Urethra, 583

collecting discharges for bactcriologic
examination, 49
tor microscopic examination, 43
diseases, 593
malfonnations, 590
methods of examination, 581
Urethral caruncle, 613
Urethritis, 593
causes, S93
physical signs, SM
prognosis, 593
symptoms, 593
treatment, 594
Urethrocele, 608
causes, 608
definition, 60S
differential diagnosb, 610
physical signs, 609
prognosis, 610
symptoms, 60S
synonym, 60S
treatment, 61 1
Urethroscopy, 585
Urethrovaginal fistula, 76S
causes, 7^
definition, 768
diagnosis, 768
prt^nosis, 768
symptoms, 768
treatment, 768
Urinal, ambulatory, 764
Urine, suppression (post-operative), S73
Urogenital sinus, 158
Uterine colic, 721
fibromata, 36S
fibroids, 368
ligaments, 479
examination, 479
Uterus, 196
bicomis, 311

Uterus, collecting discharges for bacteriabgic
examination, 50
for microscopic examination, 44
cordifonnis, 311
development, 309
didelphys, 310
diseases, 313

dilatation and curetmcnt, 955
displacements, 318
duplex, 3ro
foreign bodies, 315
in imperforate hymen, 160
injuries of body, 313
malfonnations, 309
membranaceous, 311
methods of examination, 196
position, 318

removal for diseased appendages, 569
septus, 310
subseplus, 311
supports, 31S
tuberculosis, 745
unic33rms, 311
x-rays in cancer, 75

Vaoika, ais
collecting discharges for bacteriologic
examination, 50
for microscopic examination, 44
development, 134
diseases, 141

in imperforate hymen, 160
malformations, 334
niethods of examination, 115
prolapse of anterior wall, 146
sterilization of, for a gynecologic ezam-

inalion, 14
tuberculosis, 743
wounds, 238
j-rays in cancer, 76
Vaginal cystotomy, 970

definition, 970

instruments, 971

number of assistants, 971

operation, 971

position of patient, 971

preparation, 971
douche, 91

action, 91

apparatus, 9r

cleansing, 94

hot, 92

->l

INDEX.

ro77

Va^nal douche, medicated, 94
technic, 91
warm, 93
flatus, 395
causes, 195
dcBnition, 395
treatment, 196
hjsterectomy with damps, 999
after-treatment, 1005
definition, 999
instruments. 999
number of assistants, 999
operation, looi
position of patient, 999
variations in technic, 1005
with ligatures, 1006
after-treatment, 1009
de&nition, 1006
instruments, 1006
number of assistants, 1006
operation, 1007
position of patient, 1006
tampon, 177

method of maldng, 177
touch in rectal examinations, 71
Vaginismus, 33 1
causes, 3zi
definition, 331
diagnosis, 133
prognosis, 333
symptoms, »a
treatment, 131
Vaginitis, 366
adhesive, 373
causes, 366
definition, 366
emphysematous 374
gonorrheal, 371
granular, 373
papillary, 373
senile, 373
simple, 367
tubcrtular, 743
varieties, 367
Vaginorectal fistula, 769

diagnosis, 73
Van Hook's method of uretero-cystostomy,
676
of uretero-ureterostomy, 676
Varicocele of broad ligaments, 549
causes, 549
description, 549
diagnosis, 550

Varicocele of broad ligaments, progDOsis, 550
symptoms, 549
synonym, 549
treatment, 550
Varicose veins, 1S9
causes,. 189
definition, 1S9
prognosis, 190
results, 190
symptoms, 190
treatment, 190
Vascular tumors of urethra, 613
Vaselin as a lubricant, 34
Vegetations of vulva, 303
Venereal affections as causes of diseases
peculiar to women, 143
ulcers of vulva, 300
warts of vulva, 303
Ventral fixation of utertis for prolapse, 331
hernia, 88 r
causes, 881
prognosis, SSi
symptoms, 883
treatment, 883
suspension of uterus, 353
Verruca, 303
acuminata, 303
causes, 303
diagnosis, 303
prognosis, 304
results, 104
symptoms, 303
treatment, 304
vulgaris, 303
Vertical and transverse tubules of parova-
rium, 545
Vesical calculus, 643
causes, 643
diagnosis, 644
prognosis, 645
symptoms, 643
treatment, 645
neoplasms, 649
Vesico-urethral fissure, S99
causes, 599
definition, 599
description, 599
differential diagnosis, 600
physical signs, 600
symptoms, 600
treatment, 600
Vesico-uterine fistula, 764
causes, 764

*il

'I,
i

1078

INDEX.

Vedco-uterine fistula, definition, 764

diagnosis, 764

prognosis, 766

s^ptoms, 764

treatment, 766
Vcaico-uterovaginal fistula, 76A

causes, 767

definition, 766

diagnosis, 767

prognosis, 767

symploms, 767

treatment, 767
Vc^covaginal fistula, 750

causes, 751

definition, 750

description, 750

diagnosis, 7J3

prognosis, 753

sjmptoins, 7SI

treatment, 754
hernia, 146
Vestibule, development, tjS
Vicarious menstruation, 717

definition, 717

diagnosis, 717

frequency, 717

prognosis, 717

dtuation, 717

symptoms, 717

treatment, 717
Vomiting during an abdominal operatjon,

909
Vulva, 15a
absence, 154

collecting discharges for bacteriologic
eiamination, 49
for microscopic examination, 43
diseases, 171
double, 15s
e;icision, 963
garrulity, 295
incontinence, 295
infantile, 155
malformations, 154
methods of examination, 151
precocious development, 155
sterilization of, for a gynecologic examin-
ation, 24
tuberculosis, 739
wounds, 164
i-rays in cancer, 76
Vulvar entcrocele, 194
entero-eptplocele, 194

Vulvar epipkicele, 194
Vulvitis, dermal, ai6
diabetic, 1 78
foUicular, 176
simple catarrhal, 17*
tubercular, 739
Vulvovaginal glands, collecting dtscharga
for examination, 44
cysts, 181
of duct, iSi
of gland, 181
ducts, inflammation, 180
inflammatioD, 179

Wandeking kidney, toaS
Warm vaginal douche, 93
Wash room, 822

care. Six

description, Sia

equipment, 83 a

lockers, 82 2

supply taUc, 833

wasbstand. Si 2
Water, drinking-, 98
action, 98
administration, lot
constipation, 10 1
disease. 98
distilled water, 100
excessive use at meals, 101
filtered, 100
importance, 98
in obesity, 101
natural waters, 101
purity. 99
quality, 99

special directions, lOO
spring-, TOi
sterilizers, 810
Wire cage for steam sterilizers, 80S
Wounds of vagina, 138

causes. 23S

prognosis, 240

results. 340

symptoms, 239

treatment. 140
of vulva. 164

aseptic, 168

causes, 164

classification, 16S

complications, 166

incised, 168

moex.

1079

Wounds of vulva, lacerated, 1:69

open, 166

punctured, 170

septic, 168

subcutaneous, 168

symptoms, 165

treaimeat, 166
Wylie's method of shortenitig round liga-
ments, 357

X-KAYS in gynecology, 75

acne, 77

X-nys In gynecology, cancer of uterus, 75

of vagina, 76

of vulva, 76
diagnostic value, 75
ecwma, 77
elephantiasis, 77
genilo-uiinary sinuses, 76
lichen planus, 77
prurigo, 77
pruritis vulv*, 77
sarcoma, 76
technic, 75
tuberculosis, 76

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yet by the UM of thin bible paper and flexible morocco binding it is only 1 )f
tnchct thick. The re»uU \a a truly laxurious specimen of book-making. In this
new edition the book has been thoroughly revised, and upward of 6fieeii hundred
new terms that have nppcared in recent medical lileraiurc have been added, ihits
bringing the book abMluiely up to date. The book contains hundreds of terms
not to be fntind in any other dictionary, over 100 original tables, and many hand-
lomc iUuui«lions. a number in colors.

PERSONAL OPINIONS

Howud A. V.tAXy. M. D..

•' Or. UottsAd 1 ilMtioAAry 11 ailminlitr It n 10 well goiiea up and of nicfc cooKBiat
tise. No nron ban bom lound tn my use et ll."

RMwrfl Park. M. D..

/^f/riur tf Priatiff'- «•■' finuUtt *f Strgtty mJ ^ OiMitMl AuryN?. £M*m«9 ^

' I nun MJUiowledfc mr uioatiliaMttl at techif ha* nucb he bu tondenied within r«k-
linlf SBall tpMC, I 6nd kotlilnfl lo crttKIK, nry much 10 cnmman'l. and wm\ inltmMd la
Awllac tama «r dH an aord* ohitb »n not iu ottiir nntii illeHonina.'*

i^^

lo SAUNDERS- BOOKS ON

Stevens'
Modern Therapeutics

A Text-Book ot Modern Materia Medica and Therapeutics. By

A, A. Stevens, A. M., M. D., Lecturer on Physical Diagnosis in the
University of Pennsylvania. Octavo of 670 pages. Cloth, ^3.50 net

JUST ISSUED— NEW (4tli) EDITION
Ad^tod to the N«w (1905) FharaMcopeia

Dr. Stevens, by his extenuve teaching experience, has acquired a clew,
concise diction that adds greatly to his work's pre-eminence. In this editioa
new articles have been added on Scopolamin, Ethyl Chlorid, Theocin, Veronal,
and Radium, besides much new matter to the section on Radiotherapy. The
numerous changes in name or strength of various drugs and preparations, as
called for by the new Pharmacopeia, have also been made. TT»c work inclades
the following sections : Physiologic Action of Drugs ; Drugs 1 Remedial Measures
other than Dnigs ; Applied Therapeutica ; Incompatibihty in Prescriptions ; Table
of Doses ; Index of Drugs ; and Index of Diseases ; the treatment being eluci-
dated by more than two hundred formulse.

OPINIONS OP THE MEDICAL PRESS

Uoivenily Medical Magazine

" Thf iuilhor has failhfiilly preientcd modern Iherapeuiici in a compreheniive work . . .
and it will be found a rirtiable guide and sufficiently eompreheniive for tlie pfijiician in
practice. '

Biirtol Medico-CZiimr^cal JotDHal, Briitol

"Tills addiilon lo the numerous works on Therapeutics is dislinctly a good one. . . . [i
Is to be recommended as being systematic, clear, concUc, very Curly up to date, and carefully
Indexed. ■■

Monro's Manual of Medicine it«G«tir i»a-d

Manual of Medicine. By Thomas Kirkpatrick Monro, M. A., M. D.,
Fellow of, and Examiner to, the Faculty of Physicians and Surgeons,
England ; Glasgow I'hysician to Glasgow Royal Infirtnary, Glasgow, etc
Octavo volume of 901 pages, illustrated. Cloth, (5.00 net.

THE VHACTKIi OF .MF.niCISE.

Hatcher and Sollmann's
Materia Medica

A Text-Book of Materia Medica: including Laborator>' Excreiscs
in thv Histologic and Chvniic Ivxaminiitioii of Drugs. Jly Robrxt A,
Haiciikk. Ph.G.. M. D,. of Comull LTnivi-rsily Medical School. New
York Ciiy ; and Tobald Sollmaxn. M , l>.. ..f the Western Rcscn'c Uni-
vcrsit>', CIcvebml. Ohio. i3moor4it im^^cs. Flex, leather, ;z.oo net

RECENTLY ISSUEI>-A NEW WORK

Thb wdtIc U a pnctical Icxt-lmok. Ircalin)* ihc Bubjcci by actual experunenia|
deinunsTraiions.

Joaraal of th* AmOTic&n M««lical AnociMiim

' 71u' iini.'k II v'li wiiiivii, ilio ilnuaAoaiiiMt an icomLand Itie book l> )o liemoiniii«ndtd
ai n practical cuide In Uic Ijtxinloiry uud)r u( malrtia mnlk.-i.''

Eichhorst's Practice

A Text-Book of the Prncticc of Medicine. By Dk. IIkkmann

Eichhokst. University of Zurich. Tran^slatcd .ind edited l»y Auiii»-
TUs A. EsH.SKR, M.I)., Professor of Clinici! Medicine, Philadelphia
Polyclinic Two octivos of 600 pages cnch, with over 150 iltustra-
lioiis. Per »et: Cloth, $6,00 net; Sheep or Half Morocco, S7.5O net.

BullMJii of John* Hopkim Hoipitel

" lint book i> *■• iKfllroi one u.f \\y kind, Im cumplcwoeH. ytt brciil]r. ih* cllsleal
molTicHlt. Ihc niccllrni [Miraeniitii Ota Ifulmrnl and wawring -phcn. wll] malic tl tcrj

Bridge on Tuberculosis

Tuberculosis. By N<)Rman Briogk. A. M., M.I)-. Kmcritus Pro.
lessor of .Medicine in Rush Medical College, in affili^ition wiUi tlie
University of Chicago. t2mo of 302 pages, iltustRilcd. Cloth.
$1.50 net.

¥tm»tM\ N««i, t««« York

" llxifonshlr rqMncnUllra o( our (XMtical oMfhodt of dagmiib and IKauasM a\ (he

13 SAUNDERS" BOOKS ON

Thornton's Dose-Book

Dose-Botdc and Maniul of [h-«scrlptloa-WritliiE. By E. Q. Thorn-
ton, M, D., Assistant Professor of Materia Medica, Jefferson Medical
College, Phila. Post-octavo, 392 pages, illustrated. Flexible Leather,
$2.00 net.

Just Issued— New (Sd) Edition

Dr. Thornton, in making this revision, has brought his book in accord with
the new (1905) Pharmacopeia. Throughout the entire work numerous references
have been introduced to the newer curative sera, organic extncts, synthetic com-
pounds, and vegetable drugs. To the Appendix, chapters upon Synonyms and
Poisons and their antidotes have been added, thus increasing its value as a botdc
of reference.

C. H. Mllhr, M. D..

Pn/tistr of Pharmatehgy. Norlltmtittr* l/nit/ersity MtdUal Sckml. Chitagt.

" I will be able to make coniidereble uu of that pari of its contents rrUtJng (o the e<HTect
tenuinology ai used in pieicnpdon-wriliiig, and It will affanl me much pleiuure to recomiceBd
the book to my classn, who often &il to find this infbnnBtion iti their other texl-books."

Barton and Wells' Thesaurus

A Thesaurus of Medical Words and Phrases. By Wilfhed M.
Barton, M. D., Assistant to Professor of Materia Medica and Thera-
peutics, Georgetown University, Washington, D. C- ; and Walter A.
Wells, M. D., Demonstrator of Ivaryngology, Georgetown Universitj',
Washington, D. C. i2mo of 534 pages. Fle.xible leather, $2.50 net;
with thumb index, $3.00 net.

" We can ca',ily ^ee the value of such a book, and can certainly recommend it to our
readers. " — Boston Mkihial ani) Ritruicai. Joitrnal.

Mathews' How to Succeed in Practice

How to Succeed in the Practice ol Medicine. By Joseph M.
Mathews, M. D., LLD., President American Medical Association.
1898- '99, l2mo of 215 pages, illustrated. Cloth, J 1.50 net.

Jelliffe's Pharmacognosy RMcndjimed

An Imriiduction lo I'harmacognosy. By SMITH Elv Jelliffe. Ph. D..
M, 1>.. Professor of Pharmacognosy and Inslructor in Materia Medica and
Thenipeiitics in Columbia 1,'niversity (College of Physicians and Surgeons),
New York. Octavo of 265 pages, illustrated. Cloth, (2. jo net.

Gould and Pyle*s
Curiosities of Medicine

AnomaKes and Curiosities of Mcdi«itw. By George M. Govld.
M.D., and Wau'E.k L. Pvle. M. D. An encyclopedic collection of
rare and c?:traordinary cases and of the most striking instances of
abnormality in all branches of Medicine and Sutgciy, derived from an
exhaustive research of medical literature from 'On origin to the present
day. abstracted, classified, annotated, and indexed. Handsome octavo
volume of 968 pages, 295 engravings, and 12 fiill-istge plates.

Popular E<l>lioo : Cloth. 13-00 ii«l i Simp or H*lf Morocco, U-OO *Mt.

Am a complMc «n<l latboriutive Bocik ol Referance this work will be of v^Iue
DM only to memben of the medicat profcuioii. hut to all pcrtnns interoied in
gencTDl »ci«niiric. tociologtc. »n<l medicolegal iopic« ; in £*ct, ilic hImchcc of any
cnitiplete work tipun lite subject makex thU volume ooe of die mo»l itupofunt
literary innot-itioni nf the (Uy.

Tbc LmcM, London

~ Tlic (>oiik U u ■■■oDiimcni of uniiriii); rattxj. Lmh diurtminail'in, and eniAUon. . . .
Wr bninlljr rcCoinmeiKl 11 to Itie piofeiilon

Saunders* Pocket Formulary

Jul luiM4~New vTth) EdMon-^W'Hh 46O New Fomaulu

Saunders' Pocket Medical Formulary. By Wiujam M. Powell,
M. I)., author of " Ksscnlmls of l>Uc;i>c.i of Cliiidrcn "; Member of
I'hiladcipliia Pathological Society. Ccnlaining 1S31 formulas from the
best-known .iuthuritic:i. With an Api>endix containing Poiwlogical
Table. I-"i>rinulas and iJoses for Hypodermic Medicalioti, Poisons and
Ibcit Antidotes, Uiametefs of the Fcnwle Pelvis and Fetal Head.
Obstetrical Tabic, Diet-list, MateriaLi and Drugs used in Antiseptic
Sunjcry, Tre-ument of Asphyxi;i from Drowning, Surgical Remem-
brancer, Tal>le!i of Incompaliblcs. Kruptivc p'c\*ers. etc.. etc. In flex-
ible morocco, with smIc index, wallet, and flap. S' "S "cL

Johiu HopUm HoapMiJ Bulletin

Amncnl .(. lutli » **, a> I: nuke «ij*«ululi'™ of H ■* bu> at pouailv, ll U rctnuk-
■Ut bow (ni*ch urormiiiion it^ «uibut bo sucoci^dcd in eaUlac iaio h> inall ■ tMok."

14 SAUNDERS- BOOKS ON

SoUmann's Pharmacology

IncludinfE Therapeutics, Materia Medica, Pharmacy,
Prescription-writing. Toxicology, etc.

A Text-Book of PharmacoioKy. By Torald Sollmann, M.D.,
Professor of Pharmacology and Materia Medica, Medical Department
of Western Rc'^erve University, Clev,.'larid, Ohio, Handsome octavo
volume of 900 pages, fully illustrated.

JUST ISSUED— NEW (ad) EDITION

Because of the radical alterations which have be«n made in the new (190;)
I'harmacopeia, it was found necessary to reset this book entirely. The author
bases the study of therapeutics on a systematic knowledge of the nature and
properties of drugs, and thus brings out forcibly the intimate relation between
pharmacology and practical medicine.

J. r. Fotheiintfham, M. D.

Pro/, of Thtrapeutici and Theory and Practueo/ Prfscri&imjp, Xrinitv Affd. Cetttge, TortmtM.
"The work certainly occupies ground noi covered In so conciK, useful, and scientific ■
manner by any other text I have read on ihe Kubjects embraced/'

Butler's Materia Medica

Therapeutics, and Pharmacology

A Text-Book of Materia Medica, Therapeutics, and Pharmacology.

By George F. Butler, Ph. G., M. D., Associate Professor of Thera-
peutics, College of Physicians and Surgeons, Chicago. Revised by
Smith Kly Jklliffe, M. D., Professor of Pharmacognosy-, Columbia
University. Octavo of 694 pages, illustrated. Cloth, S4.00 net ; Half
Morocco, 1S5.00 net.

JUST ISSUED- NEW (5th) EDITION
Adapted to dM New ( 1905) PhannacopeiB

For this fifth edition Dr. Butler's leiit-book has been entirely remodeled, re-
written, and rc^et. All obsolete matter has been eliminated, .inii special atten-
tion has l)een 1,'iven to the toxicologic and therapeutic effects of the newer com-
pniinds. A classification has been adopted which groups together those dnigs
the predominant action of which is on one system of organs.

Medical Record, New York

■ Niitlimg h^ breii omiilcci by I lie author which, in his judgment, would add 10 the com-
plelcnos- iif llic tuxt, and Ihi- sludenl or Rcncral reader is given I'le beneiii of laleil advica
beatiin; upon ihc valui- of druL;s and remedies considered."

PRACTICE. MATERIA MEDICA, Etc. 15

The American Pocket Medical XKctionary. 401 Ed. Recently iut»d

The Amekican Pocket Medical Dictconary. Edited hy W, A, Newman I)"E-

LAHr>, M. D., AssisUnI Ob^elriciBn to (he Hixpital of the University of Pennsylvania.
Containing the pronunciation and definition of the ptincipal words used in medicine
■nd kindred sciences, with 64 eilen^ve tal>le$. Flexible leatlier, with gold edges,
fl.OO net ; with thumb index. tI.Z5 net.

'*[ can RcamDvnd \i ro oar «Iud«nii wUboot n*crve."— J. H* KollaDd, M. O*, DraH ^ tkt
Jt^trtoK Mrdical Colitgty PhiLmdcLphiH.

^^rordt's Medical Diagnosis. Fowtt Editioii. Xevbed

Medjcal DfAGNOsia, By Da Oswald Vierokdt, Professor of Medicine, Univer-
sity of Heidelberg. Translated from the fifth enlarged Gcnnan edition by Francis
H. Stoaht, a. M., M. D. .Octavo, 603 pages, 104 wood cuts. Cloth, ^.00 net;
Sheep or Half Morocco, (5.00 net.

" Hat b««n rvcoifniird u a prAclkal work of rhc hi^m vmlue. It may be coniidFred IndiBpcoublc
boib ID iludcnu and pcmciitionen."— F. MiDDt, M. D., latl Pr^tlisr ^ TMrerji anrf /"raillct in
fjArw^td UHrttrtitf,

Cohen and Eshner's Dia£noiis. Second Revbed EdUcm

Essentials of Diagnosis. By S. Solis-Cohen. M. D., Senior Assistant Professor
in Clinical Medicine. Jefferson Medical College, Phila. ; and A. A. Eshner, M. IJ.,
Proressor of Clinical Medicii]e, Philadelphia Polyclinic. Post-oclavo, 382 p^es ; 55
illustrations. Cloth, Sl.oo net. In Saundtri Question-Comptnd Strics,

'*ConriK in Ihe Ircalmcnl of subject, tene in cxpmuon of Tki." — Amtrk*n Jawrnal ^ Ikt
Mfdieai Scifmctr.

Jia/t luued

Morris* Materia Medica and Therapeutics. New (7U1) EaitioD

Essentials of Materia Hbdica, Thebapki.tics, and rRKScmiTioN-WBiTisc;.

By Hbnry MoKKIs, M. D., late Demonstrator of Therapeutics, Jefferson Medical
College, Phila. Revised by W. A. Bastedo, M. D., Instructor in Materia Medica and
Pharmac-ilogyatColDinliia University. I Zmo, 300 pages. Cloth, fl.OO net. Ih Saiiiuitri'
Qtustion-Com^nd Series.

" C>IV10( (all IV lidpreH the mind and itutinct in a Uatins BaDDQ." — Bttffata MtJical Jimrn^.

V/iUiami' Practice of Medicine Recendjr iiiued

ESSENTIALJi C)F THE PRACTICK OK MEDICINE. Bv W. R. WtLLlAMS. M.D,,

formerly Instructor in Medicine and lecturer on Hygiene, (.ornell Univer.-iiy ; and
Tutor in Therapeutics. Cotumbia University, N. Y. 12ino of 456 p:igcs, illustrated.
/<! SauHdiri QucstinB-CBmpend Serin. Double nnmlier, Ji.7S net.

Stooey'i Materia Medica for Nurses sec^tSl!^ elk,,.

Materia Mkoica for Nurses, By Emilv M. A. St*>nkv, Supcnnicndent of the
Training School for Nurees al Ihe Cnmey Hn^ipiral, SoiiTh llo^Ton, Mass. Hand^omi'
lamo volume oF 300 paj^ca. Cloth. $1-50 n^.
"It coniain* Rbout «vcry(btiiff ihU * nun* ought to know in regard lo crruf:i/'—_/mfj»4i/ ^ /At

Grafstrom's Mechano-thcrapy Se^oST^^TH^ed

A TltxT-BooK OF Mechano-THERAPY (Massaf-c and Medical Gynmaslicsi. Ry
Axel V. GeaFSTRoM, R, Se., M. D., Attending Physician in Augusiut Adolplms (irplian-
agc. Jamestown, N, Y. omo, loo pages, illusir.iiccl. Si 15 nri.
"Cmainlv (iitlil]« its mission in TFnd«in|^ compreheiiaiblc the aubjeclt of manacF nnd nedical

i6 SAUNDERS' BOOKS t»A' PRACTICE. Etc.

Jakob and Eshner's Internal Medicine and Dta^nosia

Atlas AND Epitokb of Inteknal Medicine aku Clinical Diagnosis, fhjl
Chr. Jakub, of Erlaogen. Kdiled, with additions, by A. A. K^llNKK. H. D.hl
feasor of Clinical Medicine, Ftiitsdelphii I'oi]rcIinic, VN'ith iS^ colured Ggimi
68 plate>i, 64 teit-illuUntions, 359 pages of texl. Cloth, (3.00 Del. /■

Hand- Alias Seiits.

" Cut be rtcomiiwndcd UbbdiUlinEly 1u fhe pfmcticins phyiki&n no Ic*h lb*a to tbc lE«daE'-l
Bulltlin nfj-luu Htpki-a Hnfilai.

Lockwood's Practice of Medidae. Reri^S^/tSSrf

A Manual of the Practicf, ok Medicine. By Geo. Roe I jh'kwood, M I'.I
Altending I'hysician lo Ihe Bellesue Ilnipital, New York City. Octavo, 847 pi|&|
with 79 illuitralions in Ihe leit and zx full-page plates. Cloth, (4.00 net.

'* A work of poiUivc mcrii, Hbd Qua which we gUdly welcome." — A>uh i'^rk JkttiiuiAi J^mrmtt-

SaliniCer and Kalteyer'a Modern Medicine

Modern Medici NK. By Julius L. Salinhkh, M. D., tale Ass't Prof, of Clinal
Medicine, Jeflenon Medical College: and K. J. Kaltevek, M. D., Demon Mnw ^
Clinical Medicine, Jeflenon Medical Collie. HaodMine ociato, Soi p«ge», iL»
tnled. Cloth, (4.00 neL

"1 h4ve cverully eimAined the book, Hhd find il ID be ihorou^hly Iniiiwonhy in mU r^pccbtVt
viliuble IH I -book Inr Ihi medical tludenl."— Sam'l O. L.. Poltec, Fcrmirlji Prifitirr uj I'riKfm
And Frattkt ef t^difiMf, ijaftr iMttik-'it LW/f/f, San Krancucu.

Heating's Life Insurance

How TO Examine for Life Insurance. By the late John M. Keating, H. D.,
Ex-Preudent of Ihe Auocialion of I jfe Insurance Medical Directors. Kojal octm,
all pages. With numerous iltuslralions. Cloth, fz.oo net.

" Tkls ji by fu- the ai»i uadiil book which hat yel appeand on iaaujaiKe eit&Diinatjon." ittAd

Nnri.

Corwin'i Phyucal Diagnosis. Thtrd eaukm, ReviMd

Essentials of Phvsical JHacnosis oi-' the Thorax. By A. M. Corwis, A. M.
M. I'., Professor of lliysical liia|;nosis, Coileiie "f Phvsician-i and -Surf-cons, Chicago
zro pages, illustrated. Cloth, flexible cover>, (1.15 net.

" A Tno»l eicellenl Llille wnrk. Ic arrange! orderly and in aeqti«ii<:F the VBruiufe Hihjr-vttve pheaomcaj
Id JaKi*^') tLiluilon dF a careful diagno^it."— y.'Hrjhi/ .y' S'f'Tfui artd MiHlat /V«f4j^j.

American Text-Book of Theory and Practice

.\MEKICAN TkXT-I!<«>K ok IHK ThLFOkV AMI rEACTICE OK MeIUCINK, Edited
by the late Wll. 1,1am I'ekpeI!, M, D,, I.L. I>., I'rufessor of the Theory and I'raciict
of Medicine and of Clinical Medicine, Inivirsilv of Penna. Two lianilsome imperial
octavoi of about 1000 pages each. Illustrated. Per volume: Cloth. ^5. 00 net : .^heep
or Half Muruccn. th.oo ncl-

■' I am quite lure il will command ll-eif holh td praf litlonm and aiude ma of Dedicine. and becofpa
one of our moil popular le at -hookt."— Alfred Laomia, U. D., LL.- D., /V^yVjj.'r p/ ratkaipnamJ
f'r^tUt fif MtiUtne. UKiifTiiiy of Iht Cisy ,'/ ^nv Yi'rk-

Stevens' Practice of Medicine, n*™- (7A) EdWon-jint ia>ued

.\ MlMIAL OK THK PRACTKF oi Medktvf. By A. \. Stkvkns. A. M., M. |l..
Priifci^or t)f Patlmlofjv, Woman's Meilical Ccillt!pe, Pliila. Specially intended Av
stii'ienls prepatinp for yr-idiiniinn ami huspilal examination*. Post-octavo. 556 |agc-;
illmtrslecl. Flevible Uailier. (1.50 net.

"All nfrllen CHiii<len«:nniTi i>f ih'' e^smijii'. nf mr<lica^ praciice for the sludrni. and may be f^'un^
;ilsn ,in eXLelleiil reminder f.ir ihe buiy phy*ii:ian.""Aujffj/,' M.'dkjl JuitrHAl.

. 1

I i

^^^^^^^^^^1 LAME MEDICAL LIBRARY ^1

^^^^^^^^^^^ To avoid fine. tli» book thooM be icturixd on
^^^^^^^^^^H or before the date tut ilatnpcd below.

-I

N201
AB29
1906

A8hton, li.

Practice of gyne-
-oology. , 6907a

DATI DOB

)

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