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t 



A TEXT-BOOK 

ov 



PRACTICAL GYNECOLOGY 



FOR PRACTITIONERS AND STUDENTS 



D. TOD GILLIAM. M.D. 



EmrritUB Profraior of Gynecology In Ohio Stato University College of Medicine, and 

Sometime Professor of OynecoloKy Starling MedUal Collegi', Gynecologist to 

St. Anthony and St. Francis Hospitals: Consulting Oynecologlsl to Park 

View Sanitarium, Columbus, Ohio; Fellow of the American 

Aasoelktion of Obstetricians and Oynecoiogislh: Member of 

the American Medical Association, of the Ninth 

International Medical Congress, etc. 

Asn 

EARL M. GILLIAM. M.D. 

Professor of Diseases of Women In the Ohio State VnlversUy, 
Colhgo of M«'dlelne. Cnlunibus. Ohio. etr. 



FIFTH REVISED EDITION 



Illustrated with 353 Engravings, a Colored Frontispiece, and 
13 Full-Page Half-Tone Plates 




PHILADELPHIA 

F. A. DAVIS COMPANY, Publishkrs 
Kxr.i.isH Dki'ot 

St.WI.KY PhII.I.II'^. L(i\11()\ 

1916 



COPYRIGHT, 1903 
COPYRIGHT, 1907 
COPYRIGHT, 1908 
COPYRIGHT, 1911 
COPYRIGHT. 1916 
BT 
F. A. DAVIS COMPANY 

CopyriKhi, Great Britain. All Rixhta Reserred 



L'. S. A. 
Company 
Strut 



f • • « « 
••♦ ••• • 

• # * • • 



.-Ac\ 



x-y<- 



PREFACE TO FIFTH EDITION. 



In preparing the fifth edition of Practical Gynecology', it has 

been my endeavor to bring the work fully up to date. In doing this, 

undesirable matter has been supplanted by that which is new'er and 

better. This has necessitated many small changes — changes too 

numerous and scattered to be enumerated here. Mindful of the 

original plan and purpose of the work, an earnest effort has been 

made to keep it as plain and practical as possible and, in size, within 

the limits of an easily handled volume. In this, as in former 

editions, I am indebted to my son. Dr. E. M. Gilliam, Professor of 

GjTiecologj', Medical Department, Ohio State University, for valuable 

assistance. 

D. T. G. 



333 East State Strket, 
CoLUMBi's, Ohio. 



(Hi) 



459SA 



PREFACE TO FIRST EDITION. 



T HAVE endeavorwl to make this book plain and practical for the 
student and busy practitioner. T have dispensed with bibliographic 
references, and have made few citations of authorities. Moot ques- 
tions have been given scant attention, and effete matter has been 
excluded. In the choice of technicjue I have aimed to give sufficient 
variety to meet the varie<l requirements and no more. Scientific 
methods in classification and arrangement have not l)een strictly 
adhered to wliencver, in my judgment, a plain, connected narrative 
would render the te.xt more intelligible. 

The book is divided intf) fifty chapters of as nearly uniform 
length as possible to correspond to the number of lectures and recita- 
tions usually allotted to the subject during a collegiate term. 

I am indebted to Dr. J. H. J. T'pham for the chapters on the 
ureters and kidneys, and to Dr. Earl M. Gilliam for the chapters on 
the rectum and much other valuable assistance in the preparation of 
the work. To the artist, Mr. Robert Bowie, I am under obligations 
for faithful and efficient work in the preparation of the illustrations. 

D. T. 0. 

50 North Foiirth Stkeet, 
Columbus, Ouio, 



(iv) 



CONTENTS. 



PAGE 

ISTBODUCTOBY 1 

CHAPTER I. 

Ukxebal Causes of Diseases or Women 3 

Social State — Physics and Physiology as Applied to Gynecology — Dress 
— Muscular Exercise. 

CHAPTER II. 

Gynecolooic Examisatiox 12 

Anatomic Knowledge — Case-book — Preparation of the Patient — 
Methods of Examination — Examination of the Abdomen; Inspection; 
Palpation; Percussion; Auscultation — Examination of the External 
Genitals and Pelvic Structures; Vaginal Examination; Bimanual 
Examination. 

CHAPTER III. 

Gyxecx>looic Examinatio.n (Instbumental) and POSTrBE 25 

Instrumental Examination — I'terine Sound — Speculum; Introduction 
of Bivalve Speculum — Dilation of Genital Tract — Posture; Dorsal; 
Left Lateral, or Sims's; Knee-Chest; Erect; Trendelenburg. 

CHAPTER IV. 

GY.NECOLOOIC TECHNHjrE 37 

Definition — Cleanliness — Germs ami Germ Infection — Sepsis — Asepsis 
and Antisepsis — Preparation for Operation — Room — Instruments — 
Gauze Sponges — Dressings — Ligature and Ligature Material — Sponges 
— Operator and Assistants — Aprons — The Patient — Abdominal Section 
— Closure of the Incision — Dressings — After-treatment — Little At- 
tentions. 

CHAPTER V. 

GY.NECOI/XJIC TECH.NIQI-E COMPLICATIO.NS AND SEQrEL.« 67 

Shock — Hemorrhage — Sepsis: Treatment — Infected Wounds; Stitch- 
hole Abscess — Abdominal Fistula — Hernia — Prevention of Post-opera- 
tive Adhesions — Flushing and Drainage. 

CHAPTER VI. 

COXSTIPATIO.N 69 

CHAITER VII. 

DiSOBDEBS OF Menstbuation 73 

Menstruation — Precocioiis and Delayed Menstruation — Menstrual Pro- 
dromes — Vicarious Menstruation — Menopause — Amenorrhea — Emansio 
Mensium — Suppressio Mensium. 

CHAPTER VIII. 

DiSOBDEBS or Menstbuation (Conrluried) 81 

Dysmenorrhea — Neuralgia — Inflammatory — Mechanical — Membranous 
Treatment — A Study of Dysmenorrhea. 

CHAITER IX. 

KLAlfOBMATIONS OF THE GeNITAL TRACT, StERIUTY. ETC 88 

MilUer's Ducts — I'teriis Duplex — I'terus Bicornus — t'terus Septus — 
I'terus Unieornus — llermaphrodism — Pseudohermaphrodism — Steril- 
ity; Definition; Causes; Prognosis; Treatment — Subinvolution of the 
Uterus — Superinvolution of the Cterus. 

(V) 



vi CONTENTS. 

CIIAPTKR X. PAGE 

Diseases of the Vulva 95 

Hypertrophy — Nymphte — Clitoris — Adhesions of the Labia — Vulvitis; 
Simple; Purulent; Follicular — Inflammation of the Vulvo-vaginnl 
Cilands— Cysts of the Vulvo-vaginal Glands — Kxanthemata of the 
Vulva — Pruritus VuIvib — Kraurosis of the Vulva. 

CHAPTKR XI. 

Diseases of the Vulva: Specific, Mauonant, anii Tbaumatic 105 

Specific Disease of the V^ulva; Chancre; Chancroid — Syphilitic Hyper- 
trophy of the Vulva — Injuries of the Vulva — Varicose Tumors of the 
Vulva — Hematoma of the Vulva — Elephantiasis of the Vulva — Neo- 
plastic Growths; ^falignant Growths; Causes; General Characters — 
Epithelioma — Carcinoma — Sarcoma — Vulvo-vaginal Hyperesthesia and 
Vaginismus — Coccypodynia — Classification of the Inflammatory Af- 
fections of the Genital Organs. 

CHAPTER XII. 

Diseases of the Vagina 116 

Atresia an<l Stenosis — Imperforate Hymen — Vaginitis; Simple; Gon- 
orrheal; Septic; Granular; Adhesive; Emphysematous — Cysts of the 
Vagina — Fibroid Growths of the Vagina — Malignant Growths of the 
Vagina. 

CHAPTER XIII. 

Injcbies to the Pelvic Floor — Median Lacerations 130 

Levator Ani — Vaginal Sulci — Complete and Incomplete Ijicerations — 
Immediate Operation — Intermediate Operation — Secondary Operation 
— Laceration Extending up the Recto-vaginal Septum — Ristine Opera- 
tion. 

CHAPTER XIV. 

Injuries to the Pelvic Floor — Lateral Lacerations; Results 146 

Lateral Lacerations — Relaxed Perineum — Emmet's Operation — Sutures 
— Concealed Laceration of the Sulci — Flap-splitting Operation — Re- 
sults of OiK-rations on the Pelvic Floor — Subinvolution of the Vagina 
— Prolapse of the Vaginal Wall — Cystocele — Oval Denudation — Stoltr's 
Operation — Goffe's Operation — Watkins'g Operation — ^Author's Opera- 
tion — Rectoccle — Entcrocele. 

CHAPTER XV. 

Genital Fisti-l.* 16!) 

I'rinary Fistulse — Fecal Fistulte — Preparatory Treatment — Oi)erative 
Technique — Operation by Denudation — -Flap-splitting Operation — Flap- 
inversion — Transplantation — Colpocleisis — After-treatment — Vesico- 
uterine Fistulee — Vesico-utero-vaginal FIstulie — I'reteral Fistula — 
Vaginal Operations — Abdominal Urctero-cystostomy — Urethral Fis- 
tulee — Fecal Fistula — Recto-vaginal Fistulte. 

CHAPTER XVI. 

Displacements of the Uterus : Ascent and Descent 185 

Normal Position of the Uterus and How Maintaine<l — Intra-ab<lom- 
inal Pressure — Retentive, or Suction, Power of the Abdomen — .\8eent 
of the I'tenis — Descent, or Prolapse, of the Uterus — Freund's Opera- 
tion — Hysterorrhaphy — Ventrofixation. 



CONTENTS. yii 

CHAPTER XVII. PAGE 

Displaceme:>tb of the Utebus: Flexions and Vebsions 195 

Versions and Flexions of the Uterus — Anteflexion; Flexion of the 
Body on the Cervix; Flexion of the Cervix on the Body — Lateral Dis- 
placements of the Uterus — Retrodisplaeements of the Uterus. 

CHAPTER XVIII. 

Replacement and Retention of the Utebus — Kellooo's Opebation 203 

Replacing the Uterus — Manual Replacement — Instrumental Replace- 
ment — Retention of Uterus After Replacement — Mechanical Supports 
— External Shortening of the Round Ligaments — Kellogg's Operation. 

CHAPTER XIX. 

Ventbosi'speksion of the Utebcs — Invebsion of the Utebus 220 

Ventrosuspension of the Uterus — Round Ligament Ventrosuspension 
of the Uterus — Inversion of the Uterus. 

CHAPTER XX. 

Inflammation of the Cebvix Utebi — Tbophic Disobdebs 232 

Inflammation of the Cervical Mucosa (Endocervicitis) — CJIandular 
Cervicitis — Cystic Degeneration of the Cervix — (Jranular Erosion of 
the Cervix — Glandular Polypi of the Cervi.x — Cervical Tulwrculosis — 
Cervical Hypertrophy — Hypertrophic Elongation of the Cervix — 
Supravaginal Elongation of the Cervix — Atresia and Stenosis of 
Cervical Canal. 

CHAPTER XXI. 

Lacebation of the Cebvix Uteri 245 

Laceration of the CVrvix Uteri — Emmet's Operation — Schroeder's Op- 
eration — Amputation of the Cervix. 

CHAPTEU XXII. 

Canceb of the Cebvix Utebi 250 

Causes — Origin and Progress — Symptoms; Hemorrhage; Discharg;>; 
Pain — Diagnosis — Course and Termination. 

CHAPTER XXIIL 

Tbeatment of Canceb of the Cervix I'terf 270 

X'aginal Hysterectomy — Wcrder's Operation — Kelly's Operation — 
Wertheini's Operation — Amputation of the Cervi.x — .imputation by 
Electrocautery — Curettage and Cauterization. 

CHAPTER XXIV. 

I.nflammation and Infectious Diseases ok the Utebus — Exdo-metritis. 287 

The Endometrium — Endometritis — Bacteria of Enilometritis — Mo<lili- 

cations in Character and Course of Endometritis — Symptoms and 

Course — Examination — Diagnosis — Treatment. 

CHAPTER XXV. 

CtrBETTAGE, ATMOCAUSIS, AND TUBERCULOUS ENDOMETRITIS .300 

Curettage — Evils of Curettage in Streptococcic Infection of the Uterus 
— Atmocausis — Tuberculous Endometritis. 

CHAPTER XXVI. 

Mauonant Diseases of the Body of the Uterus 311 

Carcinoma — Adenoma Malignum — Sarcoma — Fibrosarcoma — Decid- 
noma Malignum. 



yiii CONTENTS. 

CHAPTER XXVII. page 

FlBBOID TUMOBS OF THE UtEBUS 321 

Fibroid Tumors of the Uteru»; Submucous; Interstitial; Subserous; 
Intraliganipntous — Degenerations; Cystic; Myxomatous; Fatty; Cal- 
careous; Malignant — Edematous Fibroids — Inflammation; Suppura- 
tion; fiangrcne — Growth — Changes in the Uterus and Adnexa — Pain 
— Hemorrhage — Pressure Symptoms — Differential Diagnosis — Fibroid 
Polypi. 

CHAPTER XXVIII. 

TBEATMENT of FlBBOID TuMOBS OF THE UTEBI'S 334 

Medical Treatment — ElcctrionI Treatment — Vaginal Operation; Enu- 
cleation ; Morcellation — Myomectomy — Supravaginal Hysterectomy ; 
Baer's Oi)eration; Kelly's Operation — Panhysterectomy. 

CHAPTER XXIX. 

l.NFECTIONS OK THE KaLLOPIAN Tl'BEH — SaUINOITIS 350 

Anatomy — Salpingitis — Streptw-occic Infection — (ionoeoccio Infection 
— Route of Invasion — Catarrhal Salpingitis — Interstitial Salpingitis — 
Pyosalpinx — Hydrosalpinx — Hematosalpinx — Adhesions — Tubo- 
ovarian Abscess — Effects on Function. 

CHAPfER XXX. 

Salpingitis: Symptoms, Diao.nosis, and Medicai, The.vtment 364 

Hemorrhage — Di.scliargos — Pulse and Temperature — The Sepsis Result- 
ing from Pelvic Infection — Physical Signs — Differential Diagnosis — 
Prognosis — Medical Treatment. 

CHAPTER XXXI. 

El-KCTBICAI, AND SrKCICAL TBEATMENT OF SaI.I'INOITIS 376 

Electrical Treatment — Operative Treatment; Salpingo-oilphorectomy — 
Complications. 

CHAPTER XXX If. 

TCIIEBCILOSIS OF THE FaLI/JPIAN TiBES — PeI.VIC CELLULITIS 385 

Tubal Tuberculosis — Pelvic Cellulitis — Operations through the Vagina 
for Pelvic Infection. 

CHAPTER XXXIII. 

Ectopic CJestation 398 

Changes in the (Icnital Apparatus — Rupture of the Tube — Tubal Abor- 
tion — Death of the Ovum — Rupture into the Peritoneum — Rupture 
into the Broad Ligament — Disposition of the Ovum after Di'ath. 

CHAPl'ER XXXIV. 

Ectopic (Jestation (Concluded) 408 

Symptoms — Spurious Uilmr — Physical Signs — Diagnosis before Rup- 
ture — Diagnosis after Rupture — Operation. 

CHAPTER XXXV. 

Diseasek of the Ovakiks— Defective I)evei.op.\ient — Displacements — 

Conoestion 417 

.■\natoniy — .Absence of Ovary — Rudimentary Ovaries — Supernumerary, 
or .\ceessory. Ovaries — Displacements of the Ovary — Hernia of the 
Ovary — Hyperemia or Congestion of the Ovary. 



CONTENTS. ix 

CHAPTER XXXVI. paob 

INFLAMMATION OF THE Ov ABIES (OoPHOBITIS ) 424 

Oiiphoritis — ^Acute Oophoritis — Chronic Oophoritis — Tuberculosis of 
the Ovarj'. 

CHAPTER XXXVII. 

OvARiAX Cysts — FoixicrLAB and Glandi'lab 433 

Ovarian Cysts — Simple Cysts — Follicular Cysts — Cysts of the Corpus 
Luteum — Tubo-ovarian Cysts — Proliferating Ovarian Cysts — Glandular 
Cyst*. 

CHAPTER XXXVIII. 

Ovarias Cysts — Papiixomatous, Dermoid, asd Tbbatomata 445 

I'apilloinatous Ovarian Cysts; Metastasis; Histogenesis of Proliferat- 
ing Cysts — Dermoid Cvsts — Teratomata — Complications of Ovarian 
Cysts." 

CHAPTER XXXIX. 

Cijxicai. History of Ovabian Cysts 457 

Clinical History of Ovarian Cysts — Methods of Kxaniinntion — Differ- 
ential Diagnosis; I'terine Atresia; Uterine Fibroids — .\scites; Fecal 
Impaction; Phantom Tumor; Distended Bladder; Retroiwritoncal 
Cysts; Obesity; Desmoid Tumors — Relation of Colon to Abdominal 
Tumors. 

CHAPTER XL. 

Ovariotomy — Accidents and Comim.ications 472 

Treatment of Ovarian (,'ysts — Ovariotomy — Coniplicitticms of Ovariot- 
<miy; Mistaking the Omentum for Propcritoneal Fut^ — Delivery of 
the Multilocular Cyst — .Adhesions — Pedich? — lntruli};!imcntous Cysts 
— Accidents of Ovariotomy .\ppendicectomy — Resection of Bowel; 
Murphy Button; Connell's Method; Lateral Anastomosis; Incomplete 
Operations. 

CHAPTER XLI. 

Abdominal and I'elvic Lesio.ns crrirER than Gynecologic 484 

Cesarean Section — Gastric and Diiiidenal I'Icer — (iastrotomy — (Jastro- 
jcjunostomy — Cancer of Stomach — Partial (lastrectoniy — Rupture or 
I'erforation of Hollow .\bdominal Viscera — Cholecystotoiny — Chole- 
cystectomy — Cliolcdochostomy — Cholecystenterostomy — Pancreas 
— Appendi.x. 

CHAPTER XLI I. 

Solid Tr.M<)Rs or the Ovary — Cy.sts ok the Parovabicm 516 

Fibromata — Myomata — Papilloniata — Cnrcinomata — Sarcomata 
— Parovarian Cysts; Simple Parovarian Cysts; Papillomatous Par- 
ovarian Cysts. 

CHAPTER XLIII. 

DlijGASES OF THE VrETIIRA AND BLADDER 524 

Methods of Kxaminatlon — Instruments — Anatomy of the Crctlira — 
Malformations of the I'rethra — .\bsence of the I'retlira — Hypospadias 
— Urethral Caruncle — Prolapse of the Urethral .Mucosa — .Atresia of 
the Urethra — Overdistension of the Urethral Canal — Incontinence of 
Urine. 

CHAPTKR XLIV. 

Diseases of the I'rethra and Bladder {('oniiuurH) .").'15 

Stricture of the Urethra — Urethrocele — I'rctliritis — Vesico-urethral 
Fissun- — Diseases of tlie Bladder— Divisions of the Bladder — Con- 
genital Malformations of the Bladder — Exstrophy of the Bladder — 
Cystitis. 



X CONTENTS. 

CHAPTER XLV. page 

Diseases of the Ubetrba and Bladdeb {Concluded) 547 

Diagnosis of Cystitis — Treatment — Applications through the Cysto- 
scope — Cystostomy — Post-operative Irritable Bladder — Irritable Blad- 
der — Vesical Calculus — Vesical Tuberculosis — Tumors of the Bladder. 

CHAPTER XLVI. 

Diseases of the Ubetebb 661 

The I'rctera — General Considerations — Anomalies — Injuries to the 
Ureters — Ureteral Anastomosis — Ureteritis — Stricture of the Ureter — 
Ureteral Calculus — Vaginal Ureterotomy — Ureterotomy from Above — 
Ureteral Catheterization. 

CHAPTER XLVII. 

Diseases of the Kidneys 872 

The Kidney — Oeneral Considerations — Anomalies — Methods of Exam- 
ination — Urinary Examination — X-ray Examination^Movable Kid- 
ney — Cystonephfosis — Hydronephrosis. 

CHAPTER XLVIII. 

Diseases of the Kidnets (Concluded) 584 

Pyonephrosis — Renal Infections — Tuberculosis of the Kidney — Renal 
Calculus — Renal Tumors. 

CHAPTER XLIX. 

Oi>ebations on the Kidneys 598 

Nephrectomy — Nephrotomy — Pyelolithotomy — Nephrolithotomy — 
Nephropexy — Partial Nephrectomy — Operative Measures for Injuries 
of the Kidney — Results of Operation. 

CHAPTER L. 

Diseases of the Recti'm 606 

Anatomy — Reetal Kxaminntion — Instruments — Abscess of the Anus — 
Epithelioma of the Anus — Stricture of the Anus — Sphincterismus — 
Pruritus .\ni — Anterior Rectocele — Posterior Rectocele — Prolapse of 
the Rectum — Proctitis ; Acute Catarrhal; Chronic Catarrhal; Dys- 
enteric; Gonorrheal — Periproctitis. 

CHAPTER LI. 

Diseases of the Rectum (Continued) 622 

Ischio-rcotal Abscess — Fissure and Irritable I'Icer — Fistula; Varie- 
ties — Rectal Tuberculosis — Tubercular Ulcer — Tubercular Stricture — 
Tubercular Fistula — Chancroid of the Rectum — Syphilis of the 
Rectum — Chancre; Mucous Patches; Condylomata; Gummata — Stric- 
ture of the Rectum; Traumatic; Syphilitic; Tuberculous; Malignant 
— Dilatation — Proctotomy; Internal; External — Bacon's Method. 

CHAPTER LII. 

Diseases of the Recti'M ( Concluded ) 638 

Hemorrhoids; External; Internal — Treatment of Hemorrhoids — In- 
jection Method — Ligation — Podreze Method — Clamp and Cautery — 
Whitehead's Method — Martin's Method — Polypoid Growths of "the 
Rectum — Papillomata — Lipomata — Fibromata — Retention Cysts 
— Cancer of the Rectum — Curettage— Colostomy — Allinghnm's Method 
— Excision — Kraske's Operation. 

Index of Regional Syuptomb. Genekal Index. 



LIST OF ILLUSTRATIONS. 



Prontupixcb. Arterial Suppljr of the Oenltal Apparatus. page 

Pu^TE I. Bimanual Examination from tbe Side 24 

Plats II. Dorsal Position 32 

PuATE III. Left Lateral or Sims Position 34 

Plate IV. Knee-Chest Position 36 

Plate V. Development and Malformations of tbe Oenltal Apparatus 82 

Plate VI. Pig. 1, Showing Outline of Incisions. Fig. 2, Reinforcing Sphincter 

Suture Tied and other Sutures in Place 144 

Plate VII. Showing Method of Making Transverse and Longitudinal Incisions . . 160 

Plate VIII. Showing Method of Dissecting the Vagina from the Bladder 1«0 

Plate IX. Showing lutroductlon of Sutures through the Edges of tbe Flaps and 

Underlying Uterus 160 

Plate X. Continuous Sutures of Anterior Vaginal Wall 160 

Plate XI. Sagittal Section, Showing Results of Operation 160 

Plate XII. Dorsal Posltioa, with Author's Perineal Rrtrartor Adjusted 260 

Plate XIII. Trendelenburg Position 340 

no. 

1. Universal Chalr-table 18 

2. Bimanual Examination with Finger In tbe Rectum 22 

3. Bimanual Examination 23 

4. Simpson's Uterine Sound 25 

5. SIms's Uterine Sound 25 

6. Uterine Sound with Oauge 26 

7. SIms's Perineal Retractor 27 

8. SIms's Depressor 28 

9. Jackson's Perlr.eal Retractor 29 

10. CoUins's Traction Forceps 39 

11. Author's Self-retaining Perineal Retractor 30 

II. Weighted Perineal Retractor 30 

13. Brewer's Bivalve Speculum 31 

14. Author's Aseptic Vaginal Speculum 31 

15. Pratt's Rectal Dilator In Graduated Sizes 32 

IS, 17. Hypodermic Syringe for Examination 33 

18, 19. Compression Forceps 37 

20. Boeckmann's Steriliser 40 

21. Boeckmann's Sterilizer (Chamber for Dressings) 40 

J2. Boeckmann's Sterilizer (Tray for Instruments) 41 

22. Glass Brush Box 41 

24. Glass Ligature Box 41 

25. Cabinet for Dressings 42 

26. Instrument Stand 43 

27. Instrument Tray 43 

28. Double Wash-stand 43 

29. Operating Room at St. Anthony's Hospital 44 

30. Robb's Razor for Shaving Pudendum 45 

31. Abdominal Section; Incising the Peritoneum 47 

22. Knife for Abdominal Section 48 

33. Scissors for Abdominal Section 48 

34. Saline Solution Injector 68 

35. Canvas Chair 62 

X. Uterus.— Menstrual Period,— Showing Congested Area and Destruction of Mu- 
cous Membrane. (Photomicrograph by Oramm) 74 

17. Hard Rubber Graduated Dilators for Cervical Canal 83 

38. Peaslee's Cervical Dilators 84 

19. Palmer's Cervical Dilator 84 

40. Cervical Dilator for Sterility 92 

4L Follicular Vulvitis 97 

42. Abscess of Vulvo-vaglnal Gland 99 

43. Venereal Warts of Vulva. (Author's Case, from Photograph) 105 

44. SIms's Glass Plug 113 

45. InflaUble Rubber Cushion 114 

48. Hematocolpos 116 

47. Hematocolpometros 117 

48. Blunt Curved Scissors for Atresia Vaginas 119 



(.Xi) 



J^ LIST OF ILLUSTRATIONS. 

Fia. PAOB 

49. GonococcUB of Nelsser. (PhotomlcroKraph by Qramm) 122 

60. Walls of Vagina, Showing Musculaiia MucoaiB, etc. (Pbotomlcrograph by 

Oramm) i 123 

(I. Fountain-syringe 125 

S2. Irrigator, with Cut-off 126 

63. Eamarch'a Cut-off (or Irrigation 12S 

54. Douche-pan 128 

56. Powder-blower 127 

56. Carcinoma Introltus Vaglnie. (Pbotomlcrograph by Oramm) 128 

67. Median Laceration of the Perineum. Sllng-like Action ot the Levator AnI 

Mainulned 131 

68. Lateral Lacerations of Perineum. Sllng-like Action of Levator AnI Destroyed. . 132 

69. Mathleus Needle Holder 134 

60. Curved Needles 135 

61. Author's Automatic Spring-eye Needle 138 

62. Peaslee's Perineum Needle 137 

63. Median Laceration of the Perineum, Extending up and Involving the Septum. 

Rectal and Vaginal Sutures Placed. (First and Second Steps) 138 

64. Median Complete Laceration of the Perineum. Rectal and Vaginal Sutures 

Tied, and Skin Sutures Placed. (Third and Fourth Steps) 139 

66. Perineorrhaphy (or Incomplete Laceration ot the Perineum. (Hegar's Opera- 
tion) 140 

66. Parkinson's Ether Inhaler 141 

67. Esmarcb's Chloroform Inhaler 141 

68. Lennlker's Leg-holder 142 

69. Tenaculum 142 

70. Emmet's Scissors 143 

71. Kelly's Pad 144 

72. Relaxed Perineum, the Result of Lateral Lacerations of the Perineum 147 

73. Perineorrhaphy (Emmet's Operation). Denudation (First Step) 149 

74. Perineorrhaphy (Emmet's Operation). The Crown and V-Shaped Sutures in 

Place (Second Step) 161 

75. Knee Scissors (or Flap-splitting Perineorrhaphy 153 

76. Perineorrhaphy. (Flap Operation. First Step) 164 

77. Perineorrhaphy. (Flap Operation. Second Step) 165 

78. Cystocele and Rectocele 158 

79. Operation (or Cystocele by Oval Denudation 159 

80. Stoltz's Operation (or Cystocele 160 

81. 82, 83, 84, 84a. Tbe Author's Operation (or Cystocele, comprising Ave cuts 

showing the successive steps of Incision, Dissection, Sutures, and Final 
Results 162, 183, 184, 165, 166 

85. Genital Flstulse. (Scheme) 169 

86. Tenaculum 170 

87. Kelly's Tenaculum Forceps 171 

88. Fistula Scissors 172 

89. Vesico-vaginal Fistula. (Denudation Operation. First Step) 173 

90. Fistula Needles 174 

91. Veslco-vaglnal Fistula. (Denudation Operation. Second Step) 175 

92. Vcslco-vaginal Fistula. Flup-spllttlng Operation. Bladder-wall Sutured 176 

93. Female Catheter 178 

94. Rubber Self-retaining Catheter 179 

95. Recto-vaginal Fistula. Sutures Placed 183 

96. Normal Position of the Uterus 185 

97. Uterine Ligaments, Showing them All on Same Plane 186 

98. Prolapsus Uteri 189 

99. Inflatable Ring Pessary 192 

100. Anteflexion: Flexion of Body on Cervix, Utero-sacral Ligaments Shortened 196 

101. Anteflexion: Flexion o( the Cervix on the Body 197 

102. Glass Stem Pessary 200 

103. Retroversion o( the Uterus 201 

104. Congenital Retroflexion o( the Uterus 204 

105. Bimanual Reposition o( the Retroverted Uterus. (First Movement) 206 

106. Bimanual Reposition o( Retroverted Uterus. (Second Movement) 207 

107. Bimanual Reposition o( Retroverted Uterus. (Last Movement) 208 

108. Rtpositlon o( Retroverted Uterus by the Sound 209 

109. Sims's Uterine Rcpositor (or Replacement o( the Retroverted Uterus 210 

110. SmIth-Hodge Pessary 211 

111. Thnmas-Smlth Pessary 212 

112. HodRe Pessary, Showing Varying Degrees o( Curvature 213 

113. Adjusting the Pessary 214 



LIST OF IIjLVSTRATIOXS. xiii 

TJO. PAQB 

114. Kellogg'i InatrumenU tor External Sbortenlog of tbe Round LIgamenU 215 

115. Kellogg's Operation tor External Sbortcnlng of the Round Ligaments. (In- 

cision) 216 . 

116. Kellogg's Operation tor External Sborten'.ng ot the Round Ligaments. Anchor- 

age of the Ligament. (First Step) 217 

117. Kellogg's Operation for External Shortening ot tbe Round Ligaments. Anchor- 

age ot tbe Ligaments. (Second Step) 218 

118. Kellogg's Operation for External Shortening of tbe Round Ligaments. Anchor- 

age of the Ligament. (Third Step) 218 

119. Bullet Forceps for Holding Uterus in Hystcrorrbaphjr. (Kelly's Operation) 220 

120. Ventrosuspension of the Uterus. (Kelly's Operation) 221 

121. Author's Button Forceps, for poking up tbe Round Ligament In Round Liga- 

ment Suspension of the Uterus 222 

122. Ventrosuspension of tbe Uterus. (Gilliam's Operation. First Step.) Passing 

a Thresd under the Round Ligament 223 

123. Retractor for Retracting Skin and Fat in Round Ligament Ventrosuspension of 

tbe Uterus 224 

124. Author's Perforating Forceps, for Piercing tbe Walls and Securing the Thread 

by which the Round Ligament Is Drawn Into Place 224 

125. Ventrosuspension ot tbe Uterus. (Gilliam's Operation. Second Step.) Piercing 

the Abdominal Wall and Grasping tbe Thread which Holds tbe Ligament 226 

126. Ventrosuspension of the Uterus. (Gilliam's Operation. Third Step.) Drawing 

up the Ligament through the Puncture In the Abdominal Wall and Securing 
it by Suture 226 

127. Rubber CoU 227 

128. Rubber OloTe 227 

129. Replacing tbe Inverted Uterus 228 

130. Reducing an Inverted Uterus by Splitting the Posterior Lip of tbe Cervix. 

(First Step) 229 

131. Reducing tbe Inverted Uterus by Splitting tbe Posterior Lip of tbe Cervix. 

(Second Step) 230 

132. Cystic Degeneration of the Cervix 233 

133. Granular Erosion of the Cervix 236 

134. Thomas's Suction Syringe for Removing Cervical Secretions 236 

135. Emmet's Applicator 236 

136. Uterine Dressing Forceps, tor Wiping away Secretions and Applying Tampon.. 237 

137. B.uttle's Spear for Puncturing the Cervix 239 

138. Artificial Leech for Abstracting Blood from tbe Cervix 240 

139. Supravaginal Elongation ot Cervix 241 

140. Hematometra 242 

141. Operation tor Pinhole Os. (First Step) 243 

142. Operation tor Pinhole Os. (Second Step) 243 

143. Alpha Syringe 248 

144. Volsellum Forceps tor Steadying the Cervix 249 

145. Author's Cervical Knife 250 

146. Heavy Scissors for Denuding the Cervix 260 

147. Emmet's Cervical Needles 261 

148. Counterpressure 261 

149. Denuding the Cervix 262 

150. Trachelorrhaphy. Sutures Placed. (Bmmot's Operation. Second Step) 253 

151. Trachelorrhaphy. Sutures Tied. (Third Step) ^ 2.S4 

152. Amputation of the Cervix. (Scbrocder's Operation) 255 

153. 154. Flap AmpuUtion of tbe Cervix Uteri. (Second and Third Steps) 256 

155. Shield and Forceps tor Twisting Wire Suture 257 

166. Cancer of the Cervix 262 

157. Sponge Tent 267 

158. Laminaria Tents 268 

159. IrHgatIng Stand 271 

160. Byford's Traction Forceps 272 

161. Bemays's Uterine Tractor for Insertion within the Canal 272 

162. Vaginal Hysterectomy. Freeing the Cervix Posteriorly. (First Step) 273 

163. Pean'a Retractors 274 

164. Vaginal Hysterectomy. Freeing tbe Cervix in Front. (Second Stop) 275 

165. Scissors 276 

166. Broad Ligament Forceps 276 

167. Vaginal Hysterectomy. Applying Clamp to Right Ilroad Ligament, the Left 

Being Id Place. (Third Step) 277 

168. TulBer's Anglotrlbe 278 

169. Vaginal Hysterectomy. (Fourth Step) 281 

170. Vaginal Hysterectomy. (Fifth Step) 282 



xiy LIST OF ILLUSTRATIONS. 

Fia. PAQB 

171. Paquelin Cautery 284 

172. Straight Cautery Knife 285 

173. Curved Cautery Knife 285 

174. Strong Curette for Cervical Cancer 286 

175. Uterus of Olrl of Fourteen. X 8 Diameters. (Pbotomlcrograpb by Oramm) . . 287 

176. Utricular Olands 28S 

177. Uterine Olands. Normal. (Pbotomlcrograpb by Gramm) 288 

178. Uterus: Huscularls Adjacent to Gland. Normal. (Pbotomlcrograpb by Gramm) 289 

179. Lymphatics and Lymphatic Glands of Uterus 290 

180. Lymphatics of the Uterus, Showing Route to Fallopian Tulie 290 

181. Endometritis. (Photomicrograph by Gramm) 291 

182. Streptococcus. (Photomicrograph by Gramm) 293 

183. Goodell's Cervical Dilator 300 

184. Dilatation of the Cervix • 301 

186. Irrigating Curette 302 

186. Emmet's Curette Forceps 303 

187. Cervical Speculum 304 

188. Lennlker's Packing Forceps, fcr Carrying Gauze into the Uterine Cavity 306 

189. Langstaff's Intra-uterlne Douche 306 

190. Berlin Glass Douche 307 

191. Cancer of the Dody of the Uterus 311 

192. Carcinoma of Uterus. (Photomicrograph by Gramm) 312 

193. Large Cervical Dilators, for Preparing the Way for Digital Exploration of the 

Uterine Cavity 318 

194. Slms's Screw for Removing Tampon 314 

195. Round and Spindle Cell Sarcoma of Uterus Degenerating. (Photomicrograph 

by Gramm) 316 

196. Fibrosarcoma of Uterus Removed by Panhysterectomy. (Author's Case. From 

Photograph) 317 

197. Sarcoma of the Body of the Uterus (Inverted). (Author's Case) 318 

198. Uterine Fibroma. (Photomicrograph by Gramm) 321 

199. Uterine Myoma. (Photomicrograph by Oramm) 322 

200. Positions of the Subserous, Interstitial, and Submucous Fibroids 323 

201. Method of Removing Pedunculated Subserous Fibroid by Turning Down a Cuff 

of the Peritoneum 323 

202. Large Spherical, Cervical Fibroid (Intraligamentous), Removed by Panhys- 

terectomy. (Author's Case. From Photograph) 825 

203. Interstitial and Multinodular Fibroids partially Intraligamentous. Involving 

Body and Cervix. Removed by Panhysterectomy. (Author's Case. From 
Photograph) 329 

204. Fibroid Polypus of the Fundus being Cut Away 330 

206. Large Submucous Fibroid Protruding through Os 330 

206. Multinodular Uterine Fibroid. (Author's Case. From Photograph) 331 

207. A Subserous Fibroid Simulating Retroflexion of the Uterus ' 332 

208. Straight Uterine Scissors 336 

209. Morcellatton of the Submucous Fibroid to Reduce Its Volume and Facilitate 

Delivery 337 

210. The Remnant of the Fibroid Leaving its Bed under Traction 337 

211. Morcellation Forceps 338 

212. Arterial Supply of the Genital Tract 339 

213. Doyen's Myoma Screw, for Lifting Uterus out of the CavUy 340 

214. Green's Retractors 340 

216. Halsted's Retractors 340 

216. Abdominal Hysterectomy. (First Step) 341 

217. Doyen's Straight Broad Ligament Forceps 342 

218. Pean's Curved Broad Ligament Forceps 342 

219. Abdominal Hysterectomy. (Second Step) 343 

220. Sponge Holder 344 

221. Deschamp Needle 344 

222. Cleveland's Ligature Carrier 244 

223. Abdominal Hysterectomy. (Third Step) 345 

224. Abdominal Hysterectomy. (Fourth Step) 346 

225. Kelly's Hysterectomy Spud *♦* 

226. Abdominal Hysterectomy. (Fifth Step) 347 

227. Abdominal Hysterectomy. (Kelly's Method) 348 

228. Abdominal Hysterectomy. Hemisectlon of the Uterus 349 

229. Wall of Fallopian Tube. Normal. (Photomicrograph by Gramm) 350 

230. Transverse Section of Fallopian Tube. Normal. (Photomicrograph by Gramm) 361 

231. Staphylococcus Pyogenes. (Photomicrograph by Gramm) 356 

232. Bilateral Pyoaalplnx. (Author's Case. Drawn from Photograph) 369 



LIST OF ILLUSTRATIONS. xY 

no. PAGE 

233. Tubo-ovarian Abscess. (Author's Case. Drawn from Specimen) 362 

234. Enlarged Tube and Ovarjr Simulating Retroversion o( the Uterus 368 

235. Improved Bed-pan 372 

23«. Salplngo-odphorectomy 382 

S3T. Tuberc?le Bacilli. (Photomicrograph by Oramm) 385 

238. Tuberculosis of the Fallopian Tube 387 

2S». Tuberculosis of the Fallopian Tube 388 

240. Pelvic Cellulitis 391 

241. Potaln's Aspirator 392 

242. Rubber Drainage Tube 393 

243. Operations through the Posterior Vaginal Fornix. Enlarging the Opening by. 

Stretching 394 

244. Ectopic Gestation, Showing Sites of Implantation of Ovum 399 

245. Ectopic Gestation. Rupture Into the Peritoneal Cavity 404 

24«. Ectopic Gestation. Rupture into the Broad Ligament 405 

247. Ectopic Gestation. Tubal Abortion. (Author's Case. Drawn from Specimen).. 406 

248. Hematocele 410 

249. Hematoma 4U 

250. Clamp Forceps for Arresting Hemorrhage 413 

iS\. First Thing to do In Ruptured Ectopic Gestation: Arrest Hemorrhage by Ap- 
plying Clamps 414 

252. Ripening Follicle, Human Ovary. (Photomicrograph by Gramm) 418 

253. Cortex of Ovary, Young Girl. (Photomicrograph by Gramm) 419 

254. Bacilli Coll Communis. (Photomicrograph by Gramm) 424 

2r>5. Oophoritis. (Photomicrograph by Gramm) 427 

236. Scheme Showing the Different Positions from which Cysts may Originate 433 

2.'>7. Glandular Cyst of the Ovary. (Photomicrograph by Gramm) 438 

KS. Papillomatous Ovarian Cyet, Woman Forty-seven Years Old. (Photomicro- 
graph by Oramm) 439 

2S9. Areolar Cyst 440 

ISO. Colloid Cyst, Ovarian. (Photomicrograph by Gramm) 441 

set. Ovarian Cyst with Double Pedicle. (Author's Case. Drawn from Specimen) .. 443 

262. Stalk of a Papillary Cyst 446 

263. Ruptured Papillary Cyst of the Ovary 447 

264. Ovarian Dermoid Containing a Switch of Hair Fourteen Inches Long. (Au- 

thor's Case. Drawn from Specimen) 451 

265. The Dull Area of an Ovarian Cyst. (Author's Case. Drawn from a Photograph) 461 

266. Ascites, Showing Resonant and Dull Areas 464 

267. Ascites with Patient on her Back, Showing Resonant and Dull Areas 465 

268. Ascites with Patient Vertical, Showing Resonant and Dull Aifcas 466 

269. Medium-sized Ovarian Cyst. Showing th^ Dull Area In the Center and the 

Crescentic Area of Resonance at the Top and Sides 467 

270. Large Ovarian Cyst, Showing Resonance In One Flank Only 468 

271. Taifs Cyst Trocar 472 

272. Ovariotomy: Tapping and Extraction of the Cyst 473 

273. Spencer Wells's Sac Forceps 474 

274. Ovariotomy: Tying the Pedicle 475 

275. William's Pedicle Forceps 476 

276. Enucleation of the Intraligamentous Ovarian Cyst 477 

277. Packing and Vaginal Drainage After Enucleation of an Intraligamentous 

Ovarian Cyst 478 

278. Ovarian Cyst Weighing One Hundred and Seventy-six Pounds. (Author's Case) 480 

279. Appendlcectomy: After LIgat'.ng the Meso-appendix Is Cut through and a 

Clamp Forceps Applied to the Root of the Appendix 507 

280. Appendlcectomy: a Purse-string Suture is Tightened Around the Inverted 

Stump of the Appendix 607 

281. Knapp'B Intestinal Forceps 507 

282. Murphy's Button 508 

28J. Kayo's Intestinal Needles 508 

284. Murphy's Button Forceps 508 

285. Connell's End-to-End Anastomosis. (First Step) 509 

28*. Connell's End-to-End Anastomosis. (Second Step) 509 

287. Connell's End-to-End Anastomosis. (Third Step) 510 

288. Connell's End-to-End Anastomosis. (Completion of Third Step) 510 

289. (^nnelPs End-to-End Anastomosis. (Fourth Step) 511 

290. (^nnell's End-to-End Anastomosis. (Completed) 511 

291. Lateral Anastomosis. (First Step) 61! 

292. Lateral Anastomosis. (Second Step) 513 

293. Lateral Anastomos'.s. (Third Step) 514 

294. Lateral Anastomosis. (Fourth Step) 514 



xvi LIST OF TLLrSTRATIONS. 

Fia. P-^oe: 

295. Adenosarcoma of Ovar7. (Photomicrograph bjr Oramm) AS 

296. Cyst of the Parovarium. (Author's Case. Drawn from Specimen) S^o 

297. Kelly's Calibrator «-» 

298. Cystostjope 52.^ 

299. Electric Cystoscope 52s 

300. Head-mirror Sa? 

301. Examination by Electric Cystoscope 527 

302. Position of Bladder Sphincter 532 

303. Method of Insertion of Mattress Suturea 633 

304. Urethral Dilator 638 

305. Skene's Endoscope 640 

30«. Metal Female Catheter 544 

307. Rubber Catheter 644 

308. Irrigating the Bladder 549 

309. Artificial Veslco-yaginal Fistula 561 

310. Artificial Veslco-vaglnal Fistula. (Kelly's Operation) 552 

311. Ambulatory Vrlnal 663 

312. Vesical Sound 657 

313. Sajous's Snare 560 

314. Showing Steps of Van Hook's Anastomosis Operation 664 

316. Kelly's Urethral Searcher 566 

316. Kelly's Evacuator 667 

317. Kelly's Urethral Catheters 668 

818. Kelly's Urethral Catheter 669 

319. Kelly's Bladder Forceps 570 

i 320. Harris's Segregator 575 

321. Tuberculous K!dney 689 

322. Mulberry Calculus of Kidney v 693 

323. Adenoma of Kidney 596 

324. Manual Dilatation of the Sphincters 608 

' 325. Mackenzie's Condenser 609 

336. Dividing Structures Overlying Fistulous Tract 628 

327. Proctoscope 610 

828. Kelly's Rectal Dilators 6U 

329. Rectal Supporter 616 

I 330. Cauterizing Prolapsed Bowel 616 

I 331. Cautery Iron 617 

; 332. Wight Ring Artery Clamp Forceps 617 

333. Truax'e Atomizer 619 

; 334. Cook's Rectal Speculum 624 

I 335. Plain Silver Probe 627 

336. Dividing Structures Overlying Fistulous Tract 628 

i 337. Wales's Soft Rectal Bougie 634 

I 338. Conical Rectal Bougie 635 

339. Blunt Curved Bistoury 636 

340. Wight's Angular Forceps 639 

341. Ligating Pile 641 

342. Pratt's T- forceps 642 

343. Kelsey's Hemorrhoidal Clamp 642 

344. Mathews's Rectal Forceps 643 

345. Clamping and Severing Pile 645 

346. Snaring off Polypoid Growth 646 

347. Kocher's Angular Forceps 647 

348. Malignant Stricture of Rectum 649 

349. Sterilized Rod passed through Mesentery 651 

360. Inguinal Colostomy 852 

361. Noble-BaldwlD Anastomat 654 



PRACTICAL GYNECOLOGY. 



INTRODUCTORY. 

Gynecology is the science that treats of the diseases peculiar to 
womiJi. As a special and distinct branch of medicine, gynecology is 
of cc-mparatively recent birth. Not many years ago all that was 
known and done in this line belonged to the province of general medi- 
cine. The practice of gynecology consisted, for the most part, in 
replacing the malposed uterus, the adjusting of pessaries, and the 
application of remedies to the cervix and uterine canal. The evolu- 
tion of gynecology into a distinct branch is due largely to the genius, 
enterprise, and indomitable courage of our own illustrious Sims. He 
is spoken of as the father of gynecology. The evolution of the branch 
has been rapid and marvelous. It has developed from a small bud 
on the body medical to a great overshadowing branch second in mag- 
nitude and importance to that of general surgery alone. Indeed, it 
has become distinctively surgical in all its aspects, and is more closely 
allied to general surgery in scope and character than any of the so- 
called specialties. America claims not only the distinction of giving 
birth to this great and beneficent specialty, but has maintained her 
position in the front rank of discovery and operative technique. At 
the same time our countrymen have been swift to adopt the views and 
practices of foreigners from any source whatever, when such have 
been found to be in the line of progress. The gynecologist of the 
last quarter of a century has been exceedingly active and aggressive, 
and it is to him we are indebted for many of the most wonderful 
achievements of surgery. It was he tiiat taught us the practicability 
and unfolded the wonderful possibilities of abdominal surgery. 
Once in the abdomen, he did not confine his sphere to the uterus and 

(1) 



2 PRACTICAL GYXliCOI.OGY. 

appendages, but, finding himself confronted by pathologic and abnor^ 
mal conditions of other organs, made bold to attack the same, and by 
persevering effort obtained the mastery. Thus it is that he now not 
only removes the uterus and appendages, with their multifarious 
growths and pathologic conditions, but includes therewith the sur- 
gery of the intestines, stomach, liver, spleen, and kidneys. The gyne- 
cologist must of necessity be an abdominal surgeon, and aa such 
allows no imaginary line to bound his sphere. 



CHAPTER I. 

GENERAL CAUSES OF DISEASES IN WOMAN. 

Thb foundation for much of the suffering of woman is laid 
in childhood and adolescence. If the process of development is 
eeriously interfered with at this period, the individual will never 
attain to that degree of physical and mental vigor to which she is 
entitled. It must not be forgotten that the mental and moral natures 
are intimately associated with and dependent on the physical. The 
apparent exceptions to this rule, as sometimes seen in interesting 
invalids, are only apparent, and if closely analyzed will disclose the 
fact that the mentality is of that scintillating type, and the morality 
of that fervid type, which are closely allied to aberration. The sound, 
evenly balanced mind belongs to a sound body. Not only is a sound 
body essential to a sound mind, but sound morals as well. It is a 
fact not generally understood that the moral being is inherently inter- 
woven with and closely dependent on the physical. An individual 
who, by reason of physical infirmity, is deprived of the legitimate 
pleasures incident to a healthy body is very prone to seek for them in 
other and forbidden channels. To a perfectly healthy man or woman 
mere existence is a pleasure, and they are usually content with exist- 
ing conditions. The North American Indian is kinder to his female 
children than we are to ours. With him the children of both sexes 
are on equal terms. With us the female almost from the cradle is 
placed under a different regime from her brother. Taught to ob- 
serve the proprieties from early childhood, she is denied the health- 
giving pleasures of the rougher sports. Her brother comes in from 
his play with glowing cheeks and a ravenous appetite, and when he 
seeks his couch it is to fall into a deep and refreshing sleep. She 
spends most of her time within four walls, is done up in stays and 
tight-fitting clothes, has little in the way of recreation, and that of 
the tamest sort, and to cap the climax is placed under tutorage at a 
tender age and is expected to compete with her sturdy brother in 
mental attainment. And what is the result? Simply that which 
might be expected : a frail and delicate body, a high-strung and un- 
stable nervous organization, and a hot-house brain. She has been 
reared and educated for invalidism, incapacity, and life-long suffer- 
ing. 

(3) 



4 PRACTICAL GYNECOLOGY. 

Happily the conditions portrayed above are not so prevalent to- 
day as they were a generation ago, and it is devoutly to be hoped that 
the reformation may continue until our women shall be bequeathed 
at least the same degree of health, strength, and vigor as her uncivil- 
ized cousin. There can be no reasonable objection to schools and 
mental training for the girl any more than for the boy, provided she 
be given the same opportunity for physical culture, and that cogni- 
zance be taken of her inherently more impressionable nature. Due 
allowance should also be made for that very critical period of her 
existence which comes with the establishment of the menstrual func- 
tion. It should be continually borne in mind that the transition 
period from girlhood to womanhood is much more important and 
freighted with weightier consequences than the same period in the 
male. It not only calls upon her normal energies, but makes heavy 
draught on her reserves; so that a diversion of these energies often 
works disaster. Competitive examinations and examinations for 
grade are among the most pernicious features of our school system, 
and should be abolished. 

SOCIAL STATE. 

Altered conditions of life and the social state are often respon- 
sible for the ills of woman. It is said that the African negro woman 
in her natural state and habitat is seldom, if ever, afllicted with uter- 
ine fibroma. Transplanted to this country and surrounded by the 
environments of civilized life, she becomes exceedingly prone to it. 
Women who change their mode of life often suffer from menstrual 
disorders. A sea-voyage will not infrequently cause a stoppage of 
the menstrual flow for many months. As between marriage and celib- 
acy there is little to choose. Married women are more prone to 
cervical cancer and the various accidents incident to parturition, such 
as laceration of the cervix and perineum, subinvolution, cystocele, 
rectocele, and prolapsus uteri. Single women and sterile married 
women are more subject to uterine fibroids and cancer of the body 
of the uterus. Celibacy brings its own train of evils incident to an 
unnatural mode of life. 

Malformation of the Female Sexual Organs due to arrest of 
development plays a role in tlie production of the diseases of women. 
Atresia of the vagina or uterine canal, with retention of the secretions 
and menstrual fluids, is one of the most common examples of dis- 
turbance arising from this cause. 



GENERAL CAUSfiS OF DISEASES IN WOMAN. 5 

Septic and Specific Infections are among the most common 
causes of disease in the female. A very large percentage of her 
ailments are traceable to one or the other of these causes. Septic 
infection occurs as the result of unclean handling of or operations 
on the genital organs or as the result of abortion or labor at term. 
It is almost without exception due to carelessness or ignorance on 
the part of the nurse or medical attendant. Gonorrheal infection 
is especially prevalent, and gives rise to some of the most serious 
ailments to which woman is heir. Both septic and gonorrheal in- 
fection may start in the lower genitals and by extension involve the 
entire genital apparatus, with the most disastrous results. 

PHYSICS AND PHYSIOLOOY AS APPLIED TO GYNECOLOGY. 

It has been said that the genital apparatus of woman is the 
pivotal point around which her life revolves. This, while meas- 
urably true, should not be taken too literally, lest it lead to a dwarfed 
conception of the scope and character of this branch of medicine. 
It should not be forgotten that the genital apparatus of woman is 
under the dominance of the same laws that govern the general econ- 
omy; that gynecology is not an isolated entity, but is closely allied 
to and intimately interwoven with general medicine. The man who 
limits his field of vision to the genitals of woman and gauges his 
practice accordingly will always remain a pigmy in his profession 
and a discredit to himself and his calling. Let it be understood 
and ever borne in mind that sound genitals belong to a sound woman, 
and that a sound woman is the product of heritage and a properly 
regulated life. Firmness of fiber, symmetry of form, grace, and 
beauty are all heritages of healthful habits and environment. 

Of all agencies which contribute to cell- life and energy, which 
multiplied means somatic life and energy, there is none that com- 
pares with the blood and its supply. The ancient dictum that the 
blood is the life has a broader significance than is usually accredited 
to it. Sudden and complete withdrawal of the blood from the tissues 
leads to speedy death; incomplete blood-supply leads to structural 
degeneration and functional incapacity. The blood is both food and 
air to the tissues, and it is the scavenger as well. It conveys the 
life-giving principles and takes away the effete and poisonous prod- 
acts of metabolism. 

The blood to fulfil! its destiny must be in circulation; stagnant 
blood can neither act as purveyor nor scavenger. Aside from the 



6 PRACTICAL GYNECOLOGY. 

heart's impulse, the circulation of the blood is promoted in many 
ways. Chief among the aids to circulation are pressure upon or 
contraction of organs, muscular action, and the movements of res- 
piration. These are sometimes merged, but can best be considered 
under separate heads. 

1. Pressure Upon or Contraction of Organs. — Beginning at the 
distal extremity of the circulatory apparatus, — ^that is, in the organs 
or tissues, — pressure or squeezing gives the initial impulse to the cir- 
culating fluids, empties the lymph-spaces, and presses the fluids 
forward into the venous radicles and lymph-channels. With the suc- 
ceeding relaxation — for it must be imderstood that the pressure to 
be eflfective must be intermittent — the freshly charged blood pushes 
in, fills all the ramifications of the capillary system, and discharges 
its freight of food and oxygen into the tissues. 

2. KuBonlar Action. — Muscles in action contract, swell up, and 
become firm. In so doing they compress the veins and displace the 
blood, which, owing to the system of valves with which they are pro- 
vided, can only go in one direction : that is, toward the heart. This, 
like the foregoing, to be eflScient must be intermittent, as steady 
pressure prevents the refilling of the veins and hinders rather than 
facilitates the circulation. This accounts for the fatigue resulting 
from standing. 

3. Hovements of Bespiration. — The movements of respiration 
are duplex, and affect alternately the two great cavities : the thoracic 
and abdominal. With inspiration the chest expands, the diaphragm 
descends, and the abdominal and pelvic viscera are displaced down- 
ward. With the expansion of the thoracic cavity there is a coin- 
cident contraction of the abdominal, due to the descent of the dia- 
phragm. This causes an increased intra-abdominal pressure, in 
which the viscera are squeezed and emptied of their contents and 
the vessels compressed as in muscular action. Synchronously with 
the expansion of the chest the thoracic vessels are dilated and the 
blood drawn into them. In expiration the chest contracts, forcing 
the blood into the heart, while at the same time the abdomen ex- 
pands, allowing the abdominal vessels to refill from those in the 
extremities. 

Another effect of the alternate movements of respiration is the 
alternate ascent and descent of the abdominal and pelvic viscera. 
If the perineum be retracted and the cervix uteri exposed to view, 
its upward and downward movements corresponding to those of res- 
piration become conspicuously manifest They are depressed in 



GENERAL CAUSES OF DISEASES IK WOMAN. 7 

inspiration and lifted upward in expiration, the upward movement 
of the diaphragm exerting a suction force. This suction force, which 
is otherwise known as the retentive power of the abdomen, will be 
more fully considered in connection with the uterine displacements. 
The movements of the viscera would be much more conspicuous if 
the abdominal walls were rigid and imyielding, and as it is they are 
lai^ly influenced by their fimmess and resiliency. The effect is to 
give exercise to the muscles and ligaments contributing to their vigor 
and strength, and the rhythmical impact of one viscus upon another 
acts as a gentle massage. It will be seen then how important to the 
welfare of the individual is the unrestrained play of the forces under 
consideration. 

This leads us to the subject of dress. 

DRESS. 

The object of clothing is to protect the body from the extremes 
of heat and cold, from wind and water, from mechanical and chemical 
irritants with which it may be brought in contact or which may be 
brought in contact with it. Esthetically, clothing is worn to cover 
nakedness and as an adornment. The ideal dress should be as light 
as compatible with comfort, and dry and clean. In weight and quality 
it should be adapted to the climate and season. The under-garmenta 
especially should be open-mcshed, to provide for ventilation and give 
ready exit to the exhalations of the body. They should be elastic to 
accommodate the various postures of the body, and there should be 
no constriction to hamper movement, embarrass circulation, or in- 
terfere with muscular action. The clothing should be evenly dis- 
tributed and protect all parts. Thinly clad or bare extremities with 
a surplus of clothing about the hips is bad hygiene. Beauty of dress, 
80 called, should give way to utility and liealthfulness. 

But our ideas of beauty are largely influenced by habit and edu- 
cation. A pretty girl in a bizarre habit would not be pleasing to the 
eye and would excite unfavorable comment, but if all the girls were 
to adopt a like habit it would not be many months until we should 
begin to look upon it with favor. The fact is, it is the woman that 
adorns the dress, and if by virtue of this fact man can be brought 
to endure or even admire a habit of dress that is pernicious and con- 
ceals the real beauty of form, that hampers and distorts it, how much 
more would he revel in a garb conducive to health and comfort, 
normal development, and unrestrained movement 1 



8 PRACTICAL GYNECOLOGY. 

It augurs well for women that in late years there has been an 
effort in the direction of dress reform. It is unusual now to see a 
woman tightly laced or with high-heeled, tight shoes. Garters are 
almost a thing of the past. Still, there is room for improvement, 
and the crusade against unhygienic dress should never be abandoned 
until the ideal is attained. Many women wear high and close-fitting 
collars. These, by pressure upon the windpipe, the cervical vessels, 
and muscles give rise to embarrassed respiration, headache, disturb- 
ance of vision, and cerebral congestion. The neckwear should never 
come higher than the middle of the neck, and should not be close 
fitting. It may be supplemented, when necessary, by a scarf loosely 
applied. 

The most serious fault of the conventional dress of to-day is the 
constriction and immobilization of the middle portion of the trunk 
by means of waist-bands and corset. By constriction of the waist 
and in proportion to the tightness of constriction the breathing ca- 
pacity of the chest is diminished, the upward and downward play 
of the diaphragm inhibited, the underlying viscera compressed, the 
abdominal contents forced downward, which in turn crowd upon, 
confine, and immobilize the pelvic viscera, and in general derange 
the normal physiologic processes dependent on unrestrained action 
as set forth in the preceding section. The corset splints the chest 
and abdomen to the extent of its length, abridging muscular action 
and destroying natural flexibility. As a result, the trunk-muscles 
lose tone and become atrophied. They are incapable of performing 
the functions for which they were intended, and the woman becomes 
dependent on the corset for support. She has a weak back, and col- 
lapses when the artificial support is removed. Handicapped by such 
restrictions, she is not disposed to attempt healthful exercise, from 
which, under the circumstances, she could at best only receive scant 
benefit. 

Exaggerated portrayal of the evils resulting from the use of 
waist-band and corset can avail nothing. The best way to antagonize 
evil is by truthful delineation of its effects. Everybody knows that 
women survive these incumbrances and in many instances enjoy a 
fair degree of health. This is due, in part, to the fact that woman 
is a chest breather; that diaphragmatic respiration is not so neces- 
sary to her as to man. This is a provision which adapts her to the 
office of maternity. With her a full-terra pregnancy, which not only 
fills, but distends the abdomen does not greatly embarrass respira- 
tion, and it is a notable fact that tumors and dropsical effusions of 



GENERAL CAUSES OF DISEASES IN WOMAN. 9 

the abdomen are much better borne by her than by man. Her im- 
munity is furthermore due to the resourcefulness of Nature, whereby 
apparently insurmountable difficulties are met by expedients well 
known to the pathologist. Instance the collateral circulation by 
which Nature averts the evils of an occluded blood-vessel. Never- 
theless a woman cannot violate the laws of health with impunity. 
The day of reckoning will come and is here, though she does not 
realize it. Civilized woman is not what she ought to be nor what 
she might be, by reason of dereliction in dress. The subversion of 
physiologic processes tends to physical degeneration and loss of 
strength and endurance. It strongly predisposes to disease, and 
reduces her to a condition of semi-invalidism. Women of this type 
sometimes make interesting invalids, but the pallid, languid, nerve- 
racked beings who pose as such are in no wise comparable to the 
splendid specimens of bright-eyed and buoyant womanhood as we 
get them from the hand of Nature. 

The proper dress of woman should consist of one, and usually 
two, layers of clothing which conform to the shape of the body 
including the lower extremities. This is necessary in order to pro- 
tect that portion of the body below the waist-line from the under- 
currents of air which sweep up under the skirts. The under-garment 
should be of one piece, — a union suit, — and should be made to fit 
snugly at the ankle. The material should be open-meshed, and con- 
sist of wool, silk, or linen. The superincumbent clothing may be 
in one or two pieces, but should be directly or indirectly hung from 
the shoulders, and preferably so fashioned as to distribute their 
weight and support as evenly as possible over the surface of the body. 
A good part of the weight may be borne by the hips. There should 
be no waist-bands. In a woman with normal development of the 
trunk-muscles there can be no reasonable objection to suspending all 
the clothing from the shoulders. The ungirded flowing robes of the 
maids and matrons of ancient Greece were picturesque and beautiful 
and incomparably more attractive than the dress of to-day. Trailing 
skirts, however, should not be used for street-wear, as they gather 
Tip the tuberculous sputum and other germ-infested media, which 
after drying are brushed off in the living-room, to be thrown into the 
air with every sweeping. When women cannot be induced to discard 
waist-bands, — and to be candid there seems to be little probability 
of such a desideratum in the near future, — a short, loose corset is 
preferable, as it helps tp sustain the clothing, wards off pressure, and 
to an extent diminishes constriction. 



10 PRACTICAL QYNECOLOaY. 

MUSCULAR EXERCISE. 

American women are peculiarly derelict in mnscnlar exercise. 
In this respect they compare unfavorably with the women of Eng- 
land and continental Europe. There are few things that contribute 
more to the physical and mental well-being of the individual than 
properly regulated exercise. Muscular exercise stimulates circula- 
tion, promotes oxygenation of the tissues, conduces to physiologic 
ruetabolism, develops the muscles, reduces fat, and increases the 
activity of the brain. In a test made at the Elmira Reformatory 
with twelve dull boys whose average in studies for the preceding six 
months was 45 per cent., a course of physical culture brought the 
average up to 74 per cent. "With physical culture," says Dr. Wey, 
"there came an awakening and cerebral activity never before mani- 
fested in their prison-life; the dull and stolid look gave way to a 
more intelligent expression, and the eye gained a brightness and 
brilliancy that before was conspicuous by its absence." 

Physical exercise, to be of the greatest advantage, should be 
judicious and timely; it should be tempered to the individual and 
regulated as to time and duration. What would be a pleasurable 
recreation for one might be a harmful physical exertion for another. 
Active exercise should never be taken on a full or empty stomach 
or under conditions of great fatigue. It should never be" so violent 
as to induce labored respiration nor so long continued as to produce 
exhaustion. Exercise under the restraint of improper clothing is 
bereft of half its benefits. It should always, if possible, be made 
an occasion of diversion and pleasurable emotion, and varied accord- 
ing to inclination. Solitary walks or monotonous processions with 
the sole object of exercise are too funereal to be of much benefit. 

The best time for exercise is after rest, sleep, and refreshments : 
that is, in the morning. Walking, horseback-riding, bicycling, swim- 
ming, or even running in moderation are among the best exercises 
for general effect. Of these, walking has the greatest range of use- 
fulness. Horseback-riding is exhilarating and salutary. The late 
Dr. Frank Hamilton used to say that one of the best things for a 
man's insides was the outside of a horse. Whenever the weather 
conditions permit, exercise is better taken in the open air. Women 
in full vigor and properly clad may brave the elements and take 
some form of out-of-door exercise in all conditions of weather. A 
light, airy chamber is the next best substitute for out-of-door exer- 
cise. Properly directed physical culture, dancing, or games requir- 



GENERAL CAUSES OF DISEASES IK WOMAN. H 

ing the exercise of all the muscles, or even house-work, if engaged 
in with pleasiirable zest, may be of great service. Weakly women 
and women of indolent turn should be inducted into habits of ex- 
ercise by gradations. They will usually require restraint at first 
and encouragement later. Congenial company and emulation are 
strong incentives to exercise. Women with pelvic affections should 
refrain from active exercise during exacerbations of the same and 
during, immediately before, and after menstruation. Some women 
may not be able to engage in active exercise. For such, passive ex- 
erdse or massage may be substituted. 



CHAPTER II. 

OYNECOLOOIC EXAMINATION. 

As IKTIHATED in the preceding chapter, the gynecologist does 
not confine himself to the reproductive organs of the female. His 
domain extends from the diaphragm to the pudendum. Nor could 
he limit himself within narrower bounds if he would, for oftentimes 
through mistaken diagnosis, or from injury to or implication of 
other organs, he will be compelled to deal with them or retire igno- 
miniously. Therefore in his examinations he must include the 
external organs of generation, the uterus and its appendages, and 
the entire abdominal region. 

The first essential to a successful examination of affected organs 
is a thorough acquaintance with the normal anatomy and relation 
of parts, and a familiarity with them as acquired by the use of the 
various methods of examination. This is acquired only by protracted 
and painstaking effort. To the beginner, one part is very like another 
and their differentiation exceedingly difficult. It is, as aptly re- 
marked by Morris, like seeking for the middle ounce of mush in a 
kettle of mush. The tyro in gynecology may have eyes and ears and 
touch as acute as his preceptor, and yet he will fail to note the 
pathologic changes or to distinguish one part from another. It is 
thus in all departments of life. A man in a strange city amid the 
medley of sights and sounds will not be able to distinguish the 
usual from the unusual. He will probably not even note the fire- 
alarm. He has eyes, but sees not; ears, but hears not; fingers, but 
feels not. In time and by practice the student begins to distinguish 
first one and then another of the points of differentiation, until 
finally, if persevering and earnest, he becomes proficient in the use 
of his senses and faculties in the mapping out of organs and the 
detection of pathologic changes. 

The next essential is method. No man can become an expert 
and safe diagnostician unless he is habitually methodical. The man 
who is not methodical in his examinations will often overlook some- 
thing of importance, and occasionally the main factor in the case. 
He must tdce nothing for granted, some very damaging blunders 
having been committed by excellent diagnosticians from negligence 
in this respect The pregnant uterus has been mistaken for an ovarian 
(12) 



QYNKCOLOGIC EXAMINATION. 13 

cyet, and many other mistakes of more or less serious import have 
been committed, not from incapacity, but because of inattention or 
carelessness. He must cultivate the habit of observation. He must 
always be on the alert; he must use all his senses at all times; and 
especially must he rely upon the sense of touch, for it is upon this 
he will have to depend more than all the others combined. It is 
remarkable to what degree the sense of touch can be developed. By 
the tips of his fingers the expert can develop a mind-picture of an 
organ as perfectly as though it lay exposed before his eyes. By this 
he can determine its size, shape, consistence, and position. It is a 
favorite saying among teachers that the would-be gynecologist must 
develop an eye on the end of his index finger. 

It is good to keep a record of your cases, both for the purpose 
of engendering habits of accuracy and for future reference. Often- 
times the previous history of the case will be of great value. A record 
is also of value as a source from which to compile data and elaborate 
scientific deductions. It will entail some labor and take some time, 
but, once the habit is formed, it will fall in with the daily routine 
and cease to be a task. The record should be simple, and yet so 
elastic as to include all that is necessary. After much thought I have 
adopted the following, which answers the purpose quite well: — 

Case No '"»• Date January 1, 1903. 

Name Ma ry Smith. AnE »^ 

BESinENCK Columbus. O. SOCI AL STATE >'"•"'"'• 

Diagnosis Pyoaal plDX-bilateral 



TbBATMEKT Double S«lplDgo.o6phorectomy. 



nionw APnun January 22, 1903. Rrhitt.t Recovery. 

Sex Page 

These forms, which contain the essential items common to all 
cases, constitute the body of the book, and are printed two on a page. 



14 PRACTICAL GYNECOLOGY. 

In the back part of the book a certain number of pages — say, one 
page to five of those described above — are reserved for a more com- 
plete description of the case. These pages are headed : — 

Foix Eepobt of Cask No. Skk Paok 



Here also only essential facts are recorded; but as an aid to 
accuracy and methodical description it is well to have a list of ref- 
erences written or printed on card-board including in regular order 
all the details of an exhaustive examination. This can be glanced 
over at the time of making the record. 

Preparation of the Patient. — As a preliminary to all examina- 
tions, it is necessary that the bladder and bowels be empty. For 
this latter an efiBcient cathartic should be administered the night 
before. A full bladder or loaded rectum increases reflex excitability 
and adds materially to the difficulties of an examination. A loaded 
rectum, by encroaching on the pelvic space, offers mechanical ob- 
stacles to vaginal manipulation and renders rectal exploration well- 
nigh impossible. At home the patient should be clad in a night-dress 
or loose wrapper; but at the office this is seldom practicable. She 
should, however, on all occasions be as simply and as loosely clad as 
possible. Tight-fitting and superabundant clothing are effectual bars 
to a satisfactory examination. All constriction should be removed 
from the waist, so as to allow perfect freedom of the respiratory 
movements and natural adjustment of the various organs. The waist- 
bands should be unfastened; the corset and corset-cover removed; 
and, in fact, every close-fitting garment from surface to skin should 
be unbuttoned, unhooked, or untied. It is also better that the drawers 
be removed; and, if closed, this becomes imperative. It will not 
do to slip them down to or below the knees, as this binds the legs 
together. Women will often insist that their clotliing is loose, or 
will merely "let them out" here and there; but firm insistence on 
the part of the physician will usually enforce compliance, and she 
will esteem him all the more for it. As a hint to beginners, I will 
Bay that nothing serves to allay the embarrassment of both patient 
and physician so effectually as scrupulous and minute attention to 
the details preliminary to examination. It carries with it a business 
air that assures and pleases the patient. 

Hethodi of Examination. — In making gynecologic examinations 
we employ sight, touch, hearing, and occasionally the sense of smell. 
It is seldom that one of these methods is relied upon to the exclusion 
of others. As a rule, two or more of them are combined. Instru- 



QTNBCOLOGIC EXAMINATION. 16 

ments are frequently used as accessories when the part to be exam- 
ined is not accessible to the unaided senses. The sense of smell plays 
a very unimportant r61e in gynecologic examinations, but is some- 
times suggestive, as in the case of advanced cancer and in certain 
septic conditions of the genital tract. In speaking of the various 
methods of examination, all that can be done in this connection is 
to cite a few illustrative applications to a general principle. 

Examination of the Abdomen. — The abdomen is examined by 
inspection, palpation, percussion, and auscultation. 

Inspection. — ^The woman clad in her ordinary night-attire is 
placed on her back in bed or on a table and the abdomen exposed. 
Motives of delicacy will dictate that all parts of her person not neces- 
sary to a thorough examination should be covered. A glance at the 
abdomen will apprise us of the surface indications. Linae albicantes 
tell the story of a pre-existing abdominal distension, usually, but not 
necessarily, from pregnancy. They may arise from any form of pro- 
nounced and prolonged abdominal distension. Large veins indicate 
interference with the venous circulation, and are often associated with 
intra-abdominal growth. They are especially significant of malignant 
growth. 

The size and contour of the abdomen are to be considered. A 
symmetrical enlargement may be due to tympany, a deposit of fat 
in the abdominal walls, ascites, or cystic or solid growth. To the 
practiced eye there is a diiference in the appearance of the fatty and 
tympanitic abdomen. An ascitic abdomen is somewhat flattened at the 
top and bulges laterally, while an abdomen containing a cyst or solid 
growth is more moimd-shaped. A small abdominal growth may be 
situated eccentrically : may lie to one or the other side of the median 
line or in the upper or lower zone of the abdominal region. Some 
abdominal growths or encysted fluid accumulations are irregular in 
outline. In these the abdomen is asymmetrical in appearance. The 
thickness and firmness of the abdominal walls and the mobility or 
fixedness of the growth have much to do with the surface indications. 

Palpation of the abdomen is more instructive than inspection. 
The patient should lie on her back, with the limbs partially flexed 
and the abdomen bared. Palpation may sometimes be conducted 
under cover, but this does not allow of that freedom of manipulation 
that insures the best results. The finger-nails should be trimmed 
close, the hands well warmed, and the manipulations begun in the 
gentlest manner. Cold hands or abrupt digging into the abdominal 
walls are apt to frighten the patient and lead to willful or reflex hard- 



XG PRACTICAL GYNECOLOGY. . 

ening of the walls. By gently passing the hands over the surface 
of the abdomen, followed by gradually increasing pressure and mass- 
age, the patient's fears are allayed and reflex muscular contractions 
obviated. Sometimes by engaging the patient in conversation her 
thoughts may be diverted from herself with happy effect. It is 
sometimes necessary to instruct the patient to relax the abdominal 
muscles and to breathe regularly. "Let yourself go and don't hold 
your breath" are injunctions frequently used. It may be necessary 
to anesthetize the patient. In difBcult cases deep palpation may some- 
times be accomplished by depressing the walls simultaneously with 
the expiratory movement, maintaining the pressure during inspiration, 
going deeper at the next expiration, and so on until the object is 
attained. 

Both hands should be used, and, if a tumor or other mass be found, 
the hands should be placed over it palm to palm, the ulnar edges resting 
over the center or most prominent part of it and then separated, 
hugging the tumor all the while until they have reached opposite 
sides of it. In this way its location, size, and general contour can be 
made out, and, by a rocking movement, its mobility or fixedness. 
The effect of the respiratory movements on the growth is sometimes 
of diagnostic value. All intra-abdominal growths of moderate size, 
when not fixed by adhesion, ascend and descend with the movements 
of the diaphragm in respiration. On the other hand, a tumor of the 
kidney is not thus affected, because it is not in the peritoneal cavity 
and is not subject to intra-abdominal influences. The range of mo- 
bility and the direction of the same are of like import. A movable 
kidney will swing through a larger arc and will approach nearer to 
the median line than a distended gall-bladder. Pelvic tumors when 
movable describe an arc about the pelvis. 

Percussion. — Cystic tumors and accumulations of fluid in the 
abdominal cavity may be recognized by the fluctuation-wave com- 
municated to them by percussion. By placing a hand on one side 
of the abdomen and with the fingers of the other tapping lightly the 
opposite side, a wave of fluctuation will be felt. Sometimes, and 
especially in fat women, this maneuver will elicit a thrill that is hard 
to distinguish from the true fluctuation-wave. This is easily elimi- 
nated by making an artificial diaphragm in the abdominal wall be- 
tween the percussing and palpating hand. This is usually done by 
an assistant, who applies the ulnar edge of his hand along the middle 
line of the abdomen and makes firm pressure. This in no way inter- 
feres with the impulse-wave of fluids within the cavity. It is well to 



GYKECOUMJIC KXAMINATION. If 

remember that the fat-wave will not cross the umbilicus, and in the 
absence of assistance a very satisfactory and reliable examination can 
be made by keeping the umbilicus between the two hands while per- 
cussion is made from different points. 

It is sometimes necessary to shift the position of the patient in 
order to relax certain sets of muscles, or to bring the part sought 
for within easy reach. Thus, for examination of a movable kidney, 
the patient is placed on the side opposite to the kidney to be exam- 
ined, with her body slightly bent forward and the limbs flexed. Per- 
cussion is a very valuable aid to diagnosis. In ascites, when the fluid 
is free in the abdominal cavity it always gravitates to the lowest point 
according to the position of the patient. Likewise the intestines when 
not bound down, being light and filled with gases, will float to the 
surface and occupy the highest level. If the patient lie on her back 
the crest of the abdomen will yield a tympanitic resonance on per- 
cussion, while the flanks will be dull. If she lay on one side or the 
other, or assume the sitting or standing posture, it will always be 
found that the fluid is below and the gases uppermost, as isdicated 
by the percussion-note. An ovarian cyst, a solid tumor, or an en- 
cysted fluid accumulation will yield the same percussion-note in all 
positions; that is, it will be dull over the mass and resonant at the 
sides. In the diagnosis of abdominal growths percussion is often 
of more value than inspection or palpation. 

Auscultation of the abdomen may be practiced by the ear directly 
or through the medium of the stethoscope. Considerations of deli- 
cacy should not prevent us from making use of tiiat method that will 
give the best results. The patient should lie on her back within easy 
reach, and the examiner should have a comfortable position so as 
uot to interfere with his breathing or circulation. It is often neces- 
sary to determine the presence or absence of pregnancy or the life or 
death of the fetus in utero. By auscultation we can detect tlie fotal 
heart-sounds and the uterine and placental sounds incidental to preg- 
nancy. We can also detect the purring of hydatids and the friction- 
Bounds of the peritoneum. In obstruction of tlie bowels the bor- 
borygma of violent peristalsis is a valuable aid to diagnosis, while, on 
the other hand, an absence of the peristaltic sound would indicate 
intestinal paralysis. 

Examination of the External Genitals and Pelvic Structures. — 
These examinations, when practicable, sliould always be made on a 
table. The table should be provided with stirrups or a foot-rest, so 
that the patient's hips may be brought well down to the end without 

2 



18 



PRACTICAL GYNECOLOGY. 



cramping Uic limbs, Tliere iire niouy olcgant tables and gynecologic 
cliaii-s on the market, ami tin; differuncts bt-twoi'n them are not so 
niarkeil nor so essential us to eall for special liititinetiun. As between 
tables nn<l ebairs, it may be ^uid tbat tbe tabic alone is adapted to 
tbe operating-room. For otiiec use tbe ebuir is a little more elegant, 
takes up less room, ani\ answers the purpose of nrdinarv practice. 
The patient — prepared as indicated above — takes ber position on the 
table, her feet are placed in the stimips, a cover thrown over her, 
and the clothing drawn up so as not to interfere with tlio necessary 
manipulations and observations. 




4 



Fig. 1. — Author's Operating Table. 



The special features of this table, aside from its general conforma- 
tion, are: — 

1. An extension rod, wliirh slides in and nut at the foot of the 
table. 

2. The legholders, which fit into the posts and which can be set at 
any height by means of a set screw. 

3. A revolving in.^trument tray, which is attached to the legholder 
and can be raised or lowered at will. 

\. The bodv lift, plain, or provided with movable side brackets to 

fix the kidney during operation and to keep the patient from rolling. 

5. The shoulder supports, which are small, neat, and movable. 



OWKCOT/X;iC KXAXriXATlON. 



19 



They are hingetl at tlio fides of tlii> tiildp anil run he adjusteil imme- 
diaU'lv for iiise or (umiMl undfr tlie tnbU' itut itf the way. 

Ci. A support for reital trrntnifiit or iniiintaininjr the kiiec-chest 
posture. Tills is i'lTe<'te<l hy a strap fxlendiiif? from onu legliolder to 
the Cither at a proper lui'ilit; tlio patient l<nccl8 on tlie shelf, covered 
hy a blanket, liis body tlirown forward over the strap. 

7. The sliicld lu-tween the anejstiietist and operator, which fits 
snugly around the end of the table wlien not in use, and which can be 



Fig. lo- — Aulliur'a Oiwrntiiij; Tutile. 



raised to tlie vcrtirai or any desired anjjli- and lixed hy a set screw 
■when nee»led. 

The extension rod at tlie end of the table has many uses: (a) In 
vaginal or reetal operations, a towel tiirown over it protects the 
s^ittures from contact with liie drop leaf, (b) Drawn out a little 
farther it makes a foot-rest for the patient in examination or treat- 
ment, (c) It acts as a dotiche-pan holder in operations on the vagina 
or re<tuu». (d) I'ullcd out so as to allow the legs to be lowered 
thnnigh it and strapped to tlio drop, the same douche pan placed 



30 



PRACTICAl. HYXWOWWY. 



In'twirn tlu* end of tlie o\ti'iu>ion rml nml Hid patient's knees nets a* n 
ri'Cfpliu'li' r<ir tMilid (ip(inj:cs in iilxloiiiiiiiil "[MTiititms. {>•) Bv plnciiifj 
till* iilii'll fi'iini under tlir liili e i>n it iind ii(ljii.''liii^ llir I'xtciision rod 
U> the ien<;tii of t\iv patient, n full k-ii<.'Ui tnlde in obtained exactly 
fitted to tlie stultire (if the piitieiit. I'lverv attju'linient i* an integral 




Kig. It/.— Author'* 0|M<rutiug Tublu. 



part of Uie tnlde and always at hand, there lieing no pieces to lay 
n«de and gatlier up when nettled. 

It is projM?r to siiy that the stand siijjhtly elianpod is constructed 
after the fii-sliion of the Ualdwin tahle. 

In»prvl\on of the Erlcrnal Grnitnh. — The cover may now be 
thrown hark over the knees, or depre.at'wl between the thigliH and the 
exaniiniition niitde l.hroujih a i*lit. Many [intients will resent un- 
neeessan- exposure, and this part of the cxatnination ghould be made 



GYNECOLOGIC EXAMINATION. 21 

with as little exposure as is compatible with thoroughness. Tlic 
inspection should not only include the external genitals, but also all 
contiguous parts. Thus, the anus, perineum, fourchette, labia ma- 
jors, nymphse, vestibule, clitoris, hymen or its remains, urethra, and 
even the orifices of the small ducts of the vulvo-vaginal glands should 
be inspected successively and critically. For your own protection 
sores and discharges should be closely examined, to guard against 
syphilitic infection. This has happened repeatedly to physicians, 
and offers a strong reason for inspecting the external genitals before 
resorting to digital examination. If docnicd advisable, the lower 
s^ment of the anterior wall of the rectum can be brought to light 
by everting it from the vaginal side. A finger is introduced into the 
vagina, palmar aspect backward, and by a circular sweep carries the 
tiseues toward and through the anal outlet. In women of firm fiber 
this is often very painful. In others it is quite devoid of pain and 
easy of accomplishment. 

Digital Examination. — After careful inspc^ction of the superficial 
parts the examination is continued by the sense of touch. This, which 
is known as the digital examination, is made by the index finger of 
the right or left hand. The left hand is preferable for examinations 
of the left side, and vice versa. The beginner sliould practice with 
both so as to become ambidextrous. For deep touch, and in some 
other conditions, two fingers are used to better advantage than one. 
The finger — well lubricated with vasclin, soap, or some other bland 
lubricant — is carried up to the va<;inal vaiilt and careful note made 
of all essential features along its route. The firnineps or laxity of the 
canal, the temperature, the dryness or moisture, the jiresence of 
morbid growths, cicatricial hands, etc., pl.ould all he taken into ac- 
count. Then the cervix should he invcstijratcd as to its position, size, 
shape, consistence, smoothness or irregularity, and the condition of 
the OS. 

Rectal Indagaiion. — In vir^^ins with intnct hymen, and under 
some other conditions, it is desirable to c-undiut the dijiital examination 
by the rectum. (Fig. 2.) Ky this route much valuahio information 
may be obtained as to the position and fri'iicral coiulition of the pelvic 
contents. Properly conducted uiuler favorin^r conditions, it is occa- 
sionally more satisfactory than the va^rinal examination. Ks[)ccially is 
this the case in relation to (he contents of the posterior se-riiKMit of 
the pelvic circle. In the nornial po.-itioii cif the utenl^ the cervix is 
within easy reach, and in case of relro\cr>ioii the fundus and uterine 
appendages are more accessible than in vaginal indagation. 



• PRACTICAL «YNECOLOaT. 

For more thorough examination of the uterus and its adnexa, 
the cervix should be seized by a tenaculum or bullet forceps and 
drawn down. This gives little or no pain, as the cervix is compara- 
tively insensitive. By the aid of this maneuver tlie uterus and ap- 
pendages are brought within easy reach of the examining finger, and 
can lip palpated both behind and in front The advantages of this 



Fig. 2. — Bimftaual Examination with Finger in the Rectum. 



metliod of examining the pelvic organs are not sullieioutly under- 
stood. 

bimanual Examination. — Having explorpd the vaginal canal, the 
finger unaided has reached its legitimate boundary. For further in- 
formation concerning the jielvic viscera it is nwessary to resort to 
bimanual examination. In this both hands are used, one being placed 
on tlie abdomen just above the pelvic brim and one or more fingers 
of the other hand in the vagina. The object is to bring the pelvic 



OYKECOLOQIC EXAMINATION. 



23 



etructures, one after another, between these two hands, in order to 
determine their pliysical condition by tlie sense of touch. If the 
nterufl be in normal position, a linger ])laced on the cervi.x while the 
outside hand presses downward just above the symphysis pubis will 
bring the organ between thera. It will be recognized as a more or 
less resistant body, and the cervix is felt to move distinctly when 



J 



•-■. ' 



\ 



/■ 



t 



JNt:-^"^ 



# 



v 



Fig. 3. — Bimanual Examination. 



impulses are communicated to it through the body of tlie organ by 
the outside hand. (Fig. 3.) To depress the abdominal walls the ulnar 
aspect and tips of the fingers should be used. The uterus, having 
been located, should be e.xplored systematical ly. The vaginal finger 
is drawn forward and upward so as to rest on the anterior surface 
of the body of the uterus. Now, by the conjoint action of the fingers 
on the anterior and posterior g\irfaces, the organ is gone over in detail, 
and its size, shape, and consistence determined. 




2i PRACTICAL GYNECOLOUY. 

There are several ways of employing the sense of touch in exam- 
ining the pelvic organs, each of which has its advantages under vary- 
ing conditions. One is to place the fingers of the outside hand 
directly over the part to be examined, and without moving the fingers 
glide the intervening tissues over it. Another is to hold the fingers 
passive while the organ is moved about under them. A third is to 
steady the organ with the vaginal fingers while the outside fingers 
are moved about over the surface to be examined, all the while keep- 
ing in touch with it by a series of light pressures. For examination 
from the vaginal side a reversal of the same tactics may be employed. 
Of these three methods, the first is generally practiced, and it is, 
on the whole, the most satisfactory, for the reason that the fingers 
never leave the surface under examination, and can take note of 
slighter variations in contour tlian by the last. (Plate I.) 

Should the uterus be retrovcrtod, it will be necessary to restore 
it to the normal position before a satisfactory bimanual examination 
can be made per raginam. Here, however, a bimanual rectal ex- 
ploration can usually be made without difficulty. The ovary, when 
in jiosition, can usually be found by placing one or two fingers in the 
right or left lateral vaginal fornix, as far out as possible, and de- 
pressing the abdominal wall over them so that the fingers of one 
hand can be felt by those of the other through the intervening tis- 
sues. Xow, by drawing them downward and toward the uterus the 
first intimation of the presence of the ovary will be its slipping from 
between them. Once located, it can easily be found again and pal- 
pated. The Fallopian tubes, round and ovarian ligaments in their 
normal state, and because of tlieir softness and pliability, are difficult 
to distinguish except by experts and imder favoring conditions. 
Recognition of these structures in their normal condition is more 
a test of tactile skill than of any real practical value. The ureter 
Ciiii be found by gliding tlie finger forward and outward from the 
cervix. It will be distinguished as a rather well defined cord run- 
ning parallel with the pelvic brim and forming the dividing line 
b(>twe<'n the soft and pliable structures around the uterus and the 
firmer ones at the peripliery of the pelvic space. When inflamed it 
is much more easily found than in the normal condition. In patlio- 
logic conditions all the pelvic structures, with but few exceptions, 
bi'fome firmer, larger, and much more easy of <lotoction. Diseased 
ov;iri('-! and tulios settle in the pelvis, and are more easily reached by 
llie YU'^inal liuL'er. 



CHAPTER III. 

QYNBCOLOaiC EXAMINATION (INSTRUMENTAL) 
AND POSTURE. 

EXAMINATION BY THE AID OF INSTRUMENTS. 

The Uterine Sound. — The uterine sounds most commonly in use 
are those of Simpson and Sims. They are about twelve inches long 
and from one-twelfth to one-eighth of an inch in thickness. They 
are slightly bulbous at one end and enlarged and flattened at the 
other. This latter serves as a handle. They are usually made of 
copper, plated, and should be of one piece. Formerly the handle 



Fig. 4. — Simpson's Uterine Sound. 

was of hard rubber and corrugated, but since the daj'S of asepsis this, 
very properly, has been superseded by the metal handle. The Simp- 
son sound is provided with a little hump two and one-half inches 
from the end, to indicate the normal depth of the uterine canal. 
The Sims sound is more flexible than that of Simpson. The Jenks 
spiral sound is very flexible, and is sometimes useful in following the 




Fig. 6. — Sims's Uterine Sound. 

sinuosities of a crooked canal ; but, aside from determining the depth 
of the canal, such sounds are of little utility. Uterine probes are 
more delicate than sounds, and are seldom called for. 

Use of the Sound. — The position of the uterus and the direction 
of the canal should be determined, at least approximately, before any 
attempt is made to use the sound. The sound should be curved to 
correspond to the direction of the canal, taking into consideration 
Uie relative positions of the uterus and vagina. In the normal 

(25) 



26 PRACTICAL GYNECOLOGY. 

uterus in its normal position the distal three inches of the sound 
should be curved to represent the eighth part of a circle, or, in other 
words, the point should form an angle of forty-five degrees to the stem 
of the instrument. After locating the os, drop the tip of the finger 
back a little so that its palmar surface will be on a line with the 
entrance to the canal. Guided by this the sound is made to enter 
the cervical canal, and by depressing tlie handle the sound glides 
up the canal to the fundus. Sometimes the point of the instrument 
will become engaged in the folds of the cervical canal or be arrested 
at the internal os. This must be overcome by delicate manipulation, 
by elevating or depressing the handle, by rotating it from side to 
side, or by bringing the cervix forward with the finger in the vagina. 
Under no circumstances is force to be used. Sometimes, especially 
in acute anteflexion of the uterus, by bending the sound at the 
handle end in a direction opposite to that of the distal curve, intro- 
duction will be facilitated. When the cervix is bent forward, form- 
ing an acute angle with the body, by entering the sound with its 




Fig. 0. — Uterine Sound with Gauge. 

concavity backward, and then, when it becomes arrested, rotating !! 
80 as to bring the concavity forward, it will often pass the obstacle and 
enter the uterine cavity. Finally, in intractable cases the uterine 
canal may be straightened by seizing the cervix with a tenaculum or 
bullet forceps and drawing it down. The sound may be used with 
or without the speculum. Most experienced gynecologists prefer to 
use it without, as it gives a greater latitude of motion. 

The sound acquaints us with the length of the uterine canal and 
its direction and patulousncss. Conjoined with abdominal palpation 
it enables us to determine the degree of mobility of the uterus and its 
connection with other structures. In practice the sound is frequently 
employed to replace the retroverted uterus. The sound is by no 
means a harmless instrument. Its unskillful use has often led to 
serious or even fatal results. Traumatism of the endometrium and 
perforation of the uterine walls are of common occurrence. Septic 
matter may be carried up from the cervical canal or vagina, 'i'he 
sound should not be used without a preliminary cleansing of these 



GYNECOLOGIC EXAMINATION— INSTRUMENTAL. 27 

parts and a sterilization of the instrument. This latter can be quickly 
and effectually accomplished by passing it through a flame. Under 
aseptic conditions the perforation of the uterine wall by the sound 
is almost never followed by evil consequences. The more experi- 
enced one becomes in bimanual examination, the less use he has for 
a sound. Still, it is a very useful instrument, and at times indis- 
pensable. 

The Specalnm. — The speculum for diagnostic purposes has a 
very limited field. As a means of diagnosis it does not compare in 
any sense with the bimanual examination. It is, nevertheless, held 
in high esteem by the fledglings of the profession, while to the laity 
it is the sine qua non. With them "seeing is knowing," and they 
cannot be made to understand how an examination can be conducted 




Fig. 7. — Sims's Perineal Retractor. 



without the speculum. About all that can be made out by the spec- 
ulum that cannot be done better by other means is the color of the 
parts and some of the finer lesions of the vagina and cervix, such as 
are produced by exfoliations of the epithelium. Cylindrical specula 
have gone out of date. Tliore are two kinds of specula in general 
use; the bivalve and the perineal retractor. The perineal retractor, 
as its name indicates, is an instrument to lift up or retract the peri- 
neum, and with it the posterior vaginal wall. The Sims perineal 
retractor, which is the original and type of all perineal retractors, 
consists of a shaft and two blades: one large and one small. The 
blades are at opposite ends of the instrument, and are set at right 
ansles to the shaft. They are concave on one side and convex on the 
other, being fashioned to conform to the ehape of the vaginal canal 



28 PRACTICAL GYNEOOLOaY. 

and so as not to inflict pain either in introduction or in the subse- 
quent retraction of the perineum. 

The patient should be on her left side in the Sims position, to 
be described directly. To introduce the retractor, the labia should 
be separated by the fingers of the left hand, and the blade inserted 
with its convex surface toward the perineum. In pushing it home 
the distal end of the blade should be made to follow the curve of the 
sacrum so that it will come up behind the cervix. The retractor is 
now drawn forcibly upward and backward so as to retract the peri- 
neum. There is an art in holding the retractor to avoid fatigue and 
consequent unsteadiness. The untrained assistant is apt to grasp 
the outside blade and stand aloof from the patient. As a consequence 
he soon tires, and a rocking motion is communicated to the speculum. 
Sometimes it slips from the vagina. He should take his position 
alongside the patient, his left forearm resting on her hip. He should 
seize the shaft of the retractor with his right hand, the thumb looking 
upward and resting on the imder surface of the outer blade. He 




Fig. 8. — Sims's Depressor. 

should now bring his elbow to his side, which affords him steady 
support. The left hand can be used to hold up the nates and retract 
the soft tissues from the vulvo-vaginal outlet. When the patient is 
in the proper position, and the retractor is used, the air rushes in 
and inflates the vagina and affords an excellent view of the vaginal 
wall and cervix. 

The Sims position is the most favorable for the use of the peri- 
neal retractor. Even with the patient in the dorsal decubitus a very 
good view of the lower portion of the anterior vaginal wall can be 
obtained and the cervix exposed. In this' position, however, the 
anterior wall falls in from above, and partially, if not entirely, ob- 
structs a view of the deeper structures. To overcome this, an in- 
strument known as the depressor is used to lift them out of the way. 
This form of speculum is most satisfactory when properly used, and 
is the only one through which operations on the vagina, or the deeper 
structures through the vagina, can be performed. For operative pur- 
poses, and especially for operations on the uterus and for transvaginal 
operations on the pelvic viscera, the blades of the retractor are made 



GYNECOLOGIC EXAMINATrON— INSTRUMEKTAL. 29 

flat and in most instances much shorter than those of tlie Sims. The 
sliorter blade admits of digital manipulations beyond their extremi- 
tiee, the parts being brought within reach of the finger by traction 
forceps. Hetractors are sometimes placed on the sides and front as 
well as tlie posterior wall of the vagina. 



Fig. 9. — Jackson's Perintal Retrtietor. 

For bringing down the uterus traction forceps with strong flat 
jaws and short, flattened teeth should be used. The old-fashioned 
volsellum, with its long, sharp prongs, — and, for that matter, the 
bullet forceps also, — are objectionable in that they inflict a puncture 
wound and easily tear out. Traction forceps of the icind mentioned 
above seldom bring blood, and are so strong and take such firm hold 



FSg. 10.— Collina's Traction Forcepa. 



on the tissues that almost any necessary degree of force may be used 
to bring the uterus down. 

The principal drawback to the use of the perineal retractor is that 
it requires the help of an assistant. This has, to an extent, been ob- 
viated by devices whereby the speculum is made self-retaining. Such 
devices are, for the most part, troublesome, and not altogether satisfac- 
tory. For the dorsal position some excellent self-retaining retractors 
have been devised, but, as they are more or less painful, they are not 



30 



PRACTICAL GYNECOLOGY, 



often resorted to without an anesthetic. The author's self-retaining 
perineal retractor, shown in the accompanying cut, gives an excellent 
exposure of the anterior vaginal wall and cervix, and alTords excellent 
facilities for operations on the same. As it is provided with a ratchet, 




Fig. 11. — .\utli(ir'a S<>lf-retniiiing Pcrincnl Retractor. 

any amount of perineal traction that is necessary or desirable can be 
secured by it. The weighted retractors are very convenient, but will 
not always overcome the resistance of a rigid perineum, and are 
liable to slip out, especially in the case of a lacerated perineum. 




Fig. 12. — Weighted Perineal Retractor. 

For ordinary office practice and the medical treatment of the va- 
gina and cervix the bivalve speculum is much more generally used than 
the perineal retractor, 'i'liis is because of tlie ease and facility with 
which it can be used without the aid of an assistant. The modifica- 
tions of this speculum are too numerous to mention. To my mind 
there is none that possesses so many points of excellence as that of 




OTNECOLOGIC EXAXUNATION— rNSTRTTMENTAL. 



31 



Brewer. The blades resemble the duck-bill in general contour, and 
are' flat and narrow where they iriipiage on the delicate and sensitive 
structurea at the vaginal outlet. As this is the narrowest portion of 
the canal a very considerable divergence of the blades at the distal 




Tig. 13. — Brewer's Bivalve Speculunk 

end can be secured without making undue pressure on these sensitive 
surfaces. There is also a deep notch iu the upper blade to accom- 
modate the urethra, and which alTortls greater freedom in the use of 
the sound. The instrument is so constructed as to be adapted, equally 




Fig. 14.— Author's Aseptic Vaginal Speculum. 

to the virgin and the matron, thus obviating tlie necessity of keeping 
on hand specula of different sizes. For purposes of cleanliness tlie 
author has devised a speculum modeled after the Brewer, but so con- 
structed as to admit of its being taken apart instantaneously for 




32 



PRACTICAL GYNECOLOGY. 



cleaning. It consists of Uiree pieces, and works with a ratchet in- 
stead of screws. To take it apart all that is necessary is to separate 
tlie blades widely and lift them apart. It answers every purpose, and, 
as there are no screws to work loose, it never becomes rickety. 

To Introduce the Bivalve Speculum. — The speculum is taken 
in the right hand with the index finger extended along, and pro- 
jecting beyond, the posterior blade. The instrument is tilted to one 
side, so that the upper lateral edge will pass to the right of the urethra. 
The labia are separated by the fingers of the left hand, and the end 
of the speculum, guided by the tip of the riglit index finger, engaged 
in the opening. As it passes up the canal it is rotated so as to bring 
the blades into proper position, and at the same time given a direc- 
tion downward and backward so as to bring the longer posterior blade 
up behind the cervix. The blades are now opened and the cervix will 
be found l)etween them occupying the center of the field. Should the 
attempt be unsuccessful, it is better to withdraw the instrument en- 
tirely, as it is difficult to change the relative position with the speo 

Fig. 15. — Pratt's Rectal Dilalor in Graduated Sizes. 

ulum in the vagina. In subsequent attempts it will generally be found 
necessary to give the speculum a more decided backward inclination. 
In abnormal positions of the cervix (the position of the cervix should 
always be ascertained by preliminary digital examination) the direc- 
tion of the speculum should be changed to correspond. Occasionally 
the cervix will have to be drawn into the field by the tenaculum. In 
practice the bivalve speculum is serviceable in making applications 
to tlie cervix, vagina, and uterine canal, and in placing tampons. 
Cervical cysts may be punctured through and cervical polypi may be 
snipped off, but not with the same facility as with the perineal 
retractor. 

Dilatation of the Genital Tract for Examination. — In virgins a 
close and resisbmt hymen will often interfere seriously with digital 
and specular examination. This can usually be overcome by a little 
prudence and patience. As the parts about the hymen are very sen- 
sitive, it is necessary to get the confidence and co-operation of the 
patient before proceeding. Assure her that what you are about to 



GYNECOIX)GIC EXAMINATION— INSTRUMENTAL. 



33 



do will be painful, but in no sense injurious, and that if she will help 
you the object can be accomplished much more quickly and easily 
than if she resists. Tell her, furthermore, that, when the finger ia 
once well in, the pain will ceaBe. I see no need, in the majority of 
cases, in commencing with anything smaller than the index finger. 
Thia should be well lubricated and the tip of it laid gently against the 



Fig. 16. — Hypodermic Syringe for Fig. 17. 

£xamlDation. 



hymen and allowed to remain there for a few minutes. This will, in 
a measure, allay the fears of the patient and obtund the sensibility 
of the parts. Then insinuate gently through tlie opening and by easy 
stages up into the canal, pausing at intervals if the pain should be 
severe, but never withdrawing. In passing the first and second joints 
if you can induce the patient to push downward against your finger 
it will not only facilitate the introduction, but, by making her an 



31 PRACTICAL GYNEXX)LOQY. 

active participant, increase her tolerance. When the finger is well 
in, hold it quiet and press firmly with the outer knuckle against the 
pubic bone. Several seances of this kind, repeated at intervals of 
two or three days and each time increasing the dilatation by judicious 
pressure in different directions, will enable you to use the speculum 
or make satisfactory digital exploration. In cases of extraordinary 
sensitiveness I have derived great benefit from the use of the Sims 
gl;is8 plug, or, better still, Pratt's graduated metal rectal dilators. In 
iii:>ny cases the vagina need not be invaded, a digital examination by 
ti.e rectum being all sufficient, and thereby saving to the patient that 
most precious ensign of virginity: the hymen. 

Dilatation of the. uterine canal for the purpose of examination 
should not, as a rule, be undertaken without an anesthetic. When- 
ever practicable any operative procedure that may be found necessary 
should be done at the same time. The use of anesthetics for examina- 
tion should not be resorted to too often, for most patients conceive 
such an abhorrence for them after one experience as to deter them 
from submitting to necessary operative interference at a subsequent 
period. In women with a fairly patulous canal shavings from the 
endometrium may be taken by the exploratory curette without anes- 
thesia. A very gradual dilatation of the urethra for explorative pur- 
poses may also not infrequently be obtained without excessive pain. 
The use of cocaine as a local anesthetic will mitigate the suffering of 
a urethral dilatation, but should be used with circumspection, as 
disaster has attended its use. The hypodermic needle is sometimes 
useful for withdrawing the contents of cj-sts and abscess-cavities for 
examination. It should always be used under aseptic precautions, 
and pulsating vessels should be avoided. The old-fashioned exploring 
needle with a groove along one side of it should never be used, for, if 
a septic cavity is tapped, it distributes the poison along the track of 
the needle. 

POSTURE. 

The position of the patient may be changed according to special 
indications, both for examination and treatment. The positions most 
frequently used are the dorsal, left lateral (or Sims), the knee-chest, 
the erect, and the Trendelenburg. 

Dorsal Position. — In the dorsal position the patient lies upon 
her back, the buttocks to the light, with the legs flexed and sepa- 
rated. If a modem table be used, the patient's feet are placed in 
stirrups and the buttocks brought down flush with the end of the 



GYNECOLOGIC EXAMINATION— INSTRUMENTAL. 



36 



table. (Plate II.) The stirrups should neither be so far apart nor 
BO close to the table as to place the patient in a constrained position, 
while at the same time they should offer space for the necessary ob- 
servation and manipulations of the physician. This is the position in 
which most of the ordinary examinations are made. 

The Left Lateral, or Sims, Position was at one time much in favor 
in this country, but has of late years been largely supplanted by the 
dorsal. In this the patient is placed on her left side with the hips 
at the left lower angle of the table, left arm thrown back, and the legs 
acutely flexed on the body. The right leg is more sharply flexed than 
the left, and ia partially crossed over, so that the riglit knee almost 
touches the table. The right, or upper, trochanter should be several 
inches in advance of the left, or lower, trochanter, and the left breast 
shouJd rest upon the table. (Plate III.) The position is, in reality, not 
strictly lateral, but intermediate between lateral and prone. As the 
object of the position is to cause the abdominal contents to fall away 
from the pelvis, it is essential that every detail of the directions here 
given should be complied with in order to secure the desired effect. 
Anything short of this wil! be disappointing. It is usually necessary, 
after the patient has assumed the position according to instructions, 
to place one hand under the left hip and another over the right, and, 
by a combined movement of drawing on the lower hip and pushing 
on the upper, rotate the patient forward, so that the left trochanter 
is thrown in advance of the right. When the position is correctly 
assumed and the Sims speculum introduced, the anterior vaginal wall 
falls away, the air rushes in and distends the vagina, and the cervix 
Dteri is brought into plain view. 

The Knee-Chest Poeition is sometimes serviceable in manipula- 
tions on the rctroposed uterus, and in examinations of the anterior 
vaginal wall. In this the patient drops on her knees and inclines the 
body forward until the breasts rest upon the table, the head being 
turned to one side and the arms extended above the head or pinioned 
to her side. (Plate IV.) She must not sink on her haunches, but 
must keep the thighs perpendicular. 

The Erect, or Standing, Position is occasionally useful in deter- 
mining the amount of descent of a prolapsed uterus or vagina, the 
adaptability of a pessary, or other conditions in which gravity is an 
important factor in the case. The patient stands against the wall 
with the legs separated, or better still with one foot on a stool, and 
the physician drops on one knee before her, in which relative posi- 
tions the examination is conducted. 



36 PRACTICAL GYNECOLOGY. 

The Trendelenburg Position is useful when it is desirable or 
necessary to relieve the pelvis and lower abdominal regions of the 
pressure and presence of the intestines. This is of service in deter- 
mining the relations of morbid growths to the pelvic structures, but 
its chief utility is found in examinations and operations on the pelvic 
viscera after the abdomen is opened. The patient is placed on an 
incline with the head downward, and as a result the abdominal viscera 
gravitate to the upper abdominal zone, leaving a clear field for work 
and observation in the lower abdomen and pelvis. 



CHAPTER IV. 

GYNECOLOGIC TECHNIQUE. 

Gynecolooic technique is the manner or method in which gyne- 
cologic operations are perfoniied. niid emlirates nil the practical de- 
tails of such work. It incluties both jirejiaration and after-treatment. 
The last quarter of a century has l»een prolific in technical changes, 
many of which have been distinct advances. The hemostatic com- 




presaion forceps enables the operator to work with more 8j)ec(i anil 
certainty, find oftentimes converts a bloody into a bloodless operation. 
Ligating the uterine arteries instead of the stump in sii[iravaginal 
liysterectomy has transferred Uiat operation from Iho domain of 
deadly danger to that of safety and feasibility. Shelling out the 
intraligamentous cyst from below upward, as opposed lo stripping 
the ligament downward, is a life-saving change. Hut of alt the 
improvements of tecbnitiue for this or any other age, that of cleanli- 
ness takes foremost rank. Cleanliness lias become the basic principle 
of modem surgery and the cajistonc of technical triumph. It mutters 
not how brilliant, how skillful, how deft, or how swift the modem 
surgeon may be. if he has not cleanliness, he is as of sounding brass 
and tinkling c>Tnbal. His blade cannot be so swift, nor his fingers 
so deft, but the gemi will follow tliciii, and once implanted will work 
out its baleful purjnwe. The ctean-cnt tissues besmeared with germs 
Boon become ragged, sloughing caverns. But the day for discussing 

(37) 



38 PRACTICAL GYNECOLOGY. 

the merits — ^the absolute necessity of cleanliness in surgery — ^has 
passed, and the burden of effort is to inculcate and enforce the 
practical application of an established principle. 

GERMS AND GERM INFECTION. 

The germ is a vegetable growth. The frequent allusions to it 
as a bug or animal parasite are purely fanciful and intended to be 
funny. The pathogenic germs that more especially concern us as 
gynecologists are five in number. They are the streptococcus pyog- 
enes, staphylococcus pyogenes aureus, staphylococcus pyogenes albus, 
bacillus coli communis, and the gonococcus Neisscri. Most of these 
find their natural habitat in the vagina and cervical canal. The first 
is the moat virulent, and is the underlying factor in the graver forma 
of puerperal infection. The third, or staphylococcus albus, gives rise 
to stitch hole abscess and was formerly considered as a skin germ. It 
is now known to be much more widely distributed, and to play an im- 
portant role in preventing the spread of peritoneal infection by excit- 
ing adhesive inflammation in the parts contiguous to the infected area 
and thus circumscribing it. The fourth is a resident of the intestinal 
canal,, but sometimes invades the peritoneal cavity as a result of lesion 
of the bowel. The gonococcus is the specific germ of gonorrhea. It is 
frequently associated with the staphylococcus aureus in tubal abscess. 

Sepsis, asepsis, and antisepsis are terms that are very much in 
vogue. In a loose way sejiisis means the presence of germs; asepsis, 
the absence of germs; and antisepsis, against or antagonistic to germs. 
Strictly speaking, sepsis is the rrsuJt of germ infection. Germs luxu- 
riate in filth and dead tissues. They are the essential agents in decom- 
position and putrefaction. Live, healthy tissues are antagonistic to 
germs. Young cells, especially leucocytes, battle with and destroy 
genns. Hence they are called germ-killers, or phagocytes. Certain 
agencies called opsonins are found in normal blood of man and various 
animals. These opsonins prepare bacteria so that they are susceptible 
to phagocytosis. The senim of normal blood in man contains opsonins 
for various bacilli. Wright has demonstrated that of the two, the opso- 
nins are of more value than the leucocvtes, as the latter are dependant 
upon the former for their efficiency. The leucocytes must be acted upon 
by the opsonins before they are able to digest or neutralize the bacteria. 
Cleanliness is the only safeguard against germs. They cannot exist 
in the presence of cleanliness, but find their natural element in filth 
and dead tissues. Hence, unclean parts are the harborers of germs. 



GYNECOLOGIC TECUNIQUE. 



Sfl 



Anything that weakens or diminishes the vitality of tissues, or 
produces cell-necrosis, however slight, favors germ growths and germ 
infection. Septic, or germ, infection, is the surgeon's greatest enemy. 
It kills his patients and undoes his best efforts. In plastic surgery 
it prevents union, or at best allows of union by granulation, which 
often defeats the object of the operntion. Suppuration always in- 
dicates germ infection. Asepsis is tlie surgeon's ideal, — the aim 
and end of his endeavors, — and cleanliness is asepsis. Asepsis 
is attained by dislodging tlie germs or by killing them. Soap and 
water and a vigorous use of the brush usually suffice for hand 
and body cleaning. Germs may be destroyed by heat or chemicals. 
Boiling water or steam are the forms of heat most frequently era- 
ployed. Dry heat at the temperature of boiling water is also efficient. 
Metal instruments are more easily sterilized than woven fabrics. An 
immersion in boiling water for five minutes usually suffices. Articles 
of clothing, sponges, dressings, and ligatures are subjected to a germ- 
killing heat for thirty minutes tlirce days in succession. This repeti- 
tion is necessitated by the spores, which are not niTected by the heat. 
Some hours are therefore given them to develop into germs, and as 
gern»s they are easily destroyed. Antiseptic chemicals are much less 
used than formerly, their use being confined principally to such arti- 
cles as cannot be conveniently sterilized by heat or washing. They are 
sometimes used as adjuncts to other methods. It is not the germ itself 
which produces sepsis, but its product or secretion. Some chemicals, 
such as iodoform, have the power to neutralize this product, while they 
have no germicidal properties. 



PREPARATION FOR OPERATION. 

The amount and character of the preparation will depend largely 
on the kind of operation in contemplation. For abdominal work the 
most scrupulous care and attention should be given to every detail. 
This includes the preparation of the room and its appurtenances, the 
instruments and appliances, the operator and his assistants, and the 
patient. 

The Boom. — The room should be prepared by removing carpets, 
draperies, and all upholstered furniture. It is safer to remove the 
paper from the walls. The wood-work should be washed with soap 
and water and wet with a 1 to 1000 mercuric bichlorid solution, 
which should also be applied to the walls. Benches, tables, and chairs 
ahould be treated in like manner. Basins and vessels of all kinds 



40 



PRACTICAL GYNECOLOGy. 



ehouM be cleansed and scalded. The water used in the operation 
should be boiled, turned into sterilized vessels, and covered with 
sterilized towels. There should be an abundance of it, both hot and 
cold. 



Fig. 2(».^l;u<-(:kniBnn'B Sterilizer. 

Instrnments. — Metal instruments may be sterilized by fifteen 
minutes' exposure to steam heat or five minutes to boiling water. The 
addition of a little soda — 1 per cent. — to the water prevents rusting. 
Sharp instruments, such as knives, are dulled by heat, and may usu- 
ally be made sufficiently clean by scrubbing with green soap. 



i-SvKt^ 



Sl.-^Boeckmann'g Sterilizer (Chamber for Dressings). 

Gauze Sponges, Dressings, Ligatnre, and Suture Material. — 
These are sterilized by steam or boiling water. They should be ex- 
posed to a boiling heat for thirty minutt-s at a time for three days in 
succession. Articles to be sterilized should be inclosed in towels or 
other convenient wrapper, each kind by itself — the sponges in one 
package, the dressings in another, and tlie instruments in still an- 
other. These should not be undone uutU needed. Ligature and 




GYNECOUKJIC TECHNIQUE. 



41 



Buture uinU'rittl is coilod loosfly around glass spools and plaood in 
test-tubes, tlie ends of which are pluggoti with cotton. The icjtton 
I'fTeotufilly excludes genu?, while it in no way interferes with tlio 
applirnliou of heat, or even the free circulation of steam within the 
tube. 




Fig. 22. — Boeckmiinn's Sterilizer 
(Tray for Iiiatruments ) . 



Fig. 23.— tilasa Bruah Box. 



The best method of sterilizing catgut is still a moot (|ues.tion. 
A simple anil efficient way i.s to soak the catgut in plain water for 
thirty-six hours at the ordinary temperature, tlien in a 5-pcr-cent. 
solution of formalin for a like period, when it is taken out and placed 
in glass jars containing alcoiiol. Just before it is used the jar cou- 
taming it is placed in the sterilizer ami allowed to remain twenty or 




Fig. 24. — CtlasB Ligature Bos, 



thirty niiimtes. A gauze cover should replace the glass stopper to 
permit the eseajie of the vapors generated hy the heat. 

Sponges. — Gauze sponges have almost entirely supplanted the 
marine sjMuigc, chiefly because of their availability and tiie ease and 
thoroughness with which they may l)e sterilized. They are ea.«ily 
prepared, and owing to their cheapness can he and are discarded after 
each ofieration. Tiiey are prepared liy folding the gauze upon itself 
several times and tacking the edges with thread, seeing to it that the 




^^V 42 PRACTICAL OYNECUUXiY. ^^^| 


^^^H raw edges are turned in. i'ads of larger size aud iliickur Umii Uic ^| 


^^^1 spongus are useful t<i luuiect the intestines where a lung abduniiual ^| 


^^^1 ineisiun h niadr. A intiveiiii-nt i^i/.e for the i<iionge is live inches ^M 


^^^M sijuare, and tliut df the pad nine or ten inelies t^ijiiare. Tiie enre of ^H 


^^H the sponges is one of the most in]]>ortaut duties of the nurse, as it ^| 


^^^H is an ohjeot of solieitudc to the operator. Many seriuui< aiiil fatal ^M 


^^^^^^ t^ ir «» mishaps have oee\irred as '^M 


^^^^^B ^1^^ j£^ l£\ ^'"^ rest:lt of leaving sijonges ^M 


^^^^^H i^^BJ ^^^B ^fln '''^' cavity ^M 


^^^^^P I^El /JSEl ITiIe "^^^'^ ^1 


^^^V ■HRaBnJV.^^^^Bj ^nk vigilance and methodical at- ^M 


^^^H 1^ 1 v* tention to tlio sponges are ^| 


^^^1 I^B"^ w^^f, 1 the oidy safeguards against ^| 




^^H 1 MB ^B. 1 dei>t. They should be ^M 


^^H V ^B C^^ C^ ^ ^V '^""-^ arranged ^| 






■^7^^^ 


fG Iv Jfetr>< "^ 


/ation, and again counted ^M 
carefully before the opera- ^M 






- ^iJ^rflHHt i J 


* turn. In counting them ^M 






^^7 ' ^^^^H^BB 


each sponge must be lifted ^M 






=^^ "Sl^^BI 


up separately to be sure ^M 






that two are not stuck to- ^^ 




1 #€»•• O"**"" 1 


get her. One sponge of each ^^ 
lot should be provided with ^M 
a ta|>e. This sponge is to ^| 
be laid ov<-r the bowels while ^H 


^m J 


1 ^^^ the incision is being clo8e<l, ^| 


^^^^^H ^B ^^'^'^ '''"' ''M**^ projecting at ^M 


^^^^^P J^^ „ .. . . ,^ . the angle and a for- ^M 
^^^^^ Fig, 25.— Cabinet for Drpssines. , , , ^M 
^^V reps attached to it. It ^1 


^^^B should he withdrawn before eoni[ilete closure of the wound. After the ^M 


^^^m completion of the oj)eration and lieforc the incision is closed, at a word ^M 


^^^M from the operator, the sponges are all counted again and again, and ^M 


^^^B if any be mii^sing it is sought for in the alxloniinal cavity. All s[>onges ^M 


^^H used should be dro))ped into a receptacle, and under no circum- ^M 


^^^M stances shouhl a .iponge be torn in two. or an individual sponge ^f 


^^^H mideil, or a sponge thrown to one side where it is liable to escape ^H 


^^^1 oliservation. A very convenient way of keeping the s])onges is to ^H 


^^H make a |K>cket at either end of a towel by folding and pinning, and 


^^^^^^ placing si.\ spcuiges iu each pocket. 


^^^^^B As an additional precaution against the loss of sponges in the 



GYNRCOLOOIC TECHNIQUK. 



43 



abJoniiiial cavity Crosscn has <]evclope<l a suliemc in which iiidivid- 
nal spungcs and pads are rephvced \>y continuous strips of jiuuzc; wide 
6trip8 to take tlie place of puds and narn>w strips t^> take tiic phico 
of lipongcit. The wide strips slumld be fiMi ynrds loni:. nine iiiciiet! 
wide and consist of 
four thick ne88es of 
gauze. The narrow 
Htrips should be ten 
j'arda long, tliree 
inches wide and con- 
sist of six thicknesk«*>s 
of gauze. For the 
wide strips the yar<l- 
wide gauze \n used 
which, being folded 
lengthwise on it^lf 
twiiv, gives the re- 
quired width and 
tliickuess. For the 
narrow strips half 
w id til of the yard- 
wide gauze is used wliich, being folded lengthwise on itself three times, 
gives the required width and thickness. For convenience of handling, 
the«<» strips uf gauze are jiinced in |)ockets made in the shi-et which 
covers the patient's body or attadied in the smiu-. These pockets. 




Fig. 2il. — TntitrunuMit Stanil. 





Fig. 27. — Instniincnt Tray, 



Kig. iH. — Double Wasli-stanil. 



tlirco in number on either side the median line, are made of sizes to 
accommodate the gauze strips; one wide and two narrow for each 
side. 'I'he gauze is sterilized in snmll bags — a bag for each strip, the 
wide gauze being previously folded ou itself after the manner that 
commercial gauze is laid down in jars, so as to be readily transferred 
t*) the pocket without too much handling. 



44 



PRACTHAL r.YNECOLOGY. 



The pocket for tJio widu gauze slioulil open on tlie side iusteail 
of tlie top as do tlie otlr<'r jxieket^. (.'rosseii refiininieiids that the strips 
be tacked to the hottoiu of the |>orkets and that extra poekets Ije pro- 
vided for tlie reieptiou of soiled gauze, hut the autiior liiids it more 
convenient and cleanly to deix)sit the used gauze into a suitable re- 
ceptacle farther removed from the field of operiitioii, 

^\'heu the operation is c'oiujileted the nunilter of strips used will 
be indicated by tlie number of poeket« empty, which may be verified 
by counting those in the receptacle. In the author's own table this 
receptacle constitutes a ]'nrt of the table. 




Fig, 29. — Operating Room at St. Anthony'ii Hospital. 

The Operator and Assistants. — They should take a general bath, 
uping soap and brush. As tlic hands are necessarily brought in con- 
tact with the instrumentts, spurges, ligatures, and wound, hand- 
cleaniiuj constitutes the most essential feature of personal prepara- 
tion. The hands should be first thnroughly washed with soap and 
water, and the dirt should be removed from under the finger-nails 
by the use of a nail-cleaner. After this a free use of green soap, 
soft wann water, and a hjind-hnish will c(ini]ilete the process. The 
scrubbing should be thorough and painstaking, and the water re- 
newed from time to time. To make assurance doubly sure some 
operators supplement the scrubbing by the use of germicidal chemi- 
cals. Of the great variety of such suggested and u.sed fur a time by 
different o|>erators there is none that has stood the t€st so satisfac- 
torily as the simple solution of bichloride of mercury 1 : 500. This 
because it is always convenient and as etlicacious as anv. After the 



OVXEC0UX;iC TEaiNIQUE. 



45 



usual KTuhbing tlie hfunh and amis are immersed in this solution 
for a few minutes and tlie rubber gloves donned, or if gloves are not 
useil rinsefl in sterile water. 

Aprons. — On or l)efore entering tiie operating-room the of)crator 
ad assistants should remove their coats, roll up tlieir sleeves, and 
i»ut on liuen aprons. Tliese should be large enough to encircle the 
body, long cnougli to renrli to the ankles, and providetl with sliort 
sleeves. They shoiiKl i)e sterilized before each operation. Sdnie oper- 
itors prefer a jacket and trowsers of the same material, as being more 
egant. The head should be coveretl with a sterilized turban of gauze 
"or linen. But it is not sufficient that the gynecologist be clean for 
the operation only, he must be habitually clean. He who neglects his 
person for days and weeks at a time is little less than a microbe 
generator, and cannot ex|)ect to render liiniself sterile by a single buth 
and hand-cleaning. lie must keep liis tingcr-nails trimmed and 




Fig. ;tO. — Rnlib's Razor for Slinvinp Piidcnilum. 



clean. T would rather sec a siiri,'ci»n willi crape around his hat than 
with black niurgins to his fiiigcr-iiails. One siguilies a death, the other 
homicide. lx)ng finger-nails often work disaster in the alulominal 
cavity by cutting through bladder or bowel in the act of broaJcing 
up adhesions. The sur;.'eoii must not attend infect inus disieases nor 
handle pathologic specimens. Practical gynecology and practical 
pathology are iucompatible. A man nnist reliiujuish one or the otiier 
or open account with the undertaker. If bmught in contact with an 
infectious ea.«e, either by operation or cxuniinalion, he nuift fnrthwitli 
purge himself by general bath, chaiifie of clothing, and repeated hand- 
cleaning. After such e.\|H>sure abdominal work should not be engaged 
in for a pcridd of several ilays. 

The Patient. — ^The patient should have a general Imlb and the 
Ijowels cleared with an efficient cathartic. For an abdominal opera- 
tion the jiubic hairs slionld lie shaved olT. As a preliminary and most 
efficient aid to the cleaning process, a towel saturaicd with green 
soap may be laid over the abdomen ami alloweil t" i'<-niaiii niie or 
two hours. The surface is now sfTubbed with soiifi and wntiT and 
tlie abdomen swathed in towels wrung out of a 1 : Hiui) bicldoridc solu- 
tion to await operation. On the following morning, or just before 



46 PRACTICAL GYNECOLOGY. 

operation and while the patient is under ether, the surface of the 
abdomen is sprayed or painted with the tincture of iodine. It should 
always be remembered that the iodine to be of any service should 
be applied to the dry skin, hence in emergency cases no preliminary 
cleansing should be attempted. Such cases, it is proper to say, usually 
do as well as tliose subjected to a more elaborate process of cleaning. 

For vaginal cleansing nothing serves the purpose better than a 
5-per-cent. Folution of creolin in green soap. Wads of absorbent cot- 
ton saturated with this solution are taken in the bite of a long forceps 
and the va<iina tlioroughly scrubbed. This is followed by a douche of 
plain, sterilized water. Thus prei)ared, the patient is placed on the 
table, the lower extremities enveloped in blanketSj the night-dress 
drawn up under the shoulders to prevent soiling, and the abdomen 
bared. A sterilized sheet is now thrown over the patient. In the 
middle of the sheet is an opening througli which the operation is 
performed. In lieu of the sheet, towels may be used. Two of these 
are placed lengtJiwise the body in sucli a way as to leave an uncovered 
space an inch or more in width along the median line. These are 
held in place by two other towels laid crosswise, one above and one 
below the field of operation, the ends of which are tucked under the 
patient. Wheji metallic or glass tables are used, the patient should be 
protected from the chilled surface by a folded sheet or gauze pad. 

ABDOMINAL SECTION. 

As a large proportion of tlie intraperitoneal operations is reached 
through the al)(iominal parietes, and as the technique of abdominal 
section i.s common to most of them, it will be described here to avoid 
imnccessary repetition. The majority of sections are made through 
the median line, but should the exigencies of the case demand section 
at any other point, the method here described will a])ply to such with 
perhaps slight modifications which will suggest themselves to the in- 
telligent surgeon. For general purposes the incision is made in the 
median line about midway i>etween the umbilicus and pubis. The 
length of the incision will depend upoji tiie nature of the case, and 
will vary from two inciies to six or eight inches or even more. Un- 
less there are ()i)vi()us reasons for making a long initial incision, it is 
a good rule to make a short one, which can easily be lengthened after 
the abdominal cavity is entered. 

The first cut will extend through the skin and su])erficial fat 
to the dense fascia overlying the muscles. It is now no longer con- 
sidered nccessar}- to follow the linea alba; hence no attention need 
he given to it. The knife may now be carried by gentle sweeps 
through the linea alba, if this be in line, or through the fascia down 



OYNBOOr/KJIC TECHNIQUE. 



47 



to Uie muscle- tissue, if tliis be in line, being careful to keep the 
incision of equal depth along the whole line, as nothing is more 
ainfusing to the beginner than an incision of unequal depth, or a 
ragged conical hole in Uie abdominal wall. When tlie muscle has 
boon laid bare a finger may bQ pushed through it, and with an upward 
and downward sweep the iibcrs separated. This exposes the pro- 
peritoneal fat, which may be lifted up with rat-tootli forceps and 
incised between them. 

The" peritoneum now appears, which under normal conditions is 
recognized as a thin delicate membrane which bulges into the wound. 
It is caught upon either side of the median line by rat-tooth forceps 




Fig. 31. — Abdominal Scot ion: Incining the Peritoneum. 

and nicked with the knife. (Fig. 31.) Extreme care should be exer- 
cised that nothing but the peritoneum is included in the bite of the 
forceps, as otlicrwisp the bowel or omentum may be wounded. When 
the peritoneum is opened the air rushes in and tiie bowels full away. 
A peep into the opening as it is hold up by the forceps will assure 
you that you have entered the pcritonenl cavity and not an uplifted 
bladder or, perchance, a cyst of the abdominal wall, as it sometimes 
happens. 

If all is well, as it usually is, a finger is introduced through the 
opening, and on this the peritoneum is split upward and downward 
with the BcisBors or knife. Care should be taken that the finger is 



rK-VCTTCAL OYS'ECOLOOy. 

k«pt ia ilMMiliahs (.-Mstact with the smooth internal surface 
I I u, to avoiil injurj" to ndlierent intestine or ona^-' 

5. _ah*»ioiiij bvtween the peritoneum and contained vise*?-' 

fuunJ, ttt iti<lii.titi*d bv an absence of that softness and pliabilit>''| 
vthitiictrriat-s tlie nonnal peritoneum, the dissot-tiou nuist be c»' 
f,.ru<--.i ^ith the utmost care, lifting up tlie deltciite lamina on e* ^ 
». the tootlietl forceps before incising them. It is usually »^^ 

MmI Wlt«T to j*ek u point liigher up or lower down or to onp fi '^ 
whciv the cavity may be readied without cncouiiterini; adhesions. 



a 




Kig. 32. — Kniff for Alxlominal Sit-tion. 

for any reason it is found necessary to lengthen tlie incision after the 
cavity has been entered, it may readily he done by pushing a finger 
iinilor the peritoneum in line with the incisiou and cutting on this 
with scissors. Should it be necessary to extend the incision above the 
umbilicus, it is better to aiake a circuit around and to the left of it, 
thereby avoiding the suspensory liganu'nt of the liver. 

Some surgeons affect a disdnin for the conventionalities of ah- 
doiuiual section, and enter the peritoneal cadty with one or two bold 




AbUoiiiiniil Section. 



I 



sweeps of the knife. Such Iwlong to, or aspire to bo classed with, the 
Bo-called brilliant operators, ami sooner or later come to grief. It is 
true that under nonnal conditions the small intestines are so pliant 
and yielding at^ lo cindu the keen e<lge of a knife swejit over tlieni; 
but, should adhesions exist, which cannot always be foretold, disaster 
must incvitflbly follow this species of reckless surgery. 

The bleeding from n Tiiedian ahdoniinnl .section is usually slight 
and evanescent. TIk> blood, as it wells up. shoidd be spongwl away 
by an assistant, to keep the Geld clear. Sjiouting vessels should be 



OYNBCOLOOIC TBCHNIQUK. 49 

caught with pressure forceps and the larger ones tied at once. It 
should be the aim to check all bleeding before the peritoneum is 
opened, for, although sterile blood is harmless, it entails extra work 
on the peritoneum and affords an excellent nidtts for germs. 

Clorare of the Abdominal Incision. — This maj be done by inter- 
rupted or continuous suture. When a good sterile catgut is available, 
the continuous tier suture is the best. With a sponge over the intes- 
tines and imder the line of incision, — a sponge with a tape to it, — 
the peritoneum is caught up with forceps on either side of the upper 
angle and the suture introduced and tied. It is now carried by an 
over-and-over stitch to the lower angle of the wound, the forceps pre- 
ceding and lifting up the membrane. Here it is better that this 
suture be tied and cut that it may not act as a germ-carrier from the 
upper tiers, which occasionally become infected. In the meantime, 
and before complete closure of the incision, the sponge has been re- 
moved. The suture, beginning anew, is now carried upward, uniting 
the muscles. Turning again, it is carried downward, with short 
stitches, through the fascia and bringing the divided surfaces into 
close apposition. Here it is tied again. This is the layer upon which 
most depends as a fortification against post-operative hernia, and 
should receive attention accordingly. Finally, the edges of the skin 
should be brought together by the subcuticular stitch. This is done 
by entering the needle at the skin edge on one side of the lower angle 
of the wound and bringing it out about three-fourths of an inch 
above on the same side, the needle having passed beneath the super- 
ficial layer of skin and parallel to its surface. It is now carried across 
to the other side and entered opposite its point of emergence and 
another stitch taken similar to the first. Thus, by alternate stitches, 
first on one side and then on the other, the upper angle of the incision 
is reached, the suture drawn taut and tied. The result is a beautiful 
line of perfect coaptation, and not a stitch visible. As there are no 
stitches to remove, the dressings may remain imdisturbed until solid 
union has taken place, or for a period of two to three weeks. 

For the interrupted suture, silk or silk-worm gut is most fre- 
quently used, preferably the latter. The original and most simple 
method of using the interrupted suture is to grasp the abdominal wall 
on one side of the incision, so that the fingers will rest on the peri- 
toneum and the thumb on the skin, and thrust the needle through. 
Then, grasping the wall on the opposite side at a corresponding point, 
the needle is again thrust through, but in reverse order to that in 
which it was passed on the opposite side. Thus, if it enters the 



50 PRACTICAL GYNECOLOGY. 

skin and emerges on the peritoneal surface of the first side, it enters 
the peritoneum and emerges on the skin of the other side. These 
sutures are placed about one-third of an inch apart throughout the 
length of the wound. As each suture is introduced its ends are 
secured by pressure forceps, one at either end, to keep them out of 
the way and prevent their accidental dislodgraent. One pressure 
forceps on either side of the incision is sufficient to hold all the 
sutures unless the incision be longer than usual. The first stitch is 
introduced midway the length of the incision, in order the more cer- 
tainly to bring the apposing sides in correspondence and secure more 
perfect coaptation. After all the sutures have been introduced their 
ends are grasped on one side by the operator and on the other by his 
assistant and lifted upward, while with the other hand each presses 
finnly against the abdominal wall just outside the sutures, thereby 
bringing the i)eritoneal surfaces together and as tiic sutures are tied 
effecting coaptation of the other layers. The sutures are now given 
into the hands of the assistant, from whom they arc taken one by 
one by the operator, who, after a to-and-fro motion to assure himself 
that he has in hand both ends of the same suture, ties tliem. The 
sutures are removed about the tenth day. Modification of these meth- 
ods according to individual preference are common, but all, or nearly 
all, are based on the technique described. 

The Author's Imbrication and Coaptation Suture. — Xobody nowa- 
days questions the utility of the aponeurosis as a safeguard against 
hernia. Many believe that it is not only the cliief, but the only real 
and effective, barrier against visceral protrusion. I am not of these, 
for, while 1 am satisfied that in the absence of this bulwark hernial 
protrusion would always and inevitably occur, I am equally satisfied 
that without the muscular backing or facing with which all fascial 
structures are provided hernial protrusions would be far more common 
than at ])resent. Take as an instance the very obese subject whose 
muscles are interlarded with fat so as to imi)air their tonicity and 
contractile efficiency, and we all know how prone such people are to 
rupture and how difficult it is to insure them against a recurrence of 
the same. It requires but little reflection to understand how by the 
tonicity of Oie muscle under ordinary conditions and by active con- 
traction under extraordinarv- pressure distributing, equalizing, and 
relieving the strain on the fascia will reinforce it in the most effectual 
way and conser\'e its structural integrity. So much l)eing granted, 
the next question is the best method of uniting the torn or cut edges 
of an aponeurotic membrane to insure the greatest structural strength. 



GYNECOLCX5IC TKCHNIQL'E. 



61 



Ii it to bo edge to edge, side by side, or by bipping one over the other? 
ComnioD sense will dictate the reply, and in this matter common sense 
is supported by abundant experience. Everybody will concede that 
the stron^cjit ixiwiblt- luiion is secured by imbrication of tbe fascia. 
It is a deplorable fnet that ventral hernia ia even at this late day by 
no means* a rare se<|uence to abdominal section. In tbe li<:ht of past 
cxjxTicnce and positive knowIiHlgf h.s to the surest means of preventing 
posto)>er«tive ventral hernia, it is to »ay the least culjiable for anyone 
to close tbe abdominal wound after ojteration in tlie carelefs and 
slipshod way in winch it is so often done. Of course, in cases of 
Mtwnie urgency io which the life of the patient depends on jirompt 
Action Bome simpler and more direct meth<Kl is justifialjle. Tbe 
method here udvwideil loay reipiire it litt'e more time — it may call 
for a little extra effort — it may be ii little awkward at ftrst to make 
the nct-essary dissections, but these sItouM not be allowed to weigh 
against tbe future welfare of the jiatieiit and with tbe conscientious 
tmrgoon will not. As to the dissections — the only possible objection 
to the method — one soon learns to do them witli neatness and dis- 
patch, and it is certainly a j:reut salisfnction after one has done up a 
pnticnt to be able to say: "There; tiiat will never give way." and b> 
feel that he has left the patient as irood us before tbe operation. I 
believe the ilay is fast aiiproaching when llie surgeon who fails to use 
the beint at his command for closing the abdominal incision will be 
lookeil upon with disfavor ami he nwide to feel that be is out of 
touch with u|)-to-date surgery. So mucli being granted, the next 
question is, how shall we effect this imbrication of the fascia so neces- 
sary to a stable union? The original way was to close the |)eritoneum 
with a running stitch, then, after di.ssecting up the fasi'ial Haps on 
eithrr sitlc, to introduce a series of mattress catgut sutures to effect 
the overlapping, to be folbweil by n running suture to tack down the 
free edge, and lin^dly a line of sutures or continuous suture on the 
akin to eoapt the superficial layers, thus making three tiers of 
futures above tbe peritoneum, two of which are buried with their 
Icnotii. In [iractising this method 1 found that quite fre(piontly after 
Die lapse of some ilays there was a serous discharge, followed later by 
a gajiing of the wound. This, which was undoiditedly due to the 
irritation produced by so much of tlic buried suture and especially 
the knots of the sjune, became such a ve.vation to me and my patients 
that 1 was forceil to give it up and return to tbe old-time nu'thnds of 
the running suture for tbe fa.^cia or more freipiently the figure-of-eight 
silkworm-gut suture. It then occurred to me to devise a method by 




62 PRACTICAL GYNECOLOGY. 

which I could get all the benefits of the overlapping method without 
the drawbacks incident to the piling up of sutures and the inclusion 
of knots in the tissues. My imbricating and coaptation suture is the 
result of this effort, and I now feel that I have a suture as free from 
objectionable features, as simple and easy of application, and as effi- 
cient and lasting as is likely to be found. It will be seen that in the 
techniques about to be described a single layer of sutures takes the 
place of three and requires but little more time to place than either 
of the three which it substitutes. 

Technique. — The method in brief is as follows: After closing 
the peritoneum clear the face of the fascia on either side of the 
incision to the width of tliree-quarters of an inch or more. As the 
upper surface of the fascia on the left side is not apposed to any 
healing surface and the only object in separating it from the over- 
lying fat is to mobilize the fascia, so that it can be drawn over and 
superimposed to the fascia on the right side, a sweep of the knife is 
all that is necessary here and sometimes even this may be dispensed 
with when the skin and fat can be easily retracted. It is very different 
with the under surface of the fascia on the left side and the upper 
surface of the fascia on the right side, for here the surfaces are ap- 
plied to each other and it is upon their firm union that the success 
of the techniques depends. It follows, then, that these surfaces should 
be laid bare and clean. The under surface of tiie fascia on the left 
side is separated from the muscle the entire length of tlie incision 
and a little beyond to the extent of iialf an inch or more. This is 
best accomplished by blunt dissection, preferably with dissecting 
scissors, which, being inserted between muscle and fascia at the edge 
of the incision, are run first in one direc^tion and then another. After 
finding the line of cleavage nothing is easier tiian to separate muscle 
and fascia ; they almost fall apart on the least touch. In cleaning the 
upper surface of the fascia on the right side, the skin and fat should 
be retracted and the face of the fascia laid bare with a sharp knife — 
scraped off. All these dissections are made easy by steadying the 
fascia with volsella, two at least being used on a side. Occasionally 
one will get into a duplication of the sheath of the rectus muscle on 
the left side, which to the beginner is quite puzzling, but a little 
experience will enable him to recognize the situation and deal with it 
properly, that is, get it off the best way he can. As a suture material 
I prefer the silkworm gut, both because it is less iriitatiufr and 
because it is less elastic, holding the aponeurotic surfaces in closer 
apposition. 



GYNECOUX! ir T K( 1 1 N IQf E. 



53 



Placing the Snture. — Ileginnin': on tin- loft side, pass tlic noedli? 
tlirougli tla> skin, fat, iiiul base or iilUi.lH'(l l)<)r<li;r (if the aiKUieiirotie 
fliip from witliout iiiwHrd, llien forward by a I/embort stitch through 
tlie aiKincurosis on the riglit side, tlien bii<kHaril tliroufrlt Hu- fnn; 
border of tliu aponeurotic flap fmin helow upward, tiien fnrwnrd again 



V 



'*- 



Fig. 33<i. — Tlif Aiillior'n l.'imiitnlii>n niul liiiliricntin); Suture for 
Clusiiig the Ahduiiiiiml Incision. 

through fat and skin on the riglit side. Each suture has a separate 
needle and no needle is used a seeoiKi time. Other sutures are placed 
in like manner at intervals of tliree-fourth.s of an inch. After all are 
placed, the surgeon gathers all the sutures of one side in his left hand 
while his assistant does the same for the opjiosite side, then, laying 
the ulnar aspect of the hand against the skin under the sutures, they 
jiress finnly against the uhdominal wall, at the same time drawing 
upon the sutures, and in this way glide the fascial surfaces one over 



54 PRACTICAL GYNECXILOGY. 

tlio other and in close apposition. As each suture is being tied it is 
sawed back and forth not only to see whether it will run and, there- 
fore, present no difficulty in removal, hut to bring the aponeurotic 
surfaces into still closer apposition. In introducing the sutures, the 
layers of tissue are picked up with long rat-tooth forceps, and one 
soon acquires the knack so as to do it in the nioft expeditious manner. 
The hands should be frequent y washed durirg this stage of the 
operation and the tissues handled as little as po.^sible. By using the 
rat-tooth forceps to i)ick up the tissues and a forcL^p? or sponge to 
retract the ti.ssues, there will be small chance of infection. I find 
this suture applicable not only to the ordinary ab:lominal incision, 
but especially to the radical operation for hernia, where its use is 
followed by the most happy results. Chroinicizcd catgut or other 
suture material may be substituted for the silkworm gut if thought 
desirable with much less chance of irritation than where the knots 
are buried. In using the absorbable suture materia! a little firmer 
apposition of the aponeurotic surfaces can be obtained by passing the 
needle through the free border of the flap from without inward. 
This cannot be done with safety, however, when the suture has to be 
renmvod, as it is liable to become locked. In actual practice the 
suture is quickly placed and is much less complicated than would 
appear from the description. 

Sressings. — The patient is now sponged off. and, if the sheet 
upon which she is lying is soiled, it is removed and dry tow^els sub- 
stituted. Sterilized iodoform gauze, several layers in thickness and 
of sufficient size to overlap the wound several inches in all directions, 
is now laid over it and glued to the surface with iodoform collodion. 
The collo(1i(m need only be a])plied to the margins. Over the gauze 
is laid a pad of sterilized cotton batting several inches thick and 
eight or ten inches scpiare. This is held in place by adhesive strips. 
A four- or six- tailed b'lndage, of sufficient length to reach one and 
one-half times around the body, is now applied, the tails being crossed 
diagonally from above downward, except the two lowermost, which 
are given a slight inclination upward. The bandage is secured by 
safety pins. This completes the dressing. 

After-treatment. — The j)atient is now put to bed and the dress- 
ings are not disturbed for a week or ten days, and not then unless for 
the removal of stitches, or because of soiling or suppuration. Soiling 
of the dressings can usually be detected by cautiously lifting the lower 
margin of the cotton dressing and peering under, or by staining of 
the bandage at the sides. Should soiling occur the dressings must 



OYNEroUXJIf TECH.Mgl K. 



55 



be removed inunedintely un<l rc|ilaii'il by olliors, ainl Ihis must be 
n.'}n-ated iit short intervals so loug as m>cfS8ary. 

Little Attentions. — For tliu ilr.-t twunty-fotir or lliirty-aix hours 
after ubdoiuinal wttiou tlic jiatii'iit is resllt-ss, if not in actual pain. 
She Sfhioni sleeps during tliu ilrst iiipht, is tormented by thirst, and 
not infre<iuently vouiiti». Ciasi'ous aceuiiiulations in tin? stoiiiiich and 
bowels, which refuse to l>e exp<'lled in the nntural way, are raised hy 
beleliing, and add to the patient's discoinfurt. The eoiiliiuicd diosal 
decubitus lieconief! constrained and irksome. The clcithinj; anil lu'd- 
diiig are apt to become disordered and wrinkled, which atiils greatly 
to her discomfort. The patient bofs for water, for a sleeping potion, 
for sornefhing to eontnd her vomiting, an<l to he turned over in bed. 
CoiMpliatiee with these requests is, us a rule, neither prudent nor 
practicable. A rectal injection of jiomial salt solution just before 
the patient is removed from the tahh; will ilo much tnward allaying 
the subsequent thirst. Neither water, foiwl: nor medicine should, 
as n rule, be given by the mouth for twenty-fnur hours, or even longer 
if the !-U>mach lia* not larome settled. The !i|)s may he moistened 
oecanionally. or the patient may be allowed ti> take water in the 
luoutli, with the injunction not to swallow it. On the second day 
sjMionfuU of hut wnter may be swallowed, followed later by a little 
«uda-wttter. When the >tomaeli beemnes scllled the quantity of water 
may be increased to the normal or to meet the needs of tlie j)atient. 
Occasiona'ly in hot weather, aiwl especijilly in the nhsenci- of gastric 
disturbance, it is allowable to give water from the first, graduating 
the quantity by the elTwt on the storaach. 

The wakefulness and vomiting are lari;ely due to the anesthetic, 
and there are no known means of obviating tlicm. Itiha!atii>ns of 
the vapor from hot vinegar will sometimes allay the vomiting, but 
as often fails. The most efficient trentment is to kee]) the stomach 
cntpty. It is seldom necessary t^i give an anoilyne. Tact and suasion 
and little attentions properly directed will do much to divert the 
mind and alleviate the distress of the patient. Changing the position 
of tlie legs, lifting up the knees and sujiporting them with a pillow, 
straightening them out again, untwisting and smoothing the cloth- 
ing and bedding, especially that ujion which the patient is lying, 
changing the jiillows and gentle rulibing of the surface of the body 
arc grateful to the patient, and will go far toward pacifying her. 
There should, however, be no hanl-nnd-fast rule of practice. Kxcep- 
tionally the most rigid rules will have to be observed, but most cases 
admit of slight departures according to the judgment of the attendant. 



66 PRACTICAL GYNECOLOGY. 

For great and persistent pain or even restlessness it is better to give 
morpliine hypodermically than to subject tlie patient to the wear 
and tear of continued suifering. For unquenchable and imperative 
thirst one may take the chances of giving water, soda-water, lem- 
onade, or tea, provided the usual methods have been tried and failed. 
Should the patient persist in her demands to be turned over, it is 
seldom that she may not be turned on her side and supported by 
pillows without danger or detriment. Common-sense, based on ex- 
perience, is the best guide in all cases. 



CHAPTER V. 

OYNECOLOQIC TECHNIQUE— COMPLICATIONS 
AND SEQUEL/E. 



SHOCK. 

Whenever practicable, the bed should be warmed ready to 
receive the patient when she comes off the table. This is all the more 
imperative in case of shock. Hot bottles should be ranged around her, 
being careful that they are securely corked and that some woolen 
fabric intenenes between them and her person. Serious and even 
fatal burns have resulted from neglect of these precautions. The foot 
of the bed should be elevated, strychnia given hypodermically in doses 
varying from '/jo to '/in grain, followed, if necessary, by stimulating 
rectal enemata. The strychnia may be repeated at intervals of from 
one-half hour to an hour until the shock is abated or until twitching 
of the muscles indicates that the limit of physiologic action has been 
reached. It is seldom necessary to exceed 1 grain of the drug in all. 
A very efficient rectal injection is found in the mistura asafcetidae, 
with which an equal quantity of hot water may be thrown up every 
one or two hours in quantities of from 4 to 8 ounces. Shock, in 
itself, as a result of abdominal operation, is seldom fatal. Crile, of 
Cleveland, who has given much patient research to the subjects of 
shock and collapse, recommends equable pressure over the surface 
of the body for the former and tJie administration of adrenalin for 
the latter. He has devised an inflatable rubber suit for patients suf- 
fering from shock by means of which a pneumatic pressure may be 
exercised over the entire surface of the body. In the absence of a 
contrivance of this kind bandaging the limbs and trunk would be a 
valuable substitute. The bandaging should be done adroitly and 
quickly in a very warm room. A flannel bandage is preferable, 

HEMORRHAae. 

The collapse from hemorrhage sometimes simulates shock so 
closely as to be with difficulty distinguished from it. If the patient 
be put to bed in fairly good condition, end after the lapse of several 
hours she be found with a rapid pulse, subnormal temperature, sigh- 
ing respiration, and cold and clamy skin, it is more than probable 

(57) 




58 



PRACTICAL GYNECOLOGY. 



that Blie is sulFcring from internal hemorrhage. Sometimes the 
patient is an.xious and restless, but quite as often apathetic. Un- 
fortunately there are no signs or ensemble of symptoms by which 
we can differentiate with precision between shock and hemorrhage. 
Especially does this apply to neurotic women. It is said that livid 
spots here and there over the surface, indicative of capillary stagna- 
tion, are pathognomonic of shock. 

The treatment of internal hemorrhage is, in many respects, 
similar to that of shock. The rectal injections and the use of strych- 
nia should be dispensed with as calculated to encourage the hemor- 
rhage by increasing the heart-power and dilating the splanchnic 
vessels. Atropine is a very valuable agent, and may be used in doses 
of from Vioo to '/50 grain, applied to any mucous surface. Ergot, 
either as a clyster or hypodermically, should be used freely and fre- 



4 

i 




Fig. 34. — Saline Solution Injector. 

quently. The injection of the normal salt solution into the sub- 
mammary cellular tissue is one of the most valuable means of coun- 
teracting the loss of blood. It should be given by gravity. A very 
convenient way is to attach an aspirating needle to the tube of a 
fountain-syringe, and, grasping the mammary gland in the hand, 
lift it from its bed while the needle is thrust under it into the 
cellular tissue. The reservoir should be elevated from four to six 
feet above the level of the patient and the needle left in place until 
the breast is thoroughly distended. The other breast may be injected 
in like manner. Absorption of the fluid is rapid, even in cases of 
extreme depression, while the increased volume of tlie pulse and 
vivifying effects on both mind and body indicate that the fluid has 
found its way into the general circulation. Most authorities advocate 
the reopening of the abdomen and searching for the bleeding vessels. 
Such, however, is the diiSculty of diagnosis, and of determining the 




GYNECOLOGIC TECHNIQUE— COMPLICATIONS AND SEQUEL.*. SO 

Bmonnt'and character of the heniorrlinge, eo many cases recovering 
from apparently hopeless depression, nnd so great is the danger from 
operative interference,— danger from shock and from sepsis, — that 
it is a serious question whether more lives are not sacrificed tlian 
saved by it. My own experience in both directions argues forcibly 
against operative interference. Still, where there are good grounds 
for suspecting an active arterial hemorrhage, it is better to reopen 
and search for the bleeding vessels. A preliminary small opening 
should be made to the peritoneum, and a silver probe introduced 
tlirough this into the cavity, when, if hemorrhage exists, it will well 
up through the opening. This and the subsequent operation, if any 
should be required, would better be done without an anesthetic. It 
is needless to say that every possible precaution should be taken 
against infection. 

SEPSIS. 

Sepsis is the most formidable foe of the abdominal surgeon. 
It destroys more of his patients than all other causes combined. His 
aim and object and greatest solicitude is to forestall it, for he knows 
full well that in tJjis lies the safety of his patient. Tait, the gifted 
champion of modern abdominal surgery, in the heyday of hia early 
achievements, misinterpreted the work of his own hands, and fell into 
the error of believing that he could battle successfully with bacterial 
infection. Speaking of one of his contemporaries, he quotes him 
as saying: "It is the peritonitis that beats us," and then, speaking 
for himself, he adds, with unconcealed exultation : "~\Ve beat the 
peritonitis." We now know, and doubtless he knew long before his 
death, that it was not the salts that beat the peritonitis after the 
operation, but sonp and water before, and clean hands and a clean 
field during, tlie operation. 

It would require more time and space than is consistent with 
the compass of this work to give an intelligent description of sepsis 
in all its varied details. All that can be done here is to touch upon 
a few of the more salient points. True, there are grades of sepsis 
nnd kinds of sepsis, swift and slow; but the sepsis that follows the 
knife into the peritoneal cavity and lights up a general peritonitis, 
or involves the general system by percolating the vascular channels, 
is the sepsis tliat concerns us here. This kind has n period of incu- 
bation of from thirty-six to forty-eight hours, during which it gives 
no sign. The intervening period may be stormy or calm. The patient 
may, or may not, be more than ordinarily restless. She may, or may 



"" 




60 PRACTICAL GYKBCOLOGY. 

not, have inordinate pain. She may, or may not, vomit more than 
usual. She may, or may not, have an accelerated pulse or be dis- 
turbed in mind. All this has nothing to do with the holocaust that 
is coming. We shall take for a type the ordinary case. She has 
experienced the usual amount of pain, of restlessness, of vomiting, 
and at the end of twenty-four hours she has settled into the usual 
calm. In the meantime the incubating process has been going on 
in the pelvis, silently, swiftly, and in geometrical ratio, until sud- 
denly a million microbes mount into the peritoneal cavity. The 
onslaught is so fierce and furious, so vast and irresistible, as to carry 
everything before it. Confusion reigns. Physiologic processes are 
reversed, and everything is working at cross-purposes. The stomach 
expels its contents upward, the intestines stand still, and the pulse 
runs riot. The patient whom you left calm and composed at your 
last visit now gives token of impending trouble. By consulting the 
chart you will see that the pulse has gone up. Gradually and by 
easy stages it has crept up to 85, 90, 100, 110, ISO. It is small, 
quick, sharp, and strikes the finger like a vibrating wire. She has 
vomited, first some clear water, then mucus, then bile, then brownish 
fluid. She is restless and tosses from side to side. She is appre- 
hensive, then panicky, and finally merges into hopeless despair. From 
the first she has an intuition that the hand of death is upon her. 
Her face becomes anxious and drawn. Her eyes are sunken and blaze 
with an unnatural light. They are fixed upon you with eager, anxious 
questioning, or roll from side to side with furtive and frightened 
glances. She presents a pitiable picture of one that is hunted, a 
picture that, once seen, will haunt you in return. Well may she 
tremble and cast about affrighted, for the pursuer is hot on her trail, 
and neither fleetness of foot nor earthly power shall avail to deliver 
her from his clutches. His name is Death. The temperature goes 
up, but bears no fixed relation to the pulse. The bowels are par- 
alyzed and distended with gas. They are obstinately constipated 
and respond to neither clysters nor cathartics. Neither flatus nor 
fecal matter passes the rectum. The abdomen is distended and tym- 
panitic, smooth, shiny, and resonant as a drum. It first appears as 
a resonant fold at the epigastrium, and rolls over the upper margin 
of the bandage. The pulse mounts higher and higher and becomes 
a mere running thread; the skin becomes cold and clammy, the vom- 
iting brown and offensive. Two days of silent preparation and two 
days of tumult give the battle to the germs, and on the night of the 
fourth day the victim goes to rest. 



GYNECOLOGIC TECUNiyL'K— COMPLICATIONS AND SEQUEL.*. 61 



There is another form of sepsis as irresistible and as unerringly 
fatal in which there is no abdominal distension, nu peritonitis, but 
which in other respect* is very like that described above. This may 
be fuhninant in character, causing the death of the patient in a few 
hours, but usually it is slower and runs its course in a week or ten 
days. In tliis form the patient is apt to complain of dull, heavy 
pains in various parts of the body and extremities, experiences chills 
[And profuse sweats at irregular intervals; the temjwrature line is zig- 
Isag, sometimes niountinj; to 105 or even highur, and again dropping 
'to or below the normal. Toward the end a colliquative diarrhea sets 
in. Nervous apprehension is not invariable, for some patients are 
placid and hopeful to the last. They are sometimes bright and some- 
•times lethargic, but more frequently the latter. I have frequently 
inquired of sucli: "How do you feel this morning." to which the 
cheery reply would come: "First rate" or "Much better, thank you," 
and tliis, too, when the skin was of cadaveric c-oldness and the death- 
dew was gathered on the brow. 

Ijet it be borne in mind that a gradually ascending pulse asso- 
ciated with vomiting, declaring on or about the second day, are 
ominous of evil and strongly suggestive of sepsis. 

Treatment, — The Jlnrpliy treatment of diffuse suppurative peri- 
tonitis by the Fowler position, pelvic drainage, and proctoclysis, is 
meeting with such measure of success as to place this once much 
idreaded afTcction in the category of curable diseases. The Fowler 
'potiition, which consists in placing the patient in the semi-sitting 
|)ostiire. drains the bacteria-laden fluids away from tlie diaphragm, 
where absorption is most active, into the pelvis where it is least 
active, from whence by pelvic druiniigc it is removed entirely from 
the body, thus preventing or limiting systemic infection. On the 
other hand, the lymjihatics become engorged with the salt solution 
aijB'frbcd from the bowel after rectal instillutiiui and refuse the poi- 
sonous products of the germ infected urea. The drainage should be 
made through fenestrated or split-rubber tulies, introduced to the 
Ifottom of the abscess cavity and taken ruit at the nm-it dependent place 
— at the lower end of the incision or through tlie vault of t!ie vagina. 
Rectal instillation of the nornui! salt wilutinn nuiy be administered 
by the ordinary fountain B>Tinge. The vagina! nozzle with its mul- 
tiple ofH-iiings is preferable, which should be bent at right angles three 
inches from the end to prevent pressure on the posterior wall of the 
rectum. (It can be bent over a spirit flanu,-.) This is introduced 
into the rectum up to the angle of the bend and secured in place by 




62 



PRACTICAL GYNECOLOGY. 



Mill* bjr lUUmuoo (Hirli.) »\ti Co. 




strapping Uie tube to the tliigh with adhesive strips. The salt solu- 
tion is delivered drop by drop, about a pint or pint and a half being 
instilled to tlu> hour. The rajiiility of iustillution is regulated solely 
by the height of the fountain, which will vary from six to fourteen 
inches above the level of the anus according to the intravisceral pres- 
sure to be overcome. No clamp or other device for retarding the flow 
through the tube is permissihle, as it is important that there should 
be no obstacle to the expulsion of flatus or bowel matter through the 
same. The pohition should he replenished every two liours and kept 
at a temperature of about 100 by surrounding the fuimtain with hot- 
water bottles. The irrigation should be maintained for several days. 
For maintaining the patient in the Fowler positinn I have found the 
adjustable canvas chair most coiivi'tiii'nt and comfortable. Usually 
Fig. as— c«ii»«» chmir No.BO. ^^^^^.^'1"" ^^ad of the bed is elevated and 

some sort of support provided for 
the buttocks. As adjunct to this 
treatment Murphy insists that no 
water be given by the mouth, and 
I hut eight hours after operation 
mild catharsis be instituted by 
small doses of caloitu'l. I iifortiiiuitely there has not been a correspond- 
ing advance in the treatment of puorjiera! peritonitis or that form de- 
j>endent on streptococcus infection. This is largely due to the fact that 
the germ occupies the lymph spaces and subperitoneal cellular tissue, 
and cannot be drained away. Also to its virulence which overcomes all 
the barriers oposed by nature, and the rapidity with which it gains 
entrance to the general circulation. Here the Murphy treatment may 
be suj)plemented by light packing of the pelvic ciivity through a free 
ojiening through llu- vault of tlio vagina liack of the uterus with gauze. 
Davis saturates the gauze with a saline solution through on opening 
iiltovc the brim of the pelvis; Pryor uset» iodofnnn gauze and also 
lightly packs the uterus with tlie same, believing that the liberated 
iodine possesses specific antistreptococcic properties. These packings 
should be removed little by little as the condition of the patient im- 
proves. Murphy advocates tJie antistreptococcus serum in these cases. 
In the symptomatic treatment of sc[itic peritonitis the indications are 
to control vomiting, relieve abilomiiuil distention, quiet pain, and 
sustain the bodily powers. Owing to tlie absence of absoq>tion and 
oftentimes paralysiii of the intestinal tract, medicines given iiy the 
mouth are practically useless. For the vomiting and abdominal dis- 



4 



GYXECOLOGIC TECHNIQUE— COMPLICATIONS AND SEQUELiE. 63 



ttrntiua notliing is so efficacious as gastric lavage. The relief foIlow< 
ing its use is so marked that patients after one experience will often 
aak for a repetition. With the ilurphj treatment there is no call 
for the rectal tube and less for oral medication aside from mild 
cathartics. Puncture of the bowel is of no avail to relieve distention, 
though an enterostomy might be of service in some eases. Strj'chnine 
in Vso'S^fliD doses may be given hypodennically to sustain the heart. 
Overzealous and persistent use of drastic measures are to be deprecated 
as tending to increase rather than abate suffering. Should all prove 
onavailing and the patient is going from bad to worse, nothing will 
allay her sufTeringB, physical or mental, so quickly or effectually as 
morphine. This should bo given in liberal doses and frequently 
re[jt;ated so as to obtund sensii)ility. 

INFECTED WOUNDS. 

Stitch-hole Abscess. — If a wound becomes infected, as evidenced 
by a dusky or unliwilthy aiipeariince of the tissues, accompanied by 
pain and fever, it sbuuld he opeacil up and assiduously dressed with 
antiseptics. An open surface with free drainage and frequent cleans- 
ing will usually suffice without the use of chemical antiseptics. In 
case of a stitch-hole abscess the offending stitch or stitches should 
be removed at once and the wound cleansed every few hours. In 
the event of an infected wound leading down to, but not through the 
peritoneum, great care should be excriised not to open into the cavity, 
lest fatal septic infection of llie peritoneum ensue. Where pus is 
formed witliin the peritoneal cavity and is making its way to the 
surface it should be allowed to point, or at least to have formed cir- 
cumscribed adhesion, before the knife is used. The surrounding 
induration and fixation of the tissues will be the guide, and the 
oj)ening sliould be cautiously made within this area. 

ABDOMINAL FISTULA. 

The simple purulent fistula is by far the most common form of 
fistula following abdomiiiMl oyx-nition. It is usunjly the result of an 
incomplete oin-ration. or infeclioii of tiu' ligature iiifiterial. In plain 
words, it means that there is something within the cavity that is 
acting as an irritant or as a foreign body and which Nature is making 
an etfort to ex]>el by keeping an open way. If a pus-tube or any 
such diseasi'd structure he left l)chind, especially if its relations have 
been disturbed by ineffectual attempts at removal, a fistula is likely 
to ensue. These fistula' may, and usiudly ilo, persist until the offend- 
ing body J8 removed. .\n infected ligature will in time come away 



64 



PRACTICAL GYNECOLOGY. 



spontftnoouBly, either in its entirety or in shreds. It sometimes findfl 
nn outlet through tlie bowoJ or bladder, and escapes unobserved. It 
may sometimes be fished up through the fistulous tract by a delicate 
hook or slender forceps, but, as a rule, such olTorts are futile, and it 
is better to await spontaneous expulsion and in the meantime keep 
the parts as clean as possible. Fecal fistulip follow rui)tur(.' of the 
bowels, at or subsequent to the operation. If a bowel be torn or cut 
during the operation it should, if possible, be repaired at the time. 
Sonietinics it is iiuiccessiblc, ns in ruptures of the rectum diH'p in the 
pelvis, when all that can he done is to facilitate the discharge of fecal 
matter per vias naturaJes, to limit the peristalsis, and provide for 
drainape. A gauze drain should be inwrtcd leading from the damaged 
bowel out through the lower angle of the aluloiuiiial incicion. Tliis 
may be removed in from twenty-four to Ihiiiv-six hours. Meanwhile 
a wall will have hucii Iniilt around it which will give vent to the 
extravat^atcd intestinal contcnt.s without danger of infecting the gen- 
eral peritoneum. 

In case of damage to the liowd which threnlcnn siulwoquent 
sloughing or rupture, and where it ii? found impnu-ticuble nr inexpe- 
dient to repair or resect the damaged portion, the same expedients in 
regard to drainage sjlumld be rejJdrti-d to a.'» advised for rupture. Before 
the patient is taken from the talde, a thorough (lihiliition of the rectum 
should be made, and in bad cases a division of the sphincter ani to 
insure an easy and unobstructed passage of the intestinal contents. 
For the first two days the bowels should be left undisturbed, after 
which a laxative may be given, and thereafter the bowels should be 
kept soluble. The promptness with which Xnturc fortifies against 
the exigencies of a fecal iistula is at times Hur]<ri.sing. In years past, 
when the glass drainage tube was in frequent demand, I have with- 
drawn fecal nuitter from it within six hours of the ojKTation. Within 
tliis brief period Nature had made a channel and built a wall around 
it to protect the general peritoneum. Where the injury to the bowel 
is not recognized at the time of the operation, and the abdomen closed 
without drainage, tlie fecal matter will usually make a track of itself 
and in a few days find exit through the wound. This is accompanied 
by severe systemic reaction and accelerated pulse. When the matter 
has found an exit free vent should be provided for it by loose and 
absorbent dressings. Formalin may be used — 1-per-eent. solution — 
as a deodorant and antiseptic, and the parts kept clean by frequent 
dressings. Most fecal fistula' close spontaneously after a few weeks 
or months. 



4 
4 

4 



4 



4 
% 



GVNKCOUXJIC TECHNiyUK— CUMPLICAIIONS AND SEQUELuE. 65 



HERNIA. 

A very considerable proportion of abrlominal sections is followed 
by hernia. This is especially true of sfctions followed by suppuration. 
UtTnia iriay occur, however, in cases timt have iiealed kindly, but in 
which, by reason of faulty technique, the parts have not been proj)- 
criy coapted. Indiscretion on the part of the patient, such as over- 
exertion or straining soon after the operation, is sometimes respon- 
sible for this untoward secpiel. It first nianifests itself as a sniiill, 
soft pouting in the line of incision, which, if ncfrlccted, praduHlly 
enlarges until it involves the entire length i»f the incision. To guard 
against hernia following sti]ipuration and cicatrization of the section 
wound there are, unfortunately, no j)revcntive measures that are 
effectual. Many have conceived the iflea llmt, as scar-tissue it' dense 
and resistant, it will oppose an effectual barrier to hernial protrusion. 
This is fallacious. >>car-tissiie, thmigh dense, w^ill not resist the 
steady, sustained intra-alHloiiiiual jircssure, because it is of too low 
vitality and is not constantly renewed as are tlie live tissues. 

Shich may be done to nbviate hernia under ordinary eircum- 
Btanees by care after the o])eratioD. The jmtieut should avoid a too 
early getting up, should guard against straining and overe.xertion, 
and should wear a snug-fitting bandage. There is a growing dis- 
position among graecologists to underrate the bandage. There are 
some that go so far as to assert that the bandage is of no benefit 
whatever as a support to the abdominal walls. Nevertheless, even the 
roost rabid of these protestants wMl utilize the bandage as a first 

[dressing and continue its use until the patient has left her bed. This 
goes to show that even such have faitli in the bandage that they are 

t unwilling to admit. 

The treatment of post-operative ventral hernia may he palliative 
or radical. As a palliative measure a properly fitting truss and ab- 
dominal supporter will often render the patient quite comfortable, 
but it will neither cure nor, as a rule, prevent the grail ual enlarge- 
ment of the hernia. The radical cure is only to be accomplished 
through operation. In most instances the abdominal contents are 
adherent to the sac. and the peritoneal cavity should be entered 
caiitioiisly lest a bowel lie injured. It is better to make the primary 
incision above or to one side nf the iicinial protrusjion and far enough 
away as to avoid the adhesions. Once into the ca\'ity, the section can 
be carried down the median line nftcr a preliminary separation of the 
adhesions. IJedundant tissues should now be excised, cicatricial tis- 
sue removed from the margins of the opening, and the different layers 



66 PRACTICAL GYNECOLOGY. 

of the abdominal wall separated and brought into apposition with 
similar layers on the opposite side, and secured by suture. 

PREVENTION OF POSTOPERATIVE ADHESIONS. 

As a means of preventing postoperative adhesions in the peri- 
toneal cavity nothing seems to have been so efficacious as sterilized, 
absorbable, non-irritating oil. Immediately after completing the 
toilet of the peritoneum in all cases where adhesions are feared or 
expected, the oil, warmed to the temperature of the body, is introduced 
in quantities sufficient to permeate all the interstices of the viscera 
and to interpose between them and the walls. Olive oil has been for 
the most part used for this purpose, though Crump believes that in 
neutral animal oil we have the ideal lubricant by reason of its bland- 
ness, absorbability, and comparative freedom from free fatty acid 
(usually not to exceed 14 "f 1 P^r cent., though it may run as high 
as 10 per cent.) ; it is acceptable to the peritoneum and imposes no 
burden on it. The 300 brands of olive oil with their varying degrees 
of acidity give less promise of uniform results. Universal or vaselin 
oil he considers as offensive to the peritoneum, difficult of absorption, 
and has a tendency to be walled off into cystic accumulations as with 
other foreign bodies in the peritoneal cavity. 

FLUSHINQ AND DRAINAQE. 

Flushing the peritoneal cavity after operation with plain steril- 
ized water or the normal salt solution at a temperature somewhat 
higher than that of the blood is a routine with some operators and 
possesses some advantages. When a quantity of the warm fluid is 
left in tlie cavity, as is usually the case, it diminishes shock by main- 
taining the bodily wannth. It also abates thirst. The chief claim 
of its advocates is that it lessens the chances of sepsis by washing 
away and diluting the germs. It is questionable whether it subserves 
any valuable purpose in the way of preventing germ infection, and, 
as it is apt to soil the clothing and table-cover, it becomes objection- 
able. It should not be used where hemorrhage is feared or where 
oozing is going on, as it encourages hemorrhage. As far as I have 
been al)le to judge, it neither tends to save nor destroy life, as equally 
good results are obtained with and without flushing. 

There is no question connected witli abdominal surgery that has 
been so fully discussed and so fiercely contested as that of drainage. 
Clinical experience and scientific investigation have denionstratod that 
in the great majority of cases drainage could be dispensed with, not 



GYKECOLOGIC TECHNIQIE— COMI'LICATIONS AND SEQUEL.«. 67 



only witli safety, but to advantage. Still, there arc occasions when 
s drain becomes apparently necessary : — 

1. When ahiicess-cavity has been opened and tlip pusi-producing 
cause cannot be removed. 

2. When from injury to the bowel or bladder or other viscus an 
escape of their contents into the peritoneal cavity is feared. 

In the latter event the gauze drain imswers every purpose. One 
end of a strip of gauze should be placed in contact with, or in the 
immediate vicinity of, the danger-point, and the other brought out 
tlirough the abdominal incision, iisualty at its lower angle. This end 
should be enveloped in sterilized ahtKiriient cottou and the dressings 
so adjusted that it can be changed without disturbing tiie permanent 
dressings. Tiiis cotton should be removed and fresh cotton substituted 
as often as it becomes saturated. Sometimes where there is much 
oozing or venous hemorrhage the gauze nmy be utilized as a hemostatic 
compress, or packing and drain combined. 

Drainage. — The present-day methods of drainage are by gauze 
and rubber tubing. Riildnr tubing will drain anything that flows and 
in any situation, iiut will not drain against gnuity unless the fluids 
are forced up througli it by pressure — iutrn-iibdoininHi pn-ssure or 
resiliency of the tissues. It is evident, therefore, that the tubal drain, 
to be most efficient, should be so placed as tu ilriiin from the most 
dependent part. On the other hand, gauze or cniiilliiry drainage will 
not drain thick matter — blood or pus — but will drain light fluids 
against gravity, provided it is in snflTicient ojuantily to meet the de- 
n>ands of the occasion; that it is of equal thickness throughout its 
length, and that its outer end m in contact with an absorbent dressing. 
In the peritoneal cavity the gauze drain excites a flow of serum which 
dissolves the pus and blood-clots and renders them capable of capillary 
drainage. The flow of serum is [)niportional to the amount of gauze 
in contact with tlie peritoneum; hence, extensive drainage re(iuire8 
much gauze. Oauze is ill-suited for the drainage of walled cavities, 
for in this situation its presence does not excite n flow of scrum. 
Here the fenestrated or split-rubber tubing is most efficient. In the 
general jK>ritoneal cavity the drain, of wlmtevcr charncler, Iiei-omes 
walled off in a few hours, so tluit a gmize clrniii, liecoining cloggwl 
for want of tlie serum solvent, nmy obstruct, nitlnr tbaii favor, the 
discharge. It is better, tbercfure. to remove it witliiu forty-eight 
to seventy-two houre unless associated with tubular drainage, .\ 
split-nibber tnbe filled with gauze, the gauze protruding from either 




A 



68 PRACTICAL GYNECOLOGY. 

end, makes an admirable drain in cases where the drainage is to be 
maintained for a considerable length of time. 

In considering the question of drainage it must not be forgotten 
that it is to the natural resources of the economy that we are to look 
for safety. The mere introduction of the drainage tube does not pre- 
vent inimical products from diffusing themselves in other directions. 
It is Nature that circumvents and walls them in by throwing out 
plastic matter and agglutinating the viscera. Without this co-opera- 
tion all our efforts at drainage would be absolutely without avail. 
After this the drainage tube furnishes an artificial route by which 
noxious matters may be expelled. But even this artificial way is not 
essential, at least in the vast majority of cases, for with almost un- 
erring instinct Nature will provide a walled-in route leading to the 
outer world through which the offending matter may be discharged. 
Where an abdominal incision has preceded, the opening will almost 
invariably be at some point along the line of incision, and tliis, too, 
despite the fact of close suturing. Should the pathogenic products 
be of great virulence, .«uch as sometimes occurs in puerperal sepsis or 
other allied conditions, they will respect no boundary-lines with or 
without drainage, and will diffuse themselves throughout the cavity. 



CHAPTER VI. 



CONSTIPATION. 



Constipation is not a disease, but u symptom of some condition 
interfering with the natural function of the bowel. It ifi more 
coninion in women tlian in men. 

Etiology. — Constipation may be due to local or general causes, 
liocal causes include |ielvic grnwths, retroflexions, rectocelc, atony of 
the Imwcl, and relaxation of the abilominal walls. General causes 
embrace errors in diet, nervous disorders, anil certain gastric, hepatic, 
and intestinal diseases. Organic di.<easc of the Ixnvel, such as acute 
intestinal obstruction, chronic thickening of the sigmoid, tuberculosis, 
or malignant growths, may be jiresfnt and should not be overlooked. 
Reflex irritation, especially of the genitourinary tract, ulcers of the 
pylorus and duodenum, anil certain drugs, such as iron, bismutli, 
opium, and heroin, tend to inhibit intestinal peristalsis. A uterine 
fibroid, a pyosalpinx, or an ovarian cyst may ])roduce sufTicient pres- 
sure on the lower bowel to cause obstipation. Extensive inflammatory 
exudates of a salpingitis may give rise to a stricture of the bowel. A 
retroflexed utertis, especinllv if adherent, by impinging upon the 
rectum, not unfrequently produces constipation and hemorrhoids. 
The hemorrhoidal ves.>iels being closely connected with the portal cir- 
cnlation, conge.-'tion of one circulation reacts upon the other; hence, 
certain diseases of the liver may favor bowel stagnation. Tears in tlie 
lateral sulci, if associated with rectocelc and desiccnt of the uterus, 
diminish the projiulsive power of the rectuui. Atony of the colon 
may resnit from disregarding nature's call; such irregularity in the 
evacuation of the bowels proiluces a dry and hardened stool. Nnnnally, 
the (ei-es collect in the lower portion of the sigmoid, there to remain 
until shortly before stool. When peristalsis begins, the contents are 
propelled into the rectum and there is a desire to go to stool. 

If the act of defecation lie postponed, a reverse peristalsis is 
excite«l and the mass is forcred back into the sigmoid. This portion of 
the bowel an<l the descending colon may sometimes become enor- 
mously distended. 

Erron in Diet. — ^The feces consist of solids and water, and the 
amount formed in a day depends on various conditions. The normal 
weight of drv solids iinxliiced on a mixed diet in the twenty-four 

(69) " 



70 PRACTICAL GYNECOI>OGY. 

hours is about one and a half ounces, and of water tlirec and a half 
ounces. With a strictly meat diet, digestion and absorption being 
more wmplete, the dry solids are diminished. A diet containing 
much indigestible material, such as cellulose, gives more bulk tu the 
feces and stimulates peristalsis, thereby favoring a more rapid move- 
ment of the bolus, and diminishing the tendency toward constipation. 
Gastric ulcer, hepatic trouble, neurasthenia, or hypochondriasis may, 
indirectly, produce atony of the large bowel and cause constipation. 
Women thus afflicted are prone to deprive themselves of sufficient food, 
and what they do take usually consists of very digestible and non- 
stimulating material. 

Symptoms. — One or more of the following conditions may be 
present: headache, lot's of appetite, furred tongue, dizziness, anemia, 
skin eruptions, intestinal flatulence, and various nervous disturbances. 
Accompanying these may be fissures, fistulae, ulcers, hemorrhoids, and 
prolapsus nni. Young women between 15 and 23 years of age are 
occasionally troubled with an anemia of the chlorotic type that is the 
result of constipation. They have a furred tongue and offensive 
breath, and frequently complain of pain in the region of the descending 
colon. 

Diagnosis. — Every woman giving a history of constipation should 
be carefully questioned and examined so as to ascertain the cause, 
location, character, and duration of the trouble; much depends on 
whether there is a functional or an organic disease of the bowel. A 
scybalous mass in the colon has been mistaken for an abdominal tumor 
or an enlarged kidney. Fecal accumulation in the upper p6rtion of 
the rectum may resemble a prolapsed ovary or a pelvic growth. 

Treatment. — A physiological evacuation of the bowels should take 
place once in twenty-four hours, although constipation may be present 
even though there be a daily movement; the amount is so small each 
time that eventually a collection of feces forms. 

Food. — It is essential that the food taken into the body should 
be of such a character as to leave a sufficient residue to excite intestinal 
peristalsis. Many cases of constipation can be cured or benefited by a 
carefully selected diet. Such does not pertain to those cases suffering 
from some serious organic lesion. It is best that a mixed diet should 
be selected. This may consist of vegetables, nuts, sa'ads, brown bread, 
Graham bread, or bran bread, ontnieal, and other cereals. To these 
may be added butter, buttermilk, olive oil, soft-boiled eggs, berries, 
and dried fruits, such as primes, figs, and plums. An apple thor- 



COXSTTPATION. 



ri 



oughly masticate<l at bwltinif, and liir<:i' tiiiiiiititii'S nf wiiter tnken 
during the (lu_v, iiiav siitliw in inilil i-iiM'>i. 

Two to four glansfuls a day of a curdled or sourinl milk may 
cauee the fvacuatioiiss lo hocoiiiu ntiriiial. After continuing for some 
woek» the amount should he gnulually rcdiiot'd. Another valuable 
trenttneiit is yeast, taken once or twice a day, depending on the number 
of movements of the bowels. The ordinary tinfoil yeast c-nke may be 
substituted where fresh yeant cannot be ohtnined. The amount adniin- 
i«twe«l should be about five-eighths to three-quarters of a cubic inch 
dissolved in a half a glassful of water. 

Agar-agar is also eflicaeious in the treatment of constipation. It 
comes in long strips, which are groun«! into umall pieces resembling 
the consistency of a coarse granular cereal. It is taken morning and 
evening in lo-urmu doses and may be increa.«ed or diminisheil accord- 
ing to its action on the bowels. It may be mudc more j)ulatable by the 
:dition of juilk or cream with salt or sugar. 

ExmtriSE. — Nothing conduces more to good health than regidar 
and judicious exercise, such as walking, horseback riding, golf, tennis, 
or gymnastics. Active exercise should be proiiibited near, or during, 
the menstrual jKriod, and to those suffering from acute pelvic trouble. 
In the old or infinii, passive exercise in ihc jVinn of massage may be 
used. During inclement weatlier, the general .strength and muscle 
tone may be maintained by substituting indoor gymnastics. In the 
young, the abdominal and thoracic muscles are resistant and help 
supfKirt the various vis<'era in their normal relation. T.,aler in life 
the mus<'les, from lack of exercise, lose their tone and sujiportivc 
qualities, thus favoring rela.xation of the abdominal wall and descent 
of the abdominal and pelvic organs; such may give rise to p<'lvic 
congestion. 

REnrLAiiiTY IN Bowel Evacitation. — Much time and attention 
phould lie given to nature's call. Nothing should interfere with the 
•et, and no haste made to complete it. Perseverance and regularity 
are essential. A daily habit of evacuating the bowels should be 
wtablisbed. The closet seat is, no doubt, [uirtly responsible for some 
of the cases of constipation. Nature intended the act to bf performed 
in a squatting posture. Such a position braces the abdominal walls 
and assi.sts in the expulsion of the dejecta. This defective arrnngcment 
of the closet seat may be partly overcome by either lowering tlie seat 
or raising the feet of the individual. 

Electhicity. — Tn selected cases electricity Iris given good results. 
A faradic current of about 9 volts, with an amperage adjusted to the 




72 PRACTICAL GYNECOLOGY. 

requirements of the patient, should be used. Two flat leaden electrodes 
are adjusted next to the skin over about tlie middle of the ascending 
and descending colon, respectively. After passing the current for 
about fifteen minutes, it is reversed for another fifteen minutes, at tlic 
end of which the first seance is closed. This is repeated until the 
evacuations become normal in consistency and frequency. 

DuuGS. — The indiscriminate use of drugs should be condemned. 
In the old and infirm, where active exercise is prohibited, certain 
drugs, such as podopliyllin, cascara sagrada, calomel, and compound 
licorice powder, may be found useful. If drugs be used, care in their 
selection and careful observation of their action should be made that 
they do not augment the trouble. 

Of all medicinal agents employed as a corrective of chronic 
constipation there is none so generally applicable as liquid petrolatum. 
Being non-absorbable and unirritating it may be used in any quantity 
without fear. As it docs not clog nor accumulate in the bowel, it may 
be used for any lengtli of time without danger of obstructing its 
lumen. Its action is that of a lubricant and protective to the alimen- 
tarj- mucosa and is not contraindicated by inflamed or ulcerated sur- 
faces. As to the kind and character of the oil, whether light or heavy, 
Russian or American, recent research geems to imply that there is 
no essential difference between them, though the heavy Russian oil has 
liitherto been considered best. 

Dose. — The dosage runs all the way from 14 to 4 or 6 ounces 
daily; these amounts divided equally and taken before meals. Just 
sufficient should be taken to secure easy action without expulsive 
effort and the amount varied from time to time as occasion requires. 
It may bo taken plain or with anytliing that will render it more 
palatable; buttermilk, lemon-juice, etc. 

ExEMATA. — Scybalous masses in the rectum may be removed 
with rectal injections. Of tiiese soap, water, and glycerin; sweet oil 
from a half to a pint, or flaxseed enemata, two teaspoonfuls of flax- 
seed to a pint of cold water, boiling it for ten minutes and straining 
out tiie seeds, answer \er\ well. Large injections should be avoided 
lest they cause loss of tone to the bowel and aggravate the condition. 

Colonic Lavaob. — The usual method of administering colonic 
lavage, with the uncertainty of the fluid reaching the colon, has 
caused it to be generally abandoned. 

Constipation due to organic trouble, such as malformations and 
faulty positions, bands of adhesions, presence of tumors and stric- 
tures, permanent benefit may be frequently obtained by attention to 
such abnormalities in a surgical way. 



CHAPTER VII. 

DISORDERS OF MENSTRUATION. 

Menstrdation, as the name implies, is a monthly flow of 
blood — from the female genitals. The blood comes from the uterine 
cavity, and is furnished by the endometrium. In this latitude the 
function becomes established at or about the fourteenth year, and 
extends through a period of from thirty to thirty-five years. This 
period, whicli is co-extensive with the capacity for child-bearing, is 
known as the sexual life of woman. In hot climates the function 
begins somewhat earlier, and in cold climates later in life. The 
cause of menstruation is unknown. Its purpose is not clearly de- 
fined. It is supposed to have both a general and local significance. 
The changes that take place in the endometrium coincident with 
menstruation are supposed to favor conception and provide for the 
lodgment and development of the ovum. This, not^vithstanding the 
fact that animals with the exception of the monkey do not menstruate. 
The systemic influence of menstruation is attested by the fact that 
women feel better when the function is regular and normal. 

Coincident with the establishment of menstruation the physical, 
mental, and moral natures undergo great changes. The girl becomes 
a woman. She takes on the lines and curves that distinguish the 
mature female from t!ie male. The increased development of bust 
and hips and general fullness of contour add greatly to her attractive- 
ness, and proclaim her readiness for niotlrerhood. She suddenly 
awakens to a realization of her social status and becomes reserved, 
dignified, and demure. 

The average period of a single menstrual effort is from four to 
five days. The amount of blood lost varies from four to eight ounces. 
The menstrual fluid, though apparently pure blood, is really com- 
posite in character. It consists of blood, mucus, epithelial cells, and 
detritus. In normal menstruation this is always fluid. Coagulation 
is prevented by the presence of lymphoid elements, of which we shall 
speak directly. The endometrium is a membrane peculiar to the 
uterine cavity. Its counterpart does not exist elsewhere in the econ- 
omy. In appearance and position it resembles mucous membrane, 
but in histologic formation it partakes of the nature of lymphatic 
tissue. It is intimately adherent to and blends with the subjacent 

(73) 




74 



pnArru.xL ovnicidukjy. 



niustulnr structure. The lymphoid colls with which it alvouiids play 
an inijxirtant role in the cliaiigt-s incidunl to nionstnialioii. A pelvic 
congestion, especially marked in the vicinity of tlie endometrium, 
precedes and lurompiiuies the menstrual act. The epithelial covering ^ 
of tlie endumetriuiii is thrown olT, not in the form of flakes, but B 
rather as individual cells. In other words, it melts away. To what 
agency this solvent action on the intercellular substance is due is not 
positively known, but there is renson to holievc that the whole proccfis 







7 



Fig. .'to. — I'teijug at MpiiMlruiil IVrioil, .SliowiiiH tin- tongestfd .Vrea and 
Oestruc-tion of Muvuuii Mcnibiuiie. ( Pliotoniirrogrupli by UraiiiiD.) 

hinges on the ovarian sccrcltuu. Tfiis secretion, transferred to the 
blood, contains certain chemical .substances (bormoiies) which cause 
a congestion of the uterus and its mucosa and an iiicreasi'd activity 
of the uterine glands. The mucous secretion of the glands contains a 
digestive or fibrin fonneni, tryj)sin, which, coming in contact witli 
the swollen cell layer, disintegrates it and at the same time opens 
the smaller capillaries, allowing the blood to escape. The trypsin 
mixing with the blood destroys the fibrinogen and in this way prevents 
clotting. This is the cxplainition of why menstrual blood does not 
clot. The blond mingled Avilli the natural secretions, the broken-down 
remnants, and the cfiithelia! cells constitutes the menstrual fluid. 
With the cessation of menstruation the lympiioid elements of which 
we have been speaking builrl uj) anew thii lost epithelial covering and 




DrsOROERS OF MENSTRUATION. 



7K 



Peliij) ill vast nuinliers in the i^iihstaiife of the cnilomotrinin to pro- 
vide a rich and succulent bai>e for tliu loiifrmont of the ovum. 

AH women do uot menstruate at regular intervals of twenty- 
eight doys. Some menstrunio only once in five or six weeks; others 
every two or three weeks. Kxce|)tionally, women menstniatc at much 
longer intervals. Dilferent women menstruate at ditferent periods 
of the month. It is noticeable, however, tiiat many women men- 
struate at or about the same time. Some women habitually men- 
struate scantily, otliers profu.sely. Deviations from the type, either 
as to time or quantity, ilo not necessarily constitute an abnormality. 
Menstruation that is regular cjr irregular, scanty or profu.se, frequent 
or infrequent, if habitual tlirough life and accimipanied by no sense 
of discomfort or evil .unsequeuccs, may be considered normal for the 
individual. 

PRECOCIOUS AND DELAYED MENSTRUATION. 

Instances are not rare in whicii meiisiniatioii makes its appear- 
ance at an earlier period than that cited in the schedule aliove. I'lius, 
it has declared so early as the eighth or tenth year, or even soon after 
birth. In all such cases an abnormal development of the genital 
apparatus is noted. On the contrary, menstruation is sometimes 
delayed for several years. This generally betokens enfeebled health 
or want of development. An early nienstruatiou jiresages a late 
menopause. This is contrary to the popular belief, but will liold 
good in tlie majority of rases. 

MENSTRUAL PRODROMES. 
Very frequently, especuiiiy among the high-strung and eretliis- 
I, the menstrual denouement is heralded by various disturbances 
of the nervous, vascular, and digestive apparatuses. These are usu- 
ally distinctly periodical, coming and going at monthly intervals, 
and if closely observed M'ill furnish the key to the situation. They 
sometimes anticipate the menstrual flux by many months or even 
several years. They consist of iicadiiche. backache, pelvic jMiin and 
fullness, alternate periods of hilarity and de[)rcssiou, hysterical mani- 
festations, epileptoid seizures, ga-stric and intestinal dyspepsia, be- 
sides many other phenoiiieim. Cutaneous eru[)tions are conitiion at 
this period, and, like most of the other associate ni"rl>id manifesta- 
tions, are rebellious to treatment. All these vanish when the function 
has become established. The establishment of menstruation is not the 
work of a day. Occasionally it has no precursors, makes its debut 
without ado. and holds an even course. JInre often, after one or two 
periods characterized by soTiie deviation from the normal standard. 




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th'-f: ■»..; ■;<: i .!••"- T ■— .".'-r-."* r.i n^t- ••■•"■vr l" rr'-^ri-j* 
iiit»-r-.;ii- f'.r >. '■■.: : :...•- ".:.■ '.:■ -.■ • " z:'- n-* i' i:"ri-- 
hcd-ior. '*f. *..•■: •>.— ■■ *. - ;•;•-:"-. • .-. -. . 'z <-- '-'>'■. ' 'iiit t niiU 
r<-l}iifi- i.'-r J-. A. ;-<." . ■!.--..•*•. r :;.> •- r"-;. "m: l vH -m. t-i1 
in th<; nor <l,-v.;-. :'.-..-r. .■;. ..-.r-r.-r.; ■--;. :-*-;. .r --t-T- m-^.-rna- 
lioji, a lo— . '/ ...••.. ••^r •. * .;. : ir* r-rr ti. I :• rr-- ;:• -ii j^ ji 

ti«H! to f.h«r f.O.Tf.*. ;..-.•.•".• .-:. •■ .-■. - .'.'.-" .';.r^ ••-• '..-i f.* •!! - C:- Illi-T 

ort'iin f.'ran '.'j: -■••" -. '.: ' -■ '. -.'• " ■:' ' ~. : ~.t- f ▼ '—a ii *:- 

a.- ;i -lllcf ft.'i:, ',r. ■».■.••"■ " - .' r i. ri ■•■ .- ..'.-.."fj -i:. II.,* •»:- •".Clir' 
c.U|)Jil'-ln<rnta.. I*. .- ..-.•. -: •:■ •'.. >.- ■'^'I'-'-/^ '.->•..,•-,.;-■,;-? A>, 

Uf«iii-<' of it-. ;j,'..'.** .ri. . y;!*. •:. .• .- * -r-; ■? '^r^-' *'■»*..« "-t-t '»;■*. 
Vi<-;irir>ii- rh'-r.-*r.M*.',r. ;:.-i > ..* i* <..';.'-* 4;.. :•...".:. ■•it "• r<r 
fni'jiMrntly -prif:j.'- fr'.ri. •:.- fv^.- '.r i.:- :ii--«i_-r^^. :;.-:■ -.t ::-.•. ■^ ~ 
i:fi-y \\i: tumor-, or o.-i -'..•'-. 

.MENOPAUSE. 

'Ill*- «— atiofi of rfi«-r:-T .«!*i'.;i .- rTiO-jr;; a* ::.r rr.rr.- ri::^^. I: 
i.a (■f»ni»rionlv lall'vl t'r.'r ' r..t:.'j'- 'li i.f'f. I*. '/-f-'^T' ".•"alW at ••r a>;''Jt 
the forty--«'V(rnth ■■-■.ir. r'l.'r-.'j:. ;• r.'iii. fi'f.r nr a rr.-j- r. **rii<?r --r larer 
[Kiriofl of life. It -•■'ioiii in^u.'i-t- • ;':<i<ff,ly. 'm'. on :h.e ci>ritrar\'. 
the j»li<;iiom«-na att^.'i'liij^' :;.•; <\,Aii'j:i- <->.t<-;,i: o-.v^r a T*riol of sjreral 
yr;Hr-. .Mcti-truatiou ;.";<:-. a- i? 'oiti'-, \i\ t't- an-l !»tart.«. but. as a 
riil«', l<"avf- wiili riior<; r'-Ii;ftan'-<' tiiMi, it >-4i\\\<:. Ttie ''aniinal anil only 
nrlialilr: r.'vjin of an a)>proa<iiiii;r rn<-n''jMU-<: i- irr'-jrularity. The llow is 
irr»'}riilar ar to tini<: an'l <|iiatitify. Tiii-. t}ik<-n in rronnection with the 
n'^*: of thf fiaticrit, fiirni-li<'.- a n-a-onalily n-Iiable ba.-i.» for diagnosis. 

'I'lii; clian;:"- i- ii-iia!ly att<'n'!ci| oy t!if: -amf cla-^:- of diiiturhanres 
that ]m-fi-<\i: till! c^idMi-linHrnt <»f rii<-ii-truafion. These are. for the 
most [lari. functional, aii'l |i<-riMin to tli<: iD-rvoujs, raj>c-u1ar. and di- 
gu>tiv«' aiiparaliiM-i. (tni- of tlif nwi-t f-on-tant i-j that of fluphing. 
Tlii-sc "hot flashi-.'' as thfr wonu-n call tlicni, are annoying and at 
times almost. iiiMilfcrahii;. I)i/7.in>-ss. faintntrr^s. mental depression, 
forjrct fulness, ami oilier [K-rvcrtcd norvoiis manifei'tationa are not 
uncommon. Dysjx-psiH and <lisor<1<-rc<] action of the stomach and 
bowels ari! fni|ucnt. Inordinate s<fMial appetite sometimes charae- 
tcri/cs the chanjre. Sxip|ircssion of the men.scs for one or several 
porioil-. followi'd by an excessive flow, is not uncommon. The patient 
and her friends are af>t to repird such flowiiigs as the natural and 
li ;.'iliifi!ite aciompaninient of the change and give themselves no con- 
'crTi. All e\(e>>ive fbiw from the uterus is a sure index of some 
i.;ii!!..lii;:ic ciiidiiion. and .should be in<iuirod into carefully. With 
tli<: iidviiit of I III- menojmusc marked cbaiigCA take place in the genital 
:;• ■•.:.'i);'i-. Tiie-i- are of a retnigrado character. Fallopian tnbea, 



DIRORDKns liK MKNSTRt^ATrON. 



ovaries, and uterus atrophy, Thu extfiiml genitals shrivel and 
shrink; the breasts betonie ?unken and flabby. 

Treatment. — 'Die treatment should i)e Inrgvly symptomatic. 
General hygienic niunagetnent is of the greatest importance. The 
bowels should be kept regular and the food should be plain and 
nutritious. Regular hours should be insisted ou. Lifjlit work or 
sonifthing to employ the liniKls and mind is preferable to idleness. 
This should be interspersed with pleasurable diversions. The bromids, 
especially the sodium bromid iu 111- to 30- grain doses, three times a 
day, is useful in eomliating nervous disturbauees. Sodjnni pliusphate 
in 10-grain doses, or guaiacol carbonate will relieve flatulence and 
check fermentative dy.=]iepsia. Opiates and alcoholic stimulants 
should be used guardedly and ennneimgogues not at ail. Moral 
suasion will go far toward relieving mental dis(|uietude. 

The extract of corjjus lutciim in doses ranging from 20 to GO 
grains tliree times a day has been extolIi.il as a corre<'tive for the 
nervous and functional disturbances attending the menopause. Ou 
tlieoretical grounds some prefer the corjjus luteum of pregnancy. 

AMENORRHEA. 

Amenorrhea is the absence of menstruation. The term does not 
apply til the physiologic abs<'nce of menstruation at the extremes of 
life, nor to that which is incident to pregnaney. .\bsence of the out- 
ward signs of menstruation, where the fluid is pent up, as in atresia 
of the genital tract, does not constitute amenorrhea. Primary amen- 
orrhea, or emawM mcnstiiiii , is llmi form in whitli inetDilruiition has 
never been establi-hed. .Seioiuliirv jiineiiorrhea, or .vw/j/^rr.weo mensium, 
is that form in wliicli menstrtiatioit eeai^cs iiftcr having been e-'taMished. 

The causes of uniciiorrhen are lot^d and general. The loeal causes 
jjertain to the genital organs, e(sj>ecially the internal organs of gen- 
eration, and consist in tlie want of development, on the one hand; 
premature atro|)hy, on the other, as in siiperiiivolutiou following 
[iregnancy, and various other pathologic lesions atli-cting the genitive 
apparatus. There is reason to believe that disorders of the nervous 
ap(iaratus dominating t!ie genital organism is sometimes responsible 
for amenorrhea. From a systemic point of view, two things are essen- 
tial to normal menstruation: gmid blood and unimpaired nervous 
energ\'. Anytlnng tending to impoverish the blood or impair the 
nervous energy mav act a< a cause of amenorrhea. Acute diseases, 
?.ueh as typhoid fever, cholera, and the exanthemata; ehronic dis- 
eases, Buch as Bright's disease and consumption; and other patho- 
logic states, such as anemia and chlorosis, are frequent causative fac- 
tors of amenorrhea. The same may be said of many other conditioua 



78 PRACTICAL GYNECOLOGY. 

which profotindly affect the nutritive processes of the economy. 
Change of climate and condition will not infrequently give rise to 
amenorrhea. This is to be observed in emigrants; also in women 
who enter upon a new vocation, as that of nursing. Insufficient food, 
mental or physical exhaustion, sedentary habits, and unhygienic sur- 
roundings are severally or combinedly responsible for many cases. 
To this list may be added an.xicty, apprehension, deep desire, and 
sudden and violent emotions. The tmmarried woman who, by reason 
of illicit relations, fears pregnancy, and the wife with an intense 
yearning for motherhood, are alike liable to miss several periods 
through anxiety. Scanty or suppressed menstruation often accom- 
panies rapidly developed or excessive obesity. Acute suppression of 
menstruation frequently follows a shock, a traumatism, or, more com- 
monly still, exposure to cold while menstruating. 

Treatment. — The treatment of amenorrhea will depend on the 
underlying causative factor. Diligent inquiry should be made into 
the general physical and mental condition of the patient, her mode 
of life, and hygienic surroundings. This should be supplemented by 
a careful pelvic examination. The possibility of pregnancy should 
always be borne in mind, especially in suppressed menstruation, and 
no radical treatment instituted until this has been excluded. For 
the primary amenorrhea, due to the defective development of the 
genital organs, little is to be expected from treatment. The same 
may be said of the amenorrhea from superinvolution following preg- 
nancy. The amenorrhea from exhaustive disease will usually correct 
itself witli, or soon after, tlie establishment of convalescence. In dis- 
eases which tend to death, as iu pulmonary tubcrculocis, the function 
is never re-establislied. People habitually look upon the amenorrhea 
as the cause of their ill-healtli, instead of the consequence, which it 
really is. That form of sujjpression which arises from change of cli- 
mate or condition is also self-regulating after the patient has become 
acclimated or reconciled to the new order of things. 

In a general way, good wholesome food, regular hours, fresh air, 
sunlight, and judicious exercise, witli such other measures as may be 
suggested by the state of the blood and nervous system, are the indi- 
cations in the way of treatment. Anemia and chlorosis should be 
treated by appropriate remedies, and obesity reduced, when possible, 
by diet, exeifisc, and such other treatment as may be found efficient 
and not detrimental to health. The alternate use of the Vichy and 
Ki.'^singcn salts are occasionally effective. Overwork, mental and 
j)hysical. should be interdicted, and sedentary habits changed to a 
more active out-door life. The acute suppression from exposure to 



I 



DISOKDKRS OF MENSTRUATION. 79 

cold is frequently associated with an acute euJometritis, and calls for 
rest in bed, laxatives, hot applicatioiiK to tlie hypogastrium, and uterine 
sedatives, such as Pulsatilla aii<l viUurnuni. Aside from the hygienic 
managenjeut, which is of paranmunt inipurtance, certain drugs have 
iieeu found beneficial and are habitually resorted to. If the patient be 
anemic, which is usually tlie case, iron is imlicated. This may be given 
in various forms and combinations. Tincture of iron, which has been 
long prepared, is vi-ry elficient in tiO-niinim doses after meals. The 
tinriurc of iron, like wine, iDii)roves with age. Should there be a ma- 
larious tendency, or need of a general tonic, quinia may be combined 
with it. The Blaud pill is one of the most satisfactory forms in which 
to administer iron. One j)ill sliould be given three times a day, and lite 
dose increased by one pill a day until three are given after each meal. 
Where renal insufficiency exists, — which, by the way, is a not unusual 
cause of amenorrhea, — Baslmra's mixture will be very serviceable. 
Arsenic and strychnia are valuable adjuncts, and are niueli used in 
combination with iron. A very eligible jirescription is as follows: — 

B Licj. |>otiiB. ar»fn 5j. 

Tini't. lUU'irt voiuic-s Sij. 

Vini (erri iiiimri .,,.,. .^ .3vj. 

M. Sig.: A deiuiertspoonful nftcr mpnts. 

The permanganate of potHssiimi and the binoxid of manganese 
are among the most efUciont jironioters of menstruation. They should 
be given in 1- or 2- grain doses three times a day, with plenty of water 
and on an empty stomaeh. Oxalic acid in '/L'-?™'" doses is also very 
effeetive. 

Electricity in its various forms is often l)eiieficiiil. For the func- 
tional di.sturbance, dis-sociated fnun organic defects or changes in the 
uterus or appendages, the faradic current is one of tlie most efBcient 
measures for tht- restoration of the function that wi> possess. One 
electrode should be introduvi'd within the uterine cavity and the other 
over tJie lumbar region, and a plfusantly strong current passed for ten 
or fifteen minutes; this trentnu'iit to he re)>rnlcil daily or at intervals 
of two or three days. For the Hiiienorrliea di'|>i'iiiling on defeetive de- 
velopment or superinvolutioii of the uterus and adnexa, the constant 
current with the positive [irvio to the liaik and the negative pole within 
the uterus is indicated. The so-ealleil eininenapogues, sueh as nie, 
savin, and tansy, are dangerous, and .should not be resorted to empir- 
ically. Probalily there is no more efficient local agency in the treat- 
tiicnt of amenorrliea Ihnn tlie solid ffhiss stem pessary of Hepperlen. 
For a description of the iiistninient. and tiietlnnl of use see page 200. 

.Assuming that the developing aiirl finu'tioning of the se.xual 
apparatus of the female arc in large measure under the control of 




PRACTICAL fiYNErfn/)nY. 



the internal secretion of the corpus lutciim, such secretion would 
a priori appear to be the rational troiitniL'nt for defects in the same. 
As it is inijiossilile to supply the secretion in its isolated state the 
nearest approximation to it may be found in the corpus-luteum extract. 
Extensive experimentation in c-onipcteiit hands seems to have demon- 
slnited that tlic corpus-luteiim extriut ails as a jmwcTful excitant of 
sexual metabolism and regidator of the sexual functions. Tlie indi- 
cations for the use of this drug are not at present well defined for tlie 
reason that it has been used in a haphazard way for all the ailments 
connected with the female {jenital system. It would seem, however, 
that euoufih had been est4ihlishe<! to warrant the use of the corpus- 
luteum extract — 

1. In eases of undevclii|)c(l uteius. 

2. To induce luunsLruatiou in young woiricu sulTering from 
functional amenorrhea. 

3. To induce menstruation in. cases of amenorrhea associated 
with excessive oiicsity. 

4. To supply the deficiency of the internal secretion of the cor- 
pus luteum iu menstruatin}^ women. Such cases are usually evidenced 
by irrejndarify of menstruation oftentimi's as.soeiated with nervous or 
other disturbances which are intensified at or near the mensinial 
period. 

5. To control tlie nervous or other phenomena incident to the 
menopftUfc. 

There is reason to believe that the chemical eonstiliients of the 
secretion of tlie corpus luteum vary from time to time, or under 
varying circumstances. At one time it may be specially adapted to 
promote the menstrua! flow, at another to control the nervous or 
other phenomena which su[)erveue on the sujipression of tlie flow, 
as in the menopause, pret;iiancy. It nuiy he tliat the corpus lutcimi 
of pregnancy is si>ecially adapted to the latter class of cases, while that 
of the iiou-prefrnant state is better adapted to promote the flow. As 
corpus-luteum extract is non-toxic when given hy tiie month, there 
is no prescribed dosage; that is to say, it may be given in larger or 
smaller (ptfliittties as the necessities of the case may seem to demand. 

(tlie of the most pojuihir prepanitions and of high ri'pute is 
put up in tablets containing 20 grains eaili, of which froni 1 to 4 or 
more tablets are given three times a day. In an average case of 
amenorrhea 4 tablets are given tiiree times a day for ten days pre- 
ceding the menstrual period, then 3 tablets three times a ilay during 
the period, then 1 tablet three times a day during the rest of the 
month. In many ca.'^.'S mucli less will .suffice, in .*ome much more will 
be required. To be of any use the preparation should be fresh. 



I 
4 



« 



CHAPTER VIII. 

DISORDERS OF MENSTRUATION (Continued). 



DYSMENORRHEA. 

Dtbmenorrhka is painful menstruation. Many women suffer 
more or less discomfort at the menstrual period, but by common usage 
a dysmenorrhea is made to include only such cases as sufTer to such 
a degree as to compel them to seek relief. For convenience of de- 
scription, and for diagnostic purposes, four varieties of dysmenorrhea 
may be recognized: neuralgic, inllummatory, mechanical, and mem- 
branous. 

Neuralgic Dysmenorrhea. — This is a local expression of the 
neuralgic diathesis. It depends upon general, rather than upon local, 
causes. It comes under conditions which predispose to neuralgias in 
other parts of the body, and is usually attended with the evidences 
of supersensitive nerves elsewhere. Examination will generally reveal 
cut.aneou8 hyperesthesia, especially over the lower abdomen and spine, 
and tender points at the emergence of the costal nerves. Patients 
80 affected are often anemic, hysterical, or neurasthenic, and not 
infrequently tlie victims of malaria, rlieuniatisni, or other diseases 
which tend to impoverish the blood and subvert nerve-energy. The 
pain resembles that of neuralgia elsewhere, in that it is undulatory 
In character and variable as to time, duration, and intensity. It bears 
no fixed relation to the flow, and may precede, accompany, or follow 
it. It radiates from the region of the uterus to the hips, back, or 
thighs, sometimes girdling the pelvis. 

Diagnosis. — The absence of obvious pelvic lesion ; the undulatory 
and eccentric character of the pain ; the presence of the neuralgic 
diathesis, as indicated by the hyperesthesia of the lower abdomen and 
spine; the tender points of Valleix, and occasional neuralgia else- 
where are usually suificient to make the diagnosis clear. 

Treatment. — The treatment should be on general principles, and 
should be systemic rather than local. Hygienic measures should take 
precedence. Fresh air, sunlight, out-door exercise, plain substantial 
food, regular hours, pleasant surroundings, and such medication as 
may be indicated by the underlying condition should be the regime. 
Iron, quinia, arsenic, phosphorus, and not vomica, and other tonics 

(81) 



82 



PRACTICAL UVNKCOLOGY. 



and reconBtructivee may be called for. Malaria, rheumatism, syph- 
ilis, or other constitutional state should be met with remedies appro- 
priate to each. The bowels should be kept regular, and digestion aided 
by the use of pepsin and the diastasic malt preparations. Some cases 
may require the rest cure, others a change of air and scene. Many 
cases are intractable, and will run a course of years despite all medi- 
cation. 

While pursuing this general trend of constitutional treatment 
with a view to ultimate cure, the monthly recurrence of pain will 
demand palliative measures. For this purpose apiol or Pulsatilla may 
be given in 5-minim doses three times a day, commencing one week 
before and continued through the period. For the immediate relief 
of pain, hot baths, hot applications to the hypogastrium, hot drinks, 
and various analgesics will be in demand. The coal-tar products, 
such aa phenacetin or antipyrin, combined with caffeine, digitalis, 
whisky, or other heart-stimulant, will usually give marked relief. 
They should be given in doses ranging from 10 to 20 grains, and 
may be repeated at intervals of an hour or more, but not oftener 
than three or four times. Unbearable pain not amenable to other 
modes of treatment may require morphine liypodormically. Great 
circumspection should be used in the administration of opiates for 
this as for other constantly recurring pain, for fear of engendering 
the fipium habit. One of the most pitiable cases of opium habit I 
ever knew arose in this way. DilTusible stimulants are often effective, 
but are open to the same objections. Finally, as a last resort, it may 
become necessary to terminate the suffering by removing the ap- 
pendages. 

Inflammatory Dysmenorrhea. — This is sometimes also known as 
congestive dysmenorrhea. There is much reason for believing that 
an inflammatory condition subtends a very large proportion, if not all 
the cases, belonging to this group. This inflammation may be located 
in the uterus, ovaries, tubes, or in the adjacent pelvic structures. As 
this form of dysmenorrhea depends upon an acquired condition, — 
inflammation, — the patient, aa a rule, will give a history of normal 
menstruation at an earlier period of life. The pain is characteristic 
of inflammation, and is accompanied by a sense of soreness. It 
radiates in various directions. Deep pressure over the hypogastrium 
or through the vaginal vault often, though not always, elicits pain, 
the pain being proportional to the degree of pressure exercised. 
Febrile reaction, as indicated by accelerated pulse and increase of 
temperature, will be observed in a portion of the cases, but will depend 



4 



J 



82a 



PKA( TU Al, aVNEC-OLOGY. 



entirely on the condition of the inflammatory lesion. The woman is 
not well in the intervals of menstruation, and examination will reveal 
the evidences of pelvic disturbance. When due to tubal or ovarian 
inflammation, tlie pain is referred to one or the other iliac region. 
It usually precedes the flow by several days or a week. It may cease 
when the flow begins or continue throughout the period. A copious 
flow acts as a deplet«nt and usually relieves the pain. 

Treatment. — The treatment should be addressed to the causativfti 
factor, whether it be an endometritis, ovaritis, salpingitis, or what 
not, Uterine displacements and adventitious growths should receive 
attention. Free purgation and hot vaginal douches as routine meas- 
ures just before menstruation serve to allay the congestion and miti- 
gate the suffering. The patient should be put to bed and kept there 
during the entire period. For immediate relief resort may be had 
to the various measures mentioned under the head of neuralgic dys- 
menorrhea. 

Mechanical Dysmenorrhea. — Mechanical dysmenorrhea is that; 
form in which a mechanical impediment exists to the escape of the 
menstrual fluid or to its formation within the uterine cavity. The 
outflow of the menstrual fluid may be impeded by stenosis of the 
cervical canal, by sharp flexure of the uterus, — anterior and poste- 
rior, — by growths within or without the canal impinging on its 
caliber, and occasionally by some impediment in tlie vagina or its 
outlet. The disturbance is most frequently associated with ante- 
flexion. Faulty development of the uterus is at the bottom of most 
cases. In such, a normal congestion, such as must necessarily precede 
and accompany the menstrual effort, is attended with suffering, be- 
cause of the lack of provision for normal expansion. Exfoliation of 
the epithelium and rupture of the capillaries are likewise difficult and 
painful. Indeed, the complex of phenomena which take part in and 
are essential to the formation of the normal menstrual fluid are 
disjoined and inharmonious. The organ is imperfect and unripe, 
and, like the nut which casts its hull at maturity, it clings to its 
decidua most tenaciously before that period. 

The pain of mechanical dysmeuorrliea is quite characteristic. It 
commences insidiously, increases gradually, attains a climax, and 
ceases suddenly. A gush from the cervix announces the fact that 
the obstacle has been overcome and the uterus has emptied itself. 
After a respite of variable duration the pain steals on, augments, 
and comes to a crisis a? before. The patient is not always aware of 
the gush from the uterus, but is generally cognizant of the fact that 



DISORDKRS OF MKN'STRIATION. 



83 



an increased flow follows the pnroxysm of [iniii. In most instances 
clots of larger or sinaller sizu will be found in tlie discharge. These 
indicate textural defect of the endonictriuiii, and ]>oint to a sparsity 
of the lymphoid elements, whose offitr it is to pruvent coagulation. 

As mechanical dysmenorrlu'a depends so frequently on faulty 
development of the uterus, it usually dates from the commencement 
of menstruation. It may, however, take its oriijin in a superinvoiu- 
tion or from a morbid growth. In time intlaminatory changes are 
apt to supervene, when the case takes on the character of both fonns 
of dysmenorrhea. 

Treatment. — The imjwdiments to the outflnw should be removed, 
if possible. Morbid growths within the cimnl or pressing on it from 
without should receive attention. The bent canal should be straight- 
ened and its caliber enlarged. The developmental defects should be 
remwiied. if {wssible. Forcible dilatation of the cer%ix meets these 




Fig. 37.— n«rd Riilibcr Graduated Dilators for Cervical Canal. 



indications in large measure. It straightens the canal, enlarges its 
dinmeter, gtimulates nutritive change, obtunds the oversensitive 
nerves, and produces an alterative efTci't on the endometrium. It 
should be done deliberately and thoroughly, and l)e followed by 
curettage and the ap]ilicatiou of carbolic acid to the endometrium. 
The occasional passage of the uterine aotmd, or, better still, the grail- 
uated dilatation and packing of the uterine canal according to the 
method of Vullict, will often yield good results. ,Stri|is of gauze are 
introduced through the cervix into the uterine cavity. These are 
removed daily and replaced by larger strips until the canal becomes 
patulous and the cavity distended. This usually retpiires several 
weeks. The alterative effect is sometimes conspicuous. No medianical 
treatment, so far as my personal observation goes, compares in etli- 
ciency to the solid-gla*s stem pessary of Hcpperlin. Its application 
shou'd be preceded by thorough dilatation, curettage, and swabbing the 
uterine cavitv with carbolic acid 95 per cent, pure, and the pessary 




84 



PRACTICAL OYXECOLOGY. 



should be secured in jiliice bv tleep cervical sutures of fsilkworm gut. 
To prevent the sutures from cutting out they should he iooselv tied, 
if tlie kni)t is used, though to fwilitate removal it is much better to 
secure them l>y shot. The pcssarN- sliould he allowed to remain from 
tJiree to four mouths. The constant electrical current is probably the 
most eHicieiil iiOTUt with which In lombiit [lie iiii'rliaiiir:il dygmenor- 



Fig. 38. — Peaslce'a Cervical Dilators. 

rhoa dependent on faulty development, and should always be tried 
before resorting to any iiieasures tiKuc radical than that of curettage. 
With the po.'iitive electrode within the iit«M-inc cavity and the negative 
over the hmilmr region, fruni 'io to }i) millifluipcres are passed. 
These Kt'uurcs are rcpeatiMl at weekly intervals, and are nf live minutes' 
duration. The general iKiilth should he looked after. For iinmcdiate 
relief such measiircs nuiy be adopted as have been recommended under 



Kig. 39. — Palmer's Cervical Dilator. 



the head of "Neuralgic Dysmenorrhea." The antispasmodics are 
especially indicate*], such as chhtral hydrate, lielladonna. stramouiuiu, 
and hyoseyamuB. 

MembranoQi Dysmenorrhea. — The conspicuous feature of this 
form is the casting olf of the crulometrium iu tinigibic fnnu. The 
membrane is cast off in its entirety, forming a mold of the uterine 
cavity, or iu patches of variable size. It oi'curs, for the most part, in 
the unmarried or sterile. It depends uim)U an inflammatory condition 



DISORDERS OF ilKXSTRL-ATION". 



85 



of the endometrium: exfoliative eniliimctritii!. The shtdiling and 
expulsion of the membrane are attended with great pain, which rc- 
M-nibk*s the paina of mi^-arriiige. When the memhrune has been 
expelletl the pain censes, or changes its cliaracter, and becomes greatly 
mitigated. Menstruation is often scant and irregular, and is not 
always accompanied by the expulsion of tlie membrane. Sometimes 
tlie membrane is expelled at alteniiite periods or at longer intervals. 
Abortion at the menstrual period may he mistaken for membranous 
dysmenorrhea, especially if habitnnl and in the early stages. It is 
seldom, however, that a woman will abort so liahitiially siiu! through 
so long a period as to cloud the diagnosi.s. The dysnienorrlieal mem- 
brane, moreover, is wanting in the large, irregular cells of the 
decidua, as revealed by tlie microscoiie. 

Tri-atmeni. — The treatment consists of curettage and applica- 
tiona of iodine or carbolic acid to the endometrium. Tliese may 
have to be rejieated a nutiibcr of times. Electricity in the form and 
administered in the manner sjiokeu of under the head of "Mechanical 
Dysmenorrhea" will be found of great value. The general health 
should receive attention. The disease is obstinate and will require 
much time and jiatience to overcome. 



A STUDY OF DYSMENORRHEA. 

I have given the above classiification of dysmenorrhea in defer- 
ence to prevailing views, and because it serves a practical purpose 
in differentiation and treatment. Strictly speaking, there are but 
two forms of dysmenorrhea : neuralgic and mechanical. Careful 
analysis will show that most, if not all, dysuienorrheal subjects are 
nenrotic, the neurotic impress being manifest in other ways than in 
painful mens^truation. In some the ncurotism is aci|inred ; in others 
it is inherent and perpetual. Kiigchnan, after an extensive investi- 
gation embracing in its scope upward of 5000 school-girls, found that 
a large prof)ortion of such were the subjects of dysnienorrliea, and 
that the intensity of suffering bore direct relation to the wi>rk and 
worry of student-life. The vacational period brought marked relief 
to the majority and cojiiplete relief to many. The mechanical ob- 
stacle to menstruation is iint cnnfinetl to the uterine orifice, as taught 
by Sims, but takes a much wider range. It is found in the endo- 
metrial epithelium, in the terminal vessels, in the structure of the 
nterine walls, and in the structural clianges incident to inflammation 
or other morbid processes. It is also dominated by nerve-influence. 

In normal menstruation there is provision aiul preparation for 




86 



PRACTICAL GYNECOLOGY. 



the act, lliut all things may wtirk in haniiony and without violence. 
The ripe fruit falls of its own ucLHinl ; tiie green fruit holds tenux-iously 
to itB stem. The e.vfo.iation of the endometrial epithelium at Btate<l 
intervals is jihysiohigic: it disiute^rrates and drops <>)T ns the hairs 
from the head. The decidual teeth of the infant uiid the skin i>( 
the ser|ient are thrown oil with ease, because they have rerved their 
purpose and are fircfiared for the ehanj^e. Under normal conditions 
and at the proper tinu' tiie endometrial epithelium becomes detach- 
able, and, liaving lost its coliesiveness, is pushed off by the capillary 
efTusiou beneath it. 

There are grounds for believing that the pain of dysmenorrhea, 
in many instances at least, is d»ie to intramural blood-pressure, either 
by reason of the tenacity of the epitheliiiiu, uudevelo])ed terminal 
vessels, or rigid, imyielding walls. All these coiiJitions are ol)8truct- 
ive, and evidences of defective development or jrerverted metabolism. 
It is not improhuble that the inflow is soiuetinu*s obstructed by spas- 
mcxlic contraction of the vessels or the tissues traversed by the vessels 
under the influence of a perverted nervous energy. I am persuaded, 
furthcriiuire, that ipiite frc((ueiitly the troulde is situated at the os 
internum ; not as a mechanical obstniction //cr sc, hut in the form 
of an •iriliiial irritation which may produce spastic and other refle.x 
phenooiena, sudi as are found in vaginismus and irritable bladder. 
This may consist of either fiiin|)le hyperesthesia or a lesion, a-s in 
fissure of the anus. Certain it is that in many of the dysmenorrheal 
cases the internal os is found e.\i)uisitcly sensitive to the passage 
of the sound. The etfec-t of full dilatation on such cases would be 
most sidutary. 

Mendtranous dysmenorrhea is mechanical in that it olTcrs an 
impediment to botli the inflow and oiittlow of the menstrual fluid. 
Inflammatory conditions may render painful the normal turgescence 
of the organs concerned in menstruation, anil interfere with those 
changes incident to tlie nienstrual elTort. The tissues concerned are 
erectile in character, and must of necesisity undergo changes of sixe, 
sha[ie, and position when filled with blood. The male penis, as one 
of the most conspicuous examples of an erectile organ, alTords an 
apt illustration of the effect of restraint under erection: held down 
by a ehordee. the act of erection is attended by excrueiatitig pain. 
The tubes and ovaries bound down by adhesion or splinted by inter- 
stitial deposits are liable to give ri«e to a sense of discomfort, if not 
actual pain, under the engorgement of menstruation. What is said 
of the adnexa will apply to the uterus. Hut the basic factor of dya- 



I 

4 
4 



4 
I 



l-4|. 



DISORDEnS OF IIENSTRLATION. 



sr 



menorrhen lies uuder all of this, and is to bo sought for in the nervous 
system. That iuHaniiimlioii of tlie genital tract, in whole or any part 
of it, is Hol of itself siiUKieiit to caime iljsinenorrhea is evidenied by 
the fai-t that many — 1 might say most of — sueh eases are uuatteuded 
by painful inenstrualion. The same may be said of the conditions 
found in the wi-ralled mecluinieal dysnienorrliea. Some of the most 
pronounced cases of flexion of the uterus lliat I have ever siH'n have 
been free from dysmenorrhea; some of the narrowest canals, some 
of the most chitted discharges. Kven instances of complete atresia 
of the genital tract are at times comparatively free from pain at the 
menstrual molimen, and seldom the cause of such suffering as we 
find in aggravated cases of dysmenorrhea. 

In the dysmenorrhea of anteflexion Schultze has introduced the 
uterine sound during the paroxysm of pniu whitli immediately pre- 
cedes the flow and which has been snjp|)(i!.fd to lie due to the efforts 
of the uterus to e.\])el the accumulated blood within its cavity, and 
found no blood in the cavity. The pain was evidently due to a me- 
chanical ohstruetion farther back, or a ncrvc-stomi, which, for the 
time being, prevented the inflow of blood. Wlien the obstruction was 
overcome, or the stonn abated, tlie 1i1<iimI niiide its appearance and im- 
mediately found an outlet throutrli ttie cervical canal. Then, again, in 
many — very many-^a.'ies of dysmenorrhea I have found the cervical 
canal more than ordinarily patuhuis. We muFt conclude, then, that a 
.supersensitive condition of the ncn-es is the biisic factor nf dysmen- 
orrhea. This is sometimes associated with an inflammatory condition 
or mechanical obstruction which may modify or even intensify the 
trouble. We find somewhat analojinus conditions in other hollow 
organs or their outlets. In that pninfid, spasmodic conilition of the 
introitus vagina? known as vaginismus, we are frequently unable to 
find any lesion. In .some instances f)f irritable bladder or irritable 
rec-tum nothing tangible can be found. Yet forcible and thorough 
dilatation will oftentimes hring about such changes in each as to he 
followetl by amelioration, if not po.>fitive cure. It is to he hoped that, 
with a more correct knowledge nf the pathology of this distressing 
malady, improved methods of treatment may give better assurance 
of success. 



CHAPTER IX. 

MALFORMATIONS OP THE QENITAL TRACT, 
STERILITY, ETC. 

MALFORMATIONS. 

These are considered seriatim for the reason that they are so 
intimately associated and arise for the most part from the defective 
development of the primitive system from which the genital organs 
are formed. Occasionally, though rarely, there is a complete absence 
of one or more of the genital organs, or they may be so imperfectly 
developed as to be of no functional value. 

The ovaries, as the essential organs of generation, are almost 
never entirely wanting, but at times are so imperfectly developed as 
to be recognizable with diflBculty. The same may be said of the 
uterus. Abnormalities of the uterus and vagina can be best under- 
stood by reference to their manner of development. In the early 
weeks of embryonic life two little tubes come down from above — one 
on either side — and terminate at what is to be the vaginal orifice. 
From these tubes (Miiller's ducts) the Fallopian tubes, uterus, and 
vagina are formed. At first they are widely separated from each other 
above, and approximated at their inferior extremities so as to resemble 
the letter V. A little later the lower segments approximate each other 
and lay side by side, while the upper segments are divergent. They 
now resemble the letter Y. Still later the upper segments fall away 
from each other and assume a position at right angles to the united 
ducts below. It now resembles the letter T. The horizontal arms 
of the T represent the Fallopian tubes, and the vertical stem the 
uterus and vagina. (Fig. 1, Plate V.) In the process of normal 
development that part of the ducts which is to form the uterus and 
vagina become fused, the partition wall disappears, and the two 
ducts become one. At the same time they enlarge rapidly, and the 
segment which is to form the uterus becomes greatly thickened. 

The malformations of the uterus and vagina arise from some 
defect in the developmental process, and consists, for the most part, 
in a failure of the two ducts to fuse or in a persistence of the partition 
wall between them. Tlius, in the event of a complete failure of the 
two segments to unite there results two bodies, each of which is sup- 
plied with a Fallopian tube, and, though misshapen, possesses all the 

(88) 



.NULKURMAriONS OK UENIXAL TRACT, STKItll.H"\ , KTC. 



89 



itial characteristics and functions of a uterus. This gives us the 
double uterus: uUrut duplex. (Fig. 5, Plate V.) When tlie lower 
eegmenl of the utcTus is fusetl and the upper part divergent the 
result is a double-horned uterus: uterus bicornia. (Fig. 3. Plate V.) 
When the two lateral segments of the uterus are united throughout, 
but the septum, or partition wall, remains, the result is the two- 
chambered uterus: uterus septus. (Fig. 4, Plate V.) When only one 
of the lateral Begmcnts of the uterus develops and the other remains 
nidimcntary, the result is the one-homed uterus: uteriis unicornis. 
(Fig. 2, Plate V.) 

The vagina is sometimes absent, sometimes rudimentary, and 
sometimes double. Occasionally there are transverse septu. and rarely 
it is one-sided, owing to the fact that only one of the lateral ducts 
develops. The anomalies of the vagina are to be e.vplained in the 
same way as those of the uterus. A double vagina may or may not 
CD-exist with a double uterus or any of the mnl formations of that 
organ, and vice versa. 

Hermaphrodism. — Hermaphrodism is a oonibin.Ttion of the es.-ien- 
tial organs of generation of both sexes in the same individual. By the 
essential organs are meant the ovaries and testicles. The external 
organs of generation are never perfect under the circumstances, and it 
is seldom that the ovaries and testicles are. Not infrequently one or 
the otlier of the latter is wanting even in recognized hermaphrodism. 
Perfect hermaphrodism, in the sense that both se.ves are represented in 
the same individual by a complete and perfect development of all the 
organs of generation, does not exist. Indeed, there is much diversity 
of opinion as regards true hermaphrodism, and the subject may 
be very properly relegated to the literature of medical curiosities. 
Writers have classified hermaphrodism according to the disposition 
of the essential organs of generation. A very simple and compre- 
hensive classification is as follows: — 

1. Bilateral, where an ovary and testicle are present on both 
sides. 

2. Unilateral, where an ovary and testicle co-exist on one side 
onlj. 

3. Lateral, where the ovary and testicle are on opposite sides, 
Paeudohermaphrodism is much more frequent than true her- 
maphrodism. It comes from defective development of the e.xtemal 
organs of generation, often associated with bodily conformation that 
renders the determination of the sex difficult. 'I'hus, the external 
genitals of the male may approximate those of the female in appear- 



QO PRACTICAL GYNECOLOGY. 

ance and arrangement. The mainmary glands may develop. He 
may be beardless, and possess, in a measure, the physical conforma- 
tion, the voice, and manners of the female. An undeveloped penis, 
cleft scrotum, hypospadias, and non-descent of the testicles may easily 
be mistaken for the genital apparatus of the female, especially by tlie 
uninformed. On the other hand, the female may approximate the 
male in type. She may have the form and carriage of a man, and she 
may have a well-developed beard. The clitoris may be largely devel- 
oped, the labia may be agglutinated, and the ovaries may have de- 
scended into the labia, thus simulating the penis, scrotum, and testi- 
cles. The diagnosis is oftentimes difScuIt and sometimes impossible 
during the life of the individual. Careful examination of the whole 
genital apparatus, supplemented by microscopic examination of the 
secretions for spermatozoa, will usually lead to a determination of 
the sex. In the absence of positive proof it is better to regard the 
subject as a male, both for the moral effect and because anomalies of 
this kind are more frequent among males than females. 

STERILITY. 

Sterility implies the inability to bring forth a living child at 
term. Some women never conceive; others conceive, but are unable 
to carry the child to a viable age ; while others still have given birth 
to one or more children, but have ceased to be fruitful. The essen- 
tials to a fruitful intercourse are that the spcrmatozoid and the ovule 
should be brought together and that each should be endowed with 
its physiologic attributes. The uterine cavity is the meeting-place 
of the sperm and germ-cell, and each has a long journey to make 
before arriving there. This journey is oftentimes beset with diflB- 
culties and dangers, and even imder ordinary conditions many ovules 
and vast numbers of the spermatozoids perish before arriving at their 
destination. To recite in detail all the causes and conditions which 
may subvert this vmion of the male and female elements would re- 
quire more space than can be allotted to the subject in this connec- 
tion. A little reflection will suggest to the reader many ways in 
which this chain of co-ordinate conditions may be broken and tiie 
object of it all defeated. 

On the part of the woman the ovule may not have been formed. 
This may come from want of development, or from some diseased 
condition of the ovaries, inflammatory or neoplastic. Sarcoma of 
the ovary alwa)'s destroys the ovule. The ovary may be so imbedded 
in inflammatory or other products, or the covering may have become 



M.VLFORMATIONS OK (iKXITAL TR-\CT, STEUILITY, ETC. 



01 



>-4gobc, as to prevent the extrusion of the ovum. The Fallopian tube 
%y be so bound down or distorted by adhesions as to prevent its 
taking up the ovum when extruded from the ovary. Tlie tube may 
Lbe sealed at one or both extremities; it may be angulated or splinted, 
i deprived of its epithelium, or degenerated. The uterus may offer no 
fit asylum for the ovnm by reason of developmental defects, morbid 
growtlis, or — more frequently still — because of inflammatory changes. 
The secretions of the uterus are at times poisonous to the ovum, and 
there are reasons for believing that the same condition may obtain 
in tlie tubes. The condition of the endometrium is probably the most 
essential single factor in the production of sterility. It is here that 
the ovum finds its resting-place and from which it draws its sus- 
tenance. It is from this that the maternal placenta is formed; hence 
it is essential that it should not only be in a condition to receive the 
ovum, but that it should actively co-operate in its development. 

Mechanical obstacles to tlie entrance of the spermatozoa are fre- 
quently adduced as causes of sterility. These consist in flexure of 
the uterine canal, elongated and conical cervix, malposition of the 
uterus, and breaks in the pelvic floor. I cannot believe that these, as 
a rule, are operative. A canal through which the menstrual fluid 
will pass, or which will admit the uterine sound, will hardly offer 
serious obstacle to the transit of a body the one six-thousandth of 
an inch in diameter. While admitting that such conditions are 
tery frequently associated with sterility, and especially the flexures 
of the canal and conical cervix, I am disposed to regard these as 
indices of developmental defects existing in the endometrium or 
elsewhere which are in themselves serious obstacles to conception. 
Indeed, I have known women to conceive under every phase of 
the so-called mechanical obstacles usually ascribed as causative 
factors of sterility. It should not be forgotten, however, that an 
absolute occlusion of the cervical canal may exist, which will effect- 
ually bar the entrance of the spermatozoa, and yet offer no obstacle 
to menstruation or the passage of the sound. A pinhole os may be 
plugged with mucus or a fold of mucous membrane may block the os 
internum. These are easily pushed aside by the sound or by the 
outflowing tide of menstrual blood, whereas a spermatozoid or an 
army of them could not push aside a film of gold leaf suspended in 
the way. 

The uterine or vaginal secretions may injuriously affect the sper- 
matozoa — sometimes killing them outright. In many instances of 
Bterility, where no gross lesion exists, the cause, aa I believe, will be 



92 PRACTICAL GYNKCOLOGY. 

found in the expulsion of the semen by vaginal contraction imme- 
diately after it has been deposited therein. I have elicited this his- 
tory from a great many women whom I have questioned in regard 
to it, and have come to regard the "spitters" as the most unpromising 
subjects for treatment. 

The general health of tlie patient occasionally plays a role in the 
production of sterility. Syphilis, gout, or rheumatism, and many 
other conditions which produce a dyscrasia or seriously affect the 
general health are at times the responsible factors. Syphilis is par- 
ticularly inimical to fetal viability, even though conception takes 
place. Women will sometimes conceive for one man and not for 
another. It should not be forgotten that the husband may be at 
fault. This occurs in about one-tenth of tlie ca.ses of sterility. Xo 
examination should be considered complete in tbc absence of tangible 
evidence of sterility in the feninle until the semen of the husband 
has been subjected to microscopic inspection. After all, the most 




Fig. 40.— Cen-ical Dilator for Sterility. 



potent, the most uiiivcisal, and the ino.>-t Iiniii'Mtuble cau.^e of sterility 
in women is gonorrlienl iiilVction of the gcnitil tract. This by pro- 
ducing alterations in the secretions, cliiinges in the mucosa, and gross 
lesions in tlie tubes and ovaries fiimishus a larger quota of sterile 
women tbaii all other cauccs combined. 

Prognosis. — Tlio jjrogiiosis will depend uj)on the cause, whether 
it be recognizable and remediable. On the wbole, it is rather favor- 
able. The number of women who remain st<?rile throughout the entire 
j)erio(l of an average married life is comparatively small. A canvass 
of communities will l)ear out this statement. Many women after long 
years of sterility become fertile, and not infrequently give birth to 
several children in succession. 

Treatment.— .\ careful consideration of all the conditions con- 
dneive to sterility should govern the diagnosis, and tlie diagnosis 
shoulil (littatc llic (reiilmcnt. Obvious cnnses sliould be removed if 
possible. Inflammatory coiidilions sliould lie correctecl, adventitious 
growths and products removed. mal|)ositioiis rectified, the elongated 
cervix amputated, and the uterine canal straightened. The two latter. 



MALFORMATIONS OF GENITAL TRACT, STERILITY, ETC. 93 

while not recognized as being in themselves prime factors, are often 
by their correction inBtrumental in bringing about otlier changes 
that are of actual benefit. The general health should be looked after 
and special conditions met with appropriate remedies. Syphilis, 
lithemia, and excessive obesity should be treated secundem artem. 
There is reason to believe that the psychical effect of local treatment 
is sometimes efficacious, inasmuch as women long barren will some- 
times conceive soon after commencing a course of treatment. Patient 
perseverance in remedial measures throughout months and years will 
oftentimes be rewarded with success. 

SUBINVOLUTION OF THE UTERUS. 

This is the result of an arrested itivoluticm of the uterus after 
it has expelled the products of conception. It may mriir after a 
miscarriage or labor at term. The retrogressive changes by whicli 
the organ is restored to something like the virginal type are inter- 
fered with and the organ remains large and boggy. Being heavy and 
?oft, it settles in the pelvis or topples over backward. It is some- 
times sharjjly flexed. As the ligament*, adnexa, and vagina par- 
ticipate in the subinvolution, displacements of the uterus are rather 
favored than opposed. The endometrium is thick, succulent, and 
thrown into folds. Glandular endometritis is common. In fact, the 
subinvolution is, in all probal)ility, due to a low grade of infection, — 
septic or sj)ecific, — which in most instaiues has its origin in the 
endometrium. A lacerated cenix or liroken ])elvic floor may furnish 
the avenue of infection. Histologically, the subinvoluted uterus is 
found to consist of enlarged blmxl-vcssels. nerves, and lymphatics, 
hypertrophied muscle-fibers undergoing fatty degeneration, and gland- 
ular hypertrophy of the endometrium. Should tiie condition persist, 
connective tissue growth supplants the normal histologic elements, and 
the organ becomes permanently hypertrophied. 

Symptoms. — The woman com])1ains of a weight and bearing down 
in the pelvis and usually of backache. There nuiy be systemic evi- 
dences of infection, such as loss of appetite, costiveness, anemia, and 
malaise. Occasicmally she is depressed and melancholic. Menor- 
rhagia is the rule in menstruating women, and leucorrhea is seldom 
absent. 

Diagnosis. — The diagnosis is made by finding the enlarged, boggy 
uterus in a woman who dates her illness from the date of confinement 
in the not too distant past. 



94 PRACTICAL GYNECOLOGY. 

Treatment. — The objet't of treatment should be to correct exist- 
ing lesions, restore the uterus to position, and stimulate metabolism. 
The uterine cavity should be explored and relieved of fetal debris. 
The uterus should bo brought into position and kept there. The 
lacerate<l perineum and cervix repairetl. The general system should 
be built up by proper hygienic and medicinal measures. Iron, qui- 
nine, strychnia, and various other alteratives and tonics may be used 
to advantage. The preparations of ergot are especially indicated for 
their specific influence in producing uterine contraction. The local 
treatment consists in a])plications of tincture of iodine to the uterine 
mucosa or vaginal vault once or twice a week, followed by the boro- 
glycerid tampon and ichthyol. Hot vaginal douches should be taken 
by the patient morning and evening. As a dernier rensort, amputa- 
tion of the cervix may be resorted to in the hope that in this condition, 
as in others, atrophic changes will take place in the uterine body. 

SUPERINVOLUTION OF THE UTERUS. 

This is the revei^se of subinvolution. Here tiie involution of the 
uterus does not stop at the nornuil stage, but continues until the organ 
is reduced much l)e!ow the normal in size. Superinvolution, like sub- 
involution, affects the entire generative apparatus, including the 
ovaries. The affection is happily rare, as the results are often most 
distressing and the disease not amenable to treatment. 

The causes are not known, but the condition has been found to 
follow excessive loss of blood at confinement, overlactation, and in- 
Jlanimatory ctmditions of the adnexa. The symptoms are amenor- 
rhea, or, if menstruation persist, a mi)st inveterate and hopeless form 
of dysmenorrhea. There is usually much disturbance of the nervous 
system Hysteria and neurasthenia are common. The diagnosis is 
made by finding the undersized uterus in a woman who has borne 
children. 

Treatment. — ^Treatment is usually unavailing. Build up the 
general system and apply electricity locally. In aggravated cases the 
only relief lies in inducing the artificial menopause by removing the 
uterine appendages. 



CHAPTER X. 

DISEASES OF THE VULVA. 

HYPERTROPHY. 

Ant or all of the anatomic divisions of the external genitals may 
become hypertrophied. The parts most frequently affected, however, 
and for which the physician is most frequently consulted, are the 
nymphae and clitoris. The causes of this condition are not well un- 
derstood. Moderate degrees of hypertrophy have been ascribed to 
local irritation, such as would arise from masturbation, excessive 
venery, or even the rubbing incident to a pruritus. The most notable 
examples of overgrowth of the n^-niphiB are found among the Hotten- 
tots and kindred tribes of South Africa. Here the nymphae attain 
an enormous development, not infrequently extending down the thighs 
even to the knees. Such a development is regarded as a mark of 
distinction, and it is said that the growth is encouraged by systematic 
stretching and massage from infancy. It is probable, however, that 
culture has not so much to do with the excessive growth as racial pecul- 
iarity. The clitoris sometimes becomes unduly enlarged, even to the 
eixe of the penis of a half-grown boy. Both conditions may give rise 
to inconvenience because of their bulk and by interfering with urina- 
tion or copulation. Owing to their exposed and unprotected state they 
are subject to unnatural irritation, and may become inflamed or ulcer- 
ated. The only remedy is amputation, with coaptation of the cut 
edges by suture to guard agaijist hemorrhage and insure speedy unioiL 



ADHESIONS OF THE LABIA. 

This 18 principally an affection of infancy and childhood, and 
depends upon a softened or immature condition of the epithelium, 
with consequent agglutination. It frequently arises from uncleanli- 
neas. It seldom gives rise to inconvenience in early life, but may at 
a later period by interfering with the uterine or vaginal discharges 
and possibly with sexual relations. 

Treatment. — As the union is not firm, all that is necessary, as 
a rule, is to get the patient in position and by pressure of the two 
thumbs in opposite directions break up the adhesions. Should it not 
yield to this, a bent probe introduced through the small opening 

(95) 



96 PRACTICAL GYNECOUXJY. 

which usually exists immediately beneath the urethra and forcibly 
withdrawn in the line of cleavage will generally suffice. Should there 
be no opening under the urethra, it is better to wait until menstrua- 
tion has declared, and then deal with the case as with an imperforate 
hymen. After separation of the labia, the opposing surfaces should 
be kept from coming in contact by pledgets of gauze until they are 
healed. 

VULVITIS, 

Vulvitis is an inflammation of the vulva. There are three varie- 
ties: simple, purulent, and follicular. 

Simple Vulvitis. — Simple vulvitis is, for the most part, the 
result of local irritation, and has its origin in filth and vicious habits. 
The most common causes are acrid discharges from the uterus and 
vagina, accumulated filth, decomposing secretions, parasites, and me- 
chanical irritation, such as scratching, rubbing, friction to allay itch- 
ing, or for the purposes of masturbation. The parts are red, swollen, 
and bathed in a watery or mucous discharge. The symptoms are a 
sense of fullness, itching, and burning. 

Purulent Vulvitis. — Purulent vulvitis is characterized by a puru- 
lent or muco-purulent discharge. It is usually the result of gonor- 
rheal infection. It may arise from a neglected simple vulvitis which 
has become infected. The redness and tumefaction are, if anything, 
more pronounced than in the simple variety. Patches of erosion and 
ulceration of the inflamed surfaces are not uncommon. In such in- 
stances the discharges are apt to be tinted with blood. The perineum 
and inner aspect of the thighs occasionally participate in the inflam- 
matory reaction and become excoriated. This is due principally to 
the irritating discharges. The synii)tonis are those of the simple 
variety intensified, though in the young or impressionable the local 
trouble may be supplemented by some febrile reaction. 

Follicular Vulvitis. — Follicular vulvitis differs from the other 
varieties in that the follicles are involved. It arises from the same 
causes, and may or may not be associated with either of the other 
varieties. In some instances the follicles stand out conspicuously as 
elevated red points. In such the diagnosis is easily made. In others 
the dilTuse redness and tumefaction oliscure tiiis foaUiro. Usually 
palpation and careful inspection will disclose the enlarsred follicles, 
from which can be expressed the miico-purulont or purulent contents. 
The surfaces of the labia arc bosmoarod with the discharge. The 
causes and symptoms are those of the other varieties. 




are aggregated under one roof, as in boarding-schools. The infection 
is conveyed from one to anotlior througli towels, bedding, and other 
trticles of common u»e. Vulvitis in a child will often awaken the 
suspicions of the parentfi, and as a consequence wrongful accusations 
are occasionally made. As the physician is likely to be consulted, 
great care should be exercised lest injustice be done the accused. 




98 



PUACTKAL GYNECOLtKiY. 



Treatment. — Much of the treatment will apply to all three varie- 
ties. The essential features of treatnu-nt are to remove the cause, 
establish and maintain cleanliness, and protect the parts from irri- 
tants and acrid discharges. These, in the majority of instances, will 
be followed by spieedy relief, but may be reinforced by soothing appli- 
cations, gerni-destroying agencies, and measures of relief for the over- 
distended fotlicles. The result, as a rule, does not depend so much 
on the variety of remedies as upon the diligent use of a few appro- 
priate ones. For cleansing purposes, vagina! douches, sitz-baths, and 
local bathing may be used. The water should be comfortably warm, 
and may be plain or medicated by tlie addition of common salt, boric 
acid, or the sugar of lead in the proportions of 1 to 100. A 2-per- 
cent, solution of carbolic acid or nitrate of silver may be used as a 
local application, as also a 1 to 2000 solution of bichlorid of mer- 
cury in obstinate cases or those of speciiic origin. The douching and 
bathing of the parts should be repeated several times in the twenty- 
four hours, or as often as need be to maintain cleanliness. Protectives 
may be applied in the form of ointment or powder. The oxid of zinc 
ointment serves the purpose admirably, as also a powder composed 
of equal parts of bismuth and chalk. Pledgets of gauze, dry or 
medicated, should be kept between the inflamed surfaces to prevent 
contact. In the follicular variety it may be found necessary to relieve 
the follicles by puncture, and, after expressing the contents, to cau- 
terize with nitrate of silver or carbolic acid. 



INFLAMMATION OF THE VULVO-VAQINAL GLANDS. 

This is usually the result of septic or specific infection. It is 
highly suggestive of gonorrhea. The duct is frequently affected to 
the exclusion of the gland. It is indicated by slight tumefaction and 
tenderness over the course of the duct, and by a reddened orifice. 
The secretion is increased, and consists of mucus or pus. The duct 
may be occluded, thereby causing a retention cyst. When the gland 
is involved it becomes enlarged, tender, and exquisitely painful. It 
forms a distinctly circumscribed tumorous projection on the inner 
aspect of the lower half of the labium. If suppurating, pressure over 
tlie gland will cause pus to exude and discharge through the duct. 
Occasionally the duct becomes permanently occluded, and may, in 
consequence, become greatly distended. (Fig. 42.) This is accom- 
panied by intense pain, but usually sooner or later the accumulated 
pus finds vent through one or more ulcerated openings below the 
orifice. Many cases recover spontaneously or as the result of medica- 



DISEASES OF THE VIXVA. 99 

tion. Others continue until relieved by surgical intervention. As 
a rule, only one side is affected at a time. 

Treatment. — Kest in tlie recumbent position, attention to the 
tuwels, soothing and anodyne applications to the inflamed area, and 
aa occasional emptying of the gland by gentle pressure will fulfill the 
indications in the majority of cages. Should guppuratioQ persist, the 



Fig. 42. — .\bi<eess of Vulvo-vaginal Gland. 



duct become occluded, or fistulous tracts form, the gland should be 
laid open by a free incision, thoroughly curetted and swabbed with 
pure carbolic acid or a 1 to 1000 bichlorid solution, and packed with 
gauze. Should the condition indicate much disorganization of the 
gland, it should be removed either in its entirety by careful dissection 
or taken away piecemeal by means of curved scissors and tissue 
forceps. The cavity may be packed with gauze and allowed to heal 



KJO PRACTICAL GYNECOLOGY. 

by granulation, or, if healthy, closed at once by suture. When the 
duct is affected, either alone or in conjunction with the gland, an 
attempt should be made to open it up by a delicate probe, followed by 
an application of carbolic acid or bichlorid. Should this fail, it may 
be laid open with scissors and cauterized or dissected out. 

CYSTS OF THE VULVO-VAOINAL GLANDS. 

These are due to the retention of the contents, and are usually 
the result of a pre-existing inflammation. They occur under two 
conditions : First, and most usually, from occlusion of the duct, and, 
second, from an increased consistence of the contents which precludes 
their escape through the normal passage. The contents are clear, 
more or less viscid, and yellowish, or of chocolate color. Cysts may 
be situated either in the gland or the duct. They are seldom larger 
than an egg, but may attain the size of the fetal head. They are 
tense and elastic and usually insensitive. They are located on the 
lower and inner aspect of the labium. They are to be differentiated 
from hernia, hydrocele of the canal of Nuck, and other cystic forma- 
tions along the course of this canal. These latter occupy the upper 
and outer aspect of the labium, and can be traced to the inguinal ring. 
If the contents of the cyst be not too viscid, the hypodermic syringe 
will reveal its character. 

Treatment. — The contents of the cyst may be aspirated and the 
sac injected with tincture of iodine, carbolic acid diluted with alco- 
hol, or a 1 to 2000 solution of bichlorid of mercury. The cyst need 
only be partially filled with the medicament, which after thorough 
massage may be withdrawn again. If this fail, tlie cyst should be 
extirpated. 

EXANTHEMATA OF THE VULVA. 

Tiic vulvar integument is subject to the same affections as the 
mucous and cutaneous surfaces elsewhere. They are produced by 
the same general causes, present the same features, pursue a simi- 
lar course, and are amenable to like treatment. Among the most 
common of these are herpes, eczema, and prurigo. Their recognition 
is important as indicating the line of treatment, and to prevent their 
being confounded with some other form of disease. The large, raw, 
circular abrasion of a burst herpetic vesicle has been frequently 
mistaken for a chancre or chancroid. The absence of a hardened base 
and the slight involvement of the inguinal glands, togother with its 
evanescence, will serve to distinguish them. Eczema may assume any 



DIS^:.\SES OK THK VI lA A. 



101 



of the multifarious forms that characterize it elsewhere. It is often 
grafted on, or follows in the wake of, vulvitis, [uuritus, parasitic and 
other affections of tlie vulva that are characterized by itching and lead 
to nibbing or scratching of the parts. In sucking for the cause of 
any of these affections, the local conditions, such as acrid discharges, 
diabetic or dribbling urine, vicious habits, and personal unclcanliness, 
should be taken into account. The graver affections — erysipelas and 
diphtheria — are happily rare, and are usually the concomitants of 
the pueri»eral state. 

PRURITUS VULV/E. 

This, as the name implies, is an itching of the vulva. The terra 
is not usually applied to the inflammatory or eruptive affections of the 
vulva which are attended by itching, but is restricted to an intense 
and persistent itching of the parts unattended, especially at the out- 
set, with any definite lesion. As a result of the friction and scratching 
of the parts, it may merge into one or the other cnnditions above men- 
tioned. The causes are many and varied, and not always recognizable. 
Among tlie most common are acrid discharges from the uterus or 
ragina, which will include the discharges from malisniant growths, 
diabetic urine, or urine that has been rendered irritating from an ab- 
normal increase of its salts, the gouty or rheumatic diathesis, and 
decomposition. Thread-worms from the bowel will sometimes cause 
it in children. Pelvic inflammation, tumors, and pregnancy, by inter- 
fering with the circulation and by reflex nervous influence, may pro- 
duce it. Local irritation from ill-fitting clothes, masturbation, and 
excessive venery are occasional factors. Habitual constipation some- 
times acts as an exciting cause. The itching is usually most pro- 
nounced in the region of the vestibule, and is often confined to a 
limited area. It is usually intermittent, intense, and insufferable, 
driving the patient to seek relief by rubbing and scratcliing, regardless 
of time and place. As a result, she eschews all social gatherings, 
becomes a recluse, and in the seclusion of her home seeks relief 
in tlie most potent anodynes. If young, she is in great danger of 
acquiring the habit of masturbation. 

The continual friction of the parts usually results in abrasions 
of the surface or an actual eczema. The disease spreads, involving 
the labia, perineum, anus, inner aspect of the thighs, lower abdomen, 
and vagina. Especially is this liable to be the case in pregnant 
women. The condition is aggravated by anything that will produce 
local congestion : undue exercise, sexual intercourse, stimulants, over- 



102 PRACTICAL GYNECOLOGY. 

feeding, and the warmth of the bed. It is common for women to 
Buffer after retiring, and in consequence their rest is broken and they 
become correspondingly debilitated. The prolonged and intolerable 
annoyance, the loss of sleep, the seclusion, and the keen sense of her 
position, in the worst forms of the trouble, render the patient morbid 
and sometimes drive her to the verge of insanity. Fortunately, all 
cases are not so severe, and many never attain to a degree of severity 
to appreciably affect the health or spirits. In the earlier stages there 
is often no appreciable lesion, or at most a little puffiness and glazing 
of the surface; but sooner or later, as the result of scratching, the 
parts become indurated, thickened, dry, and discolored, with patches 
of excoriation and scars. 

Treatment. — A painstaking search should be made for the cause, 
which should be removed if possible. In the majority of instances the 
trouble comes from a secretion from the uterus or vagina. Often- 
times the vaginal secretion is very scant and scarcely recognizable. 
It is, nevertheless, very acrid, and will provoke and perpetuate the 
trouble until shut off. As a routine measure, in the absence of other 
obvious cause, it is good practice to prevent the vaginal secretions 
from coming in contact with the vulva. This may be accomplished 
by a tamponade of wool or cotton. A roll or ball of either, just suffi- 
ciently large slightly to distend the vagina, is introduced, after wash- 
ing away the secretions, and allowed to remain from six to twelve 
hours, when it is removed, the vaginal secretions washed away by a hot 
vaginal douche, and replaced by another. The tampon should have a 
string attached to it to facilitate removal, and the patient should be 
instructed how to prepare and introduce it. If the urine contains 
sugar, as is often the case with elderly women, or if it possesses irri- 
tating properties from any other cause, care should be taken in voiding 
it, and the parts should be bathed after each urination. 

Coincident with this protective regime the underlying pathologic 
condition, whether it be general or local, should be receiving appro- 
priate treatment. The local measures so far have been with a view to 
securing cleanliness. It may be necessary to use protectives to the 
surface, as in cases of incontinence of urine. Here, a bland and sooth- 
ing ointment will be of great benefit, or ointments containing anti- 
pruritic ingredients. The carbolated, or benzoated oxid of zinc oint- 
ments, or, better still, the common white lead paint laid on with a 
brush, form excellent protectives. Ointments, however, are dirty and 
difficult to remove, and should not be resorted to except where it is 
necessary to protect the surface from dribbling or constant discharges. 



DISEASES OK Till". VL LVA. 



10;5 



Jccnsionnlly dusting-powders are equally serviceable, and possess 
the advantage of being more cleanly. Oxid of zinc or bismuth, or 
eit]ier combined with chalk, make efficient applications. The number 
of local applications which have been suggested for pruritus vulvae 
is beyond enumeration. All of the anodynes, all of the so-called anti- 
pruritics, have been recommended and tried in turn. Among the 
Lmost common are opium, chloroform, hydrocyanic acid, menthol, an- 
'tip^Tin, cocaine, iodoform, and bichlorid of mercury. A solution 
of the bichlorid of mercury varying in strength from 1-2000 to 
, 1-500 is probably tlie most generally useful local application. It 
'•bould be prepared fresh, as it soon loses strength if allowed to 
stand. A solution of nitrate of silver, 10 to 40 grains to the ounce, 
bSppJied to the parts with a camel's-hair brush, often affords relief. 
It is almost a specific in the vaginal pruritus of pregnancy. One 
grain of bichlorid of mercury to 1 ounce of the emulsion of bitter 
almonds makes an elegant and highly satisfactory application. 

In the senile form, especially in inveterate cases, lime and sulphur 
in solution, or in the form of an ointment, will sometimes succeed 
where otlier measures fail. Tait gives the following formula : — 

B Cttlcia 1 pound. 

Sulphur 2 [xiunds. 

Pat Into three gallons of wiit«r and boil down to a gallon and a hall. 
Dm locally. 

In cases that are not amenable to other treatment, it has been 
proposed to dissect away the affected mucous membrane. 



KRAUROSIS VULVAE. 

This is a vulvar sclerosis, and in many of its aspects resembles 
trachoma of the eyelids. It is characterized in its initial stage by 
enlarged capillaries, a small round-cell infiltration of the subepithelial 
structures, and epithelial growth. Later the parts become bloodless, 
shrunken, dry, and friable. It first affects the labia minora or the 
parts adjoining, the primary indication being delicate red lines or 
'spots, — tlie distended capillaries, — which shift from place to place, 
being followed by unnatural paleness, hardness, and contraction of 
the tissues. In time the entire mucous and cutaneous coverings of the 
vulva become involved, and the vulvar opening greatly contracted. 
The tissues become unyielding and brittle. Attempts at dilatation are 
exceedingly painful, and result in fissures similar to those of chapped 
bauds. There are ordinarily no subjective symptoms except the pain 



104 PRACTICAL GYNECOLOGY. 

attendant on sexual intercourse or attempts at dilatation. The sexual 
relations, in time, become impracticable. The disease is frequently 
preceded and sometimes accompanied by an obstinate pruritus. The 
course of the disease is slow and progressive and the prognosis as to 
cure is unfavorable. It has no tendency to a fatal issue, and does not 
affect the general health. 

On the assumption that the disease is a veritable trachoma. Dr. 
Arthur Johnstone recommends the yellow oxid of mercury ointment 
of the strength of from 1 to 3 per cent. The vulva and vagina are 
first cleansed with the hydrogen dioxid spray, and the ointment 
applied twice a week. The patient is instructed to use the same twice 
daily to the external parts. After marked improvement the applica- 
tions are made at longer intervals, but should be kept up for months. 
To be of much benefit the treatment should be commenced early. Hot 
sitz-baths, or fomentations to the vulva, followed by thorough drying 
and the application of a powder consisting of salicylic acid and calo- 
mel, in the proportions of 1 to 5, may be of service. Strong carbolic 
acid has beeta used as a palliative. Excision of the affected parts fol- 
lowed by suturing has, on the whole, yielded better results than any 
other line of treatment 



CHAPTER XI. 

DISEASES OF THE VULVA: SPECIFIC, MALIQNANT, 
AND TRAUMATIC. 

SPECIFIC DISEASES OF THE VULVA. 

These are the result of gonorrheal or syphilitic infection, and 
occur in the form of diffuse inflammation, gonorrheal vulvitis, vege- 
tations, mucous patches, gummatji, the syphilitic eruptions, chancre, 
and chancroid. Gonorrheal vulvitis has already been alluded to. 
Venereal warte consist of papillomatous excrescences of irregular 



Fig. 43. — Venereal Warts of Vulv«. (Author's Co'e, from Photograph.) 

shape and distri'uiion. (Fig. 43.) They are found about the vulva, 
perineum, and anus. They are the result of irritating discharges, 
and, while highly significant of specific infection, they may some- 
times arise from other causes. They produce an ill-smelling acrid 
secretion that spreads the disease. 

Treatment.— ^The essentials of treatment are to keep the parts 
clean and dry. The vagina should be washal out frequently. Clotha 
wrung out of hot water should be applied to the vulva several times 
a daj, for a period of from ten to twenty minutes. The parta should 

<105) 




I OR 



PRACTICAI. r.YNKCOUX-.Y. 



be then bathed in the mercuric bichlorid sohition (1 to 2000) and 
thoroughly dried. And, last, a powder consisting of equal parts of 
calomel and salicjlic acid dust-ed over the parts. This should be re- 
peated two or three times in the twenty-four hours. Diligence and 
perseverance are necessary to success, and the treatment must be fol- 
lowed up until the last vestige of the trouble has disappeared. Since 
adopting the above treatment I have had scant occasion to resort to 
the knife or scissors. Nevertheless, should the circumstances of the 
patient be such as to preclude the carrying out of these details, or 
should the disease fail to respond to the treatment outlined above, the 
vegetations may be snipped off and the base cauterized. 

Chancre. — It is very necessary that the primary venereal sore 
should be recognized, not only for the purpose of intelligent treat- 
ment, but also in view of the possible ulterior consequences. The 
chancre comes singly, is sharply defined, is not sunken or elevated 
above the level of its environments, is dusky red or copper colored, 
and has an infiltration at the base which is hard and disk-like. When 
taken between the fingers the base gives the impression of sheet-lead. 
This latter is especially characteristic of chancre. The sore is not 
tender, and seldom itches. The inguinal glands enlarge on both sides, 
but are not sensitive, and have no tendency to suppurate. A chancre 
may ulcerate at the center, but the periphery retains its distinctive 
characters. 

The Chancroid, — The chancroid, unlike the chancre, is multiple. 
It also is sharply defined ; but the infiltration is deeper and more 
nodular. The base is fissured and covered with a yellowish or green- 
ish-yellow scum. It suppurates freely. It is more apt to be painful, 
is often excavated, and sometimes phagedenic. The inguinal glands 
are speedily involved, but, unlike chancre, one side only may be 
affected. They become greatly enlarged, and are tender and painful 
and prone to suppuration. 

Treatment. — The chancre is self-limited and not amenable to 
treatment. One of the beat local applications is a powder consisting 
of 3 parts of o.xid of zinc to 1 of calomel. 

Chancroids should be cauterized with nitric or carbolic acid, and 
dressed with antiseptic. A convenient application is that of carbol- 
ized oil. The sore is auto-infectious, and scrupulous cleanliness 
should be maintained to prevent new foci of infection. 

Syphilitic Hypertrophy of the Vulva. — This, which in some re- 
spects resembles elephantiasis, is frequently met with in this latitude. 
It usually affects both labia. It occasionally ulcerates and may be 




DISKASKS OK THE VI LVA. 



107 



covered with warty growths. It is rebellious to treatment. An anti- 
g}'philitic course should first be tried and if ineffectual be followed 
by excision. The syphilitic skin eruptions, the gummata, and mu- 
cous patches are similar to those found elsLnviiere. 

NON-SPECIFIC DISEASES. 

Injuries of the Vulva. — These usually result from blows, kicks, 
or falls, and result in contusions, lacerations, or punctured wounds. 
Criminal assault and the first marital embraces are occasionally the 
cause of serious damnge to the structure. Contusions should be 
treated on general principles, lacerations sutured, and hemorrhage 
controlled by compression or deep sutures. Care should be taken to 
prevent infection by strict observance of cleanliness. 

Varicose Tumors of the Vulva. — These consist of overdistended 
veins, and are the result of interference with the venous circulation. 
The trouble is usually located in the pelvis. Pregnancy is the most 
common cause, but the condition may arise from any kind of a pelvic 
growth tliat interferes with the circulation. They are found most 
fre<]iiently on the labia majora. They vary in size from a barely ap- 
preciable enlargement to that of the fetal head. They may rupture, 
giving rise to profuse hemorrhage. This accident is most likely to 
occur in pregnancy or in the act of parturition. If troublesome or 
thin-walled, they should be supported by a compress and bandage. 
In ca»e of rupture the hemorrhage may be controlled by firm compres- 
sion, ligation, or deep suturing. They usually disappear or cease to 
be troublesome after the cause has been removed. 

Hematoma of the Vulva. — Hematoma, or blood-tumor of the 
vulva, is due to the rupture of a blood-vessel. It occurs most fre- 
quently in parturition. It is sometimes the result of violence: blows, 
kicks, falls, etc. It manifests as a swelling of variable size. It is 
of a purplish aspect, and tense or doughy according as it is observed 
immediately or some time after the accident. If small it will usually 
disappear through absorption, provided it does not become infected. 
If large, or if infection occur, it should be laid open, cleansed, and 
packed with gauze. In ail cases the patient should keep her bed and 
a light compress he applied. It is needless to say that infection 
should be guarded against by scrupulous cleanliness. 

Elephantiasis of the Vulva. — This is a disease of the tropics, and 
is rare in this latitude. It consists of an enlargement of the vulva 
due to an hypertrophy of the skin. The skin becomes greatly tliick- 
ened and overgrown in all its dimensions. The growth occasionally 



108 



PIUCTICAL GYNECOLOGY. 



attaiiu enormous proportions. It may be hard or soft, smooth, corru- 
gated, or warty. Jt occasionally ulcerates in places as the result of 
uneleanlincss and attrition. The clitoris is sometimes involved. It 
is due to an occlusion of the lymph-channels, with consequent accu- ' 
mulation of lymph in the lymph-spaces and hypemutrition. It is 
to be differentiated from lupus and carcinoma. In these latter the 
induration is deeper, the ulceration more extensive, and the growth 
more rapid. In lupus there is more discoloration. In case of doubt 
the microscope should be called into requisition. 

The scientific expedition recently sent to Nigeria by the Liver- 
pool School of Tropical Medicine report that they have discovered in 
mosquitoes the bacillus which causes elephantiasis. They believe that 
the experiments which are now being carried on to stamp out malaria 
by preventing inoculation by mosquitoes can be successfully applied to 
elephantiasis. 

NEOPLASTIC GROWTHS. 

The neoplastic growths of the vulva embrace a very large variety. 
The most common of the benign growths are lipoma, myxoma, 
fibroma, and enchondroma. These possess the same characteristics 
and demand the same treatment as similar growths elsewhere. The 
greatest interest attaches to the malignant growths, both on account 
of their frequency and destructivenese. As much will be said on the 
subject in succeeding pages, I have thought it better to anticipate the 
consideration of malignancy as affecting special organs by some gen- 
eral considerations which will apply to all. 

Malignant Growths. — A malignant growth is inherently destruc- 
tive to life. It is furthermore infectious within the body in which it 
is developed, and will continue to develop so long as a vestige of the 
growth remains and has living tissues to feed on. Other growths may 
kill by pressure or interference with the functions of important 
organs, but they have not the power of regeneration from a small 
residue left after operation, nor are they infectious. It is a curious 
fact that, while malignant growtlis are capable of infecting the body 
in which they develop, they are not transmissible to other bodies. 
If such were the case few surgeons would escape, as the surgeon is 
constantly delving in malignant tissues and oftentimes exposing 
himself by slight wounds incident to the operation. 

Malignant growths are always in their beginning distinctly local- 
ized, and if thoroughly eradicated are no more prone to recur than 
other growths. The manner of extension is by peripheral growth and 



DISEASES OF THE VL LVA. 



10« 



metastasis. Metastases occur by way of the blood- and lymph- cur- 

iTents, through which particles of the growths, or the active principle 

lof the same, are wafted to parts more or less remote, and finding 

lodgment proceed to develop. In this way secondary foci may be es- 

Itablished in organs and structures very remote from the site of the 

[primary growth. The seeds of infection are sometimes scattered in 

illie process of operation, causing the development of the growth in 

Mhe line of the wound. The malignnnt growths of the female geni- 

ftalia are carcinoma, epithelioma, and sarcoma. Of these, sarcoma 

'is the least frequent. Carcinoma and epithelioma are developed 

from epithelial cells, sarcoma from connective tissue. The epithelial 

growths — carcinoma and epithelioma — are distributed by way of the 

'lymphatics, while the Barcomata follow the blood-current. 

Causes. — The causes of malignant growths are not understood. 
There is some reason for suspecting that carcinoma is of parasitic 
origin. If so, the parasite does not seem capable of successful trans- 
plantation from one person to another. This, however, does not dis- 
, prove its parasitic character, for some of the larger, well-known para- 
sites cannot thus be transplanted, such as the ordinary tape-worm. 
There is a wide-spread belief that heredity plays an important role 
in the production of these growths. Such, however, is not the case, 
as only about 14 to 18 per cent, of cancerous cases give a history of 
heredity. In uterine cancer the ratio is even less. Trauma has also 
been held accountable for many cases, but investigation shows that 
only from 3 to 8 per cent, of the cases of niiili^'nant disease furnish a 
history of a pre-existing injury to the part in which the growths 
develop. 

General Characters of ilalignoni Orowlhs. — Even the most mi- 
nute and painstaking description of a malignant growth will often fail 
to convey the idea by which it may be diagnosticated. Novcrtholejis, 
there are certain general characters of malignant growth that are 
suggestive, and may greatly assist in establishing a diagnosis. The 
more fact that a growth is suspected of being malignnnt will often 
lead to an investigation through which a definite diagnosis may be 
achieved. As it will be quite impracticable in this connection to give 
an extended description of all the varied forms of malignancy that 
may affect the different parts of the genital tract, the few suggestions 
here given may be of value by giving a cue to the investigation. Ma- 
lignant growths are of different consistence, and are usually denomi- 
nated hard or soft. The denser growths, when imbedded in the tis- 
sues, are hard, nodular, and intimately blended with the tissues in 




110 PRACTICAL GYNECO/AXSY. 

which they are imbedded, consequently immovable. The softer 
growths are also immovable. The malignant growth in its latter 
stages, when it ulcerates or begins to break down, is very friable, so 
as to be easily chipped ofiE by the finger-nail, and is unctuous when 
rubbed between the fingers. As a rule, it bleeds easily and on slight 
provocation, and emits a disagreeable odor. The bottom of the ulcer 
is usually uneven and foul, the sides irregular and craggy, and the 
margins elevated, lumpy, and indurated. 

MALIGNANT GROWTHS OF THE VULVA. 

Malignant growths of the external genitals are comparatively 
rare. Here the epithelioma, in point of frequency, predominates. It 
also pursues a course so methodical and distinctive as to merit sepa- 
rate consideration. 

Epithelioma of the Vulva. — The starting-point of the vulvar 
epithelioma is usually on the mucous surface of the lower portion of 
one of the greater labia. It usually occurs in the form of small, 
rounded, masses of a whitish or dirty white color, and which project 
slightly above the surface. These little masses are hard and insensi- 
tive. They are of indolent growth, and often remain dormant for a 
long time. Sooner or later a zone of increased vascularity surrounds 
the growth, which is the signal for increased activity in its develop- 
ment. It begins to enlarge, casts its epithelium, and ulcerates. The 
margins of the ulcer are elevated, hard, and livid, while the floor is 
uneven, granular, and bathed in ichorous pus. In the ulcerative stage, 
if the infiltrated mass be grasped between the thumb and finger, little 
maggot-like bodies may be pressed out. These are the contents of 
the so-called cell-nests, and consist of massed epithelium. They are 
almost pathognomonic of epithelioma. A more or less exuberant 
papillomatous growth sometimes springs from the floor of the ulcer. 
The growth is usually confined to one labium, and seldom invades the 
vagina or abdominal wall. Later it may pass to the perineum and 
upper part of the thigh. The inguinal lymphatic glands are slow to 
become involved, but when such is the case a new impetus is given to 
the disease, and it spreads with great rapidity, and involves the 
deeper tissues. 

Symptoms. — Violent and persistent pruritus is an almost con- 
stant accompaniment of the disease, and is most pronounced in the 
earlier stages. Pain does not usually manifest itself until ulceration 
has occurred. It then becomes more or less persistent. The odor from 



DISUAbliS UF TUE VL LVA. 



IJl 




the ulcerated surface is quite disagreeable, but not comparable to that 
of carcinoma. Heniorriiages sometimes occur. The appetite is lost, 
eleeplcssnt'ss supervenes, and the patient becomes wasted and cachectic. 
The average duration of the disease, from beginning to end, is from 
two to three years. 

Carcinoma of the Vulva. — This is much lf>ss frequent than epi- 
thelioma. It occurs, for the most part, in the aged, and assumes a 
scirrhus form. Its favorite site is in the labia majora, or in or about 
the clitoris. It usually develops in the deeper tissues and rapidly 
makes its way to the surface. Tlie skin or mucous membrane becomes 
pinned down to it before the growth has approached the surface, and 
produces a depression over the site of the tumor. The ulcer is not 
unlike that of epithelioma. Speedy involvement of the inguinal lym- 
phatics and wide dissemination of the disease are characteristic. 

i^l/mploms. — The symptoms are similar to those of epithelioma, 
but more pronounced. The pain is greater, tlie hemorrhage more pro- 
fuse, the discharges more abundant, and the odor decidedly offensive. 
The patient declines rapidly and death comes early. 

Sarcoma of the Vulva. — This is the rarest of the malignant dis- 
of the vulva. Its favorite site is in the nymphas. Its progress is 
generally slow. 

Treatment. — Early and complete removal of the growth, what- 
ever its character or situation, is the only rational treatment. Ex- 
cision by the knife is the preferable method, in that the amount of 
tissue to be removed can be accurately gauged. It is furthermore 
eaner, more expeditious, and less painful than by any other method. 
There can be no question but that good and efficient work may be done 
here as elsewhere by escharotics or the actual cautery, especially in 
the hands of those who are accustomed to their use, but the suffering 
attending their use, oftentimes long draivn out, forms a serious objec- 
tion to their employment. Whatever method is used, the aim should 
be to remove every vestige of the disease by going wide of the growth, 
else the inevitable result will be a speedy recurrence. The inefficient 
use of caustics, by irritating the tissues and producing hyperemia, 
stimulates the growth to increased activity, and thereby hastens, rather 
than retards, the progress of the disease. When the disease lias passed 
the confines where it can be followed by knife or cautery, or has in- 
volved the lymphatics, the treatment should be palliative. Detergent 
washes and lotions to keep it clean, such as the non-toxic antiseptics, 
styptics and compresses for the bleeding, and anodjTiea for the pain 
are indicated. A saturated solution of chlorate of potash, applied in 





1^2 



PRACTICAL GVNECULOGY. 



the form of wet compresses, is an excellent deodorant, antiseptic, and 
anodyne, ilydrogen dioxid is antiseptic and a powerful hemostatic. 




VULVO-VAGINAL HYPERESTHESIA AND VAGINISMUS. 

As these two affections originate from the same causes, are 
amenable to the same treatment, and are practically the same in 
their essential features, they are here considered as a unit. 

In vulvo-vaginal hyperesthesia there is extreme sensitiveness of 
the introitiw vagina and contiguous parts. In vaginismus there is 
superadded painful contractions of the constrictor cuni muscles when 
the parts are touched. The condition exists in various degrees of 
severity, and in its severer forms interposes an effectual barrier to 
sexual relations. It is an affection of the nerves, and usually depends 
on some local lesion or irritant. It may be reflex or even of consti- 
tutional origin. Inflammation or cicatricial contractions at the site 
of the hjinen, with or without erosions, are the most constant local 
indications. Sometimes there is a slight hyperemia or puffiness of 
the parts, at other times absolutely no local indications whatever. 
It is sometimes associated and seemingly dependent on an inflamma- 
tion of the internal organs of generation. Reflex irritation from an 
anal fistula has been known to cause it. 

Treatment. — The cause should be sought for and treated gecun- 
detn artem. As a routine measure, dilatation of the vaginal entrance 
yields excellent results. The manipulations should be gentle and the 
demeanor of the physician such as to reassure the patient. Harsh 
measures will defeat the aim of the physician by awakening an 
unconquerable fear and antagonism of the patient and depriving him 
of her co-operation. Therefore, unless it be decided to give an anes- 
thetic, which will not usually be resorted to until other measures have 
been tried and failed, gentle and graduated dilatation will be the 
method of choice. As a preliminary, a prolonged warm sitz-bath, fol- 
lowed by a local application of some soothing lotion or ointment or 
vaginal suppository, will be of material benefit. For this purpose, 
cocaine, belladonna, or menthol may be used. An ointment consisting 
of equal parts of the ointments of belladonna, stramonium, and oxid of 
zinc, applied at intervals of from four to eiglit hours, is most efficient. 
Erosions should be touched with pure carbolic acid or lunar caustic, 
preferably after the u.se of cocaine. The finger, well lubricated, may 
now be introduced into the vagina with all possible gentleness, and 
permitted to rest there a few moments. Then, by gradually increasing 



msKASES uy TUK VLLVA. 



113 



wkn in Tarioufi directions, a moderate degree of tolerance in 
established. Tbis may be followed by the introduction of a bivalve 
speculum, or, better still, by one of the smaller sizes of the graduated 
rectal dilators. The instruments should be well warmed and lubri- 
cated, and dilatation accomplished by slow and easy stages, either by 
opening tlie blades of the speculum or by the introduction of the 
consecutive sizes of the dilator. Time and patience are requisite for 
the best results. In the intervals of treatment one of the graduated 
rectal dilators — the largest compatible with comfort — should be worn 
for several hours each day. This may be introduced by the patient at 
her home. If this treatment, after fair trial, prove imavailing, the 
patient should be anesthetized, the remains of the hymen removed 
with curved scissors, and, if the introitus vaginae be found below the 
normal in size, deep incisions should be made on either side the 
median line, and a large-sized Sims glass plug introduced. This 
plug should be worn for several days unless there be some special 




Fig. 44.— Sima's Glass Plug. 

contra-indications, and several hours each day thereafter for a period 
of two weeks. Attempts at sexual intercourse should be interdicted 
during the treatment and not resumed until a normal degree of tol- 
enuice haa been established. It will often be found neces.sary to com- 
bine constitutional with the loc^l treatment. The bowels should be 
kept soluble. 

COCCYGODYNIA. 

Coccygodynia is an affection of the coccyx characterized by pain 
pressure or motion. The pressure may come from without, as in 
sitting upon a hard surface, or from within, as in the act of defecation. 
Sexual intercourse is sometimes intolerable. Contraction of the 
attached muscles elicits pain by communicating motion to the bone. 
This occurs in various inflexions and postures of the body, especially 
in the acts of rising from the sitting posture and in sitting down. 
The condition may be recognized by seizing the bone between the 
thumb and finger — the finger being in the rectum — and rocking it 



U-l 



PllACTlCAL UVNECOUXjy. 



back and forth, whicli will elicit the characteristic pain. The condi- 
tion most frequently depends upon a localized artliritis, and usually 
follows injury from a fall, a kick, or a blow. In many instances tlie 
bone has been fractured, occasionally necrosed. A fracture of the 
bone resulting from parturition in advanced life after the bone has 
become rigid from ankylosis is an occasional cause. Kheumatisra 
is resiKinsible for a proportion of the cases. The condition is some- 
times intermittent, especially in cases of rheumatic origin. It some- 
times disappears spontaneously. In the severer forms dependent on 
necrosis it will persist for years or until relieved by surgical inter- 
ference. 

Treatment.— Immobility and rest of the dis^eased bone are the 
prime requisites. Pressure should be averted by the use of an air- 
cushioned seat (the inflatable rubber rinp) and by keeping the bowels 
soluble. Sexual intercourse should be interdicted. Movements that 




Fig. 46. — Inflatable Rubber Cushion. 

bring into play the muscles of the coccyx should be guarded against 
as much as possible. Blisters, counter-irritants, and anodyne appli- 
cations may be used over the site of the bone. A liniment composed 
of equal parts of wintergreon-oil and soap liniment is of value, as 
is also the local application of the tincture of aconite. 

Operations. — In inveterate cases it sometimes becomes necessary 
to remove the coccyx. This is accomplished by making a longitudinal 
incision over tlie coccyx, severing the muscular attachments at the 
sides and tip, lifting it up on the finger, and disarticulating from 
the inner side at the second joint. The opening may be closed imme- 
diately by deep sutures or packed lightly with gauze and allowed to 
heal by granulation. This operation becomes imperative in cases 
associated with necrosis. 

Subcutaneous tenotomy will give immediate relief in most cases, 
which by securing rest to the parts results in a permanent cure in a 



DISEASES OV THE VrLVA. Ho 

liinitod numher. As, however, tlie severed structures soon become 
reunited, its benefita are usually of short dunitiou. Tlie tenotome 
rll entered at the tip of the coccyx and swept around the bone bo as to 
tjlHK all muscular attachments at the tip and sides. 



^Uplicit 



CLASSIFICATION OF THE INFLAMMATORY AFFECTIONS 
OF THE GENITAL ORGANS. 

Believing the classification of the inflammatory affections of 
tlie genital organs according to any fixed standard is a hindrance, 
rather than a help, to the understanding, I have adopted none. Classi- 
fication is all right when it simplifies and elucidates, it is all wrong 
when it complicates and confuses. It is wrong when it foists certain 
features of a disi^ase into prominence at tlie expense of others of 
equal importance. As yet there has been no classification sufficiently 
simple and comprehensive as to merit acceptation. Some authors clas- 
sify upon an etiologic basis, others upon a histologic basis, and others 
jitill upon the clinical features. This has given rise to such a multi- 
licity and mixture of so-called varieties as to defy systematization 

destroy all cohesivenoss. The terms used to designate the various 
and varieties are in general use, and cannot be ignored. Neither 
can they be reconciled and affiliated in any system of classification. 
To adopt one to the exclusion of the others would be at the expense 
of perspicuity; to adopt all would involve so much prolixity as to 
be cumbersome and confusing. The simphst and most intelligible 
method will be to ignore classification altogether, and to describe in 
order tlie various phases and modifications of the inflammatory proc- 
eu without reference to any fixed standard. To illastrate: I have a 
case of endometritis, of septic origin, acute in cliaractcr and aifecting 
chiefly the glandular structures. If I were to tell you that I had a 
case of septic endometritis you would form no adequate conception 
of the real state of afFiiirs. If I were to speak of it as an acute endo- 
metritis or a glandular endometritis, you would still be in the dark. 
But if I were to speak of it as a case of acute, septic, glandular endo- 
metritis, tlie condition would be expressed in a few words and convey 
an intelligible idea of the real condition. 





be considered in tliis connection. The atresia may affect any portion 
of the canal or all of it. It may be congenital or acquired. In either 
event it is usually the result of Liitlamniation followeil by epithelial 
desquamation or. sloughing, with consequent adhesions of the opposing 
surfaces. The acquired form may result from trauma, from mechan- 
ical and chemical irritation, from sepsis, and from systemic affectiona, 
such as typhoid fever, diphtheria, and the exanthemata. One of the 
most common causes is inflammation and sloughing following child- 



DISKASKS OK THE VAOINA. 



117 



birth. Total or extensive obliteration of the canal, as a congenital con- 
dition, is generally associated with a developmental defect of the uterus 
and adnexa, and there are no sequences in the way of imprisoned fluids. 
The closure of the vaginal cnnal is not usually attended with any ill 
effects until after the establishment of menstruation. With the accu- 
mulation of the menstrual fluid the vaginal canal becomes distended 
(hematocolpos, Fig. 46), which, if not relieved, progressively affects 
the cervical canal, uterine cavity (hematoeolpometros, Fig. 47), and 
Fallopian tubes. The uterine and vaginal walls become hypertro- 
pbied and thickened. 



Fig. 47. — Hemalocolpometroa, 

When the tubes are involved a localized peritonitis frequently 
ensues, which results in adhesions, the tubes being bound down to the 
structures with which they are in relation. Tiiis, as will be seen pres- 
ently, adds an element of danger to the condition which must be re- 
membered when operating for atrefia. Occasionally the tubes rupture 
from overdistension or as the result of accident, giving rise to pelvic 
hematocele. Dilatation of the tubes and uterus from the accumulated 
menstrual fluid is much more apt to occur where the atresia is situ- 
ated in the upper part of the vagina. With the enlargement of the 
organs concerned, pressure symptoms are developed, especially affect- 
ing the rectum and bladder. Constipation, painful defecation, and 
hemorrhoids are common. The bladder may become irritable, and 




118 



rUACTlCAI- GYNECOrXXlY. 



■ 



there may be incontinence, retention, or dysuria. There is, of course, 
no external evidence of menstruation, and this oftentimes is the 
cause of solicitude wbich impels tlie patient to seeic medical advice. 
Occasionally the menstrua! effort is signaled by pains, — distension 
pains and pressure pains, — resulting from the additional fluid poured 
into the cavity. TJicse pains, corresponding in time to the normal 
menstruation, sometiuies afford a clue to the real ditliculty. On rare 
occasions the anomaly is presented of a double uterus and vagina, one 
of the canals of which is pervious and the otlier occluded. The 
occluded canal becomes distended with fluid and bulges toward and 
encroaches upon the normal canal. In the absence of determinate evi- 
dence of the double uterus, the slowly increasing, softish tumor felt 
within the normal canal is apt to be misinterpreted. More especially 
is this the case when the woman menstruates regularly from the nor- 
mal canal, which is the only obvious vagina. Occasionally the septum 
ruptures and the contents of the occluded canal discharge into the 
other. Pyogenic germs may thus gain entrance, and purulent inflam- 
mation of the affected side ensue. 

Vaginal stenosis is even more frequent than atresia. A tight 
stricture of the vagina may produce many of the symptoms of an 
atresia. Oozing of the pent-up secretions, however, usually betrays 
the real nature of the trouble, and may lead to t!ie detection of the 
small orifice through which they make their escape. Infection and 
suppuration of the tract above the stricture are very liable to occur. 

Diagnosis. — The imperforate hymen is readily recognized by 
separating the labia, when it will be found blocking the vaginal 
entrance. If the canal above it be distended with menstrual fluid, 
the membrane is bulged outward and is soft and elastic to the touch. 
Atresia of other parts of the canal may be made out by examination 
throtigh the rectum, aided, if need be, by a sound in the bladder. 
Should the atresia be located in tlie upper part of the vagina, a finger 
in the vagina and one in the rectum will outline the upper and lower 
boundaries of the occlusion. To outline the accumulation, and to 
determine to what extent, if any, the uterus and tubes are involved, 
the bimanual examination with one finger in the rectum will be 
necessary. The pent-up fluids, while usually consisting of menstrual 
fluid, sometimes represent the normal secretions of the uterus and 
upper part of the vagina. If infection has taken place it may be puru- 
lent in character. Where it is desirable to determine this point, a 
little of the fluid may be withdrawn by aspiration for inspection, care 
being taken not to carry infection into the cavity. 



1 



DISEASES OK THE VAGINA. 



ll'.> 



Treatment. — Surgery offers the only chance of relief. The object 
'will be to make an avenue of escape for the pent-up fluids along the 
natural route. The dangers attending the operation are threefold:, 
' aepeis, injury to the rectum or bladder, or bursting of the Fallopian 
^tubes. To avoid the first, every step of the operation should be con- 
ducted with strict reference to aseptic detail. Where the obstruction 
is low down in the vagina, or whore it forms only a thin diaphragm 
'with a distended canal above, there is little danger of wounding the 
rectum or bladder; but, where a considerable portion of the canal is 
impervious, it will be necessary to use all diligence to prevent this 
accident. 

With a finger in the rectum and a sound in the bladder, a trans- 
verse incision is first made as a starter. Then, advancing in a line 
with the normal course of the canal, the dissection is carried upward 
to near the upper extremity of the obstruction. This dissection, after 
the initial cut, should be effected largely by the finger, occasionally 



Fig. 48. — Blunt Curved Scissors for Atresia Vaginas. 

bringing into requisition the knife or scissors to sever unyielding 
bands, but never in advance of the finger. Frequent reference should 
be made to the guides in the rectum and bladder, and great care should 
be taken to keep equidistant between them. Usually the dissection 
is easy, the loose connective tissue leading unerringly to the open canal 
above; but occasionally it is the very reverse, and will require great 
care and tact to avoid serious injury to the contiguous viscera. In 
one instance I found myself cutting into the peritoneal cavity un- 
expectedly. 

When the dissection has been carried to within a fraction of an 
inch of the upper extremity of the solidified portion, as indicated 
by the finger in the rectum, and also, as a rule, by the sense of elas- 
ticity, and there is reason to believe that the tubes are implicated, 
^diaaection is stopped and provision is made against the third danger. 
The object is to prevent the too sudden emptying of the uterus and 
vagina, with t)ie consequent contraction, which, by drugging on the 



120 PRACTICAL GYNECOLOGY. 

tubes, might rupture them. Hence, at this stage of the procedure 
tlie usually distended cavity is tapped witli a trocar, and the fluid — 
which is usually thick and tarry — drawn off very gradually. After it 
has been exhausted the trocar is withdrawn, the opening enlarged, 
and the chambers gently, but thoroughly, douched with some anti- 
septic fluid. It is now loosely packed with gauze, which may be 
rejjlaced with fresh gauze in twenty-four hours, after douching. In 
case of imperforate hymen, or in any other condition in which the 
tubes are not involved, a free opening may be made at once with the 
aseptic precautions and after-treatment outlined above. 

In many instances the case is one of stenosis instead of atresia. 
The opening is soiiietimes so minute as to escape observation. In 
the hymen it usually exists immediately beneath the urethra. When 
the opening can be found, a small probe introduced through it will 
furnish a guide for the knife. In cases of extensive and complete 
atresia of the canal, accompanied by abi^ence or want of development 
of the internal organs of generation, operation is not indicated. An 
artificial vagina, made under these circumstances, closes up very 
promptly by adhesive inflanmiation. 

In one notable case I was applied to by a young lady, 18 years of 
age, of good physical development and in perfect health, who had 
never menstruated. On examination I found complete absence of 
the vagina and no evidence of utcnis or ovaries. I ftated to her the 
hopelessness of pennanent result from operative interference; but, 
as she desired to marry, she insisted on an artificial vagina being 
formed. I finally consented and made an ample vagina, and enjoined 
upon her tlip necessity of wearing a glass plug daily. She married 
soon after, and many months subsetpiently I received a letter from 
her with the cheering assurance that all was well with her up to date. 
In sul)scf|uent operaticms of like nature I have not been able to keep 
the canal patulous for any length of time. There must be a discharge 
from above to insure the perviousness of a canal. 

The Hnldinn Method of ConstrncUng on Ariifirial Vagina. — 
The method of constructing an artificial vagina which results in a 
viscus mo^it nearly approaching the normal is undoubtedly that de- 
vised by Dr. J. F. Baldwin, of Columbus, Ohio. His operation 
consists, in brief, in making an opening by blunt dissection between 
the bladder and rectum. The al)donien is then opened, and a loop 
of the ileum, or the sigmoid, is detached and drawn through the 
channel thus made. Care i* taken not to inierfore with the mesentery 
of the bowel, as this is depended upon to maintain the vitality of the 



DISEASES OF THE VAGINA. 



t21 



TSgina. The ends nf tlie intestino iilmve and below the resected 
portion ari- reunited by suture or Murpbv button. The bnwel thus 
drawn down is paeked witli gauzo, so as to distend it suffieiently, and 
attacheil to llie inurfjiu of the opening in the perineum. After a few 
week* tlie 8ej>tuni bi'twei-n tlie two \vg» of tFie bowel thus i)rouglit 
down is tut out with a elainp, and the operation thus completed. The 
author has reiwrted four eases, and a similar number cf cases have 
lioen reported l>y three other surgeons. In all, the results were 
eminently satisfactory, with no mortality. 

VAGINITIS. 

Vaginitis is an inflammation of the vagina. It occurs in two 
fiirm.« : aciit<> and chronic. 

Causes. — 15y far the larger i>roportion of the inflnmmatory affec- 
tiona of Uie vagina an* due to microbie infc<-tion. In ilie adult female 
imd including the [HTiod of spxuhI activity, the VHgina is ]irutected 
by a covering of pavement epithelium which is dense and resistant. 
This protecting cover is proof against genns under ordinary condi- 
liiins. The vagina lieing the natunil hiibitat of n variety of germs, 
and tlie female at this period of her lite lieing subjected to a variety 
of deleterious influem-es in her se.xual relations, if it were not for 
this provision vaginitis would be much more lorimion thiin at present. 
The vagina ami those portions of tlie genital tract above the vagina 
•re still further safeguarded by a germ whicli inhabit* the canal, 
which is not pathogenic, and which pr(Mluces an acid st*rction which 
is inimical to other genus. This is known as the acid-secreting genn 
of Doederlein. None of the pathogenic germs of the genital tract, 
nnlesa it \h? tlie genixK>ccus of Neisser and the gas-swreting germ of 
Welch, can thrive in the secretions of this germ, and. although the 
ragina is exposed to constant invasion nf all kinds of germs from the 
outer world, those inhabiting the canal are, as a rule, passive and 
innocuous. This, of course, presupposes an intact vagina and the 
functionally active germ of Doederlein. 

The virulence of the pathogenic germ decreases progressively 
from tlie introitus vagina', where it first meets the germ of Doederlein, 
to U>e oa cxtenmni. In the battle which ensues in its upward passage, 
the invading gertn, if it succeeds in reaching the upper portion of 
the canal, does so in such an enfeebled state that it is content to lie 
down, being divested of both procreative and pathogenic energy. It 
is claimed that the bacillus ai?rogenes capsulatus. or the gas-secreting 
gfrm, and the gonococcus are immune from the influence of the acid- 




122 



PRACTICAL GYNECOLOOY. 



secreting germ. 1 am .-kiptkal as to the immuuity of the gonoooccus, 
for, though it will apparently pass the barrier and make its way into 



thu uterine •oavity, it (ilimiM lie riTiiemncrcil that tiie active goiKx-oefua 
is selilotii fount! in the vajiinal eiuiai, ami that its entrance into tlie 
cervical canal without running the gauntlet is usually vouchsafed by 
its being deposited at the very threshold wilh thi- cjiiculnted semen. 

Simple rtiijiniti^ may arise from inechanieal injur)-, strong 
chemicals, acrid discharges, extraneous secretions (such as urine or 
feces), or any kind of irritation not dependent on pathogenic germs. 

Gonorrheal, or, as it is sometimes called, speri/ir vat/iriilis, is 
due to gonorrheal infection, and lias for its distinctive emblem the 



\ 



tTM 



Wg. 49. — GonococcuB of N. 



/ 



I micrograph hj Oramin.) 



gonoeoccus of Neisser. Directly and indirectly it is by far the most 
conimon cause of vaginitis. It is ])r(>l»abK' that the greater number 
of cases of specific vaginitis arise from the irritating cervical dis- 
charges incid<'iit to gonorrheal endometritis rather than to direct 
sjK'citic infection of the vagina. The gonocm'i'us is a surface genu 
and has little ttridcin y to invade the deeper stnictures. It, therefore, 
produces a skitniiitng inflammHtion, and is usually fouml under the 
surface epithelium. It is, Imwever, frequently as.-iociateil with other 
pathogenic germs, wlien it becomes more virulent, more penetrating, 
and more disastrous in its effects. 

Septic Vaijitiiliii is due to septic infection. The infection always 
comes from without, and is usually the result of carelessness. Opera- 
tions on and manipulations of the vagina with unclean instnniients 
or hands are prolific causes. This f<>rin of infection is both more 




DISEASES UF THE \AG1NA. 



123 



frwinenl and diuigeroiis in tlie jmerperiil stjito. The streptococci 
and ftiapiiylooocci iire the jrerinsi nio.-l fri'(|ueiitly concerned in this 
form of vaginitis. 

The climral feature:* of om; fnmi of vajjinitis do not differ mate- 
rially from tliose of another. In general, it may be said that bacterial 
vaginitis is raore virulent, more persistent, and farther reaching in 
its effect.*: the ireniis tiiuUijiIy and invade oilier orj^ans, whereas the 
simple inrtammatiou conlines itself to the area of irritation. The 
germs may, and frequently do, traverse the vagina, mount to the 
utiTiiB, and invade the Fallopian tulies, thereby leading to the meet 




Fig. 50. — Walls of Vagina, Showing Miigcularis Mucosae, etc 
(Pbotomicrograpli by Urainm.) 

i'(ii.-i-i|iienees. They invade the vulvo-vagimd duels and the 
uretlira. A urethritis ciunplicHtiiig vaginitis is strongly suggestive 
of gonorrlu'al or septic infection. A simple vaginitis sometinies 
becomes converted into a sjiecitic or septic one by the sub.«p(iuent 
implantation of germs. Sejitic vaginitis snmetiiiu-s maiiifests in 
the form of a dirty-grayish deposit on the vaginal wnll. This is 
usually spoken of as (li|ilitheritic vaginitis, hut i'< pmlinldy due to 
some other than the diphlliciitic germ, a.** the bacillus of Ixitller is 
seldom found in the detached membrane. The membrane, being an 
infiltration, instead of a surface exudation, is firmly attached to the 




124 PRACTICAL GYNECOLOGY. 

subjacent structures. Owing to the protective covering of the vagina, 
gonorrheal vaginitis cannot occur without injury to the epithelium. 
Maceration of the epithelium from superabundant or abnormal dis- 
charges is an occasional precursor. The same rule holds good in 
large measure as regards septic infection. In the extremes of life — 
in childhoo<l and old age — the epithelial covering of the vagina is 
much thinner, softer, less resistant, and consequently much more vul- 
nerable. Hence, germ infection is much more likely to occur on ex- 
posure, tliough the opportunities for infection are much less frequent 
than during the period of sexual activity. 

Aside from the local causes of vaginitis just named, there are 
certain disordered conditions of the general system that occasionally 
lead to vaginitis. Espwially does this apply to the exanthemata and 
other c<mditions of tlie system that tend to produce inflammatory 
states of the mucous and cutaneous surfaces. The pelvic congestions 
incident to pregnancy, abdominal tumors, and constipation are pre- 
disposing factors. 

Symptoms and Course. — In the acute form the disease is charac- 
terized by a sense of fullness, burning, and itching of the vagina, espe- 
cially marked at tlie vaginal orifice, and in the gonorrheal form it is 
apt to be accompanied by freqjient and painful urination. Occa- 
sionally tliere is more or less systemic disturbance in the way of 
accelerated pulse, increased temperature, irritability of the stomach, 
and disorders of the nervous system. In the chronic form there may 
be an almost total alK«ence of subjective symptoms. In the initial 
stage the parts are dry, red, and swollen. This is soon followed by 
a serous discharge, which in turn becomes punilent. It is some- 
times nuu"o-|)urulent from the admixture of secretions from the cer- 
vix or fornix vagina?. In the more virulent cases the discharge 
becomes greenish from the admixture of blood. ' It is seldom that 
the entire vaginal surface is involved, and, as a nile, especially in 
the earlier stages, the disease is confined to one or more isolated spots, 
fatches of exfoliation occur here and there, and the papilla l)ecome 
enlarged. In pregnancy and other conditions attended by excessive 
hyperemia of the canal, the papilise become very conspicuous and gran- 
ular in appearance. This constitutes the so-called (/rntuilnr vaginitis. 
Occasionally, and cspeciiilly in child ron and old people, in whom 
the epithelium is soft and thin, llie ()|)posing surfaces become agglu- 
tinated (adhesive vaginitis). In those cases the infliunmation is 
seldom diffuse, but, on the contrary, distinctly macular. 

Small accumulations of gas sometimes take place in the connect- 



126 



PRACTICAL GYNECOLOGY. 



Treatment. — For Uie acute f"iiii in tlie active stage the object 
will be to remove all sources of irritation, miiiiituin cleanliness, relieve 
local congestion, and secure rent. The patient bIiouIiI be put to bed. 
the bowels cleared and kept soluble by salines, and the vagina cleansed 
by douches of hot water, plain or me<]icated. Tlie douches may bo 
pivcn from a fountain-syringe or irrigator, and the patient should be 
recuinlient with the lii|)s somewhat elevated. The patient may, if 
necessary, administer tlie douche herself by lying crosswise the bed 



Fig. 53. — Esmarch'g Cut-off for Irrigation. 

with the hips slightly [irojeeting, her feet sujiported by chairs, and a 
rubber cloth so arranged as to carry the recurrent fluid into a re- 
ce])taele. A more cemvenicnt metluni for .self-irripition is to {)lace 
a board or frame-work r)ver the top of a batli-liib, upon which the 
patient can recline while receiving the douclie, or, still better, she may 
use a douche-pan. At lca.*t n gnllcin "f tbiid should be used on each 
occa-sion. These may be repeated iit intcrvnls of from two to six 
hours, according to the activity of the inflammatory process and the 




Fig. 54. — l)i)iirlu'imii. 



amount ami character of the discharge. A solution of common salt, 
5 to 1000. is efficacious at any stage of the trouble, and may be sub- 
stitute<l for llie plain uiiter. 

A filde later mild it.-tiingents mav be ridleil Tor; iirctiitc of lead, 
.■) to 1000; timnin or alum. 30 t<. Inoii. The strength of Ihc )L«trin- 
gent may be grndiially increa.«cd as the airute stage subsides, especially 
if it us8ume.s a tendency to chrnnicity. Tn the specific or septic fonns. 
or in the presence of germ-laden secretions, it is advisable to use anti- 



I 



,1 



L 



DISEASES OK THE VAGINA. 



127 



Septic irrigation, either aloue or combined with astringents. Those 
in most oonimon use are: bichloriil of mercury, 1 to 2000; peruian- 
ganatc of |wtawjium, 5 to 1000; carbolic acid, 20 to 1000; and boric 
acid, 30 to 1000. 

With the abatement of the acute inflammatory symptoms, tlie 
l|H'cultim niuy l)e brought into use nnii applications made directly to 
be inflamed surface. The vagina may be swabbed with a 1 to 2000 
bichlorid of mercury pohition, or a 5-per-cent. solution of carbolic 
acid. Abnide<l and ulcerated surfaces may be touched witli a r)-per- 
cent. Holution of nitrate of silver. In gonorrheal vaginitis the vagina 
may be swabbed with a 10-per-cent. solution of protargol, or it may be 
used as a douche of a strength of from 1 to 3 per cent. After douch- 
ing and swabbing, the vagina may be loosely packed with gauze or 
wo«d. This packing sliould be changed at intervals of from a few 
hours to once a day, according to the amount and character of the 




Fig. r)5. — rcmiliT-blower. 

discharge. A tliorough cleansing of the vagina sliould precede every 
packing. 

Me<licine8 are sometimes apidied in jiowder form by means of a 
powder-blower, sometimes in the form of an ointment, snmetimes 
inclosed in capsules, and Bonietimes as supposiUiries. In whatever 
form used it is essential to thoroughly cleanse and dry tht' vagina 
before each ai)pli<ation. The eftieiency of treatment will depend not 
so much on the multiplicity of rcmedios as on the proper choice and 
intelligent use of a few. 

Sexual relations should be suspended until after complete recov- 
''CTV, and all traces of the disease should be eradicated before treatment 
is concluded. Foci of infection slimild be sought out nol only in the 
vagina, but also in the uterus, urethra, and vulvo-vaginal passages. 
For quieting the patient and securing rest in the active stage of the 
ilisease. phenacetin. lodeine, or uiorpliine may be used It has been 
fashionable to nse suppositories for this purpose, hut if used at all 
they should be used with the utmost care, lest infective matter be 
carried into tlie rectum. 




128 



rRACTICAU CYXKCOLOUY. 



TUMORS OF THE VAGINA. 

Cysts of the Vagina. — \'a}iitial cysts are much more common than 
usually cuijjiosi'd, Liefause (>o oftun unrei-ognized. They wcur singly 
or in groups, and may be situated on any portion of the vajjinal wall. 
Tht'y are riuite superficial, thin walled, and filled with a clear, serous 
fluid. Occasionally the content.* are murky. They may he mucilag- 
inou.s i)T purulent in character. The cysts are seldom large, but 
sometimes attain the size of an egg or even larger. They are usually 



Fig. 58. — Cari-inonia Intrnilii-i \'iipnie. ( Plintoniierogfmpli 

U^' (jruiiiin.) 



firmly iiiiluMlded and intirnatelv adherent tn the surrounding struct 
ures, but are occafitaially polypoid. They are lined with cylindrical 
or pavement epithelium. They give rise to no symptoms except, per- 
liajis, an increa:*ed leiunrrheal dischar^'e. and when large more or loss 
obstruction t" the canal. The jniruh-nt cyst is usually painful. 
Vaginal cyst* may arise from; 1. Ocrhisittn nf the vaginal follicles 
(retention cysts). 2. From patcliis of epithelium which have been 
tuiTieil under in operations on the vagina or as the result of trauma 
(inclusion cysts). 3. From unobliterated spaces in Gaertner's duct. 



DISEASES OF THE VAGINA. 129 

Treatment. — ^They should be dissected out and the raw surfaces 
brought together by suture. When this is not practicable, a large por- 
tion of the cyst-wall may be excised, the lining membrane removed or 
destroyed by chemicals, and the cavity packed with gauze. The gauze 
should be removed and replaced from time to time until the cavity has 
heale<l. Polyjwid growths may be ligated and snipped off. 

Fibroid Orowths in the Vagina. — Fibroid and fibromyomatous 
tumors of the vagina are sometimes met with. They seldom attain 
much size, are usually soft and succulent, and in many respects re- 
semble the vaginal cyst. They should be removed and the wall 
sutured. Papillary growths should be snipped off and cauterized, and 
the vagina lightly packed until the surfaces are healed. The fibroid 
and papillary growths are about the only benign growths that are 
found in the vagina. 

Kalignant Growths of the Vagina. — As primary growths these 
are extremely rare. They partake of the same characters and present 
a symptomatology very similar to the malignant growth.'* of the vulva. 
The sarcoma, as a primary growth, is more frequently met with in this 
locality than the cancers. The posterior vaginal wall and the poste- 
rior vaginal fornix are the favorite sites for all forms. 

The diagnosis and treatment are the same as for similar growths 
elsewhere, but the opportunities for radical measures for the com- 
plete eradication of the disease are greatly abridged, as compared 
with the vulva, and are seldom successful. 



CHAPTER XIII. 

INJURIES TO THE PELVIC FLOOR— MEDIAN 
LACERATIONS. 

It is only within a comparatively recent period that the perineum, 
its nature and functions have been properly understood. As a conse- 
quence, errors in diagnosis and treatment have been painfully preva- 
lent. The old idea of a perineal body as a thick triangular plug, with 
its base extending from anus to vaginal outlet on the skin surface, and 
tapering to a pointed extremity in the recto-vaginal septum, has been 
exploded. In its stead we find only the meeting-point of some muscle- 
fibers inclosed within several layers of rather dense fascia. It was 
formerly taught that the muscle-fibers converging from the sides of 
the pelvis were inserted into the so-called perineal body, and that the 
natural and inevitable result of a rupture of this body would be the 
drawing apart and separation of the two halves, with consequent de- 
struction of the pelvic floor and prolapse of the pelvic contents. This 
view is intrinsically wrong. The pelvic floor is made up, in the main, 
of the fibers of the levator ani muscles, reinforced by the different 
layers of the fascia. The fibers of this powerful muscle pass backward 
from the pubo-ischiatic rami to the sides and posterior aspect of the 
rectum, distributing in course fibers to the perineum. Roughly speak- 
ing, it may be regarded as a sling, which, skirting the vagina, passes 
backward to infold the rectum. The effect of its contraction would be 
to lift the rectum upward and forward, which in turn closes the 
vaginal outlet by pressure from below upward. By reason of this 
pressure from below the posterior vaginal wall is closely applied to 
the anterior wall, which it supports. 

In the normal vagina in a state of rest we find no open canal, but 
a transverse slit bounded at either extremity by a vertical slit, which 
in outline, by cross-section, resembles the letter H. These vertical 
slits are caused by the apposition of the anterior and posterior vaginal 
walls, with their necessary infolding over the inflexible tissues at the 
sides of the canal. They constitute what are known as the vaginal 
sulci. They are often the seat of lacerations in childbirth, and con- 
stitute the most serious lesions of the jK-ivic floor. One of the greatest 
evils resulting from lacerations of the pelvic floor is prolapse of the 
pelvic contents: the anterior and posterior vaginal walls, including 
the bladder and rectum, and of the -uterus. 
(130) 




INJCRIE'* TO TIIK PELVIC F1-<10R— MEDIAN. 



131 



It ha« been seen that the effect of activi! conlniction of the leva- 
tor ani rnusck-s is to close the vaginal orifice by pressure from below. 
The nonrml tonicity of the muscle subserves the same purpose, and 
is the iiinst potent factor in maintaining snug apposition of the vag- 
inal walls and of giving support to the structures above. Conse- 
quently a median tear of the perineum, which in no way interferes 
irith the bulk of fibers of this powerful muscle, will not destroy the 
pelvic floor and will not remove the vaginal support, for the sling pass- 
ing behind the rectum is still intrfct and will now, as before, render 
efficient support to the pelvic contents. (Fig. 57.) True, in com- 
plete laceration of the perineum the sphincteric action of the vagina 




Fig. 67. — Median Laceration of the Perineum. Sling-like Action ol 
the I>evator Ani Maintained. 



urill have been impaired. True, tlie transversus perinei muscles, and 
Bome of the fibers of the levator ani which are inserted into the peri- 
neal raphi, will tend to draw the two halves of the perineum asunder, 
but the more powerful belt that passes outside of these fibers more 
than counterbalances their antagonism and keeps guard over the 
introitus vaginse. Far different is the effect of a laceration of the 
vaginal sulci, or of any other portion of the recto-vaginal septum 
tlian in the middle line. Here the fibers of the sling are sundered, 
and in proportion to the extent of the tear is the disability of the 
pi'Ivic floor to sustain the superincumbent weight of the pelvic con- 
tents- (Fig. 68.) 



182 



PRACTICAL r.YNECOLOiiY. 



Etiology. — Lncflrations of the pelvic floor are, in the vast major- 
ity of infitances, due to childbirth. Inordinate pains, precipitate 
labor, iinvieliling soft parts, faulty position, and tlie unskillful use 
of the obstetric forceps are all factors. Occasionally in obtse sub- 
jects the muscles will be so interlarded as to render them friable, and 
laceration will occur under what would otherwise be normal condi- 
tions. I Lave known the perineum to lay open like butter before the 
advancing head with very moderate uterine contract iono. Lacera- 
tion may occur in the delivery of a uterine fibroid. It sometinies 



Fig. 58. — Ijitcral Laceration of Peiinpuin, Sliiit,- like Action of 
Levator Ani Destroyed. 

results from external injury, as in falling on a stake or in sliding 
down an incline and coming in contact with some hard projecting 
body. The line of cleavage in lacerations of the pelvic floor may be 
in the median line or at the sides, one or both. 

Median lacerations pass in the median line through the middle 
of the perineum, and sometimes e.vtcnd well up into the vagina. 
These are the most common as well as the most harmless lacerations, 
as may be inferred from the foregoing. The lateral lacerations are 
usually confined to the sulci at the sides of the posterior vaginal wall. 
They are not infrequently associated with a median tear of the peri- 



inji;riks to thk pelvic fi-o«ir— median. 



13a 



oeum. They are the most serious of tears, because of the destruction 
of the sling-libera of the levator ani musoles, and tlie consequent loss 
of support to the vagina and pelvic organs. Such lacerations, if ex- 
tensive, are liable to be followed by cystocele, rectocelc, and prolapse 
of the uterus. 

Complete and Incomplete Lacerations. — When the laceration 
involves tlie sphincter ani, and extends into the rectum, thus convert- 
ing the two passages into one, it is said to be complete. Lacerations 
that do not involve the sphincter ani are said to be incomplete. 
Complete lacerations may extend far up the recto-vaginal septum, 
or may barely involve the anal outlet. Incomplete lacerations may 
be shallow or deep, and may even implicate some of the external 
fibers of the sphincter ani. Not infrequently they skirt around the 
anus, laying bare the sphincter-muscle without impairing its useful- 
ness. Complete rupture of the perineum, by destroying the action 
of the sphincter ani, leads to permanent incontinence of feces. This, 
unless relieved by the art of surgery, renders the subject of it most 
lamentable. Fecal matter is extruded without let or hindrance, and 
the intestinal gases are prone to escape with audible sound on the 
most inopportune occasions. Such unfortunates generally withdraw 
from society and contact with the outer world, and immure them- 
selves within the four walls of their domiciles. Fortunately, all tears 
of the sphincter are not so disastrous, and the patient retains a reason- 
able degree of control under normal conditions; but, with liquid 
stools and active peristalsis, as in diarrhea, die control ceases. 

Diagnosis. — Perineal tears should be looked for and recognized 
immediately after delivery. Digital examination should not be relied 
on, as it is inadequate and apt to be misleading. The patient should 
be placed crosswise the bed on her back with the buttocks well up to 
the edge. She should be opposite a good light. The legs being sup- 
ported and the thighs flexed on the abdomen, the physician should sep- 
arate the labia, wipe away the blood, and examine carefully the extent 
and direction of the tear. He should not only ascertain the extent 
of the tear through the perineum, but — what is far more important — ■ 

jhould follow it up into the vagina, clearing away the blood and 
sing the parts asunder with his fingers. Oftentimes he will be 

^orprised to find the vaginal tear much more extensive than he had 
anticipated and out of proportion to the external manifestations. 
The vaginal sulci on both sides should be carefully scrutinized, for 
it is here that the most damaging lesions occur. The soft and sodden 
tissues of the vagina immediately after delivery would give little evi- 



134 



PR.\CTICAI. r.Y\ErOI.()GY. 



dence to the most higlily educated touch, but to the eye, notwith- 
standing the general dark suffusion of the mucous membrane and 
lacerated Btructures, the rent is easily recognized by its bleeding sur- 
face. 

In the light of our present knowledge, the timid or careless ob- 
stetrician cannot, in such cases, take refuge behind a superficial sutur- 
ing of the external parts, for the inexorable consequences of a broken 
pelvic floor will manifest themselves ever after. In old and neglected 
cases appearances are different. The torn surfaces are contracted, 
altered in shape and position, and covered with a membrane scarcely 
distinguishable from normal mucous membrane. According to the 
depth of the tear the distance between the anus and vaginal opening 
will be shortened and the vaginal outlet will assume a more horizontal 
inclination. If the rupture be complete, the vagina and rectum will 
have a common outlet and the patient will have lost control of the 



I 




Fig. SO.— Mkthieu's NeedU-hoIder. 



bowels, in whole or in part. The tendency of the torn sphincter is 
to retract and straighten out like an unstrung bow. Thus, in time 
the sphincter is to be recognized as a slightly curved bvmdle of muscle- 
fibers on the posterior asjiect of the anus. The anterior margin of 
the anus is formed by the lower edge of the recto-vaginal septum, and 
runs in a straight line from one sphincter end to the other. It has a 
sharp, cicatricial edge, and is fringed on its under surface by the pro- 
tniding mucous membrane of the rectum. This latter is often mis- 
taken for piles. 

The degree of retraction of the sphincter is governed by the 
depth of the tear up the recto-vaginal septum. By retraction of the 
sphincter the torn edges of the septum become drawn farther and 
farther apart until they form a straight line across the front of the 
anal outlet. In shallow tears the ends of the sphincter are sometimes 
knit together by cicatricial tissue and so closely approximated that the 
patient experiences little or no inconvenience. For reparative pur- 



I 
I 



IXJl'KIKS TO THK I'KIA IC" FI.UOK— MKUIAN. 



135 



it is essential that the ends of the sphincter should be definitely 
located, that they may be brought into accurate apposition. In many 
a dimple or depression of the skin marks the site. When such 
*ifl not the case, teasing the muscle by pulling or pinching it will 
excite contractions, with consequent imlrawing of the skin at both 
extremities. The skin overlying the sphincter is thrown into radiat- 
ing folds, which afford a very reliable index of the position and length 
of the muscle. 

Treatment. — The treatment of a torn perineum and of injuries 
to the pelvic floor is exclusively surgical. Very slight tears involving 
the perineum alone may sometimes be left to Nature, but even such, 
if detected early, are all the better for being neatly closed, as they 
open an avenue for infection of the recently delivered woman. If 
allowed to heal by granulation they are prone to leave a tender cica- 
trix. With reference to time, the operations for the repair of the 



Rg. 60. — Curved Needles. 

pelvic floor are classified as immediate, intermediate, and secondary. 
The operation for the repair of the lacerated pelvic floor, especially 
the median perineal laceration, is denominated perineorrhaphy. 

Immediate Operation. — This is done within the first twenty-four 

hours after delivery. A physician who attends a case of labor is 

, grossly derelict if he fails to make a careful inspection of the pelvic 

(floor as soon after delivery of the child as consistent with the safety 

of the mother. If a laceration is found, it should receive immediate 

attention. There are several and important reasons for this, chief 

among which are: 1. The parts are in their natural relation, and, 

if properly brought together and held there by suture, union by 

first intention occurs and perfect restoration achieved. 2. Neglect 

of this precaution exposes the patient to infection through the open 

rvonnd, which if it does not result in anything more serious is liable 

to entail a protracted invalidism and consequent subinvolution of tha 

ateruB and genital tract 3. It leaves her a cripple so far as the gen- 



136 PRACTICAL OYXECOUXiY. 

ital apparatus is concerned, and ezpoeee her to the sequulsB of a dam* 
aged pelvic floor, such as prolapse of the uterus and vagina. 4. And, 
last, as the parts are benumbed from the recent impact of the child's 
head, the simpler forms of operation can be done without the use of 
an anesthetic. 

Every obstetric satchel should contain the implements for the 
repair of the pelvic floor. These are a needle-bolder, a number of 
medium sized curved needles, or, as some prefer, a needle with a 
handle, a pair of scissors, a perineal retractor, and a liberal supply 
of suture material: silk-worm gut, silk, and catgut. These should 
be sterilized before the operation and placed on a clean towel within 
convenient reach. The patient, being brought crosswise the bed and 
placed on her back, is drawn down iintil the buttocks are flush with 
the rail. The lep are flexed on the abdomen and supported by an 
assistant or some mechanical device. It goes without saying that the 
operator should have clean hands, and that the patient should be 




Fig. 61. — Author's Automatic Spring-eye Needle. 

The spring is pressed down in passing tlirough tlie tissues and rebounds when 

pressure is removed, forming a large eye for facility of threading. 

opposite a good light. It is a good plan to tampon the upper part 
of the vagina, to keep the blood from flowing over and ob«;uring the 
field of operation. Clean cloths of any kind may be used for this 
purpose. 

The prevalent practice of introducing all the sutures from the 
skin surface, while usually efficient in the minor forms of injury if 
given the proper direction and depth, is clearly inadequate for the 
more extensive lesions. It should be remembered that there are two 
surfaces concerned in the rent: the vaginal and skin surfaces. Su- 
tures introduced from the skin surface are liable to leave little pock- 
ets on the vaginal aspect, which serve as catch-basins for the secre- 
tions, with a resultant sepsis or perineal fistula. It is better, there- 
fore, is most instances to close the vaginal rent neatly, independently 
of and as a preliminary to the closure of tlie skin surface. Therefore, 
after separating the labia with two fingers of the left hand, two or 
more stitches should be passed deeply on the vaginal side, beginning 



INJIRIES TO THK PELVIC FLOOR- -MEDIAN. 



137 



near the upper angle of the rent. These stitches should be tied as they 
are introduced. This will reduce the external wound to a shallow gap, 
which may be closed by one or more stitches introduced from the skin 
'surface. The sutures should be passed deeply at intervals of from 
one-half to two-thirds of an inch, and tied with just sufficient firm- 
' nese to bring the parts into neat apposition. For the less extensive 
rtears in the median line catgut may be used. No after-treatment is 
necesBary. In the more extensive tears involving the vaginal sulci, a 
retractor should be placed under the anterior wall of the vagina to 
afford easy access to the parts. Here it may be necessary to use an 
anesthetic, especially in a neryous patient. Silk-worm gut is prefer- 
able as a suture material. The stitches should begin at tlie upper angle 
of the rent, and, instead of being passed straight across from side to 
aide, should form a succession of V's down the canal with their apices 
, dinx-ted toward the outlet. These when drawn taut and tied will 
' lift tiie pelvic floor which has sagged from loss of support from the 
sling-fibers. Each stitch may be tied aa introduced, and the sub- 



Fig. 02. — Peaslpe's Perineum Needle. 

8i.<quent steps of the operation are as described in the preceding 
section. Some operators use but one V-shaped silk-worm gut suture 
in each sulcus, which is applied at or near the middle of its length, 
and close the remaining jjortion of the rent with straight-across su- 
tures of catgut. The vaginal non-absorbable sutures may be left for 
several weeks. The bowels should be kept soluble and the catheter 
should not be used if it can be avoided. 

Complete Rupture of the Perineum. — In complete rupture of the 
perineum, a row of interrupted sutures should be passed on the rectal 
side commencing at the upper angle of the tear and extending to 
the ekin surface. Special care should be taken to secure perfect coap- 
tation of the divided ends of the sphincter-muscle. The sutures 
should be half deep in the recto-vaginal septum, and should be placed 
at intervals of about one-fifth of an inch. Catgut is preferable for 
this locality, as it avoids the necessity of their subsequent removal. 
One or two reinforcing sutures of silk-worm gut are necessary to 
secure firm union of the sphincter. These are introduced on the skin 




138 



PRACTlfAI- 0YNK<01.0<;Y. 



surface just outside the sphincter end, a little back of the torn end, 
and, describing a half-circle through the septum, emerge on the skin 
surface of the other side opposite their point of entrance. Interrupted 
sutures are next placed on the vaginal side, beginning at the upper 
angle of the rent, and tying each suture as it is placed. (Fig. 63.) 
Finally, the shallow gap on the skin surface is closed. (Fig. 64.) 



Fig. 



63. — Median Lncoration of the Perineum, K.vtending up and 
Involving the Seplum. Rectal and Vaginal Sutures Placed. 
(Firat and Second Steps.) 



For the vaginal and skin surfaces, silk-worm gut, or this supple- 
mented by catgut, should be used. The bowels should be moved on 
the third day, and daily or every second day thereafter. The ex- 
ternal sutures should be removed on the eighth day, and the others 
in from two to three weeks. 

Intermediate Operation. — This operation, though not often re- 
sorted to, gives, in the main, very satisfactory results. It embraces 





Fig. 64. — Median Conipk-tc Laceration of tlie Perineum. Rectal and 

Vaginal Sutures Tied, and Skin Sutures Placed. 

(Third and Fourth Steps.) 



opposed surfaces at the angles and bottom of the wound, and partly 
from contraction incident to the process of cicatrization. The parta 
should be thoroughly scraped with a curette or sharp scalpel, and the 
cicatrizing margins trimmed away with scissors. With the removal of 
the binding surface of granulations and cicatrizing tissues, the wound 



iNji uiKs TO rut; I'Klvu- vukh: mkdi.w. 



141 



brane. In order to restore tliese to their natural conrlition, it will be 
ncceesary to dissect ofT tlie adventitious covering and bring together 
the opposing raw surfaces. Various espedienta have been resorted 
to for effecting this result, but the two now in vogue are by removing 




Fig. 86.— Parkinson's Ether Inhaler. 

the mucous covering with knife or scissors, thereby sacrificing tissue, 
or by what is known as the flap-splitting operation, in which no 
tissue is sacrificed. In this latter the raucous membrane is dissected 
from the underlying structures by insinuating a knife or scissors 




Fig. 67. — Esniarch's Chloroform Inhaler. 

under it until a sufficient area has been denuded, when it is lifted up 
as a curtain while the raw surfaces beneath it are brought tiagether 
by suture. 

Of the extent and configuration of the freshened surfaces for the 
repair of the pelvic floor there is ample variety, for almost every 



J. 



142 



PRACTllAI. (iVN'ECOI.tX;Y. 



operator of note has his peculiar yiews on the subject. As the es- 
sential object of the operation is to restore as near as may be the 
pelvic floor to its primitive condition, the freshened surfaces should 
be those that have sustained injury. The vast majority of tears are in 
the median line, increasing in depth from their starting-point up in 
the vagina to their exit on the perineum. Hence, if spread out they 
would be triangular in outline, with the base at the perineum. Those 
require a triangular denudation, with the base at the perineum and 




Fig. C8. — Lenniker's Leg-holder. 

the apex on the middle line of the posterior vaginal wall. In other 
instances the tear has branched off into the sulci on one or both 
sides of the vagina. Here it will be necessary to denude a triangle 
for either sulcus, and a broad area at the vaginal outlet upon which 
these triangles are set and into which they are merged. In other 
words, there are two triangles to denude, one for either sulcus; but, 
as they overlap each other near the outlet, the outlines of the denuded 
surface resemble an inverted W. Inasmuch aa the median incom- 



L 



Fig. 80. — Tenaculum. 



plete tear of the perineum is fraught with no evil consequences, it 
is seldom subjected to the secondary operation for repair. In case 
operation is desired, the Hcgar operation is best adapted to such. 
(Fig. 65.) 

In secondary operations for laceration of the perineum, as ako 
the intermediate operations, the patient will require an anesthetic 
For this purpose ether or chloroform may be used, though my per- 
sonal preference is for ether. Anesthesia is facilitated by specially 
devised inhalers. These operations should always be performed ou 



IXJIRIES TO THE PELVIC F1.(X)U— MEDIAN. 



143 



a table, the patient being placed in the dorsal position opposite a good 
light with the perineum flush with the end of the table. The legs 
should be flexed and somewhat separated and held by assistants or 
leg-holders. As a preliminary the bladder and bowels should be 
emptied and the field of operation rendered aseptic by cleansing. The 
instruments needed will be several tenacula, scissors, needles, needle- 
holder, and suture material. Besides these there should be an irri- 
gator and sponges. There should also be some device for carrying 
off the waste fluid, such as a Kelly pad. 

Secondary Operation for Median Complete Laceration of the 
Perineum. — The first step in the operation is to locate the ends of 
the retracted sphincter ani muscle, and to lay them bare by lifting 
up and clipping away the overlying tissue. Next, the sharp cicatricial 
edge of the recto- vaginal septum, which here forms the anterior border 
of the anal outlet, is trimmed away from one side to the other. Care 
must be taken not to woxmd the healthy mucous membrane of the 



r 




^ 



Fig. 70. — ^Emmet's Scissors, 

rectum, as it is apt to bleed persistently. The septum should be 
beveled on the vaginal aspect, to increase the area of freshened tissue 
for coaptation. The next step is to denude a triangular surface on 
either side, extending from the sphincter to the inferior caruncle on 
the skin border and thence in a direction upward and inward to the 
apex of the septal tear in the vagina. The denudation should extend 
above the upper angle of tlie tear at least a third of an inch, and an 
equal margin of freshened surface should skirt its lateral borders. 

The first suture is introduced on the skin surface somewhat inside 
of and back of the end of the sphincter-muscle, and carried upward 
through the septum to the upper angle of the denuded surface in the 
vagina, where it emerges. The needle is reintroduced at its point of 
emergence, and passing through the septum downward and outward 
comes out on the skin surface under the other end of the sphincter at 
a point corresponding to that of its entrance. A second suture is 
placed just outside of this nearer the end of the sphincter and follows 




1-14 



PR.\CT1CAL l5YNKa)l,(KJY. 



a course parallel to the first, but on a higher level. Not infrequently 
the needle may be passed the full length of the circuit without being 
withdrawTi. It is a matter of little importance whether the succeed- 
ing sutures are passed from the skin surface or from both vaginal and 
skin surfaces just so that nice coaptation of the denuded surfaces is 
obtained. Special care should be taken to secure coaptation of tlie 
ends of the sphincter-muscle, for on this hinges the success or failure 
of the operation. 



Fig. 71— Kelly's Pad. 



Laceration Extending up the Recto-vaginal Septum. — Extensive 
tears of the recto-vaginal septum demand separate attention before the 
sphincter can be repaired. Here it will be necessary to denude both 
margins of the tear from the vaginal side, seeing to it that a sufficient 
breadth of fre.<lioned surface is secured on both sides tn insure firm 
union. The denudation must slant down to, but not include, the rec- 
tal mucous membrane, lest troublesome hemorrhage result. Tlie su- 
tures may be introduced from the vaginal side, commencing a little 
above the upper angle of the tear and proceeding downward to within 
a short distance of the sphincter. They should dip down to, but not 



UfjrRIKS TO Tin: I'ICIA IC KI.IMIU -MKIll.W. 



145 



include, the mucous membrane of the rectum, and be placed at inter- 
»alfl of one-fifth of an inch. Tlic better plan is to use a series of lialf- 
deep interrupted catgut snturcB on tlie rectal Ride inchuliug the 
sphincter (Fig, fiS), followed by a line of silk-worm gut sutures on 
the vaginal side, then repair the sitin surface in the usual way. 
(Fig. 64.) A silk-wonn gut suture should reinforce those of the 
sphincter. 

Partial rupture of the sphincter-muscle, whereby its action is 
weakened, but not entirely destroyed, is evidenced by an inability to 
control liquid feces. Inspection will reveal the usual signs of a broken 
and retracted sphincter external to the thin circle of sphincter-fibers 
which form the anal ring. Here it wi 1 be necessary to locate the ends 
of the broken fibers, denude, and bring thera together as in tlie case 
of complete rupture. 

The Rinline Operation. — Dr. C. E. Ristine, of Knoxville, Tenn- 
essee, has devised an operation for complete laceration of the perineum 
which has the advantage of converting the recttnn into a seamless 
tube, and thus obviating the possibility of fistulous tracts and greatly 
diminishing the risks of infection of the wound surfaces. His tech- 
nique is as follows: Dissect a flap from the vaginal nmcosa long 
enough to extend from tlie apex of the rectal tear to below the 
sphincter ani when turned into the rectum, and wide enough to leave 
a denuded surface on the vaginal side equal to the extent of the 
laceration. This flap is dissected from tlae [leriphery of the previously 
outlined or predetermined area (see Plate VI, Fig. 1) to (he margin 
of the rectal tear, whore it is left attached (hingi'd, as it were). The 
dissection should extend far enough down along the anal margin to 
uncover the ends of the sphincter ani muscle. This flap should be 
inverted into the rectum and a forceps attached to its apex, so that 
it may protrude from the anus when the ends of the sphincter are 
approximated by sutures, which are introduced in the usual way. 
One of these sutures should pa.=s through this flap to keep it from 
retracting. Tlie complete laceration is now converted into an incom- 
plete one .and is closed as in the ordinary Ilegar operation. (See 
Plate VI, Fig. 2.) 





CHAPTER XIV. 

INJURIES TO THE PELVIC FLOOR— LATERAL 
LACERATIONS; RESULTS. 

LATERAL LACERATIONS OF THE PELVIC FLOOR. 

Here the laceration follows the line of the vaginal sulci. It 
usually involves both sides, but not equally. For reasons already 
cited (the position of the child's head and the direction of the ex- 
pelling force) the left side usually suffers most. When the occiput 
impinges on the right side of the pelvis the corresponding sulcus is 
more deeply lacerated. The sphincter ani often escapes injury in this 
form of laceration, for the reason that the tear extends along the sides 
of the rectum. The skin, however, is frequently torn in the median 
line, because of the convergence of the sulci at the vaginal orifice, and 
this may extend into the sphincter. As a rule, however, it stops short 
of this or passes to one side of the sphincter on account of the loss of 
support from the torn sulci above. In other words, there is less resist- 
ance at the sides where the supporting tissues have been broken down 
than is offered by the ring of intact muscle-fibers which constitute 
the sphincter. In this, the most serious of all tears of the pelvic floor 
so far as the ulterior results are concerned, the supporting power of the 
pelvic floor is practically destroyed. Should the laceration be limited 
to one side the effect is not so general, and the pelvic soft structures 
may still retain a very considerable degree of retentive power. The 
parts usually involved in the laceration are the levator ani, sphincter 
vaginas, and transversus perinei muscles and the pelvic fascia. In 
time the mucous membrane and skin become bridged over and healed, 
thus obliterating the superficial indications of the tear. Nevertheless, 
through retraction of the muscles and fascia a gap is left on one or 
both sides of the pelvic floor which, though not obvious to the eye, 
may be easily recognized by the effects. 

Under normal conditions there is an all-pervading evidence of 
muscle tonicity and firm coaptation of the structures of the pelvic 
floor and the outlets thereto: the anus and vagina. The anal cleft 
is deep and the anus retired, being drawn upward and forward. The 
distance from the anus to the fourchette or from the anus to the 
meatus is comparatively short. Tiie perineum is slightly convex. By 
separating the labia, the anterior and posterior vaginal walls are 



IX.lI'niKS TO TIIK PKUVIC I'LCHlR— I,ATKt{ AI,. 



147 



found to be in contact If the rulva is pricked by a needle the anus 
is drawn upward and forward, the porineum shortened, and the 
Taginal outlet still more firmly closed. If the woman strain or bear 
down, the vaginal orifice closes firmly and the perineum bulges; tliere 
is no rolling out of the vaginal walls. A finger introduced in the 
vagina and pressed in different directions, backward and fonvard, 
encounters firm resistance as of au encirtliug band immediately within 



Kig. 72.— ReluN 



urn, the Result of Lateral Lacerationa of 
the Perineunx. 



the ostium vaginse. All this indicates the integrity and unimpaired 
tonicity of the muscular structures. 

Belazed Ferineom. — Compare the above with this and mark the 
difference between the normal vaginal outlet and the relaxed out- 
let which is found in connection with the lateral laceration of the 
pelvic floor. Here the cleft of the buttocks is shallow, flattened, 
and broad. The anus drops backward, is pouting and relaxed. The 
distance between the fourchette and the anus is increased, often- 




148 



PRAcncAT, nvxrcoLOOv. 



times doubled. The skin perineum may be intact or torn. When 

not torn it is pretematurally long, and is apt to fall in wrinkles 
about the vaginal orifice. The vaginal orifice is loose and gaping. 
It baa been compared by Emmet to the mouth of a bag without 
its draw-strings. On separating the labia the loose and flabby walls 
of the vagina protrude into the opening. If the patient be directed 
to bear down, the vaginal walls roll out, and, if a finger be placed 
on the cervLx, that too will be found to descend in the axis of the 
vagina. By seizing the perineum between the thumb and finger 
of both bands it may be drawn up over the vaginal outlet, even at 
times as far as the clitoris. (Fig. 72.) 

With the patient in the left lateral position, if the right buttocks 
be lifted up, the air rushes in with an audible sound, the flabby walls 
are forced asunder, and a largo, la.x-walled opening appears in the 
pelvic floor. If the finger be pressed into the vaginal sulcus, it will 
meet with little resistance and drop into a groove between the rectum 
and pelvic wall. This indicates the rent in the levator ani muscle, 
and is the essential feature of the lesion. When one side only of the 
levator ani has been torn, the contrast between the two sides will be 
very obvious. In highly sensitive patients with active reflexes, the 
degree and character of the injury may not be made manifest witliout 
the aid of an anesthetic, as the imbroken fibers may by increased 
energy supply the defect occasioned by the broken ones. The hymen 
is often less injured in the class of cases under consideration than in 
normal labor. The most aggravated cases of relaxed vaginal outlet are 
generally the result of repeated childbirth, each successive birth add- 
ing to the sum of pelvic injury. 

Operation. — For the repair of the injury just described the 
Emmet operation is not only the most rational, but from a practical 
standpoint meets the requirements better than any other devised. 
The object here is to diminish the vaginal outlet, give to it its natural 
direction, and restore its proper tone. This can only be done by ex- 
posing tlie torn fibers in the vaginal sulci and reuniting them by 
suture. The rent in the pelvic fascia will be closed at the same time. 
To accomplish this a broad base of denudation an inch or more in 
width, and extending from the caruncle on one side to that of the 
other, is surmounted by two triangles set side by side and extending up 
the vaginal sulci. The general effect is as seen in Fig. 73. To deter- 
mine the extent of this denudation more definitely, a point is selected 
on either side of the vaginal orifice at the base of the hymen, which 
when drawn together by tenacula will rt.«tore the orifice to its normal 



I 



I 



I 



].',() 



PRv\tTirAI. O^TCECOLOfiY. 



By drawing the rectocele to one side and making traction on one of 
the tenacula in the opposite direction, a triang^ular space will bo ex- 
posed with its apes looking upward into the vagina. This space 
covers the vaginal sulcus of that side and indicates the area of denuda- 
tion. The apex of the triangle is usually an inch or more fartiier 
up the vagina than the point where the middle tenaculum is inserted. 
By pulling the rectocele in the other direction the other triangle is 
exposed. 

To insure nice coaptation and perfect outline it is better to marK 
out the area to be denuded with a sharp knife. Commencing at the 
tenaculum on one side just inside the hymen, an incision is carried 
to the tenaculum on the other side along the line of junction of tlie 
skin and mucous membrane. Tlien, by exposing one of the triangles 
by drawing aside the rectocele, the knife is carriod upward along the 
outer side of the triangle to its apex, then downward along the inner 
side to the middle tenaculum. The other triangle is exposed and 
outlined in the same manner, giving the general elTect of two triangles 
sot upon a broad base. This base in itself represents a truncated 
triangle. 

It matters little how the denudation is efToctod just so that no 
islands of epithelial clad surface arc left in the area of denudation. 
For the beginner, it is better to commence at the bottom and work 
upward, thereby avoiding the flow of blood over the field of operation 
and the obscuration incident thereto. It is sometimes quite difficult 
to distinguish the denuded from the undenuded surfaces; conse- 
quently it is safer to pursue some methodical course in freshening 
the surfaces. The mucous membrane is removed in strips. Being 
caught up by a tenaculum or tissue forceps, it is cut away with 
scissors. Expert operators will frequently remove the entire surface 
in one continuous strip as one would peel an apple. The hemorrhage, 
which is usually quite free, either ceases spontaneously or is easily 
controlled by the suturing which follows. Arterial bleeding should 
be controlled by fo re i pressure, or, if persistent, by fine catgut liga- 
tures. 

Sutures. — The method of introducing the sutures is no less im- 
portant than that of denudation. There are three cardinal sutures 
upon which will depend the efficiency of the operation, and to which 
all other sutures are subsidiary: one for each sulcus and the crown, 
or gathering, suture at the vaginal orifice. These should be of silk- 
worm gut. If, as is generally the case, the left sulcus is to be sutured 
first, a silk-worm gut suture is passed at a point somewhat below the 



I 



I 





toward the vaginal outlet. The needle is entered on the mucous sur- 
face near the lateral wall of the vagina, and is given a direction down- 
ward, emerging at the bottom of the sulcus nearer the operator than 
at its point of entrance. It is re-entered at or near the same point, 
and passing upward emerges on tlie mucoua membrane of the central 





152 



PRAOTiPAL r.Y>rEroT.ooy. 



nndenuded tongiie at a point on a line with that of its original en- 
trance. Tlie object of this suture is twofold : to close in the denuded 
area, thcrohy brin;;iiig tlie torn musciilar lihei-s together, and to lift 
up tlie pelvic floor liy virtue of the V-shaped loop which einbracea tlie 
sagging muscle-fibers at a lower level than if passed directly from 
side to side. This suture is tied imincdiatelj'. This will leave a 
gapping elliptical space above, which may be closed by straight-across 
catgut sutures placed at sufficdent depth to bring the underlying tis- 
sues into nice apposition. These latter sutures can be passed more 
conveniently in order from below upward. 

By making traction on the silk-worm gut suture the part imme- 
diately above it can be brought within easy reach, and the first catgut 
suture introduced and tied. Now, by using this as a tractor, the suc- 
ceeding suture is placed and tied, and so on to the end. The opposite 
sulcus is closed in the same way, witli the exception tliat the needle 
is, or may be, introduced from the median, instead of the outer aspect 
of the denuded area. A few additional sutures may be needed to 
check bleeding. When extensive denudation of the sulci has been 
practiced, an additional catgut suture may be required below the silk- 
worm gut suture. 

The crown suture of silk-worm gut is passed from the outer 
aspect of the upper angle on the side under the raw surface to the 
mucous membrane of the vagina opposite, across to the central un- 
denuded tongue, thence outward in inverse order to the point on the 
opposite side corresponding to its point of entrance. (Fig. 74.) 
After tying this suture and placing another silk-worm gut suture in 
the middle of the wound on the skin surface, a few additional catgut 
sutures to insure nice coaptation completes the operation. The ex- 
ternal, non-absorbable sutures are to be removed in from eight to 
ten days, and others in two or throe weeks. The bowels should be 
kept soluble, and the patieut confined to her bed for at least two 
weeks. 



CONCEALED LACERATION OF THE SULCL 



In that class of cases in which the deeper structures of the suTci 
have been lacerated without injury to the skin or mucous membrane 
repair is as imperative aa in the more common form, where the tegn- 
mentary structures are involved. Here it will be necessary to expose 
the muscle-fibers by removal of the mucous membrane, as described 
above, after which the sutures should be applied as tliere directed. 



I 
I 



I 



J^^^ 




IXJLKIKS TO THK I'EIA IC J'J.OOR— LATKRAh 



153 



The Flap-splitting Operation. — This operation, while neither so 
ientific nor thorough as the Emmet operation, is, nevertheless, very 
efficient; it is easily and quickly executed and extensively practiced. 
It consistB in dissecting the mucous membrane of the vagina from 
the underlying structures, lifting it up as a curtain, and uniting the 
muscles and fascia beneath it. As originally practiced by Tait, it 
was quite superficial, but, as now practiced by the majority of oper- 
ators, it vies with the paring operation in the extent of denudation 
and in the area of muscle and fascia which are brought into apposi- 
tion. The only essential difference between this and the paring 
operation lies in tlie fact that in the latter the mucosa is pared away, 
whereas in this it is merely loosened from its attachment and lifted 
up while the muscles are united by suture. In this way there is not 
necessarily any loss of tissue, though many operators are in the habit 
of excising the redundant mucosa. In performing the operation it 




Fig. 75. — Knee Sciisors for Flap-splitting Perineorrhaphy. 



is not only necessary that the base line of incision (that toward tlie 
outlet) should be indicated by landmarks, but that the tissues should 
be put upon the stretch to facilitate dissection. 

Two tenacula are placed on opposite sides of the vaginal orifice 
just above the orifices of tlie vulvo-vaginal glands (near the inferior 
caruncles), and a third is hooked into tlie mucous membrane at its 
junction with the skin in the median line of the posterior vaginal 
wall. The parts are put upon the stretch, and with a pair of sharp- 
pointed knee scissors the mucous membrane is snipped immediately 
under the middle tenaculum. The sharp-pointed scissors are now 
pushed up between the rectum and vagina for a distance of an inch 
or an inch and a half, tlie blades separated, and forcibly withdrawn. 
The scissors are now run right and left along the muco-cutaneous line 
as far up on the sides as the tenacula, and the curtain of mucous 
membrane lifted up. A few snips by the scissors completes the 



dissection. (Fig. 76.) 




ir.4 



PnACTlCAI, fiYXETOLfKn 



While the base line of the dissection follows, for the most part, 
the muco-rutaneouB junction, it is iiip ortiint to renieinbor that it 
must turiiiinate inside of or on a higlar level in the vagina than the 
orifices of the vulvo-vaginal glands; otherwise they will be included 
in tlie denuded area, with most unpleasant results. Should their ori- 
fices be occluded, a retention cyst will ensue; othei-^-ise an irritable 
tidtulous opening, or practical failure of the operation through non- 




Fig. 7«.— PerineorrTiapliy. fDnp OperoMon First Step.) 

nnion by reason of the extravasated secretions between the dtnuided 
surfaces. The tenacula are now rcadjusteil, two being placed on thoj 
mucous niembnine above and two on the skin margin below. Thcael 
are, respectively, placed midway between the median line and the 
e.vtremities of the incision for either side. These, when pulled in 
opposite directions, change the contour of the wound into a rec- 
tangular oblong. 

While the mucous membrane is held up, a series of silkworm gut 





IXJl RIKS TU THE PELVIC FLOOR— LATERAL. 



155 



HHMtures are introduced to bring tiic opposing niUBcuiar (Surfaces to- 
f gather. The first suliirc is enteretl on the skin surface near the lower 
angle of the wouiiil. jinHSfs tlirough the muscle on timt siile, emerges 
near the bottom of the wound, crossed over to tlie muscle on the 
opposite side, and jiassing through it emerges on I in- skin surface at 




Fig. 77. — PoriinHirrlinpliy. (Flap Operation. Second Step.) 

a point opposite that of its entrance. Other sutures are introduco<i 
at intiTvuls of half an inch unlil tlie upper limit of denuilation has 
been reiiehed. These are tied in the order in which they were intro- 
duced. (Fig. 77.) A flap-pplitting Kmim-t ii|)eration may be made 
bv dissectiug a little farther up into the sulci, cutting away the flaps 
to i-orrespond with the Hinmct denudation, and introducing tiie 
iutures as in that operation. 



156 



PRACTICAL OYNECOUKJY. 



The redundant mucous membrane, which at first makes a bulky 
mass on the posterior vaginal wall, gradually undergoes retraction 
until in many instances it ceases to give annoyance. Where it is 
desirable to remove it, it may be done by catching it up in fold by 
long-jawed forceps and cutting away all that portion projecting from 
the forceps. This will be in the shape of a triangle, and may be taken 
from the median line or from the region of the sulci, as seems best. 
The edges are united by fine catgut. The si Ik- worm gut sutures may 
be allowed to remain for two or tliroe weeks. 

Where the sphincter is torn, tlie ends of the muscle are exposed 
by an incision extending from the main incision diagonally down- 
ward and outward. The first suture is passed so as to bring tlie two 
ends of the sphincter together, and this is reinforced by a second just 
outside of it. The other sutures are placed as described above. 
Should the recto-vaginal septum be torn, it must be sutured on the 
rectal side down to the sphincter. 

RESULTS OF LACERATION OF THE PELVIC FLOOR. 

The most constant and noteworthy of the results following lacer- 
ations of the pelvic floor are subinvolution of the vagina, prolapse 
of the vaginal walls and uterus, cystocele, and rectocele. These are, 
for the most part, confined to tlie lacerations involving the vaginal 
Bnld. 

SUBINVOLUTION OF THE VAGINA. 

The vagina, in common with other parts of the genital tract, 
undergoes great changes in pregnancy whereby it is increased in vol- 
ume, capacity, and capability of distension. After parturition it 
shares in the general retrogressive changes by which it is, in large 
measure, restored to something like its former dimensions. This 
process, which is known as involution, is sometimes interfered with 
by conditions of the general system, and by local lesions, such as are 
under consideration. The result is that the vaginal walls remain 
thick and heavy, soft and succulent, and oftentimes thrown into folds. 
This constitutes subinvolution. This condition may be ascribed to a 
persistent engorgement of the vaginnl ves.sels. This engorgement, in 
its turn, is due to want of support of the vaginal vessels on account 
of the broken fibers and fascia of the pelvic floor. Defective in- 
nervation also plays a role in the production of this condition, and is 
traceable to the same cause. 




INJIRIKS TO TlIK I'KIAIC KI-OOR— LATKR.VL. irj 

Repair of the pelvic floor usually restores the normal eqiulibrium 
of the circulation and completes the process of involution. Where 
such a result does not follow, it may be necessary to remove redundant 
tissue from the anterior vaginal wall, and close the gap by suture. 

PROLAPSE OF THE VAGINAL WALL. 

It is but a short step from the condition just described to that 
of settling, or prolapse, of the vaginal wall. This may atTect either or 
Ik)U» walls of the vagina, and may represent any degree from a barely 
appreciable corrugation above the ostium vagina; to that in which 
the vaginal walls crowd through the same and appear as a soft, 
tumorous mass at the vulvar cleft. This condition is frequently 
aceompunied by a descent of the bladder and rectum, although it may 
occur independently of either. By introducing a sound into the blad- 
der and a finger in the rectum it can be determined whether or not 
these organs are implicated in the descent. The treatment is to 
restore the pelvic floor, supplemented, if need be, by anterior col- 
porrhaphy. 

CYSTOCELE. 

Cystocele ie a prolapse of the posterior wall of the bladder, push- 
ing before it the anterior vaginal wall. The appearance is identical 
with tliat of prolapse of the anterior vaginiil wall. A soft, tumorous 
mass appears at the ostium vaginse or protrudes from it. Occasion- 
ally it will only be manifest when the patient is standing or under 
physical exertion. By having the patient bear down it will be ex- 
truded and plainly visible. (Fig. 78.) To differentiate it from pro- 
lapse of the vagina — pure and simple — or from a vaginal cyst, a 
sound should be introduced into the bladder and its beak directed 
downward and outward. In case of cystocele the beak of the in- 
strument will be plainly felt from the vaginal side, with only the 
normal thickness of the intervening walls between. It must be re- 
membered that the bladder-wall can be easily depressed, and there- 
fore no pressure should be exercised on the sound. A more certain 
method is to expose the cystocele with the patient on her back, and 
fill the bladder with a normal salt solution. An obvious swelling 
■nd distension of the sac make the diagnosis clear. 

The subjective symptoms are a feeling of weight and fullness at 
the ostium vaginie, with more or less bearing down. There is also 
8 sensation as though the pelvic contents were escaping. Dysuria is 
a common accompaniment In many instances the patient is annoyed 




158 



PRACTICAL (;YNECOLOr.Y. 



with a Bense of incomplete urination, which arises from the fact that 
the urine occupying the vesical pouch is not expelled. This in time 
undergoes animoniacal decomposition, irritates the bladder, and oc- 
casionally leads to cystitis. JIany cases of irritable bladder are due 
to this cause. Some patients leam to relieve themselves and obviate 



I 




Fig. 78. — Cystocele and Rfrlocele. 

this unpleasant feature of the trouble by holding up the cystocele with 
the fingers during the act of urination. 

Treatment. — As the trouble originates in the absence of the nor- 
mal support of the pelvic floor, the first and most essential factor in 
the treatment is to repair the same. With the pelvic floor restored 



i 



INJVRIES TO THE t'ELVIC KUK)U— LATKIIAL. 



150 



and the bladder sustained by its equable, upward pressure, the ma- 
jority of cases will need nothing further. If, liowever, the pouch be 
very large and protuberant, the redundancy may be corrected by ex- 
cising a sufficient area of the vaginal wall over the cystocele and 
uniting the edges by suture. Under a false impression as to the 
necessity and effectivenefs of sustaining the bladder by retrenching 
the anterior vaginal wall, a great variety of methods has been de- 
vised. Unsupported by a good pelvic floor they all fail alike, and a 
few months finds the patient in the same condition as before the 
operation. It matters little, tlierefore, what nu'tliod is used, as it 

is a tempornry expedient at 
best. Two methods suggest 
themselves because of their 
simplicity and ease of execu- 
tion. These are, respectively, 
the oval denudation with sut- 
ure and the Stoltz method. 

Oval Denudation. — In 
this an oval area is denuded 
over the site of the cystocele, 
of sufficient size to emhrncp 
the redunilunt tissue. The 
long axis of this oval corres- 
puiuls with the long axis of 
the va>;inal canal. Inter- 
rupted sutures are passed from 
side to side undor the deniiiied 
surface, and while the cysto- 
cele is pushed in toward the 
bladder along the middle line 
the sutures are secured. (Fig. 79.) This, for the time being, obliter- 
atee tlie vaginal pouch and throws it into the bladder. 

SioUz's Method. — In this a circular area is denuded over the site 
of the cystocele, which is surrounded by a single purse-string suture 
of strong silk. Tins is tightened and tied after the cystocele has been 
inverted and puslied in toward the bladilcr. (Fig. 80.) These 
methods are subsidiary to repair of the i)elvic floor, -and absolutely 
worthless witliout it. In these plastic operations the anterior col- 
porrhaphy should precede the work on the posterior vaginal wall. 

Gaffe's Operation for Cystocele. — In this operation a transverse 
incision is made in front of the cervix, as in vaginal hysterectomy. 




— Ope'ation for Cystoce'e liy 
Oval Deiiiida iuu. 




160 



PUACTICAL GYNECOIXXJY. 



From the center of this a second incision is made at right nnglca to it 
along the entire length of the anterior vaginal wall. These incisions 
go through the fascia down to the hladdcr wall. After a free dissec- 
tion of tlie entire base and sides of Uiu bladder from the fascia, the 
vesico-uterine pouch is entered, and the peritoneum torn across the 
face of the uterus and well out on to the face of the broad ligaments. 
To correct the cystoccie, the bladder is rotated on its transverse diam- 
eter and sutured as follows: A point is selected in the median line of 
the base of the bladdtT wliicli, when carried up to the torn edge of the 
peritoneum on the niirldle, an- 
terior surface of the uterus, 
will take up tlie filack in the 
base of tlie bladder. Through 
this point a chroraicized cat- 
gut suture No. 2 is passed, and 
carried also through the se- 
lected point on the anterior 
surface of the uterus. This 
suture ia left long and not 
tied. Two points are then 
selected, one at either side, 
on a transverse line with 
tlie first and about equally dis- 
tant. Through these, .similar 
sutures are passed and carried 
through a point on the peri- 
toneal surface of either broad 
liguincnt, sufficiently wide at 
the middle line to take in all 
the slack in the base of the 
bladder from side to s'de. These sutures are also left long. The 
tliree sutures are then tied successively, beginning with the middle 
one. The effect of this is to stretch the base of the bladder taut and 
smooth in every direction. The redundant fascia and vaginal mucous 
membrane are then trimmed ofT sufficiently to make them fit the base 
of the bladder snugly, and arc stitched with chromic gut. 

WatJiins's Operation. — This operation is specially adapted to 
casea of extensive cystocele and uterine prolapse in women who have 
passed the menopause or who have been remlered sterile by operation. 
The object is to bring the uterus down through the anterior vaginal 
cnl de sac and to pocket it between the anterior vaginal wall and 




Fig. 80.— 8toltz'8 Operation fur 
Cystooele. 





Showing the Methud of DM^rctinj^ the Vagina frum iIil- Bladder. 




LATE XI. 




SagittttI Section, Showing Rvsuita of l>ii«ration. 



INJURIES Td THK PKLVIC FLOOR— LATKRAL. 



161 



bladder. In lliis wav it wrvcs tlie double purpose of supporting the 
cystocele and preventing di-Hirnt of tlie utenin. 

Tlir jiutietit beiiifi piiioed in llie liliiotoriiy jiosition, tlic cervix 
in grasped witli n volscllu. and a crewentie ineision nuide anteriorly 
at thtt cervicovaginnl junetion. A scLond incision is carried from this 
along the metliiin line of the nnterinr vnjrinal wall to witliin an inch 
or less of the meatus urimiriiis. ( I'late \'ll.) This incision ghoiild 
be carrict! down to, but not injure, tlie muscular wall of tlie bladder. 
The i>liidder is next separated from the uterus by a finger covered with 
gauze and the jieritoneuni perfoiated, either by thnisling a linger 
tlirough it or by snipping with the scissors. Tliis opening should be 
etreti-hed dufliciently to permit the delivery of the uterus through it. 
The firm attiuliment of the uterus to the bladder along il» median 
line makes it safer in many cases to liberate the sides first. The 
anterior vaginal wall is now separated from the hladiter by bhmi dis- 
section, first on one side of the median ineisiou and tin'u on the other. 
This dissection is facilitateil by grasping the edgi- of the iuiisinn with 
a long-handled fonvps aiul )iusliiug nir tlie bluddiT liy jiiuize pressure. 
(Plate \'1I1.) These vaginal tbips slmuld he suHieieiiHy large to 
cover the uterus after it is brou<;iil info the vngina. The uterus is 
now delivered into the vagina and covered with the flaps. Two or 
three stitches at intervals of an inch or nuire, passed through the edges 
of the flaps and underlying uterus, secure the latter in place. ( Plate 
IX.) The uterus should not be drawn down so far as to interfere 
witli urination by pressure on the urethra, though it should be suffi- 
ciently low to give support to the cyetoeele. .\ continuous catgut 
suture along the line of incision completes the opi'ration. (Plate X.) 
The after-treatment is such as i* usual for vaginal operations. 
(Plate XI.) 

Thi' Author's Ct/storeln Operation. — Anyone who has had experi- 
ence with the old-tiuie denudiilion operations knows how utterly 
unstable an<l useless they are, luid a^iyone wlio has witne.s.-ed or done 
the radical ojwrations fif Watkins or Goffe cannot luit he made sensible 
of the formidable amount of dissection re(piircd in those ojierations. 
They are, however, thoroughly satisfaitory when completed, and, as I 
believe, justifialile in the worst forms of cystocele, especially if asso- 
ciated with marked descensus of the uterus. Noble's operation, while 
apparently tiie most simple of all, is. according to my experience, 
more difficult to perfonu than the operation to he ilescriU'd, in that it 
requires a more extensive dissection of the vaginal wall from the 





PllACnCAL OVNETOUXiY. 



d 



bladder at a point wlierc such Llissection is more difficult. Reverting 
to my own operation, it consists of: — 

1. An oval denudation of the most itioniiiiriil purl of llic cystoccle, 
as in tlie old-time operation. • 

2. Ditsectinjr flai)s from the vaginal wall on either side of the 
denuded area with which tf) cover the latter. 




Fig. 81. — Tim Author's Cyslocele Operation. The Dotted Lincg Give 
tlu- S<-liemc' of till- ()|M<rHtii>n. Tli* Cimtrnl .Aren in to he DphuiIcmI nnd on 
Either .Side of whicli Khips aro DisHPcti-il frutn I In- \'a>riiiitl WhII to Covwr 
the IX-nudfd Arcii. 

3. Bringing llic Haps iojrether over the denuded area and suturinjif 
them to it iiml U> viwh (dlier. 
The result is: — 

A. The f-ystorelc ii; effaced. 

B. The gito of the eystocele is strengthened iiy an additional layer 
of fascia^ — Uiat taken from the sides of the vaginal wall. 



INJURIES TO TUE PELVIC KU)OR— LATERAL. 



163 



Techniiiue. — ^The patient being anesthetized, pluced in the exag- 
gcrnte*! lithotomy position, nnd the perineum retracttnl, tlie lirst step 
is to gather up tlie redundant tissues aking the median line of the 
anterior vaginal wall and iniirk out tlie lines of dissft-tion. lu my 
first work 1 seized the erest of the eystot-ole with a tissne-foreeps and 
applied a light, long-hladed foreeps to the base of the fold, which 



Fig. fl2. — Tlie Autlinr's Cj-stcKvIi- Opcriifion. Incisioii at tlin ftisw of tlu- Fold 

of Rcduiidnnt Tissiir whii'li Si'|>iir»tj'H tlie .Vrpii In In- IK-niidcd (njin 

tile KIh|) which in tu be Oihsccled up und Drawn over iU 



marked the line of incision on either side, but later T have dispensed 
with the l)ase-foroe|>8 as unneeessiiry. The detail.^ are as follows: — 

1. Lift up the redundant tissue (the eystoeele) by means of r 
ti8euc-force]is. 

2. Make an ineiuinn on one side of, nnrl at the base of, the fold. 
at or near the median line. This ineisiou shoald e.\teud from within 



164 



PRACTirAL OyNE(^I.OGY. 



Imlf Jill iiuli of one end of the fulfl lo within tmlf on inch of the other 

011(1. 

:i. Carry tiic incision down tlimngli the faseia to the musculnri.s 
(if thi^' bladder. A slmrp knife and well-strettdied tissues are essential 
to expeditious work here. 

4. By bluiil ilissection. cither with the handle of the knife, dis- 



Fig. 83. — Tlip Autlior's C'ysJocrIc 0[)prnfinn. KoriiiiiiR t)i(> Flaps nn Eitlirr 

Si(Je of U>f Ari'rt to be IX-iiikIi-iI liy St'|»iratiiij; Ltie Niigiiwl 

Mu(vsii fiiiiii tliu Ulaililer Wall. 

seoting scissors, the gauze-covered finger or, m? I usually prefer, gauze 
held between the fingers, the Idiidder is seimnitcd fnim the vaginal 
wall in the direction of, and as far a«, the sulci and upward and 
downward the full length of the incision. 

•T. In ninking this dissection always keep the dissectors closely 
ap]ilied to the inticr surface nf the fascia and the latter well on the 
stretch by means of longdiandled forceps. It is also well to remember. 




INJURIES TO TllK I'ELVIC FLIX)U— LATERAL. 



166 



if the finger or gauze is used, tliat tlie blatlilt-r must be pushed olF tiie 
faaiia and not tlie wntrarv. Usually this dissection in this location 
very easy and gives rise to little endiarrasMnent, even to the inex- 
'perienced: To the latter I would say : Malce your dissection carefully 
till you eonie to muscle-tissue, and the rest is smooth sailing. The 
other side is dealt with in like manner, when it will he observed that 



Fig. fl4. — Aiitlior's ly.stnccti' (»|>criitiim. D<")iti<Iiii}f tin' fVniml Area. 
Over which the Latpral Flajia urc U> Ik' Urawu uml Suturi'ii. 

the central area — that wliiih is to he ilenuiled — is oval in sha|ie and 
flanked on either side liy the flaps dis.<ie<'ted from the vaginal wall. 
This area is now deniiclt'd as in the old-faahioned operation. 

(). The next stvp is to <lraw (lie flaps over tlie denuded area an^ 
to fasten them along the meilian line. To this end a suture is carried 
through tlie flaj) on one side at (In- Iowit extremity of the incision, 
through the middle part of tiie denuded area and acrosis to the flap on 



166 



PRACTICAL GYNECOLOGY. 



Die oppotiite side, and so on down tlie line until the donuded area is 
covered in by the Hnps from either side. The suture may be of 
rlironiioized catfrut or silkwonn ^it and may he interrupte<l or eoii- 
(iniiuiis. If inteiiuiited a «iiitinuniii« catgut suture along the median 
line will lie necessary to insure iiiee eoaptation nf the edges. When the 
cystocele is coraplicntcd witli jjrtjlapse of the uterus a suspension opera- 



Fig. 84o.^ — Author's ryatm>ele Operation. Suturing tlie Flaps to Each 
Otiicr uiid to tlic l)«'rni<ii'(l Siirfiw«' Rent-iith Tlu-iu. 



tion may be necessary, in which case less extensive dcnuilation should 
ho luade jn the vagina, it gixf wittimit saying that the [lelvic floor, 
if (k'fective, slunild be repaired, as no pUistie work on tile anti-rior 
vaginal huII ciin long endure witliout its Bupjwrt. Itecurrihg to my 
own experience, I have found the operation, so far as ease and facility 
of execution are concerned, nil that I could wish. T have never k-nown 
one to give way after having been done up in Uiis manner. The 



INJlTtlES TO THE PELVIC KL<J<)K— LATERAL. 



167 



•lissection of the vafcini>l from (hf dliuldcr wall is iiuich ojisicr when 
i'arrie<i from the siilu tlmn when hoguii in tlii' inoiliaii lim-. Altoijctlier 
the operation along these lines aeems a« netir the ideal as we are likely 
to attain. 

RECTOCELE. 

A rcctoocle presents as a wift, ttiinorous mass on I lie posterior 
rajrinnl wall, ll ik causol liy ii [iou<hitij;, or hiilgiiifj forward, of the 
lutiTior rt-ctal wall, whiih curries hefore it llie i)osterior vufjiiial wall. 
In niiMer cases it is to be found witliin the ostium vaginip, but in the 
Ferer forms it eseajies throiijih mid nfipcars at the vulvar eleft. 
[Fig. 78.) It is more conspicuous when the woman stands, and ujwn 
straining or l)earing down. Women iistiiiilv regard and speak of it 
as a falling of the woiiih. 'I'iie priinarv cause is tiio want of support 
arising from laceraliou of tlie pelvic lloor. The reetoi-ele is of gradual 
fnmintion. and is the result of yielding of the anterior rectal wall 
in tile direction of least resistance in the a»'t of defecation. Accu- 
mulated masses of fecal matter in the lower part of the rectum un- 
opposed by the normal anterior resistance also act as a causative 
factor. In the act of defecation the rectoeele crowds into or through 
the ostium vagiiue, much (o the annoyance and discomfort of the 
patient. She feels as though the passages were going to escape 
in that direction. Her s(dicitiide in iliis ilirection often itn])els 
her to make coimterpressure with the fingers on the rectocele, and 
in this way she learns to facilitate e.xpulsion through the natural 
nutlet. Aside from the distressing symptoms alluded to ahove, and 
the apprehensions arising from a jirogressive increase in the bulk 
of the tumor, the residual feeal matter in the rectum is liable to 
give rise to intlammation and ulceration of the rectal mucous 
meiolirnne. 

Diagnosis. — The diagnosis is made by introducing a linger into 
the rectum. «hen the poucli will be easily detected. 

Treatment. — Posterior eolporrhapliy and perineorrhaphy, as in 
the Enuuet or some allied ojK.>ration, is the treatment for rectocele. 

ENTEROCELE. 

Enterocele is a prolapse of the intestine into the vagina. As in 
rwi.o<'ele, the vaginal wall is cnrrieil before the advancing bowel, 
(.'ystoi-ele, rect<X'ele, and enterocele are, in reality, hernial protrusions 
into the vaginal canal. Enterocele is divisible into two forms : ante- 
rior and posterior. It is a rare affection, and the anterior fonn much 
less frequent than tlie posterior. 




168 PRACTICAL GYNECOLOGY. 

Posterior enterocele takes its starting-point from the bottom of 
Douglas's pouch. In its descent it crowds down between the rectum 
and the posterior vaginal wall, carrying the latter before it. It some- 
times fills the vagina, or in aggravated cases may escape from the 
vulva. The contents are intestine or omentum, occasionally both. 
The cause is imperfectly understood. In some instances it seemingly 
depends upon a broken pelvic floor. An abnormally deep Douglas 
pouch has been assigned as a cause. 

Anterior enterocele takes its starting-point from the vesico- 
uterine pouch. It descends along the anterior vaginal wall and be- 
tween it and the bladder. 

DiagnoBla. — It may be diagnosed from a rectocele by palpation 
from the rectal and vaginal sides. Percussion and palpation will also 
differentiate it from a vaginal cyst. If it contain intestine it will 
be resonant; but if omentum, it may be distinguished by the absence 
of fluctuation. 

Treatment. — ^Thc treatment consists in reducing the hernia when 
practicai)le, repairing the pelvic floor when necessary, narrowing the 
vagina, and such other plastic work as seems necessary to meet the 
requirements of each individual case. In some instances better results 
can be obtained by intra-abdominal surgery. 




CHAPTER XV. 

GENITAL FISTUL/E. 



Gexital fistula^ arc almonnal avenues of communication be^ 
tween the genital tract and adjacent lioilow organs. The principal 
genital ti^tultp are included under tlie heads: urinary and fecal. 




-^ 




L Cretbro-rutloail. - 



b. I . 



Iii'iiii- 



amL X KeCCo-vairlniil. 4, 
iiiol. '>. EiitcrovBClnaJ 



Ved co-uterine. 



The urinary fiRtula* are: — 

1. Frethro-viigiiial: between the urethra and vagina. 

8. Vesico-vaginal : between the bladder and vagina. 

(169) 



170 



PRACTICAL OYNErOI.noV. 



3. Vcsico-uterine : between the bliiddor and uterus. 

4. Ve!<ico-utero-vaginal : Lntwecn the liliuldcr and vagina by waj 
of a channel through the uterine wall. 

5. Uretero-vapiiial: between the ureter and vagina. 

6. Uretero-uterine : between the ureter and uterus. 
The fecal fistula are: — 

1. Kecto-vaginal : between the rectum and vagina. 

2. Entero-vaginal : between the intestine and vagina. 
Causes. — The most frequent cause of genital fistula is prolonged 

and difficult labor, protracted pressure from the impacted fetal head 
being the paramount factor. Fistulas from this cause are much less 
frequent than formerly, owing to the earlier use of the obstetric 
forceps and improved methods of expediting delivery. The old idea 
that the obstetric forceps was responsible for fistula has long since 
been gainsaid by irrefutable evidence, and the blame is now shifted 
to the deferred use of the instrument. FistuliE may result from the 
awkward use of instruments; but these are usually lacerated wounds, 
and tend to heal spontaneously. Permanent fistulie are usually the 

I = 



rfiiaiiiliiiii. 



result of oloughing from prolonged pressure. Incurable fistuke 
occasionally result from cancer or tuberculosis of the genital tract. 
Vesical calculi and abscesses in the vaginal wall sometimes result in 
fistula;, and sometimes they are produced, intentionally or otherwise, 
by surgical operations. A fistula not the result of sloughing tends to 
spontaneous closure. 

Symptonu. — Incontinence of urine and the presence of urine in 
the vagina are the cardinal symptoms of urinary fistula. The vagina 
and vulva are continually bathed in the secretion, and the parts over 
which it flows, including the inner aspect of the thiglis, are irritated, 
reddened, and oftentimes excoriated. The urinary salts, especially 
the lime salts, are deposited in the vicinity of the fistulous opening. 
The patient carries with her an odor of decomposing urine. When 
the fistulous opening is small or is situated above the ureteral orifices, 
the patient may be able to retain and void some urine per vias 
naturales. In ureteral fistula involving one side the urine in part 
escapes into the vagina and in part is voided from the bladder. The 
presence of fecal matter in the vagina and the escape of intestinal 
gases into and through the same are indicative of fecal fistula. When 



« 



I 




GEKITAL FISTIL-K. 



171 



tlie fistulous opening is very small, only the liquid feces will find 
their way into the vagina. The odor of a fecal fistula is even more 
revolting than that of the urinary fistula. 

Diagnosis. — Incontinence of urine or fecal matter should always 
lead to careful investigation. In the recently delivered woman a 
sudden gush of urine five or six days after delivery, followed by 
permanent incontinence, is highly suggestive of urinary fistula. This 
is the period at which the slough is apt to separate, leaving a hole 
in the bladder-wall. Large fistulx may be detected by palpation on 
the vaginal side, or by combining this with a sound in the bladder 
or a finger in the rectum. Smaller fistuljc may require both palpation 
and ocular inspection. 

For vesical fistula the perineum should be retracted and the 
patient placed opposite a good light. Even here it may be necessary 
to inject the bladder with a colored fluid, noting tlie point at which 
it escapes into the vagina. Solutions of aniline or permanganate of 



Fig. 87. — Kelly's Teimciiluiii Koreeps. 

potash, as also milk, are usually resorted to for this purpose. The 
milk should be sterilized and the solutions should not be stronger 
tlian is necessary to impart a deep tinge to the fluid. Small fistulous 
openings into the rectum may be disclosed in the same way. 

In ureteral fistula, clear urine will continue to well up in the 
vagina after the bladder has been filled with colored fluid. Such an 
occurrence is, tlierefore, strongly indicative of ureteral fistula, and 
should lead to more precise investigation. Careful inspection of 
the vaginal vault, or at the base of the bladder, by the aid of re- 
tractors and illumination will sometimes reveal the opening. In- 
spection of the ureteral orifices in the bladder by the cystoscope or 
catheterization of the same, or the use of the Harris separator, whereby 
the secretion from each ureter can be accurately determined and com- 
pared, taken in connection with a urinary discharge into the vagina, 
renders the diagnosis clear. In the absence of these methods of pre- 
cision, a diagnosis of reasonable certainty may be based upon a com- 
parison of the amount of urine which escapes from the vagina and 



172 



PRACTICAL GY\ECO\-<)C,Y. 



that drawTi from the bladder within a given period. After emptying 
the bladder, the patient is placed over a vessel for the space of two 
hours and then cathetcrized. If the amount in the vessel equals that 
obtained from the bladder, it is almost conclusive endence of one- 
sided ureteral fistula. 

Treatment. — Recent fistulse the result of laceration or incision 
usually tend to heal spontaneously, and should be encouraged to do 
so by rest, cleanliness, and attention to such details as will abate 
inflammation and relieve tension. Cauterization, formerly so much 
in vogue, has fallen into merited disuse, except in very small and 
recent fistulas which may sometimes be induced to heal after being 
touched by the thermocautery, or even after the use of some of the 
less potent caustics. Many and varied are the methods which have 
been resorted to from time to time for the closure of fistulous open- 
ings, some of which are applicable to fistulte in general, while others 
are adapted to special conditions. The methods in general use to-day 



Fig. 88. — FiKtulu Srissora. 

may be classified under four heads: denudation, flap-splitting, flap- 
inversion, and transplantation. 

Preparatory Treatment. — In fistula, as in all plastic work, where 
success depends on perfect and immediate union, it is essential that 
all the conditions favorable to healing should be secured, if possible. 
The tissues contiguous fo the fistulous orifice should be relieved from 
irritating influences, inflammation combated, indurations softened, 
tension relieved, and distortions corrected. For urinary fistula the 
urine should be rendered bland by the ingestion of large quantities 
of water, and by the exhibition of liquor potassa, bonzoate of soda, or 
some other alkaline preparation. The urinary salts, which are apt 
to incrust and irritate the tissues in the vicinity of the fistula, may 
be dissolved away by a weak acid solution. Dilute nitric acid — 3ij 
to the gallon — answers the purpose nicely. Copious and oft-repeated 
injections of warm boric acid solution will generally subserve every 
purpose. Cicatricial bands should be cut and allowed to heal over a 
glass or metal plug or the vagina may be packed with gauze. Where 
a fecal and urinary fistula co-exist, the former should be repaired first 



r.ENrrAi, fistil.k. 



to prevent infection of the latter. Ijong-continued preparatory treat- 
ment is solitoni called for nowadays, as moat conditions which for- 
merly l)afHed the skill of operators may now be easily surmounted by 
one or more of the various expedients with which we are familiar. 




Kig. «U. — VMico-vaginal FiBluIa. (Deniidalion Operation. First Step.) 

Thus, a contriicted vaginal orifice may be incised at the time of 
operation ; a fistula which is drawn up and bound close to the pubic 
arch may be liberated by careful dissection, and the bladder may be 
dissected from the unyielding vaginal wall and drawn over the open- 
ing 30 OS tu close it. 



i*^— -—^ 



174 PRACTICAL GYNECOLOGY. 

Operative Technique. — The following points are to be observed 
in operation for genital fistula: — 

1. The parts must be exposed by retractors under a good light 
and the patient placed in that position which will afford easiest access 
to the fistula. 

2. The tissues surrounding the fistula must be made tense by 
properly adjusted tenacula to facilitate nice dissection. 

3. The edge of the fistula at the point where the dissection begins 
should be caught up by the tenaculum or tissue forceps and held 
fairly taut while the strip is being removed. 

4. The cicatricial edge of the fistula, when practicable, should 
be removed in one continuous strip. 

5. The incision should be slanting from the vaginal to the rectal 
or vesical surface, so as to leave a beveled vivified surface for coapta- 
tion and union. This surface should be from one-third to one-half 




I 

Fig. no. — Fistula Niwllfs. 

of an inch in width, and made principally at the expense of the 
vaginal side. 

6. Always avoid, if possible, wounding the rectal or vesical mu- 
cous membrane, as it is liable to give rise to troublesome hemorrhage. 
The incision should be carried down to, but not include, the mucous 
membrane. 

7. In placing the sutures the needle should be passed down to, 
but not into, the rectal or vesical mucous membrane. 

8. The sutures should be introduced in such direction and 
manner as to insure the easiest and most accurate approximation of 
the sides of the wound. The first stitches should usually be placed 
near tlic center of the wound, and sometimes two or more of them 
will converge from different points on the periphery of the wound 
to a common center. As a result, after tliese are tied, the initial 
opening is converted into two or more smaller openings, which may 
resemble a figure 8, a clover leaf, or a double figure 8, at right angles 
to each other. The resulting scar, after closure of the fistula, will 



OENITAI- FISTLL.«. 



176 



be represented by a line, straight or curved, running lengthwise, cross- 
wise, or obliquely with reference to the vaginal canal, or by an X 
or Y. 

9. It is better to avoid, when possible, the bringing together of 
three or more angles in the center of the wound, as it is apt to leave 
a leakage at the point of junction. 

Operation by Denudation. — The classic operation of denudation 
and suture, as perfected by Sims, may be performed with the patient 



S< 



F){;. {)l. — Veaico-vaginal Fistula. Denudation Operation (Second Step). 

in the lateral or dorsal position. The exaggerated lithotomy position 
affords the best exposure of the anterior vaginal wall, and renders 
the fistula more accessible. The perineum being retracted and the 
edges of the fistula made tense by properly adjusted tenacula, the 
denudation is effected with knife or scissors. The edges of the 
fistula are denuded down to, but not including, the vesical mucous 
membrane. The vivified surface should be beveled at the expense 
of the vaginal side, and should be from one-third to one-half of an 



PRACTICAL OYNErOLOGY. 

inch in width. (Fig. H».) The sutures are introduce*! in the direc- 
tion llmt will pnxiuee tlie loat*t traction on tlie tissues: li>njritiidiiial, 
transverse, or an iuteriiii-diato dirirtion with rclVreiiee to the vaginal 
eanal. Oecasionally it will be necessary to bring the wiges together 
in Liie fonn of an X, Y. or H, althou^rh it is desiral)le to avoid Itrin"- 
ing angle.'* lojietlier if |«)s*;ible. The ueedlu is entered nbout oue-liflli 




Fig. 02. — VefticiivngiiiHl Kittiila. I''lii|) splitlinp 0]>eratioii. 
UliKlilcr-u'iill .Sutiiri'il. 



<4)£>n ineh" external to the cdfje of the vivilied surface, and made to 
enJergc at tlie inner edge of the .«atnc. care heing taken not to pene- 
trate the ve-sicai luueoua nicndirane. It is re-entered at the inner edge 
of the denuded surface opposite, and is hrouglit out on the vaginal 
mucous mendirane at a point corresponding to and opposite its point 
of entrance. The sutures are placed one-fifth of an ineli apart. 
(Fig. 91.) Silk-worm gut makes the k-st suture material, although 



GENITAI. FlSTULuE. 



177 



M 

I 



silver wire, silk, or oven catgiit may be used on occasion. Tlic blad- 
dtT should be irrigated before securing the sutures, as clots of blood 
left in the bladder are liable to provoke tenesmus, and not infre- 
quently choke the catheter. The sutures may be shotted or tied, and 
should not be drawn too tightly, lest strangulation of tissues ensues, 
with resultant pressure necrosis. When u ureteral orifices opi-ns on 
or near the e<ige of the fistula it should be turned into the bladder, 
or split up on the vesical surface to prevent occlusion. The sutures 
m the vicinity of the ureter should be iidjusted with great care to 
avoid constriction of the duct. There is a^asun to believe that nu- 
merous fatal cases following the operation under consideration have 
Itwn due to the inclusion of the ureter or ureteral orifice in the sutured 
Muuud. 

Flaihtplilling Operation. — The advantages of this over the classic 
ipcration jus-t described are that no tissue is sacrifiecil by being cut 
way, and in the event of failure the condition of the patient is no 
worse than l)eforc. It also affords a broader surface of contact, and 
ff>rnis an i-levated ridge in the bladder at the fistulous site, which 
increase the chances of I'lmi union and diminish the chiinces of leak- 
age. Another conspicuous advantage is that, in large fistula asso- 
ciat»'d with unyieliling walls, the pliable and elastii' bladder-wall may 
be s<"pai-ated from that of the vagina and brought down over the 
ojiening. In this way fiatuhe may now be dosed that were formerly 
considered beyond the reach of surgieitl skill. 

The simplesi method nf (irrfdnnitig the Hap operation, and that 
which is adBj)ti'd to the uiajority of cases, is t^i leinlt'r the edges of 
the fistula tense by jtroperlv adjusted tenacula. ami to split or dissect 
the bladder from the vagina! wall to the depth of one-third of an 
inch. The raw margins of the bladder-wall are now united by cat- 
gut suture, over which the vaginal si<le is closed by bringing raw 
surface to raw surface. (Fig. 1)2.) For this latter silkworm gut is 
preferable. Occasionally dih- line of sutures introducecl from the 
vagimd side will sullice to bring the everted raw surfaces together. 
In this operation the iuvcited edges of the vesical wall form a ridge 
iin the interior of the b!a<ldcr. which offers additional protection 
Against leakagi'. In more extensive fistula the bladder-wall is sepa- 
rated from that of the vagina to such an extent as will allow of its 
being drawn over tlie gap, when? it may be united to the bladder- 
wall on the opposite side or to the denuded vajrinal mucosa. 

Triin/ii>l(intnlion. — This is effected by utilizing tissues from con- 
tiguous structures for filling in the fistidous gap. The simplest of 



178 



PHACTICAL UYNECOLOGY. 



these is that adopted by Martin, of Berlin, wherein, by making a 
circumferentia! incision througli tiw vaginal wall at a proper rlis- 
tance from the edge of the fistula, the dissection was earned inward 
to within a fraetion of an ineii of the listnlous opening. The flap 
t!ms fonned was turned over po as to cover in the ti:?tiila, and its raw 
surfaces united hy suture along the nie<lian line. The mucous sur- 
face of the vagina thiia forms the floor of the hhidder at the site rif 
the fi.'itultt, and tJie raw surfaces are turned towanl tiif vagina. When 
possible, this raw vaginal surface may he covered hy appro.xiniation 
of the edges of tiie area from nliieli the flap had liecn di.sseeted. A 
tongue of tissue may be dissected from the posterior wall of the 
vagina and united to the margins of the fistula, and after firm union 
the Hap may he entirely severed. tKcaHioiially it will he found I'on- 
venient to utilize the body of the uterus or the anterior or posterior 
lip of the cervi.v to fill in the gap hy freshening the surfaces and 
attaching to the edges of the fistula. When the [xisterior lip is used 
for this purpose, the month of the wond) will he turned into the 
bladder, into which will he discharged the menstrual b]o<id and 



Kig. !(.■{. — Kciiialv t'atliptpr. 

uterine secretions. This is not only an annoyance slightly le«>8 than 
tliat for which the operation was jierformcd, hut is ajit to be fol- 
lowed hy serious bladder complications. It also places a bar on con- 
ception. With the im[>roved metliods nf recent years such pro- 
cedures are now seldom necessary or jtistiliahle. 

Colparhisix. — This i-onsists in complete closure of tlie vaginal 
canal. It was (iriginaliy devised for large, inoperable fistulie or such 
fistidie us were not aiiioiahle to the uietlmils then in vogue. It consist.-' 
in denuding the vaginal wiill throughout its ciicumferenec and uniting 
by suture. The vagina inav lie <lo.-.'ed nt or near the outlet or higher 
up in th<' i-aniil. The liigh tiperatioii sltmild titways he cho-icn where 
it will serve the purpose. .\s a n-sult of this operation, the blailder 
and vagina are (Imnvn iiilo one cavity and their secretions inter- 
mingled. The nieiistruid fluid i< apt In excite cystitis atid ui>wiird 
traveling inflammntion of (he virinary tract, whih-. on the other hand, 
the [wnt-iip urine is liable to give rise to inflammation of the uterus 
and Fnllopiiin tubes, or even to peritonitis. When the occlusion is 
fonned at or near the vaginal outlet, coitus is made impossible. For 




GENITAL KISTLL.*:. 



179 



th« reason cited above, the operation is seldom netessary or expedient, 
and ia little practici'd in this country. 

After-treatment. — After tin- sntiiri'i* nrv Inlrodiucd and before 
they are tied, tiie bladiier should be irrifjated to dislodt^e any clots 
that may have accumulated during the operation. After the sutures 
are tied it is a good plan to partially fill the bladder with a normal 
ealt solution to determine the presence or absence of leaki^^e. This 
fluid should be immediately withdrawn. A loose gauze pack in the 
vM«;inu gives comfort to the patient, ami afTords gentle support to 
tlie bladder. Thif> gauze should be rejilaced when it becomes soiled. 
The patient should be kept in bed for at least one week, during which 
time the bladder should not be allowed to become distended. For 
simple, easily approximated listula-, the patient may be allowed to 
void her urine withoid the aid of the catheter, but in the more com- 
plicated, and in all iloulitful cases, it should be drawn off every three 
or four hours during the first four days, nod at longer iutenals there- 
after. Many operators prefer a self- retaining catheter, whereby the 




Fig. 94. — RiiblR'r Sell ifUiiniiig Catheter. 



urine is carrieil ofT as rapidly «5 it is formed. These, if used at all, 
should be WBt*bed closely, lest they lirtome occluded by a blood-clot, 
ami ilangerouA disti'nsion of the bladder eUf^uc- They should be 
removed morning and evening for cleansing, and left out for an hour 
to give tile patient a rest. The <elf-retaining catheter may usually be 
ilispt'ns<'d wilb after the fourth day. The bowels should hu moved 
itter the second day and kept 8<jluble thereaft^-r. The silk-worm gut 
sutures limy rcniuin from li'ii {<> tirieeii diivs. 

Vesico-uterine Fistula and Vesico-utero-vagfinal Fistula.— These 
futiilse may usually be closed by freeing the bladder-wall from the 
cervix, freshening the edges of llie tistida, and uniting by suture. 
Over, this, when jiracticablc, (be vaginal f)r cervical tissues are ap- 
pro.\imated. The buried sutures should be of catgut. Occasionally, 
wlien the bhuldor-wall is very thin, it may be reinforced by a shaving 
from the cervix, ."^ome of the fistula- of this class are more easily 
remedied by s|ilitting the cer^•ix through and beyond the fistula, and. 



180 PRACTICAL GYNECOLOGY. 

after freshening the edges, uniting the cervical flaps, as in the Emmet 
operation. 

XTreteral Fistula. — The treatment of ureteral fistula usually calls 
for a high order of surgical skill, and should not be lightly under- 
taken by the inexperienced. They may be operated per vaginam or 
through abdominal incision. When practicable, the vaginal route 
should be selected by preference, as being less dangerous primarily, 
and in case of failure less fraught witii evil consequence. 

Vag^al Operations. — For a fistula in the lateral wall of the 
ureter the tissues in the immediate vicinity of the fistula and sur- 
rounding it are denuded, as in the classic operation for vesico-vaginal 
fistula, and brought tojzether with interrupted sutures of fine silk or 
catgut. When the fistula is in tiie vaginal vault and the surrounding 
tissues are sufficiently lax for the purjjose, a permanent artificial 
vesico-vaginal fi!:tula should first be made as near to the ureteral 
fistula as possible, and, after this ha.>5 healed at its margins, then, by 
denuding an area which shall surround and include both fistulous 
orifices, bring the raw surfaces together in such a way as to leave 
an open channel between the ureter and bladder. The artificial 
vesico-vaginal fistula, owing to its tendency to contract, should be 
at least half an inch in diameter, and the vesical and vaginal mucous 
membrane accurately approximated over its edges to prevent closure 
of the opening. 

When the fistula is situated at the base of the bladder, the ureter 
should be dissected up for a distance of from one-half to one inch and 
an opening made in the base of the l»la<lder. into which the ureter 
is turned and the wound closed around it. A few of the stitches are 
made to j)enetrate the outer coats of the ureter, to hold it in place, 
and care should be taken to secure nice coaptation of the incision 
without constricting the ureter. 

Iniplaiilalion of the Cervix into the Bladder. — Tn a case of 
ureteral fistula following supravaginal hysterectomy, it was Jiscovered 
that the urine escaped into the vagina through the cervical os. It 
occurretl to me that the easiest and best thing to do would be to turn 
the cervix into the bladder, which was accordingly done. \ transverse 
opening of suflicient size to admit the cervix was nuide in the base of 
the blailder. and the bladder-wall beveled so as to make a broad 
margin fi>r union with the cervix. The perii)lieral surface of the 
cervix wa.s freshened to like extent. First the up|)cr anterior margin 
of the cervical denudation was united to the upper jmsterior margin of 
the bladder denudation by a continuous chromic catgut suture, the 



GENITAL FISTl L/E. 



181 



ends of which were left long for future use. Now vertical sutures of 
silkwonn put were plact"<l so as to unite in their entire length and 
brcadtli the afoit'nairie<l nurfacea. To turn the eervix into tlie bladder 
« couple of cBtpiit sutures were passed tlirou^jh the tip of the eervix 
and tliese in turn wtre passed through ti 1(h)I) of thread projeeting from 
the eye of a catheter whieh had been introiluced per urethrani. Now 
after placing the vertieul silkworm-gut sutures in front and laterally 
the cervix is drawn into the bladder and held tliere while the sutures 
are In-ing tied, when the catheter and loop may he withdrawn. The 
marginal catgut suture is now taken up again niul carried around the 
vntcrior border of the denuded surfaces to the place of beginning, 
Trhere it is tied. In order to se<-ure as broad a surface of ajiposition as 
|>ossible the vertical sutures in this case were iiitroducLHi in the shape 
of the ligure 8, that is, entering at the edge of the freshened surface 
on the cervical side tlun- went half deep, then crossing to the bladder 
__i»ide continued to the bottom, then crossing to the cervical side 
Inrned in inverse onler to the point opposite the original place of 
utrancc. A partial failure of the first attempt, attributed largely to 
the use of the single looji instead of the figure-of-,S suture, necessitated 
a second oywration, since which there has betin no recurrence of the 
trouble nor vet any ill etTects from the implantation. 

Abdominal Uretero-cystostomy. — Wikn the vaginal operation is 
not feasible the abdomen may be openwl and the ureter dissected up 
«nd turned into the bladder. Where the end of the ureter is in- 
■ceessiblc owing to intlanimator\' exudation or other cause, the tube 
may be picked up at a higher level, fnuitl dr>wnwnrd as far as possible, 
and, if of sufficient length, cut <rlT smd turned into the bhnlder. .^ 
forceps thrust through the urethra into the liladder and out through 
the artificial opening at the fundus may be made to seize the end of 
the ureter and draw it into the bladder, where it is secured. The 
bladder may be iiuule to approximate the ureter by tenacula hookeil 
into its walls, or by threads passed through the same on either side 
of the artificial opening. If there be undue traction at the jviiut of 
union, the bladder may be stitched to the broad ligament in such a 
manner as to relieve tension. Where the ureter is not of sufficient 
length to meet the bla<Mer, the latter may be made to meet the 
deficiency to llie e.\t<'nt of an inch or more by freeing it anteriorly 
from the pelvic wall. 

The operation of rolporleitU assm-iated with a large artificially 
prepare<l vf'sirn-vfiijinnl fistula, as reeoninu-nded by some, is seldom 
justifiable. The removal of a hdnrt/ for the abolition of a ureteral 



182 PRACTICAL GYNECOLOGY. 

fistula should never be resorted to except as a dernier ressort, or when 
the kidney or ureter is hopelessly diseased. 

Urethral Fistula. — This form of fistula is comparatively infre- 
quent. It usually occurs at or near the urethro-vesical junction, and 
is much more frequently the result of laceration than sloughing. 
The laceration is apt to extend widely on either side, making a 
formidable tear at the neck of the bladder. The bladder wound tends 
to heal spontaneously, but the urethral fistu'a becomes permanent. 
When the fistula is lower down the urethra, there may be no incon- 
tinence and oftentimes little inconvenience. When the laceration 
extends transversely and ituplicates one-half or more of the urethral 
circumference, the distal margin of the tear collapses, and, becoming 
adherent, proiluces an occlusion of the urethra just below the fistulous 
orifice. 

Treatment. — Denudation of the edges of the fistula, beveled at 
the expense of the vaginal side, and perfect coaptation with closely 
ai)i>licd fine silk-worm gut suttires, will usually result in cure. A 
self-retaining catheter should lie left in the bladder for five days, 
and in eight or ten days the stitches may he removed. 

Fecal Fistulse. — These are abnormal openings into the large or 
small bowel, and in this connection are confined to such as com- 
mimicatc with the vagina or bladder. These are made evident by 
the escai)e of fecal matter into the vagina or voiding of the same 
fr()n\ the bliiddcr. The li(]uid fe<'es of the small bowel escape un- 
interruptedly, but lower down in the large bowel from the sigmoid 
to the anus the formed fecal matter may give no special inconven- 
ience imless the fistulous opening be of large size. Even here, how- 
ever, when the bowels are loose, fecal matter will escape through the 
minutest opening. 

Another very distressing sym])tom which is connected with 
fecal fistula is the involuntary escape of the intestinal gases through 
the fistula, which oftentimes rush out with an audible hissing or 
l)ul)hling sound. This, with the atmosphere of foul odor which the 
jiatieiit carries about with her, forces her into seclusion. 

Eecto-vaginal Fistula. — These are the most frequent. The 
fistula iiuiy he loeated at any |)oint of the recto-vaginal septum, from 
the cervix to the vulva. Those situated in the upper part of the 
vajziiia are must fre(|uently the result of cancerous infiltration of the 
vagiiiiii wall and snhsecptent brcakiTig down of the same. Cancer of 
the cervix is usually the starting-|H)iut for such infiltrations. The 
fistula (if the hiwer part of the septum may be due to laceration or 



OKVTTAL FISTUL.B. 



1.S3 



>ogmnp. mil in tnony iiisiaiii'os is I lie rosult of iiiipcrrt'L't union 
lfi«'r laiiTtUion "f ihf )HTineiuii invulviug the wpUiin. 

Preliminary Trmlwctit. — For jt-veral days prior to tlie opcrntion 

'Uie l)owrIs sixiiilil In* tlmronorlily mikI svstoniatically jmrj^i'd, niiil tlie 

juilientV diet rt'slrirlod to aiiiiim! ln'otliH. Milk sliould be iiitordich-d, 

from its tendency to fonii curdy masses. Tlie vapina should be 

cleaiuM'd and kept clean by repeated douches. A few hours prior to 



Kig. Uo. — Kix-to-viiffinnl Fisfut^i. Sutun-. I'laecd. 



the operation the rei turn s^hould Iw washed out, and, if at the time 
of oiicnition the contents of the inti^tiiial catia! sliow a disposition 
to escape, a tampon of {.-auzo shoulil he placed in the rectum above 
the field of operation. The rectum slioutd he thoroughly dilated and 
strictures of the canal overcome before attempting to vWe the fi.xtula. 
Trentmrnt. — For the cancerous fistula at the npper paii of the 
vagina the treatment is purely palliative, and consists in keeping the 





184 



rRACTICAL OYNECOLOGY. 



parts flean by the use ol plain iiiul (iiitist'ptic flouclies. Very pniall 
listuhi! in the lower purt of tite canal may not infrequently he induced 
to Ileal by Miine siiiiiulatinfj; iipplieution or cautery, such as the can- 
tharitlal solution, nitrate of silver, or one of the mineral aciiis. Other 
fistula' are treuted on the fianie jirineiplcs as apply to the urinary 
group. This includes denudntion from the vapnal side, witli deep 
and su]H'rfi(ial sutures (Fig. St')), Hiip-sji!itting cif the septum, and 
separate sutures for the rectal and vaginal sides. 

In recto-vaginal fistula situated near the sphinctei', or where it 
is inclosed helow liy a bridge of cientrieial tissue, nnd in case of ex- 
tensive tear (tf llie sepluni, it is better to cut tiirougli the sphincter 
and treat the case as one of neglected perineal laceration. When this 
is not done, the sphincter should be paralyzed by forcible ililatiilion, 
and the perineum incised down to the sphincter, when t!ie fistulous 
tract may be thoroughly exposed, excised, or curetted and sutured. 

When the srtinl! inte?tine opens into tl.e bladder it will be neces- 
sary to open the idxiouien. seek for tiie li-tuhi. separate the adhesions, 
nnd dose the openings in the bowel and bladder separately. This 
iiftentinie.s involves painstaking nnd perilous work. o%ving to the 
extensive nnd tirnt adhesions of the intestine. These adhesions should 
be separated with great care and with as little injury to the bowel 
as possible. Where it becomes n question of injury to bowel or blad- 
der, the dowel shoidd be protected tit the expenst- (if the i)bidder. The 
peritoneal cavity should he enrefully guarded from contamination by 
gauze pn<'king. I^esions of the bowel, inciurling the fistula, should 
be repaired first. Extensive injury may deuuinil resection or the use 
of the Murphy button. The fistulons opening in the bladder is fresh- 
ened and neatly sutured, and nsuHlly heals promptly. 

Aftir-iniitmriii. — The after-trentment is essentiiilly the same 
as that for urinary fistida, or in case of abdominal operation that 
Bpplicitble to such conditions. The bowels should be opened on the 
third ilay nnd kept solulile thereafter. Salines, when well borne, are 
the best for this purpose. 



4 

4 




186 



PRACTICAL i:YXECOI,OOY. 



almost to the vertical line. An impacted rectum will push the cervix 
forward, and thus alter its relations. Witliin physiologic limits the 
uterus may occupy any position in the pelvis, from tlie vertical to the 
horizontal with its fundus looking forward. 

A fixed uterus, whatever its position, is abnormal. The mobile 
uterus is essential to the functional integrity of all the pelvic visccr.-i. 
The position of the uterus under normal conditions is due to tlie 
ligaments, the intra-abdominal pressure, the so-called retentive power 
of the abdomen, and the integrity of the pelvic floor. The ligaments 
of the uterus are eight in number: Two utero-vesical, two utero- 
sacral, two round, and two broud. The round ligaments are mus- 
cular; all the others consist of reflections of the peritoneum, con- 
taining connective tissue with a variable amount of unstriped muscle- 






/ J. 



■■^ 



Fig, 97. — Uterine Ligaments, Showing them All on Same Plane. 



fiber. These ligaments, when the uterus lies forward on the empty 
bladder, occupy about the same plane. (Fig. 97.) As their insertions 
are not on a higher level than their attachments to the uterus, they are 
not suspensory under normal conditions. They simply act as guys. 
The uterus can be elevated or depressed to the extent of an inch or 
more with very little opposition from these ligaments. Beyond tliis 
point the ligaments offer noticeable resistance to the upward and 
downward movements of tlie uterus. 

The integrity of the pelvic floor is very essentia! to the proper 
maintenance of the uterus in its normal position. It ofllers a firm, 
resistant foundation for the pelvic organs; gives support to the 
rectum and bladder; and maintains the vaginal canal as a valvular. 



I 




DIsrL.'VCEMEXTS OK THE UTERUS. 



1H7 



I closed passage at right angles to the uterus, thus placing them in the 

I most favorable position for normal equipoise. The loss of integrity 

of the pelvic floor is by far the most potent factor in the causation 

of downward displacement of the uterus, and is a contributory cause 

Df the backward displacements. 

The want of support for the rectum and bladder results in the 
[gradual formation of rectocele and cystoccle, with consequent pro- 
lapse of the vagina. This, in turn, dragging upon the cervical at- 
tachments of the uterus, throws it backward and draws it into line 
with the canal. The uterus, being retroverted, is forced downward 
and backward by the intra-abdominal pressure, the ligaments yield 
and stretch, and the retentive power of the abdomen is wholly in- 
adequate to offer successful resistance to the combined forces operating 
against it. 



INTRA-ABDOMINAL PRESSURa 



I 

^H This is a factor for good or evil, according to the position of 
^Hthe uterus. Where the ftmdus is directed forward so that the intes- 
^Htiues rest upon the posterior aspect of the uterus, the intra-abdominal 
^Bpressure serves to maintain it in a state of antcversion, which is nor- 
^Bmal, and to prevent retroversion, which is abnormal. It also coun- 
ty teracts tlie ascent of the uterus, and, by holding it forward out of 
line of the vaginal canal, prevents its descent. If, however, the 
uterus is in a state of retroversion so that the intestines fall upon 
tlie fundus and anterior aspect of the same, the intra-abdominal 
pressure serves to aggravate the condition by forcing it still farther 
backward and downward along the vaginal canal. 



RETENTIVE. OR SUCTION. POWER OF THE ABDOMEN. 



^^P This is due to the counteracting influence of the atmospheric 
f pressure from the outside, which opposes the descent of the pelvic 
I organs through the natural pelvic outlet. A very familiar illustra- 
L tion of this physical fact is found in tapping a barrel which is filled 
^Hvith liquid. Daily experience teaches us that if only one opening 
^Bis made in the barrel the contents will not flow. This is because of 
^^^16 atmospheric pressure from without. If now an air-hole be made 
above the level of the fluid so as to admit air into the chamber, this 
counterbalances the atmospheric pressure at the opening or exit, and 
the contents escape by their own weight. If one end of a glass tube 
be placed in a vessel of water, and the other in the mouth and the 




188 



PRACTICAL OYXECOLOGY. 



air exhausted, the atmoepheric pressure causes the water to rise in 
the tube and fill the mouth. This is in common parlance known as 
suction, though a little reflection will show it to be the result of 
atmospheric pressure exerted upon the surface of the water in the 
vessel. The retent^^e power of the abdomen is a constant and im- 
portant factor in preventing the prolapse of the pelvic and abdominal 
organs, though not so effective as it might be were the abdominal 
walls rigid and unyielding to ward off the lateral pressure. 

The uterus may be displaced upward, downward, forward, back- 
ward, and laterally to either side. These are known, respectively, as 
ascent, descent, or prolapse, antcversion, retroversion, and lateral 
displacement. For convenience of description the flexions will be 
included in this category, the most common forms of which are ante- 
flexion and retroflexion. 



ASCENT OF THE UTERUS. 

This may occur as the result of the enlargement of the uterus 
so that it cannot be accommodated in the pelvic cavity, as in uterine 
fibroid ; by pelvic growth so situated as to push or drag the uterus 
out of tlie pelvis, and more especially by the intraligamentous 
growths, eiTusions, and exudations, which carry tlie uterus along with 
the distended ligament. In this way ovarian, fibroid, and malignant 
tumors, extra-uterine pregnancy, hematoma, and pelvic exudation 
may be responsible for the upward displacement of the uterus. 



DESCENT, OR PROLAPSE. OF THE UTERUS. 

In this the uterus is depressed below its normal level. There 
are varying degrees of prolapse from that in which the organ occupies 
a position in the pelvis slightly below the normal level to that in 
which it hangs between the thighs, having escaped from the pelvic 
cavity. For purposes of description, three degrees are recognized : 
that in which the organ has descended into the vagina to an appre- 
ciable degree; that in which it presents at the vulvar cleft (Fig. 98) ; 
and that in which it, having escaped entirely from the pelvis, hangs 
between the thighs. This latter is denominated complete prolapse, or 
procidentia. 

Prolapse of the uterus may occur suddenly or as the result of 
the long-continued operation of one or several of the causes which 
will be enumewted hereafter. Sudden, or acute, prolapse of the 



1 



niSPLACEMENTS OF THK UTKRITR, 



ISO 



nkrus ia very rare, the vast majority of cases being of gradual devel- 
opment. 

Causes. — Acute prolapse is, almost without exception, the result 
of violence. Among the most common ciuises are great muscular 
eirort, such as lifting and straining ; falls from a height ; blows or 
cnishing. The ordinary form of prolapse, or that of gradual devel- 
opment, is largely confined to women who have borne children and 



fig. 98— I'lOlapsus Uteri. 



iliereby have suffered material damage of the pelvic floor, as well as 
other changes incident to pregnancy and parturition. 

In these cases laceration of the pelvic floor removes the support 
from below, and, as a result, distension of the rectum and bladder 
with efforts at evacuation lead to rectocele and cystocele. The con- 
sequent dragging on the vagina makes traction on the cervix and 
causes it to descend. This brings the uterus into retroposition, and 
in line with the vaginal canal, along which it descends. Retroversion 
is, in fact, a necessary forerunner to prolapse. By some it is denomi- 
nated the first stage. The uterus being retroverted, the intra-abdom- 



I'M PR.\CTI{'AI. OVNKCOI^XJY. 

inal pnssore falls on the fundus and anterior surface of the same, 
forcing it downward. In many instances the laceration of the pelvic 
floor, and other lesions inciilent to the parturient act, have retarded 
the involutionary process, leaving the uterus large and heavy and the 
ligaments lax. 

Thus, it will be seen that in most instances a prolapse of the 
uterus is due to many factors, each of which is dependent on the 
other. Occasionally, though rarely, a prolapse may occur in the 
nulliparous woman or even in the virgin. In such case it will usually 
be found that a pelvic deformity exists, the sacrum being too straight 
and the vagina and uterus approximately in line. This, coupled with 
an absence of muscular development, offers conditions favorable to 
descent. In old people the absorption of fat, the loss of muscular 
tone, and the laxity of the ligaments act as contributory causes. 

Symptoms and Course. — Acute prolapse of the uterus is usually 
attended with other pelvic lesions, oftentimes of a most serious char- 
acter, in which the supports and ligamentous attachments of the 
uterus are torn and riven. The effect is usually attended with in- 
ternal hemorrhage, profound shock, and agonizing pain. The patient 
is unable to void the urine, and there is a sensation as of something 
foreign in the pelvis, which leads to violent efforts at expulsion. In 
the ordinary form of prolapse symptoms may be slight or even want- 
ing. Some patients complain of pelvic pain, weight, and dragging, 
and inability to walk or stand. There are also symptoms referable 
to the rectum and bladder. It is a noticeable fact that the degree 
of discomfort experienced by the patient bears no relation to the 
degree of prolapse, as many patients with the womb hanging between 
the thighs complain less than others with a very moderate prolapse. 
The rectocele and cystocele, which are usually associated with the 
prolapse of the uterus, have a symptomatology of their own, which 
has already been considered. 

Wlien the uterus passes the vulva, it is covered by the vaginal 
walls and forms a tumorous mass, pear shaped, with the large end 
downward. Within the vaginal envelope are to be found not only 
the uterus, but, in most instances, the protruding portions of the 
bladder and rectum, — the cystocele and rectocele, — along with the 
tubes, ovaries, and intestines. Occasionally, the anterior vaginal wall 
will be stripped from the bladder, thus leaving this viscus in titu. 
The 08 uteri occupies the most depending portion of the protruding 
mass. As the result of exposure, the cervix and vaginal covering of 
the procident uterus become drj and corneous, resembling skin. Ab- 



DISPLACEMENTS OF THE UTERUS. 



191 



nee of moisture, exposure to the air, attrition between the thighn, 
and contact with the clothing, together with embarrassed circulation 
from its nnnatural position, not only lead to swelling and engorge- 
ment of the mass, but tend to diminish vitality, with consequent 
ulceration. In patients of uncleanly habits, the urine and fecal 
matter with which the mass becomes bathed and besmeared greatly 
increase the liability to ulceration. 

In the earlier stages menstruation is usually increased in quan- 
tity or frequency, but later becomes diminished. Leucorrhea, which 
is often profuse at first, diminishes and disoppears as the prolapse 
becomes complete. While the procident uterus may usually be easily 
returned to the pelvis with the patient in the dorsal decubitus, in some 
instances the engorgement is so great as to offer serious obstacles 
to its reduction. This difficulty is cnlinnced by an overloaded rectum 
or distended bladder. In some instances inflammatory reaction of 
the pelvic peritoneum has resulted in adhesions, which effectually bar 
the way and render reduction impossible. Notwithstanding the great 
changes in the walls of the uterus and its environments, engendered 
by its unnatural position and its palpable exposure to septic influences, 
the endometrium usually escapes serious infection. This is ascribed 
to the excellent drainage insured by its dependent position. It is 
owing to this fact that pregnancy sometimes takes place, and that a 
pre-existing endometritis with abundant leucorrheal discharge sub- 
sides spontaneously after the uterus has escaped from the pelvis. 

Diagnosis. — Cystocele and rectocele are u.sually regarded by the 
patient as falling of the womb, but can easily be distinguished by the 
diagnostic signs peculiar to each. These have already been consid- 
ered. It may be stated in this connection that in cystocele the finger 
enters the vagina back of the protruding mass, and in rectocele in 
front of it. The same test would apply to tumors, cystic or solid, 
of the anterior or posterior vaginal walls. Furthermore, at some 
distance up the canal the finger will impinge on and readily recog- 
nize the cervix by its position, contour, and consistence, and by its 
relation to the body of the uterus, as confirmed by bimanual exam- 
ination. In inversion the external os and cervical canal are absent, 
and the minute openings of the Fallopian tubes may be discerned at 
the lateral borders of the extremity of the mass. The neck of the 
tumor is encircled by the cervix, which forms a shallow giitter around 
it, and presents no opening for the passage of a sound higher up in 
the canal. Rectal indagation reveals the absence of the uterus from 
its normal position, and will discover the depression at the upper 




192 PRACTICAL GYNECOLOGY. 

extremity of the cervix through which the uteruB has descended. A 
polypus may be recognized by the absence of a cervical canal, and 
the fact that a sound may be introduced into the uterine cavity along- 
side of its pedicle. In inf ravaginal elongation of the cervix the sound 
will demonstrate the unusual length of the canal and that the fundus 
is well up in the pelvis. Bimanual and rectal examination will also 
reveal the body of the uterus at or near its normal level. 

Treatment. — ^The treatment may be palliative or radical. With 
the improved methods of modern times and the slight risk attending 
them, the radical treatment has grown rapidly in favor and is much 
practiced. There is, however, a very considerable contingent of such 
subjects that cannot bring themselves to consent to operative inter- 
ference, and for whom other measures must be devised. 

The first and second degrees of prolapse, especially if the pelvic 
floor is not too much damaged, may sometimes be satisfactorily treated 
by restoring the womb to its normal position and holding it there 
by a Hodge pessary or some of its modifications. When this fails, 8 




Fig. 99.— Inflatable King Pessary. 

ring pessary will occasionally do good service. The inflatable ring 
pessary is a good device. In the majority of cases neither of these 
will be found effective, owing to the break in tlie pelvic floor, the 
straightness of the canal, and the weight of the uterus backed by 
the intra-abdominal pressure. In some cases a cup and stem pessary 
supported by straps under the perineum attached to a belt around 
the waist will be found efficient, but is liable to give rise to irrita- 
tion and ulceration if tlie patient be too much on her feet. The 
Braun colpeurynter is, taken all in all, probably the most rational 
and effective mechanical support of the prolapsed uterus associated 
with a broken pelvic floor. Hollow glass or rubber balls of proper 
size, and adjusted with the patient on her back, are cleanly and 
effective, and in some respects preferable. Whatever form of me- 
chanical appliance is used, it should, if possible, be removed at night 
and thoroughly cleansed before reinsertion. The vagina should also 
be douched by some mild antiseptic. 



DISPLACEMKNTS OK TIIK LTERL'S. 



193 



Operations for the restoration ami luaintcuance of the uterus 
in its normal position should, in mast inptiinces, include the repair 
of the pelvic floor, as without tliis no penuancTit result can be ex- 
pected. Cystocele of moderate degree may require no special operative 
interference; otiierwise, it may be dealt with by some one of the opera- 
tions sfMJcially designed for it, as heretofore described. The weight 
of the uterus should be reduced, its circulation improved, and its 
tonicity raised by repair and amputation of the cervix and curettage. 
A 8«"»joum in Iicd, with the hips elevatci) and the uterus kept ns near 
as possible in tlie noniuil po*;ition, will be found of great service in 
imparting lone and linnness In the vagina, the uterus, and its liga- 
ments. Polypi should be removed and ncoplasrtis of all kinds receive 
attention appropriate to each. Tlie bowels should he kept solulde, 
the bbidder should be emptied at regular intervals, and the functions 
of the body looked after in general. Catheterization should not be 
resorted to unless al)soluteIy necessary, patients will usually be able 
to empty the bladder wnipletely by pressure on the cystocele by the 
finger. 

The operations now most in vogue for repair of the pelvic floor 
and narrowing the vagina arc the Emmet, the Hegar, and the flap- 
splitting operations as described elsewhere. An enlarged or elongated 
cervix calls for amputation. In some of the minor degrees of pro- 
lapse these operations may sidlicc. but in most instances it will be 
neeessarv' to suspend the uterus from above in such a way as to throw 
its fundus forward and maintain it there. In old women with com- 
plete prolapse, the Freuiid operation of narrowing the vagina by a 
series of circular submucous silver-wire sutures is both effective and 
devoid of the dangers incident to the more formidable and prolonged 
plastic operations. l>ong-<'(intinued etherization is dau;^crous in such 
cases. In the feeble and aged, vaginal extirpation of the uterus, be- 
cau.se of tlie rapidity with which it can be executed, may sometimes 
be found expedient. This, however, makes no jirovision for the 
relaxed vaginal outlet, which will demand attention at tlie time or 
Bubsequontly. 

Hijslerorrhaphy. — Some of the niililer t'luins of prolapse may 
be treate<i by operations on the pelvic floor, the vagina, and cervix. 
Others by the addition of such measures as will keep the uterus in 
ant<-positi<iii. such as shortening of the round or iitero-sacral liga- 
ments and ventrosuspension of the uterus. These have been described 
elsewhere. 




194 PRACTICAL GYNECOLOGY. 

Ventrofixaiion. — In aggravated cases it becomes necessary to 
invoke the aid of a sustaining force from above, and in such it will 
be necessary to fix the uterus to the anterior abdominal wall so firmly 
as to preclude its drawing away therefrom and settling in the pelvis. 
Any attachment to the peritoneum is unreliable in that this membrane 
is ductile and in time becomes elongated, allowing the womb to settle 
and move backward, to the undoing of that which had been accom- 
plished. Permanent sutures, as recommended by some, are prone to 
suppurate. Ventrofixation offers the only reliable and trustworthy 
method of dealing with this class of cases. 

An abdominal incision several inches in length is made in the 
median line at the usual site between the umbilicus and pubis. The 
fundus is brought forward and the serosa scarified by the scalpel or 
needle. The parietal peritoneum is stripped from either side of the 
incision, about an inch and a half above the pubis, for such distance 
as will accommodate the fundus. The uterus is now secured by two 
sutures, which are passed through the deep fascia on one side, one- 
half of an inch or more from the edge of the incision into the ab- 
dominal cavity, not including the reflected peritoneum, thence deeply 
into the fundus from one side to tlie other and out through the 
abdominal wall on the other, emerging on the fascia. These sutures 
should be one-third of an inch apart and of No. 2 dried sterilized 
catgut. The sutures are tied and the incision closed in the usual 
manner. The patient should be kept recumbent for at least three 
weeks. By the time the sutures are absorbed, firm union has taken 
place and the fixation is complete. It must be admitted, however, that 
even this will fail under extraordinary conditions, and no auxiliary 
means should be neglected to support and sustain the uterus. 

Round-ligament Suspension. — The author's round-ligament sus- 
pension modified by drawing the round ligaments through the broad 
ligament before implanting them into the abdominal wall is probably 
as reliable as any of the methods employed. 

Varjinal Hysterectomy. — Vaginal hysterectomy supplemented by 
suturing the superior border of the vaginal wall to the liroad ligaments 
a.*! high up as convenient is an operation much in vogue, and in the 
non-child-bearing woman may often be advantageously employed. 
Let it be reiterated that in all these operations it is absohitely essential 
that the pelvic floor should receive any necessary attentions. 



CHAPTER XVII. 

DISPLACEMENTS OF THE UTERUS: VERSIONS 
AND FLEXIONS. 

VERSIONS AND FLEXIONS OF THE UTERUS. 

* Yehsions and flexions of the uterus are denominated according 
to the position of the fundus. When the fundus inclines forward, 
the condition is known as anteversion or anteflexion; when back- 
ward, retroversion or retroflexion. By version is meant a rotation 
of the uterus on its transverse a.xis; by flexion, a bending of the 
uterus on its long axis. The uterus may be bent forward, consti- 
tuting anteflexion; backward, constituting retroflexion; or to one 
or tlie other side, constituting lateroflcxion. The uterus may be 
turned forward, constituting anteversion; backward, constituting re- 
troversion ; or to one or the other side, constituting lateroversion. As 
tlie normal position of the uterus is with the fundus forward, its 
anterior wall resting on the bladder, and there is no symptomatology 
pertaining to any degree of forward tilting of the uterus, it is doubt- 
ful if there bo such a thing as pathologic anteversion. The symptoms 
heretofore ascribed to the strongly antevertcd uterus are due to an 
inflammatory condition of the organ, underweight, abnormal fixation 
through adhesions, or to some other lesion. Anteversion will, there- 
fore, not be considered aa a distinct pathologic entity. 

ANTEFLEXION. 

Anteflexion is a forward bending of the uterus. A moderate 
degree of anteflexion of the uterus is normal. It is more pronounced 
in the virgin than in the matron. Under ordinary conditions the 
anteflexion is not fi.xed, and may be overcome by slight counter- 
pressure. When the uterus is removed from the body and laid down 
it becomes straight. There are two distinct forms of anteflexion: 1. 
That in which the body is bent upon the cervix. 2. That in which 
the cervix is bent upon the body. 

Flexion of the Body on the Cervix. — In the first form the cervix 
retains its natural relations to the axis of the vagina, — that is, at 
right angles to it, — but, owing to the shortening of the utero-saoral 
ligaments, is drawn upward and backward and held there. It is con- 

(195) 




196 



PRACTICAL GYKECOLOGY. 



Bequently higher in the pelvis tlian normal, and comparatively im- 
movable. This throws the fundus forward. The uterus in these cases 
ifl usually about normal in size, but may be undeveloped or even 
infantile. The flexion is at the level of the internal os. The ante- 
rior wall of the uterus at the point of flexion is increased and thick- 
ened. The muscular wall at this point is, to a degree, replaced by 
fibrous tissue. The posterior wall, where it bends over the flexion, 
is thinned. The cenux is short, and, as a rule, the canal patulous 
and cylindrical. The endometrium, in cases of long standing, is 
changed: usually atrophied and wanting in lymphoid elements, 
though at times hypertrophied. It may be inflamed. 



Fig. 100.— Anteflexion: Flexion of tho Body on the 
Cervix, Utero-sacTul I.igumenta Shortened. 



Causes. — The primal cause is found in the shortening of the 
ntero-sacral ligamcnt«. Whether this shortening is due to some 
inflammatory condition of the ligaments or to a developmental 
change is not determined. In early life the uterus occupies a higher 
position in the pelvis than in the adult. An arrest of development 
on the part of the utero-sacra! ligaments, or any disease by which 
their elasticity is diminished, will throw the developing body for- 
ward. (Fig. !ii(». ) Intra-abdominal pressure, lacing, engorgement 
at the menstrual period, or growths in the body of the uterus will 
increase the flexion. 

Symptoms. — The cardinal symptoms are dysmenorrhea and ste- 
rility, to which may be added dyspareunia and various localized nervous 



I 



DISPLACEMENTS OF TIIE UTERIS. 



197 



derongemente. The menstrual flow is rc<riilar, but scant. It is 
ushered in by pain over the region of the womb, which is paroxysmal. 
The pains resemble those of labor, and result in the expuli»ion of the 
imprisoned blood, which is more or less clotted, and is followed by 
a period of relief. The regular menstrual flow is followed by a leu- 
corrhea which lasts for several days. The menstninl effort has a 
depressing and weakening influence on the patient. Tlie longer the 
trouble continues unchecked, the greater is the severity of the pain 
and the etfet-t on the general health. In the married, sterility, vag- 
inismus, and dyspareunia are common. Cervical complications, such 
as inflammation and erosion, are not common. 



Fig. 101. — 'Mill ii.'Moti: tii'\iiiii 1.1 ih>' I irvix on llie Body. 

Flexion of the Cervix on the Body. — In this form the cervix is 
in line with the vaginal canal. It is bent more or less sharply on 
the body, which occupiw its normal position or may be tilted more 
or less back%vard : anteflexion with rt'trovcrsion. (Fig. inl.) The 
cervix is hypertrophied, sometimes markodly so, ami usually conical. 
The uterus lies low in the pelvis. The depth of the uterine canal is 
increased, due to the elongated cervix. The attaclimont of the bladder 
to the cervix is abnormally high. The endometrium is hypertrophied 
and much thickened at the point of flexion. The overgrowth of the 
cervix is a developmental frejik which cannot be explained. 

Symptoms. — The principal symptoms are sterility, various nerv- 
ous reflexes, and more or less dysmenorrhea. The patient suffers 




198 



PRACTICAI. OYNTCCOI-Or.y. 



from backache, and a bearing down, with dragging sensations, about 
the pelvis. Vaginismus is not uncommon. The menstrual flow is 
more abundant than in the preceding form, and is less clotted and 
less painful. The succeeding leucorrhea is also more profuse. 

The essential cause of the dysmenorrhea and sterility dependent 
on anteflexion has long been a subject of controversy. On the one 
hand, obstruction at the point of the fle,xure has been advanced as 
the sole factor, and, on the other, structural changes in the endo- 
metrium. The exponents of the obstruction theory contend that the 
narrowing of the canal at the flexure otTers a mechanical obstacle to 
the exit of the menstrual flui(^, and to the entrance of the sper- 
matozoa, which fully and 8im]>ly explains all the attendant plie- 
nomcna. The oppotifuts of this view claim that a canal that will 
admit a uterine sound cannot offer any serious obstacle to the men- 
strual blood, much less to the spermatozoa, which- are only one six- 
thousandth of an inch in diameter. The truth probably lies on both 
sides. While a sound may be pushed up through the canal, it must 
be remembered that even with the greatest gentleness it exerts a 
met'lianieal force far greater than a few drops of blood behind the 
obstruction, and that it gains entrance by pushing aside tbe tissuea. 
The propulsive power of the spermatozoa is infinitesimal. It is often 
necessary to straighten the canal by traction of the cervix before even 
the sound can be introduced. It should also be remembered that 
there is a distinct thickening of the mucosa at the point of flexure, 
and that all conditions are aggravated at and near the menstrual 
period. The mucosa is engorged and swollen, the fle.xure augmented 
by the increased heavinej-s of the body, while the normal expansion 
of tlie canal which accompanies the menstrual effort is more tlian 
counterbalanced by these changes. 

But this does not account for the great pain, the nervous dis- 
turbiince, the vaginismus, the dyspareunja, the clotting of tlie men- 
strual blood, nor yet for the constancy of sterility. These are un- 
doubtedly due to structural changes in the uterus, and especially 
the endometrium, wliercby its functions are perverted and its sensi- 
tiveness increased. There is an attendant localized supersensitiveness 
of the genital tract and the parts dominated by the same system of 
nerves. The endometrium is not normal; consequently it affords no 
suitable soil for the ovule, and is probably inimical to the sperm-cell. 
It is attenuated and devoid of succulence, and is wanting in lymphoid 
elements. The epithelium clings tenaciously, and, instead of melting 
away as it should, is forced off in flakes and ahreds. The blood 





DISI'I^CEMKNTS OK THE I'TKRUS. 



i;»'» 



I 



I con 



coming too rapidly from sundered veesola and not being intimately 
blended with the lymphoid elementa, coagulates. And this increases 
Uie difficulty. 

To summarize, the chief factors of disturbance are: — 

1. Mechanical obstruction. 

2. The increase of the same at the menstrual period. 

3. Supersensitiveness of the genital tract. 

4. Altered endometrium, which is inimical to the elements of 
fecundation and increases the difficnltius of menstruation by the 
tenacity of the epithelium and the clotting of the menstrual blood. 

Diagnosis. — Bimanual examination will reveal the relation be- 
tween the cervix and body. The fingers in the vagina will recognize 
a distinct angle at the point of flexion. To exclude a fibroid in the 
anterior wall of the uterus, the thickness of the body and the relation 
of the posterior wall to the cervix should be ascertained by deep 
palpation, either through the abdominal wall or the rectum, while 
tlie anterior wall is steadied by the vaginal finger. In difBcult cases 
the direction of the canal may be ascertained by the sound. 

Treatment. — For the first form of anteflexion — that of the body 
on the cervix — the object is to straighten the canal, overcome the 
obstruction, and produce an alterative effect on the endometrium. 
As tlie utero-sacral ligaments are, in large measure, responsible for 
the abnormal position of the uterus, a seemingly rational course would 
be to deal with them direct, as one would relieve the tension of a 
contracted muscle by tenotomy. This, however, has not received the 
ction of usage. 

The canal may be straightened, temporarily at least, by dilata- 
tion. This should be by the branched dilators, and should be thor- 
ough, systematic, and deliberate. The canal should be dilated to the 
extent of an inch or an inch and a half, as indicated by the scale of 
the dilator, and from ten to fifteen minutes should be consumed in 
the process, after which the dilator should be held in position for an 
equal length of time. In the meantime steady traction should be 
e.xerted on the cervix, and the womb drawn down in the pelvis to 
stretch and lengthen the utero-sacral ligaments. After the dilatation 
the womb should be thoroughly curetted, irrigated, dried, and swabbed 
with 95-per-cent.. carbolic acid. This should be followed by a gauze 
packing, which may be allowed to remain from four to six days in 
the absence of pain or fever. The patient should remain recumbent 
for at least a week. In married women, pregnancy will sometimes 
follow this renovation, which if it go to full term insures a perma- 




200 



PRACTICAL OYNECOLOGY. 



nent euro. In tlie unmarried the procedure may have to be repiriu 
at longer or sliorter iutervals. 

Dysmenorrhea associated with anteflexion is frequently reli.'Ved 
by the gliifs stem pessary. The iuHtrument, as devised l»y Dr. ITej)]<er- 
len, is made of solid glass, teniunating iu a ilange sloping downward. 
The flange has two small holes through which sutures are intrfKlueed 
to retain the jtcsaar}' in situ. Tlie pessary choiild he introduced as 
soon after menstruation as is possible, and removed in from three to 
four months. The presence of diseased appendages and adhesions 
interdict its use. Before insertion the jnUient is anesthetized and the 
uteruf! dilated and curetted under thorough asepsis. The stem is held 
in place by silk-worm gut, the sutures being introduced deeply into 
the tissues of the anterior and posterior lji)8 of the cervix. The patient 
is kei)t iu bed from tiirce to six days, then allowed to resume her 
duties. 



I 



F)(f. 102. — flliiRS St4>m Pessary. 

In the second form of anteflexion, where the cervix is bent on 
the uterus, tlie accompanying hypertrophy of the cervix will re<piire 
attention. Here the uterus lie.s low in the pelvis, with a disposition 
to drtip, and consequently little traction should be e.\ertefl on it. 
Moderate degrees of hypertrophy of the cervix will yield to tlie altera- 
tive changes produce<l by the dilatation and curettage. The steps of 
the operation are as described above. Where the cervix is inordinately 
elongated it should be anipututed. This may be done at the same 
sitting with the dilatation and curettage. In all other respects the 
treatment is the same as in the tirst form. 



RETRODISPLACEMENTS OF THE UTERUS. 

These consist of retroversitm aud retroflexion. Hetroversion and 
retroflexion are bo frequently associated and have so much in com- 
mon as to justify joint considiTiition. The retrodisplaced uterus 
usually occupies a lower level in the pelvis. This is because of the 
fact that the long axis of the uterus is brought in line with the vagina 
through which it descends. IJetrotlisplaeement of the utenis may 
occur at any age. In general terms, it may be said that retroflexion 
is essentially a lesion of the child-bearing woman as anteflexion is 
of the nonparoua. Retroversion of the uterus, for convenience of 



DISPLACEMENTS OF THE ITTERTTS. 



201 



cription, has been dividwi iuto three degrees. The first is that 
in which the long axis of the uterus corresponds to the long axis of 
tlie body; the second, whore the uterus lies transversely across the 
pelvis with its fundus looking backward (Fig. 103) ; and the third, 
in which tlie fundus has descended below this level. It must be 
remembered, however, that this is a purely arbitrary division, and 
that tliere are many intermediate degrees of retroversion. 

Causes. — ^The causes of retroversion are partly inherent in the 
uterus and partly depend on extraneous conditions. A heavy, flabby 
uterua offers conditions favorable to retroposition. Lax ligaments 
and absence of the normal supjjort from below also favor it Both 



V'lH. lli;i. — l;i-tri)viTsifiii of Itu- ricriis, 

of tliese sets of conditions exist after childbirth and before the 
process of involution is complete. Hence, many cases of retroposi- 
tion, probably a large majority of them, date from childbirth. Acute 
inflammatory conditions of the uterus, especially those arising from 
sepsis, increase its bulk and diminish itfi tone, and also tend to pro- 
duce like changes in the supporting structures. Under these circum- 
stances, if the uterus by any chance gets a backward inclination, it 
cannot recover itself, for the ligaments which are intended to check 
and restore it are toneless and inert. Now, the intra-abdominal 
pressure falling upon the anterior surface of tlie womb crowds it 
farther and farther to the rear, and forces it into the hollow of the 
sacrum. The tendency is from bad to worse, until the extreme limit 
of retrodisplacement is reached. In the newly delivered woman the 



203 



PRACTICAI. nvNEroTXJoy. 



abdominal walls are flabby, thus, in great measure, abolishing the 
retentive power of tlie abdomen. In a more gradual, but none the 
less effective, way the broken pelvic floor acts as a potent factor in 
retroposition. 

The bulging forward of the posterior vaginal wall in rectocele 
drags the cervix forward and downward and tilts the uterus back- 
ward until the intra-abdominal pressure is exerted on its anterior 
surface, when the sequel is as described above. Inflammatory bonds 
strung between the uterus or its appendages, and tlie structures in 
the hollow of the sacrum by shrinkage may overturn and bend that 
organ into a state of retroposition. An overdistended bladder, or 
the dorsal decubitus aided by tight band.aging during the puerperium 
may impart the initial movement. Where the cervix moves forward 
in the arc of a circle as the fundus moves backward, the result is 
retroversion. When, however, as is usually the case, the cervix fails 
to resjiond to the movements of the fundus, the uterus becomes bent 
upon itself, constituting retroflexion. Usually the two are associated, 
in which we have retroversion combined with retroflexion. Prolapse 
of the tubes and ovaries usually accompany the backward displace- 
ment of the uterus. 

The effect of retrod isplacement on the organ itself is damaging. 
This arises principally from two causes: i.e., interference with the 
circulation and imperfect drainage. The broad ligaments being 
twisted, the venous circulation is embarrassed. Passive congestipn, 
especially afTecting the endometrium, ensues, which, in turn, is liable 
to pass over into inflammation. The imperfect drainage of the uterus 
invites microbic infection. Hence endometritis, often purulent, is a 
common accompaniment of this form of displacement. 

Symptoms. — One of the most prominent and constant symptoms 
of retroposition of the uterus is backache. This is referred to the 
lumbar and sacral regions. Not infrequently the pain radiates down 
the thighs, and is accompanied by a weakness of the limbs, which 
renders walking or standing irksome or even impossible. Headache 
is also common, which is referred to the top of the head, or occipital 
region. A burning pain at the nape of the neck complicates some 
cases. Constipation is the rule. This is largely mechanical, and is 
due to the pressure of the fundus on the rectum. For the same reason 
piles are frequent. Dragging on the bladder through traction on the 
vesico-utertne ligaments produces vesical irritation, and not infre- 
quently inability to control the urine. This is often taken for and 
treated as cystitis. Displacement of the ovaries often gives rise to 



4 

4 





DISPLACEMENTS t)F TlIK UTERUS. 



203 



ovarian pain. The endometritis and circulatory embarrassment give 
rise to leucorrhea, which is often profuse. Menstruation is usually 
profuse, and is seldom accompanied by pain, owing to the fact that 
the subjects are generally women who have borne children. In such 
Uie uterine canal is usually patulous and the endometrium fully 
developed or hypertrophic Reflex disturbances are, however, usually 
aggravated at this period. 

Diagnosis. — Bimanual examination reveals the absence of the 
fundus in its normal position, and the finger in the vagina discovers 
it in the hollow of the sacrum. In the lesser degrees of retrodisplace- 
ment the fundus may not be felt either by the external or internal 
hand, yet the cervix and the lower segment of the uterus may be traced 
by the vaginal finger in the direction of the fundus. The rectal touch 
will give valuable aid in all cases of retroversion, and in case of doubt 
should never be neglected. This, conjoined with traction on the 
cervix, will often enable the examiner to outline the uterus with 
great precision. When evidence, or even a suspicion, exists of im- 
flammatory exudation in the vicinity of the uterus or appendages, 
traction on the cervix should not be resorted to. Finally, the sound 
will show the position of the uterus by following the direction of ita 
canal. This, also, should be used sparingly and with discretion. 

Treatment. — The treatment is mechanical and operative. Me- 
chanical treatment consists in restoring the uterus to its normal 
position and holding it there by some mechanical device. Manual 
replacement is the method of choice, because safer, and should always 
take precedence when practicable. It is not always expedient, nor 
yet feasible, to replace the organ at once. The uterus may be in- 
flamed, swollen, and excessively tender. The appendages may be in 
like condition, or adhesions may exist which must be overcome before 
the organ can be restored. 

Inflammation should be combated by rest, by keeping the bowels 
soluble, by hot douches, and hip-baths. Excellent results are some- 
times obtained by swathing the hips in several thicknesses of flannel 
which have been dipped in very hot water and passed through a 
wringer. Over this should be placed dry flannel to retain the heat 
and moisture. This should be removed in an hour, and the patient 
rubbed dry under cover. Gradual elevation of the womb by vaginal 
tampons saturated with boroglycerid relieves the circulation and 
diminishes congestion. When the inflammation has been subjugated 
and the tenderness abated, measures for the restoration of the uterus 
may be instituted. 




204 



I'RACTrCAL GYNErOLOGY. 



When adln'iiions exist, if of recent date and not firm, they ml 
be broken up in the rectum l>y the Schulze metliod, whicii consists in 
carrying the fingers up in the rectum and hooking them in between 
the utenis and rectum, making pressure first in one direction and 
then another until all adhesions are overcome and the uterus liberated. 
Should the appendages be adherent, they may be dealt with in like 
manner. Too much force should not be exercised in the maneuver, 
and it should not be undertaken when a purulent accumulation exists 
or iB suspected in tlie pelvis, lest rupture of the same should precipi- 
tate septic peritonitis. The patient should be etherized and the cervix 
steadied by the thumb in the vagina during the operation. In ex- 



Fig. 104. — Congenital RctroUcvlon o( the Uterus. 



treme degrees of retrodisplacemcnt the uterus is sometimes caught 
between the utero-sacral ligaments and gives the impression of being 
adherent. It is most easily disengaged by pressure from the rectal 
side. Etherization may be necessary to relax the ligaments. 

Congenital Ketroflexion. — Retroflexion may be congenital or 
acquired. The congeuitul form is very rare. The position of the 
nteruB in this form is characteristic. It is not much, if any, de- 
pressed, but is located far back in the pelvis near the posterior wall. 
The organ is sharply bent on itself, so that the fundus and cervix lie 
almost parallel with each other. The fundus occupies the cul-de-sac, 
and presses against tlie rectum. (Fig. 104.) The flexion is at tlie 
internal os, and the posterior wall is much thickened. The anterior 



I 



D18PLACEMKNTS OP THE ITTERUS. 



205 



wall is thinned. Not infrwjuently the uterus is fixeil by inflammatory 
aUliesioDs. The ovarius and luhes are seldom disjilactil. Endcniietritis, 
often purulent in character, is a common acconipaninient. 

t^'ytiiptuinji. — The most prominent symptoms are backache, head- 
ache, dysmenorrhea, sterility, mid olwtipaliim. The backache is con- 
tinuous, and is associated with weiglit and bearing down. The head- 
ache is referred to the occipital region, and is more violent at the 
menstrual period. The dysmenorrhea is .similar to that of autetlexion, 
and is characterized by a scant flow and clotting of the blood. Pressure 
of the retroflexed womb on the rectum interposes a mechanical nbstacle 
to tlie expulsion of its contents, as also to the venous circulation, 
giving rise to hemorrhoids. 

iJiagnoitiii. — Bimanual examination by rectum and vagina will 
reveal the position of the uterus and the ajiproximation of the fundus 
and cervix. Usually the angle produced by the flexion can also be 
deterraineil. 

Trvntment. — Snch cases are seldom or never amenable to me- 
dianieal or operative measures designed to restore the uterus to its 
normal position. About all that can he done is to cure the endo- 
metritis and provide for drainage. This is ctlVcted by an incision 
through the projecting spur on the posterior wall, whereby the canal 
is made patulous and to an extent shortened mid straigtitencd. The 
knife should he carried from above the interoal os downward, and 
should penetrate deeply. The canal is now dilated, curettage per- 
forine<l, and the cavity swnhtifd with carbolic aciil and packed with 
gauze. The package should be snug, and reinforced by vaginal tam- 
ponade to control the hemorrhage, which is apt to be profuse. The 
packing should he allowed to remain forty-eight hours. The vagina 
sliould be cleansed and loosely packed every second day for tliree 
weeks; and it will materially add to the success of the operation if a 
fillet of gauze lie laid along the tract of the incision at like intervals 
^^^ during the tirst six or eight days. 

^H LATERAL DISPLACEMENT OF THE UTERUS. 

^^" This may occur to the right or left, and is usually due to the 

I contraci 
I be push 
I growth. 



contraction of the broad ligament or to adhesions. The uterus may 
be pushed to one side by an inflammatory exudation or a morbid 
growth. The treatment is seldom required for this condition per se. 



CHAPTER XVIII. 

LaCEMENT and retention of the UTERU5— 
KELLOQa'5 OPERATION. 

REPLACING THE UTERUS. 

WUERE no contra-indication exists to the replacing of the uterus, 
it may be done by one of two methods. That is, by manipulation or 
by the aid of instruments. The patient should be prepared for the 



4 



^^^^551 



i 



->A' 



t»:^^ 



iW- 



# 



tig. 106. — BimaDua! Rcpositica of the Rrtrorertrd UlanMi 
(Fin* MoTcnreat.) 



oooMion by empt^-ing the bladder and reciuxn and bj Tooaening th« 
cloihia^ It u ahsoiuitlf essfniial thai tken A<mU fr« $m amttric- 
ti»m ab»mi the traist. 

Xuial B*pUe^Mftt of tke Utcna. — ^This ma; be effected 
plaeing the patient on her back, in the Sima or knee-cheat 
Tbe patient being oo her ba^ vith the legi flexed, tvo fingexa 
ana hand ate introduced into the Tagina and the other hand laid 
0N abdotwi. (Fig. 105.) The ntema is first drawn avaj 
the aaenun bj pteBBare on the poatnior lip of dw oerrix (avaid 



REPI^CEMENT AND RETENTION Or" THI-; I TERUS. 



-'(17 



he bladder. Then one finger is disengaged and makes pressure on 
Uie fundus, while the otlier finger maintains the pressure on ttie 
cervix. The fingers of the extfrnul hand depress the abdominal wall 
and are forced downward and backward toward the sacral curve. 
(Fig. 106.) As the fundus rises it is caught on the tips of these 
fingers and the vaginal finger shiftp to the front of the cervix, 
which is pushed backward and upward. (Fig. 107.) Finally, as 
the uterus is brought into a state of anteversion, the cervix is again 
pushed forward, sliding llie uterus forward in the pelvis to its nor- 
mal position. If the fundus be lifted directly forward it may be 




Fig. 106. — Bimanual Reposition of Retroverted Utenti. 
(Second Movemeat.) 

caught and held by the promontory of the sacrum. This can be 
noided by swinging it around this projection to the right or left, 
Whichever is most easy of accomplishment. Another metliod quite 
as efiBcacions consists in placing the patient in the Sims position, 
and hooking two fingers over the cervix and drawing it backward. 
One finger — the second — is now disengaged, and presses upward on 
the fundus while the index finger pulls backward on the cervix. In 
tills way the womb is made to revolve on its axis and is thrown into 
anteversion. In this, as in the dorsal position, the fundus should be 
swung around the promontory of the sacrum, usually toward the left 




208 



PRACTICAL GYNEtXJIXXJY. 



InBtrumental Beplacement. — It is Beldom that the foregoing 
method will not be successful, and, therefore, the necessity for resort- 
ing to instrumental means of replacement is very infrequent. The 
instruments usually utilized for this purjiose are the uterine sound 
and the uterine repositor. Both of these are objectionable, because 
they must be introduced into the uterine cavity, which they are liable 
to mutilate and infect, and because it is impossible to estimate the 
force that is being exerted, or the effect of that force, on the delicate 



mi 



f'BlST 



/f.^/l^^ 



Fig. 107. — Bimanual Reposition of Retroverted Utenu. 
(Last Movement.) 

structures which are subjected to it. Nevertheless, conditions will 
arise in which we are compelled to resort to then; if we would relieve 
our patient, and it is a consoling fact that under the usual aseptic 
precautions the instances are few in which serious damage has resulted 
from their use. 

Beplacement by the Sound. — The sound, bent to conform to the 
shape of the canal, is carried to the fundus with its concavity toward 
the sacrum. It is now rotated so as to bring the concavity forward. 




REPLACEMENT AND RETENTION OF THE UTERUS. 



209 



In this maneuver the external end of the sound is made to describe 
the arc of a large circle, to prevent injury to the mucosa. Now, by 
gentle leverage on the sound, aided by a finger on the fundus through 
the vagina or rectum, the uterus is raised and brought forward until 
it can be grasped by the abdominal hand and forcod into position. 
(Fig. 108.) 

Eeplacement by the Uterine Hepositor. — The uterine repositor 
consists of a movable lever on the end of a handle, controlled by a 
screw at tlie external end of the handle. This lever can be made to 
describe the arc of a half-circle. It is adjusted so as to be easily 
introduced into the uterine canal, when by turning the screw it lifts 
the organ and throws the fundus forward. It is a powerful instru- 
ment, and should be nsed with the utmost discretion, and always. 



^: 



^'•i n 



.'M 






m 



Fig. 108. — Reposition of Retroverted Uterua by the Sound. 

when possible, be controlled and assisted by a finger in the rectum or 
vagina. 

RETENTION OF THE UTERUS AFTER REPLACEMENT. 

Unless retained in place by artificial means, the uterus will usu- 
ally revert to the abnormal position from which it was just rescued. 
The methods by which the uterus is kept in place are mechanical and 
operative. 

Mechanical Methods. — These include the tampon and pessary. 
The tampon is efficient and may be made to serve every purpose, but 
it requires such unremitting attention on the part of the physician 
aa to preclude its general adoption. As a precursor to the use of the 
pessary where the latter would not be tolerated, as in inflammatory 



210 



PRACTICAL GYNECOLOGY. 



conditions of the uterus and adnexa, or when a temporary effect is 
desired, as in acut* displaceniont, tlie tampon is indicated. In such, 
a wad of cotton is placed in tfie posterior fornix back of the cerviiJ 
and a full-sized vaginal tampon placed under the cervix to maintain^ 
it in position. The value and necessity of the post-cervical taiiipoaj 
will be explained fartlier on. Tliese tampons sliould be removed, and,' 
after cleansing the vagina, replaced at regular intervals : usually every 
twenty-four hours, or oftener when the discharges are abundant or 
foul. 

The Pessary. — The vaginal pessary is an agent for good or for 
evil, according as it is used judiciously or otherwise. The intelligent 
gynecologist of to-day finds infrequent use for the pessary, and yet 
it has a place in gjTiecic practice that cannot be ignored. The object 
of the pessary and the manner of its adjustment are very imperfectly 
understood by the mass of tlie profession, and hence the evil accruing 



Fig. 109. — Sims's Uterine Repositor for Keplacemcnt of the 
Retroverted Uterus. 



from its use has probably overbalanced the benefits. It has been said 
that it requires a high order of mechanical skill, and an intimate 
knowledge of the pelvic mechanism, to adjust a ppssury. This, in a 
large measure, is true, for it is impossible to adjust a pessary too 
nicely, and there are infinite shades of variotion in the pelvis and its 
contents which can only be met by mechanical instinct. Nevertlie- 
less, much good, though imperfect, work can be accomplished by any 
man of ordinary intelligence and mechanical ability who will acquaint 
himself with the cardinal facts. 

In the first place it must be learned that the pessary is made 
for the woman, and not the woman for the pessary. Almost any 
kind of a pessary can be jambed into a woman's pelvis, and often- 
times with the result of holding the uterus upward and forward. But 
this may be at the expense of grave and sometimes irreparable injury 
to the delicate structures upon which it impinges. Inflammation, 
ulceration, and even perforation of the vagina] vault, the bladder, or 



REPIJVC'EMENT AND KETKXTluN Of THE UTERUS. 



211 



the rectum have been penalties for such rash and ill-judged practice. 
On the other hand, too small a pessary dropped into the vagina will 
be promptly expelled, or, if tolerated, will be wholly inadefjuate as 
a means of support. It must be remembered that the object of the 
pessary is to sustain the uterus in its normal position without fixing 
it, and that it must not exercise undue pressure at any point. The 
uterus must be allowed perfect freedom of motion throughout the 
range of its normal mobility, and must be sustained at a level which 
will not interfere with its circulation. In other words, it must be 
allowed free play to accommodate itself to the varying positions of 
the body, and to rise and fall with the bindder. Hence, it must be 
suspended as upon a movable fulcrum, and not wedged. 

Tliis opportunity is offered by the attachment of the vagina to 
the posterior wall of the cervbc. Here exists a pouch whicJi passes 
upward and forward back of the cervix, and offers a convenient nook 



Fig. 110. — Smith-Hodgc Pcidary. 



for the reception and retention of the pessary. The effect of upward 
pressure at the vault of the cul-de-sac when the fundus is inclined 
forward is to elevate the cervix and tilt the fundus downward and 
forward. In other words, it throws the uterus into antcversion. This 
is the only place where a mechanical support can be applied through 
the vagina to produce a suspensory effect on the uterus, and it is so 
well adapted to tliis end that one is almo.«t tempted to the belief 
that it was designed for tlie purpose. Nevertheless, it retjuired the 
ingenuity of a Hodge to discover and utilize it for the support of 
the retrodisplaccd and prolapsed uterus. The Hodge pessary, and 
modifications of the same, are so constructed that one end fits into 
the pouch back of the cerv-ix, and the other is in proximity to, but 
does not rest upon, the pubic rami. This gives to the instrument aa 
viewed from the side the outlines of a letter "S" with the most 
exaggerated curve at the top, or uterine end. The pessary, as usually 
marketed, is constructed of hard rubber and is molded in one piece, 




212 



PRACTICAL GYXECOLOGY. 



ns if from a ring, of the thicknoss of heavy telegraph wire. Tho 
original Hodge pessary is almost rectangular, as viewed from the 
front; but there are modifications of this, the principal of which 
are those of Smith and Thomas. The Smith pessary is narrower 
and tapers toward the pubic extremity. The Thomas pessary has an 
enlarged and thickened cross-bar at the uterine e.xtremity. 

The pessary properly adjusted should not exercise pressure at 
any point. It should be so poised that when the uterus is in ante- 
version the pessary barely touches the vault of the post-cervical pouch, 
while the instrument, as a whole, occupies the axis of the vagina. 

Owing to its shape, if the uterus is tilted backward, pressure 
on the upper segment of the pessary will cause the lower end to 
move forward until it impinges on the pubic rami, whicii prevents 
the farther backward displacement of the uterus, and it soon return.s 
to its normal position, when the pessary drops back into the vaginal 



Fig. 111. — Thomas-Smith Pessary, 



axis. It is because of this movement, by wliich pressure on one end 
will throw up tlie other, that the pessary has received its name: lever 
pessary. Under ordinary conditions it requires but the slightest 
resistance on the part of the pessary to meet the backward movement 
of the uterus, when, responding to the conservative forces instituted 
by Nature for the purpose, it soon returns to its normal position. 
Thus, in the properly adjusted pessary there is neither severe nor 
sustained pressure at any point. 

In selecting a pessary for any case, the depth of the canal should 
be taken with the uterus in place, the patient recumbent. A finger 
should be introduced to the top of the posterior vaginal fornix, and 
the distance between this and the symphysis pubis ascertained. De- 
ducting a finger's breadth from this will give the proper length of 
the pessary. The width of the pessary should be approximately that 
of the vaginal canal, to prevent lateral rotation. It should never be 
wedged into the vagina. The curves of the pessary should conform 



REPIJlCKxMENT AND RETENllON OF THE ITKRUS. 



213 



k 



to those of the vagina when the uteruB is in place, A deep poat- 
rvical pouch will demand a longer and sharper curve at the uterine 
id than a shallow one. If the pessary press upon the neck of the 
,dder or urethra, as made evident by vesical irritation or dysuria, 
the pubic curve should be altered to correct the trouble. The hard 
rubber pessary may be molded to suit any case by heating it over a 
spirit-lamp, by which it is rendered soft and pliable. After cooling, 
which may be done quickly by plunging it into cold water, it will 
tain the shape imposed upon it. 

Introduction of the Pessary. — The pessary should never be in- 
troduced until the uterus is in position, and not then if there be 
contra-indications in the way of inflammation of the uterus or adnexa. 
Great sensitiveness at the vault of the vagina is a contra-indication, 
whatever be the cause. In introducing the pessary it should first be 



Fig. 112. — Hodge Pessary, Showing Varying Degreea 
of Curvature. 



lubricated and seized by the lower extremity, the uterine curve look- 
ing upward. The labia are separated by the fingers of the other hand 
and the pessary introduced and pushed up into the vagina until it is 
arrested by the cervix. A finger is passed back of it into the vagina 
and hooked over the upper cross-bar, which is depressed until it clears 
the cervix and enters the post-cervical pouch. (Fig. 113.) Now, 
by withdrawing the finger and rocking the pessary backward and 
forward it will settle into place. After careful inspection to see that 
it is properly adjusted and adapted to the case, the woman is directed 
to get on her feet. If all is right she should not be conscious of its 
presence. 

She should be directed to return to the ofiice in four or five days, 
or sooner if she experiences any inconvenience, and at longer inter- 
vals thereafter until satisfied that all is well. She should also be 




214 



PRACTICAL GYNECOLOGY. 



instructed to use the vaginal douche as often as need be to injure 
cleanliness. This may mean a daily or weekly douche, according to 
the character and the amount of the sooretiona. Removal of liie 
pessary at stated intervals and reinsertion after one or a few days 
gives rest to the tissues and opportunity to observe the effects. 

The Schultze sled pessary may sometimes be substituted for tJie 
lever pessary, and is especially adapted to cases in which a deep post- 
cervical pouch exists. Its lower e.vtremity lias for its point of con- 
tact the anterior surface of the cervix. It has the advantrtge of not 
interfering with the sexual relations, but is not so effective in sus- 
taining the uterus as the lever pessary. The number of pessaries that 
has been devised for the correction of the displaccuieuts of the uterus 



Y-^\ 



Fig. 113. — Adjusting the Pessary. 

ia too great even for enumeration. Time was when every gynecologist 
of note and many general practitioners felt it incumbent upon them- 
selves to devise a pessary. Most of these were worthless or worse 
than worthless. For practical purposes those that have been described 
are sufficient to meet the requirements of any case to which a pessary 
is applicable. 

Operative Treatment. — As in the case of pessaries, in time« 
agone, so at a later period when operative measures, to a large extent, 
supplanted the mechanical, the ingenuity of man has been taxed to 
the utmost to devise some operative procedure by which the mal- 
position of the uterus may be corrected and the organ retained at or 
near the normal level. Here, also, we have such an avalanche of 
technique as to preclude anything like consideration of all. I shall. 



REPU\CEMENT AKl) RETENTION OF THE UTEKUS. 



21.5 



therefore, content myself with the description of a few select methods. 
In doing this it must be admitted that many excellent devices have 
been ignored, some of which possibly may have as much merit as 
those described. Still it becomes necessary to draw the line some- 
where, and 1 irust tliat in this case it has been judiciously done. 

The operative measures for reposition and retention of the retro- 
posed uterus are: 1. External and internal shortening of the round 
ligaments. 2. Ventrosuspension. 3. Round ligament ventrosuspen- 
■ion. 

External Shoiitenino of the Round Ligaments. — While 
the name of Alexander will be always and inseparably associated 
with every operation of shortening of the round ligaments for the 



r^ 



Fig. 114. — Kellogg's Instruments for External Shortening 
of the Round Ligaments. 



retrodisplacement of the uterus, as the originator, yet the operation 
as devised by him has, in large measure, been superseded by modi- 
fications which are easier of execution and less apt to be followed by 
unpleasant sequelae. I shall, therefore, content myself with a de- 
scription of such modifications as commend themselves by reason of 
simplicity and efficiency. 

Kellogg's Opeh-^tion of Shohtenino the Round Liqaments. 
— The instruments needed are a scalpel, two blunt hooks, two re- 
tractors, an aneurism needle, three clamp forceps (one of which has 
long slender jaws), a half-curved needle, silk, and silk-worm gut. 
All the instruments should be of delicate pattern. 

1. Incision. — The incision is made close to and parallel with 
Poupart's ligament, about two inches above the external ring, which 




216 



PRACTICAL GYNECOLOGY. 



is directly over the inguinal canal. It should be about one inch in 
length. It is very necessary for the success of the operation that the 
field should be kept bloodless; therefore the first incision should be 
superficial, merely passing through tlie skin and superficial fat. A 
vein crosses near the upper angle of the incision, and a small artery 
near the lower angle. To avoid these tliey should be kept out of 
harm's way by a couple of blimt hooks, which are inserted at the 
middle of the wound and drawn in opposite directions toward the 




Fig. 115. — KeHogg's Opention for External Shortening of tlie 
Round Ligaments. (Incision.) 



upjvr and lower angles. The assistant now inserts ■ pair of le- 
traotors, with which lateral traction is made, exposing the field and 
nt t;;i? same time keeping the vessels out of the way. A few slight 
touol-.os of the knife, follower! by the blunt hooks and retractors a* 
boforo. expose the glistening ap<>neuro<is of the external oblique. By 
moving the retractors in various directions the external ring and 
Poupart's lisrament are brought into view, which form the landmajria 
of the canaL The former is recognized by tiie diverging longitndiiul 



REPLACEMENT AN'D RETEXTION OF THE UTERUS. 217 

fibers and the arcuated cross-fibers, and the latter as a dense, white 
opaque line, which forms the outer boundary of the canal. 

£. Securing the Ligament. — A small puncture is now made with 
the point of the scalpel about a line internal to Poupart's ligament 
and near the upper angle of the incision. One of the blunt hooks 
is now introduced (not too deeply) and the point turned toward the 
median line. The tissues engaged are drawn up for inspection. In 
many instances the ligament will be brought into view. When such is 
not the case it is usually included in the mass taken up by the hook, 
and should be sought for by manipulating the two hooks in such a 
way as to separate and drop successively strand after strand of the 
included tissues until the ligament appears. If the first attempt 




Kg. lie. — ^Kellogg'g Operation for External Shortening 

of the Round Ligaments. Anchorage of the 

Ligament. (First Step.) 



fails, the hook may be re-entered again and again, first in one direction 
and then in another until the ligament is found. It usually lies 
quite superficially along the outer edge of the canal, nestling close 
to Poupart's ligament. When the ligament has been separated to an 
extent to be easily handled, it is seized by the thumb and finger, and, 
while traction is made on the proximal side of the loop, the tissues 
which cling to it are detached. The ligament is drawn out as far 
as it will go without undue effort, the peritoneum being stripped 
back by the aid of the forceps. In this way from four to six inches 
of the ligament are isolated, the upper extremity of which is quite 
thick, heavy, and strong. The ease with which it can be drawn out 
diSeiB materially in different cases. It sometimes "runs" with the 



218 



PRACTICAL GYNECOLOGY. 



facility of a cord over a pulley; at others, ofFers considerable resist* 
ance. Crushing or bruising of the ligament or infection will almost 
inevitably be followed by suppuration, and, therefore, it must not be 
caught up in forceps, ligated, or handled too much. Rubber cots 
should be worn on the fingers. 




Fig. 117. — Kellogg'g Operation for External Shortening of 

the Round Ligaments. Anchorage of the 

Ligament. (Second Step.) 

S. Anchorage of the Ligament. — The ligament being drawn out 
and held up, a silk thread is passed through its loop two inches from 
its point of emergence on the proximal side. This is secured by clamp 
forceps placed near the ligament. While the ligament is held taut 
by ligature, a silk-worm gut suture is passed from the skin surface on 




Fig. 118. — Kellogg's Operation for External Shortening of 

the Round Ligaments. Anchorage of the 

Ligament. (Third Step.) 



one side through the base of the ligament and on to the skin surface 
on the other, including all the tissues on both sides that have been 
divided. The ends of the suture are secured by snap forceps. The 
aneurism needle armed with a thread is pa.ssed from without inward 
through the aponeurosis of the external oblique muscle, entering one 



RKPLACKMEXT AND RETKNilON OF THE UTERUS. 219 

ind one-half inches external to the opening through which the liga- 
ment has been drawn, and emerging within one-half of an inch of 
the same on the same side. Passing the thread which is attached to 
the loop of the ligament (the forceps having been removed) through 
the loop of the thread on the aneurism needle, the latter is withdrawn, 
bringing with it the ligament, which is thus woven into the aponeu- 
rosis. The ligament being kept taut by the silk ligature, a second 
silk-worm gut suture is introduced, passing from skin surface to skin 
surface, including all intermediate tissues and the ligament at its 
point of emergence and that portion of the ligament overlying the 
aponeurosis. The free end of the ligament is now folded back in the 
opposite direction and the silk-worm gut siitures tied, whicli com- 
pletes the operation. The wound is dressed antiseptically. The 
sutures are removed at the end of a week. 



CHAPTER XIX. 

' VENTROSUSPENSION OP THE UTERUS— INVERSION OP 

THE UTERUS. 

In the original Alexander method the ligament was sought at 
the external ring. As it is here often very much attenuated and occa- 
sionally broken up into strands, the finding of the ligament was often 
a matter of great difficulty. Many failures resulted. 

Newman seeks for the ligament at the internal ring, as also 
does Goldspohn. The latter dilates the canal, through which he in- 
troduces a finger to break up adhesions. Edebohls opens the canal 
throughout its entire length. In all these methods of external short- 




Fig. 119. — Bullet Forceps for Holding Uterus in Hysterorrhaphy. 
(Kelly's Operation.) 



ening of the round ligament, with the possible exception of Qold- 
ppohn's, it is essential that the uterus be free and mobile. Adhesions 
of the uterus or appendages, or grops lesions of the same, are positive 
contra-indications. Rupture of pus-cavities and extravasations of pus, 
followed by peritonitis and death, have been the penalty for ill-judged 
attempts at replacing the uterus by traction on the ligaments or by 
external manipulation. Complications which contra-indicate the 
external shortening of the round ligaments are more safely met by 
abdominal section. One can never be certain in advance what side 
issues may complicate the restoration of the uterus to its normal 
position. Tumors may have to be removed, a bowel stitched or re- 
sected, pus-cavities evacuated, blood-vessels ligated, the uterine ap- 
pendages or the vermiform appendix removed, and, indeed, a great 
diversity of conditions met and dealt with which could not by any 
(220) 



VENTROSl'SPENSION AND INVERSION OP I'TERL'S. 



221 



means have been successfully combated in any other way. The intra- 
abdominal methods of retaining the uterus in anteposition after iti 
replacement are hysterorrhaphy and internal shortening of the round 
ligaments. 

VENTROSUSPENSION OF THE UTERUS. 

This is also known as hysterorrhaphy, and improperly as ventro- 
fixation. In this operation the usual median section is made below 
the umbilicus and the complications dealt with. Then one or two 
fingers are introduced and the fundus brought forward. The uterus 
is now seized by bullet forceps in the median line posterior to the 
fundus, and the uterus held within easy reach. The peritoneum is 



Fig. 120. — Ventrosuspension of the Uterus. (Kelly's Operation.) 

seized with catch forceps near the lower angle of the incision on either 
side and drawn out over the edges of the wound. A curved needle, 
anned with fine silk or catgut is passed tlirough the peritoneum, 
entering one-half of an inch from the edge and emerging one-half 
of an inch farther outward, thence across to t!ie uterus, entering 
about one-half of an inch below the ay>ex of the fundus on the ante- 
rior surface and including enough of the uterine tissue in breadth and 
depth to give a secure hold ; thence to the [writoneum of the other side, 
through which it passes in inverse order. (Fig. 120.) The ends of the 
suture are secured by clamp forceps, and a second suture is placed 
in the same manner one-half of an inch higher, and passes through 
the apex of the fundus. The forceps are now removed, and the 
Buturee drawn upon to bring the uterus in snug apposition to the 



222 PRACTICAL UYNEC'OUHJY. 

peritoneum and tied. The ends of the sutures should be clipped short 
and buried in the free margin of the peritoneum, which should be 
stitched over them as a precaution against suppuration. The ab- 
dominal wound is closed in the usual manner. 

Inflammatory exudation at the suture punctures produces adhe- 
sions between the uterus and the parietal peritoneum and forms a 
bond of union between them. This gradually yields to traction and 
pressure and becomes drawn out into a band which sustains the 
uterus by its fundus and constitutes the so-called central ligament. 
This admits of free mobility of the uterus within limits correspond- 
ing to the length of the band. Hence the operation is known as a 
suspension, and not as a fixation. In some instances this band does 
not form, and the uterus remains firmly adlierent to the abdominal 
wall, constituting a veritable fixation. In others the band becomes 
so elongated that it ceases to exercise any restraining influence on 
the uterus, and the organ sinks backward into a state of retroposition. 




Fig. 121. — Author's Button Forceps, for picking up the Round Ligament ia 
Round Ligament Suspension of the Uterus. 

While the operation is well adapted to women who have passed 
the climacteric, or from whom the appendages have been removed, 
there are objections to its use in cliild-bearing women, in that it occa- 
sionally gives rise to serious embarrassment in pregnancy because of 
the inability of the uterus to develop symmetrically with the growing 
fetus. Parturition is also interfered with because of the misdirected 
efforts of the distorted uterus, which in some instances offers in- 
superable obstacles to normal labor and calls for the Ca«arean section. 
Nevertheless, many cases progress without serious inconvenience, espe- 
cially those in which the uterus has drawn away from the abdominal 
wall. 

Bound Ligament Ventrosuspension of the Uterus. — The prime 
requisite for an operative device for retaining the uterus in normal 
poise is one that will utilize the natural suj)])orts of the organ, that 
will insure a certain amount of mobility, that will adapt itself to 
the various functions of the uterus, — pregnancy and parturition, — 



VKJJTIIOSISI'KXSIUN AND IKVKKSION OF IITKUUS. 



2-23 



that will be lasting in its results, and withal easy of execution. We 
know tliat the round ligaments grow pari jmssu with the development 
of the uterus in pregnancy, and that tliey return to their normal 
condition after parturition. This 1 have repeatedly verified by ab- 
dominal section in pregnant women. Theoretically, the same change 
should occur in the ligament which has been implanted in the ab- 
dominal wall. Profiting by Ferguson's suggestion, who cut the liga- 
ment and drew the proximal portion through the posterior sheath 
of the rectus muscle, I devised the operation which I have deuomi- 



Plg. 123 — Ventrosiispengion of the Ulcriis i Gilliam's Opprolion. First 
Step. ) Pnsain); a TlireacI nmler the lioniul LiKaiueiit 



w 



nated round ligament v^ntrosuspcnsion of the uterus. The steps of 
the operation are as fnllows: — 

Operation. — 1. An abdominal incision three or four inches in 
length is made in the median line at the usual site between the um- 
bilicus and pubcs. 

2. The adhesions are broken up and the fundus brought forward. 

3. By lifting up the brniid lignment of one side on the tip of a 
finger applied to the posterior surface, the round ligament is brought 
into view and is picked up with a bullet forceps. 



224 



PRACTICAL GYNECOLOGY. 



4. Selecting a point uti inch and a half from tlie uterus, a thread 
is pa88e<l under the .round ligament, and the ends of the thread are 
brought out of the opeuing and secured in the bite of a clamp for- 
ceps, which is laid on the surface of the abdomen. 

5. The other ligament is sought for and secured in the same 
manner. 



Fig. 123. — Betnctor (or Retracting Skiu and Fat in Ronnd Ligament 
VentrofiDspeDHiuD of the Uteraa. 

6. At a point about one inch and a half above the pubes, the 
peritoneum, muscle, and fascia are caught up by a volse'la and pinned 
together, being careful that the edges of these layers are in line. 

7. Traction is now made, and with a claw retractor the skin and 
superficial fat are drawn in the opposite direction, and by a sweep 
of the knife the face of the fascia is laid bare. 

8. With a narrow-bladed knife, or better, with a Cleveland liga- 
ture-carrier or some similar instrumeut, a stab wound is made from 



ll.TIIM*M»tClL. 



Pig. 124. — Aiithor'a Perforating Forceps, for Piercing the Walla and 

Beonring the 1 bread b^v which the Huiind Ligament 

is iJrawn into Place. 



the surface of the fascia into the peritoneal cavity, one inch from tlie 
edge of the abdominal incision. If the ligature-carrier is used, the 
jaws are sepnrnted, and by an outward movement of the handle 
brought into plain view at the large opening. 

The thread which loops the round ligament is now placed in the 
jaws, the clamp forceps removed, and the ligature-carrier withdrawn, 
bringing with it the thread and the ligament. If a knife has been 
used to make the perforation, it is withdrawn and a slender forceps 



VKXTROSl SPENSIUN AND INVERSION OK UTERL'S. 



225 



introduced, with which the tliread is caught up and the ligament 
drawn into place. 

9. Now, while the ligament is held taut, with its loop end 
just above the surface of Uie fascia, a catgut suture is passed 
through it, including the tissues on either side, and back again, 
where it is tied. This is cut close to the knot, the suspending 



Fig. 125. — VcDtrr«n«pennion of thp Tteriw. (Oilliam's Operation. 
Step. ) Piercing Uie AlHliMiiiiial Wall and Grasping the 
Thread which Holds the LiKaioent. 



Second 



thread cut close to the ligament and withdrawn, and the volsella 
and retractor removed. 

10. The other side is dealt with in like manner and tl»e abdomi- 
nal incision closed. 

After both ligaments have been fastened it will be observetl that 
an opening exists between the uterus and abdominal wall of from 
seven to nine inches in circumference, and that the two openings on 
the distal side of the loop will readily admit two and sometimes three 



22(> 



PRACTICAL GYNECOLOGY. 




fingers, and are soft, yielding, and distensible — conditions under 
which strangulation of the bowel would hardly be conceivable. It 
will be observed that the uterus is not suspended, but rests easily and 
naturally on the bladder, from which it can be raised to a position 
little short of the vertical. Thus the uterus is enabled to conform 
to the altered conditions of the bladder and rectum and to the various j 
bodily movements. Should pregnancy ensue, the ligaments develop! 
pari passu with the growth of the uterus, and there is neither em- 
barrassment in gestation nor difficulty in parturition. 




Fig. 126.— VentTOBUBpension of the TJtenui. ( Gilliam 'b Opention. Third 

Step.) Drawing up the Lipanient throagh the Puncture in the 

AbdoniinnI Wall anil Sfcuriiig it by Suture. 



In my first cases I was troubled with suppuration, which was 
often protracted and aggravating. Of late 1 have had no sup- 
puration. This I ascribe to the fact that I handle the ligament 
as little as possible, and never touch it with my fingers after it 
has been drawn into place, and also to the fact that 1 clip the 
suspending thread close to the ligament, so as to avoid contami- 
nation by drawing it full length through the loop of the ligament 
after its exposure on the abdominal wall. Rubber cots or gloves 
may be used to advantage as a safeguard against infecting the liga- 
menta. 



VENTROSl SI'KXSION AXD INVEKSION OV L TKUU8. 



227 



INVERSION OF THE UTERUS. 

In this the uterus is turned inside out. The inversion may be 
partial or complete. As usually found, all that portion of the uterus 
above the cervico-vaginal junction is involved, and protrudes from 
tlie external os as a polypus. The portion of the cervix which has not 
been inverted forms an encircling band to the upper extremity of the 
protruding mass, which has been aptly likened to a cuff. This cuff 




Fig. 127.— Rubber Cott. 



is called the cervical ring. In rare instances the entire organ is in- 
verted, including this portion of the cervix. 

Causes. — In nine cases out of ten inversion is an accident of 
childbirth, and usually occurs in the delivery of the placenta. Trac- 
tion on the cord and irregular pressure on the fundus are the common 
exciting causes. It may occur from a short cord dragging the fundus 
down as the child is expelled. The non-pucrpural uterus may be in- 
verted from the dragging of a morbid growth and the expulsive eflforta 




Fig. 128.— Ruhlior Clove. 

of the uterus to dislodge it. The pedunculated fihrnid is responsible 
for most cases, and next in order come the malignant growths. I 
once did a vaginal hysterectomy in a case of inversion occasioned by 
a diffuse cancer of the endometrium. In some ins^tances a partial 
inversion of the fundus will be converted into complete inversion by 
muscular action of the womb, the womb literally swallowing itself 
in it» attempt to expel the portion which had dropped into its cavity. 
Pol)rpoid growths from the fundus often produce a partial inversion 
at the point of attachment The inverted portion under traction is 



228 



PRACTICAL OYNKCOLOGV 



cord-like and indistinguishable from the pedicle, and has been cut 
away time and again in removing the growth, with disastrous results. 

Symptoms. — The early symptoms in the puerperal form are hem- 
orrhage and pain. The pain is variable in intensity, and is often 
accompanied by a dragging or pulling sensation. The hemorrhage is 
apt to be very profuse and is sometimes rapidly fatal. Later, if the 
patient survive, it becomes intermittent, and alternates with profuse 
leucorrlieal discharge. In chronic cases these symptoms disappear, 
and there is little discomfort except from the presence of the vtiasi 
in the vagina. 

Diagnosis. — The diagnostic landmarks are the presence of a pear- 
shaped body in the vagina, the absence of the uterus from the pelvis. 



J^CJ; 



'^i^ 



Fig. 129.— Replacing the Inverted Uterus. 

the presence of a cervical ring at the upper extremity of the mass, the 
absence of the uterine canal communicating with the vagina, and the 
presence of a funnel-shaped depression on the abdominal side of the 
cervical ring through which the uterus has descended. Occasionally 
the openings of the Fallopian tubes at the lateral angles at tiie base 
of the tumor may be discerned. The inverted uterus is so similar in 
color and consi.stence to a fibroid polypus as to be distinguished from 
it with difficulty. When the openings of the Fallopian tubes can be 
made out there will remain little doubt as to its nature. The absence 
of the uterus from the pelvis may be determined by bimanual exami- 
nation, or by one or two fingers in the nx^tum and a sound in the 
bladder. The finger in the rectum will also discover the funnel- 



VENTHOSl SPKNSION AND IXVERSION OF L TKRL'S. 



225> 



shaped opening on the abdominal side of the cervical ring. The 
rectal examination will be facilitated by traction on the vaginal mass, 
so as to bring ita upper extremity within reach of the rectal finger. 
A sound introduced within the external os will penetrate but a short 
distance, and, by sweeping it around the neck of the protruding mass, 
will disclose a shallow gutter between the cervical ring and the mass. 




Fig. 130. — Rcdiii'iiij; an inverted Uterus by Splitting 

the Posterior Lip of the Cervix. 

(First Step.) 



No nterine canal will be found connecting with this gutter. Very 
rarely an occlusion of the uterine canal will be found in connection 
with a uterine polypus, but the presence of the uterus in the pelvis 
will serve to dilTerentiate this from inversion. It is a safe plan, in 
view of the disastrous consequences of mistaking an inverted womb 
for a uterine polypus, to regard a doubtful case as one of inversion 
until otherwise proven by careful and methodical examination. 



230 



PRACTICAL GYNECX)I-OGY. 



Treatment. — In the puerperal form, if taken early, replacement 
is not difficult. The uterus should be grasped in the hollow of the 
hand, the fingers closed about it, and by graduated pressure forced 
backward tlirough the cervical ring. (Fig. 129.) The lower segment 
of the uterus should be made to pass the ring first, then the body, and 
finally the fundus. Counter-pressure by the hand on the abdomen will 
facilitate reduction. Dilatation of the cervical riiig while, pressure is 



iltf^ 



Fig. 131. — Reducing the Inverted Uterus by Splitting 

the Posterior Lip of the Cervix. 

(Second Step.) 

exercised from below will often materially aid in the reduction. This 
may be effected by finger-prossure through the abdominal wall, or 
better still through the rectum. In cases of longer standing it may 
be necessary to exercise much tact and patience in the efforts at 
reduction. Long experience has demonstrated the fact that many 
cases will yield to judicious and persevering effort, that were formerly 
abandoned as hopeless. Violence and lurching movements should be 
avoided under all circumstances. A reduction often occurs 



I 
I 




suddenly ■ 



VKNTROSrSl'KXSlOX AND INVERSION OF UTERIIS. 231 

even after long snd ineffectual efforts at taxis. Tliis is because of 
the sudden relaxation of the cervical ring. The Trendelenburg posi- 
tion may sometimes be used to advantage. When manual efforts are 
unavailing, sustained elastic pressure as from the air pessary of Gariel, 
or from the cup and stem pessary supported by elastic bands, or spiral 
springs, attached to a belt around the waist, often succeeds. Gauze 
packing of the vagina has also proved effective. Persistent effort of 
the husband to consummate the act of sexual intercourse is credited 
with having cured an inveterate case. Probably in this case the suc- 
cessful issue was not so much due to the mechanical pressure as to 
the relaxation of the cervix under sexual excitement. 

Should taxis fail, operative measures may be called for. Split- 
ting of the posterior lip of the cervix is probably the most effectual 
and least harmful of all procedures heretofore recommended. (Figs. 
130 and 131.) After the organ is reduced the incisions should be 
sutured. Growths should be removed before the uterus is restored to 
its natural position. In a few cases of old standing, inflammatory 
adhesion of contiguous surfaces from pre-existing inflammation will 
withstand all efforts at reduction. As a dernier ressort, the offending 
organ may be removed by vaginal or abdominal hysterectomy. 



CHAPTER XX. 

INFLAnnATION OF THE CERVIX UTERI— TROPHIC 
DISORDERS. 

INFLAMMATION OF THE CERVICAL MUCOSA 
(ENDOCERVICITIS). 

The cervix — from its position — is exposed to many deleterious 
Influences, and is consequently very often the seat of inflammatory 
reaction. It participates in many of the inflammatory conditions of 
the body of the uterus, transmits the acrid secretions from the uterine 
cavity, and is affected by them, and is furthermore subject to the 
lacerations and contusions incident to childbirth. It is also subject 
to injury from the vaginal side, as in coition, masturbation, the various 
manipulations incident to examination and treatment, and in the 
fitting and wearing of pessaries. It is also exposed to the influence 
of pathogenic germs, gonorrheal or septic, which are introduced from 
without or are residual in the vagina. Here, as in the body of the 
uterus, it is the lining membrane that is most frequently and most 
affected, but, by reason of the anatomic structure of the cervix, the 
inflammatory changes more readily extend to the deeper parts and 
often involve the entire cervical structure. It should be remembered 
that the cervix is merely a sphincter, guarding the outlet of the uterine 
cavity. It has no intimate connection with or influence on surround- 
ing structures; is sparsely supplied with lymphatics, and these in 
their course do not traverse important or inflammable structures. 
Consequently the ultimate results of a cervical inflammation are in 
no way comparable to those of the uterus proper, in that they seldom 
pass beyond the confines of the cervical tissues. 

A specific or septic inflammation may, however, pass upward into 
the uterine cavity, or even affect secondarily the vagina. The com- 
pound racemose glands of the cervix, like the vulvo-vaginal glands, 
are favorite resorts for the gonorrheal germ. Here it will lurk for 
weeks or months, showing little activity and no disposition to quit its 
quarters, until, awakened by some untoward event, — excessive venery, 
debauchery, or traumatism, — it becomes instinct with life and nmlig- 
nant energy. The pathogenic germ, like the Scriptural war-horse, 

(232) 



IXFl-AMMATUtX (»F THE CERVIX LTF.RI— TROPllK DIsnitDERS. 233 

can SDufI the battle from afar; so that injury of tissues somewhat 
remote may call it forth. In this way gonorrheal vaginitis sometimes 
becomes secondary to cervical infection. 

Inflammation of the cervix may affect principally — though sel- 
dom exclusively — the glands or the interstitial substance. As a rule, 
the two conditions go band in hand. Inflammation of the cervical 




Fig. 132. — Cyatic Degeneration of the Cervix. 



glands (glandular cervicitis) is accompanied by excessive secretion. 
The secretion is thick, tenacious, and abundant, and is occasionally 
streaked with blood. It may become purulent or mi.xcd with pus. 
Occasionally tlie outlet of the gland becomes sealed, when, the secre- 
tion continuing, the gland will become distended, push outward, 
project from tlie surface, grow and enlarge, and finally become pedun- 
culated. This constitutes the glandular polypus of the cervix. Some- 



dh 




234 



PRACTICAL, GYNECXJLCXjy. 



times, owing to interstitial inflnrnmntion, thidcening. and pressure, 
the gland-duct becomes obliterated. The result is an increase of the 
pent-up socretious and a globular enlargement, which if it be near 
the surface may be both seen and felt. 

These glands seldom become larger than a pea, but may be bo 
abundant as to literally crowd the cervix. If punctured, they seldom 
extrude their contents, owing to the absence of elasticity of the 
cervical structures. Under pressure the secretion can be expelled. 
It is usually of honey-like appearance and consistence. These little 
retention cysts are known as Nabothian follicles, but it should be re- 
membered that they are nothing more nor less than occluded and 
distended cer\ncal glands. The condition just described is called 
cystic degeneration of the cervix. (Fig. 132.) 

Not infrequently, and especially where there is glandular in- 
volvement, where the cervix is hyperemic and bathed in abundant 
secretion, there is an exfoliation of the superficial epithelium, im- 
parting a raw, red, granular aspect to the part affected. This, upon 
superficial inspection, resembles an ulcer, and is usually denominated 
such by careless or ignorant physicians. There is, however, no loss 
of tissue, and upon close inspection it will be found that, so far from 
there being an excavation, the affected area is, if anything, on a higher 
level than the surroundings. In some instances the colunmar epithe- 
lium has been replaced by flat cells and in others overlaid by them. 
The epithelium is never wanting, and consequently the lesion is, in 
no sense, an ulcer. This condition is known as granular erosion of 
the cervix. (Fig. 133.) It is occasionally limited to a narrow margin 
around the external os, but may involve the greater portion of tlie 
exposed surface of the cervix. It is seen in its worst forms in con- 
nection with lacerations of the cervix. 

Symptoms. — Constitutional sjTnptoms in the form of chill, fever, 
and malaise are almost never present in uncomplicated cervical in- 
flammation. In many instances, in the lighter forms, subjective local 
symptoms are ill defined or wanting. In the severer grades there exist 
a dull, heavy weight and dragging in the pelvis, oftentimes associated 
with a burning sensation in the vagina. The general health is usually 
more or less affected and the patient is nervous. Reflex nervous phe- 
nomena are especially marked in the interstitial form accompanied 
by cystic degeneration. Here headuche is constant and the patient is 
apt to be nervous, emotional, and even hysterical. 

The local manifestations as revealed by examination are variable. 
The cervix is enlarged and the secretions increased. The cervix may 




INFLAMXIATlux oK THE CERVIX ITERl— TROrillC DISORDERS. 2iVi 

be soft and tumid in the uncomplicated form ; imiuratcd and nodular, 
> in cystic degeneration; raw, rod, studded with niinute granules, 
bathed in secretion, and disposed to bleed, as in granular erosion; 
or there may be seen springing from the canal or vaginal surface of 




Kig. 133.— Graniil«r Eronlon of tlie Cei vix. 



the cervix small uiaivsis, sometimes pedunculated, of bright red or 
varying hue and of oyster-like consistence, accompanied by a profuse 
slimy or purulent discharge. This is glandular cervicitis, and the 
pedunculated museee are glandular polypi. 




236 



PBAOTICAL GYNECOLOGY. 



Treatment. — On account of t!io numerous cr\-pt# and fleep 
pressioii!-, llic alminlaiit uml tciiaeiuiis sei-TL'tioii, iiud the ditTiciilh- of 
dislodging it, the medical treatment of tiie cervical canal is difficult 
and for the most part unsatisfactory. Tlie secretion can neitJier be 
wiped nur washed away. It may i)e willidniwii liy sut-tion l)y attach- 
ing a small piece of ruliher tubing to Ll>e end of a long-iiozzled 
syringe, or it may he dislodged by small bit« of sponge held in the 
bite of a dressing forceps, or, better still, it may he dislodged by bits 
of alisorbent cotton held in the bite of a dressing forceps and satu- 
rated with an alkaline siilution such as .sodium liicarbonate or the 
liquor antisepticus alkalinus of the National Formulary. 



Fig. 134. — Thomna's Suction Syringe (or Removing Cervical Secretions. 

In acute gonorrheal and septic inflamnrntion of the cen'lx an 

attempt should be made to arrest the disease before it implicates 
otluT parts or lapses into the chronic form. For this puriK).se strong 
antiseptics should l>e resorted to at regidar inten-als, and fre<|iientljr 
repeated hot douches of mililer iiolutions utilized lietween-timos. 
After freeing the canal of its mucous plug, a cotton-wrapped appli- 
cator should be dipped into one of these preparations and carried up 
into the canal. The medicines should be applied to every part of 
the cniml, and as far as |H>ssible pressed into the depressions with 
which the canal abotinds. Care should be taken not to carry the 
applicator into tlie uterine cavity. The applications most in votnie 



-«^ainilI!II||IIi 



Pig. 135. — Einnu't's Applicator. 



are pure carbolic acid and t IinrLliiH's tincture of iodine. One or 
the other of the.se may be u.-sed separately, or they may be combined 
in eijual proportions. The applieations may be made at intervals of 
from three to seven days. The application should be followed by a 
tampon saturatwl witli boroglycorid. This should l)e removed in 
twenty-four lu)urs. 

Dry Tiiicvtmkxt. — Koch, believing that vaginal douches and 
moist treatment carry infection into the canal and open new avenues 
of infection by softening the tissues, treats all ieni'orrheas of what- 
ever natnre and cervical erosions by the application of a dry powder. 

After exposing the vault of the vagina and wiping it dry, the 



I 
I 




VTIOX OK niE CERVIX ITEUI— TROPHIC 0I»URI)£K8. '237 

kivviior, whifli niunst!^ ui uiiiiuiiuiiii acfiatc 1 imrt U> 2 parte oiuh of 
lEaoliu and jiowdiTwl talcum, is iijJiiliL'd, lirst to tin- vmilt, tlii-ii to tin- 
iginal walU as the speculum is withdrawn. Une dram usualh 
butKces for oiif npplicalion. The application may be made by u 
jwder-blowtT or otliiTwist', as may be found most convenient. At 
jbseqnenl treatments, which are repeated on the fourth, eighth, tenth, 
Burteenth, and eighteentli days, moit^t masses of the powder are 
emoved and the frosli powder reayiplied. 

In tlie author'? experience there is nolhinir so eflicient in infec- 
tions capes as arpyrol or nome similar preparation of silver. After 
atroducing the speculum and wi|)ing away the secretions a tamjwn 
Jturated with a 2") per cent, or 50 per cent, solution of arfryrol is 
itroduced ajid allowed to remain from four to sis hours. This may 
repeated <laily or every second day until a marked change is 
Jliceoble, then at longer intervals. 



Fi^. 130. — Utpfine Drp««ing Forcpps, for Wiping away Secretions 
and .'Vpiilying Tampon. 

Granular erosion of the cervi.\ is symptomatic, and almost always 

ends on inflammation of the cervical glands or those higher up. 

fi is the abunchint glandular secretion in connection with the hyper- 

lia that l)rings about the erosion and swelling of the epithelium. 

kccordingly, the glandular intlammation should receive attention, 

rhich, if relieved, will also carry with it the disappearance of the 

rosion. In that form <leiK>rHlcnt on cervical catarrh I have cured 

lanular erosion by deep ligation of the cervical tissue on either side 

it Uie cervieo-vaginal juucticm. For this purp<ise 1 prefer catgut. 

>ut, if any other material be used, it slioujd be removed on or before 

l>c fifth day to avoid pressure atrophy of the tissues embraced in the 

Itxip of the ligature. 1 received my cne for this method of treating 

rannlar erosion from the fact that I had frequently noticed the 

^rosiou to disappear from tlie distal exfremitj' of the cervix after 

Bchclorrhaphy. Simple erosions, such as arise from the mechanical 

ifation of a pessary, or from tlic pent-up secretions incident to the 

rearing of a womb-veil, are quickly cured by removing the cause 

aid kcepin}: the parts clean. 



238 PRACTICAL GYNECOLOGY. 

Glandular polypi niaj' be excised without the use of an anesthetic. 
After the bleeding ia checked by compression or the use of a styptic, 
of which adrenalin is one of the most efficient, the base should be 
cauterized w^ith fuming nitric acid. 

The most important inflammatory lesions of the cervix, both in 
its immediate and remote effects, is that of cystic degeneration. It 
is but a short step from cystic degeneration to epithelioma, and con- 
sequently effectual measures for the correction of this condition ^ould 
be instituted without delay. If the follicles be few and superficial, 
they may be punctured, tlieir contents expressed, and the wall cau- 
terized. If multiple and deep seated, the flap amputation of the 
cervix should be done. In all cases where the cervix is enlarged and 
indurated from interstitial deposit, bloodletting by deep puncture 
should be occasionally resorted to. The blood may be encouraged to 
flow by the applications of the artificial leech, or better by a stream 
of moderately warm, but not hot, water. This, in conjunction with 
the weekly or semi-weekly application of the strong tincture of iodine 
to the exposed vaginal portion of the cervix, and the daily use of the 
hot douche, will result in a diminution in the size and a softening of 
the cervix. 

If multiple and deep-seated, curettage with a strong, sharp 
curette after the method of (Vaig will usually suffice to effect a cure. 
The curettage to be of any value must be deep enough to destroy the 
glands and in many instances the quantity of dchrus removed will be 
surprisingly large. As tills procedure may have to be repeated several 
times at intervals of two or tlirce weeks, and as it is usually not very 
painful, it may be done witliout an anestlietic and at the office. In 
some instiincos a j)reliminnry dilatation of tlie cervix of moderate 
degreo may be required. After cleansing the parts a boroglyceride 
tampon is pushed up against tlie cervix wliicli, after its removal 
twenty-four hours later, should be followed l)y a boric acid douche. 

In lieu of the above, Ilunner's nictiiod of deep cauterization 
will be found mopt efficient. The patient being in the lithotomy 
position, the cervix is exposed, seized by a tootlicd forcei>s and drawn 
down. The soft parts arc ])rotected from the heat by gauze packing so 
a])plied as to leave only the cervix in view. A gauze pad should also 
be jilaced under the retractor to protect the ])erineum and posterior 
vaginal wall. Tlien with the cautery heated to a cherry red it is 
jiuslied u]> into the cervical canal and two or tliree linear cauteriza- 
tions made at points e(|uidistant from each other. These cauteriza- 
tions sliould be to the dejitli of about one-eijrbtli of an inch, or the 
tiiickness of the mucosa. The ap|»lications sliould be relocated at in- 



INFLAMMATION OF THK CERVIX ITKRl— TROPHIC l)lSt)RUERS. 239 

tervaU of from ten to fourU?eu days and as often as necessary to 
effect a cure. The pain is not severe and is usually well borne, but 
with njipreliensive patients it may be well to eocainizf tlie L'er\'ix 
to a slight degree. It will not l»e necessary for tlie patient to go 
to bed. In the more radical o])eration where the entire cervical 
mucosa is burnt uwuy at one i»r two sittings, the patient fhould he 
anes'tlietized and i>ut to bt-d for several days. An interval of from 
six to eight weeks sliouid be allowed between cauterizations. With the 
separation of the eschar a week or ten days after the use of the 
cautery there will be a bloo<ly purulent discharge, of which the patient 
should be apprized in mlvanee to obviate misapprehension. These 
operations are to lie followed by the usual boroglyeeride dressings, 
followed by the boric acid ilouche. In very aggravated cases where 
the cystic degeneration converts the cervix into a tumorous mass, it 
may be easier and inorc «)iti>^factory to amputate the cervix. 



I 



Fig. 137. — Kuttic'a S[M-iir f.ir I'uncturing tin- Cervix. 

TUBERCULOSIS OF THE CERVIX UTERI. 

Tnberculoi-is of the cer\ ix is much more frci|uent than is gen- 
erally supposed. Houtiue microscopic examination of the diseaj*ed 
cervical tissue has made tliis evident. The disease is usually sec- 
ondary to tuberculosis elsewhere, but may exist in an indcfieitdcnt 
and primary lesion. The source of infection is sometimes fiimi 
above (the peritoneum or Fallopian tube), sometimes from below 
(through traveling bacilli, inferted semen, contaminated fingers or 
instruments), or it may ho borne on the blood-stri-am. It presents 
under three forms: miliary; caseous, or ulcerative; and papillary. 

1. Miliary Cervical Tuberculosis first makes its appeaniiieu under 
the epithelium of the ccrvicul canal. The tubercles are so minute as 
to be invisible to the naked eye. As a result of their presence the 
arbor vitie becxmie enlarged and villous, and the case presents the 
usual phenomena of cervical catarrh, for which it is usually mis- 
taken. Even at nn early stage the tuberculous infiltration jx-netrates 
dwply into the cervital tissues, and is always much more extensive 
than appearances would indicate. The tubercular deposit foUows tlie 
course of the blood-vefs^ds. It is n noteworthy fact that cervical 
tuberculosis seldom extends to the uterine cavity, nor corporeal tuber- 
culosis to tlie cervix. For this there is no satisfactory explanation. 
If the infection always foUnwed the course of the blood-vessels it 
would Ik? easilv accounctl for. as the vascular svstema are distinct. 



240 



WUCTKAL GYXECOUKJY. 



The miliary form is that niont common to the cervix, and usually 
persists thiouj^fhout tlic course of the disease. 

2. Caseous, or mcerative, cervical tuberculosis may be regarded 
as a transition from the miliary. In this the tubercles are larger, 
become iuai->~ed, uiul, as a result of imperfect oxy>r«'nation from in- 
adequate blouil-siij)jdy, undergo caseous dejieneration and break down 
into ulcers. The ulcers are scattered over the cervical mucosa and 
are of variable size and depth. They are covered with granulations, 
exude an abundant secretion, and bleed readily. Carteous material is 
frequently found clinging to the floor and sides of Uie ulcer. This 
condition is frc(|ueiitly mistaken for malignancy. 

3, The Papillary form takes it* ori^'iii in the arlwr vita), becomes 
tumorous, and forc-es its way to tlie surface at the margin of tlie os 
externum, whore it projects as a nodulated ma.ss. Both the ulcerative 
and [ia|pilhiry forms have been mistaken for cervical cancer, and the 
uterus extirpated under that belief. They may usually be dilTer- 




Fig. 138. — .\rtiticinl Lepoli for .Abstracting Blood from the t'er^•ix. 



4 



entiated from cancer by the deeper cohjr, the absence of pain and 
offensive discharge, the absence of induration, the presence of ca.ieous 
matter, and the smaller disposition to bleed. Of course, tlie micro- 
scopic diaracters would be entirely distinct aside from the presence 
of the tubercle bacillus. 

Treatment. — The radical treatment consists in removing the 
ut^Tus and apjiendages. This is made necessary by the fact that the 
Fallopian tubes are often involved, even though the physical signs 
do not indicate any gross changt^s in them. In cases where, owing to 
the involvement of other structures, radical measures are inexpedient, 
palliative measures may be adopted, such as curettage, cauterization, 
and the use of antiseptics and detergents. 

HYPERTROPHY OF THE CERVIX UTERI. 

True hypertrophy of ilie cervix is, for the most part, confinefl 
to the vaginal portion. It oreurs in two forms: as a lateral expan- 
sion or as an elongation. Th<' former is characterized by a bull>ous 
ex))ansion of the cervix, of moilerately firm consistence, and an irreg- 
ular surface. It occurs in virgins, and, so far as my observation goes, 
is more frwuient in blondes. It occasionally gives rise to local and 
reflex phenomena similar to those of cystic degeneration of the 
cervix. 




ISKLAMMATION OF TOE CERVLX I'TKIU— TKDl'lllC UISORDKIIS. 241 

Treatment. — Uxal applications of tlie tiucturu of iodine, with 
au occacioual abstraction of blood by deepi puncture, and elastic tam- 
I)i)n3 of wool saturated with boroglycorid may be of service. Usually 
nothing short of aiuputatioii will bo of any lastinjr benefit, 

HYPERTROPHIC ELONGATION. 

The hypertrophic elongaiiou of the cervix, the second form 
upoken of, is also a true hyj)ertrophy, but, unlike that just described, 
till? cervix elonfrates without material increase in tliickness. It may 
ittJtin tile len-rtii of aovfral inches and y>re.seiit at the vajrinal orifice. 



Fig. I.'t'J.— Siipruva^'ina! Klmigiitiiiu of Corvix. 

When exposed the unprotected part becomes dry and curncout*. This 
condition i» sometimes mistaken for prolapse of the uterus, but 
bimanual e.xaminalion, or a sound introducrd into thi» ulcriiie canal, 
will reveal the fundu.»i at or near its imrniiil level, and, moreover, 
the vagina will be found of its normal depth. The redundant portion 
t'hould be excised. 

SUPRAVAGINAL ELONGATION OF THE CERVIX. 

This presenl.s many features in common with the above, but it 
is asitoeiuteil with and dependent on a prolapse of the vaginal wall. 
The dewendinp walls drajr upon the cervi.x, which, if oppo.sed by tlie 
li^rnmentous attachments above, cause it to be drawn out into a long, 
membranous canal, so as to be scarcelv recojrnizable to the touch. 
(Fig. 13!).) The os may pass the vulva and appear between the 
thighs. The va^'inal walls invest the cervix, and in proportion to the 



242 



PRACTICAL GYNECULOGY. 



amount of descent the canal i« shortened. Occasionally the canal is 
completely inverted. Kectocele and cystwcele are common accom- 
paniments. Where the parts protrude from the vulva, they are ex- 
posed, not only to the desiecatinjf influence of tlie atmosphere, but 
to friction, pressure, and the coutaniination of the excretions, urinary 
and fecal. As a result, the cervix and inverted vajiiind walls are prone 
to inflammation, erosion, and ulceration. Supravaginal eJonjjatioii 
of the cervix niay he dilTerentiatcd from true prolapse of the uterus 
by finding the fundus near its iiornml position, and from hypertrophic 



Fig. 140. — llt'matomctra. 



"elonfiation of the vaginal portion of the cervix by noting the down- 
ward (lisjihurnicnt of the vagiiuil walls. If the woman lie ujwn iier 
hack with the hips elevated, the os will recede within the pelvis and 
may he pushed up so as to restore the vaginal canal to something like 
its uornitd depth. 

Treatment. — Some device for lifting and retaining the cervi.v in 
it*i tKtrnuil position may he tried, which failing, the cervix would be 
amputated above the vaginal vault. — supplemeided, if need be, by a 
repair of the (xdvin floor. In anijititating tlie eervi.x for either of the 
conditions above descriiied it slinuld be remembered that involution 
follows the use of the knife, and it will seltlom be necessary to excise 
all the rcdundnnt jiortion. I'snally the excision of two-thirds of that 
which is seemingly necessary will be found, after the lapse of time, 
to have been sufficient. 




IXFLVMMATIOK OF THE CERVIX I'TERl— TROPHIC DISORDERS. 243 



ATRESIA AND STENOSIS OF THE CERVICAL CANAL. 



1 Atresia of the cervical canal may bo congenital or acquired. As 

^fcf«>nj»enitjil uffittion it seldom exists except in connection with other 

^^lalformatious of the genital organg. Congenital stenosis is found 

most frequently in connection with the conical cervix. Here a long, 

tnpering cervix terminates at n minute circular os externum. This 

itttler, known hs the pinhole os. ulTer* mechanical obstacles to the 



1g. 141. — Oprrniion for Pinhole Os. 
(First Stt-p.) 



l"ig. 142. — Operation for Pinhole Ds. 
( SiM'ond SU-p. ) 



menstrual fluid, and is consecjuently often associated with dysmenor- 
rhea. Sterility is alst> coninion. Not that the aperture is tix> suiull 
for the passage of the si)ernmt<izoidH, hut because of iiiorbid riuiiiges 
in the canal incident to defective drainage, which renders that passage 
inimical to the spermatic fluid. 

It has been claimed tiint during sexual orgasm the cervix under- 
goes a species of erection and ejects the mucous plug which occupies 
its cavity, and immediately thereafter by a.«piratiun or capillary 
attraction draws up the spermatic fluid mixed with the alkaline 
wcrctions. It is furthermore claimed that the pinhole os, blocked 
t8 it is by a mass of mucus occupying the amplified space above, is 




244 



PRACTICAL <;YNEa>LOC3Y. 



incapable of ejecting its contents, wliicli contents offer an insuperable 
obstacle to the entrance of the seminal fluid. As many prolific women 
never oxjK'rii'iU'e sexual orgasm, it is hii;hly prol)able that this niethwl 
of insemination is only one of the many by which Nature safeguards 
this most important function. 

As iutiniiitcd above, the cervical canal above the external os is 
usually much dilated by reason of the ol)struction. Acquired atresia 
and stenosis of the cervical cnual is the result of sloughing after labor, 
excessive cauterization in the treatment of cervical lesions, or may 
follow amputation of the cervix where the stuni[i' is not covered with 
mucous mciiibrnne, and where the cervical mucous membrane is not 
sutured to tiie vaginal mucosa. I have seen a very aggravated stenosis 
of the cervical canal follow electric treatment. Atresia of the cervix 
in Uie menstruating woman results in retention of the menstrual fluid 
(hematometra). (Fig. HO.) Jn women who liave jiassed the climac- 
teric there may be no sefjuela' unless, perchance, septic infection of 
the uterine cavity co-exist, when the uterus may become distended 
with pus (pyometra) or gns (piiy.'^oraetra). Stenosis or atresia may 
affect any portion of the cervical canal, but is much more common 
at the external os than elsewhere. Stenosis of the internal os is often 
susjMJctcd by the unskilled on account of the dilTicuIty experienced in 
introducing the sound. As a matter of fact, stenosis of the internal 
OS is of rare occurrence. 

Treatment. — In atresia, puncture in the line of the canal, fol- 
lowed liy dilatation and the use of a stem pessary when practicable, 
will be followed by inuTiediate relief; but the tenilcncy to contraction 
is so great as to necessitate unremitting watchfulness to ])revent a 
recurrence. Am]>utntion by the flap method is decidedly preferable 
where such a procedure is feasible. In extreme cases remo«-al of the 
uterus aiul a(>pcndages may be the only recourse. Stenosis of the 
cer\"ix may be treated by dilatation or amputation. In the conical 
cervix with a jiinhole os it lias been customary to enlarge the external 
opening by removing a circular strip from its margins (Figs. 141 and 
143) and suturing tli<' miico-'sa of the canal to that of the margin of 
the canal on the vaginal aspect. This is dtmc by nuiking four incisions 
at equidistant points on its circumference, and then witli the knife 
or scissors removing the intervening tissues. 

It may be stated as a rule that a stenosis depending on n loss 
of mucons membrane from the cervical canal is not amenable to 
any treatment except that of amputation or linear incision, by which 
a mucous-lined canal may be found or formed. The specific technic 
by which this is accomplished may be modified to suit the case. For 
this purpose the vaginal mucosa may sometimes be utilized. 



I 



I 



CHAPTER XXI. 
LACERATION OF THE CERVIX UTERI. 



Laceratiok of the uterine cervix is of very frequent occurrence. 
Few women escape tlie accident in childbirth. Many lacerations are 
of trivial import and many more heal spontaneously. Nevertheless, 
a large proportion of child-bearing women give evidence of a pre- 
existing laceration, either through a want of union or by the presence 
of scar-tissue. 

Canies. — Childbirth is the paramount causative factor of cervical 
tears. Indeed, so generally is this the case that the discovery of a 
lacerated cervix in a woman is regarded as almost prima facie evi- 
dence of motherhood. Tears may, however, occur as the result of 
forcible dilatation or from delivery of an iulra-uteriue tumor. Such 
tears usually heal promptly and leave no trace. 

Clinical History. — Laceration of the cervix may occur at any 
jwint of its circumference. In the vast majority of instances it takes 
place at the sides. Occasionally it will occur on the anterior or poste- 
rior lip. The claim that lacerations occur as frequently in this latter 
situation as at the sides is, I believe, purely fanciful and untenable. 
It may be true, as has been stated, that tliey heal more readily because 
held in closer apposition, and it is furthermore true that we occasion- 
ally find cicatricial bands extending from the anterior or posterior Up 
out into the fomices, but these are rarities, and such a thing as an 
unliealed antero-posterior tear of the cervix, except in the stellate 
laceration, is almost unheard of. The superior distensibility of the 
anterior and posterior lips of the cer\nx, as compared with its lateral 
segments, are well known to the obstetrician. In the accidental tears 
of the cervix from forcible dilatation I have never seen but one in 
the lip, and that occurred in a degenerated cervix. Indeed, the 
anatomic relations of the parts are such as to favor the lateral rather 
than the antero-posterior laceration. 

Cervical tears as they are found are denominated lateral, bilateral, 
and stellate. A lateral tear may alfect cither side of the cervix, but 
is much more frequent on the left. A bilateral tear affects both sides, 
but is usually more severe on the left. This increased involvement 
of the left side is owing to the usual left lateral impingement of the 

(245) 




246 PRACTICAL GYNECOLOGY. 

fetal head. The stellate laceration, as the name implies, is a star- 
shaped laceration in which three or more fissures are found radiating 
from the cervical canal. Incomplete tears of the cervix are some- 
times met with. These occur from within outward, and do not involve 
the vaginal aspect of the cervix. If not readily recognizable by the 
sense of touch, a sound introduced into the canal will find the cleft, 
and may be felt through the thin membranous covering by the finger 
placed over it on the vaginal aspect of the cervix. 

Old lacerations — and those are the only ones that usually con- 
cern the gynecologist — present under two conditions: — 

1. As a rent of greater or less depth which has healed over. 
These are sometimes slight, presenting as a mere depression or notch, 
sometimes so extensive as to involve the entire length of the cervix. 
The tissues are soft, flaccid, and — ^barring the cleft — ^are natural in 
appearance and consistence. 

2. The cervix is indurated, thickened, everted, oftentimes eroded, 
and presents the characteristic appearance of cystic degeneration. It 
is only the second class that demands operative interference, as will 
be seen later on. 

Diagnosis. — The laceration may be evident, or the eversion and 
retraction of the torn surfaces may be so great as to efface all evi- 
dences of laceration to the unpracticed touch or sight. A cicatricial 
plug in the upper angle of the laceration also serves to conceal its 
extent. The spreading out and turning backward of the edges of the 
lacerated cervix, together with the effacement of the angle of lac- 
eration, either through retraction or scar-tissue or both, and the 
pathologic changes by which the raw surfaces assume an ulcerated 
appearance, for many years misled the profession into regarding the 
condition as one of true ulceration of the cervix. Its real nature 
was discovered by Emmet. Nevertheless, a lacerated cervix is usually 
quite easily distinguished by digital examination. It will be found 
altered in shape, size, and consistence. Instead of being circular in 
outline, it will be elongated antero-postcriorly, owing to the separa- 
tion of the torn surfaces. Instead of the natural rounded extremity 
of the cervix, it will be more or less flattened. It will be soft and 
velvety from granular erosion; indurated, nodular, and shot-like 
from cystic degeneration ; and oftentimes present a notch at the angle 
of the tear, or, in lieu of this, a dense cicatricial plug easily distin- 
guished by the finger. Furthermore, by passing the finger around the 
margin of the cervix, it will be found bulbous at the extremity, with 
indurated, upturned edges. The curled-up, projecting margins are 



LACERATION MF THE CERVIX LTKRl. 



247 



on the antero-posterior aspects. To the eye the exposed surface ap- 
pears red, raw, and angry, and is even yet inaptly termed ulceration 
of tlie womb by the careless or untutored. By geizing tlic margins of 
tlic ttuterior nuil posterior lips with tcnuculu, and bringing them 
together, the raw surfaces will be turned in and the cervix restored 
U> »ornctl\ing like its naturnl appearance. This is the crucial test 
I when oiiy doubt exists as to the nature of the lesion. 
I Aside from the physical signs as given under the head of diag- 

^^■psia, there are few symptoniB referable to the laceration itself. But 
^^■1 laceration of tlie cervix is a prominent factor, directly or indirectly, 
of many other lesions of tlie genital apparatus, the symptomatology 
will depend upon the number and character of the associate lesions. 
Occurring, as it does, at the time of labor, the normal course of 
events incident to the puerperium is apt to be disturbed, with a 
L jesulting subinvolution of the uterus. Add to this a localized sepsis, 
r and we may have glandular hypertrophy, interstitial growth, granular 
erosion, and cystic degeneration. Cervical catarrh, increased men- 
struation, backache, headache, and various phenomena, principally 
nervous and digestive, are among the most common symptoms. Where 
the tear has extended into the connective tissue of the broad ligament, 
the subsequent cicatrization will sometimes give rise to annoying or 
even severe pelvic pain. Pressure upon the cervix, or movements of 
I the uterus — as in coitus, defecation, and jolting of the body — are 
attended with pain. In bad cases, sterility not infrequently ensues, 
or conception is apt to be followed by abortion. 

Treatment. — Some gj-necologists advocate the immediate repair 
of all cervical tears. Considering that a very large proportion of 
cervical tears heal spontaneously, and tliat comparatively few ever 
demand or come to operation; tliat the condition cannot be recog- 
L juzed at this period by the sense of touch, thus necessitating the 
W ^ular ins|}ection of all women delivered ; and that the operation 
would entail such an exposure of the recently delivered woman as to 
add greatly to the dangers of the puerperium, it follows that such a 
I course would not only be unnecessary, but prejudicial to the best 
I interests of womankind. Furthermore, "the cervix immediately 
after labor is enormously enlarged. It is edematous, tremendously 
^ stretched, and stitches put in it at that time hang like ear-rings three 
days later" (Hirst). Only in case of extreme and palpable lacera- 
tion or to arrest hemorrhage from the cervix is immediate repair 
justifiable. Neither is it necessary to subject all persistent lacera- 
tions to operative interference. 



248 



THACTICAL GYXECOLOGV. 



Those of the first class should be allowed to take care of them- 
■elves. Lacerations of comparatively recent date, unices very ag- 
gravated, should be allowed time to make such amends as Nature, 
aided by judicious care, may be able to effect. Lacerations in the 
actively child-bearing woman should be let alone unless there be 
some urgent demand for interference. 

Lacerations of the second class, or those accompanied by eversion, 
erosion, cystic degeneration, and marked induration of the cervical 
tissue should be operated on. After the age of forty all lacerations 
that are not covered by mucous membrane or are attended by marked 
pathologic clianges in the cervix should be operated on. This in 
view of the fact that laceration of the cervix is regarded as one of 
the prime factors of cervical cancer. 



..iNi>''»iii2_ 



>'ig. 143. — Alpha Syringe. 

The operation for lacerated cervix will depend upon the condi- 
tions found. When all the purposes of operative interference are 
subserved by it, the Emmet oj)eration is preferable, for the reason that 
it leaves the cervix more nearly in its normal condition than any 
other. When, however, the cervix has been irreparably damaged, or 
when from any reason the Emmet operation is inadequate to restore 
the cervix to something like its natural form and function, it may 
be necessary to remove the cervix by amputation, or to excise the 
diseased portion and form a new cervical canal by turning in the 
vaginal mucous membrane. 

Almost every case of lacerated cervix which calls for operative 
interference should be subjected to preliminary treatment. The 
treatment should consist of copious douches of hot water repeated 
several times daily, the application of Churcliill's tincture of iodine 
to the cervix and vaginal vault once in five days, the abstraction of 
blood from the cervix by scarification or deep puncture at like inter- 




l-ACKKATll)X OF TilK lEUMX I TEHI. 



2W 



pnnebire and evacuation of distcndod cysts ■nlicre cysHc 
degeneration exitits, and the use of borogiycerid tampons after every 
treatment. The patient should be kept at rest and tlie bowels soluble 
by suitable lajiatives. 

In many cases a few weeks of such treatment will be followed 
bj a subsidence of the inflammatory symptoms, a disappearance of 
the discharge, and a softening of the cervical tissues. The improve- 
ment in the patient's general condition will be as marked as tiie 
local changes. Her aches and pains will have disappeared along with 
other reflex phenomena, and she will experience such a sense of relief 
as to lead her to believe that she is cured. The only drawback to this 
preparatory treatment arises from this fact, and swayed by a false 
sense of security she will sometimes decline the operation. The im- 
provement, however, is tran.sitory and can only be maintained by 
constant attention to every detail of treatment, and, unless tliis be 




Kijf, 144. — Volsellum Forceps for Steadying the Cervix 



followed by operation, the patient soon lapses into iier former con- 
dition. Whatever of good may accrue from the treatment will be 
manifest in a few weeks, — from two to si-x, — and, if at the expiration 
of that time marked benefit has not been obtained, the case is not 
one for the Emmet operation. 

Emmet's Operation (Trachelorrhaphy). — This operation con- 
sists in freshening the torn surfaces and uniting them by suture in 
such a way as to restore the cervix in as near the natural condition 
as possible. It will be remembered that the cervical tissues have 
undergone marked changes, that a plug of cicatricial tissue occupies 
the angles of the tear, and that it is necessary to provide for a cervical 
canal. Hence, it is necessary to remove all diseased tissue, not only 
from the surface of the tear, but also from the angles, even though 
this latter require deep dissection. It is also necessary to provide for 
a cervical canal by leaving an undenuded strip along the middle line 



250 



nUOTICAL OyNRCOLOOY. 



of the inner aspect of the cervix, and continuous with the canal above. 
Otherwise a cervical atresia may result. 

The patient, being properly prepared and aneatlictizcd, is placed 
on the table in the dorsal decubitus, tlie legs supported and the peri- 
neum flush with the end of the table. The perineum is retracted, — 
a self-retaining instrument being preferable for tiiis purpose, — tlie 
anterior lip of the cervix is seized with a traction forceps, and the 
uterus drawn down. The posterior lip is now seized and both forceps 



Fig. 145.— Author's Cervical Knife. 

adjusted so as to be in the middle line. Instead of the forceps for 
steadying the uterus, some prefer silk threads of convenient length 
which have been passed, respectively, through the anterior and poste- 
rior lips, the free ends of each being tied together. To denude the 
surfaces, the tissue to be removed is caught up by a tenaculum at the 
end of the cervix, and with knife or scissors cut away. This dissec- 
tion should extend from the tip of the cervix well up into the angle 
of the tear, and should be long enough and deep enough to include 



Fig. 140. — Heavy Scissors (or Denuding the Cerrlz. 

all cicatricial tissue. Especially is this necessary to remove the reflex 
disturbances after the parts have united. Many cases of trachelor- 
rhaphy are worse after operation than before, because of imperfect 
clearing of the angles. 

The opposing flap is now denuded and the process repeated on 
the other side. By passing the finger over the denuded surfaces any 
hardened areas of tissue will be detected, and should be removed. I 
have had constructed a knife specially designed for this purpose by 
which the denudation of trachelorrhaphy can be facilitated. It is 




LA. EliATION OF THK CERVIX ITKUl. 



251 



specially serviceable in clearing the angles of cicatricial tissue. A 
ill one-fourth of an inch of uudenudcd tissue should be loft in the 
middle of each flap for the cervical canal. This strip should be flared 
at the lower extremity for the os extern\im. To insure accuracy, 
sorae operators mark out the canal by a linear incision on either side 
before commencing the process of denudation. A common fault 
among operators is to remove too much of the outer edge of the 
cervix. The bleeding, though not usually troublesome, is sometimea 



.TRUAXGSEtne-CO;- 



Fig. 147. — Kiniiict'g Cervical Needle*. 

profuse. This may be forestalled by placing a temporary ligature on 

, either side above the upper angle of the parts to be excised. These 

hould be removed at the completion of the operation. Usually, 

Bver, no attention is paid to the bleeding until the denudation is 

ftWplctcd, when sutures are placed at the upper angles of the wounds 

and tied immediately. 

From two to four sutures are used on either side, and are passed 
in such a way as to bring the two flaps of the cervix together and the 



0= 



Kg. 148. — Counterpressure. 

corresponding raw surfaces into direct apposition. The needle is 
entered on the mucous membrane of the vaginal aspect of one of the 
flaps near the edge, is carried under the denuded surface, and emerges 
on the mucous membrane of the canal near the edge. Ileturning, 
the needle is carried under the denuded surface of the other flap 
from within outward, and emerges on the vaginal aspect of the cervix 
opposite its point of entrance. The two ends of each suture, after 
being placed, are secured by clamp forceps to prevent their accidental 
displacement. The last suture on either side is passed diagonally 
from the tip of the cervix upward and inward to secure perfect 




256 



PRACTICAL GYNECOLOGY. 



in contact, the tip of the cervix being sutured to the transverse ledge 
at the upper angle. The anterior flap is treated in like manner, and, 
last, sutures are introduced at the sides as in trachelorrhaphy. (Fig- 
152.) This infolding of the vaginal mucosa provides for a cervical 
canal and preserves about one-half the length of the normal cervix in 
cases which would otherwise call for amputation. Catgut, or some 
other form of absorbable suture, may be used for the transverse sutures, 
as they are not easily accessible after the lateral sutures have been 
placed. 

Amputation of the Cervix Uteri. — There are several modes of 
amputating the uterine cervix, either of which may be called for 



Fi- ir..i. 
Flap Amputation of the Oerviz Uteri. 



Fig. l."!-!. 
(Second and Third Steps.) 



nnder diiferent conditions. The flap operation here described should 
be the one of election whenever practicable, and when it can be made 
to meet the nc^ds of the case. Conical excision is open to the objec- 
tion that stenosis, or even complete closure of the canal, may follow. 
Square amputation, without covering the stump with mucous mem- 
brane, is open to the same objection, while troublesome hemorrhage 
is liable to follow both methods. The flap operation not only obviates 
these diflficulties, but leaves the parts much more natural in condition 
and appearance. 

For amputation of the vaginal portion, the cervix is split up to 
the vaginal vault on either side ; then, seizing the posterior half with 
• traction forceps, it is removed by a wedge-shaped incision, the 



LACERATION OF THE CEUVIX ITEIII. 



257 



knife being carried from the vaginal aspect upward and inward, and 
then from the inner aspect upward and outward, until the two in- 
cisions meet. The anterior half is treated in like manner, when it 
will be found that both halves of the cervix are provided with an 
anterior and posterior flap, respectively. (Fig. 153.) These flaps 
are brought together, as in laceration of the cervix, the first stitch being 
introduced at the upper angle on either side to control the hemorrhage. 
The mucous membrane of the cervical canal is attached to that of the 
vaginal aspect by two sutures anteriorly and posteriorly. (Fig. 154.) 
Where it is desirable to avoid the loss of blood during the operation, 
temporary ligatures may be inserted on either side of the cervix high 



e.TlEAlANN ACQ 



/-' 



/y 



')\\- 



m 



7\g. 155. — Shield and Forceps for Twisting Wire Suture. 

Dp BO as to be above the upper angle of the intended incision. These 
! ligatures should be introduced deeply into the cervical tissues and tied 
firmly. They may be removed at the completion of the operation. 
The vaginal flap should be somewhat longer than the inner one, as it 
tends to retract, and is thus liable to result in eversion of the mucous 
membrane of the cervical canal. 

Silk-worm gut is the most convenient suture material, and may 
be left for two or three weeks or even longer. This gives ample time 
for firm union, and, if aseptic and not tied too tightly, they seldom 
cut out. The same may be said of wire. Silk and other non-absorb- 
able suture material should be removed at the expiration of the tenth 




258 PRACTICAL GYNECOUXjy. 

or twelfth day. Catgut is not well adapted to this work, as it ia ab* 
Borbed too quickly. Any suture material that has to be removed or is 
absorbed before firm union has taken place is liable to be followed 
by retraction of the flaps, thus leaving an extensive raw surface to 
heal by granulation. Where extensive repair of the pelvic floor ac- 
companies the amputation of the cervix, chromicized catgut may 
sometimes be used with advantage, thus obviating the necessity of 
subsequent remov^. 

In supravaginal, or high, amputation of the cervix the steps 
are the same, with the exception that the cervix is freed from its con- 
nection with the vaginal vault. This is accomplished as described 
under the head of "Vaginal Hysterectomy." Here the circular edge 
of the vaginal mucous membrane should be stitched to the stump of 
the cervix in such a way as to form a covering for it, leaving, of 
course, a central opening for the cervical canaL 



CHAPTER XXII. 



CANCER OF THE CERVIX UTERI. 



In cervical cancer woman finds the sovereign affliction of her 
MX. In the sum-total of misery, loatlisonieness, hopelessness, mental 
uijriiish, and fatality it exceeds all others. The cervix uteri is 
tflcctcd witli cancer more frequently than any other portion of the 
My. It is estimated that ahout one-third of all woruen who die of 
cancer are the victims of uterine cancer. 

Causes. — Cancer of the cervii is pre-eminently a disease of the 
child-bearing woman. Not only so, but the liability of the disease is 
in direct proportion to the number of children borne. Statistics show 
that the subjects of cervical cancer have each, on an average, borne 
fire children. Virgins and nulliparous women are practically exempt 
from cervical cancer, though, as will be seen later, they are more 
jubject to cancer of the body of tlie uterus. While there are exceptions 
to this rule, the exceptions are not so numerous as appearances would 
indicate, as the unmarried woman will sometimes conceal the fact 
that she has given birth to a child. In other instances the cancer 
has followed an injury to tlie cervix, such as might occur in dilata- 
tion. Of late years it has been the fashion to ascribe cerv-ical cancer 
to the secondary etTects of a lacerated cervix, especially that form 
attended by eversion and erosion. 

The constant irritation to which the torn cervix is subjected by 
bodily movements, and especially in coition, is supposed to act as the 
exciting determining factor. There con be IRtle doubt that the 
ccnical tear plaj's an important role in the production of cervical 
cancer, but that it is the sole, or even principal, cause is questionable 
at least. A large proportion of the cervical cancers are not grafted 
on the everted and eroded cervix. Most cervical tears occur at the 
first birth, and, while it is only just to admit that there may be a 
repetition or aggravation of the tear with each succeeding labor, the 
torn and exposed surface resulting from one labor ought to yield a 
much larger percentage of cancers tlian statistics shoxv, if the cervical 
tear waa the dominant cause. But women with laceratetl, everted, 
and eroded cervices are not, as a rule, prolific; consequently they are 

(359) 





260 PRACTICAL GYNECOLOGY. 

not the women in whom cervical cancer is most frequent. On the 
other hand, it is my belief that cervical cancer is due, in large 
measure, to the contusion and injury to which the cervix is subjected 
during the passage of the child's head through the pelvic canal, and 
the repetition of this, as in the multipara, enhances the chances of 
malignant degeneration in proportion to the number of children 
borne. 

Cancer of the cervix occurs most frequently between the ages of 
thirty-five and fifty. It may, however, occur at any age from adoles- 
cence to extreme old age. It is more frequent in the hard-working 
woman than in the woman of easy circumstances. But the social 
condition of the victim is probably not so marked a factor as might 
seem, as prolificness and poverty often go hand in hand. Women in 
good flesh and apparently sound health are more frequently the sub- 
jects of cervical cancer than the ill nourished. The negrcss is com- 
paratively immune. 

Origin and Progress. — There are three forms of cervical cancer, 
depending upon the character of the epithelium from which it takes 
its origin. The distinction between these forms refers more to the 
situation of the initial lesion and the direction of development than 
to any essential difference in the character of the growth. Cervical 
cancer may take its starting-point from: 1. The squamous epithe- 
lium covering the vaginal aspect of the cervix. 2. The epithelium 
lining the cervical canal. 3. The epithelial cells of the cer^'ical 
glands. 

1. Cancer of the vaginal aspect of the cervix may occur in two 
forms: .is an ulcer or excrescence. The ulceratu;e form in its early 
stages is not easily distinguished from other ulcers; but, as a true 
ulcer of the cervix, attended by loss of tissue, is of great rarity, its 
presence should always excite suspicion. Later, the ulcers assume 
the characters of malignancy, as evidenced by the raised, hard, lumpy 
borders; the uneven, necrotic surface, from which issues a purulent 
ichorous discharge; and the tendency to bleed. The excrescences 
may be in the shape of small, rounded protuberances, or assume the 
form of a luxuriant, sprouting, cauliflower mass. The cauliflower 
variety is often of rapid growth, and may attain large proportions, 
filling the upper portion of the vnjiina and concealing the cervix. 
The growths arc very friable and vaseular, and bleed on the slightest 
provocation. The usual dirot-tion of growth is outward toward the 
vaginal wall. It may, however, pass u])ward into the cervical canal 
or in the direction of the broad ligaments. 



CAXCKR OK THE CEUVIX fTKni. 



261 



. In the second variety the growtli takes its origin in the 
H canal. If seen early, the mucosa will be found infiltrated, 
ftnd presents a dilTuse, plate-like induration, or he studded with small, 
projecting nodules. Later the cpitlielium is shed and the cancerous 
ulcer appears. In some instances where the cervi.x has not boon 
laoorated, or has boon repaired after laceration, the growth may moke 
great headway before presenting at the external os. The trend of 
this form is toward the uterine cavity, and thus it may insidiously 
and without outward sign make friglitful inroads before being recog- 
niated. It may spread toward the broad ligaments or in the direction 
of tlie cervical orifice. 

3. In this form the cancer first manifests as an irregular mass, 
or in the fonn of a nodule or nodules in the cervical wall. From its 
|)oint of origin the growth makes its way to the surface, either on 
tlie vaginal aspect or inwardly toward the cervical cannl. Sooner 
or later this breaks down, and the resultant excavation presents all 
the characters of tlie cancerous ulcer. The distinction of the various 
tj-pes of cervical cancer holds only in the earlier stages. Later, when 
extensive infiltration and ulceration have taken place, the clinical 
aspects are very much the same. 

Fortunately such distinction is not of the slightest importance, 
as the progress and termination of the disease is essentially the same 
in all. The cervix is usually enlarged, and at times markedly so. It 
is hard, more or less irregular or nodular, incompressible, and in- 
elastic. The ulcerated surfaces are uneven, often granular, necrotic, 
and liathed in an ichorous, foul-smelling secretion. The borders of 
the ulcers are raised, indurated, and irregidar. (Fig. 156.) The 
degenerated portions of the cancer are friable, and can be easily 
chipped off with the finger-nail. The detached fragments, when 
rolled between tlie thumb and finger, break down and become unctuous 
and granular to the touch. The sensation imparted has been very 
aptly compared to that of a ripe pear. 

There is usually an odor, most penetrating and abhorrent, ema- 
nating from the disintegrating cancer, which, though not distinc- 
tive, is very suggestive, and in many instances the most prominent 
Bymptom. The odor is not, as many believe, pathognomonic of 
cancer, as it is sometimes associated with other necrotic processes, 
and has been noticed in sloughing fibrnids, senile endometritis, or 
in the decomposition of the secretions of the uterus and vagina ab- 
sorbed by a sponge or tampon which has been left in the vagina 
too long. This odor is very tenacious, and will cling to the fingen 




2(i2 



PILVCTICAL orNECOUXlY. 



long after having been brought in contact with the c&ncerot 
ter. Deodorization can usually be effected by washing the 
in turpentine and wiping them dry. 

Tl>e cancerous ulcer is prone to bleed on slight provocation, 
some instances the infiltration is very extensive before the pro 
of disintegration commences. In such, the cervix becomes gre 
enlarged, bulbous, and irregular. In others, the ulceration k< 




Fig. 1.5(1. — Cancer of tlie iVrvii. 



pace with the infiltration, and the diameter of the cervix constai 
increases until it occupies the greater portion of the vaginal va 
Here the hard, irregular margin of the cervix encompassea a era 
like excavation, which extends upward toward the uterine cai 
Exceptionally the tip of the cervix will not show conspicuous alt 
tion. In such the disease has usually started in the cervical ei 
and is traveling upward. 



CANCER OF TllK (KRVIX ITERr. 



2<!.! 



fn T 



In ita advanced stages the cancer selilom coi fines itself to the 
Mnix, nor yet to the uterus. It spreads to the neiglihoring organs 
and tissues. The upper portion of the vagina is more or less impli- 
cated. The bladder is frequently involved, owing to its proximity 

the cervix. This often leads to vesico-vaginal fistula. Extension 
in the direction of the rectum is less frequent, but occasionally occurs, 
and leads to a recto-vaginal fistula. Very commonly the cancerous 
infiltration extends outward into one or both broad ligaments. This 
direction of growth is so common as to be almost tlie rule. This 
produces hardening and shortening of the ligaments and fixation of 
the uterus. The ureters may be compressed by the surrounding in- 
filtration of the cellular tissue, or their caliber reduced by direct 
invasion of their walls. This, by impeding the escape of urine, may 

ult in nephrodrosis. The retained renal secretion also gives rise 
to uremic toxemia. 

Cervical cancer shows little tendency to invade the lymphatics, 
or to affect the lymphatic glands. Occasionally the retroperitoneal 
glands will be involved, and less frequently the inguinal glands. 
These glandular involvements seldom occur before the disease has 
advanced so far as to make their consideration of little importance. 
Jlet.Tstasis to remote parts seldom occurs. The belief is quite prev- 
alent among the laity that if the disease is eradicated in one location 
it will make its apjiearance in another. In cervical cancer there is 
aiiiiost no ground for this belief. Extension of the cancerous ulcer 
in the direction of the peritoneum sometimes leads to perforation 

Eand peritonitis. This grave complication is happily usually fore- 
stalled by plastic exudation, which walls off the cavity from the 
Advancing ulcer. 
Symptoms. — The early stages of cervical cancer are, as a rule, 
marked by an entire absence of symptoms, or, if symptoms exist, 
they are of such grade and character as to excite little attention and 
_ no apprehension. This is unfortunate, as early diagnosis and prompt 
action are essential to successful treatment. The ordinary symptoms 
are hemorrhage, pain, and discharge. Either or all of these may be 
wanting, ill defined, or delayed until the disease has advanced beyond 
the reach of human skill. 

Ilentorrhage. — This does not usually take place until the ulcera- 
tive period is reached. This, in the superficial ulcerative type, may 
be at a comparatively early period. In others, especially in the deeper 
infiltrations, the disease may be far advanced before the symptoms 
manifest As a rule, the first manifestation is an increased menstrual 




264 



rRACTK-AL aYNECOt^OOY. 



flow. Sooner or later intermenstrual bleedingB occur. These usuallj 
follow some unwonted exertion or direct injury, such as physical 
exercise, straining at stool, or coitus. The post-climactoric hemor- 
rhage often ajjpears with such regularity as to encourage the belief 
on the part of the patient that it is the revival of a dormant function: 
that she has not, in fact, passed the menopause. Thus, after months 
or years of exemption a flow will return which will occur at moutldy 
intervals, or every two or three months. The bloody discharge grad- 
ually increases in quantity and duration until it becomes a serious 
menace to the general health. In some instances the lose of blood 
comes as a mere seepage mingled with the discharges, witli now and 
then a flow of increased severity; in others it dribbles almost con- 
tinuously, especially when the woman is on her feet. Furious hem- 
orrhages sometimes occur, bringing the woman to the brink of the 
grave. Death from hemorrhage is, however, of great rarity. 

Discharge. — The discharge incident to the early stages of cancer 
is in nowise peculiar, and is indistinguishable from the ordinary 
leucorrliea. It is, in fact, an increased secretion from the cervical 
gliinds due to the irritation incident to the cancerous infiltration. 
Later, when the cancer begins to disintegrate, the discharge becomes 
thin and ichorous, or of a brownish color from the admi.xture of 
blood, and malodorous from the decomposed matter which it con- 
tains. As a rule, the stench is powerful, penetrating, and utterly 
abhorrent to the olfactory sense; but there are exceptions, and in 
some instances it is never troublesome. The discharge is acrid and 
irritating, and in persons of uncleanly habit is apt to produce ex- 
coriation of the parts with which it comes in contact. 

Pain. — The pain in cervical cancer varies greatly in different 
individuals. It seldom manifests early, and is sometimes wanting 
throughout the course of the disease. Usually it is quite severe in 
tlie later stages of the disease, and in some instances is without 
parallel for atrocity. I have seen the unhappy victim crawling about 
tlie room on her hands and knees suffering agonies indescribable. It 
is lancinating, burning, or gnawing in character, and may be referred 
to any point within the pelvis. It sometimes shoots upward into tlie 
abdomen or downward along the thighs. 

Aside from these ordinary symptoroB, others may be added of 
a special character depending upon the involvement of other organs. 
The infiltration of the bladder-wall before the occurrence of perfo- 
ration gives rise to vesical irritation with more or less constant 
tenesmus and frequent urination. Proximity to the rectum uaually 




CANCER OK THE CERVIX ITERt. 



2(55 



preaages a more or less obstinate constipation. This may be alter- 
natcd writh diarrhea or dysenteric symptoms. Toward the last diar- 
rhea is common. Ureteral obstruction gives rise to discomfort, some- 
times to severe colicky pains, and to uremic intoxication. When the 
infiltration involves the peritoneum, the sharp, lancinating pains 
of localized peritonitis are added. 

In advanced cancer the abdominal walls are rigid, the intes- 
tines gathered in the upper abdominal zone, and the pelvic roof hard. 
This condition of things is probably due to the peritoneal involve- 
ment Combined with these there are usually anorexia, more or less 
gastric disturbance, and sleeplessness. The hemorrhage and drainage, 
the absence of nutrition and loss of sleep, the pain and odor lead to 
profound anemia and emaciation. Absorption of the decomposed 
excreta surcharges the 8}'stem with septic matter. Along with anemia, 
emaciation, and caciiexia, a lemon-hued skin may characterize cancer 
in this, as in other situations. 

Diagnosis. — ^In the great majority of cases cervical cancer is not 
recognized until it has made such headway as to place it beyond the 
pale of successful treatment. It has been taught that the uterus, 
by reason of its isolation, is the most favorable site for cancer, in 
that the disease is confined within definite limits, and, therefore, 
can be more easily eliminated. While this may apply to cancer 
affecting the corporeal cavity, it in no sense applies to the cervix, 
for it is a very short step from the cervix to the vaginal vault, the 
broad ligament, or tlie bladder, and this step is almost invariably 
taken at a very early period. In view of the vital necessity for early 
diagnosis it is lamentable that we have no criteria by which we can 
recognize cenical cancer in its incipient stage. Women should be 
taught to view with distrust any hemorrhage which is unnatural 
«8 to time or quantity, as also any unusual discharge. There are, 
however, so many conditions of trivial import which give rise to 
hemorrhage or discharge, and it is so often the case that the gyne- 
cologist cannot assign a definite cause for the same, that she has 
learned from experience to disregard them unless inordinate in 
quantity, or accompanied by other and more impressive symptoms. 
If, obeying the injunction of the medical attendant, she has reported 
to him on a number of occasions and finds that her apprehensions 
are unfoimdod, she finally settles down into the belief that the cry 
of "wolf" is a false alarm, and serenely awaits the issue. This is all 
the more apt to be the case with the initial hemorrhage of cancer, 
in that it is unattended with the slightest distress, whereas in 



h^a^A- 



266 PRACTICAL GYNECOIXWY. 

most other instances the inflammation or congestion which is the 
causative factor gives rise to more or less discomfort. Nevertheless, 
the doctrine should be inculcated and forced upon the attention of 
the woman, that every hemorrhage unnatural as to time or quantity 
is pathologic, and may be ominous of tlie direst consequence. Better 
still would it be if all women between the ages of thirty-five and sixty 
could be looked after at regular intervals by a competent gynecologist. 

Some of the conditions with which a cervical cancer may be 
confounded are: erosion with laceration, syphilitic or tubercular 
ulcer, cystic degeneration, cervical fibroid, and a sloughing uterine 
polypus. 

An easy method of distinguishing erosion from cancer is the 
tenacity and toughness of the velvet-like covering. It cannot be 
chipped off with the finger-nail, or, if so, docs not break down when 
rubbed between the fingers. Ileitzmann believes that we have in the 
solution of sulphate of copper an almost unfailing aid to the diag- 
nosis of incipient, ulcerative cervical cancer. According to him, the 
application of a 10-per-cent. solution of the sulphate of copper to 
the cancerous ulcer will produce bleeding, whereas the same solution 
applied to the simple erosion will result in a bluish-white coating 
without bleeding. The older erosions are to be distinguished by 
the absence of the hard, elevated, irregular margins and foul secre- 
tions of cancer. 

Syphilitic and tubercular ulceration of the cervix is so rare as 
compared with cancer that the presumption would be in favor of the 
cancer. In general appearance these ulcers often closely resemble 
that of cancer. If, after evoking the history of the case, syphilis be 
suspected, antisyphilitics should be tried; if lupus be suspected, the 
electric light treatment might be given a trial. Should the ulcer 
fail to be benefited under this regime, the case is presumably one 
of cancer. The microscope should not be ignored, nor its use too 
long deferred. 

In cystic degeneration the cysts may be seen and their contenis 
expressed after puncture. Fibroid tumors of the cervix are much 
more rare than cancer. The tumor is usually single, more clearly 
defined, smoother, and not so intimately blended with the tissues as 
the cancerous nodule. It is also denser and usually larger. A slough- 
ing polypus is more friable than cancer and by careful examination 
the healthy cervi.x may be found encircling its pedicle. 

In the initial stage, and as a means of differentiation at a later 
period, the microscope may afford valuable assistance. Liberal seo- 



CANCER OF THE CERVIX ITERI. 



2(57 



tions Bhould be taken from the Buspected part, including some of the 
healthy tissue. Scrapings are unreliable, for the reason that they 
include only disorganized tissue which may as well represent one 
degenerated process as another. These sections may usually be made 
without the aid of an anesthetic, as the cervical tissues are not very 
sensitive. Wc<lgo-shaped pieces may be excised from the cervix and 
the gap closed by suture, or, if necessary, the entire cervix may be 
amputated for the purpose of examination. The specimens should 
be placed in alcohol until they can be turned over to the pathologist. 
Not a few gynecologists, among whom are some of the most eminent, 
place little reliance on the microscope as an aid to diagnosis in 
cervical cancer, and rely chiefly on the clinical features. The effi- 
ciency of the microscope will dupend very much on the man who is 
back of it, and, though invaluable at times, it must be admitted that 
many and grievous errors have been coiuniittod through its use. As 
between the two, in general I would rather trust the clinical than 




Fig. 157.— Sponge Tent 



microscopic evidences of cancer of the cervix, but would avail myself 
of both to make assurance doubly sure. 

It should be remembered that cancer of tlie cervix is an infiltra- 
tion, and not a growth by accretion; that the cancerous mass is ill 
defined, immovable, incompressible, inelastic; that it offers a dead 
resistance to compression, and yields only when its tissues are crushed. 
It is incapable of stretching, and consequently that portion of the 
cen'ical canal which it occupies cannot be dilated. Another feature 
of the cancerous deposit which distinguishes it from the inflam- 
matory is its inabsorbability. These attributes of the cancerous 
deposit may be made use of to distinguish it from other deposits. 

It is well known that the indurated cervix of chronic inflam- 
mation may be dilated and softened under expansive pressure from 
the cervical canal. When the pressure is continued long enough, the 
cervix not only becomes dilated, but the tissues become soft, pliable, 
and devoid of lumpinesa or uneven patches. That portion of the 



268 PRACTICAL GYNECOLOGY. 

cervix occupied by tlie cancerous infiltration will neither yield to 
dilatation nor yet become softened under its influence; hence dilata- 
tion of the suspected cervix affords a valuable means of differentiation 
between the cancerous and inflamed cervix. Rapid dilatation i« not 
BO well adapted to this purpose as the gradual dilatation effected by 
the sponge or laminaria tent. 

Should the cervix be torn and the suspected deposit be in the 
everted lip, one or two sutures should be introduced through the 
anterior and posterior lips on either side so as to bring them in 
apposition, and after introducing the tent, tied so as to temporarily 
restore the cervical canal that the effect of pressure on the suspected 
part may be noted. No paring shmild be done as in trachelorrhaphy, 
and the stitches should be removed as soon as tl»e test is completed. 
This will not require an anesthetic, though it should be conducted 
with scrupulous antiseptic detail, and the woman should be kept in 
bed during the period of dilatation and for a day or so afterward. 



Fig. 158. — Laminaria TenU. 




A hard, lumpy, irregular cervix should always be an object of 
distrust, and should be subjected to every known test until satisfied 
of its character. Advanced cancer may usually be recognized by the 
unaided senses. The irregular excavation, the tendency to bleed, the 
foul-smelling discharges, the cachexia, and the complex of symptoms 
referable to the involvement of adjacent organs make a picture so 
distinctive of cancer as to be unmistakable. 

Course and Termination. — Cervical cancer usually runs its course 
to a fatal terniinntion in from one to two years. To this there are 
exceptions in which the case may terminate in a few weeks or months, 
or extend over a period of years. Very rapid growth is apt to occur 
in the young and well nourished. Death is usually tlie result of a 
combination of causes: anemia, exhaustion, inanition, septicemia, 
and uremia, each and severally playing a r61e. Hemorrhage, though 
often alarming and always debilitating, seldom kills. Peritonitis is 
infrequent. Many patients sink from exhaustion, worn out by pain. 



4 
4 
I 



CANCER OF THE CERVIX UTERI. 269 

hemorrhage, discharges, msomnia, and inability to take and assimi- 
late food. The noisome stench of which the patient is sensible, and 
about which she is acutely sensitive, helps to round out her burden 
of woes and wear her life away. Uremia is probably the most con- 
itant single factor in sealing the fate of the victim. It «)mes like 
t benediction to soothe the last hours of the wretched sufferer, who, 
mider its lethal influence, moves to her final rest "with beniunbed 
KDsibilities and clouded intellect 



CHAPTER XXIII. 

TREATMENT OP CANCER OP THE CERVIX UTERI. 

The treatment is radical or palliative. The radical treatment 
consists in the removal of the entire organ, with as much of the adja- 
cent tissues as may be deemed necessary — within practicable limits— 
to insure complete eradication of the disease. Palliative treatment is 
resorted to in such cases as have passed beyond the reach of the knife. 

"The less the disease, the greater the operation" used to be an 
expression very much in vogue. This apparently paradoxical dictum 
was founded on the fact that in advanced cancer complete eradication 
was out of the question, and consequently radical measures were either 
impracticable or inexpedient, as involving greater risk than the results 
would justify. Furthermore, anything less than total extirpation of 
the uterus for cervical cancer in the earlier stages was manifestly un- 
wise in the light of the oft-demonstrated fact that secondary foci of 
disease were frequently to be found in more or less remote parts of the 
organ when the primary infiltration was apparently confined within 
narrow limits. Neither is it possible by the unaided senses to define 
the boundaries of the primary infiltration. As a rule, it may be said 
that the involvement of the vagina, bladder, rectum, or broad liga- 
ments is a contra-indication for the radical operation. Modern surgery 
has, however, essayed to cope with many of these complications, indi- 
vidually or collectively; so that the limitations of the radical procedure 
are not clearly defined. Practically, however, and taking into con- 
sideration the capabilities of the average surgeon, radical extirpation 
should not be attempted when the disease has passed beyond the con- 
fines of the uterus. 

Gross involvement of the vagina will be recognized by the eye; 
that of the bladder or rectum by the functional disturbance and by 
the sense of touch. When the cancer has invaded the broad ligaments 
they are rendered thick, hard, and inelastic, and can be felt at the 
sides of the uterus, which they hold rigidly in one position. The old 
rule used to be that a uterus that could not be drawn down to the 
vulva was not a fit one for the operation of extirpation. This is a 
safe working rule; but occasionally the uterus and appendages are 

('2T0) 



TREATMENT OF CANCER OF THE CERVIX UTERI. 



271 



bound down by inflammatory adhesions which in themselves are no 
tar to the operation. These can usually be differentiated by exclud- 
ing the palpably thickened and indurated ligaments. 

RADICAL TREATMENT. 

The radical treatment for cervical cancer involves the removal 
of the uterus. This may be accomplished per vaginam, through ab- 
dominal section, or by a combination of the two, which is designated 
the "combined method." 

Vaginal Hysterectomy. — In the operation of vaginal hyster- 
ectomy all aseptic details should be followed as scrupulously as in any 



Kg. 159. — Irrigating Stand. 

other intraperitoneal operation, and for the same reasons. In the 
way of preliminary preparation special attention should be given to 
the vagina, pudendum, and its envirouments. After shaving the 
pudendum, it and the surrounding parts, including the lower portion 
of the abdomen, perineum, and inner aspect of the thighs, should be 
thoroughly scrubbed with soap and water, rinsed in plain, sterilized 
water, and again washed with a 1 to 2000 solution of bichlorid of 
mercury. The vagina should be irrigated first with plain water, then 
with a 1 to 4000 bichlorid solution, and loosely packed with gauze. 
Should the cervical tissues be disorganized or the seat of a cauliflower 
excrescence, these should be removed by tlie curette and carbolic acid 



272 



PRACTICAL GYNECOLOGY. 



applied to the raw surface. It is seldom necessary to give an anesthetic 
for this part of the operation. After the patient is placed on the table 
and under the influence of an anesthetic, the vagina should again be 
thoroughly scrubbed with a 5-per-cent. solution of creolin in a solution 
of green soap of the consistence of molasses, and then irrigated 
with plain, sterilized water. 

Operation. — The patient is placed in the dorso-sacral position, 
the buttockfi projecting a little beyond tlie end of the table, and the 



rig. 160. — Byford'g Traction Forceps. 

thighs flexed. The legs may be intrusted to assistants or supported 
by leg-holders. The exposed portions of the thighs, buttocks, and 
lower abdomen are covered with sterilized towels or swathed in gauze 
bandage. Slight elevation of the hips, as in the modified Trendelen- 
burg position, conduces to ease and celerity of operation by keeping 
the intestines out of the way and in bringing the field of operation 
within direct line of the vision. I first called attention to this ad- 




Fig. 161. — Bemays's Uterine Tractor for Insertion within the Can*L 



vantage at the Baltimore meeting of the American Medical Associa- 
tion in 1895, since which it has been quite extensively adopted. 

A perineal retractor being introduced, the cervix is seized with a 
strong-toothed forceps and drawn downward and forward. An in- 
cision is then made through the posterior vaginal fornix, extending 
from one side of the cervix to the other. The dissection is carried 
through the cellular tissue to the peritoneum, which is caught up by 
a rat-toothed forceps and snipped with the scissors. Witli a finger 




TUELVTMENT OF CANCEK UK THK CKRVIX I'TKKl. 



273 



thrust into the peritonea] cavity aa a guide, the opening in the 
peritoneum is enlarged to the full length of the vaginal incision. 
,(Fig. 1G2.) Should there be any disjwsition for the intestines to 
pritrudo, a roll of gauze, to which a strong thread is attached, should 
be inserted into the peritoneal cavity so as to block the opening. The 
string should be allowed to hnng out of the vagina, by which the gauze 
may be removed at the proper time. The edges of tiie peritoneum and 
Taginal wall may now be united by continuous catgut suture, as a safe- 
guard against bleeding; but this is often neglected. 



/a 






JU 



\ 



4 



i^i 



3"^" 



^«^ 



Fig. 162. — Vaginal Hysterectomy. Freeing the Uerriz 
Posteriorly. (First Step.) 



The cervix now being drawn backward, and if necessary an addi- 
tional retractor inserted to lift up the anterior vaginal wall, an incision 
is carried around the front of the cervix and well out to the sides be- 
yond the ends of the first or posterior incision. This incision should 
not be so high up on the cervix as to endanger the bladder, and should 
extend through the mucous membrane down to the connective tissue 
which forms a stratum between Uie bladder and cervix. The line of 
cleavage is through this connective tissue, and under ordinary condi- 




274 



PUACTICAL OYNECOLOOy. 



tions, with anything like ordinary care, the separation of the cerrii 
and bladder is easily effected with little chance of injury to the latter. 
If, however, it should be infiltrated, the utmost skill and caution may 
hardly suffice to avert injury to the bladder. 

Having made the initial incision, the dissection is carried forward 
with the thumb and finger, the bladder being pushed off of the cervix. 
(Fig. 1C4.) It is better that the tliumb or finger-nail be kept next to 
and closely applied to the cervix, as thereby there is less danger of 
wandering into the bladder. Unyielding bands may be clipped by 
the scissors under the eye. When the peritoneum is reached it is 
caught up, incised, and the opening enlarged as before. Both openings 
should now be stretched by tlie finger until they e.vtend well beyond 
the cervix on either side, and the anterior retractor pushed up into 




Fig. 103.— Pean'R Retractors. 



the peritoneal cavity in front of the cervix. This may be made of 
service in keeping the ureters out of the way in the subsequent stepa 
of the operation. 

If necessary, additional retractors may now be placed on one or 
both sides to facilitate the next step of the operation. The uterus it 
now drawn down in the axis of the vagina, and the little isthmus of 
mucous membrane between the anterior and posterior incisions cut 
through with the scissors. The cervix is now drawn strongly toward 
the left, and, guided by the fingers, a heavy clamp forceps placed 
on the left broad ligament so as to grasp the uterine artery. The 
forceps should be introduced close to the side of the cervix and pressed 
outward not to exceed one-third of an inch, lest the ureter be caught 
between its jaws. Pressure toward the patient's left with the anterior 
retractor at this stage will carry the ureter still farther out of harm's 




Fig. Ili4. — Vaginal Hystt^rectoiny. Freeing the Cervix 
in Front. (Second Step.) 

The retractors are now removed, with the exception of the 
perineal, and the fundus turned into the vagina through the anterior 
opening. This can usually be done by hooking a finger over it, or, if 
not, by climbing up the anterior aurface of the uterus with toothed 
forceps, by alternately placing one above the other until the fundus 
is reached and brought down. During this maneuver, and to facilitate 
it, the cervix is pushed backward and well up into the vagina. If 
possible, the ovary and tube of one side are brought into the vagina 




376 



PRACTICAL GYNECOLOGY. 



and a clamp forceps applied to the ligament external to them and in 
a direction from above downward, so as to include the ovarian vessels 
and the intervening tissues of the broad ligament to the end of the 
clamps first applied. (Fig. 1G9.) After the clamp is applied the 
attachments of the uterus are severed on that side. The other side is 
clamped and the uterus cut away. (Fig. 170.) If the tubes and 
ovaries cannot be brought within reach of tlie clamps, the uterus may 
first be removed by applying the clamps to the uterine extremity of 




Fig. ICS.— Sclsaora. 



d 



the tubes, and the appendages dealt with subsequently. In some cases 
the operation of vaginal hysterectomy will be facilitated by splitting 
the uterus longitudinally after clamping the uterine arteries, and 
removing each half separately. 

After the uterus is removed bleeding points are taken up, the 
gauze removed from the peritoneal cavity, the vagina sponged, and a 
loose gauze packing introduced up to the peritoneal cavity. The 




Fig. 166. — Broad Ligament Forceps. 

handles of the forceps are securely tied as an extra precaution against 
their becoming unlocked, and gauze is pushed up between the forceps 
and vagina to ward off pressure. The forceps may be removed in 
from thirty-six to forty-eight hours, and the vaginal packing on the 
sixth day, after which a gentle douche of mild bichlorid solution or 
other antiseptic may be given. Some operators prefer the use of 
ligatures to the forceps. Should a non-absorbable ligature material 
be used, the ends should be left long to facilitate their removal 




TREAT>fKNT OF CANCER OF THE CERVIX I'TERI. 277 

Werder'i Operation. — Wenlcr, of Pittsburgh, does a total ab- 
dominal hysterectomy, and carries bis dissections some distance down 
the vagina. The cervix is then seized through the vagina, and the 
detached uterus pulled down and cut away, including that portion of 
the vagina which had been freed by dissectioo. 



Pig. 167. — Vaginal Hysteroctomy. Applying Clamp to Right Broad 
Ligament, the Left Ileing in Place. (Third Step.) 

XcIIt'i Operation. — Kelly does a very complete operation per 
vaginam by dividing the uterus into four segments, the segmenta 
representing, respectively, the two halves of the body and the two 
halves of the cervix. As a preliminary to the operation, the de- 
generated cancerous tissue is curetted away, and the catheters intro- 
duced into the ureters as guides. A circular incision is then made 




278 



PRACTICAI, GYNECOLOGY. 



around the vagina about an inch from the cervix, and that portion 
above the incision dissected up to the cervix. The uterus is now freed 
in front and behind, as in ordinary vaginal hysterectomy, and a loose 
gauze packing placed in the posterior opening for the protection of 
the peritoneum. The fundus is next brought into the vagina through 
the anterior opening and the uterus split longitudinally through the 
median line, including the attached vaginal cuff. As the uterus is cut 
in halves each median surface is caught and held down by toothed 
forceps. The most affected side is now allowed to retract, while the 
other half is divided horizontally from within outward toward the 
broad ligament until the uterine artery is exposed and clamped. Trac- 
tion is now made on the cervical end of the body of the uterus on that 
side, while a clamp is adjusted so as to secure the round ligament and 
ovarian vessels. This segment of the uterus is now cut away. 




Fig. 108. — Tuffier't Angiotribe, 

The other half of the uterine body is next removed in Uie same way. 
The uterine vessels are now ligated and the ovaries and tubes removed 
after ligating the ovarian vessels near the pelvic brim. The clamps 
are removed as the ligatures are placed. The side of the cervix least 
affected is next removed, tying the vessels as they are exposed and 
keeping the finger on the ureter. The remaining quadrant — that 
side of the cervix where the infiltration is most marked — now remains 
to be extirpated. The work here must be bold and sweeping so as to 
get beyond the confines of infection. This delicate work is made 
practicable by the room gained through the removal of three-fourths 
of the uterus and its appendages. Should the ureter be im,)licated, 
the affected portion shouid be excised and the proximal end implanted 
in the upper part of the bladder. For thoroughness and efficiency the 
operation commends itself, and will doubtless add materially to the 
life-list in a class of cases heretofore regarded as hopeless. 



i^ 




TnE,\TMKNT OF CANCER OF THE CERVIX I TERI. 



279 



» 



The Wertheim Operation. — The ti'tlini<|UL' of the operation is as 
follows: After a tarefiil jiri'liniiiuirv treatment of tlie cancer per 
>n^inuiii b_v scraping and hurning it witli I'ii<|uclin's cautery, and 
after a thoroujih disinfection, Uie patient is placed in Trendelenburg's 
|>osilinn. and the abdominal cavity ojiened bv a median longitudinal 
incision between the symphysis pubis and undiilicus. 

1. By dividing the posterior layer of the broad ligament, the 
ureters, which aji|K'iir tlirougii the peritoneum, are exposed up to their 
entrance into the parametrium. It is necessary to avoid isolating them 
all around, and their surrounding vascular network must be spared 
a* much a* possihlo (Fickel, Sixmpson). 

2. After dividing the peritoneum, the bladder must. be separated 
from tlie uterus. 

3. Tlien follows the ligation and division of tlie infundibulo- 
pelvic, the broad, and round ligaments. The order in which these first 
three steps follow one another may be varied. 

4. The next st'p is the ligation and division of the uterine vessels 
with the surrounding cellular tissue. For this purpose the following 
manipulation serves: Tlw index linger of one hand is pushed along 
the ureter through the parametrium toward the iilaihler until tlie 
tip of the finger aj)pear8 there; the vessels are then raised on tlie finger 
which covers the ureter, so that the ligation and division of the vessels 
can take place without injun- to the ureter. The bleeding from the 
uterine ends of the vessels is stopped hy clamps or ligatures. 

5. As soon as the uterine vessels are divided, the vesical portion 
of the ureters has become easily accessible and the preparation of the 
urettTB can be readily completed. In simpler cases the vesical end of 
the ureter separates without any dilTiciilty. jiartly hy using tlie hlunt 
end of the finger, partly with a few strokes of the scissors, up to its 
ending in the bladder, and the bladder itself is separated in its 
dt'cper part from the tnmor and the vagina. If the ureter is fixed, the 
advantage of the alidominal mute is most a]i[)arent, as by careful 
preparation one can separate even firmly fixed ureters from the tumor 
without any danger to them. 

fi. Next follows the separation of the rectum from the vagina. 
The isolation of the carcinomatous organ has now been sullicicntly 
cfTccted. and it.« removal follows. 

7. For this fiur])()se, the parametrium is divided as closely an 
possible to the pelvic wall, and 

.S. The vagina is cut across. The seventh step can l)e carried out 
without any loss of blood by applying to the paraiiietriuiii, before 



280 PBACTICAL GYNECOLOGY. 

dividing it, four or five bt>nt clainijs, on eacli side, which can be 
replaced later by ligatures. Before the eighth step is begun, the 
vagina is cleaned out again by dry wiping with sterile gauze. To 
avoid infection from the cancer, strong clamps are applied to the 
vagina before its division, so as to isolate the cancer from the vagina, 
which is divided below tliese clamps. Bleeding from the paravaginal 
tissue is stopped by stitching round the vaginal stump. The division 
of the vagina after the ])receding application o£ such clamps is pref- 
erable to the procedure first adopted — namely, extracting the uterus 
from the vagina, having loosened it all around — on account of the 
more effectual control of bleeding by the former method. 

9. For the purpose of extirjjating the lymphatic glands in the 
neighborliood, it is necessary to prolong tl»e incision of the peritoneum 
upward. The great iliac vessels are, as a rule, already bare; if not, a 
blunt dissection of the cellular tissue with the finger suffices. Every 
lymphatic gland at all enlarged, in the region of these vessels, up to 
where the aorta divides and down as far as tl\p obturator foramen, 
must be extirpated. Careful checking of bleeding must be under- 
taken here al.=o. 

10. The wound must be treated as follows: The cavity created 
by the removal of the tumor is filled in loosely with iodoform gauze, 
which extends to tiie vulva. An exact closing of the peritoneal cavity 
over the gauze is effected by sewing up the anterior and posterior flaps 
of the peritoneum. The final step is suture of the abdominal incision 
in layers. 

The after-treatment is relatively simple. The strips of iodoform 
gauze are removed in from five to ton days successively. By obtaining 
primary union of the wound we allow the patients operated on to get 
up on the fifteentli day after operation. Tlie greatest care has to be 
bestowed on the Madder, which is in most cases more or less paralyze<l 
and must, therefore, be emptied by the catheter at regular intervals, 
besides a methodical washing out with a 3 per cent, boric acid solution 
or other suitable solution. The bladder usually recovers its function 
when the patient gets up. T^reterovaginal fistula, an occasional 
sequence due to necrosis of the ureter, sometimes heals spontaneously; 
s<mictimes they yield to cauterization with iodine or copper sulphate, 
but in other cases nephrectomy must be performed later. 

Remnrlrx. — The duration of the operation was at first from two 
and one-half to (wo hours; it is now re<luced to half that time. The 
mortality was from 1.") to IS per cent.; it is now about 8 per cent. 
He attributes the decrease in the death rate largely to the shortening 



TREATMKNT OF CANCtlU OF THE CERVIX UTERI. 



281 



or Hie |)('riiiil of iinpstlicfsi)) liy iloirifr all ]iri'liniinnrv work, Kiicli as 
PcrnpinjL' and unaU'riziiig tiic cani^cr ami disinft'ctiou, l)t'for<! nnostht'tiz- 
ing the patient and also tlie Bul>stitution of spinal for ^'ncral ancsthe- 
pJH whenever and so far a.« praetieable. He comments on the ease 
with which the closely adliurfut ureters could be separatetl from the 




I'lg. Iii'.). — \!i^iiiiil riv«ti'ri'itiiiiiv. (iMMirlli Mi-|i.) 

The lundu* b*a beenluraml Into the tsrIub and a rlnmp applied lo the top of (he left 

t>r»ail IlKaineiit. 

uterus and the fimily fixed lihidilcr couhl I)e separated from the 
tamor. In eases wluTe resertion of portions of the ureter, bladder, or 
rectum became necessary it was not difficult to repair them by careful 
suturing. 

As to the histological findings in fifty thousand gc<'tions he con- 
clude? that carcinoma is never wntained in lymphatic glands un- 
ehanped in size, fhape. or consistence; they are always enlargwl and 




1 1 II. — Vngiiin tiysNTCftoniy. (Fifth Stpp.) 

Alltlie actoi-hinentH of ttie utcriu tiave tweo tevered excfP> tbe upuer portion of Um 
ricbt brusd Ugament. 

One c'liimot (k'temiine from tlie physical aspects of the parame- 
trium wlu'tlier it \w involved or not. Tlic soft, distensible, and 
apparentlv iiornial parametrium was found to be cancerous in approxi- 
mately 23 per cent, of the cases, and, vice vers/i, in 14 per cent, of the 
cases where these tissues were infiltrated no cani-er was found. In 40 
per cent, of the cases the parainufrinin and lymphatics were both free 




TREATMENT OF CANCER OF THE CERVIX UTERI. 



2S3 






from cancfT, and in 20 pt-r tcni. lioih were iitlL'ctcd. Nearly all recur- 

'jent-es were in tlie lyiuphntit-s. After a lapse of five yyars 00 per 

cent, of the cases operaled on b)' this method remained free from 

F!urrenft>, a result far in advance of that obtained by any other. 
Vertbeiin seems to think tliat the gratifying results above recorded 
depend not so much on the extirpation of the lymphatics as on the 
^Kooniplete removal of the primary focus and as much as possible of the 
^^uanuiietrium. 



PALLIATIVE TREATMENT. 



When the disease has advanced to such a stage as to preclude its 
snccessful removal, the aim should be to retard its progress, abate its 
uiost distressing syniploms, and, if possible, to modify its course so 
US to render the patient as wmfortable as possible. This is effected 
liy destroying the degenerated tract and the adjoining tissues as far 
as they can be followed with safety to llu' patient. The means: adopted 
fur this purpoe are amputation, excision, curettage, and canteri/.ation. 
Amputation of the Cervix. — This, when po8.«ible, shou'd be the 
^oprration of choice. This may be acconi]ilishcd by the knife or 
ek'<-trocautery. Amputation by the knife should e.xteml niiove the 
vaginal vault. The first steps of the operations are in all respects 
iiiiiiilar to those of vaginal hystere<-toniy up to the point of entering 
the peritoneal cavity, which should not, however, be entered. The 
uterine arteries are tied on either side, the cervix split up dii Imth 
•ides, and, while the womb is held down by traction on the posterior 
T\i<'al flap, the anterior llap is cut away. A suture is now passed 
through the stump from the cervical canal outward, and made to 
include in its sweep the connective tissue and upper edgt^ of the vagina. 
This is tied and the ends left long to be used as tractors. Several 
a more stitches may be placed so as to unite tlie upper e.\tremity of the 
^^jagina to the stumj) of "the cervix. The posterior flap is now cut away, 
^Vind the stump stitched to the vagina. The vagina is washed out and 
I the cavity packed with gauze, which is to be removed and renewed at 
^^untervals of forty-eight hours for a period of eight or ten days. The 
^Vltitx'bes may be removed at the Inst dressing, or if of silk-worm gut 
' may be allowed to remain several weeks. 

Anijnitalion by the Eh-ctrocnulery. — ^This method, as practiced 
by Byrne, of New York, has yielded most gratifying results. The 
cervix is seized and drawn down as far as possible, and the slightly 
cur\-cd cautery knife made to encircle it, dividing the vaginal tissues 
parallel to its outer surface. Then, by giving the upper edge of the 



I 

\ 

ji 

the 




284 



PRACTICAI. OYKECOIXJOV. 



knife a slight inclination inwiinl, il is ciirrictl around nml aronnd, 
wliiie steady trattion is iiuuntained <m tho cenix until complete sppara- 
tion is effected. Tlie part n-moved is in the simpc of a cone, and 
usually extends as liigli as tiie internal os. By seizing tlic stump the 
knife can bo again a|>plied and anotiier core removwl. and so on until 
tlie organ is reduced to a mere shell. The knife should never lie 8I>- 
plicd or removed while the current is on. and should not be witlidrawTj 
from contact with the tissues until it has cooled, lest liemorrhage 
follow. 

Curettage and Cauterization. — When amputation or excision is 



L 



ri 



\/'\/> 



...y 



Kig. 171. — I'aquplin Cautery. 



deemed inexpedient, nuuli benefit can be derived from curettage and 
cauterization. After rapidly breaking down the diseased mass by the 
finger it is scoopeil away by the curette, the ragged e^lges trimmed 
away with scist'ors, and the entire surface cauterized. The cauteriza- 
tion may be eifectcd by the Paquelin or actual cautery or some chem- 
ical es<''harotic. fare should he exercised not to perfornte the bladder 
or rectum, as in so doing a permairient fistula will be left, which, 
though it may have occurred a few days later in the natural course 
of the disease, will be attributed to the operation and the blame 
attache*) accordingly. The best curette for the juirpofc is the solid 
strong curette used in hone surgery. 

Ai^ide from the foregoing methods cnuterizntion alone is em- 
ployed by many physicians, the form of escharolic depending upon 



TRKATMENT OF CANCER OK THE CERVIX UTERI. 



285 



;he choice of the operator. Nitric ncitl, chromic acid, arscnious acid, 
«iid chlorid of zinc arc tlie cliief of tlio caustics used for this purjwjse. 
I'lfdgft* of cotton arc saturated with one of these preparations in full 
strength and the superfluous lii|uiil expressed so as to prevent drip- 
piug. These are eriugly packed into the cervical excavation and 
covered b_v a disk of plain cotton, which is supported by a tampon 
impregnated with a polution of bicarbonate of sodu. This, by neu- 
, trulizing any c.vcei-s of free acid, will prevent injury to the vaitinal 

f"" "" 

^■mw with a combination of vaselin and ssoda before applying the 
(■4U8tic. Of late the calcium carhid has been growing in favor as an 
eficharotic. One nr two f-\nn\\ iiicccs nhout the size of a ])ea are im- 
Iwldcd in cotton or clay and placed Hgainpt the cervix and held there 
liy tl>e vagina] tampon. Whichever form is used it should be removed 
in frfun forty-eiglit to sixty liouris, and followeil by a dressing of 
iodoform gauze, which may ha it'placcd every second day. The slough 
aeparuti's in from seven to ten days. 

There are those who oppose any operative interference short of 



Kig. 172. — Struiglit (.uuU'ry Kiiifi' 




Fig. 173. — Curved Cautery Knife. 



tne radical, on the plea that the amendment is but transitory. But 
wlien we consider that the large majority of cases fall to the surgeon 
too late for radical treatment, that weeks or months of rest, recupera- 
tion, and renewed hope may be given to e«ch of these unfortunates, 
it will require no mathematical calculation to aj-sure us of the in- 
i*timable gain accniing therefrom. We not infretjuently have the 
picture of a woiiinn in the full flush of health jmssing rapidly into 
decline, with all the acconipaniuicnts (if advanced cancer. When 
brought to a realization of her condition, with all that it entails, she 
lapses into a state of unutterable woe. Her suffering and despair 
are reflected in her rigid and ijumobik- features, and the ravages of 



286 PRACTICAL GYNECOLOGY. 

the disease are too plainly told in the pale, wan face and wasted form. 
She is perchance a wife and mother, with all these names imply. Sad 
faces and ominous silence betoken the desolation that has invaded the 
household. Hope has departed and the only prospect is weary watch- 
ing and waiting through dismal days and nights for the inevitable. 
The surgeon comes and goes. The pain, the hemorrhage, the dis- 
charge, and the insufferable stench have departed with him. The 




Fig. 174. — Strong Curette for Cervical Cancer. 

patient begins to eat, sleep, and takes on flesh and color. She returns 
to her household <lutie8, is cheery, happy, and hopeful. She is again 
the wife and mother, and home is home. And when the lapse comes, 
as it will after weeks or months, perhaps, it comes quite often with 
bated severity, less pain, less hemorrhage, less discharge, and less of 
that horrible odor. There is also less of despair and anguish of mind, 
for the patient clings to a lingering hope bom of her former experi- 
ence, or becomes resigned to her fate, serenely awaiting the issue which 
is to bring deliverance. 




as a mucoufi membrane. Its situation, the fact that it lines a hollow 
organ, and its continuity with mucous membrane above and below 
give color to this view. On the contrary, its firm attachment to and 
intimate blending with the subjacent muscular layers, the fact that 
lymphoid tissue has been demonstrated as a component of its struct- 
ure, its peculiar office, and the nature of its secretions give ground 
for the belief that it is histologically very similar to — if, indeed, it 

(287) 




288 



PRACTICAL GYNECOLOGY. 



be not in fact — a lymphatic gland structure. It is probably a mem- 
brane sui generis. Notwithstanding, we shall continue to use the 




Fig. 176.— Utricular Glands. 

old nomenclature and speak of the endometrium as mucosa, and the 
interglandular structures as connective tissue. 




Jig. 177. — Uterine Glands. Normal. (Photomicrograph by Gromm.) 

There is probably no structure in the body that presents so 
many different phases, and undergoes such rapid and marked changes 



INFLAMMATORY DISEASES OF THK DTKRCS. 

as the uterine mucosa. In infancy, adolescence, maturitj, and the 
decline of life the endometjiuin differs bo widely in its structural 
attributes as to modify greatly the pathologic procesf«8 that may 
affect it The function of menstruation, the condition of pregnancy, 
and the changes that follow parturition produce marked and even 
radical changes in the endometrium. Add to these tlie developmental 
defects and the results of pre-existing disease, and it will be seen 
how numerous and multiform are the changes to which it is subject, 
and how difficult it will be to compaas them by any classification that 




Fig. 178.— U tenia: Mnsculnris Adjacent to Gland. NonnaL 
(Photoniiurograph by Gramm.) 

takes into account only one of the ordinary bases of classification: 
cause, structure, or clinical featun*. 

The normal endometrium in the period of sexual activity is 
richly endowed with glands, blood-vessels, lymph-spaces, and nerves. 
It is of moderately firm consistence, about one twenty-fifth of an 
inch in thickness, and covered with ciliated, columnar epithelium. 
The utricular glands (Fig. ITG) are closely set, dip down into and 
sometimes extend through the mucosa, and are also lined with ciliated 
epithelium. They are imbedded in a connective tissue stroma and 
surrounded by lymph-spaces, blood-vessels, and nerves. The secretion 




Fig. 180. — Lymphatics of the Uterus, Showing Rout« 
to Fallopian Tube. 

utricular glands are disposed in a single layer. This arrangement 
is never departed from except in malignant degeneration. 

The lymph-spacea which pervade the mucosa and also abound 
in the muscularis empty into diminutive lymphatics, which form a 



INFLAMMATORY DISEASES OF THE UTERUS. 21)1 

delicate net-work in the serosa and, in turn, pour their contents into 
larger vessels, which pass out through the broad ligament. (Figs. 179 
and 180.) A proper knowledge of the lyniphatica of the uterus, their 
course and destination, is essential to an understanding of the graver 
forms of infective endometritis. In the infantile state tlie utricular 
glands are not formed, their future sites being indicated by minute 
indentations on the surface. In old age they again disappear, and 
lire supplanted by a connective tissue, which is deficient in blood* 



Fig. 181. — Endometritis. (Pliotoniierograph by Gramm.) 

Tessels, lymph-spaces, and nerves. In both the endometrium is thin 
and more vulnerable than in the prime of se.Kual life. 

ENDOMETRITIS. 

Endometritis is an inflammation of the endometrium. Strictly 
speaking, endometritis as a separate and distinct disease seldom ex- 
ists. The disease, in most instances, extends deeper and involves 
other structures. The structure and relations of the endometrium 
make this almost imperative. The endometrium is provided with the 
same nerves, blood-vessels, and lymphatics as the rest of the organ, 
and consequently is affected by the same nervous influences, is sub- 
ject to the same vascular changes, and distributes its products through 





89S 



PRACTICAL OYNECOLOOY. 



the same syBtem of lymphatics. Vasomotor influences communicated 
to one part necessarily affect the other. Hyperemia, or blood-stasis, 
of one part is experienced in the other. A poison which gains en- 
trance into tlie open-mouthed vessels or lymph-spaces of the endo- 
metrium must, if it goes by the way of the blood or lymph channels, 
traverse the other. Another cause for this interlinking is found in 
tlie intimate relation of the mucosa to the muscularis. Here, as 
nowhere else, there is direct apposition and welding of layer to layer. 
There is no intervening connective tissue to break the continuity of 
an advancing inflammation, or within which the protective leucocytes 
may be marshaled to give battle to invading germs. The result is 
that an infective process or inflammation starting in the endometrium 
is carried almost invariably over into the muscularis and constitutes, 
in fact, a metritis. This is the term employed by many of the writers 
of continental Illurope. Nevertheless, as the endometrium is the part 
first and most conspicuously affected, as tlie pathologic process is often 
confined to its immediate environment and — as Welch claims — is 
sometimes limited to it, as it is from this side that tlie disease must 
be studied and combated in the living subject, and finally as the terra 
has the sanction of long usage and very general adoption, in this 
country, it is retjiined as a matter of convenience. 

Causes. — The inflammatory conditions of the endometrium are, 
with few exceptions, due to the presence and influence of patliogcnic 
germs. There is a so-called simple endometritis in which the germ 
is supposed to take no part as a causative factor, and which is sup- 
posed to arise from traumatism, retained secretions, suppressed raen- 
stniation, malpositions of Ihe uterus, and morbid growths in or about 
the uterus. Excessive vencry and masturbation have also been as- 
signed as causes. Its prime differential is the absence of pus in the 
discharges. It is subacute or chronic, very rarely acute. Without 
denying the possibility of a simple endometritis, there can be no ques- 
tion but that many of the cases which have masqueraded under this 
name are of bacterial origin, and others are mere hyperemias with 
excessive secretion. Clinically it is a disease of little importance. 
The cavum uteri in its normal state is absolutely germ-free, — it is not 
the habitat of any kind of germ, — and consequently infection of the 
endometrium must come from without. The infection usually takes 
place through the medium of unclean instramcnts: the uterine sound, 
the dilator, or curette, or some other instrument introduced int/) the 
uterus with criminal intent. It may occur from manipulations, espe- 
cially at the time of an abortion or labor at term. 



INFLAMMATORY DISEASES OF THE UTERUS. 



293 



The gonococcuB may gain entrance to the uterine cavity by an 
ascending invasion of tlie genital tract, brushing aside the acid- 
■ecreting gerni of Doeilerh-in, but is more frequently delivered at the 
08 externum along with the ejaculated semen. It may be carried from 
the vulva on the nozzle of a syringe. 

Bacteria of Endometritis. — The chief infective agencies are the 
gonococcus of Ncisscr, the streptococci, and tiie staphylococci. There 
are a number of other germs, which on occasion may infect the uterine 
CJivity, but they are so unusual and so wanting in distinctive attri- 
butes as to be of little practical significance to the average practi- 
tioner. 

Gonococcic infection of the endometrium is sometimes spoken 



Fig. 182. — Streptopocous. (Photomicrograph by Gramm.) 

of as specific endometritis. It consititutes a large proportion of the 
cases that fall under observation. In its unmi.xed form it is usually 
subacute. The gonococcus seldom produces an acute inflammatory 
reaction in any situation. The gonococcus is a surface germ, and has 
little tendency to burrow deeply into the ti-osues or to enter the lym- 
p})atic8. Hence it seldom produces systemic poisoning. It invades 
the Fallopian tubes by continuity of surface, and in this way often 
produces most serious results. It is frequently associated with other 
patliogenic germs, especially the staphylococci, which adds to its 
virulence and the intensity of the inflammatory reaction. It will 

£ accompany these germs into the deeper structures or into 
latic system, and thus be found in unwonted places. 



294 



PRACTICAL GYNECOLOGY. 



A septic infection of the endometrium is often spoken of as 
septic endometritis. The germs usually concerned are the staphy- 
lococci and the streptococci. The latter are especially virulent, and 
are found most frequently associated with the puerperal state. The 
frequency of this form of endometritis vies with that of gonorrheal 
origin. A large contingent of the cases met with are traceable to 
miscarriage. Many women date their illness from the period of 
confinement. The increased vulnerability of the puerperal uterus is 
due to the enormous increase of its blood-vessels and lymphatics, which 
afford unparalleled facilities for the distribution of germs. When 
the pregnant uterus has expelled its contents it becomes an effete 
organ and begins to disintegrate. The delriius fills the interstices of 
its walls, freights the lymphatics, and oozes iuto the uterine cavity. 
This, together with tlie clotted plugs of the exposed vessels and 
sinuses and the residual blood of the cavity, affords an excellent cult- 
ure mediimi for germs, which gain access to the deeper structures 
through the open-mouthed vessels and l^nnphatics at the placental 
site or other lesion incident to the parturient effort. 

Septic endometritis may be acute or chronic, mild or severe. 
This form of endometritis furnishes us with more violent and dan- 
gerous examples of uterine inflammation, and is farther reaching in 
its possible consequences than any of the others. The septic germs, 
especially the streptococci, invade tlie deeper structures, often in- 
volving the entire thickness of the uterus. They enter the IjTiiphatics 
and are carried to the ovaries and tubes. They are carried into the 
pelvic cellular tissue, producing cellulitis; to tlie peritoneum, pro- 
ducing peritoniiis; into the general circulation, producing sepli- 
cetnia. It is probable that secondary infection of the tissues beyond 
the uterus occurs through inflammation of tlie lymphatics or lym- 
phatic glands which the germs are traversing. In septic endometritis 
the mucosa is frequently necrotic and ulcerated, and occasionally 
covered with a diphtheroid deposit. The necrosis, ulceration, and 
diphtheroid deposit usually occur in patches, but may be diffuse and 
involve the entire surface. Occasionally the endometrium, or even 
a considerable portion of the muscular structures of the uterus, are 
cast off en ntasse as the result of a dissecting ulcerative process. 

Hbdifications in Character and Course. — \Yhile most cases of en- 
dometritis are diffuse and involve all of the histologic elements, there 
are some in which tlie inflammatory process is confined to the gland- 
ular structure (glandular, or parenchymatous, endometritis) and 
others in which the connective tissue or interglandular substance is 



IKFLAMAUTORY DISEASES OF THE UTERUS. 



295 



tilectcd (interetitial endometritis). la the so-called glandular fonn 
the inflamed glands enlarge and project from the surface. They 
sometimes boconio polypoid or pedunculated (polypoid endometritis), 
and as such fill the cavity and encronch upon or push into the cervical 
canal. In such instances the secretion is abundant, and, owing to 
decomposition, may become so olTensive as to suggest malignancy. 
A fungoid condition of tlie endometrium (fungoid endometritis) is 
due to an overgrowth of both the glandular and interstitial tissues. 
The fungous elevations are frequently cystic and lined witli epithe- 
lium. Fungoid endometritis is sometimes the result of inflammatory 
reaction, but more frequently represents an hypertrophied condition 
upon which an inflammation has been grafted. Menorrhagia and 
metrorrhagia are most pronounced in this form. 

To all conditions of overgrowth of the endometrium such as have 
been noted above the generic term of hypertrophic endometritis has 
been applied. Glandular endometritis is sometimes spoken of as 
benign adenoma. Not infrequently a glandular endometritis may be 
l(xatcd in one part of tlie cavity, an interstitial in another, and tlie 
nii\<Kl form in still another. Sometimes, instead of being overgrown, 
the endometrium is wasted and thin (atrophic endometritis). This 
especially affects the essential or glandular structure. In such, the 
glands are wasted or wanting, being supplanted by connective tissue, 
Uie membrane thin, exsanguinated, and defective in lymph- and nerve- 
gupply. Such conditions are found in hyperinvolution following 
pregnancy, in certain disordered stiites of nutrition, in old age, and 
the result of long-continued inflammation. 

In the endometrium, as elsewhere, the primary effect of inflam- 
mation is an increase in bulk, while the ultimate effect is cicatricial 
contraction. In this way we may have an hypertrophy in the earlier 
and an atrophy in the later stages of endnmotrial inflammation. In 
atrophic endometritis there is a discliarge which may be quite abun- 
ilant, but it contains little, if any. of the natural secretion of the 
utricular glands; there is occasionally some bleeding, but it is seldom 
profuse; the blood is prone to coagulate, owing to tlie absence of tlie 
normal secretions; there also exist dysmenorrhea and supersensitive- 
ness of the uterine canal. In the senile form (senile endometritis) 
the endometrium is sometimes entirely destroyed, the destructive 
process extending into the muscularis. The discharge is thin, puru- 
lent, and sometimes mixed with blood. It is acrid, producing ero- 
sions and inflammatory areas on the vaginal and vulvar surfaces. 
It is, as a rule, very offensive in hot weatlier or after muscular exer- 




296 PRACTICAL OYNECOLOOT. 

cise, and is liable to give rise to apprehensions of malignancy. There 
is a tendency to contraction of the uterine canal, and it may become 
obliterated. The vagina and vulvar orifices also become contracted 
and sensitive. Senile endometritis is usually the result of a pre- 
existing endometritis carried over into the post-climacteric period. 

Symptoms and Coarse. — The symptoms of endometritis are pain, 
increased secretion, menorrhagia or metrorrhagia, fever, and reflex 
disturbances of various kinds. These symptoms will vary according 
to the intensity of the affection, the condition of the endometrium, 
and the complications. A simple mild endometritis is seldom recog- 
nized, the symptoms being so ill defined. The co-existence of tubal 
and ovarian disease, displacements of the uterus, flexures, laceration 
of the cervix, subinvolution, morbid growths, some one or more of 
which are often associated with the endometrial inflammation, mod- 
ify and obscure the symptoms. 

In endometritis the pain is dull and aching, and is located over 
the uterus in front or in the lumbar region. It sometimes radiates 
through the pelvis and extends down the thighs. It is lancinating 
when the peritoneum is involved, and paroxysmal in case of flexure 
of the cervix or obstruction of the canal. There is, however, little in 
the character or situation of the pain that is characteristic, as this 
is common to inflammatory affections of all the pelvic organs. The 
secretion is increased in quantity and altered in quality. It is thin, 
purulent, and oftentimes bloody. It is more abundant in the so- 
called glandular endometritis. Menorrhagia and metrorrhagia are 
common. It is sometimes suppressed at the onset of tlie disease, and 
in virulent septic endometritis may not reappear. The suppression 
of the lochial or menstrual flow is generally ominous of evil. The 
fever is usually slight, but in the acute septic forms may mount to 
104 or even 106 degrees. It is sometimes preceded or accompanied 
by chills. These chills may recur daily or even at much shorter 
intervals. 

The chief reflex phenomena are pain in the top or back of the 
head, irritation of the bladder and rectum, nausea, and various dis- 
turbances of the nervous system, such as hysteria, melancholia, and 
neurasthenia. The patient is weak, exhausted, and incapable of sus- 
tained effort. All the symptoms are aggravated at the menstrual 
period. The patient also suffers more from being on her feet. Stand- 
ing is less easily borne by her than being in motion. The weakness 
and reflex nervous phenomena are out of all proportion to the local 
lesion. 



INFLAMMATORY DISEASES OF THE UTERUS. 



297 



Examination. — In the severer forms examination will reveal the 
nterus large, boggy, and tender. The cervix, also, is enlarged, puffy, 
and not infrequently eroded and granular. From the gaping os 
issues a thick, tenacious discharge, — that of the cervix, — intermin- 
gled with the tliin, purulent, blood-discolored discharges from the 
cavity. By cleansing these away, or by introducing the nozzle of a 
suction syringe into the cavity, the characteristic secretion of the 
endometrium can be obtained. The uterine sound will show a 
patulous canal, an open internal os, and a tender, bleeding fundus. 
In some instances the uterus is hard and resistant, and not notably 
enlarged. The cervix is not always implicated in the inflammatory 
reaction. In the atrophic forms the uterus is diminished in size and 
the secretion devoid of that milkiness which indicates the presence 
and activity of the utricular glands. 

Diagnosis. — The chief characteristics of an endometritis are the 
pelvic pain ; enlarged, tender uterus ; the open cervical canal ; the 
thin, purulent, and blood-stained discharges; and the sensitive, bleed- 
ing, internal surface. Microscopic investigation of the curette scrap- 
ings affords the most reliable means of differentiating an endome- 
tritis from other pathologic lesions of the uterine cavity, or of deter- 
mining the particular variety in any given case. Owing to the 
patulousncss of the canal, an exploratory curettage can usually be 
done without dilatation. 

Treatment. — In simple endometritis, rest in bed, mild purgation 
repeated daily, a bland diet, hot sitz-baths, and hot vagiual douches 
of plain or salt water will usually suffice. When the disease is asso- 
ciated with, or dependent on, some obvious lesion of the uterus or 
its surroundings, these should receive attention. Malpositions, flex- 
ures, and stenosis of the cervix should receive appropriate treatment; 
poh-pi or retained fragments of placenta removed ; and the lacerated 
cervix repaired. Morbid growths in or about the uterus and inflam- 
matory conditions of the adnexa may perpetuate an endometritis. 
In violent non-septic cases, in the absence of positive indications to 
the contrary, local treatment should be deferred until the pain and 
tenderness have, in great measure, subsided. In the specific and 
occasionally in septic forms, curettage is indicated. See "Evils of 
Curettage in Streptococcic Infection of the Uterus" (page 287). 
After the removal of the gauze on the second or third day, the hot 
vaginal douches may be resumed. In gonorrheal endometritis no 
further intra-uterine treatment will be required. 

In the septic forms a continuance of fever calls for repealed 




298 PRACTICAL OYNECXJLOGY. 

douches. These should be preceded and accompanied by all the 
aseptic details of an operation. Unless the cervical canal be very 
patulous, the douches should be administered through a reflux irri- 
gator to insure the unimpeded outflow of the fluids. Serious and 
even fatal results have followed the neglect of this precaution. The 
douche may consist of a saturated solution of boric acid, or a 1 to 
4000 solution of mercuric bichlorid, once or twic9 daily. A l-per-ceni 
solution of carbolic acid may be substituted for or alternated with 
the bichlorid solution. Other antiseptics may be used if deemed 
advisable. The stronger antiseptics should be 'followed immediately 
by a plain water douche to prevent their absorption and consequent 
poisoning. In the graver cases the vital powers should be sustained 
by nourishing liquid diet, alcoholic stimulants, and carbonate of 
ammonia. When associated with systemic infection, protonuclein, 
in 6-grain doses three times a day, will be found useful. In severe 
cases accompanied by high temperature, an ice-bag may be applied 
to the hypogastrium. This should be removed in from twenty-four 
to forty-eight hours, or at any time after the subsidence of the fever. 
Later, or in lieu of this, a hot-water bag, poultices, or turpentine 
stupes will be found of benefit. Septic endometritis following par- 
turition may call for hysterectomy to forestall fatal systemic infec- 
tion, but a measure so radical should not be resorted to in the absence 
of most positive indications. 

In the chronic and subacute forms constitutional measures are 
of more value than local treatment. Abstinence from marital rela- 
tions, regular habits, attention to the bowels, open air, sunlight, judi- 
cious exercise; loose, light, and comforbible dress; nutritious, plain 
food ; the avoidance of standing, hours of rest during the day, and in 
inveterate cases change of air and scene, supplemented by tonics, 
alteratives, and restoratives, will usually accomplish better results 
than local treatment. 

A constitutional taint or diathesis sliould not be overlooked. 
Iron, quinine, strychnine, and phosphorus are the remedies most fre- 
quently called for. Nevertheless, local measures are often of much 
benefit and occasionally indispensable. The hot douche once a day 
and the application of strong tincture of iodine to the vaginal vault 
once a week, followed by a tampon saturated with boroglycerid and 
an occasional scarification of the cervi.x where the hyperemia is 
marked, are powerful auxiliaries to the systemic treatment. It is 
seldom necessary and usually liurtful to resort to intra-uterine appli- 
cations. In my own experience such apj)licatious are usually followed 



INFLAMMATORY DISEASES OF THE UTERUS. 299 

by an aggravation of all the symptoms. I sometimes make an excep- 
tion to this rule where the cervical canal is straight and patulous, so 
as to afford an unobstructed exit to fluids and secretions. The intra- 
uterine applications may be made on a cotton wrapped applicator or 
by means of the Braun intra-uterine syringe. In hemorrhagic and 
senile endometritis atmocausis may sometimes be used to advantage. 



CHAPTER XXV. 

CURBTTAQE, ATnOCAUSIS, AND TUBERCULOUS 
ENDOnETRITIS. 

CURETTAQE. 

The instruments necessary for a curettage are: a perineal re> 
tractor, preferably a eelf-retaining instrument, such as is figured on 
page 28, a pair of traction forceps, a uterine sound, two pairs of steel- 
branched cervical dilators (small and large), a sharp curette, a cerrical 
speculum, scissors, applicator, an irrigator, strips of iodoform game a 




Fig. 183.— Goodell's Cervical Dilator. 

yard long and one and one-half inches wide, and some sterilized cot- 
ton. The patient is prepared by a general bath, thorough catharsis, 
and cleansing of the vagina. For the latter a 5-per-cent. "Solution of 
creolin in a solution of green soap answers admirably. With wads of 
absorbent cotton held in the bite of a forceps and dipped in this solu- 
tion, the vagina is thoroughly scrubbed and irrigated with plain water. 
It is understood that the surgeon and his assistants, and all instru- 
ments and appliances used in the operation, have been properly 
prepared. 

The patient, being anesthetized, is placed in the dorsal position 
and drawn down so that the perineum comes flush with the end of the 
table. The thighs are flexed at ri<,'ht angles and held by assistants or 
leg-holders. Now, if not before, the vagina is scrubbed and irrigated. 
The perineal retractor is introduced and the anterior lip of the cervix 
seized by a traction forceps and drawn down. Tlie uterine sound is 
(:u)0) 



CURETTAGE— TUBERCULOUS ENDOMETRITIS. 



aoi 



introduced to get the direction of the canal, and is immediately with- 
drawn, to be followed by the smollrr steel-branched dilator. Dilata- 
tion is effected gradually, first by expanding the blades in one direction 
and then another until the larger dilator can be used to advantage. 
This latter should be of the Goodell pattern, with blades which diverge 
parallel to each other, otherwise serious injury may be inflicted by the 
diverging extremities of the blades in the uterine cavity. (Fig. 184.) 
When sufficient dilatation has been secured — an inch or more — 
the curette is introduced to the fundus and the entire surface of the 




Fig. 184— Dilatation of the Cervix. 

endometrium Bystematically scraped. A sharp curette should always 
be used. With an irrigating curette it is not necessary to withdraw 
tlie instrument until the woric is completed, as the constant stream 
of water washes out the scrapings. Otherwise, the curette should be 
frequently withdrawn and the cavity irrigated. There still remains 
a narrow strip of endometrium across the fundus which the Sims 
curette — the instrument in common use in this country — cannot dis- 
lodge on account of its shape. This can best be reached by the Martin 
curette, which it would be well to use for this purpoae. The Martin 
curette is also better adapted to cases requiring more force than 



302 



PRACTICAL OYNECOLOay. 



ordinary, as in Bome cases of adenoma, polypoid endometritis, and 
cancer. 

After the curettage, irrigation should be continued for a few 
minutes. The cervical speculum is now introduced and a strip of 
sterilized gauze carried through it into the cavity. This may be done 
either by the use of a long, slender forceps or the uterine sound. The 
object of this is to absorb the blood and fluids remaining in the uterine 
cavity. An applicator wrapped with cotton and dipped in carbolic 
acid (95 per cent.) follows quickly the withdrawal of the gauze, and 
the cavity is swabbed thoroughly. Lost some of the acid should escape 
into and bum the vagina, a wad of cotton should be placed back 
of the cervix in such a position as to receive the discharges from the 
same. To prevent the cotton of the applicator from becoming dis- 
lodged and left in the uterine cavity — an accident which has occurred 
repeatedly — the instrument should be wrapped for a length of four 
or five inches so that it may be caught by the fingers if it shows a 
disposition to slip. The cavity should now be packed with a strip of 



Fig. 185. — Irrigating Curette. 



iodoform gauze, being careful not to fold it upon itself in the cervical 
canal and thereby obstruct drainage. 

The vagina is now cleaned out and wiped dry, the cervical specu- 
lum removed, the traction forceps taken off, the uterus pushed up, 
the redundant gauze folded loosely in the vagina, the retractor 
liberated, and the external part« sponged off. The gauze is removed 
in from two to four days and a vaginal douche given. Excessive pain 
or fever may demand its removal at any time. The patient should re- 
main in bed about one week. 

When there is difiiculty in introducing the dilator careful study 
of the direction of the canal as developed by the sound will be essential 
to success. A small internal os may sometimes be partially dilated by 
passing the sound through it and then by pressing first in one direction 
and then another. This failing, the dilator may be introduced as far 
as it will go and the canal dilated -up to the point of constriction, 
when it will often be found that the opening has enlarged sufficiently 
to admit the dilator. A more speedy and satisfactory method is to 



CURETTAGE— TUBERCULOUS ENDOMETRITIS. 



303 



iTe on hand a few of the smaller sizes of graduated dilators to pre- 
pare the way for tlie branched dilator. 

Curettage BJiould not be performed in case of diseased and ad- 
crent appendages unless it is to be followed immediately by ab- 
ominal section. Dragging on tliese is liable to produce rupture, with 
be escape of pus into the peritoneal cavity and disastrous conae- 
Juences. It occasionally happens that the curette passes through the 
Iterine wall into the peritoneal cavity. The accident is signaled by 
le extraordinary depth to wliich the instrument will pass upward, 
ad the want of definite resistance. It occurs with the upward move- 
Uent of the instrument, and seldom, if ever, with the downward 
reep of the same. The accident is most liable to occur after abortion 
labor at term, when the uterine wall is suft and friable. It may 
ccur under other conditions. This accident has happened to me 
rice, and on two other occasions it has happened to my assistant in 
By presence, lu neither case was tliere an appreciable resistance to 



Fig. 186. — Einmct'* Curette Forceps. 



lie curette as it passed through the uterine wall. I have never known 
il effects to ensue. On several occasions where I have done ab- 

Idominal section following curettage I have found blood-stained fluid 
k the peritoneal cavity which had escaped through the perforated 
Iterus. In the event of such an accident it is better to desist immedi- 
Roly and put the patient to bed. Subsequent irrigation of the uterus 
■ apt to carry fluids into the peritoneal cavity, while the contraction 
M the utenis following the administration of ergot is of ijuestionable 
utility, for, while it reduces the size of the rent, it may also cause 
le contents of the cavity to be expelled through it. Warning 
irniptoms may call for abdominal section. 

Evils of Curettage in Streptococcic Infection of the Uterus. — The 

liscriminate use of the curette in the infections following miscar- 

Bge or labor at term has greatly increased the death-rate, especially 

the streptococcic form of infection. It is a question, indeed, if the 

irette used post-partum has not killed more than it has cured. 



304 PRACTICAL GYNECOLOGY. 

Infection after confinement is saprophytic or septic. Sapro- 
phytic, or putrid, infection occurs where fetal debris has been left in 
the uterine cavity: fragments of placenta and fetal membranes. In 
itself, saprophytic infection is not very dangerous to life. As the 
saprophyte has not the power of proliferation in the living tissues 
and fluids, it ceases to do harm as soon as the pabulum upon which 
it feeds is exhausted or expelled from the uterine cavity. Strepto- 
coccic infection, which in this instance is the synonym for septic infec- 
tion, is guarded against by a cell infiltration just beneath the super- 
fical layers of the endometrium, which fences it ofE from the deeper 
structures and prevents its dissemination through the lymph- and 
blood- streams. The result is, if left alone, a stratified, or superficial, 
endometritis, which soon runs its course to spontaneous cure. 

In the limited number of cases, and in the epidemic form a much 
larger number, the germ is of exceptional virulence. Here it projects 
its baneful influence before it, and seemingly overawes and paralyzes 




Fig. 187. — Cervical Speculum. 

defensive effort. The protective leucocyte wall is either not formed 
or is 80 imperfect that it quickly succumbs to the advancing bacteria, 
and they go unhindered to complete their deadly work. Such cases are 
not amenable to any form of treatment. 

The normal mortality of streptococcic infection is about 5 per 
cent. Streptococcic infection constitutes about 25 per cent, of the 
post-partum infections, so that it will be seen that the normal death- 
rate is very small. This is much less than is generally supposed, and 
is probably below the death-rate from the same cause in former times, 
but is substantiated by statistics gathered from various sources. The 
diminished rate of streptococcic infection and the diminished mor- 
tality attending it nowadays are largely, if not entirely, due to the 
strict aseptic regime which now prevails in all sections. The germ is 
not often carried into the genital tract on dirty fingers, or, if intro- 
duced, it is usually in a half-starved and enfeebled condition from the 
absence of filth upon which to subsist. Curettage in streptococcic 



CURETTAGE— TUBERCULOUS ENDOMETRITIS. 



305 



infection breaks down the wall of protection, and openB up avenues 
of invasion to the hordes of bacteria which had been corraled on the 
surface of the mucosa next to the uterine cavity, where, if undis- 
turbed, perfect drainage and exhausted soil must soon compass their 
extinction. As the result of this broadcast dissemination of bacteria, 
now grown strong from rich diet, the death-rate increases prodigiously. 
Prior places the average at 22 per cent. 

Curettage is right and proper in saprophytic infection, though 
in the majority of cases not absolutely essential. It is pernicious and 
deadly in streptococcic infection. 

It becomes, then, a matter of much importance to distinguish 
between the two. This can only be done positively by microscopic 
examination of the lochia, the fluid being collected in the Doederlein 
tube. This is not always practicable in the less densely populated dis- 
tricts; hence it becomes necessary to depend on the clinical evidences. 
It may be stated as a rule to which there are few exceptions that 





Rg. 188.- 



"-■■■*■• '"•'■'■irlBg'J- 



-Lennicker'a Packing Forceps, for Carrying Gauze into the 
Uterine Cavity. 



saprophytic infection is characterized by high temperature, slow pulse, 
and a foul odor, whereas in streptococcic infection there is no odor in 
the earlier stages, and the pulse is markedly accelerated according to 
the virulence of infection. At a later stage there may be foul odor 
from necrosis of the endometrium. Suppression of the lochia is 
nsually an early symptom. Digital examination of the uterine cavity 
will also give valuable evidence. In saprophytic infection the uterus 
contains debris: that is, its surface is roughened. In streptococcic in- 
fection it is smooth. 

It is useless to say that the examination should be made with 
scrupulous regard to aseptic detail. If the evidences of saprophytic 
infection be convincing, the cavity should be curetted and flushed. 
In streptococcic infection flushing only is indicated. In the latter 
there should be but one flushing, which should be thorough, a gallon 
of hot, normal salt solution being used. Saprophytic and streptococcic 
infection may co-exist. In such an event, and in all cases where 




306 PRACTICAL GYNECOLOaT.. 

doubt exists as to the exact nature of the infection, it will be safer 
to abstain from curettage. 

There is no specific constitutional treatment for streptococcic 
infection. The antistreptococcic serum treatment, from which much 
was expected, has proven a failure. The silver treatment is on trial, 
with much to sustain its claims as a germicide and antitoxin. It has 
been found that germs will not propagate in the vicinity of silver, 
and that suppuration seldom occurs in the track of silver sutures. 
Acting on this suggestion, Crede has formulated a constitutional 
silver treatment. The preparation used is what is known as col- 
largolum: an allotropic form of pure silver. This is absolutely non- 
toxic in any quantity, and argyria has never been known to follow its 
use. It may be used per os in pill or solution, by intravenous injection, 
in solution, or in the form of an ointment applied to an absorbable 
surface. This latter is the form in which it is habitually used by the 
originator. Crede's ointment contains 15 per cent, of coUargolum. 




Jiig. iau. — Langstatf's Intra-uterine Douche. 

The surface to which it is to be applied — the inner surface of the 
thighs or other portions of the body where the skin is soft and thin — 
is to be cleansed and softened by the application of soap, water, and 
brush, and the ointment rubbed in from twenty to thirty minutes, 
or until it has all disappeared. The quantity used is usually from 15 
to 45 grains, but there need he no limit. The applications may be 
repeated from one to a half-dozen times in the twenty-four hours. 
ITie ointment must be protected from the light to prevent deteriora- 
tion. 

ATMOCAUSIS. 

Atniocaiisis, in the sense here used, is the application of super- 
heated steam to the uterine cavity as a therapeutic agent. Its use 
requires a specially devised apparatus, which consists of a steam gen- 
erator, and a uterine catheter which is attached to the generator by 
rubber tubing. The boiler of the generator is supplied with a ther- 



CfORETTAGE— TUBERCULOUS ENDOMETRITIS, 



307 



tnometer to register the temperature, which is to be maintained at a 
grade of from 213° to 330° F. The catheter ia made of hard nihljer 
or other non-conducting material, and provided with numerous snmll 
perforations for the escape of steam. The patient is placed in the 
lithotomy position and the operations conducted through a cylindrical 
speculum. This speculum, like the catheter, should be of some non- 
conducting material, such as hard rubber or wood, to protect the 
vulva and vagina from excess of heat. Both principle and appliance 
are the contributions of SneguiritT, of Russia. 

Atmocausis has been recommended for a variety of conditions in 
which hemorrhage and profuse discharge are leading symptoms, as 
in senile and catarrhal endometritis, hemorrhages incident to subin- 
volution of the uterus, ditfuse myomata, and arteriosclerosis. It is 
also recommended for the infectious diseases of the endometrium, and 
more especially the streptococcic and gonorrheal. It is contra-indi- 




Fig. 190.— Berlin Glass Douche. 



cated in inflammatory disease of the appendages and in cervical 
stenosis. It i^ a powerful agent for good or evil, and shiuild be used 
with the utmost care and discretion. Steam heat is very penetrating 
and destroys tissue both rapidly and to a much greater depth than is 
usually supposed. The application to the uterine cavity is usually fol- 
lowed by a pronounced irritation of the pelvic environments of the 
uterus, and might easily lead to serious consequences to the bladder, 
rectum, or appendages. The woman should be kept in bed fur several 
days. 

Too freely used atmocausis is almost hnltitually followed by ad- 
hesive inflammation and obliterutinn of the uterine cavity and canal, 
thus converting the uterus into an impermeable sarcous plug. The 
effect of an artificially produced obliteration of the cavity of a hollow 
secreting organ would be anticipated with concern, as also the ulti- 
mate effect as a factor of serious degenerative changes. Hysterectomy 




308 PRACTICAL OYNBCOLOaT. 

has been found necessary to relieve the intolerable pains resulting 
from obliteration of the uterine cavity in the menstruating woman. 

As used at present it has a limited range of application, and 
should be confined largely to the climacteric or post-climacteric period, 
finding its special province in senile endometritis. As a hemostatic 
it probably has no equal, and may be used as a dernier ressort in any 
of the conditions above mentioned, if used with judgment and dis- 
crimination. It is claimed that an application of three seconds is 
sufficient to stanch hemorrhage in a uterus of normal size, and that 
under no consideration should it be prolonged to exceed fifteen or 
twenty seconds unless with the intent of producing an obliteration 
of the cavity. Where obliteration is desired the seance may be con- 
tinued from four to eight minutes. 

TUBERCULOUS ENDOMETRITIS. 

This is sometimes called chronic, dii]Fuse tuberculosis of the 
endometrium, or corporeal tuberculosis of the uterus. It is quite com- 
mon, being next in frequency to tuberculosis of the Fallopian tubes. 
It occurs in about two-thirds of the cases of general tuberculosis. The 
infection may come from above — the peritoneum and tube by way of 
the tube; from below by way of the vagina, the infecting medium be- 
ing the semen, instruments, or fingers; or the bacilli may be wafted 
on the blood-stream. 

Tuberculous endometritis occurs in three forms: miliary, caseous, 
and fibroid. The miliary form has no symptomatology, is seldom sus- 
pected, and almost never diagnosed. It starts as a scanty deposit of 
minute tubercles in the vicinity of the tubal orifice. The deposit is 
located in the interglandular substance of the endometrium immedi- 
ately beneath the epithelium. From here it spreads and strikes deeper 
until it involves the entire mucosa, encroaching on the glands and 
crowding them out of existence. In advanced cases the endometrium 
is entirely devoid of glands. With all this destructive change the 
epithelium is not disturbed, and to the naked eye the endometrium 
does not differ materially from the normal. 

The caseous form is caused by an enlargement, coalescence, and 
massing of the miliary tubercles, with the usual result of caseation 
and ulceration. The ulcers are ragged and irregular, with overhanging 
edges. Both caseation and the resultant ulcers are confined to the 
mucosa, never being found in the deeper structures of the uterine wall. 
Beneath this is a stratum of typical tuberculous tissue, while deeper 



CURETTAGE— TUBERCULOUS ENDOMETRITia 309 

Btill the tubercular invasion can be traced into the muscularis along 
the course of the blood-vessels. This is the form with which we axe 
clinically conversant and from which a diagnosis is most frequently 
made. The surface indications are conspicuous and the deeper infiltra- 
tion, which often results in the destruction of the muscle, produces 
a marked thickening of the uterine wall. The deeper infiltrate pre- 
serves its miliary form and does not caseate. The discharge is 
usually quite abundant, and is watery or turbid. It sometimes be- 
comes purulent from pyogenic germ infection, in which case it is often 
associated with an inflammatory occlusion at the os internum. This 
will give rise to pyometra. 

The fibroid form is the result of a round-celled infiltration of 
the miliary tubercle and its surroundings, which later becomes 
converted into fibrous tissue. Under its influence the essential his- 
tologic elements of the uterus — glands and muscle — become jugu- 
lated and the walls become firm and fibrous. So far this condition 
has only been recognized post-mortem. 

Symptoms. — The symptoms of tuberculous endometritis are 
neither characteristic nor, as a rule, conspicuous. In the caseous form 
there may be a profuse leucorrhea and other indications of en- 
dometritis, but these are very much like those of other forms of 
endometritis. Occasionally caseous particles may be found in the 
discharges. 

DiagnoslB. — The diagnosis can usually only be made by examina- 
tion of the scrapings after curettage. If the histologic structure of the 
tubercle can be made out or the bacillus found, the diagnosis is clear. 
Unfortunately for the microscopist, giant cells are sometimes found 
in the non-tuberculous mucosa, and round-celled infiltration some- 
times gives the structural picture of a tubercle. Bacilli are sometimes 
scant and hard to find, though in the advanced stages they are usually 
abundant. They are sometimes found in the secretions. When the 
bacilli cannot be demonstrated microscopically, inoculation of the 
peritoneum of the guinea-pig with the scrapings will give positive 
results in from two to four weeks if the bacilli are present. Tuber- 
culous endometritis may be suspected in case of long-standing en- 
dometritis or if caseous particles be found in the discharges. Also 
if the patient be of a phthisical family, if she herself is tuberculous, 
or if she has a tuberculous husband. 

Treatment. — Cases have been cured by thorough curettage and 
packing with iodoform gauze. Iodoform is peculiarly inimical to the 
tubercle bacillus. As the tubes are more often tlian otherwise coin- 



■310 PRACTICAL GYNECOLOGY. 

cidcntly affected, and as in many instances they are the source from 
which the uterine infection was derived, one can never be sure that 
reinfection may not take place after its dislodgment from the uterus. 
Complete extirpation of the uterus and appendages is the only abso- 
lute safeguard against recurrence, though there are many cases in 
which one will choose the less radical method with the view of pre- 
serving the genital organs intact. Such cases frequently do welL 



312 



PRACTICAL GYNECOLOGY. 



other class. Malignant adenoma and deciduoma malignum are com- 
paratively recent diseoverics, and there is much yet to learn with 
reference to their clinical history and pathology. 

CARCINOMA. 

Cancer of the body of the uterus is essentially a disease of 
advanced life. It occurs most frequently in women who have passed 
the climacteric. It is also largely contined to the nulliparous woman: 
the sterile married or old maid. It takes its origin in the utricular 



Fig. 192. — Carcinoma of Uterus. (Photomicrogrnph by Gramm.) 

glands, and presents under two forms: polypoid excrescence or as a 
diiluse infiltration. It rapidly involves the deeper tissues. In most 
instances the necrotic, superficial layers are washed away in the dis- 
charges or are thrown off in the form of shreds or flakes of variable 
size. In tliis way the womb becomes hollowed out and converted into 
a mere shell. Occasionally the dead tissue will fail to disintegrate, 
and be retained. (Fig. 191.) In such, it accumulates until it finally 
constitutes almost the entire thickness of the uterine wall. As the 
disease approaches the serosa adhesions are formed to contig\i 
organs. Perforations sometimes occur into the bladder, bowel 



I 



nous I 

i 



MALIGNANT DISEASES OF BODY OF UTERUa 



313 



peritoneal cavity. This latter is usually followed by peritonitis and 
death. The tubes and ovaries are involved and metastases frequent. 

Symptoms. — The most prominent symptoms are pain, hemor- 
rhage, and watery discharges. Any or all of these may be absent. 
Hemorrhage is usually tlie first symptom to attract attention. It may 
be intermittent and copious, or more or less constant and dribbling. 
Occurring, as it does, after the menopause, it is ominous, and should 
lead to careful inquiry. 

Discharge. — The discharge is watery, usually turbid, and often- 
times foul-smelling. It may be destitute of odor. It may be more 
or less purulent or sero-sanguinolent in character. It often occurs 
in gushes at intervals. 

Pain. — The pain varies greatly in its character, location, and 
intensity. The lumbar and sacral regions are the most usual sites. 
It sometimes runs down the thighs. Periodical, paroxysmal pains. 




Fig. 103. — Large Cervical Dilators, for Preparing the Way for Digital 
Exploration of the Uterine Cavity. 



recurring at certain hours of the day, are almost pathognomonic, but 
ere not always present. The pain sometimes resembles a uterine colic, 
— which, indeed, it is, — and is occasioned by the attempt of the uterus 
to expel its necrotic contents or pent-up secretions. Peritonitic pains 
also occur in tlie later stages of the disease. Some cases suffer atro- 
ciously, others not at all. 

Diagnosis. — In the early stages of the disease there is nothing 
Biibjwtively upon which to hinge a diagnosis. The uterus is mod- 
erately enlarged, smooth, regular in outline, and movable. Later it 
becomes nodular and fixed. It may become so environed by adherent 
viscera as to be unrecognizable by palpation. An enlarged uterus in 
a woman of advanced age would suggest cancer, fibroma, or retention 
of secretions. Fibroma will usually have a history and the absence 
of atresia, as demonstrated by the sound, or escaping secretions will 
exclude retention. The hemorrhage, pain, and discharge are strongly 
suggestive of malignancy. Nodular masses on the surface of the 




314 PRACTICAL GYNECOLOGY, 

uterus and fixation througli infiltration of its ligaments and adhe- 
sions to adjacent structures in conjunction with the symptoms just 
named make the diagnosis of cancer almost positive. Unfortunately, 
a diagnosis at this stage can be of no benefit to the patient. Taking 
into consideration the age of the patient, and the comparatively re- 
cent development of the signs and symptoms, there is small likeli- 
hood of confounding cancer of the body of the uterus with anything 
else. A uterine polypus may give rise to hemorrhage, foul-smelling 
discharges, and possibly expulsive pain. This, if it does not appear 
at the orifice, may be found by dilatation of the canal and an ex- 
ploration of the uterine cavity. In all cases of doubt and at the 
earliest possible moment, the sharp spoon curette should be used 
freely and systematically over the entire endometrium and the scrap- 
ings submitted to microscopic inspection. The general health of the 
patient will give no clue until the disease is beyond control. 

Treatment. — If the diagnosis is made before the disease has passed 
beyond the confines of the uterus, as evidenced by its mobility, smooth, 
regular surface, and absence of rigidity or induration of the ligaments. 



0OS> 



Fig. 194. — Sims'g Screw for Removing Tampon. 

panhysterectomy by the abdominal route or the combined abdominal 
and vaginal method is clearly indicated. Early, total extirpation of 
the uterus for corporeal cancer yields most excellent results, both 
immediate and remote. Unfortunately, the disease is so insidious in 
its approaches that comparatively few cases are found in time to 
secure the best results through radical operative measures. 

^fedical Treatment. — In the absence of or subsequent to sur- 
gical treatment medical treatment may be resorted to. For hem- 
orrhages, hot douches of water or vinegar may be used. These fail- 
ing, the vagina may be packed with gauze, either plain or saturated 
with some styptic, such as alum or Monsel's solution. For the dis- 
charges and odor douches of some antiseptic or deodorant will be in- 
dioatcd, such as mercuric bichlorid (1 to 4000), 3 to 1000 solution 
of carl)olic acid, 2 to 1000 solution of permanganate of potash, and 
1 part to 3 or 4 of peroxid of hydrogen. The external genitals and 
thiglis may be protected from the acrid discharges by repeated wash- 
ings in Castile soap and water, followed by inunction with benzoated 
oxid of zinc ointment. For the pain nothing is so efficacious as mor- 



MALIGNANT DISEASES OF BODY OF UTERUS. 



3]r. 



phine. Its hypodermic adrainistrntion is attended with the least 
liupleasant after-effects and it should be used unsparingly according 
to the necessities of the case. 



ADENOMA MALIQNUM. 

Adenoma malignum is a malignant degeneration of the endo- 
metrium closely allied to cancer. The growth does not appear as a 
circumscribed tumorous mass, but as a diffuse thickening of the 
mucosa. The surface is velvety, uneven, and occasionally villous, and 
the membrane succulent. The gross and microscopic appearances are 
BO similar to those of glandular hypertrophy as to require special 
training and actual experience to differentiate them. The disease, 
while essentially malignant, and if left to itself, unswervingly pro- 
gresses to a fatal termination, is insidious in its approaches and tardy 
in its course; so that the patient may survive and retain the semblance 
of health long after the period allotted to other malignant affections 
if the uterus. 

Symptonu. — The symptoms are slow to manifest and not very 
characteristic. They are such as are observed in corporeal cancer, but 
of mitigated severity. The hemorrhage is less profuse, the discharges 
less abundant, the pain less severe, and the odor less offensive. Ail 
the symptoms are subject to abatement, and the period of quiescence 

einay be so protracted as to encourage the hope of a mistaken diag- 
nosis; but the amendment is fictitious, and always culminates in 
renewed activity and oftentimes increased virulence. The diagnosis 
lies between malignant adenoma and cancer, and is arrived at prin- 
cipally by exclusion. With many of the symptoms of corporeal cancer 
the course of the disease and the microscopic findings do not corre- 
epond. 

Diagnosis. — Exploratory curettage of the uterus reveals no can- 
cerous structure nor debris. This in itself will exclude cancer and go 
far toward establishing the diagnosis of malignant adenoma, as there 
is no other condition of the uterus tiiat would give the positive indi- 

I cations of cancer with the negative microscopic findings. Unfortu- 
nately, the microscopic findings are also very apt to be negative so 
far as the adenoma is concerned ; so that, while cancer may be posi- 
tively excluded, adenoma cannot be positively verified. The slow 
progress, the absence of cachexia, and the interrupted course of the 
disease, taken in connection with the negative evidences as adduced 
by the microscope, make a chain of circumstantial evidence so strong 




316 



PRACTICAL GYNECOLOGY. 



as to justify the diagnosis. In case of doubt the patient should be 
given the benefit of the doubt by regarding and treating the case as 
one of malignant adonoma. 

Treatment. — The treatment is extirpation of the uterus. This 
when timely employed gives excellent results, there being fewer re- 
lapses than from any other form of malignancy affecting the uterus. 
Curettage and cauterization only aggravate the trouble and precipi- 
tate the issue. 



^^ 



Fig. 105. — Round and Spindle Cell Sarooraa of Uterua Degenerating. 
(Photomicrograph by Grumm.) 



SARCOMA OF THE UTERUS. 

Sarcoma of tlie uterus is, with few exceptions, confined to the 
body, the cervix seldom being primarily involved. It takes its origin 
in the interglandular connective tissue of the endometrium or in the 
connective tissue of the uteriue wall. Herein lies the difference be- 
tween sarcoma and cancer, the former being a connective tissue 
growth, while the latt<?r is a glandular or epithelial growth. It occurs 
in two forms: 1. As a diffuse infiltration. 2. In tlie form of a dis- 
tinct tumorous mass: the so-called fibrosarcomata. 

Diffuse Infiltration is found in the endometrium. It may be con- 
fined to circumscribed areas or involve the entire mucosa. It is some- 



MALIGNANT DISEASES OF BODY OF UTKHUa 



317 



timee pol3'poid or papillary in character. The latter is soft, vascular, 
and brain-like. The involved surface is uneven and necrotic. The 
round-cell variety is most prevalent in this situation. The growth 
is apt to be rapid and progressive, involving first the uterine walls 
and thence passing to the contiguous viscera. Extensive adhesions 
between the uterus, intestines, omentum, and abdominal walls herald 
the advancing disease. 



Fig. lOfl. — Fibrosarcoma of Utenis Removed by PanhyBterectomy. 
(Author's Case. From Photograph.) 

Fibrosarcoma. — The fibrosarcomata develop in the uterine wall. 
They are distinctly tumorous, and resemble the uterine fibroid. Like 
the fibroid, they raiiy be subserous, submucous, or interstitial as re- 
gards location. They are usually of softer consistence than the uterine 
fibroid. They are single or multiple and for the most part belong 
to the spindle-cell variety. (Fig. 190.) 

CansM. — The causes of sarcoma are unknown. It occurs at all 
ages, but is moi-t prevalent in the decade of the menopause. It, like 
cancer of the body of the uterus, is most frequently found in the 
nuUi parous woman. 

Symptoms. — The symptoms are so similar to those of cancer of 
the body of the uterus as to be indistinguishable. These are pain. 




31S 



PRACTICAL OYNEJCOIXKJY. 



hemorrhage, and discharge. The discharge is watery, purulent, or 
sero-sangulnolent, and usually offensive. The cervix and its canal 
are sometimes unchanged, but more frequently tlie canal is patulous. 
The growth may protrude from the cervix, either from excess of de- 
velopment or from expulsive efTorts of the uterus. The degenerated 
tiesue is soft, friable, and unctuous, and presents the general charac- 
ters of cancer. Inversion of the uterus sometimes occurs in the 
progress of the disease. I once did a vaginal hysterectomy in a case 



Fig. 187. — Sarcoma of the Body o( the Utenis (Inverted). 
(Author's Case.) 

of this kind. The uterus attains a larger size than in cancer and 
become voluminous. Metastasis by way of the lymphatics is le 
frequent tlian in cancer. Cancer, for the most part, follows the lymph 
channels, while the sarcomatous elements are wafted on the blood- 
current. 

Diagnosis. — From a practical standpoint, the differential diagnosis 
between sarcoma and cancer is of little iiiiportaiice. The clinical fejit- 
ures and course are substantially the same, as is also the treatment. 
In fungoid endometritis we have a benign affection which in many 




MALIGNANT DISEASES OF BODY OF UTERUS. 319 

respects presents a puzzling similarity to diffuse sarcoma. Fungoid 
endometritis, however, seldom occurs after the menopause, is seldom 
accompanied by a bloody-serous discharge, and is not attended by the 
pain of sarcoma. The uterus is neither so large nor so tender as 
in sarcoma. The os is not so widely distended, nor does the hyper- 
trophied mucous membrane protrude through it. The constitutional 
symptoms are not so marked, and there is an absence of cachexia. 
The microscope, if properly used, will be of incalculable benefit in 
determining the presence of sarcoma. It must be remembered, how- 
ever, that mistakes even with a microscope are by no means unlikely, 
unless fortified by the proper precautions. Examination of the scrap- 
ings and detached portions of the fungoid masses, whether benign or 
malignant, may even prove misleading, as round-cell infiltration oc- 
curs in both. Often the cast-off masses in sarcoma are tiie under- 
mined healthy tissues, and would give no sign of malignancy under 
the microscope. To obviate error, therefore, it is expedient to procure 
and examine a number of different specimens from different parts of 
the uterine cavity. 

Treatment. — In the earlier stages, and before the involvement of 
extra-uterine structures, total extirpation of the uterus and its ap- 
pendages offers reasonable assurance of permanent cure. Tlio abdom- 
inal route should be chosen. When the disease lias advanced beyond 
the confines of the uterus, suffering may be alleviated by curettnge and 
cauterization, and such other palliative measures as have been recom- 
mended under the head of "Cancer." 



DECIDUOMA MALIQNUM. 

Deciduoma malignum — otherwise known as syncytioma malig- 
num, chorio-epithelioma malignum, and by various otiier alia-ses — 
is a most interesting disease of recent discovery. It belongs to the 
sarcomatous type, is intensely malignant, and usually runs a rapid 
course to a fatal termination. As the name implies, it is a malignant 
affection of the dccidua, and is found occupying the uterine cavity 
after labor, abortion, or after the expulsion of a fetal mole. It takes 
its origin in the syncytium, or that layer of tiie placenta which occu- 
pies the border-line between the fctiil and maternal portions. Au- 
thorities differ as to which it belongs. It occurs in the form of small, 
soft, roundish tumors, wliich bleed spoutiincously or on very slight 
provocation. The tumors are atypicnl rcprcsent.itivfs of placental 
tissue, and, like that, present clefts which arc filled with blood. 



320 PRACTICAL aYKEOOLOQY. 

The rich vascularity of the adjacent tissues and the tendency of 
the disease to invade the blood-vessels insure an early distribution 
of the sarcomatous elements. Metastases are consequently early and 
widespread. 

Causes. — The causes of d«ciduoma malignum are not known. Its 
association with fetal moles is so frequent as to constrain to the belief 
that there is a causal relation between them; that they both arise 
from the same cause, with modifications adapted to each. In a series 
of fifteen cases reported by Marchand 80 per cent, were preceded by 
hydatid formations in the uterus. In 177 cases collected by Pierce 
he finds the disease preceded by hydatid mole in 77 cases, normal labor 
in 30 cases, and abortion in 20 cases. 

Symptoms and Diag^nosis. — The symptoms are only characteristic 
when taken in connection with a recent delivery or expulsion of a 
mole. They are intermittent hemorrhage, usually severe, followed 
later by an offensive, turbid, watery discharge. Blood-clots are ex- 
pelled at intervals with painful contractions of the uterus. Loss of 
fiesh and strength, anemia, and cachexia are early manifestations. 
The uterus is enlarged and boggy; the cervix usually, though not 
always, patulous; and the uterine cavity filled with vegetations. 
These latter are often concealed by coagulated blood, and may be 
mistaken for blood-clots after removal. The uterine walls are soft 
and friable and easily perforated. The early occurrence of metastases 
is significant. A correct diagnosis may be quickly attained by micro- 
scopic examination of the vegetations removed by the finger or 
curette. 

Treatment. — Early and complete removal of the uterus and ap- 
pendages offers the only hope of relief. After the establishment of 
metastatic deposits nothing will be gained by operative interference, 
and none should be attempted. 



CHAPTER XXVII. 

FIBROID TUMORS OF THE UTERUS. 

The uterine fibroid takes its origin in the walla of the uterus. 
It is a benign growth, and is composed of the same histologic elements 
that constitute the muscular walls of the uterus: connective tissue 



Mg. 198. — Uterine Fibroma. (Pbotomjcrograph by Gramm.) 

and unstriped muscle-fibers. Notwithstanding this, it is an inde- 
pendent growth, neither being derived from, nor having any physio- 
logic connection with, normal uterine structure. It is probably con- 
genital in a nuclear form, and may or may not develop in after-life. 
The connective and muscle- tissues of which the uterine fibroid is 
composed vary in their relative proportions. As a rule, the connective 
tissue largely predominates. Rarely the muscle-tissue is in excess. 
When the tumor consists almost exclusively of muscle-tissue, it is 

(321) 



322 



PRACTICAL GYNECOLOOT. 



Dy some denominated a myoma. Such txunore are exceedingly rare. 
Properly speaking, all such growths as those under consideration are 
fibroniyomata or myofibromata according as the connective or muscle- 
tissues predominate. 

Tlie term fibroid is used in a general sense, and includes all forms. 
The color and consistence of the tumor dejMjnd largely on the relative 
proportions of its constituents. Those composed largely of fibrous or 
connective tissue arc dense and hard and of a whitish aspect. The 
tumor is soft and red in proportion to tlie amount of rauscle-ti.ssue 



Fig. 100. — Uterin* Myoma. (Photomicrograph by Grmmm.) 



it contains. The hard fibroid cuts like gristle, and the cut surfae? 
shows the striations of fibrous tissue. These are variously disposed, 
being often arranged in concentric rings around different focal points. 
The cut surface bulges and becomes convex. The fibroid tumor makes 
for itself a capsule by crowding back the surrounding connective tissue 
as it grows. The density and thickness of this capsule within pre-i 
scribed limits is proportional to the size of the growth. 'ITie tumor is 
loosely connected with its environments, which greatly facilitates its 
enucleation. This also accounts for its change of position under mus- 
cular contraction. In this way a tumor situated in the depth of the 




FIBROID TtniORS OF THE UTERUS. 



32\i 



Dterine wall is sometimes forced toward the cavity or periphery of the 
organ. The tumor is meagerly vascular, the vessels usually being of 
small size and few in number. They are derived from the capsule, 
which is usually richly supplied with blood-vessels. 

Causes. — The primal cause of the uterine fibroid is unknown. By 
Bme it is supposed to be derived from a little cluster of left-over cells 
rhich were not utilized in the formative process of the uterus. It is 
probable, at least, that the nucleus of the growth exists before birth. 
It usually develops during the active, sexual period of the woman's 
life: between the ages of thirty and forty. It occurs with greater fre- 



■iSf 



-O- 



Fig. 200. — Positiona of the Subserous, 
iDUntitial, and Submucous Fi- 
broids. 



Fig. 201. — Method of Removing Pe- 
dunculated Subserous Fibroid by 
Turning Down a Cuff of the Peri- 
toneum. 



quency in the unmarried and sterile. This is supposed to be due to 
the regularly recurring menstruation, with its attendant congestion, 
which conduces to the nourishment of the growth. On the other 
hand, the involutionary changes that take place after childbirth may 
cause the disappearance of the smaller fibroids before they have at- 
tained to such size as to attract atteiitiuu. Even large tumors have 
been known to disappear after childbirth. The fibroid tumor, while, 
in a measure, dependent on sterility, is also conducive to sterility by 
the changes it produces in the uterus and appendages, and the hemor- 
rhages and discharges incident to the growth. 




324 PRACTICAL GYNECOLOGY. 

Desig^nation According to Position. — Fibroid tumors of the ntemi 
are designated according to the position which they occupy. A fibroid 
tumor imbedded in the muscular walls of the uterus is called an in- 
terstitial fibroid. It is probable that most, if not all, uterine fibroids 
are originally interstitial. When a fibroid is situated immediately be- 
neath the serous covering of the uterus, it is called a subserous fibroid. 
These grow outward toward the peritoneal cavity. A fibroid present- 
ing immediately under the mucosa is called a submucous fibroid. 
These grow inward toward the uterine cavity. (Fig. 200.) Besides 
these there are other distinctions according to locality. The intra- 
ligamentous fibroid is one that pushes out between the folds of the 
broad ligament. These usually arise from the side of the lower seg- 
ment of the uterus or from the supravaginal portion of the cervix. A 
retroperitoneal fibroid is one that pushes up back of the peritoneum, 
separating it from the structures to which it is attached in the poste- 
rior plane of tlie body. Fibroids developing in front of the perito- 
neum and between it and the anterior abdominal wall are sometimes 
designated properitoneal fibroids. 

The Submucous Fibroid grows toward the uterine cavity, carry- 
ing the mucosa before it. It is usually sessile, but occasionally it 
pushes bodily into the cavity and becomes pedunculated. It then 
constitutes the fibroid polypus, described elsewhere. 

The Subserous Fibroid develops in the direction of the periph- 
ery of the organ, and forms a projecting tumor under the serous 
covering. It sometimes becomes pedunculated. The pedicle may be 
thick, dense, and fibrous, or consist of little more than the peritoneum 
and nutrient vessels. The subserous fibroid, by reason of its density, 
irregularity, and movements, is very apt to produce irritation of the 
peritoneum, resulting in effusion. The ascites, however, is seldom 
pronounced, and is not comparable to that resulting from malignant 
growth. Another expression of the irritating effects of the subserous 
fibroid is found in the adhesions between the tumor and the structures 
with which it comes in contact. Thus we frecjuently find the tumor 
adherent to the omentum, bowel, and abdominal wall. The adhesions 
are sometimes very extensive and vascular, the vascularity contribut- 
ing largely to the sustenance of the tumor. The pedunculated tumor 
sometimes Iwcomos detached from the uterus through violence or 
from pro<;ressive atrophy of the pedicle. In such cases the tumor 
either rolls around loosely in the peritoneal cavity, or else — if ad- 
herent — it is sustained and nourished by the structures to which 
it is attached. 



FIBROID TUMORS OK THE UTERUS. 



325 



The Intraligamentous Fibroid. — In this the tumor springs from 
the side of the uterus and that portion of the cervix above the vaginal 
vault, and pushes out butwcen the folds of the broad ligament. In 
this position it lifts or pushes the uterus from its natural position, and 
displaces to a greater or lesser extent all the pelvic viscera. The 
ureter is habitually displaced, and is sometimes carried fur out of line 
and in the most varied directions, so that its position with reference 
to the tumor can never be predicated. These tumors are often im- 



Flg. 202. — Tjirpe Sp\ierie«l, Cervieal Fibroid (Inlr«Iigatncnfou8'), Removed 
by PunbysUTCclomy. (Author's Case. From I'botograpb.) 



pacted in the pelvis, and exert most daiiinging pressure on the pelvic 
organs, vessels, and nerves. When they grow upward into the ab- 
dominal cavity, they carry the pelvic structures before them. Another 
form of extraperitoneal fibroid takes its origin in the supravaginal 
cervix anteriorly, and. pushes out between the uterus and bladder. 
This, in its upward development, carries the bladder with it, some- 
times even to the umbilicus. The bladder thus displaced is immedi- 
ately under the usual line of incision for abdominal section, and may 
be seriously injured by the operator. When the tumor springs from 



326 PRACTICAL GYNECOIXXJY. 

tlie posterior aspect of the cenMx it becomes retroperitoneal by passing 
under the Douglas cul-de-sac and making its way up back of the 
peritoneum. 

Degenerative Changes. — ^The uterine fibroid is subject to a num- 
ber of degenerative processes, the most common of these being cystic, 
myxomatous?, calcareous, fatty, and malignant. 

Cystic Degenemtion is due to an accumulation of lymph within 
the intermuscular lymph-spaces (lymphangiectasis) or to the ulterior 
changes produced by a myxomatous degeneration. These result in 
the so-called fibrocystic tumor. 

MyxoDMious Degeneration results in the formation of a mueus- 
likc fluid in various parts of the tumor, imparting to it a more or less 
cy.stic character. As a cause of the fibrocj'stic tumor it is less frequent 
than lymphangiectasis. 

Fatty Degeneration' is most apt to occur after parturition. It 
may occur after the menopause or under other conditions. It is sup- 
poiied to be a neces!?ary forerunner to absorption of the tumor. 

Cahareous Degeneration of tiie tumor consists in infiltrati(Mi 
with lime salts. It indicates a sluggisii movement of the nutrient 
fluids in the substance of the tumor whereby the volatile acid which 
holds the lime in solution escapes, allowing the latter to be deposited. 
The tumor, in consequence, becomes hard and stony. In advanced 
cases the tumor ceases to have any connection with the surrounding 
tissues, and, if emapsulatcd, becomes as a pea in a pod. Myxomatous, 
fatty, and calcareous degenerations are very rare. 

Malignant Degeneration of the uterine fibroid is by no means 
common, and is almost without exception sarcomatous. Cancer of 
the endometrium or of the cervix is associated with uterine fibroid 
with suilicicnt fi'cquency as to justify the belief that the fibroid in 
some way predisposes to tlie cancerous degeneration. 

KdvinatoH.i Fibroid. — The succulent or edematous fibroid is quite 
common. It is characterized by a watery infiltration, which may be 
localized or general. It is usually associated with rapid growth and 
most freipicntly found in young subjects. 

/ii/taiiiiiKilion, Sujipnratiou, and (langrene are occasional inci- 
dents in the course of the uterine fibroid. These usually arise from 
infection cither through the uterine canal or intestines. A peduncu- 
lated (ibroid may bci-ome gangrenous from torsion of its pedicle, 
whereby the blood-supply is cut off. \ gangrenous submucous fibroid 
may slouch away, and result in spontaneous cure, l)ut the process is a 
dangerous one, and is attended with a high rate of mortality. 



FIBROID TUMORS OF THE UTERUS. 



387 



Growth of the Fibroid, — The growtli of the fibroid is errntic. 
Unlike the ovarian cy»loiiin, which is regularly progressive to a fatal 
termination, it is impossible to predicate the course of the uterine 
fibroid in any given case. It often attains a moderate size and re- 
mains quiescent, or it may at any stage undergo retrogressive changes. 
■ It may develop regularly or spasmodically, slowly or rapidly. It may 
" assume such proportions or inaugurate such conditions as to demand 
operative interference, or it may run its course and finally subside 
without artificial aid. Enormous development of the uterine fibroid 
is occasionally met with. Tumors weighing two hundred pounds have 
been reported. In the year 1891 I removed one which filled a foot- 
bath tub. This was disposed of without being weighed. In most in- 
stances the growth subsides after the menopause. The menopause is, 
however, retarded by the presence of the neopla.em, and tliere is no 
absolute certainty that this epoch will bring the hoped-for relief. As 
a rule, uterine fibroids are of slow growth and self-limited. Their 
period of activity corresponds to the period of active sexual life. 

Changes in the Uterus and Adnexa. — The uterus becomes en- 
larged and its walls bypertrophied. Endometritis usually exists in 
the hypertrophic variety; occasionally it is atrophic. The tubes are 
also affected to a greater or less extent, and may present any of the 
phases of salpingitis from the simple catarrhal form to the pyosalpinx. 
They are^ often greatly thickened and elongated, and sometimes much 
distorted. The ovaries may be inflamed, elongated, or spread out over 
the face of the tumor. All the vessels leading to the uterus are aug- 
mented in size. The size and number of vessels will depend upon the 
activity of the growth. Changes in the uterus are much less marked 
with the pedunculated, subserous fibroid than with the interstitial or 
submucous. Degenerative changes of the liver, heart, and kidneys 
have been ascribed to uterine fibroid. Compensatory hypertrophy of 
the heart is also found in connection with the larger growths. Pressure 
upon the emunctories and disturbance of the circulation are the prin- 
cipal causes of these remote effects. 

. Symptoms. — The symptoms of the uterine fibroid are local and 
general. Tlie symptoms depend largely on the situation of the growth. 
The pressure symptoms are much more pronounced in the subserous 
and intraligamentous, and hemorrhage in the interstitial and sub- 
mucous forms. Some growths even of large size are attemled by no 
symptoms. The local symptoms are pain, hemorrhage, and pressure. 

Pain. — TiOcalized pnin in the uterus is due to one of two causes: 
tension of the uterine fibers from an interstitial growth, or from the 




328 



PRACTICAL GYNTCCOLOGY. 



efforts of the aterus to expel the growth, which acts as a foreign bodj. 
The first is steady and continuous; the latter, paroxysmal. Pressure 
on the adjacent organs — such as the bladder, ureter, and intestine — 
also evokes pain, which may be referred to the organ encroached upon 
or reflected in various directions. When the tiunor has escaped from ■ 
the pelvis into the more roomy abdominal cavity, these paina often 
subside or are greatly mitigated. 

Hemorrhage. — The first evidences of hemorrhage begin at the 
regular menstrual period, and are manifested by an increased flow and 
subsequently by a prolongation of the period. Eventually inter- 
menstrual hemorrhages occur and menstruation becomes irregular. A 
very profuse bleeding, either at or in the intervals of menstruation, is 
apt to be followed by amenorrhea, which may extend over weeks or 
months. Instead of the torrential hemorrhage, which occurs with 
Biioh alarming suddenness and severity, thure may be a continual 
dribbling, whicli gradually exhausts the vital fluid and energies of the 
patient. A leucorrheal discharge of a simple, sanious, or purulent 
character frequently alternates with the hemorrhage, and saps the 
patient's vitality. Hemorrhage is most often found in connection with 
the submucous or interstitial growths, but may occur in the subserous 
or intraligamentous varieties, especially if located in the line of the 
emergent vessels. 

Pressure Symptoms. — Pressure on the rectum interferes with 
the action of the bowels, produces mechanical constipation, and, by 
interfering with the circulation, gives rise to piles. Painful and diffi- 
cult defecation and proctitis may result. Pressure on the urethra 
produces dysuria, sometimes retention of urine, and cystitis. Pressure 
on the ureters obstructs these passages, and may lead to nephrodrosis 
and degeneration of the kidneys. Pressure on the large venous trunks 
coming from the extremities gives rise to a compensatory enlargement 
of the superficial abdominal veins and edema of the extremities. 

General Symptoms. — These occur from the loss of blood, the 
derangement of function of important organs, and the accumulation 
of toxins. When the bleeding is profuse or continuous the patient 
becomes anemic to an extreme degree. Sudden, profuse hemorrhage 
may even result fatally; but such cases must be exceedingly rare. 
Many patients are not notably emaciated, but, on the other hand, may _ 
be fat, flabby, and pallid. f 

Diagnosis. — In general terms it may be said that the uterine 
fibroid is characterized by firmness and insensibility. The uterus is 
enlarged and the canal elongated, as demonstrated by the sound. The 



TTOROID Tl^MOIlS HI' TIIK I'TKRUS. 



329 



tumor id in inliiiiuli" conuwtion with the uteruR, and may be do- 
tt-nniued by rectal and vajiinnl tdiii'li. assistwl by tbe band on the 
nbduinen, as also by eoncertud luovcnieiits of the tumor and cervix, 
any motion imparted to one being eomnumicated to the other. Pain, 
hemorrhage, and pressure sj-mptoms sliould Iw jriven consideration. 
Before resorting to the sound jn-egnanaj should be excluded. A 
softened cervix, a boggy uterus, and amenorrhea should always raise 
till- qihestiou of pregnancy, and load to a careful inijuiry into all the 
conditions whereby pregnancy may bo allirniod orexcludi'd. 



Fig. 203. — Intorstitial and Miiltinorfulur Fibroids partiitlly Intriiligiimentous, 

Involving Body and (Vrvix. Ucniovcd l)y I'nnhystBrectomy. 

(Author's Caso. Krom I'liotojrnipli.) 

Krlopir (jpxialiitn has been repeatedly mistaken for uterine 
fibroid. The rapid growth, the tenderness an<l bupginess t»f thu 
mass, the ooliekj- pains, faintness, and shreddy discharges will usually 
sulBce to difTerentiati- this from uterini- fibroid. 

The dermind cj/yl may be litini ami resistant, and hug the womb 
BO closely as to be practically inseparable from it. The dermoid is 
usually tender. Other cysts, especially the papillomatous or multi- 
liK-ular ovarian cyst, may so closely resoiul)le tlu- uterine fibroid in 
touch AS to be indistinguishable from it. In all such cases the absence 
of concerted movements, and the evidences acquired by rectal indaga- 

23 




330 



PRACTICAL QYNECOLOQY. 



tion, and especially tlie depth of the uterine canal, as determined by 
the uterine sound, will greatly aid in the diagnosig. 

The edematowi fibroid and the fibrocystic tumor of the uterus 
are often most difficult to distinguish from the nudtilocular cyst. The 
rectal touch and the uterine sound are here often indispensable to a 
diagnosis. It must be remembered that in certain pedunculated, sub- 
serous fibroids the uterus is not enlarged nor its canal elongated. 

The special diagnostic criteria, according to the situation of the 
growth, are as follows: — 

Interstitial Fibroids. — In the earlier stages, and before there 
is marked projection of the tumor toward the uterine cavity or the 



')*. 



fig. 204. — Fibroid Polypus of the 
FuoduB being Cut Away. 



Fig. 205. — Large Submucous Fibroiil { 
Protruding Uirough Oa. 



periphery of the organ, the moderate enlargement, the pain, and 
hemorrhage are quite indistinguishable from that of corporeal cancer. 
Here the only sure criterion lies in the microscopic examination of 
the scrapings of the endometrium. Later the size of the growth, its ■ 
projection toward the surface or cavity, and its duration will afford 
clues by which the differentiation can usually be made with compara- 
tive ease. 

Submucous Fibroids. — The most characteri.'itic symptoms are 
hemorrhage and expulsive pains. The uterus is enlarged and the canal 
elongated. If the cervical canal be patulous, a finger may be intro- 
duced and — assisted by counter-pressure from above — the cavity ex- 
plored. Should the cervical canal not be open, dilatation, either rapid 



I 
I 



I 

_ th 




Fir.UOID TUMORS OF THE UTERUS. 



3.11 



or gradual, may be resorted to. iDcision of the cervix bilaterally will 
greatly facilitate this step of the procedure. Vulliete's method of 
gradual dilatation by daily [tacking the uterine cavity with iodoform 
gauze and iucreafiing the quantity at each packing is both elhcacious 
and free from danger, but has the disadvantage of being slow. With 
the finger in the uterine cavity, the position, size, and otlier characters 
of the tumor may be definitely determined. 

Subserous Fibnnds. — These are usually multinodular, and may 
distinguished by their firmness and attachment to the uterus. The 




Fig. 206.— MuHinoduUr Uterine Fibroid. (Author's Case. From Photograph.) 

pedunculated variety may sometimes give trouble, but careful manipu- 
lation will usually demonstrate their connection with the uterus by the 
motion communicated to it by pulling or pushing the tumor in dif- 
ferent directions. By rectal examination conjoined with manipula- 
tion of the growth, the pedicle may frequently be detected and its 
attachment to the uterus verified. A subserous fibroid attached to 
the posterior surface of the uterus will sometimes simulate a retro- 
flexion. (Fig. 207.) 

The Intraligamentoua Retroperitoneal and Properitoneal Fibroids 
occasionally present insurmountable dilBculties in the way of diag- 



3.12 



PRACIICAL GYNECOLOGY. 



nosis, but in most instances the nature nnd location of the growth may 
be nitide out by the application of the rules already laid down. 

FIBROID POLYPI. 

Fibroid polypi may spring from the cervix or uterine cavity. 
They are much less frequent than the glandular polypi, and, unlike 
them, are usually single. The length of the pedicle varies, being 
sometimes short and thick, at others slender and elongated. (Fig. 
204,) They are often inflamed and ulcerated, and give rise to a more 




Ilg. 207. — A SubMrous Fibroid Simulating Retroflexion 
of Ibe Uterus. 



or less copious purulent, foul-smelling discharge. Their resemblance 
to malignant growth is occasionally very close. Endocervicitis and 
endometritis are also constant accompaniments. The cervical canal 
is usually dilated, especially in the uterine form. Interference with 
the blood-supply may cause the pedicle to slough, thus resulting in a 
spontaneous cure. A fibroid polypus is probably a submucous fibroid 
which has become pedunculated. Calcareous degeneration will occa- 
sionally convert the polypus into a mass of stony hardness. When 
such are detached and expelled, they constitute the so-called womb- 
stouea. 



FIBKOm TUMQKS OF THE UTERUS. 333 

Symptoms. — The more common symptoms are profuse, purulent 
discharge; bleeding; and colicky, or expulsive, pains. The bleeding 
may occur in the form of a more or less constant dribbling or as severe 
floodings at irregular intervals. Menstruation is usually increased. 
The pains are paroxysmal and sometimes violent. Backache and a 
tense of weight in the pelvis are frequent symptoms. 



332 



PRACTICAL OYNECOIXJOY. 



nosis, but in must instances the nature and location of the growth may 
be made out by the application of the rules already laid down. 

FIBROID POLYPI, 

Fibroid polypi may spring from the cervix or uterine cavity. 
They are much less frequent than the glandular polypi, and, unlike i 
them, are usually single. The length of the pedicle varies, being | 
sometimes short and tliick, at others slender and elongated. (Fig. 
204.) They are often inflamed and ulcerated, and give rise to a more 



hill 



V-. 



W 



'.m 



Fig. 207. — A Subserous Fibmid Simulating RetroflexioB 
of tbc UleniJ. 



or less copious purulent, foul-smolling discharge. Their resemblance 
to malignant growth is occasionally very close. Endoccrvicitis and 
endometritis are also constant accompaniments. The cervical canal 
is usually dilated, especially in the uterine form. Interference with 
the blood-supply may cause the pedicle to slough, thus resulting in a _ 
spontaneous cure. A fibroid polypus is probably a submucous fibroid I 
which haa become pedunculated. Calcareous degeneration will occa- 
sionally convert the polypus into a mass of stony hardness. When 
such are detached and expelled, they constitute the so-called womb- 
Btoaea. 



FIBROID TUMQRS OF THB UTERU& 333 

Symptoms. — The more common symptoms are profuse, purulent 
discharge; bleeding; and colicky, or expulsive, pains. The bleeding 
may occur in the form of a more or less constant dribbling or as severe 
floodings at irregular intervals. Menstruation is usually increased. 
The pains are paroxysmal and sometimes violent. Backache and a 
•ense of weight in the pelvis are frequent symptoms. 



/, 



CHAPTER XXVIII. 

TREATMENT OP FIBROID TUMORS OF THE UTERUS. 

Thb treatment of uterine fibroids is medical, electrical, and 
operative. 

Medical Treatment. — Before the advent of modem abdominal 
surgery medical treatment had full sway, and the number and variety 
of medicinal preparations used was very great. One after another 
of these was brought to the notice of the profession and faithfully 
tried. It is a matter of history that none has stood the test of ex- 
perience as a curative agent. It must be remembered that the natural 
course of the uterine fibroid is erratic; that it sometimes ceases to 
grow, may undergo retrograde change, or even disappear spontane- 
ously. A medicine exhibited at this time will get the credit for the 
favorable result, and thus be invested with virtues 'which it does not 
possess. 

About the only remedy which has stood the test of time and 
experience as a palliative, with now and then more permanent re- 
sults, is ergot. This acts by producing muscular contraction of the 
uterus and by diminishing the caliber of the smaller blood-vessels. 
In this way the nutrition of the tumor is diminished, and the hem- 
orrhages incident to its presence are checked or appreciably lessened. 
The muscular contractions force the interstitial tumor toward the 
cavity or periphery of the organ, and in the submucous fibroid occa- 
sionally cause its expulsion. The drug may be given by the mouth or 
hypodermically. Used too freely by the mouth, it is apt to provoke 
gastro-intestinal disturbances. Hypodermically it is at times severely 
painful. Its excessive use produces great depression of the heart A 
pure, unirritating, and reliable preparation should be used. Squibb's 
aqueous extract of ergot fulfills these indications. For hypodermic 
use this should be combined with water, 1 part to 10. A little sali- 
cylic acid — 2 grains to the ounce — will act as a preservative, although 
it is better to prepare it fresh on each occasion. The dose should be 
1 grain a day, gradually increased according to the tolerance of the 
patient. Both medicine and syringe should be sterilized and the skin 
surrounding the point of injection thoroughly cleansed. The injeo- 
(331) 



TREATMENT OF FIBROID TUMORS OF TUE UTERUS. 



335 



tion sliould be in the muscular tissue of the abdomen in the vicinity 
of the tumor. The same preparation may be given in pill form by 
the mouth : 1 grain thrice daily, combined with nux vomica to modify 
its action on the heart. An additional hypodermic injection, once or 
twice a week, will usually be about as much as the patient can tolerate 
over an extended period of time. 

Thyroid extract has recently come into favor, both as a hem- 
ostatic and reducing agent. It is given in 3-grain doses, three times 
daily, and may be increased if well tolerated. It is badly borne by 
some patients, and is contra-indicated in exophthalmic goiter and 
irritable heart. My own experience with the drug has not been such 

las to inspire confidence. Other remedies sometimes used are hydras- 
tis Canadensis, extract of hamamelis, and the salts of ammonia and 
potash. It may be said in conclusion that the treatment is largely 

kiymptomatic, and intended for the alleviation of pain or the arrest 
of hemorrhage. In these it finds its greatest value. 

Electrical Treatment. — While there can be little doubt that elec- 
trical treatment in skilled hands may be of benefit in certain varieties 
of uterine fibroid and under certain conditions, its use is so technical 
and the contra-indications for ita use so numerous, and, withal, the 
results 60 problematic, as to practically bar it from general adoption. 
It is not to be used in hysterical women, in the presence of inflam- 
mation of the appendages, in malignant degeneration, in fibrocystic 
growths, or in heart or kidney trouble, and is of little avail in the 
pedunculated submucous or subserous tumors or in very hard tumors 
in any situation. It is not fair, however, to scout the agent out of 
existence; yet the treatment of properly selected cases should be 
relegated to men who have proven themselves masters of the tech- 
nique. 

Operative Treatment, — The surgical treatment of uterine fibroids 
may be palliative or radical. The palliative treatment consists in 
curettage for the control of hemorrhage. It is inefficient because of 
the irregular contour of the uterine cavity, and dangerous from the 
liability to sepsis and from possible sloughing of the growth through 
injury to ita capsule. Removal of the uterine appendages, as advised 
by Tait, and ligation of the uterine and ovarian vessels, as advocated 
by Martin, are, for the most part, temporary expedients, and scarcely 
justifiable in the face of accumulated experiences. It has been found 
that the radical operation of hysterectomy is made much more diffi- 
cult after such operations, principally because of the collateral cir- 
culation, which greatly multiplies tlie number of vascular points 




;{3(i 



PRACTICAL GVNECOUXJY. 



requiring ligature, and because of their inconvenient location: over 
the bladder and in the recto-uterine space. The cicatricial tiseue also 
offers serious obstacles to the dissection. The radical operation con- 
sists in the extirpation of the growth. This may be accomplishod by 
one of two routes : through the vagina or by abdominal section. In 
many instances the uterus is removed along with the growth. 

Vaginal Operation. — The vaginal operation is limited to tu- 
mors of small size. It is seldom practiced in tumors larger than the 
fetal head. For very small tumors vaginal hysterectomy may be per- 
formed. As a rule, this operation is confined to the enucleation of 
tumors of moderate size which project into or abut upon the uterine 
cavity: submucous and interstitial. 

Enucleation. — Careful aseptic detail should attend every step 
of the operation. Operation by stages, such as the preliminary dila- 
tation of the cervix, and incision of the capsule, leaving the growth 



Fig. 208.— Straight Uterine Scissors. 



to be expelled by uterine contraction, is tedious, uncertain, and too 
often complicated with sepsis to merit approval. Cases should be 
selected that offer reasonable assurance of being completed at one 
sitting. 

The woman is placed in the lithotomy position, and the cervix di- 
lated and, if necessary, split bilaterally to the vaginal vault. The in- 
cision may be even carried above the os internum on the inner aspect, 
providing it is not carried entirely through the cervix at its upper seg- 
ment. Previous ligation of the uterine arteries will render this part 
of the operation comparatively bloodless. The capsule is now seized 
with bullet forceps and split !on}i;itudinally from above downward. 
Seizing the edges of the capsule with forceps, it is pushed back from 
the face of the tumor by means of blunt, curved scissors or an 
enucleator. The redundant portion of the capsule is then cut away, 
the tumor seized with strong-toothed forceps, and the enucleation 
continued while continuous traction is made on the growth. The end 
of the enucleator sliould bug the tumor closely all the while, to pre- 




TREATMENT OF FIBHOID TUMORS OF THE UTERUS. 



337 



vent perforation of the uterine wall. OccaBionally it will be neces- 
Bary to cut through tougli, unyielding banfls. When the tumor is 
in great part separated, it may be wrenched from its bed or rolled 
out by aid of the forceps. Should it be too large to bo delivered 
through the cervix, it may be split or whittled down to the requisite 
size. The ragged edges of the capsule should then be trimmed away. 
Digital exploration of the cavity should be made to determine the 
nature and extent of any injury to the uterine wall, and if no perfora- 
tion exist the cavity should be irrigated, dried, and packed with iodo- 
form gau2:e, reinforced by a loose vaginal tampon. If perforation 
has occurred, the cavity should be wiped and packed and ergot ad- 





Fig. 200. — Morcellation of tlie Sub- 
mucous Fibroid to Reduce its Vol- 
ume and Facilitate Delivery. 



Fig. 210.— The Remnant of the Fibroid 
L«aving its Bed under Traction. 



ministered. The packing should be removed on the third day, and, 
after irrigation, renewed. 

Morcellation. — Sometimes the tumor can be more easily removed 
by cutting it away piecemeal. (Fig. 209.) Here, under sustained 
traction, one portion after another of the tumor is excised until the 
volume is considerably reduced. At some stage of this procedure the 
tumor suddenly -leaves its bed and rolls out into the vagina. (Fig. 
210.) This is, in part, due to the continual traction, and, in part, 
to the uterine contractions, which are rendered more efTectual through 
the reduction of the volume of the tumor. In morcellation (piecemeal 
excision) firm hold should be taken on some other part of Uie tumor 
before that which is in the bite of the forceps is excised. This u to 



338 PBACTICAL GyNECX)LOaT. 

prevent the tumor from receding. The after-treatment is the aams 
as in enucleation. 

Abdominal Operations. — These are comprised under the heads of 
myomectomy and hysterectomy. These operations presuppose an 
abdominal section at the usual site. 

Myomectomy. — Myomectomy consists in removing the growth 
from the uterus. This is accomplished by excision or enucleation. 
It is applicable to cases in which the tumors are neither too large 
nor too numerous, and, for the most part, is confined to tumors that 
are located on the anterior or posterior aspect of the uterus and away 
from the large vessels at the sides. If the tumor be pedunculated, it 
is seized and steadied while an incision is made around the pedicle 
or lower segment of the tumor adjacent to the pedicle. The investing 
capsule is then pushed downward like a cuff, while traction is made 




Fig. 211. — Morcellation Forceps. 

on the tumor until the growth is separated. (Fig. 201.) The wound 
is closed by contiiious catgut suture, which may or may not be serried, 
according to its depth. In sessile tumors and those imbedded in the 
uterine wall, an incision is made over the most prominent part of 
the tumor, and the tumor enucleated by dry dissection. This in- 
cision should always, when possible, be made in the long axis of the 
womb, to avoid cutting across vessels. Occasionally adjacent tumors 
may be removed from the same opening with less mutilation than if 
a separate incision were made for each. 

It is desirable to avoid entering the uterine cavity, especially 
when there is reason to suspect infection of the same, as evidenced 
by foul or purulent discharge. Under ordinary conditions the uterine 
cavity is sterile; but such is not always the case in the presence of 
a uterine fibroid. Still, the cavity has been invaded repeatedly in 
the operation of myomectomy without untoward results. As a pre- 
cautionary measure the abdominal viscera should be thoroughly pco- 



TREATMENT OF FIBROID TUMORS OF THE UTERUS. 339 

tected by padding. Wlien several tumors are to be removed, the 
cavities of those enucleated are packed with gauze until the enuclea- 
tiona are completed. Large vessels are caught in pressure forceps 
or tied at once. The incisions are carefully closed, the mattress stitch 
being used to include troublesome vessels. The wounds should be 
carefully inspected for indications of hemorrhage before the abdomen 
is closed. 

SupRAVAaiNAL HYSTERECTOMY. — The extraperitoneal treatment 
of the etump in supravaginal hjsterectomy, by including it in the 
lower angle of the abdominal incision, is practically obsolete, and 
should be relegated to the limbo of the past. It possesses no advan- 
tages over the more modem methods, and is clearly inapplicable to 



Fig. 212.~Artcrin1 Supply of the Genital Tract 

M8C8 in which the tumor pushes out into the broad ligament or dips 
under the peritoneum. It is inappropriate in case of short vagina, 
as in many virgins, and difficult in the presence of cervical tumors. 
It entails long suffering and conlinement; it is frequently followed 
by hernia, and occasionally by fistula of the cervical canal. 

The Baer Metlwd. — The essential features of the Baer method 
of supravaginal amputation of the uterus consists in ligating the 
TCBsels before their entrance into the uterus. The principal vessels 
requiring ligature are tlie ovarian and uterine. This operation, with 
slight modification of technique, has largely supplanted all others. 

The preliminary abdominal incision, which is made at the usual 
site, should be free and ample, that the subsequent steps of the opera- 
tion may be unhampered. The patient is then placed in the Tren- 



340 



PRACTICAL GYNECOLOGY. 



delenburg position (Plate XI [I), and a careful inspection made of the 
uterus and its environments. If possible, the uterus may be lifted 
out through the abdominal incision, otherwise the operation may be 




'""■-'J-'^" 



-HW 



Fig. 213. — Doyen's Myoma Screw, (or Lifting Utenis out of the Ckrity. 

conducted with the uterus in situ. The intestines are walled off by 
gauze pads, and pads are carefully disposed back of and around the 




Fig. 214. — Green's Retractora. 



uterus to receive the discharges and prevent infection of the peritoneum. 
Retractors for holding open the abdominal incision greatly facilitate 
the steps of the operation, by aiding sight and manipulation. A broad 




Fig. 215. — Halsted's Retractors. 



retractor at the lower angle of the wound, which may be inclined to 
one side or the other, as occasion may require, is most ser'riceable. .\ 
gauze pad should be placed between the retractor and the edge of tlie 




TREATMKNT OF FIBROID TUMORS OF THE LTEIIUS. 



341 



incision to prevent pressure necrosis. Especially is this necessary in 
prolonged operations. The ovarian artery is ligatcd near the pelvic 
wall on one side, and a clump forceps placed on the broad ligament 
between the ligature and uterus under the tube. This forceps, which 
is intended to prevent the reflux of blood from the uterine side, 
passes diagonally from the crest of the ligament to the side of the 
uterus, and a little above the vesical fold of the peritoneum. (Fig. 
216.) Care should be taken not to include the bladder in the bite 
of the forceps. An additional ligature is placed on the round liga- 



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1 






' jt 


1 


i 







Fig. 218. — Abdominal Hysterectomy. (First Step.) 
Llgntures aud cinaips uppUed tu Uiu uvurinii Mid round tigniiieul itrlerlea. 



ment and the tissues divided between the ligatures and forceps. Liga- 
tures and clamp are similarly placed on the opposite side and the 
broad ligament divided between them. The utero-vcsical fold is 
caught up by a mouse-toothed forceps and divided, the incision run- 
ning across the anterior face of the uterus from side to side at a safe 
distance above the bladder. (Fig. 219.) This incision joins those 
of the broad ligament at either side. 

The next step is to strip off the bladder and push it down. This 
may be done with the fingers, blunt scissors, or a sponge in the bite 
of a long-handled forceps. The uterine artery is nejct sought for by 



34-, 



PRACTICAL GYNECOLOGY. 



taking the broad ligament between tlie tlmnib aiul fingers on a line 
with tlie cervico-uterine junction, and close to the same. The artery 
can usually be felt pulsating, and affords an accurate indicator for 
the placing of the ligature. (Fig. 223.) Should the pulsations be 
indistinct or questionable, a ligature placed in the same situation, but 
including a greater breadth of tissue, will usually catch it. Care 
should be taken to avoid the ureter by placing the ligature between 



Fig. 217. — Doyen'8 Straight Broad Ligament Forcep*. 

it and the uterus, and yet suHicient tissue should be left between the 
ligature and uterus to prevent slipping of the latter. The ureter 
normally lies about one-half of fin inch from the uterus at this level; 
but this distance may be materially increased by traction on the 
uterus. The uterine artery on the opposite side is secured in the 
same way and the uterus cut away at or below the cervical junction 




Fig. 218. — Pi-an's Curved Broad Ligament Forceps. 

in such a manner as to leave an anterior and posterior flap. (Fig. 
224.) 

After removal of the uterus, the field should be carefully in- 
spected for bleeding points. If the principal vessels have been se- 
cured, there may be no bleeding of consequence. Next in order come 
the azygos vessels, and finally there may be troubleaome hemorrhage 
from the raw surface of the bladder or from branches coming up 




TREATMKNT OF FIBROID TUMORS OF THE UTEItUS. 



iJ-l.T 



along the side of the cervix. All bleeding nuiBt be stanched before 
the abdomen is closed. The source of liernorrhage is sometimes dif- 
licult to locate, but by a systematic search with sponge and forceps — 
pushing aside prolapsed tissues, lifting up and putting upon the 
stretch overhanging ledges, and keeping the field as dry as possible 
by the assiduous use of the sponge — one will seldom fail in locating 
the bleeding points. 

The anterior and posterior flaps of the cervix are next caught up 
in forceps, tlie cervical canal wiped with gauze, and the flaps united 



,^^^B^-^ 


^tfl\ 


-«4mBP 


VHr 


A^^^^^^^^^M^^^^^^^^^I 


i^H^^fil 


"^^2 




1 


V 



Fig. 21fl.^Abdoniinal Hygterectomy. (Second Step.) 

Tbe broad ligament bus bmn cut belweou ligature* anil daui|i> and Itiu blaUdw 
U about to ba dliaeoted trtim iba ccrriz. 



by three or four interrupted catgut sutures. The gap in the brond 
ligament is closed by a running catgut suture from one side of the 
pelvis to the other. (Fig. 22G.) In this way the stump is buried 
and becomes practically extraperitoneal. Sponges and pads are re- 
moved, the pelvis wiped dry, and the abdominal wall sutured. 

Some operators prefer to cut between clamps and ligate the 
vessels after the uterus is removed ; others prefer to isolate and ligate 
the vessels individually, rather than take them up en masse. Such 
matters are not of vital importance, and will be decided by each 
operator according to predilection. 



344 



PRACTICAL GYNECOLOGY. 



Kelly's Operation. — This (also called "hysterectomy by con- 
tinuous section from one side of the pelvis to the other") is per- 
foraied as follows: Commencing on one side of the ntcrus, the ovarian 
vessels and the round liguiueut are Lgatcd, the bladder stripped 



Fig. 220. — Sponge Holder. 

down, and the uterine artery ligated ; the uterus is then tilted to the 
opposite side and the cervix cut across until the uterine artery on 
the opposite side comes into view. This is damped and the incision 
carried upward and outward toward the pelvic wall, clamps being 



Fig. 221. — DcRohninp's Needle. 

placed on the ovarian artery before it is cut. (Fig. 227.) After the 
removal of the uterus the clamped vessels are ligatod and the subse- 
quent steps of the operation are as described in the preceding section. 
If the tumor encroaches on one side of the pelvis more than the other. 



Kg. 222.— Cleveland's Ligature Carrier. 

the operation should commence on the least affected side, or on the side 
offering the most room. This precaution is indispensable in dealing 
with the intraligamentous growth, and should never be disregarded. 
One very important advantage of the operation lies in the protec- 
tion of the ureter. The body of the uterus being tilted in the direc- 



TREATMENT OF FIBROID TUMORS OF THE UTERUS. 



345 



Hon opposite to that from which the incision is being earned, the 
cervix is sprung or pushed toward the knife and away from the ureter, 
which gives ample room for clamping or tying the artery without 
endangering the ureter. 

The objection has been urged that the operation is inherently 
faulty in that the uterine artery may be cut before being clamped, 
and, retracting, give rise to exhaustive or even fatal hemorrhage before 
it can be secured. The objection is not well founded. With ordinary 
skill and care such an accident is not likely to occur, as the situation 
of the vessel as it comes up alongside the uterus is well known, and 



m/. 



Fig. 223.— Abdominal Hystorectomy. (Third Step.) 

The bladder bo* beeu dl*s«cted down und u Ugatura U beiog ({ipllvd to Ui« 
right uterloe artery. 

careful division of the last fibers of the cervix brings the vessel into 
view. Even should the vessel not be seen, a clamp can be adjusted, 
as in vaginal hysterectomy, with positive assurance that the artery is 
secured, and the dissection carried boldly forward. 

While the Kelly operation is applicable to all forms of uterine 
fibroid, it is the operation ^ar excellence for the intraligamentous 
Tariety. Under the old regime the broad ligament waa split where 
it vaulted over the tumor, and by a process of bloody dissection from 
above downward the tumor was enucleated. By this method the dis- 
Bection was carried from the terminal, arborescent branches of the 



Mfi 



PRACTICAL GYNECOLOGY. 



veesels toward the main stem in the midst of unremitting and often- 
times most alarming hemorrhage, to wliich many patients succumbed 
before leaving the table. By the Kelly method tlie source of the 
blood-supply is controlled at the outset and the remainder of the 
dissection is comparatively bloodless. It has been found tliat the 



Fig. 224. — .Abdominal Hysterectomy. (Fourth Step.) 
AU tlgaUirtM tiiivliig Utvu aiipUed, tb« oerrlx in tMslug cut iuitia^ 

tumor is dislodged from its bed with much greater facility when 
approached from below. Finally, the ureter is seldom injured when 
the tumor is rolled out from below, whereas it is in constant jeopardy 
when the dissection is carried from above downward. The location 
of the ureter with reference to the intraligamentous fibroid is most 



Fig. 225.— Kelly's Hysterettoniy Spud. 

tmcertain. It may be in front, behind, over, under, or outside of 
the growth, and thus be cut or tied without the knowledge of the 
operator. When the tumor is rolled out from below these accidents 
may be avoided. When the intraligamentous growth dips down into 
the pelvis, forming an angle with the cervix, this angle is always 
occupied by the uterine artery, and never by the ureter. Hence, there 



TREATMENT OF FIBROID TUMORS OF THE UTERUS. 



347 



is no danger of including the ureter in the clamp or ligature with 
which the artery is secured. In some instances an intraligamentouB 
fibroid may be more easily removed by hemiscction of the uterus, the 
uterus being split in the median line antero-posteriorly and by cross- 
Bection at the cervical junction, reaching and securing the uterine 
arteries from the uterine side. (Fig. 288.) The median section is 
bloodless. 

Panhtsterectomy for Uterine FrBuoiD. — In case of a badly 
diecased cen'ix, cancerous degeneration of the same, or of a large 
cervical fibroid, it may be necessary to remove the uterus in toto. 
The steps of the abdominal operation are tlic same as those described 




Fig. 220. — .'Midoniinal ny<*terectoniy. (Fifth Step.) 
The ut«rus h«ving tieeu reuovod, Uie ccrvlK und lirnatl llgiiiueul are txiiug stitched. 



noder the head of "Supravaginal Hy.stere('t<nny" up to the point of 
cutting across the cervix. Some operntors prefer to complete tlie 
supravaginal amputation and then remove the cervix separately. This 
can be easily done, and is sometimes more convenient of execution 
than to remove the entire mass together, especially in the case of a 
bulky fibroid. Usually, however, it is better not to make two bites 
of a cherry, and the cervix and body are removed together. It matters 
little whether the vagina is entered from the front or back of the 
cervix, tiie only necessary precaution being not to perforate the blad- 
der, on the one hand, or the rectum, on the other. If both uterine 
arteries have been ligatcd, the cervix may be cut boldly away after 
stripping down the bladder and making the initial opening into the 



348 



PRACTICAL GYNECOLOGY. 



vagina. Reed leaves a shell of the cervix to avoid hemorrhage from 
the azygoB and other minor branches. 

In the intraligamentous growth, however, where the section has 
been carried down on one side of the utenis, including the ligation 
of the uterine artery on that side, the technique as devised by Prior 
is probably the most feasible. It is substantially as follows: A pair 
of sharp-pointed scissors, or, better still, the perforating forceps of 
the autlior is thrust through Douglas's pouch into the vagina (being 
careful to keep close to the cervix) and spread so as to enlarge the 
opening sufficiently to admit two fingers. Two fingers of the left 



Fig. 227. — .\l)(lominal Hysterootoiny. (Kelly's Method.) 
Tba toreep* u* thuwu gnuping Ibe right ulcrlns trtorj. 



hand are pushed through the opening into the vagina and honke<l 
over the cer\ix, to act as guides for entering the vagina in front. 
When the anterior opening has been made both openings are stretched 
by the fingers or forceps until they extend beyond the sides of the 
cervix. The side upon which the uterine artery has been ligated 
is now cut through, the uterus tilted and drawn up forcibly in the 
opposite direction, and the remaining uterine artery clamped from 
below upward. The narrow isthmus of tissue which holds the uterus 
is next cut through between the clamp and uterus and the organ 
removed. It is sometimes easier to clear the cervix from below. 



TRE.\TMENT OF FIBHOID TUMORS OF THE UTERUS. 



349 



03 in the first step of vaginal hysterectomy, before opening the ab- 
domen. When this is done strips of gauze should be pushed up into 
the peritoneal cavity as indicators, as it is not alwa)'s easy to find 
the openings from above. The uterus being removed, and after care- 
ful hemoetasis a loose gauze pack is introduce<I into the vagina from 
above downward (seeing that it extends upward through the newly 
made channel to a point flush with the peritoneum), over which tlie 
peritoneum is closed, the pelvic cavity is wiped dry and the abdom- 
inal wound sutured. 



Fig. 228. — Atxloiiiinal nystprpotomy. Ilcmiscction of the Uterus. 
Th« fiuvept are lUowo gnuplug Ibe right uterine ftrtorjr. 



Fibroid Polypi. — The only treatment for a polypus is extirpation. 
A small pedicle may sometimes be twisted off. As a rule, it is better 
to cut it away with knife or scissors and sear the stump, or take a 
few stitches in it if there be a disposition to hemorrhage. (Fig. 204.) 
When the polj-pus springs from the uterine cavity the hemorrhage 
following its removal may be controlled by packing. Often there is 
little or no bleeding. Large fibroid polypi may be cut away piecemeal 
until the pedicle can be reached and dealt with as indicated above. 
Owing to the associate purulent endometritis, curettage and packing 
should follow tlie removal of tlie polypus. 




Reference is here made to inflammation and tuberculosia. Aa the 
morbid proceeses of the tube are so intimatoly associated with and in- 
fluenced by its structure, a succinct review of its anatomy will pave 
the way to a more ready and perfect understanding of such processes. 



The Fallopian tubes spring from the uterine cornua, one on either 

■ide of the uterus, and are, on an average, about four inches in length. 

That portion of the tube nearest the uterus ia narrow, and is called 

the isthmus; the outfr portion is broad, and is knowD aa the ampulla. 

(360) 




LNFEtTlONS OF THS FALLOPIAN TUBES. 



351 



The lube consists of three coats, known, respectively, as tJie peritoneal, 
muscular, and mucous. The outer, or peritoneal, coat is a duplication 
of the broad ligament, which invests the tube in such a way as to cover 
two-thirds of its surface. The other one-third, having no peritoneal 
investment, is in direct relation with the cellular tissue of the broad 
hgament, and forms the upper boundary of the same. The middle, or 
muscular, coat is continuous with that of the uterus, and consists of 
unstriped muscle-fibers. It is disposed in two layers, the external 
of which is longitudinal and the internal circular. The internal, or 



^<&?>^ 









</a 



■r-l 



■•^^jp/ 



Fig. 230. — Transverse Section of Kullopian Tube. Normal. ' 
(Photomicrograph by Graiuin.) 

mucous, coat is continuous with the uterine mucosa, and, like it, is 
covered with ciliated columnar epithelium. It is highly probable that 
this membrane, like the uterine mucosa, contains lymphoid or gland- 
ular tissue, from the fact that adenomatous growths sometimes spring 
from it. 

The mucous membrane of the lube is thrown into plications, or 
folds, which are much more pronounced in the amplified portion of 
the tube than in the isthmus. At the outer extremity of the tube the 
mucous membrane projects as a fringed border. This is known as the 
fimbriated extremity. The peritoneal and muaculai coats terminate 




352 



PRACTICAL GYNECOLOOIt. 



abruptly in a circular, somewhat constricted, ring at the base of the 
fimbria. At either extremity of the tube is a constricted orifice, the 
inner of which communicates with the uterine and the outer with 
the peritoneal cavity. The first is called the ostium internum, and 
the second the ostium abdominale. The caliber of the tube increases 
from the uterine to the abdominal extremity. At the uterine ex- 
tremity it is very small, barely admitting a bristle. 

' The most important items in connection with the anatomy of the 
tube in relation to its pathology are the continuity of its lining with 
that of the uterine cavity; the relation of the uncovered portion of the 
tube to the cellular tissue of the broad ligament; and the outer opening 
of the tube, which communicates directly with the peritoneal cavity. 
The first provides for an extension of the inflammation, simple or 
infectious, by continuity from the endometrium to the mucous lining 
of the tube; the second by extension by contiguity from the tube to 
the cellular tissue of the broad ligumcnt; and the third for an escape 
of infectious matter from the tube into the peritoneal cavity. 

INFLAMMATION OF THE FALLOPIAN TUBES 
(SALPINGITIS). 

Inflammation of the Fallopian tubes is of exceeding frequency. 
It is the most common of all diseases to which these structures are 
liable. Because of its frequency, tenacity, and the serious changes, 
both structiiral and functional, which it entails, it is more productive 
of invalidism than any other of the diseases peculiar to the sex. 

Causes. — In the vast majority of cases the inflammations of the 
Fallopian tube come by way of the uterus. The continuity of struct- 
ure between the lining membrane of the uterus and tube provides 
an unobstructed thoroughfare by which the inflammation may travel 
unhindered. Tubal inflammations are, almost without exception, in- 
fectious in character and of microbic origin. While it is possibly true 
that a simple inflammation may result from direct injury, or from 
the congestion incident to suppressed menstruation, or may even be 
transmitted from the uterine cavity, such inflammations are so rare 
and usually so transitory as to be of little consequence. 

It has been the custom to classify the infectious inflammatory 
diseases of the Fallopian tubes into septic and specific, or gonorrheaL 
This classification, while possessing the merit of simplicity, is no 
longer tenable in the light of modern bacteriological research, aa 
sepsis is common to all forms. Furthermore, with increasing knowl- 



INFECnONS OF THE FALLOPIAN TUBES. 



353 



edge of the multiplicity of germs concerned in the morbid processes 
of the tubes, and their individual traits, it is not practicable at present 
to classify them in groups without imparting a warped conception of 
their distinctive attributes and pathogenic function. 

The germs principally concerned in the production of infectious 
inflammation of the Fallopian tubes are the streptococcus and gono- 
coccus. The gouococcus is the specific germ and essential cause of 
gonorrhea. A very large majority of the infectious inflammations of 
the tube are of gonorrheal origin. The streptococcus, or erysipelas 
germ, is very prevalent, and is the underlying cause of many infectious 
processes in man, and may be communicated to the genital tract by 
the fingers or instruments in making examinations or in perfonning 
operations. These facts, because of their groat practical importance, 
will be reiterated and emphasized throughout the consideration of this 
subject. We shall now proceed to a more detailed description of the 
modus operandi by which the individual germs affect the tubes. 

Stueitococcio Infection op the Fallopian TonES. — Strep- 
tococcic infection of the Fallopian tubes is usually the result of con- 
tamination from unclean fingers or instruments in conducting exam- 
inations or performing operations about the genital tract. The puer- 
peral state is peculiarly auspicious for the development of streptococcic 
infection; consequently it is found most frequently and in its most 
aggravated form in connection with abortion, miscarriage, or labor at 
term. The non-gravid uterus will stand, with comparative impunity, 
an amount of injury and exposure to this form of infection that would 
be disastrous in the gravid or recently delivered uterus. The same 
statement applies to other sections of the genital tract. The source 
of infection may be the uterine cavity (usually the site of placental 
implantation), a lacerated cervix, a lacerated perineum, or even an 
abrasion of the vagina or vulva. 

The route of the streptococcus, so far as can be determined by 
observation and deduction, is, for the most part, by way of the lym- 
phatics, and, in consequence, its manifestations are first and most 
notably found in the subepithelial and deeper layers of the distal por- 
tion of the tube, which are in the direct line of the lymphatics, and 
for the same reason the tubal infection is attended with more general 
and earlier involvement of the surrounding structures than in gonor- 
rheal infection. As the lesion from which the infection is spread is 
often situated on one side of the sagittal line entirely within the 
province of either the right or left lymphatic system, it follows that 
the tubal infection is as frequently unilateral. The route of the strep- 



352 



PRACTICAL GYNECOLOO'S. 



abmptly in a circular, somewhat constricted, ring at the base of the 
fimbria. At either extremity of the tube is a constricted orifice, the 
inner of which communicates with the uterine and the outer with 
the peritoneal cavity. The first is called the ostium internum, and 
the second the ostium abdominale. The caliber of the tube increases 
from the uterine to the abdominal extremity. At the uterine ex- 
tremity it is very small, barely admitting a bristle. 

* The most important items in connection with the anatomy of the 
tube in relation to its pathology are the continuity of its lining with 
that of the uterine cavity; the relation of the uncovered portion of the 
tube to the cellular tissue of the broad ligament; and the outer opening 
of the tube, which communicates directly with the peritoneal cavity. 
The first provides for an extension of the inflammation, simple or 
infectious, by continuity from the endometrium to the mucous lining 
of the tube; the second by extension by contiguity from the tube to 
the cellular tissue of the broad ligament; and the third for an escape 
of infectious matter from the tube into the peritoneal cavity. 

INFLAMMATION OF THE FALLOPIAN TUBES 
(SALPINGITIS). 

Inflammation of the Fallopian tubes is of exceeding frequency. 
It is the most common of all diseases to which these structures are 
liable. Because of its frequency, tenacity, and the serious changes, 
both structural and functional, which it entails, it is more productive 
of invalidism than any other of the diseases peculiar to the sex. 

Causes. — In the vast majority of cases the inflammations of the 
Fallopian tube come by way of the uterus. The continuity of struct- 
ure between the lining membrane of the uterus and tube provides 
an unobstructed thoroughfare by which the inflammation may travel 
unhindered. Tubal inflammations are, almost without cxce[)tion, in- 
fectious in character and of microbic origin. While it is possibly true 
that a simple inflammation may result from direct injury, or from 
the congestion incident to suppressed menstruation, or may even be 
transmitted from the uterine cavity, such inflammations are so rare 
and usually so transitory as to be of little consequence. 

It has been the custom to classify the infectious inflammatory 
diseases of the Fallopian tubes into septic and specific, or gonorrheal. 
This classification, while possessing the merit of simplicity, is no 
longer tenable in the light of modem bacteriological research, as 
sepsis is common to all forms. Furthermore, with increasing knowl- 



- ■ ■■ : ::v.* loun'iniil .• 
■ - • . .'. triiit!". il i ■ I • 
:. : ." ■ :« "■•.•::.>!it mipai' • • 

• . ■• .'it:'. jMilmi'i II • '. 
:. • • " • ...y I' nirriii'l .- • 

• • ':...'.• I'lan lul"- :i'- • 
_ ■ ■ ■■'.;? '.s t!ii' '•1 ' 

A •.• :. .••;!_'•• ii.;ij-.i.'. : 
• : .'• ;jir:.«-.il • ; .■ 
; •.•:.i'.' n:. ;i;.i - • 



■!• 



354 



PRACTICAL GYNECOUJGY. 



I 



tococcus, leading it in at the back door and up through the deeper 
structures of the tube, results in destructive lesions of the same before 
involvement of the epithelial dud surfaces of the mucosa. When, 
later, desquamation of the epithelium takes place, it is not in the form 
of individual cells, as iu the gonococcic infection, but is thrown off in 
floes, as the result of an undermining necrosis. 

Streptococcic infection of the Fallopian tube, as compared with 
that of the gonococcus, is characterized by greater celerity and in- 
tensity, more prolonged acuity, and broader dissemination. The 
invasion is rapid, and the symptoms, both local and general, pro- 
nounced from the outset. The attack is usually ushered by a chill or 
chilly sensations, and the temperature mounts to 100 to 105 degrees, M 
with a pulse-rale of from 100 to 140. The patient seldom leaves her " 
bed in less than three weeks, and may be confined for as many months. 
Quite early the effects of the disease on her general system are plainly 
manifest in the pallor, loss of flesh and strength, and general de- _ 
crepitude. Exceptionally, the disease pursues an unostentatious f 
course indistinguishnhle from that of some of the milder infections. 

Gonococcic Infection ok the Fallopian Tubes. — The pres-_ 
ence and position of the gonococcus in the Fallopian tubes are im-^ 
portant as indicating the character of the inflammation and its manner 
of extension. While it is a demonstrable fact that purulent inflamma- 
tion of the Fallopian tubes is due, in the majority of instances, to 
gonorrheal infection, yet the gonococcus can only be found in about 
20 per cent, of the cases. This does not indicate its absence as a 
primary and essential factor in the disease, but rather an extinction 
of germ-life under circumstances adverse to its life and propagation, fl 
It is a well-known fact that germs will perish in their own secretions " 
if pent up, and will starve to death on uncongenial soil if prevented 
from migrating. The gonococcus is short-lived and perishable, and 
must be fostered with care to insure perpetuation of the species, h 
There are certain localities in which it will live and thrive indefinitely, | 
such as the vulvo-vaginal glands and Skene's ducts, and it will hold 
with considerable tenacity to the urethra, cervical canal, or even the 
utricular depressions of the uterine cavity; but in the closed Fallopian 
tube it is usually short-lived. 

The habitat of the gonococcus in the tube is of no less interest 
as indicating the manner in which it excites inflammation, but also 
the probable route by which it finds entrance to the tube. Almost 
all observers agree that the germ is a surface rider, and has little or 
no disposition to ensconce itself beneath the surface of living tittuw. 



I 



I 




INFECTIONS OF THE FAU^OPIAN TUBES. 



355 



Further, that it finds its favorite abode in the slime or scum of sup- 
puration which covers the living tissues: in the leucocytes, detached 
epithelium, or unconfined. It is seldom found in the living epithelial 
cell in situ, nor yet in the leucocytes between them. 

The desquamation of epithelium in gonococcic infection is in 
the form of individual cells in contradistinction to that of streptococcic 
infection where it is shed in patches. Gonococcic invasion of the 
tube excites inflammatory reaction, not only in the mucosa with which 
the germ may be in contact, but also in the muscularis, and not in- 
frequently the peritoneal investment. This would lead to the in- 
ference that the inflammation was not so much due tn the contact 
with the germ itself, if at uU, as from toxins seoiitLd by the germ and 
which percolate through the tissues. 

Route of Invasion. — One fact well established and generally 
accepted is that tube infection by the gonococcus almost invariably 
proceeds from the uterine cavity. The other facts are generally con- 
ceded: 1. That the most common route of invasion of the Kallnpian 
tube by the gonorrheal germ is by continuity over the mucous mem- 
brane from the endometrium. 2. That the gonorrheal germ may 
follow the blood and lymph channels. Evidences of this fact ore 
numerous and incontestable. The micro-organism has been demon- 
strated in the blood, in the endocardium, and in the large serous 
cavities: the pleura, pericardium, and peritoneum. It has been found 
in the course of the lymphatics, and not infrequently gives rise to 
superficial or deep-seated inflammation of the IjTnphatic glands along 
the line traversed by the lymphatics which drain the genital organs. 
A. most familiar example of this is found in tlie gonorrheal bubo. 
Nevertheless, this method of infection of the tubes is of extreme rarity, 
and for all practical purposes may be ignored. Migration of the 
gonococcus through the tissues has not been proven, and is at such 
variance with its known habits as to excite the gravest doubts as to 
its feasibility. There remains then, practically, but one route of 
gonorrheal invasions of the Fallopian tubes, and that is by the way of 
the mucosa. 

MiscELLANBons Germs. — Bcsidcs the streptococcus and gono- 
coccus, a number of other germs are occasionally concerned in the 
production of salpingitis. Among these are the staphylococcus, 
bacillus coli communis, pneumococcus, and the tubercle bacillus. 
Staphylococcic infection of the tube, contrary to previouB belief, ia 
comparatively rare, and plays a very unimportant role in the inflam- 
matorj affections of the same. The bacillus coli communis is oc- 




356 



PRACTICAL GYNECOLOGY. 



casionally found, but always as the result of intestinal adhesion to the 
tube. It may be communicated from an adherent and diseased vermi- 
form appendix, with which tubal disease is not infrequently associated. 
This form of infection, when it occurs, is characterized by great 
violence and profound systemic disturbance. Fortunately for the 
patient, the pus formation, which is abundant and venomous, usually 
finds exit through the intestine. The pneumococcus is found so rarely 
88 to be more a matter of curiosity than of practical importance. The 
tubercle bacillus, on the contrary, is of such paramount importance aa 
to demand separate consideration. 



.^ T 



^^, 






*Oi 



IT--**-: 



fv: 



:V^ 



Fig. 231. — StApliylococcu* Pyogcnos. U'liotomicrograph by Grunm.) 



Other Cadses. — ^It is a fact well established that certain gen- 
eral infections, such as measles and scarlatina, may give rise to salpin- 
gitis. Such cases are seldom found in their active stage, and are 
recognized chiefly by their results. P^ortunately for the innocent ■ 
virgin, in whom such conditions are found, an explanation is offered 
by this mode of infection which does not impugn her chastity. The 
salpingitis so commonly associated with the uterine fibroid, and oc- 
casionally with other pelvic tumors, depends, in most instances, on 
germ infection, made possible by the diminished resistance of the 
involved structures to the ordinary sources of infection. 




INFECTIONS OF THE FALLOPIAN TUBES. 357 

Varieties. — Salpingitis occurs under two forms: catarrhal and 
interstitial, either of which may be acute or chronic. 

Catarbhal Salpingitis. — In catarrhal salpingitis the disease is 
limited to the mucous membrane of the tube. It is characterized by 
hyperemia and thickening of the membrane, increased secretion of 
mucosa, and probably by a slight degree of enlargement of the tube. 
There are no definite symptoms, and the condition generally goes 
nnreeognized. The disease usually terminates in resolution or, by 
extending to the deeper structures, merges into the second form. 

Interstitial Salpingitis. — When the deeper structures of the 
tube are involved in the inflammatory process, the condition is known 
as interstitial salpingitis. The inflammation may be confined to the 
mucous and muscular coats, or may involve the entire thickness of 
the tube, including the peritoneum. The structures become congested, 
infiltrated, and thickened, and the tube elongated, tortuous, and in- 
creased in diameter. The changes are more marked in the ampulla 
than in the isthmus; so that the tube becomes distinctly enlarged in 
its outer half. That portion of the tube attached to the mesosalpinx 
does not elongate in proportion to the rest of the tube, and produces 
an effect somewhat analogous to chordee in the male : that is, the tube 
is curled upon itself, which, in connection with the clubbed extremity, 
gives it a retort-like appearance. The ovary is usually embraced in the 
concavity of this curve. The isthmus, while it doos not participate in 
tlie enlargement to the extent of the ampulla, nf.verthflws bKt>iries in- 
filtrated and of cord-like density. Under tlit-se conditions the tube 
becomes friable and sometimes almost cheesy in conjiitt-nce. Section 
of the tube will disclose a swollen mucous membrane, bathed in pus 
or maco-pus, distorted plicae, exfoliation of epithelium, and thickened, 
degenerated walls, which under the lens are frequently found in- 
filtrated with pu£-corpuscles. 

The ulterior effect on the tubal structure will depend upon the 
virulence of the poison and the activity and porsisteree of the inflam- 
matory reaction. A mild poison with ir-cicrate inf.an.niiftion may 
leave the tube somewhat enlarged and infiltrated, but with the £ui>- 
sidence of the reaction the products ntay It absorbed, Icav.ng the 
tube little the worse for the ordeal. A^ain, rt?'!ut;cn n.av be iricom- 
plete and the tube left more or le-s? distcrtel ar.d czlvi/.-'i. A low 
grade of inflammation p*:r?iriis2 for E.-,r.tr.; or yc^ars may result in 
an overgrowth of coniiective tissue, with co::;ej-.;'::.t d-rstniction of 
the normal histoloaric elements, t:r.dtr •which the t':;'r/e wiil become 
converted into a dense, fibrotis structiire. This latter is frequently 



358 PRACTICAL OYNECOWXJY. 

spoken of as fibrous degeneration of the tube. More frequently the^ 
inflamniation is of a more active type, resulting in the formation of "^ 
pus, both in the canal and in the interstices of the tube-wall. 

In many instances before this stage is reached the infections 
matter will have found its way into the peritoneal cavity, either 
through the ostium abdominale or the walls of the tube. This will 
excite a localized peritonitis, with an exudation of plastic matter, 
which will usually result in sealing the point of leakage, or in walling 
ofT the peccant matter from the general peritoneal cavity. This 
eminently conservative process is the safeguard against general infec- 
tion. When the poison is of extreme virulence or escapes too freely, 
extensive or general peritonitis supervenes. Such a result is excep- 
tional save in the puerperal septic form. The plastic exudation may 
agglutinate the fimbriated extremity of the tube to the ovary, or any 
portion of the tube to the contiguous structures: the broad ligament, 
uterus, intestines, or bladder. Usually the inflamed and heavy tube 
sinks lower in the pelvis, either at the side or back of the uterus, and, 
through one of those remarkable conservations of Nature, wraps itself 
in the broad ligament, that it may not. be the source of more extended 
infection. 

More frequently the escape of septic matter into the peritoneal 
cavity is prevented by the closure of the ostium abdominale. This 
is effected by an elongation of the muscular and peritoneal coats, with 
a coincident curling inward of the fimbria and a closure of the circular 
orifice, which is finally sealed by a plastic exudation and adhesion of 
the peritoneal margins. This serves the purpose of retaining the 
secretions within the tubal canal. The uterine end of the tube usually 
also becomes sealed, or so diminished in caliber as to offer an impedi- 
ment to the passage of the fluid in that direction. In consequence 
the tube becomes distended with the secretion. This secretion may 
be purulent, bloody, or watery in character, constituting the three 
forms of retention cyst; known, respectively, as pyosalpinx, hemato- 
salpinx, and hydrosalpinx. 

Pyosalpinx. — This, as already indicated, is an accumulation of pus 
within the lumen of the tube. Such accumulations sometimes assume 
large proportions so that the tube may attain the size of the fetal 
head. As ordinarily found, the tube does not often exceed the size 
of a Bologna sausage. (Fig. 232.) The tubal walls are of unequal 
thickness and usually friable; so that care and do.xterity are necessary 
to prevent their rupture during the proooss of enucleation. They 
occasioually rupture spontaneously, with most disastrous results. Thi» 



INFECTIONS OF THE FALLOPIAN TUBES. 



359 



accident would be much more frequcut were the tube not walled in 
and protected by neighboring viscera, which are agglutinated to it by 
peritoneal exudation. 

The contents of the tube vary in virulence according to the stage 
of the inflammation. The nearer the onset of the inflammation, the 
more virulent the pus. Old accumulations of pus are apt to be sterile 
from the death and decadence of germs. Six weeks of uninterrupted 
quietude will usually suffice to render the contents of a pus-tube 
innocuous. This, however, does not apply to the streptococcus, as 
it is more tenacious of life, and may retain its virulence for a long 
period. A fresh invasion of germs may occur at any time, with the 
effect of restoring the virulence of the tubal contents. This is usually 
the result of injury or irritation: violence or excess. This renewed 




Fig. 232. — niluterni Pyo'<alpiiii. (A\ithoi"s Case. Drown from Photograph.) 



infection may come by way of the uterus or from an adherent bowel 
or bladder. 

Salpingitis associated with the formation of pus is very persistent, 
and will often continue during the active, sexual life of the woman. 
It remains as a smoldering fire, to be fanned into a blaze by accidi-nt, 
exposure, or over-indulgence. These relapses occur at longer or shorter 
intervals, but can be predicated in the average case with almost abso- 
lute certainty. After the menopause, with its coincident atrophy, 
ischemia, and enervation of the genital apparatus, the trouble ceases. 
It has been asserted that under favoring circumstances the pus may 
undergo fatty degeneration and absorption or be deposited on the sidea 
of the tube as inert and innocuous matter. 

Hydrosalpinx. — In hydrosalpinx the contents nf the tube are 
watery. They sometimes are variously tinted from the admixture of 



3(50 



PRACTICAL GYNECOLOGY. 



blood. The tube-wall is thin and transparent, and in old cases con- 
sists of little more than peritoneum and connective tissue. (Fig. 238.) 
The contents are bland and lui irritating and devoid of germs. Spon- 
taneous cure sometimes occurs from rupture and collapse of the tube, 
the contents being absorbed by the peritoneum. 

The pathogeny of hydrosalpinx is very imperfectly understood. 
By some it is regarded as representing the first or last stage of salpin- 
gitis. According to this view, it may occur as a serous effusion, the 
result of a mild salpingitis, or as the final stage of a pyosalpinx in 
which the pus has undergone caseous degeneration and absorption, or 
deposition, leaving the clarified contents of the tube as a limpid, 
watery fluid. Not infrequently evidences of such a change are found 
in caseous matter clinging to the sides or ensconced in the recesses 
of the tube. The fact of the ostium abduminale being occluded has 
been regarded as prima facie evidence of an infectious matter in the 
tube at an earlier period; so that the initial fluid must have contained 
germs. The addition of pyogenic germs to the fluid would convert the 
hydrosalpinx into a pyosalpinx. In the absence of such germs steril- 
ization evidently occurs. My own opinion is that the pathogenic germ 
of hydrosalpinx lias as yet been unditferentiatod. The distended tube 
of hydrosalpinx may contain a pint or more of fluid, but it seldom 
attains a size larger than a pear. 

Hemalosalpinx. — In hematosalpinx the contents of the tube con- 
sist of blood. Intratubal hemorrhage from a malignant growth or 
tubal pregnancy does not properly belong under this head. Hemato- 
salpinx may be produced by interference with the venous circulation 
of the tube, whereby the blood is dammed up and escapes by rupture 
of the vessels, as in torsion of the tube and venous thrombosis; by a 
reflux of blood from the uterus in genital atresia or as the result of 
spastic uterine contractions; by a vicarious tubal menstruation, and 
by traumatism. It is believed that in the majority of cases hemato- 
salpinx arises from an effusion of blood into a hydrosalpinx. The 
closure of the abdominal ostium in hcmatoBnlpinx has been variously 
ascribed to intratubal infection, peritubal infection, and the influence 
of extravasated sterile blood. 

Pathology. — The lesions resulting from salpingitis are numerous 
and varied, and de]>i'nd upon the character and virulence of the infec- 
tion and the intensity and duration of the inflammation. In the 
absence or paucity of pus-forming germs there may be little or no 
suppuration, and yet the infectious matter may be sufficiently irritat- 
ing to produce marked changes in the tube and its environments. 



INFECTIONS OF THE FALLOPIAN TUBES. 



3r>i 



ThuB, the tube may be enlarged, infiltrated, and distorted without 
the presence of pus. Sliould any of this fluid escape into the peritoneal 
cavity, a localized peritonitis, with or without adhesions, will result. 
A lingering uon-purulent inflammation of the tube occasionally results 
in an overgrowth of the connective tissue, which, as it contracts and 
hardens, reduces the tube to a hard, fibrous cord. In the intenser 
forms of infection incident to the puerperal state the poison sweeps 
through the system with the fury of a tornado, leaving few scars and 
oftentimes no pus to mark its deadly course. It is neither rational 
nor safe, therefore, to gauge the virulence of an uifectious fluid by 
the amount of pus which it contains. Nevertheless, in most instances, 
the more virulent infections of tlie tube are attended by the formation 
of pus, which infiltrates its walls, slimes the mucosa, or, if the tube 
is sealed, accumulates within and distends it. 

The escape of infectious matter from the tube into the peritoneal 
cavity, either through the ostium or the waiis of the tube, is the 
signal for a battle. Myriads of cells are marshaled to the spot to 
oppose the invaders, and the field is bestrewn with the dead on both 
sides. Coincidently with the marshaling of the phagocytes an at- 
tempt is made to fortify against the invader by constructing a wall of 
defense between the avenue of entrance and the general peritoneal 
cavity. For this purpose an exudation of plastic matter is thrown 
out which comjiletely surrounds the germ-infested district, and shuts 
it off. In building this wall every organ and structure within reach is 
utilized: intestine, omentum, broad ligament, uterus, bladder, and 
abdominal wall, separately or collectively, as the case may be. These 
jre cemented and covered by plastic matter so as to present an im- 
passable barrier. 

This, then, is the explanation of the adhesions so frequently 
found in connection with and following an attack of salpingitis. It is 
eminently a conservative process, but, as will appear later, is not an 
unalloyed benefit. In this environment the ovaries and tubes are 
oftentimes completely enveloped. In professional parlance they are 
"snowed under," and cannot be outlined. The exudation with the 
agglutinated structures will sometimes form a mass which fills the 
pelvis and extends well up into the abdomen. The untrained are very 
apt to be deceived as to the size of the appendages in such cases, con- 
ceiving them to be miich more bulky than they really are. After 
entering the abdomfn and separating the adhesions, he finds, to his 
surprise, that they only form the nucleus of the mass which he had 
mapped out by bimanual examination. 



3fi2 



PRACTICAL OYNECOLOOT. 



The plastic matter thrown out to protect the general peritoneftl 
cavity may undergo one of three changes, and it is upon the character 
of the changes that the future welfare of the patient depends. 

1. It may be absorbed, leaving the tube free. 

2. It may melt down into pus, leading to distressing sequels. 

3. It may organize, whereby it becomes endowed with a vitality 
which assures its permanency. 

The adliesions are not always effective. Before the intensely 
virulent germ they melt away and cease to olfer successful resistance. 
As a rule, they serve the purpose for which they were intended, and 
confine the infectious matter within safe limits. 

The adhesions vary in character and arrangement. The recent 
adhesion is soft and rrcamy, hut in time becomes firm and resistaaL 



Fig. 233. — Tubo-ovarian Abscess. (Author's Case. Drawn from Specimen.) 



It sometimes forms a layer between two broad, contiguous surfaces 
like two pieces of buttered bread applied face to face. These are 
spoken of as bread-and-butter adhesions. A thin, gauze veil falling 
over the organs is called spider-web adhesions. Sometimes the ad- 
hesions are disposed in the form of bridles or bands between more or 
less widely separated structures. Very dense adhesions are spoken ol 
as fibrous, or leathery. 

Adhesions to the tube not only bind it down, but sometimes 
produce sharp flexures, which diminish or even obliterate its canal. 
The bowel may likewise be angulated so as to greatly embarrass its 
vermicular motion and impede the passage of its contents. Cases of 
obstruction are not rare from this cause. Other viscera may be inter- 
fered with. The erectile tissue, such as abounds in the genital ap- 



I 
I 




INFECTIONS OF THE FALLOPIAN TUBES. 



363 



paratus, may suffer from the enforced restraint imposed by the ad- 
hesions. This applies with special force to the uterus and tubes during 
Ihe menstrual molimen and under sexual excitement. One form of 
dysmenorrhea — the so-called tubal — is largely due to the fixation and 
compression of the tube under congestion. Ureteral obstruction and 
irritability of the rectum and bladder are often due to the some cause. 

The plastic matter forming the adhesions sometimes becomes 
infected and breaks down into pus. The pus usually forms in little 
pockets along the course of the tube or in the vicinity of the tubal 
orifice, and constitutes what is known as multiple pelvic abscess. 
Leakage of infectious matter through the walls or from the orifice 
of the tube is the exciting cause. An ovary may be agglutinated to 
the tube, either at its fimbriated extremity or by contact with its wall. 
In case of pyosalpinx infection may be communicated to the ovary, 
leading to the formation of an abscess in its substance. Such an 
abscess communicating with a tubal abscess through an opening be- 
tween them constitutes tubo-ovarian abscess. (Fig. 233.) It is prob- 
able that in many instances a burst Graafian follicle is the avenue by 
which infection takes place. Occasionally, though not with the fre- 
quency one might expect, the cellular tissue of the broad ligament 
becomes infected through that portion of the tube which is in contact 
with it and whicli has no investment of peritoneum. This gives rise 
to cellulitis, and may end in pelvic abscess. As will be seen later, 
cellulitis is usually the result of streptococcic infection through the 
lymphatics coming from the uterus or lower genital tract. 

Effects on Function. — The chief function of the Fallopian tube 
is to conduct the ovule from the ovary to the uterine cavity. The 
essentials for the proper performance of this function are flexibility 
of the tube, perviousness of the canal, and an unbroken line of ciliated 
epithelium to waft the ovule on its way. As has boon seen, one of 
the results of salpingitis is the destruction of the ciliated epitlielium 
in its entirety or in patches. Another is thickening and rigidity of 
tlie tube, and still another the angulation or bending of the same 
whereby its caliber is reduced or obliterated at one or more points. 
The result is that the ovule is arrested in its passage, or makes a 
difficult and halting journey toward the uterine cavity, which, if it 
succeed in reaching, does so in an enfeebled and decrepit condition 
incapable of fecundation. The natural result is sterility. Should 
the spermatozoa find their way into the tube and find the ovule 
blockaded, and fertilization ensue, a tragical event will have occurred, 
for the result will be tubal gestation. 




CHAPTER XXX. 

SALPINQITIS: SYMPTOMS, DIAQNOSIS, AND MEDICAL 
TREATMENT. 

Symptoms. — The symptoms of salpingitis depend upon the stage 
of the disease, its intensity, and tlie anatomic parts involved. It 
should not be forgotten that an inflammation of the Fallopian tube 
is seldom confined to the tube alone, but is constantly associated with 
endometritis and very frequently with ovaritis, localized peritonitis, 
and occasionally with pelvic cellulitis. None of these has symptoms 
so distinctive as to be regarded as pathognomonic, nor is it possible 
to eliminate the symptoms belonging to any one of them from the 
complex as usually found. The chief symptoms are pain, hemor- 
rhage, and discharge, with now and then an increase of pulse and 
temperature. 

The pain varies in character and in intensity, both in different 
individuals and in the same individual at different times. Some 
women pass through the entire cycle of pathologic changes due to 
tubal inflammation, even to the point of complete destruction of the 
tubes, without at any time experiencing a degree of suffering to send 
them to bed. Others — and these constitute the great majority — ^will 
suffer almost continuously from the pain and discomfort attending 
the inflammatory process. The pain varies in character. It is at 
times dull and heavy, at others sharp and lancinating. This latter 
is usually regarded as of peritoneal origin, and denotes a localized 
peritonitis. In most instances the pain is paroxysmal, with remis- 
sions or intermissions in which the patient is comparatively easy. 
The paroxysms may amount to agony uncontrollable by the ordinary 
methods of medication. The pain is usually referred to the region 
of the ovaries, whence it radiates throughout the pelvis and down the 
anterior aspect of the thighs. 

Even in the absence of notable pain, and conspicuously so in its 
presence, tenderness over the site of the tubes may be elicited by 
pressure or succussion. The suffering is intensified by the erect post- 
ure, by bodily movements, and by the congestions incident to men- 
struation and sexual excitement. Walking and riding are decidedly 



SALPINGITIS— MEDICAL TREATMENT. 



365 



uncomfortable, and in aggravated cases unbearable. The woman 
stiinds and walks with the body inclined forward; her movements 
are deliberate and cautious ; in rising or sitting she eases herself into 
position by the aid of her hands; and in riding sustains herself with 
hands upon the seat, to deaden the effect of jars. Distension of the 
bowels and bladder are painful, and efforts at evacuation more so. 
The bowels become torpid and the bladder irritable; hence constipa- 
tion and frequent urination often go hand in hand. Sexual inter- 
course is painful and oftentimes unbearable. A peculiar form of 
dysmenorrhea occasionally attends such cases. It is due to the in- 
gestion and swelling of the bound-down tubes and ovaries incident 
to the menstrual effort. The pain, which may be agonizing, begins 
from several days to a week before the flow, ajid continues tliroughout 
the period. The pain is referred to the region of the ovaries, which 
distinguishes it from the purely uterine dysmenorrhea, which is 
located nearer the median line and seldom precedes the flow by more 
than a few hours. 

Hemorrhage. — In most instances an increased frequency and 
duration of menstruation accompany the severer forms of salpingitis, 
especially marked in the stages of exacerbation. Exceptionally, and 
for no apparent reason, menstruation is diminished or suppressed. 
Tliis ktter is very apt to occur in the salitiugitis of tuberculosis, and 
should arouse suspicion. 

Discharges. — The discharges are in no way characteristic, and 
are significant only in so far as to indicate a pelvic lesion, which in 
conjunction with other signs and symptoms helps to round up the 
symptomatology and confirm the diagnosis. 

Pulse and Temperature. — At the onset of an acute interstitial 
salpingitis, and with each exacerbation, the pulse is accelerated and 
the temperature increased. But the febrile excitement is not of long 
duration, nor, as a rule, is it marked. It is questionable whether an 
infection confined to the tube is capable of producing a febrile reac- 
tion. The chances are that in tfiose cases in which it occurs there 
has been an escape or absorption of si-ptic matter from the tube. 
With the formation of pus, especially if it occur in the lymph-beds 
surroujiding the tubes, there may he a more or less persistent eleva- 
tion of temperature, with or witiiout an increased pulse-rale. Such 
cases will also be attended by the other evidences of mild septic 
infection. 

A very characteristic feature of tubal infection is the occurrence of 
exacerbations at irregular intervals. Between them the woman may 




366 PRACTICAL GYNECOLOGY. 

be comparatively free from symptoms, or even imagine herself cured ; 
but, if pus be present in or about the tube, it is a smoldering fire, to 
be fanned into a blaze by accident or indiscretion. Most of these 
exacerbations are due to leakage of pus from the tube or its environ- 
ment, less frequently from a reinfection. At such times all the symp- 
toms are intensified, and the woman takes to her bed. Pelvic peri- 
tonitis may ensue. This is signalized by an abrupt elevation of the 
pulse and temperature, usually preceded by a chill. The pain is 
increased, and is continuous, with paroxysms of great intensity. The 
abdomen is distended, tympanitic, and exquisitely tender. The ab- 
dominal walls are rigid, the bowels constipated, and the patient is 
harassed with frequent, painful, gaseous eructations from the stomach.' 
The facial expression denotes suffering. She lies on her back, with 
her legs drawn up to relax the abdominal muscles and diminish the 
intra-abdominal pressure. 

The Sepsis Resulting from Pelvic Infection. — In suppurating 
cases some women lapse into a condition of serious invalidism, which 
comes, in great measure, from septic infection from the pelvic pus- 
depots. Sepsis of a more or less severe type is so constant a factor 
in the systemic disturbances arising from the pelvic infectious dis- 
eases, and is so habitually unrecognized as such, that a few words 
with reference to its less pronounced forms will not be inappropriate. 
It should be borne in mind that sepsis does not emanate alone from 
pus formation, but may arise from any germ-laden fluid or germ- 
infested tissue. 

While violent, general septic infection is easy of recognition, 
the usual conception of the more common and milder forms is hazy 
and ill defined. It may be laid down as a rule to which there are 
few exceptions that systemic phenomena attending pelvic disease is 
of septic origin. There are no pathognomonic symptoms which can 
be attributed to either of these, and yet, if one or two essential points 
be borne in mind, misinterpretation of mild sepsis will but seldom 
occur. 

As an illustration of one of the most common of the pelvic dis- 
orders we shall take a case of pyosalpinx. A sterile pyosalpinx givea 
rise to no systemic disturbance, but a pyosalpinx in its active stage, 
where the germs are abundant and vigorous, produces systemic phe- 
nomena of a violent or subdued type, according to the amount of 
general infection. The toxins are absorbed and distributed, and the 
effect is manifested in the morbid reaction which follows through- 
out the body. 



SALPINGITIS— MEDICAL TREATMENT. 



S67 



The most constant and essential feature of the less deadly forms 
of sepsis is fever. This is of greater or less intensity, and is usually 
ushered in by a chill or chilly sensations. The general effect of tl>e 
poison in the system is to produce a depression of all the vital ener- 
gies. The woman feels weak and indisposed, if not positively ill. 
The appetite and digestion are impaired, and there may be vomiting 
and diarrhea. The impress on tlie nervous system is manifested by 
nervousness, wakefulness, and depression of spirits, or occasionally 
by mental hebetude and somnolence. The ulterior effects are pallor, 
emaciation, and debility. In very mild or evanescent forms a slight 
elevation of temperature, often so slight as to be unsuspected unless 
measured, and an almost inappreciable weakness and malaise, may 
be the only indications of infection. 

Physical Sigm. — In the initial stage of an acute attack it is 
seldom that a satisfactory examination can be made, owing to the 
exquisite tenderness of the parts. Moreover, at this stage the tubes 
are soft, pliable, and mobile, and elude the touch. About all that 
can be determined is an indefinite fullness in the locality of the tubes, 
which, taken in connection with the pain and tenderness, is very 
significant Later, after the subsidence of the acute symptoms, the 
tubes may be distinguished as elongated, tortuous, indurated masses, 
pendent or extending outward from the uterine cornua. Tlieir position 
varies, as also their contour. Tliey are almost invariably sunken in the 
pelvis by reason of their increased weight. They are quite frequently 
found deep down in the pelvis at the sides, or back of the uterus. 
Occasionally they are found resting on the bladder, or on the anterior 
surface or fundus of tlie uterus, when that organ is retroverted. 
Whether extended or coiled or bound to tlio uterus, careful bimanual 
examination will usually determine their attachment to the uterine 
cornua by tracing the cord-like isthmus from tumor to uterus or 
vice versa. 

Bimanual examination is much more satisfactory in women with 
thin and flaccid abdominal walls, but even in thick-walled women the 
finger in the vagina, with counter-pressure from above, can usually 
trace and putline the tube from the vaginal side. When there is 
much exudation, with adhesions to the surrounding structures, a con- 
glomerate and indefinite mass will occupy tlie position of the tube. 
Under such circumstances the tube can neither be palpated nor out- 
lined. Hydrosalpinx and hematosalpinx present to the finger as soft, 
thin-wallcd cysts occupying the popitiou of the tube, and usually 
preserving the elongated outlines of the moderately distended tube. 




3G8 



rnACTICAL GYNECOLOGY. 



In many of these conditions rectal examination will be of the greatest 
assistance in determining the situation, character, and extent of the 
pelvic lesion. 

Diagnosis. — In forming a diagnosis the history, symptoms, and 
physical signs should ail be token into consideration. In a case of 
recent origin, the history of a suspicious intercourse, miscarriage, or 
labor at terra, or, in lieu of wliich, evidence of an existing gonorrhea, 
or of recent delivery coupled with pelvic pain and tenderness in the 
region of the ovaries, and a well- or ill- defined fullness at the side 



I'^^l/J 



a 



'(* 



^ 



Fig. 234.— Enlarged Tube and Ovary Simulating 
Retroversion of the Utcrua. 



or back of the uterus, are almost sufTicicnt to justify the diagnosis of 
tubal infection. Later in t!ie disease, when the tubes have become 
thickened and hardened and the tenderness abated, there will usually 
be little difficulty in outlining the tubes. They will often be felt as 
elongnted, tortuous bodies extending from the uterine cornua across 
the pelvis, or as coiled masses at the side of or behind the uterus. 
Occasionally they will be curled up on the fundus or nestled in the 
vesico-uterine space. When the tubes are rolled up and glued to the 
posterior aspect of the uterus, the resemblance to a retroflexion is 



SALPINGITIS— MEDICAL TREATMENT. 



369 



sometimes very piizzling. (Fig. 234.) The pain, tenderness, and 
other evidences of pelvic inflammation should here put one on guard. 
A careful rectal examination will usually locate the fundus in its 
proper relation and in most instances there will be found a well- 
defined sulcus between the uterus and the attached mass, or at least 
a broken line or absence of continuity, such as would exist if the 
organ were bent upon itself. If doubt still exists, the gentle intro- 
duction of the uterine sound will reveal the position of the uterus and 
its relation to the mass. In long-standing cases, in which nothing 
remains but the atrophied tube invested with its fibrous adhesions, 
about all that can be made out will be a cord-like process occupying 
the position of the tube and an indefinable sense of crumpling and 
contraction of the peritoneal pouch. 

Hydrosalpinx and Hematosalpinx are soft, thin walled, and 
fluctuating, and are usually unilateral. Tliey are not, as a rule, 
tender, and if not overdistendod are elongatud and present indenta- 
tions on the surface corresponding to the furrows of the normal tube. 
They are indistinguishable one from the other, and usually difficult 
to distinguish from other small pelvic cysts. This difficulty is in- 
creased when the tube becomes spherical from overdistension and 
Vhen it is adherent. It may be mistaken for an ovarian, parovarian, 
or broad ligament cyst, or even an ectopic pregnancy. The attach- 
ment of the tube to the uterus, when it can be made out, together 
with its size and shape, will serve to distinguish it from either of the 
above-named cysts. Also, if the normal ovary can be made out on 
that side, ovarian cystoma can be excluded. Ectopic gestation would 
be excluded by the absence of its characteristic symptoms and signs. 
Further than this it is impossible to go, and the fact remains that 
hydrosalpinx and hematosalpinx are more frequently undifferentiated 
than otherwise. 

Pyosalpinx is always adherent and usually imbedded in lymph. 
It is quite often agglutinated to the contiguous structures. If it 
stands alone it may be definitely outlined as a thick-walled, boggy, 
tender mass. In shape and size it often bears a close resemblance 
to a sweet-potato. It is seldom that distinct fluctuations can be 
elicited. Quite frequently it is associated with ovarian abscess. It 
is to be differentiated from ectopic gestation, suppurating pelvic cysts, 
and pelvic abscess. 

The physical characters of pyosalpinx and ectopic gestation, as 
elicited by examination, are almost identical, and one is frequently 
mistaken for the other. The indications of pregnancy, the rapid and 




370 PRACTICAL GYNECOLOGY. 

continued development, the fainting spells, and shredded, bloody 
discharges from the uterus would point to ectopic gestation, while 
the absence of these and the presence of fever from absorption of 
septic matter, together with the clinical history of the case, including 
the acute and exacerbation stages, would point to pyosalpinx. 

Suppurating pelvic cysts of various kinds may be confoimdcd 
with pyosalpinx, but the size, shape, and thinness of the walls of 
the cyst as compared with the pyosalpinx will usually suffice to distin- 
guish them. As between pyosalpinx and pelvic abscess, the latter 
forms in the midst of infiltrations and lymph-beds, and, therefore, 
seldom has a definite body with definite shape. 

Prognosis. — The prognosis as to life is not bad. In an extended 
experience embracing a period of many years I have known of but 
one death from direct extension of gonorrheal infection through the 
tubes into the peritoneal cavity. Streptococcic infection is much 
more dangerous to life, and yet the cases are comparatively few in 
which tubal infection even of this character terminates in death. 
Numerous cases occur in which the poison is distributed from focused 
points in or about the tube as the result of violence. Traction on the 
cervix, as in the minor operations of curettage and trachelorrhaphy, 
or even manipulation, as in massage or manual examination, have 
resulted in rupture of the sac and distribution of infection, and women 
have thus lost their lives who would have never succumbed to the 
disease had not Nature's barriers to further infection been rudely 
demolished by the hand that was intended to heal. No minor opera- 
tions should be attempted on the uterus, no traction made on the 
cervix, nor rude efforts at palpation of the pelvic viscera indulged in 
in the presence of pus or other infectious fluids, or even when such 
are suspected. The aggravation of sjonptoms following these attempts 
is usually ascribed to irritation, but is, in fact, due to the escape of 
septic matter. The lives of professional prostitutes furnish cor- 
roborative evidence of the non-fatality of the purulent salpingitis if 
let alone. These women, as a class, are unalterably opposed to the 
unsexing operation for commercial reasons, and yet, despite the fact 
that their lives are one continual ro»md of dissipation in utter dis- 
regard of all rules of life and health, few succumb to the disease. 
Many cases of the milder forms of salpingitis undergo perfect reso- 
lution. Others leave the tubes more or less crippled, and, last, the 
tubes may be so disorganized, bound down by adhesions, and pus- 
ridden as to entail more or less continual suftering and permanent 
invalidism. 



SALPINGITIS— MEDICAL TREATMENT. 



371 



Treatment. — The treatment of salpingitis is medicinal, electrical, 
and operative. In the acute stage, as also in the initial stage of the 
subacute form, the object would be to control inflammation, limit 
exudation, and prevent the distribution of infectious matter. This, 
in a very large proportion of cases, may be effected by rest and regu- 
lation of the bowels. The good that may be accomplished by prompt 
and scrupulous attention to these simple measures is incalculable. 
The disease will be limited in scope and intensity. As a result, the 
ravages of the disease amid the pelvic viscera will be greatly curtailed 
and structural clianges in the tube itself reduced to the minimum. 
To be sure, there will be instances in which, despite of all, the infec- 
tion will proceed xmchecked: cases in which it will sweep unhindered 
through the tubes into the open expanse of the pelvis, over which it 
will spread like a consuming fire, but such instances are few as com- 
pared with tlie number in whicli timely and judicious management 
will avert the worst phases of tubal infection. 

Fulminant attacks occur infrequently except in the puerperium, 
and it is seldom that any other will not yield to proper treatment so 
far as to tide over the acute stage. Many cases will recover entirely 
under tins regime, while others will be so much improved as to render 
operative interference unnecessary. Where the disease has made such 
ravages as to necessitate operative interference, the time gained by 
the preliminary treatment will be invaluable to both patient and 
surgeon, aa during such time germ-life will have become extinct, or 
enfeebled to such an extent as greatly to diminish the dangers of the 
operation. The principal bar to the accomplishment of the maximum 
of good in these cases lies in the fact that the physician is not called 
soon enough. 

Promptly, at the first signal of trouble, the patient should be 
placed in bed and at rest. The rest should be absolute, and, if pos- 
sible, every convenience contributing to that end should be provided. 
The patient should be unclad, placed in a comfortable bed with com- 
fortable surroundings, and left undisturbed in the care of a com- 
petent nurse. After this the bowels should be cleared, preceded, if 
need be, by enemata to unload the rectum. For moving the bowels 
some form of saline is preferable, as by its use several indications are 
met. The bowels are unloaded and large quantities of fluid drawn 
from the tissues whereby the pelvic circulation is relieved, the pelvic 
tissues depleted, absorption stimulated, secretions unlocked, and in- 
directly exudation modified. Epsom, Rochelle, or Crab Orchard salts, 
given in broken doses of from 3ss-j hourly until five or six doses are 




372 PRACTICAL GYNECOLOGY. 

taken, will usually result in frequent and copious evacuations. This 
will be followed by a relief of suffering. After the first thorough 
cleansing of the alimentary canal, the bowels should be kept soluble 
without active purgation. Any mild laxative that is found most 
agreeable to the patient may be used for this purpose. The exhibition 
of the laxative should be timed so as not to interfere with the patient's 
rest at night, those of slow action being given at bed-time and the 
more active ones in the morning. The list may contain any of the 
salines mentioned above, the compound licorice powder, cascara 
sagrada; the aloin, strychnine, and belladonna pill; or any other 
drug or preparation that the patient may have found to be gentle and 
effective. 

The food at this stage should be somewhat restricted in quantity 
and bland in quality. It would better be liquid, and in the form of 
strained soups, broths, and gruels. Occasionally one of the proprietary 
food preparations not too rich in the albuminoids, predigested or 




Fig. 235. — Improved Bed-pan. 

malted, will be found to answer the purpose admirably. Vaginal 
discharges — either acrid, foul-smelling, or abundant — should be 
washed away by vaginal douche. The patient should be kept as quiet 
as is compatible with her comfort, and should not be allowed to get 
upon her feet, or even out of bed to attend the calls of Nature, re- 
course being had to the bed-pan. That she is not seriously sick ren- 
ders these precautionary measures none the less imperative, as thereby 
serious sickness and possibly irreparable damage may be averted. 
The intelligent physician alone may estimate the value of his services 
in warding off more serious complications, for neither the patient not 
her friends can be made to understand the situation. Nevertheless, 
no pains should be spared to impress upon them the gravity of the 
situation, nor in securing their full and free co-operation in carrying 
out the details of treatment. 

Drugs for the relief of pain and producing sleep should be 
avoided so long as there is no urgent demand for them. Opiates are 



SALPINGITIS— MEDICAL TREATMENT. 



373 



especially harmful by locking iip the secretions and inducing con- 
stipation. Nevertheless, there are cases which, from their intensity 
and persistence, demand such roitialiea. Phonacetin, codeine, or 
morphine may be tried in the order named. The morphine is better 
given hypodermically, as exhibited in this manner it disturbs tlie 
stomach less and is less constipating. Small doses at long intervals 
will usually suffice. Trional and sulphonal may sometimes be used 
to advantage for quieting nervousness and inducing sleep. Counter- 
irritanta and derivatives applied to the cutaneous surface of the 
hypogastrium are sometimes used with apparent benefit. These con- 
sist of embrocations, hot-water bags, and blisters. Stupes and fo- 
mentations, while soothing, require unremitting care on the part of 
the attendant, and are, therefore, not ahvaj-s eligible. Poultices and 
the greasy preparations, such as lard and turpentine, so popular with 
the laity, are filthy and germ-breeders, and should be eschewed save 
under very exceptional circumstances. The hot-water bag is not open 
to these objections. Blisters to the hypogastrium frequently give 
much relief, but leave a raw surface, which interferes with examina- 
tion and might prove a serious obstacle to operative interference ; but 
the application of the adhesive rubber dam to the surface would, in 
large measure, ob\nate any evil results from this cause. A hygro- 
scopic earthy preparation, such as is sold under the name of "anti- 
phlogistine," may be advantageously substituted for some of the 
above-mentioned applications. These external applications, while of 
limited value, serve to reassure and satisfy the patient, and relieve 
the tedium of confinement by impressing her with the belief that 
everything possible is being done for her. 

Later, when the more acute manifestations of the disease have 
subsided and there is less danger of disturbing the relations of tlie 
tube, the systematic use of vaginal douches may prove of great benefit 
by driving the blood from the pelvis and stimulating absorption of 
the inflammatory products. For this purpose they should be hot, 
copious, and prolonged, and should be administered with careful 
regard to certain details, which are essential to their efficiency. The 
primary effect of heat on the tissues is to increase the volume of 
blood ; the secondary effect, to drive it out by diminishing the caliber 
of the vessels. The blanched and shriveled hands of the washer- 
woman after long immersion in hot water furnish familiar evidence 
of this fact. The water, therefore, should be as hot as can be borne 
with comfort, and its contact with the tissues maintained for a con- 
siderable lengtli of time. A temperature of 110 degrees has been 



374 PRACTICAL GYNECOLOGY. 

found best ; a gallon of water, about the proper quantity ; and fifteen 
minutes, about the length of time the douche should be oontinued. 
This is all accomplished by placing the patient on her back with a 
douche-pan under her, and hanging the reservoir of the syringe at 
an elevation not to exceed two or three feet above the level of the 
body. The water flows into the vagina gradually, distends and 
balloons it, and escapes at the vulva. The inflow and outflow are 
so timed that without an undue waste of water the temperature is 
maintained at the maximum, and this, with the quantity in the 
reservoir, can be kept up from fifteen to twenty minutes. Meantime 
the effect of the sustained heat on the pelvic circulation is most bene- 
ficial, in that it drives the blood from the pelvis, constringea the 
vessels, abates inflammation, and conduces to absorption of exuda- 
tion. This may be repeated from one to three times a day according 
to the exigencies of the case. The nozzle of the syringe should not 
be of metal or of any heat-conducting material, lest the patient be 
seriously inconvenienced by its contact with the vulva. Vulcanized 
rubber is best for the purpose. 

To promote the absorption of exudates and restore the pelvic 
circulation to its normal equilibrium, local treatment will frequently 
prove of great benefit. It should not be resorted to until the acute 
stage has passed and the inflammatory process has assumed a low 
grade. This will be indicated by the subsidence of pain, tenderness, 
and fever. The vault of the vagina, including the cervix, may be 
painted once a week with tincture of iodine and a tamponade of 
lamb's wool or cotton saturated with boroglycerid placed in the 
vagina. The tampon should be removed at the expiration of twenty- 
four hours and replaced every alternate or third day. Hot vaginal 
douches should follow the withdrawal of the tampon, and repeated 
as often as may be deemed necessary. If the cervix be swollen and 
turgid, the occasional abstraction of a few ounces of blood from it 
by deep puncture will be of benefit. This will seldom be required 
oftener than once a week or once in two weeks, nor should it be 
repeated too often. A gentle douche of warm water will encourage 
the bleeding, which is apt to be scant. A 10-per-cent. solution of 
ichthyol in glycerin, applied on a tampon to the vaginal vault, is of 
apparent utility in promoting the softening and absorption of exu- 
dates. As a sorbefacient it stands easily first in professional favor. 
Fresh air, judicious exercise, proper diet, and regular habits are all 
important factors in the treatment. In the absence of pus massage 
is of undoubted efficacy in promoting absorption and liberating ad- 



SALPmornS— MEDICAL TREATMENT. 375 

hesions. But before this is resorted to the absence of pus in the 
pelvis should be accurately determined, lest serious damage ensue. 
The liberation of sterile pus would, of course, be much less harmful 
than that of recent infection. As one can never be quite sure that 
pus does not exist, especially in connection with the grosser struct- 
ural changes, it is safe to defer massage until the pus shall have had 
reasonable time for sterilization. 



CHAPTER XXXI. 

ELECTRICAL AND SURGICAL TREATMENT OF SALPIN- 
GITIS. 

Electricity. — ^There are good and apparently sufficient reasons 
for believing that electricity properly handled in judiciously selected 
cases may be of great benefit in promoting the absorption of exudates. 
That it is capable of stimulating physiologic metabolism, and thereby 
indirectly conducing to the absorption of inert or lowly organized 
plastic matter, admits of no doubt. Unfortunately, it has its limita- 
tions, and requires a most intimate knowledge of its properties and 
their relation to pathologic conditions to render its use beneficial or 
even safe. The contra-indications for its use in pelvic troubles are 
active inflammation and the presence of pus. By common consent, 
it should not be used under such conditions, and yet Massey uses the 
faradic current in the height of inflammatory reaction as a soothing 
and palliative measure. He uses the vaginal bipolar electrode at the 
bedside, and exercises extreme caution and gentleness in turning on 
the current and gauging it to the patient's feelings. The seances ale 
continued for fifteen minutes. It soothes and pacifies the patient, 
annuls pain, and conduces to refreshing rest. The application is 
repeated daily. 

For more advanced cases, where the active symptoms have, in a 
measure, subsided, the constant current is used. One pole (the nega- 
tive) is introduced into the vagina or uterine canal, and the other 
applied to the surface of the abdomen. The electrodes are fashioned 
according to the uses for which they are intended, the vaginal being 
large and spherical, and the uterine of a size and shape to adapt 
itself to the uterine canal. Some of the latter are made flexible to 
admit of easy and painless introduction. The abdominal or indif- 
ferent electrode is expansive, being from five to eight inches in diam- 
eter, and molded to conform to the shape of the abdomen. It con- 
sists of a metal plate or disk covered with clay, cotton, spongiopiline, 
or some other absorbable material, which is moistened to increase its 
conductivity. This distributes the current over a large surface and 
enables the patient to endure a much stronger current than would 
(.nr.) 



BUnOICAL TREATMENT OF SALPINGITIS. 



377 



otherwise be tolerable. The vaginal electrode is first used with a 
measure of from 30 to 50 milliampfires, the seances lasting from three 
to five minutes, according to the tolerance of the patient. This may 
be repeated once or twice a week and continued so long as satisfactory 
results are obtained. 

I.Ater, if need be, the uterine electrode may be brought into req- 
nisition. This part of the treatment should be approached with the 
utmost care, and should be tentative, to be desisted from, suspended, 
or modified upon the first indication of unfavorable reaction. Rash- 
ness here may precipitate a recrudescence of the disease in all its 
initial fury, or even inaugurate new evils more damaging and dan- 
gerous than the original attack. Massey, while recognizing the deli- 
cacy of the imdertaking, does not hesitate, on occasion, to attack pus 
cases through the intra-uterine application. He used the flexible 
electrode, which is introduced with the utmost gentleness only part 
way up tlie canal, advancing little by little with each seance, accord- 
ing to the effect on the patient. The seances at first are of short 
duration, not exceeding three minutes with a mild current. In the 
absence of unfavorable results the strength of the current is increased 
and the intervals between them diminished. In old and intractable 
cases, not refractory to intra-uterine application, catnphoresis is rec- 
ommended. Here the positive, mercuric-coated, copper electrode is 
introduced into the uterine cavity and the negative placed over the 
abdomen. The distribution of the cupric-mercurial salts in the path 
of the electric current produces an alterative action and conduces to 
the absorption of exudates. 

Operative Treatment. — Operations for the relief of the inflamma- 
tory affections of the Fallopian tubes are ranged under two heads; 
conservative and radical. Conservative operations have for their 
object the preservation of the organs, and, in so far as possible, the 
restoration of anatomic integrity and functional activity. 

Radical operations have for their object the relief from suffering 
and the restoration of health by removal of the offonding organs. 

When and how to operate are questions not easy of solution, as 
the conditions are so variable and are influenced by such an in- 
finitude of modifying circumstances. Consequently, no hard and fast 
rules can be laid down for the guidance of the surgeon. Nevertheless, 
there are certain general principles which, if judiciously made use 
of, will go far toward solving the question. Unquestionably, of late 
years, the tendency has been in the direction of too much operative 
interference. Witli the improvement in technique and the low rate 



378 PRACTICAL GYKECOLOQY. 

of mortality attending pelvic and abdominal operationa, coupled with 
the immediate relief from distressing symptoms, both patient and 
surgeon are prompted to early recourse to that method which offers 
the most direct results. 

The ulterior results of these operations are not given the consid- 
eration that their importance demands. Furthermore, pelvic surgery 
has a mortality of its own, and the indiscriminate resort to operative 
measures on every pretext will swell the mortality list far beyond 
that which would accrue from the disease. The natural history of 
tubal disease as deduced from the ante-operative era, and as may be 
verified now by observation of cases treated expectantly, fully bears 
out this view. Albeit operative interference in properly selected cases 
is essential to the best results, and is a priceless boon to womankind. 

It may be laid down as a rule to which there are few exceptions 
that operative interference of any kind is seldom called for in the 
acute stage of the primary attack. Especially does this apply to gon- 
orrheal infection. Occasionally in streptococcic infection the ad- 
vance is so rapid that the question resolves itself into immediate 
operation or death. Unfortunately, the result here is too often op- 
eration and death, as the poison is so fleet-footed, subtile, and deadly 
as to outrun and elude the surgeon and defy restraint. One of the 
most comforting assurances the physician can have in streptococcic 
infection is the swelling of the tubes and the matting and massing 
of the pelvic viscera. It indicates that the poison is traveling by way 
of the tubes, and is not being distributed broadcast through the lym- 
phatics. It indicates, furthermore, that the poison has been en- 
trapped, and that it will not escape unless liberated by violence or 
meddlesome surgery. In violent infectious disease of the pelvis 1 
always hail with satisfaction tubal infiltration and plastic exudation 
as harbingers of safety to my patient. In other words, pelvic adhe- 
sions in the active stage of pelvic infection should be regarded with 
friendly interest and fostered as the best possible safeguard against 
general infection. 

E.specially hazardous is surgical interference where the exudation 
is vaulted into the abdominal cavity. Here the tubes must be reached 
through coils of agglutinated intestines, exposing an extensive area 
of gcrm-infosted surface in the most vulnerable part of the peritoneal 
cavity. True, there are surgeons who operate regardless of time or 
condition, and it must be admitted that in many instances their 
results are all that could be desired ; still, such will pay for their 
temerity in an unwarrantably large death-rate, which is all the more 



SimOICAL TREATMENT OF SALPINGITIS. 



deplorable because unnecessary. Good judgment and fine discrimi- 
nation may enable the surgeon to select cases for operation even in 
the acute stage without materially affecting the death-rate, but these 
qualities cannot be communicated, nor in the absence of which can 
the practice be imitated witli safety. 

Time and patience, with a judicious use of the measures already 
indicated, will, in many instances, bring about the subsidence of 
inflammatory reaction, and, more frequently than is generally sup- 
posed, lead on to a symptomatic, if not actual, cure. Yet, after all, 
there will be cases demanding surgical relief, which under this regime 
will be taken at the most opportune time to secure the best possible 
results, and the conscientious surgeon will experience much gratifica- 
tion in the knowledge that only the es.sentially surgical cases have 
been included in the category. An exception to non-operative inter- 
ference in tlie early stages of infection may sometimes be made in 
favor of curettage of the uterine cavity. Where tliere is reason to 
believe that some of the products of conception have been retained, 
these should be dislodged either with the finger or curette, and washed 
out either witli sterilized water or a mild antiseptic solution. Later, 
in any form of infection when the di.«ease has become comparatively 
quiescent, but with little or no tendency to resolution, curettage by 
removing the source of infection will often prove of decided benefit. 
Pus in the pelvic cavity would, of course, be a positive contra-intlica- 
tion to curettage unless it is to be followed by immediate abdominal 
section. All operations on the tubes themselves, whether radical or 
conservative, should be accompanied by curettage of the uterus. 

If after ample time and opportunity, and in spite of the non- 
operative measures (including curettage, if deemed necessary) the 
disease prove intractable, resort may be had to more heroic measures. 
E-xceptions to these dilatory tactics may be made in the case of pus- 
tubes. While pus-tubes may, and sometimes do, undergo changes by 
which they cease to harass the patient, they are, as a rule, long-lived 
fomenters of mischief, entailing so many restraints on daily pursuits 
and pleasures as to justify interference at the earliest possible mo- 
ment compatible with safety. The social state of the patient may 
also demand early operation. The busy house-wife or wage-earner, 
compelled by necessity to be up and doing, cannot await the slow 
process of restoration in its natural course, nor yet avail herself of 
the rest and means by which this may be expedited, hence she is com- 
pelled to accept the quickest and surest means of relief from an 
infirmity which stands between her and her daily bread. 



380 



PRACTICAL GYNECOLOGY. 



Ab between radical and conservative operations on the uterine 
appendages, the question often resolves itself into one of expediency. 
Usually pus-tubes and tubes which have undergone marked degenera- 
tive changes are not amenable to conservative treatment, and should 
be removed. Occasionally tubes which are not so greatly damaged 
may be so treated as to relieve suffering and in some instances restore 
function. Adhesions may be broken up and the tube liberated, un- 
folded, and restored to its natural position. The fimbriated extremity 
of the tube may be unsealed, and on rare occasions the fimbria un- 
furled. The tube may be incised in places here and there, the con- 
tents removed, and its caliber restored by the use of the knife and 
probe. When it is impossible to restore the fimbriated orifice, a new 
ostium may be fonned by excising the sealed extremity of the tube 
and stitching the edges of the mucous and serous coats together, or 
by incising the tube at the most eligible point (usually near the 
distal extremity and in proximity to the ovary) and suturing the 
mucous to the serous coat. 

The results of such operations have sometimes been brilliant. 
The patient has been relieved from suffering, and the functions of the 
tube restored. Pregnancy has followed the opening of the lumen of 
the tube, even through an artificial ostium. Still, it must be con- 
ceded that conservative operations on the Fallopian tube are too often, 
if not in the main, disappointing. Many such cases, after a longer 
or shorter period of expectancy and unabated suffering, again repair 
to the operating-table to have the offending organs removed. Con- 
servative operations on the Fallopian tubes, as already intimated, are 
usually limited to such cases as offer a strong pmbability of relief or 
of restoration of function. Occasionally a patient will be willing to, 
take the chances of continued invalidism or a secondary operation 
rather than to part with the essential organs of generation. Anxiety 
for a child is usually the motive which prompts such a course. Under 
such circumstances the surgeon is justified in taking chances that 
would otherwise be unwarrantable. 

The question frequently arises as to whether both appendage 
should be removed when the disease is apparently confined to one.^ 
Long experience has taught that gonorrheal infection almost invari- 
ably attacks both tubes — usually one after the other, and the removal 
of one side will sooner or later be followed by disease of the other, 
oftentimes demanding a second operation. In view of this fact, it 
is better to remove lioth tubes at the same sitting, even though one 
is to all appearances perfectly healthy. Streptococcic infection is, 



however, usually confined to one side, and shows little disposition to 
mvolve the other. Here only the diseased tube should be dealt with. 
Hydrosalpinx and hematosalpinx are usually harmless; their mere 
presence, unaccompanied by distressing sj-mptoms, is, therefore, no 
justification for their removal unless section has already been made 
for other cause or under mistaken diagnosis. ■ 

Salpingo-oophorectomy. — This is the name applied to the op- ' 
eration of removal of the Fallopian tubes and ovaries. The two organs 
are usually removed simultaneously, for the reason that they are so 
intimately associated anatomically and so correlated physiologically 
and pathologically that one is seldom seriously affected to the exclu- 
sion of the other. Occasionally it is found expedient to remove the 
tube alone. This is called salpingectomy. 

After the usual abdominal incision between the umbilicus and 
pubis, two fingers of the left hand are introduced into the opening, 
palmar aspect forward. This position of the fiugers should, as a 
rule, be maintained throughout. The tips of the fingers are first 
applied to the parietal peritoneum at the lower angle of the ineision, 
and glided downward and backward over the bladder to the uterus, 
which is the landmark by which the appendages may be located. Glid- 
ing the fingers outward from the posterior aspect of the uterus, the 
appendages are located and the adhesions — if any exist — broken up, 
first on one side and then on the other. The ovary and tube of one 
side are lifted up and brought out through the incision, either upon 
or between the fingers, or, if necessary, aided by the thumb. 

The next step is the ligation of the veg.sels. The first ligature is 
placed near the pelvic wall, and is passed through the thin, trans- 
parent portion of the infundibulo-pelvic ligament beneath its thick- 
ened border, through which the ovarian vessels course. This thin 
portion of the ligament can be pushed forward on the tip of the finger 
and the ligature carrier pushed tli rough it under the eye, tJius avoiding 
the puncture of any small vascular branch. After tying this ligature 
j'another is inserted near the uterine cornu so as to include the Fal- 
lopian tube and the vessels beneath it. (Fig. 236.) Here the same 
precautions should be taken as before to avoid puncture of branch 
sels. 
After tying this ligature, the mass, including the tube and ovary, 
is lifted up and cut away, care being taken not to cut too close to the 
ligatures lest they should slip. Before complete severance of tlie mass 
it is well to catch up tlie ligament at either extremity with clamp 
forceps to prevent retraction. Some operators use the ligatures fo^ 



382 



PRACTICAL GYNECOLOGY. 



this purpose, but the practice is a dangerous one, as traction on the 
ligature may result in partial displacement, which, not being observed, 
may result in secondary hemorrliagc after the cbdoraen is closed. If 
the ligatures are well placed, there will usually be no hemorrhage 
from the raw edges of the broad ligament between them. Should any 
bleeding points exist, they may be ligated with fine catgut, or con- 
trolled by an over-and-over suture of catgut run from one end of the 
stump to the other. In case both sets of appendages should require 
removal, the same technique would apply to the opposite side. 



Fig. 23C. — Salpingo oophorectomy. 

TIm right tub* !• being ligatured prepuatorjr to remoTiL Tba led tube hu bean remorad 
aod the broad Ugauieot 1* being cln*od bj * ruuniog catgut lutur*. 



A more expeditious, but far less safe, method of ligaturing the 
appendages is to transfix the base near the center with a double 
ligature, give them a twist around each other so as to interlink them, 
and tie each half of tlie pedicle separately. As an additional precau- 
tion, the ends of one of the ligatures are brought back so as to en- 
circle the whole pedicle and again tied. By this method it ia essential 
that the pedicle should not be put on the stretch by traction on tlie 
appendages at the time the ligatures are being tied, lest retraction 



SURGICAL TREATMENT OF SALPINGITIS. 



383 



of the stump should ensue, with consequent displacement of the liga- 
ture. It is equally important that a good button should be left beyond 
the ligature. There are several objections to this method, the chief 
of which is that by the crumpling of the broad ligament at the site 
of ligation the ligature is located at the apex of a cone: a very dan- 
gerous position- Another is that the tension on the broad ligament 
is often so great as to occasion much suffering, both during and after 
convalescence. The Tait knot is even more dangerous, and should 
never be employed by one not schooled to its use. 

Aft€r securing the pedicle and cleansing the cavity by sponging 
or irrigation, account should be taken of the sponges and instruments 
to be sure that none is missing. Before closing the incision tlie omen- 
tum should be drawn down so as to interpose between the intestines 
and the line of incision. This will prevent intestinal adhesions to 
the abdominal parietes along the line of incision. 

Complications. — An adherent onicntum may have to be sepa- 
rated before access can be had to the appendages. Injuries to the 
omentum should receive immediate attention, as the bleeding is apt 
to be persistent, and, if not looked after immediately, may elude 
detection. Firm and extensive adhesions of the tubes and ovaries may 
prove very annoying, and their liberation is sometimes a matter of 
great difficulty as well as danger. Misdirected efforts in such cases 
are very apt to result in failure or disaster to the patient. 

Not infrequently a formless mass will be found occupying the 
pelvis, which will be very puzzling to the inexperienced, there being 
apparently no landmarks and an effacemeut of all lines of demarka- 
tion. Such masses seem to be covered by peritoneum in no way dis- 
tinguishable from and apparently continuous with the general peri- 
toneum. When encountering such it should always be remembered 
that there is a seam somewhere, which if found and followed will 
result in the complete enucleation of the diseased appendages. This 
seam is known as the line of cleavage. The initial and most important 
step is to locate the line of cleavage. Gentle pressure with the tipa 
of the fingers at some point along this line will usually result in the 
separation of the tissue. Into this opening one or two fingers are 
thrust. A start being made, the line can usually be followed by 
pressure, ilrst in one direction and then in the other, until complete 
separation is effected. This line will usually be found deep down 
in the pelvis and well back toward the hollow of the sacrum. Blind 
force should never be used at any stage of tliis most delicate and 
important part of the operation. A false passage, once formed, will 



384 PRACTICAL OYNBCOLOQY. 

lead to almost inevitable failure and disaster. Under such conditions 
a large incision and the Trendelenburg position are of great benefit 
to the less experienced operator, as thereby he may have the assistance 
of his eyes. It occasionally happens that after following the line for 
a variable distance it becomes lost. Here, by delving deep into the 
crevice and hooking the fingers forward and upward the mass may be 
rolled out of its bed. This maneuver should not be lost sight of, as 
it is often the key to success. In all these maneuvers the palmar 
aspect of the fingers is applied to the mass which is under process of 
enucleation. 

Occasionally the appendages will be found perched upon the 
fundus, or occupying the vesico-utcrine space. In every case where 
there is the least reason to suspect pus, provision should be made to 
prevent soiling of the peritoneum by the proper disposal of pads and 
sponges. If a pus-cavity be opened during the process of enucleation, 
the pus should be received on sponges, which are immediately dis- 
carded, and not to be used again. Hemorrhage from the raw surfaces 
is sometimes quite free, but is seldom persistent. Temporary packing 
of the cavity while attention is given to other details, of the operation 
will usually suffice to arrest it. Should the oozing continue, a long 
strip of gauze may be packed in and the end brought out at the lower 
angle of the incision. This will serve the double purpose of a tampon 
and drain, and may be allowed to remain from one to three days, as 
may be deemed advisable. 



38(5 



PRACTICAL GYNECOLOGY. 



carried up the genital canal by the spermatozoa. That the germs cling 
to and are transmitted by the spermatozoa finds plausible support in 
the fact that tubal tuberculosis occurs most frequently in the woman 
of active sexual life, and, furthermore, by the oft-repeated demonstra- 
tion of the tubercle bacillus in the testicle and testicular fluids of 
phthisical men. It is also found in the gonorrheal discharges of such. 

The presence of the tubercle bacillus in the substance and secre- 
tions of the genital organs of the male does not necessarily imply in- 
fection of the organs which harbor them, as in many instances the 
organs themselves are sound. The tubercle bacillus may infest a part 
without infecting it. It may spread over a raw surface, traverse the 
lymphatic or blood channels to remote parts, or, as has been seen, 
swarm in the secretions of a glandular organ without infecting the 
tissues with which it is brought in contact. In other words, it will 
often pass over and through tissues to find a congenial soil in which 
to luxuriate and work out its characteristic pathologic results. A 
familiar example of the elective affinity of the tubercle bacillus is 
found in pulmonary tuberculosis, in which the germ must have passed 
the nose, mouth, and throat in order to fasten upon the lung. 

There can be no reasonable doubt but that in primary tubercu- 
losis of the Fallopian tube the germ in most instances finds its way 
to the tube through the natural genital passages. There are reasons 
for believing that in some instances it takes the lymphatic route from 
some raw surface on the vulva or vagina, as evidenced by the fact that 
it locates in that portion of the tube — the distal — which is in line with 
the lymphatics having their origin in the lower genital tract. It has 
been supposed that the blood sometimes acted as the carrier of the 
germ from a more or less remote point of inception, but this, in the 
light of recent experimental research, is quite improbable. Lasker, 
in a series of tests to solve the question as to the presence of bacteria 
in the blood in cases of pulmonary tuberculosis, found the blood 
sterile in 67 out of 68 cases, and, inasmuch as the patient in whom 
the bacteria were found died in 19 hours, he attributes the presence 
of germs in that case to agonal disjunction. 

Secondary infection of the Fallopian tubes is not only much more 
frequent than the primary, but also in most instances travels a dif- 
ferent route. The primary infection with great uniformity travels 
from Ik'Iow upward, whereas the secondary infection very generally 
pursues a course from above downward. Secondary tubal infection in 
the vast majority of cases arises by continuity from tubercular peri- 
tonitis. Infection of the tube may be communicated from any of the 



FALLOPIAN TtJBERCULOSIR-PELVIC CELLULITIS. 



387 



tuberculous pelvic or abdominal organs with which the tube is in con- 
tact or to which it is adherent. The known fact that the tubercle 
bacillus can pass through the walls of the ulcerated intestine into the 
general peritoneal cavity, taken in connection with the experimental 
researches of Firmer, who demonstrated that fine particles of matter, 
as of cinnabar, introduced into the peritoneal cavity soon found their 
way into the Fallopian tube through the ostium abdominale, leaves 
little doubt but that tubal infection may occur from an intestinal 
tuberculosis. The same rule would doubtless apply to tuberculous 
ulcer or abscess of any of the organs abutting upon the general peri- 
toneal cavity, which would greatly multiply the opportunities of sec- 
ondary infection of the tubes. Excreta from tlie tuberculous intestine 
sometimes act as the vehicle by which the germ is conveyed to the 
vulvar cleft^ from whence it ascends through the genital canal. The 



TT^.^ 



Fig. 238. — Tuberculosis of the Fallopian Tube. 
Tb« left tube Is ituddtHl with tuberolea. Uyclruaalpinx Ut hIiuwu ua the right tilde. 



transfer may be made through the instrumentality of soiled fingers or 
clothing. And, finally, here, as in primary infection, the lymphatics 
may convey the germs from more or less distant focal deposits to the 
Fallopian tube. 

Symptoms and Course. — Tubal tuberculosis is usually bilateral. 
It occurs under two forms: 1. As a well-marked lesion with obvious 
tubercular deposits. 2. In a masked form, in which the tube presents 
no tangible lesion. 

In the first form the appearance of the tube is very much like 
that of salpingitis from other causes, and is subject to almost infinite 
variety. Added to this in most instances, miliary tubercles are found 
in greater or less abundance studding the surface of the tube. (Fig, 
238.) Not infrequently nodular masses of tubercular deposit and the 
fibrous formation incident to the same are to be found projecting from 
the surface of tlie tube. These are prone to assume a bead-like arrange- 




ass 



PRACTICAL GVNECOLOOY. 



ment along its course, constituting the rosary-shaped tube of Hegar. 
(Fig, 239.) This is quite characteristic of tubal tuberculosis, and 
when present is of diagnostic value. The fimbriated extremity is 
quite often occluded and the lumen of the tube filled with liquid, 
creamy, or caseous matter. This represents the mixed products of 
disintegration and inflammatory exudation, and is seldom purely 
purulent. Primary tuberculosis is usually of tardy development and 
is inherently chronic, whereas the secondary form is characterized by 
greater activity and earlier manifestation of gross lesion. The former, 
coming as it does by way of the genital canal, first encounters and 
affects the isthmus of the tube. This, in many instances, gives rise 
to a characteristic enlargement of the isthmus, most pronounced at 
the uterine e-xtremity and tapering as it proceeds outward. This 
enlargement sometimes forms a distinct shoulder at its junction with 
the uterus, at others appears as a prolongation of the uterine comu, 




Fig. 239.— Tuberculosis of tlie Fallopian Tube. 

On the left ia ■howu iho aboulder-lUie «ulurgciueut of Uie Ulbmiu Kiid on Uie fight 
Ibe ro(ary.Uk« tube. 

and is regarded by Hegar as almost pathognomonic of tubal tuber- 
culosis. (Fig. 239.) 

The tubercle bacilli, as they enter the tube from the uterine 
cavity, are brought in contact with and not infrequently confine them- 
selves to the mucosa and its immediate environment. In many in- 
stances the tube suffers no palpable lesion for a very considerable 
period. Such tubes are habitually overlooked, both in operation and 
autopsy. These, which form no inconsiderable proportion of tuber- 
cular tubes, constitute the masked form referred to above. They are 
classed by Williams under the head of "unsuspecte<l tubal tubercu- 
losis." Gradual and progressive involvement and destruction of the 
mucosa, with accumulated detritus in the lumen of the tube, and 
infiltration and thickening of the tube-walls, is the usual order of 
sequence. Some cases are characterized by a marked and progressive 
increase in the fibroid elements of the tube-wall, as the result of 



FALLOPIAN TUBKRCULCeiS-PELVIC CELLULITIS. 38!) 

bacterial stimulation, until the tube becomes of almost cartilaginous 
consistence. Calcareous infiltration of the tuberculous foci is occasion- 
ally observed. Both fibrous and calcareous degenerations are conserva- 
tive, and may result in spontaneous cure. In advanced tubal tuber- 
culosis we find peripheral extension, adhesions to the omentum and 
contiguous viscera, encysted fluid and purulent accumulations in the 
midst of the same, and almost limitless variations in the size and shape 
of the tube. 

Diagfnosis. — In a very large proportion of cases the symptoms are 
in no wise distinctive. As a matter of fact, the diagnosis is seldom 
made until the tubes have been cut down upon. If the patient is the 
subject of a pulmonary or other recognized form of tuberculosis, if 
she gives a family history of tuberculosis, or if her husband is tuber- 
culous, tubal lesion otherwise unaccounted for might very justly be 
suspected of being tuberculous in character. The shoulder-like en- 
largement of the isthmus at the uterine end and nodular formations 
along the course of the tube, when detectable by palpation, are 
valuable data upon which to base a diagnosis. In the same line Osier 
places stress upon an enlargement of the tube with an ill-defined, 
anomalous mass in the abdomen. On several occasions I have made 
the diagnosis in the absence of appreciable enlargement of the tube 
based upon a persistent tenderness in the vicinity of the tube and an 
unconquerable rigidity of the abdominal muscles. Probably the most 
trustworthy indication of tubal tuberculosis, where the signs are not 
distinctive, is the persistent and progressive character of the trouble. 
Finally, the presence of the tubercle bacillus in the scrapings from 
the uterine cavity or in the aspirated fluids of the tube would render 
the diagnosis almost certain. 

Prognosis. — The natural tendency of tubal tuberculosis is to ex- 
tend, to distribute infection, to undermine health, and to destroy life. 
Surgical interference in cases of primary infection will usually suffice 
to stamp out the disease. In secondary infection, when not too far 
advanced nor seriously complicated with other foci of infection, it 
retards the progress of the disease and prolongs life. 

Treatment. — The only treatment of any avail is to remove the 
affected tubes with or without hysterectomy. In a surprisingly large 
number of cases removal of the tubes alone, even in the presence of 
obvious involvement of the uterus, has resulted in cure. Where the 
uterus is not removed it should be curetted. Peritoneal involvement 
is no contra-indication, but rather an additional incentive to operation, 
as the mere opening of the ab(^omen has a most salutary effect on 



:i90 



PRACTICAL GYNECOLOGY. 



tubercular peritonitis. Advanced pulmonary phtliisis and general 
tuberculosis are positive centra-indications, unless the local condi- 
tions are such as to produce more wear and tear than would result 
from the operation. The operative treatment should be supplemented 
by such other measures, medicinal and hygienic, as are applicable to 
tuberculosis and the condition of the patient. 



PELVIC CELLULITIS. 



Before the advent of abdominal surgery pelvic cellulitis, or in 
flammation of the pelvic cellular tissue, was credited with a large 
proportion of the inflammatory conditions of the pelvis. We now 
know that pelvic cellulitis is comparatively rare, and that a large 
majority of the inflammatory affections of the pelvis take their origin 
in the Fallopian tubes. Nevertheless, pelvic cellulitis is a factor — 
and, by reason of its course and consequence, a very important factor — 
in the inflammatory affections in the pelvis. Tlie essential cause of 
pelvic cellulitis is, in the vast majority of cases, streptococcic infec- 
tion. Other micro-organisms are capable of producing it, notably the 
staphylococcus and the bacterium coli, but comparatively seldom do 
BO, for the reason that they are not active invaders and are not so 
likely to be introduced through accident or carelessness. It never 
arises from gonococcic infection, and consequently pelvic cellulitis 
does not, as a rule, complicate gonorrheal salpingitis, as claimed by 
some writers. Pelvic cellulitis is, furthermore, most frequently asso- 
ciated with the puerperal state: in most instances follows an abortion 
or labor at term. The history of the case will, therefore, furnish an 
important clue to the nature of the affection. 

The invasion is in most instances by way of the lymphatics. 
Very infrequently the germ may make its way through the thrombus 
into the blood-current; may follow the genital canal up through the 
tube, or pass directly through the tissues. The route of invasion is 
usually along the layers of connective tissue or fascia of the pelvis to 
which the pathologic changes are confined. Consequently the affec- 
tion is not diffused and uniform throughout the pelvis, but is confined 
to certain strata, and extends in certain directions to conform to the 
layers of connective tissue. As the germ gains entrance through 
some lesion of the genital tract, — an abrasion or laceration of the lower 
portion of the canal or cervix, or the locus of placental implantation 
in the uterus, — it follows that the line of invasion of the cellular tissue 
is from this pivotal point in some one or other direction. (Fig. 240.) 



H 



I 
I 



FALLOPIAN TUBERCULOSIS— PELVIC CELLULITIS. 



■Ml 



In bj far the larger number of cases it follows the cellular tissue 
botfteen the folds of the broad ligament, and is almost invariably 
unilateral. Occasionally it will be found in the cellular tissue in front 
of or back of the uterus or in more remote parts. The effect is to 
bind the uterus firmly to the pelvic wall. 

The chief characteristic of the exudation of pelvic cellulitis is 
the great density imparted to the infiltrated area. This is at first 
rather soft and edematous, but soon assumes a stony hardness and 
an absolute immohility which is quite different from the bogginess of 
tlie inflamed tubes. 

The tendency of the infiltrated cellular tissue is to suppurate. 
The suppuration is apt to occur at various focal points, which may 
coalesce or remain distinct throughout the course of the disease. Sup- 



'^W., 



'•..•.■> 




Fig. 240.— Pelvic Cellulitis. 
Tb« dotted arsM indlonic tiia varluus direetloua In which It iniijr extend. 

puration of the pelvic cellidar tissue, once inaugurated, is very liable 
to continue indefinitely unless arrested by surgical intervention. Sup- 
purating pelvic cellulitis is usually deiionii noted pelvic abscess. This 
terra is, however, generic, and embraces a number of pathologic proc- 
esses in the pelvis characterized by the formation of pus. It is ap- 
plied to pyosalpinx, suppuration of the lyniph-bcds around the in- 
flamed tube, ovarian abscess, and to the suppurating hematoma and 
hematocele. The pus, in suppurating cellulitis, seeks an outlet through 
the bowel, bladder, rectum, vagina, and abdominal wall. Not infre- 
quently it finds exit through a long and tortuous passage and con- 
tinues to harass the woman during the period of her natural life. 
These fistulae add greatly to the discomfort of the patient and to the 
difficulties and dangers of operation for her relief. When the pus ap- 
proaches the peritoneal surface, its rupture into the cavity is fore- 




3!»'> 



PRACTICAL GYNECOLOGY. 



stalled by an embankment of contiguous viscera agglutinated by 
plastic exudation. By this means the catastrophe of an immediate 
fatal peritonitis is averted. 

The streptococcus finds a particularly congenial soil in the pelric 
cellular tissue, and its tenure of life in this situation is sometimes 
remarkable. Ordinarily it will have run its course within from two 
to twelve weeks, but Miller, of the Johns Hopkins Hospital, cites an 
instance in which cultures were made from germs that had apparently 
survived the initial infection over twelve years and another in which 
a fatal peritonitis induced by them followed an operation two years 
after subsidence of active manifestations of the disease. Fortunately, 
such longevity is not often met with, but, unfortunately, there are 



< 




Fig. 24L — Potain'B Aspirator. 



no means of determining this fact except by control tests with the 
matter itself. 

The diagnostic criteria by which a pelvic cellulitis may be recog- 
nized are the history of infection, usually dating from a miscarriage 
or labor; the solidity of the infiltration; its one-sidedness with refer- 
ence to the uterus; the fixidity of the latter, and the extension of the 
infiltration from the uterus to the pelvic wall. Suppuration of the 
mass is almost never attended by fluctuation, but can be predicated 
with almost absolute certainty by the stony hardness, which indicates 
a stage of advancement in which pus is almost always present. 

Treatment. — The gravity of pelvic cellular abscess, its persistence, 
the distressing consequences of fistulous opening into some of the 
hollow viscera, and the possibility of rupture into the peritonea) 
cavity, with its inevitable fatal result, call for prompt and positive in- 



FALLOPIAN TUBERCULOSIS— PELMC CELLULITIS. ;]«);5 

torference. Surgery ofTers the only rational and certain means of relief. 
The abscess should be attacked through the most direct route com- 
patible with safety. In all cases it should be the aim to avoid, if 
possible, the peritoneal cavity. 

If it can be reached through the vagina an incision should be 
made through the mucous membrane over the most prominent point, 
and the dissection continued with the finger or blunt instrument until 
the pus-cavity is reached. Great care should be exercised not to injure 
the ureter or important blood-vessels in the vicinity. Some operators 
prefer to locate the pus with an aspirating needle, and to follow its 
track with a pair of sharp-pointed scissors, a perforating forceps, or 
other like instrument, and to enlarge the opening by expanding the 
blades. If the abscess is located at the base of the broad ligament, an 
opening made back of the cervix close to the affected side will usually 
enable the operator to break through the intervening tissues with his 




Fig. 242.— Rubber Drainage Tube. 

fingers and reach the pus-cavity without jeoparding important struct- 
ures. This course should always be pursued when practicable. 

An abscess located in the vesico-uterine cellular tissue may be 
reached in front of the cervix. The superficial abscess will sometimes 
be easier to reach through the abdominal wall, the incision being car- 
ried just above and parallel to Poupart's ligament, and the dissection 
carried down outside the peritoneum. The abscess once reached, the 
cellular tissue should be thoroughly broken up, the debris washed 
away, and a drainage tube inserted through which the cavity should 
be irrigated once or twice daily until the cavity is practically oblit- 
erated. In case of doubt as to the involvement of the ovaries and 
tubes, — a contingency by no means rare, — an exploratory section 
should be made to clear up the diagnosis, as any operation not includ- 
ing their removal where they are grossly diseased would not only be 
futile, but prejudicial to the patient. If it should be found necessary 
to operate through the abdomen, every precaution should be used to 



394 PRACTICAL GYNECOLOGY. 

avoid contamination of the visceral or parietal peritoneum or the 
wound surface by properly adjusted pads and careful manipulation. 
Should the appendages be found healthy, the abdominal incision 
should be closed and the operation conducted extraperitoneally. 

OPERATIONS THROUGH THE VAGINA FOR PELVIC INFECTION. 

Vag:inal Hysterectomy. — Many surgeons are in the habit of re- 
moving the uterus through the vagina in bad cases of pelvic infection, 
claiming for the operation less danger and greater efficiency than 
attend operations by the abdominal route. They base their claims on 
the more effective drainage through the vagina, greater safety to the 
patient in that the protective arch which interposes between the 
infected area and general peritoneal cavity is not broken through, and 
the diminished shock from non-interference with the intestines. They 
furthermore claim that even where the adnexa cannot be removed the 
drainage is so perfect that the infection dies out and in most instances 
a permanent cure results. 

Operation. — The instruments needed are a knife, a pair of long- 
handled scissors curved on the flat, three traction forceps, four perineal 
retractors, a small Pean retractor, four broad ligament forceps, and 
several hemostatic forceps. The retractors being introduced, the 
cervix is seized with traction forceps, and an incision made in front 
from side to side, being careful to avoid the vesical wall. A similar 
incision is made behind, but not so close to, the cervix. From the 
junction of these incisions a linear incision three-fourths of an inch 
in length is carried outward on cither side along the base of the broad 
ligament. This imparts greater mobility to the uterus, and when 
drawn to one or the other side increases the distance between it and 
the ureters. With finger and scissors the cervix is freed from the 
bladder, a retractor being inserted into the opening, which greatly 
facilitates the process. In like manner the cervix is freed from behind. 
Forceps are now applied to the broad ligament on either side so as to 
include the uterine arteries, and the portion thus secured cut through, 
keeping close to the uterine wall. The side retractors may now be 
dispensed with, the forceps taking their place. The cervix is next 
split up on either side and the posterior half amputated. The anterior 
half is also amputated, but before complete severance a new hold 
must be taken by the forceps on the anterior uterine wall above. Prom 
this time on the operation consists in dissecting off the bladder, — 
if this has not already been completed, — splitting the anterior uterine 



FALLOPIAN TUBERCULOSIS— PELVIC CELLULITIS. 



395 



wall in the middle line, seizing the same on either side, and cutting 
it away piece by piece until it is destroyed and the fundus reached. 
The anterior retractor should continually follow the finger into the 
depths of the dissection, and the traction forceps should always secure 
a new hold on the tissues above before a piece is cut away. Wlien the 
peritoneal cavity is reached, the Pean retractor, if not already in use, 
should be substituted for the anterior one, and should be pushed up 
into the cavity. Traction on the fundus will now cause it to roll for- 
ward and out into the vagina. Forceps are now applied to the upper 
half of the broad ligament from above downward and the uterus cut 
away. Should it be practicable, the adnexa are removed at the same 
time, otherwise they may be left. Pus-depots, whether in the tubes 
or elsewhere, are opened, washed out, and drained, care being taken 
to protect uninfected parts by gauze packing. Adhesions to the 
uterus can usually be separated under the eye after its inversion into 
the vagina. A pad of iodoform gauze is placed over the tips of the 
broad ligament forceps to protect the intestines from injurious press- 
ure, and between the forceps and vaginal wall to protect the latter. 
The forceps are removed at the end of forty-eight hours and after 
gentle irrigation the dressing replaced. The gauze pads above the 
vaginal vault are not removed for six days. Tiiis latter is very im- 
portant, as premature removal of gauze from the peritoneal cavity 
has often resulted in death by disturbing the adhesions by which 
Nature is trying to protect the peritoneum. Premature removal of 
this gauze abo conduces to descent of the intestines. 

Operations through the Posterior Vaginal Fornix. — It is some- 
times expedient and oeciisioiially necessary to explore the pelvis, drain 
an abscess, or perform other operations through the posterior vaginal 
fornix. Where there is reason to believe that virulent infectious 
matter exists in the pelvis the vaginal route it safer than the abdom- 
inal, and — conditions being favorable — should be chosen by prefer- 
ence. This will apply with special force to the acute streptococcic 
infections, in which removal through the abdominal route would 
greatly endanger infection of the peritoneum. In some instances large 
accumulations of pus in the pelvis may be drained through the vaginal 
fornix preliminary to the more radical operation by abdominal section. 
In such cases ample time should be given to drainage and irrigation, 
to reduce and improve the character of the infectious matter before 
resorting to section. The vaginal route may sometimes be chosen as 
a matter of convenience, as where the vagina is ample and short and 
the abdominal walls inordinately thick from obesity. 



396 



PRACTICAL GVKFXOIXXJy. 



Operation. — The operation consists in making an opening into 
the peritoneal cavity just back of the cervix, as in the first step of 
vaginal hysterectomy. After thorough cleansing of the vagina, and, 
if necessary, curettage of the uterus, the perineal retractor is intro- 
duced and the cervix seized with a strong traction forceps. The 
incision is to be made near to and just back of the cervix where the 
vaginal mucosa is reflected from it. The line of demarkatiou between 
the attached cervical and free vajrinal mucosa consists of an elevated 
crescentii ' '! ' ' : MirDu.-; iniMiiKiain' with its c< ■ ) ''■ tuward the 



Fig. 243. — Operations Ihruugh the Posterior Vaginal Fornix. 
Enlarging the Opening by Stretching. 

cervix. This, if not apparent, may be made so by pushing up the 
cervix with the traction forceps. This fold should be seized near its 
middle with a tenaculum forceps, and, while the cervix is pulled 
downward and forward, traction is made on the mucosa downward 
and backward. An incision an inch in length is now made through 
the mucosa parallel to the fold, between the tenaculum forceps and 
cervix, and the dissection carried up to the peritoneum through the 
cellular tissue by means of the finger, aided, if necessary, by the 
scissors. The wound is made to gape by means of traction or re- 



FALLOriAN TUBERCULOSIS— PELVIC CELLULITIS. 



397 



I t ractors, so that the peritoneum may be plainly visible. The peri- 
^^Bncuin is picked up with a pair of delicate forceps and snipped, the 
^^bening being enlarged by spreading the scissors. In case of infected 
^^nbes or pus-depots with adhesions the peritoneum may not be recog- 
nized as a distinct membrane, and is liable to be fused with the 
structures above. Here caution will be necessary to avoid puncturing 
I a bowel or other viscus, and sharp instruments should be used cau- 
^Hously, if at all. After entering the peritoneal cavity there will 
^^sually be little difficulty in breaking up adhesions with the finger, nor 

■will there be much danger of going astray, as the line of cleavage is 
■sily followed. In this way the ovaries and tubes may be liberated 
pd pus-depots broken into and emptied. Should the opening be 
BO small, it may be enlarged to any desired extent by stretching. This 
■ done preferably by introducing two fingers of different hands back 
fe back and making pressure in opposite directions. (Fig. 243.) 
y Through tlie enlarged opening the tubes may be delivered and removed. 
^Mor explorative purposes the patient may be placed in the Trendelen- 
^^urg position, the intestines maneuvered out of the pelvis by means of 

ijuze sponges held in the bite of long-handled forceps, the uterus 
eld forward on a trowel or retractor, and the pelvic cavity exposed 
y retracting the posterior lip of the wound. Under a good light a 
irge area of the pelvic cavity becomes plainly visible. 
After-treatment. — Where drainage is desired a good-sized rubber 
rainage tube is introduced into the cavity and brought down into 
the vagina. The drainage tube may be reinforced by a loose gauze 
packing, the upper end of which is engaged in the lips of the wound. 
A very efficient T drainage tube may be improvised from a piece of 
[Straight rubber tubing by splitting it down from the end an inch or 
^Miore, making a hole on either side just below the angle of the split, 
^^nd passing the ends of the split portion through the hole of the 
corresponding side (Reed). These ends project at the sides and pie- 
vent the tube from becoming dislodged. The drainage tube may be 
continued as long as desired. In case of exploratory section and 
where permanent drainage is not necessary the wound may be packed 
with gauze supported by a loose gauze vaginal tampon. It is better, as 
i a rule, not to allow the gauze to project into the peritoneal cavity, 
^^but merely to fill the wound flush with the peritoneum. The upper 
^MBUze packing should not be disturbed until after it is roofed over, 
^which will usually be in from six to eight days. The vaginal packing 
^may be removed at any time after the third day if deemed necessary, 
Bthcrwise it may be left until the upper packing is removed. 




CHAPTER XXXIII. 



ECTOPIC QESTATION. 



Normal pregnancy can only occur in the uterine cavity. He 
and here only, are to be found all the conditions for the reception, 
maturation, and expulsion of the products of conception. Ectopic 
pregnancy and ectopic gestation are the terms used to designate a 
pregnancy anywhere outside the uterine cavity. Extra-uterine preg- 
nancy, as the term implies, signifies a pregnancy outside the uterua. 
This would apply to the overwhelming majority of cases of misplaced 
pregnancy, but there are a certain limited number in which the preg- 
nancy occurs in that portion of the Fallopian tube which traverses 
the uterine wall to which the term extra-uterine would be clearly 
inapplicable. Ectopic pregnancy and ectopic gi^tation are, therefore, 
the better terms to use in a generic sense, as they embrace all forma 
of misplaced pregnancy. 

The term "tubal pregnancy" is very much in favor, and haa much 
to recommend it, in that it is definite and expressive of the exact situa- 
tion of the ovum. Furthermore, there can be no question but that 
in almost every instance the primary implantation of the dislocated 
fertilized ovum is in the Fallopian tube. Still, there are grounds for 
believing that the primary implantation may, with extreme rarity, 
occur in the ovary: ovarian pregnancy. This view is supported by 
the fact, apparently well attested, that ovarian tissue has been demon- 
strated in the capsule of the gestation-sac, and the corresponding 
Fallopian tube found to be perfectly normal. 

Dr. Catherine Van Tusaebroek, of Amsterdam, Holland, came 
into possession of a perfect specimen of early ovarian pregnancy. 
Bland-Sutton, to satisfy himself as to its genuineness, visited Am- 
sterdam, and was allowed to examine the specimen critically, and sup- 
plied with sections to take home with him. He reports the case aa 
being complete in every particular. Still, there remains the possi- 
bility of the transference of the ovum from the tube or its fimbria 
10 the ovary at a very early period, and a subsequent severance of the 
tubal connections. 

With this one possible exception, ectopic gestation never occura 

(398) 



I 




ECTOPIC GESTATION. 



S'M 



primarily in any other place. The old idea that it might occur in 
the peritoneal cavity or in the pelvic cellular tissue has long since 
been exploded, and the presence of tlie ovum in these situations is 
accounted for by some one or other of the accidents to which it is 
subject in its abnormal situation, and by which it has become dis- 
lodged. These will be more fully explained later. Practically, be- 
cause of its extreme infrequency and doubtful authenticity, ovarian 
gestation may be ignored and sole attention given to the various phases 
and manifestations of tubal pregnane^'. 

Gestation may occur in any part of the tube. It may occur ii 
the isthmus (isthmian pregnancy), in the ampulla (ampullar preg 
nancy), in the infundibulum or abdominal extremity of the tub) 






ft'.^' 



>\ 



Fig. 244. — Ectopic Gestation, Showing Sites of Implantation of Ovum. 

1. tutcnUtlal pragnancf. 2. iRlhmlan pregnancy. 3. Ampullar prvgimuuy. 4. lufuudib- 
uUr pregnaoay. &. Tubo-ovurluu pregnancy. 

(infundibular pregnancy), or in that portion of the tube which 
traverses the uterine wall (interstitial pregnancy). (Fig. 244.) For 
years past it has been taught and believed that tuba! gestation occurred 
most frequently in the middle portion of the ampulla. Bandlcr denies 
this, and claims tliat isthmian pregnancy is by all odds the most 
frequent. He adduces evidence to show that in a series of 148 cases 
only 18 were ampullar. 

Some hitherto considered cases of interstitial pregnancy are due 
to the development of ova which have found their way into Gaertner's 
duct. When the ovxun lodges in the infundibulum, the fimbria may 
become spread out over the ovary in such a way that in the subse- 
quent development of the ovum both tube and ovary contribute to its 
support. This constitutes the so-called tubo-ovarian pregnancy. 



A 



-100 



PRACTICAL GYNECOLOGY. 



These terms are convenient as indicating the site of implantation of 
the ovum, and are of practical importance as indicating the probable 
course of the gestation. 

Causes. — The essential cause of tubal gestation is as yet one of 
the mysteries of medicine. In some instances no abnormality of the 
tube can be found to account for the anomaly. Hitlierto the opinion 
has prevailed that tubal gestation was due to some lesion of the tube 
which interfered with its function as a carrier of the ovule from the 
ovary to the uterine cavity. Many of these lesions have been ascribed 
to the results of tubal infection. The tube may be distorted, bent 
upon itself, or bound down so as to interfere with its vermicular mo- 
tion. Obstruction of the canal may result from polypoid growths, 
angulation of the tube, stricture, or by pressure from without. The 
motion of the cilia may be impaired as the result of disease, or the 
epithfliuni may be exfoliated in patches, leaving pitfalls into which 
the ovule tumbles and becomes hopelessly entrapped. In one case of 
my own in which it became necc-ssary to remove the uterus to control 
the hemorrhage, examination of the specimen revealed an amplified 
uterine extremity of the tubal canal which would admit the little 
finger. Here the fetus had escaped into the broad ligament, and tlie 
placenta was attached to the posterior surface of the uterus under 
the peritoneum. The only e.vplanation I could find for the arrest of 
the egg in this instance was tliat it had either fallen into a pit or — 
and this is more probable — that the enormously enlarged caliber of 
the tube toward the uterine side had deprived the ovum of the normal 
propulsive power by which it should have been assisted toward the 
uterine cavity. 

Hcrzog repudiates gross tubal lesion as a causative factor in tubal 
gestation, and believes it to depend, in many instances at least, on a 
congenital abnormality. In several instances he has been able to 
demonstrate a blind passage or diverticulum from the true caniil into 
which the ovule has wandered and developed. He believes, moreover, 
that the tubal mucosa participates in the menstrual act and under- 
goes the same changes in a minor degree as the uterine mucosa, 
whereby it becomes fitted for the reception of the ovum. This latter 
view is admittedly theoretical, and is unsubstantiated by tangible 
evidence. It is furthermore controverted by the experiments of 
Mandl and Schmit, which go to show that the healthy or normal 
tubal mucosa is not adapted to pregnancy, or, in other words, does 
not afford a suitable nidus for the ovum. These consisted in tjing 
off the tubes of animals between the fecundated ovum and tlie uterus. 



I 
I 



I 



BCrOPIC GESTATION. 



-101 



» 



In no case did ectopic pregnancy result. When, however, the uterine 
horn was tied off, cornual pregnancy resulted, clearly accentuating the 
difference between the uterine mucosa and that of the tube. Hcrzog 
claims that a diseased tube is in no way resjxjnsible for tubal preg- 
nancy, as it makes fecundation impossible. Undoubtedly, gross dis- 
ease of the Fallopian tubes is incompatible with pregnancy of any 
kind, but the milder forms of tubal disease have been so universally 
regarded as standing in causative relation to tubal pregnancy that 
the commonly accepted views of the most careful and aatute men of 
the profession should not be discarded lightly. 

Course and Termination. — While it is possible for a tubal gesta- 
tion to continue as such to full term, the conditions render such a 
termination exceedingly improbable. In uterine gestation the uterus 
grows part passu with the development of the fetus, and there is at 
no time distension or thinning of the utorint; walls. In tub.il gesta- 
tion tlie tube is distended from the first, or at least from a very early 
period after the implantation of the ovum, and the distension and 
thinning of the walls of the tube become more and more marked as 
gestation advances. The almost inevitable result is rupture of the 
tubal walls. This event is hastened by the encroachment of tlie 
chorionic villi, which, burying them.«elve8 in the tube-wall, still 
farther attenuate and weaken it. In this connection there e.xists also 
a material difference between tubal and uterine pregnancy. The tubal 
placenta is made up almost entirely of the fetal side, tlie maternal 
side being filmy in structure. In uterine gestation the maternal 
placenta is well developed and prevents the encroachment of the 
villi upon the uterine wall and consequent weakening of the same. 

Changes in the Oenital Apparatus. — A consideration of the 
changes in the tube and other organs of generation in connection with 
tubal pregnancy will go far toward explaining many of the pheumupna 
attendant on this condition. As has been seen, when considering the 
causes of tubal gestation, there are reasons for believing that the tube 
undergoes preparatory changes for the reception of the ovum, coin- 
cident with and similar in character to those of the uterus. Micro- 
•oopic research has demonstrated a decidua, and, after implantation 
of the ovum, the serotina. The distinctly circumscribed encapsula- 
tion of the ovum so aa to confine the blood in the maternal sinuses 
witliin a distinct zone and in direct relation with the chorionic villi 
can only be accounted for on the hypothesis of a decidua reflexa, or 
by peripheral adhesions in close contact with the ovum. Analogy 
favors the former view. In the tube, as in the uterus, under like 




402 PRACTICAL GYNECOLOGY. 

conditions, there is also greatly increased vascularity, with edematooa 
infiltrations of the tube-walls. This is most conspicuous at tlie site 
of implantation. This infiltration accumulates between the mus- 
cular bundles and in the meshes of the connective tissue, whereby the 
thickness of the tube-wall is increased at the expense of its strength 
and resistile capacity. In other words, the tube is thicker, but 
weaker, by reason of this infiltration. The muscle-fibers of the tube 
are increased in size, but not in number. This is conservative so far 
as it goes, but the muscular structure of the tube is so attenuated, and 
the increase in bulk so limited, as to count for little against the rap- 
idly increasing pressure from within. 

Soon after the implantation of the ovum the ostium abdominale 
begins to show signs of closure. The sealing of the tube is accom- 
plished in the same way as in salpingitis : that is, by infolding of the 
fimbria and jutting forward of the peritoneal, circular margin and 
subsequent contraction of the same until the orifice is closed. ITiis 
takes place gradually, but is usually completed before the expiration 
of the second month, sometimes within a period of three weeks. The 
size and shape of the tube will correspond to the period of gestation 
and the situation of the ovum. 

True to its maternal instincts, the uterus undergoes changes in 
tubal pregnancy similar in character, though differing in degree, to 
those which occur in normal pregnancy. In anticipation of the ex- 
pected guest which is never to arrive, it becomes clothed with a 
decidual membrane and begins to develop. The decidua thrives and 
grows up to a certain point, or until accident befalls the ovum, when 
it is cast off, either entire or in shreds. The development of the 
uterus does not throughout keep pace with the period of gestation, 
nor yet does it proceed in the same direction. Usually the increase 
in size is not very marked, but occasionally it attains a size equal to 
the third or fourth month of utero-gestation. The growth is prin- 
cipally in the direction of its long diameter. 

Leaving out of consideration the continuance of tubal gestation 
to full term, — a contingency so remote as hardly to be worthy of 
consideration, — the terminations of tubal gestation are: — 

1. By rupture of the tube. 3. By tubal abortion. 

3. By death of the ovum. 

Rupture of the tube is, by all odds, the most common termina- 
tion. The rupture may occur into the peritoneal cavity or into the 
broad ligament. The relative frequency of intraperitoneal and broad 



■CTOWC GESTATION. 



403 



itent ruphire has never been established, bat from the best data 
our command it would seem tliat the former is twice as frequent 
the latter. Very exceptionally, in the interstitial variety, the 
' rupture occurs into the uterine cavity, whence the ovum is espelled 
per vias naturales. En by far the larger number of cases nipture 
occurs between the first and second month: usually about the sev- 
enth week. It is seldom delayed beyond the third mouth except in 
the interstitial variety, in which it sometimes goes on to the fifth 
mouth. In this variety rupture is apt to be delayed on account of 
the heavy muscular walls with which the ovum ia surrounded. It is 
the most dangerous of all on account of the size of the vessels and 
tlie tremendous outpouring of blood which attends it. The sudden- 
ness and ferocity of the hemorrhage usually precludes successful 
surgical intervention. 

The contributory causes of rupture of the tube in tubal gesta- 
tion have already been alluded to. They are, first, the pressure of 
the growing ovum and distension of the tube-walls; second, ihc 
separation of tlie muscle- and connective tissue fibers by edematous 
infiltration; third, the weakening of the tube-wall at the site of pla- 
cental implantation by the villi which have eaten into its substance; 
fourth, an effusion of blood, either in the tube-wall or ovum, which 
suddenly and at times greatly augments the rending force. This 
latter is tisually the determining force which precipitates rupture, 
and also accounts for early rupture before the tube has become so 
distended as to give way before the growing ovum. 

For reasons above stated, the rupture is most prone to occur over 
the site of the placenta, or where the villi are most concentrated. 
Rupture of the tube may be complete or partial. When a large rent 
is suddenly made in the tube the ovum is extruded and violent hemor- 
rhage ensues. In partial rupture there is a more gradual and easy 
parting of the fibers, and hemorrhage is limited. Occasionally the 
ovum pushes into the rent and acts as a plug, preventing the elTusion 
of blood. The effects of rupture, both immediate and remote, will 
depend largely upon the direction in which it takes place. As has 
already been seen, rupture may occur into the peritoneal cavity or 
into the cellular tissue between the folds of the broad ligament. 

Buptnre into the Peritoneum. — Rupture into the peritoneum 
(Fig. 245) is fraught with much immediate danger, as there is no 
provision for stanching hemorrhage except such as is inherent in the 
vessels themselves, or the accidental impaction of the rupture. While 
it is by no means phenomenal for a patient to survive the first rupture, 




404 



rilACTlCAL GYNECOLOGY. 



it is also a laincntahle fact that many are swept into the grave by the 
profusion and persistence of the hemorrhage. A fatal hemorrhage 
usually terminates within twonty-four hours, and occasionally in 
much less time. When the o^mm is extruded in its entirety, severing 
all vascular connection with its matrix, it quickly perishes, and if 
the woman survive the immediate perils of her situation the case 
may terminate happily. Much will depend on the stage of develop- 
ment and the presence or absence of infection. A non-infected dead 
ovum up to the age of several months may be digested and absorbed 
by the peritoneum. In many instances of ruptured ectopic gestation 
the ovum cannot be found at operation, either because it has taken 
refuge among the intestines or undergone digestion. If not absorbed 




Fig. 245. — Ectopic Gestation. Rupture into the reiitonpul Cavity. 



it may suppurate. The suppurating ovum with its attendant blood- 
clot is a malicious guest of the peritoneal cavity, and may easily lead 
to a fatal peritonitis. More frequently, however, in the earlier stages 
the ovum and clot become walle<l in, constituting a pelvic abscess, 
which may find an outlet spontaneously or require surgical inter- 
vention for its relief. Should the extruded ovum become encysted, 
it may mummify or be converted into adipocere or a lithopedian. If, 
however, it retains vascular connections with the tube, it may sur- 
vive and develop. The growing placenta under these circumstances 
spreads over the adjoining territory and forms vascular attachments 
to other structures, such as the broad ligament, uterus, intestines, 
bladder, or abdominal parietes, from which it derives its blood-supply. 
The eifused blood is either absorbed or breaks down into pus. 



EXTTOPIC GESTATION. 



dOo 



Bnpture into the Broad Ligament. — When downward rupture 
^to the cellular tissue between the folds of the broad ligament occurs, 
fcmorrhnge is seldom serious, because of the counter-pressure exerted 
by the resistant cellular tissue. (Fig. 240.) This results in the forina- 
»n of a hematoma, which is limited or extensive according to the 
Amount of hemorrhage. In this sitiiation the blood clots more readily 
lan in the peritoneal cavity. Tlie embryo usually dies either from 
Isruption of its vascuJar connections or from pressure. The blood- 
^ot, with its contained embryo, is either absorbed or, if infected, 
suppurates and forms a pelvic abscess. Infection is much more fre- 
quent in this situation on account of the propinquity of the rectum. 
If the fetiiB survive the primary rupture, the placenta may form 



Fig. 240. — Ectopic Gestation. Ruptiirr into tlii> limad Lifjamcnt, 



achmenta to the uterus, the floor of the pelvis, or spread out over 
dome of the newly formed gestation-sac. In this situation and 
under these conditions the fetus has a much better chance of going 
to full term than in the peritoneal cavity. It makes room for itself 
by pushing aside the pelvic viscera and burrowing under the perito- 
neum. In this way it may strip off the peritoneum from large nroas 
in the direction ot its growth. The broad ligament gestations furnish 
a large proportion of the cases which reach full term. The tension 
of Uie broad ligament may, however, become so great as to result in 
a secondary rupture into the peritoneal cavity. 

Tubal Abortion. — Tubal abortion is the extrusion of the ovum 
through one or tlie other of the natural outlets of the tube. (Fig. 
17.) In the ordinary acceptation of the tenn it implies the extrusion 




.40fi 



PIlACnCAL GYNECOLOGY. 



of the ovum through the ostium abdominale. This most frequently 
occurs wlicn the ovum is located in the outer segment of the tube and 
in proximity to the ostium. It may result from muscular contractions 
of the tube, but more frequently from hemorrhage into the tube back 
of the ovum, which dislodges and pushes it in the direction of least 
resistance. The effects on the ovum are similar to those of rupture, 
and are influenced by the same conditions. In most instances it is 
destroyed, but, if by any chance the placental attachments are not too 
seriously interfered with, it may survive to bnttle with the same 
exigencies as beset the ovum which has been cast into the peritoneal 
cavity by rupture of the tube. Blood in the unruptured Fallopian tube 



V ' 



c^or'^^^ 



Fig. 247.— Ectopic Gestation. Tubal .Abortion. 
(Autlior's Case. Drawn from ij|)ecinien.) 



is strongly suggestive of tubal abortion, which may be verified by 
finding the chorionic villi at the site of implantation. 

Death of the Ovum. — It seldom happens that the product of tubal 
conception arrives at maturity. W'licu it does, it is usually ill devel- 
oped, malformed, and incapable of independent existence. Vast num- 
bers perish at a very early period, not a few of which yield up life 
before being expelled from the tube. The unit value of the ectopic 
fetus is, therefore, almost nil, and should have no consideration when 
weighed ncjainst that of the mother. 

Disposition of the Ovum or Fetus After Death. — The dead ovum 
in the earlier stages of dovelopiucut, wliether it be in the tube, the 



BCTOPIC GESTATION. 407 

peritoneal cavity, or the cellular tissue of the broad ligament, usually 
undergoes absorption. The effused blood also disappears under the 
same process. lAter, when fetal development has progressed to the 
formation of a bony frame-work, it will usually undergo one of several 
changes. If its sac is intact, absorption of the liquor amnii and the 
gradual desiccation of the tissues will result in mummification, or, 
by the deposition of calcareous salts in the tissues the fetus may be 
converted into a lithopedian. Such dried specimens are usually in- 
nocuous so long as they remain encysted and free from contaminating 
influence, from which they are almost immune. One or two cases 
have been cited in which they were carried by their hostess for a half- 
century or more, and numerous instances are on record in which they 
have remained quiescent during the natural life of the woman. An 
encysted calcified or mummified fetus is not incompatible with normal 
pr^nancy. 

When the fetus is deprived of its envelopes, the warmth and 
moisture, in the absence of air, may result in maceration or adipocere 
formation. Such cases are liable to become septic, and are always 
a serious menace to the life of the woman. The broken-down fetus 
may find exit through the rectum, vagina, bladder, or abdominal wall. 
In one case of my own the fetal debris was discharged through the 
rectum, and it became necessary to remove the angular and sharp- 
edged bones by the aid of the forceps. All that saves the life of the 
woman in these cases of disintegration of the fetus is the fact that 
they are usually walled oflE from the general cavity and protected by 
an enveloping cyst, which prevents the absorption and distribution 
of peccant matters through the general system. Nevertheless, the 
condition is full of peril, and not a few succumb to peritonitis or 
general toxemia. 



CHAPTER XXXIV. 

ECTOPIC GESTATION (Continued). 

Symptoms. — The early symptoms, if any exist, are those of normal 
pregnancy. These may be well or ill defined, but are nsoally less 
marked than in normal pregnancy. The most characteristic of them 
— missed menstruation — will have a significance or not according to 
the menstrual habits of the woman. The habitually regular woman 
will take note of the fact, and will be inquisitive as to its cause. 
Women are seldom indifferent as regards pregnancy, being radically 
opposed to or ardently desirous of finding themselves in that con- 
dition. Hence they are usually on the alert for any manifestations 
of the same. Women who have previously borne children will often 
surmise pregnancy even when the symptoms are obscure, or when 
there is nothing definite upon which to base their opinion. Such 
surmises on the part of the mother should not be treated too lightly, 
for, although she may not be able to give voice to her impressions or 
punctuate the symptoms in detail, she is endowed with a sense which 
takes cognizance of the shadowy complexus, and places an inter- 
pretation on it which is oftentimes surprisingly correct. The close 
sympathy between the uterus and ovum makes of the former a tell- 
tale through which accidents befalling the ovum are announced. Any- 
thing that materially affects the integrity of the ovum is evidenced 
by a bloody discharge from the uterus. Hence, tubal hemorrhage, 
tubal abortion, rupture of the tube, and death of the ovum are habit- 
ually signalized by a bloody discharge from the uterus. Consequently 
it is seldom that the woman passes two consecutive periods without 
a show. In many instances this bloody discharge is looked upon as 
the reappearance of menstruation and regarded with complacency; 
or, if very profuse and long continued, as an abortion. Fragments 
of the decidua or casting of the same en masse seemingly confirms 
the diagnosis of abortion, and not only deceives the patient, but too 
frequently the physician as well, and lulls both into a false sense of 
security. The flow is seldom that of a regular menstruation, being 
intermittent, profuse, or dribbling. 

(408) 



ECTOPIC GESTATION. 



409 



H 



i 



Coincident with the above signs or sometimes later, the woman 
complains of colicky pains in the lower abdomen. They vary in 
verity according to the cause. They may be due to excessive dis- 
ension of the tube, as a result of hemorrhage, or to parting of some 
of the fibers of the tube-walls. Sudden and complete rupture of the 
tube with violent hemorrhage is attended with agonizing pain, faint- 
ness, collapse, and all the indications of internal hemorrhage. The 
internal hemorrhage may be so profuse as to destroy life in a very 
short time. This is the usual termination in complete rupture of 
the more advanced cases, unless the woman be rescued by surgical 
intervention. 

In some instances, the stagnation of circulation incident to the 
fainting will result in temporary or even permanent hemostasis. 
Not infrequently when the rupture is incomplete, the woman will 
have repeated attacks of this kind, though, as a rule, less violent until 
, the fetus is expelled from the tube. In a case which fell to me in 
ithe fifth month of gestation, tlic patient gave a history of having 
experienced three previous attacks, in Ihe last of which she had been 
confined to bed seven weeks. In tiie fourth attack, in which I waa 
first summoned, I found her moribund from the loss of blood, and 
notwitiistauding immediate operation and the use of restoratives, 
including hy})odermocly8i8 of normal salt solution, she failed to rally, 
and died within an hour. In many instances there are no warning 
symptoms of which the patient takes cognizance, and the rupture 
comes with appalling suddenness. 

Rupture into the broad ligament is often followed by paroxysmal 
and oft-ropeated pains, due to the prossure or rending of tissues by 

Cthe growing ovum. This, of course, applies only to cases in whicli 
the fetus survives the rupture. Tubal abortion may or may not be 
accompanied by symptoms of pain or internal hemorrliage. Effusion 
of blood into the peritoneal cavity, even though sterile, provokes a 
localized peritonitis, with its attendant pain and tenderness. The 
general appearance of the patient after a considerable internal hemor- 
rhage from tubal pregnancy is anemic and distressed and oftentimes 
with all the facial indications of extreme illness. 

Spurious Labor. — The culmination of a full-term ectopic gesta- 
tion is tumultuous and tragic : stormy, fruitless labor for the motlier, 
and death for the child. Spurious labor, in its outward manifesta- 
tions, may closely resemble true labor, but is usually characterized by 
irregularity. The individual pains are of unequal frequency and in- 
tensity, with occasional lapses or even lengthy pauses between each 




110 



PRACTICAL GYNECOLOGY. 



Berios. la other words, spurioua labor is more like a aeries of short 
lahore than the regularly progressive labor of normal gf-station. It 
may last from several hours to as many days. When it is ended the 
child is dead and the mother undelivered, but the culmination is 
nevprthol(«s auspicious, for, with the death of the fetus immediate 
danger ceases, and in a few weeks the placental circulation will have 
ceased or have become less active, when she may be delivered through 
tlie agency of surgery. 

Physical Siyng. — In the incipient stage of an ectopic gestation 
there are no physical signs. With the development of the ovum there 



S^ 



Fig. 248.— Hemntocele. 

will be a corresponding increase in the size of the tube. Ijater there 
will be an appreciable enlargement of the uterus, and there may be 
some softening of the cervix and patulousness of its canal. These 
signs become more marked with the advance of gestation, and maj 
even become conspicuous, but, as a rule, those pertaining to the uterus 
seldom do. Before rupture the differentiation of tubal pregnancy 
from a pus-tube is most difficult. The experienced clinician might 
be able to distinguish a little more bogginess or an exaggerated pulsa- 
tion of the tubal vessels, but ordinarily these finer distinctions are not 
apprehended by the average physician, nor can they be implicitly 
relied upon by an expert Immediately after rupture the detection 




EtTOl'IC GESTATION. 



411 



of fluid in the poritonoal cavity is seldom practicable. The patient 
is in no condition for the sjstematic examination which would be 
of utility in determining that point, and the tenderness and rigidity 
of the abdominal walls render such an examination nugatory in the 
absence of an anesthetic. 

After the blood has gravitated into the pelvis, coagulated, and 
become roofed over by adliesions, it becomes conspicuous as a tangible 
mass and easy of detection. An effusion of blood in this situation 
— that is, within the peritoneal cavity — is spoken of as hematocele 
in contradistinction to hematoma, in which the blood is effused into 
the cellular tissue bet\veen the folds of the broad ligament. The dis- 
tinction is important, and the best way to keep the physical charac- 
ters of each in mind is to remember the conditions under which the 



* Fig. 240.— Hpinatoma. 

effusion takes place. In hematocele the ctTusion is unrestrained except 
by the boundaries of the peritoneal cavity, and when it settles in the 
pelvis it occupies the whole pelvic space symmetrically. (Fig. 248.) 
Through the vagina the distended Douglas pouch can be felt as an 
inverted cone or dome, with ito apex in the median line. The uterus 
may be somewhat elevated and pressed against the symphysis, but it 
is not displaced laterally. The intestines crowded upward impart 
increased rotundity and resonance to the upper abdoininal region. 
In hematoma, or rupture into tlie broad ligament, the effusion is 
limited by definite boundaries, — the folds of the broad ligament, on 
the one hand, and the resistant connective tissue, on the other,— eo 
that a palpable fullness is immediately apparent. (Fig. 249.) It is 
either distinctly lateral or, if it encroaches on the other side, it does 
BO by displacing the uterus toward tliat side. A finger in the vagina or 




413 PRACTICAL OYNECOLOOY. 

rectum and a hand on the abdomen will detect the mass extending 
from the uterus to the pelvic wall. If it occupy the left side of the 
pelvis it encircles the rectum and collapses its walls below the peri- 
toneal attachment to tlie same, producing a stricture of the gut, and 
consequent diflBcuIt defecation, which is very characteristic of left 
lateral hematoma. This latter can be easily demonstrated by a finger 
in the rectum. Coagulation of the blood imparts solidity and dis- 
tinctness to the hematoma which admits of definite outlining. Hemat- 
ocele and hematoma are, in most instances, due to ectopic gestation. 

Diagnosis. — Before Rupture. — It is seldom that the history and 
symptomatology of an ectopic gestation prior to the rupture of the 
tube are so well rounded as to warrant a positive diagnosis. Never- 
theless the diagnosis is not infrequently made, and verified by explo- 
rative incision. Such diagnoses, however, for the most part, are 
provisional and tentative, and based upon probabilities. Opportu- 
nities for such diagnoses are not aa frequent as might be desired, for 
the reason that the symptoms of an early ectopic gestation before 
rupture are seldom sufficiently pronounced as to impel the patient to 
seek medical advice. In most instances, where the diagnosis has been 
made, the patient has been under medical surveillance for some other 
trouble, or, suspecting pregnancy, has consulted a physician to have 
her mind set at rest. Rarely she applies to the physician on account 
of symptoms directly attributable to the ectopic pregnancy. Ectopic 
pregnancy before rupture may be suspected if along with some of 
the symptoms of pregnancy — such as missed menstruation, morning 
sickness, or mammary changes — there exists a tubal evlargement on 
one side. The probabilities are increased : 1. If the tubal enlarge- 
ment is of recent date and there is no evidence of recent infection. 2. 
If there is an absence of fever indicating tlie absence of acute tubal 
infection. 3. If the tube is boggy and pulsating. 4. If the patient 
gives a history of sterility extending over a number of years. This 
latter should not be accorded too much weight, as even fertile women 
may occasionally be the subjects of an ectopic gestation. Finally, 
in case of doubt, where the preponderance of evidence is in favor of 
ectopic pregnancy, curettage and microscopic examination of the 
scrapings will clear up the diagnosis. 

After Rupture. — The diagnosis is much more easily made after 
riii)ture, as the indications are much more definite. Here will be 
found in a more advanced stage and in a correspondingly more marked 
degree tlic ovidonces of pregnancy as elicited by physical examination 
of tlie womb: the enlargement, shape, consistence, and cervical 



ECTOPIC GESTATION. 



•I 13 



changes which attend that condition. To these are added the phys- 
ical changes in tlie tube itself, the colicky pains over the region of 
tJie tube, the faintncss or collapse and other indications of internal 
hemorrhage: a bloody discharge from the uterus which contains 
ahreds or casts of decidua. Usually there is very pronounced tender- 
ness of the pelvic and lower abdominal regions, with rigidity of the 
abdominal walls from localized peritonitis. Later, when the blood 
has collected and coagulated, the physical characters of nn hemato- 
cele or hematoma are conspicuously manifest. If the fetus survive, 
its regular and timely development, its movements, and the corrobora- 
tive evidences elicited through ballottemcnt, palpation, and the fetal 
beart-sounds, taken in connection with an empty uterus, leave no 
loop-hole for mistake. In all these investigations the fact should not 
be lost sight of that a normal and ectopic gestation may co-e.xist. 




Fig. 250. — Clamp Kurceps (or Arresting Hemorrhage. 



Prognosis. — Doubtless many cases of ectopic gestation would re- 
cover without treatment. This includes that very large contingent 
in which the ovum perishes early with or without rupture, and in 
tubal abortion where the hemorrhage is inconsiderable. But even 
here infection may call for interference at a later date. In many 
instances, however, the best interests of the patient are subserved 
by interference, and in most this to be eiTectual must be prompt. 
Profuse hemorrhage, as indicated by ehocJc, should always be met 
promptly with knife and ligature. 

Treatment. — Operation. — The dangers from operation up to the 
third month are so small as compared with the risk attending the 
average case of ectopic gestation as to justify the operation in every 
recognized case. The only treatment worthy of consideration is sur- 
gical. The operation for the relief of ectopic gestation may be among 
the easiest and safest or the most difficult and dangerous in surgery. 
The safety of the operation hinges largely on the stage of pregnancy 
and the site of placental implantation. Before rupture all that ia 



414 



TOACTICAL OYKECOLOGY. 



neccitsary is to remove the affected tube, than which nothing can b« 
easier. After rupture with continued bleeding, the first requisite i« 
to seek for and secure the bleeding vessels. The abdomen should be 
opened with all expedition compatible with aseptic precaution, and, 
after hasty removal of such clots as are immediately in the way, 
clamps should be applied to the ovarian artery. The first clamp is 
applied to the uterine extremity of the broad ligament, including the 
tube, and the second to the infundibulo-pclvic ligament near the pelvic 
wall. (Fig. 251.) Usually the first clamp will be suflTicient to arrest 
the hemorrhage, as the Tsssels which supply the tube and ovum are 
recurrent branches of the ovarian artery, and receive a large propor- 



/e.^^» 



\ 



Pig. 251. — First Thing to do in Ruptured Kotopic Gestation; 
Hemorrhage by Applying Clanipa. 



Arrest 



tion of their blood from the uterine side through anastomosis with the 
uterine artery. After the hemorrhage is stanched the tube and its 
contents may be removed, ligatures substituted for the clamps, the 
cavity cleansed, and the incision closed. Where the patient is not 
greatly shocked from loss of blood, the toilet of the peritoneum shoiild 
be conducted with great care and deliberation, either through sponging 
or flushing; but, in case of profound collapse or imminent danger 
to life, little attention should be paid to the blood in the peritoneal 
cavity, and the operation completed as quickly as possible. 

After tlie fourth month the operation for ectopic gestation is 
fraught with so much danger as to almost exclude it from legitimate 
surgery. By most abdominal surgeons it is placed in the retired list 




ECTOPIC GESTATION. 



-Ji; 



until after tlie death of the fetus, unless it should be imperatively 
demanded by the condition of the patient. This danger arises from 
the placenta and the risk of uncontrollable hemorrliage from disturb- 

fing its relations. A coiled rattlesnake in the peritoneal cavity would 
scarcely be more obnoxious to the surgeon or more dangerous to the 
patient tlian an unfavorably planted living placenta of advanced ges- 
tation. Before opening the abdomen, and in many cases even after 
tlie abdomen has been opened, it is quite im]X)88ible to determine the 
site of placental implantation until the gestation-sac has been entered. 
Not infrequently it is cut down on or partially detached before the 
operator is aware of the fact. Under these conditions the hemorrhage 
comes with startling suddenness, and immediately submerges the 
field, placing the operator at a woeful disadvantage. Under such 
circumstances quick action and well directed effort on the part of 
tlie surgeon are the only safeguards to the patient. If the placental 
attachment is such as to admit of ligation of the vascular feeders, all 
may be well, but if, on the contrary, the source of hemorrhage is 
inaccessible, the situation is pregnant with pci-il. Attachment to 
the free surface of the broad ligament or uterus usually admits of 
effective hemostasis by ligating the ovarian vessels of one or both 
sides. Occasionally it may be necessary to ligate the uterine vessels 
or even to perform a salpingo-hysterectomy. Occasionally, the uterine 
vessels cannot be reached from above without disturbing the placenta. 
In such case it may be expedient to clamp them through the vagina. 
When the placenta is attached to the intestines hemostasis by the 
clamp or forceps is impracticable. 

In all cases where the removal of the placenta is considered extra- 
hazardous it should be left undisturbed. Here the sac should be 

|.op>ened cautiously ; the fetus extracted ; the cord clamped and cut, 
leaving tlie end protruding from the wound ; the sac packed with 
gauze, and the mouth of the sac stitched to the abdominal wall. The 
gauze may be renewed at intervals of from five to eight days, or 
oftcner if the exigencies of the case demand. As a rule, the less 
frequently the gauze is disturbed, the less danger of hemorrhage. 

I Recently placed gauze adheres firmly to tlie tissues and may easily 
cause a detachment of the placenta in attempting its removal, whereas 
gauze which has been in contact with the tissues for a longer period 
becomes slimy and free, and can be removed with the greatest facility. 
Putrescence of the placenta may call for antiseptic irrigation or the 
application of liquid or dry antiseptics. I prefer the use of hydrogen 
dioxid, and absorption of the residue by means of sponges in the bite 



416 PRACTICAL GYNECOLOGY. 

of long, slender forceps. This maneuver should be executed with th© 
utmost gentleness and caution to avoid hemorrhage. 

In most instances if the fetus has survived the fifth month, i^ 
has passed through the cycle of rupture and hemorrhage or is no ~ 
likely to do so; hence the immediate perils have greatly decreasec^-^ 
and it is better to wait until the dangers incident to the placenta hav^^ 
been eliminated before operating. This will occur after the cessatioc::^*- 
of placental circulation, which usually occurs within six or eighC^^ 
wccivs after spurious labor, though it may be deferred much longer. 
The life of the child should not be put in the balance against that 
of the mother, for, as has been seen, such children are ill fitted for 
independent existence, and seldom survive. Partial detachment of 
the placenta with violent hemorrhage during the operation should be 
met with firm pressure over the placental mass by means of sponges 
or towels and digital compression of the aorta. After cleansing away 
the blood and examining the environments, if removal of the placenta 
is deemed feasible it may be proceeded with under aortic compression, 
the individual vessels ligatcd, and a firm compress applied over the 
site of placental implantation. A sterilized rubber bag filled with 
small shot makes one of the most effective compresses, and might, 
with advantage, be added to the armamentarium for such occasions. 



CHAPTER XXXV. 

DISEASES OF THE OVARIES— DEFECTIVE DEVELOP- 
MENT— DISPLACEMENTS— CONGESTION. 

ANATOMY. 

The ovaries are two almond-shaped bodies, situated one on either 
side of the uterus and about one inch from it. They are about one 
and one-half inches in length, three-fourths of an inch in breadth, and 
one-half of an inch in thickness. The average weight of an ovary is 
about ninety grains. The pointed extremity of the ovary is directed 
toward the ut€ru8, and its more convex broad surface posteriorly, so 
that it is easy to determine to which side an ovary belongs, even after 
removal from the body. Ovaries vary in size in different individuals, 
and in the same individual at different periods of life. In the healthy 
adult virgin the ovary is plump and smooth and is at the maximum 
of development. The ovaries are somewhat elongated in pregnancy, 
but without increase in other dimensions. After pregnancy they be- 
come reduced below the virginal standard and never regain it. In old 
age they become withered and wrinkled and bereft of functional 
activity. The infantile ovary is shaped like a caterpillar, and extends 
along the Fallopian tube. It sometimes preserves this form through- 
out life. I have recently seen one at the operating-table which was 
nearly or quite three inches in length. The ovaries of the same indi- 
vidual are seldom symmetrical in size or shape. 

The attachments of the ovary are to the broad ligament, uterus, 
and Fallopian tube. That portion which lies in contact with and is 
adherent to the broad ligament i* called the hilum. It is through the 
hilum that the ovary receives its blood-vessels, nerves, and lym- 
phatics. The ovarian ligament attaches the ovary to the uterus. It 
extends from the inner pointed extremity of the ovary to the angle 
of the uterus between the Fallopian tube and round ligament. It con- 
sists of unstriped muscular tissue, and is covered with peritoneum. It 
is about one inch in length. The ovary is attached to the Fallopian 
tube by one of the fimbria. The infundibulo-pelvic ligament, being 
a continuation of the broad ligament from the extremity of the tube 
to the pelvic wall, acts indirectly as a support to the ovary through 

(417) 



418 



PRACTICAL GYNECOLOGY. 



the latter's attachment to the broad ligament and Fallopian tabe. 
This ligament is about four-6ftli8 of an inch in length, but become 
elongated in the child-bearing woman. The attachments of the ovary 
arc such as to insure it a certain amount of mobility, and at the snine 
time restrain it within certain prescribed limits. Through the ovarian 
ligament it always mainfaius a relatively close relation to the uterus 
and follows that organ even in its displacements. 

The blood-vessels are the ovarian arteries and veins. The ovarian 
arteries are analogous to the spermatic arteries in the male. The «• 



Kg. 252. — Ripening Folliele. Human 0\'»ry. 
(Photomicrograph by Grainni.) 



rangement of the veins is of considerable importance from a pathologic 
point of view. The right vein empties into the vena cava, which it 
enters at an acute angle. It is provided with a valve which effectually 
prevents a reflux of blood. The left vein enters the left renal vein ■ 
at an obtuse angle and has no valve, which is supposed to account for 
the greater frequency of congestive and inflammntory troubles on this 
aide. 

The essential histologic element of the ovary is the Graafian 
follicle. Besides the Graafian follicles, the ovary is made up of con- j 
nective tissue, unstriped muscle-fibers, blood-vessels, nerves, and lym- j 



DISEASES OF TIIE OVARIES. 



419 



pliiitics. The portion of the ovary which is not attached to the broad 
ligainent is covered with germinal cpitlioliiim, which is continuous 
with, but differs in cliaracter from, the cpitlieiium of the peritoneal 
investment of the broad ligament. 

The ovary is divided into two portions: the oophoron and the 
paroophoron. These anatomic distinctions are of importance, The 
oophoron is the essential functioning part of the ovary, and is made 
up principally of the Graafian follicles and their contained ovules. 
It is sometimes called the cortical portion, and constitutes the bulk 
of the free projecting portion of the gland. The ovules in an ovary 



\ 



Fig, 253.— Cortex of Ovary, Young Girl. 
(Photomicrogriiph by Qramra.) 

are countless. They have been variously estimated at from thirty 
thousand to one-fourth of a million, an apparently prodigal provision 
for fertility and an indication of Nature's valuation of the reproductive 
function. These ovules are all formed before birth. The par- 
oophoron, or medullary portion of the ovary, forms the core of the 
gland and that portion which is in relation with the broad ligament, 
utlierwise called the hilum. This consists of connective tissue, and, 
88 has been seen, gives passage to the blood-vessels, nerves, and lym- 
phatics. In this situation vestiges of fetal life in the form of gland- 
tubules sometimes form the starting-point for neoplastic growth. 





4->0 PRACnCAI- GTXKOLOGT. 

ANOMALIES OF DE\-ELOPJNEXT A\D POSTTION 
OF THE OVARY. 

Abtenee of the Onxj.—The OTary, as ihe essential ozgan of got- 
cmioa in the ittLile, ie so caxtfullj pn>Tide.i f.jr ia thcidieme of 
life that, so far as knowledge goes, it U never absent except in cou- 
nection wiin the itoit gross and palpable defects of other portions of 
the genital apparatus. It will sometimes elude detection during life, 
either from malformation or malposition, but a (auefully conducted 
autojKj will seldom, if ever, fail to bncg it to light. If not found 
in the pel vis it may sometimes be found in a hernial protrusion or 
possibly in the abdominal cavity, from whence it has never descended. 
The female generative organs, being of duplex origin, may sometiuMi 
be defective or wanting on one side. In such an event the oTarr may 
be wanting on that side, as also its congener, the corresponding kidney. 

Bndimentary Oraiies. — Persistence of the rudimentary state of 
the ovaries in the grown-up individual, while by no means common, 
is, nevertheless, sufficiently often met with to make it a matter of 
practical importance. It ia usually associated with other evidences of 
immaturity, local and general, and stamps the patient with the impress 
of sexual crudity. This is manifested not only in the lack of finish 
of the genital organs, but also in the bodily conformation, carriage, 
and demeanor. The bodily conformation is usually that of a child 
and is built on straight lines, with narrow hips, flattened bust and 
hairless pudendum. The woman with rudimentary ovaries never men- 
struates and is always barren. As a rule, she is devoid of the sexual 
instincts. From the rudimentary type there are varying degrees of 
development of the ovaries, with corresponding approximation of 
the individual to the normal, both in structure and function. One 
fully developed ovary is sufficient to invest the woman with all the 
attriltutes of her sex. Occasionally the rudimentary ovary will be 
found associated with a normal physical development and the cor- 
related graces, sexual impulses, and emotions of the perfect woman. 
It is proliable that in such the arrested development of the ovaries 
is the rfsult of disease in early childhood or before birth. Peritonitis 
iiiid tlif; exanthemata have received credit for stunting the growth of 
the ovaries. The subjects of the rudimentary ovary are, as a rule 
shallow-minded, neurotic, and not infrequently the victims of hystero- 
epilejisy. These conditions are not incompatible with a childish 
vivarity and restless activity. A positive diagnosis as to the condition 
of the ovaries is seldom practicable except through abdominal section. 



DISEASES OF TUR OVARIES. 






It can, however, often be forecast with a reasonable degree of certainty 
by a consideration of the salient features as portrayed above. 

Treatment. — Treatment addressed to the ovaries with a view 
of encouraging development and function is entirely unavailing. 
Should the patient be harassed with violent cyclic disturbances or 
epileptic seizures corresponding in time to the normal menstrual 
period, the ovaries might be removed with a view of stopping their 
ineffectual impulses and with slight prospect of benefit to the patient, 
though it must be admitted that such a result is exceptional. I would 
expect more benefit from oophorectomy in that class in which the 
ovaries were stunted by disease than where the glands were inherently 
istitute of developmental energy. 

Snpernnmerary, or Accessory, Ovaries. — Bland-Sutton says: "As 
the evidence at present stands, an accessory ovary quite separate from 
the main gland, so as to form a distinct organ, has yet to be described 
by a competent observer." Notwithstanding this assertion from one 
of the highest known authorities, other observers of acknowledged 
ability have laid claim to the discovery of a supernumerary ovary. 
Winckel, Kochs, and Keppler each claim to have found a third ovary 
and tube. In the light of such multiplied evidence from such sources, 
the possibility of such an occurrence can hardly be questioned. Still, 
it must be admitted that the condition is one of extreme rarity and 
of slight practical importance. Lobulation of the ovary by constrict- 
ing bands — the result of peritonitis — and more or less wide separation 
of the segments is of much more frequent occurrence, though by no 
means common. These separated fragments of a single ovary are 
often spoken of as accessory ovaries: an obvious misnomer. The 
accessory ovary and the scattered fragments of the divided ovary find 
their chief clinical importance in relation to the operation for bringing 
about an artificial menopause. Here it is essential that all ovarian 
tissue should be removed, and the object of the operation would be 
defeated should one of these bodies escape detection. The presence 
of an accessory ovary has been offered in explanation of the persistence 
of menstruation after the supposed complete removal of the ap- 
pendages. The ultra-extreme rarity of the true accessory and the very 
great rarity of tlie divided ovary as compared with the frequency of 
the phenomenon alluded to invalidates the assumption except in very 
exceptional instances. 

Displacements of the Ovary. — As before stated in describing the 
anatomy of the ovary, it enjoys considerable freedom of movement 
within normal limits, but is withal so definitely connected witli tlie 




423 PRACTICAL GYNECOLOGY. 

uterus that it follows the movements of that organ both within and 
beyond its normal range. Minor displacements of the ovary are not 
easily recognized, for the reason t'.iat no definite radius marks the 
boundary between the normal and abnormal. Such distinctions, how- 
ever, are of no practical consequence, as the slighter deviations have 
no pathology. Pronounced displacement may occur in any direction 
as the result of adhesion or morbid growths. A fibroid growth may 
lift or crowd the ovary far beyond its normal radius, as also may an 
adherent intestine. For the unadherent ovary prolapsus is, by all 
odds, the most common form of displacement. While the prolapsed 
ovary may preserve a position lateral to the uterus, the tendency is 
for it to gravitate into Douglas's pouch and toward the median line. 
Here it may contract adhesions, but in the absence of infection 
usually remains free. Ovaries thus displaced are apt to become en- 
larged and tender from circulatory interference, pressure, and trauma. 
The enlargement is due to congestion and hyperplasia, more frequently 
the former. The symptoms are those of pain and dragging, with 
various and indefinite reflexes. The pain is referred to the normal 
site of the ovary regardless of its abnormal position. 

Treatment. — The habitual displaced ovary cannot be restored 
to position and held there by any mechanical contrivance yet devised. 
If of recent date, replacement and posturing in the knee-chest posi- 
tion, or a more or less sustained decubitus with the hips elevated, 
supplemented by the douche and tamponade to reduce pelvic conges- 
tion, may be of some avail. If associated with a displaced uterus, 
correction of the latter will usually be all-sufficient for the restoration 
of the ovary. Should the purely mechanical means fail to accomplish 
the result, the author's round ligament ventrosuspension of the uterus 
will be indicated. Should the ovarian ligament be very lax, it may 
be necessary to attach it to the proximal portion of the round ligament 
by a single catgut suture. This should be done before the round 
ligaments are drawn into the abdominal wall. 

Hernia of the Ovary. — Hernia of the ovary is congenital or ac- 
quired. Both forms are rare and usually occur into the inguinal canal. 
Congenital hernia of the ovary is often bilateral, and when not so is 
more prevalent on the left side. It is due to the persistence of the 
canal of Nuck. It is often associated with hernia of the Fallopian 
tube and occasionally with that of the uterus. Acquired ovarian 
hernia usually follows a pre-existing inguinal hernia of the bowel or 
omentum, the ovary being drawn into the canal through adhesions 
to these structures. It usually follows parturition when the ligaments 




DISEASES OF TUE OVARIES. 



423 



«re long and the tiosues lax. It occurs most fTequently on the right 
side. This form rnay take place through any of the canals leading 
from the pelvis: the crural, the greater sacro-ischiatic, or obturator 
foramina, or even the umbilicus, 

Diagrwsis. — A palfiable enlargement in the groin, pressure upon 
which evokes a dull, sickening pain and nausea, is suggestive. If the 
patient be an adult, there may be an increase of bulk and tenderness 
at the menstrual period. If the condition is associated with intestinal 
or omental hernia, the characteristic symptoms of these may be super- 
added. Absence of the ovary from the pelvis, when this can be 
determined, will materially aid the diagnosis. 

Treatment. — Except in recent cases it is seldom practicable to 
reduce the hernia by taxis. It should, however, be given a trial, and 
if successful a truss applied. Operation, as for hernia and reduction, 
or removal of the ovary, according to indications, will be found most 
feasible in the majority of cases. 

HYPEREMIA, OR CONGESTION, OF THE OVARY. 

A more or less persistent excess of blood in the ovary constitutes 
hyperemia in the pathologic sense. The condition is quite frequently 
spoken of as congestion of the ovary. A physiologic increase of blood 
in the ovary occurs in sexual excitement, at the menstrual period, and 
in pregnancy. Prolonged or inordiiuite sexual excilenu'nt is a prolific 
cause of hyperemia. Impediment to the venous circulation of the 
ovary, as in malpositions of the glands or twists of its mesentery, and 
the irritation resulting from the impact of morbid growths and foreign 
bodies, may give rise to it. An improperly used pessary is sometimes 
responsible for ovarian hyperemia, though in recent years this cause is 
not operative to anything like the extent that it was some years ago, 
when pessaries were so much in vogue. Ovarian hyperemia some- 
times results from the vascular turgcscence incident to inflammation 
of contiguous pelvic organs. Excessive hyperemia may result in the 
rupture of blood-vessels, the effusion of blood, and the formation of 
an ovarian hematoma. In the light of recent developments it is not 
improbable that some cases hitherto regarded as simple ovarian 
hematoma are, in reality, examples of ovarian gestation. Such in- 
stances are, however, undoubtedly rare. In a general way the hyper- 
emic ovary resembles an inflamed ovary, from which it cannot always 
be distinguished at the bedside. It is only a short step from aggra- 
vated hyperemia to inflammation, but that step becomes an impassable 
gulf in the absence of the essential exciting cause: bacterial infection. 



L 



CHAPTER XXXVI. 

INFLAMMATION OF THE OVARIES (OOPHORITIS). 

As ALREADY intimated in the preceding section, ovarian inflam- 
mation is of bacterial origin. It is questionable if a true inflamma- 
tion of the ovary arises from any otlier cause. Trauma, mechanical 
irritation, prolonged and aggravated congestion, sudden suppression 
of menstruation, acute rheumatism, and the eruptive fevers are occa- 



Ftg. 254. — nnoilti Coli CotnmuniB. (Photomicrograph by Oramm.) 

sionally accompanied or followed by oophoritis, but where opportu- 
nity is offered it will almost invariably be foimd that some form of 
micro-organism is at the bottom of the inflammatory trouble. Some 
of these furnish the specific germ of infection directly, as the exan- 
themata; others through irritation or injuries by which germ inva- 
sion is facilitated. The bacteria concerned in the production of 
Oophoritis are practically the same as those of salpingitis, are derived 
from the same sources, and reach the ovary by the same avenues. 
The chief of these are the streptococcus and gonococcus, although the 
bacillus coli and the pneumococcus are of sufficient frequency to de- 
serve mention. Almost any pathogenic genu may be the eesential 
factor of an oophoritis, and it is not improbable that the specific 
(424) 



I 




INFLAMMATION OF THE OVARIES (ObPUOKlTIS). 



425 



W 



I 



gerni8 of the eruptive fevers play a much more importunt role than 
is conceded to them; but this field haa not been sufficiently worked 
to give prominence to such. The bacillus tuberculosis will receive 
separate consideration. 

The infectious micro-organisms reach the ovary: 1. By the 
lymph- and blood- channels. 2. By continuity of surface over the 
mucosa of the vagina, uterus, and Fallopian tube. 3. Through the 
floor of an ulcer (intestinal) into the peritoneal cavity, thence to the 
ovary. 4. By contiguity of structure from intestine to ovary by way 
rof adhesions binding them together. 

By reason of ita isolated position, primary infection of the ovary 
is of exceeding infrequency. Consequently oophoritis is, aa a rule, 
associated with infectious disease of other structures, which in many 
instances obscures or even masks the symptoms of the ovarian inflam- 
mation. In most cases the concomitant trouble is in or contiguouB 
to the genital tract, and consists of an infectious endometritis, sal- 
pingitis, or localized peritonitis. The various portions of the genital 
jct are sometimes affected one after another with an appreciable 
interval between them, at others in such rapid succession as to appear 
•Imost simultaneous. Occasionally the virus will piiss over or through 
the intervening structures — the uterus and tubes — to fasten upon the 
ovaries without leaving a mark in its course. Inflammation of tlie 
ovaries may be acute or chronic. 



ACUTE OOPHORITIS. 

Tliis is usually the result of streptococcic infection, and, as in 
most instances of such infection of other portions of the genital 
apparatus, is intimately associated with and in a measure dependent 
upon the puerperal state. The mode of inva.'sion is almost exclusively 
by the lymph- and blood- channels. In consequence, the germs gain 
entrance to the intricate depths of the ovary and are disseminated 
throughout its substance. As where the germ is there will the in- 
flammation be, the latter is apt to involve all the structures of the 
ovary from center to circumference. Its initial manifestations are, 
however, most conspicuous in the follicles, and in rare instances may 
be confined to the same. This constitutes the so-called follicular, or 
parenchymatous, oophoritis. Less frequently in the acute form the 
inflammation is chiefly confined to the connective tissue, and is then 
denominated interstitial oophoritis. These distinctions, while of 
interest to the pathologist, are of little practical value to the clinician, 
as it is usually quite impossible to differentiate them at the bedside. 




426 PRACTICAL GTNEOOLOGT. 

As will be seen farther on, other germs may be the leading faeton 
in the production of an acute oophoritis, and the manner of inrasion, 
course, and consequence of the disease modified accordingly. The 
gonococcus comes by way of the Fallopian canal and fastens upon 
the surface of the ovary, producing a superficial inflammation which 
has received the name of periodphoritis. The gonorrheal germ seldom 
penetrates deeply into the substance of the ovary, and is never found 
in the pus of the deep-seated abscesses of the same. The gonococcus 
is a slow-going germ, and does not often give rise to an acute inflam- 
mation; nevertheless acute perioophoritis of gonococcic origin doeB 
occasionally occur. The bacillus coli usually finds its way into the 
peritoneal cavity through the floor of an intestinal ulcer or paaeaB 
directly from the intestine to the ovary through adhesions binding 
them together. In either event the ovary is attacked from the surface 
and the initial lesion is a perioophoritis. This bacterium, however, 
is a deep-sea fish, and sooner or later penetrates to the depths of the 
organ, exciting inflammation as it goes. The pneumococcus is sup- 
posed to gain entrance through the general circulation. The ovarian 
lesion may occur iudependently of pneumonia or tuberculosis. It is 
very virulent, and extends its ravages to the peritoneum and adjacent 
structures. Happily, it is quite rare. The surface germs, such as the 
gonococcus and bacillus coli, sometimes find a ready passage to the 
deeper structures of the ovary through the corpus luteum. 

Morbid Anatomy. — The ovary is swollen, soft, and suixulent 
The vessels are increased in size and tlie finer ramifications of the 
same apparent to the naked eye. The walls of the follicles are in- 
jected, the liquor foUiculi turbid or blood-tinged, and the epithelium 
redundant, which sooner or later falls into disintegration. A round- 
cell infiltration crowds the stroma in the vicinity of the follicle and 
in the more aggravated forms pervades the entire gland. At a later 
period minute purulent points are disseminated through the ovary 
in greater or less abundance. These, by coalescing, form larger depots, 
and may go on to the complete destruction of the organ. Along with 
these internal changes the surface of the ovary becomes involved, 
accompanied by a superficial exudation and a responsive action in 
the contiguous structures, with the result that the ovar/ becomes 
bound down, covered over, and oftentimes completely hidden from 
view. The organs implicated with the ovary are usually the Fal- 
lopian tube, the broad ligament, or the intestine. Thes*, adhesions 
are sometimes dense and difficult to deal with, especially iii the strep- 
tococcic infection, which, coupled with the fact that the pua is apt 



INFLAHLMATION OF THE OVARIES (Ot)PUORlTIS). ril 

to be virulent, has imbued surgeons with a wholesome dread of the 
purulent ovary. A less virulent infection may run its course with- 
t suppuration, and possibly without material damage to the ovary, 
ough in most instances such structural changes are wrought as to 
lly destroy its functional usefulness. Some ovaries are func- 
tionally useless that have all the macroscopic indications of perfect 
organs. This is more apt to be the case in the rheumatic ovary or 
in the lesions associated with the eruptive fevers. 

Symptoms and Diagfnosis. — Acute oophoritis may be ushered in 
bjr a chill followed by Ilnut, nausea, and vomiting. The local mani- 



^■put su 
^Hhougl 
^Birtua 




Jig. 866. — OBphoriOa. (Photomicrograph by Gramm.) 

tations are pelvic pain and tenderness. The pain in its greatest 
tensity is referred to the normal site of the ovary, the tenderness 
to the actual position of tlie organ. Those symptoms may be blended 
with and obscured by the disease of which the ovaritis is a part, or 
with which it may be associated, as endometritis or salpingitis. In 
diseases attended by great pain, as in acute rheumatism, or high tem- 
rature and general distress, as in the eruptive fevere, or obtundod 
ibilities, as in puerperal sepsis, the ovarian trouble may be com- 
pletely masked and go unchallenged. Physical examination will usu- 
ally reveal the enlarged and tender ovaries, by which the diagnosis 
may be confirmed. They will often be found prolapsed behind the 



^oera 

H^ensi 




428 



PRACTICAL GYNECOLOGY. 



uterus, and, as a rule, can be palpated to greater advantage through 
the rectum. Tlie examination should neither be rough nor hasty. 
Gentle, persistent manipulation not only secures the co-operation 
of the patient, but overcomes the reflex antagonism of the guarding 
walls, thereby giving results surprisingly satisfactory where the first 
indications were anything but reassuring. 

Treatment. — Tiie treatment of acute oophoritis is, in all respects, 
similar to that of acute salpingitis: rest in bed, saline laxatives, tlie 
ice-bag, or fomentations or other form of application to the abdomen, 
and, when well borne, the hot vaginal douche. Should the disease not 
yield to this treatment and suppuration occur, oophorectomy should 
be performed. Here, however, as in salpingitis, operation should be 
delayed, if the indications are not too imperative, until such time as 
there is reason to believe that gcrra-life has become extinct Unfortu- 
nately, this does not occur with the same promptitude nor certaint 
in the ovary as in the tube, and a period of quiescence does not ha» 
the same significance here as there. Therefore, at whatever period 
the ovaries are removed, every safeguard should be employed to prevent 
infection of the peritoneum, as the pus from an inflamed ovary ia 
proverbial for its deadly rancour. Nevertheless, it is sometimes found 
of attenuated virulence or even sterile. 



CHRONIC OOPHORITIS. 

Chi-onic oophoritis occurs under two forms : cystic and cirrhotic. 
In tlie first the ovary is studded with small cysts varying in size from 
that of a small pea to a cherry. In some cases the entire ovary 6eema| 
to have been converted into an agglomeration of cy?ts. In others they" 
are sparsely distributed in the substance and over the surface of the 
organ. The cysts have their origin in the Graafian follicles, which 
have become distended with fluid and transformed into veritable cjsts 
by fatty degeneration and absorption of the ovule and granular mem- 
brane. The walls are thickened and the vessels dilated. The con- 
tents of the cysts are usually watery, but may be blood-tinged, turbid, 
or mucilaginous. The stroma is infiltrated with cmbr3onie cells 
which become converted into connective tissue. Whether the 
changes in the follicles are due to inflammation within themselverf 
or to interference with circulation and nutrition, as a result of 
growth and pressure of the connective tissue, is still a moot ques- 
tion. 

In the second, or cirrhotic, form there is a marked increase in 



INFLAMMATION OF THE OVARIES (OOPHORITIS). 



439 



^atru 

^VToce 

■pand 

whi 
tlie 

^d 

en 
of 



_tbe connective tissue (interstitial) elements and a corresponding 
crease of the follicles. This may culminate in the complete de- 
tructioD of the follicles and substitution of connective tissue, or the 
procees be arrested at any stage. In the cirrhotic ovary, as in other 
idular organs, tlie morbidly developed connective tissue impinges 
^pon and crowds out of existence the essential histologic elements, 
which are, in this case, the follicles. In the earlier stages of this form 
tlie ovary may be plump and elastic, but later it becomes dense, pale, 
id wrinkled. In some cases of chronic oophoritis, the changes are 
Bufined to the surface, resulting in the formation of a dense, thick- 
ened tunic. This, by preventing rupture of the follicle and escape 
of the ovule, as effectually destroys functional activity as though the 
parenchjTna had been destroyed. 

Causes, — The causes of chronic oophoritis are practically the same 
"as those of the acute form of the disease, but of modified intensity. 
Many cases arise from the acute form by mergment into the chronic 
state. Gonococcic infection is essentially sluggish and furnislies 
many examples of chronic oophoritis. The causes of ovarian hyper- 
emia which have hc«n enumerated under that head are contributory 
to chronic oophoritis, but are not in themselves sufiBcient to produce 
tlie dii^ease. 

Symptoms and Diagnosis. — The local symptoms are pain and ten- 
derness. These are not usually so marked as in the acute form, and 
^Bre subject to great variation in different patients and in the same 
^Batient at different times. Even in the comparative absence of pain, 
^Kndcmess may be evoked by pressure on the ovary. The pain is 
mcreascd by the intra-abdominal pressure and gravitation of blood 
to the parts, as in bodily exercise, or the erect position, as also by 
coition and defecation. It is also increased by the congestion incident 
^^D the menstrual period. Many cases of chronic oophoritis are at- 
^Hended by menorrhagia. This is especially true of the cystic ovary, 
which gives rise to a most intractable form of uterine hemorrhage. 
The most prominent of the reflex symptoms occur in connection with 
the digestive and nervous systems. These are sometimes the chief 
source of complaint on the part of the patient. Sterility is not un- 
common, both because of the destruction of the follicles and by reason 
of the thickened capsule, which prevents the rupture of the follicle. 
Palpation of the ovary will reveal its unnatural tenderness. In tlie 
earlier stages, and in the cystic form, the ovary will be found enlarged. 
Later in the cirrhotic form the ovary may be reduced in size and of 
fibrous consistence. 




430 



PRACTICAL GYNECOLOGY. 



Pro^osis. — Chronic oophoritis, once well established, seldom 
ceases during the active sexual life of the woman. In some cases it 
subsides into a low grade with little symptomatology; in others it 
nags the woman continually and renders licr life bereft of pleasure 
or usefulness. Cure by medicinal treatment is not to be expected, 
though the patient's condition may be much improved thereby. Moet 
cases recover after the menopause. 

Treatment. — The treatment is palliative and radical. Continual 
circumspection is required on the part of the patient to avoid such 
excitations and exposures as are known to be injurious. Ample time 
should be allotted to recumbency and rest both night and day; the 
bowels should be kept soluble and coition indulged in moderately, if 
at all. The patient should keep her bed at the menstrual period, and 
should take to bed upon the first indication of renewed trouble, and 
remain there until it has passed off. Ilot vaginal douches should be 
taken morning and night, and the vaginal vault painted with Church- 
ill's tincture of iodine, or a combination of this with ichtbyol once 
a week. This should be followed by a tampon saturated with boro- 
glycerid. If the patient is unable to avail herself of these measures, 
or if in spite of them the disease continues unabated, the offending 
organ should be removed. 



TUBERCULOSIS OF THE OVARY, 



4 



Tuberculosis of the ovary, at one time questioned, is now a 
demonstrated fact and of not infrequent occurrence. Next to the 
tubes and uterus, the ovaries are the most frequently affected of the 
genital organs. It has been found tliat the ovary is frequently tuber- 
culous even when there are no outward manifestations of the disease. 
This applies especially to the miliary form. The manner and method 
of infection are as yet undetermined. It will probably be found that 
infection may take place through any of the avenues by which germ 
infection usually takes place. The fact that the miliary tubercle is 
BO generally found in the superficial zone of the ovary would give 
color to the belief that such infection comes either by way of the 
tube or peritoneum. While cases of tuberculosis of the follicle have 
been reported, the process is, for the most part, and to a greater degree, 
confined to the stroma. The miliary form is much less frequent than 
the caseous. In the latter the ovary is enlarged (sometimes greatly 
Bo), covered with plastic matter, and adherent to the uterus or broad 
ligiuueut. The caseous deposits, varying in size from a mere speck to 



INFLAMMATION OF THE OVARIES (OOPHORITIS). 



431 



that of a marble, are disaeminated through the stroma, and, as the 
disease advances, form larger cavities by development and coalescence. 
In this way the ovary sometimes becomes converted into a mere sac 
of matter, and may attain the size of the fetal head. While the 
miliary tubercle has been repeatedly demonstrated, the tubercle ba- 
cillus is seldom found. 

There are a number of incidentals connected with the microscopic 
examination of the ovary for tuberculosis that make it a matter of 
considerable difliculty, even for the experienced microscopist. It will 
be recalled that the miliary tubercle consists of the giant cell imbedded 
in a mass of smaller cells, and that caseous degeneration reprosents 
another phase of tuberculosis. In the ovary the giant cell cannot be 
depended on as indicating tuberculosis, as it is asserted on good au- 
thority that the giant cell in an isolated form is to be found in the 
non-tuberculous ovary. On equally good authority it is claimed that 
caseous deposits may be found in the ovary independently of tuber- 
culosis. It is furthermore asserted that section of the atrophied fol- 
hcle and of the normal follicle to one side of the ovule presents a 
picture so like the miliary tubercle as to be scarcely distinguishable 
from it. 

The differentiation can only be made by noting the difference in 
arrangement of the nuclei of the giant cell and those of the follicle. 
In the giant cell the nuclei are less regularly arranged, but are so 
disposed that their long axes are in direct line from center to periph- 
ery, something like the spokes of a wheel, whereas in the follicle the 
long axes of the nuclei intersect this line obliquely. In most instances, 
however, in the tuberculous ovary, the typical tubercles may be found 
in some portion of the structure, which, if clearly brought out, would 
dispel all doubt. 

Symptoms and Diagnosis. — Miliary tuberculosis of the ovary has 
no symptomatolog}'. The abscess formation within the ovary, coupled 
with the peritoneal involvement, will give rise to the usual symptoms 
of pelvic abscess, which may be severe or mild according to individual 
conditions. There is no reliable method of differentiating the tuber- 
culous ovary from the inflamed and enlarged ovary from other causes ; 
still, there are certain indications which, taken in connection with 
the history of the case, will not infrequently lead to a correct diag- 
nosis. The tuberculous ovary is, as a rule, only slightly sensitive. It 
usually becomes agglutinated to the side of the uterus or to the broad 
ligament, and is often associated with a healthy tube, or, if the tube 
be diseased, it is at the uterine extremity which characterizes the 




432 PRACTnCAL GYNECOIXXIT. 

tuberculous salpingitis. If in connection with these symptoms the 
patient gives evidence of tubercular infection elsewhere, or is of a 
tuberculous family, and there are no tangible evidences of other form 
of infection, a diagnosis of ovarian tuberculosis may be made with 
considerable confidence. 

Treatment. — The only treatment worthy of thought is the re- 
moval of the oiTending organs. This is eminently satisfactory, and, 
when not complicated by too extensive local infection or by general 
or pulmonary tuberculosis, is usually sufficient to stamp out the 
disease. 



CHAPTER XXXVII. 

OVARIAN CYSTS— FOLLICULAR AND GLANDULAR. 

The ovary, more than any other organ of the body, is a fertile 
field for neoplastic growth. Especially does this apply to the cystic 
growths, for here, more than anywhere else, are the anatomic condi- 
tions favorable to the development of cysts. The parenchyma of the 
ovary is little else than a conglomeration of cysts — the Graafian fol- 
licles; the entire physiologic life of the ovary is devoted to the 



./ ( 



I 



Fig. 256. — Scheme Showing the DifTcrent Positions from which 
Cysts may Originate. 

L Girtner'a duct. X FdlopUn tabe. 3. Vertical IuIiuIm of parovarium. 1. Tubule* 
of Kobelt. 6. Parouphorun. B. Oupboroo. 

nurturing and development of the same, which by easy transition may 
be transformed into pathologic cyst formations. Tlie tubules of 
Pfliiger — remnants of embrj'onic life — also contribute to the forma- 
tion of pathologic cysts by becoming occluded and filled with the 
cretion of their lining epithelium. Other methods of cyst formation 
will be alluded to later. 

The neoplasms of the ovary are divided into ajstic and solid. 
The cystic growths of the ovary are much more common than the solid, 
and present a diversity of character and structure. To simplify and 
facilitate the study of these, a number of different classifications have 

(4:53) 





434 PRACTICAL OYNECOLOOY. 

been formulated, most of which have more or lees merit, but, with 
advancing knowledge, one after another has fallen into disuse. These 
classifications have been based upon certain characteristics by which 
the cysts of the ovary may be divided off into groups, each group being 
distinguished from the other by some dominating attribute, such as 
place and mode of origin, structural formation, or clinical history. 
One of the best of these classifications, because the simplest and most 
easy of comprehension, is that in which the cysts were grouped ac- 
cording to the region from which they sprang. Thus, cysts of the 
obphoron constituted one group, of the paroophoron another, and of 
the parovarium still another. It was maintained that the cysts orig- 
inating in one of these groups were different in structure and clinical 
features from those of the others. Modem research has rendered this 
beautiful scheme untenable because inaccurate. The varieties of cyst 
formation of the ovary and its environment are not circumscribed by 
definite anatomic boundaries. In that classification the so-called 
glandular cysts were supposed to originate in one of these marked-off 
zones, and the papillary cysts in another, which, as will be seen later, 
is wholly incorrect. Without violence to any of the known attributes 
of ovarian cysts they may be grouped under the following heads: — 

1. Simple cysts. 2. Proliferating cysts. 

3. Dermoid cysts. 

SIMPLE CYSTS. 

These are little, if anything, more than retention cysts which 
enlarge more from an accumulation of their contents than from 
actual growth. They are lowly organized, sparsely supplied with 
blood-vessels, and are not endowed with the property of propagating 
daughter-cysts or other form of neoplastic growth. In most instances 
the cyst-wall becomes thinned by distension through the accumula- 
tion of cystic contents, though exceptionally the growth of the wall 
keeps pace with the increase of contents. Simple cysts never attain 
a large size, and are often denominated small cysts, in contradistinc- 
tion to the proliferating cysts, wliich are practically of unlimited 
growth. Simple cysts are subdivided into: (a) follicular cysts; (b) 
cysts of the corpus lutcum ; (c) tubo-ovarian cysts. 

Follicular Cysts. — These take their origin in the ovarian follicles, 
and are primarily the result of any condition which prevents the 
rupture of the matured follicle. Chronic oophoritis, which imbeds 
the follicle in a connective tissue matrix, increases the density and 



OVARIAN CYSTS— POLLICUI^R AND GLANDULAR. 



435 



thickness of the tunica albuginoa, or covere the surface of the ovary 
with a plastic exudate, is supposed to be the dominant factor in the 
production of follicular cysts. The inflammation may also con- 
tribute to the cyst formation by increasiug tiie activity of the epi- 
ttioUal cells lining the cyst-wall, and by promoting transudation into 
tJie cyst-cavity. Under this stimulus also the rudimentary follicles in 
the deeper portions of the ovary may be prematuroly developed. In 
thJF way a number of follicles may be affected simultaneously, but, as 
a rule, one dominates the others and crowds them out of existence, 
or fuses with tJieiu to make one large cavity. 

With the enlargement of the cyst the ovary itself becomes atro- 
phied and spread out over its surface, forming a thickened portion 
of the cyst-wall. The follicular cyst, as usually found, seldom exceeds 
the size of an orange, though cases are on record in which it has 
lined the size of the fetal head or even the adult head. In the 
irlier stages the uionibrana granulosa remains intact, but sooner or 
later becomes modified, so that a stratified epithelium supplants the 
columnar. In the larger cysts the epithelium is entirely wanting, 
'having undergone fatty degeneration or pressure atrophy. The ovules 
are also destroyed at a comparatively early period, though occasionally 
an ovule may be found in a cyst of considerable niafrnitude. The 
Cfintents of the cyst are usually clear and limpid, with a specific 
gravity of from 1.005 to 1.020, tliough they may be darkly discolored 
from the presence of blood or purulent from septic infection. Hem- 
orrhage into the cyst may convert it into a hematoma. Clinically, 
the small follicular cyst is indistinguishable from tlie cystic ovary of 
chronic oophoritis. Where the cyst exee<'ds in size that of tlie normal 
ovary, it is safe to class it as a follicular cyst. As a rule, both ovaries 
are involved, though this is not a rule without numerous exceptions. 
Cyst of the Corpus Luteum. — Tliese have their origin in the 
corpus luteum, and are tlie result of degeneration and cystic disten- 
sion of its cavity. It does not appear how the rupture in the follicle 
becomes closed so as to allow the cystic distension, but it is probably 
tlie result of adhesive inflnmination. The cyst of the corpus luteum, 
like other follicular cysts, seldom attains a large size, and as usually 
found docs not exceed that of a hen's egg. It is round or oval in 
shape, of a grayish or yellowish-gray color, and is provided with 
thick walls. The walls consist of two layers, tlie outer of which is 
fibrous, while the inner preserves the characteristic hue and appear- 
ance of the corpus luteum. This inner yellow layer is loosely attached 
to the outer layer, and is thrown into folds. Under the microscope 



436 



PRACTICAL GYNECOLOGY. 



this layer reveals the budding processes peculiar to the corpua lateum. 
The contents are usually dear and watery. Hemorrhage into the 
corpus luteum may give rise to a distinct blood-cyst, which under 
exceptional circumstances may attain a large size. Tlic corpus luteum 
cyst is unilocular, usually single, and located at one of the poles of 
the ovary. Exceptions as to size, number, situation, and contonU of 
the corpus luteum cyst are occasionally noted, as in that of the 
follicular cyst. 

Tubo-ovarian Cyst. — This, as its name implies, is a cyst conjointly 
involving the tui)e and ovary. It is the result of a coiuninnication 
being established between the cystic cavity in the ovary and tlie tube, 
tlie latter of which may or may not be cystic. The pathology of the 
tubo-ovarian cyst is unsettled, but it is probable that the term em- 
braces a number of different pathologic processes characterized by 
cyst formation conjointly involving the ovary and tube. It may arise 
from any form of cystic distension of the tube, such as pyosalpini 
or hydrosalpinx, which forms a communication with any form of cyst 
of tlie ovary, such as the follicular or corpus luteum cyst or ovarian 
abscess. Conversely any of these cysts of the ovary may buret into 
the undistended, but adherent, tube, with tlie result of forming a 
tubo-ovarian cyst. The only excuse for considering the tubo-ovarian 
cyst in this relation exists in the fact that the majority of such cases 
are supposed to arise from the follicular cyst. In all cases of tubo- 
ovarian cyst the tube is agglutinated to the ovary, either by its 
fimbriated extremity or at some other portion of its length, and tlie 
opening between the two may be at the os abdominale or at any point 
of contact. The tubo-ovarian cyst has but one cavity, though there 
is usually a spur or remnant of the septum where the walls have been 
destroyed between them. The cyst is distinctly retort-shaped, the 
globular end of which is formed by the ovary and the stem by the 
tube. The contents are usually clear, but subject to variation. In 
some cases the eyst discharges its contents through the tube into the 
uterus at more or less regular intervals, by which it is temporarily 
relieved. The tubo-ovarian cyst is usually not larger than an orange, 
though it may attain to several times that size. It is usually exten- 
sively, if not dcn.«ely, adherent to contiguous structures. 

Symptoms. — The symptoms are essentially the same as those of 
chronic oophoritis, and consist of pain over the region of the ovary, 
with the various reflex phenomena which attend the chronically in- 
flamed organ. To these are added pressure symptoms when the cyst 
is impacted, and the embarrassment incident to adhesions when such 




OVARIAN CYSTS— FOLLICULAR AND GLANDULAR. f,); 

exist McDorrliagia and metrorrhagia are sometimes prominent symp- 
toms, as in cystic oophoritis. 

Diagnosis. — Bimanual examination will reveal the enlargement 
and oftentimes its cystic character. The suffering and disability en- 
gendered by the simple cyst of the ovary are proportionately much 
greater than in the proliferating cj'st of etjual size, which, as a rule, 
is devoid of either. The absence of development after it has attained 
its limit of growth will also aid in tiie diagnosis if the patient be 
kept under observation. The simple cyst is more frequently bilateral 
than the proliferating cyst. 

Treatment. — The only treatment for cystic disease of the ovary 
is surgical, as no other remedial measure is of the least avail. If one 
could be sure of the diagnosis, simple cysts of the ovary unattended 
by sufTcring might be safely ignored, as they are not intrinsically 
dangerous, but the possibility of mistaking a papillomatous or der- 
moid cyst, which are dangerous at any period, for a simple cyst makes 
it safer to operate in all cases. Unless there be cogent reasons to the 
contrary, it is better to remove the diseased organ, and if, as is fre- 
quently the case, the tube is seriously affected, it should be removed 
likewise. If, however, both sides are aiTected, the question of sterility 
becomes of paramount importance. Here if it is found possible to 
do so with reasonable assurance of success, a conservative operation 
may be performed by eradicating the cyst and bringing the raw sur- 
faces together with fine suture. Where this cannot be done, a shaving 
of sound ovarian tissue left attached to the pedicle will at least per- 
petuate the menstrual function, and may avert absolute sterility. 
Usually, however, the pathologic conditions of the ovary will be such 
as to offer little encouragement for conservatism. 

PROLIFERATING OVARIAN CYSTS. 

The proliferating ovarian cyst, as its name implies, is charac- 
terized by a more or less active proliferation of its histologic elements, 
more especially of the epithelium and connective tissue. It is highly 
organized, abundantly supplied with blood-vessels, and, as already 
intimated, has a growth of its own. In most instances the prolif- 
erating cyst is a breeding cyst: that is, it gives birth to other cysts, 
which, in turn, may develop and hreed still other cysts. Cysts which 
give rise to secondary cysts have been designated proligerous cysts, but, 
as will be seen later, they are not essentially different from the ordi- 
, nary proliferating cyst, as the secondary cyst formation is a mere 




438 



PRACTICAL GYNECOLOGY. 



incident resulting from the overproduction and tubular depression 
of the epithelium into tlie cyst-wall, the mouths of which have become 
occluded. Instead of cystic formations in the walls of the mother- 
cyst, there may spring from its walls little warty excrescences, which 
develop into papillomatous growths. This gives rise to two distinct 
forms of cystic growth known, respectively, as: — 

1. Proliferating glandular cyst. 

2. I'rolifcrating papillomatous cyst. 



.^ 



kv 



Fig. 267. — Glandular Cyst of Uie Ovary. (Photomicrograph by Gratnm.) 



The glandular cyst is so called because of its epithelial clad 
chambers into which the actively secreting cells pour their elaborated 
secretion. Tlie dominant histologic feature of this form is the epi- 
thelial growth. The papillomatous cyst is so called because of the 
papillomatous growth which develops from the cyst-wall and usually 
grows toward the interior of the cyst. The dominant histologic feat- 
ure of this form is the connective tissue growth. 

Pfannenstiel proposes to classify the proliferating cy^ts accord- 
ing to their chemical constituents, or rather with reference to the 
presence or absence of a definite chemical constituent in the content* 
of tlie cyst. This substance, long recognized as a frequent constituent 



OVARIAN CYSTS— FOLLICULAR AND GLANDULAR. 



439 



of the contents of the proliferating cyst, was formerly known as 
paralbumin or nietalbumin, but closer inquiry into its nature divulged 
the fact that it more nearly resembled mucin. It differs from mucin, 
however, in not being precipitated by acetic acid, and contains an 
element of sugar which is liberated when boiled in the presence of 
^dilute mineral acid. In consequence of its resemblance to, but non- 
dentity with, mucin it has been given the name of pseudomucin. 



Rg. 268. — Papillomatous Ovarian Cyat, Woman Forty-seven Years Old. 
(Photomicrograph by Granim.) 



The cysts which contain this substance are designated as pseudo- 
mucinous cysts, while those that do not contain it are called serous 
cysts. The amount of this substance found in the contents of pseudo- 
mucinous cysts varies within wide limits. Some with gelatinous 
contents, as the smaller colloid cyst, are exceedingly rich in pseudo- 
mucin, while others with more liquid contents contain much less of 
it. The pseudomucinous cyst also differs from the serous cyst in the 
character of its epithelium, the epithelium of the former being cylin- 
drical, while that of the latter is columnar and very frequently is 
ciliated. 

While at first sight this classification may seem to differ radically 




440 



PRACTICAL GYNECOLOGY. 



from that into glandular and papillary, there is, in reality, little 
practical difference between tliem. The glandulnr cyst is character- 
ized by an albuminoid or mucoid secretion, while the contents of the 
papillary cyst are serous or watery. As a matter of fact, the glandular 
cyst is tlie pseudomucinous cyst, and most papillary cysts are semus 
cysts. The exceptions to this rule are so infrequent as to be of little 
consequence. The behavior, clinical course, and consequences of the 
glandular and papillary cyst are so widely different and the gro8» 
appearances of the two so strikingly unlike that it is a matter of much 
more importance to distinguish between them than to determine 
whether a cyst docs or does not contain a definite chemical substance. 
This does not, however, minimize the value of the discovery nor 



J^.sVT 



v*W 



Tii 



'el>>f 






«»v 



&iii 



Fig. 259. — Areolar Cyst. 

detract from its usefulness as a means of diagnosis, or of determining 
the nature of questionable growths. 

Aside from the classification just considered there are a number 
of variations in structure and substance which for convenience of 
description are designated by terms expressive of each. Thus: a 
unilocular cyst is a cyst having but one chamber; a multilocular cyst 
is one that is divided into a Dumber of compartments or diambers; 
an areolar cyst is one that is composed of a great number of small 
cysts bound together by an areolar or loose connective tissue, and 
which upon section presents a honeycombed appearance; a colloid 
cyst is one in which the contents are gelatinous in consistence, and a 
myxomatous cyst one in which the connective tissue stroma ia eoft- 
ened and mucoid in appe.'irance and character. 




OVARIAN CYSTS— FOLLICUI^AR AND GI^NDULAR. 



Ml 



GLANDULAR CYSTS. 

These are sometimes designated as multilocular ovarian cysts, 
ovarian adenomata, and pseudomucinous cysts, Tlicy are by far tlic 
most common of the cystic growths of the ovary. They are usually 
unilateral, both ovaries being affected in only about 4 per cent, of the 
cases. The glandular cyst is of unlimited growth, and if not inter- 
fered with will continue to develop until the woman is crowded out 
of existence. In times past, when abdominal surgery was little prac- 
ticed and less believed iu, there were umuy instances of enormous 



Fig. 200. — Colloid Cyst, Ovurian. (Photomicrograph by Gramm.) 



cystic growth of the ovary. Such tumors are now seldom found, 
owing to the facility and safety with which they can be removed. 
The majority of ovarian cysts encountered by the surgeon of to-day 
vrill average from ten to twenty pounds in weight, or even less, though 
occasionally they are much larger. In very exceptional instances, aa 
the result of ignorance or timidity on the part of the patient, ovarian 
cysta of enormous magnitude are met with. Carteledge has reported 
one weighing two hundred and forty-five pounds, upon which he 
operated with a fatal result This is the largest on record. In the 



442 



PRACTICAL GYNECOLOGY. 



spring of 1899 I operated on one weighing one hundred and seventy- 
six pounds, The patient is still living and in excellent health. With 
the one exception, so far as I know, this is the largest ovarian cyst 
ever successfully removed. 

The glandular cyst is found most frequently during the active 
period of sexual life, or between the ages of thirty and forty-five, 
though it occurs much earlier or later in life. Neither infancy nor 
extreme old age is exempt. NuUiparous women are more subject to 
these growtlis than child-bearing women. This has been ascribed to 
the uninterrupted recurrence of pelvic congestion incident to men- 
struation in the sterile woman. The shape of the tumor depends 
much on its composition and structure. In a general way it is ap- 
proximately spherical or ovoid, but is sometimes distinctly lobulated, 
and may be very irregular in outline. The irregularity of contour 
is principally due to the combination of cysts entering into its com- 
position. The older cysts are usually smooth, and conform to the 
shape of the abdomen. The outer surface of the glandular cyst is 
smooth, glistening, and pearly, though this is sometimes modified by 
the character of the contents, as st-cn through the wall, or to inflam- 
matory or necrotic changes affecting the latter. The wall of the cyst 
consists of fibrous tissue with a sparse scattering of elastic tissue and 
unstriped muscle-fibers. Normal ovarian tissue is sometimes demon- 
strable in the vicinity of the pedicle, which is always flattened and 
spread out and never recognizable as a distinct organ. The occasional 
discovery of a corpus luteum in this tissue signalizes the fact that 
glandular cystoma is not necessarily incompatible with pregnancy. 

The cyst-wall is thickest in the vicinity of the pedicle and thinnest 
at the opposite pole. It is divisible into throe layers: an externul and 
internal fibrous, and a middle layer of loose connective tissue. In the 
thinner portions of the cyst-wall these layers are fused, and do not 
admit of separation. The outer surface of the cyst is covered with a 
layer of germinal epithelium : a heritage from the free surface of tlie 
ovary. The inner layer is covered with cylindrical epithelium similar 
in character to the epithelium of mucous membrane, to which it some- 
times bears a striking resemblance. In tlie larger growths these cells 
may flatten out under pressure, assuming the character of pavement 
epithelium, or they may even disappear, leaving the walls of the cyst 
unclad and bare. The middle layer of connective tissue gives passage 
to the larger blood-vessels and lymphatics, and is usually very vaa- 
cular. These vessels also ramify on the surface of the cyst and in the 
connective tissue between the loculi. In some cases, especially in the 




OVARIAN CYSTS— FOLLICULAR AND GLANDULAR. 44f 

areolar form, these vessels are very large and abimdant, and may give 
rise to serious or even fatal hemorrhage if thoy are injured and un- 
attended to. 

The glandular cyst is always multilocular. In the earlier stages 
it is obviously so; but as the growth advances the septa melt away 
under pressure until in some of the older growths there remains 
apparently but one cavity. Close inspection will, however, always 
reveal the ridge-like elevations on the interior cyst-wall which are 
the atrophied remnants of the septa, or small flattened cysts jutting 
from the interior or imbedded in the substance of the wall. The 
unilocular glandular cyst is therefore one in appearance ouly. 



f^TC'- 



Fig. 261.— Ovariftn Cyst with Oouble Pedicle. (Author'* Coa*. 
Drawn from Specimen.) 

The contents of the glandular cyst represent the secretion of its 
epithelial lining. This secretion in its pristine form is more or less 
thick and turbid, with a specific gravity of from 1.010 to 1.050. In 
its physical properties it is subject to great variation in different cysts 
and in different loculi of the same cyst. Ordinarily it is of about the 
consistence of molasses, though it may be of any consistence, from 
that of a thick-set jelly to that of an attenuated mucus. It is often- 
times tenacious, ropy, and slimy. In very old cysts it is occasionally 
almost watery, though even under these circumstances it is apt to 
retain its turbidity. This thinning of the c)'st contents is probably 
I due to the degenerative and pressure changes of the epithelium. The 
contents may be amber-hued, ochery, green, brown, or black from the 



I 




444 PRACTICAL GYNECOLOGY. 

admixture of blood. Exceptionally it is colorless. The pedicle of 
the ovarian cyst is made up of the ovarian ligament, the crest of the 
broad ligament, and the Fallopian tube. It is generally thickened 
and elongated. The pedicle may be long, slender, short, thick, or 
broad. In bilateral ovarian cystoma the cysts sometimes become 
fused, in which case the apparently single tumor would have two dis- 
tinct pedicles. (Fig. 261.) Unless the true condition was recognized, 
the situation would be very embarrassing to the operator. 



CHAPTER XXXVIII. 

OVARIAN CYSTS— PAPILLOMATOUS. DERMOID. AND 
TERATOMATA. 



PAPILLARY OVARIAN CYSTS. 

The distinguishing cliaructeristic of this cyst is a papillary 
growth springing from the interior of the cyst-wall. The papillnry 
cyst is frequently intraligamentous, and according to the older classi- 
fication was supposed to spring from the paroophoron, or from the 
remains of the Wolffinn bodies situated therein. While this view is 
not supported in UAo by recent investigation, there is reason for 
believing that occasionally, at least, these growths do take their origin 
in that part of the ovary in relation to the broad ligament, and that, 
in growing in the direction of least resistance, they make their way 
between the folds of the broad ligament. In many instances, how- 
ever, they develop in the direction of the peritoneal cavity and are 
distinctly pedunculated. The relative proportion of papillary cysts 
which develop between the folds of the broad ligament and into the 
peritoneal cavity is indeterminate, and varies in the experience of 
different operators. Probably there is not much difference between 
these two modes of growth. 

The e.xtra peritoneal, or intraligamentous, cyst has no pedicle, 
and in its removal must be enucleated. The papillary cyst is usually 
bilateral ; in fact, so commonly so tliat, in every case where a papillary 
cyst is found affecting one ovary, the otlicr should be scrutinized care- 
fully for evidence of like affection. The papillary cyst, unlike the 
glandular cyst, is of limited growth, the cyst seldom attaining a size 
larger than the adult head, though in exceptional cases it has equaled 
that of the uterus at term. These cysts are apparently unilocular, 
and, in the sense of having but one large cavity, they are so; but 
careful e.xamination will always reveal small cystic spaces in the wall. 
Scientifically, therefore, they are muUilocular, while practically they 
are unilocular. 

The cyst-wall proper consists of two layers, both of which are 
kfibrous, the outer being compact and dense and the inner less com- 
pact and loose. Unstriped muscle-fibers are sometimes found in the 

(445) 





446 



PRACTICAL GYNECOIXKJY. 



outer layer. Blood-vessels abound in both layers. When the cyst is 
intraligamentous, — that is, when it grows between the folds of the 
broad ligament, — it acquires an additional envelope, the peritoneum. 
The internal surface of the cyst is covered with a single layer of 
columnar epithelium, which is often ciliated. From the interior of 
the cyst-wall spring papillary growths which may be in the form of 
small, warty excrescences or large, arborescent masses. The latter 
have a distinct stalk, from which the branches are given off like the 
branches of a tree. (Fig. 262.) These are sometimefi grouped, some- 
times disseminated over the entire surface. They are covered with 
the same epithelium that lines the cyst-wall. 

The papillomata are usually of a grayish aspect, though they may 
be of a dusky-red or darker hue from the pigment of extravasated 
blood. They are subject to fatty and calcareous degeneration. Fatty 
degeneration imparts a yellowish tint to the growth. The conienti, 
unlike those of the glandular cyst, are clear and watery, with a specific 




Fig. 202.— Slalk of a. Papillary Cyit 



gravity of from 1.005 to 1.035. Most examples of this growth belong 
to the serous variety of Pfannenstiel, and are devoid of mucin. The 
fluid is amber-tinted, but may be variously discolored from the ad- 
mixture of blood. It is partly a secretion from the lining celb and 
partly a transudation from the blood-vessels. Exceptionally, the 
growth partakes more of the nature of the glandular or pseudo- 
mucinous cyst, when the contents may be turbid, slimy, or thick, from 
the presence of mucin. One of the most frequent accidents of the 
papillary cyst is the rupture or perforation of the cyst-wall by the 
papillary growth. (Fig. 263.) As a result, the fluid contents escape, 
and the papillary growth develops untrammeled in the peritoneal 
cavity. Occasionally the papillary growth from the internal surface 
of the cyst-wall is so luxuriant that it completely inverts the ruptured 
sac like an inverted puff-ball, the sac being transposed to the interior 
of the growth. Such cases are sometimes mistaken for a papillomatoua 
growth emanating from the surface of the ovary. 





OVARIAN CYSTS— PAPILLOMA, DERMOID, TERATOMA. 447 

Metastasis of the papillary growth almost invariably occurs after 
rnpture or perforation of tlie cyst-wall. The metastasis is usually 
confined to the peritoneum, though it may alToct any tissue exposed 
to contact with the growth or its secretions. It is due to the ingrafting 
of small particles of the papilloma on the surface of the exposed tissue. 
In this way all the peritoneal surfaces — visceral and parietal — may 
become infected and give rise to secondary growths. When once 
formed they are difficult to eradicate, reinfection occurring in spite 
of the most painstaking effort on the part of the surgeon. The fluid 
contents of the growth may be the medium of infection even though 
the growth itself does not come in contact with the peritoneum, The 
abdominal walls in the line of incision are sometimes infected, and 
in the intraligamentous variety the papillary growth sometimes eats 
its way into the bladder, rectum, or uterus. Ascites is a common 



Ci. 






, --■>-*-■- - 



Fig. 203.— Ruptured Papillary Cyst of tlie Ovary. 



accompaniment of papillary infection of the peritoneum. It is some- 
times present in tlie absence of peritoneal involvement. Because of 
the metastasis and tendency to recurrence, the papillary cyst is the 
most dangerous of abdominal cysts, and, although a benign growth, 

' is not much less to be dreaded than the malignant growths, after 
it has once broken through the cyst-wall. 

Histogenesis of Proliferating Cysts. — For many years the his- 
togenesis of ovarian cysts has been a subject of earnest inquiry and 
much laborious research. The question is not yet settled, though 
much has been learned of a definite character which places the matter 
on a firmer basis than at any previous period. Formerly all cystic 

fgrowths of the ovary, of whatever character, were supposed to orig- 
inate in the Graafian follicles. Ijiter, this view was supplanted by 
that in which the origin of the glandular cyst was referred to tlie 
tubules of Pfluger, and of the papillary cyst to the remains of the 



448 



PRACTICAL GYNECOLOGY. 



Wolffian body. The tubules of Pfliiger, it will be remembered, are 
fonned by the growing downward into the ovary of the surface or 
germinal epithelium in the form of tubular processes. It ia from 
them that the Graafian follicles are developed ; but occisionally the 
last step of the process is not completed, and some of the tubules 
rcnuiin and persist throughout life. Under some form of stimulufl 
tlxese tubules were supposed to be quickened into activity, resulting 
in the formation of the glandular cyst. 

Later research has shown that the Graafian follicle is, to some 
extent at least, concerned in the production of the proliferating cyst, 
and possibly to a much greater extent than has been definitely deter- 
mined. In this respect patliology has experienced a partial reversal 
which carries it back to that period in which all ovarian cysts were 
supposed to have their origin in the Graafian follicle. While the 
former view was too radical, it will be seen that the cystic tumors 
almost without exception have their origin in the inward-growing 
germinal epithelium which is represented in the tubules of Pfliiger, the 
. Graafian follicle, and other epithelial collections in the substance of the 
ovary. It is claimed on good authority tliat at any period of life the 
germinal epithelium may grow downward into the ovarian stroma and 
form the starting-point of a proliferating cyst. It is not improbable, 
therefore, that an ovarian cyst may take its origin in either the 
Graafian follicle, the tubules of Pfliiger, the inverted surface epithe- 
lium, or the remains of the Wolffian body. Another very important 
fact recently developed is that the glandular cyst and the papillary cyst 
may originate from the same source, that the determination of one or 
the other is apparently fortuitous, or that they may be blended in the 
same growth. It is claimed that all cysts — the papillary as well as 
the glandular — start in a proliferation of the epithelium of the 
structure from which they spring, and that this epithelium becomes 
redundant, so that there is not room for it to lie fiat on the internal 
wall of the cyst. 

The nature of the cystic development will depend upon the direc- 
tion in which this redundant epithelium develops. If it grows into 
the cyst- wall in the form of a glove-finger or tubule, the orifice will 
become constricted by the underljnng connective tissue, and a closed 
cavity result, which will develop into a secondary cyst. This is the 
origin of the glandular cyst. If, on tlie contrary, there is an up- 
heaval of the epithelium toward the cavity of the cyst, a fissure or 
crevice will be formed at some point of the epithelial covering of the 
basic membrane, which latter will grow up through the gap and 





OVARIAN CYST&— PAPILLOMA, DERMOID, TERATOMA. 



•11!) 



develop into a papillary growth. This is the origin of the papillary 
cyst. This view of the determining factors of dilTerentiation between 
the glandular and papillary cyst is based entirely upon the physical 
aspects as revealed by the microscope. In my opinion, the essential 
cause of differentiation lies deeper than these ourface indications, 
and the upward or downward growing of the epithelium by which the 
character of the cyst is determined is not a matter of accident, but 
an inherent and predetermined property of the growth as dctiuitely 
filed as any other evolutionary process of the body. 



DERMOID CYSTS. 

The dermoid cyst, as its name implies, is a cystic growth in which 
are found dermoid, or skin-like, structures. Dermoid cysts are found 
in various parts of the body, but the ovarian dermoid diiTors from the 
others in certain essential particulars which stamp it as a distinct 
form of growth. The distinguishing features of an ovarian dermoid, 
as compared with others, will receive attention farther on. The 
dermoid is the least frequent of the cystic growths of the ovary, con- 
stituting only about 3 to 5 per cent, of them. Simple deruioid cysts 
of tlie ovary are usually small, ranging in size from that of an orange 
to that of the adult head. They may become larger as tlie result of 
inflammation or by fusion with glandular cysts with which they are 
often a9.sociated. They are usually unilateral, although in about 15 
per cent, of the cases they are found on both sides. Occasionally two 
or more dermoids will spring from the same ovary. The typical 
dermoid is unilocular. Fusion with other dermoids of the same 
ovary or communication with the chambers of the glandular cyst 
may give the impression of multilocular formation, but careful in- 
spection will reveal the dual character of the growth. 

The ovarian dermoid has been found at every period of life, from 
infancy to extreme old age. They are most frequent between the 
ages of fifteen and forty-five, or during the menstrual epoch. The 
dermoid is usually an intraperitoneal growth and ppdunnilated like 
the glandular cyst, but occasionally it grows downward between the 
folds of the broad ligament and has no pedicle. The external surface 
of the dermoid presents a dull aspect, and is frequently of a yellowish 
or brownish hue. The walls of the dermoid are composed of one ex- 
ternal fibrous layer, to the inner surface of which is attached the 
skin-like substance from which the c}'st derives its name. This may 
clothe the entire inner surface of the cyst-wall, or be limited to cir- 




450 



PRACTICAL GTNECOLOOT. 



cumscribed areaa. Beneath this membrane and between it and the 
external layer is an adipose structure. In the skin-like structurei 
are found all the elements and attributes of the sJcin, such as hair, 
nails, homy projections, and sebaceous and sweat glands. In the 
adipose tissue beneath may frequently be found tissue and structure 
formations in great variety, such as bones, teeth, cartilage, unstriped 
muscle-fiber, and brain and nerve tissue. Less frequently, glandular 
formations resembling the miimmary and thyroid glands, and most 
rarely structures resembling the imperfectly formed eye and ear and 
other anatomic parts in a more or less perfect state are present. In 
fact, almost every ti.<suo and structure of the human body haa been 
found in the ovarian dermoid. It is tliis great variety of tissue ele- 
ments which distinguishes the ovarian dermoid from the dermoids 
of other localities, in which, as a rule, only skin and its appendages 
are found. 

The situation of these structures in the walls of the cyst is marked 
by a prominence which is designated as the parenchyma body. In 
many instances the structural formations are rudimentary and im- 
perfect, but in shape and arrangement they often approsiraate that 
of the liiimnn body. The hair of the ovarian dermoid is usually of 
a blonde or reddish-brown color, though it may be variously shaded. 
In color it bears no relation to that of the surface of the body. It 
may become gray or white with age. It may clothe the entire dermoid 
surface or be distributed here and there in tlie form of tufts. It is 
usually short, but has been known to attain a length of five feet. (Fig. 
2G4.) It is constantly being shed and mingles with the cyst contents. 
It is sometimes found rolled up in bails of fat. The teeth are usually 
imbedded in bone or cartilage, which may resemble the jaw, and are 
set vertically. They are sometimes found free in the cavity. They 
are usually few in number and imperfectly formed, though as many 
as three hundred have been found in a single dermoid, and some very 
perfect specimens are occasionally met with. The inci.sors and molars 
largely predominate. The bones are usually in the shape of plates 
and spiculffi, and simulate the bones which lie under hair-covered 
surfaces, such as the jaw, cranium, and p\ibis. T^ess frequently other 
forms of osseous structure are represented, especially tlie long bones 
and joints. 

The contents of the dermoid cyst are made up of the secretions 
and off-scourings of the dermoid membrane, and consist of sebaceous 
matter, hair, and exfoliated epithelium. They are oily, pultaceons, 
or semisolid, and of a yellowish or brownish color. After death or 




OVARIAN CYSTS— PAPILLOMA, DERMOID, TERATOMA. 451 

noval from the body the contents solidify. The ovarian dermoid 
is quite subject to inflammation and suppuration, when it becomes 
very dangerous. Even in the apparently unaffected dermoid the 
contenta are apt to be acrid and soruetimes virulent, from which a 
fatal peritonitis may ensue should any escape into the peritoneal 
cavity. Tapping of the ovarian dermoid has resulted fatally in a 
number of cases. 

The Histogenesis of the ovarian dermoid is not as yet fully deter- 
mined. Two theories are advanced to account for the conditions as 
we find them. The first, which is known as the "inclusion" theory 
and which held sway for many years, supposes the growth to take its 



.*Bii 



^r- 



Fig. 264. — Ovarinn Dermoid Contjiining a Switch of ITair 

Fourteen Inches Long. (.Author's Case. Drawn 

from Specimen.) 

origin in a bit of displaced embryonal substance which has become 
imbedded or included in the ovary, and which under some form of 
stimulation assumes the protean forms of development as found in 
the dermoid. The second, known as the "ovular," theory supposes 
the growth to take its origin in the ovule, in which alone are blended 
all the elements which go to make up tiie ti.«sue8 and stnicturos of 
the human organism. Under normal conditions the evolution of 
the ovule takes place under the energizing influence of the sperma- 
tozoa, but here the stimulus is unknown and the tendency is in tlie 
direction of parthenogenesis. The number and variety of anatomic 
structures found in tlie ovarian dermoid, embracing almost every 





452 PRACTICAL aYNECOLOaY. 

phase of tissue formation, and representing all three of the embryonal 
layers, are most easily accounted for on the hypothesis of an OTular 
origin, and this is the prevailing sentiment of to-day. Wilms sus- 
tains the ovular theory by cogent argument, backed by careful and 
extensive research. It is only proper to say that Bonnett, still ad- 
hering to the inclusion theory, supports it by ingenious reasoning, 
claiming that parthenogenesis is not an attribute of the higher forms 
of animal life, such as the vertebrates and man. 

TERATOMATA. 

The teratoma is closely allied to the ovarian dermoid in that it 
contains anatomic and structural formations bearing resemblance to 
those of the human organism. Like the dermoid, it is supposed to 
originate in the ovule. Unlike the dermoid, it is not cystic, but made 
up of solid structures, though it may be interspersed with numerous 
small cysts, the result of degenerative changes. It is absolutely a^p- 
ical in its histologic elements, structure, and arrangement, and con- 
sists of a heterogeneous conglomeration of elements and parts con- 
fusedly jumbled together. The epithelial cells are atypical, as in 
cancer; and the connective tissue structures are embryonic, as in 
sarcoma. It is a pedimculated growth, lobulated, and presents a 
smooth external surface. The growth is unlimited, and may attain 
enormous proportions. It is exceedingly malignant, and is dissemi- 
nated both by metastasis and implantation. By some it is supposed 
to represent a malignant degeneration of the dermoid cyst at an early 
stage, wliich would account for the disarrangement and confusion 
which are so characteristic of the growth. 

THE COMPLICATIONS OF OVARIAN CYSTS. 

Ovarian cysts may be complicated with local and systemic con- 
ditions of almost every conceivable character. The most important 
of these, because the most frequent, are: inflammation, adhesion, 
suppuration, torsion of the pedicle, ascites, and rupture. 

Inflammation. — Inflammation is common, and is usually the re- 
sult of infection from the Fallopian tube, vermiform appendix, intes- 
tine, or bladder, in the order named. The smaller pelvic cysts are 
more subject to inflammation than the larger cysts which occupy the , 
abdominal cavity. Dermoids are especially liable to inflammation. 
Among tlie most common results of inflammation of ovarian cysts are 



OVARIAN CYSTS— PAPILLOMA, DERMOID, TERATOMA. 45;^ 



tlie adhesions which thej contract with contiguous structures. Some- 
times these adhesions are quite limited, and when so usually occur 
between the infecting organ and the cyst. Thus, the adhesions may 
be limited to the tube, appendix, a loop of inti'stine, or the bladder. 
Quite frequently, however, they are more extensive, and may involve 
the entire cpt-wall with all environing stnicturos. Recent adhesions 
are soft and easily broken up, but the older adhesions are apt to 
become organized and dense. The latter are vascular, and sometimes 

.contain vessels of large size, especially if connected with vascular 
organs, such as the uterus, bowel, or bladder. Adhesions are not 
always an unmitigated evil, as might appear at first sight, for it some- 
time* devolves on them to preserve the vitality of the cyst when the 
blood-supply is cut off through the pedicle. The appendi.v is fre- 
quently attached to the cyst-wall, and should be looked after in opera- 
tion lest it be forcibly torn asunder with disa.>itrou9 consequence. 

Occasionally an inflammation of the cyst terminates in suppura- 
tion. The dermoid cyst, because of the character of its contents, is 

,fi6i)ecially prone to suppuration. Suppurative infection of the cyst 

rtlirough tapping used to be of frequent occurrence, but is now happily 
seldom seen because of the discontinuance of the practice. The sup- 
purating ovarian cyst gives rise to severe constitutional symptoms, 
as manifested in the pulse, temperature, gastro-in test inn! disturbance, 
and loss of flesh and strength. These are due to the absorption of 

,toxic elements, and will culminate in death unless relieved. The 
suppurating cyst contracts adhesions to adjacmit viscera through 
wliich the pus finds exit. In this way it may discharge into the 
bladder, bowel, vagina, rectum, or through the abdominal wall. When 
it discharges into the bladder it generally provokes a violent cystitis. 
The dermoid is peculiarly irritating. Hair, bones, and teeth thus 

.occasionally find their way from tlie cyst-cavity into the bladder. 

^These may form the nuclei for vesical calculi, and the hair sometimes 
becomes wadded and engaged in the urethra, interfering with the 

.evacuation of the bladder and adding greatly to the distress of the 
patient. When the c^'st connects with the bowel, and sometimes as 
the result of decomposition, the cyst-chamber becomes partially filled 
with gas. This imparts to the cyst a tympanitic note on percussion 
which may be confusing to the examiner. 

Torsion of the Pedicle. — Axial rotation of the ovarian cyst, with 
consequent twisting or torsion of the pedicle, is an event of not 
infrequent occurrence. On an average, it occurs in about one case 
in ten. The torsion may consist of one partial turn, or there may 



454 



PRACTICAL GYNECOLOGY. 



be many complete turns, bo that the pedicle is twisted into the sem- 
blance of a rope. The causes of the rotation of the tumor on its 
axis are not known. It has been ascribed to the alternate filling and 
emptying of the bladder, to tlie passage of the focal mass along the 
colon, and to bodily movements, such as turning in bed. It occurs 
more frequently with tlie smtiller cysts, and for some reason is more 
frequent in pregnancy. The direction of rotation is usually from 
without inward. The results will depend upon the degree of torsion 
aiid the rapidity with which it is accomplished. In fact, the whole 
matter depends upon the amount of compression to which the vessels 
which supply the tumor and which reach it tlirough tlie pedicle are 
subjected by the torsion. The veins, being more compressible than 
the arteries, are the first to siifTer. In consequence, the venous blood 
is dammed up in the tumor and the vascular channels greatly en- 
gorged. Sooner or later rupture of the overdistended vessels occurs, 
and blood is poured into the cyst-wall and ca\'ity. Very exceptionally 
a rupture will occur on the external surface of the cyst-wall and tlie 
blood escape into the peritoneal cavity. As a rule, the external sur- 
face of the cyst becomes covered with a plastic exudation, which cause* 
it to adhere to the viscera. 

The symptoms are rapid enlargement of the cyst, accompanied 
by rending or tearing pains and shock, followed sooner or later by 
evidences of toxemia. Patients have died from the loss of blood alone. 
In aggravated cases which survive the initial stage the cyst-walls may 
become necrotic from pressure, the extravasated blood exerting such 
pressure as to shut off the blood-supply in the circulating vessels. 
Where the torsion comes on gradually tlie vessels in the pedicle may 
accommodate themselves to the altered condition, and there may be 
no appreciable effect on the tumor. In chronic torsion the pedicle 
sometimes becomes twisted in two, mainly as the result of pressure 
atrophy and arrested circulation, thus severing the tumor from its 
normal connections. In such cases the cj-st may derive its blood- 
supply from the structures to which it has become adherent. 

Diagnosis. — The diagnosis is based on the rapid enlargement of 
the cyst, the attendant pain, and the evidences of shock, and consti- 
tutional symptoms indicative of toxemia. A previous knowledge of 
the cyst and its status makes the diagnosis easy. 

Treatment. — In acute torsion of the pedicle with rapid enlarge- 
ment of the growth and the coincident phenomena of pain and shock, 
immediate removal of the cyst is called for. Temporizing usually 
results in increased disability and accumulated difficulties and dan- 



OVARIAN CYSTS— PAPILLOMA, DEUMOIU. TERATOMA. 455 



gcrs. The patient should be sustained by the use of cardiac stimulants, 
such as strychnine and brandy hypodermically, clysters of asafetida, 
and hypodermoclysia of normal salt solution. She should be well 
protected against cold, the operating-room brought to a high tempera- 
ture, and the operation performed as expeditiously as compatible with 
safety. Owing to the altered condition of the cyst-wall, the use of 
the trocar may not always be foftsible. In such cases a free abdominal 
incision through which the cyst may be delivered entire, or an in- 
cision into the the cyst which will admit of rapid evacuation of the 
cyst contents, should be practiced. A Turck sterilized rubber bag filled 
with hot water and thrust into the peritoneal cavity to counteract 
sliock may sometimes be used to advantage, especially if the operation 
be prolonged for any reason. 

Baptore of the Ovarian Cyst. — This is an accident which, though 
not often brought to the attention of the surgeon, is much more fre- 
quent than such a fact would indicate. Spencer Wells in a series of 
three hundred cases found that rupture of the cyst had taken place in 
8 per cent, of them. Many ruptures probably occur in the smaller 
cysts without the knowledge of the patient because of the absence of 
symptoms to indicate the same. The rent in the cyst-wall usually 
heals and the cyst refills. In some cysts the rupture is repeated time 
after time, as evidenced by the number of scars found in the cyst-wall 
after removal. The predisposing causes of rupture are thinning of 
the walls from overdistension, fatty or other degenerative changes, 
suppuration or thrombosis, and the erosive action of papillary growths, 
which literally eat their way through the walls, ilany cysts are weak- 
walled from the beginning, and it is from this contingent that the 
larger number of ruptures are realized. The exciting causes are usu- 
ally a blow or fall or pressure on the cyst-wall. When the cyst-wall 
has become attenuated and weakened, a very slight impulse will be 
sufficient to determine the rupture. Sneezing, coughing, vomiting, 
turning in bed, coitus, straining at stool, and the manipulations in- 
cident to a physical examination are among the most common of the 
exciting causes. 

Results. — Rupture of the ovarian cyst is usually devoid of danger, 
for tlie reason that it is apt to occur in the simple, thin-walled cyst 
with bland contents. Under other conditions the rupture may be 
fraught with direst consequence. Where the escaped fluid is bland 
and unirritating it is absorbed by the peritoneum and expelled by 
the kidneys. An active diuresis in proportion to the amount of fluid 
contained in the cyst always follows the intraperitoueul rupture. The 




45(i PRACTICAL GYNECOLOGY. 

expelled fluid is pale and limpid, and when the cyst is large may be 
phenomenal in quantity. When the fluids are acrid or poisonous, is 
in the suppurating or dermoid cyst, peritonitis and toxemia are almost 
sure to follow, with a fatal result. The escaped contents of a cyst 
may infect the peritoneum with a growth similar to that of the cyst 
from which they escaped. Thus, escape of the contents of the papil- 
lomatous cyst may be followed by papillary growths of the peritoneum, 
those of the colloid cyst with colloid growths, and those of the dermoid 
cyst with dermoid growths. Hemorrhage following rupture of the 
cyst is seldom profuse, for the reason that the rupture usually occurs 
at a point where the walls are thin and comparatively free from ves- 
sels. Rupture from violence may, however, be followed by alarming 
or even fatal hemorrhage. Occasionally the cyst will rupture into 
the bowel or bladder, or in some of the other directions spoken of 
under "Inflammation" of the cyst, in which event the contents will 
be discharged directly from the viscus into which the rupture has 
occurred. 

Symptoms. — In the majority of instances the rupture occun 
without pain, vital depression, or any other systemic disturbance. 
If the cyst be of any considerable size, there will follow an appreciable 
or even marked diminution in the size of the abdomen, preceded and 
accompanied by an active diuresis. Through the collapsed and flaccid 
abdominal walls the residual cyst-wall may often be palpated with 
great distinctness. Should the cyst be ruptured by violence, there may 
be great pain, faintness, and evidences of internal hemorrhage. Rupt- 
ure of the septic cyst will be followed by the vital depression and grave 
symptoms of an oncoming peritonitis. 



CHAPTER XXXIX. 

CLINICAL HISTORY OF OVARIAN CYSTS. 

The clinical history will depend largely upon the situation, size, 
and character of the growth. The papillomatous cyst presents a dif- 
ferent history from the glandular, and the intraligamentous from that 
which occurs free in the peritoneal cavity. These differences have 
been foreshadowed in the preceding pages, and it only remains to call 
attention to the most salient features of each. 

Symptoms. — Small or moderately developed ovarian cysts are 
often devoid of any symptoms sufficiently marked to attract the 
patient's attention. It is by no means unusual to find a patient with 
an ovarian cyst of which she had neither knowledge nor suspicion. 
Large cysts will, of course, force themselves on the attention of the 
patient, and usually make themselves felt by crowding upon the 
stomach and lungs. Intraligamentous cysts, by reason of their con- 
fined position, are apt to give rise to pressure symptoms at an earlier 
date. They may press upon the rectum, giving rise to mechanical con- 
stipation, hemorrhoids, or dystenteric symptoms; upon the bladder, 
giving rise to irritable bladder or retention of urine; and by pressure 
upon the ureter produce ureteral obstruction and nephrodrosis. Dis- 
ablement of the kidneys as the result of compression of the ureters 
and direct pressure of the larger tumors is a very common accompani- 
ment of the neglected cystic growths of the ovary. In a series of forty 
autopsies on such cases Doran found the kidneys diseased in four-fifths 
of them. 

Another very common symptom of the intraligamentous growth, 
whether it be cystic or solid, is menorrhagia. This is due to pressure 
on the large veins emerging from the uterus and the interference 
with the return of blood from the same. Pain is seldom a prominent 
symptom of the ovarian cyst, and is often entirely absent. When 
present it is due to pressure, inflammation, or some of the accidents 
to which the cyst is subject. Ascites occasionally occurs as the result 
of mechanical irritation of the peritoneum, occasioned by the presence 
and mobility of the tumor. It is seldom a prominent symptom except 
in the papillomatous variety. Here it arises from the intrinsic irritat- 
ing properties of the escaped contents of the cyst. Pronounced ascites 

(457) 



458 PllACTICAL GYNECOLOGY. 

occurs in malignant degeneration of the cyst. The ascitic fluid in 
such cases is apt to be dark, and frequently bears a close resemblance 
to prune-juice. In large cysts pressure on the veins may produce 
edema of the lower extremities and lower portion of the abdomen. 
The uterus — ^though often displaced backward or forward, upward, 
downward, or laterally by the cystic growth — is not, as a rule, ma- 
terially affected in its functional activities. Menstruation generally 
proceeds with regularity. Occasionally it is increased, as in the in- 
traligamentous cyst, and less frequently diminished or absent. Preg- 
nancy is by no means rare, and constitutes a complication of much 
gravity. 

The rapidity of growth of the ovarian cyst varies within wide 
limits. Proliferating cysts are the most rapid of growth, and will 
sometimes enlarge appreciably in a few weeks' time. Papillomatous 
and dermoid cysts are usually of slow and limited growth. They will 
sometimes remain quiescent for long periods. Much difference as to 
the rapidity of growth exists even between cysts of the same character. 
The termination of cystic growths of the ovary, if undisturbed, ii 
in death. The exceptions to this rule are so infrequent as to be 
unworthy of consideration, and should under no circumstances be 
taken as an argument against operative interference. Taking into 
consideration the variable rapidity of growth, it is impossible to 
predicate the duration of life in any given case. The average life of 
the woman with a proliferating ovarian cyst is about two or three 
years from the date of its first appearance as an abdominal growth. 
Some cysts will grow so rapidly as to terminate life in a much shorter 
period. Slow and measured growth of the cyst will sometimes estab- 
lish a tolerance which will enable the patient to survive a degree of 
development far beyond that which would have been tolerated had 
the growth been more rapid. It is from such cases that are derived 
the records of enormous cystic development and longevity of the 
patient which form such an interesting chapter of earlier history. I 
have known patients to be alive twelve to fourteen years after the 
cyst had been recognized. Such cases, however, are extremely excep- 
tional. 

Cysts which have been tapped refill rapidly. In times agone, 
wtien tapping was the only surgical resource, the records teem with 
instances of remarkable recuperative energy of cysts from which the 
contents have been withdrawn by tapping. In one case nearly 10,000 
pounds of fluid were withdrawn in successive tappings. Simple cysts 
may disappear after tapping or ruj)ture, though, as a rule, the breach 



CUNICAL HISTORY OF OVARIAN CYBTS. 



459 



I ad 

Is 



healed and they refill. The proliferating cyst always refills. Death 
the result of impaired appetite and digestion, sleeplessness, and 
terference with respiration and circulation. Nephrodrosis and im- 
irment of the kidney may contribute to the fatal result. Death 
y sometimes be precipitated by one of the accidents to which the 
syst is subjected, such as torsion of the pedicle, rupture, and suppura- 
tion of the cyst. 

Methods of Examination. — The means employed to determine 
the presence of an ovarian cyst and to dilTerentiate it from other con- 
ditions which may simulate it are: inspection, palpation, percussion, 
and auscultation. 

It is important that the patient should be prepared for the 
examination by a preliminary evacuation of the bowels and bladder. 
The clothing should be removed or loosened and so disposed as to 
admit of the untnuiimeled use of all the means of examination. Small 
pelvic cysta which have risen into the abdomen may be examined 
limanualiy. The typical uncomplicated ovarian cyst is spherical, and 
iresents a smooth or lobulated surface according as it is simple or 
conglomerate. The cyst may be located in front, back of, or at either 
side of the uterus. In most instances it has fallen down into Doug- 
las's pouch. If the cyst be pedunculated, it is distinctly movable, the 
range of motion depending on the length of the pedicle. It may 
sometimes be pushed up into the abdomen or moved from side to side 
within an extensive radius. These movements are independent of the 
uterus, and indicate that the tumor has no intimate relation with it. 

^If the cyst be intraligamentous it is neither so distinctly spherical nor 
movable, and is in more intimate relation with the uterus. It is not 
often that fluctuation can be detected in the small ovarian cyst, but 
they possess an elasticity which to the experienced touch is quite 
Characteristic. Dermoid and papillomatous cysts are less elastic and 
more boggy. The uninflamed cyst is comparatively insensitive, and 
I may be handled freely without eliciting pain. 

l^^ In most instances it is not possible to distinguish between the 
^■iff^ent cystic formations, nor yet is it material, as all alike should 
^Receive the same treatment. The cyst may be distinguished from dis- 
^^nased uterine appendages by the history, which excludes pelvic inflam- 
mation; by the spherical shape, and by the absence of sensitiveness. 
The cystic tube is elongated, club-shaped, or coiled. It may be dis- 
' tinguished from the uterine fibroid by its regularity of outline, its 
I greater elasticity, and by its dissociation from the uterus, as indicated 
' by its independent movements. An inflamed, adherent, or imbedded 




4(50 PRACTICAL GYNECOLOGY. 

cyst may cloud the diagnosis or make differential diagnosis impossible. 
In such cases the patient should be given the benefit of the doubt and 
the case treated on the supposition that the tumor is cystic. 

In cysts which have escaped from the pelvis or grown up into 
the abdomen, additional methods of examination are required. The 
woman is placed on her back with her thighs flexed and the abdomen 
exposed. The extremities and genitals should be covered with a sheet. 
In lax or thin-walled women the position of the cyst is indicated by 
a mound-like elevation or prominence. Cysts of medium size usually 
occupy the middle of the abdomen, though cysts of this or smaller 
size may be located distinctly on one or the other side. When a .cyst 
is located on one side of the abdomen it is usually taken as an indica- 
tion that it sprang from the ovary of the corresponding side. The 
rule will hold good in many cases, but is by no means infallible, as 
a long pedicle may easily allow of displacement to the opposite side. 
By palpation the general character of the surface may be determined, 
which will be smooth and spherical in the unilocular cyst, and 
lobulated and perhaps irregular in the multilocular cyst. By placing 
the hand on one side of the cyst and gently tapping the other with 
the tips of the fingers, fluctuation will be elicited. If the cyst be 
unilocular, the fluctuation wave is distinct; if multilocular, the wave 
is shorter and less distinct and sometimes inappreciable. In women 
with fat abdominal walls the movement imparted to the semifluid fat 
by percussion will often so closely resemble the percussion wave of 
the cyst as to be indistinguishable from it. This may be eliminated 
by forming an artificial diaphragm in the abdominal wall. This may 
be done by directing an assistant to apply the ulnar edge of the hand 
to the surface of the abdomen midway between the percussing finger 
and the hand opposite, and make firm pressure. This arrests the 
fat-wave or any other that may be communicated through the ab- 
dominal wall, so that any impulse perceived is known to arise from 
the agitation of fluid in the peritoneal cavity. The same result may 
be secured by percussing across the umbilicus from side to side or 
in a longitudinal or diagonal direction. 

Aside from the fluctuation wave, which is elicited and recognized 
by a combination of percussion and palj)ation, percussion is the most 
reliable means of determining the presence of an ovarian cyst. Where 
the abdominal walls are thick and firm, or where the cyst fills the 
abdomen, it is indispensable and gives more infurniation than all other 
methods combined. By it the cyst may be definitely outlined and 
its size and situation accurately determined. The percussion note 



461 



over the cyst is dull, while that of the unoccupied space is resonant, 
such as would proceed from the stomach or intestines. The intestines 
are usually crowded upward and to the sides; consequently the reso- 
nant area of the abdomen is in outline something like a horseshoe 
with the convexity upward. In very large cysts the resonant area is 
confined to the upper portion of the abdomen and to one flank. (Fig. 
265.) The relative positions of the dullness and resonance are never 
changed by positions of the body or other cause. 

Differential Diagnosis. — There are many conditions of the pelvis 
or abdomen which to outward appearance more or less resemble the 
ovarian cyst, and which have on occasion been mistaken for it. 
Usually it is not ditlknilt to distinguish between them; nevertheless 
there are isolated cases in which the differentiation is extremely diflB- 




Fig. 266.— The Dull Area of on Ovarian Cy«t, (Author'a 
Case. Drawn from a Photograph. ) 



cult or impossible. In some of these it is of the utmnst importance 
that a correct diagnosis be made; in others, a mistaken diagnosis will 
be of technical rather than practical import, and will be burdened with 
no serious consequence. To mistake the pregnant uterus for an 
ovarian cyst may be fraught with the most disastrous consequence, 
whereas if a pus-tube is mistaken for an ovarian cyst no serious result 
is likely to ensue, as the same treatment would be indicated for both. 
Happily the conditions demanding differentiation are, as a rule, 
capable of solution. Pregnancy, obesity, tympany, or other condition 
in which operation would be uncalled for can usually be difTerentiated 
with absolute certainty, or at least they invest the question with so 
much uncertainty as to stay the hand of the cautious surgeon until 
the doubtful features of the case can be eliminated. Happily, also. 




462 PRACTICAL OYNBCOLOOY. 

the greatest diiiiculties are encountered in differentiating the ovarian 
cyst from other pathologic conditions in which the treatment indicated 
for one would be applicable to the other. It matters little whether 
the abdomen be opened for an ovarian cyst, inflamed appendages, or 
broad ligament cyst, or whether it be a papillomatous, dermoid, or 
glandular cyst, as all alike demand operation by abdominal section. 

Among the more common conditions with which an ovarian cyst 
may be confounded are: pregnancy, uterine atresia with retention of 
fluids and gases, uterine fibroid, ascites, fecal impaction, phantom 
tumor, distended bladder, mesenteric cyst; cysts of the liver, kidney, 
and spleen; and desmoid cysts. 

In attempting the differential diagnosis of the ovarian cyst from 
other conditions which may simulate it, first ascertain if the growth 
is of pelvic origin: if it springs from the pelvis and is attached to 
the pelvic organs. If of pelvic origin, the next question is to deter- 
mine the organ from which it developed. If this cannot be determined 
with ease or certainty, it will be necessary to proceed with the search 
systematically. As the womb is the most accessible organ in the 
pelvis, the examination will usually begin with this. 

Locate the uterus, and if possible map it out, and especially seek 
to establish its connection with or independence of the growth. For 
this purpose every known method should be resorted to: bimanual 
examination with fingers in the vagina or rectum, dragging down the 
uterus with a volsellum while the rectal finger explores its surface and 
determines its relation to the growth (Hegar's test), noting the effect 
of movements of the uterus on the tumor or of movements of the 
tumor on the uterus; if they move in concert the growth springs from 
or is attached to the uterus; if a movement imparted to one is not 
communicated to the other, they are independent. This may be 
designated as the movement test. The greatest range of movement 
may be obtained by pulling down on the cervix or lifting up on the 
tumor. An attempt should be made to locate the ovaries; if both 
ovaries can be located, the tumor is obviously not ovarian. 

Pregnancy. — One of the most frequent errors, as well as the most 
serious, is to mistake the pregnant uterus for an ovarian cyst. This 
mistake has not only occurred to the inexperienced, but too often to 
the schooled diagnostician. It is usually the result of overconfidence, 
though cases are encountered which, for a time at least, baffle the 
skilled diagnostician. In difTerentiating between pregnancy and the 
ovarian cyst the history of the case should be well considered. The 
development of the growth is more rapid in pregnancy, and is usually 



CTJNICAL HISTORY OF OVARIAN CYSTS. 



4fi3 



^ 



ina 

i 



ended with the Bymptoms peculiar to that condition: suppression 
menstruation, nausea and vomiting, and other reflex disturbances, 
should not be forgotten, however, that these are not always present 
in pregnancy. An attempt should be made to outline the uterus by 
anuaj examination, and to separate it from the tumor. Softening 
the cervix (Hegars sign), periodical contraction, quickening, fetal 
movements, heart-sounds, may all or severally by their presence or 
absence help to solve the problem. In case of doubt wait, examine, 
d re-examine at monthly intervals until pregnancy is affirmed or 
eluded. Operation for ovarian cyst may well be deferred in the face 
of such a grave responsibility, even to the completion of gestation, 
though this will seldom be necessary. Unmarried women who have 
been guilty of indiscretion will not infrequently deny the knowledge 
or possibility of pregnancy, and will even submit to operation rather 
than admit their guilt, or with the hope of ridding themselves of the 
evidences of it. In examination for ovarian cyst the possibility of 
pregnancy should always be uppermost in mind, and no diagnosis 
made nor action taken until this condition can be excluded. Preg- 
nancy may complicate an ovarian cyst which may or may not have 
been known to exist. With the increased vascularity incident to preg- 
nancy the growth becomes greatly accelerated. The rapid increase in 
the abdominal enlargement, with the usual phenomena of pregnancy 
will cause the patient to seek medical counsel, when by careful exam- 
ination the condition will be disclosed. In many respects the external 
idences of hydramnios are similar to those of an ovarian cyst. A 
'stic body can be detected in the peritoneal cavity, and fluctuation is 
ten quite distinct, which is not the case in the normally pregnant 
uterus. In hydramnios pregnancy usually pursues a normal course up 
to the sixth or seventh month, when there is a rapid and inordinate 
enlargement of the abdomen. The history of the case, together with 
the softened or obliterated cervix, the patulous canal, and the presence 
of the fetal membranes easily accessible through the open os will 
leave little doubt as to the nature of the case. 

Uterine Atresia, with Retention of Fluids and Oases. — Distension 
of the uterus with blood, pus, or gas will be wanting in the signs or 
mptoms of pregnancy, and upon investigation the cervical canal 
be found occluded. The tumor will occupy the position of the 
uterus, or, if displaced, the absence of the uterus of recognizable form 
ill suggest the nature of the body. 

Uterine Fibroid. — The uterine fibroid seldom occurs before the 
tieth year, and gives a history of slow development. It is often 



uter 
wiU 

^^lir 




AC, I 



PRACTICAL GYNECOLOGY. 



irregular in outline, firm, heavy, and non-fluctuating. Ita continuity 
with the uterus can usually be determined by bimanual examination. 
Movements of the tumor are communicated to the cervix, and via 
versa. In the submucous and interstitial forms menorrhagia is a fre- 
quent EjTnptom. Here, also, the uterine sound will reveal the 
increased depth of the uterus. Auscultation reveals a blowing sound. 
In the subperitoneal fibroid the depth of the canal may not be 
materially increased, but connection of the tumor with the uterus may 
be determined by movements imparted to one by dragging on the 
other, and by rectal exploration of the tumor and pedicle while the 
uterus is forcibly drawn down. The edematous, pedunculated fibroid 
is regular, soft, and semifluctuating, and is most apt to occur in the 



I 




Fig. 266. — Aicitei, Showing Resonknt and Dull Area*. 

young. Such a case is often quite impossible to distinguish from the 
multilocular cyst or the cyst with viscid contents. 

Ascites. — In ascites the fluid is free in the peritoneal cavity, and 
unless the cavity be full to repletion there is less tension and resistance 
to the palpating hand. By pressure it is displaced, and the abdominal 
walls may be depressed here, there, and elsewhere with little effort. If 
the patient lie on her back, the abdomen does not preserve its dome 
shape, as in the case of the cyst, but flattens and bulges at the sides. 
(Fig. 2C6.) Percussion will elicit resonance over the summit of dis- 
tension and dullness over the sides and flanks. This is exactly the 
reverse of what occurs in the ovarian cyst. The resonance at the high- 
est level in ascites is due to the gas-filled intestines floating to the 
surface of the fluid. (Fig. 267.) If the patient be placed on one side 



^ 



t 




CLINICAL HISTORY OF OVARIAN CYSTS, 



465 



or the other, or in the sitting posture, the fluid will always gravitate 
to tlie lowept levfl and the intestines float to the surface; hence the 
tone of resonance and dullness changes accordingly. (Fig. 268.) 
In the ovarian cyst there is no change. (Fig. 209.) Where the 
abdomen is greatly distended with fluid the mesenteric attachment 




i-'ig. ;,. 



J 

liauk, Sliowing 



Resonant and Dull Areas. 



may be too sliort to allow the intestines to reach the surface. Here, 
by depressing the abdominal wall and displacing the surface fluid, the 
intestinal resonance may be elicited. In the large ovarian cyst the 
resonant area is confined to the epigastrium and one flank. (Fig. 
270.) In case of encysted or pocketed ascites it may be impossible to 
make a positive diagnosis without exploratory incision. Usually, how- 




plus those of the cyat. The tumor may be palpated by displacing the 
free fluid. An ovarian cyst filled or partly filled with gas will be 
resonant on percussion, but will preserve its shape and may be recog- 
nized by palpation. 

Fecal Impaction. — An accumulation of hardened fecal matter 
in the bowel sometimes forma a mass of such magnitude as to present 





I 



Tig. M9 — Mediuni-sized Ovarinn Cyst, Bbowtng the Dull Area In the 
Centar and the Crescentic Area of Keaonance at the Top and Sides, 



Tympany, or Phantom Tumor. — The phantom tumor is the re- 
sult of gaseous distension of the abdomen, and is usually associated 
with a morbid fear of or desire for pregnancy. It is most apt to occur 
just before the climacteric. It is attended by many of the subjective 
symptoms of pregnancy, but in some cases these are absent, and the 
condition has been mistaken for an ovarian cyst. The percussion note 
will be tyin]ianitic and palpation negative. Careful examination of 






of the ovarian cyst. It is, however, more ovoid and elongated in an 
apwaxd direction, is more distinctly prominent at its pelvic pole, and 
is UBually quite tender and associated mth more sufTcring and consti- 
tutional disturbance. There is also frequently an overflow of urine 
from the bladder, which keeps the patient wet, and, as in many in- 




CUNICAL HISTORY OF OVAHIAN CYSTS. 



4fl9 



litanccs the retention is mechanical, the pelvis will be found impacted 
with a fibroid, a cyst, or a retroverted pregnant uterus. The possibility 
of a distended bladder should always be borne in mind, and where the 
least suspicion exists the viscus should be emptied by the catheter. In 
most instances of this kind the ordinary female catheter is neither 

[long enough nor of the proper curvature to reach the cavity of the 
t»ladder, and a male catheter should be used. From lack of this pre- 

'caution 1 have known the bladder to be cut down upon even after the 
ordinary female catheter had been used on the table. 

Retroperitoneal Cysts. — Such cysts, taking their origin in the 
pelvic region, will be distinguished by their fixedness, and by the fact 
that a finger in the rectum will show them to be behind instead of in 
front of it. Cysts developing from the abdominal cavity or upper zone 
of the abdomen when small may usually be differentiated by their 
position and absence of attachment to the pelvic viscera. A.8 a rule, 
those emanating from the liver, spleen, or kidney will give a history 
of having developed from the region of those respective organs in a 
direction downward and toward the median line. The intestines will 
be crowded before them and the resonance will be in the lower abdo- 
men and on the side opposite to that from which the growth sprang. 
They sometimes prolapse into the pelvis and apparently grow upward. 
This may make the diagnosis impossible. Where both ovaries can be 
found independent of the growth, ovarian cyst may be excluded. The 
hydatid cyst crepitates under pressure; cysts of the kidney grow up 
under and push the colon inward in front of them, which is resonant 
on percussion; and splenic tumors have £in association of malaria or 
leucocythemia- 

Obesity. — An accumulation of fat in the abdominal wall and 
omentum has frequently been mistaken for an ovarian cyst. Small 
cysts may co-exist with this condition and be ditficult of detection. 
Much fat in the abdominal wall is incompatible with large cysts, as 
they produce atrophy and thinning of the wall. The inordinate thick- 

'ness of the abdominal walls may be demonstrated by grasping them 
in the hand. The fat abdominal wall becomes pendulous in the erect 
position and lurches to the side upon which the patient is reclining. 
Percussion yields a muffled resonance, and the fat-wave may be elim- 
inated by creating an artificial diaphragm. 

Desmoid Tumors. — These are growths in the abdominal wall 
springing from the intermuscular connective tissue or fascia, and if 
large so as to cover the greater portion of the abdominal wall may 
be very puzzling. The tumor is rotund and resistant, and rises 




470 PRACTICAL GYNECOLOGY. 

abruptly from the abdominal surface. Its intimate relation to the 
walls may be determined by working the fingers under the margins of 
the growth and moving it about; it always goes with the wall and 
draws the wall with it. The vaginal and rectal touch may determine 
its independence of the pelvic organs and may develop its extra- 
peritoneal situation. 

RELATIONS OF THE COLON TO ABDOMINAL TUMORS. 

In making a differential diagnosis of an abdominal tumor, it is 
important for the surgeon to remember the relationship which the 
colon bears to the other abdominal viscera. This point has been 
brought up and elaborated by Baldwin and others. Briefly, the 
ascending, transverse, and descending portions of the colon constitute 
three sides of a square, and divide the abdominal cavity into four 
regions: the central region, surrounded by the colon; the superior, 
above tlie transverse colon; and the right and left lateral regions. A 
tumor originating in one of these regions may crowd over into another, 
but it does so only by displacing the colon, and it is the study of this 
displacement which enables the surgeon to determine, as a rule, the 
origin of the tumor. 

In the central area, in addition to tumors connected with the 
uterus and ovaries, will be found tumors of the omentum and mesen- 
tery, of tiie retroperitoneal glands, of tlie small intestine, and mali;r- 
nant, parasitic, and other rare growths, the diagnosis of which must 
be determineil. if at all, by other means ; their relationship to the 
colon simply determines their location, not their character. 

If the colon cannot be outlined satisifiutorily when the examina- 
tion is in progress, it should be distended liy air, which can be forcc<l 
in through the anus by means of an ordinary bull) syringe or bicycle 
pump. The ascending and descending colon will be found on the 
outside of all tumors originating in either the ovaries or uterus. The 
kidney is beliind the colon, and when it develops into a tumor does 
so by sei)arating the layers of the mesocolon, so that the colon will be 
found in front of the tumor or toward its inner side. Tumors of the 
adrenals, and those developing in the pararenal tissues, or from the 
Woltlian body, will produce an anterior or inward displacement of the 
colon. If the tumor is in a movable kidney it may present in the 
central area, but when the jmtient lies dr)\vn it will be found to slip 
back behiiul the eohm, unless liehl by iidliesions. The spleen must 
nece.ssarilv be on the outside of the di-seending colon, or if greatly 



CLINICAL HISTORY OF OVAEIAN CYSTS. 471 

enlarged will override it: the colon can never be on the outside of 
the spleen. Tumors of the liver crowd the colon down, or override 
it. The same is true of an enlarged gall-bladder. This will usually 
serve to differentiate an enlarged gall-bladder from a tumor of tlie 
right kidney. Tumors of the stomach will crowd the transverse colon 
downward. Tumors of the pancreas, in the vast majority of cases, 
crowd forward between the stomach and the transverse colon, though a 
cyst of either extremity of the pancreas may appear behind the colon, 
and thus simulate a tumor of the kidney. Tumors of the omentum 
involving its dependent portion cannot from relationship to the colon 
be distinguished from tumors arising in the pelvis; their diagnosis 
must be determined, if at all, by exclusion. A cyst developing between 
the folds of the mesentery or mesocolon must be diagno.sticated by 
other means than by relationship to the colon itself, but, as a rule, its 
exact character is not determined until the operation. 



CHAPTER XL. 

OVARIOTOMY— ACCIDENTS AND COMPLICATIONS. 

The only rational treatment for the ovarian cyst is its complete 
removal, which is denominated ovariotomy. Tapping, once so much 
in vogue, is now without sanction or excuse. It never cures except 
now and then a simple cyst, and the dangers are manifold without 
any compensatory advantages. Strong adhesions form at the site of 
tapping, greatly increasing the diflBculties of operation; large vessels 
may be punctured, giving rise to serious, if not fatal, hemorrhage ; the 
cyst contents may escape into the peritoneal cavity, which, in the case 
of the papillary cyst, may infect the peritoneum or in the suppurating 




Fig. 271.— Tail's Cyst Trocar. 



or dermoid cyst give rise to fatal peritonitis. In case of enormous 
development of the cyst, such as is occasionally found in the prolif- 
erating glandular cyst, where respiration and circulation are so seri- 
ously interfered with as to invest the operation with special risk, it 
may be allowable to draw off the fluid in whole or in part, that the 
patient may have a few days of respite and the impaired functions 
restored to something like the normal. 

OVARIOTOMY. 

Ovariotomy for an uncomplicated, pedunculated cyst is one of 
the easiest of major operations. After due preparation with special 
regard to sepsis, the bladder having been emptied and the alimentary 
canal purged, the patient is etherized and placed on the table. The 
lower extremities are enveloped in blankets and covered with a steril- 

(472) 



OVARIOTOMY— ACCIDKNTS AND COMPLICATIONS. 



473 



sheet. The night-dress is drawn up under the shoulders to pre- 
ent soiling, and the chest protected by suitable covering. The ab- 
domen is bared and vigorously scrubbed with alcohol, and a sterilized 
sheet, with an opening through which to work, thrown over all. 

The peritoneal cavity is entered through a short incision in the 
median line midway between the umbilicus and pubis. The glistening 
surface of the tumor now presents, into which is thrust an ovarian 
trocar. The trocar should be entered noaror the upper than lower 
angle of the incision, as with the escape of contents the sac settles 
toward the pelvis. A rubber tubing should be attached to the trocar 
of suiiicient length to conduct the fluid into a cateh-basLn beneath or 



Fi.. 



tioy: Tnjiping and Extruclion of the Cyst. 



at the side of the table. (Fig. 272.) An assistant should keep the 
abdominal walls at the edge of the incision in close contact with the 
cyst to prevent entrance of the contents into the peritoneal cavity. 
This can be done by hand pressure with a towel intervening. As the 
tension of the sac diminishes with the loss of fluid, it is caught up on 
either side of the trocar with volsclla or other suitable forceps and 
drawn out. Little by little it emergc>8 through the opening until it 
finally escapes, discloi^ing the pedicle. The sac, being wrapped in 
gauze or sterilized towel, is now held by an assistant while the pedicle 
is transfixed by a strong ligature and tied. (Fig. 274.) It is safer 
lo carry the ligature through double, remove the carrier, divide the 




474 



PRACTicAi- (:yxecol,o(;y. 



ligature into equal lengths, and tie each half of the pedicle separatclj, 
and as a finale one of the ligatures may be carried around the entire 
pedicle and tied again. The sac is now cut away, being careful to 
leave sufficient button to prevent the slipping of the ligatures. Some 
operators first apply a conipre.'^sion forceps to the pedicle, and after 
removal place the ligature in the groove produced by it. This gives 
greater security against secondary hemorrhage. The opposite ovary 
should now be examined for evidences of disease, and dealt with as 
conditions may indicate. After noting that there is no hemorrhage 
from the pedicle, and sponging away any fluid or blood that may have 
escaped into the peritoneum, the abdominal wound is closed, the dress- 
ings applied, and the patient put to bed. If this were all of ovariotomy 
it would rank as one of the simplest and easiest of operations. It i« 
the witnessing of such cases that fires the novice with a desire to 




Rg. 273.— Spencer WelU'» Sao Forcepa. 



become an abdominal surgeon, and too often incites him to under- 
takings for which he is unfitted. 

Complicationi. — The complications of ovariotomy are numerous 
and varied and sometimes most embarrassing. One of the most fre- 
quent of tliese arises from the atrophy of the abdominal walls. 

Mistaking the Omentum for Preperitoneal Fat. — In case of 
atrophy and disappearance of the properitoneal fat tlie peritoneal 
cavity has been entered unawares and the omentum mistaken for it 
and boldly incised. The greater vascularity of the omentum, together 
with the fact that its vessels run vertically, while those of the fat 
and fascia run transversely, will serve to distinguish them. Usually, 
however, the distinction is much more readily made by drawing out 
the omentum or by introducing a finger and sweeping it around in 
the peritoneal cavity. Close adhesion between the cyst and the atro- 
phied abdominal wall result in the effacement of all lines of distinc- 
tion between the layers and lead to embarrassment in the operation. 
In such cases the peritoneum has been stripped from the abdomin&l 



OVARIOTOMY— ACCIDENTS AND COMPLICATIONS. 



475 



I wall under the impression that the cyst was being separated. If the 
fcerator does not discover his mistake before, he will come to a line 
B the lateral aspect of the abdomen where the peritoneum is closely 
Hheront and will resist all ordinary attempts at further separation. 
B all cases where doubt exists, the incision should be carried up to 
Hic umbilicus, where the cyst and abdominal wall seldom coalesce, 
i; f rom which point the work of breaking up adhesions may proceed. 
^By feeling one's way carefully after going through the skin, lifting 
^^p layer by layer with mouse-toothed forceps, and carefully incising, 
the surface of the cyst may often be reached and recognized by the 
compactness of its structure, which differs radically from the lami- 



Fig. 274. — Ovariotomy: Tying the Pedicle. 



I pate 

BroF 
^Tind 



nated and web-like structure of the connective tissue remains of the 
^peritoneal fat. Where these methods fail, the cyst may be incisc<l 
and tlie contents let out, and an attempt made to deliver it by in- 
, \'cr8ion. To invert the cyst a liand sluiuld be thrust into the cyst- 
^Kavity, with which the posterior wall is seized and drawn out tlirough 
^Hbc incision, thus coinplftely turninj: it inside out. 
^y Delivery of the Multilocular Cyst. — In nuiltiloeulnr cysts after 
emptying the main cyst, the trocar, guided by the hand, may be thrust 
into one after another of the contained cysts until the tumor is so 
far reduced in size as to admit of delivery. These secondary cysts 
Bay quite often be broken down by the hand introduced into the cyst- 




47« 



PRACTICAL OYNECOLOOY. 



cavity. Where the contents are viscid, the trocar may be dispensed 
with, the opening enlarged, and the cyst emptied by hand or external 
pressure. Dermoid and papillomatous cysts, as also infected cyst* 
of small or medium size, should be removed entire by making liberal 
section of the abdominal wall. 

Adhesions. — Light adhesions may be broken up by introducing 
the hand into the abdominal incision and sweeping it over the face 
of the tumor. Dense adliesions would better be dealt with under the 
eye when practicable, by drawing them up to the opening after the 
cyst has been emptied. The sponge is often of great assistance in 
separating adherent surfaces, but should be used according to nile. 
Tlie rule is to sponge off the delicate structure from that which is less 
delicate. The cyst-wall should bo pushed off from the abdominal wall ; 
in adhesions to the viscera, the latter are sponged or coaxed off of the 
cyst, being careful to preserve the integrity of the viscus at the expense 
of the cyst, if necessary. In some cases, to prevent injury to tlie 




275. — William's Pedicle Foreeps 



intestines or other important organs, no attempt should be made to 
break up the adhesions, but the attached portion of the cj-st-wall 
should be excised and left. The inner secreting surface of the excised 
portion should be destroyed by cautery or otherwise, and when prac- 
ticable folded upon itself and stitched. Very dense adhesions in the 
form of bands or bridles may require the use of scissors. Where there 
is reason to suspect vascularity, they should be cut between pressure 
forceps or ligatures. 

Pedicle.— Where the pedicle is of unusual breadth, it should be 
tied in sections. In lieu of this, and in many respects preferably, the 
ovarian artery may be tied external and internal to the pedicle, which 
will as effectually control the hemorrhage. After cutting away tlie 
cyst the stump of the pedicle is whipped over with catgut, which serves 
the double purpose of stanching any bleeding from small aberrant 
vessels and of closing in the raw surface. 

Intraligamentous Cysts. — In some intraligamentous cysts which 
project well into the peritoneal cavity, a pedicle may be formed by 



ovari<w5my=agctdentsa5 



I.ICi 



traction on the cyst, in which case it may be dealt with as a pedun- 
culated growth. The parovarian cyst may be delivered by incising 
the peritoneum at a convenient place and then stripping it off. The 
proliferating intraligamentous cyst may be enucleated by cutting 
through the peritoneum on a level with the pelvic brim posteriorly and 
rolling it out of its bed from below upward. (Fig. 276.) All bleed- 
ing points are secured by forceps and subsequently tied. A general 

Bzing may be controlled by gauze packing. (Fig. 277.) Should it 
I necessary to drain, an opening may be made into the vagina through 

►hich a gauze drain may be carried. Should there be no bleeding after 
igftting the vessels, the gap in the broad ligament may be closed with 



'O'l 





Fig. 276. — Eaucleation of the Intraligamentous Ovarian Cyrt. 



Hgt 
^^ea' 



catgut suture. A bloodless operation for the intraligamentous cyst 
has been devised by Hall, of Cincinnati. He first taps the cyst and 
draws off its contents, then ligates the ovarifin artery near the pelvic 
wall on both sides. He now proceeds as in supravaginal hysterectomy, 
gating and cutting on the side opposite the cyst until the cervix is 
ched. The bladder having been stripped off and the uterine artery 
secured, he cuts across the cervix, catches up the uterine artery on 
the opposite side, and delivers the cyst from below upward. In 
women who for any reason are incapable of ciiild-boaring this is the 
ideal metliod, as it gives perfect control of the hemorrhage. It is 
but just to say that Hawkins, of Denver, independently, and without 
reknowledge of the Hall operation, adopted the same technique. 




478 



PRACTICAL GYNECOLCX 



As illustrative of some of the difficulties occurring in ovariotomy 
and the manner in which they may be dealt with, I will give a case 
occurring in my practice on March 25, 1899. The patient, S. Q., 
residing at Bethcsda, Ohio, was 45 years of age, and had noticed 
the growth about thirteen years. She had one son seventeen years 
of age. She wa« referred to me by Dr. D. M. Murphy, of Bethesda, 
who in writing stated that the growth was of sixteen years' standing. 
When brought into the presence of the patient I must confess that 
I was surprised and disconcerted. As she lay in bed on her side with 
her back to the wall the tumor filled the bed, and as it quivered and 
vibrated with the respiratory movements, it presented a spectacle that 
I shall never forget. It was simply monstrous and inliuinnn. In its 
huge and tremulous expansivcncss it reminded one of a mostodonic 





Fig. 277. — Packing and Vaginal Drainage After Enucleation of 
an Intraligamentoua Ovarian Cyit. 

amniotic sac. A peculiar feature was the comparative laxity '^f the 
cyst and abdominal walls, which allowed it to flatten out and rpreiid 
all over the bed, and it extended from high up on the chest to below 
the knees. The face, chest, and arms were emaciated to the last 
degree, while the lower half of the abdomen was knobby ard in- 
durated, as in elephantiasis. The lower extremities were truly ele- 
phantine in shape and appearance. She was examined lying on her 
side, as the pressure of the tumor on the diaphragm gave rise to 
suffocating symptoms. The percussion wave was strikingly distinct 
over all parts. She was helpless in bed, and it required the assistance 
of several persons to change her position. Nevertheless, if placed on 
her feet she could walk. (Fig. 278.) 

On the day of her admission to the hospital, in attempting to 
change her position in bed the tumor gave a lurch and carried her 



!■ 

i. 



OVARIOTOMY— ACCIDENTS AND cnM PLICATIONS. 



479 



bodily to the floor. It required the combined efforts of several men 
and nurg(?8 to replace her in bed. She was tall, and of large frame, 
but, with the exception of the lower extremities, had wasted to a 
skeleton. She was of buoyant disposition and rather inclined to be 
jovial. I found her to be a woman of more than ordinary intelligence 
and shrewdness. She inquired with some show of coucem whether 
the removal of the growth would be attended with danger. On being 
informed that it would, she expressed a wish to be tapped and' sent 
home. I explained that tapping would be a measure of doubtful 
expediency, aa the refilling of the sac would make such a draught on 
her vital resources as rapidly to exhnust them, and that the tumor 
would certainly kill her if it were not removed. She then said that 
she would leave the matter entirely in my hands. I told her that we 
would both consider it for twenty-four hours, as I confess that I had 
little hope of benefiting her. On my next call we agreed to operate, 
and she was in the best of spirits. She arrived in the city on Wednes- 
day evening and tlie operation was set for Saturday morning. This 
was March 25, 1899. 

She took the ether nicely and was placed on the operating-table 
on her side. The bulk of the tumor extended over the side of the 
table and bad to be supported by an assistant. This assistant was 
relieved at short intervals, as the position was too irksome to be main- 
tained for any length of time. An incision six inches long was made 
down to the sac, and revealed a thickened abdominal wall, consisting 
entirely of hyperplastic connective tissue. The cyst-wall was also 
tliick and dense, and was with difficulty penetrated by the trocar. 
Thus, it will appear that the abdoniinal and cyst- walls had grown 
pari passu with the cyst accumulations, and that neither suffered from 
tlie pressure atrophy usually found in such cases. A large wash-tub 
was placed to receive the contents, which were of the color and con- 
sistence of very muddy water. The fluid left a greenish-yellow deposit 
on anything with which it came in contact. When the' tub was nearly 
full it was removed, and a waste-water tub substituted. It required 
three of these besides the large wash-tub to receive the contents. 
These tubs were all removed to one side of the room, that no ex- 
traneous matter might find its way into them. 

We now placed the patient on her back and attempted to break 
up the adhesions between the cyst-wall and abdominal parietes. These 
were found to be so dense and extensive that after working awlijle I 
became convinced that the method was impracticable, and so opened 
np the cyst and attempted to deliver by inversion. In tliis I was 




PRACTICAL GYNECOLOGY. 

foiled, and bcguu to fear that I should have to content myself with 
an incomplete operation, when suddenly well down on the left side 
the adhesions began to give, and from this point I was enabled to 
strip off the sac in all directions. The pedicle was broad, and was 




Fig. 278. — Ovarian Cyst Weighing One Hundred and Seventy-six 
Pounds. (Author's Case.) 



secured by a chain ligature. The cyst was cut loose and dropped into 
a receptacle, We now attempted to wash out the cavity, but the two 
gallons of water poured in disappeared as completely as though poured 
into a waste-pipe. I now saw that nothing short of a tub of water 
would avail to flush the cavity, and the attempt was abandoned. The 



OVARIOTOMY— ACCIDENTS AND COMPLKATIONS. 481 

redundant tissues of the abdominal wall hung down on either side 
of the table and covered the thighs to the knees. The surface was 
thrown into innumerable folds and fissures, but the folds were much 
larger, and the wrinkling le^s conspicuous than in other large ab- 
dominal growths, because of the unusual thickness of the parietes. 
In attempting to sponge out the cavity I found pools of fluid in all 
eorts of out-of-the-way places. The wound was now closed, but in 
applying the bandage we found that, do what we would, a large pendu- 
lotu mass extended down over the thighs. 

The fluid contents of the tumor were now measured, a quart 
measure being used for this purpose. This was done by a Sister, 
supenrised by the chief nurse. The count was made aloud and re- 
peated by two censors and witnessed by several by-standers. There 
was no chance for deception or mistake. A quart of the fluid, ex- 
dusire of the vessel, was found to weigh two and one-fourth pounds 
almost precisely. Of this fluid there was seventy-five quarts and a 
fraction. The cyst-wall, with its residue, weighed a few ounces less 
than seven pounds. Altogether the tumor weighed a little more than 
one hundred and seventy-six pounds. 

The patient did well from the first, although the pulse-rate con- 
tinued at or about 100 for two weeks. Tlie only trouble arose from 
the maceration and excoriation of the skin in the deep sulci between 
the contiguous folds, necessitating tlie use of cotton packing as a 
protective. There were present at the operation Dr. J. J. Magruder, 
chief of staff, who gave the anesthetic ; Drs. E. M. Gilliam and C. F. 
Oilliam as assistants; Dr. Murphy, the family physician; Drs. 
W. B. Moore and E. M. Parrot, as spectators, besides the Sister Supe- 
rior and three nurses. This, so far as I can learn, is the largest 
ovarian cyst ever successfully removed in Europe or America. Reif- 
anyder reports one from China which weighed 18314 pounds. 

ACCIDENTS AND COMPLICATIONS OF OVARIOTOMY. 

Hemorrhage, sometimes of an alarming cliaracter, may occasion- 
ally occur from the cyst as the result of laceration or puncture of its 
vessels. In all such cases the pedicle should be sought and clamped 
immediately, as it is froTn this source tliat tlic tumor derives its 
blood-supply. Slioiild the pedicle not be accessible, compression of 
the abdominal aorta and other temporary expedients for controlling 
hemorrhage- may be resorted to until the pedicle can be reached. 
Bleeding of the surfaces laid bare by breaking up adhesions should 



482 



nUCTICAl. r.YNECOLOGy. 



bo met by ligature of all spouting vessels and gunzc comprcseiou for 
oozing. Kxtt'iisivf <lcniitlnti«n or injury of the uterus may call for 
iiystcrcc-toniy. The abdominal cavity should never be i loscd upon a 
bleeding uterus. 

Injury of the omental vewels i^hould never be lost Higlit of tluring 
operation, and should be followed by ligature and usually amputation 
of the distal portion. The onientum in treacherous, and vessele which 
have ceased to Meed on wxposure to the air, or as the result of shiK'k, 
are liable to give rise (o debilitating, if not dangerous, hemorrhage 
after the abdomen is closed. 

Injuries to the small intestine, bladiier, rectum, uterus, ureter, 
and other vissi'ora may occ\ir during operation. Injuries to the blad<Ier 
or the rectum muy \>v clojjud by suture, cure being taken to avoid the 
nmeosa. 

It is also important in all mucus-lined viscera to avoid suturing 
mucous surface to mucous surface, as they will not unite. Kither the 
raw surfaces or peritoneal surfaces ghouhl be coapteU. 

Injuries to (be utcrus may also be sutured, providing tho hettior- 
rliagc can be eirectuaily controlled; otherwise, it is safer to remove 
the entire organ. Injuries to the small or large intestine or ureter 
uiay be closed by fine suture, or muy denumd resection and anasto- 
mosis. 

Many of the accidents of ovariotomy are the result of carelessness 
or want of skill on tlie part of the ojierator. A reckless abilomiual 
incision may result in serious damage to the bowel or bladder if either 
have intervened Itetween the cyst-wall and the peritxmeum. Forcible 
rending of adhesions may tlo irreparable daiiuige to the viscera impli- 
cated, and the careloes tying nf vessels may result in the slipping of 
ligatures. 

Many fatal cases of ])ost -operative hemorrhage are traceable to 
this cause. Sjiouges and instruments have been left in the ab<loniinal 
cavity with fat«l rt<»iult. Fist\da may follow the use of infirted 
ligatures. It is also a coninion seijucnce of incomplete work, as where 
infected tissue is left in the abdomen. Obstruction of the bowels 
residts from twisting, or adhesions and ventral hernia from im(ierfe<-t 
coaptation of the incision. 

Incomplete Operations. — In some eases (lie cyst is so e.xU'nsively 
and firmly adherent to Ibe- intestines or other important viscera as 
to render its removal impracticable without iniine<liate and grreat 
jeopardy to life. In such easuB the eyst tnay be opened, its contents 




OVARIOTOMY— ACriDKXTS AND COMPLICATIONS. 483 

evacuated, and after cutting away roduntlant portions the open end 
of the cyst may he stitched to the alxiominal wall. 

In ca-w of simple cyst temporary packinji with iodofonn gauze 
will sometimes lead to adhesion and obliteration of the cavity. As a 
rule, the cyst refills. 



CHAPTER XLI. 

ABDOMINAL AND PELVIC LESIONS OTHER 
THAN GYNECOLOQIC. 

The gynecologist, as before intimated, must l)e prepared to suc- 
cessfully cope with other than purely gynecologic conditions or he will 
every now and then be compelled to close an abdomen over lesions that 
will require a reopening later by a more competent surgeon, or doom 
his patient to continued invalidism or possible death. These lesions 
sometimes present as complications, sometimes are encountered unex- 
pectedly as the result of mistaken diagnosis. Then again, as a large 
proj)ortion of obstetric work is done by the general practitioner, and as 
surgically trained obstetricians are few as compared to the number of 
surgically trained gynecologists, it follows that the latter are much 
more frequently called on to help out in Cesarean section than the 
former. In fact, the technique of Cesarean section is as nearly allied 
to the domain of gynecology as to that of obstetrics. In practice, 
gynecology and abdominal surgery are inseparable, and, whether ex- 
pressed or implied, a work on gynecology would be all the better for 
including the technique of abdominal surgery. Especially does this 
apply to a work of the scope and character of this, where the aim is 
to give as concisely as possible the essential facts pertaining to the 
subjects treated. 

CESAREAN SECTION. 

In the usual section the ai)doinon is opened below the unlbilicus 
by an incision in the median line al)out four inches long. An 
assistant steadies the uterus and keeps the aiidominal wall in contact 
with it by jdacing a hand on cither side and making pressure. This 
close contact of the abdominal wall to tlic uterus should be maintained 
until the uterus is emptied or even later if necessar\' to prevent the 
escape of the contents, especially the amniotic fluid, intfl the peritoneal 
cavity. Tlic uterus is now carefully opened down to the membranes 
by an iniisitm coextcni-ive with that in the abdominal wall. The 
mciubran(>s are separatwl by sweeping tlic hand around between them 
and the uterine wall. Should the placenta present, the fingers may 
be jiuslicd through it or it n^ay be separated along with the membranes. 
Keforc witiidrawiuiT the hand the thigh tliat is nearest or anterior is 
seized and the child delivered. Bullet forceps are next placed at the 
(484) 



LESIONS OTHEK THAN cVNlCi rii.tMiic. 



4S5 



Upper and lower anjili-s of llic utorinc iiRision to jrive better eontrol 
of Llio orgau ami to faoilitatc the tiulis-eijui'iit steps of the (iiioratinii. 
Now follows the delivery of the jibieeuta and ineuihranes and any larjfe 
clot< that may ])renerit. Tliei't- jihunld lie nn s(p«iiiring of the uterine 
cavity, no dilating or attempt at draiiia^ic thrnugh tiie eervieal canal. 
for such interference is not only not necessary, but actually prejudi- 
cial. Hcniorrhaire, if any, is eacily controlled hy packini; the uterine 
cavity with gauze. The uterus is dosed hy six to eiiiht iuterrui)tcil 
sutures of number two chromic catgut. The packing, if any, is 
gradually withdrawn as the sutures are placed. These shoiih! he 
introduced deeply. The first line of sutures is covered in l>y ii con- 
tinuous, rather deep Ix-mhert suture of the same niatorial. hut much 
finer. These shouhl he so introduced as to secure neat aiiprovinnition 
of the serous surfaces. The Hlidonien should he closed in the usual 
manner, omitting the toilet of the peritoneum. A lij.dit hinder is 
a[)i»lied to avoid undue rMunpression of the uterus. 

Vaginal Cesarean Section. — This consists in splitting the cervix 
and uterine wall anteriorly to a depth sutticient to admit of the 
delivery of the child. This will necessitate the separation of the 
hladiler from the uterus as in vaginal hysterectomy. After delivery 
the incision is closed with chromic catgut. 

STOMACH AND DUODENUM. 

Gastric and Duodenal Ulcer. Symptoms. — Pain, vomiting and 
hcmateniesis, tenderness over the epigastrium, ami rigidity of the 
recti muscles have in the past been regarderl as the cardinal symptoms 
of gastric ulcer. The pain is referred to the epigastrium, thence 
radiating to the region of the left shoulder-hlade. If now we add 
hyperelilorhydria or excess of hydrochloric acid we have embraced 
about all the signs and symptoms a.^cribed to gastric ulcer. How 
many of the above sympt/)ms are distinctive of gistric nicer, how miiny 
are common to alfections other than those of the stomach, and how 
many are purely neurotic are <piestions that nnisl he asked and 
answered in every in<lividinil case. The fact is that no one or any 
nundicr of the sym))toms enumerated al)ove, taken individually or 
collwtively, is pathognomonic of gastric idcer. This arises from the 
fact that the stomach is intensely and broadly sympathetic, tlint dis- 
turbances of the Ftomnch occur in a great many ditTerent diseases, 
and that these disturlmnces are occasionally so prominent as to mask 
the real disease. Especially does this apply to the diseases of 
intimately related or^ians, such as the duodenum, liver, including the 




486 PRACTICAL C.YNECOIX)GY. 

gall-bladder and pancreas. These organs, along with the stomach, 
are all derived from the forcgut and have the same blood-supply, the 
same nerve-supply, and are so intimately correlated that it is often 
most difficult if not imijossible to distinguish the affections of one 
organ from the other. In point of fact, the actual diseases of the 
stomach are few, the simulated diseases many. The influence of the 
mind over this organ is conspicuous, and it is for this reason that 
neurotics furnish so large a proportion" of the so-called stomach dis- 
ease, and, incidentally, it is for this reason that lalwratory tests are 
often so unreliable. The mental perturbation incident to such tests 
often leads to such changes in the gastric secretion as to defeat the 
object of the test. Strong emotion, such as anger or fear, will, at 
times, inhibit the gastric secretion entirely, and an excess of hydro- 
chloric acid may not only fail to show in the test, but the findings 
may indicate a deficiency of the same. Then again, as the most 
imj)ort«nt factors in stomachic digestion are motility and free transit 
through the pylorus if the muscular action of the stomach be unim- 
paired and the food mass find an easy outlet through the pylorus, 
digestion may go on painlessly, inecnsjbly, the patient will be well 
nourished, and tJiere may be al>solutely no Rynij)toni8 to indicate ulcer 
of the stomach or other grave lesion. In such cases perforation of 
the stoTiiach or duo<lenum may be the first signal of trouble. It should 
also be remembered tiiat, while hyj)ercl)lorhydria plays so important 
a role in the early stage of gastric ulcer, it progressively decreases as 
the ulcer grows old until in the chronic indurated ulcer there may be 
a total absence of the acid. This, tiien, ceases to be a symptom and 
becomes only sijinificant as a part of the history of the case. In 
weighing the ])rol)abi]ities as lietween gastric and duodenal ulcer it 
should be borne in mind tiiat tiie chances of duodenal ulcer are as 
3 to 1, and tiiat tiie duodenal ulcer is four times as frequent in the 
male as in the female. The old belief that it was the food mass in the 
stomach that excited or intensified the pain of ga-<tric ulcer, and that 
an ulcer of the stomach or duodenum could be located by the length 
of time elapsing between the ingcrition of food and the manifestation 
of pain, is hardly tenable in tiie light of present knowledge, and if any 
such rehitioii exist* it must be accounted for in some way other than 
the impinging of the food mass on the ulcer. On the other hand, 
there is niucii to su])port the belief that excess of liydrochloric acid is 
the niniii factor, if not the sole one, in exciting the pain of gastric 
an<l <hiodeii!i] ulcer, and that it is iisnnlly the empty stomach that is 
iminful. Confirmation of this belief is found in the fact that the 



LESIONS OTHKR THAN GYNECOLOGIC. 



487 



taking of food in Uie stoniiKli almost invariaiily rt'lieves the pain, 
temporarily at least, and that ant-atidsi, siucli as liicarbonato of soda, act 
in tile same way. The one absorb.-* and dilutes the acid; tlie other 
neutralizes it. If it bo objwted that llie empty stomach contains no 
hydrochloric acid reference may be made to the profuse salivation 
resultiu}; from the irritating influence of an ulcer of the mouth. As 
ad<litional evidence tliat the hypersecretion of hydrochloric acid goes 
on in the interval of digestion the habitual occurrence of sour .stomach 
and intensely sour eructations late at night in the victims of gastric 
ulcer fully attest. Hci-e a gla«s of milk or a morsel of food quiets the 
distress by neutralizing the acid. As to the value of the different 
symptoms accredited to diseases of the stomach it should be borne in 
mind that some of them are purely legendary and do not properly 
belong in that category. Some are cninmon to a number of diseases 
and some chimeras of the brain. Tims, vomiting is common to so 
many disorders, general and local, that as a symptom of stomach 
disease it is almost worthless when tnkon alone. Heriiatcmesis, by 
most authorities consiilered a.s almost pathognomonic of gastric ulcer, 
occurs in cirrhosis of the liver, and in certain oth^r conditions in 
which the blood or id ood- vessels are changed. 

It is common to find patients with heart disease (cardiac insulB- 
ciency) referring all their troulde to the stomach. Tlic ga.«tric 
disturbances incident to preg