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Copyright, 1897, 
By W. B. SAUNDERS. 



U11 



PREFACE. 



In writing this book it has been our earnest desire to 
relate facts and describe methods belonging to the science 
and art of GynEecology in a way that may be useful to 
students for examination purposes, and which will also 
enable them to practise this important department of sur- 
gery with advantage to their patients and with satisfaction 
to themselves. 



London, June, 1897. 



J. BLAND SUTTON, 
ARTHUR E. GILES. 



CONTENTS. 



CHAPTER I. 

Thb Anatomv op the Reproductive Organs of Women 17 

Oraries, 17; ParoTBrium, (8; Fallopian Tubes, (8; Ulenls, Ig; 
Vagina, XO; Vulva, 31; Arteiies, 23; Veins, 25; Lfmphatics, 36) 
Nerves, id; Pelvic Peritoneum, z6; Mesoroetrium, 26. 

CHAPTER H. 
Phvsiolocy op the Reproductive Organs op Women 30 



CHAPTER III. 
Methods of Examination of the Female Pelvic Organs .... 38 
Abdominal Examination, 38; Vaginal Examination, 391 Bi- 
manual Examinaiion, 40; ihe Ulerine Sound, 41 ; the Volsella, 44; 
the Speculum, 45 ; Examinaiion under an Aiuesthetic, 48. 

CHAPTER IV. 

Malformations of the Reproductive Organs of Women .... 49 

Malformations of the Vulva ', Hetmaphrodism ami I*seudo-her' 



naphrodism, 49. 



CHAPTER V. 



Malformations op the Reproductive Organs of Women (Con. 

tinued) 59 

Mai fonnat ions of the V^na, 591 Absence of the Vagina, 59; 
Atresia of the Vagina, 59; Stenosis of the Vagina, 59; Double 
Vagina, 60 ; Malformations of the Uterus, 61 ; Absence of the 
Uterus, 61 ; Rudimentary Uterus, 61 ; Infantile Uterus, 61 ; Single- 
homed Uterus, 63 ; Double Uterus, 63. 



6 CONTENTS. 

CHAPTER VI. 

PAGB 

Retention of Menstrual Produci^ in Atresia 68 

Atresia of the Vagina, 68 ; of the Os Externum, 68 ; of the Os 
Internum, 68 ; affecting One Half of a Double Uterus or Vagina, 
68. 

CHAPTER VII. 

Diseases of the Vulva : Agp-changes ; Inflammations 77 

Age-changes, 77 ; Injuries, 79 ; Varix, 79 ; H^ematoma, 80 ; Vul- 
vitis, 80 ; CEdema, 83 ; Erysipelas, %i ; Gangrene, 84 ; Abscess, 84. 

CHAPTER VIII. 

Diseases of the Vulva (Continued) : Cutaneous Diseases .... 85 

Eczema, 85; Herpes, 85; Lupus, 86; Syphilis, 86; Elephanti- 
asis, 86; Pruritus, 87; Kraurosis, 88. 

CHAPTER IX. 

Diseases of the Vulva (Continued) : Morbid Conditions of the 

Clitoris, Urethral Orifice, AND Perineum 91 

The Hymen, 91 ; Diseases of the Clitoris, 93 ; Urethral Caruncle, 
93 ; Ruptured Perineum, 94. 

CHAPTER X. 

Diseases of the Vulva (Continued) : Tumors and Cysts 97 

Lipomata, 97 ; Myxomata, 97 ; Sarcomata, 97 ; Angciomata, 97 ; 
Papillomata, 97 ; Epithelioma, 97; Carcinoma, 99; Mucous Cysts, 
99 ; Sebaceous Cysts, 99 ; Cysts of Bartholin's Gland, 99. 

CHAPTER XI. 

Diseases of the V^\GINA : Age-changes; Displacements; Injuries . 102 
Age-changes, 102 ; Cystocele, 103 ; Rectocele, 103 ; Enterocele, 
107 ; Injuries, 107 ; Foreign Bodies, 108 ; Fistulx, 109. 

CHAPTER XII. 

Diseases of the Vagina (Continued) : Vaginal Infection and the 

Vaginal Secretions 111 

Normal Vaginal Secretion, III; Pathological Vaginal Secretion, 
114; Varieties of Discharge found in the Vagina, 117. 




CONTENTS. 7 

CHAPTER XIII. 

DiS&iUES OF THE VAGINA (CONTINUEtl) : INFLAMMATCUN. TUMURii, AND 

CVSTS - IIS 

Vaginilis, Il8; Sarconm, I241 Epithelioma, 115; Mucous CysU, 
125; Gaitncnao Cyita, 125; Peri-urelhral CyiU, lz6; Echinococcns 
Colonics, 136. 

CHAPTER XrV. 

Diseases OF THE Utervs : Flexions an 11 [fis placements 127 

A[^-chiiMges. 127 ; Ulerine MeasuremcnU, 1271 Anteflexion, iiS; 
Relrofleiion, 129; Relrovereion, 131. 



CHAPTER XV. 
Diseases op the Uterus (Continued): Displacements; Hvper- 

trophy and Atrophy 136 

Prolapse and Proddemia, 1361 )Iypertrophy of the Supra- vaginal 
Foition, 141 ; Hjrpeniophy of the Vaginal Portion, 144; Atrophy 
of the Utenu, 146. 

CHAPTER XVI. 

Pessaries 147 

Ring Pessary, 148; I lodge ' Pcssuy, 148; Vaginal Stem Pessary, 
150; Contraindiotiona lo Ihe Use of Pessaries, 1501 Retained 
Pessaiy, tjl. 

CHAPTER XVIl. 

Diseases ov the Uterus (Continued) : Ikversiom of the Uterus . 153 



CHAPTER XVHI. 

Diseases OK THE Uterus (CoNTiNUBD): Injuries; Diseases besklt- 

iNC from Gestation . i 

Laceratiun of the Cetvii, 160; Pertbration of ihe Uterus, 1631 
Superinvululion, 163 ; Sulniivolulioii. 164 ; Retained Products of 
Conception, l6j, 

CHAPTER XIX. 
Diseases of the Utehus (Continued): Diseases of the Endo- 



Acute EndotneEntii, i6g; Chronic Endomdiitis, 173. 




a Disease of I he 
Disease of the Corporeal Endui 



CHAPTER XXI. 

Diseases of thk Utbbus (Continuku) : Mvomata i8i 

Intnimural MyomolD, iSz; Submucous Myoniiia, t!J4; Subserous 
Mynmala, 186; Sccuodai? Changes, |S6; ImpaCIion, iSS; Myomnta 
and Pregnancy, 189. 



CHAKTER XXII. 

iSEASRS OF THE UTERUS (CONTINUED) : CLINICAL CHARACTERS ANT) 

Treatment OF Myomata 192 

Clinical Characters, 192 ; Uiagnosis of Myoniala and I'legnancy, 
19J; Niitmal Pregnancy, 194L Hydraronjan, 195; Retroversion of 
the Gravid litems, 195 ; Comual I'Tegnancy, 196; Tieatment of 
Myumata, 19S; Polypi, 201. 



CHAPTER XXin. 

Diseases OF THE Utshus (Continued) ; Sakcoma, Adenoma, and CaB' 

Sarcoma, 302; Epillieliuma, ao6i Adeiioma, 207; Cardnomi of 
Ihe Cervix, xoS; CatcinDmi of the Body of the Uterus, 312; Re- 
leDlion- cysts, 213. 



CHAPTER XXIV. 

Diseases of the Fali^pian Tuhes 

Salpingitis, 3151 Pyosalpinx, 317; Hydroialpii 



3l8 1 Hxmalo- 
sa1|Htix, 319; Tubercular Sdpitigiiii, 3iOi TumoisofUK Fallopiim 

Tube, 233. 



CHAPTER XXV. 

DtSEASRS op TUB FALUOPIAN TUBES (CONTINUED): DIAGNOSIS AND 

Theatmekt of Salpingitis 224 

Aculc Salpingitis, 224; Chronic SoliNngitis, 21;, 



J 





Di^EAseii OF THR Fallopian Tubes (Continued) ; Tubal Gustation . 219 

Tulial Cliai^cs, 130 ; ihe Tubal Mole, 331 ; Tubal Alnnion, 732 ; 
:, 134; Tubo-ittermi: Gcsialum, 239. 



CHAPTER XXVn. 
Diseases of the Fallopiam Tubes (Continued) ; Tubal Gestation 

(Continued) . . . . ' 2 

DingniHis, 241 ; TreaUnent, 245. 

CHAPTER XXVHI. 

Diseases OF THE Ovaries a 

Agc-chnngci, 350 -, MalFurmUions, 251; Displaccmcnls, 251; 
Corpus Luieum, 255; Apoplexy of the Ovniy. 256; OSpborilis, 
257 ; Cuihosis of the Oviuies, 359 ; Ovarian Neuralgia, 259. 

CHAPTER XXIX. 

Diseases of the Ovaries (Contikuf.u) : Tumors and Cysts .... 2 
Fibfumata, z6i ; Myoniata, 261 ; Sarcomata, 262; CnrcinuniB, 
263 ; .Simple Cyttit, 263 1 Aitennniala, 265 ; Dermoiils, 265 ; Pufil- 
lomatous Cysts, 269 ; t^iDvanan Cysis, 270 ; Gajlncrion Cysts, 271. 

CHAPTER XXX. 
Diseases of the Ovaries (Continued): Sfxokdarv Chanof^s in 

Ovarian Tumors 2 

Sepiic Infection, 273; Axial Rotolion, 275 ; Rupture, 276; Symp- 
loms and Diagniisis of Ovarian Tutnors, 277. 

CHAPTER XXXI. 

Diseases of the Ovaries (Continued): Differential Diagnosis 

AND Tkeatment OF Ovarian Tumors 2 

Phantom Tumor, 282; Pregnancy, 282: Asdics, 2831 Diilended 
Bladder, 283: Kidney, Spleen, I.iver, 2S4; Ovorinn Tumors and 
Pregnancy, 285; TreatmeRl of Ovarian Tumors, 286, 

CHAPTER XXXH. 
Diseases of THE Pelvic Peri'I'oneiiu and Cellular Tissue . , . , 2 
Septic InfeclioD, 388 ; Epiihelial Infection, 289; Hydropcriloncum, 
2901 Pelvic CeUulitis, 2921 Pelvic Abscess, 293. 



lO CONTENTS. 

CHAPTER XXXin. 

Diseases of the Pelvic PESiTONErM ani> Cu-lular Tissue (Con- 

TlNUEIl); TUMOKS 296 

L.i|iomata, 39G; Myamata, 296: Sarcomala, 297; Echioococcus 
Colonies of the Pelvis. 197. 

CHAPTER XXXIV. 

DlSOKDERS OF MENSTRUATION 3OI 

Amenoirhcca, 301 1 CryplomenorrlKca, 303 ; Mcnonhagia and 
Melrorrhagio, 304; Dy&menorrhcea, 306; Membrmous Djxoieiiur- 
rhua, 310, 

CHAPTER XXXV. 
Vaginismus and Dvspareunia; Stekimvv 31a 

VaEioismus, 312; Dyspareunia, 313 ; Slenlily, 314- 

chapter xxxvi. 

Diagnosis 318 

Family Hisloi; and Previous Hcahli, 318; Menstrualion, 319; 
Conlineinenls and Miscarriages, 319; Pcesent Illness, 31OJ Present 
Symptoms, 321 ; Rectal uid Vesical Sjrmptoms, 322; General 
Symptoms, 323. 

CHAPTER XXXVH. 

Diagnosis (Continuet) ; The Physical Examination 325 

General Health and Appearance. 325 ; Heart, Lungs, etc. 315 ; 
Abdomiaal Examination, 325 ; Vaginal Examination, 32S. 

CHAPTER XXXVni. 

GvNAcoLoiiiiAL Operations m 

General Considerations. 333 ; Operations during Menstruation, 
33Si Preiaralion of the Paiieni, 335; the Crutch, 336; the 
Steriliser, 339. 

CHAPTER XXXIX. 



PcrineoTihaphy, 3411 Removal of Urethral Canincle, 3471 Re- 
moval of the Clitoris, 348 ; Bartbolinian Cysts, 349 ; C^lporrbaphj, 




COJVTJiNTS. 
CHAPTER XL, 

Vauinul Opkkations (Co( 

riitt Genital Canal 
VesicO' vaginal Fialuta, J51: Ureleni-vnginal Fi^lula, 354; Ulero- 
vesica! FistuJ*. jSSi Rtclo- vaginal Fistula. 355; Coipocleisis, 355 ; 
ImperfonUe Hymen, 355; Cicatricial Union of Ibe Labia, 3561 
Occlusion of the Vagina, 357 ; Atresi.i of the Cervij, 35S. 

CHAn>:R XLl, 
Vaginal OrtkATioNS (Continukd) ; OrEHATioNs on the Uterus , , 359 
DilataliuQ of the Cervix, 359 ; Cucelling, 360 : Vaginal Myumcc- 
loiny, 363. 

CHAPTER XLIL 
Vaginal Operations (Continued): Opesations on the Utekus 

(Continued) 368 

Tracheloirhaphy, 368; Ampulatiou of ihe Cervii, 370 ; Amjinia- 
tinn of Ihe Hypeitrophied Cervix, 37a 1 Vagiual Hysterectomy, 373 ; 
AnlcKor Colpotomy, 376. 

CHAPTER XLHL 

Abdominal Operations i Ghnekal Considerations 379 

Oeliotumy, 379; Preparation of the I'aticnl, 379; InslnimenU, 
380; Sulure and Ligature Material, 380; Sponges, 381; Ihe Table, 
382; Anjslliesia, 382; Ahdomina! Incision, 381; Closure of the 
Wound, 383; Dressing, 384 1 Irrigation, 384 ; Drainage, 384. 

CHAPTER XLIV. 
Abdominal Opkrations (Continubd) ; Ovabiutomy and Oophohec- 

TO"V -.387 

Ovariutoniy. 387 ; Incomplete Ovariotomy. 394 : Anomaluiis (Jvari 
otomy, 394 i Repeated Ovariotomy, 395 ; O6(ihoreclomy, 395. 

CHAPTER XLV. 

Ahihjminal Operations (Continued): Ovakiotomv {Continued) . 399 

Aftet-lrcalinent, 399; Bisks of Ovariotomy. 401 ; liijuiy to Vis- 
cera, 401 ; Foreign Ftodics l^fl in the AUIomen, 404; Rciguclx uf 
OTBriniomy, 405 -, Remote EUTects uf Ovariotomy on Primary uid 
Secondary Sexual CbaractcfB, 407. 



CHArTER XLVII. 

Vhdominal Opkrations (Cominukd) : Opkrations o> 

Sui>ra-vai;inal Ilystcrccloiny, 41 1; Pan-liystcreclo 
inecloniy, 415; Ca'sarcan Section, 416; Porro's C 
Hysteropexy, 419 ; Shortening the Round Ligament 



LIST OF ILLUSTRATIONS. 



I. S^IUl lection of ihe female pelvis 19 

a. The »alTa of an aduli la 

3. Diagram nf ihe uterine anil ovarian aileries 33 

4. Diagram of the hypogastric stem 24 

5. Diagram of ovulation 33 

6. St^es in the formalion of a corpus luleum 34 

7. The uterine sound ■--.... 42 

a. Volsella: 4S 

9. Fergnsson's speculum 46 

10. The duck-bill speculum 4^ 

11, Generative oi^ans of Ihe einbcjo 51 

t>. Generative oigans of Ihe male 52 

13. Generative oigans of the female 54 

14. The external organs of a hypospadiac male 56 

15. Uterus in a boj 57 

16. Exalrophy of ihe bladder in a girl 58 

17. Rud i memory utems . 60 

18. Conical cervix 61 

19. Normal nolliparous cervix 61 

90. Muhipsrous cervix 61 

31. Unicorn uterus 63 

33. Uterus Incomis 64 

33. Utems didelphys . ■ 65 

34. Diagram illustiBting the effects or atresia 69 

35. Diagram illustrating the effects of atresia 70 

a6. Vulva of a girl 77 

37. The Hollentot apron 78 

38. Variations in the shape of the hymeneal aperture 91 

39. The vestibular bulb and Bartholin's glands too 

3D. Cyslocele and rectocele 104 

31. Vaginal secretion containing Ihe vagina bacillus 112 

33. Cultivation of the vagina bacillus 113 

33. Gonococci Ilj 

34. The uterus in sagittal section (27 

35- Diagram illustrating flexions of the uterus I30 

13 



LIST OF ILLUSTRATIONS. 



Prolapse of Ihe uterus ijS 

Hyjietlroph)' of ihe supra-vajiinal cervji I+I 

Two (llagruiu conlrasting hypeiUnphy of Ihe vaginal and of the 

supra-vapoal [mrlion of the cervix I43 

Diagram lo show the three zone& of tlie cervix 144 

A prolapsed uterus iu sagittal section 145 

A ring (rubber) pessary 14IS 

Hodge's pessary 149 

Glycerin pessary I49 

Vaginal slem-pessary 15I 

Inversion of tlie uterus 154 

An inverted uterus (opened) 155 

Partial inversion of the uterus 156 

Uterine repositor 158 

Ijiliueral laceration of the cervix 160 

Four diagrams of cervical Inceralion 162 

Retained fragment of placenta 165 

Midoscopical appearance of recent placental tissue ....... 166 

MicroscojHcal appearance of retained placental tissue I66 

Horiwnlal section of the body of Ihe uterus t68 

Adenoninlous disease of the cervix 174 

Adenomatous disease of the cervix 174 

Microscopic characters of adenomatous disease of the uterus . , . 175 
Microscopic characters of adenomatous disease of the utctus . . . 176 

Uterus, showing tnyomatn 182 

Inlra-cervical myoma 183 

Very vascular myucna 184 

Uterus with an extruded myoma 1S5 

Impacted uterine myoma 189 

Gmviil myomatons uterus 190 

Mucout polypus zoi 

Dcciduomn of the uterus K>3 

Group of decidual cells 304 

Sarcoma of the cervix uteri 10^ 

Microscopic chaiBcteis of uterine san»>ma 3o6 

Carcinoma of the cervix uteri 107 

Microscopic characters of carcinoma aoS 

Cancer of the cervix uteri 205 

Cancer of (he cervix uteri implicating the ureter 210 

Microsco]Mc chikracters of cancer of the uterus 213 

Kallofiian tube with occluded ostium 316 

Tulio-ovarian abscess 218 

HydrouliNnx 119 

Tubercular solpin^tis lal 



J 



LIST OF ILLUSTRATIONS. 



79. ' Tnbeiculat salfxngilis 126 

80. Gravid Faltoptan tube with occluded ostium 131 

81. Tubal mole IJI 

S3. Tube after tubal abortion a33 

83. Uterus with deddua in situ 237 

84. Pelvic organs of a Tcelus 851 

85. Hernia of the ovaiy 253 

86. Fibroma of the ovaiy 362 

87. Oraiian dermoid 264 

SS. Orarian leeth and bone 265 

89. HicroscoiHC characters of skin Trom a dermmd 366 

90. Ovarian dermoid in a girl of seven years 267 

91. Papillomatous cysl 369 

93. Parovarian cysl 370 

93. Ovarian fibroma obstructing labor 285 

94. Diagram of local abdominal swellings 326 

95. Diagram of local abdominal swellings 337 

96. Crutch for gynecological operations 337 

97. Patient in the liiholoroy posilion 338 

98. A sterilizer 339 

99. Penneorrhaphy ; first slafje 343 

100. Peiineortbaphy : second stage 343 

101 . Perineorrhaphy : third stage 344 

103. Operation for vesico-vaginal fistula: mode of passing the sutures . 354 

103. Fenlon's dilators , , . . . 361 

104. Curettes 361 

105. Trachelorrhaphy: first stage 369 

106. Trachelorrhaphy : second stage 370 

107. Trachelorrhaphy : third stage 371 

108. The fint stage of vi^nal hysterectomy 374 

109. Ovariotomy-trocar 3ii7 

1 10. Ovariolomy-tFOCar 3S8 

111. Pedicle.needle 3S9 

113. Sponge-holder 3S9 

1 13. Diagram to illusiiate the position of the uterine arteries during ab- 

dominal hysterectomy 413 

114. Diagram to illustrate the posilion of the uterine arteries during alh 

dominal hysterectomy 413 

115. Method of suture in hysteropexy 430 




DISEASES OF WOMEN. 



CHAPTER I. 

THE ANATOMY OF THE REPRODUCTIVE ORGANS OF 
WOMEN. 

The essential organs of reproduction in a woman are 
two glandular bodies known as the ovaries, in which ova 
(eggs) are formed. The remaining organs, more or less 
subservient to the ovaries, are the Fallopian tobes, which 
conduct the ova to the uterUB, in which, when fertilized, 
they are retained through the embryonic stages. The ute- 
rus communicates with the exterior by the Tagina, a 
mucous tube which receives the intromittent organ (penis) 
for the purpose of impregnation. The orifice of the vagina 
is limited in the virgin by the hymen. The parts exter- 
nal to the hymen are termed the vulva, and consist mainly 
of modified skin arranged in folds. The folds of the vulva 
contain the peripheral end-organs concerned in sexual sen- 
sation, and some glandular structures the secretion from 
which facilitates the introduction of the virile organ. Each 
part requires separate notice. 

The Ovaries. — Each ovary is an olive-shaped body, 
somewhat compressed in its long axis, projecting from the 
posterior fold of the mesometrium. It lies near the brim 
of the true pelvis, surrounded on two-thirds of its circum- 
ference by the ampulla of the corresponding Fallopian tube. 
Each ovary is connected with the cornu of the uterus by 
a band of muscular tissue named the ovarian ligament. 



1 8 DISEASES OF WOMEN. 

Morphologically the ovary consists of two parts ; that which " 
forms its free surface is the egg-bearing pari, and is called 
the oophoron; the part in relation with the mesometrium 
is the paroophoron, and represents the degenerated re- 
mains of the glandular part of the mesonephros. It con- 
tains no folHcIes, but is rich in blood-vessels. 

The Parovarium. — This structure is easily seen, when 
the mesosalpinx js stretched and held between the eye and 
the hght, as a scries of tubules radiating from the ovary to 
join a longitudinal tubule. situated at a right angle to them, 
Although the tubules converge as they enter the paro- 
ophoron, nevertheless they remain distinct. Each tubule 
ends blindly, and is lined with epithelium. When present 
in its typical condition, the parovarium consists of throe 
parts: an outer series of tubules, free at one extremity, 
known aa Kobelt's tubes; an inner set, termed the vertical 
tubules (the parovarium contains, as a rule, twelve tubules; 
sometimes as many as seventeen may be counted, and in 
other specimens as few as five); lastly, running at right 
angles to the vertical tubules, there is a larger tube which 
may occasionally be traced downward to the vagina. This 
is Gartner's duct ; it corresponds to the vas deferens in 
the male. 

The Fallopian Tubes. — These tubes conduct ova from 
the ovaries to the uterus. Each tube is continuous with the 
superior angle of the uterus, posterior to the point of attach- 
ment of the round ligament. When straightened a Fal- 
lopian tube measures on an average 4 inches (10 cm.); it 
opens by a peculiarly fringed opening — the abdominal ostium 

■into the ccelom (peritoneal cavity). The inner third or 
isthmus of the tube is tortuous and narrower than the outer 
two-thirds, termed the ampulla. Each Fallopian tube lies 
in the free border of that portion of the mesometrium known 
as the mesosalpinx. The ampulla of the tube embraces the 
ovary (Fig. l). When an ovum escapes from the ovary it 
falls among the tubal fimbria: and gains the ostium of the 




ANATOMY OJ- RErROlHXTlVR ORGANS. 19 

tube; it is then propelled by muscular contractions along 
the tube to the uterus. The outer end of the Fallopian 
tube is connected by a modified fimbria, termed the tubo- 




ovarian ligament, with the end of the ovaiy opposite to 
that which receives the ovarian ligament 

The Uterus (}VoMb\ — A pyriform body, consisting 
mainly of involuntary muscular fibres, and containing a 
central fissure-like cavity lined with mucous membrane. 
Superiorly this cavity is continuous with the lumen of 
each Fallopian tube; inferiorly it communicates with the 
cervical canal by an orifice known as the interna! os. The 



20 DISEASES OF WOMEN. 

Uterus is divided into three parts, of which two — the body 
and fundus — project freely into the pelvic cavity and re- 
ceive an investment of peritoneum. The fundus is that 
portion lying above the level of the internal orifices of 
the Fallopian tubes ; the lower limit of the body is the 
internal os. The remaining segment of the uterus is the 
neck or cervix : it invaginates the mucous membrane of 
the vagina, forming a conical protrusion in this tube. The 
cervix is traversed by a central passage known as the cer- 
vical canal, communicating with the uterine cavity above at 
the internal os, whilst its lower opening is known as the 
external os, or commonly the " os uteri." 

A fibro- muscular process — the round ligament — projects 
from each angle of the uterus anterior to the Fallopian 
tube, and after traversing the inguinal canal is gradually 
lost in the tissue of the labium niajus. 

The Vagina. — This is a dilatable mucous canal extend- 
ing from the vulva to the cervix uteri. The bladder and 
urethra lie on its anterior wall ; posteriorly it rests on the 
lower segment of the rectum. It receives the penis during 
copulation. When distended it is circular in section, when 
empty its cavity is represented by a transverse fissure, the 
anterior and posterior walls lying in apposition. The direc- 
tion of the vagina is represented in Fig. i , from which it 
will be seen tliat the posterior is longer than the anterior 
wall by nearly an inch (2.5 cm.). The average measurements 
are 2J in, (6 cm.) for the anterior and 3J in. (8 cm.) for the 
posterior wall. The recess formed by the reflection of the 
mucous membrane over the anterior aspect of the cervix 
uteri is known as the anterior vaginal fornix, the recess 
behind the cervix is the posterior vaginal fornix ; it is a 
deeper cul-de-sac than the anterior. The mucous mem- 
brane of the vagina is thrown into numerous transverse 
folds : on the anterior wall a vertical fold begins behind the 
urinary meatus and extends upwards for nearly i in. (2.5 
cm.). When very distinct it is called the anterior column 




A/i/ATOMY OF RF.PRODVCTiVE ORGANS. 21 

of the vagina. A similar fold present on the opposite 
wall is named the posterior vaginal column. The outer 
orifice of the vagina is bounded on each side by the leva- 
tor ani muscle. The orifice can be greatly narrowed by 
the contraction of these muscles. 

The Vulva. — This term is applied collectively to those 
structures often called the external genitals, and includes: 
I. The Mens Veneris. 2. The Labia majora and minora. 
3. The Clitoris. 4. The Hymen. 

The Afons Veneris. — This is an eminence formed by a 
collection of subcutaneous fat situated in front of the sym- 
phy.sis pubis. The skin covering it is in the adult con- 
spicuously furnished with hair, usually of the same color 
as that on the head of the individual. 

7711' Labia Majora. — These are two large parallel folds 
of skin extending from the mons Veneris to near the anus. 
Tlie fissure between the labia — the rima pudendi — is defi- 
nitely limited posteriorly by a thin cutaneous fold known 
as the fourchette. which forms a horizontal commissure 
between the labia and marks the anterior limit of the peri- 
neum. The outer surfaces of the labia are beset with hairs 
and glands and are more deeply pigmented than the skm 
generally. The opposed surfaces of the labia are pink, 
and possess rudimentary hairs, but very large sebaceous 
glands. The subcutaneous tissue of the labia contains 
dartos, fat, and, deeper still, erectile tissue in the form of 
two oval bodies known as the bulbi vestibuli (Fig. 29). 

Tlie Labia Minora (A^>«//w).— Two thin, pink, cutane- 
ous folds, which though hairless are rich in large .sebaceous 
glands. The nympha; lie parallel with the greater labia : 
above they become confluent at the fr^enum of the clitoris : 
below they are gradually lost on the inner surfaces of the 
labia majora. 

Tke Clitoris. — This is a rudimentary penis, but differs 
from it in not being traversed by the urethra. It arises by 
a crus from each pubic arch, near the symphysis. The con- 



^2 DISEASES OF WOMEN. 

^uent crura form the body of the clitoris, which is held by 
a suspensory ligament to the front of the symphysis, The 
extremity ends in a small glans-like body formed of erec- 
tile tissue, and peeps from a cutaneous prepuce-like fold 
which inferiorly forms a median bridle or frxnum. 

The Hymctt. — A septum of mucous membrane at the 
junction of the vagina and vulva. When the labia are 
widely separated, as in Fig. 2, the hymen has the appear- 




, ance of a perforated diaphragm. When the parts lie in 
I their natural positions the hymen forms two folds and the 
L perforation becomes a fissure; the edges of the fissure are 
f then the most prominent part of the hymen and he paral- 
rfcl with, but deeper in the vulvar cleft than, the nympha;. 



^ 



ANATOMY OF REPRODUCTIVE ORGANS 



23 



When the labia are separated certain spaces are exposed 
which receive special names. Of these the most conspicu- 
ous is the vestibule, an area hmited in front by the glans of 
the clitoris, behind by the margin of the vulvar orifice; 
laterally it is limited by the converging borders of the 
nymph*. The urethra terminates in this space. At the 
posterior part of the vulvar cleft there is a well-marked 
depression limited by the hymen and fourchette, known as 
the fossa navicularis. 

The opposed surfaces of the labia, great and small, are 
kept moist with the secretion furnished by the glands lodged 
in their cutaneous investment. In addition there are two 
special structures known as the glands of Bartholin, which 
measure 1 cm. in width, lodged one on each side near the 
outer aperture of the vagina. The orifice of each duct 
opens in the recess between the corresponding labium mi- 
nus and the fold of the hymen (Fig. 29). 




The Arteries. — 1. The Ovarian Artery.— This vessel 
arises on each side from the abdominal aorta below the 
renal arteries, and runs downward in the subserous tissue 




DISEASES OF WOMEW. I 

to pass behvccn the layers of the mesometrium at the brim 
of the pelvis ; it then makes its way to the side of the 
uterus near the fundus to inosculate with the uterine artery. 
In its mesometric course branches are distributed to the 
ovary, Fallopian tube, fundus of the uterus, and the meso- 
metric connective tissue (Fig. 3) ; an arterial twig also issues 
from it to anastomose with a small vessel derived from the 
deep epigastric artery, which is conducted along the round 
ligament of the uterus. 

The Uterine Artery. — In a large proportion of cases 
this artery comes from the hypogastric trunk, a branch of 




MiddU k^morrhoi,!.. 



Dm Lh( hypo£utric ilcm (Pa 



the anterior division of the internal iliac, which breaks up 
into superior vesical, inferior vesica!, and uterine branches 
fFig. 4). In other cases the uterine artery arises as a sepa- 
rate branch from the anterior divi.sion of the internal iliac. 
[t runs under the pelvic peritoneum toward the cervix : on 




ANATOMY OF REPRODUCTIVE OKCANS. 



25 



entering the mesometrium it turns upward and pursues a 
tortuous course on thi; side of the uterus nearer the pos- 
terior than the anterior surface, and on approaching the 
fundus inosculates with the ovarian artery. In its course 
along the uterus it gives many branches which pass across 
the anterior and posterior wall of the organ to anastomose 
with corresponding twigs from the opposite artery. 

3. The Vaginal Arteries. — There arc two or three vagi- 
nal arteries which arise from the anterior division of each 
internal iliac artery, or they may be derived from the uter- 
ine or middle ha.'morrhoidal arteries. They traverse the 
pelvic connective tissue and ramify on the walls of the 
vagina, anastomosing with the vessels of the opposite 
side. 

4. The Vulvar Arteries. — Tlic greater and lesser labia are 
snppHed by branches from the superficial and deep external 
pudics and the superficial and transverse perineal branches 
of the internal pudic. The clitoris derives its blood-supply 
from the terminal branches of the internal pudic arter>', 
which arises from the anterior division of the internal iliac. 
This vessel also gives branches to the skin and the deep 
tissues of the labia, including the bulbi veslibuli. 

The Veins. — 1. Ovarian Veins. — These are situated 
mainly in the mesosalpinx, where they form the pampini- 
form plexus. Near the outer end of the mesosalpinx the 
veins coalesce and form a single vessel — the ovarian vein — 
which joins on the right side the inferior vena cava, and on 
the left side the renal vein. 

2. The Uterine Veins. — These form a large plexus in each 
mesometrium ; the individual branches are sometimes very 
large, From this plexus a single trunk issues to join the 
internal iliac vein. 

3. The Vaginal Veins. — These form a plexus around the 
vagina from which definite branches issue and accompany 
the arteries. 

4. The Vulvar Veins. — These also accompany the cor- 



26 



D/SEASES OF IVOMEN- 



responding arteries. The superficial external pudic vein 
terminates in the great saphena vein. The internal pudic 
ends in the internal iliac vein. The veins from the buibi 
vestibuli communicate with the vaginal, pudic, and obtura- 
tor vein.s. 

The I<ymphatics. — The lymphatics follow the course 
of the veins. Thus the lymphatics from the oyaries, 
the Fallopian tubes, and fundus of the uterus accompany 
the ovarian veins and terminate in the lumbar lymph glands. 
The lymphatics of the round ligament of the uterus join 
the inguinal glands; whilst those of the lower segment of 
the body of the uterus and its cervi.t open into the glands 
lying alongside the iliac vessels. The vaginal lymphatics 
join the pelvic glands. The vulvar lymphatics open into 
the inguinal glands, but those from the clitoris accompany 
the internal pudic arteries to the pelvic glands. 

The Nerves. — The nerves of the ovaries, Fallopian 
tubes, and uterus are derived from the sympathetic system, 
and are conducted to them along the vessels : branches 
from the renal plexus are conveyed to the ovaries and tubes 
by the ovarian arteries, whilst the hypO[,'astric plexus, inter- 
mingled with twigs from the third and fourth sacral nerves, 
supplies the uterus and vagina. 

The vulvar .structures are supplied by the iUo-inguinal 
nerve and the long pudendal branch of the small sciatic 
nerve. A branch of the genito-crural accompanies the 
round ligament of the uterus into the labium majus. The 
clitoris is supplied by the internal pudic : this is a compara- 
tively large nerve, and its terminal twigs end in tactile cor- 
puscles. This nerve by its superficial perineal branches also 
supplies the labia. 

The Pelvic Peritoneum.— The pelvic peritoneum in 
women has a complex disposition which it is necessary to 
thoroughly appreciate in order to comprehend the various 
morbid conditions to which the pelvic organs are liable. 

The peritoneum as it descends from the posterior wall of 





ANATOMY OF REPKODUCTiVE ORGANS. 



27 



the abdomen enters the cavity of the true pelvis and covers 
the anterior face of the sacrum, the ureters, sacral plexus 
of nerves, and iliac vessels : it also invests the first part of 
the rectum and forms the meso-rectum. It gradually leaves 
the sides of the second part of the rectum and, passing on 
to the upiier- 2 cm. of the posterior vaginal wall, extends 
over the whole of the posterior aspect of the body of the 
uterus. Continuing, it invests the fundus and anterior sur- 
face of the body of the uterus, and leaves it at the level of 
the internal os to cover the posterior surface of the bladder, 
and tJien ascends on the anterior abdominal wall. As the 
peritoneum invests the uterus a fold known as the meso- 
metrium (broad ligament) extends from each side of it, 
which becomes continuous with the peritoneum investing 
the iliac fossa. Thus tlie transverse fold formed by the 
uterus and its mesometria divides the pelvic cavity into two 
recesses, of which the posterior is the recto-vaginal fossa 
{poHch 0/ Douglas) And the anterior the utero-vesical fossa. 
It will be necessary to study these fossae and the meso- 
metrium in detail. 

The Hesometrimn. — This important fold is formed by 
the peritoneum as it is reflected over the uterus and Fallo- 
pian tubes ; it consists of two layers of serous membrane. 
The part in relation with the uterus and tubes has the fat 
of the subserous tissue replaced by unstripcd muscle tissue, 
but as it approaches the floor of the pelvis fat again appears 
in relation with it. The mesometrium lodges between its 
layers, in addition to the Fallopian tube, the ovary with the 
parovarium, Gartner's duct, the ligament of the ovary, the 
round ligament of the uterus, the ureter, the uterine and 
ovarian arteries, the pampiniform plexus of veins, and the 
lymphatics of the uterus: these structures are embedded 
in loose connective tissue. Two strands of muscle tissue, 
the utero-sacral ligaments, pass from the lateral aspect of 
th^ cervix to the sides of the second sacral vertebra. 

The upper portion of the mesometrium is called the 



28 



DISEASES OF WOAtEN. 



mesosalpinx; it is included between the Fallopian tube, the 
tubo-ovarian ligament, the ovary and the ovarian ligament, 
and contains between its layers the parovarium and the 
associated segment of Gartner's duct, the ovarian artery and 
veins, and the uterine end of the round ligament of the 
uterus. 

The Recto-Tag:inal Fossa (Pouch of Douglas).— 1\i\s. 
is a cul-de-sac of the peritoneum in relation with the floor of 
the pelvis, situated, as its name indicates, between the rec- 
tum and the upper 2 cm. of the posterior vaginal wall and 
the cervix uteri. Laterally the upper limits of this pouch 
are the utero-sacral ligaments. The pouch is deeper on the 
left than the right side, the peritoneum being carried down- 
ward by the rectum. When the pouch is not occupied by 
intestine or omentum, its anterior and posterior walls are 
in apposition. 

The Tltero-vesical Fossa. — This is a shallower cul- 
de-sac between the bladder and the body of the uterus. Its 
depth varies with the empty or distended condition of the 
bladder. 

The Ovarian Pouch. — This is a shallow recess in the 
posterior layer of the mesosalpinx. It varies in depth, 
being small and inconspicuous in many, whilst in others it 
is deep enough to accommodate the entire ovary. In the 
virgin the ampulla of the tube falls over the mouth of the 
pouch and conceals the ovary. 

Canal of N'nck. — In addition to the two fosss actually 
within the pelvic cavity, there is a peritoneal pouch directly 
connected with the anterior layer of each mesometrium 
which partially invests the round ligament of the uterus 
and accompanies it through the inguinal canal to the la- 
bium. This pouch, known as the canal of Nuck, normally 
becomes obliterated in the adult. 

In order that the student may thoroughly comprehend 
the relations of the pelvic peritoneum it will be useful to 
summarize briefly the manner in which it invests the parts : 




ANATOMY CI- REPRODUCTIVE OKGAiVS. 29 

1. Tfie Ox'ary. — This projects from the posterior layer 
of the mesometrium and strictly has no peritoneal invest- 
ment 

2. The Fallopian Tube. — This is invested on two-thirds 
of its circumference. The tubal ostium communicates with 
the cfElom (peritoneal cavity} on the posterior aspect of 
the mesometrium, below the ovaiy and near the brim of the 
pelvis. 

3. The Uterus. — The peritoneum covers, posteriorly, the 
whole of the surface of the body and fundus of the uterus 
and supravaginal portion of the cervix ; anteriorly, the fun- 
dus and body to the junction of the body and cervix. The 
sides of the uterus are in relation with the connective tissue 
of the mesometrium. 

The Round Ligament of the Uterus. — In the pelvis this 
structure is invested by the anterior layer of the mesome- 
trium. As it traverses the inguinal canal it invaginates the 
peritoneum ofthe canal of Nuck. 

4. The I'agina. — The only part of this tube in relation 
with the peritoneum is the posterior cul-de-sac. 



CHAPTER II. 

THE GENERAL PHYSIOUXJY OF THE REPRODUCTIVE 
ORGANS OF WOMEN, 

The development, maturity, and decline of the reproduc- 
tive powers in a healthy woman correspond to the men- 
strual life, the beginning of which is termed Puberty, while 
its termination is the Menopause. This period extends 
from the age of thirteen to that of forty-eight, with individ- 
ual variations. Warm climates, sedentary and luxurious 
habits, and emotional stimulation are associated with early 
puberty; late puberty is commonly found ii^ the opposite 
conditions. Puberty is sometimes defined as " reproductive 
maturity ;" but it must be remembered, first, that concep- 
tion sometimes occurs before menstruation has begun ; 
secondly, that the uterus continues to grow till about the 
eighteenth or twentieth year and the woman cannot usu- 
ally be considered as sexually mature till this time. 

The external indications of approaching puberty are: 
enlargement of the breasts (mamm«). development of hair 
in the axilla; and on the mons Veneris ; subjective sensa- 
tions such as fulness of the pelvis, backache and shooting 
pains in the thighs, and lastly some alteration in the dis- 
po.sition, in the direction of shyness and reserve. The 
actual establishment of puberty is reclconcd from the first 
menstruation. 

MENSTRUATION. 

1, Clinical Features. — After the first menstruation, 
which may be rather abundant, it is not unusual for a. pe- 




PHYSIOLOGY OF REPRODUCTIVE ORGANS. 31 

riod of irregularity to succeed ; then after some months the 
process assumes its regular rhythmic form. The periodicity 
varies with individuals, and in the same individual at differ- 
ent times ; most frequently twenty-eight to thirty days 
elapse between the commencement of one period and the 
commencement of the next. The total quantity of blood 
lost at each monthly period varies from t«'o to three 
ounces {60 to 90 ccm,) and the flow lasts from two to seven 
days. Sometimes on the third or fourth day it ceases, to 
recommence in diminished quantity after twenty-four hours 
for another two or three days. A discharge of mucus 
commonly precedes and follows that of blood. The latter 
has all the characteristics of ordinary venous blood, except 
that it does not coagulate, owing to admixture with mucus 
from the cervical canal; it also contains epithelium derived 
from the uterus and vagina. When abundant, it may be 
bright red. and clots may form. Under favorable condi- 
tions menstruation is painless, especially for the first few 
years. Later, and in some cases from the first, an aching 
pain in the sacrum precedes the 'flow, passing off as this 
becomes established. Suprapubic pain may cither precede 
or accompany the flow — generally the latter. In London 
about 30 per cent, of women continue to menstruate pain- 
lessly. The intensity of the pain varies from slight discom- 
fort to intense agony preventing the woman from getting 
about or from attending to her ordinary pursuits. No 
hard-and-fast line can be drawn between normal menstrua- 
tion and dysmcnorrhcea. Similarly, there is great varia- 
tion in the nature and amount of constitutional disturbance ; 
headache, lassitude, sickness, obscure reflected pains are not 
infrequent, with mental depression or irritibility. Lastly, 
in a few cases the genera! health is better than during the 
intermenstrual periods. 

II, Anatomical and . Physiological Changes. — 
A. OTii/iilwi.—Thh signifies the ripening and escape of 
ova from the ovaries. When these glands (which are the 



32 DISEASES Of WOMEN. 

dominant organs of reproduction in women) fail to develop, 
sterility results, and thu woman generally retains the physi- 
cal characters of the child. Thus tlic breasts are small, the 




h»cm fZZ^"^'!""'' 



pubic hair is scanty or absent, and the pelvis is n 

than usual, whilst menstruation does not occur or is much 

delayed. With tlie onset of puberty the ovaries, previously 



FHVSIOLOGY OF REPRODUCTIVE ORGANS. 



33 



small, enlarge and exhibit the periodic series of changes 
known as m'ultUion. 

Ovulation consists in the growth and shedding of an 
ovtun, which first sinks more deeply into the stroma, and 
then approaches the surface of the ovary; the follicle in 
which the ovum is contained bursts, and the ovum itself is 
discharged. Normally it finds its way into the Fallopian 
tube and is propelled along it to the uterus; should the 
ovum be fertilized it develops into an embryo. Failing this, 
it passes out, probably with the menstrual discharges. 

The process of ovulation will be readily understood by 
a reference to the accompanying diagram (Fig. 5) repre- 
senting its successive stages. From this it will be seen that 
a given ovum first becomes surrounded by a layer of small 
cells, to form an orarian (Graafian) follicle. At the same 
time the stroma bounding the follicle becomes denser. On 
one side of the ovum a line of cleavage occurs in the 
[lie of the surrounding cells, and the space is found to 
pun fluid. The ovarian follicle now presents an appear- 
hich has been compared to a .signet ring ; the margi- 

Fcells receive the name of tnembrana g;Taiitilosa, 
whilst those immediately surrounding the ovum are called 
the discas proligerus. As the follicle grows it approaches 
the surface of the ovary, and its envelope becomes vascu- 
lar from enlargement of vessels derived from the stroma. 
The ripe follicle bulges on the surface; the most promi- 
nent point, which is non-vascular, gives way and the ovum 
escapes, surrounded by the discus proligerus. This consti- 
tutes the dehiscence of the ovum. The cavity of the fol- 
licle becomes filled with blood, derived from the vessels in 
its capsule, and the capsule itself contracts in folds. The 
blood-filled cavity with its convoluted walls is called, from 
its yellow appearance, the COTpUS Intenm (Fig. 6). By 
degrees the liquid part of the blood is absorbed. The cor- 
pus lutcum becomes paler and shrinks and is converted 
into cicatricial tissue whose only ultimate trace is a scar 



34 D/SEASES OF WOMEIV. 

or cicatrix on the surface of the ovary. By the repeti- 
tion of this process, the smooth appearance of the young 
ovary is replaced by the rugged aspect of the ovary of the 
adult. 

When pregnancy occurs, the corpus luteum, instead of 
reaching its fullest development in three weeks and disap- 
pearing in three months, persists in a well-developed form for 
three or four months, after which It gradually diminishes, and 
commonly disappears in two or three months after delivery. 

Probably a certain number of ova fail, on their dehis- 
cence, to enter the Fallopian tube, and are lost in the cce- 
lom (peritoneal cavity). Maturation (ripening) of ova may 




>g(U(c(A. E, G.}. 



occur before puberty, and ripe ova have been detected in 
the ovaries at birth. The view formerly held, that an ovum 
ripens at each menstrual period, is now abanSoncd by most 
authorities. Nor is there any evidence that ovulation occurs 
alternately in the two ovaries ; there is apparently no con- 
stant relation in the activity of the two glands. 

B. Changes in the UUrns. — The only part of the uterus 
which shows menstrual changes is that between the inner 
orifices of the Fallopian tubes and the internal os. The 




P//YS/OLOGY OF KEPA-ODUCT/fE OKG^XS. 



35 



Fatlopian tubes themselves take no part therein (Sutton, 
Heape). The precise nature of the changes, which alftct 
the mucosa alone, has been much disputed. The classical 
views have been as follows : 

(a) That the whole thickness of the mucosa, down to the 
muscular layer, is stripped off and shed at each monthly 
period (Pouchet. Williams). 

(b) That the surface epithelium only is cast off (Leopold, 
Kundrat and Engelmann). 

{c) That the mucous membrane remains quite intact 
(Coste, Moricke), 

The difficulty of obtaining specimens of the healthy 
menstruating uterus has led to this divergence of views. 
There is, however, reason to believe that in some of the 
higher apes the process closely resembles that which occurs 
in women ; and, ba.sing our description partly on compara- 
tive observations (Sutton, Heape) and partly on researches 
on the human uterus, the changes are as follows : 

The mucosa of the non-menstruating uterus is composed 
of a stroma containing numerous glands and blood-vessels, 
and covered by a single layer of cubical epithelium. Shortly 
before menstruation begins the stroma-cells proliferate and 
the superficial vessels become dilated; with increased con- 
gestion the dilated capillaries break down and blood is 
extravasated into the superficial parts of the stroma under 
the epithelium. I^ter the epithelium gives way, probably 
in part from a degenerative change, and is cast off. along 
with portions of the stroma and of the glandular epithelium. 
The debris passes out with the menstrual fluid. After a 
time, regenerafion of the mucosal surface takes place, by 
re-formation of blood-vessels and by the reproduction of 
epithelium, partly from the torn edges of the glands and 
partly by the transformation of stroma elements (Heape). 

During menstruation there is a slight spontaneous dilata- 
tion of the cervical canal, attaining its maximum on the 
third and fourth days (Herman), 



36 DISEASES OF WOMEN. 

Ill, The Significance of Menstmation. — We need" 

not refer here to old theories, which are merely ol" historic 
interest. The first attempt to explain menstruation from the 
facts of anatomy and physioSofry resulted in the Ovulation 
Theory, which supposes that regularly, every month, an 
ovum ripens and is set free, leading to uterine congestion 
and menstruation. This theory, which was widely held 
during the second quarter of this century, through the 
work of Lee, Negrier, Bischoff and Raciborsky, is now 
generally discarded; for repeatedly instances have occurred 
where menstruation has recently happened and there has 
been no trace of the ripening of an ovum ; and, on the 
other hand, where ripe follicles and recent corpora lutea are 
present and menstruation has not been established, or has 
ceased, or is in abeyance. An explanation has therefore 
been sought in the periodic variations of nutrition, as 
■ shown by the pulse, temperature, blood-pressure, and the 
quantity of urea excreted. This is the Cyclical Theory 
(Jacobi. Goodman. Reinl, and others). The existence of the 
variations is established; but that they are the cause of 
menstruation, is not. 

Probably the simplest way to regard the whole matter is 
as follows ; The female organism presents a tendency to an 
alternation of nutritive and reproductive activity. The 
alternation has a monthly rhythm ; but to inquire why. 
is as fruitful as to ask why the respiratory rhythm should 
be about four seconds or the cardiac cycle something under 
one second. 

Periodically, then, the body prepares itself to take on 
reproductive functions ; in this preparation the vaso-motor 
system acts as chief agent, as shown in variations of tem- 
perature, pulse, and nervous manifestations, as well as in 
ovarian and uterine changes, The latter are directed to 
the protection and nutrition of a developing ovum, for the 
changes preceding menstruation correspond closely to the 
early stages in the formation of the decidua of pregnancy. 



PHYSIOLOGY OF REPRODUCTIVE ORGANS. 37 

If, however, no fertilized ovum be ready, a miniature abor- 
tion occurs, for the nidus of the early embrj'o must always 
be freshly prepared. After the menstrual discharge, the 
uterus begins its preparations anew. Menstruation, there- 
fore, is a missed pregnancy. 

The Menopause. — The onset of the menopause pre- 
sents very varied features. In some women there is no 
disturbance at all ; menstruation goes on normally and then 
simply ceases, without prodromata ; this occurs most often 
among unmarried women. In other cases menstruation 
becomes irregular in its periodicity, while the quantity 
becomes variable; after an unusually long interval there is 
a final and rather profuse flow, and the menopause is estab- 
lished without any constitutional trouble. But in the 
majority of women the "change of life "is not so easily 
effected. Various nervous phenomena appear; the patient 
is subject to hot flushes, attacks of giddiness, obscure pains 
in breasts, abdomen, and hnibs. Digestion is disordered, 
with flatulence and constipation. There is a great tendency 
to deposits of fat, which, with the flatulence, may cause 
■■ spurious pregnancy," or a phantom tumor. Many women 
become depressed, and unstable minds may cross the 
border-line of insanity. It is, therefore, with many, really 
a " critical period," demanding careful supervision. 

The pelvic organs show corresponding anatomical 
changes. The ovaries become smaller and wrinkled ; the 

igina contracts and assumes the shape of a cone, at the 
I of which is a dimple representing the os uteri, — for 
:; vaginal portion of the cervix atrophies and disap- 
The uferine body diminishes in size, and in extreme 
cases can hardly be felt. 



CHAPTER III. 

METHODS OF EXAMINATION OF THE FEMALE PELVIC 

ORGANS. 



Accurate diagnosis is not a matter of intuition. It de- 
pends on a scientific interpretation of physical signs and of 
symptoms. 

The value of symptoms is threefold. ThLy determine, 
first the necessity, and secondly the method of examina- 
tion ; thirdly, they influence the interpretation of signs. 

The value of physical signs is that they are of the nature 
of facts; for their discovery, training and a systematic 
method are essential. This chapter is concerned with the 
exposition of a systematic method ; whilst the student will 
obtain his training by the application of the method in the 
out-patient room and by the bedside. 

Abdominal Bxaminatioti. — This should always be 
made first, in the classical order: Inspection, Palpation, 
Percussion, Auscultation. 

Impcction. — This shows the size of the abdomen, and 
may reveal striic, pigmentations, prominence of superficial 
veins, irregularities of surface, as evidence of past or present 
distention or of intra-abdominal pressure. 

Palpation shows in the first place the resistance of the 
abdominal walls, and when carried deeper will give infor- 
mation as to the enlargement of particular organs or of 
certain parts of the abdomen. If there be any abdominal 
tenderness this is also revealed. It is often necessary to 
ascertain the condition and relations of the liver, stomach. 
Spleen, and kidneys. Palpation is also most important in 




EXAMIXATION OF FELVtC ORGANS. 



39 



pregnancy. In tlic absence of a tumor occupying the pel- 
vic inlet, the sacral promontory can be easily reached. 

Percussion indicates the nature of local or generalized 
abnormalities discovered by palpation ; solid, liquid or gas- 
eous local conditions may thus be analyzed, and the size 
and di.stribution of tumors or of collections of fluid may 
be ascertained. A loaded colon, often of significance. 
will sometimes be discovered by this and tlie preceding 
method. 

Auscultation has also its value, chiefly in pregnancy and 
in certain uterine tumors where a venous murmur may be 
heard. 

In conducting the above inquiries the position of the 
patient may require to be changed; she may be turned to 
one or the other side, or the knees may be drawn up in 
order to relax the abdominal muscles. 

Inspection of the external genitals is often unnecessary, 
at least in the first instance, whilst in other cases it will be 
indicated by the nature of the symptoms complained of 

Vaginal Examination. — For this purpose the patient 
may lie on her back or side. 

The Dorsal Position. — We take this first because it is 
the best for a complete pelvic examination. It is often 
convenient to let the patient retain the position in which 
the abdominal examination was made, the knees being 
drawn up. 

The right hand is used for the vaginal exploration, and 
the left for abdominal palpation, the physician standing on 
the right side of the patient. Or, if more convenient, the 
patient is placed at the foot or side of the bed, with knees 
drawn up and everted, the physician standing or sitting 
opposite the perineum. In either case the examination is 
made in the same systematic manner. 

The index finger, well lubricated, is introduced into the 
vagina by gently feeling for the perineum, and passing 
forward till the posterior margin of the vaginal outlet is 



40 



DISEASIiS OF WOMEN. 



reached. In the vagina, the finger should press chiefly 
against the posterior wall. It must be remembered that 
the direction of the vagina is toward the body of the first 
sacral vertebra. After the character of the vaginal walls 
and of the cervix have been noted, the left hand Is placed 
on the abdomen, to make the 1(111130031 examination. 
The abdominal wall is depressed just above the pubes, the 
fingers being placed as flat as possible to avoid hurting 
the patient with the nails or finger tips. The position of 
the pelvic brim must be remembered; for exploration of the 
posterior regions of the peU'is the hand will have to be 
placed nearer the umbilicus; similarly, it must be moved to 
one or other side in examining the lateral parts of the pel- 
vis. As the external hand is moved, the finger in the 
vagina is moved at the same time, passing into the anterior, 
posterior, or lateral vaginal fornices, in order to meet the 
external fingers; and gentle pressure must be made till the 
inside and outside fingers meet, or till .some definite struc- 
ture is felt between tlicm. 

In women who have borne children it is generally better 
to use two fingers for the vaginal examination, because we 
can thus reach higher up, and a better idea is obtained of 
the position of the organs. 

Still using the dorsal position, a recto-nbdominal cxami- 
ttation may be required, either in the first instance in virgins 
or to give additional information in others. Much may be 
made out by this method : the general size, po.sition, and 
shape of the uterus can be determined, the posterior surface 
of the uterus explored, and the appendages often distinctly 
mapped out. 

In certain cases a rccto-vaginal-abdominal examination is 
resorted to; this is especially useful in defining exudations 
or solid bodies in the recto-vaginal fossa, for vaginal touch 
alone might suggest that these were in the rectum, while 
rectal exploration alone might give the impression that 
they were in the vagina or connected with the uterus. 



EXAMl.WATION OF PELVIC OA'GA^VS. 4 1 

T/u Lateral Positioti. — The patient lies on the left side, 
with buttocks projecting over the edge of the bed, and 
with the knees drawn up. In this position the relation of 
parts is not so clear, and the beginner will more readily 
make mistakes. It is well, however, to accustom oneself 
to both methods, and in certain cases it is useful to employ 
both in turn. But for some purposes the lateral position 
answers all requirements, especially when the bimanual 
examination is not necessary; whilst for some manipula- 
tions, both for diagnosis and for treatment, it is preferable. 

Tlie lithotomy position, with pelvis raised and knees flexed 
on the abdomen, is seldom required for an examination, 
unless under an anesthetic. 

The semi-prone position, or Sims', is useful when it is 
required to examine, with the speculum or otherwise, the 
anterior vaginal wall, and sometimes for purposes of treat- 
ment. The patient lies on her left side, and partly prone ; 
both knees are drawn up, the right in front of the left. 
The patient's chest lies almost flat on the pillow, the left 
arm is placed behind her or hangs over the edge of the 
bed. 

The genu-pectoral position is occasionally required ; for 
instance, to replace a retrovertcd gravid uterus. The pa- 
tient rests on her chest, arms, and knees, the pelvis being 
raised and the thighs vertical. 

We have so far traced the methods to be adopted, and 
the information that may be obtained, in using the hands 
alone. We must now pass under review the various acces- 
sory procedures, with the aid of instruments. Of these the 
most important is the uterine sound. 

The Uterine Sotmd. — This is a rod of copper, silver- 
plated, rigid enough to retain any shape imparted to it, and 
flexible enough to admit of being bent with the fingers. 
It is set on a handle which is flattened, and rough on one 
surface (Fig, 7). The sound is straight in the portion 
next the handle ; the distal portion is curved, the concavity 



HBK^M 


^M 42 DISEASES OF H'OA/EA'- H 


^V being on the same side as the rough surface of the handle. 1 


^B _ The curve is of such a nature that | 


H 


j^ the last zj- in. (6.2 cm.) form an H 


* 


,^^ angle of about 140° with the 1 




5r straight portion; and at the junc- 1 




^ tion of these two parts there is a | 




e 


well-marked knob or angle on the 
convex side, which can be readily 
distinguished by the finger, and 


^ 


3 


' which marks the distance to which 


■ 


' 


the sound should enter a normal 


■ 




, uterus. The instrument is gradu- 


■ 


ated by means of notches on the 






convex side. The first notch is 1 J 






, in. (3.7 cm.) from the tip ; the knob 




i I 


. or angle forms the next mark, 2}[ 
^ in. (6.2 cm.) from the tip, and the 










, remaining notches are i in. (2.5 


■ 


t 1 


cm.) apart; the first being 3J in. 


I 




(8.7 cm.) from the tip. The length 


■ 




1 of the uterine canal is easily meas- 


■ 


' / 


ured by placing the finger on the 






point Just outside the external os 


1 


8 


' when the sound has passed as far 


y 


k 


as it will, and keeping the finger in 

II its place while the sound is being 

11 withdrawn. The distance is read 

yX off by means of the graduation 


%ff . ■ H notches. ■ 


11 1 ^1 The sound should not be used ■ 


f ft 1 ^^k when the patient has missed a H 


1 ■ 1 ^^M menstrual period, unless preg- H 


■y^F 1 ^^V nancy be certainly excluded ; H 


mation, malignant disease of the H 


uterus, or when the vagina or cervix is septic. All these H 




EXAMINATION OF PELVIC ORGANS. 



43 



points can be determined by the preliminary digital ex- 
aminations. 

How to Use the Sound. — It is most important that the 
position and direction of the uterus should be first deter- 
mined, so that if, for instance, the uterus is strongly flexed, 
a little additional curve may be first imparted to the sound ; 
if the organ be lying much ante- or retroverted, an idea 
can be gained beforehand of the general direction that the 
sound will take. This settled, the finger is placed so as to 
rest against the os, and the point of the sound is carried 
along the concavity of the finger and guided by it into the 
cervical canal. Once entered (a matter of little difficulty, 
as a rule), the handle of the sound is to be carried gently 
back to the perineum. In most cases this will suffice to 
cause the end of the sound to slip through the os internum. 
No pressure need be used. But if the uterus is retro- 
verted, the concavity of the sound should first be directed 
backward, and by moving the handle slightly forward the 
sound enters the cavity. In some cases, when there is 
lateral deviation of the uterus, or when the canal is tortuous 
(as when a myoma is present), a little patience and care will 
be needed. But always desist rather than use force. The 
introduction of the sound is sometimes facih'tated by taking 
hold of the anterior lip of the cervix with a volsella, and 
drawing it gently down, 

Information Giv(» by the Sound. — It is possible to intro- 
duce and withdraw a sound, and to realize little but the fact 
of its introduction ; but, used as an extended, sensitive 
finger, it will teach much. At the outset the degree of 
patency of the os will be noted, the smoothness or other- 
wise of the cervical canal, and the existence (if present) of 
muscular spasm at the os internum ; one gets also a general 
idea of the firmness or flabbiness of the tube, through which 
the sound is passing. The sound once introduced, the 
length of the cavity can be measured, and by gentle rota- 
tory movement its width may be gauged. Projections may 



44 



D/SEJSES OF WOMEA'. 



be met with, as sessile tumors, which at first obstruct the 
passage of the sound. Sometimes, also, two distinct direc- 
tions will be found in which the sound passes, as in a bipar- 
tite uterus. Meanwhile the patient will herself have given 
some indications ; at certain points she may complain of 
pain, as in passing through the internal os, or when touch- 
ing the fundus. If the bimanual examination has revealed 
a tumor it will now be noted whether the sound passes 
into it or not, and in the latter case whether movements of 
the sound are at once conveyed to the tumor or vici' I'l-rsa; 
in this way a uterine can often be distinguished from a non- 
uterine tumor. When the tumor is uterine, by placing one 
finger in the anterior and the other in the posterior fornix. 
or with one finger in each lateral fornix, it may be possible 
to determine whether the tumor is in the anterior, posterior, 
or side wall of the uterus. 

As the sound is withdrawn, it may be felt to be gripped, 
cither by spasm or by mere narrowness of the passage ; we 
have here the test of stenosis. If, while the sound is intro- 
duced as far as possible, the finger be placed on it up against 
the cervix, and it be kept in this position when the sound is 
withdrawn, the length of the cavity can be exactly read off 
Lastly, we look at the sound, to see if its introduction has 
caused bleeding. 

The Volsella. — This is principally an instrument for 
treatment, but may be required also for diagnosis. It is 
used to draw the cervix down, and is generally applied to 
the anterior lip. In most cases an antero-posterior grasp 
of the anterior lip is obtained ; but in nulliparae with a small 
cervix it is often more convenient to seize the lip trans- 
versely. When the uterine canal is bent, traction on the 
cervix tends to straighten it, and thus facilitates the intro- 
duction of the sound. The ordinary volsella (Fig. 8) is 
slender, with thin hooks ; for obtaining a firm hold, as when 
the uterine canal is being dilated, the bulldog volsella (Fen- 
ton's) is a very convenient instrument. 



EXAMINATION OF PELVIC ORGANS. 45 

In removing a volselia, care is required lest the vagina 
be caught and torn. 




Fig. B-~Bu11dDS vd 



The SpectUmn. — Introduced as an instrument of diag- 
nosis, the speculum has now become an appliance for 
treatment. There is very little that a speculum shows that 
cannot be discovered by touch. It is convenient, however. 



46 niSEASF-S OF WOMEN. 

to see at times the condition of the vagina and the cervix. 
The simplest is the cylindrical or Firgusson' s speculum 
(Fig. 9). This is a hollow cylinder of stout glass, silvered 
like a mirror and coated with vulcanite. Its extremity is 
bevelled and is very liable to chip. When this happens it 
will scratch the patient and cause pain. To introduce it, 
the instrument is warmed and lubricated with oil or 
vaseline and the perineum is 
held backward while the end 
of the speculum is pressed 
against it. The instrument is 
gently pushed in the direction 
of the vaginal axis. If care be 
taken to avoid pressure ante- 





riorly against the pubes, -and if a suitable size be chosen 
the procedure causes no pain. As the speculum passes up, 
a general view is obtained of the vaginal walls, and finally 
the cervix comes into view. If the uterus is lying forward, 
the anterior lip of the cervix may alone be visible, until this 
is drawn down with a tenaculum or volsella. In other po- 
sitions of tile uterus the inferior surface of the cervix comes 




^ 



OF PEL VIC ORGANS. 47 

fully into view. A small swab of cotton-wool should be at 
hand to clear away the mucus and blood (if any) from the 
surface of the cervix ; this can then be examined with ease. 

The duckbill {Sinis') speculum {^'\%. 10) can be used only 
iti the semi-prone or the lithotomy position, and requires an 
assistant to hold it. By its means a good view can be ob- 
tained of the anterior vaginal wall and of the cervix. 

Tlu bwahc {Citsco's) speculum is easy to introduce, and 
allows of considerable separation of the two free ends, 
whilst the part embraced by the vulvar outlet is not further 
distended. A good view of the vaginal walls may be ob- 
tained by slightly rotating the instrument. It has the dis- 
advantage of complexity of screw and hinges, making it a 
matter of difficulty to keep it perfectly clean. 

Neugchaucr's speculum is one of the most generally con- 
venient. The larger posterior blade is first introduced, well 
lubricated ; the smaller blade lies within the larger, the two 
together forming a cylinder where they touch. Any degree 
of separation of the inner ends of the speculum can be ob- 
tained that may be desired ; a good view of the cervix can 
be obtained, and by using one blade alone the anterior or 
posterior vaginal wall can be explored. 

A very useful instrument is Auvard's speculum. It is on 
the principle of Sims' speculum, but is made '" self-retain- 
ing " by means of a weight on the handle. The handle 
itself is grooved, so that it can be used as a conduit for 
fluids when the vagina is being douched. Its special value, 
however, is for purposes of operation ; it can only be used 
with the patient in the lithotomy position. 

It is sometimes necessary to include in one's examination 
the digital exploration of the interior of the uterus. Ex- 
cept immediately or soon after confinement or miscarriage, 
or when the cervix is dilated by a tumor (polypus), this can 
only be done under an anaisthetic, and the cervical canal 
must be dilated. Tents were formerly used for this purpose, 
but they are always tedious and often unsafe, and except in 



48 DISEASES OF WOMEN. 

special circumstances it is better to carry out dilatation at 
one sitting. 

Examination under an Anaesthetic.— We would 
lay special stress on the importance of this as an aid to 
exact diagnosis. In the case of unmarried girls and nuUi- 
parous women with narrow vagina it is especially indicated ; 
partly, in the former case, for ethical reasons. That it may 
be satisfactory, the rectum should be first emptied by means 
of an enema, and the urine drawn off, if necessary, by 
catheter. 

The first advantage is the avoidance of pain; as a con- 
sequence the examination can be much more thorough, 
and deep pressure exerted as required. In the second place 
the muscular relaxation allows of a much better bimanual 
examination. There should be no difficulty, in an ordinary 
case, in exactly mapping out the position of the uterus, 
ovaries, and tubes. The differential diagnosis of pelvic 
conditions from one another and from renal and other 
abdominal tumors is comparatively easy. 

Small pelvic swellings are often easily overlooked in an 
ordinary examination; whilst an examination under an 
anesthetic in the lithotomy position will generally dis- 
cover them without trouble. In addition, the bladder and 
rectum can, if necessary, be thoroughly explored. 



CHAPTER IV. 

MALFORMATIONS OF THE REl'RODUCTIVE ORGANS OF 
WOMEN. 

MALFORMATIONS OF THE VULVA. 

Hermaphrodism and Pseudo-hermaphrodism. — 
Hermaphrodi.sm implies the combiii.ition in an individual of 
functional male and female sexual organs. 

Men and women are distinguished from each other by 
two sets of sexual characters, primary and secondary. 

I^mary Sexiial Characters. — These are directly associated 
with the function of reproduction. In a man they include 
the penis, the testes with the vasa defcrentia, the prostate, 
and Cowper's glands. In a woman they consist of the 
vagina, the ovaries, the Fallopian tubes, and the uterus. 
Secondary Sexual Characters. — These comprise those 
' features which enable the male to be distinguished from the 
female irrespective of the organs of reproduction and those 
used for the nourishment or protection of the young. 

The characters belonging to this group, so far as the 
I human family is concerned, are exclusively in possession of 
I the male. Man is distinguished from woman not only in 
I the possession of a beard and greater muscular develop- 
I mcnt with its necessary accompaniment, greater physical 
strength, but he has a more powerful voice, and the skin of 
I his trunk and limbs is thick and more abundantly supplied 
I with coarse hair, which has a somewhat different disposition 
I in women. In man the front of the chest is usually covered 
^with hair, and that on the pubes passes upward to the urn- 




D/SEASES OF IVOME.V. 



bilicus, whereas in the female it is restricted to the mons 
Veneris. A less constant feature, but one which seems con- 
fined to men, is a luxuriant growth of hair on the promi- 
nence of the pinna known as the tragus. 

Secondary sexual characters are not present in the young, 
but become manifest at puberty, by which term we signify 
reproductive maturity. At this period the generative or- 
gans increase in size, and in the male become functionally 
active. In the female, puberty is more strikingly declared 
by the institution of menstruation. 

Until the advent of puberty the boy, so far as secondary 
characters are concerned, resembles the female as much as 
he docs the male, but after that period he begins to assume 
those indicative of the male. 

It occasionally happens that children are bom with mal- 
formed external genital organs which render it difficult to 
determine whether the child is male or female ; even when 
the individual attains puberty the secondary sexual charRC- 
ters appear in such form as to increase rather than to 
diminish the doubts which were entertained at the child's 
nativity. 

When doubt exists as to the sex of a child it is often 
termed an hertnaphrodlte. This term is employed by natu- 
ralists to signify an animal possessing conjoined ovaries and 
testes (a combination occasionally occurring in vertebrata 
and known as an ovotestis), or an ovary on one side and a 
testis on the other. There is no example on record of such 
combinations in a human individual which survived its 
birth, but individuals to which the term hermaphrodite is 
usually applied are those in which there is defective devel- 
opment of the external genitals and the secondary sexual 
characters resemble those of the female. So far as the 
human family is concerned individuals with malformed ex- 
ternal genitals should be called psendo-hermaphrodites. 
Before proceeding to describe the leading features of this 
condition it will be necessary to briefly review the main 



MALFORMATIONS OF REmoDLXTtVE OKGANS. .$1 

facts which have been ascertained in regard to the develop- 
ment of the organs of reproduction. 

The early embryo possesses in a potential form the pri- 
mary sexual organs of both sexes, and at an early stage in 
its development it would be impossible to determine its sex 
(Fig. 1 1). In this undilferentiatcd stage the future reproduc- 




IhiTmbrrahcfaic 



a (Hmlc). 



tivc organs are represented by two glandular masses which 
ultimately become the genital glands, and associated with 
them is a remarkable temporary organ known as the meso- 
nephros (Wolffian body), furnished with a series of tubules 
— the mesonephric (Wolffian) tubules, opening into a duct 
— the mesonephric (Wolffian) duct, which terminates in a 
recess, known as the uro-gcnital sinus, which opens to the 



S3 



DlSE.-iSES OF WOMEN. 



exterior. In addition to the ducts just mentioned there is 
another pair, Icnown as Miillcr's ducts, which are peculiar 
inasmuch as they open into the coelom (pleuro-peritoneal 
cavity); they run parallel with the mesonephric ducts and 
open into the uro-genital sinus. The external opening of 
this sinus is surmounted anteriorly by a vascular body 
and laterally is limited by two parallel folds of skin. 

In the male (Fig. i 3) the genital masses become testicles, 
the mesonephric (Wolffian) tubules and ducts develop and 




become vasa eflercntia ; the main duct on each side is known 
as the vas deferens, which ultimately opens in the floor of 
the urethra, the adjacent parts of which become execs- 



MALFORMATIONS Ol- HErRODVCTIVE ORGANS. $3 

sively developed and form a musculo-glandular organ, the 
prostate. Coincident with the growth of the mcsonephric 
tubules and duct the glandular part of the mesonephros 
atrophies, and its vestiges are incorporated with the testis 
and lie between the body of the testis and its globus 
major, closely associated with the vasa cfferentia. Usually 
the Mulleriaii ducts atrophy except at their extremities, the 
lower of which fuse to form a sinus in relation with the 
prostatic urethra — the sinus pocularis; the anterior ex- 
tremity being probably represented by a pedunculated 
body, the cyst of Morgagni. 

In the female (Fig. 13) the Mullerian ducts develop and 
fuse in their middle and posterior thirds to form a median 
muscular organ, the uterus and vagina; the anterior thirds 
remain separate as the Fallopian tubes. The genital masses 
become ovaries ; the remains of the mesonephros and 
the associated tubules and duct persist as vestiges. The 
glandular elements of the mesonephros are known in the 
adult ovary as the paroophoron, its tubules form the vertical 
tubes of the parovarium, and the duct occasionally persists 
throughout its whole length as Gartner's duct. 

It has already been pointed out that the orifice of the 
uro-genital sinus is surmounted by a small eminence and is 
laterally limited by cutaneous folds. In early embryonic 
life this orifice is common to the terminations of the urethra, 
genital passages, and alimentary canal. Subsequently the 
orifice of the gut is separated from the uro-genital passage, 
the posterior orifice becomes the anus and the anterior be- 
comes the uro-genital opening, and the structures in its 
walls specialize into labia majora. labia minora, clitoris, and 
hymen, with the various recesses which in the adult receive 
special names. 

In the male further fu.sion and development take place ; 
the parts which in the female persist as labia fuse together 
and form the scrotum, and at the same time the anterior 
prominence enlarges and becomes the penis ; the lateral 



34 



DISEASES Of-' WOMEN. 



folds fuse in the median line to form a canal, known as the 
membranous and penile urethra, along its tower border. 
Finally the testicles descend from the lumbar region into 
the false pelvis, then, preceded by a pouch of peritoneum, 




traverse the abdominal wall, and finally occupy perma- 
nently the scrotum. 

Thus a study of the developmental history of the genital 
organs enables us to prove that the female possesses ves- 
tiges of male organs, whilst the chief male organs are 



MALFORMATIONS OF REPRODUCTIVE ORGANS. JJ 

represented in the female, as set down in the subjoined 
table : 



Adult MaU. 


AdvU Ftmali. 


Body of testis. 

Vma efferentix, 
Vas ilefetens. 


Oajihoron. 
Dact of Giulner. 




Fallopian lube. 
Uterus. 


Sinus (nculiiris. 

Corpom c.ven,osa {penis). 

Proslalic UTCthta. 


Vagin.. 

Corpora cavernosa [clil.Jtidis) 

Glans cliloridis and vestibular 

Urelhia. 


Membranoui urethra. 


Vestibule. 


Folds at the enimnce to sin 

Cow pet's elands. 
Scrotum. 


a Hymen. 

Unrthotin's gluids. 



The embryology of the genitalia makes it clear so far as 
the external organs are concerned that the male organs are 
more highly specialized than those of the female, and if the 
fusion of the parts concerned in forming the penile urethra 
be arrested, a condition more or less resembhng the female 
is the consequence. 

For example, the external genitals represented in Fig. 14 
illustrate this very well. The erectile body is really an in- 
complete penis, the penile urethra is represented by a groove 
opening into a cul-de-sac which corresponds to an incom- 
plete vulva. The two halves of the scrotum have failed to 
unite across the median line, and thus resemble labia majora. 
The right one contains a testis ; the left testis was retained 
in the inguinal canal. This individual was a hypospadiac 
male, but to his misfortune was brought up as a girl. 

Imperfections of this kind in the external genital organs 
are associated with modifications of the secondary sexual 
characters. The distribution of hair on the pubes may resem- 
ble the female type ; often it corresponds to that of a male. 
Menstruation depends on the co-existence of a uterus; of 



DISEASES OF WOMEN. 



S6 

this more will be stated later on. The mammx may be as 
large as those of a woman ; more often they are of the male 
type. The hair on the head is no guide, for if an indi- 
vidual ha.s been trained as a boy it is short ; if a girl it will 
usually be long. The presence or absence of hair on the 
face varies. A pseudo- hermaphrodite may have an abun- 




dant beard and mustache. At puberty the voice changes 
to that of a man and sexual inclination is manifested for 



It is a significant fact that the condition of the external 
genitals in pseudo-hermaphrodites affords no reliable indica- 
tion of the nature of the internal genital organs. An in- 



MALFORMATIONS OF KF.PKODL'CTIVE ORGANS, 



57 



dividual with such imperfections as are presented in Fig. 15 
mayor may not. have a uterus and Fallopian tubes. On 
the other hand a uterus may be associated with a perfect 
penis and testes. The presence of a uterus does not enable 
us to decide the sex in a doubtful case. In questionable 
cases of sex the only absolute test is the genital glands. 
The presence of ovaries is decisive proof of a female ; testes 
indicate the male; and, as accurate discrimination between 




a testis and an ovary is only possible on microscopic exam- 
ination, it is only in exceptional circumstances that such a 
test can be applied. 

It is impossible in an elementary work of this kind to 
describe the various defects of the reproductive organs which 
occur in pseudo-hermaphrodites, but in the majority of 
these unfortunate individual the genital glands are testes, 
notwithstanding the fact that many of them have a uterus 
with Fallopian tubes. 



j8 D/SE/ISMS OF WOMEN. 

The majority of pseudo-hemiaphrodites are brought up 
as girls ; this is a misfortune, because at puberty (which 
may be greatly delayed) the supposed girl suddenly assumes 
the voice of a man and begins to grow a beard. 

When there is doubt as to the sex of a child it should be 
named, trained, and educated as a boy. 

Exstrophy of the bladder has sometimes given rise to dif- 
ficulty in determining the sex of a child (Fig. i6). Careful 




lrD|>hy uf Ihc bliddci 



examination will dispel this difficulty, for on cleaning the 
pink vesical mucous membrane exposed at the pubes, urine 
will be seen to escape from the orifices of the ureters. 




MALFORMATIONS OF THE REPRODUCTIVE ORGANS OF 
WOMEN (Continued). 

MALFORMATIONS OF THE VAGINA AND 
UTERUS. 

Absence of the Vagina. — This may occur when the 
uterus also is absent ; but the uterus may be well developed 
and tliL- vagina absent. 

Partial Absence of the Vagina. — This is more com- 
mon, and the middle part is most often deficient. There is 
then a short sinus opening e.>:temally, and admitting a probe 
for a distance of perhaps J to 2 in. (i to 5 cm.) ; the cervix 
opens into a closed pouch, the remains of the upper end of 
the vagina. A sohd, cord-like band of connective tissue 
may connect the two portions ; less often the lower half of 
the vagina is absent. In some cases a very short external 
sinus is present and the rest of the vagina is absent. 

Atresia of the Vagina. — A transverse septum may 
exist at any part of the vagina, but it is most common at 
the vaginal orifice. This condition was formerly described 
as atresia of the hymen, but careful examination will always 
discover the hymen adherent to the under or external sur- 
face of the septum. This condition is due to the lower end 
of the fused Mi'illcrian ducts having failed to open into the 
cloaca. The symptoms and treatment of these conditions 
will be described in Chapter VI. 

Narrowing (Stenosis) of the Vagina.— A very nar- 
row vagina may be due simply to partial arrest of develop- 
ment; in other cases it would appear that one Miillerian 
duct has failed to develop; this may occur wilh a nomial 



60 DISEASES OF WOMEN. 

uterus or in association with a uterus of which only one 
half has developed (uterus unicornis). 

The trcalmtnt is dilatation with graduated bougies. 

Double Vagina. — This is always associated with double 
uterus;. It may give rise to no symptoms, even after mar- 
riage ; but the longitudinal septum may be torn through 
during either coitus or childbirtJi. More often one half is 
enlarged by sexual intercourse, and pregnancy occurs in 
the corresponding half of the uterus. 

In other cases one half only is completely pervious, the 
lower portion of the other half ending blindly, either at the 




vulva or at some higher point. The symptoms may then 
be peiplexing, as menstruation may seem to be free while 
the occluded portion is really the scat of ha^niatocolpos 
{Chap. VI.). As in the case of a single vagina, the middle 
portion only of one half may be obliterated; its lower por- 
tion then appears as a sinus opening by the side of the 
larger vagina. 

Treatment. — If a double vagina be discovered, the sep- 
tum should be divided throughout its whole extent, or, 
better still, a longitudinal strip of it be removed, so as to 
throw the two cavities into one. This will minimize the 
risk of complications during delivery. The vagina must 




MALfORMATIONS OF REPRODVCTtVE ORGANS. 6l 

be packed with gauze till heal- 
ing has taken place, to pre- 
vent the reunion of the cut 
edges. 

Malformations of the 
Uterus. — Absi-rtcf of the ute- 
rus may occur with or without 
absence of the ovaries. 

Rudimentary TJteros. — 
The uterus niay be present in 
the form of a very small body 
with rudimentary horns and 
Fallopian tubes (Fig. 1 7). 
From incomplete examination 
such cases have been erro- 
neously described as absence 
of the uterus. The ovaries 
are small. Important other 
malformations or general ar- 
rest of development usually 
co-exist. But. when this is 
the only malformation, the 
secondary sexual characters 
appear late, or not at all ; and 
menstruation is absent. 

In&ntile Utems. — The 
uterus preserves the type 
which it presents normally at 
birth ; that is to say, the whole 
oi^n is narrow in proportion 
to its length, and the cervix 
is long in proportion to the 
body. The external os is small 
(pinhole os) and the cervix 
conical (Fig. 1 8). Acute ante- 
flexion frequently co-exists. 




62 



DISEASES Of WOMEN. 



This may be associated with general arrest of development 
of the genital organs: or the other parts may be well 
formed. Figs. 19 and 20 are introduced for comparison 
with the conical cervix. 

Symptoms ami Sigtn. — The only indication of the condi- 
tion may be absence of menstruation in youth, with sterility 
later. Ip other cases scanty and painful menstruation 
occurs. 

Bimanual examination shows the presence of a small 
utcru.s, probably anteflexed. If a sound can be introduced 
through the narrow external os, it will be found to enter 
for only i^ or 2 in. (3 to 5 cm.). 

Treatment. — In the absence of symptoms, no treatment 
should be attempted, as nothing will avail to induce growth 
of the uterus to its proper size. If dysmenorrhcea be pres- 
ent, elforts may be made to straighten an anteflexed uterus 
and to render its canal more patulous by dilatation. The 
sterility is incurable. 

Atresia of the external os may be congenital or acquired. 
Both are rare. Menstruation may be entirely absent, and 
the symptoms and signs will then resemble those of the 
infantile uterus.- If the ovaries and the body of the uterus 
be well developed, menstrual moltmina will occur, with the 
accumulation of menstrual products within the cavity of the 
uterus. (See Ha:matometra.) 

Single-homed TTtems ( l/terus uHiconiis). — If one half 
only of the uterus fail to develop, this condition results (Fig, 
21). Both ovaries may be well developed, but as a rule 
the one associated with the rudimentary cornu retains its in- 
fantile shape. The vagina is often narrow and the uterine 
cavity small. Nevertheless, no symptoms may be present 
and the woman may menstruate, have sexual intercourse, 
and become pregnant, just as in the normal condition. On 
the other hand, if pregnancy occur in the rudimentary horn 
it practically takes the course of a tubal gestation, resulting 
in rupture. 




MALFORMATIONS OF KF.PRODUCTIVE ORGANS. 63 

Double TJtems.— There are three types of the con- 
dition known as double uterus, viz. the uterus septus, the 
uterus bicornis, and the uterus didelphys. The primary 
feature, embryologically, is incomplete union of Miiller's 
ducts. 

I. In the uterus septus Ihc ducts have fused exter- 
nally, but the septum formed by their approximation per- 




.— Vtem unlconll. 



sists ; consequently the uterus seen from the outside appears 
normal. On section it is found to contain two distinct cavi- 
ties. The septum may extend to the vulva, producing a 
vagina with the appearance of a double-barrelled gun ; or 
it may involve the uterus alone, the vagina being single ; or 
it may fail to reach the external os. in which case the cer- 
vix looks normal when seen through a speculum. This is 
the utinis subscplus. 

2. In the uterus bicomis external union has occurred 
in the lower part of the uterine body, but is wanting in the 
upper part; so th.it when such a case is bimanual ly ex- 
amined, the depression between the two halves of the 
fundus is plainly felt (Fig. 22). Here also the extent of 
the septum varies, reaching to the vulva, to the os exter- 



64 DISEASES OF WOMEN. 

num. or to the os internum only. The last kind gives die 
variety known as uterus bkornis unkoUis. 

3. In ntems didelphys (Fig. 23) the two halves of the 
uterus have remained externally distinct, and can be moved 
independently of one another. The vagina are invariably 
separate, though united by connective tissue, and a loose 




(Scfanxder). 



bridge of connective tissue and peritoneum stretches be- 
tween the cervices. A well-marked fold of peritoneum 
usually .stretches directly between the bladder and rectum, 
passing between the two halves of the uterus. 

Each uterus has its own Fallopian tube, whose point of 
junction with the uterine body is indicated by the origin of 
the round ligament ; i( has also its own ovary. 

The two halves are often unequally developed, and one 
vagina may end blindly above the vulva, so that the corre- 
sponding uterus is quite shut off from the outside. 

Diagnosis. — The presence of two vaginal canals is a cer- 
tain indication that the uterus is double. Where the vagina 
is single, the malformation of the uterus may be discovered 
in one of several ways. Thu.=!, when the division involves 
the cervix, two ora externa may be .seen through the Specu- 
lum ; on bimanual examination two separate uterine comua 



MALFORMATIONS OF REPRODUCTIVE ORGAm, 65 

may be felt, with a depression between. The condition may 
be suspected from the passage of the sound in two different 
directions; when one half has become occluded, with reten- 
tion of menstrual blood, the opening of the fluctuating 




tumor may reveal the presence of the second canal ; lastly, 
some complication during delivery may lead to diagnosis. 

A careful examination is required to distinguish the 
variety of double uterus. If bimanualiy the fundus feels 
normal in shape, whiLst two cervical openings are present, 
and two sounds can be simultaneously introduced without 
coming in contact inside the uterus, the case is one of 
uterus septus. If a well-marked central depression exists, 



66 DISEASES OF WOMEN. 

we have to deal with uterus bicomis or uterus didelphys. 
If the cervix be single, it is a two-horned uterus. If it be 
double, the following points will serve to distinguish the 
two. In the case of the uterus bicomis, the two halves are 
closely adherent, usually for some distance above the level 
of the internal as ; and they cannot be moved independently. 
In the case of the uterus didelphys, the two halves can be 
so moved ; indeed, one may be found lying in front of, or at 
some distance from the other; and further, the separation 
down to the level of the external os can be distinctly felt 
by recto -abdominal examination. 

In both cases the points of two sounds simultaneously 
introduced may diverge widely, pointing perhaps to the 
respective iliac crests, while the handles cross each other in 
the vagina at right angles. 

As a rule, each horn or each half-uterus can be felt to 
have attached to it its own Fallopian tube and ovary. 

Complications. — One half of a double uterus may be oc- 
cluded at the cervix ; or there may be atresia of the cor- 
responding vagina ; in which case the symptoms of hsemato- 
metra arise. Otherwise a double uterus may give rise to 
no symptoms at all, and several pregnancies may be passed 
without the condition being suspected. In other cases some 
complication arises during delivcrj', leading to discovery of 
the condition ; but considerable perplexity may be caused 
at first. Thus in some cases an obstetrician has on exam- 
ination found a wide vagina and dilating cervix ; a later 
examination, in which the finger has inadvertently entered 
the second vagina, has revealed a narrow vagina and a 
closed OS,' 

The following are the clinical complications to which a 
double uterus may give rise: 

1 . Unilateral atresia, with retained menstrual products. 

2. Dyspareunia. 

' For a summaty of recordeiJ cases of uterus diJelphys ihe reader is rcfemd 
(o iht ObUel. Tram., vol. nuvii. 




MALFORMATIONS OF REPRODUCTIVE ORGANS. 6/ 

3. Double vaginitis or endometritis, treated unsuccess- 
fully by applications to one side only. 

4. Obstruction to delivery by a displaced empty half. 

5. Obstruction due to the vaginal septum. 

6. Retained and undiscovered products of conception in 
one half in cases of double pregnancy. 

The two halves of a double uterus may menstruate inde- 
pendently. When pregnancy occurs in one half, a decidua 
forms in the other half. 

Treatment. — A double uterus does not require treatment 
as a rule ; but if a double vagina exists, the septum should 
be removed. 



CHAPTER VI. 



RETENTION OF MENSTRUAL PRODUCTS IN CASES OF 
ATRESIA. 

According to the situation of the atresia and the duration 
of the symptoms, the following conditions maybe met with, 
shown diagrammatically in Figs. 24 and 25 ; 

I. Atresia of the Vaginal Orifice. — At first the men- 
strual blood collects in the vagina, which becomes distended 
(A) and often bulges through the vulvar aperture — IttEtnalo- 
colpos. I_ater, the cervix distends and its walls are thinned, 
the body of the uterus not being at first affected (E) — 
fuEiHatotrachelon. By continued accumulation the body of 
the uterus is involved (C) — htEiiiatoiniira. Lastly, the Fal- 
lopian tubes may become distended {D) — hematosalpinx. 

II. Absence of the l^ower or Middle Portion of 
the Vagina. — -The distention occurs in the same order as 
above, first the vagina (£■) and then the uterus (/•") being 
affected. The lower portion of the vagina, if present, is 
patulous. 

III. Atresia of the Os Bxtemtim. — The vagina re- 
mains normal, and hiematotrachelos first occurs {G\ It is 
probable that considerable distention may take place here 
without the body of the uterus sharing in it. Later, 
hsmatometra and hematosalpinx may follow. 

IV. Atresia of the Os Internum. — The cervix, as 
well as the vagina, remains free, and a pure ha;matometra 
is found (//). As a congenital condition, this is rare. 

V. Atresia affecting One Half of a Double Uterus 
or Vagina. — Changes occur in the same order as in the 




MENSTRUAL PRODUCTS W ATRESIA. 6g 

case of the undivided organs; when the atresia concerns 
the second vagina, ha^nlatoco]pos is first found, the cystic 
swelling extending either down to the vulva (/) or only 
part of the way, by the side of the patent vagina (/). 
Hsmatonietra follows (K), or it occurs alone if the atresia 




affects the os externum (Z). In the diagram the various 

forms of atresia in cases of double uterus are represented 

as affecting the uterus bicornis ; but similar conditions 

are found in connecdon with uterus septus and uterus 

didelphys. 

. Secondary Cltanges. — The dilated walls of the vagina, 



TO DISEASES OF WOMEN. 

uterus, or Fallopian tubes become thinned out ; the contrast 
between healthy and distended walls is well seen in the 
uterus itself, where the endometrium suffers considerable 
atrophy, and the muscular coat is thinned. This thinning 




may be partly compensated, as in the case of an aneurysm, 
by the deposition of blood-clot on the internal surface, and 
partial organization of the fibrin. 

Suppuration may take place, cither spontaneously or 
through a temporary fistulous aperture. When the atresia 
is secondary, this result is more common. The vagina, 
uterus, or Fallopian tubes may then become bags of pus. 



MENSTJtUAL PRODUCTS I.W ATRESIA. 7 I 

and the terms pyocolpos, pyometra, and pyosalpinx are 
applied, 

Signs and Symptoms. — The first symptoms generally 
occur within the first year or two after puberty. The 
patient gives a history of having experienced periodical 
monthly molimina without external menstruation [crypta- 
menorrhcea). Pain is sometimes felt from the first ; in other 
cases it occurs later, and increases in severity and duration 
as distention proceeds, till it becomes continuous. Symp- 
toms of pressure on surrounding organs may also be pres- 
ent. If suppuration takes place, febrile symptoms appear 
and the patient falls into a hectic condition. 

Physical Signs. — On abdominal palpation a tense fluctu- 
ating swelling may often be felt rising out of the pelvis ; 
and if the obstruction be at the vulva it may be seen bulging 
here also. Fluctuation may be obtained on pressing alter- 
nately on the abdominal and vulvar swellings. When the 
uterus itself is not involved, it may sometimes be felt 
through the abdomen as a solid projection at the summit 
of the cystic swelling. 

We will consider in succession the physical signs afforded 
by the different conditions above enumerated. 

Atresia af tlu- Vaginal Orifice. — The finger at once meets 
the resistance of the cystic swelling at the vulva, and no 
passage exists by the side of it. By combined rectal and 
abdominal examination it can be felt that the mass fills 
the pelvis ; if seen early the fingers may meet above the 
swelling, or the undilated uterus can be made out. If 
hxmatometra also exists, the swelling is larger; but the 
degree to which the uterus is involved cannot usually be 
determined till the retained fluid has been evacuated. An 
irregularity of the summit of the swelling can often be felt 
by the abdomen when the Fallopian tubes are distended ; 
but this is not always the case because the tubes are apt to 
be drawn into a position parallel with the uterus, just as 
when the uterus is enlarged by pregnancy or a myoma. 



72 DISEASES OF IVOMEN. 

Absence of the Lower or Middle Part of the Vagina.-^^ 
The short cul-de-sac, when it exists, is patent for 2 or 
S cm., but nothing further can be mado out by the va- 
gina. On examining by the rectum, the finger will read- 
ily recognize a sound introduced through the urethra, 
there being but little tissue intervening. But, higher up, 
the finger meets the resistance of a cystic swelling, con- 
tinuous with a similar swelling felt by the abdomen when 
the distention is considerable. If the vaginal deficiency 
extends to near the uterus, it may not be possible to reach 
the hsmatocolpos through the rectum ; and an ill-defined 
abdominal fulness may be the only thing felt. But this, 
taken in conjunction with the history and symptoms, may 
serve for diagnosis. 

Atresia of the Os Externum. — ^The cervix presents in the 
otherwise normal vagina, as a smooth fluctuating swell- 
ing in which no aperture can be discovered. Bimanu- 
ally the mass is felt to occupy the position of an enlarged 
uterus. The fundus may be felt as a smaller and harder 
projection at the summit of the elastic swelling. 

Atresia of the Os Internum. — The cervix feels and ap- 
pears normal; the body of the uterus is uniformly en- 
larged, and feels almost exactly like a pregnant uterus. 

Atresia of One Half of a Double Uterus or Vagina. — 
The patent half of the vagina is narrow, but other- 
wise resembles the normal. The uterus appears to be 
pushed over to one side, and the sound passes in a lat- 
eral direction for a normal distance. On one side of the 
vagina is felt a fluctuating swelling, extending down to 
the vulva, or reaching only part of the way. It bulges 
toward the healthy side so as to further narrow the va- 
ginal passage. By bimanual examination the swelling is 
felt to extend up to the side of the uterus, with which it 
is closely connected. When the vagina is undivided, and 
the atresia is situated at the external os of the second 
Uterus, the upper part of the vagina is very wide. At one 



MENSTRUAL PRODUCTS /.V ATRESIA. 73 

side is the cervix, through which a sound can be passed 
into the uterus, when it takes a lateral direction. The rest 
of the vaginal summit is occupied by a cystic swelling 
lying to the side of the uterus and cervix, which it has dis- 
placed beyond the median line. The depression between 
the distended and the empty half of the uterus may be felt 
by abdominal palpation or by the bimanual method. 

Diagnosis. — A h^matocolpos is usually readily diag- 
nosed by the signs and symptoms above mentioned. 

Haematometra must be diagnosed frnm pregnancy: the 
integrity of the hymen, the absence of vaginal pulsation 
and discoloration, and of the symptoms of pregnancy will 
serve as a guide, as will also the condition of the cervix, 
which is elastic and smooth in the case of ha:matotrachelos, 
and which does not present the softness characteristic of 
pregnane)', when the obstruction is at the internal os. In 
cases of doubt the patient may be kept under observation 
for some time ; the swelling will increase, but not nearly so 
quickly as is the case in pregnancy. Heeniatotrachelos 
might be simulated also by a cyst in the upper part of the 
vagina ; careful examination will discover the cervix beyond 
the cyst in this case. Other conditions which superficially 
resemble htematometra, such as inversion of the uterus or 
a large cervical polypus lying in the vagina, do not occur at 
the age at which h^matometra is met with ; and there 
should be no difficulty in the diagnosis. 

Retention of menses in a second vagina or uterus leads 
to much greater difficulty in diagno.sis. Thus, hEematocol- 
pos must be distinguished from absc&ss in the vaginal wall. 
pelvic abscess burrowing down by the side of the vagina, 
vaginal cysts, encysted collections of fluid bulging down in 
the recto-vaginal pouch, and. when the upper part of the 
vagina is principally involved, from ovarian or parovarian 
cysts and distended tubes. The latter would be recognized, 
principally by their shape, on recto-abdominal examination. 
The nature of lower vaginal swellings will probably not be 



74 



DISEASES OF WOMEN. 



made out till they are incised ; whilst in the case of swellings 
higher up, the abdomen will most Ukely be opened, under 
the impression that the case is one of ovarian cyst. 

Haematometra in a second uterus is often diagnosed as 
ovarian or tubal cystic disease, or as a dermoid. The only 
clue, in the absence of all trace of a second cervix or of a 
double vagina, lies in the close connection of the swelling 
with the uterus ; but even this distinction may not be ap- 
parent, as the depression in the fundus in the case of uterus 
bicornis, or the almost complete separation of the two 
halves in the case of uterus didetphys, gives the impression 
that the swelling is extra- uterine. As a matter of fact, the 
nature of the case is rarely recognized until the abdomen 
has been opened in the operating theatre or the post- 
tHor/ii'i room. 

Resuils. — If left untreated, the fluid gradually accumu- 
lates, the size of the swelling causing great discomfort as 
well as severe pain. Two grave complications threaten: 
suppuration may take place and a large abscess form, which 
opens into the rectum or the ccelom (peritoneal cavity) or 
points externally ; or rupture of some part of the sac occurs. 
The dilated tubes are most likely to give way. as in them 
the greatest thinning of the walls takes place. From 
either complication death may result. It is important to 
remember that a hsmatocolpos or h^matotrachelos exer- 
ci.ses injurious pressure on the ureters. 

Treatment. — A hsematocolpos must be opened. The in- 
cision should be free, and the contents allowed to escape 
without any pressure. By too rapid evacuation, rupture of 
a htcmatosatpinx may be brought about ; but the danger of 
this has probably been exaggerated. A more serious risk 
is that of septicemia; on this account the strictest asepsis 
should be adopted. When the greater part of the fluid has - 
been evacuated, gentle irrigation may be employed to clear 
out the residue and prevent decomposition changes from 
taking place. The principal difficulty in after-treatment lies 





MENSTRUAL PRODUCTS IN ATHESfA. 75 

in the tendency of the orifice to contract ; for this reason 
the incision must be free, and, if necessary, a part of the 
wall should be dissected out. The passage of bougies may 
be subsequently required from time to time. 

The treatment of atresia with absence of a part of the 
vagina, is more difficult An attempt should be made to 
dissect down to the deeper part of the vagina, so as to 
make a complete vagina; this is especially nece.ssary in 
cases of retention. The first difficulty is in the actual dis- 
section, which must be made between the urethra in front 
and the rectum behind: a distance of many centimetres 
may be traversed before the blind end of the vagina is 
reached. The second, and perhaps greater, difficulty is to 
maintain the patency of the vagina when formed. With 
this end in view various plastic operations have been 
devised, portions of skin fieing turned in. Repeated ope- 
rations, extending over many months, have sometimes been 
required; but several ultimately successful cases have been 
reported. 

H.-ematometra also requires incision. Sometimes the 
obstructing membrane is so thin that a probe or sound can 
readily be pushed through it; in other cases a knife is re- 
quired. After incision, forceps should be introduced to 
secure a free aperture, and after evacuation the cer\-ica! 
canal is loosely packed with iodoform gauze ; whilst later 
the tendency to contract must be met by the use of 
dilators. 

When, in case of himatometra with deficiency of the va- 
gina, it is found impossible to maintain the new channel in 
a sufficiently patulous condition, or when the formation of 
such a channel is not practicable, it will be necessary to 
carry out radical measures, such as oophorectomy or 
hysterectomy. 

Lateral Juzmatocolpoi must be treated on the same prin- 
ciples as the above, but the vaginal septum should be freely 
removed, so as to make only one vagina, otherwise the 



76 DISEASES OF WOMEN. 

Opening will almost certainly close again, and, having once 
been opened, septic organisms may find tlieir way in, and a 
pyocolpos be found the next time instead of a hiemato- 
colpos. Of this there are several instances on record. 

In the case of lateral haematometra, vaginal incision 
should be practised when possible, and part of the uterine 
septum may be removed, to prevent re-closure. If the con- 
dition be discovered after opening the abdomen, vaginal 
incision should still be perfomied when the two halves of 
the uterus are closely connected ; although, if at the same 
time there be vaginal deficiency, hysterectomy will probably 
be called for. 

In cases of separation of the two halves of the uterus, as 
in marked instances of uterus bicomis or uterus didelphys, 
the occluded half may be removed by hysterectomy. 
There are several cases recorded in which this was done. 

Ha;matosalpinx calls for removal of the distended tube. 

Charactere of Retained Menstrual Blood.— The 
evacuated fluid is a dark chocolate color, sometimes almost 
black. It is thick and flows slowly, like treacle or honey. 
It is mixed with mucus and seldom contains coagula. 
Microscopical examination shows the presence of epithelial 
debris, and btood-corpuscles in various stages of disintegra- 
tion. The viscidity is due to partial absorption of the 
liquid portion of the blood. 




AGE-CHANGES; INJURIES; VARIX: HEMA- 
TOMA; INFLAMMATION. 

Age-changes. — Infancy. — At this pt.riod the nions 
Veneris is devoid of conspicuous hair and the labia majora 




appear as two parallel cutaneous eminences; the thin edges 
of the labia minora project between them and are pink like 
mucous membrane {Fig. 26). 

Puberty. — At this stage the pubic hair becomes conspicu- 



78 DISEASES OF WOMEN. 

ous and usually grows freely on the outer surfaces of 1 
greater labia. The labia increase in size and usually con- 
ceal the nympha;. Their opposed or internal surfaces remain 
pink, whilst the outer surfaces become pigmented, especially 
in brunettes. 

It occasionally happens tliat the nymphae grow after 
puberty, and instead of remaining concealed within the vul- 
var cleft, protrude and 
resemble a pair of elon- 
gated molluscan palps. 
When the nymphae 
protrude in this way 
they undergo a curious 
change : those parts cov- 
ered by the labia ma- 
jora retain their pink- 
ness and possess as 
usual very large seba- 
ceous glands, but the 
palp-like portions be- 
come deeply pigmented, 
lose their sebaceous 
glands, and occasionally 
delicate hairs of two 
or more centimetres in 
length grow from them. 
Fui. .j-Th. "'""j;;^=_|^»';""' (Bi-ch=rd ..J Lajjj^ minora elongated 
in this way are some- 
times spoken of as " hypertrophied nympha; ; " some writers 
attribute tht: condition to masturbation. It reaches its 
maximum in Hottentot women, whose "apron" is really 
formed of greatly elongated nymphie (Fig. 27). 

Menopauic. — After the forty-fifth year the hair on the 
mons and labia, like that on the rest of the body, becomes 
white and Is gradually shed. The greater labia shrink as the 
subcutaneous fat disappears and the nympha: project be- 





^ 



DISEASES OF .THE VULVA. 



79 



yond them. The vulvar orifice is often greatly narrowed 
in consequence of the shrinking of the structures border- 
ing upon it. 

Injtuies. — The vulva is liable to injury from fails upon 
pointed objects; cuts from potsherds when chamber-pots 
break whilst women sit upon them ; kicks from brutal hus- 
bands; and violence during rape. The labia arc sometimes 
lacerated during the careless use of midwifery forceps. 
Deep wounds of the vulva arc invariably attended with free 
bleeding. 

Treatment. — Turn out the clots, secure the bleeding 
points with forceps and ligature; oozing may require re- 
straint with firm pads and pressure. 

Varix. — The vulva is well supplied with veins, and con- 
tains especially a good deal of erectile tissue. Obstruction 
to the venous circulation in the pelvis, abdomen, or thorax 
consequently readily causes the veins to assume a varicose 
condition. This is found very often during the later months 
of pregnancy; and in some cases the enlargement may be 
extreme, forming a^welling, on one or both sides, as large as 
a fist, involving principally the labia majora, and presenting 
to the touch the characteristic feeling of " worms in a bag," 
which is met with in varicocele of the scrotum. The left 
side is more often affected than the right. The dilated and 
tortuous veins can also be readily seen through the skin. 
The veins of the thigh are generally also involved; and on 
inspecting the vagina, similar venous plexuses may be seen, 
extending up a considerable distance under the mucous 
membrane. There is a great risk of rupture of these veins 
during delivery; either the surface veins may give way, 
giving rise to serious bleeding, or subcutaneous rupture 
may occur, producing a hematoma of the vulva. 

Trcalmrnl. — Rest in the horizontal position diminishes the 
swelling; but when associated with pregnancy, no cure can 
be hoped for till after delivery. In severe cases it may be 
advisable to induce premature delivery, to diminish its se- 



So DISEASES OF WOMEN. 

verity and duration, and, through the smaller size ol 
child's head, lessen the risk of rupture and thrombosis. 
When due to other varieties of backward pressure on the 
veins, the cause must be treated. 

Slight cases are often associated with chronic constipa- 
tion, and in these, as well as in severer cases, great im- 
provement results from attention to the bowels. Excision 
of the veins gives good results. 

Hjematoma of the Vulva. — This is due to subcu- 
taneous rupture of veins in the labia majora, and is nearly 
always traumatic. A fall or blow may cause it, but it gen- 
erally follows delivery, especially when tlie child's head is 
large and has rested long on the perineum. 

The condition is usually easily recognized from the his- 
tory, and from the presence of a smooth, fluctuating swell- 
ing in the labium majus, which has formed quickly and is 
irreducible. These points serve to distinguish it from 
hernia, and from abscess and cyst of the labium. It may 
not be easy to distinguish it from simple oedema ; but this 
is unimportant, as the treatment is the sjmg. 

Treatment. — On no account should a hxmatoma be 
opened, unless it is enlarging quickly, when there is prob- 
ably a large vessel ruptured ; in this case a free incision 
should be made, the clots turned out, and the bleeding- 
point secured. Otherwise the extravasated blood tends to 
absorb readily, and generally subsides in two or three 
weeks. 

Occasionally a h.-ematoma ^ppuratcs and requires free 
incision, drainage, and strict cleanliness. 

INFLAMMATION OF THE VULVA. 

Vtllvitis. — This may arise from many causes. In girls 

it is often due to dirt, thread-worms, and tuberculosis of 

the uterus. The same causes may produce vulvitis in adult 

women. Other causes are vaginitis resulting from gonor- 





rhcea, and extension of inflammation from surrounding struc- 
tures. Vulvitis is not uncommon in tlic newly married. 

Si^HS and Symptoms. — The patient complains of throb- 
bing pain and heat in the vulva, aggravated by walking and 
by long sitting ; generally also of discharge. When se- 
vere there are constitutional febrile symptoms. When the 
urethra is aflected there is burning pain on micturition. 

The vulva is congested and consequently swollen. The 
swelling may affect individual parts, as the labia majora, 
nymphs, or clitoris ; or the whole vulva may be involved. 
It may be bathed in discharge from the vagina, which 
may be raucous, muco-purulent, or purulent ; in gonorrheal 
cases it is always purulent. As the result of these irri- 
tating discharges the skin is often excoriated, not only 
over the vulva, but also over the contiguous part of the 
thighs and round the anus. When due to injury, bruising 
and ecchymoses may be seen. On the other hand, when 
of gonorrhoeal origin, two rather characteristic signs are 
present: firstly, urethritis; the meatus is red and swollen, 
and on pressing on the urethra through the vagina, from 
within outward, a drop of pus commonly escapes. Sec- 
ondly, affection of the ducts of the Bartholinian glands ; in 
this case the orifices of the ducts can be readily seen as red 
points situated laterally in the angle between the hymen 
and labia minora ; on pressing the duct between the finger 
in the vagina and the thumb outside, a drop of pus may 
escape ; or a definite swelling, due to abscess, may be pres- 
ent in the situation of the duct (see Abscess of the Vulva). 

The lymphatics of the vulva pass to the horizontal set 
of inguinal glands ; these will therefore be enlarged and 
tender in cases of severe vulvitis. 

Diagnosis. — There is no difficulty in recognizing vulvitis, 
but the diagnosis of its nature is often as difficult as it is 
important. The question is whether, in a given case, the 
condition is gonorrheal or not. On the answer much 
often depends, such as questions of criminal assault and of 



Sz 



mSEASES OF WOMEN. 



unchastity. If the gonococcus be found in the pus, the ex- 
istence of gonorrhcea is established; its absence, however, 
is no proof to the contrary. If the inRammation be non- 
purulent, if the urethra be unaffected, and if the Bartholin- 
ian ducts be not involved, the probability is strong that the 
case is not gonorrhceal ; in the opposite conditions the 
probability is in favor of gonorrhoea. Some information 
may be derived from the existence of urethritis in the hus- 
band; if he have a marked purulent urethritis and the pus 
contains goiiococci the argument is in favor of gonorrhoea 
in the woman. In children, want of cleanhness and tuber- 
culosis will serve as a clue; but it must be remembered 
thai gonorrhtea is a possible condition even when there is 
no suspicion of criminal assault. Some epidemics of vulvo- 
vaginitis in little girls have been of this nature ; and the 
source of contagion has sometimes been traced to bad 
social conditions, such as the fact that a child, sleeping in 
the same bed as a father or mother suffering from gonor- 
rhcea, lias become contaminated. 

Course and Compliailtons. — A simple vulvitis runs a short 
course to recovery, under proper treatment. If neglected, 
or if .septic from the first, the possible complications are 
urethritis, labial abscess, cedema and gangrene of the labia, 
infection and abscess of Bartholin's glands, inguinal bubo, 
vaginitis, endometritis, salpingitis, and peritonitis. 

Treatment. — The patient should be kept in bed if possible : 
if there be constitutional disturbance, this is essential. The 
parts must be kept thoroughly clean; a warm sitz-bath, 
medicated with boracic acid, carbolic {i ;6o), or biniodide 
of mercury (i : 2000), and repeated several times a day, 
will ensure cleanliness and relieve pain. After a bath or 
irrigation the vulva should be well dried and dusted with 
oxide of /.inc. and a pad of cotton-wool applied. If there 
be suppuration on the surface, all discharge should be re- 
moved by irrigation, and the surface swabbed over with 
nitrate- of-silver solution (2 per cent.), chloride of zinc (5 per 





DISEASES OF THE IVLl'A. 

cent.), or carbolic (lo per cent, in glycerin). Fomentations 
wrung out of boracic acid may then be applied. When the 
inflammation i.s severe, the patient should he with the knees 
supported on a pillow and separated to prevent the contact 
of the tender surfaces. 

(Edema of the Vnlva. — This may occur as the result 
of vulvitis, and is then commonly due to spreading of the 
inflammatory process to the deeper tissues, involving vessels 
and lymphatics. More often it depends upon pressure on 
the pelvic veins, by tumors, pelvic inflammation, or the 
pregnant uterus. It may also form part of a general 
anasarca the consequence of cardiac or renal disease. All 
parts of the vulva are affected, but the principal enlarge- 
ment is of the labia majora. The whole vulva may attain 
the size of a ftetal head. 

The fr-C(f/w/c«/ consists in rest in bed, moderate purgation 
and warm fomentations, if due to phlebitis and lymphatic 
obstruction. When due to pressure, the cause must if pos- 
sible be dealt with — e.g. a tumor should be removed; pel- 
vic inflammation should be treated as described under that 
heading: pregnancy may occasionally require to be pre- 
maturely terminated. As a palliative measure, small punc- 
tures may be made with a narrow-bladed scalpel. 

Erysipelas of the Vtilva. — This generally follows 
labor, and occasionally wounds of the vulva. It behaves 
in the same way as when affecting the skin elsewhere; but 
owing to the laxity of the connective tissue of the labia 
there is much swelling. Since the use of antiseptics in 
midwifery it is less often seen, and should be regarded as a 
prfvattable disease, at any rate when occurring as a com- 
plication of childbed. 

It is seldom confined to the vulva, but spreads thence to 
the thighs, abdomen, and buttocks. The labia minora are 
apt to suffer severely, for their blood-supply is interfered 
with, and ulceration, perforation, or gangrene may follow. 
It is important that when this condition exists no internal 



84 - DISEASES OF WOMEN. 

examination should be made ; otherwise the internal oi^^ans 
may be infected and septiciemia supervene. 

The Ircalmcnl is tliat of erysipelas in any other part of 
the body. 

Gangrene of the Vulva. — This occurs under the fol- 
lowing conditions : 

1. As the result of injury, especially long-continued 
pressure of the liead in the third stage of labor, or from 
the unskilful use of instruments. 

2. Following tedema, cellulitis, or erysipelas of the vulva. 

3. As a complication of some of the exanthemata, as 
small-pox, scarlet fever, measles, and typhus. 

4. In underfed and dirty children, when it is analogous to 
noma or cancrum oris. 

5. As a result of phagedenic ulceration. 

Except in the last case, when the clitoris is apt to be in- 
volved, the nympha; are most apt to suffer ; they may be 
perforated, or the lower portion may slough off. 

The irfafificnt consists in supporting the patient's strength ; 
in keeping the parts as clean as po.ssiblc with antiseptic 
applications ; and in relieving pain by hot fomentations, with 
opium internally, if necessary. 

Abscess of the Vtllva. — This is occasionally due to 
injury or to suppuration following on cellulitis, er)'sipelas, 
or haematoma. But in many cases it arises in the .sebaceous 
glands of the labia and in the ducts of Bartholin's glands. 
As a rule, one side only is affected. As might be expected, 
gonorrhcea is the principal cause. 

The signs are those of an abscess in other situations, 
local redness, sweUing, heat, and p.iin, often accompanied 
with febrile symptoms. 

Treatment. — This consists in a free incision to evacuate 
the pus. warm bathing followed by fomentations, and strict 
cleanliness. 





CHAPTER VIII. 

DISEASES OF THE VULVA (Continued). 

CUTANEOUS AFFECTIONS. PRURITUS. AND 
KRAUROSIS. 

Eczema of the Vulva.— The mucous surface is not, as a 
rule, involved, but the cutaneous surface presents a number 
of papules which become vesicular and break, allowing; of 
the escape of serous fluid ; the vesicles then dry up with 
the formation of small scales. The intervening skin is hot 
and erythematous. Successive crops of vesicles may ap- 
pear. Eczema is found associated with -some constitutional 
conditions, as diabetes, rheumatism, and gout; and some- 
times with local conditions in which irritating discharges are 
present — e. g. vesico- vaginal fistula and endometritis. It 
may run an acute or a chronic course. The most trouble- 
some symptom is irritation, which causes scratching and 
thereby aggravation of the disease. Menstrual disorders 
are frequent (Hebra). 

Treatment. — The vulva should be kept clean and dry. 
Frequent bathing with boracic lotion and dusting with- 
oxide-of-zinc powder will suffice in mild cases. When ob- 
stinate, and when the skin has become white, thickened, 
and cracked, the vulva should be painted over, under an 
anxsthetic, with carbolic acid, one part to four of glycerin, 
and a simple dressing, such as a boracic ointment, applied. 

Constitutional causes must at the same time receive ap- 
propriate attention. 

Herpes of the Vulva. — This is also a vesicular condition, 
but the vesicles are arranged in small groups, and the Inter- 



86 DISEASES OF WOMEN. 

veniiig erythema is less marked, or absent. The vesicles 
may run together, forming bull^. Herpes is not infrequently 
associated with the menstrual periods, esijccially when these 
are characterized by dysmenorrhea ; and with pregnancy. 
If a herpetic patch ulcerates, it may resemble a chancre, 
especially if the inguinal glands are affected. Great irrita- 
tion is the principal symptom. 

Treatment. — This is similar to that recommended for 



I^UpUS of the Vttlva. — Probably many distinct condi- 
tions have bet-n described under this name, such as various 
syphilides when ulceration has occurred, gummata, and 
elephantiasis. The condition found in kraurosis, when 
there are small reddened sensitive patches, has been called 
lupus, and indeed the latter term has been loosely applied 
to almost any ulceration of the pudenda. 

It is better to restrict the term " lupus " to tuberculous 
skin lesions; and in this sense lupus of the vulva is ex- 
ceedingly rare. It then presents the characteristics of 
lupus as seen on the face, and may, like that, be mainly 
ulcerative or mainly hypertrophic and "tubercular" in 
form. It runs a chronic course. 

Syphilis. — This disease may manifest itself on the vulva 
as a primary sore (chancre), or as mucous plaques and tu- 
bercles. Tertiary lesions and gummata are uncommon. 
In the late stages the opposed surfaces of the labia are 
liable to a change similar to that often seen on the tongue, 
and known as leucoplakia. Vulvar, like lingual Icucoplakia, 
may ulcerate and become a precursor of epithelioma. In 
infancy congenital syphilis sometimes declares itself in the 
labia in characteristic coppery-red spots. 

BlephantiasiB. — This affection is common in tropical 
countries, but is rare in Europe. It consists of hypertrophy 
of the subcutaneous connective tissues, accompanied by 
dilatation and thrombosis of lymphatic vessels and spaces. 
This change is often associated with fiiaria in the blood. 



PrSEASES OF THE III 1.4 87 

The skin is generally thickened and rugose, like the rind of 
. an orange, and pale. The labia majora are its ra\'orite seats ; 
more rarely it affects the clitoris, and still more ranelj- the 
labia minora. The legs may be affected at the same time. 
When the enlargement is great and much discomfort is 
caused by the hea\y pendulous masses ^which sometimes 
weigh many pounds), the}' should be rcmo\-ed with the 
scalpel or thermo-cauter>'. 

FmritUS. — Itching of the vulva ma)- arise from a vari- 
ety of causes. They may be arranged in three groups : 
I. Irritating Dischai^es; II. Diseases of the Vulva; and 
III. Reflex Irritation. 

Group I. — This u-ill include diabetes, cystitis, and leu- 
corrhcea. 

(a) DiadcUs. — The mai^ns of the urethra and the vesti- 
bule are congested. The examination of the urine and the 
history of the case will establish the diagnosis. The irrita- 
tion may be lessened by sedative applications to the \'ulva 
and urethra. Pruritus is often the first sjmptom which 
leads to the detection of diabetes. 

(b) Cystitis. — The pruritus is generally a minor feature, 
and is usually relieved by washing out the bladder. 

(c) Lauorrhaa. — In view of the number of instances in 
which leucorrhcea exists without pruritus, it .seems doubt- 
ful whether this cause can act alone, without some predis- 
posing or accessory condition. Nevertheless, the cure of 
the vaginitis or endometritis, as the ca.se "may be. will 
generally be followed by disappearance of the pruritus. 
In many cases the inflammation has started with gonor- 
rfacea; and then the concurrent urethritis helps to keep 
up the irritation. 

Group n.— (a) Congestion of the r»/7-«.— This may be 
due to varicose veins caused by pressure in the pelvis; or 
to functional causes. In the former ca.se the causal condi- 
tion must be dealt with ; the pos.sibic conditions arc retro- 
version of the gravid uterus, simple pregnancy, a uterine or 




P/SEASES OF WOMEN. 



ovarian tumor blocking up the pelvis, pelvic celluliti5,T 
intra-abdominal pressure on the vena cava. 

Functional con[;cstion may be associated with the men- 
strual epochs, and the pruritus will then be periodic; or it 
may be due to masturbation. The latter is not Infrequently 
associated with pruritus, but whether as cause or effect it 
would be difficult to decide. 

(b) Vulvitis. — The skin of the affected parts is at first red 
and hot; later it becomes pale, thickened, and cracked, ap- 
pearing as if sodden ; often there are marks due to scratch- 
ing. It is always worse at night. Treatment may be begun 
in mild cases by sedative and cooling applications, such as 
evaporating lotions, glycerole of belladonna, or opium or 
cocaine ointment. In more obstinate cases the parts should 
be painted, under ether, with a solution of carbolic acid in 
glycerin (i : s), and the resulting sore treated with non-irri- 
tating dressings. Other caustics also have been recom- 
mended; but this is one of the most successful. Cure 
will follow in most cases, though several applications may 
be required. If this fails there is only one course left — 
viz. to excise the affected parts. 

(c) Pidiailus Pubis. — This is readily recognized on in- 
spection. The pubcs should be shaved and thoroughly 
cleansed with a solution of pcrchloridc of mercury (l:looo). 

Group m. — Rfjffx Causes. — (a) From the Rectum. — 
Thread-worms may be responsible, or some unhealthy con- 
dition of the rectal mucous membrane, such as anal fissure, 
or a rectal polypu.s. Pruritus ani is generally added to pru- 
ritus vulva; in these ca.ses. 

(b) From the Bladder. — In cases of vesical irritability 
with frequent micturition pruritus may be present as a re- 
flected neurosis. Bladder sedatives, such as hyoscyamus 
and belladonna, are then indicated. 

(c) Froiii the Utents. — Pregnancy sometimes is associated 
with priiritu.s. even when there is not marked leucorrhea. 

Kraurosis Vulvae.— This disease to which Breisky in 




l88S gave the name kraurosis [xpwJpoz. dry, withered) was 
first accurately described by Lawson Tait, in 1875, as an 
atrophic change affecting the nynipha;. 

SymJXoms. — The patient complains of irritation referred 
to the vulva, excessive pain during sexual intercourse and 
on passing water, and of a yellowish discharge. The irri- 
tation is worse when the patient is warm in bed, and com- 
monly disturbs or prevents sleep, As a result, the general 
health is impaired, the appetite fails, and the face has a 
harassed look. 

Physical Signs. — In the early stage the skin of the labia 
minora, vestibule, and clitoris is smooth and shiny ; the 
urethral meatus presents a red, caruncular appearance, and 
along the margins of the carunculse myrtiformes there are 
small patches as of subcutaneous hfemorrhage, which are 
often exceedingly tender to the touch. Later, tlie nymphs 
diminish and finally disappear, while the orifice of the vagina 
becomes so contracted that, even in a multipara, it will 
barely admit a finger. The pubic hair has a peculiar stub- 
bly aspect, and near the labia majora may be coarse and 
broken. In the final stages the vulva is very pale, with a 
look as if it had been ironed, all folds and creases having 
been smoothed out. 

The vagina, above the hymen, is not affected ; the labia 
majora also generally escape, but in many patients kraurosis 
of the vulva is associated with marked atrophy of the 
uterus. 

Pathohgy. — The dise.xse occurs mostly after the age of 
forty; its cause is unknown. It is best described as a pro- 
gressive atrophy of the vestibule and nymphx. 

Microscopically the affected parts show great increase of 
fibrous tissue, running principally in bands parallel to the 
surface. The vessels and nerves arc compressed as they 
pass between these bands, and this accounts for the 
petechial hemorrhages and the great sensitiveness found in 
the early stages, and for the bloodlcssness and comparative 



go 



DISEASES OF WOMEN. 



insensibility later on. The papill;u arc small, the rete Mal- 
pighii thin, and the sebaceous and sweat glands disappear. 

Course and JVognosis. — The disease, if left alone, runs a 
chronic course of five or six years; during this time there 
is great suffering and discomfort, but ultimately, when the 
atrophy is complete, the pain disappears. The parts remain 
friable ; even coitus may cause troublesome lacerations, and 
these are considerable if pregnancy and labor supervene. 

Treatment. — Palliative measures are unsatisfactory. Sed- 
ative lotions, cocaine ointment, etc. give only temporary 
relief. The pruritus may be stopped for a time by painting 
over the affected parts, under anaesthesia, with a 20 per 
cent, solution of carbolic acid in glycerin. Failing such 
remedies the application of the thermo-cautery to the red 
and painful spots is very useful. Occasionally it is neces- 
sary to excise the affected parts. 



92 



D/SEASES OF iVOMEN. 



The variations are as follows : A small circular aperture, 1 
centrally situated [A); a crescentic fold posteriorly, the 
aperture being anterior {b)\ a fringed condition in which 
the margin is indented in several places (c); a double ori- 
fice with a transverse division (£>); a double orifice with an 
an tero- posterior division {£) — this resembles the external 
appearance of a double vagina, for which it must not be 
mistaken ; lastly, the cribriform hymen {f\ in which there 
are several perforations. 

Variations in Strttcture. — It may be very thin and easily 
torn; or dense and unyielding, requiring division before 
coitus can take place; or. thick and fleshy. It may be 
unusually distensible and yielding, so that a finger or small 
speculum may be introduced, or coitus occur, without rup- 
ture. When the legs are separated the hymen may be- 
come so tense that the finger cannot be introduced, whilst it 
niaypasseasily when the thighs are approximated (Brouardel), 

This small structure has therefore an important medico- 
legal bearing. A permeable hymen, or one of the shape 
shown in Fig. 28, D, must not be taken as a certain indi- 
cation that intercourse has taken place; and secondly, an 
unruptured hymen is not positive proof of virginity. 

Treatment. — A rigid or contracted hymen may require 
dilatation or division, to allow of coitus taking place. 

CamncnlBE hymenales result from the rupture of the 
hymen caused by coitus ; they consist of the portions of the I 
hymen which arc left between the radiating tears, and touch 
one another so that in the undisturbed condition the hymen I 
may still appear intact. When everted they resemble the J 
petals of a daffodil. 

Caxunculs myrtifonues are due to more extensive 1 
stretching of the hymen, as during childbirth. ' They ap- 
pear as isolated nodules round the hymeneal margin, and I 
are produced by tearing through of the base of the hymei 

Cysts. — Small cyst>i lined with epithelium sometimes 
form in the tissues of the hymen. 



DISEASES OF THE VULVA. 93 

Painfhl caruncles of the hymen are a frequent source 

of vaginismus and dyspareunia. They apjwar as a scries of 
congcsttd spots, resembling small recent bruises, and ex- 
ceedingly sensitive, situated at the hymeneal margin. They 
occur principally in cases of kraurosis vuIvee, and are often 
found associated with urethral caruncle. For treatment 
see Kraurosis. 

Imperforate hjTnen is considered under the head of 
Atresia Vulva; (p. 68). 

The rupture of the hymen is generally attended by 
pain of short duration and slight bleeding. The latter 
may occasionally be so profuse as to demand surgical 
intervention, and may even be fatal. 



MORBID CONDITIONS OF THE CLITORIS. 

Inflammation. — This may form part of a general vul- 
vitis, or it may be due to the development of a venereal sore 
or phagedenic ulcer. In other cases the prepuce becomes 
adherent to the glans of the clitoris, and the pent-up secre- 
tion (smegma) sets up irritation which may lead to ulcera- 
tion or a small abscess. The treatment of this condition 
consi.sts in separating the adherent margins of the prepuce 
and keeping the parts clean and dry. 

elephantiasis is usually associated with elephantiasis 
vulv.-e; occasionally the clitoris is affected independently of 
the labia and forms a tumor hanging down as a large mass 
in front of the vulva. 

Epithelioma. — ^This is a somewhat rare affection of the 
clitoris. The prognosis after removal is favorable, as the 
glands arc affected very late and there is but little tendency 
to deep or extensive spreading. 

Treatment. — This consists in complete extirpation of the 
clitoris and its crura. 

Urethral Cartincle. — This is a small red fleshy growth 
situated on the posterior aspect of the urethral meatus. 



94 



DISEASES OF WOMEN. 



Pathology. — It occurs at or after middle life. It is oflm 
associated with kraurosis vulvae, and in these cases it 
probably due to the atrophic chtinges which characterize 
that condition ; for there is often a striking similarity be- 
tween some kinds of urethral caruncle and those red and 
tender spots round the hymeneal margin which occur so 
constantly in kraurosis. 

In other cases, however, there is no accompanying krau- 
rosis, and the caruncle is then usually larger and more 
prominent, and is due in all probability to changes taking 
place in Skene's ducts, two small recesses in the floor of 
the urethra. It is possible that these changes have an in- 
fective origin, but their pathology is not quite clear. In 
some cases the structure of the caruncle is suggestive of 
adenoma; in others the principal feature consists in the 
increase of thin-walled vessels like those seen in piles, and 
has suggested the name urethral hemorrhoid. The view 
that a caruncle is alway.s due to changes occurring in the 
urethral ducts receives strong support from the fact that 
the caruncle is invariably situated on the floor of the urethra 
in the situation of the ducts. 

Symptoms and Signs. — The patient complains as a rule 
of pain and tenderness at the meatus, with a burning sensa- 
tion on passing water, and sometimes of frequency of 
micturition. Occasionally the caruncle gives rise to bleed- 
ing and pain on coitus. A caruncle is readily recognized 
on inspection, presenting the characters above described. 
It often extends from one to two centimetres up the urethra. 

Treatment. — Tlie simplest plan is to remo\c the small 
growth with .scissors, or to destroy it with the thermo-cau- 
tery under an .m^sthetic, 

THE PERINEUM. 
This term is applied to the cutaneous and subcutaneous 
tissues intervening between the fourchctte and the anterior 
margin of the anus. Its centre corresponds to what is 




DISEASES OF THE VULVA. 



known in the male as the central point of the perineum. 
On section (Fig, l) it is triangular and marks the meeting 
of the sphincter of the anus, the transverse perineal and the 
rudimentary bulbo-cavernosus muscles. It also contains a 
strong meshwork of connective tiysue, and fibres of elastic 
tissue intermingle with the confluent attachments of the 
muscles mentioned above. 

Ruptured Perineum. — By this is meant a tear extend- 
ing through the lower part of the posterior vaginal wall 
and the perineum; it may extend into the anus. 

Cauies. — It is almost invariably due to parturition, but 
occasionally it is produced by surgical procedures, such as 
the extraction of large uterine polypi or foreign bodies from 
the vagina. 

When it occurs during labor the predisposing circum- 
stances are — 

1, Disproportion between the size of the head and the 
genital passages. 

2, Precipitate labor. 

3- Want of care in the dehvery of the head or shoulders. 

4, Certain mal presentations, especially the unreduced 
occipito-posterior. 

5. The use of instruments. The application of forceps 
does not, however, necessarily endanger the perineum ; on 
the contrary, properly used, it may lespen the risk of injury, 
by controlling and guiding the expulsion of the head, 

6. Morbid conditions of the perineum : as undue softness 
I and friability, which may be due to long-continued pressure 

of the child's head; undue rigidity; or diminution ofelastic- 
( ity as the result of chronic inflammation, 

7, The risk is greater in primiparae, and increases with 
the age of the primipara. 

Varieties. — The following are met with ; 

t. Partial. — Little more than the fourchette may be in- 
volved; or the perineum may be divided to a greater or 
less extent, but the sphincter ani remains intacL Within 



96 DISEASES OF WOMEN. 

the vagina, the tear nearly always occurs to one or other 
side of the posterior vaginal column. The tliickiiess and 
firmness of this structure prevent a median split. 

2. CompliU. — ^The laceration is anteriorly the same 
the partial variety, but posteriorly it extends through the 
sphincter ani, and may pass for some distance up the anterior 
wall of the rectum. 

3. Central. — In this kind, which is uncommon, the ante- 
rior part of the perineum remains intact, but a tear occurs 
at some place between the fourchette and the anus. It is 
due, as a rule, to long-continued pressure of the child's 
head, whereby the vitality of the thinned-out perineum is 
so impaired that it gives way at its most prominent point. 
Or perforation may occur later from gangrene, a vagino- 
perineal fistula thus resulting. Cases have also been re- 
corded in which the central tear was so large that the child 
was born through it, passing out behind the posterior com- 
missure of the vagina. 

Results of Rupttired Perineum. — When the rupture is 
partial, there is a tendency to prolapse of the vaginal walls, 
especially the posterior ; this may be followed by a more 
complete hernia of the pelvic floor. There is also inability 
to retain a pessary when this is indicated on account of 
prolapse or retroversion. 

When the rupture is complete, in addition to the conse- 
quences mentioned above, there is diminution or loss of 
control over the rectum, causing incontinence of faeces or 
flatus. 

Treatment. — When a perineum becomes torn during par- 
turition, it should always be repaired at once. Two or 
three sutures will usually suffice, and union readily occurs. 
When not seen till some time after, secondary perineor- 
rhaphy is retjuired. 




CHAI'TER X. 

DISEASES OF THE VULVA (Continued). 

TUMORS AND CYSTS. 

The vulva is liable to lipomata, myxoniata, sarcomata, 
an[{c:iomata, papil lomata, epithelioma, and carcinoma. 

IfipOtnata. — These may arise in the fatty tissue of the 
mons or in the deep connective tissue of the labia; they 
usually form sessile tumors, but may be pedunculated. A 
sessile lipoma is apt to be mistaken for an omental hernia 
occupyiofj the canal of Nuck, and vtec vtrsa. 

Myxomata. — These form irregular lobulated peduncu- 
lated tumors of the labium ; they are usually single and the 
skin covering them is deeply pigmented. 

Sarcomata. — The.se are very rare ; the commonest spe- 
cies is melanoma (melanotic sarcoma), arising in the pig- 
mented tissues of the greater labium. They are usually 
rapidly fatal from dissemination. 

Angeiomata. — Ntevi occur in the labia of children ; the 
more serious plexiform angeioma is very rare. 

Papillomata ( Warts). — These are very common on the 
vulva and surrounding cutaneous surface, and are often asso- 
ciated with irritating vaginal discharges, especially gonor- 
rhctal. 

Bpltheliotna. — This arises on any part of the vulva 
and occa.sionally occurs primarily on the clitoris. It is rare 
before middle life, but the liability increases with advancing 
years. The opposed surfaces of the labia are liable to 
those changes so often seen on the tongue and known as 
Icucoplakb; vulvar-Uke hngual leucoptakia may be the 



98 D/SEASES OF WOMEN. 

precursor of epithelioma. Epithelioma of the vulva runs 
much the same course as in other situations and quickly 
involves the inguinal lymph-glands. In the late stages foul 
ulcerating cavities form, and the depressions formed by the 
primary disease and those resulting from the necrosis of 
the infiltrated glands join to form a continuous bleeding 
and discharging cavity. Death comes about from exhaus- 
tion and distress induced by pain, frequent bleedings, and 
mental anguish. Sometimes a large vessel is opened by 
ulceration, and rapid death from bleeding ensues. 

Diagnosis. — This is usually easy; the conditions most 
likely to be mistaken for it are — 

{a) Papillomata, especially if inflamed or ulcerating, 

{b) Hard chancre. This forms a single ulcer, with hard 
base, and no tendency to spread. The inguinal glands are 
small, separate, and amygdaloid. 

(<■) Soft chancres are multiple; there is no induration; 
and they heal rapidly under proper treatment. 

(rf) Lupus is distinguished by alternations of tubercular 
masses, ulcers with bluish undermined edges, and contract- 
ing cicatrices. There may also be tracts of healthy skin 
between the ulcers, whilst the cancerous ulcer is compact 
and shows no tendency to heal. 

({■) Sloughing phagedena appears as a breaking-down 
abscess with gangrenous walls and free secretion of pus. 
There is no induration, and the history of venereal infection 
points to its true character. 

Treatment. — If seen early enough, free excision is the 
proper treatment and the prognosis is generally good. 
When practicable, the cut edges of the vagina should 
be sutured to the skin at the margin of the wound; the 
urethral mucous membrane should be similarly treated 
when the growth surrounds the urethral meatus. When 
the clitoris is alone affected, complete extirpation of this 
appendage is necessary. 

If the growth has extended deeply into the vagina, or 





DISEASES OF THE VULyyI. 99 

has spread extensively, palliative treatment is alone possible. 
The discomfort may be relieved by frequent antiseptic irri- 
gations and dressings smeared with eucalyptus and vase- 
line; anodynes, of which morphia subcutaneously admin- 
istered is the best, are usually required to relieve pain. 

Carcinoma. — This is a very rare affection of the vulva ; 
it arises in Barthohn's gland and involves the labial tissues, 
infects the lymph-glands, disseminates, and recurs after re- 
moval. Structurally it mimics the acini of the gland. 

CyBis of the Vulva. —These are of three species: 
mucous, -sebaceous, and cysts of Bartholin's glands. 

Mucons Cysts.— These are found principally on the 
inner surface of the labia minora, and seldom attain a large 
size. They should be opened, and if they recur the cyst- 
wall should be dissected out. 

Sebaceous Cysts.— These resemble similar cysts in 
other regions. The small black spot marking the orifice 
of the duct will generally give the clue to their origin. 
They are liable to be infected by vaginal discharges and 
then usually suppurate. An abscess in a sebaceous gland 
requires free incision ; an enlarged gland requires excision. 

Cysts of Bartholin's Gland. — These usually arise in 
the duct, but in chronic cases the gland may enlarge. 
Sometimes the occlusion is not complete; the duct may 
then become dilated for a day or two, and this Is followed 
by a sudden discharge of mucous fluid. In the case of 
complete retention the fluid may be watery or viscid ; oc- 
casionally it resembles the contents of a ranula. 

Symptoms and Course. — The patient complains chiefly of 
discomfort, sometimes of pain. The inconvenience may be 
felt in walking or sitting, whilst the pain may be a constant 
aching due to distention, or take tlic form of dyspareunia. 

An inflammatory condition may be present from the first 
as a complication of gonorrhtea. Pus is then found exuding 
in small drops from the duct-orifice; later this tends to 
close up, and abscess results. 



lOO BISEASFS OF H'OMEN. 

A simple cyst is fairly well differentiated from the sur- ' 
rounding structures; but if suppuration sets tn, the cyst- 
walis become thickened and Infiltrated, and the distinc- 
tion between them and surrounding tissues is obscure. 
When an intermitting cyst is examined during its stages of 
collapse, the gland itself may be felt, between the finger in 




Fic. >9.— The r'ehl UbiuiD mi 



the vagina and the thumb outside, as a little mass the 5i2e 
of a pea or small bean. 

Diagnosis. — The cyst presents a characteristic pear-shaped 
swelling, occupying the most dependent part of the labium 
inajus, tlic narrow end of the swelling being uppermost, i 




DrSE.^SF.S OF THE VULVA. lOt 

It is only when it gets large that it involves the upper part 
of the labium. In chronic cases the orifice is rcatlily seen 
as a small pit in the angle between the hymen and the la- 
bium minus (Fig. 29). The lesser IJp is not affected when 
the cyst is small ; when large, it is stretched and flattened 
over the swelling. Suppuration is readily recognised by 
the much greater pain, the redness of the. skin and mucous 
membrane, and the heat of the part. 

Three conditions require to be dtflerentiated from a 
Bartholinian cyst or abscess: 

(a) Hismatoma. — The swelling is more -uniform through 
the labium majus; it feels usually more doughy, and there 
is commonly a history of injury or recent parturition. A 
hematoma may aflect the leaser lip alone. 

(b) Inguinal Iltrnia. — This appears at the upper end of 
the greater lip. and tends to disap|>ear when the patient is 
lying down ; there is an impulse on coughing, and it may 
be resonant In any case there is not a free flattened space 
between the swelling and the inguinal opening. 

(c) Hydrocele of the Canal of Nuck. — In this case the 
swelling occupies the upper or middle part of the labium, 
the lower end being free. There is no impulse on straining 
or coughing, nor is the swelling affected by the position of 
the patient 

Treatment. — The only satisfactory way of dealing with a 
Bartholinian cyst is to dissect it out. 



CHAPTER XI. 

DISEASES OF THE VAGINA. 

AGE-CHANGES, DISPLACEMENTS. INJURIES, 
FOREIGN BODIES, AND FISTULiE. 

Age-chanf^es in the Vagina. — In the child the 
vagina forms merely a transverse slit. The walls are 
thrown into numerous close folds, mainly transverse, and 
more marked at the side. 

After puberty the vagina becomes larger, the widening 
affecting especially the upper part. There are, however, 
considerable variations in individual cases ; in some the va- 
gina remains nearly the same width above as below ; in 
others, the capaciousness superiorly forms a marked con- 
trast to the narrow entrance. 

After marriage the folds become somewhat flattened out, 
and the whole vagina becomes dilated, owing to the ca- 
pacity of its walls for stretching. 

Childbirth accentuates the changes, and after repeated 
labors the folds become almost obliterated, and the orifice 
may remain gaping, owing to stretching or rupture of the 
sphincter vaginae. At the same time the walls become lax, 
and tend to protrude through the vulvar orifice. 

With the onset of the menopause, atrophic changes set 
in. The walls now become quite smooth on the surface; 
and the lumen becomes contracted, especially at its upper 
portion ; with the result that the fornices are obliterated, 
and the whole vagina assumes a conical form, with its apex 
upward. At the summit of the cone the cervix forms a 
small projection ; or, this also becoming atrophied, the vag- 




inal vault becomes almost pointed, with a small depression 
at its apex reprL-scnting the external os and barely admitting 
a sound or a probe. 

DISPLACEMENTS OF THE VAGINA. 

These are commonly associated with displacements of 
the uterus, the whole forming the typical " hernia of the 
pelvic floor;" but as the vagina may be affected principally, 
or alone, we shall here describe the two chief types — viz. 
cystoceic and rectocele, 

Cystocele. — This is really a hernia of part of the blad- 
der into the vagina, the vaginal mucous membrane form- 
ing its outer covering ; or it may be expressed as a deflec- 
tion of the vesico-vaginal septum toward the vagina. It 
forms a smooth, rounded swelling, which bulges through 
the vulvar aperture when the patient coughs or strains. If 
the lower part of the anterior vaginal wall is mainly af- 
fected, the swelling is more propedy calleda urethroc€lt- ; in 
this case it is smaller, and the thickened urethra can be felt 
as a median projection through the vaginal wall. 

Rectocele. — This is a hernia of the rectum into the va- 
gina, covered by the mucous membrane of the posterior 
vaginal wall. It forms a swelling resembling that produced 
by a cystocele, except that it is on the posterior aspect of 
the vagina. If the finger be introduced into the rectum it 
can be passed into the pouch in the vagina ; and similarly 
a sound introduced into the bladder can be passed into a 
cystocele. 

A rectocele is nearly always associated with a deficient 
perineum ; and further, cystocelfc and rectocele are often 
found together. When this is the case the vulvar outlet, 
when the patient strains, is occupied by two smooth swell- 
ings placed one in front of the other; between them the 
finger can be passed' up to the cervix (Fig. 30). 

Causes. — The direct cause of these conditions is a relaxa- 
tion of the tissues forming the vaginal walls. This, again. 



I04 DISEASES OF WOMEN. 

is brought about mainly by parturition. Women who have 
borne a great number of children are the princi[>al suflerers, 
and most cases come under observation between the ages 




of tliirty and forty-five. After the menopause the general 
tendency to atrophy of the genital passages counteracts in 
some measure the laxity of the vaginal walls. 

The mechanism of the displacement differs slightly in the 
production of a cystocele and a rectocele. 

Cystocelc. — It will be remembered that the anterior vagi- 
nal wall is attached more firmly below, opposite the pubes, 
than above ; now in the case of a tedious labor, when a 
large head presses for some time on the vaginal walb, the 
anterior wall is forced down, and its attachments to the 




DISEASES OF THE VAGINA. 

pubes are loosened and may even be separated. After a 
first confinement tlic parts may regain more or less their 
normal fixity. But after repeated labors, especially if dif- 
ficult, the lower part of the anterior vaginal wall remains 
[jermanently loosened from its pubic attachment, and tends 
to prolapse whenever the intra-pelvic pressure is increased, 
as when the bladder is full ; when the patient strains at 
stool or coughs ; and in some cases when she simply 
stands erect. 

A cystocelc may arise in another way. Owing to the 
fact that the principal attachment of the anterior vaginal 
wall is at its lower end, it follows that if the uterine sup- 
ports be loosened, and the uterus comes to lie low in the 
pelvis, the upper and lower ends of the anterior vaginal 
walls are approximated; the intervening; part bulges back- 
ward, especially when the bladder is full; and in this way 
also a cy.stoceic is product;d. 

Rtclocdc. — The posterior vaginal wall is mainly attached 
above, being held in place by the utcro-sacral folds. When 
these are lengthened and rendered lax, as by the dragging 
of a heavy uterus or as the result of repeated labor.s, the 
posterior vaginal wall hangs lower, and may bulge in the 
form of a rectocclg. The tendency to this is greatly in- 
creased if the perineum be torn, as the inferior support is 
then lost. Indeed, a slight degree of rectoceic is possible 
when the perineum is torn, even if the utero-sacral folds 
remain at a normal tension, and the uterus is in its proper 
position. But it is evident that, owing to the superior 
attachment of the posterior wall, there can be no great pro- 
lapse of that wall as long as those attachments remain firm. 

In accordance with the above considerations we find, 
first, that cystocelc is more common, and usually more 
marked, than rectoceic; secondly, that prolapse of the 
uterus strongly predisposes to prolapse of the vaginal 
walls. 

Sympitnns. — The patient complains principally of "bear- 



io6 




DISEASES OF WOMEN. 



ing down," and of something protruding from the vulva. 
In out-patient practice the statement made is often that 
"the womb comes down." The feeling of weight and 
dragging is aggravated aftur long standing or walking, and 
during defecation. With cystocele and urethrocele there is 
often frequency of desire to pass water. On making an 
examination, the vaginal outlet is seen to be occupied by 
one or two swellings according as one or both conditions 
exist. In recent cases the mucous membrane retains its 
normal character; in those of long standing it may be 
thickened and hard, approaching the appearance of the 
skin. The swelling is distinguished from a protruding 
cervix by the absence of the os externum and by the feet 
that it has an anterior (cystocele) or a posterior (rectocele) 
attachment. A finger passed through the anus into the 
posterior swelling, or a sound passed through the urethra 
into the anterior one. will confirm the diagnosis. The cervix 
uteri is generally met with low down in the vagina. 
Treatment is of two kinds, palliative and curative. 

(a) Palliative treatment consists in the employment of 
pessaries ; of these the most useful is the rubber ring. 
When the perineum is much torn, it is often found that no 
ring will remain in position, unless so large as to cause 
harmful pressure. An instrument of the cup-and-stem type 
may be used, such as a ring with a Y-shaped stem, the 
limbs of the Y being attached at the ends of a diameter of 
the ring. Perineal bands are fastened to the lower end of 
the -Stem. These plans are, at the best, faulty ; and when a 
simple ring cannot be retained it is much better to resort to 
operation unless contraindicated. 

(b) Curative or Radical Treatment. — For rectocele, a peri- 
neorrhaphy may be performed, either alone or .issociated 
with posterior colporrhaphy (colpo-perineorrhaphy). This 
will often allow of the wearing of a ring, even if the opera- 
tion does not entirely cure the prolapse. 

For cystocele many varictes of anterior colporrhaphy 




DISEASES OF THE VAGINA. 107 

have been devised (see Colporrhaphy). In obstinate cases 
some more serious measure may be tried, such as vaginal 
or ventro-fixation (see Hysteropexy). For cystocele asso- 
ciated with retroversion of the uterus, vagi no- fixation often 
answers well ; for the two opposing tendencies — of the ute- 
rus to fall back, and of the vaginal wall to fall down — coun- 
teract one another (Edge). 

Vaginal Hernia {Entcrocde). — A rare form of hei-nia 
sometimes occurs in which the uterus and the lower part 
of the vagina retain their proper position, whilst the peri- 
toneal pouch in front of or behind the uterus bulges into 
the vagina and is occupiL-d by coils of intestine. It is dis- 
tinguished from the conditions just described by the follow- 
ing points : 1. The swelling is not continuous, anteriorly or 
posteriorly, with the margin of the vulva ; 3. The finger can- 
not be passed into the pouch through the anus nor can a 
sound be passed into it through the urethra; 3. The cervix 
uteri is found high up. 

A vaginal hernia has been mistaken for prolapse, polypus, 
and inversion of the uterus. 

Injuries. — Serious and even fatal injuries of the vagina 
have followed rape on adult women as well as children; 
severe lacerations have been caused during willing coitus, 
due to unusual size of the penis, undue narrowness of the 
vagina, or even awkwardness on the part of the ifian. First 
coitus sometimes causes alarming and even perilous bleed- 
ing, especially when the laceration of the hymen extends to 
and involves the vulva or the vaginal wall. 

Fatal peritonitis has followed the forcible introduction of 
foreign bodies by brutal men. Women sometimes injure 
themselves fatally by introducing pointed instruments for 
the purpose of inducing abortion, or during fits of sexual 
frenzy. 

The upper part of the vagina may be lacerated by the 
careless use of instruments in operations on the uterus and 
during instrumental delivery, or by the child's head in a 



lo8 DISEASES OF WOMEN. 

long second stage of labor. When free bleeding results. 
, it may be erroneously thought to be derived from the 
cavity of the uterus. As a rule the bleeding stops readily 
under the influence of a hot vaginal douche (115° F.). If 
it persists, the lacerations may require to be repaired. A 
serious form of laceration sometimes occurs during labor. 
the recto-vaginal or the utero-vesical pouch being opened 
up. This may occur from violent uterine contractions in 
cases where the pelvis is narrow or there is other obstruc- 
tion to delivery ; it has also been produced during the 
introduction of the forceps, perforator, or cephalotribe. 
Coils of intestine may protrude through the gap, and even 
hang out from the vulva. The accident is generally fatal. 

Foreign Bodies. — The vagina, like the other accessible 
cavities of the body, is liable to have foreign bodies intro- 
duced into it. Little girls from sheer curiosity insert hair- 
pins, pebbles, seeds, fruit-stones, pencils, etc. Older girls 
introduce sponges, cotton-wool, and the like, with the hope 
of preventing conception from illicit intercourse. 

Pomade-pots, pewter pots, cotton-reels or spools, candle- 
extinguishers, and small india-rubber balls have been re- 
moved from the vagina of matrons; some of them were 
introduced to prevent pregnancy, others to act as supports 
to prolapsed womb.s. Pessaries of extraordinary shape, 
size, and complexity have been introduced by obstetric 
physicians and forgotten till urinary fistula; or stinking dis- 
charges have led to examination. Brutal men when rioting 
with low drunken women have thrust into the vagina pipe- 
bowls, thimbles, clock- weights, or pieces of metal. 

The vagina has served as a repository for stolen prop- 
erty — e.g. gems, bank-notes, jewelry, and pocket-books. 

Among odd things the following deserve mention : A 
cockchafer beside a pomade-pot (Schroeder) ; a small bust 
of Napoleon the Great; and cylinders of inverted pork-rincl. 
A woman was admitted into the cancer ward of the Mid- 
dlesex l^ospital with a certificate of "stone cancer" of the 






uterus. Examination proved the alleged cancer to be a 
piece of brick. 

When a healthy young woman is found to be suiTerinj^ 
from a stinking vaginal discharge, it is exceedingly prob- 
able that she has a foreign body in the vagina. 

Pisttllae, — As the vagina is placed between two hollow 
viscera, the bladder and rectum, it is not surprising that 
fistulous passages are occasionally formed between thcni. 
Fistula are caused by sloughing of the vagina during pro- 
tracted labor; injuries from obstetric implements; ulcera- 
tion due to pessaries .ind other foreign bodies. They also 
occur in the late stages of epithelioma of the vagina and 
carcinoma of the cervix uteri and the rectum. Occasion- 
ally they are due to ulceration of the bladder set up by ves- 
ical calculi formed around foreign bodies introduced into 
the bladder. 

Vaginal fistulx, vesical, ureteral, and rectal, occasionally 
follow vaginal hysterectomy ; usually, however, they are 
merely temporary. 

Vaginal fistuire are of four kinds: i. Yes ico- vagi na 1 ; 2. 
Urelhro-vaginal ; 3. Uretero-vaginal; 4. Recto-vaginal. The 
names are sufficient to indicate their positions. Ulero-ves- 
ical fistul.'e may be also considered here. 

SyiHfitot'is. — In the case of a vcsico-vaginal fistula the 
patient complains that she cannot hold her water. Some 
urine may collect in the bladder and be voided periodically 
if the fistula is small ; otherwise the urine escapes from the 
vagina as rapidly as it enters the bladder. The vulva and 
vagina are inflamed and excoriated by the constant wetting; 
and sometimes a phosphatic incrustation forms. 

If the fistula be rectal, great discomfort and distress is 
caused by the passage of fa:ces and flatus by the vagina ; 
though, if the fistula be small, the f^ces may be prevented 
by their semi-solid form from entering the vagina. 

The Mtthodi for the Detection of Vaginul Fistula:. — The 
persistent and involuntary escape of urine from the vagina is 



I(0 DISEASES OF WOMEN. 

sufficient indication of the existence of a urinary fistula, but 
it is not always a simple matter to localize its precise position. 

To determine this it is advisable to put the patient in the 
lithotomy position and expose the parts with a duck-bill 
speculum introduced into the vagina in a good light, A 
vcsico-vaginal or a u ret hro- vaginal fistula rarely gives rise 
to difficulty, and the pink everted edges surrounding its 
vagina! orifice soon lead to its detection. When there is 
difficulty in finding it, the vaginal mucous membrane should 
be cleared of mucus, and warm milk injected into the blad- 
der through a catheter in the urethra; it will then dribble 
through the fistula. 

Injections of milk arc very serviceable for the detection 
of uretero- vaginal fistula:. In this case when it is injected 
into the bladder none escapes into the vagina, yet during 
the course of the examination urine has continued to escape 
into the vagina. This test is necessary even when the ori- 
fice of the fistula is clearly visible. In this form of fistula, 
if the urine which escapes involuntarily from the vagina is 
collected, measured, and compared with that voided from 
the bladder, it will be found that the two quantities equal 
each other. 

In the case of a utero-vesical fistula the urine will be 
seen escaping from the cervical canal of the uterus ; when 
milk is injected into the bladder some of it escapes down 
the cervical canal ; this is conclusive. 

Treatment. — In recent injuries the blood-clot should be 
removed and dehberate search made for bleeding vessels, 
which should be secured with forceps and ligatured. Capil- 
lary oozing is best restrained by careful packing with gauze. 
The subsequent treatment is that adapted for wounds in 
general. In the case of foreign bodies, they should be re- 
moved as soon as discovered ; when long retained it is 
usually necessary to obtain the advantage of an anes- 
thetic. Persistent vaginal fistula; of all kinds require ope- 
rative treatment. 



CHAPTER XII. 




DISEASES OF THE VAGINA (Continued). 

VAGINAL INFECTION AND THE VAGINAL 
SECRETIONS. 

GoNOKRHCEA and sepsis play a very important part in the 
production of vaginitis. For the better appreciation of theJr 
influence we must make some preliminary observations on 
the bacteriology of the normal vaginal and uterine secre- 
tions. 

The Normal Vaginal Secretion. — In the following 
remarks the excellent account given by Doderlein will be 
followed. 

Origin. — The vagina contains no glands ; and some ob- 
servers have consequently inferred that the secretion found 
in the vagina is derived in every case either from the cer- 
vical or Bartholinian glands. This view is disproved by the 
following considerations : First, the cervical canal is nor- 
mally occupied by a tenacious plug of mucus, which shuts 
off the cervical from the vaginal canal ; secondly, the Bar- 
tholinian glands usually secrete very little fluid, and the 
ducts open on the outside of the hymen; thirdly, in clo.sed 
vaginal cy.sts a tyjiical vaginal secretion is found : fourthly, 
the cervical and vaginal secretions present markedly dif- 
ferent characters. 

The vaginal secretion is derived from the shedding of 
squamous epithelium together with the exudation of some 
lymph-serum. Normally, it forms a thin coating on the 
surface of the vagina. 

ChariKters. — It is a rather thin opalescent fluid, devoid of 



112 n/SEASES OF WOMEN. 

viscidity, and sometimes, when abundant, forming a while 
flocculent and curdy matter. It gives a strongly acid re- 
action, due to the presence of lactic acid. Estimated quan- 
titatively, tile acidity is equivalent to 0.4 per cent, of sul- 
phuric acid or 0.9 per ctnt. lactic acid. In the new-bom 
tiie action is neutral ; in the healthy virgin it is acid ; in 
normal pregnancy the acidity is greater; whiLst in patho- 
logical conditions tiie reaction is feebly acid, neutral, or even 
alkaline. The acidity disappears during and for some days 
after menstruation, and for five or si.x weeks after normal 




labor. Examined microscopically, the vaginal secretion in 
the new-born contains only squamous epithelium. In the 
virgin and in normal pregnancy there is constantly found, 
in addition, the vagina-batillus (Figs. 31, 32); whilst in a 
certain percentage of cases a fungus is found, the Aloniiia 
Candida. The vagina-bacillus and the fungus are invariably 
absent from pathological secretions. 

The vagina-bacillus belongs to the anaerobic bacilli. It 
may be cultivated on agar or gelatin, or in bouillon, blood- 




D/SEASBS OF THE VAGINA. 



113 



serum, or milk. It requires moisture and warmth equiva- 
lent to the body-temperature. It occurs in the form of 

short straight rods. As the result of pure cultivations 
lactic acid is invariably produced, equivalent quantitatively 




to 0.5 per cent, sulphuric acid, which corresponds to I.125 
per cent, lactic acid. 

Rote of the Vagina-baeillus. — To this bacillus is due the 
presence of l.ictic acid in the vaginal secretion, as indicated 
by the fact that when the bacilli arc absent, a.s in the new- 
born and during the puerperium, the reaction of the secre- 
tion is always neutral. In its presence saprophytes and 
pathogenic micrococci, such as the streptococcus and sta- 
phylococcus, are unable to develop, and before long perish. 
When the vagina-bacillus is absent, as in the lochial secre- 
tion, both saprophytes and staphylococci are able to flour- 
ish. The Moniiia is a harmless organism which can only 
grow in the presence of the vagina-bacillus ; that is, in the 
healthy vaginal secretion. 

The antagonism between the vagina-bacillus and patho- 



ri4 



DISEASES OF WOMEN. 



gcnic organisms is illustrated by the following experiments 
described by Doderlein : 

(a) A pure cultivation of the vagina-bacillus on peptone- 
agar of three days" growth was inoculated with a cultivation 
of the staphylococcus pyogenes aureus. The staphylococci 
were soon destroyed. When, however, the two bacilli were 
inoculated on agar at the same time, the vagina-bacillus 
perished, showing that abundant products of the growth of 
the latter are required to destroy the staphylococcus. 

(b) The vagina of a virgin was inoculated with a bouillon 
culture of staphylococcus pyogenes aureus. After six 
hours an abundant cultivation of staphylococci was ob- 
tained therefrom. After twenty-four hours only a few 
colonies were found; these further diminished on the sec- 
ond and third days, and by the fourth day the staphylo- 
cocci had been quite destroyed in the vaginal secretion. 

As a result of the protective influence of the vagina- 
bacillus it happens, as Winter has shown, that when patho- 
genic organisms are found in the normal vaginal secretion 
they are always in a condition of weakened virulence. 

The normal cervical secretion con.sists almost entirely of 
mucus, in which are found entangled a few columnar cells 
derived in part from the surface epithelium and in part from 
that lining the glands. It is in consequence viscid and 
tenacious, so that a plug of it filling up the external os is 
often very difficult to dislodge. Its reaction is alkaline or 
neutral, and it contains no micro-organi.sms. 

Pathological Vaginal Secretion. — This is thin, yel- 
lowish white, or, if pus be mixed therewith, greenish. It 
may be so abundant as to flow from the closed vagina, giv- 
ing all the symptoms characteristic of leucorrhcea. Its 
reaction varies from faintly .icid, through neutral, to 
.strongly alkaline. Examined microscopically, it is found 
to contain epithelial debris, and often pus-cells. 

Both in cover-glass preparations and by cultivation it is 
found to contain saprophytic bacilli and micrococci — 




DISEASES OF THE rAGf.VA. 



staphylococci and often streptococci. The vagiiia-bacilliis 
and the monilia fungus are never present, 

A palholoyical vaginal secretion may be regarded as 
a favorable cultivation medium for pathogenic organisms. 
Doderlein performird eighteen inoculation experiments with 
pathological vaginal secretions on rabbits, and in every case 
septicaemia resulteil. 

The transition from a normal to a pathological secretion 
may be brought about in two ways : 

First, by mere functional increase in the amount of secre- 
tion, such as arises from sexual excesses. Thus in thirty 
prostitutes examined by Doderlein the secretion was not 
once (bund to be normal, even when there was no specific 
gonorrhceal infection. Masturbation, the wearing of rubber 
jiessaries, frequent and purposeless vaginal irrigations, and 
the introduction of alkaline substances, such as soap, may 
have the same ofiect. 

Second, through pathological organic changes, such as 




are found in endometritis, adenomatous disease of the cer- 
vix, vaginitis, and cancer. 

Besides the organisms of sepsis there is sometimes found 
a specific micro-organism, the gonococcus of Neisser (Fig. 




w 



33). It must be remembered, however, that, as Bumm has 
pointed out, the vagina often escapes gonorrhceal infec- 
tion, owing to the resistance offered to the entrance of 
gonococci by the stratified squamous epithelium, whose 
superficial portion is hard and horny. But the disease 
readily attacks the urethra and the delicate columnar epi- 
thelium of the cervix. 

In cases of gonorrhcea the vaginal secretion is therefore 
usually altered indirectly by the admixture therewith of 
the unhealthy cervical secretion, which is abundant, alka- 
line, purulent, and consequently albuminous; and the 
vaginal secretion accordingly acquires these characters. 
The vagina-bacillus perishes under these circumstances ; 
and a favorable soil is provided for the development of the 
pathogenic germs previously described. The actual inocu- 
lation of these pathogenic germs may occur during men- 
struation, sexual intercourse, gynjcco logical manipulations, 
and parturition ; in the latter ca.se not only through vaginal 
examinations and operative procedures, but al.so through 
traumati.sm incident to labor. 

An important practical deduction to be drawn from these 
considerations is, that in cases in which the vaginal secre- 
tion departs from the normal type special care should be 
taken to disinfect the vagina before resorting to any intra- 
uterine manipulations, even the passage of the sound, lest 
the uterine cavity, previously unaffected, be inoculated with 
septic organisms. 

Having thus briefly reviewed the pathogenesis of vag- 
inal infection, we may enumerate the principal morbid 
conditions which may result therefrom — viz.: Vaginitis; 
endometritis, of both cervix and body ; salpingitis, ca- 
tarrhal and purulent; septic peritonitis; pyocolpos and 
pyometra; and pelvic cellulitis. These results may follow 
either from sepsis alone, or from sepsis complicated by 
gonorrhtea. 

In concluding these remarks on the secretions, the fol- 




lowing resume of the different kinds of discharge found in 
the female genital passages may prove useful; 

1. Normal vaginal discharge, of which the characters 
have been given above — viz. white, creamy or curdy, and so 
slight in quantity as not to attract the patient's attention. 

2. A clear viscid discharge, composed principally of 
mucus. This is the normal cervical discharge, and is usu- 
ally not seen except on examining with the speculum; but 
it may be mixed with the vaginal discharges at the begin- 
ning and end of menstruation, and occasionally, when 
abundant, at other times. 

3. A muco-puruient or purulent discharge, yellowish or 
greenish according to the proportion of pus. This is seen 
characteristically in acute gonorrhoea, and commonly re- 
sults also from chronic endometritis. It is the variety most 
frequently spoken of as " the whites," when containing but 
little pus. It stains and stiffens the linen. 

4. Watery discharges may result from simple hyperemia 
of the genital passages, and occasionally from intermittent 
hydrosalpinx. They are also found in cases of cancer, but 
the discharge then assumes more often the characters of 
the next variety. 

5. Fcetid discharges occur as the result of ulceration, 
and the principal conditions which produce them are re- 
tained pessaries, sloughing fibro-myomata and polypi,- de- 
composing products of conception, and, most frequently of 
all, cancer. 

6. Bloody discharges, other than menstrual, may be due 
to cancer, endometritis, fibro-myomata. polypi, adenomatous 
disease of the cervix, and lacerations. The discharge is 
often pinkish in cancer; but in any of the above con- 
ditions it may vary from a very slight rose tint to the red 
of almost pure blood. 



CHAPTER XIII, 

DISEASKS OF THE VAGINA (Continued). 

INFLAMMATION; TUMORS AND CYSTS. 

Vaginitis. — The chief causes of inflammation of the 
vagina arc — (a) Injuries, such as result from obstetric ope- 
rations, accident, foreign bodies, retained pessaries, immod-- 
erate coitus, and careless application of caustics to the 
uterus ; (b) Infeclions, such as gonorrhcea, sepsis, and tuber- 
culosis; zxi^ic) Pregnancy. 

According to tlie age of the patient different types will 
be found. In children it may be simple, or due to thread- 
worms, gonorrhcea, and exceptionally to uterine tubercu- 
losis. In adults it is nearly always gonorrhoeal. Want of 
cleanliness and constitutional conditions are predisposing 
causes, as they favor the growth of pathogenic organisms 
(see preceding chapter). It is through a disturbance in 
the secretion, associated with congestion, that pregnancy 
may induce vaginitis. 

Pathology. — As in inflammation elsewhere, the first con- 
dition is congestion, causing heat and redness of the mu- 
cous membrane. The discharge which is produced is 
known clinically as leucorrhea, and consists at first of a 
watery fluid, with cast-ofl!' epithelial cells. If the latter are 
in great quantity, the discharge is no longer clear, but white 
and turbid (hence the name). If pus forms, it imparts a 
yellow or green color to the discharge. 

In simple cases the inflanmiation soon ."iubsides, without 
further change than more or less desquamation of the ejM- 
thelium. In senile vaginitis atrophic changes follow: the 




DISEASES OF THE VAGINA. II9 

epithelium is reduced in thickness, and fibrous changes 
ensue in the mucous membrane, which narrow the lumen 
of the passage. The same result may occur in places from 
the action of caustics ; but here the epithelium may be 
deeply destroyed, and the contraction is sometimes marked 
(see Complications). When the vaginitis is purulent, from 
sepsis or gonorrhoea, on microscopic examination the epi- 
thelium is seen to be at first swollen, due to infiltration 
of round cells in the papillae, which are very vascular. 
The interpapillary spaces are filled up by exudation of cells 
and serum, till the papillx cease to be distinct. The epi- 
thelium then becomes thin and presents the appearance of 
granulations, which bleed readily (Ruge). The gonococcus 
itself is not able to penetrate the stratified vaginal epithe- 
hum (Bumm); but the staphylococcus and streptococcus 
appear to be able to do so. 

Under proper treatment the granulations subside, and 
the epithelium gradually resumes its normal appearance. 
But when the inflammation has been very virulent, large 
patches of epithelium may be detached, mixed with coagu- 
lated exudation ; and this condition has been described as 
diphtheritic, membranous, or desquamative vaginitis. 

I'anififs. — Clinically it is useful to distinguish the fol- 
lowing varieties of vaginitis : 

(a) Vulvo-vaginitis of children ; 

(b) Vaginitis of pregnant women ; 

(c) Gonorrhueal vaginitis of adults; 

(d) Senile vaginitis ; 

(e) Membranous vaginitis. 

(a) Vuh'o-vaginitis of children acquires some of its import- 
ance from its medico-legal bearings. The question of crim- 
inal assault .sometimes arises, and the medical attendant 
should bear in mind the following points: First, vulvo- 
vaginitis of simple character may occur when there has 
been no violence nor external interfercMice of any kind. It 
is then found mostly in weak and neglected children. Sec- 



I20 DISEASES OF ll'OA/EJV. 

ondly, vulvo- vaginitis may be produced by indecent vIS 
tence short of rape. Thirdly, gonorrhceal vulvo-vaginitis 
may occur, in epidemic form, in schools; the starting-point 
may be an accidental contamination by tlie bed-clothes 
when children sleep with parents or elder brothers; and 
infection may be spread with towels or other linen, or b>' 
the use of one bath for several children. Fourthly, the 
gonorrhoea may result from rape ; this is probably rare 
in proportion to the total number of cases. 

This form of vaginitis has been found at all ages from 
early infancy to puberty. 

The symptoms are sometimes sUght ; with the exception 
of a mucous or purulent di.scharge they may be absent. 
Hut more often the child complains of pain, scalding mic- 
turition or itching; and there may be some febrile dis- 
turbance. It has been shown that thread-worms may set 
up vaginitis in children by passing into the vagina from the 
rectum. The smallness of the hymeneal orifice in children, 
while it is in some measure a safeguard against infection. 
tends to aggravate the disease when once established, and 
is a difficulty in the way of cure, because it favors the re- 
tention of discharges. 

(b) Vaginitis of Pregnant Womrn. — To what has been 
said about this we need only add that at times it may be 
due to latent gonorrhtea, allied to gleet in the male, taking 
on increased activity as the result of the congestion caused 
by pregnancy. 

Vaginitis may occur also during the puerperium. as part 
of a puerperal infection, and is then generally septic. The 
laceration or bruising of the vagina by the passage of a 
lai^e head or by instruments favors inflammation; and 
indeed, apart from infection, there is always some degree of 
traumatic inflammation in these cases. 

(c, d, e) Gonorr/urai vaginitis is the most common form 
of vaginitis in adults, and what is here said of vaginitis in 
general applies more especially to the gonorrhceal fonn. 




DISEASES OF THE VAGINA. 121 

SenUe and membranous vaginitis do not require special 
description. 

Symptoms. — The patient complains of pain and burning 
in the vulva; smarting pain on passing water; dyspareunia 
and discharge. On examination, the vaginal walls are hot, 
red and swollen, and acutely tendtr to the touch. The dis- 
charge, generally yellow or green, is found bathing the ex- 
terna! genitals as well as the vagina. The signs described 
under the complications of vulvitis may also be present. 
In senile vaginitis the discharge may be thin and sanious, 
leading one at first to su.-ipect carcinoma of the cervix. 

Diagnosis. — As stated under Vulvitis*, the matter of prin- 
cipal difficulty and importance is often to distinguish gonor- 
rhceal from non-gonorrhceal vaginitis. In the absence of 
pus, the probability is that the inflammation is of simple 
character ; but in cases of some standing this sign is of less 
importance. When there is pus it may be septic in origin, 
or it may come from the cervix uteri, and not primarily 
from the vagina. A careful examination must therefore be 
made with the speculum, when, if the vagina is at fault, it 
will be seen reddened and studded over with brighter red 
points. In all cases of doubt a careful search must be 
made for gonococci. Implication of the urethra and of the 
Bartholinian ducts affords strong presumptive evidence of 
gonorrhcea ; by some, either condition alone is regarded as 
certain proof Leucorrhcea due to endometritis or carci- 
noma is distinguished from that due to Vaginitis, by the use 
of the speculum. 

Course and Complications. — If left untreated a simple 
v^initis docs not give much trouble ; but the results of 
gonorrhtea are far-reaching and serious. The most im- 
portant is the spreading of the disease up the genital pas- 
sages, producing successively endometritis, purulent salpin- 
gitis, and septic peritonitis. For this reason gonorrhtea is 
a much more serious condition in women than in men. 
Nor does the danger stop here. Under the influence of 



122 DISEASES OF WOhfE!^. 

pregnancy a latent gonorrh<Ea may reawaken to virulent 
activity, in the vagina, the uterus, or the tubes; or the 
trouble may lie dormant till labor comes on, when a rapidly 
fata! form of puerperal septiciemia may develop, for which 
the medical attendant may incur undeserved responsibility- 
In other and perhaps more frequent cases sterility results 
from the scaling up of the fimbriated ends of the Fallopian 
tubes, which become converted into bags of pus. This is 
generally associated with a troublesome form of dysmtnor- 
rhcea. It is evident, therefore, that no effort should be 
spared to treat energetically and thoroughly every case of 
acute gonorrhceal vaginitis. 

The infection of the urethra seldom causes any complica- 
tions in women ; stricture is very rare, and consequently 
the bladder, ureters, and kidneys commonly escape. At 
times, however, cystitis may be set up. 

In addition to the complications mentioned under Vulvitis, 
the following have to be considered : 

Vesico-vagiiial and Recto-vaginal Fistula. — These occur 
more often from other causes, but may result also from 
severe vaginitis attended with ulceration. 

Atresia Vagina!. — This is especially apt to occur when 
there has been much destruction of the epithelium, and is 
therefore often well marked when the vagina has been much 
injured by caustics applied to the cervix uteri. In such 
cases, if examined at a later date, the finger discovers the 
vagina to be contracted, usually a little below the level of 
the external os. The contraction may be so great as barely 
to admit the finger-tip. But if this can be passed through 
the constriction, which is often annular, it enters an ex- 
panded part of the vagina, in which is found the cervix. 
The vagina may. in fact, be said to present an hour-glass 
contraction. The condition, if it occur in later middle age, 
about the time of the menopause, causes but little trouble; 
but in earlier adult life the contraction may go on to oblit- 
eration of the canal, and hfematocolpos results. Similarly, 




DISEASE.t OF THE VAGINA. 



123 



; more rarely, the external os may become stenosed or 

I, giving rise at first to dysmenorrhoea, and later to 

jatometra. 

itltnt ophthalmia is a frequent complication of vulvo- 

i in children, the infection being conveyed directly 

; patient's lingers or indirectly through linen and 

mitts ranks next in order of frequency to ophthalmia 
[nplication of gonorrhcea in young women. 
^orrhaal rheumatism also occurs, but less frequently 
■ among men. 

regnosis. — From the above it will be seen that when 

■atment is not thoroughly carried out. the prognosis is 

s regards the subsequent health. With proper care, 

r. in the early stages, the outlook is very satisfactory. 

Treatment. — In the treatment of simple vaginitis, all that 

I required is to keep the patient in bed and to order vaginal 

louches of warm unirritating lotions, such as boracic acid 

3j or 3ij to the pint) or subacotatc of lead. 

For gonorrhceal vaginitis, a more energetic treatment 

|SiU5t be undertaken in order to abort the course of the 

r and diminish the tendency to complications. The 

I following will be found an eflective method: The patient is 

I anaesthetized and placed in the lithotomy position ; the 

[ vagina is then well irrigated with a solution of carbolic acid 

I (1 : 40); after which it is thoroughly swabbed out with a 

I solution of carbolic acid in glycerin {i : 10), or with a .solu- 

i of chloride of zinc {10 grs. to 5j); the cervix is simi- 

y treated, and a uterine probe may be dipped into the 

olution and applied to the uterine cavity. The vagina is 

I again irrigated with carbolic lotion (i : 40) or a satu- 

d solution of boracic acid; iodoform tampons are placed 

X^Sa/t vagina, and the patient sent back to bed. The aftcr- 

isists of douches, morning and evening, with 

boracic loliim. 

treatment under an anxsthetic cannot 



124 



DISEASES OF WOMEN. 



be applied, douches of carbolic acid (i : 40) should be 
ordered morning and evening; it is not advisable that much 
force should be used, lest toxic discharges be forced up into 
the cervical canal, 

A milder method, often serviceable when there is much 
pain and tenderness, is a course of hot sitz-baths, twice 
daily. In children it is advised that, in the acute stage, care 
should be taken that the child's head be not immersed in 
the bath, lest the eyes become contaminated by the dis- 
charges. After bathing or syringing, iodoform bougies 
may be placed in the vagina, each vaginal bougie contain- 
ing 3 grs. of iodoform. For children smaller bougies are 
employed. Chronic vaginitis is not seen except in associa- 
tion with chronic endometritis, and its treatment is described 
with that of the latter condition. 

The treatment of complications must be carried out as 
may be required. 

An abscess in the vaginal zvall may be due to eirtension 
of pelvic cellulitis into the connective tissue of the vagina, 
and the abscess -cavity may remain connected with that 
from which it is derived or become cut off from it ; or it 
may be due to suppuradon in a vaginal cyst. The febrile 
symptoms and the redness of the vaginal wall over the 
swelling will point to its true nature. The treatment con- 
sists in evacuating the pus by means of a free incision. 

TUMORS AND CYSTS OF THE VAGINA. 

The vagina is rarely the seat of tumors : they belong to 
four genera: lipomata, myomata, sarcomata, and epitheli- 
oma. Lipomata and myomata are very rare. 

Sarcomata. — Examples of this genus occur in adults; 
it appears that they are rare before forty years of age. 
They are sessile, ulcerate early, and bleeding is the first 
sign which attracts attention (Gow). In children they have 
a tendency to be polypoid. They cause death by interfer- 
j ing with the bladder or rectum (D'Arcy Power). 





Bpitbelloma. — This disease may arise in any part of 
ihc vagina! mucous membrane, but it is more liable to 
begin at the junction of the vulva and vagina, or on that 
portion which is reflected over the cervix uteri. When 
epithelioma attacks the vulvar end of the vagina, it is very 
apt to begin near the urethra! orifice. In such cases the 
inguinal lymph-glands are early infected; the ulceration 
quickly involves and perforates the vesico-vaginal septum 
and leads to a fistula. When the posterior wall is attacked, 
ulceration leads to a recto-vaginal fistula. 

It is very extraordinary that the early stages of this 
fatal disease cause so very little inconvenience that patients 
rarely seek advice until the disease has long passed the 
limits of justifiable surgery. 

Cysts. — The vagina is liable to the following species: 
mucous. Gartnerian. and peri-urethral cysts, and echino- 
coccus colonics. 

Mncons Cysts. — These are small and resemble retention 
cysts, but their nature is doubtful. Some observers con- 
sider them as retention cysts of vaginal glands ; others 
deny the existence of such glands and explain these cysts 
as due to obliteration of the mouths of crypts in the vaginal 
wall. By others, again, thfey are regarded as due to dila- 
tation of lymphatic spaces, and are described as associated 
with gaseous bullK in the condition called emphysematous 
vaginitis. 

They occur not infrequently in cases of vaginitis and 
endometritis, resembling superficially the Nabothian fol- 
hcles seen on the cervix. 

Gartnerian Cysts. — The pathology of these cysts is 
described in connection with the parovarium. 

Cysts arising in the terminal segment of this duct pro- 
ject as soft fluctuating swellings in the upper part of the 
vagina; sometimes two distinct cysts ari.sc in connection 
with one duct. They vary greatly in siiie ; some do not 
measure more than two centimetres in diameter, others may 



126 



D/SEASES OF ll'OMEN. 



exceed these dimensions three or four times. The inner 
wall of the cysts is lined either with cubical or stratified 
epithelium, 

Peri-urethral Cysts.— Small cysts are sometimes found 
in the anterior vagina! wall near the urethra : sometimes they 
bulge into the urethra. Skene is of opinion that these cysts 
arise in the ducts which he detected and described In the 
floor of the urethra near the meatus. 

Bchinococcas Colotiles {Hyilatiiis). — These are very 
rare and are generally due to cchinococcus colonies in the 
mcsomctriuni burrowing in the recto-vaginal septum. 

Treatment. — This is the same as that employed for tu- 
mors and cysts in other regions of the bod)' — namely, re- 
moval — but in the case of sarcomata and epithelioma it is 
rare for the disease to come under observation before it has 
so deeply involved the rectal and vesical walls that inter- 
ference with it only anticipates the complications which en- 
sue in the natural course of the disease, — rectal and vesical 
fistulse. Cysts when small arc readily enucleated, and the pro- 
ceeding is safe if the operator keeps close to the cj'st-wall. 
In the case of large Gartnerian cysts which burrow from 
the vagina into the mesometrium, unless great care is exer- 
cised the ureter may be easily dhmagcd and a troublesome 
fistula result. When there is difficulty or anxiety in enu- 
cleating vaginal cysts, the surgeon may freely incise them, 
evacuate the contents, and stuff the cavity with gauze; the 
cyst is then slowly obliterated by granulation. This method, 
however, though safe, is rarely certain, for the rent in the 
wall may close and the cyst re-form. Enucleation of the 
whole of the cyst-wall is the only sure method of treat- 
ment. 



CHAPTER XIV. 

DISEASES 0¥ THE UTERUS. 

AGE-CHANGES; FLEXIONS AND DISPLACE- 
MENTS. 

Age-changes. — The uterus undergoes some important 
changes between birth and puberty. In the new-born in- 
fant the uterus has no fundus, Us 
summit is often deeply notched, 
and the neck of the uterus is 
larger than its body. The arbor 
vitee is very distinct. The body 
of the uterus lies above the level 
of the brim of the true pelvis, and 
its anterior surface forms a well- 
marked curve where it rests on 
the urinary bladder. Toward pu- 
berty the fundus develops, and the 
organ assumes the pear-like shape 
so characteri-stic of the mature ute- 
rus (Fig. 34). After the meno- 
pause, it shares in the general 
atrophy ofthe reproductive organs. 
The cervi.v especially diminishes in 
size until it becomes merely a 
small button-like projection at the 
inner end ol the vagina. ihe uunn mod ihc •djHim pan or 

Measurements. —The fully- ;?;,7h^"/ ""'''"■ *""'""" 
developed virgin uterus has the 

following average dimensions: length, 3 in. (7.5 cm.); 
breadth, 2 in. (5 cm.); thickness, i in. (2,5 cm.); length 

117 




128 DISEASES Of WOMEN. 

of cavity, 2j in. (6.2 cm.); weight ij ounces (43 grammes). 
After pregnancy the uterus never regains its virgin propor- 
tions and remains, until the menopause, enlarged in all its 
measurements and increased in weight. 

FLEXIONS AND DISPLACEMENTS OF THE 
UTERUS. 

It has been customary to include anteversion among the 
displacements of the uterus ; as this is the normal position 
of the uterus, and never gives rise to symptoms, it will be 
omitted from the list of pathological conditions. 

We have then to consider the following: Anteflexion; 
Retroflexion ; Retroversion ; Prolapse and Procidentia. 

Anteflexion of the Uterus. — This, when moderate, is 
normal ; it becomes abnormal when exaggerated. 

Causes. — It is most often congenital; less often it is due 
to parametritis involving the utero-sacral ligaments. The 
subsequent cicatricial contraction may draw this portion of 
the uterus backward, causing anteflexion. 

Symptoms. — Even a considerable degree of anteflexion 
may exist without causing any trouble, especially in the 
young. When symptoms are present they are — (i) dys- 
menorrhcea; (2) sterility; (3) reflex nervous phenomena. 
The way in which dysmenorrhcea is produced is not quite 
plain. It has been attributed to obstruction to the outflow 
of blood by the projecting angle ; but this is improbable, 
for in the first place the menstrual flow in these cases is 
always moderate and even scanty, and the amount of blood 
passing at any one time is therefore small ; and in the 
second place obstruction would necessarily cause accumu- 
lation behind the ob.struction.and this never occurs. More 
probably the pain is caused by the contraction of the muscle 
fibres at a disadvantage. The dysmenorrhcea generally 
comes on some years after the first establishment of men- 
struation. 

Sterility is due partly to the fact thai congenital ante- 




DISEASES OF THE UTERUS. 



flexion is generally associated with under-development of 
the uterus, and a pinhole os; but it may also result from 
the tilting forward of the cervix ; for when the canal is 
straightened and the cervix points backward, conception 
sometimes follows. 

Reflex nervous phenomena are not uncommon ; one of 
the most frequent is bladder-disturbance. 

On examination the fundus is felt like a knob just in 
front of the cervix, and between the two the tip of the fin- 
ger rests in a well-defined angle. The sound is arrested at 
the internal os, and in order that it may pass to the fundus 
it may require to be sharply bent forward, for the canal of 
the cervix often makes a right angle with that of the body 
of the uterus. Two varieties of anteflexion are found: in 
one, the cervix is in its normal position, whilst the fundus is 
bent forward and downward {Fig. 35, III) ; in the other, the 
fundus is in normal position, while the cervix is bent for- 
ward and upward (Fig. 35, II). 

Treatment. — Vaginal pessaries are absolutely useless. 
Two courses are open : first, dilatation of the cervical canal ; 
secondly, a plastic operation. The dilatation should be 
carried up to 12 mm. It has the effect of straightening the 
canal. It may be necessary to repeat the dilatation after a 
few months, or to pass a few smaller dilators from time to 
time. In virgins these repeated manipulations are a disad- 
vantage. Plastic operations include the division of the cer- 
vix, by a single median incision or bilaterally. 

Retroflexion of the Uterus. — This occurs, rarely, as 
a congenital condition; more often it is a complication of 
retroversion (Fig. 35. V). In the former condition, if the 
fundus of the uterus be brought forward, for instance by 
the sound, it springs back into the faulty position as soon 
as the sound is withdrawn. But when associated with ret- 
roversion there is at first free hinge-like movement at the 
internal os, and the fundus, if replaced, remains in the new 
position. If it remain long retroflexed this mobility be- 




DrsKASES OF THE UTEKUS. 

defecation, and constipation, due to the pressure of the 
fundus on the rectum. 

Sterility is not a prominent symptom of retroflexion. 

Treatment. — If the uterus be freely movable, as indicated 
above, the flexion should be first corrected by digital 
manipulation, or failing this by the sound, and a Hodge 
pessary introduced. Special care must be taken lest the 
uterus be brought into a position of antevcrsion while 
the flexion remains unreduced (Fig. 35. VI). The posi- 
tion of the cervix must accordingly not be taken as a 
guide, but the fundus must be felt bimanually in front 
of the cervix. 

If the uterus be rigid, a Hodge pes.sary will not correct 
the flexion ; dilatatioji of the cervix is then the proper 
treatment, and a Hodge pessary may be subsequently 
applied, or a plastic operation may be undertaken, such 
as hysteropexy. 

Retroversion of the Utems. — Retroversion of a nor- 
mal-.sized uterus is, under certain circumstances, physiologi- 
cal; for instance, in a patient lying on her back with a full 
bladder. In such a case it is not an uncommon thing to 
find, on making a second examination a few days later, that 
the fundus is lying forward. The same thing may occur 
with a uterus that is slightly enlarged, as in early preg- 
nancy, and during the early weeks after labor. These con- 
ditions, therefore, require no treatment. In other cases 
retroversion is a pathological condition. 

Causes. — 1. Relaxation of the uterine ligaments, as the 
effect of repeated pregnancy. The utero-sacral, round, and 
broad ligaments are all involved, for if any one pair of the 
three retained its normal tension, retroversion would be 
resisted. 

2. Increased weight of the fundus, due to chronic con- 
gestion, subinvolution, pregnancy, or myomata. 

3. Cicatricial contraction following pelvic inflammation ; 
such as shortening of the utero-sacral ligaments when the 



132 DISEASES OF WOMEN. 

round ligaments are relaxed. If these remain tense, ante- 
flexion is produced instead. 

4. Pressure on the front of the uterus, due to an ovarian 
or other tumor, or to a frequently over- distended bladder. 
A wandering spleen lodged in the pelvis has sometimes 
caused the same result. 

S- Retroversion is in rare cases due to a fall or sudden 
strain ; it is a question whether this cause can operate with- 
out the predisposition indicated under paragraphs 1 and 2. 

Symptoms. — These vary according as the retroversion is 
simple or complicated by pelvic inflammation or fixation. 
Among the symptoms caused by a movable retroverted ute- 
rus, there may be sudden pain, if the displacement has been 
accidentally produced; otherwise the patient complains of a 
feeling of ill-defined weight and fulness in the pelvis, due, 
probably, to congestion. From the position of the fundus 
there is oiten discomfort during action of the bowels, and con- 
stipation. Bladder disturbance is not common unless the 
uterus is enlarged ; aud then there may be enough pressure 
of the tilted cervix again.st the base of the bladder to cause 
frequent desire for micturition with dysuria; followed by 
complete retention of urine. If the fundus remains for some 
time low in the recto-vaginal (Douglas's) pouch, the tubes 
and ovaries are dragged upon, and one or both of the latter 
may become " prolapsed ;" in that case dyspareunia is gen- 
erally complained of, as well as dysmenorrhoea, and ster- 
ility is usually present. 

When complicated with pelvic inflammation, the chief 
symptoms are — pain, often excessive and continuous; se- 
vere dysmenorrhoea ; irregular metrorrhagia, due to the 
fact that the uterus cannot contract properly ; abundant 
leucorrhcea, caused by the pelvic congestion ; general 
weakness, and secondary nervous disturbances. 

The reflex nervous disorders consequent on retroversion 

and retroflexion (for the two conditions are frequently com- 

l bined) require some notice. A list of them would com- 




DISEASES OF THE UTEKUS. 



prise all known functional disorders ; and. while the associa- 
tion of some of these with displacement may be considered 
as a coincidence, there are many which must be regarded 
as directly due to the uterine condition, as is shown by 
those cases in which reposition of the uterus is followed by 
immediate cessation of symptoms, whilst these come on 
again at once if the displacement recurs. The most fre- 
quent reflex neuroses are — digestive disorders, especially 
vomiting; cardiac disturbances; frequency of micturition 
and incontinence of urine; headache and neuralgia. In 
some cases of long standing, the restoration of the uterus 
to its proper position is not followed by improvement of the 
reflex disorders ; although the first appearance of these may 
have coincided with the commencement of the uterine trouble. 

Complkations. — Among these we might reckon the ner- 
vous disturbances Just referred to. The local complications 
include pelvic inflammation, prolapse of the ovaries and 
tubes, and hernia of the pelvic floor, — namely, cystocele, 
rectocele, and prolapse of the uterus. As we shall point 
out in discussing prolapse, retroversion of the uterus is 
nearly always the first stage in the production of that 
condition. 

Treatment. — The first thing is to replace the uterus, with 
the fingers alone if possible ; with the sound if necessary. 

Digital Manipulation. — Two fingers are introduced into 
the vagina and are made to press on the fundus, through 
the posterior vaginal fornix, in a direction forward and up- 
ward. If the uterus be fairly rigid the fundus can readily 
be tilted up by pressing backward on the front of the cer- 
vix. The fundus being raised by either method, the fingers 
of the other hand depress the abdominal wall above the 
uterus and bring the fundus forward, whilst the fingers in 
the vagina assist by pressing the cervix back. The manip- 
ulation may be assisted by placing the patient in the genu- 
pectoral position; and in difficult cases, when the use of 
the sound is contraindicated, this should be done. 



(34 DISEASES OF WOMEN. 

Replacement with the Sound. — The sound is passed with 
the concavity of the curve pointing backward. When 
the point is at the fundus, the handle is brought round to 
the front with a wide sweep, so that its intra-uterine portion 
rotates on its longitudinal axis, but does not otherwise 
move. On no account should the semicircle described by 
the revolving portion be made by the point of the sound. 
The handle is then gently and slowly drawn backward, in 
the middle line, toward the perineum, until the fundus can 
be felt with the hand on the abdomen. While the sound is 
being withdrawn, the finger in the vagina should be pressed 
against the cervix, to keep it in position. 

The uterus having been replaced, some form of Hodge 
pessary is then introduced, paying attention to several 
points. Thus the instrument must fit properly; it must 
be adapted to the width of the posterior fornix, and 
also to the length of the vagina. If too long, it is apt to 
press on the urethra, and cause difficulty in micturition; or 
it may pre.ss on the rectum and produce a tendency to con- 
stipation. If the vaginal walls are lax and the fundus 
heavy, the instrument is likely to be tilted up anteriorly, 
and the retroversion is reproduced. If an ovary is lying in 
the recto-vaginal (Douglas's) pouch it may be pressed upon, 
and much pain will result. An instrument made of block 
tin answers well; it is clean, and can be moulded to any 
desired shape. One or both of the posterior angles can be 
depressed to prevent pressure on the ovaries, and the an- 
terior bar may be indented so as to form an arch over the 
urethra. The relation of the breadth to the length of the 
instrument can also be adjusted, Asa rule the posterior 
bar should be made to project well forward and upward. 
When adhesions are present, treatment must be different. 
t'ObviousIy, to put in a pessary is to add risk to ineffi- 

l ciency. The one thing needful is to restore the mobility of 
the uterus. If time be no object, this may often be attained 

[ by a somewhat prolonged course of rest in bed, combined 




DISEASES OF THE UTERUS. 



with a depletory treatment by means of vaginal irrigation 
and tamponsofijIycL'rin, with or without ichthyol (5 to toper 
cent.). During this treatment an occasional attempt must 
be made to raise up the uterus ; for this purpose the sound 
may be used, but it requires to be employed with great 
care. After some time it will often be found that the uterus 
can be moved a little, and by degrees the normal position 
can be restored. When this occurs a Hodge pessary is in- 
troduced and kept in for some time. 

If suppurative disease of the appendages be present, the 
above treatment will generally be futile ; and until the of- 
fending organs be removed no permanent cure can be hoped 
for. 

Sometimes the adhesions, by long neglect, have become 
so firm that they cannot be overcome by the above means. 
An operation then gives the only hope of cure — namely, 
opening the abdomen, freeing the adhesions, and suturing 
the fundus to the abdominal wall (hysteropexy). This 
should not be lightly undertaken, but the risk attending it 
should be carefully weighed with the alternative of not 
operating, which may mean a life of chronic invalidism and 
impaired usefulness. 

Even when there are no adhesions, pessaries may, after 
long trial, entirely fail to relieve the retroversion and the 
attendant symptoms ; and here also operative interference 
may be required. Hysteropexy and the operation for 
shortening the round ligaments are the two principal 
methods of deahng with this condition. 



CHAPTER XV. 



DISEASES OF THE UTERUS (CoNrrNUED). 

PROLAPSE AND PROCIDENTIA; HYPERTRO- 
PHY AND ATROPHY OF THE UTERUS. 

The terms prolapse and procidentia arc applied to 
different degrees of the same condition : when the uterus, 
though low down, lies entirely in the vagina, it is spoken 
of as prolapse ; when it protrudes through the vulva, as 
procidentia. 

Causes, — All the causes of retroversion of the uterus, 
except cicatrical contraction due to pelvic inflammation, 
may be regarded as predisposing to prolapse, inasmuch as 
the former is the first stage of the latter. The exciting 
causes are — 

1. Increased intra-abdominal pressure, either continuous, 
as in the case of ascites and abdominal tumors, or inter- 
mittent, as from frequent straining efforts or a chronic 
cough. 

2. Weakening of the supporting structures of the pelvic 
floor, such as relaxation and hypertrophy of the vaginal 
walls and laceration of the perineum. A very patulous con- 
dition of the vulva, such as is met with sometimes in mul- 
tipara;, may have the same effect as a damaged perineum. 

3. Traction on the uterus from below, by the weight of a 
hypertrophied cervix, by a cervical tumor, or by repeated 
operative manipulations, whereby the uterus is drawn down. 

Pathology. — It occasionally happens, when the pelvis is 
large and the vaginal walls are very lax, that the uterus 
becomes prolapsed in a position of anteversion ; but this is 





DISEASES OF THE UTERUS. 1 37 

rare. The uterine canal is normally at right angles to the 
vagina, and in the great majority of cases the uterus must 
come to lie in the axis of the pelvic outlet before prolapse 
can occur to any extent. As long as it lies in the axis of 
the pelvic inlet, deficiency of the pelvic floor has no appre- 
ciable effect, and intra-abdominal pressure simply presses 
the whole uterus backward against the posterior vaginal 
wall and the sacrum. But, once retroversion takes place, 
the lack of perineal support is felt, and increased pressure 
leads to descent of the uterus toward the vaginal oriiice. 
The mechanism presents a close parallel to the delivery of 
the head during parturition in the unreduced occipito-pos- 
terior position : the long axis of the head does not conform 
to that of the pelvic outlet, and delivery is delayed ; whilst 
as soon as rotation forward of the occiput places the long 
axis of the head in relation to that of the pelvic outlet, 
descent is easy. 

As the uterus descends, it draws down with it the upper 
part of the vaginal walls, whereby the vaginal fornices are 
deepened. If the initial causes remain at work, and the 
vaginal orifice be large, either from stretching or from 
deficiency of the perineum, the cervi.x protrudes from the 
vulva (Fig. 36), and eventually the greater portion or the 
whole of the uterus comes to lie outside, covered by the 
vaginal walls reflected over it. In this way a mass the size 
of the closed fist may be found outside the vulva. 

When the whole vaginal attachment is very lax, the 
lower portion of the vaginal walls may take part in the pro- 
trusion, in the form of a cy.stocele and rectocele; whilst in 
exceptional cases the tubes and ovaries, the bladder, and a 
considerable portion of the intestines may come to lie in 
the hernial ma.ss. 

There is another mode of production of prolapse in which 
descent of the whole uterus is not the principal feature : but 
the first stage is hypertrophy of the supravaginal portion 
of the cervix — /. c. the part situated between the ititernal os 




DISEASES OF 



and the vaginal portion. In the course of the hypertrophic 
elongation, either the fundus must be pushed upward or 
the vaginal portion downward. The latter is the course of 
least resistance, and is consequently followed. In these 
cases the cervix may be low down, while the fundus is 
nearly in its normal position and the uterine cavity is found 
to be greatly lengthened (Fig. 37), Later the whole uterus 
may assume a lower position as the result of the increasing 



weight of the cervix. Authors difler in the relative influ- 
ence which they ascribe to these two conditions, primary 
descent and hypertrophy, in the production of prolapse; 
the difit-Tcnce is no doubt partly due to the fact that in 
q^es of primary descent a certain degree of secondary 
hypertrophy generally occurs. We believe that primary 
descent is the more frequent condition. 

Results of Ih-olapse and Proddenlia. — The continued re- 



DISEASES OF THE UTEJiUS. I39 

troversion leads to chronic congestion and hyperplasia of 
the whole uterus; but the effect is most marked in the 
cervix, which is less supported by surrounding structures 
and more exposed to the influences leading to chronic in- 
flammation. We find, therefore, chronic cervical catarrh 
and cervical hypertrophy in the majority of cases, whilst 
adenomatous disease is frequent. 

In cases of procidentia the cervix is greatly thickened. 
By the rubbing of the clothes and exposure to the air the 
exposed surface of the vagina and cervix is hardened and 
thickened, so that it comes to resemble skin, and patches 
of ulceration are not uncommon. Thtse may attain the 
size of a florin ; they have a clean, punched-out appearance ; 
the base and margins are smooth and the latter are neither 
raised nor undermined. When the protrusion has been re- 
duced and kept in position for some time, the hardened sur- 
face becomes moist and soft again, returning to its normal 
condition. 

Sigfis and Symptoms. — The patient complains of a feel- 
ing of "bearing down;" of trouble with micturition and 
defecation; of pain and fatigue in walking; and of "falling 
of the womb." When the uterus is low down, but still con- 
fined within the vagina, the symptoms are often more severe 
than in procidentia ; indeed, it is not uncommon to meet with 
patients who have been going about their work for a consid- 
erable time with a large mass protruding from the vulva. 
The signs are generally obvious. In the milder cases the 
cervix is felt to be low down in the vagina, the uterus being 
in a position of retroversion. The sound shows that the 
uterine cavity is lengthened, and the amount of lengthening 
will afford information as to the degree of hypertrophy in 
the case. A rectal examination will complete the informa- 
tion ; for when there is not much hypertrophy the level of 
the fundus will be ca.sily reached by the finger, whilst in 
cases of considerable hypertrophy the fundus may in this 
manner be felt to occupy nearly its normal position. 




^ The < 
^^^ subsit 
^B Pre 



DISEASES OF WOMEN. 

Procidentia is evident on inspection. The external os 

11 be found usually on the most prominent part of the 
and occasionally in front of or behind this point when 
the case is complicated by a large rectocele or cystocele. 

Diagnosis. — This is easy ; but procidentia may be sim- 
ulated by inversion of the uterus. Here the surface is 
redder and softer, and instead of the central orifice of the 
external os the two lateral orifices of the Fallopian tubes 
are seen. A large polypus may at first sight be mistaken 
for procidentia, but the ab.sence of an orifice and the 
presence of a pedicle leading up to the cervix will establish 
the diagnosis. It is important to determine whether the 
case is one of simple descent or of hypertrophy of the 
supravaginal cervix, as the treatment is different ; this may 
be done as above mentioned under the head of physical 
signs. It should be ascertained also whether there is any 
cause for the prolapse beyond deficiency of the pelvic 
floor and relaxation of ligaments; so that, if found, this 
may be dealt with. 

Tnatmenl. — A prolapsed uterus must first be placed in 
proper position, or a procidentia reduced. In many cases 
the introduction of a rubber ring pessary will then suflice 
to prevent recurrence. But it will often be found necessary 
to repair a torn perineum, removing at the same time re- 
dundant portions of the vaginal walls, before the ring will 
remain in the vagina. When such an operation is contra- 
indicated, and the vaginal orifice is so wide that a ring can- 
not be kept in, some form of pessary with a vaginal stem 
and perineal bands will be required {see Chapter XVI.). 

In cases of procidentia where the exposed surfece is 
much ulcerated, the patient should he kept in bed. emollient 
applications made to the ulcers, and vaginal douches given. 
When the ulcers have healed a pessary may be introduced- 
The congestion usually requires no special treatment, as it 
subsides when the uterus is maintained in a normal position. 

Procidentia due to supravaginal hypertrophy of the cer- 




DISEASES OF THE UTERUS. 14I 

vix must be differently dealt with : here complete reduc- 
tion is not possible, as even when the fundus is in normal 
position the cervix is low down. Amputation of a por- 
tion of the cervix must therefore form the first step in 
the treatment ; and it may be required also when the 
hypertrophy is secondary to descent. Cases of prolapse 
and procidentia which resist milder measures require further 
operative procedures, such as ventro- fixation of the uterus 
or the shortening of the round ligaments. It is in cases of 
this kind that hysteropexy has often given the most brilliant 
and satisfactory results. 

Alexander's operation succeeds, not by pulling up the 
uterus, but by maintaining the fundus in a position of ante- 
version. The first stage in prolapse, retroversion, being thus 
prevented, the prolapse itself is prevented. If the shorten- 
ing be not sufficient to cause anteversjon, it is useless; for 
the fundus is then able to move freely along an arc of a 
circle whose radius is determined by the length of the round 
ligaments, and whose centre is at the symphysis. The arc 
corresponds closely to the pelvic axis. 

Total extirpation of the uterus has been advised and 
practised for the treatment of procidentia. The operation 
is under the circumstances singularly easy, but the ques- 
tion of the justifiability of so radical a measure is an im- 
portant one. 

HYPERTROPHY OF THE CERVIX UTERI. 

This presents two varieties according as the supravaginal 
or vaginal portion of the cervix is affected. 

Hypertrophy of the Supravaginal Portion. — This 

may occur as a primary or secondary condition. 

When primary it may in some cases be inflammatory in 
its origin, and some authors have supposed it to be so in 
every case. But we think' it doubtful whether metritis often 
has this efiect, and prefer to regard the origin as unex- 
plained. Specimens examined after removal have some- 




resulting condition is the same. The cervical portion of 
the uterine canai is elongated. The vaginal portion of the 
cervix retains its proper length, or may be slightly elon- 
gated ; but a false appearance of great lengthening is pro- 
duced by the dragging down of the vaginal fomices by the 




cervix as it descends (Fig. 38. a). For the same reason the 
vagina is always shortened. 

The symptoms and physical signs are those of prolapse- 
The proper treatment i.s amputation of the cervix. 

Owing to the close attachment of the bladder to the 
anterior surface of the uterus, it remains in front of the cer- 
vix as it lengthens ; and a sound introduced into the bladder 
may be felt to pa.ss down apparently in the substance of 
the anterior part of the cervix. Similarly, the peritoneum 
is closely connected with the posterior surface, and the 
rectovaginal (Douglas's) fossa becomes deepened when the 




I 



DISEASES OF WOMEN. 

cervix lengthens, so that a process of peritoneum may be 
found under the vaginal reflection on the posterior surface 
of the cervix. These facts require to be borne in mind in 
amputation of the cervix, lest the bladder be injured. The 
opening of the cttlom (peritoneal cavityj is less serious, and 
is perhaps in most cases unavoidable. 

A distinction is made by many Continental writers be- 
tween hypertrophy of the supravaginal portion proper, and 
the part which they describe as 
the intermediate portion (Fig, 
39). The former is said to cause 
obliteration of both vaginal for- 
nices (Fig. 37), whilst in the lat- 
ter variety the po.sterior fornix is 
preserved (Schroeder). In the 
form which we are now about to 
describe both forniccs remain. 

Hypertrophy of the Vagi- 
nal Portion of the Cervix. — 
This i.s often spoken of as the 
mfrm'aginal portion ; the above 
term is more correct. A small 
degree of hypertrophy often oc- 
curs, as previously stated, in connection with chronic cer- 
vical catarrh and erosion ; the enlargement is then more 
strictly speaking due to inflammatory infiltration, with 
thickening of the glandular tissues, and we need not dwell- 
on it further. 

Hypertrophy proper is a developmental or congenital 
condition, but it is described here instead of in the chapter 
on Malformations for convenience and for the sake of com- 
parison with the previous condition. The growth takes 
place principally at the time of puberty, and nothing is 
known as to its causation. It is generally associated with 
stenosis of the external os, which presents the "pinhole" 
type. The elongation may be so great that the cervix 




39. — Diognn af the thri 
flhE iiteiini uctk (SthrDedci] 



DISEASES OF THE UTERUS. 



1 45 



protrudes through the hymen. The vaginal reflection is 
attached to the base instead of near the apex of the hyper- 
trophied portion, and consequently the length of the vagina 
is not diminished (Figs. 38, b, and 40). This serves as a 
striking distinguishing feature between this and the form 
of hypertrophy previously described. The bladder and 
recto-vaginal pouch retain their normal positions and thus 




diminish risk of either being wounded during the opera- 
tion of amputation. 

The symptoms to which it gives rise are a sense of dis- 
comfort and the feeling of a foreign body in the vagina ; 
sometimes it causes dysmenorrha-a, menorrhagia, and leu- 
corrhoea. But in some cases, if the cervix remains within 
the vagina, no symptoms may be complained of till afier 



146 DISEASES OF WOMEN. 

marriage, when it gives rise to dyspareunia. The diagnosis 
is a matter of no difficulty when the length of the vagina 
has been ascertained. The only possible treatment is am- 
putation of the cervix. 

ATROPHY OF THE UTERUS. 

Atrophy occurs normally after the menopause, and may 
proceed to such an extent that the cervix entirely disap- 
pears, leaving only a small aperture in the vaginal summit 
to represent the external os, while the fundus may shrink 
till it becomes a mere knob surmounting the vagina. The 
menopause may occur prematurely, but otherwise naturally, 
in women who have not borne children, and in whom con- 
sequently it cannot be ascribed to supcrin volution ; and in 
these cases a similarly marked atrophy may take place. 

Atrophy may follow also an artificial menopause, pro- 
duced by the removal of the tubes and ovaries, or by a 
disease destroying their functions, such as pelvic inflamma- 
tion, salpingitis, and ovaritis. Certain constitutional con- 
ditions produce the same result, especially tuberculosis and 
chlorosis, less frequently diabetes, Bright's disease, chronic 
morphinism, insanity, and other central nervous disorders. 
Lastly, it occurs in the form of superin volution after de- 
livery (see p. 163). 



CHAPTER XVI. 



PESSARIES. 



A PESSARY is an instrument used to support the pelvic 
organs in cases of hernia of the pelvic floor, or to maintain 
in a normal position a uterus which has a tendency to flex- 
ions or displacements. 

Pessaries must be regarded as a palliative method of 
treatment, though at times a radical cure may be effected 
by their means. In late years their use has been restricted 
by the introduction of operative measures; but operations 
are in some cases contraindicatcd by the age or ill-health 
of the patient or by her unwillingness to submit to them, 
whilst in other cases they fail to relieve the condition for 
which they are undertaken. Pessaries remain, therefore, 
indispensable, though they should be used as seldom as 
possible. 

To be eflectual. a pessary must answer the following 
requirements: 

1. It must maintain the normal position of the uterus and 
vaginal walls, and relieve symptoms. 

2. When it is in its place the patient should be uncon- 
scious of its presence. 

3. It must be light, smooth, not acted upon by the 
uterine and vaginal secretions, and not irritating to the 
vaginal walls. The best materials for this purpose are alu- 
minum, vulcanite, block tin, celluloid, and hardened india- 
rubber. The last three have the advantage that they can 
be moulded to any required fonn; in the case of celluloid 
and india-rubber this is done by immersing them in boiling 





r 




DISEASES OF WOMEN. 

water, when Uiey become soft, regaining their rigidity on 
cooling. There are three types of pessary in general use. 

The Ring Pessary (Fig. 41).— This should be made 

of good hard rubber, with a central wire spring, so that it 

may be compressed to faciUtate 

introduction and may regain its 

sliape when released. 

It is used for cystocele, rec- 
tocele, and uterine prolapse — 
/. 1*. for hernia of the pelvic floor. 
It should not touch the bony 
parts of the pelvis, but should 
slightly stretch the lateral vaginal 
walls. It depends for its efficacy 
on the integrity of the posterior 
vaginal wall and the levator ani, 
and is useless when the perineum is much lacerated; for 
then it comes out as soon as the patient strains, as during 
coughing, sneezing, and defecation. The same result fol- 
lows if the ring be too small, whilst if too large it interferes 
with the action of the bladder and rectum and may cause 
vaginal ulceration. 

A rubber ring should not be left "/ situ longer than six 
months without being seen to ; for the rubber tends to 
become rough and corrugated, leading to irritation of the 
vaginal mucous membrane and profuse leucorrhcea. In 
some cases this effect follows in a shorter time, three or 
four months; in others a pessary of the best rubber may 
be worn for a year without inconvenience. 

The Hodge Pessary.— This is, in surface aspect, rec- 
tangular, with the upper angles rounded; in profile it 
resembles an opencd-out S (Fig. 42). It is used for back- 
ward displacements of the uterus, when the uterus is 
movable. It may be made of vulcanite, aluminum, cellu> 
loid, or block tin ; the two latter will be found most con- 
venientj as it is often necessary to slightly modify the shape 




Tic. 4).— a Elyurin posary, Hi^gr p,ittem. 

means of pessaries is that the instrument should fit. 



ISO 




DISEASES OF WOMEN. 



Modes of Action. — Like the ring, the Hodge pessaty 
should not touch any bony points, Tlie action is described 
as that of a levtr, thi; middle portion of the pessaty resting 
against the posterior vaginal wall and forming the fulcrum ; 
the intrapelvic pressure acts in a direction downward and 
backward, mainly against the Jower portion of the pessary-. 
and this tends to tilt the upper end forward and upward 
against the posterior surface of the body of the uterus. 
Another influence is exerted also: when the posterior 
vaginal fornix is pushed upward, the cervix is drawn back- 
ward, and if the uterus be fairly rigid, the fiindus is in this 
way tilted forward. The backward pressure of a heavy 
uterine body is also resisted, through the lever action of the 
Hodge pessary, by the anterior vaginal wall, as long as this 
is not much relaxed. It is in harmony with this explana- 
tion that the crescent-shaped instrument is used, with the 
lower end pointidg forward; but pressure on the urethra 
must here be specially guarded against 

The Vaginal Stem Pessary. — This consists of a cup 
or ring mounted on a stem, the lower end of which projects 
from the vulva, and has attached to it perineal bands which 
pass forward and backward to be fastened to the waistband 
(Fig. 44). Such an instrument is sometimes used for pro- 
lapse of the uterus or vaginal walls when the perineum is 
so deficient that a ring cannot be retained and the age or 
other conditions of the patient do not allow of repair of 
the perineum. Zwaneke's pessary is on the same principle, 
but has the disadvantage of being difficult to keep clean. 

Contra-indications to the Use of Pessaries. — No 
pessary should be used when there is any inflammatory 
condition of the genital organs, — pain and irritation would 
be the result. In the unmarried pessaries are undesirable 
except when symptoms are severe and there is a strong 
probability of cure by their means. When the uterus is 
fixed, pessaries are harmful as well as useless ; it is vain to 
hope that they will overcome adhesions. So. also, when 



PESSARIES. 



<Si 



the uterus is markedly retroflexed as well as retroverted it 
is useless to put in a Hodge pessary unless the flexion be 
first corrected: for all that would result would be an ante- 
vith retroflexion. Whatever the position of the 




uterus, a pessary should not be introduced unless the mal- 
position gives rise to symptoms. 

Retained Pessary. — The first efTcct of a pessary long 
retained is vaginitis ; if the vagina has not been kept clean 
by douching, the discharges become purulent ; the pessary 
hinders their exit, and comes to lie ultimately in what is 
practically an abscess-cavity. The bad effects are aggra- 
vated by the contraction of the vaginal orifice which occurs 
at the menopause. If the pessary be a ring or a Hodge, 
the vaginal wall in contact with it becomes ulcerated, so 
that there results a groove lined with granulations. These 
tend to grow up around the pessary, and may at length 
grow over and fuse, forming a bridge of tissue holding the 
pessary firmly imbedded in the vaginal wall. In the case 
of a flattened pessary with perforations the granulations 
may in like manner sprout and project through the pcrfora- 



152 DISEASES OF WOMEN. 

tions, forming bands between the anterior and posterior 
vaginal walls. In this way it may no longer be possible to 
remove the pessary without considerable violence, whilst 
this result is contributed to also by the narrowing of the 
vaginal outlet. The pus becomes offensive ; and, if the 
cause of irritation be not removed, constitutional symptoms 
indicating septic absorption may arise. 

The length of time required for a pessary to set up such 
ulceration varies with the shape of the pessary and with 
the frequency or otherwise of douching; in the absence of 
douching a few months may suffice for the production of a 
considerable groove, esjjecially in the case of a tightly- 
fitting pessary with a narrow edge. 



CHAPTER XVII. 
DISEASES OF THE UTERUS (CoxtINUed). 

INVERSION OF THE UTERUS. 

A UTERUS is mverted when it is turned inside out ; this is 
true in two senses, for, as the organ inverts, its fundus 
passes into the vagina and is protruded beyond the vulva. 

Inversion of the uterus is only possible when its cavity 
is dilated ; that is, during pregnancy or when a polypus is 
present. In by far the greater proportion of cases the con- 
dition is a complication of delivery at term, and is nearly 
always due to an unskilled individual dragging upon the 
cord of a stiU adherent placenta. Although this variety 
of inversion belongs to the province of obstetrics, it is 
necessary to briefly review its leading feature.^. 

The inversion may be partial, the fundus not extending 
beyond the mouth of the uterus ; it may extend through 
the OS uteri into the vagina ; or the inversion may be so 
complete that the uterus from mouth to fundus is turned 
inside out (Figs. 45,46). In a complete case of acute inver- 
sion, as it is called when it follows immediately on delivery, 
the outer surface is formed by the mucous membrane of 
the uterus, and is ragged, vascular, and bleeding, and the 
inner or uterine ostia of the Fallopian tubes are visible. 
The interior of this large sac is lined with peritoneum and 
contains the round ligaments of the uterus with the Fallo- 
pian tubes ; the ovaries, as a rule, remain on the edges of 
the sac. In some instances small intestine and omentum 
drop into the cavity. The manner in which the tubes and 




presence of the tumor distends the cavity of the uterus and 
the polypus is pushed into the cervical canal by the muscu- 
lar efforts of the uterus ; this traction under favorable 
mechanical conditions produces inversion of the fundus, and 
finally the polypus with the inverted fundus makes its ap- 
pearance in the vagina or even protrudes beyond the vulva. 



1S6 DISEASES OF WOMEN. 

When the inversion takes place gradually it is termed 
chronic. 

Acute inversion of the uterus is always a grave accident; 
many patients die in a few hours from shock or loss of 
blood. In years gone by the inverted mass has been cut 
away by practitioners in ignorance of the nature of the 
accident. When the patient escapes the immediate dangers. 




ulceration, sloughing, bleeding, and exhaustion destroy her 
in a few weeks or months. 

Chronic inversion of the uterus has a different history. 
The patient suffers from menorrhagia or metrorrhagia, leu- 
corrhcea, and vesical troubles, which lead to an examination, 
and the tumor-like ma-ss is detected in the vagina. In 
many cases its nature is recognized, but this is not always a 
simple matter. 

Care must be exercised — 




Ii To distinguish between an inverted uterine fundus and 
a uterine polypus. 

2. To recognize a case in which a polypus is responsible 
for the inversion of the uterus. 

A submucous myoma protruding through the os uteri 
often strikingly resembles a partially inverted fundus. 

In cases of acute inversion there should be no difficulty 
in diagnosis, but when the inversion is of long standing the 
exposed surface becomes grayish-white like skin. 

In partial inversion great caution in diagnosis is neces- 
sary, but with the help of the sound the difficulty is easily 
surmounted. When the sound is introduced through the 
mouth of the uterus between the inverted fundus and the 
uterine wall, it is arrested at less than its normal length ; in 
the case of a polypus it will pass to the full length, or more 
often to a greater distance. 

In some cases, especially when the patient has a thin 
belly-wall, a cup-like depression can be felt to replace the 
natural convexity of the uterine fundus. Sometimes this 
depression can be detected by a finger introduced through 
the rectum. In doubtful cases an examination under ether 
is desirable, and if necessary the urethra can be dilated and 
the condition of the uterus determined by a finger intro- 
duced into the bladder. 

Treatment. — In recent cases reduction of the inversion 
may often be effected by taxis. The patient is placed under 
an anesthetic and steady pressure made by the fingers on 
the walls of the uterus, near the cervix. The principle on 
which taxis is applied for this condition is the same as that 
in reducing a hernia, namely, the part last inverted should 
be returned first. 

When inversion is chronic there appears to be more risk 
and difficulty in immediate reduction, and it is customary to 
use an instrument called a repositor (Fig. 48). This instru- 
ment consists of a perforated cup-shaped disk fitted on a 
stem which may be straight or furnished with a perineal and 



158 D/SEASES OF WOMEN, 

a pelvic curve. The lower end of the repositor permits of 
the attachment of elastic bands connected to a waist-belt 
supported by braces which pass over the shoulder. When 
in use the waist-belt is fitted to the patient and secured by 
the braces. The cup of tlie repositor is adjusted to the 
fundus of the inverted uterus, and the elastic bands fixed to 
the repositor and waist-belt maintain a continuous pressure. 




The patient is kept in bed, and, if the proceeding causes 
pain, morphia injections may be given. At intervals of a 
few hours the amount of progress is observed and the 
bands are readjusted. As soon as tlie fundus is reduced 
to the level of the internal os it is desirable to change the 
cup of the repositor for a smaller one. for when reduction 
is complete a large cup is imprisoned in the uterine cavity 




msEASES OF THE UTERUS. 



159 



and is sometimes so firmly held as to cause difficulty and 
anxiety in its extraction. By means of the repositor an in- 
verted uterus may be reduced in twenty-four or forty-eight 
hours, even when the inversion has existed for some years. 
When inversion is due to a polypus the latter is excised 
before reduction is attempted. 



CHAPTER XVIII. 

DISEASES OF THE UTERUS (Continued). 

INJURIES OF THE UTERUS; DISEASES RE- 
SULTING FROM GESTATION. 
I,aceration of the Cervix.— C<(/«t.s.— laceration is 
sometimes produced by operations on the cervix, but in the 
vast majority of cases it occurs in childbirth. The imme- 
diate causes are precipitate labor, a large or well-ossified 
foetal head, and the application of forceps before dilatation 
of the cervix is complete. A natural labor may result 
laceration when the distensibility and elasticity of the cervi 
are impaired by disease, such as carcinoma and chroni 
inflammation. 

Results of Laceration. — When a cervix is torn (as during 
labor) the raw edges become healed over by granulation 
and cicatrization, but as a rule 
without uniting. The resulting 
fissure does not necessarily give 
rise to symptoms, even if deep 
or bilateral. For the cervical 
mucous membrane may grad- 
ually acquire the characters of 
the vaginal epithelium; the ex- 
,tema! os retreats, as it were, 
toward the internal, while the 
anterior and posterior lips of 
Fio. w-i!^ia.i™M/i«ra,ion or ihe ^^^ ccrvlx bccome in reality 
lips or lappets, which can be 
readily separated to a greater or less extent (Fig. 49). A 




D/SF.ASES OF THE UTERUS. l6l 

cervix in this condition is not uncommonly discovered 
when a vaginal examination is made on account of other 
symptoms. 

But the lesion may take a less favorable course. The 
exposed cervical mucous membrane may become unhealthy, 
either alone or as part of a general endometritis ; it then 
becomes congested, and, in consequence, the lips become 
separated. The tendency to separation is exaggerated if 
there be a marked coincident flexion of the uterus. The 
everted mucous membrane is then bathed in the unhealthy 
secretions (arising partly from the uterus) found in the 
vagina; and it is but a short step from this condition to 
that of erosion, with the formation of the cysts known as 
Nabothian follicles. The congestion and cedenia of the cer- 
vix commonly spread to the body of the uterus, which 
becomes heavy and enlarged, resembling the condition 
found in subinvolution. With the chronic endometritis and 
metritis so produced is frequently associated prolapse of the 
ovaries into the recto-vaginal pouch ; especially when there 
is also retroflexion. Tlie ovaries share in the congestion 
and become unduly sensitive. 

Signs and Symptoms. — A lacerated cervix does not, as 
such, give rise to symptoms, except, occasionally, bleeding 
in recent cases. Such symptoms as are present depend on 
the accompanying endometritis, and include leucorrhcea, 
sacral aching, a feeling of weight and '" bearing down " in 
the pelvis, and dyspareunia. 

From lime to time lacerations have been held responsible 
for many reflex neuroses ; we believe this to be entirely 
erroneous ; for although such neuroses have disappeared 
after repair of the cervix, the improvement must be attrib- 
uted to the simultaneous curing of the inflammatory con- 
dition. 

A laceration is readily detected by digital examination 
and may be seen by the use of the speculum. Lacerations 
vary in nature and extent. There may be a split on one 



l63 



DISEASES OF WOMEN. 



side only, the cleft extending only a short distance from the 
external os, or reaching up to the junction of the cervix 
and vagina. It is more frequent on the left side, running a 
little forward, and sometimes bifurcated externally; and 
this is attributed to the greater frequency of the left occip- 
ito-anterior position of the child during delivery (Fig. 50, a). 
An occi pi to -posterior position will cause a laceration of the 
posterior lip (Fig. 50, .b). In other cases this split is bilat- 
eral, so that the cervix presents well-marked anterior and 




posterior flaps (Fig. 50, i>); or several fissures may be 
found, radiating from the external os (Fig. 50, c). A Fer- 
gusson's speculum somewhat masks the extent of lacera- 
tion by holding the lips in contact; some form of bivalve 
speculum gives, therefore, a better view. The presence of 
a complicating endometritis will be determined at the same 
time. 

A bilateral l.iceration with considerable cversion of the 
mucous membrane may resemble adenomatous disease with 
but slight laceration, because the two lips cannot be brought 
together ; on relieving the congestion by scarification the 
true condition will be recognized. 




D/SEASES OF THE UTERUS. 



Treatment. — When no inflammatory conditions are present 
no treatment is required, except as a prophylactic measure. 
Inasmuch as laceration predisposes to endometritis, it may 
oflen be considered advisable to repair the rent with a view 
to diminishing the risk. 

When the laceration is followed by the more serious 
results above described, the operation of trachelorrhaphy 
or repair of the cervix is indicated. 

Perforation of the Uterus.— This may occur as the 
result of the incautious use of the sound or of metallic di- 
lators ; even when carefully used a sound may pass through 
the uterine wall in some diseased conditions where the wall 
is soft, friable, or thin, as in sarcoma, carcinoma, and cystic 
degeneration of the chorion (hydatid mole). When this 
accident occurs the sound passes considerably beyond the 
normal distance, and its point may sometimes be felt under 
the abdominal wall. Bleeding may result, but it is seldom 
considerable. With a clean instrument and a fairly healthy 
uterus no untoward symptoms may follow, but in the 
opposite conditions septic peritonitis may be set up, with 
serious or fatal results, 

DISEASES RESULTING FROM GESTATION. 

Superinvolution. — This signifies premature atrophy of 
the uterus following delivery. It is brought about by de- 
bilitating causes, such as multiple and frequent pregnancies, 
post-partum hemorrhage, and prolonged lactation. Some- 
times there is no apparent cause. 

The condition may bo permanent, leading to a premature 
menopause ; or temporary, the uterus regaining its proper 
size as the patient recovers strength. The only symptoms 
are diminution or cessation of menstruation, and sterility. 
On physical examination the uterus is found to be small. 
The diminution affects the substance of the uterine walls 
rather than the length of its cavity ; consequently the 
bimanual examination gives more reliable information than 




1 64 DISEASES OF WOMEN. 

the passage of the sound; and for the same reason extra 
care is required in the use of the sound, as the thin and 
often softened walls are easily perforated. 

Treatment. — We must rely principally on hygienic meas- 
ures and the administration of tonics; the prognosis, how- 
ever, is not very favorable. 

SabinTOlation, — By this is meant a condition in which 
the return of the uterus to its proper size after delivery is 
arrested. 

Causes. — Subinvolution may be due to — 

(i) Debility brought about by malnutrition; by a severe 
and lengthy labor; by post-partum hemorrhage; or by 
too early resumption of active duties after delivery. 

{2) Chronic endometritis preceding labor. Post-partum 
hemorrhage is very likely to occur in such a case, and it 
must then be regarded, not as the cause of subinvolution, 
but as the result of conditions leading also to subinvolu- 
tion. Indeed, it is po.ssible that the relation of hemor- 
rhage and subinvolution should always be regarded in this 
way. 

(3) Puerperal endometritis. 

/"d/Atf/o^'.— Subinvolution presents two varieties, depend- 
ing on its origin, whether inflammatory or trophic. In the 
trophic variety the muscle-fibres are large and pale, and 
the intermuscular tissue and mucosa are cedematous. The 
vessels and lymphatics are dilated from the want of proper 
muscular contraction. For the pathology of the inflamma- 
tory variety sec Chapter XIX. 

Signs and Symptoms. — Besides general weakness, the 
symptoms are — abundance and long duration of the lochia; 
irregular losses after the lochia pro|x:r have ceased ; pro- 
fuse leucorrhcea; a feeling of weight in the pelvis; and 
backache. On examination the vagina is bathed in dis- 
charge of a serous or sero-purulent character, sometimes 
tinged with blood. The uterus is large, heavy, and flabby, 
and not uncommonly retroverted. 



DISEASES Of THE UTERUS. 165 

The condition must be diagnosed from retention of prod- 
ucts of conception ; in the latter case bleeding is more 
marked, but otherwise the signs and symptoms are so 
similar that exploration of the interior of tlie uterus may 
be required to establish the diagnosis. 

TraUiiit'Ht. — The general treatment should be tonic with 
rest in bed. Hot intra-uterine and vaginal douche.s should 
be given, as these induce uterine contractions which play 
an important part in the process of involution. In more 
chronic conditions hyd rot he rape u tics and change of air 
are indicated, and applications of the galvanic current, the 
negative pole being placed inside the uterus. In the way 
of medicines ergot may be given, in combination with iron. 

Retentioti of Products of Conception.— A portion 
of placenta or ot nKnibrLuie- may remain attached to the 




uterine wall, both after full-time delivery and after abortion. 
It is most frequent in the latter case. The principal symp- 




i irregular hemorrhage, continued in some instances 
for many months. The other symptoms and the physical 
signs closely resemble those just described as resulting 
from subinvolution. 

The diagnosis generally rests between retention of pla- 
cental fragments, polypus, and sarcoma, but, clinically, a 
placental remnant forms one variety of polypus (Fig. 51). 
In any case the diagnosis cannot be made with certainty 
without exploration of the interior of the uterus. The 
microscopic characters of recent placental tissue are shown 
in Fig. 52, and those of such tissue when retained for some 
time in the uterus, in Fig. 53. 

Treatment. — When symptoms are not urgent, palliative 
measures may be adopted, such as the administration of 
ergot and iron, and vaginal douches. But if there be 
reason to suppose, at the outset, that retained products are 
present, there is no object in delay, and the uterine cavity 
should be explored. Shortly after a labor or miscarriage 
the cervix may be sufficiently patulous to allow of this 
being done without dilatation. In other cases dilatation 
must precede exploration, which should be done by means 
of the finger in the uterus. If placental fragments are 
found, the curette should be used, removing all rough and 
protruding parts of the surface until the interior is quite 
smooth. 




DISEASES OF THE ENDOMETRIUM. 

The mucous membrane lining the cavity aiid the cervical 
canal of the uterus is termed the endometritun. It 
differs from mucous membranes in general in having no 
submucous layer (Fig. 54); this is due to the fact that 




nearly the whole of tht. muscular t ssue of the uterus is 
morphologically mu culans mucosae (John W lliams). Com- 
parative anatomy supports this view. The endometrium is 
peculiar in undergoing rhythmic changes during sexual life 
coincident with menstruation ; when the uterus is occupied 
by an oosperm (fertilized ovum) the endometrium of 
the uterine cavity is changed into a thick membrane known 
as a decidna, which h incorporated with and shed coinci- 
dently with the placenta. Menstrual and decidual changes 
are entirely confined to the endometrium lining the uterine 
cavity. The mucous membrane lining the cervical canal is 
called the cervical endometrimn. The endometrium of 
the uterine cavity has a smooth surface, it is soft, spongy 
red, and covered with ciliated columnar epithelium. The 





DISEASES OF THE UTERUS. 1 69 

glands which beset it are simple tubes lined with a single 
layer of columnar cells continuous with those on the sur- 
face; the cells near the orifices of the glands are ciliated. 
The glands dip obliquely into the stroma of the mucous 
membrane and sometimes bifurcate at the extremity. The 
cervical endometrium is firm and forms rugae, giving rise to 
an appearance known as the arbor vilw. Tiie orifices of 
the racemose glands open on the surface in the pits between 
the rugas. The epithelium in the upper half of the cervi- 
cal canal is of the columnar ciliated variety, in the lower 
half it is stratified. In addition to the glands, the mucous 
membrane of the lower part of the canal contains numerous 
vesicles visible to the naked eye and known as the ovules 
of Naboth. 

The endometrium is liable to the following diseases : 1. 
Inflammation; 2. Adenomatous Disease; 3. Tuberculosis; 
4. Sarcoma; 5. Carcinoma. 

Acute Endometritis. — The chief causes are sepsis (in- 
fection with micro-organisms) following labor or abortion ; 
instrumental interference with the uterus ; extension of 
vaginitis or gonorrhoea; or gangrene of a uterine myoma. 

When inflamed, the endometrium presents the usual cha- 
racters of an inflamed mucous membrane ; it is swollen, 
and the surface is covered with a purulent exudation. On 
microscopic examination its tissues are found infiltrated with 
leucocytes, and if submitted to bacteriological examination 
the infiltrated tissues and discharges will occasionally fur- 
nish the micro-organism which initiated the disturbance- 
The great difficulty which besets the study of morbid states 
of the endometrium is the fact that in order to examine it 
the cervical canal must be dilated ; even then the informa- 
tion can only be acquired by the finger, or more directly' 
from the study of fragments removed from it by means of 
the curette. 

In recent years a good deal of useful work has been 
accomplished, and we know that acute endometritis follow- 



170 




DISEASES OF WOMEN. 



sit IS 



ing on labor and abortion — " puerperal endometritis " 
called — is caused by the introduction of pathogenic 
organisms, such as the streptococcus and staphylt 
due to lack of scrupulous aseptic precautions on the part of 
doctor, midwife, or nurse. These minute bodies flourish in 
the discharges, and lead to decomposition of blood-clot or 
fragments of placenta which may be retained in the uterine 
cavity. The ultimate course and consequence of endome- 
tritis occurring during the puerperium, or as a sequence of 
operations on the uterus, or due to gangrene of a myoma 
or extension of gonorrhoea, are much the same. 

In many cases, especially when the infection is of a mild 
type, the inflammation subsides, and, like those conditions 
called catarrh, leaves no trace. In others the inflammatory 
changes may extend beyond the mucous membrane into 
the muscular wall of the uterus, and even involve its serous 
covering. When endometritis involves the uterus in this 
way it is sometimes called metritis (an unnecessary refine- 
ment). When the infection is very virulent it will lead to 
gangrene and sloughing of the endometrium. 

The most serious consequence of the disease is due to its 
extension to the mucous membrane of the Fallopian tubes; 
then the infectious material finds its way directly into the 
pelvic section of the ccelom (peritoneal cavity) and in many 
instances with a fatal result. (This disaster is discussed in 
the chapter devoted to Salpingitis.) 

Signs. — Constitutional disturbance is the rule, except in 
gonorrhceal endometritis ; apart from the febrile disturbance 
the patient complains of pelvic pain and profuse, ofTensive, 
purulent, and sometimes blood-stained discharges. Rigors 
are not uncommon, and the temperature ranges from 99* 
or 100° to 105° F. 

On examination the vagina is hot, and before the stage of 
abundant discharge may be dry. The uterus feels heavy 
and bulky, and is tender to manipulation. Later it becomes 
fixed if pelvic cellulitis supervenes. The cervix is at first 




DISEASES OF THE VTEKUS. 

soft, but later it is hard and firm. Viewed through the 
speculum, the cervix appears red and thickened, and mu- 
cus, either viscid, rauco-purulent, or sanious, is seen to 
exude from the external os. 

Diagnosis.— The history and the febrile condition will 
point to the diagnosis, and lead to vaginal examination, 
when the above conditions will be found. 

Course and Prognosis. — Acute endometritis of puerperal 
origin is the only one which is at all frequently fatal, and 
then the fatal result depends more on general than on local 
conditions. In all other cases the tendency is to recovery 
after a more or less protracted convalescence. The most 
serious complications are pelvic peritonitis and cellulitis, 
pyosalpinx, and sterility. Uncomplicated endometritis re- 
sults usually in no more serious condition than a chronic 
hyperplasia, which may induce dysmenorrhcea and some- 
times sterility. 

Treatment. — The patient must be kept in bed and the 
usual treatment of febrile conditions adopted. For the 
treatment of puerperal septicaimia the student is referred 
to text-books of obstetrics. 

As regards local treatment, much may be done. Thus 
at the outset intra-uterine irrigation should be resorted to, 
using for this purpose solutions of perchloride of mercury 
(i : socw) carbolic acid (i 140) ; nitrate of silver (1 : 500), or 
chloride of zinc {1 per cent.}. The irrigation maybe fol- 
lowed by the introduction of iodoform pencils into the 
uterine cavity, or by swabbing out the uterus with a 
stronger caustic (iodized phenol, liniment of iodine, or 
chloride of zinc 10 per cent.) applied on an intra-uterine 
probe swathed with cotton -wool. 

Some have strongly recommended curetring for gonor- 
rhueal endometritb ; there is, however, the risk of opening 
up fresh surfeces to infection; and the same objection ap- 
plies to dilatation of the cervical canal for intra-uterine 
medication. The ri^k may be diminished by following up 



172 




D/SEASES Of IfOAfEAT. 



the curetting by swabbing out the uterine cavity and the 
introduction of iodoform pencils. 

As the vagina is often also affected, especially in gonor- 
rhoea! cases, it must be treated at the same time, as pre- 
viously described. 

Much benefit is derived, in the earlier stages, from scari- 
fication of the cervix and the abstraction of blood; this 
answers better than leeches, whicli were formerly used for 
this purpose. It may require to be repeated several times, 
at intervals of a few days. 

The after-treatment consists in the employment of hot 
vaginal douches of weak antiseptics twice daily. After 
each douche an iodoform tampon may be placed in the 
vagina, or a glycerin tampon dusted over with iodoform. 

In addition to or in place uf the vaginal douches hot sitz- 
baths may be given. Pain is greatly relieved by fomenta- 
tions applied to the lower part of the abdomen and to the 
perineum ; in other cases morphia suppositories may be 
introduced into the rectum or opium given by the mouth. 

Chronic Endotnetritls. — Citusis — (i) This disease may 
be a sequela of the acutu form ; {2) it may be due to gonor- 
rhcea or .sepsis, without a preliminary acute .stage ; {3) it may 
result from chronic congestion, due to catching cold during 
a menstrual period or caused by uterine displacement ; {4) 
it may result from abortion or dehvery at term, when it 
takes the form of subinvolution. 

Pathology. — The changes foimd in the mucosa are similar 
to those that occur in acute endometritis, but they are less 
marked. Moreover, several varieties are described, accord- 
ing to the structures principally affected. 

(a) Glamiular Endometritis. — The glands are enlarged 
and dilated, and their lumen is occupied by proliferating 
and cast-off epithelium, mixed with mucus. This condition 
must be distinguished from adenomatous disease of the 
endometrium (page 174), in which there is a new formation 
of glandular elements. 




DISEASES OF THE UTERUS. 



173 



(b) Interstitial Endome Iritis. — Here the glands are not 
directly affected, but the stroma shows at first increase in 
its cells and infiltration of leucocytes, and later a great for- 
mation of fibrous tissue. The vessel-walls are thickened, 
and small retention-cysts are formed in the deeper layers by 
pressure on the gland-ducts. Eventually the glands may 
almost disappear, the mucosa consisting chiefly of fibrous 
tissue. 

(c) Hemorrhagic Endometritis. — The principal alteration 
is in the vessels, which are dilated and in places ruptured, 
leading to extravasation of blood in the superficial layers of 
the stroma. There is no polypoidal formation, such as is 
found in the adenomatous condition to which the same 
name is sometimes applied {see page 178). 

These three conditions are sometimes found associated 
in the same specimen; and the endometrium of the cervix 
and body may be affected separately or together. 

The symptoms and signs are practically those of adeno- 
matous disease, and similar local treatment is required. 




CHAPTER XX. 
DISEASES OF THE UTERUS (Continued). 

DISEASES OF THE ENDOMETRIUM 

(Continued). 

Adenomatous Disease [Erosion) of the Cervical 

Endotuetrium.— The mucous membrane coveting the 
neck of the uterus consists of two portions : one lines the 
cervical canal — the ct-n'ical endonielrium ; the other covers 
the vaginal portion of the cervix and belongs to the vagina. 
The two portions meet at the externa! os. "The mucous 




I 



membrane covering the vaginal aspect of the cervix is 
really a cup of stratified epithelium, resembling a tailor's 
thimble, which fits on the lower end of the uterus " (Wil- 
liams). It contains a few simple glandular crypts. The 
cervical endometrium in its lower segment is beset with 
racemose glands and tlie ovules of Naboth. The glands 




DISEASES OF THE UTERUS. 



of the cervical endometrium are very apt to enlai^e and 
multiply, forming a soft, velvety, pink mass which extends 
beyond the normal limit of the external os and invades the 
tissue of the vaginal portion of the cervix, forming a soft, 
velvety areola, in color like a ripe strawberry, and minutely 
dotted with spots of a brighter pink (Figs. 55, 56). The 
surface is usually covered with tenacious mucus. 

This pink tissue is composed of glandular acini lined with 
columnar cpithehum (Figs. 57, 58). In cases of bilateral 



/a^ 



laceration of the cervix the whole of the exposed surfece 
is generally tumid with this overgrown glandular tissue. 
Occasionally this glandular overgrowth projects as a 
pedunculated process from the mouth of the uterus, and is 
then termed a mucous polypus; two or more may be 
present. They are dotted with minute pores indicating the 
orifices of the glands, and are soft. They usually spring 
from the endometrium near the os. which is generally 
patulous when these pedunculated adenomatous bodies are 




176 DISEASES OF WOMEN. 

present. Histologically, they arc composed of an axis 
fibrous and muscular tissue covered with mucous mem- 
brane. As long as the bodies remain in the cervical canal 
the mucous membrane covering them possesses a single 
layer of columnar epithelium, but when the polypus pro- 
jects into the vagina the mucous membrane of the pro- 
truding portion loses its glands, or they become mere 
crypts, and the epithehum stratifies. 

In some instances the pink tissue is smalt in quantity and 
is dotted with numerous cystic bodies of the size of cori- 




ander seeds; these are enlarged ovules of Naboth, and are 
probably due to distention of the acini of the cervical 
glands. When the adenomatous surface is extensive and J 
the follicles are numerous, the white dots on a pink ground ] 
produce a characteristic appearance. 

In vcrj- rare cases a group of follicles will hang a: 
grape-like maiss in the vagina. These may be called race- 
mose adenomata. 



DISEASES OF THE UTEKUS. 



17; 



Causes. — Nothing is known concerning the cause of this 
affection. It occurs in virgins and in mothers; extensive 
adenomatous patches are often associated with lacerations 
of the cervix, and the disease is more common in women 
who have had children than in nuHiparse, 

Syinptofits. — Adenomatous disease of the cervix gives 
rise to vaginal discharge, indefinite pain, and general weak- 

The discharge is commonly known as " the whites ;" 
teclmically it is termed leucorrha-a. The normal secretion 
is clear and viscid like the white of an egg. but in marked 
cases of adenomatous disease it may be yellow or greenish. 
Pain usually assumes the form of backache ; often it is re- 
ferred to the submammary region, and occasionally to the 
perineum. Pruritus is sometimes present. The continual 
discharge weakens the patient and leads to many subjec- 
tive signs, such as nausea, headache, giddiness, sleepless- 
ness, and similar disturbances, often attributed to hysteria 
and vaguely classed as neuroses. 

Diagnosis. — On inspecting the vulva traces of the dis- 
charge are usually visible externally. On examining with 
the finger, the cervix may feel enlarged and softer than 
usual ; the uterus may be bulky. On introducing a specu- 
lum, tenacious secretion will be seen covering the exposed 
surface or issuing from the cervical canal. This is removed 
by a cotton-woot dab, and the presence, extent, and cha- 
racter of the adenomatous tissue determined, as well as the 
existence and degree of any coexisting laceration. The 
conditions most likely to be confounded with this disease 
are epithelioma and carcinoma of the cervix. 

Treatment. — When the disease is of small extent it is 
easily dealt with in the following manner: The parts are 
well exposed by means of a Fergusson's speculum, and 
the mucus removed by means of cotton-wool dabs on 
sponge-holders or speculum-forceps. Iodized phenol (iodine 
four parts, carbolic acid one part) is then freely applied to 




DISEASES OF WOMEN. _ 

the diseased surface by means of cotton-wool wound on a 
uterine probe; it is useful to apply some of the caustic for 
a short distance up the cervical canal by means of the 
probe. If there be any conspicuous follicles they should 
be punctured. A tampon is then introduced and the 
patient directed to douche the vagina daily, to keep the 
bowels open by means of simple saline purges, and to 
abstain from alcohol. In some cases one application of 
the iodized phenol is sufficient. 

When the disease assumes the polypoid form the pro- 
cesses are easily detached with forceps or a curette. 

When the disease is more extensive it may require several 
applications at intervals of a week, but in these cases better 
results are obtained by placing the patient under ether and 
thoroughly destroying the adenomatous tissue by means of 
Paquelin's cautery, or scraping it away with a curette, tak- 
ing care to deal with the whole length of the cervical canal, 
and then applying the cautery, iodized phenol, or any suit- 
able caustic to the denuded surface. Radical treatment of 
this kind entails rest in bed for a week or ten days. 

When adenomatous disease is associated with bilateral 
laceration and is clearly a source of suffering, the perform- 
ance of trachelorrhaphy is indicated. 

Adenomatous Disease of the Corporeal Endome- 
trium. — The endometrium lining the cavity of the uterus 
is besel with tubular glands, which, like the glands of the 
cen'ical endometrium, may undergo local enlargement and 
form sessile or pedunculated processes known as mucous 
polypi. They pos.sess a covering of columnar epithelium 
and a framework of connective tissue containing glands 
identical with the tubular glands of the endometrium. 

This disea.se is sometimes described as villous or poly- 
poid endometritis. When menorrhagia and metrorrhagia 
are prominent symptoms it is .sometimes referred to as 
hemorrhagic endometritis. 

Symptoms. — These consist of a uterine discharge which 




DISEASMS OF THE UTEKLfS. 

may be mucoid, muco-purulent, or bloodstained. In many- 
cases there is a distinct history of menorrhagia. 

Diagnosis. — On examination the uterus is usually en- 
larged, and the introduction of the sound is followed by a 
slight loss of blood. 

In many cases the only way of actually determining the 
nature of the case is to ana^sthetize the patient, dilate the 
cervical canal, and explore the endometrium with the finger. 
Should any polypi be detected, they are easily detached 
by means of the curette. 

Treatment. — ^This turns upon the diagnosis, and b usually 
carried out at the time the uterus is dilated ; it consists in 
completely removing the polypus or polypi, and then cu- 
retting the endometrium and applying iodized phenol. 

Tuberculosis. — This disease may attack any part of the 
endometrium ; it occurs more frequently in the mucous 
membrane of the uterine cavity than in that lining the cer- 
vical canal. Nothing is known of its early stages, for the 
majority of cases do not come under observation until the 
disease has reached its caseous stage and has infiltrated the 
muscular wall of the uterus. Occasionally isolated nodules 
are found in the endometrium. The infection is very liable 
to spread to the Fallopian tubes and infect the peritoneum 
(Chapter XXXIII.); a very large proportion of cases of 
general tuberculosis of the peritoneum arise in this way. 

Tuberculosis of the endometrium is not frequent as a 
primary disease, but in many cases, especially in children, 
it is associated with tubercular lesions in the lungs and 
bones. 

It is by no means easy to demonstrate the presence of 
bacilli in the uterine lesions ; the same holds true of the 
tubes, but when tubercular lesions are found in other parts 
of the body as well as the uterus, and yield tubercle bacilli 
to appropriate teats, the inference that the uterine lesions 
are likewise tubercular is a fair one. 

Tuberculosis of the endometrium is frequent in children 



l80 DISEASES OE WOMEN. 

and may occur in the first year of life. This is a fact of \ 
some importance in opposition to the theory that infection 
may be conveyed with the semen during coitus. 

Tuberculosis of the uterus is very rarely made out during 
Hfc ; its presence may be suspected in Uie case of young 
girls and young virgins with a persistent purulent vaginal 
discharge, especially if tubercular foci can be localized in 
their lungs or bones. 

Treatment. — This disease is so seldom diagnosed that 
radical measures have rarely been practised on the endo- 
metrium (see Tuberculosis of the Fallopian Tubes). 



CHAPTER XXI. 

DISEASES OF THE UTERUS (Continued). 

MYOMATA (FIBROIDS). 

Before describing the characters of uterine mj-omata it 
is necessary to consider a few points in relation to the dis- 
tribution of the muscular fibres of the uterus. 

The uterus is a muscular organ, and its fundus with the 
chief portion of its body is closely invested with peritoneum 
directly continuous with the lateral folds Icnown as the broad 
ligaments (or the mesometria). The cavity of the uterus 
is lined with mucous membrane (the endometrium) rich in 
glands and tracts of unstriped muscle-tissue. (The student 
should refer to the morphological view of the nature of the 
uterine wall on p. i68.) 

In regard to the serous investment of the uterus, it is 
important to remember that in many situations the sub- 
serous tissue is practically a bed of fat, but where it comes 
into relation with the uterus it consists of a layer of un- 
striped muscular fibre directly continuous with the uterine 
tissue and with the muscular layer of the mesometrium. 
In young adults this stratum may be separated from the 
uterus with the peritoneum. 

Thus there are three situations in the uterus where my- 
omata may arise — (i) In the true uterine tissue: such are 
said to be intramural or interstitial myomata. (2) In the 
mucous membrane : these are called submucous myomata. 
(3) In the subperitoneal tissue: these are termed subserous 
myomata. 

Myomata may arise in, and remain confined to, any one 



1 82 



DISEASES Of . 



of these layers, or they may arise in all three situations in 
the same individual. 

I. Intramural My omata. — These maybe single or mul- 
tiple; in their early stages they resemble, in section, knots 
in a piece of wood. These tumors have distinct capsules 




and are firm and even hard to the touch. The bundles of 
muscle-fibres are often interwoven in such a manner that 
they present a characteristic whorled appearance. Myom- 
ata arise in any part of the uterine wall (Fiy. 59), but they 
are more frequent in the body or the fundus than in the 



l84 DISEASES OF WOAtEN. 

cartilage ; these contain a large proportion of fibrous tis- 
sue (fibro-myomata) and grow slowly. Some are as soft as 
a fatty tumor, and consist of large cells ; these are very 
vascular and grow rapidly. Some of these intramural 
mynmata are so rich in blood-vessels that on section they 
look not unlike cavernous na:vi (Fig. 60. Such tumors 
furnish a loud venous hum on auscultation. 




Sometimes a myoma confined to one wall of the uterus 
will appear as a simple tumor, but on section it will be 
found to consist of two or more tumors, each possessing 
its own capsule. 

2. Submucous Myomata. — These tumors arise in the 
deeper layers of the mucous membrane, and, as soon as they 
attain an appreciable size, project into the uterine cavitj*. 
Many of them remain sessile, but the majority tend to be- 




DISEASJuS OF THE UTERUS. 

come stalked, and are then termed polypi. Whether sessile 
or stalked, they arc invested by the uterine mucous mem- 
brane. The presence of a myoma in the wall of the uterus 
or projecting into its cavity leads to great thickening of the 
uterine wall, accompanied by increased vascularitj', which is 
often manifested by mcnorrhagia and intermenstrual liemor- 
rhage — m etrorrhagia. 

The pedicle of a submucous myoma may be long enough 
to allow the tumor to be extruded into the vagina (Fig. 62), 




and it may present itself at the vulva. When this happens 
an interesting change takes place in the character of the 
epithelium of the extruded part. So long as the tumor 
remains within the cavity of the uterus, the mucous mem- 
brane covering it is indistinguishable from that lining the 
cavity of the uterus, and the surface epithelium as well as 
that lining the recesses of the glands is of the columnar 
ciliated variety. When the myoma enters the vagina the 
epitfaelium covering the extruded portion becomes con- 



186 



DISEASES OF WOMEN. 



verted into stratified epithelium on all those portions sub- 
ject to pressure, but the epithelium in the glandular re- 
cesses remains columnar and ciliated. 

The extrusion of a myoma through the cervical outlet 
sometimes ends in its complete detachment; this is of 
course curative. More often the extrusion leads to sec- 
ondary changes inimical to life. When a stalked myoma 
escapes from the cervical canal, its pedicle is firmly grasped 
by the cervix; this interferes with the circulation in the 
tumor, leading to marked cedema of the myoma and to 
gangrene; the dead mass becomes infected with micro- 
organisms, decomposes, and sets up septic changes in the 
uterus, leading to sloughing of the endometrium, salpingitis, 
peritonitis, and the usual dread sequences. 

3. Subserous Myomata. — It is rare for myomata arising in 
the subserous stratum to attain large dimensions. Like 
the submucous variety, they quickly become pedunculated. 
As many as fifteen or twenty of these bodies may be 
counted on the peritoneal surface of the uterus, varying in 
size from a pea to a walnut. Such myomata rarely cause 
inconvenience, and are often found after death in individuals 
in whom their presence lias never even been suspected. 
Large single pedunculated subserous myomata weighing half 
a kilogramme sometimes cause trouble from the mechanical 
effects they are liable to produce. Any of these varieties 
may occur together in the same uterus ; indeed, it is usual 
to find subserous and intramural myomata associated. In- 
tramural tumors are often present alone; but it is by no 
means rare to find moderately large examples in the uterine 
walls accompanied by a small submucous myoma ; and the 
latter is far more frequently the source of dangerous hemor- 
rhage and pain than its large companion. Sessile sub- 
serous myomata sometimes attain prodigious proportions 
(5 kilo,). 

Secondary Changes. — The chief are — Mucoid degen- 
eration ; fatty metamorphosis ; calcification ; septic infection. 



DISEASES OF THE UTERUS. 187 

Mucoid Degeneration. — Large myomata are especially 
prone to soften in the centre, whereby large tracts of tissue 
become converted into mucin. When this change takes 
place extensively, the tumor resembles a cyst; it is then 
often termed a " fibro-cystic tumor " of the uterus. The 
actual conversion of the tumor substance is preceded by 
oedema of the connective tissue, and the cells assume the 
spider-hke shape characteristic of myxomatous cells ; then 
it becomes as structureless and diffluent as vitreous humor. 

Fatty Metamorphosis. — This change is rarer than the pre- 
ceding. A localized collection of fat has been found in the 
centre of a pedunculated submucous myoma. 

Calcification. — Old uterine myomata. large and small, are 
liable to become infiltrated with lime salts. The deposit 
does not take place in an irregular manner in the tissues of 
the tumor, but corresponds to the disposition of its fibres. 
On examining the sawn surface of a completely calcified 
uterine myoma, the whorled arrangement of the fibres is so 
completely reproduced as to leave no doubt as to the nature 
of the mass. When these calcified tumors are macerated and 
the decayed tissues washed away, the calcareous matter re- 
mains as a coherent skeleton of the tumor. Such changes 
have actually taken place whilst the tumor remained in the 
living uterus; they were formerly termed " uterine calculi," 
and when found in coffins in old burying-grounds are some- 
times imagined to be very large vesical calculi. 

A subserous myoma is very prone to calcify, and, if its 
stalk be thin, is apt to be twisted, and the tumor, becoming 
detached, falls into the crelom and finds it way into all sorts 
of queer recesses. A detached nodule of this sort may 
tumble into a hernial sac. 

Septic Infection. — It occasionally happens that a myoma 
which has existed many years and given rise to little incon- 
venience, suddenly enlarges, assumes formidable propor- 
tions and causes severe constitutional disturbance. These 
changes are due to septic infection which may follow injury 



1 88 DISEASES OF WOMEN. 

in the course of a clinical' examination or attempts at re- 
moval ; it may become infected from a hollow viscus like 
the bladder or intestine. Occasionally the changes super- 
vene on labor or abortion. 

The appearance of an infected myoma is very striking. 
On section it looks oedematou.s and exhales a sickly odor. 
On microscopic examination the muscle-cells are separated 
by multitudes of leucocytes, and micro-organisms are de- 
monstrable in the tissue. 

Sections of an inflamed myoma under the microscope re- 
semble very closely sarcomatous tissue, and there is little 
doubt that many specimens described as "sarcomatous" 
or " malignant " degeneration of " uterine fibroids " were 
of this nature. 

Malignant Changes. — The conversion of innocent into 
malignant tumors is a matter surrounded by clouds of un- 
certainty, but there are some clearly described cases in 
which secondary tumor.s have occurred in the lungs, fur- 
nishing the histologic features of myomata, and a large my- 
oma has occupied the uterus. 

Impaction, — A myoma is said to be impacted when it 
fits the true pelvis so tightly that it presses upon the rec- 
tum and urethra. Occasionally a myoma may be so firmly 
fixed in the pclvi.s that it cannot be displaced by pressure 
applied through the vagina (Fig. 63). 

There is a form of temporary impaction to which myom- 
ata in women between thirt>'-five and fifty are liable. A 
myoma may be of such a size that it i.s easily accommo- 
dated in the pelvis, without pressing injuriously on the 
urethra or rectum, during the intermenstrual period. A few 
days before the flow appears the myoma becomes turgid, 
and this increase is sufficient to cause the tumor to press on 
the urethra and cause retention of urine, demanding the use 
of a catheter; as soon as the flow appears the urethra is set 
free. 

Impaction, whether temporary or permanent, leads to 




DISEASES OF THE UTERUS. 



baleful affects on the bladder, ureters, and kidneys. Very 
large uterine myomata rising high in the belly will lead to 
dangerous complications by pressing on the ureters and 




Fig. 6j.— Felviiinuciiul 



rectum at the pelvic brim. Sometimes such tumors press 
on the iliac veins and cause cedenia of the lower limb. 

Tlterine Myomata and Pregnancy. — The coexistence 
of a myoma in the uterus and pregnancy is often a serious 
condition, tliL- gravity of the association depending largely 
upon the situation of the tumor (Fig. 64). For example, 
an interstitial myoma may rapidly grow in correspondence 
with the increasing size of the uterus due to pregnancy. 
The presence of the tumor may induce abortion, and as 
the uterus involutes the myoma may disappear. 



igO DISEASES OF WOMEN. 

Abortion complicated by a myoma greatly imperils the 
mother's life from bleeding. 

When the tumor is of the subserous variety and pedun- 
culated it is apt to become cedematous and mechanically 




interfere with the ascent of the uterus. In such a case 
abortion is the rule. 

When a myoma occupies the cervix it offers mechanical 
obstruction to the transit of the foetus, and a submucous 
polypus may be driven out of the uterus in front of the 
presenting part. A sessile submucous myoma may not In- 
terfere with pregnancy or delivery, but a sessile subserous 




myoma near the neck of the uterus would offer an insuper- 
able barrier to delivery at or near term. 

The Chief Causes of Death.— These are— 

1. Hemorrhage. — Copious loss of blood may be a cause 
of death; frequent bleeding produces extreme anzemia, which 
may indirectly lead to fatal complications. 

2. Mechanical Effects. — Intestinal obstruction may result 
from pressure on the rectum, or a loop of small bowel may 
become entangled by the stalk of a pedunculated myoma. 
Pressure on urethra or ureters may lead to cystitis, saccu- 
lated kidneys, nephritis, or hydronephrosis and pyonephrosis. 

3. Pregnancy in a myomatous uterus may terminate hap- 
pily ; more often it leads to abortion and imperils life from 
bleeding. A myoma may disappear during involution of 
the uterus. 

4. Sepsis. — A gangrenou.s myoma may infect the uterus 
and establish fatal septicxmia; purulent material may travel 
along the Fallopian tubes and set up fatal peritonitis. 



CHAPTER XXII. 

DISEASES OF THE UTERUS (Continued). 

THE CLINICAL CHARACTERS AND TREAT- 
MENT OF MYOMATA. 

Clinical Characters. — Uterine niyomala, the com- 
monest genus of innocent tumors to which women are 
liable, are unknown before puberty, and rarely attract 
attention until the twenty-fifth year; from this age they 
increase in frequency, and are most common between 
the thirty-tliird and fifty-fifth years. Hard myomata usu- 
ally cease to grow after the menopause ; some shrink at 
this period, but the majority remain in statu quo and some 
slowly calcify. Occasionally a soft myoma will grow very 
rapidly after the menopause. 

Symptoms. — In a very large proportion of cases the earliest 
indication of a myoma in the uterus is excessive menstru- 
ation (nienorrhagia), and this may be complicated by ute- 
rine bleeding between the menstrual periods (metrorrhagia). 
These hemorrhages are often the only symptom which leads 
the patient to seek advice, and on examination a large pel- 
vic tumor may be detected. In many cases there is no ob- 
vious enlargement of the uterus, and the existence of a 
small submucous myoma (polypus) is a matter of presump- 
tion founded on clinical experience, only proved or dis- 
proved by dilating the cervical canal and exploring the 
cavity of the uterus, In many cases when the patient 
seeks advice the myoma is actually presenting at the 
mouth of the uterus. 

When the myoma is so large as to rise out of the pelvis 




DISEASES OF THE UTERUS. 

;ually occupies the hypogastric region, but if peduncu- 
lated it may lie in the flanks and simulate an ovarian tumor. 
To palpation it may be smooth, but when the surface is 
tuberose it is a valuable sign. Auscultation sometimes 
furnishes valuable evidence, for a soft, rapidly-growing my- 
oma often yields a loud venous hum synchronous with the 
pulse and indistinguishable from the uterine souffle heard in 
pregnancy. This hum may be present a few days before the 
onset of menstruation, and disappear as soon as the flow 
occurs, to reappear immediately before the next menstrual 
period. 

On vaginal examination the tumor will be found closely 
a.ssociated with the uterus. The body and cervix may form 
part of a globular mass, the mouth of the womb being indi- 
cated by a small dimple. 

The sound often gives great assistance; in the majority 
of cases myomata lead to enlargement of the cavity of the 
uterus. The sound facilitates localization of the tumor, and 
often enables the surgeon to determine whether the uterus 
is involved partially or entirely. 

The employment of the sound demands extreme care: a 
myomatous uterus is sometimes gravid. When free bleed- 
ing follows very gentle use of this instrument, it is often an 
indication that there is a submucous tumor projecting into 
the uterine cavity. 

The chief conditions which coraphcate the diagnosis of 
large uterine myomata are pregnancy and ovarian tumors ; 
the latter are fully discussed in Chapter XXXII. 

in some cases the detection of uterine myomata is simple 
and certain; in others the wisest and most experienced find 
j;;reat diFficullic.s in the way of exact diagnosis. 

Differential Diag:no5is of Pregnancy and Myom- 
ata. — Tumors of the internal genital organs of women are 
most frequent during the sexual period of life — from the 
fifteenth to the forty-fifth year; and, as many species of 
tumors {so far as rate of growth and size are concerned) 



194 




DISEASES OF WOMEN. 



simulate pregnancy, and vice inrsd, it naturally behoves 
every surgeon to make himself familiar not only with the 
signs of normal gestation, but with the abnormal forms as 
well. It is also important to remember that his professional 
reputation may be wrecked, and a single woman's social 
position may be ruiniid by such a blunder as attributing the 
enlargement of her belly to a gravid uterus when it is due 
to an ovarian or a uterine tumor. 

It will be convenient to discuss the diagnosis of preg- 
nancy under the following headings: Normal Pregnancy; 
Hydramnion ; Retroversion of a Gravid Uterus ; Comual 
Pregnancy; Extra-uterine Pregnancy (see Chapter XXVII.). 

1. Normal Preg:nancy. — In the case of a married 
woman at the childbearing period of life under usual dr- 
cumstances there is little danger of error; but a married 
woman with a rapidly-growing uterine or ovarian tumor 
may imagine herself pregnant, and even arrange for the 
advent of the baby and have the nurse ready to receive it. 

The following constitute a group of signs of pregnancy 
which, if carefully sought for, rarely mislead: 

1. Amenorrhcea. 

2. Fulness of the breasts, with the presence of milk. 

3- Pigmentation of the mammary areola;. 

4- The soft tumor in the hypogastrium which hardens 
and softens under firm, continued pressure of the palm. 

5- Movement of the ftttus. 

6. Ballottement. 

7. Softness of the cervix. 

8. The fcetal heart and the uterine souffle. 

The cases which give rise to difficulty are those in which 
individuals have motives for concealing their pregnancy, or 
cases in which there is some abnormal condition of the 
fcetus or its membrane, or tumors in addition to pregnancy. 
It is also important to remember that women may conceive 
even as late as their fifty-ninth year. In the first set of 
cases it is easy to recall instances in illustration of " the 



DISEASES OF THE VTERUS. I9S 

pertinacity and apparent innocence " with which unmarried 
women will sometimes deny the possibility of pregnancy 
even when they are actually in labor. 

In cases of unmarried women the greatest caution is 
necessary before expressing an opinion that the case is one 
of pregnancy ; by a little waiting the case settles itself, and 
in doubtful conditions nothing is to be gained by giving an 
opinion straight away, whereas two months is, as a rule, 
sufficient to lead the patient to thoroughly realize her con- 
dition, and she may not, in the circumstances, deem it ne- 
cessary to trouble the surgeon a second time. 

Two rules should be observed in dealing with cases of 
suspected pregnancy : (i)Whcn in doubt, defer expressing 
an opinion, and see the patient again after a few weeks' in- 
terval. (2) Nti'cr pass a sound where there is even a sus- 
pkion of pregnancy. 

II. Hydranmion. — This complication of pregnancy has 
many times been mistaken for a large, rapidly growing 
ovarian cyst. The trouble consists in the accumulation of 
an excessive quantity of amniotic fluid. Usually the gesta- 
tion proceeds normally till near the seventh month ; then 
the belly increases in size in a rapid manner and causes 
great inconvenience and distress. Clinically the enlarge- 
ment furnishes the signs of a very large ovarian cyst. 

Should there be any difficulty in the diagnosis as between 
hydramnion and a pelvic tumor, the employment of the 
uterine sound will settle the difficulty. It will probably 
terminate the pregnancy, but this is preferable to an ab- 
dominal section made under the supposition that the patient 
has a tumor. The amount of fluid present in cases of hy- 
dramnion is sometimes almost incredible and may amount 
to many litres. Hydramnion is usually .associated with 
twins. Ballottement is, as a rule, not only easily obtained, 
but unusually distinct. 

III, Retroversion of the Gravid Uterus — This means 
that the fundus of the uterus is lodged in the hollow of the 



196 DISEASES OF WOMEN. 

sacrum, and is prevented from rising on account of the 
sacral promontory. As the uterus enlarges the cervix is 
raised and pushed forward, compresses the urethra, and 
causes retention, often accompanied by incontinence (ischuria 
paradoxica). The clinical signs of a gravid uterus in this 
condition are very decided. First, there is the presence of 
an oval hypogastric tumor (the over-full bladder); a history 
of pregnancy between the third and fourth months; and on 
examination a rounded elastic swelling (the body of the 
uterus occupying the hollow of the sacrum) will be felt, 
whilst the cervix lies behind the pubes, and sometimes so 
high that the finger can hardly reach it. On passing a 
catheter and emptying the bladder the hypogastric tumor 
disappears. On examining the abdomen bimanually the 
fundus of the uterus cannot be detected anteriorly. These 
facts serve to distinguish an incarcerated uterus from a 
uterine myoma, tubal pregnancy, or ovarian tumor. The 
diagnosis is usually verified by rectifying the position of the 
uterus. After emptying the bladder, upward pressure on 
the uterus through the vagina or the rectum will cause it 
to ascend. Sometimes it will be necessary to administer 
an ana-.sthetic in order to effect the replacement 

IV. Comtial Pregnancy. — It is pointed out in Chap- 
ter V. that the uterus sometimes presents the bicomed 
condition chaiacteristic of many mammals, such as cows, 
mares, and ewes. It is well established that a bicorned 
uterus in women may become gravid, the pregnancy go to 
term, .ind delivery terminate as happily as in an organ of 
normal shape. When one horn only is gravid — and this is 
the usual condition — the non-gravid cornu enlarges and a 
dccidua is developed within it. When a woman with a bi- 
corned uterus comes under observation in the early stages 
of pregnancy and is submitted to physical examination, 
there is great probability that the unilateral position of the 
enlarged cornu will lead to an erroneous diagnosis, and sev- 
eral cases have been recorded in which, under the supposi- 




tion that the patient was suffering from an ovarian tumor, 
uterine myoma, or tubal pregnancy, cttliotomy has been 
performed. In some instances the gravid half of the uterus 
has been amputated before the nature of the condition was 
appreciated. 

There is, however, a variety of cornual gestation of deep 
interest to the surgeon. When an oosperm lodges in the 
rudimentary cornu of what is known as the " unicorn 
uterus" (Fig. 21, p. 63), gestation may proceed without 
inconvenience for three or more months, but, as delivery 
by the natural passages is impossible, the ultimate results 
are similar to those of tubal pregnancy. 

The clinical signs of gestation in the rudimentary horn 
of a unicorn uterus are those of tubal pregnancy, and in 
many instances even during the post-mortem inspection the 
nature of the lesion is overlooked. 

The relation of the round ligament to the gestation sac 
forms a ready means of distinction between a gravid Fallo- 
pian tube and a cornual pregnancy: 

(1) In a normal uterus the round ligament springs from 
the upper angle, immediately in front of the tube. 

(2) In tubal gestation the round ligament is attached to 
the body of the uterus on the uterine side of the gestation 
sac. 

(3) In cornual pregnancy the round ligament is situated 
on the outer side of the gestation sac. 

Pregnancy in the rudimentary comu of a unicorn uterus 
runs a different course to tubal pregnancy. In the case of 
the tube, rupture (or abortion) usually occurs before the 
twelfth week, whereas in cornual pregnancy the gestation 
may go on to full term, and then ineffectual labor leads to 
the death and subsequent mummification of the fcetus; or 
the gestation sac may rupture at any ])eriod from the sec- 
ond to the ninth month. 

The pregnant comu of a unicorn or of a bicorned uterus 
may undergo axial rotation. 




DISEASES OF WOMEN. 



Treatment of Myomata. — When a small-stalked poly- 
pus appears at the mouth of the womb it is easily dealt with. 
The vagina is douched with an antiseptic solution and the 
tumor seized with a stout volsella and gently twisted off 

When the pedicle is thick it should be cut with scissors. 
Some operators prefer to divide the stalk with a wire snare or 
an ecraseur, a contrivance rapidly disappearing from surgery. 

Often the presence of a submucous myoma is conjec- 
tural; then the cervical canal is dilated sufficiently to allow 
the uterine cavity to be explored with the finger. Small 
myomata thus discovered are often easily seized with for- 
ceps and detached. Larger sessile myomata require more 
deliberate treatment. It is sometimes necessary to split the 
capsule of the tumor and then enucleate it with the finger. 
The myoma may then be gripped with a stout volsella and 
gently rotated out of its bed. When the base of a submu- 
cous myoma is very broad it demands great prudence in 
operating. 

It occasionally happens that a myoma is detached in 
this way, but it is too large to be withdrawn through the 
cervical canal. Under such conditions three courses are 
open to the surgeon : He may either freely incise the cer- 
vix bilaterally, or the bladder may be turned ofT the an- 
terior aspect of the cervix and the cervical wall cut through 
in the middle line anteriorly as high as the internal os. This 
will easily allow of the delivery of the tumor, and the cer- 
vical incision is closed with sutures. Or the tumor may be 
removed piecemeal with scissors and forceps (morcelle- 
ment). By whichever method the patient is deprived of the 
myoma, the uterine cavity is flushed with water at no" F., 
which quickly causes the uterus to contract and bleeding 
to cease. The cavity is lightly plugged with gauze and 
the vagina tamponed. 

The plugs are withdrawn in twenty-four hours ; warm.. 
douching is employed twice daily, and, in the majority of 
patients, recovery is rapid and complete. 



D/SBASES OF THE UTERUS. I99 

The treatment of myomata too targe for the summary 
measures just detailed demands careful consideration. If 
these large tumors could be removed with the same ease 
and safety as ovarian tumors, there could be no doubt as to 
the advisability of surgical treatment. The removal of a 
myomatous uterus through an incision in the bcUy-wall is 
a grave proceeding even in the hands of dextrous and ex- 
perienced operators. Each year, happily, results continue 
to improve, and there are hopeful signs that the chances of 
success will soon equal those of ovariotomy. 

The measures fall under three headings: 1. Oophorec- 
tomy ; 2. Myomectomy ; 3. Hysterectomy. The indications 
for adopting one or other of these proceedings will now be 
given. 

It has already been mentioned that myomata cease to 
grow, and even shrink, after the menopause. Taking ad- 
vantage of this fact, surgeons often anticipate the menopause 
by removing the ovaries (oophorectomy). This method is 
not applicable to all cases, for in many the ovaries are so 
involved in the tumor that they cannot be completely re- 
moved, and if only a portion of an ovary be left menstrua- 
tion continues and nullifies the operation. Many attempted 
oophort'Clomies have terminated in hysterectomy. It is the 
rule not to interfere with uterine myomata unless they di- 
rectly threaten the patient's life. Oophorectomy for my- 
omata is being rapidly superseded by hysterectomy. 

The following rules in regard to the surgical treatment 
of uterine myomata may be useful : 

(l) A myoma is the cause of serious and repeated bleed- 
ing, producing profound anaemia; the bleeding is uninflu- 
enced by rest and the administration of ergot. When these 
troubles are not due to a pedunculated myoma projecting 
into the uterine cavity, and the menopause cannot be reason- 
ably expected for two or three years, oophorectomy should 
be performed ; failing this, hysterectomy, if the anatomical 
conditions are favorable. 




200 DISEASES OF WOMEN. 

(2) A myoma of moderate size in a woman between 
thirty and forty-five becomes impacted and causes reten- 
tion of urine at each menstrual period. Such a case is very 
suitable for oophorectomy. 

The following conditions demand hysterectomy: 

(1) A myoma rapidly increasing in size and extending 
high above the pelvic brim and pressing on the colon, so 
as to cause intestinal obstruction. 

(2) A myoma rapidly enlarging after the menopause. 

(3) A fibro-cystic myoma. 

(4) A myoma that has given little trouble suddenly be- 
gins to enlarge rapidly, accompanied by rapid pulse, high 
temperature, and signs of septicsemia. These signs indicate 
septic infection of the tumor. A gangrenous myoma should 
be removed without delay ; occasionally a gangrenous myo- 
ma is too large to be removed through the vagina, and re- 
quires abdominal hysterectomy. 

(5) The large pedunculated myomata, which simulate 
ovarian tumors, may be easily dealt with by transfixion and 
ligature of their pedicles (abdominal myomectomy). 

There are several methods of performing hysterectomy : 
the steps of each are given in detail in the chapter devoted 
to this operation. 

Myomata Complicating Pregnancy. — As uterine 
myomata and pregnancy sometimes coexist, it will be use- 
ful to briefly summarize the dangers which may occur with 
such a combination ; they are — i. Abortion; 2. Mechanical 
impediment to delivery; 3. Free bleeding on abortion or 
delivery at term; 4, A subserous myoma may inflame; 5. 
A submucous myoma may become infected and necrose; 
6. Septicemia. 

The stages when some of the above troubles may arise 
and the appropriate treatment for each may be indicated thus : 

1. During Pregnancy. — It may be necessary to induce 
labor; to enucleate the tumor when it grows from the 
cervix ; to perform abdominal hysterectomy. 




I 



2. The Difficulty dfclarts itself during Labor, — It may 
then demand hysterectomy. 

3. Complications during the Pitcrperium. — These may re- 
quire abdominal myomectomy or abdominal hysterectomy. 

Polypi. — All stalked or sessile tumors which hang from 
the internal wall of tlie uterine cavity or its cervical canal 
art; termed polypi. The term is a very old one, and has 
merely a clinical significance. 

The microscope has taught us that polypoid tumors of 
the uterus belong to different genera. 

The hard "fibroid polypi" are composed of unstriped 
muscle-fibre and fibrous tissue; they are myomala 01 Jibro- 
tnyomala (Fig. 62). 

The soft " mncotis polypi " consist of ttdematous con- 
nective tbsue in which glands 
may be scanty or abundant. 
These are adenomata (Fig. 

Many polypi are detached 
fragments of placenta, and 
used to be called placental 
polypi (Fig. 51). 

** Malignant polypi " 
are protruding or fungating 
processes of carcinoma (can- 
cer). 

There is one cimical feature tervici canni ia e .-■ ) 

common to all varieties of 

polypi, except occasionally small pedunculated adenomata 
of the cervix, and this is irregular loss of blood. The small 
cervical polypus (Fig. 65), even when it does not cause 
bleeding, often produces muco-purulent discharge from the 
canal. 





CHAPTKR XXIII. 
DISEASES OF THE UTERUS (Continued). 

SARCOMA, ADENOMA, AND CARCINOMA. 

Sarcoma. — The tissue of the uterus, like striped and 
and unstriptd muscle in other regions of the body, is occa- 
sionally the seat of sarcoma, sometimes of the round- and 
sometimes of the spindle-celled species. The uterus differs 
from a muscle in the important fact that it is occupied by a 
cavity lined by mucous membrane which, during sexual life, 
is very active. 

Until recently it was believed that sarcomata of the uterus 
were somewhat rare : this error may be attributed to the 
fact that in clinical work it is so customary to regard malig- 
nant disease of the uterus as the equivalent of carcinoma 
that no steps are taken to verily the nature of the disease 
by histologic methods. 

In T893, Sanger and Pfeiffer independently described a 
variety of uterine sarcoma which in its microscopic charac- 
ters so strongly resembled decidual tissue that it has be- 
come customary to speak of it as " deciduoma." However, 
the records of a large number of similar cases have been 
published, which make it clear that many e.tamples of ma- 
lignant disease formerly classed as "uterine cancer" are 
really sarcomata which contain a large number of cells 
similar in size and character to the big cells found in the 
placenta and known as " decidual cells." 

Recent observations have brought to light the important 
fact that sarcoma of this variety is very liable to occur in 
the endometrium within a few weeks or months of abortion 



DISEASES OF THE UTERUS. 203 

or delivery at term. The course of the disease is marked 
by oft-recurring profuse hemorrhage, great emaciation, en- 
largement of the uterus, and the appearance of secondary 
nodules in the thoracic and abdominal viscera, and occa- 
sionally in the bones. The disease is fatal and runs a very 
rapid course. 

The uterus is enlarged, and, rising out of the pelvis, gives 
rise to an obvious tumor in the hypogastrium. The en- 




largement is usually nodular, and on section the nodules or 
bosses are filled with a soft reddish mass resembling the 
pulp of a pomegranate (Fig. 66). 

Some observers hold the opinion that sarcomata of this 
variety arising shortly after a labor or an abortion have 
their origin in retained fragments of decidua or placenta, 
but the evidence is not sufficient to support this hypothesis. 



204 



DISEASES OF WOMEN. 






It is well established that the histologic features of a sar- 
coma are largely modified by its environment, and as very 
large connective-tissue cells (decidual cells, Fig. 67) are 
abundant in the endometrium of a gravid uterus, it nat- 
urally follows that these cells would be conspicuous in a 
sarcoma arising in a uterus recently gravid. 

Sarcomata occur in the uterus of nulHparous women, and 
they may arise in the cervix. Pernice has described a very 
remarkable example which involved the vaginal portion of 
the cervix (Kig. 6S). It had a racemose appearance, the 
grape-like bodies being composed of cells, some of which 
were oat-shapcd; others were typical spindles, many of 
them presenting across striation indistinguishable from that 




Fig. d^.—K group of dc 



of striped muscle (Fig. 69). In the basal parts of the tumor 
gland-like spaces existed lined with cylindrical or with cu- 
bical epithelium. (These were derived from the glands in 
the cervical endometrium.) After removal this tumor 
quickly recurred : it was removed a second time, but reap- 
peared and rapidly infiltrated the uterus, forming a large 
mass; death was speedy. On microscopic examination of 
the recurrent tumor no striated spindles were found, and the 
tumor had the characters of a .simple spindle-celled sarcoma. 
Diagnosis, — It is rarely possible to distinguish in the early 
^L stages between a sarcoma and a carcinoma of the body of 
^^L the uterus. It is, however, an important fact that sarcoma 
^H^ of the uterus is more apt to occur during the chtldbeaiing 



DISEASES OF THE UTF-KUS. 



305 



period of life, whilst cancer of the body of the uterus is un- 
common before the menopause. 

The chief signs of sarcoma arc frequent bleedings from the 
uterus, producing great aiia;mia and emaciation, accompa- 




nied by marked enlargement of the uterus. When these 
signs follow on a recent labor or an abortion, they are sus- 
picious signs. 

It is, however, certain that many of these signs are caused 
by retention of a fragment of placenta or a uterine mole : 
under such conditions the cervical canal should be dilated, 
and the cavity of the uterus explored and any retained frag- 



2o6 

ments removed. Should a morbid product other than pla- 
centa or a mole be detected, it is desirable to reserve pieces 
for microscopic examination. 

Treatment. — In the early stages of uterine sarcoma vag- 
inal hysterectomy gives the only hope of cure. 




^-ccltB (Fernicc). 



Epithelioma. — This disease only attacks that portion 
of the uterine cervix which is covered by an extension of 
the vaginal mucous membrane. It may begin as an ulcer 
or as a raised warty mass. It quickly destroys the cervix 
and involves the vaginal mucous membrane. 

Treatment. — When the patient comes under observation 
early — that is, while the epithelioma is restricted to the cer- 
vix — amputation of the ccrvi.'^ gives good results. It is im- 
portant to bear in mind that operations for epithelioma in 
this situation are very limited by the close proximity of the 




DISEASF.S OF THE UTERUS. 



bladder to the anterior surface of the cervix. Recurrence 
usually takes place at the cut edge of the vaginal mucous 
membrane. 

Amputation of the cervix uteri for epithelioma is attended 
with a very small risk to life. 

Adenoma. — This genus of tumors occurs in the endo- 
metrium of the body of the Uterus and its cervical canal 







{seep. 174). The condition sometimes described as " ma- 
lignant adenoma" of the body of the uterus is carci- 
noma. 

Carcinoma.. — It will be necessary to consider this dis- 
ease in two sections : 



208 DISF.ASES OF WOMEN. 

1. Cancer oritjinating in the mucous membrane of the cer- 

vical canal of the uterus ; 

2. Cancer arising in the mucous membrane lining the uter- 

ine cavity. 
I. Cancer of the Cervical Canal. — This disease is 
unfortunitLlj vtrj Lomni in ami ni ly begin in any i>art of 
the mucous membram. lining the cinal (Fig, 70), Careful 
observations show conclusively that the disease starts in the 
mucous glands and the histologic feature of the cancerous 
mass IS a cancitun of tins. M imK (Fig. 71). In its early 



ytffyki; 




stages the disease is strictly limited to the cervix, but H 
grows quickly and infiltrates the connective tissue of the 
mesomctrium (broad ligaments), the vesico-vaginal and 
recto-vaginal septa. The surfaces infiltrated by the cancer 




DISEASES OF THE UTERUS, 

ulcerate early and destroy the vaginal portion of the cer- 
vix, and then extend to the supravaginal parts of the neck, 
and finally involve the body of the uterus, and in the last 
stages of the disease this organ becomes eroded until 
nothing but a thin shell remains. 

The lymph-glands in the course of the iliac vessels are 
soon infected, and finally those of the lumbar set. 

Dissemination is frequent: secondary deposits occur in 
the lungs and liver, and they are sometimes met with in the 
bones, but not with the same frequency as in mammary 
cancer. 

SymptifiHs. — Cancer of the uterine neck is common be- 
tween the fortieth and fiftieth years: it may occur as 
early as the twenty-third year, but between twenty-three 
and thirty it is certainly unusual. 

Like uterine myoma, this disease belongs especially to 
the latter part of the chitdbcaring period of life, and it is 
almost exclusively confined to women who have borne at 
least one child. 

The signs of cancer are bleeding, offensive vaginal dis- 
charge, and sometimes pain. The first two are the signs 
which usually lead women 
to seek advice. 

On examination, if the case 
is in its early stage, the edges 
of the OS will be found evert- 
ed (Fig. 72), and a fungous 
mass protrudes from the ca- 
nal and bleeds on the slight- 
est touch. Diagnosis is rare- 
ly diflicuit. 

Conditions sometimes mis- 
taken for cancer are aden- 
omatous disease of the cer- 
vical endometrium (erosion) and small sloughing polypi. 

In the late stages, when the cervix is destroyed and an 






DISEASES OF THE UTERUS. 211 

6. Intestinal obstruction may follow adhesion of small or 
large intestine to the uterus, or direct extension of the 
growth to the rectum. 
Hydropcritoneum and hydrothorax may be due to sec- 
ondary nodules of cancer on the peritoneum and 
pleura. 

Treatment. — When the disease is detected early, before it 
has had time to overrun the cervix and implicate the vagina 
or infiltrate the connective tissue surrounding the supra- 
vaginal section of the cervix, high amputation of the cervix 
m.iy be carried out with good prospect of prolonging life. 
When there is reason to believe that the disease has ex- 
tended beyond the internal os, then the whole uterus should 
be extirpated by the vaginal method. Many operators 
maintain that in carcinoma, even when limited to the vag- 
inal portion of the cervix, the best treatment is vaginal 
hysterectomy, and it is highly probable that this view 
will prevail. 

Cancer of the Cervix and Pregnancy. — It is quite 
certain tlial a woman with cancer of the cervix may con- 
ceive, and it is by no means easy in the early stages to de- 
tect the complication, because in many cases cancer of the 
cervix leads to enlargement of the uterus. 

In a large proportion of cases, when pregnancy and can- 
cer of the cervix coexist, abortion occurs; nevertheless, the 
pregnancy sometimes goes to term, and it becomes neces- 
sary to determine whether the patient should be submitted 
to Cesarean section or hysterectomy. The course most 
usually followed is Carsarean section. In the majority of 
cases in which this complication is encountered the disease 
is too extensive to permit of radical surgical measures for 
its relief When the existence of cancer is detected in the 
mid-penod of gestation, it is advisable to terminate the preg- 
nancy, and in a few days deal with the cancer, if it should be 
in such a stage as to afford hope of a successful issue. 
Cancer of the uterus and an ovarian cyst may coexist 




DISEASES OF WOMEN. 



This combination is rare, but the presence of the cancer, if 
extensive, would be a bar to ovariotomy. 

Cancer of the cervix and uterine myomata sometimes 
coexist. In the early stages such a combination could be 
eflectively dealt with by panhysterectomy. In the later 
stages of the disease the capsule of the myoma is involved 
by ulceration, and the hard tissue of the myoma is infiltrated, 
softened, and destroyed with remarkable rapidity. 

Cancer of the Body of the XTtems. — This is much 
less frequent than cancer of the cervix. It arises in the 
tubular ylands which exist in the mucous membrane lining 
the cavity of the uterus. Little accurate knowledge is forth- 
coming in regard to its early stages. The cancer remains 
for a long period restricted to the body of the uterus, and- 
eventually creeps into one or both Fallopian tubes : it rarely 
invades the cervical canal, and then only in the late stages. 
It is apt to perforate the uterine wall and infect the perito- 
neum. 

Symptoms. — Cancer of the body of the uterus is rare be- 
fore the forty-fifth year ; it is most frequent at or subsequent 
to the menopause ; most cases occur between the fiftieth and 
seventieth years ; the patients are nearly always nullipara. 

The signs that usually attract attention are the occurrence 
of fitful hemorrhages after the menopause, followed by pro- 
fuse and offensive discharges, which are often blood-stained. 
On examination the cervix feels normal and may appear so 
when examined with the help of a speculum, but the uterus 
often feels larger than natural. 

The disease is very apt to be mistaken for some variety 
of endometritis: on the other hand, endometritis is fre- 
quently regarded as cancer of the body of the uterus. 

The diagnosis is usually made by dilating the cervical 
canal and removing a fragment of tissue from the uterine 
cavity and examining it microscopically (Fig. 74). 

Treatment. — When the cervical canal* is dilated for diag- 
nostic purposes, the mucous membrane should be scraped, 




DISEASES OF THE UTERUS. 



for if the disease should prove to be simply some form of 
endometritis, the curetting will be beneficial ; even if it 
should be cancer, this manner of treatment is often useful 
in checking bleeding for a time. 

In some instances it will be clear, on examining the uterus 
after dilating the cervical canal, that the disease is cancer, 
and if the operator is satisfied from the mobility of the ute- 
rus that there is no implication of surrounding tissues, he 




will do well, if he has the consent of the patient, to remove 
the uterus. 

Vaginal hysterectomy for cancer of the body of the ute- 
rus is followed by excellent results, immediate and remote. 

Occasionally cancer of the body of the uterus causes 
such enlargement of the organ that abdominal hysterec- 
tomy is necessary. 

Retention- cysts. — When from any cause the cervical 
canal is permanently obstructed, the secretions of the glands 
and, at certain periods, menstrual blood are retained and 
dilate the cavity of the uterus. Retention -cysts of this kind 
receive names according to the nature of the retained fluid. 




I 



DISEASES OF WOMEN. 



Hmtnatometrc — This form is due to retained blood : its 
causes and treatment are discussed in Chapter VI. 

Hydronulra. — This results from cicatricial occlusion of 
the cervical canal, usually the result of injury during par- 
turition, and is particularly apt to occur in one horn of a 
double uterus. The secretion from the glands accumulates 
and distends the cavity of the uterus, and the distended 
organ mimics a myoma or a pregnant uterus. 

Pyomctra. — This is occasionally a sequel to hydrometra 
and hxmotometra; putrefactive organisms gain access to 
the highly albuminous contents of the uterus and establish 
suppuration. Pyometra is not an uncommon complication 
of cancer of the cervix uteri. 

It may be taken as an axiom that if occlusion occur dur- 
ing menstrual life, hsematometra results ; after the meno- 
pause, hydrometra orpyotnetra. If the occlusion is due 
to cancer, then pyotnetra is the consequence. These con- 
ditions are more frequent in two-liorncd uteri than in those 
of normal form. 

Diagnosis and Treatment. — So far as hBematometra is 
concerned the chief points in diagnosis and treatment were 
described in Chapter VI., and the details therein mentioned 
will serve to guide the student in the recognition of pyome- 
tra, which is a somewhat infrequent condition, except when 
it complicates carcinoma of the cervix. An uncomplicated 
case of pyometra is easily treated by freely opening up the 
cervical canal, evacuation of the pus, and the employment 
of efficient irrigation. 

Echinococcus Colonies. — These are rarely met with 
in the uterus ; they occur as cysts situated immediately be- 
neath the peritoneal investment of the uterus. 




CHAPTER XXIV. 
DISEASES OF THE FALLOPIAN TUBES. 

MALFORMATIONS. DISPLACEMENT, IN- 
FLAMMATION, AND TUMORS. 

Malformations. — These are of no practical importance. 
The abnormality which is most likely to attract attention is 
the presence of one or even two accessory ostia in the am- 
pulla. An accessory ostium is surrounded by a tuft of 
fimbriae. Deficient development or total absence of a tube 
is usually, but not always, associated with defective develop- 
ment of the corresponding half of the uterus. 

Hernia of the Tnbe (Salpingoccle).— This is rare, but 
hernia of lln.- ovary am! tube is by no means uncommon. 

Inflammation of tbe Fallopian Tubes (Satptn^tis). 
— This is nearly always secondary to septic infection of the 
genital tract. 

The chief causes are septic endometritis following labor, 
abortion, or gangrene of a uterine polypus; gonorrhoea, 
tuberculosis, and cancer of the uterus. 

The changes produced by septic endometritis and gonor- 
rhcea are almost identical, and the effects produced may 
be studied under four headings : i . The acute stage ; 2. The 
occlusion of the tubal ostium; 3, Pyosalpinx; 4. Hydro- 
salpinx. 

The Acute Stage. — When the infection extends from 
the mucous membrane of the uterus to that of the tubes, 
the tubal tissues become soft, succulent, .swollen, and friable. 
The surface of the mucous membrane is covered with glu- 
tinous pus, which exudes from the abdominal ostium when 



2t6 



DISEASES OF WOMEK. 



the tube is squeezed. When this infective material escapes 
from the tubes into the pelvic section of the coelom it sets 
up pelvic peritonitis, which is not infrequently rapidly fatal ; 
when it supervenes on delivery or abortion it is commonly 
termed "puerperal peritonitis." The occurrence of infective 
peritonitis in this way has been demonstrated on many oc- 
casions by carefully conducted autopsies. Acute gonor- 
rhceal peritonitis sometimes occurs in the same way, tliough 
it is far less frequently fatal than that which follows septic 
endometritis. 

The direct channels established by the Fallopian tubes 
between the cavity of the uterus and the ctelom (general 
peritoneal cavity) facilitate peritoneal infection. But its fre- 
quency is diminished in a very important manner by occlu- 
sion of the abdominal ostia of the tubes — a pathological 
sequence of great value in so far as the saving oP life is 
concerned. 

Occlusion of the Ostitim.— When inflammation ex- 
tends from the tubal mucous membrane to the peritoneum 
adjacent to the ostium, it 
leads to the formation of 
adhesions in consequence 
of the organization of the 
exudation, which leads to 
the matting together of 
the tubal fimbria" ; this 
also glues them to the 
ovary and posterior layer 
of the broad ligament, and 
occasionally to a coil of 
intestine. This mechanic- 
ally seals the ostium. 

There is another in- 
teresting and probably 
slower way in which these ostia become occluded. The 
fimbrix are luxuriant protrusions of tubal mucous mem- 






pin". 


of th. K.UDpi.n lube. 1 


he w 


plMdr occluded. 






DISEASES OF THE FALLOPIAN TUBES. 



branc beyond the ostium. When the tubes are inflamed 
the muscular and serous coats lengthen and bulge over the 
fimbria; until each ostium appears as a rounded smooth ori- 
fice instead of being fringed ; gradually the rounded margins 
contract, cohere, and occlude the opening. In the early 
stages, if the rounded end of the occluded tube be slit up, 
the fimbriae will be found crowded inside the tube. This 
mode of occlusion is termed "salpingitic closure of the 
ostium" (Fig. 75). 

This sealing up of the ostium is a remarkable and con- 
servative process in so far as the life of the individual is 
concerned. The occluded tube now becomes the seat of 
important changes whereby it is converted into a pyosal- 
pinx. a hydrosalpinx, or undergoes sclerosis. 

Fyosalpinx. — This may be defined as a Fallopian tube 
with an occluded abdominal ostium, the cavity of the tube 
being distended with pus. 

In the early stages a pyosalpinx may not exceed the fin- 
ger in thickness, but in a fair proportion of cases the tube 
becomes distended and its walls thicken in some parts and 
thin in other, until it assumes the shape and attains the 
sine of a ripe banana. Exceptionally a pyosalpinx forms 
a swelling large enough to rise above the brim of the 
pelvis. 

A pyosalpinx adheres to adjacent structures, such as the 
ovary, mesometrium, bowel, and especially the rectum. 
Sometimes the wall of the sac bursts and the pus is dis- 
charged into the ccelom (general peritonea! cavity) and sets 
up fatal peritonitis. More frequently a pyosalpinx opens 
into the rectum and the pus escapes by the anus. This is 
one method of spontaneous cure. 

In severe cases of salpingitis, as has already been men- 
tioned, the ovarj- is almost always implicated, and while the 
tube is undergoing conversion into a pyosalpinx an abscess 
forms in the ovary. The sacculated pus-containing tube and 
the abscess in the ovary may remain distinct, but very fre- 



2|8 



DISEASES OF WOMEN. 



qiiently the two fuse together and form what is known as a 
tubo-ovariati abscess (Fig. 76). 

Hydrosalpinx. — This may be defined as a Fallopian 
tubi; distended with serous fluid in consequence of inflam- 
matory occlusion of its cffilomic ostium. 

Salpingitis does not always lead to occlusion of the ab- 
dominal ostia of the tubes. A mild attack may conveniently 
be described as "catarrh of the tubes," and, like a nasal or 
gastric catarrh, subsides and leaves no trace- When the in- 



OvAriim lig.imtiil- 




flammation has been sufficiently severe to seal the ostium 
the tube is permanently damaged. Such a tube becomes 
passively distended with fluid and converted into a legume- 
shaped cyst 

A hydrosalpinx sometimes possesses walls so thin that 
it is tiansluccnt and devoid of adhesions. In other cases 
the wall is universally adherent. Some, if not most, exam- 
ples of hydrosalpinx are secondary to pyosalpinx, the puru- 
lent contents of which have become sterile. 




219 

Hydrosalpinges vary greatly in size : tlie specimen repre- 
sented in Fig. jy is of average proportions. When a hy- 
drosalpinx exceeds that size, it wilt often form a sivelling 
appreciable above the brim of the true pelvis ; very large 
specimens are often erroneously termed tubo-ovarian cysts 
and ovarian hydroceles. 

Intermitting Hydrosalpinx. — It has been stated on clinical 
evidence that the fluid in a hydrosalpinx may escape through 
the uterus, the blockade of the uterine end of the Fallopian 
tube being raised. Such a condition is termed " hydrops 
tubx profluens," the escape of the fluid taking place at 




irregular intervals. Profuse di.scharges of pus and fluid 
occur in connection with pyo- and hydrosalpinx, accompa- 
nied by a diminution in the size of the tumor, due to the 
formation of a fistula between the cyst and the rectum or 
the vagina. 

It is a fact of some interest that the uterine end of the 
Fallopian tube is rarely obliterated in salpingitis. Of course 
the tumidity of the mucous membrane would be sufficient 
in most cases to obstruct the passage of fluid from the tube 
into the uterus. 

Hsematosalpinx. — This term is applied to a distended 



220 DISEASES OF WOMEN. 

non-gravid Fallopian tube with an occluded abdominal 
ostium. Tht cavity contains blood or blood-stained fluid. 

Ha;matosalpinx is a rare condition : many specimens for- 
merly catalogued under this term prove on careful exam- 
ination to be gravid tubes. This matter is discussed in the 
section devoted to Tubal Pregnancy. 

Sclerosis of the Tubes. — Every Fallopian tube affected 
with chronic salpingitis is not converted into a pyosalpinx 
or a hydrosalpinx : it may become changed into a hard, 
fibrous body traversed by an irregular canal. 

In the early stages of salpingitis the tubal walls are in- 
filtrated with inflammatory exudation: gradually this exu- 
dation organizes into fibrous tissue and the true tubal struc- 
tures atrophy. It is a ver)' slow process, and probably six 
years is required for the conversion. The process is identi- 
cal with that which leads to stricture of the male urethra. 
It is not unusual to find a hydrosalpinx on one side of the 
uterus and a sclerosed Fallopian tube on the other. 

Sclerosed tubes are sometimes sources of danger, as 
small abscesses form in them, perforate the wall of the tube. 
and lead to adhesion of small intestine, and cause fatal in- 
testinal obstruction. 

Ttibercular Salpin^tis. — Most examples of this dis- 
ease are undoubtedly secondary to tuberculosis of the en- 
dometrium. The naked-eye features of a tubercular tube 
are often very characteristic, but it is sometimes impossible 
to distinguish it from a pyosalpinx. In many instances the 
abdominal ostium is occluded and the tube tightly stutfed 
with caseous material (Fig. 78). On removing this material 
the mucous membrane presents the usual velvet-like ap- 
pearance characteristic of the walls of a chronic abscess. 

In many patients tubercles are found in other parts of 
the body, so that it is diflicult to decide which is the pri- 
mary seat of the disease. The bacilli are often difficult of 
detection ; however, when tubes are found distended with 
caseous pus and deposits containing tubercle-bacilli are 




DISEASES Of THE FALLOPIAN TUBES. 

found in other organs, it may be used as evidence that the 
disease in the tubes is Likewise tubercular. The only abso- 
lute test of tubercular salpingitis is the detection of the 
tubercle-bacilli in the contents or the tissues of the Fallo- 
pian tube. 

It is an important clinical fact that many cases of tubercu- 
lar peritonitis in infants, girls, and young women are due to 



\ 




infection from tubercular tubes in consequence of the ostia 
remaining unoccluded. Exceptionally infection of the peri- 
toneum has resulted from perforation of a tubercular tube. 
It is also possible that the tubes may sometimes be infected 
secondarily to tubercular peritonitis, due to tuberculosis of 
the intestine. 
Kon-inflammatory Stenosis of the Tubal Ostium. 
. — There is a curious and Somewhat rare variety of tuba! 



VISEASES OF WOJiTEU. 



distt-'iition which is sometimes, though erroneously, de- 
scribed as pyosalpinx; it is not caused by septic changes 
in the uterus or by gonorrhea. The patients are usually 
virgins, or, if married, they are sterile. 

In well-marked specimens the tubes become converted 
into huge banana-like or legume-shaped cysts, which not 
only appear above the pelvic brim, but may reach as high 
as the navel. The abdominal ostium is usually completely 
occluded, but traces of the fimbria; may be observed even 
in extreme cases. The contents of these dilated tubes 
are viscid like old honey, and are occasionally of the con- 
sistence of putty. In some specimens the mucous mem- 
brane resembles wet chamois leather. This rare variety of 
tubal disease seldom causes inconvenience until the enlarge- 
ment of the tubes produces obvious swelling of the lower 
part of the belly. The change probably depends on non- 
inflammatory (possibly confjenital) stenosis of the abdom- 
inal ostia of the Fallopian tubes, 

Tmnora of the Fallopian Tube. — These are exces- 
sively rare, and belong to four genera: Myoma, adenoma, 
sarcoma, and carcinoma. 

Myoma. — Tumdrs composed of unstriped muscle tis- 
sue growing from the Fallopian tube are among the great- 
est rarities of oncology : this is extraordinary, considering 
the extreme frequency of myomata in the uterus. Even 
when growing from the tube they rarely attain such sizes 
as to be clinically important. 

Sarcoma. — At present this is so rare a tumor of the 
tube that it may be regarded as merely of pathological in- 
terest. 

Adenoma. — Tumors composed of glandular tissue have 
on several occasions been observed growing from the tubal 
mucous membrane. An adenoma of the Fallopian tube 
may assume the dendritic form of a large papilloma, or con- 
sist of a mass of cyst-like swellings and resemble a bunch 
of grapes. The stroma of the tumor consists of delicate 




DISEASES OF THE FALLOPIAN TUBES 



connective tissue in which glandular acini, lined with a 
single layer of columnar epithelium, are imbedded. Some 
of the cysts present in these turners contain intracystic pro- 
cesses. A curious feature connected with these tumors is 
the presence of free fluid in the belly — hydroperitoneum. 
This is due to the secretion from the adenoma escaping 
through the abdominal ostium of the tube and irritating 
the peritoneum. Although the peritoneal fluid may be 
evacuated, It accumulates as long as the adenoma is allowed 
to remain. Removal of the adenoma at once and perma- 
nently arrests the effusion. 

Carcinoma. — This disease as a primary aflection is ex- 
cessively rare. The tubes are occasionally implicated by 
extension of cancer from the uterus. 



CHAPTER XXV. 



DISEASES OF THE FALLOPIAN TUBES (Continued). 

DIAGNOSIS AND TREATMENT OF SALPIN- 
GITIS. 

Acute Salpingitis. — The leading signs of this affection 
arc not dependent on the tubes, but become manifest when 
the infection extends from the tubes to the pelvic perito- 
neum. When this disease is secondary to septic endome- 
tritis the signs often come on with great suddenness. The 
discharges from the uterus are offen.sive; the patient may 
have a temperature of ioo° F. Suddenly she is seized with 
a rigor; the temperature rises to 103° or 104°; the belly 
quickly swells; and in twenty-four hours there is clear evi- 
dence of infective peritonitis. In some of these cases death 
follows in a few days ; in others the patients slowly recover. 
When these signs supervene on delivery or abortion, the 
condition is often called puerperal peritonitis. 

Similar attacks are sometimes seen after operations upon 
the uterus, and may complicate a gangrenous intra-uterine 
myoma (polypus). 

As a rule, slow accession of symptoms indicates gradual 
extension of infection from mucous and muscular to serous 
tissue. Sudden onset of the .severe signs means actual leak- 
age from the tube into the ctelom {general peritoneal cav- 
ity). In some cases acute infection of the peritoneum is in- 
dicated by profound collapse. The above signs may be 
interpreted thus : slow extension leads to chronic changes ; 
leakage, as a rule, leads to general infective peritonitis, and 
not infrequently to death. 



DISEASES OF THE FALLOPIAN TUBES. 



225 



It should also be borne in mind that sudden infection of 
the pelvic peritoneum during labor may arise from the 
bursting of a pyosalpinx, or a suppurating ovarian cyst of 
small size. 

Acute pelvic peritonitis sufficiently severe to imperil hfe 
occasionally occurs in the early stage of gonorrhcea before 
the ccelomic (abdominal) ostia become sealed. 

Trfatmeiil. — Acute salpingitis demands absolute rest in 
bed and the routine use of mild vaginal injections. The 
bowels should be kept regular with mild saline purgatives. 
When the pelvic pain is very great warm fomentations 
should be applied to the hypogastrium, and morphia or 
opium may be judiciously prescribed. 

When the signs indicate extensive fouling of the peri- 
toneum and the patient's life is imperilled, the surgeon may 
have to consider the advisability of performing cceliotomy. 
In all cases in discussing treatment the surgeon is bound to 
remember that his diagnosis is not infallible, and, though 
the signs may mdicate leakage from an infected lube, it may 
be due to :v rupture of an ovarian or a perityphlitic abscess. 
In such cases cceliotomy is the only hopeful course. 

Chronic Salpiug^itis. — This is a very common disease, 
and one that not infrequently imperils life; even in cases 
when life is not endangered, the pain and inconvenience 
tliese women suffer are often such as to render them chronic 
invalids. 

The chief points are these : The patient is usually be- 
tween twenty and thirty-five years of age, and furnishes a 
history of difficult labor or abortion, followed by a pro- 
tracted illness, since which she has been sterile and suf- 
fered from excessive, prolonged, and often painful menstru- 
ation. Defecation and sexual congress are sources of pain ; 
some complain also of a vaginal discharge. Married women, 
and occasionally single women, furnish details of such a 
kind as lead us to believe that an attack of gonorrhoea 
marked the beginning of the trouble. 




D/SEASES OF WOMEN. 



The symptoms, briefly summarized, are menorrhagta, 
pain, and sterility. 

Tubercular salpingitis lias wider age-limits, as it occurs 
in children from eighteen months onward (Fig. 79). In 
girls after puberty this variety of .salpingitis is often accom- 
panied by amenorrhcea. 

On examining the abdomen an irregular tender swelling 
may be .sometimes detected in one or both flanks ; more 
frequently there is an indefinite swelling, and in some, on 
palpation, a sense of resistance can be made out, but in 
very many cases no swelling can be detected. 

On internal examination there will be found lying on 
each side of or behind the uterus an elongated swelling, 




which usually gives rise to great pain when pressed by the 
examining finger. Not infrequently the uterus is acutely 
retroflc.xed, and then the uterine fundus with the enlarged 
tubes and ovaries forms a rounded ridge running trans- 
versely across the pelvic floor. 

As a rule, a moderately distended tube can only be felt 
through the vagina or by the bimanual method. 

Tactile judgment is a very important factor in the diag- 
nosis of pelvic swellings. To estimate the size, consistence, 
fixity, or mobility of a tumor lying in close relation.ship with 
the uterus requires experience. 

In a general way, it may be stated that it is impossible to 




D/SEASES OF THE FALLOPIAN TUBES. 

accurately diagnose between the various forms of tubal and 
the following forms of ovarian disease ; 

1. Tubercular abscess of ovary ; 

2. Apoplexy of the ovary ; 

3. Small ovarian cysts, tumors, or dermoids ; 

4. Small parovarian cysts ; 

5- Gravid tubes previous to rupture or abortion. 
The following conditions are very liable to be mistaken 
for tubal disease : 

Retroflexion of the uterus ; 

Pelvic cellulitis ; 

Fecal accumulation in the rectum ; 

A kidney in the hollow of the sacrum ; 

A small uterine myoma ; 

Cancer of the sigmoid flexure of the colon ; 

Abscess, due to inflammation of the vermiform appen- 
dix burrowing into the mesometrium ; 

Tumors of the sacrum or innominate bone ; 

Tumors of the mesometrium, including echinococcus 
colonies. 
When a Fallopian tube is so distended as to render it 
capable of being felt above the pelvic brim it is liable to be, 
and often is, mistaken for an ovarian cyst. On the other 
hand, when ovarian and parovarian cysts arc not large 
enough to be felt above the pelvic brim they closely simu- 
late pelvic cellulitis or distended tubes. 

Treatment. — When the tubal mucous membrane has be- 
come seriously damaged and the tubes fixed by adhesions 
to surrounding structures, then drugs are of little avail. 
When such persons are able to lead a life of ease they often 
become chronic invalids and try Continental health resorts, 
where they visit the springs and indulge in baths, especially 
the mud-baths of Bohemia. In poorer patients such treat- 
ment is out of the question, and in order to lead a useful 
life, as well as to escape from pain, they willingly submit to 
surgical measures. 




228 



DISEASES OF WOMEN. 



The ordinary rules of surgery suggest that when the 
physical signs indicate that the Fallopian tubes are occluded 
and distended with pus or other fluid, producing pain and 
inconvenience, so as to cause the patient to lead the life of 
a chronic invalid, it is justifiable to remove them. 

Removal of the Fallopian tubes and ovaries (oophorec- 
tomy) is justifiable and the only radical means of treatment 
in the following conditions : Pyosalpinx and tubo-ovarian 
abscess; hydrosalpinx; ovarian abscess; tubercular sal- 
pingitis. 

In tubercular salpingitis oophorectomy should only be 
undertaken when there is no evidence of tubercle in other 
organs, such as lungs, bladder, or kidneys. The method 
of performing oophorectomy is described in the section 
devoted to the description of operations. 




CHAPTER XXVI. 
DISEASES OF THE FALLOPIAN TUBES (Continued). 

TUBAL PREGNANCY. 

In order to reach the uterine cavity an ovum must traverse 
the Fallopian tube. When an oosperm (fertilized ovum) is 
retained in the tube it develops and gives rise to the condi- 
tion known as "tubal pregn.incy." 

Concerning the cause or causes of tubal pregnancy noth- 
ing is known, and this uncertainty will continue until reliable 
evidence is forthcoming in regard to the situation in the 
genital passages where ovum and spermatozoon normally 
meet. It is reasonable to believe that fertilization normally 
happens Jn the uterus, but when it occurs in the tube it is 
accidental and tubal pregnancy is the consequence. It is 
probable that when an ovum is converted into an oosperm 
the latter immediately engrafts itself on the adjacent mucous 
membrane, whether it be tubal or uterine. 

Tubal pregnancy may happen as a first pregnancy in 
women who have been married eight, ten, or even twenty 
years. A Fallopian tube may become gravid in the newly 
married or in the mother of a large family. Both tubes 
may. in very exceptional instances, be gravid concurrently, 
or one tube may become pregnant years after its fellow. 
Very rarely two oosperms are retained in the same Fallo- 
pian tube — twin tubal pregnancy. Tubal may complicate 
uterine pregnancy. 

An analysis of a large number of cases establishes the 
fact that tubal pregnancy is very apt to occur in women 
who have been sterile many years, and has given color to 



230 




DISEASES OF It'OAtEJV. 



the suggestion that chronic salpingitis and loss of tubal 
epithelium may predispose to this accident. A careful se- 
ries of investigations on an abundant supply of material 
teaches us that a healthy Fallopian tube is more likely lo 
become gravid tlian one wkieli has been inflamed. 

The events which follow the retention of an oosperm in 
a Fallopian tube vary according to its position, thus : 

Retention in the ampulla and isthmus is called tubal 
gestation. 

Retention in the portion traversing the uterine wall is 
known as tu bo- uterine gestation. This variety requires 
separate consideration. 

The stages of tubal pregnancy will be described in sec- 
tions, as follows: 

Changes in the tube; 

The tubal mole ; 

Tubal abortion ; 

Tubal rupture ; 

The decidua and placenta. 
The Changes in the Tube. — During the first month 
or six weeks following the lodgement of an oosperm, the 
tubal tissues are swollen and turgid; occasionally at the 
site where the villi are implanted the tubal wall becomes 
very thin. In many ca-ses, especially when the oosperm is 
lodged in the ampulla of the tube, the abdominal ostium 
gradually closes by a process very analogous to that de- 
scribed as resulting from salpingitis. Occlusion of the ab- 
dominal ostium is a slow process and requires probably 
eight weeks for its completion {Fig. So). When the oosperm 
is retained in the isthmus or in the uterine section of the 
tube the abdominal ostium is rarely affected. In a [air pro- 
portion of cases the ostium dilates instead of contracting. 
There is as yet no good explanation forthcoming in re- 
gard to these two opposite conditions, but they exercise an 
important influence on the subsequent course of the preg- 
nancy. Microscopic investigation of the uterine end of the 



DJSEASES OF THE FALLOPIAN TUBES. 



-, to show that it is not obstructed when the tube 



tube s 

The Tubal Mole.— The changes which occur in the ' 
oosperm arc the same whether it be lodged in a Fallopian 
tube or in the uterine cavity : in each situation it is liable to 
become converted into what is known as a " mole." Such 
a body is an early embryo and its membranes into which 
blood has been extravasated. Tubal moles vary greatly in 
size 1 some have been detected with a diameter of i cm. ; 




Fig. tu,— Gn>id Fillopui 



lib umpkldii ocduded »Uuin. 



others measure 5 or even 8 cm. Small tubal moles are 
globular, but after they attain a diameter of 3 cm. they as- 
sume an ovoid shape. The amniotic cavity usually occu- 
pies an eccentric position ; occasionally the embryo is de- 
tected within it (Fig. 8i). More often it escapes, or is de- 
stroyed by the original catastrophe which formed tlie mole. 
When no embryo, amniotic cavity, or chorionic villi can be 
detected by the naked eye, a microscopic examination of 
sections will lead to the detection of chorionic villi. They 
arc very characteristic structures (see Fig. 52, page 166), 



232 



DISEASES OF WOMEN 



and as certain evidence of tubal pregnancy as the embryo 
itself. 

It is an interesting fact that the blocd in a tubal mole lies 
between the chorion and the amnion in a temporary space 
known as the subchorionic chamber. This blood is derived 
from the circulation of the embryo, and a large proportion 
of the red corpu.scles are nucleated. 

Tubal moles only arise in the first two months following 
fertilization. The laminated condition of the clot presented 
by some of these bodies indicates that a mole is sometimes 
formed by a succession of hemorrhages. 




Tubal Abortion. — It has already been pointed out that 
the lodgement of an oosperm in the outer third of the tube 
usually leads to occlusion of the abdominal ostium by the 
end of the eighth week. So long as this orifice remains 
open the oosperm is in constant jeopardy of being extruded 
through it into the ccelom (peritoneal cavity), especially 
when lodged in the ampulla of the tube; the nearer it is 
situated to the ostium the greater the risk of its ejection 
(rom the tube. To this accident the term tttbal abortion is 
applied, for it is parallel to those early abortions occurring 
in uterine gestation before the end of the second month ; 




DISEASES OF THE FALLOPIAN TUBES. 

and it further resembles them in the fact that the oosperm 
is nearly always converted into a mole. 

In tubal abortion the mole is occasionally discharged 
through the ostium into the ccelom (peritoneal cavity) with 
a copious hemorrhage, accompanied with the usual signs of 
internal bleeding, and death may occur early from the 
I thus induced or from shock. In such instances 




the mole, being very small, may escape recognition when 
the clot is examined either at operation or post-mortem. 

The amount of blood discharged into the ccelom under 
these conditions sometimes amounts to two, three, or even 
four litres. When the mole is extruded from the tube 
through the unclosed abdominal ostium it is described as 
" complete tubal abortion " (Fig. S2) ) very frequently the 



234 



DISEASES OF WOMEN. 



mole is retained in the tube ; it is then referred to as " in- 
complete tubal abortion." The retention of the mole leads 
to recurrent hemorrhafje. The loss of blood in both varie- 
ties of tubal pregnancy is often so great as to imperil life. 

Tubal abortion is of great interest, as the bleeding which 
accompanies it was formerly erroneously ascribed to metror- 
rhagia, reflux of menstrual blood from the uterus, or hem- 
orrhage from the tubal mucous membrane. 

Rupttire of the Gestation Sac. — It is an undeniable 
fact that every gravid tube left to itself either aborts or 
bursts. When from any cause tlie pregnancy is disturbed 
before the abdominal ostium is occluded, the probability is 
in favor of abortion, but a gravid tube often ruptures in 
spite of a patent ostium. When the pregnancy advances 
until the ostium is closed, then the tube bursts at some 
period between the sixth and tenth week following impreg- 
nation ; this accident is rarely deferred till the twelfth week. 
This is called primary rupture, and may be intraperitoneal 
or extraperitoneal. The determining causes of the rupture 
are of various kinds, such as jumping from a train, chair, or 
carriage; defecation; sexual congress; examination of the 
uterus, etc. Occasionally no such influence is demon- 
strable. 

Primary Intraperitoneal Rapture. — In this variety 
the rupture is so situated that the blood escapes into the 
crelom and inundates the recto-vaginal fossa. The embryo 
or mole may escape through the rent or be detained in the 
tube. 

The blood effused may amount to two litres or even 
more. Extravasations of this kind were formerly called 
pelvic haEmatoceles, l"his term could, with advantage to 
the student, suffer obliteration. 

The dangers of primary intraperitoneal rupture of a 
gravid tube are rapid death from hemorrhage or death 
from repeated hemorrhages. Women occa.sionally survive 
a limited hemorrhage, and the efl'used blood slowly absorbs. 




DISEASES OF THE FALLOPIAN TUBES. 



When the bleeding is not excessive the blood collects in 
the rectovaginal fossa, and floats up the coils of intestines, 
and these, with the omentum, gradually form a covering to 
the fossa by adhering together, thus isolating the blood in 
the pelvis from the general peritoneal cavity. Taylor has 
shown that the effused blood in these c.ises sometimes 
coagulates in layers and forms a spurious cyst. 

Primary Bxtraperitoneal Rnptore. — In a fair pro- 
portion of cases the tube bursts m that portion of its cir- 
cumference lying between the folds of the mesosalpinx. 
When this happens the mole and a varying amount of 
blood are forced between the layers of the mesometrium. 
As a rule, the bleeding is arrested before it assumes 
dangerous proportions in consequence of the resistance 
which occurs when the mesomctric tissues become dis- 
tended. This is fortunate, for the blood and mole are 
entombed in the mesometrium, and rarely cause subse- 
quent trouble. 

Rupture may take place, the embryo with its membranes 
remain uninjured, and the pregnancy continue; for. no 
longer confined within the narrow limits of the tube, it be- 
gins to avail itself of the additional space thus offered, and 
burrows, as it grows, between the layers of the mesomet- 

According to the manner in which this mode of rupture 
is sometimes described, it might be imagined that the tube 
splits and the products of gestation are suddenly discharged 
from the tube into the mesometrium. This is not the case, 
or the pregnancy would in every instance come to an end 
from the dissociation of the foetal from the maternal struc- 
tures. A careful study of the morbid anatomy of the acci- 
dent indicates that the slow and gradual distention of the 
tube causes it to thin and gradually yield in that part of its 
circumference uncovered by peritoneum, until an opening 
forms, accompanied by sudden hemorrhage, which produces 
collapse, the profundity and duration of which depend upon 



236 D/SEASES OF WOMEN. 

the amount of blood effused. This artJIidal opening gradu- 
ally extends, while the growing embryo and placenta make 
their way into, and by degrees occupy, the new area of con- 
nective tissue opened up, unless the life of the embryo is 
terminated by renewed hemorrhage. 

When gestation continues in this way it is spoken of as 
" mesometric pregnancy," because the sac is formed in part 
by the expanded Fallopian tube and the layers of perito- 
neum forming the mesometriura. 

The Placenta and Decidna. — In tubal gestation the 
placenta is liable to many vicissitudes which influence very 
seriously the life of the ftetus, and are such grave sources 
of danger to the mother that they demand great considera- 
tion from the surgeon. 

A uterine placenta consists of fcetal and maternal ele- 
ments, but a tubal placenta possesses fcetal elements only 
(chorionic viUi), for in a tubal pregnancy a decidua forms in 
the uterus, not in the tube ; further, the tubal mucous mem- 
brane takes very little share in the formation of the placenta. 
It is the primitive character of the tubal placenta whidi 
helps to make the embryo's life so precarious. 

The Decidna. — In all varieties of tubal pregnancy a 
decidua forms in the uterine cavity; it is rarely retained 
until term ; when it is, the membrane is thrown off during 
the false labor characteristic of that period. More fre- 
quently the decidua is discharged in pieces during the early 
period of labor or is expelled whole with signs of miscar- 
riage. Decidure vary in thickness from 6 to 8 mm. They 
may be described as bags resembling in outline an isosceles 
triangle (Fig. 83). The base corresponds to the fundus of 
the uterus, and the apex to the internal opening of the cer- 
vical canal. At each angle of the triangle there is an open- 
ing. Those at the basal angles correspond to the Fallo- 
pian tubes, and the apical orifice to the cervical canaL The 
outer aspect is shaggy, and the inner surface is dotted wilh 
the orifices of uterine glands. The angle corresponding to 




the internal orifice of the cervical canal J: 
by a large opening. 

The histology of a dectdua is best studied in sections cut 
parallel with the surface. In this way the epithelium hiiing 
the ducts of the uterine glands is well shown. The spaces 
not lined with epithelium arc blood-vesseb. 




It is useful, for chnical purposes, to be familiar with the 
microscopic characters of decidux, because it happens that 
an early uterine abortion often simulates primary rupture of 
a gravid tube, and vuc versa. On examining shreds which 
have escaped from the vagina one is able to decide by 
means of the microscope whether they are fragments of 
decidua or chorionic villi from a uterine conception. 

Displacement of the Placenta. — Up to the date of 



238 DISEASES OF iVOMEN- 

primary rupture the fonnation of the placenta has been 
proceeding ill relation with the mucous membrane of the 
tube, but after this occurrence, if the disturbance is not 
severe enough to terminate the pregnancy, the course of 
events is modified in a remarkable manner, and the ultimate 
result is largely determined by the relative position of the 
foetus and placenta. 

When the embryo is situated above the placenta, the 
latter gradually grows and insinuates itself between the 
layers of the mesometrium (broad ligament) until it comes 
to rest upon the floor of the pelvis. Should the embryo 
lie below the placenta, the fcetus will ultimately come to 
rest on the pelvic floor, and the placenta will be pushed 
upward by the growing fcEtus. 

This gradual displacement leads to disastrous changes, 
such as repeated hemorrhages into the placenta, which im- 
pair its functions and lead to arrest of development and 
death of the fcetus. A tubal ftetus, even when it survives 
to term, is always an unsatisfactory individual. When res- 
cued by the surgeon these fcetuses rarely live more than a 
few weeks or months. Many are ill-formed and present 
hydrocephalus, club-foot, ectopia of the viscera, and the like. 

Should the ftrtus die early, the placenta gradually atro- 
phies, and in cases of lithopasdion there is no trace of it. 

Secondary Rupttire of the Sac. — The constant ten- 
sion to which the gestation sac is exposed may, if increased 
by a sudden hemorrhage, lead to rupture and death. This 
is known as "secondary intraperitoneal rupture." Occa- 
sionally the gestation continues to term ; then symptoms 
of labor set in, and, as delivery by the natural channels is 
impossible, the sac may burst into the ccelom. Escaping 
this, the fcetus dies, and, remaining quiescent, becomes 
mummified or is transformed into a lithopaidion. Later the 
soft parts may become adipoccre. or decompose. When the 
fcetal tissues putrefy, then the pus bursts through the blad- 
der, rectum, vagina, or through the abdominal wall, and 




DISEASES OF THE FALLOPIAN TUBES. 



fragments of fcetal tissue and bones are discharged from 
time to time. This is known as " secondary extraperitoneal 
rupture." 

A lithopa;dion — that is, a fcetus whose tissues are impreg- 
nated with lime salts (calcified) — may remain quiescent for 
many months or even fifty years ; indeed, may never cause 
subsequent trouble; but it is always a potential source of 
danger, for if pathogenic micro-organisms gain access to it, 
suppuration is the inevitable consequence. 

Thus, of the two varieties of secondary rupture, the intra- 
peritoneal may occur at any period from the date of the 
primary rupture to term ; whereas the extraperitoneal variety 
may not take place for months or even years. 

The cases of secondary intraperitoneal rupture where the 
foetus is found free among the intestines were formerly re- 
garded as examples of fertilized' ova which had become 
engrafted on the peritoneum and developed into foetuses. 
Happily, this error no longer prevails, and we now know 
that all forms of cxtra-uhrinc pregnancy pass ihdr primary 
stages in the Fallopian tubes. 

Tubo-nterine Gestation, — When an oosperm lodges 

in that section of the tube which traverses the uterine wall 

it is termed tubo-utcrlne gestation. It is very rare, many 

specimens described under this name being examples of 

I pregnancy in the rudimentary horn of a unicorn uterus. 

This variety runs a somewhat different course to the 

I common variety of tubal pregnancy. For example, pri- 

\ mary rupture may be delayed to the si,xtcenth week. The 

I sac may rupture in two directions. It may burst into the 

coelom, and is often rapidly fatal ; or it may rupture into 

the uterine cavity and be discharged like a uterine embryo. 

A tubo-uterine gestation-sac never ruptures into the meso- 

metrium (broad ligament). 

Although in many examples of tubo-uterine gestation 
primary rupture may be longer delayed than in purely 
tubal gestation, nevertheless the sac sometimes bursts very 



240 



DISEASES OF WOMEN, 



early ; in such cases death usually takes place within a few 
hours from hemorrhage. 

An examination of the clinical details of cases of un- 
doubted tubo-uterine gestation indicates that intraperitoneal 
rupture of the sac is more rapidly fatal in the tubo-uterine 
than in the purely tubal form. This is due to the greater 
amount of hemorrhage, because not only are the walls of 
the gestation sac thicker, but the rent often extends to, and 
involves, the wall of the uterus. 




CHAPTER XXVIl. 
DISEASES OF THE FALLOPIAN TUBES (CoNTiNUEn). 

DIAGNOSIS AND TREATMENT OF TUBAL 
PREGNANCY. 
Diagnosis. — The signs of tubal pregnancy vary accord- 
ing to the stage of the gestation; they will therefore be 
dealt with in sections, thus: 

1. Before primary rupture or abortion ; 

2. At the timo of primary rupture or abortion ; 

3. From the date of primary rupture to term ; 

4. At and after term. 

1. Before Rnpttire or Abortion. — Since the pathology 
of the early stages of tuba! pregnancy has been carefully 
investigated and a clear distinction recognized between a 
gravid tube and a hematosalpinx, many cases have been 
recorded in which a correct diagnosis was made before the 
operation was undertaken. This is very gratifying, and it is 
a matter of great importance for the patient, as it spares 
her the awful peril which attends rupture of the tube. 

The patient usually gives a definite history of a missed 
menstrual period after having been previously regular; fol- 
lowing on this event she begins to experience pelvic pain 
which induces her to seek advice. On examination an en- 
larged Fallopian tube is detected. When there is no his- 
tory of old tubal disease, or any fact in the history of the 
patient suggesting septic endometritis or gonorrhoea, then 
presumption favors a fjravid tube. 

2. At the Time of Primary Rupture or Abortion. — 
The tube bursts or abortion occurs at some period before 



242 



DISEASES OF WOMEN. 



the twelfth week : the effect upon the patient depends upon 
the scat of rupture. When it takes place between the layers 
of the mesometrium (broad ligament), the symptoms will, 
as a rule, be less severe than when the tube bursts into the 
ccelom, because the pressure exercised by the blood ex- 
travasated into the tissues of the mesometrium tends to 
check hemorrhage ; whereas the ccelom will hold all the 
blood the patient possesses, and yet produce no haemostatic 
effect in the form of pressure. 

The symptoms of intraperitoneal rupture are those charac- 
teristic of internal hemorrhage. The patient complains of 
a sudden feftling " as if something had given way ; " this is 
followed by general pallor and faintness; the voice is re- 
duced to a mere whisper: sighing respiration; depression 
of temperature; rapid and feeble pulse; usually vomiting ; 
and in some cases death ensues in a few hours. Should 
the patient recover from the shock, she will sometimes state 
that she suspected herself to be pregnant. 

The symptoms of rupture are often accompanied by hem- 
orrhage from the vagina, and shreds of dectdua will be 
passed, so that the case resembles in many points, and is 
occasionally mistaken for. early uterine abortion. Error in 
such circumstances may be avoided by examining the 
shreds discharged from the uterus : if they are found to be 
chorionic villi, the pregnancy is clearly uterine. 

The rapidity with which the rupture of a gravid tube will 
sometimes destroy life has caused more than one writer to 
describe this accident as " one of the most dreadful calami- 
ties to which women can be subjected ; " indeed, it may be 
so rapidly fatal that many cases have been recorded in 
which death has been attributed to poisoning until dissec- 
tion, instituted in many instances by the coroner, has re- 
vealed the true cause of death. 

In extraperitoneal rtipture — tliat is, when the tube bursts 
so that the blood is extravasated between the layers of the 
mesometrium — the symptoms resemble intraperitoneal ruj>. 




turc, but, as a rule, are not so severe and the signs of shock 
pass off quicker. On examining by the vagina a round, ill- 
defined swelling will be detected on one side of the uterus; 
when the effused blood is large in amount the uterus will 
be pushed to the opposite side. When the bleeding takes 
place into the left mcsometrium (broad ligament), it will 
sometimes extend backward under the peritoneum and in- 
vade the connective tissue around the rectum, so that when 
the exploring finger is introduced into the rectum a semi- 
circle—sometimes a ring — of swollen tissue will be felt en- 
circling the gut. 

The escape of decidual membrane from the uterus accom- 
panied by blood is also an important and fairly constant 
sign. Occasionally it will be necessary to pass a sound into 
the uterus ; when the tube is gravid the cavity of this organ 
will be found slightly enlarged and the os invariably patu- 
lous. 

The greatest difficulty in these cases is to be sure that 
the rupture is purely extraperitoneal. In a few cases the 
rupture may involve the peritoneal as well as tlie meso- 
metric segment of the tube. 

Abortion or rupture of a gravid tube is often simulated 
by lesions of other abdominal organs ; for example : 

Perforation of stomach or intestine ; 

Sloughing of the vermiform appendix ; 

Bursting of a pyosalpinx ; 

Intestinal obstruction (acute) ; 

Renal colic ; 

Biliary colic ; 

Axial rotation of an ovarian tumor (acute) ; 

Strangulated hernia. 
3. From the Date of Pregttancy to Term. — Not infre- 
quently after primary extraperitoneal rupture the symptoms 
of shock pass off and the embryo continues its develop- 
ment ; in many instances the patients believe themselves 
pregnant, and the hemorrhages from which they suffer and 



244 



DISEASES OF IVOMEN. 



the signs indicative of the primary rupture may merely 
cause temporary inconvenience. As the embryo increases 
in size the abdomen enlarges, but differs at first from ordi- 
nary uterine gestation in that the enlargement is lateral 
instead of median. 

From the third month onward the leading signs of tubal 
gestation may be summarized thus : 

(a) Amenorrhcea is occasionally found; frequently there 
is hemorrhage from the uterus occurring at irregular inter- 
vals, accompanied by the escape of decidual membrane. 
This last is a valuable diagnostic sign. It is even more 
valuable if the patient has missed one or two periods. 

(b) There may or may not be milk in the breasts. Its 
presence is a valuable indication. From its absence nothing 
can be inferred. 

(c) The uterus is slightly enlarged ; the os is usually 
soft, as in normal pregnancy, and patulous. 

(d) A large and gradually increasing swelling to one side 
and behind the uterus. Occasionally the fcetal heart can be 
heard, and in advanced cases the outlines of the fcetus may 
be distinguished. 

(e) When a woman in whom the existence of tubal ges- 
tation is suspected is suddenly seized with collapse and all 
the signs of internal bleeding, it is indicative of rupture of 
the gestation sac. 

(f) Tubal pregnancy is very apt to occur after long 
intervals of sterility. 

4. At Tenn. — In spite of all the risks that beset the hfe 
of an extra-uterine child and that of its mother, the preg- 
nancy may go to term. Then a remarkable series of 
events ensue: 

(a) Paroxysmal pains come on, resembling those of natural 
labor, accompanied by a discharge of blood and mucus, and 
dilatation of the " os." 

(b) This unavailing labor may last for hours or weeks. 

(c) The mamma; may secrete milk for several weeks. 



I 



DISEASES OF THE FALLOPIAN TUBES. 24$ 

These signs sometimes pass away, and as the amniotic 
fluid is absorbed the abdominal swelling subsides. Months 
or years later suppuration takes place in the sac, and ftetal 
tissues may be discharged through the belly-wall, rectum, 
vagina, bladder, etc., and give a clue to the character of the 
abscess. 

Various conditions may complicate the diagnosis of tubal 
pregnancy; thus: 

1. Uterine and tubal pregnancy are sometimes concurrent. 

2. Uterine sometimes follows tubal pregnancy. 

3. Tubal pregnancy may be bilateral. 

4. Tubal pregnancy may be repeated. 

5. Tubal pregnancy and ovarian tumors occasionally 
coexist. 

It is also important to bear in mind that tubal pregnancy 
may be simulated by a variety of conditions : 

1. Uterine pregnancy ; 

2. Pregnancy in a bicomed uterus ; 

3. Retroversion of the gravid uterus ; 

4. Spurious pregnancy ; 
5- Ovarian tumors; 

6. Tumors of the mesometrium ; 

7. Uterine myoma ; 

8. F«ces in the rectum. 

TREATMENT OF TUBAL PREGNANCY. 

The risks and difficulties of operations for tubal preg- 
nancy depend mainly on the stageat which they are required: 

i. Before Primary Rapture or Abortion. — In this 
stage the operation required is practically that of oophorec- 
tomy. 

2. At the Time of Primary Rupture or Abortion. — 
When the symptoms of hemorrhage are unmistakable and 
the patient's life in grave danger, cteliotomy should be per- 
formed without delay, unless there is good evidence that 
the rupture is extraperitoneal. The employment of this 




DISEASES OF WOMEN. 



method is in strict accordance with the canon of surgery, 
valid in other regions of the body — viz. arrest hemorrhage 
at the earliest possible moment. 

There are fcw accidents that test the skill, nerve, and re- 
source of a surgeon more than coeliotomy for a suspected 
intraperitoneal rupture of a gravid tube, and few operations 
are followed by such brilliant results. 

The method of performing the operation before and at 
the time of primary rupture is identical with oophorectomy. 

Occasionally the rent in the tube will involve the fundus 
of the uterus, especially when the embryo is lodged near 
the uterus. Such rents should be carefully sutured, 

3. Subsequent to Primary Rupttire.— Tlie majority 
of cases are submitted to operation at periods varying from 
a few days to weeks, or even months, after the tube has 
ruptured. (It has been already pointed out that in an ex- 
ceedingly large proportion of cases the tube is occupied by 
a mole.) 

When the tube ruptures the hemorrhage may not be so 
profuse as to induce death, and the woman, recovering from 
the shock, does not manifest sucli grave symptoms as to 
demand surgical aid. The consequence is, that the patient 
remains for several weeks under palliative treatment (unless 
a renewal of bleeding kills her), and at last she seeks surgi- 
cal advice ; appreciation of the true nature of the case leads 
to operation. 

In such cases, when the iibdomen is opened, the free blood 
in the abdominal cavity is easily removed by irrigation with 
warm water. The damaged tube and ovary arc removed 
as in oophorectomy. When there is much free blood care 
must be taken that no clots are allowed to remain in the 
iliac foss.-E. When the blood has remained in the coelom 
for several weeks after rupture it is invariably necessary to 
drain. 

4. Mesometric Gestation. — When a Fallopian tube 
bursts and a mole is displaced between the layers of the 



DISEASES OF THE FALLOPIAN TUBES. 247 

mesometrium. operative interference is rarely necessary. 
Occasionally repeated hemorrhage renders it imperative to 
incise the abdominal wall, open the mesometrium, and turn 
out the clot, and, after stitching the sac to the edges of the 
wound, allow it to tjradually close. 

In those cases where the embryo survives the primary 
rupture and continues to grow, an operation may be neces- 
sary at any moment on account of secondary rupture. 
When gestation has not advanced beyond the fourth month, 
it may be possible to remove the embryo, tube, ovary, and 
adjacent portion of the mesometrium with the placenta 
and to thoroughly clear away all clots. When it has ad- 
vanced beyond the fourth month, the placenta is too large 
to be treated in such a summary manner. Certainly after 
the fifth month operative measures for tubal gestation re- 
quire consideration under two headings : 

1. The treatment of the sac ; 

2. The treatment of the placenta. 

1. The Treatment of the Sac. — The gestation sac in 
the last stages of tubal pregnancy consists of the remnants 
of the expanded tube and the mesometrium, which may be 
thickened in some parts and expanded in others. To the 
walls of the sac coils of intestine and omentum usually 
adhere. 

Experience has decided clearly enough that the safest 
plan is to incise the sac. remove the fcetus, and stitch the 
edges of the sac to the abdominal wound, precisely as In 
the plan recommended after enucleating large cysts and 
tumors from between the layers of the mesometrium. 

2. The Treatment of the Placenta. — With our pres- 
ent experience the rules for the treatment of the placenta 
may be formulated thus: 

(i) When the placenta is situated above the fcetus it is 
good practice to attempt its removal. 

(2) In some instances the placenta becomes detached in 
the course of the operation and leaves no choice. 




DISEASES OF WOMEN. 

(3) When the placenta is below the fa:tiis it may be 
left. 

{4) Should the placenta be left, the sac closed, and symp- 
toms of suppuration occur, then the wound must be re- 
opened and the placenta removed. 

(5) If the fcetus dies before the operation is attempted, 
the placenta can be removed without risk of hemorrhage. 

The ^reat risk of violent hemorrhage renders an opera- 
tion for tubal pregnancy with a quick placenta, between the 
fifth and ninth months of gestation, the most dangerous in 
the whole range of surgery; hence it cannot be urged with 
too much force that when it ia fairly evident that a woman 
has a tubal pregnancy it should be dealt with by operation 
without delay. 

After Death of the Foetus at or near Term.— Ope- 
rations after the death of the ftetus are less complicated 
than when it is alive and the placental circulation in full 
vigor. Not only is the proceeding from the operative point 
of view simplified, but the results, in so far as the mother is 
concerned, are much more satisfactory. 

When the operation is undertaken in cases where the 
fcEtus is in the condition of lithop^dion the procedure is 
very simple, because the placenta has completely disap- 
peared. When the foitus is converted into adipocere the 
fcetal tissues adhere to the walls of the sac and render the 
process of removal tedious. 

After Decomposition of the Foetas and Suppura- 
tion of the Sac. — After death and dccomposkiuii uf the 
fcetus, .sinuses form by which pus, accompanied by fragments 
of foetal tissue and bones, finds an exit, either through the 
rectum, vagina, bladder, or uterus, or at some spot in the an- 
terior abdominal wall below the umbilicus. The treatment in 
such cases is simplicity itself. The sinuses should be dilated 
and all fragments removed from the cavity in which they 
lie. When this is thoroughly done, the sinuses will rapidly 
granulate and close. Partial operations are useles'*; if only 




DISEASES OF THE FALLOPIAN TUBES, 



249 



a portion of a bone is allowed to remain, a troublesome 
sinus persists. 

The difficulties and grave dangers which surround sur- 
gical intervention in the late stages of tubal pregnancy 
make it clear, that the interests of a patient are best served 
when the surgeon removes a gravid tube as soon as it is 
clearly rccogniiied. 



CHAPTER XXVni. 

DISEASES OF THE OVARIES. 

AGE-CHANGES; MALFORMATIONS; DIS- 
PLACEMENTS; THE CORPUS LUTEUM; 
INFLAMMATION. 

Age-cianges. — The variations in tin.' shape of the 
ovary from infancy to old age are very striking. At birth 
the ovary is an elongated body, resembling in shape a min- 
iature but somewhat (fattened cucumber, lying parallel with 
the Fallopian tube; not infrequently its borders are crenate. 
and occasionally it is traversed by a longitudinal furrow. 
The infantile form of the ovary gradually changes, and at 
pubeity it has become transformed into the smootii, olive- 
shaped gland indicative of the mature woman. From the 
accession of puberty until the forty-fifth year the general 
contour of the ovary remains undisturbed, but the smooth- 
ness of its surface is marred by scars, the effects of repeated 
lacerations caused by the rupture of ripe follicles. The 
actual size of the gland varies according to the individual : 
on an average it measures in length 4 cm., transversely 2.5 
cm., and is about 1.2 cm. thick. Its average weight is 6 
grammes. Rarely are the two ovaries equal in size. 

From the age of forty-five onward the ovaries diminish 
in size. This alteration is accompanied by arrest of men- 
struation. As the gland shrinks its surface becomes irregu- 
lar and is often marked by deep wrinkles. At the same 
time profound alterations are in progress within the gland, 
for the ova and their follicles gradually disappear, and in 
advanced life nothing is left but a corrugated body consist- 



DISEASES OF THE OVARIES. 



251 



ing of fibrous tissue traversed by a few blood-vessels with 
thickened (sclerosed) walls. An ovary in a woman of 
seventy years weighs about i gramme — that is, one-sixth 
of what it probably weighed at the age of twenty. 

The periods of life mentioned above for the supervention 
of age-changes are very arbitrary, and in some women they 
occur much earlier and may still be regarded as physiologi- 
cal. But when the ovaries are small and puckered early in 
the .sexual period of woman's life (thirtieth year), the con- 
dition is described as pathological and the ovary is said to 
be atrophied, It is very difficult to estimate from a naked- 
eye examination of an ovary its ova-forming value. Many 
women with small ovaries have had large families, whilst 
others with sexual glands of twice or thrice their dimensions 
remain sterile in spite of every effort to become mothers. 

Halfonnations. — The ovaries like other organs are 
liable to irregularities in their development. 

Congenital absence of both ovaries is rare, and is asso- 
ciated with defective development of the uterus. Absence 
of one ovary usually accompanies deficiency of the corre- 
sponding half of the uterus and the Fallopian tube and ab- 
sence or misplacement of the corresponding kidney. In 
the malformed condition of the uterus known as " unicorn 
uterus " the ovary often retains its infantile (cucumber- like) 
shape. 

Supernumerary or accessory ovaries are mentioned by 
some writers as of common occurrence. A careful consid- 
eration of the evidence makes it clear that small pedun- 
culated bodies near the ovary are ver>' fre<|uent. but they 
are not accessory ovaries. Many of them are partially 
detached tubes of the parovarium, stalked corpora fibrosa, 
or small myomata of the ovarian ligament. 

So far as the facts at present stand, a supernumerary 
ovary, so separated from the main gland as to form a distinct 
ovary, has yet to be described by a competent observer. 

Displacements. — Under tliis heading it will be neces- 




DISEASES OF WOMEN. 



sary to consider three conditions: Undescended Ovaiy; 
Hernia of the Ovary ; Prolapse of the Ovary. 

(a) Undescended Ovary. — In tlie embryo the ovaries, 
like the testicles, are in close relation with the kidnej's: 
gradually they migrate to the pelvis, and at birth they lie 
on the psoas magnus muscle in close relation with the in- 
ternal abdominal ring (Fig. S4). Soon after birth the ovaries 
occupy positions in the true pelvis near its brim until db- 
turbed by accident or pregnancy. 

In very rare instances an ovary remains in the neighbor- 
hood of the kidney or in some position between the kidney 



and the brim of the true pelvis. In such a case it retains 
the infantile shape. In a certain proportion of cases of un- 
descended testis on the right side the caecum fails to de- 
scend to its normal position in the right iliac fossa. Reten- 
tion of the right ovary in the loin is associated with a 
similar disposition of the cecum. 

(b) Hernia of the Ovary. — An ovary may occupy a 
hernia! sac either alone or in company with the Fallopian 
tube, omentum, intestine, etc. ; most frequently it occujmcs 



DISEASES OF THE OVAKIES. 



253 



a sac in the inguinal region, less frequently in the femoral. 
It has been found herniiitcd through the obturator foramen. 

Following the method adopted with other varieties of 
hernia, when the ovary alone occupies a hernial sac it may 
be termed an oophorocck ; when accompanied by the tube, 
a salpingo-o'dphoro(de ; hernia of the tube alone would be a 
salpingocik. 

Oophoroceles may occur in the early months of infancy, 
but congenital hernia of the ovary is excessively rare. 




rts. Bs^Menibi tt ibe orwy a 



>1 of Niick trmn a cKIU ibne 



Many writers on hcmia refer to it as a common condition ; 
hence it is necessary to point out that the rounded, movable 
bodies so frequent in the inguinal canals of female infants 
are in most cases hydroceles of the canal of Nuck. As a 
rule they disappear. 

Hernia of the ovary may occur at any age ; it has been 
observed as early as the third month (Fig. 85) and as late 
as the seventy-third year. 

A strangulated oophorocele or salpingocele gives rise to 
signs such as characterize cpiploccles or enteroceles. The 



2S4 



DISEASES OF WOMEN. 



signs of strangulation sometimes depend on axial rotation 
(torsion) of the herniated ovary and tube. 

The fundus of the uterus as well as the ovary and tube 
has been found in an inguinal sac. and several cases have 
been reported in which a pregnant uterus with its append- 
ages has occupied a sac protruding through the inguinal 
canal. 

In all cases in which a supposed ovary is removed from 
the inguinal region its nature should be substantiated by 
the microscope ; in many instances bodies excised in this 
way have on microscopic examination turned out to be 
testes, and the supposed women pseudo-hermaphrodites 
(see p. 57). 

Treatment. — Herniated ovaries and tubes require removal 
when they are a source of pain and in women who cannot 
wear a truss. The operation has been almost entirely con- 
fined to those who have to maintain themselves by hard 
work. The operation is performed as for inguinal hernia: 
The pedicle is secured with silk, the ovary and tube cut 
away, and the stump returned into the coelom. The sac is 
dissected out and its neck secured with reliable catgut. 
When herniated ovaries or tubes become strangulated or 
undergo axial rotation (torsion), operation is the only choice, 
as the urgent symptoms are rarely likely to be differentiated 
from those which arise from strangulation of herniated in- 
testine. 

(c) Prolapse of the Ovary. — At puberty the ovaries 
lie parallel and on a level with the brim of the true pelvis. 
From this position they are liable to be disturbed by 
pregnancy; retroflexion of the uterus; enlargement. 

Pregnancy. — The alteration in the size of the uterus dur- 
ing pregnancy, and the stretching to which the pelvic peri- 
toneum, Fallopian tubes, and ovarian ligaments are sub- 
jected, cause them, especially if pregnancy be frequently 
repeated, to become very lax. Under these conditions one 
or other ovary, instead of retaining its usual position at the 



DISEASES OF THE OVARiES. 255 

brim of the true pelvis, may drop upon or near the floor of 
the recto-vaginal pouch. When the left ovary is thus dis- 
placed it lies between the upper part of the vagina and the 
rectum. 

An ovary thus displaced is said to be prolapsed, and not 
infrequently is a source of much pain and distress, for it 
becomes pressed upon during defecation, and patients com- 
plain of the severe pain they experience during sexual con- 
gress (dy spare unia). 

Retroflexion of the Uterus. — In this misplacement the 
ovaries are drawn into the pelvis and sometimes become 
adherent to its fioor. 

Enlarged Ovary. — When an ovary is enlarged from the 
presence of a tumor of moderate dimensions its weight will 
!cad to stretching of the ovarian ligament, and it will fall 
with the associated structures into the recto-vaginal pouch. 
A small parovarian cyst will act in a similar way. 

Diagnosis. — On vaginal examination a small rounded or 
elongated body will be found low in the recto-vaginal fossa, 
and usually on the left side. The frequency with which 
prolap.sed ovaries occupy this side is due to the fact that 
the fossa is deeper on the left than on the right side. On 
touching the ovary the patient winces and complains of 
pain. These painful sensations are most acute when the 
ovary is touched, but they are often evoked when the neck 
of the uterus is pressed, because the ovary is then squeezed 
between the uterus and the rectum. 

Trtatmcnt. — When prolapse of the ovary depjends on ret- 
roflexion of the uterus it may be relieved by rectifying the 
malposition of the fundus and maintaining it in the normal 
position by a pessary. In troublesome cases it is some- 
times necessary to perform hysteropexy. When the pro- 
lapse is due to the presence of a cyst or tumor, then ovari- 
otomy is the most appropriate method of treatment. 

The Corpus I,titeiUii. — This curious body is liable to 
the following secondary changes : It may be converted 




DISEASES OF WOMEN. 



into a cyst ; it may become a corpus fibrosum ; it may 
calcify. 

(a) CyslU Corpora Ltttea. — The centre of a corpus luteum 
is occupied by a cavity which in the early stages is filled 
with blood. The walls of such cysts are thick and of a 
bright-yellow color when fresh ; the cavity is lined with a 
thin, delicate membrane and filled with albuminous fluid. 

The cysts rarely exceed the dimensions of a ripe cherry 
and cause no inconvenience. 

(b) Corpora Fibrosa. — These are tough, semi-opaque 
bodies, and are due to fibrous changes in the tissue proper 
of a corpus luteUnt. Many contain a small central cavity, 
others a laminated body. Less frequently they become 
calcified. Sometimes a corpus fibrosum is pedunculated, 
and is then apt to be regarded as a supernumerary ovary. 
Corpora fibrosa may attain the dimensions of a ben's egg 
(Patenko). 

Care must be exercised to avoid confoimding apoplexy 
of the ovary with hemorrhage into the cavity of a small 
ovarian cyst or extravasation secondary to axial rotation 
of an enlarged ovary. 

Oi-arian Concretions. — In very rare instances blood effused 
into enlarged ovarian follicles may undergo colloid changes 
and form den.-ie bean-shaped bodies. 

(c) Calcified Corpora Lutea. — When calcified a corpus 
luteum may be irregular in shape or rounded ; it usually 
exhibits a bright-yellow color, and consists of tough, fibrous 
tissue impregnated with calcareous particles. 

These bodies arc usually firmly imbedded in the ovarian 
stroma; the concretion may be nodulated on its outer sur- 
face like a mulberry calculus, and lodged in a cyst in the 
substance of the ovary. Two calcified corpora lutea may 
be present in one ovary : they must not be confounded with 
calcified corpora fibrosa. 

Apoplexy of the Ovary. — The rupture of a mature 
ovarian follicle is always accompanied by a trifling amount 




DISEASES OF THE OVARIES. 



of bleeding; when a follicle is unusually large the blood- 
clot occupying it may be as big as a ripe gooseberry. Fol- 
licular hemorrhage of this character rarely gives rise to any 
serious consequences. 

Occasionally blood is extravasated so freely into a follicle 
that it bursts the walls and invades the stroma, converting 
the organ into a spurious cyst, the walls of which arc formed 
of expanded ovarian tissue and the cavity filled with blood. 

For such conditions the term "apoplexy of the ovary" 
should be reserved. It may be defined as hemorrhage into 
the oz-arian stroma through rufture of a foUkle (Doran), 
Cases have been reported in which the ovary has been en- 
larged from this cause to the size of a billiard-ball. 

Blood extravasated into the ovarian stroma undergoes 
the same change as when it escapes into other solid organs ; 
that i.s. the fluid parts are absorbed and the clot gradually 
becomes decolorized until nothing but a yellowish mass of 
fibrin remains. Occasionally it will be of a dirty-brown 
color, resembling that found in an old hematocele of the 
timica vaginalis testis. 

Extravasation of blood in the ovarian stroma occurs 
when the ovary undergoes axial rotation. 

Inflammation of the Ovary (Oophoritis). — Acute and 
chronic inflammatory diseases of the ovaries are so con- 
stantly associated with salpingitis, to which they are in 
nearly all cases secondary, that they were considered in 
Chapter XXIV. 

There are several conditions which it will be necessary to 
briefly discuss here. They are — !. Oophoritis secondary to 
mumps; 2. Tuberculosis of the ovary; j. Abscess of the 
ovary. 

I. Oophoritis and Mumps. — Girls and young women 
during an attack of mumps occasionally complain of pelvic 
pain. In a few cases, where the suflering has been suf- 
ficiently severe to warrant a vaginal examination, the ova- 
ries have been found enlarged, tender, and painful. As a 



2S8 DISEASES OF WOMEN. 

rule, the ovaries are affected during the subsidence of 
mumps. In a few exceptional cases the pelvic pain has 
preceded the parotid signs. 

In this connection it is important to bear in mind that 
parotitis is not infrequently a sequel to injuries or operations 
upon abdominal viscera, especially the pelvic viscera. 

At present there is no explanation forthcoming of the 
relation of oophoritis and orchitis as sequels of mumps. 
Indeed, the whole of the evidence rests on clinical ob- 
servation. 

2. Tuberculosis of the Ox'ary. — This disease may attack 
the ovary in the form of small miliary nodules limited to its 
surface (as a rule, it is then part of a general peritoneal 
tuberculosis), or it may occur as a collection of caseous 
pus in the substance of the gland, and is then secondary 
to tubercular salpingitis (sec Chapter XXIV.). 

3. Abscess of the Ovary. — Suppuration in the ovary is 
in the majority of cases secondary to salpingitis. Abscess 
of the ovary apart from tubal infection may occur in patients 
with tubercular lesions in other organs. 

In one unusual case an ovarian abscess occurring in a 
woman twenty-one years of age contained a piece of sew- 
ing-needle 2 cm. long (Haviland). 

Treatment. — The clinical features of ovarian inflammation 
arc so bound up with those of pyosalpinx and its complica- 
tion that the details will be found in Chapter XXV. 

Perioophoritis. — Chronic inHanimation in the pelvis in 
the immediate neighborhood of the ovary is almost sure to 
involve this gland. Thus after pelvic peritonitis and pelvic 
cellulitis the superficial parts of the ovary are infiltrated and 
adhere to surrounding structures. As the inflammatory 
products organize, the ovary becomes imbedded in tissue 
almost as dense as that of a cicatrix. 

Perioophoritis is said to occur as a sequel to typhoid 
fever, rheumatism, the exanthemata, and chronic alcoholism. 
It is occasionally seen as a consequence of ascites. 



DISEASES OF THE OVAKIES. 



259 
e painful 



The most important results of perioophoritis ; 
menstruation (dysmenorrhoea) and sterility. 

Cirrhosis of the Ovaries. — Ovaries arc occasionally 
met with in women between twenty and forty years of age 
presenting a peculiar wrinkled appearance. Such ovaries 
are said to be cirrhotic, because the ultimate effect upon the 
proper tissue of the ovary is similar to that seen in hepatic. 
renat, and pulmonary cirrhosis — that is, destruction of the 
proper tissue of the liver, kidney, or lung, as the case may 
be. The great difference in fibrosis of the ovary as com- 
pared with this change in other organs is, that in the ovary 
the connective tissue of the stroma .shows no evidence of in- 
flammation. In a cirrhotic liver tho interstitial tissue is infil- 
trated with small round cells, but in the cirrhotic ovaries 
this is not the case, even when this change occurs in the 
ovaries of a woman who has also a cirrhotic liver. 

The changes described as cirrhosis or fibrosis of the 
ovaries, occurring in women between twenty and forty 
years of age, require investigation. Even the cause or 
causes producing the change are imperfectly understood. 

Orarian Netiralgia. — Under this term it is usual to 
consider a group of symptoms consisting mainly of pain in 
the pelvic and subumbilical regions, whilst on the most 
careful physical examination nothing abnormal can be de- 
tected in the pelvis to account for the painful .symptoms. 

Many of the patients are single, highly neurotic, and com- 
plain q{ X)\^ globus hysUrkus ; spme are highly religious, 
and therefore emotional. Others may be highly educated. 
intellectual, and interested in the " fine arts." Occasionally 
the troubles occur in mothers living with their husbands. 
Unfortunately, a large proportion of these patients arc 
addicted to two vices — alcoholism and masturbation. 

The troubles do not arise before puberty, but may occur 
at any period during sexual life, and in some the symptoms 
are markedly accentuated at the menopause. 

The patient complains of pain in one or both iliac fossae; 



26o 



DISEASES OF If'OAfEM 



it is often increased by the pressure of the clothes, by walk- 
ing, riding, or exercise in any form; some patients remain 
confined to bed for weeks and even months, and some 
actually become bedridden. With many, sexual inter- 
course increases the pain ; in nearly all, the suffering is 
worse during menstruation. 

Although these pains are often described as ovarialgia, it 
is quite certain that the ovaries are not the source of the 
painful sensations, because they have in many instances 
continued, and even become intensified, after bilateral 
oophorectomy. In some the severity of the symptoms 
has led surgeons to remove the uterus ; even this extreme 
method has failed to afford an escape from the pain. 

Treatment. — This is of little avail, as may be inferred 
from the variety of methods which have been employed. 

Nothing is so prejudicial as local treatment: frequent 
examinations, the use of vaginal tampons, pessaries, and all 
kinds of electrical treatment do great harm. Change of air, 
employment, a happy marriage (especially if fertile), often 
lead to improvement. 

Anodynes, such as opium, morphia, chloral, are danger- 
ous, and above all alcohol should be strictly forbidden. 

Surgical measures are equally useless, for unilateral and 
bilateral oophorectomy may do good for a few months, but 
the almost inevitable relapse leaves the patient worse than 
before. Even sham oophorectomy and vaginal hysterectomy 
have been tried with the same temporary success. These 
patients are hopeless with physician and surgeon, singly or 
combined. Many become chronic alcoholics ; some figure 
in divorce courts; others end their days in lunatic asylums. 




CHAPTER XXIX. 

DISEASES OF THE OVARIES (Continued). 
TUMORS, DERMOIDS, AND CYSTS. 

The ovary is a somewhat complex organ histologically 
and morphologically, and this fact explains in a measure 
the extraordinary frequency and variety of the tumors 
which arise therein. 

The oophoron contains a connective-tissue stroma into 
which strands of Hbrous and muscular tissue are prolonged 
from the ovarian ligament. From these tissues are de- 
rived — I. Fibromata; 2. Myomata; 3. Sarcomata. 

The ovary contains epithelial elements in its follicles 
which are possible sources of — 4. Carcinoma. 

The follicles with their rich epithelium are the sources 
of — 5. Cysts; 6. Adenomata; 7. Dermoids. 

The paroophoron is the probable source of (8) papil- 
lomatous cysts, and the persistent tubules and ducts of 
the mcsonephros are the sources of (9) parovarian and 
(10) Gartnerian cysts. 

I. Fibromata. — ^Tumors composed entirely of firm 
fibrous tissue occur in the ovary and sometimes attain 
large dimensions (5 kilogrammes). Many ovarian tumors 
reported to be sarcomata have on careful microscopic 
examination proved to be fibromata. 

3. Myomata. — Tumors of the ovary composed mainly 
of unstriped muscle-fibre or a mixture of muscular and 
fibrous tissue are very rare. 

Fibromata and myomata of the ovaries occur as encap- 
suled tumors (Fig. 86), whereas the sarcomata infiltrate the 
ovary throughout. 



d 



202 DiSEASES OF WOMEN. 

3. Sarcomata. — The ovary (like the kidney and retina) 

is very prone to become the seat of sarcoma in early life. 
To this succeeds a period of comparative immunity, fol- 




lowed by a second period of renewed but diminished 
liability. 

The sarcomata of infant life attack both ovaries in more 
than half the cases ; they grow rapidly, attain formidable 
sizes, and quickly destroy life. 

Structurally, they consist of round- and spindle-celled 
elements, in which collections of cells are often conspicuous, 
resembling the alveolar disposition characteristic of cancer. 
These supposed alveoli are ovarian follicles entangled in the 
general overgrowth of the ovarian stroma. 

The first period of exceptional liability ends at puberty ; 



DISEASES OF THE OVAklRS. 263 

ovarian sarcomata are very rare from the sixteenth to the 
twenty-fifth year. From this age to forty-five they are 
occasionally met with, and are in most cases unilateral. 
They rapidly destroy life. Ascites comphcates the last 
stages. 

4. Carcinoma. — Many tumors of the ovaries described 
as cancers prove on careful e:*amination to be sarcomata. 
Much confusion has arisen from the fact that ovarian fol- 
licles entangled amidst the sarcomatous tissue mimic the 
structural peculiarities of cancer. Tumors of the ovary 
occur in which the chief changes are centred in the follicles, 
and the tumors conform in their clinical characters to carci- 
noma : they grow rapidly and infect the peritoneum. Pri- 
mary cancer of the ovary requires investigation with a full . 
supply of material. 

Secondary Cancfr. — It is a curious rule that organs which 
are frequently the seat of primary cancer are rarely the seat 
of secondary deposits, and vice versa. To this the ovaries 
are not exceptions, and it is somewhat remarkable that sec- 
ondary cancer affects both organs in more than half the 
cases. 

Carcinoma of the mamma, the pylorus, and the uterus 
are the chief species which lead to secondary deposits in 
the ovaries, Melano-carcitioma is apt to lead to secondary 
nodules in one or both ovaries. 

5. Simple Cysts. — These may be unilocular or multi- 
locular, and ari.'ie in the ovarian follicles. In a small cyst, 
and in the lesser cavities of the multilocular variety, the 
walls are hned with epithelium, which may be columnar, 
cubical, or stratified according to the size of the cyst or 
loculus. 

In cysts containing three or four litres of fluid the walls 
will be found to consist entirely of fibrous tissue ; no epi- 
thelium can be detected. It is impossible to state definitely 
the size of a cyst in which the epithelium disappears. The 
absence of epithelium is due to atrophic changes, the conse- 



264 DISEASES OF WOMEN. 

quence of the continual pressure exerted by the accumulat- 
ing fluid. Precisely similar changes may he studied in the 
mucous membrane of greatly distended gall-bladders. 

An extremely simple means of determining an oopho- 
ronic tumor is to note the relation of the Fallopian tube ; 
it lies curled up on the cyst, and when the parts are 




Fic, 87.-Ov.r 

stretched the tube and tumor arc separated by the meso- 
salpinx {Fig. 87). 

A unilocular ovarian cyst may attain an enormous si:!e. 
Probably the largest on record was removed (by Dr. F.Iiza- 
beth Reifsnydcr. a lady missionary at Shanghai) from a 
Chinese woman twenty-five years of age. The sac yielded 
100 litres of fluid and the patient recovered. 




DISEASES QE THE OVARIES. 

6. Adenomata. — These are important and interesting 
tumors. They possess a fibrous capsule, and internally con- 
sist of a great number of loculi, some of which will scarcely 
accommodate a pea, whilst others hold a litre or more of 
fluid. 

The loculi in the early stages of growth arc lined with 
tall columnar epithelium and the walls contain mucous 
glands. In some tumors the lining membrane is indistin- 
guishable from mucous membrane. The fluid contained in 
such loculi is identical with mucus, and it varies in consist- 
ency from that of the " white of an egg " to the gluey con- 
dition of jelly. 

Ovarian adenomata attain enormous dimensions — thirty, 
forty, and even fifty kilogrammes. 

7, Dermoids. — A very large proportion of cysts arising 
in the oophoron contain skin or mucous membrane, or both 




these structures, and some of the many organs arising from 
and peculiar to them, such as hair, sebaceous, sweat, mu- 
cous, and mammary glands, as well as bone, horn, nails, 
and teeth (Figs. 88. 89). Tumors of this kind are called 
dermoids. They may be unilocular or multilocular. and 
attain a weight of twenty, or even forty, kilogramme*. 
It is necessary to indicate how impossible it is to separate 




The coiitfiiti uf 3. d;;imoii! usually coiisiat uf a pultaceous 
mixture of shed epithelium, fat, and shed hair. In some 
complex multilocular dermoids some of the loculi contain 
mucous membrane and are filled with mucus ; others pos- 
sess hairs ; and a few may be quite barren. 

It is impossible to determine in many cases, from a r 
naked-eye examination, whether an oophoronic tumor 
should be regarded as an adenoma or a dermoid. In prac- 




DISE^S£S OF THE OVARIES. 

tice the presence of a tuft of hair or a tooth is a useful and 
ready way of settling the question. Failing this, a careful 
microscopical examination is necessary. 




Cysts of the oophoron occur at all periods of life, and 
even in young girls sometimes reach a great size (Fig. 90). 



268 



DISEASES OF If OMEN. 



In some instances the tumor will weigh more than the body 
of tile patient. In one case a girl weighed 27 kilos and her 
tumor 44 kilos (Keen). Ovarian dermoids have been seen 
as early as the first year of life and as late as eighty-three. 
There is no authentic record of an ovarian dermoid in a 

ffEtUS. 

Malignancy of Adenomata and Dermoids. — It has been 
supposed, on inadequate evidence, that these tumors some- 
times exhibit malignant characters. It is a curious fact 
that when a loculus of a dermoid bursts into the ctelom the 
epithelium is liable to become engrafted on the peritoneum 
and give rise to secondary tumors. There is no evidence 
based on post-mortem examination that after the removal 
of an ovarian dermoid recurrence has taken place in the 
stump. It is a fact that in women dermoids have never 
been found growing primarily from any abdominal viscus 
save the ovary. 

It is important for the student to recognize that all the 
curious structures found in ovarian dermoids are peculiar to 
skin or mucous membrane. Organs, such as hver, kidney, 
and intestine, or limbs and bones of definite shape, such as 
the femur, humerus, vertebra, or skull-bones, are never 
found. The fact serves to sharply distinguish dermoids 
from teratomata, which are derived from suppressed em- 
bryos. 

Confusion has occa.sionally been introduced when a care- 
less observer has mistaken a lithop*dion, the result of a 
tubal pregnancy, for a dermoid. On the other hand, ova- 
rian dermoids have been mistaken for the products of what 
used to be vaguely called " extra-uterine gestation." 

Ovarian dermoids have also been regarded as a kind of 
imperfect pregnancy. It is, however, open to any one pos- 
sessing average patience, ordinary capacity for observation, 
and the usual training in histology to demonstrate to his 
own satisfaction that the epithelium of the ovarian follicle 
is the source of all the structures found in ovarian dermoids. 




DISEASES OF THE OVARIES. 



and tliat such curious expressions as parthenogenesis, im- 
perfect conceptions, lucina sine concubitu, excess of forma- 
tive energy, etc., which have encompassed this question 
with such clouds of mystery, must yield to deductions 
from accurately observed facts. 

8. Papillomatons Cysts. — These differ from simple 
cysts of the ovary in the fact that they are invariably uni- 
locular and their inner walls are beset with warts (papil- 
.lomata. Fig. gi). They also differ from the three preceding 




species in the fact that there is reason to believe that they 
arise in the paroophoron. 

These cysts do not affect the shape of the ovary until 
they have attained an important size : they always burrow 
between the layers of the mesosalpinx, and, when large, 
make their way between the layers of the mcsometrium by 
the side of the uterus. Papillomatous cysts are most fre- 
quent between the twenty-fifth and hnieth years. The 
warts vary greatly in number: some cysts contain but 



270 



DISEASES OF WOMEN. 



few ; in others they are so luxuriant as to cause the cyst to 
burst; tlie warts then protrude as soft dendritic vascular 
masses, and the surface cells become detached and engraft 
themselves on the peritoneum and form secondary warts, 
This accident is usually followed by hydroperitoneum. 

9. Parovarian Cysts. — These are of two kinds : the 
most frequent are small pedunculated cysts arising in 
Kobelt's tubes; they are of no clinical interest. 

The most important cysts are sessile and remain between 



Fallopian luii. 




the layers of the mesosalpinx. When the cyst is large the 
Fallopian tube is stretched across its crown (Fig. 92), 

Small parovarian cy.sts are, as a rule, transparent, but 
when they exceed the size of a cocnanut the cyst-walls 
become thick and opaque. Small cysts are lined with 
columnar epithelium, which is sometimes ciliated; in cysts 




DISEASES OF THE OVAfHUS. 



of moderate size the epithelium becomes stratified, and in 
large cysts it disappears. 

The fluid they contain is limpid and slightly opalescent; 
specific gravity, 1002 to 1007 ; reaction slightly alkaline. 
A substance precipitated by alcohol is present in large 
quantity. 

In large cysts the fluid is often turbid and may contain 
cholesterine. When parovarian cysts rupture into the coelom 
(peritoneal cavity) the fluid is quickly absorbed and excreted 
by the kidneys. 

The chief anatomical points which enable a parovarian to 
be distinguished from an oophoronic cyst arc — 

1. The peritoneal coat is easily stripped ofl"; 

2. The ovary is usually attached to the side of the cyst ; 

3. The cyst is, as a rule, unilocular ; 

4. The Fallopian tube is tightly stretched across the 

cyst and docs not communicate with it. 

The age at which parovarian cysts occur is of some in- 
terest. It has already been mentioned that cysts of the 
oophoron are encountered at any period, from fa;tal life up 
to extreme old age. The occurrence of a parovarian cyst 
has not, so far, been recorded in an individual before the 
age of sixteen. Many undoubted ca.ses have been observed 
at seventeen, eighteen, and nineteen, the cysts being large 
enough to rise above the pubes. Before sixteen the paro- 
varium appears to be quiescent, but on the advent of puberty 
it seems to undergo great stimulation ; a very large propor- 
tion of cj-sts, generally classed as ovarian, removed between 
the ages of seventeen and twenty-five, arise in this interest- 
ing structure. 

10. Gartnerian Cysts. — There are good reasons to 
believe that some papillomatous cysts of the mesometrium_ 
especially those which burrow deeply by the side of the 
uterus, arise in persistent portions of Gartner's duct. 

Cysts of this character which burrow deeply often entail 
risk in removal, as they lie in intimate relation with uterus, 



2/2 



DISEASES OF WOMEN, 



ureter, and bladder: the cyst when large will come in con- 
tact with the iliac arteries and veins at the brim of the pelvis, 
and even rest upon the inferior vena cava. 

Gartnerian cysts arising in the terminal segment of the 
duct project into the vagina. In some instances these cysts 
may be treated surgically through the vagina with greater 
success than by cceliotomy. 

Orarian Hydrocele. — In many mammals the ovary 
is surrciunded by a tunic of peritoneum resembling the tu- 
nica vaginalis testis. The Fallopian tube opens into this 
cavity ; thus the ova reach the uterus without entering the 
ccelom (peritoneal cavity). Occasionally this peritoneal 
pocket becomes distended with fluid, and is conveniently 
called an ovarian hydrocele. Such a cyst is very rare in 
women: many specimens described as ovarian hydroceles 
are very large examples of hydrosalpinx. 



CHAPTER XXX. 

DISEASES OF THE OVARIES (Continued). 

SECONDARY CHANGES IN OVARIAN 
TUMORS. 

Many of the secondary changes to which ovarian tumors 
are liable imperil life. The chief changes arc — i. Septic 
infection ; 2. Axial rotation ; 3. Rupture. 

I. Septic Infection.— When air or intestinal gases gain 
access to ovarian cysts, then suppuration with all its attend- 
ant evils is the consequence. Contamination may arise from 
puncture with a trocar or aspirating needle. More fre- 
quently it is due to the entrance of gases from the intes- 
tine, due to adhesion of the tumor to an adjacent coil of 
bowel, or to the vermiform appendix ; or to infection from 
the Fallopian tube. 

The result of the suppuration is to set up almost universal 
adhesions to surrounding structures; in acute cases severe 
symptoms arise, and unless the pus finds an exit the patient 
dies. Even when the pus finds an outlet the patient leads a 
miserable existence, becomes emaciated by the prolonged 
discharge, and dies worn out by suffering. 

In acute suppuration of a large ovarian cyst the symptoms 
are very characteristic. The patient presents the usual 
signs of an ovarian tumor, with pain and tenderness on 
pressure; the pulse is rapid and feeble and accompanied by 
great emaciation and exhaustion. The temperature is at 
first high — standing at 100° or 102° F. in the morning and 
rising to 103° to 105° in the evening. As the patient be- 
comes more and more exhausted toward the close of the 



274 



DISEASES OF WOMEN. 



case the temperature may fall, and has been recorded as 
low as 95° F. This low temperature has been observed in 
cases where the pus was unusually offensive. In many 
cases the urine contains albumin. The cyst sometimes 
contains gas; under such conditions the tumor-dulness is 
replaced by a highly tympanitic note. It is a fact of some 
interest that suppurating ovarian cysts have given rise to 
signs simulating typhoid fever, and the patient has been 
treated for tliis disease until the accidental discovery of the 
tumor made the case clear. Suppuration of an ovarian cyst 
has followed an attack of typhoid fever, and typhoid bacilli 
have been found in the pus. 

Suppurating dirnioids of the ovary are by no means in- 
frequent, and, like other forms of ovarian cysts, when in- 
flamed they become firmly adherent to surrounding struc- 
tures. They may burst into the ccelom, the rectum, bladder, 
vagina, or even through the abdominal wall near Poupart's 
ligament, or at the umbilicus. 

Adhesions, from whatever cause arising, are a source of 
anxiety to the operator when they are abundant. A few 
straggling omental adhesions are of no moment, or a few 
fibrous band.s connecting the cyst to the anterior abdominal 
wall ; but when tracts of small intestine or colon are firmly 
united to the cyst-wall by broad fibrous band.*^, or the tumor 
is fixed to the pelvic peritoneum by dense adhesions, the 
task of removing the tumor is very anxious, tedious, and 
occasionally impossible. 

The mode by which adhesions arise is identical with the 
process by which bands form in connection with the intes- 
tines. The peritoneum becomes inflamed, and the exuda- 
tion which accompanies that process — the so-called lymph 
— organizes and undergoes slow conversion into fibrous 
tissue. When the parts united by this material remain Jn 
apposition whilst it organizes, a sessile adhesion results. 
When there is movement between the parts during the pro- 
cess, then the uniting material becomes elongated into 



DJSEASES OF ri/E OVARIES. 275 

bands, broad or narrow according to the extent of surface 
involved. 

2. Axial Rotation, — Abdominal tumors of all kinds are 
liable to turn round on their axes — a movement which leads 
to twisting (or torsion) of the pedicle and interferes with 
the circulation in the tumor. Ovarian tumors, large and 
small, are very liable to rotate. This movement frequently 
occurs when an ovarian tumor complicates pregnancy or a 
uterine myoma: it has been especially noticed to follow the 
diminution in size of the uterus after delivery at term or 
abortion. 

Rotation of a cyst in the early stages of pregnancy is 
probably due to the gradual enlargement of the uterus dis- 
placing the tumor upward: as the pressure is exerted upon 
one side of the cyst, it would be in a favorable position to 
impart a rotary motion to a non-adherent cyst. 

The amount of rotation varies greatly. In some cases 
the cy.st has only turned through half a circle ; in others as 
many as twelve complete twists have been counted. The 
direction of the rotation may be from right to left, or vice 
versa, but cysts exhibit a stronger tendency to rotate toward 
the middle line than away from it. Tumors of the right 
and left side are equally liable to rotate. 

The effect of torsion on the circulation depends on the 
tightness of the twist, and this varies with the thickness 
of the pedicle. The vessels in a long, thin pedicle would 
suffer ob.struction quicker than those in a short and thick 
one. When a pedicle is twisted the thin-walled veins be- 
come compressed, whilst the more resilient arteries continue 
to convey blood to the cyst. The result is severe venous 
engorgement, and this leads to extravasation of blood into 
the cyst-wall ; in many cases the veins rupture and hemor- 
rhage takes place into the cavity of the cyst. The hemor- 
rhage may be so profuse as to cause profound anxmia, and 
even death. Cases have been reported in which a patient 
has died in a few hours from this cause. 



276 DISEASES OF WOMEN. 

Occasionally the tumor will become completely detached 
from its pedicle in consequence of torsion. 

The signs of acute rotation of an ovarian cyst are often 
so characteristic as to lead to a correct diagnosis. When a 
woman complains of sudden and violent pain in the abdo- 
men, accompanied with vomiting, and she is known to have 
an ovarian tumor, or she presents herself for the first time 
to the surgeon, and these signs are associated with an ab- 
dominal swelling, the physical signs of which are indicative 
of an ovarian tumor, axial rotation should be suspected. 
When the patient has an ovarian tumor and is pregnant, or 
has been recently delivered, this is an additional reason 
for suspecting that the symptoms arise from a twisted 
pedicle. 

It is important to remember that the predominant signs 
of acute axial rotation of abdominal organs and tumors arc 
those common to a strangulated hernia minus stercoraceous 
vomiting, and even this will be present should a piece of 
gut be involved in the twists of the pedicle. 

3. Rupture. — Ovarian cysts are liable to burst into the 
ccclom cither without any obvious cause (spontaneous rup- 
ture) or from violence ; for example, during " an immoderate 
fit of laughter," or whilst stooping to "button the boots," 
during vomiting, coughing, the manipulation of a physi 
cian, or a fall. 

The signs of rupture of an ovarian cyst are — (a) Sudden 
accession of pain, accompanied by aUeration in the shape 
of the tumor; {b) Subsequent profuse diuresis; {c) Gradual 
reaccumulation of the fluid in the cyst. 

The results of such an accident depend on the nature of 
the cyst. The rupture of a parovarian cyst is not attended 
with ill effects ; the cyst may refill and burst repeatedly. 

When the rupture of an ovarian cyst is due to axial ro- 
tation, then the patient may die from hemorrhage. In the 
case of an adenoma the mucoid material forms a curious 
sago-like deposit on the peritoneal surface of the viscera. 



D/SEASES OF THE OfAXlES. 277 

In rare cases, cells from a dermoid will become engrafted 
on the peritoneum and form fiecondaiy dermoids. 

The rupture of papillomatous cysts is invariably followed 
by secondary warts on the peritoneum and hydropcrito- 
neum. When suppurating cysts burst into the cckIohi, 
rapidly fata! peritonitis is tlie consequence. 

Ovarian cysts, especially dermoids, may burst into hol- 
low viscera, usually the rectum or the bladder. When the 
contents of a dermoid escape into the bladder, it is a source 
of great mi.sery, a,s the hair, teeth, or bones serve as nuclei 
for phosphatic deposits. 

Modes of Death, — Tumors of the ovaries are now so 
promptly removed when discovered that there are happily 
few opportunities of studying the way in which they destroy 
life. It will be useful to enumerate the modes of death: i. 
Pressure on ureters, hydronephro.sis, uraemia; 2. Cystitis, 
pyelitis; 3. Intestinal obstruction; 4. Suppuration of cyst, 
septicsemia; 5. Peritonitis from leakage into the ccelom; 6. 
Large cysts impede respiration by pushing up the dia- 
phragm and compressing the lungs; 7. Hemorrhage from 
rupture of cyst ; 8. Im[>cdiment to labor. 

Symptoms and Diagnosis. — The .symptoms which in- 
duce women witii ovarian tumors to seek advice vary with 
their size. When the tumor is restricted to the pelvis, the 
troubles it may cause are different to those it may produce 
when it is large enough to rise above the pelvic brim and 
occupy the abdomen. When the tumor is large enough to 
rise up out of the pelvis the only troublesome symptom, in 
a very large number of cases, is progressive enlargement 
of the belly. This, in a married woman, is often attributed 
to pregnancy ; in young unmarried women it is a source of 
annoyance, as it leads occasionally to a suspicion of preg- 
nancy. At other times the pressure-effects induced by 
ovarian tumors, such as troubles with the bladder, hydro- 
nephrosis, cedema of the leg, and dyspncea, induce patients 
to* seek advice. 



278 DISEASES OF WOME^. 

When the tumor is small enough to be accommodated in 
the pelvis, it causes trouble by becoming impacted and ex- 
ercising baneful pressure on bladder, ureters, rectum, and 
intestines. 

Should complications arise (such as axial rotation, inflam- 
mation, or suppuration of the cyst), they will lead to detec- 
tion of the tumor. 

In a typical case of ovarian tumor the size of the abdomen 
is increased. With a big cyst the enlargement is general, 
but when the tumor is of moderate dimensions it is localized 
to one or other flank. Local enlargements due to ovarian 
tumors are always mo.st marked below the level of the um- 
bilicus, The skin of the abdomen sometimes presents a 
brown discoloration and the superficial veins may be dis- 
tended. 

On palpation the swelling feels firm and resisting. In 
cystic tumors its surface is uniform, as a rule, but multi- 
locular cysts may have an irregular surface ; this is also true 
of ovarian adenomata. Manipulation rarely causes pain. 
In large cysts a wave of fluctuation can easily be produced ; 
in multilocular cysts the sign is restricted to large cavities. 
The distinctness with which the wave is perceived depends 
upon the character of the fluid and the thickness of the 
abdominal wall. 

Percussion furnishes valuable evidence. The crown and 
sides of the swelling are quite dull, but on approaching the 
loins the dulness gradually gives way to resonance. If now 
the patient be turned to one or other side, we .shall find that 
the alteration in position does not aflect the percussion-note. 
In those exceptional cases where the cyst communicates 
with intestine the swelling yields a tympanitic note on per- 
cussion, due to the presence of intestinal gas. 

Auscultation, as a rule, gives no information. Gurgling 
of intestines and, occasionally, the pulsation of the aorta 
may be perceived, and very rarely a bruit has been detected. 
In non-ovarian tumors this method of physical examination 



DISEASES OF THE OVARIES. 279 

often affords valuable information. After examining tlie 
abdomen the surgeon should explore the parts by an in- 
ternal examination. As a rule, this is best made through 
the vagina, but in young. unmarried girls it will sometimes 
be necessary to make the examination by the rectum. In 
this way the surgeon ascertains the relation of the tumor to 
the uterus, the condition of this organ, and the state of the 
rectum. In uncomplicated cases of ovarian tumor the in- 
formation furnished by a vaginal or rectal examination is 
negative, but it should always be undertaken. 

The recognition of a large, uncomplicated ovarian cyst 
is one of the simplest processes in clinical surgery. The 
signs may be thus summarized : A swelling of the abdomen, 
most marked below the umbilicus, associated with absolute 
dulne-ss to percussion all over the tumor, most marked on 
its summit, and fading away to resonance in the flanks ; 
such dulness is not affected by alteration in the position of 
the patient. If such signs be associated with a uterus of 
normal size, the presumption that the swelling is an ovarian 
tumor is as certain as most things in clinical medicine. 

The diagnosis of simple cases of ovarian tumor rarely 
gives rise to difl^culty if the surgeon duly weighs the various 
signs together, and does not place too much reliance on any 
one of them. Difficulty arises sometimes in distinguishing 
between ovarian tumors and conditions which simulate 
them : the greatest care and skill is needed when diagnosis 
is complicated by secondary changes in the cyst and by the 
coexistence of other tumors, abnormal conditions of the 
abdominal viscera, ascites, or pregnancy. 

The diagnosis of ovarian tumors involves the question of 
the diagnosis of abdominal swellings in general. Indeed, 
there is no organ in the belly which has not at some time 
or other given rise to signs resembling those presented by 
an ovarian cyst. These facts alone will serve to show that 
there is no pathognomonic sign indicative of an ovarian 
tumor. In many cases the methods of physical ( 



28o 



DISEASES OF WOMEN. 



tion are incompetent to enable us to form a correct opinion 
of the nature of an abdominal tumor until it has been 
actually exposed to view; even when the abdomen is 
opened, doubts and difficulties sometimes arise. It will be 
useful to mention the various conditions which have been 
mistaken for ovarian tumors, and vice versa. 



CHAPTER XXXr. 

DISEASES OF THE OVARIES (Continued). 

DIFFERENTIAL DIAGNOSIS AND TREAT- 
MENT OF OVARIAN TUMORS. 

Method of Examination. — When a woniaii suspected 
of an abdominal tumor comes under observation, it is the 
duty of the surgeon or physician, as the case may be, to 
inquire into the history of the case. Information concern- 
ing the age, social condition, and menstrual history is often 
as important in diagnosis as a knowledge of the general 
physical condition of the patient and the facts she may be 
able to relate concerning the tumor itself. 

In conducting the physical examination of the patient she 
should, whenever possible, be undressed, for nothing is so 
unsatisfactory as examining an abdomen to ascertain the 
existence or nature of a tumor when the parts are encum- 
bered by partially loosened skirts, stays, petticoats, and 
other garments. 

The patient should be placed, when undressed, with her 
back flat upon a bed or couch and the legs covered with 
a sheet or blanket. The surgeon should be careful that 
his hands and finger-tips are warm, as cold fingers are 
very uncomfortable to the patient and hinder a proper e.v- 
amination. 

At the outset he first attempts to assure him.self of the 
existence of an abdominal swelhng by employing his eyes, 
aided by palpation and percussion ; often auscultation ren- 
ders important assistance. 

Tumors are often simulated by obesity^ and an accumu- 

181 




D/SEASES OF WOMEN- 

lation of subcutaneous fat has so deceived surgeons that in 
several recorded cases the abdomen has been opened before 
the character of the enlargement was recognized. 

The strangest of all conditions simulating tumor is the 
"puffing up of the belly" known as phantom tttmor, 
where a woman thinks she is pregnant or suffering from a 
tumor. To avoid error, it is only necessary to be aware 
of the possibility of the condition. On percussion the belly 
is everywhere resonant, and by cautiously engaging the 
patient in conversation during the manipulation the belly 
becomes quite flat. If after physical examination the sur- 
geon is unable to decide the question with certainty, he 
should arrange for the administration of an anaesthetic: as 
the woman becomes unconscious the swelling diminishes, 
then the belly becomes flat ; as consciousness returns the 
swelling of the belly reappears. 

Phantom tumor is liable to occur in sterile women who 
have married late in life, and especially in women who have 
a morbid desire for pregnancy. It is occasionally met with 
in women who have borne children, and now and then in 
young wives. Sometimes it is seen in women who have sub- 
jected themselves to illicit intercourse and fear the results. 

It is difficult to understand how this condition could be 
mistaken for an abdominal tumor, yet more than one case 
has been recorded in which the abdomen was opened to 
remove the supposed tumor. Most of the cases occurred 
in the early days of ovariotomy, and now that surgeons are 
fully aware of the condition, and with the assistance afforded 
by an anaesthetic, such blunders are not likely to be made. 

Pregnancy, normal and abnormal, and uterine tu- 
mors, often simulate ovarian tumors (see p, 193}. The 
remaining conditions which are apt lo be mistaken for ova- 
rian tumors are the following: 

1. Ascites and hydroperitoneum ; 

2. Distended bladder ; 

3. Fsecal accumulation ; 




L 



4- Renal cysts and tumors ; 

5. Splenic enlargement and tumors ; 

6. Morbid condition of the gall-bladder; 

7. Cysts of the pancreas, mesentery, or omentum ; 

8. Lipomata; 

9. Echinococcus cysts. 

Ascites. — An accumulation of free fluid in the belly is, 
as a rule, easily distinguished from an abdominal tumor, but 
many instances have been recorded in which ascites has 
been mistaken for an ovarian cyst, and vice versa. 

A well-marked case of ascites rarely causes difficulty in 
diagnosis. The abdomen is uniformly enlarged : when the 
patient lies on her back the fluid occupies the flanks, and 
when abundant the sides of the belly form a convex curve 
from the lower ribs to the crest of each ilium. On percus- 
sion the flanks and lower half of the abdomen are dull, 
whilst around the umbilicus a clear resonant note is ob- 
tained. If the patient be now turned to one or other side, 
the conditions are reversed; the higher flank becomes reso- 
nant and the umbilical region dull. This shifting dulness 
is the most characteristic sign of ascites. In addition, when 
the fluid is present in sufficient quantity, a percussion wave 
may be easily produced from side to side. 

When free fluid in the ccelom is associated with second- 
ary cancer or the presence of a tumor, innocent or malig- 
nant, then the diagnosis may be difficult. This condition 
is discussed in the chapter on Hydroperitoneum. 

Attempts have been made to detect "among the fluids 
found in the belly and in cysts of the ov3r>-, characters 
(chemical, microscopic, or spectroscopic) which would serve 
to distinguish them from each other, but to no puri>osc. 

Distended Bladder. — It is of the first importance in in- 
vestigating a doubtful case of abdominal tumor to obtain a 
sample of the urine, and to ascertain the quantity as well as 
the quality of the secretion. An oz'erfull Madder has a 
striking pyriform shape, and may extend as high as the 



284 DISEASES OF WOMEN. 

navel and simulate a tumor. Such over-distention may be 
due to pressure on the urethra from a pelvic tumor or a 
retroverted (incarcerated) gravid uterus. 

Ftecal accumulation (coprostasis) in the rectum, caecum, 
or colon will simulate an abdominal tumor. Copious enem- 
ata will quickly settle the doubts in such a case. 

Thi Kidiuy. — Abnormal conditions of the kidney often 
simulate ovarian tumors, especially sarcomata, hydrone- 
phrosis, or pyonephrosis. When movable, misplaced, or 
single, a kidney has often caused great difficulty in diagnosis. 

The physical signs of a renal tumor are very character- 
istic. There is a swelling in one or both loins which yields 
a dull sound on percus.sion. but, as the colon lies in front 
of the kidney, an area of resonance is usually present when 
it is percussed from the front. 

The Spleen. — When enlarged, this viscus forms a tumor 
extending from the left hypochondrium obliquely down- 
ward to the umbilicus, and as far as the pelvis when very 
large. It gives rise to dulncss on percussion, moves up 
and down with respiration, lies in front of the colon, and 
presents a characteristic notched border. 

Occasionally the spleen ha.'i such a long pedicle that tt 
may reach every region of the abdomen and even lodge 
on the floor of the pelvis. Such "wandering" spleens are 
liable to twist their pedicles. 

Very large spleens have been mistaken for ovarian ar 
uterine tumors, more often the latter. In one remarkable 
case ctEliotomy was performed, and a tumor supposed to 
be a uterine myoma was removed; sub.sequently, when the 
fragments were examined microscopically, the tissue was 
discovered to be splenic (Vameck), 

When the spleen is occupied by 3 large echinococcus 
colony, then the resemblance to an ovarian cyst is very 
close. 

The Liver. — When the liver is greatly enlarged it has 
simulated an ovarian tumor. A very distended gall-blad- 



H^ dcr T 

H even 



DISEASES OF THE OVARIES. 



28S 

dcr may simulate a renal tumor, cancer of the pylorus, or 
even an ovarian cyst with a long pedicle. But a s^ry 
large hydrocholecyst has been known to reach into the 
hypogastrium. 

A greatly distended stomach, a large cyst of the great 




omentum (omental hydrocele), chyle cysts of the mesen- 
tery, pancreatic cyst, and echinococcus colonies in relation 
with any abdominal viscus are sometimes sources of diffi- 
culty in diagnosis, but they rarely complicate the differen- 
tial diagnosis of tumors of the genital organs. 
Ovarian Tumors and Pregnancy. — Throughout the 



286 DISEASES Of IVOMEX, 

description of the diagnosis of ovarian tumors considerable 
stress has been laid on the necessit\' of careful discrimina- 
tion between a tumor of an ovar^- and pregnancy. It is 
now important to discuss the difficult)' and dangers when 
the two conditions coexist (Fig. 93). 

When an ovarian tumor complicates pregnane^', it is not 
too much to state that the life of the woman is in peril 
throughout the period, and the danger increases with each 
succeeding month of gestation, and culminates with labor 
or abortion. 

During pregnancy the chief dangers to be apprehended 
arc — 

(a) Axial rotation of the tumor ; 
(bj Rupture of the cyst ; 

(c) Incarceration of the tumor in the pelvis ; 

(d) With large tumors, impediment to respiration. 
When the tumor is not interfered with and pregnancy 

goes to term, delivery may happen easily and safely; but 
in many cases the following grave complications may 
occur : 

I. Wlicn the tumor is situated aboz'e the uterus: 

(a) Rupture of the cyst ; 

(b) Axial rotation ; 

(c) Suppuration of the cyst. 

. 2. When Vie tumor occupies the pehis it offers viechanical 
impediment to delivery. The fatus invariably dies in these 
circumstances. 

The following accidents may happen : 

(a) Rupture of the cyst ; 

(b) Rupture of the uterus ; 

(c) Rupture of the vagina ; 

(d) Extrusion of the tumor through the anus. 

Treatment. 

The treatment of ovarian tumors, including in this 
general term tumors of the oophoron, paroophoron, and 



DISEASES OF THE OVARIES. 287 



parovarium, is early removal. It has been shown by an 
overwhelming amount of evidence that the earlier these 
tumors are removed the more likely is the operation to be 
followed by success. The removal of an uncomplicated 
ovarian tumor, by a surgeon of experience in abdominal 
operations, is the safest and most successful major operation 
in sui^ery. 

Ovariotomy has been successfully performed on an infant 
of two years and on a woman of ninetj*-four years. In 
girls between the age of ten and fifteen years ovariotomy is 
attended with great success. Even suppurating cysts are 
removed with admirable results. 

Mortality. — Speaking generally, the deaths from ovariot- 
omy vary from 5 to 10 per cent, in experienced hands ; now 
and then operators get a run of 20, 50, or even too cases 
without a death. With less experienced surgeons the 
death-rate will vary from 15 to 20 per cent. 

(h'arioloiny during Pregnancy. — Before the fourth month 
of pregnancy ovariotomy is attended with an exceedingly 
low risk to life, and the chances of disturbing the pregnancy 
are small. After the fourth month the risk of abortion 
increases with each month. When an ovarian tumor is 
discovered during labor or abortion and it impedes delivery, 
ovariotomy should be performed without delay. If it offers 
no obstacle to delivery and causes no dangerous symptoms, 
it may remain till after the puerperium. When a puerperal 
woman known to pos.sess an ovarian tumor exhibits un- 
favorable symptoms, ovariotomy should be resorted to with- 
out delay. 



CHAPTKR XXXII. 

DISEASES OF THE PELVIC PERITONEUM AND CONNEC- 
TIVE TISSUE. 

SEPTIC INFECTION; EPITHELIAL INFEC- 
TION, HYDROPERITONEUM; PELVIC CEL- 
LULITIS AND ABSCESS. 

The pelvic region of the coelom in a woman diflers from 
that of a man in that the peritoneum lining it is more com- 
plexly arranged and invests more organs ; in addition, two 
mucous canals — the Fallopian tubes — open directly into it. 
The frequency of peritonitis in women is out of all propor- 
tion to its occurrence in men, and the excessive liability of 
women to peritoneal infections is almost entirely due to this 
curious relationship of the pelvic portion of the ctclom to 
the Fallopian tubes, 

I. Septic Infection. — In dealing with salpingitis it was 
pointed out that septic affections of the uterus, whether 
arising primarily in the cavity of that organ or extending 
to it from the vagina, are very liable to implicate the Fal- 
lopian tubes. In a fair proportion of cases the inflammatory 
process extends beyond the tubes and directly infects the 
pelvic peritoneum. When the septic matter which thus 
escapes into the ccelom is very virulent, grave disturbances 
arc set up and death may ensue in a few days. 

It was mentioned in Chapter XXIV. that in a large 

number of cases salpingitis is a result of septic endometritis 

t following upon abortion or delivery at term ; it is important 

I also to appreciate the fact that when pelvic peritonitis occurs 

a sequel to labor it is in very many cases called " puer- 

al fever " or " puerperal peritonitis." As a matter of 




DISEASES OF THE PELVIC PERITONEUM. 



fact, observations are by no means wanting to demonstrate 
that in many cases thus classed the disaster (causing in very 
many cases the death of the patient) was due to actual con- 
veyance of septic matter from the uterine cavity into the 
recto-vaginal pouch. 

Serous Pcrimelritis. — The essential features of this variety 
consist in a collection of inflummatory exudation in the 
recto-vaginal fossa, which floats up the adjacent intestines 
and omentum; these become matted together and to the 
uterus, so as to form a sort of spurious roof to the pelvis. 
Under these conditions the fluid collected in the pelvis very 
closely simulates a retro-uterine cyst. 

When inflammatory exudation collects in the utero- 
vesical pouch and becomes, as it were, encysled by the 
intestines, the condition is sometimes called " anterior 
serous perimetritis." The physical signs of such a collec- 
tion of fluid have so deceived sonic surgeons as to lead 
them into the belief that they had to deal with an ovarian 
tumor. 

2. Epithelial Infection. — In this book mention has 
been made of epithelial infection of the peritoneum, and it 
will be useful to briefly summarize our knowledge of this 
condition. It occurs in connection with the following aflcc- 
tions; 

(a) Papillomatous cysts ; 

(b) Ovarian dermoids ; 

(c) Cancer of uterus, gall-bladder, rectum, and .sig- 

moid flexure. 
It has already been stated that when papillomatous cy.=^ts 
rupture into the ctelom the fluid contents of the cysts, often 
heavily charged with cells, are scattered over the perito- 
neum : it naturally follows that the recto-vaginal and utero- 
vesical fossK become inundated with fluid, and the cells 
sink to the lowest parts of these recesses. In many cases 
the cells engraft themselves on the peritoneum and grow 
into warts. This accounts, in cases of affection of this kind, 



290 DISEASES OF WOMEff. 

for the abundance of warts on the pelvic peritoneum in com- 
parison with other parts. 

Similar changes are sometimes associated with the rup- 
ture of ovarian dermoids, and one case has been reported in 
which the peritoneum was beset with small tufts of hair 
secondary to an ovarian dermoid. Several cases have been 
carefully observed and reported, in which the peritoneum 
has been dotted with minute dermoids secondary to the 
rupture of primary ovarian dermoids. 

In Chapter XXXIV. it will be shown that echinococcus 
colonies sometimes infect the peritoneum in a similar 
manner. The condition is strongly exemphfied when the 
peritoneum is infected with cancer. Any one who has had 
merely a moderate experience in the dead-house must have 
noticed in individuals dying from canctr of the uterus, 
colon, or gall-bladder that in the majority of instances the 
peritoneum ia free from deposits. Yet occasionally a case 
comes under observation in which the peritoneum is crowded 
with hundreds of minute nodules. In such cases a careful 
examination of the tumor will reveal the existence of a small 
process of the cancer which has perforated its serous cover- 
ing. This process may be no larger than a split pea, yet it 
is sufficient to produce hundreds of secondary nodules on 
the peritoneum. When the cancer involves the peritoneum, 
fluid is sure to be exuded (hydroperitoneum), and the move- 
ment of this fluid serves as an excellent means of dissemi- 
nating the epithelial cells over the belly. 

3. Hydroperitonetmi.— This may be defined as an 
accumulation of free fluid in the belly, due to the irrita- 
tion of primary or secondary tumors of the abdominal 
viscera, or to the extension of tubal disease, especially tu- 
berculosis, to the peritoneum. 

Fluid effusion in the belly secondary to cardiac or renal 
disease or obstruction to the portal circulation is due to 
passive causes, and the name ascites should be restricted to 
it: hydroperitoneum depends on an active irritative cause 



DISEASES OF THE PEL I'JC rEFlTONEUM. 



291 



and is met with in the following pelvic conditions : Papil- 
lomatous cysts of the ovaries ; ovarian sarcomata ; ovarian 
dermoids with burst loculi ; occasionally with inflamed ova- 
rian cysts and uterine myomata ; tubercular peritonitis ; mild 
forms of salpingitis; and adenoma of the Fallopian tubes. 

In the greater proportion of cases hydroperitoueum 
causes no difficulty. Scattered nodules in the omentum 
and in the parietal peritoneum are signs rarely misinterijreted. 
The conditions which give rise to difficulty are those occur- 
ring in women about mid-life who are apparently in excel- 
lent health, but seek advice on account of increase in the 
size of the belly, which furnishes on physical examination 
the ordinary signs of ascites; but there is no cedenia of legs 
or eyelids, no cardiac disease, urine normal in quantity and 
quality, and no signs of liver trouble. On careful examina- 
tion of the abdomen there is no evidence of the existence 
of a solid tumor, and perhaps on vaginal examination only 
an indefinite resistance is made out on each side of the 
uterus. In such conditions the fluid increases in quantity 
very rapidly and renders interference imperative. 

Treatment. — In all cases where there is reasonable doubt 
as to the cause of hydroperitoncum it is a wise course to 
place the patient under the influence of an anesthetic and 
make a small incision in the linea alba midway between 
the umbilicus and the pubic symphysis, and, after allowing 
the fluid to escape, it is usually easy to determine the cause 
of the hydroperitoncum. In many cases the peritoneum, 
visceral and parietal, is found dotted with a multitude of 
minute secondary nodules ; then the fluid is cautiously 
sponged out and the incision closed. Even then it is to 
the patient's advantage, as a clear diagnosis is ensured. On 
the other hand, and by no means infrequently, a peduncu- 
lated and ea.sily removable tumor of the ovary, uterus, or 
Fallopian tubes is found, the removal of which is accompa- 
nied by a rapid convalescence and restoration to vigorous 
health. 




292 DISEASES OF WOMEN. 



It is also important to remember that hy d rope rit one um is 
sometimes complicated with hydrothorax, and tlie removal 
of the cause of the ccelomic effusion — ovarian, uterine, or 
tubal tumor — is sometimes followed by rapid absorption of 
the fluid in the pleural cavities, 

4 Pelvic Cellulitis (Parametritis).— This signifies in- 
flammation of the connective tissue between the folds of 
the broad ligament (mesometrium). 

Causa. — It is usually a sequence of septic changes orig- 
inating in the ccr\-ical canal and cavity of the uterus follow- 
ing abortion, delivery at term, especially instrumental deliv- 
ery, and operation on the uterus, and is often associated 
with some injury opening up a communication between the 
uterine canal or vagina and the connective-tissue tract of 
the mesometrium ; for example, a deep laceration of the 
cervix. It occasionally complicates salpingitis. 

Pathologically, pelvic cellulitis docs not differ from septic 
inflammation of connective tissue in more superficial regions 
of the body. The change consists in the infiltration of the 
connective tissue of the mesometrium with inflammatory 
products, and the effects depend upon the extent of tissue 
involved and the nature of the virus. 

The infiltration usually involves one broad ligament, dis- 
places the uterus, and at the same time fixes it. When the 
left broad ligament is involved the exudation may surround 
the rectum. When the infiltration is very extensive it ele- 
vates the broad ligament above the level of the true pelvis, 
and the exudation extends into the subserous tissue of the 
anterior abdominal wall. Occasionally it infiltrates the 
connective tissue in the cave of Retzius and forms a 
rounded swelling immediately above the pubes: in a small 
proportion of cases the exudation extends into the tissue 
between the cervix uteri and bladder, raises up the perito- 
neum, and obliterates the utcro-vesical pouch. Such exu- 
dations sometimes give rise to considerable hypogastric 
swellings and cause extreme irritability of the bladder. 



DISEASES OF THE PELVIC PERITONEUM. 

In a very large proportion of cases the exudation sub- 
sides in the course of a few weeks and the patient r 
in some it slowly extends into the subserous tissue and 
converts the belly-wal! into a firm resisting mass. In such 
cases the illness may be prolonged for many weeks and 
even months. 

In a certain proportion of cases suppuration occurs, re- 
sulting in a pelvic abscess. 

The common forms of pelvic cellulitis are rarely mis- 
taken for other conditions, and should there be any doubt 
a little patience will, in most cases, enable a correct diag- 
nosis to be made, for rest will promote absorption of the 
exudation. 

5. Pelvic Abscess. — This term signifies a collection of 
pus between the layers of the mesometrium. Usually it 
is the sequel of an attack of pelvic celluhtis, but it is 
sometimes due to the presence of a sequestered extra- 
uterine ftetus (iithopaedion), decomposing blood-clot due 
to mesometric rupture of a gravid tube, echinococcus 
cyst, or pus from a pericecal abscess burrowing under 
the peritoneum. 

The pus in a pelvic abscess points and escapes in one 
of many situations. The abscess may open into the mucous 
canals of the pelvis — rectum, vagina, or even the bladder. 
It may point in the groin, immediately above or below 
Poupart's ligament ; the pus will sometimes burrow beneath 
the fascia lata and point in the middle of the thigh, usually 
on the outer side. Occasionally it travels by the side of 
the urachus and points at the navel; exceptionally it will 
burrow through the greater sciatic notch and gain the 
buttock. 

Signs. — The onset of pelvic cellulitis is usually marked 
by a rigor, followed by pain in one or both flanks; febrile 
symptoms supervene, and, as the exudation increases, trou- 
bles during micturition or defecation are experienced. 
These signs arc of greater significance when they follow 




DISEASES OF WOMEN. 



within twenty-four or thirty-six hours of abortion, deliver}', 
or operation on the uterus. 

Diagnosis. — On examining through the vagina, a hard 
mass will be found occupying one or both ligaments ; in 
many cases the hard masses arc conjoined by a ring of 
hard tissue surrounding the neck of the uterus. When the 
whole extent of the ligaments is infiltrated the swelling is 
perceptible at the brim of the pelvis and in the hypo- 
gastrium. 

When suppuration occurs, the temperature, pulse, and 
general condition of the patient are those accompanying 
large collections of pus. The local signs are — the pre- 
viously hard masses become softer, fluctuation is detected, 
or the overlying skin is oedematous and perhaps red. The 
abscess is then said to point. 

The pus furnished by a pelvic abscess is often intensely 
fcetid; this is mainly due to c on t.ami nation from the bowel. 
In the course of the formation of the abscess the peritoneum 
is stripped from the wall of the rectum, and its tissues, be- 
coming softened, allow of the passage of intestinal contents 
loaded with pathogenic micro-organisms into the exudation, 
and putrefaction is established. 

Treatment. — In the acute stages of pelvic cellulitis the 
patient is confined to bed, the bowels kept regular by means 
of saline purgatives; and warm vaginal douches should be 
frequently administered by a careful nur.se. Glycerin tam- 
pons help to relieve the pelvic congestion. When there b 
much abdominal pain, warm fomentations to the hypogas- 
trium give great relief. 

When suppuration occurs and the pus can be localized, 
an incision should be made into it and the abscess drained. 
It is preferable to evacuate a pelvic abscess through the 
belly-wall rather than by an incision in the vagina. Should 
the abscess burst into the vagina, the aperture of commu- 
nication is apt to close, and defective drainage leads to 
reaccumulation of pus : under tliese circumstances it is 



DISEASES OF THE PELVIC PERITONEUM. 



295 



advisable to dilate the opening to ensure drainage. When 
the abscess is due to suppuration of a gestation sac the 
sinus should be enlarged, and all fragments of bone and 
other fcetal tissues removed. 

As in all cases of prolonged suppuration, the patient's 
strength must be supported by nutritious and easily digest- 
ible fSod ; quinine and iron preparations are useful, and 
health is finally restored by change of air. 




CHAPTER XXXIII. 

DISEASES OF THE PELVIC PERITONEUM AND CONNEC- 
TIVE TISSUE (Continued). 

TUMORS OF THE MESOMETRIUM (BROAD 
LIGAMENT). 

In addition to tumors of the ovary, parovarium, and 
Gartner's duct, others sometimes arise from the round liga- 
ment of the uterus, the ovarian Hgament, as well as from 
the proper tissues of the mesometrium, and so simulate 
ovarian and uterine tumors that accurate diagnosis from 
physical signs is impossible. 

It will be convenient to describe them in the following 
order ; Lipomata, myomata, and sarcomata. 

IfipOtuata. — Under normal conditions fat is sometimes 
seen between the layers of the mesometrium, but it is 
rarely met with in the neighborhood of the Fallopian tube. 

Occasionally the broad ligament is occupied by a fatty 
tumor as large as a fist, and in one exceptional case a 
lipoma reaching as high as the navel was successfully enu- 
cleated from a woman thirty-two years of age : it weighed 
5 kilogrammes (Treves), 

Myomata. — Unstriped muscle-fibre apart from the litems 
and Fallopian tubes exists in three situations in the meso- 
metrium: (i) in the round ligament of the uterus; (2) in 
the ovarian ligament ; (3) in the connective tissue between 
its folds. 

(i) The Round Ligament of Ike Uterus. — Myomata and 
fibromyomata arising in this structure are rare. Several 
examples have been recorded in connection with the part 



DISEASES OF THE PELVIC PERiTONEUM. 



297 



of this ligament which traverses the inguinal canal. They 
are oval in shape and have been reported as big as cocoa- 
nuts. 

(3) The Ovarian Ligament. — Myomata of this structure 
have been observed as large as a fist. They simulate small 
ovarian tumors and require the same treatment — that is, 
removal. 

(3) Mesometric Myomata. — A stratum of unstriped mus- 
cle-fibre lies immediately beneath the peritoneum forming 
the mesometrium, and replaces the subserous tissue which 
exists in other regions: this layer of muscle-fibre is directly 
continuous with the muscle-tissue of the uterus, and is oc- 
casionally the source of myomata which may attain large 
dimensions. 

Mesometric myomata are, as a rule, bilateral, and when 
of moderate size they are mobile, ovoid in shape, and easily 
enucleated. After a time they grow with great rapidity, and 
may in a few months attain a weight of ten kilogrammes 
or more. As the tumor rises out of the pelvis it carries the 
uterus and its appendages with it. The rapid growth and 
the profound way these large tumors sometimes affect the 
patient's health are due to septic infection of the tumor. 
The tissue of such myomata is very liable to become myx- 
omatous, resulting in the formation of large cavities ; calci- 
fication is not infrequent. 

Mesometric myomata occur after the thirty-fifth year- 
They are very formidable tumors to deal with; the best 
method of treating them, even when large, is enucleation. 
More than half the cases succumb if operation be delayed 
until the tumor rises above the pelvic brim. 

Sarcotnata. — They are very rare in the mesometrium 
and usually consist of spindle-cells. They grow very rap- 
idly and quickly destroy life. 

Bchinococcus Colonies (Hydatids) of the PelTls. — 
In connection with the pelvis it will be necessary to con- 
sider echinococcus cysts in the following situations : (a) 



298 DISEASES OF IVOMEN. 

The uterus ; (b) The mesometrium ; (c) The pelvic bones ; 
(d) The omentum ; (e) The Fallopian tubes. 

There is no authentic example on record of a primaiy 
echinococcus cyst of the ovary. 

(a) The Uterus. — Echinococcus cysts have on several 
occasions been observed growing beneath the peritoneal 
investment of the uterus and forming a tumor as large as 
the patient's head. 

Clinically, such cysts simulate either an ovarian tumor 
or a uterine myoma. When the cysts contain vesicles there 
is no difficulty in determining their nature in the course of 
an operation. When they are sterile the echinococcus 
origin of the cyst is rarely suspected. 

(b) The Mcsonietrium. — Many examples of echinococcus 
colonies between the layers of the broad ligament have 
been reported. As a rule, they form part of a general 
invasion of the subperitoneal tissue. The colonies are apt 
to communicate with the vagina, bladder, or rectum, and 
the characteristic vesicles escape with the urine or faeces. 
Such communications lead to septic infection of the cyst, 
and suppuration, with all its evils, is the consequence; or 
sinuses form in the groin, and the patient sinks exhausted 
from long-maintained suppuration. 

(c) The Bony Pelvis. — Not the least interesting circum- 
stance in connection with echinococcus cysts affecting the 
pelvis is the effect they produce on the bones : firm osseous 
barriers offer little resi.stance to the invading propensities 
of echinococcus cysts, and they pass from the ilium into the 
sacrum irrespective of the sacro-iliac synchondrosis. Hy- 
datids of the ilium or ischium erode the walls of the ace- 
tabulum and overrun the hip-joint, and when left to run 
their course unchecked will extend into the head of the 
femur. 

(d) The Omentum. — Large echinococcus colonies in the 
great omentum lodge in the true pelvis, and so simulate the 
physical signs of ovarian cysts that they deceive the most 



DISEASES OF THE PELVIC PERITONEUM. 



299 



careful and experienced surgeon. Occasionally they dip so 
low that they lodge on the floor of the pelvis and fill the 
recto-vaginal fossa. Accurate diagnosis is then very dif- 
ficult, indeed almost impossible. 

(e) The Fallopian Tubes. — Very exceptionally, echinococ- 
cus vesicles have been found in the Fallopian tubes. In a re- 
markable case in a woman thirty-two years of age (reported 
by Doleris) both tubes were so stuffed with ve.sicles that 
they formed a large tumor reaching above the umbilicus. 
The mass weighed 2 kilogrammes, and consisted of the two 
tubes coiled upon themselves like small intestines, and so 
elongated that one measured 57 and the other 53 cm. 
The tubes were successfully removed. Maloney described 
the case of a girl fourteen years of age whose right Fal- 
lopian tube was greatly di.stended and thrown into convolu- 
tions by a mass of echinococcus vesicles. The girl had 
echinococcus cysts in her liver, and one adherent to the 
fundus of the uterus had communicated with the Fallopian 
tube. 

Secondary Peritoneal Infection. — In the course of a cceU- 
otomy for echinococcus cysts minute cysts and nodules are 
sometimes seen scattered over the peritoneum, particularly 
in the pelvic region. Many of these nodules show the 
lamination characteristic of echinococcus membrane, and 
occasionally booklets will be detected. This condition is 
due, in all probability, to the escape of fluid from an echi- 
nococcus cyst, in consequence either of rupture or of leak- 
age during tapping. Brood -capsules escape with the fluid, 
and. gravitating to the recesses of the pelvis, engraft them- 
selves on the peritoneum. 

Diagnosis. — The clinical recognition of echinococcus 
cysts in the pelvic organs, mesometrium. or bones is some- 
times made by a sort of " lucky guess " when other and 
more common diseases can with certainty be excluded. 
Occasionally when a patient seeks advice for pelvic trouble, 
and brings " vesicles " which have escaped by the rectum, 



300 



DISEASES OF WOMEN, 



vagina, or urethra, much speculation is spared. When the 
bones are eroded and swellings form under the skin, they 
are punctured and characteristic fluid with vesicles and 
booklets escapes, and so the diagnosis is established. 
When the cysts suppurate the physical signs are those of 
abscess. 

Treatment — When the cysts take the form of peduncu- 
lated tumors, either of the omentum or uterus, they require 
the same treatment as ovarian tumors — viz. ligature and 
removal. When sessile or when their false capsules are 
very adherent, enucleation of the* mother cysts is a very 
successful measure. 

Should the cysts burrow in the mesometrium and open 
into hollow pelvic viscera, then the treatment of the sup- 
purating cavities and sinuses is very unsatisfactory and is 
rarely successful. The method of dealing with them 
should be on the same principle as that adopted for pelvic 
abscess. The course of the case is very protracted, and 
death usually occurs from septic complications. 




CHAPTER XXXIV 



DISORDERS OF MENSTRUATION. 



AMENORRHCEA; MENORRHAGIA AND ME- 
TRORRHAGIA; DYSMENORRHCEA. 

Ainenorrhoea. — This signifies absence of menstruation 
between puberty and the menopause. Considered clinic- 
ally, it is of three kinds: 

(i) Primary Amenerrhaa. — Although the patient has 
passed the ordinary age of puberty, menstruation has never 
occurred. 

{2) Secondary Amenorrkaa. — Menstruation is suppressed 
after having once been established. 

(3) Cryptomaiorrhtta. — Menstruation occurs, but its prod- 
ucts are retained in consequence of atresia, of the genital 
passages. 

Primary Amenorrheea. — The physician should set about 
his inquiry systematically. Firstly: Has the patient never 
menstruated? She may be the subject of congenital 
absence or of arrest of development of the uterus or its 
adnexa. This is ascertained by a recto-abdominal examin- 
ation, with the assistance, if necessary, of an anesthetic. 
If such a condition be found, interference is obviously use- 
less and unnecessary. If the organs are present and nor- 
mally developed, the case may be one simply of delayed 
puberty ; there are instances on record of menstruation 
occurring for the first time after the age of twenty, the 
patient being otherwise quite healthy. In such a case 
interference is equally contraindicated. Attempts to estab- 
lish the function by electricity, massage, drugs, etc. are to 




DISEASES OF W0ME2^. 

be deprecated as long as the general health is good. Even 
pregnancy may occur before the appearance of the menses. 
If, on the other hand, a constitutional cause of amenorrhoea 
exists, such as phthisis, chlorosis, or cretinism, this should 
be treated on general principles and on the lines laid down 
below. Many patients seek advice on the supposition that 
the amenorrhcea is the cause of their ill-health or is in itself 
detrimental. This idea should be combated, for it is an 
advantage rather than otherwise to an antemic woman 
not to menstruate. It may even be advisable to endeavor 
to check free menstruation in cases of ansemia. 

Secondary Amenorrhwa. — The menses are suppressed 
after having been previously established. That amenorrhcEa 
may be due to pregnancy is a fact that must be always 
borne in mind, even in the case of unmarried women and 
whatever their station in life ; a mistake on this point may 
lead to very unpleasant consequences. The practitioner 
should therefore be on the alert, especially when amenor- 
rhcea has suddenly supervened in a healthy woman pre- 
viously regular. There will be usually very little difficulty 
in verifying the fact, and in the early months a guarded 
opinion should be given. If pregnancy can be excluded, 
the inquiry into the cause of the amenorrhcea will be sim- 
plified. Suppression of the menses for a few months after 
the first onset of menstruation occurs not infrequently 
in perfectly healthy girls; in such cases we may look for 
its re-establishment in due course without any active 
measures. 

Premature cessation of menstruation sometimes occurs: 
it may be due to a mental shock or to systemic disease. 
When there has been no such cause at work, these patients 
often give a history of relative sterility ; for instance, they 
have borne only one or two children during ten or fifteen 
years of married life. 

Pathological conditions causing amenorrhcea are local 
or constitutional; among the former may be enumerated 



DISORDERS OF MENSTRUATION 



303 



atrophy of the ovaries and excessive involution of the 
uterus. The most common constitutional causes are an- 
aemia and phthisis, where the amenorrhtsa Ls undoubtedly 
beneficent. Acute febrile diseases may be followed by 
temporary amenorrhtea, and the same result follows from 
a cold caught during menstruation; the popular estimate 
of the harmful results of getting the feet wet during a 
period is supported by experience. 

Lastly, certain chronic intoxications, such as that result- 
ing from morphiomania, have the same effect. 

Cryptonunorrluva. — The patient experiences a monthly 
molimen. but "sees nothing." This is not infrequently the 
precursor of the onset of menstruation. In other cases we 
have to deal with the retention of the menses. When there 
is occlusion either of the cervix or of the vagina the men- 
strual blood accumulates every month, and gradually pro- 
duces distention of the vagina or uterus, or both. Abdom- 
inal examination then reveals a pelvic tumor whose size 
varies with the duration of the retention : a combined recto- 
abdominal examination will usually place the diagnosis 
beyond doubt, especially if an imperforate hymen is also 
found. Surgical treatment is required (see p. 74). Two 
points should be remembered in this connection: firstly^ 
that the menstrual molimen may occur in cases of congen- 
ital absence of the uterus, where there is consequently no 
retention ; and, secondly, that retention may c<^xist with 
the appearance of the menses in cases of double uterus or 
vagina. 

Treatment. — ^This has been in a measure indicated in the 
analysis of the etiology of the condition. Imperfect devel- 
opment, if not too marked, may sometimes be remedied by 
stimulative treatment in the direction of increasing the pel- 
vic circulation. This is probably the modus operandi of 
most emmenagogues : it is doubtful whether any of them 
has a s[>ecific action on the uterus. They should be given, 
if possible, just before the time of an expected period. 



304 



DISEASES OF WOMEN. 



Warm foot- or hip-baths will often assist the process if 
administered at this time. 

Phthisical patients should be treated with tonics and cod- 
liver oil. Anemia yields readily, as a rule, to iron, which 
is best given either in the form of Bland's pills, of which 
nine may be taken daily for six weeks, or in a saline ape- 
rient mixture. Constipation is a constant feature of amen- 
orrhcea associated with antemia, and saline laxatives should 
form a routine part of the treatment. In cases of simple 
ansmia and chlorosis, so common among shop-girls and 
domestic servants, menstruation will almost invariably be 
speedily re-established as the anaemic condition improves. 

Amcnorrhcea is not infrequently found among the in- 
sane; if in such a case menstruation comes on again, the 
mental condition often improves, indicating, not that the 
amenorrhcea is the cause of the insanity, but that nutritive 
conditions, which were probably responsible for both symp- 
toms, have improved. Return of menstruation without 
mental improvement makes the prognosis bad as regards 
the insanity. 

Menorrhagia. — This denotes excessive bleeding at the 
menstrual periods, and is a relative term. What is an 
ordinary menstrual flow in one woman may constitute men- 
orrhagia in another. Some lose more in three days than 
others in seven or eight. So the loss sustained by a patient 
at any one time must be judged of in relation to the stand- 
ard of her habitual mcnstruation-ty]>e. 

Metrorrhagia means a discharge of blood in the inter- 
vals of menstruation. Menorrhagia passes insensibly into 
metrorrhagia, and the two conditions may be considered 
together. 

An abundant menstrual discharge occurring but once 
and limited to the period need cause no anxiety. Repeti- 
tion of such a hemorrhage or its prolongation into the 
intermenstrual period necessitates a careful inquiry into 
the cause, To continue to treat menorrhagia with drugs. 




D/SORDF.RS OF AfENSTRUATfON. 



without examination, is unpardonable : in this way, especially 
at the age of the menopause, uterine cancer has frequently 
been able to make such strides and gain such a hold that a 
miserable existence and a speedy death have been the only 
possibilities left ; whilt in other cases a small polypus, whose 
removal would have h>cen most e.isy, has been allowed to 
blanch a woman to such an extent that months or years 
have been required to make up the lost ground. 

The constitutional causes of menorrhagia are purpura, 
scorbutus, and ha;mophilia. Their place in the etiological 
list is unimportant, on account of their rarity. The local 
causes have a close relation to the age and sexual history 
of the patient. They are as follows : 

In Virgins. — Below the age of twenty-five the most com- 
mon cause is uterine congestion, which in turn may be due 
to exposure or cold at a menstrual period. This condition is 
curable by rest and warmth. From the age of twenty-five 
onward, polypi and myomata are responsible for most cases 
of menorrhagia : probably the hemorrhage is produced in 
the same way in both instances — viz. by the increased vas- 
cular condition of the endometrium ; for we often find large 
interstitial or subperitoneal fibro-myomata without any 
menorrhagia ; but it is very rarely that we meet with the 
submucous variety without excessive menstruation. A 
small polypus may lead to greater hemorrhage and more 
excessive blanching than any other condition. The small 
cause here seems quite inadequate in comparison with the 
magnitude of the result. The treatment js obvious — dilata- 
tion of the cervix and removal of the polypus. 

In the Married. — In addition to the above conditions we 
meet with others to which in many cases the hemorrhage 
is due. Thus we often hear the following history: A 
patient states that she was in good health till she had a 
labor or a miscarriage some months or years previously, 
and that she has never been the same since. Menorrhagia 
has come on, with or without metrorrhagia- If it was a 



D/SEASES OF WOMEN. 



nation that^ 



306 

miscarriage, further inquiry often elicits the information that 
the patient was up and about two days after. Examination 
usually reveals one of two conditions : {a) The uterus is 
enlarged and bulky ; the os is patulous, and through it pro- 
jects a little clot or shred of tissue. Portions of placcn< 
or membranes have been retained, and involution has 
hindered. At or near the time of the menopause this coi 
dition is especially apt to be overlooked, because the short 
period of amenorrhcea, followed by irregular hemorrhage in 
a woman who has not borne children for some years, is in- 
terpreted by the patient, and, unfortunately, too often by her 
doctor, as meaning simply " the change of life." The proper 
treatment is to remove the remains of gestation, dilating the 
cervix if necessary. 

ip) The cervix is found torn and its mucous membi 
everted and eroded. The endometrium is hyper jest hetic,1 
covered with fungous granulations, and bleeds readily. Peri' 
metritic tenderness may be also present, in which case thfr. 
uterus is more or less fixed. Attention should first be^i 
directed to the inflammatorj' condition : when this has sul 
sided the cavity should be curetted and the cervix repaii 
if necessary {see Curetting and Trachelorrhaphy). 

From the age of thirty-five onward, cancer of the uteruS' 
must always be thought of as a jxissible cause of hemot^ 
rhage: unmarried women are not exempt from it, but iti 
is much more common among those who have bo! 
children. 

On the subject of treatment little more need be said,' 
The local measures above indicated are the most important 
to these should be added rest in bed when the hemorrhage-i 
is at all severe. Hydrastis, viburnum, ergot, cannatus 
indica, hyoscyamus, and hazeline are useful as accessories 
as sole treatment they cannot be relied on. 

Dystnenorrhoea. — This means "painful menstruation/ 
but we must qualify our definition, for 60 to 70 per cent <rf. 
women sufler pain during menstruation, but we cannot say' 



r 



DISORDEKS OF MENSTRUATION. 



307 



that wc have to do with dysnienorrhcea in this proportion 
of cases. Further, the intensity of pain docs not depend 
solely on the nature of the processes occurring peripherally 
in the generative organs, but rather on the relation between 
this factor and another — to wit, the central receptivitj- — so 
that, given the same pelvic conditions in two women, the 
nervous sensitiveness of one may lead to dysmenorrhcea, 
while the nervous stabihty of the other may allow the i>e- 
riod to occur with very little disturbance. Recognition of 
this fact clinically will make easier both the interpretation 
and the treatment of the phenomena of painful menstruation. 

It is generally thought that dysmenorrhosa is associated 
with scanty menstruation ; the reverse is more often true. 
To understand the matter we must not, however, be content 
with generalizations. Painful and profuse menstruation is 
generally associated with great congestion before the flow 
begins, and the pain occurs during this congestive period; 
the commencement of the flow is then accompanied by a 
feeling of relief. When menstruation is painful and scanty 
the pain more often occurs during the flow and has its origin 
in painful uterine contractions. The situation of the pain 
has also its significance : when this is in the back the cervix 
is generally at fault, whilst pain referred to the umbilicus is 
related to disturbance in the body of the uterus, and es- 
pecially in the fundus. Pain in the iliac fossa; is connected 
with ovarian irritation, and shooting pains in the thighs are 
often due to a subacute inflammatory condition of the jxrlvic 
connective tissue. Further, we may have reflected pains 
elsewhere, the most frequent being in the breasts. The 
constitutional origin of dysmenorrhcea is illustrated in the 
case of girls who suffer greatly when in London, but who 
menstruate painlessly when in the country, 

I. Dystncnorrlura of Constitutwnal Origin. — This must be 
thought of, first, in dealing with girls and unmarried women, 
for obvious reasons. We meet with two well-defined types : 
the first is the neurotic. Menstruation has often been pain- 




3o8 DISEASES OF WOMEN. 

ful from the beginning, and the flow is generally scanty.' 
The organs are normal in many instances, and the most 
careful c^camination leads to no other conclusion than that 
the nervous system is unduly sensitive and unstable, 
other cases the uterus is under- developed. This type i 
the one met with so often among girls whose physical edit 
cation has been neglected, and who have passed most o 
their time in-doors, either in luxurious indolence or 
study. It is but rarely seen among the working classes 
but is found among school-teachers and sometimes amon{^ 
servants. The remedy lies in improved hygienic conditions^! 
more exercise, plain food, early hours, regularity of habits,! 
with a definite occupation in some cases and restricted I 
mental work in others. The second type is that of malnu- 
trition. Here we often find that at its onset menstruation 
was painles.s. Anemia and constipation, with their atten- 
dant train of symptoms, are common, and dysmenorrhoea 
alternates with periods of amenorrhoea. The same altera- 
tion in the routine of daily life must t)e secured as in the 
first type, with the addition, where necessary, of iron tonics J 
and mild aperients. Nerve sedatives may be used in both \ 
cases before the period, especially chloral, hyoscyamus. andl 
belladonna, but they must be given with discretion. 

Not too much reliance must be placed on the constitu*] 
tional treatment of dysmenorrheea. It has its place, buti 
will also often disappoint. While it should be persevered] 
in patiently when no local cause for the dysmenorrhoea J 
exists, it should not be tried too long before making anl 
examination. For it must be remembered that a rectal'l 
examination will often give the information we want; andl 
it is better in certain cases to make a vaginal examinationJ 
under an anarsthctic than to go on working in the dailcj 

II. Dysmtnorrluea of Local Origin. — This is the mcx 
common kind of dysmenorrhoea, and the following cauaj 
conditions are met with : 

Faults of Conformation. — An imperfectly -developed uterus J 




DISORDERS OF MENSTRUATION/. 



309 



is often associated with dysmenorrhoea, but the nature of 
the relation is by no means clear. 

Stenosis of the os internum, other than congenital, is of 
two kinds — anatomical and physiological. The first is due 
to cicatrization or fibroid induration, the second to spasm. 
Probably both varieties act in the same way, by rendering 
the uterine contractions painful. The pain in these cases is 
always referred to the back, and is allied in character to 
labor-pain.s. It \?i seldom that the sound will not pass into 
the cervical canal, but it may not be possible to introduce 
it past the internal os without an anaesthetic. If it does so 
pass, the patient complains of sudden pain in the back, 
which she will often state to be just like her menstrual pain. 
Probably the passage of the sound induces reflux spasm, 
which causes the pain. It should be remembered that the 
true test of narrowing is difficulty in withdrawing the sound ; 
difficulty in introducing it may be due to other causes, such 
as tortuosity or sharp curving of the canal, or want of skill 
on the part of the operator. 

The proper treatment is dilatation of the cervical canal 
under an anxsthetic during an intermen.strual period. It is 
a good plan, in cases of persistently recurring muscular 
spasm, to nick the margins of the internal os in one or two 
places with a fine bistoury. 

Faults of Position. — Both versions and flexions may give 
rise to dysmenorrhoea, as described in Chapter XIV. In 
the former the pain is due mainly to congestion ; in the 
latter it is probably produced in the same way as in cases 
of stenosis — viz. by the occurrence of painful contractions. 
The condition finds a parallel in the dystocia due to faUing 
forward of the uterus in cases of pendulous abdomen. 
Many women, however, menstruate painlessly in whom the 
uterus is markedly flexed ; so the cause is probably com- 
plex. It is a matter of common experience that dysmen- 
orrh(Ea associated with uterine fle.xlon is often found in 
nervous women. But, whatever explanation we adopt, the 



3IO 




DISEASES OF WOMEN. 



fact remains that correction of a flexion is followed 1^ 
relief of the menstrual pain in a certain proportion of cases. 
This method of treatment should therefore be tried ; for 
details see the section on Flexions and Displacements of 
the Uterus. 

Pflinc InflammalioH. — This is a fruitful cause of dysmen- 
orrhcea, especially in women who have borne children. It 
may be peri-uterine or iiitra-uterine. In the former the 
uterus is fixed in the midst of the inflammatory mass, and 
the extra congestion at the menstrual periods and the 
hampered uterine contractions are alike sources of pain. 
The hi.story and the condition found on examination wili 
readily lead to a correct diagnosis. Dysmenorrhcea, it 
must be observed, is not usually a marked feature in pelvic 
inflammation, and probably the patient will seek advice on 
other grounds; but when it is the prominent symptom, the 
result of treating the inflammation is, as a rule, highly sat- 
isfactory. We cannot here enter into the subject in detail, 
but the broad lines of treatment are rest in bed, hot vaginal 
douching, fomentations to the abdomen, purgatives, and 
occasional glycerin tampons, 

Intra-uterinc inflammation as a cause of dysmenorrhcea 
is easy to explain'. The mucous membrane of the uterus 
becomes very sensitive when inflamed ; the menstrual con- 
gestion causes pressure on the nerve-endings; and the 
same effect is produced when the uterine contractions press 
the inflamed surfaces together. The treatment is that of 
the causal pathological condition. 

Membranous Dysmenorrhcea.— This signifies painful 
menstruation accompanied by the discharge of membrane 
H from the uterus. 

H Causes. — The literature relating to the causes of mem- 

^ft branous dysmenorrhcea is very great, actual facts are few 

^^k and relatively unimportant, conjectural causes abundant, 
^H positive knowledge practically nil. 
^^K 1 Signs. — In typical cases the patient during the menstrual 




DISORDEKS OF MENSTRUATION. 

period passes a membranous cast of the uterine cavity, 
sometimes entire, more frequently in two or more pieces. 

When complete, a menstrual decidua is a bag in outline 
like an isosceles triangle, the base corresponding to the 
fundus of the uterus; at each angle there is an opening, 
to correspond to the uterine ostia of the Fallopian tubes, 
and the apical opening to the internal orifice of the cervical 
canal. Menstrual decidua; rarely exceed 2 or 3 cm. in 
length, and are scarcely 2 ram. in thickness. The inner 
surface is smooth and dotted with minute pits, orifices of 
the uterine glands. The outer surface is shaggy. The 
histology is like that of the decidua of pregnancy. 

The patient complains at the beginning of the flow of 
pain, intermitting in character, which gradually increases 
until the membrane is expelled: then the pain usually 
ceases. The membrane is discharged usually before the 
end of forty-eight hours after the onset of the menstrual 
period. 

Diagnosis. — Membranous dysmenorrhtea must not be 
confounded with the decidua discharged from a case of 
tubal pregnancy or from the unimpregnated horn of a 
bicorned uterus when its companion cornu is gravid, or the 
membranes in a case of early abortion. 

" No case can be regarded as one of membranous dys- 
menorrhcea unie.ss membranes are discharged regularly, 
at regular monthly periods, and for a considerable time" 
(Champneys). 

Treatment. — Drugs are useless; pregnancy, even when it 
goes to full time, does not cure the condition. Dilatation 
of the uterine cavity and curetting afford temporary relief. 



CHAPTKR XXXV. 



VAGINISMUS AND DYSPAREUNEA; STERILITY. 

yag;inisiims. — This term is applied to painful reflex 
contractions of the muscles surrounding the vaginal orifice 
when attempts arc made to effect coitus. The muscles 
chiefly at fauit are the levators of the anus. 

Causes. — i. It occurs in the newly married owing to 
rigidity of the hymen, to smallness of the vaginal orifice, 
to an inflammatory condition of the hymen or carunculfe 
myrtiforme.s, or to hyperesthesia. Tlie latter may be the 
result of mere nervousness or of hysteria ; and vaginismus 
from such causes may persist for months or years after 
marriage, and lead to much domestic unhappiness. 

2. It may be due to vulvitis or vaginitis ; to ulcers, sores, 
or excoriations about the vulva; to inflamed Bartholinian 
glands; to urethritis or urethral caruncle. Piles will often 
provoke painful contractions of the levators of the anus 
during copulation. 

3, It occurs in later life in connection with kraurosis 
vulva;, the nerve-endings in the vulva being rendered un- 
duly sensitive by subcutaneous cicatricial contraction. 

Dyspareunia should be read in association with this 
section. 

Treatment. — The first essential is to discover the anatonji- 
cal cause, if one exists ; otherwise time and effort may be 
wasted in the adoption of constitutional treatment, wheaa 
simple local application may effect an immediate cure. 
Thus, in all inflammatory conditions, the.se must be treated 




VAGINISMUS AND DYSPAREUNIA ; STERILITY. 313 

by the methods described under their respective headings, 
and temporary sexual abstinence must be enjoined. When 
the vaginal orificf: is small, the use of simple lubricants such 
as vaseline may suffice ; if not, it must be dilated with the 
fingers or with dilators, perferably under an anaesthetic ; a 
series of Fergusson's specula often answers very well. A 
rigid hymen should be incised, and a sensitive one excised. 
Simple vaginal hypcraesthesia may be relieved by a vaginal 
pessary containing half a grain to one grain of cocaine, and 
made up with cacao butter ; this is inserted ten to fifteen 
minutes before intercourse. Hyper<esthesia is also often 
improved by dilation under an aniesthetic. Caruncles and 
cysts must be removed. Vaginismus due to kraurosis 
must be treated by ana;sthctic local applications, such as 
carbolic acid, cocaine, or menthol ; or by dissection, as de- 
scribed under Kraurosis. 

In the case of hysterical or nervous women, constitu- 
tional remedies may be required, including sedatives such 
as bromides or hyoscyamus. 

It must be remembered, however, that the cases where 
no local treatment is available are very rare, and include 
cases of "incompatibility" which are beyond the reach of 
medical intervention. 

Dyspaxeuiiia. — This signifies pain during sexual inter- 
course; it may exist without vaginismus — that is, without 
reflex contraction of the vaginal orifice. The causes of 
dyspareunia are much the same as those of vaginismus, 
and may be classified as follows : 

1. Psychkal causts, as mere incompatibility or aversion 
when the marriage is unsuitable ; nervousness ; or wauvatse 
honU. 

2. Analomkal Causfs.~(a) Smallness of the vulva and 
vagina, congenital and due to under- development ; or ac- 
quired, as the result of cicatricial contraction or kraurosis 
vulvae. .__ 

(b) Inflaminatofy conditions of the vulva or vagina. 



314 



DISEASES OF WOMElf. 



(c) More deep-seated conditions, as prol.ipse of the 
ovaries and pelvic inflammation. 

Sterility. — With causes of sterility affecting the man wc 
have not here to do, but they must never be lost sight of 
in investigating a case. For the want of carefully-directed 
inquiry, the woman has not infrequently been erroneously 
held responsible for a childless marriage. 

In considering sterility as it concerns women, we must 
draw a broad distinction between — 

(A) Conditions which do not allow of conception. 

(B) Conditions which do allow of conception, but which 
do not allow of development. 

(A) Conditions which do not allow of Conception. — (i) 
Age. — Save under exceptional circumstances conception 
does not occur before puberty, After this age fertility gen- 
erally increases, attains its maximum at about the age of 
twenty-five, and then declines. Thus Matthews Duncan 
gives the following figures as the result of the analysis of 
4447 cases : . 

Age al mnniage: 

15-19; 20-24; 25-29; 30*34; 3S-39: 40-44; 45-49; 50. etc. 

7.3: o.— ; 27.7; 37.5; 53.2; 90.9; 95.6; IQO. 

That is, in proportion as marriage is deferred the probabil- 
ity of sterility is increased. After the age of forty the 
chances of childbearing are remote. 

The following laws, which Matthews Duncan enunciates, 
are also worth bearing in mind : 

The question of a woman's being probably sterile is 
decided in three years of married life. 

When the expectation of fertility is greatest the question 
of probable sterility is soonest decided, and vice z'crsd. 

Relative sterility will arrive after a shorter time according 
as the age at marriage is greater. A wife who. having had 
children, has ceased for three years to exhibit fertility has 




VAGINISMUS AND DYSPAREUNIA ; STERILITY. 



probably become relatively sterile — that is, will probably 
bear no more children — and the probability increases as 
time elapses. 

(2) Deficiinl Ch'ulation. — When the ovaries are under- 
developed sterility is absolute. The atrophy which they 
undergo as time goes on has the same effect, and to this 
may be attributed the increasing sterility as the age of mar- 
riage is postponed. Ovarian disease, such as solid tumors 
and cysts, also leads to sterility. These conditions may 
generally be diagnosed by careful bimanual examination. 
Delay or absence of menstruation cannot be regarded as an 
absolute indication of sterility. 

(3) Deficient Uterine Changes. — When the uterus is very 
small and menstruation absent or scanty, sterility nearly 
always results. This may be in some cases due to the 
concomitant deficiency of ovulation ; in others to the in- 
ability of the uterus to prepare for an oosperm (fertilized 
ovum). 

(4) Incomplete Sexual Intercourse. — This may be due to 
narrowness of the vagina or to a rigid hymen. It must be 
remembered, however, that conception may occur when 
penetration has never taken place, 

(5) Mechanical Obstacles to Impregnation. — Under this 
head are included all cases of atresia, whether of the vagina, 
of the internal or external os of the uterus, or of the Fallopian 
tube. The latter frequently becomes sealed up at its fim- 
briated extremity, as the result of pyosalpinx; uterine atre- 
sia may also be due to disease, but congenital atresia is 
probably more common. Vaginal atresia is nearly always 
congenital. The mechanical obstacle may consist not in 
atresia, but in want of adaptation ; as, for example, in cases 
where the cervix is pointed markedly forward, either from 
retroversion or from anteflexion. The spermatozoa, which. 
as the result of intercourse, come to lie principally in the 
posterior vaginal fornix, are then unable to make their way 
through the os externum, which is turned away from them. 



3l6 DISEASES OF WOMEN. 

Polypi and other tumors in the genital passages may also 
be the cause of sterility. 

(6) Noxious Discharges. — Septic and gonorrhoeal dis- 
charges are injurious to the vitality of spermatozoa, and to 
this cause is probably partly due the sterility which is found 
in cases of gonorrhcea, endometritis, and adenomatous dis- 
ease of the cervix. Gonorrhiea has perhaps an even more 
considerable effect in the clianges which it induces in the 
Fallopian tubes. Strong antiseptic and frequent simple 
vaginal douches also prevent conception, 

(B) Conditions which allow of Concepiion, but wlack do 
not allow of Development of the Oosperm. — Under this head- 
ing are included, first, the as yet obscure conditions which 
lead to extra-uterine gestation; and secondly, pathological 
conditions of the uterus which cause early abortion, such 
as disease of the endometrium and acute flexions of the 
uterus. 

Treatment of Sterility. — It is most important that the 
practitioner should first ascertain whether the cause of ster- 
ility is remediable or not, for nothing leads to greater dis- 
appointment of the patient, and, as we may add, to greater 
discredit to her attendant, than the confident holding out 
of a hope which is doomed to non-fulfilment Therefore 
the development of the uterus and ovaries should be first 
investigated : if under- developed, treatment is useless and 
no hope should be held out. 

In cases of atresia the obstacle may often be overcome, 
as by division of a vaginal septum or by uterine dilatation. 
Correction of a malposition of the cervix will often be fol- 
lowed at once by conception. 

Inflammatory conditions of the uterus give a fair pros- 
pect of a favorable issue as the result of appropriate treat- 
ment, whether they have acted by preventing conception or 
by leading to early abortion. The same cannot, however, 
be said of tubal disease, where the prognosis is bad. But 
treatment should nevertheless be undertaken on conserva- 




VAGIKISMUS AND DYSPAREUNIA : STERILITY. 3I7 

tive lines. Similarly, polypi and other tumors should be 
removed, preserving the integrity of the uterus. 

Harmful discharges will be removed by the treatment 
of the uterine or vaginal conditions which cause them. 

Lastly, the conditions of intercourse must be inquired 
into and the patient advised accordingly. 

Sterility due to psychical causes is probably irremediable 
in most cases, but moral treatment is most likely to suc- 
ceed. Here the judicious husband will probably be a better 
physician than the medical attendant. 



CHAPTER XXXVr. 



DIAGNOSIS. 



Accurate diagnosis depends upon a systematic method 
of inquiry into symptoms and examination of physical 
signs. We shall here give an outline of the way such 
inquiry and examination should be set about. 

The anamnesis, or account obtained by questioning 
the patient. The age, occupation, and civil condition should 
be first noted as a matter of routine, for these points may 
influence subsequent inquiries. We may then proceed in 
the following' order; 

(a) Family History.— The present health or cause of 
death of the nearest relations should be noted. A clue 
may thus be gained as to the probability of tuberculosis, 
syphilis, or neuroses in the patient's case. 

(b) Previous Health. — Inquire concerning exanthemata 
or rheumatic fever in childhood, an.-^mia after puberty, 
syphilis or gonorrhcea after marriage, and previous treat- 
ment for disease of the pelvic organs. Thus, a history of 
gonorrhcea, followed by repeated attacks of pelvic inflam- 
mation, will lead one to suspect tubal mischief, and it may 
explain the presence of vaginitis, endometritis, or a liar- 
tholinian abscess; tuberculosis may lead to the diagnosis 
of tubercular peritonitis from other abdominal swellings 
or of tubercular salpingitis when the tubes are affected ; 
it may also clear up the nature of vulvar cutaneous affec- 
tions. A history of operative treatment for dysmenorrhcea 
will prepare for the finding of congenita! smallness or ante- 
flexion of the uterus ; whilst, if the patient has worn pessa- 




VlAGffOSlS. 319 

ries, a present vaginitis or endometritis may be explained, 
or retroversion, or hernia of the pelvic floor may be expected. 
So also the patient may liave had curetting, trachelor- 
rhaphy, amputation of the cervix, perineorrhaphy, or ab- 
dominal section performed, and these will all shed light on 
the present condition. 

(c) Menstmatioti. — The age of the onset of menstrua- 
tion, and of its cessation if the patient be past the meno- 
pause, should be noted: also its regularity, duration, the 
quantity of the flow as estimated by the number of diapers 
used, and its association with pain. It is important to 
ascertain whether the character of the menses has altered ; 
thus, if there has been a gradual diminution, followed by 
cessation, in a young woman, it is probably due to ana:mia ; 
diminution in an adult is ollen associated with ovarian 
tumors. Increase in the duration and quantity will point 
to a polypus, to retention of products of conception, or to 
pelvic congestion ; it may be due to a fibro-myoma, a poly- 
pus, or to malignant disease. The diagnosis, especially be- 
tween an ovarian tumor and a fibro-myoma, is often facili- 
tated by a careful inquiry as to menstrual changes. Recent 
amenorrhcea, following on previous regularity, is always 
suggestive of pregnancy. When the menses have never 
appeared and the patient has reached adult life there is a 
likelihood of congenital malformation, with or without re- 
tention of menstrual products. 

(d) Confinements ; Bfiscaniases. — ^Thc patient may 
give a history of sterility after several or many years of 
married life. This, especially if associated with dysmenor- 
rhcea, will lead one to suspect under-development of the 
uterus, or if there is at the same time a history of gonor- 
rhcea, there is considerable probability of disease of the 
uterine appendages. This probability is increased if the 
sterility has supervened after a single pregnancy or after 
one or two miscarriages; whilst endometritis will at the 
same time be looked out for. Relative sterility, when 



DISEASES OF WOMEf/- 

there has been no gonorrhceal disease and when the men- 
strual loss has increased, will prepare one to find fibroid 
changes ; but a somewhat similar history, with recent ir- 
regular losses following an apparent miscarriage, is rather 
characteristic of tubal gestation. 

Repeated miscarriages in early married life, followed by 
delivery of a viable child, usually point to syphilis. Re- 
peated miscarriages coming on after the birth of several 
living children may be due to inflammation or displacement 
of the uterus. 

When the patient is a multipara who has had several 
difficult or instrumental labors, one is likely to find a 
laceration of the cervix, or a rupture of the perineum with 
its attendant symptoms of hernia of the pelvic floor. 

Recent instrumental or otherwise abnormal labor followed 
by severe illness often means pelvic inflammation, cither 
peritonitis or cellulitis ; at the same time, this may follow a 
labor that has been apparently normal, and may be due to 
the reawakening of a dormant infection in the vagina, uterus, 
or Fallopian tubes ; to a suppurating ovarian cyst; or to sec- 
ondary changes in a dermoid. 

Metrorrhagia or menorrhagia dating from a miscarriage 
or from a labor at term is most often due to the retention 
of portions of placenta or membranes. 

Various vulvar affections, such as cedema, hematoma, 
and cellulitis, may owe their origin to a recent labor, 

(e) The history of the present illness should next 
be inquired into, so as to obtain an idea as to its mode of 
origin and duration, A good deal of care is necessary in 
elucidating this, as the patient's statements are often not 
only vague, but contradictory. Bleeding that has lasted a 
month maybe due to miscarriage; irregular bleeding for 
two or three months may indicate tubal gestation or can- 
cer ; bleeding that has gone on for many months is more 
likely to be due to a polypus or to a myoma. So also a 
tumor that has existed many months without much increase 




DIAGNOSIS. 



in size cannot be due to pregnancy. An illness that has 
come on suddenly, with severe pain, generally indicates 
pelvic inflammation, but it may also be due to tubal ges- 
tation, to the rupture of a cyst, or to torsion of a pedicle. 
The history of new growths is a gradual onset, whilst con- 
ditions such as chronic endometritis and uterine displace- 
ments have probably existed, off and on, for several years. 
The history of tubal disease is generally that of chronic 
ill-health with periodic exacerbations. 

(f) Present Sj'mptoms. — In the out-patient room and 
in the consulting room the symptoms will generally be 
ascertained at the outset; but in "taking out a case" in 
hospital it is best to first obtain the previous history. In 
many gynaecological conditions the symptoms present a. 
marked similarity; thus, pain referred to the sacrum or 
hypogastrium, and pains on sitting or walking, leucorrhcea, 
menorrhagia, and dysmenorrhcea, may be met with in the 
most varied diseases. We shall attempt, however, to 
analyze them to some extent, in order to estimate the value 
to be attached to them in forming a diagnosis. 

Pain. — This, when referred to the umbilicus and hypo- 
gastrium' in front and to the sacrum behind, generally indi- 
cates uterine disorder. It is found characteristically as 
dysmenorrhcea. It is said that the pain may be further 
localized, and that sacral pain has its origin in cervical con- 
ditions, whilst when the fundus is involved the pain is re- 
ferred to the umbilicus. This view receives support from 
the fact that in passing a sound through a narrow cervix or 
internal os the patient often complains of sudden pain in 
the back, whilst on touching an inflamed fundus abdominal 
pain usually results, A sense of aching, fulness, and ill- 
defined weight, often summed up by the patient as " bear- 
ing-down pain," is associated with pelvic congestion, and 
also with dragging on the uterine attachments, as in cases 
of prolapse and of retroversion of a heavy fundus. 

Pain in the iliac regions and shooting down the thighs is 



322 



DISEASES OF WOMEN. 



often due to congestion or inflammation of the uterine ap- 
pendages, but it is also a frequent manifestation of neuras- 
thenia, when it may.fattU tic mteux, be called neuralgic. 

The above kinds of pain may occur irregularly or almost 
continuously; they may come on as the result of long 
standing or much walking; and they are then worse in 
the evening. Or they may be limited to the menstrual 
periods. 

Lastly, pain may come on suddenly and acutely. When it 
is situated in the iliac region, the most frequent causes are 
rupture of an ovarian cyst, pyosatpinx, tubal gestation, or 
torsion of the pedicle of an ovarian tumor or cyst. A sud- 
den pain referred to the back sometimes marks the occur- 
rence of displacement or of inversion of the uterus as the 
result of a fall or strain. 

General acute abdominal pain is usually due to the onset 
of pelvic inflammation. 

Lfticorrhira. — Tlie character of the discharges should be 
carefully inquired into, and the account given by the patient 
may often be confirmed by the subsequent examination. 
The information to be derived therefrom has already been 
given in discussing the secretions {Chapter XII.). 

Menorrhagia ami Mctrorrliiiglu. — The significance of 
these is described in Chapter XXXV. 

Rectal and Vesical Symptoms. — Straining at stool, 
tenesmus and pain preceding and during the action of the 
bowels, are generally due to pressure on the rectum due to 
retroversion of the uterus, to pelvic inflammation, or to a 
tumor situated more especially at the back or left side of 
the pelvis. Such a tumor may consist of a subperitoneal 
myoma, a uniform enlargement of the uterus from fibro- 
myoma or pregnancy, a parovarian cyst in the recto-v^inal 
pouch, or a cyst in the lefl broad ligament. Constipation is 
favored also by these conditions, and the pain is then aggra- 
vated by the hardness of the motions. When the patient 
complains of " bearing down in the back passage" piles are 



DIAGNOSIS. 323 

o(\en found, due in part to constipation and pelvic con- 
gestion. 

The principal bladder symptoms are frequency of mic- 
turition, incontinence, retention of urine, and burning pain 
on passing water ; both frequency and incontinence may be 
of nervous origin and occur in anicmic and neurotic girls. 
In such cases the absence of organic cause for the symp- 
toms is shown by the rehef which follows simple hydro- 
static dilatation of the bladder. In other cases these condi- 
tions arise from moderate pressure on the neck of the 
bladder, causing continual irritation. If the pressure be 
greater, retention results, and later the overflow due to 
retention — i, e. a spurious incontinence. The conditions 
which give rise to pressure are retroversion of a gravid or 
otherwise enlarged uterus, pelvic inflammation, and the 
jamming of the uterus against the pubes by a growth fill- 
ing the recto-vaginal fossa. Burning pain on passing water 
is always found with gonorrhoeal urethritis, and it may 
occur also from non-gonorrhteal leucorrhcea! discharges, 
cau.sing pcri-urethral excoriation and irritation. 

General Symptoms. — Under this heading are included 
symptoms other than pelvic; thus, a patient with amenor- 
rhtEa may complain of palpitation and shortness of breath 
due to anxmia : amenorrhoea due to this cause docs not, of 
course, require a vaginal examination. Or the complaint 
may be of one or more of the reflex functional disorders 
above enumerated: this will necessitate the preliminary 
examination of the organs to which the symptoms are 
referred ; if these organs be normal, an explanation must 
be sought in the pelvis. 

Weakness, headache, anorexia, etc. occur in almost alt 
cases where the general health is affected, so that they have 
but little diagnostic value ; but loss of flesh in addition may 
give a clue to the presence of tuberculosis or malignant 
disease. 

The evidence to be obtained by questioning the patient 



324 



DISEASES OF WOMEN, 



has been set forth in some detail, not with a view to repla- 
cing physical examination, for symptoms are proverbially 
unreliable, but rather to su]g^gest possibilities and direct the 
course of further examination. Many things are missed 
simply because a man is not on the look-out for them, whilst, 
on the other hand, it is in a measure true in medicine that 
" the eye sees that which it brings with it the power to see." 
Consequently, during the process of diagnosis all possibili- 
ties should be arrayed and retained before the mind until 
one after another is definitely excluded as examination pro- 
ceeds. By this means little will be missed, though at the 
same time there may be left in the mind at the conclusion 
of examination an uncertainty as to which of two or three 
conditions is actually present. 



CHAPTER XXXVII. 



DIAGNOSIS (Continued). 
THE PHYSICAL EXAMINATION. 

{a) General HealUi and Appearance. — The information to 
be gained under this head comprises (i) evidences of fever, 
as indicated by pulse and temperature, by extra dr>'ness of 
the skin, or by sweating; (2) evidences of wasting; (3) in- 
dications of the general nutrition of the body. In the face 
we shall read signs of anaemia, jaundice, cachexia, habitual 
suffering, or anasarca. There may be cedcma of the lower 
limbs, or varicose veins, indicating backward pressure in 
thorax, abdomen, or pelvis. General signs of under-devel- 
opment may be noted, such as a childish face, smallness of 
the breasts, a narrow pelvis, and deficiency of pubic hair. 
Dark mammary areola and the presence of milky secretion 
in the breasts may give useful information as to a previous 
or present pregnancy. 

[b') Condition of tlie Cardiac, Respiratory. Digestive, Ex- 
cretory, and Nervous Systems. — This part of the examina- 
tion need not always be made exhaustively, but no well- 
marked pathological condition should ever be overlooked. 
Thus when there has been sudden pain or collapse a per- 
forated gastric ulcer, or venniform appendix, or a gall-blad- 
der with impacted stone may require to be diagnosed from 
tubal gestation, a ruptured cyst, or pyosalpinx. Renal or 
biliary colic may simulate pelvic pain. 

(r) The Abdomen. — Note the presence of stri^ as in- 
dicating former distention, and dilatation of superficial veins 
as evidence of intra-abdominal pressure. 



326 DISEASES OF WOMEN. 

Swelling of the abdomen may be due to the folloM'ing 
conditions : 

(i) Causing uniform or regular enlargement: Deposition 
of fat, especially at the menopause ; distention due to flatus ; 
ascites and tubercular peritonitis; pregnancy; uniform 
enlargement of the uterus from fibro-myoma ; large ovarian 
tumors ; large hydronephrosis. 

(3) Causing irregular enlargement : Small ovarian tumors ; 
encysted peritoneal effusions ; myomata ; moderate enlarge- 




ment of kidney from hydronephrosis or new growth — mov- 
able kidney; enlarged spleen ; omental tumors ; malignant 
disease of the intestines ; ectopic gestation (Figs. 94, 95). 

We must begin by excluding the first two conditions: 
palpation and percussion will generally suffice, especially 
under an anesthetic. Ascites is indicated by the absence of 
definite limits, the dulness in the flanks and hypochondriutn 




tilACNOSlS. 



with resonance in the epigastrium, the Hne of dulness hav- 
ing a margin concave toward the umbilicus, and the varia- 
tions in dulness on altering the position of tiie patient. An 
encysted collection of peritoneal fluid may, however, have 
fairly definite margins, unaltered by the position of the 
patient, and lie excentrically. 

The next question is. Docs the swelling originate in the 
pelvis ? If so, palpation cannot reach its lower margin ; if 




we find the swelling median and uniform, it is probably a 
gravid uterus, a uterine myoma, or a large ovarian tumor; 
if arising laterally, it may be a small ovarian tumor, a fibro- 
myoma, an ectopic gestation, or pelvic inflammation. 

If, on the other hand, the lower limit can be defined, we 
have to do with an abdominal tumor. If left-sided, smooth, 
passing up under the left costal margin, and superficially 
dull, it is probably spleen. If nearer the middle line, and 




DISEASES OF WOMEN. 

disappearing under the costal margin, with an area of reso- 
nance superficial to it, it is probably renal. A movable 
kidney will be definable above and below. An isolated 
and well-defined tumor somewhere near the umbilicus is 
probably an omental tumor, malignant disease of the intes- 
tines, or a p:increatic cyst. 

(d) Vaginal Examination. — It is frequently advisable to 
begin with an inspection of the genital organs ; for, in the 
first place, we may thus avoid the risk of infection from 
gonorrhceal discharges and from syphilitic sores; and, sec- 
ondly, we shall note the existence of malformations of the 
vulva, cutaneous affections, and enlargement of the nyniph;e, 
indicating irritation, kraurosis vulva;, and laceration of the 
perineum : these present no difficulty in diagnosis. We 
shall also determine the presence of swelling in the vulva, 
such as hsematoma, labial cysts, labial abscess, etc. 

On introducing the finger wc note the condition of the 
hymen, and the pain and spasm .so induced may indicate 
vaginismu.s. At this stage the character of the secretion 
should be observed: if muco-purulent, wc shall find inflam- 
mation higher up ; if malodorous, we may have to do with 
carcinoma, a sloughing myoma, a polypus, or a retained 
pessary. 

If we find the vaginal walls protruding, the case is prob- 
ably one of cystocele or rectocele ; and this may be con- 
firmed, if necessary, by passing a sound into the urethra or 
the finger into the rectum. 

Heat and dryness of the vagina indicate pelvic inflamma- 
tion; heat and great moisture indicate vaginitis or pelvic 
congestion; the latter may be due to pregnancy, in which 
case we shall find the well-known purple coloration. 

Marked pulsation of the vaginal vessels is most often 
due to pregnancy or uterine myoma; if confined to one 
fornix, there is probably tubal disease or tubal gestation. 

At this stage we shall discover swellings in the vagina 
due to cysts or to lateral hsmatometra: the exact diag- 



VIAGNOS/S. 329 

nosis will probably require aspiration with a fine trocar. 
Growths affecting the vagina will be recognized without 
difficulty, but we may find other things projecting, such as 
polypus or an inverted uterus, which must be investigated 
as previously described. The condition of the cervix next 
occupies us — lacerations, erosion, faulty position, softness 
due to pregnancy, malformations, cancer, the patulousncss 
or otherwise of the os externum. If the cervix be normal 
in these respects, we proceed at once to ascertain the posi- 
tion, mobility, and size of the uterus by bimanual examina- 
tion. If the position be faulty, it may be due to a simple 
displacement, to pelvic inflammation, or to the distortion 
due to a tumor pressing on it ; fixedness may also be due 
to one of the last two conditions. If pelvic inflammation 
be present, it will be indicated by the board-tike hardness, 
converting the structures at the summit of the vagina into 
a kind of firm roof. The position and limits of the efliision 
are determined by bimanual examination, and the parts will 
usually be very tender to manipulation. A large, soft, 
movable uterus is nearly always indicative of pregnancy ; 
this may be simulated by a soft fibro-myoma, and in diag- 
nosing the condition we shall have to be guided by the 
hi.story, especially the suppression or increase of menstrua- 
tion, and by the age of the patient, for fibro-cystic tumors 
generally occur after forty, whilst pregnancy is then less 
common. The possibility of hxmatometra in one-half of a 
double uterus or in the single organ must be borne in 
mind. If pregnancy can be excluded, the sound may be 
passed, and this will show whether and how much the 
uterus is enlarged. If it pa.sses not more than three and a 
half inches, the enlargement may be due to subinvolution, 
chronic metritis, hypertrophy of the cervix, a small polypus 
or retained products of conception : to further determine 
which of these conditions is present, the cervix must be 
dilated and the uterine cavity explored with the finger. If 
the sound passes from three and a half to six inches, we 




I 



DISEASES OF IVOMEN. 

have to do with a fibro-myoma of the uterus, as a rule. 
But sarcoma and carcinoma of the body of the uterus may 
also cause considerable enlargement; the free bleeding on 
passing the sound will give a clue; and, in addition, the 
uterus may be more or less fixed. It must be remembered 
also that in lateral lijematometra the patent half of the 
uterus may be considerably elongated. 

Supposing the uterus to be fairly normal, we next ex- 
amine the adnexa. An endeavor should first be made to 
trace the Fallopian tubes from the comua of the uterus 
outward: if normal, they will be felt bimanually as cord- 
like structures, and in some part of their course we shall 
meet the ovaries, whose position will be generally indicated 
by their tenderness to pressure and the shrinking of the 
patient. If enlarged, the tubes will be felt as elongated 
swellings: the thickening may extend right up to the 
uterus or it may affect principally the distal portions. At 
the same time a small ovarian cyst or a distended tube may 
be discovered. Enlargement of the ovaries, tubes, and 
broad ligaments can often be more distinctly felt, and their 
limits better ascertained, by recto-abdominal examination. 
Sometimes tubal and ovarian swellings are found occupy- 
ing the pouch of Douglas, which they may depress so as 
to obliterate the posterior vaginal fornix. A mass is then 
felt behind the vagina, and rectal examination may be 
necessary to determine whether the mass is between the 
vagina and rectum or in the rectum itself, for scybala in 
the rectum give much the same sensation. And here we 
may remark that the feeling of a swelling in the pouch of 
Douglas or in the left broad ligament may be so closely 
simulated by malignant disease affecting the sigmoid flex- 
ure that a rectal examination is necessary to clear up the 
diagnosis. It is often impossible to distinguish between 
tubal disease and small ovarian or broad-ligament cysts. 
When double and following on an attack of gonorrhcea 
the probability is in favor of tubal disease; but bilateral 



DIACKOSIS. 331 



ovarian cysts are not uncommon. It is then sometimes 
possible to feel the tube passing over the swelling, or. when 
the tubes are aflectcd, the ovaries may be felt separately. 
On the right side tubal disease is often closely simulated by 
disease of the vermiform appendix. The history will serve 
as a guide ; but sometimes the diagnosis can only be made 
after the abdomen is opened. 

The consistency of a small pelvic tumor is often very mis- 
leading, so that a tense cyst may be mistaken for an out- 
lying myoma, and i-ice versa. When a mass of some size 
occupies the recto-vaginal pouch we may have to dbtinguish 
between a cyst, an enlarged retroverted uterus, a subperi- 
toneal myoma, and a hsematocele. If the passage of the 
sound be contraindicated, this is somcrimes difficult; but 
careful examination under an anaesthetic may enable us to 
feel the fundus of the uterus distinct from the tumor, A 
ha;matocele under such circumstances will generally be due 
to rupture and subsequent encystnient of a tubal gestation; 
but it may also be due to tubal abortion. 

Tubal disease, extra-uterine gestation, and small cysts, 
especially when suppurating, may be complicated by pelvic 
inflammation : it will then be necessary to wait until this is 
partly absorbed before the nature of the original swelling 
can be made out. 

In the case of large pelvic tumors the diagnosis lies 
principally between fibro-myomata of the uterus and ovarian 
cysts. The latter may be p;irtly solid or the former fibro- 
cystic, when the difficulty will be increased. The menstrual 
history is here of great service, for increase of menstruation 
is the rule in fibro-myomata, cystic or otherwise, while it is 
the exception in the case of ovarian tumors. For further 
diagnosis we may pass the sound : if the uterine cavity be 
of normal length, the tumor is extra-uterine. And the 
same may usually be said when the tumor can be moved 
independently of the uterus, though at times a large sub- 
peritoneal myoma may have a long, thin pedicle. If the 



332 



D/SEASES OF WOMEN. 



I 



fundus can be felt bimanually independent of the tumor, as 
can often be made out under an anaesthetic, the tumor U 
probably ovarian : it will generally be found in such a case 
that the fundus has been jammed up against the pubes or 
backward into the cavity of the sacrum by the growing 
tumor. It must be remembered that an ovarian tumor and a 
uterine myoma sometimes coexist ; that either may be found 
complicating pregnancy ; and that in rare cases any one of 
the three may be found in connection with a double uterus. 
In all these cases the diagnosis is very difficult, and no 
general rules can be laid down. Cceliotomy will probably 
be required before an exact diagnosis can be made. 

We have not attempted to do more than give an outhne 
of the principles of diagnosis in examining the female 
genital organs ; and in conclusion we should like to empha- 
size three points : 

Firstly, the necessity of exploration of the cavity of the 
uterus when symptoms point to intra-uterine mischief and 
the cervix is comparatively normal. 

Secondly, the great advantage to be gained by combining 
a rectal examination with the bimanual method. 

Thirdly, the importance of an examination under an 
anaesthetic in all cases of doubt. By this- means the 
abdominal muscles are relaxed ; the resistance of the pa- 
tient due to pain and tenderness is obviated, and, perhaps 
most important of all, the examination can be made in the 
lithotomy position, which is the only position in which all 
parts of the pelvis can be thoroughly explored in their 
natural relations. 




CHAPTER XXXVIII. 
GYN,€COL0GICAL OPERATIONS. 

Operative procedures upon the female genital organs 
permit of division into two groups — i. Vaginal operations; 
2. Abdominal operations. 

Both groups demand for their successful performance the 
same qualities of head and hand as arc necessary for carry- 
ing out operations in other regions of the body. The indi- 
vidual ambitious for success in operative gyna;cology must 
possess a sound practical knowledge of pelvic anatomy 
and pathology, and carry out rigidly all the details of what 
is known as aseptic surgery. The more thoroughly he 
attends to the preliminary preparation of the patient, the 
selection of the room and surroundings, and the more care 
he devotes to the sterilization of the instruments and mate- 
rials employed in operations, the greater will be his measure 
of success. 

To facilitate the sterilization of instruments it is now usual 
to have them made of metal throughout. Of course all cut- 
ting instruments are made of steel, but knives may be fitted 
to handles which are coated with nickel, so that they retain 
their brightness. 

It is assumed that the student before he begins the study 
of gyns-'Cology has been a dresser, and is already familiar 
with the common tools of surgery, such as knives, dissect- 
ing-forceps, artery- forceps, pressure-forceps, needle-holders, 
retractors, and the like. He should also be familiar with 
the various kinds of m.iterial employed to secure blood- 
vessels and wounds, such as catgut, fishing or silkworm gut, 
and silk. His occupation of dresser will have made him 



I 



334 DISEASES OF WOMEN. 

acquainted with the various kinds of material used as dress- 
ings for wounds. 

Although a large number of gynaecological operations 
may be carried out with the assistance of the implements 
employed in general surgery, nevertheless there arc certain 
instruments indispensable to the performance of vaginal 
operations. Some of these, such as the speculum, the 
uterine sound, and the volsella, have already been described 
in Chapter III. Others will be considered with the opera- 
tions in which they are of special service. 

The student should realize that it is part of his duty to 
make himself familiar with the names of the instruments as 
well as to understand their use. If he has the least taste 
for mechanics, there is much to interest him in the construc- 
tion of surgical in.struments. and there is need also for im- 
provement: the names of some great surgeons, famous in 
their day for operative ability, are saved from utter oblivion 
by the fact of being associated with the invention or im- 
provement of some useful instrument of surgery. Thus 
the history of instruments employed in special departments 
of surgery is indirectly the history of the specialty. 

In gyniecology, as in other departments of surgery, many 
operations are carried out upon definite principles, the out- 
come of the accumulated experience of many operators. 
The student, however, should remember that the descrip- 
tion of an operation is, in fact, merely a narration of prin- 
ciples: the details require modification according to the 
necessities of the case and the complications which may 
arise during its performance. 

Before embarking upon an operation the surgeon should 
satisfy himself that the patient has no constitutional defect 
likely to militate against success. Thus chronic renal dis- 
ease, diabetes, lcucocytha;mia, haemophilia, malaria, chronic 
alcoholism, and visceral disease are conditions which need 
to be carefully considered in advising patients to submit to 
operations which are not urgently necessary. In grave 



GYNAECOLOGICAL OPKKATIONS. 335 

conditions where life is in imminent peril, where nothing 
short of operation (so far as human foresight enables one 
to judge) holds out any prospect of prolonging life, then 
the constitutional defect is not allowed to bar operative 
interference. 

In arranging for operation in women during the sexual 
period of life there is one function almost invariably to be 
considered — namely, menstruation. 

Operative procedures on the external genital passages 
are barred during menstruation, and, as a rule, the patients 
themselves fix the day of operation according to their 
knowledge of the expected appearance or disappearance 
of the menstrual flow. It must, however, be borne in mind 
that with many women the anxiety occasioned by an ex- 
pected operation will defer or even arrest a menstrual 
period, but more frequently it anticipates the regular 
date. 

When a woman is suffering from intra-uterine myoma, 
carcinoma, or retained products of conception, uterine bleed- 
ing is no obstacle to operation, but necessitates it. 

In abdominal operations, such as ovariotomy or oopho- 
rectomy, it is the rule not to operate during menstruation, 
but occasionally the environment of a patient is such that 
the surgeon neglects to regard it. Operations of this kind 
performed during menstruation do very well, and we have 
never seen anything untoward arise in such circumstances. 

The ensuing accounts of operations will not be merely 
descriptions of the methods of performing them, but will 
contain information concerning the various sequelae and 
remote effects, as well as the immediate risks to life. 

In order to prevent repetition it will be useful to describe 
the preliminary preparation of the patient. 

In all operations belonging to this group it is important 
to secure the .services of a nurse who has had a gyneco- 
logical training. Such a nurse understands the methods 
of washing and disinfecting the vagina, is apt at passing the 



33^ DISEASES OF WOMEN. 

catheter, and without fuss arranges the patient and prepares 
the nuedful apparatus. For any operation under an anaes- 
thetic the patient should abstain from food for at least four 
hours — six is preferable: this not only prevents vomiting 
during the exhibition of the drug, but diminishes the chances 
of its occurrence on the return to bed. As in other cases, 
the rectum should be thoroughly emptied by an enema 
some hours before the time fixed for the operation. 

It is good practice to have the nurse in attendance upon 
the patient at least forty-eight hours before operation : they 
grow accustomed to each other, and the nurse is able to 
douche the vagina systematically — an important matter 
when there is a purulent or offensive discharge. In ordi- 
nary cases a douche, morning and evening, of a quart of 
warm water lightly tinged with permanganate of potash 
answers every purpose. When the discharges are offensive, 
then it will be necessary to employ a lotion of perchloride 
of mercury (r ; 5000). 

The room (when there is opportunity for choice) should 
be well lighted and well ventilated. If near a bath-room 
or water-closet, the surgeon should satisfy himself that 
these offices are in a sanitary condition. 

In all vaginal operations the patient lies upon her back, 
fixed in what is known as the lithotomy position by means 
of the crutch (Fig. 96). Her buttocks are brought well to 
the edge of the table, and a piece of waterproof sheeting 
adjusted so as to convey any fluid or discharges into a con- 
venient receptacle. The table should be so arranged as to 
face a window free from the encumbrance of thick blinds or 
curtains. 

The Crutdi. — This invaluable instrument consists of 
two stout circular bands fitted with leather straps and 
buckles for gra.sping the legs just below the knees : the 
bands are fitted to a sliding cross-bar of iron which can be 
lengthened at will by means of a thumb-screw. When 
fixed to the legs the patient can be secured in the lithotomy 




GYN. 'ECO LOGICAL OPERATIONS. 



position by a broad strap passing obliquely around the 
shoulders (Fig. 97), 




Every well-trained nurse in arranging for a vaginal ope- 
ratiou prepares the following things : 
I. A firm and convenient table ; 



338 DISEASES OF WOMEN. 

2. Waterproof sheeting ; 

3. A dozen towels ; 

4. Plenty of warm water; 

5. Douche-can ; 

6. Cotton -wool ; 

7. Catheter; 

8. Some good brandy ; 

9. Vessels in which to immerse the instruments; 




10. Antiseptic lotions according to instructions; 

11. Vaselin or glycerin ; 

12. Tampons. 

In the performance of vaginal operations certain instru- 
ments are indispensable, and it will save much repetition to 
enumerate them : 

1, The crutch for fixing the patient in the hthotomy 

position ; 

2. The duck-bill s]>ecu]um for exposing the area of 

operation ; 




GYN.aCO LOGICAL QPEKATIONS. 



3. The uterine sound Tor determining the length of the 

uterine cavity and the position of the uterus ; 

4. The vesical sound to indicate the position of the 

bladder; 

5. Vulsella for manipulating the uterine cervix; 

6. Sponge-holders ; 

7. Steriliser. 

The Sterilizer, — A convenient and portable form for 
sterilizing instruments is shown in Fig. 98. It is made of 



I 




copper and stands on four legs, which leave sufficient space 
for a spirit-lamp or gas-jet to be placed underneath. The 
sterilizer is half filled with hot water, the instruments placed 
in the wire basket, immersed in the water ; the lid is closed 
and the boiling maintained for twenty minutes, A new 
fish-kettle makes an excellent sterilizer. 

In describing the various vaginal operations and in enu- 
merating the requisite instruments it will be assumed that 



340 



DISEASES OF WOMEN, 



the operator is already furnished with those mentioned in 
the above list. 

The operations will be described in this order : 



Group i. — Vaginal Operations. 

A. The Perineum. 

B. The Vulva. 



C. The Vagina. 



D. The Uterus. 



Perineorrhaphy. 

Removal of urethral caruncle ; 

Removal of the clitoris ; 

Tumors and cysts of the labia. 

Colporrhaphy ; 

Vaginal fistulas ; 

For atresia of the genital passage. 

Dilatation and curetting ; 

Vaginal myomectomy ; 

Trachelorrhaphy ; 

Amputation of the cervix ; 

Vaginal hysterectomy ; 

Colpotomy. 





CHAPTER XXXIX. 



a', and ^^^B 



OPERATIONS ON THE PERINEUM. VULVA, 
VAGINA. 

PERINEORRHAPHY; REMOVAL OF URETH- 
RAL CARUNCLE; REMOVAL OF CLITORIS; 
COLPORRHAPHY. 

Perineorrhaphy. — Under this term are included the 
various operations pL'rformcd for the repair of lacerations 
of the perineal body in the female. 

Many methods of operating have been devised for this 
purpose, but they have been greatly modified in the last 
fifteen years, with the result that it has become one of the 
simplest, safest, and most certain of all gynaecological ope- 
rations, providing care is exercised in the preparation of 
the patient, in the details of the operation, and in the after 
treatment. 

Perineorrhaphy may be described in two sections : 

1. When the laceration is partial; 

2. When the laceration is complete. 

Preparation of the Patient. — To ensure success it is ne- 
cessary that the patient be confined to bed for a few days, 
and her bowels should be thoroughly and regularly evacu- 
ated. The vagina is douched twice daily with a solution 
of permanganate of potash, and if there be a purulent 
discharge from vagina or cervical canal, this should be 
treated thoroughly before any attempt is made to repair 
the perineum. 

Instruments required in addition to those enumerated on 
p. 338: 

Scissors, angular and flat ; ha:mostatic forceps ; silkworm 



342 



DISEASES OF WOMEN. 



gut; silver wire; perforated shot and coils; needles in 
handles ; shot -compressor. 
Partial I,aceration of the Perineum.— The patient 

is fixL-J ill the lillintnriu- iniMtiiin, and the operator intro- 
duces ilir 111 1 ■ V ■ ■ ■ Ji.nul into the anus. 







so as to put the parts in front on the stretch. With a pair 
of sharp-pointed angular scissors the vaginal mucous mem- 
brane is raised up as a flap by splitting the recto-vaginal 
septum, and the flap is carried up on each side as far as the 
original limit of the perineal body (Fig, 99). 

No attempt is made to arrest the bleeding, but the assist- 




OPERATIONS ON PERINEUM. VULVA. AND VAGINA. 343 

ant keeps the field of operation clear by repeated applica- 
tion of a sponge or moistened cotton-wool dabs. Care 
should be taken not to buttonhole the vaginal flap while it 
is being raised. 

As soon a.*! the flap is sufHcicntly raised, it is held up by 
the assistant with a pair of forceps whilst the sutures are 




inserted. These may be of silkworm gut or silver 1 
according to fancy. They are introduced thus : A net 



344 



DISEASES Of WOMEN. 



in handle curved at right angles (or it may possess a simple 
terminal curve) is introduced at the skin margin on one side 
and buried deeply in the tissues, and then brought across 

the gap and through the opposite hnlf of the perineum, so 




•-fJ 



that its point emerges at the skin margin corresponding in 
position to its point of entrance on the opposite side (Fig. 
lOO). During this procedure the fingers of the left hand 



OPERATIONS ON PERINEUM, VULVA, AND VAGINA, 345 

are kept in the rectum to ensure that the needle in its pas- 
sage does not perforate it 

The first suture is introduced near the anal end of the 
perineum, and the remainder are continued in series till suf- 
ficient have been passed to bring the parts well together. 
In an ordinary case three or four are sufficient. The ope- 
rator pleases himself whether he arms the needle with the 
suture before passing it, or threads it after transfixing the 
tissues. 

The mode of securing the sutures is of some import- 
ance. It is usual to run a small coil of silver wire along 
the two projecting ends of the silkworm gut or wire, and 
then draw the ends through a perforated shot : the parts 
are then drawn sufficiently tight and the shot secured by 
squeezing it with the shot-compressor (Fig. loi). 

It is usunlly necessary to introduce here and there a 
superficial suture to keep the flap of mucous membrane 
well up to the skin-margin. 

The great advantage of fastening the sutures with shot 
and coil is that it greatly facilitates their removal, for it is 
only necessary to cut through the upper part of the coil, 
thus removing the shot The coil then slips off and leaves , 
the end of the suture exposed, thus enabling it to be with- 
drawn. 

Complete Laceration of the Perineum. — When the 
split involves the margin of the anus, without passing 
through the sphincter, its repair is carried out on the lines 
above described. When the sphincter is involved the tear 
u.sually extends some di-stance up the anterior wall of the 
rectum and the operation has three objects: (i) to provide 
a posterior wall for the vagina ; (2) to form an anterior wall 
for the rectum ; (3) to form a new perineum between these 
two structures. The first object is secured by raising a flap 
toward the vagina by splitting the recto-vaginal septum, as 
above described. The second object is attained as follows: 
A flap is taken up on each side of tlie anterior part of the 



346 DISEASES OF WOAfEKT. 

rectum, by carrying the dissection backward in a fashion 
corresponding to that by which the anterior Rap is raised 
by carrying the dissection forward. The total superficial 
incision is thus H-shaped. the upper limbs of the H passing 
forward by the sides of the vaginal orifice, the posterior 
hmbs backward, just external to the margin of the anus, 
and the cross*bar consisting of the transverse split in the 
recto-vaginal septum. The posterior or side flaps are 
turned backward and inward, and secured together by a 
continuous catgut suture. There is now a raw surface, 
shaped like a pyramid with its base superficial: the ante- 
rior border of this base is formed by the anterior flap ; the 
posterior border by the joined posterior flaps ; the sides of 
the base are formed by the skin-edges, and when brought 
together carry out the third object above mentioned, the 
formation of a new perineum. 

The manner of introducing and fastening the main sutures 
is the same as in the operation for partial laceration. By 
the approximation of the sides of the pyramid the anterior 
border is doubled up forward on itself, forming a ridge on 
the posterior wall of the vagina ; and the posterior border 
is similarly doubled up backward, forming a ridge on the 
anterior wall of the rectum. 

The principle on which these simple methods of repair- 
ing a lacerated perineum are based was introduced by 
Lawson Tait; it has revolutionized the surgical treatment 
of lacerated perineum. It was no uncommon thing for a 
surgeon to spend an hour and a half"in making flaps and 
suturing them in order to attempt to repair a perineum, and 
a large proportion of operations failed. Now the operation 
can be performed in ten or fifteen minutes by an operator 
of average dexterity, with certainty of success. 

There are few operations so simple to perform, but harder 
to describe or more diflicult to comprehend, even from the 
best descriptions. As a matter of fact, the operation must 
be witnessed in order to be understood. 



OPERATIONS ON PERfNEUM, VULVA, AND VAGINA. 347 

After-treatmcttt. — An important detail is to insist that the 
bladder be relieved regularly every six or eight hours by 
the patient's own eflbrts or with a catheter: the bowels 
should be relieved every day naturally or with the help of 
purgatives or an enema. 

The sutures are withdrawn about the fourteenth day; 
it is wise to keep the patient absolutely resting three 
weeks. 

Removal of Urethral Canmcle. — This troublesome 
condition admits of two methods of treatment : 1 . Excision ; 
2, Destruction by the cautery. 

Whichever method be employed, it is wiser to have the 
patient anesthetized. No doubt many cases have been 
successfully treated under the use of local anassthetics, but 
for the satisfactory relief of this condition it is, before all 
things, necessary that, whatsoever method be employed, the 
removal should be thorough. 

Instruments required in addition to the list on p. 338: 
Iris-forceps and scissors; needles and sutures; catheters; 
sponge-holder; Paquelin's cautery. 

(i) Excision. — The patient is anaesthetized and secured 
in the lithotomy position. The urethral orifice is well 
exposed in a good light and the bladder evacuated by 
means of a catheter. The bill of the speculum is then 
introduced into the vagina, and the urethra dilated with the 
uterine dilators up to No. 6. The caruncle is then carefully 
dissected from the muscular layer of the floor of the 
urethra, and followed up the canal until its limits are 
reached, and snipped off Useful instruments for this 
purpose are the delicate forceps and scissors employed for 
operations on the iris. After the caruncle is snipped off 
there is generally free bleeding: this is easily controlled by 
passing two thin silk sutures through the cut edge of the 
urethral mucous membrane and the free margin of the 
urethral orifice. When the sutures are tied the bleeding 
ceases, Should any little vessel stilt spirt, it may be 




AND VAGINA. 349 



are divided. Should tlie oozing be free after the larger 
vessels have been secured, the application of a sponge or 
cotton-wool compress wrung out of very hot water may 
control it. Failing this, the cut surfaces should be seared 
with the point of a Paquclin (or an electric) cautery at a 
dull red heat. 

Occa-sionally the diseased parts maybe removed with the 
scalpel, and leave sufficient loose skin to enable the edges 
to be brought into apposition by means of sutures. This 
is very desirable, .is it controls the oozing and should be 
followed by immediate union. When the diseased surface 
is destroyed by the cautery, or the surrounding tissues are 
so involved that a wide removal of skin as well as clitoris 
is necessary, then the denuded area is left to repair by 
granulations and cicatrization. 

Ttunors of the I/abia. — No definite plan can be de- 
scribed to meet the needs of every variety of tumors occur- 
ring in this region, but the principles involved are those 
which apply in other regions of the body. It is advisable 
to have the hair removed from the part, the field of ope- 
ration washed thoroughly with warm soap and water, and 
a compress wrung out of an antiseptic solution applied 1 
for twelve hours before the time fixed for the operation. | 
r As the labia are very vascular, operations on them are 
attended with free bleeding. It is always a great advantage 
to bring the skin-edges together even when it is necessary 
to sacrifice this tissue freely, as in the case of epithelioma 
or melanoma. In applying dressings to operation wounds 
in this region it is essential to arrange them in such a way 
that they need not be disturbed during micturition or be 
soiled during the act. 

Cyst of Bartholin's Gland. — The incision should be 
vertical, at the junction of the skin and mucous mem- 
brane. When it is possible, the cyst should be removed 
without being punctured or incised; for the operation is 
easier, and in the case of abscess the tissues are not soiled 



I 



350 DISEASES OF WOMEy. 

with the pus. But it is often very difficult to avoid punc- 
turing a suppurating cyst. 

Hemorrhage is generally moderately free from the ven- 
ous plexus round about ; this is especially the case with sup- 
purating cysts. In the deeper portions small branches of 
the internal pudic artery may be cut and require ligature. 
The slight oozing which persists is best controlled by pass- 
ing three or four deep sutures from one side to the other; 
each suture should enter and leave the skin 3 mm. from 
the cut edge, and should pass under the cavity left by the 
removal of the cyst without penetrating into it. 

Even when this is done there is generally a little effusion 
for the first twenty-four hours, so that it is advisable to 
place a small drainage-tube at the most dependent part of 
the wound, and keep it in for twelve to thirty-six hours, as 
required. 

In addition to the deep sutures, a few superficial ones 
may be used to keep the wound-margins in accurate 
position. 

A dressing of iodoform gauze is applied, and changed 
frequently to avoid urinary contamination. If there be 
much vaginal discharge, a douche of permanganate of pot- 
ash or perchloride of mercury {i in 5000) solution is advis- 
able twice or thrice each day. 

Colporrhaphy (£7c/w/r/m/A)').— This term is applied to 
an operation (of which there are many modifications) for 
narrowing the vagina by dissecting away a portion of the 
mucous membrane, cither from the rectal aspect (posterior 
colporrhaphy) or from the vesical aspect of the vagina 
(anterior colporrhaphy). The operation is mainly employed 
for the relief of severe prolapse of the uterus, cystocele, 
and rcctoccle. 

Posterior Colporrhaphy,— The patient is secured in 
the lithotomy position and the vagina thoroughly exposed 
by a duck-bill speculum. An elliptical incision, one end 
of the major axis being close to the cervix, the other near 



OPERATIONS ON PERINEVM. Vl'LVA. AND VAGINA. 351 

the vulvar orifice, is made in the mucous membrane, taking 
care not to cut deeper than the rccto-vaginal septum, lest 
the bowel be cut open. The vaginal mucous membrane is 
then cautiously dissected off: the amount to be removed is 
estimated by the laxity of the parts and the degree of nar- 
rowing which the operator regards as necessary to meet the 
needs of the case. After removing the mucous membrane 
and securing the bleeding vessels, the cut edges of the mu- 
cous membrane are brought into apposition by a continuous 
silk suture or interrupted sutures of silkworm gut, wire, or 
such other material as the operator thinks well to employ. 

The patient is kept in bed for at least two weeks ; her 
bowels are regulated, and the bladder should not be allowed 
to become over- distended. The sutures should be removed 
in about ten days. 

Anterior Colporrhaphy. — This is a similar procedure 
carried out on the anterior vaginal wall. The bladder is 
verj' liable to be injured in dissecting off the mucous mem- 
brane, and is particularly liable to be punctured when the 
sutures are introduced. 

Colpo-perineorrhaphy. — Posterior colporrhaphy is 
often combined with perineorrhaphy : all that is necessary, 
in addition to the procedure described under the latter ope- 
ration, is to remove with scissors a wedge-shaped piece of 
the vaginal flap, and then to bring the resulting edges of 
the flap together with fine sutures. 



CHAPTER XL. 

OPERATIONS FOR VAGINAL FISTULA AND ATRESIA OF 
THE GENITAL CANAL 

In this chapter the following fistulx will be considered : 
I. Vcsico-vaginal ; 2. Ureth ro- vaginal ; 3. Uretero-vaginal ; 
4. Utcro-vesical ; 5, Recto-vaginal. 

The successful operative treatment of these conditions 
demands not only operative dexterity and perseverance on 
the iKirt of the operator, but experience and judgment. A 
clean linear cut in the bladder or ureter heals spontaneously, 
but fistula; which need the assistance of the surgeon are al- 
ways the result of sloughing and loss of tissue. 

IWparatioii of (he Patknt. — This consists in thorough irri- 
gation of the vagina and complete evacuation of the bowels. 
The excoriation of the vulva and the adjacent parts of the 
thighs heals quickly enough when the leakage of urine is 
arrested. 

Instruments required: The crutch; duck-bill speculum; 
vesicovaginal fistula knives; thin needles in handles; silver 
wire ; fishing gut ; dissecting-forcqjs ; wire-twister ; scissors. 

Vesico-vaginal Fistula. — In the majority of ca.ses the 
lithotomy position is the most convenient, but special con- 
ditions may demand a different position. 

The principle underlying the treatment of all fistula; of 
mucous canals applies here — namely, 

I. The vivifying of the edges of the fistula ; 
3. The careful suturing of the edges ; 
3. Immediate union. 

I. i'arhi}; the luigcs of the I'istith. — This is effected in the 




OPERATIONS FOR VAGINAL FISTULM, ETC. 353 

following manner : Access to the vagina is obtained by means 
of a duck-bill speculum held by an assistant. The margins 
of the fistula are then freely pared by means of a sharp, deli- 
cate knife mounted on a long handle. These knives arc 
usually supplied in sets of three or four, with the blades 
adjusted at difiercnt angles to meet any difficulty according 
to the position of the fistula. In paring the edges care is 
taken to avoid bruising, but it is necessary to thoroughly 
vivify the whole circumference of the fistula. 

Application of Sutures. — The sutures may consist of silk 
thread, silver wire, or silkworm gut. Whatever material is 
used, it should be introduced with a slender needle and 
should traverse the muscular, but not the mucous, coat of 
the bladder or urethra (Fig. 103). This stage affords much 
scope for ingenuity on the part of the operator. 

When silkworm gut or silk is used the sutures are se- 
cured with a reef-knot : when the silver wire is used it is 
fastened with the S-headed twister. 

After the sutures arc fastened it is wise to test the wound 
to ascertain if it be water-tight. For this purpose milk is 
injected into the bladder. Should any escape through the 
wound, an additional suture is inserted at the situation of 
the leak. If all be secure, the bladder and vagina are 
gently irrigated with warm water and the patient returned 
to bed. 

After-trmtnuHt. — It is advisable as soon as the patient re- 
covers consciousness to allow her to lie on her side or even 
in the prone position. 

Some operators prefer to keep a catheter in the bladder 
for several days : others of equal experience reject this 
method and enjoin the regular careful use of the catheter. 
It is importint to keep the bowels regular. 

Riino'jttl of Sutures. — These may be withdrawn about the 
eighth or tenth day, and this is best effected under an an- 
icsthetic. 

When the iistula is small, its complete closure may be 




— Mnbod oT puling 



the operKtlon for KtlGO'VaEituJ Ei 



the confinement to bed. The misery these patients suffer 
makes them importunate in regard to operation. 

The most difficult fistulcc to close are those situated near 
the vesical orifice of the urethra and those near to or actu- 
ally involving the ureteric orifice. 

TJretero-vaginal Pistulee. — These often close spon- 
taneously; failing this, attempts should be made to close 
them by a plastic operation on the principltis employed for 
the occlusion of a vesico-vaginal fistula. In some «ases 




OPERATIONS FOR VAGINAL FISTULA., ETC. 

surgeons have removed the kidney in order to relieve wo- 
men of their almost insufferable distress, 

Utero-vesical Fistula. — This is very rare, and in order 
to deal with it the surgeon will find it necessary to separate 
the bladder from the neck of the uterus, as advised in the 
first steps in the operation of vaginal hysterectomy, in order 
to expose the vesical portion of the fistula. 

Recto-vaginal Fistula. — This is a fa;cal fistula, and 
when it complicates grave diseases of the rectum or vagina, 
such as cancer, sarcoma, or syphilitic lesions, operations are 
not admissible. 

When the fistula follows an injury and persists, it is treated 
on the same lines as a vesico- vaginal fistula. The operation 
may be conducted from the rectum when the fistula is acces- 
sible, but most operators prefer to carry out the treatment 
through the vagina. 

Colpodeisis. — This term signifies an operation for the 
closure of the vagina. It has been practised for the relief 
of incurable forms of vesico- vagina I fistulae. 

The principle of the operation consists in vivifying the 
whole circumference of the vagina below the fistula, and 
then bringing the pared edges into close apposition by a 
means of silver-wire or silkworm-gut sutures, on the s 
principle as that employed for closing vesico-vaginal fistula. ' 

The Operative Treatment of Atresia of the Geni- 
tal Passage. — It will be necessar)' to discuss operations 
coming under this heading in the following order: i. im- 
perforate hymen ; 2. Cicatricial union of the labia ; 3. Oc- 
clusion of the vagina; 4. Occlusion of the cervical canal. 

All these operations are undertaken for one or other, and 
sometimes to effect all three, of the following objects: [a) 
Evacuation of retained secretion ; (b') To establish a per- 
manent opening; (c) To rv:store the function of the parts. 

t. Imperforate Hymen. — It will be useful to begin 
with this condition, including under the phrase " imperforate 
hymen " those cases in which the lower end of the vagina 



DISEASES OF fVOMEIf. 



the hymS 



356 

is obstructed by a diaphragm independent of t 
(See Chapter V.) 

Many of these patients are heaUhy young girls of fifteen 
to twenty, and in such cases the surgeon endeavors to fulfil 
the three objects stated above. 

Instruments required, in addition to those described on 
p. 338: retractors; pressure-forceps; scalpel; catheter. 

Sups of the OperatioH. — The patient is secured by means 
of the crutch in the lithotomy position, and the recesses of 
the vulva well douched. A catheter is introduced into the 
bladder, and the septum separating the vulva and vagina is 
then freely incised. This is followed by a free flow of dark- 
colored, tenacious fluid (old blood mi.xed with secretions). 
As soon as the fluid ceases to flow, the tube of the douche 
or irrigator is introduced, and the remaining fluid is freely 
washed out with a weak solution of permanganate of potash* 
The opening is lightly stufled with gauze. ^k 

When possible an endeavor should be made to secdij 
the edges of the sac formed by the distended vagina, bring.' 1 
them down, and secure them to the edges of the septum, 
the redundant parts of which should be freely cut away. 

After-trialment. — Nothing in surgery is simpler than the 
evacuation of a ha;matocolpos due to a thin horizontal sep- 
tum. Simple as the operative measure is, it used to be fol- 
lowed by direful results from decomposition of retained se- 
cretion. It is in the highest interests of the patient to thor- 
oughly evacuate the secretion, and to keep the cavitj' well 
drained and regularly irrigated during ten or fourteen days 
following operation. Having watched the case safely through 
this stage, it then becomes necessary to maintain the patency 
of the orifice. This is often a very troublesome perform- 
ance, and not infrequently so diflicult and even impossible 
of performance that it is in some cases necessary to pro- 
duce an artificial menopause by oophorectomy, and even to 
carry out hysterectomy. 
Cicatricial Union of the l^abia.— In this condit« 




OPERATIONS FOR VAGINAL FISTULM, ETC. 357 

operative measures are needed to remedy defects caused by 
noma; burns; injury during delivery. 

When the cicatricial union follows noma and bums, it 
may lead to complete occlusion of the vulvar orifice in girls, 
and produce the same results as imperforate hymen — 
namely, h^matocolpos. To remedy this it is insufficient 
merely to perforate the obstructing septum ; it is necessary 
to dissect away the cicatrix and endeavor by means of an 
adjustment of skin-flaps to fill in the gap. To obtain flaps 
for this purpose the surgeon will often need to exercise his 
ingenuity. Some may be obtained, as in rhinoplasty, by 
turning down adjacent skin, or brought from other regions, 
as by Thiersch's method. 

When operative measures are employed to remedy cica- 
tricial contractions due to injury during labor, they are un- 
dertaken often to restore the functions of the part or to 
relieve dyspareunia. For these ends they are rarely suc- 
cessful. 

For Occlusion of the Vagina. — Under this heading 
will be considered oix;rations where the vulva is naturally 
developed, but the vagina ends in a cul-dc-sac. 

In these cases operations may be demanded to allow of 
tlie escape of retained secretion, or they are performed to 
allow of the exercise of the sexual functions of the parts. 

No definite steps can be described to guide the operator. 
Each case presents difficulties demanding for their satisfac- 
tory accomplishment much care, experience, and often in- 
genuity on the part of the operator. 

The objects to which the surgeon directs his attention 
are these: 

1. To assure himself as far as possible that the patient . 
has a normal uterus and functional ovaries; 

2. To secure a passage lined continuously with mucous 
membrane from the vulva to the neck of the uterus, capable 
of admitting intercourse. 

If in the course of the operation he ascertain that the 



358 



DISEASES OF WOMEN, 



uterus is small and ill-developed, then it is useless to 
proceed. 

Operations for Atresia of the Cervix. — These are 
demanded for the relief of blocked secretions. The condi- 
tions are threefold : haematometra ; hydrometra ; pyometra. 

The object in such operations is not only to evacuate 
the retained blood, secretion, or pus, as the case may be, 
but also to maintain a patent orifice. 

In many cases it is sufficient to relieve the strictured 
canal, and then keep the passage open by means of bougies. 

Experience teaches the uncertainty and difficulty of the 
method, and the improvement in surgery has led some ope- 
rators to carry out abdominal hysterectomy in these cases ; 
it is more radical, but is freer from risks of septic peri- 
tonitis, than the traditional methods of operating through 
the vagina. 



CHAPTER XLI. 

OPERATIONS ON THE UTERUS. 

DILATATION OF THE CERVICAL CANAL 
OF THE UTERUS; CURETTING; VAGI- 
NAL MYOMECTOMY. 

Dilatatioti. — It may be necessary to dilate the cervical 
canal for the following puqioses: i. To remove retained 
products of conception; 2. Curettage; 3. For Dysmenor- 
rhtea; 4. Removal of a polypus; 5. Diagnostic purposes 
in suspected cases of polypus or cancer of the body of the 
uterus. 

For whichever of the above purposes the procedure may 
be necessary, the principle of effecting it is the same, but 
there is a slight difference in detail. 

In addition to the usual gynecological instruments (see 
p. 338) it is necessary to be furnished with dilators and a 
curette (scraper). 

Uterine Dilators.— There are many varieties of dilators ; 
the set we find most useful were designed by Dr. W. H. 
Fenton (Fig. 103). Of these, ten make a set : each consists 
of a curved metal rod made of copper and electro plated 
with silver. The advantage of using metal dilators is that 
they can be immersed in the sterilizer. Each dilator is 30 
cm. (12 in.) in length, but differs in thickness at each end, 
so that afier introducing the narrow end into the uterine 
cavity the operator reverses the instrument for the succeed- 
ing number. For instincc, the dilator in Fig. 103 at its 
upper end has a diameter of 10 mm. and at its lower end a 
diameter of 1 1 mm. The degree of graduation is represented 




DISEASES OF WOMEN. 



in the drawing, and the actual diameter of a particular dilator 
is also given. In using these instruments they need to be 
thoroughly lubricated. It is also well to have a distinctive 
mark, so that the operator can easily distinguish the smaller 
from the larger end. There are many ways of doing this : 
in the set represented the higher number is distinguished by 
a metal collar. These instruments are very useful for dilat- 
ing the urethra when it is necessary to explore the interior 
of the bladder. 

The Ctirette (or Scraper).— This term is applied to an 
instrument employed for scraping the cavity of the uterus 
or its cervical canal. There are several varieties of curettes : 
some are shaped like a spoon with sharp edges, whilst others 
are ring-shaped with thin edges (Fig. 104). They are fur- 
nished with handles so that they may be effectively used. 
Some curettes are made hollow, and are connected with an 
irrigator by means of india-rubber tubing, so that a stream 
of sterilized water or an antiseptic solution issues from the 
instrument and flushes the uterine cavity whilst the scrap- 
ing is in progress. Flushing curettes are very inconvenient 
instruments to handle. 

The principle of the curette is this : All soft processes 
and diseased tracts of mucous membrane or retained pieces 
of placenta and dccidua are easily detached by it, whilst its 
edge is not sharp enough to damage the underlying mus- 
cular wall of the uterus when the implement is u.sed with 
due care and gentleness. 

The Steps of the Operation. — The patient is deeply anes- 
thetized with ether and secured in the lithotomy position by 
means of the crutch. The vagina is then douched with 
warm water, and the bill of the speculum introduced into 
the vulvar orifice. The anterior lip of the cervix is secured 
with a volsella, so as to be under the control of the opera- 
tor. The uterine sound is then gently introduced to furnish 
information as to the length and direction of the uterine 
cavity. 



OPERATIONS ON THE UTERUS. 36I 

The dilators arc then introduced in the following manner : 
They lie in their proper order in a vessel of warm water (or 
weak antiseptic solution) close to the hand, or, preferably, 
they are taken up in turn by the nurse and dipped in vase- 




^ 



if 



line or a vessel containing glycerin and perchloride of mer-^ 
curj- (t in 2000), and then introduced into the cervical canal 
with the right hand, whilst the operator makes counter- 
traction by firmly grasping the volsella, which is fixed to 




DISEASES OF WOMEN. 



the cervix, with the left. The early numbers usually pass 
easily so long as they are well anointed and introduced into 
the axis of the uterine cavity. 

The rapidity and degree of dilatation vary with the neces- 
sity of the case. Thus, when the operation is undertaken 
to remove retained products of conception, the softened cer- 
vical canal dilates very easily, and the dilatation is carried on 
until the canal is large enough to admit the index finger, 
and permit thorough exploration of the uterine cavity. 
(The finger will follow No. 16 or 18.) 

For diagnostic purposes in cases of suspected polypus it 
is wise to dilate sufficiently to admit the finger; in this way 
exact information as to the seat, size, and condition of the 
tumor is obtained. 

When needed for suspected disease (cancerous or other- 
wise) of the endometrium, dilatation to No. 10 or 12 is 
sufficient, as this allows the introduction of the curette and 
abstraction of fragments, and even complete curettage of 
the uterine cavity. 

For dysmenorrhcea, the dilatation is rarely carried beyond 
No. 8. In many cases of uterine polypus occurring in single 
and sterile married women the cervical tissues do not easily 
yield to the dilator, and great care is necessary to avoid ex- 
tensive laceration of the cervical tissues in the vicinity of 
the internal os. 

It is sometimes an advantage to secure the neck of the 
uterus with two volsellie — one on the anterior and one on 
the posterior lip. 

There are two opposite conditions to be borne in mind 
when using dilators: A soft and yielding cervix, as in 
patients who have recently aborted or who have a can- 
cerous uterus, readily admits the instruments, but is easily 
perforated by the sound or thin dilators. A firm, unyield- 
ing cervix easily lacerates, and the exercise of undue force 
during the introduction wilt cause the instrument to perfor- 
ate the uterine wall or tear the lower part of the cervix 



OPERATIONS ON THE UTERUS. 363 

from the upper in a circular direction. Unless the direction 
of the uterine canal be carefully observed, a false passage is 
apt to be made, burrowing into the uterine tissue or into 
the mesometrium. 

After the canal has been dilated to the requisite size, and 
the operator has met the requirement of the case by abstrac- 
tion of fragments of placenta or a polypus, etc., he thor- 
oughly douches the cavity with warm water ; then dries it 
with pledgets of cotton wool on a uterine probe, and applies 
iodized phenol, iodine, or any application he deems necessary 
to the endometrium. In cases where the oozing is free, the 
cavity may be plugged with sterilized gauze, or gauze im- 
pregnated with iodoform, aristol, or other drugs in fashion. 
The vagina is tamponed, the surrounding parts arc dried, 
and the patient returned to bed. 

Aflcr-treattnent. — This is very simple. In twenty-four 
hours all tampons and plugs are withdrawn and a warm 
vaginal douche administered twice daily. 

In the simplest case it is wise to keep the patient confined 
to her bed ten days : in other cases no rule can be laid 
down : it must be decided by individual experience. 

Dangers. — Dilatation of the cervical canal is the sim- 
plest of all gyna!cological operations, and if conducted with 
scrupulous care and cleanliness should have but one risk — 
namely, that of the anaesthetic. It is, however, occasionally 
a source of grave danger and death. Fatal results have 
been due to the following causes : 

1. Perforation of the uterus with the sound, curette, or 
dilator, and fatal peritonitis. 

2. Septic endometritis spreading into the Fallopian tubes. 

3. Pelvic cellulitis secondary to laceration of the cervix. 

4. Rupture of purulent collections in the Fallopian tubes 
(pyosatpinx) or ovaries (ovarian abscess). 

;. Should dilatation be incautiously advised and the uterus I 
be gravid, abortion would be the almost inevitable conse- I 
quence. 



DISEASES OF WOMEN. 



iding will b3 



>statHH 



364 

Vaginal Myomectomy. — Under this heading 1 
described the various operations for the removal of myomata 
from the cervical canal and ca^ty of the uterus. 

Instruments required in addition to those enumerated on-, 
page 33S: scissors, scalpel, buU-dog volsella, ha:mosta 
forceps, sponge-holders. 

Sfffs of the Operation. — These vary considerably acconj 
ing to the size, character, and position of the tumors. It 
will be convenient to describe the simple.st condition, and 
then proceed gradually to those that may offer very great 
difficulty. 

The patient is secured in the lithotomy position by means 
of the crutch: the vagina is thoroughly douched, and the 
cervix exposed by a duck-bill speculum. 

A P(dunculahd Myoma {Polypus) protruding from Ihe 
Cervix. — In such a case the operator carefully examines the 
polypus with the view of ascertaining, if possible, the point 
where the pedicle is connected with the uterus: he should 
also satisfy himself that the uterus is not partially inverted 
(see p. 157). With a stout pair of scissors the pedicle is 
snipped through and the tumor detached : then the fore- 
finger is introduced to be certain that there are no other 
polypi. The parts are then thoroughly irrigated and dried 
with cotton-wool on the uterine probe; tampons impreg- 
nated with a mild anti.septic reagent (liquid or jxiwder) are 
inserted into the vagina, and the patient returned to bed. 

Aflcr-irealmnttt. — The tampons are removed in twelve 
hours and the vagina douched twice daily. If there ha.s 
been much bleeding prior to operation, and this has pro- 
duced marked an;emia, some mild preparation of iron may 
be prescribed. Convalescence at the end of two weeks is 
the rule. 

A SessUe Myoma Protrudes at the Cervix. — Wlien such a 
tumor does not exceed the size of a bantam's egg, it may 
be dealt with in the following way: 

The cervical canal is dilated until it easily admits t 




OPERATIONS ON THE UTEKUS. 365 

finger : tliis enables the operator to determine the size and 
position of the tumor. With a scalpel he divides the mucous 
membrane overlying the tumor, and with his finger or a 
raspatory shells the tumor out of its capsule up to its base. 
With a stout bull-dog volsella (Fig. 8) the tumor is seized 
close up to its base, inside the capsule, and then he gently 
and cautiously rotates the volsella, and at the same time 
drags upon it: this twists the myoma, aud after two or 
three complete turns it is dragged out of its bed. 

The uterus is flushed with water at log" F., then care- 
fully dried with cotton-wool on a sponge-holder or forceps. 
When there is free oozing the cavity is plugged with anti- 
septic or sterilized gauze. 

The chief danger in this operation is seizing the tissue of 
the uterine wall instead of the tumor. Free bleeding, and 
even fatal peritonitis, may follow a tear through the wall 
of the uterus. 

When the myoma is septic, the cavity of the uterus should 
be thoroughly curetted. 

Occasionally it happens that after reflecting the capsule 
of a myoma it cannot be extracted without the exercise of 
unjustifiable force. It is then advisable to leave it for a few 
days until the uterine contractions extrude it somewhat 
from iLs bed. Then a renewed attempt will usually be 
successful. There is always great danger of bleeding 
and sepsis, and such cases are nearly always attended 
with anxiety. 

S(i$ik and PedunadiUiti Ulcrinc Myomata with an Vndi- 
lated Crn'ical Canal. — When the symptoms indicate the 
probable presence of a submucous myoma the operator 
dilates the cervical canal and explores the uterine cavity 
with his finger. On detecting a myoma he then determines 
its size, seat, and character. When it is small, he pro- 
ceeds according to tlie instructions detailed in the two 
preceding sections. 

It occasionally happens that he finds himself face to face 



« 



I 



366 DISEASES OF WOMEN. 

with one or other of these conditions : l . A large pedun- 
culated myoma; 2. A large sessile myoma with a broad 
base. 

In the first example it is easy to detach the tumor from 
its pedicle by rotation, but the difficulty will be met with tn its 
■' delivery." In the second example there will be difficulty 
in detaching as well as in delivering it. 

This brings us to the consideration of the important ques- 
tion : How large a tumor may be safely and expeditiously 
delivered by vaginal myomectomy ? 

We will relate our own practice in this matter : With a 
yielding cervix the cervical canal can be readily and without 
risk dilated up to No. 20 (a diameter of 25 mm.), and this 
will allow of the extraction of a myoma of the size of a 
bantam's egg. Submucous myomata are often ovoid. When 
the tumor exceeds these dimensions its detachment and de- 
livery may be facilitated by free bilateral division of the 
cervix up to the vaginal reflection : should the bleeding be 
free, the uterine artery may be secured at the end of each 
incision by means of a silk ligature and an aneurysm needle. 
Myomata with a diameter of 5 cm. may be detached and ex- 
tracted in this manner. The divided surfaces of the cervix 
are easily brought into apposition and secured with silk- 
worm-gut sutures. 

When a myoma equals in size a foetal head it is possible 
to remove it through the vagina by the method known as 
" morcel lenient." The cervical canal is dilated, and then 
the cervix is split on each side with scissors : the uterine 
arteries are then secured with ligatures. The division of 
the cervix gives free access to the uterine cavity. Some- 
times it is more useful to turn the bladder off the cervix, as 
in the first stages of vaginal hysterectomy ; then ligature 
the uterine arteries and split the anterior wall of the cervix 
as high as the peritoneal reflection. 

The next step of the operation consists in freely incbing 
the capsule of the tumor ; then, after enucleating it to its 



OPERATIONS ON THE UTEKUS. 367 

base, the operator proceeds to remove it piecemeal by 
means of scissors and stout volsella;. 

Myomectomy by " morcellement " is greatly in favor in 
France. In this country it is not widely practised. The 
custom of the leading gyni-ecologists in this country is 
to limit vaginal myomectomy to tumors not exceeding a 
diameter of 5 or 6 cm. — roughly the dimensions of the 
patient's fist. When a myoma excteds these dimensions 
abdominal hysterectomy is the safer method. 

The dangers of vaginal myomectomy are — hemorrhage ; 
damage to the walls of the uterus ; inversion of the uterus ; 
septicemia. 

Some gynxrcologists employ an antiquated instrument 
called the "ecrascur" to divide the stalks of pedunculated 
submucous myomata. !n a few years it is to be hoped that 
this instrument will only be seen in museums. 




CHAPTER XLII. 



OPERATIONS ON THE UTERUS (CoNTiNUEn), 



TRACHELORRHAPHY; AMPUTATION OF' 

CERVIX; VAGINAL HYSTERECTOMY; C 

POTOMY. 

Trachelorrhaphy. — This name is applied to an o 
tiun for the repiiir of lacerations of the cervix uteri. 

freparation of the Palient. — This is very importa 
order to secure a successful result. It is advisable th; 
patient should be kept in bed for a week or ten da 
order to allow of regular vaginal douching to rcduc 
congestion of the exposed mucous membrane of the 
vical canal. In some cases it maybe necessary to i 
local applications of iodized phenol, or to cui«tte t 
metrium. 

Instruments required in addition to those enumera 
p. 338 ; Scalpel ; reversible tenacu la- forceps : needles 
silkworm gut; dissecting- forceps. 

The Stt-f>s 1)/ the Operation. — The patient is an;esthc 
and fixed in the lithotomy position, and the cer\TX 
exposed by means of the duck-bill speculum. The o 
is then secured by the reversible tenacu !a-forceps, as si 
in Fig. 105. By means of scalpel and forceps the ope 
dissects flaps from the exposed surfaces of the cervix ta 
care to preserve a narrow strip of mucous membrane ii 
middle line (Fig. 106), which will form the lining for the 
cervical canal when the flaps are approximated, W 
the surfaces are being vivified there is usually free ooi 
this is useful, as it serves to deplete the cervix and di 
ishes its volume. 





OPERATIONS ON THE UTERUS 369 

The cervical flaps arc now brought together and retained 
in apposition by the reversible tenacula-forceps (Fig. 106): 
this instrument enables thi; operator to manipulate the cer- 
vix during the introduction of the sutures. For this pur- 
pose a slightly curved needle on a handle is very convenient 
The sutures may be of silver wire, silkworm gut, or silk, se- 







cured with shot and coil {Fig. 107), Silkwomi-gut sutures 
secured by knots are quite sufficient. 

When the sutures are fastened, a sound is passed into the 
uterus to ensure that the cervical canal is free. The parts 
arc then carefully dried and the vagina lightly stufTed with 
iodoform gauze. 



370 
After 



DISEASES OF WOMEJV. 



-This 



keeping the * 



r-trcalnicHl- 
dry as possible. When there is discharge, and irrigat 
required, then the vagina si 
be carefully dried after 
douche. 

Sutures are removed or 
tenth day; for this purpose 
patient is placed in the It 
omy position, facing a good I; 
with very nervous patient; 
aiiitsthetic is nccessarj-. 

Amputation of the Cci 
tJteri.— Amputation of the i 
of the uterus is performed 
epithelioma, cancer, and Iij 
trophic elongation. 

The methods of perfon 
this operation have been gn 
modified and simplified : it 
"%'i^i'™"Hl^''(A!'E" oT" therefore be advantageous t* 
part from the usual custoa 
describing every modification that has been introduced, 
give an account of the principles of the oj)eration. 
necessary to point out that vaginal hysterectomy is so rai 
coming into favor that amputation of the cervix will ii 
majority of cases, be superseded by this more thor 
operation. 

Instruments required in addition to the list on p. 
Retractors; catheter; needles on handles ; ha;mosUlie 
ccps; electric or Paquelin's cautery; dissectin^-fon 
sterilized silk ligatures; six (antiseptic) sponges. 

Steps of the OpiratioM. — The cervix is thoroughly exp 
by the introduction of the bill of a large speculum : wit] 
sound the operator determines the position of the cei 
canal and estimates the mobility of the uterus ; by mcai 
the vesical sound the precise relation of the bladder tf 




OPEfiAT/QNS ON THE UTERUS. 37 1 

cervix is ascertained. The cervix is firmly grasped with a 
stout volsclla and drawn down : with a scalpel the surgeon 
transversely divides tlie mucous membrane on the anterior 
wall of tlie cervix as high above the cancer as the bladder 
permits ; the assistant keeps him informed of the position of 
bladder by retaining the sound in the lowest part of the 




—Tiachctvrrlupkf : Stage 3. Onure of ihc ccrvial IU|a uit Bellied of 



vesical cavity. Having divided the mucous membrane, the 
bladder is easily detached from the cervix by the handle 
of the scalpel. 

The knife is then carried through the mucous membrane 
on the sides and posterior aspect of the cervix. The next 
step is to secure the uterine arteries as they run on to the 
sides of the cervix near the spot where the vaginal mucous 
membrane is reflected on to it. When the bladder is dc- 



~H with two threads, and as close to the cervix as 
order to avoid the ureter, 

Having secured the artery on each side, the 
be amputated with a scalpel, with scissors, or b 
the galvanic or Paquelin's cautery. When 
arteries are deliberately exposed and secured 
bleeding from the stump, but a small artery hei 
in the cut edge of the vaginal mucous membra 
quire to be seized with h^Emostatic forceps or Ii| 

The vagina is then douched, dried, and tam 
the patient returned to bed. 

The after-treatment is simple : opiates are so 
quired. The tampons are removed in twcnty-fou 
the vagina douched twice daily. The catheter is 
eight hours unless the patient can void her urii 
this is always an advantage. Convalescence is u; 

Dangers. — In judiciously selected cases th 
is one of the safest in surgery. The pitfalls are 
bladder may be injured in the process of separa 
the cervix. If the arteries are tied at a distam 
uterus, the ureters are apt to be included in I 
When the posterior incision is carried too far bai 
tum may be damaged and cause a temporary f] 
If the peritoneum is accidentally incised and the 
nal fossa opened, then the incision should be clo 
cellulitis .^nH neritnnitis may ari.se jf astriHi- n>»^ 



OPERATIONS ON THE UTERUS. 373 

The patient is prepared and arranged as when the opera- 
tion is performed for cancer. The incisions are made in 
such a way as to allow flaps to be fashioned from the over- 
lying mucous membrane. When the tissue of the cervix 
proper is cut through, there is always very free bleeding 
and the spouting vessels are not easy to secure with forceps 
or ligature. It is preferable to touch them with a Paquelin 
cautery at a dull-red heat. The flaps of mucous membrane 
are now brought over the cut face of the cervix and secured 
with sutures to the margin of the mucous membrane lining 
the cervical canal. 

This mantEuvre is necessary, as it prevents undue retrac- 
tion and contraction of the cervix, which may uldmately 
lead to atresia of the cervical canal, with various unpleasant 
consequences. 

Vaginal Hysterectomy. — This signifies the removal 
of the uterus (and sometimes the ovaries and Fallopian 
tubes with it) through the vagina. It is mainly performed 
for cancer of the cervical canal and cancer of the body of . 
the uterus, but it may be necessary to remove the uterus I 
by this route in such conditions as sarcoma of the uterus ; 
chronic intractable endometritis ; uterine myomata ; and in- 
tractable procidentia in older women. 

The instruments required are the same as those employed 
for amputation of the cervix. 

77(1- Sups of the Operation. — The patient, duly anxsthe- 1 
tizcd. is fixed in tile lithotomy position facing a window..! 
The surgeon, seated at a convenient level, introduces the J 
bill of a large speculum into the vagina. The cervi.x is^"! 
then seized with a stout volsel la and drawn down. The I 
assistant by means of a sound in the bladder keeps the I 
operator informed as to the precise relation of that viscus to I 
the cervix. 

The mucous membrane on the anterior a.spect of the 
cervix is then transversely divided with a scalpel, taking 
care not to injure the bladder. The operator then separates 




tossa through the postenor cul-de-sac ol tli< 
sponge is then inserted to restrain as well as 
intestines. 

The operator now deals with the broad lig 




Fic. loS.— Fini itagc of vigliul hyuterecK 



OPERATIONS ON THE UTEKi'S. 375 

divided with scissors, care being taken to leave sufficient 
tissue to prevent the ligature from slipping. The same 
manceuvrc is carried out on the opposite side. The effect 
of this is to free the uterus considerably, and to enable it to 
be well drawn down by the volsella. A double ligature is 
now carried through the remaining section of the mesome- 
trium and the two halves are tied: the upper ligature encir- 
cles the Fallopian tube, ovarian vessels, and ligament, as 
well as the round ligament of the uterus ; the tissues be- 
tween the ligatures and uterus are divided, .ind the fundus 
of the uterus now comes easily into the vagina and permits 
the ligatures to be readily applied to the opposite side. 

If the silk threads have been properly secured, there is, 
as a rule, no bleeding. Should any vessel be observed 
Spouting, it is readily seized with forceps and ligatured. 
The surgeon examines the ovaries and tubes, and should 
they show signs of disease they can be easily removed. 
After counting the sponges the vagina is then irrigated with 
warm water, and two or three long strips of gauze inserted, 
which serve to prevent the intestine being forced into the 
vagina during vomiting or straining, and at the same time 
act as an efficient drain. 

The ligatures are left long, and their ends, knotted to- 
gether, lie in the vagina. The ligatures which are applied 
to the upper parts of the broad ligaments may be cut short 
and allowed to remain as after ovariotomy : if ascjitic, they 
cause no trouble and convalescence is considerably short- 
ened. 

On the whole, we think the best results follow the use of 
ligatures, but some operators dispense entirely with ligatures 
and clamp the broad ligaments with long slender forceps, 
and then cut the uterus away from its connections. These 
forceps are left in situ forty-eight hours and are then re- 
moved. 

Colpotomy. — Experience acquired in the performance j 
of vaginal hysterectomy has taught surgeons that the intra'- 



I 



376 DISEASES OF WOMEN. 

peritoneal relations of the uterus and its appendages may 
be explored, with reasonable safety, through an incision in 
the vaginal cui-de-sac. 

When the incision is made posterior to the cervix, it is 
called posterior colpotomy. When the operation is carried 
out anterior to the cervix, between it and the bladder, it is 
called anterior colpotomy. 

Colpotomy is employed for the following purposes : For 
retroflexion of the uterus; small tumors of the ovary; for 
tubal pregnancy ; for tubal disease ; and for prolapse of the 

Instruments required in addition to the list on p. 338 : 
Scalpels ; h^mo<itatic forceps ; dissecting-forceps ; needles 
in handles; silk; silkworm-gut; needles; volsellse. 

Anterior Colpotomy. — The patient is placed in the 
lithotomy position and the bill of the speculum introduced 
into the vagina ; the cervix is then drawn down with a vol- 
sella and a sound is introduced into the bladder. The vag- 
inal mucous membrane anterior to the cervix is incised 
transversely, taking care not to injure the bladder, (Some 
operators make this incision vertical.) With the handle of 
the scalpel the bladder is detached from the cervix, as in 
the first steps of a vaginal hysterectomy. The peritoneum 
as it passes from the uterus to the bladder is divided, and 
the operator's fingers arc now in the utero-vesical pouch. 
This enables him to ascertain accurately the position of tlic 
uterus and the coexistence or otherwise of ovarian enlai^e- 
ment or distention of the tubes. 

When an ovarj' is prolapsed or obviously diseased it may 
be withdrawn through the incision, its pedicle ligatured, 
and the organ removed. This would be a vaginal oopho- 
rectomy. Retroflexion of the uterus is dealt with thus: A 
sound is introduced into the uterus, which is then straight- 
ened and anteverted. A curved needle armed with a silk 
ligature is passed through the anterior aspect of the body 
of the uterus; the ends of the suture are carried through 



op£X4r/oys ON the vterus. 377 

the margins of the vaginal incision: when this ligature ts 
fastened it maintains the uterus in position and at the same 
time closes the vaginal incision. The adhesions which 
form in consequence of these proceedings are supposed to 
retain the uterus in its rectified position. 

In some cases where the uterus is mobile in its flexed 
condition it is unnecessary to open the utero-vesical cul- 
de-sac. The fixation of the uterus thus becomes an 
extra-peritoneal proceeding, but then the operator is 
unable to ascertain the true condition of the ovaries and 
tubes. 

Some gyniEcologists have advocated the fixation of the 
uterus to the bladder. This is, however, a method not to 
be recommended. 

The subsequent treatment is very simple : the bowels are 
carefully regulated, and the vagina douched twice daily 
with a weak solution of permanganate of potash. 

The advantage claimed for this operation over abdominal 
hysteropexy (ventro-fixation) is that it is safer and avoids 
the chance of a yielding cicatrix. 

Noble, in writing of the results of vaginal fixation of the 
uterus, states : " Over one-fourth of the pregnancies follow- 
ing this operation have eniled in abortions, and the recent 
literature is burdened with reiiorts of versions, artificial ex- 
tractions, forceps operations, craniotomies, and Porro opera- 
tions, so that I feel that, following its originators, we must 
consider it as condemned by its results, and as an unjusti- 
fiable operation in the case of women of childbearing age " I 
(1896). 

Posterior CoIpOtomy.— This is an extremely simple | 
proceeding. The field of operation is exposed as for anterior | 
colpotomy, and the recto-vaginal fossa is reached through | 
3 transverse incision in the posterior cul-de-sac. The sur- • 
gcon is then able to ascertain the condition of the uterus \ 
and the ovaries and tubes. Through such an incision he is J 
able to break down adhesions which may fix the uterus, or 



378 



DISEASES OF WOMEN. 



remove a prolapsed ovary, or a small ovarian tumor, or a 
gravid tube in its very early stages. 

In cases of fluid effusions, such as exist in posterior 
serous perimetritis, or extravasation of blood following intra- 
peritoneal rupture of a gmvid tube, or tubal abortion, this 
method of exploring the recesses of the pelvis is regarded 
as being safer than an incision through the linea alba. 




CHAPTER XLIII. 

GROUP n.— ABDOMINAL OPERATIONS. 

In this group the following operative procedures will be 
described: i. Cceliotomy ; 2. Ovariotomy; 3. Enucleation 
of sessile pelvic cysts and tumors; 4. Oophorectomy; 5. 
Operations for tubal pregnancy ; 6. Hysterectomy ; 7. Hys- 
teropexy ; S. Shortening the round ligaments. 

CCELIOTOMY (LAPAROTOMY). 

When the surgeon opens the abdomen for the purpose 
of removing a tumor growing in a viscus, the operation re- 
ceives a specific name according to the organ concerned, 
such as ovariotomy, nephrectomy, splenectomy, and so 
forth. In very many cases the conditions preclude an exact 
diagnosis, and the operation of making an opening into the 
belly cavity is styled ccEliotomy, but it may become a colec- 
tomy, or an oophorectomy, etc. There are many condi- 
tions in the abdomen requiring treatment through an incis- 
ion in its walls which do not readily lend themselves to a 
lingle expressive term — for instance, omental tumors, cysts 
of the mesentery, and cchinococcus colonies — so that it 
becomes convenient to u.se the term cceliotomy as express- 1 
ing an operation by which the belly-is opened by a cut. 

In all the operations described in this section the import- 
ant step is to gain entrance into the ctelom (or peritoneal 
cavity) by an incision in its parietes, most frequently through 
the linea alba ; it will therefore be convenient to describe the 
mode of preparation of the patient, the requisite instruments, 
and the manner of carrying it ouL 

Preparation of the Patient.—W. is advantageous to keq) ^ 



38o DISEASES OF iVOMES'. 

the patient confined to bed for two or three days preceding 
the operation. She should be prepared as for any other 
serious surgical proSeeding. The rectum should be emp- 
tied, preferably by enemata, and the patient should abstain 
from food at least six hours before the operation: this di- 
minishes the chances of vomiting. The nurse shaves the 
pubes and washes the abdomen with warm soap and water. 
Six hours previous to the operation the lower part of the 
belly is swathed in a compress soaked with an antiseptic 
solution (such as carbolic acid i in 60 or perchloride of 
mercury 1 in 2000). Immediately before the patient is 
placed on the table the bladder should be emptied naturally 
or by means of a catheter. In ail abdominal operations it 
is a great advantage to employ nurses who have had spe- 
cial training in " abdominal nursing," 

Instniments. — All instruments employed in performing 
celiotomy should be constructed of metal, as this enables 
them to be thoroughly sterilized by boiling. The follow- 
ing are always necessary: 2 scalpels ; 12 hemostatic for- 
ceps ; 2 dissecting- forceps ; 2 retractors ; needles ; .lilk ; 
catgut; silkworm gut; Z4 cotton-wool dabs and 2 flat 
sponges ; 2 sponge- holders. 

All sponges and instruments should be counted and the 
number written down before the operation is begun. 

Instruments should be immersed in hot water. Sponges 
should be washed in water {at TOO° F.) during the operation. 

Stiture and I,igahire Material.— The three most 
useful materials at present employed in abdominal sui^-ry 
are silk, catgut, and silkworm gut. 

(i) Silk Thread. — This material has a wide range of useful- 
ness, as it is employed to secure pedicles, for the ligature of 
vessels, and for sutures. Silk may be easily sterilized, cither 
by prolonged soaking in anti.septic solutions or by boiling. 
It is convenient to wind the thread on a glass spool, boil it 
in the sterilizer for twenty minutes, and then preserve it in 
a solution of carbolic acid (i in 20), Sets of these spools 



ABDOMINAL OPERATIONS. 38 1 

provided with silks of three degrees of thickness answer 
most purposes — a stout plaited silk for ordinary pedicles ; 
a thinner silk for vessels, omental adhesions, or sutures for 
the skin ; and fine silk for securing torn edges of bowel. 

Silkivortn Gut [Salmon Gut). — This material is obtained 
from the bodies of silkworms when about to spin. It is 
obtainable in large quantities from fishing -tackle manufac- 
turers, as it has long been employed by anglers. Silkworm 
gut is an admirable material for sutures, .and is not injured 
by boiling. It is preserved for use in carbolic-acid solutions 
(l in 20). 

Catgut. — A very useful and easily absorbable ligature 
material prepared from the intestinal wall of sheep. The 
great difficulty is to obtain it free from germs, because im- 
mersion in hot water softens and quickly destroys it. 

A method of sterilizing catgut by steam has been devised ; 
after rendering it aseptic it is wound on glass spools and 
kept in a sublimate solution. 

Although catgut has many drawbacks, it is the only 
material yet devised which can be led in the wounds to be 
quickly destroyed by the tissues. 

Sponges and their Sabstitntes. — Nothing is so con- 

nicnt for removing blood from a wound as sponges: 
their absorbent powers and softness are excellent, but it is 
difficult to sterilize them, and their price makes it necessary 
to use them for a series of operations. Sponges when new 
are prepared in the following way : They are well beaten 
to shake out the dust, then immersed several hours in 
water containing hydrochloric acid (5 ccm. to the litre) ; 
they are then washed thoroughly in hot water and kept in 
a solution of carbolic acid (i in 40). After sponges have 1 
been used they are thoroughly washed in water, then | 
immersed in water to which some carbonate of soda is 
added. They are again washed in running water, and 
preserved in carbolic-acid solution (1 in 40) or dried and 
kept in air-tight glass jars. 



382 DISEASES OE WOMEN, 

Any sponge which has been in contact with a se[ 
wound or pus should be promptly cast into tlie fire. 

The high price of sponges and difficulty in their sterilisa- 
tion have induced surgeons to employ pads of cotton-wool 
or gauze moistened with sterilized water or antiseptic 
solutions. 

Another excellent substitute is prepared by making bags 
of gauze and tlien filling them with absorbent cotton-wool. 
These, often called cotton-wool or gauze sponges (or dabs), 
may be easily sterilized in the hot-air sterilizer (oven) or 
may be impregnated with antiseptic drugs. 

The Table. — In the majoiity of cases a table such as 
is employed in ordinary surgical operations answers every 
purpose. It is necessary to place beneatli the patient a 
strip of waterproof material covered by a towel. 

In some cases, in dealing with small cysts adherent to 
the floor of the pelvis or in searching for bleeding points, 
it is a great advantage to place the patient in the Trendelen- 
burg position, in which the pelvis is raised and the head 
and shoulders lowered; this allows the intestines to fall 
toward the diaphragm and leaves the pelvis unen- 
cumbered. 

AnEesthesia. — Some surgeons prefer chloroform or the 
A. C. E. mixture ; others employ ether. Ether administered 
by a skilful anresthetist is the safest agent yet discovered 
for prolonj^ed an.-esthesia. 

The Abdominal Incision. — The patient being com- 
pletely unconscious, the operator, with his assistant oppo- 
.site him, divides the skin and fat in the middle line of the 
belly, between the umbilicus and the pubes, for a space of 
7 cm. This incision should reach to the aponeurotic sheath 
of the rectus: any vessels that bleed freely require seizing 
with hemostatic forceps. The hnea alba is then divided, 
but, as it is very narrow in this situation, the sheath of the 
right or left rectus muscle is usually opened. Keeping in 
the middle line, the posterior layer of the sheath is divided 



ABDOMINAL OPERATIONS 383 

and the subperitoneal fat (which sometimes resembles 
omentum) is reached ; in thin subjects this is so small in 
amount that it is scarcely recognizable and the peritoneum 
is at once exposed In order to incise the peritoneum with- 
out damaging the tumor, cyst, or intestine, a fold of the 
membrane is picked up"with forceps and cautiously pricked 
with the point of a scalpel; air rushes in. destroys the 
vacuum, and generally produces a space between the cyst 
(or intestines) and the belly-wall : the surgeon then intro- 
duces his finger and divides the peritoneum to an extent 
equal to the incision in the skin. 

It is important to remember that the bladder is some- 
times pushed upward by tumors and lies in the subperito- 
neal tissue above the pubcs : it is then apt to be cut. 

On entering the ccelom (peritoneal cavity) the surgeon 
introduces his hand and proceeds to ascertain the nature 
of any morbid condition that he sees or feels ; or he evac- 
uates free fluid, blood or pus, which may be present. Oc- 
casionally he finds that attempts to remove a tumor would 
be futile or end in immediate disaster to the patient; 
then he desists and closes the wound, and the procedure 
is classed as an exploratory co£liotomy. Should a re- 
movable tumor, such as an ovarian cyst, an echinococ- 
cus colony of the omentum, or the like, be found, it is 
removed. 

The recesses of the pelvis are then carefully sponged in 
order to remove fluid, blood, or pus ; the sponges and for- 
ceps are counted and preparations made to suture the 
incision. 

Closore of the Wound. — This consists in suturing 
each layer separately. The peritoneum is first secured 
by a continuous suture of fine silk. The sheath of the 
rectus is then brought together by interrupted sutures of 
silkworm gut. I,astly, the skin is secured by interrupted 
or continuous sutures of silk or other material according to 
the fancy of the operator. The great advantage of this 



J 



384 D/SEASES OF WOMEN. 

triple mclhod is that it minimizes the risk of a yielding cica- 
trix and obviates the use of an abdominal belt. 

Dressing. — This should be very simple. A fold of 
sterilized gauze or cyanide gauze, covered with two or 
three pads of cotton-wool or gamgee tissue, retained in 
position by a flannel binder fastened with safety-pins, is 
sufficient. 

Irrigation. — When the ccelom (peritoneal cavity) con- 
tains free blood, pus, faical matter, etc. previous to or 
during the performance of cceliotomy, such fluids are most 
expeditiously removed by thorough irrigation with water 
at a temperature of 110° F. The precise method mat- 
ters but little. In well-appointed operating theatres an 
apparatus for irrigating the belly is certain to be present. 
In private practice much depends on the ingenuity of the 
surgeon. A simple and very efficient irrigator may be 
made by inserting a long piece of india-rubber tubing in a 
large jug filled with water: on exhausting the air from the 
tube and elevating the jug, the water will issue in a steady 
stream from the tube, and its force can be regulated by 
raising or lowering the jug. When no tube is at hand, the 
water may be poured into the belly direct from the jug. 
In order to irrigate the ccelom the patient is turned a httle 
to one side, and the waterproof on which the patient lies 
may be arranged to conduct the water as it escapes from 
the belly into a receptacle under the table. The irrigation 
is continued until the water comes away clear, care being 
taken that the inflowing stream is directed into the iliac 
fossa; and the recesses of the pelvis. As soon as the out- 
flowing stream is clean, the water retained in the pelvis, the 
iliac foss^, and in the neighborhood is quickly soaked up 
with sponges. 

Plain waliT that lias been boded and allowed to cool to the 
rcijiiisilf lemperalure is tlu safest medium for peritoneal 
irrigation . 

Drainage. — After the removal of an adherent tumor or 



ABDOMINAL OPERATIONS. 385 

uterine appendages blood may ooze from a number of 
points too small or inaccessible to permit the application 
of ligatures. In such circumstances it is sometimes desir- 
able to insert a drain-tube, When peritoneal drainage was 
introduced glass tubes were used, but india-rubber tubes 
are more satisfactory, as they admit of being cut to any 
length, and are less liable to damage the viscera with which 
they may come in contact 

The tube should reach to the floor of the recto-vaginal 
fossa, whilst its upper end projects from the lower angle 
of the wound: its sides should be perforated The cuta- 
neous orifice is surrounded by absorbent dressing to receive 
the escaping fluid. As a rule, there is at first a free escape 
of blood or blood-stained serum, and the dressing requires 
frequent changing: at the end of twenty-four hours it rapidly 
diminishes. It is impossible to frame definite rules in re- 
^rd to the removal of the tube, as so much depends on 
the nature of the case, but, as a rule, it may be discarded at 
the end of the second day. 

Drainage is rarely necessary after ovariotomy : it is fre- 
quently needed after the removal of a firmly adherent 
pyosalpinx. 

The Mikulicz Drain. — In 1886, Mikulicz of Cracow de- 
scribed a method of draining the pelvic eavity by means 
of antiseptic gauze. A bag is made of gauze ; to the bot- 
tom of this bag a double silk thread is attached. The bag 
is introduced into the bed of the tumor in the pelvic cavity, 
and is then stuffed with strips of iodoform gauze. It is an 
advantage to insert a drain-tube in the middle of the bag 
and .stulT the gauze around it. The gauze is quickly infil- 
trated with the infused fluids which slowly ooze through it, 
and escape at the free fnd into the dressing, which needs fre- 
quent changing (thrice in twenty-four hours). As the ooz- 
ing diminishes, pieces of the packing are slowly with- 
drawn, and at last the b^ is removed by means of the 
thread. 



386 



DISEASES OF WOMEN. 



It is difficult to decide when to remove a drain of this 
sort : it should not be disturbed for five days, but may re- 
main without detriment fourteen days. In this way the 
gauze acts as a haemostatic plug as well as a drain. 

Peritoneal drains of this kind are, fortunately, rarely 
necessary. 



CHAPTER XLIV. 

OVARIOTOMY AND OSPHORECTOMV. 

OVARIOTOMY. 

Ovariotomy signifies the removal through an incision in 
the abdominal wall of tumors and cysts of the ovary and 
parovarium. 

The preparation of the patient is the same as that de- 
scribed under Coeliotomy, and the additional instruments 
required are — ovariotomy trocar; pedicle-needles and silk; 
pedicle-forceps. 

Tlu- Ovariolomy Trocar. — Very many ovarian cysts are 
filled with thin fluid which will easily flow along a narrow 
tube, and as the cyst-contents sometimes amount to many 
quarts or even gallons, it is a point in the operation to con- 
duct this fluid into a receptacle. The ovariotomy trocar is 




designed for this purpose. It is constructed so that it has 
a cutting edge which will enable it to be thrust through 
a stout cyst-wall: this cutting edge, shaped like the point 
of a quill pen, is ensheathed in a sliding barrel moved by 
a mounted thumb-piece, so that it can be protected at the 
wish of the operator. On the sides of the instrument there 
are two spring hooks for retaining the instrument in posi- 
tion after its point has penetrated the cyst-wall. The trocar 



DISEASES OF WOMEN. 



I 

^H is fitted to a metre and a half (about live feet) of ini 

^H rubber tubing. The mechanism of this complicated instru- 

^H ment should be carefully studied by those proposing to uae 

^H it. These trocars are very clumsy, and unless in constant 

^H use work stiffly and easily get out of order (Figs. 109 and 

■ 

^H Pedicle-needle. — This instrument is designed to carry the 

^H ligature through the pedicle of the tumor. The stem of 

^H the needle is about 1 5 cm. long, and is composed of nickeled 

^H steel adjusted to a metal handle (Fig. 11 1). The stem is 

^H curved toward the end, which should be bluntly pointed. 

^H Near the free end it is perforated by two holes, one behind 



the other; eacli siiuulii be i:a]>abie of easily accommodating 
the thickest ligature silk. 

As a matter of fact, any needle capable of carrying the 
ligature will serve the purpose of a pedicle-needle, but the 
needle represented possesses many advantages which an 
operator will realize as soon as he begins to acquire 
experience. 

Sponge-holders. — "Sponges on sticks" are undesirable 
in abdominal operations. His useful to employ instruments 
in which sponges or cotton-wool or gauze dabs can be easily 
mounted. A useful form of holder is shown in Fig. 112. 
It is an ovum forceps ; the opp<jsed sides of the fenestrated 
blades are devoid of serrations. The handles are furnished 
with clips. These holders can be put to many useful pur- 
poses besides holding sponges : they are easily sterilized. 



\ 





OVAK/OTOMY A.VD OOPHORECTOMY. 



Steps of the Operation. — As soon as the operator enters 
K ctelom (peritoneal cavity) and recognizes the bluish- 




[c-hsldct. 

ray. glistening surface of an ovarian cyst, he inserts his 
Bid and passes it over the wall of the tumor to ascertain 





the presence or absence of adhesions. Instead of a typical 
ovarian cyst, he may find a solid tumor or an enlarged 
uterus; secondary nodules may exist on the peritoneum 
and indicate a malignant tumor, or adhesions may be so 
strong and so numerous that it will be undesirable to con- 
tinue the oixrralion. 

It is of the highest importance to be satisfied as to the 
nature of the tumor before proceeding further: to plunge 
a trocar into a pregnant uterus or a uterine myoma is an 
accident sure to involve the operator in anxious difficult^'. 

Emptying the Cyst. — Feeling satisfied that the tumor con- 
tains fluid, is not connected with the uterus, and is removable, 
the operator proceeds to tap it. The trocar is thrust into 
the cyst, and the fluid rushes through it and is conducted 
by the tubing into the receptacle under the table. As the 
cyst collapses, the trocar is rendered harmless by sheathing 
it ; the cyst-wal! is seized with forceps and drawn into the 
spring clips on the side of the trocar, and as the cyst 
empties it is gently withdrawn through the incision, whilst 
the assistant keeps the bclly-wall in apposition with the 
cyst by gentle pressure until the pedicle is reached. Empty- 
ing the cyst is not always so simple. The fluid is some- 
times viscid like jelly, or in the case of dermoids resembles 
paste. Then it is necessary to make a free opening into 
the tumor and remove its contents with the hand. It is 
occasionally necessary, in multilocular cysts containing clear 
fluid, to introduce the fingers, or even the hand, to break 
down secondary loculi, in order to facilitate the extraction 
of the cyst-wall through a small inci.sion. When the tumor 
is suspected to be a dermoid, and in all cases where it is 
scarcely larger than a cocoaniit, it is more prudent not to 
tap, but enlarge the incision and withdraw it entire. 

Adhesions. — -Large portions of omentum may require de- 
tachment, transfixion, and ligature with thin sterilised silk 
to arrest the bleeding. Intestinal adhesions require care 
and patience : sometimes the separation may be eflccted by 



OVARIOTOMY AND O^PllOSECTOMY. 39I 

gently wiping with a sponge. Adhesion to the peritoneum 
in the pelvis is often a source of great difficulty, and care 
must be taken not to damage the ureters or large vessels, 
such as the vena cava and the iliac veins. 

Adhesions to tlie bladder are rare and require great care ; 
it is wise to introduce a sound into the bladder whilst sepa- 
rating it from the cyst. 

Tlie Pi-dick. — When the tumor is withdrawn from the 
belly the pedicle is usually easily recognized; the Fallopian 
tube serves as an excellent guide to it. The pedicle con- 
sists of the Fallopian tube and adjacent parts of the meso- 
metrium containing the ovarian artery, pampiniform plexus 
of veins, lymphatics, nerves, and the ovarian ligament. 
When the constituents of the pedicle are unobscured by 
adhesions the round ligament of the uterus is easily seen 
and neSd not be included in the ligature. 

In transfixing the pedicle the aim should be to pierce the 
mcsometrium at a spot where there are no large veins, and 
tie the structures in two bundles, .so that the inner contain 
the Fallopian tube, a fold of the mesometnum, and occa- 
sionally the round ligament of the uterus, whilst the outer 
consists of the ovarian ligament, veins, the ovarian artery, 
and a larger fold of peritoneum than the inner half. 

Pedicles differ greatly : they may be long and thin or 
short and broad. Long, thin pedicles arc easily managed, 
The assistant gently supports the tumor whilst the operator 
spreads the tissues with his thumb and fore finger, and trans- 
fixes them with the pedicle-needle armed with a long piece 
of silk. The loop of silk is seized on the opposite side and 
the needle withdrawn. During the transfixion care must 
be taken not to prick the bowel with the needle. The loop 
of silk is cut so that two pieces of silk thread lie in the 
pedicle. The proper ends of the threads are now secured, 
and each \% firmly tied in a reef knot : for greater security 
the two ends of the inner thread arc brought around the 
pedicle and tied again, so as to thoroughly secure the vessels. 



392 DISEASES OF imMEflT. 

After the operator has gained some experience in this 
simple mode of tying the pedicle he may then, if he thinks 
it desirable, practise other methods. 

After securely applying the ligature, the tumor is removed 
by snipping through the tissues on the distal side of the 
ligature with scissors. Care must be taken not to cut too 
near the silk or the stump will slip through the ligature; 
on the other hand, too much tissue should not be left be- 
hind. The stump is seized on each side by pressure-for- 
ceps, and examined to see that the vessels in it arc secure ; 
it is then allowed to retreat into the abdomen. Should it 
commence to bleed, it must be retranslixed and tied below 
the original ligature. 

Occasionally a broad, short pedicle will contain so much 
tissue that it will be necessary to tie it with three threads. 
To do this the pedicle is transfi.ved with the silk, the loop 
is divided, and the two threads are interlocked. The outer 
thread is tied as usual. The needle is refilled with a single 
ligature and transfixion performed. The needle is then 
unthreaded, and the untied end of the silk belonging to the 
first ligature is passed into the eye of the needle, which is 
then withdrawn. The second ligature, before it is tied, 
must be interlocked with the third thread. When the 
threads are tied they will hold the tissues firmly. 

It is impossible to frame absolute rules for ligaturing the 
pedicle. In this, as in all departments of surgery, common 
sense must be exercised, and at the present day, when ova- 
riotomy is practised so widely, no one would think of per- 
forming this operation without assisting at or watching its 
actual performance by an experienced surgeon. 

Having satisfied himself that the pedicle is secure, the 
surgeon examines the opposite ovary, and if obviously dis- 
eased he removes it, securing its pedicle in tlie way just 
described. 

He then proceeds to remove any blood or fluid from the 
recesses of the pelvis by means of careful sponging. Whilst 



OVARIOTOMY AMD OOPHORECTOMY. 393 

employed in this way he gives instruction to have the 
sponges and instruments counted. 

When the operator limits the number of sponges to six, 
he can easily have them displayed before him. He then 
proceeds to suture the wound in the manner described on 
paye 383- 

Sessile Cysts. — It occasionally happens that the sur- 
geon exposes a cyst in the pelvis through an abdominal 
incision, and, alter tapping it, finds he cannot withdraw the 
(yst-wall from the pelvis. 

Sessile cysts of this Icind are removed by what is known 
as enucleation. The peritoneum overlying the cyst is cau- 
tiously torn through with forceps until the cyst-wall is ex- 
posed ; then by means of the fore finger the surgeon pro- 
ceeds to shell the cyst out of its bed, taking care not to tear 
the capsule or any large vein in its wall : it is also necessary 
to exercise the greatest care to avoid injury to the ureter. 
It is not uncommon, after enucleating a cyst in this way, to 
find a ureter lying at the bottom of the recess. 

When the enucleation is complete, the operator carefully 
examines the walls and secures oo^Jng ves.sels and ligatures 
them. The edges of the capsule are then brought to the 
margins of the abdominal wound and secured with sutures 
to the peritoneum. An india-rubber drainage-tube is then 
inserted, the abdominal incision closed in the usual way, 
and the wound is dressed. 

The capsule of a sessile cyst requiring treatment of this 
character is formed by divaricated layers of the mesomet- 
rium (broad ligament). 

Enucleation is needed for — 

(«) Papillomatous cysts and cysts of Gartner's duct 
burrowing deeply between the layers of the 
mesometrium ; 
(i5) Myomata of the mesometrium ; 
(it) Very large examples of hydrosalpinx and pyo-l 
salpinx ; 




DISEASES OF WOMEN. 



{d) Some ovarian cysts, especially suppurating der- 
moids ; 
(e) Tubal pregnancy in the mesometric stage. 

Enucleation is usually accompanied by more loss of blood 
than simple ovariotomy, and the prolonged manipulation 
is often responsible for severe shock. 

Incomplete Ovariotomy. — The surgeon may start on 
an operation, and after opening the abdomen may find many 
adhesions, yet feci that the removal of the tumor is possible- 
He sets to work, overcomes many of the difficulties, then 
suddenly finds such extensive and firm adhesions to im- 
portant structures at the floor of the pelvis that he 
deems it imprudent to proceed. In such a case he evac- 
uates the contents of the cyst, and if it be an adenoma, the 
semi-solid contents are freely removed, and the edges of 
the cyst are stitched to the abdominal wound as described 
in the preceding section, and the cavity drained. 

This mode of dealing with a cyst is usually termed 
" incomplete ovariotomy." It is occasionally referred to as 
" marsupialization," because the cyst forms a pouch or bag 
near the pubes resembling that of the kangaroo. 

An incomplete ovariotomy is a very difierent condition 
to an enucleation. The cavity left after enucleation closes 
completely, but when the wall of an ovarian cyst or 
adenoma is left, the tumor gradually reappears, or it may 
suppurate so profusely that the patient slowly dies ex- 
hausted. There are few things sadder in surgciy than 
the slow, miserable ending of an individual who has been 
.subject tn an incomplete ovariotomy. 

Anomalous Ovariotomy. — In a few instances, gener- 
ally under an erroneous diagnosis, surgeons have removed 
ovarian tumors through an incision other than the classical 
one in the linea alba. Under the impression that the tumor 
was splenic an ovarian tumor of the right side has been 
.successfully removed through an incision in the left linea 
semilunaris. 



OVANIOTOMY AND o'dpllQUECTOMY. 



395 



An ovarian tumor supposed to be a renal cyst has been 
successfully extracted through an incision in the ilio-costal 
space. 

Strangest of all, a small ovarium deimoid has been 
removed through the rectum under the impression that 

wns a polypus of the bowel. 

Repeated Ovariotomy. — Very many cases are known 
in which women have been twice submitted to ovariotomy. 
Thus it is the duty of the surgeon when removing an 
ovarian tumor to examine carefully the opposite ovary. So 
many examples are known of women who have borne 
children after unilateral ovariotomy (twins and even triplets) 
that this alone is sufficient to prohibit the routine ablation 
of both glands. 

A second ovariotomy is not attended with more risk 
than the first, but more care is needed in making the 
incision, for. should a piece of intestine be adherent to the 
cicatrix, it would be very liable to injury. 

OOPHORECTOMY. 

This signifies the removal of the ovaries and Fallopian 
tubes through an abdominal incision, for affections mainly 
inflammatory; also the removal of healthy ovaries and 
tubes in order to anticipate the menopause. 

This operation is performed for the relief of a variety of 
diseases connected with the internal generative organs: 

(I.) Tubal diseases, such as pyosalpinx and tubo- 
ovarian abscess; hydrosalpinx; tubercular salpingitis; 
tumors of the tube — myoma, adenoma, carcinoma ; gravid 
tubes; ha:rmatosalpinx. 

(11.) Ovarian diseases; for example, ovarian abscess; 
apoplexy of the ovary ; hernia of the ovary ; prolapse of 
the ovary. 

(III.) To produce artificial amenorrhoea in such i 
conditions as uterine myoniata , ha.'matoco]pi>s or ha;mato*l 
mctra; osteomalacia. 




DISEASES OF WOMEN. 



(IV.) In Nerve Troubles. — Oophorectomy has been 
performed in order to anticipate the menopause in hystero- 
epilepsy; epilepsy; some forms of insanity; dysmenorrhcea 
unassociated with demonstrable diseases in the ovaries. 

For the performance of oophorectomy the patient is pre- 
pared as for ovariotomy, and the instruments needed are 
the same with the exception of the trocar. The Trendelen- 
burg position is of great advantage, as it enables the surgeon 
to view distinctly the depths of the pelvis. 

The abdomen is opened in the usual manner and situa- 
tion : the surgeon then seeks the fundus of the uterus, and 
with this as a guide he is able to find the ovary and Fallo- 
pian tube. When the parts are not adherent it is a very 
simple matter to seize the ovary and tube, draw them into 
the incision, and retain them in position by pedicle-forceps, 
whilst the broad ligament is transfixed and secured with 
silk ligatures. When the tubes are filled with pus and 
fixed with firm adhesions to the floor of the pelvis, and 
perhaps intestine, the manipulations necessary to detach 
the tubes and ovaries from their surroundings demand 
great care and the exercise of much patience. 

When the tubes are in the condition of pyosalpin.\, the 
tubal tissues arc in places so thin that even under the most 
cautious fingers the sac bursts and septic fluid rushes into 
the pelvis. 

On the other hand, the ovaries may be so firmly fixed 
to the floor of the pelvis that they break and portions of 
ovarian tissue are left ; this often impairs the subsequent 
results, as menstruation continues if only a portion of an 
ovary is left. 

In the case of oophorectomy for uterine myoma the ova- 
ries in many cases are easily found : occasionally it happens 
that the ovary on one side is easily reached and manipu- 
lated, but the other i.s so incorporated with the myoma that 
it cannot be entirely removed ; hence the prudent surgeon 
assures himself of the possibility of removing both sets 



OVARWrOAtV AND O'driiORECTOMY. 397 

of appendages before he proceeds to apply the liga- 
ture. 

In order to perform oophorectomy satisfactorily, the es- 
sential point is to be able to bring the ovaries and tubes 
into the wound to permit the application of the ligatures ; 
Uiese are applied in exactly the same manner as in ovari- 
otomy. The assistant must be especially careful to avoid 
dragging on the tubes and ovaries, for they tear easily, and 
the ligatures need to be very cautiously tied, as any jerk- 
ing is very apt to lacerate the tissues and necessitate 
retransfixion. 

When oophorectomy is practised for myoma of the ute- 
rus, one difficulty is to obtain sufficient tissue between the 
ovary and the uterus to make a secure pedicle, because the 
mcsometrium is so stretched that when the parts are tied and 
cut away, the tension upon the ligatures is so great that tlicy 
may slip off When this hap[)ens in the course of the ope- 
ration it is sometimes very difficult to discover and secure 
the vessels, and in very many cases it has been necessary to 
perform hysterectomy to control the bleeding. Should the 
accident happen after the patient has been returned to bed, 
it is in most cases fatal. 

After-treatment. — This is conducted on the same lines as 
after ovariotomy. 

The dangers are the same, but oophorectomy is attended 
with greater risk to life than ovariotomy. It is, however, 
important to remember that the greatest operative risk is 
with those cases in which the necessity for surgical inter- 
ference is the greatest. 

When oophorectomy is performed for pyosalpinx, there 
is risk with the pedicle, because its tissues are often infected, .1 
and this may cause it to slough and set up fatal peritonitis | 
or give rise to an abscess in the stump which may burst J 
through the scar, the rectum, or bladder. 

When only a smalt portion of an ovary is left behind:! 
oienstrOation will continue, and when double oophorectomjrl 



398 



DISEASES OF WOMEN. 



is performed to anticipate the menopause, such an accident 
will nullify the good expected of the operation. 

When oophorectomy is performed for myoma of the ute- 
rus the great risk is hemorrhage. 

The sequelcs are the same as after ovariotomy. 




CHAPTER XLV. 
OVARIOTOMY AND OOl'HOBECTOMY (Continued). 

THE AFTER-TREATMENT AND RISKS. 

TiiE patient is returned to a warm bed with t;entlencss, 
to avoid vomiting: a pillow is placed under her knees. 
Care must be taken that the hot-water bottles do not come 
in contact with the patient's skin, so as to cause blisters. 
As consciousness returns, pain is complained of, and, if se- 
vere, it may be relieved by morphia, either subcutaneously 
or in the form of a suppository. The routine use of this 
drug is injudicious. 

Vomititig. — This troublesome complication is best re- 
lieved by keeping the stomach empty at least twenty-four 
hours. If there is faintness or shock, stimulants, such as 
brandy and water, or even milk, beef-tea. or the Hkc, may 
be administered by the rectum. The bowel will easily re- 
tain three ounces of beef-tea at a temperature of tOO° F. 
slowly injected. In some cases the vomiting persists for 
two or more days, and when accompanied by increased fre- 
quency of pulse and distention of the belly, it is usually an 
unfavorable sign. 

Diet. — At the end of twenty-four hours small quantities 
of barley-water, water, or milk and soda-water may be given 
by the mouth at regular intervals : at the end of three days ~ 
the bowels should be relieved by an enema, and then boiled 1 
fish or fowl may be allowed, and the patient soon requires " 
convalescent diet. 

DiBtention of the abdomen is due to the accumula- 
tion of gas in the intestines. It is usually first observed in 



400 DISEASES OF WOMEN. 

the transverst; colon. It occasions in some cases much dis- 
comfort, and it is not always easy to relieve it The pas- 
sage of the rectal tube every three liours as a matter of 
routine is useful, or the administration of a small enema. 

The Bladder. — The urine requires to be drawn oflT by 
the nurse every eight hours by means of a clean, soft ca- 
theter. Before passing the catheter the nurse bathes the 
orifice of the urethra, so that no mucus is conveyed from 
the vulva into tlie bladder. It is a good plan to encourage 
patients to pass water unaided. 

To Clean a Cathelcr. — Immediately after use the catheter 
should be syringed with warm water, then with warm sub- 
limate solution (i in 2000) or a solution of carbolic acid 
(l in 20); it is then immersed in a glass tube containing 
one of the above-named solutions. Before using a catheter 
it should be wiped with a piece of sterilized gauze and 
thoroughly oiled. 

Bowels. — At tlie end of four or five days the bowels 
will occasionally act of their own accord. Usually, how- 
ever, it is necessary to use a simple enema ; and this is, in 
the majority of cases, quite sufficient. When opium has been 
freely administered, still more active measures may be re- 
quired. 

Temperature. — This should be observed every four or 
six hours and duly recorded in the note-book. The first 
record after the operation is usually subnormal; in twelve 
hours it becomes normal, and may even be raised half a 
degree. During the first twenty-four hours it may ascend 
to 100° F. without citusing alarm; beyond this, especially 
if accompanied by a rapid pulse, an anxious face, and dis- 
tended belly, it is sufficient to make the surgeon anxious. 
A temperature of loi" or 102° F., unaccompanied by other 
unfavorable symptoms, is not a cause for alarm unless main- 
tained. The very high temperatures which used to alarm 
surgeons were due to absorption of carbolic acid, especially 
when the spray 'was in fashion. 



or^KluTOMV .-lAWi OOPJIOHECtOMY. 



401 



Poise. — This is a valuable guide, and even more trust- 
worthy than the temperature. When the pulse remains 
steady and full there is no cause for alarm. When it in- 
creases in frequency to 120 or 130 or more beats in the 
minute and is thin and thready, then there is danger even 
with the temperature only slightly raised. 

Metrostaxis. — After operations for the removal of both 
ovaries and tubes blood sometimes escapes from the uterus 
and simulates menstruation. It usually begins within the 
first forty-eight hours after the operation. Metrostaxis 
occurs in or about one-half the cases, and has nothing to 
do with menstruation. 

Sutures. — On the seventh or eighth day the sutures 
will require removal. It is a good plan to allow two to 
remain (taking care not to leave any that are causing irrita- 
tion) twenty-four hours longer. After removing the sutures 
a broad band of adhesive plaster should be firmly fastened 
across the abdomen, with a good grip on each hip. This 
precaution is necessary, as an incautious or violent move- 
ment, such as coughing or straining, may cause the skin- 
edges of the wound to gape. 

Should suppuration or stitch-hole abscesses occur — and 
these are rare — they must be treated on general principles. 

Bed-sores may give trouble after ovariotomy in an el- 
derly and enfeebled patient, as after any other surgical pro- 
cedure which requires the patient to remain for several con- 
secutive days upon her back. With due care and watchful- 
ness on the part of the nurse, a bed-sore should not occur, 

THE RISKS OF OVARIOTOMY. 

The performance of ovariotomy is attended by several 
risks; the chief are indicated in the subjoined list: (i) 1 
Shock; (2) Injurj- to viscera; (3) Bleeding; (4) Perito- ' 
nitis; (5) Foreign bodies left in the belly; (6) Tetanus; 
(7) Parotitis (septic); (8) Insanity; (9) Thrombosis and 
embolism. 



402 



VJS/iASHS OF WOMEN. 



(i) Shock. — This varies gruatly. The removal of even 
a small (jvariati tumor may be followtid by j^rtat collapse. 
It is more common after prolonged operations and enuclea- 
tion of tumors from the mesometrium. 

Genewlly the patient quickly reacts on her return to bed. 
After severe operations the patient may not regain con- 
sciousness for some hours, and occasionally collapse ter- 
minates in death. 

(2) Injury to Viscera. — Those most liable to injury 
during ovariotomy are — (a) The intestines ; {p) The blad- 
der ; (<■) the ureters ; (c/) the gravid uterus. 

(a) Intestines. — These may be cut or lacerated in making 
the abdominal incision ; more frequently they arc torn in 
detaching adhesions. The vermiform appendix has been 
divided before its nature was suspected. The bowel has 
been pierced by the pedicle-needle whilst passing the liga- 
tures, and has even been tied to the pedicle. In suturing 
the abdominal wall the intestines have not only been pricked, 
but accidentally stitched to the belly-wall. 

Wounds of intestine should be immediately sutured with 
fine silk. A wound of intestine overlooked is almost cer- 
tainly fatal. 

{b) The Bladder. — A full bladder has been punctured 
with a trocar in mistake for a cyst : it has been opened in 
making the abdominal incision and torn in separating adhe- 
sions. Wounds of the bladder should be immediately 
closed with fine silk sutures. 

{(■) Tlie Ureter. — This duct has been torn in separating ad- 
hesions on the floor of the pelvis and at the brim of the 
pelvis. It is especially liable to damage during the process 
of enucleating tumors from the mesometrium. 

Small wounds may be clo.sed with a suture. When 
the duct is completely divided, the upper end should, if 
possible, be invaginated into tlie lower; failing this, the 
proximal end is brought out of the wound. This will 
entail a subsequent nephrectomy. A ureter accidentally 



OV^IRIOTOMy AND OQPHOK LCTOM Y. 403 

divided has been successfully ent;raftcd into the wall of the 
bladder. 

(ti) Injury to n Gravid Uurus. — When ovariotomy is 
undertaken during pregnancy the surgeon is necessarily 
on his guard against mistaking the enlarged uterus for a 
cyst. Injury is very liable to happen when there has been 
an error of diagnosis and pregnancy mistaken for a cyst. 

To plunge a trocar into a gravid uterus is a serious mis- 
fortune, and has happened on several occasions. In such 
conditions there are three courses open to the surgeon ; (i) 
Perform a Ca;sarean section; (2) Amputate the uterus; 
(3) Sew up the puiicture without disturbing the uterine 
contents, 

Each of these methods has been practised with success, 
but Ca;sare3n section has so far given the best results, 

(3) Bleeding. — Intermediate hemorrhage may be due to 
the .slipping of an ill-applied hgature from the jxrdicle or an 
adhesion. 

Oozing, which is scarcely appreciable when a patient is 
collapsed, may become very free when reaction occurs. 

Severe internal bleeding is manifested by well-known 
signs — pallor, cold skin, rapid but feeble pulse, and sighing 
respiration. When these signs are manifested, the wound 
must be reopened, tlic clots turned out, and the bleeding 
point secured. 

Hemorrhage usually occurs within the first thirty-six 
hours. After enucleation has been practised and the broad 
ligament ligatured, but not drained, bleeding may take place 
within it and form a hematoma. As a rule, it is slowly 
absorbed. 

(4) Peritonitis.— This was formerly the terror of the J 
ovariotomist. Its frequency has been diminished by im-i 
proved methods of dealing with the pedicle, greater cleanli-l 
ness. antiseptic and aseptic precautions, and the employment 
of irrigation with or without drainage. Peritonitis may 
arise from infection at the time of the operation in conse- 



404 



DISEASES OF irOMKJV 



I 



quencc of the escape of pus or other fluids from the interior 
of cysts or tumors ; from sponges and instruments inadver- 
tently left in the abdomen ; from operations conducted in 
rooms in which sewer-gas and similar deleterious agents are 
present ; from damage to and subsequent sloughing of por- 
tions of the viscera, gangrene of the stump, pieces of adhe- 
rent cyst-wall, or adhesions; from decomposition of blood 
carelessly left in the pelvis or that has oozed after the 
operation. 

Its occurrence in a fatal form is not likely to be mistaken. 
The pulse is rapid (120, 130, or 140), at first full and bound- 
ing, then quickly becoming thin and feeble. The tempera- 
ture may be subnormal, then slowly rise to 100°, 102*, or 
103° F. These signs, accompanied by vomiting, the fluid 
being bile-stained or like black coffee, an anxious and 
pinched face, sunken eyes, and distended abdomen, form a 
picture never mistaken when once seen. Death is rarely 
long delayed. 

(5) Porelgrn Bodies I^eft in the Abdomen. — Every 
writer on ovariotomy insists on the importance of exercis- 
ing the utmost personal vigilance in counting instruments. 
and especially sponges, after an abdominal operation. 
Nearly all the cases in which foreign bodies arc left in the 
abdomen end fatally, and more than one writer has ex- 
pressed the opinion that the accident has probably been 
overlooked where no post-mortem examination was made. 

Besides sponges and forceps, such things as pads of tar- 
letan, iodoform gauze, and a drainage-tube have been left 
in the coelom. 

In a few lucky cases a sponge or compress has given rise 
to an abscess, and the foreign body has been discharged, 
sometimes through the belly-wall, sometimes through the 
anus. Forceps thus left behind have made their way into 
the bladder, the c^cum, or have escaped at the navel many 
months after the operation. 

(6) Tetanus. — Since the clamp has been banished, tet- 




OlAHIOTOMY AND 0OPI/OR£C70MY 405 

anus rarely attack:; the abdominal wound. Ovariotomy 
should not be performed in rooms recently plastered. In 
practice it is to be remembered that tetanus arises from 
tnfcction, and all instruments wliich have been in contact 
with a case of tetanus should be sterilized by prolonged 
boiling. 

(7) Parotitis. — Inflammation of the parotid gland is apt 
to complicate injuries to. and operations upon and in, the 
abdomen. One or both glands may be affected, and in a 
large proportion of cases suppuration occurs. This form 
of parotitis runs no regular course: it may subside and 
recur in the course of the convalescence from the original 
injury or operation. 

(8) Insanity. — Acute mania occasionally complicates 
the convalescence from ovariotomy. !t was common dur- 
ing " the reign of the carbolic spray." In the majority of 
cases it quickly subsides. 

(9) Vascular Disttirbances. — Thrombosis of the iliac 
veins sometimes follows ovariotomy, and gives rise to 
oedema, usually of one leg. 

Emboli.sm of the pulmonary artery has been several 
times recorded in the course of convalescence from ova- 
riotomy, but the diagnosis has only been demonstrated by 
actual dissection in very few instances. 

The SeqneUe or Retnote Risks of Ovariotomy. — 
These include — (1) Intestinal obstruction; {2) Perforation 
of the intestine; (3) Trouble with the ligature; (4) Yielding 
cicatrix. 

{0 Intestinal Complications.— It is diflficult to esti- 
mate with any approach to accuracy the relative frequency 
of intestinal complications following ovariotomy. The dan- 
ger is nevertheless real. 

Intestinal obstruction may be acute or chronic — may su- 
pervene within a few days of the operation or be delayed 
for months or years. The causes are fourfold: (a) The 
formation of a band ; {b) adhesions to the pedicle ; {c) ad- 




4o6 



DISEASES OF WOMEN. 



Iiesions to the cicatrix ; {//) strangulation in a sac formed c 
a yielding cicatrix. 

(2) Perforation of Intestine. — This may arise from 
pressure of a drain-tube or damage to the wall of the gut 
in separating adhesions. The rectum is the most frequent 
scat of this accident. 

(3) The Wgature. — When a piece of sitk thread or 
whipcord thoroughly sterilized by boiling is applied to a 
healthy pedicle, it causes no evil consequences, and is either 
encysted or slowly removed by the aggressive leucocytes. 
The thread disappears in about a year, but the knots re- 
quire at least an additional six months. 

When the ti.ssues of the pedicle are infiltrated with in- 
flammatory products, especially when the Fallopian tube is 
septic, the ligature, instead of being absorbed, excites in- 
flammation and becomes surrounded with pus. An abscess 
around the pedicle may give rise to the following compli- 
cations : ((?) fatal peritonitis ; {b) the akscess may open 
through the abdominal cicatri.v and form a sinus; (c) it 
may perforate the rectum or even the bladder. 

When a sinus results from an abscess of the pedicle it 
usually persists until the ligature is discharged : this may 
require many months. When the ligature escapes into the 
bladder, it may form the nucleus of a vesical calculus. 

(4) The Cicatrix.— One of the most troublesome and 
frequent sequel.'E of ovariotomy used to be a yielding cica- 
trix, which allowed the formation of a large ventral hernia. 
In very many cases these hernia caused more trouble than 
the disease for which the operation was performed, besides 
being a source of danger. 

The inconvenience of wearing a belt is such that many 
women prefer to run the risk of hernia rather than be en- 
cumbered with such an apparatus. 

When the abdominal incision is clo.sed with a triple 
of sutures, as described on page 3S3,thc chance of a yield- 
ing cicatrix is very slight and the bell may bo discarded. 




Oi'ARlOTOMY AND OOPUOKECTOMY 4O7 

Cancer of the Cicatrix. — Cases have been reported in 
which, after removal of ovarian adenomata, tumors simitar 
in structure have appeared in tlie scar. In some cases such 
tumors have been associatt^d with wide dissemination due to 
recurrence of a malignant tumor. In some cases the tumor 
has been attributed to direct infection during removal of the 
primary tumor. 

The Remote Effects of Ovariotomy on the Pri- 
maiy and Secondary Sexual Characters. — The remov- 
al of one ovarj- has no effect upon women, and a large num- 
ber of instances have been reported in which pregnancy has 
followed unilateral ovariotomy. 

The removal of both ovaries is followed in adult women 
by sterility and persistent amenorrhiea. and these are the 
only two constant effects which can be attributed to it. 

ThL- amcnorrhoja is practically an artificial menopause, 
and is usually accompanied by that peculiar vaso-motor 
phenomenon characteristic of the "* change of life," familiar 
to climacterics as "flushes." The influence of double ova- 
riotomy on the sexual passion is hard to estimate, and can- 
not be Lik-en into account when the life of the individual is 
directly concerned. Women have lived happily with their 
husbands after removal of both ovaries. The nubility of 
women after double ovariotomy is a difliicult question. It is 
certain that many women have married after removal of 
both ovaries. 

There is no evidence that complete removal of both 
ovaries in a mature woman leads to any unusual develop- 
ment of the secondary sexual characters, or atrophy of the 
breasts. It may cause obesity in a woman who has a tend- 
ency to form fat. 



CHAPTER XL VI. 



OPERATIONS FOR TUBAL PREGNANCY. 



For the performance of these operations the methods are 
very similar to those for oophorectomy and the cmicleation 
of cysts from the mesometrium. We shall therefore merely 
mention the special details. 

At the Time of Primary Rupture. — In this stage the 
surgeon opens the abdomen in the middle line, and on 
dividing the peritoneum there is usually a free rush of liquid 
blood, The hand is immediately introduced into the belly, 
and on recognizing the fundus of the uterus the surgeon 
passes his hand along the Fallopian tube, first on one side, 
then on the other, to distinguish that which is damaged. 
The tube is then drawn into the incision and clamped with 
forceps; the mesometrium is then transfixed, and the liga- 
tures secured exactly as described under the operation of 
oophorectomy. 

The free blood and clot are then removed, and if the 
surroundings are favorable for the purpose, the pelvis is 
freely irrigated. Otherwise the blood and clot are thor- 
oughly removed by cautious sponging. Care is tiken to 
remove blood which may have lodged ill the iliac, the utero- 
vesical, or the recto-vaginal fossa:. 

When the blood is thoroughly removed either by irriga- 
tion or sponging there is no need for drainage. 

The wound is then sutured and dressed as after ovari- 
otomy. 

Afkr-trcalment. — This is of very great importance, for 
the great loss of blood and the shock place these patients in 
a very critical condition. As soon as the jKiticnt is returned 



OPERATIOXS FOk TUBAL PHEGNANCY. 4O9 

to bed, warm bottles are placed around her, and an enema 
coHMsting of three ounces of milk (or beef-tea or even warm 
water) and half an ounce of brandy is injected into the rec- 
tum every hour for twelve hours. Its continuance is then 
determined by the state of the pulse. To relieve thirst, for 

few hours the patient is allowed to wash the mouth with 
cold water or even to sip hot water. 

At the end of tiventy-four hours there is generally pain in 
the belly (due to attempts to e.xpel the decidua). To relieve 
this, twenty drops of laudanum may be added to the enema. 
The nutrient encmata may be discontinued at the end of 
twenty-four or thirty-six hours, and the patient fed freely 
by the mouth if there be no vomiting. 

Snbseqnent to Primary Rapture. — When it is neces- 
sary to interfere with a collection of blood in the recto- 
Vaginal fossa, the belly is opened in the middle line, and on 
reaching the clot the surgeon removes it with his fingers, 
and then attempts tn bring the damaged tube into the wound, 
and removes it as in oophorectomy. The blood-containing 
recess is freely irrigated or thoroughly sponged. 

In cases where the blood has been standing for several 
weeks it is usually advisable to employ drainage. 

After-treatinent. — This is conducted on the same lines as 
after enucleation of sessile cysts. 

Hesotnetric Rupture {HiTinatoma). — In these cases, 
unless the surgeon has had considerable experience in this 
class of surgery, he is liable to be extremely puzzled to 
make out the nature of the swelling when he has incised 
the parietes. The bulging, dark-red mass often resembles 
a solid tumor. To attempt its enucleation is disastrous. 
All that is required is a free incision into the summit of the 
m.xss, and removal of the embryo, clot, and placenta. The 
edges of the sac-wall are stitched to the skin-incision and 
its cavity drained. The remainder of the wound is closed 

after ovariotomy. 

After the Fifth Month. — The operative treatment of 



410 



DISEASES OF WOMEN 



the iale stages of tubal pregnancy has already been con- 
sidered in Chapter XXVII The method of performing the 
operation consists in making a free incision into the abdo- 
men, as recommended in describing ceeliotomy. The 
operator then endeavors to make out llie nature of the 
sweUing and determines its relation to the uterus. He 
must satisfy himself that the swelling is not a uterine or an 
ovarian tumor. When he fc-els a.ssured that he is dealing 
with a gestation sac, he freely incises it and withdraws the 
ftetus with its placenta and the surrounding clot. When 
the ftetus is dead, there is rarely much difficulty with the 
bleeding, but with a living placenta the hemorrhage at this 
stage i.s often appalling. 

The necessity for correct diagnosis and ready appreci- 
ation of the pelvic condition is very great. When the sur- 
geon mistakes a gestation sac for a tumor and attempts to 
enucleate it. he is very apt to injure large blood-vessels or 
a ureter, or tear a hole in the bowel ; wherea.s when the 
nature of the case is recognised and the sac opened, the 
walls of the sac isolate the field of operation from the belly- 
cavity and prevent injury to intestines (except the rectum 
when the ftetus occupies the left mesometrium). The sub- 
sequent treatment of the case is the same as that adviseil 
after enucleation of cysts from the mesometrium. 

The Risks of Ceeliotomy for Tubal Pregnancy in 
its I,ate Stages.— When the ftetus is dead the o|R;ralivc 
risks are very small indeed, and do not exceed those of 
ovariotomy. 

In ca-ses where the fcetus is alive and the placental circu- 
lation in full vigor the risks arc greater than those of any 
other abdominal operation. About two-thirds of the 
patients die. The risks arc threefold: (i) hemorrhage; 
{2) shock; (i) peritonitis. 

The risk of peritonitis is due to the decomjKtsition of tlic 
placenta when it has been left behind. 



CHAPTER XLVII. 
OPERATIONS ON THE UTERUS. 

These arc — i Hysterectomy; 2 Abdominal Myomec- 
tomy; 3. Cesarean Section ; 4. Hysteropexy; 5. Shorten- 
llic Round Ligaments. 

. Hysterectomy. — This signifies the removal of the 
uterus, and, as a rule, thu ovaries and the Fallopian tubes. 
Wlicn the uterus is removed through an incision in the 
, belly the operation is de^^cribcd as abdominal hysterectomy. 

(«) Snpra-vaginal Hysterectomy. — The prehniinary 
stages and tliu insirunientB required are the same as those 
jbr an ovariotomy. 

Si^/>s of the Operation. — In this method, when the tumor 
scarcely rises out of the pelvis, it is a great advantage to 
have the patient in Trendelenburg's position. 

The abdomen is opened as for ovariotomy, but the in- 
cision will be much longer to enable the tumor to be with- 
drawn. iLs actual length is of course regulated by the siite 
of the tumor. It some cases it will extend from the pubcs 
to a point near the ensiform cartilage. The enlarged uteru.s 
is then brought out and the intestines protected by a warm 
Rat sponge. The surgeon then seeks the appendages, and 
transfixes the broad ligament with a pedicle-needle armed 
with a stout silk thread. The threads are tied tightly, and 
in such a way as to enable the tissues between the two liga- 
tures to be divided. When the same process has been car- 
ried oul on the opposite side the uterus is then well raised 
out i)f the pelvis by the assistant. 

The surgeon now makes a transverse cut through the 



412 DISEASES OF WOMEN. 

peritoneum on the anterior surface of the tumor or the ute- 
rus, a short distance above the level of the bladder ; then 
by means of the handle of the scalpel he opens up (he con- 
niictivc tissue between the bladder and the uterus, and is 




thus able to peel the peritoneum and bladder from the 
uterus. 

A similar transverse incision is made across the posterior 
surface of the tumor, and the peritoneum on that aspect is 
carefully peeled off! When this manceuvre is properly car- 
ried out the layers of the broad ligaments are directly con- 




OrLKATiON^i ON THE VTEKUS. 



413 



tinuous with each other, the cervix of the uterus litandiii^ 
up freely between them. 

The operator now proceeds to ligature the uterine artery 
on each side. He selects a stout ancurysm-needle set at a 
right angle, armed with a stout silk ligature, and passes it 
around the vessel at the spot where it passes on to the cervix 
(Figs. 1 1 3 and 1 14), and ties it securely. Having litjatured the 
vessel on both sides, he then cuts the uterus at the level to 




which he has reflected the peritoneum. Sometimes a small 
ve.ssci may bleed in the stump and needs to be secured. 
Often the uterine arteries are clearly seen, and they may 
then be deliberately tied as in an amputation stump. 

The floor of the pelvis and the parts exposed between the 
split broad ligaments are carefully sponged and freed from 
blood and clots, and the peritoneal flaps are now carefully 
sutured together, so as to exclude the stump from the pel- 
vic cavity. The abdominal wound is then sutured in the 
usual manner. 



414 



DJilEASKS OF liOA/lL\V. 



AJler-lreatiHcat. — This is conducted on the same lines as 
after ovariotomy, and, as a rule, the convalescence is as 
quick. 

The special risks in this operation are hemorrhage ; injury 
to one or both ureters or the bladder; and infection of the 
I>critoneum through the cervical canal. 

yb) Pan-hysterectomy. — This signifies the removal of 
the whole uterus through an abdominal incision, and dilfers 
from the preceding method in that it leaves no stump. 

The patient is prepared as for ovariotomy, but in addition 
the vagina is carefully made aseptic, and it sometimes facili- 
tates matters if the vagina is filled with aseptic gauza 

Trendelenburg's position assists the surgeon greatly in 
this operation. 

The early stages are the same as for the preceding 
method, and the broad ligaments are secured with silk 
ligatures. The bladder is stripped from the uterus, and the 
surgeon makes his way downward along the anterior aspect 
of the cervix into the vagina. 

The posterior connections of the vagina and cervix are 
severed with scissors, and at the lateral angles the iiterhie 
arteries may be secured with ligatures before division, or 
they may be caught with forceps and divided, the cut end 
being securely ligatured with silk. The cervix is then de- 
tached from the lateral aspect of the vagina and removed. 
Any spouting vessel in the mesomelric tissue or the cut 
edges of the vagina is secured with forceps, and the margins 
of the divided peritoneum and broad ligaments are brought 
into position with sutures, thus occluding the abdominal 
end of the vagina. 

This operation is sometimes modified in the following 
manner : Before opening the abdomen the patient is placed 
in the lithotomy position, and the cervix freed from the 
bladder and vagina as in the first stages of vaginal hyste- 
rectomy: then the patient is placed in the Trendelaibut^ 
position and the operation completed through the abdomen. 



O/'EAAr/ONS ON THH VTERVS. 415 

After the suture of the broad ligaments the pelvis is freed 
fi-um blood and clot and the abdominul wound secured as 

cteliotomy. 

It sometimes happens in tht performajice of supra-vaginal 
hysterectomy that the operator is able to peel the perito- 
neum off the cervix below the level of tlie insertion of the 
cervix into the vagina. When this is the case and the uterus 
lit away, he finds that he has opened the vagina and thus 
unwittingly performed a pan- hysterectomy. 

Supra-vaginal hysterectomy and pan-hysterectomy may 
[lerformed e;isily. safely, and quickly; convalescence is 
as rapid and as uneventful as after ovariotomy. There are 
many modifications described by various surgeons, but the 
principles are those related above, and the operation, which 
gives remarkable results, is being rapidly perfected. 

. Myomectomy. — This signifies the removal of a pe- 
dunculated uterine myoma through an abdominal incision, 
without removal of ihL- uterus. 

The patient is prepiired as for ovariotomy or hysterec- 
tomy, and on opening the abdomen the surgeon finds a 
myoma growing from the fundus of the uterus and possess- 
ing a narrow pedicle or stalk which enables the tumor to be 
protruded through the wound. In such a case the tumor 
may be removed and the uterus preserved. 

When the tumor is small and the pedicle narrow, the 
Luter may be transfixed and ligatured as in the case of an 
ovarian cyst : the tissue of the pedicle is very tough and 
requires to be tightly tied. 

HnucUatioit of Myomata. — Occasionally a myoma of large 
size may project from the uterus or even rest incarcerated iji 
the pelvis, and, though projecting from the uterus, yet offer 
so short a pedicle that it would be folly to attempt to se- 
cure it with ligatures. In such a case there is an alternative 
method. The tumor should be well exposed and its capsule 
spUt with a sharp scal|x.'I, and the myoma may with a little 
ore be rapidly enucleated from its bed. The capsule can 



4l6 DISEASES OF WOMEN. 

then be bunched toyethi;r. and may be utilized as a pedicle, 
transfixed, and secured with silk ligatures : the abdominal 
wound can then be completely closed as in ovariotomy. 

The after-results of abdominal myomectomy and enuclea- 
tion of uterine myoma are admirable, as the surgeon is able 
to leave not merely the uterus, but the ovaries and the tubes 
as well. In some instances the patients have become preg- 
nant and had happy deliveries. 

Operations on the Pregn an t Uterus. — The opera- 
tions which come strictly under this heading are — 
C-Tsarean Section ; 
Porro's Operation ; 

(3) Cfiesarean Section signifies the rcmoz'ol of a fcctus 
and placenta from the uterus through an incision involving 
the abdominal and uterine snails. 

When it is known some days beforehand that the patient 
will be submitted to this operation, she should be prepared 
as for ovariotomy, the vulva and the vagina being thor- 
oughly washed and douched. Often it happens lliat the 
operation is undertaken after labor has commenced and in 
circumstances which make time very precious. Even then 
the abdomen, pubes, and vulva can be thoroughly washed 
with warm soap and water and lightly rubbed with chloro- 
form and cotton-wool. 

Instruments. — A scalpel; probe-pointed knife; volsella; 
si.K pre.ssure-forceps ; scissors; suture-needles, curved and 
straight ; catheter ; sterilized ligature silk, catgut, and silk- 
worm gut. 

The Abdominetl Incision. — After the patient is under the 
influence of ether and the bladder emptied with the catheter, 
an incision is made in the linea alba from the umbilicus to 
the pubes. The belly-wall of a woman advanced in preg- 
nancy is ycry thin. and. unless the surgeon be cautious, the 
knife will come in contact with the uterus before he is aware 
of it. 

The uterus lies just under the incision, and ihe opera- 



OPEK.ir/OA'S OA' THE VTE/ti'S. 417 

tor ascertains that it lies centrally (often the uterus is 
somewhat rotated to the rijrht or left], and then makes 
I free incision through the uterine wall and extracts the 
f<£tus and placenta: as the uterus contracts he sh'ps his left 
hand behind the fundus and grasps the uterus near the 
I'ix, and efll-ctiially controls the bleeding. The assist- 
ant passes a large warm flat sponge into the belly to restrain 
the intestines and omentum. Should the surgeon be anx- 
ious about the bleeding, he may apply a whipcord ligature 
-around the uterus. The uterine cavity is sponged out, and 
the linger passed along the cervical canal into the vagina 
1 order to ensure a free passage for blood and serum. 

We now come to the most important stage of the opera- 
tion — namely, suture of the uterine incision. The wall of 
the uterus has an inner layer of mucous membrane, then 
a thick stratum of muscle-tissue, and Rnally an outer layer 
of peritoneum. The wound is first closed with a series of 
sterilized silk sutures which involve the mucous and adja- 
cent half or thereabouts of the muscular layer. These 
BUtures should be fairly close together, for tliey not only 
bring the parts into apposition, but serve to restrain the 
bleeding. A second row of silk sutures is now inserted, 
including the serous coat and adjacent half of the mus- 
cular layer. These threads should not be tied too tightly, 
as the tissues of a gravid uterus are soft and easily tear. 
In closing the uterine incision the surgeon should not 
spend time in vainly endeavoring to staunch the bleed- 
ing from the edges of the incision : this is best effected by 
dextrously inserting and securing the sutures. 

The recesses of the pelvis are carefully cleaned by gentle 
sponging, and the parietal wound closed as after ovariotomy. 
The dressing varies according to the fancy of the operator: 
whatever its nature, it is secured by a finnly adjusted 
bandage or roller. 

Sterilization. — When C-esarean section is performed 
the uterus is preserved, and after convalescence the patient 
37 



4i8 



I'ISliASES OF WOMEN 



is in a position to rc-conceive. There may be conditions 
in which the patient is desirous to produce more children, 
even with the terrible risk bcfort; her of having them 
extracted by Caesarean section. 

On the other hand, women, knowing the great risk they 
run, ask that steps may be taken to prevent what they con- 
sider a catastrophe. This is a very simple matter, and in 
order to sterilize the patient the surgeon may perform 
double oophorectomy, or adopt a simpler method and 
pass two silk ligatures around each Fallopian tube by 
transfixing the mesosalpinx, and after tying them firmly 
divide the tube between the ligatures. Any measure short 
of this is useless: conception has on several occasions 
taken place when the tubes have been secured with a single 
thread on the plan employed in the ligature of an artery in 
continuity. 

The advantage of sterilization by ligature and division 
o^ the tube over double oophorectomy is, that young 
patients are spared the inconveniences which almost always 
result from an artificial menopause, 

PoiTO'S Operation. — This signifies the removal of a 
fcetus from the uterus as in Ca;sarean section, followed by 
hysterectomy. 

In the original method of performing this operation the 
abdomen is opened, the uterus incised, and the fretus ex- 
tracted as in Ciesarcan section : the uterus is then with- 
drawn through the wound and encircled with the wire of 
a serre-nceud ; needles are inserted and the uterus cut away 
above the pins. The parietal peritoneum is then sutured to 
the stump below the wire and the abdominal inci.'^ion 
sutured. This clumsy method of removing the pregnant 
uterus is now replaced by that described under the title of 
supra-vaginal hysterectomy (p, 411). 

Operations for Displacements of the Uterus. — These 

are of two kinds : Hystern|x:.xy {ventro-fix.ition of the uterus), 
and Alexander's operation (shortening the round ligaments). 



OPERATIONS ON THE UTERI'S. 419 

(4) Hysteropexy implies the fixation of ihc uterus by 
means of sutures to the anterior abdominal wall. This 
operation is performed for two conditions : severe retro- 
flexion of the uterus and prolapse of the uterus. 

The instruments required are those necessary for incising 
the abdominal wall as for celiotomy, plus some curved nee- 
dies of various sizes and degrees of curvature. 

I. Rtlroficxion of tlu- Uterus. — The Steps of the Opera- 
tion, — The patient is prepared with the same rigid precau- 
tions as for ovariotomy, and the abdomen is opened as for 
that operation, except that the incision is shorter, On 
entering the ccelom the operator deti^rmines with his fingers 
the position and condition of the body of the uterus. If 
it be free, it is then straightened and the condition of the 
ovaries and the tubes ascertained. 

In a fair proportion of cases of severe retroflexion of the 
uterus much of the distress depends upon a prolapsed 
ovary : should the surgeon deem it necessary to remove 
the painful ovary and tube in such a case, he can secure the 
uterus in position by transfixing the stump by a silk or 
fishing-gut suture to the peritoneal edges of the wound: 
in some cases it may be desirable to carry this restraining 
suture through the muscle and fascia as well as the 
peritoneum. 

When he finds it undesirable to interfere with the ovaries 
or tubes, then with a curved needle, armed with fishing gut 

silk, he first passes it through the peritoneum at the edge 
of the wound, then through the anterior surface of the ute- 
rus, and finally through the opposite peritoneal edge: when 
this suture is tightened it will be found to draw the uterus 
to the anterior abdominal wall, and at the same time ap- 
proximate the divided edges of the peritoneum. If desir- 
able, two or more sutures may be introduced (Fig, 1 15). 
The rest of the wound is then carefully closed in single, 
double, or triple layers according to the habit of the 
operator. 



4^0 



DISEASES OF WOMEN. 



2. Prolapsf of the Utcnts. — When hysteropexy is nee 
for a large, bulky, and prolapsed uterus, the stops of the 
operation are the same as for retroflexion, but it is necessaiy 
to introduce a greater number of retaining sutures. Further, 
as the uterus tends to slip downward into the vagina, it is 
an advantage, as soon as the fundus of the uterus is drawn 
into the wound, to transfix it with a stout suture either of 
silk or fishing gut, in order that the assistant may use it as 
a holdfast to keep the uterus in position whilst the surgeon 
introduces the main sutures. In some cases where the ute- 




rus is very large it may be requisite to employ four. five, or 
even six sutures to secure the uterus to the abdominal 
wall. 

In all cases of hysteropexy the uterus is of necessity su- 
tured to the lower angle of the wound, and is therefore in 
close relation to the bladder. It facilitates the operation to 
introduce the lowest sutures first and then gradually work 
up to the fundus. The wound is then closed and dressed 
as described for cteliotomy. 

After-treatment. — This is conducted on exactly the same 
lines as after ovariotomy. 




OPERATIONS ON TNE UTERUS. 

The Risks. — When hysteropexy is performed by sur- 

■ori!? experienced in abdominal work it should have no 
mortaiity. In a small percentage of cases it has been fol- 
lowed by difficulties during labor. These risks are small 
when the attachments are made as directed above. 

(5) Alexander's Operation : Shortening the Ronnd 
J^igaments. — The principlc.of this operation consists in 
ex[>osing the round ligament of the uterus in each inguinal 
canal, and shortening it so as to straighten a retroflexcd 
uterus. 

Instruments required: Scalpels; dissecting-forceps ; pres- 
sure-forceps ; scissors ; needles and suture material ; re- 
tractors. 

The Steps of the Operation. — The patient is prepared and 
placed in position as for celiotomy. The skin is incised 
as if for the radical cure of an inguinal hernia, and the sub- 
cutaneous tissues divided until the intercolumnar fascia and 
pillars of the external abdominal ring are clearly exposed. 
On dividing the fascia, the round ligament will be seen as a 
round red cord lying in relation with the genital branch of 
the genito-crural nerve. The ligament is now gently dis- 
sociated from the loose tissues in which it lies imbedded. 
The ligament of the opposite side is next exposed. 

As soon as both ligaments are freed the assistant passes 
a sound into the uterus and holds the organ in its natural 
position. The operator then draws evenly and gently upon 
the ligaments until the sound is moved. The ends of the 
jound hgaments are then secured in the following manner: 
A thin strand of catgut is passed by means of a curved 
die through one pillar of the ring, then through the 
round ligament, and finally through the other pillar: by 
this means when the suture is tied it not only secures the 
round ligament, but at the same time closes the external 
abdominal ring — the skin-edges are secured with thin 
sutures, and the wound is then dressed. When the patient 
is returned to bed the knees are bent over a pillow. 



422 



DISEASES OF WOMEN. 



The wound is dressed at the end of forty-eight hours and 
the drain-tube removed. It is customary to keep the patient 
in bed for three weeks. 

The chief difficulty experienced in this operation is an 
anatomical one — viz. the ready recognition of the round 
ligament as it issues from the inguinal canal. This is, as a 
rule, a matter of simplicity to surgeons accustomed to ope- 
rate on inguinal hernia. It is certain that many operators, 
not too familiar with the anatomical details of the inguinal 
canal, have found difficulty in carrying out this operation 
on the lines introduced by Dr. Alexander. 

Like the operation of radical cure of inguinal hernia, it 
ought to be free from risk. 





^^29^1 




"H 


J 


INDEX. ^H 


Abdomikai. (liitenlinn aOer ovarim- 


Aiiitnwnhrea, secondary, 302 


omy, 399 


Ampulnlion of the cervix for cancer, 




370 
for hyiwnrophy, 372 , 


incision in cfclioiomy. jSa 


hcmia, 406 


AnitBlheaia, 382 


swell ingj, 326 




Atectss, ovTisn. 258 


Anamnesis {Gr. ova, anew; *ii>^ir, 


i*ivic, 293 




Into ovarian, llS 


Anatomy of the Fallopian lube. 18 


Taginnl. 114 


of iheov.ry, 17 


vnl™.84 


of Ihe pelvic peritoneum, »6 


Accessory ralium tnbtr. at 5 


of Uie uterus. 19 


ovaries, SJI 


of the vagina, zo 


Atlcnonia (Gr. ait^, a ^land) of the 


of the vulva, Jl 


oYBry, 165 


AnteHeiion of the uterus, 128 


of I he menu, 307 


Antevcreion of the uterus, 128 




Apoplexy of the ovnry. 256 


endometriuni, 174 


Arteries, ovarian, 23 ^^^^^| 


of the corporeal endome- 


uterine, anatomy 24 ^^^^H 


trium, 178 






^H 


Age changei id the ovaries, 250 




in the utetiu, IZ7 


m ^H 


ii> the vagina, lo3 


in vaginal hysterectomy, 374 ^^^H 


it, the vnlva. 77 


35 ^^H 


inl^uence of, on slerililjr, 314 


25 ^^^^1 




Ascites, diagnnsis of, 183 ^^^^| 




Atresia (Gt. d. negative; rerpaii'u, to ^^^^| 


Alexander'! operation. 141. 421 


petforalel of the cervix. 68 _ ^^^ 


Aroonorrhmi (Gt. a. negative ; ^^. a 




month i filu, to flow) 301 


of the OS externum, 68, 73 1 


concealed. Sre CryptimuHor- 


of the 0. iMemum. 68. 7» 1 


rha-.i. 301. 303 


of the vagina. 68. 71 ■ 


primary, joi 


oiwralion for. 357 1 


4» M 



Atrophy (Gr. art-ifn, 

ishment) uf Ihe 

of the Ulmu. 146 


vary, 250 


mr- 


of the vagin 

of the vulva 


See A-/-<7«™« 


.89 


Axial tolalion 


ovaria 


n luinore 


275 


lUcru.us (L. />a 


«?/««., 


a little rod) 


vaginal, i 


varioto 


my. 401 





i( ladder- distent ion, diagnnsig of, 283 
Bladder- injuries, during abdominnl 

operstioriE, 402 
Blndder-symploms, 322 
Umvols. regulation of, after ovariol- 

Ilroad ligament. Sec Mtiamelrium, 
27 

CThSAREAn section, 41G 
Calcificalion of coqxvm lutea. !56 

of fiTlDs. See Lilko/^dion, 230 

of mynniBls, 1H7 
Canal of Nnclt, nnalomy of, 28 

hydrocele of, 101 
Carcinoma of ihe body of the uterus, 

of Ihecervin, 208 
□f the Fallopian tube, 123 
of the ovary, 263 
of Hie vuItb, 99 
Caruncle, urelliral. 93 

removal of, by cautery, 348 
by dissection. 347 
Cflroncull hymennles (I,, tammula, 
dim. of earn, flesh ; hymrH\ 92 
myrtitonnes (L. myrtum, a niyr- 
lle-berry; forma, sLr|>c), 92 
falheter, cleanBing <if, 400 
mode of pas-slng, 400 
CalheteHzBlion after ovariotomy. 400 









348 



of urethral 



i (L. ■ 



Ihe neck -, 
nb), adeoo- 
malous disease of, 174 
amputation of, 370 

atrophy of, 146 

epithelioma of, 206 
erosion of. 174 
bypeniDphy of, 141 
laceration of, 160 
repair of Sec Trackelor- 

Cicatricial unicm of the labia, 356 
Cicatrix, cancer of, 407 

yielding, 406 
Clitoris (Gr. nifrropfi, from nJiic, 1 
key), anatomy of, 3t 
elephantiasis of, 93 
• epithelioma of, 93 
inflammation of. 93 
removal of. 348 
Creliotomy (Gr. txiiila, the belly; 

r**.ru, 10 cul), 379 
Colpoclcisit (Gr. jrfSirof, the vagina; 

t/irtiif, a shutting np), 355 
Colpo-])eiineorrliBiJiy, 351 
Colporrhaphy (Gr. ■dJirof, the vagina; 
tm'fil. a seam), anlerior. 351 






■ 350 



Cdlpotomy (Or. niJirnf, the vagina : 
rf/iFW, to cut), anterior, 376 
posterior, 377 

Conception, retention of products of, 
16s 

Cuuhnements, historj' of, in diagnosis. 



319 



Conical a 



<.6i 



litutional diseate, a contraindi- 
cation for opcratioD, 334 



^^^^I^H 


INDEX. 425 1 


Corpom fibrowi, t%t> 


DebiKcnM irf the oviun [I.. .Uhmo, 


Ciirpus lulcnm (L, «ir/>o, ■ body; 


to split open). 33 


/«/™™, yellowish). anM- 


Dennoids (Gr. i^n^, the skin; flHof. . 


oniy of, ii 


likeDeis). s6s 


fnlcificd. 256 




cystic. ss6 


51 


aiBcoMi of. 355 


Diabetes a cniise of pruriius, 87 


Cribrifomi hymeti. 91 


a conlmindication for opcralion. 




334 




Uilalalionof thecervi«,3S9 


deni /J^, B monUi; ^0, b 


dangers of, 363 


flow). 71.303 


of the vagina, 313 


Curetie, 360 


Diplofoccus of Neisser. See Gimo- 


Curetting, 360 


• 0icn>, 115 




Dischaises from female jjcnilal pa»- 


(iw^Hdf, circular), 36 


sagea. 1 17 




Discus proligerus (L. discus, from Qr. 


Prtgnnrnty. 194 


iinnf. a qiiolt ; frolts, off^iring : 




gir<: i» bear), 33 


cause of pruritua, 87 


DisplacementB ot Falliqiian luhea. 


Cyaocele («(m-<c : «*»!!. a lumor). 103 


ai5 




of ovaries, 251 




of uterus, 128 


dcnnoid, 265 


uf vagina, 103 


Ganncrion. 125, 271 


Drain. Mikulicz, 3S5 


of hymen, 9a 


Drainage, in ctrliotoiny. 384 


of Morgafini, 53 




mucous, 99, 115 


Dysmenorrhnra (Or. ^.'r, with dif- 


ovsrlBD. 361 


ficulty ;/-*..;, Wo), 306 J 




constitutional, 307 ^^^^| 


pamTBTiiui, 270 


in llcaion5 of the 128. .^^^^| 




^^H 


retention, 213 


local, 308 ^^M 


setiacrouE, 99 


membranous, 310 ' 


of vagina. 115 


Dynpareunia ((ir. »l.ioini»ifP».(. ill- 


of VulvB, 99 


niBtcd ; from ilif ; irrlpiwwr. a 




hed-fellow), 313 


Dfu^iPlTA (I„ iltaiie. to fall down 




flnm). menslmal, 3II 


EcHlNoniCClTS colonies in the fallo 


ulcrinr. in ruhal pregnancy. 236 


pinn tubes. i9g 


Decitlual (tIIk. 104 


in llie mrwimelrinm, 2oS 


DecidtHmtA molignum, zoi 


_^ 



426 



INDEX. 



Echinococcus colonies in the pelvis, 

398 
in the uterus, 214, 298 

in the vagina, 126 
secondary infection by, 299 
Ectopic gestation (Gr. fKroTrof, dis- 
placed). See Tubal Gesta- 
tion^ 229 
Elytrorrhaphy (Gr. i?.vrp(iv, a sheath, 
the vagina ; /m^r^, a seam). See 
Colporrhaphy. 
Endometritis (Gr. Iv6tjv, within; fivrpa, 
the womb), acute, 169 
cervical, 174 
chronic, 172 
corporeal, 178 
glandular, 172 
hemorrhagic, 173 
interstitial, 173 
puerperal, 170 
Endometrium, adenomatous disease 

of. 174 
anatomy of, 168 
diseases of, 168 
morphology of, 168 
Enterocele (Gr. evrtpov, intestine ; 

Kij^.Tjy a tumor), 107 
Enucleation of broad ligament cysts, 

393 
of myomata, abdominal, 414 

vajjinal, 363 
of sessile ovarian cysts, 393 
Epithelial infection of peritoneum, 

289 
Epithelioma of clitoris, 93 
of cervix uteri, 206 
of vagina, 125 
of vulva, 97 
Erosion of the cervix. See Adenom- 
atous Disease of Cerz'i.r, 1 74 
Evacuation of the cyst in ovariotomy, 

390 



Examination, abdominal, 38, 325 

bimanual, 40 

recto-abdominal, 40 

under an amesthetic, 48, 332 

vaginal, 39 
Excision of tumors of the labia, 349 

of urethral caruncle, 347 
Exstrophy of the bladder, 58 
Extra-uterine gestation. See Tubal 
Gestation, 229 

Fallopian tubes (after the anato- 
mist Fallopius), adenoma 
of, 222 
anatomy of, 18 
carcinoma of, 223 
development of, 53 
displacements of, 215 
echinococcus colonies of, 

299 
hernia of, 215 
inflammation of, 215 
malformations of, 215 
myoma of, 222 
papilloma of, 222 
pregnancy in, 229 
removal of, 395 
sarcoma of, 222 
sclerosis of, 220 
tumors of, 222 
False passages during dilatation of 

the cervix, 363 
Family history in diagnosis, 318 
Fatty degeneration of myomata, 187 
Fibrocystic tumors of uterus, 187 
Fibroids of uterus. See Myoma^ 

181 
Fibroma of the ovary, 261 
Fibro-myoma. See Myoma^ 1 81 
Fimbria (L. fimbritey threads) of 
Fallopian tube, anatomy of, 18 
inversion of, 217 



Fioibriaicd exiremilr or FallopiftD 

tube, occluuon of, nb 
FiKula ( L. Jli/n/a. uylbine tubulv). 
■bdommal, 406 
detection uf, 109 
operaliotu for. 353 
redo- vaginal, 109 
Ircotmeiit of, J52 
urclcro-vaginal, 109 
urclhro- vaginal, 109 
ulerU'Veiical. 109 
vciico-roginal. 109 
Fliwlilng curette, 360 
Foreign bodiet left in abdomeo, 404 

in vagina, tot) 
fourchelle {¥t. faurthitU, B unall 
fork; \^ fitrca,^ fork], anal- 

UceralJon of, 95 
Gaktner'^ duel, analomy of, 18 

cy>1* ur, 125, 171 
Cenu-peclnral |K>sili<in, 41 
Glands of [laithblin. alxceM of. 84 
analnmy of, ij 
cyitt of. 99 
ulerine, 169 
Glandutar endometrlti*. 171 
Gonococcos, cliaraclere of, 1 15 
Gunurrbi.m ( Gr. vdi^, semen : ^a. a 

flow). Si. iiS 
Conorrhmil enilomelrilis, 169 
sal|)ii>g>Iii. JI5 
urelhiiLis, 81 
vnRiiiilis, 1 19 
vulvitis. 81 
Gronlian follicle { nfler von GnuUe, ibr 
aimtomiat : I./ii//iVH/«i. a lillle 
V). 33 
G]iiuecalogical ojicnliuna, jjj 



EX. 427 

llxnuUocnlina (Gr. lupu\ ttt^iror, a 
rccm. the vagina). 68 
UlenU, 75 

operalitiD lor, 74, 35C 
lliematoim of bcoad ligament, 335 

u\ vulva, 80, toi 
Hii'tnalomclrii |Gr. ni/10; /i^rjin. lUc 
womli), 68, 73. 314 
oiicrUion for, 75, 358 
Hn^moloaalpinx (Br. lii/ia-, a63.nty^, 
a iruniprt, tbc Fallopiui tube), 
68 
Ha:tDato>traclieIoS [CiT.mjia; TpdjiUac, 

the cervix), 68 
Hxmoptiilia, a conlraindicalion for 

operation, 334 
Hemorrhoge after ovarioloin;, 403 
Hennaphrodism (Gr. 'Efifi^, Mer- 
cury, representing the male 
part ; "Ao/indiri;, Venui, repre- 
senting the female pari), 49 
Hernia (U. htmia, a rupfure), ab- 
dominal, 406 
inguinal, idi 
of Fallopian lube, 115 
of pelvic floor, 103 
vaginnl, I07 
ventral, 406 
Homology of male and female gen- 
erative organs, SJ 
llotlenlol apron, 78 
Hydatids. Sec MckinacMeus Cole- 



Hydnunnii 



.,297 



OBIS from myoma. 



Hyilrocele |Gr. /"'upi water; ii'/>5,a 
lumor), of the cand of Nuck, 



428 



INDEX. 



Hydrops tubse profluens, 219 
Hydrosalpinx (Or. Ww/j; odATr/)^, 
the Fallopian tube), 218 
intermitting, 219 
Hymen (Gr. i'//^)', a thin membrane), 
anatomy of, 22 
caruncles of, 92, 93 
cysts of, 92 
imperforate. See Atresia of the 

Vagina, 59 
rupture of, 93 

variations in shape and structure 
of, 92 
Hypertrophy of the cervix, supravagi- 
nal, 141 
vaginal, X44 
of the labia minora, 78 
of the uterus, 141 
Hysterectomy (Gr. iW/y^o, the womb; 
fxro/i//, a cutting out), 411 
supravaginal, 41 1 
total (pan-hysterectomy), 414 
vaginal, 373 
Hysteria, 259 

Hysteropexy (Gr. varffm ; nf/^i^, fast- 
ening), for prolapse, 420 
for retroflexion, 419 

Impaction of gravid uterus, 195 
of myomata, 1S8 
of ovarian tumors, 278 
Tmix^rforatc hymen, 59, 93 
operation for, 355 
Incision, abduminal, 382 
closure of, 383 

by triple method, 384 
Incomplete ovariotomy. 394 
Indanmiation of the Fallopian tubes, 
215 
of the ovaries, 257 
of the jM'lvic jH^ritoneum, 288 
of the pelvic cellular tissue, 292 



Inflammation of the uterus, 169 

of the vagina, 118 

of vulva, 80 
Injuries of the bladder, 402 

of the intestine, 402 

of the ureter, 402 

of the uterus, 160, 403 

of the vagina, 107 

of the vulva, 79 
Insanity after ovariotomy, 405 
Instruments for diagnosis, 41 

for operation, 338, 380 

sterilization of, 333, 339 
Intermitting hydrosalpinx, 219 
Intestinal ol)struction after ovariotomy, 

405 
Intestine, injury of, 402 

Inversion of the uterus, 153 
Irrigation in cceliotomy, 384 

KoHKLT's tubes, 18 

Kraurosis vuUx (Gr. Kpavpo^, dr>'), 89 

Lahia majora ( L. /<i^///w, a lip ; ma- 
jusy greater), abscess of, 84 
anatomy of, 21 
cicatricial union of, 356 
cysts of, 99 
ha'matoma of, 80 
minora (L. miituSy smaller), an- 
atomy of, 21 
hypertrophy of, 78 
See also J'uha. 
laceration of the cervix, 160, 368 

of the perineum, 95 
Laparotomy (Gr. "katr^pa, the flank, 
from 7.a7Tnpbc, soft ; Ttfivu, to 
cut), 379. See Ca/iotomy. 
Leucocythwmia, a contraindication for 

oj>eration, 334 
I.eucorrha*a (Gr. ?rt'Af<5f, white ; /vwa, 
a flow) a cause of pruritus, 87 



■^33^^ 




INDEX. 429 






J»' 


iBmmxnhaa. 30J 


vuiclies iiF, 117 


cyclical Ibcory of, 36 






UKbIiWIIIs, bruad. S«i- MtiemeMum, 


in relolioii to operoUon, 335 


27 


qvuIht llieory of. j6 


uvatlan, 17 


painful. See />j'imtniar/4<u(,306 


lOUIIll, ZO 


phyiiology of. 31 


ulrro taciaJ, 17, 28 


pmfuM;. Sec Mtnorrhagia.yn 


LigiUUrc. rale of. 406 


iignificancc of, 36 


mwcriol. 380 


McBomelric Bestalioo, ajS.Hog 


Evrnu dain|» in bystneclomy, 


Mesoiuctrium (Gr. wout. middle 1 M- 


37S 


rpa, Ihe woiub), sbccess of, 393 


Uthnp^dion (Gr. i»K,ai\ODe; irir. 


■naiOTny of, 17 


. child). 239 


cya* of. 370. 271 


Liwr.clingnoiisareiiliUKcmcnUur, 184 


echiiiococcoi colonics in, 198 


Lymphmiu of the geniul ur^iiiu. 16 






iHlitis, 293 




lipumal* »r, 396 ^^^^H 


nuion. 334 


inyoiDa of. 396 ^^^^H 


Malformaliwis of ihe eileniitl gcailai 


Snrconiala of, zgy ^^^^^^| 


orRWis. 49 


Mesuncphnc duclk 51 ^^^H 


o( ibc F«llu|Mamubci. 215 


Mesonephros (Gr. ftfooc! Kfr-tf, kld-^^^H 


uf Ihe liyraen, 91 


SI -^^H 


a( llic ovuiH, 151 


M«.««l,,.o, iGr. ^.K% aAXmyi. tlie ^^H 


1 of ■I.EnW.m.61 


K«llnpi,n lube). j8 ■ 


1 of Ihe vagina, 59 


Metritis (Gr. u^rpa.lbe womb), BCUlc, J 


1 of Ihe nj]y«. 49 


169 J 


Memlirana gr>iiuIo6a, 33 


ccnical, 174 ^^^^B 




17a ^^^^H 


Mciiupmue (Gr. fifv.a moiilh: iroi'Oit. 


^^^^H 


> Hopping nalunill)'). j; 


■ 73 ^^^^H 


Mciiijrhnjp* (Cr. /tir/, a munlh; pi/}- 




.■.,«-. to bu« fonb), 304 


Melronh«i;i« (Gi. iii,rpa;}rirrin>li'. lo 1 


Meii-ltual blood, char.ete™ 0/, 31 


Imnt forth). 304 1 


rrtainrd, chuBCten uf, 76 


Metroswii* (Gt. ;.4r,w; irrrffu, 10 ^^^B 


MenaiuaiiQii (1.. memtnus/ii, aioiitii- 


flow dro|> by drop). 40I ^^^^| 


ly), aliKnce of. See AiiifHi<r- 


Mikulici 3S5 ^^^H 


ri«.i. 301 




•(.alomy of. 31 


3'9 ^^^ 


cesutioti of. See Menffaiisf, 37 


Mooillu Candida in llir vaginal Kcrc- ^ 


clinicul fc*lurca of, 30 


tion. Ill 1 

ft " 



430 



INDEX. 



Mons Veneris, 21 
Morcellement of myomata, 366 
Mucoid degeneration of myomata, 187 
Mucosa (L. mucositSy slimy), uterine, 

35, 168 
changes during menstruation, 35 
Mucous membrane. See Endome- 
trium ^ 168 
polypus, 201 
MUller's duct, 52 

Mumps in relation to oophoritis, 257 
Myoma (Gr. /ii)f, muscle) of the Fal- 
lopian tube, 222 
of the mesomctrium, 297 
of the ovarian ligament, 297 
of the ovary, 261 
of the round ligament, 296 
uterine, degenerations of, 187 
impaction of, 188 
interstitial, 182 
operation for pedunculated, 

364 
for sessile, 364 

septic infection of, 187 

submucous, 184 

subserous, x86 

with pregnancy, 189 
Myomectomy, abdominal, 415 
by morcellement, 366 
vaginal, 363 

Nekdles, pedicle, 388 
Nerves of the genital organs, 26 
Nympha.* (Gr. VJ//97, a bride ; the ex- 
ternal organs of generation in 
female). See Labia Minora ^ 
21 

OlsKSlTY, diagnosis from ovarian tu- 
mors, 281 
Occlusit>n of the cervical canal, 68 
of the ostium tulxe, 216 



' Occlusion of the vagina, 59, 68 
Oophorectomy (Gr. inh^; 0opfo>; f<cro- 
//7, a cutting out), 395 
for diseased appendages, 228, 395 
for nerve-troubles, 396 
for ovarian disease, 396 
for uterine myoma, 396 
Oophoritis, 257 
oophorocele, 253 

Oophoron (Gr. txJv, an egg ; i^tftiu, to 
bear), anatomy of, 18 
cysts of, 263 
inflammation of, 257 
See also Ch>ary. 
Oosperm (Gr. cxiv, an egg; ampfia, a 

seed), 229 
Operation table, 382 
Ophthalmia, a complication of gonor- 
rhoea, 123 
' Os uteri, 20 

Ostium tulxe, accessory, 215 
occlusion of, 216 
stenosis of, 22 1 
Ovarian abscess, 258 
arteries, 23 
concretions, 256 
hydrocele, 272 
ligament, anatomy of, 17 

tumors of, 297 
neuralgia, 259 
ix)uch, 28 
Ovariotomy, 387 

after-treatment of, 399 
anomalous, 394 
during pregnancy, 287 
incomplete, 394 
rejHjated, 395 
trocar, 387 
Ovary (L. ovarium, an egg kee|)er, 
from cn»um, an egg), absceso 
of, 258 
absence of, 25 1 



^^^39^1 


L ^ 


1 


^^^^^^^H 431 ■ 




Hupilloina 0! ihe vulva, 97 


adL-i>uiiiii uf, 265 


I'nrunietrilia (Gr. iro,«». beside 1 fi'/r/m. 


•Bi-chaiigts of, 35Q 


the wouib). Si-e J'rMc Cil/w 


uiaUiuiy u(, 17 


lilii, 393 


«|»plcKr of. »56 


Paroophoron (Gr. Tu/ni, betide; uov; 


■lTO|iliy iif, ^su 


p.i,.fw). analomy of, 18 


CHtdnoma of. 263 


eysU of, 269 






t) sis of. 163 


Piuuvariau cytt*. 270 


dtrinoids of, 365 


rBTovariiiDi {•lapi, beside; vvarium). 


(beplsL-emCDlsor, 251 


analumy of, iS ^^^ 


cnlwgtd. 255 


Pedicle, ligalarc of. 39I ^^^^| 


filffoiu. uf, 361 


388 ^^^H 


fibrosi* of, SS7 




hernia of, 3J2 


twisted. 275 




Pelvic abic^, 393 


multonnalions of, 351 


cellulitis, 293 


myoma of, 361 


jicritoneuiii, analouiy of. 26 




epithelial infection of, J89 


prolapse of, 354 


septic infection of, 288 






supeniumcrary. 251 


peritonitis. 18S 


lulirrculusis of, 358 


tumors, diagmais^f, 331 


lumots of, 361 


Pcrimctnlis (Gr. nc,». rtniadi /«/r,«, 


a»inl roUlioB of. 275 


the womb). 3S8 




septic. 388 


im|»clioti of, 278 


serous, 389 


lupIurE of, 376 


Perineal liody. 95 


ieplk changci in, 273 


Peiincorrh^y (Gr. ir./jiwiiw; /in»*. 


uiidciccndEd, 253 


a seam), 341 


0*ula Kabolhii [L. tvu/um, dim. of 


for complete lujiltue, 345 


OVUM, an egg), 169 


for partial ropiufc. 341 


Ovulalion. 31 




dtlicieW, 3 IS 


rounding dislticl). onalotny of. 


iheoiy. 36 


94 




repair of, 341 ^^ 


PAIK, value of. in (Uignoiis, J2I 


nii>tute 95 ^^^^H 


FkohyiterecluiDy (Gr. n-ac. total; 




lcTfpa;i,7o^).4I4 


^^^H 


rapiltoma of the Fallopian lulie, 222 


Peritoneum (Gr ra wrpiTiviuov. lit. ^^^H 


of (he ovary, 2O9 


that which is stretched over). V 


of ibe peritoneutn, 323 


See /'/hiic /•rritomeuM, 188 1 



^^nHi^^i 


432 ^^^^^1 




I'ret.'naucy, willi carcioonia uf Uw c«r- 


9c|]lic, zSS 


viv, an 


sennu. iSg 


wiih mjo™. 189 


lubercular, 291 


with ovarian tumor. 285 


Pcn-urethral cyals, IJ6 


Preparation of patieols fiir operation, 


I'uuiitics (Low L. feaatium, from Gr. 


33S. 379 


jrfiroic. ui owai-shsped slooe 


Pressure- force] J* in liyslerecloniy, 375 


for playing a fiarae like uur 


Primary scxunl cliiiadere. 49 


(IraughU; afterward a plug uf 


Procideulia of the uterus, 136 


linen, resin, elc. for vaginal 


IWapst! of the ovary, 154 


tueaicalion). 147 


of theuteni*. Ij6 


l-ataxy. Hodge, 13*, IA» 


of tbe vaginal wills, 103 


relained. 151 


Pruritus vulva;, 87 


riug. 14S 


Pseudocyesis (Gr, V«mW. false ; -«- 


vagiQal si™, ISO 


«n.C, pregnancy), 2»2 


riianlum tumor. 282 






l-utwrly (l../«<irj, youth), uiuel of, jo 


3*5 


Pulse aflet ovariotomy, 40J 


rinbok », ei 


I'yoeulpos (Or, <rwo»-, put 1 mi^.rrot, Ihc 


riacenU, reWincd portions of, 165 


vagina), 70 


tubal, Sib 


Pj-omelra (Ur. ni™; t^Tin. the 


licalraeiU of. 247 


womb), 70, 114 


ulerine. aj6 


PyosaliMnx (Gr. rwv. aa^mii. Uie 


rlacenlal polypne, »I 


Fallopian tube), 70, 317 


I'olypua (Gr. TroXt, muiyi t<*i, foot). 




cervical, 20I 




fibrmd, 201 


symptoms. 322 




Recloccle (L. rectum, tbe bowel; Gr. 


mucous. 201 


11**7. » luinot), 103 


operatmn for, 364 


Recto-vaginal fossa, analnmy of, 27 


plai'eiiul. 20[ 




I'orro'iciperiltioii, 418 


Kcnal disease, a conlraiadicaliou fat 


Kiuch of Douglas. See Kfitotmgi- 


operation, J34 


nal Fossa, 27 


tumors, diagnosis of, 184 


Preijnaiicy, comual, 196 


Ketxaitor, uterine, 157 


diagnosis uf. from nlyuma, 19J 


Retained menstrual products, 68 


diseases arising froui, l6j 


pessary, 15! 


exlra-ulerine, 229, 408 




mesomelric. 236 


RetrofleiioQ of the uterus, 129 


Dornuil. signs of, 194 


Retroveision of the uteiiis, 131 


spurious. 28» 


of the gravid uterus, I9J 


tubal, 229, 4C« 


Reversible tenacuU forceps. 369 



^ H^^^^^^l ^^^^^^^1 


H^P 433 1 


^ffienmBlbm, ■ complication of gon- 


Seasile myomala, treatment of. 364 ■ 


orthtca, llj 


ovarian cysU. tiealnient of, 1 


Kouud ligament of the ulerus. anat- 


m 1 


omy of, ao 




sboncning of, 42I 


Sbnt-and-coil BUIurea, 345 ^^^^| 


lumo'S of, 296 


Sound, 41 ^^^^1 


RuiHure of ovariau cysli, 376 


Speculum. Auvard'*, 47 ^^^H 


tubal, diogDDSis of, 141 


Cusco's, 47 ^^^H 


primatr,extra-p«ritoncal.335 


Fergusson's, ^^^^H 


intra-periloDeal, ^34 


Neugehauer-s, 47 ^^^H 




^^H 


^39 




inlra-perilODcal, 338 


384 


Uealment of, 145, 408 


Sponge-holders, 3S8 






Salpingitis (Cr. tra^wiyi, a Irumpci, 


Stenosis (Gr. <n-h«f, narrow) of the og 


Ibe Fallopian tube), aij 


extemum. 61 


nculc, 215, 214 


of the OS inlernutii, 309 


chionlc, 230, 125 


of the ostium tubx, 331 


gonocihiEal,2iS 


of the vagina, 59 


wplic, 317 


Sterility, 314 


tBbercular, 220 






Steriliier, 339 


tiunot). 3 IS. 353 






of patient during Cesarean sec- 


Sarcoma, decidual, 202 


tion, 417 


of ibr Fallopian tube, 223 




of the ovary, 363 




of the Dieras, 203 


Supernumerary ovaries, 25. 


of the vagina, 1 34 


Suppuration of Bailbolbian cysu, 


of the vulva. 97 


99 


Secondaiy sexual chatacleis, 49, 407 


of ovarian cysts, 373 


Secicliotu, normal, ill 


Suture material. 380 


pathological, 114 


Sutures, removal of, 401 


uterine, 114 


Symptoms, Taluc of, in diagnout, 318 


vagimU, .1. 


331 






Septic infection {Gr. orrruoic, putrid) 






Tamponfl, glycerin, 172. 178 


o[ ovarian tumors. 373 




of peritoneum, 288 


Tenacula forceps, reversible, 369 


of iciained incnKs, 74 


Tents, 47 


38 i 



434 



INDEX, 



Tetanus after ovariotomy, 404 
Trachelorrhaphy (Gr. r/Ki;fcXof, the 
neck, the cervix; ^x^, a 
seam)y 368 
Trendelcnbuig position, 382 
Trocar, ovariotomy, 387 
Tubal abortion, 232 
gestation, 229 

operation for, after fifth 
month, 409 
after rupture, 409 
at the time of rupture, 
408 
rupture of, primary extra- 
peritoneal, 235 
intra-peritoneal, 234 
secondary, extra-perito- 
neal, 239 
intra-peritoneal, 238 
mole, 231 
Tuberculosis of the Fallopian tube, 
220 
of the ovary, 258 
of the peritoneum, 291 
of the uterus, 179 
of the vulva, 86 
Tubo-ovarian abscess, 218 
cyst, 219 
ligament, 19 
Tulx>-uterine gestation, 239 
Tumors of the broad ligament, 296 
of the Fallopian tubes, 222 
of the mcsomctrium, 296 
of the ovarian ligament, 297 
of the ovaries, 261 
of the round ligament, 296 
of the uterus, 181 
of the vagina, 124 
of the vulva, 97, 349 
Twin tubal pregnancy, 229 
Twisted (pedicle. See Axial Rota- 
tiofiy 275 



Undescended ovaries, 252 
Ureter, injury of, 402 
Uretero- vaginal fistula, 109 
operation for, 354 
Urethra, diseases of, 93 
Urethral caruncle, 93 

operations for, 348 
Urethro-vaginal fistula, 109 

operation for, 355 
Uro-genital sinus, 51 
Uterine arteries, 24 

changes in menstruation, 34 
lymphatics, 26 
mucosa, 35, 168 
nerves, 26 
probe, 171,363 
repositor, 158 
souffle in myomata, 193 
in pregnancy, 194 
sound, 41 
veins, 25 
Utero- vesical fistula, 355 

fossa, 28 
Uterus (L. uterus^ the womb), absence 
of, 6x 
adenoma of, 207 
age-changes in, 127 
anatomy of, 19 
anteflexion of, 128 
ante version of, 128 
atrophy of, 146 
bicomis, 63 
carcinoma of, 207 
didelphys, 64 
displacements of, 128 
echinococcus colonies of, 214, 298 
epithelioma of, 206 
fibromyoma of, 1 81 
Hexions of, 128 
hypertrophy of, 141 
infantile, 61 
inflammations of, 168 • 



^^Di^C3 


^KP 435 1 


Vtatu, injuries '>f, r6o 


Vacina. slrnosis of. sg 


inrrrBionof, IS3 


lumois of. 1 24 


nieisareiiMDtsof. 127 


Vaginal Incillus. 112 


myomata of. iSl 






liystereclomy. 373 


procidenluof, 136 


myomectomy. 363 


prolapse of. 136 




relralle\ion of. 119 




relrovrnton of, 131 


in children, II9 


nidimenlBry. 61 


n. ptegnanl women. 120 


uiconu of. 202 


senile. 119 


<cplus.63 


septic, 1 19 


iiiiBlc homed. 61 


ample. Its 




Veins, ovarian. 25 


luperinvolulion of. 163 


Uterine, 25 


tuberculoRi of. 179 


vaginal, 25 


wmoniof. 181 


vulvar. 2S 


uniconiis, 63 


Vcnlrofixalioa of the uterus, 4'9 


1 


Vesical symptoms, 32J 


Vagina (L. vagina, t sbeMb). abscess 


Vesico-vaginsI fistula, 109 


of. ,24 


operation for, 352 


■UcDce of, 59 


Vestibule, 23 


■ge chauKcs in. 102 




■naloiTiy of, 20 


for operation, 334 


..«5i»0f.59,68.l22 


Volsclla. 44 


opcralion for. 357 


Vomiting after ovariotomy, 399 


eyas or. lis 


Vulva (L. PMfM. the female eMemal 


diieasesof, lo; 


genilaU), aUce«s of. &) 


displacemenU of. 103 


age-changes of, 77 


double, 60 


anatomy of, 21 


echiitococciu coioniFs of, 126 




epithelioma of, 125 


atrophy of. See A'rauraiis, 89 


lululx of. 109 


carcinoma of, 99 


foreien bodies in. 108 


congestion of, 87 


hctni« of. 107 


cysts of, 99 


infeclioQof, til 


e«emaof,85 




elephantiasis of. 86 


injuries of, 107 






erysipelas of. 83 


nonnni weietion of, 111 


gangrene of, 84 


sarcoma of, 124 






herpes of, 85 



436 



INDEX. 



Vulva, hypertrophy of, 78 
inflammation of, 80 
injuries of, 79 
irritation of, 87 
kraurosis of, 89 
lipoma of, 97 
lupus of, 86 
malformations of, 49 
myxomata of, 97 
oedema of, 83 
papillomata of, 97 
sarcomata of, 97 
syphilis of, 86 



Vulva, tuberculosis of. See Lupus, 
86 

tumors of, 97 

varix of, 79 

warts of, 97 
Vulvitis, gonorrl^oeal, 81 

pruriginosa, 88 

simple, 81 
Vulvo-vaginitis in children, 1 19 

Wolffian body. See Mtsahrphros, 

duct. See Mesonepkric Duct, 5 1 






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I of engraving have enabled the publisher lo produce illustrations which U is 
ilieved are superior lo those in any similar work. 



COHTBIBITTOB 



r. Chirki H. fiimwll. PhilaMphi 
FhiBCH S. Conner, (.-indniuli. 
Frtdirie S. Dennri^iw Vnrli. 



Lewi. S. Pilchr: 



. Hlladelphi- 

:de, AnnArbar. Ukh- 

lEilo. K. Y. 

Sew Vork. 

i»k ii ■ fmir tttcx oF iIh pRient ntwllloa of A 
rr h>Eh O'ltcr or oieril. ind thai Kngllili «Ltip» 
lureti If ihcy art la prscrvc > poaidon In (he n 



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PRACTICE OF MEDICINE. By Amencan Tcuchcis. EdUed 
by William Pepper, M. D., LL.D., Provosi and Professor ot ihe Theory 
and Proclice of Medicine and of Clinical Medicine in ihe Uiiivei^ly of 
PennsylvanuL, Complele in Iwo honilsome royal-octavu volumes a\ about 
looo pages each, wilb illustralions la elucidate Ibetext irhercver necessary. 
Price per Volume : Cloih, f J.oo net ; Slieep or IlaJf-iyirjiDCcu, fhao neL 

TOLKME 1. COSTAlMSt 



AND I 



HyiienE.— Feven <Ep)Mmanl, Simple Con- 
llniw J. TrphiB. Typhgid. Epidemic Ccrcbro 
fci^iu] McniUHiiU. luad RflUpdlu}.— ScdHa- 
lina, Meulu, RSihdn. Vinulu, Variolnid, 
V.icaalA,Varicc]U, Mumitb.WhDoplnc-conghj 

TOLWHE II. 

UriM (Chcmislr/ and MicroKnpyJ.-Kid. I 
ncy and Lun»,^Air-pa>A«£ci {Lacynt ftnd 
Biunchilind Pleun.— Fharynll.tEiDpliaBiil. 
Stomach und InlatisH liodudmg IniaJiul 
Pua>lt«), Hart, Kan».. Arurla And Veini. { 



i«»iij, Clinden, and Timniu.— 1 
uii. ScroTuLi. Syphllii, Diphtherii, ] 
B, Mllarll, Cfiolen, uuTVelldw J 
fervvu. MuscuJir, ud Mental Diie 



ncluding 



I 



tion, Symptomatology, Diagnosis, Prognosis, and Trealmcnl, including 
■ ' ' The rcc ■ - ' - - - ' '- "- 

s diseases 



fully described, a> well as the 
eniion and cute. The suhjecB 
e fully considered in a s^anle 



of the bacterial origin of t 

bearing of Ihe linowledge so gainea upon pre 

of Bacteriology as a whole and of Immunity n 

Methods of diagnosis are given ihe most raJnule and rarcful ai 
enabling the leader to learn the very latest methods of investigation without 
consulting works t)>ecia11y devoted to the subject. 



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Dr. 1.5 Billine!. Philithlphii. 
Fiancii DcfutieJd, Nc. Votk. 
KegrnaldH. Fid. Botion. 
J.ina W. Kolliind. PhilidcIpU 
HtOT M. LymAo, ChiCMO. 
WilUui Oiler, BAlUmore. 
■' We TCTieired ihe Bnt m\ytn>r. oF i 

S^in "n, thHct gf ?^"i' 
.ecuniie .t.d tlar. 1. » * 

" A Iruity counRcllar for 



-, Wllli^im Pepper. PbllAdelphJA. 
W CiilmAnVhomiwid. New York. 

Jura T. WhflUker. CinchinUl. 
JuH* C. WilwB, PhUtddpM*. 
Honiid C. WiwiC PhllAdelpiaa. 



» i>ei h. . 
.lien, well Ar 



eil-1)ool( ihmild be-" — Htm K 



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One decided innovation is Ibe large number of aulhon, ncaily every article 
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Dr. S. S. Adinn. WMhIngI 
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A. D. Blackadii. Mdm 
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Chula W. BuiT. nila 
W. E. - ■ 



I 

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F. Cnrrier New Vofk. 



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Ralua u. uinio, rniisittipiRa 
j. H. DaOalB. ?Mbddpbu>. 
1. N. Oaabith. Chlcaao. 
tdvaid P. Divii, Philailflphli. 
Jaha B. Dnvcr, Philnddphla. 
13 E. dc Schwiinid, Phil«ld(.ht 
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Chirla Witringinn ILirle, Qua 



GriSi^. Phiiidelphli. 



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tP. Cww GriSi^. PI 
. A. [Urduny. Si. L 
M. P Hatftdd, Cbicue 
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I. Willlain While, PhUadelphTi. 

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AN AMERICAN TEXT-BOOK OF GYNECOLOGY. MEDICAL 
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cuss mooted points, still ihe n 
plained. The operations reci 
having a picture of the procedi 
10 gissp the iilea. "' 



description*, eicepting (hose essential lo s dear 
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E. E. MwiUDineni, 
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"ThemMinoublec 



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MEDICAL DIAGNOSIS. By Dr. Oswald Vilrordt, Professor of4 

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DISEASES OF THE EYE. A Handbook of Ophthalmic Practice 
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THE PICTORIAL ATLAS OF SKIN DISEASES AMD SYPHI- 
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CATALOGUE OF MEDICAL WORKS. 



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ESSENTIALS OF ANATOMY AND MANUAL OP PRACTI- 
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^.■•~Jc,rn^rfAm.r, 



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, A MANUAL OF PRACTICE OP MEDICINE. By A. A. Stevens. 

A. M., M. D., Instructor of Physical Diagnosis in the University of Penn- 
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12 IV. B- SAUNDERS 

MANUAL OP MATERIA MEDICA AND THERAPEUTICS 

By A. A. Stevens, A. M., M. D„ Instruclor of Physical Dingnosis ii> 
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T, the book it ndii 
■nd il will be IbuiHl ■ relinUc guide."— UniB€riUj Mrdical Maf^v" 



NOTES ON THE NEWER REMEDIES: their Therapeuiic Ap- 
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SECOND EDITION, BB-WRITTEN AND QBEATLY ENLAAQED. 

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■ CATA 



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t 



CATALOGUE Of MEDICAL WORKS. 13 

SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of 
TerniB and Words used in Medicine and Surgery. By John M. 
KtAiiM;. M. D., eililor uf " Cyclofscdia of Diseases of Chiidieo,- etc.; 
aiiUiur u! llie "New Pmuouncmg Dictionaiy uf MedicinE; and Henkv 
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by Ihcir DOl containing the hundreds of new words now used in carrenl liten- 

e, especially those lelaliiig to Electricity and Bactetioli^y. 

iarV.biyKcuraKmKnBinoli«y.Mceblu*aou,addd.fiDiiion,"— y™™j/«^-l«K7^ 



" fiiief. yd cooblcle . . . . ir CDItUiitt ihc vtry latctl □ 
pulmenb ef mediciuc."— ,Mw York MtdksU SKtr-d. 



I SAUNDBRS' POCKET MEDICAL FORMULARY. By WtUJAU 

M. Powell, M. D., Allendinfi Physician 10 llie Mercer House for Invalid 
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tDiamcIera of the Pemsle Pelvis and Fecial Head, Obslelrical Table. Diet 
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with side index, wallet, and flap. Price, tl.75 net. 
A concise, clear, and correct record of ihe many hundreds of famous formnUe 
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14 W B. SAUNDERS 

DISEASES OF WOMEN. B; Henry J. Uarbigues, A.M.. H.D. 

Professor of Utslelrics in Ihc New York Pcel-Craduale Medical School 
and llus|>iuli Gynecologist la Si. Mark's Hospital and lo Ihe Cetman 
Dispensary, clc, New Vork City. In one very handsome oclavo ta 
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A PRACTICAL work on gynecology for the use of students and pranitionen, 
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the author, and cansid«able space has been devoted to the subject. The chiq>- 
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upon Ihc large hospital and private practice of the anthor. The text is eluci- 
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BXOEBPT OP OOMTEMTS. 

Devclotuntot of ib< Fcnule GcnluU.— Annldmy of ihe FebijiW Pdvic Oroni— PliTh 
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MFmlruatian and Mctronhiiii.— Lcucnrrhea— Ditcuo of the Vulia.— Diwaia nf the 



— Dlif^sH 



II Oviriej.— DisKuti of the Pel. 



Tbe rsccptloa acccirded ts thia 
peilod whieb bas elapuil alnee it* 
a* a leat.baok by more than Bo of 
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work haa beta m 
iHue it bai been 
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at Hanarlog. In th 
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A SYLLABUS OF GYNECOLOGY, arranged in conformity with 
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room, as the subject is presented in a mnnnet at once systematic, clear, lucdncl. 
and practical. 



CATALOGUE OF MEDICAL WORKS. 



OUTLINES OF OBSTETRICS; A Syllabus of Lectures Deliv- 
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reference. 



Lanlyhuilbnan 
trUt. New York. 



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SYLLABUS OF OBSTETRICAL LECTURES in the Medical 
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TEXT-BOOK UPON THE PATHOOENIC BACTERIA. Speciallr 

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CATALOGUE OF MEDICAL H'ORKS. \f 

HOW TO EXAMINE FOR LIFE INSURANCE. By John H. 
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tURSINO: ITS PRINCIPLES AND PRACTICE. By Isabu. 
AdaMJ flAMrroK, Graduate of the New York Training School for 
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PRACTICAL POINTS IN NURSING. For Nurses in Privmle 
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THE CARE OF THE BABY. By J. P. CRtwER Grifpith, M. D.. 

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umo. Piice. Ji.so. 



praclilione 

THE NURSE'S DICTIONARY of Medical Terms and Nursing 
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DIET LISTS AND SICK-ROOM DIETARY. By Jekome B.Thomas, 
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DIETS FOR INFANTS AND CHILDREN IN HEALTH AND 
IN DISEASE, hv LoLis Starr, M. D., Editor of ■■ Kt, Amct 

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NERVOUS DISEASES. By Charlks W. Burr, M. D., Qinical Pro- 
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HZOl Bland-Sutton, J. 16847 
B642 The diseases of nomen, 
1897