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Full text of "A text-book on the practice of gynecology, for practitioners and students"

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A TEXT- BOOK 



ON THE 



PRACTICE OF GYNECOLOGY 



FOR PRACTITIONERS AND STUDENTS 



BY 

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 



BY 



JOHN V. ALTENEDER 



Scconft Edition 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 
1906 



r 



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

righted, January, 1906. 



Copyright, 1906, by W. B. Saunders Company. 



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 

r 

J CHAPTER VU. 

i Hydrotherapy 77 

I 

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 



i8 



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 






a 



n* 



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. 



It 



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. 



33 



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 






24 



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 



f 



h 



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 



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- 



Si 



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). 




a6 



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. 



37 




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). 



aS 



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. 



39 




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. 



31 



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). 



31 



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. 



33 



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). 



34 



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. 



35 



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. 



37 



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. 



39 



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 



a 







© 



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. 



40 



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. 



4' 



a 



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 



I 



.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 ■«- 





4' 



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. 



43 



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 



44 



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. 



45 



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). 



46 



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. 



47 



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 



48 



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. 



49 



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- fc WMu 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. 



I 



$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. 



53 



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 producv<I by the infecting orRanism^, M;i\ing thu< increased 
in nuntlier. Ihe inv^dint; miiro-or^nisms are possibly de&iroyed by the pnxc>a 
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. 



55 



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. 



I 



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. 



57 



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). 



58 



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 



63 



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. 



6J 



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. 



64 



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. 



65 



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 < I em< •nitrate the rebtluiu* o[ the intestines with an abdomliul 
p;roirth, nml to <lUtitigui<}i l>ctwcen awitos anil a cy*!. 



^Ht^A',. 



u 



'"^flP^*^ 



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

Km* ibii dw Ji Jn m c nwhf 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 




66 



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. 



67 



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 



m 



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 




68 



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. 



ej 




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 »). 



?o 



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. 



71 



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. 



7! 



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. 



73 



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. 




74 



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. 



75 



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 



n 



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, 



77 



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. 



L 



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. 



79 



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. 



Si 



■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. 



83 



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. 



8S 



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. 



86 



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. 



88 



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. 



89 



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 



90 



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. 



9' 



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. 



92 



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^ 



93 



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. 



94 



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. 



96 



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. 



97 



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. 




98 



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. 



99 



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 
pa fu t m 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<i put in a 
tool plate. It is advisiWe in have m\ huU K»llon IwUles «> 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 



M 

\ 



^ 



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* 

If 



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 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-juic e an d 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. 



"S 



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 



nS 



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 



/ 



/i 



M 



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. 



"4 



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, 



"7 






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<i apparatus, 
lOMrcver. the loss nf heat is reduced to a minimum nnd \-arie-'> 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. 



I 



I 



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 



Tm 



m 



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.<i of heat 
n in the 'kIkt methods on ac- 
int of the rapidity of the How. 
Rapidity. — The mervotr 
luultl l>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, 



1 



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 
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 orKan<i n{ the body in o tioTmal condition. The game ttf 
t>lf 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 <i>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 



I 

L 



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 re<i>Rli>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. 



A 



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. 



fl 



<y 



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 



\i 



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'-: 




I 



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 



I 



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 



/. 



y-i 



-isss 



.v-.i-v;.^ 



f"^-^! 



X' 



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.<i ■■■»>. 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. 



N 



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 oblaine<i only in the eaHy Uaxt* of 
tbo di-»cjsc. Ilu- iKOtc lynn>haI^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. 



i 



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>e<i>nies 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 an<i l>ec<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. 



Ml 



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). 



f 



/j 



Fio. 104-— Aioiuioa* o* m Lasu. 



L 




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. 



f 



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. 



"3 



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}- <i>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><I bath dov> 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. 



"5 



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. 



"7 



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. 



"9 



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. 



"i 



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<i hyperesthesia may al«> 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. 



MS 



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 ettftte<I by indirect in.>ipeciioTi 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. 



"9 



' 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 
, t ospeclion 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. 



ni 




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). 

16 



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. 



US 



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 






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 



n 



CVSTOCELE. 



>49 



M 



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: 



^ 



h 



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 aWTe sp ondingly 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"^ 




G 



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* 



Ai 



'\ 



■<\ 



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»<U and ihe renal reflexes bieix>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. 




@ 



a 



® 


in 


,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. 



t 



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 



K 



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 



E) 



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 



J^ 



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- 



©) 



0> 



® 



©1 



® 



® 



® 



© 



-®- 







® 



IM.. 



k-~twmjltt]im L^to ui TH OritATitM n*fl nil Miwjvai. or k Pm>(iiii iri4<ui rim 



^ 



®G 



ACTUAL Size 



D 



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. 



09 



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>ii<I>iitniata. 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 
db wue 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 
m e 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- 



t. 



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<i aImo>.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 




i 



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 K mi/ i n itM 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 uteru<i 
arc then thorouKhly palpated mth the ri-cul finder iind a (.ireful nnie made of all 
|)alhiiU>g: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. 



2 



.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. 



m. 



'>. 



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. 



i" 



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. 



I 



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 



3U 



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 -<i>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 
j by 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- 



L^ 



^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 



a 



u, 



^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> 



X 



^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 



m 



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 cnbrge<i 
chronic coniK^lion or h\-[>crtri>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.. 



MS 



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! 



m 




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. 

13 




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- 



jL 



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 



J 



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. 



M7 



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. 



1 



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- 



C^ 



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 



r 



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<i (>«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 



n 



'fundus 



I ! 



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. 



N 



n 



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 



1^ 



'•^'^; 



-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 uieru<i itself. These lesion* are considered in their 
Kif>ei-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. 



\\\ 



y> 






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- 



m 



i! 



Fia. 4i4.'-Suaiil'coi-( Pidioiii Tuuo* of iui 









4' 



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 



/ 



li 



* 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