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DISEASES OF WOMEN: 



A TREATISE ON THE PRINCIPLES AND PRACTICE 



GYNECOLOGY. 



FOR STUDENTS AND PRACTITIONERS. 



BY 

E. C. DUDLEY, A.M., M.D., 

PBOr&SOR OF GYNECOIXXiY, NORTHWESTERN UNIVERSITY MEDICAL SCHOOL; QYNECOLOOIST TO 

ST. LUKE'S HOSPITAL, CHICAGO; FELLOW OF THE AMERICAN GYNECOLOGICAL ABSOaATION ; 

CORRESPONDING MEMBER OF THE SOCI^Tfe OBST£tRICALE ET GYN£C0L0GIQU£ DE 

PARIS; FELLOW OF THE BRITISH GYNECOLOGICAL SOCIETY; ONE OF THE 

FOUNDERS OF THE CONGRfeS PfeRIODIQUE INTERNATIONAL DE 

GYNtCOIXKJIE ET D'OBST^TRIQUE ; EX-PRESIDENT OF 

THE CHICAGO GYNECOLO<;iCAL SOCIETY. 



SECOND EDITION, REVISED AND ENLARGED. 



WITH 453 ILLUSTRATIONS OF WHICH 47 ARE IN COLORS AND 
8 FULL-PAGE PLATES IN COLORS AND MONOCKHOAflE.-, 




LEA BROTHERS & CO., 

PHILADELPHIA AND NEW YORK. 



COPYRIGHT, 1899, 
By lea brothers & COMPANY. 



* • ••• 



wMTodrr a. Thomson, 

fLCOTROTVMfW. PHILADA. 



MiiM or 

WILLIAM «!. DOMNAN. PHILADA. 






IT HAS BEEN THE AUTHOR'S AIM TO BE A WORTHY PUPIL 



THOMAS ADDIS EMMET, 



THIS BOOK IS AFFECTIONATELY DEDICATED. 



-w>. ^v«iu^ * iiMt< xhIy is of all other things in 

. ,>^>^N3iy»iJiii •* nwieJT; but then that remedy 

«^ .:^^*.».>* * inve. FcftT the same Bubtility of the 

»^ :««a^ jkic^ puwihilitr and easy failing ; and 

^.4.« <Ai is«ur.<k j«h:^I to be the more exact.*' 

'X*>fa- !tAC\*s, iu the Second Book of the Projicienee and 
.iif^metment of Learning, 



PREFACE TO THE SECOND EDITION. 



A FULL statement of the plan and sc^ope of this book will be 
foiim] in the preface to the first edition. In that edition a stren- 
uous attempt was made entirely to avoid speculative and theoretical 
discussion, and to set forth, from what was known, 8uch definite 
material as would be of ^reatent immediate helj) to the student and 
practitioner* The second edition necessarily retains, therefore, most 
af the ^nbjeet-matter of the first. In order, however, to secure 

[greater accuracy and completeness, a nundier of changes and addi- 
tions have been made. The ftmctioual disorders of menstruation 
and sterility, although recognii^ed only as symptoms, and as such 
discussed on many piiges wherever they occur as results of disease, 
liave, for convenience of reference, been skelcttmized and brought 

I together into four new chapti^rs : Chapter LI., on Premature 
Menstruation, Prot meted Menstraatioii, Amenorrhoea, and Scanty 

r Menstruation ; Chapter LII.^ on Meni>rrhagia and Metrorrhagia ; 
Chapter UIL, on Dysmenorrhtpa ; and Chapter LI V., on Sterility- 
These cliapters constitute an entirely new part of the book, Part VI. 
To emphasize the causal relations of many diseases to the disorders 
of menstruation and sterility, to avoid needless repetition, and to 

I secure compactness and co-onliuation of the text, much that 
pertains to the subjcr^ts of Part VL is referred to tlie chapters 
that sp<^cially treat of the tniusal disi'ases. Other chapters, notably 
ihoi^ on Cystitis and Diagnosis, contain much new matter. Every 
chapter and nearly every page will stiow evidence of revision, 
either verlial or essential. By numerous changes in words and 
phranes, and by the expansion, rearrangement* or rewriting of 
many paragraphs, I have tried to add eh^arncss and force to tlie 
text. Seventy-eight pages of reading-matter, thirty-one 



osir?9 




e PREFACE TO THE SECOND EDITION. 

lions, most of them specially drawn for the book, and six fuU- 
puge plates have been added. 

A pronounced feature of the first edition consisted in the grouping 
of subjects, not by the more common regional method, but, so far as 
jK>ssible, from the standpoint of pathological and etiological sequence. 
The student, it was thought, would, under such a plan, more easily 
recognize and proiHirly emphasize the functional unity of all the 
reproductive organs ; would study the various pelvic disorders in the 
combined forms which they ordinarily assume; and would more 
readily, therefort*, grasp the significance of morbid processes and the 
pnictic4il relations of these pn)ces8es in one another. This arrange- 
ment of subjects has, almost without exception, called forth the 
unqualified approval of n»viewers, teachers, and students, and is 
tliert»f()ro retained in the present edition. 

In sending forth this volume, I wish to place on record my 
earnest appreciation of the rec*eption acconled to the first edition 
when it was given to the profession a year ago. 

E. C. D. 

lf.17 Indiana Aventje, Chicago. 
December, 1899. 



PREFACE TO THE FIRST EDITION. 



This hook is designed to be a pmctieal tre^ti^?e un gynecology, ihv 
the use of pmetitionerH and students ; to contain the most uppmved 
precepts in prkiciples and praetiee ; and tu exclude whatever m nc>t 
based niM>n pathoh>gy or carefully ohst»rved expi'rienee. If any them- 
pcrutic measures of viilne have nut heeu fully pri-seuti^'tl, a justifieation 
may he found in the authors eucleavur to make tlie tt^\t direct and 
clear by the selection of th**^* measures which, in liis judgment, are 
most uaefid. 

The autonomy of each patliologieal pnx^ess as it may conseeutively 
affect the different pelvic orgjms has been lus far as p4jssihle preserved 
by the division of the work, not into the usual chajiters, eat*ii treating 
of the diverse disease.*^ of a i^peeial oi^au, hut rather un [>athoh»gieal 
lines into fivepirt^*, as follows: L, General Principles; II., Inflam- 
mations; HI,, Tumors, Malformations, and Tul)al Pregnancy; IV., 
Traumatisms; V., Displacements and Pelvic Massage, By this classi- 
fication, rather pathologiciil than ivgional, it is Impeel that the reader, 
especially in the part on Inflammations, will gain a better grasp of 
the sequence and significiince of each pathological process. The 
student will have a mucli more rutifmal and comprehensive idea, for 
instance, of metritis by ch>scly assiwiating it with vulvo- vaginitis, 
salpingitis, ovaritis, and jieritonitis, than by regarding it as a distinct 
and independent lesion. If the utcnis were considered regionally, on 
the other hand, tumors, traumatisms, and other diseases would l>e 
thrown in between uterine infections ami causal or resultant infec- 
tions in other parts of the pelvis, aufl tlnis a most instnietive rela- 
tionship would be ohsfMired. Tin- assoriatiim of Tubal Pregnancv 
with New Growths in Fart III., although not essentially on pitho- 
logical grounds, is yet convenient from the standpoint i»f diagnosis. 

Etiological sequence has also been observed ; for exam^^l" T>is- 



8 



PREFACE TO THE FIUb'T EDITION. 



placements result fmni Inflammations, Tumors, and Tniiimatbms, 
and are therefore plaeed after tlit'ni. 

In order to give clearnesa and brevity to the text, and to bring 
out im[K>rtant distinctions with foree, illustrations in an unusual 
number, and largely fn>ra original drawings, have been introdueeil. 
Speeial eare has been taken in the pre|)anUiou of the new and full 
illustrations in Perineorrhaphy, Lacerations of the Cervix, and 
Ve^ieo- vaginal Fistula, and of the many colored illustrations in 
the parts ou Tumors autl Displacements, 

In Chaptei^ IV. and XVII. an eflbrt has been made to indieate 
the value of niutine topical apiTlicatinns, nueh as are eommonly and 
extensively euj ployed in ollicc praetice, to rt^strict the amount of 
meddlesome and injurious local treatment to whieh the reproductive 
organs ar*' uften subjeetetl, and to rt*ter those cases whieli do not 
n?quire l<«*al treatment U* the wiiler field of internal metlieine or 
surgery. 

Since dysmenorrhtea, ameni*rrlMea, mennrrhagia, and sterility are 
only synipt(jms, and not diseases, and must, theiTfore, always be con- 
sidered from the standpnint *if tlie multiform affections which He 
back of them, and since these functional disorders are discussed on 
many pages, whcrevtT they occur as symptom.^ of tlisease, it has \tvvu 
deemed proper to depart from the usual plan of eollceting them into 
a separate chapter; accord i ugly » th** reader is referred for the consid- 
eration of those subjects to the index. 

The relations of dress to the health and diseases of women are of 
so much im|Mirtauee that tl*e aiitbor has ventured to summarise them 
in a sepanitc chapter— (liapti-r IX. 

Pelvic Massage after the Brandt methml is set forth in the closing 
chapter, as a snpplenient to the tivatment of Displacements. The 
various manipulations, shown in a series c»f nineteen illustrations, 
ajKirt from any thenipeutic value which they may have, are sf>eeially 
useful as a means nf diagnosis and for the reduction of displace- 
ments. 

Quotations, abstracts, adaptations, and illustrations, when taken 
from other works arc credited in foot-notes giving Imth the authors' 
names and tlic books consulted. The writer has not intentionally at 



PREFACE TO THE FIRST EDITION. 9 

any time omitted to give credit for the work of others except when 
the matter was so familiar as to have passed into the realm of com- 
mon knowledge. 

Much credit is due to Miss Mary L. Rue and Mr. H. F. Andrews 
for the preliminary sketches of a large number of the new illustra- 
tions. Dr. H. M. Bannister, in many parts of the book, and Dr. 
Palmer Findley, in the part on Tumors, have rendered valuable ser- 
vice by making numerous abstracts from the literature ; from these 
al)stracts considerable material has been selected and rewritten in the 
preparation of the text. Acknowledgment is also gratefully made 
to Dr. Daniel Eisendrath for critical proof-reading and valuable 
.^suggestions in Parts II. and III. 

The author desires to record his appreciation of the uniform 
courtesy and liberality which the publishers have shown in their 
part of the work. 

July. 1898. 



CONTENTS. 

PART I. 

GENERAL PRINCIPLES. 

CHAPTER I. 

PAGE 

THE PHYSIOLOGICAL PERIODS IN THE LIFE OF WOMAN 17 

CHAPTER II. 
ANTISEPTICS. ASEPSIS 25 

CHAPTER III. 
DIAGNOSIS 49 

CHAPTER IV. 
LOCAL TREATMENT 89 

CHAPTER V. 
MINOR OPERATIONS 95 

CHAPTER VL 
MAJOR OPERATIONS 115 

CHAPTER VII. 
DRAINAGE IN MAJOR OPERATIONS 128 

CHAPTER VIIL 
AFTER-TREATMENT IN MAJOR OPERATIONS 136 

CHAPTER IX. 

THE RELATIONS OF DRESS TO THE DISEASES OF WOMEN 146 

11 



12 CONTENTS. 

PART II. 

INFECTIOUS INFLAMMATIONS AND ALLIED 
DISORDERS. 

CHAPTER X. 

PAGK 

INFECTION AND INFLAMMATION OF THE REPRODUCTIVE ORGANS . 153 

CHAPTER XI. 

VULVITIS. VULVO- VAGINITIS, VAGINITIS 162 

CHAPTER XII. 

ECZEMA VULV^ HERPES VULV-^:, KRAUROSIS VULVAE, PRURITUS 
VULV^ HYPERiESTHESIA VULVAE, VAGINISMUS 179 

CHAPTER Xin. 
INFLAMMATION OF THE UTERUS 188 

CHAPTER XIV. 
ACUTE METRITIS 193 

CHAPTER XV. 

CHRONIC METRITIS . . 202 

CHAPTER XVL 
(IIRONIC ENDOCERVICITIS 204 

CHAPTER XVII. 

CHRONIC ENDOMETRITIS 210 

CHAPTER XVIIL 
CHRONIC MYOMETRITIS 229 

CHAPTER XIX. 
PELVIC INFLAMMATION 232 



CHAPTER XX. 
PELVIC CELLULITIS 240 

CHAPTER XXL 

INFLAMMATION OF THE UTERINE A PPEN DAG F*S- 8 ALPINOITIS, OVAR- 
ITIS, PELVIC PERITONITIS 248 



CONTENTS. 13 

CHAPTER XXII. 

PAOB 

SYMPTOMS, DIAGNOSIS, AND PKOONOSIS OF SALPINGITIS, OVARITIS, 

AND PELVIC PERITONITIS 259 

CHAPTER XXIII. 
TBEATMENTOFSALPINGITIS, OVARITIS, AND PELVIC PERITONITIS. . 267 

CHAPTER XXIV. 

URETHRITI8-PR0LAPSE OF THE URETHRA— SUBURETHRAL ABSCESS- 
CYSTITIS— PYELITIS 298 



PART III. 

TUMORS, TUBAL PREGNANCY, AND MALFORMA- 
TIONS. 

CHAPTER XXV. 
TUMORS OF THE VULVA AND VAGINA 319 

CHAPTER XXVI. 
TUMORS OF THE UTERUS— ETIOLOGY, HISTOLOGY, SYMPTOMS, DIAG- 
NOSIS. AND PROGNOSIS OF MYOMA 329 

CHAPTER XXVII. 
TUMORS OF THE UTERUS— TREATMENT OF MYOMA 344 

CHAPTER XXVIII. 
TUMORS OF THE UTERUS— BENIGN ADENOMA 365 

CHAPTER XXIX. 
TUMORS OF THE UTERUS— CARCINOMA 369 

CHAPTER XXX. 
TUMORS OF THE UTERUS— SARCOMA AND DECIDUOMA MALIGNUM . . 389 

CHAPTER XXXI. 
SOLID TUMORS OF THE OVARY 396 

CHAPTER XXXII. 
CLASSIFICATION AND PATHOLOGY OF OOPHOROTIC CYSTS AND PAR- 
05PHOROTIC cysts. PAROVARIAN CYSTS. AND OVARIAN HYDRO- 
CELE 398 



14 CONTENTS, 

CHAFfER XXXIII. 

FAGE 

SECX)NDARY CHANGES— SYMPTOMATOLOGY, DIAGNOSIS AND DIFFER- 
ENTIAL DIAGNOSIS OF OVARIAN AND PAROVARIAN CYSTS ... 409 

CHAPTER XXXIV. 

OVARIOTOMY 428 

CHAPTER XXXV. 

TUMORS OF THE FALLOPIAN TUBES, BROAD LIGAMENTS, ROUND LIGA- 
MENTS, AND URINARY ORGANS 434 

CHAPTER XXXVI. 

TUBAL PREGNANCY 439 

CHAPTER XXXVII. 

CONGENITAL MALFORMATIONS 454 

CHAPTER XXXVIII. 
CX)NGENITAL GYNATRESIA WITH RETAINED MENSTRUAL FLUID. . . 474 



PART IV. 

TRAUMATISMS. 

CHAPTER XXXIX. 

NON-PrEKPEKAL INJURIES TO THE VULVA, VAGINA, AND CERVIX 

UTERI .... 481 

CHAPTER XL. 
THE PERINEUM AND PERINEAL REGION 482 

(^HAPTEK XLI. 
PERLNEORRHAPHY 490 

CHAPTER XLIL 
PUERPERAL L.\CERATION OF THE CERVIX UTERI 510 

CHAPTER XLIIL 
GENITAL FISTULiE 53T 



CONTENTS. 16 

PART V. 

DISPLACEMENTS OF THE UTERUS AND OTHER 
PELVIC ORGANS. MASSAGE. 

CHAPTER XLIV. 

PApE 

DISPLACEMENTS OF THE UTERUS 563 

CHAPTER XLV. 
MALr LOCATIONS OF THE UTERUS 571 

CHAPTER XLVI. 
RETROVERSION AND RETROFLEXION 501 

CHAPTER XLVII. 
TREATMENT OF RETROVERSION AND RETROFLEXION 597 

CHAPTER XLVIII. 
ANTERIOR MALPOSITIONS. ANTEVERSION AND ANTEFLEXION .... 622 

CHAPTER XLIX. 
INVERSION OF THE UTERUS. HERNIA OF T?E UTERUS AND OVARY . 639 

CHAPTER L. 

MASSAGE 654 



PART VI. 
DISORDERS OF MENSTRUATION AND STERILITY. 

CHAPTER LI. 
PREMATURE MENSTRUATION. PROTRACTED MENSTRUATION. AMEN- 
ORRHCEA. SCANTY MENSTRUATION GT7 

CHAPTER LII. 
MENORRHAGIA AND METRORRHAGIA 683 

CHAPTER Lin. 
DYSMENORRHCEA 688 

CHAPTER LIV. 
STERILITY 691 



PART I. 
GENERAL PRINCIPLES. 



CHAPTER I. 

THE PHYSIOLOGICAL PERIODS IN THE LIFE OF WOMAN. 

The development from infancy to maturity and the decline from 
maturity to senility are common alike to man and to woman. In 
man the anatomical and physiological changes from the time of birth 
to the period of youth and virility and the cessation of sexual power 
in old age are gradual and even processes, free from special outlay of 
energy, unmarked by critical periods, and uncomplicated by nervous 
or mental disturbance. In woman these transition-periods are char- 
acterized by great expenditure of energy, by rapid sexual change, 
and by distinct nervous and psychic phenomena ; they are the criti- 
cal turning-points in her life. At the first crisis the reproductive 
organs, more complicated than those of the male and hitherto in- 
active, suddenly become the centre of great and rapid development ; 
from this j)eri<Kl forward until the second and final crisis her vital 
forces arc es|>ecially subject to the exactions of menstruation and 
maternity. The diffenMice of the sexes^ in early infancy has a poten- 
tial siirniticance only; as maturity approaches the lines diverge; as 
childhrMxl recedes they are wide apart ; finally in old age they draw to- 
gether until, in the second childhood as in the first, they again coincide. 

The life of woman may be divided into five j)eriods, each corre- 
sponding to a sjK^cial phase of her sexual existence ; they are infancy, 
puberty, maturity, tlie menopause, and senility. 

Infancy. 

Infancy includes the first ten or twelve years of life, and, although 
a j)eri(Kl of great pathological significance, is rather a subject of ptedi- 
atries than of gyne('(>logy. During this j)eriod the reproductive 
org-ans are, for the most part, functionally dormant ; they are under- 
going a gradual development ])reparat(>ry to the more rapid and 
radical changes of puberty. Malformations and inflammations occa- 
sionally observed in infancy will be described elsewhere. 

Puberty. 

Puberty is the period in which the child becomes the woman ; 
like the menojxiuse, it is a critical transition-period ; upon its normal 

» Edward H. Clark. Sex in Education. 
2 17 



18 



GENERAL PRINCIPLES. 



courHe depondrt innrh of the after-health, comfort, and usefulness of 
th(* imlividiml ; its influeoees are fiitKlameiitnl, not i>nlv in the re]in»- 
ductive (>r|»iHis, Imt in i\w entire woman. Pulierty hiis hotli an anti- 
tuinicml jmd u jiliyj^iulogieal l)asis. 

The Anatomical BaBis of piiherty is the fidl ph}\sieal dtn'elop- 
nient of the reprndnetive orginis. The infiintile ntenis is small, soft, 
and |)kLsti^^ ; it varir;? in size from that of early iniimcy (Fi^un^ 1) to 
thitt of the ehihl-ulerus just befoiv puberty ; at tlie hrginning of 



TUBE 



Fn^riiK I. 
UTERUS 



OVARY 



FRINGES 



CERVIX 



Utenui, FttUopInn tube** and ovarie* of an Infknt one month old. Natural alaj*> 

puberty its canal would, perhaps, measure two inehes ; when folly 
devetojKHl at the en<l of pulwrty the lont^th is two and ont^-half 
inrhes. Sinnlar eliangi's oeenr in thi^ ovaries and in tlie otlu'i' p-iiilal 
( ) i'jra n s . P n 1 *e r ty i s a I so m ; i r k e ( I I »y e u 1 a rge m 1. 1 1 1 of the j m ' 1 v i s , b v 1 1 1 v 
ajipeanuiee of hair m\ the nmu.s veneris and elsewhere, by a general 
ronutliug of the form ^vitli adijMXse tissue, ami by notable psychie 
eliangp-.. 

The Physio loerical Features of piil)erty art* the appearanee fif 
menstruation and ovulation ; they indieatr tliat tlu' sexual nervous 
organization is a}>prr»aehiug that maturity whit-h rt^ndcrs tlie woman 
capable of prwreatiou. 

Menstruiition is ehanu-terized liy a bloody, mncoiis distdiarge eon- 
hiiuing epillu'lial cells and lymph eorpnscles ; it mrnrs at regular in- 
terval unk'ss intcrrupled by uteni-gestati«m and hietation, or by 
disease or by the menopause ; it is the physiologit*al event of a peri- 
o4lieal n^rurrent development in the nulometrium, tlu' event of an 
organie r*yele in tlie sexual life. It first appears, on the avenige, 
about tlie fonrteeuth or fifteenth year, souietiuies as early as the ninth 
or tenth, and r»«^cnisi(mally ur^t until after the eigliteenth. Instaiic*€\s 
have bef»n reeordefl in which apparent sexual maturity ocTunvd as 
earlv as the fourth or filth vear ; it eouies as a rule earlii-r iii warm 
and later in f«»Id el i males, Karly menstri»atit>n is often followeil by 
late lueuopause. The hunuin nn^n-trual eyele *'i»ver^ a periiwl of about 
twenty-i^ight days; the flow <'outinues normally \v*mi three to seven 
days. The avenigi* am<ninl during this time is fi*oin four to five ounces. 
Painful nieustruation is always protvf of some pathnlogic*al condition* 
The fiornuil flow i^ preee^led by a sensiition of weight in the pelviis, 
t UlaM SutUrn. Surgical DlacaMs of Uie Ovaries ami FaU<it»lati TuImi*. t^. :tl , 



THE PHYSWLOOICAL PEBIODS IN THE LIFE OF WOMAN. 19 



The utility and pliysiulogy of mi-nstniation have bceo the sniijcct 
of many stmuge stipurstitioos and s{x'i'iilutions. Nothing is known 
of iti? cause or i^ignifii^nce. Even the clianges vvliit^-h the endome- 
trium undergoes dnriug menstrnatiou are t^till the siil>ji'et of speeida- 
tiou and of diverse opinions. One siiys that the ern-poreul mncosii is 
i?tripjx*d otf elear to the nuiseular layer at eatth reeurring tlow ; 
another, that only the epithelial layer i.s slu^l ; another, that a newly 
organize<l ti.^sue ia developed in the intcrnienf^trual jieriod, and that 
thi;? ah-Uie is ca>^t ii6\ Clearly such conilicting opinions cannot l>a 
rt*conciled. 

Bland Sutton ^ made a series of observations on the endometrium 
of monkeys and hahoous, on the Fallopian tiiljes of women whieh 
ha*l U^Mi re mo veil during mtustriiati^ai, and on the uteri of women 
who had died during menstruation. His eonrhisiou was: *^Iu 
the human uterus the destruetive ehunge is limited to the epithe- 
lium, and it is doulitful if fhis eliauge occurs under normal eiindi* 
tions." 

Arthur W. Johnstone, of Cincinnati, who has studied with h'nses 
of very high power tlie endometrium in its menstrual phases, has a 
rheorv that the uturine mucosa is an adeuuid struetiire like the tonsils, 
the thyroid body, thymus glands, lymphatic glands, and lymph tis- 
sues in the walls of the intestine. He says that the essential cells of 
the en<lometrium originate as most minute eorpusculargninules, which 
e^iu ]»e observeil mdy with vptv jiowert'ul lenses antl nuder the most 
tavorable atmospheric eonditiouh* These eorpuseular lymph grannies 
develop not by segmentation, but by gradation into mature t^ells, and 
ft»rm the emlometrium. If pregnancy orxnir, they contribute to the 
formation of the ]»laeentii; otlicrwise they j>erio<lie4dly <Iegenemte and 
are washcnl away with each reeurring menstrnatitju. Tliis theory is 
most ingi'uious^ and serves to account for many of the phenomena i»f 
menstruation and gestation ; it lias ut»t yet, however, received full 
confirmation. 

Ovulation involves the maturing of tlie Graafian follicle, it.s rupt- 
are, and the escape of the ovnm. Until rewntly, menstruation has 
'been thought to bean external manifcsta- 
li<ui uf" ovulation ami dtpeutlcnt u[H>n it; 
but wliatevcr may be the relation Ijetweeu 
these two fuut-tions, that of cause and 
eifeet is no longer tenable, bccmise, first, 
tliere is a regular i>erifHlicily in the men- 
strual cycle, and tfiere is n*j such eyelifal 
regularity in the maturingof the (iniafian 
"follicle and tlie dist-barge »>f the ovum ; 
this pnxTss is continuous, and occurs 
even in the maituiT firtus ; second, men- 
struation sometimes continucH after re- 
moval of the ovaries. There is, howevtT, 
reason to eoiu-ludc that uvidatiijii and 
menstruation are lioth under the cun trol of the same nerve appa- 

' H1iin«i Kutt«m t^UFKioal Otju^oBii* nf itu* Ovnrlef* iiiid Kallupiao Tube*. 



Fjqi'RE 2. 



':f'i 



,M 



Section of (ivftrY+showini 
uf tiva. Natural a 



a HpLTjliiK 



20 



G ENEMA L PniNClPLKS, 



ratus, and that the nerves of the uterus and ovaries have a certain 

co-ortriuatioiK 

Although the apjwarance of inenstniatioii indiciites that maternity 
is poi^sible^ it hx net itiean?^ foUows that the development of the indi- 
viihuil is eoJn|*Iete iit this time, nor tliat she is eajwibleof fu!tillin|2: the 
recjtiirements tjf nmteniity. Until iiboiit the twentieth year tlie ner- 
vtMjs system is uiieijnal to the stmin uf ehihl-bearing iind ehi Id-rear- 
ing ; the muscles are inadequate to the earryjng and expulsion of the 
child ; and the pelvis is often too small to give it safe exit. The 
periixi of puberty should, tliereforc» he taken as; extending not only 
over the few months re(|uired for the establishment of menstruation^ l»ut 
always as ineluding the time neeessary for lull physieai deveh*nrnent. 
During this jx^riod the energy of the girl is taxed by the rapidity of 
the sexual development, by tlie great liability to circulatory dis- 
turbances, by the physical and mental strain of education, and by the 
conventionalitit*s of society, which may recjuire injurious changes in 
dress and jKTSoual hat)it>. The neees^ity, therefore, fur great care is 
apfxirent. Nutritious and simple diet, frequent rest, moderate amuse- 
ments, and adequate exercise are essential. Study, esjx'eially iluring 
menstruation, shouki never be pressed to the point of ihtigue. Inas* 
much a."^ passional life now begins, and the whole nervous organiza- 
tion is therefore subject to new impulst»s and requirements, reading 
and assoc^iations sh<ndd he earei'ully si'lected, and should exclude 
whatever may unduly excite the emotions. Errors coinnnttcd now 
may leave impressions which can never be effaced and may have 
grave consequenees. Mahuitrition, psychoses, sterility, menstrual 
and other functional disonlers are possible results^ and may make the 
woman a hofx'less invaliil. For reasons already given, one of the 
most si»rious errors is ]iremature marriages 

Acconling to prevailing iileas, tlie higher education and civiliza- 
tion strongly tend tu check and to jK^rvert the development nf wtiman, 
to cause numerous weaknesses, to increase tlie burdens an<l dangers 
of maternity, and to lessen the vigor of the oti'spring. We are told 
that the republic is in danger from the deterioratioTJ of our women. 
The limits of this work cannot include an adequate discussion of *hc 
subject; nor are sutrieient tact.^ known upon which to base a %'id id con- 
clusion. These pessimistic fort^lioilings, however^ have arisi u and 
gaimnl headway mthcr upon assertion than upon fact. The ability 
of the squaw imnKHliately after partmnticm U\ n*snme the march is 
often nrgetl as an argument nguinst tlie higher education of woman; 
but this proves nothing. Observation amimg Indian wonu-n has 
abundantly shown tliat want of care, during and after labor, is the 
constant cause of contplcte prola|ise of the uterus, vagina, and bladder, 
and of numerous other diseases which are relatively much more ]uwa- 
Icnt among thrm than among the higher e hisses of civilized women. 
The cilucated woman could '* resume the march'' if it WTre necessary, 
and liistory has shnwn nuiny heroic examples; but education has 
tauglit her that tins is utisiife. 'l^lu* savage wonuui ltM»ks old and 
withcre<l at thirty ; the high-class civilized woman preserves some- 
ihing of youth until after the age of fifty. The highest eivilixation 



TBE PHYSIOLOQWAL PERIODS IN THE LIFE OF WOMAN. 21 

and it** resultant heredity, nntwithstaiiding it.s artificial and social re- 
quirements, does not reinforce, but more than offsets any deteriorat- 
ing influence whieh may come of a dejiiirture from primitive condi- 
tions. This is the reason why the vitality of a civilized nice is much 
greater than that of the .savagCj and why civilized woman lias a power 
of resistance wliieh, if prnperly trained ami direr! nl, will eualjlc her 
to endnrc and to survive many trials to which a ruder organization 
would snccuml). To make the deterioration »>f woman, and throu)j:h 
this the enfeehlement of the race, a price whicli must he jiaid ibr 
the higher educatiiui and civilization, won hi be to reverse the law 
of evolntion and trt put in its place a law of the survival of the un- 
fittesT. 

The changes of pulxn'ty arc in some cases associated with an en- 
largement of the ihyroiil ghnids, en I led goitre. This condition is not 
iincommrvnly limited to the period u£ puberty^ — that isi, it may di.sap- 
pear with the eomidete estid>lis!iment of menstruation. In early goitre 
the glands are soft ami almost fluctuating. If the enlargement per- 
isists, the tumor becomes fibnuis, hard, and chronic. Such cuhirp;c- 
'nipnt may be treated in the early stage with inunctions of biniodide 
i>f mercnr}% 30 grains to the ounce. This sliouhl be applied daily for 
p«*ri(jils of fotir or five days. When the skin becomes irritated the 
application shoidd be interrupted until the irritation litis subsidetlj 
and then resumed These inunetions, tf^gethcr with the continued use 
of calomel or the bichloride of mereury, in minute closes, will some- 
^times result in rather prouipt disappt arance of the swelling. The 
liyroid extnict in doses of two grains three times a day will in some 
etieet a mpid cun:' ; if distinct im[»rovenient is not apparent in 
or three weeks, it shouhl be discontinued; in any case its use 
should he guanled, and the dose regulated if necessary to an am<junt 
at will not cause disagreeable nervous symptoms. 

Maturity. 

The time of sexual maturity extends from the end of puberty to 
about the torty-secf>nd year. Under normal conditions this is a rela- 

itively healthy jwrioiL llidike puberty and the menojmuse, it is com- 
|janxtively free from the neuroses and psychoses, except those Cfm- 
ueeted with pregnuney. The woman is subject, however, to the bur- 
den^ and accidents of pregnancy and nuiternitv, ami to phvsieal and 
mental overstrain ; she is also lialile to the occurn^nce t>f nnn-nuilig- 

Lnant neoplasms of the uterus and ovaries which endanger life }U1<1 
ie4dtht and to the dangers »if puer[wrjl and other affectiems. During 
the child-bearing |K?riod th<* gomn'oecus of Ncisser is one of the most 
potent causes of metritis, pyosalpiux, ovaritis, [leritonitis, (*ystitis, 
pyelitis, and nephritis. (See remarks on gonorrhoea in Chapter X.) 

The Menopause. 

The menopanw, sometimes called the climacteric, sometimes the 
ehange of life, is the second crifit^al periiHh It usually necurs between 
the ages of forty and fifty. The time of its occurrence is abnorm; 




of the rf'prodiirtivp ort^ns and rpssiition of tli<'ir functions. Tiic foU 
lirles nf the nvarii'S tlisiipprar, {n\<l tlw imisciiIarjiiMl t*;|jiTRliilart'lf merits 
of the uterus beenme rudimentary ; both ur^iis shrink to .small, 

Bl«n(3 S^uiton. i^urgical Disenses nf tht^ Oviirli-s and Fallopian Tnbei. 



tHB PHYSIOLOGICAL PERIODS IN THE LIFE OF WOMAN, 23 

hard bodies eora posed mo.stly of dense fihrDiis tissue. The Fallopian 
tuba** become shorter and narrower, and sometimes their oaniils grow 
together at one or more points. The uterine cunal often closes at the 
internal or external os. The vii^inal portion of the ntenis in many 
ciise^ disiippears, st> that the upper extrenuty of the vagina is directly 
continuous with the uterine canal. The va^iua becomes narrower 
and shorter, and lo^es its elasticity ; its lining of (javemont epitheliura 
often gives way to a fibrous-tissue surface containing more or less 
cicatricial tismie. Like changes o<?cur in the vulva. The breasts also 
atrophy, lose their glandular elements, and become smaller, unless, as 
often (XH'urs, the atrophic loss is supplied or even t*utbalaneed by the 
de|>osition of fat. 

The essential phenomenon of the riiemqKiuse is permanent arrest 
of all functions peculiar to the reproductive organs. It is the inver- 
sion of the de\'eiopmental process of puberty. It marks the end 
of active eexual life. The atrophic changes ai*e known as senile 
atrophy. 

FiGU&B 5, 



Atrrjphlcf] ov«ry iind Fallopian tube, frozn a woman frixty-eliyht yeari old. Natural §i»e.' 

The Bymptoms of the nienf>|\inse are referable to two stages : a 
stage of menstrual irregularity jireceding the cessation of the menses, 
and a post-cessatiiui stage (tf variable systemic disturbances. In nor- 
mal or nearly n(»rmal eases the irregularities are not excessive ; the 
sv-.temie disrurbancfs are slight. Tbi're is a |>eriml of unstable equi- 
librium. The woman may at tinier be unusually capricious and emo- 
tional ; yet she passes through this pliysiologieal crisis with only a 
few minor disturbances. She may have the clinracteristic vasomotor 
flushes, perspiration, vertigo^ somnolence, numbness, and faintuess. 



J Bland Sutton. Surgioal Discast's of ihc Ovaries mifl FttUor.iaii Tulwi^ 



24 GENERAL PRINCIPLES. 

The menstrual function ceases as it began, with marked symptoms 
refc^rablo to the nervous system. 

Irritability, apprehensiveness, hysteria, melancholia, and other 
psycliic, disturbances are common in the abnormal cases, and may 
Im» (exaggerated. The menstrual deviations vaiy in wide limits. The 
flow may gradually decrease and come at lengthening intervals until 
it alt()g(»ther ceases ; it may occur at short intervals or become con- 
tinuous ; it may become so excessive as almost to amount to danger- 
ous hemorrhage ; or life may be jeopardized by a slow, continuous 
drain. 

There is an increased tendency to malignant disease of the uterus 
and breasts during this period. The excessive fear of this may prey 
injuriously on the mind of the woman. The menopause often cures 
|K*lvio disease; this is because pathology is physiology modified by 
diseas<», and because atrophic changes when they arrest physiological 
pr(K^(»sses may also at the same time put an end to pathological proc- 
esses. KspcK^ially is this true if the pathological processes have 
(le|M'n<led u|)on the functional activity of the organs involved. It 
therefore follows that a woman who has suffered for years from 
chroiiie uterine or ovarian disease may now enter upon a long period 
of increased vigor and robust health. It may, however, Ihj a danger- 
ous, vwu a fatal mistake to assume that the ills occurring at this time 
of life projM»rly belong to the menojxiuse ; that they neeil give no 
anxiety; that they will disapi)ear with it; and that they therefore 
require no attention. Although such a notion prevails, yet some of 
the most gnive disorders of the menopause are consequent upon 
iKitholo^iral states over which atrophy of the reproductive organs can 
nave no control. (\)ntinuous and excessive hemorrhages and exces- 
sive nervous disturbances nw. matters of specially grave solicitude, 
since the one nuiy indicate malignant disease and the other may tend 
to mental derangement, l^nnnpt diagnosis and energetic treatment 
may he imperative. 

Senility. 

The decline of life is normally a |K»riod of repose. The functions 
of the reproductive organs having ceased, the organs have little 
]»liysiological >iguiticance. The special disonlers and dangers of this 
|H'ri(Hl, such as iuflauiuiations and neoplasms, will be considered in 
their |>rop<>r coinuH*tious. 



CHAPTER II. 



AJS^TISEPTICS, ASEPSIS, 

The subject of this chapter falls under two heads : septic infection 
and a^ptic technique. 

SEPTIC INFECTION. 

Septic infection formerly c^iLsed an appalling mortiilitv in the major 
gynecological operations and made the minor inanipnlatitJiis extra 
peri Ions. The fear of infection was so great that when the malady 
was neither fatal nor very dis^ablirig the practitioner often iisetl tem- 
jKirizing mea^*ures, however unpnunising, to the exclusion of snrgical 
measures, liowx^ver rational. Now the application of the aseptic prin- 
ciple hassi maile all gynecohigieal procedures relatively safe.^ 

Sepsis is the genend term for all surgical infections of microhic 
origin. The term asepsis^ with its corresponding adjective aseptic, is 
UBed to imply the absence of these infections. Sepsis is doubtless due 
more to the pnwhict^ of bacteria than to the bacteria themselves. 
Septicaemia, toxtemia, sa])rit'inia, and pyieuiia are terms used to signify 
ditfereut forms of infection. The presence of infectious microbes in 
the circulation, together with the chemical action of their products, 
gives rise to the condition called scptieiemia. 

Other mir robes exist locally, but may send ont tlieir prmlucts 
through the circulation, thereby producing septic toxjemia. When 
the toxoi^mia is due to the products of pntrefactive Ijactcria it is often 
called siipnemia. When pus emboli are carried tfj rough the circuia- 
tion from a ftxnis of suppuration, to set up other fwi in di tic rent jmr- 
tions of the bixly, the condition is called pyicmia. These terms, 
although widely used, are not absolutely definite. Our knowledge of 
the conditituis whirh they signify is incomplete. An apprehensi(>n 
of their uu-aning, however, 18 essential to an appreciation of modern 
surgiciil literature, 

Microhic invasion may be in the form of wound infect itm ; it may 
also occur directly in the uuljniknu eutaucons or mucr«is surfaces. 
The niicnHorganisms most important and most often found in gyne- 
cology are : 

The 8taj>hylocoecus pyogenes aureus, The gouoeiwcus of Neisser, 
The staphylococcus pyogenes albus, Tlie Ijaeillus coli com munis, 
The streptocoecns py^jgenes, The bacillus tuberculosis. 

* Fr»r a niU rUiscimsiori (*f ueptfe tcchtilqut*. tlie rwader L» rfforrfd to the excellent work on 
that jiub)(!Ct by HuiitL-r Robb, l*rof^»M»or of i;ynecf4ogy in the W*'KU"ni Keserve l;iU%'ersity, 
(IcvHuml* Ohio, and formerly A s«ooi ate in 0ync'c*)loKy In JohnB Uopkiii« linlvt*r»ity, RaUI- 
mora. Md, 

2^ 




* 



t'i»init iif tliL'ir rarily or IfsstT virulenrc. Among tlit'ni iire the bacillus 
of tetanus, nm] thr baeillus of tnali^imiit iXMleniM, Intth mre, uon-pyo- 
gienic, uihI most vinilont ; the bacillus pyogenes fiotiflus, tlie pm-umo- 
c<x?cU8, the Ijaeilliis pyocyaneim, actiuomyce^, and the staphyloc^occus 
epiJerniis t»f Welch. 



Staphylococcue Pyogenes Aureus and AlbuB. 



I 



These are the most frcrpieut and widely distributed, and are the 
most abundant sources o( suppunition. Both are saprophytes — i ^,, 
tliey rtourisli on non-living niattrr and are readily cuitivated in the 
vurious organic media. The slaphybicoccns aureus is found in almost 
all abscesses. Ii u>ually apjKnirs in grou|»s, often in pairs of fours. 
[n ridtures oj>en to the air it forms large, golden-yeHow masses* Its 
pathogenic j>ower is varialde, being sometimes more virulent, some- 
times les8 virnlent, It*s pyogenic' ]>rop<Tties in man have been clearly 
proved by the experience of iiarri, who rubbed into the uninjured 
skin of his arm a pun? eultnre of this organism. Four days later a 
lai-gi* cnrbunele surrounded liy isolated furmielcH apjieared at the site 
of the intx^nlatiou. The iuHanniuition ran the usual course, and it 
Wmit only after several weeks that the skin healed over completely. 
8rventt*en seiins remaiueil as a lasting proof of the success of the ex- 
perintent/ It is the usual niicrobe of local suppuration, but is said 
lo cause geru'nd septicemia from puerperal or surgical infection. The 
^tapliyhHMH'cus allnis closely resemldes the annuls in forui and func- 
tion ; but is more hx-al, less viruh-nt^ and often associati^l with it. 
Holli varieties are found with other pyogtniic microlx?s. On eultnre 
ihr MtaphyltHH^xjus albns forms white masses. 



* 



The Streptococcus Pyogenes. 

ThiH tuion^iie i» one of the most virulent, fatal, and perhaps the 
tiUMt imp4»rtnnt t»f the pyogenic micro-organisms. It occurs usually 
til dmin« of numerous cocci joinetl together. On culture it fornix 
iiliiHito tHilonies rather than large masses. It is probably identical 
with the Mtri^ptiHHHvns of erysijx^las. It ib less loi^til in its effects and 
much uioiv viruh'tii than tiie stapbylwrx^cns. It is one of the m<»st 
V indent mier^worgimisms of pueriieml and traumatic septicaemia and 
Mi'ptio pt^ritoiiihH. 

The Gonococcus, 

Th«> Cloiiooooous of Neisser is tlie microbe of gonorrhea. It is 
not r*vidiiy indtivatiHl in nuMlia outside the body. Its nature is there- 
fi*n^ mlheV iKal of a ptirasiti' than of a saprophyti". It may be colon- 
i^e^t in bhHHl-fH^nnn. Its iidW'tioii is innvryecl only from living indi- 
vitbmU. Il l!* n dipUH>iHH'tis, the two members of each group being 
tUiMeneil limnnl iMicli other to the biscuit sbap. Its most striking 
|MHndiarttY in \U jmwer to |>eiietmte and intrench itself in the deeper 
t Aa«H<^ from A»«|4K' SurgU-fti Technique. RohU, 



ANTISEPTICS. ASEPSiS, 



27 



my&rB beneath the mucous surfaces, especially in glandular structures. 
Il nyiy penetrate to di^.taut organs of the IkkIv, having been found in 
the joints in cases of gonorrlKciil rheumatism, in tlie fierspi ration, and 
lo toe moscaW struct iu*es of tlic heart.* Its greatest jKithc^nic sig- 
nificance i^ due to the |>en>islency of its infection and to its destructive 
■ciioti Qpon the organs which it infects. It does not set up general 






FlOlTtB S. 



# ..I 



TtQVMM't 



f' A'-J 



i^ 



'5; 



Btwpto c oc e iia pjotgeaet. 



Gonocoocttt. 



ricmift. 



WiGVRM 10. 



p^cttlTia QoU fnfinrn^nii# 



Ptii'umocoocuB, or micro- 
coccus lAjiceciliitiifl. 



Ficriti IL 
Bacillus tuborculoslft. 



spticiemia. Its action is local, and is most marked and disastrous in 
tie conjunctiva, in the infantile vagina, and in the Fallopian tubes of 

adults. Tlie gonococcus has In'on f#»iuid in the muscular wall of the 

uterus- See Chapter X., on luHammation. 



The BacOlus Coli Commimis. 

This germ is saprophytic—/, e., it lives on dead matter. It is 
variable in shape, but is usually a short, thick baeilhis witli mniulHi 
ends, sometimes almt^t as broa<l as long. Its rjornial habitat is tlje 
intestine, and it is said to be a frequent microbe of |KTitouitis folh>vv- 
ing intestinal lesions, and although its vindeney in cxuisinir perit*>nitis 
lias been questioned, yet pure cultures of it have apparently pnwhK^l 
the disease in the lower animals. It has also been found in ihc gi'ni- 
tal and urinary tracts. 



tDemotutrmled by Councilman in a case of mriicArdltU fr^l lowing KoaorrbcM. 
■FIcutCB ft-ll are ftom Kobb't Aieptic Surgicftl Tecbmtque. 



28 GENERAL PRINCIPLES. 

The Pneumococcus. 

The micrococcus lanceolatus, or pneumococcus, the peculiar coccus 
of pneumonia, is another parasitic microbe not easily colonized in the 
usual culture-media. It commonly occurs in the saliva, and is doubt- 
less the source of the often-observed virulence of that secretion. It 
is an oval, encapsulated diplococcus shaped like a spear-head, occa- 
sionally forming itself into short chains. It is the microbe of croup- 
ous pneumonia, is pyogenic, and is sometimes associated with the for- 
mation of pus in the peritoneum, joints, and genitals.* 

Ba^cillus Tuberculosis. 

The bacillus of tuberculosis is often found in a form of peritonitis 
known as tubercular peritonitis; also in pyosalpinx. It has been 
found in inflammations of all the geni to-urinary organs. Infection 
from this microbe is seldom a sequence of traumatism, and it is there- 
fore hardly to be feared as a result of surgery. On the contrary, sur- 
gical operations often have a decided inhibitory eflTect on the progress 
of tubercular peritonitis, the disease having in many cases disappeared 
after simple exploratory incision. 

Micro-organisms have been abundantly proved to be the cause of 
the septic and inflammatory diseases of women. In the examination 
of the vaginal secretions of nearly two hundred women Doderlein 
demonstrated about one-half to be abnormal. In 10 per cent, of the 
abnormal cases he found the streptococcus pyogenes. Inoculation 
experiments showed that in 50 per cent, of these the microbe was 
pathogenic for animals. Clivio and Monti have found the strepto- 
coccus in five cases of puerperal peritonitis. Czerniewski found it in 
the lochia of thirty-three out of eighty-one cases of puerperal fever, 
while in the lochia of fifty-seven healthy women he found it but once. 
In ten fatal cases he demonstrated its presence in the organs after 
death. The countless myriads of cocci present in a single microscopic 
field of fluid taken from the alxlomen in a case of septic peritonitis 
show the developmental power of the micro-organism. For a physi- 
cian to go immediately from a case of erysipelas or of streptococcus 
phlegmon, or of any other virulent infection, to visit other patients, 
even after the most painstaking disinfection, is scarcely safe. Repeated 
disinfection on two or three consecutive days is desirable, perhaps 
necessary. To go without any disinfection beyond the ordinary wash- 
ing is criminal.* 

The causation and course of infection necessarily depend upon the 
source, virulence, and number of the organisms ; upon the volume 
and nature of their products — that is, of the toxalbumins ; and upon 
the local conditions. The presence of foreign bodies, of pathological 
secretions, of bruised, congested, or dead tissue, would be favorable to 
infection. In the vast majority of cases infection is carried to the 
wound by the touch of the surgeon or his assistants or appliances ; 
tliis is called heto^o-infection. AtUo-infeciion ^ which is supplied by 

1 Etheridge. Pneumococcus Abscess of the Ovary. American Journal of the Medical 
Sciences, April, 189fi. 

* Adapted fW>m Robb. Aseptic Surgical Technique. 



ANTISEPTICS. ASEPSIS, 



29 



organisms already existing in tlie patient ni the time of the operation, 
b relatively le^n fre([iient. Some l>:i(*teriu onclcHibtedly reach the 
wound lhr<iii!^h t!ie air; but they are iisiially nut virulent, and are 
therefore not dangerou.s. Fortunately the Uuid.s and living tissues of 
the body have germicidal power, ana consequently offer a degree of 
resistance to bacterial invasion. Mnny germs therefore, whieh in arti- 
i\vm\ media would flourish, may become inert wl»en c^xpnsed to the 
re^istiince of living tiKsue. I^ince this resistance is often inadequate, it 
ljei:^mes neee8sary so far as pr>ssihle to exclude the orgjinisms from 
the field of oj>eration by ase[>tic nnj'asnres, or to destroy tliem by anti- 
^itic agents. It is clearly imjxirtant that the power of tissues to 
resint oi^anisms l>e not imjKiired by the too free use of chemicid anti- 
septics or mechanical agents. 



ASEPTIC TECHNIQUE. 

The mere acceptance of the aseptic idea is inadequate. Its 
th»*rough and systematic application is essential, not only in major 
o|K'Ritions, but even in simple manipulations* Efficient technique is 
the outgrowth of a comprehensive gnisp ami an intelligent apprecia- 
tion of septic infection, its aiuscs, prevention, and remedies. It re- 
quireiiy above all, the development of what has been aptly called the 
aseptic eonscienee. 

Asepsis is the nbsence of infections Ixieteria. Strictly speaking, 
this may be an ideal condition, since it is not always fully realized ; 
but it is usually possiljle to limit the number of bacteria to a safe 
fiiinimum, or to render them harmless by means of drugs, chemicals, 
and other agents, 8nch agents nm called antiseptics. When the 
antiseptic has the pi>wer U) destroy germs it is often called a disinfec- 
tant. The use of antiseptics mtiy be either pn^phylaetic or ther;i|jeutic. 

Aiwpsis involves a great number of details varialde mid hai-d to 
a n t i ci ])a t e . T h e i r e om pi e t e d e se r i p t i o n is i m | >oss i b 1 e a nd u n ne ee ssa ry * 
Once grasp the irreat priucijile of asepsis, and the subordinate details, 
otherwise complex, t>ecome simple. The intelligent operator, for ex- 
ample, who knows that septic infe<*tton is the result of contact, need 
not be tr)ld that during an opf^ratinn he must keej) his haiul ntf from 
whatever is not sterile. The danger f>f sepsis is in a measure prrq^or- 
tionate to tlie length of the ope raticmj to the exposure of the wound 
or cavity, and tn the extent of the traumatism. Jt foUuws, tlierefure, 
that an openttion should be finished as rapidly and with as litth' oper- 
ating as possible. At the same time the slf»w operator, if gentle anti 
firm in his movements, is less <taiigrrous tlian fine uf nipid and violent 
movements. Acenrdingly, gentleness and rapidity are ilesiralde. 

The object rif the prrjphy lactic use nf antise[>ti<'s is as^'psis. Before 
any gynecologiixd nrx^ration or manipnlation the operjitor*s hands, the 
instrnments and other applianres, aial tlie field of the opcniti^m or 
manipulation 'should be renderetl surgically clean and so maintaitied 
throughout the openition. The tlicnipentic use of antiseptii-s is indi- 
cnted when infection has uctually oecurred. Then tlic fii'ld (if infec- 
tion, if h)cal, may l>e oj»ened and disinfectc*! or dj '** the infec- 



GENERAL PRINCIPLES. 



tioo ts Bystemic, the internal iis^j of antiseptic drugs may be indicated. 
Wlmi tnere is no iuieetion, and the use of uritiK^ptie dfnij^s is there- 
imt prophylactic, tliev sliould Ix^ uaed but s|mringly, if at all, anil 
aot in contact with the wound. This is because they may J>v their 
' * * pn>pertiej5 defeat their own object or indnee dangeryus, even 
>ning. Their use is to secure surgiciil cleanliness, as soiip 
to s*i'ure a'stliehc cleanliness; and, that iil>jri't having been 
1, ibey should be wtu^hed otl' with sl^Tilizcd water froni the 
■is mud instruments before these are brought in contact witli the 
iiiM. The pn>phylaetie use of suitiscpties is an antiseptic procedure 
ammKftic result, 

Antiaeptic Ag-ents. 

Vh^M^ ^tmj^ t^rbolic acid, corrosive sulilimate, and formaldehyde 
ft, ttti^ mmoof the most reliable and pmctical antiseptic agents. 
Imt ifr the BKi^t (Hiwerfnl and availal>!e giTtiiieirlc, au<l the most pnie- 
ulAv lilt Slpnlirat ion of everything which it dfies not injure. The 
lanlllMntaDd the hot-air sterilizer Iiave bei^u ninstly discai-tled fur 
Moist heat is employed in the form of l>uiliug 

I by Boilingr. Absotnte sterilization for laboratory work 

_^ ^ibr thirty minutes on tliiY'e consecutive days; but fiir 

^liM^ftl MnaSM oue boiling for thirty niiuntes is am j tie. In fact, 
^mSmC^ MOWMnic micn)bes anil their spores are destroyed in a 
Hgll^ ^liiVivr tumt* A gnmt advantage of this niethtRl is its sim- 
ttHl^lli. ^Cip CMNplicitti^l a p]uirat us is recpitrcHl. 

ky Steam is efficient » available, and widely appli- 

^et>nnectetl with an njjcrati^m that is ncit injured 

_ .^ **^> jtsi»ptie by this means. For tliis piirjiosc uimi- 

ttiifM. oltriliirr have been dcvise^d, tliat uf Arnold In-ing most 

i. tl Ofc*tiiaius a cliambtT for the articles to l)e sterilized. 

'*-■'--->•< the air from this chamber and^ coming in contact 

vs, li^tnrcs, towels, gowns, aprons, dressings, and 

- thorn sterile, or at least pnictically safe fur sur- 

a sixty minutes. Tlie Hfn-t-kmann stcam- 

- bv so-t*aIled '* over-steam sterilizati<in/' is 

1^ mon^ eftwtive than the so-rallcd *' under- 

4 Arnold ami other's. Tliis sterilizer has the 

- _- ffic drt^Hsings so much, and is provided with 

' 'IV they are taken out. This pnMx^ss, re- 

^^ two or three CO tisi'cn live days, insUH's the 

ii. rx\H that miglit otherwisi' survive tin* iirst 

.^ t^K- next day. F<»r a dcH'riptiou of the author's 

......*i.^*^*.<^ t^vmhint'd, •'•<"*' I'igmvs lo, 1(>, aiKl 17. 

mtIuI ijcrnjicide, is^ [RTliaps, the most valu- 
\\'^ ^ u^i^l in cleansing the instruments, cloth- 

iu; h1 in fMHincctioji with njM'ratioTis, iind fur 

* \m\ operator, but more es|M'ciallv for 
r the snrgiHMi and liis assistant. The 
^^lltJ grvvu soap, is immeasnnibty 



A NTfSEPTICS. ASEPSIS, 



31 



superior to all others* Its uses will be further eoii side red in the 
" PrejKinitioii for an As€|»tie AlRl«niiiiKil Sections- 
Carbolic Acid is a chonural niitisLi*tit^ of jL::reat p<)wor. It also has 
the highest germicidal ami de<*d(inuit properties, and has been more 
freely lAud generally use<I than any other antiseptic j but its destruc- 
tive properties render it dangerous h^r the patient antl inconvenient 
for the operator Fatal poisoning is not an uiieomnion result of its use. 
Il etirrotles instrnnieiits, injures the skin, and by its local an^e^tlictic 
projierties impaiis the tactile sense. Its use is now limited to llie dis* 
infection of very small areas of loeal infeetton, where tlie qnantity used 
18 not sutlicicnt to cause systemic poisoning, even though the aeid be 
iise<l in full strength. The <langer of washing out septic cavities with 
1, 2^:, or o jxT cent, >oIutionH generally ]in>liibits its use in that way ; 
pnifound sh(H"k has repeatedly foU«» wed tiie introduction of weak solu- 
tions into the reetuni. It is soIuIjIc in iioi water to the ani*>unt of 5 
jK^r cent. Its solubility is much increiLsed by the addition of an equal 
cpmntity of glycerin. 

Corrosive Sublimate, like ciirljolic acid, is a germicide of consider- 
able power; but is danger* ms [{' brought freely in con Uict with the 
pitient, **IIalstcd has shown that irrigation of fresh wounds witli a 
solution of hii'hloride of mercury as weak as 1 iu l(M)tHj is followed by 
a distinct line of superficial necrosis," ^ This would jcojKiRlize the 
healing prrxx'sses, and, together with tlic danger of fatal systemic poison- 
ing, would ])rohibit it^ use iu irrigation of fresh wounds and septic 
cavities. Its use is further restricted by recent investigations which 
have not fully sustained its earlier claims as a gerniieitle. Its chief 
use is for disinfe(^ting the hands at\er prolonged serulibing wntli soajr, 
and for the sterilization of surgical dressings, and for s(4uti<»ns in which 
ligatures and spi>riges may be kept. Tlie drug, how^cver, should be 
washtxl out of them with sterilized %vater, ah*ohi>lj or ether before they 
are used* Irrigation of the bhiddcr by a solution as weak as 1 in 10,(K)i) 
has bwn followed by most violent exfoliative cystitis. It should never 
be used in the urinary system. 

Sodium Carbonate. Commtm washing-s<Mla is an active germi- 
cide when used iu a 1 per ecut. solution with water, but it d<x*s not 
become active until the solution has been rjusinl to the lioiling-point ; 
then sterilization is much more raj>id than in plain boiling water. 
The b<>iling solution is said to flissolve the eapsule of tlte germ and 
to destroy it in live minutes, ^fhis form of sterilization is best suited 
to instruments and other apjdianecs that are not injured by heat. 

Formaldehyde Gas is generated- by passing tlie vapor of wood- 
ulcoliol — ruethylic alcohol — ^mixcd with the oxygen of the air tlirough 
lieatrd platinum gauze. The cheniiral change is re]>rescnteil by this 
foniuda ; 

CH4O ^o- rij,u ^ up. 

Ah the wood-alcohol vapor, CH^O, passes through the heated phi- 
tiniim gauze it gives np tw^o atom8 of hydrogen, which combine with 

' ! I hni<juc, p. 42. 

in nf Mr. BorLram K- HoUiftter. of CbicAgo* and U kuown hm 
Holh ,, ^ itur. 



GENERAL PRISCIFLES, 



septic inj^trumeut bagi^, the convfiitional sterilizer, the cunib^^rstmie 
trav!* and s|Mjuge-basiiis wliich make up the usual inipeilimenta i)f 
musical practice outside of hospitals. The apparatus fulfils the re- 



FHiVRS 14. 




liistriinK'iit'p4jui-h rolled and Ue<l 



quiremcnts, iii*^l, of an aseptic histruiueut-eui^e ; seroiid, of a steam- 
s? t eri 1 i ze r ; t h i n 1 , i if i u s t r u iti c n t - 1 ray s a n* I s po iigi?- bas ins. 1 1 ei » n ^ i st s 
of two reetaiigular sterilizers made of copper, niekle-plated, in whicli 
luay l*e packed all instruments and other appliances requisite for an 



Fjarmt Uk 




OombliMtlfiti tttitnsm<'nt'r«iic, «t«rlllieT» upatijri* iMuilnt. and tmyt, pAcUtHl, ready to be tAkpn to 

ftii (fiwrAtlon.* 

abihiminal set'tiou fjr far any other onlinary surgical opemtioii. Its 
com|M>ucut jitirts may further Ik* tist'd sepamti*ly as pjius, spouge- 
ha^^ius^ and traVH, Tlie whtile (Mitfit, euelusetl iu a washable canvas 
cover or in a telescope vali^, is sixteen inches long, nine inches wide, 

I Dudley. Jgurual uf ihv Alocrtcaii tledlc«l AtAucUUoti. 




ANTISEPTICS. ASEPSIS. 



37 



broken side of the sterilizer in the right-hand cut of Figure 16. 



I 



The lower tray is onr inch above the hottom of tlie steriliser, and ( 

sting upon the lower, contains 
??paee of one inch lietweon the 



^tr 



enti^ 



Th. 



tiiins 

towels, dressings, hgtitirrcs, etc. The 

bottom of the lower tray and the Itotttmi of tlie sterilizer — /. e., hclow 
the line A B, Figure 16 — is filled with i^terilized water. The small 
trayj?i, D and G, are filled with burning aleohoL These trays are set 
upon saucers to prevent burning the table-top. The burning aleoHoI 
converts the water into steam* which sterilizes the contents of the 
wire-gauze trays. One of the two detacliable handles resting on the 
table between the tw^o trays may be used to put out tlie flame by lift- 
ing the small alcohol-tray in contact w^ith the bottom of the sterilizer, 
The^ detachable handles are also designed for use in tseparating the 
different parts of the sterilizers after the sterilization is complete/ 

Finally, the several parts of this apparatus may be broken op into 
sponge-basins, pans, and trays. The two large copper boxes become 
sponge-basins. The two top covers Vjeeome tmySj holding sterilised 
water, inside of which two of the gaiize-wire tniys containing the in- 
struments are placed. See Figure 17, F and E, 

The gauze trays may l>e lifted out by the detachable handles and 
placed in the covers without iKindHug the sterilized in^iitrumenLs. The 
other two gauze trays to the left of the sp(mge-basin (Figure 17) hold 
the towels^ gauze, siK>ngcs, dressings, and other things which have 
hetm sterilized in them. Tlie two small, square, shallow cups which 
contained the alcohol now beeome trays for needles, ligatures, and 
other small appliances, S^'c Figure 17, H and G. Observe that tliis 
.•sterilizer is cpiite as well adapted for sterilization by boiling-water as 
by steam. After tlie ap])aratus has been under steam for sixty min- 
utes, especially if this process has been repeated three times un con- 
secutive days, not only its contents, but also its various parts which 
an^ to be UJ^d as sponge-basins and tniys, are thoroughly sterilized. 
Rich member of the apparatus is supplit^l with one or more slots or 
rings, into which fit the detachalile nietallie handles alix^ady men- 
tioned. These handles are uset\tl to se]>arate the sterilizer into its 
several partes w^hile hot, and to avoid Linnecessary handling. After an 
operation, even upon a septic ease, all the parts of the apparatus may 
be washed and then st4'ri]ized by boiling in a large wash-boiler. The 
boiling water should contain 2 {Mi^r cent, of sodium carbonate. 



I 



Preparation for an Aseptic Abdominal Section. 

Asepis necessitates a number of antiseptic procedures all looking 
to an aseptic result. Tlie scrupulous j)re|Kt rations about to be out- 
Hnc<l for major operations arc nc^t intemled to inij>ly that eipia! care is 
nnneeeHsary for miiuir ojx^ rat ions, because' the Litter are by no means 
fret* from danger of fatal sepsis, and becniuse a performance seemingly 
of minor importance in the beginning may end, accidentally or pur- 

MU«cf,if ijHtHl with th'mHiffhneK'iJfl oflpctivt?, UiouKh iirohnbly le^n ai^,x}utt> 
ft! vdf pMviitH, The imtcr 1m invprftfUfaWt* for Merillmti'in in phviiV* 

Jtj I , >Ti» Aftlclea niiiv be wlerlMzLMl by tht: formiiltlehytle giia, transfcrri 




38 



GENEEAL PRINCIPLES, 



}K>sely, in opening tlie jibdomen or in some other capital procedure. 
Traumatic inibcti<m of the poritoiifimi involves the g:ravest eoiir^e- 
qiiences, lience the nee<l of extreme preeuutions in teehiiiqoe ; aiiJ 
since tlie jijrcater may incliMle the lesser, the siime technique will 
sutlicp for the minor proreilures. 

The recklessness which results in the nil necessary removal of 
pelvic orp;aiis seldom escapes criticism* The recklessm^ss which re- 
sults in the unncccssiirj^ introduction of sepsis into the peritoneum is 
often passed by witlu^ut comment. Tlic danger to life, however^ is 
determined less by what the sur^^eon takes out than by what he puts 
ill. The devfdopmeut of .sepsis requires two condititms : first, piUho* 
genie bacteria must be present; second, the way must be opc^ui-d fur 
them to enter. Experiment has shown that they may be transmittc*! 
even throufi^h the unbroken skin or mucous mcnd>nxne, l>ut timt trau- 
matism makes au o]>cn door. Patho*»:cuic bacteria have their source, 
fii-st, in the ojjcrator or his iissistants; second, in the instruments a?id 
other appliances ; third, in the patient. The antiseptic procedures to 
an aseptic result must, therefore, be these: 

1. Pn^'pamtion of the opemtor and his assistants. 

2. Prepn ration of the iustninients, sponges, dressings, and other 
appliances, 

;i. Preparation of the patient. 



1. Preparation of the Operator and His Assistants, 

The operator and his assistants shtjuld he in good health. Since 
the bivath may be the medium of infection, they should especially l>e 
fn^'c from nasid catarrh nnd coryza. Disorders of nutrition whi<'h 
involve deticient elimination thntugh the bowels and kidneys may 
throw that function upon the lungs, ami cause the breath to be loaded 
with fetid prmlucts, an undoubted source of infection. The bacteria 
of saliva may be most infectious ; hence unnecessary talking over the 
field of operation is objectionaltle, fV*r snuil! particles of siiliva and its 
bacteria nmv reach the wound. The daily hath is an impair taut part 
of the routine of aseptic surgcr)\ Sjx'cial ch*thing made of w:i>hablc 
material is desirable ; for women the usual costume of the t mined 
nurse, and for men trousers and shirts or short coats. Special chitli- 
ing for ojwmtion has a threefold advantage. It protects the o|icrator 
from taking cold after leaving the oj>c rat ing- room in bis ordinary 
clothing, which, if worn during tbt^ o|ieratirm, might be wet with 
[)ei*spi ration. It saves the ordinary c*hithing t>om contamination when 
the operation is upon a septic cuse. It is, above all, an antiseptic 
measure in the interest of the patient. 

Sterilization of the Hands and Arms. The extreme mortality 
of abdominal sections in former times was due in great |>art to dirc(*t 
infection from the Jiand of flic o|K^nitor. To wash the liands ra|>idly 
in soiip ami water and then to dip them in some antiseptic solutittn, a 
not uncommon practice even now, gives little protection against intcc- 
tion. Absolute sterilization of the skin without injuring it is idc^al 
and impossible. Practical asejisis, however, is possible. To bring 



ANTISErnCS, ASEPSm 



39 



this aborit niimennis ant is^jpt it's Iiavc hoi'n used ; by untisepties is 
meant aiitiseptii- tirii^s unil antiseptic inc^asiiri's. Of these, |>roloiiged 
scrubbing with green soap sterilized by heat and with hot water are 
the must efFeetive. A mixture uf alcohol and Hiilphiirie ether, wliieh 
have germieidal properties, each one part, with f'uur parts of j^reen 
mnxp, makes a valuable hqnid antiseptic stwip. The green scjap slionhl 
be of good quality and previously sterilized by heat. Beat one pound 
of this R>ap in a capsule with two ounces of alcohol until unifi>rmly 
snnmth. Transfer to a glass bottle of at least three pints capacity 
an*! add two ounces of ether. Cork well, agitate, and set aside for 
two hours. Tlien add, with thorough shakini^, two onnces each of 
ether and alcoliol previously mixed. The scrubbing of the Imnds 
and fitrearms, to be effective, must l>e in soap and water as hot as can 
be born e wj t h o n t pos i t i \' e d i sco m i\ » r t . T lie 1 1 ea t i s a va 1 n a b le a id i n 
the removal of dirt. The sernbbing must be thorough aiul vigorous, 
and prolon^d ibr at least fifteen minutes* The longer the scrubbing 
the more difficult it is to cultivate bacteria from the scrapings of the 
skin. 

Prolonged scrubbing makes the hands safe, not so much by the 
destruction of the bat-teria as by their mechanical removal. They are 
removtHl together with the secix^tions of the skin and other foreign 
matter ujwn wliich bacteria flourish. To scrub the hands and tVire- 
arms always use a very large brush, preferably witiuiut handle. The 
lai^e brush is inilispcnsable ; it cannot, however, be made to reaelj 
those i?tmnghotds of kicteria so often overlooked or neglected, the 
angles between the Angers; to scrub out these angles thoroughly use 
a lirush \vith a handle of ordinary size, but do not attempt to scrub 
the other piirts of the hands and the arms with such a brush ; it is U>q 
small. Destroy all brushes tliat hu\'e been used in septic eases. 
Bnishes not in actual use should be niaile aseptic and kept in aseptic 
gan7X' or towels. 

After scrubbing with sajio viri<lis^preferably the li<|uiil antise|)tic 
&oap just mentioned— wash off all traces of soa|) witli clean water, 
then wash with alcohol ; this dissolves out the fat from the skin ; then 
with another brush ,s<^'rub again for one minute in an acpicous solution 
of brelilori<le ot* mercury, I in 3000. 

Wlien the patient is on the table and the abdomen ts nncovered, 
let ti»e aniesthetizcr, before making the incision, jvuir freely over the 
hands of the operator and his flrst assistant a (puintity of ether — L e,, 
let the hands h' washeit in a stream of ether whii'h shall How over the 
hands and tYon* them direetly n|>on the [Kit icut's abdomen. The ether 
is then wijx*d (»fi' from the abdunun with a wad of dry, sterilized 
gauze. This will tend further U* sterilize tlie liands ami abdomen. 

Sterilization of the Nails, Hair, and Beard. Let tlie nails be 
cut sliort ; long nails retain (piantities of dirt which any amount of 
scrubbing may fail to dislodge. They are also a [KJssible cause of un- 
necessary irritation, not t<j say traumatism, and may therefore be both 
the carriers of poisiui and the instruments for its intK-uhition. The 
wlmrtrT the hair tlh- less chrt will there be to fall irom it into the 
wound. The hair and scalp must be kept clean by frequent washing 



GENERAL PniNCIPLES. 



The loiigj full board is an iin necessary source of dan- 
ger; tke less beanl the Ix'tter. A gauze turhan al>niit tiie o|Knntyi''s 
Madenards the wound fnun fine particles uf dirt which tiiight other- 
vw fill from tlie hair; if hruught well down on the tore head, the 
tslBm aheckrbs per^ pirn Hon and then:4>y keeps it from droppiiiij^ into 
ifemttnd. The ojjemtor^s forehead, if wl4 with |ierf*|)i ration, may 
ht kipt dfy by means of a towel in the hand of a s|HM'ial assistant, 

* k and arms are now immersed in a sat united solution of 

' of potassium nntil stained a deep mahogany color, and 

I ft boC saturateil solution of oxalic acid. This decolorizes and 

strrilizes theui. The acid solution may now be washed 

iiailucil water. ^ 




i Tlsrji&ATioN OF Instruments, Sponges, Dressings, akd 
Other Appliances. 

of Instrumentfi, All instruments not injured by 

W simlised by boiling or by steam. Sterilization by boif- 

Italhrtv^ or thnx^ minutes if the boiling water contains 1 

.<f fJhiPi riirlM^nate. Tliis method is juTfeet in its resnlts 

' tnc^irutiients have been osc^d in a septic eiise. Boiling 

^ilutioii 18 no more efficient, and it injures the instru- 

ran ojieration instrtmients, stponge-basins, trays, and 

ht thorougldy \vashe<] in soap and waier to re- 

hJilt^aixi then sterilized by boiling in a large wash- 

ly b to sterilize instruments hy l>oiling just after 

It W ^sttBBi JQe^t btrfore usiug; During an ojk.' nit ion the in- 

i^sfanvkiWrnfTailgiHl in trays and covered, not with antiseptic 

nimtiaed water. 

Water may be sterilized by boiling for 

■MOB three consecutive <lays. One boiling 

• ilk l*fr for surgical pnr(xjses. If not already 

before boiling. In aseptic surgery ster- 

IVmt many pnrjMises, such as to wash the 

ciperatioii, to irrigiite the wound, to wash 

the tniy, and, wlien indicattnl, to wnsh 

TteplUons should be sterilised ffH" an al)- 

" iSHr iia^ually providtnl with n^ceptaelcs for 

BilV houst^ water may be stt*rilii^ed and 

i««fatk>ti ill two large wash-boilers, prefer- 

*Wf hot wntl half cold, so tluit by mix- 

T ^r s^vuretl. 

• <»l^ sluadd lx» of grKwl (piality and 

^-1)^% wel s u set! f b r d ry i ng glass wa re 

^J^-«i\h] in the ordinary way, then 

ivJiitiii earlwnate, ironed, done up 

w^- ^ ^^kna, light box. Twenty towels 

section. Just before o]>eni- 




w 



ANTISEPTICS. ASEPSIS. 



41 



tion they should be re-sterilized by steam or by formaldehyde gas, or 
by lK)th' 

The Sterilization of Sea-Bpon^es hy the ii^ual pnxsesses of wash- 
ing and 8oiikiii]S( in antiseptic drugs is tedious, difficult, and not 
alway?^ adequate. Tiie micfrtain results of these nietluKls liiive led 
lUfjsl abdoniinal surgeons to abaiuhm sea~sponges» and in substitute for 
tliero the readily sterilized jt;:auze. Sea-sponj^es, however, have greater 
afeurbinjs: power and greater elasticity ; they are therefore superior to 
gauze both for sponging out blood and for i>aeking to eoiitrol small 
bleeding- points by pressure. Notwithstandiug these advantages, they 
are sterilized with great difficulty » and arc therefore not preferred, 

Since the intro<hiction of the fomialdehyde gas process 8ea- 
sponges, it is said, may without injury be sterilized in a few hours, 
and may therefore agaiti eome into general use. Before exposure to 
the gas tfiey should be soaked in water to expatul aufl open their 
pires, placed in a canvas bag and the sand beaten out of tliem, then 
wju^hed thrciugh several waters for a long time, or placed under a 
faucet from which water may run over them ftjr several hours until 
all remaining sand has been washed out. 

The Sterilization of Gauze Sponges is by boiling, by steam, or 
by formahlehyde gas, or better by both. They should be made of 
four thicknesses of sterile gauze, and should be six inches wide by 
twelve to sixteen inches long. Smaller sponges may l>e overlooked 
in the abdominal cavity and lost^ or, at the end of a long operation in 
which many sponges have been used, they may be difficult to fiud. The 
fniyed edges of the gauze should be turned in and stitched, other- 
wise loose threads may stick to the wound or be It^ft in the cavity 
and become irritating foreign bodies. Round sponges of gauze and 
absorbent cotton eombine^l may be made hy wrapping the cotton 
jiimiewhat loosely in sipmres of gauze, the corners being brought to- 
gether and tied at the top with thread.^ The cut edges should be 
folded and hemme<l as above directed for flat sponges. Hfunid 
sponges are in no respect superior, and are much more liable to lie 
lost in the abdominal ciivity ; hence the flat shape, both of giinze and 
sea-sponges, is preferable in abdominal surgery. 

The Sterilization of Silkworm-grat, Silk, and all Dressings may 
, be by formaldehyde gas or by steam. Three sterilizations on con- 
' secutive days are desiralile. 

The Sterilization of Catgut by boiling lu alcohol and soaking in 
ajitiscptie solutions is not always reliable. Tlie gut may be rendered 
i^nrgimlly safe by either one of two processes : 

1* The dry-lieat process of Boeckmann, 

2* The formahh^Tyde pnx;ess. 

1. The Dry-heat Process, The individual strands, cut in lengths 
of tw*o or three teet, are coiled, and each is double wrap]K"d in parathn 
paper and placed in a small envelojK^ and carefully sealed. The en- 
velopes are then placed in a wire basket. This is exposed to dry 
heJit, temperature 284*^ F., for a peritxl of three hours on each of 
thn*e successive days. It is necessiry that the temperature on the 

' Hunter KnM> Ascfitfc Surgical Technique, p. 1V2. 



42 



GENEUAL PRINCIPLES. 



first day be graflnally mise<l to tlie required (lefjrep ; this is beeou^e 
tiie giU is rendered brittle l>y a rapid intTease of tenipenitiirc licfore 
the iiioifiture l*as been dried out iirnl rep!aee<l bv the abs(»r|iti(»n of 
jmraffiii frnni the piper. Let the teinj>erature l>e raised to 212^ F. at 
the end of the first hour, and maintained at this point for one hour 
eontinuonsly ; then raise it nrradiially so that at the end of tlie third 
hour it will be 284*^ F. The temperature nuist now be held between 
284^ and PMf^ F, for tlirt^e honrs. In repeating the prwess on tlie 
&ceond and third days the tempeniture may Ix* rapi<lly raised to the 
rcquircil degree, 

2. The Formaldehyde Process. Formiddehyde fornix definite 
cheniie^xl compounds witl) albuminoid snbstanees. Tlie cheniieai proe* 
eB8 which taki's place in the aliniminoids so nuKlifies the character of 
the gut that it will resii^t boiling in water for twenty or more niin- 
ntes* Tlie immediate aeti(m of the form aldehyde is to render the 
gut brittle. The tensile strength, however, is restored by boiling, and 
the boiling may be repeated one or more times without material injnrv 
to the gnt. After boiling the gut may be preserved for use in abso- 
lute alcohol, or a sufficient (jtiautity for use may be boiled just before 
each o|MM^ation, Ligatures prepared by this jirocess will resist ab- 
sorption as hmg as the ordinary ebromie catgut. The writer lias 
foumi them intact six w^eeks after tJie operation. Drj' heat may he 
substitutec] fur boiling. 

The formahh^iydc process com prises five steps : 

1. Tlie gut is tightly wound on sections of glass tnl>e, and the 
ends are secured. This prevents contraction and thickening on 
boiling. 

2. The fat and other soluble substances are removed by soaking 
for twelve hours in ether. 

3. The gut is transferred to a 5 per cent, solution of formaldehyde 
and soidvcd in it for twenty-fmir hours, 

4. The tubes are kept under constantly running water for twenty- 
four hours, to wash out thc> excess of formaldehyde. 

5. Final sterilization is secured by boiling twenty minutes in 
w^ater. 

Aseptic and Antiseptic Dressings, such as gauze and absorbent 
cotton, are now articles of eonmierce. If obtained from the best 
sources, they may be reltalde. Absolutely safe antisejUie and aseptic 
gtiuze may be readily prepared Ijy the surgeon or nurse. Many kinds 
of antiseptic gauze are used ; two varieties, however, the sublimated 
and the borated, fulfil all indications. Aseptic gauze is also neces- 
sary. Sublimated gjuize is useful for external dressings ; it is eontra- 
indieated in the dressing of exposed surfaces, because dangemus, even 
fatalj poisoning lias resulted from absorption of tlie lu't^ldoride of 
mercury. It should never be put into the abdominal cavity. Borated 
au.d aseptic gjiuze may be used with safety on exposed surfaces or even 
in the peritoneum. 

To Prepare SubUmated G-auze, boil plain commercial gauze ten 
nunutes in a 2 per cent, solution of sodium carbonate, wash thor- 
oughly with clean water, boil for thirty minutes in a 1 tu 1(},0(K1 



ANTISEPTICS, ASEPSIS. 

aqueous solution of hiehlnride of merciin^ containing 5 per rent, of 
glycerin, let it stand in the fiohition tor twcho hoiiry and dry. 

To Prepare Berated Qauze^ boil plain coniinercial y^inzc ten min- 
ates in a 2 per cent. ?*olntion of stKliuni ciirl>onati% wash with ch-an 
water, boil for thirty minutes in a satumtt'd a(|iicHKis solution of boiir 
acid, and dry. 

To Prepare Aseptic Gauze, boil plain eommercial ganze thirty 
minutes in a 2 p<^r cent, solution of KfMlium carbonate and wash with 
8terilizeil water. The formaldehyde proc*es8 in addition is doubly safe. 

Combination absorbent dressings ermi posed of a thick layer of 
cotton or wood-wool between layers of gatii^e, abdominal bamlages, 
utensils, gauze drains, the operation -table— in short, wliatever may 
come into tangible relations with the np<*rat[on — shotdd be aseptic. 

The Operatin^r-rooms should be clean, well ventilatod, well lighted, 
and free from infectious dniins and from other septic influences. Re- 
move carpets, stuffi?il furniture, and every object liable to give out 
[mrticles of dust. Disinfection by means of the fumes of burning 
snlphur is often attempted, but unh^S8 supplemented by steam vapor 
it is probably useless. Formaldeliyde gas is said to lie etfeetive. Tl*e 
disinf taction of a room by formaldehyde g;is requires a large aj (pa- 
rat us. Fortunately, however, infection is rather l)y direct contact 
than by tlie metlinm of the air. Special disinfection of the air is 
therefore less needed tiian thorough soajwind- water cleansing of t!ie 
ror»m itself, I)oor-knol)s and other ^larts of the room or its furniture, 
if liable to he in contact with the hand of the oi>erator or his assist- 
ants, should be covered with antiseptic gaiize. 

In }mcking or otherwise handling instruments and dressings which 
are to be used in an operation one may handle them with sterilized 
gloves, 

3. Preparation of the Patient. 

The antiseptic preparation of the patient has a twofold purpose : 
tirst, to remove, destrciy, and limit the p<iwer of pathogenic bacteria; 
this requires the local a|>|diejition of antiseptic measures to the abdo- 
men, external genitals, and vagina. Second, to enable tlie patient to 
resist any bacteria that may remain or ihn'clop. Tliis may require 
both rt^gidativeand niedieiiial treatment. A searching general exiuni- 
nation from the stand-point of internal nuHliciue should be made in 
every case. This examination may show |>hthisis or diabetes, tvr sfnne 
other contraindication to an ojieration ; or it nuiy show some condition 
which wotdd make the operation extra-perilous. Then tlie prcpam- 
tory treatment shonld Ijc directed to that condition. To lie forewarned 
h tu be forearmed. 

Wlicu the ojieration is not one of emergency the prcparatinn nuiy 
well inclnde several days of observation and treatment. In tins way 
often the patient's pecutiarities may be measured, and her power to 
resist infection may be increased. Let the abdomen and tfionicic 
organs be examined, es|MHaally the hmgs, hcjirt, and kidneys. A f|uau- 
titative examination of urine may shnw a dcticjerjcy, for example, of 
urea; then a few days of judicious diet and diuretics may turji the 



44 



GEyEHAL PRINCIPLES, 



result of an opemtion in tlie patieiit^s favor. The daily general bath^ 
with friotion, Ix'siclefl Ix'int^ an antiseptic iiR'aiJiire, increases tlie action 
of the skin antl relic ve.s tJic kidneys. 

The Bowels. Bowel distention impedes the operator and lengthens 
the operation. It is a dnngerous conipliealion ln>th during and after 
the operation, and is the cause of ;i great deal iif mortality, 80 far 
as pficticable, then, let tlie ho we Is he em|>tied of gases and solids and 
«f whatever may ferment autl fnrm gas, f^xperiinent has sliown that 
the coantlesg myriads of imctcna hahitnally present in the intestine 
mav be reduced by catharsis and intestinal antiseptics to a relatively 
ingiietiificant number ; henee the following measures are suggested to 
fvnoer the bowel Sj a^s nearly as possible, ascptie: 

L For several days before the tij>ei*alion exclude all food that is 
fidbte to lennent. 

2* On the third night befoi-e the opnition give five grains of blue 
iMss. If the bowels do not act freely the next mornings give an 
IT of castor oil. One day before the oi>enition give a iSeidlit;^ 
Itr or sorae other active sidine purge. Two com pound eathartie 
■aaiY be substituted i'or the lihie mass* Kepeat tue cathartics if 

3^ Givi^ repeated high er>pir*us enemas during the two days before 
tiar ly mtioa. The enenuis may be of stiff soapsuds, each pint con- 
liftMiiy^ ihofooghlv mixed, a drachm of turju'otine. Persevere in 
iki^ltfilil no eonsiclcrable atU(Hint of gas retnains. If the tnrjx-ntijie 
eneillA does not snifiee, try a mixture containing two 
I of glycerin, Epsom sjdts, aiul water. Vsq a Hcxible rectal 
h irtu walls, three lect long, and give the enema as high as 

t itiv^ abso, four times a day, an intestinal antiseptic. Bismuth, 

Tlh^L 'TliaiMlil^ ttiieture of cardantmn, and guaiacol are among the 

(hn|i2«i cHnantttOolv used. Nothing is In'tter than a capsule eoutaining 

ticianuMn three grains; oil of cinnamon, one-third grain ; 

. w ^t^ oi' bismuth, three gmins. 

iiMltat^ Ihe Field of Operation. Every abdominal section 

ii*h^ ftw dminage or for otlier reasons, that an opening be 

■ m tbe ivritoncal cavity into tlie vagina ; lience the necessity 

»H*l ivtilv the alxlominal wall, but also the vaginal surfaces 

< -^ Uia Abdomen. On the night before the ofx^ration 

*^ or ti)h«iit the ni*jns veneris and external pudenda ; scrub 

* \kitU i*nvn siuip and hot water, and cover it with a 

.uv Let tlie |n)ultice be removed in two Imurs, 

Mv uaslu^d otK Soap is incomjiatible with the 

.! to \h' apidit^l. Next wash tlie abdomen 

* V*,,., ither, and appiv a large, thick gauze dressing 

I h% i*IHX> jMilution of bicliluride of mercury, 

^ V i\al Pudenda and Vag-ina.. The mons veneris 

IuiwhI, thivc vaginal douches are to be given 

t^HV^xnitivc days before the operation, Esieh 

.1 M\ fir^l, jitrnnLT soajisuds made of green soop; 



ANTISEPTICS, ASEPSIS 
sterilized water ; third, solution of bichloride of mercury, 1 

Jubt before conmiencing the opt^rution, when the pfitient is under 
the anaesthetic, the external genital,s and surruunding parti? are thor- 
oughly scrubbed with a large nail-brusli.and t lie vagina is thuroiighly 
^rubbed and swabbed out witii a wad i)f gauze in the gmsp of a long 
luemostatic forceps, Sterilized gn-eti soap or the litjuid antiseptic 
5n>ap» deseribetl on pfige 39, slioidil he used. All soap is now washed 
away in a stream of sterilized water jMxured from a pitcher, and tlie 
parts are further sterili/AMl by another stream of 1 to 2fX)0 l)iehloride 
of mercury solutiou. It is a wise preeautioii, especially in a case of 
infectious endometritis, to euretle and disinfect the emlometrinm 
beft)re proeeetliug t<j open into the pelvic cavity. 

In the giving of tl^e douclie the Kelly {>ad will be found more 
useful and more pnietical than the bed-pan. Figure 18 shows the 
appliance and also makes evident its use. The two objections to 
Kelly's jmd are, first, that it is not always obtainable ; second, it is 
tlifficult to keep clean, and is therefore for surgical purposes apt to be 
septic. 

Figure 18. 



C 



THU^Jl tmtNt CO 



Kt'lly's pad. 

The writer uses a pmetical substitute for the Kelly patl that 
obviates both objections. It is simjily a piece of sheet ruliber, three 
feet wide and four and one-half feet long. The rubber sheet at its 
upper end and sides is folded over rolls of towelling or muslin, so thsU, 
a^ in Kelly's pad, the water will be directed into the bucket behrw. 
See Figun> UK Rubber sheeting is available everywhere, is eusily 
cleaned, and so inexpensive that it may be fre^|uently renewed b Shinn- 
ing which has the rublier finish on both sides is preferable. The 
opiiinar\M>il-cloth used to cover a kitchen table is obtainable in almost 
every htouse. 



Preparations for an Aseptic Vaginal Operation. 

The surgerj^ of the vaginal portion of the pelvic floor is usually 
classijiied under the head of miuur operations, Ttiis designation, since 
it implies that the oj>erations are trivial and safe even without full 
precautions, is misleading and dangerous- High vaginal amputation 
of the cervix uteri and the removal of an intm-uterine tumor Ijy 



46 



GENERAL PRINCIPLES. 



inoreeUement, for example, are oloarly niajcir operation*?. Ciirettenienti 
periiieorrhapliy, traehelorrhapliy, tlilutation of the wrvix, ck»i^yn^ of 
vagiiiul fistulie, though ri'latively siifc% are in an absolute sens^ tlari- 
geroUaS. Failure to observe aseptic technitpie in vaginal o]>erations, 
although le.Hs fre(|uently fatal, h yet full of danger. Tlie possibility 
of a fatal pneuniouia or uephrilrs as the direet result of an unelean 
** minor" vaginal o|>eratit*ii is not snflieienlly appreciated, A single 
case will serve to illustrate — ^** From one know all/' 

FlOVKK 19. 



S0 



%^ 



rrnotlcul aul:wlUule for the Kelly pud. 



"A woman ^ fifty-ei^lit years of age, six weeks after a perineor- 
rha[)hy j^niclnally devehjjxHl sympti>nis of nepliritis. Examination of 
the urine then showed albumin and hyaline and gnuiidar easts. She 
gradually grew worse, and died in coma a week later. At the autopsy 
minute abscesses were found in the liver, spleen, kidtieys, intestines, 
and in the lieart-musele. Agar-agar Esmareh tnlu's nuide from these 
organs gave in every ease a pure culture of stap!iy!*ieoeeus pyogenes 
aureus. The entrance of infection was found to have Ijcen tlie deep 
p.Tin<'al tissues, where, just beneath the line of wound, small eollee- 
tion?^ of pus were found. Externally, the wound appeared to have 
healed |RTfeetly.*" 

t Hunter Robb. AMptic 8urglcal Technlqut* p. M. 



ANTISEPTICS, ASEPSIS. 



47 



The Ajsepsis of Minor MampuIationB and Examinations. 

Since the unclean uUmne prctbi.' lias re|)oatedly caused fa till metro- 
peritonitis;, and since ** Jt*iith lias been carried to many a woman under 
the finger-nails," it fulluws tliat the samt' principles wliicli apply to 
-iu-ixi<.^il work also liuld ginwl in the ordinary routine exam i nations and 
i^M-il treatment of the pelvic organs. 

Asepsis of the Patient. Steri I iz:ition of* the enilonietrirnn, vagina, 
and vuh'a preparatory to iirilinary (jtiiee maoipnlation is impractica- 
ble, not to say inipos-sihle. Keasonable safety is, however, secured by 
the hot vaginal douclie, wliich the patient usually takes Ijeiore ap|ily- 
ing f*»r trtnitnient. As a supplement to this it is ln'st to \vi}H' out the 
vagina with dry absorbent cotton on long hx*k forceps, and then witli 
ah^rt>cnt cotton saturated with a 5 \vi'T cent, solution of earljolic acid 
in glycerin, or with a 1 to 2(XW aqueous solution of lnchl«M'ide of 
mercnr)'. Disinfection of the vagina or vulva in this way is es|>e- 
ciallv essential if the uterine cavity is to be instrumcntally or digit- 
ally expo»e<l or treated. By this uieans the cndomctritun is protected 
^^aiu^t the entran<'e of septic matter, which otherwise may lu^ easily 
carried in from the vulva or vagina on the instrument— a very com- 
mon m<j*ie of infection. 

Asepsis of the Hands. The cleaning and disinfection of the 
handd and nails before and after the most onli nary digital examina- 
tion are imperative, not only to guard against the carrying of poisiin 
fn>m patient to patient, but to prevent sclf-inoculatioi) with si>ecitic or 
non-sjKXrific virus through some abrasion upon tlic hand. Let the 
nails be trimmed sliort. 

Asepsis of the Instruments. The usual {>nietice of simply wash- 
ing an instrument in soap and water after each trciitnieut is unsafe. 
Ortlinary washing does nr^t remove bacteria and thereby piTvent their 
instrumental conveyance from one patient to ant tt her Surgical clean- 
linesis may be secured in the following numucr : Wash the instru- 
ments in hot water and green soap ; let each instrument be thoroughly 
wipetl with absorbent cotton saturated with 90 jwr cent, carbolic acid 
with glycerin. To (hi this easily two strong forceps are lu'ciled, one 
in the left hand to hold tlic cotton^ the other in the right hand to hold 
the instrument. The instruments thus moistened with carliolic acid 
are then thrown into a pan containing a boiling ll per cent, atiucous 
solution of sodium carlmnate, and left there for at least two minutes. 
It is convenient for this purpose to have always during the office- 
hour a deep tniy of the solution constantly boiling over the Hame of 
a ?pirit-lamj> or a gas-lnirner. A l»etter way is to have scvcnd sets 
of instruments, which may l>e used one after the other, and then all 
disinfected together at the end of the (Kthce-hour. This saves time 
and insures siifety. 

The camel's-hair |M?neil, brush , and sponge <^nnot readily be ster- 
ilized, and are, there tore, daugerous for rcjM'ated use. Al>sorl>ent cot- 
ton wound n|Mjn an ap]jlicator or stick, or gras|KHl by the dressing- 
forceps, may be used for pnrpttses of local application or for wiping 
oat the vagina, and may then be destroyed* 



48 



GENERAL PRL\X7PLES. 



The liubricant of VaBelin© or Oil, usually kept near tlie exainijia- 
tioii-table, is yDiieccssarv for luhrieatiiig |HirjiiJSc*s when tire natund 
secrL-tions aro pmfuse aiiJ thiiuselve:^ serve that ptirpuse. S<inio arti- 
^I'ial lubrirant is alway^s useful, however, to protect the operator's 
Ji liters against infe<Hion ; hut the lubricant is often a souiTe of sepsid 
in itself, or it may easily heeonie so by eon tact with the unelean tinker 
or instrument, (iuuorrhieal and other infeetiim is frequently earried 
trom patient to patient in tliis way. Neither tinkers nor instnmients, 
theretbre, should eonie in contact witfi the liibrie^iit, uidess they are 
free from vaginal and other secretions — unless aliii^oliiteiy clean. The 
hibriciint should be ase]vtie and iion-irritatinp:, Olive oil and vaseline 
are often septic and always hard to wash otf. Soap is apt to irritate 
the sensitive vnlva. For several years the author lias used glycerin. 
It is a most excellent Inbrieant and deodurant. Even after digital 
examination of extremely fetid utero- vaginal cancer, the fonl, nauseat- 
ing wloi% usually so lasting, nuxy he washed otf tlie examiner's hand 
liv placing it under a stream of running water, if i>efore the exami- 
nation the hand was frt^ely lubricatetl with glycerin. For this pur- 
pose a superior quality of glycerin is retjuired. 

The adaptability of glycerin for this purpose has led to the prepa- 
mtion of a glycerin ointment. It is put ui> in soft metallic collapsi- 
ble tubes, such as are used for vaseline and paints. The ointment is 
forced out of the tube by compressing the l>ottom between the tliumb 
and tinge r and folding the tlattened end as the tube is emptied. The 
use of the tube ol>viates tlie risk ol" coutannnating the lubricant by 
the soiled fingers. The pnqiaration is a sterilized combination 4»f the 
folhiwing ingredients : Oil gauitheria, 2 gm, ; boric acid, 23 gm, ; 
cornstarch, 88 gm, ; pure glycerin, 885 gm. ; tragacanth, 17 gnh' 

A Word of Caution or Protest. Many a distressing jx'lvie in- 
fet^tiim owes its origin to incildlesonie office gvnwology. Instru- 
mental invasion of the endometrium antl other manipuhitions which 
retjuire nim^h force an^ procedui*es which, under any conditions, may 
l>e tar fnun triHing. The physician^s otliee does not furnish tor them 
a uniforndy side environment. They require and should have the 
safeguards of tlic home or the hospitid, 

' The fi^rmula is the otitoomc of numiTnUH t'XtJ<'rlmi^nla by pArke, D*Tt9 A Compony, who. 
nptiu ihv itHthnr » ttuKUfefitlnn, bnve iierfi'itt'tl Uic i;iri.'jMt.miion. It li m»(!v by them uiitler the 
liHiiie *'Glyi'i*riii EmuliU'nt." 



CHAPTER IT I. 



niA<JXOsis, 



'he subject is divider! into two piirts : fir^t, the rlinical history ; 
second, tlie physical cxaniiiiatiiiih 



The Clinical History. 

Before ai^king questions or ret'ording any of the liistory it is well 
to let the jiatient niake her owu statement without suggestion ; this 
will relieve her nf nervousness and eotn(j(»se her ndnd for the syste- 
matic questioning. 

Histories are usually kept in hiaiik euse-hoftks printed and linuiid 
for the |,Rirj>ose. A very prartieal way is to keep them in indivitloal 
envel(>]M's, made of strong manila paper, eaeli liistory in an envelo]>e 
by itself^ with the name, residence, and date of the first visit written 
across the end. The histories ai^e kept in alphaheticuiUy arrangtM:! 
pigeon-holes, wliere they may be readily found. The great advantage 
of this plan is that I lie lust^iries mjiy ht^ written away fi'om the oftiee 
on seraps <if jiaper, and do not have to be n^picd^ l>ut may l>e tiled 
away together with any snbsecpu'nt curres]>ondenrc', jinvcriptions, or 
additional notes. 

Form for Record of CassB. Tlie .skeleton form given on the fol- 
h>wing pages is suggested fWr the eiuivenient and systematic record of 
Lci»s<*s» The printed Ijlank is suliject to such erasures and additions as 
■the individuiil ciise may retpnre. In using sueh a blank une must 
keep in mi ml the fact that no steref>ty|ied form enn inelude sugges- 
li<ins for all the points that are lialde to eome uji in (Connection with a 
esi^e. Unless, therefore, one supplements the inquiry by sueh ques- 
litms as each s(XK4al case may ctdl for, he will fall into a dangerous 
rf>utine. 

The reconl fHrm liere |)resented will hrlp the studrnt and yuntig 
praiHitioner to tbrm the habit of acH-umte ami systematie diagnosis. 
As one giun^ exjKriencHi ami automatic grasp, and jndgi's less from 
midtifttrm details and more from princi]iles, he will gradually elimi- 
nate fmm his histories and reeonls all that is not essential to the 
effii'ii'ut analysis of his cases. A few general statements may then 
sf»rve the [airpose of a praetieal memoran<lnnL 

In rtK'ording a case one may ecinveniently use aliljreviations iind 
signs, for example, the plus sign ( ! ), thi* miniis sign (--), the jiius or 
minus Sign (±:), the ssero sign {()), the sign of equality (=); and the 
letter n may signify (H-) excessive, (— ) less than normal, (±) variable, 
(0) no, none, or negative results, { -) i-rpials or amouuti* to, (nj nor- 
mal ; \\ ft* ^ wonhl be, fur examjdi', a short expression for ' * 
11 rg the absence of vesical symjitoms. 




GESERAL PRINCIPLES, 



RECORD OF A CASE; 

; -» lam OkM Momal; r, vwuMe; fll nn, none or Mcathr* resuKftt 
'tnwormaX. 




^^ tC-^ •^^i^ • „ 




■ 1 I 111 I iU Urgt, *U m^ ...^ ..C^Ur. Utt 



^« .t^mumi^ right mmd Ufi, tkpHiMgdawn tk^ks, kyp0gmstru. 



••4fi||ft 



"* ^^^p^^S^^BV^^riMK. " IValktme tmdnPectmtlj^jtfndimf 



;<■ 1*11 Mil iiiioi 






Urinatu- ^- ■ tttius dmrmg^ night. 



^^^. ^.^'mmm >* iimmJimgor wmUting. 



distress, duutUitm, 
MH h0ur or tw t^fier tmtimg. 



^ fc- -- *«H<N «HMhMM^ mn hour or tw 



« c^s' 



^'-.. 



«*. V 



^. , wRi, */ *»w- CWtfr 



nAONOShS. 



51 



.5,^, si^J-i^-Uy 



, mtrt*t'ytnrst, mtitratikfmim. 












^ Sugars - , UttA/y^A litAt S9li4i.^ff^a^^ 






JL IVikit Euo^iAlMM, OUfiwi^ i«t Tnilamil i 



(L[ ^U^^va^ l^^^e^e:^ ^^€4/1^^^ Sl'^-^l/ur^ 
/J tjtAk^mic U^iUnJ^ttZ^A^ n-TXyj^At/t^ yXnvytify 






}}{UitrutCt a^ p*waU. -Vrndtv^ V^'SW K^*«^ 



iyJS.AL PRISCIPLICS. 

- :: : Muti>f'tlu> common. The ])atient had 

•■i.i • . 't' itimkI I'amily liistory. The* iiu'iistriial 

. ' :. jH^rit'ctly normal until aiUT the tir>t 

':.^ aliiKtrmal clovel(»j»monts rfconlotl in 

' ••. !j.-.vnainns of the* cervix and ]K'rinonm 

!-'.:. t i.f iute(*tion ; hence int('cti<Mi spr«*a<l 

'.:•'{ j>««s-ihly al.so through the |»animetric 

:': rube, nvary, and adjacent jHTitcmeum. 

■^ - ■ 'ir^rus with its apinMida^es t«»jrcther in 

- i -.-placement was increased and iRTiKtii- 

_ ■ :" the uterus, by impairment oi' >np|>i»rt 

. :h:n i>, from injury to th<* |H'lvii* floor 

. .. - ■.-.VMhiti'd state of all the jH-lvic nrjnins 

' ^ . ri-e to menorrha^ia and leuc«>rrha*a. 

- •.► :niainia, neurasthenia, nervous irri- 

.::iiinn. Ditticidty of walking and 

:..N:'.t— ami from <lispla<'en)ent <>f the 

. . «<-.-.ary exercise, and still further 

!i. The incivased frecpiency of uri- 

" :\x\ may 1m' explained by the fa«'t 

-. • ::d to a l<>wer level and <lni'r «»n 

^- - . -liiL^'ji-li liver, faulty nu'tabnli>m. 

• . : .-t' oilier urinary s<»li<ls, excess nf 

"^* --al nephritis, are all n<it inicom- 

"-iii ami infection. 

i:u«-i-are«»ft<'n incnaM'*! by the 

• . :i;;-e im definite hn^al >ym|»tnius. 

^ • •■: the presence of [u'lvic* symi>- 

:! ^'y extnijH'lvic di^o^lers. 

-. ;i-r are nm-t reali>tic and be- 

. - ni!l eXpH'-Mil by the late I)r. 

. iiu -i l:ir«:ely fmm the fret>, 

i'>tlr-. tin- cark> and <'are?» 

-: ..■uuiimu -ymptoms <»f this 

• ■ . \« rv \t\w^ wliieh lay tnuli- 

:.• ;iilnniit> ni" the W4»mb. 

• . I 'iiv . i:r« at wearine.-s an<I 

-*. !!Kibiliiy In walk any dis- 

•■ '*': iihii In-. ii:ipt:i4-he, an<l 

. .V .1' l.ivnl. or >u|)prr.-M'd 

.Mv r : l:' II' r:il >piual and 

^ ■ ^ :"\ \\u- h IT. «»r in Imtli 

•\ ' •'., ..Ill- : th«- wnman i> 

. , . J-: - :.• Im il lintl. an*! >he 

. '• w!.. ;i -lu' lill a-lecp. 

•■.; -■ . .ti. n timcir^ that 

•x ■• . . :r.i- nmnb ^o fn*- 



DIAGNOStS. 



53 



Quently that she fc^rs palsy or paralysis. Nor dom the skin escape 
tliegt'Derai syoi^tathy. It iKHnniit's dry, harsh, ami f^ciirfy, and pig- 
menlar>' de|i*Ji?its ap{>eiir uudrr the eyes, anmnd the nipples, ami in 
the chin and forehead. The syniptoiii-grtHip of iiervrm^^ exliaiistion, 
— anflpmia, baekaehe, hearing-rl*nvnj flitlieult walking, ovarian pain 
and nii^nstnial disLirders — ahht)u^li oiU'ii with^nit the least gyneein 
)<«€:iail si*:iiifieaijee, is usually the .signal for a gynecological diagnosis. 
Any p^lvie organ simuing the slighte.st irregnlanty is singled out iis 
tlie culprit and promptly placed on trial. Endless injanons loctil 
ireiitment and grave surgical oj>e rat ions may now ciiuse the woman to 
sfuffermuny things from many physicians." 

A-sGoculell aptly remarks : ** If no tiingible disonler of the sexual 

oi^n??lK'di,scc>vcral>le, the invisible endometrium or ovaries must take 

the blame and receive the lix-al treatment. Whatever the inlook or 

thf outlcMik, a local treatment, more or less severe, is liahh* to be the 

i^^ne. Yet these very exacting symptoms may he dne wholly to 

nerve-strain, or^ what is synonymf>ns, to loss of l>ruin-control <n'er the 

lower nerve-centres, and not to direct or to reflex action from some 

srjpjKist^i uterine disorder, Neidier, for that matter, may they come 

from s<tme real, tangihle, and visible nterine lesion which jmsitively 

exists. Thus it liapjjens that a harmless anteflexion^ a trifling leucor- 

rlj<iea,aslig!it displacement of the womb, a small tear in tlie cervix, an 

insigniflcant rent of the ix^rineum, or, what is almf»st always pn'seut, 

an ovarian ache, each plays the part of the will-o'-tlic-wisp to allure 

the physician from the bottom factor. To these paltry Icsitms — ^Ije- 

eause they are visibh\ palpable, and ponilerable, and hci-anse he has by 

education and by tradition a uterine bias — he attributes all his jmtfent's 

troubh^ ; when\*is a greater and subtler force, the invisible, impal- 

fiuble, and imjmnderable nervous system, may be the sole delinquent. 

The sutferer may l>e a jilted maiden^ a bereaved inother, a grieving 

widow, or a neglected wife, and ail her nterine symptoms — ^}*es, every 

one of them — may be tlie outcome of her sorrows and not of her lixiil 

lesions. She is suflering from a sore hniin, and not from a sore 

womb." 

We may admit the extreme wisdom of GcMxleU's summing up; at 
the same time wc must insist that an exhaustive analysis of a patient's 
condition will often lead to conclusions less inipondenible than his c.r 
partf statement would imply. The case above outlined on the record 
blank will not only show an example of |»ossiblc diagnosis ; but, if an- 
alyze<^l, will also show that the cure of aggravated local lesions may not 
result in the eoniplete recovery ^if the patient ; such cure will, how- 
ever, be an iin|>ortant step in the rigfit dtrection. A common mistake, 
when there are otlicr more general and, perhaps, more serious anoma- 
lies, is to exjieet, njxjn the correction of local lesirms, prom])t and 
complete relief. It would also be cr|ually a misiake to follow the 
po«5{«»ible implication of (io(H Id I, and, because we kntnv that local treat- 
ment of pal|>able Im^al lesions cannot completely cure the jmticnt, fail 
to give that trentment, and thereby fail to cure her as fiir as we can. 
It is, moreover, improl)able that a harndess anteflexion, a trifling 
lencorrhcea, a slight displacement of the w-omb, a small tear of the 





54 GENERAL PRINCIPLES. 

cervix, an insignificant rent of the perineum, or an ovarian ache would 
often lead a serious practitioner away from the " bottom factor " to 
useless or injurious gynecological treatment. 

Not less essential than the gynecological part of the record is that 
which belongs to the general condition of the patient Age, tempera- 
ment, bodily habit, heredity, color, the heart and blood-vessels, the 
digestive tract, the liver, spleen, and, even more important, the kid- 
neys, all demand close and careful attention. 

The Physical Examination. 

Examination calls into use the special senses, supplemented by such 
conditions, instruments, and appliances as will increase their power or 
widen their range. 

The conditions to be fulfilled for an adequate examination are num- 
erous and variable. Among them are: 1. Cleanliness. 2. Empty 
bladder and rectum. 3. A suitable table. 4. Proper attitude and 
position for the patient. 

Cleanliness and asepsis have been emphasized in the last chapter ; 
their importance cannot be exaggerated. Exception : If it is desired 
to study the character of the uterine, vaginal, or vulvar secretions, the 
preliminary douche and disinfection of the parts may be omitted. 

The rectum and bladder should be empty for the following reasons : 
1. These viscera, when full, displace the pelvic organs by pressure. 2. 
Retained feces and urine maybe mistaken for solid and cystic tumors. 
The full bladder pushes the uterus and its appendages upward and 
backward and greatly increases the difficulty of conjoinea examina- 
tion. Even a small quantity of urine in the bladder may cause the 
patient to make the abdominal muscles so tense that the uterus cannot 
be felt between the hand over the pubes and the examining finger in 
the vagina. A preliminary cathartic to clear the bowels of feces and 
gas should therefore precede the first examination. 

The Examiningr Table. The digital examination may be made 
with the patient lying on a sofa or bed ; hut, as Marion Sims has 
taught, " the one is too low and the other is too soft and yielding for 
a s]>eculum examination.'' Even the digital touch and palpation are 
much better made on a table. If the bed is used, the patient should 
lie across it, with the hips well to the edge, and not lengthwise of the 
bed. The table is essential for a thorough speculum examination. 
The conventional office chair, although less objectionable than the sofa 
or bed, is, by comparison with the table, inferior. An onlinary pine 
kitchen table, two feet wide, four feet long, and two-and-one-half feet 
high, covered with a blanket and sheet and supplied with a pillow, 
will answer every purpose almost a.s well as the more elaborate table 
commonly used in office and hospital work. There is some advantage 
in having the end of the table upon which the pelvis rests about three 
inches higher than the end upon which the head rests. 

The Position of the Patient. Two positions are in common use, 
the dorsal and the left latero-prone position of Sims. The knee- 
chest, the standing, and the prone positions are less frequently used. 



DIAGNOSIS, 



55 



Eiich of these pfjsitions has advantjigcs peenliar in itself and to the 
iciiiclitioiis under wljieli it in eui|jlHyr(l. They will be de.seribt^d as the 
oc*xi^ioD urise8, 

Examinatioti of Young- Girls* The first examination of a ytning 
*^irl is approached vvitli rehietance, and is, if possible, avoided. The 
:uiv*untages of ana^thesia from the stautlpoiut of modesty must be 
apjiarent to all. If the hymen is intaet, an effort shoultl be made to 
pun the net?e8sary iiifnrmatitm by a eonjiiined digital exphiration 
tJin^JU»^h the rectum, tht* palpating hands being over the hyfK>gaft- 
rritim. 

Conduct of an Examination. The elotliiiig about the ^vaist 
having been h^osened^ the patient by stepping upon a ebair, the skirts 
having been niistnl beliind, sits upon the extreme end of the tabk\ 
She is then assisted to he u{>on her back, tlie head, not the shoulders, 
.mi|)|>orte<l by a pi How. Before lying down she is covered with a 
'sheet* Under the sheet, and without exposure, tite feet are lifted 
from the chair to the tal)le, placed about six inches apart, tlie clothing 
in front is pushed above tlie knees antl the knees are widely sepa- 
nit*^<l. Tiie Hexure of tlie thighs, secured l>v placing the feet on the 
liiible, relaxes the abdomirja! muscles and facilitates palpation^ The 
nlge of the sheet as it falls cn'er the knees is parted back between 
the thighs so as to expose only the part to U^ ins(>eeted — that is, the 
vulva. The patient is assunnl that she is neither to be hurt nor un- 
duly cxj>08ed. She is now ready for: 

1. Inspection of the external genitalia. 

2. Digital examination of the vagina and rectiim, 

3. Conjoined examination. 

4. Percussion, pal|xitiun, and auscultation. 

5. Meusunition. 

6. InstFimiental examination. 



1. Inspection. 

rnspeetion of the external genitals and their surroundings is de- 
sirable, first, as a foiY*warning against possible inoculation of the ex- 
amining finger witli venereal or other infection. Some historic eases 
there are of surgeons who have gone to tlieir ileatli from this cause. 
Any abrasion on the hand sh<ndd be protected with a eolhxlion and 
cotton flressing : a very thin layer of cotton is jdaced over the abm- 
»ion before the eollmlion is applied. Look for lact!rati*nis, sears, and 
^ther cvi<lenees of parturition, vulvitis, tumors, urethral caruncles, 
irethritis, eruptions, hemorrhoids, anal fissni*t% fistula in a no, pin- 
worms, pruritus, *pdenia, cystm'ele, reetocele, ulcers, tnfhnnniation of 
Skene's glands, and other anomalit\s. Note the ealilur and elasticity 
of the vulvar orifice. Is the clitoris enlarged or imprisoned under 
Ljin a<Ihcn*nt prepuce? Such adiiesions may give rise to pronount^ed 
fteflex disorders. The virgin vulva is usually small, with the hymen 

IK»rfopated only by one or more small openi ugs. It is, perhaps, need- 
ens to add that the absence of such a liymcn is neither proof nor 
even Btroug evidence of nnehastity. The virgin labia niinam are 



7 i"; . !.j. ]•--•'. and flaliby, 

:»-.■ . .-. ::..- inilii-sititniri are 

'M. : : ..- iaU'i inu«.-li tn-at- 

.-- '--.:: ::.' *'::lj.-^;■l of somo 

'.: • :•• • r •::•■:;%»:• Mr;:^nis ii<»r 

■ •• "— :* :!i- -jH'Oiiluin to 

:i- Tt:: r^. ::.. r'.tnni, ami, 

- - •: z • :. :•.::! |i..lvi>. Tlie 

- .:. -x..:..:!..i::-.:i. ami liy \{< 
: " -^ :. - • r iiaracior nf a 

" " ■ j:. >■> **( ovarian 



T', arrZ- 





• :h- rijrht wa^ 
>. Th»- irreat 




'•::j liR- ^«inn» 


:: r.: ^-rr 


:- i!.'»n- ♦a^iilv 


;-. - :...* 


::; ..v-*- n-la- 


..- ■■* r.: 


r- :Vr-.|»i.nt nn 


j^ r T.S'r, 


•.:i!:'l i* iM-tttT 


!.: !.:.:.•: 


:* ]• :'! iViv ti» 


'. "t;;^ '\ 


:.::'-iL.!i..n nf 


:w.::.: :!. 


Tw.. tiiiir'T- 


\. .::.::.:;:: 


••n ■■:' tfiiu-ir-.. 


;^- riir'i 


f'v Kinijh. t in 



• j-.iiin.l lty tli»' 
tain'i*. 
•.V..W }.. :}i.ir«»:ijlily ami 
• **• --i a kr.-»\\l» 'II''" ot' 
: •• r !!.♦• t'«'nli th»- ninn* 
; • r ':.•» -I:.:Iit i-liaiiL^rs. 
. -v :ti th. ir iii«t]i«M| nf 
* r'.:«!5 \ i\:«ir a* it' lir 

• • ■ r\ :\. wliii li fl-iN 

:!::i*:«»!i •»!' imp«ir- 

'• ^\ ■'*.'. |M-* lii- fiiiiT'-r 
" '■ ■::' li.iviii:: iaiiM*«l 

. :'.I!y T.I im«lrr-taml 

• - - • Vi :!ii- I'xaiiiiiui- 

• . * rilnil 4»iily as 

•. •• '. in.! tlu- wail! 

:.' pr.ii'tiiM' i»t* 

. '': :'>ii\-tinir('r i^ 



DIAGNOSIS, 



57 



lubricated with glycerin, mild cii-^tilG i^oap, or glycerin craoUiiMit — see 
page 48 — and tlicn nlowiy introduced^ the piilmar ^nrfhce Iieiiig di- 
nsi'ted Jownwai^ so as to depress the jierinenni toward the reetnni ; 
it notes die rigidity of tlie perineum, the prenenee, ahsencej or coii- 
>iVteticy of the feces in the reetura, the ealibre and rehixatioii or ri- 
fitlityof the vigina, and the condition of the sacrum and coccyx. The 
IMlmar surface of the lingerie now directed alternately toward tlie 
lateral and the anterior [)ortion5 of the jielvis and .^wept around the 
iTTvh, The direction, size, form, and couf^istency of the cervix, 
the cahhre and form of the os externiim, anrl the presenee or aliseuce 
of laceration become appiirent. The right hand is now placeet t>\x*r 
the abdomen behind the pubes, and the inquiry continued by con- 
joiriiMl examination. Irritation of the clitoris may give rise to sexual 
excitement ; hence the examining hand should be kept well away fnan it. 
Digital examination with the prntient standing, has some value as a 
means of diagnosis in uterine disphi cements, Kxaminntion may be 
made with tlie w^oman in the left latero-prone position, hut for gen- 
eral pur[>oses is not recommended. This position is reserved rather 
for speculum examinations and operations. 



F|i*rRE2n. 




Digital t^verslnn of the antis.^ 

Eversion of the anus, a8 shown in Figure 20, enablei^ the examiner 
to judge of the condition of the lower part of the rectum and anus. 
This may l>e done either in the dorsal or lateral position. 

3, Cotdoined Examination. 

The student will find the deseriptions of various manipulations in 
the chapter on Pelvic Massiige of great service in the study of eiui- 
joine<l examination. 

» After MundC'. l>Jive»port*« Dieeoaefl of Women, 




DIAGNOSm 



59 



Usually, however, the right hand forces them down to a |wint where 
tliev may be readily oxaniiued by digital touch. Tlic latter methfxl 
is ii:iu:illy preferable, becau,se the applieatioa of umch foree in the 
vaginal or rectal touch may be liarmfid to the patient or may impair 
the tactile sense of the finger. A eorabi nation of both methtKls i,s 
desirable. The necessary amount of force will vary with the toler- 
aiicj? of the patient and the skill of the examiner. The reach of the 
fiamining finger U matenally increase*! by forcing tfic elastic peri- 
neum Uickward and toward the interior <jf the pclvi.s. Thi.s is usually 
not difficnit, for during the examination the knuckles of the middle, 
ring, and little lingers on the left hand are pressed against thecuta- 



FlOXTRF 2rt 



-^ — -L- 



I 



Cbnjohied lecto-vaginftl pHtpation. 

neon^ surface of the perineum. Upward pressure on the perineum 
may \)e made with the three outside fingers closed, as shown in Figure 
21, or ojxjn, as shown in Figure 22. In the latter and j>referable 
method the web between thr^ index and mi<hlle fingers is in contar^t 
with the perineum and exerts the pressure. 

Bimanual examination, to be effective^ requires long practice. The 
beginner fails, first, to bring the orgjins properly between the two 
hands ; second, to appreciate what may be within Ids reach. Sliould 
the thickness or rigidity of the nlKlominal walls |)rcvent the downward 
prei5sure of the hand hchind the pubcs, the resistance may be overcome 




UEKBRAL PRINCIPLES, 



.or 



by 8ucees>ive s^hort strnkoi^ of vibratory 
The diffienlty is often the result of 
the patient's iiervousness. 
The examiner should, tliei-e- 
fore, avoid siidtlen mo\'e- 



jLs 



1 la tic 



ment 

A deep inspiration by the 
pitient, foUimed by a quick 
expimtion, whibj steady 
prei^siire is l>ein<r made, may 
momentarily relax the mus- 
cles, and thereby affVird the 
examiner an opportunity of 
rapidly palpating the pelvic 
organs. An examiner of 
acute touch and qniek |K^r- 
ception will sometimes in- 
stantaneonsly gain the re- 
quire<l information in this 
way. During the examina- 
tiou the patient sliould keep 
the mouth o|>en. 

If the uterus and its ap- 
pendages are sensitive, or 
fixed by adhesions, the at- 
tempt to force them up to- 
ward the ontside hand may 
he 1 utile or even dan^^erons. 
IX^^p jnilpation behind the 
piiU*s is then necessary. 
One should rememl>er, how- 
ever, diat even a little force 
injudiciously applied by 
eillier hand may rupture 
a pU4s-]KX"ket or tul>e, and 
^ i^riotiss results. 

yfii0itifm fNMikles one to judge of the follow* 

^m 4i*«ew It^nn* location, position, consist- 

^4$^^Jli^ W llM^ lltrnif^, the pres«mce or absence 

iiiii^M^ If thtrt i» displacement, is the uterus 

>W<ii>d by iHlhesions, and therefore ir- 

•vf^ i» n tumor in the [Kdvis, in it a 

iiiMMlotn* towelling? If the former, it 

W lltt^^r^ It iiJ tender on pn ssure. Is 

K^iH¥^^i»k CMT the Fidlopiiin tube, or the 

•V? Is it eystic or soHil, ma- 

i %Mrt|^nttte in (he ]>elvis or in 

ilwe all, is il pi^sibly due to 



i 



will 



oiitit' tip ugain under 




61 



For |>alpation of the pclvii- organs, see Chapter L, on ilai*.^ge. 
Conjoined examination by rectal instead of vaginal touch may eon- 
irm, disprove, or sn|)plement tlie previous observations and inipres- 

Canjoiaed recto- vaginal pidpation is made with the left index- 
finirer in the rectum, the thnmh in tlie vagina, and the right hami 
(jehiud the pubes. See Figure 23. In this way the prinenm is well 
pu*ht?d up towanl the interior of the pelvis. If the abdominal wall 
i< thin and relaxed, the various pelvic «>rgans, when toreed down by 
the hand behind the pnbes, may bo picked ujf, s<> to .spak* between 
iJie thumb and hnger ami detinitely |>a!pated. 

Pal pit ion of the {ndvie organs, especially the ovaries and Fallopian 

tubes, is often fixcilitated by tl rawing the uterus toward the vulva by 

tneaDsi of a uterine tenaculum or stnal! tooth -ibreeps. During the 

plpation theiie instruments may, if necessary, be hela by an assistant. 

For this purpose Howard Kelly uses a tenaculmn with eorrngated 

handle* The cervix is caught with this tenaenlnm anri drawn down 

to the outlet ; then the tenaculum is licld against the ball of the thumb, 

while the index finger is insf^rted into the rectum or vagina, and used, 

in conjunction with the alxlominal hand, to examine the pelvic organs. 

Failure to engage the u terns between the two hands in conjoined 

examination may be due to a backwanl displacement, or to rigidity 

of the alidominal muscles, owing to a state of sensitiveness itt the 

parts under exa mi nation, or to the nervonsness of I he patient. The 

hilter condition may call for ani^sthesia. 

Becta.1 touch, whether digital or conjoined, may be impeded by coils 
of intestine in the pdvis interposed between the finger and the viscera 
to be jxilpated. This miiy be a vended by a simple device of Kellv's; 
"The rectum and bladder are tirst evacuated » tlic patient is put in the 
knee-chest posture, and a sj^eeuluni is introduced into tlie rectum, 
^Xbis lets in a large amount of atr, and the bowel hulloons out and 
jjplies itself broa<lIy over the Siicnd hollow and the posterior surfaces 
:}f the uterus and left broad ligament, and in a minute or two the 
small intestine falls away into tlie upper abdomen. Tlie patient must 
then l*e turned on her back^ care being taken to keej) the pelvis con- 
stantly higher than the rest of the abdomen, so us not to let the intes- 
tine;? gravitate ag-ain into the pelvic cavity. On making the bimanual 
examination the [xdvic viscera are, felt with startling distittctness, the 
rectal finger enters a large air-cavity no hniger impede d by the mu- 
[>ii5 folds ; the o|>euing from the lower into the uj>p( r rectum is 
eadily found ; and the posterior surface of the uterus and the ovaries 
and ttd>es feel as if •skeletonized in the |>elvis. They lie so clearly 
exposed to touch that their minuter surface-jn'cuUarities, tissures and 
elevations, and variations in consistency, can Ijc detected, 

"The roots of the sciatic nerve may also Ijc palpatrd by the rec- 
tum, as shown in Figure 2fi ; such an examination will sometimes 
fveal the sourcf of an obsr-nre intm-pelvic pniu wliith has previmisly 
een attributed to an ovarian or a iiterine origin. Tlie patient must 
be conscious, and as the fingers are drawn over the tender cord a cry 
of }x\in will be elicited," 



GESEEAL PRIXCIPLES. 



Too fMrittar biHmming of the n^etum just di^scribefl is f^ome times 

EkMH the previous introductioD iif the specotuiu in the 

Dr. Frank Billings, in a verbal commiinit.*aiion» 



\ -^ 



t /r> 



Jkerrhei^mi 



^^ 



m 



-<s. 



i\ 



I^ImMmu ^ tiM i%K^ of tti«f ffc'iMttc nerve U>' rectnl touch. 

' ftK ahiK*»l universal presence, and its value as a dlagnos- 
,vf ihe lioweL The writer has repeateclly and 

TtitiiHiliim>il'"Ti with the Sound. One may be unable 

> Wlher a tumor is of uterine or extra-uterine 

tv iIhmi W immoliilized by the sotnid piissed 

KeUl inimovalvlr by the liand of an ii>hist- 

>k*«idit\l l>y a tooth-iore<*ps or teiiaeiiluni 

Wi^ e\aniitier may tlien determim' whether 

\\s^ ^orro^ x^T imleiHMHlcntly of it. In case of 

, .u' i^^Ij' K\ or of an extni-uterine tumor ad- 

fiiL 

^ nation is ap|i4irent in Fi|rnre8 29 

' Fiirnrt^ 2*J, whieti re|)resents a niynni- 

!MUiie impression as in Figure 30, 

lick rotyoiniil examination, in Figure 

'' HiU»rtexion» while in Figure 29 it 

r H myonia. The exaet tlii-ection 

' rhe uterus to tlie tumor might 

V or the sound. 



DIAGNOSIS, 



63 



AnflBsthesia. If the abdominal muscles are rigid, or the pelvic 
organs very sensitive, or the patient too nervous to permit an adequate 
examination, the surgeon should insist upon further examination under 



FXGtJBE 27. 




rtenis drawn down bj* means of tooth-forceps to facilitate manual examination or 

replacement.! 



ail anaesthetic. Intelligent treatment may otherwise be impossible. 
Accurate and adequate diagnosis lessens the number of exploratory 
incisions and unnecessary operations ; or it may cut short a vast 

* I>avenport*R Diseases of Women. 



DIAONOSrS. 65 

of the vermiform appendix. Inflammation of this part is so fre- 
quently associated with infection of the uterine appendages, especially 
on the right side, as to render imperative in every case a very careful 
examination for possible appendicitis. Equally important is the ex- 
amination of the kidneys. One who has not systematically included 
the renal organs in his examination will be astounded at the revela- 
tions of such investigation. Hydro-nephrosis, abscess and stone in 
the kidney, tubercular kidney, loose and floating kidney, and stricture 
of the ureter are among the pathological conditions which are com- 
monly and culpably overlookea by the gynecologist. In this connec- 
tion the mere mention of intestinal, gastric, splenic, and hepatic 
disorders should be sufficient. 

5. Mensuration. 

Mensuration is a most important factor in the examination of new 
growths and other lesions causing abdominal enlargement. The sub- 
ject will be further considered in connection with the special diagnosis 
of these disortlers. The measurements of the bony pelvis frequently 
have great significance, not only from the obstetrical, but also, espe- 
cially in the matter of displacements and malformations, from the 
gynecological point of view. The reader is referred for pelvic men- 
suration to the literature of obstetrics. 

6. Instrumental Examinations. 

As already stated, the development of modern gynecology has been 
made jXissible by the use of instruments of precision designed to in- 
creaife the jwwcr or widen the range of the senses. This statement 
has even a greater force from the therapeutic and surgical stan<ljK)int 
than from the (lia^^o^^tic. The diagnostic methods already described 
will usually furnish the groundwork of accurate and adequate diagnosis. 
Instnmiental examination, however, may supplement and verify con- 
clusions already reached. It is, however, as compared with digital 
tonch, of minor importance. Some of the instruments used for diag- 
nostic purposes are : 

1. Sjieculum, 5. The exploratory needle and aspirator, 

2. The sound and probe, G. The stethoscope, 
.*5. The dilator, 7. The microscope, 
4. The curette, 8. The cystoscopy 

The Speculum. The choice of the speculum is simplified by the 
-uitcment that of the innumerable varieties only two reijuire very 
serious consideration, and that these two act on the same principle — as 
IK-rineal retractors. They are : 

Sims' speculum. • 

Simon's s|)eculum. 

Sims' Speculum. This instrument is of great simplicity and 
effectiveness. The objection, sometimes urged, that its efficient use 
ref|uires long practice, is a mistake. Whoever once masters the simple 
principles of the left latero-prone position will have little or no diffi- 
culty. The failure to appreciate the mechanical relations of this posi- 



m 



GENERAL PRINCIPLES. 



tiou to 8ims^ s|>eculiim will explain most of the fli,sjipp€intmt?iit8 
resultiiif^ iram its use. AnotlitT siUcgtsl disiidvaiitaju';!' of Sims' spc^cn- 
lum is till* necessity of a truiiHMl a.s^istant to hold it* If the examiner 
himself knows how the iiistrmjif'nt should be held, tho assistum ni'vd 
not be trained. In gynecological examinations the presence of a 
third j>er."5on i.s, for obvious reasons, an iidvautage. Examinations at 
the patient^s hiiuse may nsually hv made with the as,sistanee of some 
niend)i'r of tlie fumily* The physician who has a large otfiee [>raetioe 
caii have die a^sitttunce of an office attendant ; or if this is impraetic- 

Fmmui ai. 




BlwA* specnlum and depresAor. 

able, a mfHlificKl self-retaining Sims' speculum may Iw used. Sw 
Figures 32 anrl ^^t\, 

TlMimas, after lon^r exiierieiiee with ^^ther instruments, makes a 
statement something like tiiis : ** Learn the um- i»f Sims' siweulnm, 
[>ersevere in the method for three nmntlis, and you will never give 
it up.** Emmet, whose ex|)erience with the instrument is, perhaps, 
greater than that of any other, Hays : ** I>r Sims' instrunjent has been 
motlitied in various forms, and new ones have been invented on the 
stime prineiplcj with tiie view of dis|M_*nsing with an assistant; but, 



-pui, I 



DIAGNOSIS. 



67 



I 




I 



as yet, nothing has been devised which can take it.s place. This in- 
strtimeiit is so simple in design, and 80 perfectly does it fnlfii every 
reqairement, that it will probably never be sopersedeiL 

** As long as the snle use of the speculum was to l>nn|;; the cervix 
into vieWj and tt» faeilitate the passage of the porte-<'anstique in the 
treatment of supposed ulceration, the cyliiidrieal speculum sufficed. 
With the advance of knowledge in the treatment of uterine disease, 
it liecame necessar>^ to gain more space and light. The cylindric^ 
sfieculum was therefore gradually gujx'rseded by various instruments 
with expanded blades to open out the upper portion of the viigina, 
but nearly every sj>ecnlnni of the kind that I have seen is so long 
that it displaces the uterus more or less, and by continued use tends 
to dilate the ufiper jiortion of the vagina. I liave known Ijoth retro- 
version and prolapse of the uterus to oeenr in this way from the 
repeated use of the valvular speculum . The amoimt of space and 
fight obtained by any of these instroraonts is very small in eonitKiri- 
with what is atioi-ded by Sims* epeeuluni, and they are useless for 

s u rgica I proceed u re s. 

"The older members of the profession w^ho have become dexterous 
in the use of some special instrument eamiot be expected to change it 
for a new one, or to appi'eciate the necessity f<»r doing so. But the 
yoijng<?r practitioner should begin with Sims' speculum, if he wishes to 
hold a pc)?rition in the advance, Full justice, in the light of our pres- 
ent knowledge, cannot be done in the treatment of uterine disease by 
any other inM rumen t than this [x^rineal retractor, or some other basei 
on the same principle, and, like it, cajiable of exposing the whole 
\-agina. 

In a single generation the use of this instrument has advanced 
the knowledge and treatment of the diseases and especially the in- 



Flot RE 32. 



ClevelaD(j'6 seif-rHuinmg gpuculum. 



juries of women, from profound ignorance, to a front rank, if, indeed, 
not beyond that of any otlier braufli of surgery/'' 

The Self-retainingr Sims' Speculum. Modifications of Sims' 
sjiecuhim to make it self-retaining have been devised by Emmet, 
Cle%^eland^ and others. They are all inferior to the original Sims* 




m 



GENERAL PRINCIPLES. 



instrument, but superior to any one of the multiform cjlimlrical and 
bivalve instruments. 

Cleveland'^ speculum is one of the best examples of its kind. As 
shown in Figure «33, it is held iu plaee by a stnt]> attaehetl to the outer 
blade, by a .^lol at its inner end, aud by the metal baud between the 
blades. The stmp posses up over the coecyx and sacrum to join a belt 
buckled around the waist. Traction by the strap on the speculum 

^"" THE 33. 



^\- 



'V 



^ 



y 



CteyeUnd's s«lf>reuiai&g ipecQlam in placv. 



retracts the perineum. The blade has a flange for holding up the 
right l>utt4>ek and hibium. 

The Left Latero-jjnme Pomtion, In order to appreciate the action 
of Sims' s])oculum it becomes necessary to study the effect of Sims* 



Fioriiz Si. 



Incorrect representation of 8lm»' left latero-prone poiltlonJ 

latero-prone {position upon the jielvic organs. Like the knee-chest 
jiosition, i»f which it is a nKKlitieation, it causes the vagina to till with 
air, and the anterior and jmsteriur vaginal walls^ — or, to speak more 
comprehensively, the pubic and sacral segmeuts of the j^'lvie floor — 
I Altor Lebtood. From Thomu and Muad^, DlieMc* of Women. 



DIAGNOSIS, 



69 



to separate. The speculnin then exaggerates the eftert of thh pod* 
tion by hooking or amwing back the ]»erineniii, whieh exjiosea almost 
the entire surface of the widely opened vaginaj and causes the cervix 
to be drawn somewhat toward the vulva. 



FlGUIMt S5. 






I 



Correct latero-prone poaitiori.i 

Two requirements are essential to the .successful u.se of Sims' spec- 
olain — correct position of the piitieut and proper liolding of the in- 
strument. The patient is to he placed on the left ,side. tlie liips heing 
over the left-hand corner of that end of the tiihle wliich is toward 
the operator; the knees are to be drawn up toward the abdomen, and 
the right thigh flexed slightly more than the left* The patient's left 
arm reste behind her on the table. This permitg the right slioulder 
to be thrown for wan 1 and de|)ressed toward the right side of the 
table » ^o that the position becomes latero-pnmej — tluit is, hiteral and 
slightly prime at the hips, and almost wholly prone at the shoulders. 
The left side of the head rests upon the table, the lace looking to the 
right.. The right arm hangs over the right side of the table, and the 
long axis of the trunk extends oblicpiely acrt^ss the table from left to 
right.- 

The steps of an examination with Sims' speculum are these : 

1. Place the patient, the waist clothing being loose, in Sims' left 
Itero-prone position, the head^ not the shoulders, supiK)rted by a very 
lin pillow. 

2. Protect the buttocks with the towels, Figure 36. 

3. Let the nun?e lift up the riglit labium, Figure 37. 

4. Introduce one blade of the s|>eeuium and i>Iace the other in the 
mirse^s hand. Figure 37. 

•>* With the depressor in the right hand, push the anterior vaginal 
ill forward until the cervix conies into full view. 



I From Hei;«r an<1 Kaltonbach 
« E, C. Dudley, in Araericau 



OjKrutive Gyn&kolojrie. 
Intern of tfynecology. 



70 



GENERAL PEiNCIPLER 



6. With a wad of absorbent eottoti in the grasp of the titeriiie 
tlressin^^-furrepH, wipc^ out any s^ecretioii in the vagina that may be 
fyyntL 

7» If tlie sound is to bo pushed or the uterus otherwise instrumen- 
tal ly examined, change the depressor to the left hand and nse the 
right for this purpose. Instead of using tlie depressor during instrn- 
ment^ition of tlie nterns, it is often desirable to steady the cervix with 
the tenaenlum or tenueidynx foreeps, 8er Figure S7, 

In many ca?es the vagina balloons with thi' inrush of air* and the 
%vliole field eomes into full view withtiut the use of the depressor. 
The patient is now ready for : 1, inspection of the entire vaginal sur- 
faee j 2, instrninental examination of tlie interior of the uterus. 

Inspection of tlie vagina will enable one to judge of the presence 

Ftt.rkE 36. 



K 



X 



Patlenl in SimB* left Utero-pronc po«itton md protectod by towels. Reidj tor Introduction 

of Si in a" upct'Uluui » 

or absence of vaginitis, ulcers, laceration of the cervix, erosion, cystic 

degeneration, vaginal cieatricesj traumatisms, vapc'n^d fistnW, carci- 
noma of the cervix, and other new i^rowths. Path4^hj|rical disehargies 
may be taken for microseopie examination, and their ^source, whether 
from the uterus or the vagina, may l>e ol»serv(Ml. 

Simon's Speculum, shown in Figim^ 39, is a perineal retractor 
8in)ilar to Sims*, bnt with shorter and flatter blades, wliieli are made 
of different shajws and sizes, and aiT adjustable to a common handle, 
80 that th(»v may be changed to meet the requirements of tlic C4ise. 
It is a favorite instrumerjt with (xerman snrgcotjs. It thtlers from 
Sims' chiefly in the manner of its u.se» which requires the patient to 
be in the d(»rsal decubitus, and the thiglis to be flt-xed in the lithotomy 
position. An objection to this instrument is tliat during its uec the 
vest CO* vaginal walls iirv liable to fall down to wan! the speenlnra, and 
the lateral walls to fall together in such a way us to obscure the field 

* Aft«r DaveniHtrt, Dlieiuittt of Women. 



^ 




DIAONOSIS, 



71 



opmnnn. To i^livkte tins difficulty oire uses a smaller tlioiigh 
»imimr retractor which acts in Uie opposite direction, like the anterior 



FlOURK 37. 



FiotniK 3* 



it 



BK&min&tlon wltli Sim*' ipeculum. The tr>wels ure omitted in order to show 
the i'Xftct p<)9ition of the pel via ami thigha. Pn^jsaiy^ pf pruhe or curette : vmr- 
tljt •t«tt(lie<l by vulaellum. 

blade of the bivalve spec nl urn. Lateral depressors also 
are oftc^^ required mi either side. All of these are more 
or less in the o|Krrator's way. The intrrMloetion of the 
i*ound, enrette, or other instruments to the interiori>f the 
uterus is more ditlk-oU in the dorsal than in the Sims 
position ; and if the or^n be anteverted or anteflexed, the 
instrument is especially liable to be arrested at some point 
on the fx»sterior Widl of tlie cervix or at the internal os, 
pund refuse to mss further. 8imon\s spccnhnn is less 
^tjisily held, and requires more assistants, more attach- 
ments and depressors^ than Sims^^ it fi:ives less light ami 
spjice, and for geneml diagmistic use, tJiereforc, should 
never hav^e the preference over the Sims' instrument. 
For vaginal hystereetomy and many other o|x? rations 
involving vaginal section the Simon instrument is 
pn^ferable. 

The Probe and Sound have id ready been mentioned 
in connection with conjoined palpation as a means of 
rdiagnosis in tumors. In some eases the soimd, and Ej^met's uterine 
Je!i|>ecially the prolx^, may 1m' ditlicult or impossible to fircssinK forceps. 
hsjH in the dorsjd |x>sition, biit may l>e reailily passed with tlie aid 
Sims' speculum in the lateral position. 




vulst^Ihim frirr^'ps, p:*ntly dniw it ffjward tht' viilvn, and |wiss the in- 
stnimeut, bcmiing it iR-forc (iitrtKluftiln* tti uoiitoriii, as nearly as the 



73 

surgeon can judge, to the direotion of the canal The forward trac- 
tion of the uterus greatly facilitiites the passage — in fact, is sometimes 
essential. 

FiGlTRB 42. 



Scuiidi of Simpson and Bims compared ; sections of full si/e 



DanfjevH of the f>ound and Probe, Numerous cases of grave infec- 
tion foUowing the use of these instruments have given rise to an 
impression tliat they are dangerous. The risk, however, is practically 
nothing if complete asepsis is maintained. Even a clean instrument 
may carry infection from the vagina or vulva ; hence the necessity of 

Uborough asepsis of these parts. The sound without asepsis is more 
Dbjectionable than the probe, for it is not only equally liable to be the 
carrier of sepsis, but is more liable to wound tlie sensitive endomet- 
rium, and thereby open the tloor to microbic invasion. The passage 
of the fine pi*obe is usually painless. The sound in a sensitive, 
inflamed uterus may be intolerable. 

The diagnostic value of the sound and probe is sometimes very 
great. One may, for exampk*, be unable to locate the uterus except 
by the direction which the sound takes. The tortuosity of the canal, 
moreover, may at once show the relations of a myoma to the uterus. 
.\gain, the kngth of the canal in a myomatous uterus is increased, 
hut nr^t materially increased, by the presence of ovarian and other 

L€xtni- uterine tumors. The case, h«>wever, is rather exceptional in 
rhich the soTmd or probe is a necessary' means of diagnosis. The 
niore ex|iencnce one has, the more edticated *>uc'*s touch, tin* less one 
will need to usc^ these instruments fur diagnnstic purposes. 

Uterine Dilatation may l)e acc(mi|>li,shed in the following ways : 

1. By graduated bougies, or sounds, after tlie method of dilatation 
of the male urethra. 

2. By instruments of diverging blades constructed on the principle 
of the glove-stretcher, 

3. By water dilators. 
4» BV tenti^. 



74 



GENERAL PRiyCIPLES, 



Dilatation is more frequently n'f|nircd ff»r therapeutic* than fur 
tliagiUKstie purposes. The ohjeet of diagnostic dilatatii>D is to ajx^n 
the entiomotriuni in ortler that by means of the curette a 8j>ecimeD 
may be riMuovcd fur microscopical examination, or in order that the 
finger may be used for intra-nterine digital tiKuch« Tlie technique is 
the same for diai^nnstie as for therapeotie diktatifUi. See, tlierefore, 
a description of the latter in Cliapter V., on Minor Opemtions, 

Diagmostic Curettage. The object of diagnostic curettage is to 
remove cnongli diseased tissue for mierosenpieal or other examination. 
If the curette is small, and the os is patuluusj curettage is sometimes 
possilile without anaesthesia or jirevious dilatation. Usually, however, 
the procedure recpiires lioth, Mieroseopicai examiuatinn of the 
scrapings is frequently the only means of differentiatirui between 
hemorrhagic endometritis, the remains of abortion, post-idiortum 
eudometritis, benign adenoma, eannnoma, and sarcoma. The teeh- 
niqiu^ of curettagt* js described in Chapter V* 

The Exploratory Needle and Aspirator lia\'e the same diagnostic 
and themjKmtie signifit-anee in gynecology as in other dejwirtments of 
surgery — /, r*, the removal of Huiih The contents, for example, of a 
saetosidpinx, a renal cyst, a pelvic aljscess, or an ovarian cyst may be 
removed for visual, chemical, or nneroscopieal examination. 

The uses of the stethoscope and mieroseope will, as the occasion 
requires, l>c mentioned in the diagnosis of special dis(*ases* 

Examination of the Anue and Rectum. 

Rectal touch and eversii*n of the anus l>y means of the finger io 
the vagina have alrea<ly been noticed in the earlier pages of this 
eliapter. Numerous speeuhi have been devised for inspection of the 
interior of the rectum. For examination of the h>wer part of the 
rectum, Sims* speculum is immeasund)ly su|KTior to all others. It 



FloniE 48, 




Proct4Moope S inchei tooff antl I Inch wtde. The «liarnioidosco))e is the iiLme except In 
lenirth, which Ij 14 incfae». Tiie ln^trymiMa is firovideri with an obturator : U It In nearly aU 
respect! except §tse Identtcttl with the {^^ti/ecopc shown In Figure 5«>. 

is nsi'd for this purpose the siime as for %'apinal examination — 1\ f»^ 
with the |>;dient in the left laten* prone |iKisitii>n. 

The Proctoscope and Sigmoidoscope. The frequent association 
or confusion of rectul disease with the diseases of women mav render 




DIAGNOSIS, 

nece&ssLTV the inspection of the upper part of the rectum ; for this 
purf>osc Kelly uses a tubular s|ieouluni, called u prf>cto«eope^ about 1 
inch in diuructcr un/l S inches long. For ytill higher exaiuinatinus 
he UHcs the sigmoidoscope of tlie same diameter, but 14 iiiehes Unig. 
The patient is examitKx! in the knee-breast pusitiotr^ the same positiim 
ns is used in cy^stoscopv, Figure ^tH^ and the light is thrown in by a 
Head-mirror, Examination through these instruments is most satis- 
facU>ry. 

ExaminatiOu of the Urinary OrgranB, 

The means of exaininatit*n are these : 

1, Urinalysis. 

2. Palpation and percussion. 

r3. Cystoscopy and ureteral exphjnitiou mid eatlieterization. 
4. Segregation of urine, 

!♦ Urinalysis. 

The stn<ly of the urine involves, first, chemirjil ( xiuninatiim : 
secxind, microscopical examination* 

Fi«;nRE 44 



ItreUiral dilfttor. l*nt1t:r»corocl nunjeralB ludicate diametent Iti mJHlmetre«, 



FlciUHE i't 



Oum ureteral cnthctcr ; 35 to 50 cm, lriri(^. 

The chemical examination will show clianges in the pn>portion or 
quality of solids, and will suggest the possible relation of these 
clumges to ]xithologi(*al cunditioiis and fuuctional disorders. Fi>r 
example, decrease in urea may signify nephritis. Al>undance of uric 
aeiti would indicate that mori* exercise and less nitrogenous foofl 
should he taken. Excessive acidity would ac<Miuut inr irritation of 
the bladder and frequent urination. The mien (seu pi t^a I examination 
may |>n»ve and locate the existence of disease in either the kidney, 
ureter, or bladder. 



2. Palpation and Percussion. 

Palpation and [lerenssion over t!ie hypogaHtrium may give strong 
evident of distention of the ldad<ier ; further evidence wouhl be the 
bulging of the anterior vaginal wall toward tlie vulva, and constaul 
dribbling of urine. The evacuation of a large quantity t*f urine 
through the catbcter would be proof. 



GENERAL PRINCIPLE. 



Palpation with ci>njoinetl exam i nation may show a tumor in tlie 
l>la<lilor. Vaginal and metal touch may also give mnch information 
relative to the urethra, bhidder, and ureter. Vaginal touch will en- 
able one to jodge of .^eiihitivoncss in the tirethni and neek of die 
bladder. In the anterior wall of the vagina to either side of the 
metliau line the ureter may often be felt as it pajiseH in a polite rior 
and lateral direetiou on either side of the cervix toward the kidne?y. 

Fir#URE 46. 



SVl«iiatof. Used tot witlid rawing rt^afdn&l urlnti. 

Tmvn% 47, 

■ BaMi ^fcM i|^^ ( iTVffi II I inrr^i^— ^1 



It IK normally a flattened ^ cord -like, soft, yielding band. Pathoh>gi- 
e^J changes often make it easier to nxHjgnize as a hanl, round, hirger, 
more renit^ting eortl, A Injugie intrcKlueeil tlirtaigh ihe urethra into 
the ureter faeilitates the palpation. Tendernes.^ ahaig the line of the 
ureter indicatcji inrtairnuatiou ; this inflammation u^ the nix'ter, when 
II u recognize*], often lead« to disap|>ointment in the treatment of cys- 
titis. 

The interior of the bladder may l»e pal|iat/ed by the sound or by 
the finger. The sound enables one tti judge of i\\e presenee or ah- 
Hence of a stone or a tumor. Vesical hemorrhage following the 
intriHluetion of the sound indicates the possible preMMiee of inflam- 
mation or of a tnraor. Palpation by the finger tlirongh a dilated 





78 



GENERAL PBINCIPLES. 



urethra is to lie condemned, for two reasons r first, it j^^ives no in for* 
matic^n wliieh eaumit be better obtained by means of the cystoscope ; 
seeond^ permanent ineurable incuntinciice of urine from iujury to the 
urethni ueeui*8 in about -3 per cent, of the cjises. Digital exploration, 
if made at all, shouUl be uiade throngh an artifiGial vesico-vaginal 
lis tula, opened for tlie purjHjse, S^^e Cystotomy fur Cystitis. 

Inspection. The ]H'iseiiee or absence of cystowie, urethrocele, 
prolapijc of the uretlira, InHamniation, ami new growths about the 
meatus may be recogtiize<l by ihreet visual examiuation. tSee luflani- 
matinn of Skene's Glands, under Vulva- vaginitis. 

3. Cystoscopy and Ureteral Exploration and Catheterization. 

There are two classes of cyst4»sco]>es : they are 

The cylindrical cysrnscojte; 

The dec t riea I ey st« »sc< ipe. 

The Cylindrical Cystoscope. Numerous instruments have been 
devised for the inspection of tlic int*Tior of the l)ladder. It is the 
great merit of Dr. Howard Kelly to have popularized and |)erfccted 
an effective and satisfactory mt^ans of intravesical inspection. The 
foll<»wing is an adaptation from the description given by Dr. Kelly:* 

The essential fealnres of the mctluwl are i 

1. Atmnsplieric tlilatatiou of the bladder in4lneed by posture. 

2. IntrtHbictiim t*f a simple straight sjiecnhiin withoiit fenestrum. 

3. Examination of the interior of the bladder and urethra by 
reflected light. 

The instrnnicnls re<piired arc: 

1. A grMwl light ami a head mirror. 

2. A urethral dilator, Figure 44. 
3» A vesical speculum w itli an obturator, Figures 52^ 53, and 54. 

4. A suction apparatus to empty tlie blatUlcr, Figure 46. 

5. A long mouse-tootlx forceps. Figure 50. 

6. A searcher for discovering the ureteral orifice. Figure 48. 

7. Twu nreti-nd bougies, 

8. Tw<> ureteral eatljeters. 

The sp'cuhun in m<»st ct>mmon use has a diameter of one centi- 
meti*e. If urctliral dihitation tu this extent is painful, one may pro- 
duce lcK*al anaesthesia Uy the apjdication of a 10 jK^r cent, s^ilntion of 
ewaine. This may Ix* applictl within tlie meatus on a uterine appli- 
caO»r wotiud with cottou. In eases requiring nitire dilatation and in 
very nervous eases, general amesthesia, esj^cially in tlie first examina- 
tion, may Iw uecessary. 

The full sp<'cial set of nunieiDUs graduated instruments formerly 
used to dilate the urethra is unnecessary. Stretching of the meatus 
by the ennical dilator alone lias been fr»und snflitMcut, 

A full set of sfM^cnla CHmprises various sizes ranging in diameter 
from 5 mm, to 20 nmi, — tme-tiftli io fliree-(|Uartcrs of an inch. The 
latter, aect*rding to Simon, is the oiitsifle limit of safe dilatation. For 
some nrf'thnis it is doubtless beyond the limit. 

t Dlficaa^^i^ I if thi^Ki'umlr aiadder awI Vrx^iUra Johni Hopkitw HcioplUl Bulletin. No vetnber, 
1B9i). AiU6ric«ti Jouriiiil of tilwtetricA. Jiinuiir/, \h1H. 



I 



I 




DIAGNOSm 



79 



The [)08itioii of tlie {witient i.s the chief essential. It may be the 
don^al or the knee-hreast position. Figures 56 mid 58. 

For exfiniinatiori in tlie dorsal ivositioii the hips of \hv patient 



FiauEJC SUL 




No. 16 eystoAcripc. Actiml iilx«. 



miiftt Ir' eli'\':itetj ulxjut twelve iiielies ahi>ve the plane of the table. 
Tht? Hjreculum iiuw hein;^ introduced lljroii^h the iiretlira, thf air 
nijihes in and halloonn the bla^lder. Tlie n^sidiud urine must he re- 





C|-ttoMope without obtttmtor 



The extent of surface Been at one time will tlei>entl iipjn the dis- 

Umvi' uf the vvv fmm the rvstn*iOiipe, iis wiA] lus upon the diameter of 
tlie itij^tru nunU aud its nearness to ttie field of vision. By sweeping 
the cyatiiHcope from side to Bide, up and down and around, all jwirts 



DIAGNOSIS. 



81 



rapidly and eucc^e^sively hroiiglit to view. One may observe 

identity a wide variety of i>athologieal eondiHon?^, such as nco 

plasmts, inflammation, olcemtioii, st'ars, dilated vessels, discoluratiuii, 
aud foreign bodies. Tlie most sigiiiliciiat pf>ints for observation are 
the trigone and the openings of the ureters. 

ToexiK>se the trigone, withdraw the specnliini until the mueoiis 
membrane c»f the inner extremity of the urethra begins t<j elose over 
it ; then advance it and slightly th^press tlie outer end. The mnensii 
at this point is usually of a tlark-pink color, in contra,st to tliL* lighter 
glii?tening appearance of the surrounding surfaces. 

To expose the ureters, let the end of the speculum project into the 

FicuBJS 55. 



Eftnd holding eystoicope In a^t of ttitroducthm.* 

bUddcr one centimetre, with its handle raised. The inter-ureteric 
ligament may now in some cases l>e seen by its slightly raised trans- 
verse fold or by its distinct diiferenee in color. A ureteral orifice 
should now be situ by turning the speculum about thirty degrees to 
cither side. By eoutiuurais watching, little jets of urine will be secu 
to spurt from the ureteral opening at intervals of about a minute. 
The appeanmee about the ureteral ojM^uing is variable. It may nuly 
Ik? recognizenl by the perifKlie spurts of urine. It may be seen with 
the greatest ditlienlty only as a tine ^lit in the mueosii. The opening 
may be in si slight depression — a pit or dini]>le. In some inflamma- 

^ KnVy^ DJseiA»c« ot Ibe Female Bladder anci Urethra. Twentieth Century Practice, 
ft 



82 



GENERAL PRINCIPLES. 



tory cases the opening may be through an eminence of soft granut 
tii^siie or through the iip|xirendy i-vertod ureteral mucosa. If tlit- uiv- 
teral orifice h in view, the searcher will readily |>ass an inch or more 
into the duct. The ureteral catheter oix om- or lioth sides inav now 
be introduced, and the urine taken directly as it flows iVoni the kid- 
jiejs. This may insure uaerriug diagnosis of the eoudition of either 
kidoey. If the tjucstion of tlie renio%al of one kiduey is under con- 
sidemtion, it is clearly of tlie greatest advantage to know tlie exact 
or approximate condition of the other. 

PiGuite 56. 



/ 




Doniil pofllifon. Eler&ted pelvis 

The beginner will often have p:reat diificnlty in findinpj the nn:*ter. 
Even the exp^^rienced surpfcou often fails. The difficulty, however, 
always decreases with intellierent practice. 

Examination in the Knee-breast Position. In many cases, 
es|i4'cially of stout w(»nicu, in which the Idadder dfK»s not readily 
hMllnon with air in the dorsid position, it wHIt do so in the knee4)reast 
p«jsitii»n. Fi^^ure '')H shows the orflinary knce-hreast jmsitioiK Figrure 
59 shows this position motliflcd. Tiiis ni(Hlifieation, with the buttm*ks 
directly over the cjdves of the Iclts or ankles, instead uf vertically 
over the tlii*rhs, ha> hern fiumd by Kelly ti^ yield better results, both 
in difficult iwmI in sim|4e ca^es. 

The examination is conducted on the same principles as in the 

1 KeUy. niiejMMJs uf Ibu FeniAle BUddcr and Uretbr*. Twc»ntielh Centun' Ctaotlce 



I 






I 



Introdticing aearcher Into leH oreleral oHflne.' 



nal rnd of the tube. The final devplnpnif/nt nf tlii.« instnvment hegaii 
widi Nitze in 1876. He placed the eleetricat vacuum liirlit at the 
inn**r pxtremity of the ttjhe in such a manner as to ^^jve (lirect 
lUiuni nation an*l to tnxnsmit to the eye through a series of U^nses an 
exaet pieture of the lihidiler mneosa rnaii'nitied. In all tlie^^e iiistrn- 
mentH the electric cnrrent h fnrnislierl by a battery from which 
in-HuIatec] condiirtors pass tliroriuli the tnbe to and from the lamp. 
Thi-» inhtniment is nsed with the bladder tilled with water and the 
psitient in the dnrsal p<*sihon. 

CompariBon of CystoBCopes. Cystoscopy arrd nretei-al ex]>lora- 
tion in the female, owinii t*» the slmrtncss and dilatability of the 
nretlini, nmy l>e tjatisfaetorily aeeomplished by means of the ^imph* 

♦ Keilf, DUeMct of the Fcmalo Rlndder iiiid Urttbra, Twentieth Century Practice. 



84 



GENERAL PRiyClPLES. 



tubular cvt^toseopG already described. In examinations of the male 
urethra llie j)rit^matiij elect roscnjx^ on account of it 2^ magnifying 
|M>wer and tlie greater distance of the field of iusjx^ction from the 
eye, is indispensiilile ; although for gyneeohigieal ptirpoties the lubtilar 
eystoscope i.s serviceablcj the eleetrfwiijie is |jreferable. 

Value of Cystoscopy. By ineau^ of tlie cystoscope the entire 
interior of tlie bladder may be brought into view ; foreign bodies, 
tunmrs, and other piitholugieal changes may l)e recognized and 
the ureters uud the pelvis of the kidney may be callieterized or 



Fl'JtHK "»H. 



^ 



h 



« t 




iLuei''t)rf>ii«t [Kjsiiion , rysltiscopi' Introduccii ; soaad sbowa pOtUtot) of &t)Al ortHct-J 

ntherwi:*e explored. The im=t rumen t has often revealed the pn*sence 
• if stones, tunmrs, and ulcers which had entirely eseaiH'd detcclitm liy 
the sound. Numerous cases in which cystitis is *>f nnly 8e**nndary 
im|K>rtanoe to other nss(Knate<l lesions, such, for cxjimple, as tuniurs, 
tuberculous ulcers, piles, or heuiorrboids of the liladder, are now 
daily observed by the cystoscoix*. 

Cystoscopy is of great value in preventing blirul and meddlesome 
treatment for a class i\( cases which present the subjective symptoms 

* KcUy l>it«t'H»t'8 Iff i\x\i Female Bladder and I'rethm, Twtriitlcth Ccotur)' l*r«cticc- 





TtftiOll, 



lo^lllod knee-brexst position, ofteii yfcldinFr 1)cUcr dtatentlon of blftdder than with thij^hi 
"■ The •trapti are uooecewwry. Tht! patient may, tiven under ether, he rtadf ly ht-Ul (in4 
by mn aasistant during the ejrpl oration.' 

of eystitijiy but in which inspection fails to show any lesion wlmtever 
of the bladder mueosii. 



1 



FldURK 60. 







mm 



Nitze's eystoacopo. 



The value of the irist rumen t is inva\(*u\\\]ih when only limitetl 
are diseascMl, as, for oxaniplej iti the mikl iiiHuuimations of the 



FiouRK m. 




Ctopcf'i cyitoacope. The iDStrument b prrtviiled wfiti a gMlda lur the poasiige of the ureteral 

catheter. 

trigone and in fiasure at the neek of the bladder. Under ^uch eondi- 
tionft the opi»rutor, ini^tead of treating the entire vesical niueof^a by 

» K«Uy, DlM£«a«« of Use Female Bladder ami ITrutUra. Twentieth Century Practice. 




86 



GENERA L PRLXCIPLES. 



mrans of injections murL- r>r less stroii^^^ may direct to the diseased 
»)art only nny a]>plieation vvltirli may 1k' iridieatcHl, 

The Segre^ator, AnotluT iristrunient of jr^reat inj|K>rtanee is the 
segregatDf of Harris ; it eollects the urine directly and separately as it 
jKisses from eacli ureter into the bladder The itistniment lias two 
great advanhjg<*s over tlie ureteral catheter: first, unlike that instru- 
ment, it is available for tin* non-exjiert; seeuud, it diM's not invade 
and therefore eaunot infect the uretei"^. The in^tnnnent con8iHt^ of 



TbdlflKT^galor without atUihmviUs nm] with its tvvi>tiiihcit rsiii foiitiict with oneauoiher ready 
to bL^ iuKcrted Into tlit^ liladdt^r, 

two uatlieters, their strai^:bt port ions being- ineloscnl in a tiatteneil 
tube, and each bcin^ sepanite and nn>vable on its long:itudiua! axi.s. 
Fi^i^nre 02 shows the tube graduated to 19 t*cntinietrcs and euelosing 
lite two (Mtht^ters. Their vesical ends pnitrude to the ng;lit and tlieir 
outer entls to tite left. The niet^hanisin is such that, the tjistrunient 
having been intrtxhieed into the bla<hler, the two t^atheters may be 
rotated uik>ii their long axis so tltat their curved bladder-entis will 

FititHE C3. 




Ft^jrrcKAtor wltli the <>nd(i of the catheter ■epareted, k« they itnpeiir mtXet Introductlnn Into 
ti ,1 lilies ahaw thi' Icver which misi'n the bUdder-wftU between tUc wp- 

II r< tt) fornis a watershed, A bottle 1b Attiich4i*d by a rubber lubv tu each 

1 ; iiriiic, 

lie as indicat4Kl in Figure 68, one ou one side and the other on the 
other side of the trigone. A metiillie lever, Fig. tM, is now intro- 
duced intf> the vagina in the female, or the reetimi in the male, and 
attached to the shaft »»f the instrument. This lever is indicated in 
the lower part of Figure 03. It i> attached to tfte catheter tutK? 
by means ot* a forked metallic appliance and held up by a 8piml 



spring; it< function is to elevate tluit portion of thehladiLr wall 
which lies between the twu .se[>aratcHl ctids of tlie rotated catheters ami 
thereby to form a waters! leil. Tlie urine as it drops on either slile 
fronv each ur(»teml oriJice is now separated ami flows 4jut thnjiit^h tlie 
catheter on the corresponding side. Kaeh eatlit^ter is contiiiiieil by a 
mliber tube to a bottle for the retx'jvtion of urine. The liottles are 
pnjvide<l with a rubber suction bull* wliieli may serve to eri-ate ii 
partial vacuum and thereby to attract the urine. Bt^fore using the 

FlOUKK 64. 



The watershed lever detached from the catlielera. 



"S^regator one should e^irefully study the directions of its inventor, 
which afH^ompany the instrouieut.' 

The value of this instniment d<'pen<ls not only u|KJn the fact tliat 
without ureteral catlieterization w^e are enablrd by its use to sej>anite 
the urine of the one kidney from that of the other, but also upon tlie 
(act that we temporarily, as it w^^re^ eliminate tlie bladder from the 
urinary tract. In eases of a diseased kill ney one may demonstrate 
the pnvsenee or alisenee or ascertain tlie cornlition of tlie other kidney, 
and therei)y avoid the not unknown post-niurtera embarrassment of 
fiiuling it either absent or useless trom disease. 

It in nec<*ssary to a correct diat^misis of cystitis, for exauifile, that 
we know what abnorn»al ccmstitiicnts in the urine have their origin 
within the bladder itself Normal urine suffers no chan^ufc in a normal 
bladder free from ni ic robes ; hcnee a eouiiiarisrui of anidyses of urine, 
taken fn>ni the bladder, with urine taken directly from each kidney, 
may at once indicate the exact location of the disease. There may 
be present the subjective symptoms of cystitis— that is, pyuria, pain- 
ful and frequent nri nation, and ammoniacal nrine — and yet the bladder 
may be frt*e from diseasi'. 

The pointvS to lie observed in urine thus obtained arc tht reaction 
msid the presence or a!>sence of pathological pniducts, such as piis, 
bKuxi, epithelial cells, bacteria, and crystals. Tlie reacticni of the 
ariue should be taken at once, as seef>ndary clian^-es sfuuetinuns occur 
quite rapidly. If urine taken directly from the kiflneys jM>ssess a 
aormal de|^rce of acadity, while that from the bhuhler be alkaline, it 
is very evident that the p:itholot;it'al jiroce^^s prixlucinji' the alkalnuty 
mn^t reside within thr' bladder. If urine fn»m the kitlneys be free 
from patholnpc-al i>nMlufts, while that from tlu^ bladdt^r contains pus, 
epithelium, or bacteria, the involvement of the bladder is unqnes- 
tionablct 

t Rafris. Traflflai7tIoiii of the Chicago Gynecologleal Society. November, 1808 ; and M^dl- 




88 GENERAL PBINOIPLE& 

BbQdoratary IncdsioiL 

When other means of dia^oeis have &iledy and it is necessaiy to 
examine the pelvic or abdominal organs directly by tooch or by flight, 
the surgeon will for that pnrpose open the peritoneum by expforatoiy 
incision. The incision is made either through the vagina — ^va^;iiial 
section^ or through the abdomen — abdominal section* The inoiflioii 
having been mack, the fin^r is introduced^ and the diagnoris made 
by direct touch. The section may, if necessary, be enlaced so as to 
bring the pelvic and abdominal contents into view. Kmple toudbiy 
however, through the incision only lar^ enough to admit tne finger, 
is always safer and usually eives more information than visual exam- 
ination. All vaginal and abdominal sections should be first explotm- 
tory. These sections are described in the chapter on the Treatment 
of relvic Inflammation. 



CHAPTER IV. 

LOCAL TREATMENT. 

The principal procedures in local treatment are these : 
L The hot-Mrater vaginal douche. 

2. Tamponade. 

3. Topical applications. 

1. The Hot Vagrinal Douche. 

The choice of the syringe, the frequency of the douche, the time 
and length of each application, the temperature of the water, the 
proper use of the bed-pan, the position of the patient, and long per- 
sistence in the treatment, are all essential to good results. 

The small fountain-syringe, in general use, requires refilling several 
times during the application of the douche, and is therefore inadequate. 

FlOUBB 65. 




Lord's douche apparatus. 



The common bed-pan, since it must be frequently emptied, is likewise 
unsatisfactory. A simple device, known as Lord's ^ douche apparatus, 
is free from both of these defects. See Figure 65. 



» Dr. F. H. Lord, Piano, Illinois. 



89 



90 



GENERAL PEINCIPLES, 



It consists of a biioket, A, larf^e enough to hold two or three 
gallons of water, t^iis|K'n(]t'd on a lumk alnnit four ivvt aho^e a concli 
on which rests the largo hrd-paii, B; a 8uft ruhher siphf*n, A CD, 
having nt A a weight heavy enough to retain that end of the siphon 
in the huttoni of tlie hneket A ; an ordinary soft-rubber syringe-bnib 
at C; a deviee for slnitting oif the current between C and I>, and a 
female syringe-tul>e at I>. Another ruliber tube is attached to an 
oj>ening in the bed-jnin and leads to the bneket E. 

Directions. The bucket A is to be filled with water of the proper 
teniperatnre, the shut-t^ff being cIosimJ, The patient is then to lie 
placed npon the bed-pan in the pruijcr position, the tnbe D to be 
inserted into the vagina as far as it will i>as.s, tlie bidb C to be cum- 
prcsscil once or twice, and the shnt*otT openetl. The vvjiter will then 
flow through the siphon without eonipression of the bnlb, iill the 
vagina, oxerHow intn the bed-pan, and pn^^ thence into tlie bneket on 
the fliK>r below. (_*oTnnioidy it may be more convenient t*> place 
bucket A npon a shelf than to suspend it. The concli should be of 
some unyielding material, otherwise the l>ed-pan will settle so low as 
to prevent tiif^ drain of water into bucket E. 

The following is designe<l to impress the importance of strict 
observance of di-tail in the application of the douche. In no other 
manner will its good eflects be realized ; 



Qrdmarjf mdhod of application. 
I, 
The doucho is «i>pae4 with the yjAlicnt In 
the lining fMwtitre. po thai ihe liijc-ctcd wiiter 
eannot fiU the Tagrlnii and Imthe the ctTvfx 
uteri, but [naieiid n'tuma aloras the tub4.> of 
the Byritig« u fut u it flows Iq. 



n. 

The Tiatlont ts not lmppe«in*d with Ute Im- 
portaoco of rt*g«IiiHly in ila iidniinistmtkm 



The tempermture U not ipecifled or heed€4. 



TV. 
The paUf nt AbAtidotia It* tisf aflur & short 



Proper method qf applicaHon. 
I. 
The douche should In'pftriahly b«^ glviii with 
the imtient lyhig on the htwk, with Ihc 
iihouldem ]ovf, the* kneta drawn up, the hipe 
tdevnted on & t)cd-pAn, »0 that Iht* uutlcl uf 
the vagina tnny be above even' other pari 
of it. Then the VAfdna will t>e kept con- 
tlnuany overflowing while the douche la be- 
ing given. 

IL 

It Bhitnld he given ai least twice every dny, 
mturnini^ anit evening, and generally tho 
length of each ap[>l^pntion should not be Ivsa 
than twenty mlnutetf, 

Uh 
The temiH^niture nh^tohl l»e a» htj?h aa the 
patient ciui endiire without dlstrefw, n tnay 
l'>e increased from day to day» frum lOCH or 
lOf"^ to 11.^'' tir \2fP Fahr. 

TV. 
Tts use, \u the nin|ority of eaaea. should 1k) 
etmtloui it fnr me^nth^ at leait. and ftomellmcs 
fur two or three years, Pemcverauee U of 
prime importance* 



A i^ati.'^fuctory snhstitnte for the hed-pan may h<* made as f<»llo\vs: 
at the f^ide of an luilinary iK'd |ilaee two chairs with sjiaee enon^di 
between them to admit the h)wer l)ncket; spread a rnl>her sheet over 
tlie inide of the Iwd ho that one end of the sheet may fnll intt) the hneket 
btduw in the form of a trough. The <hjnche may then he given with 




LOCAL TREATMENT. 



91 



nbe patient lying across the l>e<l» the hips resting over the edge of the 
ami one foot on eaeh cliair. Tlie water will find its way along 
the rubber trongli into the biicket below. 

Modes of Action. The douche acts in a twofold way : 

1. As a vasomotor stimulant. 

2. As a eleansing agent, 

1. Vasomotor Stimulant. Emmet, the strongest advocate of the 
donche, attributes its goml cifeets to the stiniulatiiig intluenee 4if the 
hot wati^r on the v^asomotur nerves. The nerves are stimulatetl, lie 
say 33., by reflex action, and the dilated congested vessels are thei-eby 
tnnde to contract. In this way congest ictn is said to be k^ssened, 

[aljeiorption of morbid prfKhiets hastenerl, and lond ntitritiun iinproveiL 

2. Cleansing Agent. The vagina in }>elvie iaHmnmution is a 
-way, and to some extent a re*"r|>ta*'le, l<>r pathnlugieal secre- 
tions* These s«?cretions flow into it from the uterus, the Fsdlopian 
tube^ai^ pelvic abscesses, and frtmi the vjigiual mucous membrane itself. 
Unless kept clean, the vagina may become an incubator and a dis- 
tributing point for bacteria. The value of the duuclie, therefore, as 
a means of asepsis, is seUVvideut. When h>cal disinfection is rc- 
qiiire«i, the hot-water douche may have in solution some antisej>tic 
substance, such as lysol, carbolic acid, corrosive sublimate, boric acid, 
salicylic acid, or peroxide of hydrogen. 

The indications for the donclie, as suggesti'd in tlie foregoing fxira- 
graphs, are chieHy in the treatment of chronic pelvic iuHam mat ions. 
The powder of heat to stimulate and contract bloodvessels makes the 
douche also useful in the treatment of utc^rine hemorrhage. The pr(*- 
vailing disposition to extend its nse to the routine treatment of all 
pelvic disorders should be disconi-ageil. 

There are constantly present in the normal vagina gn*at numbers 
of lactic acid bacteria ^vhose fimction is to render the vaginal secre- 
tifm acid, and therefore to make it an unfit <'ulture-grouud for about 
^t) per cent, of all i)athogenic bacteria. The wasliing out of these 
normal germs and their acid secretion nee»essarily makes the vagina a 
less ditficnU barrier for diseai*e-gernis to jmss, and therefore opens tlie 
way for infection in the higher zones of the pelvis. The indiscriminate 
routine use of tlie douehe in the normal vagina is for this reason of 
questionable propriety. 



2. Tamponade. 

The principal indications for tamponade are: 

L Inflammation. 

2. Hemorrhage. 

1. Inflammation, Tiimponade in the treatment of inflammation 
is designed, according to the indication and manner of ap]ilication, to 
fulfil one or more of thrt»e jjurpi^ses. It may be used : A, as a means 
of pressure ; B, as a vebiele for the application of medicinal sub- 
sfanceis ; C, for dminage, 

A, The pressure-effect of the tampon is chit^fly useful in tlie treat- 
ment of disjdacements, es|M'cially displacements due to inflammatory 




92 



GENERAL PRINCIPLES. 



causes. The subject will bo further discussed under the head of 
Pelvic Inflammalioos and Displacements. 

B. As a vehicle for the intrmhietiuu of medicaments the vaginal 
tampon lias become a routine factivr in gynccolu^y* It is most fre- 
queutly used as a carrier of glycerin. The ol)ject sought is to ciiase 
a watery discharge from the genital tract, and then^liy to deplete the 
vessels and overcome congestion, (xtKul residts have often followed 
this treatment. How far ihey sshouhl be attributed to tlie tamponade, 
and how far to the cumtive forces of nature, or to the as^tx'iatcil syst- 
temie treatment, it is often difficult to say. If the tampon is left in 
for more than twenty-four hours, it becomes otfensive, and may be- 
come a hotbed of infection ; hence, if u^ed at all, it should be renewe<l 
daily, or at le^st sliotdd be i-emoved an the day following its applica- 
tion. Its indiscrimiuate use as a routine measure, though lens harni- 
fnl thjui intni-ntcrinc medication, should lie diseoiu'siged ; its theni- 
|M/ntic value has been nujcli overestimated. 

0. Drainage of tlie endometrium for endometritis, by means of the 
intra-uterine tampon of aseptic or antiseptic giuize, has been with 
many a favorite means of treatment. See chapter on Treatment of 
Endometritis, 

2, Hemorrhagre, lleniorrhage from the vagina may often be eon- 
trolled by means of a tight vnginal tampttn. It is, bowever, better 
to find the hteeding-point and secure it by more definite surgical 
means. 

ITteriuc hemorrhage, whether from endometritis, uterine tumors, 
or abortion, may demand immc<liate control. The vaginal tampon 
is most commonly used for this piir|>osc. It is, however, a cund>er- 
gome measure, and in bad cases often fails. Great distention of the 
vngina !>y a large* tam|Hin interferes with the functions of the bladder 
and rectum, and is a mecliauieal c^insc of di.scomfort. 

Intra-ukrinc tamptmafh is a most practieiil, comfortable, and 
effective treatment for uterine hemorrhage. It should he in the form 
of a eontinu*ius strip ol' aseptic or antisejUie gauze about two inches 
wid(\ The cervix having l>een cxjiosed by a Sim,-?' s|W'culum and 
steadied by a vulsellnm f(»rceps, tlic strip is iutrtKluced by means of a 
slender dressing- forceps^ sound, or similar instrument. The seeretions 
abhorb(*d by the tamjxnj dccomp^ise nipidly, anil beci^me a jwiwerful 
soniiee of infection ; henee the g^iui^e .'^liotdd be renewed daily or every 
t>vo day^i. 

Material for the Tampon. If elastic pressure is required, fine 
lambs' wool is su[K'rior to absorbent <'otton. F<*r otlier purposes the 
continuous strip of aseptic gauze is i>refenible to cither. 

3* Topical Applications. 

Applications to the Uterus. ** How many times have you i^er- 
rnauenllv arrcsttMl a long-slauding uterine discharge by menus lA" tf^pi- 
('n\ a])|ilications to tljr eiidometrium?'* is a rpiestion wliieh the writer 
has put to scores of physicians with large pmctice. The object of the 
question has Ir'cu to measure, if i>ossiblt*^ the value of such hxud 




LOCAL TREATMEST, 



itmetl^aS^s commonly nnd extensively used in office p met ice — a 
Itment mostly dirccteil to the uterus for the ndief of endonietritH 
anfl cervical erosion. The rejvlie?? have been most siguilieant. hi 
tlie vast majority of cases the reply has been, " Not one, or very 

Intra-uterine medic4ition commonly results in failure and disap- 
pointment, f«»r two principal reasnus : tirst, it is "vften used in unsuit- 
aide ea.se^s ; second, even tliougli tlje ease be suitable, it is often ini- 
pn.iperly used. 

Eflieieut intm-uterine medieaiiun requires that tlie medicinal sub- 
g^tance l>e bruught in conta(^t with the uterine raut^osa. Ordinarily 
the medicament is carried into the endometrium when that cavity ia 
full of uterine secretions. These secretions form a thick pniteetive 
coating over the mucosa. The application odxes with and may 
exhaust its virtue in ehcmiml eoinbiiuttion with the secretions^ but 
does not re^ch the diseasetl mueons membrane. It frequently occurs 
that the applicator at various points inHicts slight wounds up^ul the 
endometrium, and thereby ojiens the door to septic invasion. Pelvic 
infection may be the residt. The treatmentj therefore, unless care- 
fully applied, hkiv be dangerous. 

The prerequisites to s:de and efficient intra-nterine applications arc : 
first, a clear indieatiiui and detinite appreciation of what the appliea- 
t ton is to accomplish — that is, the case must be properly selected ; 
second, prejmratory disinfection of the vu I vo- vaginal surfaces and 
tlilatation and washing out of the endometrium ; the disinfection is 
specially essential as a precaution against infection. 

The Proper Selection of Gases will exclude, at least, three large 
classes of cases : 

A. Those in which the increased uterine discharge is not due to 
local, but to general systemic disonlers, such as cliolmmia, malaria, 
diabetes, and goi»t. Under such conditions the remedy will l>e not 
l«»cal, but geuenil,and the ease will be referred U\ internal medicine. 
The disappearance of such a discharge during loeal treatment should 
be attributed not tu the raeiknesfinie applications, but to the associated 
systemic treatment or to the cHU^ative force of nature. 

B. Those in which the panxmetria and other circum-nteriue struct- 
ures are infected, or in which tliere is a uterine or extra-uterine tumor, 
or some other anomaly which would render topical ap]>liciitions use- 
less or dangerous. These cases will he referred to surgery. See 
Treatment of Endometritis, in Chapter XA'll. 

C- Those in which tlie uterine discharge is due to some non-infec- 
tious h)cjd irritant of non-bactcrial origin, such, for examjile, as tem- 
porary uterine flis[>lacenient from an over-crnwded bowel or an over- 
distended bhuldcr. When the local irritation is rcmuved the disorder 
usually disappears. 

The pro[>riety of routine \\k\\\ treatment for ant>ther class of cases 
may l>e que3tione<l, to wit, eases iu wliich the uterine mucosa is the 
subject of uncomplic^ited bacterial infection, or in which, even if 
there lie coniplieations, these are not such as to ctrntra-indiratc intra- 
uterine medication. If in this class of cases it is wise to introduce 




94 



GE^^EMAL PRINCIPLES, 



medicinal substances to the endumclriiim, the steps of procedure will 
have to be as follows : 

1. The preparatory dilatation and eleansincp havinjj been matle, 
expo8e tiju cervix by means of a speeulurn, pre lent bly SiniJ^'. 

2. Seize the cervix by means of a small trnaeulum, or tenaeulum- 
foreeps, in the left liand, ami liold the cervix steady. 

3. With tiie ri^ht hand piLss the aj^piicator^ wtanid with cotton 
which has been stituraied with the require I niedicanient, into the 
uterine eanah 

Few patients will tolerate the neet^ssary dilatation witljont anfes- 
thesiu ; hence, intni-nterine medication thus restricted must cease to 
be an every-ilay rontine oHiee jimcedurc, Wit Inn tlie limitations 
above outlined it rises to the dig^nity of a .^nrgieul nieasnre, am! as 
sueli is no longer a potent cans^j nf pelvic inteetion. The general 
nseleasness of freqnent and long-eon tinned nteriiie applications for 
this class of cases is more fully set forth in the chapter on the Treat- 
ment of Endometritis. 

It follows fnmi the al»ove that a very lar^xe jirojKirtion of the 
women wfio were fonnerly made the subject of extensi\e intra-nterine 
treatment should he treated rather by medical or surgical means, or by 
both eondnned. If they do not present well-defintHl indications for 
snrgii'al treatment, they should be relegated to the field of internal 
medicine. The legitimate tield for routine topical applications to the 
uterus is limited. 

The use of Ijougies containing various meflieaments, the intnMluc- 
tion of intm-uterijie supfwisitories, the injection of various tluids into 
the uterus, the packing of the endometrium witli giiiize^ and other 
similar prrH-edures will, according to their value, be prej?ented, or 
omitted, under the t real ment of special disorders. 



FkjUr^ 66, 



^Bcaaoilllll) 



Emmel's ailver mppUcfitor. 

Applicators to the vulva and vagina, in<duding tlie vaginal ptrtion 
of the uterus, are rudieated for the (*ure or palliatinii of the various 
inHammatorv aifcctions nf those orgsins. Ointments, lotions^ douches, 
and strong I'ansties nmy Uv a[>p!ic<l precisely as they wonhl inider 
similar conditions to otiier parts. See Treatment of Vulvo- vaginitis, 
Chapter XI. 

Direct treatment to the urethra, Idadiler, and ureters will l>e dis- 
cussed in tliaptcr XXIA''., on Inflammatinn nf the I^riuary Organs. 

Other Ibnns of local treutnu'nt, such as searifi<^ition» leecblng, ami 
elect ro-therafx'uties, will, ai»eording to their meriti*, be presenttHl in 
connection with special subjects. 



1 




CHAPTER V. 

MINOR OPKRATI0N8. 

Thls fiubjcK^t involv^c^s a ^onsiclenitioii of tlie prf^pamtory tmatnieiit, 
the Q[3e rating- table, ani^sthe!?in, iustrumeuts, iipjjliance^, siituivs, ligu- 
tiires, dresciiri^s, the' time and plare uf i>i:>e ration, assistants, operative 
technique, and after-treatment. 



Preparatory Treatment. 

The preparation for an ope ration, largi?ly a matter of antiseptics 
and asepsis, h set forth in (.■hapter II, 

Faultv nntritfon from any causes, sucli as syphilis, gont, rheu- 
matism, nephritis, diabetes, anti purpumj may interfere with the suc- 
cess of an operation, and may the re tore call for systemic and liygicnic 
treatment. 

Operattng'-tables. 

For vaginal operations the table should be approximately forty- 
it inches long, twenty-fotir inches wide, and twenty-seven inches 
li^h. Operations in private houses are usually performed on the 
€»>ranion kitchen table or lanndry table, or ujKjn the narrow dining- 
.table. The length of the table i^hould not be greater tlian that given 
ibove, for wh^n the thighs are flexoil and the patient <lrawu toward 
the openitor the heail slioald not be too far from the aua\^thetizer, 
who stands at the end of the table op[>osite the oj>erator. While the 
pjitient is being anicstbetized the feet and legs may rest temporarily 
on a chair or small stand at the foot of the table. Tins is removed 
when the thighs are flexed, just before the operation begins. 

Clover's Crutch is one of the Ijest of nnnierons devices to jtold 
the thighs flexed and the legs in position during those vaginal ojkt:!- 
tions which are done witli the patient in tlie dorsid position. *Su<'h an 
apparatus is convenient, but unnecessary. The knees may be rcathly 
hehl by two a^istants^ one on each side. 

Acute synovitis of the knee-joint followed l>y auchyhisis has occa- 
sionally l>een observed to follow vaginal t^perations. This was un- 
explainc<l until E, H. Webster, of Evanston, Illinois, suggested 
Uiat an assistant, while holding the thighs in tliis Hexcil position, 
might (tirelessly throw bis weight upon the leg, or lean hea vdy upon 
it, and thereby flex t[ic joint ti* a ilangerons degn^. 

All gynecological tables^ wlietlier aserl for (examination or ojx'ra- 
ion, Hhtmld be made as sngg-ested in (liapter III., with an inclina- 
Uim of three or four inches, the foot of the taiile Ijeiug to that extent 
above the head. 

95 



96 



GENERAL PRINCIPLES. 



The accessories to the operatum-tal>le iuclude knee-resls, rnblier 
sbeeta^ and smaller tables for instruments, dressings, and ligatures, 

AnseBtbesia. 

In the ah^enm of lieart or kidney ler^ions the operator, aeconling 
to his indivieliial preference , will be jiistilied in tlie choice of cbloro- 
finin or ether. (Iihu'ofnrra iu the ease of kidnt-y disease and ether 
in heart disease are genenilly iireferred. Minor opemtitais under 
eueaine shoidd be undiTtaken vnW with j>:reat caution. The drug is 
dangerous. The choice and mode of administnition of anaesthetics 
in gynecology follow, unmodified, the general principles of surgery. 

Instruments. 

Sims' speculum and Simon's Fpeculum have already been described 

in the chapter tin Diagnosis. For oi>enitions on the vaginal widls, 
such as tlie closure of vaginal fistulte, repair of the lacerated cervix, 
division of the cervix, dilatation of th*' cervix, and curettage, Hims* 
speculum is regarded Ijv all who liave duly lamiliarized themselves 
with its use as inctmipanibly superior to all others. 8c*e Chapter III. 

Simon's s|K>eulum, though for jilastic vaginal work inferior to 
Sims*» is yet for some ]vur|)oses a more pnictieal instrument. It has 
one advantage over Sims*— /. e., the patient bfiug in the dorsal posi- 
tion, on a Kelly [lad or rubber sheet, the opt^mtion may, with Simon *s 
speculum, be done under constant vaginal irrigation. 

Simon's instrument and the dorsal position are superior to Sims* 



FlOUBK 67. 





Vtilsi-ntim forci^pd. Ilctwceii the two tcetli of eiich black* is a de*.'p o|>eiiiTip to lUM^oniinodfito 
the neeillt; in the pajiaa^v uf ii atiturc. The ififftnimont iian ficlsaorB-nmidk'D unci is atHJUt ton 
iuches ioag- A« reduced liiva. B, aecUoti of fuU si«e. 

and the latero-prone |x>sition for all nperathms in which the |»elvic 
cavity is to In* ojwncd throui^h the va^jina, siu'h, tor example, as 
vaj^inal hysterectomy, va^injil stdpinj^^fi'toniy, and vaginal ovariotomy. 
Vulsellum fi*reeps, -similar in eonstni(*tion ti> those shown in Figure 
67, are useful in varioUi^ ojierationH in ttie uterui^and alujul the cervix. 



I 




MINOR OPERA Tl(L\S. 



97 



?v serve to grawp and draw duwti the eervix, to grasp an iiitra- 
miie tiimor, and to stvatly tUv corvix during the piw.suge of a siitnre 
or during curett;igt>. 

SciHSors. Tilt' minor gyiiwologi^^il openiti<jns may Uv performed 
either with the scnssors or witli a knife. Tht^ ehoiee (h/jwnils inueU 
upon the eiiuwition and halvits of tlie operator, Tlie .srissor,*^ cause 
Ittsft hemorrhage, ami when one beeonjes aeeustonied to their use lie ean 
work more accurately and ton re rapidly. xVny strtmg, well-inarle, 
slightly eurveil sin.ssors will sutfiee, but tliose of Em met are es|>eeially 
adapt^ to intmvaginal, perineal, ami vulvar ojxTatkms. Figure 68 
^how?* a pair of blunt- pointed Keissors, with straight blades bent hiter- 
ally upon the shank at an angle of thirty degrees. They are useful 

Figure 68, 



Emmet's sicissors for di vM i n^^ the < crvi x. Rrflitntnl si3u.\ 

for dividing the eervix, for tnaking an artifieial vesico-vaginal or 
tin?thrn- vaginal fistula, and for dlvidiug cieatrieial bands in the 



vagina. 



Fir»VHK m. 



Em tn el's sUghlh' nirvefl scissors. ReduLt^d Mixt; 

Emmet's slightly- ami ftdly-eurved scissors are almost indispens- 
mble for denuding in plastic operations ; the i^lightly-eiirved, Figure 

FlMBE 70. 



Emmet's fUU-tiun'ed bcit^iMire. Rvduceil &iio. 



6fl, are Ufted for jK^rineal and for ordiu:iry intnivngina! dernulatiou ; 
rhe ^inoii_dv-*»orvid. Figure 70, are eonvenieut for tieuuding a strip 




98 GENERAL PRIXCIPLES. 

high up across the vagina <»r cervix uteri in fistula and oervix oj>er-1 
ations. The scis^ofn tvjireseuttnl in Fignrus 69 and 70 are curved 
tnwanl till- rig-ht, and are iuteiided to hv us-hmI with the riglit hand. 
Eniniet nicotitnis al^t* two other:*, witli curves to the h^ft ; but if h 
sc^ireely pos,si!j!e to imagine an openition in which the latter woukl be 
necessary. 

Emraet's w^ire sciKsors, with bhidet> pointtHi and slightly eurvcKi on 
the Hat, arc useful for removing sutures, and sometimes fur cutting 
out ei(*atricia! tissue* The slightly-curvetl scissors, Figure G9, an- 
ssver all the jmrposes for which stniiglu scissors are usually eui ployed. 

Spong'e-holders. For intmvagiual operations it is well lo have 
tliree or four or more spjnge-lioklers, Figure 71, twelve inches hmg, 
in which sponges trimmed to the desired size and shape may be fast- 



FiarKE 71. 



iymuiiu>iM*u 



Sims' spungi-hulclLT. A, KcdMt-cd wiz^?. B Si?rt ion of full size, 

ened. Ordinary hremostatie fnn-cps with long handles serve the pur- 
pose equally well, and, if gauze spuuges arc used, even lictter. 

Uterine Tenaculum. Numerous tissue-fnrecps have been devised 
for gnispiug the tissues to be denuded or excised, l>ut a properly-con- 
struetcd teuaeulum in the educated hand is the most convenient and 
effective instrument for this pur|)ose. With the tenaculum the 
0]JenitfU' can pick uj> and hold a smaller amount of tissues and can 
thcn^ft>re denude more superficially than is pussil>le with the tissue- 
firrceps. The instrument. Figure 72, has a |K"rfcH:*tly straight hmik a 
little more than a quarter of an inch huig and at rtglit angles to the 
shaft. It shcHild be so strnng and stifl" tliat consiilerablc force* niay 
be a|)|vli(Hl in the line of the iusfnimcnt, without breaking or bending 
the hoiik ; or ju a latcnd di recti* ni, withi>ut lu^nding the shaft. The 
uterine teuaeulum is usct^d m»t only in deuu<lation, l>ut also in almost 
every step of a gyne<n^lngical exaiui nation or o|Mjration. In some 
i»[x*rations as many as four of thtiu may be required. The instru- 
ment is shown in Figure 72. 



1 



When to Operate. 

Although it is a general rule not to ujK'nitc during menstruation, 
it h:is by no mt'aus iK^eu proven tliat o|M^rations arc more tiaugerous 
during tliis jwriod. When menstruation U so long continued or sf> 
pn»fusc» as t<i cudangt^r life or health, immeijiate operation may he ini- 
ptTative. The presence of ntenstrual fluid, however, is unfavonible, 
though riot usually a bar to union by first intention iu a cervix ojiem- 
tion. An ufMTation |n^rf*»riucd luiniediatcly upon ihc close of nieu- 
Btrimtion uught cause it lo rt*a|»pear; if t^xi near the antiei|>ated 




MiyOR OrERATIO.\\>,. 



99 



FititiKK 7i 



I 



period, it inight excite a pririutLliiiv How. One may safc?ly operate 
beiwet^n the third day after the clo??e of one period and thf tenth 
day before the anticipated appearance of the next. 

The question f>f primary or secondary oj>emttons5 
after puerperal lacerations Jias been much discussed. 
Emmet's o{>eration fur hu'eratlon <«f the cervix, unless 
there lie hemorrha^*^ from the torn surfaees, is ordi- 
e<pAriIy <lelayed until after the jMierjH^rium. Many suc- 
«esifut ea^s of immediate oj^* rat ion, however, have 
been rep>rt6<L For lacemtion of the jK-rineuni, how- 
ever extens«ive^ the immediate uperatiiui is desirahle, fur 
two rea."*«>ns : Tlie torn pjirts can he aeeoratcly adjusted 
to tlieir former relations, which is almost impossible in 
the secondary operation ; and the operation, if well jier- 
fomieil, generally results in union, and thereby pro- 
U*rt5 the patient ag^ainst septic infeetion through the 
ti»m surfaces. The writer, therefore, would advise the 
primary orient ion of |Kjrineorrha])hy evcTi as late as 
two days after delivery. Me has repeatedly operated 
un the second and thinl days, and once on the ninth, 
and, with scjircely an exception, the delayed oj>eration 
hBs resulted in satisfactory union. If, however, the 
primary o[)eration has been delayed for a number of 
days, it i» best, befort^ irUnxhieing the sutures, to liciuide 
with ihe curved scissors a narrow strip all a run ml tlie 
torn surfaces, in order that fresh surfaces may be brouglit 
together, A delay of a few hours after labor insures 
greater free«hmi from capillary oi)zing from the torn 
surfaces, which sumetimes ix*curs affcin^ closure of the 
wound, and which may prevent nnifUL Moreoverj if 
amesthesia be reipiired, it is better to wait for peraia- 
Dent n?traction of the uterus ; otherwise the aruesthetic 
Biay cause relaxation and consequent uterine hemor- 
rhage. 

It is the duty of the a<'C(*neheur at tlie close of the 
poerperium to examine the uterus, vagina, and peri- 
Deiim^ and to repair any jMierjH'nd laceration or injury 
before evil rcsirlts have deveh>ped frojn it. Operations 
mskv be nef.*essary even dtiring lactation. The child 
sbouhl lie kept fnmi the breast only until the mother 
haj5 fully recovereil from the aniesthetic. 

Operations diiringr Pregrnancy shonhl be restrict(Ml 
to (tk^es of immediate and urgent necessity. Plastic 
op«Tations, as a rule, may be eleferrefl. Tumors con- 
fit^ted with tlie repn»ductive organs, such as carcinoma 
of the cervix, ovarian cyst, uterine polypi, vaginal 

lors, vulvar and rectal tumurs, may have to be re-gterimit^nacuhitji. 

>ved. The danger of iibortiLm fnlltnving <>peratifms 
Iff ring pregnancy is <'hiefly frtjui possible sepsis — Lr,, fmm toxaemia ; 
even the toxaemia from ditl'usible poisons and drugs, such as iodine, 




100 



QENEHA L PKISCIPLES. 



carl)olic acid, hidilorido vif imTciiry, and tjiiiTiiiie, may itidiK'O iibor- 
tioii ; lieiici^ the u:?e of iiucli drugs slioiild l*e litniti-il and juilk'iou:^. 

Multiple Operations. Wht^n several (»|>cmtifins are nect\ssary it 
may be prnper to ptTlbnii tiieiii at <m(? isitting. A rapid i»j)orator may 
safely jjerforni dilatation of tlie utiriue canal, curettage, trachelor- 
rhuphy, elytrorrliaphy» jieniieorrhajdiy, and the i-enioval of lK*nior- 
rhoids at one tinie. This aruoaiit of ujH'rating at one sitting wcmld 
har\ily be {KTmissihle for a slow oj>erator or a Ix'giiiner. The time of ^ 
an operaticjn .should usnally be less than an hour and a half or twd 
hours. Abdnniinal section or vaginal section is sometimes eombiiu^l 
with pliLstie vaginal work. This eombinatioiij although at times per 
mitjmble, is not gene rally approved. 



Plastic Operations. 



This subject comjirehends all 0}R'rations for the repiiir of lacerations 
of the cervix and })erineum, and of vaginal tistulfle ; it also includes 
certain operations on the vaginal walls known as elytrorrluiphy, and 
nnmertius operations on the uretlira, vulva, ami anus, 

A clear aj»pre(»iation of the (liiises of failnre will contribute to 
suc^'css in plastic surgery. Two pnnci|>al causes of faihiiv an* : Hrst, 
pirts which never ouglit to be united are often brought together ; 
second, fanlty tcchuicjiie may resiilt in failun^ of union. 

One of the most common batl results of the ifjiair of the lacerated 
(t^rvix uteri or ]U'rinemn is the nnion ed' ]>arts which were not together 
l)efnre the injury, and cannot be united withHiu harm. A plastic 
o|>i>nition which restdts in union is commonly calle^l snccessftd. If, 
however^ there has been nnion of wrong parts, actual harm may have 
Ix'cn done. The flap-splitting openition of {K'rineorrliaphy tiK> often 
gives this result. 

Union by First Intention will almost always result from a cor- 
rect operation. Tnie^ in certain cases of vaginal Hstola in which 
there has been great loss of tissue from sloughing, failures may ari^e 
from the cicatricial character of the parts or from difficulty in hohl- 
ing the edges together. In very fat subjt^cts i»erineorrhaphy, es|ie- 
cially when tire ruptui-e extends through the s|ihincter ani mnsc^Ie, 
nuiy fail even after the most skilful iif»eratiuih Certain systemic 
diseases, among them iliaWtes, are urdhvonible f<ir nnion. Generally 
tlie conditions of sueeess art^ within tlie coutrHl <»f the i»|M'rati»r. 
These Ciuitlitions are simple, but ahst*lute ; and the ojKTator who has 
neglected them can neither fairly attrilnite his failure* Uy the debilitat(*d 
state of the jKitieut, mtr to chance, nor Uv accident. Inrleed, nnion 
must altnost invarialdy fulluw if the -^urfacc^s t^i ht* ntiitcd an^ pn^pcrly 
prepared and kept in tMUitact for a week. The first etjndition, asepsis, 
has h(**ii disctissed. The others will be presenttHi in the following 
panigniphs. 

Denudation. The patient having lir^'u elheri/ed, placed in posi* 
tion, and the* tirld of o|H'nitinn exposed, the surfaces to be nnitcd 
should be denuded, f 'ctrn'ct dc^irudatifin is a prcrc(pu?sitc tu hetiling 
by first intention. Surfaces to be united sh«*uUI be hu denuded tliat 



\ 




Miyon OPERATIONS. 



101 



when brought together they will fit accurately, otherwise a part oi" 

the denuded surface, being in ct>ntact with an iindeiinded Hurfaee^ 

inu.«t heal by ^mnulatinn and .sn|ipH ration, which may cxce^t^ively 

imtate the rest of tlie wound, and alMiiys prmhiccs eieatrieial ti.ssue, 

which is xvTY objectiuTial>!i\ The tU'inuhHl suriat^e sliouhl moreover 

U* $m<K»th and free from shn?ds, whirli might die ami become .sources 

of feplie infection. EvtTy particle of membrane or skin within the 

area of denudation should be scrupidously removefL If t!ie surface 

be jKTfiK'tly healthy, tire more suju-rlicial the denudation the iK-tter; 

hnt «H>«^^t'-ed and ciciitriciid tissms do not readily unite, and should 

tiierefore, when practiciible, l>c renio%'cd, 



p 



^j:^. 



^ :< 



M 



I wHh the Utmumiam %ud iclswre. Figure Gy 1* a bt'lter inystrnlion nf the Bclisaw 
here used. 

Figure 73 ^hows the action of the tenaculum and sciAson* in 
denuding. The KUjic^rionty of the tetiarnliini a.s a ^ub.stitntt! f<tr the 
ti*^*«iue-fore*:'pt^ must become apparent to any one wIjo will faniiliarfze 
himself witli its Uiii\ 

KeedleB. A rfnind nee4llo h preferable to one with a cutting edge. 
The incii^Hl wound made by the latter is gt^nerully tcjo large for tlie 




102 



GENERAL rniyciPiEs. 



putiiro, blectls freely, is prune tn siipp unite, ami requires much time 
fur heiiliug. The puncturLKl wuuiilI hukIo by ll»e fumier readily 
shrinks down upon the suture, is less liable to bleed or to suppurate^J 
ami, after the removal of the suture, heals more quickly* The ti^ue, 
ejipeeially in the cervix uteri, is, however, ofteu so dense us to neces-1 
sitate the use of a needle with n cutting' edge. 

Many of the most dexterous operators prefer the straight needle 
to the curved. The straight needle has two advautiiges : firiBt, bow- 
ever deeply it may Iw. buried in the tissues, the position of its jK»int 
can always l>e determined from its din^etion and length; second^ the 
force employcMl in its introduction Ix^ing in the direction of the 
needle, it may without any danger of brexiking be of much smaller 
calibre than the curved nt^eclh*, which must be introduced by a force 
exerted in the line of a timgcnt to the curve. 



A 



A> Slir&tght Deodle for externa]: jtuliirea In porlntHrrhnphy. I) Straight anrl curred llflfflMi 
Ibr aperattoTiB on the vnHinal wftlb and cervix* and for veslco vsjuinal f^atiilin ; the upper needlv 
under B Is trorftrjM>inteil for very denae tiMiues. C. SimoiiK Mtronuly-inirvid needle* iVir vc»ico- 
vftKhml riMtulu. Tiw neetlle iDArked A w«"nld W better for eeneml ti*.e. If miidv eumewhAt 
shorter and t^llf^hlly curved aiC tho point. The aeeond needle under If Is U'st suited for cervix 
and pertoeum oiieniljons. 

Till! j^inil^ht needle, in a word, re<juires less force for its intrtMlue- 
tion, i* lesrt liable to break, antl makes a smaller woiuul. ^Moreover, 





KtDinct'j ueeditf'furcv'ijci The spring UtWL^in ihi,- Imiidkn <■l)lilK.t^i iUvm to «i>cu wheu the gjusf* 
Ifl relAxed. A. Reduced ei^e. B. SecU'Jii wf fuU tijse. 

the simple rotation of the needle-foreeps on its bm^ axiJ^ by a turn of 
the wriM enables tlie o[>erator to HWt»ep the st might needle around a 





Tb« intfrwluotl(»Ti i.f a threttdfd ticedltt to close u kcerated perineum* 

ad the needle may ehaii^re almost eonptantly rliirinp: itH pas^^age. 
In tilts way the stniJ^lit needle may he mad** to carry a satnre armiiul 
m ctirve more aceiinitely than the eiirved needle, and often more 
rffteily* Obviously, the kw-k Itjreep*^, wliich do not permit of this 





104 



GENERA L PRIXCfPLES. 



fveedfnn of iTiotion, are imsdik'd to Mirli inaniputations^. Figure 75 
repiT^^i'iits Eniiiiot's needled wet' ps without loc*k. The eye of tlie 
iieeille, if inehidetl in tlie gra^^p of the forcej^s, may be cnisheil ; to 
avoid thi^, gni^^p it on the proximal side of the eye. The plain , 
foutkI point, however slmrp, sonietHues encounters g;reat resistance in 
passing tliroii^h dense tissne, Tlie tnw'ar point rvpn^^ented in Figure 
74, or the saddlers point, is less ohjeetioiuilde than the eiitting edge, 
and may be int rod need almost as easily. 

Various iieedles with handles attaehtnl or detaehed, and of differ- 
ent curves ami shapes, have Ix'en devistnl, 5ome with eyes at their 
points, some witltout eyes, and othei*s of eylindrieal torni, thnnigh 
whieli tlie sat ore is jmssed lengthwise from one end to the other. 
They ciimplieate rather than simplify an o|ieniti4)n ; they make 
punctured or incised wounds many times hirger than the sutures 
^hicli they are to contain ; they are in uo respect sujierior to the 
simple needle and thread. 

The Application of Stitures. The most nractieal materials for 
entnres are silkworm-gnt and ealgnt. The ix^euhara*! vantages of each 
will he presented in the description of the sj>eeial t>penitions» Befoii? 
tlie introihietion of the sutures, approximate tlie denudeil snrfaecs 
with tcnacida to determine whether tliey are of such size and sha[K:> 
that their union will pHwhiee the desired result, anti whether accurate 
coaptation of tlieir margins can be secureil without undue traction, 
whieli might cause the suture to cut out. Then luHik up tlie margin 
of tlie wound witli a tcnat-uliim, intnKlui^e tlic needle, and apply 
counter-pressure as in Figure 7(j, until the needle c^an 1r' seizeil and 
drawn through with the forceps, Sune operat<jrs tise the l)lunt lonik 
for counter-pressure; hut a strong tenaculum which will neither 
hi-eak nor bend is often preferable, becjuise it may also he fixed in the 
tissues at the very pc*int where the o|K*rator desin^s to force tlie needle 
through, and it thereby insures greater precision in direeting the 
needle to its juiiut of exit. The use of the tenaculum also avoids 
multiplicity of instruments. 

Uterine tissue is often so dense that gn^at force is required to drive 
the needle through it. For this reason the passing oi the needle h 
often the most trying part of trachelorrhaphy* 

In naiking counter-pressure the tenat^ulum may slip and the uterus 
rt^»cive a violent ami sudden jerk, wliich is not without danger, es|)e- 
eially when often ri'pcatciL This may he avoiiltd and the »tpc ration 
facilitated by hohli ng the flap in the vulsellum forceps. Figure G7, 
while the needle is lieing force<l througli lietwecn its teetli. Th(*se for- 
ceps may be made by filing the teeth *>f Hank's force]>s shorter and 
finer, and by tiling a deejier t*peuing between tlic tw*» tct^th (d' caeh 
blade. The sutures shouhl lie alJ^nlt one-fourth of an inch a}xirt, 
^should include considerable tissue, and, if practicable, should j)08s en- 
tirely under, not through, the denndcHl surface, so as not to l>e in *x>n- 
taet with any portion ut the wound, WIh'u at a distance from the 
denuded surfaee they are less liable U* irritate and produtn? swelling 
and intlamruatic*n, and are therefore less liable to cut. 

The tying of the sutures should be done with the greatest care. 



I 



I 
I 





HemoTlng a nulurc 



tion occur, earlier. Sutare.s about the vulvn mid perineum should be 
r^roove<l in about ten day.s. If left mueb lou^rer, they may lieeome 
Ifpow or cause poppunitioii. In tln' vm^iikiI walls tbey may be left 
si*veral day?^ lonjrer. In the cervix, wliere sup])iinit!on seldom cHrorg, 
rhry ^^hol1U) lie remyve<l in about two week,<, imles,^ perineorrfKipliy 
fwii< lK*en done at the same time, in which case their removal cannot 




Hiifely Ik? undertaken in Ivm than three nr four weoks. To remo^ 
u suture soize thr freo viul witli a fbriM'|js, ami with the >eiss4n^ cut 
th*' nean^st .^^irle of tlie luoji. See Figure 77. C'uttin^^ tlie nearest 
siile tends tn lioM the fn\'<hly united wound together durin<j: tlie with- 
(Iniwal of tlie i^uture ; if the htop wen* cut on the hirtlier side, its 
reniuval would tend to reo|>eii the wound* It is well to seize with 
the foreeps only one of the fi-ef ends, for ttie other would then Im? 
avaihible in ease tliis one were aeei dentally eut off. Always make 
suilieieut tmetion tt* hriug tlje Itiop in si^dit hefore enttiug, otlier- 
wise bi>tfi sides may he eut ot!' hehnv the knot and tlie luop left. If 
then the ends of the loop retract, as they iisnally do, its removal m 
extremely difficult ; it may rt^niain indefinitely and keep ii[) a eonstant 
suppunitiou. Its final removal may neeessitate anaesthesia and an 
incision. 

Assistants. Four assistants are nsually re([uired tur a gyueco- 
Ingieul H[>t*nition^nie to give the ether, one U) wasli sponges, i>ne at 
the o|>erat4>r*s left, to hold the speculum, and one at tlie operator's 
right, to sponge and render other assistauee. If the <i|ieration \w on 
the p'riucum <ir vulva, and the patient he in the dorsal deeuiiitus, 
the thighs must he flexed and hehl in the lithotomy [Kisition by the 
two assistants on tlie right and left. The assistants in charge of the 
ether ami sponging shcMild Uv physicians. The wasiiing of s|KHiges, 
holding of the speculum, and threading of needles are better done 
by nurses. 

Dilatation of the Uterus. 

Rave in except icmid cases, it is impossilile l>y any speculum yet 
devised to ins|>ect the iuterior of the utertis. The cavity of the 
u terns may, however, by dilatation be made surgically aeeessible to 
tlic examining finger or to instrnmcntatitm. The intlicatious for dila- 
tation may he diagnostic* or thcra]K*ntic, or both. Among these indi- 
t>ations are stcno-^is or stricture of the eanid, nteriue hemorrhage dtu* 
to endonietritis, nco[)lasms^ ahi^rtions, and pathological anteflexions* 
The mt^ans and methods are these: 

1. Incision. 

2. Tents. 

*?. (iraduated siinnds. 

4. Instruments of diverging blades. 
1. Incision (>f auy pirtiou of the uterine <*aual may he required in 
order tt> render the endometrium aeeessible for instrumental or nuinnal 
interfen'uce. IVnt incision is esjunnally ap|>licahle to the lower part 
of the cervical canal and to tlic extiTnal os, and is performcil tor 
congenital or accpiircrl sten^isis. Its tibjeet is to insure tlic free out- 
flt»w nt»t <mly uf im-ustrual fluid, Imt alH» of the uterine mncns, 
which, if ri'taitied, beronn-s oticnsivc, irritates the uterine mucosa, 
and causes hypi-rscen^tion. Oftentimes the uterine secretions are j*o 
impeded in their passage through the strieturcd os intennun or exter- 
num that they nccumnlate, distend the nteriue cavity, and are thrown 
off at irrcgnlar intervals witli ex]iulsive pains simtdating labor-]inins. 
This explains certain cases in which there is a reenrrenee in the inter- 



4 




^flMP^wal peritid of all the painful phenomena of obstruetive dys- 
ifiorrha^a. 

Schn»eder, in certain eii.scs, especially of intra-iiterine potypi, 
incises the cervix bnuterally, seizes the prKsterior lip with a vulselliim 
forceps?, and, with hh finger as a dilatnr, works liisi way to the uterine 
mvity. The uterus, dilated iu tliis way and well drawn thiwn, is very 
no(Ms.'?ible, The^^' latt-ral ineisifins extend into thi' dangerous nei^li- 
lutrhood of the paninietria, Tfie safety (d" the u|MTati(ui nuist there- 
ft>ru depend upon thonnigh antisepsis. In a rigid uterus, nion'over, 
it ift often impracticiible to ineise and dilate aeeording to the method 
of Schi-oeder. 

The author's merhod of rendering the entire uterine eavity and 
the uterine walls aeeessible for tlie removal 4jf myoniata thnuigh t!ie 
vngiTia by fi^ee median incision td* the antt^-iur uterine wall will be 
de:?<'ril>ed uufler the 8urgieal Treatment fd* Myomata. 

2, Tents. Tlie danger oi' infection from the use of tents is so 
griiat tliat, exeept as indieated in a later ]>anigrapfij their use is not 
approval, S|Minge, tnpelo, and sea-tangle are tin* materials r>f whieh 
fhev are commonly made; if they are introdueetl into the uteros in 
tile dr)% compressed state, the mucous seeretirui» sti undated by their 
prrsenee, causes them to swell laterally to a diameter two or three 
timc^ greater, and, eorresp>ndingK% to dilate tlie canal, 

Sfionf/e-ftntJt, whieh have a dilating f>ower of three or four times 
their diameter, are nuide of disinteeted, eouii>ressed spongiv, straight 
ftr curved to fit the uterine canal. They aiv perjiu*ate<l irom end to 
pft<l to admit a strong thread, by means of which the tent nuiy l>e 
lidd together during removaL Otherwise a fnignient may be left 
hehiriil Jind be an unsus|K*cted source of dnngennis infection. 

The sponge-tent nt>t only expjinds, but at the same time softens 
the walls of the uterus, and therel>y pre|mres them fur further dilata- 
tion, antl renders the eavity more aeeessible for surgi^'al iutf^rference ; 
in this rest>ect it is more elective than tupelo or lamina ria, and much 
more etfeetive than steel dilators, which usually leave the uterus so 
clastic that, immediately after their removal, the intnxluction of the 
finger or of an instrument for diagnostic or surgical purposes may 
without further dilatation be impossible. Tlie stdltening ellect is the 
rpr^ult of excessive irritation, ctmgestion, seereti^uij and hvpersc^ere- 
tion due to the presence of the spnuge. Under sucli eonditiuns it 
may» in an incredibly short time, be<'nme offensive an*! dangerously 
R*[)lie from deeompositi<ui of tlu' abs*irbed secretions. It often also 
be«H>mes so adherent and incurpfmited with the intra-uterine mem- 
hmne ttiat portions r*f the epithelial hiyer may be stripjicd off when 
it is removed. The surfaces thus ex]it»scd wuuld furnisli a reiuly 
avenue for abs<»rptiou. Disastnuis results seldom fdlluw the applica- 
tion of a single aseptic sponge-tent uidess the patient has suffered 
from a previous cellulitis t^r [leritonitis, but th<* danger increases 
rapidly with the intrtxluction of the second aiul third. Many opera- 
tors now discard them altogether. 

T\tpr/n-h^fih^ made from tlie tupehi-tree (A}/xsr? atptaimi)^ exjiand 
Ipss powerfully, but mure rai>idiy tt»an sponge, to about double their 





cunipr*'sstHi sizr, and, inasmuch as tlicy do not so rpadily ber*onie 
otrcnsivo fniiii tfi-cuiupositifm id' tin* absDrl>e(l sftTrtioiiri, tliey are less 
tianM;i nnis. Thi'V aiv Ktmig-hi mui jnHexil>lr, and tlRTcibre ntit easily 
iiitiXMlijced in lul^os of tivnte Hexion, es|ML^(niilly when there is inimo- 
l*ility at tlie angle of flexnre* ThtT are, however, very Bmuoth, and 
slip into place wlien the ciinal is straight^ or nearly stmii^dd, more 
easily tlum sponp'. If the tent seh/etet! is foiniil on trial ti^ hv tiMi 
hu'i^e, it neeil not l>e thmwn away, but may he easily eut <lown tu tlie 
rcfjiiired size with the poiiknite. A standanl autlxir has inelnded 
anicing the many advantages of the tupelo-tent the jKJSsibility of 
reeornpressing it fiir re^R'ated use ; hut for ohvions reasons, sncli a 
pnirtiee can be neitlier sate nt>r permissible, 

Lftminttri(f-tt\tiltff also ralle<l sea-taiigle tt-nts, have m<tre ex|ianding 
power than tn|M'lo and hss than sponge, i>iit tlieiraetion is st* slow 
that tliey are liable to l)e expelh'd fmrn the uterus beif>re they have 
become sntlieiently ex|janded iu be self-retaining. They liave but one 
advantage over the tnpel(», which is their tlexihility. After soaking 
in warm water for a tew niinntes they may be bent to any de>ireu 
curve, and may I here fore l)c introduced in castas ai' uterine Hexure. 
They are pcrfunitcd frnm cu<l trieud to make then^ dilute more rapidly, 
acctnthng to tlie rceommt^ndatiou of lh\ (ireenhalgh, of London. 
Ex}Kyision of laminaria is very sk»w, requiring tliirty*fiix hours for 
the maximum dilatation. 

Introduction and Removal of Tents. Unless the uterus be so 
h*w that the os externum is near to ttic vulva, a speculum will l>e re- 
<|uircd for the intnMluetiim of a tent. Sims* s]K^euliun i> most suitable 
and, indeed^ indispensahl<* in ditlii'idt cases, es|K'eially when the uterus 
is nnieh antetlcxed or antevcrttHl. Befc*re introducing the tent the 
vagina and vulva shotdd be thoroughly cleansetl, the cervix ex]>o&ed 
hv the s|>cculum, and the direetifm and curve of the uterine canal 
ascertained hy the probt* ; then a tent of eorresjionding curve should 
be seiz(Ml in the forc^eps an<l intrcHluced while tla- cervix is fixed with 
a trnacnhim, as shown in Figure 7H. A small tampon of antiseptic 
cotton slioulil then l>e place<l against the cervix to hold the tent in 
place, Tiie time ret] ui red for a sponge or tujK*lo to reach its maxi- 
nutin dilatatiiin is fnmi six to twelve hours. Several small tents may 
be intro«ince<l at one tini(\ instead of a singh' large one» The careless 
or uuskiltnl introdu(ii<in of a tent has occasionally resulted in |XT- 
foratinn r>f the uterus and conset[Uent p(Tit(*nitis. S^e Figure K:i, 

The tent may sometimes he rernovi^d by tnietion on the attached 
thread ; but when consiclenible lorce is rerpiired it is better to use tlie 
sp<M'nlmn and forceps, and in making traction to nse counter-press- 
ure apiinst the cervix, which nniy he steadied Ijv placing two fingers 
against it, hy fixing it with the vulsclium fon *eps, or by encircling 
it with tlie f»ue>t Tilted end i*i' a Sims' vagina! <h'pressor. After the 
removal of tlie tent sonic bhwul usually tlows fnmi the intnt-uterine 
siirfu(*e. This surfaci' is usually more «»r less abraded^ cs[>eeia!Iy if a 
<«ptmge-t4'!it has Ik^^} used. The enthimetrium should then^fore be 
thoroughly washrd out with an anti^'ptie sulution, to Ijc f(»lh*wed with 
an ajjplicatiuii of Chureliiirs lincturc of itMline over the entire ule 



i 



^ft^OR OPERA TfONS, 



in9 



rine cavity, lo ci»si?s requiring further dilatiitioii tlKMinlino sliuulJ 
Ix* iunitte<i niitil tlir last triit liiis hem reoioviML The (hniirer uf cmi- 
tinuiHis dihitation by iiitn^liu^in^ our ti iit after niKiihi r i> wvv ^reiit. 
As alR^dy t^takHl, the ahrrnung jvsiiUs hiiv*' gruerally fulhiweil the 
me uf the second or the thiiTl tent, >^eMfiJii the first. A tent i^houhl 



Ff^.l'RK TH. 



^1 



■5\"P 



IniToiiuftkin of a U?nt. Slm*. 



not under any cireum.^tanees lie iiUowed to remain in the iiteriig more 
tkan twenty-four lirnirs, aiirl ^^^i'lierally not Tnore tliaii twelve. The 
rents furnished l>y instniment-nmkers are nt>t always iiseptie. Before 
mng them, therefore, it is always well to siibjeJt tliem to the drv- 



Fl'.l'Ht 




RerUiced ntm. 



the disHi- 



heat process of Boeekman, as described in Chapter II. for 

fectian of catgut. 

3* Graduated Sounds. The nterus, like the urethra, may he 
(iilateil by means of graduated soinids. Fiti:ure 79 shows Penslee^^ 
riterine dilators. H(*|^ar and Hanks have also devised similar instru- 
ment'^ which are ecHiallv servieeahle. They are partienlarly adajited 
to ca^eji in wliieh the aiMiominal wails are thin and lax, so that the 
uterui^ may be easily Hxtnl by the hand i>ver the abd*tmen, whih' fine 
eoillid afitcr another Is forced into the ennal until the required dilata- 






4. Diverging: Instruments. Innumemble injitrum^^nts have lK^€»n 
devised witli bUuie^ wliicli diverge and dihite the uterus wlieii the 
Juiiidles are pre^^^ed or screwed ti^gether. See Figures 80, 81 » and 82, 

Wiithen'8 dilator and GoodelTs nifxlifieation of EUinger's dilator 
have j^errute*! blades to prevent tlieni fnnn slipping out during the 
pmeess (»f dilatation ; tliis aeeident is nineh more liable Ut t>eenr with 
the latter instrument, on aeeomrt t»f the jiarjillel action of its bhides ; 
and tiutwithstatiiling sti^ong connter-traetion with the vnljselliun for- 
eej)s it does m-ciir in many easier lung before dilatation is com- 
pleted. The blades of the Wiithen dilator diverge in a fan-like 
manner, and, sinre for this reason tliev do not slip ont, are to l>e pre- 
ferred. These dilators art.* genendlv toit lieavv to l*e insertefl until the 
way has bei-n r^pentnl Iiy a lighter instrument, like PahnerV, or by the 
smaller gnidiiated sotnids, or hy a tent. It is im|mrtant that all in- 
8tnnnents for powerful <lilatatioii be snppliiHl with the thumb-sorew 
for si-rewing Hie ha miles apurt. If the handles are compressed with 
tlie hand, ru|>tnre of the uterus is apt to occur. Tlic smaller tlilator 
<»i' Palmer d*»*'s not re^juire the serew, 

T)\\ (iiMidi'll,' *»f ]*hiladel])hia, ^vaK foremost among the advcxmtcs 
<»f this metlhKl of dilatation. In a large experience with extn-me 
dilatation under etlier he had no fatal result and no serious intlam- 

^ Aiavrietm Jountot of OtMtctrlcs, IS&I. p. 1179. 






MiNOn OPERATIONS. 



HI 



raiUorv di?iturbancc, Ht* carrier! ttit^ tlilritation to tliiT'c- fourths of 
an itieli in the thiii-vvali**<l, unyielfliiig^ iiiikiitik' iitoriis, tiiul tiMJoe and 
oue-qiiartcr incho.s in on li nary mso.^. In cuh' of n ngnl^ uiiyiekling, 
(ir rhiii-%riiIlf,Hl uterus, whk:h might tear tVfim mpid exj>:ni.sicm of tlie 
Jibting bhide^i, it is permissilik* to coiniOL'nt'o tlk' tlilatation with u 
-mnsr€'- «»r nipi4o-tent, the softening inHuenee of whidi ronckri^ the 
ctiiiul mon* easily and thorongldy ilikitabk^ by the foreibk^ niethcKl. 

The dangt:'rs of *lilatatifm arc from tranrnatisni and sepsis. 1l»ere 
luav U* extensive ruptun* from over-ilistention l>y mjiid tlilatation of 

til rigid uterus* Dangerons liemorrliui^i^ peritonitis, and dt-atli may 
H^ult. A uterus nipturtHl by dilatation should be puekcni and druiiied 



FnSUKB tSQ. 




t^f ftseptic gauze. An abdominal nr vairiual section may be neee^sarj' 
to ooptrol beniorrhji^e. The s[)eeial dangers of dilatation In* tents, 
»ik1 the imjx>ssibility of enfnreing thorough antisepsis in their use 
have been eonsiden^d in a previous ]>aragniph. It wonkl, however, 
Im* a fatal mistake to suppose tluU antisepsis rteprives (bhitation by 
any methml of all its ptnnls. All iiianipulatitms uf this elass, siiys 
Fritsch, are dangerou>, and not to tie employed unkss the inilieation 
i*^ quile ek^^ir. Existing pelvic intlammatioii, acute or chronic, is a 
mm\ii c^^ntmindie-ation. Indeed, the history of a majority of fatal 
^^^c*? includes previous cellulitis, peritonitis, or metritis. Dilatation, 
however slight, by any method, shonhl be regarde*! as a surgical 
<»penition, should always be done nt the patient's h<»use fu* a hospitab 
funerat the office, and should be followed liy wt^I in bed for a time 
Varying from one to seven days. Foreildc ililatation, cither by sounds 
«>r by diverging instruments, except wlu'ri the dilatation is to be slight, 
r^ aires ati amesthetic. If there be tenderness <»r other signs of inHam- 
rnatiou aUiiit the uterus, or if the jKiticnl has suffered from a previous 
iuf*?ction, ice should be kept *iver tlie hypogastriuni until the dangrT 
ha.'? p«is^d. Sw Treatment of Pelvic Intlamniation, 

The s|>*^eial advantages of ench method of dilatation may be sum- 
marize* I as follows : 

Incision. Contmction of the os externum and lower portion td' 
tiie uterine canal is best treated^ according to the nature of the case, 
either by Fritsch's operation foreularging the os externum by incision, 



^ 



112 



GENERAL PRINCIPLES. 



or by S(;linx*<ler*>^ ope'nition of hiluteral iiictisioii of the cervix. See 
Treatment of Cerviciil Eridumetrhis, 

Tents. S[M>iige*teiits are tlie most diiugeroiis, tnpclo tlie least, 
Lamiminii has but one advanta|^(* over tnpelo — its nexibility and 
atlaivtaljility to a tortiions canal. In ;i ease of rii^id liyperplastie or 
thin-walkMl cervix not safely <lilatable by rapid means, the tent is 
i'siHuMully indieated as a ineunB 4>f prejuiration for rapid dilatation by 
jLHTuluated sounds or divei-ging iiistrunit nts. 

Graduated Bounds and diverging dilators are generally the safest 
and Hiost effect ive means of dilatation, and should have the preference 
unless the sol telling etieet of tfie tent is especially desired. 

One* may combine the j*rincij>le (»f graduated sounds in the use of 
diverging dilators. This requires a series of dilators of gniduated 



n 



/i 



^^j^^/ 



l*U?ru»< fwTfnr»t<Hl by & tufK'lo.tiMil. Fipiri' l<> It ft islmwH size of knit bt-fore and afler exjtaiision 

sizes. The small instrument is first inserted, and the blades spread ; 
thf dilator next larger is then used in the same manner; and so 4)n 
thnuigh the serie\s, Bef^ire sf^reading the blades ea(4i instrument acts 
as :i gradnati'd sinnul ; as the blades divei*ge they act on tlie principle 
of the glove-stret<'her. At least four <lilators are rw|uired : two of 
the Pabncr or Xott iiattern, and two of the Watheji variety. 

A small light dilator as a means of complete dilatation has two 
disadvantages : first, fhc liglit bhwles may benti and fiiil to streteb the 
canal iKTonrl a limited degree ; second, if they tlo not spring or iK'nd, 
they are apt to imlieil themselves — that is, crush their way into the 
nterine walls. The resrdt is not dilatation by stretching, but by tear* 
ing. The wtMnul thus inf1icte<l may be dangerous. This unftirtunate 
re>inlt may be avoided liy the use of a gnnlnateil series of instruments. 

The teciuji^pje of dilatation is simple ; 1. IHsinfLi't the vagina and 




MINOR OPERATIONS. 



113 



fiRvaT 2. Exix>w tht^ r<^rvix Ijy a Sims^ or Simon's ppeciiliitiu 3, 
(rRk^p the cervix firmly in tlio teeth of ii viilsi'lluni fbreep?^< Figur^^ 
U7. 4. Intro^luce the sueeessive dilators and ^hnvly st^rew the blades 
»part 5. Wash out the uterine eav^ity with sterilized wat^.^- from a 
foontain-j^yringe through a rubber tube and eimula. The ordinary 
^liss? female catheter is a good ejiinda. The dilatation .shouhl ho suf- 
ficient tn give a free returu-tlow through a single eaiuda : if the dila- 
lition is not sufficient, irrigation is usnally eontmindieated j hence 
ika double-current cunnla is seldom refjuiixnl. 

8al(Hngitisy sactosalpinx, and other forms of circnmuterine inflam- 
rnatiou may contra inilieate dilatation. 

Curettagre. 

The ttitignostie sign ifiamee of the curette has been given in Chapter 
III Its tlierapeutic purpose is the removal of diseased tissue or 
t^^rr'igu Ixxlies from the interior of tJie nterus. The symptomatic 
iiniioations are usually hemorrhage, uterine diseliargeH, or s^rpticieniia 
<liU' lo Home intra-uterine cause. The instrunieut was first used in 
WZ by R^'camier ; it has passe<l througli numerous mtMliJieittions, 
and an account of its disastrous results — perforation of the uterus, 

FiGt RF JM. 



y^///^0^. 



Tllomia*! dull wire eurette. 



tHetritis, salpingitis, cellulitis, jH'ritonitis— it has received at times the 
^•vert**l eeiisun% not wholly ini<leserved. 

The dull euretti', shown iu Figure 84, is made of flexil>le copper 
wifi% The loop at its extremity has slightly flattened but not rutting 




.■^iuis thuri>, fvncJftrali'il steel riirelle. A. Hv4mi 



^vij^. LI, .-cetJOTi of full sm-. 



»lge8; it^ shank may \m^ bent like a pr<>be t*i enuf< irm to the direc- 
tion of the uterine canal. Whatever the fon-e applied, it is not likely 
^> injure the sound tissue, altlumgh it will remove loose foreign 
Wh'f^. such as the secundines of an abortion. 




114 GENERAL PRINCIPLES. 

The sharp curette, shown in Figure 85, is designed to remove such 
diseased tissues as are more intimately connected with the uterus^ for 
example, an infected endometrium, benign adenoma, and malignant 
growths. The loop is of steel, and has a sharp cutting-edge. The 
shank is of flexible copper, and may be bent to conform to the direc- 
tion of the uterine canal. 

Operation. The steps of curettage are these. See Figure 37. 

1. Dilate through a speculum, preferably Sims', as above de- 
scribed, sufficient for the easy admission of tlie curette. 

2. Steady the cervix with the vulsellum forceps and introduce the 
curette. 

3. Should the object be to remove some foreign body, the dull 
curette will readily accomplish this if used like a rake. Little force 
is required. The sensation imparted to the fingers will show whether 
all the foreign substance has been remove<l — i. e., whether the loop 
glides over a smooth surface. 

4. If the object is to remove diseased tissue, the sharp curette 
should be used with a back-and-forth scraping motion round and 
round the endometrium. The operator will know when the tissue 
has been sufficiently remove<l : first, by the fact that no more comes 
away; second, by the sensation Avhich the curette imparts to the 
fingers, of a hard, resisting, more or less healthy, intra-uterine sur- 
face. 

5. The diseascil tissue having been scraped away, the endometrium 
should be washed out with sterilized water, as described on page 103. 

6. If it is desirable to apply a medicinal substance, such, for 
example, as a saturated solution of iodine crystals in pure carbolic 
acid, tliis may l>e done by means of an a])plicator or a fine dressing- 
forceps wound with absorbent cotton. Before making the applica- 
tion, ]>a(»k absorl>ent cotton under the cervix, to absorb any fluid 
whi(^h otherwise might run out and irritate the vagina. 

7. The after-treatment is rest in bed for a week, with vaginal 
douches twice daily of one-half of 1 per cent, solution of lysol in 
sterilized water. 




Modified Trendelenburg table. 



p«e a s^hort tible may be supplemented by a stiiuil or by anotLer 
shorter table. 

The Trendelenburg Position. A favorite table fur huhpital uh-, 
m\ e.HjKH'ially for abdominal section, is that of Trendelenburg or one 

tl5 




no 



GENERAL PRISCIPLES. 



K 



of its nuraeroii?i nifxlifieations. The top of the table may, at any time 
during an operation, be ri-ariily adjusted to atiy desired angle, and hy 
this means the hips may he so elevated as to eaiise the intestines tO'fl 
gravitate away fnim the pelvis toward the diaphnigni* Tl*e surgeon ■ 
may then gain, in tavomble eases, an almost nnohstruetetl view of the 
jielvic basin and may work deep in the pel vie cavity nnimj)edeil bv 
the distended intestines. It is ev<'n maintained by adv^K-ates uf this 
position that in these tavorable eases the o juration may be proeeetled 
with as readily as if it wem on the external surface. Extravagant 
claims are made that tliis position makes pelvic surgery easy, so thai 
an indifferent (jjierator may Rifely undertake it* The table is useful 
iUiring ana?st!iesia, whert the pulse and respiniti<jn fail and it beeomei? 
desirable to elevate the lower extremities and lower the head. The 
forward Jlexure of the head upon the body as here shown may impede 
respiration, and is thert*fore objectionable. This fact would suggest 
t!»e use of an inclined ]diuie nj>on wbieli tlie head as well as the btxiy 
may rest. 

The advantages of this posit ii>n, altliongh admitted, should not be 
over-estimated. Besides the fact that in many eiises the field of ojR*r- 
ation is not i-endered more acr^essible, the positifni has several dis- 
advantages : iirst, infectious fluids which esr^ajH^ during the o|>eration 
are certain to gravitate toward (he diaphnigm, and may infect the 
general ijeritoneum ; second, the abdominal mnscles are often made 
more rigid j third, with the patient on an ordinan.- ti^ible, Iai^\ flat 
sea-sponges^ or gauze pads nniy he used in such a way as to keejj the 
iitestines ont of the way, and thereby to exjMise the deeper |iarts of 
the pelvis. The Trendeleidnirg pijsition does not overeome, but rather 
lessens a few — only a few — of the difhenltics and dangers of abdom- 
inal surgery. 

The Knig portalde Trendelenburg frame is adapted to private prac- 
tice, and is one of the nn>Kt praetieal devices of its class. It is made 
<if light maleriab covered with washable canvas, adjustable to an ordi- 
nary woiiden talde by means itf elami>s, and readily carried from 
place to jjlacc. 

Substitute for the Trendelenburg Table. The end of a com- 
mon taVde may be raised on a bhw^k or chair so as to give it the re- 
ipiired shmf. The jmtient then, with the legs falling over the foot 
of the taltle, may be readily adju.sttd to tlie desired ajjgle withont 
rec(»urse to the nu>re or less complicated Trendelenburg talJe. 

The Preparatory Treatment. The neeessa ry a n ti se ptie prooetl u res 
to an aseptic result have been set forth in rha(>ter IL After the 
patient is on the tnble and under amesthesia it is well to scrub the 
abdomen again with the sterilize4l soap and water, then wash with 
clean water, then with a 1 to lOOO solution of bieldoridc of mercur)', 
and fiTisiUy with etht^r. This is es|>ecially impc^rtiuit in eases of acute 
jM'lvie sn PI jurat ion in which thc>roiigli serubliing before {uuesthesia is 
not tolerated. The patient's clothing should be of light tiaimel — _ 
imdervest, drawers, woollen stfvckings, and night-gouTi, * ■ 

It is furthermore impr>rtant, bef(»re In'ginning a grave o|K»ratioD, 
that the various organs of elimination be snfticiently active, so that 




MAJOR OPERATIONS. 



117 



?r of autointoxi('utit>n fn>Hi tlie retriition of waste-pmducts 
rt'duced to the iiiiTiimunK The dt'iiiaiHl made \\\)im the patient 
by the openition itself reduces the eliniinalhig aipaeitj of these or- 
gans, soDjetiines to the point of danger; hence the inijjerative neces- 
sity of lightening their burden, ( ^-ireful exaniinaliou of the kidneys 
od heart may lead to essential pn panitory treatnieut of these orgrans. 
The Incision. To open the ahdumen oidy a few iustrnnjents are 
required ; in fact, it may be laid down as a ^*^iu*ml jiroposition \\mi 
the most skilful surgeons oj>erate with the fewest instruments. A 
scalpel, a few stronj^ fuemostatic forceps, long and nhort, and a pair 
rf strong straight-b laded scissors are quite sutficient. Twelve snort 
and six long hiemostatie forceps will sutfice for any o[>e ration. Sir 
Spencer Wells and others have rej>r*rted easrs in wlueli, after the 
operation, hiemostatie forceps were tViuiid post nnirteoi in tlie peri- 
toneal easity. In order to avoid this, one sluudil always o|wrate with 
the same number of ibrceps, t)r at least carefidly couut and record 
the atimljcr l>efore the o{H?nxtion is l)eguu, and before closure of the 
vfound. Unless the o|>enitor is certain of his assistant, he will ilo 
Will to count them himself The incision for gynecological ex plora- 
tiun or ojieration is usually in the median line near the pubes. 




A. Reduced siae. B. Se^^titm of full size. 



Exploration. Ever)' abdominal section should commence as an 

Jtxploraton' incisiiui, arn*! shendd therefore at first be only long enough 

ytii admit the index finger for exanxiuatiou. If it is nceessary to iiitro- 

/ tllKv the hand, the incision may be extendeil in either direction. The 

/ f^wnator now decides whetht*r lie will closr the wound after the simple 

diagnostic exploration, or |U'f>cced to a etimplcte ojK'ration. Mr. Tait, 

in urging the exploratory incision as the first step of an al>dominal 

opemtion, once wisely said : ** It is always easy to turn an exploratory 

iDcisinfi iuto an oj>eratiou, but often fjuite impossible to turn an inconi- 

plete operation into an exploratory ineisron.*^ 

The median incision through the linea alba doe.s not expose nr 
wound the recti museles. If however, the linea alba lias been dis- 




118 



GENERA L PRINCIPLES. 



jjhie<'il l>y a tumur or by other raiises iiikI 18 not readily found, one I 
may properly ignore it, eiitdirertly tlirou|]rli the upper faiscnal shuath 
nl' the miisele, se^Ktrate its fibres loiigitudinaliy^ ami then divide the 
jstructurejs beneath until the eavity is reaelietl. Many operators have 
adopted thit^ metho<l in preferenee to the usual incision through thej 
linea alba. The pur|K>se i,^ to secure union of the muscular structures 
themselves, and thereby get a thicker, stronger cieatrix. When cut- 

Ftaims 88. 



^ 



I 



ting down upon a tumor, one often reaches the linea alba with thef 

first stroke f>f the seal pet, and the subperitoneal fat with the second. 
The fat is then sepanue<l Uy the tiriger anit handle of the scal|>t4, and 
the jKTitoneal membrane exposed. Blee<ling- points are now seen rtni ■ 
by pressnre-ftireeps ; ligatures art^ seldom re<juire{|. The jM^ritonenm 
is then superficially eauglit by two small pressure- forceps. The u]n*r- 
ator's left hand retains i»ne» and that of the assistant the other. The 
IK^ritoneum is usually so tninshiecnt that tlie viscem just beneath cmi 
be seen as it glides over them ; it is nf*w lilted from the viscera by 
tfie pressure-forceps, ami by a single stroke of the s<:'alt>el dividt^l 
between them. The groiwed director formerly in use is rather a 
hindrance than a help. In grasping the jicrittmcnm in the two for- 
eeps for incision, «uie should be eiiix'ful not to inelude a bit of intcjs- 
tinal wall. Tlu' writ<'r once in this way opened the intestine. Im- 
mediate suture, however, iTsultctl in prompt union, and no pernmnent 
harm w^as done. Sonictimes the intestine is adherent to the parietal 
peritoneum. The ineision must then be made slowly and with great 
rare. One may sometimes avoid cutting tlirough the bladder-wall by 
i*eeognizing in time its greater vascularity. If the intestines or hladder 
nre adherent ami nnret^oguizable, this tact will I>e apparent by tht"^ 
failure of the op<'nitor to see the viscera throngli the translucent 
|x^ritoncumj or by the fact that the pc^ritonenm diH?s not, as in an 
iirdinarv casie, glide over them. It is then better to prolong the in- 
eision upward or downwanl and enter the ul)diimcn jdiove or behm. 
The adherent viscera may then lie detached, and the inci^iun com 



I 




MAJOR OPKHATIOXS. 



to Its original jKiiut, Delihemtiun, eatr, ami jiulgnient will 
Ufiiially enable the iK^ginner to tiiid his way safely to the ahdoiiiiiial 



vntj 



the 



The cavity being open, tlie iticisioii may he lengthened as desired by 



the inserted index-lingers 



^uide. The length of the 



scissors 
jiicision will vary wim tne reijnirements rn ine ease and me tiextenty 
of tlie o|>erator ; the shorter the inrision the less the danger. Snt- ' 

Ifieient nwjm, however, shonld l>e given for eiVeetive wurk. The 
added risk of a longer ineision by enniparison with the added safety 
of an nninipeded oiiemtion is insigniHeatit. The pre^sure-foireps 
may now Ik? iTmoveu fi*om the bleeiling-piints ; if at any jwint the 
bleeding eontinnes, it may be eontrolled by torsion or by fine catgut 
ligature. 
Before invading the abdominal cavity for pnr|X)ses of examination 
or operation, one should seize the margins of the jM^ritoneum by two or 
three foreeps on either side, and draw it ont through the wound tc^ward 
itJ!« cutaneous edges so as to make it cover the cut surfaces. The wound 
is thereV>y protected and the pentr*neum is not stripiH^d off from its ad- 
jacent tissues as it might otlierwise l>e during the snl>se*|neut manipu- 
lations. 

Adhesions. Tlie conditions which give rise to adhesions usually 
alj^ cause more or less thickening of tlie |x*ritoneiun. Sometimes the 
parietal peritoneum is so thi<'k as to l>e imre(*ognizable. The operator 
may be uncertain whetlier he has cut through the peritoueumj and this 
uneertainty may 1k» increased by the presence of adherent intestines. 
^^jflrge areas of peritoneum liave been detached from the adjacent ab- 
\ dominal wall uiuler the wrong impression that the peritonenm had 
\ been dividcnl, and that intraperitoneal adhesions were being separated. 
Exjierience in such easels is the gtiide. There arc no safe rules. 
Adhesions are usually sepamted by nieans of the finger, tlie hand, or 
tlie sponge. If great care is not nsed in sepam ting intestinal adhe- 
sions, one or more coats of the l)owel wall may be stripped oft' with 
the adherent tissues; this might result in sloughing and a e<aise(jneut 
feeal fistula. Such an lujiiry, therefore, sliouhl be promptly rejmired 
by drawing together the |>cntnneal margins with fine catgut or i^ilk 
/iiltnre**. The s]i^)nge, as use<l by the late Thomas Keith » is a most 
/ u^ful means <»f sejwiraiing the adhesiotJs betweeni intestines or onieu- 

^** Imn and a tunu>r. By ])ressing firmly against the adherent bowel at 
ihe point of its attaehment to the tumor, rme nniy literally s|>onge it 
away frtmi the tnmfu\ It is surprising t*j ncite tlie facility with wliieh 
flltbcr firm adhesions may thus be broken. In breaking the adhe^ 
^ions in this way one avoids stripping off one or more coats (»f the 
howel. On the contrary, the [»eritorieaI i-overiug of the tutnor is apt 
to remain on the boweL Tlie spimge mctlnKl is more gentle, more 
eflective, and h'ss proiln(*tive of shock than the usual method oi" tear- 
ing with the finger. Adhesions Ux) strong fiu* the spongr- t>r finger 
have t^> be cut. 

Hsemostasis. Heniorrhag** rbiring an <>peratioTi ts treated on 
genemi surgical principles by inrriprc^ssnre, ligature, sponge-pre^i^ijure, 
or ^lyptte^. 




^effirieiit styptic ; it may be applied witli tli** Fiponge, 

Hfi'mastusis of the vessels of the jH'diele is by ligature or sutare, 
ami will be ileseribed elsewliere in the seetions on the ^peeiitl ojK*ni- 
tion.s. 

Intraperitooeal Ligatures and Sutures. Silk would \n* imobjee- 
tiojuible if it were always possible to insure complete asepsis of tin* 
tiehl of oj>eration during eonvide.seence, ITnfoi*tniuitely» suppuration 
around the suture or ligature is sometimes inevitable; then, if tlie 
patient survive, a sinus forms, lending usually through some ]M>iut in 
the external wonrid to the surface. Suppuration nuiy n(»w eoutinue i 

for weeks, or months, or years, until tlie sutui-e is dish«lgrd and cast ^| 
out (»r manually removed. Catgut sutures and ligatures disappear by ^^ 
absorptiou in a few (kiys or weeks. Jf of ginKl quality and jirojK'rly 
disinfected, tliey an' ]»erfeetly reliable and sate. Tlie humiliating 
exjM?rieuee which the surgeon must oeeasioi rally have with silk will 
be avoided by their use. 

Closure of the Wound. The ♦ordinary methf>d is by lli rough- 
and'through interrupted sutures, inehtdiug the entire thickness of the 
abdifuiiual wall, and tied upon the skin. The sutures are placed 
about thn'e-eighths of an incli apart, and ineliule a margin of skin 
and jR^ritonemu alnait onc-ijuarter of au inch wide— that is, the 
needle enters the cutaneous sui^uee a (juarter of an iut^li from the 
margin of the wound, tninstixi^s all the layers of the abdominal wall, 
emtTges on the peritoneal side rdso a quarter of an iueii from the 
peritoneal margin, enters the peritoneum <m the opj>osite side at an 
equal distance from tlu' margin, passers thnaigh the wall on that side» 
and enu^rges at a point oj>]M>siie and eorrcspundiug to that at which it 
fjrst entered. 

Silk, silver wire, catgut, ami silkworm-gtvt have all been nsed as 
sutures. The last mentioned, thoroughly sterilizcil by lie a ling, is pn - 
ferred by most ojwrators. Let the sutures l>e drawn and titH.1 with 
only suffiiacnt tensiitn to hold the fragments together. If tied to4) 
tightly, tlicv strangulate and cut the tissues, and favor suppuratit^n 
alung their c(»ursc. If the cutaneous margins of the wtauid gum- 
after the <le<']i sutures are tied, the margins of skin may be brougut 
together |jy su|M'rtieial sutures. 

Just before and during the intrtxhietion of the needle the assistant 
shouhl eateh up with the pressu nr*- force j is the margin of the rectal 
sheath, and nuikc traction upon it toward the opposite side of the 



MAJOR OPERATIONS. 

wound. The same action is to be rt'j>eiittHl as tho needle is passed on 
the other side. The effeet of this after the sutures are tied is to 
bring the mar^s of the fascia into elo^^r contact* The sntures are 
tisnally removed in about two weeks. 

When the wound is not more than two iuehes long, and no drain 
is tised, the through-and-th rough inethwi of closure, if eart^fully made, 
\^ usually adequate, l^ the incision has been long, antl especially if 
fOiuplicated by a drainage-tnix* or dm in age-gauze, ventnd hernia is 
apt to result. To avoid this, tlie margins of the peritoneum and 
linea alba may be united by a supplementary continuous suture of 
fine, buried catgut. 

Tlie Buried Catgut Suture Throughout, Dr. George M, Edebohls/ 
of New York, uses fine catgut sufficiently chromicized to resist 



PioiTRE m. 



FloUltl 90. 



/, 



II 




Ftfure ^.— Fascial sheathe of rectus m uBcle *ni one *k1e, beinjj iplit by fteiaaors. Blue folor 

- atf perttoneuiiu Red c^lor reprcseEis rectus musrlt!. 

„iir«; 90^Shdwinf deep tier of huricd ninrjintr oitffut Bulurtv The *njture embrnciea 
Deom, posterior edae cif the divided fasrhi. and inuiic'le. Red color Tepres-ents ref'ti iiiub- 

I rcunJlMl by aeeond tier of raiining ent^rtit sutures. 

:»rption for six weeks. His method \^ ns fijlluw?^ : In order to 
give broader surfiices for eieatrizatiun, ami eonj^eijnently p:reater 
^rength, the incision is made through one of the reeti miiseles and 

> Amerleaii (iyneoologleal and OkHtotrieiil Jniirnal, May, 18%, 




122 



GENERAL PRINCIPLES, 



its sheath. If, perchance, tlie incision has been made directly 
through the linea albii, withont exposing a rectus mu.sclc, the sheath 
is to be delibcmtely tlividefl on cither side with the scissors, as shown 
ill Fignre 89. This ^ives donble fascial edges and broad noiscular 
stirfaces for union. The purpose is to approximate the muscular and 
fascial layers of the wound so as to seen re appjsition of honiologous 



FlOUltE 91. 



m 



FiornK 92, 



F«iN7lal mari^iis of wound clooed by leoond tier 
fO€ huried running suiure. Sutures of the sklu and 
ful are not n'pn'!»entfil. Tht- knot b liMwel}" mftdr %n 
illuHtnit^ proju^r nmtiufr r»f lyinir bnrk'd ofttifut. & 
»i Rifle turn in the t^i>t Imlf antl a fJouhle turn hi the 
teoLiiid half of the knot. The recll muscles are now 
fitvertil in by fiiacia. 



IF 

BubcutancnUB suture, for closure 
of external margjni of wounds be^lnip 
IntrtHluctsd. l)ec*|K*r rascinl nuturca 
shown below, [kitted llnei indicate 
burlt'd suture in filBre, 



jiarts, and to retjiin them in nppniximation hmg enough to insnix* 
firm union* 

The running suture is [>rt*ferahle to tlic intcrrupU^b fii^t, iK^ause 
it brings honiohigoiis struetunv'^ mon* a<MHinitely and more cpiickly 
togetln*r ; second, rjeeansc the burietl knots arc decreased in niimljer 
or entirely avoitU'd, The second advantage is considerable, for the 
bulky catgut knot tends to suppiiratit)n ami failure of union 

Closure* of the abtlouiinal wnund by liuricd catgut sutures, aa 
described by Edebuhls, is niade as fulhiws: 

The needh* is intro<luced at tfie hnver extremity of I lie wound on 
the riglit side, and at the tirst thrust is carried tliruugli fascia ami mus- 



i 




MAJOR OPERATIONS, 

cleand ijeritoneum. Figure 90* As it emerges on the opposite side it 
includes peritoneum and mu.sele only ; the fascia is not inehuled* The 
Miture is then eontinued as a running suture the length nf the wiMnKl, 
and unites the peritoneum, posterior iascia, and innsele. It is then 
oirriwl back to the starting-pointy wliipjiiug together the anterior 
facial edges, from which it finally emergfs on the right side, and is 
tied. Figure 9L This la the only buried knot. The subcutaneous 
fat is not sutured ; it falls into plaee and takes eare of itself. The 
^Insure is completed by whipping together the margins of the skin, 
dtlier subcutaneously or by means of tlie over-and-over stitch, with 
fine catgut. The subcutaneous suture is prefemble. The writer has 
i^peatedly used both methods in the same wound and fjl)served sup- 
puration ID the part closed by the whip-stitch only. This doubtless 
comes from the staphylococcus epidermis which the sulwutaneons 
suture does not disturb. 

In plaee of the ehromieized catgut, the formaldehyde catgut may 
be u?(m1. The latter resists absorption fi>r five or six weeks. The 
closure i^ best made w*ith Xo, 1 or size gut. The method of the 
buried suture is most satisfactory, especially for long woiuids, when 
the abdom i na I wal 1 is th i n . 

In operations for ventral hernia, the splitting of the sheath of 
tk' recti muscles and the buried suture will be found most effective. 

Stitch -abscesses are very liable to occur unless the following pre- 
(Hiiitious are observed : 

b The abdomen should be opened witli a sharp scalpel which will 
make a clean cut, not a ragged , uneven incision. 

2. Great care should be used dnritig the operation not to bruise or 
tear the wounded surfaces. 

3. All l)leeding should l^ arrested l>efore closure of the wound. 

4. Abs«jlute asepsis shoukl be secured in handsj instruments, 
'^puDges, and sut tires. 

\ 5, The sutures should not be drawn too tightly. 

Should suppuration in the wound or along the sutures occur, the 
»anires, if of the throogh-aud-througli variety and tied on the skin, 
should l>e at once removed. Tlie buried suture must l.>e left in place 
until it is absorbed. A dressing, wet with a saturated solution of 
boric acid, two parts, and alcohol^ one part, should be continuously 
applie<.l. Free drainage by incisicm should, if necessary^ be estal>- 
lishp<h Immobilization of the abdominal walls l>y a firm bandage 
will lend to prevent sepamtion of i\\v suppuniting wound, 

Sponer^s, The openitor according tt) lus preft^renee may use 
fSBOxe or sea sponge's. See Sterilization of Spongt»s, Chapter 11. 
They are used not only in the removal of Idriod and other fluids, but 
it may be desirable to pnck them in large numbers into the cavity, 
either to control hemorrhage by pressure or to hold the intestines and 
other viscera out of the operatorV way. In nearly every abdominal 
section numerous sponges are used t*or this latter purpose. 

Spongrs Lf^i tn the Ahdomen, It is quite impossiiile during the 
prepress of an abdominal section for the operator to keep track of 
the exact number of sponges which may be inside of the abdomen \ 




GENERAL PELXCIPLES. 

lieiice numerous humiliating, not to say fatal, results of closure of the 
woiiml aud completion of the operation with oue or more sjjcjii^res 
n'maiuing in the pei'ittmeal cavity* Tlie not infrequent oecurrenoe 
of lliis tlcplorable accideuti eveu ut the hands of careful nieu^ is the 
writer^s excuse for iutrodueing two personal exju'riences ; verily, how 
much experience oue may get from a single case ! 

Thr Jirnt r(m' was oue of exteusive suppumtion of the uterine 
appeudages with nearly universiil ukl, tirm jHlhesions tliroughout the 
pelvis, and with the uterus enlarged by infectious endometritis and 
metritis to about four times its natural size. All the diseasi-d urgans 
were removed Ijy abdominal and vagina! section. The opera! ion, 
especially the hysterectomy, was exceptionally difficult and tedious. 
The broad ligauu'nts were so short aud thick as to be inaccessible for 
the ligature, and almost for the clamps. Each ligtmicnt was so thick 
that through the vagiua it had to be clamped in three parts. The 
patient was put to bed apparently nearer dead than alive. The 
writer *s usual precautious had been taken to prevent closing the 
woun<l with a sponge inside. The sponges Iiad lM?en brought to the 
operation in sterilized packages each etrntainiug eight, so that the 
nufuber must have been eight or some nmltiple of eight. Only large, 
flat gauze sponges were tised. The o|jeration was begun with the 
eight sponges of one package, wliich were counted. Two additional 
packages of eight each were reipiired in the course of the operation, 
all of which were su|>poseil to liave l>ecu accunitely counted by the 
luirst* in charge of them. Just I>efore the al>douiinal sutures were 
intrtKlneed tin* nurse was directed to eonut the s|)ouges. 8he iviwrted 
them ** all out." After the intr(Hlnet!i)u of the sutures, and before 
they were tied, she was told to count them agiiin, and this count aUo 
uuule the number twenty-four and **all out.'^ With the evidence of 
a double conut, that there could be no sjxmge in the abdomen, the 
wound was closed. 

Thnn^ hours later the nurse reported tliat one of the gauze sponger 
used in the alxhunen could not be fonud. After consultation with 
two colleagues it was decided to assume for the time that the missing 
sponge had bwn lost outside the abdomen, and that consequently the 
|K*ritoneal cavity was clear. 

Convalescence was uuinternipted till the tenth <!ay, when the 
stitches were removed. At this time there was noticed a st^mi*resimant 
masi^ of irregular ovoid shajH*, as large as a mediinn-sized orange, in 
the region of the right kidney ; it gave to the palpating hand the nen- 
sation of a nuiss of gauze mingled with adherent intestines. Two 
colleagues agreed tluit it won hi l>e wise to wait tor devehipmcnt*. 
Sixteen hours later, at H p.m., the mass had increased in size, lie- 
ctune painful, the pulse had risen from 100 to 120, and the temi»era- 
turc from I^ff° to 101'", There was slightly iuereased distention, 
aeer>m|>jtni(Hl by a tendency to pronouueed nausea. After a hasty 
eonsultation, the family being fnlly informed of our suspicions and 
fears, chlorofc^rm \vas hastily givx^n and the abdomen ojM'ncd dirtH*tly 
over the mass. The iucisifiu was made without the usual jv^sistants, by 
artificial light, at midnight, and rt»veale*l, not a sjMjngi', but a much 




• niarged kidDeysiirrouiMltd :uk1 covcrhI by lirnily adherent intestines 
IrMijKil and matted together in an irrcgidar mass. In working thrfingh 
rlie rhickened, nnrecognizable, adherent parietal jR'ntoneara, and 
U^twet'U the layers of visceral peritonenm and the adherent intes- 
tJues, also thickened and difficult to recognize, the intestine was ae- 
cMnitally 0|K'ned. Tlie ojx^ningwas ininiediately repaired with inter- 
ni|mxl I^jid)ert sutures, and the alnhHiiinal wound elosed withont 
finiin. 

Three dayg later the contents of* the small intestine, prohably the 
(ipiN^r [wrt of the ilenni, luinie through tlie ahdcHiiiual wound, and an 
inte?.tinal fistida was therehy demon strateil. During the tollowing 
five weeks no feces p:issed by the anus r all bowel evacuations ranie 
thnm^^h the fistula, llie opening was so high in the bowel that uutri- 
turn was jieriously inipaire<l and eiuaeiation beg;in. The fear of a for- 
midable operation to i^estore the integrity of the bowel increased day 
bv Jay. Finally, to the writer^s nns|>eakable relief, in the sixth week 
tVnl matter apjieared at the anus* Tlie fistula f>egtin to contmetj and 
id a few days was eonipletely closed. The kidney enlargement en- 
tin^Iy >ubside<i, an<l rei)eated urinalysis showed no evidence of fnnc- 

tlitinal inijxiinnent. 
The prolcHiged anxiety and distress of such a case are beyond de* 
5cri|ition. They are, both for the surgeon and for the patient, a life- 
shortening experience. The luirden of this case was lightened, first, 
fcv the ultimate receivery of tlie patient; second, by the compieto re- 
lief wlueli she has since experieneed from a distressing intestinal 
«itarrh which had mach^ her a semi-invalid lor (if teen years. This 
relief xs attributed to the continuous rest to which that portion of the 
boNVel Ijelow tlie injury was subject wliile the fistula was oj>en. 

Tlir Htvotid cam was one of iutra-liganu'utons (»varian cyst on each 
?ide, with double sactosalpinx, serosa j and miiversal a<lhcsions. The 
?|)onges wei-e carefully counted before the incisifvn was made. Befom 
fne wound was closed the nurse c<nmted them ngaiu and reported mie 
mis^sing. After a search of fifteen minutes among tlie abdominal 
viscera, the nurse in the meantime looking for the s|>onge outside, 
it couM not be found. In the lio])e of finding the sponge, the inci- 
i^ion, previoiisly short, was then extended to the navel, preparatory to 
triTTiing out the intestines, when the uursc fonud the sponge outside ; 
it had been carelessly misplace*! in a jur and ovtM^Iookcd. The patient 
/'•>rtunately recov^ered* 

These tWi» t^is<»s illustrate the degree to wliieh a surgeon, with all 
the respinsibility, may he powerless to protect fiis jiatient against tlie 
iupffieieney or carelessness of an assistant whose shortcomings, j>er- 
(jijince, he may be uuablc to discover until it is tOf> late. 
/ Thv premntions which mny be taken tn imler, so far as (Possible, 
yWguartl against accHlentally leaving a sponge in the abdominal c;jvity 
f /re as follows : 

. / 1. All sponges should be so large iis not easily to he overlouked hy 
' the ofR'rator. If sea-sponges arc used, let tliem all be the hrrgest flat 
^pongt*^. and ol" as nearly uniform size as prissil^lr. (ran/e sponges are, 
however, preferable, lliey shouhl be made of good absorbent gauze 




OENEEAL PBhWlPLES. 



w siaailer ones, then, 



in four thicknesses, and rilxnild \w of iniiiorm size, at lea^t six incliei? 
wide by t\v*^!ve to sixteen inehes long. All sponging can be tliine 
witli large as well as with snuill s]HKiges. l^et the 
be di(*ca riled. They serve no useful [nir[M>se, 

2. All sponges designed for abdominal seetion shoidd be kept in 
paekages of eight eaeh. This innnher will snttiee for the * ordinary 
tjperation. If more aiv nrediMl, aihlitinaid |iaekages may be uprneiL 
As soon as a [>arkag(^ is opera d, the spnogrs should l>e aeeurately re- 
eonnted and ret-unled. This pmcuntion will invariably fix tlie number 
for any operation at eight or a multiple of eight. 

3. Toward the close* of the njieration the s|)onges should be agiiin 
counted. Exjierience tias shown that nnih^r the denita'idizing inthienee 
of hurry and exrilnneut whieli often go witli the elose oi" n d^'sjx'nite 
operation, the nurst' in eliarge of the spongt/s is liable to blunder in the 

\\ count. It is wi'll, the IT fort', that the count be repeated two or three 
^^inies, and, if pos>it)le, by diiJcrent individuals. 
^ ' The ot>erator, whose every enei^y is employed in the effort to 
shorleti the time of ojM>nition, cannot stop ft*r sponge connting; yet 
(ndy a surgeon vim appreciate tlie satisfaetiiai w^liich lies in tla* abso- 
lute knowlcclgi' that every sponge is out. The writer, therefore, now 
uses a simple tie vice by wliieh tlie nuud)er of sponges nuiy at a glance 
lie apimnnit to any one* It is this : At the time of closing the wound 
the sponges are arningcfl in rows of four each on a talile covered with 
a sterilized toweh The siibject is so urgent that, even at the risk of 
seeming triviality, the aecompaiiying cut is introduced* 



Fig r BE 95. 




8ponjct» armii}9f4 In rnwiTof fciiir eaeh. 



Dre498ing and Bandages. The orflinary condnnation aseptic d reus- 
ing of g*<Hize and WfMid-wool or cotton, seeun^l iiy strips of adhesive 
Idaster and a firm abdominal liandage, will stitfict-. The nui'se slioidd 
>e eautioned to use care lest the tlressing and bandage slip up and 
expose the lower end of tine wound. If a vulva ilressing is also used, 
it shoidd be kept separnte frcmi the abilrmnnal dressing, for otherwise 
Huids may |Kisshy eapilhirv jitlraelion tVom one to tia* other; tins may 
explain the fact tluit stiti-h-abscehsi-s usually begin at the lower end 




MAJOR OPERATIONS, 127 

of the wound. It is well to use two abdominal bandages^ one to reach 
from the hips to the umbilicus or, if necessary, higher, and the other 
to lap over the lower part of this and reach to the middle of the 
ti^hs. The lower bandage keeps the dressing from slipping upward. 
It may be loosened for movement of bowels or urination. 

2. Vafirincd Section. 

The vaginal route for opening into the peritoneal cavity is often 
preferable. The incision may be made either anterior or posterior 
to the uterus — i. e., between the uterus and rectum or between the 
uterus and bladder. The techniaue of the procedure varies within 
wide limits, and will therefore be described in the discussion of special 
operations. See Vaginal Section in the chapter on the Treatment of 
Pelvic Inflammation. 

3. Sacral Besection. 

Hysterectomy and other intra-pelvic operations have been performed 
through an opening made by resection of the sacrum after the method 
of Kraske. The value of the method has not been established. The 
reader is referred for further information to the literature of the sub- 
ject by Kraske and others.* 

^ A deacription of the Kraske method may be found in a i>aper by £. E. Montgomery, Trans- 
tctloDgof the American ABsociation of Obetetriciana and Gynecologists, 1891. 



CHAPTER VII. 

^^.^^RAINAOE m MAJOR OPERATIONS.* 



Two classes of dr 



esent themsch 



6rst, 



linage cases 
whtehj up to the time of operation, iire fi*ee from iiifeetioo ; second^ 
cases in which infection lias f»ccnrrcil previous to the oiwralioii. Tn 
the first class helung solid aud tn'stic tumors and tnlnil |u"egnaiicjcs 
which Iiavc not become infected ; to the second class htdoiigs jwdvic 
itirtainination in its various forms and stages^ such as intlammatinn lif 
the FaUupiaii tnhe and ovary, including jjelvic abscess, pyosalpinx, 
and inft^rtt'd toini>rs. 

Drainage in Non-infectiouB Cases. In tins class of cases, decidinj 
to be non-infectious — that is, not primarily infected — the sole indi- 
c^ition for drainage is the removal of bhxKl^ scrum, or other non-infec- 
tions rttiids such as might otherwise acctnnidute in the periton^nmi, and, 
if left there, liecomc infectious. Both experiment and ex]H'rifnce have 
clearly shown that the non-infe<'tious IjIocmI and si'rnin whirh may 
accumulate in tlie peritonenin nffer a clean, ndeijnsitr ojM^rjtion have 
little or no power for harm. Sc>ruin and li([uid blood are nifmlly ab- 
sorbed, (^oagulated blootl may be aljsorbcil, or it may become enca|>- 
fiulated and grail ually removcil by the action of leucocytes ; or it may 
become organi;^ed and remain harndcss ftjran indefinite piTiod. Both 
blofKl and st^rum are excellent cnltnrt'-media for niicrol>es ; hence the 
Otressity to keep lliem nun-infet*tious hy sisejitie surgi*ry. The ]vi'rit*>- 
nenni has gn*at power to resi>t iidl<^tit)n. It is known to taki» u]i and 
flisjxise of large i plant it ies of infectious ninterial, even without *lniin- 
age. Recent studies and cxpcrioncr^ ]irove thai the dmin is often more 

i>«*tent as a m<'dinin fVir the introduction of sepsis than for its removub 
)niinage, therel'on!, after a clean ojienition in a case not hitherto in- 
fiH^ted, is eontniindiratL(], 

Drainag-e in Infectious Cases. The above desigiiaticm, ** infer- 
tiuus cases/' means cases of infectious antecedents, Racterir»1ogical 
examinations of reprmbictive organs removed for cbronie infianmia- 
li»ry disease show that the pus is usually sterih% or, if organisms are 
pre^sent, they are seldom a(*tivi**at the time, ** In forty-four spt^ci- 
mens of ovaries and tubi's» org;inisms resend>ling gonfK*<K*ei were 
found in six ei>ver-glass preparations, hut did not grow in cirlturcs. 
The stajdiyhx'occus allms and aureus and streptococcus were found 
once in culture. With these exc**ptions, the forty-four aisf^s were 
ne^tive. FiTty-six uteri were examined, in none of which were 

» One ctf till' moflt vmliuiMi' I'onlHbutlon? y«?t mndi* (o tlif* suhjoct f*f perilnnoal flmlnncf* U 
trr>m ihf |K>n of Dr. 4, 'i Clark, lU^niikril ciynrrulojtlftt In J*:j1iii* nn|>klii!i Ilo«f»ltnL Tlu' Miitlnir 
tiA« miKle nuiiierfnj« ndatitiitiotiR Trnin UiIk ti«ifH.'r. 8«?if Aiiii^rkwiti Juitraal tif Owilelrir-s, May, l^yT- 

* Clark. AniLTican Juufnal of « fbttetno*. Jiim\ }i^^f7. 
128 



1 
I 



I 



I 




DRAmAGE ly MAJOR OPERATIONS. 



129 



organLnms found in culture. The gonococi^us was observed only once 
lU cover-glass preiaa rations. 

"These results in geneml ooineide with the reports of Menge, 
Sfhaiita, lieymond, and MagilK* In the exiinirnfttion *»f r>ne hundred 
and forty-four eases by Schauta, strept<K?iX!ci timl stajihylLwoeei were 
tourwl four times. Menpje has ohserved thi^ stapltyh>cfK't*us onee in 
twent)'-«ix ca?=^e3«, and Mo rax once in thirty- three eases. Cases of pneu- 
mococcus infection have been reported by Zweifel, Fruiiimeh ruid Wert* 
heim, A fatal pneumootx^cus jieritonitis follow eil tlie hdection in 
certain eases of Fromniel and Witte. Reynioud and Mntrill Ijelieve 
that a salpingitis may l>e prwhicrd by the colon bacillus, and ihiiik 
that it gjiins entrance through ailhesions or thnuigh close projHnijuity 
to the intestine." From genend review of the bacteriol(»giral con- 
ditions in these cases» we concbtde that at the time of nperatiou tlie 
initial infecting organism has ki-gely disappi^ared and that infection of 
tlif* tieritoneum from the diseased area is tliej*efore not likely to occur. 

Formerly the esejijK? of the smallest (|tuintity of ptis into the |K*ri- 
tonfiim iluring an operation was considered an inifMLimtive indication 
for ilminage. Now, it follows from the tbregoing paragmphs diat 
even lai^ quantities may esc-ape ami, being i>erfectly free from viru-- 
lent or ftctive microbes^ not call for dniinage. 

Comparison of a hirge nutnl>er of drained pus-c^ise8 with an equal 

y^nmlier «>f like cases not drained has been reported, and unifurnily 

/ shows a st ro n g p I'e po n de m i ice < d' re co \' e r i es i n t h i^ n < > ii-t 1 ra i nagc se r i cs. 

V Thin preponderance is con\ineing proof that the tlrainiige was at least 

i\usc'lei^. The larger mortality in the drainetl cases is attributable to 

infection introduced through the drain. 

Further Evil Results of Drainage. In addition to the increased 
danppf already mentioned fnmi the direct intnxluetion of infection 
thmtigh the nie<Iium of the drain, the following evil results are not 
infrwjuent : 

A. Obstruction of the bowel. 

/l Fecal fistula. 

V 3. Vesical complications, 
^ 4, Hernia. 

1. Ol/HlrttctioH may occur from adhesions set up l>y the irritating 
pri'*<>aoe of the drain. An adherent intestine sharply kinked may 
^uildenly become im[>ermeabh% or gradually cuntrac^tiiig Imiuls may 
^Iwlyshut off its lumen. Most frequently the obstruetiou is partial, 

^MA ^ives rise to constipation and griping i>aius for days or weeks id'ter 
'wt operation. In such casi's, when fatal, die anlr>|>sy has usually 
4own the intestines matted together a roimd the drainage cavity in an 
oorpccjgnizable mass. 

2, /Verj/ Fl^nh is the occasional result of necrosis fnim direct 
presHiire of the drain. The irritating presc^nce of a gauze drain may 
contribute to fin iriHan mint ion sfi ilestrnclive as to produce iierrosis 

consequent fistula. If tin* IjowcI lias l>ecn opt^ned rluring in\ 

ratioui and has h<*en well re])aired, the drain is unfavorable to 

naion and is contra-indicated. If, however, the intestinal opening 

' Aiiottlf of Surjfery, 1890. 





GENERAL PRINCIPLES. 






190 



has been made deep in the jwlvis, or is otherwise so inaccessible as to 

Srevent thorough siitiiriii^; \{\ iii i\ wnrd, union is improbable, the 
rain is indicated us a nieanr^ (»f rxit for fecal matter. 

3. Vesical (hmpiieullon^. The territory to be drained is usually 
in close relation with the bladder, JnHanimation around the drain, 
therefore, niay give rise toatlliesiuns Ijetween the Ijlmlder and atljae^^nt 
organs, or may invade the bladdt^r; in either case vt*ftical disturb- 
ance more or less severe may arist\ 

4. Hernut in (h'niued rasi-s is mneii more common than is nsuallv 
gnpposed. This is lierau.se tlie dm in sepamtes the fascitil sheaths of 
the recti muscles and other surfai^res which otlierwise wonld immedi- 
ately unite ; the small brea<'h tlius made in tlie \v;dl inrreas4\s, and 
more or less liernia is the result. Hernia k\ss often results from 
y^inal than from al)doniinal drainage. 

To Prevent Infection, ancj thereby to avoid the necessity for drain- 
is an essential purpose of every abdominal section. Tlie subject 
may be summed np in the proposition that the opemtion sliould be 
performed in such a way as not to retpiire drainag-e. This involves 
the following jvreeautiuns : 

L Insnn^ thortjugb asepsis of hands, instruments, and other ajjpli- 
ances. 8ee Chapter IT,^ on Antisejities and Asepsis, 

2. Wherever tliL' pcriton^'um is injured or sacriticeil, let the injured 
part, if |M)ssible, be covered by adjacent peritoneum. This may re- 
cpiire numerous suturcs and careful plastic work. 

il, Control hemorrhage, if praetit-able, even to small oozing points. 
Tliis, for warjt of time or fur other reasons, may l>e impractieid>le. It 
may tireu be safe \i\ leave small aceuniulatirms to he taken np by t!ie 
pt^ritoneuni rather than by a drain. 

4, Avoid all unnecessary injury to the tissues. All traumatisms 
favor sepsis. Do the opi^ratiou ade([uately, but witli the least pi>ssible 
mount of operating. 

If, during the operation pu8 ruptures into the jHTitoneal cavity, 
it should l>e removed as soon as possible by eart^ful spfinging. 
If the pus is sterile, the sponging is sufficient. If there is rc«a*son 
to fear that it is septic, the jieritcmeal cavity should be freely 
rigated with a normal sidt solution, six-tentlis of one pfT cent. 
t1ark ' ad\oeates thorough |K'ritf»neal irrigation whenever any \m^ 
comes in ctmtact with tlie peritoneum. He says: ^* For the last three 
vears it has been tair custom not only to irrigfite the abdominal csivitv 
thoroughly after all o[K^rations where pus or other fluids have est»aijea, 
but frec|uently also to leave as much as one litre of sidt solution in 
the f^eritoneal cavity before closing the abdominal wound." The 
writer cannot too strongly ui*ge t!ie n'tenti«tn of considend)h^ salt 
Hcdulion in the abdimien af\er irrigjititm. It is nipidly absorbed, and 
then»by not only <*arries out septie matter, Vmt increases the arterial 
pressure. 

'* It is tt well-known principle in physics that a substance will un- 
dergo comhustion or solutioti nnn-h more rapidly in a finely-divided 
state Uian when it is masscnl togetlicr. The same principle may be 

» American Journftl or Obstetrlca, M»y, 1897. 



I 



I 
I 

I 




'drainage in major operations. 



! to the tlisposal of foreign niatkT in the piTitoncal cavity. I 



d til 



/ 

R' 



{Mtello'd exix^ninents thv l*-iit'(K^yteK could easily snrroui 

nmlkT foreign bodies and carry them into tlie general circulation 
tlinHJ|i^li the spiioe^ in the diaphragm ; where the borlies were larger, 
many leucocytes were reqnirtil tor tliis ta.sk » and the remt^val of t^till 
lar^tT [Kirticles could only be aeeoiiiplii^hed after tlieir encapsulation 
tml i«iilit*e<pient slow disintegnition by the h4jcocytes. His experi- 
ments als4> deru oust rated that there existed an intra-peritoneal current 
t-aplilt of transport ing eariuine bodies^ eveu against the force tjf 
^nivitv, from the pelvis to the diaphragm. When to these conditiona 
Vf ;ukl tlie pro veil fact that the nonual [leritoneuni can take care of 
a large amount of infectious matter witlioat danger to the animal, 
itap|iear> that there can be no question that it is l>ctter to disijjte- 
^le and distribute infeetious matter rather than allow it to remain 
in a JDcali^ed area.'* ' 

'ostural Drainag"©- This methixl, atlvueated by Clark, consists 
In elevating, imnuMliately after the 4»[)eratiou, the ffmt of the l>ed 
eigbti\*ti inclies, antl maintaining that elevation for a peno<l of twenty- 
Smr to thirty-six hours. The object is butli to |>revent Hui<ls from 
accumulating in pockets or limited spaces, and to distriljute tlieni by 
gravity throughout the perirouenjn, where from contact with broader 
?ilrfa<!*;s they are more reailily taken up. The method also includes 
fn>e irrigiition of t!ie j>eritunenm at t!ie time of the openition with 
§ix-tenths tjf a 1 j>er cent, normal sidt solution, and the retention of a 
(Hiit (If more of the fluid in the al>dnmen. This is to wasli out as 
ittur-h a8 posi!.ibb of the septic flui<l, and to dilute the remainder s<» as 
tiMJi'prive it of its vindence. 

This postural metlirHl of tirainage is oUt^red as a propliylactic 

iCiisiine against postnuwrative peritonitis, but nrd <7^ a ivttyffitu' mea^- 
ntr nfirr fh4* paitoniftH m cdabrmhrtL It sliould, thf^refore^ not be 
eiupluycil when an openitiou is performed for the relief (»f [mrnlent 

riionili^, or for inflammatory conditions a&sociated with genera! 

ritanitis, as, for instance, some cases of ap|x^ndicitis.*' 
The general indications and contraindications for tirainage will a}>- 
jxiir frcmi the foregoing paragniphs to be as Ibllows; In a clean opera- 
ti'»n, one in whicli not only the pus,, but also the sac contsiining it is 
r«*move*l, and in which theretbre no discMscd surfnees are left open to 
secrete septi*.* matter and kt^ep up the siip|ily^ drainage is eontraindi- 
*'iitd. The non-septic fluids and, to a limited extent, the septic fluids, 
will l»e taken up and dispose*! of by tlie pertt<in(Mmi more safely than 
l»y the drain. On the other hanti, when ]>ns-pnnlucing surfaces are 
J*''t without drainage, they may continue tn be a persistent source of 
iufirtion, and the supply t^f septic matter may be grtuiter than the 
("Titimeum can take up. Then oneof twt> results must ff*llow : either 
a<iheiiive pcTitonitis is S4»t up around the iliseased parts, and the iufectcil 
territory is walle<J off by plastii: etfnsion j or the mieroHirganisms and 
tlioir fMHsonous pnMbiets are spread throughout the fieritoneum, and 
tl>**nce jM>uretl in fjital quantities into the genend circulation. Under 
thcjie conditions drainage is indicate<l at the time of ojwration. If, 




atter operation, .sepiu- imui liccfimt^s wiiiJt'xi otr, no tmie ^liouJu be 
^n oiM'iiiug and dmiiiing tfio absees^s. The septic iudioations fur <1 rain* 
age iirv 

1. Geneml septie peritonitis 
I / 2, The presence or a nidus f>f infeotioD whence septic matter inu«4 

/ continue to be propagaterl. This may be an open intestine, an abscess 

\ a eyst, an in fee ted hjenuitoeek*^ nr a lai-ge aiu<iunt of neenitie tissue 

L \ wliieli eannot be salely nMooveti The intlieatiori may be clear when 

I \ ohl and extensive adhesions are present, when an absL*ess or an infected 

I \ haematocele occurs in the jx^lvic cellular tissue, or when a cyst is so 
L Y _ firmly adherent and necrotic that it cannot witli safety be entirely 
I. \ n*moved. In tlxese conditions the dniin gives an ontlet for the septio 



\ 



■Ik y fluid and llie biniken-tlowu necrosiHl tissue. 

^H \ 3. ilemorrhage whieli eannut l>e controlled by 



temporary pressiii*e, or hot stK>Dge5, 



Different Forms of Drainaere 



I 



suture, ligature, 



Tubular Drainage is usually tli rough soft rubber or email glass 
tubes. For drainage through the vagina rubber is preferable to glaii^. 




TasIdaI giiuie drain ejtU'udlti^ trom Doui^Iilb's pouch iathe rulva for capinary drmtmco. 

The tube is especial ly useful as a medium fi>r drainage and for wash- 
ing out septic <»avities, such as abscesses which liave Ik'CU walled off 
(nmi the general fXTitoneunK The prescuee, luAvever, of a hibe in 

» AdnpUtloii (hiin Wmtklrui. American ciynt'coloiflral and OluiteiriciiJ Journal^ M«irch» lt0k_ 



DRAIN AGE IN MAJOR OPERATIONS. 



133 



tin peritoneal csavity usually causes in a few hours^ the surroiimling 
Ofgans to be fused tngethcT. Tiie spaf^e whicli tlie tiilie occupied is 
dien ifiolated from the reniain<lcr of t!ic peritoneum, and it^ tlic only 
fipace which it am possibly draiu. For this reason tubular drainage 
ia the ab<]omen ha.s h^n largely discarded. 

/Capillary Drainage, The tx^ntininMis strip id* gauze has been 
/eitensively used for e^ipillary peritouoid drainage through hn{]\ the 
\iigirial and the abdominal wound. As stated in the f(»regoiug para- 
graplts, i 1 18 a [jpl i ctd) 1 e to t he sec* j nr I a n d thin! i n d i eat i on s for d iix \ n age . 
There are two prineipal indie^tiori.s tV>r the use of gauze packing in 
ibdominal and jK^lvio operations : L H emr>rrhage which cannot be 
practically controlled in any otlier way witliout unduly prolonging the 
operation; the packing then used is immediately a compress, but if 
left longer than is necessary for hemostatic purposes it becomes a capil- 
lary drain. % The dciiirubility of rpiarantiniug the tield of operation^ 
from the general jM'rIfniie:iI c;ivifv. The mpidity with which adhe- 
§ion:4 iTVriii'a round t lie jKH-klo^ is well known. Tn a few hours the 
septic area \^ shut otf froui the general peritoneum by adhesions, and 
ia \\m way septic fluid is walled oB' and mostly confined within 
narrow limits. 

The above use of the gauze should not be confounded with its use 
asa Jruiti, The value of gauze for drainage as usually understiMxl-^ — 
tliatig, for the removal of any fluid which may form ia tlie peritoneal 
civity — is probably overestimated. The [teritoneuui has often demon- 
itratal its ability to take care of large quantities of seert^tion. If, as 
many assert, it be true that the presence of a drain excites the secre- 
tiouc^f hirge quantities of fluid which would not otherwise be seereted 
At all, it follows that the drain is often not so necessary as the large 
(jtiantities of fluid whicli it c:irnes off* seem to indicate. Clearly it 
w<uiki Ihj absurd to use a ilrain for the purpose of carrying off* secre- 
tions wfiieh it had itself produced. Moreover, the gauze packing 
often acts as an obstruction to the removal of fluids, and may there- 
for**^ if required as a drain, have to be used in conjunction with tubu- 
lar lirainsige* 

Abdominal Drainagre. if employed, may be either by the tul>ular 
|>rl)y the eapilhiry method, Tlie route from the |K'lvis to the abdom- 
inal wound is h>ng and in clos4) relatiims with the bhukler, intestines, 
twl omentum, which organs shcndd have no neeessary relation with the 
fit'lj uf o|>eration, but which, from contact with the drain, are unfortu- 
tely liable to infection, adlicsions, perforati<m, and hernia. More- 
r, the long i-iniis left after the removal of the drain is often slow 
tobeal, and its otiter end is prone to contract rajiidly and leave in the 
pelvis a troul>lcs<*me, undrained t»r imperlectly drained pocket. For 
these reasons tlie abdominal route is < objectionable, 

ShonUl it be net^essary to drain thrraigh the abdomen, a small glass 
twh(? or gauze may l>e use<L The iVunuer should be long enough to 
n:a<*h lu the bottom of the pelvis, and is kept from slipping into 
*Jie aWomen by a flange at the outer end. This form of drainage 
IT be useful in operations for peritonitis an<l for the removal of 
'U« effusions. The wound is dressed by packing gauze over it and 




iM 



GENERAL PIUNCJPIES. 



aroiinrl the protruding ^>ortiuti of the tub*'. A |X*rfonit€cl thin ^hert 

of riibhtT ditin is yiui[>po<l over the tlniijijo ami a mass c»f al^sorhmt 

cotton i,s plared over tlic end of the tube and enveh^jWHl in the rubl>er 

dam. The eotton absorbs all the dniina|]^e-Huid. It sh<ndd l>e n*-^^ 

newed oft*'Ti enoiigli to keep it dry. The rubber dam crmfiues tlie 

dniinage-liuiil to tlie eotton and thereby proteet** the drer'ssiu^ prt»per 

from moisture* Tfie tit time fur the removal of a drain is when it 

ceases to drain or when little Hnid eoines tlirongh it In draining 

for non-snppurative eases the tirst fluid is Uisuaily a dark blcMMly 

serum. When tliis diminisbe.s in quantity and becomes light colored 

jfr colorless the drain sliould be removed. A glass drain shonld W 

<^ turned arimnd twiee daily. This is to prevent parts of tlie onientnm 

\ from working their way into the small holes at tlie inner euil of the 

\tube. Sueh an aeei<.lent may give grrat tniulile in the final removal 

of the tid>e. On this account it is better to use tubes with oidy 

the large ojw^nings at the two ends, and without the small perfoni- 

tions shown in Figure 95. 




Ketth's small gloss drainage- tube. 



Vaffinal Drainage* The route from the pelvic cavity to the vagina 

IS short and direet ; liunee the vaginal drain is generally preferable. 
If in the o|R>n!tion an o|Mniing between the pelvic cavity and the 
vagina has not been niatle, ami dniinage is necessary, it is often better 
to make the oi>ening for that puqKise. The great ailvantages of the 
vaginal route are: 1, minimum risk of hernia ; 2» natural and de- 



de see nee. The safety 
largely uiM>n tlie pre- 



[M^nflent dndnage ; 3, nutre satisihetory conv 
of this route^ as shown by expenenee, depend: 
ions th(U*ongh disinfection of the vngina. 

The manner of intrmlueing a gauxe tli'ain, whether alKloniinal or 
vaginal, is as follows : The end of a Ciuitinuous strip of doulde gau»^ 
with the edges turned in antl stitched together to prevent fraying, \^ 
doubleil liackward and forwar<l np4>n itself, like the tolds of a fan, 
from the part to l>e dnune<l to the surface. Over this an external 
dix'ssi ug is placed and changed as oft^-n as it iK'Cfimcs saturated. Fig- 
ure 88 shows a vaginal ilmin in place. 

The time for removal of a gauze imcking varies with its purjKise. 
"^If iise<l to control hemorrhage, it may be rcnn^ved in twenty-four 
hours ; if the indieation is dniinag<\ it may 1h' left for five days, im- 
Icss, as <K*easi<*nallv hapjK'ns, it acts as an impi^limcnt to dniinag<\ 
The writer has repeatedly 4ihscrve*l patients to show signs of sejitic 
absorption on the second or third ilay, wlien the rt^moval of the giuize 
was h>l lowed by a gush of pcnt-un fluid and prompt relief of all 
urgent symptoms. It is not usually necessary, after the removal i>f 
the original dniin, to introdnet* fresh gauze. If at any time the oj>en- 
ing tends to con t met \m\ nqmlly, or dndnage become.s impertect, the 
gauze niiiy l>e renewed or a tulw* may l»e inserted. 



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DRAINAGE IN MAJOR OPERATIONS, 135 

Th dassUxU dictum is, or has been, " What in doubt, drain.'' If, 
koieever, the irritating influence of the drain is to cause the secretion of 
pM, which otherwise loovld not be secreted; if the peritoneum, left to 
ituify is capable of taking up and disposing of large quantities of fluid, 
ftm, to some extent, of septic fluid; if the drain is more prone to intro- 
duce ihan to carry out sepsis — then the dictum may liave to be reversed^ 
^ When in doubt^ don't drain^ 



CHAPTER VIII 



AFTEK-TEATMENT IN MAJdU OPERATIONS, 



After-treatment in Simple Oases. 

Thk great niiyority of alKloniiual swtions, if projx'riy perfiiriiiecl, 
are fiillowed by iiornuil ruiivalrsfont^e, and tlieiTf(ji*6 require littk* 
active treatment. 

Best, bcKlily a ml iireiUal, Is tlie first coiisifleration, Tlie palieiit is 
to be placet I in a bed j) rev ion sly warmed by means of hot-water hot ties 
or l)a^s. If there is a teudeiiey to slux'k, the warm applications 
sboidd be left around her. The careless nt^e of hot-water bottles or 
riiblxT bag8 liefcjre recovery from the ana\^the.<ia has oc(»asioiially 
H'sulted in serious burns* In caie case the writer observed an enor- 
inons bli.Hter on the outer surface of each thi^b ; io anotherj on tlie 
8ole c^f the foot. Both patients siistained deep shaighing of the 
eutaneons and sabeutane(nis strnetures, which linally recpiireil exten- 
sive skill-grafting; As the freezing of water in a ptju' more readily 
takes place when there is no circulation, m* in e4inditions i>f shock, 
when the eircidation is feeble, hums are mr>re liable to <*ceur. 

The patient is usually ke|>t on the liaek for two or threi^ days. She 
is a])t to attribute to this position the inevitatjtc jKiin and discomfort 
from the ana^stliesia and the ojieration. It may then l>e wise, if she 
insists* to turn her on her side. If ^he does not have the expected 
relief, she will then mow readily assume the dorsal pnsition ami more 
patiently wait i\>v the natural subsidence of pain and iliscimifort, 
which, if all g(»es well, a little time is sure to bring. 

Rest for tile stomaeh is desirable. A variable tiegree of irrita- 
bility of the whole iligc^stive tniet h the ctmimon result of anjesthesia, 
especially in eases of alidominal section. The vomiting and nausea 
of this state arc nitlu'r in^-reafrcd than diminished by drags, tcKnl, and 
ilrink. The only tn-atnu^nt is to withhold them until the toxa»niia 
of the aniesthesia has passed off. In S4jnie (^as(*s the exception may 
Ik- made of giving slowly a teaeujiful of hot water. This may Ix* 
jrnimptly thrown up, but it will wash nut tlie st(»maeb and, ]KTebanct% 
give a little relief. The knees may be dniwn up into the most com- 
fortable position and supported on a pillow or rolL The judgment 
and discreticm of a wise nurse will furnish a guide mtire useful than 
the most (daliorate rules. The tx^st nurse wull move, when p^issible, 
along the lines of least resistauee, or, when uecf»ssary, will use a 
gentle firmness that inspin*s cfuifidcuee. She will carry her patient 
rwi,st tlie critieul p^ri^wl with the mini mum of friction and discomfort. 
The exclusion of n^lativcs and friends from the bedside is usually 
imperative, and will riot U- *lii1ieuh if proiK*rly managed. They 



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AFTER-TREATMENT IN MAJOR OPERATIONS. 137 

tave^ p**rhaps, travelli^d long <listanei?s, ami ?^riously believe that tlie 
Ci>nifi>rt and consolation whieh they «loiie eaii g'ive iire hijLrhly es-suntiiil 
to the patient*^ rfXH>very. They nniat be toll I in kindly Imt jKisitive 
words that the results of experienee in thoiisiinds of coses diniion.strato 
rfie M'cessity of abs(»hite qniet ; that the piTsenee of the hushiiii(l, the 
toother, or other near relative:^ exeftos emotitm ; that emotion cuii- 
jiimf'.s energy, of whieh the patient lius none tc» sjiare. Sneh a state- 
ment is usually suffieieui ; if not, the surgeon must enforee whatever 
rt^uliitions the welfare of the patient may ihjmujuL If siie heeomes 
K^Jtless and anxiou>>beeause the relatives are kept out, it may be well 
to admit them. Most patients, however, (luring the fii-st two or thi*ee 
diV'sdo not ask for them, and many prefer not to see them. Fre- 
qttent ?^ponge-bathing, eai*e to keep tfie bed-elothing under the patient 
jHn^nh, and sneh otlier minor attentions as only ii good nurse eaii 
suggest, all eontribute to tiie desired end — rest. 

The BoT^els. If tlie temj>erdtuix% jvulse, and respirations are 
i)'>nnid, or nearly tM>, and there is no abdominal distention nor f>ther 
ujjilivonible sign» movement of the bowels may be deferred until the 
**oiinfJ Jay ; then they should be moverl by an enema or a mild eathartie. 
Smie sin^eonsi eommenee immediately after tiie ojx*rati*in with lialf- 
?raiii (losei?^ of ealomel given every half-hour until eiglit *»r ten doses 
Iwve U'cn given or the bowels aet. If there is no aetii>n, tfie eahjmel 

ki^inuaediately followed by a saline j>urge, or an enema, or botli. 
/Hiirly catharsis is a g<3od precaution against sepsis and peritonitis, 
ami may be used in all east^-^ in whieh tliese com pi i eat ions are esjM*' 
ciiillv feared. In perfeetly normal eases it is unneeessiiry. ICarly 
mMVPinent of the l>owels, however, is desirable in all eases. After 
thf initial movement they shouhl be kept regidar by eatharties or 
€Denjas, or both. 

Plain of variable degree is usually piTsent during the first day or 
two. Opium and its pre|>arations loek up the seeretions, induee 
nfiiiH^a, arrest |K*ristalsis, eause distention, and mask any symptoms 
which otherwise might give warning of approaching danger; they^ 
«nm'<)ver, counteract the influenec of eatharti(*s, and woidd therefore 
prove a serious obstacle if it Ix^came necessary to move the bowels. 
Such drugs, if given at all, should he given with great eireunisjiecticm, 
, /4Tuj#plmte of eodeia creates less nausea, eonstipation, and other dis- 
f tlitbioees, than opium or tnorpliine; the hy|wMlermie us*^ of it in hulf- 
piin dot*es is sometimes [HTmissible, tluring tlie iii-st twenty-four 
\ mirs^ to allay nervous irritation and jtain and to insure needed 
f^t There are conditions of great nervous irritation in which nior- 
- ptine in full doses is strongly in*licated. iS'e Hysterical Vomiting, 

mm 142. 

r / Thirst. '*Oh, for a gwd drink !'' is one of the first *-alIs, The 
f/w>mmon practice of witldiolding water as a routine is not to be cotn- 
\ tnmileii. In the absetiee of nausea it may he given cold or hot in 
\moch*mte, even iti satisfying, quantities. The amount may be left to 
He discretion f)f an intelligent nurse. Charged waters, ginger ale, 
Hiampagne, and other such drinks, while permissible, are not usually 
htjnirtj, and may do harm. 



GENERAL PRINCIPLES. 



<^ Fcw)d. Except in casc;^ of exljaustion, fiHwl it? to hv witlitjekl f<»r 
one or two davH. It h usual to eumnu'iu'e tending alter the bc^welnt 
act or flatiirt passes. Eriietati^xiti of gjis from the siunmch are aii 
indieatiori fur witldioldiiit^ food. Tlie dowinvanl |»asMi*:;e of ttatus i?* 
^ ^iHiil proMinistic sipL *" (^////* crcpikil ivVrrf." Tlie <liet for thr tirst 
few (lays is preleraUly milk, with or without huie-water, hegimiiog in 
small doses and, ae^'orditig to the trKlerance of the t^tomaeh, gradually 
itioreast^d. A teasptjonful at ii time may he given at fin>t, and re- 
peattnl in thirty minntes. If this is tolerated, the di>ses may after a 
iew liooi'i^ be douhle<l, and so on till s<:'veral <»uneesata time are given. 
Finally, after two tir three days, if all goes well, the anKaint may be M 
largely increased imtil fall q nan titles are taken. V 

I y Getting Up. The patient may sit up about the end of the thirtl 
^^ week ; if the incision was long and tlie iniiou is not tpnte firm, sht; 
\ should be kept tu bed hniger. 

Atter the sutures have l>een removed the Wiiund is to be dresscnj 
a8 bid ore J exeept with progressively ligliter dressings, fur a jM/rirKl 
of two weekri. The m^w eicjitrix sbonkl l)e su|)pe»rted fir.*^t by stnips 
of atlhesi\'e plaster, and later, wlien the patient begins to walk, by 
a pro|>crly-adjnste<l bandage. A variety of suitable bandages may 
be fonnd at the instrument or drygofxls shops. The liandage shraihl 
be w<trn eoutinuHUsly in daytime i'or six months, A lighter Hannel 
bandage may be used at night. 



After-treatment in Complicated Cases. 

Shock associated with abdominal Motion is the same as after o 
operations and injuries. If it oeeui*s during the i>|ie ration, Ui^p at 
onee the extnmie Trentk'lenhurg position, ami H < k h 1 t be_[R> ri t o n ea 1 
Kivity wilii a quart or more uf normal satt^^olutiou, six-teiiTbs of T 
per cent., at a tempeniture of 105^ F., and ctauplete the opersition as 
8(x>n as possible. AlkT the o|je ration elevate J he^ ft K^t-ol* tllt:_be*k 
Among other measures for the treatment of sluK'k art* tlie apidieation 
<d' dry lu'at Uy the suHjiee ; the hypodermic administration at jaU^'ch - 
nine sulphate every four houis in doses of one-ttnrtietli of a grain 
each ; the free hyjHxlermie use of wliiskey, at least four dniehms every 
hour; the hy poller mie irijiMi'tion (d*t\vo gnu' us of earn phor dissol veil Jn 
ten minims of steriiijied olive oilj to be given every btmr ; and^opions 
high rectal enemata of warm nornuU salt sulntijjir, U* be retained if 
pfi?-sible. Shc»ck !s most apt to oe(*ur when ecuKsidemble blmKl has 
bcM'U b)st during the ojjeration ; whether troru this cause or nrtt, the 
nri^ent iu*healion is to hi I th(^ I dood vessels, and tlierehy increase arte- 
rial pn'ssnrc. The most etleetive means to this end is liyiK»derrno- 
cWsis ; this is tlie infusion through an aspini tor-need k' iif large ipmn^ 
1 1 ties of normal salt solution diivetly into the tissues. It is usual to 
introflner tk'eply under eaeli breast at least eight oimees, and, if indi- 
cated, to repeat in the outer tliigh or ahdijmiual wall. See l[y|ioder- 
miM'lvsis. 

Secondary Hemorrhage. It is often diOieult to ditfe rent rate hem- 
orrliage from slux-k. The former, if post-oj>erative, is usually slow 



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ther ■ 



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may tiot dee lure it^elr until .several hours utter tue 0|H^raUuTU 
The lilt ter mure cf^nunotily begins sonie time dunnt;j tht* oj>e ration. 

Diagnosis, The symptoms of hemorrhage nrv well kimwn. The 
patient has, perhaps, nillieil well fruiii the operation^ with gootl pulse 
mt\ tempenitui-e. Presently, or within a lew hours, there are symj>- 
lom* of approaehing collapse— /. f,, rapid, threudy pulse, auhiiornia! 
terapenttiire, pallor, sighing, guping^ and c^old sarfliei". It* these syn*p- 
tonis app€*ar, the prestniet^ of niiirh elotted hlocKl in the drainnge-tnhe 
mav clear the diagnosis. The gtiuze drain wouki siiow a stain at 
de6|itT red than oithnary blood senini should make. Both of tJiesc 
signs, however, may fail. 

If there is no drain, one may often work a small glass female cathe- 
tft through the wound between the stitehes. Hemorrhage w^ould then 
■ , declare itself by the pres^'uce *)f elear hliKid in the catheter. In eases 
b whtre hemorrhage was feared the writer has oeeasionally tied the 
IF Btitures in b<jw-knot.'^. This facilitates the opening of a part of the 
I \ wound for diagnostic ptirj>oses and obviates the necessity of reintro- 
ducing the sutnres. 

Trtotment, To reopen the wound, find the source of hemorrhage, 
apply a ligatnit^ or a pR'Ssu re- forceps, sponge or wasli out the cavity, 
ami cKise the wonml with the {mtient bordering on collap.^% is, indeed, 
a serious nodertaking. If, however, there is hemejrrhage, any otlier 
attempt to check tlie bleeding is not only useless, but a dangerous 
waste of time* 

EH^poflrnnocl^siK Next to the lig-ature, the most effective means 
of wim bating the results of hemorrhage is the hypoilerniic injection 
of large quantities of normal salt solution. The strength, according 
to Baeon, should be* not, as generally directed, six -tenths of one per 
^nt, but about eight-tenths — Le,^ eight pirts in one thousand. An 
even teaspoonful of tidde s*ilt in a pint of water is a safe auil reliable 
, af*[jmxitnation to the retjuired strength. 

The tet'hniipic of this simple an<l most valuable prijei'dnre is as fol- 

I \m^: The saline solution and the appamtns for its inject iou are steril- 

i vusi hy boiling. The solution having been boiled^ is now cooled to 

lhenro|ier temiwrature, Siiy 110° F, The surface through which the 

n€e<lles are to be intr(J^hleed is steriliKed, and the needles, as shown in 

thiMliagnim, are thrust deeply InUt tlie ectlular tissue under the skin. 

h Tie solution flows from the l>ottle or fnrniel by its own weight. An 
plevation of four or live foet is necessiirv U* make the fluid How freely* 
Conntant gentle massuge over the injii-ted area will pruniote the dis- 
tribution and absorption of the fluith Ten or fifteen minntcs will 
ii-snally suffice for the introduction of a pint of solution. If the a|>- 

Iiaratns shown hchnv is not available, a glass funnel attached to a large 
lyjvxlermie needh* l>y means of a long ruVjber tube is an adetjuate 
^^ubstitutc. The fluid passes rapidly into tlu* cin^datiivn, iunnediately 
^bcrea'^ing the arterial pressure ; the proeednre gives rise to little or no 
H^in. It is sometimes necessary, after an cxhansting hemorrhage, to 
>^njeci at int-ervals as much as three or four quarts in a single day. 

The prime indication to increase arterial pressure is onlinarily more 
safely and quite as eifeetivcly fulfilled by this method as by the direct 






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ApjMirACuii for hyp«>d«?niitM*ly8iii. The fimiK^l r'niilniiis lw«>Jity oiincPB. A ruliher tube, wfth 
BhtU-^m atlnrhv*!. r4H]in'ri« ii wjlh it Y-Khttj>erl iilnf*.H tul^. Two itninll rubb<T tiitH'a fonneet 
thin with ljir>re ai4i>lr«l"r T*«MMlh^*i or large l!iy|>*«lertnk' |M>it9tJi. The Injerttttn may Ih* tniific" (nto 
the thighs, abdomiiial wAlU or under the brciiutlA. Tho Auhmaminary rt- glun Is u«ti&IIy Bc]«*cted.''i 

siiJiie fL^ that for Kliork. Tf fofn] is not tolomtiMl hy thf» stomach, 
rrrtal alinioiitatitui slioiilil \w nsrd i'v<'ry four liours. A gooil t*om- 
hiriMtinn for this |>iirposf const^^ts uf tlu' white of uii e^, three ouncen 
of jK-jitiJiuzecl inilk% and *me otirn;e of whit^kev. 

Sepsis. Tlif |»hoTioTiK*na of sep^in are oftc^n eotisidered iintler the 
tmnw peritonitis. TlnTf* are two vanetie^ : first, plastic or ailliesive ; 
siM^niid, pxtHlativc. In tin* plastic variety adhesions may fonn amitiid 
tfie diseased area ; in this way tli<^ iidVetion may be shut off* from the 
^eneml |M'ntoneiirn and i oiifined within narmw limits. In the exnda- 
tive variety the plastie or di"fens!\'e action is ahstmt or inadequate, and 
the infee'tion therefore j^preatls throiightait the peritoneimi and sets up 

' Dr. C, H, B«it»ii. Inti^nmtioniil UluicN* ¥oL l.» 8«cGud SrHea, 




AFTER-TREATMENT IN MAJOR OPERATIONS. 141 

% wptd and fatal bkKMUjKns4jiiing, It is ;i niistiiki^ to iittrihiiti' tlio 
evils of t^p^is to tlie as8<K*iated perit^jiiiti.s. Tlif inHiiiiiniiitury [ii'ikths 
b an effort of iia t u re to pr ot-ec t t ! ic ge \\ ( ^ ra 1 s y i? t f ' n \ ; igii i n j? t in tVn -t inn: 
if [iteic and adhesive, it may *suc<jeeil ; if rxiulativr, it iisiially fiiib. 
It is the infetrtion that sj>ecially endangt rs life, not the associated 
peritonitis, which may or may not save it. Sepsis, then, or, to use a 
better term, Infeetion, may lic elinieally elasisified as frdlows : 
^-' 1. L4:)cali2ed inteetioo* 
Xs.^2. General infeetiou. 

l/ljoeaiized Infeviion, This usually finds itn ex press irm In the 
form nf an abscetfs at tlie seat of the ojx?ration. It may he around 
an ioft'Cted pe<liele, sutui*e, or li^tiire. The nidus may be a surface 
laid l«ire in the operation luid not eovered by peritoneum, nr it may 
lie pathological tissue whieh ei>uld be, or at least was not, removed. 

The bymptoms are tliiise of sept ie absori>lion : they are mpid hut 
ujually strong pulse, variable elevation iu temperature, IfM^alized pain, 
sweats chilly sensations, with little or no tendeuey to eol lapse. Ex- 
aminution will usually show a progressively enlarged swelling in the 
pt'tviti. This is usually felt Uy c;on joined exarui nation » Stiteli-abseess 
luay give rise to the same symptoms, hut usually in less degree. 

Treatment is simple and satisfactory. Under antesthesia the 
al)«!e»8 should be promptly opened and d mined. The dniinage- 
phaouel is usually through tlie incision by wineh the iK'ritoneum was 
enterwl in the original ojx^ration — /. e,, through the abdomen or 
vagina. If a drainage-rube is already in the wound, there nuiy be 
>p<>utaneous rupture of the abseess into the tube* In an aggravated 
cajie it is si^metimes brst to make tbrougli-antl-throngh drainage from 
the aWoniinal wound to the vagina, Uubber tnbe<, not gituzej are 
belt for drainage, 

2. frrneraf Infeetion of the Prnfojtrum— i (\, exudative j>eritonitTs, 

KHalied — is fatal. Every abd( mi iuul surgeon is painfully liuniliar with 

the cliarat^teristio symptoms. He* has deseried them from afar as 

<»ne may discern tlie dark (*loud upon the luuizon. In the balance 

l>ctw<.vn bo[Te and fear he has watched the anxious faee, the dniwii 

j'Xpression, the progressively rising temperature, the nausea, at first 

JtttributtHl to anaesthesia, then as this subsides tlie vomiting of sepsis 

whidi takes its place, the fretpient regurgitation of bile mixed with 

bUi^l and mucus and gntwiug darker and *larker- lie has reeogutzed 

fhe gradual failure of th<' pulse, fir^^t weak, then running, then threa4lv 

r'> (he vanishing [wjiut, the paretic and distending bowels, whieli refuse 

[<» act^ the rapid respirations, the cold extremities, the staring eye^, 

the wide nostrils, and, finally, the inevitable collapse. 

Treatment is utterly uselt*ss. The symptom-group just outlined 
may, however, be present in less grave conditions, nmong them tlie 
Kx^al, ctrfnmiscribed inlectirui above deseribed. Bowel dist^'ution, 
vomiting, fever, and rapid, weak pulse may be also due to causes 
rither than general perit(»neal infeetion. In view of this possibility, 
therr*fon% active trt*atmcnt may be imlieated. 

Tlie first effort shoidd 1m^ directed to the movement of the bowels. 
Trj^ calomel, one-half grain, every half-hour until the bowels have 



^ 



142 



GEyERAL rniNCIPLES. 






acted. Let this he followed, if necessary, by the solution of citrate 
of iiiiSi^nesiJUiij a vvinegkissful every fifteen minutes, nr more if tlie 
storiKK^i will tolf^nite it. CVjpious rectal enemuta nuiy stimulate the 
hriwels to nvi, or at least to ex\)el the flatus. Tin- eueninta may Ik» 
tff stiff Castile soapsuds, with a dniehin of turpeutiue thomoghly 
mixed in eiich pint. It may be a mixture of glyeeriii^ KpRvm salt, 
and water, eaeli two ounces, or a quart of olive oil or linseed oil, A 
large enenTa sboidd lie f^iven slowly through a lon^ rectal tul>e intn>- 
dueed as high as ]iossible, with the (wtieut on the left side. The 
muscular walls of the howcl in tiiis eouditif»u are generally paretic; 
heuce the great dit!icnlty in stimulating them to contract ami by peri- 
stalsis to expel their contents. 

Whiskey, stryehuine, camphor, ammonia, rectal alimentation, and 
other supjKirtiug measures maybe used as descril>ed ft*r the treatment 
of shock, Uuflcr such nuiungemeut patients with symptoms like 
those fif general peritonei! I iutection may recover* 

Serum-thenipy, or the antitoxin-treatment of sepsis, is on trial, and 
with results thus far not un|jromisiug. There is some ho|x* that 
developments ahmg this line may result in the discoverv of suei^essful 
sjiecitic treatment of general sepsis. The time for a more |>ositive 
statement on this subject has not come. 

Hysterical Vomitingr. In ahmit 1 |^K*r cent, of abtlominal st^ctions 
the operation is followed by vomiting, frequent, violent, prolonged, 
and exhausting. The nervous depression is ]jrofound ; the puW may 
rise to 1 70 or IHO Uy the minute. The eondition may continue for 
seveml days, witli final re<'overy, or nuiy jtass into collapse. The 
pathohigy of this phenonuHial nerve-storm, with tlie stomach for the 
storm -ei'Utre, is unexplained. It may lie flue to toxteuria, or to lof:*id 
irritation similar to that which priMluc^es the vomiting of pregnancy. 
The cau*^es are widely different from those of the sepsis above 
desf*ribed. The it is little or no fever; the temperature may l>e 8ub- 
normab us in slnx-k j the bowels are sekhmi distended. There is 
simply colossal, almost ineessaut^ vomiting. Stiirvation and the 
\^oIent exertion of the vomiting soon exhaust the patient. The rcla- 
tion of the stomach disturbance to the associated nerve depression 
may be causative, concurrent, or resultant, 

Trmfmrtit. The vomiting sometimes suddenly ceases without ap- 
piirent cause. The removal of the sutun's or of a drainagc«tul>e has 
fieen followed by |>rompt relief. In one eas(^ in the writer*s pnictice 
the vomiting [>romptly and [K'riiiant*nt!y ceased ujx>n simply re-o|>en* 
ing the lower end of the abflominal wound ; nothing abnormal was 
found, and the wound was again closed. 

The diagnosis once made to the exclusion of septic [peritonitis, the 
trt^atment ih simple and effective. It is the free hyiKHlermie use of 
morj>hiue in iloses sufficient to allay all nervous irritation, to induce 
slcf^p, and» above idb to give the stoniach and Imwels rest. Fnder tlie 
influence of morphine food is retained, and in two or three <lays the 
patient recovers. The indication also is for liyp<Klermic injections of 
strychnine, one-thirtieth of a grain everv* four hours, and for rectal 
alimentation. 



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AFTER-TREATMENT FN MAJOR OPKRATlfL\S. 143 

y^ Obetmction of the Bowels as a post-operative accident is not 
\ un<*i>trimoiL 

ihitiirs. In addition to non-snr^ieal causes wliich nniy at any time 
be prf»!ient, there are tho^se causes tliat result directly from tlie oj>pra- 
tinu. The bowel tua vjje bent sharply mion itself — i t\, knuekleil so 
US to make ixx^lusjmiarTlve pmiiror ffexurc. If at the same time 
^idlieriioiis fi»nu at ur near the pdlnt ol* tlexui'e, ininioliilization takes 
plaivjthe bowel cannot straighten itself, an<l the ubstnirtiiin is uslul>- 
liJi.w} <iinetinieH a |xirt cnily of tXie cirenmtrrence of tj»e bowel is 
] ei ther in a'heT nml^openjtJil — L!ttr*-''s hernia — or between 
i;j iji I ^ *j. adlieaion. The iliviTtionlnm looks like a nipph* as it pro- 
tnuVs from the ('on vex surface of the inti^stinal loop. On relieving 
the eoiistrietron the nipple (lisap|>ears, leaving a deej»ly indented, dark 
blue ring. This torm of hernial oljstrnetion is parti;d, and therefore 
l«*s? severe than when the bowel h entirely oceinded. Vomiting is 
h'*s free and less apt to be fecah F'latns in small qnantities may 
t»iitimje tt» pass* The downward |3assiXge of feces is not always 
wholly interrupted. In Lnises of \'aginal section when the wound is 
left r>|xni and the ganze drain used, the s|>ace ociMijiit'd by tlie drain 
mny ui)ori the removal of the drain receive a mass of intestine, Tlie 
result may be adhesion and ol>strnction, Occasiunally a htop of 
bowel works its way betwet*n the margins of the wtuinil and becomes 
pinched, oc^duded, and adherent. This is not a very infretpient 
f^M\\i of capillary vaginal draina^re. Tlie evils of drainage have 
Ijeen ?nore fully iiinU^l in Cljapter VI L 

Clearly, adhesions are mm-e apt to occur between surfaces not 
covennl with pt^ritoncura ; hence the importance of careful ])lastic 
work during the operation, to cover, so far as possible, all exposed 
!>urfiKH*s, 

r/tf* dmgnOi<h is the same as for obstruction (if tfie bowel from 

otlitT ciinses. Nausea, vomiting, first of bile, lirially oj' frci's, 

akloftiinal rlistcntion, and rapid [aiise are among the prominent 

symptoms. Peritonitis is first hjcal and confined to the aHecti-d part; 

hdt later may liccome general. Death usually follows in a few days, 

unless the patient is relieved by surgical means. The diagnosis imce 

made, no time should l)e lost in relieving the obstruction or in making 

inartificial anus above tlu? ol>struction. If the artifieiai anus is 

mnHe, a later operation may be oewssary to restore tlie integrity of 

the bi>wel and close the sitms. In many (^ses, however, both of 

thesi' results tinally occur without a secondary operation. 

J One should be careful noi to ctmfonnd rntestinid paresis with ob- 

/itrrtction. The former may take place as the result of the perit<meat 

Y infec'tion, already explainefi. Obstroctiim, moreover, may be simu- 

^latc*<l bv conditions relatively much less gnive. 

Sinvises. The h>ealized intection described above eommoidy sub- 
sides on drainage. iSmietimes the source of infection is continuous ; 
tfien the drainage -track becomes a sinus, and may continue to tmnsmit 
pns until the infective substance is rpmove<L This substance is usu- 
ally an infecte<l ligature or intra-abdimiinal suture which refuses to 
be ca.*t off. It may remain ftu- months or years a continual nidus of 



144 



GENERAL PRL\'CIPLES. 




mfeHhm and siinpiiration, nr mux iii any time come away, Hpmta- 
iKMjiis flo.siiro ot ih<^ 8imis upon ivtnoval of the iiifertive siili>tant»e 
i,s the aloHK'^t invarialilt^ rnh. If not spntitaiiuuiii^ly tlirovvii «)t!*, siirh 
ligatures or sutures may often l»e nuighi 31 nd tishttl nut bv iiu-ans of 
an iiis^trument arting on the principle of a enH*het-rieedk% or by 
means of a very small dull curette. Should these fail and tlio dit*- 
cluirge continue for a number of months, the in* beat Son h to cut 
down and remove the offendin|^ eanse. The ojH'mtifm is usually 
i?iin[>le aiul relatively safe. An ineisiiui through the ahdoniiual wall 
in the track af the original wound eouimonly enables the o|K*nitor to 
dilate the deijjer part of tlie sinus and seize the ligiiture ; if not, the 
adherent viscera may be earefidly se^wi rated until the nidus is reaclrccl 
and removal. 

L<iug-eontinued suppuration is a reproacli to the surgeon ; it is 
annoying, irritating, and, even though pbglit, tends to pnxbiee dc^gen- 
emtion of the kidney and other impttrtatit orgjuis ; heure the impor- 
tance rif etfieient methotis iVir tbr |irevention of it or i\*r removal of 
the olfendi ug source, 

IWventioH. The use of absorbable catgut sutures and ligsitures, 
wliieh, if prejvarril Ivy the foru»aldehyde or dry -heat process, may be 
al)si»lutely sterilized— see Chapter IL^ — is a most satisfactory pre- 
ventive, 8ilk, silkworm^gut, nu^allie, and collier non-absi»rl»abIe 
yutures and ligatures are, for the reasons indieated» not generally 
used in peritonea! surgery. 

Fecal Fistula. Tlie bowe! during an openitiou may he 4>jH^neil, 
or so iujuretl that au ojieiiiug is liable to tneur later. In either evi^-nt 
the iujury shouhl 1h* reimired before elosing the alMlomeu, In a 
small proportion of sueh ease> the sutures fsdl, or the bowtl tijk'Us at 
some unsusjMV'ted piint. The result usually is hw^al inteetion, as 
alr(*arly described, followed by a fecal fistula with discharge of the 
l)owel^:!ou tents tbmugh a sinus in the wound. 

The fistida, in a miijority <>f eases^ if left a fi-w days, weeks, or 
months, will rlose spontaneously. Closure is usually more pnvmpt in 
sinuses through the vaginal tlian tlirough the alidHnitnal wouiuh TIjo 
explanation of this may be that tlir sinus is sfiorter and the vaginal 
w*ouud less aeeessible, and tlierefore less tampered with. If the fistula 
dm^s nc»t finally he*a!,an r»peratiou for its closure may He ni'cessarv- 

l^rinary tistida fnllows tin' same geneml laws as iWn\ fistula. The 
fiirmer seldom <K!curs exe<'pt where the bla<hh'r has been aiTidentally 
o|>encd in the opc-ratifui and the sutures for its closure have lailtHb 
The presence of the fistida is recognized by the a|ipeaninee of tirine 
through a siiuis f»]wnii ng through thi' wound. Tlie treatment is to 
iiitroduee a seH'-rt'tainirig catheter and keeji it iu the nn-thni until the 
fistula cdo^es. Si'vondary >utun's are seldom reipiired. 

Stitch-abscess. Snppunition in the alMh*minal wound may usu- 
ally be avoided by scrupulous asepsis. If it <H?*-urs, the sutures, 
unless buried, should be removed, and a wet dressing applieti. The 
dn^ssing may Im* of gauze, wet with a saturated solution ot boric acid. 
CVmph^te healing usually follow\s in a few weeks. In aggravated 
aises the abst'css nuiy have to be t)])eued and dmitied. 



I 
I 




AFTER-TREATMENT IN MAJOR OPERATIONS, 145 

Removal of Sutures. One may carelessly cut the loop on both 
sides of the knot ; in such a case the ends of .ihe loop retract below 
the sar&oe and cannot be reached. If the loop does not become 
encysted, there will be suppuration around it, which will persist until 
it worb out, is fished out with a crochet-needle, or an incision is made 
for its removal. 

Ventral Hernia. The chief causes of ventral hernia are the 
drainage-tube — see Drainage — and improper closure of the wound. 
Tbe treatment is to reopen the abdomen in the old cicatrix, split the 
sbeaths of the recti muscles, and reunite the wound as already directed 
for ordinary closure of an abdominal wound. 



CHAPTER IX. 

THE BELATIONB OF DHRSS TO THE DISEASES OF 

WOMEN J 



Mannkr of livinj^, eiivimnment, food, sleep, work, re8t, recr«i- 
tioii, exeiTi,st% juul elutliinji^ must neceMBiirily have a determinate in- 
flueiic*' oil tlic i*n>j>liylaxis himI eiire of diseas^e. The gy iieenli>gist, 
therefore, who gives to tliis suhjeet its true weiglit will stand ii|h)ii a 
deeideil vaiitage-grouiul over tliat fine wh*»se resources are Itiiiited ti» 
drugs, hieal treatment, and opemtive measures, (hie of the mtt^i 
ativuma of all ob,staele.H to the |vreventioii and cure of the diseases of 
women 18 t^ishiou in dress. 

So hjnjLj as seiiir'ible dress appt'ars eeecntric aud excites ridieule 
women will adhere to tlie prevaiHug nnxles, and will tlierefore be 
ham [K- red not fmly iu the pursuit of Rrreatioii and exereise, bnt also 
in the [lerformaurt* of tlie mon? essentia! physiological functions. 
Uoder such conditions fashion must cimtinne to prevail against strong 
nerves, [K>wc*rful museh*s, and robust health. As stHUi as the gin 

)>ass4^*s from the nursery to the drawing-room, and the ^In^ss of eliilil- 
lood is changed tor the eonvcntional dress of fashion, some of the 
evils of what wc call civilization become manifest. She can neither 
walk, run, u<*r e%*cn breathe without embarrassment. The fact that 
woman has endured and survived the tyranny of dress for centuries 
without more serious results, says Emmet, is convincing prtiof of her 
|w>wer of enduRinee. 

The prevention ami cure of the diseases peculiar to women require 
tlie i'ulfilnicnt of thnr pritjci^val conditions in dress: 

1. Even distribution for uniform protection against cold and wet. 

2. Freetlom from ^vuist constriction. 

3. Freedtnn from traction. 

1. Even Distribution. Uneven distribution is conspicuous in the 
piwailing mfnies of dros. The undergarments an* usually of cotton 
or nlltcr light materiid and are often sleeveless aud low in the neck* A 
profu-iou of skirts hang loosely about the hiwcr extremities and give 
them rehuivcly little prc»tection. The outer garments are usually of 
thin material, and, aeetmli ug to tlie eii]mee of fashion, may or may not 
cover the arms, neck, and upjrcr part of the bust. The bonnet is use- 
less for protection. The feet nrv often held in the vice-like gras|Y of 
thin, liigh-ht*i*led coverings wliieh more n^semblc stilts than shoes. 
They expose the woman tt) greiit danger froui cold an<l prevent fret* 
exereis4\ In contnist with such inadeipiate protection for the up|HT 
aud lower extremities, tlie waist and hips arc swathed and compresMHl 

» The writtT, in thin preacntaLtion of the sobjff t, has adapt^tl tn^lj frimi the work 
Kotwrt L, Dfckiaiion. of BrooklyrK m\f\ J. H. Kelluinr. of BatUe Crevk. 

146 



1 



I 
1 




THE EELATWyS OF DRESS TO THE DISEASES OF WOME^. 147 

ID a 'Uorrid zone ^' of whalebone, corse^ belts, nteels, skirts, and 
other eumbersomc material. ^ 

3» Waist Constriction comes chiefly from the eorset, which not 
only constricts the waist, but dislocates tlie thoracic viscera upward 
and the alnloniimil viscera dowinvanL It restrains the abdominal and 
doi^I muscles, and may cause them to atrophy from disuse. It pre- 
veniN ^v its stillness^ the iinduhitory movements of tlie abdominal 
walli*aiKl restricts {>eristalsis* 

Xomiul breathing retpiires the lungs to be eximnded in all direc- 
tions ai»J is therefore not costal nor abdonjiiial^ l>nt a combination of 
Ud). Waist constriction immobilizes llie abdomen, and thereby pre- 
vrrit!< aWominal breathing. This involves a hjss in Inng-power wliich 
rnunnf be supplied by any compensatory increase in costal breathing, 
Mi>rr oviT, the diaphragm, fnmi up wart! pressure, and tlie i^elvic tltM>r^ 
rinu downward pressure, are remlered inactive and atrophic, and are 
thi nby imable to make their upwani and downward movements which 
rtorraally should be transmitted to the alxlominal and pelvic viscera. 
T\\e [ihvsiological imjKirtanee of these respimtorv movements is very 
^rrat. They are a ^^>rt of natural nmssage. The descent of the 
dJiipbragm with each inspiration increases pressure in the abdominal 
t^vitv and lessens that in the chest. The reverse of this occurs with 
^xpimtion. 

Alternating pressure and relaxation upon the blocKl- and lyraph- 
vfisf^lfi secure free einnilation, AUeniating contraction antl relaxation 
muH'ular bundles of the uterine ligaments and of the other 
and muscular j>arts of the |jelvic floor serve to maintain their 
nomml nutrition and tone. Alternating rest and motion are essential 
l«the health of the organs and their supports ; waist constriction im- 
mobilizes them and stops their |»hysiobjgical m*)vements. The jKdvic 
vei tis t' I n p t y i 1 1 to the g riNi test a rea of c o rsc t j > r ess u re ; the I o ng a nd 
pTpendicidar column t»f lihxHl of this area is Iry such pressure 
daramed back upon the pelvic organs, especially u|xm the ovaries. 
Tlie consequence is passi\*e congestion, an unfailing source of disease* 
Even the Jooecly worn cornet excites great downward pressure wheu- 
*vpr the woman sto<ips forward, as she must do in sitting and rising. 
Sewing-women, clerks, writers, and students, wdio wear corset^s, are 
esp*^*ially subject to this evib* Figure KK). 

Tfie garter is injurious from its tendency to obstruct the venous 
cinndation in the legs, 

3. Freedom from Traction. The abdominal and dorsal muscles 
and the hips have to carry the weight of numerous skirts and such 
other gannents as usually oppn'ss that area. In the effort to sustain 
this weight the muscles become i>ermanently tired, h^se their tonicity, 
njnd are powerless to prevent a still farther increase of downwanl 
pre^murp upon the jxdvic floor and jHdvic oi^ns. 

Figures !>8 and 99 are given to illustrate some of the evils of undue 
preHSure and uneven traction. 

To compare ordinary mmles of dress with those which give freedom 






GENERAL PRINCIPLES, 



of motion, '^one ha.s only to look at a lot of twirls od the way to the 
gyranaHiun},'- siiid ii Va,ss;*r teacher. '* They dra^ along; they have 
do spirit nor spring in them ; they are in their iirdinary clothes/' I^ook 
at the game ?^et eoniing on to the gymnaHinm floor in their light Xog- 
gery ; they skip and dance and run in the lil:>erty of their nnrestraine*! 
and nntnimmelled motion ; they are diflerent beings." 

Fig 17 EC 57. 




Flffiirp 97<— Girl In eopsH and withmit forsct. An exact ri*])n>']uctlon from a i}oiiipciiJte 
ptKittifi^raph. Koti^ thf two uiitll[it^& at ih*^ wal^tJ 

FlfiurtjUS.— A coract-d^fornied fi^re, abowing the dispimwment of slomach, liver, colon, 
anil kidnoy«,* 



In laying aside waist eonHtrietion avoid half-way measnre^, such m 

looiscnin^ the corset or substitnting thi^ stHcallcd health- waist, which 
too often is oidy an aggravated form of corset. Leaving ot!* the cor- 
set altogether and retaining the mimerous skirts with their bands and 
belts to drag upon the waist and hips rather increase than lessen the 
eviL The only jndieious com promise is temporary sup|Kjrt by means 
of a suitable waist liaving little or no stitfness, which shall cover the 
shoulders, anrl npon which skirts, dniwers, and other garments mav 
be buttimed, si» that their weight may be distrilnited over the slumlders. 
This shonld be worn, if at all, only dnriog the period of aggravated 



> Dickinson. Hare'B System of Practleal Tberapeutlca. 



* AllcT Kellogg. 




Dilgnim of ft Dormml Ugure, ehowlag the Intenuil organs In tbelr nonnal poftttloni.i 

rover, dres8 waist, iinderdrawers^ white clniwerH, corset, flannel skirt, 
d«^ .skirt. Counting each band as two thicknesses, these make 
seventeen layers about the waiiiit ; and allowing tweoty-five inches as 
wak circnmferenee» these seventeen layers if joined end to end would 
mnkea bantkge thirty-four feet h)ng. Figure 101. 
Hygienic dress requires four garments, namely : 

1. Union undergarment. 

2. Equestrienne tights. 

S. Muslin waist and skirt. 

4. Dress in one piece, or so made that its principal weight may be 
di.Htributed over the shoulders, bust, and hips. This makes four 
layers about the waist. Figure 102. 

1. The union undergarment is a union of the undershirt and 

» After Kenogg. 





160 



GENERAL PRINCIPLES. 



FmvnK too. 



'k 



drawers in one piece ; the open stritle is supplied with a broad flap, 
as a protection to the external genit^ilia unci to gnurd the other g:ir' 

nients from their f^eiTetions. The ma- 
teria! of the suit may be wilk^ wool, ar 
cotton, or any mixture of these. In 
winter it should l>e heavy, with high 
neck and long sleeve*^, and should reach 
to the ankle. In summer it may be 
liitchter, with lower neck and short skn^ves, 
and should reach to the knee. 

2. The equestrienne tights are the 
substitute for the heavy wiwdlen petti- 
coiit, and arc designed for out-iluor U6C* in 
winter. They reach from waist Ui ankle, 
corresponding to tlie man's trotisersi, 

II The muslin *?kirt and waist are 
often made in one piece, but there are 
praetitiil advanta^s in making them 
separate. The waist^ if separate, should 
reach well down over the hips, and the 
skirt, made without ban<I, should be but- 
toned to it. The open i^tride of woman's 
garments is a patent source of infection, siiTC(% in ctmjunction with 
tlje dust-sweeping skirts, it exposes the external genitals to the en- 
trance of dust and other fine particles, which arc always irritating 
and often the vehicle of infectious bacteria, Closc^d muslin drawers 
are thereft>rc desirable iis a means of protection, and these also may 
be buttoned to the waist* 

4. The dress may be in one piece, after the ** princess " pattern ; or, 



ForwAvd IjetnlinR. rorai^i Hte*b fore- 
ing the pelvic ttrgans dnwuward.* 



thirt 
Ihawenhand 

}ihit4: Drauiers band 

Cbraet 

Ffann^'Kiiirt band 
miUf-9kin hand 
, Dre»9'^^i^t band 

ft L*VtJ» 

Lftyere of in«teilAt »baul wakt in old »tyle of dress.* 



FioefiE 102. 





<tn<1 tkifi 
'Drf0t 



a 



Layvro of waterinl nlxiut waist la 
new lityle ^)f dr*-^ » 



if in two pieeccS, the ekirt^ unless too heavy, may Iw attached to the 

waist with hooks, in which ca.se its lining may be (Continued over the 
ahoulders in the form tif a carefully fitted skeleton waist. 

The y^arments just described may Ix? mtwiified in many ways to suit 



individual requirements and tastes, but the essential principle must be 
observed, viz. ; uniform distribution, freedom from undue weight and 
traction, and freedom from constriction. Light whalebones may l>e 



» Steele- A dftriiB. " Ikniuty <»f VoTm and (Jthcc of V«*i^tur«'/* 
■ After Dickinson. tlare^B Syilcm of Practiral T h era pcu tics. 




THE RELATIONS OF DRESS TO THE DISEASES OF WOMEN, 151 



u?«ful in the waisi-S4'ani8 for very stout women with pendulous breiists* 
Pn>per dresa and con&et|iient freeduiii of iiiotioii will stiiiiulato the 
woman to outdoor ejcercise and indoor gymnastics, which, if tblloweti 
mth system and jjersevenince, will usually give normal tone to the 
utxlomimd and thoracic musclcii and normal firmness to the breasts. 
Artificial support therefore, except in Jiggravated cases, is to be dii^ 
couraged. 



Ftai'BK 108. 



FiorKK 101. 



I ; and 1<H &te not Imftj^iiftry, They rare faUUful rcpresciiitatl«tnj4 of m stout woumn 
: tlio enfivetitionftl (Jrcus nntt n Hhij^j^i^h U(c fnr |ir<ii|H?r dri ss ami ntiiriTia! eunclUluiiM 
1 iiifig, iin<J fxorcibe. The trausfuriiiiiliuu was wrought in a few mouths.^ 



Union undergarments of all grades and descriptions, adapted to the 
needs and circum.stances of all classes, mny now hv tcnind in the sliops. 
Economy, health, c<*mf«*rt, and, U* tlie pro[>cr]y educated S4'nsej iK-auty, 
all combine on the side nf proper tlrcss. It is marvellous that the 
nionstrosities of fashion have so completely overshadowed tlie natural 
beauty of form ami figure. From the standpoint of beauty shall we 
choose the natural lines of the body or the artificial lim^s of the coi*set, 
the garment fitted to the woman or the woman fitted to the garment? 

* Modtfled from Steek'-Adanuj. 



152 GENERAL PRINCIPLES. 

Imagine the attempt to add to the dignity of the licm or to the beanij 
and grace of the greyhound by the ose of arlificial means to change 
the natural lines of their bodies. Throwing aside the all-controlli^g 
bias of fiishion, who shall say that the woman is so inferior to the 
lower animals in form and figure that she must be taken-4n in some 

Elaoes and let out in others? In this connection tlie words of Her^ 
art Spencer have peculiar force : '' Nature is made better by no mean, 
but Nature makes that mean ; over that art which you say adds to 
Nature, is an art that nature makes.''^ 

1 Herbert Spenoer. Flnt Mndplee of Fhlloeoplij. 



PART IL 

INFECTIONS, INFLAMMATIONS, AND 
ALLIED DliSORDERa 



CHAPTER X. 

GENEUAL. CONSIDERATIONS OF INFPXTION AND INFLAM- 
MATION OF THE REPR<Ji>ULTIVE OlKiANH. 



Infection of iitjv one of tln2 n?prndiictive orgiiiis is liiiljlc to liave 
the cl<>s<^st relations to j^imilar iiifW-tioii of ii }Kirt or all of the otliern; 
for this rcsisoii lio intelligent eonsiilemtion and sutisfuetor}' explaiia- 
tiivn of tlie niorlnd jirowss in any uiic 4jrg:an nmv iiet-essitate a t>tydy 
of tht* infection of llie pelvic i>rgan.H us a wlioh-. 

The tli.stinetioii between iiifeetitiii and intlaiuniation is of tlie 
gnmtest jmietieid ini|K>rt^int*e. Infeetiyn is that eimdition in wliieli 
foi'ei^n media of irritation liave gained access to tlie body, and^ eitlier 
met*lmnically or by means of tlieir prmluets, disturbed ite fnnetitms. 
Thet^.* media are capable of being transmitted to other organs and 
♦>ther individnals. In most €4*ses, at leasts the invading irritant, if 
known, is of baeterial oriu^in. The orf^atiisnis, nnless arrested, are 
prone to mnltijily ra[ndly, to spread into new territory, to transmit 
tljrir toxic pnxlnrfs in the general eirenhition, and to <le.stroy or 
aeriously enilanger the life of the patient. 

The IcK^I territory irritateil by the organisms and thtnr toxins 
be<'ome8 a centre to which !enet>eytes in variable nnnibers rapidly 
migrate, and in this way the prcM^ess often <-alled sero-plastie inliltra- 
tion iH est^iblislied, Ry this iniihration a limiting wall rs formed 
aronnd the infected space. Tliis wall confines the infective ]>roc«'ss 
to narrow limits, and may |>rote(*t the general system against the 
pois4>n. The fiirmation of the limiting wall gives rise to heat, red- 
ness, pain, and swelling: this is iriHammatiim. In view of these 
fact** inflammation is not really the disease, but an c Unrt to limit the 
clifl<?n>w?. The alnir>st universjd nse of the word inflammation to 
signify the disease* makes it diftienlt in the deserifjliim of the morbiil 
processes to conform to the ideas above expressetl. The attempt will, 
nawevcr, \ye made to nse the two wonls infection and iuHammation in 
their proper relations. 

163 



154 LM'-KCTlOiXSj lyFLAM.UATIOKS, AM) ALLIED DISORDEB& 



Etiolog'y, 

It is iiiipuptant to remtTiiljer that \\ui wtucly of a morbid prooeflft] 
in an organ ur gnuiji of orgaiLs is simply tho study of tlieir aiiatoiny 
and pliysiology as modilicd by that pnu'ess* The inflammatory 
prtjct^^s has heen detineil as the reliction which living tissue exhibiu^ 
to morbid irritation. This defiriitioii being correct^ twtj cunditioMs 
must be essentia! for tlie de%"elopinent of inteetion and inflammation : 

L The soil must he pre|iai'ed and reativ t<i react to the morbid 
irritation. Clearly, tissne whieli has the power ti> resist the irritation 
and to hold it within physiologieal bounds will not inflame* 

2. The irritating inttnenee mnst be present. 

These eonditions divide themselves into predisposing and exciting 
cau^s« The predisposing causes may be system ie or local. 

The System ic Predisposmg' Caiises include whatever tetjds to 
render the system less resistant to morbid influcnees. Thr so-cuHetl 
diatlieses fall under this head : amemiaf dial>etc„s, rheumatism, gout, 
lithannia, and elioheniia an^' exiimples. 

The Local Predisposing Causes comprise whatever contributed 
to make the organs an ae*'essihlc and receptive soil for infection. 
They are obvious in the following anatomical and physioh»git^l con- 
ditions ; 

Tlie genital tract, from the vulva to the peritoneum, is an open 
canal ^ |mtent to the atmosphere below and terminating above in the 
free open ends of the Fallopian tubes. It is not only open to such 
niicrobie germs as ahonnti in the air and jM'netnite everywhere, but 
is also a place of dcjH^sit for virulent bacteria. 

The rupture of the ciipillary vessels of the eiuhimetrium in nien- 
strnation and of the Graafian follicles in ovulation, although yihysi- 
ological, results in solutions of continuity and in hemorrhage, and is 
therefore traumatic. These tniu mat isms and the menstrual engorge- 
ment of the pelvic organs under liealthy eonditions pass by with 
little or no discomfort ; but if some morbid irritation npM*t the normal 
bahuire <tf nutrition, lire menstrual congrstitm may beccmie patho- 
logical and may be the flrst stage of an inflanunation. The morbid 
eongcsti<m may be set up in the internirnstrual period inde|H*n4lently 
i\i the menstrual congestion. The liability to inflammation is, how- 
ever» greater during the menstrual week. 

In addition to the physiologieal traumatisms alrea<ly mentioned, 
the tmnmatisms of parturition, of al>ortion, <d' inipn»jH*r loral treat- 
ment , ami of o|M*mtir>ns still further op**n the way for the entrance 
of infection* Violent coitus, nuisturbatit>n^ the eareh^ss use of the 
imclean catheter, impure water in bathing, and soili'tl linen in the 
toilet arc some of the means l>y which goufUTlici'al, syphilitic, and 
other intiM'ticjus may devehip in the genital tra(*t. 

The f:onditions of nteriHgt station, |Kirturition, and the puerpt^rium 
are more jicrilous ; henrc infiM^tifin itf the puerpcnd woman is more 
destructive* l)ecomiK>sitl s<»en»tions and the prwlucts of fatty degen- 
eration iWim involution and from the menotmnsc* favor the develop- 
ment of jKUhogenie microbes. Tumors^ displacements, tight lacing. 



I 
I 



I 



I 



i 




GENERAL CO XSIDf: RATIONS 



tni Q(imt\\nilinn are among the eommoii tu<*al piTdispcKsitig causes of 
morlmJ co»ge??tion in i\w p€*lvi.s. Clearly tfit^ predispo.siiig caii&es 
almidy outlined supply the first condition of infet^tion — preparation 
of the soil. 

The Exciting Causes comprise agents tlmt have the power to 
prwinw and to niuintain morbid irritation, Gnmtly pre ponde rating, 
at Irast Hraong these, are the pathogenic niierohes and their products. 
The eJftent to which inflammation may he pnxhie<*d by irritant^s of 
non-hut" terial origin without the jiresenee of any baetena whatever is 
a miestion not fully settleil. AuKJng the pathfjgenic microbes not 
selaom found in the genitalia are tlie .^taphylm^tM^ci and streptococci 
of suppuration, the bacilbis tuberculosis, the bacillus coli commnuis, 
and the pneum*XMM:»cus of Fninkel, Bladder parasites and the sapr<i- 
phytes from the rectum and *'ohfu have easy access. 8ec Chapter II., 
(m AntisepticH and Asepsis, The bacilhis culi comtnunis lives in acid 
tufflia, and can thus easily pass through the acid secretion of the 
vagina to tl»e uterus. 

The Gonot'occiis of Xemn*, one of the most frequent, destructive, 
and insidious factors in gen ito-un nary infection, is elsewhere partially 
di!?cussed in connection with Vidvo-vaginitis, iSal|)ingitis, and Acute 
Metritis; its chief p^3wer fur harm lies in the lasting vitality of the 
gem long after apparent <nire* The gouocroccus may remain inac- 
tive in the mucous crypts, liable at any time, even while quiescent in 
liie individual, to Ik? eommnnicate<I to another Hence many an inno- 
wnt and previously healthy wcnnan, shortly after marriage to a man 
whostipposed himself to Iiave been cured of gonorrhfea years before, 
may by contact with the atteinmted vims get a destructive gonorrhff-al 
infection of the genitourinary organs, 

8<wne mf«^t important observations upm this subject have been 
nrndt by Werthcim. He repirts that human scrum agar is the best 
niltnre-grormd for gouoeocci. In this culture at 40^^-43^ C. they retain 
llidr full reprtKluctivc caimcity. A direct exjM'Hmcut fnmi pure cult- 
wit^ fnun a gleety discharge of two years* standing gjive the fi>llowing 
inff*resting results; 1, Attempted reintwtion of the original urethra 
w^ith this culture was always a failure. 2, The culture when trans- 
planted to a coccus-free uretfira priMltice<l typical acute gonorrhfea. 
3, Infection from this back again t(> the original urethra gave a In\sb 
g^norrha*a, wliich after a typical acute course of five or six weeks 
n^\n subsided into a chronica gleet. Thus, by j>assing the gtrnm^occi 
tJm>ugh another individual— that is, through a new culturo-ground — 
tJiey became again virulent to the urethra which was invulnerable t«> 
tliem before* 

This explains the fact that an apparently healthy subject of chronic 
g<;norrhfea may infect his hitherto uninfected wife and become again 
infected fmm her^ — /. e., the gontjcwci by passing thruugh the new 
Cfllture of the wife again become virulent fur the husband. In due 
time each becomes tolerant of the genu : wfiicb, however^ may develop 
nrute infection in another {K?rson. Tlie eornnion notion tliat gonor- 
rhcea in women may be chronic from the beginning is weakcntKl by 
ihe experiments of Wertheim. We can now understand wliy the 





^ 



gonococon^i, vxcn after years of apt>ar(*nt cure, may regiiio its full 
vinili iR'L'. 

Tlie ^ivatest danger is of extension to tlie Fjillopian tyL>eii; tliis 
will be furtljtr ruiisidertHi in the chapter on 8;il pi ngiti!<. The microbe 
may be fountl in the uterus and tubes long after it has disapjR^arecl 
from the vajsjina. Tlie |mvemejit epithelioni of the vagina and the 
prestniec of the kietie-aeiil l)aeteria nurnially toiind there* hy Doderlein, 
[Kige liVi^ make the vagina relatively innnune* The ervjits of the 
uterine and tubal mneosa fnrnisli a ready resting*plaee for the g£*rni.* 
Kven Iwrv, in many easei^, it is only found thnnng the exaeerbationfi, 
Metistruation iavors, but does not insure its revival. It may for long 
jK!riiJ<l8 remain eoneealcHl in a ^eniiKiuieseent state, a de.«tn>yer of 
health, a meuaee to life. The ireqnenry of chronic gtuiorrlnea — the 
latent goninvrlnea of Ni^eggenith '^has been variously estimated. 
There an- reasons to lear, however, tluit the j>creeutage is very high. 
Hsinger^ announces that 25 per eent, of liis liospital and private jia- 
tients havegonorrhiea. Lonier* found the tliploewens in fully 60 j>er 
t*<'nt. ol' the nises it] Sidiroder's clinic. One observer places tlie 
average as high as 80 per cent. 

The statistics (pioted alime are taken from clinics largely made up 
of prostitutes and seini-prostitntes, a fact which will necessiirily 
UHHliiy a judicial (estimate of their value. Tt is, oiorcoverj essential 
to appreciate two other facts; first, the evidence on this most eompli- 
cattnl rpiestion, although snflicicnt to lead to the greatest apprehension, 
is not yet sutlicient to establish definite and undenialde proof on the 
extrf*me sid*' td' tlie ipiestion ; secouil, many cxci Ih'ut clinical observers 
in private juactiec arc dispnse<I, ou the wliolc, to onalify the tlangiT and 
til ennchtdc tliat it is vastly overestimated. If tlie (piestions involved 
were nuitters oidy of seientifie interest, their soIutit>n would pru|>erly 
wait for further and more exact observation; but the ** danger and 
duty of the hour" are ctmeerned with mond, not scientific, problems, 
ind tht* moral oldigations ait> serious enough to lead tlie writer tu pre- 
sent the suhjeet even from tlit^ e.r patie stand |)oint. 

Why do lai^e numl)ers of a]>]mn*ntly healthy young women date 
their [Kdvie infection from the inarriage-wcck ? Is it, as one author 
declares^ the ** fatigue and exeitcnient of tlie wetl ding-journey ?" Why 
do so many women witli jHTfectly (leveIo|x'd repHKluctivc organs re- 
main sterile from the time of marriage or a Her the birth of a single 
child and a dangerous ** chihlbed fever''? The causation of too 
rrtany of such erases of hopelessly discas4il nteri, tubes, and ovaries, not 
to mention pnwiitis, with somctinies rectal stricttire, urethritis, cystitis, 
py<'blis, and nephritis, has been explainetl by the woixl idiopathic 
Their liistories, if written, wcMild id'ten tell <»f an appatY'iitly cuiikI 
gonorrluea, bt^fVuT ru- afu-r marriage, in the husband. If the most 
destructive iidection may folhiw contact with a sufyci't id" gonorrhcea 
after the discharge has ceased, htiw perilous must l>e the slight gleety 



» Slclnm hin'ider Ikrlin^T kUnlfldior WMchcnnrhria. 1W7. No. 17. From PoEzf . 

• NiififiHTiilh. Ijrtf nt (if>norrli(i*n. Tmn*. Amtr. liyii. Soclely, vol. I. p. 2fi^, IS7fi, 

' Sj\nu«'r Ufl>or die lleKiehurn: dir *h inorrfmiMht'ti xu Infeklfon jm Puerperal KrmnktmgfML 
ViThAfidhitigPti <tiT iH'UtftChfnniivm hcrfinH filr ^ivniikrtbttfiL'. Leipzig, 189ft. 

* Lijiuer. I>cutftt!he medlelui:kclu'r Wt.clKii*i'iirU\, 188i>, No. iU, 




M90 often disregarded ! Young men are sometimes advised 
to roam* in order to improve tlieir .^exiial hygiene, and so to cure an 
intnidable clironic but *' intioceot ^leet/' 8uch a*lviee may result in 
tl]p df^truction of the reproductive organs of au innocent woman. It 
h clmibtle^ possible, perhaps not unusual, for gonorrhoea to be so 
cured that the individual csinuot transmit tlie disease. FaUure, how- 
ever, to cultivate the gonoeoccus tVum the urrtlind Mccretiuns does not 
pmve its absence. So U»ng as it am l>e eultivated nuirriage sliould l>e 
pmliibitfHl. In every suspected ease marriage slundd he deferred at 
least antil rejx^ited attempt.s at eultuiT have tadcil. A gonurrhceal 
record does not necessarily settle, hut it alwajii compHcates the ques- 
tion whether the individual may safely marry. 



Pathologry and Course. 

Bacterial invasion and eonseiiuent infection may spread and in- 
Tolvf any or all of the gen i to-urinary organs by either or both of 
two routes : 

L By oontinnity of mucosa* 
2. By the lymphatics or })looflve8sels» 
Infection by Continuity of Mucosa. The course is usually np- 
winlfrom the vulva or vagina, through the uterus and FaHnpian tubes 
to the ovaries and peritoneum, or tlirougli tlie uretlira, vagina, blad- 
Jer, imd ureters to the kidneys. The numerous glands of the vulva 
are strongholds where tlie virus may intrcncli itself and whence the 
constant supply may fiufl its way to the organs idjove. 

The vagina, advaTitageously covered witli pavement I'jiit helium, is 
relatively snHK>t!ij like skin, and is supjjlieil with au acid secrctirm* 
Bact<>ria, aeeonlingly, tind lodgi mcnt there less easily than in the 
vulva. Mori'over, the aei<l medium unfavt>rable in the growth of 
about 90 pt^r cent, of all pithogenic microbes makes the vagina a 
Jifficult barrier to pass, 

Tlie uterus, although protected by these anatomical and pliysio- 
bgiml conditions of the vagina, is itself especially vulnemble on 
tojoimt iif the loose arningenu.!nt and tliimiess of its epithelial cover- 
ing, the villous network of its arbor vita^, the confluence and mniifica- 
tm> of its glands, and the ri(*hncss of its periglandular and pcri» 
vas<*ular network. By reason of these conditions the rcrvix uteri is 
adapted to receive, retain, atul distribute infectit^n. Were it not for 
liie muscular eonstrieti<»n at the external and internal oni and the 
uterfj-tubal constrictions the frequency of infection of the endo- 
mctrinni would be much greater.^ 

The Fallopian tuljes are eudiryologieally and anatomically con tin u- 
1*1 with the uterus ; they are, in tact, a part of it, and subject to the 
e causes of infection. Thi- ovaries and [n'lvie peritoneimi, iu direct 
communication with the tubes, may i*eeeive infcctirui from below. 
Infection by continuity of ruueosa, however, although usually from 
below, dfjes not always come from that direction ; it may reach the 
ovaries and pelvic peritoneum from above, and descend through the 

* Bonnet and I'etit. Traltv rratiriue de OyDi^ciiltit^e. 



I met 





p 



I 



I 



liibe^, uterus, and %'agina to tlu? vulva. 
example, usually goet* in tliis direetitm. 

Infection by the Lyniphatics and BloodveaselB is iiiiilfniable in 
puer|K*ral wonii'n. The trail nuui.->iii i»f iKirturition, often very exten- 
jiive all the way from the uterus to tlie vulva, may o|>c»n wide the 
dijor for iiiftrtion to be trauj^niitted l>v the vessels. The ilebtruetive 
influenee of the iiiflaniniation-^/. f,, phlebitis and lyniphangitis — on 
the vessels themselves may seriously and |>ermanently impair tbe 
nutrition of ail the pelvic organs* 

It has l)een eommouly aeeepteil l>elief that, save in puerperal 
eases, infection travels by contiuuity of mueosu, but the route by 
the lymph and bloodvessels has often been denied. It is elear, 
however, that if infeetinn is, as is jvmved by the bubo, utiL^n tnius- 
mitted by way of the lymph vessels to the inguinal glands, it may 
also travel by way of the lymph vessels a mueh shorter distance, 
from the vagina or cervix to the pirametria, pc^rimetria, and Fallopian 
tubes. This reasoning by analogy has been verified by exjK^riment. 
^me observers, notably Lueas-Championni^re/ maintain timt this is 
the more cKmimon mode of infection. Wertheim, fronj experimental 
investigation on white mice, ndjbits, dogs, and guinea-pigs concludes 
that gonocoeens infection can pass through [javement c|jithplium and 
ctmnectivc tissue so as to reach the lymphatic and vascidar channels, 
and he c^irried by them fron) the vagina or cervix to the* ovaries*, 
lubes, and [leritoneum, prtxlucing thus ovaritis, salpingitis, and peri- 
t^>n i t i s . ( i ig I i o * a 1 s*> ex pv ri m e n ta 1 1 y d c m o n s t ra ted that in feet i on may 
travel from the vagina, cervix, and bladder to the broad ligaments 
and may pnxluce extra-tubal pelvic abscess. He maintains that in- m 
fcctiim by the vessels is more frequent than hy continuity of surface. I 
When the hitter occurs he asserts that it is more conimouly in the 
descending order from the tubes to the uterus. This statement of 
Giglio may have to be revised, 1 

ContiniM*us infection docs not always mark the coorgt* of the ■ 
microbes through the vessels. The microbes colonize at the j>oints 
of least resistance ; hence the tubes may suppumte and the ligtimenta 
and ovaries go free. When, how^evcr, tlie microbes travel by way of 
the mucosa a continuous infiammation is usual, though nc»t invariable. 

Iiitet*tion by tiie veins is siM'cially common in puerperal cases. It 
has often procluctHl genend septi(*a^mia and pyicmia through very m 
slight lesions. The arteries also may carry infecti**n. This is proved 
by the tact that bacteria have been found in places where they must 
have been c^irricd by the centrifiigid circulation; for example, the 
gonw*occus iu the knee-joint,* Hetero-infection of the genitalia — 
i p., infection from without- — is not the iti variable rule. IHseaiJod 
iirgans may send their germs by way of the lymphatics or bloodvessels, 
and prmluce secondary infection of the indvie peritoneum, ovaries, 
tubes, and either genitalia. Tubercidar infection of the tul>es, second- 
ary to that of the lungs, is a familiar example. 

t PftrU Burgiccl Socletjr TninsActioxti, December. 1888, Sevf York Medical Joiinua. Utach 
22; \mo. 

• Olglto. Annnltrt di OhstiMrirlft e Oinepcjloffi*. May und June, 18BB. 

• I^itlier. Knmrnluni^ kliniaohe Vurtrftgc, lHy:«, 




GEyERA L CONS f Dim A TIONS. 



169 



Eijjerifnent and eliniciil ohservaiitni aLso i^lunv that both puer]>eral 
and Uf>n-fMjer[.>eral inte<ninii may travel by blrMjdvt^ysels, by lymph- 
t'biiiind.'s, and by roiiti unity of siirfaeo. The relative frt^(|ueiR"y, how* 
I vef^ of f hesio modes of tnin.smi.saioii is u niatter of s|R'Ciilation. Prob- 
aj>lv' tlie route by contiimity of surface is really a -sujwiTfioial lymph- 
mut<?— that is, the infectiou may tnivel tdoug tlie lynipli-ehaimuls of 
tfie niticoesa* 

Glapseification. 

\jii us now mLse a ijuestiou rehitive to the looseness and confusion 
'j| tie current classifications. The term simple infection as distiii- 
jruish<»<i froin septic, for example, has no strict pathologiml raeaTdng. 
It b Dot yet settled whetlier the so-called simple iTifcction is nseplic 
or whether it is only slightly septic. We know that an infection 
wemJngly vcr>' mi hi may readily take on a decidedly virulent char- 
jicler. We may tliink of tlie infective or inHainmatory prw^ess in 
m^ml ways: 1, As having gone only into the congestive stage ; this 
wtiiilij \}e a mih! f<jrm. 2. As having gone on to the stage of effu- 
^inn or snppiiratitin* 3. As l)eing the result of ii mild or more virulent 
iofec'tion. 4. As occurring in structures of gnmter or less resistance. 
What is there in such conditions to designate on the one hand as 
sirapk, on the other as septic? In the present state of our kntjwl- 
*^^ we must use for descriptive purposes atj a*laptable, and therefore 
flexible, nomenclature. In this nomenclature words like simple and 
i^ptic c3io have only a h)ose clinical significance. They eann(»t l)c 
liHlized as the outcome of scientific ckissification. We may sinif>lify 
ilif fiubjec^t by throwing out such a word as simple. 

A distinction between acute and chronic inflammation, since these 
ct^nditions enter extensively into the pathology «>f the diseases of 
Wiwnen, is most important. Many deny alt4>gt^ther the existence, for 
Wample, of chronic inflammation of tlie endometrium. Hiime attrib- 
ute the condition which is usually chisscd inuler that name to conges- 
tioij; others call it a subinflanimatory state. It may he well to re- 
mark that an essential factor of inflammati<m — -round-cell inflltration 
^i?i found in thf>se chronic conditions^ and that they may therefore he 
pmperly ciiLssed as inflammatory; this migration of white corpuscles 
iKwever, occurs more slowly, and may in some eases be very slight, 
bi this respect the diflerence between acute and chrtmie inflammation 
i*<me of degree. We shall avoid the ([uestion wliether certain coiidi- 
<i«tjs should bet-ailed congestive, inflammatory, or subinflammatory. 
Till' di scansion of this question is tiresome and unprofitable— a eon- 
Ust largely of wonis. The folhnving outline of stmie of the phe- 
tt"meaa of inflammation will help make clear the distinction between 
'ti'iiti* inflammation and tlu^ c<intlitioiis which are usually grouped 
<i^hI*t the name chnvnic inflinnmation. 

The inflammatitry reaction w!iieh living tissue exhibits to morbid 

^Titation is first defensive, and then construijtive or I'epamtive. The 

wiij^ive process is an eifort to circumscribe the diseiise by thnming 

^^niiid it a ItmitiHl wall of exudate ; the morbid force thus confined 

lilhl wneentrated within narrow limits is within these limits more or 




I 



160 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS, 

less niteii8€! aiul det^tructive. It may result in the sacrilioe of a par 
fur tlie Hixfety of the whole. Tlie force of the disease is spent in thi 
ik'scriictive |)roeess, and may Xw active only or rliiefly within the limits-* 
inj^ wall. Finally, nuniial conditions of nutrilion are re-eistablished^ 
the erfn.^tnietive or reparative pnieess iK'Comes active, and the liniitinp^ 
wall is all ><\ rbed . J f 1 1 if^ r on s t n le t i \" e ' p r t>ce88 continues until rc^ j m i r i i^ 

fr»n*}d**te and tla^n ^-rast^s, the |»art will resume itis norma) funetions 

the iiiHamniation will be at an end. 

Acute Infliammation. If the infection is of siieh virulence or 
otherwise of sueh eliaracter as to call forth the (lefeni^i%*e pnjoesses 
jusi <l(*siTihcil, ami to |jnHlure bliHHl-stasis with more or les8 severe 
i*wrlliii|r^ paiu, heat, and redness, and finally to prmhicc local de5>tnjc- 
tinu, I lie inrtanimatiou is acute. Tlie disease tuay terminate with 
n'solutiou or go on to suppuration. 

Chronic Inflammation. If the irritation 18 of minor intensitv-, or 
in any otlu-r way of siieh character as to fall short of provoking much 
ihdcre^iv*' at*! ion, there will be little i^v no limithig wall, and conse- 
ijut^utlv no jutense rlestructive process eon(*eutrated within a eireuni- 
«irrilie*l hjKiee; lii'at, swelling, jvaiii, and ivdness, if present, will lie 
more ditl'nse ami less pron^aineed. Chronic iuHainniatiim oceiii*H 
under these con<Htions — a mininuim of defence and an excess of eon- 
put ruction, 

( 'hrotiie hiflammation may follow acnte infection, or may have been 
subacute t*r chronic in tlie iK^gimnng. The excessive constructive action 
which belongs tu it explains tlie hyperplastic and hy|H'rtro|)hic results 
nf NHcnlletl chronic metritis. It also explains certain morbid nutri- 
tive changes in the blfHwl and lymph vessels of the pelvis and in the 
eellnlar tissue* of the |KOvis. S<*lcrotie changes in other organs, such 
Mn arlerial Heterosis and interstitial nejdiritis, offer a closf^ analogy. 

It is nnprofitable to speculate on the ipiestion whether the eondi- 
tionK just deKcribed nnder the name chronic inflammation may better 
be el asni fieri as (nmgt^stive or as siibinllammatory states. They are 
riM^ogni/jdde unfler either of these names. They ocenr more fre- 
oiiejidy iu neun»pithi<" women, and espcially in cases of tlie variotis 
(halhesi's — ^aiui'Uiia, litlueniia, gout, ehoheniia. Diabetes also is a 
•itrong predisptising cause. They arc usually less dangcn^us to life 
and oi'li'ii uu»re rlcsirneiivc to health than the acute iuflamniations. 
Thev conHtitulc a large proportion of the ailments of women and in- 
ch nfe rNoriM* of the nuKst ditstix'ssing ailments. They are persistent 
rnal hani, ol'len iiu|tossible, to eim^. In such cases it is frequently 
dillleidl 1o draw the lines Iwtween those congestions which fall short 
of inlhouuiattttu and actual intlanimatitui. ( >tre of the most eoninion 
IbrrnK id* Ho-called uterine catarrh is that which occurs in women of 
fii'ftrH'itt riimifitifirt' pow*r — that is. the bowels, kitlncys, and other 
I'lirniiiative organs fail siiftieiently to throw off the waste-protlucts. 
Under these conditions th«* nuicous glan<lsof the nterus» for example, 
whose fuuclion is not excretory, nuiy vicariously undertake to make 
j^Mid the delieieney. An nns|K'akab!e amount cd' mhilifrvttff and ht^ 
jnt'itiuti lf>eal ireatment is constantly being applied to the endometrinni 
in ^♦uch eas4'H» 



GENERAL CONSlDFRATIOyS. 



161 



i 

I 



The j^igTiificanei? of |ioIvic iiiftH"ti*>n viiries arconlin^ t*! the resist- 
HDW ((f the iiatieiit, to IIhj locution and oatiu'e of tin* >^triR'tureH iii- 
volveij, aud to tlie vinitenoe of the <':iuses which priKhjeed it. Strong 
prtJisposing causes make the WiJiuaii less ahle to resist morbid irrita- 
tioD;an(l infection once established is more likelv to be severe and 
pnoin^'iive- If infetition is eontineil to siijx'rfieial areas, its gravity is 
rcljitively much less than when deeper structures are diseased* Endo- 
memtijSp fi>r example, is less serious than an inriarnmation invi living 
flw? ntmnv wall or the psinmietric lymphatics and veins. Moreover, 
tljesanie kind of infection may he more serious in some places than 
io others. This may l>e illnstnited by the c^ase of a man who picked 
liis teeth with a vaccine lunnt and experienced a nmst disln'ssing 
resiult. Some bacteria are harmless anfl some only miMly virulent. 
The gouococcus, for example, is nntre general, anil therefore more dis- 
abling than the stai>hylo€occas. The streptococcus pyogenes is more 
dimgerous than either. 

Irom tlie foi-egoi ng it is ea^y to explain why an infection, even in 
the(tiLi*per structures, may, if not from very destructive bacteria, pre- 
sent in the m<ire acute stages most of the sulijcctive and some of the 
objective apjK^aniue^'s of a fatal disease, and yet after a tvw days 
lenninate in a rt*turn to complete health. The reason is also cibvious 
why a supcrticial vulvar infeetiim, apparently ,inn*x*entj may be the 
result of a gonococcus or of a strepttx^oeeus invasion, and m<ay by 
continuity of snrtaeej or by way of the lymphatics or veins, finally 
ilftjtmy life or render it miserable and useless, Home organisms 
nm excite little or no defe u(h^^/. e,^ may not attract leucc»evtes — 
and may therefore sweep tli rough the system with rapidly destructive 
tod &tal force. This would be iut'ectiou without detensivc inflara- 
matioQ, The germ of tetanus is an example. 



I 

I 
I 



I 
I 



■ Tl 

I 



Diagnosis and FrognoBiB. 



The symptoms are often utterly disproportionate to tlie lesions. 
An infection of little danger may cause the greatest suffering ; another, 
which directly threatens life, may be almost |minless. Objective ex- 
amirution should, thereftire, especially in acute teases, be thorough. 
The gnhjective symptoms may be misleading. The prognosis depends 
iJ)>on the region iufecteil, the general and local resistance of the 
patient, and the extent and nature of the infection. 



1 




Treatment. 










■ The treatment 
I lauBt therefore be 


rcfpiires 

referred 


the individualization of 
to tlie special subjects. 


each 


case, 


and 


^^^ 11 












^ 



CHAPTER XL 



VtTLVITIH, VrLVO-VAGINlTLS, VAGINITIS. 

TuK extenxal genitals are tho lubiii mujora and nunora ; the clitori^^, 

with its |ire|>uco ; t\w V€stil>uk% inclii<Uiitj tlio iiu*atus (iniiiirius; tli*:* 
fuHiHti navieularis, sum I tht* livineti. TIr' liymeii si*|iiinitt'S the extcrruii 
grriitalrt fmin tin* vagina. Thrir covering is futaiiotius^ although if 
|>iirtak<js .somewhat of the nature of mucous membra iie, 

DefinitionB. 

VtdvitiB h inHamniation of tlie extenusl penitals. 

Vaginitis is inilanuiiatiun of the mucosa ami snhmucosa of the 
vagina. 

Vulvo-vag'initis is iiitlamniathin of the vulva ami vagina. 

The importance of vulvitis aiiil vulvo- vaginitis is eommooly under- 
estiuiateth Iiiflamuiation seemingly trivial may start in the vulva 
niul mpidly extend to all the re|mMluetive and urinary organs* It-s 
jKissihIi' gnivity may he that t>f metritis, salpingitis, ovaritis, peri- 
tonitis, nrethritis, eystitis, pyelitis, and nephritis. 

Claesification. 

The inflanimatlt^n may be acute or chronic ; it has h<^n classified 
and its forms reeogni/AHl : 

L Aceoi'ding to the nature of the exciting cause wliirh may have 
pruKhicHsl it. 

2, AciHmling to the siMK»ial structures involved. 

1. Etioloeric^l ClasQiflcation. The following inflammations are 
of haetrriul origin. They may occur as vulvitis, as vaginitis, or as 
vulvu-vaginitis : 



Oonorrho'ul, 

KrysiiK-latous, 
Piplitueritic, 



Tnhcretdons, 

Mycotic, 
Syphilitic. 




Vnlv<vvagitml inflammation is also often causc<l by mk 
which lire idrntiiuil with thcxse pnxiiicing tratmiatic iufeetion, sucl 
tilt gtapiiyh^NHvi of .Huppiimtion. Minced infection may l>e caused bv 
thf^"* m!cn>lHH* in oaimeotioti with those indii^tcd in the above cla^i- 
'flt^tion. 

The niien*br of hviJuHs has not been enltivated, and is therefore as 

C*t unknown exivpt by iti^ eftVets, The etiologicid classification will 
> of siptvial iuten^t in counectioti with the etiology. 



i 




VULVITIS, VULVO-VAQINITIS, VAGINITIS. 



168 



2. Anatomical Classification. Vulvovaginal iriflammatian tiiay 
attack .special structures, such as the ?^kiii, mueouh HJuniljmtK', t-i^llular 
ti?)sue,|>lsmd6, ami fallieles. This is withuiit n^fereuce iu tlie |mrtieular 
nature nf the niiiTo-orguuisitis which nitiy have been the irritatiug 
cause of the infeetioii — L *\, these aiiatt*rnit*al forms may eonie from 
kcksk of widely diiferent natures* The auutomical forms are : 

Superfieial vulvo-va|riiiitis, Follitnihir vulvitis, 

Senile vulvo-vaginitis, Furuucular vulvitis, 

Gliinduhir vulvitis, Emphyriematous vaginitis. 
Pani vaginitis, 

Tk cla-isiticjitiaris ahove outHned cannot from the f^linieal stand- 
point aU'avsi Ije followed, Au etibrt^ however, to ditlereutiate be- 
tween the various forms should, for both clinical and Bcientilie 
ftafion^, be attempted. 

B'lema, kraurosis vulvj©, herpes vulvee, and other allied disorders 
will Im? presented in the following chapters. Pruritus vnlva? and vag- 
ioiimtis, although often symptoms of vulvo- vaginal inflammation, arc 
^•t'oeiiropthie signiliranee, aud arc therefore sometimes classed among 
t he gy r jecol ogi ea 1 ue n roses. 

The general consideration of vidvar and vaginal inflammations 
influfe certain fiurtors in etiology^ pathology, and diagnosis which 
•re more or less eoinmon to all varieties. To avoitl re^K^tition and to 
|iv(> a general impression of tlu* whole subject, these factors may be 
hluA]^ before taking up the sjx^cial ftjrui. 



General Consideration of Etiology. 

Predisposing- Causes* The jiredisposing aud exciting Cranses have 
Wn outlined iu the preceding chapter on the Principles of Inflam- 
mation, Among the particular prc^lisjxjsing causes of vulvo-vaginal 
inflammation are the following : 



Filth, 
Obesity, 
The diatheses, 



Vaginal fistulse, 
Excessive coitus. 
Mast url)at ion. 



Exciting Causes, Numerous bacteria, some of which luive been 
ilri'ady indicated iu the etiological classiiieation together with their 
^'pforfnets, an* nndoubt^nlly among the essential causes of the various 
fottns of vulvo-vagiual inrtammatiou. They include the gonococcns, 
the stn^ptocoi^cns jiyogenes, tlie staphylococ<'i, the bacillus tubcrculo- 
*t^ the microt>e ot diphtheria, and the infci^tiou of syphilis, 
Vulvo-vaginal inflamniation is oecasionully, and especially in ehil- 
It wn, a sequel of such acute infectious diseases as diphtheria and scar- 
btiha. 
The media of infection may be : 
Pathr»lt>gic discharges fr<im the uterus or tubes. 
Disc* barges from j>clvic abscesses. 




.* * ■• 



iJiXJiATIOyS, ASD ALLIED I'LSolU'ERS. 



::y<iLJ.'r;:^<. 



. mIvmI Mpr" 



<'e.'tJLl*y in casos of severe pniritiK-, eonic "!>> 
^ v-r>- -fun the inorbiil irritatiim is fiirnishr^ 
: sic-x-^:': bladder, im^ters, or kidiu-vs. Infi^c*- 
■> . :'.v,i i«r i'rom the .siirn»undiii^ nitaneou.s 
:- .?:. 'lirtvt infection or fix»ni an irritating* 
^■:' • :■ v-: i:i the jK'lvis. 

:•- : .Vi.:-*-. with the }M>ssible exception of 

• * - ■■ V :'v;:is have Wen n'conled. 

-j^ ^' ■''■'_■ --*arv oircuhition the vulva is sui)er- 

:. «. • 1\ txiv<sive oily secretions undergo 

■-. ' -. 'vvl.ioli cause intense* intractable cn'- 

.:' :ho thijrhs and nates, a CNmdition 

•..■.ilattHl and deconiposc<l secretions, 

■.- ivrspinition is free. Masturlwition 

. . ■. ■.'■.Tk;iSO. 

^ ,: ■ -.^■- e-ijRH'ially in chronic vnlvo- 

^ '. v-**.i:<ix^sition of the jiatient ; sec»ond, 

■-.•, :v. its hn-ation. Badly nourislunl, 

^ . .'■', vnxli>|H>scHl to chronic disease*?. 

t ^' ■• •• .^\ i. ari* esiK'cially apt t<» pro- 

V . "v-oTion. however, of the infection 

^ - ^ *. - v.ijKil factor in the chronicity of 

"... txv^'Uic intn'n<*hed in the vid\-ar 

'S-h intlvtions may travel upwanl 

^ V .r vv'.i'uics may exist in the niuci- 

■ •■ ':• :vi tin- j>oint be distributed not 

.-:•. :.:1h>. |H'ntoncum, (vllnlar tissue, 

:: t \;ij:ina and vulva. The vulva 

. ■..■::i r. an' the two gn*at distribut- 



,V-'a! Anatomy in General. 

' .^i*'. :\\u\ ulcerative pnK'csses are 

• :v..iiii»n. Thr pnK'css is catarrhal 

, . -iria^t' tif the normal sccn»tion, 

. -. .-.'... »rrh:i^ic when it contains an 

. \\]'%'\\ i\\r destructive pnK*ess has 

' :^!>>«1mci»<I din|M><lcsis, and nlivra- 

'•>-. The catarrhal often pn»cedes 

- ■-. : |H'ri«Ml. 

■■.: ehronic cases usually iH'conies 
V--'"^" niicroix' d<M's not pnKlu(*e su|>- 
• V ;i dcLTit'c iui|Kiin'<l. A cinunn- 
^ V ^urn»uiid('d by an area of catar- 



VULVITIS, VULVO-VAGmiTIS, VAGINITIS. 

Aal inflammation. The necrotic tendency may not go beyond ero- 
sioH ; k JMV me rely i m pai r wit ho u t 1 1 cs 1 roy i ng the skin or ni u cosa, 
or it ma? extend far below the surface and form a deep ulcen Vid- 
viii? ami vaginitis may exist sejiarately or t<^ether. 
StKulW gmnidar v id \^ a- vaginitis is due to swelling and hyper- 

Lrruphv of the vulvo- vaginal papilloe, i.s chiefly found in the vagina, 
afld, tliuUffb Dot eoniinetl to that perirx!, is eonmioncst during preg- 
oancr. It is eharacterixwl by small, ronnd, protuberant granulations 
Katrcre*] thickly over the ailected surface. 
The iuflammation may result in extensive nlceration of the vulva 
nrva^'na, or of both. Suili<*ient plastic material may be throw^n out 
to caiis^ adhesions moro or less tinu between the nymplia? or the lal>ia 
majom, or between the vaginal walls, or between the vagina and the 
*«rvii. Partial or complete closure of the vtdva is not nneommon in 
dijldreii. Such adhesions usually yielJ readily to slight force. They 
naemble the adhesions ofteu found between the prepuce an*! the glana 
pfoisof the male child. These adhesions may Ijo between the clitoris 
and its prepuce, and may give rise to serious ner%'ons disturbances. 
The stirihces may be si> thoroughly united that they can (udy be sepa- 
IiM by dissection. Strong atlliesious are less likely to occur iu mar- 
ni%\ womeu than in vii^ius and aged women whose organs are at rest. 
L If ^norrhfca Ix? exceptje<lj su|i|Jumtion is mostly eou fined to the 

ft vulvitis of children, esjiecially children with defective nntritiou. The 
^yttitruleut secretion of vulvitis or of vaginitis is ereatny, abinidant, and 
^Hlftlodoroas. Numerous minute points of suprfieial suppuration iu 
^^ limited area may run together and form an ulcer. In this way 
manyareiisof ulceration may l>e formed. If ulcerative changes iu- 
volvt* the small bloodvessels, the secretions will be streaked with 
Wood. Severe cases may |>resent hemorrhagic areas, great swelling, 
and even gangrene. 

Extension of vulvar inflammation to the vagina is common, though 
nt)t so cfrmmon as it would be were it not for the following anatomi- 

rttl and phvsiologii^d ermditions of the vagina: it- is smrxjth, and, 
pWiig covered with pavetnent epithelium, closely resembles skiu ; it 
» poor in glands, anil is therelore not subject to intense catarrhal 
affiKitions. 
Drxlerlein ' has distinguishe<l microscopically two secretions of the 
vagioar one the normal secretiim, a whitish, milky, strongly acid dis- 
charge without mucous admixture ; the other a patliologieal secretion, 
yellowish, faintly acid, often neutral or alkaline, sometimes loamy 
^^\ mixed with mucus. Iu the normal secretion a uon-pathogenic 
filial bacillus was found constantly present. Dmlerlein^s exi>eri- 
f^nU with cultures showed that this bacillus gives to the normal 
«cn!tion its acid reaction, wliich is due to lactic acid. Tliesc normal 
^*ginul bacilli were found t** be uu favorable to the growth of the 
staphylococcus pyogenes aureus. In fact, the vast majority *)f i^iatho- 
|*nic bacteria do not thrive iu nn arid medium. In the patholugical 
*wretion Doderlein found the pathogenic bacteria to be increased 



^ DMerlelti. ** FHu Bcheldeniokret und Seine B«deiitunK fllr das pucrpvrftl Fiet»er/* 
nt. Uipdr, IWS, VP- ^^' CentmlbUlt t Gyailkologte, 1892, Ku. 11. 



BfocEi* 




166 INFECTTONS, INFLAMMATIONS, AND ALLIED DISOEDEES. 



J 



and the normal vaginal microbes to be decreased. The abnormal seer 
tion usually originates in the cervix uteris is toxic to animals, and 
its hostility to the normal vaginal miembe decreases or neutraliz^^^ 
the acidity of the vaginal seeretion, thereby ai!urdiiig a favoral^^ Tc 
cnUure-groynd in the vagina for jiathogenic bacteria. A lesson to Mr^M? 
learned from these obser%*ations is the importance of stamping omjt 

Figure 106. 




> 



Granuliir vagtuitlsJ 

vulvar inflammation, and thereby preventing its invasion of the higher 
genitals, especially the cervix uteri. 

When vaginitis ot*enrs the desquamated cells of vaginal epithelium 
give rise to a thick, jMsty accunuilation of smegma not unlike vernix 
caseosa. When the epithelium is shed and the deejjer structure 
exposed, pus is tlirown olf from the exposetl surfaces. 

Vulvi>vaginitis, if superticialj strongly tends to recovery. It 
becomes <tbstinate when the vulvar glantls already described are 
involved, and may be intractable when it rt^aehes the mueii:ian>us 
glanils of the uterus. Reference is tnade to the remarks in the pfe- 
ceding chapter on tlie relative cajuicities of the vulva^ vagina, and 
cervix to rt»ceive, retain, and distribute infection. 

Chronic Vulvitie and Vaginitis may occur scf^wirately or tc^ther. 
Clinically, clironic vulvitis and vaginitis are more conimonly ol^rved 

1 Fnim Ht'lUiuunii. lu Tlutmob niiU Mund^'i Dtoeavoi of Woiatm* 



,^ 



WLVITJS, VtrLVO-VAOLSITIS, VAQlNlTm 



167 



than acute; they nitiy follow the acute^ or may have been chronic or 
5ubflctite IE the begirmiiig. 

Symptoms and Diagnofiis in General. 

Tk' purpose of a diagnosis i.s not so much to give a name to the 
imuae h^ to furnish a basis of rational treatment. A diagnosis 
AM inchule, therefore, tlie source, variety, and eornplieations of 
llie (liseiLse. It would be absurd to confute tlie treatment to the arc^ 
I'finllaiianation if, for example^ the disease were peeondary to metritis, 
eiruinomu, cystitis, or vaginal fistula. Attention to wneh complica- 
tftins as fisi? are in ano, hemorrhoids, rigitl .spliincter, threadworm and 
endometritis often gives relief. The diaji;iio.<iH should liave H{>ecial 
ft^fi^rence to the possible extension of the disease into tlie dncts of 
tlie vulvar glands and urinary orgiius. The discharge from a |>elvic 
iksoess lias been mistaken for the secretions of vnlvo-vaginitis. 

The svmptom-gronp in arnte rulro-vnt/inal Inflammfiffon comprises 
ifritatioa, pain, reihiess, swelling, ami increased usecretion. Tlie sys- 
temic symptoms of inflammation are al^seut or slight, excML^pt in cases 
W extensive phlegmon or suppuration. The paiu ami swelling are 
prften se intense that the patient must lie down with the thiglis apart 
CafLHnoaiatous ichor caustvs irritation rather than pain. Frequent 
urirmtioQ and dysuria are common. Urination is painful from con- 
inct t»f urine, especially wheu the infection has extended to the 
tirethra and bladder. 

The Jise4ise starts with local irritation, congestion, redness, swelling, 
jiiiD, and heat* The labia minora sometimes swell to twice the size 
f ihe finger, and may consetjuently close the vulva; they have a 
right, gUsteniug apj>eaniuce not utdike the inflameel swollen prepuce 
f the male. The paiu is tliroldung and extreme in proportion to the 
Iwellitig. The inflamed surfaces, which may incbide both vulva and 
^ina, are at tirst <lry, but soon liecome uioist in consetpiencc of an 
Hort of the glands to ndicve the congestion by increased secretion, 
flic secretion, usually profuse, is a chief evidence of the disease. In 
liklren the disease, unless due to gonorrlircal infection, is usually con- 
fiocd to the vulva. 

(Jironw vulvar and vrnjimd injfamynafihns arc recognized by their 
fr^i^tency, by their tendency to recur when aj^purently en red — see 
rullicalar and Glamhilar Vulvitis^— anrl sometimes l>y the presence of 
t^^wion of tlie vulvar, vnginal, or vulv<i-vaginal surfaces. They are 

RamcterizAKl by a scanty, tliin, ycll(*w discharge, usually more or less 
rnlcnt; by gi-eat lo4^jil irritation; by variable redness; by slight 
dling, and oft^*n by excessive granulation. T!ic surfaces, espec^i- 
y the vulvar surfaces, finally become hanl, rcilematous, leathery, 
[mn^hment-likc, and painfuL A ]>rincipal symptom of clintnic vulvar 
^Mammation is an intolemble, often intractable, itching and burning. 

Treatment of Vulvar and Vaginal Inflammatioii in General. 

The experiments of Dodcrleiii — see page 165 — would suggest 
^iginal douches of a 1 per cent, aqueous solution of lactic acid. 








:-> z'7z\r:.y.\ [yFL.ij£3ur::y<. as: Aizszii^ disorders. 

T - w- III-: ••-•ir!" -:• - i^'.i.- ". .-: • ii- i :r ■-_ ■^..v.rLa which grov^^ 
: :■ -: ":.— :.a. 

r_- 1-1 - i« ■^.::i!/- ?-:• t.-r r- ri -■- v- -^:r«-:: -3-. I>iist an*:/ 
- V . ■ ■: ...: • ':u. : jr-iij:-- !a;a •- •: -t -::i^ v^Ilvlti^, oasil^^' 
"-- : > ~:_ 1 :-•: *: -•! .• •:c'-!i-rr-: -^i-iTr. Ar i :r :-hylaxis apiinst 
-:.- - ■- ^.'r ■■ — :.-. i.-«i L- 1 >~-r "r r . -. r. :i.:uiii?t sudden 

.. :_— -: --:.■•--:■ :.--. ->- :_■ -^-i iri v-r- -.:- •:. : :;ikt- thi* phioo of 
-:- ■.:.:.• c. \ •^- 'jtrc: i^iv-r-. I i-t :.i i; -:. '.\rr4»ath applied 
- -:•■ :---':;i- ^' : "i..* -- i.i -z ['-.•^*:'i' ^i- rii;\iix:*. Stri»iig s«ip is 

Ti-T rrftfc."i::i»r£i-: :l Ar^Tc Til-rr^is - urdy I^.'ul. and inoludes 

\ — ri"::..^ «-u.: -:t — r t-ni TU- :i~' r.. Mil«i nlkalini- ><.)h]tions, 

..- - •:: :.:: "'i-.tm-. \ wi i-irLfi : :i> v';lva, may combine 

\ : :• ■- -• •* -• •' ". -• t-T: i -a. -x:.:**!, ':p«Q Wins washinl off 

\ : \ 1 -:i \ir' • i — rif r^: -^in v •••-:i.:. W aching ?hi»ii hi l)e fre- 

. . : ' >i~'. ;."- : ":r- ':«.'-:"• n :• c r.iiriLpik'"jri»>n-.siioh a.sa h)tion 

-.-« 1 ;;.:;"! - i ;-• »: r ii-ra:e 't' UaJ and fluid aqueous 

-. . ' v.. .1' r ^t •" ' i!-. n: :i- «:.-? ?4.i :::..n of aniipyriue, the 

- >. : . - . . • ! i -.i..!-. "Ill- 4 ^••r'trcr. « intnifUt of morphine 
^ . :.-'-. . :-i :.l%;:-::i»' ?• 1 :*::■ c 'T k*X the 5 ]x>r cent. 
^ , ".." .. "*>• ^ irr. *i--:-i.a:h '-r rhe ici*-bajr applied 

■ .. ;. • . 1 -;.-^ * i ^Jizr^.tii: irritatiim and burning. 

-^ . . . ^ .! '. n:.^-. A ?»• nil Mipju^iiton- containing 

..:.. % ^•*:..:-. j::«- -fxrrj-': "f l^vlladonua, one-fourth 

*. ... :.:i; -M.- " r: :• i>:>tdtt.l sK-t^p. Avuid oint- 

- .:.::..:. '^ :.:.;i..: ii:. Vi?< '.!:>. «;I»:ir or *tifft iuhI with wax, 

.., ., * " :•- \\i:\j. rj.r. i*. m jwrauil without tiH) mueh 

^.. J., ,- :■ :.r*.5-? ?^i:i:mrt^l with a southing anti- 

.. . .: t • ;:■■••■. .•.:"v-.r T •.:!:<. in. 

. .. -, . -:=.:< .:' n.nndic-i to allay irritation and 

^ ...ll d.-»- t'f ao»»nitc may W indicated. 

\ V jviMvit- is t>s<iiti;!l. Si|n»riHcs and ano- 

.. . ■ - - -. •> ;rn:aTi»'n an»l |uiiu. KuUics and other 

»■' .; iJnati-ari' is iKHtliil to avoid carrvinc 

.*v:i :■» the vajrina «»r uterus by the .syringi»- 

.>.,. ,.— .^.r- j.f Chronic Vulvitis includes, in adtlition to such 

* .> :v.:;v U- indiratc<l, astringi'Uts and, in obstinate 

^ .7:..v> -houM be 4ln*s>(Hl with puizc t'onipn*sses 

. • •• aiiucHMs snlution of the bichlori<ie of nier- 

.. ..n- -olution of carbolic aci<l. IfthcdiscaM? 

:»■'.! '\\\ piil»is or other jKirasitcs, mcn'urial oint- 

.. ab«»vr >olutit»ns, should Ik* usimI to destroy 

■ \;jLM"al douche may be siipplenicnte<l with a 

, iTi or zinc sulphate, one drachm to the (juart 

. ^i,.n i> «»fteu promptly curc<l by the twi^ tist* 

:.„. ,,intnient. The cnMhsl surfaec»s, having 

\ .iii-tid with calomel or with the subg:dlate of 

.•:iM- of seven* pruritus almast mimcidous 



VUL VmS\ VUL VO'VA GIMTfS, VA GINITIS, 



169 



i^ljVj\somerimo8 fijltnvs tlie fnx* withtlrawal of bltMal frojn the uterus, 
eltlicrbvst'iinficatiMn or by ieeclii's. 

(imnular ii>flatiini:ition of the vn^ina iiiiiy hv entvd by painting 
tlie granulated jjart with a 1 to 40 solution of nitrate of silver and 
ihWv jiaeking the vagina with ganzc. The treatment of viilvo- 
va^'tml inflammation will often deniaurl the n'nH^\al nf a eiiusal 
t'DfJiMiietritis. (Jb^tiuate ea^es often yield to frequent ajijilieations of 
]'* or 20 per cent, of ichthyolate *A' ummoniuni in glycerin. The 
Application is best made with a eumpre^ss secured by a bandage. 

SPECIAL FORMS OF VUL VO-V AGIN AL INFLAMMATION. 

Hiespeeial forms of v id vo- vagina! i n flam naatiott will be considered 
sepafftiely io the following jKimgraphs. 

Qonorrhoeal Vulvo-vagrinitis. 

The gonoeoeeus, one of the most aetive and most virulent elements 
io tlie diseases of women^ lias been ibiind in all of the genito-uriiiar)' 
organs, and is the eaiise of a large jiroportion of the cases of destruc- 
tive metritis, salpingitis, and o%*arttis. 

Gnnarrhnea is always the result of gonococ-cus infection. The dis- 
•we is characterized by a strong tendency to penetrate and spr€*ad^ 
llldi^ prone to attack the follick^s and glandular sirnetures of the 
vnlva, egjieeially the vnlvo- vaginal glands and Skene's glands. Dif- 
fuse and deep cellular inflammation and abscess of the vnlva may 
rijsult from gonocoeeiis infection. See remarks on the gonococcns, 
upon recurrent gonorrhtea in woman, jmge 155. 
G^jnerrhfca not uncommonly extends throughout the genito-nrinary 
tnict, although tlie constant downward current of urine may m a 
nuiwure protect the more distiint urinary organs. If the infection 
ofiginates in the vulva, it usually extends to the vagina, and r/ce 
rmwT, The urethra seldom esca])es. The inguinal glands may l^e 
infected by tninsmission of the infection through the lymphatics, and 
ape«?5pecially prone to suppuration. 

Children are mon? subject to tliiHi infection than is generally siip- 
fomt It may come from in fee ted bed-lineUj from bathing with 
infected cloths or spi>nges, or from the unclean hands fif infected 
nurses. In children the disease is less liable than in adults to extend 
t«) the vagina, because the vagina is protected in a measure by the 
hymen. It may, however, be easily carried upwanl on the douche 
|wiiiL 

Diagnosis. A suspicions exposure, great pain, ami unusual sys- 
f^mic disturbance shonkl excite suspicion. Radiation of pain to the 
rpctuni, perineum, and bladder, urethral burning, and involvement 
of the deeper granular struct n res are strong diagnc^stic signs. The 
fJOfiitive diagnosis depends upon finding t!ie gonococcus by micro- 
scopic examination. 

Treatment. It is highly imywrtant to stamp out the gonorrho^al 
infection while yet in the vnlva or vagina, and thereby keep the 





170 TSFECTIOS\% INFLAMMATTONS, AND ALLIED DISOEDERS, 



1 



infection from goinj^ to tire higher zones of the genito-iiriiiary systej 
wh*^re it is always dt'stnietivt* and oftiMi fatal. Di^inffH^taiUs — i 
giTmicides to the extent of the pat Kent's tMleratioy— arc indieatt-^-^i 
H<»rynidoiis eleaiiliness should be eiifdret'd and ri^itlly niaintaine--^/ 
If the disease is in the vti^inaj let the volvo-vuginal surfaces B'>c* 
painted^ iis in ^niniilar vaginitis^ witli sohjtion of uitnite of silver .r*^ 
forty p:rains to the ounee. The vagina and vulva sliotild then I yr 
|ta(*kv4l with dry suhliniated or hunited gjinze, whieh should l>f* 
rera-wt'd as ofk-n as it beennjes moist froni the secretions. At earb 
tina' t>f elmnging the gau/.ethe siirfaees Khuuld be thoronghly t*leanse(i 
by means of a warm 5 jkt cent, atpieous sohition of earbolie acid; 
ihiH is Ui hv followed by a thorongh washing with peroxide of 
liydrogen, whieh is veiy" cleansing to the deeper ghmdidar stroetures. 
Hie diet mast Ik* non-irritating. Urethral or blad(h*r cooiplieation 
calls fur diuretic drink?=. Cmytais of iehthyol, aristol, or dermatul 
in llie urethra, if tolerated, may Ihj useful. 



Erysipelatous Volvo- vaginitis. 



I 

I 

I 
I 



Krysiplas is primarily an inflammation of tlie lymphatic vessels of 
the* skin or mucous membrane. The infection is eansed by a strepto- 
fiiccns himilar tu the strcpttwMx-eus pyogt*ues — |H^rhaps identical with 
it, '^I'hc disease is trbrile, always acute, often suppnmtive and sujier- 
li<»ial, aiu! chicHy cliameterized by a tendency to spread. There are 
thrc(t varit^tics: the erythematnus, the vesicular, and the gangrenous, 

Tho Erythematous erysijM'las of the vulva and vagina is the 
tnildcst form. It pivsents rtnlness and heat of tlie surface. The skin 
or mucous Tui^mbnine is but little swollen, and the tendeney is strongly 
(iiwanl spun I a neons recovery. 

Tho VoBioular form is more severe, is ehaneterizefl by intense in- 
rtamuiatioti of t!ie skin or nuieous membrane, by marked OHlema, and 
bv the appeaninct* under the surface of vesicles or bnlhe whieh, like 
blistiMN, t^intain st^runu Finally^ infection in these vesicles n>ay cause 
huj»pun»lii>n, and the inflammation may extend to the dee{>er stniet- 
uvi'f* anil beiM»me phlegujonous. 

ThtJ Oangrenoud is the nv«^t dangerous form of erjsijxdatous vuU 
viti)** It apjitirentlv n^sidts fr%m\ rapid development of the strepto- 
etHvi and their proiluels in the lymph channels and eouneetive-tissne 
wiHUHv** so as tti sunt oft' nutrition »nd cause necrosis. It results in rhe 
de^^t ruction of hirgt^ urtms or of j^^mall patches of skin or niucous 
iueiuhmni\ . ■ 

PMt^MH is* t»lVn asjiv^ciat^nl with erys5i>elatons vulvitis. It in- ■ 
vnlveii not only the lymuhatie vt^^^sels, but also the ghuulular elements ■ 
anil the d*H*iH^r iHunuvtive tissue. The inflammation may \ye diffuse 
or en UhI, and may lenutimte by resolution or by suppuratitin. 

I 1 mUis vulv%v-VHjfiiiHl iiiflamnuuion iK'cnrs not infrc^cjuently 

in verv yiHinn itifnntii bv exlemion fn»m the navel, ^*r it may spread 
(Vi\m t1u* vulva tt» the thi|rl«^ and nates; it is scinietimes observtMl in 
ehih(h«H>il« luit i^ mn* in mlult$i. except in childbed, where it is a most 
tuflWlHiti. 1)«k1 nulriimn and iilth are strong predisposin^r 




VULVITIS, VULVO-VAGINIT/S, VAGINITIS. 



171 



¥. 



a>M^\ The pn>gnosis is ordinarily more gmvo in infants than in 
ihildri'n or adults. Generally speaking, the progno^^Ls is favtirahle, 
ibiibtful, or grave according to the extent and severity of the dif^ease, 
Gangrene of the vnlva, espeeially in iniants, h almost always fatal. 

Treatment dfM^s not diflbr materially iVom that of the diphtlu'ritic 
fnm; fH?e below. If the inflaniniation hecoine phlegmonons and it'- 
5ultin suppnration, tlie abseess siiuuhl he openeth The gangrenons 
variety c^lls for rigid disinfection witli pure carbolic acid and strong 
j?p|»|icntiDg measures. 



Diphtheritic Vulvo-vaginitis. 



Ttiis form of vnlvo-vaginal inflammation rarely oeeurs in the non- 
puerperal adult. It attacks children during epidemies, and is then 
ij>ii:illy communiciited from diphtheria whiefi has originated elsc- 
wIh r(\ It is more eommonly the liteal manifestation of a very grave 
fomi of pueqK^ml fever which sometimes ocxiurs in epidemics, espe- 
mliy in the obstetric wanJs of hospitals. 

There are other formsi of membranous vnlvo- vaginitis in which 
tLe germ of diphtheria is not present. 

Treatment. The general treatment inclndes energetic supporting 
measiiR^s, Buch as <|uinine, the ruineral aeids, tincture of chloride of 
inm, and sometimes heart stimulants. The bowels sliould be koi>t 
n^ubited, if neeessar}-, by mercurials and salines. The hx'ii! treat- 
ment k the same as in the general therapeuties of vidvo-vaginitis : 
antitoxin and other measures are indicated as for diphtheria elsewhere* 



Tubercular Vulvo-vaginitis. 



^V Tubercular inflammation has been found in every portion of the 
I gt^nital tract, the oriler of fre([aency for the variiuja porticuis being 
i the Fallopian tubes, cor|>ns uteri, ovaries, vagina, cervix uteri, and 
vuhx It gives no eharaeteristie synij>toms ; the diagnosis *h^|K'nds 
upon iimling the bacillus tuberculosis. The disease is usually second- 
an' to tuVK^rculosis in some extra-|>elvie organ, although it maybe 
primary in the genitals. It is prfjl>abl(% though not certain, that 
tulKTcular infection may be the result of coitus.^ Tubercular vulvo- 
vafrinitis is rare. 

The Treatment of tubercular vulvo*vaginitis is the same as that 

of Urltcrcular disease elsewhere-^/. f\y systemic and ltj«d. Proper 

■<\ outiloor life, e^irefnl attention to nutrition, thorough strong 

ii/ation, and, if necessary, removal of the affected |mrts, are 

indicated. See Lupus Vulva?', Cluipter XXV. 

Mycotic Vulvitis and Vaginitis. 

This fijmi of infection is most common in diabetic subjects ; certain 
frmgi — myc*>ses — ^chief among them the leptcrthrix and leptomitus, 
are often found in the vulvar secretions, ancl arc doubtless the excit- 
ing caii^e of this form of vulvitis. There are continual itching and 

> J Whltrldife Williums. Johns not>l£ln» Hwspltal ReportH, iii. pp. 8.V152. 





172 INFECTIOyS, ISFLAMMATIONS, AKD ALLIED niSOROERS, 



biiniiiip Tlio [iruritus i.s extn^me. Tlio dt'pre.Scsing uifluence t>f the? 
h\ jHTsecretion, sli'Oj>lt'ssiR's.s, imln, and loss uf ap|>etite are apt to 
IkisUmi the t'atiil re?^ult of the diulvetes. The vulva thruugboiit ha,s a. 
roppery-reJ eohjr, is iniieh swolleiij and Ls dry in sume jxirt.s and 
moist ill othei-s. Scnttt-hing may cause here and there eonsiderable^ 
hleeJing. The »kin i^ dry and hritth?, wrinkled and rigid. The 
atft^otinu nsually invades the l-iikls uf the griiin, the nious veneris and 
tlie folds nf the nates, auJ invty surruund the anus. An improve*- 
nn'ut in the general eoutiition of tlie patient nuiy lessen the local 
disease. It usnally returns, however, and with increased severity.* 

Diahetic uritie apparently favors the development of the fungi, 
although the disease is not always assoeiated willi sugar in the urine, 
Furuneuliisis often eompUeates tliabetie vulvitis, 

Vulvo-vagiuiiis arid vagiJiitis, not only in diabetic but also in 
nou-diahetie wonit^n, Iui\'r hvvn observed in eonnection with certain 
fungi — leptothrix^ and oidinm albieans.' 

Etiolog-y, CVdarrh of tlie genital traet and pregnancy are predls- 
ptising causes. The miern-organisin may Ik* brought in contact with 
the genitals by iutereonrse, especially with a diabetic man. The fun- 
gus may be c^irrii'tl rui the linger of the gynee<»l(»gist. Wiriekel cites 
twii eases in which the infection ajvparently was tmc(:Hl to the touch- 
ing <d' the genitals by the hand dnstetl with flour. 

Symptoms, Dia^rnosis, and Progrnosis. The leptothrix causes 
less distress than the oi'diuni aUfieans. The latter may induce severe 
itchingj burning, heat, and incTcascd se<Tetion. The .siwelling of the 
vagina may extend to the vulva, and then l>e so great tfiat the 
patient cannot stand nor walk. The epithelium is exfoliated and the 
urine causes pjdu when in ctmtaet with the ex|>osed snrface^s. The 
irrita(ioii ntay Ijc extreme antl paroxysmal. 

Vulvo- vaginal mycosis usually btgins with a subacute inflam- 
mation whieli extends throughont thr vagina. In tlie vulva the 
inner surface oi' the nymplue and the fulds about the meatus urinarius 
ar*.^ chiefly affected. Small yellow spots upon tin- reddened mucous 
membrane or skin, which cannot be &eraj)c«l oflf without at the sume 
time removing the epithelium, arc clianicteristic of the disc^ase. 
These spits, taken together with finding the micro-organism by 
niifroscujiie examination, Mill estaldish the diagnosis. The prngiiosis 
i> variable. The tlLscase s«»metiines disappeai^s in a few days undrr 
treatment. In pregnant wonveu it may cuntinne until after de- 
livery. 

Treatmetit. This often includes attention to the associated dia- 
betes. A diabetic <b"etary, tonics, and mild saline laxatives are first 
indicated. Tlie intoh'mble itching and 1 hi ruing necessitate hx^l 
remedies, of which many liavr been used with varying and tempjrar)' 
success. Wash tlioronghiy with a tepiil solution of corrosive sub- 
limate, 1 to 2000, or with a saturated solution of boric acid, Ben- 
zoated oxide of zinc ointment, or an ointment of vaseline and sali- 
cylic acid, 1 to 200, is us^'ful. The sitz-bath, temiKTatnR^ 80*" F., 

» Wlnc'kel. nisi^'jisi'* of Witinrn. 

» lliiussnimio, nie ranuliLii der weilil. Ofsclilechtiorgiinc, Berlin, 1870, Winekelt 

■ Wtnckul. 




VUL VITIS, VUL VO' VA GI^'ITIS, I VI aiSITIS, 



173 



mpnl fiir an hour, often ^ivcs relict"; to this hiith may he mMvil 
limraAnf Indian iiieiil. Astringent washes of tiinniu or aliiin, or 
^Hlplmtt' of zinc, may be indieiitetl. 

SijKc the skin in mycotic vulvitis is already dry and hrittlc, it is 

not well to dust the vulva with powdc^r. To ndieve the sntfering, 

whidi i^i usually woi'se at night* place a comprcx^s moistened witli a 3 

jjcreont, s<ilution of carbolic acid on tlie j>artri Ijefore the patient goes 

Jto M. Anrxlynes maybe used locjilly ; one ptirt of chloroform to 

rive parts of alnmnd oil, ointments of Itelladonna and morphtne, or a G 

[XT cent, solution or iHiitment of cocaine may gi%^e tern poniry ndiei". 

The rlisease in a dialx*tic .subject is usually intractable or incurable. 

S-^ Funincular Vulvitis and Prnritus Vulvte. 

Mycoses of t!ie vulva and vagina in .subjects not suffering froiu 
dJAlx^tes are usually self-limit l^iI or easily ciuvtl by the treatment 
above indicated. The vagina! uiycoscs require douches of earbolie 
acid, 3 [>er cent., or of corrosive sublimate solutiou, 1 in 200(>, Tlie 
mycoeea of pregnancy are usually limited to that state. 

Syphilitic Vulvo -vaginitis and Chancroid, 

The subject inehides the primary, secondary, and tertiary forms of 
syphilis. 

Chancre develops not until after an incubation of from ten to 
twenty days, usually tlie latter. It is first a reddened excoriated sp<^t 
or a hardened papule with or without ulceration. The charaeteristic 
feature is indumtion. The indurdtioii may be parch uient-1 ike and 
^•ipfrtirral, or it may be deep and rea<"h laterally far l>evond the e<lge 
of the erosion or ulceration. The iudin^ated tissue is hard, like carti- 
lage. In the ulcerative form the ulcer is usually small and funnel- 
?»hape(|j with sloping edges, snperiicial or deep ; the edges are never 
'mclerrnined. Tlie bottom of the uhxn^ is gmy, the discliarge sero- 
piftilent and never free. Kiirely more tlnlu one chancre ever appears 
in t!i^ same pt^rson. The inguinni glands usnnlly cnlargCj but do not 
LrfOj»pumtt\ Chancre is only the local sign of syphilis, and iti* pus is 
^^toidv, if ever, auto-inoeulable. 

Chaucroid, which is a purely local infection, lias no period of incii- 
tation, is auto-im deniable, has a njunded or oval margin, abrupt or 
raj^t'd cilges, no iudtiration, and may develop into a large or phage- 
denic ulcer. The inguinal glands are prone to .suppurat(^ Large 
numbers of chancroids nmy occur on the siime perse ui. 

The secondary and tertiary tchious of syphilis include mucous 
patches and gummala. The presence of these patches upon the 
gi'nitaLs in no respect modifies their general character. 
wgL Treatment. The treatment is that of syi>liilis or, iis the ease mav 
^fc^ chancroid. The locjd lesions may be complicated witli other forms 
of vulvo-vaginitis, whi(4i shfvuld have sjicinal attention according to 
their class. The treatment <»f the syphilitic lesions in the genitals is 
the same as when they occur elsewhere. 





174 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 



i 



I 



* 



Superflcial Vulvitis and Vaginitis. 

This is sometimes rnlkKl Ainqile inflamtnatioti. When acute it afteo 
piTMhiees nil Id systemic fever aiitl soinetimes exeessive swell iiig» pain, 
ami irritation. The disonler is erythematoiLs and resemhies mtieariii. 
It diies not ^ive rise tn nitieh exudate, is not very virnlent, and ^^eldoin 
or never extends to tlie follirnhir or glandular elements ur to the uterus* 
It teuda to rapid resiilution on removal of tlie irritatinf^aiuse. It often 
nuise8 exeessive oHlenia of the kbia niinoni, whieh may disapi)ear in a 
few hours. 

The eauses i>f superfieial vulvitis and vaginitis are often htrgely 
meehanieal, sm-li as masturbation, exeessive eoitns, rnl>binjj, si^nitehing, 
presence (jf pin worms or the |Kirasites of the taenia eireinata. Irritating 
vaginal or uterine diseliarges — stale luine, an<l canrerous iehor — are 
among tlie ehemieal causes. The inflammation may be in the form of 
vulvitis, vnlv<»-vaginitis, or vaginitis. It does not involve ihe <*nriuni 
in the vulva nor the snlymueosa in the vagina. Tin* mildness of the 
ntleetion is due to tlie lesser virulenct^ of the exeiting eanse or to its 
superiieinl loeation, or to hotli. Thi- treatment has already lHH?n 
dei^ribed in the general tlierapcuties of vulvo-vagioal inflammation. 
tk-^e page 167, 

BenOe Vulvo-vaginitis. 

Senile vulvo*vaginitis is usually, thongli not always^ a fH>i]iewhat 

diH'p inflammation. The retnigressive pbysiologifal proeesses of the 
mrnojKiuse whieh result in senile atrophy of thi* reprcKhietive ctrgans, 
destroy in great part the epithelial portion of tlie ujueous membrane ■ 
<d' the uterus and vagitia; it ba^* alni the same etleet u])on the nmca- ^ 
rutaueous eovn^ring (»f the vulva, and the lining of the uterus, 
vagina, and vulva bi-eomes larg*ly e*)mposi'd of fibrous tissue. This 
fl]>rous tissue when inflamed is prone to granulate, to suppurate, to 
<'iratri?:e, to e<uitraet, and to form adbrsions of any surfaees in eontaet 
with one auotlier. Stenosis at the internal or external os uteri may 
prt^veut free dniinage of the uterine f^x^retions. Thes* secretions, 
already jiathologii'id, Avben retained bec«>nie exeessively irritjiting. 
Similar scrrrtrnTjs alsoe<»me from the vagina and vulva. Aged w*imen, 
therefore, wl»o have long jvassinl tlie menopaus*% are sul>jt*c*t to a most 
irritating vulvo-vaginitis — a most exhausting and distressing pruritus 
vulvae. The adhesions often entirely envelop the vaginal portitm of 
the ei-rvix ami may [lartially oblit^^nite the vagina. The vulvar glands 
and mueous eryj>ts, es]ip<^ially in jiruritus eases, are extensively 
involviHl. Removal (d* them 18 the oidy means of relief from the 
itjtfilerable itebing and burning. Si^e Treatment of Glandidar Vul- 
vitis Iwdow. [n other res | »<•<•! s the trtatmi^nt is the winie a*% that 
alrt^ady laid down in the g*'ntTal tbempeutit^s, juigt* 167. 

Glandular Volvitdfi. 

Inflammation of the Urethral Crypts. Five or six small moe- 
nn>S4» ghinds an^ situate*! aroimtl the meatus. They have short duets 
with wide o|x*niugh ; tW4j of them are in littlr depressions on eitljer 




VULVITIS, VVLVO-VAGtNITIS, VAUISITIS. 



175 



FujrHE 106. 



ride f>f the nicatut^. Inflammation in tht^se glands or crypts, i>i)t 
unrornmon during and afttT the nK'noj>ayse, may cause a most por- 
mWiU pruritus with extronu' itohing and Ijiiming ; this occurs most 
JTiviuenlly in connection with senile vulvitis. 

Inflammation of the Vulvo-va^nal Glands, The vnlvo- vaginal 
glands of Bartholin are on either side of the vaginal orifice near the 
|iO!fterior extremity of the bulb of the vagina. Their ducts are aSiout 
om-half inch long and ojK-n into tlie fossa navicuiaris. 

Inflammation r)f these glands comes by extension from the external 
jiirface, Tlie glands, or their atferent duets, or both, may be involved. 
Aftippuniting gland may poor out pus through its duct; or the dnct 
may close by adhesive inflammation and form an abscess; or the 
rtoelimioo of the duet may result in the distention of the duct with the 
Darmjil secretion of the gland. This would be a retention-cyst. One 
"rlM>ili glands may be atfected. The disease is very common. 

Diagnosis. Abscess is distinguisiied from retention-in'st of the 
giaoik by the presence of acute pain and heat in the fTirmer and the 
liMeaoe of them in the hitter. Enlargement of the gland under either 
of these two conditions is distingnished from phlegmonous vulvitis by 
the location of the former, which corresponds to that of the gland, 
«^liile pldegmon may be any- 
wWre in the vulva; and from 
vulvar hernia by the absence <jf 
thf I'liaraeteristic signs of hernia. 

Gbindnlar vulvitis, once es- 
UbII*hLHl, is prone to become 
djnmie. The glands serve as a 
culturt^^rouud for the infecting 
Wrcria, and superficial vtdvo- 
vaijirritis, though appan:*utly 
<'»rp<j, may again anti again 
r?<itr from the infected glands. 
Tln' vulva, through its gland- 
"br structures, is a great dis- 
tributing point of pelvic infec- 
tion. The i>eriodieal congestion 
f»f menstniation is a recognized 
pH'dlspnsing cause of recurring 
pelvic inflammation. The ca- 
pwity of gland rdar structures 
to nveive, retain, and tlistribute 
infe'tion wilt often explain the 
ff»^iicntly observed attacks of 
Current gonorrhoea in women . 

An explanation of latent ^. , . , .u , • , , . i. 

pnorrhfca in the male, discussed t^r abscess J 

oj^ X<)eggerath, may be the same 

^ timt made in the preceding paragrttph for recurrent gonorrhoea in 
wnmen, 

^ From ThomA» and Mund^. Diseuava of Wumeii. 




176 lyFECTlONST 



lAMMATlONS, 



The Treatment of Glandular Vulvitis, when acute mu\ non-sup 
punitive^ 18 palliation and cleanliness, the latter to be setmrcKJ chiefly^ 
hy tlisinfectants. Wheni the inftaniinatifin is chronic the treatfuea^ 
varies with the different j^ lands, as fi41ows: ■ 

The five or six small nineonH erypts near the meatus uriiiariu$J| 
when inf'eeted, are the seat of an intoh^rable pruritns. To cure thii-s 
destroy the jij^lands by th*; aetnal eantery or hy exeision. The anthor*r»^ 
preference is to excise them, close the wounds by suture, and let then 
unite by first intention. 

The treatment of an abscess of a vulvo-vaginal ghmd is tfie a^ame 
as tor aljseess following: phlegmoiions rnfliminiation ; it shoidd l>e| 
widely o|M^ned, the wound |>aeketl witli gauze, and made to heai f rom [ 
tlie bottom by granulation. In opening tlie abscei^s find tlie gland, j 
if possible, and remove it. 

When a retention -cyst has fornie<l from occlusion of the duct the 
me should be dissected out, the wound sutured and drained w'ith a 
small rubber tube or with gtiuzc. If drainage is not used, the woun4 
usually suppurates.* Sometini<*s chmiiie supnnnition 4if the glaii4 
oi'curs thrniigh the oi»i'n duct. Tlien the unet should be widely 
inciscil, the gland removed, and the wound packed with gauze, or 
sutureil au<l drained as described above. 



Follicular Vulvitis. 

The labia minora and majora are abundantly supplied wi'th hair- 
bulbs, sebaceous follich's, and 
FmtTiimi07, sweat-follicles. In Ham mat ion in 

these structures is iollicidar vul- 
vitis or folliculitis. The general i 
apiKMinincc of the surface, except 
sliglit eong**stion, is imehangeth 
The inflamed o]>eningsof the fol- 
licles scattered over the labia mi- 
nora auil nuijom an^ small, red* 
elevated, and sw<*llcn. Cliildren 
a re n fit s u bjec t to folliculitis. The 
inflammation may tuiginate in the 
follicles or may extend to them 
from the external surface, a.s in 
glandular vulvitis. The infec- 
tion (jften remains entrenched in 
the ftillirles hmg after it has dis- 
appean-d from the external sur- 
face, and from these lurking- 
places may again and again rein- 
fect the surface. 
:. Adhesive inflammation may 

^"^-•^T--^^ close the openings of the ducts^, 

roUlcuUrvuivitii* vrhen the secretions will be re- 

1 The author published this openUon in the ChicAgo MedJcAl Hevk'w In 1B80. 
* From Tliomaj» and Mutid^. 



f 




VUL VirrS, VITL VO^ VA GiyiTfS\ VA aiNITIS. 



177 



lained aiid form abscesses as large as a pea ; otherwise the discharge 
]9 abundant, purulent, and often otfensive. 

The Treatment of Follicular Vulvitis, The disease may l>e so 
tkply seated that it resis?t8 all surface applieatioiis and yields only to 
i\mi deep ca uteri suit ion strong enough to destroy the Hecreting struct- 
ure. Ft>r this purpose use the fine gidvano-eautery needle or the piiint 
oftt^»rr»bi* made red-hot in the flame of a spirit-lamp. 

In follicular vulvitis with oeehision op'U eaeh follii-le with a siiiiill, 
shnf|>-jM>iuted knife, and then apply the tine-pointed eonieal solid 
*iicJc of nitrate of silver. This may be done under ct)caine without 

Furuncular Vulvitia. 

Funmculosis usually starts in the hair- follicles and extends to the 
pumiunding cellular tissue. The resultant boil may be devehn>ed at 
Dumerous piint^ in the labia majora, where the diseases is usually con- 
fined. Some women have ao unexplained tendency to this form of 
vulvitis. Furunculosis is common in diabetes. The author has 
observed that glycerin tamponade is appiirently an exciting en use of 
boik The ineipif ut boil may often be aborted by pulling out the 
hair from die inHamed hair-bulb, thereby giving drainage. 

The Treatment of furunculosis is the same in the vulva as else- 
wlM^re— *\ t\, o[>en and ilnun the abscess. Numerous boils sometimes 
follow one another, or occur in successive clusters in one locality. 
Such r^nrring infection is usually due to the presence of the microbes 
of >uppuration, whieli reniaiu ou the surfaci' ready to ]>roduce reinfec- 
tion af any favorable point. I>aily cleansing of the surface and thor- 
oogb disinfection witli the ointment of biuioditle of mercury (1 : 60 1 
fof two weeks after the last boil has disappeared are effective means 
rf ppopbylaxis. 

BmphyBematous Vaginitis. 

This rare disease occurs mostly in pregnancy. It is chanictcrized 
W numenius small, soft cysts of variable si^se just under the vaginal 
larface. These cysts contain serous fluid and gas. The affection is 
Hually associatctl with other forms of vaginitis. The diagnosis may 
w Vf ritied by priekiag the cysts ; then the g^is escaj>es with a blow- 
lOf-^^miuL In pregnant women the cysts disap|K'ar without treat- 
ment at the end of pregnancy. 

Treatment. In puerperal ciis^^s the treatment is expectant. In 
Oon-pnerperal cases, if the cysts do not €lisaj)|X'ar under antiseptic 
douches, they should be ofxrned and the vagina paeked w-itli anti- 
*«piic gauze.' 

Parava^nitis. 

Paravaginitis, sometimes called disse<!ti ng vaginitis, is a rare dis* 
which involves the submticous eount'ctive tissues. Burrowing 
are formed with |>eri vaginal fluctuations. The musculature 
r the vagina and vulva, in wh^le or in part, mny sepanite and slough 

The cicatricial eontmctiou which follows 





178 ISFECTIOyS, ISFLAMMATIOyS, ASD ALLIED DISORDERS. 

will then cause stenosis or atresia. It is often impossible in su 
cases to restore the calibre of the vagina or vulva by operative mec 
ures. Secretions of bloixl or menstrual fluid may accumulate abo 
the atresia in the vagina, uterus, or Fallopian tubes. This disease 
usually due to a grave infection by the streptococcus or by the ger 
of diphtheria. 

Treatment. The pus should be freely evacuated as soon as it i 
discovere<l. If sinuses form, they should be incised and drained 
Plastic ojierations and dilatation may be required to overcome cicatri 
cial ci^ntmctitHi and {x>ssible atresia. Atresia from this cause is no 
to Ijo eonfuseii with the congenital atresia described in the chapter or 
Malformations. 




CHAPTER XI L 

ErZEMA WLVJE, IIERPEH VULV.i; KRAUROBIR VULV^, 
PRURITUH VULV.V; llYPKR.luSTHESIA VULV.E, 
VAGINIHMUS. 

.bcoNQ the disorders allied to vulvo^vaginal iiiflamniatiuri are 
wz^ma viilvje, herpes vulvm, kraurosis vulvae, pruritu.s vulva*, aud 
vaginismus. 

Eczema Vulvae. 

J'v/f^ma vulva is an infreqiieut diR?a.s4\ and mostly eon fined to 
|inpi;ii]cy. It may be acute or eliruriic* Tfie eruption eonsist.s of 
uiKliiks, ve-sicles pustides, and seabs, with variable redne.-^H, swelling, 
anil moisture of the skin. The vesicles contain serous fluid. Pus 
lA ftKiini under the se^ibs in the more severe crises. The skin and 
^>imimeii the suheutaneouH tissues aix* iuti It rated. Aeute eczema 
w n niaiii loeal and terminate within two weeks. Chronic eezenia, 
rficn iatraetable, may extend to the nions veneris, thighs, and nates, 
wilii m*elling ami suppumtion. 

Treatment. The general treatment consists of mercurials and 
alitwM, oon-irri tat iug diet, avoidanee of wine and liquor, and hygienic 
living, The h^eal treatment varies witli tiic eontlitiou. Whenever 
thr rtiil)*^ II ta neons structures are expos<."d, tlie yolid nitrate of silver 
punt should lie applied ^ care being taken to touch only the ex(xised 
^uHlici^ri, Oftentimes munerons very minute abnisions may be seen 
*ith tliLMinaided eye or through a magnifying glass. These should 
b^Wicalely touchetl with the finest point 4if nitrate of silver. The 
ipplicatiou should l>e repeat^^l every live days until the abrasion dis- 
•PP^fs, The following ointment is usefid : 



Ointment of nifle urttt^r 
LAnoUfi . . 
Oxide iif xirie 
Boric licUl 

AmmotiiAied ichtliyol 
Thymol 



1 ounce, 

1 tlraehtu. 

40 grain*. 
5 *' 



Dusting with bismuth 



The parts should Ix^ kept clean and dry. 
oftea give^ relief. 

Herpes Vuli^se. 

An herpetic eruption, not unlike herpes labialis, is occasionally 
••J)«>rved upon the vidvar labia. There is little redness or swelling 
ff»<? disease is usually self-limite<l ; like herpes in other places, it 
^n^ its course in a few days and disap^^K^ars, 

179 




180 nfFECTIOXS\ INFLAMMJTIOSS, AND ALLIED BLSORDERS. 



KraurosiB Vulvae. 

Kniunisis viilvfe as the name iiulinUes, is a shrinking of the 
vulva; its literature dates only from 1875.^ The di^t^ase is charac- 
t4?nziHi by atrophy of the cutaneiUiB covering of the vulva, especially 
of tlie inner surfuee of the nyniplne* Tlie shin apjx'ars dry and 
shrunken, Tlie siirfaee liii^« the tense, glistening appeurjiice of scar 
tissue, and tlie disease differs from ecj'.eiua in its atrophie ]irm*esses. 
The alleetion causes distressing paroxysms of itching and Imrning 
pain in the diseased j^rt, Sametinies the vulvar orifice is extremely 
contracted. The rlinical features are S4> cliaraeteristic that once rec- 
ognizi'd tliey will never be mistaken for those of any other diseaj*e. 
The hair annuKl the vulva is tliin and dry, and late in the disease 
almost entirely absent. The vulva appears small and infantile, the 
labia minora are shrnnkcn and, tinatly, almost absent : the skin is 
pale, witljout pigment, but stn*ldeil with numerous irregukirly-shapetl 
reddish-brown blood spots, M'hich on in6j>eetion appear slightly de- 
pressetl below the surface. These spots are confine<l entirely to the 
vestibule, bnt disappt*ar in tlie later stages of the disease*. The skin is 

dry, soniet i rues f racked , ahnided, 
FiGunB 108. ^J^^\ tx*c*jisic»nally gives forth a 

&light| brown, pnrnlent dis- 
charge* The natural elasticity 
of the vnlva is entirely lost. 
The orifice is so eont meted as 
usually to jirohihit the intro- 
duction of tlie spe<-'uliim. The 
sensitiveness of the parts is 
very great, es|>ecially while the 
brown spots are present, Thls^ 
trtgethcr with ttie tenseness of 
the vulvar (vritice, causes ex- 
treme dys|Kireunia ; in fact, 
usually |)rolubits coiti*m.^ 

The Pathology of this dis- 
ease is not fnlly known. In 
addition to the foi'egt»ing ]Kitho- 
lc»gicid chungcs, nuiy be men- 
tioned :i thiekening of the layer 
of epiilermis, det^rease in the 
number of sebaceous glands, 
and sclerosis of the connective 
tissue. The tightly con t meted 
skin is so stretched (»ver the 
parts that even the pressure of the examining finger may make deep 
rents. 

1 RobPrt F. Wfirr Tf^hthvosU of the Toiaj^ruo «iKl V'uIvr, New York MinllrnS Jouniiil. March. 
1875, Brc isky : Kraurosis Vulvee, Centralblnlt filr Gynftkolo^ie, 1885. n ;i\H. Luwsim Ttiil : Dls 
ensos or Womt^n, 1>« Bros. & Co., 1881*. p, f>3, c:. A. Kccd i Tmns, Aioerlcmn Associalioo of Obite- 
triflrinH and r^vnt'cnUndf^i*. 1894. H».\vnrrl T ^irmyr-iir: Ibid,, 1895, 

*Ad«pkd from Lonirvcar, Anit'rit nn nb*itvtrlf al Journal, 1885. 

• From Bonnet and Pettit. Trailt* pruthiue dc GynAcolqgle. 



LlnoM of union fn IxinoyeAf's operation 
It ran ms is vulvii;> 



for 



PRURITUS riTLV^ 



181 






Loiigrear ha.s observftl a clc^p cirrlititic-like hiiutj of fibrous tissue 
entinelv s*5parate from the ciitaoeous i!«jveriii|ir. lb' iv^nis this band 
i^the essential lesion, and gives to tlie sujK^rticial eliungen a seconilary 
iinportamx*. Tliis fibrous bantl replaces tbe loose cellular tissue 
tlinui^h wliich the nutrient vessels pa^ss to tlie skin, ami by itsgnnlual 
ml continual eontraction causes not only the vulvar shnnkag(% but 
abtlie strangulation of the blood vessels which pass to and fniin the 
oveftyiiig cutancoui* structures. This disturbance in cireulatioii ©x- 
plain-^ the spots of ccchyraosis in the earlier stages of the disease, and 
the atrophic changes in the later stuge. The j^viiin is explained by 
mrchanical presaure on tlie nerves and by the resultant neuritis and 
pTineuritis. 

Treatment. This new formation of fibrous tissue is of sj>ecial 
mkr^t fmin the surgical sliind point. Clearly the removal of this 
bftml, together with the contracted superficial structures, is essential to 
tkvure *>f the disease. The usual opcnitiou of removing the dcgene- 
ttted and contracted mu co-cutaneous structures may relieve the acute 
^vraptoms, but c:in have no effect on the stenosis. Spontaneous 
Twovery is S43metimes rejjortcd ; but this is only a relief fmni the 
Hupersensitiveness of the vulva, never from the constriction. The 
^Umm band, unless removed by oj>emtion, is permanent, Longyear's 
'►|iemtion is analogous to the Whitehead operation fur hcniorrhoids. It 
cottfUts in the removal of all the sn|K*rficial diseased structures, 
toftetfier with the fibrous band beneath, and union of the external and 
intHnjal mai>ri"^ o^' the wt>imd. Au incision with scissors is first 
mnilf along the lateral and posterior margins of the vulvar orifice, 
divitling the diseasctl structures from tbe healthy skin ; then the mar- 

5111 of the diseased tissue, including the fibrous ban*!, is seized with 
it^ittg-forcei>s and dissected loose from the underlying tissues to the 
^'^inal inlet. This tissue is then cut away. The anterior vulvar 
structures an? iliss4M7terl loose in the same manner, care being taken to 
ctii t^refuUy round the urethral orifice. After removing all the dts- 
pjnhI structures in this way, the margin of the healthy vaginal wall 
fthove ig pulled down and dissected loose from the underlying jiarts 
iiml the whole circumt'iTence of the vagina. This loosening of the 
. inul wall permits the inner margin of the wound to Ije brought 
invn to the outer margin. The two margins are tlien united with 
dt'i'l* silkworm-gut and su]>crficial catgut sutures, or with fine buried 
fonnaldt'hyde catgut. Complete relief has followed the ojje ration. 



PrurituB Yulvee- 

In neuropathic cases of vulvar inflammation the irritation, itching, 
1 burning are intense, intolerable, intractal)Ie, and thereby constitute 
R^mrlition called ]>ruritns vulva\ Because the nervous element often 
prc^inminates the disease has been classed as a nervous affection. Pru- 
ntu,^ 114, however, rather a symptom than a disease. It may arise from 
» vuriety of cjuises, may exteml over the adjacent mucous surfact\s, and 
»^<4Vn aggravated by t-tforts to get relief by scmtching; in this way 
the Imliit of masturbation is sometimes formed. The intense suffer- 




182 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 



mg c?aiiBeft loss of sleep, exhaustion, and sometimes alarming DervouA j 
depression. Sexual excitement ami orgasms may oceiir. Priinius f 
may be eomplirate*! by nielaneliolia, liystero-iieuruHt\s, and other fornix 
of insanity. These psy el loses may or may not l>e dependent on tlie 
disease. In many eases a paroxysmal wave recurs with great violence 
upon exercise or U(K>n getting into a warm l>ed. The nervous elenifDt 
hn& not been adefjuately explainetl ; it may be a cause, or an efleet, or 
a ct»ineitlenee. Oi'tcutimci? the inihmimatory clement i> insignifieaDt 
or apparently absent. 

The Pathology of pruritus is not fully known. It is eonmdeml 
by some autliorities to be of ])uivly nervous origin ; by others, vki 
follow the lead of modern etiologieal theories, m^ of baetfrial origin. 
T h e truth 1 i es be twee n the two ex t re nies , The re n i ay n n d » » u bt cd \y be 
an irritation of the sensory nerves of the vulvar skin of pnrely ncuro- 
puthie origin ; when this irritatirni (occurs it is usual ly aggravated by 
the presence <d' more or less vulvitis. The tangibk- patbfilogy is | 
largely^ therefore, the same as has been alreatly described under 
vulvitis. 

Etiology* It follows from the above that the aiuscs of pruritus 
will iu elude those of vulvitis* Numerous atti'nipts tu explain the 
causation of pruritus have sometimes made up in seicutiiic ehiboratiofl 
what they kicked m clinical value. ^ 

The foHowing classes of causes are worthy of consideration ; 

1. Circulatory causes. 

2. Secretory causes. 

3. Parasitic causes, 

4. Median iral causes. 

5. Tlierniic causes. 

1. {'iiTiiittfonf rrri/wK In certain disorders, such as icterus, dia-J 
betes, chronic nephritis, the bb>od contains bile, urea, or sugar, all I 
of whicli may, by action on the nerve-endings, cause itehiug of the] 
jmrts. Morphine, alcohol, or imhiform sometimes has a similar] 
action. 

Erytliema, herj>es, urticaria, and other such skin disorck^rs which | 
involve stasis liyjK'nemia, may wcur in the r<*gii>n of the pudendal] 
and hemorrhoidal vrins ; tliey are then characterized by the inten^l 
pruritus wliich they cause, 

2. Srt'irtoty raufics. Abnonnal srcr*'ti«ins of the vulvar cutaneous I 
glands, vagina* or uterus may, espeeially if <*onibined willi the above-] 
menti(med causi's, procbiee great irritation in the terminal sensory 
nerves cd' the vulva. Secretions from tlie diseased bowel or anus may j 
by chemical action produce pruritus ani and, by extension, give riseJ 
to pruritus vulvse. 

3. Pttruiiiiic erru^^/r. Animal jmrasites, such as |H'dienli and 
aacarides, and vegetable panisitcs, such as h^ptothrix, oidium, and 
leptomitus, and the t^nliiuiry Ijacteria of indamination have been ' 
presented under Vutvn-vaginitis. The vegetable fKiitisites give rise 
to a skin disease sometimes called prurigo. 

1 A lEOit elaboTnt« and tPienUflc di*<?uiaiion of the etiology i>r pruritus 1ih« been contrib 
hf ranger. Genttitlbtatt fUr GynJUolofde. ISM, No. 7. 



PRURITUS VULVjE. 



183 



4. 3ffchanicaf causes incUide masturhation, immoderate handling, 
tod scratching. 

i Thtr-mic caiLses, Heat and cold are kiuiwn to canse a peculiar 
pniritns, called id winter prnritu?^ hyenialis and in summer pruritns 

Above all tliese caases another and more e>sential eltnic nt must he 
takf^n into the account; it is what 0Q04le1l onee cidled die invi.sihlL% 
mtinjj'lble, and iniponderahlc influence on tlie nervouH system ; it is 
tkJifficuUy, not to say the impjssihility, of reckoning with this ele- 
ment tliat often niaJccs the disorder persistent or intmetable. The 
nnfel that can be affirme<l witli our present limited knowledge is that 
there is an irritation of the scns^jry ner%'*vorgjin of the skin, and that 
maDV Pluses may contribute to its excessive di'veh>pment. Whatever 
the tangible lesion may be, nervous irritability and liy{>eriesthesia are 
tl\rar8 essential elementri. 

ItJtolerable itching of the anus is a fre<}«cntly recognized accom- 
paniment of habitual constipation, and is often associated with pruri- 
ttis vtJvie. This may l>e explained by th(^ fact that tlie vnh'a is 
innervated by the siime nerves that supply the anus. The intestinal 
fcocomaines which have been recognized as a cause of pruritus ani 
nay the nAo re also ca use pru ri t us v u 1 v^. 

Symptoms and Course. The irritation is apt to occur in parox- 
ysmal waves. The paroxysms may recur after vigr>rf>us exercise, 
esj)ecially in warm weather, before or after menstruation, or upon 
ei|}o«nre to artificial heat. In some cxises tliey apfvear upon getting 
into a warm bed. The desire to rub or scratch for the relief uf the 
iiritaition is almost irresistibh*. This instinctive effort at counter- 
trritation greatly aggravates tlie pruritus. As Thomas aptly remarks, 
*" tlie disease and the rcmeily wbich instinct suggests react upon one 
another, tlie first requiring the second, and the second aggmvating 
the tirst, until a most rebellious and deplond>Ie condition is dcvelo|>ed ; 
tbe patient, bereft of sleep l)y night ancl tormented constantly Ijv day, 
finally gives way to despondency and de}jression.'' The loss of sleep, 
the use and abuse of anodynes^ and the neurosis incident to the dis- 
rnuy even contribute to the development of melancholia or some 
ther form of* i n sa n i ty . 

The pruritus may extend to the vagina, anus, thighs, and abdomen, 
hMome cases tJie irritation begins in the anus. 

DiagnosiB and Proernosis. Pruritus is not a disease^ but a symp- 
tc(n; diagnosis must therefore de|>end upon the identification of the 
^i«»Q.^tive lesion. In so far as the disease depends upon tangible and 
^sible conditions the diagnosis and progn<»sis will ftdlnw along the 
lint^ alrea<ly laid down in Chapter V., *m Vulvitis. A clear appre- 
^tion of the special etiology of the disorder as given above will 
w a majority of cases open the way to accunite diagn<»sis. 

Without great care the examination may fail to disclose the point 
^Q<1 ^urce of irritation. An irritating discharge, for example, so 
flight as to be unknown or ignored Iw the patient, may be sutficient 
*<^prrKluce the most distressing irritation, and may therefore have the 
utmost sigoifie^nee. 




184 INFECTIONS, INFLAMMATIONS, AND ALLIED DI80RDEB& 

In the vast majority of cases one or more of the following condi- 
tions will be found present^ and will partially or wholly explain the 
irritation : 

Vulvitis ; Ichorous discharge from cancer; 

Vaginitis ; Incontinence of urine ; 

Endometritis ; Pathological urine ; 

Urethritis ; Intestinal disease ; 

Urethral canmcle ; Vulvar eruptions ; 

Parasites ; Onanism. 

Most commonly associated with pruritus are vulvitis, vaginitis, and 
endometritis. The fact that these diseases do not commonly produce 
the disorder is explained by the absence of the essential neurosis. 
Senile vulvo-vaginitis is most prone to cause excessive irritation, and 
the pruritus when due to this cause is exceedingly obstinate. 

The pruritus of pregnancy and the menopause is commonly limited 
to those states. In general the prognosis is indeterminate. 

Treatment. The treatment of vulvo-vaginitis already laid down 
is necessarily a part of the treatment of pruritus vulvse. 

A multiplicity of remedies recommended in the therapy of any 
disorder may be taken as evidence that our resources are limited or 
that the disorder may result from one or more of a wide variety 
of pathological conditions. Both of these propositions are true of 
pruritus vulvae. 

It is clear that the treatment must be directed to the cause of the 
irritation ; to this end the reader is referred to the therapy of vulvo- 
vaginitis and of the numerous diseases and disorders already mentioned 
under Etiology and Diagnosis. 

In many cases the irritation is apparently the outcome of pent-up 
sexual energy. It is a common observation that a neurotic woman 
who suffers intensely from pruritus has entire relief upon the return 
of her husband from a ])rolonged absence. 

While the radical treatment is in progress palliative measures are 
always demanded for the immediate relief of the urgent symptoms. 
Fortunately, most of the palliative measures, since they allay irritation, 
are in a degree curative. In order to remove irritating discharges, 
one may use sitz-baths and vaginal douches of water or antiseptic 
solutions. 

The following local applications may give relief: 

The surfaces after each bath may be dried and freely dusted with 
calomel, bismuth, starch, or lycoixKlium powder. The calomel is gen- 
erally prefenible. 

A vaginal tampon of gauze will often protect the vulva from the 
discharge, and therebv give tonii><)rary relief. The tampon may to 
advantage be satunited with a solution of acetate of lead in glycerin, 
one drachm to the ounce. 

Great relief is sometimes experienced from a gauze compress over 
the vulva, saturated with the dilute solution of subacetate of lead and 
laudanum, equal parts. The compress should be frequently changed. 



PBURITJrs VULV^. 



185 









A onnprpj^s satumtcd witli ii irsoliitinn of corrosive Rublimate, 1 to 
ICK.Mi, h, [KThiips, the most otiectivc r^iiigli* rciiieily. This applu'utiim 
orMricfbnii of mercurial in unction will act iis if by magic when tlie 
C8M.4* i^ [mrasitic. 

ahllis wrung out in very hot water and applied to the vulva, just 
befi>n' the imtient goes to bed, niay relieve c»r pre\'ent the paroxysm 
whiVlj (Njmes on after retiring. 

Ai?tn)ng infu.sion of tobieeo;' buth iis a vaginai douche and on tlie 
Tulvar t'ompreslis, i.s said lu be mont etHeacioui^. 

Ointments are u^ful from the soothing eflect of their (M>nstituents 
not\ hecau^e they protect the [>artj* from (^ontnet with irritating dis- 
dmivf^, They are also an excellent vehielc for the applieiition of 
parasiticides. 

In rare csi^en the pruritus is due to a growth of ^^hort, stiff, inverted 
bir*m the labia majora r»r [>ulies. This condition is called irirhurj^iif. 
Pmupt and permanent relief follows the removal of the hairs and tlie 
d('strueti«»n of their hnlb,^ by electrolysis. 

The treatment of tiic disorder, if <lue to the dialx-tic, uric at*id, 
or lather diathesi.s, must include tlic appropriate dietetic and other 
hvgienie measures. 

In a ca^e, in which the neurotic element prevailed/ prompt and 
complete relief h reported to have followed the smoking of tobacco. 
Painting the vulva with pure ichtliyol has l>een known to effect a 
radical cure. In a ease observed ijy the writer, an accidental applica- 
ion uf pure earl)olic acid was followed by permanent cure. 
Highly seasoned nm\ highly tiitrogrmotis fiiud and stiiuulating bev- 
aggravate the irritatioiij ami should l>e avoided. For the 8anie 
scratching and rubbing of the part arc injuritius. 
Finally, there h danger of forming the habit of using cocaine^ mor- 
iiie, or other narcotics ; for this reason their use should be guarded 
ith judgment. 
When ap|>arent causes have received due attention, and the dis- 
tm' hai* rej^istetl all treatment, opemtive interference may become 

Sanger's conclusions on this point are based upon experience, and 

tve attention. He says : 

1,1 The partial or total extir[)ation of the vulva is a legitimate 

ration that should often be performed in chrtmic, otherwisCj 
incurable prnrlin^i ruft*(r^ He calls it tit/ritif.s pritrtf/inofta. 

(2) The removal of the glans clitoridis, especially in elderly women, 
vberi the nerve terminations have usually lost their specific sensibility 
te reason of the disease, is permissible. 

(•I) In younger fn^rsons, if the irritation is circurascribed, one 
n»ay fry to give relief by a partial opemtiou without removal of the 
Hitoris. In elderly women, and s(mietimes even in younger women^ 
when the disorder is extensive, tht* whole vulva should be extirpated 

1 the parts rcpaire*l by a cfirr-esponding plastic ojicratton. See 

Seal Treatment of Kraurosis Vnlvse. 

* Thomim ami Mmni6. Ol^-^nses of Woraeii. 

• ThomaAt in Thuiijaia flwd Mundd. Dlstsnsea of Woiuen. 







I8(i INFECTIONS, INFLAMMATIONS, ANU ALLIIJ) DISORDERS. 



Hyperaestheeia of the Vulva, 

Tliomns' lia.-^ (loscrilMHl, iiniler this natiic, a raivdisonler of the vulv: 
wliirli (icriirs ill liysterk-al ami tlc^^fKUident woiXH'ti at or near the iiit^rio 
|«iiih(.'. It I'onsi.sts uf an excessive seiisil>ility of the iiorvt's 8upplyiij| 
lh(* niucouis mem b nine tjf some part or all of the vulva. 

The ^lii^litest frietiMn exeitej^ intolerable pain and nervousness j 
even a eiirrent of et^ld air pnxluees diseoniiort, and the least prei*— 
Hure iH intolerable. Sexual irUerconrw iis ofieu impossible. 

Tl*e diM-ase is sometimes; assoeiated with vnlvititi or a painful 
iMM'tbral earnnele ; in (»ther eases no tangible or visible eau.se e^in bi^ 
found. Jt ilitfers from pruritus by the absenee of itehing, and from 
vaginismus in not eausing spismtxlie eontmction of tlie vagina. 

The Treatment is unsatihfaetory. Even the eomjilete destrnetion 
of (he nuKHMis ineml»rane of the sensitive area witli eansties, r»r ils 
exeir^ion, has faiUd (ogive relief. Sexual intereoursc* should Im» pro- 
hibited attd Hie patient plaeed in hygienie surroimdings and with 
ebeerl'ul e^nnpany, Tlie general treatment is by tonics, sai-bathing or 
warm -water liathing, and nia.^sage. Local lesions, if present, are 
(iiHiled niHM»nling to their sfx^eial imlicationg. 



Va^kdsmtiB. 

hike pruritu»4 vulvae, thi^ rare condition is not a disease, but a 

nervous syniploin due in ,sonie cases to appreeiable, in others to 
nnknown eansi-s. It 18 eharaetirized by spasino4lir contraetions of 
1 1*1' nuiseles surrouraling the vulva and lower portion of the vagina. 
The enndition is analogous ti> laryngismus. The spasms oeeur upon 
Httrm]ittHl eoitnsor u]mui the attempt to make a digital or speeulnm 
examination. The writer has observt»d one feitrrmgly neun^tie ease in 
whieh ihr wiMuan declared that the spasm <K*currcd violently whenever 
eoitu?^ was atti»in|4etb but not tlie slightest objection was made to 
digital or H|KMidiun examination, 

Etioloffy and Clinical Couree. The condition is mostly ecadim^ 
to yimng nenn*tie, hysteri**al women. The pal|mlde or visible lesion is 
liKUtUly in tin* f*>rm of an irritable hymen or an irritable carnnele of the 
ntentUH urinarius. If the hynien has bt^en ruptured, the irritation will 
be in its remains — t hi' earnnenke myrtib^nnes. Tliese earnn*dt's and 
tlie nri^lhnd earnueh* iti son»e casrs rontain a snperabnndanee of exco^^- 
nivt^lv si*nsiti%'e and targe nerve- filaments. They, in taet, may re^^em- 
lib* neniiuuata. In other eases the sensitive earnnclesare absent, and 
the vaginii^mns is ehamcterizcd only by an excessively sensitive vaginal 
outlet, wliirh may «*r may mvt be the seat of inHammation or erosifm. 
|{e|>eated attempts at coitus agsiinst an unyielding intact hymen may 
give rise iw vnlvitis and extreme tenderness — a eonditiem wliich 
Mhonld not be <*onfituiuled with vaginismns. 

Tlu*tc may Ite no n|*pnMMablc I'tinse of the disorder s^ave a nnigres- 
Mively itier<*using nervtuis apprehensi4in on the part of the wife ; eiieh 
attempt gives rise togrt*ater nervous exeitement until the j>ainand fear 





b 



coitfisaml the extreme spasm ocJie cootmetion of the levator ani and 
neigiilHU'ing miisele.s whieli form the j?phiiH.'ter vaginie preclude the 
iibiiitv of a successful effort, Thomas has given t*i ihis distressing 
symptom the elegant name '' dysparoimia/* "Penis eaptivus*' has 
Wri known to result from an otltcrsvise successful eoitus,' 

Treatment- Any clLscoveralilc Joeal cause should be removed. A 
vulvar tamjxiu of ^uze saturated with a 4 per cent* solution of cocaine, 
tt')it in phice ten minutes befurc the attempt, may lead to successful 
mtu-satid therefore to utero-gestatiou and parturition. Maternity in 
mnt^t casesj though not in all, eiiccts a cure. 

Vulvar inflammation and erosion require the treatment tlescrihed 

under Vulvo-vaginitis. Excision of the irritalde caruncles and 

gradual or forciljle dilatatiim of the vagina have in many cases given 

r»'iief. The mere division of a rigid or ijn]>crforatc hymen may be 

tfficietit to remove the obstacle, (iratlnal dilatation is made by the 

itrwluction of graduated rectal bougies, to be worn an hour or more 

iily. Forcible dilatation requires etherj and should be followed by 

gQHtiBued wearing of a Sims vaginal plug. Meantime the patient 



Figure 109. 




Sima gla&H vernal plug. 

tmains in bed until the divnlsed vaginal walls have healed. The 
should be removcfl only during urination, defecation, and the 
jivinij of the vaginal douche ; after healing it may be daily introduced 
^' tiK' jiatient in order tn retain the etfeets of the divulsion. In 
«iMinute ca^es divulsion will he inadr^ijiiate. It is sometimes neees- 
san U} incise deeply at several points or to make two ipn'te deep 
lateral incisions on either sith* near the posterior vulvar commissure, 
Tliesc* incisions should completely divide the underlying muscles and 
^nnr fascia; they may be closed by lines of union running at right 
^^g\vH to the directions in wliieh the incisions were made, or until 
Ming is established they may he kept open, as already described, 
"V moans of the vaginal [dug. 

Sims has advised coitus uiuler anjesthesia for severe cases. Large 
Q'ises of morpliinc» or local anesthesia by means of cocaine, would 
prhaps serve a better purpose. 

I HJldcbraod, of Koaig6^>«i^. Thomas and Mund^f Dlaensea of Women. 






I 



This chapter should be read in connection with Chapter X*, on i\w 
General Principles of Infrctinn and Infltinimation ofthe Pelvic Organ.s. 

Iiiflaniinati**!!^ liroadly di-fioccl hh the reaction which living tissue 
exhibits to morbid irritation, may include a wide variety of lesions. 
These lesionri, as related to the uterus, have been varioiif?ly and fjome- 
tiniej^ vaguely designated m ehrouic metritis, *subaeut€ metritis, siubin- 
flamniatory states, irritative states, and congestive 8tates, This defi- 
oition, however, is not intended to include neoplasms , although the 
divisi*in between these and inflammatory formations may at c?ertain 
jK*ints Ik? urbitniry. 

Anatomy and Physiology. The study of metritis is the study of 
the anatomy and ])hysioh»gy of the uterus as modifiefl by inflamma- 
tion* A review of such parts of tlie anatomy and physiology as will 
aid in a descripti(>n of these inflammatory processes will be useful. 

Tlie interior of the uterus is divider] into two cavities, the cavity of 
the corpus and the cavity of the cervix. The former is protected from 
injurious influences fri>m above by the two muscular constrictions which 
divide it from the FaUopian tubes; from lielow by a similar arrange- 
ment at tlie internal os. The cavity of the cervix is in a like manner 
pmteeted from inteetion from above l>v the internal os ; from below by 
the external os. 

Tlte I'teriiic Wall is made up of three layers : the mucous layer, 
ealletl the endometrium ; the miiseular layer, called the myometriu]]] ; 
and the ^H'ritotund h*yer, sometimes called the jx^rimetrium. 

The Emhmctrium is C4imp(>seil of lymphatics, bloodvessels, nerves* 
glands, and connective tissue, and in covered by a single layer of 
ciliated eoluniuar epitheliuuK This epithelium also lines the uterine 
glands and is cuntinued tlirnugli the Fallopian tubes. The same 
variety of epil helium, nnxlified, aLsii lines the cavity of tlie ccrvir, 
Piivement epithelium covers the external vaginal j^ortion of the 
cervix ; it tiikcs the imvement form at the external os. 

The ftlamh of fhr (}trpHH fieri are tubular, narrow, branching 
depressions, Tlvey dijj <Iown into an*l through the endometrium and 
penetrate to the muscuhiris. These tubular glands, ytenetrating 
everywhere througliout the cnd*imctrium, make up a veiy large jxirt 
of its volnnie. They all o\wn iuio the uterine cavity, sometimes two 
by a single nritice* 

The coq>orcal endometrium is bound firndy to tlie inner layer of 



P 




INFLAMMATION OF THE UTERUS. 



189 



the musciilaris by connective tit^sue which is continuous with that of 
the myometrium, 

Tk Liffitph Spacer nnd Ljpnph Vt^ji^d^ of the ut^Tut! ure ahundant 
in the endometrium, in the muscuhxr stmta, and in the ^eroft^i. They 
lie in die interglaiidnUir spaces, snrnnind the niu^nenhir bundles, com- 
municate with a fine laee-iike network in the uterine scRKSti, and tlien, 
^'ouverging, pi8s by large channels outward throu^li the Ijroad liga- 
leotg. See Figure 112. The uterua is richly supplied with nerves, 



FKiritF nil 



FlOUBE HI. 



(^'mA 



p^? 



^ii 



>^ 



Tlguix* 110.— Vertical suctlcin thToiitfh uterine mucous membrane : <*, coliimoBr epUhfUum; 

i^trnn*? KlandA: rt, connective OsityL* siirroytniliig glimtlh; vr. hkiodves^sela J tww*, subuiucoua 

!•«*»- Tti^ elamlii »resh.j\vu in lntth Um^itmUiml Jind imnpiVLn^c st^ftion, j*cini-diiipniromii!lc.^ 

Fiifurv llL— LiinKituiIinal sertlun of uptnir part of I'mltmu-lriyni, shnwlni^ yttsrine f^land^i ut 

b»f\imlinic of pr<?i;iutn<'/. Twit'f the nnUinil size. 

"Ifcrtiw cuvity^ vemi-diagr&Eiiniatic.* 



d, d, d, d. flisliil extremities of glaudH ; a, <i, n, 



mih spinal and sympathetic* The arteries and veins are described 
the chapter on myomata. 

Tlie minute anatomy of the cervix differ?^ from that nf the corpus 
latm in the following piitictdar^. Its mncfuis surface iias a [jeculiar 
W vitie appearance, as shown in Figure 1 1.3. The intra-t*ervieal mu- 
^*sii, like the corporeal, is Irnal with a sitigle layer of ciliated columnar 
ffHtlielial cells* These cells, nuKlified to tlie sliape of a cup, pass 
W'thotit cilia into the ccrvieal frlands, Tlu; epithelial cells are slKU^ter, 
^^\ tlic connective-tissue cells are closer together in the ct^rvical than 
^^ tilt* corjK>real mucosa. The ccrvic^d niuccKsa, more dense than the 
I Corporeal, in bound less firmly to the museularis by looser ermncctive 
Iti^ue; It d«x^ not {iartiei|>ate in meustruation. An important func- 
tion of the cervix is that of a sphincter to sejmrate the corpus uteri 

* Turner: from Aiii«*rlcftii Syulem nf (*yiiecology» « Ibid. 




Afbor ritm MrmtifemcQt of th 



» Xtlvt Polrirvr, In Powi's Trt'tttifc ou fJyncrolofry. 
* Mmuq. ASyalcimtf liynecoloBy. From rittyniif. 



INFLAMMATION OF THE UTERUS. 

ik dmdua and the nonrirthhii,^ «jf tho tMal>ryc». The eonoecti ve-tissii<' 
tvlh [jrmluce the celLs i»l" tlie doeidiia oi' pR'gniiiu'y ; tliis, with tlie 
[irti^n:ts8 of utero-gostution, iiiutiires» Ijivofimes over-ripe, degenerates^ 
and» btiiig oi* no further iise^ at tpriii is ("aj^t cvif. 

The iuo8t sigiiifieant factor in metritis in the eiKionictrimii. It 
pn?^iit< in the devehjpmcntiil and atrojiliin changes of puberty and 

I the iiU'n(Hianse, in the vascuhir ehuoges of the menstrual ebb and 
iSow, widely an<l eon,stantly varying stiites. InHanmuilion of the 
lltum^ may oceur ilnring infancy, before tfm endometrium has 
inutuml; during puberty, when it is niaturing ; <luring maturity, 
wlmiit htis rt^ached its full physiological j^igniHcanee ; during the 

I meuoiuiusie, when it is undei*going degeneration ; or durini^ senility, 
when in the physiological sense it has fotvver <li.saj>}>eared. The 

I ticcurrence of metritis under such (Fi verse couditions partly explains 
ihe wide and varialde range of its plienomena ami the ditlietdty of 
deMTiption, and parlly accounts fi>r the eunfusion of elassitication and 
nomenclature which runs through the literature. 



ClassificatioD. 

Tie geneml subject, classification of infection and inflammation, 
hfi> be^n discusst^l in Cha|iter X. The current classifications of 
m<»triti!? are numerous and faulty. 

The Btiolo^cal Claesiflcation is based njxm pi'edisposing causes, 
swh a* parturition or trarmvutism, ami upon the liaeterial causes. 
Tlii^ilijtii'idty in ideuti tying the causes and in differentiating betweeri 
the many causes in a given case detracts i'reui the value of the etio- 
\*y^u'i\l t'lassificiition us a elinic^d gniilc. 

A kicteriological classiti<nition may, under cfinditions of more 

[waft kaowltHlge, ultimately become a pmetical diagnostic, prog- 

Ip^lir, and tlieraiieutic guide. Already indications point strongly 

10 this direction. Unfm^tunately, sucli a scientific working guide 

">'>^l, except to a limited degree, be ilefcrred to the future. 

The Patholgrical Classification, .su-cidledj into catarrljal, snjipu- 
■^tivi"^ gnmular, and uleemtive metritis, is nither a designation of 
"'-''t^in phases of the inflammatory process than a classification. 

The Anatomical ClasBiflcation includes endometritis; coq>oreal, 
<^tvical, parenchymatous, and glandular metritis ; parametritis and 
I'^'nmctritis. If tlu'se varieties usually occurred as distinct eirenm- 
^-fiM lesions instead «*f complicating one amitlier, if eacli could be 
boH-n by its own f»eculiar symptom group, if nnlinarily one couhl 
^f Himc^idly s<.'panited ihnu the other, tlien the miatomical classifica- 
^'>ii woul d n ot be, as it i s, i m p racti cal a nd m i s 1 eac ling. En d t >me t ri t i s, 
"^•"♦"Xmniile, cannot huig continue without involvt^ment of the myo- 
'oetrium, and n\r rrrmL In eithtr form there will he congestion and 
'•^tiscfjticnt increased secret ion thrnugh the glands, and the glandular 
.^thiptures will also he involvetl. tJenend metritis iuchides tlie ]>eri- 
^iif^l c*iveriug of the uterus, 'l^liere are no sharp clinical or |Kitho' 

«il lines of demarcation between the anatomical divisions of 
fttfTine and neri-uterine infect imi. 




192 INFECTIONS, INFLAMMATIONS, AND ALLIED DmOBDEBS. 



To illustrate the hopelesBnesB of the attempt to claBsify y 
observe 'the following from an otherwise exodknt modem 
This work classifies metritis into (1^ acute inflammatory, (2) hemor^ 
rhagie, (3) catarrhal^ (4) chronic painful. In the first division the 
word inflammatory is tautolqeicai. Anv of the so-called varieties 
may be hemorrhagic^ catarriml^ or painfuL It is possible, llier^n^ 
to retain of this classification but two words — acute and chrooio. 
The following paragraphs will still furd^r show that any elabotmle 
attempt at dennite classification, even though diagrammatically 
attractive, is clinically impossible. 

Nomenolatiire. 

The nomenclature of the foregoing paragraphs, although not Hie 
outgrowth of adequate classification, is yet useful as a means of nanir- 
ing certain forms and phases of metjitis. Such words as gononiMMlii 
parenchymatous, and catarrhal are convenient for purposes of desora^ 
tion. The name endometritis, for example, will be used to desoribe 
not a distinct lesion independent of the rest of the uterus, but laHier 
an essential part of uterine infection. In this way we shall not lose 
sight of the clinical relations between the various forms and ph a ses 
of metritis. 




CHAPTER XIV- 

ACUTE METRITIS. 

H'hex infection roaches xhi^ iitoriis it usually attaeks fii^t the 
mmN>sa> It then mav t^xtentl to the itnuiiK'truKn aiitl [>eritoiiriHiL 
Metritis i:* therefore a com bi nation of eii*lotnetritis, niyonietritis, lunl 
prinietritis. The .Ktonu-centre of the infection is tlie endometrium 
tad its ('i*!*entbil factor endometritis. It is im|>ossible to preserve tlie 
mtononiy of either one of these three factors of metritis, or to ilniw 
MviitB lines of division Ix^tweeii tliem. The terms endotnetritis, 
myometritis, and perimetritis will he used not to describe sepantte 
and distinct lesions, but rather to identity the morbid changt*s that 
my tiocur in definite? parts of an infected uterus. 

Etiology. 

The Ptiology has l>eeii outlined in the chapter on the Geneml Prin- 
^pit' iif Pelvic InHammations. 

The Predisposmg Causes include those influences that pi-^xiuee 
"teriiie congestion, sur*li as menstruation, suppression of the menses, 
*ii?<pl.iC€raentB, constriction of the uterine eanal and eonseijnent 
*>Mniction to tlie fn*e outflov^^ of secretions and menstrual fluid, 
t* venerv, menstrual cong^estion, taking cold durintj^ men- 
[^ hot and euld douchini:; during menstruation, the s^j-ctdiwl 
*iiiithe^s — amon^ them Uthiemia, eholiemia, ana'^mia* gout, and rhen- 
DJ^tism, the abuse of jM^ssiirie^ ; l)at, above all, jKirtnritioii, abortions, 
and tramnatisms. These conditions ainl others like them were for- 
nit'rlvstijvposed to bt* t!je essential causes. Now it is known that they 
'^^ntribute to the pnMhiction of metritis as predisjiosjjig causes when 
Hipplemented by some other influenee. This iiifinen<'e is the exciting 
<^iis<* It is usually priKinced from without^ seldom procbieed within. 

Exciting' Causes. Among the exciting causes numerous bacteria 
*^l tlieir pro<luc:t.s predominate. Their signiticauee has been par- 
I'alty discussed in the Geneml Principles of Inflammation, Chapter 
•Sand in the Etif»logy of Valvo-viiginitis. They usually invade 
^wearily of the cervix uteri fnmi belnw, intreneh tliemselves in the 
trvi^al glands, and theocr may l)e distributed dircftly by roiiti unity 
^' siirfiice to the corj>oreal enthnnetriuni, the Fall<»pian tuln^'^, ovaries, 
^ p«lvie peritoneora ; or they may pass dirt^^tly by tlie lymphatic or 
Veooiis cirfMilation from the cervix, vagina, rectum, or blathler to the 
"i^riog and j>eritoneum. From these organs they may des*'eud by 
*Otinuitv of the mucosa through tlie tubes to the endr»metrium. 

The cavities of the cervix and corpus uteri, es|KTiaUy the latter, 
*^ normally fi'ce from pathogmrie bacteria. Biictcria may, how- 
ls 103 




194 INFECTIONS, INFLAMMATIONS, AND ALLIED DISOBDEBS, 

ever, easily find access, and, once there, will be active or inactive 
according to the prej^ence or absence of predisposing causes ; that is, 
ac<*onling to the degrt^e of resistance which the tissues exhibit to their 
pres€»noe. The corjM)real and cervical mucosa, penetrated throughout 
with a great abundance of tubular glands, are especially adapted to 
incubate and distribute Iwcteria. This accounts for the tendency of 
metric and perimetric infei*tion to become chronic. 

The gonoc(x;ous of Neisser, since it has great power to penetrate 
the glandular elements and to intrench itself therein, is one of the 
most friK|uent and destructive causes of metritis. The staphylococci 
of suppunition are conmionly found also in suppurative enaometritis. 
The streptococcus pyogenes, generally admitted to be the germ of 
erysijwlas, is very infectious and very fatal. A streptococcus infec- 
tion does not usually spread by continuity of the mucosa, but may 
rapidly follow the lymphatics and veins to the muscular and peri- 
toneal layers, Fall()j)ian tubes, parametria, and ovaries. It is often 
the infectious germ in the graver forms of puerperal and traumatic 
pelvic inflammation. Its great danger lies in tlie fact that it does not 
strongly attract leucocytes, and therefore does not excite defensive 
action. The diphtheritic and tubercular bacilli, the bacilli coli com- 
munis, and other bacteria may also be the exciting causes of metritis. 
The infcyction is often intnKluwd from want of cleanliness during the 
pueriwral stiite, from inii)erfect asepsis in parturition, in treatment, 
or in surgiail operations. Direct infection through coition is very 
common. 

During the thri*e or four days after parturition and just before 
menstruation the physiological congestion of the uterus renders it 
most susceptible to infection. The cervical portion at all times is apt 
to be the liabitat of j)atho^enio germs; such germs are often intro- 
duced by the physi(Man\s linger, or upon sej)tic instruments, of which 
the unclean uterine sound is a striking example. The infectious 
material may hv inactive, unless the soil is ])rej%ired to ret^eive and 
develop it ; but when the traumatisms of abortion and parturition, 
of accident an<l of surgery, have oikmuhI wide the door for bacterial 
invasion, infection will be the natural result. 

Pathologry. 

The lymph channels bring into direct and close communication 
with one another the endometrium, myometrium, parametric cellular 
tissue. Fallopian tubes, peritonc^um, :ind ovaries. The uterine mucosa 
now beconu^s botli the starting-point and the distributing-point of the 
infection. The infected endometrium may readily and abundantly 
pour its poisonous products through the lym|)h stream, with resultant 
lymphangitis, myometritis, cellulitis, salpingitis, peritonitis, and ova- 
ritis. Very significant is the fact that the lymph sjiaces have no 
walls exce|)t the cellular tissue around them. This exposure of the 
cellular tissue may explain th<» susceptibility to infection of the 
uterine, ])ara-uterine, and peri-uterine connective tissue. Infection 



ACUTE METRITIS, 



195 



may aki be civrrierl by t\w vt'ins to all ptirts of the uterus and its 
^ummndings in the same maimer as by the lyni|>li ehiiniiels. 

The diseiise iniiy spread from the eiidonietiium not only by tlie 
vessels, but also by cootimiity of mticosa to the FaUopian tuben, 
peritoneum, and ovaries, or may dencend from these organs to the 
emi(»metrium. 

Tbe .<wift and terrible march (*f the traumatic and piierjwral infee- 
lion^ to a (les t ru ct i ve o r eve ii fa ta 1 res u 1 1 is | >a r t i a I ly e x | > 1 a i n ed by 
thpchif*e physiological and anatomieal relations of the lympli stream 
to th^ endometrium and uterine jxTitoneum, See Figure 112. The 
irriuintg, usually strcpt(X'm>ej or otlter pus coeei and tlieir produets, 
ait* taken up by the lymphatics ur veins and widely distributed. The 
vt*:?e^l!4 may serve ordy as carriers of the irritant, or it may infect 
tbi'in and produce lymphangitis, lymphadi uitis, or j)ldehitis. The 
inibmmation may he so intense as to destroy the vessels, or resolu- 
tion may bring about eomplete recovery. In Hani mat ion in the lym- 
ftticsl>^ veins may result in lymph thrombosis or venous thrombosis, 
sis nature's way of limiting the spread of the inftn'tiou. When 
Ttoivery takes place the lymph or bbxMl stream is re-established 
annmd the obstructed j>arts of these vessels l>y collateral eireulation. 
Ffrilymphangitis and ]ieri phlebitis may occur iu the cellular tissue 
»Pt>uml tlie thrombosed lymphatics and veins* This process when it 
take* place in the parametria is pelvic cellulitis, a disease almost for- 
p>ttta in these day of tubal and t»viiritin pitliology. iSee Pelvic 
t'elluHtis, 

The anatomieal changes may be summarized as follows : 

Infiltration of the interglandalar and intermuscular connective 
fiii-n*:' with small round cells. 

Eng<)rgenient of the lymph sfmces, lymph vessels, and blood- 

Extravasation of blncKl in limited spaces. 

'*^wcl!ing of the entire orpin. 

•*>H'elliTig and redness of the inflamed endometrium. 

E-TfVNi^ive secri'tion of tlie uterine glands. 

The niilder eases, chiefly ehamcterized by engnrgement, increased 
^creriinu and |)ain, may subside in a few days, and the uterus niay 
wther U-come normal or hipse into a state of ehronie metritis. In 
^y more sevei-e forms ttie disease may run a destnietive course to 
tJie death or {)crmaut'nt ilisability of the patient, Its extent will 
^n^ with the virulence of the exciting cause and the reststimce of 
"'t' inflamed structures* Abscesses rarely develop in the myo- 
""'tnnui except in connection with myomata. Inflammation of the 
"">c^>?« may be catarrhal, sujijiurative, uh-i-rative, hemorrhagic, or all 

Agmve form of acute din^^asc has lieen described under the name 
♦iipfclheritic or dissecting metritis.* The infcetiim is usually puer- 

CbI, but is sometimes a seipiel of non-puer)Hrnd diphtheria. It may 
a»«ociated with gangrene of the vulva, and may w'cur after scarlet 



'^aniiftjw. riifscctlng Mctrtttii, New Vurk M^'tfknl JaurnaiL 1882, vol. ixxvi. p. 537: 




196 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

fever, typhoid fever, or cholera. In puerperal cases, says Garrigues, 
the diphtheritic infiltration may extend from the endometrium to the 
neighborhood of the peritoneum^ cutting off a large part of the mus- 
cular layer, which after weeks or months will be expelled as a pear- 
shaped body. Dissecting metritis may be connected with similar 
disease of the vulva and vagina. 

The ultimate changes in the uterine glands^ uterine connective 
tissue and muscularis, and in the peritoneal covering of the uterus, 
are discussed elsewhere. See Chronic Endometritis, Myometritis, 
and Peritonitis. 

Symptomatologry. 

The symptoms of acute metritis dejKMid upcm the extent and 

f;ravity of the diseiise, and therefore may varj- within wide limits 
rom those of a mild infection to those of the greatest virulence. 
An apparently mild metritis may, however, result in the most de- 
structive pelvic infection with all the results of grave peritonitis. 
The onset is usually marked by a chill, followed by variable high 
temperature and pulse ; the imin is often intense. Inhere is usually 
tenesmus of the rectum and bladder. Menstruation, if present, may 
suddenly cease, or the flow may increase. The menstrual fluid is 
mixed with the secretions of the inflamed glands. The congestion 
often passes off as menorrhagia comes on. This is nature^s way of 
relieving the engorged vessels. The discharge, especially in the 
gonorrhoeal form, may rapidly become purulent. When the inflamed 
uterus contracts to expel its abundant secretions the agony is that 
of exaggerated labor-])ains. Bearing-down and heat in the pelvis 
are often excessive. Wlien the disease has extended to the Fallo- 
pian tubes, ])elvic connective tissue, ovaries, and especially when 
it invades the ix'riton(Mim, there will often be grave ptomaine 
poisoning, with anxious facies, increiised vomiting, and tympanites. 
Unless such infection is cut short by surgical measures the result 
may be rapidly fatal. The mode of death is usually by ptomaine 
poisoning. See Perilymphangitis and Periphlebitis. 

Diagrnosis and Profirnosis. 

The diagnosis is based upon the changes just described. Digital 
touch usually causes great pain, and may require anaesthesia. The 
corpus uteri is large and soft. The cervix is swollen, the os usually 
patulous and often surrounded by erosion. The vagina is hot, and 
the arteries strongly ])ulsatinjr. The urgent necessity is to watch for 
tubal and iw^itoneal extension. See Diagnosis of Sidpingitis and 
Pelvic Peritontis. The mere recognition of acute metritis is wholly 
inadecinate. Unless the state of the uterine appendages and para- 
metria is accurately made out, theraj>eutic indications of the greatest 
urgency may be overlooked ; one should therefore in case of doubt 
insist upon exjunintition under ether; as the ease progresses reixnited 
examinations may he necessary. 

The prognosis of acute metritis is always disquieting, often grave. 
The disease may terminate in nipid resolution or in chronic metritis. 



ACUTE METRITIS. 197 

EsUiUidoii to tlie peri toiieii til involves immediate danger to life or 
ri'moU' danger to health. Tlie relative vinilfoee of ilitfL'i'eiit nii- 
i'n>be» liaii been discussed in tlie panignipliH on Etiology. Puer|)end 
metritis its most liable to spreiiil with the lym|)li stream, and is, 
t^jumlly when ibie tx» the j^tri'ptfM^iX'Ciis pyogenes, the gmve.st furm ; 
tliis form even when early re<rogiiized and promptly treated by mdi- 
lal surgery is apt to result fatally. 

Treatment. 

The treatmeat is prophyluctie, abortive, palliative, expectant, and 

.surgical. 

Prophylaxis includes the avoidance or removal of the predispos- 
in^Efimi exei ting causes. Reference to the etiology will suggest the 
ap(iro|iriate indications. Susceptibility is greater during the puer- 

E'ral state, parturition, abortion, the puerperinm, and menstruation, 
xtra care, therefore, at such times is essential. Ks|>ecially forbid 
mukf exjM»snii:' of all kinds. Avoid the bacterial exciting causes by 
i***p«^ Aseptic midwifery is imperative. The minor gynecological 
aiKj obstetric examimitions and manipulations without asejLsis are 
Juiiircrous. After an aseptic curettiige, trachelorrhaphy, perineor- 
riuipliy, or any otlier o{>e ration on the vaginal side of tlic jx^lvic floor, 
• •ne large or two small ice-bags over the liypogastrium. The 
Mir^t be in contiict with the skin. Its utility is destroyed by the 
intermediate towel or napkin. In order to take up any water which 
n»i):ht condense on the surface of the bag and run over the jiatient, 
jurnmnd the sides and top of the bag with absorbent cotton. To 
bold ilie ice in platx' when the ptitient is on the side, lot it be secured 
by a \i-ide alxlominal Uindage. Above all, use every means to pre- 
vent the .spread of a vulvo-vaginitis^ esj>eciiilly if it be gonorrhceal, 
^> rhe uterus. See Treatment of Vulvo-vaginitis. 

The Abortive Treatment is ap|>!ieable oidy in the onset, and in- 

cWeii such antipldogistic measiin^s as may cut short the attack during 

tln^jjtage of congestitui. If the metritis lie assfxnated with raenstrua- 

H^tn or with the suppression of that function, or witls repeated chills, 

''rH-itii great prostration, use the hot- water Img in place of the ice. 

The old flaxseed poultice is unclean, ineffective, and unless renewed 

iJ'try often does not hold the heat. A large blister over the hypogas- 

vm\ may sul>stitute or supplement the ice. Leeches are of great 

•Itif if prttniptly and thoroughly applied. Use five or more over 

<-h inguinal region and five to tfie perineum — two or three are nse- 

s*. A mrmt essential thing is early and active catharsis by a mer- 

ftrial purge, two grains of ealomel or five of blue mass, re|K*ated if 

^•c^sary, and followe^l by Rochelle salt or some other sidine. The 

llniimatration of cjuinine in fidl doses, and of opium, has been followed 

jygood results, but their value is qucstional>le. The greatest nu'dieal 

(Plinnce is in the mcreuria! anrl saline purge, leeclies, and ice. Tlie dis- 

) once estaldi shed luiist run its course. The treatment is palliative 

Bpectant in tlie uiildi'r citses, but may have to be energetic in the 

j virulent* In caae4^ of metritis following a plastic gynecological 




198 INFECTIONS, rNFLAMyfATIONS, AND ALLIED DISORDERS, 



aj>eratiun the sutures sfioiild be iniau'diately removed and the deniicJed 
surfaces eatiterized with pure carholic a<'id. 

The Palliative Treatment iiichides rest in IxhI, anodynes, es-i^ecially 
the opiatert, tlie hut (»r warm wattM' vaj^^inal dnuehe~the liot* water bug, 
ami the hot liip-|mek. Whin the acute «tage is subsiding there may 
be use for the i^lyeeriii nm\ wtKil vaginal tarupuuade, CJjapter IV. 
Latefj iodirje euunter-irntatiuu may be applied to the hypt>ga.strium 
and vaginal fornix. Deep searifieation thruugli the speeulnni i*elievefi 
the engorged vesi?els and may abort or palliate the attaek. L#et the 
cervix he piereed mther fn^ely at several points by means of a fine- 
pointed bistonry or Buttles* sjiear-pointed hinee. The oozing may l>c 
prokniged by tepitl water or stoj>pi'd l>y the hot-water dunehe, or, in 
a very viLsenhir ease, by the tampon. Should pain l>c intolerable, use 
a ^npnository of aqueous extract of opium, one grain, and extract of 
bellacionna, one-sixth of a grain. 

Expectant Treatment. The milder self-limited infections which 
have no grave systemic or local nninifestations may be dismisse<l with 
j>alliative or expectant treat nieot. In grave infections it may be ex* 
tremely difficult or impossible to t^hoose wisely between the danger nf 
the disease ami the extra peril of surgical interference ; hence, even in 
fieri ons cases, the expectant course may liave to be considertKl. 

Siirg'ical Treatment. When the systemic condition is grave and 
the nervous system indicates prcifiiuud ptomaine poisoning, the disea.^ 
under any treatment will in a large proportion of erases terminate 
fatally. A number of practical and momentous questions at once 
arise ; 

Question 1. Is there simple absorption into the circulation from 
some focus of decomposition in the uterus? Is the toxicmia due to tlie 
products of a decomposing foreign lirHly, such as a Ijlood-clr^t^ a frag- 
ment of placentn, retnined membrauej or pent-up lochia ? In other 
words, is it due to the absorbed pnjd nets of putrefactive bacteria? To 
put tlie question in a more concise form, Is it sapnrmia? If the 
answer be in the affirmative, the indication is clear and imperative to 
remove the putrefying mass, wash out the cndonietrium, and establish 
drainage*. Tlie ofrending mass may l>e removed with the finger, the 
placental forceps, or, if m-eessary, with the dull curette, Sharp curet- 
tage, powerful cauterization, and all other severe surgical measures in 
this coimection are unnecessiiry, dangerous, and fbrlndden. 

Question 2. Is the nterine mucosa tlie seat of an infection^ and as 
such is it the distributing |)oint of bacteria which may spread and infect 
the titerine af>pendanges and peritoneum? If the bacterial invasion 
has ext(^nded beyond the uterus, to what extent are the nterine 
appendages and perituneum invaded? Is the systemic disturbance 
such as to suggest that the bacteria and their ] products are very liable 
to enter the general circulation in <[Uantities sufficient to give rise to 
pronounced septicaemia ? 

Question *i Have pus emboli l*een carried through the circula- 
tion from o!ie focus nf suppuration to set up other foci in ditferent 
parts of the body, and thereby produce metastatic abscesses? To put 
the question in another form, Is thert* or is there likely to be pyemia f 



ACUTE METRlTm. 



199 



If the answers to the secomi and third quorics are in the affirina- 
tivii^ it becomes essential to decide whether the itifcctiun lias spread wo 
Ctrkpnd the uterus as to make tlie metritis relatively inrtigiiiticant. 
Cli-arly, if there are metastatic ubscenses, or if even infeetiun has 
spr^^iiii to rhe other pjlvic organs, rturgieal treatment of tlie intra- 
nt* rint' infect ion alone won hi he useless and mi^ht add to the daii^^r. 
Atxiominal or vaginal section iiiitl the dminanr^ of the abscesses, or 
even the removal of the uterus and its aj>peiidages, would tlu^n have 
to be CO aside red. 

The mihler cases, as already state<l, may be safely left to palliative 
smicxpwtant treatment. Tfie graver inf*H'tions in) fortunately have 
10 the majority of cases passed beyond tht* rang*; tff intra-uteriue thera- 
jieutics before the question of o|>«!nitive interferenei' is forced upon the 
surgeon. We may, however, be eoneerneJ with the question, What 
surjfical measures, if any, are justifiable in tlie effort to prevent the 
further spread of dangerous acute uterine infection which is stilt nearly 
or quite confined to the uterus? 

Thr method of dihitation, cin^^^ttage, and drainage of the cndoriie- 
triiim li:ks now to he considered. In tliis cousidc ration let ns not lose 
^ghtof the purpose of these procedures : it is to cut short the uterine 
inffction and to prevent its extension ; or, if already in a degree 
extended, to limit its fon^e by withdniwing the toxic supply. Partial, 
itiefficient curettage, which opens up and exposes fresh lyinpbatics and 
veins, but do+?8 not remove all the infeetc<l mun>sji, will prepare the 
wny tor further infection, which may be more viruh'nt and more 
sweeping than the first ; as tersely stated b\' De Lee, such a procedure 
is like raking over a patch of lawn after sciitteriug seed {>ver it— a 
vpritable insemination. It is evideutj therefon*, that cnrettage, if 
imljcate<l at all, shrudd be thorough ; should, indeed, stop at nothing 
fthurlof the removal of the entire infei-ted inticosa. The sharp curette, 
whicli ha"^ genendly been consi<hn*ed a muvv daug^Tons instrument 
than thf dull one, is then less dangerous. The o|M'rations reported by 
Prviir, Krug, an<l others, intleed prove that the sharp curette in cans 
fill Imnds is much less dangerous than has Ijeen supposed. The 
tlioroiigh application of it in selected cases has, ac*conbng to relial)le 
^•port, l»een followed by prompt tlecrcase in the fitomaVne poisoning 
^^tl in t!ie other grave symptoms. 1lie oppouerjts itf the openition 
'W'hre, not without reason, however, that most of the recoveries 
^ouhl have occurred withrnit it, anil that many of the failures have 
wciirrcd in c^juseipience of it. 

If the infcK^ted endometrium has Iwoome soft, f*[K)ngy, friable, and 

meemted, and if it is decided that its thorongli removal will lessen 
TO danger of the extensicui of the infection, the steps of the o[>em- 
*ifm will be as follows : 

h Aniesthesia, 

1 Preparation of the vagina and external genitalia as directed for 
Door ope nit ions in Chapter IL 

•1 Dilatation of the uterus, unless it is already sufficiently opco. 

4, Removal *^>f the infectiHl endometrium by means of the sharp 

ette ; see Curettage, Cha))ter V. 




200 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

5. Tliorough irrigation of the endometrium with hot sterilized 
water. 

6. Thorough mopping out of the endometrium with cotton wound 
on dressing-forceps, and dipped in a saturated solution of iodine crys- 
tals with pure carbolic acia. 

7. Placing of an antiseptic dressing over the vulva. 

Some o|K?rators omit the iodine and carbolic-acid applications and 
rely upon the thoroughness of the curettage to remove all infectious 
matter. An advantage, however, in the use of this powerful disin- 
fectant lies in the fact that it insures thorough disinfection of any 
infected shreds which may have escaped the curette, and that by its 
cauterizing effect it so shuts the mouths of the freshly opened lymph- 
vessels and bloodvessels that further absorption througn them'is less 
likely to occur. 

It is the custom of many excellent operators to tampon the endo- 
metrium lightly with a continuous strip of antiseptic gauze^ and to 
fill the vagina with another strip somewhat wider ; after twenty-four 
hours they remove the gauze, repeat the intra-uterine irrigation, and 
introduce fresh gauze. Antesthesia is now not usually required. 
Before the removal of the gauze it is well to make a thorough intra- 
uterine application of creolin or of a 25 per cent, solution of ichthyo- 
late of ammonium in glycerin. It is a mistake to saturate the gauze 
with such medicinal substances, because they interfere with its chief 
function — caj)illary drainage. Iodoform and sublimated gauze have 
caused dangerous poisoning, and are therefore not approved. If the 
grave symptoms have subsided, tlie gauze may be removed at the end 
of twenty-four hours and need not be renewed. In very infectious 
cases some operators renew the gauze and irrigate with dioxide of 
hydrogen daily until the uterine secretions become normal. See 
Treatment of Chronic Kndoniotritis, Chapter XVII., for a further 
discussion of intni-uterino curettage and drainage. 

The ojx^ration given above is less dangcrt)us and more rational than 
th(» meddlesome half-way measures of intra-uterine medication and 
irrigation of the undilated septic uterus. The judicious selection of 
ceases is manifestly a matter of gn^it difficulty. If proper selection 
can b(» made, the oj)cration in careful hands may be jxjrmissible and 
useful. 

In puerperal infections, especially in streptococcus infections, the 
toxins are apt to be specially deficient in their power to attract leuco- 
cytes — that is, to build up a limiting wall around the infected centre 
and thereby to protect the general system against invasion. For this 
reason the puerperal infections, especially if of the streptococcus 
variety, arc said to offer a relatively strong indication for early inter- 
ference. But the strepto(»occus germ may reach the uterus in an 
hour; in two or three hours more it may have ])assed far beyond the 
uterus, where the curette cannot reach, much less remove it. 

Future bacteriological researches may open the way for an etio- 
logicid classification that will furnish a siifc^ and definite guide to 
the therapeutic indications. AVork in this direction thus far, how- 
ever, gives little promise of immediate practical results. In this 



ACUTE METRITIS. 



201 



(vmnection we may add that scrum therapy i%* uodevehii)od, and 
liierefore, in a practical seiisci is not yet very |)ertineui to tlie .siibjeet. 

Die writpr's j>t»rsoiial conviction on the value of dilatation, euret- 
tigp, and drainage of the endometrium in acute infet^tion is that the 
mcasiiiv shouhl In? limited in its ajjplieation. [jct no man be hired to 
\}\f prrforniaiice of tiits dangerous opt/ration in an acute ca?5C because 
of the ea-^% safety, aud etHcacy t>f tlic Kime proccilurc in cli runic eniJo- 
riHitntk The only cases in wliich it shtadd be per for rued ure those 
wliidi will otherwise result in thm^eroos spreading of tlie infection. 

Clearly curettage is ccjutraitidieatcil in the numerous and gmve 
i:H>i in which the* infection has passed to the jKiranietria, not from 
tliH endoiiiotrintn, but by the lymph vessels or blcRKl vessels. 

All admit the practical ditficnlty, not to say impossibility, of selec- 
tion ni an t<j limit the operation to those inleet ions which arc really 
iktigeroiis, and still confined to the uterus. It is, mortHJver, a prac- 
tical qiiestitm whetlier the course of grave puerperal, gonorrhteal, nr 
ininmatic infec^tion is often arrested by tlic procedure. At the same 
tim»* finv will deny that the op^nitioii has repeatedly given rise to 
tlit^l msidtri. On the <>thcr hand, ex|)ectauey and palliatiuu will 
ofitij he rewarded by the subsidence i>f grave symptoms aud final 
recovery. One c^mnot Ujny strongly urge iu all gmve and doubtful 
«ww an examiuation, or, if necessary, rejieated examinations under 
Anesthesia ; s<:*e Diagnosis and Prognosis, 

There can be for a surgeon no greater cause of regret than the fact 
tbi he has exhaustetl the resisting forc<\s of his )iatietit by a danger- 
"u,^ half-way measure which itself may have eontriljuted to the neees- 
f^itvfora more radical operation, and that while with the promise of 
^•K*h a measure he has b^-en lulling himself into a sense of false 
wourity the infection has gained irresistil)Ie fijree. If urg*:'nt indica- 
tions, arise the best hope of recovery may be in abdominal or vaginal 
^H^tiuii and drainage, or the removal of the intwtt^l uterus together 
With its appendages Th*'se operations, if indic-atecl at all, are made 
ow^sary by the rapid spread of the infective process and therefoi'*? 
i)<*t\)nie at once im|M'rative. Until the necessity for such exti^?me 
niedsures becomes apparent, there is at least virtue iu the attitude 
^'f watchful expectancy. See Vaginal luciriiou and Drainage, in 
Chapter XXIIi: 



CHAPTER XV. 

CHRONIC METRITIS. 

Chronic metritis is usually understood to mean inflammation of 
the uterine muscularis, a condition more accurately described by the 
word myometritis. The former term is here taken in its broader 
literal sense, and is used to designate chronic inflammation of the 
uterus in general, without special reference to any part. Chronic 
metritis includes chronic endometritis, myometritis, and perimetritis. 
Uterine inflammation, acute or chronic, generally starts in the mucosa. 
The various parts of the uterus — /. r., the endometrium, myometrium, 
perimetrium, corpus, and cervix — are never involved in sharply-cut 
areiis of disease, although any one of them may be the specially 
affected part of the diseased organ. In this respect chronic and 
acute infection are alike. The endometrium, however, often furnishes 
the groundwork for the pathology, diagnosis, prognosis, and treat- 
ment. In some cases the infection is nearly or wholly confined to the 
endometrium. 

Infe<*ii()n of the uterus as observ-ed by the clinician, except acute 
gonorrhccal and puerperal metritis, is generally chronic. 

The striking phenomena of acute metritis are the active infective 
and inflammatorv [>r()cesses. The term chronic metritis stands not so 
much for definite pr<x;esses as for certain chronic changes, more or 
less f)ermanent, in the quantity and quality of the glandular elements^ 
muscularis, bloodvessels, lymphatics, and connective tissue. These 
changes are usually hyjKTpla.stie, hypertrophic, or atrophic. The 
nature of the process or processes back of these states has been the 
subject of a long and unsatisfactory discussion. The causal element 
has been variously designated as infective, inflammatory, irritative, 
subinflammatory, and congestive. There is [)ropriety in calling the 
condition inflammation, because the essential element, infiltration of 
round cells, is generally present ; their migration occurs, if at all, 
more slowly than in acute inflammation. The differences between 
acute and clironic inflammation are larg(»ly those of degree. 

The Causes are largely identical with those of acute metritis : 
anajmia, gout, rheumatism, lithaMuia, choleemia, in many cases espe- 
cially underlie and perpetuate the disease. The infectious element 
may reach the endometrium from the peritoneal cavity through the 
Fallopian tubes ; usually, however, it is transmitted directly through 
the vagina. Ununited lacerati<ms of the (H»rvix may cause and 
aggravate the disorder. Utero-gestation may be associated with 
inflammation so plastic as to make the strongest adhesions between 
the placentia and the endometrium. Clironic inflammation always 

202 



CHRONIC METRITIS, 203 

presappoees two conditions, a minimum of defence and a maximum 
of repair. See Chapter X. 

The Patholofiry has many features in common with that of acute 
metritis, and, like it, may involve all the structures of the uterus : 1. 
The epithelial and gland elements. 2. The lymph channels. 3. The 
connective tissue. 4. The bloodvessels. 6. The muscle cells. 6. 
The nerves. The chronic changes in these various parts may be the 
ontcome of acute processes already described under acute metritis ; or 
there may have been no clearly marked acute stage — /. e., the disease, 
It lea£t apparently, may have been chronic or subacute from the 
beginning. To avoid repetition the student is referred to the Etiology 
and Pathology of Acute Metritis. 

The subject of chronic inflammation of the uterus will be con- 
tinned on the following pages under the headings Chronic Endocer- 
vidtis, Chronic Endometritis, and Chronic Myometritis. Perimetritis, 
« infection of the peritoneal covering of the uterus, will be described 
onder Peritonitis. 



CHAPTER XVI. 

CHRONIC METRITIS (Continued). 

Chronic Enik)cerviciti8. 

In studying tliis subject the reader should constantly have in 
mind the jphysiologicail and pathological unity of the reproductive 
organs. Infection is seldom confined to a single part of the 
uterus ; on the contrary, it usually extends to other parts and com- 
monly spreads to adjacent organs. We are considering nothing 
less than the whole subject of metritis, but with special reference to 
the cervical mucosa. 

The single layer of columnar epithelium, the underlying connective 
tissue, the lymph spaces, the lymphatics, the veins, the arteries, and 
the nerves which make up the intra-cervical mucosa, are subject to 
certain chronic changes that pass under the name chronic endo- 
eervicitis. Similar disease of the corporeal mucosa is called chronic 
endometritis. * 

Etiologry and Pathologry. 

Endocervic^itis, often called cervical endometritis, is inflammation 
of the cerviciii mucosa. The prtnlisposing systemic and local causes 
and the l>acterial exciting causes have been pointed out in Chapter X. 

The disease is in some respects like, in others unlike, corporeal 
endometritis. It often occurs by extension from vulvo- vaginitis. It 
nirely descHMids from the corpus. It may have been carried as a 
primary infection, without intermediate infection of the vulva or 
vagina, direct to the corvic^d mucosa. As in the corpus uteri, it may 
involve not only the nnuHJsa, but also the submucosa and muscularis. 

It is siiid that the normal endometrium is free from ,|)athogenic 
bacteria, but that the cervical cavity usually contains them. This 
would explain the greater tendency of the cervix at all times, espe- 
cially upon sight tnuiniatisms, to bec(mie inflamed. The cervical 
glands, well adapted to receive, retain, and distribute infection, easily 
become a culture-ground for bacteria. Once intrenched in the gland- 
crypts, the germs may remain attennateil and relatively quiescent for 
hmg perimls, and then may develop new cultures and spread. 

The ])athologi('al sequence of a seemingly insignificant infection of 
the cervix uteri, especially if acute, may be either by continuity of 
surface to endometritis, salpingitis, ])eritonitis, and ovaritis; or by the 
pelvic lymphatics and veins to pelvic lymphangitis, phlebitis, j)eri- 
tonitis, and ovaritis: thus acute infectitm is seldom confined to the 

1 EudocorvicitiN is a word of faulty di-rivntion, but justified by convenience and usage. 
204 



CHRONIC ENDOVER VIVITIS. 



205 



cervix, but is apt tu involve tlio other pirtn c>f the litems. The cor- 
piL^ uteri nml ailjacent organs aiv likely to be involved if the chronic 
cenidiis husj followe<l an acute irirtaeTUDtition ; le^s likely if it was 
I'linmic from the hegioniog. 

iihmtlular enlargement and interstitial hypertrophy are the chief 
[tttliultjj^^ioal factors. In this resjieet endoeervicitis offers a close 
tnalogy to corporeal eiidonietritis* The swollen mucosa, especially 
if tk cervix be lacerated, takes the direction of least resistance, and 
my pmt r u * le 1 1 1 ro i igh t he os ex te rn u n i . T 1 1 e t h i e k e n c d e ve rted ni n c< \ 1 1 s 
membrane may give to the tni^rvix the appearance of grwit enlarge- 
ment, a condition not unlike that of the prolapsed hemorrhoitlal anus. 
The cervix is sometimes so eroded as to suggest the name of coek's- 
«jnih prjunlations ; this granular erosion on the external cervix gives 
it the appearance of ulceration, and in the older literature it is wrongly 
^cal!(tl. Such erosion is rare, except on the lacerated cervix : tlie 
mtioosa, however, is only diseased, not, as in u lee ration, destroyed. 
Non-jipecific ulceration of the cervix is nire, almost unknown* See 
OwptcT on Lacerations of the Cervix Uteri. 

The engorged open cervical glands in great numbers pour out their 
sttretiori up>n the vulvo- vaginal surface. The discharge, unlike that 
f>f emlonietritisj is thick, ropy, viseidj abundant, and gelatinous. It 
niay only with difficnlty be dislodgtMl from its anchorage iii the cer- 
^ial glands. In nullipara the internal and external um are some- 
l^me^ so constricted as to catise retention of the cervical secretions 
^ttd consequent dilatation of the cervical cavitv. See Figures 118, 
U9,and 120. 

Glandular enlargement occurs in two forms, the polypoid and the 
rstic 
The Polypoid Enlargement produces diminutive mucous polypi, 
nailer, of iliffereut origin, and softer than fibrous polypi. The enlarged 
Jflaiisb protrude upiu the surface ; their mouths Ix-come obliterated; 
tlie glandular tissue is oxlematous from retained secretions ; its base 
*^mtitricts ; and the little mass becomes polypoid* See Polypoid 
JEndu metritis, so called, Chapter XXVII. These |)olypoid growths 
ai^ essentially adenomata. They correspond to the adenoids of nasal 
pathology. See Adenoma Uteri^ Chapter XXVIII* 

The Cystic Form of Glandular Enlarg-ement, called cystic 
♦•}!;e»eration torming follicidar cysts, is caused by the <x.'<'lusion of 
■l" <4>cniiigs of the glaridular caujits hy adhesive inflammation. The 
^imls then distended with retained secretions become retention cyst**. 
T^cse c)^ts often form both inside and rmtside of the lacerated cervix ; 
^Moni in the nulIi{>iirous cervix. The distendcHl glands are of globular 
^l^peand vary frtmi the size of a millet- seed to that of a pea. Tliey 
^•^ quite tense, and to the touch give the sensation of shot under the 
^i'K Their contents are a viscid, white~of-egg-like se*"retion, some- 
'itnr^ iiuici^puH, sometimes a dark cheesy matter. These cysts, 
"^-Ciirding to Emmet, are of\en the cause of great reflex nervous dis- 
[t'Jrbaftee, See chapter on Laceration fif the Cervix for a fuller dis- 
[cu>v^ion of cystic degt-neration and for cervical endometritis due to 
Ikc^ratioii of the cervix. 



206 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

DiagrnoBiB. 

The diagnosis of endooervicitis is simplified by the aooessibility of 
the diseased structures^ especially when the inflamed swollen mucosa 
is rolled out in contact with the vagina or when the erosion extends 
out over tlie external os. Figure 114. See Laceration of the Cervix. 

Treatment. 

In the treatment of cervicitis it is well to remember the physio- 
logical fact that irritation to the opening of a duct will stimulate and 
increase the secretion of the gland or glands from which the duct 
leads ; and, conversely, the withdrawal of the irritation will cause a 
decrease in the secretion. The same is pathologically true of the 
uterus. Its canal is a duct leading from the uterine glands. The 
irritation of endooervicitis, therefore, may increase uterine secretions. 
It follows that whatever will allay irritation in the cervix must tend 
to relieve the excessive glandular activity. 

Figure 114. 




Sehriidcr's operation. A thickened diaeiwed cervix retiuiring resection. The dotted lines 
sliow wfaiere the incisions should be made. 

In acute or recent endocervicitis the treatment, especially if the 
infection be ^onorrhd^jil, .should be strongly disinfectant. The pur- 
])os(» is to ]>rov(Mit extension to the oorjMis uteri and jiarametria. First 
clean out the mucous pln^, then thoroughly apply a saturated solution 
of iodine in 05 per cent, carbolic acid over the whole intra-cervical 
mucosa. Tlie stronp: tendency of the inf(K»tion to spread, and the 
consequent dan<j:er oi' the (lis(»ase beinjr e^irried to the corporeal endo- 
metrium by th<' careless introduction of instruments past the internal 
OS, should be k(»i>t constantly in mind. 

When the chronic disease prcK'ess has |>cnetrated to the deep mucous 



CHMONia ENDOCER VWITIS. 



207 



UIh ami glandular pockets, siipi^rficiril treatment will faiL It then 
h^mm^ necessary to destroy the hitVeted nuieosa* l>ecply-aetiiig 
ouisticH may aecoiiipHsli this, hut the rcsidting cicutrieial coiitnidion, 
ttpecially whew the c^uml is not very patoloiis, etHitraiiidieates their 
u«. The same ohjection in less degiTe applies to tlie removal of the 
mtirosa by sharp curettage. Thorough excision and eoverinfi^ the niir- 
Ikces thereby ex prised by a plastic openiliou is usually tlie l)est treat 
|jnt?nt. The of>eration of Sehnxler ^ fidlils this indicatiou. It ii 
jerfurmed ^la follows : 



13 



FlOUBR 115. 



**l<Sto'i op«nition. Disemacd tiaauesi exctaed. Suturee in place for the iitjiau <»f the vttKl"»l 
to the Intra -uterine maTginfi of tlie wuuti4, but vua ytt tied. 

Under ether, through Sims* speeuhini, the cervix is drawn toward 

""- vulva and divided bilaterally with .»^<nssors to or beyond the 

iit^'n)- vaginal jnnction. The anterior and posterior lips arc then 

^'ifldv f^epanited with tc*nacnla. Tlie eonditiou is now like that of 

t'ltensive bilateral laceration of the e(Tvix. The lateral incision 

'wnIJ 1m* derp t'non^di, s<) that when the lips are fon-ed ajrart all flie 

'"'^'iised intra-ixTvIcal mucosa may be ex[>ost'd nnd excised. The 

'iJM^nOr an<l posterior flaps are now tnrncd in :ind unite*! with sutures 

NHhf intra-c?ervieal margins of the woinuh Two or three sntnres are 

'^'^jiiii^l to secure each flap. The hiteral incisions, now much 

^hi'fU;ue(] by the toltling in of the flaps, may after suitable denudation 

'>e closed l>y suture, as in Emmet's *»peratiHn for laceration of the 

''p'ix» Upon compietifui of the f>j)eration the flap sutures will Ik? 

Mtiiattfl deep in ttic cervical canal, where removal of them would be 

''jfeilt. They should therefore lie of t^-itgut. The lateral puturea 

MirmM {j<^ of -^ilkwvu*m-gut or fine formahh'hyde catgut. If silkworm- 

l?ut, rhcy should be removed in about two wrecks. The operation, if 

'^11 done, is follower! by permanent cure and freedom from stenosis* 

* BaudbtH li tWr KrankhoiitTi dcr wtlLliclien (jesthkchtsorKane. 





208 IXFECTIONS, INFLAMMATIONS, AND ALLIED DrSORDEtlS. 

Great evru'sion thnHijrh the os externiiin, giving the oiitri)Ut'd umrnsa 
u heniorrhoidiU !i|)pjimiKX*, is iisiinUy due to laceration of the (^ervix^ 
fin<l .shnnli! lie treatt^l iis sneh, Src Km met V Operation, Such ever- 
feioii may jni^fribly, liowever^ oeeur in the virgin cervix. The soft, 

FlUfRB llfi, I 



Rehr^er^ oiKsmti<in. Vn^^iuiHl nmrghi^ suturvd lo tibe intrauterine iiiar^ns of the \rtjun<!- 
Uil^ral hurfflccs deuiided ami Milurta p<ift»^^^l, but nut yet lied. 

spongy, gmivular nmases ghoulil thou lie rennived with the eurved 
!*eis,^ors, thtMUit surfaces cauterized, an*l the cervix tlrc^sctl with stripti 
of gauze siitiirated in a mixture of 10 jit^r cent, ammoiiiatcd iclithyt»l 
ID glycerin ; the dressings tu ho changed daily until the swrfacses have 

Fiotrwi 117. 



I^teml BUtur«8 introduced for Ok* comnli'iioii uf the opemiiun, and tied. The whit^ dot* in 
the (IS externura reprcaent the cntlh of tha protruding auturet*, wbii h are nov? rolJed liir inic* 
the cervical eHtial. 

healed. Thi^i treatment will be disappiinting if there be extensive 

endometritis ithove, unless that nlsr> he included in the plan of treat- 
ment. See Tn^fitment of Endometritis. It will, however^ 1m} wholly 
Kktisfactory if tlu' iMflumniution in essentially confintnl tt> the lower 
eervicul mucosa. 

Polypoid cndfK-ervieJtis, 80calledj requires the removal of the aden- 
omatous growths by means of the shar[i cun^tte or the stMssors, When 
glandular disease is extensive it may hv ueeessary to i^erform SchKW 



4 



« 




FtorBi; tia 




l~aperation. The cystic form of glintliilur eiilsir^ement rarely 
occurs in the nulli parous woman. The cninlitiuii and treat meat thereof 
arc (lescrihed under I^eeratJons of the Cervix. 
I^Srhrfwlpr'fi operation is ussually indicatcHL 
^h In nulli|)«ir^ the internal and external era 
^pe sometime.^ so narrow that tl»e cervical se- 
cMion^are retained and <lis{end t!ie cervical 
mvity quite beyond its normal ^m\ Sonie- 
tinn^ iht* internal os is open, and tlie corpus 
b correspoudingly enlarged from the same 
niise. The retained secretions give rise to 
fffnt irritation and reflex disturbances. The Hnhoieos.i 

niirmjil treatment is to open the canal by free 

mmn of the external os, aial, if necessary, l>y dilatation of the 

inurnal us. Exploratory eurettagi* will show whether tlie eiidorae- 

Imim nqiiires thorough dilatation, therapeutic curettage, and cauter- 

Mimu In order to prevent the external os from closing again a 

iAi4ic ujienition should be made to keep it open. Scliroder's opera- 

in,aln'iicly described, will sulfiee for this purpose; or the incision 

) W maile very free and during the healing process kept wide open 

weaas of gaiize-jxickiug. Sec Figures 119 and 120. 

The pinhole (ks is usually congenital 

FifitTiK 119. ^^^^\ chivvy confiued to nullii>arte. It 

mny, however^ occur as the result of 

caustics or of Um tight closure in the 

Figure 120. 





■OiMl dJUted by iitctin*? secretions 
-lOMtructlofi (It as fxiormim. Line* 
jTiliJc of *js externum indiciiie 
. incljslona.* 




Cruf inl jii(:tI«ionj In Frit* he's opemlion/ 



'^TSttion for laceration of the cervix uteri. The const Hcted external 
"Muay he opened by Fritche's operation, as shown in Figure 120, or 
"V foreil>te dilatatirm. After the application of either of these 
^Jffliodft tlje OS is liable to recon tract. Sehrfkler^s operation^ which 
pv<>s fjcrraanent results, is therefore prefend>le. 



UyneHpoloiry- 
* From Th 



omiia and Mviiidi^ « OiBeiiseB of Women* 



> Ibid. 





CHAPTER XVIL 
CHRONIC METRITIS (Continued). 

Chronic Endometritis. 

In studying endometritis one should remember that the infectecl 
endometrium is often only a part of an infected uterus, and that this 
infection in many cases is not limited to the uterus, but in variable 
degree may involve the uterine appendages and parametria. 

The layer of columnar ciliated epithelium, the connective tissue, 
the blood- and lymph-vessels, and the nerves which compose the 
endometrium are, like the similar structures in the cervix, subject to 
chronic infection. Certain pathological changes result from this 
infection, and are the essential factoi's of chronic endometritis. 

Etiologry and Pathologry. 

The predisposing and exciting causes are the same as already 
described for acute metritis. The most usual source of the infection 
is from the cervical mucosa. 

It is here important to remember that not every increased secretion 
is proof of endometritis. There may be an effort on the part of the 
mucosa to relieve, by an increase<l secretion, a chronic venous conges- 
tion in and about tlie uterus ; or the mucous membrane of the uterus 
in common with that of other organs may be engaged in vicarious 
eb'mination of effete matter which the proj>er excretorj' organs have 
failed to eliminate : such conditions strongly predisiK)se to and are 
])resent in a large proportion of cases of endometritis, but are not in 
themselves endometritis. 

Tlie general pathology has already been forecast under acute 
metritis. The special pathology will be presented in the description 
(►f the different forms. 

After death the mucosa is mottled, dark, soft, swollen, and some- 
times easily detached. The bloodvessels are increased in size and 
number, the lymph vessels are enlarged, the interglandular si)aces 
are infiltrated, and the entire utcTus usually engorged and swollen. 

The possible phases of the inf<?ction may occur separately or may 
combine in one (rase ; they an* : 

a. ( -atarrhal, when the inHanimatory product is simply an increased 
secretion ()f mneus. 

A. Snppunitive, when the inflammatory product contains pus. 

c. Ulcerative, when there is molecular death of a part. 

(J, Hemorrhagic, when the vessels have sufficiently opened by 
necrosis to give the secretion a distinct bloody color. 

210 




, **Nonot neces^rily inereiise in mt tuber. Theye hyiwrtrophic changes 
**^'«' letl to the frequent demgnation of thi?^ form as hiiperirophie 

. Tljere is another inflammatory eouditinn in whlfdi tlie glands are 
^'l<?neased both in size and in nnmher. This h sometimes called 
■^P^j^ajdic endowetrltla ; it ha,H ht'tMi said to occupy a somewhat in- 
^fn)p(liate jK>sition Ijetween inflammatory and neophistic growths, 
't may Jumper ly he elassitied as adenoma. The associated endnmetritis 
^'►fiM tfien 1h? an incidental faetur, A further descnphun of adenoma 
Jjv Ite fbiHid in Chapter XXVill., on Tumors of the Uterus, 





212 IXFECTIoyS, L\FLAMMATI(M\S\ ASD ALLIED DISOIIDKRS. 

in botli liy[KTtroplyo luid so^c'iilletl hyperplastic ciidonu'triti-** the 
glandn, fiortually straight ar ueiirly .st might bL-coiiic ti»rtiioii>, grow 
lonii^er, ami soiiiethiies (ku'idedly p.-notrate the riuiseukrib, 

Intemlhkd EmhmeitiftH is eharartorized hy an atrophic proet^s 
and by the conversioii of the iiiterglaiKlidar eonneetive tissue into 
harcU fibnmt* siib.staiice like cicatricial tissue. The etJect of the ecu 
traeting lil*ruus tissue is to shut off tlie nutritlou of the glands at" 
tliereby to crush mU ar»d destroy thenu 8uch glands as are ri 
obliterated mwy l>e changed to retention eysts. The rnueous. nu'i 
braue in parts or througliout, if the destriietive process \m» Ix^en coi 
plete, undcrg<x.*s atrophic ivhauges as in senile atro}>liy, and Ijeeon:! 
a thin layer of cicatrix-like tissue, tinally coveretl with sonietliing m 
uidike pavement epithelium. Tliis atrophic process may be associa 




ParcnchyniAtond endont<;tritU ; loiigitiirtinal sectioii ofgtiinds, Uliitxlpt mticb rlotis»' 
tortuous ftml reaching to the miuculnrifl.' 



with and uuiy fulhiw hypertrophic fjlaudular endometritis. The l ^ 
fnruis UKiy be only jihascs of otie diseas*' pnwess ; the inter^itiC 
cnmmt^nly ftilh)ws the pareochyiuatiMis furni. The result in eicatrira 
devchipincnt is similar to that jirtxluccd by the destructive aetS 
of chloride uf /iuc or other stroug eaustries. The condrliun 
cirrhotic. j 

Poly]Miid euflometritis, so-called, is a condition first de**cribed I 
Rccamicrr It is a concurrtniee of the interstitial f4»rm with ^ro 
glandnhir eulai-ii^ement. It is tnarked by excessive, tlifluse, glandule 
interstitial, aticl vascular dcvelopmc^nt and by cystic deg(*neralion ^ 
the glands. Snne of the cystic glands have the character nlrea^ 
descril>e<l under interstitial endometritis; others beiHime fungoid pH 
jections, so-f*alled, nimn the surfaces,— that is, small, soft, }wlypiW 
bodici* like nasal polypi, often |K'dnncnhih d, variable in size, tUfl 

• Aniano ; MJen^copisoh-^iyTiiikoUf.rhi n DlitirtitMtlk. 
I I'asxl ; LTrilon MMlcale <Sc FariA. June 1 to b, IfidO. 




vm lumina. b, double hivuKiuwtiun. sbuwlng three lumina, c, IrreguUr 

J^'roatous from pertained secretions. A simikr polypoid develop- 
^^i occurs also in the cervix, and luis already been described in 



Fior»E 125. 



FioURE 126. 





■J 



Mil c(*f!n tu*idtfled by InterPtltftl endometritis- 

f^noniuil iuue<*£ii. Trunsvenie secttou. ronoeetive t(«aiie Inrreiised. Glands cnuhed 

Semi-diftgr&mmatic. out or ihunged to retention cyati. Sfini-dla- 

pi-Amimitic. 

XVI, Tbe.se ('liange.-^ tnake tbe eiidonietriiim exeessively 
[''i^'K, ,*oft^ iind redematoMs. The di^^oase iiieliuleH the ^hindidar and 
Semitial fornix moditiGd. Like so-called by|i>erjilji.stic endometritis, 

I Amann ; Mk'roeojptacb-GynJikalogiBcIica Diu^noatik. 



1 



214 ISFECTIOyS, ISFLAMMATIOXS, AND ALLIED DISORDERS. 

it has been mii\ to hold an intermediate place between inflammation 
and iieopla.sms. Endometritis is present, but only as a cooiplicatitjii of 
the new growth, which will be again rt^cognized under benign ade* 
noma* The libroos tissue which takes the place of the interglandular 
comiective tissue may develop abnodantly. The excessive glandidar 
and vascular enlargement explain.'? the chief euhjeetive symptoms : 
exhaustive glandular seeretionri and hemorrhages. See Benign Ade- 
noma, Chafiter X X V I J I. 

Clinical Fohms of Endometritis. 

The clinical varieties of end*>metriti8 may be ui='nally referred 
one or both of the histological forms. Their indivi<hial peculiarities 
are dependent upon intereurrent conditions. The clinical forms are : 

Post-abortum endometritis. 

Exfoliative endometritis. 

Senile endometritis. 

Tubercular endometritis. 

FiorRE 127. 



Dc 



Hr 



Oi z. 



Po«t-ftbortum eiic!ometHtl!<. Pcctlon of etidnTrn" f • . ite a lonff lime 

aHltT ubortloti, showing dedduiil pcII^ undcliorionic viili, V<: ^^Leidual cells; t'A. Z.» chorionic 
villi.' 



Post'AhoHum Endoineiritw, Abortion may be a cause or an effecfc 
of endometritis ; in either ease the disease may present certain peculiar- 

» Auiaun. Wicroftcopisoh-tJyuttkoIogischeu Dittguostik. 



CHROXIC ENDrmETHITIS. 



215 



inflammatiati, which is nifhtT interstitial than glanthilar, 

arrest of involutioii in the niucous meinl>rane at tlit' site nf 

iW ovnle and of the adjacent mueo.sa — u c,^ of the deeidua nerotina 

deeidua vera. The arre.st of involution may be only in places ; 

kii^ gives rise to islands of decidual celk eireuniserilied within the 

iri^junding mucous membrane by tlie round cells of inflammatory 

e^ue. It must lx« ditrcrentiated from the Ixemorrhagic conditinn due 

I the rek'utittn of jxjrtions of the oiiibryo and from tlie ordinary t'U(!f»- 

Metritis whieb may re.^nlt therelroiu,' and fn>m the uterine deeidua 

i«<toffiii tiilnil pregnancy. The hitter does not contain chorionic 

Sfilk The treatment is sharp curettage, di^infcctioUjand drainage of 

Mnfiometrium* 

Erfolitithr EndomrfntU^ usually called rnend>ranous tlysmenorrli<ea, 
pfe chamcttrized by the ilctiicbuient of tlie outer layer of the end<jnie- 
trium in pieces or as a whole^ and its expulsion from the uterus. It 

FitiURfi 128. 



tte fruo uttrlnG cavity In cxfoliaiire endometrUis, membranous d j smenorrhcea, natural size' 

tnav ocfur at puberty, with the first menstruation, and crmtinne 
"fnii finitely, or may eonimence at any time during menstrual life, 
-V]lli[)arfe and niidtipara? are both subject to it. The character, 
|l''''^'in'ty, and completeness of the tlirnwnnjff membrane vary with 
"'^;iivi(Iimlsj and from time to time in t!u* same individuab Tlie 
'J"^r<N-'o|)ic resembhiuee between the exf<diated membrane and tlie 
^l*^'iJtui of early abortion may lead to confusioii in diagnosis. The 
'■^"^ of the detached endotnetriuin and their nuetci, however, al- 
muii^h .H<imetimes enlartred, as if niidcrtr^Mnt' a ehan":e to deeicbial 
'^'W are never the produet of conception. The membrane discharged 
*^\y\ the uterus in the course of extra-uterine j>regnancy resembles 

J'^Hw*<*»'r- Randbuch der Krankh<?iteii der "\vcibllchtjn Ge»<*hlechtiKitTginit», siebetite 

idos And MtimltS l>i8cn»i*H of Winn«m* 

iire ftlMO Lolik'iti' HeseUscb. f. Ueb. u. Gyn,> Februarj , 18*6. Zeltaclirtft 

46&. A. Martin : PiBonses of Wiiiuciu 





INFECT fONS, lyfLAMMATIONS, AND ALLIED DISORDERS. 

tlirit of exfoliative ondoinetnti,^. The tlischargt* of .sudi a nicnihrano, 
tlHTefijre» may n'fiiure purefiil liifttTeiitial diagno.sis hot ween tlie two 
{■otxhfions. The deeidual cells of tlie f*trmer are niiieh larorer and do 
not run tain ^^hiods; thuse of the dysnienorrhreal ineoibraue contain 
uterine glands. The yium, like severe labor-|>ain8, usually apj>ear 
before, and continue uitfi remi^sion.^ throu^dioiit, the flow. Subjective 
symptoms may di.'^appear in the inter*nienhtrual period, or there may 



C^^' 



MenBtm&l dccidua In niembTanoos dyfroenoTThaea. *» »t* .ToacoDC. A. $urfiiee 

ffiliinifmr epitlieliiirii; if, detidual cella^i. c, straliira proprluiu, uhi? h i^huwa Inflltmtion of 
le u k oc-y t PS ; ( ', gl mid . ' 



be the onlinary si^ns of endometritis, the tnflanunation taking on a 
somewhat aetite character diirinnr menstrua tirHK The disease is per- 
sistent, iiitractablcj often incurable. The treatment is the same as 
for obstinate endometritis in general — i e., thorough sharji curet- 
tai^rc, with eanterization of the endometrium, in the hope that the 
new rndometrinm may he healthy. See Treatment of Endometritis. 
Electrolysis after Ai>o«to!i has given only inditlerent results, 

Saiiic Ehthmietn'tls. After the menopause, when the uterus has 
undergone senile ntrophy, it is subject to a most hanissiug ftjrm of 
purulent endometritis; it is usually the relic of an earlier infection, 
and is due to the action of bacteria on the atnipluc, less resisting 
endometrinm.^ The discliarge contains nnmeroiis bacteria, is com- 
monly offensive, purulent, often tinged with blootl, and is so irri- 
tating as sometimes to cause a most distressing pruritus vulva?. The 
infection may destroy the exhausted senile mucosa and jjenctrate into 
the muscularis. Cicatricial stenosis ib frequent. Complete cicatricial 

I Apitinii. M!pn>*ire)plMt h-GvnakolQglaohfn DliignoaUtc. 
* Cofltb : from Thomiis unci ^dmtlt}, p, G;1L 



I 
I 




CHROMC ENDOMETRITIS, 



217 



liiHiim in the utrrint^ ranal, nsuuMy at i\w internal or, often oecur!-^. 
riiif may cause the utoriiM* stHMT'tioos to be retained and the distejide4l 
organ to become a thiii-walled reteotion-eyst. The ennthtioii isealh'*! 
pyoinetra or hydronietm, according as the retaineil fluid is piirii- 
ent or watery. The utcrioe canal, if not occhided, is apt to be nar- 
>wcfl at one or more places by cicatricial contraction ; this obstrne- 
tion to the dminage of secretions aufgnivates the disease. Other forms 
cif endimietritis may retard the senile atrophy id' the cervix, or the 
corpus, or the whole uterus, long after the proper time for the com- 

FiomE i.in 



^', 



rtfrflne dpotdtm ciwt oflT in tubal protroancy ; o»>servi* large dJocidiml cells containing no 
■UttTliiu tflurul; ihe ofK»n Bnncis nrc bloudw^sels; obflen't" the relatively umaU tiueUdii a*, com- 
||Miri-<l Mith tlie ^vll [iroto|.t]a$m.' 

ulete raenojiianse,' and the orgsm may remain large from this eunse. 
inch enlargement ditf<^rs fn»in that of distention. In the former tlie 
^Uterine walls are thick, in the latter distended and thin. In most 
eaiK?s of senile endometritis the uterus is not enlarged, hut mtlier in a 
hitati" of full senile atrophy. The retained products of senile endo- 
{metriti.s may give ri.'^e to reflex distiirliances, innutrition, and to sys- 
temic <Iepri»«*si«m, even to septic poisoning. 



)l£»1u^ 



roncmiiMch'OynSikoloffliielien DlnunnKlik. 
' MMlCftte de Suiiiite Kcunatii, mj(i, No. !>. Abstract In Cenlmlblutt i\i^ Oynii- 



218 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

The microscopic changes are like those of atrophic interstitial 
endometritis, already described. 

The glands and epithelial elements in the last stages of the disease 
are destroyed and the submucous structures laid bare. The destruction 
of the glands makes catarrhal inflammation impossible. The ex- 
posure of fibrous tissue, moreover, is favorable to the development 
of suppuration, granulation, and ulceration — three characteristics of 
senile endometritis. The disease may be corporeal or cervical, or 
both. Laceration of the cervix is a frequent complication. The 
offensive discharge, the occasional uterine enlargement, and systemic 
depression may lead to confusion between this disease and uterine 
cancer. Cicatrization may bring about a spontaneous cure. Usually, 
however, unless cut short by treatment, the suppuration persists. 

The treatment is that of aggravated endometritis in general. In 
the worst suppurative cases vaginal hysterectomy may be necessary. 

Tabei'cuJar Endometrititf. Incipient tuberculosis of the uterus 
usually takes the form of endometritis. It may reach the uterus 
from without by hetero-infcction, or may be transmitted by auto- 
infection from another infected organ. See Tubercular Salpingitis. 
Hetero-infection is rare, but may occur through the vagina by coitus 
or by instrumental or digital interference. It sometimes ot'eurs in 
the cervix in the form of sharply cut ulcers, and when far advanced 
may extend to the corpus ; * its clinical resemblance to cancer is then 
quite marked. Auto-infection generally reaches the uterus through the 
Fallopian tubes.^ In such cases the disease finally extends from the 
endonietriuni to the myometrium. There is also usually a prior in- 
volvement of the peritoneum. Often the pelvic organs — uterus, blad- 
der, colon, rectum, ovaries, and tubes — are matted together by adhesions, 
witli abscesses and broken-down tissue.* Tubercular endometritis is 
relatively rare ; it is recognized by the historj' of the case and by 
microscopic examination of the scraping. The treatment must be 
the removal of the uterus and its appendages. 

Symptoms of Chronic Endometritis. 

The symptoms of acute endometritis, that is, peritoneal tender- 
ness, hypogastric ])ain, pelvic weight, rectal and vesical tenesmus — 
may in some degree continue, but as the disease becomes chronic 
these symptoms cease to predominate; in their place comes a 
symptom-group which always contains some of the following factors: 

Menstrual and interm(»nstrnal disturbances. 

p]xcessive mucous discharges. 

Purulent discliarges. 

Hemorrhages. 

Sterility. 

Systemic disturbances and reflex disorders in other organs. 

(Obstructive dysmenorrh(ra may result from cicatricial stenosis, 
especially if the menstrual blood coagulates in the uterus and is forced 

> Pozzi, vol. iL p. 2^1. '-• Hnnnrt and Petlit. p. 193. Figure 63. 

3 IlecberR:. C'omralblutt f lir (iyiiak(.k.j;ie, 1892, No. 50. 



fHit b? powerful contriietions* The pain will then bo intermittent. 
Interruetistniul pain from the expulsion of aecumnlateJ seeretiun hi 
the utenifl may occur in the same way» The exces>iive menstrual 
[v\m, like labor pain, in exfoliative eudometritis lia,s aln^atly been 
noted* Congestive dy^iraenorrha^a often preeedcs the How, hot siib- 
M<^ as «ooii a^ 1 1 1 e e ng o r^ed ves.se h are re 1 i e v eil I )y the es tu I d i s 1 1 1 n e j 1 1 
**t' the flow* The uterine nerves, already sensitive fn>ni neuritis 
eusily become when crow i led by t!ie distended hlnod vessels of the 
swollen uterus, the seat of ^reat menstrual and iutermenstnud piiin, 
Hy^iersecretion is a constant and pronounced symptom. It nmybe 
fatarrbal or pnrulenti» or mixed, and often contains hlood. Meiior- 
fiiagiaaad intermenstrual hemorrhage commonly result from glandu- 
lar and especially from inlerstitial eotlometritis.^ 

Sterility and abortion are tm|uejitly assoeiatefl with the disease, 
'^rility may result from complicating ovariti.^ or obstruction in the 
J^allopian tubes, or from destruction of the spermatozoa by the uterine 
*ecretionr*, or from their mechanical exclusion from the uterus by the 
p'«^ of teuaeious mucus usually fouml in endocervieitis ; or, as sotm 
SH the ovale enters the uterus, aljortion may occur from the hostile 
envinmnient of the diseased mucosa . The failure of the ovule to 
■l^npbnt itself upon the mucosa may give rise to no subjective symp- 
toms, .^o that the existence of preo^nancy may be unrecognized* 

The systemic and reflex disortlers are chiefly refm-able to the nerv- 
otis system. Among them are neuralgia, iudigestiou, malnutritinii, 
novfMiJ! dyspepsia, aniemia, chlorosis, spinal irritation, and hysteria. 
Till' iniloruetriti.s, may be a cause or an ett'ect nf the al>ovc associated 
<lisor(lers, or together with them may be a concurrent result of some 
common cause, or may have had primarily no ()athological connection 
'^th them. 

DiagmosiB of Chronic Endometritis. 

TIic diagnosis of chronic endometritis is su^ested by the symp- 
^^^'^ oEitline^l a!K>ve. The intriHluetion of the sound or probe muy 
^Mitly wouod the inflamed endometrium and cause great jjain nnd 
^%ht bleeding. The d liferent varieties have been descrihed cai the 

Thn differential diagnosis between tlie lunnerous varieties alreadv 
^i^thnifl will de}>end u|»on the removal of portions of the diseased 
^nposa and its examination by the microscope. A very small curette, 
Without previous dilatation, will often sufliice ff>r diagtiostic purposes ; 
^^ l^ist it will settle the question whether a thempeutic curettage is 
'"T<s?viry. Tlie diagimsis hctweeu enilometritis and adenoma, carci- 
^jorna, and Sixret>ma will deiiend, first, upon the history of tlie case, 
^^^^ture of the discharge, and conjoined exanu nation ; secoudj uprm 
^henirptte and the microscope. The discharges f mm adenoma, ear- 
^^^'^inn, and sarcoma are more profuse, mnre offensive, more water v, 
^^i Usually contain more blood. Cachexia and other systemic dis- 
^"^'""rs are more marked. A discharge from the vagina rir from a 
l^ivic abscess ojiening into the uterus or vagina, or a discharge from 

» A. Mdrtin. DiseaHos of Women, pp. '20^, 308. 



220 lyFECTIONS, INFLAMMATIONS, AND ALLIED DIS0RDEB8, 

the Fullopian tubes, may be mistaken for the product of endometritis. 
Inspection will show whether the dischai^ cx)mes from the uteru8 or 
not ; a small piece of cotton left for a few hours against the cervix 
will sometimes show the source. Secretions passing through the 
uterus from the inflamed Fallopian tube are apt to be rather period- 
ical than constant, and the perio<licity is often marked by expulsive 
pains in the uterus — " colica scortorum " — ^and followed by temporair 
relief from pain — /. f., the tube may refill and empty itself at inter- 
vals. In some cases, however, the discharge is constant. The diag- 
nosis requires a history of the case and physical examination. The 
condition is often connected with other pelvic inflammation. Pus 
from a pelvic abscess is recognized by finding the sinus through 
which it discharges ; such a sinus often opens into the vagina, seldom 
into the uterus. 

PrognoBis of Chronic Endometritis. 

Relapse is very common. The mildly infectious cases, usually 
calknl simple endometritis, yield readily to systemic treatment. The 
strongly infectious cases always require surgical treatment This in 
most cases will bring about at least a symptomatic cure — i. e., it will 
stop the discharge and may relieve other symptoms. Whether the 
diseased uterine mucosa win be restored to its functions will depend 
upon the extent to which it has been impaired by the disease or must 
be destroyed by the necessarj' treatment. The prognosis is espe- 
cially discouraging in exfoliative, senile, and tubercular endometritis. 
Hysterectomy is sometimes necessary. 

Treatment of Chronic Endometritis. 

The treatment varies with the structures involved, the nature of 
the infection, the chronicity of the disease, and with the preponderance 
of systemic or local origin. The treatment of cervical differs from 
that of corporeal endometritis ; that of a gonococcus infection might 
have to be energetic and strong, while a milder infection would 
require only simple or expectant treatment. Obstinate cavSes of long 
standing may yield only to the most radical surgical measures. Many 
authors attempt to draw a line between what they call simple endo- 
metritis and septic endometritis. This line can have neither a 
scientific nor a clinical basis. It is better to distinguish, on the one 
hanil, tlic catarrhal non-purulent cases in w^hich general circulatory 
disturbances — that is, diathetic, systemic causes — predominate; 
and, on the other hand, the cases in which local infection pre- 
dominates ; in the first class of cases predisposing causes predominate ; 
in the second class exciting causes. See Chapter X. The septic ele- 
ment is not confined to the second class, nor the systemic element to 
the first. An appreciation of the foregoing will suggest the following 
division of treatment : 

1. Systemic treatment. 

2. Topic^d treatment. 

3. Surgical treatment. 



CHEOMC EXDOMETRITIS. 



^yetemic Treatment is witlt'ly ajipliralilL* to a very large class 

of ai^c'H, sometimes cijlltd siihinrtaiuniatury, whicli arise not so miuvh 

fmm l«x*al infection as from stagnation of llie general eirenlation. 

The tetugnation is usually iissoeiated with disortlers of t lie lieart, lungs, 

Uver, kidneys, or with sneli disonlers us unteniia, leuka^njin, eiil<jrosis, 

diabetcif, rlieinnatism, imd goiiL The utern^ may jiartieipate in 

the gi?neml eirculatory tlisinrhanco anil take on a eiUarrhal eniidi- 

lion. In this class of eases tlie catarrh nsnally involves not only 

ihe uterus, but also extra-pelvie organs, esijecially the organs of the 

T<?s(jinitt)ry, digestive, and urinary systems. The m neons meml>ranes 

geiifmlly are less resistant and therefore more liable to inteetion, 

(."atarrh is often the vicarious aet of a mucoim mend>rane to tlirouoif 

wa?te-pr(xlucts which it Wiiuld nt>t normally have to eliminate at alL 

When relieved of such nn natural elimination its resistauce to the 

niicmbe is thereby increased, ant I the infection may in this way cease. 

It is clear from the foregoing that iu the absence of marked local 

intktion the treatment shonld be not so much hx^al as systemic. 

Indet^l, when the uterine disorder is mainly eousequeni upon systemic 

<'!nis<:«? l<X'al I refitment may be nselessy |K'iiia|»s injurious, ()u tfje other 

Iwnd, the uterus participates in tlie gtnienil iju^n'ovenieul wlien the 

fxtm-jielvic and systemic disorders mentioned in the preeeding para- 

pphliiive been ixdieved. The needs are, first, a thorough diagnosis 

^^«n tlie standpoint of internal medicine, and, second, tlie treatment 

m any eondition which may disturb the balance of tlie general cir- 

f'lllation or nutrition. If the uterine secretions are purulent, or sys* 

^ernic treatment proves iuadec|nate, topical or surgical treatment may 

^*<^inj[)C'rative, 

Rlieumatic, gouty, and syphilitic subjects reqnire special n^gula* 

^•^t* and medical treatment* Rheumatism and gout very often 

p^H* and perpetuate the disease. It is impi^'ative that the kidtieys 

*^ made to eliminate their proper amount of urea and otlier solifls, 

^'Wvfise tlie burden may fall on the m neons glau<ls of other organs, 

^*^^ example, the uterus. In i^very ease, thei^elorcj a quantitative 

•'Analysis should be made to show the amount of solids excreted in 

^Wenty-fonr hours* In the uric acid diatliesis, lithia spring waters, 

^^ the salts of litliia in solntion, are most usefnK The gnmidar effer- 

^^iu^ s^xlinm ]diosphate in eo])i<ins draughts of pure soft water is 

l*>ite as g<x>d as miueml spring water, possibly better. The diet 

^•»nu|(| inchule less animal ant! more vegetable ft>od. Auicmia, nota- 

**ly tli€ aniemia of tat women, is often the cjujse of local engorgement, 

*^pi«('ially in the uterus. In such eases local treatment is useless. 

*'^»w, manganese, the bitter tonics, mineral waters, nutritions food, 

*^de(j(mte exercise, and regular liabits are essential. The thy mid 

*^PaH has been much praised iu tln^ treatment nf this class of 

'^J^mic women, and the nse of it is saiil to l>e followed by rapi/l redue- 

***^« <>f fat. Endometritis associated with sy |dii lis will often yield 

**^* *fj**eifie trt^atment. 

Constipation is almost constantly associated with uterine catarrh. 
I^i^e accumulations of old, hard feeal matter displace and keep \\[i 
^^^'O.'itaijt engorgement of the uterus and other pelvic organs. Tlie 





222 INFECTIONS, INFLAM3IATI0NS, AND ALLIED DISORDERS. 



I 

r 



siiwessfiil treatment of constipation is essential to the relief of the 
endnmetritis. The treatment should he rather regulative than 
Jiir<liriiiaL Strong hixativi-s tend to congest tlie alKhmiinal and 
|M.dvii' <«rgaiLs — the very condition we want to relieve — ^and f^hould 
therefore l>e avoided. liygienie measures alone may he adequate. 
Tliei>e inclnd*^ reguhir prop'rly selected diet, regularity in exerei-«« 
and es|»eeially in timci^ id' going to stooL Massage is a must valitahle 
remedy, hoth lor its direct inHuence on the action of the bo web 
atid on the general eireidati^n. Mineral waters, magnesium sulpliate, 
magnesium citrate, lithium citrate, sodium pluisphate, Carlsbad 
salts ai'e most useful. They are best given in cnpiniis draughts ujion 
rising in the mfjrning* A large draught of crihl water af the same 
hour will often cause free action of the bowels. The conventional 
pill t>r some positive cathartic like aloin or ixHlophyllin at bedtime, 
which nsually acts strongly the next mf>rning, is objectionahle, and 
huch drugs if given at all should be in small divided doses ciind>inf*<l 
with irnu and nnx vomica, and given at least three times a day. The 
cathartic dose Bhouhl be diminished each time the prescription in 
renewed until only the tonic remains. Polypharmacy in to l>e 
avoided. 

Taldet triturate of calomel long continued in verj' small dt^ses — 
one-thirtieth to one-tentli t^f a gniin— three times a day fulfils a mnb 
tijdc indication . It establishes a steady stream of bile — bile is a 
most elfective intestinal antiseptic — th 1*0 ugh the intestines, renders 
the glandular organs more active^ dishnlges morbid accumulations 
and secures pniper elimination through the bowels and kidneys. All 
this bnlanees the eircnlatinn and stimulates nutrition. No single 
ih'ug has greater value than cahtmel in the treatment of tlie inflam- 
mil to ry attcctious of the mucous membrane wlien due to .stagnation 
of the general eireulation. The bichloride of mereur)" in minute 
doses — one-hundredth of a gmin — may be equally nsefiil. In the 
continued use of mercurial salts always observe the usual rule to 
secure n^irmal fretMlom uf the Ixiwels, if necessary, by the judicious 
use of salines. 

Colonic fiiishings of warm castile soapsuds, or of a 1 jx^r cuniU 
solution of smlium biearlmnate — from one to three quarts — are mogt 
tiseful, esi»eeially in the early treatment of obstinate constipation. 
They should be given in the left latero-prane posit t<ni — Sims' position 
— or, better, in the knee-chest po.-^ition. To be n»ost eftWtive they 
must V>e very copious, slowly given, and n'tained at least fiir ^aeveral 
minutes. Five per cent, of glycerin adds to their cfleetiv(*ness. The 
prompt disapjK'amnee oi' bearing-down, dragging -pains, luickache, 
briwel distent iou, intestinal indigestion, and depression, which <ift^n 
fi>lh»ws the ehniring out of the liowels, is in striking contrast with the 
frequent disapptiintment, not to say increas4' of symptoms, whieh 
usually tblldws the timc-houorcil topical treatment. The disease i.s 
most obstinate in virgins. In corpulent young winnen cure is almoi>)t 
im|M»ssible uidess the nutrition be imj»rovt*d and the weight reduced. 

The general and .sc*xual hygiene, too often ueglecte<l, ifichiding 
dress, exereit^e, food, sexual relations^ and care at menstruation, ha,^ 



i 



CHRONIC ENDOMETRITIS. 

already l>een discusseiL 8]K^<;i!iI attt'tUion shoiihl Ik* given to lueal 
and gi'Qeml biithing. A comprehensive gm>?p of tlie jsuhjetit, liowevtT, 
iDVolve^ the whule tlM of general intt^rniil meiUeioe. 

2. Topical Treatment has been as niueli over-estimated as systemic 
Ireatmem has been negkctetl* Muhitiides of women have, nntbrtu- 
imtL-lv, formed tlie habit of receiving useless routine treatment fur tlie 
rvlief of uterine discharges. Once eiiminaie the ciises already 
i iKkxI in the foregoing paragrapli whiclj require not hwal, hut 
., -iLtuic treatment, and the remainder will be relatively smaller, and 
will be raositly made up of the clearly infections cases. Few seientific 
in*nec*jlogists tonlav place great value on oHice-treatment i'or distinctly 
infwtious endt*nietritis. Tlie number ttf such eases definitely en red 
bv toj»ii.^l applicatiouSj when compared with the great number 
tn*att*il, is insignificant. In making such comparison we must 
exclade numerc»ns eases which have needed only systemic treatment, 
and hiive been cured by it, notwithstandijig the aSvSocjiated topical 
ireatmwit which they did not need. 

The endometrium has been the subject of a vast amount of sometimes 
Tuiid, iivdst times useless, ofi times dcstriu'tive topieal treatment. Since 
other or3y:ans, the nose, stomacb, iutestiucs, bladder, aiu! eye, are sub- 
jal to the same catarrhal conditions an<l sulyect to them from tlie 
same general causes, consistency would indicate topical treatment for 
them at^>. If in a given case^ for example, the whole intestinal canal 
and bladder and endometrium Avere catarrhal, it migiit be quite as 
iviiHuiable to apply fuming nitric acid tt» all as to one. Such an experi- 
nunt would not oidy show that the human uterus bas etuhnx^J an ini- 
nienr^* amount of abuse, but would successfully demonstrate tlie 
ab^unlity of topical treatment applied to a mucous membrane when 
ihi" discliarge is only one of many hx^al eviih'uces of a general condi- 
ti'>n- Clearly a large proportion i>f cases l>eloug mther to internal 
iiiidicine than to gynecology. Very significant is the fact that hmg- 
^jutimifd and often repeated handling of tlie genitals may give rise to 
p^ydiic irritation or depression, A woman once habituated to local 
trparrnent may even become a monomaniac on tbat suljject. 

The milder intni-uterine treatment as ordinarily practised is long, 
^^h)m, andj if Uijt nsele>s, at least uncertain. Such treatment, 
wjiHluT mild or severe, at the dfjctor's office or at the patient's house, 
d Iroqiiently rejK^ated with in<litferent aseptic care, often sets up new 
'"httiou, or may c-arry the old infection to deeper structures, Tiiia 
may dangerously invrdve the parametric lymphatics and veins, the 
"jyoinetrium, Fallopian tul>es, eel hilar tissue, peritoneum, and ovaries, 
^^ ?» rule, the causes which do well on mihl, topical treatment WT»uld 
*^"en do better on systemic treatment alone. If excepticuial cases of 
'^''^•-punilent uterine catarrh require local applications^ such treatment 
^intilfj never be long continuccL 

Intm-uterine treatment is usually eftective in ]iroportion to its 
^ner^\ Only those a^xplieations wliicli have tbc power to flestn^y 
lhedi>iea^ structures arc capible of arresting puruk^ut endometritis, 
hi doing this, however, they niaydcstr<»y the endometrium, injure the 
myometriums and reduce the uterus to a cirrhotic-Hke cicatricial eon- 




224 jyFECTTOyS, INFLAAfMATIONS, AND ALLIED DLSORDERSi 



<litiun. Su^rility mid porniancnt irritaliility of all the ix-lvic organs is 
a (latyral result* Kkctrolysis, miv\c uoid, eiininiie acid, elorid*' of 
ziti<\ acitl nitrate of iiiereurv* and the actual luiiitery, esjMJciallv if 
often applied, produce cicatricial steiiorii:^ and atresia, Mitlj all their 
evii rcsidts. Alr€ady numerous operations have been devised with 
hut little Huceess to reopen tlie coritnicted uterine canal.' The chlo- 
ri<Ie <jf zinc pencil jiroduees a slongli of the endoinetrinni and H»mc- 
litnes of juiiseular ti^slle ; tlic use of it may i>e followed not only liya 
chronic pin-ident discharge, l>ut hy a scrioiis infection of the apfR'nd- 
ag4's from tlie septic sloughing endonielrinm. The endonietriurn lias 
n(»w i>ermanently lost its epithi'lial covering the chief protection of 
the uterus against bacterial invasiruh Contrast tliis condition with 
that in wliieh the diseased structures liave hern removed by an ascplle 
curettage and the healthy abraded surfaei s are all ready to reproduce 
a new iinhHuetrium. Tlic tVe4]Ueut application of strong caustics to 
the ern lorn etri urn is prohibited. 

One fjiode of action by electricity is hy eantcrization ; another mode 
is saitl to Ije by a <leep etf'eet on the bloodvessels. It may by con- 
tinuetl use arrest a uterine disc^luirge. The chief value of it is in the 
tiT^atment of the soft flabliy heriiorrhagie ntenis, and especially in the 
enthjnictritis associated with myoma. Other nu'asu res, however, are 
usually pre feral lie. Electricity is pain fid, tedious, often unduly 
destructive, and may be ilangcrous, Cirreat cieatrieial formations and 
hopeless stenosis in the emlometrinm are anjoug the jM>ssil>le residt-«, 
Thes(* ctfects are not limited to the disease, but may inchule healthy 
Ptnu'turcs. The immediate dangers are greater than those nf a<eptic 
cui*ettag<^. (Tcuei^ally speaking, the metlnid is not to be approved. 

It is not tiie author's purpose to condemn unrcserveflly the oorx- 
ventional treatment. He lias eareiully tested the vaginal douche, the 
swalibing otit of the uterus with cotton, the injection of astringents, 
tlie vaginal and intra-uterine apidieations of dry jurwdersj intra-iiterin© 
IH'ueils of various alterative and caustic substances, wind glycerin 
!am[Hmade, eleetricitv, and intni-uterine gauze tamponade. The dili- 
gent and patient use of such means has been followed by much disa|i- 
poiutment, to say nothing of some jwsitive harm. Topical treatment 
should seldom be long etmtinued. It has a moix? legitimate place as a 
supplement than as a snl>slitute for systemic and operative m'atnient. 
A reproach will I»e liftetl from the nicflical profession when the intlis- 
criiuinatc use of topical treatment shall have been relegated to the 
ilark ages of gyneiM>h»gy. 

If topical treatment is to be nsed, e8i>ecially if it is to bo intra- 
uterine, let the aseptic* precautions be as careful as for a surgicsd r»iK*ra- 
tion. Sec Clia|>ters IL and IV- The patient should invariably have 
had a tluirongh vaginal tlonche nf green soapsufl>, wilh careful s<'rul»* 
bing of the external genitals am! vagina. The cervix is cximim**! by 
8im^* speculuin ; the vagina is then thoroughly wiprd out with dry 
al>sorbent etittrm on dn'ssing- forceps and swabbed with cotton ^tu- 
rated with a h per cent, solution of carbolic acid or a 1 percent, mxluttoii 

1 Of \h**^\ UiHt of otto Kuatiivr, of DrctJaa, It the Ifttcftt «Dd moBt roditAl, CentmliUitl Ar 

GyniLkologic. N<». 30. \mf^ 




CHRONIC ENDOMETRITIS. 



226 



nlin. Slight traction is now matle on the eervix by tenaculii (>r 
blunt -ttM>th forceps to straighten the uterine eunal, and the eiidunie- 
iriurn is cleansed by means of cotton woiintl on :iji applicator, Tlit? 
cerviitil plu^ of mucus, if present, should l>e rcinovcd. The desired 
Implication may then be carried into the endometrium by means of the 
applicator aguin wound with fresli absi>rbent cotton, or, if the canal l)e 
vvry ojx^n, by means of fine dressing- forceps, A jiledget of cotton 
saturate*] with glycerin or a 10 per cent, mixture of amnion ia ted 
icliihyol and glycerin may be placed in the vagina its a protect ion and 
!«jritj* hygroscopic etrcct. Over this place a [jledget of dry cotton to 
kwp the first in position and to absorb moisture. The vaginal tam- 
\*m should be removetl in twenty-four hcairs. Intni-nterino cleanli* 
0688 is tho first requisite. To secure this an open canal and normal 
dniMgi* are essential. During such treatjuent coitus is prohibited. 

hfra-uUrint' gaiizv tampomuh has lK*i:!n extensively used for dila- 
t:ition and drainage in tlie non-oprrative cases. Increasing quau- 
titi(p^of a narrow strip of antiseptic gauze are packed into the uterus 
ir» successive treatments, until the endometrium has become gradn- 
atlv dilatcMl to a <liametcr of one-third or one-half inch. This ililata- 
tion poriuits easy anil thorough intra- uterine topical treatment and 
'ImiimjI^T, os|iecial!y cjipillary drainage when the gauze is in place. 
This raethml, In the author^s hands, has l»een occasionally saccessfnl, 
hut lesh so than the reports of its advocates would seem ind promise, 
itrtat care is necessary lest the gauze, instead of carrying out septic 
matrrial, may carry it in. 
It would l>e evm fusing and is unnecessary to name the innumerable 
lud chemicals which ari* lauded for inira-nteriue medication, 
iuucid and iodine, for their disinfectant and astringent eitect, 
nim the requiremeuts in glaudiilur endometritis so far as topical 
^i^itment can meet them. lehthyol in interstitial endometritis, 
althmij^h useful, has not entirely fulfilled its early promise. 

3. Surgical Treatment. "Wlien the disease is distiuetly infectious 
in4 c'lironic, topiciil and systemic treatment are both inadequate^ 
alilifMijyrh lM>th nuiy properly sup]>lemeut surgical measures. The dis- 
ease*] endometrium must l)e removed by the nharp vitreUc. Tlie oper- 
ation b rendered extni-hazardoiis by active inflammation in the Fallo- 
pian tulx?s or by any <»lli(?r active panimetric inflammation which 
^nAfT^ the uterus imnmbile or very sensitive to the toueli, If for 
iiny reajion it must be done under these adverse conditions, the 
?^^test aseptic care should be taken to prevent dangerous lymphan- 
^'jk phlebitis, and |x^ritonitis. A genend description of curettage 
^11 Ix' found in Chapter V, Salpingitis, ovaritis, peritimitis, and 
'^'lliilitis were formerly considered |iositive i-cmtniiudieations for in- 
vidini^ the uterine cavity. At present, although, these diseases, if 
'''"]"nit', call for es|>ecial care, they are not tr» Ik* considered as ueces- 
^^nly prohibiting intra-uterine o])emtious, ]>rovided these operations 
■•"f of such a character as to remove the disease from the endome- 
^^um. They do, however, prohibit all intni-uterine interference 
^liirh falls short of this. Ordinary intm-nterine treatment, even 
"laminations with the sound, nuiy be more dangerous than thorough 
u 




226 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 




dilatation and sharp eurettagie. Incomplete dnll curettage is sped' 
ally dangemuR, for it exfM>sos the .snrtiiees to ab^>rptioii and at tbe 
same time may leave hi feet ions matter to be absorbed. Inflamed 
tubes and ovaries *^fteii lieeoine healthy, or at least symptomatieally 
cured, after the primary souree of infection has bet'U removed from 
the liter uy. In order to facilitate the curettage and insure dniinage 1 
let the dilatation Ix^ tliorongh. 

Uff/eneraiion fij Enfifmuinum after Curelktge. Not only i* t!i€ 
sharp enrette eHieient, bat the reeeut investigations of Werth'uiwJI 
others show that pr(»mpt regeneration of the uterine mneosa tbllovv^^ 
its use. Studies of the reeeiitly curetted endonietriiiiu show tliaCH 
the work is often imperfectly done^ and that large port it ms of the dij*— ^ 

eased inueosa, [lartieularly in the eornoa and latenil walls, are appar ' 

ently inaeeessible lo the ordinary eurette. Special small curette 
should therefore be used fi>r these jmrts. 



hesf 



FiorRE 131. 



a~. 




Vcrticul section of iiti*rinf gland* three months afleT sharp curettage, a *?urfiicc epttbe-l 
Uum. ft, New-foruitil Inlands, c. tnlerglauduliir tissue, r, i. BluudvesMk. d. IfuscuUr lutttia.i I 

Werth reports liistological examinations of six uteri removed at ^ 
}H'rio<ls vaniug from three to sixtw^n days after curettage. All ca^^ 
gh*iwed unequal results of the stamping on the varions parts of the 
utc^rine niueosji. S<>nie parts \v<'re untonehed. In s*»nie the* super- 
fieial layers had been renmvefl and the deeper layers left, and in other 
parts the museularis had been attacked. The niuri>s;i in tbe fundus ■ 
and iu the lateral portions of the eavity was most fi-etjuently left ™ 
iDtact. Tfie abrasions tm the unterior wall were dw^per than on the 
posterior. They were also deeper in the lower part id' the corpus 
near the internal os. This is explainetl by the eonveiyeiiee of the 
downward stn^kes of the enrette. Except in places where the nins* 
cularis had iwen injured l>y the enn^tte, the entire lining of the uterus 
was covered w^ith new mneosa, the glandh ii|K'niug freely on a surface 
of unbroken snjR'rtieial epithelium. This young mucosa was charac- 
terized by a great preitomkntnee of fibrillary connective tissue over 
the connective tissue of the stroma. The regenerating tissue was 

' I VntrttlblnU t\\T (iynfikologic, No. 7, 1806, 
» Nouv. Areb. d'OUtdtrlnue et de Gyn6cK»lo0e. 



I 




CHRONIC ENDOMETRITIS. 



227 



wippM with blrxKl vessels which grew out of the musciilaris or out 
f»ftlu» remaiuing mucosa. The vt'ssels were .siirroiiiitled with a broad 
munlle of fibrillary connecti%'e tissue which followed their ramifications 
atmsi^t to the surface of the mucr^sa. 

The glands were regenerated froni their deeper portions that the 
wiMle had spared, e.^peeially from those Avhieh were situated where 
the muci>sa <lips deep down into the miiseularis ; they grew out 
' r^l the surface togetlicr witli the surrounding bloodvessels and 
^ riilar coiMiective tissue. Tlie surrounding stroma was observed 

Figure 132, 



imm^ 




'f,.^ 



>. i, - . 



,^^5^S^^St&""» 



tJterfne mucosa H ft y-three ilays after CBLUteriKntl on. a. Surface epithcl lam. &. Connective 
JJf. f tad d. Cross-section of glands deprived wf their epitliellum ^nd in a state of cystic 
"^ieoizitloo« iOiiD^ of them much dilated, m. Muactilaiis.i 



fi^qnently to grow more rapidly than the glands, and to give a some- 
^^'hat irn?gular, jagged contour to the regenemted endomelriurn. The 
^yperficial epithelium was found to be regenerated priucipally from 
that of the ghmds. In some plaees the young epithelial cells were 
foiimi flattened and euhirged. In ihe later stages of the regen- 
eration of the mucosa the excess of fibrillary conneetive tissue was 
"t>i«erved to dtsapjK'ar by hyaline degeneration. This process on the 
flftti day after curettage was visible in the subepithelial layers; and 
^►fl the tenth day only a few fibril la* were left in tlie superficial 
«tri»ma ; in their places were large, sjjindle-sliaped cells, with several 
processes of protoplaspm. Only in those parts where the rauscularia 

* NouT- Archlv. d'0bst{'trl>que ct de Gjrntoolo^e. 



228 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS, 

had been abraded existed a condition which resembled that of granu- 
lation tissue. 

Figure 132 will convince the student that destructive cauterization, 
at least during the age of maturity, is most objectionable. 

A thorough application to the endometrium of a saturated solution 
of iodine crystals in 95 per cent, carbolic acid, immediately after the 
curettage, is desirable. Its action on any neglected portion of the 
diseased endometrium may be good ; it insures asepsis, and by its 
coagulating effect plugs the open lymphatics and veins, which other- 
wise might become the carriers of possible infection to the deeper 
structures. The application, if indicated by the uterine discharges, 
may be repeated just before the next menstruation. When the 
application is made immediately after the curettage all blood should 
have been previously washed out of the uterus, and its flow, if pro- 
fuse, stopped by means of a saturated aqueous solution of antipyrine. 
Many operators * omit the iodine application, and maintain that the 
results are better when it is not used. The author's experience has 
been in favor of its use. Uterine gauze tamponade immediately after 
curettage is strongly indorsed by most operators. Entirely good 
results may, however, be obtained without it. The objections to its 
use are that, even though lightly packed, it is often promptly expelled 
by powerful uterine contractions, and that instead of draining it 
may reinfect the uterus. The more thorough the dilatation is before 
curettage the less liability there will be to expulsion of the gauze by 
uterine contractions.^ 

The treatment of endometritis, even with the curette, is not uni- 
formly successful. Dilated and obstructed bloodvessels cannot always 
be restored to their proper calibre. Disorganized lymphatics, nerves, 
and glands do not always resume their normal functions. Regenera- 
tion of lost structures is not always possible. In these respects endo- 
metritis offers a close analogy to nasal catarrh. In the glandular 
forms of this disease, while the endometrium yet retains enough of 
its integrity to insure regeneration of its glandular and epithelial 
structures, the sharp curette offers both a symptomatic and histological 
cure. When the disease has progressed to the atrophic stage of inter- 
stitial endometritis and the endometrium is physiologically destroyed, 
only a degree of symptomatic cure is possible, and anatomical cure is 
impossible. When endometritis is complicated with extensive chronic 
metritis and obstinate pelvic infection the uterine discharge will per- 
sist regardless of cnretta«re or of any other intra-uterine treatment. 
Under such conditions hysterectomy may be the only way of relief. 
Since this extreme measure might be indicated more for extra- 
uterine than for uterine inflammation, the consideration of it is 
referred to the subject of Inflammation of the Uterine Appendages. 

^Krujf: Amtirican Gynecological and Obstetrical Journal, January, 1896, p. 79. Pryor: 
Ibid., p. 10. « Loc. cit. 



CHAPTER XVIII. 

CHRONIC METRITIS (Continued). 
Chronic Myometris. 

Hypertrophic Myometritis. Interstitial or Cirrhotic Myonietritis. 
Superinvolution. Non-puerperal Atrophy. 

The purpose of tlnj* Chapter is merely to descrilie tlie elian^s 
tht take place in myometritis— that i?^, in the niyonietriurii of an 
inflamed uterus^* The ilisease is almost always seeomlarv to en do- 
ra(*triti^ and co-existent with it, and inasmuch as it is always as^so- 
cialed dtlier in the relation of cause or effect with infection of adjacent 
simt'tures, such, for exanifde, as the perimetrium and parametria, it 
caa never be a distinct lesion. Chronic heart, hint^, untl other vis- 
cem! diseases "which eml»arniss the einilatioti appear to cause contti- 
imi which are histologically similar to, if not identical with, those 
of myometritis. 

There are two forms of myometritis,^ — tlic hypertrophic, in which 
there is increase of all the histological elements; and the interstitial 
or cirrhotic, in which there is an increase of the connective and loss 
of the muscular tissue. This has l^eon called areolar hyjK^rplasia, 
Th^ geeond form often follows the first. In fact, the most frequent 
loatDraical factor in the later stage of myometritis is increase of 
iDtemiu§eular connective tissue. The causes are largely those of 
wtecedent endometritis. Any infection of the endometrium may 
ttteoJ to the myometrium, but such extension is more likely to f>ccur 
>« I sequel of labor or abortion. 

Hypertrophic MyometritiB. 

Sahinvolidtjcm is a frequent example of hypertrophy, and is pro- 
Juctnl as follows : The mnscidar elements, enormously increased 
Jiirin^ the evobition of pregnancy, fail to undeppif^) normal pliysio- 
'•i^cahh^eneration and absorption after labor. The connwtivc tissue 
^l-*<> remains superabundant. The lymph and bloodv^essels continue 
''^fi^N full, and stagnant. The uterine walls are thickened from 
'""Hf^^tion and infiltration. The entire uterus is usually, though 
I'^'t alv^rays uniformly, enlarged— that is, hypertrophy may pertain 
*sp^iiilly to the cervix or to the corpus uteri. The uterus may be 
J^(t as br^ as normal and the canal may measure three or four 
^ches. The organ remains soft and flexible. The flexibility cDnfi>rms 
^ the fact that many uterine flexures date from the pncrpcrium. 
Subinvolution may be defined as the failure of a physiological hyper- 
^pby to subsiile after labor. 

32P 



230 INFtVTIOXS, I^fFLAMMATIOyS, AND ALLIED DISORDERS, 



Son-pHcrpend hifperlrophy is pathological from the beginning and 
often tK'i-urs in woitu'ii wiiu have nevt^r Ijerii pregnajit. It is .somt* 
times clinic-ally ini|KJ.sj5ibie to distingaisli IjL'twwn the puerj>eral and 
noii-pnerperal varietiei^. Both are apt to be the result of myometritis. 



FiGtTRE 133. 



FicrKE 1^ 





Hyporlruphy of the cervix uteri : the spreml Iljjjertrophy of the corpus utoH" 

Ing apart of the cervix la due to lacemtiun and 
eTeraioQ.^ 

Greiit hypertrophic elongation of the f=iupravnginal and enlarge- 
ment of the infra vaginal portions of the cervix, with descent, are 
described in the chapters i»ti I^'ieeratioo of the Cervix antl Displace- 
ments, Sf^nietimes hyj>ertn*pliic cnhirgemcnt pertains ch icily to the 
corjnis nteri, sometimes to the cervix ; or it may uniformly involve 
the entire organ. Hyjwrtrophy of tlie eervix ie often confonodcd 
with laecration. Th*- symptoms, like the ciiiises, are almost identical 
with those of the associated endomt^rilis. In the absence of niarktxl 
endometritis, perimetritis, or parana'tritis, the nterns is not ver)' 
sensitive to the toneh. Downward disjilaec^nieut from in<*reased 
weight is nsnal. Perverteil menstrual and other iunctions are the 
same as in endometritis. The pritgnosi^ is much more tiivonible for 
pner]>enil than for non-pnerperid myometritis. Snbinvobition, if 
r»on-infectiouSj is ot\en only tcnqwirary. The disease is apt to be 
obstinate and destrnetive in pnifnirtion as the infectious element |>re- 
dominates. The treatment is largely that of the associated eudo- 
metritis. 

Interstitial or Cirrhotic Myometritis, 

Hyperplasia of the connective tissue, whether juierpeml or uou- 
pucriieral, may follow hy|>ertrophy or may develop independently %}i 
it. This form of the disease often results in a sort of jtathologic^d 
involution, with the fiillowiug permanent ehmiges : The lymph and 
bloodvessels shrink aud wither, the nntriticui of the niuscnlar ele- 
ments is cut oJfj and they disapijcar as if eroW4led out by the in- 
creasing connective tissue ; the uterus now^ becomes hanl aud aneemic ; 

» From ThoniBS and Mundi!', DiAeasea of Woiii«*n- 



CItROyiC M YOMETHJTIS. 



231 



• 



It mny Still remain large from the f^iqKinihundant ronnective tissue, 

baiiiaaUv» oicatrix-Iikt% this niiiy coiitrai't and rtiluce tlio organ I'ven 

»elow its normal size. Tlie influence of these chants iijm.hi tl*e 

jervp.4 is great irritation and suh,sei[«etit jwiin. The whole org^:ui with 

fits apjK'ndages and adjacent .struetures is in a state of pernianent 

linivlnutntioiL In extreme eases tfie u terns and its a]iprn<la<^es juay 

■ bve t<i 1h^ removed. St^e Iniiamniation of the Uterine ApjHindagerf. 

L)cal treatment is very nnsatif^factory. 

Sup erin voluti on . 

Sti[)tTinvoIation^ as the word implies, is an excess of involution. 
The pfwes< of degeneration and absorption after labor passes Ijeycmd 
the plwsiologieal limits, and the uterus shrinks Ijehnv its normal size 
and beoouies soft and exeessively mol)ile. The eondition resend>h*9 
senil*' atraptiy of the menojituise. Apj)areJitly there are two dis- 
tinct varieties of sn|^>erinvolutiou — one temjiorary, tlie other perma- 
nt^nt, They are ditlerenliated by the faet of a normal piierperiam in 
tiw t4?mpomry variety, and in the permanent variety by t!ie history^ 
«f a febrile pner|K'rinm. In the latter variety one or more of the 
fi'prfKluetive organs or [larts thereot— /. e,, the endometrium, myo- 
mi'triiira, and uterine appimdages — beeonie infected and jihysiologi- 
•ally ciestroved* In tlie tempomrv variety spontaneoun recovery may 
'xturmid tlie woman may again bear children. In tlie destruetive 
ffinii there is ]iermanent atrophy of all the stniotnres involvetK 
Menstruation, if it returns at all, is seanty and general Jy painfid. 
Iiiimwliate amenorrhtea is (lie rule. There is sumetimes a painful 
ttiolimeu in place of uieiistroation. 

Non-puerperal Atrophy. 

There is another class of cases in which atrojihy of the reproduc- 
tive organs occurs independently of parttirition* This form of 
ilnjphr i^; generally the result of chrotiie wasting disease, like tuber- 
^^\\om and diabetes; or of acute infections disease, like scarlatina, 
rnbe^jja, and enteric fever. There \i^ always cessation of menstrna- 
^'tin. This is a eonservntive eflort rd" natnre to save the patient *s 
Wfxd and strength. Unfortunately, however, the ill-health of the 
I'atij^nt is often wrongly attributed to the amenf^rrhoni, and treat- 
^^i designed to stimulate and re-establish menstruation is some- 
^'nu^ used. By such means the woman's vitality may be still further 
*xhiitb4tetL The above tacts from the therapeutic standpoint^ espe- 
niilly ill tubercular and other wasting diseases, are very signifieant* 
Clf-arly the treafrm'tit should not be local, but systianic. 

^iilx*rinvidution and non'puer|M*ral atrophy ai*e mre ; their causes 
obscure; the precise rchition of intianimation to their develop- 
^'tPiJt is not known. Except in the temporary non-intectious form 
^u^'ady mentioned, rer'i>very rarely or never takes place. Elect rieity, 
8pon^>-tcnts» h>cal massage, nnd all other forms of hw-al treatment are 
^^ «|(ipstionable value. Internal medicine and general hygiene are 



imlirati'd for their systemic effect 




CHAPTER XIX. 

PELVIC INFLAMMATION. 

Anatomy. Routes of Infection. General EtLologry and 
Sifirnificance of Pelvic Inflanunation. 

Inflammation of the uterus, as outlined in the foregoing chapter, 
may extend to the surrounding lymph channels, veins, cellular tissue, 
Failopian tubes, ovaries, and peritoneum. The subject of pelvic 
inflammation therefore includes lymphangitis, phlebitis, cellulitis, 
salpingitis, ovaritis, and pelvic peritonitis. 

Anatomy. 

The Fallopian Tubes are developed by that part of MuUer^s ducts 
above the round ligaments. The part below the round ligaments, 
together with the Wolffian ducts, converges to form the uterus and 
vagina. The tubes therefore are directly continuous with the uterus. 
The bifurcated uterus of the lower animals is a combination of these 
two organs. The mucous, muscular, and peritoneal layers of the 
uterus arc directly continuous into and form the tubes. By analog}' 
of uterine nomenclature these three layers of the tube are named 
from within outward, as follows : 

1. The endosalpinx. 

2. Tlie myosalpinx. 

3. The perisalpinx. 

The tubes extend from the horns of the uterus outward on either 
side and follow a bending course along the upper border of the broad 
ligament to a variable length of from three to five inches. They are 
divided into three parts : 

The isthmus. 

The ampulla. 

The fimbriated extremity. 
The Idhmm — /. t., the constricted portion of the tube — starts from 
the endometrium at the horn of the uterus, runs through the uterine 
wall, and continues outward toward the lateral wall of the pelvis about 
one inch. The calibre of the isthmus at the uterine junction, ofdium 
uhrhmniy is so small as scjirccly to admit a bristle. This constricted 
portion, unless dilated by disease, would prevent an intra-uterine 
in]c«^tion or secretion from entering the abdominal cavity. It also 
8t»rv(»s U) ])rotect the tube against infection from the uterus and the 
uterus against infection from the tube. 

The Ampulla is the expanded i>ortion of the tube, and easily admits 

232 



PELVIC I^'FLA3IMATI0K 



233 



the uterine probe. It nui:? from the itsthniiis backward and downward 
awund the outer border of the ovary, and tertiiinates in an expanded, 
trumpt-shiiped part called the ini\ind)l>uhiDi. 

The Fimbriated ExtrcMitt/ at the al>doniiiial opening is really the 
tennination of tlie ampulla. It is made np of irregularly shaped proc- 
es8«8, all freely movable except one, which runs along the tubo-ovarian 
tigBHient and joins the ovary. Thei^e firabriie are braneheri from the 
bigh mucous folds of the endoeaipinx. 

TheaMominal openings of the tubes are suipetimes multiple, with 
more tbn one fimbriated extremity for a single tube, 

Tk Endosalpinx, or mucousi lining, continuous with that of the 



FlQVBE lo6. 




r 

I"- 



^^nsMecUon of the nommi FAlIoplan tube at the fl«Utim uterinum. HArtnack Oc. 2, Obj. 2. 
JJ^ojoai. f. Clrculiur muscle fibree, b. Longitudiuftl muBcle fibres. L Subperitoneal con- 

"^m?, id made of loojse connective ti.s??ne covered with a sinofle layer 
'1^ ciliated columnar epithelinm. The cilia are always directed tr»wnrd 
*j*<^ uterus, and probaldy serve to propel the ovum in that direction, 
/litnuicr^sii in the isthnins is relatively smooth ; in the ampulla it rises 
*JJ numerous high folds. This is abundantly shown in eross-seetion by 
y^w 136. The presence of glands in the Fallopian tube has been 
fl^nial. Bland Sutton^ after an extensive comparative studv of the 
fe of thi' h>wer auiuials and of woman, declares that the ]jlicution9 
'^^ folds of the tubal tnucons membrane are disposed on the same 
["^inHpIe as the glands in the uterus. 

The nrohablc function of the tubal f«ilds is to provide an allui- 
tniuons fluid for the ovum n^ it traverHieH the t!ibe. The tube f>ar- 
^•<^ipates only in slight degree if at ail in menstruation. As shown in 
*rtopic gestation, it retiiins some power to fertilize the ovum. 



» Auj^uM Martki. Krauklieaeii dor EUelter. 





234 IXFECTIONS, INFLAA^fAMATIONS, AND ALLIED DISORDERS. 

Hie Mtfom!plit.r is made of two nnisoiilar layer?*, intornal ein^ular 
and external lon^^itiidinah Thesr layers are continuous with tlie cor- 
respunding layers in the uterus. It is not known whether or not the 
tube has peristal tie power. 

The PerhaljiinA'y or i>eritoneal investment of the tube, meet^ the 
mucous lining at the alKlominal opening. It covers about four-fifths 
of its eirctunfereiiee and, converging toward the broad ligament, forms 
a narro^v nie,s<jsalpinx» Between the layci-s of the mesoi?alpiirx is an 

FluL'ltfc 136, 




nhundance of loose connective tissue through which the lymph and 
bl I mhI vessels and nerves directly reacli the tube. 

Ovary. The abiloniiual end of the tube is nonnally elo&e to the 
ovary and conimiinieatcs with it by the tnbo-ovarian ligann*nt. Th 
ovarian ligament connects the ovary with the uterus, I^*tween tb 
in.sertions of these two ligaments the ovary is joine<l to the jK>sterioi 
fold of the broad ligament by a broad base, the hiliinn through which| 
pass its lymphatics, bh mm! vessels, and uerxes. Above the* hilum 
ovary is covered, not by peritoneum, but liy g4'rm cpiHieliuni 
called, which furms the Gmafian follicles and Irooi wliieb the ov 
originate. The minute anatomy of the ovary n^ further eoiisidereii i 
the chapters on Ovarian Tumors, 

Cellular Tissue. An abundance of loose eelluiar timuc binds 

^ Augtifit MAriln. Kmnkhelten der Ellcltcr. 



■I the 
1, ^ 




PEL VIC I^FLA MM A TION. 



ik' pelvic viscera topjether It is continuous with the celkilar tissue of 
theukrusand its appendages, and is toiind in larg;e quantities especially 
in the bruad ligaments ; it is the medium through which the lymph 
ami hlomivessjeis and nerves connect the n ten is with its appendages, 
ami bring them all into close anatomieal, pliysi(dogit*al, and patho- 
Ifigical rflatii>ns. The cellular tissue, and partieularly that of the 
bnxiil ligaments, becomes therefore a most signitictint factor in jielvic 
infection. 

Boutes of Infection. 

Since tlie source of circtim uterine infection is nsnally endometritis, 
it follows iUnt tlie routes by whi*4( it passes to the outlying strtictures 
mitritofb'ii h'ad from the endometrium. Twii such n Mites have already 
been outlined, one by continuity of mucosa, another by tlie lyni(jh and 
blt^Wvesselp, See Chapter X, 

TlitroiUc by confinuittf of murom is evideiiccil l>y the facts: first, 

that t'miosalpingitis is kmnvn to fuOow endometritis when there is no 

rfvement of the lympiiaties or veins or para-uterine eoimective 

&; j^eetmd, that the same niierobcs are fonnd in the intiamed 

[teiicosfi of t!ie uterus and tid»cs when there is no iufliiminatitju of the 

Uiibmiieous connective tissue ; third, that the tuba! iufeetion is some- 

tinji's limitetl to the uterine eiul of the tube and directly continuous 

[vitli fiinnhir inflammation in the horn of the uterus. 

The lymphiith' tthd venous routes are evidenced, first, by tlie fre- 
(j'Jt^iit preseni'v of salpingitis in the alKh>minaI <'nd of the i\\\w un\y — 
' if it had travelled from the uterus by continuity of surface, the inter- 
yeniog miict>sa would usually, thmigh not necessarily, have been 
'"fet'tal ; second, by the frerjuent infection of tlie pam-uterine 
lymphatics and veins, together with the connective tissue around 
them, when tlu.^ Fallopian tubes are nonnuL 

The relative frequency of selection in these two routes is unknown, 
riie^^mocm-cus, formerly thought to thrive onlv<m epithelial surfaces, 
'i^i'* been found in eonneetive tissue, and is known to be carried by 
tlie lymph route.* Its presence in tlie uterine muscles^ and in the 
emliM'^nlium^ has also been denifmstrat*'d. The propag-atiou of other 
^Otivlious microbes in the blood and lymj>li vessels, and their tmns- 
""^^iori through them, has long l>een rect>gniz*'<L The investigations 
^*t Ij(^»j>old show the endometrium to be so abundantly supplied with 
'yf^if'batic vessels that it has even been called a lymphatic gland. The 
'ymph route, therefore, is demonstrable both fnuu the bacterial and 
f^»n the anatomical standpoints. The route l>y contiimity of surface 
^ay also be a lymph route — that is, the infection may spread through 
*"t' lymphatir-s of the mucosa, 

Tlie lymph vessels run from the uterus outward into the ccl hilar 
ti^^de between the fob Is of the broad ligaments, along panillel to the 
ItiUs and the ovsirian ligaments to the inguinal, fibturator, and iliac 
lymph glands. These vessels are in direct communicati*!!! with the 

The author in inclebted to ¥.m\\ RIoh for certain abstracts from the literature on the 
•fi4toi»]r nfid p»tholt>ffy of sjilpinuitis and ciVftrltfs. 
;lii. Lehrhuf'inliT r 



UugiiJt Mart In 
*AagiiflC Martin. 



?hrl>nf^ii AvT Frftuenkmnkheiten, 180.1 
Ceuiralbljvtt fiir Gyniikokpgic. 18U5. 



•!>i?yden. 




sitle (lie coui>«e of the normal cirnilarion in the uterine and tubal 
lymphiitics and veins. Observe that the current is outward both 
fr(»tu the uterus and from the tubes. The vessel, a b c, would carry 

t Alter Potricr, in Fosci. Trefttise on Gytieeolui^. * Hugg^ited bjr lUei. 




lion away from the uterus to the ptimmt^tria ; but the jmssago 
llFiiuld not naturally Ix? froni a h e U\ thv tube over h d, because the 
I course through that vesisel iy in the fn»pn.site direction. Suppose, 
kowever, thrombosis to occur in v^essel a^ f/ c* hetv\(^en f/ and e', as 
skwn on the opposite side. Then the outward current of a' b* might 
be strong enough to overcome the force of the currtTit d* A' and turn 
it in the opposite direction, as shown by the arrows^ direct to the 
tniie. The same condition and the same exphiiiation wtndd account 
fur tlie transmission of infection to other extni-uterine j>elvic organs, 
[ even though the natural current were in the opposite direction. 

Reversal of the current is, however, scarcely necessary to explain 
I infrction by the lymphatics, because the circulation is so slugtrish 
that ittloes not strongly oppose the transmission of infection ; more- 
over, infection may to a very great extent be carried with the circu- 
latiou direct. The veins an^tstomose freely ; their current is strong, 
auJ requires therefore a decided obstacle to give it a new- direction, 
Traasmission against the venous current therefore is more difficult 
and IftssfreciuenL The final transmission of infection from the uterus 
to tk tubes by the veins probably occurs only when the current is 
revcDji+Hl by extensive throTiibic plugging. 

Transmission by continuity of mucosa does not invariably involve 
atl tlie epithelial surfaces over whit-h the infection has passed. It 
ii^ probably possible^ although not usital^ for infection to travel 
from the endometrium to the abdrmiinal end of the tube %vithout 
intervening infection of the uterine end. Even though the uter- 
ine end ha-s been infected, it may, owing to its smootlier surface 
and gri-ater resistance, have recovered, leaving the disease only at 
the Eilxloniinal end. 

Thp lymph channel may be the mere ciirrier of infection, and may 
iteelf sliow no trace of inriamraation, ut it may be inflamed through- 
^«t; this is because the l>acteria by whatever route carried will erdnn- 
J^e at [loiiits of least resistance, and because the resistance along the 
^>u^e may or may not be sufficient to withstand their force. Freciloni 
mjtn infection in the vessels therefore does not pro%^e that infection 
has parsed by continuity of mucosa. 

A third route of infection of extm-pelvie organs is illustrated by 
thecagpsof Binkley* and Rol>b.- Binkley's cas<3 was purulent salpin- 
pti^ foll^^^yjjj^ purulent append icitis, a sequence frefiuently obiscrved. 
ln[>er(!ii|nr peritonitis^ often extends to the tube, ovary, and uterus, 
m Very rare cases it originates in the cervix uteri and reaches the 
ovarif^:^ and tubes from that point.* Usually it spreads from the 
I Fritoneiun. 

Etiology of Pelvic Inflammation. 

^ince extra-uterine pelvic infection nsually originates in the endo- 
I '^^'^Iriiim, its causes will for the most part correspond witli those of 
[^ndoitietritis. It may, however, start from infection in the intestines, 

' Bfnlclcy. Cincinnati Lnnret and rUnic, MRrch »1, 1896. 
« R<tbb. iohna Hwkirifl HospmU Bull ft! n, No, iK), 18&2. 

* Hreat. GeniUl TubHrculwi? ckr WidlK^r. Sluttirftrt, 1S96. 

* WilUatiia, iahutt Hopkins Hmpjt&l KepKirt, im± 



238 ISFECTIOyS, TSFLAMMATIONS, AND ALLIED DISORDERS, 

blidder, |ieritonetmi, or vajritni. Inflammation of the uterine ap- 
pendage:^ may be a se<jiiel of {\i<\ acute iiilectioiiH diseases*. Pelvic 
Mmatocele may become the seat of iiifeetion and be the predisposing 
oaase of a pelvic abscess. See Tubal Pregnancy. 

I^ioeration of the perineum and cervix, and other tran mat isms of 
peirturition and of enr^-ry, may open the way for the entnince of in- 
ttvtt<vD thniugh the bkMid and Ivmpli eliannels. The pneqK^ral and 
trtiimiatie infections more fre(|uently take this route* Infection may 
be eswrieil to the uterine appeiithif^es from external cervicitis.* 

The microbes of the infwtious diseases have been quite generally 
found in the genitals. Among them are the gonococcns, the tul^ercle 
liaciltus, tlie streptococcus and staphylococci, the bacterium coli com- 
munis, the pneumococcus,* the typhoid bacillus,^ the niierol>e of iliph- 
ihfria,* and the kicillus of malignant rcdema.* At h'usl two cases of 
aetinomyc«X'sis have In^en n^iwrtet!/ One of the most frequent mmles 
i»f iotW^tion is by uncleanly operations, local treatments, and exami- 

Significemce of Inflamination, 

CHliHHnuierine inflammation involves diverse changes in the Fallo- 
|uaii tube^ ovaries, jK?lvic peritoneum, lymphatics, lymph spaces, 
vviu.S and ^H-lvic cellular tissue. Infection of the Fallopian tulies or 
ovarii^ may have the closest relation with infection of any or all of 
tbe^ MnnHurrs. In this connection it is essential to grasp not only 
Itue ttHtHiv atul anatomical results, but as well the siguificauce of the 
luiMllllUltor}* pnxvss. The greatest danger is not from tlie iuHamma- 
licm, but fifom the infection. Inflamniation is an effort of nature to 
tkffi^lid the iJi?m*nd system against infection, Chapter X, If the 
Uitivliou has jKisstHl by ix>nti unity of surface through the tube, it no 
?*iH.kiH»f rvHclK*s the jH^lvie cavity than the peritoneum attempts ta 
|>r\^twt it>ielf tnun further invasion by prompt closure with intlamma- 
^%frs adhesions of the alHlunnnal opuiug of the tulH\ The uterine 
\mkX ttiiiv likewise* bt* «*h»s<Hb and the jwisou thereby shut off also from 
]||ie tsHlMaietrium. 

\\ !u n tlio inftvtion has react rhI the jK-lvic cavity and prtKluced 
M*>r* He itiftammatory process may promptly confine the |K>ison 

M lAXviastc tdl^Qpnir *>f the vessels, or the lymph effusions may be 
^lllll^^f^ ^Y Mtf$lc4Miiu adhesions and a protective wall be fornu^d ; in 
^Pt mMM^ tf t>l^**^ processes takes place, the infection will s^K^c^lily 
i^v«j1v**' iki^ ig^ytta peritoneum, and its jioisonons pnMlnets will l>e 
ifeCt^vi^i^ and pvureil iu fatal quantities through the broad 
^^^H into the gt^nenil circulation. 

with the profound depression of the nervous 

Qmiiiea, the anxious fiicies, the pan*tic and dii^ 

L^MlAi ^ywp*'^^^^'''*^ which gii to make up the symptom- 



»of IK* OTArteft And FalMpfaii Tube*, 18M. 

* . No. n. 1H02, 

p^jhrlft, No, 21, 1803. « Ibid. 

I land Grnikotoffte. No. 'i^ 
_ „, Ontcml WaU for Gy nakolcwle. p. 5§0. imL Oimt 
ti^icv^ 1 ; Uonatschr. f. Gc<b. und Qyn,, 180^ quoted 1 



PELVIC INFLAMMATION. 239 

group of peritonitis. These grave symptoms are wrongly attributed 
to peritonitis ; they are rather the result of the profound ptomaine 
poisoning which the peritonitis is perhaps unsuccessfully striving to 
shut off from the general circulation. 

When the infectious poison starts from the endometrium and goes 
forward by way of the lymph channels or veins in the cellular tissue 
of the broad ligaments, these vessels may simply transmit the poison 
to the peritoneum, tubes, or ovaries, and themselves escape infection ; 
or the course of the poison may be arrested by thrombic plugging of 
the vessels and by consequent extensive and destructive perilymphan- 
gitis or periphlebitis. The result may be an almost overwhelming 
pelvic cellulitis. The inflammation may be for the most part confined 
and the poison may spend its force within the limits of the cellular 
tissue of the broad ligament. The destructive process in the tissue 
may be so great as to end in permanent impairment of the pelvic 
nutrition and in chronic invalidism; but the pelvic cellular tissue has 
taken the brunt of the poisonous attack, sacrificed itself, and perchance 
saved the life of the woman. See the following chapter on Pelvic 
Cellulitis. 




1 J/. Levator anU 

Three dtvlsloiui of the pelvtc mvlty— vtx., periUineal, subperitotieat. tnd mbcuUii^oiii,* 

cellular tissue around the uterus and vn^ina, more es^pecially that 

between the folds of the broad lipinieuts. The temi paramctritii? h 
tm> restricted J since the <lisease rniiy tx^cur in the lawer regions of tlio 
pelvis* around the vajjinn ami hriwel. (/olhditis Uenrs somewhat the 
fwinie relation to peritonitis as ]>iienmonia bears to pleuritis — that ts, it 
h uttually associated with a variable degree of iKTitouitis. 

^ After Fehling. Lebrbuch der FrBUenkranlteUen. 
240 




PELVIC CELLULITIS. 



241 



I 



Etioloffy, 

Parametritis, or, as it is coninionly «illod, pelvic w! lull lis, is 
tifrUaUy of puerjx^nil origin. Its caiisos {hrreiVire are largely iilenti- 
Gll with tlioj^e of puer{>eral inftxitinn. The etif>Io|ry in general is 
considered in Chapttir X* The gonoenenis iiiLS het^ii fnnnd in e(»n* 
nee live tissue, Hegar lias ol>served it in the lymph vessels uf the 
|Kiniinetria, Tim must freipieiit baeteHii in eellnlitis are the eomrnoii 
pus cocci. The soiiree of the infection is usually the inrtiyned uterus j 
but it may start from the ijerineum, vagina, bladder, or rectum. The 
rectum, urfthra, and bladder art? freijueot sources of cellulitis in 
men. It may l)e due also to nnelcan therajx^ntie appliances, such as 
t^, and pessaries, and to se[>tic niani]>ulation.s generally. Trau- 
ti*^m8, ei5|>ecially those of |>arturitioii, ojRqi the way for tlic entmnee 
of the bacteria. Althnugh celhilitiri most fretpiently oecurs an the 
result of pueriKiHil infection, it is l>y no means confined to that state. 



■ reel 

Is 

I 



Pathology and Pathological Anatomy. 

The disease may affect not only the cellidar tisstic in the broad 
ligaimentii, pnKlueing parametritis, but sotnetinics the utero-sacml or 
utenj-vesical cellular tissue. (3ceasif>nally tlie disease encircles the 
uterus and ii< then called eireinn uterine cellrilitis. 

Cellulitis reaches the cellrdar tissue liy way of the lymph channels 
or reins, and is primarily tli ere fore a lymphangitis or phlebitis. 
The lymph spaces have no walls save tlie eelhiiar tissue around 
them; inflammation of this tissue must he cellulitis. When infec- 
tion is travelling by way of the lymphatic vessels and veins, which 
do have walls, aiid inflammation results, it will first he in the 

lis. An early attempt is made to cheek the spread of tlu:; dis- 
hy tlinunhosis. Destruction of the walls of the vessels may 
follow. The intlamiTCitiou will then spread to the surrounding 
fltrnctureg. This woidd be |R^rilymphangitis or peri[>hlebitis. The 
ti!«.<^ue around the vessi^ls, however, ia celhdar or connective tissue. 
The disfrase in it.s fidl development is llien^fore celhditis. Hence to 
define cellulitis as perilymphangitis or peri phlebitis might he strictly 
accurate. 

The cellular tissue of the jjclvis binds the variotis organs tc^ther 
and fills nearly all the space in the j>e1vis not occupied by tliem ; it 
exists in great (piantities anunul tfic uterus, vagina, rectum, bladder, 
and tlie p^ioas and iliacns muscles, an<l furnishes an abuntlanee of 

Uerial fi>r the development of cellulitis. 

Cellulitis, like other inflammations, is divided into three stages : 1, 
ct>ngestion ; 2, effusion ; and 3, suppuration. The flisease may ti^r- 
minate with either of these stages. Successful ab^irtive treatment 
mav arrest it in the congestive stage. If it gtK*s to eflusiim, it may 
enJ in rej?olution and complete recovery, or continue as chronic 
cellnUtts, or go on to sufipuration an<l form a jielvie abscess. 

The blorxl and lympli vessels here and there are plugged with firm 
inflammatory thnjmWises. If resolution does nt>t follow, the tlirom- 




242 INFECTIONS, INFLAMMATIONS, AND ALLIED DISOEDEES. 

boses hroak tlown ami the corresponding spaces are filled with pus. 
The infeetii>ii spreads trotii these sniidl eullcctions, which are, in fact, , 
small abscesses, anil lVcf|iicntly leads lo the foriiiutiun of single or ^ 
in id ti pie abscesses in the broad ligaments. TJiese abscesses creep ■ 
ahmg the meshes of the hx>se connective tii?sue, avoiding the rtnuer 
and stronger parts, and unless opened burst into the vagina, bladder, 
or intestine, or above Po opart's ligament, rarely below it, or into thi' 
labia niajora. Abscesses of celhditic origin most iVequently burst J 
into the v;igina ; lliiisf of tubal origin, es]x*eially if siirnmnded by ■ 
jK-rituiieum, are more apt to break into the bowel or bladder. The 
bursting of an abscess tli rough the eiitaneons sorface or into an org:m 
which atlVii-ds ready dniinage may, if it does not cause fresh infec^tion, 
l>e followed by sjK*ntancons eun\ The iiiTaking of an abscess intoj 
the peritoneum may set np fatal j>eritooitis. 

FlQUliB 140, 



^^, 



-mt 



<^3 

h 



^,^^ 



'-j'^'y. ^ 



..iti^: 



PttraTnetriUs, Exudate In Ipfl snV.pentoTn*al mvlty, etowftlnR oorpus utcrf to ripbt. Piir*^ 
colpit^H in ri^hl sub<-iitnneuiiH cflvUv. cTowdiiiu * i-rvix Dli?rf iitnl vAt^ina to It-fit. Tlili latter 
would produce a i»erift!inl aliscp***, and wuuld usunUy be followed by fi§lala in nun. 



In verv severe eases, with extensive invasion of the lymphatics, 
tlie wliole eelbdar tissue of the jwdvis may be involved in pani- 
cystitis, paraciiljiitis, paraproctitis, and parametritis. This type 
usual Iv resnlts in multiple al>sccsses and great systemic dislnrbanee. 
It is known as the ertfsfpt'ftts nutligmtm intenmin of Virehow, or fUfiuxf 
irlfufiih of Pozzi, Tliere may also be extensive ht^morrliage^s from 
destroction of t!ie bh^odvessi^ls! The clinical picture in these cases is 



PELVIC CELLULITIS. 



243 




diat of an acute geneml septicsemiii. The infpption may result in 
getKT.il pTitunitis and aceiininliitions fif jms may fnrin tliruiighoiit the 
aWomiual cuvitv. The condition is rare and the rate of mortality 

Fi>rmerly cellulitis wvt^ considered the central lesion in pelvic 
ioflaniuiatitjn. Salpingitis, ovaritis, iind j)eriton!tis were searcely 
zed a* surgical diseases, A great advance was made in y>nu;ti- 
, vie pitholtigy when Buttey, He^ar, Tait, and others sluiwed the 
vajstly greater Relative importaue(% fVoni the surgie^d stancl]u>int at 
ieaiU ef tubal inflamniatiou. When purulent accumnlations iu the 
pelviii were commonly attributed to celhditis, and were therefore left 
to theiUijelves or treated l>y iucisinu and drainage into the vagina, 
the fail un*s were many and imexplained. As soun, luiwever, as tliey 
were {renenilly recognized as accumidutions of pu!* in the Fallopian 
tube^ it was easy to understand why incision and drainage wen* so 
often followed by failure. It was because the tube is lined by mucous 
tuhraue and because chronic snppnnition of mucous surthces, even 
'a drained, is most intrac*table. On the other baud, a ('ellnlitis 
!?nrrounded by cellular tissue vviicu emptied is apt to close 
spontanei^nsly. Pelvic eellnlitis tliendore, unless complieated by 
taW communication, eitlier term i nates rapidly by resolution with 
cmnplde recovery, or, if suppiu-ation oecurj it empties sjumtaue- 
OQsly or is evacuattHJ by incision, and like a furunele, which it 
fesembles, promptly disjippcars ; hence the celhditis abscess, unless 
of tubal origin, sehlom becomes chronic, and therefore has little 
or no part in the more familiar chronic pelvic suppuration fnr 
*hich rlie uterine apjjeudages and s^nnetimes also the uterus have 
to he removed. 

The clinical experience of the laparotomist shows pelvic suppura- 
tion to be almost always iu the tube. It rarely shows a trace af pus 
in the cellular tissue below; and if |>e reliance an abscess be fouinl 
llit?rr.', it usually gives evidence of liaving bni*st from the tul>e into the 
Wirl ligament. 

The above facts have led to a tendency of late years, especially 
^m» the laparotomists, to deny the existence of pelvic cellulitis, anil 
>imce the trijile proposition ; that cases of extni-uteriue pelvic 
:nation are, cxce[)t iu rare instances nf poerjiernl (U'igin, esseu- 
^'•tih of tnl>al development; that nvaritis and peritonitis ar<' always 
|*<^fMidary to tubal *lisease ; and that an abscess in the broad ligament 
t^ th<>re only when a pi-evious infection of the Fallopian tube has 
f'Tml itji way thrmigh the mesosalpinx into the parametrium. In 
rtij* connection let us renn-mljer tluit the *liscasc occurs in men, who 
tive no Fallopian tulw's. Why slmuhl the cellular tissue rd' the jielvis 
w fri*e when the same tissue in every other part <d' the budy is subjtx^t 
t^' inflection ? Would it not be just as reasonable to assume that 
pHritis IS the central lesimi in all pulmonary infection, or that peri- 
Ji+'phritis IS the es,sential factor in all cases of contracted kidney? The 
lUcHrion, however, is not settled by a priori reasoning. P(»st-mortem 
itttdies prove the fret|uent existence of acute cellulitis abscess not 




244 INFECTIONS, INFLAMMATIONS, AND ALLIED DISOEDEB& 

only by nipture of a sactosalpinx into the parametric cellular tissaei 
but also by the direct, lymphatic or venous route. 

Chronic Atrophic CMviiti^. There is a form of chronic cellulitis, 
described by Freund, characterized by atrophic changes analogous 
to cirrhotic disea.se in other organs.^ This disease may originate 
in inflammation of the uterus, bladder, or rectum, and is especially 
apt to include chronic atrophic pericystitis and periproctitis — t. e., 
inflammation of the connective tissue around the rectum and blad- 
der. This would cause contraction of these viscera and shortening of 
the vagina. 

The atrophic contracted cicatrix-like cellular tissue may cause 
excessive versions and flexions of the uterus. Since, however, the 
symptoms would be due rather to tlie cirrhotic disease than to the 
uterine deviations, mechanical support would be of little or no value. 
Perineuritis ; neuritis ; destruction of blood and lymph vessels ; pinch- 
ing of the ner\'es, lymphatics, bloodvessels, and ureters by the con- 
tracting cellular tisi«ue ; pain ; local malnutrition ; a wide variety of 
reflex ner\'ous disturbances ; chronic invalidism : all these are among 
the results of the atrophic process. 

In contrast with the chronic atrophic cellulitis of Freund, is the so- 
callc<l cellulitis of Stapfer.^ It consists of hard, (edematous indura- 
tions in the abdominal walls and in the walls and floor of the pelvis. 
The disorder is characterized l)y pelvic discomfort and pain. The pain 
is sometimes neuralgic in character, usually inconstant, transitory, and 
severe. The inflammation is of very mild type, \s\i\\ slight systemic 
disturbance. The transient nature of the disease suggests the analogy 
of urticaria and a probable angioneurotic element m its causation. 
Stapfer declares that the condition is common, and oflen mistaken for 
more serious affections. 



Symptoms and Diagnosis. 

The symptoms are nearly identical with those of inflammation of 
the uterine appendages. The reader is therefore referred to that sub- 
ject, es[)ecially when the inflammation is secondary to salpingitis or 
ovaritis, or situated in the upper part of the broad ligament near the 
tubes and ovaries. When the disease is at or below the base of the 
])road li<rjinient away from the api)endages the location of pain and 
swellinir will (H)rrcsjK>nd to that of the inflammation. In acute cellu- 
litis there will be severe radiating pain, hi^h fever, chills, great local 
sensitiveness, pain shooting down the thij^hs, inability to walk or 
stand, and painful urination and dolecation. Acute symptoms may 
decrease, and when suppuration occurs reappear, modified by the 
signs of hectic fever. 

Pus in the subperitoneal cellular tissue, whether connected with 
tubal suppuration or not, may burrow through the loose cellular tissue 
and discharge anywhere in the vagina or rectum, or through the cuta- 
neous surface above Poujwrt's ligament. Complete recovery in the 

» Freund. Parametritis chronica atrophicans circumscripta ot <lifl\i8a. (^entralblatt fQr 
Gynakol ogio. » Stapfer. Aunalos de (lynecologie, July, 1S98. 



PELVIC CELLULITIS, 



245 



wm-txAd cases may pnnnptly ftjllnw free evacuation. Abscess for- 
[inatioD is usually roarkotl by cluUs^ and later the presence of pus 
is ailended liy hectic fever. 

The (liriguusis of jiiininietritis whvn connected with tubal disease is 
Deeessarily cojifu^cnl with thai uf the original afleetifin ; it is -simply 
ao exten riion < » f I !* e la 1 1 v r i ii to the I j roa d 1 i ^ in e n t s . \V 1 1 e n sa 1 p i n g i t is 
Mil pinuiietritis are due t<> .Hinudtaneoiis infection^ as oi\en oi-eurs in 
tie pufTj>eral eoudition, the difficulty vi^ diagnu.sis 'm very great, and 
lhi<dit!iculty i-^ increased by tlie fact that a thoroiicrh examinaticjii in 
tip i>eginning is usually so paintul as to l>e almost impraetieul»le. 
On [)iil[»atiou the exudate of cclbilitis is found tri he lower in die 
pt'lvis than sactosalpinx, less strictly defined as t(» its boundaries, 
gent'mlly uni lateral, occasionally bilateral, or before or behind the 
ttt^rus. On the other han<b if the tube alone is distended, it is telt 
mon? retrolate rally than laterally, and is more elastic than the celhi- 
te exudate. The sense of elastic Huctuation is more nuirked in the 
thin walls of hydrn>alpi-nx than in the tliiclc walls of pyosalpinx. 
Parametric exudate unu-e closely resembles the latter. 

Pelvic luematoraa or Ineniatncelc in the pamnietrium forms a tumor 
fte same in shape as that of an iuHammatory exudate. The history, 
kwever, is character tzetl by su<Iden onset, overwhelming piin^ sub- 
»tonual teraperaturej an*l, in some cases, rapid absorption with com- 
pline recovery. IL^ematoeele may, htnvevcr, terminate in infection 
*tMl iiKsce^??i. See Tubal PrejEcnaney, 

Pelvic peritonitis, commonly the result of tubal diseasCj may 
w (Yinfused with cellulitis. In fact, there is usually more or less 
pritonitis accompanying cellulitis. The symptoms are much the 
s««ip in the two conditions ; but they arc less trrave in cellulitis and 
*Bwec«>ramonly nnilateral. The exudate of jieritonitis is more likely 
t«8urri)tmd the nterus and to fix it in the mediiui ]>osition ; while tlie 
wrutT inflamraatory tumor of parametritis, if confined to one side, 
^11 force the uterus to the extrt*m<: opptisite side. The Intend dis- 
Pwement therelw proiluced is reversed when the exudate resolves 
*ftil the uterus is finally drawn by the rontracting l>road litjpamcnt to 
iw o|j|K>^ite side. The exudate of peritonitis is less prominent to 
^m jmlpation tlmn that of cellulitis. 

Prognoais, 

The pmgnosis in the acute form, if uncomplicated with tubal dis- 
^^^ >? usually good. The in Ham mat ion may terminate in speedy 
'*^lntit>n. If abscesses form, there may be rapid an<l complete recov- 
*^' aittT evacuation of the pus. When pus tubes coexist their re- 
n»ov:iI ixijiy he ncces«nry. The chronic atrophie c(dlulitis of Freund 
*' •♦'Htinate for symptomatic and hoj>ele,ss for histologieal cure. 



Treatment. 

*rmbnent of Acute Poramefrith. Tlie reader is especiallv referred 
W m prophylactic, palliative, abortive, and surgicid treatment of 




24-^; tyypA^noy?^ isila^oiatioss^ axd allied disorders. 

zfrrtr rri^rrr.'.i-. ^M-rrz, :r.r- H^^fAr*= i- ?^>i>iary to salpinsxti^ the treat- 
::.<-;.• ::.">• r^ ^I'-r-^r-r*! :•'• lir c:rr:>r app»-i>iag«E<. If the s«:*urve of 
rh- a^-r;v: ;:.>-i -:!•.. r; rji^- h^r^ri a w»rf;-*i cMr in a ^crg^cal opc-nition 
or in j^ir.'jr; ::•■:.. .r: :h- f:ir-»-^i -^^rfin.^ies- I* dbon-ughly cauterized. 
For u/.r |rfirj»/2e ;: n.^sy •>: a^:^; — ary :... xvfni.-ve the >aturv^ frum a 
T'jtiiT^i <>:r\ii or i^rlrifr'jrrj. >L -l*i ihr: -•-uree of infecrii>n he an 
ifi :'':<-•*:* I *-ri'loLr.*-tni;rr*. ::• r^-ni«>vil r.y •hirp ocnrttage may be ei:»n*id- 
'rPr'J. Sr.^ ChapUT XIV. Av.-i-i n.r:nDe uterine treatment. 

Tr*ohn*iff. in Chr^ft'i''- f'r*rj^. A^ hen acure symptom? suWide let 
u\^*'r]r:ou \jt: prr»rri^'>r*i hy th- ipp'.icatioa of Chnrt^hillV tincture of 
ifpl'iu*: Uf th'r va^rinal f"nj:x in«i li.*^ inguinal r^ons. The hot-water 
v^^inal doiK-L':. ar *k--rii.-:«i ::i < hapier lA'., is u.<^ful. .Small do»e< 
of ^•alorn'.'l. on<:-twfrrjii»;:ij "f a irrain thniv rime? a day. with valine 
niin'-ral wat^-r to r^-cur*; regularity of the hMnweli^. are *trr.ngly indi- 
csiUil. .Sitz-f/ath» and hot fr-mf-ntation* are palliative and promote 
n-orptioij. Th^r fi»mjati<in of j»i;s i- a di^tinvt indication for its 
removal. Wli'-n .-iij*iiurati^»n ^^-er-urr t-arly in the di^^ase the evacua- 
tion of tlu; pii- ir ofti-n f<»l^•^^e^l hy complete cure. Chn^nic suppura- 
tion in'lir-ate- tul^al diK-a?re. um] may therefore require removal of 
tli#' apjK-mL'jg*-. An acute- jK-lvic ab?«ce5* due to cellulitis is ii>uallv 
U-t ojKn«-<J iliroii^rlj tlu.* vagina. The pu« is easily made out by 
fluctuation, generally to (mo r»i<lf- i«f the utenis. Its presence may be 
\f'niit'4l by I lie a-pirator nf-f-<Ilc or by the large hypodermic needle. 
TIk- w-t'tUt' njay then be u-f-il as a guide, and the o])ening enlarged by 
intrMliKJii;: tlir- *liiir|>-|>'jintfd rci-sors and spreading the blades'; 
aft»r t|j'- prrliniiunry incj-jdn throngh the vaginal wall the remainder 
of th*- r»jKriirig may. as (lf>cril>Hl in Chapter XXIII., be made with 
th*' firjg^r. T\u'. hiI^Ikt tube or ganzo drain may lx» insertc*d and the 
vM^ina i»iirk<'rl with gauz(». Should the ^urgeon evacuate a supposed 
r;*llijliti- ab-r*-.-.-, and tlie di.-earre j»rove to have been pyosalpinx 
iri-t<'ad, no harm has bern done, for such accumulations of pus, esjM?- 
cially whrn acute, sometime yield to the same ojK^ration of incision 
and drainage as adv<K»ated above fr>r cellulitis abscess. Later, the 
tube ruay, if necessary, be removed by al)dominal or vaginal section. 
An o|Mijing thrr»ugh the rectum is inaccessible for after-treatment, 
eoiupliejite- drainage, fiivors reinfection of the abscess-cavity, and is 
thrnf'orv* to be avoide(l. In this connection the reader is referred to 
the treatment of jwlvie .-uj)|)uration hv incision and drainage — Chap- 
ter XX in. 

Ibiekell rej)orts uumerous ca>es in which parametritis resnltetl in 
the f'oniiMtion of circiimscrilu'd .-erum instead of j)us in the cellular 
tissue. These collections are said to exist occasionally in considerable 
(juaulities. Kemoval l)y aseptic aspiration results in radical cure;* 
hrnrc if upou o|)eration the fluid ])rov<» to be serum, and not pus, 
further o|»('niug and drainage may be unn(»c(»ssarv. Pus, however, 
may have so far h)st its cor|)Uscular eh'ments as to resemble pure 
serum. A microscopic exann'natiou of tiic* iluid therefore, to settle 
the (liagnosis and the <|uestion oi' drainage, may be necessary at the 
time of the operation. 

> lirlckrll. AimTlciin Jouriml of tho Mcdl<*al Sciences, April. 1877. 



PELVIC CELLULITIS, 247 

The treatment of chronic non-suppurative cellulitis — that is, the 
atrophic variety of Freund — is discouraging. The estimated value of 
8en-lmthiiig, electricity, glycerin and tannin tamponade, vaginal and 
H'cial douches, and painting with i(Kline, varies widely with different 
phy.sicians. The author has not found such measures of great value. 
The chief reliance must be in local and general massage and in sys- 
temic treatment. 




on ou 

FIG. I. a, 5nlpingiti% Cl«t>arrhMll« Hemorrhntiica, Cro»» S«clion. m, Ml| 
of the tube, w, Mucohh of the tube. /, Lumen of the tube. Plf?roc«rnilne ^ 
(Hiinriack« Oc, 2; Objective 4,^ 6, Leiicocyten contninlny blood pignieiit with j 
nml red blood oorpusclee IVom th© txib«l muc*i««. iHarlnfick, Oc, fi; OI]^ectl^ 

PlG.fi, SMlpinqUi« Purulentn Aeuin Oextm« ou. Uterine openlnQ of I 
««» AbdonilnftI end of lube, ov, Bight ov«iry. A Purulo-HbHriOU* depoeit ; 
terlor vievv^ nntural size, 

FJO, 8. Swlpingiii* Puruleiiti* Cfifo ^extrp. om, Uterine end «>r ^ 

A*^ R0fitan of AbdoniifiAl end of tu»>«j. Willi strongly ad 

^omi^Hor view, nuturwl eUo 



tERINE APPENDAGES. 

1, If the ahdomina! end of tli<:^ tuhn remains open, the jjooretion 
mayflt^wout aud infeot the adjiieeiit peritcmeiim and the epithelial 
covering of the ovary. The ovarian inflammation in then peri- 
ovaritii*» If, however, there be at the time a freshly raptured Graafian 
f/llicle, the infection raay enter the ovary and prtidnee ovaritis. 

2. The intWtion may pas^ tlirou|i^h the walls i>f tlie tuhe l>y way 
of the lyn»ph cliannel^ and produce j>erisalpingitiH — /. f\, intlamma- 
tiou of the perit^J^eal coveriuj[^ of the tuhe ; thus hx-al jieritonitis 
may iiprtad to the jxdvic or even to the general perituneom. 

U. Tlie inf*jK^tion may pass through th(* mesosalpinx into the loose 
wDnective tissue Ik* t ween the folds of tlie lintafl lii^anieut. l^^nder 
\\\^ conditions perilyniphan*:itis aud perii>hlebitis may fieeiir — i. r., 
lluM'dlnlar tissue aroutid tlu:; lymph ehaunels aud veins may beeome 
iuflamed. This inflammatiuu is [>elvie eellulitis* A diseussiou of 
pehic (Cellulitis and its relaticmg to salpingitis will be found iu Chap- 
UtXX. 

Tlif seermd and third ratxles of extension are more likely to oeeur 
if the tube has beeome distended by pathological secretions, a common 
fimilt of plastic occlusion of the two ends or of mechanical closure 
from swelling. Occlusion from swelling does not continue if recovery 
tftkes place; that from adhesive intlaiiunation is usually permanent. 



Catarrhal Balpingitis, 

This IS usually the result of the extensiou of a catarrhid endo- 
flietriti-i, It is apt to be confined to the tube, and is essentially an 
^^^fealpingitis. The pathology has been discussed under iluutes of 
liilectiou and under Etiology, pages 2*15 aud 237, The disease itself 
'^milcl) more mild than purnleut salpingitis, and is much less likely 
*o result in dangerous extcnsiun. The nuicosa is thickened, hyper- 
wmi<?, and infiltrated with round cells. The epithelium is not usually 
destroyed. 

Purulent Salpingitis. 

Pumlent, like catarrhnb inflammation of the tube maybe acute or 
^|"|"uit\ Mncli of the pathology lias already Ijcen described under 
i-tiology and Routes of Infectitm. 

Pathological Anatomy. Thr^ infection usually involves all three 
iayers of the tubo ; hence it includes endosalj>ingitis, myosalpingitis, 
^^^^ perisalpingitis. The extremities of the tube may lie closed or 
^-Uimw open. In chronic eases they usually close aud pus accumu- 
^^*J in the tuln* ; if they do not close anc] pus escaj)es into the 
Fftoneum, the result may be fatal peritonitis. Catarrhal inflamma- 
tion amy chan^ to purrdent ; and, conversely, the contents of a 
fMimlpnt tube may by absorption of the pus cells be changed into a 
^'m» fluid. 

Tile germs which prrHluc4'd tlie disease are much more fn^quentlv 
*l|^on,strable iu acute than iu rhroriic salpingitis. In elironic salpin- 
f^^i^ it is often impossible to find them, dironic accnmidations of 
f^ in the tubes arc usually sterile^i. (\, the micro-organisms have 





250 lyPECTIONS, INFLAMMATIOSS, AND ALLIED Dl 

disappeared and the pus is no longer infectious. It is said that tb< 
Imeteria die from the accumulation nf their own products. Till 
escape of such sterile pus into the pelvic cavit)* from ruptured tul>ef 
dtiring aperation, or from any other cause^ is not so dangerous as i 
waa supposed to be when pus was considered always infectioius. 

From the very iK^inning of purulent endosalpingitis the nius 
cular and connective tissues, as a rule, partake of the inflammatory 
changes. The lymph vessels and bloodvessels of the mucosa beconn 

FicntE 14iL 



r'r- 



Opii-y 



^ 



N 



V 



TvA^ 



VnV^^ 



1 fun* 



Luse pycMAtpiux and tubo-ovflrUn nbscc**. Tube commmiicaicst with abtcest in OTAry. TW I 
and ovary l>olh commuDicate with rectiimJ 

dilated. The epithelinm is finally lost, and in its place is a lining ol 
granular tissue jncupahle of reproducing normal mucosa. 



SactoBalpinx. 

When both mnh of the tuKp are closed either by swelling or bj 

adhesive inflanimiititin, and the walls boeouie dfsteudf><l wilh thi 

accuninlati.»d secretions, the disease is called sactosidpinx. Thre< 

varieties are distinguished, as follows: 

Sactosa 1 pi u x se rowi^ — 1 1 \' d msii 1 1 ji it x . 

Sactosalpinx punilcnta — pyosidpinx* 

Sactosal|>i nx hiemorrlnigica — ha^raatosalpinx. ^^^^ 

The serous aceuraulatiou of catarrhal sidpingttis is known as mctoi 

» SoUon. Surreal DlBeaset of 0»c Ovuriti and Kftll'jpion Tubes, 



4 





i^Ipinx serosal, or hydrosalpinx. A purulent accumulation is sacto 

&lpinx purnlcnta, or pyoyalpinx. Hn?raatosalpinx, or sactosalpinx 
haBmorrhagica, is an sccojuulsition of blood in tlic tube. 

Extensive and firm adliesioni^ usually take place between the pus 
tubes and the adjacent organ j?, cs{>c^ciallj the ovaries. Tubi>ovariau 
"rabscess or purulent tubo-ovarian cyst may form tlirough sueh adhe- 
sions. 

The odor of the pus is often very offensive, and, if the tube be 
adherent to the reetuni, is fecah 

Pus sac* often burst into other adherent organs — rectum, blailder, 
or vat^ina^ Unlike cellulitis abscess, pyt>siilpinx dm\s nnt often birrst 
spontaneously into the vagina. Tlie relief which cuines from the 
rupture of a pus tube into an adjacent organ is apt to be temporary, 
for the pus usually reaecumulatcs. The escape of fluid from a hydro- 
salpinx or pyosalpinx into the uterus will be dis<'ussed under Salptn- 
gitLs Profluens. Hydrosalpinx in one tube and py<»salpinx in the 
other are not uncouimoo, S- pa rate cumpartmentSj formed by occlu- 
sion of a tube al diffi^rent points, may result in the distention of these 

omjMirtmcnts with diifereut fluids ; hence there may^be iu the same 

abe hydrosalpinx, pyosalpinx, antl ha^matosalpinx. 

FlOtTRE 113. 




ifTene section of a tiiti€ and inc«o«ii!pIti^t In which the latter 1b Inflltratt'd wUh inflam- 
rantory ftroduct-i ssocnndHry to Konorrbcca,* 

The distendcil tube often has the form *jf a pear. Its narrow part 
to>nir<l the isthmus will cfirrespunrl to the stem ; the wide juirt will be 
the distended sunpidla. In hydrnsidpinx the Huid is clear, and in the 
jsence of ndljesiuns to tin* broad ligament the site is often found 

cly movable in the pouch of Douglas, 

Haematosalpitix may occur as the rcsidt of hemorrhagic Sidpin- 
g^tK The sac walls, especially if the hemorrhage he ntm-inflamma- 
tory, as in tubal pregnancy, are very thin ami easily nip^ * The 

1 Blimd Sutton. Surgtcal Oiftcikscs of the Orarien and FaUopiAD 



lyFLAMMATION OF THE UTERINE APPENDAGES. 



253 



TyMbo-ofarian C)/«t, A tiibo-ovarian cyst may form in the follow- 
ing way : The adhesion of a .^u-tosalpiiix to a cy^stie ovary may be 
fQllowed by the bursting of a small ovarian cyst into the tube and 
the ei»tablishment of a permanent oomnimiiciition between the two* 
During the furth*'r growth of the tubal i?ae, wliieh i,s now part of a 
tubo-ovarian ey>t, the ovarian eyst is snbjeet ti> tlie sanje pressure as 
the walls of tlie tube ; hrnee the ovarian structure beeomes flattened 
out so as to form a thin wall ihr the ovarian portion of the composite 
cyst, and the ehameteristic structure of the ovary is thus lost. ^ This 
b cot to be confounded with ovarian hydrocele. Tubo-ovarian cyst 
or abscess may occur in conneetiun with either hydrosalpinx or 
pyosalpinx- 

8PBCIAL VARIETIES OP SALPINGITIS. 

Salpingritis Follicularis. Sometimes the folds of the swollen 
mucosa are pressed strongly together, the epithelium disappears, and 

FieUBK 140. 




ftlJloMilfttux iMciido folllculftriB. The folds Imvci beoftmc Htllnn^nt to tmv another, rorini nf; tuim- 
€TOU» rFt*nnan-«yi(t«. Tbe epHht^Ual Unlng hua Iwvn mijstly deatroyed by pre&curu.* 



the folds grow together. The deeper parts of the inflamed mucosa 
may thus be partly or wholly shut off from the lumen and form 

1 Max Uiinmv Arc hfv fflr Oynilkolo^ie. li<H.\ 

* Amann Mlrn)«c<n>l.sh'tiyniiktjh>gifli'htin OiugnoRtlk. 



254 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS 

small cysts. This is called salpingitis foUiculariay^ or pseudofollicularis, 
and is not uncommon in catarrhal inflammation. 

Salpineritis Isthmica Nodosa. In the isthmus of the tube sal- 
pingitis follicularis is sometimes as^sociated with considerable new 
formation of connective and muscular tissue, forming small lumps or 
knots. This local thickening of the uterine end of the isthmus is 
called salpingitis isthmica nodosa,^ a condition sometimes confused 
with myoma or adeno-myoma. 

Salpineritis Diffusa. In chronic cases the whole wall of the tube 
becomes thickened from diffuse inflammation, salpingitis diffusa. 
The muscular layers and connective tissue arc infiltrated with small 
round cells. Hy|)ertrophy of the muscular layers* has been attrib- 
uted to reiwated contractions of the tube set up by the presence of 
an abnormal amount of fluid. In this way the contents of the tube, 
unless the abdominal opening has been closed by swelling or by ad- 
hesions, may be forced into the ]>critoneum. In diffuse salpingitis 
the tube is enlarged, hard, and often tortuous, and its swollen congested 
mucosa is rolled out through the abdominal opening. The secretions 
may be clear or cloudy, catarrhal or j)urulent. 

Salpingitis Profluens. In salpingitis serosa closure by swelling 
at the abdominal or uterine end is common. The swelling may 
periodically subside enough to let the confined fluid escape. This is 
called salpingitis proflxicns. The escajK? of the fluid is attended with 
severe colicky pains. The name colica scortorum has also been given 
to this symptom. 

Salpingitis Vegetans. In hydrosalpinx the sac walls, if much 
distendod, may become quite thin, although inflammatory thickening 
may take j)lace proportionately to the growth of the sac. The 
mu(;ous folds usually atrophy. If the folds survive, they become 
attenuated, and floating in the fluid present an appearance described 
by Sawinott* as salpingitis vegetans} 

Tubercular Salpingitis. The disease is generally secondary to 
tuberenlosis in other organs, and is of frequent occurrence.* Whit- 
ridgo Williams found it in 7.7 ]ht cent, of ninety-one cases of removal 
of the uterine^ apiKMi(lap:os. It very rarely occurs from direct infec- 
tion l)v coitus or otherwise. It has been observed as early as the fifth 
year of life, and is the only form of salpingitis often found in virgins. 
It usually attacks both tubes and extends to the surrounding parts. 
Tubercular ju'lvie disease is characterized by mild pyrexia, weakness, 
often sj)lenic enlar<r<*nient, and thickening of the subperitoneal tissues.* 
The teinleiicy of the disease is toward atresia of the tube and the 
formation of pyosalpinx. 

Tubercular salpingitis may be acute or chronic. The abdominal 
end of the tul)e is in general open in the acute and closed in the 
chronic cases ; the contents of the tube, if closed, are serous, purulent, 
or ciiseous. The mucosa in acute cases may contain many small 

> Aumist Martin. Dii* KniiiklMMtfii <l('r Eil«'itor. ISO"). 

2('hitiri. Zritsc-hrift fiir Htilkuiulo, 1SS7. Sriuuita. Arrhiv ftir Gyniikologie, 1888. 

•» Kaltciibnch. Criitrulblatt flir (Jyiiakolojrio, ISKT). 

< Auirust Martin. Di*- Krankhcitt-n «lcr Eilcitcr, 1W».V 

* Williams. Johns Hopkins H(»s])ital KeiH»rts. vol. iii.. No.«<. 1, •_', :i. 

•Etielxjhls. Transactions, American CJynccoloj,Mcal Ahsociation, 1891, vol. xvi. 



INFLAMMATION OF THE UTERINE APPENDAGES 






tubercular nodules. In tlujse iiotlulcH are found few giant cells and 
many tubercle Imeilli. (Mironie tubercular saetosalpinx is often a 
i^e s;ic with fluid or raseons pus. The joueosa i.s destroyed and the 
\c 18 lined with granular tissue, wliieli eontiiins nnnierous ^iant and 
cpithelioi*! cells. The tuhereh' l)aeillus in this tissue is often impofi- 
sihle to Hnd. The j>erisalpinx presents the same inicniscojiic appe^ar- 
ance as tlie mucosa — ^that is, there are numerous giant cells ana few 



FlGlTKK 147. 




TuberculAr perltnetfitfa, fjcritDiiUi:^, ami italpiogilla ; sActoealploz. 

any tidjr'rele liiicilli. Chronic fibroid tuberculosis' of the tubes is 

II peculiar form described by Williams. In this variety the forma- 

Vm of connective tissue is the final stage of the tubercular infec^tion. 

The contract iufj- fib mas tissue around the tubercle nodules crushes out 

lie miliary tuljereles and ]>re vents the spread rd* the diseas*\ 

The symptoms, dia;^no>is, and treatment of salpingitis will be pre- 
BDt4?d in the two following chapters. 






OVARITIS. 

Etiology and Pathology. Inflammation of the ovary is usually 
>ndary to that of the tnlx^s. It may, however, occur independently 
mlpingitis, by extension throufxb the lym]>h channels or veins 
from other organs. It follows from the above that tlie etiu!<\gy nnist 
that of the anteeeilenf infection, 

Ailhesions Ijctween the tube and ovary, espeeiidly when recent^ 
eontaiu many lymph vessels ; hence fmet<'ria fiave a slinrt, aceessible 
n»ute to tlie ovary. Adhesions surrnuuding the wliole or parts of the 
ovary may prevent the normal buj-sting of the (iraafiun follicles. 
The ft^llieles will then liecomc n^tenticm^^ysts. When tlie inflamma- 
tion reaches tlie substauee of the ovary from the adln>i(ms nw the 
surface the ovarian connective tissue may increase and the urgan 
btM^ome hard and tirm — that is, sclerotic. This again f*reveuts the 
'mrsting of the Graafian fnllicles, and is a frequently unrecognized 
\\m of Bterility. Great numbers of follicles may appear ready to 

» WUUftin*. Johns Hupkim Hospital Reports, Gyueeology, voL iU, 




256 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS, 

burst at the saiuu tiiiit^ The oviiry w ill then be eovenxl with many 
small cysts. This has been willeil niicrocystic degenemtiun. This 
form of degeneration and the atrophy eotiseqnent upon it are often 
assneiated with aiiieiiorrh«Ea, or painful scanty menstruation, and 
sterility. The integrity of tlie c<^rtieal or fuuetioiiating fX)rtiou of 
tfie ovarv' is essential to normal menstruation and maternity* See 
Chapters LI. and LIV. 

Ovarian al>scess may arise in the eonneetive tissue or may be a 
previously formed eyst infected from a pyosidjiinx. See Tubo-ovarian 
Cyst and TulHj-*jvarian Abscess. Tnbereulur ovaritis is not verj' 
eonuuon : it otn-urs usually in eonneetiim witli tubercular infection 
of the tubes or j>eritoneuni. 

The symptoms, diagnosis, and treatment are deferred to the two 
following chapters. 

PELVIC PERITONITIS. 

Patholog^y. The two principal forms of |>eritonitis arc : 
L Ptastie or adhesive perit(»nitis. 2. Exudative }>entonitis. The 
two forms usnally <x*cur to<r<Mher. Tlie jdtistie form^ however, has 
Ix-en observc^d with litth.' or no exu<late. In additicm may be men* 
tiontd tnberrular peri t* in it is and paehy|ierit*>nitis, 

Phtfitir or Aiihf'aii't' PvrUoaltls, Thu formation of adhesions teuils 
to shut oif and localize the infection and to prevent it from extend in jr 
to tlic general pcritonenui ; the inieetion is therel>y limited not only 
in exteni and i|Uantity, but its force is s|»ent witliin narrow limits. 
Within these limits tlic j)roc(\<s may be very intense and the part nuiy 

FlGUKB 148. 



Right Hud left pyueuljjlax. Right* atlhwiiom boi wet-n uvnry and piiK tube« Uttd between pna sue 
ttud jKiaterior pelvic Willi. Schenitttk.i ' 

be sacrificed fur the benefit of the wh<tle. See remarks on Acute 
Inflammation and the Si;rnitininee of InOanunation, in Cliapters X, 
and XVIII. The nia.\imum of exudate with the minimum of 

-i Murtii). Die Kraukheiteu der Eileitt^r 



INFLAMMATION OF THE UTERINE APPENDAGES. 



267 



tiefensive adhesion is dangerous ; conversely, the minimntn of extidate 
with llie maximum of adliesioti is rohitively Hnio, Adiiesions iDay be 
>lo\vly broken up by movemi'uts of the iuU^stiues and liy absorption, 
i>r tliev mav bei^ionie iirm anil pi-rinanr'ni; lienee the organs maybe 
dtixnif^ly matted together, will* resultant displaeemetit, stemisis, strict^ 
are, tjcrlusion, and kinking; peristalsis is then impeded ami luitrition 

There may be at different points aeeimiulation.s of i>us walled »>tf 

fn^ni the general peritoneum by adherent intestines ami other viseera. 

if the peritonitis becomes geueml^ it is usually fatal. The strong 

fendeney, however, is to protect the general ijeritoneuiu by adhesions 

betveen the peritoneal surfaces around the intianied area, and thereby 

to limit the disease. See Localized InfeetioUj Chapter VHI, 



FlUUttE 149, 



'/) 



tit ttid left pus tnbci Adherent to one another Right tuhe iLdherent to Tenuifonn appendix. 
Left tube fi4hereut to uterus and rectum. Schemntic^ 



Pelvic {K'ritonitis usually be^rins with perimetritis or perisalj>in- 
giti^, the infection having reachetJ the peritoneum from the uterine 
or tubal mncosii. Sometimes the origin is extm-pelvic; in such cases 
the uterusi and uterine apjjendages may not be involved. The dis- 
ease, especially in eon nee t ion with gonorrhfeal ^salpingitis, is very 
I'omnion. Tlie frerpieut recurrence of aente local exaeerl>ations 
furnishers a familiar indication for the removal of the uteriLs and 
the titerine appendages. 

The exudate consequent upiin infection of the peritoneura may be 
serous or purulent ; it mayor may mit be mixed with blood. Pro- 
t<?ctive adhesifjns often include uumerous [jartitions through the in- 
fected parts ; hence several dislinet eolleetions ui' Huid may be 
formed. These eolleetii>ns are sometimes serous in one part, puru- 
lent in another ; the whole nuiy form a tumor filling the pelvis and 

1 Martiu, Ulo KraukheiU^n der EUijiter. 
17 





258 INFECTIONS, INFLAMMATIONS, AND ALLIED DISOBDEB& 

the lower part of the abdomen, and having the appearance and manj 
of the physical signs of an ovarian cyst. 

The fluid may be absorbed or may break into a neighboring organ. 
In the latter way communications may be formed between the pelvic 
cavity and the bowel, bladder, or vagina. Sometimes the pus finds 
its way to the cutaneous surface. Accumulations are most frequent 
in the pouch of Douglas. The microscopic findings show a few round 
cells in the serous, numerous pus cells with a few red blood-corpuscles 
in the purulent, and numerous white and red blood-corpuscles in the 
hemorrhagic collections. 

Exudaiive Peritonitis is the result of infection which does not 
strongly tend to provoke defensive action, and is therefore more 
liable than the plastic variety to become general ; for this reason it is 
often more dangerous. 

TiibeiTular Periioniiis is of frequent occurrence, and is usually 
characterized by small, sometimes minute pearly tubercles or points 
scattered over the peritoneum ; it is commonly associated with more 
or less ascites. Figure 147. 

Pachyperitonitis. Oftentimes the peritoneum is much thickened and 
supplemented by the formation upon its surface of new membrane, 
which gives it a leathery appearance. The vessels in this new mem- 
brane early rupture with circumscribed hemorrhage. This is called 
pachyperitonitis. 

The symptoms, diagnosis, prognosis, and treatment of peritonitb 
may be found in the two following chapters. 






CHAPTER XXII. 

SYMPTOMS, DIArjX08IS» AXD PROGNOSIS OF RALPINGITIS, 
OVAKITLS, A:ND pelvic PElilTONITlS. 

<Mritis aiiti pelvic |K^ritoniti?^, althoii*:;!! in a sense separate dis- 
«iae-, iirt usually so closely related to salpingitis that the symptoms, 
ifiagtuisis, prognosii*, and treatment are largely iiielndeil io those of 
wipingitis. For convenience and to nvoitl repetition, therefore, the 
.^jmptoms, diagnosis, prognosis, and treatment of these intectiuns will 
be presented together. Inflammation of the organs under discnssion, 
teit'n as a whole, is sometimes designated as adnexal inflammation^ or 
iiiflarurimtion of t!ie uterine appendages* 

Symptoms* 

Thp symptoms nf intlamniation of the uterine ajipendages, inelnding 
iWjM'lvie peritoneum J vary with the extent, virulence, aeuteness, ana 
BHt'danitul conditions of the disease. Usually the tubes are less sen- 
sitive 1(1 pain than the uterus and ovaries. The milder catarrhal 
mftuiimations, even though acute, may c:tnse sym]>tfjms so slight as 
*:m!i'ly t»i fix the patientV attention upon the diseased part; they may 
pverinin iheir course and disiippear, leaving no tnwe except jx^rhapa 
^noatfr liability to future inf(*cti<m. Such mirecognized mild conges- 
tive an<l ciiturrhal att4ieks of salpingitis are probably more frequent 
^n k generally supiwised. 

Local |>ain or discomfort in the affected part does not ahvays eor- 
l^pnijil to the seriousness of the infection. There uuiy be only a 
'I'lll aching or a sensation of burning not suWieient to impress the 
l>a(ii'rit seriously unless aggravated by local prcssiux', by vaginal 
^'^afijination, by exertion, or by defecation, and yet the tube may be 
dUrfuled, reaily to Inirstand discharge its poisiinous contents into the 
P<'nloiieal cavity. Tlu" pain of salpingitis is always much increased 
H'ht'ii the disease includes peritonitis and ovaritis. 

A srnall minority of cases is characterized from the beginning of 
J''*' attack by very arutc colicky pains in the rcgicui of the tubes, with 
JNUtvals of comparative comfort. This symptom , from its fretpiency 
'•1 prostitutes;, has been called eo/iea ^rortarnm. Its mechanism has 
■^n explained on the supposition c»f tubal sjvasm due to the irritating 
pf^noe of con lined Huid, jnst as Huid coufiued in the ntc^nis may 

IN* |jainful uterine ctuitnictinns. The spasnuMlic jtain may also ha 

I'^d l*y the irritated or irjflatned peritoneum around the diseased 
^y,^ or by a distended bowel ; Schauta *'imsiders it characteristic of 
^Q^jjimjitU mihmieu nodoHa. 

» MiirtiB. Die Krankhelten der ElluUcr. p. 104. 

259 




SYMPTOMS, DIAGNOSIS, AND PROGNOSIS OF SALPINGITIS. 261 

tie t/^ricle, and the presence of pain sliootiiig down tlie thighs are 
diani(Tteristic of ovaritis. Acute ovaritis may, however, give litth? or 
M) (!i5<ximft»rt. 

Cfuronic Ovaritisy like the acute^ i.s also usually associated with 

dk^^ af the tobes and ptritoneiuii. It may, linwever, continue 

lifter tlic ^_^au<ative inflammation in tljuse organs lias disap[)t*arcd. 

fhf.Hvmptoms include menstrual disonlers and a wide range uf pains 

I lod discomforts. The pains are fre(]uently referred to di&taut partss, 

' !'* the navel, hreastSy and lumljar region. The chronical ly eon- 

a* intiamed ovary is often prolapsed to the pouch of DcniglaSj 

wlkTe the distressing mechanical etlects of jvressnre during defecation, 

micturition, coitus, and exercise are very pnmnanced* Dyspannuria 

I* the nde. The spinal and sympathetic nervous plexuses in the 

plvjjj ar*3 subject to great irritation ; henee a great variety of retlex 

nervmis influences. Among the niuiieroua symptoms more or less 

'''jUimon are indigestion, malnutrition, jKdvic and extra-pelvic neiu'al- 

gia, listeria, inability to w-alk, and other motor disturhunces. Tlie 

reader will k n o w f r c * in the a bo ve that o va r i t i s i s u s na ! ly o n 1 y o n e of 

the clinical features of a more or less giineml pelvic iutlammation. 

DiagnoBia, 

The sym[)toms outlined in the foregoing paragraphs point to the 
pmlKibility of inHaraination around the uterus. Indeed, it is usually 
«a.<y to recognize the presence of acute pelvic inflammation, es|>ecially 
then the pelvic cavity is crowded with inflamed organs and with 
pmdiictjs of inflammatitm. The physical examinatiun, however neccs- 
mrvto viTify the diagnosis, will fretjuently not only fail to establish 
«huq> iliagnostic lines between inflammation of the ditrercnt pelvic 
t^rpin?,hnt also between pelvic inflammation and other morbid ef>n<li- 
tion>,»iirh as tumors, with wliicli the inflammatory mass may be eon- 
fc*d. The subjective symptoms in the milder cases may be w^holly 
Overl(j(>ked. Indeed, the existence even of pvosaljurix is sonietimea 
«nn^os;ni/,i.d until rupture of the tube ami tlie escape of pus have set 
ttp 11 da n i^> ro u s |m? r i to u i t i s . The p re se n ce of e 1 1 do metritis eve n sh o ii Id 
place m^ on guard against possible salpingitis. 

In onler to avoid the rupture of a pus tube or abscess wall great 
cai^ in the palpation of uterine appendages is imperative. 

TIk^iy* is usually a recent or remote antecedent background of acute 
or difftnic infpctiim in some neigliboring organ ; the diagnosis there- 
f»^re should inchulc both the inflamed a|>pcndages and the antecedent 
^^iisitive inflammation, nsufilly endometritis, but sometimes vaginitis, 
vulvitis^ cystitis, proctitis, or appendicitis. 

Among the subjective symptoms will be dull, often burning, con- 
»tant^ remittent, or intermittent pain and local tenderness. The 
^m^y pains about llie tuljcs, already mentioned under symptoms, 
i*r^ '^trnngly diagnostic. Occasional exacerbations of local peritonitis 
f'^^n h*akage of the tube or from other sources are characteristic <>f 
ft^Xnl inflammation. In oixler to establish the diagnosis the symp- 
nw already outlined must be supplemented by physical examination. 





2t)0 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDEEJS, 



Th(* spasmodic paiq of salpingitis profliicins, already described on 
jmge 254, l»as alwo Iji-eii explained on the ^^iijipositioii til* painful con- 
tract ion of the irmsetilar walls of the iul)e and uterus^. Jt is proliahle, 
however, that wide distcntiun of the tube woidd so paralyze the muB- 
cuhir layer that it could not contract. The pain therefore, a.^ in the 



condition def^cribcil in the foregoing paragraph^ may als^o be due to 
peritoneal irritatioi 
During the mor 
niented hy that of uien^itniation ; hence the pains are increased and 



pe ri toneal ir r itat ion . 

During the monthly [icriod the pathological congestion is i^tipplc- 



dysnienorrhoni is the rule. Increased menstrual flow, even to the 
extent of nicnorrhagiuj is common. AnienorHitea or scanty menstru- 
ation is seldom observed and when present points to possible tuljer- 
culosis. ^ 

Greatly dilated and swollen tubes, especially when associated with ■ 
bx'al peritonitis, always jiroduce mechanical disturbances. This is ~ 
nn»re marked when the swelling has been mpid. The more gradual 
the swelling the more opportunity the parts have to adapt themselves 
to the new conditions. The mecluniical synijitonis are variable and 
numerous. They include painful urination anrl defecation, difficulty 
and |min nn walking and standing, pelvic neundgia, and many reflex 
symptoms rcferaljle to tht* cerebro^spinal and digestive systems, 

Perltomiiii is a eonnnon result: of inHiimmatitm of the uterine ap- 
penilages, The symptoms in the acute stage very irregularly with 
the extent of the disease. They may be slight or absent ; or may in- 
clude great pain, nausea, fever, alxlondnal distention, retmction of 
the thighs, anxifuis lacies, and great nervous depression. The greater 
the tendency of the peri limit is to l>ecome general the more aggravated 
will be the sym]itoms. The symptoms, however, are sometimes alto- 
gi'ther disproportirmate to the gravity of the infection. Suppurative 
HJilpingitis, es]H'cially ru]vtnre of a pns tube, is most likely to cause 
dangerous |>eritonitis. The greatest discomfort, pain, and disturbance 
of fiiuction in the pelvis, especially about the rectum, uterus, and 
bladder, may c<>me from mechajtical causes^ such as tensioFi on bands 
of adhesion athl pressmr and tnu'tiou upon the inflamed peritoneum. 

Sterility in these cases is explained by the hostile influence of the 
secretions of the inflamed tube ii]Km the impregnated ovum or sper- 
matozoa ; <u% if the tube has closed, by the mechanical interruption of 
their ]mssnge through it ; ur by tlie failure of the (Jraiifian follicle to 
rupture through the thickened, timgh, chronically inflamed ovarian 
cortex- 

The StftHptmn^ of Acufr OrffritfH iwe usually c<m founded with those 
of an anteccflent inflammation in the neighboring otgans. If the 
ovary can he ilistinguished from these orgtms by conjeiined examina- 
tion, it will be felt as a tender muss^ the seat of heuvy, burning, 
severe pain in the right f>r leiV iiiguinul regit m. Pain on pressure 
will usually be as>(H'iati*d with nausea, and will radiate down the 
thighs and <>ver the abdomen. Tliere will nf\en be pain in the 
breasts and always more or less fever. ^Vhen these symptoms pre- 
dominate over all others acute ovaritis may lie inferred. The sicken- 
ing sensation, especially on pressure, not uidike tliat from pressure on 



BYSiPTOMS, DIAGNOSIS, AND FEOGNOSIS OF SALPINGITIS. 26S 



^ 



Arcumte and aderjimte diat^noslti* betwi^en tlie various forms of 
irt(^!ilpitix an€l certaiu oviirian noopbisms is ditticult. TheHt" nay- 
ijjiisms are; 1, small uvariari or i>Mruvariaii 4\vsts ; 2, small hiolid 
ovarian tiiinorii ; 3, small uvariaii dernM»ids. The diagnosis, wlu'n 
|)<>^ible, is ma*le by tinding" tlii^ tube and tmcing it to the uterus, 
Wbeu small cysts are imjMieted in th(^ jn-lvisand their sliape distorted 
differt'Dtiation, except l>v an exploratnry incisicjn, may be iraj>ossiljIe. 
" difitended tube felt above the pelvie l)rim is easily eonfuunded with 
marijin evstoma. The frefjuent eoexisteuce id" these small tumors 
writli sactosalpinx may render the diagnosis without exploratory inei- 
slon inipossilde. Trimrirs of the sacrum or ilium are distinguished 
W iii«^ir hx-ation, hardness, immobility, and inttinato relations witli 
the h\my [lelvis. Malignant disease of the caecum, or sigmoid flex- 
nvQ, or uterine appendages, simulating adiiexal inrtammation, may 
Ite tiiagtiosed by the eliuieal histoiy, l>y palpation, or by ex])lonitory 
incision. 

The physical examination and the clinical history will usually 
R^rve to distinguish appendicitis, intestinal adhesions^ and intestinal 
'►bHiniction from pelvic inflammatioiL A loop of iiilestine adherent 
to the tube or broad ligament may deeitledly obscure the diagnosis, 

Feeal accirnin hit ions are found by palpation and removed by 
athartirs. 

Extra-uterine pregnancy is usnally in the tube, and is therefore 
fhiniilt to ditferentiate from inHamnuit<jry saetosidpinx* The hist<»ry 
<^ that 4if modified pregnancy. The pnrgress is more uniform antl 
ihe liability to tubal rupture is greater. Enlargement of both tubes 
*'<Mil<i iisiiaily exclude it, although there might be sactosjilpinx on one 
A and tubal pregnancy on the other. 

I'teriDe flexions and versions nniy lead to confusion. It is often 
Qiffipiilt to distinguish between the displaced eiu^pus uteri and an 
infianjuiatijry swelling close to the uterus. Conjoined examination 
*fid the sound will usually demonstnite the real condition, 

Thp diagnosis of parametritis and its relatioti to adnexal disease 
Iiavc Ix^en discussed in iliapter XX. 

Pelvic ha^matocele from rupture of a tuhid gestation sac or from 
*^y other cause occurs sirddf^nly^ with exeruciuting pain and symp- 
toins of hemorrhage^ and without evidence of inflammaticm. Later, 
^"fetiou may be set up in the hjemati>cele cavity and a pelvic abscess 
%vMake the place of the luTmatoma, The physical sigus will then be 
*'^^ Hias' of an abs(T*ss f'rouj otfier causes. 

The tl i tf e r c n t i a t i o n « * f 1 1 1 e v a r i o u s a*! r i e x a I i n fla m mail o ns fro ra on e 
^«*ther, especially in their acute stage, is ofteu ilifficult. Ovaritis, 
^i^iJiilly a consequence, SHmetinics a cause of salpingitis, is not easily 
*^"^tinguished from it when the two organs are fused together by 
f^'Wions. When the tube is distcndcil with fluid the difficulty is 
iurr(use<l. 

The distinction between hydrosalpinx and pyosidpinx is sometimes 
tolfiossible. The diagnotic points are as follows; 

^ J. fllftttd Sutton, Surgieiil DiBeases of the OYariei and FaUopIan TutMis. 





26 



TlOyS, AND ALLIED DiS 



PlujH knl Kt( i mhmt ion h by ex te rna I |iii 1 pa t i on a ml co njoi u etl rn ai » i po- 
latioiL The former is tiHualiy inadequate. The latter, whicli ineludts 
external jialpation, in matle with the left iinlex-iinger in tlie vagina 
and the right hand ovt-r the hyj^K^jj^astriiun ; or, as set forth on j«ige 
p59, witli the h^ft index-tinker in the rectum, the ihunih in the vagiira, 
and the rij^ht hand <iver tlie liyiK>jL!:astrinni. Light, conjoined |ial|i(a* 
tiou will sliow an irregnlar elongiited swelling on one or both sides 
of the uterus, frequently extending into the |mj«c1i of Doitglai*, or 
even sometimes in front of the uterus. It is often impossible to 
make out the conipuuent |iarts of such a mass. They will, however, 
usually include the inflamed lube or tubes together, in varying degi-ee, 
with diseased ovaries, ijentoneunij intestine, omentum, bladder, ancl 
uterus. These structures nsay lie matted together in an irregidar^ 
imlefiuite tumor. The one nearly constant factor in such a mass ij^ 
salpingitis. 

Aduexal disease often occurs only on one side, more frecjtiently ot^ 
the left than on the rights and very i'requeutly on both sides, Th^3 
p r i n c \ I la 1 aifec 1 1 cm] s w i 1 1 i w h i e 1 1 i t m ay Ik • con f u sed a re : 

Tiunors of the uterus, tubes, broad ligaments, intestines, sacrum - 
and ilium. 

Appendicitis. 

Intestinal adhesions* 

Fecal accuin ulations. 

Ex t ra-u te ri ue preguancy. 

U teri ne d i spluccments. 

Pammetritis. 

Hn^matoma. 

MytMuata developing from the lateral walls of the uterus between 
the folds of the lirijad ligaments in Im-utain and tVirm may simulate 
^actosalpinx ; but, unlike sactfvsalpinx, they are hard, more closel)^ 
inee»rporated with the uterus» cause more uterine erdargement, are- 
more apt Ixj set up menorrhagia, develoj) more gradually, pr^xluce 
morti pressure symptoms, are usnally pairdess, and lack the Iiistory 
of tu Ham ma tiou. 

Neoplasms t>f the tubes and broail ligaments are less painful, of 
glower growth, and more fVei* from adhesions than aduexal inflamma- 
tory tumors. They also give no history of intlanynation. 

Tumors of the intestines, es[x^cially if adherent to the ap[Knidages, 
may be very difficult to distinguish fnmi afluexal inflammation. The 
lK»wels should be thoroughly moved liefore thi" diagnosis is attempted. 
If not adherent, the mass will be easily sepanitcd iVom the pelvic 
organs ; if there be adhesions, an exploratory incisitui may be neces- 
sary. 

Ovarian tumors, if small and adherent, are sometimes indistin- 
guishable from sactosalpinx exee|>t by exploratory incision. They 
are usually of more globular sha|K', while saetosnlpinx is oblong or 
of kidney shape. They are alst» less closely counerted with the 
uterus. Large ovarian tumors will he excluded by tht^ir size. Tu1k>- 
ovarian cyst, des<^ribed in Chapter XXL, will usually be recognized 
only after exploratory ineisioo. 



WMPTOMS, DIAGNOSIS, AND PROGNOSIS OF SALPINQITIS. 



At'cumte and a(lei|iiate diagnosis ^ between the various forms of 
actiisalpinx and certain ovarian neoplasms is difficult. Tliese neo- 
Ipbras lire: 1, small ovarian or pamvarian cnsts ; 2, small s<»lid 
[(J^rian tnoiors ; 3, small ovarian dermoids. The diagnosis, when 
[piwiible, is made by tinding the tube and tracing it io the uterus. 
IwliensniaU cysts are imjwu'ted in the |jelvisand their sbaj>e distorted 
differentiation, except by an cxphmttfiry incision, may l)e impossible. 
\ distended tube felt above the pelvic brim is easily confoun^lefl with 
ovarian cystoma. The irerpient ci^existencc of these small tumors 
^Hi i?actosidpiiix may render the diagnosis without cxphiratory inci- 
sion impossible. Tumors of the siicrum or ilium arc distiuguishLtl 
bj iheir hx^ation, hanlness, immobility, and intimate relations with 
tlie bony pelvis. Malignant disease of the ctccum, or sigmoid flex- 
ure, or uterine apjicndagcs, simolating a<lncxal inflinnmation, may 
lie diagnosed by the cliniail history, by palpation, or by explomtury 
\mmn. 

The physical examination and the clinical history will usnaliy 
fierve to distinguish apjMmdicitis, intestinal adhesions, and intestinal 
oWnictiou from |ielvic inflammation. A loop of intestine adherent 
lothttiibe or broad ligament may decidedly obscure tlie diagnosis. 

Fmil iiccumulations are found by palpation and removed by 
cathanips. 

Extra-uterine pregnancy is usually in tlu^ tube, and is therefore 
"Wnilt to differentiate from inflammatory sactosalpinx. The lust(*ry 
i> that of modified pregnancy. Tfic progress is more uniform and 
if»^ iiahility to tubal rupture is greater. Enlargement of both tubes 
^'HiM usually exclude it, altliough there might be sactosalpinx on one 
side and tubal pn^gnauey on tbi^ other. 
1 Uterine flexions ami versions may lead to confusion. It is often 

^iiifiriilt to distinguish between the displaced ciu^pus uteri and an 
'nUanmiatory swelling close to the uttTUs. (juijoine<l examination 
*^^l tlio sound will ustially demonstnite the real condition. 
The diagnosis i>f parametritis and its relation to adnexal disease 
_ ^'vc Ixjpii discussed in (Jhapter XX. 

^K I\'lvie hiematoeele tVom rupture of a tubal gestati(*n sac or from 
^B*^y otiipr cause oeeurs suddtmly, with excruciating psiin and symji- 
^■F>"ks of hemorrhage, and without evidence of intlammatiim. loiter, 
^■^fo'tion may Ik* set up in the bannatoeele cavity and a pelvic abscess 
Jl^ay take the place of the ha*matt»ma. Tlie physical signs will then be 
*'ke tlioHi* of an absress from oilier causes. 

riie differentiation t>f the vari<ius adnexal inflammations from one 
JUiothcr, especially in their acute stage, is often difficult. Ovaritis, 
^^M\y a consequence, sfuiietimes a cause of salpingitis, is not easily 
^^'^tiiipushed frotn it when the two organs are fused together by 
^♦'hesians. When the tube is distendetl with fluid the difficulty is 

The disttncti^ui between hydrosali>inx and ]Tyosalpinx is sometimes 
p<Msible, The diagnotic points are ns follows: 

» J. Bland Sutton, Surgical Diseases of the Ovaries and FuUopian Ttibea, 





264 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 



Hydro9alpinx. 

1. Systemic disturbance relatively slight. 

2. Less fever and pain and adhesions. 

8. Bursting of the tube and discharge of its 
contents into the abdomen may give relief. 

4. Walls of tube distended, thin, smooth, elas- 
tic, and fluctuating. 

6. More usually associated with catarrhal 
endometritis. 

6. Thin, overstretched tubal wall easily rupt- 
ured. 



Plfotalpifiz. 

1. Systemic infection Arom abBorpUon of pos 

often marked. 

2. More fever and pain and adhesions. 

8. Bunting of the tube and discharge of iti 
contents may cause dangerous peritonitis. 

4. Walls of tube thick, hard, sometimes stony, 

resistant, nodular, less elastic, and lest 
fluctuating. 

5. More usually associated with purulent en- 

dometritis. 

6. Walls usually thick and not so easily rup- 

tured. 



Exceptions. Sometimes the pvosalpinx wall is thin and necrosed 
in places ; at other times, when the distention has been rapid, it may 
be thin throughout, and therefore quite as easily ruptured as in hydro- 
salpinx. On the other hand, the contents of pyosalpinx, with its 
thick, tough walls, may by absorption of the corpuscular elements of 
the pus be changed to a serous fluid, making a modified hydrosalpinx. 
Such a tube would not be so easily ruptured. 

The diagnosis between hydrosalpinx and hematosalpinx is as 
follows : 



Hydrotalpinx. 

1. Walls smooth and elastic. 

2. Slower development. 

8. Rupture may give relief. 



nxmatoiolpinz. 

1. Wall smooth and less elastic. 

2. Sudden development. 

S. Rupture may cause dangerous hemorrhage. 



In rare cases the displaced kidney, spleen, and other abdominal 
viscera may simulate adnexal disease. 

The distinction of one form of bacterial infection from another must 
depend upon the bacterial examination of the secretions. Such an 
examination is always desirable, but sometimes impracticable. The 
vulvo- vaginal and uterine secretions in the acute stage usually contain 
the causative germs. Pus long confined in the tube is apt to become 
sterile. This explains the freedom from infection so often observed 
after a pus tube has ruptured witliin the |)eritoneal cavity during its 
removal. The inflammatiim may continue long after the original 
germs have disa])j>cared, or at least after their presence can no longer 
be demonstrated. 

Amvsihcsia i.s often necessary in order to make a satisfactory diag- 
nosis and differential diagnosis of adnexal inflammation, and should 
be used in cases of doubt. Relaxation of the abdominal muscles under 
aniesthesia j>erinits more (efficient palpation with the minimum force, 
and consequently with the minimum risk. Many unnecessary lapa- 
rotomies would doubtless be avoided by more careful diagnosis under 
anaesthesia. The more or loss distended bladder or bowel has often 
been mistaken for a pathological collection of serum, blood, or pus ; 
hence evacuation of the bladder and rectum is a prerequisite to 
examination. 

Exploratory Inemon, In serious ])elvic disease the diagnosis, if 
not possible or satisfactory by the al)ove means, may be made by 
explonitory vaginal or abdominal section. The incision may be the 
first step of a radical operation or, if the operation prove unnecessary, 



SYMPTOMS, DIAGNOSIS, AND PROGNOSIS OF SALPINGITIS. 265 

it may be safely closed. It is a grnxl rule always to begin a peritoneal 
operation as a diagnostic exploratory incision, Mr, Tait wis(»ly 
remarks, " It is better to tnrn an exploratory incision into an opera- 
tion than it is to turn an operation iiitu an exploratory incision.^ The 
late Charles T. Parkes, whose c^arly lo*5S will not soon be replaced, 
when questioned by a bystander at the beginning of an abdominal 
I aec tion, replied, ** I don't know what it is, and I am tilled of guessing*" 

H^ PrognosiB. 

In acute adnexal inflammation the prognosis varies with the nature 
of the infection and with the extent of the diseiisc. If the tube rupt- 
ure and diseliargcs pus into the peritoneum, a fatal peritonitis may 
follow. If the infection is confined to the tube, the prognosis is usually 
fiiv(>rable, but the removal of the appendages may be necessary for per- 
manent recovery. 

Simple catarrhal salpingitis and mild ovaritis may run their courses, 
perchance unrecogniztxl, to recovGr}^ They may even leave no trace 
lichind them save an increased liability to further inflammation. The 
more chronic the disease the less favorable the outlook for expectant 
treatment. Sactosalpinx, especially the purulent variety, rtirely 
recovers without oj>erat!ve interference. This rule, however^ is not 
without exception* Pus cavities may rupture spontaneously and dis- 
charge their contents through the bowel, uterus, bladder, vagina, or 
cutancoug surface, and recovery may follow ; but such a possibility 
does not offer substantial hu\H' of relief. In fact, even when such 
runture and discharge are followed by relief the result is usually 
only temporary, and the jiatient may succumb to repeatcnl infection. 

Serous sactosalpiux, although little dangerous to life, may, by per- 
manent closurt* of the tul>es, cause loss of function and, if the disease 
is bilaleral, sterility. Pundent saeto^salpinx is a constiint danger even 
to life. The gonocxx^eus is less perilous to life, though probably more 
dangerous to healtli than the streptococcus. Tlie streptoeoecus is apt 
to destroy the woman, while the gonococcus in a physiological sense 
destroys the repriKluctive urgaus and makes a eluTmic invalid. 

The danger of o|)eration varies somewhat with the extent of the 
disease, but chiefly with the kind of fiperation, the operator, and the 
nature of the causal bacteria. The mortality shown by some statistics 
is enormous; other reports give almost 100 per cent, of rcco\'eries. 
The n^moval of a gonoco<^cus sactosalpiux is less dangerous than that 
of a streptococcus siict*isalpinx. This is especially true if the sac 
ruptures into the ]>ent(meum. 

One hundn^d an<l iorty-four eases of removal of sterile pus tubes 
show a mortality of 2,8 per cent,' The average mortality, among the 
best operators, following removal of pus tubes is from 2 to 3 i>er cent. 
The o[>e rations in sixteen cases of gonococcus sactosalpiux in whieh 
the sac was removetl intact show a mortality of G,2 per cent,; in 
seventeen caaes in which it hurst during removal the mortality rises 

t Schauta. Ci^niralblaU filr Gynikkologle, p. 502, 1898. 



266 INFEOnONS, INFLAMMATIOJtS, AND ALUBD JDmOBDBBA 

to 11.7 per cent. In another similar seriea the mortality was & 
per cent, and 11.1 per oent respectively.' 

It is evident from the above that the prognoms of the opermtioi 
favorably affected by the removal of the^ appendages without mpt 
and escape of pus into the pelvic cavity. The average mortaL 
however^ with modem asepsis and teohniqae is small, except tar 
streptococcus cases^ and these fortunately are not very namerona. 
iMarCln. Ue Kiankhelten dn Bteltar. 



'Chapter xxiii. 



tEATMENT OF SiVl<PlXGlTI8, OVARITIS, AND PELVIC 
PEKt^mNITiS. 

The troatmciit of inflammation of the uterine appendages is non- 
surgical and surgical. 

Non-surgical Treatment. 

The treatment of the mihler adnexal inflammation, when early 
recognizeil, m hirgoly the .siime as that of the* eausative endnnietntis. 
Quiet, frecpieut ix-st, jiidifioii!? active and passive exercise, avoiilance 
of &exual excitement, re^^nlation of the bowels, nutrititais and non- 
stimulating diet, and tlie proliibition of tea and cotlec in neurotic 
ca.4e8, are anion^^ the routine measures, Rei>eate4l cxaaii nations and 
trc^atments, especially rongh jialpatioo of a sactosidpix, may, as stated 
under Diagnosis, pn^ve ihmgerous. 

Medical Treatment. In a(;ute cases pain may be relieved by 
^ium or its derivatives ; but they musk tlie symptoms and check the 
:»retions, and are therefore to that extent eontniintlicated. The 
occasional practice of locking np the bowels and iirevcnting peristalsis 
by the free use of opium lias hrt^n largely abanrloned. On tlic con- 
trary, rather active eliinination tlirough the bow^Vts anil kidney has 
become the more accepted pnietice ; hence non-*?oiistijiating pd Ha fives 
arc* iimudly snbstitntc<I for opium. Of these, tlic coal-tar 4lerivatives, 
diloral hydrate, hyoscyamns, an*! sodium bromide are among the 
more U!S4:'fid and least ulijectionahle. The eodeia phosjjliate repfatfd 
in half-gniin ih)ses is perliaps the least object irmiible oi' the prepii ra- 
tions of opium, Should the nervous symptoms predominate and 
denmml the more dependable morphine, the constipating effect may 
be overcome by the addition of an eijual amo!uit (»f podophyllin. 

Elimination is often well seeare<l In- means of rectal eneniata 
containing magnesium sulphate, glyeerin, or spirits of turfjentine, as 
descrilx'd in ("hapter VIIL, or, if |MJsitive jMirging hv ntjuired, by 
tlie us*.^ of some acti%*e eathartic. One may itse to a<l vantage retreated 
doses^ of calomel, one-half gmin in each, followe*! Iiy Rochelle salt, 
solution of magnesium eitratCj or &ome other a|>]u*opriate naline. 
The calomel itself is botli catliartie and diuretic. When the stomach 
will not tolerate onliTiary cathartics, a grain nf calomel may be fjut 
upon the tongue every hour until the bowels act. A wry high, 
retainal enema of four ounces of the saturated .solution of niagnc- 
ftium sulphate often gives promjit relief. 

There is a form of chronic Iji la feral aduexal disease which Bcjircely 
goes beyond irritation and congestion. Thijs is referretl subjectively 



268 INFECTIONS, INFLAMMATIONS, AND ALLIED DLSORDEBS, 

to the region of the ovaries. It is quite common amon^ nervous, 
overwrought spinsters and girls, is usually associated wim nervous 
irritability, is sometimes transient, oflten intractable, seldom dangerous. 

Overwork and overexeitement from study or social requirements, 
and especially music,* by the physical strain of practice and by the 
power of music to excite the emotions* at the developmental period 
of puberty, are potent and, among the higher classes, common causes 
of ovarian irritation. Many a hopeless neurotic invalid may in 
mature life date her invalidism from mental and emotional strains 
at the time of puberty. 

The treatment of the somewhat intangible irritation outlined above 
is mainly hygienic and moral, and largely, therefore, belongs to inter- 
nal medicine. It should, however, be rather regulative than medic- 
inal. Unsatisfied sexual requirements, conscious or unconscious, 
demand that the attention be drawn away from the reproductive 
organs. If the patient has reached the proper age, marriage may be 
indicated. Otherwise let there he a change of environment and pro- 
motion of new interests. A careful, all-around examination may 
show some causal and removable extra-pelvic fault in the patient or 
her environment. There will often be found disturbance of the 
heart, liver, or kidney, or intestinal indigestion ; such disorders may 
explain the impeded' circulation upon which the ovarian irritation 
largely depends. There is usually an associated mild endometritis, 
which yields, if at all, to systemic treatment. The useless sacrifice 
of countless ovaries in this class of cases is a reproach to surcery. 
Menorrhagia, a frequent result of this condition, is well treated by 
ergot, preferably given in rectal su])positories, five to ten grains every 
eight hours until the flow is controlled. 

Skene recommends for nionorrhagic and neurotic cases the con- 
tinned use of the fluid extract of hydrastis in thirty-drop doses, and, 
as needed for nervousness and sleeplessness, twenty to thirty grains 
of sodium bromide, to be given well diluted at bedtime, and repeated 
if ne(»essary.- 

The modical treatment not only of the above form of ovarian irri- 
tation, but of chronic adnexal inflammation in general, includes the 
judicious use of tonics, laxatives, alteratives, and hypnotics. It must 
conform to the goiienil principles of internal medicine, and differs in 
no essential ])()int from the general treatment of the extra-pehdc 
inflammations. 

Local Treatment. Re]K)sition and retention of the displaced 
uterus })y niechani<!al su])port may open up the collapsed uterine 
or tubal canal, secure drainage of retaintnl secretions, and by over- 
coming traction on the })l()od vessels may relieve congestion. The 
j)rime indication to restore the balance of circulation is often ful- 
filled by a ])essary. Special attention, however, is directed to its 
contraindications, as laid down in ( liapter XLVII. 

Catheterization, j)rol)ing, and direct treatment of the Fallopian 
tubes through the uterus have been projwsed and may, perhaps^ 

» Lnwson Tait. DiHepses of the Ovaries, p. 9<), 1883. 
sMiMlic'iil (Jyuecology, p. 2:^0. 



TREATMENT OF SALPINGITIS AND OVARITIS. 



269 



• 



I 



vW these organs an? dilated by disease, be possible; but they are 
unless and daogerous {jrtM^edurcs. 

Cnld-water coils ur the rubber ice-bug apjiHed to tlie abdomen, the 
application of a large blister to tliat part of the hypogastrium wliich 
fa over the seat of max i mum pain, and the free use of leeches, are 
vtry serviceable, es|3eeially in the aliortive ti'eatment of acute eases. 
Atleist eight leeehe8 should be applied : one or two are useless. 

The l<x:al treatuient of ehrouie adnexal intlammation has for its 
'chief object tlie tj uiekeui ug of the pvelvie eireuhition aufl- the j u*o mo- 
lion of a hsorpt ion of morbid pnxluet.s. It iucluites : 1, the hot- water 
vnpm] douche; 2, the vaginal tamjxmade (»f lamb'-s wool siiturated 
with glycerin or glycerin and iehthyol ; 3, the hot hip-paek ; 4, elec- 
tririty; 5, massage. 

fkr hol-watrr vftf]finaf fJouche and the wool vaginal tamponade are 
^fecribed in Chapter IV. 

The Hot JIip-pft(^k is a most efficient form of hydrotherapy. The 

apjiiication of it is as follows: Let an ordinary sheet be folded 

'f-n^Iiwise into sev^eral thicknesses, bo that its width will reiich from 

the iimhi liens to the middle of the tliighs. Let tliis be made into 

^ roller bandage, dippsl in very hot water, and wrung as nearly 

«lr>*as pjssible, preferably by a clothe^-wriuger. Pass this bandage 

^^veral times aroiuid the pelvis, so as to envelop the zime from the 

^^TOhilicus to the middle of the thighs. Cover it with a dry sheet anrl 

-■^^t the patient lie in it for thirty minutes. It is well, in order to 

^■^tein the heat as long as possible, to place between the wet and dry 

^^T^et a rubber sheet or a rubber bag f»f hot water. The pack should 

*^* repeated daily, or twi^'c daily, according to the tolerance of the 

J***tient- An iK-easioual fil)jectiou to its use is its temleney to cau&e 

I^^fuse menstruation. The treat men t is a most efficient means of 

^^Jmulating the pelvic circulation, and thereby of promf>ting absorp- 

*^^oq of morbid prmlucts. Chrouie constipation, ];>elvic pain, dy.smen- 

^^iThoea, and otlier functional disturbances often give way promptly 

^Hcier it55 influence. As a result of such treatment tlie disorder nuiy, 

-tiowever, lapse into suliacnte ovaritis with sometimes constant, some- 

^^nies* remittent symptoms. 

^^kdriahf. The galvanic electrmle, even with light dosage, has 

^^^Used exteusi ve flest ruction and cit^atricial couti^ictiou iu tlie genital 

^^^cl, es[)ecially in the njipcr part of the vagina. The intra-uterinc 

^i^^jtnxle is pain fid and often iutolerablc, Tlie occasional dangerous 

^Ufvctiou folh>wing its use is proverl>ial. The faradic cmuTut is used 

*» a form of deep l(x?al massagp, and the galvanic for its ^sup^posed 

^^CSolvent effects. Roth are said to promote absorption. The electri- 

^ri treatment of pelvic inflammation, after a long and faithful trial, 

"^>5, in the authurs bands, proved itself nfitber in safety nor efficiency 

^uul to the pniUiise of its ilevutees. 

Prhk 3Ias>(af/t' tor chrotnc inflammation around the uterus, a 
tt^tinent develo|)ed by Thure Brandt, stands at the liead of the non- 
'^pwive local measures* The massage is indicated for: 1^ the 
f^tnoval of inflammatory exudates ; 2, tlie Ijreaking up and stretcliing 
"^t lidliesions ; 3, the restoration of function to contracted or over- 



X 




270 lyFECTIONS, lyFLAMMATIONS, AND ALLIED DISORDERiL 

Btret<:lied ligaments ; 4, the reposition of displaced organs* The possi- 
ble dangers f)f niasvsage are ViTv great; lienee the imperative necessity 
of must eiirefid stutly in every ea^ie of the two urgent eon trai ml i ca- 
tions — aeute inflannnation and tlie prestiie^e of pus. Tlie vnh»e of 
mtussage, espeeially in the iliagno.sis and treiitnient of displaeemetit^ 
is so great that a jsjjeeial chapter will be given to it — Chapter Ij. 

The nnxles of t refitment outlineil above may be indicated in con- 
nection with giirgieal tn'iitmeni : ior example, vaginal aspiratiim of 
hydrosalpinx, followed Ijy etlieient local masstige and by sueh sys- 
temic treatment as would improve the patient's resistance to infection, 
may rei?nlt in cure, 

Surffical Treatment. 

When the disease has progressed to permanent obstnictioD of the 
tube and the formation ot pyosalpiiix, without periodical discharge!^ 
of pus til rough tlie uterus, and especially when the wc^sional attack 
of local peritonitis proves that the irdection is not constantly confined 
tu the tubes, the treatment described abfjve is no longer conservative; 
its continuance may be even more dangerous than the most pronounced 
opr^rative measun\ A tinu* lias come when a radical o]>enition, even 
to the removal t>f the diseased organs, may hv less dangerous than the 
disease, and, relatively s|>caking, then*fore becomes the c<in>ervative 
procedure. The inflamed tube, eidargcd to the size of the Hnger,' will 
seldom return to its normal Mate and functions. If, together with 
this eonditiiinj tliere be evidence of suppuration or great loe^il irrita- 
tion, the iiidie-alion fnr (^peratitm is clear. 

Fnr the preparatory treatment, see Chapter II. 

The operative treatnumt of aeute pelvic iidlanimatiun does not 
differ niateTially in ]uinciplc fri^m that of the clironie. It, Iiow- 
€ver, moiT frequently retpiires vaginal tlian abdominal section. 

The removal of the Falloj>ian tube alone is called salpingectomy ; 
that of the ovary alone is called oophorcctnuiv. When tulje and 
ovary are removed t^^gether the o]K*nition is ficsignatetl as odphoro 
salpingectomy, or salpingo-oopboreetcmiy. Usage reserves tlie word 
ovariotomy to signify the removal of an ovarian tumor. 

RouteB of Operation, There are two recognized routes for the 
operative treatment of inflamed uterine appendages,^ — the abdom- 
inal and the vaginal. An ^^iN'mtirin by the abdominal route necessi- 
tates abdominal section » also called creliittumy or laparotomy. An 
operatimi by the vaginal route involves vaginal section. It is often 
necessary to combine abdominal and vagina! section in one operation. 



I 



ABDOMINAL SECTION, 

T!ie reader is referred to Chapter V,, on General Principles of 
JIajor Ojje rat ions, Ibr prepamtory me<lical treatment, fc»r the tech- 
nique of abdominal section, and for the general cnuduct of tlie ojxTa- 
tion. It is often necessary to add to this opemtion a vaginal section, 
hence the importance of making in the vagina and about the vulva 

1 SchuuU. Centra Lbliitt fUr Gynilkolo^lc, ISS, 



TREATMENT OF SALPINGITIS AND OVAEITI& 



271 



Ibe same aseptic preparations as would be madi* if vaginal section 
. %tre planned from the beginning. 

S^^mctimes the inflammaton^ exudate has extended through tlie 
[leritoneum to the subperitoneal stryetiires, and so drsoi^anizcnl and 
di!^gui?*ed the part^ as to render them diffienlt of reec»gnition* Under 
these conditions carefnl dissection is necessary, in opening the abdt>- 
men, to avoid the unfortunate accident of opening directly thruugh 
the thickened, leather}^ peritoneum into an adherent bladder or 
intestine. 

If adherent omentum is in the way, it may i>e sepamted gently 
with the sponge — that is^ sponged off from it.s attachments. If not 
adherent, it may be pushed aside. Any ble*:Kling-p«Dints should be 
seeurcil by fine catgut ligtitureSj torsion, or temponiry forci pressure. 

If the case be simple, with no adiiesions, or if the atlhesioos be 
few and easily broken, the o|>eration will be relatively simple. The 
itidex*iinger of the left hand finds the fundus and posterior wall ui' 

FrauRE ISO. 



Showing tnuufixlou of broad ligament ivith Peaaloe'a necdlo. 

the uterus, and then maps out the diseasc'd areas in that region. 
The finger, starting fr<)m the poste^i^>r wall of tlie uterus, swe^-ps 
ahjng the msterior fold c^f tlie broad ligaments m\ either side and 
examines the Falbtpian tub*^s and ovaries. Thesu organs, now acces- 
sible lo siglii and touch, may be subjected to any necessary oix^nition 
nr manipulation. iSce Trcndeleuburg Position. The incision, if too 
^nort, may lie lengtliened. The intestines are pushed upward nnd 
[>1ated l>y tiat gauze or sea sponges. If there arc no adliesions, the 
appendages may Ik* lifted gently np into flu^ wound aud examined. 
Th«' surrountling exposed parts slundd be protected liy gauze spouges. 
If the removal of the appendage is necessary, tlie operation will be 
as follows: 

The tube with its mesosalpinx and the ovary are gras|>cd firm' 



BTLAMMATIONS, AND ALLIED DISORDERS, 



laaddrawn up into the abcloniinal incision. Thee 
^ pedicle-needle eontnining tht^ lig^iitiire through th^ 
tml onder the appendages, close to tho uterus, include « 
tiycviBaliif <^ die round ligtinient, Tliis round-lipuneut Um>pl^| 
mflr iMB €tt tlie interior surface of the broad ligament. In onles" 
thU ^ dltm tube SUIT be included in the ligature^ tlie needle .^houtd^ 
t fi^i^rfT t|i£ menae end of the broad ligament at it^ uterine junelion j 
the horn of the uterus. The pe<liele-nL*t^dle^^ 
f«t aas pflOHi is made to transfix the broad ligament qim< 
at two or three points from side to side* Tbu 




TREATMENT OF SALPINGITIS AND OVARITIS, 



273 



first made and tlien il ra wii ti^lit ; a single turn is then made and 
dm\ni ti^bt. The knot is tlien eonipleted by another *louljle Itirii, 
Tfit Staffortiiihire Knot was iirst used hy Lawsiui Tait. The V\y^- 
mre i^ p^^sed with the |X'd if vie- needle, as tles^^ribed in tlie toregoinj^ 
j»ni;a[mplL and tlie needle is withdrawn so as to leave the l(x>p em the 
furlhtr side of the stamp. Figure ITjO, The ltH>p is then dniwn 
nvttthr tumor or mass to be removed, Fignre 151, and one of the 
iW mds drawn thrungfi it so that one free end is under an*l the 
other over the retracted loup, Fignre 152. Both free emls, lieing 
mn'i] by the right hand^ are drawn tightly tli rough tlie pedicle ; at 
tb'same time the thumb and forefinger of the left liand grasp the 
ligatun' where the free en<ls cross the loop, and make lirm eounter- 

FlOVB£ 152» 



C 



9of lifiinre retmctcd over pjediele (linlj.laced between llie two free euds^propiinitrtry to 
tying SUiffurdshLnj kqot. 



PJH^iir^ against the pedicle until complete constriction is secured, 
^'^iiri? 153 ; then with the ai<l of the assistant the lig:atnre is secunly 
^'-"^1' It is then passed around the |K*dicle nnd tied again. The 
»wlv]intagi»s of the knot arc that, while it ties the pedicle in two hahes, 
"'t;^' liidves arc compressed into one mass. They are, moreover, 
uiiifnriniy eomprt\*^sed, and very great const rietiiig force may be used,' 
The author, after seeing Mr. 'hiit use the Staffordshire knot, nnder- 
^^^^ ti> use it himself The residt demonstrated the fat^t that a 
*[ir^^itn can sometimes get an immense amount of experience in a 
-'^fi^'Ie case. The ligiitnn' was imperfectly a]>plre(l, lunl *l(^ath from 
hdhopphage res u lied in a few hours. The essential precaution is to 
<iraw (he ligatures \'evy tight, and secure thereby the maximimi con- 
*fnrtirin before the knot is tied. To guard against the hiosening of 
^"t' lii^iture l>etwwai the time of tightening and the time of tying it 
''•^ thumb and fniger should still retain their hohl,as shown in Figure 

• AdMpted ftinn TfliCw Disi'asc^fl of the Ovaries, ISSS. 
18 




TREATMENT OF SALPINGITIS AND OVARITIS 



275 



t»thers. Oft times tlic pellicle, too lar^o to bn w^eun'tl by a single or 
tli>ulile ligature, may be safely tm\ in several parts. 

Mo^t oj^rators, for extra safety , apply an additional ligature to 
ilje ends of the ovarian artery on either side of the stump. One 
. _rature pa^sses around and eonstricts the fre<* mari^iii of the l>n>ad 
li^rament between the ovary and the lateral wall of tlie pelvi.'^ ; this 
is the part of the br<j>ad ligament through which the ovarian vessek 

FlOUBE 155. 




Bhcyiring the StaffordAblre ktiot tied and unchorage ligatures paswed bul not tied. 



fttss ; it is called the infundibulo-pelvic ligament. The other ligature 

MiTTiiunds the horn of the uterus and inelucies niueh of the liroatl 

Viijr^Hnont at tlie pHut where the Fallopian tuben join tlie uterus. 

T\\vne two ligjitures, one on eitlier .side of the stump, arc also passed 

ihrriiiirli the ]>ediele on t!ie distal side of the liganire, so that when 

iKil ihey not only seen re the o\"arian artery on both sides of the 

ftump, but also serve as sutures to unite that portion of the pedicle 

which is on the distal to tliat |Kjrtion whteli is on the proximal side 

*»f the ligature. The ligature is thereby covered In- the union of the 

*urfnc'os on either side of it. One or two similar sutures may lie m 

plaixtl aa to cover the ligature nil aroun<l the stumps This device is 

« sa%uanl against cutting the pedicle too short and against the slij^ 

P^j: off of the 1 i ga 1 1 1 r e . The a n c ho nif^i^ 1 i ga t u res s h o u M be passe* 1 

M (it'd before the mass is removed. Figure 1 5*^^^ 

hiring an openttiiMi the surronnding peritoneum shouhl be pro- 
*«'t(M| ag-ainst possible rupture of tubal or ovarian abs<'esses by the 
"^' use of s|Kmges s(> pla4'4'<l as to absorb any escafiing fluid, Tbese 
1*oiigrs, if contaminated, shouhl not be iutrtxlueed into the cavity a 
'•^M time, hut sh*)nld be removed, laid aside, and clean sponges 
^1 ill their place. 

The o|)enition just described leaves the ent surfaces raw, and 
wierefon? more lial^le to hcrouie adherent to adjacent |>oritonenm. 
^>ch iitlhesion has iiitmietimes produced kinking of the boAVel aii4 



276 lyFECTIONS, LS'FL ANIMATIONS, AND ALLIED DISORDERS 

conset|Uoiit fatal intestinal obstniction. Syinptoiiis of intesttuial 
olKstruetion from this f^iuse if observed early may be succesisfully 
relieveti by riH)p€4iing the wound and breaking np the reeent adht— 
gions* See Chapter VIII. In order tt) prevent mich adlie?iioti thc^ 
omentum may be stitched over the stump with fine i?ilk f»r eatg«^ 
sutureB, or the raw surfaces may be searni with tlie aetual cauter\^_ 

Operation Without a Pedicle J The tleeidetl advantages of thiff== 
method will be at onee apparent. Tlie t<^ehniqiie is as foHows : 

Plaee a ligature on the infundil)ui4j-i)elvie ligament — i. t\, on thai 
portion of tlie broad ligament between the ovary and the wall of i\w 

Figure 156, 

f] 



iO^ 



Showing the glover's stitch and ibe method of introduction. 



pelvis. Plaee another ligature on the other end of tlie broad ligament 
where it joints the uterns. This litr^itn re should not inelude the Fallo- 
pian tube. These two ligatures largely shut oW the f>vartan vessels 
from the parts to be removed. Grasp the tube, ovary, and adjacent 
jmrlioiT of the broad ligament in the left hand» and with the scissors 
remove them. As tliese parts are severed any bh Hiding-points may 
be si»eured by t('mponrry IVuvi pressure, li* any of tlie tul^e is left, 
the result may be impairtnl by tlie eontinuanee 4»f physiological and 
pathi>h)gieal priieesses after the operation ; henee the mH^essity of fl 
c^irefully dissecting out even tlie eornual portion of the tube. Fine ■ 
catgut ligatures are now placed upon the bletMling points, and the 
margins of the broad ligament woimd are whipped over and together 



J This has Wt'n jiroprist^ by Pulk, Clinicnl Gynccnlofjy; Keatinfi^ and Coe, p, 37!)» , 
rttse, AvncricHn Jcmrnal nf Objittjirit's, August, 1855ft; find by Wntkina, 'I'riinMt'llrms Amertcttn 



Oynerologk'fll Snciely, liSlKJ- 
Watitlns. 



by F*e!i- 
_ . , ►raertcttn 

The peculinr gloTC-Htltch shown in Figurt? Ii^wh* suggt^ied by I 



fATMENT OF SALPINGITIS AND OVARITIS. 



277 



iy afine, runnint^ ciitunt suliiir. The uterine wound made by dis- 
^•tingout the uterine end of the tube is elo.sed by internipted sutures 
■or by a oj^ntiniiation of the runninjo^ xSiihire just described, 
imon^ the great adviintages of this oietliofl are : 
I Tlie omissiun of the tubal ligature jiud stujup, which are apt to 
rtiipimd perpetuate hx'al irritatiuu. 

2. Tlie entire I'cnioval of tlie tul>es, wiiieb |[];euerally insures physitv 
logid and patliol<jgie4il rest for the reniaiuiug uterus. 

3, Tlie maintenance of the normal relations of the round and l)road 
ligaments to tlie uterus and their functions as uterine supports. 

i Tbe absence of a stump which may possibly slougli and pnxluce 

5, The covering of all exposed suivfaecs with peritoiieuraj which 
leasen-^the danger of post-operative adliesions. 

<). Freedom from danger of infection through the uterine cornua, 
siich <lauper being avoided by the entirt^ removal of the tube and 
soturiii^' of tlie tubo-uterine wound, Ries has lately given timely 
y^Amwf (if this danger, esjwcially when the quickly absorbable catgut 
li^'^ihiR.; are used. 

On aeeount of ihese advantages, unless the patient's condition 
Jemantls the more ra|>id application of the ligature en masne t-4> save 
itine, the oj>eration without a pedicle or stump is to be prefer red. 

la many cases the a<lhesions arc so extensive and firm that the re- 
W'lnilof the ap{>endages involves great traumatism and the uncovering 
'^iWcxid surfaces— t*>o l>road to cover by any plastic w ork on the peri- 
totiiMim. The rule, therefore, to cover all exposed surfaces, although 
Buund, is often impnictieable. 



OomplicationB. 

^^ fii^eidfirs and dangerH of the ojieration may be so great as to 
nuke it one of the most formidalde in surgery. The special technique 
toiTiM the varied ecmditions of grave pelvic inflamniation will turn 
'^P^"n the presence r>r absence, first, of pus or other infectious fluid; 
•'^*1, s<?e<>nd, of adhesions. 

Teclinique in Pus Cases. Although the pus in chronic py opalpinx 
''^ 'i>^mlly sterile, it is not always so; hence it is safer to pnwHHMl, 
•■'^^'^ptin matters of drainage, on the sup|>ositiou that all ptis or other 
■^'Ji*! ifl infectious, and, if possible, therefore to enucleate the sac 
Without lireaking it. Aspiration <»f a part of the fluid from a very 
Hse tiilie may decrease the risk of rupture. Contact of the pus of a 
"^ptured tube with the pt-ritoiu'imi may have no serious resiilts, for: 

1. The tbiid may lie sterile, and therefore innocent. 

-. Even though intcetions, if thoroughly washed or sponged out, 

Jl'fr&^idue of septic matter may be taken up by the peritoneum and 

^y^n off by the organs of elimination. The <:^i|>acity of the ptTito- 

Uin to take care of such fluids is very gi*eat, Tlie conditions, liow- 

'^•'t under which it docs or does not do so are not fully known, 8i*e 

ptfT VIL, on Drainage. 

lie rrifxtstence of pyosalpinx and a conimnnicating parametric 




278 rNFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

abscess c!eiirly renders the clenn enueleation of the pus sac impos- 
sible* After the removal of such a tiilnH tlie parametric absec^i 
cavity must in every case Iw in direct commanifatiuii with the pelvic 
cavity. A Frw oj>ening from the cul-^Ie-sac of Doiig!a.« into tlii* 
VJigiim and etfeetive gjinze dminati:e by that route are iiow desirable. 
If poBsihle, the general al)donHiKii eavtty should be shut off by st itch- 
ing the omentum or ]M?ritonetrm over the abscess ^alL If there l>e a- 
para metric abscess pure and sim]>h% witliout tulial or other cnnoectioos^ 
the pus is much better evacuated and drained through the vagina. 
This would involve the abandoimient of the abdominal route and the 
Bubstitution of the vaginaL In some cases, even with tnlial eon- 
ncetions the vaginal route may l>e nreitrable. 

When the jx^lvii' viscera are niattco together with strong and exten- 
sive adhesions, including a great (|uantity of inflammatory exudate and 
pus, the operation may become h>ng, extensive, and ver)- dangerous. 
Such conditions usually require a relatively long incision. In addi- 
tion to the removal of the appendages, vagiiud drainage and hyi^ 
tercctonjy may be net pessary. These eases frequently offer most 
favora1>le indications for tlie vaginal route. 

Tlie class of euj^es described in the fon'going paragmph furnish 
mo8t of the mortality in oiVphoro-salpingectomy. Such formtdal^ie con- 
ditions may even jirohiijit the radical operation and require, instead, 
simple incision and drtdnagc t»f the pus cavity, Oftlimes the adhesions 
between the visceral iwritoneum covering the tUseased organs and the 
parietal peritoneum through which the incision is made are so exten- 
give that the o|wrator may find his way directly into the pus cavity 
without e xposu re of t h e ge n e m 1 | >c^ ri t o ne n m , In bu eh ea ses i t m ay be 
wise not to attempt the removal of tlie appendages, nor even to make 
a complete diagnosis, l>nt rather to Iwatc, incise, and drain the pus 
cavity. A nu>re ra^lieal (Hieration may l>e n*ade later, If necessiir)% 

When the adhesions described above do \mA [lermit din'Ct opening 
of the pus cavity without exj>osure of the general pritonenm, the 
surgeon may^ after nuiking the exploratory incision, locate the pus sac, 
at\d without immetliately opening it stitch it to the |mnetal peritoneum. 
A few «lays later, when adliesitms have formed, tlie abs<:!ess may be 
opened wi tin ait involvement of the general peritt*neum. Many sur- 
ge(ais |>erforni both opi'raliuns at one time, as fol low's: 

1. Open the abdomen and locate the pus sac. 

2. Pack sponges all around tf) protect the iwritoneum. 

3. Remove the fluid by the aspirator. 

4. Wash out the sac by reversing the action of the aspirator, 
being taken not to ctmtaminate the surrounding p'rittmeum, 

Tk Enlarge the aspirator ojiening by incisinn, and unite with intcr*^ 
rupted eatgut sutures the viscera! j>eritoneum around this incision to 
the parietid {w^ritoneum anujnd the abdoniinal incision — L e., join the 
two incisitms into one. | 

6. Curette tlie sae f(»r the removal of gnmulations, bhxKl -clots, ' 
and other undrainable material. 

7. Drain with rubber tube or glass tube or ^auze. Constant drain- 
age may be recpiired for months before permanent closure of the 



TBEATMENT OF SALPIXGITIS AXD OVARITIS. 



279 



vouud. So long aii tlie patient's health improves or continues good 
it is betttT to wait for the >^imi,s !u elo^e. If at any time tliere he 
eviiienceii of new pus forniation, a nnlical optTation for removal nf 
liie t uV>e h ho u 1 ti he eo ii s i* 1 e vim 1 . 

U|¥jiiopenin|^ the abdomen oue may locate a pus sac adherent to 
Rime other jxirt of the abdominal wall. It might then be goo<l .siir- 
f;crv tn cloiJe the first ineision and make another flireetly into the sac. 
Thiabi^ceas could then b<i evacuated without contamination of the 
(leritotieum. 

The rases described above are often more etHcicntly treated by 
vaginal section and drainage, or by the removal of such organs 
thmngh the vagma, as the case may require* 

The indications and tcelinitjue of washing and sponging ont the 
jMritoiieul cavitVj and the indications :ind modes of abdominal drain- 
aLTam! die toilet uf the peritoneum, are discussed under the General 
Principle.-? of Peritoneal Surgery, in Chapters VI. and VII. 

Technique in Adhesions. Conservative surgery specially reserves 

for rnuf leaf ion only hopelessly diseased organs. Strong and exten- 

wendhesions are among the most common ditfieulties in the renu)val 

^^'fjiu eh organs. The first objective point, as in the simple cases, is 

tb fundus and the posterior wall of the uterus. Frtmi this point tlie 

•iufrfT searches out tiie dist^ased orgtms on either side and recognizes 

ttfir relations to adjacent structures. An o\*ary or tul>e, even 

^lioiigh imbeddetl in ap^mrently inseparable adhesions, may often be 

^mM out with relative ease if the weaker lines of cleavage can 

"•^ fuiuid and made the starting-points of enucleiition. Let the tip 

^' the index and middh^ fingers of tlie left hand search for sulci 

/>etwet^n the diseased appendnges and the adherent surtaces. Look 

^or points of least resistance, and follow their lead so long as the 

'^Iinration does not require undue fiu'ce ; then look for other such 

P'Hnts. Tlie finger advances with gentle firmness, using the side-to- 

*^e and toantl-fro motion, until by pres,sing ture and there, and by 

Punching the adherent structures apart, the outlines of the offending 

J^l^gans are ma*le clearer and ch*arer. By this means they are finally 

J^oljited and bnuight up into tlie wound. The technicpie of removal 

*® then the same as for non*adherent ajijiendages. 

Technique in Hemorrhage. During the enucleation it is not well 

M> >,top for minor Ijleeding points, L<'t the orgtms be isolated from 

we he<l of adhesions as ni[>idly as safety will [>ermit. Always keep 

^l>rim^Ts packed around to control heniurrliage by pressure and absorb 

W*>n1^ pus, or serum. Wlien the appendages an' cut oiF and the 

*^*^litnry ligatures applied the bleeding will usually have ceased. If 

^ot, [lack hivt sponges firmly ngiiiust tlie blecili ng surfaces, frecpientty 

chnuiflng them to prohmg the heat. Double ligature of the ovarian 

Vf*^.|^ on fither side of the stuniji, as already described, is always a 

S^^xl safeguard and often necessary. A sterilized saturated solution 

^f atitipyrine, as recommended by Koswell Park, is a valuable ha^mo- 

**aiie. If bleeding is not controlled by [jrolonged hot-sptmge press- 

^"^lantipyrine, and ligature of the ov^arian vessels, and the bleeding 

Hiti^mDnot be secureil by isolated ligatures, it is better not to prolong 




TREATMENT OF SALPIMJITIS AND OVAEITIS. 



281 



contmitirlicati'*! by the exhausted eonclitinii of the patient, reseotioti 

miifbt be preferable, ihr if the artifieiiil amis did not chise ^jMUitaiie^ 

oi]j^Jv rei^ectioii would subsequently l*ave to be made. 

3, If the o|>enin^ is so (ieep in the |)elvis as to be inaccessible or 

jtfrt patient is too exhausted to permit suture, tlie territory around the 

fijjttik may be quarantined from the gi^neral i>erit<iiietim by means of 

gauxe poking". Adhesions will form in a few hours aronnd the jiack- 

inf and tliereby sluit nH' the leakin*^ hr^wel from the general perit^i- 

mnim. The writer has sneeessfnily treated two eases by this mctliml. 

The ^'lUize may be brought out thnnigh the abdominal wonnd ; or if 

the istuki is deep in the ]>etvis, it is Ix^tter to pass the gauze dniin into 

the vaj^nna through an oi>euitig made for the purpose and close tlie 

abdoniimd wounrb 

1 If the iistida is too large for suture, the parietal peritoneum 
ruyy he made to take the place of the lost intestinal wall. This will 
ntjuirt* tlie e<lges of the Vistula to be united to the abdouiinal wall by 
iwerins of a plate of deealeified bone or other materiaL The ]ilate 
should have small pe rib rat i on s * >ne-s i x th of a ti i n c h a }>a rt a 1 1 a ro u n d 
imt il^ outer edge ; it is plaeed inside the intestinal opening, and 
through this perforation the margin of the bowel may be stitched to 



FlotTRR 187. 




\ ^''■toiQQiii of the Intestine at the tw^ points wber« it had rommuntcftted wtth the aactosal- 
pinx. One row of sutures introduced. Author's cjiae. 

™*^ panVtal {>eritouenra. The sutures slioukl transfix the bowel wall 
itKl th(. tihdofiiinal wall and be tied on the skin. This would ajjproxi- 
'^'**»^ .serosa to j^erosa/ 

, f«G following ea.se is illustrative and instruetive. In an opem- 
:'^'^ at St. Luke's Hospital, Chieago, a large friable pus tulje was 
'j' "'omaumieatifui witli the bowel at two pointy. After enueleatiou 
Jl^rij ^'ag ji Ustula too large t*j be closed at each of these points. 
t^fl«! bowel wall surrouudiiig the fistula was, moreover, extremely 

I Solar Ha the writer i» tnforme*! this method has never before been suggeiitcd. 





282 INFECTIONS, INFLAAfMATIONS, AND ALLIED DISOBDERS, 



thickened and frialjle. Tlie first impulse was to resect the bowel at 
each point of injiny. Instead of this most formidLible oj>t*nition, how- 
ever, the following plan was stieeessAiUy adopted : The two ojienings 
were brought together and united by three rows of fine contiDUOus 
sutures. The fistid.^e were therel>y utilized as openings for an inte^^ 
tiiial anastaiiiosis. The abdoniinal wound was closed without drainage 
save a slight gauze drain extending from its upi)er angle to the 
neighborhooti of the intestinal suturrs. This drain was removed on 
the fourth day. Both intestinal and al)th*minal wounds hat^e at thf 
Ihiw of thin writinf/ permanently ehwed, the latter with slight suppura- 
tion. This principle has been employed in the repair of gunshot 
wounds ; but, so far as the writer is informed, it has never been used 
in a case like the above. 

VAGINAL SECTION. 



The maxim that every peritoneal section should begin as an explo- 
ration lic»lds true as well for vagina! as for abdondnaJ section. 
TluuYJUgh sharp curettage an<l cleansing of the endometrium are 
essential prcliniiuaries. Tlie object is^ first, to remove the original 
source of infection, so that in ease the uterus and its appc»ndages on 
one or both sides are not removed the danger of further infection 
from the endometrium will l>e re<luced to the minimnni ; second, ti) 
prevent infection of the peritoneum from tlie uterus during the i»i>era- 
tion. Vaginal section according to the indiciition is made either 
anterior or posterior to the uterus, or both anterior and posterior. 

Poderior Vaginal Sedion, 

The posterior incision is made close to the litems, l>etw^een the 
cervix uteri and the rectum, from the post-vaginal tornix into the 
pouch of Douglas. The stejjs of the ojK^ration are a* follows : 

1. The patient is to be placed in the dorsal position and the vaginal 
portion of the cervix exposed by Simon's retmetors. 

2. A semicircular incisicju^ large enough to admit two fingers, is to 
be made directly behind the uterus in the line of the ntero-vaginid 
attachment; the incision to be made with blunt-pointed scissiirs 
curved on the flat, the point being directed toward the uterus and the 
cervix being drawn down by the vulsellum forceps, 

3. The loose cellular tissue back of the cervix between the vagina 
and tlie pouch of ]>ouglas is to l>e stripped back fitf fnnji the cervix by 
I he blunt jjoiiit of the scissors, by the handle of a .sealpl, or by the 
finger, until the peritoneum is reached. 

4. The peritoneum is to be divided close to the uterus by a snip 
of the scissors. The clf)sed scissors points are now to be jjassed 
through intc» tlie jwiuch of Douglas and tlie o|K»ning dilate<l by 
si>reading the blades. The ojH^niug is to be still further enlarginl if 
necessary by curcful cutting with the scissors or by tearing with the 
fingers. 

5. The index and middle iiogers of the left hand are now intro- 
duced into the pouch of Douglas, and u digital exploration of the 



I 



I 



I 
I 



I 



TllEATMEST OF SALPISGITIS AND OVAEITIS. 



283 



pi vie cavity is mutle. If Hiiffieient r«M>iii liiis not Ix^eii gainedja pt r- 
jjt'iiJu'tilar incision, beginning in th<j rnitlcHc of tlu' posterior bordm* 
of the one already descriljod and running toward the reetniii, may he 
made. In catting down towanl the bowel tlie left index-finger in the 
rectum slionkl be used as a guide* This finger is now withdrawn, 
thoroiiifhlv cleaned, and rcintrnihiced into the poneh of Douglas ; the 
rig[|]t liaml is placed over the hypogastrium behind the pubes^ ami tlie 
rx:tfiiiniitiDn is nnide [jreeistdy a.s in onlinary bi manna I jwdpadon, l)ut 
witiiarlisduct advantage — /. *\^ the palpating finger is in tlirect eon- 
tU't with the nterns and its appen^Jages. 

Tbrongh this incision the various oik? rations n{H>n tlie ai)|K'udages 
tnarbe prfornicd. The tubes, ovaries, and corpus uteri — the adhe- 
sion.*, if present, having been broken uj> — may be tlrawu tlmtugh the 
voinid into the vagina and examined. One or both *if the apijeiulages 
Wi\}' y removed. The incision may l>e extended^ if necessary, to a 
^'aginiil hysterectomy, which usually involves also the removal of the 

Posterior vaginal section is not wtII adapted to the removal of the 
appeiwlages ; it is, however* siK^cially applicable to the incision and 
'Iraiiiage of jH'lvic pns-euvities. These cavities may be in the tubes, 
"varii'Sj ur pelvic connective tissue. The o[*e ration for their incision 
*im1 drainage will be described on page 290, 

Anterior Vaginal Section. 

Ppritoneal section anterior to the uterus — /, p., between the uterus 
si>il bbdder — renders the uterus a nil its appendages more accessible to 
^>aM!rvutive mdieal operation than posterior section, but less acces- 
?iMe tlmn abdominal section. The technique is similar to that of 
I'^^terior section, and is as follows ; 

Tlie patient is plaeed in the thjrsal position and the cervix exposed 
y •^irnan's retractors. The cervix is sei/.ed with vulsellum or linllet 



^orijc^h, 



'|H and drawn toward the vidva, A tmnsverse si'micireular 

^'icision elose to the uterus, in a line with tlie utero- vaginal attach- 

f^^'^it, is made whh scissors through the anterior vaginal fornix ; or, 

^J^'^t^'iiii of this, the incision is made in tlie longitudinal direction in 

'*^me<iian line through the anterior vaginal wall fVom the anterior 

^■*tll ijf the cervix t*nvard the bla<hlen Tlie hitter incision is preiV'r- 

^hle, iMY-ause, without great care, espeeially if the cervix is small, the 

•^UisvfTse incision is liaijle to injure the ureters. In making the 

'^'igittiilinal incision, the operator should not only draw the cervix 

•^tcri well down, but also make strong downward traction on the 

'•terior vaginal wall. This is done with a tooth- or bnllet^forceps 

Unflif^l to tlie wall between the cervix uteri and the ui^'thni. If 

'^ longitudinal incision give insuifieient rcMnn, it may be supple- 

^***htc^l by t!ie transverse, Tlie combined l<»ngitndiii:d and transvei*se 

*^U have the shape of the letter T, They are <hown in the Surgical 

*^*ntnient of Myomata, Chapter XXVIL, also in Figure 158. 

The uterus is now drawn strongly forward, and the structures 
**ia*rnt to its anterii»r wall are stripped t>fl", keeping clc»se to the 



^ 



284 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

uterus, as described above for j)osterior section. As the bladder is 
Ix'ing separated from the uterus it is held up out of the way by an 
anterior retractor or the finger. When the peritoneum comes into 
view it will be recognized as a thin, translucent membrane reflected 
from the uterus. A sound passed into the bladder will prevent cut- 
ting that organ for the peritoneum. The peritoneum being exposed, 
it is snipped with blunt-pointed scissors. The opening thus made 
into the j>elvic cavity is enlarged by introducing the two index-fingers 
and tearing laterally, and, if necessary, by careful cutting with the 
scissors. During the separation of the bladder from the uterus a 
sound in the uterine canal may be useful as a guide. 

The corpus uteri may now, if adhesion do not prevent, be seized 
with vulsellum- or bullet-forceps and drawn forward into extreme 
anteversion. The fundus may even be drawn into the vagina. If 
there be adhesions, they may be loosened with the left index-finger 
introduccil over the fundus uteri, the corpus being at the same time 
drawn more and more into the vaginal opening. The Fallopian tubes 
and ovaries follow the corpus, and may thus be subjected to examina- 
tion and any necessary operation. They may be wholly or partially 
removed as in abdominal section. The closed fimbriated extremity 
of a tube may be opened or the ovarj'^ may be resected. See Con- 
servative 0|)erative Treatment of Adnexal Inflammation in the fol- 
lowing paragraphs, pages 292-295. 

The removal of the appendages by anterior vaginal section does 
not materially diifer in technique from their removal by abdominal 
section. Haemostasis may be secured by the usual ligature of the 
stump close to the uterus or by running sutures in the broad ligament. 
Sec pages 270-270. The appendages should be brought into full 
view ; this may require very firm traction, and the uterus may have 
to be drawn from side to side. Ijigiiture of the infundil)ulo-pelvie 
ligament, which controls the ovarian vessels, is often difficult, some- 
times impossible. The most important part of the operation should 
be under control of the eye. SometiuK^s the broad ligament, if short, 
tense, and adherent, cannot be readied througli the vagina. It may 
in such case bo safer to abandon the vaginal and resort to the alnlomi- 
nal route. If there is difiieulty in returning the uterus, enlarged by 
congestion, from torsion of th(» ligaments, the Simon retractor may 
be used in the manner of a shoe-horn, and the uterus slid in on the 
smooth blade. 

The blood-clots having been sponged out and all bleeding points 
secured th(» wound is closed as follows : The peritoneal margins are 
drawn down and aj)proximate(l by means of pressure forceps. They 
are then whij)ped together with a running, fine catgut suture. The 
suture is continued as a buried suture to unite the vesical to the 
uterine surfaces of the wound and finally, as a running suture to close 
the vaginal margins. The vagina is lightly packed with aseptic 
gjuize. The anterior inctision, except for drainage of pus-cavities, is 
preferable to the post(;rior. It involvf^s less danger of post-uterine 
adhesions, which may result in fixation of the retroverted or retroflexed 
uterus. Moreover, it offers by anterior vaginal fixation a cure for 




p^lvk; di!i4?ase i.s rendered more accessible by the combined auterior 
and pusteriur iiicisioiis. 

Effects of the Removal of the nterine Appendages. 

The removal of the di.seased appeiidnges bas beetj iisuiil in liydro- 
saipinxand h the rule in pyojialpinx. The o])erati<)ii, if llH»n»ugbly 
fHT|i>rmed, is generally i oil owed Uy atruphy and eonstMpient arrest of 
ilioction in the uterus, Ils result should [)e to precipitate the meno- 
paii5e. The artificial [n^othiction of this critical periwl give^ rise to 
pheiiuDoeua quite similar to those which characterize the natural mcuo- 
pibe, except iu most cnses menstruation is at once pcM'maneutly ar- 
restal. The |><jpular irnpressiou tliat tlie ojiijration uusexes the 
Woman in a mental sense *>r renders her mascnline is a miistake. 
htmis frequently ask whether it will result in the growing of a 
b«inl<»r the development of a bass v<jire; but no such residt has even 
Wm ob^rveil. Tlie operation perhn^mcd on a young girl wuuld 
doubtless arrest I lie intrapelvic ami some of the extrapelvie develoji- 
DiPiital processes of puberty, but development once made is per- 
mmmt. 

The eifect of tlie operation upon sexual desire is variable^ but 
prul)ably no mt^re so than that of the natural menopause. 

The question of insanity as a result of the operation has been 
^^smA-^ it probably occurs no more frequently tlian ;»fter other opera- 
tions of eipial gravity, probably not oftener than with the natural 
meiiop<iu:^e. 

Tbfi primary object of the operation is the removal of certain 

'^^'^iris which wouh! otherwise be dangerous to life or destructive to 

«^ltb. A most i(nportant secondary result is the arrest of physi<>- 

%*cal function in the remaining nterns. In this connectinu it is 

^^^^ that, since pathology is physiology moilified by disease, the 

^^''^^'phic changes in the uterus consequent upon the operation nuiy, 

^^ the same time that they arrest ]>hysiHh)gical processes, also put 

J^ 'Tid to pathological processes. Esp^H'ially is this true in the in- 

aatQtnl uterus, disease of which is often perpetuated by the consmntly 

f^'"rring menstruation, Tlie frequeirt disjqipeanince of metritis 

^^m tlie atrophic uterus verifies a recognize<l principle, that physio- 

^^•Cfil rest may favor the cure of disease. If the uterus is healthy 

/*^nly the seat of mild catarrhal inflaniuuitiun, it will nsuallyj n|)on 

r^^ removal of the appendages, jkiss rapidly into the atropbic state, 

7^*1 give no more tnmble than would a uterus after the usual meno- 

^u.sp^ Unfortunately, how(^ver, this very crmimon sequence of the 

/^'^oval of the appendages is not constant. The atropine process does 

P^ always follow, or, if it fVillnws, may fail to remove the iufec- 

Y^n, The infected uterus may be tlie source of pc*rnieious menstrua- 

^^^y amounting at times to menorrhagia. A surviving and intmct- 

M<? endometritis often gives rise to pmfuse uterine dist^harges. 

*^hauiitive dmins upon the paticnt*s strength from such cause may 





28 G lyFECTIOXS, L\FLA3IMATI0N.% AND ALLIED DISORDERS. 

destroy her resistance to dbease^ reinforce the uterine iDfection, and 
perpetuate a group of disabling nervous symptoms. 



Should the Utenie be Removed with the Appendages? 

This question has been foreed upon the surgeon by the numeroim 

immefliate and remote fsiikire.^ %vhich have followed the removal of 
the appcndiiges alone. When the appendages on one H*le are healthy, 



d, and when 



or not di.seiiised euDUgli tu ueeessitate tlieir rem ova I, ana wtieu on or 
or bolh sides enough eaii tie left to give hope dmt the reproductive 
function may be preserved, the an.^wt-r is clearly negative. The 
esnential ipiestion is, What shall be done with tlie uterus when the 
apjiendages on lioth sides have to be removed? It may be urged 
with enusidemlde foree that the faiUire to l>ring about atrophy of the 
uterus and arrest of functinn, and to secure consequent relief from 
pernicious symptoms, comes, lu many eases, of faulty technique in 
the operation. Artluir W* Johnstone and Lawson Tait have shown 
that when the tubes are taken oflf close to the uterus and every par- 
ticle of tlie appendages removed, arrest of menstruation, atrophy 
of the uterus, and a satisfaelory menopause, even in cases of iideeted 
uteri, are apt to fuHow, The explanation of this is simple and as 
follows ; The thortmgh ri'moval of tlie tubes cuts off the ovarian 
arter\' and the supply from the uterine arter)' at the point of anasto- 
mosis M ith the ovarian. As |rointed out by Johnstone, it also cuts in 
a similar way the nerve conmt^tiiuis of the uterus; hence the ob- 
served atrojilty and arrest of fuiu^iiui. It lollows from the above 
that if the ajjpendages are jirnpi^^ly removed hysterectomy is not 
necessarily indicated. The claim of the enthusiastic hysterectomist, 
therefore, that when the apjMiiulages have been sacrifieed the uterus 
necessarily becomes a | meruit -ions, continuous, disabling, and dangerous 
source of infection, may, as a imiversal projxisition, be disregardeil. 
In onler to bring about the most safisfaetury resnils the tubes sliould 
lie removed not merely close to tijc uterus, but the entire tubes, even 
as they penetrate the eormia, should be removed to the uterine mucosa, 
and tlie eornual wounds shotdd be closed by eatgut sutures. The 
fact has alreadv been mentioned that the removal of a tube by tJie 
t»rdiuary stump and ligature nicth(Kl often results in leakage of 
uteriue secret luus. 

When tlii' inft^ction is acute the removal of the appendages upon 
extension of the infection to those organs and to the peritoneum may 
be wholly inadequate. The propriety of leaving the infected uterus 
while the <'ausative infection in the endometrium is still overwlielm- 
ing the pelvic lymphatics with its septic supply may l»e most qnes- 
tionablc ; for the uterine infection may eoutitine to spread to the 
]ieritoneuui even after removal of the appendages. If vaginal iu- 
cision and dniinage are deemed inadequate, the removal of the uterus, 
together with tlie ajipendages, may be necessary for two reasons: 
first, to cut off the septic supply ; second, to facilitate drainage. 
When this is done convalesceuce is more rapid and less complicated 



TREATMENT OF SALPIXGITIS AND OVARITIS, 287 

tlian after the mere removal i>f the appendages ; this would bo es]M^- 
cially true in very virulent pntirjx^ral euses. 

Objections to Hysterectomy. 

1. The fact that the uterus serves as a sort i4* htjj>p<»rt for the 
Vn^tnal vault and is neeesj^iry tluTL'fVjre to the integrity c»i' the [mhic 
floor and vagina. 

2. The porvHibility that n-moval uf the uterus, in addition to re- 
moval of the apj>endagt^s, disturbs the moral anti physical well-heitig 
of the woman to a greater extent tlum tlie removal of tlu' appendages 
alone. However this may be, nuiny w«imen have the strongest aver- 
j^ion to its removal, 8o far as may be, without harjo, tlieir wishes 
should be respected. 

3. The faet that the removal of the uterus, espeeially by the hand 
of a slow or in ex IX' rt ofjcrator, involves additional shor^k nnd danger, 

4 . Th e poss i I » i n t y t h a I h y st e r ee i\ nu y may ea u > e se< *< ► n r I a rv ( 1 e ge n e ni - 
live changes in the sjjimd cord or bndiK Tliis a|>|>nreut result has been 
observed as a sequel of major «»penitions in other |*arts, es|>eeially 
those involving extensive iujury to nerve structun*s, 

^5. There are reasons to infer that the uterus, like the ovary, may 
havx^ an important function as an climinative organ. 
6. The absence of a clear indication. 



Indications for Hysterectomy, 






1, The matting together of tlie reprrMluetive orgims in one infectetl 
niass^ with pockets of pus, The difficulty of o|x»nition does not ^ neces- 
sarily, neutralize this imlieation. 

2, Tubereuhjsis i»f the reproductive organs. 

3, Compliealing malignant diseaj^e, 

4, Complieatiug uterine myouui which cannot be removed without 
ficing the uterus, 

5, Involvement of the endometrium in destructive inflammation, 
Mj that the uterine wnll, itself j^trongly infected, becomes virtually the 
wall of a pus-eaviiy ; unilcr these eonditi^^u tlie uterus is at onrc a 
pernicious source of danger to health luul life, and, if remuvalile, 
should under no circumstances be left. 

The value of the uterus as a s^upport and a completion for the 
vaginal vault has led some operators to remove the corpus and leave 
the (HTvix, or at least t!ic vaginal portion of it. This can be done 
only when the op'raUon is pcrfurnied by tlie abdoiuinal route, a 
route which coutem]ilate<l onginally but one wound^ aud that through 
th<* alxlomen. To knive llie cervix, therefore^ after removal of the 
corpus, i^ a natund corol lary of the alidomiual fiperatiou. If hyster- 
ectomy, on account of the infectious character of the uterus, is to be 
done at all, the operation should at least inchHle that [uirt which is 
ui^ually most infected iuid then-fore most j>ernicious — t!i*" t-ervix. The 
idea of leaving it would never occur in connection with th** '">cfiual 
operation. 



288 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

Technique of Vafirinal Hysterectomy. 

All preparations are made as for vaginal section, including curet- 
tage of the endometrium. The {latient is placed in the dorso-sacral 
{Hisition, the legs protected with long, sterilized woollen stockings. 
The vagina, having been thoroughly disinfected, is held open by 
Simon's retractors, and the uterus seized and drawn down as in ordi- 
nary vaginal section. The cervix is then incised all round by a circu- 
lar cut in a line with the utero-vaginal attachment. The uterus is 
then detached from the bladder anteriorly and the rectum posteriorly, 
precisely as in anterior and jwsterior vaginal section. 

Figure 158. 







LIiKS of nntirif»r, postorior, nnd latornl inoisions in vuKinal section. A. Anterior inriRlon. P. 
iN)>tcrior incision. L, L. Ljitenil incisions. 

In order to ip\\n greater spneo for operating two lateral incisions, 
eaoh about one-half ineh hnig, may be made in the vaginal wall. 
Tliese ineisions extend fnnn the lateral margins of the vaginal wound 
and re.^enible similar in<'i.sions aln^ady de.^eribed in anterior and poste- 
rior seetions. If still greater s])aee is needed, the jn'rinoum may be 
divided longitudinally, but should be reunited at tiie close of the 
operation. 

If the uterus is in its n(>nnal position the eorpns may be dniwn 
through tlie anterior opening; if retroverted or retrofloxod, it may ho 
everted tlirougli the posterior o])ening. This is accomplished by teuao- 



TREATMENT OF SALPINGITIS AND OVAEITJS, 



289 



ula urvul^llum-foreop!?. Seize the corpus as lii^h as posisible, draw it 
ilt^vvjiasfar as it will come, then gnisp it hif;:lier up an*! make more 
injilion, ami soon until the e version iy euriiph^e. The broad liga- 
ments are then elanipi'd Uy si mug pressurc-fon-eps or tied oil' Uy 
li)?ature^^ as deseribeu in tlie openitiuo of hysteix.'ctoniy for eanrer. 
hmn^ I be operati*>ii lateral, posteriur, and anterior retraetors are 
I freauf'ntly reqnimd. 

If the uterus is lai^, it may be removed in jmrts. The opera- 

lorcritsoff pieee after pieee with seis!Sor{^. This gives more working 

lJ»*»tu. The method is known as moreellation. The anterior f»r 

'p)*Ii^rior lip of I he entire eervix may he first removed. Then the 

wrjius raay be split in tlie median line and eaeh half separately 

mii'fveii, or the entire uterus may be diviih^d in the longitiidiual axis 

anJ each half reniove<l by itself. Before cutting the uterus away 

from the broad ligaments they should he previously elami>ed or liga- 

tnm\. If the hnnu] ligament is very large and sht>rt, it may he 

iieHs?4iry to tie it in parts. If the eorjius cano(*t lie drawn into the 

%-ii^iua, the ligaments and their vessels may be elamiR'd or ligatured 

Atid cut progressively until they have been entirely severed ; the 

tiijerus is then removed without eversion. In some eases a single 

irljimp guided by the finger may l>e matle to eompivss an entire l>n>ad 

liniment, Kversion of the uterus and eonsequeut torsion of the 

br^tttl lijpjiment may tend to sli|)ping otf of the elam|)s tir ligatures, 

F'atiil hemorrhage has been attributed to this eause.^ 

Thi; (Jiffieulties are much inerease*l when the uterus and its 

^■^Pppc^boreis are fixed by adhesiims. The uterus being drawn down 

^J*lH*'adied by the vulsellum-forreps in the right hand, the adhesions 

iire lm»kea up by the finger precisely as iu the openitiou already 

«i<*vrihHl for the removal of the apfieiKliiges. The ailherent apjiend- 

^.U^ living been freec!, tlie openitiiui prcweetls as if there had Inru 

^^' "Ibcsjons, The further teelinique of eh>sure r>f tlie woimd is laid 

•' '\(i iu the desc*ri|ition of hysterectomy for eaucer. 

*^rfiin(Uff, The elass of eas4's discussed above offers a large field 
'*■* 'Iminage. Gauze is preferable to tubular drainnge. The teeh- 
^^\)^ of a|»pUeatiou and rern<jval is dt-serihi-d in ('lia|»ter VIL 'ilie 
^'^%S If left, al>o in a measure serve the purpose <if drainage. They 
*^^^m, Imwever be i*emoved at the end of forty-eight to se\'enty-two 



Hysterectomy without Removal of the Appendages. 

"hfnthe appemlages are firmly matted and bound together, and 

[ ^^'^^t insejwirable from the surrounding struetiires, and their re- 

Jl^f'Val practically forbidtlen by the desperate risk of tlie fiperatiou, 

'Items may bo removeil and the pus sacs frwiy o|iened ami left 

*'Rua into the vagina. Even if some pus jMwkets are o%^erloiiked, 

'**?wil| probably break scKiner or later into the won mi Such pus 

F^ whether tulial, ovarian^ or pnrametrie, when ilniiiied in this 

fy.^Ji a rule, become oblitenited ; if tul>al or ovarian, they generally 

^ euMhlng, AnnKlfl of OynecQlc»gj% JAiiuiiry« 189(1, 



290 JaWFECTIONS, IyFLAMMATIO^'S, AND ALLIED DISORDERS. 



undergo atrophy. Although this? ^xirtijil operiition is only |>erniiseible 
for tilt' reasons given above, yet it has Iwvn fullowwl by entirely satis- 
factory results. The explanaticni in tlie tolloAVing paragraph is sub- 
mi ttech 

The removal of the appendages and consequent cutting ofl' of the 
vaseular and nervous eonneetion of the uterus arc usually followed by 
atrophy, eessatiou of tiuietion, and subsitlence of disease in that 
organ ; conversely, similar ivsults in tlie Fallopian tubes and ovaries ^H 
sbunhl naturally tV«liow the eulting otf of their vaseidar and nerve ^M 
eonneetinns by tlie removal of the uterus. In one recorded ea»>e of 
liystereetomy the remaining tubes, liowever, licciime healthy and did 
not atrophy. On the contniry they were, during several years after 
the operation J the medium of menstruation. The menstrual fluid 
passed from tiicm into tlit^ vagina.' This ease speaks against the idea 
tliat the tubes do not partii'ipate in tnenstrnatinn. In anotlier ease* 
pregnancy occurred in the isthniie portir^n of the tube; there was 
consequent hcinorrhage intu tlie vagina; the tulial opening was dilated 
and tlie pnxluct of conception curetted away. 



Aspiration of Hydrosalpinx through the Vagrina. 

The contents of sactosaljiinx serosa — ^hydrosalpinx — may >>e re- 
moved by aspiration, and if the aspiration l^e fnHowcd by efficient 
local massage of the tube the cure may be iiermanent. As explained 
in (liapter XXL, ix'elysifm of the ends of the distended tube may 
have occurrcil mechanically from swell i tig of the mucosa or oi^ni- 
ciiUy from adhesive inflammation. SjHintancous reo{)ening of the 
tul)e and rcstonifion of its functions are probable under the former, 
improbable under the latter conditions. 



Vaginal Incision and Drainage of Sactosalpinx. 



Incision and drainage of saetosalpinx is a recognized proeednre. 
Ijandau rather warmly i-ecomnieiids it even in pyosalpinx. Its value, 
however, is more positive in hydrosalpinx. The pr*H*e*lure, even 
when successful, sehlom restores the function of the tube, but pro- 
duces, instead, complete (»bliteration of the lumen, thereby convert- 
ing it into a cord. The same pn*cess sometimes occurs sf>ontane- 
onsly as a n'sult of n-carriiig ajn>endicitis or recurring siilpingiti^. 
The disease is then known as aj)|K'ndicitis oblitemus i>r salpingitis 
obliterans. Int-isif^n and ilrainage may bring aliout or hasten this 
residt. The indication for incision and <lnunage fur paranietrie 
abscess is much clearer tluin for saetosalpinx. See Chapter XX, 

Incision and Drainage for Chronic Saetosalpinx wdien the diH- 
tended tube mn be isolatinl by palpatitm is perfMrmed as follows; 
First thf* vagina and vulva are tci be thoroughly <lisinfected, the 
patient being in the lithotomy position ; ihe saetosalpinx, by steady 

> WeUcr Van Hook, TTnpublishod cane, 

» WtTitlfntT. Contrnlttlfth Itir GyniikoIof^iCt 1S96, No. 4, p 111 



,re.* 1 



• L*itidmj. Archlv fiiT Ojniikologic, 
Eilelter. p. LM8, 



No. 40» p. 85. Augtwt Martin. lilt Krankheiten der 



TREAT}fENT OF SALPINGITIS AND OVARITIS. 



2i)l 



pfps!!un> 4»f the assistanfs hiim]^ is now fixctl downwanl toward the 
vagina, and a trocar projKTly eiirve*! nr straight, guidi^l hy the li-ft 
index-fio^cr, is introchitxHl into the* sac. Oh this trwar as a fj^nide, 
with sliarp-}xauttMl scissor?^ enlarge the o[)einng so as to ad in it the 
in^f. The scissors are made to enlarge the ojK'iiiug by working 
their pint throngh the wall with alternate spreading and elosing of 
ihe i>liwles. The sae is washed init with a hot 1 to l\\H)() hieldoritle 
of meniiry t=iolution and drained witli ganze siitorattMJ with a 1 per 
c^iiL Milntion of tonualin. The gauze is removed an*l replaced in 
fony-^ight Innirs by ordirnirv antiseptic gauze. The formalin is not 
rfpeatf^d except at rather long intervids, and^ if healing pr«>gresses 
nimlly, not at alt, Tlie sae, if it does mA contract promptly, may 
krauterizcfl witli a satnrated sohiti*in of iiwline in carbolic aciil. 

The of>enition sliould always ami imperatively inclnde the tlior- 
nuirb removal of the causal infection in the uterus by aseptic sharp 
curctlage. Failure to do this will ofVen lead to disastrous results. 
Ill hydrosalpinx, aspiration and massage, as outlined above, may 
bring jihont rcstoralion of the tubal function, and shtndd therefore 
betrie<l befon:' incision and ilrainage. The method has Ireen nearly 
clHoletL' fur twenty y(*ars. Its residts bcdoi^^ the days of Biittey, 
jTjiir, and Hcgar showed relatively few itn mediate on res and a dis- 
iKiniging number of failures to arrest the jx^nicions or fatal march 
<»f liiUd and ovarian suppnnition. On the other hand, tlie more 
rj/hcsi] cKtirj»ation of the (lisf^ased organs has saved innnmemi>le 
Wanxii from lifelong invalidism or death. The re-establishment of 
iiirHi«iri and drainage as a recognized and useful procedure has, how- 
ever, liecn made possible by the addition of sharp uterine curettage 
111 ast/psis. 

There will always be great difficidty in drawling the line betw^een 

fcas<\'^ which may be relieved by ineisiun and drainage and those 

'idemand extirpatiun. The iVn-mcr treatment will lie a[j]>licalde 

itl)p mnre recent and acute ciises. TiuM»l(h'r chronic suppnrative 

tin which pi^rmanent changes have takrm phiee will often rerpiire 

rtir|)ation of the diseased orgaits. In spite of the reeonnnendation 

Lmdau ami numerons sueeessful eases report^Kl hy Vulliet, 

oiilliad, Abbott, and others, it is not strongly indicated in chronic 

pViNiliiinx. The suec*ess of the operation retjuires the removal of the 

^*M and prevention of new infectioTi ; ami the fidlihnent of these indi- 

t*uif)ris in the many pfjssible eavilies and recesses of a pris tube, and 

^the neighboring pns-pockets whose walls are deeply infected, is 

^n Ijeyond the power of simple drainage and disinfection. 

Tnhf^rriddr Stippurfition in the uterine appentlages oHers the great- 

^ t n^sistanee to all conservative measures, and is therefore genenillv 

*<5mi(ted to contraindic'ite incision and ilminage. The great fn»- 

<|Utnry of elironic tidicreular intectifjii materially cuts downi the 

nmiilipr of cases suitable for dniinage. It ig, moreover, usually 

difliealt to recognize and exclude the tnlwrcnlar eases until the pus 

htslxh^n removed and examined. The suggestion to defer the radical 

enuion until conservative measures have lie**u fried and failed is 

akened by the fact tiiat after incision and drainage the removal 





292 INFECTIOA'S, INFLAMMATIONS, AND ALLIED DISORDERS. 

of the diseased organs is always more difficult, tedious, and dan- 
gerous. 

The foregoing paragraphs relate more especially to incision and 
drainage for chronic sactosalpinx. 

Incision and Drainagre for Acute Pelvic Suppuration. The 
])elvic organs and products of inflammation may be matted and fused 
together in a conglomerate mass. The individual organs may be 
wholly unrecognizable. The pationt\s general state from septic pois- 
oning is often so grave as to render a more radical operation extra- 
hazardous. In these conditions, whether the suppuration be tubal, 
ovarian, or parametric, or all combined, vaginal incision and drainage 
offer strong and i)ositive indications. The advantages are : 

1. Relative safety. 

2. Relative efficiency. 

3. Probable preservation and possible restoration to function of the 
diseased organs. 

Operation} After preliminary sharp curettage the incision is 
made behind the uterus precisely as described on page 282, for poste- 
rior vaginal section. If the post-uterine circular incision gives too 
little sj)ace for thorough intra[>elvic exploration and manipulation, an 
additional perpendicular incision may be made from the centre of the 
posterior border of the first. This incision runs in the median line 
of the posterior vaginal w^all from the cervix toward the rectum. 
During the making of this incision the index-finger of the left hand 
should be in the rectum as a guide to prevent wounding the bowel. 
The finger, after thorough ck^ansing, being now returned to the pouch 
of Douglas and the right hand being over the abdomen, the examina- 
tion proceeds as in ordinary bimanual j)alpation. The left index- 
finger jHMietrates backward and to either side until the bimanual sen- 
siition indicates that tlie free j>eritoncuni posteriorly is almost reached. 
In shifting the finger to the right or left, and with it the superimposed 
hand, the septic mass will usually be found and penetrated without 
difficulty. 

The exudative material will he evident to the touch of the exam- 
ining finger. In acute eases an abscess-cavity will usually be found. 
During these manipulations the peritoneal cavity may be accidentally 
oix»ned. This does not s]>ecially add to the danger. It is well, how- 
ever, to retain the finger in the opening leading to the abscess until 
any eseai)ing ])ns may be washed out of the vagina, and the peritoneal 
cavity protected by gauze ]>aeking against the inflowing of pus. The 
finger may tiien b(* withdrawn and the pus-cavity evacuated; slight 
pressing upon the abdominal wall will Ik^Ij) to emj)ty the cavity. The 
])ackiiig is now replaced by fresh gauze and the finger reintroduced 
into the pus-eavity. This is for the purpose of finding and in like 
manner emptying any neighboring abscess; failure to do this may be 
disastrous. The other side of the pelvis is now^ explored, and, if 
necessary, treated in the same way. All hard inflammatory masses, 
whether pus-containing or not, are to be penetrated by the finger. No 

> Femand Uenrotin. Tho Conservative Sui-pioal Troalment of Para- and Perl-uterine Septic 
Diseaise. Transactions of the Anieriean (Jynecological Society, 1885. Adaptation. 



inslrnment save the finger is to be used after tlie incision throiigli the 
vagiuitl wall ha,s been made* All inrianimatory i\m having been 
penetrnteil, ttieir ex|Hj.se(i eavities are naw to be paeked with a single 
strtp of sterilized gauze, al>oiit three iiiehes wide, sutnmted with a 
s^jhiiiofj itf lurinalin 1 to "liHK Tlie outer eud of the gauze Mtrip 
f*hfmid be carefully retained in tlie vagina to faeilitate removal. Con- 
siderable gauze sliould be retained in the vagiual wnnnti in order to 
kwpiti>fM»n and insure drainage. Tlie ojxTation is completed by the 
appliciuinn of a light vaginal gauze tarupou. 

Ttio inflammatrvry deposit will be f^mnd in some cases in the 
m*^m line just posterior to tlie utenjs. Whether intra-peritoneal 
or i^xtm-peritoneal, it must he tljoroughly penetrated and dniined 
until it i.^ evident by biuiannal toneli that the finger has reached its 
oiitennost limits. The finger should be worked from side to side 
until the surgical sense indicates that the drainage will be sufficient, 
la some eases the finger cannot go far liaek in the median line with- 
otif ojieijing into the peritoneal cavity, hut turning to one siile or the 
otiier tlie layers of the broad ligament may be sepirate<l and, witli- 
out invading the peritoneum at all, the finger may be pushed into 
J^rjEfe lateral masses. 

Xs already state*!, the jwlvic organs and pnxlaets of inflammation 
app often so matted and fused together in a conglomerate mass that 
t^e operator may be unable to recognize individual organs. He is 
o«lv guidcil to septic inflammatory miusses by the touch. Parametric 
^b^iess and circunisi-ribed intra-peritoneal accumulations of pus ofler 
wrter cliances of permanent cure than pus tubes. 

Vaginal incision and drainage are sometimes indicated as tera- 
p>rizing measures in extensive chronic pelvic suppuration, and even 
'n a tuberculous case, if the ]>atient\s strength is inadequate to the 
'Core radical operation, incision and drainage are indicated. Even 
luough radical cure does not follow, there it^ usually prompt and pro- 
*>ounoed improvement, often sufficient to j>ermit the subsequent re- 
ttloval of the uterus and diseased organs by vaginal section ; these 
cases offer the strongest intlieation for vaginal as against abdominal 
a^pction* They are often practically inopt^rable by the former, though 
with relative safety manageable by the latter. 

If the abdomen has Ix^en opene<l and tlie case apjK^ars to be raore 

8uiti^ for the vaginal route, one may intrcKlnce the sutures for closure 

of the alxlominal wound, au<l before tying them proceed according to 

t-W iuilication to the vaginal ojK^mtion, This gives the additinnal 

*d\^autage of the abdominal opening for guidance in the vaginal work. 



Salprngo-Stdtnotoniie.* 

This operatifm in selected castas is designed to save and restore the 
*p[>»'nihi^es to their normal function instead of removing them. 
^ i>t Martin reports sixty-five cases with two <leaths, neither of 
^^ II !i was of its**lf attributable to the o[>cration. In IHSfj he began 
to^pen the closed abdominal ends of tubes and to study microscopi- 

» A Mnrtin, DJo Krankheitcn der EUeiter, p. 213. 




294 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERiL 

eally tlieir contents and tlie condition of their wuUs. His method id 
as folluws: 

L Bring the tnhe as far as possible up into the abdominal wound. 

2* Protect the adjacent pelvie org*4ns by plaeing under the tuiie a 
flat sjKinge. 

3- Open the end of the anipiilla witli rn'i.'^soi's. The point of 
ehjsiire may be recoguisted by a scar in which the fimbria* are still 
visible. fl 

4, Strip tlie tube of fluid by pressure applied from the uterine ^ 
toward the abtlominal end, 

5. If the contents lie serous, odorless, and all fluid, and the mucosa 



'-t/iM/J 



r^ii 



t'^ 



Consorvfttlve opcrfttiotia «n ovurieii, I'nr 
all of left ovary preMerved. Siimll detach c^i i 
from U, The ovaries show whip Blllrht*^ for i 



1 «f right ovury by rcsecUan. N«. 

r below left fivary has bt'eii irmo 

catction wounds. 



sIkiws onlv slip^ht swellinir and reildenin)]f, and the fohls are only Hat- 
teiieil by pressure, slit the tul>e up fur a distance nf about one int'lL 

6, If the cojiditiim in tlie up|HT ynvl ui the tuln^ still appears to 
be only eatnrrhal, ehise tin* lonptudinal wound with three tine catgut 
sutures. Any larijt^ superfluous tai^s are to be cut *itf. 

7. The borders of tiilial inncosa jit the end of tlie tube and the 
[M^ritontnun are to be united In* tine eatj^ut sutures so that the oi)ening 
shall ^ape and the nuieosa shall stay everted. 

Hemorrhage is slight and easily ecmtrollrd liy fine li^tnres. Thp 
everting sutures at the end <if the aui}>ulhi bold tlie new ostium close 
to the ovary. Tlie now rL'o[>eiied ttil>e, tof^(*ther witli the ovary, is 
replaced in the alKlunieiL Any ovarian atlhesions are to be broken 
up. According to Martin, this opemtion olfers no greater dangt*rs 



TREATMENT OF SALPINaiTiS AND OVARITIS. 



I 



any other ereliotomy complicato<l l>y [)eritoriitis» Pregnancy fol- 
lowed in two casc*s in whicii tliis operiition Und been perftirmed on one 
side and the appentJiiget? Iiatl Iieen extirpated on flie other. 

The general conelnsion is that extir|jatiyn tor atresia of tubes 
whose contents are not infections may be nnjustiiiable* The opera- 
tion, however^ can resnlt in restoration of function only when the 
uterine end is r»jK'n, or when, if clusjcd, the clusLii*e is due to swelling 
and not to inflammatory adhesion. 

Resection of the Ovary. 

The diseased portion of a partially diseased ov^ary may he removed 
by resection, and the remaining la-althy part saved. The indieati«>ns 
fiir resection ai'e these : 

1. The saving of a portion of the ovary in order to preserve its 
repr*»dnetive funetions. 

2. The savinij^ of a jiorhon of the ovary in onler to pi*eserve 
menstruation ami other fn net ions of |)robul)h.^ importance not defi- 
uitely known, among theju possible elimination and secretion. 

ReprcKluetion has ivpeatedly followed the operation when the 
ttterus, the tube, and only a very small fragment of the ovary were 
left. The doty of the sTirgenn to leave tVir tliis pur]K>se, when jirac- 
tic^ble* any fnnetionating part of an ovary, is tlierefore clear.^ The 
preservation of menstruation and other possible IVinetions is urged by 
many competent ol>servers. As a rule, women are better mentally 
and physically if menstruation and ovnlation are maintained np to 
the |>eriod of nature's menopause. The pr>ssible secretory and elimi- 
native functions of the ovary justily the opemtor in leaving it, or any 
healthy portion of it, even though tlie diseased tubes and uterus have 
to he removcnl/^ 

77**' Operaiion of Reaeeiion simply involves the excision by seal|>el 
or scissors of tlie diseased p^irtion and closure of the wound by mrans 
of fine interrupted or continuous eatgiit sutures. 

All conservative o[wnrtii*ns ibr of^ning closed tul>es and resection 
of ovaries should be supplemented by the release *»f the Jippeiidages 
from any adhesicKi which mny ho present. 

Ocnrinn Ertrnvi or Ikumvafed (Jntrh.'^j which may be ffaiml in the 
drug shops prepared for internnl administration, ai'e mneh in vr>gue, 
and are said to give relief for the disiigreeable symptoms of the nieno- 
pnii^c, whether induced by oophorectomy or by nature. 

Relative Advantages and Disadvantages of the Abdominal 
and Vaginal Routes in Pelvic Surgery. 

Advwniage^ of the Ahdominal Bouie : 

1. A larger field is open for o|>emtion. 

2, The operator may st^e what he is doing instead of depending 
largely on touch, 

» pi»Ik- Opf' nitloris of the rteriiie A|ipt'm]ii^n «. wflb a View to Freservinj: thv FiiriflioiJH of 
OrtiUtiftti *u«l Mi'iiHtrunlliJii, TrutiiJtK-niiris nf t]jr ATiioiieRn Gynfcyktgk'al Hofk'ty, IBV^. 
f"itrjitMlf> Seeruzione lutt-rua (kllu Ovdics WJ6. 



296 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDEBS. 

3. Diagnosis of unsuspected conditions and complications is much 
easier. 

4. The abdominal section is adapted to laige tumors and pusHsacs, 
and to conditions high in the pelvis. 

5. The appendages may be removed with better chance of avoiding 
rupture of a pus-sac. 

6. There is less danger of wounding intestines^ bladder, or ureters 
and greater facility in the control of hemorrhage. 

7. The frequent concurrence of appendicitis and other abdominal 
lesions with pelvic disease and the impossibility of reaching them by 
the vagina. 

8. It gives more light and more space for conservative work. 

Advantages of the Vaginul Route : 

1. It gives better drainage, and is therefore specially adapted to 
cases of vesical or intestinal fistulse. 

2. It avoids abdominal scar and risk of ventral hernia. 

3. It is suitable for cases of small tumors without high adhesions. 

4. When properly performed it lessens the danger from shock, and 
is therefore suitable to cases of extreme pelvic infiltration which are 
inoperable, because too dangerous, by the abdominal route. 

5. It involves less handling of the intestines, and therefore less 
consequent danger of intestinal adhesions. 

6. Recovery is less complicated and more rapid. 

Unfortunately, the vaginal route is, for at least a very large pro- 
portion of eases, impracticable. The long, narrow virgin vagina or 
the vagina which has become contracted from senile atrophy may 
render the field of oj^eration almost inaccessible. A very large 
uterus with exceptionally short, thick broad ligaments and greatly 
enlarged appendages, with adhesions extending beyond the reach of 
the finger, may also be difficult or impossible to manipulate through 
the vagina. Under such conditions the abdominal route is much 
safer. 

In many cases it is well to begin the operation in the vagina and 
continue by that route as far as the greatest safety will permit, and 
then, if necessary, open the abdomen and complete the operation by 
the combined vaginal and abdominal method. Conversely, the 
abdominal section may have to be supplemented by the vaginal. The 
combined operation may be the deliberate purpose from the beginning, 
or the necessity for it may become apparent only in the course of the 
o|>eration. 

In an uncertain proportion of cases the advantages of the two 
routes are so evenly balanced that either is ix^rmissible ; the election 
must then rest with the individual bias of the surgeon. The choice of 
procedures has in a measure been forecast in the description of six?cial 
operations already described. 

Throwing aside the bias of individual operator, whose efficiency 
may be greater along the route of his own greatest experience, and 
estimating the vaginal openition on the basis of its absolute value, 



TEEATMENT OF SALPINGITIS AND OVARITIS 297 

f}ieie ^rill remain a large proportion of cases in which this operation 
iQ3y be done more safely than the abdominal. In such cases it is the 
operadon of election. The general proposition, therefore, is : first, 
operate through the vagina so far as practical — i. e,, when the diseased 
ovaries and tubes are low down near the vagina and within reach of 
the finger; second, operate by abdominal section when they extend 
\igh up toward the abdominal cavity beyond the reach of the finger. 
The frequency with which the vaginal route will serve for the 
entire operation will increase with the experience and practice of the 
operator. A dexterous vaginal operator will easily overcome diffi- 
culties which, without abdominal section, would be to the ordinary sur- 
geon impossible. 

It will be seen from the above that each method has its special 
advantages and disadvantages. Some of these last are less real than 
they seem ; for example, an objection to vaginal hysterectomy is that 
it affords only a limited field of operation and small chance for visual 
control of the work. This does not necessarily appeal to the skilled 
operator. The danger of hemorrhage is an avoidable one if due pre- 
CMtions are used. Injuries to the bladder, ureters, and intestines may 
<wmr with either method, but in vaginal hysterectomy the perfect 
diaioage makes them less dangerous if they do occur. 

The operator should not permit his prejudice in favor of either 
^wte to lead him to pursue it to the extreme, for that part of an opera- 
tion which is easy by the vagina is often most difficult by the abdo- 
"wnjand vice verm. 



CHAPTER XXIV. 

"UHETHHITI8— IVROLAP8E OF THE I RETriTlxV— SUB-UIIE- 
TH KA L A aS(^?:8H—CY8TITI8— PYELITIS. 

UBETHRITIS. 

Etiology. The predisposing and exciting cimses are the same as 
for iiiflaniiiiatioii in general, Amont;; tlie exciting causes the gono- 
coecLH is verj frequent ; gonorrhoeal iiii'ectiou usually oecurs by exten- 
sion from the vulva or vagina. Other causes, such a? syphilis, tuber- 
culoi^is, ervj^iiielas, and diphtheria, iire much less eonimon. A prolific 
source of inil'ctinn ii? tlio uneleau catheter. 

Patbologry and Diagnosis. The lo:^s virulent and milder infec- 
tions are, aeeonling to Kelly, most marked in the anterior and poste- 
riur walls of the urethra. The nnicosii as exposed by the cystoscope 
— Chapter III. — is swollen and red from distention of tlie vessels, 
and, upon instnunental examination, may bleed. The urethral 
inflauM'd glands stand out prominently as oval, yellow spots, and in 
tlie anterior part of tlie urethra sometimes give forth a secretion 
which liHiks like |>us, Vnit may be only epithelial d^^bris. The tender- 
ness in tiie milder infections is less marked than in the gonorrha^al 
viiriety. 

(rOj/orrAoW infection in the acute form is intense and somewhat 
characteristic. The swoUen mucosa, at first of deep-red color and 
finally covered with |mis, protrudes through the meatus, and has 
much the appearance of tin inflamed, prolapsed anus. It is exces- 

FmrBE 160. 



''fH9$y 



Urethra l&ld opon, 8kene*a gUnd* dltteudud bj- prolwi** 

sively sensitive to touch and, espeeially when touched by an instru- 
ment, is apt to bleed. Burning and p.iin on urination may be intense. 
Microsco]>ie exnmination of the ]His will show the gonoc-occus. The 
inversion nsnally disiip|>ears as the urethritis subsides. 

Skenc^s (Jktmh. The urethral glands of Skene are^ in this eon- 

• Skene'if Discuses of Women. 
308 



URETIIRmS, 



299 



a<*otion, of great pathologienl significance. They consist of two 
P|flaiHlular tubules situated one on either side of the mxi thro-vaginal 
wall. Eiich tubule extendi, fnjm a point just within the meatus 
urinarius, parallel to the uretbru to a distance uf about five-eighths of 
an inch. The tuliules branch into the muscularis of the urethro- 
vaginal wall. They are iine<l with columnar epithelium. Wlien the 
urethra is swollen and the meatus everted, the i^jKi^nings of the tubules 
appear just outside tiie urethni. Tlie nnrnially placed ojmnings are 
s^.'en on either side by separating the lateral labia of the meatus 
urinarius. 

When inflamed these tubules gi%T forth upon pressure a white 
prous or purulent discharge. The mucous membrane around their 
openings* a* in follicular pliaryngitis, is swoUeUj thickened, and of a 
hnght yellowish-gray color, or the orifices may be surrouoded by a 
gninular areola.^ The intcetiou involves also the peri-gland uhir 
structures. The urethro-vaginal wall in the neighborhood of the 
tubules \s usually swollen and everted. The inflanuuation is gener- 
_ftlly purulentj vers' ofteu gonorrhceal, and may give rise to a free dis- 
liarge* Occlusion of the ttibules by adhesive inflammation and the 

FiouHfi 161, 



Tmiuyeiw section of uf^tbra* sbowinK Bland on Dsch Kide, magnified,* 



juent formation of retention-cysts is possible. There is often 
It tenderness on pressure. Clirouic infection, as a rule, gives rise 
to little or no {lain on urination. Inflammation in these glands, until 
^described by Skene, had been mistaken for caruncle of the urethra. 



* Sketuj's Diseajses of Wuraen, 



» Ibid, 



300 IXFECTIONS, INFLAMMATlOyS, AND ALLIED DISORDERS. 

The bright- red areola upon the swollen and thickened mucous mera- 
bmiie about the opeoitxgs of the tubtihs closely resembles caruncle. 

Differentiation between Inflammation of jjjkene's Glands and 
Caruncle of the Ukethra, 



Infiainmaiion i>f Sken^g Giandl. 
L UrlnJitioii not usually pftinfkLL 
2. Two protubemnce* correspond to ilte of 
openings of tubules. 



3> RemoTAl of protuberance does not cure. 
4. MouthJi Of tubulGss inflamed , 



Omtftcif ttj the Urethra. 

1. Urination tioltifnl. 

2, Uiually only one protuberance situated^ 

anywhere in circumference of meatus or 
within mctfttus* but usually on posterior 
wall. 
S. RemoTAl cures, 
I 4. Mouths of tubules nonnal. 



As pointed out by Howard,' the t:onoeo<ciis may become intrenclied 
in these glands, as id the glands of Bartholin, and from time to time 
furnish the infection for recurrent gonorrhcea. Even though the 
disease may have di,sappeareil from the external surfare, reinfection 
fnim the glands may repeatedly occur. Tin's source of mnfection, 
unless eai"efully sought, is liable to be overluokcd. If the urethral 
glands are in a state of suppurationj the pus may be strip|)ed out of 

Figure 102. 



/ 



Bm 



\ 



Openings of tho two Inflamed tubulei. Senil-diiigTaffiiDAtic. 

them by pressure of the finger and a stroking motion against the 
urethro- vaginal walL The wliite point in Figure 164 represents a 

I H. a Howard. Champaign* lUlnols. 



302 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS, 

Treatment of Urethritis. The milder non-p^onorrhnpal form, if 
not complicatLHl by eystihs, niay ii?:iiaHy be promptly rured by a few 
applieatioiis made at intervals of f<mr irr five days of 3 per cent, solii- 
t juris of rdtrate of silver. The applieation is made i>y an applicator 
wound with cotton, through a urethral spi.-eulum. Extreme forcible 
dilatation of the urethra has lieen miieh practised for the relief of this 
and the more intense tonus of urethritis, and has often gfiven prompt 
and pronounced relit^f, Penuanent injury to the urethra a n(f conse- 
quent permanent incurable incontinenee of urine have, however, 
resulted aliout three times in a hundred i»f such dilatations. Extreme 
dilatation is therefore prohibited. Emmet^y so-called button-hole 
ojK^nition, described under ^t^et^re of tire urethra, answers the thera- 
peutic indication of dilatation, and dws no! impair the retentive 
power ; it also has the advantage of rendering the diseased mucosa 
accessible to direct hwal treatment. The opening may at any time be 
closed l>y interrupte<l sutures ; but inasmuch as there is usually no 
functional impairment the closure is seldom calked for. 

Gonorrhceal urethritis, if acute, is treated tirst by a single applica- 
tion of a 10 per cent, solution of silver nitrate, then by rest ; com- 
presses to the vulva, saturated with lead water and laudanum, or 



Emmet's buttdn-bole opemtloa.^ 

sedative suppositories in the rectum, may give relief If the irritation 
is very great, tlie compress may be saturated with a 5 |>er cent, solu- 
tion of the muriate of fm^aine. The nuMlical treatment will be the 
same as f u' gonorrhd'a in the nude. 

Chronic intlamniation in Skene's glands, especially if gonorrheal, 
usually n'sists all conservative measures. If it does not yield to the 
application of nitrate of sHver fnsad on a Hne probe, the entire length 
of the tubules should he laid opim on the vaginal side, using a probe 
as a guide. The glandular structures are then to be destroyed by 

1 i.;jiiitii"i. AniLTifuri System of Ujneculogy. 



PROLAPSE OF THE URETHRA. 



303 



Stic or by excii^ion with soij^sor.^, and tlie surfaces miide to heal by 
iulatioiK To fihse the nitrate of s^ilver on tlie j)rolje, let the muU 
melte<l in a small rewptaele over a spirit-lanip, anri <li[i the end of 
the probe into it rejjeak'dly so as to cnat it over a thin layer of the 
salt. 

Dreaiment of Urethral Strict nn\ Tl»e inHaniinatory process may 

have been S4> intense as to proiluee eooinietinj^ cieatrieinl tissnc and 

, c*>nsecpient stricturt^ The eause of this uneorinnotj lesion is usually 

lp>norrhcpa or trauma* The treatment is dilatation hy oieatis of 

[irrLiduated sounds, as in strietnre of the male urethra, Hhonh! dihita- 

tion fail, a urethro- vagi rial fistula may be made and the vaginal 

margins sutured to the urethral margins of the o[)ening. When the 

^edge$% have seenn:*ly healed the iistula may be eloscnl by denndatiun 

ioti the vaginal surtaee, the iuterriipteil silkvvnnn-^nt sutures being so 

placed as to give ample calibre to the restored urethni. See Figure 

Prolapse of the Urethra. 

Description- Prolapse of the urethral inueosa and submiioosa, 
with urethritis, is a condition described by Emmet J The prolapsed 

PlGI/RE 1^6, 



Emmet'a opcratioti for prolapse of thf nrfthrn* 



mucosa projeets from the upjM-r fir lower margin (»f the meatus or 

feurrounds the entire outlet of the un^thra. The nrethm is obstructed, 

|nd as the obstrnrtion increases there is frotpient or constant urethral 

L»iiesmu8, Finally the rntire nrrtliral mue(»sa and submucosa may 



1 rrlnciplen and 



met ire of f iymcfilnKy. ArlaptiiUun. 
' "Yttclict^ of Uytiecolfjtfy, 



304 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

be rolled out so as to resemble a greatly prolapsed anus. The 
urethral canal dilates, and, as the circulation is obstructed, the rolled- 
out structures become o^dematous. Cystitis and infection of the 
kidney are possible results. 

When the prolapse is confined to the upper or lower wall of the 
urethra and the outrolle<l tissues are from the outlet of the canal, they 
resemble hemorrhoids, and may, as in the operation for hemorrhoids, 
be removed by ligature. 

When the prolapse is extensive and circular, removal in a mass is 
prohibited, first, because more prolapsed tissue usually follows and 
promptly takes the place of that which has been removed ; second, 
because a distressing stricture of the urethra may result. 

The Treatment of such extensive prolapse is to return the displaced 
mucosa, if possible, and apply urethral massage — Chapter L. If 
relief does not follow after a few treatments, it is well to make a small 
artificial vesico- vaginal fistula, and thereby give the urethra perfect 
rest. The massage may then become more effective. If these meas- 
ures fail, the prolapse may be i>ermanently cured by making what 
Emmet calls a button-hole slit in the urethro-vaginal wall and draw- 
ing through this the excessive mucosa and cutting it away. The 
sutures for closure of the opening are introduced before the excision. 
During the passage of the sutures a sound should be in the urethra. 

Sub-urethral Abscess. 

This is an abscess in the urethro-vaginal wall. It has been 
described by I^awson Tait ^ under the name urethral cyst. Its path- 
ology is not fully explained. In the limited number of cases described, 
the sac oceu])ving the urethro-vaginal wall has varied in size from 
that of a walnut to that of a hen's egg, and has communicated, by a 
small opening, with the urethra. The presence of this sac has been 
explained by Tait as a congenital defect, and by Kelly as a retention- 
eyst formed by inflammation and occlusion of Skene's ducts and the 
subsequent perforation of the urethra wall. Inasmuch as Skene*s 
ducts are probably the remnants of Gartner's ducts, the congenital 
and cyst theories may both be true.'' 

The tumor has the appearance of pronounced cystocele, is well 
defined, and very tender to the touch. Pus and ammoniacal urine 
often escape from it through the uretlini. The tenderness is so great 
that anaesthesia is usually recjuired for examination. If the commu- 
nication with the urethra is exposed by a urethral speculum and 
pressure be made upon tlu^ sac, one may, as the sac is reduced in size, 
see its contents forced into the urethra. 

The Treatment is to dissect out the sac-NN'all and close the wound 
with interrupted silkworm-gut sutures. These sutures at the same 
time should close the urethral opening. Complete anatomical and 
symptomatic cure follows this operation. 

' I)isens«'s of Women and Abdominal Snrpery. 

'^ Uurrigues. System of (.iynocolut^y by American Authors. 



CYSTITIS, 



305 



CYSTITIS.^ 

In |Tntholi)^y and Rympt^>m?; inHiimituitinn of tho fomali' bladdiir 
iiiifcrs in few r<'.s|n-("ts i'nmi tliat ui' tlu' male. The im-n\h\v .sniiives 
of infi^lion, tbi* relative sihirtiiess of the frmale iit^thra, ami tiie 
ea^y accojs'^ to ihr IjlutMei* thnHigli the vr^i<:'o-va'_i[iial wiill, [mwevcr, 
^ivc to the etiology, liiagnosis, mid trentinent a elear gynecnlogieul 
j^i^nificanee* 

When th*' diagnosis of cystitis was l>ased njinii tlic pn'srntn' nf pus 
in the uriin* and (jaiufnl and frequent nriuatinn, its treat men t pive 
less satistaetian to the pliysieian \un\ less relief tu the patient tfian 
that of ahni»st any otlu^r iuHainmatHry «lisnnh-r. Now these symp- 
toms, pynria an<I |.xunfai an<l frecpiL^nt ari nation, are reeognized as 
rejgults not only of inHammation of the fjhuhler, bnl also of a variety 
of other k*sions, espeeially h'sions of tlie ureter, kidney, and nrethra. 
Morc^fjver, the eystitis its(lf, wliieh is often tluaiglit of as a distinct 
diiscase, is now ahno^t relegati^l to tlie rank uf a syrnptoni, and is 
projx*rly considered si>lely in its relatiiais tn eertaiu deejier lesions 
which individually or ei^lk'etively may nntkriie and prrjietuate it or 
may resnh fr*»m it. Within a single derade the management of this^ 
syrciptoni has risen from the pljjne of empirieisin ami has taken its 
place niwm the scientiiic basis of pathohtgy. Tliis change has come 
abenit chiefly as the result oi' two causes : 

Etiolugieal investigiitirmSj espeeially including Ixn^teria. 

Improved instrumentation in diagnosis and tivatinent. 



Etiology.^ 

In addition to mtist of the sonre-es of infection common !4) cystitis 
in the male, the* female l>ladder is more snbject to enntairrent infection 
fiH»m the same eansrs which giv^e rise to infection of the repniductive 
organs. The suserptibility is increased dnring the n-enrriag physi- 
oIc»gieal rfMigcstiun iif menstruation and **s|>eeiiilly during the puerperal 
state. Furthermore, infection nniy rwidily sprend from the repro- 
dnetive to the urinary orgarjs. Vidvitis, for examph% may extend to 
the nrt*thra, hlad<ler, and ureters. Sueh extensitm i*y tlie urinary 
organs, however, is somewhat retardi^d Uy the fact tl«at the nrimiry 
trart is fi^eely washcnl by a downward current of urine and Ijv the 
further fact that the urine, Wing aci<l, is a hostile nuHlium for alxHit 
1*0 per (tent, of [Mithogenic bacteria. A not infrccjuent predisposing 
eatiHe of cystitis is stont* in thf* bladder. 

It 18 most importunt to distiTiguish clearly the predisposing from 
tlic exciting causes. Amtmg tlie predisposing canse8 are: 

1. Pathological nrine. 

2. Retention of nrine. 

3. Tumors. 

4. Foreign bodies^ especially stcaie. 

5. Traun»a, 
6- Any hieal or systemic cause of congestion or blood stasis. 

» Tilt' ftuthor Hm uiilizied In the prepftrRtton of the part on Cj^ntiti* and CjfttoMfOpy t-ciplous 
»t»tnirti from ihe Ut^raturv kin^ay furtiblicrl by It. Eawnrd Sauer, 

• iivnu. Trnnwictlona American SurglcRl AssocinlJoTi, 1Wi8. CoiusuUed. 

30 



306 INFECTIONS, INFLAMMATIONS, AND ALLIED DISOBDEBS. 

These were formerly considered the essential causes of cystitis. 

Vastly predominating at least among the exciting causes are the 
pathological bacteria and their products. The bacteria most fre- 
quently found are : 

1. Bacillus coli communis. 

2. Gonococcus. 

3. Bacillus tuberculosis. 

The bacteria less frequently found are : 

1. Proteus vulgaris, Hauscri. 

2. Staphylococci pyogenes. 

3. Streptococci pyogenes. 

4. Diplococcus pyogenes. 

It is generally agreed that the gonococcus and bacillus tuberculosis 
are prone to attack the healthy bladder, and that they require little if 
any predisj>osing causes. On the other hand, a normal bladder is 
said to oifer much resistance to the other bacteria — that is, they do not 
become active except in conjunction with <lefinite predisposing causes. 

Ammoniacal urine is known to result from the decomposing action 
upon urea of certain bacteria, notably the proteus vulgaris. The 
frequent association of alkaline ammoniacal urine with cystitis has 
given rise to the more or less common impression that the disease 
depends upon the irritating action of urine which has undergone 
ammoniacal decomjwsition, and that such decomposition is necessarily 
associated with cystitis. Johannes Miller,' of Wurtzburg, was the 
first to overthrow this idea. He showed that in 73 percent, of the cases 
of cystitis the urine was acid. Soon after the observations of Miller, 
Melcliior ^ reported th(» results of sixty-two vcrj' accurate observations. 
He found that ammoniacal deconi]>osition was only a minor phe- 
nomenon, and that in many of the severest forms of cystitis acid urine 
Wiis present even to tlu; time of death. Almost all investigators now 
reach the uniform result that the bacillus coli communis, or a very 
closely related microbe, is the one most frequently found in cystitis. 
Out of one hundred and twenty cases collected by Rostoski ^ this germ 
was found in eighty eases. Whenever the bacterium coli commimis 
was found alone the urine was acid ; whenever proteus vulgaris was 
found it was alkaline. Alkalinity with bacteria coli communis is 
said to be always due to association of other microbes. 



Instrumentation. 

Within a few years the cystoscope has revolutionized our knowl- 
edge of the pathology, diagnosis, and treatment, not only of cystitis, 
but of many other hitherto more obscure urinary disorders. 

In former times, when the princi|xil factors in etiology were 
stricture of the urethra, foreign bodies in the bladder, and, in the 
male, enlargement of the prostates and when there was no means of 
vicAving the mucosa, the finger through the dilated urethra and the 

» Rostoski. Deutsche iiRMlicinische Wochenscrift. S. 235, 1898. 
a Monatsborieht vn)er don (lesnmtloistungon. Heft 10. 
» Deutsche Medicinische Wt)chcnschria, 18U8. 



CYSTITIS. 



807 



found were the only ami rather diiliiuus means of explarinfi^ the blad- 
der. Digital exploration with its att4'ntiii!it (iangei>i was then eoiimion 
practice* As lat-e na 1883 Sir Heurv Tlnnnpson/ in hii^ w^ork on 
^^Mffiifil Etphrafiony reiwrtecl as the resiih i>f two year.s' obser%'atinn by 
Bftiat nn^thfxl a series of over tliirty eases of Innior in t[ie bladder nj)nri 
' v^'hirh he had operated. Most signiiieant in *'niitcast is the report of 
AWxamler Stein/ two years earlier, in whieh he was able to cfvllect 
friiiu all the lit<3rature, inelnding post-mortem observations, only about 
twciit)' case?;* 

By means of the cysto,s<x>|ie the entire interior of the bladder may 
Isebroiii^lit into view ; foreign bodies, tumors, and other jnitholoi^ical 
cbngGh may be reeognized, and the nreters aiul tlio jielvts of the ki*l- 
nt*y may lie explored. The instrument liud often reveahnl [Iw presenee 
of ftUmPs tumors, and ulcers whieli has entirely escai)etl deteetion by 
the soiiad* NumeroitB cases in which cystitis is of only secondary 
itnjxjriancc to other assoeiated lesions, sueh for example as tumors, 
luUrtnjIous ulcers, and t>iles, or liemorrhoids of the liladder, are now 
daily ulKserved by the cystoseope, 

Cysfoseopy is also of great value in preventing blind and meddle- 
^UTie irfutrnent for a class of cases whi<*b present the subjective symp- 
toms^ of cyst it is, bnt in which inspection fails to shmv any lesion what'- 
e vtr of I he b lad ( le r m ucosa . 

The value of the instrument is also inealeulalde when only limited 
ar»^s are diseased ; fir example, in ease of mihl inflammation of the 
trigone and in tissnre at the neek of the bladder. Un<ler sueh eun- 
Jitions the operator, instead of treating the entire %Tsieal mucosa by 
m^ns uf injections more or less strotig, may direct any desired ap- 
plicalioQ to the disettsed part only. 

Cla^siflcation. 

In our present state of knowledge of the snhjeet a perfect classi- 
fieatiou is impossible. Numerous classifications have been proposed. 

Anatomical Classification, According to the special structures 
invrilvftl, this comprises: pericystitis, paracystitis, interstitial cystitis, 
»Dd t'EidrKWStitis. Tlie difficulty, not to say frequent impossibility, of 
'^'psimtinu tiiese varieties one from the other and the fact that tw'o <jr 
m^ire T^tially coexist render this classitieation, although diagrani- 
tnaiiejilly ,^^^5^^^^;^^^ ^I'jj^i^jjjly imp^issible. There are no sharp lines 
*'* *'emari3;ition between tlie anatomical forms. 

The Pathological Classification inelurles lumicrous varieties, 

^ as catarrhal, suppurative, ulccTative, hemorrhagi*-, exudative, 

xfoliative, ami tissnre eyslitis. These, however, arc rather phases 

possible stages than ilistinet varieties of the inflanmiatory pro- 



BarCtedolofirical Classification. This might comprise as many 

'^^'f'^ lij* there are varieties of infective microbes. The principal 

nu have already been meutioucd. This classification, although 

S*^'i<* attractive in the laboratory, is often impractical at the bedside. 

^ IfcUlfW Am. Oyn. and Obatet. Jounidl, Jan., 1809. « Ibid. 




a08 lyFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 



It is pogBible, however, that the more exact knowledge of the future 
may give to it the status of ii seientitic workhig guide. 

Thee^e various elassiik-atious, }jowever, from the Ptaud point of 
nomeiiekitiire are very eouveiiieJiL Siieli won:lr> as g^unorrhaal, 
ueiitet ehnmifj suppunitive, and inten^titia! are useful for purpo.'^ei? 
of descriptiun and to designate the various formn and phases of the 
infective process. For example, we shouUl use the word endtK'Vstitis 
to (k'seribe not a distinct legion iiide[w.>nfknit of the rest of the bladder, 
but rather an essential part i>f an inflammatory process* 

Pathology and Diagmosis/ 

Cystitis, in the first place, mtist be differentiated from simple irri- 
tability c»f the bladder; a enuditif>n tound in netinisthenic subjects. 
The diagnosis and treatment are usually those of some underlying 
neurosis. 

The att^L-mpt will not l>e made to differentiate all the phases and 
varieties f»f cystitis, but rather to outline the more prutmnneed types. 

In the beginning (*f cystitis the eysttiscttpc shows the h!oodves;«k 
to be less sljarply defined than in heakh. iSwm the normal light 
pink, almost whitish, color of the mueosa assumes a deeper and 
det'jK^r hue until the sharp deniarcation between the vei^sels is lost 
and the whole surface is finally of a uniform deep rtnl. The epithe- 
lium niay be east <iff in small particles from circumscribed areas 
eitlitn' narrow or hroatk ami tlie surfaces thus expnsed may take on a 
granular a^ipearance. Finally in severe eases one may observe exces- 
sive swelling and tpdema of the bladder wall and pus eoagnlation* 
The urine in such cases contains epithelial detritus and pus cells in 
large quantities. 

The frequency of mixed infection and the presence of other diflS- 
culties may render it im}Missiblc to distinguish between all the differ- 
ent bacteriologienl varieties; it is, however, usually possible and is 
often desirable to diflercntiate the tubercular from other varieties, 
especially from the gonorrhieak 

Differentiation of Tubercular and Gonorrhceal Cystitis. 



1. Ixiratcrl elilvlly about the trigone. 

2. Inflammatory^ rtjuctlufi zurio absent. 

8. LocAl tiibercnIWT cystitis not very cf»mmoTi ; 
gpneml tubtTonlar cj-stUia very rare. 



Otmirrrhtrfit Oyttitu. 

1. Not nt an so confined. 

2. Clear gnfliinituBtory reaction zone, later 

ebangin}<to dull brown color 

3. Of eoraraon oeeiirrenee both locAl and ftn- 

erttl. 



4, ChttfttftLriAiL'*! by presence of small tubercles 4. Charaeterired ettrly by Insular areas of re- 



situated aUmi the trigone and ureteral 
orillcea. 



h. No pTcJectlng tufts of pu«. 



6, No iubperttoneal extrava^atSori of blood* 



7. BadtluH tubercuLoeUi. 



active inflummatlon, with healthy or 
nearly hi'althy intermediate mucosa. Later 
Insiilar areas becomeit confluent and ex* 
tend over whole mucosa. 

5. Project iiiij tultn of gouorrhoeal pua are apt 
to t*e pre stmt. In chronle stage regions of 
elevatli^n muy be excavftted by ulceration. 

fl. In ver>' acute stage there is aubperitini^al 
extra vasatioti of blood. 

7, Gonococcus. 



1 Adaptation, KoUiiher. Die Erkrankungen der WeiMlcheQ Harnrdbre nnd BUm. 



CYSTfTIS, 



309 



The picture here dniwn off^iuiorrlural cyst i tin corresponds in some 
degreie with that oi' other iion-ttiUprcuhir varii^^ties. 

CVrtain so-«illrJ ohiiiriil and patlif^logieal forniH and jdirast'S of 
cystitis may Ix^ designatL'd as follows and have great diagnostic 
significance : 

1, Snjjerfitna! cy^fitirt. 

2, Suppurative cy,stitis. 

3, Ulecnitive ey,stiti8* 

4, Exudative cystitis. 
6. Exfoliative cystitis. 

6. F'is^nre cystitis. 

7. F*jreiifn-bo<ly cystitis. 

8. Leuci)[ilakia cystitis. 

1, Superficial Cystitis. A large proportion of the cases of 
chronic inflammation are of tliis variety. It is generally called 
catarrhal cystitis ; the term Hhonhi be restricted to surface infection 
and to cases in which tlie product of inHamniation comes from the 
superficial epithehal elements of the blaildcr mucosa. The disease is 
marked by nioderate swelling, redness, and extoliation of epithelial 
cells ; the urine contains a modt-rate iinKMint of pus and is usually acid. 
Erosions, ulcenitifmsj and^ as a cmise(|Uenec, more abutvdaut suppura- 
tion may follow — that is, cystitis, (jriginidly catarrhal, may Ijecome dis- 
tinctly suppurative. Gnnit alkalinity rd' the urine indicates a rather 

iiivanced stiige, when tin* cystoscope will reveal a deposit <>f grayish- 
white c<jIor containing nmco-pus. 

2, Suppurative Cystitis. In this form the inflammation may 
have Ix-en dit!\ise from the beginning and have involved both the 
.Hnj>erficial and deeper structures of the bladder wall. As well 
fttatcfl by Senn, the microbie infection is of sufficient intensity t^j 
destroy the pr«>to|)lasui of the jiafhologinil products of the inflam- 
mation and thus trnusform the leuciu^ytes and epithelial nnd cnnnec- 
tive-tissne cells intf> pus corpuscles. The urine cnutains an abundance 
of epithelial cells and pus. The ulcerative prrKeess uiay involve the 
<lcej>er structures and in exce|>tional (^ses may lead to perforation. 
The urine is acid, or, if ammoniacal, may be so from decomposition 
due to the intereurreui!c (jf nnerolH s other than tliosc which jvrfHluced 
the original infec^tton. In the amuniniacnl inline will often be found 
the dipl(»coceus pyogenes and the pmreus vulg:iris. Suppurative 
cystitis, botii in its acute and elirouic stages, is pnme t*j invade the 
ureters and kidneys. In fact, chronic uncomijlicated suppurative 
cystitis is rare* Tlie cystoscope reveals the local conditions as 
a I rea< 1 y d esc ri bed . 

3, Ulcerative Cystitis. The idcerative phase of (cystitis hai* 
llready l>een mentioned as a later stage of the eatarrhal or su]i[Hrra- 

rtive varieties. The term is here used to ^lesigniite that variety in 

which niccmtion is tfie initial or, at least, a very early factor. The 

infection, as tlescriVjed by 8eun, appears to be of a jieculiar kind 

and limited in extent. The resulting inflammatftm leads (piickly to 

-Crn»um>*cnbed necrosis. There is usually a single 4'ir<'UiMst*ribed 

[tlh-**r, the so-<»alled * simple^ ulcer of the bladder. This form of 



310 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

cystitis is quite rare and resembles in many respects gastric ulcer and 
the round duodenal ulcer. 

The first symptom is increased desire to urinate ; intermittent 
haematuria then appears. The ulcer may become incrusted with phos- 
phates. Fragments of the deposit break off now and then, and may 
be passed with painful paroxysms, or may be retained to serve as 
nuclei for calculus formation. Finally the bladder becomes con- 
tracted and the mucous membrane extensively ulcerated. Ureteral 
and renal lesions may now arise. This form of cystitis is undoubtedly 
the result of an infection through the blood, the inflammation attack- 
ing the tissues around an infected embolic infarct and reaching the 
surface of the bladder by a process of ulceration. Ulcerative cystitis, 
like gastric and duodenal ulcer, is found quite frequently in young 
male adults, less frequently in the female. There are usually no 
antecedent or attending predisposing local causes. In the diagnosis 
the cystoscope is indispensable.^ 

4. Exudative Cystitis. This is characterized by the formation 
upon the bladder mucosa of a so-called membrane ; hence it is usually 
designated by the rather confusing descriptive terms, " membranous,^' 
" diphtheritic," " crou]K>us," or *' fibrinous." The exudative mem- 
brane is the product of the inflammation ; it is in fact apt to be the 

t)roduct of extensive necrotic changes and as such indicates a grave 
esion. There may be extensive destruction even in the musculature 
and especially in the deep bloodvessels and lymphatics. The urine 
is usually alkaline. The disease has been chiefly observed in puer- 
peral women. The urine contains fibrinous shreds or cast-off patches 
of membrane. Cystoscopic examination reveals a yellowish-white 
membranous formation which may often be picked off by means of 
forceps j)assed through the cylindrical cystoscoj)e. 

5. Exfoliative Cystitis. This variety is analogous to so-called 
dissecting metritis and dissecting vaginitis. The infective process and 
inflammatory reaction arc most virulent and intense and result in the 
destruction and detachment of the mucosa, and together with it 
sometimes of the muscular layer of the bladder ; these may be exjKilled 
in frn^ments with the urine or may have to be removed from the 
bladder by a surgical procedure. It is the most grave and virulent 
form of cystitis, and is apt to be fatal. The conditions are like those 
of exudative cystitis intensified. The diagm>sis between the two 
forms depends upon the macroscopic and microscopic character of the 
masses removed or thrown off from the bladder. The disease was 
early and fully described by Boldt.- 

6. Fissure Cystitis. Fissure cystitis is caused by secondary 
infection of a traumatism at the neck of the bladder or in the tri- 
gone. As seen tlirongh the cystoscope, the fissure is usually cov- 
ered by a brownish or yellowish exudate surrounded by an oedema- 
tons area. 

7. Foreign-body Cystitis. (Vstitis caused by foreign bodies 
varies with the character of the IxhIv and the conditions of infection. 
A smooth body may be tolerated without subjective symptoms. A 

> AdaptaUon from Sonn. * American Journal of Obstetrics, June, 1899. 



CYSTITJ^i, 

mugh or aiT^nhir suijHtanct^ rnsiy prejcluce trauma and thus opeu tlie 
way to any furni of iniVctiun. 

8* Leucoplakia CyBtitis.* This is ehamcttTiZL^d hy the appear- 
ance of t^niyi.sh or whitish small circumscril>ed area? .situuti'd usually 
m the trip)ue. The epithelium has uuilerguue ehau^(\-^ wliieli render 
it opatjue aud wliteh have bei'ii likened t^) tlje c li;n»^es nf keratitis. 
The eyi!tMse<>|K' reveals a uuruher 4it* jTray iMh-whili' rilieetiuLr spitK of 
a <Iiaiueter appmximatiug one-fourth ineh. These spotrf while de.s- 
quamatrn^ are helow the level of tlie surrr»uudiu^ niueoaa; after 
desquamatiou has eeased they beeome Hush with the nujeosa. A most 
prouiHineed sidyeetive symphnu is au latolenibh^ aiul ahnost eonstant 
desire to urinate. Mieturation may lie attempted as often as once in 
fifteen minutes throti^h (lu* day, and almost as frerjueutly diirinjL^ the 
night. Leuei»])lakia results from huig-eou tinned ehrouie ureas of 
inflammation; it may be the starting-point of generdl cystitis. 



Treatment.^ 

The treatment of eystitift falls under four heads : 

1. I*ro|thvlaetie. 

2. Medieinal. 

3. Topieal. 

4. Sur^ic;d» 

Prophylaxis.' Nuuhtous autopsies npou subjects who have not 
stiHert^l froui eystltis have shown a hypenemie state of the blad<ler so 
markt^l that it must liave Ikh^u of l<ui^^ ^Innilitut, yt^t whieh had ruit 
gone to the ejctent of iufeetion aud intianimatiou. The explanatitui 
must be that the infective eleuu*nt ha<l luU In-en present, or if present 
had not Ix'eorne active. On the other hand, th** ipiestion has In-cn 
raised aud usually answered iu the uei^ative whether the men' pres- 
ence of infective microbe's alone, bacillus tuberculfKsis and i^iMitK^oeeus 
excepted, cJin easily |u^oduce cystitis. It is coinmouly aai't'^'d that 
infection must usnally de[>eml upon : tirstj an almornud comlitiou of 
the soil which renders it susceptible ; second, upon the presence of 
the bacterial exi*itiu^ t*inise. A tw(>fnM in<lieatinu is obviruis : to kee]> 
the blaihh'r iu a state of resistance, and Ut avoid tlie introduction of 
infective materia L 

Susceptibility to Infection may res id t from cither systemic or toeal 
fttatcto. The systemie conditions are i>fteu the result of faulty elimi- 
nation and ccuisequeut defective ciretilation. He|iaticand c:irdiae ilis- 
orders, kidney insnliieiency, constipation, ji^iuit, litlucuiia and c^hohcmia, 
anjrniia, diidietcs^ rheunuitism, at oncr» sup^f^est themselves. These 
Hisorflers call for hygienic and medical treatment, for jiidi(*ions 
elimination and nutrition. At the risk of seemin*^ t<Kidv«M'nte rcHititic 
measures iir»e nuiy su^;:c*^st the vnlne of niercnrlals and salines. The 
Jprriter has occasionally been ^ratifitul at the disa|»p<*amuce of irritation 
t>f the bladder after the ndministration three times a day for a num- 
ber <»f weeks of calomel iu doses tuie-teuth to oue~twenti(4h tjf a 

lin supplementt^nl by the free use of natural tir artificial mineral 

1 Jkdii|itaUon from KoU>ihec * Klclnch, Am, «iyii. utid OlwtLt Jo«r,, INW. njrisiiUi*d. 




312 INFECTIONS, INFLAMMATIONS, AND ALLIED DISOEDEM& 



waters or cif pure watrr. It is ok^iirly essential to enforce jndicious 
rule.s for fo<Kl, exeifi.sej and ^^le<'|^ 

'Die intrfKliictioii of the eatlieter under the sheet, its jmssage with- 
out jH'eparatory disinfeetion of the vnlva, tlie n^Q of tW aseptie 
catheter, and the slight tr4iomati8m which its use may cause, ao^l the 
almost certain ingress uf septie matter througli siieli traumatism, are 
well known to every intelhgeut pliysieian, lint unfortunately niany 
intelligent physieians, although intellectually cogniasant of the facts, 
are not alive to their importance. 

The possihle rehitions oi' jvtirtnrition to cystitis are most significant j 
among such relations are those which arise from certain {xdvic ilefects, 
sneh, for example, as contraction or excessive inclination of the jnlvis; 
sncli defects may retard or obstruct lal>or, and tlicrehy cause prohmged 
prt'ssnre of the child upon the I ladder, a condition in 1 1 of danger. 

(icstation iu a retroHexed nterns friially euhirges tlie nterus nntil 
it becomes impacted under the Kicnil promontory, then jiressure of 
the cervix upon the neek of the bladder forces the blatlder against 
the pnhes, prevents complete evacnation, a nil results in the reten- 
tion of residnul urine. This urine neeessjirily l>eci»nies tleciaiiposi'd, 
ami is th*'n a nn»st favorable culture-ground for bacteria; the 
almost inevitable ivsnlt is cystitis. If there be present in combina- 
tion the three elements, congestion, decomjKised n^sidnal nrine, and 
bacteria, even though any one alone might be inetfective, infection is 
almost nnavoidalde. Tlie nerjessity for prompt replacement of the 
dis|)laced gravid nterns is imqnestioned. 

Medical Treatment. The medical treat nu^nt already disenssed 
as a piwi of the pro]>hylaxis has, especially in connection with other 
forms of treatment, great value. The principles are necessarily tiiose 
of general internal medicine. The parlicnlar indications have rt*fer- 
ence to tlie use of such drugs as may change ihc qnality or increase 
the (piantity of the nrint . If the nrine is stnmgly acid, for examj)le, 
it sht>uld he diluted by the free tiri idling td' fluids or rcndei'ed less 
acid by the use of alkalies; if alkaline, its rcactimi may be nnHlilicd 
hy the use of acids. For this purpose benzoic acid, ahme or combined 
with borax and dissolvcfl in cinnamon water, is a classical and nscfal 
remedy. The indication to relieve subjective symptoms is twofold : 
first, to alhiy snlfering and nervons irritation ; and second, to render 
the [MUient less intnh rant of topicnl and snrgieal treatment. 

In su[»erticlal miltl cystitis, with frecpu'nt urination and mild pain- 
ful contractions of the bladder, prompt relief sometimes follows liie 
tlaily ajiplic^itiini of a nnjtal suppository containing two or three grains 
of ichthyol. In more aggmvated easels opinni may he sybstitiitc<l 
for iclithyol. The irritating cilccts of coni-eiit rated urine may Ive 
avoided by the frr*pient <lrinking of water. Lest there be frecpjcnt 
urination during the night, the drinking may he largely coitHned to 
the morning and early at>ernc»on hours. To seenre good sleep let the 
ichthyol snpjKisitories be nsed two or three hours befi»ri' bedtime, 
and followed if necessary by the opium or morphine suppositories 
at bed t inn*. 

The bowels should be kept normally free by mild laxatives. 




CYSTITIS. 



313 



^^"^c cathartics should be avoided. Uva ursi, triticum repens, the 
*sia«a8te salts^ buchu^ eucalyptus, and many other time-honored and 

5fa«8ic8l remedies may be useful. Rest, especially in the acute stage, 

-'s AigJily important 

Topical Treatment. The washing out of the bladder as a routine 



FXOVBB 167. 




^^Wtihingout of tbe bladder. The Irrigation may be repeatedly made by alternately raising 
?JJtew*'*°*? ^^® ftmnel; when the funnel Is raised the fluid flows into the bladder; when 
**^eied it returxui to the ftinnel. 

P'Wedure is not approved. Irrigation is, however, positively in(li(*atecl 
^fcen necessary for the removal of loose irritating shreds or other 
matter. 



314 INFECTIONS, INFLAMMATIONS, AND ALLIED DISORDERS. 

The superficml forms of cystitis respond promptly to topical treat- 
ment. If the cystitis is general and superficial^ a 10 per cent, emul- 
sion of i(Kl(»form in oleum sesame may be thrown into the bladder 
with a hard-rubber syringe. If, after two or three applications of the 
emulsi<m, there is sufficient toleration, four ounces of nitrate of silver 
solution may be injected into the empty bladder and immediately 
replaced by free irrigation of normal salt solution. The strength of 
the silver solution may varj' according to the toleration. Begin with 
1 per cent, and cautiously increase the strength if necessary even to 6 
per cent. ; some practitioners say 10 per cent. The treatment may be 
repeated every two or three days. Oftentimes two or three mild 
injections will eifect a cure. 

In many cases the infection is localized, and when localized is 
usually confined to the trigone or inner end of the urethra. The 
silver application should then be confined only to the affected part 
It may be made of any desired strength by means of a cotton swab 
introduced through the cylindrical cystoscope and kept within bounds 
by the immediate instillation of salt solution. Mild infections in the 
trigone often yield completely to a single treatment. Fissure cystitis 
may be promptly and permanently cured by this means, but aggra- 
vated cases sometimes require the solid stick. Accompanying ure- 
thritis should be treated simultaneously with the cystitis. 

When the infection has caused deep infiltration into the bladder wall, 
as in exudative or diphtheritic cystitis, the treatment is to be conducted 
in two stages — first, wash out the bladder to remove the shreds and 
other putrid material ; second, apply the disinfectant. In washing 
out the bladder use small quantities of fluid and repeat until the fluid 
returns clear; then apply the disinfectant, preferably the silver 
nitrate. 

If tlie socrotion on the bladder wall is mucroid in character and 
stringy, it is better to use normal salt solution than pure water. 
When the bladder is so jxiinful as to resist all efforts at treatment it 
may he anacstlietizod with 10-20 c.c. of a 4 per cent, solution of anti- 
pyrin. This should be loft in the bladder about twenty minutes. If 
treatment leaves the bladder very painful, cupping, hot ap])lications, 
or opium suppositories are indicated. 

Cystitis with granulations or ulcers require a very long time for 
healing; for this pur{)()se nothing is better than silver nitrate solution 
or the solid stick. 

In exfoliative cystitis any systemic cause of the disturbance should, 
if possible, he removed. The membrane when it becomes gangrenous 
should be taken away by means of forceps. A permanent catheter 
should then he inserted both for protection to the bladder from the 
results of distention and for the injection of antiseptic solutions. In 
these eases the systemic condition is very grave and requires the 
maximum support. 

Surgical Treatment. The surgic^il procedures in the treatment 
of cystitis are as follows : 

1. Dilatation of the urethra. 

2. Vaginal cystotomy, also called coli)o-cystotomy. 



CYi^TmS, 



315 



The iiidirntioos for this oiw^mtitm 



»1 Curettage of the bladder. 

4. Lithotrity. 

5, Extiii-vesiml (>|iemti(«is. 
1 Dilatation of the Urethra. 
*as follows : 
A. To cure lociilizcMl fVi^iitis in the reginii of the trigone, coriiiuordy 

cs^lled trig^jiiitis, aiui fissure at the neck, eulled li>i?ure cystitis. The 
rrnxle of cure in fissure cystitis is doubtless similar to tliat of anal 
ti:3sure by dilatation of the sphineter ani muscle* 

B* To enable the openitor to sec ami tR'ut surgically or topienlly 
'V^^^ital ulcers, vesie^l heniorrlifmls^ small jijrowths, and other attections 
^>f the hlailJur, and to permit the erushin<j^ of stone. 

The dilatation is made by means of the urethral ililator, Fi^nre 44. 
In ptissing the Jnstrumeut one should note the extreme untunil 
diameter of the urethra and then liniit the dilatation to about twice 
^liis diameter. Further stretching is apt to rupture the nrethro- 
"V^oal wall, and may cause |>L'nnanent ineontinenee of urine. The 
^0. 16 cystoseope, Figure 52, measures the extreme safe tliameter ibr 
t.lj<* average urethra. Exceptional v^ise^ may arise in which this 
^moiiot of dilatation eould be safely htereased fir in whieli it might 
o^ dangf^rous. Whatever stretehiug can he done withnut tearing is 
saJk The dilatation may be started with the conical tlilator, Figure 
"W, and completed with the cystoseopt*, Figure 55. 

2. Vaginal CyBtotomy. This is tiie formation of bd artitxcial 

^**ico- vaginal fistula. It iipens tlie way to intravesical topical 

^^eatments and operations. Through this ripening tumors may be 

^'eniavtHl and (lis<*ased sur faeces eatiterizeil mid curetted. In clinmic 

^ses of great, hing-contiuued, and unrelieved suttering eolpo-eystot- 

Omy has, by giving the Idadflcr eomjilete rest, furnished immediate 

^/>d iins|M»akable relief The o|M/ratiou has two objects— first, pallia- 

5^Ve; setH)nd^ curative. In a certain prr»piirtiou of cases the disease 

'^ the bladder ami up[>er zones of the urinary tnict is so extensive 

y^m the operation can only be palliative— tliat is, an anatomical cure 

■^ sometimes impossible. In some of these cases the bladder is per- 

*niinently e^jntnicted to the capacity of perhaps one-half ounce. No 

^ne would think of making a secouihiry operatir>n f^r the chising of 

Mic* fistula under such contlitions. In numy other cases the artificial 

^pcming may he only teniftnniry. It gives tlie best opportunity for 

<**rf^»t local treatment to diseased parts of the Ijladder, and for a; mf»st 

TO^fctive vesical douche, which can be thrown in through the urethra 

^nd allowed to flow out thrt^ugh the tistula and vagina. Very many 

<^5li?eg of otherwise intractable t'hronie cystitis have been cured by this 

^eth(Hl with subse<pient closure of the fistula and the cures, if not 

^anatomically complete, w^ere at least sym|>t<)matically satisfactory. 

In i^uch eases the much contracted bladiler may finally even resume 

'^> physiological calibre, 

0}}i-rntion. Tbf^ patient is prefenibly in iSims' position, with the 
fnt^'pjf^r vaginal wall exposed by Sims' speculum. A hirge sonnri is 
^otrtKlueed through the nrethm, nml its point pressed against tlic 
^'f'^^it-al mucosti in the middle of the long axis of the vcsico- vaginal 





316 rXFECTIONS, INFLAMMATiC/NS, AND ALLIED DISORDEBS. 



septuiiK An inei?sit>n is nuw niatlo upon tlie sound th rough the seputm 
with ihe knite ur srissors, Hie jMijrit of the .sound will then pass 
thrnuj^h into the vagina, Tlii' opeuintjr thus made is enlarg^ed so as to 
extend one ineh in the me<Jian line of the h)ng axis of tlie ve&ic4H 
vat::inal septum. Its npper end will he ahorit one-half inch frfim the 
anterior wall of the eervix uteri, and its lc»wer end the same distance 
from the neek iA' the lyh^hler. The margins of tlie vesitml and vagi- 
nal mneosa are tlien nnited liy tine interrupted eat^ut sntui'^s. 

This valuable o|iepation is the deviee of T. A, Kmniet. 

In some of the less severe cases sufficient improvement take^ place 
in a few months to permit the closure of the tistula, with permanent 
relief. 

In the more elironir eases in whicli the hladder walls are much 
thiekened, deeply infected, dis<irganized, an<l ci Hit meted, an*! |iarticu- 
hirly wlien the cystitis is eoniplitmted with pyelitis and nephritis, the 
listnla sluudd remain ojieii, for its closure will inevitaldy In* followed 
hy relapse. 

If cystitis he eompliciited hy stone in the Idadder, the treatment 
may well be an artificial vesieo- vaginal fistula, instead of a crushing 
ojK'nition tfimngh the urethra. Tiie fistula is preferred for two 
reasons : iirst, the crushing <iperation may involve ohjeetionable dilata- 
tion of the urethra ; second, the fistula is useful as a means of drain- 
age for the cure of the cystitis, 

Colpo^eystotoniy may be further indicated for tlie removal of foreign 
IxKlics ; it also furnishes an opening for the cauterisation or curettage 
of ulcers. 

3. Curettage of the Bladder may he done through the tubular 
cystoseope, hut better through an artificial vesico- vaginal fistula. It 
is intlieated in indfilent ulcers, especially those of tnliercular origin. 

4. Lithotrity and Lithotomy. A stone in the bladder may be 
crnshed flircMigh the urethra or removed tlirough an artificial vesico- 
vaginal fistula, A small stone, nr nit her foreign body may be re- 
moved entire^ through tlic dilated uretlini. Prompt relief from cys- 
titis usually follows. 

5. Extra-vesical Operations. Parametritic, perimetritic, or 
tul>al aljscess nrav hy rupture into the bladder cause cystitis. Incision, 
evacuation, and draiiiage of tbe pus cavity, or removal of the pus 
siie, is usually fullowed by |)roni]>t tnire. 

As a final stage in the treatment of cystitis, the bladder if con- 
tmeted may often be made to return to its nornuil size by methodit^l 
dislentinn with in^-reasing quantities of salt solution; but this should 
only be n ruler taken after the cystitis has been cured and the patient 
is free from the dangerfci of a recurrence of the malady. 






i 



Summary. 

1. The conditions which were formerly considercil the pi*irae causes 
of cystitis have rcH^eded to their proper place, and nmst be estimated 
only as predisposing (*auses. 

2, The recognition and appreciation of pathogenic bacteria as the 



CYSTITIS, 



317 



eicitit^ causes of cystitis is e.^sential to a scientific understanding uf 
«ie jjathfilo/^y, etiology, anil treatment, 
J. Alkalinity of u rim* drpcnd?; upon the aetitm of ei^rtaiu ba(*teria, 
Ootahly the pn>teu,s vulgaris, in tlie dL*etJinpo,sitiuii of urea. Tlie 
hadllus «uli eunniiunis, wliieli is one of the most frequrnt eanser^ of 
cy.^tili*;, [^ one of a elas.s wljieli tloes not de compose urea and thcrei'ore 
dties not priKJnee amamniaeal urine. Contniry to the uliler opinion, 
ulblinity i;; not the rule ; on the contrary, In the inajnrity of eani^^s the 
iirijie n^maius acid. Alkalinity il' pre.seiit is the work of other mi- 
orijlie^s secondarily in trod need. 

4. The classical symptoms *A' vesieal pain, frtupient nri nation, and 
pu-i in tlie iirinc are wholly inadetpiate as a basis for the diagnosis of 
c^ystiti?,. Moreover, the condition called cystitis has receded from the 
Pi^nk of a distinct disease to that of a symptciiu, and shtudd l>e so 
^^^lyitinltNl. The mere recognition tjf the fact tliat cystitis exists is lUit 
^ tiiiignosis ; a fact is not a diagnosis. Ijiileeil, the recctgnition of 
•cystitis may by cinitnist witlj tlie recognition of its complications be 
of very minor importance. 

5. The diagn»»sis must comprehend not only the presence of inf(?c- 
^Od in tlje bludiler, but, what is more important, it tnnst embrace 
y\o source, nmtcs, type, complications, and variety of the asso(*iatc'd 
"^Hanunatory reaction. Simple uncomplicated inflatumation of the 
tlaiJdcr is rare, 

<i. The endoscope and eystoseope can alone open the way to efficient 
exploration and diagnosis, can alone <lefine the indicatiims for topical 
Ot* surgical treatment ; what is more essential still, they alone can pre- 
pare the way for the exnnu'ner to distinguish 1 between cystitis and a 
wide variety of other urinary affections of the bladder, uretlira, 
ureter, and ki<lney. One is astounded at the revelations of the eys- 
toe^rope in the recogtiition of most iinjKjrtant lesions which nuist other- 
"^ise have |mssed unol)served. 

7. The washing out of the bladder as a routine measure is not 
apprt>v»Hl. The injeeti^m of disinfectants is indicated only in general 
or nearly gene nd tystitis. For localized cystitis direct applications 
to tilt* part affcctL'd shoirld be made tli rough the endosco|)e. 

8, Dilatation af tlie urethi*a is indicnted for localized cystitis at or 

^^mr the neck of (he bhulder. The efficiency of the procedure for 

»uoh localized cystitis has given it an undeserved recognition in the 

trt^tment of general cystitis whicli under cystoscopy it cannot now 

i^-tain, 

B. The most valuable disinfecting topical application in cystitis is 
tile nitrate of silver. 



PTELITIS AND NEPHEITIS, 

This topic has a special gynecological significance in the matter of 
*^'*j^o»is and treatment by means of the cystosco|ic and the uretend 
calheter, which have been described in Chapter III. The uretend 
<^theter* is intrmbK-ed into the ni*eter through tlie cystoscope. By 

1 AdAptation fruni Howtird Kelly. Dij3«a8(?ft of the Female BladdL'raiid Urethra. 




318 INFECTIONS, lNFLA3IMATfONS, AND ALLIED DISORDEBS. 



this means one may wash out the urinary tract up to and iDcludt 

the pehirf of t lie kMnry ; us a result tif this treatment apjiarent cu 
in eases of hydro-urcler and py<)-nrt'ter ha%'e heon ree<n'ded. 

To wasii oiit the nreter the jxitient is plaeed in the knee-b 
jMivsition ; the ureteral catheter, witli a i^hort pieee of rublier tubii 
attached^ tilled with a sterilized borie-ucid suhition, and elanipt*d 
keep the solution from running out, is ]>assed through the cvstosc^i 
into the ureter and the eystoseitpe withdrawn, A sterilized j^la^ fu 
nel, with an attaelietl ral^ixT tul>e eighteen inches h>ng, is filled wii_ 
llie irrigating solution, and tlie two niliher tubes an* eonneeteil hy=^ 
small glass tube with a point sutlieiently fine to tit mXu the tulje - 
the ealheter. By nosing the funnel above tlie level of the IkkIv t- 
rtuid is made to flow through the ureter into the pelvis of the kidni^ 
When the funnel is droj)|K'il below the level of the boily ihe fli ^ 
Hiturus ; tlms, by alternately raising anti lowering tlie funnel, tn 
fluid is made repeatedly to flow^ hark and tbrth and to wa^h out fc: 
ureters and pelvis of the kidney. The tluid niayj if de*ireil, 
changed one or more times during the treatment. The appara^ 
iH similar to that shown in Figure l*i7* 

Purulent or other aeenmulations in the ureter should be permitlfc 
to run out through the eatlieter before the washing out. 

The praetirid value cd' th*' ureteral eatheter as a lherai»entic a; 
remains to Iw estimated. The attempt t^) eure ehnade infection in 
uterus, nose, thnnit, anti other niueous cavities by washing them 
with various fluiils has nt>t generally been iolloweil with gmit suec 
It is prohahle that the ureter and [>elvis <if the kithiey will nrjt l>e 
exeeptiun tn the rule, Kelly jaits forth a w*»rd nf wise precaution 
the urgency of making all ureteral manipulations with extreme gen 
ness, Tlie catheter must never be pushed up higher than it 
readily jmss, for such violence would injure the mucoea and might 
followed by dangerous, even tatal inte(*tiou. 



■^ a 

m Id 




PART IIL 

TUMORS, TUBAL PREGNANCY, MALFOR- 

MATIONa 



CHAPTER XXV. 



TUMORS OF THE VULVA AND VAGINA. 



Varix. 

HfTmatoma. 

Papillonia. 
Carcluonia. 
Sarcoma. 



Varix. 



Fil>rc»myunia. 

Lipoiiui. 

Lupus. 

Neuroma. 



Varix is an aggrejii^ation nf dilati^d or varicose veinn in the erectile 
tis-iiio of the bulbi va^iniB. The varicose state is ciiiis^^d by obstruction 
to the circulation. This oKstructiuii of'tcri arises rrotii direct pressure 
upon the venous trunks by the jsjravid uterus. The pressure may be 
exerted by tumors or by inflarnmatory exudates. Habitual constipa- 
tion, ]x»rtal olistruction, ami viserral cliseasc may underlie and p<T- 
petuate the dis^irder ; it beloujL*;^ rather to advanced than to early life. 
The tumnr is oval, ^liibular, or scrjR'utinc^ anti may grow to the 
&ize of a chiUFs lieadj The surface is ir^r^'jrular and of dark-blue color. 
The mivss teniponirily tlisap|>ears on pressure, Tlie subjective symp- 
toms include a variable juiiritus and, especially on walking or stand- 

LlDg, a sensation «)f fulness and weight. Rupture of thp distendc*! 

fveinfl often occurs during parturition ; it may 1m? the result of trau- 
matijsm or may hr s|>iuttaneous. External rupture may cause danger- 
ous, even fatal, hemorrhage. Subcutaoe<tus rupture into the cellular 
ttHi^ue give>< rise to an accumulation of bliiod called hiemutoma. 

The Treatment includes mechanical support of the uterus, if dis- 
placed, regulation of the Ijowrls, reriu*vai of waist c^mstrietion, the 

Lmpplication to the varix of n pad held in place by a T bandage, the 
Use of astringent lotions, and^ especially during pregnancy, frequent 
rest. The radical surgieal treatment is the same as woidfl he indicated 
by the general principles of surgery for varix in any other location, 

1 Holden. New York Medlcul Record* July, 1868. 

31» 




taxis ; it miiv teriiiinutt* bv ahHirptmn 
or by su PI 111 ration, 



320 TUMORS, TUBAL PREQNAIfCY, MALFORMATIOy& 



HaBznatoma. 

Htfmatonm is an extravastatiun nf Ulocxi, not a new growth, but is 
described here beeiiutie it has eertain relatit^ns with varix and fri>m 

tho standpoint ftf diagnosis. The 
FiarsBlW. Causes have hevn inilicated in the 

foregoing j>uragraphs on varix, and in 
the section on Traumatisms, Chapter 
XXXIX. The tumor may develop 
ni|)iillv or slowly even to the size of 
an orange, m communly iinihiteral, 
glo!>ular, elastic, and of a violet iH>lt>r. 
It is distioguishtJ fmra pmh^idal 
hernia by the absence of impulse on 
coughing and by lion-rediiction f»n 
inute by absfirption 
1, or the bhKKl-<dot 
may bc*romc encysted* The treat- 
ment in the t^arly stage is tn arrt»st 
blci'di ug by means of pressure ami 
the iee-bag. If an abscess d eve hips, 
it should be freely i>pencd and drained. 
A cyst- wall, if formed, should be dis- 
sected out and the wound closed by 
deep sutures. 

Elephantiasis — Pachydemiia» 

This ilisease is primarily a chronic 
recurring lymphangitis. It is as- 
sociated with hyjK^rphisia of the con- 
nective tissue, skin, mucous mem- 
brane, and epidermis. The whole 
pri>eess results in tlu' formation of a 
tumor* often of large size, ami is 
most frequent between the years of 
puberty and the menojmuse. It is 
rare in tempc^nito, cuninion in tropical 
climates, au*l epitleniic in certain low- 
Iviug i'ouutries along seaeoasts and in 
the i -lauds of the tropics. An 
organism eal]e<l the fihtri a sattff^iiinis 
hotitihii< has been fonnd in the blood- 
an<l Ivmph-vessels of the aftWted part^ and is believed to be the 
exciting eause,^ The tumor may inv(dve the whole or a part of the 
vulva, most frequently the two labia nuijora, less frequently the 
cHtorisj and least frequently the uymphie. 

The growth, when large, Is apt t«I be ipiite pendulous. Its surface 




Elephiintlatfis of viilvii.* 



* Frnm Honnut and Petite^ rtjmecolofty. 

» lK:lAflel(J and Fruddeu's PaUioIoglcftl Anatomy and Hlit^iogy* 




TUMORS OF THE VULVA AM> VAGINA. 



321 



I 



bo sniootli, rough, (is.suretl, warty, or iilrenito^L The tumor, 
esjie<*inUy if uk*eratecl, jj^ives forth a s^ero-allnuinnous rxiuluto, Tliis 
may tn* iK\ profuse as to dpniand fivfni<*nt rhmi^c' of firithinp:, Uteera- 
tion 19' cHinimon a,s tlie rrsiilt of frii'tfuji. C asos of twenty years' dura- 
tion have l>ecn reeordf^l. Tlip «^ular|r<'d lal)ia may n-ai'li the enormous 
weight of fifty pounds. Both labia are i^iraultaneoui^ly involved. The 
ifigttinAl glands on Uith side-s are 

cnlanrtHl Chyhiria is a fir- fiuume i«y. 

i|Ueiitty eomplieatioiK Tltt^ dis- 
ease docH not din^etly impair 
the ^^neml lieahh ; it is, liow- 
ever^ <]isa1>ling frouk its meohani- 
e^il interference with uriuationj 
walking, and coitus. 

The Differential Dia^nosia 
fnitn p:i|»illoma, eareinoma, sar- 
cxitna, tibnmia, and lipoma de- 
|>ends n|ion the clinieal history 
lis onlltued in the foregoing 
{ieiragra|»hs iiud upin the niic- 
riKseojiie findings. All thei«e 
growths < litter frotn elephatuixsis 
in the ab>?em?i^ nf any indiira- 
tif»n of the surrounding skin. 
Lupu.s presents more extensive 
nleemtions, deeper inclnration, 
darker e«»lor, and has for its es- 
sential faetor the tn be role ba- 
cillus. 

The Treatment is excision. 
The numerous dilated lym|jh 
channels inen^ase the ilangtT <jf septie absorption, and in the opera- 
tion render the most extreme usepsiii imf>erative. 




App«^iiri4nce of tht* vulvn iiflpr operation fur 
elrphuiiUaiiJM.^ 



Papillomata, Condylomata, or Warts. 

These growths are eharaeterized by hyjR^rtrophy of the papiltas of 
ihe skin or mucous rnemlmme, increase of eonneetive tissue^ and 
thiekening ot* xhv e|iitlieli;d eovering. They are divided into three 
general elasses : 

1, Xon-s|>eeific — simple papilloniata — ordinary warts. 

2, Gonorrlueal — comlylomata aeuminata — pointed condylomata — 
specific veg**tation or venereal warts. 

3, Sypbilitie — flat eondyhnuata* 

Xon-ftperifie^ Simple Papiihrnufftf, or ordinary warts, are not uueom- 
monly fimnd on the mons veneris — less frpr|uently on the labia. 
They art* of unknown origin, usually of dark-I>rown eolor, are not 
deeply dividetl, may have a broiul base or may be ]>eduneulated, and 



» fiimuet anit Pttlte, Gjnecoloify* 



ii 



< 



M 



322 



TUMORS, TUBAL PREGNANCY, MALFORMATIONS. 



are not ajit tu cualesce into hirge, coniivict nmssos. The treatment is 
exeiMion with the jsliarp eurette and enutt riziition of the base. 

(rottorrluidt UVui^i, or warts at least assoeiated witli goiujrrha.*ii, 
are tuuiid on the vidva, vagina, cervix uteri, perineum, and ahont 
the anus. These warts oeeur singly, in groups, or iu eaulitiovver-like 
masses. The growth may be i^o large as to interfere wiih coitus, 
nriuation, or defeeation. The surface is soft, moist, of bluish color, 
and divided intn small nodules with pointed ends like a c(M?k*s comb. 
Wlieu the growth occurs iluring [jregnaiK-y it is nipid, but may im- 
mediately disaii[K'ar after labor. There is usually a ecjexistent fetid 
vaginitis. The questiou has beeu raided whether tliis form of etjudy- 
hjmata may not occur inilejiendently of the gonoeoccus, but the elioi- 
cal evidenec, including the results of baeteriological studies, strongly 
jxiints to at least a coexistent gonorrhnpa. Zeisler, in a verbal eom- 
munication to the writer, siiys that the part played by the gonoeoecus, 
except as a predisposing cause, is dtmbtfuh 



FtftrRE no. 



Simple warty vegeUtionB of ttie vulva * 



The treatment includes, first, thorough cleansing and disinfection 
of the diseased n\trrou ; second, the removal of the so-<^alled vegeta- 
tion with scissors, anfl i-auterization of the l»ase ; third, antiseptic 
dressing and washes until the ptirts have healed ♦ The danger of 
puer[>eral sepsis and nphthalmia of the newborn infant strongly sug- 
gests radical measures during jvregnancy, 

F/at ( bmiiffomftfa, — mnditietl ni neons patclies^ — ^are of syphilitic 
origin and may involve large surfaces of the vulva and vagina. 

» Tarnier, in Foiuers TrtjaUise ftn Oynecolpgy. 



TUMORS OF THE VULVA AND VAOINA. 



323 



Thev are soft, grayish^ have a broad base, and yield to antisyphilitic 
treatment 

Carcinoma of the Ytilva. 

Cam noma of the vulva is rare, and is apt to be of the pavement- 
eell variety — epitlR*liotiia, The autlicn* t^ljserved ojr* at^e of cylin- 
driral earcinonia immediately after thi* removal of a eaneerous iiteniB. 
In tJiis case the disease was d(»ubdes> transphinted frnm thr* iitenis to 
tht-* vagioa during the operation. Pnmipt exeisicin was followed by 
radical cure* 

Pavement-Cell Carcinoma begiiin as a small, liurdj whitish, nmgh 
au<l pai titers papillary excreseenee, .situated at any point on the vulva, 




biit more commonly on tlie sulcus Ijetweeu the labia majora and 
minora. There is first a ^rrufhial iiiv<»lvrinent of tb<' superlirial 
itrurtiire** anaiiid the growtli, then ni|)id ulecmtiun and pain, Tlie 
ingiiinnl glands on the «ide corresponding to the <lisease are invidved. 
Ttie margin of the uleer is elevated^ hard, and of a bluish -red color. 
The base is granular and covered by a semi-opatpie, putrid i^cretion. 





324 TUMORS, TUBAL PREGNANCY, MALFORMATIONS. 

Small, pearly bodies may often be squeezed from the epithelial 
nests at the base; these nests are highly diagnostic. The labium 
becomes greatly infiltrate<l, very hard and thickened, and is finally 
destroyed by ulceration. The discharge is very foul and malodorous. 
The disease rarely extends to the opposite labium^ vagina, or abdom- 
inal wall. It may invade the perineal and peri-anal regions. Epi- 
thelioma of the lip and of other [)arts where skin and mucous mem- 
brane meet offers a close analogy to epithelioma of the vulva. 

The diagnmu is cliiefly from lupus and syphilis. Unlike cancer, 
lupus is recognized by the insignificance of the pain, by the relative 
freedom from foul secretions, by the tendency of the ulcers to cicatrize, 
by the slight liability of extension to the inguinal glands, and by the 
slow progress of the disease. Epithelioma destroys life in about two 
years after the l)eginning of ulceration. Syphilis may be recognized 
by the history of infection, by the ])rescnce of secondary and tertiary 
lesions elsewhere, and by the effect of specific treatment. 

Cylindrical Cell Carcinoma may l)e soft or hard. The relative 
l)roportion of epithelial elements to the connective tissue is greater 
in the former, less in the latter. The tumor begins more deeply in 
the cellular tissue. It is characterized by irrt»gular-shaped cylin- 
drical cells imbedded in the meshes of connective-tissue fibres. 
Progress is more rapid than in epithelioma. The tumor more rapidly 
breaks down, the hemorrhage is frequent and profuse, the ichorous 
discharge is abundant, the inguinal glands are early enlarged, and 
systemic effects appear earlier and are more marked. The. disease 
terminates in sej)sis and marasmus. Death occurs earlier than in 
epithelioma. 

The treatment is radical excision before glandular involvement. 

Sarcoma of the Vulva. 

Sarcoma is of mesoblastic origin and is so rare in the vulva as to 
])rocln<le accurate description. The ]K)Ssil)lc varieties are : first, round 
cell ; second, spindle cell ; third, myxosarcoma ; fourth, melanosar- 
coma. They preferably develop in the labia majora, but have l>een 
found in the nymplue. The growth, according to the variet}', may 
be slow, resembling that of lipoma;^ or ulceration may be early, 
rapid, and destructive.^ The usual characteristics of sarcoma of the 
vulva are rapid growth, late ulceration, variable hemorrhages, and 
late involvement of the inguinal glands. The systemic breakdown, 
though more rapid and marked, resembles that of carcinoma. All 
recorded cases have terminated fatally. Death usually results from 
rapid involvement of distant organs through the venous current. 

The Treatment is removal at the earliest possible date. The 
author here records a snccessfnl operation d(»ne more than fifteen 
years ago for the removal of a spin(ll(»-cell sarcoma of the mons 
veneris. There has been no recurrence.^ 

1 Hcukcl. * Hildcbmndt. 

» The microscopic exuininiitioii was by Lester Curtis, Chicago. 



TUMORS OF THE VULVA AND VAGINA. 325 

Cysts of the Vulva. 

The pathology of cvsts of the vulvo- vaginal gland has been ex- 

eoed ID Chapter Xi. under Inflammation of Bartholin's Glands, 
only satisfactory treatment of such a cyst is to open the sac, 
dinect out the sac-wall, and close the wound with sutures. 

Fibromyoma of the Vulva. 

Fibromyoma belongs to the connective-tissue group of benign 
tomors, and is thcrefbre of n)csoblastic origin. It is composed of 
IhfDUR connective tissue and a variable amount of muscular fibres. 
The histological characters of this tumor will be given more fully 
nderthe subject of Fibromyoma of the Uterus. The tumor is com- 
■011I7 small, and, when large, is apt to be pedunculated ; it is smooth, 
in^lar, or lobulated, is not adherent to the skin, and, according to 
die amount of fluid in the interspaces, may be hard or soft; it is often 
deented from friction but is rarely the seat of an abscess. The 
^ptoms are median icid, and are due to weight and pressure. The 
tatment is excision. 

Lipoma — Patty Tumor of the Vulva. 

Lipoma is composed of lobuli of adipose tissue in a flbrous mesh- 
•wk, and originates in the fatty tissue of the labia majora and 
■008 veneris. It is distinguished from fibromyoma by the greater 
BJpidity of growth, by the lobulated surface, and by a peculiar sensa- 
tiii to the touch. This sensation is such as would be expected from 
«^of cotton under the skin. Lipoma may grow to the weight of 
ten pounds, may extend to the knees, and may be i)edunculated ; it 
■8 been mistaiken for hernia. The treatment is excision. 

Tuberculosis — Lupus of the Vulva. 

His disease, from the pathological point of view, would be classed 
■itobercnlar inflammation of the vulva. The tumor-like mass, how- 
••cr, presents physical characteristics in common with certain tumors; 
■ooe, from the clinical and comjiarative standpoint, the disease may 
■•described here. S(»e Tubercular Vulvitis, Chapter XI. 

Tbbercular vulvitis, commonly called lupus, is rare. It occurs in 
fc vulva, usually during the |)eriod of maturity. The two charac- 
Wstic lesions are : first, the formation of tubercles and nodules, 
•kidi undergo cheesy or colloid degeneration, and, finally, ulceration 
■•I cicatrization ; second, a variable increase throughout the affected 
■Wi of connective tissue. 

The ulcer is of red color, with a granular base. It may be 8U]>er- 
fciil or so deep as to make permanent fistula? between the bladder, 
^na, and rectum. The cieatrieial contnietion which follows the 
ulceration may even result in strictures of the urethra, vagina, or 
''Bctuin. The ulcers create pus and liave a tendency to bleed. 

The hypertrophic process may or may not be associated with 



TmiORS\ TUBAL PEEQNANCY, MALFORMATIONS, 



iilceralirvn* Tlie g<_^uend tliickoniiiir and incliinition t>f the affi^cte 
part ouiy l>e so extenf>ive as U) jil\e the* labia tlie ap|waranc*e of 
marked elephantiasis. The vuh'a and periDCLiiii bew)me stiiddeil 
with iiuduk^s of red or vioh.i t^olor. 

Great ehronieity and little [xiin are notable eharucteri^tics of the 
disease. Thc^ general healtli may continue uninipairi'<l for many 
years. There is nsiially a liistury of tulx^rculosis antedating that of 
fhe vulva. Primary hipns vulvie is n»re. Spontaneous recx>very 
eehiom occurs. 

The treatment sh<ndd he radical. Early exeifiioa of the diseawd 
part togetlier with a layer of healthy tissue around it gives good 

FlOUKK 17.1 



DUCT 



Anterior portion of a cow's vagina, shnwin^ two large eysta developed In the terminal ^qErmcnt 

of Otirtners duct J 

promise of permanent enn^ If it is too hite for this, the ulcerated 
jmrts should be treated by sharp curettage and the actual cauter)% 

Enchondroma and Neuroma of the Vulva. 

Enchomlnjma ant! nenroma are surgical curioBitics. Simpson^ has 
re]H)rted the only authentic case of neuroma, Schneevogt and Bar- 
tholin have each recorded a case of enchondroma. 



Cyste of the Vag^ina. 

Vaginal cysts, altlmugh ran*, are the most frequent of the tumors 
origiuatiug in the vajj^ina. They are pmbably from the embryoiinl 



*8iitUni. Tumors, Intic'ctnliiiiil i!rthgD»nt 





TUMons OF THE VULVA AND VAGINA, 



327 



reroaias of Gartner- s duets.' An ix-liinm-oecut^ ryst* \iVi^ \w^n reported. 
Embryonal vaginal cyst> are iii^ijully n<it larpjer than a walnut, although 
Veit hiis re|Kjrted ant? as lar^re as a t<etal hea*L^ ^^ hry are eirenm- 
gcriljetl, tense, elastic, rarely [RHliineulated, and eoniinanly tmilwukr ; 
Uiey occur singly, or, in rare itKstancn's, are arrange<l in groups of 



fWuBXlTS. 




C&rcinomn of vaginal wiilL 



two, three, or four in a row. The t*yst-wall Is enni posed ty^ fihrt^us 
tia^up, with an inner lining of eylindrical or pavement epithelium and 
an onter coverinfr of vairinal mucous niomhrane* The eontentn are 
eommimly viseid, trani^parent, au*l «>f a |ialc^-yLllitw color. Tiie <K?ca- 
sional chrK»o!ate color is explained by the presence f>f MuikI, pus, ami 
epithelial cells. 

The (litTercntial diagnosis is from cysfoecle, reetcteele, emphysem- 
atftns va*]^initis, and va^jrinal hernia. Cystoeele is demonstrated or 
cx'*lnd'Hl l>y the pound in the hladder and the finger in the vagina; 
rect*K*clc by one finger in the rectum and aoollier in the vagina. The 

» Vrft. Kmnkheilen dcr \v*?ibL Geschlecliti*orgaijt\ 18M7, p .>H, in Vlrchow'» namlbucti dcr 
•p«r l*»th<iL ur»n Ther , B'l. yL 

» porn If Arch, de Toroli>j;t.?, IWU, p. 103, Powl, Medical •ntj Sur^tcal Oynceology. 
* Putxi. Medical and Suririea) Gynecology. 



328 TUKOBS, TUBAL PRBGNANCT, MALFOBMATmM& 

cysts of emphvsematous vaginitis contain gas, are usually mnltipk^ 
and do not tolfow the course of G&rtner's ducts. The hernial tumor 
temporarily disappears on pressure and gives an impulse on ooughiiM: 
if the cyst is within easy rsach. the treatment is excision ; if it 
is very close to the rectum, bladderi or ureters, the vaginal aids 
should be remov^, the remainder curetted or cauteriied, and the 
wound packed with gauze. 

Fibromyomate cS the VagbuL 

These tumors differ in no essential point from rimilar growtliB of 
the vulva and uterus. They are of rare occunence, and uaoally 
small, but sometimes are laige enough to give the mechanical symp- 
toms of pressure and weight. The treatment is enucleation. 

Oaroinoma and Sarcoma of the Vagina. 

Carcinoma of the vagina usually occurs by extension from primary 
carcinoma of the cervix, uterus, or rectum ; it seldom oriffinateB in 
the vagina. Sarcoma of the vagina is almost uidmown. The treat* 
ment— early excision — gives most ansatisfeotory results. 




CHAPTER XXVI. 

TUMORS UP THE UTEKUa 
MYOMA. 

Btiolo^, Histology and HistogeneBie, ClaBsification, SyinptoniB, 
DiagTLOsis, Differential DiagrnoBis, Progmosis. 

This tumor, like the uterus, is composted nf fihroiis criinieetive tis- 
iiueftDj non-striated muscle fibres. It is the mu^t eumnion and one 
of the roost important of all uterine tumors. 

Figure 174. 





V. 



CttW i -l t ction of a vMcular myomft, iho wing cave rn<iua aIniuMkI 

Etiology. 

The causes of myoma are not definitely known. The develop- 
Bt belongs to the age of sexual maturity : they rarely if ever occur 

^ Vlrcbow. in button's Tumari«, ItinoccDt and Maljgtinut. 

32W 



S30 



TUMORS, TUBAL PREONANCY, MALFOUMATlOys. 



before puberty or after the mcntjpiiiise ; they are more freqiieut ll 
the !ie)irr*j tlmri in the white raet% Heredity is a ^it^n^g■ etioh>gieal 
fuel or. 

Patholog'ical Anatomy. The tumor i.n usually f^harplj eircum* 
scribf^d, suigle or multiple, Imnl or soft, of pinkish c>r whitish color, 
eoniniouly of slow growth, iiiul in size varies with Id the widest possible 
limits. On cross-seetiou the gross appearance is glistening and mav 
be homogeneous^ but more usually the eut surface is striated witti 
dense fibrous septa whi<'h divide the section into lobules. The spaces 
between the septa arc lilled with muscle fibres. See Figures 175 and 
180. In later development a loose, fibrous capsule is formed which 
simrply defines the growth from iti^ surn>undings. 

The bloiMlveasels of the filjrousciipsule |K'nctrate tlirough tlie septa 
to tlie ouisele cells. These growths are oecasitmally sui>ject to exten- 
sive venous obstruction and to eonsec|uent dilatation of their veins. 
This <iften leads U> the fiu'matirm of cavernous spaces ; hence the blood- 
supi>ly, not only in ditfcrent tumors, but at diflereut times in the same 
tumor, is subject to great variation. This eliangeaijle bliKKl-supply 
aee(»unts for corresponding vn nation from time to time in the size of a 
tumor. Hard white tumors of a slow growtli, containing a relatively 
large amount of filuYUJs tissue, are apt to have n limited blood-supply. 
On the other hand, the soft pinkish tumor of more rapid growth, with 
a relative pre|jondemnce of muscle cells, is always more vast^ular. 

nietoloery and HistoerenesiB. 

The characteristic cell elements are non-striated fusiform muscle 
fibres with clongjited nuclei. These fibres cross one another in all 
directions ; hence the bloodvessels cannot, as in the myometrium, 
run jjarallel with the muscle fibres, but necessarily cross them at all 
angles. These vessels are therefore sixM-ially liable to constriction 
iVi n u the co n t m ct i 1 e n n i sc 1 e fi I > re s , T" li i s a r nmgo n i e n t i s so u n fa \'o ra b le 
to nutriticju tliat in some tunuirs the muscular elements either undergo 
atrojihy or fall short of full develojnnent, The fibrous element, on 
the other hand, being nearer to the uUiraatc blood-supply and l»eing 
more prolific, may increase disproportionately. This partly explains 
the great variation in the relative <juantity of muscular and fibrous 
tissne^ — a variuhon which ranges iVorn a tumor com})osed almost 
wholly of musi'h* fil>res to one entirely comjx>sed of fibrous tissue. 
The latter growth is usually call<*d a fibroma. 

Nothing is known of the histogenesis of these tumors save their 
origin in the my<»blast. This source, regardless of secfHidary changes 
which nuiy modify the relative quantity tif the muscular and connec- 
tive tissue, stamps them as myoniata. Ternis like leiomyonux, fibro- 
myoma, and fibn*ma should be use*l only to designate special character- 
istics. The tujnor does not lose its identity as a myoma even though 
its muscular elements have been replaced by fibrous tissue. 

Leiomyoma^ Flhromyoma^ and Fibroma, The soft vascular tumor 
described in a foregoing pa ragniph, because it contains a large amount 
ol' muscular tissue, has Iwen called a hkmi^oma. The hard, more 



I 



I 




" ■■*^^iare of a myoma. Wavy Iwnndaof lonff Bphidle cellii with r<>«l-shapGd nucleL At one 
point soiiiti cells urti diviacil tmnsverstly. MBKUllicd,* 

^*^ termi^ aiv relative and, to an extent, arbitntry and to be used 
^uly ff^Y convenience of desert pt ion. 

■ Secondary Changes. 

H *I*he secondary chaogea common to ut-erine myomata are as follows ; 
^^^L Fatty degeneration. Septic infeetion. 

^^^P Mucoid and other cystic degeneration. Malignant changes. 
W Calcifieatioo. 

■ - ^atty Defeneration pertains to the muscle iihrcsj and may I'esult 
^ their complete destruction. The blood-sunply may tlien in a 
^^=B^ure be crushed out by the c<uitraction and solidification of the 

J^*"Oiis eoniieelive tis.sne ; the tumor, tlius deprived of nutrition, will 
-ni-^^j. j^j jj^ very hard, small, rudimentary mass. This process niay l>e 
^**^^1 or genend ; it is spt^cially liable to occur in rather small tumors 
^"^ ^ |Kirt of the atropliie changi*s of the menopause; hence numerous 
'^l**>ntaneous cures at this period. 

Mucoid Degeneration is prone to occur in large fibromyomata. 

\h** fibrous tissue is converted to a mucin substance resend>liug the 

^^treous humor of the eye. The conversion of the tissue substauce to 

iftiu^tn is preceded l»y rpdcma and by rapid increase in the size of the 

^Voniii. Sections of the tumor wiiieh form the boundary of the 

^^ftened spaces sh*nv ever}' gradation from fusiform cells to those of 

thi? irregularly branched, spider-like shape to wliieh the term mtfjronm 

oas lu*en given. The j>r«H!ess may result in the formation td' muuerous 

small cyst«, or the tumor may l>e converted into a large spurious cyst 

* American System oroyneeulouy. 




TUMORS, TUBAL PREGXANCT, MALFORMATIONS. 

having for it,s wall tlio fibrous capsnlc of the original myoma. This" 
is cjiIUh:! a /i/>ror?/.sf/r tumor J 

tlvlt'ma may cause j^o iriucli dihitiilion of the lymph hpaces ats to give 
the whok' tuuu>r an apj^earanee of oiarktHl cystic degenenitioD. The 
dilated cavernous veins alrt^dy described may be converted into 
blrMMl-cysts, 

Calcification occurs most frequently in subperitoneal tumors^, both 
lai^ and small. The prf*ces,s may be geueml or locii!, and luay jier- 
tarn to the fibrous septa or to the eajisule. Exceptionally the eutiR* 
tumor is displaced by lime salta and converted into a stone — ^o-called 
womb-stone, A section of such a intone made by the saw will S(*me- 
times take a higli ptdish. The whole arraugement of the fibrous septa 
and capsule will tben apjK^ar reproduced in the lime sidts and will 
identify the tumor. More eomnxmly the spaces between the septa do 

FKnTKE 176. 






m^^Z 



^t 






il<i£ii 



K^^^ 



Ftbrocyatic myoma uteri. The interior of the tumor shows the fibrocystic chiuiget. 

not calcify, but disappear by some other degenerative process. This 
gives the calcified part a porous^ worm-eaten ap|K*arance» or coral-like 
foruK When the calrificatiMU is ehietly or wholly in the fibrous caj>- 
side the tumor is *'overcd by a tliiu, liard crust whirh may closely 
resemble the fietal skull. In the enucleation of such a tnuHjr from 
the corpus uteri the writer once found a i^leifie<l ciipsnle which, 
through the overlying |ieritoneal and subiKTitoneal structures, felt so 

I BlJUicl Sutton, Tiimort, Innwent and Miill^nniit. 



TUm)RS OF THE UTERUS^MYOMA 



ranch like a fcetal head — ^siiture:?, funtaiielles, and all— tliat for fear 
of preguancy he was almost led iu aliaiidoii the openuioii.' 

Septic Infection. A niyonia wliieh lias ftjr years )^iveo rise to no 
inc4mvvnieiice tnay suddenly lieeonie inftM-litL This will cause rapid 
ineivase in size, hi|^li juilse and terufjeniture, ^reat pain, and tit her 
evidences of septir-jernia. The moile of infection, stjnR'tinies obscure, 
is usually explaine<l by the pn^sence of one or more of the usual 
causevi of pel vie inflauinuition. The electrode and the unclean intra- 
iilcrine snund arr^ potent causes. Extt^nal violence ot'ten jirecedes 
the infeetiiUK (Kiplioreetrnny ])erfi)nued ibr the purp*)se of antici- 
jKilin^ (lie menopause, osmosis <*f Unit! an^l tjjas from an adherent 
intt*stine or blad*ler, are possible sources of intiu'tton. A fatal residt 
is almt>st inevitable unless the diagnosis is made early and the tumor 
h*mnve«l/' 

Malignant Changes due to carcinoma and sarcoma will be con- 
siJcre*! under tlmsc subjects, Chapters XXIX. and XXX, 

Claaslflcation. 

Location. The tumor may be anywhere in the uterine substance, 
but in the majority of eases it is in tlu^ brnly id' tlie iitf^rus. Tumors 
of the cervix uteri are apt to be small, those of tlie corpus larger. 




334 



TmfORS, TUBAL FREGNANCT, MALFORMATIONS. 



The fbllowing cki^i^i fixation ib from the rej^ional staDclftoint* 

Intrniiiiiral niyomiitii. Suhpt'ritoneal iiiy<jmata. 

SuliinuccHis iiiyoniatii. CVrvi<^al inyoeiiala. 

Jnfviimurid Mi^omatn, Any nenpkism sitiinR*d in iUv niuseiA 
wall of t\w utoriis — tliat is, in tlir iiiyumetriiim — Is an intmrnta 
tiiinijr. It iiiiiy bo anywiien^ lietwetm the nuicoiis liuiiig and '^_ 
serotLs coveritig. A gniwth, which to external examination ap|ie-a: 
to be one tnmor, on section proves to be u gronji of two or njore t i 
tinet tumors, each having iLs owu capsule. The intranioral tnmom^ 



J 




rrYil 



Shnpe of Abdomen m»de by multiple royoms with thin alKlocnlnAl walU. A maiigiuiiic Kn>wth 

mlglic have 11 Bi>iii]illar iiiifH^iirAiice. 

wholly snrroundetl by Ihc imiseular wall ' of the nteni.s ; this accounts 
for the fjreater blnfKl->Hpf»Iy antl more nijiid ^rmwth. The (jmw^th is 
UMially firm, sharply definrd^ and eneapnulated ; Init may Ik* .soft^ ill- 
defined, and withcmt a detfnite eapsule. The tumor will always irri* 
tatt' the snrroniitlio^ nHiS4idar tissues, aiul cause thcni to rt>ntnici 
UjHin it. If it !K ncaNT tu the endmnctrrnin than tu thc^ fieri tuaeum^ 
the |»r<'pondcrancr of mnscidar tissue on the |K*ntoneal side will slowly 
foree it toward the interior «*f tlic nterns and tend to make of it a sub- 
mneons tnmor. If the pn^jKHidenince of mnsc»tdar tissue is between 
the lim?or ami the endoou'trinm, tlie din»etron of least resistance will 
\w toward the iM^rit(»neuni, and the gn*wMh will tend to l>econie Hib- 
[M'ritt»neah 

Sii(nnnrtifu< Mt/tmmht may oriprinate in tlie miiseular tissue of the 

mu(*4»sa, and he, then*fon\ primarily submucous; or an inlramuRiI 

tuiuiir may, as explainctl iu ihc foregoing panigniph, become* j*econd» 

Hfily fiubmneons. The secondarily sulmiueons tnnjor h apt to renmiri 

1 Button. Tumori, Innocent mml B<^nli:n. 




Multiple m^omatA. 



vary in size within wide limits, and hy their presence the uterine 
cavity may Boroetinies beeonio cnormuiiKlv tlistendefJ, Uterine e«»n- 
tract inn, morenver, may fon-v tlic tniimr thnnij^^!! the cMi^rvix uteri intoj 
the vagina^ ami cornet imu> the |M'dieh% hy this downward fnrt*e, 
becomeh 8o elungated that the <*xtrit(hni!: niasw is evrn fin^'ed thnjugh i 
the vulva* Inversion of the uterus is a |M>^?iil>h' result of tncj 



TUMORS OF THE UTEBUS^MYOMA. 



337 



'downward tniction upon the fandus nten of tlie extruding mibmiieous 
tumor. The petlicte may bt^ const riet*^! l>y {>rt^<sure of the cervical 
canal, or may become twisted, lliis wuiild caiLse tedema, and nii^lit, 
by diiting off the circulation, result in gangR^ne of tlic tumt)r. 
Gangrene may be followed by sj>ontaneous and detachment cure. 
Usually, however, the extrudt^l mass remains, {ind, in ('(m,se(|uence uf 
tlie o?dema, gangrene or prolfinged uteriuc hemorrhage l)ecmneK a 
menace to health or a destroyer of life. 

Subperlfoneaf 3/j/o//w/ff^some times called subsenuLs — may l)e either 
single or multiple, and oci^sionally reach the cnormoun size of forty 
or fifty pounds. Such a tumor may work its way some distance 
from tfie point of origin between the folds of the broad ligjiment, and 
become an intraligamentous myoma uteri.' The subserous tumor 
bears tlie same relations to the peritoneum tluit the submucous mynma 
bears to the euilometrium — /. t\, it may have lieeu primarily sulisennis^ 
or an inti-amural tumor may have l>een forced outward by uterine 
c^mtnictions until it has beennie Heeontlarily subperitimeal. A tunmr 
primarily subperitonealj if of large size, is pedunculated ; if seectiidarily 
subperitoneal, it is more apt to remain sessile, A peduocnlated sub- 
serous tumor may, in rare cases, become ilctached from tlic uterus and 
remain as a migrating tumor, free and harmless in the abdominal 
cavity, or may receive its nutrition thruugh new adhesions which 
ha%'e formed between it and Bome of the pelvic or abdominal viscera. 

Jltfomaia of th^ Cemx Uteri are of rather infrequent wcurrenee. 
They folhnv the .same law as to development and hicatinii as myoruata 
of tlie IxmIv of the uterus. Subserous growths may sjiriug from the 
supnivaginal portion of the cervix, Mvomata rarely appear on the 
vaginal portion, A siibraucous cervical niyi)nia is usually petluncu- 
hited. it may have the appearance of a uterus inverte*! into the 
vjigina. See Inversion of the Uterus, An interstitial cervical 
myorua e^iuses by its presence a thickening of the ccrvteal wall around 
itj and by pressure and stretching a corresponding thinning of the 
opposite wall, 

Symptonus, 

The chief symptoms may be described under the following heads; 

Hemorrhage. Congestion, Pain and diseoinfbrt. 

Pressure and traction. Miscellaneous symptoms. 

Hemorrhage J the most inifwrtant tind the most pronouncetl symp- 
tom, begins not as a suddt-n, profuse fltnv, as in wircinonia, but as a 
graflual increase in menstruation ; the bleeding occurs frequently, is 
prolongwl, and from ordinary conditicuis, such as exercise or coitus, is 
easily excited. The irritating presence of the tumor sets up a hem- 
orrhagic endometritis, the hemorrhagic area being the cndtmietrium, 
not, as sometimes supposed, the tumor itself. Nor is the hemorrhage 
8j)e<'ially confined to the mucous covering of the tumor. Fatal hem- 
orrhage, however, has t>ccijrred from rupture t)f a bloodvessel in the 
growtlu* 



I Delafleld and Pnidden. Pwitliolojjiral Anntomy and lIEstology. 
t Duucan^ Edlnbuiigli Medioil Journal, nSiST. Piixatl. 



22 




338 TUMORS, TUBAL PE EG NANCY, MALFOEMATION& 

The degree of hemorrhage de|>piids iipon the hieatioii of the tumor 
retative to the endometrium and the peritoneum. The eloser its rela- 
tions to the iiterim^ mucosa the greater the hemorrhage; tlie mmrer 
to the peritoneum the leSvS the [lemorrliage ; lienee meuorrhagia it* 
almost hi variable with the suhmiieous variety, lei^s severe but \cry 
eommrm with the intmniunil, and usually sligljt or absi-ut with the 
sid*|H'ritoneaL The peduneulatetl submucous and the pedunculated 
subperitoneal myoniata stand at the two extremes, the former pro- 
dueing the greatest hemorrhage, tlie latter none at all. 



Siibmurijus polypoid mjoniA reflembilug aq iciTertcd utenia. 

The presenee of a myoma often delays, prfdtings, or prevents the 
menopause. The tumor, howe%*€r, may participate in the atrophic 
prtK-esses of this crisis, and become mueh smaller, or may even disa(>- 
[Mmr, Sometimes the menojmus*" lias the opposite efieet — *\ r., great 
anil sudden increase of gnmth. This is a strong indieatirm for myo- 
nuH'tomy or hysterectomy. 

Preeeure and Traction eiuise numerous mechanical and other dis- 
tnrbanees of the rc*etum, bladder, ureters, urethra, and of the uterus 
itself. Among these are hemorrhoids, constipation, rectal and vesical 
tenesmus, mucous diarrlnva, trcf|uent urination, dysuria, retention of 
urine, and uterine displacements. Pressure iipou tlu* venous trunks 




TUMORS OF THE UTERUS—MYOMA. 



339 



often rausrs groiit tlihitation of the voiiis ami passive conpjestion 
throiiglioiit the |K^ivi.s. Tliis netH^ssarily impairs tlie nutrition of the 
pelvic or^aiiJ4. Occhision of a ureter by piussiire has caused hydro- 
nephrosit?.^ 

A myoma in the anterior uterine wall, even though small, miiy^ hy 
pressure, cau.^e extreme vesical irritation, aiul may even he a eause of 
cystitis, Snppres.sion of urine i'rnni pressin^e or traetioiij espeeially if 
an unclean catheter he iisedj is another cause of cystitis. Frequently 
a myoma becomes iuearcerated under the promontory of the saerimi 
and continues to grow there. The pressure-symptoms, unless the 
tumor is sjjontaueously or manually forced up into the aljdominal 
canity, will then he intense. In sucli a case there will be great pain 
and interference with functions ni>t onh' in the jR^lvis, but also in the 
thighs and legs* 

Uterine displacements may result from pressni-e, traction, and 
increased weight. A tumor situatefl above, Ix^low, to eidier mtle, in 
front, or back of the uterus may force it in the ojiptjsite direction, or 
raav draw it hy traction in the same direction, or, by increasing the 
weight of the uterus, may eiuise prolaj)se. A myoma, lor example, 
which has grown too large tor the pelvis to hold it, and has there- 
fore risen into the ahdfjmen, will cause by traction upward displace- 
ment. 

The Pain and Discomfort incident to this affection have been 
|iartin Hy described in the f«iregoing paragraphs under Pressure and 
Traetiiin, Baekar^hc, bearing-down, dragging sensations in the |K^lvis, 
and painful uterine contractions are familiar subjective symptoms. 
Expulsive contraetitajs of the uterus upon a mural or submucous 
myoma, especially during the |>eriml of menstrual congestion and 
irritation, may be transient or constant, mcKlerate or severer 

Miscellaneoua Symptoms. lutermenstrmil uterine discharges 
usually occur in the progress of the disease. They may be purulent 
or serous, or both ; they are eonim(*nly mixed with Ijlood, anil are 
often profuse and exhausting. The watery di.sfjharge — ^hydrorrho^a — 
so commonly associated with malignant disease is very infrequent; 
when present it is more transient and less oBensive thafi in cancer or 
sarcoma. Dvsmenorrhcea is common. 



Diagnoeis. 

Uterine myomata, unless very small and associate^l with metritis, 
are usually not diifieult to n^cognis^e. The symptoms outlined in the 
foregoing paragraphs, althongh diagnostic, are far fmm pathogno- 
monic. The diagnosis will always dejiend upon the physi(*al signs— 
that is, n[»on inspection, paljjatinn, conJoincHl exanunatit^n, and ex- 
ploration of the uterine cavity. Se*^ dui}>ter III., on Diagnosis. 

Inspection and Palpation will show enliirgement of the alKlomen, 
unless the tumor is too small to produce that result. External juilpa- 
tlon» if the tunn^r is large, discloses in the pelvis and lower abdnnu*n 
a solid, ususdly hard, though sora<^times stjft mass. Exceptionally, 

* Murphy, Lomloti J4nirriiil <jf Mtdllilne, October, l8Jy. From, Poxxi. 



340 



TUMORS, TUBAL PREGNANCY, MALFORMATIONS, 



the growth hits u jieculitir ehistieity wfiich resemblos fl net nut ion. The 
percussion- wavt^ |>cfMiIiar in ovarian evst.^, however, i?; aUsent, The 
tiHiKir nuiy be siiip^le and syniinetrieal, gh>l>nhir, c»r ol)hn»g. The 
presence of multiple niyoinata niay, with llieir inmierous projections, 
give to the uterus a nit*st irreguhir form. Many small tumors may 
be distril>uted 8o evenly throughout the uterine walls as to eaus^e a 
nearly symmetriea! enlargement of the uterus. In sueli a easi% Iuyw- 
cner, llie snrfaee usually gives to the toneli a sensation of small ntxUi- 
lar irregularities. Iiis|)eetion, pal]>ation, aiul ptavussjon will be 
fnrtiier considered in e<umectiou with the diHereutia! diagnosis. 

Coiyoined Exainination. The inde.x or the index aud mitldle 
finders in the vagina, tlie palmar surface directed toward the nierus 
and tnmru", aud the paljKating finger of the right liaud over the 
ahdomen, will, if the abdoniiual nuiseles are not toy tense^ enal>le the 
o|MTator ty (HOlitu* the uterus and its myomatous pni^jeetions. In 
the majority of cases ordinary eoujfuned <'xami nation will complete 
the diagnosis. The palpation is often mucli facilitated by meann of 
tlie thumb in tlie vagina an<I the index-linger in the reetiuu. This 
enables the ojKTalor to \\lvk up, so to speak, the eidarged uterus 
between the tlnuub ami linger. Iid'ormatiuu through the examin- 
ing finger is ohtaineil not so mueli hy fin\'ing it up agjuiist the 
tiuuor ii^ hy strong pressure of the tnuitu* agiunst it l>y means of the 
right hand over the abdumeu. If tliu alHlondnal walls arc rigid or 
thick, ana?sthesia may be necessary. 

Intra-uterine Exploration ik made by the finger, the sound, r^r the 
curette. Digital exploration of tlie interior of the uterus is possilde 
only %vlien the nterineeana! is filiated. The dilatation nmy l)c hnuight 
abotU hy instrnmental uu-aus or by expulsive uterine contractions 
upon an intra-uterine tumor, which may have the effect of fon-ing it 
out. The iudex-fiuger in the tltlated uti'rus will recognize liy din-ct 
touch the presence and eltaraeter of an intni-nterine myoma, and may 
materially aid in its renntval. 

The Sound and Curette. Thv one phif^kai sign constant for all 
ntirine niijmmtht h eiotif/ation of (he idvnne eariftf. Tlie inereased 
Icngtii is [jroportiouate to the size of the timior, and may reach se%*cn 
or more inches. The sound is often necessary to measure this length, 
A Buhnuieons tumor may, imless great care is used, olxstruet the pa?-- 
^iage of the sound and lead to a wrong nieasurenient, Sulunueous and 
iutrauniral tiuuors priijn-r into the uterine eavity, and tliereby render 
the ruerine canal tortuous. Ilcuce the sound or jirohc will Ik» ile- 
flectcfl, and as it glides over the growth thedefleeti(m will indicate the 
size of tiie growtli, the degree to which it |>nijcets into the uterine 
cavity, anil th*' dr|iih of the uterus with whicli it is connected. The 
cnrette is useful tor certain purpt^ses uf diflercntial diagnosis and will 
be further considered nr»<ler that head. 

Differential Diagrnosis. 

The principal lesions frotn which myoma must he differentiated are 
the following : 




TihUORS OF THE UTERUS^MYOMA. 



341 



Normal pregoatncy. 
CarciuotiKi \uu\ smrcoma. 

Iiivension of tin* ut<*riis. 
Uterine displacements. 
Incomplete abortion. 



Ovary. 

Pelvic infill mtirm.s. 
Pelvic cyst8, 
Ssietosalpinx. 
Tubal jiregnancj. 
Floating kidney. 



Pregnancy. Normal irtero-gestation will l»e excltidetl by the ab- 
sence of tbc nsiitd fsigns of prc^rnuicy. The ditlieulties in diagnosis 
will enmmonly arise in al>ni^rnial jnvgnaneies, esjH'cially in placenta 
pnevia and iii psendo-nien^trnatii>n etjnnected with pregnancy. If the 
enlarjj^'inent of the n terns lie synirnetrie^l and the rate of growth 
usual for a pregnant uterus, and the* os be soft and patulous, pregnancy 
is highly probable. If, xm the other hand, the cervix be hard, the os 
non- patulous, and the uterus irregular in outline from the presence of 
a hard, resisting mass, the diagnosis is probably myoma. In doubtful 



FiGU&B 183. 



X 



\£^%^ 



Anteflexion of the u tenia ilmulmttng myoma. 

the myoma, if present, will under observation declare itself by 
llatively slow gn^vvth. Tlie j>os,sible coexistence of pregnancy 
and myoma slnadd 1h; kept in mind. 

Carcinoma and Sarcoma. Tlie e%'idences of malignant disease, 
inchuling tbe sudden unset i>i' hydrorrlKcn, tlie blocMly, fetiil discharge, 
the rapid cnniciation, and tlie niierosctjjjie (inding of can*inoina or 
sare^Hiia in the .scampi nga, will definitely exclude myoma, A slough- 



342 



TUMORS, TUBAL FEEONANCY, MALFORMATION& 



ing, extruding myoma may, however, both in the profuse fetid dis- 
chiiri:;eniKl in tlie seusatiuo to the examiner on touch, elosely resemble 
etireioonia or .sarcoma of the eervix. The tliagnosis tUeu will defjeiid 
on the micro^eope. 

Metritis often corajilieates uterine myomata, and is diffieult, often 
impossible, to dilfen^ntiate from t^niall, multipl*% interstitial growths. 
The gvmmetrieal form of the uteruH irf the distinguishing feature of 
metritis. See Figure 1H5, 

Inversion of ^a Uterus, A uterine myoma protruding into the 



Myom* BtmuUUnR antoflexion of the ulerof. 



vagina may haye the appearanee of an inverted uterus. The sound 
will then glide past the tumor into the utenis above. Conjoined 
reeto-abdominal exa mi nation will deinonstnite tlie absenee of the 
uterus in its normal locaticju if it lie inverted into the vagina. See 
Inversion of the Uterus, Sec Figure 182. 

Displacements of the Uterus are reeognized on conjoined exami- 
nation l>y the svmmetrieal eontoor of the utenis aud l>y tin* ehauge in 
the direetion of tiic uterine eanal as demonstriited by the 8ound, 

Inconaplete Abortion with hemtu'rliagt^ will be iveognized by the 
history of the interrupted pregnaney and by mieroscopic examination 
of the serapings. 

The Ovary, espeeially if adherent to thr ut^-rus, sometimes simu* 



TUMORS OF THE UTERUS— MYOMA. 



343 



lates a small pedunculalctl fiuhscrous iiiyoiiia. The myoma, liowever, 
is smuother, moro lirm, aiul less sensitive to pressure. 

Pelvic Inflanimatory Infiltrations, unlike iiiyoniata, always ^nve 
a history of pelvic inHamniatioii, are very tender on jiressure, immo- 
bile, and prone to disap|>ear by resolution or to umlcr^r^ suppuration. 

Pelvic Cysts are distiuguishe<l from myomata by flnctuatioji, by 
their indepeutleuce of tbe uterus, by their more rapid growtli, by tlie 
tiormal (jr ueiirly jioruml length of the uterine eiivity, and by the 
absem-e of uterine hemorrhage, 

Sactosalpinx develops more nip idly, is commonly situated at tlie 
side of the uterus, is of ekuigateti ovoid fornij is fluctuating, is more 
or less tender on pi-essure, and dt>es not cause material enlargement 
of tlie uterine Liavity. 

Ectopic Pregnancy gives a history of gestation. The gestation- 
8ae clo>eIy resembles siictoi^lpinx. Ru)>ture of the tube pnxluces 
pelvic liicmatocele. A deeidna may be cast out of the uterus. The 
reader is referred to Figures 127, 12!>, and 130. 

Floating Kidney, unless ailherent, is readily replaced ; it has the 
form of a kidney, and may be tender on pressure. 



Pro^noBis. 

Myoma may be present throughout the [period of sexual activity 
and produce no subjective symptoms, or it may give rise to the symp- 
toms already outlined. It may particijmte in senile atrophy of the 
reprothictive organs at the meno^iause or in involution after prcg- 
nancVj and tims become much smaller or disappear. On the other 
h a n 1 1 , it n i ay a t e i t h e r of th cse t i ni es grc > w f a rger. 1 1 n s ua 1 1 y de ve I ops 
rapidly during gestation. Even small growths^ if near the emlome- 
trium, nmy threaten life from hemorrhage. Couiplie^iting cardiac and 
renal diseases render the prognosis more gnive. The causes of death 
include hemorrhage, sepsis, |K*ritouitis, and sectuidary changes in the 
tumor itiiclf. The prognosis after operation is outlined in the next 
chapter. 



CHAPTER XXVII. 

TUM0R8 OF THE UTERUS (Continued). 

TREATMENT OF MYOMA. 

The trwitinent includes nieclicatioiij nianipuliitions, intm-uterine 

tJiiiiiHUiiuk, intni-ulerine i^typtics, eleetrolysi!?, ainl i^ui^ical operations. 
Tlie tit^atmeiit is, therefore, mni- surgical and surgical. 



NoiiH3urgieal Treataient. 
1. Medication. 
2^ jManipuhitirmH. 
3* Intra-ulerine tamponade. 

4. Intni-utenne styptics, 

5. Eicetrolysis, 

1. Medication* Erjiot stands at the head af the numerous drugs 
that have l)een used iu the treatment of uterine mvoma. Indeed, 
no otiier drug, save prjssibly hydnistis t^na<lensis, has any s|H^riaI 
value. The latter is Kiid to have ?5f>me power to control hemorrhage. 
The effect uf ergot is to reinforce the natural modes of cure. Ita 
possible action is : 

(t. Ergot may stiniuhitt* the uterine museuhiris to eontmct on a 
myrnna or its pwHcle so as t(» cut off nutrition aTid produce atropliy or 
g:ingrcne of the tumor. Tlie gangrtmous tumor, unless expelled or 
renuived, is a source of gn^it danger. 

b. If tlic myoma is sidHniicous or intramuml and near the endome- 
trium, the a*'tiun of the drug may sf) increase the expulsive power of 
the myomctrintn as to ex|>tl iln- tumor *>r force it to a hiwer level, 
and thcreivy simplify its surgical removal, 

c. If the myoma is subp^/ritoneal or intramural and near the j>cri- 
toneunij the iuereased uterine eontraetions may force it further out-- 
wan! and result in the formation ai' a ]K*<liele. This would relieve 
the myometrium nf tlie irritating presence of the tumor, stop the 
bleeding, and diminish the pain, 

(f. Ergot is saiil to diminish the hlood-supply to the uterus, and 
thereby control hemorrhage in two ways— first, by eontrat^tion of tJie 
uterine museulnris ; second, by c(»ntraction of the bloodvessels. 

The value of ergt>t as a means of mdical cure is strictly limited; 
its power to cxjm'I the tumor is chiefly confiTJcd to the sim|jle huI»- 
pi*ntoneal fK*dnu<'ulated myoniata, whi(*b yield miist rapidly and 
readily to surgitM\l measures, (fiingrcne of an intnimural tumor 
is a po,ssible resnlt of the use of ergot, and the drug is, in such 
cases, more dangerous than the fiurgieal removal of the tumor, 

344 



TU}foRS OF THE UTERUS^MYOMA, 



345 



Ergot is chiefly vahiiiljle in tontnilliog honiorrluig^'j ami theroby pre- 
serving the vitality uf the imtient until relief may VAmuj with the 
oienojKiuse or wit!i surgical renioval. This iintieati^ni is stninger 
during the itienstniul week. The drug, if loiig euntirmed, is not well 
borne by the .stoniaeh ; he nee it shoiiKl be given either by hypodermic 
injection or by reeUil .snppi^sitories. The dose is det<^nnined by the 
effect. If use<l at all, enougli should l)c given tocontrtil the bleed- 
ing. Tile ice-bag over the hyjM^gustnuni is a valuabie aid to ergot, 

2. Manipulations. Sometimes a myoma becftniei? incarcerated in 
the small pelvis. Two results may follow: first, serious pressure- 
symptoms; second, a^lema <jf the tumor. The immediate indie^ition 
is to force the tumor np into the abdomen. This is done by the finger 
or tiugers of the lett hand in the vagina or rectum. The kuee-breast 
positirm is most favorable to this tnnitmeut. Anaesthesia may be 
necessary. In some cases the tuniur is [)rnne to fall into the pelvis 
minor and to eause great mechani<'al distnrlmnccSj so that daily re- 
placement is necessary. If the tumor is not rephiceable and pi*esianre 
symptoms are urgent, its removal may l>e imperative, 

3. Intra-uterine Tamponade. When hemorrhage is |>rofnse and 
exhausting the most effective means r>f tem[Hirary lucmosta.sis is by 
intra-utcrine tam[>onade. Its ap]>bcatiou is l>est made tlirough Sims^ 
specnbuu with the patient in the left latcro-f>rone positii^n. St»e 
Chapter IV. In aggravated CJises it is ueeessary to repeat the tampon 
fievx^ral times at each menstruation, A cfmtinnous strip of aseptic 
gauxe should be tightly packed into the uterus, es]tecially into the 
i -e r \' i ( -a 1 ea v i ty . T 1 j *^ ]>ac k i n g s h o i d d be re m o vc d e v e ry \\ >r ty - e i gl \ i 
hours until the flow has ceased. In tlvis way an exhausted exsangui- 
nated patient miiy in a few wveks regain str^'Ugtli to endure the radi- 
cal opemtion. This treatment in the luimis of the author has in one 
case been followed not only by entire relief of nienorrhagia, but bv 
the almost total flisnpjK^arancc of the tumor. The tampon was uscil 
during three consecutive nH:*ustruations, and the tun)or was red need 
fnnn the size of a child's head to that <y? a hen's egg. Tlu* age <if 
the patient, forty-five years, and the near a)>proaf*li of the meim- 
pause may partially, at least, aeenunt for the result. 

4. Intra-uterine Styptics, such as Churehiirs tincture t»f iodine, 
solution of iron persulphate, and the 10 per cent. sohiHon of anttpy- 
riiie, may be injected irrlo the uterus for the control *»f heruorrliage. 
Tliese agents, especially tlu" iron persulphate, are af*t to bu^m hai*il 
bloo<l-clots,w^hich may become scptie autl therefore daugerfMis. The 
method is altogether inferior to that of t;unptuiade, 

5. Electrolysis. The [M^rsonal ex|*eriem'e an<l observaticm of the 
writer, extending over several years, have hnl him to the following 
conclusions: P^'irst, currents strong emuigli to he effective are often 
so excessively painful as to be intolerable; second, the agent in a 
limited number cd' scleeted ^ases of intramural tumors is e^qKible of 
giving more iw less rcdief from the symptoms of hemorrhage and 
pain; thinl, appreciable and pcrmaneut reduction in the size of the 
tumor is an nnnsna! result; fonrtli, disappciirancc of the tmnor as a 
result of electrolvsis seldom occurs. In one case the WTitcr observed 




346 TUMORS, TUBAL PREGNANCY, MALFOEMATIONS. 

till* disappearanofi of an iiitraTiuiml soft myi>ma after about twenty 
elwtrolytie treatments, the current varyin;? from one hundred to two 
huiidnMl and forty-iw<* milhamf>^res. The cure in this c*ase n]a\\ 
however, liavo iK'cn duo to the nieiifipaiise, whieh was etjineidi-nt with 
the ireatnteiit* The observations of Vineber*j^^ iijKvn tlie statisties of 
Keith, En^ehnanii, (xautier, and other eminent eWtro-tberajxMitistf*, 
show three hundR'd and seventy-two cases with nine eure^ and five 
deaths — an exee,ssiive mortality when ermtrasted with the limited 
number of cures, (jalvano-puneture ami electrolysis in iibroevt^ts 
are stmngly con^lemued. The earlier promises of the enthusiastic 
siip|Mirters of electrolysis have not been fulfilled. Its immediate 
doiiji^ers also are considenible. The survival of the electrical methotl 
in ^fyneeology depends ehiefly upon the fxilient's ignorance of its 
inadequacy and dangers, upon lier worship of the mysterious, upon 
an unreasoning dread of o|ierative measui^es, and upon a desire to 
grasp any uther jjromising means of relief. 

Surgical Treatment. 

It would be iniprofitable to enlarge upon a great variety of pro- 
cedures which have become or seem destintnl to Irf'conie f>bsolete. 
The more uhefiil ojierations for the treatment of fibromyoraata of the 
uterus will be divided a* fulhjws : 

1, Palliati%*e oj>e rat ions. 

2* Kadieal vngina! operations. 

3. Kadieal abdominal operations. 

1. Palliative Operatioxs. 

The pdliative operations are : a. Curettage* b. Ligature of the 
uterine arteries and broad ligaments, c. Removal of the uterine 
appc^ndages. 

a. Curettage. The irritating pre**enee of the tumor often gives 
rise to hemorrhagic endometritis. Curettage is then^fore indieated 
precisrdv as it wcnd^l be in hemorrhagic endometritis from any other 
auise. The ojM*ration is genr rally followed by sf>me relief from tlie 
n»enorrhagia, init is seldom pennanent in its results, and must usu- 
ally, therefore, be repeatcnl again and again. It is esiH^eiidly useful in 
t^iunection with iutm-uterine gaujie tamfmnade to control hetjiorrhnge 
until an exhausted patient cun gain IiIo*k1 and strength for a more 
rtidical ojRTation, or, in eases of small tinuors, until the menopause 
has passtnL Curettage of the niyomat(»us uterus gives increaseil 
danger of sepsis ; henee the necessity tor strict antiseptic eaiT. For 
a deseri|»tJon of eun^ttage, see Cha)>ter IV. 

i. Ligature of the Uterine Arteries and Broad Ligaments. 
The pur(»ose of these measures is to sliut ofl' the blood-su]iply to tlie 
uterus, and* by tins nutans, to iuiluee atrophy of the growth. Gott- 
schalk, »»f Berlin, reports cases of nndtiple myoma in wliieh he ligti- 
tured tlie uterine arteries with good results. Martin ligatures the 
» Americitn Tex I -book or Gynecology. 




TUMORS OF THE UTERUS-^M VOMA, 



347 



whole base of the br^wl ligament .^o as to include not only the uterine 
artery, Init its hnuiehes aitti eertaiu uterhie nerves. Me even gt>es so 
fur in ile.speratc cases as to ligature also the ovarian artery on one 
siile. Robinson reports siieeessfnl eases in whieli he lias ligatured the 
Fallopian tubes and broad ligaments^ including the 4jvarian and uter- 
ine arteries on both sides. The method has hitherto failed to elieit 
mneh diseussiiKi, Even its authors of late preserve on the subject 
an uniinnns silence. 

c. Bemoval of the Uterine Appendages. This procedure, which 
suggests the names of Battey, Hegar, and Tait, when properly carried 
out—/, e., when the ligatures are (>laeed close to ilie uterus so as to 
inelutlc a large part of the broad ligament — usually stops the liemor* 
rliage and n'duces the tum<^r, sometimes even causing it to disappear* 
It^ *langers, however, are nearly if not (juite as great as those of the 
more mdieal operatiiuis. This is especially true since the teehnicjiie 
of the latter has now been perfected, lieiuoval of the ovaries and 
Fallopian tuljes for myomata is alniost an obsolete operation ; at 
leiLstj it will be perfi^rnietl only in rare ca^es of small tumors in 
whichj for some special reason, hysterectomy and myomectomy are 
inadvisable. 

2. Radical Vagina i. Operations. 

The vaginal o]>enition is preferable when the tumor can be reaflily 
reached by that route. All cervie^il fibroids, all intra-^uterine pedun- 
culated fibroids, and some of the int^re accessible submn(*fHis fibroids, 
have usually been removed by way of the vagina. In their removal 
the ecraseur and galvano-eautery, so often used fi>r luemostasls, are 
unnecessary, because the hemorrhage is either nf>t feared or can be 
readily controlled by the uterine tampon. The vaginal route has 
usually been reserved tor tumors of a size not larger than the 
capacity of the small |x4vis. 

The radical vaginal operations are; ff. Ilemt*val of small pedun- 
culated intra-uterine myomata. 6. A^aginal liystereetomy. (\ Vaginal 
enucleation and moreellation, 

a. Removal of Small Pedunculated Myomata. When the 
uterus is dilated, either by uterine eontraction on the tumor or by in- 
strumental mrans, the pc<lunculated tumor is seizeil by the vulsellum 
forceps or bullet fon*eps, flraw^n th>wn, and removed by the scissors* 
The uterus U then packed with aseptic giuiKe. 

6. Vaginal Hysterectomy. When numerous small tumors are 
scattered throughout the uterus, and the number is so large that indi- 
vidual enucleiition is impossible, and wiien, moreover, the uterus is 
not to(» large to be delivered through tlie vngina, it may be i-enioved 
entire by vaginnl hysterect<uny. The f»perati<ui is the same as vaginal 
hy s t e re e to m y fo r en re i n o m a. iSe o V ha f ft e r XXIX. De 1 i ve ry t h n 1 1 igli 
the vagina sonnet imes pi^\sents unexpeete*l dillieulties. The surgeon 
should therefore l>c prefjai^r'd for a supplemental alnlomiual section. 

c. Vaginal Enucleation and Moreellation. Intrtimunil myotnata, 
especially if situated in the lower segments of tlu* wirpus or in tlie 
cervix uteri, and not Um large, may be safely enucleated and removed 



340 



TUMORS, TUBAL PREGyASCT, MALFORMATIOSS. 



tliniiigh the vagina. Latterly the vaginal method has been often and 
«M»e@gfully lifted by cenain French .^nr^iim. for the removal uf quite 
large tumoi^« Their removal is aecumpli-he*! by rej>f*atedly jH-izing 
the prei^enting pirt of the tumor with the vuLrellum forceps and cut- 
ting away as lai^e a piece as possible with the scisi^ors, one piece after 
another, until the whole ttimor has been removed. This is the opera- 
tion by traction and morcellement or morcellation* The metlitxl, 
although generally supjwjsed to be of more recent origin, wag virtu- 
ally deseril3ed by Thomas Addis Emmet more than thirty years ago, 
and has been constantly advocated and practised by him ever siucxf. 



X; 




Muttijile mymnm c^ 



If recto ray, » 



It IS applicable to those cases in which the tumor is accessible through 
the vsj^'ina, liut too large to be ermrleuted and debvered entire. 

TIh' i>|M/nition of tnictiim nml mfmx'lktioii, ^\]ipu its technique is 
more jxciKTally iindi'rstoo<l and its advaiitaije?; more appreciate*!, will 
nndoylitcdly hci^onie more and n»ore ;i [iroccHltire of cicetitm in plii*^^ 
of hysterectomy. Many large siihni neons or mnral tniiiorS| lor wliich 
the abdvimen is now o|>t*ned and the ntenis saerifice<l, may be nipidly» 
safi'tyy and effectually n^movcd by this nictlicMl, 

One strong cnntraiiHlieatinn to the vaginal roirtr must always be, 
however, tlie possible |ircscnee of ])ns tul>es or ovjirian abscesses, so 
c*ftcu unrecognized or unreeognizahle when they CM'cur in connection 
witli large, in*cgular filiromy^miata. Oftentimes an tinsnspt^ted pus 
tulx' lias been ruptured by the enucleation or niorc(*llation of a 

' Km Hit t. I'ntulijli'B and rnictiee uf Uyiieeology, 



TUMORS OF THE UTEEUS^MYOiyA. 



351 



or by morcellatitm. If llie tnmnr be of muml origin, it may be 
neee^saiy to diviile tht* tniicous membrane and s!il)jacent musfiilar 
tissue before comnieiiein^ the cnticleation. Thiri ineisitm should be 
pamlk'I to the uterine eanal. 

The writer liaa made use of an improvement upon tlie two lateral 
incisions;. It is a simph^ median ineision through the anterior wall 
of the uterus arid is made as toUowi^ ;' 

L Make a eireular ineision in front uf the uterus whieli ?jhall 
:^eiianite the vagiual wall from the cervix at the utero- vaginal attach- 
ment, as shown in Figure 188. 

2, Incise tlie anterior vaginal wall from the mid* lie i>oint of the 
first ineision for a distance of about one inch, taking care not to 
invade the hkuUIer and to avoid tlie ureters on eitlier side. These 
incisions an^ the same as for anterior vaginal section, describeil in 
Chapter XXIIL 

3. S<^[iarate the bladder from the uterus by means of the finger or 
some hi nut instrument, keeping close to the uterus until the peri- 
toneum is reached, but not divifled. Tlien expose with retractors or 
fingers the anterior wall of the uterus. Figure 189. 

FiornE 190. 



B 



\'ulaeUum forceps. A. Reduced slate. B. Section of fun siic. 

4. Divide the anterior wall of the uterus longitudinally in the 
median line by means of scissors to whatever extent it may be neces- 
sary to render the tumor accessible. Figure 18P. If necessary the 
peritoneum may be opened and the itjcisiou carried up into the corpus 
uteri. 

This simple anterior itici.sion permits wide separation of the laterid 
fragmentB of the anterior uterine wall, and thereby exjKJses the endo- 
metrium, and may render accessible a myoma in any part of the 
uterine wall. It has the following advantages over the lateral 
incisions: 1. There is less tninmatism— one incision instead of two, 
2. The parametria are not oj^eiieil and exposed to inissible sepsis. 

* TrflTisattirniN Miimetiotrt Stftte \k'iUfiil Sociiety, 1W», published In Iho Journul of the 
Amcrjr'An Medical AssociatUm, Augiist 1;», IK$^. 



352 



TUMORS, TUBAL FEEGNAJVCY, MALFORMATIONS, 



3. The tumor is more accessible, hecatise the auterior uterine wall 
m out of the way, i instead of being between the operator amJ the field 
of ojH'ratiirn. 4. A rimrli hmtrer iiicisi*)!! may be made, if neces- 
sary, l)eeaiJso tlie broad ligainems are not involved. 5* There h le^s 
hemorrhage. G. The jielvie cavity may l>e eai^ily reached through 
this incision fur any aeeessory o[>eration on the uterine appendages 
or )>ent<inermi. Even a small pedunculated subperitoneal tumor 
could be removed. 



3. Radical Abdominal Operations- 

These o{>eiTitions are adapted lo large subperitoneal and intramural 
tumors which eann<kt well Ix^ removed through the vagina. Tl*e fol- 
lowing is a general division of the siilijeet: 

a. Openiiinns with extraix^ritoneal ha*mostasis* 6. Operations 
with intniperiloneal lutmoslasis, 

a. Operatjonfi with Extraperitoneal HaemostaBiB, This subject 
recalls the old contest Ix^tween the elanip and the intraperitoneal liga- 
ture in the treatment of the pedicle in ovariotomy— a contest which 
resulted in a conijilete victory for the ligiiture, and necessarily estab- 
lished the general principle tliat the extraperitoneal method is rela- 
tively dangerous, and, eonst^qneiitly, wlieuevcr perfect ha?niostasis 
by the intraperitoneal method is imietiealde, t^hould be avoided, 
Uruloubtedly this general principle should apply with some force to 
the removal of other abdi>minal tumors. Nevertheless, the earlier 
statistics in myomectomy and hysterectomy show that the dangers 
which necessiirily belong to the clamp were more than balanced liy 
the insufficientcy of any means, then known, of intnij>eritoncal 
hsemostasis. 

The advocates of the clamfv based their objections to the ligature 
upon the observation that the moist, soft, uterine stump when hga- 
tured and returne<l to the abdomen would at once become a source of 
danger from liemorrl*age and tlecf imposition, with consetpient sepsis 
and |>eritonitis. Howev<T tightly the ligature was drawn around the 
uterine stump, however carefully the flaps of the stump were stitched 
together, however pc^rteet tlie h^moBtasid may have apju-ared ujion the 
completion of the ojK'ration, the fact remained that shrinkage of the 
stump within a few hours, and consef|Ucnt loosening of the ligatuivs, 
almost inv3irial>ly i»ceurre<l from the escape of serum, and fatal 
hemorrhage or sepsis too often fr*l lowed. The extraperitoneal treat- 
ment, the re to re, was for a time almost universal, and with imjvroved 
tee!vni(|Ue gave promise of becoming the established methotb In the 
hands of Keidi and a few other very gkilfid surgeons it gave a 
singular freedom from mortality ; but in the hanils of the average 
opTator the mortality was unfortunately tcK* gi*eat. This was so 
becaujie of the extreme* <lifficulty in k» cping the stump aseptic. It 
would suppunite in many cases and was then the medium of peri- 
toneal infection. 

In mvomeetomv the history of ovariotomy has reiieated itself — 
first, the intra per ttoneiJ tiTratment of the stump ; second, the extra peri- 



d 




TUMORS OF THE UTERUS— MYOMA 



353 



I 



I 



I 
I 



toTieal treatment, retjdoretl tieressary on aeeount of tlie tlifficnlty of 
iiitrtiperitonpal hiemostasis. Now, final ly, tiie intraiuTitoneal treat- 
ment has become the established methrMJ in inyoniectoniy and hjs- 
tereetomy. 

The es.sential condition formerly wanting was supplied by simple 
lisjattire of the nterine arid ovarian %'es>:cls, ttiereby shutting otf the 
bltiod-supply J'roni the fiehi f>f operation. This not only renders the 
operation hlomlless, hut prevents scrondury hemonijage. It is sur- 
prising that tlie very tirst operator who attemptt^d myomeetoiny did 
not realize the surgical necessity of first shutting off the IiKkmI- 
current by ligaturing these ves.st'fs. Instead id' using this simple, 
direct, natural procedure, we liavc been fiir a <puirter of a century 
groping about in the dark, searching iu *nit-of-the way places for a 
raetluxl by which w^c (*ould secure iiitrti])eritoneal hiemostasis* Just as 
eo^>u as Baer, Eastman, and others liegan to ligature these vessels the 
whole procixhu'e becmne simple. It is the old st<jry of Columbus and 
the egg over again. 

It would be iui[>rofi table to continue the discussion of the clamp 
agai nst the i n i ra| n-ri tonea I 1 ig; i hi re i n t he su rgiea I t rea tmcn t of u leri ne 
myoma. The sul)jcct is rapidly [jassing out of tlie field <dMisenssiou 
and becoming a matter of ancient history. The ft'W remaining advo- 
cates of extra |M*ritoneal h^mostasis claim that in at least a liniitcd class 
of cases the uterine stump, if not too large, may be brought into the 
abdominal wound and fixed there by means of the chtmf* or serre- 
n<eud, and that t!ic ope rat inn may thereby be coniplete<l in a much 
shorter time than w*nihl l>e rc<|uircil by tfn^ intrajjcritoneal metliod. 
Furthermore, it is claime<l that if the condition of the ])atient is pre- 
carious the extraperitoneal clamp, or serre-nceud, or elastic ligature, 
may be useful, l)ecause they enable tlie surgeon to eomph'te the 
removal of the tumor \w\x\i the niininunn of operating, and so fulfil a 
useful indication — the saving t>f tinn^ Tlie author, hovve%cr, during the 
|)ast six years hiis not had occasion to use extrnju'ritoneal htemostasis. 
6* Operations with Intraperitoneal HaemostaBis, In this class 
of operations the relatSojis of the tuuior to the uterus and the surround- 
ing eomliti on s may determine its removal in one of tlu'ee ways: 1. 
Certain myrunata nuiy be removed without sacrificiug any pan of the 
uterus. 2. All rd' the uterus, except the irdVa vaginal portion \A^ the 
cervix, may have to i)e removed with the tunion J^. The entire uterus 
may have to be retnoved. The ojiemtions therefore are: 

1. Myomectomy — without sjicrifice of the uterus. 

2. Supravaginal hystercctiimy. 

3. Couiplctc hysterectotny. 

Mt^omrHoitti/, Sulifwritoneal tumors, if pedunculated or if not 
too broadly attaclRH^l to the uterus, may often be removed with 
slight traumatism. The uterine woiuid is then rcatlily clostnl with 
interrupted catgut sutures, and the alidominal wound is clos4'd without 
drain. Huch an operation is very simple and safe. Sr^e Figure lf)L 

Intramural tumors, even though c[uite large, may often, with the 
greatest case, be shelled out of tlu ir beds and the nterine w^ounds stic- 
oessfully closed. The tumor-cavity, if not too large, is obliterated by 





EzeisioD oi t> 



ilunculAtiMl iiubp«HU)fieAl myomA. f^uttir^R fti plnee rvady for dewing the utertne 
woutul* Exciied tumor sbgw n detftclied. 



of tli«* tumor and the closure of the uterine wound hemorrhage i8 con- 
trolle<I by n trmprmiry elastic lijraturr around the lower segment of the 
uterus. Bct«*n' clu.siiig theabtlominal wound tin's ligjiture Ls removed^ 




t^tcros with eight myomata to be removed and one bLiop; removed, 



Tl»e mortality of this methotl for small tumors, tii whicli the traimm- 
tii^ni ii^ slight, is surprisingly small. 

lu case of a largo tumor, and consoqueutly of large traumatism 




Bmme uteruA a» shown In preTioui f^gtire. Show:> mt?thod of closing wounds made b>* rcnutva] 

of myutiiala. 

with onormoiis surfaces to be united by buried sutures, the methoil 
invf»lves too great danj^er of sepsis, and should be uicKlified as fo!h*ws : 
After tht' tumnr has been shelled out from the uterine wall an op-niug 
is made directly from the tumor cavity to the uterine cavity » If the 




356 



TUMORS, TUBAL PREONANCT, MALFORMATSONB. 



Fkfsk IM. 



uteriiie canal i^ patnlock&, a eootiiiiMMK ^trip of gauze 13 carried from 
the tumor cavity directly throogll iotu the v^nu, and the tumor 

csTitr is park<>d with the ^^ame 
ooiitiiioo«is strip* The tempurary 
elastic li^tnn^ amond die uterus 
doeg not int*^rfcre with the rnirtv 
ducci«>n of the gauze. The uiiTine 
wound is then closed, as above 
de^ribed^ by buried sutures aud 
deep Lembert sutures of catgut. 
The peritoneal margins of this* 
wound, thus turned in and united, 
rapidly grow together, and the 
whole uterine traumatism, now 
ii4olated from the peritoneum, is 
adequately draineci through the 
vagina. If the uterine canal is 
not sufficiently patulous, it may 
be dilated or liilatendly incised 
by means of a herniotomy knife, 
or it may be both dilatetl and in- 
eise< 1 , The vagi na is loose ly fi 1 1 ed 
with gauze t4> meet that which pro- 
trudes from the uterus ; an al>sorb- 
cnt vulvar dres^^ing, to be changed 
as often as it becomes moi^t, com- 
pletes the capillary drain. The 
gauze is removed in two or three 
days. Care is necessary in the 
closure of the ntr rine wonnd that 
the giuize he not caught in a su- 
ture, Ijewiuse then its removal 
^vnyld have to Ix^ p>st|xiiicd un- 
til after the absorption of the 
suture. 

An intraligsimentons myoma 
may be readily shelletl out fmm 
its bed between tlie fitlds of the 
broad liframent. The same principles of drainage apply as in the i/ase 
of intramural tumors, except the route of dniiimge. This should be, 
nt*t througli tht^ uteri m^ canal, Imt thrfiUfrh an o]iening which is readily 
made from the tumi>r cavity to a p^iint in the vagina just back of or 
in frcint of the uterus. Tn cxefptioaal eases it may be neet*ssary for 
purposes of hEemostasis hy li^atui-*' the ovarian or uterine arterj% or 
both. Exprience has shown that sloughing of the litems fn»m thus 
cutting r>ff its blocKl-supidy is not to be fen red, 

Intni-nbdomimil closure with vaginal drainaire of the tumor^cavity 
was early suggested antl practised by August Martin, of lierlin/ but 
t DiaeaB«ft of Women. S«coiid American edltlun. pp. 'i8^29L. 





An intramural inyoum hxa^ 'it'en cnuclcttiecl ; 
tumor tuivtty In lommunicatiiJti wish iitLffne 
ciivUy tH'tntc otilitemted by continuous lauriefl 
efttgiit suture; iit«ro-v«ginal gauxe drain In 



4 
I 




latmUgamcptoiis myDjaa has hCQu removed from sf»acG between folds of broad Ugament. 
Gau2c dinin from Lhln g]>aee through an op«nf ng direct into vnKinei. 

organs will be surprised at the number of cases in which this is 
entirely feasible. The niutilatint^ operation of hystereetomy for 
inyoma is often iieeeas^iry, but ntit so ufteii as the statistics at the 
present time would indicate. In the vast ninji^rity t>f cases the uterine 
appenfla^es will be fnirud ni>rniai, and in a large proporti*ni of this 
majority the tumor may be enucleated from the uterus and tlie wound 
s u ecessf u 1 ly c 1 osc^ , pree i sel y a s wo u I d he r e q u i red fo r th e re m o va I of 
such a tumor in any other part of the body. Cases of very large 





am 



TUMORS, TUBAL PREGNANCY, MALFORMATIONS, 



timiorB, and ea^t^s in whit'h many ^nmW tumors are .scattered through 
tlie uterine wall, may requii-e hysterectomy ; but the conservative 
oi^^ratiou iif sinqih* eiiiicleutinn will often apply when the tumor u 
even lurj^jcr than tiie t<etnl head, and in cases of multiple myomata 
even when there an: mauy tumors. The preservation of the uterus , 
when tile ai>j>et)daj^e8 liave to 1k» removed is, unk*ss the organ 'm 
iuibeted, desinible. This subject is more fully di.seu8Hed in Chapter I 
XXIIL 

l>rainage of the tumor cavity by stitching it into the abdominal 
wound and packing it witli gauze' has been successf idly carried out in 
many eases. The vaginal route iVir dniinage, however, ofler^ decidtHi 
advantages, and will therefoi'e usually be prt^ierred.- fl 

2. Sitpravafjiinal Ili/iiteredomt/, The usual |>reliminarv measuR^s " 
in abdominal ojKa-ationSj to disinfect the vagina and thereby to avoid 
possible perittmeal infection i'mm that suurce, are impe rati ve, l>ecJtuse: 
first, irdectiou may I>a^s through the cervical cannl to the peritoneum ; 
second, vaginal drainage may require an i»|>rning to be made anterior 
or posterior to the uterus, or the operation may liave to be extended 
to c<»mplcte hysterectomy by the removal of the cervix. This would 
bring the vagina even more directly in relatitm to the peritoneum. ^m 

The ahthjuunal ineision, fii*st madt* only long enough for exptoni-H 
tiun w ith the finger or hand, may, if t!ie tumor is U* be remove<l, Ijc 
lengthenetl for that jiurpose. The bladder is often drawn far upward 
by the tumor, and might be injured by a low incision ; lience the incis- 
ion should not be begun too near the pubes. The i*emaining steps 
of the i>pei^ti(ai are these: 1. To bring the tumor through the ab- 
dominal wfiiind. 2. To ligature the uterine and ovarian ves.«els. 

3. To remove the tumor and the supravaginal portion of the uterus. 

4. To make the toilet of the peritoneum. 5. To close the wound. 
Tlie delivery of the tumor is sometimes made by pressure on the 

alKlominal walls around the incision, thereljy squeezing it out as one 
would s<jueeze out pus after opening an abscess. Usually, liowever, 
it is delivered by traction with heavy vnlsellum forceps. The cork- 
screw often used is objectional>le, In'rause sometimes it lK"c*»mes ^M 
advisidilc to al>andon the radic^il operation and only make an exploni- fl 
tory incision ; then the deep wound of the screw would be a disiub 
vantage. Somt^times tlie delivery of the t tun or is im|M>ssible tmtil ^ 
after s^mje t>f the ligjilnres have been placed and the mass has been H 
j>arti;dly at least severed from the bro:ul ligaments. If the incisi<in ^ 
is v<'ry long, its upi^r part nuiy be closed at once. This serves to 
keep tlie intestines baek and to lessen their exposure. 

The arteries to Ix* ligated are sliown in Figure 11 Hi. The ovarian 
vessels are first secured by pissing a ligature around the outer m 
extremity of the hniad ligtiment close to tlic w^all of the |>elvi8 — L ^., " 
around the infundibulij-pelvic ligament, lieflex hemorrhage from the 
nt(/rus is prevented by a ligiiture or force]>s on the uterine end of the 
ligiuncnt. Each broad ligament is thus tied. The uterus an<l its 
appendages are then freed from the upper portion of the broad liga- 

* polk. E, C. Dudk>\ S^nn. 

3 The autlior iiso4 utem-vftgiiml drninaBt* in myomectomy in April. 18S8. C3Me reported in 
Ameri ciLQ Juurnal of Otwtctrica, September. 1889, 




OS uTERf' Vagina cut opcn schind 
VBSctalar mpply of the titemi and Its appendages. 

ments by severing with scissoi-s the ligaments between theMi ligatures. 
See Figures 197 and 198, The uterine peritoneum Ls nuw to be 




BrrMul Ugamontaml inflindllyulo-i^elvJs Ujfament UgiUureU nn each aide. Ovarian vessels 
thereby 8ecnrc*d, Ligature uf tho nterluu vea»el», iifi shown ht-re, if* Uiiiiany deferred to a latt;r 
stage of the operation. 

g[i'<lled by lightly |>iissing the seui[>el, nr pointed seissors, anmnd the 
uterus an ineh or mure above the att4ielimeni of the bladder to the 

1 Flares 197, 198, and 199 were suggested b^ similar iltystmtlous uf Baldy and Penrr«e« 
of whlcii they are mudil^eatiuus. 





I 



Tumor anij auprara^uAl portloiu of otenia cut dWHy, AnUiriot hihI iMwUTlor edm ot 
perlt^ineal wmiuiid belni? whipped together hy a running cotirut ititiire In urtlt-r lu covt- r uterine 
fttuniFf ntuX the iituini« mftde by llMturcs of im*rfne tiruries. In »omi' cmihii* eturapa of the 
ovArUn «rt€rlt:a cao »li*o be dmwn down and covert'd, 

arteries are located sometimes by si^ht ; oftencr by touclt. Eacli one 
i^ then seeured by a li|^uture isolated or en masse* This ligature, in 



TUMOUS OF THE UTERUS^MYOMA. 



361 



ortler to avoid the ureters, Hhoiikl be ohjse to thfi lUerus. See Fi^»rc& 
198 an<l 199. In some eases the tumor so fills tiir jti'lvis ttiut Hk* 
ligatures eaiuiot be applied* Then, a k'niporafv elastic ligature having 
been thrown around the cervix, the tuuu^r may be rapidly ennek7ilecl 
and the ligatures afterward applietl. 

In tlie removal of the tumcu' and tlie supra vagi ual portion of the 
uterus a wedge-shaped ineiwion is made with scissors thmugh tbe lower 
pnnion f>f tbeeervix \ this pennits tbe easy iiiversirm t>f the uterine Haps. 

The toilet of the peritoimum eonijirises the following ste])s : L 
Ligature of any bletHliug [n>iiits. 2. Cauterization u^ tlie riTvieal 
Ciinal with carbolic acid, 'X Closure of tbe cervical canal, 4. Cover- 
ing of the stumps with i)eritoneoni. Figure 1*J*J shows the anterior 
and posterior cervical flaps thus united and tlie peritoneal flaps being 
whipjM'd tc^getber by a continutais eatgut suture. AH intru-al»domiual 
suttires and ligjitures may be silk or catgut, jjreferalily the latter. The 
drainage, if rerpiired, is best made througli aji opening post4'rior to the 
uterus into the vagina, Tbe necessity for drainage, however, woidd 
usu:dly rendiT the removal of the entire cervix desirable. It is com- 
mon in supravaginal hysterectomy to close without dminage* The 
aUlominal wound is closed in the usual manner. 

3, (hmpidr Ahdonutiuf HyHterevfmmj, The removal of the entire 
myomatous uterus is indicated : first, when tbe uterus is septic or uther- 
wise so diseased as to render the presence of any part of it unsafe; 
second, when extensive pel vie suppuration or traumatism requires 
vaginal drainage. 

The operation, exeef)t ligature of the ovarian vessels and division 
of tbe broad iigjiments^ iliffers from supravaginal hysterectomy only in 
certain teebnical details ; When tbe cervix is accessible throngb the 
vagina the first incisinris may be made as fur vaginal bystcreetomy, 
the bladder and tbe rectum Ijeing stripped away from the cervix ^ in 
some cases as far as the pelvic cavity. The broad ligaments are sepa- 
rated throngh the vagina and tied off as high as practicable. The 
extent to which this can be ilone will vary greatly with tbe itulividual 
ease. The vagina is now temporarily }iacktHl with a continuous strip 
of gauiie. Tlie final removal of the uterus through the abdomen 
is greatly faeilitatefl even by a small anKunit of vaginal detaelinieut. 
The vaginal incisions, if impraetieaiile in the lieginning, may some- 
times be readily made after tbe abdomen has been opened antl the 
nterur. has been free<l from tbe broad ligaments above. The abdiunen 
having been opened, the operaticm is cfuitinued as already descril^ed 
for supnrvijgiual liysterectomy ; the uterine arteries are usually tied 
a little further from the uterus. This necessitates the greatest care 
not to intdude the ureters, wliieh cross them quite near tbe nterus. 
The uterus is tlien removed by means of strong scissors. It is im- 
portant that the incisiims for this purpose be always made t*lose to the 
nterns. No harm is done if, on citfier side, a small portion fjf the 
lateral walls ftf the t'crvix uteri be left behind. 

If the vagiiial incisitms have previously extended into the pelvic 
cavity, the final removal of the uterus will be easy. If the incisions 
have not extended so far, the removal will not be difficult; but if 



362 



TUMORS, TUBAL FREONA^'CY, MALFORMATIONS. 



no Viiufinal iufisions liave l»oen made the oi>cmt4.>r may find it quiU* 
tedious, if not ditfienir, to work his way down int43 the vagina. The 
attpnipt has cKvasioiially ivsidted in opeiijnix tlie reetnrii, bladder, or 
urett r. This dittieidty may be largely overeome by a simple deviee,* 
a.s fdllows : 

The hlachlcr havinp^ been stripped from the cervix at^ far down 
as piJB.sihki toward the vagina, the uterut* is drawn by means of vul- 
selluni fureepH well up through the abdominal wonnd* This trac- 
tion exposes the anterior wall of tht* eervix^ whieh is now freely 
divided with sharp seissors by a bingitadina! ineisinii and the cervical 
eanal thereliy laid open. See Figure 2(K>, One Idade of the scissors 
is now pnssetl direetly down through the external u^ to the vagina, and 
tlic entire anterior eervieal wall is divided. The linger now readily 
passes to the vagina, and serves as a guide for the rapid removal of 
the organ by a <'iiruhir incision around tiie eervix at its vaginal attach- 
ment. In some cases it is enu venient to reserve the ligaturing of tlie 
uterine arteries uirlil this part of the operation. 

Any small bleeding vessels arc now tied iiv twisted. If the broad 
lignment on eitljer side is gaping, its peritoneal tblds are bronglit 
ti^gether by a rnntnng suture. Any surfaces exposed by the trauma- 
tism of the 0]KTation are, if j^nu^ticable, covered by drawing the |>eri- 
tuneum over them and stitching it there. The vaginal wound ischjsed 
on the alidoininal side by interrupted <ir runrung eatgut sutures. In 
this wuy the jveritoneal margins of the wound lUX' inverted as by the 
Leuibert suture. Tlie vaginal margin of the wound may at the ^ame 
time Ijc chK^ed by the simie or another suture. 

If the stumps of the broiid ligaments ami ligatiircil vessels can be 
drawn down into tlie vaginal wound, the sutures at the extremities of 
the wound, if properly reiuforeed and pas.<eHhthnnigh them, will serve 
to Inild them there. The ligaments when fixed to llie vagina in thisi 
way serve to suppt^rt the pelvic floor, and thereby t«» prevent rectcKX'lc, 
eystocelc, and entercicele vtiginalis» This disposition of the broad lign- 
nu'nt stumps is mcjst desiralde, though not always por^silde. 8i^e 
V n gi n:i 1 1 lys tercet omy. 

Draiujige, if retpured, is made by packing the field of operution and 
the vngina with a continuous strip of ase|Ktic gauze and leaving the 
vaginal wound partly or wholly ojx^n. See Chapter VII. The ah- 
dijminal wound is usually c]os(mI without drainage. 

77*e fhiiif/f^r of the removal of n uterine myoma varies with the 
skill of tlie operator, the location and relntions rtf the tume»r, and the 
couditifin of the patient. The mortality of the abdominal operation 
in the hnnds of the avernge operator bus Iwen jihu-ed at about 15 per 
cent. This is too high. Under favfmd)le conditions an expert surgeon 
should have at least 95 per cent, td* recijveries. Statistics usually 
show a mortality of about tI5 ]>er cent, in the removal of intndiga- 
nuMitous tumru's of broad utfrine connections and of supnivaginal 
tumors of the upper part of the cervix. This, again, is too high. The 
method already {lescrihcd for the renin vnl of these tumors with ganxe 



I 
I 
I 
I 



1 This mt'thod nf excMsiTip the cervix frmm Uie »hf1mriitiid side of the pelvic floor ha« bren 
\i»ed hy the author for «ev«?nil yearn with Rrcat satlefuction. 



TUMORS OF THE UTERUS— MYOMA. 



363 



drainage toward thfj vaginsi, when required, tdosure of the tiiraor- 
cavitv in the itUhirnoii, and^ if iie<;es.s;iry, ligature of tljc uterine vos- 
sels, lia>i redueefl \\w niortality tt» a very 8Jiiall ratio. Vaginal hysterec- 
tomy of the rimall myoma tons uterus has a mortality of not more than 
2 or 3 per cent. The removal of a tumor from the infra vaginal 
pjrtion of the eervix and the removal of intra-uterine polypi through 
the vagina are praetieally vvitliout danger. Tlie long-eontinyed nien- 
orrhagia so commorVlv assuciated with uterine niyomala may so ex- 
haust the woman as greatly to deereatKi her re«istanee, and thereby to 

FioTTRR 2no 



i\ 



Longitudinal Incision of the anterior waU of rhD ct;rvix lo ftacllilwl© complete hystereclomT* 

increase the danger of an operation ; hence the oce^isional necessity 
of preparatfUT curettxige, uterine tamponade, general treatment, and 
delay until the syt^temie eouditiou is more favorable. 



Myomectomy during Pregnancy. 

The following conditions more or less strongly contraindieate sur- 
gical treatment during pregnancy; L Small size and slow growth of 
the tumor, 2. Location of tfic tumor where it will not materially 
inter fen' with utero-gestation €»r obstruct delivery, .'). Prolnihility 
that it will rise spoutaneou.'^ly, *»r may be mamudly forced out of the 
}>clvis into tlie ahthimeu, where it will not interfere with pregnancy 
or jiarturition, Tlie opposite of these conditi*uis may call for surgical 
measures. The following radieal measurt*s luay then be considere<l : 

L If the foetus ia not viable, abortion, and, later, myomectomy or 
hyBtcrectomy. 



364 TUMORS, TUBAL PREGNANCY, MALFORMATIOS& 

2. If the child is viable, Csesarean section or Porro's opeimdon, or 
complete hysterectomy. 

3. Removal of the tumor without interrupting pregnanqr or sMri- 
ficing the uterus. 

If surgical interference is inevitable, and gestation has not ad- 
vanced beyond the end of the third month, the indication is for 
abortion. Interruption of gestation at this time, and a radical open- 
tion for the removal of the tumor later, would be the safest couree 
for the woman. After the third month the danger of abortioD is 
enormously increased. This increased danger comes from the dif- 
ficulty of delivering the placenta, from infection, and from hemor- 
rhage. CflBsarean section, to l)e immediately followed by oompkfe 
hysterectomy or supravaginal hysterectomy, may now, in the inteiat 
of the child, be deferred, if possible, to the period of viabilitjr — 4i* 
IS, to the end of the seventh month, or later. The removal of the 
tumor without sacrificing the uterus or interrupting gestation may be 
preferred when the tumor is subperitoneal and removable with small 
uterine traumatism. This operation is specially indicated in subperi- 
toneal pedunculated tumors. 

An infected myoma demands radical measures, and if the uterus 
is also infected may call for not only myomectomy, but for hyster- 
ectomy. See Plate V. 




Myomatous Uterus, five months pregnant. Twisted Pedicle, 
Infection of Myonna and consequent Peritonitis; Hys- 
terectomy; Death from Nephritis. (Specimen 
fLimished by Dr. A. C. Haven.) 




Sesalle adcnomftlaof the cervix at tbe 
external oa utert.^ 



and raay also penetrate the musciilarit** It often presents a small^ 
velvety areola of pink eolor, covered with tenaeious mneas. 

Tlie peihincnlated vuriety is simple or multiple, is coniposcd of 
raoemcK^ glands, connective tissue, and, usnully, mnsele fibres, and is 
04>vered by colnmntir epitlieliuni, wliich trcuenillv l>ee<nneft flattened 
to pavement epithellnm when the growth protrudes into the vagina. 



t From Thomas niid Mund^ ; De Bln^ty. 



> From ThomM and 3Iutid6. 



36(i TUMOBS, TUBAL PREGNANCY, MALFORMATIONS. 

Tliis disease has In^n t^rrcmeoiLsly clas??ed as ptilypf»id endometritis. 
The go-called hyj>erplaj*tic (not hypcTtrophic) glandular endometritis 
18 etiseatitilly adenoma. See Pathology of Endometritis. 



Adenoid polsrpu" "^t ^^c cervix alerl. So-cAUed folUeular hypertrophy J 

T\w racemose variety is rare ; it has the appa ranee ^4^ a so-called 
hydatid mole, and may spring from any jwirt of the uterine mueosa ; 
it may he ioeal or geneml. In minute striieture it is the same as 
po \y pt »i d a tie m i ni a . 

Symptonis. 

The symptoniii, for the most part, are those of the associated endo- 
mi'tritis — /. c, menorrhagia, metmrrhagiu, ami inereasefl secretiim. 
The leueorrh*m is serous or muco-piindenL The gn'at prsietieal sig- 
nificance of benign adenoma is ita tentleney to become malignant ; 
hence the nei-essity fur early diagousis, thorough curettage, and 
watch fi 1 1 ex |R*ctaney . 

Diagrnosis. 

The diagnnsis is by the micruseope, and is, first, from hypertropliic 
glandular endometritis; second^ from maligns*nt adenoma- — i. c., fnim 
eaffinoma. Sharp dingnn>tir lines en n not always be drawn ln'tween 
these three cotiditions. They may shath^ into «>ne another by almost 
imp<*reeptible gradation. Typical eases will show* the folhjwing dis- 
tinctions ; 

1 PozzL TrcaUto on Qynccolui^y. 




H-i. f., cnnecr The 
-' broken thncmeh into 



of i\w *liiHHksi* to rt^lllnl tft«*r ciircttagf* is partly explainttl bv tlie 
occti^iuiml tUihm* tti n*«H>Yi» nil die pmwth und to its teiideiicv to 
InHMiiue inHli^nant* Kt^jH^ilfnl n^ium of the disease after curettage is 
evitlem^* i»f nialigimiicv utid may itnlieate hysterectomy. 




CHAPTER XXIX, 



TUMORS OF THE UTERUS (Continued), 
CARCINOMA. 

Pathology. 

Carcinoma may arise from any portion of the utorine mucosa — 
L e, from the cylindrical eptthelinni of the corporeal or cervical 
glands, from the surface cylindrical epithellnra uf the interior of the 
uterus, or from the pavement epithelium outside the external os. 
The variety of the cancer eorres|>(nids to tlic tyjK^ of epithelium from 
Avliich it springs. Cyliuilrica! cell carcinoma occurs on the corporeal 
and intracervical nuicosa, and the pavement-cell variety occurs on the 
external vaginal surface of the cervix. This ride is not invariable. 
E version of the intracervical mucosa is quite common — see Lacera- 
tion of the Cervix- — hence the frequent formation of the cylindric^d cell 
carcinoma outside of the apparent os externum. On the other haoti, 
pavement cpitheHuni may be present in the cervical ciiual, or even 
beyoml tlie internal os in the uterine cavity, and there give rise to 
jKiveu'ient-eell carcinoma.^ 

From the pathological i=?tand]K)int there are thus two varietieg of ear- 
cinonia. One type is that in which the snuamous cells of the eer%ux 
have multiplied in au atypi**al mauuer aiKl have invadefl the dee|>er 
tissues; this is the sc»-called cjiithclioma, like that which occurs at 
the junction of the skiii and runcosii of the lip. The otiier tyjie is 
that in which the cyliudricid cell gland acini of the interior of the 
cervix and corpus uteri multiply in au atypicat manner, invade the 
inierglandular stroma, and thus conform to the carcinomatous type. 
This is the variety meutioued in the pi-evious chapter as malignant 
adenoma ; the growth is there chissed as primarily a l>euign adenoma 
whi*'h has undergone malignant degeuemtion ; this tnin sit ion -stage, 
however, is not necessarily a part of the development of carcinoma, 
as the growth may be malignant from the beginning* 

Carcinoma of tlie cervix usually originates near the os externum, 
where the cylindrical and pavement epithelium meet. The tendency 
of the growth early in the disease is either to cxtentl ti> the sub- 
mucous structures or to confine itself chiefly to superficial areas. 

When it invades the deeper tissues the affected portion is enlarged, 
hani, marlde-like, and friable. The surface is smooth, glistening, 
and flattened, or tuay be niKlular. Tfie growth rapidly extends and 
early ulcerates. The margin of th(* ulcer is irregular^ hard, and 
usually raised. The base is irregular an<l bleetls easily. The ulccra- 

> Rles. Americjin Oynecolnjrir'al nud Obstetrical JmimRl, February. 1896; Zeltaclirift PQr 
G^burUhQUt! und Uyniilcalti^e, vol. xxlv. 

34 369 




Tkit fivmi wUch, io eutiy siafei, nonfincg ilKlf to the superficial 
i tnietufiMi in wmeiimeB calkd pApUknr or c««filk»«er cancer; it 
origiiiatoi on tiie vaginal portion of the cervix^ mpidly aprattib to the 
vaginal walU^ filU the upper part of the vagina, nlcerates eartr, and 
bleedit freely^ The jn"t>wth is iH>ft, very %-ascoIar, and lendi?^ to speedy 
defftmction <>f the cer\*ix and vaginal walK 

In ran* «we« the ulcerative process destroys and exca\*atesi the walU 
of theoervix before the growth appears ontside on the vaginal portion. 

Ktiolofiry. 

The diiieaiie h more frequent among the white race$ than among 
the Afrirjinn and A><iatifw. The lower classe>^ of any race are more 
nuiiee^itilito than the higher. Carcinoma is found very frequently in 
the ix-rvix, i*omewliJit let^x eoramonly in the e«»r|jus uteri, Tbift is 
doubtleais IjccaUK* the eervix 18 more exposed to the influence of coittis 

t aiig« Mid Vellt In AiDcrlc&D Syilcm of GyuecottiK;. 




I 



The j^vmpttmi^ in the f'arly ,sta^uH att* ah^-ent. As the disease jiro- 
grcsses tf»o Inllowinji: disorders always appear: 

1. Hemorrhage. 

2. Uterine ilL-icharges. 

3. Pnin. 

4. Vitieenil disorders. 

5. Cachexia* 

1. Hemorrhagre is usually the fir*t symptom and 18 the result of 
uleerative pnx^esses by wliieh the 1»1<kkI vessels of the gruwtli are 
o|>ened. It is, unfortiniately, often attributed to irregularities uf the 
meiio|>anse or to a return of menstruation after that period; ht^nce 
the faet that the bleeding of earcinonia is (iften disrt'ganled until the 
disea.se has [>rogres,sed beyond tlie ho[K^ of cure. The reappeamnoe 
of hemorrhage oue, two, thrc*e, or more years after the ineuopansc* is 
strong presumptive evidence of eaiieer, and demands immediate 

* From 1k)ntiet H Pt'tll. 







TUMORS OF THE UTERUS^CARVINOMA. 



373 



examination. The loss of bloody at first slight, is commonly iiotit^ed 
after straining at stooU or vigorous exercise, or coitns. With the 
progress of tlie diseiise the hemorrhage inereanes ; it may be nearly or 
quite constant, may occur at irregular intervals, or in the form of 
meuorrhagia at the cataraenia. Usually the ^Jatient^^ strength is slowly 
exhausted by a persistent, slow seeping away of the watery blotxt. 
On tiie other haiitl, profuse, even dangerous, hemorrhages are possible. 



PlGlTRE 211. 



t^^. 






dr 



^i^ -> 



Fftvement'i'ell carcinoma— ». e., epithelioma. Trans form All on of typical to atypical gland 
ptriictur^ft.i p. Pavement ef*lliieuiim. Jk, Cancer, tn. Cancer nodules. df.Renialnjs of gland. 



2. Uterine Discharges. A fonl, most offensive^ watery discharge 
eommonly follows soon after the tirst ap]iearaiiee of the hemorrhage. 
Earlier this diseliarge may be serous, transperent, and inotlorons; but 
as ulceration increases it becomes profuse, tnrbid» hl*iody, sometimes 
purulent, and always of a most nauseating fxlor. This symptom con- 
tinntfs more or less constant to the end, and is eiiaraeteristic of malig- 
nant disease. The discharge is called *^ carcinomatous ichor/' i>r 
** cancer juice." 

3. Pain is mrely present while the growth is confineil to the vaginal 
jK>rtion of the cervix. In%'olvement of the corpus ntcri iind of the 
structures around tlie uterus may give rise to sharp, lancinating pains. 
These piins, though often described as JKlth^^gn(nuonie, are by no 
means constant or confinctl to cancer. They niny l>e siipph^mcnted 
V>y the pains of jK'lvic jK^ritonitis. The jH^ritnuitis protects the general 
peritoneum liy atlli<:sion8 which fr>rni in front of the invading car- 
einonin. Tlie jKiins are due to pn^ssurc on the pelvic nerves or to 
actual involvement of those nerves in the carcinoma ; they arc com- 
monly referred to the region of tlie t>elvis, perineum, or thighs, and 
usually imlicate that the disease is past oj^^rative cure. The lower 
extremities become (edematous from hydramiia^ from pressure, and 
from thrombosis of the |xdvic veins, Eitdioli may be dislodged from 
tlie thnmibi and carried to. the lungs. The fatal rcsnlt is tlien from 
enibolism, septic jmcumonia, and iMilnnmary cedema. The retention 
of secretions in the uterus from (K'clusion of the cervical canal by the 

* Rugc and Veit, from Amtjriean System of OyneiJr.|o^* 



TUMORS, 



PHEGyANCY, MALFORMATIONS. 



invadiiig carcinoma may give ri«*e to livilroinetra or pyometra, and 
cause sjwsnKKlic expulsive uterine pains like lulmr jmiiig. 

Metiistasis to the lungs, kiduoys, liver, and other viscera is com* 
men })Otli Croni carcinoma of the corpus and of tlie cervix. 

4. Visceral Disorders may t)C consequent ii|K>n pressure or 
invaBion of neighboring organs. Tl^e Wadder Ix'cunies irritable. 
Vesical catarrh, strangury, painful nrination, pyuria, and cytstitis 
may follow, Vesico-uterinc or vesico- vaginal tistuUi often re#>ults 
from the destructive ulcerative processes. U re tero- uterine and 
urctero-vagiual, recto-uterine and rectc»- vaginal fistula may occur in 
the same way. Nephritis, unemia, hydronephrosis, and atrophy of 
the kidney are among tlie usual resultant eomplirations. Consti|M- 
tion is explained as follows: Fii^^t, the patient, through fear of jmn 
ami hkM^ding, voluntarily retains the feces ; second, the feces l)e€ome 
dry and hanl from loss of water in the ichorous diseharget? ; third, 
the l>owcl is iucii|>aeitatcd by tlic disease for the ready expulsion of 
its contents. Diarrhoea may be cansetl hy irritatitiU of the bowel 
from the invasion of the cancer. Alternating constipation and diar- 
rhtmi are common. 

5. Cachexia apfK^ars not very late in the eoui^ie of the dii^ase, 
and is a eliaracteristic symptom. It is market! l»y emaciation, a 
yellowish paHor of tlio skin, profound aiuemia, and great depression 
of both mind and body. It is caused by sajn'a^mia from the aljsorp- 
tinn of necrotic tissue and by malnutrition tliie to anorexia, vomiting, 
pain, and liemorrhage. 

Diagnosis. 

The sooner the carcinomatous uterus is removed the greater the 
protection iig^ainst recurrence ; hence the earliest postsibie diagnosis is 
imperative. The diagnosis is made by 

The clinical history. 

The physical signs. 

M icroscopic exam i na tion . 
The Clinical History, as outlined in the foregoing paragmphs, 
gives strong evideuce, thougli not proof, of cancer. 

The Physical Signs arc dcnioustratcd by conjoined examination 
and ins|>eetiou. The extremely D'tid mlor which clings to the ex- 
amining finger despite mneh washing and the prolonged use of the 
nail-brnsh, may usuidly hv avoided by the iVee use of glycerin as a 
lul>rii-jint. The in tilt rating earcinonia of the cervix is recognized as 
a thick, hai'^l, lufire or less nodulaiv friable growth. The friability ih 
almost pathnguonjonic. The nlrers, if |jri"sent, have nn irregular, hard, 
raisc^d margin, and uneven base, and lih'cd fretOy upon slight injury. 
Through the sjK'cnlimi the gnrface l>cfore nlceratirm appears smooth 
or nodular, niarble^like, and glistening. After nleeration the surface 
is ragged] and irregular^ and nuiy show large excavations from the 
sloughing of carcinoinatons tissue. The entire cervix may di.sappear 
in this way. The jiapillumatous sujH'rtieitd variety appears as a soft, 
friable, Ideeding, cauliflower-like mass. 

VurcinQmn of the Vcmx may in the beginning be easily over- 




TUiMOHS OF THE UTERUS-CARCLXOMA. 



375 



looked* The cervieal wall anuind the external os may be only 
slightly thiekenetl on the atleeted .side. The indumtetl ti.ssue may 
appear almost insigi»ifi«uit. Its extreme friability and persistent 
bleeding on slight abrasion will, however, he strong diagnostic factors. 
Subjective symptoms may even be absent. Exeision t*f a small pieee 
for microscopie examination is now im|K>rative. This shnuld lie 
wedge-.shapcdj and should include a portion of tlie surr*>unding 
healthy tissue. The sHght wound may be closeil hy one or two 
sutures. Cerviciil scjTipings are usually unfit for examitiation. 

Qireutortui of th^ Corpus Uteri is in tlie beginning often impissibie 
to recognize. It is apt to come between the Vi^^s of forty and fifty* 
There \s increased and irrt^guhir menstruation, which is often wrongly 
attributed to the menoj>anse. A slight watery diseliarge, even though 
odorless, is^ if present, highly dingnostic. If the <liseharge is very 
malodorous, the evidence is much stronger. The general strength of 
the patient may be almost up to the normal standard. Conjohied 
examination shows notliing save, jicrhaps, a slight enlargement of the 
uterus. Life may now depend u]>on a sjieedy (hagnosis. The whole 
question centres in the pnMluet of curettage und ttie microscopic find- 
ings. Should no microscopie evidence fif eaneer be foimd, the curet- 
tage must be repeated whenever the licmorrhage reappears. In 
cancer the discharge always recurs promptly. The scrapings are 
usually much more abundant than in benign growths. See Diagnosis 
of Benign Adenoma, Cha|»ter XX VI 11. 

Ath'diit'rd (hrcinoma of the body of tlie uterus is reef>gnized by tlie 
symptoms alrt^ady described and by CHnjfiiued examination. The 
uterus is enlarged— often two or more times its normal size. It is 
hard, nodular, and^ in the later stages, more or less fixed, Karly 
fixation also occurs in cervicjil cancer. The causes of fixation are 
similar to those winch pnMluce the siime condition in |wlvic inflamma- 
tion — /, (\, the extension of thi' disease through tlie lymph-cluinnels 
I to the parametria* The absolute diiignosis may depend upon the 
I microsco|jr. The recognition, however, of advanced carcinoma, 
I whether of the cervix or corpus, even without the raicroi*cope, is 
I usually not difficult, ** He wlio runs mav read." 



Differential DiagtioBis. 

The diseases most liable to be mistaken for carcinoma are : 

My o m a , Sy [ »h i I i s . 

Benign adenoma. Chronic metritis. 

Incompl^'tc abortion, Ijacemtion of tlie cervix. 

Endometritis. Ichthyosis uteri. 

Sarcoma. Tidierculosis uteri. 

Sloughing nufoniffy Ifenifpt adenoma, hwompiete afmrtifm, and etulo- 
mdriti^ each has it.s peculiar symptom -group. In typical cases 
this will suffice. In other cases the diagnosis must be confirmed by 
the niierosco|>e. The appearance of early carcinoma of the cervix 
may be almost identical with that oi' small cervical mycmiata or 
hypertrophy. The diagnostic points are as ffdlows : Myoma and 



37e 



TUMORS, TUBAL PREGNANCY, MALFORMATIONS. 



inflammatory tliickeniiig — /. */., liypiTtrophy — <m section are hard and 
resisting. They are BulytH^l to orosion, but not to tlie more destruc- 
tive process of iilcemtion. On the other hand, ciircinomu is friable, 
marrow-like, and always uh^erates. Sareoma has much the same 
clinical hist4)ry as cancer, and is recognized only by the micrciscope. 

Sj/phiitH will Ijc known by the clinicid history. In doubtful ciises 
specific treatment should clear the diagnosis- Vhronk' metritU shows? 
a history of inflammation, is usually asi^<jciat€*d with endometritis, does 
not cause the carcinomatous cachexia, nor the oflensive watery dis- 
ehai^e. On conjoined examination the uterus is symmetrical, while 
a carcinomatous uterus is often noclnlar. 

Laveratioii of ifw eenu'jr is characterized by inflammatory aod 
mechaniciil results that may closely resemble carcinoma of the 
cervix. See Pathology an<l Diagnosis of Laceration of the Cervix* 

li'kibyosh Uteri. This condititjn, first describetl by Zelk'r,* 1884, 
is marked by the presence of two or more layers of stratified epithe- 
lium. The presence of stratifietl epithelium in the cavity of the 
uterus hiis been observed in connection with inversion of the uterus, 
with cervical jM>lypi, and, according to Zellcr, with chronic endome- 
tritis. Transition of columnar to |)avement-cell epithelium m-curs in 
hydromet ra and hamiatomctni and in cxtra*nteriue pregnancy. The 
transformation may occur where, from any cause, the mucosa is 
stretched and flattened ont ; such epithelium may become stratified. 
The ciuidition gives rise to no unusual symptoms except such as 
wouhl ordinarily l»e ol>scrvcd in endometritis or in the beginning 
ofcan^iuoma in the corpus uteri. Tlic scTiipings of stnitified epithe- 
lium under ilie niicrosc<jj>c nuiy have a similar a pfM^a ranee in ichthyosig 
uteri and carciuoma uteri. If the microscopic findings show that the 
stratified epithelium is limited to the su|verticial structures, the case is 
one of ichthyosis uteri. If the epithelium penetrates the underlying 
connective tissue, or muscular layer, it is carcimmia. Just as benign 
adenoma or ^dandular hypcrlrophy may be the starting-pnint of car- 
cinoma, so icluhyosis may precede the development of c^ircinoma. 

Causes of Death. 

Hemorrhage, although it may slowly exhaust the vitality, is rarely 
a direct cause of dc^aih* Fatal peritonitis seldom occurs from exten- 
sion of the disease. In the vast majority of cases death is from 
marasmus or unemia, or botli. 



Progtiosis. 

Tlic sole h<ipe of radical cure is in surgical removal of the car- 
cinoma. All drugs are of qnestionable value or useless. If the 
growth has pnvgressed beyond the limits of a nidical operation, death 
in the near future is inevitable. The disease will sometimes tlestroy 

r P1jitU'ni'pith<>l hii rtenis (Irlilhymi^ uU^rinaK Zi^itur-hda Hlr fk'burteh<nfc urifl 
I Ti« I 31 L K iff. m »♦' n < ■ II ( ' * ipf m t iu n !< me t h udt- d v^ I ' ten i son rti n nnm . Zcltich r f fl 
I. viml Cyrijikolnuie, IJaini sxlv. IchlhyotlA, Anierlcaa Uynt-eulogle*! »u<l Ob- 



• ?^-\\ 






TUMORS OF THE UTERUS— CARCINOMA. 



377 



life ill a few iiit>iiths or wchl^Ics ; it may for a timo beconie apparently 
inactive, or develop very jslowly, and then go on to a rapid termuiu- 
tit*n. The prognosis as to tlie limit of life sliould be guarded. A 
general ^^tatentent that death is more liable to occur within one year 
than aft>er two years* would usually bo safe. 

Treatment. 

The trefttment is radical when the disea.se has not extended be- 
yond the limits of entire removal ; palliative when it cannot all l>e 
removed. The radical treatment should always be complete hysterec- 
tomy. Tlie i)ld praetiee of high amjmtation of tlie eervix for eervieal 
cancer should never be resorted to, fur one can never be certain that 
the disease is not also present and unrecognizetl in the corpus uteri. 
It may have developed there in one of three ways ; 1. It may have 
extended from the eervix to the eudometrinm ; 2. The corpus may 
have an independent growth ; 3. Careinoniatous emboli may have 
passed from the cervix to the lymphatics f>f tlie eoi'pus and be 
entirely unreeognizable except by the microscojx'. The removal of 
the growth by the gtU va no-cautery, except as a palliative meaBure, is 
not generally approved. 

Inrlteattonj^ and (ymtrahid/cationfifor Htftdereeiorm/, Hystereetomy 
is in dim ted if the disease is limited to the uterus. Such limitation 
wilt lie inferred i 1, By the normal mobility of the uterus ; 2. By the 
absence of any enlargement f>f the lymphatic glands in the pammetrisi ; 
3, By the abseucr of the disease on tlie vaginal walls. Enlargt'ment 
of the glands is evidence that the disease ha.s extended beyoml the 
uterus. This does not positively eontraindieate IiyHtereetomy, but 
renders the prognosis less iavorable. Whether enlarged or nc>t» the 
glands should, if practicable, be removed. The relation of these 
glands to the carcinomatous uterns otTers a close analogy in the rela- 
tions of the axillary and subclavian glands to cancer of the breast. 
Extension of cancer to the vaginal walls, if slight^ does not tlefinitely 
eontraindieate hysterectomy, provided tlie diseaseil portion of the 
vagina can be removed with the uterus. Extensive involvement of 
the vagina and fixati<m of the uterus in surrounding cancer eontra- 
indieate th<* i>pcration. 

Wlien the fliseasc ban passed lieyond the hope of radical cure, 
but not l>evond the limits of palliative hysterectomy, hysterectomy is 
sometimes |>erformed for the teni|Mjrary relief of symptoms ; its 
benefits, howeverj are not usual ly sufficient to overbalance its dangers. 



VAOINAL HYSTERECTOMY. 

The vaginal route for the removal of tlu^ carcinomatous uterus is 
usually preferred. Two methods of hcemostasis are in use : first, by 
forei pressure ; ^ second, by ligature. 

' P^n: Gftz«ttcdea HApitftTii, Pads. 1888. Lev'<)n« de Clhilque Chirurgical de rHflpital St. 
LoMii. torn. L. il., Iv., \\ Hirhdot : LT^nkm M6dicftle, »d «»rle«. voL x]\\. pp. «iW91 ; V&tIh, I»H(J, 
lhU\., TK 274; l*ari8, Febninry 19. 1880. Secheyron: Report of the Araderny nf Medicine, Paris, 
1887. Terrier, F. ; Revue de rhlrurgle, Paris, 1BK8. E. C- Dudley : Transactions Amerienn iiyne- 
c<>logicftl J?oclety, 1888, voL xiii. 



378 



TUMOIIS, TUBAL PIiEGNA^X% MALFOIiMATIONS, 



Vagrinal Hysterectomy with HsBmostaais by Forcipressure. 

The technique of thi' ojK^mtion with hteniostiisis by foreip reinsure is 
aa follows: The patient \h placed io the lithotomy poisitioii, and the 
vagina disinfected. See Cha{>ter 11. Any tnineerons disease aroond 
the ext<^rnal os f^liould be seraped utf witli the (■urt'tte or burnt ofi' with 
the actnal cautery ; the cervix should thin be plugged with a small 
strip of gauze, and the os uteri closed with one or more sutures. 
This will c<uiiinc the uterine secretions and keep them away from tlie 
{leritoneum and field of ofx^ration, a most important precaution, for 
coDtaet of cancer tissue with the wound has often resuUcd in the 
transplantation of the disease and new infe/ction. The author has 
observed a heginuiug cancer on the abraded jK^ritienm three weeks 
after hysterectomy ; tliis was at once thoroughly excised and the 
won ml closed by pcrincijrrhaphy ; the |)atient was free from cancer 
three years later. After chising the os externum, again disinfect the 
vagina. Expose the cervix with one or two 8im*ui's retractors; 
seize it with strong vnlsellum forceps and dmw it toward the vulva. 

At this jioint insjK'ct well t|je vaginal tissue around the cervix. 
The permancu(*y of the result, csj>ccially in ccrvit^al cancer, will often 
de]M:'nd upon the removal with the uterus of a considerable jXFrtion 
of adjacent vaginal tissue, 

A free incision with the scissors is now made all around the cervix 
at a safe distaiuje from the disease. The loose tissues around the 
cervix arc easily strip|MHl hack by nn^ans of the finger or handle of 
the seal pel J keeping as close to tlie uterus as the disease will permit. 
Control small blccding-points by catgut ligature. In this way the 
circnm uterine structures may be stripped back from the uterus until 
the exp^^sure of the cervix is measured by a zone three-<^uarters of an 
inch or more wide. This zone extends aTi*eriorly and posteriorly to 
the anterior and posterior utenKjx'ritoneal reflec^tious, atid laterally 
to the hroad ligament. The uterus am now Ijc drawn down much 
lower^ and, with the bladder thus separated from the uterus, (he 
ureters, which lie close to the uterus, can lie easily avoided. Tlie 
post-cervical structures are now further separated by means of the 
finger or the handle of the scalpel, or the closed blunt scissors, until 
the cul-dc'sac of Douglas is op( ned. This upenitig is easily enlarged 
by intrcHluciug the two index-fiiig<'rs and tearing latendly to tlie 
region of the broad ligaments*. A large gauze sponge, with a string 
attached to facilitate rcujoval^ is now forced through into the cul- 
dc-siic of rhiughus. This will protect the pelvic viscera and absorb 
blood during the remainder of the opei-ation. 

Tlie ]ieritoneal edge of the post-utcrinc wound is now unit4>d to 
the vaginal cflgt* hy means of a continuous catgut suture. A like 
opening anterior to the uterus between the uterus and bladder is also 
made into the peritoneal cavity. As was done posteriorly, this open- 
ing is enlarged to the region of the broad Hganu^nts by lateral tearing 
with the in<!ex -fingers, and its fjcritoneal edge is stitclicd to the 
vaginal edge. The wliip-stitch by which this is dune anteriorly and 
posteriorly reduccb the size of the wound and prevents bleeding, and 



fUMORS OF THE UTl 



TNOMA. 



379 



thereby simplifies the (*peratiiui. The anterior opening may some- 
times be more easily niatle by passitig the index-tinger through the 
po!?terior opening, am!, if p^^ssible, hooking it over the broad liga- 
ment, so that it may .serve in some degree as a guide, and thereljy 
prevent the ojierator from wounding the bladder, ureters, or anterior 
uterine walL Then the index-linger of the left hand or a blunt hook 
is hooked over the left broad lig;imentj the ligament is dmwn down 
and seized by haemostatic forceps, the grasp Ijeing at a sutlicient dis- 
tance from the uterus to prevent the instruments from slipping off 



FlGfKE 212. 



jr4rrct,'p!4 i()r tlHmping the broad IJgamenta, 

after the organ has been severer!, The.se force|>s are constructed on 
the principle of Pean, but shntdd be Ixeavier and with jaws about two 
inches long. Various broad ligament clamps have been devised, !>ut 
none fulfils the indication better than the straight^ strong hiemostatic 
forceps. The forceps' handles are securely locked, the ligament is 
severed close to the uterus, and tlie whole uterus pulled outside. 
The organ now hangs by the other broad ligsmient. This in turn is 
clamped in the same way, and the uterus is removed by a few strokes 
of tlie scissors. The ovaries ant! Follopian tubes, unless already in- 
cluded ^vith the broad ligaments, may be secured by separate forceps, 
If, upon examination, tlie operator fears tliat the broad ligament is 
diseased beyond the grasp of tlie fori-eps, he may put on other lb reeps 
hack of those first a[>plie(l. The tirst forceps may then be removed 
and the suspected tissues cut away. Fatal hemorrhage has resulted 
from the sHpping of the broad ligament forceps; hence the necessity 
of so making the incision through the ligament as to leave consider- 
able tissue on the distal side of their jaws. To prevent the forceps' 
handles from snai>])ing apart, they should be securely tied togetlier 
with strong thread. 

In many eases the uterus is much eidarged, and the ligaments 
therefore on either side extend so higli in the j>elvis that they t?annot 
he drawn down within the grasp of a single pair of foR^eps. Then 
one pair of forceps may be put on, and that part of the ligament 



380 



TUMORS, TUBAL PREGNANCY, MALFORMATIONS. 



which is in their gnisp dividcKL The uterus can then be drawn 
further down^ and the ix'niaining portion of the ligament, liaviog 
been clamped by one or more forceps, may be severed. If so much 
space ID the vagina is occupied by forceps as to imf}ede the operator, 
fa single forceps may be applied back of two or more, and the latter 
then removed. Some oixrators leave the vaginal wound ojx^n for 
drainage with or without gauze packing. If no packing i,s us^ed, the 
peritoneal margins of the wound usually fall together and promptly 



FlGVIlB 218l 



/A 



tJtenu ftiit«¥erted and corpus drHwn ihrouf^b into vagina ; dgbt broad ligfunent bcliiff drawn 
down 1»3r index-finger and cUmficd by forcepe. A. Corpus uteri, B. Orvix uteri. 

unite. Numerourt caseF, however, of annoying intestinal adhesions, 
protrusion of tlie bowel, feeal fistula, intestinal obstruction, and |>eri- 
tonitl** prove tlu* danger of this pnietice. The wound may be elr»sed 
by the eontiuuous or iuterruptnl eatgut sntnri^ If drainage is re- 
quired, a small rope of twisted gauze or a rubber tube^ or both, may 




Brood ligftmcnt on both sides entirely in the gra»p of forceps. In ftrtun.! practice it in iiftual to 
flamp iitid Si'Ver the left ligament first, and then the riglit 

Whenever pnieti<^alTlo tlio liroac! ligament stunipH ifihonld be drawn 
down intotlie vagina anil fixed t!it re by eat^ut sutnresj so that every- 
thing int'hided in the bite of the tV^rceps may l)e in the vagina. The 
advantage of this in twofold: L All tnuiinatisms, wive the i^imple 
]M*ritoneai wound, are excluded IVom the |x^rttoneLim. 2. The liga- 
raentH, when united to the npjM-r end f»f the vagina, support the jKdvic 
floor, and with it the re<'tum, 1 bladder, and vagina, t?o that euteroeele 
vaginalis U prevented. See Figure 210. 

Reeto vaginal ami vesieovaginal fistn he are occasionally the result of 
vaginal hygterertnniy. Sliouhl sueh aeeident oceur, the repair i?^ 
simple. In uniting the |>eritoueal edges to the vaginal e<lgc8 of the 
wound anterior and posterior to the uterus by the whii>stitch already 
des<Tibed, it is tmly uei'essary to use aihlitioual interrupted sutures 
at the {Mjint of the fistula. These sutures sliouhl not be buried, but 

iFit^iirefl 214,215, 2l6«mi]d 218 are fiuggGBtiHl by those tf Biildy uivd Penrose, of which they 
are mudlflcntioaj. 



:»2 



TimonS, TUBAL PRKaNASCY, MALFORMATIONS. 



should include tlie [Tf/ritoneal and vaginal nirttxi"^* The Btronjj ten- 
<l(Tn-v of iR'ritoneal wurlacos tn adhere to any cxp^j^od {surface renders 
union ulm<i.st certain. 



Ftrttre 2tft. 



./? 



f/i 



k\->( 



Two hrtMid IJ^iiiDc-iit forfH!^)" <'n each aide tn place. LigiimeiU iCTcr&d on one side and parlly 

eevered on the oLher. 



Vaffinal Hysterectomy with HsBmostasie by Ligature. 

FIieinot?tiLsis hy liirnturp involves no very material ehange in tii'li- 
nitjtie save the use of li^atiirL^s iji j>laee iif prej^sni^e t'oreejis. Alter 
the anterior and posterir»r ii|R^ninj^s already desenbed liave Ijeen made, 
and the br*»ad lij^unents have been isolated, eaeh ligament may be 
tnins fixed ant I tied ai mn>isv^ or, if very lar<re, in sections. The ai>- 
plieation of the hjiriitnrc may lie faeilitatei! liy retrovcrtinj^ or ante- 
verting ihe nterns, ;hh1 Iiy dniwin^ tlie corpus throngfi eittier the 
anterior or the posterior iipt^ning by mt-ans of vnlndhini forceps. 
Thirt twists the ligatnents n|Min themselves, makes them smaller, and 
brings their np|K*r margins nearer to ihc operjitor. St^parate ligjitun:'s» 
are usually needed for the nterine ap[>endage>. The followirjg ents 
will show the teehnioue of the t»|X'ration. l'3*ich ligtunent is nsnally 
ligatnred in two or three sections. The ligtitnres — prefend>ly catgut 
— are passed by means of anenriHm needles, or with the ordinary 
thrcadwl needle and foreeiis. Portions of the ligament on either bide 
are progressively tie<l and cut away fn>ni the nterns nntil the organ 
is finally removed. In many cases hystercetomy is facilitated by 



TUMORS OF THE UTERUS— CABCiyOMA. 



383 



dividing the litems into two halves. Eufh hiilf may th(*n ht* drawn 
tliroiigh tlie vagina separately and rerouved. The ends of the Hga- 



FlOLiRE 216. 



Bads of broad ligament stumi^ fixed by forceps and nut ii res. to the ends of vagi rial wound. 
^utUTva alone am m^nntilJimv^ used* 



tiires, having been left Lmg, are now nsed to draw the stumps down 
into the vaginal wound^ where, as in the foreipressure operation, they 
are fixed not by foreeps lint by the sutnres whieli are used in the 
closure of the wound. The lipiturcs are now eut short. If the 
stumps will not reaeh to the vagina, tlieir ligsitiires are ent short, and 
they are n^tnrnefl to the pel vie eavtfy. St onetimes all the stumps are 
too short, and theretore must he treated intra peri toneally. Tlie vag- 
inal wouikI will then be elosetl as the eoudilion may refpnre, with or 
without the gjinze dniitL S(^e Chapter VII., on Drainage, 

After-treatment, The general proee<lnre in after-treatment (lifters 
in nothing from that of ordinary abdominal s^'i^tiun. The foreeps and 
vaginal gauze and the drain, if there he one, should !>e remfjved at the 
end of forty-eight hours, and a oDe*half of 1 |>er eeut» lynil douche 
given. If the wound has he<'n left of>en au<l packed with gauze, 
great eare should be nsetl lest in its removal a 1«m)j> uf intestines he 
drawn into the vagina. The douche may be rejx^ated diiily, or, if 
the discharges ar^' fetid, oftener. Let the dou^-he be a weak eurreut, 
lest it force its way through the fresh adhesions into the general 
peritoneum. 




Breed U|$]tiiienU iteoitd hf threat en moMte llg«tore« on escli side. t4gPiD«nt terered on left 
ti<lif and parti J ttfrered un rigbL 

Helative Merite of the Ligature and Forceps Operatioii. 

77i*' udrnntnfje of prenffure force pn over the ligature are: 1. The 
jjreatt^r facility of apjilkatifm vcrj' iDiilerially sluKrtens the oper- 

> Aft«r Aucual 3f«rtiu« tn American Syilem of Gynecology. 



TUMORS OF THE UTERUS— CARCINOMA. 



385 



ation ; therefore in a difficult case, with iniieces^ibte broad ligaments, 
they are safer. 2, The forceps may he made to grasp a confide iti hie 
portion of the broa*I ligiimerjt; the ligimieiit may he drawn do wii and 
grasped further baek by another f*>reep8 ; more of the ligament may 
in this way he ine hided than would he possible with the ligature. 
Whatever the fureeps grasp will wliKigh ; by tfiis means a very large 
p<>rti<m of the tigameut may be ilestroyed. Some part of the diseat^e 
wlueli the ligatare niiglit have missed may therefore be removed with 
the slough, 3- The forecps taeilitiite drainage. The secretions find 
their way out along the solid instrument by continuity of surface. 
4. If tlie ftjrceps are properly eonstroeted and appliedj the security 
ag-ainst secondary hemorrhage is vtny great. 

The €Usfu{vanlmf€.s of the Jrirceps as com|)ared with the hgature 
are : L Tliey e4inse great snfrering to the patient. 2. Their removal 
is {lainful. 3. Convalescence is apt to be more protracted and com- 
plicated. 

Both the ligature and the forci pressure operations are efficient and 
satisfactory ; there fore j whieliever is most convenient or will most 
facilitate the opTation shouhJ be used. The foret^ps will always be 
prefemtile in grave cases» especially when the ligaments are very 
tiiick and inaccessible. Ofttimes both methods will be useful iu the 
same case. 

Combined Operation of Abdominal and Vaginal Section, 

When the vulva and vagina are small and the uterus ig lai^^ 
high in the i>elvisj or fixed, its removal througli the vagina will be 
very difficult Under these conditions, after making the vaginal 
incisions and separating the cervix from its surroundings, as already 
dcscribeil, the operation may be better finished through an abdominal 
opening. The tecliniquc is the Bamc as that described for hystero- 
myoraectomy. 

Mortality of Hysterectomy for Cancer. 

In properly selected cases^ — ^see Indications for Hysterectomy— the 
murtality of vaginal hysterectomy for cancer is s;malL In one series 
of more than iifty iMinsecutive ci^F^es the author had no death. Out 
of ten combined operations in which the abdomen also was opened 
he had two deaths. 



Recurrence of Carcinoma after Hysterectomy. 

The recurrence of cancer of the uterus after hysterect(miy is less 
frefjueut than after its removal fr^jm other parts of tlie bmly. Even 
in eaneor of the breast, where hy reason of the exposed position of 
the growth the diagnosis is usually made earlier than in the uterus, 
recurrence is much more frequent. This is true notwithstanding the 
common practice f>f th(irough removal of the subclavian and axiUary 
glands in connection with tlje breast ojjerations, and notwithstanding 

26 




386 



TUMORS, TUBAL PREGNANCY, MALFORMATIONS, 



the fact that in the usual hysterectomy the pammetri<* glands are" 
sc'ltloin removed, Tlir statistics of the best onemturs sliow fretnlom 
from the disease two or more years after vaginal liystereetomy id from 
alioiit 40 to t>C) JMT eeiit» of all eases.^ 

In order to prevent reeurronee of the disease the usual rule for 
the removal of ciineer in other regions applies — i, r.,eomplete removal 
of all the apparently diseased tissue and of as wide a margin of 
iidjaeent tissue as safety will permit. This rule is billed upon the 
invariable tendency of cancer to foUow tlie vessels, especially the 
lymph vessels, into the surrounding structures. 

More Kadical OperationB of Hysterectomy, 

More radical operations for the further prev^ention of recurrence, 

have, though thus far with little encouragement, l>een proposed, viz., 
the removal of all ]>en-uterine and lumbar glands- and the exei.^ion 
of the broad ligaments close to their pelvic attaclmu^nts;'' Both of 
these proctHJures require ereliotoiiiy and greatly iucreaso the trau- 
matism* The removal of the broail ligaments involves the following 
steps: K The uterine artery on each side must be dissected out 
beyond its vaginal tiraneli, and tied, 2. The ureters must be dis- 
sected free from the l»ase of the broatl ligaments, 3* To avoid 
wounding the ureters they must each contain a bougie passed throngli 
the urethral speculum. Tlje increased traumatism, great difficulty 
of technique, and, above all, tiie time retjuired would probably 
increase the mortality of the operation enough to oflWt any i^ssible 
advantage. 

The (liffioidty and danger of tlie removal of broad ligaments and 
all the lymphatic ghmds in connection with the hysterectomy for 
tiancer, will be apparent from examination of Figure 219, 



Palliative Treatment, 

When cancer has extended to the Madder or rectum, or has materi- 
ally involved the vagina or pai*ametria, and e.^pe eially when the uterus 
is fixed, hystere<»toray is extni-dangerous atid useless. Unfortunately, 
the onset of the disease is so insidious that the early symptoms of 
pain, hemoTrhage, and watery disi-harge are either overluoked or 
attributed to other causes ; henee the diagnosis is not usually made 
until too late CtiV radical cure; then palliative treatment <"au hold out 
at best onlv relief from sutl'ering during the few months of remaining 
life. Palliative treatment is l>^►th local and system ic» 

Tlie ofjjvcf of ionfi hrahnnd is to cheek the exhausting hennirrhagos 
and discharges. This is l>est accomplished by sliarp curettage of the 
more sufM^rfieiab soft, ul<*erating |x>rtion of the cancerous growth. 
Remember that the disease may extend through the vesieal, rectal, or 
uterine walls, and that, witliout care, the bladder, bowel, or perito- 



itm. 



' AmcrfCMH Toxt biK»k of Gynecol oiry, 

• Rle« M(i<lem TrMitmf nt of i'fttu'er of the Uterus. ChlcHRu MeiUcul Hecarder. NoTcmber» 



• i, Q. CUrk> Johiu Hopkin« Uunctln, xUf., xUii . July ftod Augtitt, um. 




TUMORS OF THE UTERUS— CARCiy DMA. 



387 



neum may be opened. The reJunclant cancerous mass havinj^ been 
rerin>vcrl, the surfaee thus exposeJ sliould be seared over with the 
Paquelin or galvanic cautery, or cauterized with nitric acid or with 
an 8 per cent, .solution of chromic acid. 

The cancerous growtli may be kept down and the fetid di.sehai^es 
at the sauK' time detMlorized by the application every three or four 
day 8 of a j^at united solution of iodine crystals in pure carbolic acid. 
This application it^ be.^t made on f^niall tampons. The healthy parts 



FlOUBE fit. 






Lymphatics taf uteruii and upper third of vagloa.* 

of the vagina may be protected by covering the mucosa with gauze 
pads. 

Deodorizing douches are uscftd to destroy the nauseating fetor of 
the di.^cliarges. Among the best of these are peroxide of hydrogen, 
a 2 |)er cent, solution of potassium j>ernianganate, a WTak solution of 
formalin, or liquor sodte ehlorinatie, one jmrt t^j ten parts of water. 

* After W. W, HujJselL in American Ju^iriial of Ob(»telrica. 




388 TUMOBS, TUBAL PREGNANCY, MALFORMATIONS. 

The hemorrhage is best controlled by the curette and cauteruation, 
already described. A sudden profuse hemorrhage may be checked by 
a douche of hot ivater, hot vin^r, or hot alum solution. Should the 
vaginal tampon be used^ it will become intolerably ofiensivei and 
should therefore be removed in twenty-four hours. The erosion and 
excoriations of the external genitals and nates, which are caused by 
the ichorous dischaiges from above, may be relieved by frequent batlir 
ing and by the application of bensoated zinc oxide ointment. 

The general treatment includes r^nlation of the bowels and Iddneys, 
tonics, nutritious food, mild exercise, and massaee. Pain is a dear 
indication for morphine or opium. Life will Be limited to a few 
months; hence the danger of the opium habit is not significant. 
Numerous drugs, both for local and systemic use, have been lauded 
as cancer cures ; they are, so fieir as their merits have been investi- 
gated, useless. 



CHAPTEE XXX. 

TUMORS OF THE UrKIiUS--SARCOMA AND DECIDUOMA 

MALIGNUM. 

SARCOMA. 

Sarcoma is a malignatnt tumor belonging to the connective-tissue 

group. As eoiu pared witii eiireiuonia, it is of rare oeourrenoe. The 
disease, which may apiK^ir at any time during the age of sexual 
maturity, has been ol>serveil as hite ns tlie age of seventy. Like evin- 
ce r, it is more frequent at about the |>eriod uf the menopause— tliat is, 
between forty and sixty. 

Histogenasis* 

Sarcoma may develop from any of the following sources : 1 , the 
interglandular connective tissue of the endoniutrinni ; 2, the intermus- 
cular connective tissne of the myometrium ; 3, tlie walls of the IjIoikI- 
vessels ; 4, the perivascnlar conneetive tissue ; 5, the muscle cells ;^ 6, 
any of the structures of a uterine myoma. 



Pathological Anatomy. 

Three well-defined clinical forms have been described: 

tn Fibrosarcoma, 

6, Diffuse sarenma. 

t% Rntryoides — grape-like sarcoma, 
fi. Fibroearcoma, often called interstitial sarcoma, is the form that 
develops in the intermtiseular eimnective tissue. It is also frecpiently 
ttie resnlt of the so-called sarctmiatijus <legeneralion of a myoma. 
Like myoma, the growth may Ik- submueons, intramural, or subserons; 
its form and consistency are variable — /'. e,^ round, oldong^ or irregular, 
soft, or hard. The disease may be eireumscril»ed or diffuse. Its fre- 
quent ongin from a myi>ma <»ften gives it the !ip|H'a ranee of that 
tumor — i. *\^ of single fu* eireuniseribed ikkIuIcs seatterLnl ihroughont 
ttlie uterus. The growtli is rarely eneapsulated, tliough usnally well 
defined. The chameteristie cells arc round or spindle. The spindle 
cell mnre frefpiently predonji nates. These cells are often so elongtited 
as to apf>car like tibrons tissue ; lienee tfie name fibrosa reoma. 

b. Diffuse Sarcoma usually develops from tfie interglandular eon- 
neetiv(* tissue of the endometrium. In this furm the snadl round cell 
usually preilnminates over the spindle cell. The growth may be c<m* 
fined to sepirate areas, or may infiltrate the whole endonietrinni and 

1 WhltHdge WillfjiTns. Amerk^titi J our Lint of Ob«telrict, ISQi, yoL z:xix. 



390 



TUMORS, TUBAL FREGNANCV, MALFORMATIONS. 



rapiiily involve the entire uterus and juljaceiit organs. It develops* 
b<*tlj toward tlie eiidonietriiun and peritoaenni. Intra-uterine .s;irriFrna 
may take the form of iiumeiHius soft niedidlary p'^lypi. W'ht^n removed 
by the curett^j tljey have the gi*(jf?s appearance of earcinoriia. 



FlGURK 22Q. 



^^ 



FlliroiuiTcoma or »pindle-cea surcoma* SetuI-diiiitrajnTnnUc.i 

Cp Butryoides or Grape-like Sarcoma ia extremely rare, and usu- 
ally originates in tlie eervix. It has the f*>rm of eyst-like ninsses resem- 
blinji; hyilatid molr^!. I1ie growth is eoTn[)0,se<l mostly of ronnfl and 
spindK* eells ; it has been i>hserve(l in the nteri nfadidt wcMiien and 
children, and in the vagina of children,' The development of this 
extivmely mnli^naiit growth is most nij>id. 

Other varieties of cervical sarccjma are stiJl more rare. 

All sarcomata, especially the djflnse, are extremely vascnlar* The 
bh Mid vessels an^ snnictimes so enrirmntisly dilated as to ftirm t^aveni- 
ons spaces* Tiic lyrnph spaces may dilate into cystic cavities. 

Symptoms, Course, and Diagfnosis, The symptoms and course 
vary with ilifli'rent forms of sarcoma. The interstitial spindle-eell 
sarcoma, fiirmerly calh^l reenrriiijr iibrnid, is sometimes of slow 
jtrrowth. In exceptional eases it may not destroy life for several 
years. Tlic dill'usc, small ronnd-ccll sarcoma, <m the contrary, is 
tmllnarily much more malip:nant than carcinoma; it often goes on to 
a fatal result in a tew months. The lendeiiey of sarcoma is to scatter 
its nixlnles thrrajgh the uterine walls, to jienetrate the blmxl vessels, 
to extend t<i the pcritonenm, and to involve a<ljaeent organs* The 
thiekcncdj enlarged ntenis, the hhuMcr, and the neighboring intestines 

' AiiK^rkfin Systlttri of OyTiocT>UjKy. 

• Fevk. Fritm PUyfiilr's t^yBtem of Uyneoolagy. 




UiKryoldes, grnpc-lilce utrcomA, The DiiorofcopEe Ikiidinir* ^huw »]>indle cells. 8oinc of thv 



TUMORS OF THE UTERUS— DECIDUOM A MALIGN UM. 393 

through tlie vt^ius to distrint ur^iins. In tliis respect it diffirrs iVum 
carcim>ma, wliich is apt to truv4'l by the lyuiplintie?* and to ho ar rested 
by throtnhic plugging at points much nearer to tlie urigiiiul seat of 
the disease. The syniptemis and clinical conrse of interstitial sareoma 
in the beginning may so closely resend>le tlinse of myoma as to make 
the clinical diiignosis wholly nnrcliuble. The clinical course and 
physical signs of this variety in the later stages are almost ith^ntieal 
with tlioso of cancer. 

When sarcoma takes the place of myonui the growth rapidly 
increases. Hitherto painless, it now causes intense snft'ering. 
Hemorrhages are increased and supplemented by watery, sanious 
discharges, which, after the onset of ulceration and gangrene, have 
,n otibnsive mlor. There is a facial cx|>ression of distress. The 
•general depression is out of proportion to ttie anannia and inanition. 
Pres,sure symptoms, cachexia, and emaeiatiun are more and more pro- 
nounced, and of very rapid development. If the sarcoma becomes 
polypoid, the pain fn>m uterine con tractions is spasmodic^ and hemor- 
rhages arc fref[ucnt and prolonged, 

positive diagnosis is only possible by the microscope. 
Treatment. Tiie treatment, both radical and palliative, is the 
same as for carcinoma, vi/.., early liysterectomy, if possible. Unless 
all the disease can be removed , the operation Inistens death, ior it 
opens the venous channels, and thereby favors metasta,^is. Palliative 
hysterectomy — a questionable remedy in i^areitioma — -is therefore pro- 
hibited in sarcoma, See Hysterectomy for Cancer* 



Deciduoma Maligniim. 

Pathology, This dist»ase, first described in 1889,^ is the most 
malignant of all uterine timiors. The growth differs essentially 
from all other neoplasms ; its essential cell element is a large giant 
cell, Figure 225. This cell is embedded in a kind of cellular tissue 
which resembles sarcoma, ami which makes up the greater part of 
the growth. The pn*seuee of so much sarcoma-like substance has 
raised tlie question whether the disease is not essentially sarcoma. 
On the other hand, the tumor is epithelial,* ^' the tissue combining in 
its formation being ; L tiyncytium^ — L t\, the uterine epithelial layer of 



EXPI.ANATIOX OF FmFRE 223, 

1. Orrix uteri, with tumor hnuKkig frnm it (niituml slxe), Sound pisaod through cervical 
CAiial, L, n. Urie of excision ; a. «, nuil b, horry-Uke growths ; c. fViigujeutg of <lelleate epithelial 
membmnv covering a nurnb-er of \hv iMTrics. 

2. Beftlon of a b€irry hanlcned in alcohol (BtJaecho. Oc, i?, Ohj. 7); a, type of stroma ; ft, 
numerous int^riaciu^ AtriHtcd muscular Hbrcs ; c, tihrca tn whk-h the »trla' cnuTiot yet be seen ; 
At limes, f, these flhrt;a iirv cut IrauHViTsely. 

;i. <'ella from the third tumor, frvnh si>eclmen : o, stollHte cell with numeroin mii lei ; b, 
spindle ccllu wUh udc touj? nucleus ; at r the endfi of the wpimlle fatly ; cf, spindle ceUn* with 
several n in? lei ; t, fatly dchris with free nuclei, partly fatty. 

1 Striated spindle cell from the first timior. 

&. Muscle fibres from a five to six weeks' old embryo. > 




« Ranjyer. A Syntem of fJyuccolc^ry, by PInvfair 

• Mm re hand . K r run 1 *ln y fn i r ' f* s v m t vm m f i ; y n crt A oijy 

»Frt>m PerDlce, in Thomaa aud'Munde, iJi ceases of" Women, 



TUMORS, TUBAL FKEGNAyCY, MJLFOIIMATIONS. 

the chorion, 2. Tlie dooiunt of the .so-ailkd cellular layei* — layer of 
Lttiighant^— /, *:\, the eelmlernml epillielial hiyer of tlie elmriun/' The 
qiie.Htiun has ihereftjre als<j been raised whether the t*;ro\vth Ls not 
carciiionui. The elas^ifieati<iii, however, li^ mih jtnlhr. The disease lias 
been variounly designated, according to the jioint ol" view, as flyn- 
iiomaj ftarcomti^ tlcviduo erlltdarf\ and serotinal tumor. 
The growth is rich in bhM>il-.Hnj»|dy ;' the blood it? eonfincil within 
'7n*egular simcei? ; the vessels have no walls ; hence the frequent hem- 
Fro i^bk 224. 






K^. 



V 



"V 



^^ 






V 



&ucooia of liie enilomeirliiiQ.* 

orrhagos. XcfTotic elnmges lake place early. Tender the neeroj^ed 
tissue is solid tumor, ancl lUKler tliis is normal uterine tissue. In the 
development of the growth the normal constituents of the uterine 
wall are nipidly replacwl Ijy invasion of giant cells and small, round 
cells. 

Symptoms and Diagnosis. Prnl'usc hemorrhage occurring after 
lal»>r or abortion is the most el uirar tens tie symptom ; it is iiitcrniit- 
tent and commonly so |>rofiise as to cause proftMin^l aniemia* Curet- 

t H. M- Jtiii*^. A rlinlriil and Pathological fttufljrof l»ccldiiotiitt MuIigniiiD. Jahns flopkltit 
HoiipttAl Rcp<irtB, vol. vi. 



TUMORS OF THE UTERUS— DKCIDUOM A MALIGN UAL 395 

tage^ivf'ri hut transient relu'f. Tlie discharg*^ is profiists watery, and 
otlen frdil-snielliijj^. Hyiiatitl'likc moles may he discharfred with the 
lieraorHia^e. The uterus ni|ndly enhir<^es. Metastasis takes ])lace 
by the venous route, most eoiinuHnly to the lungs, anil gives rise to 
symptoms referahie to tlie newly iiifeeted part. Amenihu emaciation, 
and i-aehexia tVdIow in rapiti suecest^ion. Even though the disease 
be removed l>v early hystereelijmyj death in a tew months iri nsnal. 

Figure 225. 



dK-. 



ai^ttifUt of «iecid!inma. a. Oooidiiftl cell wiiii thirteen nuclei, h. Sami\ witli four nuclei. 
<*, Oiiint ci'll In |inn:esH<rr formation, uitli Uirec iiiicki. </. Liiliiuel ear decidual cell enekised 
In rtitltiululed stromii. c KcticulHte*! stronia,* 

Physieal examination will sIhiw an enlarged uterus, movable or fixed 
by adhesion. Smooth, seeon<lary no<luk*s may be felt on the tubes. 
The uterine eavity may be sutficiently o]x;n to admit the fingen 
Digital exfiloratiou will tlien detect masses of soft tissue and eoagula 
of blood usually localized in the uterine wall. The al>ove history 
a nil sy mjitorus are iiighly diagnostic. Mieroseopic examination of 
the scrapings will clear the diagnosis. 



I 




Frainnente of decldunina from same specimen ii» sliuwu Id Figure 225. a. Deridual eellit. 
Ltjueoeytes. c. BluoiJ aoriniaclcs. d. lntvrmu«<ulur cellular Umuc. e. Fusiform c«lli. 
/. Rotlcufum.« 

Treatment, Prophy lax is requires thorough removal of all retained 
products of coueeption and pnjmpt attention to post-abortum and 
puerperal hemorrhages. The surgical treatment is the same as that 
alrendy laid <lown for careintuna, viz., early hysterectomy. 



* Siinger, from Pu^xi, 



* Slinger, from TrcntiHe on Gynecology, Pyxjel. 





Cancer of the ovftry» iecotitlary to cancer of the brpHst. Both BUlifi afftctc'd. 

tuiwor with the uterus, and, as in ovarian cyst, is made up of the 

broad lipinient, o%'itltjrt, ovarian 1 lament, and ovarian vessels* 
About fj jRT cent, of all ovarjjui tiinioi^s are soliil. 

' J. Bland Sutton. Surylcal DiAcaaea of the Ovaii«a and FallopiaiJ Tut»e«, 

39e 




SOLID TUMORS OF THE OVARY. 



ay? 



I Tiu 
pro 



Fibromata ure Ijistologically iilentical witli similar tumcfrs in otlier 
fn'o^iin.'^. They are <tf rare u<-Turreiiee, s<eliUHn grow to large jsize, and 
are usually pedimculated. 

Myomata are rare, tlioiigli not hj vay^ as fibromata. They are 
oomposedof the usual unstriped muscle fibre and fibrous tissue — fibro- 
inyoma. The tnuf*ele filire i.s traceable Worn tlie ovary to the ovarian 
ligament at the [joint where live Hij^inieiit penetrates the paror>phonHK 
The distinction between the myoma and the sjiindle-eell sare*>ma, even 
with the microscope^ is not always easy. These tumors sometimes 

\x to large size. 

Sarcomata are not of frequent occurrence. They sometimes 
cjccur, especially among children, in connection Avith dermoid cysts, 
or follow their removal. The spindle-eell is nuire frcfjuent tlian the 
round-cell variety. As in sarciima elsewhere, rapid growth^ speedy 
degeneration, and metastiitic infection of other ftrgans cliaracterize the 
disease. Both ovaries are usually primarily involved at the same time. 

CarciQoma. Little is known of primary carcinoma of the ovary. 
It usually arises, if at all, in botli ovaries at the same time. Second- 
ary carcinoma may occur by extension from ncigldjoring organs or by 
metastasis. 

The identtfication of solid ovarian tumors will usually require the 
clinicid history, conjoined manipulation, exjdoratory incision » and 
microscopic examinatimi. The clinical history will often suffice to 
sei^arate tlie malignant from the lienign growths. Conjoined exami- 
nation will outline a tumor in the ovarian region, will show that it is 
not connected with tlie uterus, and will determine its size, form, 
mobility, aiul consistency. Exploratory incision will further define 
its ] physical characteristics ami its exact relation to adjacent organs. 
The diagnosis is concluded hy the microscope. 

The Tirafmeat of benign growths withtmt pressure symptoms or 
functional disturbance is expectant. That of large Ijcntgn tumors or 
of malignant timiors is early renioval. The nnHle **£ enucleation 
and ligature of the pedicle is the same as for cystic ovarian tumors. 
See Ovariotomy. 




Showing cjst-prc)dudn^ region of the ovary and its surroundinea. A. Odphoron, B. Pftrod- 
p!n>r«>ii. C\ nirovurinm, K. Kobelts tube*. G. G&nner'& duct,* 

mner part of tlie orpni, is in relation with the hilum of the ovary, and 
h somi'times called tlie vascular or mcilnllary zone ; it is coaipi^sied of 
til » rims tissue traversed by nuniernus blood vessel s» and never contains 
follicles or ova. The paroophfiron is not in lie cunfoumled with cer- 
tain extra-ovarian tubides, called the |)arovariiini. Ovarian cysts may 
be classified, aeconliufi: to the eyst-prmbicing rejtrion of the ovary 
in wliich they springs into two divisioTis : A. Those which develop 
fmm the oophoron^ — oophorotic cysts. B. Thoi^e which develop from 
the paroophoron — paroof>horotic cysts. Parovnrian cysts which de- 
velop not from the nvary bnt trom the iiarovariom, being extra- 
ovarian, will be considered by themselves. 



OOPHOROTIC CYSTS. 

There are various theories of the development of (wiph orotic cyst», 
many of them comfdex, confusing, vague, and not proven. We have 

» The elaMifteiinrm und patholopry of ovaHun and narovnrlnn cysts follnvr miilnly those of 
J. Bhmd Sutton, nnd are tc*?*<ime extent iin AdaptJitlun from hU work, Surgical M-cu^i* of the 
Ovarii^ And Fanr)piati Tutn^ 

* J. Bland Suttitn. Surgical Dltcuea of the Ovaries And Fallopian Tubes. 



CLASSIFICATIOX AND PATHOLOar OF OVAHIAN CYSTS, 399 

the highest authority for the assertion that they spring from the Graa- 
fian follicles. It is at least proved that these follicles largely enter 
into their development. The subject will be treated from the stand- 
point of their follicular origin. 

Cysts of the oophoron may be clinically divided luto: 1 . Unilocular 
cysts* 2. Multiloeular cysts. 

Unilocular Obphorotic Cyste. 

Unilocular wjvhorotic cysts, sometimes called monocysts, are, strictly 
speaking, rare. These cysts in their incei>tion are enlarged Graafian 



m 



Inciptent o5phorotlc cyst In right Dvury. CnUrJcttloT oopharotir cyn in left ovary. Adenoma 
of the eodometriuni. LT. Lcfl tulje. RT. Right tube.* 

follicles, and when small their ^alls are lined with typical membmna 
granulosa. Almost all tumors classeil as monocysts may ap[mrently 
have a single cavity, but. close examination will usually show numer- 
ous small locnli in tiicir walls. Sometimesj as stated by Sutton, 
imperleet septa or bands running from one part of the cyst- wall to 
another shfiw that the cyst was originally multil(M"nlar. Parovarian 
cysts, which are usually unilocular, liave often iKeu mistakeu for 
(iniloeidar ovarian cysts; hence the possible inipre4>sioii that the 
latter are quite common. 

The cyst-wall is tfiin and t^omposcd of three layers; the outer 
layer of endothelial cells, or (K?easionally, on small growths, euboidal 
epithelium ; the middle layer of white fibrous tissue, and containing 
bloodvessels and lytBp>hatics ; the inner layer, or lining of mem bra na 
granulosa like that of the Graafiun follicles. This is maintained 
until the cyst reaches the* apprf»ximiite size of an p^g. In tumors the 
size of an orange the lining layer c^banges to flat, stratified epithcliuni. 
In large cysts of one or more gjdlf^us the epithelium disappears by 

1 AfltT Bctgel. 





400 



rrJIOES, TUBA I PR Kii XI NC\\ MA L FORM A TIONS. 



n\m\i\iy mul ^ives way to tihroiit^ lissiit\ The atru|»hie process iss due 
to tilt' j*re>sure of llie fluitl ooiitt'Dt,**, Tlie |ietlii'K', wljkdi conoects 
not only tliese Init other pixlmieykited ovuritui cysts with the uterus, 
is iiut<le up of broad ligament, round ligament, oviduet, and ovarian 
liloodvessels!. 

The rtuid eontained in some luiilocular cysts is Mentical with 
mucus. This doubtless coures fVuni their lining of eobnnnar ejutlie- 
linm, whicli di}>s below the snriuce, as in muciparous fj:lands. 

In some uoph orotic cysts the walls are lined with skin supplied 
with an outgj*o\vtb of liair, sebuce<jus and sweat glands, teeth, and 
other dermal apiK'Uilages; these are dermoid cysts. 

Uniloeninr oiVpliorotic cysts vary in ^\ze from the capaeity of a 
single folliele to that of several gallons. 

Multilocular Oophorotic Cysts. 

Multrhx-nlar eysts, or polyeysts, are probably identical in their 
motic rpf devehii>mcnt with the unihieulur variety jnst described — 
i, €',, tliey iipparentiy develop from the Graafian follicles. 

An aggregtUion of Graafian follicles which have failed to ru))ture 
and disehargc their eonteut^s may be distended by their own secretions. 
The failure to rupture may be due to inflammatory thickening and 

Figure 230. 



Microcystlc degvoermtiuo of ovary.i Such eniAn cysts mts take oa eaEC<!CiiY« growth or m^ 

remain lu here represented. 



trMitrheniug of the walls of the sac. The follicles may then remain sim- 
jile small retetili*m eysts. See Mierocystic Degeneration of the Ovary 
in Chaj>ter XXI. Ketention eysts may form in one or many follicles. 
On the other hand, the fi ^llieles may take on new growth and develop 
into pal|>able ovarian cysts. Figure *SSi) shows the honeyoond^ecl 
arnmgcment of the small nudtij>le eysts. This simple cystie devel* 
o|inieut may increase uutil the tumor becomes enormous, a burden to 

k After Belgel. 



CLASSIFICATION Aa\D PATHOLOGY OF OVARIAN CYSTS. 401 



the patient and a destroytT of life. Witl» i iicreasi n^^ size, as in the 
uniUMHihir variety, the vvlU of epitlieliiim lininjj^ tlie various compart- 
ments become flattened, and may linally disappear by pressure. The 
cyst- wall has the same structure as that of nionocysts. 

In niiiny cases the germinal epithelium of the Oraafiaii follieJes 
goes to form ghmdidar struetures, and the tnrnor becomes a so-c-alled 
gbudular cyst or an atleuoma. Adenoma will be recogiii^ied as one 
of the moBt common forms of ovarian cyst. It often grows to euor- 



Fj^irKK J31. 




Portion of *n oiraiian adenoma* showing the vaiietlea of locull. e. Prtmafy* d. Seeondaiy.i 

moUB size. The whole is made up of numerous email eysts or loculi ; 
they varj' in size fnjm the e^ipaeity of a drachm U> a quart or mor€ 
of fluid. Sutton recognizes three varieties of loculi ; 1. The large 
primary eav'ities, 2. A honeyeoml)e*l'like mass of cavities whieh 
develop in tlte wall of the primary cyst and jmtjtH'ts into it. This 
mass is made up of secondary cysts; they are moeous retention cysts. 
3. Small-sizc<l fmvities without honeyc*imlKHl arrangement** which 
have the histological characteristics nf di-^tcnded ovarian follicles. 
The relation nf the primary and secondary cysts to each other is 
shown in Figure 231. Ovarian adenoma has a strong tendency to 
become malignant ; hence the importance of it** early removal. 

1 J. Bland Sutton, Surgical Di*ca««» of the Oirariea and Fallopian Tubes. 
H 



402 



TUMORS, TUBAL PJiEGXANCY, MALFORMATWSJS. 



In these cysts am oft<jn fiamd dermoUl elements in small or large 
(|iiaat]t]es, i^uch as hair, minxm.^ ineoibrarns skin, st^baceous and sweat 
glands, iinstriated muscular fibre, fat, and tooth, A gingle tumor 
may have some cysts containing dermtml elements, others containing 
mucus, and others which are like di.stended Gniatian follicles. 

The adenomatous cyst often shades into the dermoid cyst8 by a 
gnidation which, from tlie t'linieal stand jRiini, is almost imj>ercep- 
tible ; tlte dividing hne, therefore, l)etw€en the adenomatous and the 
dermoid varieties of onpliorotic cysts is arbitniry and impossible to 
define. The ^reat clinical importance, however, of dermoid cysts 
calls for sjx^cial deM'ription. 

Oopkoroiic Dermoid Ct/st^. The dermoid may be defined as a cyst 
containing skin or mucous merahmne. Some cysts contain both ; they 



•'wBl^ff^f 



*x 



! 'A3 



>^/ 



l^v\ 



4" 



'"^^Z 

M^-^ 



Portion of walj of ovarlm dcpmoid <3y*L ci. W*U. *». ElevntionPt riitupcned of fkltj and 
eutaneoufl tisane, f. Hnir rf. Teeth.' 



are found not only in the nvary, but in various other |mrts of the 
biwly. The quantity of dermoid elements is variabhv. The skin or 
mucous niembrane may line the entiiv cyst or may be <liscernible only 
over small istdatcd areas. When the dermoid elements are contained 
only in a i^ingle small eonijmrtment of a large mnltil<i€u1ar cyst the 
dermoid chanicter of the growth is apt to Im overlfMike*!, 

* From Ztegler, in Amcrleiifi Hyrtcm of Gynecology. 




CLASSIFICATION AND PATilOLOaY OF OVARIAN CYSTS, 403 

Oiiph(L)rotic tk'nmnds may cuntuin tiny or all of tlie fnllowlng struct- 
ures and their prmliiets ; Skiiij nuii'ou?; tnembrane, sebaceous gbiiids^ 
Bweat glamlsj hair, teeth, ma mime, nail, horn, bone, unstriped muscle, 
fat, and braio-liko matter. Fij^iire *Jt32 iUustrates i^ome of the j)eciUi- 
arities of these extratjrdiuary growths. 

Tile !iau* Hometime.s is present iu great almiidance, and may be 
matted together in tiie form <if a round ball the size of an orange. 
The color aceordiiig to SnttoUj is \'ariable^ but *K>es not neeestiarily 
eorrespimd with that on the iodividiiars head. In aged people it 
may l>e gray, and may have been nhed, leaving the eyst-lining balfh 

Extensive involvement of both ovaries m <lermoid eystic disease, 
even though little normal ovarian tissue remains, does not positively 
rentier the woman sterile. In one ease the patient, at the age of 
thirty-nine, had had twelve children, the last one was three months 
old, at the time of removal of two derrnoitl ovaries.^ 

I Dermoid tumors oecnr at all ages, frt>m infancy to extreme senility. 

They are occa,sit>naIly found in ehildren and are not uneomnion in 
young women. Unlike otlier foriiis of ovarian eysts which destroy 
lite in tliree or funr years, dertnoids may exist for a lifetime and give 
little or no inconvenience. They have hi^n tbund post mortem in 

Iagetl women ^vho may have liad them from tlie pericnl of sexnal 
maturity and have never been aware of their presence. Like other 
cysts, however, they may at any time undergo suppuration and other 
secondary changes, and therefi^re become dangerons. Although usu* 
ally classed as innoeeut tumors, they iK'c^asionally give rise, especially 
in childhood, to malignant degenenU ion. 

■ The tluitl-con tents of a pronounced dermoid cyst is an oily fat ; at 

■ the temperature of the body it is liquid, but at a lower temperature 
semi -sol id. 

The yaturul Finkl-conlents of an Onlhian/ Oophnroiie Vyd are 
usually transparent, clear, and of li|^ht stmw-i'olor, and of a speeitic 
gravity from 1010 to 105D. In the progress of the disen,se secondary 
changes m^<nir which make the widest variati<ni in its physical prop- 
erties. This variation is caused by the admixture of Idnml, pus, fat, 
epithelial cells, cholesterin, and by ehcmicid elianges. The Huiil there- 
fore nniy be thick, tliin, dark, light, clear, muddy, chocolate-colore<L 
The fluid of (janiojilnirotic cysts, about to be ileseribed, is apt to 
remain clear, thin, and light-colored. Chemical prc*[>erties and 
microscopical appeamuoes are ranch the same as those of oophorotic 
cysts, 

PAROOPHORITIC CYSTS. 

Pathologry* These cysts develop in the parmVphoron. See Chapter 
XXXII. They are not to he confi>nnded witli an entirely different 
tumor, the parovarian cyst, that deveh»])s from the parovarium. * Vsts 
w'hich spring from the paroophtu'on have the follow i Tig characteristics: 

L They are rare before the twenty-tifth year, more common between 
the ages of thirty and fifty, seldom grow to the large size of the 
oiiphorotic cysts, and are usually unihwular. 

' CuUlngworth. J. Blniid Hutton Sur«ir»l li^iseiuea of Uie Ovndtius iind FaHopian Tubt'S. 




404 



TUMORS, TUBAL PH KG NANCY, MALFORMATIONS. 



2» They caiiimonly develop between ihe layers of tlie mes^jsalpinx, 
and finally, with increased growth, separate the kyers of the broad 
ligament and force their way between them to the Jateml walls of the 
utenis, and often, therefore, feel^ on digital touch, as if they wx*re an 
outgrowth from the uterus, 

;L They eontiiin in variable f|nantity warty or papillomatous 
growths ; hence the name {mpilloiiiatous cysts. It should be noted in 
this connection that other papillomatous cysts are found in the ovary 
and broad ligaments which have not developed from the paroophoron. 

FiariUE 233. 



^ 



Pmrodphofotif cyst. Its T<*lationB to tbe tubi\ ovary, and mcsnitalpinx arc well thowii« 
warty ])apnJomatt)Uii development b ibown instde the cyst cavity. ^ 

The cvst-wall is eompnsed of the usual fibrous tissue and of an 
i n n e r 1 i n i n g o f cy 1 i n d r i ca 1 e { i i tl i el i u m . The sou iTe of this e p i th e 1 i 1 1 n\ 
18 not definit(*ly kunwn. It is thought to be from remnants of epithe- 
lium from the Wolfliau body.^ 

The chief chamctcristic of these cysts is the |>apilloniatous or 
w^arly growth whi<'li they contain. The warty masses proliferate 
mpidly, bleed fn*ely on manijiulatiou, are soft and friable, vary in 
quantity from that <*f the smallest wart to that of an oningt^ may be 
either st*ssile or iK^luncutated, an<1, according to the variable l>Iood- 
supply, pale or pink. These pafjillnniatous elements may so incrt*ase 
in quantity as to force their way by rupture or pt^rforation thn>ugh 
the cyst-walls, spn^ad over the outside, and aficet the adjacent jx^ri- 
toneuni. They sometimes undergo calcification. Warty ovarian cysts 
may be associated wnth dcrnniids, nntl tvccasionally with sarcoma of 
the ovary. Tapping is contraindi4'ate<l, for if fluid csca|>es into the 
alKlominal cavity the jwritoneum may become infectc**!; hence in their 
removal care sliouhl be used to jvreveut the escape of fluid. 

Other pupillomatous cysts which, aceonling to J. Bhmd Sutton, do 
nt^t spring fnmi the jwiroophoron, difl'eiv he says, as follows, fmm the 
warty {jaroophonitic cysts just described : 

t Ijumti. Tmn»ai-Uuu8 raihologioAl Bockty. L«indon, vol. jc^xli. « Ibid. 




CLASSIFICATION AND PATHOLOGY OF OVARLiN CYSTS. 406 

1. They inny h(\ in iiny part af the ftViiry. 

2. They lire Ufsuiilly timltiple. 

3. The wiirts are of almcKst cartihiginouH hardness. 



Piatms 331. 



LO 



fH 



m^l 



Yi'J^P^ 



i^». 



rcy 



'^?^. 



Buperficfnl papilloma 1 11 vol vlng both ovarlfs. HO. Right ovuryK LO. Left ovary. /u. Fundus 
uteri, he. Hyiilhie cyst pv, l*fiplJlary ve^ftJitions. cy. €yntic tumor: bfr. Bfomlvt*s&el8. 
hm, HyihaUl of Morgagni, old. Ahdomliial oriflee of right tul»f . otjs. AMoinlnal oril^ee nf left 
tub€, kc. Cukarmius deposits, ti. Brijfld lii^ameiit. Ir, Elound 111 (Earn eut. av, Aln. veapertllionlH. 
«/, Uteru«. ptm. Vagliml portion af uteruo. t^. VRginal wall laid upen.i^ 

4. They are not known to grow to such size as would make them 
dangerous to life. 

6. They are frequently associated with uterine niyomata. 

6. They are apt to ?^pring from the neij^hborhood of the paro- 
varium anil to burrow betweeo the hiyers of the mesosalpinx, quite 
away from the parovarium. 



PABOVARIAN CYSTB. 

The parovarium from which tliese tumors spriug is the remnant 
of the Wiilffiau body. It has no known physiological signifieanee. 
The epididyuii?? and va,s*i (^fferentia in the male also spriug IVom the 
Wolllinn hotly and are the honiohjgue of the jiarovariuni. If tlie 
brnafl ligiiment is stretehed and held up to the light, a series of small 
tubules will bo seen radiating from the ovary and jtHuing at right 
angles a longitudinal tubule. The tubules are the parovarium. See 
Figure 228. They ar^" of tliree ktuds : 1, Tfie vertieal tubules. 
2* The outer tubules, free at one eud — Kobe It's tubes. 3, The longi- 
tudiuid tul>e — Gartner's duet. Tlds duet is the honiologue of the vas 
defereus in t!ie male ; it may fi<*eiisi(uially \w tnieed downward to the 
vagina. The parovarium lies between tfie folds <jf the mesosalpinx. 

The little tubules of Kobe It are very often distended by their tin id 
eontents into si 



cyfi 



uiy not larger 

1 Aflf^r Coblene. 



pea. 



cysts, 



406 



TUMORS, TUBAL PREGNANCY, MALFORMATlVS^ 



which luive little or no sign iti ran co^ are fretjuently confoimdei] \ritil 
tlie liydatid of Mor^rujini. A distetHled vertical tubule may bt*eume 
g€parate«l antl fimn a jMHluneuIated cyst. This may rupture, disc ha rtre 
itj? contents into the abdoniiual cavity, and become obliteratedp The 
remnant of the cyst-wall then presents a fringe-like apiK^aranep. 

The usual |)arovarian evHt i^pnngj? from a swingle vertical tubule* 
When the tiuuor develops? from a single tubule it is monoeystic. Most 
commonly it develops ami remains bt^tween the layers of the mesosii!- 
pinx. As it gmws larger it forces it^ way between the hiyers of tlie 
mesometrium—that it^, the broad ligament — and lies in close relation 
with the uterus. Tiie FaUopiaii tube, with its Umbriated extremity 
attache*! to the ovary and its uterine end to the uterus, is stretched 
over the enlarging eyst-walh The tube in this way is often enormously 
elongiited ; its lunieu usually remains open. The tiuibria^ are easily 
recognizeiL 

The walls of small cysts are usually quite thin and trans]>arent ; 
when larger tliey become thick, o|jaqiu?, pearly-like, and c*f conjunc- 
tival blue color. The lining of the small cysts preserves the ccibuunar 
epithelium of the tubule; in larger cysts the epithelium becomes flat- 
tened ; in the largest cysts the atrophic influence of pressure is so 
great as entirely to destroy the epithelium. 

FiouEE 23S. 




I 



Smiin purovarlan cTit. o. Tteru^. ^. Ovary r. Tumor.' ^;hfmlutf the rclntions of iJicovary 
Mini VnlU*\n\a.n tubes to Ou* cyst. 

Unlike the ovarian cyst, which is a diseastnl (»vary, the parovarian 
cyat usually has a normal ovary attaebed to its side. The fluid is 
almost always clear and eolorh\<s, like spring-water, and on the nitric- 
acid and heat test sliows albumin. The specific gnivity is usually 
much lesj^ than lOHl The reacfiou is faintly acicb See Tabular 
Diagnosis Ix-tween Parovarian and Ovarian Cysts, in tljc next chap- 
ter. Adliesions rarely form alnrnt these cy.*^ts. Tlie jH'ritoneal cover- 
ing is easily st rippxl off*. 

The parovariiun does not take on demonstrable cystic disease Iw^fore 
the age of pulK^rtv. The more common age for the ilevelopnu^nt of 
this tbrm of eyst is from eighteen t<i thirty-fiA'c. 

Ctfuf^ of the Ih'offff Lhjammi. This name is reserved by many 
to designate parovarian cysts. Various other cysts, however, also 
develop in the broad ligament. The name, therefore, has no definite 

» AOer Bantock* in AmcriciiD Hj^tcm of Cyti ecology. 



CLASSIFICATION AND PATHOLOGY OF OVARIAN CYSTS. 407 

significance beyond the faet tliat it designates a cyst situateii between 
the layers of tlie ligament* 8ueli a cyst may originate in the ovary 
and gradually force its way between the fokk of the broad ligament. 
It not uncommonly originates in the paroophoron near the hiliim of 
the ovary. The gn^at majority of broad ligament cysts are either 
paroophorotic or f>arovarian. When tlu^y are of ovarian origin they 
are usually called intraligamentous ovarian cysts, 

OYARIAK HYDROCELE. 

In this rare and enrious disease the dilated Fallopian tube conimii- 
nicate:^ by it^ abdominal opening with the cavity of a eyst. The open- 
ing is usually lai'ge and circular. Ae^^rding to Bland Sutton/ the 
formation of the cyst is analogous to that of hydnxrele in the male^ 

FiGttRE 2:56, 



Orarlftn hydrocele. Nutuml sizt'. F. FalloplaD tube. V. Uterus.* 



He gives evidence to show that it arises in a tuni(5 of peritoneum, 
whicTi sometimes invests the ovary as the tunica vaginalis covers the 
testis. 

Ovarian hydrocele may enppnratej and may then easily be ct>n- 
founded with a tubo-ovarian absces.s. The treatment is ovariotomy, 

* SuTgleal Disease!* of the Oviiries and FnlhipUn Tubes. •Ibid. 



408 



TUM0B8, TUBAL PREGNANCY, MALFOBMATJON& 



• Ovarian hydrooele has hitherto been confounded with tubo-ovBTum 
cyst The distinctions between these two cysts are shown in the 
following tabular statement: 



Oyabiam Htdbocsli. 

1. Salpingitis hu nothing to do with the 
cause, although it maj be present as a com- 
plioation. 

2. The opening between the tube and sao is 
laige and round or oral, and is the dilated ab- 
dominal opening of the tube. 



S. The tube, not large. Is usually tortuous, 
Uke the worm of a retort. 

4. There is apt to be an intermitting dis- 
diarge of fluid from the tube through the 
. uterus.— Aydrogif tete prqfiitmu. 



TuBOHiTABUM Crcr. 

1. Salplngitisisac 
b^ween the tube and ovarian efit I 
XXI. 

2. The opening Is variable In ilae, and naa- 
ally does not correspond to the ahdmrntwai os- 
tium; if the cyst Is pumtent-^ a., If His a 
tubo-orarian absccw the opening Is nsnally 



S. The tube Is usually larger and not lor- 



4. Theintermittlug 
Jfaou—not common. 



CHAPTEE XXXIII, 



SECONDARY CHAJsOES-^SYMPTOMATOLOGY— DIAGNaSIS 

AJS[D DIFFERENTIAL DIAGNOSIS OF OVARIAN 

AND PAROVAIIIAN ( YHTS. 

BECONDART CHANGES, 

The principal secondary changes in ovarian and parovarian cysts 
are : 1 . Infection. 2. Twisting of the pedicle. 3. Rupture of the 
cyst. 

1. Infection. 

The sources of infection iVom whicli bacteria may re^ch the cyst 
are the adjacent organs^viz., the adherent Fallopian tube, urinary 
bladder, and intestine. Formerly^ Avhen tapping and aspiration were 
frequent and a.-^epsis was disregardwl, infection was frequently intro- 
duced by the puneture. Small cysts tJiat remain fixed in tlie pelvis 
in close relatious with the pelvic viseera are more subject to intlani- 
matiori than the hirge growths that fill the abdomen. When adlie- 
sions occur in large eysts they are usually stronger and more extensive 
in the pelvis than in the abdomen. 

The Fall(»[>ian tube is doubtless the greatest carrier of infection. 
This may be iuferretl from tlie fart that when an infected cyst becouies 
adherent to adjacent or^^ius the strongest adhesions are usually where 
the poison, if it came through the tube, would first reach the cyst — viz., 
about the alxlomiual end of the tube. The infenvnce is strengtheued 
by the almost constant presence of salpingitin in connection with in- 
fection of the cyst- wall. Infiammatiim and eonserpieiit adhesi<uis from 
this sonrce are nut, bowcver, confined to the neighlH)rhoo<l «>f the tube ; 
they may extend indefinitely over tlie tumor, gluing it t<i any adjacent 
peritoneal surface, viseeral or parietal, and the infection may even 
jieneti*atc the eyst-wall. 

The intestine and bladder, if inflamed, are prolific sources of infec- 
tion. The inflamed gut readily adheres to the cyst-wall, and becomes 
softened by the inflannnatory processor thin frrmi the atrophic results 
of pressure. (lerm-bearing guises mirv, according to Sutton, pass into 
the cyst and set up auppunttive inflamuiation of the sac, or the ad- 
herent gut and sac-walls may become f>erforated ; the sac-contents 
will then esea]w \yy way of the bo web Extensive infection of a cyst 
is not infrequently traceable to an inflamed adherent vermiform 
apix'utlix. 

Sfippnrtittfm. Inflaniniation of the cyst often goes on to suj>j*tn^a- 
tion anil to the formatioti of the most extensive adhesions. In acute 
suppu ra t i on the sy m [> torn s ra p i d I y becom e g ra v e ; t h ey a re : 1 . S ud- 

in 




410 TU3I0nS, TUBAL PREG^AMJY, 3fMF0RMATI0N$, 

dim I'tilarj^omt'nt af the tumor, 2, Sevore pain and tenflernesis. 3» 
Kupid jiJid wmk j>nl>^i'. 4. High tempenitiirt! aiid <^xliaii>tion. Acute 
nepliritis, witli albmninuria, is n fretjUfnt cum plication. In ^onic 
eases putre taction leads to tho tbnoation of ga;^cs in tlie cyst. A 
ttympunitir note is then elieited by percussion over the tumor duluess. 
In rare eases rupture of the siie and the discharge of its purulent con- 
tents through the intestine or some other viseus may avert the other- 
wii^^ fatal resnlL Usually the only hope lies in prompt ovariotomy. 
AtlkmnitH are among the most constiiut resolts of inflammatioD. 
Formerly they were the hSte twir of the surgeon. Now, with improved 
tech nipple, tumors that would formerly have lieen ahandtniefl after 
au explc^ratory incision are almost always removed. Adhesions may 
be abdominal or pelvic^ visceral i>r parietal. Visceral adhesions are 
those wliieh untie tujuor t<j the uterus, bladder, liver, and other 
abdominal or pelvic viscem. Atlhesions to the omentum ai^e common 
and often extensive. Intestinal adhesions sometimes give rise to 
dangerous, even fatal, obstruction of the bowel. Pelvic adhesions are 
more inaeeessilile, and therefore more dreadetl tlian the parictiU. Two 
large oviirian cysts, one from the right and the other from the left 
ovary, may eome in contact with each other and l>ceome strongly and 
broadly united. The difficulties of diagnosis and opemtive removal 
are then maeh increased, 

2, Twisting of the Pedicle. 

Rotation of the cyst, with consequent twisting of the pedicle, is an 
occasional and serious accident. 

Af^iffr Tormon is a sudden rotation of the cyst with sufficient twist- 
ing of the pedicle to set up grave symptoms. 

(Iiroftir Tortiiou is a slow rotation of tlie cyst, with gradual twisting 
of the pedicle. This gives the tumor au op|Mirtunity to readjust itself 
to the changed conditions. The symjitoms are le.^s severe and the 
courst* more prolongeil than in acute torsirtn. The impaired cireula- 
tion may be partially restored through adhesions. The jiediele in 
rare eases is completely twisteil off. The detaefied tiunor must then 
receive its !>lood-supply, if at all, by way of vessels which reach it 
only til rough adhesions. 

The Causes to whicli this occurrence has been attributed include 
alternate distention and evacuation of the bladder and bowel, a fall, 
violent exertion, and tight lacing. Rotation occurs most frequently 
when the tumor is eomplicated by pregnancy and when l)oth ovaries 
are cystic, especially when there are two eyst,s of consideralde size. 

Patbologrical Results and Symptoms. The cireulalion to and 
from the tumor passes tiirough the jK'diele ; lieuee t4U*sion of the 
I>edicle ?nust obstract that circulation. This obstruction will pertain 
more to the easily compressible veins than to the more resistant 
arteries. Blood may thertdbre flow in through the arteries after tlie 
return venous circulation has Ik^ch obstructed. This, in proportion 
to the flegree of tr>rst<m, will set up congestion. There may be only 
a flight tuiuelkctioii of the cyst- wall, jierhaiw occasional extravasa- 



UNGES. 



411 



tious of blood from small vessels* Id severe cases tlie venous en- 
gorj^einent may be so intense as to cause rtiptur*^ of the larger vessels, 
rapid and great distention of tlie sac from prol'use heinorrhuge, rup- 
ture of its walls, and tlie discharge of its eoiitcnts inio the abdonien. 
The liemorrhage may be ra pi* Uy tatub 

The twisting of the pedicle of a small eyst may, In- cutting tiff the 
I'irciilation, cause it to atrophy and practical ly to disapj»eur. Tlie 
atrophieil cyst nniyeveo become detached from the j>edieleand remain 
free in the abdomen. This fortunate result w<ndd clearly be possible 
only under conditions of absolute freedom fnan infectiorL As already 
explained, infection nuiy reacii the eyst frum various sources. Rota- 
tion, if suftlciently acute to cut off the venous eirculatiou, would 
result in gsingrene of the eyst, and, urdess ovariotomy were speedily 
made, infection and death w^ould ordinarily follow. 

The Treatment of both acute and chronic torsion is ovariotomy. 



3* Rupture of the Cyst* 

The cyst may rupture into the abdominal cavity, into auy purfr of 
the alimentary canal, or into the bladder. One locuraent of a multi- 
ItKudar cyst may rupture into another. Thin- walled secondary locu- 
raents very comnifuily rupture into the abdtuiiiiial cavity, leaving 
the rcnuiining com|>artments of tlie cyst intact. The opening made 
by the rupture may revniite und the cyst refill. 

Causes. Rupture from direct injury may be due to a blow, a fall, 
violent examination by the surgeon, sudden movement of the patient, 
or to powerful contraction of the al)dominal muscles in parturition. 
Spontaneous rupture is often caused by overdi stent ion of the stic. 
This is espcially liable to <jceur when tlie eyst-wall, or any part of 
it, from inflamnuition, distention, t»r other cause, is tliin or degcner* 
atetl, T^u'siun of the pedicle as a cause of rupture has been nottil in 
a preceding paragraph. 

Results. A ruptured parovarian cyst may in exceptional cases 
become obliterated ami therein' spoutaneously cured. Ceases of sup- 
posed ovarian cysts have n*]>eatcdly been i^eported as cured by tap- 
ping; but it is known that an ovarian eyst carmot be cured in this 
way; tlic tuuuu's in question must therefoj-e liave been pirovarian. 
The farmer practice of ta|»|3ing ovarian cysts, as a means of radical 
cure, has therefore been abandoned. Even parovarian cysts are better 
treated by rem oval. 

The contents of a parovarian cyst are usually mild and innocent. 
Rupture c>f tlie sac and discharge of its contents iuUi the abdnmen 
are theretore Imnuless. The fluid is quickly taken up anr! eliminated 
by the kidneys. If the Huid of a cyst pass by rupture into the 
stomach, intestines, or bladder, the opening may close and the rjic 
refill, or the r>pening may remain and transmit the contents of the 
vise us to the sac. In this way an ovarian cyst may be filled with 
feces and gjis from the bowcb The tumor-duhiess is then replaced 
by resonance on percussion. 

If the sac ruptures and sends its rtui<l int^i the peritoneal cavity, 



412 TUMORS, TUBAL PREGNANCY, MALFORMATJOy& 

the results are immediately more serious, Tbe aceident is usiuIIt 
marked by j^uddeu piin. A munueyst will discharge iti* whole con- 
tents and collapse- A polycyst, u[xid the rupture of one or more of 
its locuineiitf, only changes it8 ^hape. The escaped fluid is usually 
elimiiiated by immediate, prctfu^se diuri^srs, and the .sac may gradually 
refill. The gravity of the case will depeud ufM>n the nature of the 
tliii<l : if the fluid is bland^ like that of a parovarian cyst, the condi- 
tioii is not grave ; if irritating, like that of most ovarian cysts, tlier^ 
will usually lie tuort^ or less severe jieritonitis with adhesions; if 
infectious, as in an inflamed cyst, the result may be fatal peritonitis. 
Such a ca^se would demand immediate ovariotomy. 

The malignant degenerative changes mentioned in a former chap- 
ter arc not verv uucomoion. 



STMPTOMATOLOOir. 

There arc no pathognomonic signs of ovarian disease. The symp- 
toms of ovarian and parovarian tumors involve a consideration of 
the following topics : 

1. Secondary elianges. 

2. Pressure. 

3. The faeics ovariana* 
1, The Symptoms due to Secondary Chan^t^s. Inflammation^ 

tw^isting of the |>tdicle, and rupture of the cyst have been outlined in 
the fort^going jm rag rajahs. 

2* The Presaoire Symptoms. Tumors whi<4i fill the small jx>lvis 
may, by pressure n|>on the rectum and bladder, give rise to obstruc- 
tion^ tenesmus, hemorrhoids, cystitis, fretjuent urination, and dysuria. 
Pressure uiK>n the iliac veins causes aM:lema of the vnlva and lower 
extremities. Ascites may result from ]>ressiire on the vena cava or 
from malignancy. Both large and small cysts displace the uterus 
forward, backwaixl, or to otie side, I^arge cysts which have risen out 
of the peK'is into the abdominal cavity may cause little or no dis- 
turbance ; or, on the other hand, by pressure upon the abdominal and 
thonicic viscera they may set np the most distressing symptoms. 
Among these sym|)toms are weakness of the heart, nipiil pulse, and 
dyspncfii from upward pressure on the diaphragm ; nausea, vomitings 
and other functional dislurlmnces in tlie alinu'ntarv tract tVom pix'ssure 
on the stomach and bowels ; catarrluil jaundice from |w>rtal conges^ 
tion and pressure on the liver and bile-ducts. The brcaihing may 
be so difficnlt tluit the [jatient must continuously maintain, night and 
day^ the sitting po^^hire. 

3, The Facies Ovariana. Tliis is a |>ecnlijir fat*ial expression 
that is highly diagnostic of the disease in its later stages. It is dif- 
ficult to describe, but once seen is easily remembered. The natural 
facial exprcssifui is mmlifietl as follows: 

1. The face is shrivelled, elongated, and has an anxious and care- 
worn expression, 

2. The nostrils are widc% the angles of the nose* and mouth are 
drawn down, and the lips are thin. 





Enormous Ovarian Cysi» with Pendulous Abdomen and 
Charaeleristic Emac 



DlAGJ!^OSm 



413 



3. The cheeks are furrowed and tlie face is marked by deep 
wrinkles. 

4. The spacer between the eyelids and the bony margin of the orbits 
is sunken and hollow. 

5. The wIioIl^ areolar ti.ssue of the faee Ls atrophied, 

6. The face irf pale, but not with that pecnliar leaden, sallow, or 
parchment-like eolor seen in malignant diseases/ 

FlotrilE 237. 



f^\^ 






V 



^' \ 



r.. 



The fitpita ovarlana.* 



The fueifft ovariana is quite in contrast with an indescribable and 
less marked facial expression known as the facies ^itenna. This is 
often pre,sent in pregnancy and sotiietime,'^ in cases of uterine tumors. 
The face is full and flushed. 



DIAaNOSIS. 

The recognition of a large, uncomplicated ovarian cyst is usually 
not diffienlt. The nieans of diagnosis are these :* 

1. Clinical history. 

2. Inspection. 

3. Palpation. 

4. Perenssion. 

5. Co njt lined examination. 

6. Measurement. 

7. Aspiration or tapping. 

8. Exphiratory incision. 

1 Acl*nt«tkin from Pcnsk'r^ Ovarimi Tumftrs, « PeAfllee'i Orarlttn Tumorf. 

" Id the dlairnuNlH And lUnVreritlal dJnKnoais t have made nu in eroue adaptations fh>m tho 
clEMlf^al work on ovwrittn tumors by my honored friend tind teachiT, the late Edmund Raadulph 
PeMlee, 



414 



TUMORS, TUBAL PREGNANCY, MALFORMATIONS. 



The physical examination by ioyj>cction, palpation, fiercussioo, or 

<x»iijoine<l mauipulatiun requires that the abdomen be exposed and that 



the 



le palient lie mix a bard emielj or table, preferably the latter, 

1. The Clinical Hietory should iiieliide a consideration of the sec- 
|t>ndary changes as outlined in Chapter XXXIII. It als^o includes 

the j^ym|>tom.s note<l in the foregoing paragraphs, the age, M>etal con- 
dition, pregnaneies (if any), family historj, and menstrual history of 
the patient. 

2. Inspection, If the tumor \h small, the enlargement will be 
most apptirent on tlie affected i=iide ; as it grows larger and rises out of 
the pelvis the swelling will 1>e greater in the lower fmrt of the abdo- 
men between the pubes and the timbiiieus, and will be nearer the 
median line. Abdominal enlargement from a unilocular ey«t is 
obviously more symmetrical than from a multilcxnilar eyst. With 
declining strength the facies ovariana becomes m(»re pronounced, 

3, Palpation will show an elastic, fluctuating tumor: if small, in 
the |ic4vis ; if large, extending into the atKlomen. The mass will be 
more distinct on the aUccted side. Its relative jxjsition will not change 
with cha n ge i n the j losi t i i * n t li* 1 1 1 e | >a t ic n t , T lie d eg ree a n d charact er 
of elasticity will vary with the ti-nscness of the cyst and the consipt- 
cney of its contents. A greatly distended tense sac, esptvially if the 
conteuts are semisolid, may feel like a solid tumor. 

Although it is nm^ to Hrjd solid luatter predomiuating in the ovarian 
cyst, large masses i\f ap[nirently solid matter, and smaller ut?<JuIes of 
very haixl or bone-like substLince, are tjften to lie dctcctt^l by palpa- 
tion. The more solid parts nre fomitl nither in the [>elvis than in the 
L«bdomen. The diftereTit hx-imients of u mnltilocular cyst an- tn some 
• cases easily outlined by palpation. The cyst may someTimes l>e mo%'ed 
froru side to side, and up aiul di>wu ; the degree of mobility will de- 
jH'ud upon its size, tbi' length of the pedicle, and the extent of the 
adhesions. In cases of very thick or rigid abdominal walls, and 
ei^pecially of snudl tumors, anaesthesia facilitates the examination. 

4, Percussion. The tumor sue, with its eontents, cvrt upies the 
interior part of the abdomen ; the intestines are in the posterior, 

"lateral, and umxT pnrts ; hence the maximum duluess on percussion 
will be over tlie anterior and lower jxirtions of the abdomen. Sinc^ 
the cyst extends from the pelvis, the duluess will be continuous from 
the alMloraen into the pelvis ; it will, however, cease* aliruptly or shade 
off into resonance and tympanites at tin* limits of the tumor, toward 
the sides of the alxlivmeu and toward the ♦lisiphmgm. This is bcn^ause 
the spaces above and to the sides of the tmuor ar*e tilleil with intestines. 
For the relative areas of duluess and resonance, se*e Differential Diag- 
nosis of Ovarian Cyst and Ast^ites. The location of the cyst docf^ 
not i'hange witli cliangc in the ])osition of the patient ; the areas 
of duluess t■orre^[K>nd to the location of the tumors, and arc con* 
Btant. 

Thf Pa'ritjuHmn llV/rr usually present is elicited by placing the 
finger-tips of the left hand to one >ide of the tumor, and with the 
finger-tips of the right hand sharply ta|»ping or thumping, or w^ith 
the thumb and finger suajipiug the otiicr side. In very tense cysts 



DIFFERENTIA L IHA (iNOSlS. 



415 



and in cysts with semisolid content.'^, like dt^rnioitls, tlie wiive iiiiiy Ik* 
absent. 

6. Coiyomed ExaminatioDj wliirh iiii'loilcs viigiiial uiid rectal 
toiicli, will usually show the relations of the uterus to the tyst. The 
imixirtuuce of this means of diagnosis is great^ fr>r any eyst of pelvic 
origin not connected with the uterus is almost certainly <»varian or 
parovarian. If therefore, upon vaginal or rectal touch, the uterus 
proves to be healthy and normal ly mobile, with little or no increase 
in tlie length of its cavity,, the presumption is in favor of an ovarian 
tumor; if, upon eonjfjined examination witli one or two lingers of tlie 
left hand in tlie %^agina or rectum, atul the right hand over the abdo 
men, the uterus can be made out distinct and se|janit« trom the cyst^ 
the pnxjf of an ovarian tumor is almast complete. 

in very exeeptiiuKiI cases of ovarian cyst, however, the uterus may 
be enlarged, drawn up out of the true jielvis, immobile, and otlier- 
wise abnormah The cyst may he so moulded to the pelvis as to press 
the uterus forward and upward aiul Hal ten it against tlie pubes. 
The tumor and the uterus may, through adhesions or hx^ation, be 
nearly or quite insejmrabte from each other; such conditions ai*e 
very indicative of uterine tumors, but are occasionally foiuid with 
ovarian cysts. See Differential Diagnosis of Ovarian CVsts and 
Uterine Tumors. 

6. Measurements. The circular measurement of the alKhunen is 
increa.^d. The distance from the anterior superior process of the 
ilium t«» tlu' imibilicus is greater on the affeeteu side. The distance 
from the |>ubes to the umlalicus is relatively more increasiMl than that 
from the umbilicus tf) the ensiform eartilage, 

7. Aspiration, err Tapping"^ iuiee a eoiumou means of diagnosis, 
is now almost abandoned. This is because there is always some 
danger from the iMjssible esca|K* of fluid into the abdominal cavity. 
The diagnosis c*an usually be made witluuit tapping, and, moreover, 
an exploratory incision is safer and more ctJective, 

8. Exploratory Incision is die Hnal resort in diagnosis and ditFer- 
ential diagnosis. When this is done the patient should be prepared 
for ovariotomy, and the tumor» if opendile, should be removed. 

DIFFBRENTIAIi DIAaNOSIS. 

This subject involves i first, the differential diagnosis of o<3pho- 
rotic, paroophorotic, parovarian, and dermoid cysts from one another; 
second, the differentiation of ovarian and parovarian cysts from other 
conditions with which thev have Ijeen confounded. 



Distinction between Oophorotic, Paroophorotic, and Parovarian 

Cysts. 

This distinction has been giv^en under |>athological anatomy and 
s€condar\^ changes. The following tabular statement, however, wUl 
emphasize the differential points : 




DIFFERENTIAL DIAGNOSIS. 



417 



may be distinguished from the three kinds of cysts just tabulated are 
these: 

1. Facies ovariana comes very late, if at all. 

2. The tumor may exist for many years without impairment of 
the general health. 

3. Abdominal enlargement usually to one side ; is otherwise sym- 
metrical. 

4. The tumor does not grow to very large size. 

5. The contents are too thick to permit tapping even with a large 
rocar. 

6. Inflammation of cysts and adhesions not very uncommon. 

7. Spontaneous rupture not common. 

8. (Edema of lower extremities rare. 

9. Fluctuation and percussion wave obscure or absent. 

10. Sac contains dermoid elements. 

11. Tumor apt to undergo sarcomatous-1 ike degeneration, especi- 
ally in children. 



The Differentiation of Ovarian Cysts from Other Conditions 
that may be Mistaken for Them. 

The pathological conditions that have been mistaken for ovarian 
cysts may, for convenience of description, be divided into those which 
originate in the pelvis and those which originate in the abdomen. 



Pregnancy 



Uterine tumors 



INTRAPELVIC CONDITIONS. 

Normal gestation, 
Hydramnios, 
Tubal pregnancy, 
Gestation in one horn 
of a bifurcated uterus. 

Myoma, 
Sarcoma, 
Carcinoma, 
Metritis, 
Haematometra, 
Ilydrometra, 
I*yomctra, 
I Physometra. 



Inflaitimatory 
enlargement 



[ Parametritis, 
Pelvic abscess. 
Sactosalpinx, 
Peritonitis, 

. Pericaeal abscess. 



Abdominal Conditionh. 
Ascites. 

Encysted ascites. 
Hydatid cysts. 
Renal tumors. 
Floating kidney. 
Pancreatic cyst. 
Enlarged liver. 
Mesenteric cyst. 
Cysts of the urachus. 
Enlarged gall-bladder. 
Intestinal tumors. 
Fatty tumors. 



One or more of the above conditions may coexist with ovarian 
cystoma. The diagnosis is then complicated, difficult, and, without 
exploratory incision, may be impossible. Before taking up the sub- 
jects outlined in the foregoing table it is important to consider the 
following question : 

Question I. : Is there any tumor at all within the peritoneal 
cavity ? 

The abdomen has been repeatedly opened for the removal of a sup- 



418 



TUMORS, TUBAL PREGNANCY, MALFORMATlvm. 



posed (»viirian tumor, when no tumor of auy kind existed; even tooir 
freciueutly, tapping and aspirdlitm have been done when no fluid was 
present. One author, in his statistieal tables, mentions no le^s tbin 
twenty-one 4*ases of tliis kind,' The ibl lowing eotjditions may liavL' 
the appear;uR*t^ of an intiti-iilHh»tiiiijal enlargement when no such eo* 
large n lent exists : 

1. Fat in the abdominal walls. 

2. Phantom tumor, 

3. Tympanites. 
4* Fecal aei-nmulaliirns, 
5. Distt^ndi'd bladder, 
♦j* Diluted >t<jnu4rlh 

1. Fat in the Abdomiual WaO. An eminent British surge*^^^ 
onee laid o|M:^ii the abdomen from the pubes to tlie ensiform cartila^-^^' 
only to find, instead of an ovarian cyst, a mass of subeutaneons iz^" 
Similar l)lnnders liave repeatedly (K'eurred. Such an error at l^^^^ 
present day, however, would be alniost imjwssible. No propter sig^^^^ 
of ovarian cyst would he present in sueh a ease. The mass of fat ^^^1 
the abdominal wall may he grasped between the liands and isolate""""*^^ 
from the abdomen. Vaginal toneh wonlil also yield negative evidenc^^^^ 
of a tumor, (jreat thickening of the abdonunal wall fnun cedema ts^^^ 
di ffe re n t i a ted by p i 1 1 i rig c n p i-ess ii re. 

2. Phantom Tumor, Some hysterical women have the power so t^^*^ 
coutmet the abdnminal muscles as to force up the tympanitic iutestint^^^ 
into a buneii, and in tliis way to make an apparent alKloniinal enlaige- 
ment in ft*rm like that of a tnmor. Prohmged firm pressure with the^ 
palms of the hands usnally overcomes the nniseular contraction. The 
percnssion note is decidedly tynipauitic, Amothesia completely ex — 
]M>ses the deeepti<UK 

3. Tympanites. The almost incredible blunder has occ^asionally 
been ma<Ie of uiistidving tympanites for an ab<lominal tumor. This 
has usually occurred when the evidences of percnssion and palpation 
were obscured by large amounts of abdominal fat. Tympanites will 
be known by resonance on p+^reussioUj absence of the percuijsion wave, 
and by the negative results of vaginal toucli. 

4. Fecal accumDlations iu the bowel have cn'cas ion ally led to the 
suspicion of an ovarian cyst. The history of constipation, supple- 
mented by palpation, will eleiir the diagnosis ; if not, active catharsis 
will remove all doubt . 

5. Distended Bladder. Retained urine may aceumnlate in large 
tpiantity imtil the bladder appears l>etween the pubes and nmbilieus 
as a distinct fluctuating tum*vr. The external appearance, on in- 
spection, jmlpation, and ]>ereussi(»u, is very like ovarian cystoma. 
The anteri<u' vaginal wallj Imwcver, bulges into the vulvar orifice. 
There is an almost or quite continuous ovei-flow of urine through the 
uretiira. Hyj>ogtustnc pain and distress are urgent. The use of the 
eatheter will st^'ftle all possible doubt. 

6. Dilated Stomach. The author personally knows of one casein 
whieh a deservetlly eminent surgeon opened the abdomen for a hup- 

« John Clary, in Ovnriiin TumoTS. IB72, P«A«lee. 



niFFEREXTIAL DIAGNOSIS. 



419 



posed ovarian cyst, ami found iiisteat! a ditatel stoniarh. The condi- 
tion would be distin^oibiied (Voni ovarian cyst by the rHaxiniuiii nn- 
largemcnt above instead of below tlie iiiid>iliciirf, and by resonance on 
poreussion all over the tumor. A |jositive test is to let tlie patient 
swalhnv water wtiile the stc^thij^eujx^ is placet! over the tumor. As the 
water reiiehes the stoniaeti its gurgling sonud will be clearly heard all 
over the enlurgemeuL 

Given sufficient evidence that there m a tumor, the next inquiry 

IB 

QiTEHTiON 11. : lii the enlargement of pelvie or of abdominal 
origin ? 

li* not of pelvie origin it cannot be ovarian, and therefore does not 
come within the scope of this inquiry. If the hand cannot be inserted 
by dee|» tirni pressure between the tumor and the symphysis ]>ubis^ it 
is inferred that the tumor rises from the pelvis j if the vaginal and 
rectal touch confirm this inference, it is so decided,^ The |>elvic 
origin of the tumor being estaidished, the next inquiry is^^ 

Question III. : Is the tumor possibly due to pregnancy? 

The humiliation nf attempting to remove from a pregnant woman 
an ovarian tumor which drtes nut exist may he avoided Ijv assuming, 
until the contrary is proved, that every abdominal enlargement is due 
to pregnancy. 



Diffarantial Diagnosis of Normal GeBtation and Ovarian Cyst.^ 

Ovarian Cy^t. 



Normal GisfrrATroN. 

1. EnJAfKemetit suiideti, rapid, and uauaUy 
iymroetrical, 

2. Fork's natural and heaUhy. 

3. Superficial vein« of abdturaea not ©n- 
larged. CfMenia r>f aiikl«!i! not unciommon 
alter seven months, 

4. Fluctuation rmt distliitt iinleaa liquor 
amnll is excesMh'i:'. 

5. Sbfenstniatkiu arrested, 

i. Vaginal tfiueh rit'te<'t§ sofleiiliiff and ap- 
parent ahortcnint^ of the cervix rtiui enlarge- 
raeiit of the uieruji. No extra-uttrUie tumor, 
7. Itallottement glvtm impulse of frotus, 
S. Fff tal heart aounda after twentieth week. ' 
9. F«j?tal moveraenta about sixtwnth week. [ 
10. Enlarged setiaeeouH glands iiud iireola i 
about ntpples darkened. 
IL Tumor has dyv*;loped in i*ix to nine ,] 



L Enlargement gradual and, until tumor 
becomc'fl large, ajym met Heal. 

2. Fades ovariana. Page 4 IS, 

3. VcinM enlarged. tE^k- ma exceptional and 
only after one or two yeans. 

4 . I'H M a 1 1 y \ e ry d in net . eapeel all y i n mono- 
cysls. 

:>. Nut uftuiilly arresteil unless Inte in the 
dkeai^e. 

6. l"teni» unchanged exce|jt hy displace- 
meul. uRually in front of or behind the cyst. 
Tumor extra -uterine. 

7. Ballottement give^ negative re^ulti. 
a None. 

*J. None, 
Ul. iUinily ImitAted. 

11, Development eontinuea one to three 
years. 



If the fetus is dead, the heart sounds and fcctal movements will, 
of eoiirse^ not hr* ]vtT.sent, 

Oviirian ^yst nnd |>ri'o:naTiey not infnM|uentIy cuexi.^^t. Tlie diag- 
nt>sis is then made by the clitiieiil hist<iry nf both eonditions, by palpa- 
tion, and by eonjoiued exanii nation, 

iliffframtiioH is an t'Xi-es^* of amniotic fluid. There is normally 
frnm six to thirty oiiiiet's ; this amrnint may be increase*! eiiormun«Iv, 
giving the uteruH ttie a]ipearanee of an immense cyst. The attempt 

I Adaptaliun frtim Peaskt'is uvariau Tumors. ' Ibid. 



420 TUMORS, TUBAL PREGXANCY, MALFORMATIOX& 

has occasionally been made to tap or remove such a tumor bv mb' 
take for an ovarian cyst. 

Tubal Fregnancif. The diagnosis of this condition i/i-ill be foand 
in Chapter XXXVI. Unlike ovarian cyst, it gives an early, thougts 
irregular, histor}- as of normal pregnancy. Conjoined examinatioim 
before rupture shows a boggy, fluctuating, pulsating tumor at the side 
and back of the uterus. After rupture the tumor is less distinct^ 
non-pulsating, and non-fluctuating. At or near the time of rupture 
the endometrium throws off* a modified decidua of pregnancy. The 
symptoms of rupture are urgent ; they are those of pelvic tuemato- 
cele, and are not likely to be mistaken for any symptoms of ovarian 
cyst unless it be those of rupture of the sac or twisting of the pedicle. 
Gestation in One Horn of a Bifurcated UteniB. The unilateral loca- 
tion may give it the appearance of an ovarian cyst or of a myoma. 

Question IV. : Is there a uterine enlargement due to other 
causes than pregnancy? 

The pathological conditions suggested by the question are these: 

Uterine myoma. Haematometra. 

Uterine sarcoma. Hydrometra. 

Uterine carcinoma. Pvometra. 

Metritis. Physometra. 

DifFerentiation of Uterine Myoma firom Ovarian Cystoma.' 

Uterine Myoma. \ Ovarian Cystoma. 

1. Slow growth. I 1. Usually more rapid growth. 

2. Facial exi)re8sion unchanged. Face may 2. Fades ovarlana. 
be full and flushed ; later pale from hemor- < 

rhage. 

3. General health usually unimpaired ex- , 3. General health early impaired from 
copt from loss of blood. If submucous or emaciation. Not painful. 

mural, may be i)ainful. ^ 

4. Abdomen usually very asymmetrical 4. Abdomen more symmetrical, especially 
from irregular shape of tumor. ' when tumor is large. 

b. Abdominal veins not usually enlarged. 5. Usually enlarged, especially in large 

poly cysts. 
f>. Action of kidneys normal. I 6. Kidneys less active. 

7. Usual menorrhagia. I 7. Menstruation unchanged or diminished. 

8. Elasticity, not fluctuation. No jjercus- 8. Fluctuation marked. Percussion wave 
sion wave. marked. 

y. Surface firm and usually l«>buluted. I 1>. Surface yielding : in monocysts, regular; 

I in polycysts, irregular. 

10. Va^Miial touch iiiul conjoined examina- I jo. Uterus normal, except displacement from 
tion show tumor <UnHe nnd Hrm. and. unless ^ pressure. Tumor compressible, fluctuating, 
ptidnneuliited, continuous with uterus. Uterus detached fk'om uterus, 
large and iieavy. 

11. Uterine cavity much elongated. 



\ 



12. Ulenis moves witli tumor. 

13. Negative results from aspiration. 
Exccj>thni.—\ sut)j>eritoneal myoma with a 



11. Not materially elongated. (This is a 
most imp«>rtant diagnostic point.) 

12. Doe.s not move with tumor. 

13. Positive results from aspiration. 
Errrptinn.—A cyst with semisolid contents 



louK' iKMlide moves indcinndently of the yields negative results on aspiration. Fluctua- 
utcrus. and the uterine cavity is not nec«'s- ' tion. if present, is indistinct, and percussion- 
sarily lengthened. If the myoma has dej,'en- wave is absent or indefinite, 
erated to a fibroey.«l, there ^\ ill »m» more or less ' 
fluctuation, and aspiration may yield positive i 
results. I 



1 A<la|»t«Ml from l'ca>:lee'> Ovarian Tumors. 




shape of abdomeo made by largi* rouDd, nearly lyminetrlcalt uUsrlne myoma. 

viz., more puiiij great tendency to early nlferation and other de- 
generative ehanM;e.s, more profnse lieniorrhag-es, offensive watery or 
tlomly tliR!harge, and a sj>eedily fatal resnlt. 

Differentiation of Metritis from Ovarian Cyst, 

Metritis gixea a history t*f inrtarnmation, ami is apt to be asjao- 
ciateil with parametritis, salpinj^^iti^^, and ovariti.^, Tlie n terns is 
never enhirged to more thun two or three times its normal size, and 
in IVinti is always syain\etrieal. Conjoined examination will show 
that there is no extra-nterine grow th. There are also tenderness on 
pressure and diminished mobility. 

Differentiation of Hsematometra, Hydrometra, Pyometra, and 
Physometra from Ovarian Cyst. 

The uterine enhirgement is always synimetrical, and the orja^n, 
whether distended witli bloo<l, sernm, jms, or gas, gives a greater or 




422 



TUMOI 



^AL PMEGIi'ANCy, MALF0EMAT10N& 



lessor seristi of fliR-timti^ni, but not the clear fluctuation of a ey.sU 
See Retained Menstruation, Chapter XXXVI II, P^xamiuatioii will 
show tliat the os extern nui or tlie cer%^ieiil eaiuil at souie ]K>int h com- 
pletely elosed. Unless the Fallopian tubes are also distemle<l the 
enlargement will be entirely euutined to the uterus. 

Q,i:KsTi<*N V. : Is the enlargement extra-uterine, and |xvssjbly 
due to iuHammatitm? 

This (p Jest ion suggests the following conditions : 
Paraniet r i tis. I lyd rosal | jj i l\ . 

Pt^lvic abscess. Peritonitis. 

Pyosaipinx. Perica?eal abscess* 

The history of inflammation and the eltjsc relations of the enlarge- 
ment to the uterus will aid greath^ in the recognition of any of tln-se 
diseases. In all, except jwssibly hydrosalpinx, there will be great 
tenderness on pressure. 8aetosalpinx, whether the tulie Ix^ distend<*d 



M 



^. 



Ovurmtj tumor with oiicUea. Obfturve pitttrusiun of umbilicus. 




with serum, pus, or blood, will usually be identified by its locution to 
the side and bark of the uterus, but more especially by the irregular, 
elongated, tortuous, or ovoid form (>f the nias^. A pns-tul^e is much 
more lik«4y to Ix? adherent than an ovarian cyst of small size, A 
paranu'trie absix'ss is always contiiuious with the side of the uterus 
and situated in the broad ligament. Suppuration, anterior or Lmsterior 
to the uterus, is also innt^panible from the uterus. Pericieeal absoess 
or appendicitis may be sns|>ected trnm its hx^ation. 

Question VI. : Is the tumor of abdominal origin, and therefore 
not ovarian ? 



DIFFERENTIAL DIAGNOSIS, 



423 



A large ovarian cyst may have a pedicle 80 long as to permit the 
entire tumor to ri^^e out of the pelvis into tlie abdominal cavity* It 
may even be possible to insert the haiicl <leeply between the tumor 
and the symphysis pubis. Conjoined vtiginal and reetal touch may 
not discover tlie pedicle, nor establish the pelvic origin of the eyst ; 
it is sometimes difficult to differentiate such a cyst from other tumors 
of abdominal origin. 

The following pathological conditions are suggested : 
Ascites. Enlarged liver. 

Encysted ascites. Mesenteric cyst^ 

Hydatid cyst^s. Cysts of the urachus. 

Renal cysts. EnlargtHl gall-bladder. 

I>isplace<l or floating kidney. Intestinal tumors. 

Pancreatic cyst. Fatty tumors. 



Di^arential Dia^noBis of ABcitea and Large Ovarian CjBt} 



ASCtTES. 

1. Previoua history of visct^ml difieofle. 

2. Enlargement conijjaraUviIy Budrten. 

3. Face puffy: color waxy \ early aDEtmla, 
4> Patient on back, eulargeinent syiu metri- 
cal ; flat in fnmt, 

5. I^ntiiig up, abdomen buli^ea below. 

6. Navel prntojneDt and thinned. 

7. Fluctuation decidudly clear. dllTUae 
throughout abclnmen^ but avoids hig^hcst |)ciTta 
in &n pOBitionst aud alwayn ha« a hydmatatlc 
IcveL 

9. IntestiDes float on top of iluid : hence 
percusftioQ give« clear tympauUlc note over the 
blgheflt parts of abdriminal cavity, and dulncss 
in lowest parts fur all posiihmH — *. e,. areuit of 
resonance and dulncss change with p4}Bitiun. 

9. Vaginjil touch detects fluctuationp bulg- 
ing into vagina. 

10. Uterus in prolapsed location, but poeltlon 
unchanged, i^ha and mobility unchange^L 

11. Hydraflfogues tind diuretlc§ temporarily- 
remove the fluid. 

12. Fluid light i>tra\v color and thin. Coagu- 
lates spoil taneoutsly. 

Exeeptions.—The Intestines may be adher*?nt 
to the posterior part of the abdominal cavity, 
and the fluid may therefore be in the anterior 
part, or the amount of Stiid may be so great that 
the intestines held hack by mesentery or adhe- 
sion cannot float to Jt« surface ; then the areas 
of resonance and dulnes^s, except im very deep 
percuMdonj may l>e similar to those of a cyst. 

G&» In the colon may produce clcamt'ss In 
the Hanks. 

Encysted ascites— t. e,, fluid c**nflned to a 
limited part of the alxlomcn by adhealons— may 
give the same areas of d illness and resonance 
as a cyst. 



Ovarian Cyst. 

1. No such historj'. 

2. Gradual. 

8. Facics ovitrlana. Au^rmia later. 

4. A syni metrical until tumor is quite large; 
prominent In front. 

5. No appreciable changv. 

0. Navel usually unchanged. 
7. Leas clear; limited to cyst : not modihed 
by change of j»osUion. No hydrostatic level. 



I 8. No cbaugc in areas of dulness and reso- 
' nance with change of jRjajiion, Iiulneas over 
cyst. Llcar resonant note in all parts beyond 
! cyat Umlia-(. c. in Hankii and toward the 
j dlftphragnn. 
J y. Vii)finid fluctuation loan clear or absent. 

lf>. t*tem« cllsphiccd forwnrd or backwardi Or 
laterally by pressure of cyat. 
H. Medicinen have no effect. 

12. Fluid light or dark and of varying con- 
sistency; ttlbumi nous, but does not coagulate 
spontaneously; may Ciuitiiin colloid matter. 

.Bin5(?pfioiM.— Flanks may be dull from feces in 
the coloa. 



Cy^i may communicate with the intestines 
I and be filled with gas. This wauld give a 
tympanitic ntrte all over the cyst 

The eyst may be Hmall and glued to the 
posterior part of the abdoiiiitial cavity by adhe- 
elons. The Intestine might then be in front of 
it and give a tynipftuitic note over the most 
prominent part of the enlargement 



J Adaptation from Peaslee's Orarian Tumors. 



42« TUMORS, TUBAL PEEGXANCY, MALFORMATIONS. 

vagina, rectiini, or bladder ; the diagaosm h then clear. Hydatid 
cysts are mrf. 

Differentiation of Kenal Tumors and Ovarian Cysts. 

'I'liii distiiK-tiujt between renal tumors and other abdoniioal and 
pt^lvi*' rtdargements is often extreniely difficult. They have been 
re|»eatedly mistaken, not only for ovarian tumors, but as well for tumors 
of tlie pancreas, liver, spleen, intestine, omentum, and utenus. With* 
out an exjvlorntory incision, the greatest e^ire and the widest general 
knowliKlg*' may be inadetpiate to a diagnosis. The enlarged kidney 
huK Ik'cii foundj not only so loose as to occupy almost any location 

FtGVRE 245. 



/ 



Kidney In the hoUow of the Bttcrum, A. Artery. I'. Vein. U. ITreter.* 



or pfisilifm in the ahd*mien or pelvis, but fixed by adhesions in it« 
HjaJ-lfM'atii>n — for example, to tlie pcOvie lirim or to the sacrum. In 
HUeh aises the clinicid history ami ratioiuil signs — ineluding urin- 
fdysii^ — will usually give evidence of renal disease. A renal cyst 
may he hydronephrosis or pyelone]»lmisi8. The differentiation is a^ 
follows : 

t J. Blaad Suttou. 8un^c«l DlieUM of Ibe Ov«riei And FBUoplAn Tubei. 



DIFFERENTIAL DIAGNOSIS. 



ATI 



HTDRONEPFTROSI!*. 

1. Erilargeiiiriit utiilalci'iil ami ftnm above 
downward' Growth Win^tl in region oT kidney. 

2. Expression iinihanp'd. 

3. Gfiiwlh usually slow. 

4. Intestines may be in front yf tumor. 

5t Fluid not necest^aHl)' albuminous; may 
contain caIcuII. 

6. Vjiginal touch negative, 

7. Urine may conl^ilD pus, blood, or albujoiLn. 
Exctptions.—ln ease of a movable kidne^r the 

tumor may ni>t be fixed. 



Ovarian Cvfrre. 

1. Enlargement at first unilateral: later sym- 
metricai and fri*m below upward. No fixation. 

'I, Fables ovarlaraa. 

3. Growth rtilativcly rapid. 

-i. Inteiitlnes inthe flanks above and back of 
luroor. 

5. Fluid albuminous : no calculi. 

6. Tumor usually fi.lt by va^nal touch, 

7. Urine generally normal. 
BteqpHon^—ln case of odbesioiu the cyst 

may be fixed. 



In pyelonephroisia the symptom.'rt of suppuration will also be 
present. 

Pancreatic cyst, enlargeil liver, mesenteric cyst, cyst of the 
urachus^ enlarged gall bhulder, intestinal tumors, sub{>eritoneal or 
omental fatty tumors^ all of whicli may grow to large .sizt*, have been 
mistaken fijr ovarian cysts. With tu'dinary care and ,skill, however, 
such mistakes are not very likely to arise. All these tumors develop 
from aliove downwanl, and may usually be di.stinguished from ovarian 
cyst by their hieation and physical characteristics. They do not pro- 
duce tlie facies ovariana, and, unlike ovarian cyst, are usually beyond 
the reach of vaginal touch* 

Exploratory Incieion. 

Finally, in c^ses of doubt, the question may be settled by explora- 
tory incision. Indeed, every ovariotomy — xqs^ every abdominal 
section — ^sliould begin iis an exploratory^ incision, Mr. Tait's wise 
caution, already quoted in connection with the diagnosis of pelvic 
inflammation, will bear repetition here : ** One may easily turn an 
exploratory incision into a complete openition, but it may be a serious 
matter to turn an incomplete operation into an exploratory incision." 




CHAPTER XXXIV. 

OVARIOTOMY, 

The ^enenil prinoijiles whit-h api>ly to this operation are fully Iilm* 
down in Chapters II L, VI., VII., V III., and to avoid repetition tnat^^^ 
be studied in tbuse ehapter?s. 

Eleetrieity, iocisiou and drainage, and numerous drugs have beex^ 
tried in the treatment of ovariiin eyst^ ; they are all uselegis. Tlm*^ 
trc^atnient is summed up in a single wortl — ovariotoniy. The opera — 
tion was first p*rf(>niied in 1809 by an American surgeon, Ephriarra 
McDowell, of Ihunilie, Ky. 

Removal of the Ovarian Cyst, 

The ^subdivisions of tlie snbjeet are these : 

Pre para tury treat men t. 

The alxlonnnal iiieision. 

Empty in jj and flornering the cyst 

Ligature of tlie pe<licle. 

Closure of the wound. 

Drainage. 

Ai\er-treatinent. 

Accidents and eomplications. 
The Preparatory Treatment and arrangements? for the operatioUp 
including the selection of .sponges, ordinarj^ instruments, operating- 

Fir.HRE 246. 



r-c^ 



"f'imiii^ 



N^^laton forcepa, A. Reduced siz^. B. Section of fUU flixe. 

table, and assistants, have been outlined in the Genend Consideration 
of Major Ojierations, Chapters IL and VI. The instninients and 
appliances speeially required are : 
438 



OVARfOTOMY. 



42^ 



16 Small prpssare-foreeps, Figure 87. 
t> Loii^ piv?isure-forcei>j>, Figure ^i^, 
2 Nelaton tbrcepB, Figure 24(>, 

1 S<^alpel. 

2 Pairs of Btraiglit scissors, long and short 

1 Ovariutoiny trocar. Figure 248. 

2 Peaslee's needles, Figure 249. 



B 



Curved for<%ps for clamping pedicle tiefore applying ligature. A. Reduced sise. B. Bection of 

fun Bl2&. 

12 Needles for closing the abdominal wound. 

Drainage tubes, 
12 Short needles, round at the point, for intraperitoneal plastic 
work, Figure 74, 
1 Rubber sheet. 

1 Bucket to catch the cynt fluid. 
1 Small, curved trocar, 
4 Retractors. 
The Abdominal Incieion. O\ariotoniy, except for small, non- 
adherent cysts, is performed by alxlomiual sec^tion. The incision is 
made through the abdominal wall in the median line near the pubis ; 

FiGUBK 248. 



Bmineffl ovariotomy trocar. Reduced slse, 

it has already been described in Chapter VI. Vaginal section, some- 
times used for very small cysts, is described in Chapter XXIII. 



FjfirRE 24a. 



Peaiilee's needle. KtKluced sfie. 



Ordinary J uncomplicated ovariotomy requires an incision not more 
than two or thi'ee inches long* 



430 TVMOns, TUBAL PKEGNANCY, MALFOEMATIOyS. 

Fdouebeso. 




&aiAll« euired trocsr for emptying fituatl cy^it^, Ki^duce^l aii^. 
Ftovnu 251. 




Retractor for drawing ftiwjt abdomln&l wouiuL Reduced site. 

Emptyingr and Delivery of the Cyst, As soon a* tlie peritoneal 
cavity is opened^ the evi^t, of [lei^uliur lilui* or gmyisli- white cx>lor, m 
seen directly through the ojK^ning. The oyst being exiKised, the 
a.'*si,staTit turns the pntient partly on the side, so that the aMoiuen will 
Im^ direete*! toward the operator, and holds her steady. The trocar, 
with an attaehrd rubber tube, is tlien tiinist througli the cyst-walU 
and the fluid is drawn off into a Inieket provided tor the purpr>se. 

As soon as the fluid begins to flow the eyst-wall is scizctd close to 
the trf>ear with the Nt^aton or hmg forceps — one or two pairs — and 
as the sae <'Uipties the e(>llapsing walls arc rapidly dmwn through the 
abdoniiiud wound, A lum-adlierent niouoeyst with thin w^alls is 
usually delivered in this way witli great ease. 

In case of a ixrlycyst, the point of the triH^ir may, without complete 
withdrawal, be snecessively thrust into one eonipartmeiit after another 
until all are emptied and the collapsed sae is delivered. 

The f>bstaeles to the deliven^* of the sae are: 1, See* »n da ry cysts, 

2, Senusniid or semifluid I'ojitents, and solid portions of the cyst» 

3, Adhesions, 

The secondary cysts may be tu4) numerous to be taj^jKnl by the 
trocar. Delivery may then be aeertmplished through a larger incision, 
or, the trocar having been withdrawn, one or two fingers, and, finally, 
the left liiHitb intrmlueed into the sac breaks Uf> the ]>artitions between 
the seondary cysts — as it were, eviscer:it4"s the cysts. During this 
manipulation the foi-cepB in the right hand must keep the i»j>ening ia 



OVAEIOTOI[[r. 



431 



the c ys t- wa 1 1 d raw (i wel I ou ti! i J e oi t lie abdo in i ria 1 i u e i s i o 1 1 . T I li s i s i m* 
portaiit, in iirder to prevent eseape ut" tlie evst-Huttl into the ulMlutueiu 

Semisolid or senjiHiiid contents finiiid in dennfml and colloid cysts 
will not rnii through the tn^can Often toniors are partly eystie and 
partly solid. A longer incision is ueeessary tor the delivery of such 
non-collapsible tumors. This is made npward and to the left of the 
nmbilieus, with scissors and the left index-tinger as a guide* 

Adhesions are tlie most common obstacle tii the easy delivery of the 
siie. They may be parietal or visf^eral. Tlie general technique in ad* 
hesions is ilescribed in l'ha[)ters VL and XXIIL The cyst should 
usnally lie tapjied and the tin id dniwn off before the adhesions are 
bri*keiL The diHereut parts of the sac fmm wliieli adherent intestine, 
omentum, and otiier struetnres are U* l>e s<' para ted may usually be 
brought sut^essively into tlic opening, and thi^ adiiesious broken until 
the tumor is free. If this cannot be dt>ne, the incision is lengthened 
and the adhesions separate<l in sifn. In loosening adliesitms it is well 
to secure bleeding points, as they occur, by forcipi-essurCj or torsion, 
or fine catgnt ligatures. The tumor liaving been frecil, the operation 
pn>ceeds as already descril^ed for non-adherent tnmor. 

Ligature of the Pedicle. The cyst luiving been drawn through 
the abdominal incisitm, the |M*diele is tiwl with catgut *'lose to the horn 
of the uterus, and the tuunjr cut utt* with scissors about one inch from 
the ligatures. Pedicle sutures to keep the ligatures from slipping are 
described on page 275. In?5tead of ligtituring the jjediclc en. ma^e^ 
the tumor may be renu>ved and htemostasis secured by suture and 
ligature of the broail ligament, as described for i-emoval of the uterine 
appendages on |mge l276. The latter methtxt is preferred. See pages 
270 to 277. 

cyst flui*I may be perfectly innocent, or, on the contrary ^ may, 
from suj)i>unit!on or other eansos, contain infectious matter. The 
thick, gelatinous cfiutents of colloid anil id' dermoid cysts are usually 
infections, and, if brought in cimtact with the iwritoneum, mav cause 
dangerous infection. In order to avoid such contamination it is 
often safer, when the Huid is known tt> lie infectious, to make a Umg 
incision and tieliver the tumor Intact withmit attempting to pniu^ture 
the cyst and ilraw^ off the fluid. 

Clos\ire of the "WoTind, Drainage, and After-treatment. These 
subjects liave Ijceu fully considered in Chapters VI., VII., and VIII. 

The Accidents and Compli cations ' are such as may occur in ab- 
dominal sections for any purpose. 

Exfrn^hn of tfjc boweO during openition shotdd be prevented by 
the assistants; if it occur, the bowel should be immediately returned 
and held by Ijroad gauze [xids or towels. 

Strip^tlitf^ of the partehri pf^riioneum from tlic abtlominal wall, under 
the im])ressi<ui that it is an ail he rent cyst, may <wcur e%X'n to the expe- 
ricnceil ojHTator. Peritoneum thus detached is apt to slough ; and 
thcrelVuv, if not too extensive, should be removed with the tumor; 
if it is not removed, there should be drainage of the space between the 
detached [jeritoneum and the subjacent structures. 

I AUtiutt. System uf Ciynecology. 




Rupture of the cyd wall and er^ape of its contt^nts are harmless if 
the fluid is iiincirent ; unforHuiatt^ly, tlie tliin, friable, gzingrtnou^ 
cyst;^ that art* a])t to contain iofeetitJiijH tliiidh arc the oms iiiotit liable 
to nipturt:. The clear indiaition after rupture is tlH>rmighly t(F 
irrigate the c^ivity with normal salt solution — six-tenths of 1 j>er 
cent. If there is nntieipitiun of rupture, one may juiek sjK»nge8 
around and nnder the cyst to absorb the Huid as it esciq^es. 

Injuries to the inteMlnex^ ureter^ ot^ hlmkivr arc sometimes Qna void- 
able. The bowel is specially lialde to be (Opened in breaking np adhe* 
sions. In operating deep in the pelvis, the bladder or ureter may be 
cut even by a carcftil operator. Injury to tlie intestine or bladder 
shonhl be immediately n^iKiiriHl by stiture. If the ureter has been cut, 
the sorgetni will have recourse to one of the fulhnving procedures: 1. 
The cut ends may, if praetical)le, be renoitt d by end-to end approxi 
mation after the methml of W'ellcr Van Hindv. 2. The attempt 
may Ik* made to turn the ureter into the bladder. 3. The ureter may 
be brought out tlirough the abdoujinal wound, 4. The kidney on 
the affected side may be removed, 

Fonifpt htMfim left in fbr aMomrti, such as sponges, forceps, and 
other iustruments, have caused ntnucrous deaths, not only after 
ovariotomy, but after many other aMominal operations. See 
Chapter VI, 

Intestinal obstruction, the principles of drainage, and the after- 
treatment have been pi-esented in Chapters VI L and VIII. 



Removal of Intraligamentous Cysts. 

Parooph orotic, parovarian, and even simple ovarian cysts may de- 
velop between the folds of the broad ligament. They are then called 
intndigamentotis. Tlie genesis and the ukmIc of development of these 
cysts have been fully describinL The jvarovarian cyst is easily pc^eled 
out of tlie bn*ad ligament. The paruc>phc*rutie and other papillom- 
atous cysts may, if intraligamentous, j>resent the greatest diftcnltios in 
removal. Such tumors c»ftcn lie tleep and tirmly Hxed in the substance 
of the Ijroatl ligament, aud are therefore bard tu enucleate. 

Before attempting the enucleation two ligatures shouhl be applied, 
one on the iufundibulo-pelvic Hj^ament, the other on the uterine end 
of the broad ligament. The tirst ligature cuts f>trthe ovarian artery 
as it enters^ the |Kdvis; the second, if deeply platted, cuts off the utero- 
ovarian anastomosis. These ligatures deprive the broad ligament and 
inekided tumor of a great part of their blood-supply, and the fright- 
ful liemrirrhagp sometimes encountered in the removal of a papillom* 
atons intndigamentous cyst may be therefore measurably avoitled. In 
order \o contrnl hcmtirrhage, one sbindd be prepared^ if necessar}% to 
ligature also the uterine vessels, or even to remove the uterus. 

The tumor may lie removed, according to its depth, in one of two 
ways : If it is not ver\' deep, and lies rather loosely in the broad liga- 
ment, the ligament and cyst sometimes may be excised and removed 
tiig4'tber. This proreduR* is very much like that described in Cliapter 
XXII L for the removal of the uterine appendages without a pedicle. 



I 
I 

I 



OVARIOTOMY. 



433 



Tl»t' otfier iiiethml is that of enuclentioii. Tliis i\s sonietimeH nn ex- 
tnnni'ly (liiliruli and iK'niorrhagiti uiK^ratioii. Astlio i'mK^leatinn pro- 
('<'e<ls tlii^ blt'o<liiii>' points, so far ii> possibl*', tirv Ht'oiiri^d liy tiiK' catgut 
li^tiires. The siir liaviii|r hcL^ii removeil, \hv raw l)lc»<Mliii^ surfaces 
Wtweon tlio folds of tlio broiid li^jcjiiiuvnt arc tenipnmrily packed with 
hot gatizf^ sptiii|jres to stop the oozing. The re<luiHlant portions of the 
ligament niay bo trimmed oii' with tfiescis-sors, the edges may be turned 
in and united with deep interrupted or eontinuous .sutuiT'."^, If the 
eavity from whii'li th(^ sae was enueh^ated is too large to he obliterateil 
by inversion^ as above described^ or tlie oozing from its surfaee id 
nticontrolhildej an opening may be made from the bottom of the etiviiy 
close to the uterus directly into the vagina. The end of a long strip 
of gsiuze may he carried through this opening into tlie vagina, the 
cavity jKickerl full, ami tlie edges of the bri>ad ligament closed over it* 
Tliis leaves tin* bk'cding |>art entirely ci^vercd by peritoneum, renders 
tlu: niw surfaces extraperitoneal, ccuitrols liemorrhagc, and provides for 
drainage. Care to avoid the ureters is necessary in tlie enucleation , 
in the [jku'ing of deep ligatures, and in the iiicision into the vagina. 
The ureters are sometimes situated dangerously near the field of 
operation. The gauze drain, which is the same as that descrilied in 
Chapter XXVII., may be remtjved through the vagina in two or 
three day 8. 



Ovariotomy Duringr Pregrnancy. 

An ovarian tumor complicated by pregnancy gives rise to the fol- 
lowing dangers : 1. Twisting of the pedicle. 2, Abortion. 3. Ob- 
struction to labor, necessitating Ciesarean section or ovariotomy during 
labor. From these and other possibilities the 4langer to the life of the 
elnld and the mother is extreme. The danger uf timely ovariotomy 
before labor, as compared witti that of the exjiectant treatment, is 
relatively small. The indication for early ovariotomy, llu'rcfore, is 
generally clear. Puncture of the cy.nt, as a substitute for i^vsiriotomy, 
h |>ermissible only when ovariotomy 18 impractica!)k\ The chief 
danger of both puncture and ovari(»tomy is from ].M»ssihlc sepsis and 
conscrpient at)funion or jirematun- lalnir. In the complieatitju of 
pregnancy the necessity fur an early, rapid, gentle^ clean ovariotomy 
is apparent. The pedicle always 4*ontains large vessels, nn<l should 
therefore be tied witli special canr. Moderate doses of ctideine may 
he useful in the after- treatment. 

28 



TUMORS OF THE BOUND LIGAMENT, 



435 



Tumors of the Broad Ligament. 

Tumors of the broad ligament ioeliidi- nvvonia, lipoma, cystoma, 
carcinoma, ami sarcoma. 

Myoma and Lipoma are pathological rurio.^itie.s and do not grow 
to large size. The other growtlis have alrcuidy been described* 



Tumors of the Round Lig^ament. 

Tnmors of the round ligament include myoma, fibroma^ cyst or 

hydrocele, sarcomu, and carcinoma. 

Myoma and Fibroma, acconling to Cot*, are more common in 
multipara, and more frequent on the right than on the left side. The 
growtli may be intrai^oritoneal or extrajK^ritoneal, Myoma is com- 
monly jxHlunenlated, iiard^ uf slow growth, pninless, not tender to 
pressure, and may be either wraootli or lolmlated. When large it 
may cause prt\ssnrf symf>tonis ; if extniperitoneal, it may be found in 
the inguinal eanal i>r in the labium riiaju«* No impulse upon cough- 
ing or straining is tninsmitteil by the tumor, Rednctiou of the 
growth is impossible unless j^mal! and near the internal inguinal ring. 
During pregnancy it may rapidly inereuse in size. 

Tlie dhupmsih is from *jvariau and omental liernia, enlarged inguinal 
glands, and cysts of the glands of Bartholin. Ovarkin hernia is dif- 
ferentiated from myoma of the ronud ligament by its o\oid form, 
tenderness on pressure, possibility iyf reduction on pressure, anil by its 
increase in size during menstruation. Omenlal hernia may be as hard 
as myoma and impossible to recognize witliont an exphn^atory incision, 
Enhtrf/ed inf/uin(fl f/iattfh are distinguished by the history of infection 
and by the lobulatt^l outline. VtfHfj< of the f/hntfh of Barthofm are 
distinguished by their lm:ation. In myoma the tumor originally 
lies above the loc^^ition of the glands of Barlliolin. Exploratory 
puncture will s^^rve to identify the cyst. The treatment is extirpa- 
ti<>n. 

Cyst or Hydrocele is suppostHl to be develojw'd within the canal 
that represents the original round ligament, the eanal being at first 
hnllow instead f*f solid. It may appear in tlie form of several cystjs, 
or of a (collection of fluid either within the inguinal eaual or at 
the external ring. Hchroder reports a case in which tliere seemed to 
be a commniiieation l)etwcen the cyst and the peritoneal cavity; at 
least the fluid could be i'orccfl by pressure inside the abdomen. 
The writer has never observctl a ease of hydrocele in the round liga- 
ment.' The tlifferential diagnosis is from myoma of the cord and 
inguinal hernia. From myoma it is distinguislied by the sense of 
fluctuation and by exploratory puncture. From hernia the growth is 
distijignishcil by not transmitting an impulse on coughing, by failure 
to reduce by taxis, antl by fluctuation. The treatment is extirpation 
of the siic and ilirect snturiug. 

Sarcoma and Carcinonia are so rare as to be of interest chiefly as 
pa 1 1 1 o I ( >gi ca leu r i i isi t i es, 

^ Adapted from Ooc, in tLi^tlng and Coc'h ClfnkHl Gyii€C[>log>'. 




CHAPTER XXXV. 

TUMORS OF THE FALLOPIAN TUBES, BROAD LIGAMENTS 

ROUND LIGAMENTS, AND URINARY ORGANS. 

Tumors of the Fallopian Tubes. 

The tumors of the Fallopian tubes include myoma, adenoma, 
adenomyoma, cysts, carcinoma, and sarcoma. 

Myoma of the tube rarely occurs, seldom obstructs the oviduct, 
and is commonly too small to be of clinical significance. One case, 
however, is reported in which the tumor reached the size of a child's 
head.* Salpingitis isthmica nodosa and tubercular salpingitis have 
been mistaken for myoma of the tube. 

Adenoma, as termed by J. Bland Sutton,' or papilloma, as first 
described by Doran,' is not uncommonly found. The growth usu- 
ally begins as a small papilloma or wart, and may attain the size 
of a large orange. It may present the appearance of a so-called 
hydatid mole, a multiple cyst, or a cauliflower growth. A frequent 
complication, according to Sutton, is hydro-peritoneum. This results 
when the abdominal end of the tube is open and the secretion passes 
from the tube into the peritoneum. When the abdominal end is 
closed and the uterine end open there may be a bloody discharge 
through the uterus. Adenomata frequently undergo malignant de- 
generation ; early removal of the tube is therefore indicated. 

Adenomyoma. This is characterized by a Fmall nodular enlarge- 
ment of the tube. It has been fully described by Recklinghausen, 
and later by Ries, as originating in the remnants of the Wolffian 
body. The various nodular enlargements of the tube, including 
adenomyoma, may be caused by a numl)er of pathological conditions. 
The differential diagnosis between them must be made by the micro- 
scope. They cannot be distinguished by clinic^il examination. 

Cysts of the tube are of frequent occurrence, but of little clinical 
imj)()rtance. Small pedunculated cysts, known as hydatids of Mor- 
gagni, are often to be found at the fimbriated extremity. Numerous 
minute cysts with thin walls are frequently seen on the mucous sur- 
face of the tubes. 

Carcinoma, as a primary growth, is very rare in the tube, and, 
when ])resent, is usually th(^ outgrowth of adenoma. Secondary car- 
cinoma may be the result of extension from the ovary or the body of 
the uterus. It is seldom, if ever, secondary to cancer of the cervix 
without first involving the body of the uterus. 

Sarcoma of the tul)e is exceedingly rare, and its origin obscure. 

» Sir J. Y. Sim|i8(»ii. From SyRtem of Gynoooloir>', Plnyfnir and Allbutt. 
- Surjrical Diseases of the Tn!i('S and Ovaries. J. Bland Sutton. 

^Trannactions of [he I'atholoErioal Society of London, vol. xxxi., p. 174. Surgical Disease* 
of the Tubes and Ovaries. J. Bhmd Sutton. 

434 



TtJMOJiS OF THE HLADHKR. 

same pnaci[)ks of ]mthology, diaguo??is, prognosis, mid tn*atiiirnt as 
when tliev uceiir in tlie vulva. 



Tumors of the Bladder. 

Tumors oriiriiKitjrig in the hladdrr arc* nirc. Tln'V iKU'or niiicli less 
I'l'tiqueiitly in the ieniule than in tlie uiide bladder. 




HaiiTifn in th« bladder. * 



Benign tumors^ ospeetally if jtnlypoid, are ca?*ily removed through 
an artificial vcaieo- vaginal iistula. Htemo.sta.sis may, if neeessiry, be 



FuiURE 2M. 




Tumor in the bladder* 



t AiivuriL 



* IUI4. 



436 



TUi\WRS\ TUBAL riiiiaNAyrr, malformations. 



TumorB of the Urethra, 

TIr* |>riiR'i|Mil varieties of iiretliral tumor are caruncle, miicuus 
polypiL^, coiulyloma, wart, rareinoma, and .siireoina. Tlie most fre- 
qnent seat is the meatus yrinaHiis, t'arciiionia and sarcoma are ajjt 
to oeeiir by extension from t!io vulva t*r vajj^iiia. 

Urethral Caruncle. Tliis not uiR'ommon growth is a small^ soft, 
red, friable mass sitiiatwl usually at tla* margin of the nR^atus aiul on 
its vji^inal side. It may, however, be anywhere in the urethra. The 
growth oeeurs in nirvous, irritable women ; and, tlRHi|;^h no age ie 
exempt, it is most frequent at or near the nieno|>ause. There is often 
a pr e V i o US h i sto ry o f pe 1 v ie d i sea se . Con tae t o f 1 1 le pa r t w i t h i r r i tat i ng 
discharges from above is among tlR' conuuonly assigned causes. Micro- 
scopic examination of tln^ growth shows tlie jiapillary layer of the 
urethral mucosa U\ l>e softencnl anrl atr^iphieiL Fi>r ttiis reason the 
walls of the capiUaries are deprived of tlieir iiatuml support, and tliere- 
forc dilate^ This explains the vascidanty and the tendency to bk*ed. 
The nerve hlanRnts are expensed, and then^fore abnormally sensitive. 
Tliese histologieal facts ex phiin tlR* friability, vascularity, and hyj^er- 
sesthesia. The sensitiveufss iti these growths is often so extreme as 



mm 



to cause the greatest agony on urinalion, There is great vascularity, 
which may cause bleeding even upon liglit touch. The dtff'crvntial 
ffwfpimh from iuHammatic^n of Skene *s ghiuds has alrt^ady been ilis- 
eussed in Cluipter XX I V. Thr trtaimrnf is excision with the scissors 
umler the base of the growth, and union of the wound by suture. 
The eaulerv is commonly used, but is disappro%*ed on account of its 
unneeessarily tlestruf^tive and cicatricial etlects. 

Warts, MucouB Polypi, Carcinoma, and Sarcoma follow the 

^ Auvard. 




438 TUMORS, TUBAL PREGNANCY, MALFORMATIONS. 

secured by leaving the forceps for a time on the stump. A sessile 
growth^ on account of its inaccessibility and its hemorrhagic tenden- 
cies^ is much more difficult of removal. Diagnosis is made by cystos- 
copy. 

Malignant disease is almost always an extension from the cervix 
uteri. The treatment is wholly palliative. 

The differential diagnosis of vesical tumors is from stone and other 
foreign bodies in the bladder. Figures 252, 253, and 254 show a 
stone, a hairpin, and a tumor in the bladder. 



CHAPTER XXXVI. 



TUBAL PREGNANCY. 



Tubal pregnam-y includes all farms of gestatioD that originate 
outride of the uterine cavity. The old idea, that extra-uterine preg- 
nancy comprised three types — v'iz., tulmlj ovarian, and abdominal— 
has become obsolete ; no authentic case of gestation originating in the 
ovary or upon the peritoneum has ever come to lights So far na 
known, all ectniiic gestation originates in tlie Fallopian tube. Preg- 
nancy in a ni(linicntary horn <if a bicornate uterus is virtually a 
tubal pregnancy. 

Ectopic pregnancy was formerly considered a rare condition. 
Now we know it to be of relatively common occurrence. Pelvic 
hseniatocele, ftrnierly attributed to other causes, is now recognized, 
in the vast majority of cases at least, as being due to rupture of the 
gestation-sac of tubal pregnancy. 



Etioioery. 

The causes of tubal pregnancy, though they have been the subject 
of a vast amount of sjieculation, remain obscure. If fecundation in 
the human species normally occurs only in the cavity of the uterus, as 
held by Tait and J. Blatid Sutton, then \vv must considi-r tul>al preg- 
naucy due to an abnormal fecumlation of the ovum by vagrant s|K*r- 
matozoa in the tube. It is not established, however, that these 
authorities are correct. Assuming tfiat spermatozoa normally wander 
beyond the uterus, and that the ovum may nnrmally receives its fertil- 
ization before it finds a uterine attaeliment, it follows that some 
abnormal condition, either in the ovule or in the tube, might cause the 
ovule to im[)lant itself in the tube. 

The diameter of the human unimpregnatcd ovum is not over two- 
tenths of a millimetre; that of the tube, two or three millimetres; 
after impregnation the ovule rapidly increases in size ; but under 
ordinary conditiims there is ample time for it to pass into the uterus 
before disproportionate enlargement takes [dace. The great nuijori ty 
of tubal pregnancies* moreover, occur toward tlie abdominal end of the 
tube — that is, in or very near the ampulla, where the tube is large. 
The question of the si^e of the tube, therefore, is not very pertinent 
to this discussion. The fcvllowing additional causes of tubal preg- 
nancy have been suggested : reversed peristalsis ; the preseu<^e of 
accessory tubes ; kinks, access*»ry openings, or want of develojiment 
in the tubes ; and, finally, great length and tortuosity, hernia, or 
diverticula of the tubes. None of the suggested causes, however, 
accounts satisfactorily for the phenomena. 

439 



...: J IS -yAyCY. MALFORMATIoys. 

"J- - ^: ::.- .vmn requires ii surlaco denudetl 
- . :. :. Hv »ktlares that the normal uterus 
.:. :- -.:. r. iiun^truation, furnishes this eoii- 

- :.- : r---.-/.: ut salpingitis, may furnisli tlie 
T .: - 1 > \vtakened by two facts : First, tlie 

- .. : : .ivnuiletl as a result oi' menstrua- 
• J- . l-i> 'xrurred when there were no 

\ -• ' y prt'irnaney may occur in woman, 

^ ! - —•'':: ut mon>truation. Neither men- 

. - - •>. i- I— i-niial to the attachment of 

.• ::.r i.-nj: |H-ricxls of sterility. This 
-.- \ —■: d hy the fact that chronic sal- 
^ :: :.:Vh ami tU-struction of the cilia, 
.-_• t ■■ ^^vule to the uterus and at the 

i". rhf tube. 
.: v7^^,:='.-*"^7 i^ explained as follows: 
• .. :-. ' -•'^'^■l^'pnient the uterus was bicor- 
v :- r.>. .'f which the Fallopian tul)es 
• - •'< In other words, the uterus con- 
^.^*- v.... :Man tubes. In some women 
, - - - - "•: v-nd or functional reversitm to 
. - r - • - :.:-t Ty, the stronp'r the tendency 
., ": ., - :: :.iUd pivjrnancy. This mi^du 
., ...>Lt- : ^.-^r.ancies observeil in the same 

... - . -:r::ctinir the tubes are fre<|Uent 
:. ■ .;•.> Kxnis<' the morbid condition 
» . ". > uncertain. 
. . .. -jx- p;aiv normally only in the 
, . — ^ -< A ,.^rc, as in the tul>es, ectojuc 
^- ^ -:::iplc. There are, however, 
^ ^ ' ' / ^?>*v that sjKM-matozoii mav 
^ . • - ' . onital passives or even ii) 
^ K ">. . :!v only condition essential 
.-: '--ir impn^jrnaticm, shall iiud 
' ^ .., : • t." ;:\»\uh uutsi<le the uterus. 
" '" ^ • ''^-- ■> «»n the tnuismi^rnition of 

-^' ^, -.'.'. •• ';^ tulv of the other. Both 
jl », - '-'i '■ '>^vn well attested in which 
-' '**'^.J^ *i^'« ""^* ovary on that side was 
■*" J^^ I ^tn r.'.cx^ :uul tulwil j)re^nancy in 
*' *.^^*»i--'^ .•••qni< luteum only in the 
• •***'"^ .j:^ !«r/vtHi il|.|t th<' ovum must 
i' ^' " :,s I* ••' tbo iul>e where it fiuallv 

^^ ^iisinon of tubal pregnancy is 



TUBAL PE EG NANCY 



Formation of Chorion, Amnion, Decidua, and Placenta,^ 

During the fir^iit montli or &^ix weeks of tubal pregrmney that 
portion of the tube in which the fertilized ovum is htd^ed becomes 
thinner and very vascular an J turgid. The niiicous luenibraiie be- 
comes stretclied and hs folds ctiaefHi. Tlie clianges thnl occur to tlie 
fertihzed ovum after impregtjation are iilentieal^ wlietlier it be in tlie 
tube or tlie uterine cavity. The membranes by which the embryo is 
enclosed are sitniliir to tljuse iu iutra-uterine gestation. Tliese meni' 
branes can be studied to advantage in tlie so-c^alle*! tubal mt>Iei?, which 
are similar in origin to uterine moles. The cluuion is shaggy with 
villi, and reseml*les in gross and luicroscopic aiv[>earances that found in 
intra-uterine gestation. The villi aj/pear as clusters of circular i)otlies. 
The embryo lies withiu the amniotic cavity, and the strneturc of the 
amnion and its relations to the euibryo and chorion arc almost the 
same as in intm-utcriue i)rcgnancy. 




Intenrtitial prcgmiiH^y.^ 

The formation i*f the placenta iu tubal gestation differs in several 
particulars from one d(tvelop(4l in the uterus. In normal gestatimi 
the uterine mucosa and the fietal strnctures lioth contribute to the 
formation of the placenta ; but in tubal pregnancy the tubal mucosa 
plays a very insignificant part. A tubal placenta is alrnf>st entirely 
derived from the embryo. 

After a careful study of graviil tubes, J. Blanr] Sutton states that he 
has failed to tiud a tubal deeidua. Althougli none forms in the tubes, 
it is a curinus circumstance that one forms in the uterus. It is thrown 
off during ialse laljor, or, if tlie patient goes to term, is expelled later 

1 J. Blanrl Suitnn, in AUbutt aivl Playfiilr'e Syntern of Oynecology. 
■ J. Bland SuUori, in WttwU'r's Ectopic Preffimncy. 



442 



TUMOBS, TUBAL PREGSAl 



lALFORMA TIONB, 



in j^nifill tnrpnents and without pain. Thi;? iritm-nterine ilocidua has 
lit] \\w t'leinontj> of a deoidaa of normal intm-uterine preguuocy. 
The myo^lpinx at first undergoe.s hyJ^ert^o|>hy» but smin that 

1>oriioii to whioh the pWvnta is attached l>ecome!? thinned, and the 
iiiodlesi of nnusindar fibres are separated; this favors early ropture. 

Frequency. 

TnUal pregnancy is not infrequent. Indeed, pelvic hfeinatoeele, 
whicli is not nncornnioi>, is almost invariably the result of ei-*topic 
gestation. In thirty-five hundred general autopsies Formad found 

FlQVftS 254L 



Jtuplttfffd tsthmlc ClntMli^iyutjotuuA^ prvenftncr of right tube. Third moDtb. Marked develop- 

mem of (locldua in titcruiJ 



thirty-five eetopie prepfnaiieies, or 1 per eent. This is, fic»rhaps, the 
largest peiH'euln^r*^^' repurteiL The extiqxiition of diseased tolK^s has 
lih»u^ht tc» lijfht many cases uf tubal gestation that would not 
otljerwine have been reeopnized, and has therel>y added to our 
estimate of their frt*<jiieuey ; tin's estimate is still furtht^ inereastKl 
by inicro»i?opie diagnosis of the decidna east off hy the uterus in the 

» A. Mttrtln, Die KruiikheltiMi F.llrllcr 



TUBAL PnEGNANCr. 



4U 



spurious labor wliiidi always oct*iir8 at some period of tubnl [irog* 
iiaiicy. 

Repetition of tubal pregnane ie« in the same individual has already 
been noticetl* Roth tubes may be siinultaueoiiHly pregnant. Twin 
tubal pregnancy in the same tub^ and concurrent tubal and uterine 
gestation have been reported. There is no absolute rule as to the 
frerpieucy of the condition on either ^ide. Tubal pregnancy has been 
reported after extirpation of the uterus, the tube still having a con- 
nection with the vagina,^ 

Varieties. 

Tubal pregnancies are designated aceording as the seat of implan- 
tation is respectively at the uterine end, the middle region, or near the 
abdominal extremity of tlie tube — that is, they are ; 

1. Interstitial pregnancy, 

2. Isthmic pr eg nancy, 

3. Ampullar pregnancy. 

Tlie subvarietics will be noticed in describing each type. The 
primary classification depends ujK>n the original site of implantation, 
not upon subsequent accidents of development or secondary changes. 

FlGlTHE 257. 



i^. 



.y 



X 



AmpuUftT pregnancy. Right tube. 



Fcutuj* surmunded with coagulated blood, 
nection.' 



Longitudinal 



A normal pregnaney may become extra-uterine by rupture of the uterus, 
as in a ease reported by Ix^opold/' but that di>cs not make it extra- 
uterine in the sense here e<nisiderccl. 

1. Interstitial Tubal Pregnancy. This is by far the least frequent 
form. Lwlgemeut of the ovum takes phice in tliat part of the tul>e 

> Wendllea. Monatst'hrm mr^nburtwhtilfv und GjrniLkolQgie. 1895. ContralbUtt fUr (JytUL^ 
kaloKie. No. 4, lim. 

< A. Martlti. Die Krankbi'iten der Eileltitr. ■ Arcbiv n\T rj; nkkologie, IvfJ 



444 TUMOm^ TUBAL PSEGNASCY, MAUOR}IATlOy& 

which tra verses the uterine wall, and the foetus develops in a cavity 
formed in the substance of the nteru*^. This cavity may open into 
tliat of the utenLs, making a tubo-uterine pregnancy ; or it may in 
rare instances extend ontward between the layers of the broad ligti- 
ment^. Webster * conclude.* that in some ca^^es of interstitial prf^- 
nancy the ovum develops in the side wull of the uterus?, in a diver- 
ticulum formed by the incomplete fusion of Muller*^ ducU which 
sometimes occurs in this particular region. Pregnancy in a rudi- 
mentary horn of the uterus, although Ijaving a pathology of it.*^ own, 
i.s yet not unlike a tubal pregnancy. The course and outcome of 
ititer?ititial pn^gnancy will be noticed later in connection with that of 
the other forms. 

2, Ifithmic Pregnancy is more frequent than interstitial, le-ss fre- 
quent than iimpullar, pregnancy. The ovtmi is lodged in the middle 
regic^n ; and there is generally, before rupture, a spindle-sba[>ed dilata- 
tii^u of the tube. So-calleil [M*duneulated tubal pregnancy is |>ossible in 
tills part of the tube, and hiLs in a few crises gtme to term. This occurs 
when the ovum is kulged in a diverticulum or angle ctf the tul>e. 
Under such conditions the walls of the tube may be thick or thin in 

[parts, with consequent greater liability to rupture in the tliin parts. 

3. Ampullar Pregnancy. This is the common variety. The 
attachment of the ovum takes place in the ampullar or onter third of 
the tube. Tubo-ovarian pregnancy ix-curs when there is a prior adlu*- 
sion of the ampulla to the ovary, so that both cootribute to form the 
gestation-sac. This is a subdivision of ampullar pregnancy. 

Development and Course of Tubal Gestation. 

After the ovum has attached itself to the tubal wall it continues 
to develop. Naturally the conditions are not so favorable as in 
normal gestation : the tubal walls are less suited to its lodgement, 
and eontrilnite less fully to its nourishnieut and development than 
.does the uterus in normal pregnancy. Unless the ovum is insertnl 
■well in toward the uterus, as in interstitial pregnancy, the whole tube 
becomes extra vascular, turgid, thinner, and, in must cases, less and 
less resistant. The margin of peritoneum around tiie ostium abdora- 
inale thickens and forms a ring about the timbricp. This ring by the 
eigfith week usually ch)ses over and shuts the tube. The develo]!- 
ment of the ovule iu tlie tube, so far as tire conditions will permit, 
ciintinues to follow the s^imie course as in the uti/rus. 

As the fo'tus enlarges the ctairse of gestation will be modified in 
one of the following ways : 

a. The foHus, if in or near (he anipnllit, maybe exjH'lled from the 
tube thri>ugh the oslium abdominale intf> thtwibdominal cavity. This 
is called tiil>a! aborti^ni. 

ft. The tube may ru|jtore and j*artly or wholly discharge the fcBtus 
in nnv of four dirertiuns : 

L Into the abd<mrinal cavity. 

2. rnt4> the space between tlie broad ligaments. 



TUBAL PREGNANCY, 



445 



3. Into a space formed by atlhe.siotis between the tiibt" and ovary. 

4. Into tb*^ nterntJ. 

a. Tubal Abortion necessarily oceiirs wliile tlie ostium abdom- 
inale is still open — that is, befiire tlie eij^litii wvvk. The nearer the 
imjilantation <d* tlie ovide to the ostium the f2:reater tlie liabflity to 
abiirtion. In tins aandent the prtxhiet of eonce[>ti(m— sometimes 
ealh:d tubal mule — is (h'selmro:e<l with free hem*trrljage through the 
still open ostinm into the abdominal euvity. The heniorrtiaf^e gives 
rise to the formation of intraperitoneal pelvic li0pmatoeoh\ The acci- 
dent may be fatal from shrM^k and loss of blofxh or the patient may 
recover. In some eases the mole lies fpiiescent in the tube, ajul if oidy 
partially detached it ^ives rise to repeated and (langi^rons hemorrhage. 
The false nterine deeidua is usually thrown off with uterine heuKUThage 
when the tubal abortion takes place* The latter oecurrenee may be, 
a.s it were, masked by the uterine hemorrhage. Tubal abortion does 
not occur in interstitial and is rare in isthmie pregnancy ; after tvc<4u- 
SKjn of the ostium it eau hardly occur even in the ampullar variety. 

/*. Tubal Rupture. Rupture of the tube may iK'enr at any period. 
It is nrvt very usual in the first mimtli, is fpute liable to oeeur in the 
second, and rapidly becomes less frequent after the beginning of the 
thirdj still less in the fourth. It may be due to direct tension on 
the tubal walls from the growing fnetns, but is commonly brought 
about by hemorrhage between the iwiim and the sac. Among tlie 
other causes are meebauieal violence from falling, jumping, digital 
examination, and coitus. The rupture usnally takes place where the 
hemorrhage l>egins — that is, at the placental insertion. The fa^tal 
membranes are not necessarily involved in the t<^ar. If the ovum 
still retains its placental insertion, as it does in nire cases, it may 
continue to grow, M(>re commonly it is extruthnl through tlie rupt- 
ured tubal wall and passes into the abdominal cavity ; or it may pass 
dcjwuward between the folds of tlie luY>ad ligjiment or into a cavity 
formetl by adhesiims between the tid>al wall and the ovarv. 

Rupture in interstitial pregnancy may be either into the abdomen, 
where it is apt to be rapi<lly tatal from hemorrhage and shm-k, or into 
the uterine cavity, where the pn^guancy may continue as in normal 
gestation. Rupture into the uterus may occur much later than the 
fourth month. 

If the feetiis in ampullar or isthmic pregnancy is not entirely cut 
off by rupture from its nutritive connections, or disorganized by 
hemorrhage, and especially if the rupture is into the space between 
the folds of the broad ligtiments or into a tubo-ovariau cavity, gesta- 
tion may go to full term. If the JVetus and its investing membranes 
escape into the general |H^ritoneal cavity, the placenta remaining in 
the tul)e, it is possible, thougli nire, for *levelopment to continue. 

The obi notion that a free embryo t^onld escape and ingraft itself 
on the jK'ritoneum is obsolete. The experiments of I^opold on dogs 
demonstrate the great absorbing piwer td' the peritoneum » and in(H- 
eate that no organism tlius introduced cftnld possibly survive. 

In very' rare instances the j>edunculattMl isthmic pregnancy already 
mentioned may go to term in the unruptured tnl>e. 



I 




446 TUMOMS, TUBAL PREGNANCY, MALFORMATIONS. 

li ni\vXnw uocurs early in pregnancy, hemorrhage may lie slight ; 
but after the first month it is apt to be formidable ami may cause 
death in a few lionr?*. If the hemorrhage is slight^ we have the com- 
mon ty^^ of retro-uterine hnematoeeh\ wliieh, if not aggravated by 
repeated bleedings, is generally ene* ttnl and gmdnally absorbed. In 
istiimie and ampullar gestation the jptnre is i\\\vn downward between 
the layers of the br(Hid ligament. The bhwKi is then poure<l out into 
this confined space. The natural teoileney iif this eonfinement is to 
check tlje hemorrlmge. The bhurtl thus aecumulated is called a bmad- 
ligament lifenjatueele. The more gradual the rupture and the more 
dight the hemorrhage, the less the general and local disturbance will 
e. Umler suefi conditions the eudjryo and its envehipes and placenta 
will liave a better chance to ailapt themselves to their enlarged and 
enlarging quarters, and may go on to term. 

If the esciipe*! end>ryo develops in a cavity formed by the two 
hiyers of the Ijn^ad ligament and the outer wall of the tube, the preg- 
nancy is called tubo'lhjameniouR, x\s the fret us develops it presses 
aside and displaces other organs, the layers of the br*)ad ligament 
become compressed or thickened ami form adiicsions to surround- 
ing i^arts, the jxTit^meum is pressed npwanl and stripfied from the 
bladder and alKhmiinal wall, the uterus is displaced to the opposite 
side and, according to the direction of pressure, upward or down- 
wanl. 

If the placenta is situated in the upper part of the tube, so that it 
is pressed up al>ove the ftetiis toward the abdomen, forming a tubal 
placenta pran-ia, the danger from secondary rupttu*e of the gestatiitn- 
sac into the al>domen is very great ; such an accident is apt to be fatal. 
If tlw placenta is situated below the fret us toward the mesosalpinx, 
ami pressed down upon the pelvic floor, this danger is less imminc^nt ; 
for rupture in this situation, since it does not of necessity directly 
involve the placenta, is attended with less hemorrhage and less risk. 

All isthmie and ampullar pregnancies, if left to nature, end with 
death of the fcetus. The tubo-nterinc variety of interstitial preg- 
nancy may, as already explaineil, result in the |iassage of the embr\*o 
into the uterine cavity and sulxscrjuent normal gestation. Tiilial preg- 
nancy going on to term seldom results in the extraction of a viable 
child. The few children who survive the operation for their removal 
almost always die in early infancy. 

Secondary Chancres in Connecticm with Tubal Gestation. 

If the death of the fictns occur in the earlier weeks and the 
nic>ther survive, the subse<pienl conditions will vary according as tljc 
embrvo is retained in its envelopes or is cast out free in the abdominal 
cavity. In ihe latter ease it may be quickly absorbed ; in the former^ 
absoriition, ahhough slower, is the usual ultimate result. (iestntir»n 
that has ailvauccil fur sevend months may give rise to a variety of 
change*. The t*etus may uu<lergo a prrwcss 4»f mummification and 
remain encapsulate*l in the IkmIv <»f the mother for years, Chiari has 
Imported a case in which the mummiiiHl foetus was carried for fifty 



TUBAL PREGNANCY, 



Wi 



years. It may undergo eak-areoiLs degrnt'mliun, so-called, and become 
a lithnptedionj and remain in that state lor years. The mnmniitied or 
. calcareouji ftetus oritinarily gives little trtKible ; it may, howe%er, Ije- 
'come the seat of suppamtion, and as a eoiisi^fjnenee tfie jmtient may 
sueeanib to exlianstion from peritmiitis or blood-puisoning. On the 
other han<l, spontaneiais opening of the abscess into the intestines or 
vagina, or through the abduminal walls, may lead to recover)\ A 
lithopredion has been the ineeiianieal eanse of obstrnction in labor. 
The formatimi of a uterine deeidna ami its discharge in tubal preg- 
nancy liave been ah'eady nienhoned. The mnsenlatnre of the nterus 
also nntlergni's hyfK^rtraphy. Tlie organ may enlarge to the size of the 
ftiurth niontli of pregnancy, amt then to some extent diminish. If 
tliu tufml |>regnancy is interrnptcd by abortion or niptnre, the nterus 
generally at the same time throws off the deeidna with a bloody dis- 
charge. This spurious labor may, however^ ocunr at any time, and 
always does occur at some time in the course of rlic gestation,' 



Symptoms. 

To some extent the symptoms of tubal pregnancy have already 
' been indicated. In some cases the menstruation is uninterrupted. 
The usual signs of pregnancy, such as pigmentation, fulness of the 
breasts, and nutrning sii-kness, may be present or absent. Fninkeuthal ^ 
says that during the first eight weeks the oi\linary subjective signs 
are absent. This statement is true for the majority of cases. Slight 
uterine hemorrhages may occur at irregular intervals from the begin- 
ning. Colicky pains, pri>bably due to uterine contractions, apfxnir 
toward tlie end of tlie secfuid month, and are apt to continue at 
irregular intervals throughout the whole period of gestation. The 
signs of interstitial pregnanty arc much like those of normal uterine 
gestation. This is expknned by the nearness of the gestation-sac to 
the endometrium. 

When tubal pregnancy goes on beyond the fourth month the ex- 
terna! sign of asymmetrical enlargeincnt in the al>donTen b<.^gins to 
appear. The pressure symptoms are much like those of uterine preg- 
nancy. In tnho-lign men tons pregnancy there is exaggerated pressure 
on the pelvic organs. Finally the usual signs of fieta! life arc pres- 
ent, and in the latter months of tubal pregnancy jwiinfu! fietal move- 
ments are common. 

The pnins of spuriou.^ labor resemlde those of normal parturition, 
and are sometimes very deceptive. They may be slight or severe. 
Cases are recorded in wliich they continued for days and even 
weeks, or recurred irregnlnrly for long |K^riofls. One or two eases 
have been rejunnetl in which the sac ruptured into the vagina at the 
time of spurious labor and the child wns pro<luced by the natural 
passage. Rupture into the intestine antl expulsion of the ffctns 

» For ft full rlesoH]^tSnn of the mierosoopioal chftraotir of the f<otnl envelope, the iit^Tiue 
decidutt, and Uit' miiiulf rhJinfca In the (fi^t«tltjn-mn*, nnd for a mon* exlcnrk'tl ncconnt of ihc 
flegent'Ttttive rhank't'M Uiat ofriir in ronnertiioii with tnhul uest«tinn, the reader ib nforred to 
the m(M ref*ni and tHjnipk-U" wnrka on this Bnhjett. thoee uf August Martin. Wcbeier. and 
J. Bland SnTton, 

' Tmnsuf'tiuos rhlmgo gynecological Societjr. 



TUBAL PEEayAixar. 



449 



A.S alreaily stuhnl, iK^tnorrliago itito tlie space betw^^'cn the Mih nf 
the* bnxid litjruiijeiit is continetl, iiiul tliorrfVire liuHtt^tL It' tho loi\x* is 
surticieiitly strong to cans*' seeuialary intraperitoneal rupture — -that is, 
rupture (Voiii the iiiterior of the ligatueut tu tlie peritoueuru — tiiere will 
he great dangc^r of profimiul acute aiuemia an<l collapse. If tlie bhxjd 
is eonfiucil, tlje vcsiai! antl reet4il tenesmus and other symptoms due to 
tearing aud pressure tiiay be overwhelmiug. 



Diagnosis. 

lu the early period of tubal pregnancy tliere are no certain means 
of diagnosis. Tlie patient may have noticed no irregularity in Iwr 
pbysiitlogical life, and mny have been utterly unaware of lier coiulit ion 
until the occurrence of ru])ture or abortion. This is especially likely 
to be the case w^iien the aljortion or rupture occurs very early after 
iinpregnatiiui. Usually, however, it occurs between the iburtli aud 
ninth weeks; during this time certain anomalies already mentioned, 
such as irreguhir menstruation or pain, may have attracted attention 
and led to t\u^ ilis(*uverv of an enlarged tuln'. It is a siguifit?aut tact 
in diugnosis that tubal pregnancy often occurs after long jjeriodi^ of 
sterility. Sui'li sterility is thereiV*re a sus[)icious circunistanee. The 
microscopie finding of the eastnitf decidua is, of counse, strongly 
diiign**stie. In the later perirMls (»f gestation many of the usual signs 
oditied ai '" 



of pregnancy are moi 



and distorted bv aliuonnal conditions. 



Differential Diagnoeis. 

Tlie following etjuditions may simulate or coexist with tubal preg- 
nancy: Spuriruts pregnancy. Certain conditions of abnormally tliin 
uterine walls, together with displacement of the uterus. Normal preg- 
nancy, with the uterus in positicKU Normal ju"<:guaucy in a retrofiexed 
or laterottexed uK'rtis, Oviirian and other tumors. 

Pregnancy in the rudimentary horn of a uterus unicornis, though 
of ditferent p;ithnl<igy, is stihjeet to the same laws of diagnosis and 
treatment as ordinary tubal jiregnaney. 

Tubal gestation in the fully develoiMztl horn of a bicornate uterus 
m:iy l>e mistak(*n for ectopic pregnancy. Such a pregnancy woidd go 
on TO normal delivery at term, Correct diagnosis in sn(*h a csise may 
prevent an imnecessary iil>dominal secticm, and is therefore nnist 
ini])ortJint. 

The clifferential diagnosis of tubal abortion aud rupture is to be 
mafle from the following c(indilions : 
Huj>ture of u snetosjd|>iux. 
Itujiture of an aneurism, 
RujUun* of an <vv:iriau tumor, 
Ap|wudieitis, with rujiture of the apy>cndix. 
Perforation of the stomach or intestine. 

IIa*mato(*ele from causes not dr|>endent n|x>n tuba! gestjition. 
Noiu* of the above-named eonditiinis, however, produce the ftvnijv 
tora-group outlined in the above remarks on diagnosis. 

2^ 



460 TUMORS, TUBAL PREGNANCY, MALFORMATIONS, 

ProgrnoBis. 

This IS always doubtful and serious. Spontaneous recovery is, how- 
ever, not uncommon. In former times pelvic hsematocele was not, in 
the majority of cases, recognized as related to tubal pregnancy, and 
was therefore usually treated on the expectant plan. Under such con- 
ditions sj)ontaneous cures were frequent. Our knowledge of the tnie 
pathology and the consequent greater frequency of operative inter- 
ference does not change tiie fact that spontaneous recovery iivill often 
occur just the same, even though the name of the condition has been 
changed from hsematocele to tubal pregnancy. However, recovery 
occurs much more frequently with than without operation. In two 
hundred and seventy-eight cases for which there had been no opera- 
tion, collected by Schauta, Martin, and Orthmann, one hundred and 
eighty-seven, or a little over two-thirds, died ; while five hundred and 
seven, or 80 per cent., of six hundred and thirty- six cases operated 
upon, survived.* 

Treatment. 

From the observations already made, it follows that the treatment 
of tubal pregnancy will, as a general rule, be operative. The safet)' 
of the patient is immeasurably greater if the diaenosis is made and 
the operation performed in the earlier weeks, before the time of 
tubal abortion or rupture. Unfortunately for the great majority 
of cases, the first intimation of the diagnosis comes with one or the 
other of these accidents. 

Tlie treatment will vary with the varying conditions. The four 
possibilities are : 

1. That the diatrnosis has been made before the time of rupture or 
abortion. 

2. That rupture or abortion has just occurred. 

3. That the patient has survived the inimeiliate eflTects of rupture 
or abortion, and gestation has ceased with the death of the foetus. 

4. That rupture has (K'curred, but the foetus is alive and gestation 
is still going on. 

1. Treatment before Rupture or Abortion. The tube and its eon- 
tents should be immediately removed. Only by this means can the 
woman be protected against the extreme peril of continued tubal ges- 
tation. The danger of the operation is not greater than the removal 
of the uterine aj)j)endages under other circumstances, and the technique 
is the same. In very ninny cases tubal pregnancy is unrecognized 
until the abdomen has been opened on the diagnosis of a supposed 
hydrosalj)inx or j)y()salpinx. This fiict, as Penrose says, emphasize:* 
the value of the rule to o]X'rate for all gross lesions of the tube. 

2. Treatment Ln mediate!// after llupture or Abortion. The general 
rule is to ojwrate without delay. It may be unwise to wait for reaction 
from th(» shock and honiorrliagc^ for hemorrhage is the very indi- 
eation for interference. Indeed, the immediate objeet of the operation 
is to stop the hemorrhage. 

» A. Martin. Krankheiton der Eileitcr, 1895. 



TUBAL PEJ-yiNAyCY. 



451 



The writor has rot^onle^l two casL-s in which thi' patients WT^rc in 
appaiviii cuUapM', and tV»r tliis fi^ason it was nt*t tlenneil wise to opemte 
iinlesjs there sliuuld he a tendeney tu ndly. In botli Ciises there w^ere 
slow improvement and final reeovery withcMit oiK^ratiim. A few 
nionibs later in Imth eases the priwlnet^s ui' cuneeption had entirely 
disiippJUHHl by iil»sorption. These eases show that without operation 
the proirnosis, even in tlie must extreme conilitions, is not hopeless. 
The operation is as Ibllows : 

Tiie abdomen is opened as tor the removal of the nterine ii|>- 
|.»enLlages. The tube anJ^ together with it, the broad ligament, are 
graspc*! and pulled into the wound ; two strong jKtin* f»f lueniostatic 
loreeps are ptaeed on the l^roatl ligament — one on the iufundihulo- 
pelvie extension of it, near the pelvic wall, the other close to the 
uterus; thii^ will eontrr^l tlie ovarian artery at its point of eiitraiiee 
botli to the ligament and to the uterus. Ijigiitures are immediately 
euhstituted tor the forceps, tlie tube removed, and hiemostasis secured 
as deseribe<l in Chapter XXIIL If there is a cavity between the 
fohls of the broad ligament, it may be obliterated by tine buried 
fjatgut sutures. 

The five infusif»ii f»f mvnnal salt solution, two or more pints, by 
hyp<jdermoc lysis, prefenibly under the breast, is strongly indicated. 
This infusion, which may he given, according to the indie^ition, before, 
during, and after the ojx^ration, has turned the seale for recovery in 
many a desperate case. If the hemorrhage has been great, Franketi- 
thal ail vises direct transftision of blocnb 

There is apparent merit in the suggestion ^ to place the patient in 
the Trentlelenburg position, in order that the l>lood may be distrihuted 
over larger fieri toneal surfaces, and therefore have better eluinee tor 
absorption. The oljjcct is to avoid shock, loirali zed htematmx'Ie, and 
jjossihly avr»id ojw^ratiou. 

3, If ntpfHrp or (fhudfon haa oernrrrft, and the patient has recovered 
from its inmiediate ejects, and gestaticm has rcased with the death of 
the ftetus, there may be spoutaueou.s cure, with absorption and *lisap- 
pesiranec of the prinhicts of conception. Under these favomble con- 
ditions, es[>ecially if there he eontimmus gradual iujproveraent in the 
symj)toms, one may adojit tlie plan of watchful expeetaru-y. Fnink- 
enthal says: "Treat eonstTvatively cudy those eases i^ven sfinie time 
after prinuiry rupture, when you are ni'ast ma bly certain of the death of 
the ftetns, when the alarming symptoms have subsi^led, and when, 
presumably, absorptitui is going on/' Intraliganumtous rupture 
(weurring within the first three or f(»ur weeks of gestation is nither 
Jiable to be followed by recovery and absorption. One must, iu>w- 
ever, t*e prepared to operate |)rom})tly npim the least evidence of 
.second;! ry rupture and hemorrhage or uj>on the onset of infection. 
Even in this class of r^ases, Imwever, it is jw?rniissil>Ie and possibly safer 
to operate, and thereby relieve the w^oman of the danger incident to 
the presence of a dead fetus in the pcdvis. 

Previous to the fourth or fifth ui<uith the entire gestation-sac and 
its contents may usually be i-emoveit without great danger of fatal 

t SJppcl OntmUilntt fUr r;ynuk-i1*.*fle. 1896. 




452 



TCMOSS, TCBAL r&SGSJXCr, MALFOEMATIOKS. 



bemtmhsi^. At kaist tlie hrmorrhage, if tTQiiblesunie, may l>e eon- 
trailed by ligumre of the mi»rmn vessels^ or, if iiewsj»ary, of the 
ovaran and uterine veasek. After tbe fiettis ha^ been tleatl for ??ome 
rime then? i:* Utile or no duger rf hanorrhage in 8e|*uniting the 
pbceota. 

4- Jffftilaikm km (kAniimW be^^ond ikf fourth or fifth month, aud 
ibe child b living, die reiuo\^I cif tie Icetus, U«^ther with the placenta 
and gestatioo-sae, i:^ pmetiaible in only a small minority *)f eafe»ei=i, and 
tbeo only in the hand> of tlie exiierieneetl aiul ex[iert c»|>erator. The 
cooditious favorable for lhi.< radical ope mtion are inuml in the rare 
pedunculated tubal pn^iamnes already nientione<l, in wliirh gestation 
may go to term witnoui niptur^', and in other rare cnf^es in wliiili tlje 
sac can be ii?«-Jated, brought thn>iigh the wound, and a jK^liele formed, 
or Its attachments separated without exce^^isive henRirrhiige, Ligature 
of tbe ovarian and uterine ve;v^4sdcn^ not t^mtrul the terrible hemnr- 
rhage whieh at this jieriod atid under ordinary ennditions iiivanalily 
follows sei^iaration of the platvnt;i. The surgi^on must assume the 
great resp<insibility i»f a deeision, when the aWomen is open, whether 
or not he will attempt the removal of the gestation-sac. The delMw 
erate attempt to remove it has many times resulted in uncontrollable 
and fatal hemorrhntn\ In ojx'uing the sae the ojn^ator may acei- 
dentally ineist^ or jKirtially si*|xmite the phuvnta an<l Jiu*l hijiiself face 
to fiiee with a most formidable, if not unmanageable, hemorrhage. 
Compression of the aorta ami ligatun]' of the uterine and ovarian 
arteries, if im^mptly and skiHully exetMitid, may or may not save the 
patient's life. In the vast majority of cjtses in which gestation is in 
progress Ix^yond the fourth or fifth month the ojKralor must he con- 
tent to incise the sac, rtMuove the foetus, stitch the s;ic to ilie abdtimi- 
nal wound, and leave the phuvnta. J. Rhnid Sutton proposes, instead 
of stitching the siic to the wt»untl, to eloM- it wiih sutures* This is 
done in tlie hop- that the placenta will nndeigo atrophy or absorptituu 
The danger of inf\H*li^m in a sae thus closed would be considcrablt*. 
The more usual and ^afe^ phm, therffi^re, is to leave the placenta and 
estahli^b gauze or tubular ilraiuage. After two nr llmH- weeks, wlien 
the ]*lacental circulation has c«*ascd» the wound may lie reop ne<l, the 
gauze removed, and the placenta taken away. Another mtu-e rornnHin 
and approvcil piiietiec* is (o let the placenta disiutegnUe and dmin 
away as debris. 

Snn(» o|K*ni^ors prefer to delay op'ration until after term, when 
the eiiild has died and tlie placental eireulalion has ceasi'fl. The* 
produc*Ls of conception may llu^n be removed entire, with the 
minimum danger of hemorrhnge. This plan necc^sarily involves the 
daTi^cTs incident to the cimtinued jiresence of an (»xtrji-uterine fotus. 

The Ahdomfnat Vtrmut /Ar VittfUutI lloufe. If the pro^lncts of 
conr-epti^Hi are low down and quite accessible, if gf^station has not 
|mssed ln'ynnd thie eighth wer'k,* and If the tube is movable so tliat it 
can readily l>e brouirht tjut through the vaginal wound, it is perm is* 
mble to operate by that route. If I lie gestation sac is iM^twi^en tlie 
folds of the biHjad ligament and tlie ehild has been for some time dead, 
* Frankcnthal. TrmnBActlons Clifefiso (iynecc»loglc&l Sool^ijri 1WM, 



TUBAL PREGNANCY, 453 

and the placental circulation has therefore ceased, one may remove 
the products of conception, unless too large, through the vagina. In 
all other cases the diflSculty of controlling hemorrhage through the 
vagina is too great, and the abdominal route is therefore to be pre- 
ferred. The difficulty of ligaturing the infundibulo-pelvic ligament 
through the vagina is an objection to that route. 

In all cases of ectopic pregnancy at term the viability of the child 
as compared to the life and welfare of the mother is a very secondary 
matter. Few children are produced alive, and fewer still survive 
many days. The few who do survive are physically and mentally 
inferior. Harris^ collected a number of cases of living children of 
extra-uterine pregnancies, and in 1895 reported to Orthmann that of 
fifty-seven whose histories he had been able to trace only five survived 
their second yeiir. 

> American Journal of the Medical Sciences, August-September, 1888. 



CHAPTER XXXVII. 

CONGEN ITA L :vi A LFORMATIONS. 

Mai.fohmatioks tnay hv due to arretted dL'vt!l(>))mpnt or to exceji- 
^]vv <leveluptnent. In the iirKt ela,ss of aiiom.ali('s wc have the ntal- 
foriuatiuos due to the prnsisteure ot'eud>rynnul eoiidiiinns; the ?^*eond 
cbss inrliides tlie hypertrophie^s and liiultiplieutioiis of otberwjs^e 
iioFiiud ori!"aiis and tissues. 

The j^eiiital or^atii? in the fcetus a}i|xar in a stnii-tiH'*- eallcHl tlu* 
genital (*niiiieiice, which first lies on each .^ide of the nuilian line and 
subdivides later, the inner portion forniitig the sexnal gland — tli*^ 
testi(*Ie in the male and ihe ovary in the female — while tl»e outer 
yeetion heeornes the WolHian ducl.s and hodies and tlie eauul^ of 
Midler. In ihr female embryo at term tiie Wnlttian l>o<Iies, Mhieh 
had servi'd the funetion of tin* kid nry ihiriiig end>ryonal life, atrophy 
and heeome the htxly of Kt^sennuUler, wlnle the ducts of MiHler in 
their upper portion form tlie tubes, and in their lower jiortion eoaleM*t^ 
with the Wolffian dueti^ to prmluee the uterus^ and va|i::ina. It ii> 
es.'^i'ntial 1(1 keep these faels in mind in c^onsidering the gc?nital mal- 
formations due to arrest or excess of devehiprneut. 



Malformations of the Ovaries. 

Malfdrmations of the ovaries are not numerous. They eonsi'^t 
rnainly in laek of develo|vment or in excessive development. The 
principal anomalies are thest*: 

Accessory or constricted ovaries. 

Su[icrnnincniry r^varies. 

Absence of the ovaries, 

Kudinientary ovaries. 

Ouigimital hypertrophy of the (^varies. 

Congenital displaeenient of the ovaries. 

Accessory Ovaries jire f<Hind In from 2 to f\ per cent, of niitnp^^ii 

They are always of small sisce, and arc |unt*nerally (connected with tL, 

normal i^vanes Ijy a iitKluneulated or sessile attaehnient. Two or 

three* may he foun<l in oin- case. They are usually piirts of the 

orit^inal «*varv st^parattKl during late fa*tal life by the eunstrietion of 

peri ton tlie Inuids. The iivarv may be thus divided into cfjual halve8 

oi' may he cudy partially divided* The* presence of atvessory ovaries 

may account fi»r preijjnani^y after both ii varies are snp]M)sed to have 

been removf^b 

Supernumerary Ovaries* Ordy unc authentic (^ase has l)ccii 
rejwrted.* Tins was a third f^varv situated in front of the uterus 

* Winckcl, In AilbuU ancj rinyfatr^ System of GyatTology. 



CONOKNITAL MA LF0R3U TIONS, 



455 



in direct relutimi with the bladder, and eoriiicctorl to the uterus hy a 
strong ovarian ligament. Thi.'^ ovary wa.s twiee the iiiu'niul size. 
The two otJier ovaries were nurnial and of eqnul size. There was no 
trace of jieritonitis in the neighborhotHh 

Absence of the Ovariee is a rare condition. It i^ usually asso- 
ciated with imperfect dcveh>pmetit or abscjiee of one a)V more of the 
other sexual organs. An absolute diagnosis can he made only Ijy 
autopsy, for the ovary may be present in an abn^jruKil lin^ation or in 
a partially developed state, and may theretijre Ik.' overlooked. Absence 
of one ovary is apt to be assot^iated with al>sence of the correspond- 
ing half of the uterus and Fallopian tnlje. The writer has, however, 
in one ease operated iVir tlie removal of the snppnmtiug riglit tube 
and ovary, and found a jierfectly developed uterus antb ^f» f**r '^^ 
con hi he discovered, entire absence of the left tube and ovary. There 
was only a slight protuberance at tlie loft uterine cornu to mark the 
point where the tube should have joined the uterus. Figure 258. 



FrniiRE 2r>H. 



Alwenr^e of the left oviiry, with fuU develofirat'iit nf the othiT ffeiiitiil orpnns. Thk wnuM 
bcaKMMi illiistmUoii uf theauthur'a fftse, A. Corpus lUcri li. FiiHupian lube. C. Ovapy. 0, 
Broita Ui£^am<}nt. F. tVrvix uWtI. G. VaginA.i 



Rudimentary Ovaries are not very nncornmon. They are of 
small size, and tlie Gniafian ff41ielcs are absent or nidimentary. The 
nterns may be normal or may be also nulimcntary. 

Cong'snital Hypertrophy of the Ovaries. Excessive frrowtli of 
tlie ovary has been recorded, hnt this cannot be strictly classed as 
malformation. It hns hvon attributed to hypenemic or inflammatory 
conditions during fietal life. 

Congenital Diaplaceinent of the Ovary. ** Non-descent of an 

1 A. Mftrtlti, Die KrankhLilen tier Ellfiter. 




45ti 



TUMOILS TUBAL PREGNANCY, MALFOBMATiONS. 



fjvary i.s a rare* but not unknown anomaly, Blaud Sutton has re- 
portctl a case in Avliieli tlte rigitt ovary was atlhercut in tlif lower 
iKjnk'r of the kidni'V of the same mlv, and I l»a\o K'en a ca.<e in the 
newborn intant in whu^h it was attached by peritonitie bands to the 
cseeum. It has l^een stated that it may be fun ml free in tlie peritoneal 
cavity." At least oeeurrences of this kind have been reeonled, 8ir 
Astk\v Coojwr, lor example, once tmnsphuited the testicle of a cock 
to the abdominal eavity of a hen, where it eoiuinued to grow, 

** Insti^ad of nf>n-deseent, ther«* may be ilisloeation of the ovaries 
downward int<j the injj^ninal eanab Aeeordinj;: to Pneeh, congeni- 
tal inguinal hernia of tlie ovary is mneh mt>re common tlian ac- 
quired, and Zinnis has recently reported an instance of it ; but Bland 
Sutton states that he knows of no case in wliich the ovarian nature 
of the herniated btHly has been proved by microscopical examination 
conducted by a e(>mpetent observer* Herniation of the ovary, v^liieh 
may be uni lateral or bilateral, is nsnally associated with displacement 
of the Fallopian tnbe, and sometimes with nnilt*ornration of the 
uterus and mal[>osition of the kidney. It may be due to defective 
development of the round ligament and a patent condition of the 
canal .)f Nuck/;^ 

(Jilt teal Sif/nijii\jnce of Ovarian 3faIformafhm, The absence of 
one ovary, if the other is perfectly develt^jKd, iloes not render the 
woman sterile- On tlie contrary, her reproductive functions may be 
in no respect impaired. If both ovaries are rudimentary or absent, 
sterility is the rn!e. There is usually wanting in such cases the 
normal devehipment at puberty ; there will also be an assm-iated 
faulty general nntritifin, a wt ak nervous organiziition, chlorosis, and not 
uncommonly a growtli of hair on the face, especially the upper lijK 
The indivitlual may retain even the general physical characteristics 
of infancy and ciiildhomh or there may be an appartnttly full develop 
ment of the extr!t-|)etvic organs. 

TIte (IhifpioHiM of orarhfn maffftnnattotti^ is ma<le liy tlie above signs 
and svniptoms and by the recognition on conjoined examination 
of nndeveloped, absent, aecessory, or otherwise anomalous ovaries. 
Karly an<l accnrate diagnosis is important, for only by this means 
will the woman be saved from a possible long-continncfl and useless 
treatment for sterility. It is often impossible to say that an appar- 
ently rudimentary ovary is congi iiit:d, for it may liave bc^en subject 
to atro|»liic changes consecpicnt upon the acute infcK'tious disea^e*^ of 
childhtHKl. 

Malformations of the Fallopian Tubes. 

These malformations are analogous to those of the ovary, and are 
therefore as f< »1 lows : 

Sup-rnnincrar)' tubes. 

Accessory tubes and ostia. 

Inci'eased length and excessive convolution. 

Rndimentnry development. 

Absence rtf the tubes. 

1 Quoted rrtiiii Altbutt Aad PiAjHar, SjrttQvn of Gynerotni^. 



4 



< 
4 

i 

n 
4 




458 



TUMORS, TUBAL PREGXAXCr, MALFOnMATIOXS, 



Rudimentary Development. The nidiiiientiiry tube is iisuallv 
iniporfonite, bojiig a mere lihrous oonl witli, perhaps, the semblaiKr 
of an t)\yen ainpiilla and tiiiibrife* The eorrespontlinir ovary may or 
may not l)e also rndimeatary or absent. The aeeitleiit is due to fail- 
ure of develojniient of MiUIer^s fbiet. 

Absence of the Tube inure fre<jnently jii^r tarns to one tlian to both 
sides* When l*oth tubes are absent the uterus and ovaries are also 
ysiraliy WiUithiii^. Cases have been reeoriied in whieh the tube and 
kithiey on the same side were absent. Al)seuee of one tube is usually 
associated with want of devehipment of the corresi>onding side of tlie 
uterus- — that is, with uterus lOiirornhK, 

Titr Cfifiicai Sif/itifieana' of raid tbrniat ions of the tubes is much the 
jsauve as that already outlined for malformations of the ovaries. 



Malformations of the Uterus. 

The developmental defeets of the uterus form a large proportion 

of tlu* genital nialfornialions. They have Itcen elabomtely f^tudied 
a!i<l elassiiied, but for the most part may be ranged under two general 
lieads ; L Tljose due to inx]K*rieet devi^upnient of Midler's ductst. 
2* Those due to imperfect blending of the same. 

FiornE 262. 




Double iitcrui. uterus ^Idelphyn. a. Hluht cuviiy. 6 tvfi raviiy. e. Rlnht ovmy. rf. 
RJgfit niund lijKAiniMit. f. Left rouud llgJimcnt, /. UH ttjbc*. jj. U-ft vuglnal i«jrUim. /i. Ktgbt 
Tajiiml p-trtlou. t Bight vugln*. J. i*ll vagina. *, PftrtUion between tlic two vaginieA 

Infantile UteniB. If tlie Slullerian duets unite btit <lo not eon- 
tinne to devtdop^ the result will In- an uudcvelo|K»d, infantile, or fcetal 
uterus. If the arrest *»f develo|»nient occurs very early in fivtal life, 
the uterus will be extremely rudimentary. It may consist of an in- 
fantile cervix, ami in place of the corpus only a fibrous citrd extend- 
ing from the Bite of one Falloptafi inK'ning to the other. If arrest 




CONQEMT. 1 L MA LFOHMA TWNS. 



469 



of tk^velopiiH^nt dfK^s not occur until after hirth, tlie titorus will be 
snudk^r \lniu normal, hut in utlier rt^i^peets not strikiot^ly different 
from the fuliy ilevefoped o 1*^1111. 

The anomalies due to defeetivu^ blend i 11 j^j of IM idler's duets are 
numeruu.s and fre<j uent. Nearly e%'ery degree u\' iniperfeet fusion 
has been observed. The following auumidies are due to this 
eaui^e. 

Double Uterus, The most extreme anomaly ilne tti defeetive 
bleniling is the tlouble uterus (uterus didelphys), in which there are 
two eomplete organs lying side by side, eaeli Mtdleriaa duet having 
formed a prfeet uterus with eervix and fnudui>, but witii oidy one 
eornu, one Fallopian t!d>e, arul one round lig<iment» Either ui* these 
uteri may I>e fa net ion ally eompetent. Pregmuifv and parturition 
may therefore proceed normally. On the olhrr hand, one may be 
rudimentary or inijierforate. If the imperforate organ is fu net ionally 
aetivx^t it may liecome distended with menstrual blood and funn 
ha*matonietm. This will require surgieal interference. 

Accessory Uterus* A very cur ions and mre nial formation is the 
uterus aeeessorins. In this condition, besi^los the normal uterus, 
there exists another n terns anteriorly, between it and the Idadder, 
In one case a tliml uterine kjbe was found attached to the single 
cervix of a bilid uterus. It \b hanl to account for these anomalies. 
The assumption has been made that the accessory organ wasdeveloi>ed 
from a divertieulum of a Midler's dnet. 



FlGl^ttii 263, 



ilv 



— 5 



trtonw bicoTiii* imioelllfl. «. VaKiivfiJaid ^^peIJ. ?>. Sin ijk- cervix. €^c. rterlne horna. 
/,/ Koiiml Ugamenta. cf, d. Fallopiiiii lubes, c, c. Ovarlea.i 

Bicornate Uterus. Next in importance to the diTuble uterus 
is the much more frequent bicornate utenrs, in which fusion of 
Mrdler's ducts has oeenrn^d lower down than normal, with the 
result of producing a Y-shaped organ. This deformity occurs in all 

^ Kusaraaul, in Mann'^ American Systein of UyntJCtilogy, 




460 



TUMORS, TUBAL PREGNAyCY, MAJJ'ORMATIOyS, 



degn?t\s. Ill one <*xtrome, the septum extemls the wliole length of il^e 
cervix and gives rise to a tloiibie os exteriMun ; in tlir other extreme 
the two cornua may be separated only by a notch at tin* ttinduj^ 
(Litems conhlormi.s). 

Uterus SeptuB. In this anomaly there is complete division of tlie 
ntenis into two eavities by an an tero- posterior vertical partition or 
si^ptimi. Litems subseptiis signiiies an iniperfeet septum and coniie- 
cjuent partial division. This is not indicated by the external apj>ear- 
anee of the <jrgan. The septum inuy be comph'te or iiieomplete, or it 
may form only a ridge on the interior of the uterns. It may even 
extend through the cervix » or it may be confined to the cervix or to 



ff 



l*loru!i sfptus duplt?x (nat^irol elxoU ''tmipteMy doiibU> tittrus mid tn*^<injpletply doubls 
Vftgluii of a Kirl twenty-two yoam i>f n^c. o. a. TuIms. h.b. Fundus of tlif dotitile utcnii. 
r, f , r. rartition of iittTiu. d^ d. Cavities of tht? uterine bodies, r, f, Intcniftl urU^rc*. //. 
ExtiTtinl \x&lU of thf two nec'kn. p, p. Extt^rnftl oriJk€«. h, h. Vaghiul cartulH i, pArtitioti 
Mhleh diTlded the npifT third of the vajfino kito twn hiih'e*,* 

the corpus. There may he, in fact* every possible variety in the 
i«itnati»»n m completeness of the septuni. Tlic ty|»ii^aK if not the com- 
monest, form luis two lateral cavities involvini^ Imth IhkIv and cervix. 
The bieornate and septate uteri have a similar clinical significance. 
In either tljcre is liabh' to be an imperforate eondititm of one side of 
the septum or tlie other, with resulting hieTnatometm. Pregnancy 
occurring in one of ihe horns of a bieorDate litems^ especially if a 

I Kuwinaul, iu Mann'i Amerlc»Q SysUia of cijrnecology. 



CONGENITA L MA LFORM. I TIONS, 



461 



.^eptuni ulf*o exii^ts, may givr rise to tlio ditticultic^ and dangers of a 
tubal grsiatioii. Mcnstriiatiun is liahlt- to he frequent and otherwise 
abnornial, an*! partnrition to he ernliarrassed. In a suh.^eptate uterus 
lUidprL'sentatiuns are prone to occur and the in.sertion of the pkcenta 
to be abnt>rniiiK 

There is in the above varieties a eomplete gradation between the 
donl>le uterus on tlie one hand, and the nterus septns on the other. 
Tlie relntive chmensions of the two liorus may vary to the extent of 
cooiplete absence of nne, and eonsecpient nterns unieornis. 

Uterus Unicornis. Wlien only one hc^rn of the uterus is well 
develojied^ or only one exists, w-e have the siugle-liorned uterus, or 
nterns uuieornis. Tlien^ are here failure of fusion and more or less 
atropliy of the duet on one side. The kidney, ureter, ligaments, tnl>e, 
and ovary on the side of the lacking or imperfect eornu are also, as a 
rule, rndimeutary or absent. The rudimenlary horu maybe hollow 
or solid ; if the former, its cavity may or may not connect with that 

FlGUItE 265. 



LT 



kRT 



Lr 



■^ 



Vtemi QTifcornis. LH. Left hnrn. AT. I^ft tube. L.o. Ia*H ovary. RH. RlgJit horn. ET. 
Right tube. Eff, Right osiirj\ ELr. Right round Uganifnl. LLr. Left nmiid Ugameiit.i 



of the developed horn. If menstruation takes place in the closed horn, 
there will he lia^matometrti, and the normal progress of menstruation 
on the other si*le will lead to eon fusion in the diagnosis. Bilateral 
hicmatonietra, both horns being imperforate, would give rise to less 
difficulty in the diagnt^sis. 

Amuug the less important anomjilies of the uterus are the following : 

Defect or absence of the vaginal portion of the cervix. 

Septate i(s cxternnni, with no tnice of septum above. 

N^>rmal development on one side an<l defective development on the 
other ; this would he an approach to a unieornate uterus. 

Flat <*r a relied fundus. 

Omgcuital prolapse, retroversion, retroflexiotj, or anteflexion. 

("migcnitai ( oniniunicatiiui between the endometrium and intestines 
or bhulder. 

In a remarkable case one siile of the bipartite uterus is said to have 
de%'elof»eil on the exterior of the bmly. 

Premature Development of the Uterus. This is usually Uriso- 

^ From Si'hriwler Aint-nmn System of Gynt'culogy. 



462 



rUMOnS, TUBAL PKEGNJNVV, MALFORMATIOyS, 



ciatuil with 3!?inu!ar prrt'Oi-ity in the oilier genital organs. Young 
girls nuiy thus inejistruate at a very early age and show the i?exual 
ctevelupmeiit of mature yeara 



Malformations of the Vagina. 

The vagina, in eoninioii wilh tlie uterus, is ft>rnu'd l>y die coah*s- 
eenee *jf\Muller's duets, aiul therefore shares largely in the niaHurnia* 
ti(in,s of that organ. Tlins tlie (hiuhle uterus and the nterug septnsare 
cnninionly asscKmiled with dciohle vagina. 

The congenital anomalies of the vagina are these: 
Vagina septa. 
Absence tif the vagina. 
Ati\'sia of the vagina. 

Vagina Septa. A completely double vagina having two canals, 
*€ich opening into an external vulva of its own, 18 very rare, only one 
ai.se, that of Katharin Kaufmann, having been reported. In this ease' 
the pelvis was dividcKl by a periloneal fold into two lateral eavities; 
eaeii half rontained a bhulder, a unieornate uterus, an ovary, a Falbi- 
pian tube, and a rectum. The spinal cord was bifurcated at the level 
of the tliird lumbar vertt^bra. 

The ordinary and nineli more eonunon double i^r septate vagina is 
tlivided into two passnges by a septum above the vulva. The Iiynien 
may have one or two openings, and the septum, as in die uterus, may 
Ix* eomplete or {xirtiah 

Doylile uterus antl double vagina often e^vxist. In some eases 
the vagina is double and the utern^ single, with die os externum then 
opening into one side of the donbk^ vagina. The otiier gide ends in 
a cul~de-sae. If, under these ennditions, the blind passage be alone 
nsetl for edition, sterility will result. In other eases both sides may 
be in commnnieation with the uleru,--. The septum may be so imper- 
fect as to constitute only a ridge ahmg the posterior and anterior walls 
of the vagina. 

The septum seldom divides the passage into exactly espial halves. 
Coitus is usually confined to one side. In ease of uterus nni(*ornis 
the vagina may be very small— in fact, of only half size. This is 
because oj(c of Midterms ibiets has failed in development from the 
uterus down, and the r»ther has dev( liip^d only on its uwn side, pr<»- 
ducing a unilateral vagina. In ea>o of double uterus, or uterus septus, 
or uterus bieornis, one-half of the vagina may l>e imperforate, with 
resulting accumnlation of menstrual hbHxl in the uterus and vagiiui tm 
that sid(\ This is hjematonietra and ha^matocolpos. 

Aside from the possibilities of sterility and iMematoenlpos, and fnmi 
the uterine con<litions which may be associated, a vaginal scjitum is 
not of itself a very serious matter. It may never be su speeted nntil 
jiartnrition, and even ttien tlie septum may be destroyed or jaished to 
one side by the passing child, 

Coinplete Absence of the Vagrina is usually associated with 
abhence or defect of tlie ovaries, tidjes, and uterus, and with a generally 

« Keportcd by PuppiiiBtT. AUbutt and Play fair, Syitein of Gfneeology, 



I 




COSGENITAL 3iALFOnMA floyS. 



463 



(k'fortive sexual organ izati<»iK li', liowever, the defect h oiily in that 
part of Miillerls duets whifli furujs the vaginu, the uterus and tiihes 
(nay be intnually developed. Ahseuee of the vagiiiu will tlieu lead 
idler puherty to reteiitiou c»t' the uieustrual prrxluets ami the lU'cessity 
of niukin^ an artitieial vaghial jiassage. This is iudieated iu order to 
give exit to retaiued menstrual fluid, and is p^^rmissihle to estahlish the 
physiological fntegrity of tlie vagina* Impregnation autl partnrition 
have tak(*n place through a vagina thus opened* This suhjeet will ]ye 
further etuisidere*! in the next ehapter. 

Inflammatory Atresia of the Vagina mast not he cunfuuiided 
wit It eongeuital absence of the organ. Tiie funner is the result of 
adhesive inHanimations whieh may be fietal and involve the whole 
leugth of the passage, or it may he due to inHammation oeeiirring 
in childhiHjd or in adult life; see Dissecting Vulvo- vaginitis. In 
a ease of adherent vaginal walls^ the walls when sc[^arated will, 
wherever the in Ham mat inn has not been destruetive, he lined with 
vaginal mneosii. la congenital absenee of the vagina tlie mucosa 
has never develojied. Tlie re is only connective tissne between the 
vesieiil and rectal walls. 

The remaining vaginal anomalies are rare; they include diverticula 
and conimunieatiuus between the vagina and other organs, snch as 
the rectnni and urethra. These openings are dependent not upon 
defects of MiUkT^s duets, hut rather upon ftetal cloaeal conditions, 
hereafter ti> be descril>ed. 



Malforrnations of the Hymen, 

The hymen is an organ of variable strength and form. It may 
be annular, nf^tcheit, findrriated, fenestrated, cribriform, crescentic, 
thick, thin, fragile, ttHigh, or vascnlar. Some of these conditions are 
normal, others but slightly abnormal. Complete absence is extremely 
rare, if not unknown, I m perforation, so-called, is a condition usu- 
ally due to closure of the end id' a Midlerian thiet, and is therefore 
in no sense an aliuuroial hymen. 

The im]>m'tanee td' these ariunialous conditions varies. A rigid 
hymen makes eoitns painful ur impossible, a very vasenhir membrane 
may lead to a temporary pndnse hemorrhage, and imperfeetion gives 
rise to hienKi{^M'ulp^ls, or in extreme cases also to hiematometra, and 
demands operative interference; see Congenital Atresia of the Genital 
Tract, A rigid liymen may, after uuirriage, ret|nire divulsion or 
incim{>n. 

Malformations of the Vulva and Anus. 

This suljjeet beci>mes relatively simple when we nnderstand the 
embryological development uf the vnlva and anus. At the end of 
the sixth week of fcetal life the tangible <!ifferentiation of sex l>egins, 
and the developujcntal changes which then normally take place are 
shown in Figures 266 to 270:* 

At first the allantois which forms the bladder, the rectum, and the 

1 After Schrikler. From Hiirt and Barbour, Manual of Gynecology. 




TJie upiM^r t>«ri '>f the iiro-frptiHiil alnu* has rontrmtiU \nUi Ihe urethra; the lower partitiii, 8V, 
now becoined the vulva. /*. Perineum. H, Kofluni. l\ Vi^iia, ft, Bluddcr. lu Un*thr«. 

Presently there is a depression in the ekin wliic^h o|>enHi inward to this 
cavity, tlms forming tlie elrmra. The eluicjil openinfr ^^ n'^^ (11% ided 
into two |wirt8 by a septnni, wlnc^h liit^r di'Vi'lnjis into the iM»niienm» 
The posterior i>ortion of tlie ehiiica thus divided becomes the anns. 



CONGENITA L MA LFOUyfA TIONS. 



465 



The anterior part becomes the urn-genital stiuis. Tliis sinus in its 
upper part beeoures the urethra, timl in its lower part the vulva. 
Tlie anomalies of the vulva and anus are : 

Atreisia, 

Persistent cloaca. 

Hyposijailius. 

Epispadias. 
Atresia of the Urethra, Vagina, and Anus. The rloaeal divi- 
sion by which the uretli ra, vagiua, and anu.'^ are ojK^ned and thereby 
proltjuged to the external t^uHacre may fail to take j>hic(% This fid In re 
will result in eoniplcte atresia of the vagina, uretli m, and anus. The 
perineal septum may be absent, as shown in Figure 271, or present, 
as shown in Fij^ure 272. In the latter ease the opening between the 
rectum ami the nro-genital sinus will be closed. This condition of 
complete atresia lias oidy been observeil in stillborn tVetal monstrosi- 
ties, Tlie bladder, urethra, and vagina^ — that is, the nro-genital sinus 
—are apt to he distended with urine. 



FiGiTRK 27L 

R O 



n 



\ i 



/